OBGYN 2023 Last

UNIT ONE
Introduction to Obstetrics and Gynecology
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Objectives
After completion of this chapter students will be able to:
define important terminologies used in obstetric and gynecology
Define common ethical, social and legal issues in obstetric and gynecology
Discuss current issues, trends in newborn, under five, and maternal mortality in
Ethiopia
Explain the nurses ‘role in maternity and women’s health care
Identify considerations for providing care to families in a culturally diverse society
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Introduction
Common terminologies
Obstetrics:
Is the branch of medicine that dealing with the structure(Anatomy) and
Function ( Physiology) of female genital organs
 Is concerned with preconception care (before pregnancy), pregnancy, labor, and the
puerperium in both normal and abnormal circumstances
It is concerned with the health of the woman and fetus
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Gynecology : Branch of medicine dealing with the female pelvic and urogenital organs, in
both the normal and diseased states , including breast
It encompasses aspects of contraception, abortion and IVF
It covers a woman’s general health care, including care of her reproductive organs, breasts,
and sexual function.
It also includes management of hormonal disorders, treatment of infections, and training in
surgery to correct or treat pelvic organ or urinary tract problems
Viability: capability of living, usually accepted as 24 weeks, although survival is rare.
For developing
10/13/2023 country it is 28 weeks K.A 4
Terminologies…cont’d
Gestation: age of pregnancy from conception to delivery
Gravida: Number of pregnancy, regardless of pregnancy outcome
Para : refers to past pregnancies that have reached viability
Nulligravida: woman who is not now and never has been pregnant.
Nullipara: woman who has never completed a pregnancy to the period

of viability. The woman may or may not have experienced an abortion
Multigravida: woman who has been pregnant more than once
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Terminologies…cont’d
Primipara: woman who has completed one pregnancy to the period of

viability regardless of the number of infants delivered and regardless of
the infant being live or stillborn
Primigravida: woman pregnant for the first time.
Multipara: woman who has completed two or more pregnancies to the

stage of viability
Grand multi Para = a woman who has given birth five times or more
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Overview -Ethical, Social and Legal Issues in Oby/Gyn
Ob/Gyn professionals often encounter various ethical, social, and legal issues.
Ethical Issues:
a) Patient Autonomy:
respecting a patient's autonomy and their right to make decisions about their own
healthcare.
challenging when it comes to issues like reproductive choices, such as abortion or fertility
treatments.
Balancing a patient's autonomy with medical best practices and societal values can be a
complex ethical dilemma
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Overview -Ethical, Social and Legal Issues in Oby/Gyn…
b) Confidentiality and Privacy:
OB/GYN providers deal with sensitive and personal information about their
patients.
They must respect patient confidentiality and privacy, ensuring that their
medical records and discussions are kept confidential unless there is a legal or
ethical obligation to disclose information.
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c) Informed Consent:
Professionals in this field have an ethical obligation to obtain informed consent

from their patients before any medical procedure.
They must provide comprehensive information about the nature, risks, benefits,
and alternatives of the treatment or procedure to allow the patient to make an
informed decision.
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Social Issues:
a) Access to Care:
• Access to Oby/Gyn care can be an issue, particularly for marginalized

populations or those living in underserved areas.
• Social factors such as economic disparities, cultural barriers, and limited

healthcare infrastructure can limit women's access to essential reproductive
healthcare services.
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b) Reproductive Rights:
Women's reproductive rights are a significant social issue in this field.
Discussions on abortion, contraception, assisted reproduction, and

sterilization often intersect with moral, religious, and societal values, and can
lead to debates and conflicts.
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c) Gender Disparities:
OB/GYN practitioners may face social issues related to gender disparities.
These can include issues such as unequal access to medical education and
professional opportunities, or
discrimination and bias against women in healthcare settings.
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Legal Issues:
a) Malpractice:
As with any medical specialty, OB/GYN practitioners need to navigate the
potential legal risks associated with medical malpractice.
 Issues such as improper diagnosis, surgical errors, and failure to provide

adequate care can lead to legal consequences.
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b) Informed Consent and Refusal:
 Legal issues may arise when patients claim they were not adequately informed
about the risks or alternatives to a procedure, or
 when they refuse certain treatments based on personal or religious beliefs.
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c) Reproductive Law:
The field of obstetrics and gynecology intersects with various reproductive

laws, including those related to contraception, abortion, and assisted
reproduction.
Practitioners need to understand and adhere to these laws to ensure that their
practice is legally compliant.
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• In summary, obstetrics and gynecology is a medical specialty that often involves

navigating complex ethical, social, and legal issues related to patient
 autonomy, confidentiality, access to care,
 reproductive rights,
 gender disparities,
 medical malpractice,
 informed consent, and
 compliance with reproductive laws.
• OB/GYN professionals must be well-informed, respectful of patient rights, and make

decisions
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that uphold both medical best practices
K.A
and ethical principles. 16
Current issues, trends in Newborn, under five, and maternal
• Infant and child mortality rates are basic indicators of a country’s

socioeconomic situation and quality of life (UNDP 2007).
Neonatal mortality: the probability of dying within the first month of life
Post neonatal mortality: the probability of dying after the first month of life
but before the first birthday
Infant mortality: the probability of dying before the first birthday
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Current issues, trends in Newborn, infant and under five…
Child mortality: the probability of dying between the first and the fifth
birthday
Under-5 mortality: the probability of dying between birth and the fifth
birthday
• All rates are expressed per 1,000 live births, except for child mortality, which
is expressed per 1,000 children surviving to age 12 months.
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 Ethiopia was making progress in reducing both infant and maternal mortality rates,
although challenges still remained.
During the 5 years preceding the survey, the infant mortality rate was 43 deaths per
1,000 live births.
The child mortality rate was 12 deaths per 1,000 children surviving to age 12 months,
while the overall under-5 mortality rate was 55 deaths per 1,000 live births.
The neonatal mortality rate was 30 deaths per 1,000 live births, and
 the post neonatal mortality rate was 13 deaths per 1,000 live births.
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under-5 mortality rates for the 5 years

preceding the survey declined from
123 deaths per 1,000 live births in the
2005 EDHS to 55 deaths per 1,000 live
births in the 2019 EMDHS.
Similarly, infant mortality decreased
from 77 deaths per 1,000 live births in
the 2005 EDHS to 43 deaths per 1,000
live births in the 2019 EMDHS.
Neonatal mortality decreased from 39
to 29 between the 2005 and 2016
EDHS, but has remained stable since
the 2016 EDHS.
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Trend in maternal mortality rate in Ethiopia
Maternal Mortality Rate (MMR):
• Ethiopia has also made efforts to reduce maternal mortality rates, although the
progress has been slower compared to infant mortality.
• According to the World Bank, the MMR in Ethiopia was estimated to be 401
deaths per 100,000 live births in 2017.
• This represented a decline from previous years, as the MMR was 676 deaths
per 100,000 live births in 2000.
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Trend in maternal mortality rate in Ethiopia…
• To address maternal mortality, the Ethiopian government implemented various
initiatives to improve maternal healthcare services, increase skilled birth
attendance, and enhance access to emergency obstetric care.
• These efforts have contributed to the reduction in maternal deaths, but

challenges such as limited resources, infrastructure gaps, and regional
disparities continue to affect progress.
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The nurses ‘role in maternity and women’s health care
1.Prenatal care:
Nurses work closely with obstetricians and midwives to provide prenatal care to
expectant mothers.
They perform initial assessments, take medical histories, and conduct P/E
They also monitor fetal development, perform ultrasounds, and educate women
about healthy lifestyle choices during pregnancy.
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The nurses ‘role in maternity and women’s health care…
2.Intrapartum care:
Nurses play a critical role in labor and delivery.
They provide emotional support to laboring women, monitor vital signs,

administer medication, and assist with pain management techniques, such as
relaxation techniques and epidurals.
They also monitor fetal heart rate during labor and assist with fetal monitoring
devices.
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3.Postpartum care:
After delivery, nurses provide care to both the mother and newborn.
They help with breastfeeding support, educate mothers on postpartum self-

care, monitor vital signs, assess wound healing, and assist with newborn care,
such as bathing and feeding.
They also provide emotional support and educate new mothers about
newborn care and parenting techniques.
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4.Gynecological care:
Nurses play a vital role in providing gynecological care to women of all ages.
They perform routine examinations, such as Pap smears and breast

examinations, and educate women on contraception methods and family
planning.
They also provide support and care for women experiencing gynecological
issues, such as menstrual irregularities, pelvic inflammatory disease, and
menopause.
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5. Health promotion and education:
Nurses educate women about overall health promotion and disease prevention.
 They provide information on healthy lifestyle choices, such as diet and

exercise, and prenatal and postpartum support.
They also educate women about STI, cancer prevention, and routine
screenings.
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6.Advocacy and emotional support:
Nurses advocate for women’s rights, choices, and healthcare needs.
They provide emotional support during various stages of pregnancy and

childbirth, as well as during gynecological examinations and procedures.
They ensure women are informed and empowered to make informed decisions
about their health and well-being.
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In summary, nurses play a multifaceted role in maternity and women’s health
care.
They provide comprehensive care, promote health and well-being, offer

emotional support, and act as advocates for women.
Their expertise and compassionate care contribute significantly to the overall

well-being of women in all stages of life.
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Caring for the family in a culturally diverse society
• In a culturally diverse society, care of the family involves understanding and

respecting the different cultural practices, values, and beliefs that families may
hold.
• It requires taking into account the diverse needs, perspectives, and experiences
of families, and recognizing that there is no one-size-fits-all approach to family
care.
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Care of the family in a culturally diverse society…
• Here are some key considerations for providing care to families in a culturally
diverse society:
Cultural sensitivity:
Healthcare providers should take the time to educate themselves about different
cultural practices, beliefs, and values that may impact family dynamics and care
decisions.
This includes being aware of religious practices, dietary restrictions, traditional

healing practices, and cultural norms around family roles and responsibilities.
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Language and communication:
• Communication is crucial in understanding and meeting the needs of diverse families.
• Healthcare providers should make efforts to provide communication support for

families with limited local language proficiency, such as interpretation services or
translated materials.
• they should be open to different communication styles and ensure that information is
presented in a way that is culturally appropriate and easily understood.
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Collaborative decision-making:
In a culturally diverse society, families may come from different cultural
backgrounds where decision-making processes may vary.
Healthcare providers should strive for shared decision-making, involving the

whole family in the care process,
while respecting the cultural norms and values that guide decision-making
within each family.
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Respect for diversity:
Families in a culturally diverse society may have different family structures,

including extended families, or single-parent families.
It is crucial for healthcare providers to recognize and respect these diverse
family structures and provide appropriate support and care.
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Recognizing health disparities:
• Healthcare providers should be mindful of health disparities that may

disproportionately affect certain cultural or ethnic groups.
• They should aim to provide equitable and inclusive care, addressing social
determinants of health and working towards reducing these disparities.
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Cultural competence training:
• Healthcare providers should receive ongoing training and education to

increase their cultural competence and sensitivity.
• This includes learning about different cultures, histories, and health beliefs to
better understand and provide compassionate care to culturally diverse
families.
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Community involvement:
• Building partnerships with community organizations and leaders from different

