Wateen For Obstetric

‫‪Wateen‬‬ ‫محمٍد ظلبُ‬
‫ُيريج طباػة امللف ورق ػلشان ًظهر بطورة منسقة ومرثبة غن امفون أو امالب ‪ ,‬والفضل ًمت‬
‫ثقس ميه ل ‪ 3‬أجزاء ( لك جزء ‪ ) 45‬ػلشان ًبقى أسهل ويكون مشجع ػيل قراءثه لكه ‪ً ..‬مت‬
‫امرتكزي ػيل أول ‪ 40‬ضفحة الن ال بؼد كدا مرتثب ػلهيم ‪ 20+‬ضفحة الس ئةل ال ىف أخر‬
‫املذكرة ‪..‬‬
‫ال حٍلقٍةوال إال باهلل^^ ‪...‬‬ ‫ال إلي إال هللا ‪ ...‬واصجغفر هللا ‪...‬‬ ‫هللا امبر ‪...‬‬ ‫‪...‬‬ ‫الحمد هلل‬ ‫صبحان هللا ‪...‬‬
‫‪1‬‬
‫‪Wateen‬‬ ‫محمٍد ظلبُ‬
‫بشم هللا الرحمن الرحّم ‪.‬‬

‫ّ‬
‫واح ُل ْن ُغ ْق َد ًة ِّمن ِل َشا ِهُ (‪ْ َِ )27‬ف َق ٌٍُا َق ٍْ ِلُ (‪)) )28‬‬
‫((‪َ ...‬ر ّب ْاظ َر ْح ِلُ َغ ْدري (‪َ )25‬وِ ِ ّش ْر ِلُ َا ْمري (‪ْ )26‬‬
‫ِ‬ ‫ِ‬ ‫ِ‬
‫صٍرة ـي ‪.‬‬
‫‪ ‬دغاء قبن المذامرة ‪...‬‬
‫‪ ‬اللٌم اهَ اصالك فٌم الوبّن وحفق المرصلّن والمالئلة المقربّن اللٌم اجػن لشاهَ غامرا بذمرك وقلبَ‬
‫‪...ツ‬‬
‫بخطّجك وصرى بفاغجك اهك غلَ ما ثطاء قدِر وحشبَ هللا وهػم الٍمّن‬
‫‪ ‬دغاء بػد المذامرة ‪...‬‬
‫‪ ‬اللٌم اهَ اصجٍدغك ما قرات وما حفظت فردى لَ غود حاججَ وال ثوشّوّي موي ظّائ إهك غلَ ما ثطاء‬
‫قدِر ‪...ツ‬‬
‫‪‬‬
‫املذكرة غبارة غن ثلخيص ملهنج امنسا ال أخدانه يف املكية ‪ ...‬فهيا أساس يات امنسا ال هيرتثب ػليه‬
‫أس ئةل الاهرتفيو ‪...‬‬
‫املطلوب قراءة امللف رسًؼ ًا‪ ,‬هو ضفحاثه كتيري شوًتني بس مع امقراءة برسػة وبؼد ثلخيص اس ئةل ال‬
‫‪ nursing intervention‬و مراحل تكوين اجلنني وامتغريات يف ادلورة امشهرًة وأشهر اخملاطر‬
‫والمراض اخلاضة ابمنسا هتاليق ادلهيا بس يطة وهتطفي مؼاك ػىل‪ 30‬او ‪ 40‬ورقة ‪...‬‬
‫اس تؼينوا ابمطور من ػىل امنتعمشان ثفهموا مراحل تكوين اجلنني ووضؼيات اموالدة وامتغريات‬
‫ابدلورة امشهرًة وغريه ‪...‬‬
‫ويريج امرتكزي ػىل أخر امطفحات ( اخر‪ 18‬ضفحة ‪ 9‬فهيا أس ئةل متنوػة ػىل امللف ‪...‬‬
‫ال ثنسوان من دغواتمك ‪ ...‬وربنا ًوفقمك وًؼينمك حبوهل وقوثه ^^ ‪..‬‬
‫القلٍب ‪َ ...‬و َؽ ْا َق ِب َما ِب ِي َّص‬

‫الػ ْد ُر َّصالر ِح ّْ ُ ‪...‬‬ ‫ُ‬ ‫ْ‬
‫اظجملت غلَ الّاس‬ ‫إذا‬
‫الخ ُف ٍْ ُب ‪...‬‬‫الملارى واصجقرت ‪َ ...‬و َا ْر َص ْت فُ َا َمام ِو ٌَا ُ‬
‫ِ ِ‬ ‫ُ‬ ‫و اوـوت‬
‫الؾر وجٌا ‪ ...‬و ال اغوَ بحّلجي االرِ ُ ‪...‬‬ ‫ً‬ ‫ّ‬ ‫َ‬
‫و لم ثر الهلطاف ِ‬
‫اللفّي المشجتّ ُ ‪...‬‬ ‫ُ‬ ‫ِمن بي‬‫‪ُّ ...‬ن‬ ‫غٍث‬‫قوٍو موك ُ‬
‫ثاك غلَ ٍ‬ ‫ا َ‬
‫ثواًت ‪َ ...‬ف َم ٍْ ُغ ٌٍل ِب ٌَا َف َر ٌج َق ْر َِ ُ ‪..‬‬ ‫الحادخات اذا ْ‬
‫ِ‬ ‫و ُّنمن‬
‫… ‪… Mahmoud shalaby‬‬
‫ال حٍلقٍةوال إال باهلل^^ ‪...‬‬ ‫ال إلي إال هللا ‪ ...‬واصجغفر هللا ‪...‬‬ ‫هللا امبر ‪...‬‬ ‫‪...‬‬ ‫الحمد هلل‬ ‫صبحان هللا ‪...‬‬
‫‪2‬‬
Wateen ُ‫محمٍد ظلب‬
 Obstetrics .  It’s a branch of medical science which deals with child birth and
concern with the care of the female during and after pregnancy .
 Gynecology .  It’s a branch of medicine , which deals with diagnosis , treatment and
prevention of pathology of the reproduction system .
 Maternity .  The state of being mother ( motherhood ) .
 Maternal and  It’s a branch of nursing which deals with the care of mother
child nursing . and children .
 Neonatal .  It’s the period from birth through 28th day of life .
 Fertility .  Between 15-44 years in women .
 Fetal death of  It’s the death in which the infant of 20 weeks or more gestational
still birth . age dies in utero prior to birth .
 Infant  The death of infant before the first birthday .

mortality .
 Maternal  Maternal death resulting from the reproductive process .
mortality .
 Maternal  Many women may suffer temporary or permanent disability or
morbidity . diseases or ill health due to complications of pregnancy e.g anemia ,
hypertension , uterine prolapse ..etc .
 Birth  It’s a legal responsibility evidence of age , citizenship and family

certificate . relationships .
 It’s required for military service , passports and to collect benefits on
retirement .
... ^^‫ال حٍلقٍةوال إال باهلل‬ ... ‫ واصجغفر هللا‬... ‫ال إلي إال هللا‬ ... ‫هللا امبر‬ ... ‫الحمد هلل‬ ... ‫صبحان هللا‬
3
 The goal of maternity care .
1 Keep human reproduction a normal physiologic process .

2 Protect the mother and her baby from any problems .
3 Provide physical and emotional support during the period of reproduction .
 Role of maternity nurse in modern maternity care .
1 Practitioner .
2 Teacher .
3 Counselor .
4 Diagnosing .
5 Clinician .
 Activities and practice of maternity care .
1 Provide family planning information and advice .

2 Diagnose and monitor pregnancies .
3 Provide a programme of parenthood preparation and complete preparation for childbirth .
4 Care for and assist the mother during labor .
5 Conduct spontaneous deliveries .
6 Recognize the warning signs of abnormalities in the mother and infant .
7 Examine and care for the new born .
8 Carry out the treatment prescribed by a doctor .
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 Principles of maternity nurse practice .
1 Working in a positive relationship with women .

2 Avoiding harm by using the best information .
3 Having adequate skills to deliver effective care and support .
4 Promoting health and well being .
5 Women centered care .
6 Appropriate support for maternity nurse .
7 And interface with other professional , midwives , doctors , nurses
and health visitor and hospitals and mechanisms for consultation
, referral and transfer .
8 Cost effectiveness .
 Direct ( main ) causes of maternal mortality .
1 Hemorrhage .
2 Hypertension .
3 Genital sepsis .
4 Medical disorder ( e.g heart disease or anemia ) .
5 Thromboembolism .
6 Postpartum collapse due to :-
 Hypovolomic shock .
 Neurogenic shock .
 Septic shock .
 Cardiogenic shock .
 Amniotic fluid embolism , eclampsia .
 Indirect causes of maternal mortality .
1 Cardiovascular disease .
2 Anemia .
3 Infectious diseases .
4 Hepatitis .
5 Diabetes .
6 Neoplasm .
7 Neurological disorders .
5
 Reduction maternal mortality .
1 Improvement ( blood transfusion , antibiotics anesthesia

management and correct electrolyte balance ) .
2 Development of training and education programs in obstetric

and maternity care .
3 Better hospital facilities .
4 Antenatal care .
5 Training of traditional birth attendance ( conduct deliveries

without license and have less information ) .
 Problems of traditional birth attendance .
1 Lack of scientific medical information .
2 Prescription of folk medicine .
3 Inability to differentiate between normal and abnormal labor .
4 Using of some drugs improperly will lead to dangerous effect .
5 Unaware about the principles of sterilization and disinfection .
6 All instruments they keep are unsterile .
7 Doctors and professional midwives view of the traditional birth

attendance group is an underestimating view .
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 The female bony pelvis .
1 Support and protect the pelvic content .

2 Accommodation of the growing fetus .
3 Form the relatively fixed axis of the birth passage .
 The structure of the bony pelvis ( 4 bones ) .
1 Two innominate ( hip bones ) .

2 The sacrum .
3 The coccyx .
 Pelvic ossification is complete by 20 years of age .
 The two innominate bones .
 Divided into 3 parts :-

1 The ilium :- the broad and upper prominence of the hips .
The iliac crest is the margin of the ilium .
2 The ischium :- the strongest bone , lies under the ilium .

 Its base is the ischial tuberosity ( can be palpated when
sitting ) .
 Above the tuberosity is the ischial spine ( estimation the level
of the fetus head depend on it during labor ) .
3 The pubis :- forms the anterior portion of the innominate bone .
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 The sacrum .
 Wedge shaped bone , consists of 5 fused vertebrae .

 Sacral promontory ( in the upper portion of the sacrum ) .
 The coccyx .
 Small triangular , below the sacrum , last on the vertebral column .

 Move backward during labor to provide more room for the fetus .
 Joints of the pelvis ( 4 joints ) .
1 Two sacro iliac joints .
 The strongest joint in the body .

 Join the sacrum to the ilium thus connect the spin to the pelvis .
 Provide little movement of the sacrum during labor .
2 Sacro coccygeal joint .
 Join the sacrum to the coccyx .

 Allow the coccyx to bend backwards during labor .
3 Symphysis pubis joint .
 Unites the two pubic bones anteriorly .
 Ligaments of the pelvis .
 Is a band of rough tissue connecting bones , holding them

in position .
 Each of pelvic joint is held together by ligaments .
1 Sacro-iliac ligaments .
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2 Sacro-coccygeal ligaments .
3 Sacro-spinous ligament .
 Connect the sacrum to the ischial spine .
4 Sacro-tuberous ligament .
 Connect the sacrum to the ischial tuberosity .
5 Pubic ligaments .
 Division of the pelvis ( true and false ) .
A- The false pelvis .
 The part above the inlet and plays no part in children .

Cavity of it is shallow .
B- The true pelvis .
 It forms the bony passage through which the fetus must

pass during labor and birth .
 Cavity of it is an irregularly curved canal .
 It consists of 3 planes :-
1 The inlet ( The brim ) .
 Upper border of the true pelvis .
2 The midpelvis ( pelvic cavity ) .
 Space between the inlet and outlet .
 It’s a curved passage ( slow and control the passage of fetus through it to
prevent any pressure on the fetal head ) .
3 The outlet .
 The lower portion of the pelvis .
 Viewed from below ( ovoid or diamond shape ) .
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 Bounded by anteriorly ( with pubic arch ) , posteriorly ( the tip of the

coccyx ) , laterally ( ischial tuberosity ) .
 Types of pelvis ( 4 ) .
 Gynecoid ( the classic female type , 50 % of woman ) .

 Android ( represent the male pelvis , 23 % of woman ) .
 Anthropoid ( 24 % of woman ) ( the flat pelvis ) .
 Platypelloid (3%of woman ) ( the flat pelvis ) .
 Mons pubis ( mons veneris ) .
 It’s Hair covered fat pad .

 Lying over the symphysis pubis .
 Labia Majora .
 Two rounded folds of fatty tissue covered with skin .

 Highly vascular structure .
 After puberty the hair develop on its outer surface .
 Protect the inner valvular structure .
 Labia Minora .
 Two flat , reddish folds of tissue.
 Anteriorly , they fuse to form the prepuce ( covering of the
clitoris ) and the frenulum ( a fold of tissue under the clitoris ) .
 It joins to form the fourchette under the vaginal opening at the
midline .
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 Clitoris .
 An erectile organ ( composed of erectile tissue with numerous

sensory nerve endings ) .
 Vestibule .
 An almond ( like eyes ) area enclosed by the labia minora .

 It contains opening to the urethra , Skene glands , vagina , and
Bartholin gland .
 Skene glands :- located on each side of the urethra .
 The hymen :- connective tissue membrane , surrounds the
vaginal opening .
 Bartholin gland :- located posteriorly on the sides of the
vaginal opening .
 The glands during sexual intercourse produce mucus for
lubrication of the vagina .
 Perineum .
 The area between the fourchette and the anus .

 A skin covered muscular area that Covered pelvic structure .
 Vagina .
 Lie between the bladder and rectum .

 The upper end of it is the vault .
 The cervix projects into the vault forming four Fornices ( posterior ,
anterior and two laterals ) .
11
 The vaginal walls are pink and thrown into small folds to ease
stretching .
 The acid medium of it prevent inhabitation of organisms .
 Function .
1 Passage for menstrual flow .

2 Receive the penis and sperm .
3 Passage for the fetus during labor .
 Uterus .
 Pear shaped muscular organ .

 7.5 cm ( long ) , 5 cm ( wide ) , 2.5 cm ( depth ) , Weight 57 gram .
 It made of
1 The body ( corpus ) .

 Round upper most portion of the uterus ( the fundus ) .
 Within it , is the insertion of the fallopian tubes ( cornu or the horn
of the uterus ) .
2 Isthmus .
 Area of connection between the cervix and the corpus .
 In pregnancy it enlarges to form lower uterine segment .
3 Cervix ( neck of the uterus ) .
 Lowest portion of the uterus , protrudes into the vagina .
 Made up of fibrous connective tissue and elastic tissue enable it to
stretch during vaginal childbirth .
 It has :-
 Internal os :- opening between uterine cavity and the
endocervical canal .
 endocervical canal :- between external and internal os .
 external os :-opening between the endocervix and the vagina.
 It feels firm with a dimple in the center which marks the external os .
12
 Layers of the body of the uterus ( 3 ) .
1 The endometrium .
 Highly vascular lining made up of 3 layers , the outer 2 of which
are shed during menstruation .
2 Myometrium ( muscle coat ) .
 Made up of layers of smooth muscle that extends in 3 different
direction ( longitudinal , transverse and oblique ) .
 The purpose of extending is to assist in expelling the fetus during
the birth process ( outer myometrial ) , constricting blood vessels
after child birth and control blood loss ( middle myometrial ) .
 Fibers of inner myometrial keep the cervix closed during
pregnancy and prevent menstrual blood from flowing back during
menstruation .
3 Peritoneal coat ( Perimetrium ) .

 The outside lining of the uterus .
 Position of the uterus .
 Central cavity of the true pelvis , with the external os at level of

the ischial spine ( when bladder empty ) .
 Normally is anteverted anteflexed .
 Anteverted :- the cervix is bent forwards on the vagina
forming an angle of about 90 degree .
 Anteflexed :- means the body is bent forwards on the cervix
forming an angle of about 160 degree .
 Anterior :- lie utero-vesical pouch and the bladder .

