سيمينار نسا 2022

seminars
in
For
Third Year Nursing Students

By
Teaching Staff Members

Faculty of Nursing
Assiut University
2021-2022
‫رؤية القسم ‪:‬‬
‫يسعى قسى تًريط صحخ االو وحذيثى انىالدح انى انتًيز وانريبدح في يجبل‬
‫رعبيخ انًرأح خالل يراحم انحيبح انًختهفخ ‪.‬‬
‫رسالة القسم ‪:‬‬

‫قسى تًريط صحخ االو وحذيثى انىالدح ثكهيخ انتًريط جبيعخ اسيىغ يعًم‬
‫عهى اعذاد كىادر يؤههخ عهًيب ويهبريب ويهنيب في يجبل تًريط ايراض اننسبء وانتىنيذ‬
‫ورنك ين خالل ثرايج تعهيًيخ تستنذ عهى يعبيير أكبديًيخ يعتًذح وثحث عهًي يىاكت‬
‫يتطهجبد انحبظر وسىق انعًم ين اجم انًحبفظخ عهى صحخ انًرأح وتحسينهب اثنبء‬
‫فتراد حيبح انًرأح انًختهفخ ‪.‬‬
‫االهداف االستراتيجية لقسم تمريض النساء والتوليد والصحة األنجابية ‪:‬‬
‫‪ .1‬اعذاد غالة يتًيزين في يجبل تًريط اننسبء وانتىنيذ قبدرين عهى‬
‫تقذيى افعم رعبيخ صحيخ نالو اثنبء فتراد حيبتهب انًختهفخ‪.‬‬
‫‪ .2‬تشجيع انطالة عهى انًشبركخ ثبنجحث انعهًي إلعذاد غبنت قبدر عهى‬
‫انًنبفسخ في سىق انعًم يحهيب وعبنًيب‪.‬‬
‫‪ .3‬تنًيخ قذراد اععبء هيئخ انتذريس وانطالة وتشجيعهى عهى انتىاصم‬
‫يع انهيئبد انًحهيخ وانعبنًيخ نتطىير كفبءح انتعهيى وانجحث انعهًي‪.‬‬
‫‪ .4‬اكسبة انطالة انًهبراد انتًريعيخ انتي تًكنهى ين انتفبعم يجتًعيب‬
‫نالرتقبء ثصحخ انًرأح اثنبء فتراد حيبتهب انًختهفخ‪.‬‬
Table of content
NO Title Page no
1 Fetal Skull 1-11
2 Fetal Circulation 12-24
3 Fetal Surveillance 25-37
4 Hyperemesis gravidarum 38-43
5 Rhesus-Iso immunization (Rh) 44-54
6 Episiotomy 55-64
7 Oxytocin (Pitocin) Drugs 65-73
8 The Placenta 74-87
9 Cesarean section (C.S) 88-96
10 Gynecological instruments 97-104
11 Gynecological investigations 105-115

Fetal Skull
Fetal Skull
By the end of this lesson, the student will be able to:
1. Identify the function of the Fetal skull

2. Enumerate the importance of landmarks
3. Describe the normal and abnormal position of fetal
skull during labor process
1
Fetal Skull
Fetal Skull
Outlines:
1. Introduction
2. Regions and landmarks of the fetal skull
3. Regions of the fetal skull of obstetrical importance:
 Vertex
 Sinciput or brow
 Face
 Occiput
4. Bones of the vault of the skull consists of five
main bones including:-
 Frontal bones
 Parietal bones
 Occipital bone
5. Sutures and Fontanelles
6. Diameters of the fetal skull
7. Moulding
2
Fetal Skull
Introduction
The fetal skull is the largest bony structure in the fetal body
and this has implications for the progress of labour and the
outcome of a vaginal birth. This is regardless of whether the
head is born first as with a cephalic presentation, or last, when
a breech presentation. The application of the fetal head, when
this is the presenting part, to the uterine cervix (cervical os)
plays a large part in the effectiveness of uterine contractions
and the influence of these on labour progress.
Regions and landmarks of the fetal skull
The skull consists of vault, face and base.
⮚ Regions of the fetal skull of obstetrical importance:
1. Vertex: it is bounded by the anterior fontanel, two
parietal eminences and the posterior fontanel.
2. Sinciput or brow: extends from the anterior
fontanel and the coronal suture to the orbital
ridges.
3. Face: extend from the orbital ridges and the roof
of the nose to the junction of the chin and the
neck.
4. Occiput: it lies between foramenmagnum and
posterior fontanel and the part below the occipital
protuberance is known as sub occipital region
3
Fetal Skull
⮚ Bones of the vault of the skull consists of five main

bones including:
1. Two frontal bones from the forehead or sinciput. The
frontal bones fuse into a single bone by 8 years of age.
2. Two parietal bones lie on either side of the skull and
ossification center of each is called parietal eminence.
3. Occipital bone lies at the back of the head and forms the
region of the occiput.
Bones of the vault of the skull
4
Fetal Skull
Bones of the vault of the skull

⮚ Sutures:
The cranial sutures are fibrous joints connecting the bones
of the skull. These are four sutures in the vault; which are
of obstetrical significance:
1. Frontal suture: lies between the frontal bones
2. Sagittal suture: lies between the two parietal bones
3. Coronal suture: lies between frontal and parietal bones
on either side of the head.
5
Fetal Skull
4. Lambdoidal suture: lies between parietal bones and the

upper margin of the occipital bone on either sides of
the head.
Fontanels of fetal skull

⮚ Fontanels:
Fontanels are areas of the fibrous tissue membrane found at
the angles of the parietal bones where ossification is
incomplete at birth. These are:
1. Anterior fontanel or bregma:
● It is formed by the meeting of the frontal, sagittal and
two coronal sutures.
● It measures 3-4 cm long, 1.5-2 cm wide and it is
diamond in shape.
● It normally closes at age of 18 months.
6
Fetal Skull
2. posterior fontanel:
● It is formed by the meeting of the sagittal and two
lambdoidal sutures.
● It is roughly in the shape of a triangle.
● It is small and normally closes at 6 weeks of age.
Diameters of the fetal skull
7
Fetal Skull
⮚ Diameters of the fetal skull:

Diameter Attitude of the head Presentation
1. Suboccipito- bregmatic: 9.5 cm Complete flexion Vertex
extends from the nape of the neck
to the center of the bregma.
2. Suboccipito- frontal: 10 cm Incomplete flexion Vertex
extends from the nape of the neck
to the anterior end of the anterior
fontanel.
3. Occipito- frontal: 11.5 cm from Marked deflexion Vertex
the occipital eminence to the root
of the nose.
4. Mento vertical: 14 cm extends Partial extension brow
from the mid-point of the chin to
the highest point on the sagittal
suture.
5. Submento vertical: 11.5 cm Incomplete extension face
extends from the junction of the
mouth and neck to the highest
point on the sagittal suture.
6. Submento- bregmatic: 9.5 cm Complete extension face
extends from the junction of the
mouth and neck to the center of
the bregma.
8
Fetal Skull
⮚ Moulding
The bones of the fetal skull are normally connected by a thin
layer of fibrous tissue which allows each bone to move and
slide (override/overlap) to adjust to the size and shape of the
maternal bony pelvis during labour; this process of overriding
is called moulding.
Moulding occurs when:
● Pressure is applied to the skull from the surrounding
maternal tissues.
9
Fetal Skull
● Overlapping of the skull bones occurs resulting in a

reduction of the diameter of the skull according to where
the pressure has been applied.
Moulding
Benefits of moulding:
● Enable the fetal head to negotiate passage through the
pelvic brim and outlet.
● Helps to safeguard the fetal brain from being directly
compressed during labour and birth; however, where
labours are rapid and/or pressure on the fetal skull is
10
Fetal Skull
excessive, Once the baby’s head is born, the moulding

gradually subsides but this might take several days.
Complications of severe moulding:
● Brain injury may arise.
● Excessive overriding of the fetal skull bones places strain
on the delicate soft tissues lying beneath
11
Fetal Circulation
Fetal Circulation
By the end of this lesson, the student will be

able to:
1. Describe the shunts involved in fetal circulation.

