Obstetric notes for Kon-ne

Garang
By Senior Tutor and Professional
Midwife, Christine Nakayenga.

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 PART 1

NORMAL OBSTETRIC

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Section 1; common terms use in
obstetric
Obstetric-the scientific study of happening
during pregnancy, labour and puerperium
Gynecology- branch of medicine dealing with
diseases of female reproductive organs
Mid-wife - A trained person who assists
women during childbirth.
Obstetrician – specialist in obstetric
Gynecologist – specialist in diseases of
female reproductive organs

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 Menarche – first menstrual period of a woman
 SRHR – sexually reproductive health rights
 STIs – Sexual transmitted infections
 SRH – sexual reproductive health
 ICM – international confederation of midwives
 WHO – World health organization
 Congenital – born with the baby
 E.M.O.C – emergency obstetric care
 B.E.M.O.C – Basic emergency obstetric care

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HIV – human immunovirus
AIDS – acquired immunodeficiency syndrome
MTCT-mother to child transmission
PMTCT- Prevention Mother To child
transmission
Fetus – the unborn baby from 8 weeks to
delivery
FP – family planning
Prenatal- A period during pregnancy or
before birth

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N.L.M.P – normal last menstrual period
E.D.D – expected date of delivery
Gestation – a period or duration of a
particular pregnancy
Abortion – expulsion of the product of
conception before viability i.e. 24 in
developed countries and 28 in developing
countries
Pre- term – period after 24/28 weeks but
before 38 weeks of gestation

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Grand multigravida – being pregnant for
more than four times
Natal – during labour or childbirth
Post natal – the period after birth up to six
weeks
Partum – during labour or related to
childbirth
Puerperium – the period after
childbirth/labour up to six weeks

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Antenatal - a period during pregnancy but
before labour/childbirth
Ante-partum - refer to before onset of labour
Gravid -being pregnant
Primigravida - being pregnant for the first
time
Primipara – having given birth to her first
child
Multigravida – being pregnant for more than
one times

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L.M.P – last menstrual period
Neonatal – during the first 28 days of
baby’s life
Peri-natal – during the first seven days of
baby’s life
Post mature – born after 40 weeks of
pregnancy

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Section 2; Female bony pelvis
 Introduction;
• Gynecoid pelvis – pelvis ideal for childbirth
• The structure of the female pelvis is important to
understand because it is the canal through which
the fetus must pass during the normal process of
birth
 Functions of the female bony pelvis;
• Support the weight of the upper part of the body
• Transmit the upper body weight to the lower limbs
• Contain and protect reproductive organs
• Passage for fetus during birth

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Structure of the female bony pelvis;
Made of 4 bones namely;
• Left and right innominate or hip bone
• Sacrum
• Coccyx
Innominate bones are;
• Ilium
• Ischium
• Pubes

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Ilium
• Large upper flared out part
• Its anterior surface is concave and known as
iliac fossa
• Its upper most curved border is called iliac
crest
• Ends in front at the anterior superior iliac
spine
• Ends backward at the posterior superior iliac
spine
• Both spine and crest are palpable under skin
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• Below the iliac fossa is a ridge called ileo
pectoneal line ending at pectoneal
eminence
• Ileo pectoneal eminence is a rough
swelling where the Ilium fuses with the
pubic bone at the end of ileo pectoneal
line
• Below the ileo pectoneal line on the outer
side of the innominate bone is a cup
shaped depression, the acetabulum,
where the femur articulates to form a hip
joint
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The Ischium
• Lowest bone/part of the innominate bone
• Form part of the acetabulum above, below it Forms a
thick round mass below it called ischial tuberosity
• When in sitting position the body rest on the two
ischial tuberosity
• Ischial tuberosity can be palpated through the
buttocks and its distance apart is measured to assess
pelvis size
• Posterior and superior to the tuberosity is a sharp
projection directed backwards and slightly inwards,
the ischial spine dividing the greater and lesser
sciatica notches and is an important landmark
palpated vaginally to assess the size of the pelvic
outlet

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The pubis
• Small bone made of a body and two
rami/arms
• The upper arm/ramus joins the Ilium at
the ileo pectoneal eminence
• The lower ramus joins the ramus of the
Ischium forming the anterior boundary of
obturator foramen
• The bodies of the two pubis meet at the
symphysis pubis and make the pubic arch
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The sacrum;
• Lie between the two ilia and form the back
of the pelvis
• Wedge shaped bone made of five fused
vertebrae
• The first upper vertebrae is large and
projects forward, its centre is known as
sacral promontory
• Sacral promontory is an important
landmark of the pelvis because it is to
which the size of the anteroposterior
diameter of the pelvic brim/inlet is
measured to determine the size of the
pelvis. In some cases it may prevent the
fetal head from entering the brim
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• There is ala/wing on either size which
articulate with the ilium bone at the sacro-
iliac joint, while its apex articulate with
coccyx at the sacro-coccyxgeal joint
• Its smooth concave anterior surface is
called hollow of sacrum, it is important in
making the pelvic capacity/size
• Has a rough convex posterior surface for
attachment of muscles
• Has 4 pairs of foramina/opening through
which the sacral nerves passes

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The coccyx;
• Small bone lying below the sacrum
• Made of 4 fused vertebrae

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Figure 1; the diagram of female pelvis showing the important
landmark

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The pelvic joints;
There is little movement of pelvic joints in
non-pregnant state
During pregnancy there is small certain
softening and stretching of ligaments due
hormones of pregnancy. This result in slight
separation of joints giving rooms for the
passage of the fetal head in delivery
Four pelvic joints are;
• Sacro-iliac joints – left and right[2]
• Sacro-coccyxgeal – 1
• Symphysis pubis 1
KON NE GARANG 20
The pelvic joints

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Sacro-iliac joint;
• Made up of articulate of ala/wings of
sacrum with ilium
• Allow for limited backward and forward
movement of the tip of sacral promontory
• During pregnancy there is a strain on
these joint more common in multiparous
women to complain of backache at few
week after delivery

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Sacro-coccyxgeal joint;
• At the base of the coccyx joins with the tip
of sacrum
• Allow the coccyx to bend backward during
the birth of the head
Symphysis pubis;
• A Point where two pubic bones are join by
cartilage
• Slightly widen during late weeks of
pregnancy giving little movement which
may pain on walking

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The pelvic ligaments;
 Bind the pelvic bones together
 Ligaments binding the sacrum and the ilium at the
sacro-iliac joint are the strongest in the whole
body
 They are;
1. Sacro-tuberous ligaments - binds the sacrum
to the tuberosity
2. Sacro-spinous ligament – connect the sacrum
to ischial spines, they form the posterior wall of
the pelvic outlet
3. Inter pubic ligament – binds both pubic bones
together and strengthens the symphysis pubis
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Parts of the pelvis;
 Bony pelvis as a whole is divided into 2 parts;
• The false pelvis
• The true pelvis
 The false pelvis;
• Made up of the upper part of the flared outer iliac
bones. It is of little important in obstetric
 The true pelvis;
• Made up of the sacrum at the back, Ischium at the
side and pubes in front. It has 3 parts;
• The pelvic brim
• The pelvic cavity
• The pelvic outlet
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The pelvic brim;
• A ridge of almost round in shape except where the
sacro promontory projects in at the back
• Its boundaries parts are;
• Sacro-promontory
• Wings of the sacrum
• Sacro-iliac joints on both sides
• Ileo pectoneal lines – left and right
• Ileo pectoneal eminences – left and right
• Upper inner border of the bodies of the pubes
• Upper inner border of the symphysis pubis
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The pelvic cavity;
 Extends from the pelvic brim to the pelvic outlet
 It is a curve canal which is hallow in front and
deeper at the back
 Circular in shape
 Its boundaries are;
• Hallow of sacrum
• Sacro-iliac joints
• Ischium and sacro-spinos ligaments
• Right and left upper and lower pubic rami
• Bodies of the pubes and the symphysis pubis
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The pelvic outlet;
Lower part of the pelvis
Diamond shaped
Its boundaries are;
• Lower part of sacrum at the back
• Coccyx at the back, it extends backward
below sacrum
• Sacro-spinous ligaments and the ischial
spines on the sides
• Pubic arch at the front

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Diameters of the pelvis;
• Diameter is a straight line passing through the
centre of a circle or sphere
• Pelvis diameters are the measurement across the
pelvis canal [the brim, cavity and outlet]
• The four important diameters are;
• Antero-posterior diameter – from the back to the
front of the pelvis
• Olique diameters [left and right] from a landmark
at one side to a point on the opposite side
• Transverse diameter – from the widest point on
one side to the widest point on the opposite side
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Diameters of the pelvis
inlet/brim;
Antero-posterior diameter
• From sacral promontory to the upper border
of symphysis pubis and measures 11 cm
• Also called true or anatomical conjugate
• First diameter for the passage of fetal
head[engagement of the head] into the true
pelvis
Right oblique diameter;
• From the right sacro-iliac joint to the left ileo-
pectoneal eminence and measures 12 cm
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Left oblique diameter
• From the left sacro-iliac joint to the right
ileo-pectoneal eminence and measures 12
cm
Transverse diameter
• From the widest point at ileo-pectoneal
line immediately behind the ileo-pectoneal
eminence and measures 13 cm

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The diameters of the pelvic
cavity;
• Antero-posterior diameter 12 cm
• Right and left oblique diameter 12 cm
• Transverse diameter 12 cm
• NB; All in the same direction since the
cavity is circular

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Diameters of the pelvic outlet;
 Pelvic outlet is wider from front to back and
narrow from side to side
 The upper border of the pelvic out let is at the
level of the ischial spines
 The lower border of the pelvic outlet is diamond
shaped
 The diameters are;
1. Antero-posterior – from the apex of the pubic
arch to the tip of the coccyx and measures 13 cm
2. Oblique diameter [left and right] – right
oblique diameter is from right sacro-spinous
ligament to left sacro-spinous ligament and left
oblique diameter is from left sacro-spinous
ligament to right sacro-spinous ligament. Each
measures 12 cm 33
3. Transverse diameters of the outlet are 2;
4. Bi-spinous diameter at the obstetric
outlet, from one ischial spine to one on
the opposite side and measures 11 cm
5. Inter tuberous ischial diameter at the
anatomical outlet. Between the inner
borders of ischial tuberosity using the 4
knuckles of the close first fingers on
vaginal examination

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 Measurement of diameters in cm

Pelvic Anterior- Oblique Transverse

parts posterior diameter diameter
diameter
Brim 11 12 13
Cavity 12 12 12
outlet 13 13 11

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Types of pelvis;
There are 4 types according to the shape
of pelvic brim
1) Gynecoid pelvis
2) Android
3) Anthropoid
4) Platepelloid
NB; differences in shape may be due to
race, tribe, familial or inherited
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The Gynecoid pelvis;
Normal true female pelvis because it is the
ideal size and shape for childbirth
Incidence; found in 50% of women with
an average height above 150 cm whose
hip are wider than shoulders with shoe
size 4 or larger

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Characteristics;
• Round pelvic brim except at the point where
sacral promontory projects in
• Shallow pelvic cavity with broad well curved
sacrum
• Wide greater sciatic notch
• Wide sub pubic arch 90 degree
• Transverse diameter of outlet 11 cm
Effects on labour;
• Head engages in transverse diameter of brim
• Normal mechanism of labour

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Android pelvis;
• Male pelvis
• Found in 20% of women
Characteristics;
• Triangular pelvic brim, broader at the back
• Pelvic cavity, deep and funnel shaped and
narrow toward the outlet
• Greater sciatic notch is narrow
• Sub pubic arch, narrow 60-75 degree
• Transverse diameter of the outlet, less than
10 cm
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Effects on labour;
• Head may engages in transverse diameter
or in occipito-posterior position
• The descent of the head is likely to be
difficult because of narrow pelvic outlet
leading to deep transverse arrest
• Narrow sub pubic arch tend to force the
head backward leading to lacerations of
perineum

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 Anthropoid pelvis;
• Similar to apes
• Found in about 25% of women, may be
found in tall well build women
Characteristics;
• Pelvic brim – oval shaped, increased
antero-posterior diameter, decreased
transverse diameter
• The sacrum – long, narrow and contain six
vertebrae, this increase the pelvic cavity
depth and may hinder the engagement of
the fetal head

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Effects on labour;
• Head engages in transverse diameter
of brim
• Head May descent through the pelvis
with persistent occipito-posterior
position and be born as face to pubis.
• Generally the pelvis is large that
labour is easy

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The Platepelloid pelvis;
• Simple flat pelvis
• Found in less than 5% of women
• May result from development during
childhood e.g. hard labour
Characteristics;
• Pelvic brim – kidney shaped, decreased
antero-posterior diameter and enlarger
transverse diameter
• Antero-posterior diameter of the pelvic cavity
and outlet are reduced
• Sacrum is being placed forward 43
Effects on labour;
• Head engages in transverse diameter
of brim
• Rotation of the head may be
restricted and deep transverse arrest
of the head may occur

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The pelvic floor;
Functions;
• Support the weight of the abdomen and
pelvic organs
• Aids voluntary control of micturation and
defecation
• Play part during sexual intercourse
• Play part to the fetal movements through the
birth canal during labour[mechanism of the
labour]

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Structures of the pelvic floor;
Pelvic floor is divided into 2 equal halves
that unite at the midline of the cavity.
Each half is made of fascia and muscles
The muscles are;
• Levator ani
• Coccygeus muscles

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Levator ani;
Wide muscle making the anterior part of
the pelvic floor
Originate from the inner surface of the
true pelvis and unite in front of the
midline
Together the form a sling that support the
pelvic organs

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Coccygeus muscle;
Pair of triangular sheet of muscle and
tendious fibers situated behind the Levator
ani
Origin – medial surface of the Ischium
bone
Insertion – into sacrum and coccyx
making the pelvic floor

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Pelvic floor is perforated by;
• Urethra
• Vagina
• Anus

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The perineal body;
• A body situated at the bottom of labia
minora to anal canal
• Triangular shaped, measuring 4 cm on
each side
• Made of connective tissue, thin layer
muscle and fat covered with skin
• Provide attachment for pelvic muscles

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Section 3: Fetal skull
Important of knowing the fetal skull
• Hardest part of fetus and most difficult to
deliver whether it comes first or last
• Largest part in relation to fetal body and
comparing with mother’s bony pelvis
• For adaptation between the mother ‘s pelvis
and fetal skull during child birth
• It contain brain and its structures which may
get injured as head pass through mother’s
birth canal

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Structures of skull
1. Bones of the face - Most ossified at birth and
tightly joined together
2. Bones of the vault;
• Not fully ossified/hard at birth
• Leave small spaces of membrane which form
sutures and fontanelles where bone meet
• The bones of the vault are;
i. 2 parietal bones
ii. 2 frontal bones
iii. One occipital bones
iv. Upper part of temporal bones form the vualt

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Frontal bones;
• Make forehead or sinciput
• Fuse tightly into 1 flat bone by 8 years old
Parietal bones;
• Lie on either side of skull between frontals
bones in front and occipital bone at the back
with temporal bones below
Occipital bone;
Lie at the back, form occiput region
Part of it form the base of skull, contain
foramen magnum which protect spinal cord
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Sutures and fontanelles
• Sutures are membranous space where bones
meet and join
• Vault of fetal skull has 4 important sutures;
1. Frontal suture-between frontal bones.
Completely fuse at age of 8 years
2. Saggital sutures- between parietal bones
3. Lamboidal suture- between parietal bones
and occipital bones
4. Coronal suture- between parietal and frontal
bones

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Fontanelles
• Membranous space in the skull where 3 or
more sutures meet
• Fontanelles of obstetric important are;
1. Anterior fontanelles or bregma
2. Posterior fontanelles or lambda

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Anterior fontanelles
• Fontanelles where saggital, coronal and
frontal sutures meets
• Diamond shaped
• 3-4cm long, 1.5-2cm wide
• Flat on vaginal examination, when the head
is deflexed in occipito posterior position
• Close at the age of 18 months
NB; USE TO ASSESS CHILD GROWTH IN MCH

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Posterior fontanelles
• Membranous space where Lamboidal
suture meet with saggital suture
• Triangular in shape
• Felt on vaginal examination when head is
flexed in occipito anterior position during
labour
• Closes at six weeks of age

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Obstetric importance of sutures
and fontanelles
• Allow some amount of overlapping of skull
bone to allow fetal head to pass through
the maternal pelvis during labour

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Fig; fetal skull showing regions and landmark of obstetrical important
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Fig; view of fetal head from above[head partly
flexed]
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Diameters of fetal skull
• These are important to learn because of
relationship between fetal head and mother’s
pelvis
• Some are safe for easy passage through
pelvis canal
• Some are dangerous and cause problems for
the passage of the fetal through the birth
canal depending on the attitude of the fetal
head
• Attitude is the degree of flexion or extension
of the fetal head
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Types of diameters of fetal skull
1. Transverse diameters- from one side to
other side of head
2. Antero-posterior diameters- from one
point at the front of the head to another
point at the back of the head

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 Transverse diameters of the fetal
skull
1. Bi-parietal diameter-between 2 parietal
eminence. 9.5cm
2. Bi-temporal diameter- between the
further point of coronal suture at the
temple. 8.2cm

63
 Antero-posterior diameters
1. Sub occipito bregmatic diameter;
• From below the occipital protuberance to
the center of anterior fontanelles or
bregma
• It is 9.5cm
2. Sub occipito frontal diameter
• From below the occipital protuberance to
the center of the frontal suture
• It is 10 cm
64
3. Occipito frontal diameter
• From the occipito protuberance to the
glabellas
• It is 11.5cm
4. Mento vertical diameter
• From the point of the chin to the
highest point on the vertex slightly
nearer to the posterior fontanelles
than to the anterior fontanelles
• It is 13.5 cm

65
5. Sub mentovertical diameter;
• From the point where the chin join the
neck to the highest point of the vertex
• It is 11.5 cm
6. Sub Mento bregmatic diameter
• From the point where the chin joins
the neck to the center of anterior
fontanelles[bregma]
• It is 9.5cm

66
 Division of the skull
1. Vault of the skull
2. Base of the skull
3. Face of the skull
Vault of the skull;
• Large dome shaped part above the line between
orbital ridges and the nape of the neck
• Have thin and fliable bones. At birth the allow
skull to change shape slightly
The base of skull;
• Made of bones which are firmly joined to protect
the vital centers in the brain
The face of the skull;
• Made of 14 small bones which are fairly joined
and not compressible
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Regions and landmarks of the fetal
skull
Regions of fetal skull;
• Areas with obstetric importance related to the
degree of flexion or extension and presentation of
fetal head
• Important regions are;
1. Occiput-lies between the foramen magnum and
posterior fontanelles
2. Vertex-part between anterior fontanelles in front
and posterior fontanelles at the back, 2 parietal
eminence on the sides
3. Sinciput or brow-area between anterior fontanelles
and coronal suture to orbital ridges
4. Face- runs from orbital ridges and the root of the
nose to the junction of the chin[mentum] and neck
68
Fig; diagram showing the anteroposterior
diameters of the fetal skull

69
 Keys
SOB-suboccipitobregmatic=9.5cm
SOF-suboccipitofrontal=10cm
OF-occipitofrontal=11.5cm
MV-mentovertical 13.5cm
SMV-submentovertical 11.5cm
SMB-Submentobregmatic 9.5cm

70
Diagram showing the transverse diameters of the
fetal skull

71
Diagram showing regions of fetal skull

72
Section 4: The female
reproductive organs

73
The female reproductive
organs
 Classifications;
• External genitalia/vulva
• Internal genitalia
 External genitalia;
• Mons veneris
• Labia majora and minora
• Clitoris
• Vestibule
• Urethral orifice
• Vaginal orifice
• Anal orifice
• Bartholins glands
74
 Details of Each Parts
Mons veneris;
• Made of a pad of fat
• Lie over symphysis pubis
• Covered with pubic hair at puberty
Labia majora/greater lips;
• 2 folds of fat, fibrous tissue and skin
• Situated on either side of vagina
• Anteriorly the fold joins in front at the
symphysis pubis
• Posteriorly at the perineum

75
Labia minora/lesser lips;
• 2 thin fold of skin between labia majora
• Space between labia minora is the vestibule
where the vagina orifice, urethra open into
• In front the minora surround the clitoris and
behind is where the join together to form
couchette
Clitoris;
• Small erectile organ
• Sensitive with a lot of blood supply
• Play role in sexual intercourse in orgasm

76
Urethral orifice;
• Opening into urinary bladder in pelvic cavity
• Lie behind 2.3 cm at the back of clitoris
Vaginal orifice;
• Lie between urethra and anus. This
relationship is importance in obstetric
Bartholins glands;
• Small glands which open into the vestibule
on either side of vaginal orifice
• Lie behind labia majora
• Secrete mucus which lubricate the vaginal
walls
77
SUPPLY OF NERVE AND BLOOD TO
THE EXTERNAL GENITALIA
Blood supply to the external genitalia;
• External and internal pudental arteries
• Venous drainage into internal and external
pudental veins
Lymphatic drainage;
• Inguinal canal
Nerve supply;
• Branches of pudental nerves

78
Diagram showing parts of
external genitalia;

79
 Internal genitalia;
Located in pelvic cavity
They are;
• Vagina
• fallopian tubes
• Uterus
• ovaries

80
 Vagina;
Definition
• Potential canal
• Run parallel to the urethra from the vulva to
the cervix
• Run upwards and backwards in pelvic
• Behind vagina are; the pouch of Douglas,
rectum, and perineal body
• Lateral to vagina are fascia and uterus
• Below vagina is vulva

81
Size;
• Anterior wall 7.5 cm because the cervix
project into it
• Posterior wall 9-10 cm
Parts of vagina;
• Vault – upper end of vagina where cervix
projects into it, it is divided into 4 arches
called fornices;
• Posterior fornix is the largest where cervix
attaches at the back
• Anterior fornix lies in front of cervix
• Lateral fornices lie on either side of the cervix
82
 Layers of vagina;
• Outer covering layer made of areola tissue
• Middle layer made of smooth muscle
• Inner layer lining of stratified epithelium that form
folds known as rugae which allow vagina walls to
stretch during child birth
 Content of vagina;
• No gland
• Secretions are from leakage of fluid from the lymph
and cervical mucus and Bartholins glands
• Vaginal fluid PH is 4.5 strong acid in reaction –
prevent growth of microorganisms[pathogenic
bacteria]
• NB; Following menopause PH of vagina become
slightly alkaline about 7.5 so vaginitis occurs more
often in menopaused women

83
Functions of vagina;
• Organ of sexual intercourse
• Allows the passage of sperm to the cervix
and then to uterus and fallopian tubes
• Passage of menstrual flow to external
vulva at vagina; orifice
• Expands to allow passage of fetus during
the second stage of labour

84
 The uterus
 Definition
• Flat muscular organ
 Location;
• In true pelvic cavity
• Lie behind the urinary bladder and in front of rectum
• Lean forward, known as ante version
• Bend on itself, known as ante flexion
 Structure of uterus;
• Non pregnant uterus is a hollow muscular organ
 Size of uterus;
• 7.5 cm long 5 cm wide, 2.5 cm depth, 1.25 cm wall
thickness
• Cervix make lower third of uterus and measure 2.5 cm
long

85
 Parts of uterus;
1. Fundus; Dome shaped on top between
insertions of fallopian tubes
2. Body of corpus; form the upper two third of the
uterus and the greater part
3. Cornua; two outer angles of the uterus where
fallopian tubes enter parts/join the uterus
4. The cervix; potential space between anterior
and posterior walls, triangle in shape, base of
triangle being upper most
5. Isthmus; Narrow area between the cavity and
the cervix. It is 7mm long. It enlarges during
pregnancy to make the lower uterine segment

86
 The cervix of neck of uterus;
• Parts which protrudes into the vagina known as
supra vaginal portion
• Lower half is in the vaginal canal known as intra
vaginal portion
• Opening; cervix has two opening;
• The internal os[mouth] between the isthmus of
the cervix
• The external os, a small opening to the lower end
of cervix
 Cervical canal;
• Part of the uterine cavity
• Shaped like narrow tube at end side and wide in
the middle
• Content glands which secrete mucus, this mucus
during pregnancy is known as operculum
87
 Uterine wall;
 Made of 3 layer
 Middle layer is the thickest
 They are;
• Endometrium
• Myometrium
• Perimetrium
 Endometrium;
• Inner layer
• Made of ciliated epithelium tissue[mucus
membrane]
• Line uterine cavity
• Goes on shedding in thickness throughout
menstrual cycle
88
 Myometrium;
• Middle layer made of muscle fibres
• Thickest layer, more in upper part of uterus and
thinner at the isthmus and cervix
• Muscle fibres run in different direction i.e.;
• Outer longitudinal fibres; located at the upper
uterine segment responsible for contraction and
retraction of uterus
• Inner circular muscle fibres found in lower
uterine segment. Responsible for relaxing and
allowing to be stretch in labour so that cervix
dilates
• Middle oblique muscle fibres; surround the
uterine blood vessels and after the delivery of
the placenta control bleeding
89
Perimetrium;
• Outer layer made of double serous
membrane which drape over the uterus
covering it on either side and anterior wall
of the supra vaginal cervix and reflected
up over the bladder

90
 Nerve and blood supply to uterus
 Blood supply to the uterus;
• Uterine artery; branch of the internal iliac artery
• Uterine veins-branch of the internal iliac veins for
drainage
 Nerves supply to uterus;
• Autonomic system, sympathetic and parasympathetic
nerve via Franken Hauser’s flexus or pelvic flexus
 Lymphatic drainage of uterus;
• Internal iliac glands; collect lymph drainage from
uterine body
• Cervical area drain to other pelvic glands
• This provide effective defense against uterine
infections

91
 Support of the uterus;
Uterus is kept in normal position in the
pelvis by surrounding organs and the
following structures;
1. Urinary bladder at the front
2. Rectum at the back
3. Pelvic floor muscles

92
 Ligaments of the uterus;
• Transverse ligament; attached to the uterus
on either side then stretch to the cervix
• Utero-sacro ligament; at the back of
transverse ligament stretching backward from
the cervix to the sacrum
• Round ligament; attached to the uterus in
front of the fallopian tubes, then move
forward and are attached to the inguinal
canals ending in labia majora
93
 Function of uterus;
1. After puberty Endometrium goes on
shedding through regular menstrual
cycles
2. Accommodate the product of conception
up to time of birth
3. Uterus expels the baby during labour

94
Fig; lateral cross section view of
uterus

95
 The Breast Anatomy
The female breasts
The female breasts, also known as the mammary
glands, are
accessory organs of reproduction.
Situation
One breast is situated on each side of the sternum
and extends between the levels of the second and
sixth rib.
The breasts lie in the superficial fascia of the chest
wall over the pectoralis major muscle, and are
stabilized by suspensory
ligaments.
96
Shape
Each breast is a hemispherical swelling and
has a tail of tissue extending towards the
axilla (the axillary tail of Spence).

Size
The size varies with each individual and with
the stage of development as well as with
age.
It is not uncommon for one breast to be
little or larger than the other.
97
 Gross structure
The axillary tail
the breast tissue extending towards the axilla.
The areola
A circular area of loose, pigmented skin about
2.5 cm in diameter the centre of each breast.
It is a pale pink color in a fair- skinned woman, darker in a
brunet, the color deepening with pregnancy.
Within the area of the areola lie approximately 20 sebaceous
glands.
In pregnancy these enlarge and are known as Montgomery's
tubercles.

98
The nipple

lies in the centre of the areola at the level of

the fourth rib.

A protuberance about 6mm in length,

composed of pigmented erectile tissue.

The surface of the nipple is perforated by small

orifices which are the openings of the
lactiferous ducts.

It is covered with epithelium.

99
 Microscopic structure
The breast is composed largely of glandular
tissue, but also of some fatty tissue, and is
covered with skin.
This glandular tissue is divided into about 18
lobes which are completely separated by bands
of fibrous tissue.
The internal structure is said to be resemble as
the segments of a halved grape fruit or organ.
Each lobe is a self-contained working unit and
is composed of the following structures
100
Microscopic structure of female breast

101
 Parts of breast
Alveoli:
Containing the milk- secreting cells. Each
alveolus is lined by milk-secreting cells, the
acini, which extract from the mammary blood
supply the factors essential for milk formation.
Around each alveolus lie myoepithelial cells,
sometimes called ‘basket’ or ‘spider’s cells.
When these cells are stimulated by oxytocin
they contract releasing milk into the lactiferous
duct.
102
Lactiferous tubules: small ducts which
connect the alveoli.

Lactiferous duct: a central duct into which

the tubules run.

Ampulla: the widened-out portion of the

duct where milk is
stored. The ampullae lie under the areola.

103
 Blood and nerve supply to the
breast
Blood supply Blood is supplied to the breast by the internal
mammary, the external mammary and the upper intercostals
arteries. Venous drainage is through corresponding vessels
into the internal mammary and axillary veins.
Lymphatic drainage This is largely into the axillary glands,
with some drainage in to the portal fissure of the liver and
meditational glands. The lymphatic vessels of each breast
communicate with one another.
Nerve supply The function of the breast is largely controlled
by hormone activity but the skin is supplied by branches of
the thoracic nerves. There is also some sympathetic nerve
supply, especially around the areola and nipple.

104
 Section 5: Puberty
Definition
• The age at which the internal reproductive
organs reach maturity both in male and
female

105
 Puberty in female
• Usually start at age 12-14 yrs, may be
earlier or later
• The ovaries are stimulated by
gonadrotrophin from the pituitary gland
follicle stimulating hormones and
luteinizing hormone

106
Physical and psychological changes
in puberty in female
• Uterus fallopian tubes and ovaries reach
maturity
• Menstrual cycle and ovulation
begins[menarche]
• Breast develop and enlarge
• Pubic and axillary hair begin to grow
• Increase in height and widening of pelvis
• In fat deposition in the subcutaneous tissue
especially around the hips and breast given
feminine appearance

107
 Puberty in male
• Begins at 10-11 years may be earlier or
later
• LH from the anterior lobe of the pituitary
gland stimulates the interstitial cell of the
testes to increase the production of
testosterone
• LH influence the development of the body
to sexual maturity

108
 Changes occurring in puberty in
male
• Growth of muscle and bone and marked increase in height
• Enlargement of the larynx and deepening of the voice, it
breaks
• Growth of hairs on the face and axilla, chest, abdomen and
pubis
• Enlargement of penis,scrotum and prostrate gland
• Maturation of somniferous tubules and production of
spermatozoa
• The skin thicken and becomes oily
NB
• in male fertility and sexual ability tend to decline with age
• Secretion of testosterone gradually declines beginning at
about 50 years
• No period comparable to menopause in female

109
Section 6: The menstrual cycle
 Definition
• A menstrual cycle (also termed a female reproductive
cycle) Can be defined as periodic uterine bleeding in
response to Cyclic hormonal changes or a series of
changes that occur on the ovary, uterus, and cervix in
response to hormonal Change.
• The average age at which menarche (the first
menstrual period) occurs at the average age of 12.8
years. This may occur as early as age 9 or as late as
age 17 years.
 The purpose of a menstrual cycle is;
• To bring an ovum to maturity and renew a uterine
tissue bed that will be responsive to its growth should
it be fertilized?

110
Graph of menstrual cycle

111
 Description
• The average age of onset of menstrual cycles is 21 to 35 days.
• The accepted average length is 28 days.
• The length of the average menstrual flow is 1-9 days and the
average length is 5 days. Amount of flow is from spotting to 80 ml
on average.
• Four body structures that are involved in the normal physiology of
the menstrual cycle are:
 The hypothalamus
 The pituitary gland
 The ovaries and
 The uterus.
 Cervix
• For a menstrual cycle to be complete all four structures must
contribute their part, failure in activity from any part will result in
an incomplete or ineffective cycle

112
Symptoms of menstrual cycles in some
women;
• Anxiety
• Fatigue
• Abdominal bloating
• Headache
• Appetite disturbance
• Irritability
• Depression in pre-menstrual period.
• Abdominal pain during ovulation and the release of
accompanying prostaglandins.
• Irritation when a drop or two of follicular fluid or blood
spills in to the abdominal cavity. This pain, called
mitlelschmerz may range from a few sharp cramps to
several hours of discomfort. It is typically felt on either
side of the abdomen (near an ovary) and may be
accompanied by scant vaginal spotting. It is known as
Mitlelschmerz.
113
 Phases of menstrual cycle
 Proliferative phase:
• Immediately following a menstrual flow (occurring
the first 4 or 5 days of a cycle), the endometrium,
or lining of the uterus is very thin, only
approximately one cell layer in depth. As the ovary
begins to form estrogen (in the funicular fluid,
under the direction of the pituitary FSH), the
endometrium begins to proliferate, or grow very
rapidly, increasing in thickness approximately eight
fold. This increase continues for the first half of
the menstrual cycle (from approximately day 5 to
day 14). This half of a menstrual cycle is termed
interchangeably as the proliferative, estrogenic,
follicular, or postmenstrual phase.

114
 Secretory phase
• What occurs in the next half of in a menstrual
cycle depends on whether the released ovum
meets and is fertilized by spermatozoa. If
fertilization does not occur, the corpus luteum in
the ovary begins to regress after 8 to 10 days. As
it regresses, the production of progesterone and
estrogen decreases. With the withdrawal of
progesterone stimulation, the Endometrium
• of the uterus begins to degenerate (at
approximately day 24 or day 25 of the cycle). The
capillaries rupture, with minute hemorrhage, the
Endometrium sloughs off, and menstruation starts.

115
 Section 7: Fertilization, development
and embedding of the fertilized ovum

Ovum;
• Female reproductive cell of woman
• Largest cell in the body 0.16 mm in diameter
• Has 46 chromosomes XX
Spermatozoa;
• Male reproductive cell of man
• Found in cement
• Normal number 50 million cells per ml of
semen
• Size; 0.05 mm long 116
 Structure of sperm
• head- with a pointed end
• Body-store energy for movement
• Tail- propel the sperm along
• Has 46 chromosomes 2 being sex
chromosomes XY

117
 Fertilization
• The union of the ovum and the sperm
• Occur at the ampulla of fallopian tube

118
 Mechanism of fertilization
• After ovulation the ovum moves toward the uterus through
the fallopian tube
• During sexual intercourse 300 millions sperms are deposited
in the posterior fornix of the vagina
• Sperm with the aid of peristalsis movement of the tube and
their propelling movement travel toward the fallopian tube.
Only the strong sperm will penetrate into the
ovum[fertilization] or conception occurs
• As the head of the sperm near the ovum, the acrosome burst
releasing the hyaluronidase which rupture the semen of both
cells and allows the sperm to enter the ovum
• Once the fertilization has occurred, the ovum secrete a
substance which prevent all other sperms to enter
• At this stage the fertilized ovum is known as the zygote with
22 pairs of automosomes and 1 pair of sex chromosomes

119
 Development of fertilized
ovum[embryology]
• Zygote-From conception to 3 weeks
• Embryo- from 3weeks to 8 weeks
• Fetus- from 8weeks to terms/birth
After fertilization the zygote divides and
subdivides into 2 then 4 the 8 then 16 etc
as it travels along the fallopian tube as
follows;

120
• First day ovum divides from 1 to 2
• Second day, 2-4
• Third day, 4-8-16-32 and so on until it form
a small ball of cell known as the MARULA
• From third to seventh day, a cavity with
water form in the marula known as
blastocyst
• At one end the cell clump together forming
the inner cell mass, the remainder of cell
are push to form outer lining
• 4 days after fertilization the embryo enters
the uterine cavity,The trophoblast develops
quickly and is the one which absorb
nutrition and ready to embed into the
decidua
121
Diagram showing the development of
fertilized ovum
122
The syncitio trophoblast layer[outer
layer]
• Compound of nucleated protoplasm which
break down the tissue in the process of
embedding
• It erodes the walls of blood vessels of the
decidua making the nutrients in maternal
blood to reach the developing organism

123
 The cytotrophoblast-middle layer
• Made of single layer of cells which produce a
hormone called chorionic
gonadrotrophin[HCG]
• Inform the corpus luteum that pregnancy has
begun and corpus luteum then continue to
produce estrogen and progesterone
• Progesterone maintain the integrity of the
decidua so that shedding does not take place
and menstruation is suppressed
• High level of estrogen suppresses the
production of follicles stimulating
hormone[FSH]
124
 MESODERM-lies below the middle
layer
• Consist of loose connective tissue similar
to those in inner cell mass and the two
continue at where they join in the boy
stalk
• So the placenta develop from the
trophoblast

125
 Early development of fetus
The inner cell mass;
1. While the trophoblast is developing into the
placenta for nourishment of fetus, the inner
cell mass is developing into the fetus
2. The cell differentiate into 3 layers, each of
which will form particular parts of the fetus
called;
• The ectoderm
• The mesoderm
• The endoderm

126
1. The ectoderm;
• Forms the skin and nervous system mainly
2. The mesoderm;
• Form bones, muscles and also blood vessels,
including those which are in the placenta
• Some internal organs originate in mesoderm
3. The endoderm;
• Forms mucous membranes and glands
NB;
• The 3 layers together are known as the
embryonic plate
• Two cavities appear in the inner cell mass,
one on either side of the embryonic plate
127
Fig ; 13 days blastocyst

128
 The amniotic cavity
• Lies on the side of the ectoderm
• When the cavity is filled with fluids, it
gradually enlarge and folds round the
embryo to enclose it
• The amnion forms from its lining. It swell
out into the chorionic cavity[formally the
blastocele] and eventually obliterates it
when amniotic and chorionic membranes
come into contact

129
 The York sac
• Lie on the side of endoderm to provide
nourishment for embryo until the
trophoblast is develop sufficiently to take
over
• Part to the formation of the primitive gut
• Some float in front of the embryo until it
atrophies and becomes trapped under the
amnion on fetal surface of the placenta

130
 The embryo
• Product of conception from implantation
to 8 weeks]
• During embryonic period, the organs and
system of the body are laid down in
rudimentary form so that at its completion
they have to grow and mature for further
7 months. It is now known as fetus

131
 The placenta at term
• Placenta; a flat round mass which act as a
temporal organ of the fetus during
pregnancy
• Size; 20 cm wide, 2.5cm thick in center,
weight 1/6 of the baby body weight at
birth

132
Diagram of maternal surface
of placenta

133
 Embedding of fertilized ovum
• 3 days after entering the uterine cavity, the zygote
remain free from embedding into decidua
• After which it rests on the decidua, tiny
projections of the trophoblast similar to roots with
power of digging into tissue and implant into
decidua a process known as negation[nesting] is
normal complete by 11th day after ovulation and
Endometrium closes over it completely
• The trophoblast rapidly develops into the placenta
and its formation is completed by 12th week of
pregnancy
• Fetus[organs],amnion, umbilical cord and liquor
amnii develop from the inner cell mass

134
 Changes in Endometrium during
pregnancy
• Endometrium is called decidua during pregnancy
• From conception the increased estrogen causes
the Endometrium to grow thicker four times its
non pregnant thickness
• The corpus luteum produces large amount of
progesterone which stimulates the secretory
activities of the Endometrium glands and increases
the size of blood vessels. It makes the decidua
soft, vascular, spongy like bed in which the
fertilized ovum implant. 3 layers are found
including;

135
 Changes in Endometrium during
pregnancy cont…
1. Basal layer
• Lying immediately above the myometrium
• Unchanged in itself
• Regenerates the new Endometrium
during puerperium

136
 Changes in Endometrium during
pregnancy cont…
2. Functional layer;
• Consist of tortuous glands which are rich in
secretions
• Stroma cells are enlarged in what is known
as the decidual reaction
• Depends against excessive invasion by
syncitio-trophoblast and limit its advance to
the spongy layer
• It provide a secure anchorage for placenta
and allows it access to nutrition and oxygen
but as soon as the baby is born, separation
occurs from the placenta
137
 Changes in Endometrium during
pregnancy cont…
3. The compact layer;
• Form the surface of decidua and composed of
closely packed stroma cells and the neck of the
glands
• The blastocyst embeds within the spongy layer
and deferent areas of the decidua are identified
according to their relationships to it
• The decidua underneath the blastocyst is termed
as the basal decidua and that which covers it is
the capsular decidua and the remainder is called
the parietal or the true decidua
• As the embryo grow and fill the uterine cavity,
the capsular decidua meets and fuses with the
parietal decidua
138
 Early development of the placenta
1. The trophoblast;
a) Small projection begin to appear over the
surface of the blastocyst, becoming prolific
at the area of contact
b) The trophoblastic cells differentiate into 3
layers;
1. The syncitiotrophoblast [synatium]-the outer
layer
2. The cytotrophoblast - middle layer
3. The mesoderm or primitive mesenchyma -
lying below the inner layer cytotrophoblast
139
 Parts of placenta
1. Maternal surface;
• The side of placenta attached to the decidua
• Purplish red in color
• Divided into 15-18 cotyledons[lobes] by
deep groves or sulci.cotyledons contain
masses of chorionic villi
• Covered by thin layer of trophoblastic cells
and small deposits of lime salts which feel
gritty on touch

140
 Fetal surface of placenta
• Side adjacent to the fetus
• Smooth, white, and shinny with umbilical
cord inserted in the middle
• From the insertion of cord, the blood
vessels extends radiating to the periphery
like roots of tree. These vessels gives off
branches which enter into the tissue of the
placenta supplying each cotyledon with
main branch of umbilical artery and vein