 Posterior :- lie the recto-uterine pouch of Douglas and the rectum .
 Lateral :- broad ligaments , the uterine tubes and the ovaries .
 Superior :- lie the intestine .
 Inferior :- lie the vagina .
13
 Supports of the uterus .
 It’s supported by the pelvic floor muscles and maintained in

position by several ligaments :-
 The transverse cervical ligaments .
 The uterosacral ligaments .
 The broad ligaments ( from the folds of peritoneum ) .
 The round ligaments ( from the cornu anteriorly ) .
 The ovarian ligaments ( from the cornu posteriorly ) .
 Function of the uterus .
1 Receive the fertilized ovum from the fallopian tube .

2 Implant the fertilized ovum .
3 Offer nourishment and protection to the growing fetus .
4 Expulsion of the fetus during childbirth .
5 For cyclic menstruation .
 Fallopian tubes .
 Extends laterally from the cornu of the uterus toward the side
walls of the pelvis .
 It covered by the broad ligament .
 10-11.5 cm ( long ) .
 Divided into ( 4 parts ) .
 The interstitial portion ( 1.25 cm lies within the wall of the uterus ) .
 The isthmus ( narrow part extends from the uterus 2.5 cm ) .
 The ampulla ( the widest part 5 cm long , fertilization usually
occurs in it ) .
 The infundibulum ( funnel shaped , has finger called fimbria ,
attached to the ovary ) .
14
 Function of the fallopian tubes .
1 Transport the ovum from the ovary to the uterus .

2 Site of fertilization .
3 Provide nourishing environment for zygotes .
 Ovaries .
 2 almond shaped glandular structure .

 4 cm in length , 2 cm in wide , 1.25 cm in diameter .
 Composed of :-
 The medulla ( supporting framework for the ovary ) .
 The cortex ( active part of the ovary, contains the ovarian follicles in
different stages of development ) .
 Function of ovaries .
1 Production of ova .
2 Production of estrogen and progesterone .
 Accessory organs of the female reproductive system .

They over lie pectoralis major muscles .
 Extend from the 2 to 6 ribs and from the sternum and axilla.
 Each breast has a nipple surrounded by circular area of pigmented

skin called the areola .
 Each milk gland of the breast divided into 20 lobes which are
divided into lobules .
15
 All of the glands in each lobe produce milk by acinar ( alveolar )

cells and deliver it to the nipple via a lactiferous duct .
 The nipple has 20 small opening through which the milk secreted .
 Ampulla ( lactiferous sinus ) portion of the duct , located posterior

to the nipple ( reservoir for milk before breastfeeding ) .
 Cooper’s ligaments ( fibrous suspensory ) separate and support the

glandular structure and ducts .
 Scrotum .
 Muscular pouch suspended from the perineum .

 Support the tests and regulate the temperature of the sperm .
 Testis .
 Two ovoid glands .

 Each one is composed of several lobules containing interstitial cells
( Leydig’s cells ) and a seminiferous tubule .
 Leydig’s cells responsible for the production of testosterone .
 seminiferous tubule produce spermatozoa .
 Penis .
 Composed of 3 cylindrical masses of erectile tissue ( 2 corpus

cavernosa , 1 corpus spongiosum ) .
 A distal end is bulging , sensitive ridge of tissue , the glans , the
prepuce ( remove surgically after birth – circumcision - ) .
16
 Epididymis .
 Responsible for conducting sperm from seminiferous tubule to the

vas deferens .
 Some sperm are stored in it and receive their nutrients from the
cells lining the epididymis .
 Sperm are immobile and incapable of fertilization as they stored
in the epididymis .
 Sperm takes 12-20 days for travel through the epididmyis and 64
days for reach maturity .
 Vas deferens ( Ductus deferens ) .
 Hollow tube surrounded by arteries and veins and protected by a

thick fibrous coat .
 It carries sperm from the epididymis through inguinal canal into
the abdominal cavity , where it ends at the seminal vesicles and
ejaculatory ducts .
 Sperm mature as they pass the vas deferens , they are still
immobile due to acidic medium of the semen produced at this
level .
 Blood vessels and vas deferens ( called the spermatic cord ) .
 Seminal vesicles .
 Two pouches lie along the lower portion of the posterior surface of
the bladder and empty into urethra by ejaculatory ducts .
 They secrete a viscous alkaline liquid that has a high sugar ,
protein and prostaglandin content ( so sperm is become motile ) .
17
 Ejaculatory ducts .
 Two ducts pass through the prostate gland and join the seminal
vesicles to the urethra .
 Prostate gland .
 Lie below the bladder .

 It secrete a thin , alkaline fluid ( with the secretion of the seminal
vesicles , protect the sperm of being immobilized by the naturally
low pH level of the urethra ) .
 Bulbourethral glands ( Cowper’s glands ) .
 Two glands lie beside the prostate gland and empty via short
ducts into the urethra .
 They also secrete fluid like seminal vesicles and prostate gland .
 So semen is derived from 60 % ( prostate ) , 30 % ( seminal
vesicles ) , 5 % ( epididymis ) and 5 % ( bulbourethral ) .
 Urethra .
 It’s a hollow tube leading from the base of the bladder to outside
of the body ( it lined with mucous membrane ) .
18
 Menstruation .
 Monthly cyclic as shedding of blood and mucous epithelial cells

from the uterus .
 Ovulation .
 Discharge of the mature ovum from the ovary .
 Menarche .
 The first menstruation starts at the age of 8-16 years .

 For most girls it’s 12-13 years .
 Characteristics of normal menstruation .
 Rhythm :- every 21-35 days ( average 28 days ) .

 Duration :-2-7 days ( average 3-5 days ) .
 Blood loss 30-80 mls .
 Iron loss :- 0.5 – 1 Mg .
 Poly menorrhea < 21 days , Oligomenrrhea > 35 days .
 Hypomenorrhea < 2 days of duration , menorrhagia > 7 days .
 Hypomenorrhea < 30 ml of blood loss , menorrhagia > 80 ml .
 Periodic changes occur in the cortex of the ovary under

the control of pituitary hormones .
19
 Phases of the cycle .
 Follicular phase .
 It starts on 1 day of the menstrual cycle and continues until

ovulation ( 10-14 days ) .
 Follicles in the ovary grow and form a mature egg .
 Hypothalamus initiates this phase ( increase level of estrogen from
the maturing follicular cells ) .
 The dominant follicle cell induce the proliferation of the
endometrium and myometrium ( the thickening support an
implanted ovum ) .
 The pituitary gland release FSH which stimulates the ovary to
produce 5 -20 immature follicles .
 The anterior pituitary gland secrete LH ( luteinizing hormone )
which is responsible for affecting the final development and
rupture of the mature follicle .
 Ovulatory phase .
 After ruptures of mature follicle it releases a mature ovum

( oocyte ) .
 It occur in 14 day in a 28 day cycle .
 When ovulation occur drop of estrogen is dropped .
 Ovulation take place 10-12 hrs after the LH peak and 24-36 hrs
after estrogen level peak .
 The life span of ovum is only 24 hrs .
 During ovulation the cervix produces thin , clear , stretchy ,
slippery mucous that help sperm to travel to meet the ovum for
fertilization .
 Ovulation take place 14 days before menstruation .
20
 Luteal phase .
 Begins at ovulation and lasts until menstrual phase of the next

cycle .
 After rupture of follicle and releases the egg , it close and form
Corpus luteum ( secrete progesterone ) .
 Progesterone induces the endometrial glands to secrete glycogen ,
mucus and substances for implantation and it rises the body
temperature ( 0.5-1 F degree for 12-16 days ) .
 In the absence of fertilization The corpus luteum begins to
degenerate and ovarian hormone levels decrease .
 Due to decrease of estrogen and progesterone the endometrium
undergoes involution .
 FSH and LH are generally at their lowest levels during luteal

phase and highest during the follicular phase .
 It’s the cyclic change occur in endometrium in response to

the cyclic change occur in the ovary ( regulate by estrogen
and progesterone ) .
 Phases of the cycle .
 Proliferative phase ( Follicular ) .
 Start with enlargement of the endometrial glands due to

increasing amount of estrogen .
 Blood vessels become dilated and the endometrium increases in
thickness .
 Lasts from day 5 of the menstrual cycle to the time of ovulation .
21
 Secretory phase ( Luteal ) .
 It follows ovulation to about 3 days before the next menstrual

period .
 It occurs under progesterone level .
 The endometrium becomes thickened and more vascular ( growth
of spiral arteries ) and glandular ( secreting more glycogen and
lipids ) for implantation .
 Menstrual phase .
 It begins as the spiral arteries rupture secondary to ischemia ,

releasing blood into uterus and the endometrium is sloughed off
and passes out via the vagina .
 Most women report bleeding for an average of 3-5 days .
 Nursing management of normal menstruation .
 Assess color , odor and amount of blood .

 Psychological and emotional support .
 Sexual intercourse should be prohibited .
 Bathing regularly .
 Sanitary pad should be applied .
 Good perineal and hygienic care .
 Mild analgesics .
 Increase intake of warm fluids .
 Eat well balanced diet rich in iron to replace blood loss .
22
 There are two glands that produce the hormones

that regulate ovulation :-
 Hypothalamus ( secrete lutenising hormone releasing hormone

– LHRH – stimulate the pituitary gland ) .
 Pituitary gland ( produce FSH , LH ,Leutotrophic hormone –LTH-).

 FSH and LH ( called gonadotrophins ) .
 FSH :- initiation of follicle growth .
 LH :- transformation of the lining granulosal cells into

luteal cells after escape of the ovum .
 LTH :- Growth and maintenance of the Corpus luteum .
 The union of a single egg and sperm .

 The ovum present in ovarian follicle .
 At the time of ovulation the follicle growth and increase in size due
to accumulation of fluid .
 During growth of the follicle the ovum enlarges and in 36 hrs it
undergoes a major process of maturation .
 Lutenizing hormone (LH) :- stimulate ovulation ( tiny open in the

follicle occur ) , the ovum and little fluid escapes and the fimbriae
of fallopian tube catch it .
 High estrogen level increases the motility of the uterine tubes so

the cilia of it capture the ovum toward uterine cavity .
23
 Two layers surround and protect the ovum ( Zone pellucida – the
inner - , corona radiate – the outer - ) .
 Ovum is fertile for 24 hrs after ovulation if it doesn’t unfertilized

by a sperm it degenerates and is reabsorbed .
 Characteristics of normal sperm .
 Volume of semen 1.5 – 6 mls .

 Density of sperm at least 20 million per ml .
 Sperm remain viable with the woman’s reproductive system for
2-3 days .
 Is the process by which a sperm fuses with an ovum to

form a new diploid cells or zygote ( it occur in the ampulla
of the fallopian tube ) .
 The process of fertilization .
 Sperm deposition .
 At sexual intercourse the male deposits between 200-500 millions

spermatozoa in about 3ml of seminal fluid in the female vagina .
 Sperm transport .
 The sperm take 2-7 hrs from the cervix to the fallopian tube .
 Fructose in the seminal fluid is the energy source for the sperm .
 Sperm move by the tails of its structure ( fragella movement ) .
24
 Ovum transport .
 After ovulation it moves by the cilia lined the tube and the
peristalsis movement of the fallopian tube to the ampulla .
 Sperm capacitation .
. ‫القدرة الجلقّحّة‬
 It’s a physiologic change that removes the protective coating from
the head of the sperm to fertilize the ovum .
 It takes about 7 hrs .
 The acrosomal reaction .
 It follows the capacitation .

 The acrosome caps of the sperms surrounding the ovum release
their enzymes which break down the outer layer of the ovum .
 Cortical reaction .
 After penetration of a fertilizing sperm the zone pellucid of the

ovum undergoes a reaction that prevents additional sperm from
entering the ovum .
 Fusion of ovum and sperm .
 After the sperm enters the ovum , the second meiotic division is
completed forming the nucleus of the ovum and ejecting the
second polar body then the nuclei of the ovum and sperm is fused (
produce diploid zygote 46 chromosomes ) .
 The ovum contain one X chromosome and the sperm contain X or Y
( XX =female , XY=male ) .
 Intrauterine development is divided into 3 stages :-

 Ovum ( Preembryonic stage ) .
 Embryo .
 Fetus .
... ^^‫ال حٍلقٍةوال إال باهلل‬ ... ‫ واصجغفر هللا‬... ‫ ال إلي إال هللا‬... ‫ هللا امبر‬... ‫الحمد هلل‬ ... ‫صبحان هللا‬
25
 The first 14 days of human development starts after

conception .
 The development after fertilization can be divided into two
phases :
1 Cellular Multiplication .
 Begins as the zygote move through the fallopian tube toward the
cavity of the uterus ( this transport takes 3 days or more ) .
 The zygote then enters a period of rapid mitotic divisions called
Cleavage .
Cleavage .
 Is the division of zygote that occur after fertilization and
before implantation .
 During cleavage the zygote divides into 2 cells , 4 cells , 8 cells

these called ( Blastomeres ) .
 The blastomeres are held together by the inner layer of the

fertilized ovum ( zona pellucid ) .
 The blastomeres will eventually form a solid ball of 12-16 cells

called The Morula .
 As the morula enter the uterus :-

 The intracellular fluid in the morula increases and a central cavity
forms within the cell mass .
 Inside this cavity is an inner solid mass of cells called blastocyst .
 The outer layer of cells that surround the cavity is called
Trophoblast .
26
 At the end , The trophoblast develops into one of the embryonic

membranes called the chorion .
 The blastocyst develops into a double layer of cells called the
embryonic disc ( which the embryo and the amnion will develop ) .
 Is the embedding of the developing blastocyst in the

uterine wall 7-10 days following fertilization .
 After implantation the endometrium ( Deciduas ) is
differentiated into 3 layers :-
1 Decidua basalis :- the part of the endometrium between the
fertilized ovum and the muscular wall of the uterus .
It unite with the chorion to form the placenta .
2 Decidua Capsularis :- the part of the endometrium that covers

the fertilized ovum superficially .
3 Decidua Vera ( parietal deciduas ) :- form the rest of endometrial

lining of the uterine cavity which is not in contact with ovum .
2 Cellular differentiation .
 About 10-14 days after conception , the inner cell mass of

blastocyst differentiates into the primary germ cells layers
( the ectoderm , mesoderm , endoderm ) .
 The ectoderm ( upper layer of the embryonic disc ) give

rise to :-
 Epidermis glands , nail and hair .

 Central and peripheral nervous systems .
 Lens of the eye .
 Floor of the amniotic cavity .
27
 The mesoderm ( middle layer ) develop into :-
 Bones and teeth .

 Muscle , dermis and connective tissue .
 Cardiovascular system and spleen .
 Urogenital system .
 The endoderm ( lower layer ) gives rise to :-
 The epithelium lining of respiratory tract and digestive tract .

 Forms the roof of the yolk sac .
 The stage lasts from day 15 to 8 weeks after conception .

 In , this stage the development of the organ systems and the main
external features is occurred .
 The embryonic membranes .
 The Chorion the first outer membranes develop from the

trophoblast , has many fingers like projections called Chorionic
villia .
 The amnion the second inner membrane develop from the inner
cell mass ( blastocyst ) , it contain the amniotic fluid .
 Amniotic fluid .
 Come from the maternal blood , the amount increases weekly .
 The normal amount 800-1200 ml of liquid .
 Having less than 300 ml is associated with fetal renal
abnormalities ( oligohydramnios ) .
 Having more than 2 L of amniotic fluid is associated with GIT and
other malformation ( Hydramnios ) .
28
 Function of amniotic fluid .
1 Protect the embryo against mechanical injury .

2 Control the embryo’s temperature .
3 Permit symmetric external growth and development of the
embryo .
4 Allow the umbilical cord to be free from compression .
5 Allow freedom of movement and prevent adherence to the
amnion .
6 Allow fluid for analysis to determine fetal health and maturity .
 Yolk sac .
 Small and functions only in early embryonic life .

