Obstetric

Edna Dahir
RN MSc SRH
 INTRODUCTION
Obstetric:
Field of medicine that deals with pregnancy
(prenatal), delivery of the baby, and the first
six weeks after delivery (postpartum period)
 Prenatal

The prenatal period is the time from conception until

delivery of the fetus.
 Pregnancy

Nine calendar months or 10 lunar months

Forty weeks or 280 days
Divided into trimesters
Three intervals of three months each
Known as gestational period
 Maternal Health Mortality and
Morbidity
Maternal health refers to the health of women during
pregnancy, childbirth and the postpartum period.
While motherhood is often a positive and fulfilling,
for too many women it is associated with suffering,
ill health and death. The top leading cause of
maternal mortality and morbidity include
hemorrhage, infection, high blood pressure, unsafe
abortion and obstructed labor.
 Cont.…
Lack of access to modern health care services has great
impact on increasing maternal death. Most pregnant women
do not receive antenatal care; deliver with out the assistance
of trained health workers etc.
The life time risk of death as a result of pregnancy or child
birth is estimated at one in twenty – three for women in
Africa, compared to about one in 10,000 for women in
Northern Europe 75% of Maternal morbidity and mortality
related to pregnancy and child birth are due to five obstetric
causes. Hemorrhage, sepsis (infection), toxemia obstructed
labor and complications from unsafe abortion.
 Cont….
Care of childbearing families has become a major
focus of nursing and midwifery practice today. To
have healthy children, it is important to promote the
health of the childbearing women and her family
from the time before children are born until they
reach adulthood. Prenatal care and guidance is
essential to the health of women and fetus and to the
emotional preparation of a family for childrearing.
 Cont…
The pregnancy related mortality and morbidity ratio is
an estimate of the number of pregnancy-related deaths
and complications for every 100,000 live births. This
ratio is often used as an indicator to measure the
nation’s health.
Maternal Mortality Definition:
The death of women while pregnant or within 42 days
of termination of pregnancy, irrespective of the duration
and the site of the pregnancy from any cause related to
or aggravated by the pregnancy or its management.
 Cont.…

Maternal Mortality Ratio (MMR):

The number of maternal deaths per 100,000 live
births, a measure of the risk of death once a
woman has become pregnant.
Maternal Morbidity Definition:
Morbidity refers to the unhealthy state or medical
complications in women caused by pregnancy,
labour or delivery.
 Maternal morbidity rate (MMR):
A morbidity rate looks at the number of cases o a
disease occurring in a giving number(usually
100,000)of the pregnant population.
Leading Causes of Maternity Mortalities:
There are mainly two types of causes for maternity
mortalities. One is pregnancy related causes and
another one is medical causes. Both of those have
pointed in the following in step by step.
 Pregnancy Related Causes of
Maternity Mortalities(direct
cause)
Various pregnancy related causes for maternal mortalities are-
Unsafe Abortion( Septic Abortion),
Severe Antepartum and Postpartum Hemorrhage( APH, PPH),
Puerperal Sepsis,
Early pregnancy /Ectopic pregnancy,
Pregnancy Induced Hypertension (Eclampsia/ Pre eclampsia),
Delayed and Obstructed labour,
Placenta Previa,
Uterine Rupture.
 Medical Causes of Maternal
Mortalities:(Indirect cause)
Different medical causes for maternal mortalities are-
Anaemia,
Thrombosis and Thromboembolism ,
Jaundice,
Diabetes,
Hepatic failure,
Renal failure,
Cardiovascular disease,
Severe anesthesia Complications.
Cont.…
 Cause of Maternal Morbidity:
Various causes of maternal morbidity have presented out in
the following:
VVF( Vesico Vaginal fistula),
RVF ( Rectro Vaginal Fistula),
Perineal tear,
Uterine prolapsed,
Vaginal stenosis,
PID ( Pelvic inflammatory disease),
Infertility,
Amniotic fluid embolism,
Blood transfusion reaction,
Hysterectomy.
 Child mortality and morbidity

A child's risk of dying is highest in the first 28 days

of life (the neonatal period). Improving the quality of
antenatal care, care at the time of childbirth, and
postnatal care for mothers and their newborns are all
essential to prevent these deaths. Globally 2.6
million children died in the first month of life in
2016. There are approximately 7 000 newborn deaths
every day, amounting to 46% of all child deaths
under the age of 5-years.
 Cont…
Preterm birth, intrapartum-related complications (birth
asphyxia or lack of breathing at birth), and infections
cause most neonatal deaths.
From the end of the neonatal period and through the first
5 years of life, the main causes of death are pneumonia,
diarrhoea and malaria. Malnutrition is the underlying
contributing factor, making children more vulnerable to
severe diseases.
 Importance of Obstetrics and
Gynecology nursing and midwifery