cultural backgrounds can enhance the care provided to families.
• This can help healthcare providers gain insight into specific cultural needs and
resources, as well as facilitate mutual trust and collaboration.
• By implementing these strategies, healthcare providers can enhance the care they
provide to families in a culturally diverse society, promoting better health outcomes
and overall well-being for all families, regardless of their cultural background.
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Unit Two: Anatomy and physiology of female reproductive
system
Presentation outline
 Objectives
 Female pelvis:
 Bones of the pelvis
 Pelvic bone joints
 Pelvic bone ligaments
 Divisions of the pelvis
 Diameters of the pelvis
 Types of pelvis
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Objectives
At the completion of this session the students should be able to
• Describe the anatomy of female pelvis
• Discuss the female reproductive organs
• Relate the bony pelvis and other reproductive organs to pregnancy and
delivery
• List different types of female pelvis
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Anatomy of bony pelvis
Functions -Female pelvis
• To support and protect the pelvic contents.
• Important to childbearing
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Cont…
Pelvis
• The pelvis resembles a bowl or

basin;
• Its sides are the innominate

bones, and its back is composed
of sacrum and coccyx.
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Bony structure
Made up of four bones;
• Two innominate or hip bones
• One sacrum
• One coccyx (or tailbone).
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Features of Hip Bone
Ischial ramus +
Pubic ramus
= ischiopubic ramus
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Cont…
The ilium
• Is the broad upper prominence of the hip.
• The iliac crest is the margin of the ilium
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Cont…
The ischium
• The strongest bone lies under the ilium and below the
acetabulum.
• Has large prominence known as the ischial tuberosity

which the weight of seated body rests.
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Cont…
• The ischial spines arise near the
junction of the ilium and ischium
and project in to the pelvic
• The shortest diameter of the pelvic
cavity is located between the
ischial spines.
• The ischial spine can serve as a
reference point during labour to
evaluate the station of the fetal
head.
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Cont…
The pubis
• Bowed front portion of the innominate bone.
• Extended medially from the acetabulum the midpoint of the bony pelvis, the
two pubic meet to form a joint
symphysis pubis.
• The triangular space below this junction is known as the pubic arch.
• The space enclosed by the body of the pubic bone the rami and the ischum
is called
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the obturator foramen. K.A 47
Cont…
The sacrum
• a wedge shape bone consist of the fussed vertebrae .the upper border of the
first sacral vertebra is known as the sacral promontory .
• The anterior surface of the sacrum is concave and is referred to as the
hallow of the sacrum
• The coccyx
• The small triangular bone last on the vertebral column.
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PELVIC BONE
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Cont…
Greater sciatic
Anterior superior iliac foramen
spine
Ilium
Sacrospinous ligament
Ischial spine
Pubis
Lesser sciatic foramen
Sacrotuberous ligament
Symphysis pubis Ischium
Obturator foramen
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Pelvic joints
There are four pelvic joints
• One symphysis pubis Sacro-coccygeal Joint
• Two sacro-illiac joint
• One sacro-coccygeal joint
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Cont…
The symphysis pubis
• A cartilaginous joint formed by junction of the two
pubic bones along the midline.
The sacro -iliac joints
• The strongest joints in the body; Join the sacrum to the
ilium and thus connect the spine to the pelvis
The sacro- coccygeal joint
• Formed where the base of the coccyx articulates
with the tip of the sacrum.
• In non pregnant slight movement
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Pelvic ligaments
Ligaments hold each of the pelvic joints together
• Interpubic ligaments at the symphsis (1)
• sacro iliac ligament (2)
• sacro coccygeal ligament
• sacro tuberous ligament (2)
• sacro spinous ligament (2)
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Pelvic division
Pelvic cavity divided into the false pelvis and the true pelvis
False pelvis
• The portion above the pelvic brim, bounded by the lumbar vertebra posteriorly,
the iliac fossae laterally, and the lower abdominal wall anteriorly
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Cont…
The true pelvis
• Portion that lies below the pelvic brim
• Represents the bony limits of the birth canal.
• It is extremely important in childbearing because its size and shape must

be adequate for normal fetal passage during labour and at birth.
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Boundaries of Pelvis
False pelvis
Iliac
fossa
False
pelvis
True pelvis
True pelvis
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Cont...
The true pelvis consists of three parts
Inlet,
Pelvic cavity, and
 Outlet.
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The Pelvic Inlet (Brim):-
Boundaries
 Sacral promontory,
 Ala of the sacrum,
 sacroiliac joints,
 iliopectineal lines,
 iliopubic eminencies,
 upper border of the superior pubic rami,
 pubic tubercles,
 pubic crests and
 upper border of symphysis pubis.
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Boundaries of Pelvic Inlet
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Diameters of pelvic brim/inlet
(A) Antero -posterior diameters:
Anatomical antero-posterior diameter (true conjugate) = 11cm
 from the tip of the sacral promontory to the upper border of the symphysis pubis.
Obstetric conjugate = 10.5 cm
 from the tip of the sacral promontory to the most bulging point on the back of
symphysis pubis which is about 1 cm below its upper border.
It is the shortest antero-posterior diameter.
Diagonal conjugate = 12.5 cm
 i.e. 1.5 cm longer than the true conjugate. From the tip of sacral promontory to the
lower border of symphysis pubis.
External conjugate = 20 cm
 from the depression below the last lumbar spine to the upper anterior margin of the
symphysis pubis measured from outside by the pelvimeter . It has not a true
obstetric importance.
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Diameters
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(B) Transverse diameters:
Anatomical transverse diameter =13cm
 between the farthest two points on the iliopectineal lines.
 It lies 4 cm anterior to the promontory and 7 cm behind the
symphysis.
 It is the largest diameter in the pelvis.
Obstetric transverse diameter:
 It bisects the true conjugate and is slightly shorter than the
anatomical transverse diameter.
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(C) Oblique diameters:
Right oblique diameter =12 cm
from the right sacroiliac joint to the left iliopectineal
eminence.
Left oblique diameter = 12 cm
from the left sacroiliac joint to the right iliopectineal
eminence.
Sacro-cotyloid diameters = 9-9.5 cm
from the promontory of the sacrum to the right and left
iliopectineal eminence, so the right diameter ends at the
right eminence and vice versa.
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Oblique diameter
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Sacro-cotyloid diameters
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Pelvic cavity
• Extends from the brim above to the outlet below .

• Is a curved canal with a longer posterior than anterior
wall.
• All the diameters of the cavity considered to be 12 cm.
• Anteroposterior diameter
• Oblique diameter 12cm
• Transverse diameter
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The Pelvic Cavity…
The boundaries of which are:
The roof is the plane of pelvic brim
The floor is the plane of least pelvic dimension
Anteriorly the shorter symphysis pubis
Posteriorly the longer sacrum
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3. The pelvic outlet
Diamond-shaped
Is the lower border of the true pelvis
Diamond shaped pelvic outlet
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The Pelvic Outlet
It is bounded by;
 the lower border of symphysis pubis,
 pubic arch,
 ischial tuberosities,
 sacrotuberous and sacrospinous ligaments and,
 tip of the coccyx.
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Diameters of pelvic outlet
Antero - posterior diameters:
o Anatomical antero-posterior diameter =11cm
 from the tip of the coccyx to the lower border of symphysis pubis.
o Obstetric antero-posterior diameter = 13 cm
 from the tip of the sacrum to the lower border of symphysis pubis as the
coccyx moves backwards during the second stage of labour.
Transverse diameters:
o Bituberous diameter = 11 cm
 between the inner aspects of the ischial tuberosities.
o Bispinous diameter = 10.5 cm
 between the tips of ischial spines.
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3. The pelvic outlet…
Oblique diameter
Is said to be between the obturator foramen and sacrospinous ligament,

though there are no fixed points.
The measurement is taken as being 12cm
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Measurements of pelvic canal in centimeters
Brim Cavity Outlet
Transverse 13 12 11
Oblique 12 12 12
AP/OC 11 12 13
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TYPES OF PELVIS OF FEMALE PELVIS
Caldwell- Moloy Classification of Pelvic Types
1. The Gynaecoid (true female pelvis) (50%)
2. The android (male type pelvis) (20%)
3. The anthropoid (ape type pelvis) (25%)
4. The platypelloid (flat pelvis) (5%)
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Gynacoid pelvis
True female pelvis
• Has round brim and blunt ischial spines
• Straight side walls
• Shallow cavity
• Well curved sacrum
• Pubic arch 90"
• Best suited for child birth

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Android pelvis
• It resembles the male pelvis.
• Heart shaped brim.
• Narrow fore-pelvis.
• The side wall is converged.
• The ischial spins are prominent.
• Pubic arch <90"
• Predisposes to an occipito posterior position

and is the list suited to child bearing
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Anthropoid
• Long and oval shape brim.
• The anteroposterior diameters are longer

than transverse.
• The ischial spins are not prominent
• The side wall is diverged and the sacrum is

long and deeply concave
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Platypelloid pelvis
• Flat pelvis
• kidney shape brim
• the anteroposterior diameters is reduced and the

transverse is increased.
• Blunt ischial spins
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Comparison of pelvis
Features Gynaecoid Android Anthropoid Platypelloid
Pelvic brim Round Heart shaped oval Flat
Fore pelvis Generous Narrow Narrow Wide

Sacrum Curved Straight Deep concave Flat
Side walls Straight Converges Diverges Diverge

Ischial spines Blunt Prominent Blunt Blunt
Sciatic notch Wide Narrow Wide Wide
Pubic angle 90 degree < 90 degree > 90 degree > 90
Incidence 50% 20% 25% 5%

Labour outcome
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Good OPP K.A
Fairly good Deep at inlet 92
Types of pelvis…cont’d
Possible effects on labour
The Gynaecoid pelvis:
 The head usually engages in transverse or oblique diameter in a round brim.
 Labour: Prognosis- Good ,unless there are other cxns eg. Malpresentation, big baby
The Android pelvis:
 The head engages in the transverse diameter.
 Will be excess moulding and labour will be delayed
 Deep transverse arrest often occurs;
 Danger: Deep perineal laceration
 Labour: Prognosis: Poor
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Types of pelvis…cont’d
The Anthropoid pelvis:
The head engages in the anteroposterior diameter
Occipito posterior position often occurs
Labour: face –to – pubis is common.
Prognosis: Fairly good
 The Platypelloid pelvis:
The head engages in transverse diameter.
 Labour: Delay at inlet is the problem
Once the inlet is passed, labour prognosis will be good.
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Prognosis: Depends on the inlet K.A 94
Pelvic assessment
Why pelvic assessment?
To determine adequacy of the pelvis
When to do pelvic assessment

Prenatal- during late pregnancy (for primi ≥ 38wks)
Intranatal - during labour
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Pelvic assessment…cont’d
 Methods of pelvic assessment

a) Body build
b) Clinical pelvimetry
c) Radiologic Assessment of the Pelvis
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2. Clinical
2. Clinical
Measurement of Diagonal conjugate:

Normal: 13 cm
OBC= DC-2cm
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3. Radiologic Assessment of the Pelvis
X-ray pelvimetry
 Is rarely used today
When an accurate measurement of the pelvis is indicated, MRI may

be used
The advantage of MRI over x-ray or CT for pelvic ass’t is the lack
of ionizing radiation exposure
Indications
Clinical evidence or obstetric history suggestive of pelvic abnormalities
A history of pelvic trauma

