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Standards of Care

Standards of Care in Mental Health Nursing

Standard of care refers to the degree of care that a reasonably prudent and competent mental health nurse would exercise under similar circumstances.

It is a benchmark against which nursing actions are judged. These standards include both clinical competence and ethical conduct, reflecting the nature of caring for individuals with mental health conditions.

Sources of Standards:

They were enunciated by the American Nurses Association (ANA) in 1973.

Professional Organizations: Bodies such as the American Nurses Association (ANA) or country-specific nursing councils publish detailed standards of psychiatric-mental health nursing practice. These are often the primary source.
Legislation and Regulations: Laws like the Mental Treatment Act, Nurse Practice Acts, and patient rights legislation set legal mandates that directly influence nursing standards.
Institutional Policies and Procedures: Each healthcare facility develops its own policies and procedures, which must align with professional and legal standards and guide staff behavior within that specific environment.
Accrediting Bodies: Organizations that accredit healthcare institutions (e.g., The Joint Commission) set standards that influence care delivery and quality.
Published Literature and Research: Evidence-based practice guidelines, nursing textbooks, and peer-reviewed research contribute to defining optimal care.
Expert Consensus and Case Law: The opinions of expert witnesses in legal cases and previous court rulings (case law) can establish or clarify standards of care.

Key Principles Guiding Mental Health Care:

Underlying all standards of care are fundamental ethical and philosophical principles that are particularly salient in mental health:

Patient Safety: Paramount in all care, especially concerning risks like suicide, self-harm, or aggression.
Therapeutic Relationship: The development of a trusting, empathetic, and professional relationship is central to effective mental health nursing.
Autonomy: Respecting the patient's right to make decisions about their care, even when their capacity may be impaired, and supporting them to regain decision-making abilities.
Beneficence: Acting in the best interest of the patient, aiming to do good.
Non-Maleficence: The duty to do no harm.
Justice: Ensuring fair and equitable access to care, regardless of background or diagnosis.
Fidelity: Being faithful to promises and commitments made to patients.
Confidentiality: Protecting sensitive patient information, which is especially critical given the stigma often associated with mental illness.

Legal Aspects in Psychiatric Nursing

The practice of psychiatric nursing is influenced by law, particularly initial concern for the rights of patients and the quality of care they receive.

The client’s right to refuse a particular treatment, protection from confinement, intentional torts, informed consent, confidentiality and Promotion of research in mental health nursing.
The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.
Cost-effective nursing care: Studies need to be conducted to find out the viability in terms of cost involved in training a nurse and the quality of output in terms of nursing care rendered by her.
Focus of care: A psychiatric nurse has to focus care on certain target groups like the elderly, children, women, youth, mentally retarded and chronic mentally ill.
Record keeping are a few legal issues in which the nurse has to participate and gain quality knowledge.

STANDARDS OF MENTAL HEALTH NURSING

The purpose of Standards of Psychiatric and Mental Health Nursing practice is to fulfill the profession’s obligation to provide a means of improving the quality of care. The standards presented here are revision of the standards enunciated by the Division on Psychiatric and Mental Health Nursing Practice in 1973.

Professional Practice Standards

Standard I: Theory

The nurse applies appropriate theory that is scientifically sound as basis for decisions regarding nursing practice. Psychiatric and mental health nursing is characterized by the application of relevant theories to explain phenomena of concern to nurses and to provide a basis for intervention.

Standard II: Data Collection

The nurse continuously collects data that are comprehensive, accurate and systematic. Effective interviewing, behavioral observation, physical and mental health assessment enable the nurse to reach sound conclusions and plan appropriate interventions with the client.

Standard III: Diagnosis

The nurse utilizes nursing diagnosis and/or standard classification of mental disorders to express conclusions supported by recorded assessment data and current scientific premises.

Nursing logic basis for providing care rests on the recognition and identification of those actual or potential health problems that are within the scope of nursing practice.

Standard IV: Planning

The nurse develops a nursing care plan with specific goals and interventions delineating nursing actions unique to each client’s needs.

The nursing care plan is used to guide therapeutic intervention and effectively achieve the desired outcomes.