2. Identify the events that lead the transition from fetal to
extra uterine circulation.
3. Understand the adaptive processes that allow adequate
oxygen delivery to the fetus.
12
Fetal Circulation
Outlines:
1. Definition of fetal circulation.
2. Mechanism of circulation.
3. Adaptation to extra uterine life.
4. Adult Changes in Fetal Circulation.
5. Difference between adult and fetal circulation.
13
Fetal Circulation
Definition of fetal circulation:

The fetal circulation is the circulatory system of a
human fetus, often encompassing the entire feto-
placental circulation that also includes the umbilical
cord and the blood vessels within the placenta that carry
fetal blood.
-Fetal circulation consequently differs from the adult

one predominantly due to the presence of 3 major
vascular shunts:
Three shunts in the fetal circulation:

1. Ductus arteriosus ) A connection between aorta and the
pulmonary arteries in the heart) .
… protects lungs against circulatory overload
… allows the right ventricle to strengthen
… high pulmonary vascular resistance
2. Ductus venosus )A connection between fetal umbilical vein
with the inferior vena cava ).
… fetal blood vessel connecting the umbilical vein to the IVC
… blood flow regulated via sphincter
… carries mostly hi oxygenated blood
14
Fetal Circulation
3. Foramen ovale ) a small hole between the right and the left
atrium ).
… Shunts highly oxygenated blood from right atrium to left
atrium
4. The hypogastric arteries (originate from the descending
aorta) .
…During returning blood to placenta it takes about half a
minute to circulate it take the following course.
Blood Flow: (Mechanism of Action)
15
Fetal Circulation
 Exchange of gases occurs in the placenta. The umbilical

vein carries the oxygenated blood (80% saturation) from
the placenta to the fetal body, enters the portal system.
When the umbilical vein reaches the liver, it divides into
two branches. One branch joins the portal vein in the
liver and so carries nourishment and oxygen directly to
the fetal liver. Second branch (most of the blood) flows
from the umbilical vein away from the fetal liver
through the ductus venosus directly into the inferior
vena cava.
 The inferior vena cava now contains a mixed

stream consisting of oxygenated blood from
16
Fetal Circulation
the placenta and deoxygenated blood coming

up from lower trunk and legs (lower half of the
body) but this does not seriously affect the
oxygen content of the blood brought by the
ductus venouses.
 The inferior vena cava opens into the right
atrium. The large portion of the blood (mainly
oxygenated) passes through the foramen ovale
to the left atrium. There it mixes with the
small amount of blood returning
deoxygenated from the fetal lungs through the
pulmonary veins.
17
Fetal Circulation
 After the blood passing from the left atrium

through the mitral valve into the left ventricle,
the blood leaves the heart via the aorta.
 The aorta carries the most highly saturated
blood leaving the heart (65%) gives off
branches (the coronary vessels) to supply the
head, the brain, vital centers and upper body
with the major part of the oxygen-rich blood.
18
Fetal Circulation
 The deoxygenated blood returning from the

head and arms enters the right atrium through
the superior vena cava.
 This blood is directed downward into the right
ventricle, From the right ventricle the blood
passes into the pulmonary trunk. A small
amount of blood circulates through the
resistant lung tissue, but the majority follows
the path with less resistance through the
ductus arteriosus into the aorta. the ductus
arteriosus connects the left pulmonary artery
and the terminal part of the aortic arch at a
point below which branches are given off to
the head and arms.
19
Fetal Circulation
 The descending aorta supplies branches to the

lower fetal body, the major portion of
descending aortic flow goes to the umbilical
arteries (hypogastric arteries), which carry the
deoxygenated blood to the placenta.
 Following gas exchange and uptake of
nutrients in the placenta, blood again enters the
umbilical vein and the process starts over once
again.
20
Fetal Circulation
Flow Chart of Fetal Circulation
21
Fetal Circulation
Fetal Circulation
22
Fetal Circulation
Adaptation to extra uterine life (changes occur after

birth)
 At birth the baby takes a breath and blood is drawn to
the lungs through the pulmonary arteries.
 It is then collected and returned to the left atrium via the
pulmonary veins resulting in a sudden inflow of blood.
The placental circulation ceases soon after birth and so
less blood returns to the right side of the heart.
 In this way the pressure in the left side of the heart is
greater while that in the right side of the heart becomes
less.
 This result in the closure of a flab over the foramen
oval which separates the two side of the heart and stops
the blood flowing from right to left.
 With the establishment of pulmonary respiration the
oxygen concentration in the blood stream rises. This
causes the Ductus arterioses to constrict and close.
 The cessation of the placental circulation results in the
collapse of the umbilical vein, the Ductus venosus and
the hypo gastric arteries.
 These immediate changes are functional and those
related to the heart are reversible in certain
23
Fetal Circulation
circumstances. later they become permanent and

anatomical
The hypo gastric arteries are known as the obliterated hypo
gastric arteries except for the first few centimeters which
remain open as the superior vesicle arteries.
Differences between Adult and Fetal Circulation
Criteria Adult Circulation Fetal Circulation
-Carries oxygenated -Carries Non-oxygenated blood
Artery blood away from the heart away from the fetal heart
-Carries non-oxygenated -Carries oxygenated blood back

Veins blood towards the heart to the heart
Exchange of
-Takes places in the lungs. -Takes place in the placenta .
Gases
-Increase pressure -Increase pressure on the right

Pressure on the left side of the heart side of the heart
-Received de-oxygenated
-Received mixed blood
Rt. atrium blood
Temporary Present suh as ductus venousus,
Absent
structures foramen oval,ductus arteriousus
Supplied by branch of
Supplied by portal artery
Liver umbilical vein
24
Fetal Surveillance
Fetal Surveillance
1. Identify the important of fetal surveillance.

2. Mention types of fetal surveillance.
3. Enumerate high-Risk factors to perform fetal
surveillance.
4. Mention names of ante partum fetal test.
5. Enumerate names of intra partum fetal test.
6. Correlate between types of fetal test and duration
of pregnancy the test done during it.
7. Discriminate between indications of each test.
8. Interpret for electronic fetal monitoring finding.
9. Formulate specific nursing care during fetal test.
10.Implement nursing care for fetal test.
11.Connect pregnant woman to electronic fetal
monitoring device.
52
Fetal Surveillance
Fetal Surveillance
Definition
Fetal surveillance: - means evaluating the current health
of the fetus during ante partum and intrapartum period.
Objectives of fetal surveillance
▪ To detect congenital abnormalities
▪ To detect abnormalities of the fetal growth.
▪ To detect and evaluate the severity of acute or chronic
fetal asphyxia.
Characteristics of tests
▪ Quick and easy to perform
▪ Should clearly identify the compromised
▪ Fetus at stage at which intervention will improve the
out come
▪ It should not give an abnormal result for a healthy
fetus that lead to unnecessary parent anxiety.
Types of fetal surveillance
▪ Ante partum fetal surveillance
▪ Intra partum fetal surveillance
▪ Tests for prenatal diagnosis of congenital fetal
abnormalities as :
▪ Chorionic villous sampling
▪ Cordocentesis
52
Fetal Surveillance
▪ Amniocentesis
▪ Ultra sonography
▪ Tests for assessments of fetal growth and fetal
wellbeing:
▪ counting fetal movement.
▪ Ultra sonography
▪ Biophysical profile (BPP)
▪ Non stress test
▪ Contraction stress test
1. Ante partum fetal surveillance
Indications of ante partum fetal surveillance
1-Maternal conditions:
● Diabetes mellitus
● Chronic renal failure
● Congenital heart disease /Rheumatic heart
disease
● Heamoglubinopathies(thalassemia)
● Hypertensive disorder
● Mothers age >35 ` < 16 years.
● Woman’s work environment (e.g. exposure to
irradiation).
● Poor nutrition.
● Problematic genetic history
52
Fetal Surveillance
2-Pregnancy related conditions
● Pregnancy induced hypertension
● Decreased fetal movement
● Polyhydramnios/ Oligohydramnios
● IUGR
● Post term pregnancy
● Isoimmunization
● Multiple gestations
● Unexplained fetal death.
Ante partum fetal surveillance tests
● Clinical assessment (Abdominal Examination)
● Ultra sonography
● Daily fetal movement count (Kick count)
● Biophysical profile (BPP)
● Percutaneous umbilicus blood sampling(PUB
S)
● Chorionic villous sampling:
● Amniocentesis.
● Antenatal cardiotocography
1- Clinical assessment (Abdominal Examination)
Is a clinical examination including detection of?
▪ Fetal heart sound
▪ Fetal size
52
Fetal Surveillance
▪ Fundal level
2-Ultra sonography:
1- (Real-time sonography)
▪ It is a procedure using ultra sound waves to provide
imaging of the fetus, placenta, uterus and cross –
section motion pictures of internal structures.
▪ It is non-invasive, painless and non-radiating to both
the woman and the fetus.
Use of ultrasound
This technique allows the observer to detect
▪ Gestational age
▪ Fetal heart beat
▪ Fetal breathing
▪ Viability of the fetus
▪ Fetal weight
▪ Fetal body movement
▪ Amniotic fluid volume
▪ Placenta: location , size and maturity
▪ Congenital anomalies.
Procedure: There are two methods of ultra sound
scanning.
1-Transbadominal
2-Endo vaginal (transvaginal(
52
Fetal Surveillance
1-Trans abdominal ultrasound
The procedure takes about 20-30 minutes
 Ask the mother to drink 2 glasses of water
approximately 2 hours before the examination. A
full bladder moves bowel out from the pelvis into
the abdomen, helping visualization of the
pregnancy, uterus and ovaries.
 Ask mother to lie on her back
 Spread jells over abdomen then slowly moves
transducer/probe/device over the abdomen.
 Then freeze picture and copy it for a permanent
record.
03
Fetal Surveillance
2-Endovaginal ultrasound
▪ The procedure takes about 15 minutes
▪ Ask the woman to empty her bladder
▪ Ask the woman to lie on her back and flexed her legs.
▪ In this procedure utilize a probe, which is covered by
a disposable sheath or condom, and insert into the
vagina. Once inserted the endovaginal probe is close
to the structures being imaged and so procedures a
clearer picture.
3-Daily fetal movement count (DFMC) (Kick count)