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Radiologic Assessment of the Pelvis
X-ray pelvimetry is rarely used today. When an accurate
measurement of the pelvis is indicated, nuclear magnetic
resonance imaging (MRI) may be used.
• The advantage of MRI over x-ray or computerized
tomography (CT) for pelvic assessment is the lack of
ionizing radiation exposure
Indications
• Clinical evidence or obstetric history suggestive of
pelvic abnormalities.
• A history of pelvic trauma.
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PELVIC FLOOR OR PELVIC
DIAPHRAGM
• Designed to overcome the force of gravity exerted on
the pelvic organs.
• Supporting structure to the irregularity of pelvic out let
• Providing stability and support for surrounding structure
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Functions
• Supports the weight of the
abdominal and pelvic organs
• Responsible for the voluntary

control of maturation defecation
• Influences the passive movement

of the fetus through the birth
canal and relaxes to allow its exit
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from the pelvic K.A 106
Important muscles of pelvic floor
Superficial layers
The deep layer-
• External anal sphincter
• Puboccygeus
• Transverse perineal Reading
• Iliococcygeus Assignm
• Bulbocavernosus
• Ischiocavernosus
• ischiococcygeus ent
• Membranous sphincter of
the urethra
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Female reproductive system
Consists of the
External
Reading
Internal assignment
Accessory organ of breast.
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The Menstrual Cycle
Out line of the presentation

Objectives
Introduction
Normal menstrual function
Ovarian cycle
Endometrial(uterine) cycle
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Objectives
After completing this section, the students will able to:
Describe the normal menstrual function
Discuss ovarian cycle
Describe endometrial(uterine) cycle
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The menstrual cycle
menstrual cycle: is a cyclic change in female
reproductive function approximately every 28 days in
the reproductive age women
Normal Menstrual Cycle
mean duration of the MC Mean 28 days (only 15% of )
Range 21-35
average duration of menses 3-8 days
Normal estimated blood loss Approximately 30 ml
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Ovarian cycle
Is a series of monthly repetitive physiological and
dev’tal changes in the ovaries
This changes prepare the ovaries for ovulation and

subsequent dev’t of corpus luteum whose hormones will
assist in regulating the uterine cycle and
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Ovarian cycle…
Hormonal changes:
Estrogen
Gradually increases during days 1-14; signals body to thicken the lining of
the uterus
Levels drop sharply after ovulation
 Progesterone
Levels remain low during the first half of the cycle and then increase
sharply during the second half of the cycle.
Maintaining the growth of the endometrium lining.

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Ovarian cycle…
The changes that occur in the ovary during each cycle can be divided
into three phases:
1) Follicular phase (day 1-13 )
2) Ovulatory phase (day 13-15)
3) The luteal phase (day 15-28)
These phases run in parallel with the phases of the uterine cycle and
together comprise the menstrual cycle
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If conception doesn’t occur successfully:
 Corpus luteum regresses and menstruation occurs
 Drops in steroid sex hormones
 leads to a rise in gonadotrophin levels (FH and LSH)
 initiate next cycle
 Corpus luteum: solid body formed in an ovary after the ovum has
been released into the fallopian tube
 Some women get pain before rupture –called Mittelschmerz
 characterized by cramping in lower abdomen that occurs during
ovulation
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Luteal phase lasts 14 days – then there is a regression of corpus
luteum decline in oestrogen and progesterone •
This leads to a intense spasmodic contraction of spiral section of
endometrial arterioles ischaemic necrosis shedding of superficial
layer bleeding.
• These spasms are associated with prostoglandin, which are also
associated with increased uterine contractions during menstrual flow.
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The menstrual cycle…cont’d
The uterine cycle
periodic discharge of blood, mucus, and epithelial cells

from the endometrium of the uterus that takes place
about 28 days in an adult woman throughout
reproductive period of life except during pregnancy, or
lactation or menopause
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Phases in uterine cycle
1) The proliferative phase
2) Secretory phase
3) Menstrual phase
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1. The proliferative phase
Commences five days after cessation of menses and lasts till ovulation
under the influence of estrogen.
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2. The secretory phase
Corresponds to the luteal phase and follows ovulation
under the influence of progesterone predominantly from

the corpus luteum
The thickness of the endometrium is 2.5mm
If fertilization does not take place, the endometrium

shows degenerative changes which is followed by
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3. The menstrual phase
Characterized by vaginal bleeding lasting 3-5 days
Physiologically this is the terminal phase of menstrual cycle when the

endometrium is shed down to the basal layer along with blood from the
capillaries and with unfertilized ovum
Approximately 75% of menstrual blood is arterial and 25% is

venous.
An excess of fibrinolytic activity might well impair haemostatic plug

formation in the spiral arterioles and explanation for excessive
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menstrual blood loss.
Unit Three: Introduction to Embryology and Fetal Development
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Objectives
At the end of this presentation the students will be able to;
Describe development and physiology of ovum and embryo.
Describe development and physiology of the fetus
Describe development of placenta, anatomical variations and its function
Describe development of amniotic fluid, and its function
Discuss fetal circulation
Explain what will happen to fetal circulation after birth
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Embryology and Fetal Development
Pregnancy is a sequence of events that normally includes:

Fertilization
Implantation
Embryonic growth, and
Fetal growth that terminates in birth
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Fetal development … cont’d
Fertilization -The joining together of the ovum (egg) and
sperm cells
 Occurs at ampulla of the fallopian tube, outer third of the fallopian tube
 Also called conception, impregnation ,fecundation
Zygote-Fertilized ovum
Cleavage :the series of synchronized mitotic cell divisions of the fertilized
egg
Blastomeres :a cell produced during cleavage of a fertilized egg
Morula :Is a globular, mass of cells, formed as the blastomeres continue to
divide
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The decidua
 The name given to the thick endometrial during pregnancy
 Increase secretion of estrogen help endometrial to grow 4x
Implantation:
 Is embedding or attachment of blastocyst to endometrium (decidua)
It normally occurs in the upper, posterior wall of the uterus
The point of implantation becomes the origin for the placenta and umbilical cord
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Diagram of blastocyst stage
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Blastocyst
Trophoblast Inner cell mass
Umblic Amnio Fetus

Placenta Chorion al cord n
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Blastocyst: An embryo that has developed for 5 to 7 days after fertilization
 Consists of two primary cell types/Layers :
An outer layer of cells (trophoblast)

 A layer surrounding the inner cell mass and the blastocyst cavity (blastocoele)
 It will form the placenta and fetal membranes
 An inner cell mass

 Also known as the "embryoblast“
 At one pole it will form the embryo, and a fluid filled cavity
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a) Inner cell mass (embryo blast):
 A group of cells found in blastocyst that give rise to the embryo and are
potentially capable of forming all tissues, embryonic and extra
embryonic, except the trophoblast
 The ICM differentiates into two types of cells, epiblast and hypoblast.
The epiblast give rise to:
 Cells inside the embryo
 All three germ layers of the definitive embryo, as well as extra embryonic
endoderm, mesoderm and ectoderm
Hypoblast cells
 Form only extra embryonic tissue (extra embryonic endoderm)
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b. Outer layer of cells /Trophoblast (trophoderm):
The outermost layer of cells of the blastocyst that attaches the fertilized ovum
to the uterine wall
 Serves as a nutritive pathway for the embryo
 Develop into a large part of the placenta
It proliferates and differentiates into two cell layers:
1) Cytotrophoblast(layer of Langhans)
The syncytiotrophoblast
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1) Cytotrophoblast(layer of Langhans)
Inner layer of the trophoblast
Produce HCG responsible for thicken a person’s uterine lining
Protect embryo from infection (syphilis)
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2) Syncytiotrophoblast /syncitial layer
Outer thick layer and grows into the endometrial stroma
Is multinucleated cells found in the placenta of embryos
It secretes placental hormones HCG , progesterone, estrogen and placental

lactogen to sustain a pregnancy
It erodes the wall of the blood vessels of the decidua , making a nutrient in
maternal blood accessible to developing organism
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PRIMARY GERM LAYERS OF EMBRYO

It is layers of inner cell mass
1. Ectoderm
Mainly forms the skin and nervous system
2. Mesoderm
Forms bones and muscles and also the heart and blood vessels including
those in the placenta.
3. Endoderm
 Forms mucous membranes and glands
The three layers together are known as the embryonic plate
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Stages of Growth and Development
Typically divided into three stages.
1) Pre embryonic Stage: Fertilization to 2 to 3 weeks

 Rapid cell division and differentiation
 Develop embryonic membranes and germ layers
2) Embryonic Stage: 4 to 8 weeks' gestation

 Most critical stage of physical development
 Organogenesis
3) Fetal Stage: 9 weeks to birth

 Every organ system and external structure present
 Refinement of fetus and organ function occurs
Development
10/13/2023 by month Reading assign
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Placenta:
 Is an organ that connects the developing fetus to the uterine wall to allow
nutrient uptake, waste elimination and gas exchange via the mother's blood
supply
It develops from the same sperm and egg cells that form the fetus, and functions
as a fetomaternal organ with two components
The fetal part (Chorion frondosum), and
The maternal part (Decidua basalis).
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Development of placenta... cont’d
Function of placenta:
1.Respiration: exchange of fetal O2 and CO2
2.Nutrition: break down amino acids, glucose, Ca, K, Fe…, which are needed and
used by the fetus
3.Storage: stores glucose in the form of glycogen and reconverts it to glucose as
required , iron and fat soluble vitamins
4. Excretion: excretes CO2 and bilirubin as red blood cells
5.Protection: provides limited barrier to infections except T.Palladium
(syphilis),Tubercle , Virus(HIV), Rubella
6. Endocrine : secrets HCG , Estrogen ;Progesterone
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Anatomical variations of the placenta and the cord
a) Succenturiate lobe of placenta
b) Circumvallate placenta
c) Batteledore insertion of the cord
d) Velamentous insertion of the cord
e) Bipariate placenta
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Anatomical variations…cont’d
Succenturiate lobe of placenta
A small extra lobe is present, separate from the main placenta and
joined to it by blood vessels
Danger
Retained in utero after delivery
 Haemorrhage and
 Infection
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Circumvallate/ Circum marginate placenta
opaque ring is seen on the fetal surface
It is formed by a doubling back of the chorion and amnion
Danger
Result in membranes leaving the placenta nearer the center instead of at the edge as
usually
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Battledore insertion of the cord
The cord attached at the very edge of the placenta in the manner of the table
tennis bat
It looks the table of tennis bat
Danger
Likely it is detached up on applying traction during active management of
the third stage of labour
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Velamentous insertion of the cord
 It is inserted into the membranes some distance from the edge of the placenta
The umbilical vessels run through the membranous from the cord to the
placenta
Danger
The vessels may tear with cervical dilatation and
would result in sudden blood loss
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Bipartite Placenta
Two complete and separate lobes are present, each with a cord leaving it
The bipartite cord joins a short distance from the two parts of the placenta.
Danger
The extra lobe may retained during delivery
Hemorrhage and
Infection
Tripartite placenta : is similar but with three distinct lobes.
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Appearance of the Placenta at Term
 Placental size
1st trimester : placenta >foetus
12-14 weeks: placenta=foetus
>14 weeks : placenta< foetus
28 weeks: ratio 1:4
40 week: ratio 1:7
Measures about 20 cm in diameter and 2.5cm thick from its center
• It weighs approximately one sixth of the baby’s weight at term
• It has two surfaces.

