By: NTN- 2020

Midwifery Nursing Science I

Compiled by: NT Ndjuluwa

Midwifery Nursing Science Tutor: Oniipa Campus-2020

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Unit 1: Introduction to Midwifery/overview

Define related concepts:

• Midwifery
• Midwife/Accoucher
• Community Midwifery
• Traditional Birth Attendant (TBA)
Discuss the History of Midwifery under:
 Midwifery History in Namibia pre-independence
 Midwifery History in Namibia post-independence
 The scope of practice of enrolled midwife accoucher
 Negligence
 Standard of nursing care
 Ethical framework:
 Confidentiality
 Right to privacy
 Right to information
 Informed consent

Introduction to Midwifery Nursing Science

• Midwifery Nursing Science is one of the three major field of nursing for the enrolled
nurse/midwife/accoucher training programme, of which there are four major
subjects.
• Midwifery is one of the oldest known professions in the world
• Midwifery preceded the medical and nursing professions
• Midwives were the only caregivers for women in child birth

What is Midwifery?

• Is a field of study where the midwife is trained to offer a comprehensive service to

women and families
• From before pregnancy to the end of the postnatal period
• Continues with the immunization program and the general care of the child until
school age

What is a midwife?

• A person who has been regularly admitted to a midwifery educational program,

duly recognized in the jurisdiction in which it is located
• Has successfully completed the prescribed course of studies in midwifery and
has acquired the requisite qualifications to be registered and/ or legally
licensed to practice midwifery
( Sellers volume I, 1993: xxxiii )

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What is a Traditional birth attendant? (TBA)

• Is a person without midwifery training and has learnt the art of assisting the
birth process from personal experience, or relatives, or neighbor or from known
TBA’s in the community
Midwifery subject for the EN/M/A program

• It has two components namely: Theory and Practice

• To pass the subject the Pupil enrolled nurse midwife PEN/M must meet
requirements in both theory and practice
The history of midwifery in Namibia pre-independence
Work of the Missionaries
• In January 1903 Catholic priests moved into the Kavango as far as Andara
• In 1907 a Catholic mission established a small hospital at Gobabis, which also
provided midwifery services
• At Swakopmund a number of sisters from the Fransiscan order took over the
health care of the community
Work of the Missionaries…
• They established a midwifery unit, the Antonius hospital at Swakopmund,
which they placed in charge of a trained midwife from Germany
• Germany had very strict regulations for the training and regulation of
midwives
• It was the first country in the world to introduce such legislation (Van Dyk,
1997:20)
• On 14 December 1908 Dr. Selma Rainio, a Finnish doctor arrived at Oniipa
• The work of Dr. Selma Rainio led to the extension of the Mission services
• Between 1908 and 1909 further mission stations with health care facilities were
established at Elim, Okahao and Tsandi
• By 1910 midwives were appointed in several districts and had to serve as
community nurses
• Due to the heavy work load of doctors and nurses some indigenous men and women
who had received elementary schooling at the missions, were given in-service
preparation as health attendants
• On 9 July 1911, the first proper hospital was opened in Owambo land, the well
known Onandjokwe hospital
• Onandjokwe hospital provided the first organized midwifery services in Owambo
land, it played a major role in the training of midwives (Van Dyk:21)

Problem of unqualified midwives and regulation of midwifery by law

- The quality of the midwifery services provided by the “folk-midwives of both

the indigenous and the settler communities caused a great concern
- The authorities endeavored to ensure that midwifery was practiced by certified
persons
th
- Early in the 20 century an effort was made to regulate the practice of
midwifery

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History of midwifery in Namibia post independence

st
- On 21 March 1990, Namibia gained its independence
- The new government of Namibia issued a policy statement which recognized
health as a fundamental human right
- It committed itself to the WHO target of Health for All by the year 2000 and
beyond
- The main goal of this policy is the equitable provision of health services with
primary health care as the focal point for all health care services
- The new health care policy meant that there had to be a complete re-orientation to
the concept of primary health care and community-based care

- In addition, plans have to be formulated for slotting medical missions, non-

governmental organizations and the private sector into the overall national health
plan

- Provision of counseling, advice and care during pregnancy, delivery and puerperium

- Keep simple records of the care given

- Promotion of other health related matter e.g. family planning, immunization and
breast feeding

- Provide first aid in emergencies which may occur in pregnancy, labor and
puerperium for both mother and baby

- Assist with the identification of families at risk, e.g. acute or chronic illness,
alcoholism, childhood handicapped and marital problems

Collaboration between midwives/ accouchers and TBA’s

- Midwives train TBA’s regarding clean and safe home deliveries and
notification of births
- Train them in primary health care (PHC) activities
- Midwives recognize TBA’s by appreciating their work
- Give support to TBA’s through support visits and trainings
- Involve TBA’s in community based activities such as Expanded program on
immunization (EPI)
- Assist TBA’s to get identification e.g. badges or uniform
Cultural framework

- Many of the ancient cultures had definite customs and taboos relating to
childbirth and its attendants
- For example only women who had had children themselves were allowed to act
as midwives
- Men were not allowed to be present
- Certain rituals had to be performed before, during and after labour
- These factors stress the importance of the midwife to know the cultural history
of midwifery in her/ his country as well as the culture of the individual woman
she attends in childbirth

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- Midwives working in cross-cultural situations have to be aware that the birth

process has always had special significance in all cultures, since it means the
continuation of the species
- The midwives helping with the birth process have always had a special place in
their society, and the birth process has always been associated with a variety of
taboos which protect the mother and infant
- In the education of the modern midwife and in the assignment of personnel to
specific areas, great care has to be taken that the midwives sent are culturally
acceptable and that midwives from alien cultures cultivate a particular
sensitivity to cultural aspects of the birth process
Searle, C. 1987: 8

Legal framework

- The midwife must observe the law, and must be responsible and accountable for her/
his actions
- She had to interact in a prescribed manner with mother and child, family and the
society
- The midwife was always held accountable for her actions
- Throughout the course of midwifery history the four core elements of professional
practice namely, observance of custom or laws, independent action, interdependent
action and accountability are discernible in the role fulfilment of the midwife
- The fact that such concepts have survived for millenia, indicates the importance of
midwifery in society and the fundamental need for a code of practice
- These are characteristics which are essential elements of professional practice in
modern midwifery
The scope of practice of Enrolled
Midwife/Acoucheur

• The midwife shall provide the midwifery care as stipulated in her/ his scope of
practice in the Nursing professions Act
The scope of practice entails:
- Assessment of the health needs of the pregnant woman
- Identify health needs and promotion of health care of the mother and child, by
means of examination, observations, counseling and health education during
pregnancy, labour and puerperium
- Handling of normal pregnancy, uncomplicated labour and normal puerperium

- Deliver a normal full term pregnancy, without causing danger to the mother and
baby

- Identify abnormalities during antenatal care, delivery and post natal care and refer
the patient to a medical practitioner or Registered midwife without delay

- Provide effective care to the newborn baby and mother during puerperium

- Promotion and maintenance of hygiene and physical comfort, and the re-assurance
of the mother and child

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- Promotion of exercise, rest and sleep

- Control, promotion and maintenance of respiratory functions, intake and output,

blood pressure, temperature, pulse rate and fetal heart rate of the baby

- Promotion, maintenance and improvement of the nutritional status of the mother

and child

- Promotion of breast feeding

- Provision of information on health and family planning

- Identifying and establishing a working relationship with traditional birth

attendants and community leaders to improve health services in the community

- Plan health care and health promotion activities of mother and child in health
facilities as well as in the community

- Care for the dying patient and still born infants

Standards of nursing care

Definition:
• A standard is a desirable and achievable level of performance against which
actual practice is compared (ICN,1984:24 )
• An object or quality or measure serving as a basis or example or principle to
which others conform or should conform, or by which the accuracy or quality of
others is judged
• The degree of excellence required for a particular purpose
• A thing recognized as a model for imitation
• Standard is also defined as a statement describing the expected level of
performance against which the quality can be evaluated
• Standards represent the agreed upon level of performance. (SANC, May
1994:32. Record keeping)
- A nurse/midwife must observe the standards of care to ensure the safety of patients
- The standards of an individual’s practice will be judged against normal,
accepted standards for safe practice as observed by the majority of the
profession
- The setting of desirable standards of practice provides security to the nurse
practitioner
- For then he/she knows what reasonable members of the profession expect from
him/her
- Broad macro-standards can be determined by the profession at large, but
health care services could have their own detailed explicit standards
- Broad macro-standards can be determined by the profession at large, but
health care services could have their own detailed explicit standards
- The observance of the standard is an integral aspect of responsibility for
patient care and accountability to that care
- Standards of nursing practice must be based on principles so that they can be
applied in any health care situation

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- Standards must enable the practitioner to select the most effective manner in
which to apply scientific nursing diagnosis and management and the way in
which the nurse carries out her professional responsibilities in the interest of
safe care
- There is a need to evaluate standards regularly so as to remain abreast of
progressive development in health care
- The nurse/midwife must be aware that standards of care should always be
patient centered
- Standards must be realistic, attainable, cost effective and understandable to
the practitioner
- Standards do not remain static, for they are based on contemporary knowledge
of the requirements of health care situation, the individual, family, group or
community (Searle, 4th edition 2009: 228)
Negligence in nursing practice
(Absence of due care)
- Occur when nurse/midwife have failed to do (what in the opinion of the
plaintiff) could be expected from a reasonable and prudent nurse in similar
circumstances
- What can be expected of the average reasonable and careful nurse in similar
circumstances
- The test of the reasonable person is used to establish negligence
- (a) Would a reasonable person in the position of the perpetrator
- Have foreseen the possibility of damage and
- Have taken steps to prevent such damage
- (b) Did the perpetrator’s conduct deviate from the above-mentioned standards?
- If so, the offender was negligent. If not the offender is not culpable.
- The reasonable person comprises all those characteristics which society
requires of its members in their conducts towards one another
Degrees of negligence
• Gross negligence:
- Failure to exercise even slight care to protect the right of others.
• Criminal negligence:
- Crime or an offence against the state, for which the state punishes the individual e.g.
negligence resulting in the death of the patient has serious consequences
• Contributory negligence:
- Where the one who sues may have contributed to his own injury either
deliberately or accidentally
- Nurses should guard against becoming involved in risky situations (Pera, s &
Van Tonder, S 2005:65)
-
Ethical Concepts

Confidentiality:
- A confidential relationship arises whenever one person entrusts confidential
information with another person
- Where the patient entrusted information to the nurse, the patient has the right
to believe that this confidential information will not be conveyed to others

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without the patient’s consent and that it will be used only for the purpose for
which it has been given
- There are two important aspects of confidentiality namely:
- Limiting access to information and
- Making provision for communication about intimate and other sensitive,
personal matters
Right to information
- The right of the patient to detailed information extends over a wide area which includes:
-Information about available health services to information about diagnosis
and prognosis
- When a patient admitted to a hospital, he/she receives detailed information
about the rules and regulations of the hospital
Right to privacy

- The right to privacy include both the right to respect for the dignity of the
patient, namely physical privacy and
- Respect for the patient secrets, namely confidentiality
- Nurses should be continually encouraged to respect the privacy of the patient
as a moral duty
Informed consent

 All procedures in health care require that a patient has given his/her permission
 To be able to grant consent, the patient must be fully informed about the procedure,
as well as any alternatives to the proposed treatment
 Consent is necessary from a legal point of view because it enables the practitioner to
defend him/herself, after consent has been given against a possible charge of assault
 It is necessary from a moral point of view because it displays respect for the
autonomy and right to self-determination
 There are two meanings of informed consent:

- The first meaning is where the person does not merely express agreement or
comply with a proposal, but must actually authorize something through an act
of informed or voluntary consent
- The second meaning of informed consent is tied up with formal procedures that
institutions have to follow before proceeding with diagnostic, therapeutic or
research procedures

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Unit 2: Concept Of Holistic Nursing care with cultural diverse childbearing

Psychosocial, spiritual and cultural aspects of child birth: Page126

 Pregnancy is not just a physiological change but also psychological adjustment,

emotions, thoughts and behaviours go through some variety of changes even before
the pregnancy itself.
 Some babies are planned, others are not. Whether the baby was planned or not,
what matter is the acceptance or the rejection of the pregnancy by everyone
involved. Much depend on the women’s current family situation, her marital
happiness, her reason for wanting or not wanting the baby, the timing and cultural
context. Seller: 125

Common feelings experienced in pregnancy include:

 Anxiety
 Fear
 Sexual activities
 Emotional liability
 Siblings, grandparents, friend, etc.

Preparation for parenthood

Several issues are important during early months of parenthood; some related to the
mother some to the father and the family and some to the baby. Read sellers page 130-133

The the midwife should facilitate positive parent –infant relationship by providing
opportunity for interaction.

The expected father

 Transition to fatherhood demand the role of adaptation of men all cultures

 This is a normal development and sometimes come with stress.
 Stress is determined by motivation for pregnancy, his expected role and his
ability to adapt to new change for the new role.

There are five phases of adaptation in fatherhood

1. Acceptance of pregnancy
The first and most important adaptation is to accept the pregnancy. This will also
help the woman to adapt positively.
Negative feeling from the father also negatively affects the women.

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2. Awareness of mother’s emotional and physical changes during pregnancy.

The father should be aware of all physical and emotional changes that happens
throughout the pregnancy. Positive adapation will influence his experience. If the
father is involve the baby will become real to him and not just in his mind.

3. Anticipation the birth

 In the last trimester of pregnancy, the father experience some anxiety in terms of
his partner, the baby, how the labour will progress and the potential risk of death.

4. Involvement in labour
The birth of the baby is a special crisis period and the father’s tension will be high.
Just his present at birth doen’t indicate his involvement. Involvement is when he
give emotional support to the partner while she is in labour. This will make the
woman to rely on him.

5. The father and the postnatal period

The postnatal period is also a period of crises for the father.
The father may compare the baby to his dreams, imagination and expectatins.
He also have to come to term with the sex of the baby. His acceptance of the baby’s
gender will influence the mothre’s response.
If the baby is sick or premature or abnormal, it will cause more emotional strain and
disappointment. Some eeven refuse to support the woman.