Ensuring healthy antenatal period followed by a safe normal

delivery with a healthy child and post partum period.
Prompt and efficient cares during obstetrical emergencies also
prevent so many of complications. The importance of the
obstetric and gynecology nursing are: -
Equip the nurse/midwife with the knowledge and understanding
of the Anatomy and physiology of reproductive organ to be able
to apply it in practice - With a good knowledge of obstetric
drugs including, the effect of diseases their Complications and
know how to deal with them. –
 Cont..
Develop skills in carrying out antenatal care and be able
to detect any abnormality, recognize and prevent
complications. - Select high risk cases for hospital
delivery and provide health education. –
Develop skills in supporting the women in labour,
maintain proper records, and deliver her safely and
resuscitate her new born when necessary. –
 Cont.…
Be able to care for the mother and baby during the post partum
period and be able to identify abnormalities and help them to
get-over it. –
Be able to educate them on care of the baby, immunization,
family guidance and family spacing. –
Be ready to offer advice to support the mother and understand
her problems as a mature, kind and helpful nurse/midwife.
 Somaliland
Somaliland is one of the worst maternal mortality
rate in the world like other developing countries, the
rate was decreasing gradually year after year.
In October 2020, Somaliland ministry of health and
development supported by UNICEF has reported
that the maternal mortality rate is 394 per 100,000
women giving birth.
Female Reproductive
System
The female reproductive system is made up of
the internal and external sex organs that function
in reproduction of new offspring.
In the human the female reproductive system is
immature at birth and develops to maturity at
puberty to be able to produce gametes, and to
carry a foetus to full term.
 Female Reproductive System
 Produce sex hormones
 Estrogen, Progesterone
 Produce egg (ova)
 Support & protect
developing embryo
 Give birth to new
baby
Major Organs

 Cervix
 Vagina
 Ovaries [gonads]
 Uterine tubes [fallopian tubes]
 Uterus
The Cervix
 The lower portion or neck of the uterus.
 The cervix is lined with mucus, known as
cervical mucus
 Cervical mucus provides lubrication &
sperm transport during sexual
intercourse
 During ovulation secretion of cervical
mucus increases in response to estrogen
 But when an egg is ready for fertilization,
the mucus then becomes thin and slippery,
offering a “friendly environment” to
sperm
The Cervix

At the end of pregnancy

The cervix acts as the passage
through which the baby exits
the uterus into the vagina.
The cervical canal expands to
roughly 50 times its normal
width for the passage of the
baby during birth
The Vagina
 A muscular, ridged sheath
connecting the external
genitals to the uterus.

 Functions as a two-way street,

accepting the penis and
sperm during intercourse

 Serving as the avenue of birth

through which the new baby
enters the world
External genetalia
 Vulva—which runs from the pubic area downward to the rectum.

 Labia majora or "greater lips" are the part around the vagina
containing two glands (Bartholin’s glands) which helps lubrication
during intercourse.

 Labia minora or "lesser lips" are

the thin hairless ridges at the
entrance of the vagina, which
joins behind and in front. In front
they split to enclose the clitoris

 The clitoris is a small pea-

shaped structure. It plays an
important part in sexual
excitement in females.
External genetalia
 The urethral orifice or external
urinary opening is below the clitoris
on the upper wall of the vagina
and is the passage for urine

 Opening of the vagina is separate

from the urinary opening and
located below it.

 The hymen is a thin cresentic fold

of tissue which partially covers the
opening of the vagina. medically
it is no longer considered to be a
100% proof of female virginity.
 Ovaries
 Also known as female gonads

 They produce eggs (also

called ova) every female is
born with a lifetime supply of
eggs

 They also produce

hormones:
Estrogen &
Progesterone
Fallopian tubes [uterine tubes]
 Stretch from the uterus to the ovaries and measure about 8
to 13 cm in length.

 The ends of the fallopian tubes lying next to the ovaries

feather into ends called fimbria

 Millions of tiny hair-like cilia line the fimbria and interior of

the fallopian tubes.

 The cilia beat in waves hundreds of times a second catching

the egg at ovulation and moving it through the tube to the
uterine cavity.

 Fertilization typically occurs in the fallopian tube

Uterus
 Pear-shaped muscular organ in the female reproductive tract.
 The fundus is the upper portion of the uterus where
pregnancy occurs.
 The cervix is the lower portion of the uterus that connects
with the vagina and serves as a sphincter to keep the uterus
closed during pregnancy until it is time to deliver a baby.
 The uterus expands considerably during the reproductive
process.
 The organ grows to from 10 to 20 times its normal size during
pregnancy.
Uterus

 The main body consists

of a firm outer coat of
muscle (myometrium)
and an inner lining of
vascular, glandular
material (endometrium).