Standard V: Intervention

The nurse intervenes as guided by the nursing care plan to implement nursing actions that promote, maintain or restore physical and mental health, prevent illness and effect rehabilitation.

(a) Psychotherapeutic interventions: The nurse uses psychotherapeutic interventions to assist clients in regaining or improving their previous coping abilities and to prevent further disability.
(b) Health teaching: The nurse assists clients, families and groups to achieve satisfying and productive patterns of living through health teaching.
(c) Activities of daily living: The nurse uses the activities of daily living in a goal directed way to foster adequate self-care and physical and mental well-being of clients.
(d) Somatic therapies: The nurse uses knowledge of somatic therapies and applies related clinical skills in working with clients.
(e) Therapeutic environment: The nurse provides structures and maintains a therapeutic environment in collaboration with the client and other health care providers.

Standard VI: Evaluation

The nurse evaluates client responses to nursing actions in order to revise the database, nursing diagnosis and nursing care plan.

Professional Performance Standards

Standard VII: Peer Review

The nurse participates in peer review and other means of evaluation to assure quality of nursing care provided for clients.

Standard VIII: Interdisciplinary Collaboration

The nurse collaborates with other health care providers in assessing, planning, implementing and evaluating programs and other mental health activities.

Standard IX: Utilization of Community Health Systems

The nurse participates with other members of the community in assessing, planning, implementing and evaluating mental health services and community systems that include the promotion of the brand continuum of primary, secondary and tertiary prevention of mental illness.

Standard X: Research

The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.

Impact of Standards on Practice:

Adherence to these standards is fundamental to quality mental health nursing. It:

Minimizes Liability: By practicing within accepted standards, nurses significantly reduce their risk of negligence or malpractice claims.
Promotes Quality Outcomes: Consistent application of evidence-based standards leads to improved patient safety, more effective treatments, and better overall patient experiences and outcomes.
Enhances Professional Credibility: Upholding high standards reinforces the professionalism and trustworthiness of mental health nursing.
Guides Professional Development: Standards highlight areas for ongoing education, skill development, and specialization within mental health nursing.

Standards of Care Read More »

Law and Mental Illness

Law has relevance in nearly all aspects of nursing practice, but in no other area of nursing is the law more intimately involved than in psychiatric nursing.

This is because psychiatric clients may;

be placed on treatment against their own will
pose a risk to themselves
have been charged to have committed crime while legally insane
be unable or unwilling to consent to treatment
be incapable of fully understanding medical risks
require constant restraints for their safety or others
make threats to others
undergo forensic evaluations that require nurses to testify in court

Forensic Psychiatry

Forensic psychiatry is a specialized branch of psychiatry that deals with the interface between mental health and the law.

Forensic psychiatry is a branch of psychiatric nursing that deals with disorders of mind and their relationship with the legal principles.

It is also concerned with the assessment, investigations, diagnosis and treatment of mental disorders among three broad categories of individuals i.e.;

individuals who are alleged to have committed an offence and face prosecution
convicted prisoners who develop mental illness in the course of serving their sentence
individuals who have not committed an offence but are at risk because of their mental capacity

Under existing mental health legislation in Uganda, it is not expected that the primary health care provider will provide this service. It is however advised that a PHC provider knows something about prisoners’ mental health needs for the purpose of early and appropriate referrals to centres where a psychiatrist or other mental health professionals are available.

The basic forensic psychiatry includes:

Crime and psychiatric disorders
Criminal responsibility
Civil responsibility
Laws relating to psychiatric disorders
Admission procedures of patients in psychiatric hospital
Civil rights of mentally ill
Psychiatrists and court

I. Crime and Psychiatric Disorders

There is a close association between crime and psychiatric disorders like schizophrenia, affective disorders, epilepsy, drug dependency, personality disorders, etc.