141
Placenta fetal surface

142
 Function of placenta
1. Respiration
2. Nutrition
3. Excretory
4. Protection
5. Endocrine

143
 Respiration
• oxygen is brought to the uterine sinuses
by the branches of uterine and ovarian
arteries
• Interchange of oxygen and carbon dioxide
take place at the capillaries in the villi
giving co2 and other impurities and
receiving o2 in exchange by diffusion

144
 Nutrition
• Nutritive substance are selected by
placenta villi in the cotyledons and directly
absorbed into the fetal circulation via the
umbilical vein
• Placenta stores glucose as glycogen ready
to be converted to glucose to pass to the
fetus as require

145
 Excretory
• Waste products are given off and taken
away by uterine and ovarian veins

146
 Protection
• Bacteria are prevented from reaching fetus
from maternal blood
• Some pass the barrier e.g. spirochetes of
palladium, rubella virus
• Transfer of antibodies from mother blood to
fetus for specific immunity during the first
few days of baby’s life
• Dangerous antibodies in mother blood such
as rhesus negative can pass to subsequent
babies leading to hemolytic disease of
newborn

147
 Endocrine
• HCG is secreted from 6th week of
pregnancy reaching about 15th week when
the secretion decreases
• Progesterone from 12th week of pregnancy
until it is expelled during third stage of
labour
• Oestrogen from 6th week until after
expulsion of placenta
• Adenocorticotrophin hormone[ACTH]
148
 Abnormalities of placenta
A. Structural resulting from
anatomical abnormalities which
include;
1. Placenta succenturiata
2. Placenta bipartita or tripartita
3. Placenta circumvallata
4. Placenta accreta

149
B. Diseases of the placenta
1. Hydatidiform mole
2. Placenta infarcts

150
Structural abnormalities of placenta
1. Placenta succenturiata
• Small lobe of placenta separated from the main
placenta
• Attached to the main placenta by the blood
vessels which run across the membrane from
edge of the placenta
• Likely to be retained in the uterus and will lead to
severe puerperal[secondary] PPH
• If during the examination of the placenta a hole
is observed in the membrane with blood vessel
running to it. This indicates the present of
succenturiata lobe retained. Report to the doctor
immediately for evacuation
151
2. Placenta bipartita or tripartita
• A placenta divided into 2 main parts[bipartita] or 3
main parts[tripartita]
• Blood vessels unite when joining the umbilical cord
3. Placenta circumvallata;
• Chorion membrane is attached not to the edge of
placenta but to the fetal surface away from the
edge, forming a double layer of the amnion and
chorion
• Does not cause problem
4. Placenta accreta;
• Placenta is abnormal adherent to the uterine wall,
with no space of separation from the uterus,
leading to retained placenta during third stage of
labour

152
 Diseases of the placenta
1. Hydatidiform mole;
• A mass of vesicular mole with fluid inside them, with
degenerated chorionic villi and no fetus is developed
• Dangerous complications leading to severe bleeding
in early weeks of pregnancy
2. Infarcts;
• Dead chorionic villi noted on the examination of the
maternal surface of the placenta as white on
appearance and solid on touch with gloves fingers
• It is caused by preeclampsia, eclampsia and post
maturity

153
 Umbilical cord or funis
• Extend from the fetal umbilicus to the fetal surface
of the placenta
• Structure; composed of;
1. jelly like substance known as Wharton's jelly
2. covered by amnion membrane which is
continuous from amniotic membrane covering the
fetal surface
3. In Wharton's jelly are one umbilical arteries
carrying impure blood from the fetus to placenta
• Size; 5ocm long, 2cm thick
• Insertion; Into the centre of fetal surface of
placenta called central insertion of cord
154
 Function of umbilical cord
1. Oxygen, nutrient and antibodies are
transported from the placenta to the
fetus via umbilical vein
2. Carbon dioxide, other impurities are
transported from fetus to placenta via
umbilical arteries

155
 Abnormalities of umbilical cord
1. Too long cord;
• Above 50 cm
• Likely to wound around the fetal body, twice
or thrice around the neck
2. Knot in the cord;
• True knot- a long cord may form loops
through which the fetus can pass, thereby
creating a true knot which draw tight during
the descent of the fetus during labour
• False knot are thick parts of Wharton's jelly,
there is no true knot seen
156
3. Insertion of the cord;
a) Battledore insertion - cord inserted at the very
edge of placenta
b) Velamentous insertion - cord inserted into the
membrane of the fetal sac 5-6 cm from the edge
of the placenta with umbilical cord blood vessel
running between placenta and cord
c) Vasa preavia - is when the blood vessels lie
over the os and in front of the presenting part
during labour
• Occurs in some cases of Velamentous insertion of
cord
• Blood vessel may rupture with slight bleeding. If
the bleeding become severe with dilatation of the
cervix the fetus will be affected

157
 Fetal sac
• The bag of water[liquor amnii] storing the
fetus during intra uterine life
• Composition; made of;
1. 2 membranes-outer and inner amnion
chorion
2. Liquor amnii is kept with this sac, which
rupture during labour to allow the
expulsion of liquor amnii and fetus

158
 The membranes
1. Chorion membrane
• Thick, opaque, friable membrane, adherent
to the decidua on its outer aspect, until third
stage of labour when it detaches during the
expulsion of the placenta
2. Amnion membrane;
• Smooth, tough, transport membrane
• Line chorion membrane from which it can be
detached up to the insertion of the umbilical
cord

159
 Amniotic fluid[liquor amnii]
• A fluid which the fetus floats and is present in fetal
sac from the earlier weeks of pregnancy
• Amount increase until term
• Content of liquor amnii;
1. Water-98%
2. Alkaline in reaction
3. Salts including phosphates
4. Urea and albumin in small quantities
5. Fetal epithelial cells
6. Vernix caseosa and lanugo
7. Pale milky in color
8. About 800 – 1500 ml
160
 Functions of liquor amnii
1. Medium for fetal growth and movement
2. Absorb shock e.g. against knocks
3. Keeps constant body temperature for fetus
4. Prevent pressure on cord
5. Prevent fetus from injury
6. Aid dilatation of cervix as long as the
membrane remain intact
7. Cleans the birth canal when it ruptures
during second stage of labour

161
 Abnormalities of liquor amnii
1. Polyhyramnious-excessive amount of
more than 1800 ml
2. Oligohydramnious-less than 300 ml at
term

162
Section 8: Normal Pregnancy

Obstetric

163
 Introduction to abnormal
• The carrying of the product of conception in
uterine cavity from conception to delivery
• Normal pregnancy consist of;
1. one fetus and placenta
2. two membranes[amnion and chorion]
3. liquor amnii[800-1500ml]
4. duration of 40 weeks or 280 days or 9
calendar months and 7 days.
5. No condition or disease that can
endangered mother of fetal life
164
 Physiological changes due to
pregnancy
• These changes are normal and cause by
alteration in hormones production
• Knowledge of the changes is for;
1. Explanation of many remarkable things
that are regarded as signs and symptoms
of pregnancy
2. Enable appropriate management of the
mother during pregnancy

165
 Changes by system
Reproductive system;
a) Uterus increase in size, length from 7.5-30 cm,
wide 5cm-23,thickness 2.5-20cm[wall of
uterus],weight 60-960 or 1000 g at term
b) Shape of uterus; from triangle to ovoid from
16th weeks of pregnancy
c) Uterus become abdominal organ
d) Growth of uterus; happen at regular rate
indicated by the height of fundus, this is helpful
with estimation of the period of gestation while
palpating the abdomen as follow;
166
1. 8 weeks -uterus not palpated per abdomen
2. 12 weeks -fundus lies just above the level of the
symphysis pubis
3. 16 weeks -fundus lies midway between the
symphysis pubis and the umbilicus
4. 20 weeks -fundus lies at the level of umbilicus
5. 24 weeks -fundus at the level of umbilicus
6. 30 weeks -fundus midway between the
umbilicus and xiphysternum
7. 34 weeks- fundus at the 2 fingers below the
xiphysternum
8. 36 weeks-fundus at the level of xiphysternum
9. 38 -40 weeks-fundus at the level of 34 weeks
known as lightening
167
Fig; growth of uterus showing fundal height at various
weeks of pregnancy

168
e) Formation of uterine segment; after 12
weeks of pregnancy, the uterus at the
isthmus form into 2 segments
1. Upper uterine segment; extending from the
isthmus up to the fundus
2. Lower uterine segment; extending from the
isthmus to the internal cervical os
f) Uterine coats changes;
1. Perimetrium -outer coat of uterus stretches
to cover up to maximum of the growing
uterus
2. Myometrium -middle coat become longer
and thicker with increased peripheral blood
vessels
169
Myometrium consist of muscle fibres;
i. Inner circular fibres;
• Guard all the opening of the body of uterus
• More in lower segment to allow stretching of lower
uterine segment and dilatation of cervical os
ii. Middle layer muscle fibres -become figure of eight
from oblique, contract and retract during labour
and constrict the blood vessels during third stage
of labour controlling bleeding and is known as
‘’living ligatures’’
iii. Outer longitudinal fibres;
• extends from the cervix to Anteriorly over the
fundus and down the cervix Posteriorly
• Contract and shorten during labour causing upper
uterine segment to thicken and shorten at the
same time draw up and thin out lower uterine
segment
170
3. Endometrium;
• inner coat of the uterus
• under goes changes resulting from hormone
progesterone release by corpus luteum
• under the influence of chorionic gonadrotrophin
stimulates secretory activities to make it soft, thick,
increase in size of blood vessels and spongy bed in
which fertilized ovum implant and receive nutrition
g) Cervix -becomes softer and cervical gland release a
thick mucus which form a plug known as operculum
which covers the cervical canal preventing entry of
infections into uterine cavity
h) Painless uterine contraction known as Braxton
hicks contraction felt per abdomen palpation from 20
weeks of pregnancy; the Braxton hicks do not cause
dilation of cervix but assist in circulation of blood to
placenta site
171
I) Changes in vagina;
• It becomes soft and bluish in color due
to increased number and size of veins
with increased blood supply in the
vaginal walls which cause pulsation in
the fornices

172
 Production of pregnancy
hormone[changes in uterine
system]
a) Chorionic gonadrotrophin hormone[HCG]
• Produced by cells of trophoblast from the time of
embedding of fertilized ovum, circulates in
maternal blood
• Responsible for the growth of corpus luteum in
pregnancy up to 12 weeks, when it stops and to
grow and produce estrogen
• Excrete through the kidney in urine especially
during early weeks of pregnancy and is used for
pregnancy test
173
b) estrogen;
• Produced in increased quantities by the
corpus luteum during the 12 weeks of
pregnancy, after which it is mainly
excreted by placenta
• Stimulates growth of uterus, duct and
system of the breast
• Increased production of estrogen hormone
cause morning sickness[nausea and
vomiting]during early weeks of pregnancy

174
c) Progesterone;
• Produced mainly in corpus luteum during the first 3 months
and later by placenta
• Stimulates the development of thick, vascular decidua for the
embedding of the ovum and maintains the length of the
decidua
• Responsible for full development of the glandular tissue in the
breast and preparing for milk secretion
• Relaxes plain muscles which result into;
a) Allowing growth of uterus to accommodate the product of
conception through out the pregnancy with out stimulating
uterine contractions
b) Of the ureter leading to kinked and dilated ureter with
stagnation of urine leading to UTI fairly common during
pregnancy
c) Of bowel leading to constipation common in pregnancy
d) Of the walls of the veins which may lead to varicose veins of
the legs, rectum or vulva
175
 Other hormones
1. The thyroid hormone - enlarge to 50% of its
previous size due to increased demand of hormone
during pregnancy. It is important for fetal brain
development
2. Anterior pituitary gland;
• Enlarge during pregnancy
• Increase in prolactic hormone but control by high
level of estrogen
• Increase in adnrenocorticotrophine hormone,
thyrotrophic and melanocytic which cause increase
pigmentation during pregnancy
3. Adrenal-corticosteroids are increased during
second trimester of pregnancy to protect the fetus
and may be one of the reasons for glycosuria in
pregnancy
176
4. Relaxin hormone;
• relax ligaments of pelvis joints to allow
slight ‘give’ of pelvic joints providing small
amount of extra space in the pelvis
contributing to earlier labour
5. Ovaries;
• corpus luteum in ruptured graafican follicle
degenerates after 12 weeks and its
endocrine function is taken over by the
placenta. The become abdominal organs

177
 Changes in breasts during
pregnancy
• Under the influence of ovarian hormone
[estrogen and progesterone], the breast
begin early in pregnancy to prepare for milk
production as follows
1. Weight increase to 500g
2. Pricking, tingling sensation 2-4 weeks
3. Enlarge, tense and painful. Nipple becomes
prominent and mobile at 6 weeks
4. 8 weeks-superficial veins are visible
5. 8-12 weeks- montogometry’s tubercles
appears around the nipple. The secrete
sebum to keep nipple moist 178
 Changes in breasts during
pregnancy cont….
6. 12 weeks - darkening of primary areola
7. 14 weeks - small amount of colorless
fluid can be expressed
8. 16 weeks - colostrums can be expressed
9. 18 weeks – secondary areola appears
extending from primary areola. The
stretching of the skin over the breast may
produced strae gravidrum

179
 Changes in skin during pregnancy
• From 16 weeks, stretching marks appears as
bluish-pink lines called strae gravidrum one either
side of the abdomen. Similar marks may appear
on the thigh and breast in some women
• Chloasma is a mask like area of pigmentation on
the forehead and upper part of the cheek seen
early in pregnancy
• Dark area of skin [secondary areola] appears
extending from the primary areola of the breast
• Linea nigra is a dark line extending from
symphysis pubis to or above the umbilicus. The
perineum and vulva darkens become blue due to
vascularity

180
 Changes in cardiovascular system
during pregnancy
1. Changes in wbc,albumin/globulin content;
• Volume of blood increase by up to 30% between 10-
34th weeks[up to 1.5 liters]
• Slight increase in rbc-this result in hemodilution and
fall in hemoglobin known as physiologic anemia
• Cardiac output/pumping increase by 30% from 10-28
weeks due to increased volume of blood and weight
gain. After 36 weeks the cardiac output falls
• Blood vessels; progesterone dilate blood vessel
contributing to slight hypotension during second
trimester
• Increase of peripheral vessels in the uterus

181
2. Blood pressure;
a) lowered during second t2 as hemodilution and
progesterone influence plain muscles of blood
vessels to reduce in thickness
b) abnormal physiology known as supine
hypertensive syndrome[fainting-falls in BP which
may occur during last weeks pregnancy when
mother lie on her back for long time causing
pressure of large uterus to lie on inferior vena
delaying the return to the heart] result
• Varicose veins- progesterone relaxes the plain
muscle of the vein slowing down the circulation of
blood and varicose vein are common especially on
the legs and vulva and anus[hemorrhoid]

182
 Changes in respiratory system
during pregnancy
1. Lungs;
• Displace slightly upward by diaphragm as
push by growing uterus, compressing the
lower lobes of the lung leading to slight
increase in respiratory rate to meet oxygen
need
• Difficulty in breathing in late pregnancy as
enlarging uterus pushes diaphragm upward
and compresses the lower lob of the lung
• Oxygen need increase by 20%
183
 Changes in urinary system during
pregnancy
• Increase in frequency of micturation as
growing uterus compresses on the bladder[6-
12 weeks] and in late pregnancy
• Ureter compression by growing uterus; at 16
weeks progesterone relaxes the plain muscle
of wall of ureter leading to dilating and
kicking resulting in stasis[stagnation] of urine
which may predispose to pylelitis [UTI] of
pelvis of kidney, common in pregnancy

184
 Changes in GIT during pregnancy
• Muscular structure of whole tract relaxed leading to
some minor aliment of pregnancy such as;
1. Cardiac sphincter relaxes and allow esophageal reflux which
may cause heart burn
2. Gastric juice secretion is reduced and stomach take longer to
empty
3. Intestinal walls relaxes leading to constipation
4. Craving for certain types of food known as pica
5. Increase salivation known as ptyalism associated with
nausea and vomiting
6. Nausea and vomiting is common in pregnancy due to
increase level of estrogen or hcg between 4-14 weeks

185
 Changes in metabolism during
pregnancy
• Body work highly/faster to provide
nutrition for growth and development of
the fetus

186
 Body weight during pregnancy
• There is a weight gain of 12kg due to
increased body activity for the need of
fetus and maternal tissue. It happen in the
following manner;
1. Weight in the first 20 weeks=2kg
2. In the last 20 weeks=10 kg at the rate of
500g per week

187
 Factors responsible for weight gain
during pregnancy
factor Weight gain in kg

Fetus 3.5

Placenta 0.6

Amniotic fluid 1.5

Uterus 1

Breast 1.5

Blood volume 1.5

Extra cellular fluid 1

Stored protein 1.5

total 12
188
• Check weight on every ANC visit because of
its important in early detection of the
following abnormalities likely to rise during
pregnancy
1. Fetus not growing well if no weight gain
2. Rapid or excessive weight gain which
indicates;
• Multiple pregnancy
• Occult edema, sign of hypertensive disease
during pregnancy
• Excessive liquor amnii
• Big baby[size of baby]
• Conditions such as smoking, diarrhoea,
vomiting interfere with weight gain
189
 Changes in skeletal system during
pregnancy
• Body posture change as the balance of the body is
altered by weight of the growing uterus/fetus
• Increased relaxation and mobility of the pelvic joint
due to the effect[relaxing] of pregnancy
hormone[progesterone and Relaxin]
• Shoulders are thrown backward with increased curve
of the lumbar region causing strain on muscles and
ligaments at the back leading to backache
• Pelvic joints bounded by softened ligaments allow
small amount of widening of pelvic brim known as
‘give’ during late pregnancy due to progesterone and
Relaxin

190
 Psychological changes during
pregnancy/changes in the nervous
system
• Mild degree of depression or irritability
fear or anxiety
• Need sympathy and understanding
• Like and dislike of certain food, smell or
individuals
NB; these behaviors are influence by
hormone not nervous system
191
 Signs and symptoms of
pregnancy/diagnosis
These are establish by proper history and
clinical examination based on knowledge
of signs and symptoms
There are 3 types of signs and symptoms
of pregnancy;
1. Presumptive signs and symptoms
2. Probable signs and symptoms[clinical
signs]
3. Positive signs[true or investigative signs]
192
 Presumptive signs and symptoms
• Amenorrhea
• Breast changes
• Morning sickness
• Frequency of micturation
• Skin changes

193
 Probable signs and symptoms
• Hegar's signs[softening of the lower uterine
segment just above the cervix]
• Changes of uterus in size
• Osiander’s sign
• Lacquerer's signs
• Braxton hicks contraction
• Cervix feel soft
• Uterine soufflé
• Abdominal enlargement
• Internal ballottement
194
 Positive signs of pregnancy
• Hearing Fetal heart sound
• Palpation of Fetal parts
• Palpation of Fetal movement
• u/s scanning of the fetus
• Positive pregnancy test[hcg]
• X-ray result of fetal skeletons
• Actual delivery of the infants

195
Duration of Signs and symptoms
1. Presumptive signs
• Amenorrhea-from 1-40 weeks
• Tingling breast;1-4 weeks
• Morning sickness;4-12 weeks
• Enlargement of breast;4-40 weeks
• Frequency of urine; 4-12 weeks
• Primary areola pigmentation; 12-40 weeks
• Colostrum;16-40 weeks
• Montgomery; 12-40 weeks
• Tubercles;16-40 weeks
• Secondary areola; 16-40 weeks
• Quickening;16-20 weeks
• Strae gravidrum;24-40 weeks

196
2. Probable signs
• Hcg; 1-40 weeks
• Hegar signs; 4-12 weeks
• Changes in uterus;12-40 weeks
• Jacquenier’s signs;12-40 weeks
• Softening of cervix; 12-40 weeks
• Braxton hicks;16-40 weeks
• Uterine souffle;16-40 weeks
• Abdominal enlargement;16-40 weeks
• External ballotement;16-40weeks
3. Positive signs;
• Fetal heart sign;20-40 weeks
• Fetal movement; 20-40 weeks
• Fetal parts; 20-40 weeks
• u/s scanning; 16-40 weeks

197
 False pregnancy
False[pseudo] pregnancy
• A psychological disorder where a patient believes she
is pregnant
• Presumptive signs and symptoms happen
Causes;
• Emotions stimulate the endocrine system to produce
the hormone responsible for signs and symptoms
Diagnosis;
• Obstetric examination reveal absence of positive signs
of pregnancy
Management;
• Give general anesthetic to the patient and the
enlarged abdomen becomes flat as muscle relax

198
 Duration of pregnancy
280 days, 40 weeks or 9 calendar months
and severe days
Formula for EDD

NLMP+7 days +9 months

199
Section 9: Ante natal care

obstetric

200
 Introduction to ANC
• The health care given to a pregnant
woman from the time of conception until
the birth of the baby
• ANC aims at ensuring that the mother and
fetus are in good health and that any
problem is early detected, treated or refer
without delay

201
 Objectives of ANC
1. Promotion and maintain of physical, mental and
social health of mother and fetus
2. Early detection and treatment of any disease in
pregnancy
3. Ensure that the mother make individual birth
plan[IBP]
4. Preparation for safe delivery, emergency and
complications
5. Achieve delivery of full term health baby or babies
with minimal stress and injury to mother and fetus
6. Help mother breastfeed successfully, experience
normal puerperium and take good care of her child
physically, psychologically and socially

202
 Routine management
 ANC visit varies from mother to mother depending
on indicated conditions or complications
 Recommended 4 focused antenatal care[FANC]
called goal oriented ANC for a normal pregnancy is
as follows;
1. Firth visit at 10-16 wks – risks assessment
2. Second visit at 20-24 wks – screening for
abnormalities
3. Third visit at 28-32 wks- TT immunization
4. Fourth visit at 36 wks – prepare for child
birth/delivery
203
Health services provided in ANC
First visit;
1. Advice on individual birth plan
2. History taking
3. Physical examination
4. Anemia detection
5. Screening for syphilis and HIV
6. TT, iron and folic acid given

204
Routine management cont………
Second visit;
1. Check on IBP
2. Give first SP, iron
3. Listen to fetal heart
4. Counseling and health education on danger signs
and effect of HIV and syphilis on pregnancy, PMTCT,
VCT services
Third visit;
1. Check on IPB
2. Give second SP, iron and folic acid, TT if 4th week
from first dose
3. Listen to fetal heart
4. Counseling and education
205
Routine management cont………
Fourth visit;
1. Update on IBP
2. Detect Anemia
3. Check fetal presentation
4. Listen to fetal heart
5. Do V.E
6. Counsel and educate the mother as need
may arise

206
 Health education subjects for
mothers during FANC
1. Knowing EDD
2. Preparing for baby
3. Signs of pregnancy
4. Delivery place
5. Expectations during labour
6. Danger signs during pregnancy, labour and post
partum
7. What to when complication arise
8. Access to funds in case of emergency
9. The effect of HIV in pregnancy, PTMCT, VCT
services on visit or incase of HIV positive mothers
207
 Important points to remember in
ANC
• Every mother is at risk, treat every ANC
visit especial
• Pregnant mothers with medical condition
and complications in pregnancy should
visit ANC more than 4 times

208
Activities done on each ANC visit
On first visit or before 16 weeks;
1. Registration on first visit
• Comprehensive obstetrical history taking
a) Personal data
b) Family history
c) Social hx
d) Past gynecological hx
e) Past obstetrical hx
f) Hx of current pregnancy- From 1st -4th visit
g) Hx of complain in current pregnancy – from 1st-
4th visit
209
 Activities in ANC cont…………….
From 1st -4th visit
2. Physical examination;
a) Head to toe
b) Pallor
c) Edema
d) Breast
e) Lungs and heart only on 1st visit

210
 Activities in ANC cont…………….
3. Observation and clinical investigation;
a) Temperature
b) Pulse
c) Weight
d) Giant
All from 1-4th visits
4. Obstetrical examination;
a) Fundal height on every visit
b) Fetal pole/lie on 3rd visit
c) Fetal presentation 3rd visit
d) Engagement of presenting part 3-4th visit
e) Fetal heart sound 3-4th visit
211
 Activities in ANC cont…………….
Pelvic and vaginal examination;
a) Soft tissue assessment 1st and 4th visit
b) Genital ulcers
c) Vaginal discharge
d) Cervix and uterine enlargement/position
e) Adnexal mass
f) Bony pelvic assessment [Cephalo pelvic relationship
on 4th visit
5. Laboratory investigation;
a) Hemoglobin on 1st and 4th visit
b) Grouping and rhesus factor on 1st visit
c) VDRL and HIV testing on 1st visit
d) Urine for protein, sugar and acetone 1st-4th visit
212
 Activities in ANC cont…………….
6. Drug administration and immunization;
a) Iron from 1-4th visit
b) Folic acid 1-4th visit
c) Antimalarial 3-4th visit
d) TT 2nd and 3rd visit
7. Mother education and counseling;
a) Diet and nutrition 1-4th visit
b) Rest and exercise in pregnancy -all visit
c) Personal hygiene-all visit
d) Danger signs in pregnancy-all visit
e) Effects of STIs and drugs in pregnancy-all visit
213
 Activities in ANC cont…………….
f) PMTCT 1st visit
g) Care of breast and breastfeeding-all visit
h) Signs and symptoms of labour-3rd and 4th
visit
i) Plan for delivery-all visit
j) Plan for post partum care 3rd and 4th visit
k) Family planning 3rd and 4th visit
l) Harmful habit- all visit
m) Schedule of return visit-all visit
214
Section 10: History Taking In
Obstetric And Gynecology
Obstetric

215
 Introduction to history taking in
obstetric and gynecology
History give clue to diagnosis and
management
Precaution when taking history;
a) Explain what you are going to do
b) Provide privacy to the patient, take
history in close room
c) Be polite to the patient and observe
professional ethics
216
 Contents of history taking
1. Socio-demographic data;
a) Name
b) Age
c) Tribe
d) Religion
e) Occupation
f) Address
g) Next of kin
h) Nearest health facility
i) Date of admission

217
Contents of history taking cont……..
2. Introduction of the patient;
a) Gravida
b) Para- deliveries + zero [if no abortion]
c) LNMP, EDD and WOA
3. Presenting complain;
a) Mother come for ANC with no complain
b) Patient complain of……………..
NB; Consider main complain only, in sequence
of occurrence with duration stated in order
of first, second etc

218
Contents of history taking cont……..
4. History of presenting complain;
• How the disease started
• X-tics of complains
• What was done at home and in the hospital
• Is there improvement to treatment given
• Exhaust information about system affected in complain
5. Review of other systems;
• CNS
• GIT
• RS
• MSS
NB; only system which are not mentioned in the complain and
history of complain are review

219
Contents of history taking cont……..
6. Drugs history - commonly use by patient
and the extends of response and allergy
7. Past medical history
8. Past surgical history
9. Past gynecological history;
• Abortions
• Operations
• STIs and PID
• Cancers

220
Contents of history taking cont……..
10.Past obstetrical history;
• Para
• Gravid
• Previous ANC attendant, delivery, weight of baby,
status of baby, post delivery complications
• Immunization status of previous children
11.Menstrual history;
• Menarche
• Duration of menstrual cycle
12.Contraceptive history;
• Knowledge
• Use and side effects
221
Contents of history taking cont……..
13.Family history;
• Parent alive and well
• Sibling, numbers, spacing and death, disease
responsible, during of death at time of clerking
• Familial disease e.g. HPT, DM, sickle cells etc
• Death in the family and reasons
• History of twins at maternal and paternal side
14.Social economic status history;
• Married and staying with husband
• Drinking alcohol
• Source of earning money
• Type of food eaten, availability and affordability
222
Contents of history taking cont……..
15.History of present pregnancy;
• Gravida and Para
• WOA
• Current ANC attendant
• 1st trimester; nausea, vomiting, admission, iv fluids,
blood transfusion and vaginal bleeding
• 2nd trimester; fever, treatment given etc
• Third trimester; fever, vaginal bleeding, other
complications
16.Summary;
• Be short and tailoring to diagnosis
• Age, Gravida, Para, LNMP, EDD, WOA
• Complain, abnormalities, risk factors detected and
period in history with or without improvement
223
Section 11: Physical
examination
Obstetric

224
 General examination
1. Appearance of the patient;
• Consciousness
• General hygiene
• Nutritional status
• Skin appearance
2. Anemia;
• Conjunctiva
• Papilla[smoothness indicates chronic iron
deficiency]
225
 General examination cont…………
• Tongue
• Palm
• Nail[ capillary refill]
• Jaundice on sclera
• Edema- medial malleolus and tibia
3. Breast examination; 4 lobes of breast
and axillary bed

226
 Abdominal examination
1. Inspection;
a) Abdomen distended grossly or slightly,
oval or round in shape
b) Movement with respiration, fetal
movement, scars, linear nigra strae
gravidrum
2. Palpation;
a) Superficial palpation- warmth, tenderness
and masses
b) Deep palpation- spleen, liver, and kidney
227
 Abdominal examination cont………
c) Fundal height palpation;
• At fundal height pregnancy is 20 weeks
• At xiphoid sternum 36 weeks
• From xiphoid sternum backward by 1 finger[
minus one week]
• above umbilicus, each finger is 2 weeks
• Below umbilicus each finger is minus 2 weeks
from 20 weeks
NB; FH[fundal height] = WOA[weeks of
amenorrhea]
[ NORMAL DIFFERENCE IS TWO WEEKS]

228
 Abdominal examination cont………
d) Pelvic palpation;
• Determine presentation either cephalic,
breech or part free or engaged
e) Fundal palpation or presentation- presenting
part at the fundus will help in determining
the lie
f) Lateral palpation;
• Find baby back
• Smooth curved, long continuous
• Find fetal parts[ limbs are usually nodular]

229
Abdominal examination cont……….
3. Auscultation of fetal heart sound;
• Use fetal scope
• Heart at the back of the baby around should
4. Conclusion of examination as follows;
• Normal pregnancy at term
• Pregnancy at 30/40 weeks with pneumonia
or malaria
• Pregnancy at term with Polyhyramnious,
multiple pregnancy etc

230
Conditions when FH[fundal height]
>WOA[weeks of gestation]
1. Multiple pregnancy
2. Wrong date of LNMP
3. Breech presentation
4. Polyhyramnious
5. Hydatiform mole
6. Big baby etc

231
 Conditions when FH < WOA
1. Wrong date of LNMP
2. Transverse or oblique lie
3. Dead fetus
4. Poor growth due to disease conditions or
poor nutrition
5. Small baby
NB; NORMALLY FH=WOA

232
General Examination Of A
Pregnant Mother
Obstetric

233
Introduction to general examination
of a pregnant mother
Important because it;
Provides a baseline for assessing
subsequent changes during pregnancy
Carries out during every mother’s ANC
visit
General examination of a pregnant mother
begins by assessment of vital signs

234
Preparation for general examination
of a pregnant mother
1. Environment;
• Clean warm room with light
• Clean coach/bed/mat
• Ensure privacy by closing door and windows or
screening the bed, talking in low voice
2. Equipment;
• Functional weighing scale
• Sphygmomanometer
• Stethoscope
• Fetalscope
• Clinical thermometer
• Mother ANC card
235
 Preparation cont……….
3. Mother;
• Explain procedures and expectation
• Empty bladder
• Undress but keep petticoat
• Help her on coach
• Only expose part to be examine because of privacy
4. Midwife/health worker;
• Wash hand
• Warm dry hands
• Put on gloves in case of open lesions or discharge and
examine the vulva
• Clean uniform/apron or clinical coat

236
 Phases of carrying out general
examination of a pregnant woman
1. Inspection - sight[observation]
2. Palpation - touching or feeling using
fingers and flat hands
3. Auscultation - listening using
stethoscope or Fetalscope
4. Percussion or tapping

237
 Principles of carrying out general
examination
1. Stand on the mother’s right side
2. Examine and expose one part at a time
3. Start from the further part i.e. on the left
side
4. Systematically carry out the examination
from head to toe

238
 Component of the general
examination of a pregnant woman
1. Assessment of;
• Giant/statue
• Height
• Weight
• Bp
• Temperature
NB; ensure empty bladder
2. Routine lab investigation;
• Urine for protein, sugar, and acetone
• Blood for hb estimation, grouping and rhesus,
syphilis and HIV
239
 Component of the general
examination of a pregnant woman
cont….
3. General examination, head to toe;
• Statue/giant as she work to exclude limping or
lameliness
• Height to exclude contracted pelvis, mother less than
150 cm is regarded as high risk
• Weight to assess weight gain to exclude
abnormalities i.e. excessive, low or no weight gain
• Bp to exclude hypertension and pre eclampsia
4. Physical examination of the mother;
• Carry out systematically from head to toes so that no
part is omitted

240
 A. Head
i. Scalp; cleanliness, head lice, scar, sores,
wound infection
ii. Hair-texture, color, brittle, brown[sign of
malnutrition or severe anemia]
iii. Ears- sores[behind, around or inside],
discharge[types, smell, color and
duration], location[abnormal placement
suggest congenital abnormalities of
kidneys, swelling[mastoiditis]

241
 Head cont…………….
iv. The eye- presence, location, color of mucus
membrane[normally pink], red is signs of
infection, pallor sign of anemia,
sclera[normally white, red sclera indicates
bleeding or injury, yellow indicates jaundice
and jaundice indicates hemolysis due to
malaria, sickle cell diseases and hepatitis
v. Nose- present and normal location, nostril
present and separated by septum, sores,
discharge[type, color and smell]

242
 Head cont………………..
vi. Mouth;
• Status of lip- soft and moist, exclude cleft lip,
scar, cracks, sores or ulcer, discharge
• Inner moist mouth, dryness means dehydration
• Tongue- sore, normal pink, pale yellow[anemia],
inner lips and gum[normal pink, pallor indicates
anemia, bleeding easily means gingivitis
• Teeth- decay[give broad spectrum
antibiotic[NEVER ALLOW A PREGNANT WOMAN
TO UNDERGO TOOTH EXTRACTION may lead to
severe hemorrhage
243
 Head cont………….
vii. Neck;
• soft, turn[down, up, right and left]
• Swelling.
• enlarge thyroid gland[sign of goiter] fairly common due to
iodine demand
• distended jugular vein[sign of heart disease/conditions
• palpate for enlarge thyroid gland by placing right flat hand
over the neck at the thyroid gland location and ask mother
to swallow, if a hard mass pushes your fingers it indicates
enlarge thyroid gland.
• palpate parotid gland, enlarge suggest mump or HIV
infection. It produce saliva that soften food
• Submandibular gland enlarge suggest infection
• Sublingual gland enlarge suggest infection or teeth decay

244
 B. Upper limbs
• Arms stretch, hand close to each other
facing downward and observe for;
a) Equality of arm, exclude skeletal
deformities
b) Malnutrition
c) Extra digit, swollen fingers
d) Distended veins
e) Skin status- textures, color, rashes, crack,
sores and scars
245
 Upper limbs cont……………….
• Palpate for;
a) Physical count of digit
b) Short digit indicates contracted pelvis
c) Nail status[hygiene, palm color, normal
pink]
d) Capillary refill on nail
e) Yellow palm indicates jaundice
f) Pallor palm indicates anemia

246
 C. Examination of breast
1. Inspection;
• presence and location
• shape, normally pawpaw shaped,
• scar, rashes, sore/wounds
• signs of pregnancy[enlarged, darkening of
primary areola, strae gravidrum, superficial veins,
montogometry's ‘s tubercles]
• Nipples, prominent inverted are not sitautable for
breastfeeding, sores and cracks
• Masses/new growth-mother raise arms and lower,
breast must raise and lowers equally. One
lowering or raise slowly suggest mass

247
Breast examination cont………….
2. Palpation/on touch, mother standing
holding the waist and palpate for;
• Tenderness and obvious masses
• From axilla feeling for swollen lymph nodes,
tenderness to exclude infection
• Axillary gland
NB;
• palpate while observing mother’s face to detect
area of pain
• In case of mass detected note; size,
mobility[benign]
• Fixed[malignant tumor

248
 D. Lower limbs
1. Inspection; Mother stretch her legs with feet
close to each other and observe for;
a) Equality of legs
b) Extra digit[talipes]
c) Skeletal deformities
d) Swollen ankles, toes, feet and nail beds,
jiggers or infection or anemia/edema
e) Varicose veins
f) Skin status-texture, color, rashes, crack,
sore, scar, fresh wound etc
249
 Lower limbs cont……………….
2. Palpate for; ask for size of shoes, check if
the are equal, unequal length suggest
reduce pelvic diameters
• Physical counting of digits
• Nail status, presence hygiene etc while
observing facial expression for pain
• Capillary return and varicose vein

250
 E. Vulva
• Put gloves
• Ask mother if any vaginal discharge and explain
procedures and reasons
a) Observer for;
• Perineal scar
• Varicose veins
• Vulva sore due to syphilis
• Vulva warts
• Edema
b) Vaginal discharge;
• Normally white[leucorrhea]
• Not irritant
• Not offensive and small in amount
251
 Vulva examination cont……
c) Abnormal discharge;
• Profuse
• Purulent
• Irritating
• Green discharge suggest trichomonas vaginitis
• Yellow discharge suggest gonorrhoeae
• White curdy discharge suggest Candida vaginitis
• Frothy or blood stained
NB; all they above must be treated
• Slow, blood mixed with mucus suggest labour

252
Abdominal examination of a
pregnant mother
Obstetric

253
 Introduction
Carries out at every ANC visit and aim at;
1. Confirm and access the progress of
pregnancy
2. Monitor fetal size, growth and well being
3. Identifying any abnormality than
endangers maternal or fetal life
4. Diagnose the location of fetal parts

254
 Preparation for abdominal
examination
Can be psychological or physical;
A. Psychological preparation;
a) Introduction
b) Explain the procedure and expectations and reasons for
examination
NB; expose only part to be examine
B. Physical preparation;
• Mother comfort e.g. clean coach
• Empty urinary bladder, full bladder make measurement of
fundal height difficult and discomfort to mother
NB; abdominal examine will be effective if the mother constantly
lie in the same position at each examination check.
Alternating of position like supine position lead to significant
differences while estimating fundal height

255
 Preparation for abdominal
examination cont……………
1. Environmental preparation
2. Equipments
3. Prepare mother
• explain the procedures and reasons for examination
• Empty urinary bladder
• Sitautable position
• Ensure that she does not stay in supine position for long
time because of the danger of supine hypertensive
syndrome due heavy uterus pressing the vena cava against
the hard vertebrae column
• Expose the three land mark; symphysis pubes, umbilicus,
and xiphysternum
4. Preparation of the health worker e.g. wash and warm hands
etc

256
Physical examination of a pregnant
mother’s abdomen
Do it systematically through;
A. Inspection
B. Palpation
C. Auscultation
A. Inspection; stand from the put of the bed and
observe abdomen for;
a) Size/enlarged
b) Movement with respiration, if it does not move
with respiration it suggest;
• Peritonitis
• Ruptured uterus

257
Physical examination of a pregnant
mother’s abdomen cont………..
Move on the right side of bed and observe for;
a) Skin texture
b) Scars, sores etc
c) Myomectomy, removable of fibroids in
uterus
d) Hysterectomy
e) Caesarian section
f) Signs of pregnancy; linea nigra, strae
gravidrum[bluish strae marks of the skin
g) Fetal movement
258
Physical examination of a pregnant
mother’s abdomen cont………..
B. Abdominal palpation;
• Stand on the right side of bed
• Use palm not fingers tips
• Move hands smoothly over abdomen
1. Superficial palpation;
a) A part with part on abdomen should be
palpated last
b) Masses and tender, observe facial
expression

259
Physical examination of a pregnant
mother’s abdomen cont………..
2. Hypochondriac palpation/deep abdominal
palpation;
a) Feel enlarges spleen at left side, liver at
right side
b) Note size if there is megally
c) Enlargement of these organs suggest;
• Chronic anemia
• Persistent malaria
260
 Physical examination of a pregnant
mother’s abdomen cont………..
3. First fundal palpation;
• Assess fundal height if it correspond to
the weeks of amenorrhea
• Xiphysternum = 36 weeks
• 2 fingers below xiphysternum = 34
weeks
• 4 fingers below xiphysternum = 38 – 4
weeks[indicates head gone down the
pelvis known as lightening
• Costal margin = 32 weeks
261
Physical examination of a pregnant
mother’s abdomen cont……
• Midway between umbilicus and
xiphysternum = 30 weeks
• Umbilicus = 24 weeks
• Just below umbilicus = 20 weeks
• 2 fingers above umbilicus 28 weeks
• Midway between umbilicus and
symphysis pubis = 16 weeks
• Just above symphysis pubis = 12 weeks
 NB; EACH FINGER = 2 WEEKS OR 2CM
262
Physical examination of a pregnant
mother’s abdomen cont………..
4. Deep pelvis palpation;
• Detect presentation of fetus, what is lying lowest in
the pelvis
• Soft mass and irregular = buttocks
5. Second fundal palpation;
• Detect what is lying in the fundus to determine the lie
of the fetus
• Normally, it is longitudinal
6. Lateral palpation;
• Find fetal back, determine lie of fetus
C. Auscultation;
• Asses fetal wellbeing using Picard's Fetalscope,
binaural Fetalscope
263
Summary of abdominal
examination
1. The lie is longitudinal
2. Presentation is cephalic and engage or
free
3. The position is right or left occipito
anterior
4. The fetal heart is regular at a rate of 120
beats per minutes
5. According to finding she will benefit at
the maternity center
264
Summary of abdominal
examination cont…..
Positions as follows;
1. Right occipito anterior; fetal heart sound is
heard nearer the midlines than in left
occipito anterior
2. Left occipito anterior; fetal heart heard
clearly midway between umbilicus and left
superior iliac spine
3. Left occipito posterior-fetal heart heard in
mother’s left flank
4. Right occipito posterior; fetal heart is heard
in the mother right flank
265
 Summary, Diagnostic finding
1. Positive signs of pregnancy after 20
weeks of pregnancy
2. Proof fetus is alive
3. Presentation and position
4. Diagnosis of multiple pregnancies
5. Malpresentations or lie