 The endometrium thickens during the menstrual cycle to

allow implantation of a fertilized egg.

 Pregnancy occurs when the fertilized egg implants

successfully into the endometrial lining.
Endometrium
 The endometrium is the
innermost layer as a lining for the
uterus
 During the menstrual cycle, the
endometrium grows to a thick, blood
vessel-rich, glandular tissue layer.

 This represents an optimal

environment for the implantation of
a blastocyst upon its arrival in the
uterus.
Endometrium
 The endometrium is central,
echogenic (detectable using
ultrasound scanners), and has
an average thickness of 6.7
mm.

 During pregnancy, the blood

vessels in the endometrium
further increase in size and
number, forming the placenta,

 Placenta supplies oxygen and

nutrition to the embryo &
fetus.
Anatomic characteristic of the
fetal head & maternal pelvis
 Fetal head
• Sutures
• Fontanelles
• Landmarks
• Diameters
 Fetal head

the most important part:

• largest
• least compressible part of the fetus.
• most frequent presenting part
Consist of:

1. Base:

large, ossified, firmly united, and noncompressible

2. vault (cranium) consists of:

-occipital bone posteriorly

- 2 parietal bones bilaterally

-2 frontal and temporal bones

anteriorly
Cranial bones at birth:
• Thin
• weakly ossified
• easily compressible
• interconnected only by membranes
>>>
allow them to overlap under pressure &
to change shape to conform to the
maternal
pelvis, a process known as (molding).
 Sutures
• Membrane-occupied spaces between the cranial bones
1-Sagittal suture:
- lies between the parietal bones
-extends in an Anteroposterior direction btw the
fontanelles
-divides the head into right and left sides
2-lambdoid suture:
• extends from the posterior fontanelle laterally
• separate the occipital from the parietal bones.
3-coronal suture:
• extends from the anterior fontanelle laterally
• separate the parietal and frontal bones.
4- frontal suture:
• lies between the frontal bones
• extends from the anterior fontanelle to the
glabella (the prominence between the eyebrows).
 Clinical importance of sutures
• molding of the head in the vertex presentation
• Position of fontanelle & sagittal suture can identify attitude
and position of vertex.
• By plapating the sagittal suture during labour, degree of
internal rotation & molding of the head can be noticed.
 Fontanelles
• membrane-filled spaces located at the point where
the sutures intersect
• more useful in diagnosing the fetal head position
than the sutures.
The anterior fontanelle (bregma) :
 diamond shaped area(2 × 3 cm) of unossified membrane formed
by the
junction of 4 suture.
The suture are:-
Anteriorly: frontal suture
Posteriorly: sagittal
suture
Laterally: on both side:-
coronal suture.
 It is felt on fetal head
surface as a soft
shallow depression.
 It ossifies by 18 months after birth,infant's brain after birth
Clinical importance:
1. Degree of flexion can be assessed from its position. If on vaginal
examination it is felt easily, it indicates the head is not well
flexed.
2. Helps in the molding of head.
3. can be assessed from it’s position.
The posterior fontanelle:
 It is the triangular depressed area at the
junction of 3 suture:
Anteriorly: sagittal suture
Posteriorly: 2 lambdoid sutures at both side.
• closes at 6 to 8 weeks of life
• Y- or T-shaped
Clinical importance:

1. From its relation of the maternal pelvis, position

of vertex is determined.
2. Internal rotation can be assessed from its
location.
3. Degree of flexion can be assessed from its
position. On vaginal examination if it is felt easily
and anterior fontanelle is not felt, this indicates
good flexion of the fetal head.
 landmarks
front to back
1. Nasion (the root of the nose)
2. Glabella (the elevated area between the orbital
ridges)
3. Sinciput (brow) btw AF & glabella)
4 Anterior fontanelle (bregma)
5 Vertex (the area btw the fontanelles & bounded laterally by
the parietal eminences)
6 Posterior fontanelle (lambda)
7 Occiput (the area behind & inferior to PF &
lambdoid sutures)
 Diameters

• Anteroposterior diameters
presenting to the maternal pelvis depends on the
degree of flexion or extension
head
• Transverse diameters
 Anteroposterior diameters
1- Suboccipitobregmatic (9.5 cm):
Extends from the undersurface of the occipital bone at the
junction with the neck to the center of the Anteriar
fontanelle.
2. Occipitofrontal (11 cm):
• extends from the external occipital protuberance to
the glabella.
3. Supraoccipitomental (13.5 cm):
• extends from the vertex to the
chin
-presenting AP diameter in a brow
presentation
-longest AP diameter of the head
4. Submentobregmatic (9.5 cm):
• extends from the junction of the neck and lower jaw to
the center of the anterior fontanelle.
-presenting AP diameter in face presentations
 Transverse diameters
1-Biparietal (9.5 cm):
• the largest transverse diameter
• extends between the parietal
bones.
2-Bitemporal (8 cm):
• the shortest transverse diameter
• extends btw the temporal
bones.
 Pelvic anatomy
• Bony pelvis
• Pelvic planes
• Pelvic diameters
 The bony pelvis
four bones :
• two hip bones(ileum, ischium & pubis) laterally
&
anteriorly
•sacrum & coccyx posteriorly
‘3 joints’
• symphysis pubis anteriorly
• sacroiliac joints posteriorly
 Sacrum