The test is valid after 30 weeks of pregnancy
▪ Is a simple method for monitoring the fetal condition
after 28 week’s gestation which include 3 movements
or more in 30 minutes to 1 hour, three times daily
▪ Fetal movement is reassurance sign of fetal health.
▪ Cessation of movement is correlated with F.D(fetal
death)
03
Fetal Surveillance
▪ Less than 3 FM (fetal movements) within 1 hour make
evaluation through non stress test, BPP (Biophysical
profile), or contraction stress test.
4- Biophysical profile (BPP)

▪ It is a method used to evaluate the condition of the
fetus. This method consists of an NST combined with
four observations made by real-time Ultrasonography.
It consists of 5 components each of five components
is assigned a score of either 2 or 0
Biophysical variables include:
Fetal breathing , Fetal movement , Amniotic fluid
volume, Fetal tone by real-time Ultrasonography and
fetal heart rate variability through NST.
Note:
▪ Maximum score is 10, minimum score is 0
▪ A score of 8-10 is normal.
▪ A score of 4-6 deliver if lung is mature otherwise
corticosteroids are given for 48 hours before delivery.
▪ A score of < 4 is abnormal evaluate for immediate
delivery
05
Fetal Surveillance
5- Cordocentesis
It is easier and safer method to obtain fetal blood by
directly inserting a needle into the umbilical cord at its
placental insertion site under direct ultra sound guidance.
Indications:
For diagnosis of chromosomal abnormalities ,fetal
anemia in Rh-isoimunization and fetal infection in case
of toxoplasmosis .
Cordocentesis
6-Chorionic villous sampling:

Invasive technique involving transcervical or
transabdominal aspiration of Chorionic villi using a
sterile catheter directed toward placental site under
ultrasound guidance
Indications:
Chorionic villous sampling used for diagnosis of :
1. Chromosomal abnormalities as down syndrome.
2. Genetic abnormalities as thalassemia.
7. Amniocentesis.
00
Fetal Surveillance
Involves the with drawl of a sample of amniotic fluid
surrounding the fetus by needle inserted through the
abdominal wall into the uterus and is performed after
14th week of pregnancy when there is sufficient amount
of amniotic fluid for the procedure.
Indications:
1. Diagnosis of chromosomal abnormalities as Down
syndrome.
2. Diagnosis of genetic abnormalities as thalassemia.
3. Diagnosis of open neural tube defects as open
spina bifida
4. Determine severity of erthroblstosis fetalis (Rh-
isoimunization
Complications of amniocentesis
⮚ Puncture of the fetus
⮚ Fetomaternal hemorrhage
⮚ Amnionitis
⮚ Perforation of the placenta
⮚ Spontaneous abortion
8-Antenatal cardiotocography
Involves
1. Non stress test (NST):
03
Fetal Surveillance
Evaluate FHR acceleration in response to fetal
movement
2. Contraction stress test:
It evaluates the response of FHR to stress of uterine
contraction
Intrapartum fetal surveillance tests
Types of intra-partum fetal surveillance
1. Monitoring of fetal heart rate
2. Monitoring of uterine contractions
3. Fetal blood sampling
4. The partogram
5. Recent advances
1- Monitoring of fetal heart rate Objectives of fetal
monitoring to detect and evaluate the severity of acute
or chronic fetal asphyxia.
A-Intermittent auscultation: by: - Pinard’s stethoscope
B-Electronic Monitoring: by
● Fetal electrocardiography (ECG)
● Phonocardiography
● Doppler ultrasound cardiograph
2- Monitoring of uterine contractions (topography)
● External: An external transducer is applied to the
mothers' abdomen close to the fundus transmitting the
02
Fetal Surveillance
strength, frequency and duration of uterine
contractions onto a paper strip record.
● Internal
A fluid-filled catheter is introduced into the uterus
after rupturing the membranes. The intrauterine pressure
is transmitted to the catheter then to a transducer giving
electrical signals expressing the exact pressure in mmHg
3- Fetal blood sampling
4-Partogram
Used to evaluate
- Fetal conditions
- Maternal conditions during labour
-progress of labor process
5- Recent Advances in intrapartum Monitoring
1. Monica Monitoring System
More Accurate, More Comfortable, Less Intervention

The Monica AN24 is an innovative, wearable device that
accurately monitors FHR, MHR, UA and maternal
activity, offering an alternative wireless ambulatory
monitoring solution for induction, obesity, L&D and
patient satisfaction.
02
Fetal Surveillance
2. Telemetry
Telemetry is an electronic fetal monitor without wires. It

does not improve the false readings of an EFM, but it
does eliminate many of the problems associated with
mobility and positioning. Some telemetry units are safe
to use in water. Telemetry is not available in all hospitals.
02
Hyperemesis gravidarum
Hyperemesis gravidarum (vomiting of pregnancy)
1- Define the hyperemesis gravidarum.

2- List etiology, risk factors of hyperemesis
gravidarum.
3- Enumerate symptoms & complications of
hyperemesis gravidarum.
4- Identify classification of hyperemesis
gravidarum.
5- provide proper nursing care to women with
hyperemesis.
83
Outlines
1. Introduction
2. Definition
3. Causes of Hyperemesis Gravidarum
4. Risk factors
5. Symptoms of Hyperemesis Gravidarum
6. Classification of Hyperemesis Gravidarum
7. Complications of hyperemesis gravidarum
8. Treatment
83
Definition:
Hyperemesis gravidarum (HG) is excessive, persistent

nausea and vomiting in pregnancy affecting the general
condition of the mother accompanied by weight loss.
Morning sickness some degree of nausea with or without

vomiting occurs at early morning without affecting the
condition of the mother.
❖ Etiology of Hyperemesis Gravidarum or

Pathophysiology:
The absolute cause is still unknown. There are many

theories that explain cause of hyperemesis gravidarum:
1- Hormonal changes:
 raised level of beta HCG or undue sensitivity to
normal level of HCG.
 High level of estrogen &progesterone cause hyper
salivation and decrease gastric motility.
2- Psychological factors.
3- Allergic factors:
May also be operative since large amounts of

histamine are found in case of hyperemesis gravidarum.
4- Dietetic deficiency:
As vitamin deficiency especially vitamin B complex.
04
❖ Risk factors for Hyperemesis Gravidarum
1- Previous pregnancies with hyperemesis

gravidarum
2- Molar pregnancy.
3- Multiple pregnancy.
4- Overweight
5- Nulliparity
6- Family history of hyperemesis gravidarum.
❖ Clinical presentation:
1- Pernicious vomiting (anything taken orally is

vomited)
2- Poor appetite & nutritional intake.
3- Loss of more than 25% of body weight.
4- Dehydration and electrolyte imbalance.
5- Acidosis due to starvation.
6- Jaundice developed in severe cases.
7- Low urine output.
8- Rapid pulse and low blood pressure.
9- Hemo concentration with rising BUN(blood urea
nitrogen) and falling sodium, potassium and
chloride
04
Classification:
1. Mild hyperemesis gravidarum: when there is loss

of body weight but no dehydration.
2. Moderate hyperemesis gravidarum: when there is

dehydration & circulatory changes.
3. Severe hyperemesis gravidarum: when there is

biochemical changes with complications.
Complications of hyperemesis gravidarum:
1- Circulatory failure.
2- renal failure
3- Wernicke's encephalopathy.
4- Jaundice due to liver involvement.
5- Retinal hemorrhage.
6- Delirium, coma, death.
Treatment
● Hospitalization & IV fluids in case of hypovolemia
&electrolyte imbalance to restore hydration,

electrolyte &nutrients.
● Pharmacological treatment: the following drugs
could be used as antiemetic medications, anti-emetic
VitB6.
04
● NonPharmacological interventions(Nursing role) :
1. Dietary modification (small, frequent meals& avoid

fatty and spicy food.
2. Lifestyle changes (avoid aromas of cooking, perfumes

&smoke, avoid noise, anxiety, nervousness &fatigue.
Acupuncture &acupressure, bed rest this may provide
comfort.
 Termination of pregnancy is indicated in

severe cases with jaundice, persistent
albuminuria and polyneuritis to reserve the
condition and to prevent maternal mortality.
Nursing interventions:
1. Administer IV fluids, vitamins, and sedation as

prescribed.
2. Monitor intake, output & daily weight.
3. Asses state of hydration.
4. Begin oral feeding slowly with fluids and progress to

six small feeding a day.
5. Create opportunities for the women to explore

feeding about pregnancy.
6. Provide teaching related to need for fluids.
08
Rhesus Iso immunization
Rhesus Iso immunization (Rh)