 Develops as a second cavity in the blastocyst ( 8-9 days after
conception ) .
 Form primitive RBCs during the first 6 weeks of development until
the embryo’s liver takes over the process .
 It help in transferring maternal nutrition and oxygen .
 As the embryo develops it join in the umbilical cord .
 Umbilical cord .
 2 cm in diameter , 55 cm in length .
 During the 5th week , the embryo has curved inward on itself from
both ends bringing the connecting stalk to the ventral side of the
embryo .
 The connecting stalk becomes compressed from both sides by the

amnion and forms the narrower umbilical cord ( two arteries carry
blood from the embryo to the chorionic villi , one vein carry blood
to embryo ) .
29
 Placenta .
 It doesn’t develop until the third week of embryonic development .

 15-20 cm in diameter , 2.5-3 cm in thickness .
 It weighs 400-600 gram .
 Developent of the organs .
1 The complete formation of spinal cord is at 20 weeks .
2 The complete formation of brain is at 28 weeks .
3 The complete formation of the heart at 6 weeks .
4 The complete formation of the eyes, limbs and face is at 8 weeks .
5 The complete formation of liver and spleen is at 12 weeks .
6 The complete formation of genital system is at 7 weeks .
 Factors influencing embryonic and fetal

development .
1 Quality of the sperm or ovum .
2 The genetic code established at fertilization .
3 The adequacy of the intrauterine environment .
30
 Changes in the reproductive system during

pregnancy .
 Uterus .
 Size :- increase to 20 times of it non pregnant state due to
hyperplasia and hypertrophy .
 Hyperplasia :- increase in the number of muscle fibers
( progesterone effect ) .
 Hypertrophy :- increase in the size of the muscle fibers
( Estrogen effect ) .
 Weight :- increase from 50 to 1000 grams .

 Contraction :- strong coordinated waves of contraction .
In early pregnancy known as Palmer’s sign .
 From the 16th week can be seen and felt abdominally and known as
Braxton Hicks’ sign .
 Shape :- changes from inverted pear shape to soft globe .

 Location :- change from pelvis to abdominal cavity .
 Increase in uterine blood flow and lymph causes pelvic congestion

and edema ( the uterus ,cervix and isthmus soften and the cervix
take a blue discoloration Chadwick’s sign ( the 6th week ) .
 Widening of the isthmus of the uterus between 6th and 12th weeks
of gestations .
 Softening of the isthmus is one of the most important signs of
pregnancy Hegar’s sign .
31
 Cervix .
 Softening of the cervix Goodell’s sign .
 The cervical canal is filled with a thick plug of mucus ( opreculum )
that protect the fetus and fetal membranes from infection .
 Vagina .
 Increase circulation to it which changes color from normal light

pink to a violet coloration Chadwick’s sign .
 Bluish purple or violet discoloration of vagina .
 Vulva .
 Increased vascularity .
 Fat deposition causes labia majora to close .
 Changes of the breast .

 Enlarge in size , become warmer , knotty and slightly tender .
 Vascularity .
 It increase in the 6th weeks and detect by appearance of dilated veins
under skin .
 Nipples and areola .
 The nipples enlarge in size, become more erectile and deeply pigmented.
 The areola increases in size and becomes deeply pigmented ( primary
areola between 6-8 week ) .
 At the 16th week another pigmentation appears around the primary
areola ( secondary areola ) .
 Montgomery’s follicles ( glandular tubercles ) .

 They hypertrophy and become more prominent ( near the base of
nipple and among the primary areola ) .
32
 Secretion .
 Thin , clear , serous secretion ( early in pregnancy ) .
 Thick and opalescent ( colostrum ) by the 12th week .
 Copious , yellowish and thicker ( end of pregnancy .
 Changes in respiratory system .
 Estrogen causes edema of mucous membranes of upper tract and

vascular congestion of the nasal mucosa ( epistaxis ) .
 Shortness of breath and dyspnea ( enlarged uterus ) .
 Basal metabolic rate increases and O2 requirement increases .
 Changes in Cardiovascular system .
 Heart rate increases by 10-15 beats/minutes .

 Blood volume increase ( physiological anemia due to dilution of
blood ) .
 Hemoglobin and hematocrit decrease due to increase volume .
 Cardiac output increases .
 Increase in clotting factors .
 Enlarging uterus may put pressure on the vena cava when the
woman is supine result in Supine hypotensive syndrome ( vena
cava syndrome or aortocaval compression ) .
 Avoid supine position by lying position .
 Arise slowly from a lying position .
 Wear support hose and avoid constipation to decrease formation
of varicose veins .
33
 Changes in GIT system .
 Gums become hyperemic .

 Ptyalism may increase ( the secretion of saliva ) .
 Heartburn and esophageal regurgitation and constipation
(enlarging uterus ) .
 Morning sickness .
 Hyperemesis ( more or severe nausea and vomiting ) .
 Pregnancy pica ( changes of appetite ) .
 Changes in elimination processes .
 Decrease bowel sound .

 Constipation .
 Hemorrhoids ( due to pelvic pressure ) .
 Urinary frequency .
 Changes in skin ( integumentary ) .
 Changes in skin pigmentation .

 Pigmentation of skin increases in the areola , nipples , vulva ,
perineal area and lineanigra ( dark brown line appears on the
abdominal wall between umbilicus and symphysis pubis ) .
 Butterfly pigmentation may appear on the forehead , cheeks and
nose Fascial chloasma ( the mask of pregnancy ) .
 Striaegravidarm ( stretch marks ) :- pink lines in the skin around
the umbilicus and may appear in the skin of breast , thigh and
buttock .
 It become white in colore after delivery and called Striaealbicans .
 Increase of hair growth .
34
 Changes in Central nervous system .
 Decreased attention , concentration and impaired memory .

 Sleep problems ( difficult to sleep ) .
 Changes in Musculoskeletal system .
 Lordosis due to increased progesterone and relaxation hormone .

 Relaxin hormone soften pelvic ligaments and joints .
 Increase calcium and Phosphorus need .
 Changes in metabolic .
 Increase metabolic rate .

 Increase the demands for carbohydrate, fat , protein and mineral .
 Weight gain ( 12-15 KG in total ) .
 Water requirement is increased to supply fetus , placenta and
amniotic fluid .
 Changes in Endocrine system .
 Suppression of FSH and LH production .

 The placenta produce new hormones :-
 Human chorionic gonadotropin .
 Human placental lactogen ( antagonist of insulin ) .
 Estrogen .
 Progesterone .
 Relaxin .
35
 Human chorionic gonadotropin ( hCG ) .

 It maintains pregnancy .
 It stimulates the release of estrogen and progesterone from the
corpus luteum cells of the ovary .
 Its level is high until the placenta begins to mature and take over
production of estrogen and progesterone .
 Human placental lactogen ( hPL ) .

 Secreted from syncytiotrophoblast of the developing placenta .
 It’s needed to help support maternal metabolic needs and
decreases the maternal metabolism of glucose thus making more
glucose available to meet fetal nutritional and metabolic needs .
 Placenta ( Estrogen and progesterone ) .

 It act as a temporary endocrine gland during pregnancy .
 It maintain the growth of the uterus and help control uterine
activity .
 It produces estrogen and progesterone ( by 10-12 weeks) .
 Estrogen .
 Early produced by ovary then by placenta .
 It stimulates uterine growth , increase blood flow to the uterus .
 Increase vascularization .
 Skin hyperpigmentation .
 Increase salivary glands .
 Hyperemia of gums and nasal mucus membrane .
 Support breast .
 Help in relax of pelvic ligament .
 Support fetal development .
36
 Progesterone .
 Early produced by corpus luteum and then by placenta .
 Support and maintain implantation of the developing embryo in early
pregnancy .
 With estrogen inhibits production of FSH and LH .
 Relaxin .
 Is produced by the corpus luteum and placenta .

 Inhibits uterine activity .
 Softens connective tissue in the cervix .
 Relax the cartilage and connective tissue of pelvic joints .
 Enlargement of the pituitary gland .
 Posterior pituitary gland secrete oxytocin near the end of the term .
 It stimulates contractions of the uterus during labor , delivery and
involution .
 At birth the pituitary gland secrete prolactin for production of milk .
 Psychological changes during pregnancy .
 Mood swings ( great joy to deep depression ) .

 Tearful .
 Increase need for affection .
 Fear and anxiety .
 Greater irritability.
 Headache , insomnia , palpation and dry mouth due to anxiety .
37
 Sources of psychological stress .
 Changes of body image ( loss of attractiveness , changes in sexual

interest ) .
 Concerns about health of the baby and labor process .
 Unexpected pregnancy .
 Financial situation , cultural expectation .
 It’s important to listen to the woman , let her talk and answer her
questions .
 Trimesters of pregnancy .
 First :- up to 12 weeks .
 2nd :- from 13 to 27 weeks .
 3rd :- from 28 till delivery .
 Depends on signs and symptoms and investigations .

 The signs and symptoms divided into 3 groups :-
 Presumptive sign ( Possible ) .
 It may or may not be associated with pregnancy
( subjective sign ).
 Vomiting , increase vaginal discharge , breast changes .
 Probable signs .
 It detected by a trainer examiner ( objective signs ) .
 It may or may not be associated with pregnancy .
 Hegar’s sign , Goodell’s sign , Chadwick’s sign .
38
 Positive ( sure signs ) .

 Caused by pregnancy .
 Hearing fetal heart rate .
 Feeling of fetal movement .
 Fetal parts felt by examiner .
 The care of pregnant women from time pregnancy is

confirmed until the beginning of labor .
 It’s a comprehensive health supervision of a pregnant
women so that she will be able to go through pregnancy ,
labor and puerperium without complication to herself or her
baby .
 Consists of .
 History taking .
 Physical examination .
 Special investigations .
 Instruction or advice to the pregnant mother .
 Reassurance .
 Objectives .
 Conduct the initial visit ( include medical , obstetrical and family

health history ) .
 Conduct a complete physical exam .
 Order and evaluate appropriate lab diagnosis and investigations .
39
 Identify deviation from the normal course of pregnancy .

 Define the plan of care ( nutritional , physiological changes ,
exercise and stress management , danger signs when to contact the
care provider ) .
 Components of antenatal care to achieve the

objectives .
 Medical and obstetrical supervision .

 Psychological care .
 Social care .
 Health education .
 Documentation .
1 Medical and obstetrical supervision .

A History .
 Identification information ( name , age …etc ) .
 Menstrual history ( age at menarche , last menstrual …etc ) .
 Obstetric history ( OB ) :- gravidity ( number of pregnancy ) , parity (
number of viable deliveries ) , abortion , labor .
 Gynecologic history :- past and current problems ( vaginitis , infertility ,
sexually transmitted disease ) .
 Contraceptive history .
 Medical history :- including substance use , allergies and any previous
transfusions .
 Surgical history .
 Family history :- diabetes , cancer , and any chronic disease .
 Social and cultural history .
40
 Occupational history :- exposure to toxic substance , heavy lifting ,

night work .
 Any exposure to :- tobacco , street drugs , toxoplasmosis .
 Calculating the expected date of delivery .
 Menstrual delivery interval :-
 280 days = 40 weeks = 10 lunar months = 9 calendar months and

one week .
 Neagele’s rule :- is the estimated date of delivery ( EDD ) by

adding 7 days and 9 calendar months to the date of the woman’s
menstrual period .
 Or First day of LMP + days – 3months + 1 year .
 If the woman forget the date of Last menstrual period .

 Determine it through :-
 Date of Coital delivery interval ( add 270 days to this date ) .
 Date of Quickening delivery interval ( add 22 weeks + 2
weeks to this date ) .
 Lightening + 2 weeks :- its occurrence denotes the approach
of labor .
 Estimation of fundal level .
 Ultrasound .
 Biochemical methods .
41
B Physical examination .
 Record height , weight , blood pressure , pulse and temperature .
 General examination from head to toe ( head and neck , lungs , heart ,
breasts , abdominal , Legs ) .
 Pelvic exam to confirm pregnancy .
 Check for dilation and effacement .
C Lab works .
 Urine tested ( protein , glucose and ketones ) .

 Stool analysis for ova and parasites .
 Complete blood picture to detect anemia .
 Testing for rubella antibodies .
 ABO blood group and RH factor .
 Ultrasound scanning .
2 Health education .
 Factor influencing health education .
 Health condition of the pregnant woman .
 Socioeconomic condition .
 Cultural habits and beliefs .
 Period of gestation .
 Nutritional requirements .
 Should be adequate to provide for :-

 The maintenance of maternal health .
 The needs of the growing fetus .
 The strength and vitality required during labor and lactation .
42
 Are affected by :-
 Pre pregnancy nutritional status .
 Maternal age .
 Maternal parity ( number of pregnancy ) .
 Cultural variations .
 Socioeconomic condition .
 Maternal nutrient .
 The pregnant woman need an additional 300 calories per

day .
1 Protein ( for frowth and rapid repair ) .
2 Zinc ( fetal growth and milk production ) .
3 Iron ( formation of hemoglobin ) .
4 Calcium ( blood clotting , bone building , nerve cell transmission ,
muscle contraction ) .
5 Phosphorus ( build strong bones ) .
6 Vitamin C ( formation of collagen , wound healing , bone
formation ) .
7 Folic acid ( formation of the nervous system ) .
8 Vitamin B6 ( development of fetus’s nervous system ) .
9 Vitamin B12 ( nerve cells and red blood cells ) .
3 Documentation .
 Pre natal record should be completed every visit .
43
 Schedule for return visit .
 1-28 weeks’ gestation every 4 weeks .

 28-36 weeks’ gestation every 2 weeks .
 36 weeks’ gestation until term every week .
 Warning signs should be observed :-

1 Severe abdominal pain or cramps .
2 Frequent uterine contraction .
3 Bright red vaginal bleeding .
4 Vaginal bleeding during 3rd trimester .
5 Gush of fluid from vagina ( rupture of membrane ) .
6 Edema of face , hands and feet .
7 Dysuria ( pain with urine ) .
 Teaching and counseling .
 Discuss questions , concerns and needs .

 Provide individual health instruction , counseling , guidance .
 Review recent Lab reports .
 Refer patient for other needed services .
 Physical assessment .
 Promoting psychological adaptation :-
 The nurse stay with the client during her examination .
 Attentive listening and interest in the client well .
 Reassurance about normal feelings and uncertainties .
 Reassurance the couple about the baby provide referrals for couple
who need counseling .
44
 Fetal lie .
 It’s the relationship of the long axis of the fetus ( as
related to the spinal column ) to the long axis of the
mother ( Longitudinal , oblique or transverse ) .
. ‫وؽع الػمٍد الفقرى للتوّن بالوشبة للػمٍد الفقرى لالم مملن ِلٍن راصَ او افقَ او مائن‬
 The fetus in a transverse or uncorrectable oblique is usually delivered by
cesarean birth .
 Fetal attitude .
 It’s the relationship of the parts to one another ( the
fetus is described as being in a state of flexion or
extension ) .
‫وؽع اـراف التوّن بالوشبة لتشمي ( راصي بجبقَ غلَ غدرى ورجلّي وإِدِي بجبقَ ملجفي من ـرف لٍحدى وبّبقَ ؽٌرى واخد هع داِرى‬
... ) ‫مدا‬
 Fetal presentation .
 It’s the first part of the fetus which meets the pelvic
brim and it’s the first part felt by vaginal examination .
. ‫التزء من التشم الـ ًّلٍن اول حاجة ثوزل اخواء الٍالدة‬
1 Cephalic presentation :-
 Vertex ( head is flexed ) .
 Face ( head is extended ) .
 Brow ( head is midway between flexion and extension ) .
2 Breech presentation ( buttocks ) .
3 Shoulder presentation ( the fetus in transverse lie ) .
 Denominator .
 It’s a landmark on the presenting part by which the
position of the fetus is known .
. ‫الػامن المطجرك ودى بّبقَ مٍجٍد بّن وؽع التوّن واول جزء ًّوزل اخواء الحمن‬
45
 Vertex presentation  occiput  O .

 Face presentation  chin or mentum  M .
 Breech presentation  sacrum  S .
 Shoulder presentation  scapula  A .
 Position .
 It’s the relation of the denominator to the maternal pelvic.
 The maternal pelvis is divided into 4 sections based on her right and left
and front and back .
. ‫ملان التوّن دى بوخلؿ فّي وجٍدى بالوشبة للرحم مع الػامن المطجرك مع اول جزء ًّوزل اخواء الٍالدة‬
 Fetal position is described by using 3 letters :-
 The first designates whether the presenting part is facing to the
mother’s right ( R ) or left ( L ) .
 The second is the denominator .
 The third designates whether the presenting part is pointing to the
anterior ( A ) or posterior ( P ) section of the mother’s pelvis or to
the center ( transverse –T- ) .
 Divided into face , base and vault .