Read futher seller’s midwifery second edition page 135-139

Activity
1. How psycho-social aspect viewed in regards to the following:

1.1 And expected family 126

1.2 The pregnant women, sibling 126

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Unit 3: Anatomy and Physiology of the reproductive system and the fetal skull

The female reproductive organs

DEFINITIONS
Ovulation
• Is the release of the mature egg/ ovum from the ovary
• Occurs approximately 14 days before the onset of menstruation
Puberty
• The developmental period between childhood and the attainment of adult
sexual characteristics and functioning
Fertilization
• Is the process by which male and female sex cell unite to form a
conception(new individual)

Amenorrhoea
• An abnormal absence of menstruation
Dysmenorrhoea
• Is a painful menstruation
Menstruation
• A non-pregnant woman discharge of blood and other materials from the lining
of the uterus at intervals of about 28 days each month
Menarche
• The first occurring of menstruation

The female reproductive organs

The female reproductive organs is divided into:

- External female genitalia and
- Internal Female genitalia
• The external genitalia extend from the mons veneris anteriorly, to the anus
posteriorly
The structures of the external genitalia are:
• Mons veneris (mons pubis)
• The vulva: Labia majora, labia minora, clitoris, vestibuli
• The Perineum

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Diagram of external Female Organs

External female genitalia…

The mons pubis: Is a pad of fat lying over the symphysis pubis, covered with hair after
puberty
The vulva is made up of the following structures:
- Labia majora
- Labia minora
- Clitoris
- Vestibuli: External urinary meatus, vaginal orifice, Bartholin’s glands,
Vestibular bulbs
The openings and structures contained within the vestibuli are:

- The external urinary meatus (urethral orifice)

- The vaginal introitus/orifice

- Bartholin’s gland

- Vestibular bulbs

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The mons veneris (Mons pubis)

• Is a protective pad of fibro-fatty tissue
• Covered with skin and hair
• Is situated anteriorly over the symphysis pubis
• It protects the pubic bone
The vulva
• Extends from the mons veneris anteriorly to the perineum posteriorly

The structures of the vulva

Labia majora
• Encloses the vulva on both side.
• They are made up of fibro-fatty tissue
• Covered with skin and hair.
• They are continuous with the mons veneris anteriorly.
• And join in the perineum porsteriorly.
• The labia majora are homologous with the scrotum in the male.
Labia minora
• Are two loose folds of skin, enclosed within
• and lying parallel to the labia majora
• Anteriorly they divide on either side to enclose a structure known as the
clitoris
• Posteriorly they join to form the fourchette
• Which is continuous with the skin of the perineum, and form the posterior
border of the vestibule
• The area enclosed within the labia minora is the vestibule
The clitoris

 Is a structure composed of extremely sensitive erectile tissue

 It is 1.5-2cm in length
 The body of the clitoris is made up of two crura
 Which are attached on either side of the symphysis pubis
 The posterior unattached end of the clitoris is known as the glans
 The folds of labia minora which surround the clitoris are known as the prepuce
anteriorly and frenulum posteriorly
 The clitoris is homologous with the penis in the male
 It plays a part in the orgasm of sexual intercourse

The vestibule

• Is the area enclosed within the labia minora

• It is bounded by the clitoris anteriorly and the fourchette posteriorly
• The vestibule is surrounded by the bulbo-cavernosus muscle, a voluntary
muscle
• Which forms sphincters to the urethra and the vagina

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The external urinary meatus (urethral orifice)

• The external urethral orifice is situated about 1.5cm below or posterior to the
clitoris
• Tiny ducts, which have a lubricating function open posteriorly on either side of
the orifice are known as Skene’s glands and ducts
• The vaginal opening occupies the posterior two thirds of the vestibule
• Before puberty the opening may be partially hidden by a membrane known as
the hymen
• This membrane is teared during first sexual act

The hymen…

• Further tearing of the hymen takes place during the delivery of a child and the
remaining tags of skin and fibrous tissue are known as carunculae myrtiformes
The Bartholin’s glands
• Are situated postero-laterally in the vestibule
• They are embedded deep into the labia majora and the bulbo-carvenosus
muscle
• These glands have a lubricating function especially during coitus

Vestibular bulbs

• They are situated anteriorly to the Bartholin’s glands

• Surrounding the vestibule on either side are small collections of vascular
erectile tissue, which are continuous with the glans of the clitoris, they are
known as the bulbs of the vestibuli
• When the clitoris is stimulated, the vestibular bulbs transmit these stimuli to
Bartholin’s glands, which secrete a thick mucus

The perineum

• Is the area between the posterior border of the vestibule (the fourchette) and
the anterior border of the anal sphincter
• It is made up of layers of muscle, covered with skin
• It forms the base of the perineal body
Sellers volume 1, pg- 5
Dippenaar, pg- 36

The internal female genitalia

Is made up of the following structures:

• The vagina, cervix, uterus, uterine tubes and the ovaries.
• These organs are all contained within the true pelvis in the non- gravid state

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The vagina

• Is a muscular tube, that connects the vestibule with the uterus

• The walls of the vagina are folded with rugae
• Which allows the vagina to stretch during birth
• The vagina is lined with Stratified squamous epithelium similar to skin but
without glands
• Lactobacilli or Do”derlein’s bacillus are normal inhabitants of the vagina
nourished by large stores of glucogen secreted by squamous cells
• Lactobacilli produce lactic acid, which maintains the vaginal pH between 4.0 and 5.5

• The acidic medium helps to reduce vaginal infections

• Before puberty and after menopause, the pH of the vagina is less acidic and vaginal
infections are more common

• The blood vessels are full of turns and twists to allow for stretching

Functions of the vagina

• It is the excretory duct for menstrual flow

• It is the organ that receives the penis during sexual intercourse

• It is the birth canal

The cervix

• Opens into the posterior part of the upper vagina

• The upper portion of the vagina is called the fornix

The uterus

• The uterus is a hollow and pear-shaped organ

• In its non-gravid state, it is approximately 7.5cm long, 5cm wide and 2.5cm
thick
• It is made up of a body and neck (cervix), joined at a constricted area, the
isthmus
• When pregnant the uterus is referred to as gravid
• The wide rounded upper portion of the body is called the fundus
• The fundus is the muscular part of the uterus
• In pregnancy the uterus is divided into the upper and lower uterine segment
• The fundus represents the upper segment and the cervix the lower segment
• The isthmus divides the two segments
• Below the fundus on either side, the fallopian tubes arise at the cornua(horns) of the
uterus
• The uterine cavity is continuous with the lumen of the uterine tube
The position of the uterus

• The uterus is a pelvic organ, in the cavity of the true pelvic

• It lies behind and above the bladder and in front of the rectum

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• In the non-gravid state, it lies over the bladder in a position of ante-version and
ante-flexion
• The uterus is maintained in this position by uterine ligaments, the round and the
broad ligament in a non-pregnant woman
The structure of the uterus

• The uterus is made up of three layers namely:

• endometrium, myometrium and perimetrium
- The endometrium consist of three layers:
• The compact layer(1st): columnar epithelial tissue
• The spongy layer(2nd): connective tissue
• If not fertilised, these two layers are shed during menstruation
The endometrium

- The third layer is the basal layer: A layer of connective tissue and glands

- This layer is not shed during menstruation

- It forms the basis for regeneration of the two layers (the compact and spongy) that
are shed during menstruation

- Oestrogen promotes regeneration

• In pregnancy the endometrium is called the decidua

The myometrium:

• Is the thick middle layer of the uterus

• It is made up of three layers namely:

- An inner layer of circular muscle that keeps the shape of uterine cavity

- A middle layer of criss-crossing fibres, enclosing the numerous blood vessels

- An outer layer of longitudinal muscle fibres extending from the fundus to the
external cervical os

The perimetrium

- Is the outer covering of the uterus

- It is a layer of peritoneum that covers the body of the uterus

- It divides the pelvic cavity from the abdominal cavity

- Anteriorly it is reflected forward over the bladder to form the uterovesical pouch

- Posteriorly it is reflected upward over the rectum to form the uterorectal pouch

The cervix

- Is cylindrical and form the lower third of the uterus

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- It is 2.5cm in diameter and 2.5cm long

- It consist of a canal which is 2.5cm long
- It opens into the uterine cavity at the internal cervical os and into the vagina
at the external cervical os
- The inner layer of the cervical canal is thrown into folds, made up of ciliated
columnar epithelium, interspersed with deep compound racemous glands, which
secrete alkaline mucus

- The alkaline medium affords protection to the sperm deposited into the vagina
during sexual intercourse

- The acid medium of the vagina is harmful to sperm

- The alkaline mucus of the cervix together with the cilia helps the sperm to move
from the vagina into the uterine cavity

- During pregnancy the mucus becomes thick and tenacious forming a cervical plug
called opperculum, which helps to protect the content of uterine cavity from
ascending infections

- The external cervical os is a small round opening of approximately 0.5cm in

diameter in nulllipara and is called primip-os

- After birth it is an oval opening of 2cm or more and is known as multip-os, never
completely closed again

The fallopian tubes

• The fallopian tubes stretch from the superior portion of the uterus to the
ovaries
• Sperm enter the tubes from the uterus and meet with the ovum that has been
drawn in by the fimbria of the tubes
• Fertilization takes place in the fallopian tube
• The cilia in the tube move the fertilised ovum to the uterus

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Internal female reproductive organs

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Internal female reproductive organs

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Female reproductive organs in the pelvis and their associated structures

Activity

Label the above diagram

The Ovaries

• The ovaries lie on either side of the uterus in the true pelvis, attached to the
broad ligament
• Each one is about the size and shape of an unshelled almond
• It is approximately 3cm long, 2cm wide and 1cm thick and is greyish-white in
colour
• The ovaries are attached to the uterus on either side by strong ligaments, the
ovarian ligaments

• The ovaries are also attached to the lateral pelvic walls by the infundibulopelvic
(suspensory) ligaments

• And also attached to the infundibulae of the uterine tubes by one of the fimbria

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The structure of the ovary

• The ovary consist of two layers: An inner medulla and an outer cortex
• The cortex surrounds the medulla
• The medulla is composed mainly of connective tissue
• Which forms attachments for the ovarian and infundibulo pelvic ligaments
• It contains blood, lymph vessels and nerves
• The cortex is the functional part of the ovary consist of theca cells

• Interspersed with primordial and developing ovarian follicles

• Within the follicles are the primary oocytes

• The follicles are responsible for the gradual development of these primary oocytes

• There are between100 000 to 200 000 primordial follicles present in each ovary

• Under the influence of the pituitary and ovarian hormones, oocytes gradually
develop and mature

• It is only at puberty that the ovarian follicles begin to reach maturity

• When a mature follicle will burst open at approximately every 14 days of the 28 days
menstrual cycle to expel a mature ovum into the peritoneal cavity

• The ovaries appear to lie outside the fold of peritoneum known as the broad
ligament

• Attached to it on their anterior surfaces by a fold of the peritoneum known as the

mesovarum

• The outer layer of the cortex of the ovary is made up of germinal epithelium which is
continuous with the mesovarium

• When menstrual cycle stop at about the age of 50yrs, almost no female sex hormones
are secreted, this is known as menopause.

The male reproductive organs

Objectives:
• Describe the anatomy and physiology of the male reproductive organs
• Describe the male hormones
• Describe the changes that takes place in the male and females during puberty

The male reproductive organs are:

• One Scrotum
• Two Testes
• Two Epididymis
• Two Spermatic cords/Vas deferens
• Two seminal vesicles
• Two Ejaculatory ducts

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• Two Prostate glands

• One Urethra
• One Penis
• The male sex cells are called sperm or spermatozoa
• The sperm are produced in the testes
The Testes
• Are two oval shaped organs
• Which are suspended in the scrotum by the spermatic cords
• They are equivalent to the ovaries

Male reproductive organ

The testes
• Testes are surrounded by three layers namely:
- Tunica vaginalis (outer covering)
- Tunica Albuginea(beneath the tunica vaginalis)
- Tunica vasculosa (inner layer)
• Testes are about 4.5cm long, 2.5cm wide and 3cm thick
• Each testes is made up of about 900 coiled seminiferous tubules

Sperm formation

• The sperm are formed from germinal epithelial cells called spermatogonia
• The seminiferous tubules lead into the epididymis

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• The sperm take several days to pass through the epididymis, and become
mature
• A mature sperm has a head, body and long tail

Functions of the testes

• The testes produce sperm, which are produced in the walls of the seminiferous
tubules
• By the process called spermatogenesis
• The testes produce the hormone testosterone
Ross & Wilson P: 448
Dippenaar P: 58

The epididymis

• Is a coiled tube within each testis and is about 6m long

• Maturation of sperm takes place in the epididimys and the sperm become
motile
• The epididymis leads in to the vas deferens

The Scrotum

• Is a loose pouch of pigmented skin

• Divided into two compartments, each of which contains one testis and one
epididymis
• It is situated in the perineal area
• Behind the penis and in front of the anus
• It is homologous with the labia majora in the female
The functions of the Scrotum

• It regulates the temperature of the testes

• Required for the production and survival of the sperm
• It provides a cooling unit for the testes
The vas deferens

• Is a long straight tube that leaves the scrotum and passes through the inguinal
canal on either side of the pelvis and in to the abdominal cavity
• Then curved over the bladder on either side, back into the pelvis
• The vas deferens then joins with the duct of the corresponding seminal vesicle
to form the ejaculatory duct
Functions of the vas deferens

• Most sperm are stored in the vas deferens and the ampulla of the vas deferens
• The sperm maintain their fertility for several months

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The ejaculatory ducts

• Are two short ducts about 2cm long
• Each formed by the union of seminal vesicle and a deferent duct
• They pass through the prostate gland and join the prostatic urethra
Function
• They carry seminal fluid and sperm to the urethra

The Urethra

• This is a single tube leading from the bladder through the penis to the outside
of the body via the external urethral sphincter at the glans penis
Function
• The urethra transport urine from the bladder and the semen from ejaculatory
ducts to the outside of the body via the penis
Spermatogenesis or Maturation of the sperm

• Spermatogenesis refers to the whole process of sperm production

• In which spermatogonia are transformed into spermatozoa
• The whole process requires about 74 days
• Spermatogonia grow and develop into spermatocytes
• Spermatocytes undergoes a first meiotic division and changes into secondary
spermatocytes

• A second meiotic division takes place and four haploid cells are formed known as
spermatids which undergoes a final maturation process (spematogenesis)

The structure of a mature sperm

• A mature sperm is possibly the smallest cell in the body

• It is a free swimming self propelled cell
• It is made up of a head, body and tail
• It is made up of the nucleus containing chromosomes
• The front of the nucleus is covered with a membrane known as acrosome

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Structure of a mature sperm

The structure of a mature sperm…

• The neck of the sperm is a constricted area between the head and the tail
• The tail is divided into a middle piece, a principal piece and an end piece
• The tail is responsible for the motility of the sperm
• Few sperm survive longer than twenty four hours in the female genital tract
Dippenaar P: 60

Male hormones

• Androgens: The main is Testosterone

• Follicle Stimulating hormone (FSH)
• Luteinizing hormone (LH)
• Oestrogen
For their functions: Read Dippenaar P: 60

The changes that takes place in males during puberty

Puberty: Is the age at which the internal reproductive organs reach maturity
• The age of puberty varies between 10 and 14
Changes in the male
• Growth of muscles and bones
• Increase in height and weight
• Enlargement of the larynx