1. Identify key terms of Rh iso-immunization.

2. Recognize genetic of rhesus system.
3. Describe clinical types of Rh- incompatibility.
4. Discuss the different methods of Management of
Rh incompatibility.
5. Demonstrate the care of women with Rh.
6. Provide health education regard Rh.
44
Rhesus Iso immunization (Rh)
Outlines
1. Definition
2. Pathogenesis
3. Genetics of the rhesus system
4. Types of antibodies
5. Epidemiology
6. Etiology
7. Clinical Types
8. Diagnosis
9. prevention of Rh incompatibility.
44
Definition of Rh factor:-
Is a protein that may be found on the surface of red
blood cells
The Rhesus factor: It consists of 6 antigen; C, D, E, or

c, d, e. Three antigens are inherited from each parent C
or c, D or d E or e. The person is rhesus- positive if the
red cells carry the D antigen. The homozygous Rh-
positive person is DD. The heterozygous Rh- positive
person is Dd.
Genetics of the rhesus system:
There are two alleles, D and d. Individuals who are

homozygous dominant (DD) or heterozygous (Dd) are
Rh+. Those who are homozygous recessive (dd) are
Rh- (i.e., they do not have the key Rh antigens).The
following table revealed Rhesus Inheritance Patterns
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Isoimunization:
is the development of circulating antibodies by mother
directed against an antigen of fetal origin.
Pathogenesis:
The condition occurs when the mother is Rh- negative,
and the fetus Rh- positive. Rh- positive fetal red cells
may enter the maternal circulation through breaks in the
placenta during pregnancy but in most cases this
happens when placenta separates at the time of delivery.
The fetal red cells stimulate the production of maternal
antibodies. These antibodies may cross the placenta in
subsequent pregnancies and destroy the fetal red cells.
So the first fetus is not affected unless the mother was
previously given an Rh- positive blood transfusion.
Also the second fetus is not affected in most cases
because the amount of antibodies is still small.
The types of antibodies:

There are two types of antibodies:
1. IgM is the primary immune response. It is large

in size thus, does not cross the placenta.
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2. IgG is small in size thus, crosses the placenta in

subsequent pregnancies causing fetal RBCs
destruction and anemia.
The incidence:
Rh incompatibility: is 0.5- 1.5% of all pregnancies
Etiology:
● Incompatible blood transfusion
● Fetal-maternal hemorrhage including:
● Spontaneous and induced abortion, Ectopic
pregnancy
● Antepartum hemorrhage, abruption of placenta
● External fetal version
● Delivery, cesarean section
● Manual removal of placenta
● Invasive techniques: chorionic villus sampling,
amniocentesis, cordocentesis
Clinical types:
There are 3 clinical types according to the severity of
the hemolysis:
(1) Hydrops fetalis: the most severe form

Characterized by generalized edema, hepato-
44
splenomegaly, large placenta and the fetus is usually

born dead due to anemic heart failure
Hydrops fetalis
(2) Icterus gravis neonatorum: the most common

form Characterized by:
- Jaundice develops within 48 hours after delivery
and not at birth.
- Hepatosplenomegaly is present.
- Kernicterus develops if the blood bilirubin exceeds

20 mg%.
- Bilirubin is deposited in the basal ganglia causing
nystagmus & rigidity.
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(3) Congenital hemolytic anaemia: The mildest form

It is characterized by fetus is born anemic and
jaundice occurs in the 1st 2 weeks of life.
Diagnosis:
(1) History:
- Obstetric history of a previously affected child i.e.
jaundice or edematous.
- History of blood transfusion.
(2) ABO group and Rh typing of all pregnant at

first antenatal visit
● If the mother is Rh +ve, no rhesus complication is

present & no further testing is required.
● If the mother is Rh –ve, Rh type of the husband
should be obtained.
● If husband is also Rh –ve, no rhesus complication
is present
● If husband is Rh +ve, go to step 3 in investigation.
(3) Indirect Comb's test: is done to detect previous

sensitization of mother and the presence of
antibodies.
45
● If the result is negative indicating that sensitization

has not occurred and the test should be repeated at
28 wks pregnancy.
● If the result is positive indicating that sensitization
has occurred and the test should be repeated at 4 th
week interval to monitor antibody titre and the
severity of the disease.
(4) Amniocentesis: is done if antibody titer is 1:16
or greater to determine degree of hemolysis and
severity of disease by measuring bilirubin level
in amniotic fluid.
(5) Cordocentesis: is done also to evaluate the
condition and severity of disease by determining
hemoglobin, hematocrit value, blood group &
bilirubin level in fetal blood.
Prevention of Isoimmunization
a) Anti- D serum is given to the Rh- negative mother
provided that the fetus is Rh- positive and the
maternal blood does not contain antibodies (not
immunized). The dose is 300 micrograms given
intramuscular within 72 hours after delivery.
45
b) Some given 300 µg at 28 and 34 weeks of

pregnancy to prevent sensitization during
pregnancy. if there is a risk of feto-maternal
hemorrhage as in case of antepartum hemorrhage,
external cephalic version, amniocentesis and
chronic villus biopsy. However, the woman must
receive another dose after delivery if indicated.
c) The dose is 100µg for first trimester abortion and

300µ for second trimester abortion.
Treatment during pregnancy:

(a) Intrauterine transfusion: Rh -ve group o blood is
used because it does not contain antigens
(b) Induction of labour: To avoid intrauterine death. It

is performed at 32 weeks. Before this time the fetus is
too premature to survive after delivery.
Patient Education:
● Women of reproductive age should be informed of
their blood group and Rh status
45
● Women with Rh negative should be informed about

risks & management issues before becoming
pregnant
● Women should be understand the importance of Rh

immunoglobulin in preventing Rh sensitization.
Management of the Newborn:
- After delivery, the cord is immediately clamped to

avoid further passage of antibodies from the
placenta. The cord is divided 3 inches from the
umbilicus to facilitate exchange transfusion if
indicated.
1- Exchange transfusion: It is indicated if the
unconjugated serum bilirubin reaches a dangerous
level which varies according to the weight of the
newborn.
The aims of the procedure (exchange transfusion)

are;
- Correction of anemia
- Removal of bilirubin
- Removal of antibodies
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2- Phototherapy: It is used to prevent the rise in serum

bilirubin. Blue or blue- green light converts the
insoluble unconjugated bilirubin into a soluble from
which is rapidly excreted in bile and urine without
conjugation in the liver. The eyes are covered to be
protected from light to avoid retinal damage.
44
Episiotomy
Episiotomy
1. Define episiotomy
2. List the indications of episiotomy
3. Identify Types of episiotomy
4. Mention the Advantages of episiotomy
5. Enumerate the complications of episiotomy
6. Describe the Precautions of episiotomy
7. Describe the Technique of episiotomy
8. Mention the advices will be given to woman about
care of herself at home.
9. Provide care and health education to women with
episiotomy.
55
Episiotomy
Out lines: -
1. Definition
2. Indications of episiotomy
3. Types of episiotomy
4. Advantages of episiotomy
5. Complications
6. Precautions
7. Techniques
8. Home care
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Episiotomy
Definition: -
Episiotomy is a surgical incision through the perineum made
to enlarge the introitus and assist childbirth.
Indications of episiotomy: -
A- Maternal indication: -
● In cases of anticipating Perineal tear as in primy
gravida, malposition & malpresentation.
● In cases of rigid perineum to prevent the unavoidable
tears of the perineum.
● In cases of operative vaginal delivery as forceps
&ventous to allow more space for application of forceps.
B- Fetal indication:-
● Premature fetus to protect the premature baby's head
from undue pressure.
● Malposition &malpresentation
● Macrocosmic fetus
Types of episiotomy:-
● Midline episiotomy.
● Mediolateral episiotomy.
● The J- shaped episiotomy
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Episiotomy
Midline episiotomy Mediolateral episiotomy

● Easier surgical repair ● More difficult &time consuming in
repair
● Less postoperative pain ● More postoperative pain
● Less blood loss ● More blood loss
● Dyspareunia is less ● Dyspareunia is more
● Extension are common leading to ● Rare extension and injury
anal injury
Types and techniques of episiotomy
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Episiotomy
c- The J- shaped episiotomy

● Incision is a theoretical compromise which
becomes a posterio lateral incision in practice
The J- shaped episiotomy
Effects on the mother: -

Advantages:
1. An episiotomy may speed up labour by removing the
need to wait for tissues and skin to stretch during
second stage.
2. An episiotomy may be preferable to an uncontrolled
tear if the birth is fast or the tissues are very tight.
Disadvantages:
1. An episiotomy done before the perineal area has fully
stretched will involve cutting much tissue and a
significant blood loss as a consequence.
2. Episiotomies frequently tear further, causing a bigger
wound. If extensive, this tearing can involve the anus
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Episiotomy
and make extensive surgical repair necessary.