 Face .
 Small in the newborn baby .
 Extends from the orbital ridges and the root of the nose to the
junction of the chin and the neck .
 Base .
 Comprised of bones which are firmly united to protect the vital
centers in the medulla .
 Bones of the face and base are thick , irregular and not separated
from each other to protect the vital centers in it .
46
 Vault .
 Made of soft flat bones which are thin , regular and separated by
sutures and fontanelles .
 Bones of the vault ( 7 ) .
 2 frontal bones .
 2 parietal bones .
 2 temporal bones .
 1 occipital bone .
 Sutures ( 6 ) .
 Membranous spaces between the bones of the fetal head .
 Frontal sutures ( between the frontal bones ) .
 Sagittal suture ( between the parietal bones ) .
 Coronal suture ( between the frontal and parietal bones ) .
 Lambdoidal suture ( between the two parietal bones and occipital
bone ) .
 2 temporal sutures (each between the parietal and temporal
bone) .
 Fontanelles .
 Areas of the head where suture lines intersect ( can be
palpated during assessment of the new born ) .
 Anterior fontanelle .
 Diamond shape and is located at the intersection of the sagittal

and coronal sutures .
 Doesn’t close until the baby is about 18 months of age .
 Posterior fontanelle .
 Triangle and is located at the intersection of the sagital and

lambdoid sutures .
 Usually closes by 6-8 weeks after birth .
47
 Landmarks of the fetal head .
 Sinciput  brow portion of the head .

 Vertex  the top portion between the anterior and posterior
fontanelles .
 Occiput  the back of the head over the occipital bone .
 Bregma  anterior fontanelle .
 Glabella  the bridge of the nose .
 The mentum  chin .
 Diameters of the fetal head .
 Smallest one is desirable during labor .

1 Transverse diameters .
 Biparietal ( 9.25 cm at term ) :- extending between the 2 parietal
bones .
 Bitemporal ( 8cm ) :- extending between the two temporal bones .
2 Antero-posterior diameter ( Longitudinal diameters) .
 There are 4 diameters of this type :-
1 Suboccipito-bregmatic diameter ( 9.5 cm ) .
 It’s the diameter of engagement in occipito-anterior position when the
head is completely flexed .
2 Occipito-frontal diameter ( 11.5 cm ) .

 It’s the diameter of engagement in occipito posterior position .
3 The occipitomental diameter ( 13.5 cm ) .

 It’s the diameter of engagement in brow position .
4 Submento-bregmatic diameter ( 9.5 cm ) .

 It’s the diameter of engagement in face presentation when the head
is completely extended .
48
 Molding .
 Flat bones of the fetal skull overlap each other .
 It’s physiological and beneficial because it diminishes the
diameters of the head and facilitates its passage through the birth
canal .
 It disappears within the first few days after birth .
 Station .
 The relationship of the presenting part of the fetus to the
ischial spines of the mother’s pelvis .
 Measured in Cm :-
 Above the ischial spines ( -1 to -4 cm ) .
 Below the ischial spines ( +1 to +4 cm ) .
 Station +4 ( at the perineum ) = crowning .
 Engagement .
 The presenting part of the fetus is at level of the
mother’s Ischial spines .
 Crowning .
 It means that the biparietal diameter of the fetal head
has passed just outside the vulval ring and the suboccipital
region is fixed below the symphysis pubis .
... ‫ارجع لوقفة قفر الراس غلطان ثفٌم الجػرِي‬
 When the head is crowned it doesn’t go up in the interval between
contractions .
49
 It’s the process by which products of conception are

expelled from the mother’s body into external environment .
 Normal labor ( Eutocia ) .
 The fetus is born at full term ( 40 weeks ) + 2 weeks .
 Living fetus .
 Presents by vertex .
 Occur without any interference .
 Through natural passage .
 The time not exceed 24 hours .
 With minimal complication to the mother or fetus .
 Delivery .
 The actual delivery of the baby .
 Preterm or premature baby .
 It’s labor occurring after viability of the fetus after 20
weeks and before 38 weeks of pregnancy ( 37 weeks
completed ) .
 Mature or term infant .
 It’s an infant born between 38 and before 42 weeks of
pregnancy .
 Post term pregnancy ( post maturity ) .
 Prolongation of pregnancy 2 weeks or more beyond the
expected date of delivery .
50
ً ‫فَ مذا هظرِقة بجواقض غملّة الٍالدة بس ما اخبججض‬

... ‫ خدوًا غواوِن صرِػة‬.. ‫غلمّا‬
1 Progesterone deprivation theory .
 Labor is initiated by Decrease in progesterone and increase in
estrogen ( helps the initiation of uterine contraction ) .
2 Prostglandin theory .
 It increases late during pregnancy due to increase in estrogen . ( it
increase uterine contraction and a reduction in cervical resistance ) .
3 Oxytocin theory .
 The number of oxytocin receptors in the uterus increases at the end
of pregnancy ( its increase lead to initiation of uterine
contractions ) .
4 Fetal cortisol theory .
 There is increased production of cortisol by the fetal adrenal
glands which lead to decrease progesterone and increase in
estrogen and prostaglandin .
5 Uterine stretch theory .
 Any hollow organ when stretched to its capacity will inevitably
contract to expel its contents ( uterus is a hollow organ when
stretched initiate contractions ) .
 Preterm labor may occur with early distension e.g twins or
polyhydramnios .
6 Aging placenta theory .
 Advanced age lead to decrease blood supply to the uterus which

cause uterine contractions .
51
 Passenger .
 Passage ( bony pelvis and soft tissues ) .
 Powers ( primary and secondary ) .
 Position of maternal .
 Psychological status of the woman .
 Powers .
 Primary ( contraction and retraction of the uterine) .
1 Characteristics of uterine contraction .
 Involuntary .
 Regular .
 Intermittent .
 Gradually increasing in frequency , intensity and duration .
 Fundal dominance .
2 Phases of contraction ( 3 ) .
 Increment :- begins slowly .

 Acme :- reaches a peak .
 Decrement :- contraction diminishes .
3 Parameters used to monitor uterine contractions .
 Frequency .
 The period between the start of one contraction and the start of
the next one .
 Duration .
 The period between the start of one contraction and its end .
 Intensity or amplitude .
 The power or strength of the contraction .
52
4 Effect of uterine contractions .

 Cervical dilation .
 Expulsion of the fetus .
 Placental separation .
 Prevention of post partum hemorrhage .
 Involution of uterus .
 Secondary power ( bearing down ) .

 It refers to powers of abdominal muscles and diaphragm in the
form of bearing down .
 It’s partly voluntary and partly involuntary .
 It’s required during the 2nd stage for expulsion of the fetus and
may help expulsion of the placenta during the 3rd stage .
 Prevent it during the 1st stage as the cervix is not yet fully dilated .
 Maternal position .
 It influence pelvic size and contour .
 Squatting position ( enlarge pelvic outlet 25 % ) .
 Kneeling position ( remove the pressure on the maternal vena
cava and assist to rotate the fetus in the posterior position ) .
 Psychological status of the woman .

 Refers to the feelings that woman brings to labor .
53
. ‫االغراض الجمٌّدِة للٍالدة‬

 Lightening .
 Sinking of the uterus ( descent of the abdomen ) .
 It occurs 2-4 weeks before birth in primparas .
 It occurs in the day of labor begins or after the start of labor in
multiparas .
 Allow mother to breathe easily .
 Braxton Hicks contractions ( false labor

contraction ) .
 An intermittent uterine contraction that occur throughout
pregnancy causes some discomfort and abdominal pain for
several days or 3-4 weeks before the onset of true labor .
 True labor  False labor
 Regular contraction .  Irregular .
 Gradually increasing in  No change in contraction .
frequency , intensity and
duration .
 Discomfort begins in back and  Localized in the abdomen .
radiates to the abdomen .
 Cause cervical dilation .  No cervical dilation .
 Pains increase by walking .  Walking has no effect on pain .
 Pain increase by enema due to  Relieved by sedatives or
full rectum reflex inhibit enema .
uterine contractions .
 Pelvic pressure symptoms ( after engagement ) .

 Frequency of micturation due to pressure on the bladder .
 Difficulty in walking due to pressure on the sciatic nerve resultant
with leg pains .
... ^^‫ال حٍلقٍةوال إال باهلل‬ ... ‫ واصجغفر هللا‬... ‫ ال إلي إال هللا‬... ‫ هللا امبر‬... ‫ الحمد هلل‬... ‫صبحان هللا‬
54
 Cervical changes .
 Occur several days before initiation of labor .
 Cervix softens , efface and dilates slightly .
 Increased energy level ( nesting ) .
 Many woman will focus this energy toward cleaning , cooking and
spending extra time with other children .
 Signs of true labor .
1 Painful uterine contraction .

2 Cervical effacement and dilation .
 Effacement .
 Thinning and shortening of the cervical canal ( the cervix becomes
incorporated into the lower uterine segment ) .
 Dilation .
 Progressive widening of the cervical canal ( 0-10 cm ) .
3 The passage of show .
 Blood stained mucous discharge noticed at the start of labor .
 Mucous = the cervical mucus during pregnancy .
 Blood = separation of the membranes from the lower uterine
segment or lacerations of cervical mucosa .
4 Formation of the bag of water .

 When the cervix dilates , lower part of the fetal membranes
detaches and bulges through the dilating cervix and becomes tense
during uterine contraction .
55
5 Rupture of fetal membranes ( ROM ) .

 Spontaneous ROM occurs during active labor ( the end of
1st stage ) .
 The rupture may occur as a sudden gush of fluid or as a steady or
intermittent , slow leakage of fluid and the fluid should be clear
and odorless .
 If it begins more than 24 hrs before labor is called a premature
rupture of membranes which is associated with an increased risk of
infection and umbilical cord prolapse .
 First stage ( dilating stage ) .

 Begin with the onset of true labor pain and ends with complete
dilation of the cervix .
 Phases of first stage ( latent, active and
transitional).
 Latent .  Active .  Transition .
 Length .  0-3 cm .  4-7 cm .  8-10 cm .
 Duration of  6-8 hrs .  3-6 hrs .  20-40 min .
phase .
 Contraction  Mild to  Moderate to  Strong to very
strength .
moderate . strong . strong .
 Rhythm of  Irregular .  More regular .  Regular .
contractions .
 Frequency of  5-30 min .  3-5 min .  2-3 min .
contractions .
 Duration of  30-45  40-70 second .  45-90 second .
contractions .
second .
 Show color .  Brownish  Pink to bloody  Bloody mucus .
discharge . mucus .
 Amount of  Scant .  Scant to  Copious .
discharge .
moderate .
56
 In the nullipars , effacement is often before dilation begins .

 In the multipara effacement occurs with dilation .
 Second stage ( expulsive stage ) .

 Begins with complete dilation of the cervix and ends with delivery
of the infant .
 Third stage ( placental stage ) .
 Begins with delivery of the infant and ends with delivery of the
placenta .
 Fourth stage .
 It’s the first 1-2 hrs following delivery .
 Duration of  1st stage .  2nd stage .  3rd stage .
labor .
 Primigravidae .  12-16 hrs .  1-2 hrs .  10-20 min .
 Multipara .  6-8 hrs .  10-30 min .  10-20 min .
57
 Signs of first stage of labor .
1 Contraction and retraction of the uterine muscle .
 Each contraction starts stronger and longer at the fundus and

becomes weak at the lower uterine segment .
 With each contraction the muscle fibers of the upper uterine
segment retract ( becoming shorter ) .
2 Formation of the upper and lower uterine segment .

 The uterus divides into 2 segments .
 The upper segment ( active contractile portion of the uterus , its
function is to expel the uterine contents ) .
 The lower segment of the uterus is passive , contracting slightly
and dilating to allow expulsion ) .
3 Development of retracting ring .
 The border between the upper and lower uterine segment ( it’s not
visible in normal labor , in obstructed labor is visible as a line across
the abdomen ) .
3 Polarity .
 The neuro muscular harmony between the upper and lower

uterine segments during labor (contraction and retraction).
4 Formation of bag water .
 General fluid pressure :- when contraction pressure is exerted on

the fluid if the membrane is intact .
 Fetal axis pressure :- when contraction pressure is exerted on the
fetus if the membrane is rupture .
58
5 Cervical effacement and dilation .
6 The passage of show .
7 Rupture of membrane .
 Due to contraction and dilation of the cervix .
 Signs of the second stage of labor .
 Urge to push or feeling the need to have a bowel movement .

 Involuntary bearing down efforts .
 Sudden appearance of sweat on upper lips .
 Increased bloody show .
 Shaking of extremities .
 An episode of vomiting .
 Increased restlessness .
 Signs of third stage of labor .
 The third stage of labor involves 2 phases :-
1 Placental separation .
 Signs of placental separation :-

 Uterus becomes smaller , globular , harder , higher and more
mobile .
 Firm contraction of the uterus .
 Suprabubic bulge ( due to presence of placenta in the lower
uterine segment ) .
 Sudden gush of blood from the vagina .
 Apparent lengthening of the umbilical cord .
59
2 Placental expulsion .
... ‫ غلطان ثفٌمًٍا امـجر‬114‫ارجػٍا للػٍرة المٍجٍدة فَ غفحة‬
 It may occur by one of two mechanisms :-
A Schultz’s mechanism .
 Is more common , separation starts at the center and the placenta is
expelled as an inverted umbrella ( fetal side of the placenta presenting
first ) .
... ) ‫بجوزل ماهٌا مظلة مقلٍبة ( ظمشّة‬
B Dun can mechanism .

 The placenta is detached at its lower edge and expelled as a buttonhole
(maternal side of the placenta presenting first ) .
 Signs of fourth stage of labor .
 This stage initiates the postpartum period .

 It’s commonly referred to as the recovery period .
 Danger signs of labor .
 Signs of maternal distress .
 High or low blood pressure (the low one may be first sign of
intrauterine hemorrhage ) .
 Pulse rate greater 10bpm than normal .
 Temperature > 38 C .
 Inadequate or prolonged contraction ( less frequent , less intense
or shorter ) .
 Pathologic retraction ring .
 Abnormal lower abdominal contour ( due to pressure of the full
bladder during labor ) .
 Foul smelling vaginal discharge .
 Continuous bright or dark red vaginal bleeding .
60
 Stop progression of cervical dilation or effacement , decent of the

fetus or both .
 Increase apprehension ( may be sign of internal hemorrhage ).
 Signs of fetal distress .
 High ( more than 160 ) or low ( less than 110 ) fetal heart rate .
 Appearance of meconium stained ( green dolor in the amniotic
fluid ) .
 Fetal hyperactivity ( may be a sign of hypoxia ) .
 Low oxygen saturation level ( under 40 % ) .
 It means the presenting part of the fetus undergoes

certain passive movement in its passage through the birth
canal .
‫( ًما‬8‫ فاحفظًٍا غواوِن بس مض امـجر وحاولٍا ثطٍفٍا الػٍرة الـ فَ اللـجاب‬, ‫فَ الوقفة دى اغرفٍا إن من حرمة مجرثبة غلَ الـ قبلٌا‬
... ) ‫حرمات بجم ورا بػؼ بفرِقة موظمة بحّح ثشٌن غملّة الٍالدة‬
1 Engagement .
 Occurs when the biparietal diameter of the fetal head passes
through the pelvic inlet .
2 Descent .
 It’s the downward movement of the fetal head throughout
delivery due to :-
 Contraction and retraction of the uterus .
 Contraction of the diaphragm and abdominal muscle when bearing
down .
 Unfolding of the fetus ( extension of the fetal body ) .
61
3 Increased flexion .
 Due to the head meet resistance from the pelvic wall and pelvic
floor ( chin is pressed to chest ) .
4 Internal rotation .
 Due to increased flexion the occiput meets resistance from the
pelvic floor first and so it begins to rotate forwards ( in part of
circles to ease the next movement ) .
5 Extension .
 Due to contraction of pelvic floor pushing the head upwards and
forwards ( the head continue to descent until the suboccipital
region appears below the symphysis pubis ) .
6 Restitution .
 After delivery of the head , the occiput rotate in a direction
opposite to that occur in internal rotation undo the twist of the
neck caused by internal rotation .
7 External rotation .
 It occurs after restitution in the same direction of it , so at the
end the occiput is towards one thigh and the face is towards the
other thigh .
8 Expulsion .
 After all previous movements , as lateral flexion of the shoulder
and head occur , the anterior shoulder is born before the posterior
shoulder , the body follows quickly .
62
 1st stage .
 Excitement or apprehension .
 During active phase :- become serious and concerned about the
progress of labor ( ask for pain medication or use breathing
techniques ) .
 During the transitional phase :- lose control , thrash in bed or cry
out .
 2nd stage .
 Fearful .
 Exhausted .
 Excitement that the birth is near to occur .
 3rd stage .
 Focus on the neonate’s condition .