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Appearance of the placenta at Term… cont’d
The maternal surface
Maternal blood gives this surface a dark red color and part of the basal
decidua will have been separated with it.
The surface is arranged in about 20 lobes which are separated by sulci
(furrows)
The fetal surface :

The amnion covering the fetal surface of the placenta gives it whitish, shiny
appearance.
Branches of the umbilical vein and arteries are visible and spreading out from
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insertion of the umbilical cord which
K.A
is normally in the center. 152
Appearance of the Placenta at Term… cont’d
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FETAL MEMBRANES
There are four fetal membranes : the amnion,

chorion, yolk sac, and allantoids
1) Amnion:
 A thin, tough, translucent membranous sac
derived from the inner cell mass and encloses the
embryo
 It is the inner membrane
 It is thought to have a role in the formation of
amniotic fluids (also termed as liquor amnii).
 It contains amniotic fluid
2. Chorion:
In Greek, the word Chorion" means "skin or leather.“
It is the outer, thick, opaque, friable membrane
derived from the trophoblast
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Fetal membranes…cont’d
3. Allantois:
 A membranous sac that develops from the posterior part
of the alimentary canal in the embryos
 It is important in the formation of the umbilical cord
and placenta
4. Yolk sac:
 A membranous sac attached to an embryo, providing
early nourishment
 Functioning as the circulatory system of the embryo
before internal circulation begins
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AMNIOTIC FLUID
Is a clear, slightly yellowish liquid that

surrounds the unborn baby (fetus) during
pregnancy.
 It is contained in the amniotic sac.
It constantly moves (circulates) as the baby

swallows and "inhales" the fluid, and then
releases, or "exhales," the fluid through urine
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Amniotic fluid…cont’d
Function
Allows muscles and bones develop providing free movements of the fetus
Equalizes pressure and protect the fetus from jarring and injuries
Maintain constant temp. for the fetus and provide small amount of nutrient
Protects against infection
Prevents the umbilical cord from becoming compressed and reducing baby's
oxygen supply
Aids lungs to develop properly
Aid effacement of cervix and dilatation

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Origin /Where does amniotic fluid come from?
The source is thought to be both fetal and maternal
It is secreted by amnion, especially the part covering the placenta and umbilical
cord
Fetal urine also contribute to the volume from the 10 th week of gestation onwards.
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Volume
The total amount of amniotic fluid increases throughout pregnancies until 38

weeks’ gestation, when there is about 1 liter
It then diminishes slightly until terms, when approximately 800ml remains
If the total amount exceed 1500 ml :

Polyhydramnios ( often abbreviated as hydramnios)
If less than 300 ml : oligohydamnios
Such abnormalities is often associated with congenital malformation

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UMBLICAL CORD (FUNIS)
Is a narrow tube-like structure that connects the fetus to the placenta
It is sometimes called the baby's “supply line” because it carries the baby's
blood back and forth, between the baby and the placenta.
It delivers nutrients and oxygen to the baby and removes the baby's waste
products.
It begins to form at five weeks after conception.

 It becomes progressively longer until 28 weeks of pregnancy, reaching an
average length of 50 cm
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Umblical Cord…cont’d
The cord contains three blood vessels: two arteries and one vein.
The vein
Carries oxygen and nutrients from the placenta (which connects to the
mother's blood supply) to the baby
The two arteries
Transport waste from the baby to the placenta (where waste is transferred to
the mother's blood and disposed of by her kidneys).
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Problems of conception and implantation
• There are several potential problems related to conception and implantation.

Some of these include:
1. Infertility: Infertility is the inability to conceive after actively trying for a

year or more without using any form of contraception.
It can be caused by various factors, such as hormonal imbalances, structural

abnormalities, reproductive organ issues, or genetic conditions.
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Problems of conception and implantation…
2. Ovulation disorders: Anovulation or irregular ovulation can hinder

conception as it prevents the release of an egg from the ovary.
 Conditions like polycystic ovary syndrome (PCOS): a common hormonal

disorder that affects ovaries in women during childbearing years and
hormonal imbalances can lead to ovulation disorders.
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3. Sperm issues: Problems with sperm count, motility, or morphology can make it
difficult for sperm to reach and fertilize an egg.
 These problems can be caused by genetic conditions, hormonal imbalances,

infections, or lifestyle factors such as smoking and excessive alcohol consumption.
4. Fallopian tube blockage: can prevent the fertilized egg from traveling into the
uterus for implantation.
This can be caused by infections, endometriosis, pelvic inflammatory disease, or

previous surgeries.
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5. Uterine abnormalities: Structural abnormalities of the uterus, such as uterine fibroids,

polyps, or adhesions, can interfere with implantation or cause recurrent miscarriages.
6.Autoimmune disorders: Certain autoimmune disorders, such as antiphospholipid

syndrome or lupus, can disrupt the implantation process or lead to recurrent miscarriages.
7. Age-related issues: As women age, the quality and number of their eggs decline,
reducing the chances of successful fertilization and implantation.
Advanced maternal age also increases the risk of chromosomal abnormalities in

embryos.
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8. Hormonal imbalances: Hormonal imbalances, such as inadequate
production of progesterone, can affect the thickening and maintenance of the
uterine lining, making implantation difficult.
9. Genetic disorders: Genetic abnormalities in either partner can reduce

fertility and increase the risk of miscarriages or implantation failure.
10. Environmental factors and lifestyle choices: Factors such as exposure to

toxins, high levels of stress, poor diet, obesity, or excessive exercise can
negatively impact fertility and implantation
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Fetal Circulation
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Umbilical Circulation
Pair of umbilical arteries carry deoxygenated blood and wastes to placenta.
Umbilical vein carries oxygenated blood and nutrients from the placenta.
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Placental circulation
Fetal blood, low in oxygen, is pumped by the fetal heart towards the placenta along the
umbilical arteries.
Having absorbed oxygen, the blood returned to the fetus via umbilical vein.
Temporary structure
a) Umblical vein
b) Ductus venosus
c) Formen ovale ( oval opening)
d) Ductus arteriosus
e) Hypogasteric aretries
173
Umbilical vein to portal circulation
Some blood from the umbilical vein enters the portal circulation allowing the
liver to process nutrients.
The majority of the blood enters the ductus venosus, a shunt which bypasses
the liver and puts blood into the hepatic veins.
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Foramen ovale
Blood is shunted from RA to LA,
skipping the lungs.
More than one-third of blood takes this

route
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Ductus arteriosus
The blood pumped from the RV enters
the pulmonary trunk
Most of this blood is shunted into the

aortic arch through the ductus
arteriosus
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Ductus venosus
From a vein to a vein
Connects the umbilical vein to the inferior venacava
At this point the oxygenated blood mixes with deoxygenated blood returning from lower parts of
the body.
Thus the blood throughout the body is at best partially oxygenated.
Hypogasteric arteries
Branch off from the internal iliac arteries and become umbilical arteries when they enter the
umbilical cord
They return blood to the placenta
N.B.This
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K.A unmixed blood 177
What happens at birth?
The change from fetal to postnatal circulation happens very quickly.
Changes are initiated by baby’s first breath
At birth the baby takes a breath and blood is drawn to the lung through the pulmonary
arteries.
It is then collected and returned to left atrium via the pulmonary veins resulting in sudden
inflow of blood
The placenta circulation ceases soon after birth and so less blood return to the right side
of the heart.
In this way the pressure in the left side of the heart is greater than the right
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What happens...cont’d
This result in closure of a flop over the foramen ovale which separate the two side of the
heart and stops the blood flowing from the right side
With the establishment of pulmonary respiration, the oxygen concentration in the

bloodstream rises
This cause the ductus arteriosus to constrict and close
The cessation of placental circulation result in collapse of umbilical vein, the ductus
venosus and hypogastric arteries
The structure get the following changes :-
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What happens...cont’d
Foramen ovale Closes shortly after birth, fuses completely in first year (fossa
ovalis)
Ductus arteriousus Closes soon after birth, becomes ligamentum arteriousum in

about 3 month
Ductus venosus Ligamentum venosum during first few months
Umbilical arteries Medial umbilical ligaments during first few months
Umbilical vein Ligamentum teres during first few months

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Diagrammatically
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Problem with persistence of fetal circulation
Patent (open) ductus arteriosus and patent foramen ovale each

characterize about 8% of congenital heart defects
Both cause a mixing of oxygen-rich and oxygen-poor blood; blood

reaching tissues not fully oxygenated. Can cause cyanosis.
Surgical correction now available, ideally completed around age

two
Many of these defects go undetected until child is at least school

age.
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FETAL SKULL
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Fetal skull…cont’d
Divisions of the fetal skull
 Is divided into three parts
1) The vault
2) The face
3) The base
1.The vault
 Extends from the orbital ridges to the nape of the neck
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Bones of the vault
1) The occipital bone
 Lies at the back of the head and forms the region of the
occiput
2) The two parietal bones
 Lie laterally with their ossification center called parietal
eminence
3) The frontal bones
 Lie anteriorly with their ossification centers called frontal
eminence.
 They form the forehead with land mark sinciput.
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Fetal2.skull…cont’d
The face
 Extends from the orbital ridges and root of the nose to the
junction of the chin and the neck
 The chin is termed as the mentum and is an important land mark
in face presentation
3. The base
 Composed of bones united to afford protection to the vital centers in
the medulla
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Sutures and Fontanels
Sutures
 are cranial joints or membranous spaces between the skull bones
10/13/2023 K.A 191

Types of sutures
 Frontal suture(1) : divides the frontal bones into Rt and Lt
 Coronal sutures(2) : separate the Rt and Lt parietal and frontal
bones
 Sagital suture (1) : separates the parietal bones into two
 Lambdoidal sutures (2) : separate the parietal bones from the
occipital bone
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Clinical Importance Of Suture
Permit gliding movement of one bone over other during molding of the
head in the vertex presentation , as a result the diameter of the head get
smaller so passage of head through the birth canal become easier
 Used to identify attitude and position of vertex
From the digital palpation of the sagittal suture during labour, degree of
internal rotation and degree of moulding can be noticed
Attitude: is the relationship of the fetal parts to one another or the degree of
flexion or extension of the fetal head on the neck to determines which
diameter will present in labour and therefore influences the outcome
Presentation: the part of the fetus which lies in the lower uterine pole of the
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uterus (E.g. vertex, face brow, or breech)
Fontanels
 Are membranous spaces where two or more sutures meet.
 There are two important fontanels
1. Anterior fontanel or bregma

 Found at the junction of the sagittal , coronal, and frontal sutures
 Diamond in shape and broader,
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 Recognizable vaginally because a suture leaves from each of the
four corners
 Pulsation of cerebral vessels can be felt
 Measures 3-4 cm long and 1.5 -2 cm wide
 Normally closes by the time the child is 18 months old
 If felt on V/E indicates that the head is not well flexed and large
circumference is attempting to pass through the birth canal and
 Labour is likely to be prolonged and more difficult.
 ICP can be roughly assessed from its condition after birth.
Depression in dehydration and bulging in raised ICP.
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2. The posterior fontanel or lambda:
 Situated at a junction of the lambdodial and sagital sutures.
 Small, triangular in shape and can be recognized vaginally
because a suture leaves from each of the three angles
 Normally closes by 6-8 weeks of age
 If felt on vaginal examination, indicates that the fetus lies with a
well flexed attitude allowing the smaller circumference of the
skull to pass
 Indicates the position of the fetus
Lie : Long axis of fetus to long axis of mother(longitudinal)