Involvement of the anal sphincter can lead to
weakness and problems with incontinence.
3. An episiotomy takes longer to heal and is more painful
than a tear, as muscle tissue is involved in an
episiotomy. Tears usually involve only skin and
superficial tissue, and therefore heal faster.
4. Healing can take months for some women. Sexual
difficulties and general pain and discomfort may be
felt until healing is complete. Further repair work may
be necessary.
5. Having a sore perineum and stitches that require care
can interfere with the ability to take care of a baby in
the first day's post-partum very tight.
Effects on the baby: -
Advantages:
1. Shortens second stage
2. Prevents undue pressure on the head of a
premature baby.
Disadvantages:
1. Sore and tender perineum can make it more
difficult for the mother to care for the baby after
the birth.
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Episiotomy
Complications: -
1. Postpartum pain &dyspareunia.
2. Wound infection.
3. Wound extension causing 3rd degree tear &anal
injury.
4. Narrowing of the introitus.
Instruments that uses in episiotomy:-
Needles, Needle holder, scissor, Artery, forceps syringe
10ml, perineal pad, mask, gloves, hand towel, Gauze and
anti-septic solutions.
Precautions: -
● To avoid extension of episiotomy the head advance
must be immediately controlled in order.
● If there is any delay before the head emerges pressure
must be applied to the episiotomy site between
contractions in order to minimize bleeding.
● Postpartum hemorrhage can occur from an episiotomy
site unless bleeding points are compressed
Techniques: -
● Ask the mother to lay on the delivery table in dorsal
recumbent position when the fatal head is distending
the perineum and clean the perineum with antiseptic
lotion.
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Episiotomy
● Infiltrate the perineum using 10ml lignocaine &wait

for3-5 min for anesthetic to act.
● Place the index &middle finger in the vagina with
palmer side down& facing the nurse separate them
slightly & exert out ward pressure on the perianal
body.
● places the blades of the scissor in as straight up &
down position to adjust the length of the blades on the
perianal body and cut during
● In mediolateral episiotomy cut 3-4 cm in mediolateral
direction.
● In Midline episiotomy cut 2-3cm from the posterior
fourchette down to external anal sphincter.
Repair of episiotomy
● Apply antiseptic solution to the area around the
episiotomy.
● If the episiotomy is extended through the anal
sphincter or rectal mucosa, manage as third or fourth

degree tears, respectively.
● Close the vaginal mucosa using continuous 2-0 suture
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Episiotomy
● Start the repair about 1 cm above the apex (top) of the

episiotomy. Continue the suture to the level of the
vaginal opening;
● At the opening of the vagina, bring together the cut
edges of the vaginal opening;
● Bring the needle under the vaginal opening and out
through the incision and tie.
● Close the perineal muscle using interrupted 2-0 sutures
● Close the skin using interrupted (or subcuticular) 2-0
sutures
Note:
It is important that absorbable sutures be used for
closure. Polyglycolic sutures are preferred over
chromic catgut for their tensile strength, non-
allergenic properties and lower probability of
infectious complications and episiotomy breakdown.
Chromic catgut is an acceptable alternative, but is not
ideal.
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Episiotomy
Home care:
▪ Keeping the area clean is the key to preventing
infection and to helping speed healing. The stitches will
dissolve after a period of time and do not need to be
removed.
▪ To help heal an episiotomy, a woman should:
▪ Take sitz baths or sit in a tub of warm water a few times
a day. Wash the area gently with a stream of water after
using the bathroom.
▪ Relieve pain and swelling with Tucks pads and ice
packs. Sitting on an inflatable donut helps, too.
▪ Avoid constipation to keep this tender tissue from
stretching too much. Take stool softeners, such as
docusate, and drink 8 to 10 glasses of fluids each day.
▪ Use over-the-counter pain relievers, such as
acetaminophen or ibuprofen, as needed.
▪ Avoid sexual intercourse for 6 weeks after the birth.
▪ A woman should see her doctor for follow-up visits to
check on how the episiotomy is healing.
64
Oxytocic Drugs
Oxytocin (Pitocin) Drugs

1- Define oxytocin drugs.

2- Describe the action of drugs.
3- Enumerate he indications of oxytocin drugs.
4- Mention the dosage and administration of drugs.
5- Explain the monitoring of drugs.
6- List the side effect of drugs.
7- Demonstrate the effect of over dose of drugs.
8- Mention the nursing role during administration of
drug.
65
Oxytocic Drugs
Oxytocin (Pitocin) Drugs

Outlines:-
1. Definition
2. Drug description
3. Action
4. Indication
5. Dosage and administration
6. Monitoring
7. Contraindications
8. Side effect
9. Over dose effect
10.Nursing considerations
66
Oxytocic Drugs
Brand Names: Pitocin, Syntocinon
Generic Name: oxytocin
Oxytocin: is considered one of ecobolic group which is
the opposite of tocolytic group.
Oxytocin (Pitocin): Oxytocin is a natural hormone that

causes the uterus to contract which produced in
hypothalamus and stored in the posterior lobe of the
pituitary gland.
Oxytocic drugs: are the drugs that have the power to
excite contractions of the uterine muscles ..
preparations: synthetic oxytocin available for parental
use includes:-
● Pitocin: 5 units /ml in ampules of 1 ml.
● syntomerine: a combination of syntocinon 5 units
and ergometrine 0.5 mg.
● oxytocin nasal: solutions 40 units /ml.
Actions:-
A- Uterine action:-
Oxytocin can increase the force and duration of
uterine contraction.
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Oxytocic Drugs
B- Milk actions:-
Oxytocin cause epithelium of the lacteal gland to
contract which results in milk ejection in lactating
women
Indications:-
1) In pregnancy
 Induce abortion (inevitable ,missed
abortion).
 To expedite expulsion of vesicular mole.
 To stop bleeding following evacuation .
 To induce labor .
2) In labor
 To augment labour in cases of uterine
inertia.
 To prevent and treat postpartum
hemorrhage.
3) Postpartum
 To initiate milk let-down in breast

engorgement.
Dosage and administration
68
Oxytocic Drugs
 Parenteral drug products should be inspected
visually for particulate matter and
discoloration prior to administration.
 The dosage of oxytocin is determined by the
uterine response and must therefore be
individualized and initiated at a very low level.
The following dosage information is based
upon various regimens and indications in
general use.
a) Stimulation of Labor
Intravenous infusion (drip method) is the only
acceptable method of parenteral administration of
Pitocin (oxytocin injection) for the induction or
stimulation of labor. Accurate control of the rate of
infusion is essential and is best accomplished by an
infusion pump. The initial dose should be 0.5-1 mu/min
(equal to 3-6 mL of the dilute oxytocin solution per
hour). At 30-60 minute intervals the dose should be
gradually increased in increments.
Monitoring
a. Electronically monitor the uterine activity and the
fetal heart rate throughout the infusion of Pitocin
69
Oxytocic Drugs
(oxytocin injection). Attention should be given to
tonus, amplitude and frequency of contractions, and
to the fetal heart rate in relation to uterine
contractions.
b. Discontinue the infusion of Pitocin (oxytocin
injection) immediately in the event of uterine
hyperactivity and/or fetal distress. Administer
oxygen to the mother, who preferably should be put
in a lateral position. The condition of mother and
fetus should immediately be evaluated by the
responsible physician and appropriate steps taken.
b) Control of Postpartum Uterine Bleeding

1. Intravenous infusion (drip method). If the patient has
an intravenous infusion running, 10 to 40 units of
oxytocin may be added to the bottle, depending on
the amount of electrolyte or dextrose solution
remaining (maximum 40 units to 1000 mL). Adjust
the infusion rate to sustain uterine contraction and
control uterine atony.
2. Intramuscular administration, (One mL) Ten (10)
units of Pitocin (oxytocin injection) can be given
after the delivery of the placenta.
70
Oxytocic Drugs
Warning
Pitocin (oxytocin injection), when given for induction of
labor or augmentation of uterine activity, should be
administered only by the intravenous infusion and with
adequate medical supervision in a hospital.
Contraindications
1. In late pregnancy
▪ Grand multi Para
▪ Contracted pelvis
▪ History of C.S or hysterectomy
▪ Mal presentation
2. During labor
 Grand multi Para
 Contracted pelvis
 History of C.S or hysterectomy
 Mal presentation.
 Abstracted labour.
 In coordinate uterine inertia.
3. Any time
▪ Hypovolemic state .
▪ Cardiac disease.
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Oxytocic Drugs
Side effects:-
1. Hypertonic uterine activity
2. Fetal distress & fetal death
3. Uterine rupture
4. Hypotension
5. Water retention and water intoxication
6. Neonatal jaundice
Over dose
Over dosage with oxytocin depends essentially on
uterine hyperactivity whether or not due to
hypersensitivity to this agent. Hyper stimulation with
strong (hypertonic) or prolonged (tetanic) contractions,
or a resting tone of 15 to 20 mm H20 or more between
contractions can lead to:
● Uterine rupture
● Cervical and vaginal lacerations.
● Postpartum hemorrhage.
● Uteroplacental hypo perfusion.
● Variable deceleration of fetal heart, fetal hypoxia.
● Perinatal hepatic necrosis or death.
● Water intoxication with convulsions, which is
caused by the inherent antidiuretic effect of
72
Oxytocic Drugs
oxytocin, is a serious complication that may occur if
large doses (40 to 50 mill units /minute) are infused
for long periods.
● Management consists of immediate discontinuation
of oxytocin and symptomatic and supportive
therapy.
Dosage and routs of administration