 May feel discomfort from uterine contraction before expelling the
placenta .
 4th stage .
 Focuses on the neonate .

 Begins to adjust the role of mother .
 Emotional reaction vary from joy and relief to temporary
disbelieve and withdrawal .
63
 The woman is liable to infection due to :-

 Lacerations in her perineum , vulva , vagina and cervix .
 Large placenta site is a row area for organisms .
 The genital tract after labor are excellent medium for the growth
of organisms .
 Low resistance of the woman due to exhaustion and loss of blood .
 Source of infection .
 Endogenous :- from the woman herself , presence of septic foci in

her teeth , mouth , rectum , vagina and skin uncleanness .
 Exogenous :- persons and environment .
 Measures to prevent infection during labor .
 Follow aseptic technique and use sterile equipment .

 Avoidance of surgical wounds .
 Avoidance of prolonged labor .
 Rest as possible .
 Clean environment .
 Frequent perineal hygiene .
 Hand washing before any procedure .
 Done vaginal examination only when needed .
 Monitor elevation in WBCs as it indicating infection .
64
1 Determine whether the woman is in labor or not

through asking about :- ( quick history ) .
 Expected date of birth .
 Uterine contractions (when it began and how often and how long).
 Show :- ask the woman if she had a blood stained mucous
discharge and examine her underclothes .
 Membrane :- ask her if she had a gush of fluid from vagina ( the
fluid should be colorless and odorless ) .
 Ask her if she has had enough rest and sleep .
 Any known drug allergies .
 Ask her about her previous labor and her present pregnancy .
 Bladder and bowel .
 Quality of fetal movement in the past few days .
2 Establishing a positive relationship .

 Greet the woman and introduce yourself .
 Call her with her name to increase her psychological comfort .
 Let her to ask questions and explain to her the environment and
the procedures that will be done .
 Try to understand her cultural beliefs to assess cultural needs
during childbirth .
 Reassuring her and her husband that the progress of labor will
monitor closely .
65
3 Evaluation of labor progress through maternal and

fetal assessment .
 Review history ( family , medical , obstetric , current pregnancy ) .
 Perform physical examination :-
1 General examination (assessment of heart , lungs , legs and skin ,
vital signs , pain level , mother reaction to labor ) .
2 Abdominal examination :-
 Inspect contour of the abdomen ( for pathologic retraction ring ) .
 Abdominal palpation ( Leopold maneuvers ) to identify number of
fetuses , presenting part , fetal lie and fetal attitude .
 Assess uterine contraction .
 Auscultate and record fetal heart sound with fetoscope
( normal rate 140-160 b/m ) .
3 Vaginal examination :-
 Dilation and effacement of the cervix .
 Presenting part , position and station .
 Status of membrane ( intact , bulging or ruptured ) .
 If the membrane rupture assess color , odor and amount of
fluid .
4 Collecting laboratory studies .

 Urine analysis for the presence of :-
 Protein ( preeclampsia ) .
 Ketones ( nutritional status ) .
 Glucose and leukocytes ( infection status ) .
 Hemoglobin and hematocrit values .
 Blood typing .
66
5 Psychosociocultural assessment .
 Anxiety level .
 Verbal interaction .
 Support system .
 Body language and posture .
 Energy level .
 Current living situation .
 Availability of resources .
 Cultural needs .
6 Documentation of admission .
 Reason for admission .
 Date , time and method of the woman’s arrival .
 The condition of the woman and her baby .
 Labor and membrane status .
 Social assessment .
 Comfort level and support system .
A- Cervical dilation .

 Latent .  Active .  Transition .
 Vital signs .  Every 30-50  Every 30 min .  Every 15-30 min .
min .
 Uterine activity  Every 30-60  Every 15-30 min .  Every 10-15 min .
. min .
 Vaginal show .  Every 30-60  Every 30 min .  Every 15 min .
min .
 Behavior and  Every 30 min .  Every 15 min .  Every 5 min .
mood of woman .
 Physical acre  Stay at home  Use relaxation  Breathing
measures . for as long as techniques technique .
possible . between  Reduce touch if
 Rest and sleep . contractions . sensitivity is
noticed .
67
 Encourage  Encourage
ambulation and ambulation and
upright position. upright position .
 Light foods and  Assist with  Help the woman

full liquid . position changes . to relax between
 Encourage void  Use comfort contraction .
every 2 hr . measures desired  Assist with
 Perform basic by woman ( hot or position
hygiene . cold packs ) . changes .
 Initiate  Encourage
hydrotherapy voiding every
(shower , bath ) . 2 hr .
 Encourage  Provide drugs
voiding every that relief pain .
2 hr .
 Assist with
hygiene , perineal
care .
 Provide drugs
that relief pain .
 Emotional  Review birth  Reduce  Provide

support . plan , process distraction during continuous
of labor what to contractions . support .
expect , pain  Reassure ,  Reduce
management . encourage, distractions .
 Breathing praise .  Continuous
techniques .  Keep informed Reassure ,
 Keep informed progress and encourage ,
progress and procedures . praise .
procedures .
 Keep informed
progress and
procedures .
68
B- Physical nursing care during first stage .

 Shower or bed baths ( with warm water to avoid cramping ) .
 Care perineum especially after rupture of membranes and when
show increases .
 Oral hygiene to prevent dryness and thirsty feelings .
 Brush hair to increase comfort and improve morale .
 Offer fluid and solid foods as ordered to provide hydration and
calories .
 Encourage voiding every 2 hr ( catheter or bedpan or bathrooms) .
 Bowel elimination ( bedpan or bathroom ) and then cleanse
perineum well .
1 Assessment of labor .
 Uterine contractions .
 Maternal vital signs every 5-15 min .
 Bearing down effort .
 Fetal heart rate .
 Amniotic fluid if the membrane ruptured .
 Signs of fetal descent ( bulging of the perineum , labial separation
and crowning ) .
2 Transfer the woman to delivery room .
 Primigravida when the cervix is fully dilated .
 Multipara when the cervix is 7-8 cm .
3 Preparation of the delivery room , the woman and
the attendant .
 Delivery room ( should be ready for the conduct of labor .
Should be warm for the infant .
 All necessary equipment should be present .
 Privacy .
 Aseptic technique should be maintained .
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 The woman ( place her on the delivery table and put her legs in
the leg holders ) .
 Dress her legs and thighs with sterile leggings , sterile towels over
abdomen and under buttocks .
 Empty the bladder , clean the perineum with a warmed antiseptic
solution .
 The attendant ( put on cap and mask , wash and scrub hands ,
Put on a sterile gown and gloves ) .
4 Positioning for birth .

 Dorsal or lithotomy position advantages :-
 Voluntary effort is better brought up .
 Easier monitor of fetal heart rate .
 Easy draping woman and preserving aseptic technique .
 Left lateral position advantages :-
 Decrease perineal laceration and decrease need for episiotomy .
 Easy removal of feces .
 Easy manipulation of shoulders .
5 Promotion of comfort .
 Encourage the woman to rest ( breathing exercise ) .
 Give her a few sips of water to relieve dryness of the mouth .
 Sponge the face and hands with cool water .
 Keep the woman informed of her progress .
6 Promoting effective second stage pushing .
 Woman should wait to feel the urge to push .

 She should push with contraction and rest between them .
 The push is best done with the aid of gravity in semi Fowler’s ,
squatting position .
 Tell the woman to avoid holding the breath during contraction as
it could cause a Valsalva maneuver this could interfere with blood
supply to the uterus .
... ^^‫ال حٍلقٍةوال إال باهلل‬ ... ‫ واصجغفر هللا‬... ‫ ال إلي إال هللا‬... ‫ هللا امبر‬... ‫ الحمد هلل‬... ‫صبحان هللا‬
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 Use motivate words to reduce confusion and anxiety of the

woman .
 Bearing down while exhaling and taking breaths between bearing
down efforts to help maintain adequate O2 level .
 Amnesia may occur between contractions so you may have to
rouse the woman to get her to cooperate in the bearing down
process .
7 Protection of perineum .
 Support the perineum during contraction by a sterile pad when
the head appears at the vulval .
 Episiotomy is necessary when the perineal muscle becomes
distended .
 The nurse may use hands to control the birth of the head to
prevent any injury to the infant ( by applying pressure against the
rectum and coccygeal region ) .
8 Immediately after delivery of the head .
 Remove the umbilical cord that encircle around the neck to

prevent hypoxia ( by using clamps and cutting ) .
 Wipe the nose and mouth of the baby with moist gauze to
eliminate mucus , blood or meconium in the nasal or oral passage .
9 Delivery of the shoulders .
 Between the two hands the head is grasped .

 Downward traction releases anterior shoulder .
 Upward curve allows the posterior shoulder to escape .
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 Assess vital signs .

 Monitor for signs of placenta separation .
 Assess uterine contraction .
 Assess for any perineal trauma :-
1 Firm fundus with bright red blood trickling :- laceration .

2 Boggy fundus with red blood flowing :- uterine atony .
3 Boggy fundus with dark blood and clots :- retained placenta .
 Inspect the perineum for condition of episiotomy .

 Describe the process of placental separation to the woman .
 Instruct the woman to push .
 Alternate compression and elevation of the fundus may be used to
help delivery of the placenta and amniotic membranes .
 The placenta is expelled by minimal , controlled cord traction and
use of oxytocic drugs .
 Examine placenta and fetal membranes for intactness ( to avoid
any part from retained inside the uterus to prevent complications).
 Clean the vulva area with warm water or normal saline and apply
a perineal pad or an ice pack to the perineum .
 Assist woman into a comfortable position .
 Provide warmth by replacing warmed blankets over the woman .
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 Maintain clear airway by suction of the nose and mouth and

pharynx using a mucus extractor or soft suction catheter .
 Dry the neonate and provide warmth .
 Place the new born under the radiant warmer .
 Apgar score is determined 1-5 minutes after delivery of the

infant :-
1 A score of 8-10  a baby in good condition .
2 A score of 4-7  mild/moderate asphyxia .
3 A score of 1-3  severe asphyxia (requiring urgent resuscitation) .
 Cut the cord 2-8 cm from the baby’s umbilicus .

 Examine the infant for injuries and congenital anomalies .
 The normal weight is 2.5-3.5 kg , the normal length is 5 cm .
 The head and chest are 13 inches .
 Penicillin eye drops or ointment is used to protect against
gonorrheal conjunctivitis .
 Vitamin K is give to all infants immediately after delivery against
bleeding disorder .
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1 Assess vital signs .

2 Assess fundus position of the uterus related to umbilicus ( + if
above umbilicus , - if blow umbilicus ) .
3 If the fundus not firm massage it gently to contract and expel any
clots before measuring distance from umbilicus .
4 Observe the perineum for amount and size of expelled clots .
5 Assess bladder distension ( the uterus is boggy in consistency
during distension ) .
6 Assist woman to void .
7 Observe lochia on perineal pads and on linen under the mother’s
buttocks .
8 Observe the perineum in good lighting for episiotomy or
laceration repair .
9 Provide support and information to the woman about
episiotomy and repair of it and self care measures .
10 Applying an ice pack to the perineum to promote comfort and
reduce swelling .
11 Promote comfort by offering analgesia for after pain and warm
blankets to reduce chilling .
12 Offering fluids and nourishment .
13 Encourage parent – infant attachment .
14 Documentation and recording any abnormalities that occur
( high or low blood pressure , fever , sever perineal pain , uterine
atony , excessive bleeding ) .
15 Transfer the woman to postnatal ward .
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 It’s the period after delivery during which the genital

organs involutes , it lasts for 6-8 weeks .
 Involution .
 It’s the process by which the genital organs return to

nearly their pre pregnant state .
 Lochia .
 It’s the vaginal discharge during the puerperium .
 General changes .
1 Normal Blood pressure and respiration .
2 Temperature .
 Elevated during the first 24 hrs .

 Return to normal after the first 24 hrs .
3 Pulse .
 It’s normal .
 Bradycardia is common during the first 6-10 days after delivery .
 Tachycardia indicate pain , fever , dehydration or hemorrhage .
4 Urinary tract .
 Polyuria in the first few days .

 Frequency of urine ( void 3000 ml/day ) .
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 Little amount of urine may indicate a degree of urinary retention

due to :-
 Atony of bladder .
 Epidural anesthesia .
 Prolonged labor .
 Painful episiotomy or laceration .
 Instrumental delivery .
 By day 10 full bladder function should be observed .
5 GIT tract .
 Constipation may occur due to :-

 Post childbirth discomfort .
 Atony of intestine ( increased progesterone ) .
 Decrease fluid intake .
 Side effects of medications .
 Immobility .
 Episiotomy , perineal lacerations or hemorrhoids .
 Thirst and loss of appetite may occur .

 By day 2-3 the woman should have normal bowel function .
6 Blood .
 All changes that occur during pregnancy gradually disappear

during puerperium .
 The increased coagulability of the blood continues for 2 weeks
after delivery due to decreased plasma volume to protect from
hemorrhage .
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7 Breasts .
 Colostrums is secreted in the first 3 days .

 Breast engorgement occurs .
8 Skin .
 Diaphrosis ( excessive sweating ) during the first few days .
9 Body weight .
 Slight loss in the first 2 days due to evacuation of uterine contents ,

polyuria and excessive seating .
 Local changes .
1 Uterus .
 Structure changes .
 The uterus returns to normal through gradual process of
involution .
 The involution process involves :-
 Ischemia :- due to contraction and retraction of the uterine

muscle .
 Phagocytosis :- fibrous and elastic tissue is broken down .
 Autolysis :- muscle fibers are digested by proteolytic
enzymes ( Lysozymes ) .
 All the waste products pass into the bloodstream and are
eliminated via the kidneys .
 The decidual lining of the uterus is shed in the vaginal blood
loss .
 New endometrium begins to develop from about 10 days after
birth and is completed by 6 weeks .
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 Involution may be slower after cesarean section or retained

placenta tissue or blood clot .
 Factors that enhances involution :-
 Complete expulsion of amniotic fluid and placenta at birth .

 Uncomplicated labor and delivery .
 Breast feeding .
 Early ambulation .
 Weight .
 It gradually diminishes to become about 50-70 g by the end of 6
weeks .
 Size .
 It decreases in length , width and thickness by 6weeks .
 Level of fundus .
 1-2 hrs after birth  between the umbilicus and symphysis pubis .
 Within few hrs after delivery  at the level of the umbilicus for
half a day .
 After that it progresses downward at a rate of 1 cm per day .
 After one week  it midway between the umbilicus and symphysis
pubis .
 At the end of second week it’s barel palpable .
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2 Lochia .
 Duration 21-33 days .

 It’s shorter in multiparas and with smaller babies .
 Characteristics of lochia .
 Types .  Color .  Postpartal  Composition .
day .
1 Lochia rubra .  Dark red .  1-3 .  Blood , decidual
tissue .
2 Lochia serosa.  Pinkish brown .  4-9 .  Blood , mucus ,
leukocyte and
decidual tissue .
3 Lochia alba .  Creamy white .  10 days to  Largely mucus ,
3 weeks . leukocyte count
high and decidual
tissue .
3 Ovary .
 Return of ovulation and menses .

 After 6-8 weeks in non lactating woman .
 After 6 months in lactating woman .
4 Cervix .
 Edematous , bruised , swollen and little tone .