• consists of 5 rudimentary vertebrae fused together to

form
a single wedge-shaped bone with a forward concavity
• The upper border ( base) articulates with the L5
• The narrow inferior border articulates with the coccyx.
• Laterally, the sacrum articulates with the two iliac bones
• The anterior and upper margins of the first sacral vertebra
bulge forward sacral promontory
 Coccyx

• consists of 4 vertebrae fused together to form a small

triangular bone
• end of the sacrum
 Hip Bone
In children:
each hip bone consists of :
• the ilium, which lies superiorly
• the ischium, which lies posteriorly and inferiorly
• the pubis, which lies anteriorly and inferiorly

 joined by cartilage at the acetabulum

 At puberty, >>> fuse together to form one large, irregular
bone.
 articulate with the sacrum at the sacroiliac joints >>>>form
the anterolateral wall of the pelvis
 articulate with one another anteriorly at the symphysis pubis.
The ilium,
 the upper flattened part of the hip bone
• iliac crest runs between the anterior and posterior
superior iliac spines
3-The pubis
 the anterior part of the hip bone
Pelvic brim is formed by:
• the sacral promontory behind,
• iliopectineal lines laterally,
• symphysis pubis anteriorly.

• Above the brim >>> false pelvis, which forms part of the
abdominal cavity.
• Below the brim >>> true pelvis.
 True Pelvis
bony canal and is formed by:
• the sacrum and coccyx posteriorly
• the ischium and pubis laterally and anteriorly

 It’s internal borders are solid and relatively immobile.

 The posterior wall is twice the length of the anterior wall.
 The area of concern to the obstetrician because its
dimensions are sometimes not adequate to permit passage
of the fetus.
PELVIC DIAMETER
PELVIC INLET 13.5CM
PELVIC OUTLET 10.5___11 CM
Pelvic Shapes
 Gynecoid Pelvis
• The classic female type.
• Found in approximately 50% of women.
• Characteristics:
1. Round inlet, with the widest transverse diameter
only slightly greater than the AP diameter
2. Side walls straight
3. Ischial spines of average prominence .
4. Well-rounded sacrosciatic notch
5. Well-curved sacrum
 Android Pelvis
• The typical male type
• Found in less than 30% of women
• Characteristics:
1. Triangular inlet with a flat posterior segment & the
widest transverse diameter closer to the sacrum than
in the gynecoid type .
2. Convergent side walls with
prominent spines
3. Shallow sacral curve
4. Narrow subpubic arch
 Anthropoid
• Pelvisape pelvis.
Resembles anthropoid
• Found in approximately 20% of women
• Characteristics:
1. A much larger AP than transverse diameter, creating a
long narrow oval at the inlet
2. Side walls that do not converge
3. Ischial spines that are not prominent
but are close, owing to the overall
shape
4. Variable, but usually posterior,
inclination of the sacrum
5. Narrow, outwardly shaped subpubic arch
 Platypelloid
Pelvispelvis.
• Flattened gynecoid
• Found in only 3% of women
• Characteristics:
1. A short AP & wide transverse diameter creating an
oval- shaped inlet
2. Straight or divergent side walls
3. Posterior inclination of a flat sacrum
4. A wide bispinous diameter
5. A wide subpubic arch
• The fetal head has to engage in the
transverse diameter.
Cephalopelvic Disproprtion
• CPD is obstructed labor resulting from disparity
between the size of the fetal head and maternal pelvis.
– E.g. small pelvis, nongynecoid pelvis, large fetus, or
more commonly a combination of these factors.
– True CPD is rare, 1 in 250 pregnancies or 0.4% of the
time

• Failure to progress : lack of progressive

cervical dilatation or lack of fetal descent.
– Mostly due to malpresentation or
ineffective uterine contractions.
• Treatment of CPD:
– If the surgeon is absolutely
certain that there is CPD, then a
CS is the only option for
delivery.
– But if diagnosis is doubtful a ‘trial
of labour’ should always be
offered
• If, after sufficient time symptoms of
prolonged labor or fetal distress
begins to develop, a CS needs to be
carried out.