● Controlled intravenous infusion (10 units of oxytocin
in 1Liter ringer lactate or 5% dextrose in water ).
● Nasal spray for milk let-down.
Nursing considerations
1) Assess intake and output rate &uterine contractions
& fetal heart rate &Bp,pulse and respiration .
2) Administer by IV infusion
3) Evaluate length and duration of contractions& notify
physician of contraction lasting over 1 minute or
absence of contractions.
4) Teach client & family to report increased blood loss,
abdominal cramps or increased temperature.
73
Placenta
The Placenta
1. Define of the placenta

2. Explain The functions of the placenta
3. Identify the abnormalities of the placenta
4. Recognize the structure of the umbilical cord.
5. Evaluate Abnormalities of the cord.
74
Placenta
Out line
1. Introduction
2. Definition of the placenta
3. The placenta at term
4. The functions of the placenta
5. Abnormalities of the placenta
o Abnormalities in shape
o Abnormalities in adhesion and position
6. The structure of the umbilical cord.
o Abnormalities of the cord.
75
Placenta
Introduction
The placenta is a remarkable organ .originating from
the trophoblastic layers of the fertilized ovum itself. It
links closely with the mother's circulation to carry out
functions which the fetus is unable to perform for itself
during intra – uterine life. The survival of the fetus
depends up on its integrity and efficiency.
Definition of the placenta
Flat organ measuring 17.5 – 20 cm in diameter and 2.5
in thickness it weight approximately one-sixth of the
body birth weight at full term, it’s formed by the 12 th
weeks of the pregnancy and its function to transmit
oxygen and nutrients to the baby and act as barrier to
some infection
Characters of placenta:-
It’s completely formed and functioning at 10-20 weeks
of gestation
A. Character
1- Shape Flatted disk shape
2- Weight about 500 mg
3- Diameter 20 cm
76
Placenta
4- Thickness 2.5 cm at center

5- Position upper uterine segment
B. Structure of placenta
1- Maternal surface
2- Fetal surface
3- The fetal sac
● Outer membrane ( chorion )

● Inner membrane ( amnion )
Structure of placenta
77
Placenta
Functions of the placenta

1- Respiration: O2 & CO2 pass across the placenta .
2- Nutrition: placenta responsible for transfer of
nutrients from the mother to the fetus .
3- Excretion: waste products of the fetus as urea are
passed to maternal blood across the placenta.
4- Protection: placenta provide limited barrier to
infection.
5- Storage: placenta can store glucose ,iron, and fat
soluble vitamins.
6- Endocrine:
● HCG produced by the trophoblastic layer its function
to stimulate the growth and activity of the corpus
luteum.
● Estrogen secreted in large amount through
pregnancy
● As the activity of the corpus luteum decline the
placenta takes over production of estrogen.
● Progesterone this made in the syncytial layer of
placenta before the onset of labor when it’s level
falls.
78
Placenta
● The human placental lactogen (H.P.L) has an a role

in glucose metabolism in pregnancy.
Abnormalities of the placenta:

1- Abnormalities in the shape of the placenta
2- Abnormal adhesion of the placenta
3- Abnormal position of the placenta
1- Abnormalities in the shape of the placenta:
1. Succenturate lobe of placenta
2. Circumvallate placenta
3. Battledore insertion of cord ( abnormalities of the
cord)
4. Voluminous insertion of cord( abnormalities of
the cord)
5. Bipartite placenta
6. Tripartite placenta
1- Succenturate lobe of placenta:
It is a small extra lobe separate from the main placenta
& joined it by blood vessels which run through the
membranes to reach it the danger is that this small lobe
may be retained in uterus after delivery & it may lead to
infection & hemorrhage.
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Placenta
Succenturate lobe of placenta
2- Circumvallates placenta:
An opaque ring is seen on the fetal surface formed by

doubling back of the chorion &amnion & may result in
the membranes leaving the placenta nearer the center of
the edge as usual
Circumvallates placenta
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Placenta
3- Battledore insertion of the cord:
The cord is very attached at the very edge of the

placenta in the manner of a table tennis bat.
Battledore insertion of the cord:
4- Vaelamentous insertion of the cord:

The cord in this case is inserted into the membranes
some distance from the edge of the placenta. The
umbilical vessels turn through the membranes from
the cord to the placenta. If placenta normally situated
no harm will result to the fetus.
Vaelamentous insertion of the cord
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Placenta
5- Bipartite placenta:
Two complete & separate lobes each with a cord
leaving it the bipartite cord join a short distance from
the two parts of the placenta & this is different from
the two placenta in twin pregnancy.
Bipartite placenta
6- Tripartite placenta:
It is similar to bipartite placenta but with three distinct
lobes.
2- Abnormal adhesion of the placenta:
1- Placenta Accreta
Occurs when the placenta attaches too deep in the
uterine wall but it does not penetrate the uterine
muscle. Placenta accreta is the most common
accounting for approximately 75% of all cases.
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Placenta
2- Placenta Increate
Occurs when the placenta attaches even deeper into the
uterine wall and does penetrate into the uterine muscle.
Placenta increate accounts for approximately 15% of
all cases.
3- Placenta Percreta
Occurs when the placenta penetrates through the entire
uterine wall and attaches to another organ such as the
bladder. Placenta percreta is the least common of the
three conditions accounting for approximately 5% of all
cases.
Dangers:
Abnormal adherent to uterine wall may lead to Delay
separation or post-partum hemorrhage.
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Placenta
Abnormal adhesion of the placenta
3- Abnormal position of the placenta

1- Placenta previa
2- Ectopic if planted in F.T(fallopian tube)
1- Placenta previa
Placenta is partially or completely implanted in the
lower uterine segment on either anterior or posterior
wall
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Placenta
Placenta previa
Degree of placenta previa

● Type 1 placenta previa
Structure of umbilical cord
● The umbilical cord extends from the fetus to the
placenta and transmits the umbilical blood
vessels, two arteries and veins.
● These are closed and protected by Wharton’s
jelly” gelatinous substance “ formed from
mesoderm.
Length
The length of the cord about 50 cm
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Placenta
Thickness
The thickness of the card about 2 cm
Abnormal length of umbilical cord
1- Short umbilical cord
Cord is considered short when measure less than 40
cm danger may cause clearly descent of head,
difficult labor, intrapartum Hemorrhage, and
premature separation of placenta
2- Long cord :-
Disadvantage of long cord may become wrapped
round the neck or body of may result in occlusion of
the blood vessels especially during labor.
Long cord
3- Torsion of the cord
It occurs the especial in the part near the fetus when
the Wharton’s Jelly is less abundant.
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Placenta
4- Single umbilical artery

It’s present and associated with other congenital
anomalies of the fetus.
5- Knotes
1-False 2-True
1- False Knote:
Localized collection of the Wharton’s Jelly containing
lob of umbilical vessel
2- True Knote
Occur when the fetus pass through a lob by
abnormality long cord. If light asphyxia result from
interference of circulation
87
Cesarean section
Cesarean section (C.S)
1. Define Caesarean section

2. List the indications of Caesarean section
3. Identify the timing of the operation
4. Mention the type of Caesarean section
5. Enumerates the complications of caesarean
section
6. Describe the labour following Caesarean section
7. List the indications of Caesarean hysterectomy
8. Mention the possible number of C. section
9. Discuss the nursing care before, during and after
C-section
10. Mention the advice will be given to woman
about care of herself at home.
88
Cesarean section
Outlines:-
1. History
2. Definition
3. Incidence
4. Indications:
5. Maternal indications
6. Fetal indications
7. Timing of the operation
8. Types of C. sections and Indications
9. Indications of caesarean hysterectomy
10.Complications
11.Labor following Caesarean section
12.Nursing care
88
Cesarean section
Caesarean section (C.S)
Historical:
Contrary to popular myth, caesarean section has nothing

to do with the birth of Julius Caesar. It is believed to
have originated from an ancient Roman law.
Definition:
Delivery of the viable fetus (28weeks) through an

abdominal and uterine incision
Incidence:
In Egypt, CS rates are alarmingly high, accounting for