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• Deepening of the voice

Changes in the male…

• Growth of hair on face, axillae, chest, abdomen and pubis

• Enlargement of penis, scrotum and prostate gland
• Maturation of seminiferous tubules
• Production of spermatozoa
• Skin thickens and become oilier

Changes in the females during puberty

• The uterus, uterine tubes and the ovaries reach maturity

• The menstrual cycle and ovulation begin
• The breasts develop and enlarge
• Pubic and axillary hair begins to grow
• Increase in height and widening of the pelvis
• Increased fat deposit in the subcutaneous tissue especially at the hips and
breasts

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The Fetal Skull

Learning Outcomes
• Outline the three regions of the fetal skull
• Identify the bones of the fetal skull
• Describe the sutures between the bones of the fetal skull
• Make a comparison between the posterior and anterior fontanel of the fetal skull
Learning outcomes…

• Describe the anatomical landmarks of the fetal skull

• Describe the measurements of the fetal skull

• Explain different types of movement of the fetal head

Introduction

- The fetus is the passenger who has to negotiate the maternal passage in order to be
born

- In about 95% of all labours, babies are born head first

- The head is the least compressible part of the fetus, once the head is born the body
usually follows without any problem

Regions of the fetal skull

The skull can be divided into three main regions:

• The base

• The face

• The vault or cranium

Regions of the fetal skull

The base:
- Is the bony area surrounding the opening known as the foramen magnum
- These bones are firmly united in order to protect the vital centres in the medulla
The face:
- Extends from the root of the nose to the junction of the chin with the neck

The vault or cranium

- Is the greater upper dome-shaped part of the fetal skull
- Extends above the face in front
- To the base of the skull posteriorly and includes the temporal sutures laterally
- The bones of the vault are formed from membrane and not cartilage, and the inter-
membranuos ossification has started by the tenth week of intrauterine life

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Suture:
- Refer to a thin line of membrane between each skull bone
- The sutures are useful for identifying the position of the fetal head during labour
Fontanel:
- Refer to a membranous area which is formed where three or four sutures meet
The sutures allow the bones of the fetal skull to overlap or override when the head is
compressed, thereby decreasing the dimensions of the presenting diameters
Moulding:
- Refer to the overriding of the skull bones
The bones of the fetal skull
- Two halves of the frontal bone
- Two parietal bones
- One occipital bone
The sutures of the fetal skull
The frontal suture:
- Bisects the frontal bones down the centre of the forehead
- It is a forward extension of the sagital suture
The sagital suture:
- Lies between the parietal bones
- Runs in an antero-posterior direction
The coronal suture
- Separate the frontal bones from the parietal bones
- It meets with the sagittal and frontal suture anterior to form the anterior fontanelle
Lambdoidal sutures:
- Divides the two parietal bones from the occipital bone
- It meets with the sagittal suture to form the posterior fontanelle
The temporal sutures

- Lie on either side of the fetal skull

- Between the temporal bones laterally and the frontal and parietal bones above

- The temporal suture meet the coronal suture to form a small temporal fontanelle
(tempel)

The comparison between the anterior and posterior fontanelle

Anterior (bregma)
• Is diamond shaped
• It is formed by the junction of four sutures
• It is situated at a midpoint on the top of the fetal skull
• Close at about 12-18 months after birth

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Posterior (lambda)
- Is triangular shaped
- It is formed by the junction of three sutures
- It is situated posterior of the fetal skull
- Close at about 2-3 months after birth
-
The anatomical landmarks of the fetal skull

Sub-mental area: Is the area below the chin and extends to the angle where the chin meets
the neck
It is formed by the following areas:
- The mentum, the chin
- The face
- The root of the nose
The orbital ridges (above the eye socket)

Sub-mental area:
- The glabella (the elevated area between the orbital ridges)
- The sinciput, brow or forehead
Anterior: Glabella and orbital ridges
Posterior: Bregma and coronal sutures

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The vertex:
- It is the top of the cranium
- It is the lowest area of the fetal skull to enter the pelvic brim in a vertex
presentation
Anterior: Coronal sutures and bregma
Posterior: Lambdoidal sutures and lambda
Lateral: Parietal eminences
The parietal eminences:
- A thickened and raised area in the centre of each parietal bone
- This is the area where the greatest amount of ossification has taken place
- The diameter between the parietal eminences is known as the biparietal diameter,
this is the largest transverse diameter of the fetal skull
The occiput:

- -This is the area at the back of the head, formed by the occipital bone

- - It is below the lambdoidal sutures and posterior fontanel

Measurements of the fetal skull

The transverse diameters:

Bi-parietal diameter of 9.5 cm

- Measured between the two parietal eminences
Bi- temporal diameter of 8.2 cm
- Measured between the junctions of the coronal and temporal sutures on either side of the
skull

The antero-posterior diameters:

Sub-occipito bregmatic of 9.5 cm

- Measured from below the occipital protuberance to the centre of the anterior
fontanelle
Sub- occipito frontal of 10 cm
- Measured from below the occipital protuberance to the centre of the sinciput
The occipito- frontal diameter of 11.5 cm
- Measured from the occipital protuberance to the glabella

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Sub- mento bregmatic diameter of 9.5 cm

- Measured from the angle of the chin with the neck to the centre of the anterior fontanel
Sub- mento vertical diameter of 11.5 cm
- Measured from the angle of the chin with the neck to the highest point on the vertex
The mento- vertical diameter of 13.5 cm
- Measured from the tip of the chin/mentum to a point on the vertex above the
posterior fontanel. This is the largest diameter of the fetal head

The movements of the fetal head

Flexion:
- When the head is completely flexed, so that the chin is in contact with the chest
Extension:
- When the head is completely extended, so that the occiput is in contact with the back
Deflexion (‘Military Attitude’)
- Neither flexion nor extension, but somewhere between the two
- The fetal back is straight, with the head erect
Lateral flexion:
- The head is capable of certain amount of flexion to each side (Dippenaar, P 101- 105)
Exercise: Define caput succedaneum and cephalohaematoma

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Unit 4: Human Sexuality and sex intervention

THE MENSTRUAL CYCLE

Learning Outcomes:
• Interpret related concepts
• Describe hormones connected with the menstrual cycle
Explain the menstrual cycle under:
• Menstrual phase
• Proliferative phase
• Secretory phase
THE MENSTRUAL CYCLE..
Hormone:
• A regulatory substance produced by a living organism and transported in tissue
fluids to stimulate specific cells or tissues into action
Menstruation:
• Regular monthly shedding of uterine lining (endometrium) during the reproductive
period of the female
• Menstruation lasts for about 4 days
Hormone:
• A regulatory substance produced by a living organism and transported in tissue
fluids to stimulate specific cells or tissues into action
Menstruation:
• Regular monthly shedding of uterine lining (endometrium) during the reproductive
period of the female
• Menstruation lasts for about 4 days
Menarche: refer to first menstruation

Eumenorrhoea: refer to normal menstruation

Menorrhagia: refer to heavy bleeding

Dysmenorrhoea: refer to painful menstruation

Menopause:

• The ceasing of menstruation OR

• Time of the female life span when reproductive function cease

Ovulation

- Is the process whereby the dominant follicle ruptures and discharges the secondary
oocytes into the uterine tube ready for fertilization

- Ovulation lasts for about 48 hours

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- Ovulation is stimulated by a sudden surge (increase) in LH which matures the

oocytes and weakens the wall of the follicle

Ovarian cycle

- Is the name given to the physiological changes that occur in the ovaries essential for
preparation and release of the egg (oocyte)

- The ovarian cycle consists of three phases:

- The follicular phase, ovulation, luteal phase

Hormones connected with the menstrual cycle are:

1. Hormones of the hypothalamus:

- Luteinizing hormone releasing hormone (LHRH)

• Cause the anterior pituitary gland to secrete two gonadotrophic hormones

Hormones connected with the menstrual cycle continue..

2. Hormones of the anterior pituitary gland

- Follicle- stimulating hormone (FSH)

• Stimulate the theca cells of the ovarian follicle to produce oestrogens

- Luteinizing hormone (LH)

• Stimulate the corpus luteum to produce progesterones

Hormones connected with the menstrual cycle continue..

3. Hormones of the ovary

- Oestrogens

• Responsible for growth of the genitalia and breasts

• Bring about secondary sexual characteristics of the female

• Deposition of fat in the breasts and around hips

• Regeneration and proliferation of the endometrium during each menstrual cycle

Hormones of the ovary continue..

- Progesterone

• Prepare uterus for pregnancy

• Prepare breasts for lactation

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• Cause further thickening, vascularity and glandular development of the

endometrium

- Inhibin

• Inhibit the production of LH and FSH

Phases of menstrual cycle

1. Menstrual phase

- When the ovum is not fertilized, the corpus luteum degenerates

- The progesterone and oestrogen levels decreases

- Causing the functional layer of the endometrium, to be shed during menstruation

- After degeneration of the corpus luteum, the falling levels of oestrogen and
progesterone lead to resumed anterior pituitary gland activity

- LHRH releases the pituitary gland to secrete FSH in the bloodsteam

- Oestrogen affects the basal layer, cause regeneration and proliferation of the
endometrium

2. The proliferative phase

- Follows menstruation

- Is similar to follicular phase and lasts until ovulation

- At this stage an ovarian follicle stimulated by FSH, is growing towards maturity

- Producing oestrogen which stimulates proliferation of the functional layer of the

endometrium in preparation for the reception of a fertilized ovum

- The endometrium thickens, becoming more vascular and rich in mucus-secreting

glands

- This phase ends when ovulation occurs and oestrogen production by the follicle
declines

- Ovulation occurs at about the 14th day of the cycle

- The ruptured follicle become known as the corpus luteum (yellow body)

- Luteinizing hormone acts upon the corpus luteum causing it to secrete progesterone
in large amounts

- Progesterone acts upon the regenerated endometrium, causing it to become more

vascular and secretory ready to receive a fertilized ovum

- In the absence of fertilization, the corpus luteum degenerates and becomes the
corpus albicans (white body)

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3. The secretory phase

- Follows the proliferative phase

- Is simultaneous with ovulation

- Immediately after ovulation, the cells lining the ovarian follicle are stimulated by
LH and develop into the corpus luteum, which produces progesterone

- If the ovum is not fertilized, menstruation occurs and a new cycle begins

- - If the ovum is fertilized, there is no breakdown of the endometrium and no

menstruation

Diagramatic representation of the menstrual cycle.

LHRH Releases pituatary gland

(from hypothalamus)

LH secreted into bloodstream

LH increase and FSH decrease

Ovarian follicle rupture -

(corpus luteum)

Ovum fertilized
Ovulation, ovum released on 14th day

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ovum not fertilized

Pregnancy

Oestrogen and FSH decrease

LH act on corpus luteum

Progesterone levels increase and

oestrogen decrease

Progesterone acts on regenerated

endometrium

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LH level decrease due to progesterone and

inhibin

Degeneration of corpus luteum- corpus

albicans

Leads to lower levels of progesterone and

oestrogen

Results in shedding of endometrium

Menstruation on the 28th day

Decrease oestrogen levels

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Stimulate LHRH from hypothalamus

LHRH release pituitary gland to secrete FSH

Cycle restart

Follicle mature
LH secreted

Increase oestrogen level FSH decrease

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Regeneration of endometrium

END OF THE PHASES OF MENSTRUAL CYCLE

Read more in : Seller volume 1, P: 25 or

Dippenaar P: 45

The changes that take place in females during puberty

Puberty:
• Is the age at which the internal reproductive organs reach maturity
• The ovaries are stimulated by gonadotrophin hormones namely: follicle stimulating
and luteinizing hormone
• The age of puberty varies between 10 and 14 years
• The uterus, the uterine tubes and the ovaries reach maturity

• The menstrual cycle and ovulation begin (menarche)

• The breasts develop and enlarge

• Pubic and axillary hair begins to grow

• Increase in height and widening of the pelvis

• Increased fat deposited in the subcutaneous tissue, especially at the hips and
breasts

Menopause

Occurs between the ages of 45 and 55 years, marking the end of child bearing period
• It may occur suddenly or over a period of years
• It is caused by a progressive reduction of oestrogen levels
• The ovaries become less responsive to FSH and LH
Ovulation and menstruation become irregular and eventually cease

Activity

Discuss:

Hormonal changes during pregnancy, labour, puerperium and lactation.

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Unit 5: Conception and fetal development

FETAL DEVELOPMENT

Learning Outcomes
Define the following:
- Gamete
- Gametogenesis
- Oogenesis
- Fertilization
- Embryology
- Zygote

- Embryo

- Fetus

- Pregnancy

- Trimester

Describe the process of fertilization

Describe the different stages of fetal development

Describe the placenta at term

Explain the fetal circulation

Describe the anatomical structure of the fefal skull

FETAL DEVELOPMENT

Gamete:
- Is a mature male or female sex cell
- Which is capable of functioning in fertilization
- A gamete contains the haploid number of chromosomes of the somatic cell
Gametogenesis:
- The process of maturation which occurs in both ovum and sperm
- Gametogenesis in the female is know as oogenesis
- In the male is known as Spermatogenesis
Embryology:
- The study of the developing human
Fertilization:
- The process by which the sperm and ovum unite to form a new individual

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Stages of fetal development

Zygote:
- A fertilized egg which results from the union of the sperm and the ovum is called a
zygote
rd
- This covers the period from fertilization up to twenty-first days (end of the 3 week)
Embryo:
nd th
- The period from the twenty-second (22 ) to fifty-sixth (56 ) day after fertilization
th
- From the beginning of the fourth week to the end of the 8 week (5 weeks)
Fetus:
th
- The period from the beginning of the 9 week after fertilization to term
Pregnancy:
- The period of gestation in human, divided into three trimesters (first, second and
third )
- Each a period of 3 months or + 13 weeks
Trimester:
- Pregnancy trimester is divided into first, second and third trimesters
- Each covers a period of 3 months or approximately 13 weeks
The duration of pregnancy and the estimation of the date of delivery

- In order to have a recognisable landmark, the first day of the last normal menstrual
period is used in obstetrics

- Fertilization usually takes place within 24 hours of ovulation

- Ovulation takes place about 14 days after menstruation

Estimation of the date of delivery...

- Is calculated as approximately 266 days after fertilization

- Fourteen(14) days are added to 266 days = 280 days

- The estimated date of delivery or term is approximately 280 days, 40 weeks or 9

months after normal menstrual period

Cleavage

- The mitotic division of the zygote is known as cleavage

- The zygote divide into two identical daughter cells, then four, then eight, sixteen and
so on...