266
High risk factors during
pregnancy
Obstetric

267
 Definition
1. Risk is a probability that event will occur
that expose mother and fetus to mortality
and morbidity, it is necessary to;
• Detect and treat
• Close monitoring in ANC during labour and
puerperium
• Early referral
These conditions are;
a) Previous hemorrhage APH or PPH, retained
placenta etc
b) Grand multigravida
268
 High risk factors cont…….
c) Anemia
d) Multiple pregnancies
e) Previous uterine scars
f) Underweight mother due to mal nutrition
g) Deliveries less than 2 years apart
h) Sickle cell disease

269
Conditions that affects intra uterine
growth and cause abortion or
premature labour
1. Pre-eclampsia
2. Hypertension
3. Anemia
4. DM
5. Multiple pregnancies
6. Alcoholism
7. Mal nutrition
270
Conditions that predispose to
infection of the mother and fetus,
may cause abortion
1. HIV infection[ weakened immunity]
2. Anemia[low immunity]
3. Early rupture of membrane
4. Malaria[high body temperature]

271
Conditions where deliveries may be
assisted
1. Short statue below 150 cm tall
2. Young Primigravida 17 years and below
3. Elderly Primigravida, 35 years and above
4. Previous uterine scar like CS
5. Cardiac diseases
6. DM[babies fatten leading to CPD]
7. Big babies
8. Deformities or injuries to pelvis, spine and
lower limbs
272
Condition that are likely to worsen
pregnancy
1. Renal diseases
2. DM
3. Mental illness
4. Epilepsy
5. Heart disease
6. HIV

273
Conditions that likely to cause fetal
abnormalities or diseases of the
fetus
1. Age of the mother, above 35 years
2. Syphilis
3. History of having used some drug like
sulfonamide[brain damage]
4. Alcoholism
5. Some genetic disorders[sickle cell disease]
6. Educate mother on risk if the are carrier e.g.
sickle cell disease
274
Roles of midwife in reduce risks
factors in pregnancy
1. Health education on;
a) Risk factors
b) Client concern discussion
c) ANC screening
2. Proper management
3. Accurate examination
4. Proper management of labour
5. Early referral to hospital
6. Update knowledge
275
General summary of high risk
factors in pregnancy
1. Young Primigravida, below 18 years
2. Old Primigravida, above 35 years
3. Primigravida at any age
4. Height under 150 cm tall
5. Uterine scars; myomectomy, hystrotomy and
hysterectomy
6. Previous stillbirth[born dead]
7. Previous PPH
8. Mal presentation
9. Multiple pregnancies
10. Poly hydramnious
276
Summary of high risks cont…….
11.Severe anemia
12.Severe edema
13.Previous blood transfusion
14.Hypertension
15.HIV positive mother
16.Vaginal bleeding
17.Severe illness
18.3 or more abortion in row[habitual abortion]
19.Physical disability or lower limbs or pelvis

277
Health education and advise
to pregnant women
Obstetric

278
Normal labour

Obstetric

279
Normal labour
Definition
• The process of expulsion of the fetus, liquor amnii
and placenta after 28 weeks of pregnancy
• X-tics of normal labour;
a) Spontaneous onset of regular uterine
contractions of increasing intensity and frequency
after 34-40 weeks, accompanied by progressive
cervical effacement and dilatation
b) One fetus, placenta, 2 membranes and liquor
amnii
c) Last not more than 18 hours
d) End without endangering mother’s life
280
 Stages of labour
1. First stage of labour – from onset of labour
to full dilatation of cervix
2. Second stage of labour – from full dilatation
of cervix to expulsion of fetus[delivery]
3. Third stage of labour – from delivery of the
baby to full expulsion of placenta
membranes and control of bleeding
4. Fourth stage of labour – one hour following
the full expulsion of placenta, membranes
and control of bleeding[ third stage of
labour]
281
Normal first stage of labour
There are 2 phases;
1. Latent phase – cervix less than 3 cm dilated
2. Active phase – cervix is 3cm or more dilated
NB; latent phase is not charted on partograph
Duration of first stage of labour;
a) Primigravida = 12-14 hours
b) Multigravida = 8-10 hours
Factors influencing labour;
1. Power/uterine contractions
2. Passengers- liquor amnii, fetus and membranes
3. Passage- bony pelvis and pelvis floor muscles
4. Fuel- hormones e.g. oxytocin
282
 Physiology of first stage of labour
1. Contraction and retraction of uterine
muscles
2. Formation of lower and upper uterine
muscles
3. Development of retraction ring
4. Polarity
5. Taking up of the cervix-cervical effacement
6. Dilatation of the cervical OS
7. Formation of waters
8. Rupture of the membranes
283
 1. Contraction and retraction of
uterine muscles
1. The process is involuntarily
2. Contraction surface at uterine cornua
3. Wave passes downward from cornua
4. Uterine muscles have special power of retaining
some of the contractions instead of becoming
completely relaxed and the muscles progressively
become shorten and thicker known as retraction
5. The retraction actions assists in progressive
expulsion of the fetus by the upper uterine
segment becoming shorter and thicker leading to
the lessening of uterine cavity
6. The fundus become hard and remain harder
through out the period of each contraction
284
 2. Formation of upper and lower
uterine segment
1. At the end of pregnancy uterus divides into upper
and lower uterine segments
2. The upper segment consist of thick muscular
contractile part
3. Lower segment, the area starting from isthmus, it
is thin and distensible area
4. During labour the retracted longitudinal fibres in
the upper segment pull on the lower segment
making it stretch
5. The force applied by the descending head or
breech on the thinned out lower segment aids
dilatation of cervix and expulsion of the fetus
285
 3. Development of retraction ring
• The ridge which forms at the border of a
thick uterine segment where it meets with
the lower thin segment[retraction ring]

286
4. Polarity
• The action by the upper and lower uterine
segments working together as upper
uterine segment contracts strongly and
retracting to expel the fetus while the
lower uterine segments is slighting and
dilating to allow the fetus to be expel

287
 5. Taking up effacement of the
cervix
1. Cervix shorten at the end of pregnancy
2. At the beginning of labour the muscles
surrounding the internal OS are drawn
upwards by retracted upper uterine
segment and the cervix gradually
disappear, a process known as
effacement of the cervix

288
6. Dilatation of cervix
1. The enlargement of the external OS from
a circular opening to a large opening to
allow the fetus to pass
2. Aided by good fitting of presenting part,
a well flexed head closely applied to the
cervix aiding dilatation

289
 7. Show
1. A blood stained mucoid discharged from
the beginning of first stage of labour
2. Show come from the operculum as a
result of being detached from dilating
cervix

290
8. Formation of waters
1. When the lower uterine segment stretches, the
chorion become detached from it
2. The increasing ultra-uterine pressure causes the
loosened part of the sac of fluid that bulges
downward into the dilating OS
3. The well flexed head fits snugly into the cervix
leading to making amniotic fluid in the
membranes to be placed below or in front of the
head or presenting part known as fore-waters
and the remainder of amniotic fluid lies behind
the head/presenting part known as hind waters
291
Diagnosis of labour
Signs of first stage of labour;
1. Regular, rhythmic and painful uterine
contractions increasing in frequency,
duration and strength
2. Blood stained mucus vaginal
discharge[show]
3. Progressing descent of fetal head,
diagnosed per abdominal or vaginal
examination
4. Progressive dilatation of cervix on V.E

292
Differential diagnosis of labour
1. False labour - irregular uterine
contractions not associated with cervical
dilatation or effacement
2. Urinary tract infections
3. Appendicitis
4. Abruptio placenta
5. Intestinal obstruction

293
Investigation to ensure that mother
is safe for labour
1. Blood for hb estimation, grouping and
cross matching, rhesus factor[for high
risk mothers]
2. Urinalysis for protein, sugar and acetone

294
Management of normal first stage
of labour
Immediately on admission;
1. Read and assess ANC card if available
2. Take history[medical, surgical and past
obstetrical]
3. Physical examination including abdominal
palpation and V.E
4. Monitor the mother using partograph when in
active labour
5. Do not use partograph in latent phase, mother at
9-10 cm cervical dilatation on admission and
emergency caesarian section

295
 Management of normal first stage
of labour cont………………………
• Immediate management on admission
cont…………….
6. Record information as part of initial clerking
notes
7. Give light nourishing diet including oral
fluids or IV if necessary
8. Ensure empty urinary bladder throughout
labour by encouraging the mother to pass
urine every 1-2 hours
9. Give bath on admission if conditions allows
296
Management of normal first stage
of labour cont………………………
Subsequent management of labour;
• Observe, record and interpret the following
on partograph;
10.General conditions of the mother
11.Vital observations, temperature, pulse,
respiratory rate and BP
12.Fluid intake and output
13.Urinalysis for PAS 2hourly
14.Medication given
297
Management of normal first stage
of labour cont………………………
Abdominal examination to assess for;
1. Descent of the head using assessing level
of head above the pelvic brim per
abdomen using fifth's method
2. Fetal heart rate every ½ hour in active
phase. It is listened to before and after
uterine contraction
3. Frequency and duration of contraction
every ½ hours in active phase
298
Management of normal first stage
of labour cont………………………
Vaginal examination to assess for;
1. Cervical effacement and dilatation 4 hourly
or when membranes ruptures to exclude
Prolaspe of cord
2. Appearance of draining liquor
3. Application of presenting part on the cervix
4. Degree of moulding
5. Caput formation
299
Partograph or labour progress chart
• A chart use to record observation made to
assess progress of first stage of labour
• Indication of partograph; every mother
expected to have vaginal delivery in;
a) Singleton cephalic presentation
b) Breech presentation
c) Multiple pregnancy
NB;Partograph should be use to recorded
labour progress only when the mother is in
active labour phase of first stage of labour
4cm or more cervical dilatation
300
 Partograph or labour progress chart
cont………………..
Observation to be recorded are;
a) Mother’s information; Name, age, parity, date and
time of admission, status of membranes[ruptured
date and time] etc
b) Fetal conditions; fetal heart sound every ½ hourly,
normal rate is 120 – 160 beats per minutes, amniotic
fluid and membranes, state of liquor amnii, moulding
c) Progress of labour; cervical dilatation, descent of
fetal head, uterine contractions, frequency in 10
minutes and duration in second[strength]
d) Maternal condition; vital signs half hourly, urine
output and tests for PAS, Time she passes urine and
drug given
301
Plotting or recording of labour
progress chart
Events of labour are plotted against time;
• Mother information
• Fetal conditions
• Amniotic fluid and membranes indicating;
a) I - for intact membranes
b) C – for clear liquor amnii on rupture
c) M - for Meconium stained liquor
d) A – for absent liquor amnii
NB: These observations are made on each V.E.
302
 Plotting or recording of labour
progress chart cont…………..
• Thick Meconium at anytime or absent of liquor at the
time of membrane rupture, listen to fetal heart
• Moulding of the fetal skull bones- this indicates how
adequate the pelvis can accommodate fetal heart
• Increasing moulding with head high in pelvis is a sign
of CPD
• 4 different ways to record moulding are;
1. 0 – if bones are separated and sutures can be felt
2. + - if bones just touches each other
3. ++ - If there is overlapping of bones
4. +++ - if overlapping is observe every 4 hourly

303
Process of labour
a) Cervical dilatation;
1. Normal dilatation = 1cm/hour
2. Plotted with X
3. First V.E on admission for Pelvic assessment and
recorded and There after V.E. for cervical
dilatation and descent unless contra indicated
4. Plotting must start in active phase on cervical
area of partograph when cervix is dilated above 4
cm
5. Correctly use X on line

304
Process of labour cont……….
b) Descent of fetal head;
1. Steady descent follow dilatation of cervix in
normal labour
2. Measure per abdominal palpation using the width
of 5 fingers and recorded in 5th above pelvic brim
3. Assess immediately per abdomen before
performing V.E
4. Mobile head above brim will accommodate full
width or less that indicates the head is engaging
5. Plotted with symbol O in the graph alone the
time of the other observation

305
Process of labour cont……….
c) Uterine contractions;
1. Number of contraction recorded every
half hour
2. Observations made are;
a) Frequency – how many per 10 minutes
b) Duration – how long the contractions last
in second
c) It is plotted in area of blank square
306
Contra-indications to the of
partograph
1. Mother below 150 cm tall
2. Ante partum hemorrhage
3. Severe pre-eclampsia and eclampsia
4. Fetal distress
5. Prolaspe of cord
6. Previous CS
7. Severe anemia
8. Multiple pregnancy
9. Malpresentations
10. Very premature labour
11. Obstructed labour
307
Normal second stage of labour
1. Duration;
• multigravida 5-30 minutes
• Primigravida 45-60 minutes
1. Divisions;
• From full dilatation of cervix to the bearing
down[pushing]
• The pushing stage
3. Physiology of second stage of labour;
• Uterine contractions
• Soft tissue displacement
308
 1. Uterine contractions
1. Stronger, longer and more frequent contraction
lasting about 5 minutes
2. Progressive contraction and retraction of upper
uterine segment while lower one dilate and thinner
3. Spontaneous rupture of membranes
4. Liquor amnii flow, this allow the hard fetal head to be
applied directly to the vagina and aid distension of
soft tissue
5. Fetal axis pressure increase the flexion of the head
resulting in smaller presenting diameter to rapidly
come through birth canal with less trauma to the
mother and fetus
6. Uterine contraction become more expulsive, pressure
is applied on the rectum and pelvic floor, making the
mother to feel the urge to push 309
2. Soft tissue displacement
1. By descending fetus
2. Urinary bladder into abdomen and urethra stretch
and thinned
3. Rectum flattened into sacral curve
4. Feacal matter expel
5. Levator ani muscle dilate, thin out and displaced
laterally
6. Perineal body flatten, stretch and thin like paper
7. Descending of head advance with each contraction
8. Head is bone
9. Body and shoulder in next contractions, then gush of
amniotic fluid

310
 Mechanism of normal labour
• This is the series of movement of the fetus to
negotiate through the curved birth canal
• Principles of mechanism of labour;
1. Descent take place through out
2. Which ever part of the fetus lead and first
meets the resistant of pelvis floor will rotate
forward until it come under the symphysis
pubes
3. Whatever come from the pelvis will rotate
around the pelvis bone

311
Mechanism of labour cont………
 Situation of the fetus at the beginning
of normal labour;
1. Lie is longitudinal
2. Presentation is cephalic
3. Position is right or left occipito anterior
position
4. Attitude is good flexion
5. Denominator[leading part] is occipito
6. Presenting part; vertex

312
Mechanism of labour cont………
Main mechanisms;
1. Descent of fetal head;
• Begin at the end of pregnancy in Primigravida at
engagement
• Aided by uterine contractions
• Followed by rupture of membranes, full dilatation of cervix,
maternal effort speed the descent of head
2. Flexion of the fetus;
• Increase through out labour
• Continue pressure push the fetal axis forcing the leading
part[occiput] down
• Then the occiput become the leading part of the head
resulting in the smaller diameter i.e. sub occipito bregmatic
9.5cm and bi-parietal 9.5 cm to allow easy negotiation with
pelvis

313
 Mechanism of labour cont………
3. Internal rotation of the head;
• Leading part push onto the pelvis
• Internal rotation is twisted movement of the head
due to uterine contraction and resistance from
pelvis floor
4. Restitution – slight untwisting movement of the
occiput
5. Internal rotation of the shoulder – this
movement is noticed at the same time as the
head goes external rotation
6. Lateral flexion – enable the passing of the rest
of the body
314
 Signs/diagnosis of second stage of
labour
1. Regular expulsive contractions every 2-3 minutes
2. Mother bearing feeling of push down
3. Presenting part may be seen at the vulva
4. Dilatation and gasping of the uterus
5. Gaping of the vulva
6. Bulging of perineum
7. Full dilated cervix on examination
Differential diagnosis of second stage of labour;
1. Premature bearing down as a result of abnormal V.Cs
2. Caput formation distending the vulva
3. Mal position and bad applied cervix
4. Obstructed labour
315
Management of second stage of
labour
Immediate care;
• Never leave the mother alone
Observation carried out and record on the mother’s
chart;
1. Descent of presenting part
2. Uterine contractions every 5 minutes or after each
contraction
3. Fetal rate and rhythm re-monitor every 5 minutes
4. Maternal general conditions
• BP every 30 minutes
• Pulse rate every 15 minutes
• Respiratory rate every 15 minutes
• Bleed per vagina

316
 Conducting second stage of labour
1. Ensure universal infection prevention and control
techniques
2. Provides emotion, physical comfort and support
3. Place mother in position of her choice
• Supported sitting up position
• Squatting kneeling position
• Lying on her back[dorsal position]
4. If the mother feel like bearing down encourage her
to push with each contraction
5. If the mother does not feel like bearing down, she
should be allowed to rest in left lateral position and
be elevated every 15 minutes
6. Transfer after 30 minutes of full dilatation if the
mother does not feel like pushing down
317
 Delivery of the head
7. Before crowing of the head, encourage the mother to push
with each contraction
8. At the crowning perform episiotomy if necessary
9. After crowning encourage the mother to push in between
contractions, deliver the head by placing fingers, with light
pressure control the birth of the head
10. Instruct the mother to greatly blow or sighing out breath to
avoid pushing or sudden delivery of the head
11. The head is born by extension as the face sweep perineum,
eyes are clean from within outward using each swab once,
clean the nose of mucus
12. Feel for the cord around the baby neck
• If loosely apply quickly slight down the shoulders
• If tightly applied, clamp using two artery forceps 3cm apart
and cut the cord with swab over the area to prevent risk of
birth attendant spray with blood
• Unwind the cord as soon as the cord is cut 318
 Delivery of the shoulders
13. Observe for the external rotation of the anteroposterior
diameter of the pelvic outlet
14. Place a hand on each side of the baby head over ears, apply
downward traction to deliver the anterior shoulder under the
symphysis pubis
15. Lift the baby upwards toward the mother’s abdomen and the
tract and rest of the baby is born in lateral flexion
16. Assess baby’s condition by using APGAR score at 1 minutes
and 5 minutes after delivery
17. Note the time of delivery
18. Apply tetracycline eye ointment to baby’s eyes to prevent
infection
19. Ensure clean airway using bulb syringe or according to
APGAR score

319
Delivery of the shoulders cont………
20.Congratulate the mother and slow the
mother allowing her to announce the sex
21.Note the time of birth and dates
22.Label with name
23.Apply the cord clamp and cut it under strict
aseptic technique
24.Put the baby on breast to suck if the mother
chose breast feeding
25.Keep baby next to the mother for heat[
kangaroo method]

320
Normal third stage of labour
 Duration – 5-30 minutes, may be longer up to 1 hour
Physiology of normal third stage of labour;
1. Placenta decrease in size and squeezed
2. Placenta begins to separate from the shrinking
uterine wall.
Two methods of placenta separation;
a) Separation beginning centrally at the point of
attachment to uterine wall[ Schulteze method]
b) Separation beginning at one end lateral border[
Mathew's Duncan method]
3. Uterus contract strongly after separation of placenta
and placenta begins to descent

321
4. Control of bleeding;
a) Oblique muscles fibres encloses blood
vessel sinuses in upper segment of
uterus by living ligatures
b) Strong contraction after separation of
placenta exert pressure on the placenta
site as uterus come together
c) Formation of blood clot at placenta site to
prevent bleeding

322
Management of normal third stage
of labour
1. Let the mother be in position of her choice
a) Dorsal position;
• Enables handling and breastfeeding of the baby
• Best for conducting active management of third stage of
labour
• Easy to observe bleeding
b) Sitting up position;
• Need support to handle the baby
• Intra abdominal pressure quicken delivery of placenta
2. Delivery of placenta and membrane by;
a) using active management of third stage of labour i.e.
administer oxytocin or ergometrine IM or IV at birth of
anterior shoulder

323
Management of normal third stage
of labour cont………………..
b) Checking for signs of placenta separation;
Signs;
• Sudden small gush of blood
• Rising of fundus which feel hard and mobile
above umbilicus
• Lengthening and descent of cord
• Feeling/seeing the placenta in vagina
• Mother feels uterine contraction
c) Control cord traction[CCT];
i. Place sterile receiver below the vulva for
placenta and blood loss
324
 Management of normal third stage
of labour cont………………..
ii. Place the left hand with palm facing the umbilicus
above the symphysis pubis and hold back the uterus
iii. Wind the cord around the clamp or shoulder or index
finger with the right hand apply firm steady traction
on the cord in downward, outward and upward
movement
iv. Receive the placenta with both hand when it appears
at the vulva
v. Deliver membrane slowly by advising the mother to
cough while you twisted the membrane, moving
them up and down to prevent them from breaking
and being retained in the uterus

325
Management of normal third stage
of labour cont………………..
vi. Perform quick examination of the placenta to exclude
retained cotyledon
vii. Rub the fundus and expel the clots from the uterus and
vagina
viii. Clean the vulva,examine vagina walls, cervix and perineum
to exclude lacerations
ix. Repair episiotomy or lacerations if present after infiltration
with 1% lidocaine
x. Assess and measure all blood loss
xi. Examine the placenta for infarcts, retroplacental clot, cord
vessels and membranes whether complete or not
xii. If the mother choose breastfeeding, put the baby to breast

326
Precaution to take in order to avoid
complications in third stage of
labour
1. Always administer oxytocin
2. Examine the mother before administration of
oxytocin, if in doubt wait until after delivery
3. Ensure empty urinary bladder through out labour
4. Administer oxytocin appropriately and deliver the
placenta by cord control traction
5. Avoid ergometrine in hypertensive mothers or those
with heart disease
6. Avoid harmful maneuvers e.g. fundal pressure
7. Observe strict aseptic methods
8. Carry out thorough examination of the placenta and
membranes for completeness
327
Management of Normal fourth
stage of labour
Immediate management;
1. Monitor excessive bleeding - by inspection of the
vulva every 15-30 minutes or one hour then
every 6 hours for 24 hours
2. Fundal height - check every 30 minutes and
continuous for 1 hour then 6 hourly up to 24
hours
3. mother comfortability, make her comfort by
encouraging her to pass urine as soon as she
feels like every 4 hours
4. warm drink - Provide mother with it
5. Rest- allow mother to have rest
328
Management of Normal fourth
stage of labour cont………….
Subsequent treatment;
1. Vital signs observation and general condition of the mother-
if normal send to post natal ward will all records
2. Management of abnormalities- manage any abnormality
which arise according e.g. PPH
3. Pain treatment – give analgesic e.g. paracetamol
4. Rehydration – provide 200,000 units of IV fluids, vitamins
etc
5. BCG and PVO immunization – to the baby, also birth
certificate, child health card with all information recorded
6. Counseling the mother on breastfeeding, personal hygiene,
care of the baby and family planning
7. Discharge the mother- if mother and baby are well

329
Management of Normal fourth
stage of labour cont………….
Provide the following on discharge;
a) Detailed record of labour and birth
b) Iron tablets for 2 weeks or base on hb
status
c) Child health card
d) Return date for post natal examination and
immunization of the baby[6 weeks after
birth of the baby]
e) Advice on family diet with emphasis on her
own nutrition
330
Precaution to avoid
complications during labour;
1. Stay with the mother all the times
2. Observe vital signs and retraction of
uterus
3. Correct interpretation of the finding and
immediate actions
4. Do not bath the baby during first 24
hours unless there is specific indications

331
Vaginal examination
Obstetric

332
Vaginal examination
Definition
• Also called per vagina[PV] examination
Types of vaginal examinations;
1. Digital[fingers] use in
a) Pregnancy
b) Labour
2. Speculum examination; for diagnostic
purposes in case of gynecology and post delivery
NB; DO VAGINAL EXAMINATION WITH STRICT
ASEPTIC PRECAUTIONS TO AVOID ASCENDING
INFECTION

333
Vaginal examination during labour
1. Abdominal examination must be done before
vaginal examination
2. Accommodation of finding per abdomen and
vaginal examination reveal detailed clinical
picture of the progress of labour
Indication for V.E. during labour;
1. Confirm the process of true labour
2. Determine presentation and position of the fetus
3. Assess labour progress
4. Determine membrane status 1.e. intact or
ruptured

334
Vaginal examination during labour
cont…………
4. Determine head engagement or is above the
pelvic brim
5. Exclude cord Prolaspe after rupture of
membranes
6. Confirm full dilatation of cervix[second stage
of labour]
7. Confirm lie and presentation of second twin
8. Determine causes of delayed second stage
of labour
9. Check for lacerations after the delivery of
fetus, placenta and membranes
335
When should V.E be done during
labour
1. On admission
2. Every 4 hours during first stage of labour
3. When membranes ruptures to exclude
Prolaspe of cord
4. In twin delivery to confirm the lie and
presentation of second twin and rupture
the second amniotic sac
5. Onset of second stage of labour to
confirm full dilatation of cervix
336
When V.E. should not be done
during labour
1. In case of vaginal bleeding i.e. APH
2. Less than 4 hours from previous V.E.
during first stage of labour[ too frequent]
to avoid ascending infection

337
Preparation for V.E.
1. Environment;
a) Clean bed and coach
b) Good light
c) Privacy
d) Less movements by people
2. equipment;
• Strict aseptic precaution for bowl, sterile gloves,
cotton wool swabs and vulva pad,gallipot with
aseptic solution, receiver and kidney dish
3. Service provide;
• Free from URTIs OR any septic spot on hands
• Use mask over nose
338
Preparation for V.E cont……..
• Protect yourself with plastic sterile gown if
available
• Thorough hand washing up to elbow
• Wearing sterile gloves
4. mother;
• Empty bladder
• Explain procedures
• Place in dorsal position
• Hands place under buttocks
• Head slightly toward the left side
• Encourage her to relax
339
Procedures for vaginal examination
1. Place sterile towels one on each thigh over
the pubic area and one under the buttocks
2. Place the receiver on the towels for soiled
swabs
3. Observe for any abnormalities before
cleaning the vulva
4. Using left hand swab the vulva while turning
hand and the thumb, avoid getting in
contact with anus where it can be
contaminated nor the clitoris where it may
cause discomfort
340
What is observed for in vaginal
examination?
1. On vulva;
• Scaring of perineum
• Varicose veins
• Oedema
• Vulva warts
• Vulva sores
• Vulva structures abnormalities
2. vagina;
• Normal vagina must be warm, moist and pink
• Texture-is it distensible? as tight as perineum may lead to
delay second stage of labour
• Types of discharge to exclude abnormal vaginal discharge
• Status of the rectum

341
What is observed in V.E. cont…..
3. Cervix;
a) Position;
• Anterior- felt at the center normal
• Posterior- if not
b) Effacement
c) texture;
• Soft
• Rigid [abnormal]
• Edematous – suggest mother push before full dilatation
d) Application to presenting part;
• Well applied normally
• Hanging loose suggest early sign of obstructed labour

342
What is observed in V.E. cont…..
e) Cervical OS dilatation;
• 1 finger =2cm
• Fully dilated at 10 cm
• Fully closed, labour not started
4. Presentation;
• Vertex, normal, felt by hand bone of the vault of
skull, fontanelle and sutures
• Situation of presenting part in pelvis in relation to;
a) Ischial spine
b) High up the mid cavity or below
5. Membranes status
• intact?
• Ruptured? Note color of liquor, normal clear, exclude
cord Prolaspe 343
What is observed in V.E. cont…..
6. Position- recognized back per abdominal
prior to V.E., sutures, fontanelles per V.E.
and location as follows
Number LOA ROA
1 FETAL BACK PALPATED PER FETAL BACK PALPATED PER
ABDOMEN ON LEFT ANTERIORLY ABDOMEN ON RIGHT
ANTERIORLY
POSTERIOR FONTANELLE FEEL TO
THE LEFT ANTERIORLY POSTERIOR FONTANELLE FELT
2 ON THE RIGHT ANTERIORLY
SAGGITAL SUTURE FELT IN THE
RIGHT OBLIQUE DIAMETER SAGGITAL SUTURE FELT IN THE
LEFT OBLIQUE DIAMETER

344
 What is observed in V.E. cont…..
7. Caput succedaneum- felt as soft swelling over
the presenting part
8. Moulding- felt by examining finger locating
amount of overlapping of the skull bones
9. Assess pelvis outlet;
a) Ischial spine normal[not felt]-feeling them normal
pelvis outlet
b) Sub pubic arch[angle] accommodating 2 or more
fingers that is about 90 degree, any smaller
narrow outlet
c) Those 4 knuckles or more can be fit between
ischial tuberosity
345
On completion of vaginal
examination procedures
1. Ensure cleanliness and provide vulva pad
2. Inform the mother on findings
3. Record findings on labour progress chart
4. Correctly clear and discard used
equipment and materials under infection
control methods
5. Leave the mother comfortable

346
Normal Puerperium

Obstetric

347
Normal puerperium
Definition
• This a duration from expulsion of the
placenta and membranes up to six weeks[42
days]
Physiological changes of puerperium;
1. Reproductive organs return to non pregnant
state
2. All body system recover from pregnancy
3. Lactation is establish

348
Return of organs
1. Involution of uterus - return of uterus to
normal size, tone and position
• Size of uterus; 16cm long X 12 cm wide X
9cm thick
• Weight of uterus; 900 g at the end of labour
• decrease by 1cm/day in first week
• By the end of six week; 7.5cm long X 5cm
wide X 2.5 cm thick and weight 60 gram

349
Physiological factors responsible for
involution of uterus
1. Ischemia;
• Temporary anemia of uterus cause by contraction and
retraction of muscles compressing blood vessel and reduce
blood supply
• Atrophy occurs in some uterine muscles which are
hypertrophied during pregnancy
2. autolysis;
• The process of self digestion of uterine muscles
• During pregnancy uterine muscle increase 10 times in length
and 5 times in thickness
• During puerperium they are reduced to their former size and
got rid off by being absorbed into blood stream and
excreted by kidney leading the mother to pass urine in large
amount during first 24-48 hours after delivery
350
Monitoring of the involution of
uterus

1. Fundal height decrease at 1cm per day

for 10 days
• Use tape measure from level of symphysis
pubis to the highest point of the fundus
• Ensure empty bladder before measurement
NB; no reduction in fundal height at 1cm per
day means sub involution of uterus which is
earlier signs of uterine infection and serious
complications
351
Monitoring of involution of uterus
cont…
2. Observing lochia loss or drainage
a) Lochia is vaginal discharge from uterus
[originating from where the placenta was
situated[site]] during puerperium
b) It is alkaline in reaction and vaginal is at
risk of infection at this time of lochia
c) Amount of lochia is the same as amount
of menstrual flow
d) It has a fishy smell, but not offensive
352
Types of lochia
1. Lochia rubra;
• Red
• Flow in the First 1-4 days of puerperium
• Contain sheds of decidua and blood from placenta site
2. Lochia serosa;
• Flow from 5-9th day of puerperium
• Pale creamy
• Contain leucocytes and serum from healing placenta site
3. Lochia Alba;
4. Flow from 10-15 the days of puerperium
5. Pale creamy
6. Contain leucocytes and serum

353
Observe color, quantity and smell of
lochia for;
a) Increase in amount and blood content
b) Scanty or little indicate infection
c) Continuous blood clots after 24 hours
accompanied by pain indicates retained
pieces of placenta or membranes
d) Offensive smell of lochia indicates poor
vulva hygiene or contaminated by feacal
shreds
e) If offensive smell persists in spite of good
vulva hygiene, it indicates infection of
genital tract[puerperal sepsis]
354
Management of mother during
puerperium
1. Vulva toilet;
• Twice daily or after visiting a toilet during 48 hours
using salty water
• Mother encourage to wash, dry the perineum and
change pads whenever soiled
2. Positioning;
• Prone position for 1-3 hours a day to maintain the
uterus in ante flexion and version position
• Sitting up position while resting, it aids the drainage
of lochia
3. Breastfeeding;
• Start immediately if chosen as it increase uterine
contraction leading to quick involution of uterus
• Keep breast clean to reduce infection 355
Management of mother during
puerperium cont………..
4. Diet;
• balance diet aids effective lactation for growth and
development of the baby
• Builds mother’s immunity and hb status
5. Fluids;
• plenty of fluids aid milk production
• prevent constipation
6. Bladder and bowels;
• Keep bladder empty to avoid retention of urine and
aids involution of uterus
• Open bowels by second day after delivery
• Early ambulation[walking about] helps in the opening
of bowels 356
Management of mother during puerperium
cont………..
7. Physical exercise; start 6 hours after delivery for;
• Improve circulation
• Prevent thrombosis
• Aid more circulation to breast for lactation
• Improve muscles tone of pelvis floor and abdomen
• Aid the drainage of lochia
• Maintain figure
8. Rest;
• 2 hours daily, help in physiological and emotional factors
8. Sleep;
• 8 hours daily for post natal mother, in case of insomnia get
the cause and treat accordingly
• Give analgesic for pain
• Sedative for anxiety
357
 Post natal examination
1. Done before discharge and after 6 weeks
of delivery to ensure all body system are
back to non pregnant state
2. Advise mother on baby care and herself
3. Detect any abnormalities resulting from
pregnancy, labour and puerperium and
manage accordingly

358
 PART 2

ABNORMAL OBSTETRICS

359
Hyperemesis gravidrum
Introduction
• Nausea and vomiting are common in early
pregnancy usually starting from 4-10 weeks
gestation and resolve around the 20 weeks of
pregnancy. It is a serious weakening of mother’s
life
• Incidence affect 0.3-3% of all women
• It is associated with dehydration, electrolyte
imbalance and thiamine deficiency
Definition;
• HG is excessive nausea and vomiting that starts
between 4 and 10 weeks of gestation and resolve
before 2 weeks
360
Etiology of Hyperemesis gravidrum
 Multiple factors are involve Endocrine,
gastrointestinal and psychological;
• Rising level of estrogen and hcg [common]
• Multiple pregnancy and Hydatiform mole, both of
which associated with increased hormone level
• Women with History of Hyperemesis gravidrum
experience it in subsequent pregnancies
 Other causes of vomiting are;
• Thyroid problems[not associated with
progesterone
• Urinary tract infection, gastroenteritis, malaria
need to be excluded
361
Mild Hyperemesis gravidrum
 Signs and symptoms of MHG;
• Less excessive vomiting, once or twice a
day
• No sign of dehydration or very light
• Lips and mouth may be little dry
• Not constipation

362
Management of mhg
Inquire from all women who attended ANC if
the have history of nausea and vomiting, if
the it mild to moderate advice her to;
• Rest, diet, small meal fairly frequent
• Take small carbohydrate meal
• Avoid large volume of drinks, especially milk
and carbonated drinks
• Avoidance of fried food
• Try to win her confidence[psychological
support] to help her with any worries which
may be the cause of the condition
363
Severe Hyperemesis
gravidrum[SHG]
 Signs and symptoms;
• History of vomiting for about a week or more and
persistent nauseas
• Dehydration and weakness
• Eye sunken
• Breath smelling acetone, tongue dry and coated
• Lips crack
• Concentrated urine and little in amount smelling
acetone
• Not constipation
• Albumin in urine indicates kidney damage 364
Serious signs of SHG;
• Rise in pulse and temperature
• Jaundice indicate liver damage
Investigations;
• Dip stick analysis of urine for ketone
• Blood for routine investigation; full blood count,
thyroid functional test
• Elevated hematocrit reading and alterations in
electrolyte levels and ketonuria or are associated
with dehydration
• Urine for culture and sensitivity to exclude UTIs
and rule out gestational trophoblastic disease
• Ultra sound scan to confirm multiple pregnancy

365
 Diagnosis of severe Hyperemesis
gravidrum
• Diagnosis is made where there is history
of persistent, severe nausea and vomiting
in early pregnancy for one week or more
Admission of Patient with HG
• Quickly admit patient as an emergency
• Give nothing by mouth initially and allow time
for vomiting to be controlled
• Psychologically support the patient by
reassurance, encouragement to boost her
morale 366
Treatment of severe Hyperemesis
gravidrum
• Correct Hypovolaemia and electrolyte
imbalance by IV fluids; normal saline 0.9%
alternating with dextrose 5%
• Most women response to support treatment
within 24-48 hours and eventually introduce
oral food
• Antiemetic therapy is reserved for women
who do not response to support treatment or
persistent relapse; metocloproamide tabs 10
mg orally three times in 24 hours for 3 days.
This drug is not show teratogenic in human
but does so in animals
367
• Vitamins supplements; thiamine should be
given particularly in prolong Hyperemesis
• For continue vomiting and a history
suggestive of severe reflex or ulcerative
disease then endoscopy can be done, it is
safe during pregnancy
• Note that severe Hg if not treated can
worsen mother’s condition and lead to
death because of hepatic and renal
impairment

368
 Nursing care for patient with SHG
• Daily bath hourly and oral hygiene
• Pressure areas treated 4 hourly
• Record intake and output, test urine 4 hourly,
temperature and pulse plus respiratory rate and
BP bd
• Weight on admission if possible, when improving
check weight bi-weekly[2weeks]
• Light diet will be commenced according to
response for treatment
NB; THE IMPACT OF HG ON THE MOTHER ‘S LIFE
SHOULD NOT BE UNDERESTIMATED.MIDWIFE
SHOULD ENQUIRE ALL WOMEN ATTENDING ANC
FOR EARLY TREATMENT
369
 Complications of Hyperemesis
gravidrum
• Loss of 5% or more pre-pregnant weight
• Dehydration
• Nutritional deficiencies
• Difficulty in daily activities
• Altered taste
• Metabolic imbalance
• Food leaving stomach more low digestion[slow
digestion]
• Stomach contents moving back from the stomach
• Physical stress of pregnancy on the body
• Hyperemesis gravidrum is treated as medical
emergency because of severe dehydration
370
Conditions associated with
bleeding in pregnancy
Obstetric

371
 Bleeding in early week of pregnancy
• To be fill with note

372
Bleeding during late weeks of
pregnancy[APH]
Definition
• Also known as ante partum hemorrhage
• The bleeding which occurs in the genital
tract after 28 weeks of pregnancy and
before the birth of the baby
• Intra partum hemorrhage is the bleeding
which occurs in the first and second stage
of labour
373
Types of Ante partum
hemorrhage[APH]
1. Placenta preavia
2. Placenta abruptio
3. Extra uterine[third types] may occur

374
1. Placenta preavia
• Bleeding from the placenta which is
partially or completely situated in the
lower uterine segment
• Normal the placenta is situated in the
upper segment of uterus

375
2. Placenta abruptio
• Bleeding from the normally situated
placenta which separate from the uterus
before the third stage of labour
• A small part of the placenta may separate
such as an edge or large part of the
placenta leading to severe bleeding. It is
known as accidental ante partum
hemorrhage

376
3. Extra placenta or incidental
bleeding
The bleeding which is associate with
bleeding from other parts other than
placental separation. It may be from;
a) Cervical polyp
b) Cervical tension
c) Severe vaginitis

377
Placenta preavia
• In placenta preavia the placenta is
situated in the uterus near or over the
cervix
• Incidence of 2% of grand Multiparity
women

378
Predisposing factors of placenta
preavia
1. Multiparity because placenta tissue locate
on fresh uterine lining without scars for
implantation
2. Multiple pregnancy; large site encroaches
on lower uterine segment
3. Previous scars; on the uterus say c/s,
hysterectomy or myomectomy
4. Older women; tissue denegeneration
5. Smoking; cause placenta to be large and
encroaches on the lower uterine segment
379
Types of placenta preavia
1. Type 1; placenta is situated at the upper
uterine segment but encroaching or
touching on the lower uterine segment
2. Type 2; the placenta reach to, but does not
reach the internal os
3. Type 3; the placenta cover the internal os
when it is closed, but not when it is dilated
4. Type 4; the placenta is situated centrally
over the internal os
380
Signs and symptoms of placenta
preavia
• History of bleeding; there is repeated, small
fresh and painless bleeding often at rest or
small warming bleeding before a big severe
bleeding
• On examination;
a) Mal presentation of fetus because the
placenta occupies place in the pelvis
b) Non engagement of the presenting part
especially in type 3 and 4
c) Difficult to feel for the fetal parts per
abdominal palpation 381
• Vital examination; finding will be
according to the amount of blood loss;
a) If slight blood loss, temperature, pulse
respiration and BP will be normal
b) In case of severe blood loss, temperature
will be sub normal, rapid pulse rate, rapid
respiration and low blood pressure
NB; never perform vaginal examination in
suspected or confirmed placenta preavia

382
Diagnosis of placenta preavia
• Diagnose is confirmed by ultrasound
scanning if available

Management of placenta preavia

In PHCC; Treatment depend on the amount of
blood loss and mother’s conditions;
a) If shock or about to be shocked resuscitate by
IV fluids, normal saline or ringer lactate
according to condition and weight
b) If condition improves, refer to hospital and
explain the importance of referral 383
Management in hospital
Treatment depend on;
• Amount of bleeding
• Condition of the mother and fetus
• Location of placenta
• Gestation of pregnancy