Mentally ill people may commit crime because:

they do not understand the implication of their behaviour
due to delusions and hallucinations
abnormal mental states like confusion or excitements
drug related violence

Instances when an individual facing prosecution may come to attention of a psychiatrist:

when police notices signs of mental disorder in individual under their custody
when the judge observes signs of mental disorder
when relatives raise issue of mental disorder
when prisoner reports history of treatment for psychiatric disorder
when suspect pleads insane during court proceedings

Under any of the above, the magistrate may order assessment and observation of an individual to ascertain:

whether the individual is mentally disordered
the individual’s ability to stand trial if mentally disordered
whether the accused is criminally responsible for the offence he is charged with

Responsibilities of a psychiatrist in order to find answers for the above questions:

hospitalize the accused for the purpose of observations and possible treatment or attend to matter as an out-patient case
take a full psychiatric history including history of previous episodes of illness and treatment
order an observation of patient by other nursing staff on daily basis
conduct laboratory, psychological and social investigations
make a report to the magistrate who will then decide on the best course of action on the basis of a psychiatric report

II. Criminal Responsibility

Criminal responsibility is a legal concept which refers to the extent to which an individual can be held liable for his or her offence.

According to section 84 of the Indian penal code act of 1860, “Nothing is an offence which is done by a person who, at a time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of act, or that he is doing what is either wrong or contrary to the law”.

A clinical test of responsibility may be used to determine whether an individual is responsible for an offence or not.

III. Criteria for Criminal Responsibility

Criteria for Criminal Responsibility (CCR) Score:

SCORE	Yes (1) / No (0)
1. offence required careful planning
2. offence was unrelated to symptoms of mental disorder
3. identifiable motive for the crime was not a product of mental disorder
4. mental capacity at a time of crime was unimpaired or did not impair rational judgement
5. amnesia if present is incongruent with relevant key features of crime and mental state

Score each item 1 for a Yes response and 0 for No response.

The maximum score is 5. A score of 3 and more indicates that the individual is probably responsible for an alleged crime.

IV. Other Criteria Used to Determine Criminal Responsibility

M’Naghten’s rule: This states that the individual at a time of the crime did not know the nature and quality of the act and if he did know what he was doing, he did not comprehend it to be wrong.
The Irresistible impulse act: According to this rule, a person may have known an act was illegal but as a result of mental impairment lost control of their actions.
The Durham test or Product rule: This states that an accused is not criminally responsible if his unlawful act was the product of mental disease or abnormality.
American law institute: This states that a person is not responsible for criminal conduct if at time of such conduct, as a result of mental disease or defect he lacks adequate capacity either to appreciate the criminality of his conduct or to conform his conduct to requirements of the law.

V. Ability to Stand Trial

An individual will not be expected to have an ability to stand trial under the following circumstances:

mentally ill with active signs of mental disorder
lacks ability to understand court proceedings

In cases of the above, the psychiatrist may recommend that the individual receives relevant treatment for the mental disorder and after full recovery, the individual may then stand trial. However, in cases of severe psychotic illness like schizophrenia, the case might be disposed.

Convicted prisoner: In case a prisoner who is serving sentence falls ill, he or she may be referred to a mental hospital under magistrates court Act for assessment, observation and treatment. Unfortunately, under existing laws, such an individual will not be excused from serving his prison sentence on ground of mental illness otherwise he will be released at the end of a prison sentence.

VI. Aims of Management in Forensic Work

diagnose to form a basis for treatment and recommendations to court
make report and submit to court
rehabilitate as part of management
promote acceptance of individual in his community
resettle individual back in community
promote after care following discharge from court and hospital

Civil Responsibilities and Rights of Mentally Ill Persons

Beyond the criminal justice system, individuals with mental illness interact with the law concerning their civil responsibilities and fundamental human rights.

I. Civil Responsibilities of a Mentally Ill Person:

Mental illness can, under specific legal circumstances, impact an individual's capacity to exercise certain civil responsibilities. When a person is deemed of "unsound mind" to a degree that impairs their judgment or decision-making, the law provides mechanisms to protect their interests and the interests of others.