52% of all deliveries.
The incidence varies from country to country and from

region to region and even from hospital to hospital
within a region. There has been an increase in C. section
rate over time, particularly in North America.
Indications:-
Maternal indications:
 Previous C.S.
 Previous two or more lower segment C. section
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Cesarean section
 Previous one classical C. section
 Contracted pelvis.
 Ante partum Hge:- placenta previa or
accidental hge. (Placental causes)
 Hypertensive states of pregnancy.
 Abnormal uterine action as cervical dystocia
(no dilatation of the cervix)
 Pelvic tumors
 Elderly primigravida (over 35 years).
 Multiple pregnancies.
 Previous vaginal repair which may be
disrupted by vaginal delivery
Fetal indications:-
 Macrocosmic baby
 Fetal distress in the first stage
 Malposition and malpresentation of the
fetus
 Rh isoimmunization
 Post maturity if the condition isn't
favorable for induction
 Repeated intrauterine fetal death
 Severe IUGR (small for gestational age)
89
Cesarean section
Timing of the operation:-
1 - Elective C. sections:
C. sections before the onset of labour
2 -Emergency C. Sections:
The operation is done after the onset of labor for

suspected foetal compromise, failure to progress, ante
partum hemorrhage and PIH.
Types of C. sections
1- The upper segment or Classical C. Sections
Paramedian incision 1/3 above and 2/3 below the

umbilicus in the upper uterine segment (opening in
upper uterine segment)
89
Cesarean section
2- Lower Segment C.S.
Transverse or vertical incision in the lower uterine

segment (Opening the lower uterine segment)
 lower vertical C.S

 lower transverse C.S
Risks and possible complications for C.S include:

1 -Infection of the mother's wounds
2-Damage to the mother's bladder and other internal

organs
3-Damage to the mother's blood vessels
4-Damage to the baby inflicted by surgical instruments
5- Increased risk of the baby experiencing respiratory

distress.
6- Rupture scare in subsequent pregnancy or labor.
Labor following C.S:
The old rule “once caesarean always caesarean”

changed to "once caesarean always hospital delivery”.
If vaginal delivery is allowed continuous electronic fetal
monitoring is indicated.
89
Cesarean section
Possible number of C.S (sterilization during C.S.):
No limit, but usually sterilization is done during the 4th

or 5th C.S or medical indication.
Caesarean hysterectomy
Definition
Caesarean hysterectomy is surgical removal of uterus
during Caesarean section.
Indications of caesarean hysterectomy:
1-Uncontrolled P.P.hge
2- Concealed accidental hge.
3-Un repairable ruptures.
4- Severe intrauterine infection
5- Multiple uterine leiomyoma.
Nursing care:
 If a woman has a spinal anesthetic. Once it is

certain that the baby is all right, the mother and
child can cuddle for the first time.
89
Cesarean section
 If a woman has a general anesthetic, she should
be able to see her baby once she regains
consciousness.
 Intravenous drip for the first 24 hours
 Catheter inserted to drain urine from her bladder
so there will be no need to get out of bed to go to
the toilet.
 There may also be a tube to drain fluid from the
wound.
 Antibiotics and painkillers are usually prescribed
 A woman can start drinking fluids as soon as she
feels able, although she must pass wind before
she can start eating again.
 Within about eight to 12 hours after surgery, a
woman should get out of bed and attempt to walk
around, as movement soon after the procedure
speeds up recovery and helps to prevent certain
complications.
Taking care at home

General self-care suggestions include:
 Much rest as you can for the first few days
 Avoid walking up and down stairs
89
Cesarean section
 Take a gentle walk every day to reduce the risk of
blood clots.
 Eat a healthy diet and drink plenty of water every
day.
 Warmth on the wound (such as using a heating
pad) may be soothing. Be guided by your doctor
89
Gynecological Instruments
Gynecological instruments
1- Describe the shape of the instruments

2- Identify the function of the instruments
3- Enumerate how to use instruments.
4- Use each instrument correctly.
5- Select the suitable instrument for procedurs.
97
Instruments:-
1. Sims's speculum
2. Cusco's speculum
3. Ferguson's speculum
4. Auvard's speculum
5. Vulsellum forceps
6. Hegar's dilator
7. Uterine curettes
8. Ovum forceps
9. Uterine sound
10. Female bladder sound
11.Ayre's spatula
98
1- Sims's speculum
Shape: - One blade is larger than the other
Usage:-
It used to expose the posterior vaginal wall and
expose the cervix by lubricated and passed it along
the posterior vaginal wall.
Position of the mother:-
The women should be in left lateral position.
2- Cusco's speculum
Usage:-
To separate the anterior and posterior wall of vagina
It is rotated and then opened it into the vagina.
The women should be in a dorsal position.
99
3- Ferguson's speculum :
Shape: It is a metal tube with different sizes.
Usage: Used to obtain a sterile or uncontaminated
smear swab from high vagina (post. vaginal wall).
The patient should be in the left lateral position.
4- Auvard's speculum
Shape: Is a weighted vaginal retractor
Usage: It is only used in the operating room when
the patient is anaesthetized. used to retract and hold
the posterior vaginal wall without need for assistant
in operations as D&C.
The patient is in the lithotomy position.
100
5-Vulsellum forceps
Shape: have large teeth.
Usage: it can grasp the cervix to visualize the cervix
and allow passage of some instrument through the
cervical canal during procedure as in D&C and IUD
insertion.
The patient is in the dorsal position.
6- Hegar's dilator:
Shape: - May be single or double -ended and consist of
a set of progressive sizes .one number is written on its
base to indicate the diameter in millimeters.
Usage: They are passed through the cervical canal in
turn in order to dilate it.

101
7- Uterine curettes
Shape: may have a sharp or blunt end may be double or
flushing - ended the flushing curette allow for irrigation
at the same time.
Usage: It passed into the uterus to scrape a specimen
-Remove endometrial tissue from uterus.
8-Ovum forceps
Shape: Its shape like two spoons
Usage: used to grasp, hold ,manipulate and remove the
tissue from inside the uterus including ovum and
placenta as
102
● removing products of conception from the uterus

in incomplete abortion
● removing any retained placental fragments from
the uterus after delivery.
● Position of the mother:-
the patient is in the lithotomy position.
9-Uterine sound
Shape: It is along thin instrument with graduation.
Usage: used to note the position of uterus and to
measure the length of uterus as in IUD insertion.
The patient is in the dorsal position.
103
10-Ayre's spatula
Shape: It is wooden spatula with two ended : the broad
end is for vaginal sample collection and the narrow end
is for cervical sample collection.
Usage: It is used to collect pap smear for screening
of cervical carcinoma.
104
Gynecological Investigations
Gynecological investigations
1. Identify the procedure, indication and

contraindications of cervical smear.
2. Explain the technique, indication,
contraindications of hystrosalpigography.
3. Identify the procedure, indication and
complications of laparoscopy.
4. Identify the procedure, indication of
hysteroscopy.
5. Identify the procedure, indication of ultrasound.
6. Manage women to pre and post-operative
procedure to avoid any complications.
7. Apply problem solving techniques regarding the
indications and contraindications for every
producer.
8. Provide health education for care of women after
every procedure
501
Gynecological investigation
Out line: -
1. Cervical smear
2. Dilatation and curettage
3. Hystrosalpigography
4. Laparoscopy
5. Hysteroscopy
501
1- Cervical smear:-
Indications:
● Infection e.g. candidiasis, Chlamydia.
● Atrophy
● Metaplastic cells
● Cervical polyps
● Follow up for treatment
● Abnormal vaginal bleeding
Procedure:-
● A vaginal speculum is used to visualize the
whole cervix
● Appropriate spatula are used to wipe cells
● The cells are transferred to a slide and fixed
Contraindications:
● Menstruating
● Pregnant
● Less than 12 weeks post-partum
2- Dilatation and curettage
A dilatation and curettage (D&C) is an operation
performed on women to scrape away the uterus
lining. The cervix of the uterus is dilated using an
501
instrument called a dilator. The endometrium is then

lightly scraped off using a curette.
Indication for D&C
Obtaining an endometrial biopsy
▪ Suspicion of uterine cancer
▪ A history of abnormal menstrual bleeding.
▪ Polyps .
▪ Uterine infection
● Dysmenorrhea
● Incomplete abortion (miscarriage)
● Surgical abortion
● Heavy bleeding after childbirth
● For termination of pregnancy before the twelfth
week (12 wks.).
Procedures:
● D&C is regarded as a relatively minor operation
and can be done as day surgery but a general
anesthetic is usually given. The typical D&C
procedure includes:
● Advised to have nothing to eat or drink for at least
six to eight hours before the surgery.
501
● Given an injection an hour before your operation to

make feeling drowsy.
● After that uterus is examined to determine its size
and position.
● The walls of the vagina are held apart by an
instrument called a speculum .
● Dilators are introduced into the cervix, one at a
time, to gently widen the cervix to the right
diameter.
● The curette is inserted through the dilated cervix
and into the uterus.
● The endometrium is scraped off using the curette.
● What happens next depends on the condition,
tissues sample send to lab for investigations.
Role of the nurse
● Nurses record vital signs such as temperature, pulse
and blood pressure.
● Good observation for any vaginal bleeding.
● Getting out of bed within a few hours and often are
allowed home four to six hours after the operation
if there is no vaginal bleeding.
Complications:
501
● Allergic reactions to the general anesthesia