384
Conservative treatment of placenta
preavia
In case of slight bleeding both mother and fetus are
stable and the treatment should include;
1. Admission of the mother for resting until bleeding
stop
2. If the placenta is encroaching on the lower
uterine segment, the mother is kept in hospital
until labour starts
3. Psychological support by;
a) Counseling as need arise
b) Allow children or relatives to visit her

385
4. investigations; repeat ultra sound scan in
order to;
a) Observe the position of the placenta in
relation to the cervical os as the lower
uterine segment grows
b) Monitor fetal growth
5. In case of heavy bleeding or fetus has
matured;
a) V.E. is done in theatre under general
anesthesia with the theatre ready for
immediate caesarian section
b) Doctors performs gentle digital examination
in the fornices;
386
I. If the placenta is felt CS is done without delay
II. If the placenta does not appear to be covering
the os, a finger is inserted through the cervix to
find out the location of the placenta
III. If no placenta is felt, membrane is ruptured and
labour is induced with oxytocin infusion
6. Vaginal delivery is possible in type 1 and type 2 if
there is no heavy bleeding
7. After successful vaginal delivery IV infusion if 20
units in 500 ml must continue to prevent PPH
because the placenta is situated in the lower
uterine segment where there are no oblique
muscles fibres to close off the blood vessel
sinuses
387
Active treatment of placenta
preavia
 Caesarean section; indications of CS;
1. If bleeding occurs for the first time at 38
weeks or above and the fetus is mature
2. If labour started but there is severe
bleeding
3. If the placenta preavia is type 3 and 4
even if the fetus is dead to prevent the
mother from dying of severe hemorrhage
388
Pre-operative care prior to CS in
placenta preavia
• Resuscitate mother with IV infusion or normal
saline prior to blood transfusion
• Take and record vital signs every 15 or 30 minutes
• Psychological help the mother and next of kin by
explaining to them what the procedure is and the
outcome
• Obtain written consent form from patient of next
of kin
• Blood specimen for blood grouping and cross
matching, not less than 2 units of blood must be
available before operation
389
Complications of placenta preavia
1. PPH, common
2. Maternal shock
3. Maternal death if delay to arrive to health
facility
4. Fetal hypoxia due to separation of
placenta from uterus
5. Fetal death

390
Placenta abruptio
Definition
• Bleeding due to premature separation of
the placenta which is normally situated
• It is also known as accidental ante partum
hemorrhage
• Occurs in pregnancy after 28 weeks or
before the birth of the baby

391
Predisposing factors to placenta
abruptio
• Idiopathic in some cases
• Essential hypertension
• Pre-eclampsia
• Sudden decompression of the uterus e.g. after sudden
spontaneous rupture of membranes in case of
Polyhyramnious
• Previous history of placenta abruptio
• Trauma like external cephalic version
• Smoking
• Drug abuse e.g. cocaine
• Folic acid deficiency
• Grand Multiparity
392
Types of placenta abruption
1. Revealed bleeding
• Bleeding from the site of separation of placenta
• Blood flow between the membrane and decidua and escape
through cervix and vagina
• All the blood is revealed/seen at the vulva

2. Concealed bleed
• Bleeding from the centrally separated part of placenta and blood
does not escape
• Average clot known as retro placental clot form
• Blood may enter the myometrium or as far as peritoneum that is
known as convelalaire uterus
• No blood is seen and there may be severe pain and shock

393
3. Mixed bleeding;
• Situation where some blood escape to
the vulva and some remain inside the
uterus
• There is high degree of shock in mixed
bleeding as much blood is loss

394
Severity of placenta abruptio
1. Mild placenta abruptio;
a) Slight blood loss, conceal or reveal bleeding per
vagina
b) No tenderness on abdominal palpation
c) Mild abdominal pain
d) Fetus is alive
e) No sign of maternal shock
2. Moderate placenta abruptio;
a) Heavier blood loss than in mild one
b) Severe pain on abdominal palpation
c) Hypotension
d) Tachycardia-rapid pulse rate
e) Rapid fetal heart rate-fetal distress
395
3. Severe placenta abruptio;
a) Large part of placenta is separated, say
more than half
b) Severe vaginal hemorrhage, more than litter
c) Abdominal examination of uterus feel hard
as wood and tender
d) Fetal heart sound are not heart
e) The mother is in shock

396
Assessing mother’s condition in
placenta abruptio
1. History of either;
a) Pregnancy induce hypertension
b) Recent headache, nausea, vomiting,
epigastric pain, visual disturbances
indicate pre-eclampsia
c) Trauma due to road traffic accident
hitting the abdomen directly or external
cephalic version

397
2. On general examination;
a) Mother appear anxious-feeling a lot of pain
b) May be shocked presenting with;
• Pallor of skin and mucous membrane and moist skin on
touch
• Obvious edema of the face, fingers, legs or ankles
• Low BP and rapid pulse rate
• BP may be within normal limit incase of hypertensive mother
before hemorrhage
• Estimated amount of blood loss
c) On abdominal examination
i. In conceal hemorrhage;
• High fundal height than expected according period of
gestation
• On palpation hard uterus and tender
• Fetal parts are not palpable and no fetal heart rate not heart

398
Assessing fetal condition
• There is history that fetal movement
stopped at such a date or time after
excessive movement

Treatment of placenta abruptio

• In primary health care, this is an
obstetrical emergency and any mother
with history suggesting PA needs urgent
skilled care, so immediately refer to
hospital
399
Management of shock in placenta
abruptio
1. Resuscitate mother with;
a) Ringer lactate solution or sodium chloride
0.9% IV infusion starting with 20ml/kg
over 60 minutes
 When condition improves immediately
refer her to hospital for further
management

400
In hospital
1.Management of mild placenta abruptio;
a) Admit the mother and place her in position she find
comfortable
b) If the mother and fetus conditions are good give
conservative treatment as it may be difficult to
differentiate from preavia
c) Ultra sound scanning to show location and amount of
conceal bleeding
d) If the mother is not in labour and gestation less than
37 weeks, keep in hospital for some days till bleeding
stop and placenta rescanning located in upper
uterine segment and then discharge
e) If she has passed 37 weeks, labour is induced or in
case of more bleeding and fetal distress caesarian
section is performed
401
Management of moderate and
severe placenta abruptio
The aims are;
• To restore blood loss and improve mother
conditions
• Empty the uterus as soon as possible
Active management;
a) Take blood for grouping and cross matching,
hb estimation, platelets count, urea and
electrolyte test and clotting time test
b) Carry out observation of vital signs every
15-30 minutes according to mother
condition
402
c) Pass indwelling catheter and closely monitor
urinary output
d) If the fetus is in good condition or has
already died vaginal delivery may be used by
inducing labour with rupture of membrane
and use of oxytocin
e) In case of fetal distress CS is done unless
the mother is in second stage of labour
where episiotomy and forceps delivery can be
used
f) Syntocinon IV infusion is continue for few
hours after delivery to maintain uterine
contraction and prevent post partum
hemorrhage[PPH]

403
Complications of placenta abruptio

1. Blood coagulation disorders

2. PPH
3. Renal failure
4. Pituitary necrosis leading to Sheehan's syndrome
i.e. amenorrhea, lethargic, feeling cold, dropping
out of hair and skin, loss of libido
5. Infection of reproductive organs
6. Anemia
7. Psychological disturbances[puerperal psychosis]

404
Multiple pregnancy

obstetric

405
Multiple pregnancy
Definition;
• A pregnancy of more than one fetus
• Twin is the commonest form of multiple
pregnancy
• Others are triplets, quadeplets etc

406
Types of twins
1. Monozygotic or uni-ovular/identical twins
2. Dizygotic or binocular/not identical twins
Monozygotic twins;
• Develop from one ovum and one spermatozoa
• Two amniotic sacs, one placenta and commonly
one chorionic membrane, but rarely 2 chorionic
membrane are found
• Same sex, similar palm and finger print
NB;There is high incidence of error in tissue
development and malformation which give rise to
abnormal fetus resulting form abnormal division of
the fertilized ovum forming co-joined or Siamese
twins
407
Dizygotic twins
• Develop from two ova and two spermatozoa
• Two placentae which may be joined to form
one, two amniotic fluid sacs and two chorion
• May be of same sex, but mostly different
• Do not resemble, with different palm and
finger print
NB;Fetus papyraccous is when one fetus dies in
uterus, it is flat appearing either of the types
of twin
408
Diagnosis of twin pregnancy
1. History of twins in mother or father family
or previous twin pregnancy
2. History of feeling heavy and over
burdened
3. Abdominal examination
a) On inspection;
• Large size of abdomen than the expected
period of gestation especially after 20 weeks
• Round and broad shape of abdomen
• Fetal movement seen over wide area
409
b) On palpation;
• High fundal height than expected period of
gestation
• Two fetal pole[head or breech] felt in the fundus
of uterus and many fetal limbs
• Size of head is felt small compare to the height of
fundus
• On lateral palpation two fetal back or limbs felt on
both sides
c) On auscultation;
• Two fetal heart heard
• If listen to at the same time by two difference
health workers, the rate will be of a difference of
at least 10 beats per minutes
4. Diagnosis is confirmed by ultra sound scan
410
Differential diagnosis of multiple
pregnancy
• Large single baby
• Wrong date of amenorrhea
• Polyhyramnious
• Obesity of the mother
• Hydrocephalus
• Uterine or ovarian masses

411
Effect of twin pregnancy
1. Exaggerated minor disorders of
pregnancy; Morning sickness, Heart
burns etc because of higher level of
circulating hormones
2. Anemia; as a result of iron and folic acid
deficiency due to early development and
growth of the uterus and fetal demand
3. Pregnancy induced hypertension;
due to increased hormone and fetal
demand
412
4. Polyhyramnious due to high demand
for accommodating two fetuses.
Dangerous because it add more
discomfort. Acute hydramnious around 20
weeks can lead to abortion
5. Pressure symptoms including;
increased weight and size of uterus and
its content lead to discomfort causing;
• Impair venous return from the lower
limbs leading edema and varicose veins
• Large uterus pushing on the diaphragm
and lungs leading to breathlessness
413
Management of twin pregnancy
1. Close antenatal care, every two weeks
2. Prevention of anemia by;
a) Hemoglobin estimation at monthly intervals
b) Advise mothers to eat food reach in protein,
iron, folic acid, vitamin and calcium
c) Prescription of iron, folic acid and vitamin
tablets
d) Providing fansidar and TT during second
trimester T2
414
3. Urinalysis for protein, sugar and
acetone
4. Measuring mother body weight and
examining for edema to exclude pre-
eclampsia at 2 weeks intervals
5. Admission of mothers to hospital or phcc
for rest between 30-32 weeks of pregnancy
to prevent premature labour and for
observation for anemia and pre-eclampsia
6. Counsel the husband, relatives or next of
kin to accept the twins or more babies and
support the mother
7. Refer any mother with danger
signs[complications] to hospital
415
Reason for referral or admission to
hospital
1. For rest; between 30-32 weeks
2. Bed rest and accessibility to essential obstetric
care[EOC]; 38 weeks and above
3. Lack of access to emergency transport
4. Polyhyramnious
5. Preterm labour
6. Moderate or severe anemia at any trimester
7. Ante partum hemorrhage
8. Hypertension
9. Protienuira
10. Poor past obstetric history
11. Malpresentations of the first twin
416
Management of labour in twin
delivery
First stage of labour;
1. Manage as in singleton using partograph
2. Allow the mother to use the position she
find comfortable
3. Ensure comfortable position to avoid supine
hypotension
4. Listen to the fetal heart of both fetus and
record in partograph
5. Ensure empty urinary bladder by
encouraging mother to pass urine hourly

417
Second stage of labour;
1. Confirm the second stage by performing VE
2. Be prepare to receive weak babies
3. Monitor fetal heart after each uterine contraction
4. Conduct second stage of labour for first twin as
in singleton labour
5. When the first twin is born, note the time, sex
and immediately label twin one
6. Hand the baby to the mother and put on breast
to suck if baby condition is good
7. After the delivery of the first twin, immediately
perform abdominal examination to find out the
lie, presenting part and position of the second
twin

418
a) If the lie is longitudinal, do v.e to confirm the
presentation, with the next contraction as the mother
to push and perform delivery as in singleton
b) If the lie is not longitudinal, correct it by external
cephalic version and proceed with delivery
8. Listen to fetal heart
9. Second twin must be born within 30 minutes after the
birth of the first twin
10. Membrane are ruptured and if uterine activity does
not, start IV Syntocinon may be use to stimulated it
11. When presenting part is visible mother is encourage
to push
12. Delivery will proceed as normal according to the
presentation

419
a) If vertex presentation, conduct normal
vaginal delivery
b) If breech presentation, conduct breech
delivery
13. Oxytocic drug is given IM or IV at the birth
of the anterior shoulder of the second twin
14. When the second twin is born, note the
time, sex and immediately as twin two
15. Hand the baby to the mother and put on
breast to suck if the baby condition is good
16. After the delivery of the second twin,
prepare for the delivery of placenta, once
oxytocin drug given take effect, then
conduct third stage of labour as in singleton
preferably wing cord control traction[CCT]
420
17. Placentae are thoroughly examine and
number of amniotic sacs, chorion and
placentae are noted
18. Umbilical cord vessels and presence of any
abnormalities are noted
19. Measure all the blood loss and ensure well
contracted uterus
Management of fourth stage of labour;
1. Manage as in singleton with emphasis on;
a) BP, temperature, pulse and respiration as
sudden release of fetuses, liquor amnii and
placenta may cause collapse
b) Fundus for tony due to over stretched
uterine muscle during pregnancy and labour
421
2. Ensure enough rest for mother
3. Monitor babies conditions with emphasis
on;
a) Breathing and color
b) Umbilical cord stamp for bleeding
c) Placing babies on breast to suckle and
initiate lactations
d) Ensure enough warm to avoid
hypothermia

422
Complications associated with
multiple pregnancy
• Abortion
• Preterm labour
• Polyhyramnious
• Fetal abnormality more common in
monozygotic twins e.g. co-joined twin
• Malpresentations
• Premature rupture of membrane
• Prolaspe of cord

423
• Prolonged labour
• Locked twins
• Delay in the birth of second twin
• Premature expulsion of the placenta
• Post partum hemorrhage
• Undiagnosed twin

424
Oligohydramnious
Definitions
• A severe deficiency of amniotic fluid less than
250 ml at 34-36 weeks
Causes;
1. Premature rupture of membrane
2. Severe intra uterine retardation
3. Congenital fetal abnormalities
 Diagnosis;
1. History of few or slow fetal movement
425
Examination and prevention
Examination;
1. Maternal weight gained- less than expected
2. Fetal parts easily felt on palpation
3. Fetal heart sound easily heard
4. Ultra sound show decreased amount of
liquor amnii
Prevention;
• Early diagnosis and treatment

426
Management and complications
Management;
1. Admit the mother
2. Complete bed rest to prevent premature labour, if
there are no congenital abnormalities
3. In case of confirm congenital abnormalities,
counsel the mother on induction of labour
4. If no congenital abnormalities allow her to reach
term and labour start spontaneously
Complications;
• If early pregnancy. It can lead to fetal pulmonary
hypoplasia [failure of lung to grow]
427
Polyhyramnious
 Definition
• Excessive liquor amnii of 2000 mls or more
 Causes;
• Unknown
• Diabetes mellitus
• Congenital abnormalities; anencephaly,
esophageal, atresia, spina bifida
• Rhesus iso immunization
• Preeclampsia
 Investigation;
• Ultra sound
428
Diagnosis of Polyhyramnious
It is not always easy to diagnose, but it can
be based on the following;
1. Fundus larger than date
2. Tense abdomen
3. Fetus difficult to palpate or not palpable
4. Fetal heart sound heard at distance or not
5. Ultra sound shows increase amount of liquor
6. Fluid thrill

429
Prevention and management of
Polyhyramnious
Prevention;
• Identify the cause and treat it
Management;
1. Refer to hospital
2. Try to prevent premature labour
3. Premature delivery may be the end result
so always be prepares to receive
asphyxiated baby
430
4. Artificial rupture of membrane when the
labour is established and the presenting part
is engaged with controlled flow of liquor to
avoid cord prolapsed or abruptio placenta
which are likely to occur in case of
spontaneous rupture of membranes or
uncontrolled gush of liquor
5. Counsel mother and next of kin on early
delivery[induction of labour] in case of
confirmed severe abnormalities e.g.
anencephaly
6. After delivery examine the baby to rule out
congenital abnormalities such as esophageal
atresia, need early referral to surgeon

431
 Complications
• Pressure symptoms during pregnancy and
labour e.g. edema, difficulty in breathing
• Prolaspe of the cord
• Atony of the uterus leading to PPH
• Pre term labour

432
Premature Rupture of
Membrane[PROM]
Definition
• The rupture of amniotic membranes for
more than one hour before the onset of
labour
• Can occur preterm[below 37 weeks of
pregnancy] or at term[after 37 weeks and
above]

433
Diagnosis of PROM
• Slow drainage of fluids or sudden gush of
liquor in the vagina before onset of labour
at term or preterm
• Speculum vaginal examination will confirm
drainage of liquor[clear or stained] from
the os[ check for cord Prolaspe]
• Reduced fundal height may be noted
suggesting prom

434
Confirmation of PROM
• Vaginal pad over the vulva and inspect it
an hour later for the color and smell
• Use high disinfectant or sterile speculum
for V.E;
1. Fluid may be seen coming from the cervix
or forming a pool in the posterior fornix
2. Ask the mother to cough, a gush of fluid
will escape through the vagina

435
 Differential diagnosis of PROM
• Excessive secretions on vaginal pad
• Incontinence of urine

436
Management of PROM
Depend on gestation of pregnancy
1. Drainage of liquor before 37 weeks of
pregnancy;
• Admit patient until delivery
• Start the patient on Ampicillin 500 mg orally for one
week
• Avoid further V.E
• Patient apply sanitary whenever soiled
• Check sanitary pads daily to;
a) Note continue drainage
b) Check the color of liquor especially for Meconium
c) Rule out infection[chorioamnioinitis] by checking the
smell and color of liquor
437
2. Observe for signs of chorioamionitis through;
a) Hourly temperature and pulse rate
b) Abdominal examination for tenderness
c) Weekly total WBC for leucocytosis
d) Vulva pads for smelling
e) Taking fetal heart
3. Dexamethasone 6 mg IM 4 doses 6 hourly apart
or Dexamethasone 12 mg IM 2 doses 12 hourly apart
for preterm PROM
4. Irrespective of gestation, deliver the baby if
chorioamionitis occur or incase of intrauterine
death, do not give steroids
• Delivery is done by induction unless there is
contraindication to vaginal delivery if not
complication during observation time keep her as
inpatient until 37 weeks of gestation then deliver by
induction of labour
438
5. Drainage of liquor at 37 or more weeks of
gestation
a) Admit the patient in labour ward
b) Start the patient on antibiotic Ampicillin or
amoxicillin 500 mg IM then 500 mg orally 6
hourly and Metronidazole 400 mg 8 hourly
Complications of PROM;
1. Intra uterine infection both to mother and
fetus
2. Oligohydramnious
3. Puerperal sepsis

439
Unstable lie
Definition;
• Situation where the fetus is constantly
moving and changing its lie/presentation/
position
• It is of importance after 34 weeks of
pregnancy
Causes;
• There are many conditions in late pregnancy
that increase the movements of fetus or
prevent head from entering the pelvic brim
as follows;
440
Maternal causes of unstable lie
1. Lax uterine muscles in GMG
2. Contracted pelvis
3. fibroids

441
Fetal causes of unstable lie
1. Large baby[cephalo pelvic disproportion]
2. Abnormal baby
3. Polyhyramnious
4. Mal position
5. Multiple pregnancy

442
Placenta/ cord causes of unstable
lie
1. Placenta preavia
2. Short cord

443
Management of unstable lie
Ante natal;
1. From 34 weeks refer to hospital
2. Mother remain in hospital at 36-37 weeks of
pregnancy until delivery to avoid un
supervised delivery
3. External cephalic version. If no contra
indications
4. Explain risk to mother so that she
understands the importance of reporting to
the hospital immediately when the
membranes rupture or labour starts
444
During labour;
If the external cephalic version is successful and the
lie remain longitudinal
a) Doctor will induce labour after 38 weeks
gestation
b) Induction of labour will be commenced with IV
infusion of Syntocinon to stimulate uterine
contractions
c) When the uterine contractions are well
established rupture of membranes is performed
to aid head to enter the pelvis
d) Ensure empty urinary bladder and rectum prior to
procedure
e) Frequent abdominal palpation to assess the lie
and descent of the fetal head
445
Complication of unstable lie
1. Prolaspe of cord
2. Shoulder presentation
3. Prolaspe of arm
4. Obstructed labour

446
Premature labour/preterm labour
Definition
• Labour which start before 37 completed
weeks of pregnancy
Types of premature labour;
1. Spontaneous premature labour
2. Induced preterm labour

447
Causes of spontaneous onset of
preterm labour
1. Maternal ill health;
• Pregnancy induced/chronic hypertension
• Obstetric emergency- APH
• Syphilis
2. Over distention of the uterus;
• Multiple pregnancy
• Polyhyramnious
3. Uterine abnormalities and congenital
abnormalities;
• Fibroids
• Septum in uterus
• Incompetent cervix
448
4. trauma;
• Physiological
• Psychological
• Surgery
5. Previous history of preterm labour
6. Poor general health and poor social
conditions and difficulties

449
Induced preterm labour
Indications include;
1. Maternal ill health like severe eclampsia
2. Medical and obstetric risks e.g. DM, APH
3. Causes of chronic hypoxia and intra uterine
growth retardation[IUGR]
4. Major congenital abnormality e.g. hydrocephalus
Management of Induced preterm labour;
1. Onset of labour earlier than 33 weeks of
gestation
2. Refer mother to hospital with special baby care
unit[SBC U]

450
Spontaneous preterm labour
Management;
1. Admit the mother in SBCU
2. Doctor access the mother who will decide
treatment according to;
a) Early labour-aim to arrest delivery
b) Near to delivery- prepare for delivery

451
Arresting early labour/PTL
 Use of drugs;
1. Salbutamol mg in 500ml 5% dextrose IVI
a) Start with 20 drops per minute
b) Increase to 10 drops every 15 minutes until
contractions stop or maximum 30 drops per
minute. This should stop contractions
c) Side effects are; nausea and vomiting and
tachycardia
2. Dexamethasone 4 mg 8 hourly for 48 hours
IMI. This is to mature fetal lungs

452
 Careful monitoring; regular assessment of
maternal and fetal conditions and progress in
arresting labour[same observation for any
mother in labour]
 General nursing care;
• As for any mother in labour including
psychological support and reassurance
5. Other alternative drugs;
• Ventolin inhaler 3 puffs =100 ug Salbutamol
• Oral Salbutamol 4 mg TDS or
• Brandy 10 ml 4 hourly X 3days
• Aspirin 600 mg
453
Principles of care in antenatal ward
include;
1. Continue observation of maternal and fetal
conditions particular for any other signs of
preterm labour
2. Ultra sound scanning to check on fetal well being
3. General care to built mother nutrition and general
health
4. Observe mother conditions
5. Exclude any cause and treat accordingly
6. In case of any medical or obstetric care risk-
provide particular care

454
Induced premature
labour/premature labour
proceeding to delivery
 Admit the mother
 Conduct history taking and general examination
General examination;
1. Take vital signs
2. Edema
3. Urinalysis
4. History of spontaneous onset
5. Knowledge of the reason of induction of labour
455
Obstetric examination;
1. Per abdomen; size of pregnancy and date of
delivery
2. Length, strength and frequency of uterine
contractions
3. Progress of labour per vaginal
First stage of labour;
A. Monitor general conditions;
i. Temperature 4 hourly
ii. Pulse and bp half hourly
iii. Intake and output
iv. urinalysis
456
B. Monitor obstetric conditions by;
i. Examination per abdomen;
• Length, strength and frequency of uterine
contractions
• Fetal heart rate, rhythm and strength
• Descent of presenting part
ii. Examination per vagina;
• Effacement of cervix
• Dilatation of cervical os
• Presentation and position
• Descent of the presenting part
iii. General care
• Psychological support and reassurance of the
mother and next of kin
457
Second stage of labour in induced
preterm labour
A. Skilled delivery
• Effective episiotomy to avoid delay of fetal head
at the perineum and to prevent birth trauma
B. Prompt active resuscitation of the newborn
because of;
• Possible intra uterine hypoxia
• Immature respiratory centre
• Weak chest muscle and diaphragm
• Respiratory distress syndrome[RDS] in case of
Dexamethasone given
• Prevent chilling/hypothermia
• Administer vitamin K 0.5 mg intra muscular
injection 458
Fourth stage and subsequently
procedure in induce preterm labour

• Admit baby to SBCU after parent have

seen and held the baby

459
Prevention of complications of
preterm labour
Immaturity is a major cause of perinatal
mortality and morbidity therefore;
1. Thorough care during pregnancy to
identify mothers at risk of preterm labour,
skilled medical and obstetrical care during
pregnancy
2. Skilled delivery
3. Skilled intensive care/special care for the
baby
460
Post mature baby/ Post Maturity
Definition
• Post maturity is prolonged pregnancy
exceeding 42 weeks from the last NLMP
• Post term baby is one born after 42 weeks
of gestation
Causes;
Idiopathic/unknown

461
Dangers of post maturity
1. Increased risk of perinatal mortality
2. Placental insufficiency; e.g. infarction
3. Difficult labour due to large baby. Fetal skull
ossification which make moulding difficult
4. Fetal distress
5. Neonatal hypoglycemia
6. Hypocalcaemia
7. Still birth[increases by 4 times especially above 3
weeks post maturity
8. Neonatal seizure increases by 10 times
9. Neonatal death increases by 3 times
10. Meconium passage and aspiration
11. PROM
462
Clinical features of post maturity
1. Before delivery;
a) Prolonged gestation NB rule out error in calculation
of NLMP
b) Increased fundal height
2. After birth;
a) Increased birth weight may be 4000g
b) Behavior of one to two weeks old baby i.e. more
alert
c) Dry skin, may be peeling cracked with absence of
vernix caseosa
d) w/out loss of subcutaneous tissue around the
buttocks, thigh[signs of recent weight loss]
e) Abundant scalp hair
f) Meconium staining of nail and umbilical cord
463
Management of post mature baby
• Most just need normal newborn care
• Other form of management depend on the
presenting problem or complications e.g.
hypoglycemia. Convulsions, birth trauma and etc
NB;
• mortality due to maturity increases with gestation
exceeding 3 weeks after 42 weeks
• Dangers of post maturity reduce when obstetrical
interventions are applied early e.g inducing labour
as early as it is confirmed that pregnancy has
exceeded 42 weeks
464
Grand Multiparity
Definition;
• A terminology used to describe a woman
who had delivered more than 4
pregnancies/deliveries
Effect/s;
• High risk conditions because of the
possible complications during pregnancy,
labour and puerperium

465
Pregnancy in grand Multiparity
1. Defaults attending ANC, because of larger family care
2. Pre-eclampsia, essential hypertension
3. Large baby leading to Cephalo pelvic disproportion
4. IUGR
5. Unstable lie/ malpresentations / Malposition resulting
from lax abdominal and uterine muscles
6. Incidence of multiple pregnancy increases
7. Tired/anemia as a result of repeated pregnancies,
blood loss
8. Varicose veins
9. Placenta preavia
10. backache

466
 Labour in grand Multiparity [GMG]
1. Prolonged labour resulting from lax
muscles or precipitate labour
2. Mal presentation/ malposition can lead to
difficult delivery or obstructed labour
3. High incidence of preterm labour,
hypertension and IUGR
4. PPH
5. Atonic uterus
467
Puerperium in GMG
1. Sub-involution
2. Poor lactation
3. Difficulties in micturation;
a) Prolaspe of the urinary
b) Retention of urine
c) Stress incontinence of urine
4. Anemia/tiredness/depression
5. Increased risk of DVT/infections
6. Slow recovery from pregnant state and
labour
468
Effects of GMG on baby
• Risk of stillbirth/premature labour/light of
dates/malnutrition
• Increase risk

469
DISEASES ASSOCIATED WITH
PREGNANCY
OBSTERIC

470
Introduction
• The diseases worsened by or worsening
the pregnancy
• Early detection and treatment of these is
diseases to avoid endangering the life of
mother and fetus is paramount.
• The include; malaria, anemia,
hypertensive diseases of pregnancy, UTIs,
STDs, HIV/AIDS, cardiac diseases,
tuberculosis and diabetes mellitus

471
Malaria In Pregnancy
Introduction
• Important, because it is associated with morbidity and
mortality to mother and fetus
Definition
• It is a febrile condition during pregnancy caused by a
protozoan, plasmodium species
Method of transmission;
• Bites of infected female anopheles mosquito
• Plasmodium falciparum is the most common
Types of malaria;
1. Mild or uncomplicated malaria
2. Severe or complicated malaria and resistant malaria

472
Signs and symptoms of malaria according to
severity
UNCOMPLICATED MALARIA COMPLICATED MALARIA

1. Joint pains, headaches, backaches 1. Abdominal pain accompanied by

and general malaise diarrhoea or constipation
2. Loss of appetite and may be 2. Fever
vomiting 3. Severe headaches
3. Fever, feeling of coldness[chills] 4. Confusion
and rigors 5. Convulsions
6. Coma
7. Hematuria
8. Renal failure
9. Pulmonary oedema
10.Disseminated intravascular
coagulopathy
11.hypoglycemia
473
Laboratory investigation for malaria
1. Blood slide for malaria parasites
2. Blood for hemoglobin level if below 5g%
take blood for grouping, rhesus factor
and cross matching
3. Blood for sugar level
4. Mid stream specimen of urine to exclude
urinary tract infections
5. Blood for widal test to exclude typhoid
474
Management of malaria
This include treatment and prevention;
A. Treatment; depend on severity
1. Uncomplicated malaria;
• First line sulphadoxine / pyrimethamine [SP] 3
Tablets once
• Preferably quinine tablets 10 mg/kgbwt i.e. 600
mg 8 hourly for 7 days
2. Moderate to severe and resistant malaria/adverse
effects of amodiaquine;
• treat with 3rd line treatment i.e. quinine 200 mg
base orally or IV

475
Management cont……..
a) Administration of oral quinine in case of no
vomiting; dosage regime of quinine tablets must
be given for 7 days at 10 mg/kgbwt every 8
hours for 7 days
b) Administration of intravenous quinine; incase of
complicated malaria, vomiting, confusion,
convulsions and comatose. Dosage regime; 20
mg/kgbwt[loading dose] i.e. 600 mg in 500ml
dextrose fluid over 4 hours and repeat 8 hourly,
then 10 mg/kgbwt in 500 ml dextrose fluid over 4
hours 8 hourly until patient can take orally
quinine 600 mg 8 hourly to complete 7 days
treatment
476
Management cont…….
NB; drip rate;
• Drip per minute = 20 drops
• Discontinue the infusion as soon as the
patient is able to take by mouth
• Maintain blood sugar level with intravenous
dextrose 5%
• Monitor fluid input and output
• Fetal heart rate monitoring 4 hourly
• Vital signs observations 4 hourly

477
Infusion fluids used are;
1. Dextrose 5 % 500 ml 8 hourly
2. 50% dextrose in dilution with 10mls normal
saline as bolus incase of hypoglycemia

Differential diagnosis of malaria;

Meningitis Typhoid
HIV infection UTIs
Pneumonia Trypansomiasis
Other viral infections
478
Prevention of malaria
1. Use of treated mosquito nets
2. Routine anti malaria prophylaxis-
sulphadoxine pyrimethamine 3 tablets single
dose in 2nd and 3rd trimester given in clinic.
IT SHOULD NOT BE USE IN LATE
PREGNANCY 36 WEEKS AND ABOVE-WHY?
3. Advise communities clear stagnant waters
and bushes around homes
4. Give routine folic acid and ferrous sulphate
5. Educate the communities on seeking for
medical aid at the nearest health facility or
from a trained community health worker
479
Complication of malaria
1. To mother;
a) Cerebral malaria
b) Anemia
c) Maternal death
2. To the fetus;
a) Abortion
b) Pre term labour
c) Congenital malaria
d) Intra uterine death

480
 Anemia during pregnancy
Introduction
• Important commonest cause of indirect maternal
mortality
• All health worker should ensure that no mother
under her ANC get into labour with anemia
• Refer pregnant women who are not responding to
treatment of anemia early
Definition;
• Anemia in pregnancy is a condition in which the
hemoglobin level of a pregnant woman is less than
10 gm/dl

481
Anemia is graded according to
severity as follows;
1. Mild anemia 8-9.9 gm/dl
2. Moderate anemia 6-7.9 gm/dl
3. Severe anemia less than 6gm/dl

482
Causes of anemia during pregnancy
include;
1. Repeated attack of malaria
2. Intestinal worm infestations, hookworm
commonest
3. Frequent child bearing
4. Dietary iron deficiency[nutritional anemia]
5. Sickle cell disease
6. Hemorrhage i.e. history of abortion or APH

483
Diagnosis of anemia
 Based on clinical signs and symptoms;
1. History of feeling tired easily, feeling dizzy,
breathlessness, cold extremities, swelling of legs,
heart palpitations
2. On examination; pallor of mucous membranes
which include tongue, nail bed and palms, check
for jaundice, oedema or limbs
3. Laboratory investigation if possible; full blood
count, peripheral blood film, urinalysis-
microscopic, stool for ova and cysts, sickling test

484
Management of anemia before 36 weeks of
pregnancy;
• It includes prevention and treatment;
Treatment, this is according to severity;
1. Mild anemia [8-9.9 gm/dl]
a) Oral iron tablets 200 mg once a day through out
pregnancy
b) Oral folic acid 5 mg daily through out pregnancy
c) Check hemoglobin level after 14 days of
treatment if there is an increase by 1 gm, that is
good response. Continue with treatment
d) If no change in hemoglobin level refer mother for
further management
e) Refer mother to appropriate place for delivery
485
Management cont……
2. Moderate anemia [6-7.9 gm/dl];
a) Treat the cause
b) Oral iron tablets 200mg 12 hourly
c) Oral folic acid 5 mg daily
d) Check mother hemoglobin level after 14
days and give Parenteral iron[imferon]
according to HB level
e) Continue with basic treatment and ANC
supervision every 2 weeks
f) Nutritional education and counseling

486
Management cont……..
3. Severe anemia [Less than 6gm/dl];
a) Refer to hospital at any stage of pregnancy
b) Full investigations are carried out; FBC, PBF,
Urinalysis-microscopic, stool for ova and
cysts and sickling test
c) Check total dose of imferon requirement
according to HB level and give it IM in
divided doses
d) Check HB after 2 weeks
e) Continue basic treatment and ANC
supervision every 2 weeks

487
Management of anemia after 36
weeks of pregnancy
Treatment according to severity;
1. Mild anemia;
a) Oral iron tablet
b) Oral folic acid
c) Check mother HB level after 14 days for an
increase of 1gm/dl which indicates good
response. Continue with treatment
d) If still no response or less HB, refer for
further management.

488
Management cont……
2. Moderate anemia;
a) Give Parenteral Imferon according to HB
deficit
b) Check HB after 2 weeks
c) If it increased by 1.5-2gm/dl continue
with oral iron, folic acid and diet
d) If no increase in HB refer for more
investigation and delivery in hospital
489
 Management cont……..
3. Severe anemia;
a) Refer to hospital for admission at any
gestational age and give total imferon in one
dose IV
b) If HB remain less than 6gm/dl after 2 weeks
transfuse with blood to raise HB
c) Delivery must be conducted in hospital with
good emergency obstetric care
d) Full investigations are carried out to detect
the cause; FBC, PBF, microscopic urinalysis,
stool for ova and cysts, and sickling test
490
Formula for total dose imferon[TDI]
 TDI [amount of iron needed to raise HB to the require
level = HB deficit X 250 mg of imferon]
 Add 50% of the calculated amount to allow for the
fetus and amount of anticipated blood loss;
1. For example if HB is 2gm/dl the deficit is 8 gm/dl if
the desired level is 10gm/dl, TDI will be 8 X 250 mg
= 20000 mg of imferon, when 50% of the calculated
amount is added it will be 3000 mg of imferon.
2. Mix in 500 ml of normal saline and infuse over 6-8
hours

NB; 250 mg of Parenteral iron raises HB level by 1gm

491
It is important to note that;
1. Imferon contains the equivalent of 50 mg
per ml of elemental iron dextran complex
2. It may be given IM or IV
3. Test dose of 0.5 ml[25 mg] is
administered and patient is watched
carefully for reaction over period of one
hour

492
Prevention of anemia
1. Counseling and education on proper diet
2. Deworming – Mebendazole 8 tablets from 16
weeks of gestation
3. Prophylaxis against malaria – Sulphadoxine
pyrimethamine 3 tablets single dose during
second and third stage of pregnancy i.e. between
16-28 weeks and between 28-36 weeks
4. Give hematenic drugs – folic acid and iron
tabs daily with meals
5. Early detection and treatment of cause of
anemia e.g. malaria, Urinary infections,
HIV/AIDS, TB, helminthes and nutrition

493
General management of anemia
1. Monitor in ANC every 2 weeks
2. Give folic acid and iron tabs daily
3. Continue or begin anti malaria prophylaxis with
fansidar
4. Treat existing infections
5. Manage any bone pain or sequestration crisis
6. Blood transfusion with packed cells, under
diuretics cover of HB is below 5 mg/dl
7. Refer to hospital for further management
8. Plan time and mode of delivery
9. Plan post partum care

494
Complications of anemia
DURING PREGNANCY;
1. General ill health 2. low body resistance
3. Abortion 4. Preterm 5. progressing to severe
anemia leading to heart failure
DURING LABOUR;
Uterine Atony leading to;
1. prolonged 1st of labour and its dangers
2. Prolonged or delayed 2nd stage of labour and it
dangers
3. Retained placenta
4. PPH
DURING PUERPERIUM;
1. Puerperal infection
2. Poor lactation 495
Cardiac diseases during
pregnancy
Introduction
• Early detection of cardiac disease in
pregnancy is paramount because of
maternal mortality
• Pregnancy aggravates/worsen the heart
disease
• Refer mother with heart disease early to
doctor for appropriate care

496
Definition;
• Cardiac disease during pregnancy is
function impairment of heart
Causes;
1. Rheumatic heart disease, affects the
valves, commonest
2. Congenital heart lesions

497
Classification
1. Grade 1; the patient has heart lesion on
examination but not symptoms and is detected
on physical examination
2. Grade 2; heart lesion and slight limitation on
mild to moderate activity, but has no symptoms
at rest
3. Grade 3; marked limitations[dysnoea or pain on
minimal activity-less than ordinary activity
4. Grade 4; heart lesion and marked symptoms at
rest[dyspnoenic] or patient is in failure or has
history of heart failure before or patient has had
cardiac surgery
498
Diagnosis
• Relevant history should be obtained and
recorded
• The cardio-vascular system should be
examined at first visit and the condition of
the patient graded

499
Clinical features
• History of rheumatic fever in childhood or
congenital heart disease
• Know rheumatic heart disease
• Palpitation
• Fatigue
• Cough
• Tachycardia
• Basal Crepitation may be present in the lungs

500
Investigations
• Electrocardiogram[ECG]
• Antenatal routine investigations or profile
i.e. HB, blood group, rhesus factor,
urinalysis, VCT for HIV
• Urea and electrolytes
• Blood culture when indicated

501
Prevention of heart diseases
• Health education on proper treatment of
sore throat and rheumatic fever in children
and its complications if not treated early
• Mobilizing and advising communities on
the important of ANC attendance as early
as possible
• Thorough ANC screening and proper
management given early enough

502
Management of cardiac diseases
Management of cardiac patient is a role of
doctor so refer immediately at first contact
The 4 grades of cardiac disease are manage
as follows;
1. ANC patient with grade I and II are
managed as outpatients until 36 weeks,
then admitted for hospital management until
delivery
2. Patient with grade III and IV are admitted
on first visit to ANC, investigated and
managed in the ward until delivery
503
Management of cardiac patient
cont…………
3. Nursing care;
a) Complete bed rest
b) Nursing in sitting up[cardiac] position
c) Body hygiene including bed bath and oral toilet,
prevention and treatment of pressure areas
d) Light nourishing diet with protein and iron
e) Offer bed pan regularly
f) Take care to prevent any infection[avoid infection]
g) Take and record vital signs every 4 hours
h) Avoid physical strain and emotional stress i.e. allow
few visitors

504
Management of cardiac patient
cont………..
4. Laboratory investigations
a) Weekly total differential white blood cells count to exclude
infection
b) Blood cultures and septic screening whenever needed
c) Hemoglobin level estimation on admission and as necessary
there after
d) Electro cardiograph should be done if possible to confirm
diagnosis
5. Drugs
a) Hematenic drugs
b) Benzathine penicillin at monthly intervals in case of patient
with rheumatic fever
c) Digoxin and Furosemide incase of impending congestive
cardiac failure