- The progress of the zygote first along the uterine tube, then in the uterine cavity is
described in days following fertilization

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The development of the zygote

- On the third (3rd) day following fertilization a cluster of about sixteen (16)
blastomeres has formed a solid ball known as the morula

- The morula passes from the uterine tube into the uterine cavity and the cells
continue to increase in number

By the fourth (4) day: Fluid from uterine cavity penetrated the morula and form a fluid
filled cavity (cyst), pushing the inner cell mass to one side, which will become the
embryo
- This changes the morula into a blastocyst
On the fourth (4) and fifth (5) days: The blastocyst remains free in the uterine cavity,
receiving nourishment from uterine secretions
th
From about the fifth (5 ) day: The zona pellucida starts to degenerate and the blastocyst
attaches to the uterine wall
th
On about the sixth (6 )day: The outer cells of the blastocyst become highly specialized and
are known as trophoblastic cells
- These cells secrete proteolytic enzymes that have the ability to digest and liquefy the cells
of the inner lining of the endometrium
th
By the end of the seventh (7 ) day: The blastocyst is superficially implanted in the lining of
the decidua
- The trophoblastic cells develop into two distinct layers together known as
Trophoblast/ syncytiotrophoblast
- An outer syncytiotrophoblast (syncytial cells)
- An inner cytotrophoblast (cytotrophic cells)
Syncytiotrophoblast: The inner cytotrophic layer begin to secrete a hormone known as
Human chorionic gonadotrophin (HCG), similar to the luteinizing hormone (LH) of the
pituitary gland

- On about the eight (8th ) to ninth (9th )day after fertilization: The secretion of HCG
can first be measured in the maternal blood

- - The HCG is the basis of the laboratory tests (urine and blood) for the diagnosis of
pregnancy

Implantation sites:
- Implantation of the zygote into the maternal decidua is completed during the
second week after fertilization
- The normal site of implantation is in the posterior, anterior or lateral wall of
the uterus
- The implantation bleed can cause difficulties with the estimated date of
delivery
(Sellers P: 45-51)

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Development of the zygote: 8-14 days after fertilization

th th
- From about the eleventh (11 ) to thirteenth (13 ) day after fertilization, the
cells of the cytotrophic layer have greatly proliferated, pushing the syncytial
layer outwards in finger like processes, which invade the decidua
- A third layer of connective tissue, the mesoblast forms within the cytotrophic
layer
Development of the zygote: 8-14 days after fertilization
- Secondary chorionic villi forms consist of three layers namely:
syncytiotrophoblast, cytotrophoblast and mesoblast
- By the eleventh to thirteen days changes have also occurred in the inner cell
mass

Development of the zygote: 8-14 days after fertilization

Changes in the inner cell mass
The amniotic sac: A narrow slit lined with ectoderm cells develops between the inner cell
mass and the outer trophoblast layers
The inner cell mass: Has differentiated into an embryonic disc made up of three layers
The yolk sac: The cavity of the blastocyst has now developed into the yolk sac lined with
endoderm cells

Development of the zygote: 15-21 days after fertilization

- The third week of embryonic life (The period immediately following the first
menstrual period)
- Is a time of rapid growth
Trophoblast
- The primary chorionic villi progress to secondary villi then tertiary chorionic
villi
- These vessels become connected to vessels developing into embryonic heart
Trophoblast…
- By twenty first day embryonic blood has started to circulate through capillaries
in the chorionic villi carries nourishment from maternal blood to the embryo
The inner cell mass
- Embryonic disc becomes pear shaped and elongated, the cranial expand the caudal area
elongates
The inner cell mass…
rd
- By the end of the 3 week after fertilization a neural plate has formed, the
edges of the neural plate meet and fuse in the centre of the embryo
st
- At 21 day the primitive cardio vascular neural tube have formed

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Development of the embryo: 22-56 days after fertilization

-From the beginning of fourth week to the end of the eight week
-The gestation sac can be measured with ultrasound to confirm pregnancy
-From the fifth week after fertilization fetal heart beat can be located with
ultrasound
- The cardiovascular is the first system to function in the embryo
The growth and development of the fetus

- By the beginning of the ninth week after fertilization, the human embryo has
developed into a recognizable human being
- Most of the body structures have already started to develop
- The fetus is less vulnerable than the embryo to the harmful and deforming
effects of teratogenic agents

Factors necessary for fetal growth

Oxygen: Necessary for all metabolic processes

Nutrients:
Glucose – Is the primary source for energy for metabolism and growth
- Amino acids, vitamins and minerals
- Particularly iron and calcium are necessary for metabolism and growth
- Insulin is required for the metabolism of glucose
Factors causing impaired fetal growth

- Placental insufficiency or impaired uteroplacental blood flow

- Maternal conditions such as hypertension, hyperpyrexia, chronic infections,
cardiac disease and so on…
- Genetic factors and chromosomal abberations, Down’s syndrome,
achondroplasia
- Smoking affects the rate of fetal growth because of its effect upon placental growth

- Alcohol and narcotic addiction can cause growth retardation, congenital

abnormalities and addiction in the newborn

- Infections and hyperpyrexia of the mother e.g. viruses such as rubella other
pathogenic such as Treponema pallidum

- In multiple pregnancy there is increased nutritional burden on the mother for each
additional fetus

- Maternal malnutrition, if the mother is lacking certain necessary nutrients the fetus
will also be deprived

- Prolonged pregnancy, results in the degeneration of the placenta increasing risk of

fetal hypoxia (Dippenaar P: 75)

(Abnormalities of the placenta ,membranes and cord)- moved to second semester content.

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The structures of the placenta

The umbilical cord

- The connecting or body stalk which joins the inner cell mass to the trophoblast
develops into the umbilical cord
- The body stalk consists of mesoderm cells which develop into fetal blood vessels
contained within the umbilical cord
- These blood vessels transport nutrient-enriched fetal blood from the chorionic villi in
the placenta along the umbilical cord to the heart
- Then return the nutrient depleted fetal blood back to the placenta
Blood vessels in the umbilical cord
One umbilical vein:
- Is a thin-walled, wide-bored vessel
- Carries 85% oxygenated blood from the placenta to the fetus
Two umbilical arteries:
- Are thick-walled blood vessels with a narrower bore
- Carry deoxygenated blood from the fetus to the placenta
- The arteries are usually wound loosely around the vein, along the length of the
cord
- The vessels are surrounded by a jelly like substance known as the Wharton’s
jelly
- Wharton’s jelly protects and supports the vessels
- Wharton’s jelly sometimes forms lumps known as false knots
The Amnion
- Is called the amniotic membrane
- The small cavity which appears in the ectoderm cells between the embedding
trophoblast and the inner cell mass at the end of the first week after
fertilization, is the beginning of the amniotic cavity or sac
- The membrane surround this cavity or sac is known as the amnion
- The sac becomes filled with fluid known as the amniotic fluid or liquor amnii
- The amnion comes into contact with the fetal side of the placenta and with the
chorionic membrane, where amnion comes into contact with the chorion they adhere
- The two membranes the inner amnion and the outer chorion with together with the
fetal side of placenta forms the fetal sac
The liquor amnii
- Is known as amniotic fluid
- The amniotic fluid is a clear, pale straw coloured, alkaline fluid
- During the later weeks of pregnancy when fetal kidneys are functioning the fetus
passes urine into the liquor
- The fetus also swallows the liquor which is then absorbed from the fetal intestines,
passed into the fetal circulation, back to the placenta and maternal circulation
- The whole volume of amniotic fluid is exchanged every 3 hours or half of it every 90
minutes
The amniotic fluid
- The amount of liquor in the amniotic sac increases as follows:
At 10 weeks: about 35ml

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10 – 20 weeks: 300 ml
20 – 30 weeks: 600ml
30 – 38 weeks: 1000ml
After 38 weeks: 600ml
During Pregnancy:
- To permit symmetrical growth of the embryo by equalizing pressures
- To prevent the amnion from adhering to the embryo and later the fetus
- To protect the fetus from impacts to the maternal abdomen
- To maintain embryo, fetus at a constant temperature
- To allow the fetus to move freely for the development of muscles
- To protect the fetus from infection together with intact amnion
During labour:
- To equalize the compression on the fetus caused by uterine contractions
- To prevent excessive dimunition of the placental site and consequent hypoxia of the
fetus
- When membranes rupture, the fluid flushes through the birth canal, help to reduce
the likely hood of the fetus becoming infected
The chorion
- Is the outer membrane of the fetal sac
- The chorion is an opaque, friable membrane
- The chorion has no blood vessels running through it
- The hole in the chorion through which the baby has been born is called the
fenestrum(Sellers P: 71)

Placenta at term
General characteristics of the placenta
- The placenta is circular shaped
- The diameter is about 20 cm
- The central thickness is about 2.5 cm
th
- It has a mass of approximately one sixth (1/6 ) of the baby’s mass about 500g
- It has two surfaces, called maternal and fetal surfaces
The maternal surface
- Maternal blood is present in the intervillous spaces
- Its colour is deep red
- It is divided into 16-20 lobules or cotyledons
- Separated by deep grooves or sulci
Fetal surface
- It is covered with amniotic membrane which gives it a smooth shiny appearance
- Fetal blood vessels can be seen radiating from the insertion of of the umbilical cord
- The two membrane attached to the placenta are the chorion and amnion
The functions of the placenta
Respiration
- The placenta is the respiratory organ for the fetus

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- Oxygen is transferred through the placental membrane from the mother’s

blood in the intervillous spaces to the fetal blood and circulation
- The oxygen is essential for the development, growth and survival of the fetus
Nutrition
- Nutrients necessary for normal fetal development, growth and survival e.g.
glucose, amino acids, vitamins and mineral salts are transferred from the
mother across the placental membrane to the fetus
Excretory
- Waste products such as creatinine, urea, uric acid are transferred from the fetal blood
stream across the placental membrane to the mother’s blood circulation
Endocrine
- The placenta is a temporary endocrine organ
- The hormones produced are essential to the maintenance of pregnancy

Major hormones produced by the placenta are:

- Human chorionic gonadotrophin
- Oestrogens
- Progesterone
- Human placental lactogen
Barrier
- The placenta is a barrier against harmful agents especially in the first
trimester
Enzymal function
- Enzyme found in human body has also been found in the placenta
- They are necessary for synthesis of protein, functioning of fetal tissue and so on

THE FETAL CIRCULATION

OBJECTIVES: DESCRIBE THE TEMPORARY STRUCTURES OF THE FETAL
CIRCULATION.
1. INTRODUCTION
- In utero, the fetal lungs do not function. The fetus obtains the oxygen and nutrients from
the maternal circulation. The waste products return back into the maternal circulation for
disposal.
- There are temporary structures that maintain the fetal
circulation before birth.

2. The Temporary Structures in the Fetal Circulation:

2.1 The Ductus venosus: (An opening from vein to vein)

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- This vessel is a continuation of the umbilical vein. It

connects the umbilical vein to the inferior vena cava.
- It joins the Inferior Vena Cava above the level of the umbilicus. The ductus venosus conveys
85% oxygenated blood from the placenta to the fetus.
- The Inferior Vena Cava carry de-oxygenated blood from the lower part of the body to the
heart.
- This causes a mixing of oxygenated blood from the placenta with de-oxygenated blood from
the lower half of the fetal body.

2.2 The foramen ovale

- Temporary oval opening between R and L-atrium.

- Allow most of the blood from the inferior vena cava to pass directly from the right atrium into
the left atrium.
- The pressure of the blood volume on the right side of the heart is greater during fetal
existence.
- The blood which flows through the foramen ovale into the left atrium is mixed blood, but of a
high oxygen concentration. The blood then passes into the left ventricle into the ascending
aorta, then to the heart muscles and the upper parts of the fetal body.

2.3 The ductus arteriosus (from artery to artery)

-This is a short vessel. It conveys blood from the pulmonary artery to the descending arch of
the aorta.
- This is mainly deoxygenated blood returning from the head and upper limbs via the superior
vena cava.
- The blood is directed through the right atrium into the right ventricle from where it is
conveyed to the lungs.

- As the lungs are not functioning, most of the blood is diverted through the ductus arteriosus
into the descending arch of the aorta, to mix with blood from the left side of the heart. This
blood is now only 50% oxygenated.

- As it passes through the superior vena cava, through the right atrium, it picks up some of the
oxygenated blood which is being directed into the foramen ovale.

-A small amount of blood is conveyed to the lungs for development, growth and functioning.

2.4 The two hypogastric arteries (umbilical arteries)

- Are branches of the internal iliac arteries, returning deoxygenated blood from the pelvis, back
to the placenta for re-oxygenation.
- As they enter the umbilical cord they become the umbilical arteries.

The umbilical vein

- This is the only vessel which carries unmixed blood.

- Leads from the umbilical cord.
- It carries blood rich in oxygen and nutrients.
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3.Changes which take place in the fetal circulation at birth.

- At birth the baby take its first breath and the lungs expand. It causes a fall in the pressure on
the right side of the heart.

- As blood is drawn into the pulmonary capillaries, it is oxygenated and returned to the left
atrium via the expanded four pulmonary veins.

- The pressure on the left side of the heart becomes now greater than the pressure on the right
side.
- This increase of pressure on the left side of the heart causes the valve of the foramen ovale to
close.

- The oxygen tension rises in the blood and prostaglandins are released. This causes
contraction of the smooth muscle in the wall of the ductus arteriosus. This brings about the
gradual closure of the ductus arteriosus, and the closure becomes permanent by the end of two
months.

- When the umbilical cord is severed, no blood enters the ductus venosus, this further reduces
the pressure on the right side of the heart.

-The ductus venosus constricts several hours after birth and after some weeks, it is
permanently closed.
- The Hypogastric/ umbilical arteries also constrict, atrophy and form ligaments.

In short
 Ductus venosus – ligamentum venosum
 Foramen ovale – fossa ovale
 Ductus arteriosus – ligamentum arteriosum

Activity
Discuss the cell division: Meitosis & Meiosis

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Unit 6: Pregnancy and Antenatal care

1. DEFINITION OF CONCEPTS

Menarche
- Is the beginning of menstruation and reproductive function in the female

Ante-partum
- The time between conception and onset of labor, the period during which a woman is
pregnant

Gestation
- The number of weeks since the first day of the last menstrual period (LMP)

Trimester
- The three months period in which pregnancy gestation of nine months is divided

Term
- The normal duration of pregnancy (38-42 weeks)

Gravida
- Any pregnancy, regardless of duration, including
the present one

Primigravida
- A woman who is pregnant for the first time
(gravida 1)

Multigravida
- A woman who is in her second or any subsequent pregnancy (gravida 2, 3 or more)

Parity
- Means the number of previous viable pregnancies
(either stillborn or alive)

Nullipara
- Means a woman who has never carried a previous
pregnancy to the point of viability (para o)

Primipara
- A woman who has had one previous viable
pregnancy (para 1)

Multipara
- A woman who had two (2) or more previous viable pregnancies (para 2, 3 or more.)