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Landmark of Fetal skull
 Occiput:- is the occipital bone/external occipital protuberance.
 The brow/ Sinciput:- the area bounded by the orbital ridges and
coronal sutures, composed of frontal bones
 Parietal eminences:- are the eminences of parietal bone on either side.
 The vertex: the highest point of the fetal skull bounded in front, by
anterior fontanel, behind, by posterior fontanel, laterally, by parietal
eminence
 Mentum:- is the chin.
 Vertical point:- is the center of sagittal suture.
 Frontal point:- is the root of nose.
 Sub occiput:- it is the junction fetal neck and Occiput.
 Sub mentum:- it is the junction between neck and chin.
 Bi parietal:- is the transverse distance b/n two parietal eminences.
 Bi temporal :- is the distance b/n two lower end of coronal suture
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Diameters of the fetal skull
1. Suboccipitobregmatic – 9.5cm
2. Submentobregmatic – 9.5cm
3. Suboccitofrontal – 10cm
4. Submentovertical 11cm
5. Occipiofrontal – 11.5 cm
6. Occipitomental – 9.5cm
7. Mentovertical – 13.5cm
8. Biparietal – 9.5cm
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Presenting part
 the part of the fetus that lies over the cervical os and felt on vaginal
examination
Presenting diameter
 is that which lies at a right angle to the curve of carus/ pelvic axis
Position : Relation of the denominator to the different parts of pelvis
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Molding of the fetal head
Definition: the term used to describe the change in the shape of the
fetal skull which occurs during its passage though the birth canal,
because of the overlapping of the skull bones at sutures.
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GRADING
Grade 0:- the Grade++:- Grade+++:-

Grade +:- the
bones lies side overlapping but fixed
bone touching
by side having easily overlapping
but not
an intervening separated by and cannot be
overlapping
membrane. pressure. separated.
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There are two conditions that can arise during labour and both cause
a swelling on the infant head.
1) Caput succedaneum
2) Cephalhaematoma
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Caput succedaneum
It is localized area of edema on fetal scalp on vertex presentation due to
pressure effect of dilating cervical ring and vaginal introitus.
 Characteristics
• It is physiological
• Present at birth and disappears
within 24hrs
• It is soft, diffuse and pits on pressure
• No underlying skull fracture
 A swelling on one side of the newborn's head is a danger sign and should
be referred urgently; blood or other fluid may be building in the baby's
skull.
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Caput succedaneum cont…
Mechanism:-
Pressure effect of dilated cervical ring and vaginal introitus on descending head
interference normal venous return and lymphatic drainage
stagnation of fluid
appearance of swelling in the scalp
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Cephalohematoma
• It is collection of blood b/n periosteal and skull bone
which is limited by the periosteal attachments at the
suture lines.
• Characteristics
• Appears after 12hrs of birth
• Limited by suture line
• Tends to grow larger
• Disappear within 6-8 weeks
• It is circumscribed , soft and non pitting
• May be associated with skull bone fracture
• May be treatment required
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• The blood is absorbed and theK.A
swelling is subside 213
DIFFERENCES
CAPUT SUCCEDANEUM CEPHAL HAEMATOMA

1. Present at birth on normal vaginal 1. Appears within a few days after birth
delivery. on normal or forceps delivery.
2. May lie on sutures, not well defined. 2. Well defined by suture, gradually
developing hard edge.
3. Soft, pits on pressure. 3. soft, elastic but does not pits on

pressure.
4. Size largest at birth , gradually 4. Become largest after birth and then
subsides within a day. disappears within 6-8 weeks to few
months.
5. No underlying skull bone fracture. 5. May underlying skull bone fracture.

6. No treatment required. 6. May be treatment required.
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UNIT FOUR
Physiologic Adaptations to Normal pregnancy
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Normal Pregnancy
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1.Signs and symptoms of pregnancy
Definition: pregnancy is a condition where there is a developing fetus in the uterus.
The average duration of it is nine calendar months or 40 weeks /280 days.
Gestational age based classification of pregnancy:

Less than 28 weeks of gestation = commonly Abortion
28-37 weeks of gestation = preterm pregnancy/labour
37 completed wks or 38-42 wks of gestation = term pregnancy/ labour
Greater than 42 weeks = post term pregnancy/labour
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Signs of pregnancy
Presumptive sign
Probable signs
Positive signs
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Presumptive signs
The least indicative

Includes:
Fatigue
Amenorrhea
Morning sickness
Frequency of micturation
Breast change
Weight gain
Skin change
Constipation
Quickening (1st fetal movement felt by the mother)
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Probable signs
More reliable than presumptive signs
Documented by examiner
Includes:
Change in consistency of uterus and cervix (Chadwick's sign)
Abdominal enlargement
Broxton Hicks contraction – painless irregular uterine
Contraction
Ballottement rebound (16-20wks)
Uterine soufflé - soft sound heard while auscultating FHB and
parallel with maternal pulse
Positive pregnancy test (HCG)
Hegar's sign (softening of the Isthmus/ uterus)
Goodell’s sign softening of the cervix
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Positive signs of pregnancy
Feeling fetal parts on palpation
Seeing fetal movement on inspection
Hearing FHB on Auscultation
Seeing fetal parts by x–ray and ultrasound.
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2.Diagnosis of pregnancy
 The diagnosis of pregnancy requires a multifaceted approach using 3 main diagnostic

tools:
 History and physical examination
 Laboratory evaluation, and
 Ultrasonographic
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2.1 History and physical examination findings
 Menstrual history including:
 Usual menstrual pattern including:
Date of onset of last menses
Duration
Flow, and
Frequency
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History and physical examination findings ….cont’d
Physical examination reveals:
 Enlarged uterus after bimanual examination
 Breast changes
 Softening and enlargement of the cervix (Hager's sign; observed at approximately 6 wk)
 The Chadwick sign is a bluish discoloration of the cervix from venous congestion and can be
observed by 8-10 weeks
 A gravid uterus may be palpable low in the abdomen by 12 weeks
 Currently, through the use of chemical assays and ultrasonography, to make the diagnosis of
pregnancy before many of the physical S/S are evident.

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2.2.Laboratory Evaluation
Several hormones can be measured and monitored to aid in the diagnosis of pregnancy
The most commonly used assays are the beta subunit of hCG.
hCG is detectable in the serum of approximately 5% of clients 8 days after conception and
in more than 98% of patients by day 11
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2.3 Ultrasonography
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Physiologic Changes/Adaptation during Pregnancy
 Are changes that occur in the pregnant women‘s body .
 There may be:
a) Local (to the reproductive organs) or

b) Systemic
 Are caused by several factors:
Maternal endocrine /hormonal

Fetal and placental endocrine
Fetal metabolic rate and physical demands
The women‘s physical adaptation to the changes
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1. Changes of the reproductive organs
A. Uterus
 At term, the uterus will have increased five times its normal size:
 In length from 6.5 to 32 cm
 In depth from 2.5 to 22 cm
 In width from 4 to 24 cm
 In weight from 50 to 1000 grams
 In thickness of the walls from 1 to 0.5 cm
 Blood flow increased
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Changes of the reproductive organs …cont’d
Uterus…
 The capacity of it expand to accommodate
fetus ,the placenta, the umbilical cord , 500 ml to 1000 ml of amniotic fluid, and the fetal
membranes
 The abdominal contents are displaced to the sides as it grows in size, to allows space for it
within the abdominal cavity
 Its size usually reaches its peak at 38 weeks gestation
 It may drop slightly as the fetal head settles into the pelvis, preparing for delivery
 This dropping is referred to as "lightening."
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B. Cervix
 It undergoes a marked softening (Goodell's sign)
 Increased in vasicularity and edematous
 Color bluish (pale pink –violet)
 A mucus plug, known as "operculum" is formed in the cervical canal
 Additional changes and softening of the cervix occur prior to the beginning of labor
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B. Cervix….
Operculum
Result of enlarged and active mucus glands of the cervix
It serves to seal the uterus , protect the fetus and fetal membranes from infection
It expelled at the end of the pregnancy
It may occur at the onset of labor or precede labor by a few days
When it is blood-tinged, it is referred to as a "bloody show.“
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C. Vagina:
 Color changes from normal light pink to a purple blue/deep violet which is known as the
"Chadwick's sign." due to increased circulation to the vagina early in pregnancy
 Decreased in PH due to lactobacilli
 Increases in discharge
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Changes of the breasts

 In early pregnancy, it feels full or tingle, and increase in size as pregnancy
progresses due to increase in estrogen ,progesterone and prolactin
 The areolas of the nipples darken and the diameter increases
 The Montgomery's glands (the sebaceous glands of the areola) enlarge and tend to
protrude
 The surface vessels of it become visible due to increased circulation/Hyper
pgimentation
 By the 16th week (2nd trimester) the breasts begin to produce colostrum
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Systemic
1. Changes of the skin /integumentary system
 Results from alterations in hormonal balance and mechanical stretching
 Includes :
Linea Nigra
 A dark line that runs from the umbilicus to symphysis pubis and may extend as high as the sternum
 It is a hormone- induced pigmentation
 After delivery, it begins to fade, but it may not ever completely disappear
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Systemic…cont’d
1. Changes of the skin /integumentary system…

 Striae Gravidarum (Stretch Marks)
 Pink /reddish steaks on sides the abdomen
 It may be due to the action of the adrenocorticosteroids
 It reflects a separation within underlying connective tissue of the skin
 It occurs over areas of maximal stretch--the abdomen, thighs, and breasts
 It will usually fade after delivery although they never completely disappear
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Systemic…cont’d
Chloasma : Is the brownish hyper pigmentation of the skin over the face and forehead/ chin
 It gives a bronze look, especially in dark-complexioned women
 It begins about the 16th week of pregnancy and gradually increases, then it usually fades after
delivery
 Hyper pigmentation /darken over : nipple, Umbilicus, Axilla, perineal
 Sweat Glands
 Activity of it throughout the body usually increases which causes the woman to perspire more
profusely during pregnancy
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Systemic…cont’d
2. Changes of the circulatory system
 Blood Volume:
 ⇧ses gradually by 30 to 50 %
 This results in ↓se concentration of RBCs and hemoglobin
 This explains why the need for iron is so important during pregnancy
 At term, the body has usually compensated for this decreases and resulting in normal
blood count
 Blood count is interpreted as anemia if the hemoglobin falls below 10.5 grams per 100 ml
and HCT drops below 30%
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Systemic…cont’d
Cardiac Output:
 ⇧ses about 30% during the 1st and 2nd trimester to accommodate for hypervolemia
 A patient with a diseased heart is especially at risk for cardiac decompensation 28 to 35 weeks
of pregnancy when the blood volume and cardiac load are at their peak
 Also, during labor and immediately after delivery when rapid hemodynamic changes occur
 Change in output is reflected in the heart rate
 It usually increases by 10 beats per minute
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Systemic…cont’d
Venous Return:
 The lower extremities are often hampered in the last months of pregnancy due to the expanding
uterus restricting physical movement and interfering with the return of blood flow
 This results in swelling of the feet and legs
Nursing implications:
 Advise the patient to rest frequently
 Have the patient to elevate her feet and legs while sitting
 Remind the patient not to lie in a supine position since this inhibits return blood as the heavy
uterus presses on the vessels
 This leads to the vena cava syndrome or supine hypotension
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Systemic…cont’d
3. Changes of the respiratory system
 The RR rises to 18 to 20 to compensate for ⇧sed maternal oxygen consumption, which is needed
for demands of the uterus, the placenta, and the fetus
 Women may feel out of breath and may need to sit a moment to catch their breath
 Nasal stiffness and epitaxis are common
 Diaphragm displaced up ward( up to 4cm)
 Increased chest diameter
 Lung volume and capacity increases
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Systemic…cont’d
4. Changes of body temperature
 A slight increase in body temperature in early pregnancy is noted
 The temperature returns to normal at about 16th week of gestation
 The patient may feel warmer or experience "hot flashes" caused by increased hormonal level
and basal metabolic rate
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Systemic…cont’d
5. Changes of the urinary system
 The kidneys work extra excreting the mother's own waste products plus those of the fetus due to
this enlarge
 There is an ⇧se in urinary output and a ↓se in the specific gravity
 The patient may develop urine stasis and pyelonephritis in the right kidney due to pressure on the
right ureter resulting from displacement of the uterus slightly to the right by the sigmoid colon
 Frequent urination is a complaint during the 1st through 3rd trimester
 As the uterus rises out of the pelvic cavity in early pregnancy, pressure on the bladder ↓ses and
frequency diminishes.
 When lightening occurs during the final weeks of pregnancy, pressure on the bladder returns to
cause frequency.
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Systemic…cont’d
6. Changes of the skeletal system
 There is a realignment of the spinal curvatures to maintain balance
 It is due to ⇧se in size of the uterus and pressure on the abdominal wall
 The patient walks with head and shoulders thrust backward and chest protruding outward to
compensate
 This gives the patient a "waddling" gait and lordosis causes back ache
 There is a slight relaxation and ⇧sed mobility of the pelvic joints, which allows stretching at the
time of delivery
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Systemic…cont’d
7. Changes of the gastrointestinal system
 Anatomical change:
 As the pregnancy progresses, the uterus enlarges, it rises up and out of the pelvic cavity
 This action displaces the stomach, intestines, and other adjacent organs
 Increased Appetite(pica)
 Gums edematous and softening
 Dental carries due to↓se in PH
 Epulis gravidram :swelling and softening of gingivitis