505
Management of cardiac patient during
labour and delivery
1. Place patient in sitting up position to avoid lithotomy
position
2. Grade I and II allow spontaneous labour and assist
where necessary e.g. episiotomy vacuum delivery
3. Keep emergency drugs and oxygen near by
4. Start antibiotics
5. Give analgesics
6. Grade III and IV assist with vacuum delivery
7. DO NOT GIVE ERGOMETRINE
8. Give Syntocinon 5 units IM or more to prevent PPH,
if no Syntocinon just massage uterus
9. Give 80 mg of Furosemide
506
Mgt of cardiac patient during labour and
delivery cont……
10. Stabilize the patient and observe for 2 hours then
refer to post natal ward to continue antibiotics for
2 weeks
11. Ensure aseptic technique when addressing labour
12. Be prepared for heart failure during 2nd stage, 3rd
stage and early post partum periods by having
resuscitation tray with the following;
• Morphine
• Aminophylline
• Digoxin
• Furosemide
• adrenaline
507
Post partum care of patient with
cardiac disease
1. Nurse the patient in sitting up position
2. Carry out and record vital observation on mother
chart every 4 hours
3. Administer humidified oxygen by mask if
available
4. Give Digoxin [in case of severe tachycardia] 1.5
mg IV start and repeat with 0.5 mg 6 hourly until
patient is well digitalized, continue with 0.25 mg
once a day
5. Give Furosemide 80-240 mg IV start or prn
depending on severity of the condition
6. Give Aminophylline 250 mgm IV start in order to
relieve broncho spasm
508
 Complications of cardiac disease in
pregnancy
1. Maternal distress
2. Heart failure
Post natal care;
1. Counsel the patient about her condition,
explain all the available methods of family
planning and let her make an informed
choice
2. Give her prophylactic anticoagulants

509
Diabetes mellitus during
pregnancy
Definition
• A metabolic disorder characterized by
hyperglycemia
It can be;
 Overt diabetes – mother is known to be
diabetic with signs and symptoms before
pregnancy
 Gestational diabetes – mother become
diabetes during pregnancy
510
Diagnosis
Gestational diabetes occurs in 10.5% of
pregnancies and diagnosis include;
1. Previous history of diabetes during previous
pregnancy
2. History of diabetes in her family, still birth,
neonatal deaths or repeated abortions
3. History of previous large infants 4kg and
above birth weight
4. Polyhyramnious
5. Obesity
6. Advanced maternal age
511
Signs of diabetes include;
 Polydipsia/Excessive thirst
Polyuria
Polyphagia
Weight loss
Blurred vision
Lethargy
Glycosuria
 NB; on diagnosis or suspecting DM, refer
mother immediately
512
Effects of pregnancy on DM
include;
 0-6 months;
 fetus use the circulating glucose
 it makes the fetus to grow more than expected
size.
 Mother insulin requirements is lowered
 6 months to delivery;
 Placenta produces lactogen and therefore mother’s
insulin requirement increase
 After delivery of placenta, hormone levels drop
and insulin requirement of mother increases

513
Effects of DM on pregnancy include
Recurrent miscarriages
Congenital abnormalities
Pre eclampsia
Intra uterine hypoxia
Intra uterine death

514
Diabetes can be complicated by;
Chronic hypertension
Pregnancy induced hypertension
Chronic nephropathy
Polyhyramnious

515
Investigation requested for DM
include;
Postprandial blood sugar
Oral glucose tolerance
Serial urinalysis
Ultra sound for size of baby

516
Management of DM
 Diet control and frequent monitoring of
serial blood sugar as outpatient
Give insulin according to blood sugar levels
after repeated serial blood sugar tests
Allow non insulin dependent to reach term
while insulin will deliver before 37 weeks by
either induction of labour or caesarian section
Post partum serial blood sugar test to adjust
dose
517
Management of DM cont..
 Baby is carefully manage by pediatrician
 Once glucose tolerance test[GTT] is positive,
examined the patient at ANC every 2 weeks or
more frequently according to patient’s condition
for the first 30 weeks of gestation, then every
week or more frequently until delivery
 Admit mother at 32 weeks of pregnancy for;
 Monitoring fetal well being by abdominal
examination and ultra sound
 Close observation to avoid complications
 Prevention or treatment of pre eclampsia
518
Insulin therapy
 For gestational diabetes, admit in the hospital and
do blood sugar serial[ blood at 6am, 11 am and 3
pm]. Start on sliding scale insulin. If stable can be
discharged and monitored by random blood sugars
 If a known diabetic on oral hypoglycemic agent.
Admit the patient and stop oral therapy and start
on insulin sliding scale till stable
 Monitoring by weekly random blood sugar, or
more frequent tests as case may be. This form the
bases for altering the insulin dosage. The
objective is keep blood sugar level at 3-7 mmols
/litter
 Put the patient on a fetal kick chart and serial
biparietal diameter where ultrasound is available
519
Methods of delivery in DM
Depend on doctor decision as follows;
 In case of good obstetric history and
stabilized mother’s condition induction of
labour is performed at 38 weeks of gestation
 Incase of poor obstetrical history or
unstabilized patient induction of labour is
induced before 38 weeks
 In case of poor obstetrical history or
unstabilized patient, severe pre eclampsia or
eclampsia, contraindication to vaginal
delivery, elective caesarian section is
performed
520
Management of mother during
labour in DM;
 as any other mother using partograph if she
is expected to deliver per vagina with
emphasis on;
 IV infusion and 5% dextrose – litter 8
hourly[add 50ml of 50% dextrose to 1 litter
of 5% dextrose
 Soluble insulin 20 units to 19.5 ml of normal
saline given IV as start regime
 Blood sugar level are taken hourly; labour
should start with blood sugar level of 4.5-5.5
mmols/litter. Insulin is gradually increased to
maintain blood sugar at 4.5-5.5 mmols/liter
521
Management of mother during
labour cont….
Carefully observation of any signs of fetal
distress
Observe progress of labour per abdomen
and vaginal examination to exclude CPD
Do not give insulin after delivery, until
blood sugar level is taken. Gestational
diabetes will not need further insulin
 NB inform the pediatrician about the
mother and on the day of delivery
522
Complication of DM
 To the baby;
 Large lethargic baby
 Intra uterine hypoxia
 Birth asphyxia
 Respiratory distress syndrome[RDS]
 Prematurity and its complications
 Hypoglycemia
 Hypothermia
 Difficulty to feed
 To the mother;
 Abortions
 Pre term labour
 CPD and its complications
523
HIV in pregnancy and childbirth
Counseling and testing
• All pregnant women seeking ANC should be
counsel on for testing on voluntary basis
• Advantages;
1. Enable women to take precautions to reduce the
risk of HIV transmission to their babies e.g.
choosing not to breastfeed
2. Discuss options for termination of early
pregnancy and use of antiretroviral prophylaxis
for HIV positive women[prevention of mother-to-
child transmission]
524
Effects of HIV on pregnancy; possible
associated complication are;
1. Spontaneous abortion
2. Genital tract infection
3. Urinary tract infection
4. Post partum infections
5. Post surgical infections
6. Recurrent Candida infection
7. Opportunistic infections
8. Preterm labour
9. Premature rupture of membranes
10. Low birth weight babies
11. Still births
525
Factors affecting MTCT of HIV
1. Viral factors;
a) Viral load
b) Viral Genotype and phenotype
c) Viral resistance
2. Maternal factors;
a) Immunological status
b) Nutritional status
c) Clinical status
d) Behavioral factors

526
Factors affecting MTCT of HIV
cont….
3. Obstetrical factors;
a) Prolonged rupture of membrane, more than 4
hours
b) Mode of delivery
c) Intra partum hemorrhage
d) Obstetrical procedures
e) Invasive fetal monitoring
4. Fetal factors;
a) Prematurity
b) Genetic
c) Multiple pregnancy
527
Factors affecting MTCT of HIV
cont..
5. Neonatal factors;
a) Breast feeding
b) Gastrointestinal tract factors
c) Immature immune system

528
Care of woman with HIV in pregnancy

1. Antenatal care;
a) HIV VCT;
• Pretest counseling
• Voluntary HIV testing
• Post test counseling
b) HIV negative mother;
• Inform the client of negative serology
• Educate on window period[period between
infection and positive antibody test]
• Educate on the need for repeat test after 3
months and the important of staying negative

529
Care of woman with HIV in pregnancy cont…

c) HIV positive mother;

1. Further counseling
2. Repeat the test to confirm
3. Discuss who else she wound like to be informed
4. Give emotional support required
5. Negotiate with the partner e.g. safer sex, testing
the partner after counseling
6. Educate on personal hygiene, infection prevent
and nutrition
7. Sensitize on progression of disease and possible
opportunistic infections and the need for prompt
treatment
530
Care of woman with HIV in pregnancy cont…

8. Educate on MTCT and the value of ART,

its cause and availability
9. Educate client on possible effects of
HIV/AIDS on pregnancy and the possible
effects of pregnancy on HIV/AIDS

531
Intra partum care of woman with
HIV
 About 60% of HIV MTCT is thought to occur around
the time of labour and delivery
 Factors associated with intra partum MTCT are;
1. Vaginal delivery has a higher risk of transmission
than elective caesarian section during delivery
2. Rupture of membranes for longer than 4 hours
3. Episiotomy
4. Intra partum hemorrhage
5. Invasive procedure such as penetrating scalp
electrodes and fetal sampling
6. Instrumental delivery - vacuum and forceps
7. First- born twin have a higher risk of transmission
than second born twins
532
Specific intra partum management of
mother with HIV
1. Labour;
a) Give option of a companion of their choice
b) Labour staff must be sensitive to the mother’s
fear and concerns, they should give continue
emotional support
c) Follow normal obstetric guidelines in labour
management including universal infection
prevention and practices
d) Limit the number of vaginal examination and
during any vaginal examination observe aseptic
technique
e) Where induction of labour is chose, membranes
should be left intact as long as possible
533
Important
1. Syntocinon should not be used with
rupturing of membranes
2. Induction of labour should be done using
prostaglandin pessaries or misoprostol for
HIV infected mother

534
Anti retroviral therapy
1. Niverapine;
a) Give 200 mg orally to the mother at the onset of
labour
b) Give oral 2 mg/kgbwt to the baby within the first
72 hours after delivery
Management of delivery;
1. In case caesarian section is done[elective or
emergency] give broad spectrum prophylactic
antibiotics
2. Delivery should be conducted using standard
practice avoiding unnecessary trauma or
prolonged second stage of labour
535
MANAGEMENT OF DELIVERY CONT..

3. Clean the vagina with antiseptic e.g. hibitane

[chlorhexidine]
4. Avoid episiotomy unless absolutely necessary
5. Minimize trauma in assisted delivery e.g. use
plastic vacuum extraction at low pressure, do
episiotomy if necessary
6. Wipe baby mouth and nostrils with gauze at
delivery of head
7. Clamp cord after delivery of the baby and avoid
milking the cord. This avoid spurting of blood ,cut
cord under the cover of wrapped gauze swab
536
 MANAGEMENT OF DELIVERY CONT..

8. Immediately after birth, wash the baby with

warm 0.25% chlorhexidine solution or wipe dry
with a towel or cloth to remove maternal body
fluids
9. Avoid nasopharyngeal suction of the baby
unnecessary e.g. liquor is Meconium stained. If
required, use a mechanical suction at the
pressure below 100 mmhg if available or bulb
syringe NOT mouth operated suction
10. Place the baby on the mother for skin to skin
contact

537
POST PARTUM CARE OF HIV/AIDS POSITIVE
MOTHERS
1. Routine care including monitoring of vital signs
2. Examination of uterus, cervix, vagina and perineum
3. Assessing quantity, smell and color of lochia
4. Encourage perineal hygiene and good general hygiene to
prevent infections
5. Encourage the woman to pass urine
6. Check for anemia, prevent or manage it
7. Continue emotional support[counseling as necessary]
8. If the mother opts not to breastfeed give bromocriptine to
suppress mild secretion. Attend to any breast problems
9. Protect cracked nipples by employing good breast feeding
technique, treating maternal vaginal thrush and/or infant
oral thrush promptly, if the baby has oral thrush treat the
mother’s nipples at the same time to avoid re-infections

538
Maternal follow-up
1. Monitor the mother for infections
2. Educate on prompt health services
seeking behavior
3. Encourage to continue with good
personal hygiene and nutrition
4. Advise against unprotected early
penetrative sex after delivery as this may
lead to endometritis
5. Advise on family health
539
Family health needs
1. All available method of contraception can be used
by HIV seropositive mothers
2. Non breastfeeding mothers should be encourage
where other methods are contra indicated
3. HIV infected couples should be encouraged to
use condoms to protect them against re-infection
with additional HIV strains from their partners
4. Information on emergency contraception and its
availability should be provided
5. Surgical contraception should be
encouraged/offered to HIV positive mothers and
their partners

540
Antiretroviral administered to the
mother
1. Besides anti retroviral drugs administered to
the mother to prevent MTCT, it is also
important to administer antiretroviral drugs
that can help the mother
2. Introduce the mother to clinicians, social
worker and people living with
HIV/AIDS[PLWA] for care and psychological
support
3. Direct her to clinics where she will get
constant counseling and relevant drugs/care
541
HIV Transmission and breast
feeding
1. HIV can be transmitted through breast
milk, it can take place at anytime during
lactation
2. The high transmission is in non-
exclusively breastfed infants
3. Discourage mixed feeding in HIV
mothers’ infant

542
Breastfeeding practices in HIV
1. Women who know that they are HIV positive need to
be counseled about the risks and benefits of breast
feeding their babies so that they can make informed
decisions
2. Discourage mixed diet[see ministry of health infant
feeding guideline]
3. Review and assist the mother to choose an
appropriate feeding plan
4. For mother who is planning to breastfeed, assist her
to initiate breast feeding within one hour after
delivery
5. If the mother is not planning to breastfeed, support
her decision and assist her in the preparation of the
chosen method and feed the baby as early as
possible after delivery
6. Closely monitor all babies at risk for infections,
growth and development health stages 543
Infant feeding options for HIV
positive mothers
1. During breast feeding phase, condom should be
used to reduce the chances of re-infection of the
mother with new HIV strains
2. Exclusive breast feeding;
a) The baby is give breast feeding alone without giving
other foods from birth up to four to six months
b) The baby is fed on demand
c) Exclusive breast feeding is the best for infant
nutrition and growth
d) Exclusive breast feeding prevents gastro intestinal
infections e.g. thrush that could increase the risk of
HIV transmission

544
Infant feeding options for HIV positive
mothers cont……
3. Early cessation of breast feeding;
a) Exclusive breast feeding followed by early
cessation of the breast feeding is aimed at
reducing the risk of HIV transmission by
shortening the length of time the baby is
exposed to HIV through breast milk as the infant
remains exposed for the first few months
b) When mother develop symptoms of AIDS during
the breastfeeding period
c) When the mother can provide adequate and
hygienic replacement feeding during the first few
months

545
Heat treatment of expressed breast
milk
1. Heated expressed breast milk can provide and
alternative infant feeding. This is done is by
boiling breast milk to kill the virus, however some
nutrients and antibodies are also destroyed. This
an option to consider;
a) If the mother wished to give her baby her own
breast milk
b) If the alternative methods are too expensive for
the mother
c) For the sick or low birth weight babies who are at
more risk from artificial feeding
d) During periods of increased transmission risks
such as cracked nipples or breast abscess
546
Heat treatment of expressed breast milk
cont..
2. Teach the couple or the mother how to
properly prepare and store the milk to
minimize gastro intestinal infections
3. Teach the mother how to express the
breast milk and how to sustain the
process
4. Support and encouragement is necessary
to keep up the milk supply

547
Heat treatment of expressed breast
milk cont…..
5. Wet nursing; the infant is fed by a test HIV negative
member of the family, counsel the wet nurse to practices
safe sex to be able to avoid infection during the breast
feeding
6. Replacement feeding; this is the process of feeding a baby
who is not receiving any breast milk with the choice that
provides all the nutrients that the child needs. The infant
could be fed with commercial or modified cow milk with
micro nutrients supplements. Replacement feeding needs;
a) Access to clean water supply
b) Use of utensils to feed the infant
c) Washing of hands
d) Adequate fuel to boils the water and utensils
e) Adequate time to prepare the food

548
IMPORTANT TO NOTE; THE MOTHER SHOULD
CONSIDER THE COST OF REPLACEMENT FEEDING
TO ENSURE CONTINUES SUPPLY FOR AT LEAST SIX
WEEK;

• Teach the couple to properly prepare

formula feeds according to instructions
• Educate them on proper handling and
cleaning of utensils
• Inform them that washing hands before
preparation and handling formula is
essential to prevent infections
549
Testing infant for HIV
1. Children born to HIV positive mothers will
have maternal antibodies in their blood at
birth until about the age of 18 months, this
does not mean the child is infected
2. After 18 months all children will have lost
the maternal antibodies
3. Only those children infected with the virus
will produce their own antibodies. antibody
tests can not therefore detect HIV infected
children until about the age of 18 months
550
 Pregnancy induced
hypertension
Introduction
• Women should attend ANC through out pregnancy
from the time they have missed two months
menstrual period
• The blood pressure at the first ANC visit is used as
the baseline blood pressure to compare with those
of subsequent visits
• if the woman BP is above 140/90 mmhg early in
pregnancy before 20 weeks. She is considered to
have chronic hypertension known as essential
hypertension
• Pregnancy induced hypertension is used to
describe hypertensive disorders of pregnancy
which include preeclampsia and eclampsia
551
Pre eclampsia
• This when the diastolic BP is 90 mmhg
and above or a rise of 15 mmhg with
Protienuria, oedema or both occurring
after a gestation of 20 weeks or more
• Pre eclampsia can be imposed on existing
hypertensive disease
• Incidence; common in Primigravida but
may occur in other pregnancies

552
Causes of pre eclampsia
• Unknown, but there are predisposing
factors such as;
1. Multiple pregnancy
2. Polyhyramnious
3. Hydatiform mole
4. Diabetes mellitus

553
Classification of pre eclampsia
1. Mild pre eclampsia; diastolic BP of 90 – 109
mmhg or a rise of diastolic BP from previous
reading by 15 mmhg with Protienuria or
oedema
2. Severe pre eclampsia; diastolic BP of 110
mmhg or above with Protienuria ++ or more
3. Imminent or impending eclampsia; a state
in which a pregnant woman with high BP
symptoms and signs indicating that she may
get eclampsia fit at any movement
554
The signs and symptoms are;
• Severe headache
• Blurred vision
• Epigastric pain
• Oedema of legs/face
• Oliguria
• Abnormal urea and electrolytes levels
• Increased creatinine

555
Management
 Mild pre eclampsia;
• Treat as outpatient
• Incase of good obstetric history and no
complications during the current pregnancy, the
patient is manage as outpatient, patient should
be treated by doctor
1. Encourage the patient to rest at home
2. Give mild sedation e.g. Phenobarbitone 30- 60
mg 8 hourly
3. Review patient in OPD/ANC every week to
monitor;
• Bp, urine for protein, body weight, oedema, fetal
movement[fetus kicks] and fetal growth
4. Mother is strongly advised to deliver in hospital
556
Indication for refer to hospital are;
1. Bad obstetric history
2. Evidence of poor fetal growth detected as;
• Low fundal height compare to weeks of
gestation
• No mother weight gain
3. Gestation of 37 weeks or more
NB DON’T PRESCRIBE HYPERTENSIVE DRUGS
OR DIURETICS UNLESS BP IS NOT
RESPONDING TO SEDATION AND REST
557
Management of pre eclampsia
Severe/ immanent pre-eclampsia;
• Once severe eclampsia is diagnosed,
immediately refer the patient to the hospital
under strong sedation.
• In hospital;
1. Admit for strict observation and delivery
2. Control BP with;
 Parenteral Hydralazine 5-10 mg IV slowly
over 2 mins every 5 mins until diastolic
pressure is below 110 mmhg or
 As requires or
 Give 12.5 mg IM every 2 hours
558
Management cont…
3. Prevent convulsion by administering;
• Diazepam 20 mg IV slowly and
Phenobarbitone 30 mg 8 hourly
• Maintain during induction of labour with 40
mg of diazepam in 500 ml of normal saline
titrate to keep sedated, but rousable
4. Observe BP, pulse, and RPR every half an
hour
5. Watch for signs of immanent/impending
eclampsia
6. Take blood for hemoglobin estimation,
grouping and cross matching
559
Management cont…
7. Deliver by appropriate method which may
be;
• Induction of labour
• Caesarian section
8. Continue with anti hypertensive drugs
and observation i.e. blood pressure,
temperature, pulse and respirations,
urinary output and urinalysis

560
Dangers/complication of severe pre
eclampsia
To the mother;
1. Heart failure
2. Development of eclamptic fits[eclampsia]
3. Cerebra-hemorrhage
4. Hemolysis leading to elevated liver enzymes and low platelet
count[HELLP]. It causes severe hypoxia[too little oxygen to the
brain].the mother may die from hemorrhage, eclamptic fits seizers
or a ruptured liver
5. Disseminated intravascular coagulopathy [DIC]
To the baby;
1. Intra uterine fetal death
2. Neonatal death due to asphyxia or prematurity

561
ECLAMPSIA
Definition
• Severe form of pregnancy induced high
BP, Protienuria, oedema and one or more
convulsion
• Patient may go into coma

562
Differential diagnosis
1. Cerebral malaria because of pyrexia,
convulsion and normal BP
2. Meningitis; headache, stiff neck, fever and
normal BP
3. Epilepsy; convulsion, normal BP, previous
history of convulsion
4. Poisoning; coma, convulsion, normal BP,
features of specific poisoning
5. Diabetic coma; no convulsion, BP may be
high glycosuria, ketonuria and
hyperglycemia
563
Management of eclampsia
 Principles or aims/ ABC of
caring for a patient with
eclampsia
1. Call for help
2. Clear airway
3. Give oxygen by mask
4. Control convulsion
5. Fix IV line
6. Urine catheter, frequent
analysis of urine to R/O
renal failure
7. Control BP
8. Monitor BP and fetal heart
rate hourly
9. Observe uterine
contractions and vaginal
bleeding
10. Monitor temperature,
PR, RPR 4 hourly and
more often if possible
11. Deliver baby with in 6-8
hours of first convulsion
12. Continue anti convulsion
and anti hypertensive
564
Patient with convulsion
1. Call for help
2. Lay patient flat and gently hold her down to her
a way from harmful objects
3. Keep airway clear by;
• Extend the head and neck keep head in lateral
position
• Clean the mouth, nose and throat of secretions
• Insert airway tube
4. Control fits
5. Control BP accordingly

565
Drugs use in eclampsia
Magnesium sulphate[MGSO4]
1. Indicated for fits control and prevented
2. Dose loading;
• 4 g of 20% solution IV over 5-10 min or IM
if IV not possible
• Follow by 10g of 50% mgso4 solution, 5g in
each buttock as deep IM with 1.0 ml of 2%
lignocaine
• If convulsion occur after loading dose give 4
g mgso4 IV over 5 minutes

566
Drugs use in eclampsia cont..
 Maintenance dose of MGSO4;
1. 5g of 50% solution and 1 ml lignocaine 2% IM,
every 4 hours into alternate buttock
2. Before giving dose ensure that;
• RR is 16 minutes or more
• Urine output is 120 ml or more in the last 4 hours
i.e. 30 ml per hour
• Patellar tendon reflexes are present and normal,
omit the dose if the above condition are not
satisfactory
• If RR is below 16 breaths/min the antidote
calcium gluconate 1-2[10-20 ml] of 10% solution
IV slowly until RR improves
567
Drugs use in eclampsia cont…
Diazepam;
1. Control convulsion and prevent impending one
2. It causes significant respiratory distress in neonate
and should not be use unless mgso4 is not available
3. Load dose;
• 20mg IV over 2 min
• Repeat same dose if convulsion occur again
4. Maintenance dose; 40 mg in 500 ml normal saline and
titrate to keep the patient sedated, but rousable
NB; maternal respiratory depression may occur when
dose exceed 30 mg in one hour, if RD occur, ventilate
patient[face mask/beg anesthesia apparatus] until
spontaneous respiration are satisfactory

568
Drugs use in eclampsia cont…
Hydralazine;
1. Indicated for control of BP
2. Loading dose;
• 5mg IV over 2 mins
• Check BP every 15 mins
• Repeat dose every 15 mins until BP reached
diastolic 100 mmhg
• Give IV in 500 ml normal saline, alternative drug
nifedipine 10 mg sublingual and check BP every
15 mins dose repeated after 30 mins until
diastolic BP is 100 mmHg

569
Drugs use in eclampsia cont…
3. Maintenance dose of Hydralazine
• 10 mg IV in 500 ml of NS 8 hourly
• Check BP every 5 min until diastolic reach
100 mmhg, nifedipine 10 mg sublingual 8
hourly

570
Precaution to avoid complications
1. Give hpt treatment to lower BP close to normal
over 12 hours to reduce risk of fetal death
2. Avoid diuretics except in cardiac failure and renal
failure
3. In severe pre eclampsia and eclampsia control the
blood pressure and fits and terminate
pregnancy with in 24 hours irrespective of
gestational age
4. Cauterization to monitor urine output
5. Use mgso4 as first line drug when available to
control fits and even prophylaxis in severe pre
eclampsia. Second line diazepam
6. Do not use ketamine as an anesthetic drug in
eclampsia
571
Follow up
1. After delivery monitor condition for few days in
hospital
2. Continue hypertensive drug therapy after several
days or weeks
3. See patient in OPD clinic every week until blood
pressure are settle
4. Counsel the patient and next of kin on control of
hypertension
5. If previously hypertensive or if hypertension
persist after 6 weeks postpartum refer to doctor
for further management
6. Provide counseling for family planning
572
Other hypertensive disorders
in pregnancy
• Mainly due to aneurysm cooptation of the
aorta, renal diseases, adrenal diseases, and
thyrotoxicosis
Management of other hypertensive
disorders
1. Emergency care for people with stroke and
malignant hypertension
2. Give hypertensive therapy as above;
Hydralazine, nifedipine and arrange to
deliver or refer
573
Management of other hypertensive
disorders before 37 completed weeks
of pregnancy
1. Maintain hypertensive drugs
2. Consult physician mgt
3. Monitor pregnancy progress, fetus may
often be SGA
4. Counsel mother about the need to deliver
at term
5. Review the mother every two week

574
At 37 – 40 weeks of gestation
1. Maintain anti hypertensive therapy
2. Wait for spontaneous labour
3. Pregnancy should not exceed 40 weeks
4. If pregnancy have exceed 40 weeks
arrange for delivery

575
Dangers of eclampsia
To the mother;
• Heart failure
• Cerebra hemorrhage
• Hemolysis leading to elevated liver enzymes and
low platelets counts[HELLP] syndrome
• It cause severe hypoxia[too little oxygen to brain
and possibly death of the fetus due to
vasospasm[narrowing of vessels]. Mother may die
from hemorrhage, eclamptic fits or rupture of liver
• DIC
• Death as a result of delay to arrive to hospital
576
Danger of eclampsia
To the baby;
1. Intra uterine fetal death
2. Neonatal death due to asphyxia or
prematurity

577
URINARY TRACT INFECTIONS
 Overview
• Common in cases of history of pylelitis during
pregnancy
• The commonest UTI during puerperium is cystitis
 Predisposing factors;
1. Ascending infection
2. Pylelitis during pregnancy may reoccur
3. Retention of urine/stagnant urine
• Causative organism;
1. E.coli commonest
2. Hemolytic streptococcus
3. staphylococcus
578
SIGNS AND SYMPTOMS
1. Onset is within few days after delivery
2. Raised body temperature[puerperal pyrexia]
3. Slow pulse rate
4. Supra pubic pain in case of cystitis
5. Frequency of micturation
6. Incase of pyelonephritis;
• Sudden onset
• Pain radiating from the loin to the groin
• High temperature of 40 degree Celsius may be
accompanied with rigors
7. Vomiting and anorexia
8. General malaise
9. Urine is offensive with fishy smell
579
Investigations
1. Mid stream specimen of urine will reveal pus cells
and bacteria in the urine
2. High vaginal swab for culture and sensitivity
MANAGEMENT OF UTIs;
1. Plenty of fluids to drinks at least 3000 ml daily
2. Fluid intake and output is recorded
3. Prescribe broad spectrum antibiotics according to
result of CS
4. Treatment is continue until infection is cleared
5. Further specimen of urine is sent to laboratory to
confirm whether the infection is cleared
COMPLICATION OF UTIs;
• Chronic renal disease
• Renal failure
580
 VENOUS THROMBOSIS

Definition;
• A clot formation in the veins, commonly of
the pelvis or leg
Types;
• deep venous thrombosis and superficial
thrombosis

581
Predisposing factors of venous
thrombosis
1. Prolonged labour and hemorrhage during labour
2. Varicose veins leading to stasis of blood brought
about by patient being in recumbent position e.g.
post caesarian section
3. Trauma of walls of the veins resulting from;
a) Pressure by straps when in lithotomy position
b) Pressure under the knees when in trendelenburg
position
c) Bruising on limbs when moving unconscious
patient on stretcher or trolley

582
Signs and symptoms of venous
thrombosis
1. Pain complain in the leg at calf muscles
area
2. Swollen leg increased about 2.5 to 5 cm
in girth of the affected limb. Oedema
may be extended from groins to the toes
3. Discoloration of the skin

583
Management of venous thrombosis
1. Prevention;
a) During pregnancy;
• Prevention of nutritional anemia
• Treat varicose veins
b) During labour;
• Avoid exhaustion, dehydration and hemorrhage
• Avoid trauma to the limbs e.g. pressure by straps,
under knees and bruising limbs
c) During puerperium; avoid stasis by;
• Flexion, extension and rotating ankle exercise every
2 hours on second day of puerperium to stimulate
blood flow in the calf muscles
• Early ambulation by encouraging the mother to walk
around the bed or ward
584
Management cont………
2. OBSERVATION;
a) Legs examined while bathing or making bed and
ward round
b) Note presence of localized pain or tenderness in calf
area
c) In case of swelling measure the girth of the leg using
a tape measure
3. POSITION;
a) Elevate the limb
b) Flexion, extension of the ankle joints are started
c) Leg muscle movements when pain subsides usually
with in 48 hours
d) Passive leg movements is commenced within few
days and active leg exercises
e) Patient is allowed up and about
585
Management cont….
4. DRUGS;
a) Anticoagulant heparin IV every 6 hours continued
for 24 to 48 hours
b) It is very important to test for blood clotting one
hour after each injection, sides effects of
anticoagulant drugs are;
• Hemorrhage from placenta site or formation of
hematoma in abdominal incision if given longer
than 4 hours. Avoid this in good practice
• Rigors or sudden rise in body temperature
 COMPLICATION OF VENOUS THROMBOSIS IS
PULMONARY EMBOLISM
586
SUPERFICIAL THROMBOPHLEBITIS
Definition;
• Inflamed superficial blood vessel, commonly
associated with varicose veins
Signs and symptoms;
1. Redness, discoloration of the overlying skin
at the affected site
2. Slight raised body temperature of 37.2
degree Celsius
3. Slight raised pulse rate about 90 beats per
minute
4. Onset is from 4th day of puerperium but
commonly 19th day
587
Treatment of superficial
thrombophlebitis
1. Elevate the leg
2. Encourage muscle activity
3. Patient is allow to tight with crepe
bandage on. When temperature have
subsided with no tenderness at the
affected site

588
Vesico Vaginal Fistula[VVF]
 Definition;
• This is abnormal opening between the urinary bladder or
urethra and the vagina
 Causes;
1. Sloughing of bruised area of the urinary bladder or urethra
as a result of prolonged pressure by the fetal head during
obstructed labour
2. Laceration of the urinary bladder during difficult instrumental
delivery
 Signs and symptoms;
1. Incontinence of urine starting 5 or 6 days after delivery due
to sloughing in case of bruised urinary bladder or urethra
2. Incontinence of urine immediately after delivery indicating
laceration of urinary bladder during difficult instrumental
delivery
589
Prevention of VVF
1. Encourage the mother to pass
urine[empty urinary bladder] through out
the labour
2. Ensure that the bladder is empty during
second stage of labour
3. Ensure that the urinary bladder is empty
prior to instrumental deliveries

590
Management of VVF
1. Refer to hospital
2. Broad spectrum antibiotics to prevent UTIs
3. Plenty of fluids to drink at least 3000ml daily
4. Balanced diet for building up and health
body immunity
5. Iron and vitamins supplements up to
operation date
6. Repair of VVF will be performed 3 mouths
later when her health is good

591
Prognosis of VVF
1. Good if refer early as soon as it is
diagnosed and repaired by the expert
2. Changes of wound break down are high if
not well nursed post operative which
should not happen

592
ABNORMAL LABOUR

OBSTETRIC

593
Mal position[occipito posterior
position of vertex]
• Abnormal position
• It is describe by the occiput as the
denominator point to the right or left
sacro-iliac joint
• The most common is on the right sacro-
iliac joint so it is refer to as occipito
posterior position

594
Occipito posterior position
Definition;
• A mal position of the occiput when the
vertex is the presenting part but the
occiput is lying posterior to the mother
pelvis not Anteriorly
Cause;
• Unknown, but common in women with
android or anthropoid pelvis due to roomy
posterior aspect of the pelvis
595
Diagnosis of mal position
During ante natal period;
1. On abdominal examination;
a) Inspection
• A saucer shaped like depression is noticed at the
level of the umbilicus
b) On palpation;
i. Head felt at the pelvic brim, usually high and
free because presenting occipito frontal diameter
is 11.5.cm,does not usually enter the brim until
labour begin and flexion of head occur

596
ii. Occiput and sinciput are felt at the same
level because of deflexion of the head
iii. The breech is felt at the fundus
iv. The limbs are felt on both sides of the
midline
v. The back is difficult to feel as it will in the
franks

597
On auscultation;
• Fetal heart sound is heard on the aspects of the
lateral of the mother’s umbilicus or further out in
the franks
• Fetal heart may be heard widest in the midline if
the fetus is more erect, shoulders more thrown
back[military attitude]
• It is important to note, in advance labour finding
depends on;
a) Flexion of the head
b) The diagnosis made by feeling the anterior
fontanelles Anteriorly on vaginal
examination[note where the anterior and
posterior fontanelles are stationed comparing to
mother’s pelvis
c) The surgical suture which is felt running
Posteriorly toward posterior fontanelles
598
Mechanism of labour in right
occipito posterior position
1. The lie is longitudinal
2. Presentation is vertex
3. Position is right-occipito-posterior
4. Attitude is of deflexion
5. Denominator is occiput
6. The occipito frontal diameter is 11.5 cm enters into
the right oblique diameter of the pelvic brim, with
increased flexion
7. The occiput being leading parts touches the pelvic
floor first and the occipito frontal diameter is reduced
to sub occipito frontal diameter which is 10 cm

599
8.Internal rotation, the occiput rotates 3/8 of
the circle along the right of the pelvis to lie
under the symphysis pubis and it becomes
occipito anterior position[normal]
9. Crowning the saggital suture is now in
antero posterior diameter of the pelvis with
further descent, the occiput appears under
the pubic arch and parietal bones/diameter
distend the vulva orifice and head is crowned
10. Extension of head-the face and chin go
over the perineum and head is born by
extension
11.Restitution occur with head turning 1/8 of
the circle to the mother’s right side[occiput is
now lateral]
600
12. Internal rotation of the shoulder
a) Occur the same time with restitution
b) The shoulders rotate 2/8 of the circle to
change from the right to the left oblique
diameter
13.Lateral flexion with further descent, the
anterior shoulder meet resistance of the
pelvic floor and rotates to anterior of the
mother pelvis and is born under the
symphysis pubis and the posterior
shoulder passes over the perineum and
the body is born by lateral flexion
601
Clinical course of occipito posterior
labour
 First stage of labour;
a) The descent of the fetal head is slow due to poor
fitting presenting part
b) Prolonged labour due to long rotation of the
occiput to the anterior of mother’s pelvis
c) Dilatation of the cervix is slow due to badly fitting
presenting part
d) Backache is common and difficult in micturation
e) Mother feels wanting to push during early labour
because of pressure of presenting part on rectum
 Second stage of labour;
• May be prolonged depending on the pelvic outlet
space or size
602
Management of labour in OPP;
1. Manage the mother as in normal first
stage of labour
2. During second stage of labour normal
delivery is shortened by performing
episiotomy to relieve mother from
exhaustion

603
Outcome of occipito posterior
position
1. Normal labour and delivery; when the
occiput rotates 3/8 of the circle and baby is
delivery as in vertex anterior position
2. Deep transverse arrest; when long
rotation of the occiput is caught at the level
of ischial spines i.e. occipito-frontal diameter
11.5 cm can not pass between the inner
inter ischial space which measures 11 cm
leading to obstructed labour at the pelvis
outlet

604
3. Face to pubes;
a) In occipito posterior position
i. The presenting diameters are occipito-frontal
11.5 cm,biparietal diameter 9.5cm and bi-
temporal diameter 8.5cm
ii. The head descend without flexion. The occiput
failed to rotate to front, instead the sinciput
touches the pelvic floor first and rotates 1/8 of
circle under the symphysis pubes, making the
occiput to go into the hollow of the sacrum. It
becomes persistent occipito posterior position[un
reduced occipito posterior position
iii. If the fetus is average size and maternal pelvis is
adequate, the baby is delivery per vagina as
face-pubes
iv. In average pelvis with large baby, labour become
obstructed
605
4. Face Presentation; when the head get caught
in sacro-cotyloid diameter extend and it becomes
face presentation
5. Brow presentation; is when the head get
caught in sacro-cotyloid diameter and the head
becomes partially extended and Mento-vertical
diameter 13.5cm present, vaginal delivery is not
possible
 Important to note;
• Delay in second stage of labour, for more than one
hour with no advance call for doctor or refer
mother to hospital
• Vacuum extraction or CS will be performed

606
Complications or dangers of
occipito posterior position
1. To mother;
a) Perineal lacerations due to big diameter
dilating the vaginal orifice
b) Sepsis as a result of early rupture of
membranes or repeated vaginal
examinations
c) Maternal distress
d) Ruptured uterus
e) Death

607
Complications or dangers of
occipito posterior position cont……
2. To baby;
a) Asphyxia neonatorum
b) Intracranial hemorrhage
c) Cephalo-hematoma
d) Fetal distress
e) Stillbirth

608
MAL PRESENTATIONS

609
Breech presentation
 Definition
• It is when the fetus lie longitudinally in the uterus with
buttocks[breech] in the lower part of the uterus and
with the head in fundus
 Causes;
• Hydramnious
• Multiple pregnancy
• Hydrocephalus
• Grand Multiparity
• Prematurity
• Contracted pelvis
• Fibroids or ovarian cyst[abdominal or pelvis tumors
610
Types of breech presentation
 Divided according to fetal attitude as follows
1. Complete breech = fetal is attitude complete
flexion, head and legs are fully flexed
2. Incomplete breech with subtypes;
• Breech with extended legs [frank breech],legs
extended on the abdomen
• Footling presentation; rare one or both feet present
because thighs or legs are not fully flexed
• Knee presentation; rare, one thigh is extended, one
leg is flexed
• Extended arms presentation; less common than
extended legs but are now more serious
 NB; lie is longitudinal for all these breech .The
denominator is sacrum
611
Six positions of breech presentation
With sacrum as the denominator;
1. Right sacro anterior position/RSA
2. Left sacro anterior position/LSA
3. Right sacro lateral position/RSL
4. Left sacro lateral position/LSL
5. Right sacro posterior position/RSP
6. Left sacro posterior position/LSP

612
Differential diagnosis of breech
presentation
• Face presentation
• Shoulder presentation
• fibroids

613
Diagnosis of breech presentation
during pregnancy
1. History of discomfort around the ribs due
to fetal head pressing the ribs
2. Per abdominal examinations;
a) Inspection-ovoid shape
b) Palpation- large soft mass felt at the
pelvis brim and round hard movable mass
felt at the side of the fundus
c) Auscultation-fetal heard sound at or
above the umbilicus in complete breech
614
Management of breech
presentation diagnosed during
pregnancy
1. A breech diagnosed at 32 weeks and above-
refer to doctor or hospital
 Investigations; u/s reveals;
a) Singleton or multiple pregnancy
b) Size and shape of pelvis
c) Size of fetus
d) Fetal attitude note whether legs, arms or
head are extends
e) Fetal abnormalities e.g. hydrocephalus,
encephalic etc
615
2. External cephalic version, if not
contraindications
3. Continue regular ANC visit i.e. every 2
weeks up to 36 weeks of gestation and
weekly from 36 weeks up to delivery
4. In Primigravida; admit mother to hospital
at 38 weeks of gestation for constant
assessment to avoid dangers

616
Diagnosis of breech presentation
during labour
1. History of discomfort around the ribs areas
due to fetal head pressing on the ribs
a) Per abdominal examinations
• Inspection- the shape is ovoid
• Palpation-soft mass felt at pelvis brim and
movable hard mass around at one side of
the fundus
• Auscultation-fetal heart sound at or above
the umbilicus in complete breech
617
Management of breech
presentation diagnosed during
labour
• Breech involve risks to fetus and mother
that may need CS so delivery has to be
conducted in hospital with theatre
1. First stage is conducted as in cephalic
presentation
2. Carry out observation and record on
partograph