Grande multipara
- A woman who had five (5) or more previous viable pregnancies (para 5, 6 or more)

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Viability
- The ability to live outside the uterus after birth has taken place

Viable
- A fetus who had at least six months (26 weeks) of intra-uterine existence

Abortions
- The number of pregnancies which have terminated before reaching the point of
viability

Birth
- The birth of any viable child, whether such child is alive or dead at the time of birth

Stillborn
- A child who was viable but showed no sign of life after complete birth

Intra-uterine death (IUD)

- A fetus that reaches viability, but died in the uterus before it is born

Preterm or Premature labor

- Labor that occurs after 24 weeks, but before the completion of 37 weeks of gestation

Post-term pregnancy
- Pregnancy that lasts beyond 42 weeks gestation

Lie
- Is the relationship of the long axis of the fetus, to
that of the long axis of the uterus

Attitude
- Is the relationship of the fetal parts to one another, the relationship of the fetal
limbs and head to the fetal trunk

Presentation
- Is that part of the fetus which lies in the lower pole of the uterus and which presents
at the pelvic brim

Presenting part
- Is that part of the presentation which lies over the cervical os during labour, it is
upon this portion of the presentation that the caput forms

Denominator
- Is that part of the presentation which indicates the position of the presentation in
relation to the pelvic brim and gives the position its name

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Position
- The position of the fetus is indicated by the relationship of the denominator to six
points or landmarks on the pelvic brim

Engagement
- The entrance of the fetal presenting part into the
pelvic brim and the beginning of the descent
through the pelvic canal

Lightening
- The descent of the uterus and fetus within the
abdominal cavity at 36 weeks gestation, which
results in a lowering of the fundal height and a
reduction of pressure on the diaphragm

Supine hypotension syndrome

- Is a restriction of venous blood flow from the uterus and lower limbs, due to the
pressure exerted on the inferior vena cava, when a pregnant woman lies on her back
for a long time

The Aims of Antenatal Care

- To ensure a normal pregnancy whenever possible by maintaining or where
necessary promoting the general health of the pregnant woman
- To ensure the early detection, referral and management of complications during
pregnancy
- To ensure a normal labour whenever possible, by preparing the woman physically
and psychological
- To provide careful screening of all women, and those who can deliver in health
centre or hospital
- To prepare the woman for normal puerperium and the care of a healthy newborn
baby
- To promote and prepare the woman for breast feeding whenever possible
- To provide each woman and her family with insight into the possible abnormalities
that can occur to the mother and baby for their prompt action and quick arrival at
health facility
- To promote health education and family planning

Objectives of the first ANC visit (booking visit)

- To assess levels of health by taking a detailed history and to employ

screening tests as appropriate
- To ascertain baseline recordings of weight, height, blood pressure and
haemoglobin level
- To identify risk factors by taking accurate details of past and present
obstetric and medical history
- To provide an opportunity for the woman and her family to express any
concerns they might have regarding current pregnancy or previous obstetric
experiences

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- To give advice on general health matters and those pertaining to pregnancy

in order to maintain the health of the mother and the healthy development of
the fetus
- To begin building a trusting relationship in which realistic plans of care are
discussed

Aims of abdominal examination

- To observe signs of pregnancy

- To assess fetal size and growth
- To assess fetal health
- To diagnose the location of fetal parts
- To detect any deviation from normal

2. Signs and symptom of Pregnancy

Subjective signs and symptoms of pregnancy
- Amenorrhoea
- Breast changes
- Morning sickness
- Bladder irritability
- Quickening
- Temperature elevation
- Changes in body shape
Amenorrhoea
- Pregnancy is the commonest cause of cessation of menstruation in young women
Other causes of amenorrhoea are:
- Emotional stress
- Change of environment
- Some endocrine disorders
- Anaemia
- After use of contraceptive pill
- Poor nutrition (Anorexia Nervosa)
Breast changes
- Occur from three to four weeks
Early symptoms and signs are:
- Tingling of the breasts
- Breast heaviness and enlargement
Morning sickness:

- More than 50% of pregnant women experience nausea and vomiting

- Between the fourth and fourteenth week
- The cause is thought to be high blood levels of HCG and oestrogens
- Vomiting that persist after 14 weeks or excessive vomiting are considered abnormal
Bladder irritability
- Frequency of micturition without any signs of infection occurs in early pregnancy

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- Between the eighth and fourteenth weeks

This is caused by:
- Increased blood volume
- Resulting in increased renal blood flow and glomerular filtration rate with an
increase in urine production
Quickening

- When the pregnant woman first notices fetal movement within the uterus
- In multigravida quickening occurs at about 16 weeks
- In primigravida it occurs at about 18-20 weeks
Temperature elevation
- When fertilization and implantation have taken place , there is elevation in the
woman’s temperature
Changes in body shape
- A woman may report that her clothes do not fit
- And her abdomen feels full
Objective signs of pregnancy
• Skin changes
• Breast changes
- Changes in the pelvic organs
• Abdominal enlargement
• Uterine souffle
• Braxton- Hicks contractions

Skin changes
- Linea alba changes to linea nigra
- The nipples may darkened and secondary areola become present
- Chloasma can be noticed from 16 weeks
Breast changes
- From 8-12 weeks subcutaneous veins become noticeable
- There is an increase in the size and pigmentation of the nipple and areola
- Montgomery’s/ tubercles appear
- From 16 weeks colostrum can be expressed

Changes in the pelvic organ

- Some of these signs are demonstrated during vaginal examination to be carried out
by the doctor

Hegar’s sign

- - At 6-12 weeks the embryo only occupies the upper part of the uterus. A bimanual
examination done with the two fingers of one hand in the vagina

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- And the fingers of the other hand pressing downwards and backwards on the
anterior abdominal wall, the fingers of both hands feel as though they meet because
of the soft, elongated isthmus
Jacquemier’s/ Chadwik’s sign
- From eighth week, there is a dark purplish discolouration of the mucous membranes
of the cervix, vagina and vulva
- The vagina is warm and blue, and the cervix is soft
Osiander’s sign
- Increased pulsation felt in lateral fornices of the vagina, due to increase in
vascularity
- From eighth week
(Dippenaar, P: 169)

Uterine enlargement
- At about eight weeks the uterus is the size of an orange and more globular in shape
- From about week 12, the fundus can be palpated abdominally just above the symphysis
pubis and with the gradual increase in size the uterus becomes an abdominal organ
Abdominal enlargement
- From week 12, the height of the fundus rises and the uterus becomes an abdominal organ
Uterine souffle
- Is a soft blowing sound that synchronises with the pregnant woman’s pulse
- This can be heard from week 16 on auscultation
This must not be mistaken with the sound of the fetal heart, which is more rapid and
strong
Braxton- Hicks contractions
- Are painless uterine contractions, present from 20 weeks
(Dippenaar P: 171)

3. Diagnosis of pregnancy

Conclusive or Diagnostic signs of pregnancy

Fetal heart beat

- The fetal heartbeat can be heard from 20 weeks with a fetoscope (Pinard’s
stethoscope)
- With ultrasonic, fetal heart can be detected from 15 weeks
- With electro-cardiotocograph FH can be detected from 15 weeks
Fetal parts: The fetal parts can be felt from 28 weeks
- The lie and presentation can be determined

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Fetal movements: Can be felt on abdominal palpation at 22 weeks after LMP

Ultrasonic evidence: The fetal sac can be outlined from 5 weeks and the heart beat from 7
weeks after LMP

Signs of previous pregnancy or delivery

The breasts: May be flabby with prominent nipples and persistent pigmentation of the
areola
The abdomen: The muscles may be stretched, with loose skin
- There may be scars of ceasarean section
- Silver striae gravidarum may be observ
Fetal parts are often easier to palpate than in primigravida
The vulva: Pigmentation which may have persisted with gaping of the labia and vaginal
introitus
The vagina: May be lax and roomy or it may have signs of cystocele or rectocele
The cervix: With speculum examination, the external cervical os is a transverse slit, which
easily admits one finger
The perineum: May have scars of episiotomy
Pseudocyesis
- Is a false or phantom pregnancy
- Usually the result of an intense desire for a child

4. Psychology of normal pregnancy

PSYCHOLOGICAL CHANGES DURING PREGNANCY: Pregnancy is always associated

with changes in psychological functioning of pregnant women.

It is usually associated with ambivalence, frequent mood changes, varying from anxiety,
fatigue, exhaustion, sleepiness, depressive reactions to excitement

It's normal for pregnant women to experience a wide range of emotions, from joy and
excitement to bouts of anxiety and mood swings.

Paying attention to any emotional and psychological changes during and after pregnancy
can help keep mother and baby safe and healthy.

Depression during pregnancy has been linked with a number of complications for children
once they're born.

However, it may not be depression itself, but rather a change in a mother's mental state
that is harmful to the baby.

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5. Psychological and Physiological changes during pregnancy

Psychological changes during pregnancy
Learning outcomes
• Explain the psychological changes during pregnancy on the following:
- Anxiety
- Fear
- Emotional changes
- Sexuality

PHYSIOLOGICAL CHANGES DURING PREGNANCY

Learning outcomes
• Define related concepts
• Explain the physiological changes during pregnancy of the following:
- Reproductive
- Cardiovascular
- Respiratory
- Digestive
- Skin
- Immune system
- Renal
- Skeleton

Physiological changes

Definitions
- Leucorrhea
- Operculum
- Chloasma
- Linea Alba/ Linea nigra
- Striae gravidarum
- Ptyalism
- Craving
- Pica

Physiology of pregnancy
The Uterus
- Is the organ that contains and nourishes the conceptus
- Therefore is the organ most affected by pregnancy
Functions of the uterus
- The uterus consist of a body and cervix (neck)
During pregnancy:
- The body of the uterus must relax and grow to form new muscle fibres to
accommodate the conceptus
During labour:

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- The body of the uterus must contract and retract to expel the fetus
Functions of the cervix
During pregnancy:
- The cervix must remain firm and become part of uterine cavity in order to maintain
pregnancy
During labour:
- The cervix must relax, stretch and dilate to allow the fetus to pass through the cervical
canal
The body of the uterus
- In pregnancy the uterus is divided into upper and lower uterine segments
- The upper portion of the uterus contain the blastocyst enlarges uniformly and is
called the upper uterine segment
- The lower portion softens and lengthens in early pregnancy and forms the basis for
Hegar’s sign of pregnancy
- After the first trimester as the fetal sac is filling the uterine cavity, the elongated
isthmus is gradually drawn up and this forms the lower uterine segment

The lower uterine segment is less vascular with fewer muscle fibres

The size of the uterus

- There is a huge increase in size, weight and volume of the uterus
Size:7.5 x 5 x 2.5 cm to 30 x 23 x 20 cm
Weight: 50-60 g to 900 – 1000 g
Volume: 6 ml to 5000 ml
Increase of the uterus…
The first 20 weeks of pregnancy
- The increase in size is mainly due to an increase in the number of muscle fibres
(hyperplasia)
- And due to an increase in the size of the muscle fibres (hypertrophy)
- Increase of the uterus…

- The second half of the pregnancy

- - The increase in size is mainly due to mechanical stretching of the uterus by the
developing and growing fetus

Position of the uterus

- The uterus is a pelvic organ in anteversion and anteflexion

- At 12 weeks the uterus can be felt above the pelvis

- The uterus moves up in the abdomen and displaces the abdominal organs

- At 20 weeks the uterus is dextroverted to lift from the aorta and inferior vena cava

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Braxton – Hicks contractions

- These are painless contractions of uterine muscles which occur throughout

pregnancy

- These contractions bring about the formation of the lower uterine segment and play
a role in the blood circulation in the uterus

- They prepare the uterus for labour

False labour

- Braxton-Hicks can become intense and frequent in the last two weeks of pregnancy
and some pain may be experienced

- False labour is distinguished from true labour by lack of show and absence of
changes of the cervix

The cervix
- In primigravidae the length of the cervix is about 2.5cm during the first two
trimesters
- In the second trimester, the cervix widens and softens and there is a marked
proliferation of cervical mucosa
- A mucus plug is formed which seal off the cervical canal and is known as the
operculum

The vagina

- The muscle fibres of the vagina hypertrophy during pregnancy and there is softening
of connective tissue

- Causing the vagina to develop a larger lumen and increasing the stretching ability of
the vaginal walls

- The vagina becomes more vascular and assumes a dark purplish colour

- The mucosa becomes thicker and there is a larger amount of glycogen in the
squamous cells

- An increased desquamation of the superficial vaginal mucosal cells leads to an

increased vaginal discharge

- Which may become infected with pathogens

- An increased vaginal discharge may become infected with pathogens, such as

bacteria, fungi or parasites

- The resultant vaginitis can be troublesome during pregnancy

The vulva

- There is an increased vascularity of the vulva, resulting in a darker colour

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- Varicosities of the vulva veins may occur

The fallopian tubes

- The uterine tubes together with the broad and round ligaments hypertrophy and
become more vascular and pliable

- As the uterus grows and becomes an abdominal organ, the fallopian tubes are lifted
out of the pelvis

The ovaries

- The ovaries cease ovum production during pregnancy

- The theca cells become active in hormone production and referred to as interstitial
glands of pregnancy

- The blood supply to the ovaries also increases and the ovaries are drawn up into the
abdominal cavity with the uterus and uterine tubes

- During the first 12 weeks of pregnancy the corpus luteum increases in size, under
the influence of HCG

- - From the third month, there is regression of the corpus luteum as the placenta
takes over the function of producing oestrogens and progesterone

The breasts
• The breast changes are often the first signs of pregnancy that a woman notices
- AT 3-4 weeks there is a prickling and tingling sensation in the breast
- The duct and alveolar systems enlarge under the influence of oestrogen and
progesterone
- From 6 weeks the breast gradually increase in size and have a tense, nodular feel

- At about eight weeks, there is increased vascularity which can be seen under the
skin as a network of subcutaneous veins

- By 12 week, the nipples have enlarged and become more prominent together with
the primary areola

- By the 12 week, the sebaceous glands in the primary areola enlarge and become
more prominent and known as Montgomery’ follicles or tubercles

- By week 16, the areola has extended over a larger area and become known as
secondary areola

- From about 16 weeks, colostrum can be expressed from the nipples

- The colostrum only change to milk on about the third day after the birth of the baby

- Colostrum: Is a thin yellow milky fluid secreted from the breasts from 16 weeks of
pregnancy up to 3-4 days after birth

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The skin

- There is increase in pigmentation during pregnancy

- When pigmentation is on the face it is called chloasma or the mask of pregnancy

- Linea Alba: Is a thin line extending from the symphysis pubis to the umbilicus

- Linea alba darkened during pregnancy and become known as Linea nigra (black
line)

- Striae gravidarum: Are small pinkish – brown streaks or scars that develop over the
abdomen, thighs and breasts

- They may become quite dark in multigravid brunettes and dark – skinned women

- They result from high level of circulating hormones and the rapid stretching of the
skin of the abdomen, thighs and breasts

- Striae- gravidarum or stretch marks fade after the pregnancy and later appear as
silvery streaks on a white skin or as shiny dark streaks on a dark skin