 Closed in one week and becomes slit shaped external os .
5 Vagina .
 Smooth , edematous and bluish .

 Gradually decreases in size ( but doesn’t reach prepartum size ) .
6 Vulva .
 Remains gaped for some time .
 Wound heal well unless infected
 Pelvic floor muscles gradually regain tone .
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 It’s failure of the uterus to return to its original non

pregnant size after delivery .
 Predisposing factors .
 Cesarean section .
 Prolapse of uterus .
 Uterine fibroids .
 No sucking of the baby .
 Over distension of uterus as in twins .
 Multiparity .
 Causes .
 Infection .
 Reatained placenta tissue or membrane .
 Thick deciduas difficult to undergo autolysis .
 Symptoms .
 Wide and boggy .

 Persistence of lochia .
 Passing clots of blood and her loss of blood may smell offensive .
 Raised temperature and pulse rate .
 Treatment .
 Treating the cause .

 Ergometrine tablets or drops given for 5 days .
 Curetted of the uterus to remove any retained placenta
fragments .
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 Assessment .
 Vital signs .
 Monitor vital signs every 8 hrs after the first day of delivery .
 Bradypnea ( low respiratory rate ) due to eefect of narcotic
medication .
 Tachypnea may be signs of respiratory distress .
 The blood pressure is usually normotensive within 24 hrs of
delivery .
 Any increase of blood pressure may due to anxiety , preeclampsia
or essential hypertension .
 Decreased blood pressure may due to dehydration or
hemorrhage .
 Pain considered the 5th vital signs , assess for type , location and
severity .
 Breasts .
 Assess size and shape every shift and notice any tenders or
engorgement .
 Check nipples for soreness , redness , cracks or inverted .
 Uterus .
 Assess the fundus to determine uterine involution ( the method is

similar to in local changes ) .
 Assess the woman for complaints of after pains ( cramping pain
caused by alternate contraction and relaxation of uterine muscles).
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 After pains generally last 2-3 days and may be intensified by

breast feeding .
 A soft , boggy uterus higher than expected level fundus denotes
uterine atony .
 Lateral deviation of uterus denotes over distended bladder .
 Bladder .
 Check to ensure that the woman voids within the first 6-8 hrs after
delivery .
 Check for distended bladder .
 Signs of distended bladder :-
 Fundus above baseline level .
 Excessive lochia .
 Bladder discomfort .
 Bulge of bladder above symphysis .
 Frequent voiding of less than 150 ml of urine which
indicates urinary retention .
 Bowel .
 Check for bowel movement within 2 days after delivery to void

constipation .
 Lochia .
 Assess lochia flow on perineal pad for type , amount , color , odor ,
consistency .
 Odor  should similar to that of menstrual flow .
 Consistency  should have only minimal or small clots .
 Women with cesarean section have a scant amount of lochia .
 Lochia flow increases with activity .
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 Episiotomy and perineum .
 Assess the episiotomy site every 8 hrs to evaluate healing .

 Healing completely within 4-6 weeks .
 Use REEDA scale to evaluate the perineum :-
 R  redness .
 E  edema .
 E  ecchymosis or bruising .
 D  drainage .
 A  approximation of the edges .
 Assess rectal area for hemorrhoids ( soft and pink if it present ) .
 Homan’s sign ( peripheral circulation ) .
 To determine peripheral circulation assess woman’s thigh for skin

turger .
 Edema of the feet and ankles may be experienced .
 The swelling should be bilateral and without pain .
 Any abnormality may be due to a DVT .
 Technique used to assess for Homan’s signs ( discomfort in the calf
with sharp dorsiflexion of the foot ) :-
 Position the leg of the woman flat on the bed .
 Place one hand under the leg near the back of knee .
 Flex her foot forward toward her ankle with the other hand .
 Homan’s sign is positive when the woman experienced pain during
the test .
 The pain is caused by inflammation of the vessel .
 Examination of the leg daily for deep venous thrombosis ( swelling
of the leg , temperature difference between both legs ) .
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 Emotional status .
 Observe how she interacts with her family , eye contact with her
infant , body posture and comfort level when holding the
newborn .
 Be alert for mood swings , irritability or any crying episodes .
 Early attachment .
 The process by which a parent love and accept a child and a child
comes to love and accept a parent ( attachment ) .
 Observe their care taking of baby and accepting sex of the child
and characteristics .
 Prevention of infection .
 Clean environment .
 Bed lines should be changed as needed .
 Hand hygiene before contact to the mother .
 The woman should know the important of good perineal care and
hygiene practice .
 Prevention of excessive bleeding .
 Maintain good uterine tone :-
 Fundal massage and expression of clots .

 Place cupped hand on the fundus , gently massage the fundus in a
circular motion with cupped palm until uterus is well contracted .
 Assess for uterine firmness ( uterine tissue responds quickly to
touch ) .
 In firm uterine apply firm pressure in a downward motion toward
the vagina to express any clots .
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 Teach the woman to massage her own fundus to decrease her

anxiety and maintain some control .
 Administration of IV fluid and oxytocic drugs ( to stimulate
contraction ) if the massage fails .
 Prevention of bladder distension :-
 Assist the woman to the bathroom or onto a bedpan .

 Instruct her to listen to running water , placing her hands in warm
water or pouring water over her perineum to stimulate voiding .
 Administrating analgesics because some women may fear voiding
because of pain .
 Use a sterile catheter if voiding is unsuccessful by 4-6 hrs after

birth .
 Promotion of comfort .
 Provide pain relief for after pains ( analgesics , avoid heat to

abdomen as it cause relaxation of the uterus and result in uterine
bleeding ) .
 Relieve muscular aches ( backrub ) .
 Administer cold and hot therapy ( it enhances vascular circulation
and healing for perineum ) .
 Promote perineal exercise ( Kegel exercise ) .
 Provide perineal , episiotomy care and teach woman how to care
by herself .
 Provide pain management ( area Labor ! ) .
 Bathing .
 Promote breast hygiene with clear water because soap tends to
dry and crack the nipples , wear clean pads into bra to keep
nipple dry from excessive milk .
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 Promotion of rest , ambulation and exercise .
 Calm environment and allow time to woman to sleep .

 Cover her with a warm blanket and offer her a warm drink .
 Encourage her sharing household tasks .
 Nap when the infant is sleeping .
 Stress the need for a balanced diet .
 Ambulation to reduce incidence of thrombophlebitis .
 Allow her dangle her legs before getting up from the bed to
prevent dizziness .
 When she on bed for longer hrs ( alternate flexion and extension of
foot and legs , rotate the ankle in circular motion ) .
 Exercise ( start slowly and gradually increase the amount ) .
 Promotion of nutrition .
 Food should be high in protein , vitamins and minerals needed for

good tissue repair .
 Adequate supply of roughage to help restore the peristaltic action
of the bowel ( prevent constipation ) .
 Breast feeding woman need addition 500 calories and 500 ml of
fluid for production of milk .
 Prenatal vitamins and iron supplements .
 Drink plenty of fluid .
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 Promotion of normal bladder and bowel

patterns .
 Urinary elimination ( as mentioned in previous pages ) .

 Prevent constipation by :-
 Early ambulation .
 Roughage and fiber .
 Adequate fluid intake .
 Administer a mild laxative .
 Antigas medications may be ordered for woman whom

experienced gas pains .
 Breastfeeding promotion and lactation

suppression .
 Promotion .
 Breastfeeding aids in the contraction of the uterus and prevention

maternal hemorrhage .
 Prevent or alleviate breast engorgement by :-
 Application of warm compresses .
 Wear good supportive bra .
 Encourage the newborn to suck at breast .
 Lactation Suppression .
 Avoid breast stimulation ( massage , newborn suckling or

pumping of the breasts ) .
 Mild analgesics and cold compresses may used to decrease the

discomfort resulting from breast engorgement .
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 Health promotion for future pregnancies

and children through immunizations .
 Rubella vaccination .
 Inform the woman about possible side effects and the need to
avoid pregnancy for at least 3 months because the effect of the
vaccination .
 Injection of RH immunoglobin .
 The woman receive 2 doses , one at the 28 weeks gestation and

the second within 72 hrs after childbirth .
 Kleihauer test ( detects amount of fetal blood in the maternal

circulation ) done after 24 hrs of injection to be sure about
destroyed all fetal red cells in the maternal circulation .
 Discharge teaching .
 Teach woman to recognize postpartum warning signs :-

1 Sudden , persistent or spiking fever .
2 Change in the character of lochia .
3 Evidence of mastitis ( breast tenderness ..etc ) .
4 Evidence of thrombophlebitis ( calf pain, pain with walking ) .
5 Evidence of urinary tract infection ( urgency , retention … ).
6 Evidence of infection in an incision .
7 Continued mood changes .
8 Severe pelvic pain or abdominal tenderness .
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 Before discharge , give the woman basic instruction about self care
( episiotomy , perineal , vaginal bleeding , nutrition … ) , infant
care ( bathing , sleeping habits , immunization … ) and
breastfeeding ( position , latch , duration … )
 The woman can resume sexual intercourse after the 5th week after
birth ( she use water soluble gel to lubricate vagina as it’s dry for
6 months after birth ) .
 Discuss with her about contraceptive method .

 Prescribed medication ( prenatal vitamins , analgesics , iron
supplements … etc ) .
 Follow up after discharge .
 First visit :- within 24 hrs after birth at home .
 Second visit :- day 4 after birth at home .
 Third visit :- day 7 after birth at home .
 Fourth visit :- clinic visit at day 40
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 Gynecology .
 Derived from a greek word mean study of woman .
 It’s a branch of medicine , which deals with diagnosis , treatment
and prevention of pathology of the female reproductive system .
 Gynecology Nursing .
 It’s the branch of nursing , which deals with nursing care provided
to women with gynecological conditions .
 Gynecological nursing care .
 It’s comprehensive care that given to a woman having a disease in

her reproductive organs .
 Comprehensive  physical , social , psychological and
emotional .
 Factor that prevent gyn. Patient to cooperate in

treatment and giving an accurate history .
1 The idea of exposing these organs ( sense of privacy ) .

2 The idea of removing the reproductive organs ( surgical ) .
3 The idea of hospitalization ( chronic disease ) .
4 The idea of social disease producing abnormal discharge ( syphilis
and gonorrhea ) .
 Responsibilities of the nurse caring for gyn.

patient .
1 Explanation everything ( causes , treatment , medication ,
operation ) .
2 Good relationship with the patient .
3 Know the effect of emotional and social factors on woman .
4 Know the economic status and the effect of it on her life .
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 Amenorrhea .  It’s the absence of menstrual discharge from

the uterus it can be physiological ( pregnancy ,
lactation ) or pathological ( congenital ,
hormonal disturbance ) .
 Menorrhagia .  It’s prolonged or excessive uterine bleeding

through the vagina at the time of regular
menstrual flow .
 Metrorrhagia .  It’s uterine bleeding between regular menstrual

periods or after menopause .
 Dysmenorrhea .  It’s the occurrence of pelvic pain during the

time of menstruation , which is sufficiently
severe enough to interfere with the work of
patient .
 Dyspareunia .  It’s difficult or painful intercourse .

1 Superficial dyspareunia .
 Pain is felt near the entrance or lower part of the
vagina .
2 Deep dyspareunia .
 Pain is present at the cervix , vault of the vagina or
pelvic .
 Stress urinary  It’s the involuntary loss of urine as a result of

incontinence . sudden increase intra abdominal pressure due
to pelvic disease , fistula and obstetrical injury .
 Vaginismus .  It’s recurrent involuntary spasm of some pelvic

muscle which occur during coitus .
 Urinary  It’s the involuntary or uncontrolled loss of urine
incontinence . from the bladder .
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 Leucorrhea .  It’s mucus discharge from vagina ( of cervical

canal , may be normal or pathologic) .
 Causes .
 Physiological .
 Sexual stimulation .
 Pregnancy .
 Alteration in cervical mucus ( cervical glands is
under hormonal influence ) .
 Pathologic .
 Cervicitis .
Cervical infection ( Chlamydia infection ) .
 Pelvic inflammatory , tumors or cysts .
 Ulceration of any sort (STDS and cervical erosion) .
 Pruritis vulva .  It’s sensation of itching of vulva .
 Types .
1 Pruritis without vaginal discharge .
 Parasitic infections .
 Monilia infections of the anus and rectum .
 Allergy and drug sensitivity .
 Vitamin deficiency .
 Chronic infection postmenopausal women .
2 Pruritis with vaginal discharge .
 Trichomonas vaginalis .
 Candida albicans .
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 Menopause .  It’s permanent cessation of spontaneous

menstruation .
 Climacteric .  It’s tile period of time when a woman moves

from the reproductive stage to non
reproductive stage of life through the
premenopausal transition to the
postmenopausal years .
 Infertility .  Inability to conceive or become pregnant in one

or two years and it’s a problem of 10-15 % of
their reproductive years .
 Uterine  It’s the condition of which the external os lies

prolapse . below the level of the ischial spines ( may be
congenital or acquired ) .
 Before any examinations .
 Bladder should be evacuated .

 Proper positioning .
 Ensure privacy .
 Adequate draping .
 Warm atmosphere .
 Adequate light .
 Before using any creams , paints and chemical

pessaries .
 Warm and lubricate the applicators .

 Use disposable gloves to avoid infection .
 Know how to clean or store applicators after use .
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 Investigations before any surgery .
 Blood tests .
 Urine tests .
 Vaginal investigation .
 Cervical smear .
 Chest X-ray .
 ECG .
 Preoperative care .
 Fasting .
 Bowel preparation .
 Bladder preparation .
 Pre medication .
 Bath and shower .
 Pubic shave .
 Disinfection of the site and cleansing it before surgery .
 Postoperative care .
 Regular recording of pulse and blood pressure to monitor any signs

of primary hemorrhage .
 Determine level of consciousness .
 Put the patient on flat position with foot of bed elevated .
 Check the wound site and sanitary pad for abnormal amount of
bleeding .
 Check the rate and type of infusion fluid .
 Management of urinary catheter and drains .
 Analgesia .
 Care of perineum .
 Wound care .
 Early ambulation .
 Personal hygienic care .
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 Pregnancy associated with any other condition ( medical or

obstetrical ) that has an adverse effect on the mother and
her fetus .
 A group of mothers and fetuses who have an actual or
potential high incidence of morbidity and mortality .
 Classification of the risks .
 Low risks .  Intermediate risks .

 High risks .
 Parity 1-3 .
 No medical disease .
 No previous stillbirth or neonatal death .
 No low birth weight infant < 2.5 kg .
 No high birth weight infant > 4 kg .
 Adequate hemoglobin .
 Normal weight ( 40-80 kg ) and height ( > 152 cm ) .
 Parity 4 or more .
 Height less than 152 cm .
 Obesity .
 Previous still birth or neonatal death .
 Previous prolonged labor .
 Previous abortion .
 Previous low or high birth weight infant .
 Abnormal hemoglobin .
95
 Previous uterine surgery ( cesarean section ) .

 Uterine anomaly or fibroid .
 Essential hypertension (medical disease ) .
 Renal disease (medical disease ) .
 Sexually transmitted disease (medical disease ) .
 Hydramnios ( during pregnancy ) .
 Antepartum hemorrhage ( during pregnancy ) .
 Premature labor or rupture of membrane ( during pregnancy ).
 Multiple pregnancy ( during pregnancy ).
 Malpresentation after 36 weeks ( during pregnancy ).
 Anemia ( during pregnancy ).
 Diabetes mellitus .
 Heart disease .
 Renal disease .
 Rhesus antibodies .
 Cervical incompetence .
 Oligohydramnios .
 Severe intrauterine growth retardation .
 Uncontrolled premature labor .
 Identification of high risk pregnancy by .
 Careful history .
 Organized physical examination of the mother and the fetus .
 Routine Laboratory investigation .
 Organized and careful examination of the mother throughout
pregnancy .
96
 An excessive vomiting during pregnancy that result in

dehydration and electrolyte imbalance .
 The cause isn’t known .
 It’s seen more often in primiparous , young women and women of
increased body weight .
 Signs and symptoms .
 Vomiting and nausea for a week or more .