618
3. Vaginal examination must be performed on
admission, immediately after the rupture of
membrane for the following reasons;
• To exclude cord Prolaspe
• To determine the dilatation of cervical os
• To find out whether the breech is complete
or incomplete;
i. In case of complete breech a high, soft,
irregular mass presents with feet lying
alongside the buttocks. Sacrum and coccyx
may be felt. The anal sphincter grip the
examining finger [Meconium on the
examining finger confirm breech
presentation
619
ii. In case of incomplete breech-if the legs are
extended no feet are felt but external
genitalia of the fetus is easily felt and
distinguished
iii. In footling presentation, there may be doubt
whether it is Prolaspe of the arms or footling
breech. The foot may appear at the vulva
while cervix is partially dilated or
iv. If the legs are extended and fetus is small,
the breech may slip through incomplete
dilated cervix. Leading to serious danger of
fetal head being trapped by the cervix
when the fetus is partially delivered
leading to torn cervix and severe intra
partum hemorrhage
620
4. Monitor the mother carefully in order to
avoid premature pushing
5. Ensure empty bladder through out labour
6. Prepare for delivery paying emphasis to
being prepare for;
• Performing episiotomy
• Receiving asphyxiated baby

621
Breech delivery
3 types of breech delivery are;
1. Spontaneous breech delivery - little
assistant from birth attendant i.e. in
complete breech[burns Marshall
method/manoeuevre
2. Assisted breech delivery - buttocks are
born spontaneously, but assistance is
necessary for delivery of extended legs or
arms
3. Breech extraction - a manipulation carry
out by doctor to quicken delivery in
emergency to save life of fetus
622
Second stage of labour in breech
delivery
3 cardinal rules to follow during
second stage of labour;
1. Always confirm second stage of labour by
vaginal examination
2. Ensure empty bladder-pass a urine
catheter
3. Place mother in a lithotomy position at
the edge of the bed

623
Mechanism of labour in breech
delivery
• Lie is longitudinal
• Position is sacro-anterior
• Attitude is complete flexion
• Presentation is breech
• Denominator is sacrum
• Presenting part is anterior buttock
• The bitrochanteric diameter measuring 10 cm
enters in the oblique diameter of the
maternal pelvic brim with the sacrum
pointing at the left or right ilio-pectoneal
eminence
624
Mechanism of breech cont..
1. Descent takes place with increasing compaction due
to increased flexion of limbs
2. Internal rotation of the buttocks-anterior buttock
reaches the pelvic floor first and rotates 1/8 of the
circle forward along right or left side of the pelvis.
The bitrochanteric is now in the antero posterior
diameter of the pelvis outlet
3. Lateral flexion of the body-the anterior buttock
escape under the symphysis pubis, the posterior
buttock sweeps the perineum and the buttocks are
born by a movement of the lateral flexion
4. Restitution of the buttocks-the anterior buttock turns
slightly to the mother’s right side

625
Mechanism of labour in breech
cont…
5. Internal rotation of the shoulders-the shoulders[bi cranium
diameter,12cm] enter in the oblique diameter of the pelvic
brim. The anterior shoulder rotates 1/8 of the pelvic circle
along the right side of the maternal pelvis and escape under
the symphysis pubis. The posterior shoulder sweeps the
perineum and the shoulders are born
6. Internal rotation of the head-the head enters the transverse
diameter of the pelvic brim. The occiput rotates forwards
along the left side and sub occipital region[nape of the
neck]shows under the surface of symphysis pubis
7. External rotation of the body- the body turns so that the back
is upper most a movement which is accompanied by internal
rotation of the head
8. Birth of the head-the chin, face and sinciput sweep the
perineum and the head is born by flexion

626
Position for delivery
• When the buttocks are bulging place the
mother in lithotomy position with buttocks at
the edge of the bed and two pillows under
her head
• Perform vaginal examination to confirm
second stage of labour
• Clean the vulva under aseptic precautions
• Perform an episiotomy to widen perineum
• Encourage the mother to push during uterine
contractions

627
Delivery of complete breech [burns
Marshall method]
 Delivery of the body;
i. Dressed up with sterile gown, gloves and gum boot
as birth attendant[co or midwife or dr] and stand at
the foot of the bed
ii. Buttocks are expelled by unaided, bearing down
effort by the mother. The buttocks curve upwards,
the feet disengage at the vulva and with the same
contraction the baby is born as far as the umbilicus
iii. A loop of the cord is pulled down, to avoid traction
on the umbilicus-cord must be handled gentle to
avoid inducing spasm of the blood vessels
iv. Feel for the elbows at the chest where the should be
in complete flexed breech. Wait calmly for the next
uterine contraction; do not hurry the delivery of
the baby 628
Delivery of complete breech cont….
 Delivery of the shoulders;
i. The weight of the buttocks will bring the shoulders down on
to the pelvic floor, where they will rotates into the anterior
posterior diameter of the pelvic outlet
ii. Assist the expulsion of the shoulders by using pull
downward traction and encouraging the mother to push
iii. Gently grasp the baby by the iliac crests[thumbs on the
sacrum avoiding to compress the adrenal glands]
iv. When the anterior shoulder escapes, elevates the buttocks
to allow the posterior shoulder and the arm to pass over the
perineum
v. The back must not be turned uppermost, until the shoulders
have been born. In order to allow the head to descend
down through transverse diameter of the pelvis. If the back
is turned up this time the head will enter the antero
posterior diameter of the brim extended; the shoulders may
become impacted at the outlet leading to extensive perineal
tear
629
Delivery of complete breech cont….
 Delivery of the head; as soon as the shoulders
are born the baby is allow to hang by its weight
for one or two minutes, which bring the head
down to the pelvis floor on which the occiput
rotates forward
I. The back is now uppermost-gradually the neck
elongates, the hair line appears
II. With the left hand grasp the baby feet and take
it up by an arc of 180 degree until the mouth
and the nose are free at the mother’s vulva baby
being held up side down
III. Right hand guards the perineum
630
IV. Wipe the mouth and the nose with gauze
swabs to remove mucus or use another
form of mucus extractor[sucker]
V. Deliver the rest of the head by using the
right hand to deliver the vault very slowly
over 2-3 minutes to avoid sudden
compression and release of the head which
may lead to intra cranial injury
VI. Mother is encourage to breath in and out
until completion of delivery of the head
VII.Cut the cord and show the baby to the
mother, quickly place the baby in a cot or
resuscitation table according to APGAR
score
631
Delivery of the breech with
extended head [mauriceau-smell-
veit maneuver]
• If the hair line does not appear after the
baby is allowed to hang for 1-2 minutes,
that us an indication the head is extended
• Use mauriceau-smell-veit method by jaw
flexion and shoulder traction movement as
follows;

632
Method;
a) Place the baby astride your left arm
b) With the left hand middle finger on the
tongue and other two fingers on the check
bone on either side help to flex the head
c) The first two fingers of the right hand are
placed over the shoulders and the chest
when the nose and the mouth are free,
clear airway
d) Hold the legs with the fore finger between
ankles
e) The right hand deliver vault of the head
slowly

633
Delivery of breech with extended
legs
Method;
a) Pass the right hand along the thigh to the
knee joint
b) Flex the knee by pushing in the popliteal
space towards the body
c) Bending the leg sideways deliver the leg
d) Deliver second leg flexing in opposite
direction
634
Delivery of breech with extended
arms[ Lovest movement]
 Methods; it is a combination of rotation and downward
traction by;
a) Grasping the baby by pelvis with thumbs on the
sacrum
b) Apply traction downwards and the same time rotate
the body half a circle 180 degree to bring the
posterior arm to the anterior
c) Deliver the arm in front of the face to flex the arm
d) Rotate the baby half circle in opposite direction to
bring the other arm Anteriorly and delivery the arm
in front of the face to flex the arm
e) The rotation movement must be with the back
uppermost
635
Complications of breech
presentation
To the mother;
1. Injuries to the birth canal
2. Assisted instrumental delivery which
could be; forceps delivery or caesarian
section and anesthesia complications
3. Obstructed labour

636
 Complications of breech cont….
To the baby;
1. Cord Prolaspe-very common in flexed or
footling breech
2. Birth injuries which may be;
a) fracture or dislocation of baby’s
b) part, Erb’s palsy due to damage of
brachial plexus by twisting of the neck
c) Trauma to internal organs e.g. spleen
rupture during grasping of abdomen
637
d) Damage to adrenal glands
e) Damage to spinal cord as spine fracture etc
f) Intracranial hemorrhage as a result of rapid
delivery of the head with on time to mould
or due to hypoxia
g) Fetal hypoxia; result from cord Prolaspe or
premature separation of placenta or delay
delivery of head
h) Soft tissue injury; oedema and bruising of
genitalia due to prolonged cervix pressure
cutting off blood supply and footling breech
with the foot lying at the vulva and become
oedema and discolored due to cut of blood
supply
638
Cord presentation and Prolaspe
Definitions
• Cord [or funis] presentation is when the
umbilical cord lies in front of the presenting
part and the membranes intact
• Cord Prolaspe is when the umbilical cord lies
in front of the presenting part and the
membranes are ruptured
• Occult Prolaspe of the cord is the cord lies
alongside the presenting part and not in front
of the presenting part
639
Contributing factors of cord
presentation and Prolaspe
1. Mal presentations;
a) Complete breech; most common cause as
the umbilicus is so near the buttocks
b) Shoulder presentation
c) Face and brow presentation are rare
cause of the cord Prolaspe and
presentation

640
 Contributing factors cont…….
2. Contracted pelvis - the cord slip
through between the non engaged head
and pelvis
3. Polyhyramnious - the cord is likely to
be swept down with the rush down of
fluid if the membranes rupture
spontaneously
4. Multiple pregnancy - together with
hydramnious may cause the cord to
Prolaspe
641
Diagnosis and differential diagnosis
of cord presentation and Prolaspe
Diagnosis
• History from the mother
• Vaginal examination after rupture of
membranes reveals loops of cord in the birth
canal or may be seen outside the vulva
Differential diagnosis;
• Membranes
• Footling breech presentations or
compound[hand] presentation

642
Management of cord presentation
and Prolaspe
It is an important obstetric emergency if the
fetus is alive and gestation is above 28 weeks
Aims of management include;
• Remove pressure from the cord
• Maintain the cord warm
• Immediately refer the mother
• Deliver the baby as soon as possible
• Preparedness for managing asphyxiated baby

643
Management cont………
At PHC;
1. Call for help and manage as emergency
2. On vaginal examination find out the
location of the fetus and note the
dilatation of the os and whether the cord
is pulsating and firm. Listen to fetal heard
3. Management depend on the stage of
labour[cervical dilatation, mother’s pelvis
adequacy and fetal conditions]

644
Management cont…….
If the fetus is dead;
i. For multigravida rule out any
contraindications to vaginal delivery[ e.g.
Cephalo pelvic disproportion and mal
presentations and previous uterine scar]
and allow the labour to progress
ii. Psychologically counsel the mother and next
of kin about what have happened, prepare
them for receiving a dead baby
iii. In case of Primigravida refer the mother to
the hospital because you do not know the
size of her pelvis and further management
is needed 645
Management cont….
If the fetus is alive;
During the first stage of labour or in
Primigravida;
i. If the cord is outside the vulva, wash hands
and put on gloves quickly, gently wash the
cord with warm normal saline or antiseptic
solution and put it back into the vagina to
avoid the spasm of umbilical vessels
ii. Give oxygen to the mother if possible or
ensure adequate fresh air

646
Management cont…………..
During the second stage of labour;
i. Rule out Cephalo pelvic disproportion
and mal presentation
ii. If the pelvis and presentation are normal
conduct delivery as soon as possible with
the aid of episiotomy

647
iii. Psychologically support the mother and
next of kin by explaining the conditions
and what is expected from them
iv. Refer mother to the hospital with
relatives incase of blood donors to be
needed with skilled health worker and
delivery kit and resuscitation equipment
for the bay
v. Place the mother in either trendelenburg
or exaggerated sim’s position or knee
chest positions during journey
648
Management cont…….
In the hospital;
1. Urgent admission
2. Call for help from another health worker
3. On vaginal examination find out the location
of the fetus and not dilatation of the os and
whether the cord is pulsating and firm.
Listen to fetal heart sound
4. Management depend on the stage of
labour[cervical dilatation, mother’s pelvis
adequacy and fetal conditions

649
Management cont……….
• During the first stage of labour or in case of
Primigravida with fetus alive;
1. If the cord is outside the vulva wash hand
and put on gloves quickly and gently wash
cord with warm normal saline or antiseptic
solution and put it back into the vagina to
avoid the spasm of umbilical blood vessels
2. Give oxygen to mother in possible or ensure
fresh air
3. Psychological support to mother and
relatives by explaining the conditions and
what is expected from them
650
Management cont…………
4. Notify the doctor and operating theatre
about the emergency
5. Prepare the mother for CS
6. Place the mother in either trendelenburg
or exaggerated sim’s position or knee
chest positions from diagnosis until
reaching the theatre
7. Doctor perform emergency CS

651
Management cont………
If the fetus is dead;
1. In multigravida rule out the
contraindications to vaginal delivery like
Cephalo pelvic disproportions etc and allow
the labour to progress
2. Psychological support to the mother and
relatives about the conditions and prepare
them to receives a dead fetus
3. In Primigravida take patient to the theatre
for CS because pelvis size is not known
652
 If the fetus is alive;
1. Rule out Cephalo pelvic
disproportion[CPD] and mal presentation
2. If the pelvis and presentation are normal
conduct delivery as soon as possible with
the aid of episiotomy

653
Management cont…….
 Subsequent care and treatment;
1. Conduct routine post operative care
2. Counsel the mother on breastfeeding,
diet and sexual relationship
3. Provide supportive counseling if the baby
is dead

654
Complication/dangers of cord
Prolaspe
To the mother;
1. Dangers of CS
2. Sepsis
 To the baby;
1. Intra uterine hypoxia
2. Intra uterine death

655
Face presentation
Definition
• This is when the attitude of the head is in
complete extension. The denominator is
the chin or mentum
• Engaging diameters are sub Mento
bregmatic 9.5 cm and bi-temporal
diameter measuring 8.0 cm long

656
Types of face presentation
1. Primary face presentation - occur
before the onset of labour
2. Secondary face presentation - occurs
during the labour when the head extends
instead of flexing[an outcome of occipito
posterior position]

657
Contributing factors to face
presentation
1. Pendulous abdomen - common in
grandmultiparity. Buttocks lean forward and the force
of uterine contraction is directed toward the chin
causing the head to extends
2. Occipito posterior position - when the biparietal
diameter is arrested in the sacro cotyloid diameter of
the maternal pelvis causing the head to extends
3. Petypelloid pelvis - where the bi-parietal diameter
is arrested in the reduced obstetrical conjugate
causing the head to extends
4. Poly hydramnious - where the uterus is over
distended
5. Prematurity or multiple pregnancy
6. Intra uterine death - where the fetus lost muscle
tone
658
 Positions of face presentations
 Mentum is the denominator;
1. Right Mento anterior
2. Left Mento anterior
3. Right Mento lateral
4. Left Mento lateral
5. Right Mento posterior
6. Left Mento posterior

659
Diagnosis of face presentation
 It is difficult to diagnose during pregnancy
 During labour;
a) On examination per abdominal palpation;
i. High head
ii. Prominence of the head on opposite side to the limbs
iii. Groove between occiput and back
b) On examination per vagina;
i. Presenting parts feels hard and irregular
ii. Orbital ridges
iii. Mouth and gums
iv. The fetus will suck the examining finger
v. Mentum is felt
vi. Gently pull out examining fingers and avoid injuring the fetal
face structures
660
Management of first stage of labour
in face presentation
At PHC;
1. Transfer the mother to hospital as soon as diagnosed
2. Labour tend to be prolonged due to high irregular
presenting part, Therefore apply principles of taking
care for the mother with prolonged labour as follow;
a) Early diagnosis and care
b) Accelerating of labour
c) Reassessment of pain
d) Regular careful assessment of maternal and fetal
conditions and progress of labour
e) Care out nursing care as in normal labour using a
partograph

661
Management of second stage of
labour
1. Confirm second stage of labour by performing vaginal
examination
2. It is important to locate where the mentum is
If the mentum is anterior;
i. Vaginal delivery is possible
ii. Maintain extension of the head until the mentum is
delivered under symphysis pubis then allow the head to flex
to sweep the perineum
iii. Elective episiotomy is advised to assist delivery
If the mentum is posterior;
i. the head may attempt to rotate and may end into mentum
being caught into the curve of sacrum causing persistent
Mento posterior position leading to obstructed labour.
ii. The management will be emergency lower segment
caesarian section[LSCS]

662
Dangers of face presentation
To the mother;
1. Prolonged labour and its dangers
2. Obstructed labour incase of persistent
Mento posterior position
 Dangers to the baby;
1. Hypoxia as a result of prolong labour
2. Injuries to the face structure[edema of eyes
and lips]
3. Difficulty in breastfeeding as a result of
edema on face

663
Brow presentation
Definition
• This when the sinciput presents with the
area between the orbital ridges and the
anterior fontanel
• Fetal attitude is partial extension
• It caused obstructed labour, therefore it
can be born per vagina

664
Contributing factors to brow
presentations
1. Commonly occurs as secondary to
occipito posterior position during labour
2. Maternal pendulous abdomen
3. Contracted pelvis of mother
4. Polyhyramnious
5. Anencephaly
6. Spasm of muscles of the neck
7. Tumors of the neck

665
Diagnosis of brow presentation
 Commonly diagnosed during the labour;
1. History of prolonged labour
2. On abdominal examination- the head feels large and
in spite of good uterine contraction does not enter
the pelvic brim
3. On vaginal examination-the presenting part is
difficult to be felt, but as the labour progresses,
anterior fontanelle is felt on one side and the orbital
ridges on the opposite side
 Differential diagnosis of brow presentation;
1. Breech presentation
2. Face presentation
3. Hydrocephalus
4. Fibroids in lower uterine segment
666
Management of brow presentation
At PHC;
1. This obstetrical emergency[O.E], refer mother to
hospital urgently
2. Psychological support to the mother and relatives
3. Start IV fluids in case of maternal distress before
travelling
4. Give strong sedative; pethadine 100mg IM before
travelling
5. Frequent monitoring of vital signs and fetal heart
6. Organized not less than 2 strong relatives and a
health worker with all her record to accompany
mother to hospital
667
Management cont……..
At the hospital;
1. Urgent admission
2. Go through the history of the mother records from phcc
3. Not the doctor about admission and emergency
4. Notify the theatre staff
5. Take blood for hb estimation, blood group and cross
matching, not less than 2 units
6. Start IV infusion according to mother conditions
7. Pass indwelling urine catheter
8. Start prophylactic broad spectrum antibiotic prior operation
9. Doctor will perform emergency CS

668
Complication of brow presentation
and preventions
Prevention;
1. Early diagnosis and appropriate
management
 Complications;
1. Obstructed labour
2. Ruptured uterus
3. Fetal or maternal mortality

669
Shoulder presentation
Definition
• This is when the shoulder becomes the
presenting part as a result of neglected
transverse or oblique lie
Positions of shoulder presentation;
• Dorso anterior; the fetal back lie in front of
mother’s abdominal wall, the head may be
either on the right or left side
• Dorso posterior; the fetal back lie at the back
of mother’s abdominal wall, the head may
either be on left or right side
670
 Diagram of positions
Dorso anterior position-commonest

671
Contributing Factors of shoulder
presentation
 Maternal factors;
1. Grand Multiparity as a result of lax abdominal muscle
2. Pendulous abdomen
3. Polyhyramnious because the uterus is globular and
fetus can freely move around in excessive liquor
amnii
4. Bicornuate uterus when part of fetus may be down
and fetal head lying in one horn
5. Contracted pelvis
6. Placenta preavia
7. Fibroids
NB; 1, 2, and 3 prevent the head from entering the
pelvic brim
672
 Fetal factors;
1. Multiple pregnancies commonly the
second twins
2. Prematurity because liquor amnii is too
much and comparing to the size of the
baby
3. Macerated fetus lack of muscle tone
causes the fetus to fall into the lower
pole of the uterus

673
Diagnosis of shoulder presentation
during pregnancy
Per abdominal examination;
a) Inspection; abdomen appears broad and the
fundus is low comparing to period of
gestation
b) Palpation; on pelvic and fundal palpation,
fetal head and breech are not felt. The
mobile head is felt in one iliac fossa and the
breech is felt on the opposite iliac fossa
c) Auscultation; fetal heart sound is heard
below the mother’s umbilicus
674
Diagnosis of shoulder presentation
during labour cont…
 Per abdominal examination;
• if membrane ruptured irregular outline of the
uterus is noticed on inspection
 Per vaginal examination;
• If membrane are intact the presenting part is high
• If membranes are ruptured the shoulder is felt as
soft irregular mass or cord or arm may be felt or
prolapsed
• Fetal ribs and scapula may be felt lying across the
internal os if membranes are ruptured

675
Differential diagnosis of shoulder
presentation
• Multiple pregnancy
• Breech presentation
• Severe malformed fetus
Investigation;
• Ultra sound scanning will reveal the
diagnosis

676
Management of should
presentation
At primary health care center; this is an
obstetrical emergency;
1. Call for the another health worker to help
you
2. Quickly take through history
3. Take maternal vital observations
4. Listen to fetal heart

677
5. Resuscitate the mother in case of obstructed
labour before transporting the patient to
hospital
6. Counsel the mother and next of kin
explaining to them the condition and what is
expected of them
7. Give strong sedation i.e. pethadine IM or IV
prior to transporting the mother
8. Refer to hospital accompanied by not less
than 2 strong relatives for blood donation
and skilled health worker with all written
document
9. Transport the patient with IV in place

678
Management cont……….
In the hospital;
1. Admit patient as an emergency
2. Quickly read patient referral notes or
mother’s ante natal card if available or
3. Take thorough history
4. Take vital observations and records them
5. Monitor fetal heart frequently if fetus still
alive
679
6. Resuscitate the mother according to general
condition
7. Take blood for hb estimation, blood group and
cross matching
8. Notify the doctor of the emergency admission
9. Notify the surgeon
10. Continue IV infusion
11. Obtain written consent for operation either from
the patient or next of kin
12. Pass indwelling urethra catheter prior to
operation
13. Start her on broad spectrum antibiotics prior to
operation
14. Doctor will perform emergency caesarian section
680
Complications of shoulder
presentation
To the mother;
1. Obstructed labour and its complications
2. Psychological trauma
 To the baby;
1. Intra uterine hypoxia
2. Fetal distress
3. Arm and shoulder injuries
4. Intra uterine death

681
Precaution to avoid complications
1. Careful observation of mother and fetal
conditions
2. Prompt resuscitation/prevention of treat
for shock
3. Detect and prompt treat any genital
injuries
4. Keep indwelling urine catheter for at least
7 days post operative
5. Provide patient with antibiotics

682
Post partum hemorrhage[PPH]
Definition;
• PPH is a bleeding from the birth canal
after the birth of the baby until six
weeks[puerperium ] amounting to 500 ml
or more or any amount that causes
deterioration of maternal condition
Types;
• Primary post hemorrhage
• Secondary post hemorrhage
683
Primary post partum hemorrhage
• The bleeding from the birth canal after the birth of
the baby within the first 24 hours after delivery
Factors predisposing;
1. Uterine Atony contributed either by;
a) Retained pieces of placenta and membrane
b) Prolonged labour
c) Over distended uterus e.g. Polyhyramnious or
multiple pregnancy
d) Full urinary bladder
e) Grand Multiparity
f) Anesthetics
684
Predisposing factor to PPPH
cont…..
2. Incomplete separation of the placenta
3. Trauma to the genital tract[vaginal, cervical
or uterine]
4. Bleeding disorders
5. Ante partum hemorrhage[placenta abruptio
or preavia]
6. Ruptured uterus
7. Precipitate labour
8. Fibroids
9. Mismanagement of third stage of labour
685
Diagnosis of Primary PPH
1. Direct observation of excessive vaginal
bleeding
2. Signs of shock i.e. rapid pulse, low BP
3. General condition of the mother

686
Management of primary PPH
1. Massage uterus to stimulate uterine
contractions
2. Put baby on breast[nipple-to stimulate
oxytocic reflex]
3. Ensure empty urinary bladder
4. Repeat the dose of IV ergometrine or any
available oxytocic
5. Take blood for grouping and cross matching
6. Put up IV infusion preferably normal saline
7. If placenta is still inside check if separated-
deliver placenta by controlled cord traction
687
Management of primary PPH
cont…….
8. If placenta is delivered and PPH persists;
a) Ensure the uterus is well contracted
b) Examine the birth canal to exclude
traumatic causes e.g. perineal tear or
vaginal tear or episiotomy and refer it
c) Exclude uterine rupture and manage
appropriately
9. Refer the mother to hospital after
resuscitation and condition has improved
688
 Management of PPPH cont……
In hospital;
10.Test blood for clotting time. If more than 7
minutes it indicates disseminated
intravascular coagulation[DIC] so;
• Keep patient warm
• Give fresh whole blood or fresh frozen
plasma
• Give platelets concentrate
The above drugs are ordered by doctor

689
Secondary PPH
Definition
• Excessive blood loss through the genital
tract after 24 hours to sixth weeks of
puerperium after the delivery of the baby
• Bleeding may take place from 24 hours to
sixth weeks after delivery of the baby but
commonly the 10th and 14th days

690
 Causes of secondary PPH
1. Retained pieces of membranes of placenta
2. Puerperal sepsis
3. Prolong rupture of membranes
4. Prolong labour
5. Shedding of dead tissues following
obstructed labour, or breakdown of a uterine
wound after CS
6. Bleeding disorders[poor clotting time]

691
 Diagnosis of secondary PPH
1. History of persistent red lochia, fever, offensive
vaginal discharge
2. Direct observation of excessive vaginal bleeding
3. Signs and symptoms of shock;
a) Pallor of mucous membrane and skin
b) Rapid pulse rate above 100 beat per minutes
c) Low blood pressure[diastolic pressure of 50
mmHg or below]
d) Cold clammy skin
e) Dizziness
f) Thirst
g) Oliguria
692
Diagnosis of secondary PPH cont….
4. On abdominal palpation uterus is bulky
and well contracted and tenderness
5. On vaginal examination, there is offensive
vaginal bleeding or discharge from the
cervical os. Pieces of placenta or
membranes may seen on speculum
inspection

693
 Laboratory investigations
1. Hemoglobin estimation
2. Blood grouping and cross matching
3. Blood for clotting time, prothrombin time,
thromboplastin and platelets count
4. White blood count-full hemogram
5. High vaginal swab for culture and
sensitivity

694
 Management of secondary PPH
1. Resuscitation with IV fluid
2. Give oxytocic drug if you have ruled out
rupture of uterine wound
3. Give broad spectrum antibiotic
4. Explain to the patient and family
members of what has happen and what
is expected from them
5. Refer mother and baby to hospital
695
 Management of secondary PPH
In hospital; cont….
1. Inform the doctor immediately
2. If anemia is severe[hb level less than 6mgs] blood
transfusion is given and provide iron with folic acid.
Ask relatives to provides high protein diet
3. Continues with broad spectrum antibiotic
4. Oxytocic drugs
5. Repairs of lacerations if present, Laparotomy is
performed in case of suspected ruptured uterus
6. If the cervix is dilated, remove clots and pieces of
placenta or membranes
7. If the cervix is not dilated, evacuation is done under
general anesthetic after infection has subsided
8. Nursing care as for other ill patient and according to
doctor’s order
696
Multiple pregnancy
Definition
• A pregnancy of more than one fetus
• Twin is the commonest form of multiple
pregnancy
• Others are triplets, quadeplets etc

697
Types of twins
• Monozygotic or uni-ovular/identical twins
• Dizygotic or binocular/not identical twins
Monozygotic twins;
• Develop from one ovum and one spermatozoa
• Two amniotic sacs, one placenta and commonly
one chorionic membrane, but rarely 2 chorionic
membrane are found
• Same sex, similar palm and finger print
NB;There is high incidence of error in tissue
development and malformation which give rise to
abnormal fetus resulting form abnormal division of
the fertilized ovum forming co-joined or Siamese
twins
698
Dizygotic twins
• Develop from two ova and two spermatozoa
• Two placentae which may be joined to form
one, two amniotic fluid sacs and two chorion
• May be of same sex, but mostly different
• Do not resemble, with different palm and
finger print
NB;Fetus papyraccous is when one fetus dies
in uterus, it is flat appearing either of the
types of twin

699
Diagnosis of twin pregnancy
1. History of twins in mother or father family
or previous twin pregnancy
2. History of feeling heavy and over
burdened
3. Abdominal examination
a) On inspection;
• Large size of abdomen than the expected
period of gestation especially after 20 weeks
• Round and broad shape of abdomen
• Fetal movement seen over wide area
700
b) On palpation;
• High fundal height than expected period of
gestation
• Two fetal pole[head or breech] felt in the fundus
of uterus and many fetal limbs
• Size of head is felt small compare to the height of
fundus
• On lateral palpation two fetal back or limbs felt on
both sides
c) On auscultation;
• Two fetal heart heard
• If listen to at the same time by two difference
health workers, the rate will be of a difference of
at least 10 beats per minutes
4. Diagnosis is confirmed by ultra sound scan
701
Differential diagnosis of multiple
pregnancy
• Large single baby
• Wrong date of amenorrhea
• Polyhyramnious
• Obesity of the mother
• Hydrocephalus
• Uterine or ovarian masses

702
Effect of twin pregnancy
1. Exaggerated minor disorders of
pregnancy; Morning sickness, Heart
burns etc because of higher level of
circulating hormones
2. Anemia; as a result of iron and folic acid
deficiency due to early development and
growth of the uterus and fetal demand
3. Pregnancy induced hypertension; due to
increased hormone and fetal demand
703
4. Polyhyramnious due to high demand for
accommodating two fetuses. Dangerous
because it add more discomfort. Acute
hydramnious around 20 weeks can lead
to abortion
5. Pressure symptoms including; increased
weight and size of uterus and its content
lead to discomfort causing;
• Impair venous return from the lower
limbs leading edema and varicose veins
• Large uterus pushing on the diaphragm
and lungs leading to breathlessness
704
Management of twin pregnancy
1. Close antenatal care, every two weeks
2. Prevention of anemia by;
a) Hemoglobin estimation at monthly intervals
b) Advise mothers to eat food reach in protein,
iron, folic acid, vitamin and calcium
c) Prescription of iron, folic acid and vitamin
tablets
d) Providing fansidar and TT during second
trimester T2
705
3. Urinalysis for protein, sugar and acetone
4. Measuring mother body weight and
examining for edema to exclude pre-
eclampsia at 2 weeks intervals
5. Admission of mothers to hospital or phcc for
rest between 30-32 weeks of pregnancy to
prevent premature labour and for observation
for anemia and pre-eclampsia
6. Counsel the husband, relatives or next of kin
to accept the twins or more babies and
support the mother
7. Refer any mother with danger
signs[complications] to hospital
706
Reasons for referral or admission to
hospital
1. For rest; between 30-32 weeks
2. Bed rest and accessibility to essential obstetric
care[EOC]; 38 weeks and above
3. Lack of access to emergency transport
4. Polyhyramnious
5. Preterm labour
6. Moderate or severe anemia at any trimester
7. Ante partum hemorrhage
8. Hypertension
9. Protienuira
10. Poor past obstetric history
11. Malpresentations of the first twin
707
Management of labour in twin
delivery
First stage of labour;
1. Manage as in singleton using partograph
2. Allow the mother to use the position she
find comfortable
3. Ensure comfortable position to avoid supine
hypotension
4. Listen to the fetal heart of both fetus and
record in partograph
5. Ensure empty urinary bladder by
encouraging mother to pass urine hourly

708
Second stage of labour;
1. Confirm the second stage by performing VE
2. Be prepare to receive weak babies
3. Monitor fetal heart after each uterine contraction
4. Conduct second stage of labour for first twin as
in singleton labour
5. When the first twin is born, note the time, sex
and immediately label twin one
6. Hand the baby to the mother and put on breast
to suck if baby condition is good
7. After the delivery of the first twin, immediately
perform abdominal examination to find out the
lie, presenting part and position of the second
twin

709
a) If the lie is longitudinal, do v.e to confirm the
presentation, with the next contraction as the mother
to push and perform delivery as in singleton
b) If the lie is not longitudinal, correct it by external
cephalic version and proceed with delivery
8. Listen to fetal heart
9. Second twin must be born within 30 minutes after the
birth of the first twin
10. Membrane are ruptured and if uterine activity does
not, start IV Syntocinon may be use to stimulated it
11. When presenting part is visible mother is encourage
to push
12. Delivery will proceed as normal according to the
presentation

710
a) If vertex presentation, conduct normal
vaginal delivery
b) If breech presentation, conduct breech
delivery
13. Oxytocic drug is given IM or IV at the birth
of the anterior shoulder of the second twin
14. When the second twin is born, note the
time, sex and immediately as twin two
15. Hand the baby to the mother and put on
breast to suck if the baby condition is good
16. After the delivery of the second twin,
prepare for the delivery of placenta, once
oxytocin drug given take effect, then
conduct third stage of labour as in singleton
preferably wing cord control traction[CCT]
711
17. Placentae are thoroughly examine and
number of amniotic sacs, chorion and
placentae are noted
18. Umbilical cord vessels and presence of any
abnormalities are noted
19. Measure all the blood loss and ensure well
contracted uterus
Management of fourth stage of labour;
1. Manage as in singleton with emphasis on;
a) BP, temperature, pulse and respiration as
sudden release of fetuses, liqour amnii and
placenta may cause colapse
b) Fundus for tony due to over stretched
uterine muscle during pregnancy and labour
712
2. Ensure enough rest for mother
3. Monitor babies conditions with emphasis
on;
a) Breathing and color
b) Umbilical cord stamp for bleeding
c) Placing babies on breast to suckle and
initiate lactations
d) Ensure enough warm to avoid
hypothermia

713
Complications associated with
multiple pregnancy
• Abortion
• Preterm labour
• Polyhyramnious
• Fetal abnormality more common in
monozygotic twins e.g. co-joined twin
• Malpresentations
• Premature rupture of membrane
• Prolaspe of cord

714
• Prolonged labour
• Locked twins
• Delay in the birth of second twin
• Premature expulsion of the placenta
• Post partum hemorrhage
• Undiagnosed twin

715
Contracted pelvis
Introduction
• It is important to diagnose contracted pelvis
in early pregnancy
• This a pelvis with one or more measurement
of at least 1 cm less than the normal
Effects on labour;
1. Make vaginal delivery of normal size fetus
difficult or impossible
2. Make prolonged or obstructed labour
3. Result in damage to mother and child
716
Causes of contracted pelvis
1. Abnormal shaped pelvis e.g. android pelvis,
anthropoid and Platepelloid pelvis
2. Justo minor pelvis in which all diameters are
reduced but in proportion found in short woman less
than 150 cm, occasional it can be found in woman of
average height
3. Dietary deficiency of mineral needed for the
formation of bones in childhood e.g. calcium,
phosphorous and vitamin d
4. Naegele and Robert ‘s pelvis;
a) Result due to failure in development;
i. In Naegele pelvis one ala of sacrum is missing and
sacrum is fused to ilium
ii. Robert, two sacral ala are missing and sacrum fused
to ilium
717
5. Diseases or condition in early
childhood;
a) Rickets
b) Poliomyelitis
c) Bovine tuberculosis leading to scoliosis
lateral curvature
d) Fractures of the pelvis and lower limbs
e) Carrying heavy load during early
childhood disable the development of
bones by transmitting weight on growing
bones of the pelvis and lower limbs

718
Diagnosis of contracted pelvis
1. Observation; noting the woman statue
a) Short woman, measuring less than
150cm
b) Walk with arms hanging or abnormal
giant
2. Medical history of injury or disease
involving the spine and pelvis

719
Prolonged First Stage Of
Labour
Definition
• This is when the first stage of labour lasts
for 12 hours or more without delivery
• More common in Primigravida because the
birth canal is undergoing mechanisms of
labour for the first time, but it may also
occur in multigravida

720
Factors causing prolonged first
stage of labour
1. Passenger;
a) Mal position
b) Mal presentations
c) Big baby[fetus]
d) Congenital abnormalities
2. Passages;
a) Abnormal size or shape of uterus
b) Diseases/injury to the pelvis
c) Congenital abnormalities of pelvis
d) Rigid pelvis

721
3. Powers;
a) Hypotonic uterine contractions[inertia] or weak
and irregular and infrequent.
b) Hypertonic uterine contraction usually happened
in obstructed labour.
• It is associated with uncoordinated uterine
action. The upper segment contract strongly and
there is little relaxation between pain and
contractions.
• Last longer than in normal labour. The pain is
continuous
• The cervix is dilating very slowly compare to the
strength of the uterine contraction and their
frequency. There is delay of presenting part
a) Uncoordinated uterine contractions are referred
to ineffective uterine contractions
722
Diagnosis of prolong first stage of
labour[PFSL]
• It is made when the mother get 2 or more
regular uterine contractions every 10
minutes for 8 hours and cervical dilatation
is less than 3 cm
Differential diagnosis;
1. False labour
2. Urinary tract infection=UTI
3. Malaria
723
Immediate treatment of PFSL
a) Give therapeutic test of 1g paracentamol
b) Reexamine her within 4 hours if the;
i. Contractions have stopped, the diagnosis is false
labour, allow the mother to rest for 24 hours
ii. Then discharge her if no risk factors, counsel her
to come back when the labour starts
iii. If the risk factors are present i.e. post dates,
Oligohydramnious refer her to hospital
iv. If contraction persist re-examine her to see if the
labour is progressing as shown by the additional
cervical dilatation more than 3cm and strong
uterine action
724
Immediate treatment of PFSL
cont…….
v. This woman will proceed to active phase
and go through normal second stage of
labour and normal third stage of labour
vi. Carefully carry out monitoring of labour
and recording each finding on her
partograph
vii. If uterine contractions remain mild refer
her to hospital or inform the doctor if in
hospital

725
Management in active phase of first
stage of labour
• Principles which must be followed while
caring for a mother with prolonged first stage
of labour;
i. Early diagnosis by health worker and refer
the mother to the hospital
ii. Acceleration of labour is strictly done by
doctor or clinical officer
iii. Re-assessment of pain
iv. General nursing care by the midwife
v. Thorough observations

726
Diagnosis
1. Diagnosis of prolong active phase of
labour is made basing on finding from
vaginal examinations to assesses
progress of labour and rate of the
cervical dilatation
2. In prolonged active phase, the plotting of
cervical dilatation crosses to the right of
the alert line

727
Immediate and emergency
treatment of prolonged active first
stage of labour
a) If the plotting of cervical dilatation crosses over
the right of the alert line and mother is in PHC,
transfer her to hospital unless there is a sign of
delivery soon
b) In the hospital mother is put under strict doctor
care;
i. Thorough evaluation to differentiate obstructed
labour from ineffective uterine action and
exclude mal position or mal presentation. If no
abnormalities detected doctor will rupture the
membranes
728
ii. Intravenous fluid 5% dextrose administered
iii. Cauterization to empty bladder
iv. Oxytocin if uterine contractions are in adequate
v. Continue monitoring of labour
 If the plotting of cervical dilatation does not cross
over to the right side of alert line continue as
follow
1. Provision of comfort;
a) Allow the mother to adopt the position she finds
comfortable
b) Take care of her general hygiene by encouraging
her to bath ,clean her teeth and her soiled vulva
pad and linen especially in case of ruptured
membranes
729
c) Provide analgesic to help her sleep
d) Ensure empty bladder
e) Emotional and psychological support to
explain to the mother and her next of kin
what is happening and what is needed from
them
2. Continue with carrying out thorough
observations and record them on the
partograph to early detect any
abnormality/danger
a) Mother‘s condition;
i. Temperature 4 hourly to exclude pyrexia
which may suggest infection in early rupture
of membranes
730
i. Pulse, respiration and blood pressure taken
hourly as rapid pulse rate and changes in
respirations suggest maternal distress
ii. Every urine pass must be recorded on
partograph and specimen test for
acetone[ketonuria] if presence put mother on
dextrose 5%
b) Assess the progress of labour as follows;
i. Vaginal examination hourly to note;
• Increased cervical dilatation and application of
cervix to the presenting part
• Descent of the head and presenting part
• Color of the draining liquor amnii-if Meconium
stained indicates fetus is in trouble[distress] and
must be reported to doctor

731
c) Fetal conditions;
• Auscultation of the heart sound, above
160 beat per minutes or drop to 100 and
below is a sign of hypoxia/distress and
should be reported to the doctor
immediately
• Any change in fetal heart rhythm is a
sign of fetal distress and urgent action is
required

732
Expected outcome of prolonged
first stage of labour
1. Vaginal delivery - after PFSL with increasing contraction
and cervical dilatation, labour will come to normal second
stage of labour, provided the mother and fetal conditions
remain normal with no contraindications to vaginal delivery.
Third stage will be normal and you must conduct active
management of labour
2. Assisted instrumental delivery;
a) In case of maternal distress;
i. It is immediately report to the doctor;
• During first stage of labour CS will be done
• In case of second stage resuscitate the mother with IV fluid
dextrose 5% follow by forceps delivery
• Oxytocin must be given during third stage of labour to
prevent PPH

733
b) In case of fetal distress
• CS is done and skilled health worker must
be present to resuscitate the baby