The cardiovascular system

- There is an increase volume of blood to almost all the organs of the body
The blood
- The blood volume increases by about 1.5 litres
- This is referred to as hydraemia of pregnancy
th th
- The plasma volume increases from 10 week to 34 week to reach about 3800ml
- The red cell volume increases to about 30% more than in the non-gravid state

- As the plasma volume is greater than the red cell volume, it causes a reduction in
the concentration of red blood cells, therefore a reduction in haemoglobin
concentration, this is known as physiological anaemia of pregnancy

- The white blood cells increase, but there is a slight decrease in platelets

- There is a decrease in the stored quantity of iron

- Total protein, albumin and gamma globulin levels fall in the first trimester, than
rises slowly to term

- Serum lipids increases especially cholesterol

The heart

- The cardiac output increases by 30-50% due to increase in blood volume

- The increased output is managed by an increase in stroke volume

- There is an increase in the heart rate of about 15% (90-100 beats per minute)

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The blood pressure

- In a normal pregnancy there is little change in the blood pressure until the end of
the second trimester

- The peripheral resistance of blood vessels is reduced

- The blood viscosity is reduced

- Varicose veins and haemorrhoids are common findings

Supine hypotensive syndrome

- It is caused by the pressure of the enlarged uterus on the inferior vena cava, when
the pregnant woman lies too long on her back

- It results in the patient feeling faint, pale and sweaty

- The blood pressure may be low or unrecordable

The blood coagulation factors

- There is an increase in coagulation components such as fibrinogen

- Together with factors VII, VIII, IX and X

- There is a decrease in anti-coagulation components- the fibrinolytic system

- During labour the hypercoagulable state protects the woman from excessive blood
loss

The immune system

- The immune system and defences are altered in the pregnant woman, causing increased
risk of infection during pregnancy
• Consist of immunological and non-immunological factors
• Non-immunological factors include:
- The skin, mucosal barriers, digestive enzymes, pH, temperature, proteins, enzymes,
lysozymes, transferrin and interferon
- Serum levels of IgG fall as pregnancy progresses, except in intra-uterine death
(IUD)
And intra-uterine growth retardation (IUGR)
- IgA and IgM decrease or remain stable in pregnancy
- IgE changes little and IgD increases to term

The respiratory system

- There is a relaxation of the muscles in the thorax that broadens the ribcage by about
6cm
- This increase the air volume by 50% per minute
- The diaphragm is pushed upwards and breathing becomes diaphragmatic

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- Due to pressure by the enlarged uterus, the movement of the diaphragm is reduced
- Pregnant woman breath more deeply and tidal volume increases
- There is greater mixing of gases during pregnancy and an increased oxygen
consumption
- Due to pressure by the enlarged uterus, the movement of the diaphragm is reduced
- Pregnant woman breath more deeply and tidal volume increases
- There is greater mixing of gases during pregnancy and an increased oxygen
consumption
- The increased blood volume causes engorgement of the pulmonary vessel
- There is an increased oxygen tension(Pa02) and a decrease in carbon tension
(PaC02)
- Dyspnoea may be experienced by some pregnant women
- Women may be more prone to upper respiratory infections and viral pneumonia

The Renal system

- Sodium retention, increased extracellular volume with altered renal functioning

- The renal length increase by about 1cm
- The capacity increases from 10 – 40ml
- The kidney enlarge by 1cm and renal volume increases by 30%
- Dilatation of the ureters may result in kinking in the middle portion
- The bladder muscle becomes relaxed due to the effect of progesterone, this together
with the dilatation of the renal pelvis and ureters can lead to stasis of urine
- The result of this changes is increased risk of urinary tract infection
- The neck of the bladder remain in pelvis and is pushed forward against the
symphysis pubis

- Because of the increased blood volume, there is an increase in renal blood flow and
glomerular filtration rate
- This results in increased urine production which cause frequency of micturition
- Tubular re-absorption remains unaltered
- The capacity of tubular cells to reabsorb certain substances is exceeded

- There is increased clearance of certain substances particular sugar, amino acids,

folic acid, water soluble vitamins, iodine and waste products such as urea, uric acid
and creatinine

- This accounts for the frequency of glucosuria found during pregnancy

- Protein in the urine after 20 weeks is of diagnostic value for pre-eclampsia

The Alimentary system

- Increased appetite and alteration in the type of food desired, including cravings and
pica

- Gingivitis and tooth decay during pregnancy are caused by hormones in the saliva

- The gums becomes highly vascular, oedematous and hyperplastic

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- Saliva becomes more acidic in pregnancy

- Some women may experience ptyalism (excessive salivation)

- The relaxing effect of progesterone on the musculature, causes delayed emptying of

the stomach, intestines and colon

- This permits greater absorption of foodstuffs, but also leads to constipation

- Relaxation of cardiac sphincter may lead to oesophageal reflux and heartburn

Musculo-skeletal system

- Pregnancy is characterised by changes in posture and gait

- External rotation of the femurs cause a waddling gait to compensate for

redistribution of body mass

- The symphysis pubis may widen by 10cm

- Lower limp pain may develop due to increased load on the lateral side of the foot

- The risk of ligament injury increases in pregnancy

- Muscle cramps are common in the third trimester and at night

- Compensatory lordosis develops due to a shift in the centre of gravity

Activity

Explain the psychological changes during pregnancy on the following:

a) Anxiety

b) Fear

c) Emotional changes

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d) Sexuality

6. Common Minor disorder/ discomfort in pregnancy

Learning outcomes
• Identify common minor disorders of pregnancy
• Demonstrate competency in the interventions for each condition
• Explain the education to give to women for each condition
Common minor disorders of pregnancy

Fainting:

Definition :

Causes:

- Progesterone induced, general vasodilatation of pregnancy

- Standing for long, especially in hot over crowded place
- Tight clothing, over exertion, lack of sleep, excitement and shock

Care and Education :

- Take blood pressure

- Check haemoglobin
- Reassure that the condition resolves itself after the first trimester
- Avoid standing for long periods
- Lie down when feel dizzy or sit with head between the knees
- Avoid sitting or standing up quickly from a lying position
- Eat small regular meals a day
- Avoid lying in supine position for more than 15 minutes

Nausea and Vomiting/ Emesis gravidarum

Causes
- Increasing levels of oestrogen and HCG
- Changes in the thyroid function
Care and Education
- Observe signs of weight loss and dehydration
- Check urine SG and ketones

Education

- Reassure that the condition usually disappears after the first trimester

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- Revisit daily food intake, low glucose levels seem to aggravate the nausea and
vomiting
- Have more frequent smaller meals with plenty of protein
- Avoid fatty, spice foods or large meals
- Do not take over the counter medication or self medication
- Admit to hospital when necessary: Unable to tolerate food, significant loss of weight,
ketones in urine

Frequency of micturition

Causes
- Increased urine production by the kidneys in early pregncy
- Pressure on the bladder from the enlarged uterus
Care and Education
- Take temperature to exclude infection
- Test urine for pH, protein, leukocytes
Education

- Reassure the woman that it is caused by the pressure of the uterus on the bladder

- Reduce intake of fluids in the evenings and before bed time

- Avoid standing for longer periods

- Empty the bladder regularly

- Leaning forward during the final stage of passing urine will help to void residual
urine

Fatique

Causes
- Metabolic processes of pregnancy and hormones circulating
- Cumulative effect of too little sleep
- Increased weight of the enlarged uterus

Headaches

Causes
- Effects of oestrogen and progesterone on the circulatory system
Care and Education
- Take the temperature, blood pressure, oedema
- Check urine for

Education

- Reassure the headache will pass after the first semester

- If headaches are severe or persist, see a doctor

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- Only take prescribed medications

- Protein

Varicose veins

Causes
- Effects of progesterone on the circulatory system with increased blood volume
- Pressure of the enlarging uterus
- Inherited tendency to poor veins
- Increase in parity and age

Care and Education

- Observe legs and vulva for haemorrhoids

- Do not cross legs when sitting
- Do not maintain same position for more than half an hour
- Rest in left lateral position
- Do gentle exercises
- Rest with legs and hips elevated for an hour twice a day
- Wear supporting anti-thrombosis stockings
- Avoid tight garments around the legs

Haemorrhoids

Care and Education

- Observe haemorrhoids
- Prevent constipation and straining
- Take some rest during the day
- Elevate the foot-ent of the bed
- If bleeding, cold astringent packs can be applied

Heartburn and oesophageal reflux

Education
- Small frequent meals should be taken
- Avoid fatty, oily, spice or indigestible foods
- Last meal should not be taken after 6 pm
- Use extra pillow when sleeping or resting
- If smoking, reduce or stop smoking
- An antacid may be prescribed by a doctor

Constipation

Education
- Take a good balanced diet
- Take food high in roughage/fibre and low in carbohydrates

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- Drink plenty of fluids, particularly plain water

- Take high bran biscuits, wholewheat cereals and wholewheat bread
- Perform light exercise such as a short walk
- Bowel training, to use the toilet at specific times

Oedema

Causes
- Increased blood volume
- Distension of the veins
- Mechanical pressure of the enlarged uterus
- Standing for long periods

Care and Education

- Check blood pressure

- Check haemoglobin
- Test urine for protein
- Avoid standing for long periods
- Take frequent rests with legs elevated
- The foot of the bed should be elevated
- If no improvement after good rest see doctor

Backache

Causes
- Increased lumbar curve
- Lax abdominal muscles
- Pendulous abdomen

Care and Education

- Do not stand for long periods

- Take frequent rests
- Do not wear high-healed shoes
- Do light antenatal exercises
- If backache is troublesome, see a medical practitioner

Muscle Cramps Education

- Take frequent rest during the day
- During spasm the foot should be flexed by pulling the toes up
- The calf muscles should be gentle massaged
- Rest in the knee chest position to lift pressure from the pelvic floor
- Calcium or magnesium supplementation may help

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Insomnia

Care and Education

- Take good balanced diet
- Have adequate amounts of exercise and rest
- If severe refer to medical practitioner
- Do not take medication not prescribed by doctor

Activity

7. Evidence –based care : Dippenaa,173-178

Evidence –based care (Sellers Second edition page 29-31)

Good care is based on procedures and interventions that have been justified by scientific
research in other words,evidence- based care.

Evidence-based aspects AND Application

Pregnancy

Magnesium- Sulphate for treating eclampsia

Studies have shown it to be much more effective than other anticonvulsants. In addition it
is relatively cheap and easy to use

Magnesium sulphate should be used routinely to treat all women with eclampsia following
the protocols.

Corticosteriod therapy

To prevent hyaline membrane disease of the newborn

Give IM injection to the mother between 32-34 weeks when at risk for premature birth
following a protocol

Folic Acid

Prevention of neural tube abnormalities of the newborn.

All pregnant women to take folic acid orally before pregnancy

Labour

Position for labour

A number of studies suggest that an upright, or semi-upright position shows more benefits
than a supine position

Allow women to take the position that feels comfortable in first and second stage unless
containdicated

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Mobility during labour

Several studies show that the supine position affects blood flow in the uterus ,and can
reduce the intensity of contractions

Standing or lying on the side can be more beneficial to the woman as long as there are no
complications. Women should be encourage to walk around,choose other more comfortable
positions, even take baths or showers during labour.

Fluids and food during labour

Labour requires lots of energy and can last for hours. Women need to maintain their energy
levels,Ristriction of oral intake can lead to dehydration and ketosis- this is usualy treated
with IV infusion.

Women are able to monitor their own intake and will intuitively avoid heavy meals

For normal and low- riskbirths,avoid interfering with women’s wishes for food and drink
during labour,

Encourage companionship during labour

There is evidence to suggest that women who are supported throughout labour by a
partner, friend,relative or carer enjoy several benefits

Encourage women to bring someone they trust or feel comfortable with; a partner,relative
or friend,Alternatively, establish a child birth companionship system at your hospital/clinic.

Enemas are not always necessary

There is insufficient evidence to recommend the routine use of enemas. Further medical
trials need to be conducted before the benefits and harms can be properly evaluated

An enema should be given only if the women requests it.

Stop pubic shaving

Shaving is an unnecessary procedure

Ifyou stop shavingyou will reduce the discomfort and embarrassment for women

Avoid Episiotomy

Episiotomy carries a number of risks,and the evidence suggests that routine use does not
reduce perineal trauma or improve healing.

There is clear evidence to recommend restricted use of routine episiotomy. Only done when
indicated.

Reduce use of early amniotomy

Routine erly amniotomy is associated with both benefits and harms.

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Until there is more evidence,amniotomy should be reserved for women with abnormal or
slow progress

and avoided in HIV-positive women

Suction of newborns

Routine nasopharyngeal suction of all newborn is unnescessary, and costly

It is recommended that only those babies with meconium present should undergo suction
on delivery.

HIV- POSITIVE WOMEN PMTCT

Antiretroviral therapy

Triple therapy is evidence-based best practice in developed,well –resourced settings

Neverapine ,one tablet to the mother during labour, and one dose of syrup to the baby after
bith,is highly effective in reducing the risk of transmission in low resource settings

Artificial rupture of membranes

Risk of MTCT increased.

Avoid the artificial rupture of membranes

Breastfeeding

12% risk of contracting HIV from breast milk

If women are in a position to provide safe alternative feeding,they may be encouraged not to
breast feed,they should should be encouraged to give their baby only breat milk for 6 monts
then introduce complementary feeds and continue breastfeeding for 12 months

Mode of delivery

Evidence suggest that caesarean delivery can reduce mother to child transmission of HIV.

Caesarean section is only indicated under safe conditions

Vaginal cleansing

Highest risk for MTCT is during vaginal birth

Vaginal disinfecting before and /or during laboir may help to prevent transmission of HIV.
Disinfective agents such as chlorhexidine,may be particularly useful because of their
activity against HIV.