● Cervical damage due to dilation or the passage of
instruments
● vaginal bleeding
● Infection of the uterus or other pelvic organs
● Scar tissue within the uterus, if the scraping was
too vigorous
● Puncture of the uterus.
3- Hysterosalpingography
Visualization of the uterus tube and pelvic
peritoneum by transcervical intra-uterine injection of
a radio-opaque dyes.
Indication
A- Infertility evaluation
1- Tubal Factors: tubal abnormality, salpingitis,
2- Peritoneal adhesion
3- Uterine Factors:- polyp, sub mucous myoma
B- Post- operative evaluation of previous tubal or
uterine surgery
1- Tuboplasty
2- Confirmation of tubal sterilization
C- Evaluation of menstrual abnormalities
550
D- Evaluation of recurrent abortion

E- Evaluation of known or suspected uterine
anomaly and incompetent cervix.
F- Localization of a missing intra uterine device
Technique of Hysterosalpingography:-
A- Time:-
▪ HSG should be only done during the 5 days
following the end of menstruation.
B- Procedure:-
1. Careful History taking should precede the
procedure to ensure proper timing and absence of
contra indication ensure proper timing and
absence of contra indications.
2. Careful aseptic technique should be observed.
3. Bimanual pelvic examination should precede the
procedure.
4. The external os is wiped repeatedly by antiseptic
solution.
5. Generally a canola with cone which fixed to the
cervix is
6. About 2 to 20 ml of radio opaque dye depending
on the size of the uterus
555
7. Film is usually taken after removal of the cannula

to document the adequacy of the spell and
spreading of dye in the pelvic cavity this is done
within 20 to 30 minutes after injection of an dye .
8. Prophylactic antibiotics is given if there was
dilated fallopian tube with or without or
obstruction.
Complications:
1. Collapse in some unanesthetized women
2. Allergic reaction to iodine in the dye.
3. Embolism can occur in 1% of cases
4. Peritoneal reaction and salpingitis
Contra indications:-
1. During any bleeding episode
2. Late in the menstrual cycle when pregnancy is
possible
3. History Suggestive of pelvic tuberculosis
4. Allergic reaction to iodine in the dye.
4- Laparoscopy:-
It is an endoscopic procedure where the
laparoscope is introduced at the umbilicus into
551
the peritoneal cavity to visualize pelvic organs

for diagnosis and therapy.
Indications:-
A) Diagnostic indication:-
● Evaluation of infertility cases.
● Ectopic pregnancy
● Pelvic mass
● Endometriosis
● A menorrhea
● To obtain biopsies for culture media
● Congenital pelvic anomalies
B) Therapeutic indication:-
● Tubal sterilization
● Pelvic adhesiolysis and management of
tubal obstruction
● Treatment of polycystic ovary syndrome
● Removal of perforated IUDs
● Myomectomy
● Ovarian cyst
● Ectopic pregnancy
551
Procedures:-
It is performed under general anesthesia with the
patient in the recumbent position. The bladder
catheterized and a one centimeter incision made just
below or at the level of the umbilicus. A
pnemoperitoneum needle connected to an automatic
pressure regulator is then introduced through the
incision into the peritoneal cavity. Carbon dioxide
gas is introduced via the needle to induce adequate
abdominal distension, then the needle withdrawn and
replaced by a trocar.
Complications:-
● Anesthetic complication
● Failed introduction
● Stomach, bowel or pelvic injury
● Vascular injury
● Hematomas of abdominal wall.
● Cauterization injury of abdominal organs
● Infection.
5- Hysteroscopy
A hysteroscopy is a procedure used to look inside
the uterus. A thin instrument called a hysteroscopy
551
is passed through the vagina and cervix into the

uterus to help doctor find the cause of a possible
problem.
Indications:-
● Abnormal vaginal bleeding
● Irregular cycles
● Severe abdominal cramping
● Frequent miscarriages
● A displaced intrauterine device (IUD)
● Infertility
Nurse's Role
If you are having the operation done while you are
under general anesthetic:
● Shower or bathe the night or morning before the
operation.
● Do not eat or drink after midnight.
● Once inside, a gas or a liquid is usually inserted
through the hysteroscopy to expand the uterus.
● The doctor will then carefully look at the inside of
the uterus, searching for the source of your problem.
If there are any abnormal findings, the doctor may
remove a small sample for further examination.
551
References:
 Anon (2017). Women’s experiences of maternity care

show mixed picture. [News release], 17 November.
Oxford: Oxford University Press.
 Baker SR, Choi PYL, Hens haw CA et al (2015). ‘I felt
as though I’d been in jail’: women’s experiences of
maternity care during labour, delivery and the immediate
postpartum. Feminism & Psychology 15(3):315-42.
 Bennett VR, Brown LK (2014). The fetus. In: Fraser DM,
Cooper MA eds. Myles textbook for midwives. 15th ed.
Edinburgh: Churchill Livingstone: 156-63.
 Chapman V and Charles C (2019): The midwife's
labour and birth handbook, second edition.
 Cunningham FG, Levino KJ, Bloom SL et al eds (2018).

Williams's obstetrics. 22nd ed. New York: McGraw-Hill:
95-7.
 Fraser MD & Cooper AM (2019): Myles Text
Book For Midwives. Chapter 14, pages 214-216,
15thed. Elsevier Limited.
 Oats J and Abraham S (2015): Fundamentals of
obstetrics and gynecology, 8th edition, Elseiver.
111
 Perry S E, Cashion K and Lowdermilk D L
(2017): maternity and women health care, 9th
edition, mosby.
 The Royal College of Obstetricians and
Gynaecologists (RCOG),2021.
111

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seminars

Third Year Nursing Students

Teaching Staff Members

‫رسالة القسم ‪:‬‬

1 Fetal Skull 1-11

2 Fetal Circulation 12-24

3 Fetal Surveillance 25-37

4 Hyperemesis gravidarum 38-43

5 Rhesus-Iso immunization (Rh) 44-54

7 Oxytocin (Pitocin) Drugs 65-73

8 The Placenta 74-87

9 Cesarean section (C.S) 88-96

10 Gynecological instruments 97-104

11 Gynecological investigations 105-115

1. Identify the function of the Fetal skull

⮚ Bones of the vault of the skull consists of five main

Bones of the vault of the skull

Bones of the vault of the skull

4. Lambdoidal suture: lies between parietal bones and the

Fontanels of fetal skull

Diameters of the fetal skull

⮚ Diameters of the fetal skull:

● Overlapping of the skull bones occurs resulting in a

excessive, Once the baby’s head is born, the moulding

By the end of this lesson, the student will be

1. Describe the shunts involved in fetal circulation.

Definition of fetal circulation:

-Fetal circulation consequently differs from the adult

Three shunts in the fetal circulation:

Blood Flow: (Mechanism of Action)

 Exchange of gases occurs in the placenta. The umbilical

 The inferior vena cava now contains a mixed

the placenta and deoxygenated blood coming

 After the blood passing from the left atrium

 The deoxygenated blood returning from the

 The descending aorta supplies branches to the

Flow Chart of Fetal Circulation

Adaptation to extra uterine life (changes occur after

circumstances. later they become permanent and

-Carries non-oxygenated -Carries oxygenated blood back

-Increase pressure -Increase pressure on the right

By the end of this lesson, the student will be able to:

1. Identify the important of fetal surveillance.

3-Daily fetal movement count (DFMC) (Kick count)

4- Biophysical profile (BPP)

6-Chorionic villous sampling:

More Accurate, More Comfortable, Less Intervention

Telemetry is an electronic fetal monitor without wires. It

Hyperemesis gravidarum (vomiting of pregnancy)

By the end of this lesson, the student will be able to:

1- Define the hyperemesis gravidarum.

Hyperemesis gravidarum (HG) is excessive, persistent

Morning sickness some degree of nausea with or without

❖ Etiology of Hyperemesis Gravidarum or

The absolute cause is still unknown. There are many

May also be operative since large amounts of

❖ Risk factors for Hyperemesis Gravidarum

1- Previous pregnancies with hyperemesis

1- Pernicious vomiting (anything taken orally is

1. Mild hyperemesis gravidarum: when there is loss

2. Moderate hyperemesis gravidarum: when there is

3. Severe hyperemesis gravidarum: when there is

Complications of hyperemesis gravidarum:

● Hospitalization & IV fluids in case of hypovolemia