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Systemic…cont’d
Stomach
 Heartburn (pyrosis) due to relaxation of the cardiac sphincter and may increase
nausea and regurgitation
 Slow gastric emptization
 Delayed gastric acid secretion rate /hydrochloric acid and pepsin
 Increased gastric mucus secretion
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Systemic…cont’d
Intestine
 Peristalsis is slowed b/se of the production of progesterone, which ↓ses tone and mobility of
smooth muscles
 This slowing enhances the absorption of nutrients eg. Fe
 Movement through the large intestines is also slowed due to an increase in water consumption
from this area and ⇧ses the chance for constipation
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Systemic…cont’d
Colon
 Constipation
 Hemorrhoids
Gallbladder
 Increase residual volume
 Increased biliary cholesterol saturation i.e. stone formation
Liver
 Increased concentration of phosphate and cholesterol
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Systemic…cont’d
Nursing implications:-
 If the mother has difficulty with nausea and/or heartburn, advise her to eat small, frequent
meals.
 The patient should eat a well- balanced diet high in protein, iron, and calcium for fetal growth;
high fiber and fluids to prevent constipation
 The mother should not lie flat for 1 to 2 hours after eating because this may cause heartburn
and/or regurgitation
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Systemic…cont’d
8. Hematology
 Increased:
 WBCs
 RBCs and
 Coagulation
 Decrease platelets
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Systemic…cont’d
9. Changes of selected glands of the endocrine system

 Increased:
 Estrogen
 Progesterone
 Melenocyt
 Oxytocin : by posterior pituitary
 Prolactin: by anterior pituitary
 Adrenal gland
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Systemic…cont’d
 Thyroid gland :enlarged but euthyroid
 Parathyroid Gland:
 Increases in size slightly
 It meets the increased requirements for calcium needed for fetal growth
 Placenta increases:
 HPL, Estrogen , Progesterone those causes insulin resistance
 FSH and LH : decreases

 ACTH and TSH : not affected
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Systemic…cont’d
10. Immune system
 IgG
 IgA decrease up to 30wks ,then become normal
 IgM
11. Changes in body weight
 Normal weight gain is about 24 to 30 pounds during pregnancy
 Results from:
Fetus
Placenta
Ux
Breast
Fat
Blood
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Extra cellular fluid
Systemic…cont’d
Changes in body weight….
Weight gain in pregnancy:-
There is a slight loss of pounds during early pregnancy if the patient experiences much nausea and vomiting
She then gains 2 to 4 pounds by the end of the 1 st trimester.
A gain of a pound per week is expected during the 2nd and 3rd trimesters.
A lack of significant weight gain may be an indication of IUGR
Patients with multiple fetuses, expect higher weight gain than with one fetus
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Minor Disorders of pregnancy
 Minor disorders are only disorders that occur during pregnancy

 Are not life threatening
 Mainly due to anatomical and physiological changes
 Managed by education and explanation
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1.Nausea and vomiting (morning sickness)
• This presents between 4 and 14 weeks gestation.
• Hormonal influences are listed as the most likely causes. e.g. HCG
& estrogen
• It is usually occurs in the morning but can occur at any time of the
day, aggravated by smelling of food.
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Cont.
Management:
Reassure the mother
Small frequent meals (dry meals)
Reduce fatty and fried containing foods.
avoiding food items whose smell precipitate or aggravate the
symptoms
 If persistent, anti-emetics can be given.
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2. Heart burn
 is a burning sensation in the mid chest region.
is one of the most common complaints of pregnant women
especially during late pregnancy, because at this stage is under
pressure from the growing uterus
Progesterone causes relaxes of the lower esophageal sphincter
and allows reflex of gastric contents into esophagus
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Cont,d
Management:
 having smaller meals,
 avoiding bending over or lying flat.
 Antacid preparation (aluminum hydroxide or magnesium
trisilicate alone or in combination).
 In severe cases H2 - blockers like cimetidine and ranitidine can be
used safely.
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3. Pica
Craving of pregnant woman for items of low nutritional
value like ice (pagophagia) or clay (geophagia), can occur.
No known cause has been identified but it is known to be
common in patients with iron deficiency anemia.
Management:
 Seek medical advice if the substance craved is potentially
harmful to the unborn baby.
 Providing iron to treat anemia.
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4. Ptyalism
• Is excessive salivation, is also common.
• It is not related to increased saliva production; rather it is the
result of reduced swallowing from nausea.
Management:-
• It is treated when we treat nausea & vomiting
• Simple explanations will sufficient.
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5. Varicosities
 dilatation of the superficial veins of the lower extremities and it becomes

more prominent as pregnancy advances, weight increases, and the length of
time spent upright is prolonged.
 It is due to progesterone mediated smooth muscle relaxation of the blood
vessels and increased venous pressure in the femoral veins due to
compression by the enlarging uterus.
Management:-
 Treatment is periodic rest with elevation of legs and use of elastic stocking or
both.
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6. Hemorrhoids:
 varicosities of the rectal veins.
 pregnancy causes exacerbation or recurrence of previous

hemorrhoids due to obstruction of venous return by the large
uterus and constipation.
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Cont;d
Management:-
 topically applied anesthetic
 anti-inflammatory agents for pain and swelling
 warm soaks (sitz bath),
 laxatives and modification of bowel habits.
 Surgery is reserved for thrombosed and strangulated
hemorrhoids.
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7. Constipation:
• Relaxation and decreased peristaltic activity of the gut, which is
also displaced by the growing uterus.
Management:
• Increase the intake of water, fresh fruit, vegetables and roughages in
the diet.
• Exercise is helpful especially walking
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8. Vaginal discharge
 Pregnant women normally develop increased vaginal discharge in

many instances. It is clear, whitish and odorless.
 This is the result of estrogen mediated increased mucus secretion by
the cervical glands.
Management:
 Reassurance is usually sufficient.
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9. Low Back and pelvic pain
 Exaggerated lordosis and relaxation of the lumbar ligaments cause the

common complaint of low back pain.
 Relaxation of the joints of the pelvic girdle, cause pelvic pain and gait
abnormalities.
 In severe cases there may be tenderness over the symphysis pubis which
prevents mobility. This condition is called pelvic osteoarthropathy.
Management:
• Advice the mother to sleep on firm bed.
• Advice support mechanisms of the back
• avoiding high heeled shoes.
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10. Dependent edema
 Edema of the lower extremities is common.

 It is as the result of increased venous pressure of the lower
extremities.
 It appears near the end of the day and disappears after a period
of rest.
 It is important to rule out preeclampsia especially in those with
persistent dependant edema.
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11.Fainting:-
• In early pregnancy fainting may be due to the vasodilatation before

there has been a compensatory increase in blood volume.
• Inferior venacava compression
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Cont.
Management:
 Avoid long period of standing
 Sit or lie down when she feels slight dizziness
 She would be wise not to lie on her back except during

abdominal examination
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Minor Disorders of pregnancy…
• The nursing process and critical thinking skills to develop plans for
the common problems and discomforts of pregnancy:
 Assessment
 Diagnosis
 Planning Reading
 Implementation assignment
 Evaluation Assessment
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Unit 5: Psychosocial Adaptations to Pregnancy
Psychosocial adaptation to pregnancy:

• refers to the emotional, social, and psychological changes that women
experience during pregnancy.
• Pregnancy is a time of significant transformation and adjustment, and
• it can involve a range of emotions and challenges.
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Psychosocial Adaptations to Pregnancy…
Here are some key aspects of psychosocial adaptation to pregnancy:

Emotional Changes:
 Pregnancy can bring about a range of emotions, including happiness,
excitement, anxiety, fear, and mood swings.
 These emotions are often influenced by hormonal changes, physical
discomfort, and the anticipation of becoming a parent.
 It is normal for women to experience a mix of positive and negative
emotions during pregnancy.
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Body Image and Self-esteem:
 Many women experience changes in body image during pregnancy. Weight
gain, changes in physical appearance, and physical discomfort can impact a
woman's perception of herself.
 Some women may feel positive and proud of their pregnant bodies, while
others may struggle with body image issues.
 It is important to provide support and reassurance to pregnant women,
helping them maintain a positive self-image.
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Relationship Dynamics:
 Pregnancy can affect relationships, particularly the relationship between the expectant
mother and her partner.
 Couples may experience shifts in roles, adjustments in intimacy, and changes in
communication patterns.
 Open and honest communication about feelings, expectations, and concerns is crucial
during this time.
 It is also important to involve partners in prenatal care and decision-making processes.
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Social Support:
 Pregnant women benefit from having a strong support system, including
family, friends, and healthcare professionals.
 Emotional support, practical assistance, and information can help pregnant
women navigate the challenges and changes of pregnancy.
 Joining prenatal classes, support groups, or connecting with other expectant
mothers can also provide a sense of community and reduce feelings of
isolation.
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Parental Bonding and Preparing for Parenthood:

 As the pregnancy progresses, expectant parents may begin to form a bond with
their unborn child.
 This can involve talking to the baby, feeling the baby move, and making plans for
the future.
 Preparing for parenthood may include attending childbirth education classes,
reading books about parenting, and making decisions about birth plans and
parenting styles.
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Anxiety and Stress:

 Pregnancy can bring about feelings of anxiety and stress, particularly for first-
time mothers or those with high-risk pregnancies.
 Concerns about the baby's health, labor and delivery, and the transition to
parenthood are common.
 It is important for healthcare professionals to provide information, support, and
reassurance to address these concerns and help pregnant women manage stress
levels.
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Cultural and Societal Influences:
• Cultural beliefs, norms, and societal expectations can influence a woman's
experience of pregnancy.
• Expectant mothers may face pressure to adhere to certain cultural practices or
social expectations related to pregnancy and childbirth.
• It is important to respect and validate individual cultural experiences and
provide culturally sensitive care.
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Role transitions: Maternal,Paternal,Grandparents,Siblings
 Role transitions during pregnancy can have different impacts on various family
members.
1. Maternal Grandparents:
 Emotional support: usually have an emotional connection with their daughter
who is going through pregnancy, and they may offer emotional support,
understanding, and encouragement during this time.
 Involvement: involved in their daughter's life by attending appointments,
participating in baby showers, helping with nursery preparations, and providing
general care and assistance.
 Sharing knowledge: share their personal experiences of parenting with the
expectant mother, passing on wisdom, advice, and traditions.
 Financial assistance: offer financial assistance to help cover the costs associated
with pregnancy and childbirth.
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2. Paternal Grandparents:
 Transition to becoming grandparents: Paternal grandparents may experience a
transition from being parents to becoming grandparents. They may feel the
excitement and anticipation of welcoming a new family member.
 Support for their son: Paternal grandparents can offer support and advice to their
son, who is now going to be a father, by sharing their own experiences of raising
children.
 Increased involvement: They may become more involved in their son and daughter-
in-law's life by helping with household chores, providing transportation, or even
offering to babysit once the baby arrives.
 Building a relationship: Pregnancy may provide an opportunity for paternal
grandparents to build a stronger bond with their daughter-in-law and develop a new
relationship centered around their grandchild.
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Role transitions: Maternal,Paternal,Grandparents, Siblings
3. Siblings:
 Excitement and adjustment: Siblings of the expectant mother may feel a mix of
excitement and adjustment as they prepare to become aunts or uncles.
 Emotional support: They may provide emotional support to their sister during pregnancy,
offering a listening ear, encouragement, and sometimes acting as a birth partner.
 Anticipation of a new sibling: Siblings may also anticipate the arrival of a new brother or
sister, adjusting to the idea of sharing attention and establishing a sibling bond.
 Learning and promoting responsibility: Pregnancy can be an opportunity for siblings to
learn about pregnancy, childbirth, and different family roles. It can help promote
responsibility as they may take on minor caregiving tasks once the baby arrives.
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4. Other family members:

 Celebration and gathering: celebrate the pregnancy by organizing baby
showers, making gift contributions, and showing their support.
 Sharing experiences: may share their own experiences of parenthood,
pregnancies, and raising children, providing guidance and advice to the
expectant parents.
 Assisting with preparations: helping with preparations for the baby's arrival,
such as purchasing necessary items, setting up the nursery, or offering
assistance with baby care classes.
 Strengthening family bonds: As a new member is welcomed into the family,
the pregnancy can provide an opportunity for family members to strengthen
their bonds, come closer, and create lasting memories.
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Unit 6: Antepartum assessment and care
 FANC
 MTCT/PMTCT
 Nutrition in Pregnancy
 Antepartum Fetal assessment
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Key recommendation of New 2016 WHO ANC Model
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Key recommendation of New 2016 WHO ANC Model…
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Key recommendation of New 2016 WHO ANC Model…
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Up to 12 (1st contact)
 Identification: Name, age, address, phone number, occupation, and marital status
 Menstrual history: Date of first LNMP and the regularity; current or previous breast feeding, use of
contraception; determining the gestational age and expected date of delivery (EDD)
 History of present pregnancy: Including pregnancy symptoms, fetal kicks, and any complication to
date
 Intention of the present pregnancy: planned/unplanned; if unplanned, wanted/unwanted
 Past obstetric history: Number of pregnancies and outcome of each; cesarean sections; problems and
complications, including bleeding, preterm births, stillbirths, and high blood pressure during pregnancy
 Medical history: Including cardiovascular disease, renal disease, diabetes mellitus, convulsion,
Tuberculosis, and other past and current medical problems;
 Current medication: Including therapeutic medicines, illicit drugs, herbal/traditional remedies, drug
allergy
 Gynecologic history: Including screening for cervical cancer, gynecologic surgery, STI
 Nutritional history: Number of food groups and frequency of meals consumed per day, craving for
unusual food type, apatite, emesis
 Social and personal history: Including use of alcohol, tobacco, exposure to secondhand smoke, khat,
caffeine
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297
Up to 12 (1st contact)…
Physical examination
 General appearance :for pallor, respiratory distress
 Vital signs: Blood pressure in left lateral or sitting comfortable position, pulse rate, respiratory rate,
temperature
 Weight and height: height as a baseline and weight measurement for weight gain monitoring during
pregnancy,
 Acute malnutrition screening using mid upper arm circumference (MUAC) Examining the conjunctiva, oral
mucosa, and nail beds for pallor ,
 Auscultating the chest for breathing sounds and heart sounds, any additional sounds
 Obstetric examination: Measuring the SFH and doing the Leopold maneuvers
 Auscultating the fetal heartbeat with Doppler (12+weeks), Pinard fetoscope (20+weeks), and ordinary
Stethoscope (28+weeks)
 Palpating the abdomen for any mass or organomegaly
 Examining the musculoskeletal system for any gross deformity/swelling, varicose veins in the lower limb
 Examining the FGM scar after consultation and deciding on the need of deinfibulation (in high prevalence
areas)
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GA in weeks Specific activities
20 (2nd contact) · Review the documented medical and obstetric history, and laboratory tests during first contact
· Ask about the fetal movement

· Enquire about any new development
· Determine the gestational age
· Look for the general appearance
· Measure the blood pressure
· Weight measurement for weight gain
· Look for pallor for anemia detection
· Measure arm for acute malnutrition screening using MUAC
· Measure the uterine fundal height.
· Listen for fetal heartbeat
· Perform ultrasound scanning
· Initiate iron-folic acid, and calcium, supplementation and provide counseling on adherence
· Provide deworming tabs
· Quick check for other danger signs and symptoms
· Assess feeding practices and counsel on optimal maternal nutrition; extra meal/feeding
frequency, diet diversity, including fruit and vegetables, animal source feeding
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GA in weeks Specific activities
26 (3rd contact)  Conduct same activities as week 20 except for ultrasound scanning
 Conduct urinalysis for proteinuria and urine gram stain
 Test for gestational diabetes for high risk pregnant women
30 (4th contact)  Conduct same activities as week 20 except for ultrasound scanning
 Repeat testing for syphilis and HIV if earlier test results are negative
 Repeat hemoglobin test

 Perform fetal wellbeing assessment if there is a discrepancy between
fundal height and gestational age or if there is a reduction in fetal

movement
 Counsel on birth preparedness and complication readiness
 Counsel on optimal breastfeeding practices

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34
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Prevention of Mother to Child Transmission of HIV
(PMTCT)
306
OBJECTIVE
 At the end of this session the student will be :

 Define the term PMTCT
 Describe risk factors for MTCT
 List Comprehensive Approach to Reducing HIV Infection
 ART Regiment During pregnancy and lactation
 Explain briefly about maternal nutrition
 Describe prenatal fetal monitoring
307
Outline
 Introduction
 PMTCT in pregnancy, labour,and delivery, and postpartum period
 Nutrition during pregnancy and lactating mother
308
Definition of PMTCT
 MTCT is the transmission of HIV virus from infected mother to the
fetus and child during pregnancy, childbirth and breastfeeding.
 PMTCT is a term used to describe a package of services intended to
reduce the risk of mother-to-child transmission of HIV.
309
Timing of Mother-to-Child Transmission of HIV
During pregnancy
(10-25%)
During labor and delivery (35-40%)
During breastfeeding
(35-40%)
310
HIV/AIDS DURING PREGNANCY
Epidemiology
 Women show the greatest increase in HIV/AIDS incidence in recent years.
 In Ethiopia, HIV prevalence in women is 0.4% compared to 0.3% in men.
 HIV primarily affects women in the reproductive age group, 15-49 years.
311
Effect of Pregnancy on HIV infection
• Pregnancy does not have significant influence on the progression of HIV

infection.
• However, if pregnancy occurs in late stage of AIDS the rate of maternal
mortality increased.
312
Effect of HIV on pregnancy
 In HIV infected women there is an increase in:
IUGR ( intrauterine growth retardation)
 LBW
preterm delivery
 Abortion
 Increase in stillbirth rate
 Perinatal mortality and infant mortality.
Note : HIV does not have direct influence on rate of congenital malformation.
313
Risk Factors for MTCT
 Viral  Maternal
 Viral load (the higher the viral  Maternal immunological status

 Maternal nutritional status
load, the greater the risk of
 Maternal clinical status
HIV transmission) (including co-infection with an
STI)
 Viral genotype and phenotype
 Behavioral factors
 Viral resistance  Antiretroviral treatment
314
Risk Factors for MTCT…
 Obstetrical Fetal
 Prolonged rupture of membrane  Prematurity
(longer than 4 hours)  Multiple pregnancy
 Mode of delivery Infant
 Intrapartum hemorrhage  Breastfeeding
 Obstetrical procedures  Gastrointestinal tract factors
 Invasive fetal monitoring  Immature immune system
315
Comprehensive Approach to
Reducing HIV Infection
Element 1: Primary prevention of HIV infection
Element 2: Prevention of unintended pregnancies among HIV infected
women
Element 3: Prevention of HIV transmission from HIV-infected women to
their infants
Element 4: Provision of treatment, care and support to HIV infected
women, their infants and children 316
Prevention of HIV Transmission from HIV-Infected Women
to their Infants
Core Interventions
• HIV testing and counseling
• Antiretroviral (ARV)
• Safer delivery practices
• Safer infant-feeding practices
317
Antiretroviral Treatment and Prophylaxis
ARV Treatment
Long-term use of antiretroviral drugs to treat maternal HIV/AIDS and

prevent MTCT
ARV Prophylaxis
Short-term use of antiretroviral drugs to reduce HIV transmission from

mother to infant
318
Antiretroviral Treatment
• Reduces viral replication and viral load

• Treats maternal infection
• Protects the HIV-exposed infant
• Improves overall health of mother
• Requires ongoing care and monitoring
319
Cont.…
• Currently divided:
– ANC
– Labor and delivery
– infant of HIV positive mother who didn’t receive ARV during pregnancy
or labor and delivery
320
ANC management
• Reduces risk of MTCT

• Provides linkage to treatment, care and support services
• Helps HIV-positive women stay longer and healthier
• Helps HIV-negative women stay uninfected
321
ANC management…
• Counsel and test for HIV

• Diagnose and treat STIs
• Promote safer sex practices
• Provide information on HIV
• Provide infant feeding counseling and support
322
Reducing MTCT Risk
During Labor and Delivery
 Minimize cervical examinations

 Use partograph to monitor labor
 Immediately after birth, wipe and dry the baby.
 Give BCG and polio vaccine after birth
 Provide prophylaxis for infant
323
Cont.…
Avoid
• Routine rupture of membranes
• Prolonged labor
• Unnecessary trauma during childbirth
• Minimize risk of postpartum hemorrhage
• Use safe transfusion practices (blood screened for HIV, Syphilis, malaria,
hepatitis B and C when possible
324
• Elective Caesarean Section versus Vaginal Delivery
Reducing MTCT Risk
in Women with Unknown HIV Status
• Offer rapid HIV testing with right to refuse