Vitamine and nutritional supplements

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Studies suggest that the risk of MTCT of HIV infection is associated with Vitamine A
deficiency in the mother

Give Vitamine A to pregnant women

Safe motherhood

Learning outcomes:
• Provide a brief background information on the initiation and development of the
Safe Motherhood Initiative (SMI)
• Interpret related concepts:
- Safe motherhood
- Maternal morbidity
- Maternal mortality
- Perinatal periodon
- Neonatal period

- Postnatal/ Postpartum

- Puerperium

• Identify the causes of maternal illnesses and deaths in Namibia

• Explain the contributing factors of poor maternal health

• Discuss the intervention measures for safe motherhood

• Describe the human rights that promote safe motherhood
• Describe the situation of safe motherhood in Namibia
Safe motherhood background information

- Safe motherhood initiative (SMI) was first launch in 1987 in Nairobi- Kenya
- The initiative was developed with the aim to reduce the burden of maternal deaths
and illnesses resulted from complications of pregnancy, child birth and puerperium
and to make pregnancy and childbirth safer
Safe Motherhood Initiative:
- Is a World Health Organization campaign
- To reduce maternal and child mortality and morbidity world wide
- Safe motherhood is an international effort to raise awareness of the scope and
dimensions of maternal mortality and to stimulate commitment among Governments,
Donor agencies, United Nations agencies and other relevant stake holders to take steps
to address this public health problem

- Safe motherhood programmes seek to address direct and indirect causes of

maternal morbidity and mortality and undertake related activities to ensure
women have access to comprehensive reproductive health services
From the health data monitored by the World Health Organization, maternal mortality
shows the greatest disparity between poor and rich countries

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- Safe motherhood is based on the implementation of simple, appropriate, cost-

effective strategies
- To enable mothers to have access to high-quality care during pregnancy and child
birth and related events such as fetal loss
- Safe motherhood aims to improve the health, nutrition and general wellbeing of girls
and women of reproductive age before conception and into parent hood
- In 1987 when health experts development professionals and policymakers gathered
in Nairobi to inaugurate the global initiative, maternal mortality was not a major
national or international priority
- It was often the overlooked component of maternal and child health (MCH)
- Making motherhood safer benefit not only the woman but also the health of the
newborns and children and the wellbeing of the entire family and societies
- The health of newborns is closely linked to the health of their mothers
- Evidence suggest that a mother’s death also harms the overall wellbeing of the
surviving children
- A woman’s death affects her family’s wellbeing and that of society as a whole

DEFINITION OF CONCEPTS

Safe motherhood
- Safe motherhood include a series of initiatives, practices, protocols and service delivery
guidelines designed to ensure that women receive high quality gynaecological, family
planning, prenatal, delivery and postpartum care, in order to achieve optimal health
for mother, fetus and infant during pregnancy, childbirth and postpartum
- Safe motherhood also means: To create circumstances within which a woman is able
to choose whether, when, and how often she will become pregnant
- And if a woman become pregnant, ensuring that she receives the care for prevention
and treatment of pregnancy complications
- And ensuring that pregnant women has access to skilled birth attendants and access
to emergency obstetric care if needed

Safe motherhood also means:

- Ensuring that all women receive the care they need to be safe and healthy
throughout pregnancy and child birth

Maternal morbidity:

- - Refers to sickness or disability as a result of complications of pregnancy and child

birth

Maternal mortality or maternal death:

- Is the death of a woman while pregnant, or within fourty two (42) days of
termination of pregnancy
- Irrespective of the duration and site of the pregnancy from any cause related to or
aggravated by the pregnancy or its management

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- But not from accidental or incidental causes

Perinatal period
th
• The period extending from the 28 week of pregnancy to the end of the first week of
life
Neonatal period
• The period starting at birth and ends after a month (28 days), the first four (4)
weeks after birth
• Early neonatal period
• - The period from birth up to seven (7) completed days after birth
• Late neonatal period
• - Extends/begins from day eight (8) after birth and ends on the 28th day after birth
• Postnatal/Postpartum
• - After child birth
Postnatal examination
- Maternal examination undertaken frequently during the first ten (10) days of
puerperium
- To ensure that the involution is taking place, lactation is becoming established and
mother is adapting physically, emotionally and psychologically to motherhood

Medical/Midwifery postnatal examination

- Examination at the end of the six (6) weeks of puerperium
- To ensure that mother’s body has returned to the non-pregnant state without
complication
Puerperium
- Six weeks period following child birth during which the uterus and other organs are
returning to the non-pregnant state, the fourty two (42) days period following delivery
of the baby
Live birth
- A live born baby who is over 500g in weight, irrespective of gestation who shows signs of
life after delivery, i.e. heart beats, respirations, muscle movements
Still birth
- Refer to an infant over 500g in weight, that shows no signs of life after delivery
irrespective of gestation
Abortion
- Refers to a fetus of less than 500g in weight who may or may not show evidence of
life after delivery
- It also refers to the expulsion or extraction of the placenta or membranes without an
identifiable fetus
- Perinatal death
- - Stillborn infants and babies who die within the first week of life
- Neonatal death

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- - Infants who die within 28 days of birth

- Early neonatal death
- - Refer to the death of an infant within the first week of life
- Late neonatal death
- - The death of an infant between 8 and 28 days

- Perinatal mortality rate

- - The number of stillbirths plus death of babies under one (1) week old per 1000 total
births

- Neonatal mortality rate

- - Number of deaths of infants up to four (4) weeks after birth per 1000 live births

The components of safe motherhood

• Preconception care
• Antenatal care/Prenatal care
• Clean safe delivery
• Essential obstetric care (EOC) and emergency obstetric care (EMOC)
• Perinatal care, Neonatal care
• Postnatal care
• Breastfeeding
• Family planning

Direct causes of maternal illness and death

• The three delays:

Delay to make a decision to seek care
Delay to get transport to health facility
Delay to be attended to at the facility
• Haemorrhage due to: Obstructed labour, Prolonged labour, Ruptured uterus
• Pregnancy induced hypertension (PIH): Severe-pre-eclampsia and eclampsia
• Infection, Abortion, Septicemia, Puerperal sepsis

Indirect causes of maternal deaths

• Human immunodeficiency virus (HIV) and Aquired immunodeficiency deficiency

syndrome
• Sexually transmitted infections
• Malaria
• Tuberculosis
• Meningitis
• Pneumonia

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Contributing factors of poor maternal health

• Heavy work load

• Low standard of living resulting from poverty
• Early marriage and early child bearing
• Teenage /Adolescent pregnancy
• Poor education
• Violence against women
• Poor nutrition, Poor general health
• Lack of access to health care

Intervention measures for safe motherhood

• Problem solving approach during antenatal care

• Educate girls and women on matters related to reproductive health
• Ensure skilled attendants during pregnancy and birth
• Essential obstetric care
• Emergency obstetric services for life threatening complications
• A functional referral system to ensure timely access to appropriate care and
outreach to community

• Improve family planning services

• Training of traditional birth attendants

Includes the fulfillment of several key human rights such as:

• Right to reproductive freedom: Delay early age marriage and child birth
• Rights to education and information: Including education and information relating
to sexual and reproductive health without any discrimination

• Improving nutrition of girls and women

• Right to health including sexual and reproductive health: Care during pregnancy
and child birth by trained and skilled health care professionals

• To have access to maternal and neonatal health care treatment in emergency

situations including obstetric interventions when needed

• Building linkages with other stakeholders,

which involve decision makers at the national and local levels, UN-agencies, civil society,
mass media, religious bodies, schools, non-governmental and community-based
organizations
• Involvement of men as husbands/partners, neighbours, leaders etc, need to become
more actively involved in supporting women to improve their health

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Eight health care delivery functions identified by WHO to reduce maternal deaths are:

1. The administration of parenteral antibiotics

2. The administration of parenteral oxytocics
3. The administration of parenteral anti- convulsions for pre- eclampsia/eclampsia
4. Perform the removal of retained placenta
5. Perform the removal of retained products
6. Perform an instrumental assisted vaginal delivery

7. Perform safe blood transfusions

8. Perform surgery/ ceasarean delivery

Health facilities offering functions 1-6 are classified as basic emergency obstetric
care(BEmoC)

Health facilities offering functions 1-8 are classified as comprehensive emergency obstetric
care(BEmoC)

The situation of maternal health in Namibia

- According to Demographic Health Survey of 2006, the Maternal Mortality

Ratio (MMR) in Namibia is 449 deaths per 100,000 live births.
- Of concern is that the MMR shows an increasing trend, from 225 per 100,000
live births in 1992 to 271 per 100,000 live births in 2000. Women are
particularly more at risk during delivery
- In 2000 the Government of Namibia adopted the Millenium Development Goals
(MDGs). These consist of eight goals to be met in 2015.

- MDGs 4 and 5 focus on maternal and child health.

- Millenium Development Goal 4 focus on the reduction of under-five mortality rate by

2/3

- Millenium Development Goal 5: Improve maternal health. Reduce maternal

mortality by 3/4

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Unit 7: Antenatal care

Definitions

 Viability: Means the ability to live outside the uterus after birth has taken place
• Viable: In relation to a child means it has had at least six months (26 weeks) of
intra-uterine existence
• Parity: Means the number of previous viable pregnancies ( stillborn or alive )
• Ante-partum: The time between conception and onset of labor, the period during
which a woman is pregnant
• Gestation: The number of weeks since the first day of the last menstrual period
(LMP)
• Trimester: The three months period in which pregnancy gestation of nine months is
divided
• Term: The normal duration of pregnancy (38-42 weeks)

Aims of antenatal care

- To support and encourage a family’s healthy psychological adjustment to child

bearing
- To promote an awareness of the sociological aspects of childbearing and influences
that these may have on the family
- To monitor the progress of pregnancy in order to ensure maternal health and normal
fetal development
- To recognize deviation from the normal and provide management or treatment as
required
- To ensure that the woman reaches the end of her pregnancy physically and
emotionally prepared for her delivery
- To help and support the mother in her choice of infant feeding; to promote breast
feeding
- To give advice about preparation for lactation when appropriate
- To offer the family advice on parenthood either in a planned programme or on an
individual basis
- To build up a trusting relationship between between the family and their caregivers
which will encourage them to participate in the care they receive

Objectives of the first ANC visit (booking visit)

- To assess levels of health by taking a detailed history and to employ

screening tests as appropriate
- To ascertain baseline recordings of weight, height, blood pressure and
haemoglobin level
- To identify risk factors by taking accurate details of past and present
obstetric and medical history
- To provide an opportunity for the woman and her family to express any
concerns they might have regarding current pregnancy or previous obstetric
experiences

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- To give advice on general health matters and those pertaining to pregnancy

in order to maintain the health of the mother and the healthy development of
the fetus
- To begin building a trusting relationship in which realistic plans of care are
discussed

Aims of abdominal examination

- To observe signs of pregnancy

- To assess fetal size and growth
- To assess fetal health
- To diagnose the location of fetal parts
- To detect any deviation from normal

The duration of pregnancy and expected date of delivery (EDD).

Calculation of expected date of delivery

Several methods can be used:
- Obstetric calendar, when LMP is determined
- The obstetric wheel, give both the EDD and current gestational age based on the
LMP
- EDD can be determined by using naegle’s rule
- The normal duration of pregnancy (38-42 weeks)

HISTORY TAKING OF A PREGNANT WOMAN

Learning objectives:
Interview and take history of a pregnant woman without physical medical risks within 20
minutes
Demonstrate practical competence in the interviewing technique
Keep accurate records
Interpret findings and notice abnormalities
Give appropriate health education to the client

Antenatal
• Before birth
• A care provided by midwives and obstetricians during pregnancy
• To ensure that the fetal and maternal health are satisfactory
• To enable early detection and treatment of any abnormality (deviations) from
normal

• Complete the antenatal record card

• Physical examination, weight, bloodpresure, urinalysis, blood test in pregnancy
• Taking History, general health, menstrual history, past obstetric, medical/surgical,
family history
• The midwife/ Acchoucheur’s examination of pregnant woman
• Abdominal examination( leopards manoeuvre)
• The relationship of the fetus in utero
• Indication of fetal wellbeing

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• Antenatal exercises & Postnatal exercises

SUBSEQUENT ANTENATAL VISITS

Frequency of ANC visits.

If pregnancy is normal, the woman can attend ANC as follows:

0-20 weeks: After 2 months

21-28: 6 weeks

29-35: 4 weeks

36-42: Every after 2 weeks

Pregnancy with problems or complications are seen 1-2 weeks or whenever necessary.

MANAGEMENT OF A WOMAN DURING ANC FOLLOW-UPS.

- Ensure a warm welcome and encourage the client to talk out anything that is troubling
her.

- Re-assess the psychological state of the client.

- Any existing problem should be attended to or if necessary refer to the Dr. or other
relevant services.

- Re-assess previous history for any changes and adjust accordingly, attend to the needs of
the client and keep accurate records.

- Take the necessary parameters and examinations e.g. Bp, urine test, abdominal
examination etc.

- Give out routine medications if applicable.

- Health education should be a continuous process at each visit.

- Give a date for return follow-up.

CONDITIONS WHICH ARE OF PARTICULAR IMPORTANCE FOR IMMEDIATE

REFERRAL TO A DOCTOR

- Any problem regarding the fetal heart beat or fetal wellbeing.

- Vaginal bleeding.
- Blood pressure of 130/90mmHg or more.
- Excessive weight gain, oedema of hands, legs, face and/ or protein-uria.
These clinical features may indicate severe pre-eclampsia.

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- Sugar in urine may indicate diabetes mellitus.

- Any cardiac conditions.
- Pre-term labour.
- Any abnormalities noted on abdominal palpation e.g. mal-presentations after 36
weeks.
- Multiple pregnancy and/ or polyhydramnios.
- Excessive vomiting and/ or diarrhoea.

THE ANTENATAL VISIT AT OR AFTER 36 WEEKS OF PREGNANCY

 Re-assess the client psychological state with emphasis on her preparedness for
delivery and motherhood.
- If mother is RH- negative re-check antibody titre
- Assess engagement of the head. Re-assess HB.