 Loss of weight .
 Signs of dehydration ( sunken eyes , inelastic skin ,
cracked lips ) .
 The woman is weak and miserable .
 Urine is dark in color ( contain ketones and chloride ) .
 The breath is offensive ( smell of acetones ) .
 Constipation .
 Nursing assessment .
 Assess the degree of morning sickness .

 Assess the degree of vomiting and nutritional intake .
 Assess the woman for symptoms of dehydration such as dizziness
and thirst .
 Assess the woman psychological status .
 The nurse should be alert for signs of electrolyte imbalance .
97
 Nursing diagnosis .
 Altered nutrition :- less than body requirements related to

persistent vomiting .
 Fluid volume deficit related to persistent vomiting and decreased
fluid intake .
 Risk for maternal and fetal injury related to malnutrition and
dehydration .
 Knowledge deficit , lack of understanding related to medical
condition , treatment .
 Nursing intervention .
 Maintain nutritious diet ( preenteral or enteral feeding ) .

 Maintain an adequate fluid intake .
 Maintain the woman weight .
 Correct her electrolyte imbalance ( food rich in K and Mg ) .
 Psychological support .
 Give her information about the problem and treatment of it .
 Morning Sickness .  Hyperemesis
Gravidarm .
 Onset .  4-8 weeks .  Early pregnancy .
 Time .  In the morning .  Throughout the
day .
 Resolution .  14-16 week .  Persists throughout
pregnancy .
 Food .  Related to food .  Not related to
food .
 Weight .  Maintained or  Loss .
increased .
 Ketosis .  Absent .  Present .
 Electrolytes .  Normal .  Abnormal .
 Skin turgor .  Hydrated .  Dehydrated .
 Liver .  Normal .  Jaundice possible .
 Thyroid .  Normal .  Abnormal .
98
 It’s a condition occurs only in human female after 20

weeks’ of pregnancy , the main cause is unknown .
 It’s characterized by hypertension , proteinuria and edema .
 It has 2 basic forms :-
 Preeclampsia .
 A disease specific to human being during pregnancy after 20

weeks’ gestation and early puerperium and its characterized by
hypertension , proteinuria with or without pathologic edema .
 If the case is neglected  Eclampsia .
 Eclampsia .
 It’s a sever preeclampsia Plus Fits .

 The fits = epileptic convulsion .
 The severe result of PIH is termed the HELLP Syndrome .
 Risk factors for PIH .
 Maternal factors .
 Age :- common in young women < 17 or women > 35 years .

 Parity :- primigravida are more affected than multigravida .
 Past or family history of preeclampsia or eclampsia .
 Maternal disease :- DM , chronic hypertension , chronic renal
disease .
 Low socioeconomic status and malnutrition .
 Under or over weight .
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 Fetal factors .
 Multiple pregnancy .
 Polyhydramnios .
 Hydrops fetals .
 Vesicular mole .
 Classification of PIH .
1 Mild preeclampsia .
 Blood pressure 140/90 mmHg or higher .

 Proteinuria +1 to +2 on dipstick ( 300 mg /24hrs urine
collection ) .
 Weight gain of 2.3 kg or more in one week .
2 Severe preeclampsia .
 Blood pressure 160/110 mmHg or higher .

 Proteinuria +3 to +4 on dipstick (5g /24hrs urine collection ) .
 Oliguria ( urine output < 500 ml / 24hrs ) .
 Severe edema and sudden weight gain .
 Puffiness of the face , edema of the eye lids , hands , feet .
 Blurred vision .
 Hyperreflexia .
 Irritability .
 Epigastric pain .
 Impaired liver function .
3 Eclampsia .
 Signs and symptoms of sever preeclampsia Plus Fits .
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 The fits occurs in 4 stages without interval

between .
1 Premonitory stage ( few second ) .
 Facial muscular twitches and rolling eye movement .

2 Tonic stage ( 15-60 second ) .
 Intense contraction of skeletal muscles .

 Cyanosis and spasm of the back muscles .
3 Clonic stage ( 1 minute ) .
 All body muscles contract and relax inviolently .

4 Coma stage ( minute or hours or days ) .
 A new fit may start while the patient is still in coma or recovery
from coma .
 Complications of the epileptic fit .
 Biting of the tongue .

 Heart failure .
 Cerebral hemorrhage .
 Accidental hemorrhage .
 Bronchopneumonia .
 Suffocation .
 Clinical type of eclampsia .
 Antepartum 65% ( during pregnancy ) .

 Intrapartum 20% ( during labor ) .
 Postpartum 15% ( after delivery ) .
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 HELLP syndrome .
 It’s a severe sequel of PIH, occurs in the third trimester .

 H : hemolysis  red blood cell breakdown in vessels as a result of
vasospasm .
 Reduced hemoglobin and increased bilirubin .
 EL :- elevated liver enzymes .
 Increased SGOT over 72 IU/L .
 Increased lactic dehydrogenase of 600 IU/L .
 LP :- Low platelets .
 Platelets aggregated in damaged vascular endothelium .
 Complications of PIH .
 Maternal .
 Spontaneous abortion .
 Abruption of placenta .
 Retinal detachment ( blindness ) .
 Acute renal , heart , liver failure .
 Cerebral hemorrhage .
 Maternal death .
 Fetal .
 Preterm labor .
 Prematurity .
 Fetal growth retardation .
 Hypoxia and death .
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 Management of preeclampsia .
 Prevention .
 Routine antenatal care to allow early detection .

 Asked the woman about any signs and symptoms of
preeclampsia ( edema , headache …etc ) .
 Advise the woman with severe hypertension to become
pregnancy .
 Antioxidant and vitamin C and E started in the second
trimester .
 Management during pregnancy .
 Hospitalization .
 Rest in bed for most of the day to reduce hypertension , stimulate
dieresis , relive edema , increase renal and placental blood flow .
 Normal diet , rich in protein and avoid food rich in salts .
 Observation of :-
 Blood pressure every 6 hrs .
 Fetal heart rate .
 Urine for amount and protein .
 Complete blood count .
 Kidney , liver functions tests .
 Tests to assess fetal growth ( Amniocentesis ,
Ultrasound , biophysical profile ) .
 Give prescribed medications ( antihypertensive drugs , give
magnesium sulphate to prevent Fits ) .
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 Termination of pregnancy as evidence of :-

 Intrauterine growth restriction .
 Fetal asphyxia .
 HELLP syndrome .
 Rising in serum creatinine .
 Management during labor .
 Proper sedation of the mother .

 Continuous monitoring of fetal heart rate .
 Foreceps may be needed to shorten the second stage .
 Oxytocin is given to prevent postpartum hemorrhage .
 Management during postpartum period .
 A sedative as dizepame to avoid rise blood pressure and

eclampsia .
 Urine is observed for amount and protein .
 Comprehensive nursing care and observation are continued until
blood pressure return to normal .
 Nursing management of eclampsia .
 During pregnancy .
 Hospitalization in semi dark room .

 Put the patient on her side , when turned on back tilt her head to
one side to prevent inhalation of saliva or vomitus .
 Insert catheter for urination .
 Observation of vital signs , urine and fetal heart rate .
 Give prescribed medications ( anticonvulsant drugs ,
antihypertensive drugs , IV glucose , digitalization ) .
 Don’t give magnesium sulphate if ( reflexes are absent ,
respiration rate < 12/min , urine output < 100 cc ) .
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 Maintain seizure precautions (side rails for protection , have

emergency equipment such as suction , O2 , padded tongue
blades ) .
 Provide support care during convulsions :-

 Place tongue blade in client’s mouth .
 Suctioning .
 Administer Oxygen .
 Record number and time of Fits .
 Care after convulsions :-
 Observe degree of consciousness .
 Note blood pressure , vital signs , urinary output .
 Remove saliva and mucus .
 Administer O2 , start IV hydration .
 Assess uterine contraction , assess fetal condition .
 During labor .
 Proper sedation .
 Continuous monitoring of fetal heart rate .
 If fits are controlled , termination of pregnancy .
 Foreceps may be needed to shorten the second stage .
 during postpartum period .

 A sedative as dizepame to avoid rise blood pressure and
eclampsia .
 Urine is observed for amount and protein .
 Comprehensive nursing care and observation are continued until
blood pressure return to normal .
 Classification of hypertensive disorders in pregnancy .

1 PIH .
2 Chronic hypertension ( present before pregnancy ) .
3 Chronic hypertension with super imposed preeclampsia or eclampsia .
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 Tumor ( neoplasm ) .
 A mass of tissue formed by a new growth of cells , normally

independent of the surrounding structures .
 Benign neoplasm .
 Localized mass and don’t transform into cancer .
 Potentially malignant neoplasm .
 It’s carcinoma in situ , they don’t invade and destroy but given it
enough time it will transform into a cancer .
 Malignant neoplasm .
 It’s invade and destroy the surrounding tissue , may form
metastases and eventually kill the host .
 Benign .
 Vulval Intraepithelial neoplasia ( VIN ) .
 Causes .  Signs and symptoms .  Diagnosis .

 Human papilloma virus.  Pruritis or soreness of  Biopsy .
 Herpes simplex virus 2. the vulva .  Treatment .
 Smoking .  The vulva my look  Excision of affected
 Immunosuppression . normal or bright red , area .
 Chronic vulvar dark red , brown grey or  Skinning Vulvectomy .
irritation . white areas .  Laser vaporization .
 HPV vaccine of girls
before sexual contact .
 Malignant .
106
 Invasive vulval carcinoma .
 Causes .  Signs and symptoms .  Diagnosis .

 Human papilloma virus.  Lump or ulceration .  Biopsy , pap smear ,
 AIDs .  Local bleeding . colposcopy , complete
 Pruritis vulva .  Dysuria and blood count .
 Smoking . dyspareunia .  Treatment .
 Vulval dystrophy .  Dark vulval Radical vulvectomy (
removal of its tissue and lymph nodes
Diabetes mellitus . discoloration . from the inguinal and femoral areas ) .
 Adenocarcinoma from  Radiation therapy and
bartholin gland . chemotherapy .
 Benign .
 Vaginal intraepitherlial neoplasia ( VAIN ) .
 Causes . Signs and symptoms . Treatment .

 Human papilloma  Dyspareunia .  Unifocal lesion .
virus .  Vaginal discharge .  Local excision ,
 AIDs .  Vaginal spotting . laser vaporaization and
 Smoking .  Vagina red in color . destruction by
 Radiotherapy to the electrocautery .
pelvic area .  Diagnosis .  Multi lesions .
 Depression of the  Colposcopy .
 Laser vaporization ,
immune system .  Biopsy .
partial or total
 Cervical smear test . vaginectomy .
 Radiotherapy and
chemotherapy cream .
107
 Malignant .
 Vaginal carcinoma .
 Signs and symptoms .

 Dyspareunia . Abnormal vaginal bleeding .
 Dysuria . Pain in the pelvic area .
 Diagnosis .
 Colposcopy , Biopsy , Pap smear .
 Treatment .
 Chemotherapy and radiotherapy .
 Benign .
 Cervical polyps ( tumor on the surface of the
cervical canal ) .
 Causes .  Sign and symptoms .  Treatment .

 Chronic cervical or  Menorrhagia .  Remove the polyps
vaginal inflammation .  Vaginal bleeding with ring foreceps .
 Local cervical among post  Tying surgical string
vascular congestion . menopausal women . around the polyp and
 Abnormal local  Bleeding after sex . cutting it off .
response of cervical  Leucorrhea .  Antibiotic .
cells .  Intramenstrual  Laser or
bleeding . cauterization of the
Diagnosis . remaining polyp .
 Cervical biopsy .
108
 Malignant .
 Invasive cervical carcinoma .
 Causes .  Signs and symptoms .  Treatment .
 Human papilloma virus.  Vaginal bleeding .  Excision of the lesion
 Smoking .  Vaginal mass . by diathermy , cautery or
 HIV .  Moderate pain during laser .
 Many sexual partners . sexual intercourse .  Conization of the
 Vaginal discharge . cervix .
 Metastases in the  Hysterectomy .
 Diagnosis . abdomen , lungs …etc .  Prevention .
 Biopsy .  Screening test .
 Colposcopy . Human papilloma virus
 Pap smear . vaccines .
 Iodine test .  Using condom during
 Cervicalgraphy . sexuall intercourse .
 Vitamins A ,C ,E and b12.
 Benign .
 Leiomyoma of the uterus ( uterine fibroid ) .
 Are benign tumors composed of muscular and fibrous tissue in the

uterus , they are estrogen dependent . ( common in Nulliparity ) .
 Signs and symptoms .  Treatment .

 Low back pain .  Oral contraceptive pills .
 Chronic pelvic pain .  Mymectomy .
 Iron deficiency anemia .  Hysterectomy .
 Dysmenorrhea .  Electrocauterization .
 Menorrhagia .  Diagnosis .
 Dyspareunia .  MRI ,ultrasonography ,laparoscopy .
109
 Endometrial polyps ( multiparous ) .
 Localized overgrowth of the endometrium .
 Causes .  Signs and symptoms.

 Chronic cervical or  Bleeding from the
vaginal inflammation . blood vessels of the
 Abnormal local polyp .
response of cervical  Dysmenorrhea .
cells to increased level  Dyspareunia .
of estrogen .  Treatment .
 Curettage .
 Diagnosis .  Hysterectomy .
 Vaginal ultrasound ,
 hysteroscopy ,
D& C .
 Malignant .
 Uterine cancer .
 It’s a malignant neoplasm arising from cells originating from the

uterine layers , estrogen dependent cancer .
 Risk factors .  Signs and symptoms .  Treatment .
 High level of estrogen (  Vaginal bleeding .  Hysterectomy to
using of COC ) .  Vaginal spotting . remove ovaries .
 Endometrial  Anemia .  Lymphadenectomy .
hyperplasia .  Lower abdominal pain  Chemotherapy .
 Obese women . or pelvic cramping .  Hormonal therapy with
 Polycystic ovary  Thin white or clear progestins and
syndrome . vaginal discharge . antiestrogens .
 Infertility .
 Early menarche .  Diagnosis .
 Late menopause .  D&C , hysteroscopy ,
 Breast,ovarian cancer . transvaginal ultrasound .
110
 It’s a fluid filled sac that form on the ovary .

 Types .
 Follicular cysts .
 Corpus luteum cysts .
 Theca-lutein cysts .
 Polycystic ovarian syndrome ( PCOS ) .
 Polycystic ovarian syndrome .

 Involves the presence of multiple in active follicle cysts
within the ovary that interfere with ovarian function .
 Symptoms .
 Abdominal distension .
 Hyperinsulinemia .
 Androgen excess ( hirsutism on upper lip , chin , cheeks … ) .
 Dyspareunia .
 Infertility .
 Obesity .
 Pelvic pain .
 Treatment .
 Oral contraceptive .
 Analgesic .
 Remove the cyst by laparoscopy .
 Ovulation induction agents to treat infertility .
 Changes of life style ( weight , diet , exercise … ) .
111
 Benign .
 Fibroadenoma .
 Abnormal growth of glandular and fibrous tissues .

 They are firm , freely mobile nodules .
 Between the age 15- 30 years .
 The tumor may be Excised and remove the nodules .
 Breast fibrocystic changes .
 Fibrosis or thickening of the normal breast tissue , whereas cysts

form in the latter stages .
 Caused by hormones produced by the ovary .

 Risk factor .
 High fat diet and excess caffeine intake .
 Signs and symptoms .

 Dense and irregular in the breast tissue ( cobblestone ) .
 Breast feel full .
 Dull , heavy pain and tenderness .
 Premenstrual tenderness and swelling .
 Occasional nipple discharge .
 Treatment .
 Reduce fats in diet .
 Wearing a well fitting bra .
 Using birth control pills .
 Malignant ( breast cancer ) .

 The normal breast cells are transformed into malignant ones .
112
1 The predisposing factors of puerperal infection ?