734
Dangers/complications of
prolonged first stage of labour
To the mother;
1. Early rupture of membranes leading to puerperal
Infection
2. Maternal distress leading to dehydration and
acetonuria. Ketonuria
3. Risks of assisted delivery/instrumental deliveries
4. PPH leading to shock
To the baby;
1. Fetal distress and its complications
2. Excessive moulding leading to brain damage
3. APGAR score below 4 or below
4. Intra uterine death
5. Peri natal death 735
Cephalo pelvic disproportion
 Definition
• This when the fetal head is too big for the
maternal pelvis
 Types of CPD;
1. Justo minor disproportion
2. Major disproportion
 Contributing factors to CPD;
a) Fetus may be large in relation to maternal pelvic
size or
b) The pelvis is small or contracted
 Effect on labour;
• Head will not engage/go through the pelvis brim
736
Diagnosis of CPD
1. Ante natal period;
a) Short mother below 150 cm tall
b) Lame or physical disability especially of lower or pelvis
c) Shoes size less than 4
d) Previous history of prolonged labour
e) Previous history of assisted deliveries, fresh stillbirth and
perinatal/neonatal death
f) On abdominal palpation the head or presenting part is
high[high head] overlapping of head over symphysis pubis
g) Contracted pelvis detected on clinical pelvic assessment
h) X-ray pelvimetry or US will reveal the size of the pelvis
2. labour;
• Partograph reading will show poor or no progress of first
stage of labour

737
Differential diagnosis
There are condition which also interfere
with the descending of presenting part;
1. Pelvic tumours[ovarian cyst or fibroid]
2. Placenta preavia occupying lower uterine
segment
3. hydrocephalus

738
Management of CPD
 Ante natal period;
• On inspecting Cephalo pelvic disproportion from the
history taking and clinical pelvic assessment using
ultra sound;
a) Explain findings and importance of going to hospital,
to the mother and husband/ next of kin
b) Refer the mother to hospital
In hospital;
• According to the degree of CPD, doctor will decide on
whether to use;
1. Trail of labour in Justo minor disproportion or
2. CS in major CPD on failure of trail of labour

739
Complications of CPD
To the mother;
1. Obstructed labour
2. Vesico vaginal fistula or recto-vaginal fistula in
especially in Primigravida
3. Ruptured uterus in case of multigravida
4. Death
To the fetus;
1. Hypoxia
2. Intra uterine death[IUD]
3. Inter cranial damage
4. Peri natal death
740
 Prevention of CPD
1. Ante natal period;
a) Early detection of high risk factors
contributing to Cephalo pelvic disproportion
b) Early referral of the mother to hospital
2. During labour;
a) Careful use of partograph to ensure early
detection of CPD
b) Early referral of the mother to hospital

741
Trail of labour
Definition
• Also known as trail of vaginal delivery
• It is a test to see if in the presence of good
uterine action the fetal head will flex and
mould sufficiently to pass through the birth
canal
Indication;
• Minor Cephalopelvic disproportion
• Aim; to ensure a live mother and baby who
have sustained minimal trauma
742
Contra indications of trail of labour
1. Elderly Primigravida
2. Where Maternal illness complicates
pregnancy
3. Where a previous trail of labour failed
4. malpresentations

743
The successful outcome of trail of
labour will depends on;
1. Effectiveness of the uterine contractions
2. The ‘give’ of the pelvic joints
3. The degree of moulding
4. Flexion of the fetal head

744
Management of the trail of labour
Allow mother to go to term to start
spontaneous labour, but not beyond term
because of hard post term head which
may not mould
On admission;
1. Welcome the mother to labour ward
2. Baseline observations and recording
which include; T, P , BP, urinalysis and
oedema
745
 Obstetric;
1. Abdominal examination- lie, presentation,
level of head in relation to maternal
pelvic brim [engagement] and fetal heart
2. Onset of labour if spontaneous labour or
assisting doctor if labour is induced
3. Frequency, strength and length of uterine
contraction

746
 First stage of labour; labour is likely to be
prolonged and difficult therefore
observations are vital to assess progress
of labour and early detect signs of
obstructed labour; observation include;
1. Assessment of mother’s general
condition;
a) Temperature 4 hourly
b) Pulse and blood pressure half hourly
c) Intake intravenous infusion as risk to
general anesthetic

747
d) Output/ urinalysis
e) Anti acids for high risk mothers
f) Observe carefully for signs of maternal
distress;
 Ketonuria
 Raised body temperature
 Morale dropping
 Raised blood pressure
 vomiting

748
2. Assessment of obstetrical condition;
a) Examining the mother per abdomen;
 Observe and record uterine contraction
frequency, length and strength with
emphasis of noting abnormal contractions
 Listen to fetal heart and record rate,
strength and rhythm every 15 minutes to
early detect fetal distress
 Palpate for the descent of the head every
four hours to assess the progress of
labour

749
b) Examination per vagina every 4 hours
noting the following;
 Effacement of and dilatation of the cervix to
assess progress of labour
 Descent of the head to assess labour
progress
 Presentation/position to check whether they
are both normal
 Caput/moulding to exclude if the are
excessive it indicates difficult labour that is
not progressing normally
 Color of the liquor amnii help to diagnose
fetal distress

750
 Length of labour; depends on;
a) Maternal condition remains good
b) Fetal conditions remains good
c) Steady descent of head
d) Steady effacement and dilatation of the cervix
 Progress of labour;
a) Labour is often prolonged because of high
presenting part, health worker must be careful to
check that labour does not become obstructed
b) If the labour often requires acceleration with
intravenous Syntocinon 10 units in 500 ml of 5%
dextrose under strict control/ observation

751
Pain relief; requires effective drugs e.g.
pethadine 100 mg together with phenergan
25 mg IM but not near to delivery as it
depresses as the fetus
 general nursing care
1. Position – allow the mother to lie in position
she finds comfortable
2. Taking care of the skin, hair and oral
hygiene
3. Emotional – counsel the mother and next of
kin on progress about the situation, involve
the relatives in decision making, discuss the
possibilities of caesarian section and assist
to see labour positively
752
Outcome of trail of labour
1. If the maternal and fetal conditions remain
normal and steady progress is noted then vaginal
delivery is possible. It may need to be assisted
with forceps or vacuum extraction and care is
taken to prevent PPH if long and difficult labour
2. If the maternal and fetal conditions deteriorates
or if there is lack of progress of labour, caesarian
section will be performed
3. In both types of delivery a doctors should be
present for resuscitation
4. Birth of the first baby hypoxia/ birth truama

753
Obstructed labour
Definition
• It is when there is no advance of the
presenting part in spite of strong uterine
contraction

754
Causes of obstructed labour
1. Cephalo pelvic disproportion, due to;
a) Large baby in relation to maternal pelvis size
b) Large babies of diabetes mother
c) Contracted pelvis
2. Deep transverse arrest; an outcome of
occipito posterior position, head is arrested at the
pelvis outlet by the prominent ischial spines
3. Fetal abnormalities;
a) Hydrocephalus
b) Conjoined twins, but rare cause
4. Locked twins rare cause
755
5. Malpresentations;
a) Shoulder or brow
b) Persistent Mento posterior position of
face presentation
6. Pelvic tumors;
a) Cervical fibroids-rare incidence
b) Ovarian tumors
c) Tumors of bony pelvis
Location of obstructed labour;
1. At the pelvic brim, commonest site
2. At the pelvic outlet
756
Signs of obstructed labour
 Early signs;
1. Non engagement of the presenting part in spite of
good uterine contractions
2. Slow dilatation of cervix
3. Cervix feels not well applied to the presenting part, it
hang loosely like empty sleeve
4. Early rupture of membranes
 Late signs;
• These are known as signs of impending rupture of
the uterus
• The occur in poorly or neglected obstructed labour as
follows

757
 Late Signs of obstructed labour
On examination;
1. General conditions;
a) Severe abdominal pain and mother appear distress and
anxious for help
b) Raised body temperature
c) Rapid pulse rate
d) May be vomiting with signs of dehydration
2. Abdominal examination;
a) Uterus appear molded around the fetus on inspection
b) No descent of presenting part, the presenting part is high/
not engaged
c) On palpation, uterine contractions are stronger and
continues known as hypertonic uterine contraction

758
Hypertonic Uterine Contraction
• In case of Primigravida, contraction will stops
• In multiparous hypertonic uterine contractions
continue and Bundi’s ring which is oblique line is
seen above the symphysis pubis between the
junction of upper and lower uterine segment
indicating that the uterus is likely to rupture any
time
Examination per vagina;
a) No descent of presenting part
b) Vaginal feel hot and dry
c) No further dilatation of the cervix
d) Cervix hang loosely[not applied to the presenting
part]
e) Excessive moulding +++ and caput +++
759
Management of obstructed labour
At PHC;
1. Carefully take the history of pregnancy and
labour including details and treatment given
before arrival at the health center
2. Careful observation of;
i. General condition, assessing degree of shock,
infection etc
ii. The presenting, position, fetal heart rate and
station of the presenting part and signs of
impending rupture of uterus
iii. IV infusion with normal saline, amount depend
on mother ‘s condition
760
3. IM pethadine 50-100 mg before travelling
4. Broad spectrum antibiotic, started immediately
5. Empty the urinary bladder and leave catheter in
situ
6. Psychological support by explaining to the
mother and what is expected
7. Refer the mother to hospital after resuscitation
8. Arrange for strong relatives and one health
worker with all records to accompany the mother
to the hospital
In hospital;
• Take blood for grouping, cross matching and hb
estimation
• CS section can be done
761
Complications of obstruction
To the mother;
1. Intra uterine infection resulting from prolong rupture of
membrane
2. Trauma to urinary bladder as a result of prolonged pressure
from fetal head which may lead to Vesico vaginal fistula[
VVF]
3. Ruptured uterus
4. Shock as a result of pain and hemorrhage
5. Death as a result of hemorrhage and shock
To the fetus;
1. Intra uterine hypoxia
2. Permanent brain damage
3. Intra cranial hemorrhage
4. Ascending infection may cause neonatal pneumonia due to
Meconium aspiration
762
OBSTETRICAL EMERGENCIES

763
Ruptured uterus
Definition
• A tear of the uterine wall
• It may be;
1. complete- the tear right through the uterine
wall and the fetus is in abdominal cavity
2. incomplete- the tear of muscle layer but the
peritoneum is intact
 Causes;
1. Obstructed labour
2. Previous uterine scar which may be of CS,
hystrotomy or myomectomy
764
3. Grand Multiparity
4. Excessive or inappropriate use of oxytocic
drug
5. Use of traditional herbal oxytocic by
untrained attendants
6. Cervical lacerations extended upward
may be spontaneous or from
instrumental deliveries
7. Injuries to the abdomen

765
Diagnosis of ruptured uterus
1. History of prolonged labour with continuous
painful contraction after which there was
feeling of tearing followed by cessation of
pain
2. On examination
a) Early signs include;
• Rapid maternal pulse rate
• Tenderness over existing scar
• Abnormal fetal heart sound either too slow
or too fast
• Bleeding per vagina

766
b) Late signs;
A. Per abdominal examination;
i. Abdomen appear distended on inspection
ii.Severe pain and tenderness
iii.
Fetal parts are easily palpated
iv.Uterus is palpated as separate mass from
fetus
v. No fetal heard sound heard
B. Bleeding per vagina

767
C. Mother present with signs of shock
including;
i. Thin thready pulse
ii. Fast respirations
iii. Pallor of the skin and mucous membrane
iv. Restlessness
v. Faint/collapse

768
Management of ruptured uterus
Principles of managing a patient with
ruptured uterus are;
1. Resuscitation with IV infusion of normal
saline or ringer lactate
2. Broad spectrum antibiotic therapy started
3. Blood transfusion
4. Laparotomy performed

769
At PHCC;
1. Resuscitate the patient with IV fluid before
transportation
2. Urgently arrange for transport
3. Give strong sedative e.g. IM morphine
4. Monitor maternal vital observation every 15
minutes
5. Counsel the patient and relatives on what
happen and what is expected from them
6. Start broad spectrum antibiotic prior to
transport
7. Patient must be accompanied by 3 relatives
and one health worker with all records
770
In hospital;
1. Emergency admission
2. Quickly take through history
3. Take vital observation and records
4. Notify the doctor
5. Organized blood donors, grouping and
cross matching
6. Notify the theatre staff about the
emergency

771
7. Obtain written consent form
8. Start of continue with broad spectrum
antibiotic prior to operation
9. Laparotomy is performed and doctor
decide to repair the tear or not according
to;
• Severe ruptures uterus with presence of
infection-hysterectomy will be done
• Incomplete rupture with no infection
repair of the uterus and tubal ligation is
done
772
Post natal care in ruptured uterus
1. Carry out routine post natal care as in CS
2. Counsel the mother on fertility with partner
3. Carry out observation to early detect further
complications including;
a) Peritonitis
b) Vesico vaginal fistula
c) Psychological disorders because mother is
grieved over the loss of her baby

773
Dangers of ruptured uterus
1. Internal hemorrhage
2. Severe shock that can lead to maternal death
3. Severe infection leading to peritonitis and septicemia
4. Injury to the urinary bladder leading to Vesico
vaginal fistula[VVF] or incontinence of urine
5. Fetal death
Advice on discharge;
• To come back for check up after six weeks
• If the uterus was not removed;
a. Counsel the mother and her partner on future fertility
b. Counsel for elective CS with subsequent pregnancy
• Advice on diet

774
Cord presentation and Prolaspe
Definitions
• Cord [or funis] presentation is when the
umbilical cord lies in front of the presenting
part and the membranes intact
• Cord Prolaspe is when the umbilical cord lies
in front of the presenting part and the
membranes are ruptured
• Occult Prolaspe of the cord is the cord lies
alongside the presenting part and not in front
of the presenting part
775
Contributing factors of cord
presentation and Prolaspe
1. Mal presentations;
a) Complete breech; most common cause as
the umbilicus is so near the buttocks
b) Shoulder presentation
c) Face and brow presentation are rare
cause of the cord Prolaspe and
presentation

776
2. Contracted pelvis-the cord slip through
between the non engaged head and
pelvis
3. Polyhyramnious-the cord is likely to be
swept down with the rush down of fluid if
the membranes rupture spontaneously
4. Multiple pregnancy together with
hydramnious may cause the cord to
Prolaspe

777
Diagnosis and differential diagnosis
of cord presentation and Prolaspe
• History from the mother
• Vaginal examination after rupture of
membranes reveals loops of cord in the
birth canal or may be seen outside the
vulva
Differential diagnosis;
• Membranes
• Footling breech presentations or
compound[hand] presentation
778
Management of cord presentation
and Prolaspe
• It is an important obstetric emergency if the
fetus is alive and gestation is above 28 weeks
Aims of management include;
1. Remove pressure from the cord
2. Maintain the cord warm
3. Immediately refer the mother
4. Deliver the baby as soon as possible
5. Preparedness for managing asphyxiated
baby

779
At PHC;
1. Call for help and manage as emergency
2. On vaginal examination find out the
location of the fetus and note the
dilatation of the os and whether the cord
is pulsating and firm. Listen to fetal heard
3. Management depend on the stage of
labour[cervical dilatation, mother’s pelvis
adequacy and fetal conditions]

780
If the fetus is dead;
i. For multigravida rule out any
contraindications to vaginal delivery[ e.g.
Cephalo pelvic disproportion and mal
presentations and previous uterine scar]
and allow the labour to progress
ii. Psychologically counsel the mother and next
of kin about what have happened, prepare
them for receiving a dead baby
iii. In case of Primigravida refer the mother to
the hospital because you do not know the
size of her pelvis and further management
is needed
781
 If the fetus is alive;
During the first stage of labour or in Primigravida;
i. If the cord is outside the vulva, wash hands and put on
gloves quickly, gently wash the cord with warm normal
saline or antiseptic solution and put it back into the
vagina to avoid the spasm of umbilical vessels
ii. Give oxygen to the mother if possible or ensure
adequate fresh air
iii. Psychologically support the mother and next of kin by
explaining the conditions and what is expected from
them
iv. Refer mother to the hospital with relatives incase of
blood donors to be needed with skilled health worker
and delivery kit and resuscitation equipment for the
bay
v. Place the mother in either trendelenburg or
exaggerated sim’s position or knee chest positions
during journey
782
 During the second stage of labour;
i. Rule out Cephalo pelvic disproportion
and mal presentation
ii. If the pelvis and presentation are normal
conduct delivery as soon as possible with
the aid of episiotomy

783
In the hospital;
1. Urgent admission
2. Call for help from another health worker
3. On vaginal examination find out the
location of the fetus and not dilatation of
the os and whether the cord is pulsating
and firm. Listen to fetal heart sound
4. Management depend on the stage of
labour[cervical dilatation, mother’s pelvis
adequacy and fetal conditions

784
During the first stage of labour or in case of
Primigravida with fetus alive;
1. If the cord is outside the vulva wash hand
and put on gloves quickly and gently wash
cord with warm normal saline or antiseptic
solution and put it back into the vagina to
avoid the spasm of umbilical blood vessels
2. Give oxygen to mother in possible or ensure
fresh air
3. Psychological support to mother and
relatives by explaining the conditions and
what is expected from them 785
4. Notify the doctor and operating theatre
about the emergency
5. Prepare the mother for CS
6. Place the mother in either trendelenburg
or exaggerated sim’s position or knee
chest positions from diagnosis until
reaching the theatre
7. Doctor perform emergency CS

786
 Management of cord prolapse in
hospital cont..
 If the fetus is dead;
1. In multigravida rule out the contraindications to
vaginal delivery like Cephalo pelvic disproportions etc
and allow the labour to progress
2. Psychological support to the mother and relatives
about the conditions and prepare them to receives a
dead fetus
3. In Primigravida take patient to the theatre for CS
because pelvis size is not known
 If the fetus is alive;
1. Rule out Cephalo pelvic disproportion[CPD] and mal
presentation
2. If the pelvis and presentation are normal conduct
delivery as soon as possible with the aid of
episiotomy 787
Subsequent care and treatment include;
1. Conduct routine post operative care
2. Counsel the mother on breastfeeding,
diet and sexual relationship
3. Provide supportive counseling if the baby
is dead

788
Complication/dangers of cord
Prolaspe
To the mother;
1. Dangers of CS
2. Sepsis
 To the baby;
1. Intra uterine hypoxia
2. Intra uterine death

789
Delayed second stage of labour
 Definition
• This when the second stage of labour is longer
than 2 hours in Primigravida and longer than 1
hour in multigravida
 Causes include;
1. In effective uterine contractions
2. Full urinary bladder or rectum
3. Large fetus
4. Mal position-occipito posterior position
5. Malpresentations
6. Reduced pelvic out let

790
Management of delay second stage
of labour
1. Vaginal examination is done to confirm the
position, attitude and station of the presenting
part as compared to maternal pelvis
2. Fetal heart is listened to after each uterine
contraction to note the rate and rhythm
3. Uterine contraction strength, frequency and
duration are mentioned, if noted weak put up IV
dextrose 5%
4. Refer mother to the hospital if journey is less
than 2 hours-but she must be accompanied by
skilled health worker with delivery kit

791
5. In case the journey is more than 2
hours. In effective maternal effort and in
the absence of maternal and fetal
distress;
• Encourage the mother to lie on her side
and rest for 30 minutes
• Change the position to kneeling or sitting
position may help
• In rigid perineum preventing advance of
presenting part perform an episiotomy

792
In hospital
1. Doctor may perform forceps delivery if
possible
2. In large fetus emergency CS is done
3. In case of Primigravida emergency CS is
done

793
Complications of delay second
stage of labour
 To the mother;
1. Laceration of perineal and uterus
2. Over stretching of the pelvic floor and ligament
leading to Prolaspe of cystocele or rectocele
3. Bruised urethra leading to retention of urine
possibly urinary tract infection[cystitis] during
puerperium
 To the baby;
1. Hypoxia due to prolonged head compression
2. Intra cranial hemorrhage/damage

794
Perineal laceration
 Definition
• A tear or break in the perineal tissue during labour
 Types of laceration;
1. Spontaneous tear; result from injury to perineum
which is divided into 3 according to extension of
tear;
a) First degree tear – tear of fourchette only
b) Second degree – tear of fourchette and perineal
muscle and not involving the rectum
c) Third degree – tear extending from fourchette down
to the rectum or anal sphincter.
2. Episiotomy; an artificial/intentional made incision
into the perineum to enlarge the vaginal orifice for
baby head to pass
795
Prevention of perineal lacerations/means of
lessening the risk of perineal lacerations
1. Obtaining mother cooperation by explaining the
important of listening to the instructions as to when
to push and what is expected to do
2. Having control of the advancing head/presenting part
on crowning of the head with left hand not to come
out suddenly
3. Getting small fetal skull diameters to distend the
vagina orifice by;
• Maintaining flexion and controlling to rapid extension
of head in vertex presentation, suboccipito frontal
diameter[10cm] will sweep the perineum
• Encourage extension in face presentation and flexion
in the after coming head of the breech presentation

796
4. Prevent ‘active’ extension before
crowning, sinciput should not pass over
the perineum until occipital prominence
and parietal eminences have been born
5. Keeping the hands off the perineum by
placing the palm of hand posterior to the
anus with finger and thumb on the lateral
boundaries of the perineum and bringing
connective tissue forwards will relaxation
of the perineum

797
6. Giving the perineum time to stretch by;
• Not allowing the head to advance too
quickly
• The mother is encourage to stop pushing
and use panting breaths
7. Delivering the head at the end of or
between contractions
8. Allowing the mother to ‘breath the head out’
9. Avoiding too wide separation of legs
10.Taking in delivering the shoulders and body
by preventing shoulder before internal
rotation and allowing the anterior shoulder
to escape first

798
Episiotomy
• This is an incision through the perineum and
perineal body to enlarge the vaginal orifice
Types;
1. Medio - lateral episiotomy – incision start in
the midline of fourchette, runs towards and
laterally to the point midway between the ischial
tuberosity and anus
Advantages;
a) Avoid damage to Bartholins gland and the anal
sphincter
b) Easy to make the incision and repair it

799
2. J-shaped episiotomy; the incision
starts in the midline of fourchette and
turns outwards half way the vagina and
anal orifices
 Advantage – avoid the danger of
involving the anal sphincter
 Disadvantage – difficult to make and
repair the incision

800
3. Median episiotomy; the incision starts
in the center of the fourchette and
directed Posteriorly
 Advantages – the incision produce very
little bleeding and easy to repair
 Disadvantages – risk of incision extending
further during the birth of fetal head and
produce a third degree tear

801
Indications for episiotomy;
1. Rigid perineum to quicken delivery
2. Previous third degree tear to prevent re-
occurrence
3. Breech delivery to prevent intracranial damage
and aid manipulations
4. Fetal distress to quicken second stage of labour
5. Forceps delivery to provide more room for
manipulations
6. Premature labour/baby to prevent brain damage
because skull bones are soft[not full matured]
7. Severe pre eclampsia or cardiac disease to
reduce effort of pushing
802
Procedure for episiotomy
1. No episiotomy until the perineum is distended
2. First two fingers of left hand are inserted
between perineum and fetal head to avoid
injuring the baby while making incision
3. One blade of the scissors is placed inside the
vagina, and the beginning in the center of
fourchette a Medio-lateral incision extending 2.5
cm into the stretched perineum lateral to the
outer border of the anus
4. The incision is made at the height of the uterine
contraction, it is made with one snip

803
Repair of the laceration
1. All perineal lacerations must be
sutured/repaired i.e. first degree tear is
repaired by the midwife or clinical officer
2. Second and third degree tears should be
repaired by doctor. In case it happens at
PHCC or PHCU or home delivery, the mother
is referred to hospital
3. General anesthetic is give for repair of third
degree tear
4. Perineal infiltration with lignocaine 1% is
used for the repair of first and second
degree tear or episiotomy
804
Preparation for repair of episiotomy
or lacerations
1. Explain the procedure to the mother and ensure
empty urinary bladder
2. Put on sterile gloves
3. Position mother’s buttocks at the edge of the bed
or table, her legs may be held by stirrup or held
up by your assistant /family member
4. Remove any soiled clothes form under her then
wash her genitals with antiseptic solution/soap
and water
5. Place gauze into the vagina if needed to keep
blood off the area you are suturing
805
6. Place sterile cloth under her buttocks
7. If you gave local anesthetic before
cutting the episiotomy, check to find out
if it is working well, to do this;
 Touch the cut areas with the sharp point
of needle, if she feels pain you need to
give some more anesthetic before repair
 If anesthetic was not given before the
episiotomy, give it now
8. Ensure good light source so that you can
see well into the vagina

806
9. Sit on a stool at the foot of the delivery bed
and make yourself comfortable
10.Perform a complete vagina, cervical and
perineal inspection
11.Choose 2-0 or 3-0 chromic catgut, if it is not
available, use what ever is available. If non
absorbable suture, use interrupted stitches
and one layer method, this must be
removed when healing is completed in 5-10
days
12.Place needle in the needle holder at a right
angle, clamp the teeth of the holder firmly
shut. If not clamp well, the needle will twist
on the tissue as you sew and will be difficult
to control
807
Procedure for repair of episiotomy
or laceration
1. Run your finger through the whole wound[cut]
2. Find out clearly where the top of the wound is.
Place your first suture about 1 cm above the top
of the wound in the vagina
3. Hold the needle holder in your hand
4. Use the needle holder to pull the needle through
the tissue. Never use your fingers. Using your
fingers is very dangerous because you can prick
your finger or make tinny tears in your gloves,
greatly increasing your risk of getting blood
borne infection like HIV or hepatitis B

808
5. Tie the suture off with a square knot and
trim off the short thread to about 1 cm
6. Suture vaginal mucosa using a
continuous stitch, sewing down to the
hymeneal ring
7. The needle then goes through the vaginal
mucosa, behind the hymeneal ring, and
is brought out on the wound of the
perinuem

809
8. Look inside the cut for muscle layer. Use
continuous suturing as you suture the
muscle layer. Feel the bottom of the cut, the
suture should come through just above the
bottom of the cut when you reach the end
of the wound you have closed the deep
muscle layer
9. Once you have reached the very tip of the
wound turn the needle over and start to sew
upwards the vagina, using continuous
stitching to close the subcuticular tissue just
immediately under the skin. This will leave
the wound about 0.5 cm open which will
close well spontaneously as healing occurs

810
10. Now move the suture again from the perineal
part of the wound back into the vagina behind
the hymeneal ring to be secured, tied off and cut
11. Tie off the suture with square knot. To make the
knot secure make one and half square knots. Cut
the two end of the suture off leaving about 1 cm.
if ends are cut too short, the stitch may pull part
and the whole episiotomy become loose or pulls
parts
12. Double check to make certain you have not left
any gauze or instruments in the mother’s vagina.
Wash her genitals with soapy water, dry her and
make her comfortable
 NB; REMMEBER TO ALWAYS PULL THE SUTURE
WITH NEEDLE HOLDER, DO NOT USE YOUR
FINGER TIPS TO FEEL THE TIP OF THE NEEDLE
811
Care of repaired perineal laceration
1. Early ambulation is necessary
2. Vulva toilet;
• Advise mother to wash her perineum/vulva
well with soap and water 3-4 times per day
• Keep her perineum clean and dry
• Discourage her from putting anything into
the vagina
• She should not use boiling births
3. If possible check the perineum daily 3-4
times a day, looking for redness, pus,
loosening of the sutures or hematoma
812
 Care of repaired laceration cont…
4. Diet – easily digested nourishing diet to
prevent constipation
5. In case of non absorbable suture, remove
on fifth, sixth and or even on eleven day
6. Ask her to return for examination after
one week to check the healing of the
wound and record findings

813
Maternal distress
Definition
• This is when the mother’s condition has
deteriorated and cannot corps with labour
and longer
• Do allow any mother to be reach maternal
distress
Causes;
• Prolonged labour
• Obstructed labour

814
Signs and symptoms of maternal
distress
1. Rapid pulse rate of 90 beats/minutes
2. Raised body temperature over 37.2 degree
Celsius
3. Blood pressure may be raised due to pre
eclampsia
4. Restlessness
5. Vomiting
6. Dehydration including;
• Dry mouth and tongue
• Decreased urinary output with dark urine
• Ketonuria
7. Perspiration especially around the mouth
8. Anxious-aware that something is wrong
815
Treatment
1. Resuscitation by giving her IV fluid dextrose 5%
until dehydration and condition is corrected or
2. Dextrose 50% 1 ml per kg bolus
3. Treat the cause
Outcome of maternal distress;
1. If mother’s condition improve and fetal normal.
Labour is to continue and mother can deliver per
vagina
2. If fetal heart is weak or other signs of fetal
distress are present, caesarian section can be
done

816
Fetal distress
Definition
• This when the fetal condition is in danger
• It happen when the fetus is deprived from
oxygen and become hypoxic during
pregnancy or labour[intra uterine life]

817
Causes of fetal distress
Maternal cause;
1. Prolonged difficult labour
2. Strong uterine contractions[hypertonic uterine
contractions]
3. Mal positions/presentations
4. Pregnancy induced hypertensive disease
5. Cardiac disease
6. Pulmonary tuberculosis
7. Severe anemia during pregnancy or labour
8. Ante or intra partum hemorrhage
Fetal causes
1. Umbilical cord problems like Prolaspe of cord,
short cord, true knot and Vasa preavia
818
Diagnosis of fetal distress
1. Detection of abnormal fetal heart rate and
rhythm
• Fetal tachycardia[fetal heart rate more than 160
beats per minutes
• Fetal bradycardia[heart rate less than 100 pbm
• Fetal heart deceleration after uterine contraction
2. Drainage of Meconium stained liquor amnii in
cephalic presentation
Differential diagnosis;
• Breech presentation passing Meconium

819
Emergency treatment of fetal
distress
1. If the fetal heart rate remain abnormal for 3
consecutive uterine contractions;
• Change mother position to lateral left
position
• Explain to the mother about fetal condition
• Give oxygen by face mask if possible or
open windows to ensure fresh air
• Refer to hospital if the mother is first stage
of labour

820
In hospital
1. Stop oxytocin infusion if it was there
2. Hydrate with 10% normal saline intravenously
3. Give oxygen if available, open windows and
ensure fresh air
After rehydration;
1. After give one liter of IV fluid in 30 min and fetal
heart remain abnormal perform CS if in first
stage of labour
2. If in second stage of labour with no
malformations or CPD deliver the baby quickly
with an aid of episiotomy
3. Resuscitate baby as required or refer the baby
and mother for further management
821
Subsequent treatment
• Immediate postpartum care of the new
born
• Observe baby in nursery for 24 hours if 5
min APGAR score is less than 7
• Antibiotics to the baby if membranes
ruptured more than 6 hours before the
birth of the baby
• In case the baby has died counsel the
mother and next of kin
822
 Precaution to avoid complications
1. Manage any identified maternal causes of fetal
distress
2. Be prepare for quick delivery
3. Be prepared for receiving and managing
distressed baby
4. Rule out cord presentation or compression during
routine management of labour
5. Listen to and record fetal heart rate every 15
minutes
6. Use partograph
7. Test mother urine for PAS and correct
dehydration/ketosis
8. Deliver the baby as soon as possible with
appropriate route
823
Follow up
• If the baby was born with asphyxia
neonatorum, regular check up and
prolonged follow up for 5 years is
necessary
• Advise the mother/couples on subsequent
deliveries

824
COMPLICATIONS OF THIRD
STAGE OF LABOUR
Obstetric

825
Retained placenta
 Definition;
• The failure of placenta and membranes to separate and be
delivered within 30 minutes after the delivery of the baby
 Diagnosis;
1. History of;
• time of delivery of the baby more than 30 minutes ago
• severity of bleeding if any
2. Examination;
a) A cord will be seen at the vulva or if cord cut, the placenta
will be felt on digital vaginal examination
b) Uterus not contracted and large than expected
c) History of previous retained placenta of PPH
d) Assess the degree of pallor

826
Prevention of retained placenta
1. Maintain an empty urinary bladder
through out all stages of labour and
delivery
2. Give oxytocin/ ergometrine at the birth of
the anterior shoulder
3. Avoid manipulation of uterus before
placenta is separated from the
uterus[proper management of third stage
of labour

827
Management of retained placenta
In PHCC
1. Empty urinary bladder
2. Take blood for grouping and cross
matching
3. Start IV fluid with oxytocin 20-40 units in
500ml normal saline
4. Initiate breast feeding or stimulate the
nipples so as to initiate uterine
contraction
5. Fundal uterine massage 828
In hospital
6. Controlled cord traction[CCT] to see if
placenta will separate
7. Manual removable of placenta if the CCT
failed and there is bleeding or refer/consult
the obstetrician in hospital
8. Continue with IV infusion
9. Give blood if needed
10.If partially separated do manual removable
under sedation. If failed prepare for manual
removable under general anesthetic

829
Procedures for manual removable of
placenta
1. start IV infusion
2. Provide emotional support and encouragement
3. Give pethadine and diazepam slow[do not mix in the
same syringe]
4. Give a single of prophylactic antibiotic;
• Ampicillin 2 g IV plus Metronidazole 500 mg IV
• Or Cefazolin 1 g IV plus Metronidazole
5. Hold the umbilical cord with clamp. Pull the cord gently
until it is parallel to the floor

830
6. Wearing a high-level disinfectant gloves, insert a
hand into the vagina and up to uterus. Let go the
cord and move the hand up over the abdomen in
order to support the fundus of the uterus and to
provide counter-traction during removable to prevent
inversion of the uterus
7. Detach the placenta from the implantation site by
keeping the fingers tightly together and using the
edge of the hand to gradually make a space between
the placenta and the uterine wall
8. Proceed slowly all around the placenta bed until the
whole placenta is detached from the uterine wall
9. Hold the placenta and slowly withdraw the hand from
the uterus, bringing the placenta with it
10. With the other hand continues to provide counter-
traction to the fundus by pushing it opposite
direction of the hand that is being withdraw

831
11. Palpate the inside of the uterine cavity to ensure
that all the placenta pieces have been removed
12. Give oxytocin 20-40 unit in 1 litter of normal
saline or ringer lactate at 60 drops per minutes
13. Have an assistant to massage the fundus of the
uterus to promote uterine contractions
14. If there is a continuous heavy bleeding, give
ergometrine 0.2 mg IM
15. Examine the uterine surface of the placenta to
ensure that it is complete. If any placenta lobe or
tissue is missing, explore the uterine cavity and
remove it
16. Examine the mother carefully and repair any tear
to the cervix or vagina or episiotomy

832
Post manual removable of placenta
care
1. Observe the mother closely until the effect
of IV sedation has worn off
2. Monitor the vital signs[pulse, blood pressure
and respiration for the next six hours until
the conditions is stable]
3. Palpate the uterine fundus to ensure that
the uterus remain contracted
4. Continue infusion of IV fluids
5. Transfer to hospital when condition has
improved for further management
In hospital;
• Transfuse the mother if necessary
833
Traumatic Post Partum
Hemorrhage[TPPH]
Definition;
• A immediately after the birth of the baby as a
result of injury of the cervix or upper vaginal
wall or clitoris or perineal tear[lacerations]
Causes;
1. Spontaneous delivery of large baby
2. Face to pubes delivery
3. Extraction of the baby after coming head in
breech presentation
4. Difficult instrumental deliveries

834
Signs of TPPH
1. Bleeding start immediately after the baby
is born
2. The flow of blood is continuous, often
heavy trickle, although it may collect and
form clots in the vagina
3. The uterus is well contracted and feels
hard on palpation

835
Management of TPPH
1. If bleeding continues after the manual removable of
clots and uterus is well contracted, suspect TPPH
2. Place the patient in lithotomy position
3. Inspect the vaginal anterior, posterior and lateral
walls for lacerations
4. Using vaginal speculum with good light examine the
cervix for tear/laceration
5. Clots are swabbed out of the vagina and urinary
bladder emptied
6. Apply direct pressure on the bleeding point with
folded gauze and put on a perineal pad held in place
with firm t-binder
7. Give paracetamol tablets 1 gm
8. Refer the mother to hospital
836
In Hospital;
9. Tie off the bleeding point
10.Suturing of the lacerations
11.Give broad spectrum antibiotic

837
Pregnancy Related Shock[obstetric
Shock]
Introduction
• OS is a life threatening emergency that
requires immediate and intensive
treatment to save the woman life
• It is the failure of the body circulatory
system to work normally and vital organs
i.e. the heart, lungs and kidneys stop or
do less of their normal activities

838
Types of shock
1. Anaphylactic shock-result from taking a
substance into the body which a person is allergic
to such as penicillin, toxin from bee sting and
snake bite
2. Septic shock-result from toxins produced by gram
negative organisms infecting the body, common
in septic abortion or puerperal sepsis
3. Hypovolaemia shock- result from severe loss of
blood or other body fluids
4. Cardiogenic shock- result from heart disease thus
fail to pump enough blood into circulation e.g.
heart attack

839
Types of shock cont…..
5. Vasovagal shock- result from excessive
vagal discharge causing failure of the
heart
6. Psychogenic or neurologic shock- result
from intense psychological reaction
leading to failure of heart function
normally i.e. failing to pump blood into
circulation e.g. frightening news

840
Causes of shock
1. Severe bleeding[hemorrhage] most
common during third stage of labour,
during early and late pregnancy
2. Fluid loss[diarrhoea and vomiting]
3. Infection[septic shock]
4. Heart attack[ Cardiogenic shock]
5. Allergic reactions

841
Signs of shock
1. Rapid weak pulse[rate above 110 beats per
minutes
2. Low blood pressure[systolic below 90
mmhg,diastolic below 60 mmhg
3. Pallor of mucous membranes especially of inner
eyelid[conjunctiva], palms, tongue and inner lips
4. Rapid breathing above 30 respirations per minute
5. Anxious confused or unconscious woman
6. Sweaty or cold, clammy skin
7. Reduced urine output below 30 ml per hour

842
Emergency management of shock
1. Call for help and manage with the assistance of other
health workers or relatives
2. Check vital observations
3. Ensure clear airway by cleaning the mouth and nose
clean and open
4. Turn woman’s head and body onto the side to
minimize risk of aspiration if vomits
5. Ventilate the umbu bag if the woman is not breathing
6. If the heart is not beating do cardiac massage
7. Raise the leg to increase the return of blood to the
heart[raise the foot of the bed]

843
9. Give oxygen at 6-8 litters per minute by
mask or nasal cannula if possible or open
window next to patient bed for enough fresh
air
10. keep the patient warm but do not over
head her
11.Immediately start IV fluid infusion using
large size cannula 20-16 gauge with normal
saline at the rate of 1-5 litter in 15-20
minutes, give at least 2 litters of fluid in the
first hour. DO NOT GIVE ANYTHING BY
MOUTH
12.Take specimen of blood for hb, grouping
and cross matching
13.If peripheral vein cannot be
cannulated,perform cut down 844
14.In case of severe bleeding immediately take
steps to stop the bleeding according to the
cause
15.Start blood transfusion as soon as possible
to replace loss of blood or if hb is less than
5g/dl
16.Monitor respiration pulse, and blood
pressure every 10-15 minutes
17.Catheterized and leave the patient in
sitautable position to monitor fluid intake
and hourly urine output
18.Explain to the relatives what happen and
what is expected from them

845
 Further management of shock;
• Continue IV fluid and oxygen or fresh air
with close observation
• Thorough physical examination to find
out the cause of shock and initiate
specific treatment
• If sepsis is suspected, start with
combination of broad spectrum antibiotic;
penicillin and Gentamycin plus
Metronidazole IV

846
Reassessment of patient’s condition
 Reassess the response of the woman to fluid
within 20-30 minutes. Signs of improvement
include;
1. Stabilizing heart rate[ pulse rate below 90 beat
per minute
2. Increasing blood pressure[ systolic BP below
100mmhg
3. Improved mental status, less confused or anxiety
4. Increasing urine output, above 30 ml per hour
5. If condition improves, adjust the rate of infusion
to 1litter in 6-8 hours
6. If woman’s condition fail to improve, she need
further management in the hospital
847
Important
1. Health worker should always accompany
the mother to the referral point with all
the record and to take care of the woman
during transport
2. Counsel the family members
accompanying the mother to hospital and
blood donation
3. The patient record include BP , PR, RPR,
fluid intake and output recording plus all
treatment given
848
Acute Inversion Of The Uterus[AIU]
Definition
• Means that the uterus has turned inside out
• Acute mean that it has happened suddenly
• It incidence is very rare 1/100000 women
Classifications;
1. First degree AIU
2. Second degree AIU
3. Third degree AIU
849
Causes of AIU
1. Mismanagement of third stage of labour
a) Excessive cord traction when placenta is not
separated from the uterus
b) Combining fundal pressure and cord traction
for delivery of placenta
c) Using fundal pressure for delivery of
placenta, when uterus is Atonic/relaxed
d) Short umbilical cord
e) Spontaneous occurrence due to unknown
cause

850
Signs and symptoms of AIU
1. Sudden severe pain due to the ovaries and
fallopian tubes being pulled by or into the
inverted uterus
2. Shock –usually accompany the AIU
3. Hemorrhage- this depends on whether the
placenta has partially separated from the
uterus or still adherent on the uterus
4. On abdominal examination the uterus is not
palpable
5. On digital examination a mass is felt

851
Treatment of acute inversion of
uterus [AIU]
1. Immediately prevent or treat shock
2. Immediately replace the uterus by;
a) Pushing the fundus with palm of hand along the
direction of the vagina towards posterior fornix
near the cervix
b) Working upwards to the fundus on principle ‘last
out’ first in
c) Uterus is lifted towards the umbilicus and
returned to the position with steady pressure
3. No attempt is made to remove the placenta until
the uterus is in the right position as you can not
control the hemorrhage
852
4. When the uterus is in position into the
place. Keep the hand in situ until a firm
contraction is palpated per abdomen
5. Oxytocic drug is given to maintain uterine
contraction
If the manual replace failed;
1. Gently place the uterus inside the vagina to
relieve pulling on the ovaries and fallopian
tubes
2. Raise the foot of the bed to aid relieve the
tension and prevent shock
3. Refer the patient to hospital after
resuscitating her from shock