Tests carried out at the first antenatal visit or at follow up visits

Urine test:
Glucosuria, associated with the following conditions:
- Lowered renal threshold
- Diabetes mellitus
Proteinuria, associated with the following conditions:

- Hypertension

- Pre-eclampsia

- Pyelonephritis

- Chronic nephritis

- Urinary tract infection

Ketonuria
- Diabetes mellitus
- or starving (hunger)
Blood Tests
- Blood grouping (Type of blood group)
- Rhesus factor (If negative refer to doctor)
- Haemoglobin
- Rapid Plasma Reagin (RPR): Test for syphylis
- If RPR is positive it must be confirmed with Treponema Pallidum
Haemagglutination (TPHA)
- Antigen HIVirus (AIDS)
- Antigen Hepatitis B (Hepatitis)

 Weight, physical examination (done from head to toe) &

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 Blood pressure measurement are also done during the first vist and also at every
visit.
History Taking

• Is a guide not a rigid structure

• Pay attention to your relationship with the client and the information you want
for history
• Be friendly and show respect for the patient
• Choose a comfortable setting and help the patient get settled
• Maintain eye contact and use a conversational tone
• Begin by introducing yourself and explain your role
• Help the patient understand why you are taking the history and how it will be
used
• Be sensitive to the patient’s emotions at all times
• Avoid confrontation and leading questions

Procedures to be done:

• Complete the antenatal record card

• The midwife/ Acchoucheur’s physical examination of pregnant woman
• Abdominal palpation
• Health Education

Abdominal examination ( leopards manoeuvre)

ABDOMINAL EXAMINATION

Aims of abdominal examination

- To observe the signs of pregnancy
- To assess fetal size and growth
- To assess fetal health/ wellbeing
- To diagnose the location of fetal parts
- To detect any deviation from normal
(Bennett, P: 128)

- Abdominal examination is a guide to be used during pregnancy and labour

- The examination is more useful from 28 weeks
- The woman should empty her bladder before the examination
- The examination is done with the woman lying in the supine position
- the examination must be done quickly and efficiently
The procedure is carried out in the following order:
- Determine EDD and estimated gestational age
- Inspection
- Assessment of the fundal height
- Palpation
- Auscultation of the fetal heart

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Inspection:
- Note the following:
- Skin changes
- Striae gravidarum: extensive distribution and deep pigmentation in the abdomen
skin due to excessive stretching
- Old striae gravidarum indicate previous pregnancy
- Skin changes, note the following
- Linea alba and nigra
- Rashes or skin lesions
- Sores or any evidence of trauma e.g.bruises or wound scars
- Operation scars, enquire about C/S and reason

Size of the abdomen

- Rough estimate can be made on the period of gestation, bearing in mind the estimate date
of delivery calculated

Shape of the abdomen

- Oval shaped: Indicate a longitudinal lie with the fetus well flexed

- Round shaped: Suggest polyhydramnios and/ or multiple pregnancy

- A narrow, elongated abdomen: Suggest a frank breech (extended legs)

- A heart-shaped abdomen: Suggest a bicornuate uterus

- An abdomen that is wider than it is long: Suggest a transverse lie

- A very flabby and shapeless abdomen: Suggest grande multiparity

- A saucer-shaped depression in the centre of the abdomen near term: Indicate fetal
back lying posterior (Occipito-posterior position)

- A saucer-shaped depression in the centre of the abdomen near term: Indicate fetal
back lying posterior (Occipito-posterior position)

- Fetal movement: Indicate the side of the small parts and that the fetus is well

- (Dippenaar, P: 200)

Abdominal palpation

Assessment of fundal height

- The tape measure method is only accurate between 20 – 35 weeks.
The height that the fundus has reached at certain weeks using abdominal landmarks
12 weeks: Just above the symphysis pubis

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16 weeks: Half- way between the upper border of the symphysis pubis and lower border of
the umbilicus

The height that the fundus has reached at certain weeks using abdominal landmarks..

- 20 weeks: The lower border of the umbilicus

- 22 weeks: The centre of the umbilicus

- 24 weeks: The upper border of the umbilicus

- 30 weeks: Half-way between the upper border of the umbilicus and the lower border
of the xiphisternum

- The height that the fundus has reached at certain weeks using abdominal
landmarks

- 36 weeks: The lower border of the xiphisternum

- 38 weeks: The height of fundus drop about 2 fingers breadth and remain at the level
at

- which it was at about 32- 34 weeks

- Measuring the height of fundus can give an indication of fetal growth

Types of pelvic grips

Pawlik’s grip
- Determine which part of the fetus is lying over the pelvic brim
- Determine presentation (presenting part)
The head will feel hard and round
If not engaged mobile and ballotable
Combined grip: Fundal palpation and pawlik’s grip
- Determine the part of the fetus lying in the fundus (comparison is made on what is in the
lower and upper uterine segment)
- This is likely to lead to a correct diagnosis of the Lie and Presentation)
The breech feel bulkier and softer than the head
- Bimanual fundal palpation:
- Using two hands on the fundus
- Determine what is in the funds
- Fetal limbs and feet may be felt and this will help to verify that the breech is in the
fundus
- Two poles in the fundus indicate twins
Lateral grip:
- Used to locate the fetal back

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-In a vertex presentation the back of the fetus should be on the same vertical plane as the
occiput
-Locating the fetal back help to determine the position of the fetus
Walking the fingers over the abdomen: A continuation with the lateral grip
The deep pelvic grip
- Used in late pregnancy or during labour
- To determine the level of descent of the fetal head or presenting part
- Help to verify which part of the fetus lies at the pelvic brim
- When the head is deeply engaged (no fifths of head above the pevic brim), cannot be
felt on abdominal palpation

Abdominal examination

Auscultation
- The fetal heart can be heard from 20 weeks with Pinard’s stethoscope or from
14 weeks with doppler
- The normal fetal heart beat is between 120 – 160 beats per minute

Information that can be obtained on abdominal examination

- The shape and size of the abdomen

- The height of the fundus and if this corresponds to the EDD
- The lie of the fetus
- Which part of the fetus is lying over the pelvic brim
Which part of the fetus is in the fundus

- Which part of the abdomen can the back of the fetus be felt and the limbs
- Whether the head is engaged and how many fifths of head are above the pelvic
brim
- Are there fetal movements
- Is the fetal heart rate present and normal
- Is there any uterine contractions

Causes of non – engagement of the fetal head

- Inaccurate calculation of EDD

- Full bladder, prevent head from entering
- Large presenting diameters
- Contracted pelvis
- Polyhydramnios
- Multiple pregnancy
- Breech presentation
- Placenta praevia
- Tumors or abnormalities of the uterus
- Pendulous abdomen
- Unknown causes

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The relationship of the fetus in utero: page 191

This relationship indicate the part of the fetus that will the pelvic brim first, and will
indicate the mechanism by which the fetus will pass through the birth canal during labor.

It is very important for a student to know which one is normal and which one is abnormal
in this relationship to be able to continuation of pregnancy and labor.

 Lie- is the relationship of the long axis (spine) to that of the mother. The lie can be
longitudinal or transverse or obligue.
 Attitude – is the relationship of the fetal parts to each other, such the fetal limbs
and fetal trunk. Attitude can be flexion, deflexion and extension.
 Presentation - is that part of the fetus that lies in the lower pole of the uterus and
which present in the pelvic brim. The presentation can be vertex, breech, a face, and
a shoulder or brow presentation.
96% of presentation are cephalic (head, face and brow). The breech presentation are
podalic (pelvic)
 Denominator is that part of the presentation that indicated the position of the
presentation in relation to the pelvic brim and give the position its name. The part
that is felt on vaginal examination. Occiput is the denominator in vertex, mentum
(chin) in face presenation, etc.
 Position – the relationship of the denominator to sixpoints or landmarks on the
pelvic brim. This could be anteriorly, posteriorly, laterally.
In vertex presentation with occiput as a denominator, the position is either
LOA/ROA
 Presenting part – is that of the presentation that liesover the cervical os during
labor and is where caput is formed.

Descent /engagement of presenting part –the amount of descent of the presenting part (fetal
head/sacrum) in the mother’s pelvis. Page197

Activity

Study all positions also for breech presentation. Page 197

Indication of fetal wellbeing

One of the aim of ANC is to monitor fetal wellbeing in the uterus.

The wellbeing of the fetus is linked to the wellbeing of the fetus. Amy infection of the
mother put also the fetus at risk.

 Maternal weight gain

 SFH measure increasing and correlate with LMP & EDD
 Abdominal palpation, indicating, fetal parts, fetal movements, fetal heart rate
 Fetal movement is the most reliable indication of fetal wellbeing. Mothers should be
able to monitor fetal movements as from 26 weeks.
 Non stress test, Ultra sound and ECG can be used to check the fetal wellbeing.

Activity:Read Antenatal exercises & Post natal exercises Dippenaar 2013:218

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Unit 8.Management of Lactation /breastfeeding

• Anatomy of the breast

Structure of the female breast

The breast is made up of glandular tissue, fibrous tissue, adipose tissue and is covered on
the outside by skin
1.The skin of the breast
- Is covered with skin and sub- cutaneous tissue
- The nipple is covered with primary areolar tissue
- The areola is pigmented and is less smooth
1. Skin of the breast continue

- During pregnancy and lactation, the primary areola becomes more darker and is
known as secondary areola

- The glands in the areola is made up of sebaceous, sweat and montgomery’s glands

- The oily secretion from the glands provide a protective lubricant for the areola and
nipple

The adipose tissue

- Forms the bulk of the breast tissue

- Surrounds the breast and lobes of the glandular tissue

- The amount of adipose tissue present determine the size of the breast

3.The fibrous tissue

- The fascia on which the breast rest

- Sends out extensions in the form of fibrous processes

- From the back of the breast forwards to the sub-cutaneous tissue

- These processes are the suspensory ligaments of cooper

The glandular tissue

- There are fifteen to twenty lobes in each breast

- Made up of glandular tissue and ducts

- Each lobe is made up of thirty to forty lobules

- When fully developed each lobule consist of cluster of specialized alveoli

- Making up the secretory units of the glands

- The alveoli open up in tiny ducts which are the smallest ducts of the breast

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The nipple

• Is a small conical eminence at the centre of the breast

• It is surrounded by a pigmented area called the areola

• On the surface of the areola are numerous sebaceous glands (Montgomery’s

tubercles), which lubricate the nipple during lactation

Functions of the breast

• After the baby is born the hormone prolactin, stimulates the production of milk
• Oxytocin stimulates the release of milk in response to the stimulation of the nipple
by the sucking baby
Seller volume 1, P: 119
Dippenaar Page: 114
Study the diagram of the breast in your books

The diagram of a female breast

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Defi

Exclusive breast-feeding:
- Means to give an infant only breast milk; including expressed breast milk, with exception
of drops or syrups consisting of vitamins; mineral supplements or medicines. The
exclusively breast feed infant receives no drinks; (not even water) or food.

Replacement feeding.
- Is feeding the baby with any other food apart from breast milk.

Colostrum
Is the first breast milk which can be expressed from the breasts from the 16 th week of
pregnancy.

It is a clear; yellowish; alkaline fluid. Colostrum is high in protein and low in carbohydrates
and fat.
The fluid content is less than that of breast milk, but the kilo-joule value is 300 kJ/100ml;
which is high than that of breast milk

The functions of colostrum for the newborn baby

- Provides adequate kilojoules for the baby’s needs during the first few days of life
- Satisfies the baby’s hunger; because it has a high protein value
- Provides antibody protection from infection as it has a high level of immune-globulin
A (IgA)
- Bonding with the mother in the first days of life appears to be facilitated through
breast feeding
- Colostrum is thought to have a laxative action facilitating the passing of the sticky
meconium

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Advantages/benefits of breastfeeding

For the baby:

- It is always fresh
- It is safe and free from bacteria
- Breastfed babies are more healthy than bottle-fed babies
- Breast milk is naturally designed for babies, contains all the nutrients needed by the
baby in the right proportion
- It is easy to digest
- It has the right temperature
- Protect the baby against some diseases such as diarrhea and pneumonia
- Help baby to receive love from his/her mother
- Facilitates bonding between mother and baby
For the mother
- No costs involved
- It saves time
- Sucking helps the uterus to contract
- Help to prevent breast abscesses
- Helps mother to express love to he baby
- Delays ovulation and pregnancy

Disadvantages of breast milk

- If mother is HIV-positive, the baby will be exposed to HIV infection
- Exclusive breastfeeding is not adhered to sometimes
- Feeding on demand is difficult for women who work outside the house
- Mother requires a balanced diet with additional 500-750 kilo calorie per day to
practice exclusive BF-in the first 4-6 months

Tips for successful breastfeeding

- Initiate breastfeeding within ½ hour of birth with skin to skin contact
- Reinforce exclusive breastfeeding, no water, tea or food for the first 4-6 months for
every baby
- Explain dangers of mixed feeding and HIV transmission
- Demonstrate correct positioning and attachment to the breast
- Explain feeding on demand 8-12 times(both breasts) every 24 hours
- Remind to alternate breasts when starting to feed
- Teach mother to wake baby at night if enough feeds haven’t occurred
- Review health hazard of bottles, dummies, artificial teats, and cups with spouts
- Demonstrate how to express milk and feed with cup if breast problems occur

Ten steps to successful breastfeeding

Ten steps to successful breastfeeding

- Have a written breastfeeding policy that is routinely communicated to all health

care staff
- Train all health care staff in skills necessary to implement breastfeeding policy

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- Inform all pregnant women about the benefits and management of breastfeeding
- Help mothers initiate breastfeeding within half-hour of birth
- Show mothers how to breastfeed, and how to maintain lactation even if they should
be separated from their infants

- No food or drink be given to newborn infants other than breast milk, except vitamins
or medications

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

- Encourage breastfeeding on demand

- Give no artificial teats or pacifiers to breastfeeding infant

- Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the health facility

Activity

How to promote baby- mother -friendly initiative in community, home, workplace and
health facilities.

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Unit 9. Nutrition in pregnancy, birth and lactation

Define Nutrition

Is the science that interprets the nutrients and other substances in food in relation to
maintenance, growth, reproduction, health and disease of an organism. the process of
providing or obtaining the food necessary for health and growth

Nutrition- related physiology of pregnancy

Maternal nutrition during pregnancy, and how this impacts placental and fetal growth and
metabolism, is of considerable interest to women, their partners and their health care
professionals.

In developing countries, maternal undernutrition is a major factor contributing to adverse

pregnancy outcomes.

On the other hand, with the increased prevalence of high calorie diets and resulting
overweight and obesity issues in developed countries, the impact of this overnutrition
situation upon pregnancy outcome is highlighted as a contributing factor for adverse
metabolic outcomes in offspring later in life.

Undernutrition, overnutrition, and diet composition negatively impact fetoplacental growth

and metabolic patterns, having adverse later life metabolic effects for the offspring

Nutritional requirement during pregnancy

Eating right during pregnancy - Eating a well-rounded diet with all of the right nutrients
and getting at least 30 minutes of exercise per day is important for a healthy pregnancy.
For most normal-weight pregnant women, the right amount of calories is:

o About 1,800 calories per day during the first trimester.

o About 2,200 calories per day during the second trimester.
o About 2,400 calories per day during the third trimester

Most pregnant women can meet these increased nutritional needs by choosing a diet that
includes a variety of healthy foods.
A simple way to ensure you’re getting all the necessary nutrients is to eat different foods
from each of the food groups every day. In fact, all meals should include at least three
different food groups.

Each food group has something to offer your body. For example:

 Grains are a good source of energy.

 Fruits and vegetables are packed with antioxidants, fiber, and water-soluble and fat-
soluble vitamins.
 Meats, nuts, and legumes provide your body with protein, folate, and iron.
 Dairy products are great source of calcium and vitamin D.

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Nutrition needed for HIV-positive and lactating women.

Pregnant, HIV-positive women should be encouraged to obtain needed nutrients from a

balanced diet. At this time, no specific RDAs are available for pregnant, HIV-positive
women.

A prenatal multivitamin or micronutrient supplementation is likely to be beneficial and is

an easy, cost-effective means to improve maternal and neonatal health in addition to
nutrional requirements for a pregnant woman.

Activity

Define Lactation

Indicate the nutritional needs for a lactating woman.

Reference

1. UNICEFNamibia/2015/L/Narib- Promoting exclusive breastfeeding as a standard

practice for countering malnutrition in Namibia
Retrieved February 19 2020
2. Pauline M. Sellers, 2006: Midwifery volume 1. Juta & Co. S.A
3. Depp

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