• Discuss benefits of knowing HIV status
• If HIV-positive, ARVs can be given for PMTCT and refer for treatment and
care
325
ART Regimen During Pregnancy
and lactation
326
Purpose of ART
 Reduce HIV viral load to undetectable levels

 Increase CD4 cell count
 Reduce HIV related morbidity & mortality
 Reduces the chance that a mother will pass HIV to her baby during
pregnancy, birth or breastfeeding
 Reducing transmission of HIV at the community level
327
Medical Eligibility for Anti-Retroviral Therapy
 The decision to initiate ART in adults and adolescents is guided by clinical

assessment and laboratory tests.
 For HIV infected pregnant women, the decision to initiate ART do not
require any of the above mentioned criteria.
 All HIV infected pregnant women shall start ART immediately.
328
Table 1: Summary of first-line ART regimens for adults, adolescents, pregnant and breast-
feeding women
Preferred first Alternative First Special
Line Regimens Line regimens circumstance
All pregnant and TDF+ 3TC+ TDF + 3TC + AZT+ 3TC +
breast-feeding
women, DTG* (FDC) EFV** ATV/r***
adolescent AZT + 3TC + DTG TDF+ 3TC+ ATV/r

pregnant AZT + 3TC + ABC+ 3TC+ DTG
women weight EFV
≥30 kg
329
Dolutegravir/lamivudine/tenofovir (DTG/3TC/TDF) is a fixed-dose combination(FDC) antiretroviral
medication used to treat HIV/AIDS. ATV/r = atazanavir/ritonavir , ABC = abacavir
Table 2: AZT+NVP prophylaxis dose for infant
Infant age NVP daily Dose in ml AZT daily Daily dose

dosing dose in ml
Birth to 6
weeks
Birth weight 10 mg once 1ml once daily 10mg twice 1ml twice
<2000g daily daily daily
Birth weight 15mg once 1.5ml once 15mg twice 1.5ml twice
>2500 g daily daily daily daily
Age 6 2ml once daily
weeks to 12 20 mg once or half a 50mg
weeks daily tablet once 330
daily
Table 3: Cotrimoxazole Prophylaxis Therapy
Dosage of Cotrimoxazole preventive therapy in infants and children
Age Suspension per 5 Pediatric tablet Single strength

ml (200/40mg) (100/20mg) adult tablet
(400/80 mg)
< 6 months 2.5 ml 1 tablet ¼ table
6 months - 5 5 ml 2 tablets ½ tablet
years
331
Lactating or post-partum
 Continue ART if started

 Initiate TDF/3TC/DTG if on no treatment
 Infant regimen: AZT + NVP for 12 weeks post-partum
332
Care of an HIV Exposed Infant
• Proper review through history and physical exam

• Daily AZT + NVP for 12 weeks
• Testing for HIV infection
• Support for proper infant feeding
• Growth monitoring
• Developmental assessment
• Co-trimoxazole prophylaxis
• Immunization
• Tb risk assessment
333
• Documenting and reporting

Visit Schedule
• Monthly visit till age of six months. Align with EPI schedule
• Between 6 months and 18 months, infant should accompany mother
every time mother is seen for follow up,
• Schedule frequent visits if the child is not doing well.
334
AFASS” criteria is used to determine whether a mother is able to
replacement feed
• AFASS Criteria for Replacement Feeding
• Acceptable -Mother perceives no significant cultural or social barriers to

replacement feeding
• Feasible -Mother has adequate knowledge, skills, resources, and support to

correctly mix
• formula or milk, and feed the infant up to 8- 12 times in 24 hours

335
AFASS” criteria…cont
 Affordable -Mother and family can pay the costs of replacement feeding—fuel, clean
water, and all ingredients—without compromising the health and nutrition of the family
 Sustainable -Mother has access to a continuous and uninterrupted supply of all

ingredients needed for safe replacement feeding as long as the infant needs it
 Safe -Replacement feeds are correctly and hygienically stored, prepared, and fed in
nutritionally adequate amounts. Infant is fed by clean hands and preferably by cup
336
Nutritional needs during pregnancy and lactating mothers
337
Nutritional needs during pregnancy and lactating mothers…
 During pregnancy body goes through lots of physical and hormonal changes
 Eating a healthy, balanced diet will help mother feel good and provide
everything baby need
 Micronutrients and macronutrients to support mother and her baby.
 Micronutrients are dietary components, such as vitamins and minerals, that
are only required in relatively small amounts.
 Macronutrients are nutrients that provide calories, or energy. We’re talking
338
carbohydrates, proteins, and fats.

Micronutrients:
1. Folate: is essential for neural tube development in the baby. It helps prevent
birth defects of the brain and spine.
 E.g. leafy green vegetables, citrus fruits, legumes, and fortified grains.
2. Iron: Iron is necessary for the production of red blood cells and the prevention
of anemia. It also supports the baby's growth and development.
 E.g. lean red meat, poultry, fish, beans, spinach, and fortified cereals.
3. Calcium: Calcium is essential for the development of the baby's bones and
teeth, as well as muscle function and nerve transmission.
 E.g. Consume dairy products, fortified plant-based milks, tofu, leafy greens,
and calcium-fortified foods.
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4. Iodine: Iodine is crucial for the baby's brain development and thyroid hormone
production.
 Include iodized salt, seafood, dairy products, and fortified grains in your diet.
5. Vitamin D: Vitamin D helps with the absorption of calcium and supports bone health.
 Exposure to sunlight, fortified dairy products, fatty fish, and egg yolks can provide
vitamin D.
6. Vitamin C: Vitamin C supports immune function and helps the body absorb iron from
plant-based sources.
 Include
10/13/2023 citrus fruits, berries, tomatoes, andK.Aleafy greens to ensure sufficient intake. 340
7. Vitamin A: Vitamin A is important for vision, immune function, and cell

growth. Include sources like orange and yellow fruits and vegetables, leafy
greens, and dairy products.
8. B Vitamins: B vitamins, such as B6 and B12, are necessary for the baby's
brain development and the mother's energy metabolism. Include sources like
fortified grains, poultry, fish, eggs, and leafy greens.
• N.b: meeting these nutrient needs can vary depending on individual

requirements and should be discussed with a healthcare professional or
registered dietitian to ensure a well-balanced diet during pregnancy and
lactation.
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Macronutrients:
1. Carbohydrates: Carbohydrates provide energy for the body and are an
essential part of a balanced diet. Include whole grains, fruits, and vegetables
to meet your carbohydrate needs.
2. Protein: Protein is important for the growth and repair of cells, and it
plays a crucial role in the development of the baby. Include lean meats,
poultry, fish, dairy products, legumes, and tofu to meet your protein
requirements.
3. Healthy Fats: Healthy fats, such as omega-3 fatty acids, are vital for the
baby's brain and eye development. Include sources like fatty fish (such as
salmon,
10/13/2023
sardines, and trout), chia seeds,
K.A
flaxseeds, and walnuts. 342
Cont..
Daily requirements for pregnant
Nutrient
women
calcium 1200 milligrams (mg)
folate 600–800 micrograms (mcg)
iron 27 mg
70–100 grams (g) per day, increasing
protein
each trimester
343
Antepartum fetal Assessment
objective
At the end of this session the student will be able to

 Describe methods used for fetal diagnostic tests
 Describe methods used for antepartum fetal surveillance
345
Antepartum fetal Assessment
Outline
 Ultrasound scan
 Alpha-fetoprotein screening
 Chorionic villus sampling
 Amniocentesis
 Percutaneous umbilical blood sampling
 Nonstress test
 Contraction stress test
 Maternal assessment of fetal movement 346
Antepartum fetal Assessment…
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Maternal assessment of fetal movement counting protocol

• Perception of 10 fetal movements in up to 2 hours is considered normal
• Or if 10 or more fetal movement per 12 hours period in normal pregnancy
• The decrease or cessations of fetal movement has an warning implications
- my be associated with fetal destress or death
366
Advantage to intrauterine sleep

• Informative and non invasive  Sedation fetal occur if the mother is taking
• Pregnant woman can monitor her self sedatives
• No cost  Sudden death of the fetus may occur with
Disadvantage out presiding slowing of the fetal movement
 Awareness is different in mothers

e.g. Abruptioplacenta
 Accurate Gestational Age not recurred
 Cessation of fetal movement may occur due 367

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UNIT ONE

Introduction to Obstetrics and Gynecology

After completion of this chapter students will be able to:

define important terminologies used in obstetric and gynecology

Explain the nurses ‘role in maternity and women’s health care

Identify considerations for providing care to families in a culturally diverse society

It is concerned with the health of the woman and fetus

both the normal and diseased states , including breast

It encompasses aspects of contraception, abortion and IVF

and sexual function.

surgery to correct or treat pelvic organ or urinary tract problems

Viability: capability of living, usually accepted as 24 weeks, although survival is rare.

Gravida: Number of pregnancy, regardless of pregnancy outcome

Para : refers to past pregnancies that have reached viability

Nullipara: woman who has never completed a pregnancy to the period

Primipara: woman who has completed one pregnancy to the period of

Primigravida: woman pregnant for the first time.

Multipara: woman who has completed two or more pregnancies to the

b) Confidentiality and Privacy:

Professionals in this field have an ethical obligation to obtain informed consent

• Access to Oby/Gyn care can be an issue, particularly for marginalized

• Social factors such as economic disparities, cultural barriers, and limited

Discussions on abortion, contraception, assisted reproduction, and

discrimination and bias against women in healthcare settings.

 Issues such as improper diagnosis, surgical errors, and failure to provide

b) Informed Consent and Refusal:

 when they refuse certain treatments based on personal or religious beliefs.

The field of obstetrics and gynecology intersects with various reproductive

• In summary, obstetrics and gynecology is a medical specialty that often involves

 informed consent, and

 compliance with reproductive laws.

• OB/GYN professionals must be well-informed, respectful of patient rights, and make

• Infant and child mortality rates are basic indicators of a country’s

Infant mortality: the probability of dying before the first birthday

under-5 mortality rates for the 5 years

Maternal Mortality Rate (MMR):

• These efforts have contributed to the reduction in maternal deaths, but

Nurses play a critical role in labor and delivery.

They provide emotional support to laboring women, monitor vital signs,

They help with breastfeeding support, educate mothers on postpartum self-

They perform routine examinations, such as Pap smears and breast

5. Health promotion and education:

 They provide information on healthy lifestyle choices, such as diet and

6.Advocacy and emotional support:

Nurses advocate for women’s rights, choices, and healthcare needs.

They provide emotional support during various stages of pregnancy and

They provide comprehensive care, promote health and well-being, offer

Their expertise and compassionate care contribute significantly to the overall

• In a culturally diverse society, care of the family involves understanding and

This includes being aware of religious practices, dietary restrictions, traditional

• Communication is crucial in understanding and meeting the needs of diverse families.

• Healthcare providers should make efforts to provide communication support for

Healthcare providers should strive for shared decision-making, involving the

Respect for diversity:

Families in a culturally diverse society may have different family structures,

Recognizing health disparities:

• Healthcare providers should be mindful of health disparities that may

Cultural competence training:

• Healthcare providers should receive ongoing training and education to

• Building partnerships with community organizations and leaders from different

• Describe the anatomy of female pelvis

• Discuss the female reproductive organs

• List different types of female pelvis