853
 In hospital; doctor will Use a hydrostatic pressure
by;
1. Introducing warm saline into the vagina to make the
pressure which will restore uterus into its normal
position
2. While doing this the doctor hand is seal off the
vaginal outlet
3. IV ergometrine 0.25 mg is given to secure a good
uterine contraction before the hand is withdraw
4. Amyl nitrate inhalation may be used to relax the
uterine tone or general anesthetic, this will help
uterus to return to its position or
5. Hysterectomy may be done in severe cases to save
mother’s life
6. Broad spectrum antibiotic must be started
immediately

854
Complications of acute inversion of
uterus
1. Shock if not correctly corrected may lead
to
2. Death

855
Bimanual compression of
uterus
Obstetric

856
Definition
• It is where the health worker applies pressure to the
uterus using hands to stimulate the uterus to contract
and to slow down the bleeding until referral is possible
Indications;
• Uterine Atony=no uterine contractions or weak
uterine action after the delivery of the placenta.
Resulting from the following;
1. grand Multiparity
2. Polyhyramnious
3. Multiple pregnancies
4. Anemia
5. Miss management of third stage of labour
6. Oxytocic drugs during first stage of labour
7. Full urinary bladder
857
Types of Bimanual compression of
the uterus
1. External bi manual compression
2. Internal bimanual compression

858
Preparation for bimanual
compression
1. Prepare equipment for emergency by ensuring that
the following are available;
a) Sterile gloves
b) Oxytocic injections
c) IV fluid and set
d) Cannulas,needles
e) Adhesive tape
f) Straight urinary bladder catheter
g) Bp machine and stethoscope
h) Cardiac stimulants
i) Watch or clock
j) Emergency transport
859
2. Prepare the mother;
a) Explain to the mother that she is bleeding
excessively so that fundus must be
rubbed to stop bleeding and will feel
uncomfortable for a short time
b) Ensure empty urinary bladder
c) Observe aseptic precautions
d) Ensure good light and privacy

860
Procedures for bi-manual
compression
1. Place the mother in dorsal position, put the baby on
breast
2. Call for help, a health worker or relatives
3. Place one hand on the abdominal wall and rub the
uterus to make it contract
4. Check to find out if the urinary bladder is full, if so
ask the mother to pass urine or catheterize her, rub
the uterus to make it contract or express clots
5. If the bleeding does not stop, first place one hand on
the abdomen, pressing down behind the uterus. Put
your other hand low on the abdominal wall. Then
press your hands together. This compresses the
blood vessels at the placenta site as uterus contract

861
6. Ask your assistant to give the mother 10 units of
oxytocic[syntocinon] IM or IV oxytocic infusion if
she is able or give ergometrine 0.2 mg IM unless
mother has severe hypertension. If you have no
assistant show patients relative how to hold the
uterus while you give the oxytocic drug. Ensure
that the baby is still on the breast
7. If bleeding stops; take the vital observation and
record, estimate blood loss and record, check for
bleeding and uterine contractions every 30
minutes for two hours. put baby to breast again
8. Refer the mother and the baby if necessary
because severe bleeding necessitates blood
transfusion
9. If bleeding has not stopped, continue to hold the
contracted uterus and prepare for internal
bimanual compression
862
Procedures for internal bimanual
compression
• If the external bimanual compression fail to stop the bleeding;
1. Ask your assistant to start IV with oxytocin 10 IU in 500 ml
dextrose 5% at 40 drops per minute
2. Ask the assistant to take pulse and blood pressure of the
mother every 5 minutes 15 minutes until hemorrhage stops.
If she is not able to do it. You observe for signs of shock
while performing internal bimanual compression
3. Place the patient in dorsal position
4. The right hand is inserted into the vagina is closed into a
first. The flat part of the fist is pressed firmly on the lower
port of the uterus. With the right elbow resting on the bed
between the mother’s signs

863
5. The left hand is placed down behind the
uterus per abdomen with the palm bringing
down the uterus forward and is pressed on
to the fist in the vagina. this compresses the
placental site between the two hands
6. Continue pressure with both hands for 5
minutes to let the oxytocin drug take effect
and to allow clotting time to take place
7. Bimanual compression is maintain until
uterus is contracted
8. Observe for bleeding every 15 minutes.
When uterus contract and bleeding slows
refer mother and baby to hospital or call
doctor if already in hospital

864
 Other Procedures to consider in
bimanual compression
a) Check pulse and blood pressure every 15 minutes for
half an hour if the are normal then
b) Check the vital signs observations every half an hour
for 2 hours
c) Record all the findings
d) Mother is accompanied by skilled health worker and
three relatives for donating blood
e) Do not stop external bimanual compression until you
get to the hospital. Do not give up
f) Continue with IV fluids
g) Reassure mother and family until you get to the
hospital

865
 Procedures cont……………
 In the hospital;
a) Observe vital signs every half hour for 3 hours
b) Continue with IV infusion for 3 – 6 hours until
you ensure that the hemorrhage is controlled
c) Encourage breastfeeding if the mother has chose
to breastfeed her baby
d) Can start oral fluids and eating food
NB; if internal bimanual compression does not
stimulate the uterus to contract after 10 minutes
remove your hands and try to manual emptying
of the uterus of clots[manual evacuation]

866
Abnormal puerperium

Obstetric

867
Discomforts[minor disorders]
include;
• After pains
• Hemorrhoids
• Soreness of the perineum
After pains;
• Pains causes by uterine contractions, more severe in
multipara than Primipara
• Predisposing factors; breastfeeding resulting from
baby suckling stimulating the production of oxytocin
which make uterine muscles to contract
• Give mild analgesic i.e. paracetamol 500 ml given 20
minutes prior to feeding the baby

868
Soreness of the perineum is due to;
• Bruised and tender perineum after
delivery
• Suture line or oedema
Management;
• Reduce oedema by cold saline
compression on the site
• Patient is advise to sit in the position she
finds comfortable
• Mild analgesic i.e. paracetamol 500 mg 6
hourly
869
Hemorrhoids;
• Predisposing factors; strain during second
stage of labour, hemorrhoids prolapsed
and become tender
Management;
• Local treatment; anusol cream or
suppository and application of cold
compression of saline solution
• Prevent constipation by giving aperients
e.g. liquid paraffin twice daily

870
Serious disorders or complication of
puerperium
1. Puerperal pyrexia
2. Puerperal sepsis[uterine/genital infections]
3. Extra uterine/genital infections or conditions
such as;
• Breast conditions
• Urinary tract infections
• Respiratory infections
• Venous thrombosis and thrombophlebitis
• Pulmonary embolism
871
Disorders of micturation
1. Urine retention;
• This is when the urinary bladder is full but
micturation/passage is not possible
• Causes; bruised and tender perineum and
painful perineal suture line or oedema of the
perineum
• Signs and symptoms; supra pubic pain with
tenderness and dribble of urine
• Diagnosis; swelling with tenderness on the
supra pubic area which may be extended up
to the abdomen
872
Treatment of urine retention
1. Help the mother to pass urine by;
• Pouring warm water over the vulva
• Make patient listen to the sound of
running water being pour from one
container to another
2. Pass urethra catheter under septic
methods
3. Prescribe broad spectrum antibiotic to
prevent or treat infection
873
Incontinence of urine
1. Retention with overflow; commonest types
of urine incontinence causes by;
• Bruised and tender perineum
• Painful perineal suture line or oedema of the
perineum
 Signs and symptoms;
• May be history of difficult labour
• Unable to pass urine followed by dribble of
urine due to over flow of urine from the full
urinary bladder

874
Diagnosis;
• Distended bladder is observed over the supra
pubic area
• On abdominal palpation; uterus is felt up in
the abdomen lying to one side. Distended
urinary bladder
Management;
• Cauterization under aseptic procedures and
urine drained slowly
• An indwelling catheter is left in situ for
several days until one tone of the bladder is
restored

875
Stress incontinence
• This is when sudden cough, sneezing or sudden strain cause
dribble of urine from urinary bladder, but mother can pass
urine.
Causes;
1. Damage of the pelvic floor i.e. stretching and weakness of
the pelvic muscles which support of the neck of urinary
bladder urethra caused by difficult labour
• Prognosis;
1. May clear up spontaneously
2. Condition may develop months or year after child birth
3. Cystocele[ Prolaspe of urinary bladder into the vagina] may
be present
Management;
• Colpoperineorrhaphy i.e. repair of the pelvic floor, vagina
and perineal body

876
Breast conditions during
puerperium
 These include;
1. Engorged breasts
2. Cracked nipples
3. Breast infections;
• Mastitis
• Breast abscess

877
Engorged breast
• This is when the breasts are full, heavy
and hard due to venous, milk and
lymphatic congestion
• Commonly occurs from the third day after
delivery when lactation is well established
Predisposing factors/causes;
1. Baby not able to empty the breast

878
Signs and symptoms
1. Painful breasts
2. History of baby failing to fix on breasts
3. On examination;
• Breast appear full and tense
• Visible distended blood vessels
• Hard breasts and tender on touch
4. Raised body temperature commonly on
the third day of puerperium

879
Management
• Mild analgesic i.e. paracetamol 1 gram 6
hourly for 24 -36 hours according to pain
• Apply warm compression on breasts
• Put baby on the breasts 20 minutes after
mother’s taking paracetamol tablets
• Support breasts with a wide light
binder/bandage piece of linen]
Complication;
• Mastitis

880
Cracked nipples
• This is a fissure or break of nipple skin
• Incidence; common in women with light
skins[delicate]
• It is cause by baby sacking on empty breast
and baby saliva damage the skin
Signs and symptoms;
• History of feeling pain while feeding the baby
• On close inspection of the nipples, the fissure
or small wound like will be visible

881
Management and complications
Management;
1. Advise the mother on hygiene to keep
breast clean
2. Baby is fed on health breast only
3. Paint the nipple with gentian violet 5%
4. Paracetamol 1 g whenever necessary
Complications;
• Breast infection[ mastitis]

882
Mastitis
• The inflammation of breast tissue
Predisposing factors;
• Cracked nipples
• Engorged breasts
• Bruised breasts tissue
Causative organisms;
• Staphylococcus-commonest
• Streptococcus-rare
Incidence;
• Common during second week of puerperium
883
Signs and symptoms
1. History of painful breasts
2. Raised body temperature of 38.2 – 40
degree Celsius
3. Raised pulse rate
4. Headache and vomiting
5. On examination;
• One section of the breast is red, hard and
tender, feel hot on touch
• The nipple may have a crack
6. General malaise
884
Management
1. Avoid engorgement of breast and cracked nipples
2. Advise the mother on breast hygiene
3. If nipple are cracked take baby off sucking from
affected breast
4. Support the breast with wide firm binder or brassiere
5. Provide analgesics to relieve pain and induce sleep
6. Provide antibiotics ,but not tetracycline
7. Encourage the mother to take plenty of fluids to lower
body temperature and neutralized infection
Complication;
• Breast abscess

885
Breast abscess
• The formation of pus in the breast
Signs and symptoms;
• Raised body temperature 38.2 – 40
degree Celsius
• Pain and tenderness on affected site
• Skin appear red and shinny
• Enlarged breast due to venous congestion
• Fluctuant swelling under the affected site

886
Treatment of breast abscess
1. Refer to hospital or doctor
2. Incision and drainage of abscess
3. Send specimen of pus to laboratory for
CS
4. Large dressing applied and firm bandage
to control bleeding
5. Daily spectrum antibiotics and analgesics
to relieve pain and control infections
887
Puerperal pyrexia
Definition
• A febrile condition in the puerperium in
which the body temperature rises to 38
degree Celsius or higher on any of the 2
of first 20 days after delivery

888
Causes
• Malaria
• Urinary tract infection
• Wound infections; abdomen[C/S] and
episiotomy
• Engorged breast
• Mastitis
• Breast abscess
• Thrombophlebitis /deep venous thrombosis
• Upper and lower tract infection
• Puerperal sepsis

889
Laboratory investigation
1. Swab from; high vagina, wound
secretions and sputum
2. Blood slide for malaria parasites and full
blood count
3. Blood for hemoglobin level
4. Blood for culture and sensitivity
5. Blood for grouping and cross matching in
case of severe anemia
890
Management
1. Identify the cause and treat accordingly
2. Counsel the patient
3. Strict aseptic precautions
4. Give plenty of fluids
5. Record vital observation every 4 hours
6. Transfer to hospital

891
Puerperal sepsis
 Definition
• The infection of the genital tract following childbirth or
abortion up to six weeks
• The onset is common between 7-10 days
 Sites of sepsis;
1. Placenta site, most important/serious as it affects the
large unhealed vascular area providing warmth and
moisture in which bacteria grows so fast
2. Laceration/wounds on any part of the genital tract
including episiotomy, wounds and tears of the cervix,
vaginal walls and perineal body
3. Abdominal wound in case of post caesarian section

892
Predisposing factors of puerperal
sepsis
1. Ascending infection result from;
• Prolonged labour
• Early rupture of membrane
• Bruised and damaged genital tract tissue
• Frequent vaginal examination during labour
• Difficulty and traumatic deliveries
• Retained placenta or membranes
Causative organisms;
• E.coli
• Hemolytic streptococcus from droplet infection
• Clostridium welchii/anaerobic and coli form
• Staphylococcus from droplet infection and hands
893
Clinical features of puerperal sepsis
• Depends on virulence of the organisms and patient
immunity;
Signs and symptoms;
1. Onset common on the 3rd or 4th day after delivery
2. Raised body temperature 39 degree Celsius or above
3. Raise pulse rate about 100 beats per minutes
4. Headache and feels feverish
5. Reduced appetite and may be vomiting
6. May be dehydration in severe cases
7. Sub involution of uterus-fundal height remain
stationary and bulky
8. Lochia is reddish brown, profuse with offensive smell
9. Breast milk may be decreased
10. Loss of body weight
894
 Diagnosis of puerperal sepsis
1. By Signs and symptoms
2. Laboratory investigation;
• High vaginal swab for culture and
sensitivity
• Mid-stream specimen of urine for cs
• Blood count and culture
• Swab from a localized infection e.g.
wound
895
Management of puerperal sepsis
1. Prevention start from pregnancy/ANC
• Prevention of anemia
• Advising and encouraging pregnant women
to take proper diet
• Early detection and appropriate
management of any risk conditions that may
prolonged labour and difficult deliveries
• Treating any infection during pregnancy

896
2. During labour;
• Avoid frequent vaginal examination
• Provide broad spectrum antibiotic in case of
early/prolonged rupture of membranes
• Empty urinary bladder every 2 hours to
avoid cauterization
• Vulva toilet and change of soiled pads every
time she passes urine or open bowels and
incase of draining liquor amnii
• Ensure clean safe delivery with strict aseptic
precautions

897
3. Nursing care;
• Separate room if possible or corner of ward
• Counseling
• Sitting up position to aid draining of lochia fro uterus
• Personal hygiene; oral and bath
• Nutrition; light nourishing diet while very ill and
gradually increase to high protein diet
• Plenty of fluids oral
• Rest and sleep
• Early ambulation to prevent thrombosis and its
complications
• Vital observations
• Keep fluid balance chart
• Continue breast feeding thought may be decrease
during pyrexia stage but improves as pyrexia subsides

898
Medical treatment
• Broad spectrum antibiotic starting
immediately and may changed to more
suitable one according to laboratory
results
• Analgesia to relieve pain and lower
temperature
• Iron therapy according to hb level results
• Vitamin complex drugs orally or IM

899
Complication of ps
• Spread of infection; infection may spread in case of
virulent bacteria or low body resistance of if treatment
is delayed;
1. Secondary PPH
2. Infection may spread from uterus to;
• pelvic cellular tissue leading to pelvic cellulitis
• Via the peritoneum leading to pelvic peritonitis
• Along the fallopian tube to the ovary causing
salpingo-oophritis
3. Virulent bacteria such as C.welchii enter blood stream
leading septicemia; patient become severely ill with;
swinging body temperature, rigors, vomiting, and
anemia and may be jaundice

900
 PART 3 ASSISTED DELIVERIES
AND OBSTETRICAL OPERATION
OBSTETRIC

901
Forceps delivery
Definition
• Method of assisting delivery per vagina
• Rarely use because of associated
complications with use of obstetric forceps
Types of forceps deliveries;
1. Haig Ferguson's, Bonney’s or
Wriegley’s forceps; Use when the head is
low where they largest presenting diameter
is below the level of ischial spines and head
distending the perineum

902
Types of forceps delivery cont..
2. Bernes Neville’s or Milne Murrays
forceps; use when the head is engaged,
the presenting part is at mid pelvic cavity
provided the head is occipito anterior
position. it is also use for after coming of
the head of breech presentation
3. Kielland’s forceps; use for rotating the
fetal head to correct the position from deep
transverse arrest at the level of the ischial
spines

903
Indication of forceps delivery – forceps are
applied during the second stage of labour
1. Delay in the second stage of labour
2. Maternal complications;
a) Severe pre eclampsia
b) Maternal distress
c) Cardiac disease or advanced pulmonary tuberculosis
3. Fetal complications;
a) Fetal distress
b) Prolaspe of the cord during second stage of labour
c) After coming head of the breech
d) Deep transverse arrest
e) Persistent occipito posterior position

904
Conditions necessary for forceps
delivery
1. F = full dilatation of cervix
2. O = outlet adequate
3. R = rupture of the membranes
4. C = contraction good
5. E = engaged head
6. P = position known
7. S = suitable pelvic outlet
NB; the urinary bladder must be empty
905
Preparation for forceps delivery
1. Inform doctor
2. Equipment[ trolley and instrument] are
prepare under strict aseptic precautions
3. Ensure privacy and good light
4. Prepare the labour ward or theatre
5. Be prepare for receiving asphyxiated baby[
resuscitation equipment]
6. Psychologically prepare the mother and the
next of kin by explaining to them, what is
happening and what should be done and
what is expected from them
7. Place the mother in lithotomy position
906
Procedure of forceps delivery
1. Ensure cervix is fully dilated
2. Ensure empty urinary bladder
3. Place patient in lithotomy position
4. Place sterile towels over thighs
5. Confirm position of the sutures and
fontanelles on the fetal head so that the
forceps can be placed correctly finding
the fetal ears make it easier
907
6. Provide local anesthetic to block the
pudendal nerve to relax the pelvic floor and
reduce the pain
7. Vulva is cleaned followed by episiotomy
8. Forceps used; short handled
forceps[Wrigley’s] if the head is at the fetal
head is at the perineum. Longer forceps if
the head is in mid cavity
9. Apply one blade at a time left first then right
10.Pull must follow curve of birth canal,
forward and upwards
11.Remove blades when head is crowned
908
Important note
1. Excessive traction should not be applied
as this will cause intra cranial
hemorrhage
2. It is important to prevent PPH, tears of
the cervix and vagina

909
Care of the baby
1. Resuscitation according APGAR score
2. Examine baby for forceps marks and facial palsy
3. Handle baby gently as there is a risk of intra
cranial damage, give neonatal vitamin K 1mg
4. Keep forceps marks on head clean and dry. Marks
will disappear in a day or so. A hematoma may
form under the covering of the skull bones, it
may takes one month to heal
5. The baby should be observed over a period of 24
hours for signs of cerebral irritation/ damage

910
Dangers/complications of forceps
delivery
To the mother;
1. Lacerations of the cervix and vagina if
caught between cup and head
2. Deep vein thrombosis
 To the baby;
1. Intracranial damage
2. Cephalohematoma

911
Malmstrom vacuum
extraction[Ventous]
Definition
• A simple procedure perform to aid expulsion of
fetus during the second stage of labour
Indication;
1. First stage of labour;
• In case of hypotonic uterine action[the os should
be 8cm or more dilated
2. Second stage of labour;
a) The commonest indication is delay due to OPP
i.e. persistent OPP and deep transverse arrest

912
b) Severe pre-eclampsia
c) Severe anemia
d) Cardiac disease
e) Respiratory conditions e.g. asthma,
pneumonia, pulmonary tuberculosis
f) Fetal distress
g) Maternal exhaustion
Contra indications to Vacuum extraction;
a) Severe Cephalopelvic disproportion
b) Malpresentations
c) Prematurity
d) Macerated still birth
913
Conditions necessary for vacuum
extraction;
1. Vertex presentation
2. The head must be engaged – at or below
the ischial spine and no more than 1/5
palpable above brim
3. The position of the occiput must be
confirmed
4. The cervix must be 8 cm or fully dilated
5. Good uterine contractions
6. Empty urinary bladder

914
Preparation for vacuum extraction
1. Equipment is prepared under strict aseptic precaution
including Delivery trolley with containing;
• Suturing materials
• Local anesthetic
• Check the suction apparatus and connection, if using
a hand pump you need an assistant midwife capable
of working the vacuum. Check the pump against
your hand
2. Ensure privacy and good light
3. Prepare the labour ward or theatre
4. Be prepare for receiving asphyxiated
baby[resuscitation equipment]
5. Psychological prepare the mother and next of kin by
explaining the procedure and the reason for doing it
915
Procedure
1. Place the apparatus on the bed side
2. Ensure empty urinary bladder and leaving
catheter insitu
3. Place patient in lithotomy position
4. Check fetal heart and repeat between each
contraction
5. One assistant is needed with a watch on
one hand with second hand
6. Vulva is clean followed by vaginal
examination to confirm the position

916
7. Local infiltration with local anesthetic or
pethadine may be given, in Primigravida an
episiotomy may be necessary
8. Select the largest cup that will fit in the
vagina without risk of damaging it a 5cm
cup is adequate
9. Insert the cup into the vagina sideways and
place it on the posterior fontanelle, 1cm
forward the fontanelle
10.Check that none of the cervix or vaginal wall
has been included in the cup
11.Instruct the assistant midwife start pumping
to create vacuum, the fetal scalp is gradually
sucked into the cup
917
12. Increase the negative pressure in steps of 0.2 kg/cm
square until negative pressure of 0.8 kg/ cm square
13. Wait one minutes after each increase, it should take
5 minutes to ensure adequate chignon
14. Pull steadily but gently with uterine contractions and
maternal effort. Do not pull without a contraction.
Keep a finger of the other hand on the cup and one
on the head to keep the cup in place to detect
slipping off of the cup
15. Make the head follow the direction of the birth canal
16. Observe the rule of the three pulls[ 3 real
contractions]
a) The first should dislodge the head
b) The second bring it down to the perineum
c) The third delivers the head

918
 Do not exceed 20 minutes of traction

17. Make an episiotomy only if necessary, when the head

distends the perineum or earlier if
a) Access is too difficult to accurately place the cup on
the head
b) You cannot get the right angle of pull
18. Remove the cup once the head crowned
19. With the delivery of the head the vacuum must be
released and baby received into sterile towel and
resuscitated as per baby condition
20. Follow by active management of third stage of labour
21. Record what you have done with results and times
NB; IF VACUUM EXTRACTION FAILS CAESARIAN
SECTION MUST BE DONE

919
Care of baby following delivery by
vacuum extraction
1. Handle baby gently as there is a risk of intra
cranial damage, give neonatal vitamin K 1
mg
2. Keep grazes and cut on the head clean and
dry. The swelling will disappear in a day or
so. A hematoma may form under the
covering of the skull bones, it may take one
month
3. The baby should be observed over period of
24 -48 hours for signs of cerebral
irritation/damage

920
Dangers or complications of
vacuum extraction
 To mother;
• laceration of the cervix and vagina of
caught between cup and head
 To baby;
• Intracranial damage
• Necrosis of scalp caused by the cup
coming off or pulling for too long
• Cephalo hematoma
921
Version
 Definition
• Version is alteration of the lie of he fetus in uterus to
obtain a more favorable lie or presentation
 Term used;
1. Cephalic version – the head of the fetus is made to
present
2. Podalic version – the breech of the fetus is made to
present
 Types;
1. External cephalic version – usually done during
antenatal period, sometimes in labour before the
rupture of membranes or between first and second
twin
2. Internal Podalic version – rarely done
922
External cephalic version
Indication;
• To convert breech presentation to cephalic
presentation;
1. After 32 weeks of pregnancy
2. At the beginning of labour in shoulder
presentation or transverse lie when
membranes are intact or
3. For the second twin where there is no
doctor
923
Contraindication to external
cephalic version
1. Pre eclampsia
2. Essential hypertension
3. Multiple pregnancy except in case of second
twin
4. Ante partum hemorrhage
5. Uterine scar[previous caesarian section or
hysterectomy or myomectomy]
6. Hydrocephalus
7. Dead of fetus

924
Preparation
1. Psychological; explain to the mother and
next of kin about the lie or presentation
and what is going on to be done
2. Ensure empty bladder
3. Check the fetal heart prior to the
procedure
4. Ensure privacy with good light

925
Procedure of external cephalic version

1. Patient lie flat

2. Stand on the side of the patient where the fetal
back is
3. Ask the patient to bend her knees alittle
4. Talk with her or get some to aid relaxation
throughout the procedure
5. Listen to the fetal heart noting its rate, rhythm
and strength
6. With two hands lift the breech from the pelvis
and stabilize in the iliac fossa on the side where
the fetal back is , at the same time guiding the
head to the other side of the pelvis
926
7. Maintain gentle pressure, moving the breech and
head a little at a time, if the uterus contracts,
wait until the contraction is over
8. Then continue the maneuvers until the head lies
over the pelvis and the breech is in the fundus
9. The fetal heart is listened to frequently during
the maneuver and vulva is exposed to observe
whether there is bleeding or draining of liquor
amnii
10. The whole procedure should be calm and
unhurried
11. No force is used, the aim is to gently turn the
fetus

927
After care
1. After the version, listen to the fetal heart,
often is slow or is irregular but should
recover within 5-10 minutes with the
patient lying on her side
2. If the fetal heart does not recover, turn
the fetus back to its original position
3. If the version is successful, the
presentation is checked weekly

928
Causes of failed version
1. Tight abdominal wall
2. Breech deep in pelvis
3. Oligohydramnious
4. Congenital abnormality of the uterus
5. Congenital abnormality of the fetus
6. Short umbilical cord

929
Dangers of version
1. Placenta separation from the uterus
leading to ante partum hemorrhage
2. Fetal distress
3. Early rupture of the membranes and its
complications
4. Knots in the umbilical cord

930
Induction of labour
 Definition
• The artificial stimulation of the onset of labour
when the life or health of the mother or the fetus
or both is/are in danger if pregnancy continues
 Methods of induction;
1. Medical induction;
• Prostaglandins
• Use of pitocin[syntocinon] drugs
2. Surgical induction;
• Amniotomy; rupturing of membranes
• Combined medical and surgical[commonest]

931
Indications induction of labour
1. Missed abortion
2. Hydatidiform mole
3. Severe pre-eclampsia[commonest]
4. Renal disease
5. Hyperemesis gravidrum
6. True post maturity[prolong pregnancy]
7. Reduced fetal movement
8. Fetal malformation such as anencephaly
9. Ensure a live baby in case of; previous intra uterine death
during last month of pregnancy and diabetes mellitus
10. Rhesus iso immunization in case of previous severely
jaundiced baby
11. History of repeated intra uterine hypoxia and intra uterine
growth retardation

932
Contraindication to induction of
labour
1. Cephalopelvic disproportion
2. Oblique or should presentation
3. Poor fetal condition[fetal distress]
4. Cardiac disease of the mother
5. Placenta preavia
The success of the induction depends on
how to ready the cervix to respond to
attempts to start labour
933
Medical induction of labour
1. Prostaglandins;
• Hormone given to ripen the cervix i.e.
make it ready for labour if it is not ready
2. Intravenous infusion[ pitocin or
Syntocinon];
• Commonly use after Amniotomy to
stimulate uterine contractions
NB Preparation of the equipment; ensure all
aseptic procedures
934
Preparation of the mother for
induction of labour
1. Psychologically by explaining the procedures, reasons
to mother and next of kin to understand
2. mother given Hot bath and clean vulva pad and
dress in clean gown
3. Physical general examination to normality of
everything with emphasis on lie per abdomen,
presentation and CPD
4. Check fetal heart before induction
5. Clean environment and aseptic precautions
6. Change vulva pad whenever soiled
7. Ensure empty urinary bladder, the patent should pass
urine at least every 2 hours, urine is measures and
recorded on the patient partograph

935
Action of oxytocin infusion
• It ripen the cervix and stretch the lower
uterine segment and permit the un
engaged head to enter the pelvic brim

936
Uses of oxytocic infusion
• In missed abortion and Hydatidiform mole
• Induce premature labour when pregnancy must be
terminated in interested of the mother or baby as
in severe pre-eclampsia, rhesus iso- immunization
• To avoid post maturity in condition of pre
eclampsia, essential hypertension in which fetal
hypoxia and intra uterine death may occur
• To shorten the latent stage of labour following
spontaneous rupture of membranes
• To augment or accelerate labour in case of
hypotonic uterine action[inertia]
937
Contraindication to oxytocic
infusion
• Hypertonic uterine contractions
• Fetal distress e.g. Meconium stained liquor
• Conditions presents that could cause obstruction
of labour
Authority of induction of labour;
• Senior clinical officer can order IL for premature
rupture of membranes in nulliparas and Para one
to five
• IL must be done in facility with operation theatre
as general rule, the membranes are rupture prior
to starting the infusion

938
Dose of oxytocin infusion
• The is 1 -10 IU running at a rate of 10 -
40 drops per minute
• The starting and maximum dose depends
on parity as follows;

939
Table for administration
TIME[HR] NULLIPARA PARA 1-5 PARA 6 OR MORE

U/L DROPS/MIN U/L DROPS/MIN U/L DROPS/MIN

0-0.5 5 10 1 10 ½ 10

0.5-1 5 20 1 20 ½ 20

1-1.5 5 30 1 30 ½ 30

1.5-2 5 40 1 40 ½ 40

2-2.5 10 20 2 20 1 20

2.5-3 10 30 2 30 1 30
3-3.5 10 40 2 40 1 40

3.5-4 10 40 4 20 2 20

4-4.5 10 40 4 30 2 30

4.5-MORE 10 40 4 40 2 40

940
The infusion is continue
1. Through out the labour unless there is
occurrence of very strong uterine
contractions with no relaxation between
contractions
2. Until one hour after completion of third
stage of labour to prevent post partum
hemorrhage. It is advisable to start the
infusion at 9;00 am and if labour has begun
after 12 hours, the infusion is discontinued
and the mother given sedative and
procedure started next morning

941
Observations
1. Partograph;
Mother general condition;
• Temperature
• Pulse and BP every half hour
• Oedema
• Intake-water only
• Fluid output
• Urinalysis for Protienuira, sugar and
acetonuria
942
2. Progress of labour;
• Length, frequency and duration of uterine
contraction every 15-30 min
• Descent and station of the presenting part
• Caput/moulding
• Dilatation of the cervix every 4 hours
3. Fetal conditions;
• Heart rate every 5 min in first half hour then
every 15 min later
• Color of liquor amnii in case of ruptured
membranes, Meconium stained indicated
fetal distress
4. Rate of flow of infusion oxytocin drugs
943
Indication for stopping intravenous
oxytocin infusion
• Hypertonic uterine contractions[no relaxation
between contractions]
• Fetal distress; slowing of the fetal heart,
Meconium stained liquor
• Any deterioration in the mother general condition
Complication of oxytocic drugs;
1. Poor uterine action leading to caesarian section
2. Fetal hypoxia by over stimulation of the uterus
3. Hyper stimulation caused by overdose causing
excessive, painful uterine contraction with
prolonged spasm[titanic contraction]
4. Rupture of uterus may occur in grand Multiparity
women, previous caesarian section or hystrotomy
944
Surgical induction of labour
• The artificial rupture of membranes known
as Amniotomy
• Delivery of the baby should take place
with in 24 hours as ascending infection
become a risk necessitating C/S
• Surgical induction should be done in
health facility with operating theatre
where caesarian section can be performed
in case of labour fails to commence

945
Preparation;
1. Equipment under strict aseptic precaution
2. Prepare the mother as follows;
• Psychologically
• Get consent form
• Thorough bathing
• Wearing clean light gown
• Ensure empty urinary bladder prior to the
procedure
3. Ensure clean room with good light and
privacy
946
Methodology of surgical induction
of labour
1. Explain the procedure to the mother
2. Place her in lithotomy position
Procedures;
• If the presenting head or breech is engaged in the
pelvis the membranes are ruptured with amniotic
hook
After care;
1. Listen to the fetal heart immediately after the
induction of labour
2. Vulva pads are changed when ever soiled
3. Ensure vulva hygiene to prevent infection
4. If labour does not commence within 24 hours. Broad
spectrum antibiotic so given
5. Labour is monitor using partograph
947
Complication of Amniotomy
• Failure to induce effective uterine
contractions
• Placenta separation as a result of sudden
reduction in volume of liquor where there
has been hydramnious

948
Caesarian section
Definition;
• an operation to remove the fetus, placenta
and membranes through an incision made
in the abdominal and uterine walls after
28 weeks of pregnancy
• Hysterectomy is an operation to remove
the fetus, placenta and membranes
through an incision made in the abdominal
and uterine wall before 28 weeks of
pregnancy

949
Time of caesarian section
1. Elective caesarian section is planned
because the indication is diagnosed prior to
labour, the mother is admitted to hospital at
term and operation is performed on
approximate expected date of delivery or
sooner if membranes rupture
2. Emergency caesarian section is performed
during labour as a result of difficulties or
dangers to mother or fetus

950
Types of caesarian section
1. Classical caesarian section; a longitudinal incision
about 16cm made in the upper uterine segment
rarely done because of the following
disadvantages;
a) The risk of peritonitis and paralytic ileus is more
likely to occur especially when the mother has
been in labour for more than 24 hours
b) The contractions of the upper uterine segment
during post-operative period determines against
good healing of the uterine scar
c) Rupture of the uterus is likely to occur in
subsequent pregnancy in about 4% of women

951
2. Lower uterine segment caesarian
section[LSCS]; A transverse incision is
made in the lower uterine segment. It
has the following resources;
a) Repair of the uterus is easy
b) Scar heal well
c) Rupture of the uterus in subsequent
pregnancies is uncommon

952
Indication of caesarian section
1. Contracted pelvis
2. Placenta preavia
3. Severe pre eclampsia
4. Prolaspe of cord
5. Elderly Primigravida[pg]
6. Posterior face presentation
7. Intra uterine growth
retardation
8. CPD
9. Maternal and fetal distress
10.Poor obstetric
history
11.Brow presentation
12.Obstructed labour
13.Breech
presentation in PG
or in case of
premature labour

953
Pre operative care for CS
1. Routine examination of blood and urine
2. Psychological preparation for the
operation
3. Obtain written consent form from mother
or next of kin
4. Mother’s skin is clean and shaved from
umbilicus down to thighs
5. A sedative is given to aid deep sleep at
the night before operation
954
6. Give small amount of clear fluid by mouth
up to 2 hours prior to operation and set
up IV line
7. Blood grouping and cross matching from
HIV negative donors
8. Premedication does not include a narcotic
drugs, give anti acid medication to
reduce gastric in the stomach
9. Catheterization and catheter left in situ
10.Clean sanitary pad provided
11.Dressed in clean operation gown

955
 Immediate post operative care
1. Place the patient on her side
2. Mid wife remain with patient until consciousness is
regain
3. As soon as patient become conscious, Patient is
given pillows and strong analgesic 6-8 hourly for 48
hours
4. Give sips of water orally
5. Take pulse every 15 minutes for 3 hours
6. Wound and vulva are frequently inspected for
bleeding
7. Introduce the baby to her if condition allows
8. Blood pressure is taken on return to the ward and
every 2 hours, if shocked every 30 minutes for 3
hours, then 4 hourly for 24 hours
956
During evening
1. The patient is sponged, vulva toilet, mouth wash
are attended to
2. Catheter is left in situ for 24 hours
Subsequent care;
1. Observation;
a) Vital observation i.e. T, P, RPR AND BP 4 hourly
for someday until risk of hemorrhage and
infection is over
b) Breast inspection for lactation[amount of milk].
Baby fixing well to breast if mother choose
breastfeeding, engorgement, tenderness and
cracked nipples
957
c) Wound observation for bleeding, healing
progress and signs of infections
d) Fundal height for involution
e) Vulva for lochia amount, color and smell
f) Micturation and bowels opening
g) Sleep amount of mother
h) HB estimation on 4th day to exclude
anemia which may need correction and
managememt

958
2. Early ambulation; patient must get up on
the first day and should be encourage to
exercise legs and move around the ward to
prevent chest complications and deep veins
thrombosis, examine leg, palpate groins for
tenderness every day
3. Position; patient is nurse in sitting position
to prevent chest complications and aid free
drainage of lochia
4. Introduction to diet; continue IV infusion
until bowel sounds are heard, then mother
is given small amount of water by mouth,
follow by light diet and gradually introduce
to family diet

959
 Subsequent care cont..
5. Hygiene i.e. bed bath,vulva toilet and oral toilet are
attended to
6. Feeding the baby; there is often slower onset of
lactation and posible need for some supervised
complementary feeds during the first few days until
breasts fill. Particular care is necessary to get the
mother in comfortable position for breast feeding and
she will need help with feeding the baby
7. Examination of abdomen; for distention, it should
disappear as bowel sounds are heard and wound for
bleeding and healing, wound dressed and sutures
removed at appropriate time

960
8. Feed baby according to mother’s choice
9. Lochia; tend to be heavier as uterus is
scarred and takes longer to involute.
Particular care is needed to that it follows
the normal pattern and there are not clots
or signs of infections
10.Bowel and micturation; observe for
urine retention which is fairly common, low
output or failure to pass urine must be dealt
with by first aid to get mother pass urine
using catheter. An aperients is given to aid
the mother to have good bowel action
961
On discharge
• Mother is advised to report back for post
natal examination 6 week post caesarian
section or return as soon as she feels pain
or any other discomfort/abnormalities

962
Complication of caesarian section
To the mother;
1. Hemorrhage of the wound or birth canal
2. Infection of the wound or birth canal, may
occur from around 3rd day presenting with
raised pulse rate, pyrexia and vomiting
3. Pulmonary embolism is likely to occur
around 10 to 14 day. It is prevent by early
ambulation of the patient and leg
movements
4. Lung complications e.g. bronchopneumonia
5. Paralytic ileus; when bowel becomes
paralyzed 963
 Complication cont..
To the baby;
1. Respiratory distress syndrome
2. Asphyxia neonatorum
SUBSEQUENT PREGNANCIES;
• All women previous cs must deliver in
hospital
• Admission should be one week prior to
expected date of delivery

964
Trail of scar
Definition;
• A test to see if a mother with a previous
uterine scar will be able to deliver per vagina
Indications;
1. Cephalic presentation
2. Normal size fetus
3. Normal maternal pelvis
4. Normal lower uterine segment scar

965
Contra indications to trail of scar
1. Elderly Primigravida
2. Where maternal illness complicates
pregnancy
3. Where a previous trail of labour failed
4. Mal presentations
5. Rupture of membranes for 24 hours or
more hours without contractions after 36
weeks
966
Pre trial of scar care
1. Pregnancy is allowed to go to term to allow
labour starting spontaneously
2. Pregnancy should not go beyond term
 First stage of labour, on admission;
1. Welcome the mother to labour ward
2. Base line observation and recordings should
be done and include; T, P, RPR, BP. Exclude
oedema. Urinalysis to exclude Protienuria,
sugar and acetonuria

967
3. General physical examination with
emphasis on abdominal examination for;
a) Lie, presentation, level of head in relation
to maternal pelvis brim
b) Frequency, strength and length of uterine
contractions
c) Fetal heart rate, rhythm and strength

968
First stage of labour, monitor labour
using partograph;
1. Noting progress of labour i.e. descent of
fetal head, uterine contractions, cervical
dilation
2. Fetal condition
a) Fetal heart rate and rhythm
b) Membranes status i.e. intact or time of
rupture and color of the liquor amnii
3. Assessment of mother general condition;
a) Temperature 4 hourly
b) Pulse and BP half hourly
c) Intake and output is measured and recorded
969
d) Observe carefully for signs of maternal
distress;
a) Ketonuria
b) Raised body temperature
c) Morale dropping
d) Raised blood pressure
e) Vomiting

970
Outcomes of labour
1. If maternal and fetal conditions remain well and
labour progresses normally vaginal delivery is
possible
2. Caesarian section during the first stage of labour
is indicated in case of;
 Malpresentations i.e. breech, face, brow and cord
 Suspected CPD on first examination[admission]
 A curve of cervical dilatation running on the right
of alert line of partograph
 Fetal distress

971
 Signs of impending rupture of uterus which
include;
a) Tender scar between uterine contractions
b) Hypertonic uterine contractions
c) Signs of acute fetal distress
d) Vaginal bleeding
e) Shock
f) Rupture of membranes for 24 hours or more
with out contractions
Important;
 NEVER PRESCRIBE/GIVE OXYTOCIN WITH
PREVIOUS CAESARIAN SECTION[ UTERINE
SCAR]
972
 Second stage of labour
It should not last for more than 20 minutes;
1. When the vertex is 2/5 or below, a
vacuum extraction is performed
2. If the vertex is 3/5 or above, a caesarian
section must be done

973
Third and fourth stages of labour;
1. Deliver the placenta with cord control
traction
2. Explore the lower uterine segment with
finger after delivery of the placenta
3. Observe the mother for at least two
hours in the labour ward for signs of
bleeding and shock[ vital observation
every 15-30 minutes]

974
 CONCLUSION

May God bless the work of my hands

975