 Low resistance of patient .
 Premature or prelabor rupture of membrane .
 Prolonged or difficult labor .
 Obesity .
 Intra uterine manipulation .
2 The nursing intervention during the first 24 hrs

after delivery ?
 Prevention of infection ( perineal care , clean environment ) .
 Prevention of excessive bleeding ( maintain good uterine tone
, prevention of bladder distension ) .
 Promotion of comfort ( bathing , exercise , breast hygiene ,
manage pain ) .
 Promotion of rest , ambulation and exercise .
 Promotion of normal bladder and bowel patterns .
3  List 4 causes for breast Engorgement ?
 Inadequate milk removal .
 Inhibited milk ejection .
 Change level of hormones ( prolactin and oxytocin ) .
 Baby having congenital anomalies .
113
4 Types of the pelvic ligaments are ?

 Sacroiliac ligaments .
 Sacrococcygeal ligaments .
 Sacrospinous ligament .
 Sacrotuberous ligament .
 Pubic ligaments .
5 The true pelvis consists of 3 parts which are ? .

 The inlet ( the brim ) .
 The midpelvis ( pelvic cavity ) .
 The outlet .
6 The main causes of cracked nipple are ?

 Lack of clean and dry nipple .
 Leaving baby too long at the breast .
 Infections :- stomatitis .
 Wear tight bra .
 Engorgement of the breast .
7 Postpartum follow up visit are ?

 First visit :- within 24 hrs after birth at home .
 Second visit :- day 4 after birth at home .
 Third visit :- day 7 after birth at home .
 Fourth visit :- clinic visit at day 40 .
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8 The local causes of uterine atony are ?

 Uterine fibroid .
 Presence of uterine scar .
 Over distension of the uterus by big fetus .
 Retention of placental fragment .
9 Clinical manifestation of retroversion flexion of

the uterus are ?
 Low backache .
 Dysmenorrhae , dyspareunia .
 Leucorrhae , menorrhagia .
 Difficult defecation .
10 Nursing education for woman to cope with

postpartum blues are ?
 Reassurance the woman that condition is normal .
 Encourage woman to express feelings .
 Get plenty of rest .
 Teach the mother how to care her baby .

 Teach the woman to communicate with other new mother .
 Encourage parents and family to support woman .
11 Benefits of family planning to children include ?

 Decrease mortality among children .
 Improve intellectual development of children .
 Prevent genetic disease .
 Prevent communicable disease .
 Improve nutritional status .

 Provide other opportunity for education .
115
12 Types of puerperal infection include ?

 Localized ( acute septic endometritis ) .
 Spreading ( parametritis , thrombophlebitis ) .
 Generalized ( septicemia , pyaemia ) .
13 Classification of pregnancy induced

hypertension ?
 Mild preeclampsia .
 Severe preeclampsia .
 Eclampsia .
14 The intrapartum risk factor of dystocia are ?

 Prolonged second stage .
 Failure of descent of head .
 Abnormal first stage .
 Protracted descent .
15 Women risk factor of infertility include ?

 Uterine displacement .
 Endometriosis .
 Infections .
 Endocrine disturbances .
 Anatomically abnormality .
116
16 Contraindication of induction of labor ?

 Relative .
 Abnormal presentation .
 Multiple gestation .
 Severe hypertension .
 Maternal heart disease .
 Absolute .
 Complete placenta previa .
 Abruptio placenta .
 Prolapsed umbilical cord .
 Cervical cancer .
 Active genital herpes infection .
17 The nursing intervention for postpartum

hemorrhage are ?
 Anti shock measure ( IV fluid , blood transfusion ) .
 Careful check of episiotomy if occur .
 Using vaginal pack to control oozing from cervix or vagina .
 Curettage and uterine massage to remove retained placenta .
 Evacuate the bladder by using catheter to prevent uterine atony .
18 List 4 possible complications of STDs ?

 Endometritis .
 Cervacitis .
 Salpingitis .
 Dysfunctional uterine bleeding .
 Lymphadenopathy .
117
19 List 4 prevention of RVF ?

 Avoid bearing down during 1st stage .
 Not to lie in supine position during labor .
 Frequently empty bladder during pregnancy .
 Avoid prolonged lying on the back during the postpartum
hemorrhage .
 Avoid heavy work .
 Pessary treatment .
20 The cause of reduction in Maternal mortality

rate are ?
 Improvement ( blood transfusion , antibiotics , anesthesia
management and correct electrolyte balance ) .
 Development of training and education programs in obstetric
and maternity care .
 Better hospital facilities .
 Antenatal care .
 Training traditional birth attendance .
21 The uterus is supported in its place by ?

 Transverse cervical ligaments .
 Broad ligaments .
 Round ligaments .
 Ovarian ligaments .
 Uterosacral ligaments .
118
22 No partograph is used for the following cases ?

 Elective cesarean section .
 Previous cesarean section .
 Multiple pregnancy .
 Malpresentation .
 Very premature baby .
 Antepartum hemorrhage .
 Severe preeclampsia and eclampsia .
 Hegar’s signs refers to :-Softening of the isthmus of the uterus .
 Goodell’s signs refers to : softening of the cervix .
 Chadwick’s sign refers to : discoloration of cervix and vagina .
23 The nursing management of threatened abortion

is include ?
 Bed rest .
 Sedative drug .
 Urine is rent for a pregnancy test .
 The cervix is inspected .
24 Presumptive signs of pregnancy ?
 Vomiting .
 Increase vaginal discharge .
 Breast changes .
 Amenorrhea .
 Skin change .
119
25 Enumerate 4 signs of true labor ?

 Painful uterine contraction .
 Cervical effacement and dilation .
 The passage of show .
 Formation of the bag of water .
 Rupture of fetal membrane .
26 Signs of fetal distress during labor ?

 High or low fetal heart rate .
 Appearance of meconium stained .
 Fetal hyperactivity .
 Low oxygen saturation level ( under 40 % ) .
27 Postnatal visit are ?

 First visit :- within 24 hrs after birth at home .
 Second visit :- day 4 after birth at home .
 Third visit :- day 7 after birth at home .

 Fourth visit :- clinic visit at day 40 .
28 The characteristics of ideal

contraceptive method are ?
 Inexpensive .
 Rapidly reversible .
 Readily available .
 Easy to use .
 Highly effective .
 Safe for both couples .
 Culturally and religiously acceptable .

120
29 Breast changes during pregnancy are ?

 Dilated veins under skin ( vascularity ) .
 Nipple increase in size and become deeply pigmented .
 Hypertrophy of glandular tubercles .
 Primary and secondary areola .
 Colostrums formation .
30 Enumerate 3 benefits of postpartum exercise ?

 Increase energy .
 Relieve stress , improve mode .
 Promote weight .
 Improve cardiovascular fitness .
 Strength abdominal and pelvic floor muscle .
 Reduce baby blues ( postnatal depression ) .
31 Signs of maternal distress during labor .

 High or low blood pressure .
 Temperature > 38 C .
 Inadequate or prolonged contraction .
 Abnormal lower abdominal contour .
 Foul smelling vaginal discharge .
 Continuous bright or dark red vaginal bleeding .
121
32 Indication for cesarean section are ?

 Cephalopelvic disproportion .
 Fetal distress ( not receive enough O2 ) .
 Abnormal position of the baby ( breech , shoulder ) .
 Prolapsed cord ( occur after the membranes rupture ) .
 Abruption placenta .
 Placenta previa .
 Active genital herpes .
33 Nursing instructions to relieve backache for
pregnant woman are ?
 Backrub .
 Provide Pain relief ( analgesics ) .
 Hydrotherapy ( bathing ) .
 Application of heat and cold .
 Ambulation and change position .
34 The suture of fetal skull are ?

 Frontal sutures .
 Sagittal sutures .
 Coronal suture .
 Lambdoidal suture .
 Two temporal suture .
122
35 The function of the vagina are ?

 Passage for menstrual flow .
 Receive the penis and sperm .
 Passage for the fetus during labor .
36 Immediate care of the newborn according to

priorities ?
 Maintain clear airway by suction of the nose , mouth and
pharynx .
 Dry the neonate and provide warmth .
 Place the new born under the radiant warmer .
 Cut the cord 2-8 cm from the baby’s umbilicus .
 Penicillin eye drop to protect against gonorrheal

conjunctivitis .
 Vitamin K against bleeding disorder .
37 The nursing management of episiotomy ?

 Assess the episiotomy site every 8 hrs to evaluate healing .
 Avoid sexual intercourse .
 Using heat lamp in appropriate distance to promote healing .
 Use the REEDA scale to evaluate the perineum .
 Apply perineal pad .
38 The 3 layers of the uterus ?

 The endometrium .
 Mymetrium .
 Peritoneal coat .
123
39 The phases of menstrual cycle ?

 Proliferative phase ( Follicular ) .
 Secretory phase ( Luteal ) .
 Menstrual phase .
40 The transition phase of labor characterized by ?

 Regular rhythm of contraction .
 Bloody mucous show .
 Copious amount of discharge .
 Strong to very strong uterine contraction .
41 Constipation during postpartum may be due to?

 Atony of intestine .
 Decrease fluid intake .
 Immobility .
 Episiotomy , perineal lacerations of hemorrhoids .
 Side effects of medications .
42 Nursing measure to relieve postpartum urinary

retention ?
 Assist woman to the bathroom or onto a bedpan .
 Instruct the woman to listen to running water or placing her
hands in warm water or pouring water over her perineum .
 Administrating analgesics .
 Use sterile catheter .
124
43 The role of the nurse in family planning is

including ?
 Administrative role .
 Supervisory role .
 Educational role .
 Research and evaluation role .
 Sexual and genetic counseling role .
 Counseling role .
44 Management of puerperal sepsis include ?

 General ( sedative , analgesics , rest in bed , mild laxative ) .
 Chemotherapy ( antibiotic , heparin therapy ) .
 Local ( insure free drainage , care of any infected wound ) .
 Surgical ( drainage of abscess, ligation of the femoral vein ,
hysterectomy ) .
45 Management of breast engorgement ?

 Wear good supportive bra .
 Application of warm compresses .
 Encourage the newborn to suck at breast .
 Stress reduction and relaxation technique .
 Mild analgesic may be used .
125
46 Enumerate local changes associated with the

menopausal woman ?
 Osteoporosis .
 Hot flashes .
 Increased cholesterol level in the blood .
 Vaginal atrophy .
 Relaxation of the pelvic muscles .
 Cardiac effects ( intermittent dizziness ,cardiac palpitations ) .
47 The method of transmission of HIV are ? .

 Blood transfusion .
 Vertical transmission ( from mother to child ) .
 Sexual contact .
 Direct contact with Infectious blood or body fluids .
 Re use of contaminated needles and syringes .
48 High risk women for RH incompatibility are ?

 Rh negative pregnant woman .
 Prior pregnancy with RH positive baby .
 Prior blood transfusion .
 Miscarriage .
 Induced abortion .
 Amniocentesis .
 Didn’t receive RH immunization .
126
49 Prevent genital prolapse during postpartum

period ?
 Immediate repair of any perineal or vaginal tear .
 Avoid early ambulation .
 Treatment of chronic cough and puerperal constipation .
 Proper spacing of pregnancy .
 The patient asked to lie on her abdomen for 1 hr daily to
prevent RVF .
50 Vaginal examination during labor is done

to determine ?
 Dilation and effacement of the cervix .
 Presenting part , position and station .
 Engagement .
 Status of membrane ( intact , bulging or ruptured ) .
51 Contraindication of performing exercise during

pregnancy ?
 Lung disease .
 Premature rupture of membrane .
 Pregnancy induced hypertension .
 Severe anemia .
 Chronic bronchitis .
 Orthopedic Limitations .
 Poorly controlled seizure disorder .
 Poorly controlled thyroid disease .
127
52 Function of amniotic fluid ?

 Protect the embryo against mechanical injury .
 Control the embryo’s temperature .
 Allow the umbilical cord to be free from compression .
 Allow fluid for analysis to determine fetal health and
maturity .
 Allow freedom of movement and prevent adherence of the amonion .
53 Ectopic pregnancy ?

 This is a pregnancy in which the fertilized ovum is embedded
away from the endometrium of the body of the uterus or its
implantation of the fertilized ovum outside the uterine cavity .
54 Metrorrhagia ?
 Irregular , frequent uterine bleeding of varying amount but not
excessive ( may occur after menopause ) .
55 Secondary or late postpartum hemorrhage ?

 Excessive bleeding from the genital tract occurs from 24 hrs
to 6 weeks after birth .
56 Urethrocele ?
 Prolapse of the lower third of the anterior vaginal wall with
the urethra .
57 Rectocele ?
 Prolapse of the lower part of the posterior vaginal wall with the
anterior wall of rectum .
128
58 Retroversion flexion of uterus ?

 Means backward displacement of the uterus .
59 Precipitate labor ?

 Artificial termination of pregnancy after the age of
medicolegal viability of the fetus ( after 28th week of pregnancy ) .
60 AIDs ?
 Is a breakdown in the immune system caused by HIV .
61The clinical manifestation of revealed

accidental hemorrhage ?
 Vaginal bleeding .
 Pale , irritability , increase pulse .
 Blood lost and painful contraction .

 Laxed uterus between contraction .
 Fetal head may be fixed or engaged in the pelvic .
62The clinical manifestation of concealed

accidental hemorrhage are ?
 Sudden , severe , abdominal pain .
 Systolic decrease while diastolic remain increased .
 The abdomen is very tender and rigid .
 The uterus is very hard and large .
 Some scanty dark bleeding .

 Edema of lower limbs .  Heavy albuminures .
" ‫" وأخر دغوامه أن امحلد هلل رب امؼاملني‬
129

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‫‪Wateen‬‬ ‫محمٍد ظلبُ‬

‫بشم هللا الرحمن الرحّم ‪.‬‬

‫القلٍب ‪َ ...‬و َؽ ْا َق ِب َما ِب ِي َّص‬

 Maternity .  The state of being mother ( motherhood ) .

 Fertility .  Between 15-44 years in women .

 Infant  The death of infant before the first birthday .

 Birth  It’s a legal responsibility evidence of age , citizenship and family

 The goal of maternity care .

1 Keep human reproduction a normal physiologic process .

 Role of maternity nurse in modern maternity care .

 Activities and practice of maternity care .

1 Provide family planning information and advice .

 Principles of maternity nurse practice .

1 Working in a positive relationship with women .

 Direct ( main ) causes of maternal mortality .

 Indirect causes of maternal mortality .

 Reduction maternal mortality .

1 Improvement ( blood transfusion , antibiotics anesthesia

2 Development of training and education programs in obstetric

3 Better hospital facilities .

5 Training of traditional birth attendance ( conduct deliveries

 Problems of traditional birth attendance .

1 Lack of scientific medical information .

2 Prescription of folk medicine .

3 Inability to differentiate between normal and abnormal labor .

4 Using of some drugs improperly will lead to dangerous effect .

5 Unaware about the principles of sterilization and disinfection .

6 All instruments they keep are unsterile .

7 Doctors and professional midwives view of the traditional birth

 The female bony pelvis .

1 Support and protect the pelvic content .

 The structure of the bony pelvis ( 4 bones ) .

1 Two innominate ( hip bones ) .

 The two innominate bones .

 Divided into 3 parts :-

2 The ischium :- the strongest bone , lies under the ilium .

3 The pubis :- forms the anterior portion of the innominate bone .

 Wedge shaped bone , consists of 5 fused vertebrae .

 Small triangular , below the sacrum , last on the vertebral column .

 Joints of the pelvis ( 4 joints ) .

1 Two sacro iliac joints .

 The strongest joint in the body .

2 Sacro coccygeal joint .

 Join the sacrum to the coccyx .

3 Symphysis pubis joint .

 Unites the two pubic bones anteriorly .

 Ligaments of the pelvis .

 Is a band of rough tissue connecting bones , holding them

 Connect the sacrum to the ischial spine .

 Connect the sacrum to the ischial tuberosity .

 Division of the pelvis ( true and false ) .

A- The false pelvis .

 The part above the inlet and plays no part in children .

B- The true pelvis .

 It forms the bony passage through which the fetus must

 Bounded by anteriorly ( with pubic arch ) , posteriorly ( the tip of the

 Gynecoid ( the classic female type , 50 % of woman ) .

 Mons pubis ( mons veneris ) .

 It’s Hair covered fat pad .

 Two rounded folds of fatty tissue covered with skin .

 An erectile organ ( composed of erectile tissue with numerous

 An almond ( like eyes ) area enclosed by the labia minora .

 The area between the fourchette and the anus .