Management of Property: "In case the court ascertain that a person is of unsound mind and incapable of managing his property, a manager is appointed by court of law to take care of his property which may include selling or disposal of property to settle debts or expenses." This highlights the legal provision for protecting the assets of individuals who lack the mental capacity to manage their own financial affairs. The appointed manager acts in the best interest of the person with mental illness.
Marriage: "Hindu Marriage Act 1995" states that "marriage between any two individuals one of whom was of unsound mind at a time of marriage is considered null and void in the eyes of the law." Furthermore, "Unsoundness of mind for a continuous period can be sighted as a ground for obtaining divorce." If this unsoundness continues for a period of two years, the other party can file for divorce, though "divorce is granted with a precondition that one has to pay maintenance charges for the mentally ill."
Testamentary Capacity (Making a Will): "Testamentary capacity or the mental ability of a person is a precondition for making a valid will." For a will to be legally binding, "The testator must be the major, free from coercion, understanding and displaying soundness of mind." This means that at the time of making a will, the individual must possess sufficient mental clarity to understand the nature of the document, the property they are disposing of, and the beneficiaries. Mental illness might invalidate a will if it demonstrably impaired this capacity.
Right to Vote: "A person of unsound mind cannot contest for elections or exercise the privilege of voting." This is a civil responsibility directly tied to mental capacity, reflecting the legal requirement for electors and candidates to possess sound judgment in political processes.

II. Rights of Psychiatric Patients:

The legal framework, particularly within the context of mental health care, also aims to protect the fundamental human rights and dignity of individuals receiving psychiatric treatment.

Right to wear their own clothes: Promotes dignity, personal expression, and normalization.
Right to informed consent: Ensures patients understand and voluntarily agree to treatment, or have a legally authorized person consent on their behalf when capacity is compromised. This is a cornerstone of ethical medical practice.
Right to habeas corpus: The right to challenge the legality of one's detention before a court, ensuring that involuntary hospitalization is subject to judicial review.
Right to have individual storage space for their private use or right to privacy: Protects personal belongings and maintains a sense of autonomy and privacy within a treatment setting.
Right to keep and use their own personal possessions: Allows patients to maintain connection to their identity and comfort items.
Right to spend some of their money for their own expenses: Affirms financial autonomy and choice.
Right to have reasonable access to all communication media like telephones: Maintains connection with the outside world, family, and legal counsel.
Right to see visitors: Prevents social isolation and supports recovery through family and social connections.
Right to treatment in the least restricted setting: Advocates for treatment environments that impose the fewest limitations on personal freedom, consistent with safety and effective care.
Right to hold civil service status or enter into legal contracts e.g., marriage, personal last will etc.: These rights indicate that a diagnosis of mental illness alone does not automatically remove civil capacities. Such capacities are only removed if a court specifically determines an individual is of "unsound mind" to the extent that they cannot exercise these rights responsibly.
Right to refuse treatment especially ECT: Acknowledges bodily autonomy and the patient's right to decline medical interventions, particularly those with significant implications like Electroconvulsive Therapy (ECT), unless there is a specific legal provision for compelled treatment in emergency situations or under court order.
Right to manage and dispose of property and execute wills: Reaffirms that these civil responsibilities are generally retained unless a formal legal determination of incapacity has been made.

Legal Responsibilities and Potential Liabilities for Nurses in Psychiatric Service

Psychiatric nurses are confronted on daily basis with the interface of legal issues as they attempt to balance the rights of the patient with the rights of the society. Nurses and other health care providers should never in any way violate the rights of the mentally ill.

I. Legal Responsibilities of a Nurse:

Nurses, particularly in psychiatric care, bear specific legal responsibilities designed to protect both the patient and themselves from liability. These include:

Adherence to Laws and Standards: Nurses must be intimately familiar with all relevant laws and regulations in their state or region of practice. This includes understanding mental health legislation, patient rights, and the criminal and civil responsibilities associated with mental illness. Practicing within the scope of state laws and the Nurse Practice Act is fundamental.
Patient Rights Protection: Actively safeguarding patients' rights is a core responsibility. This involves ensuring patients are informed of their rights and that these rights are respected throughout their care.
Documentation: Accurate, thorough, and timely legal documentation is crucial. Nurses must clearly and accurately maintain records of all assessment data, treatments given, interventions performed, and the patient's responses to care. These records must be kept safely and confidentially.
Confidentiality: Maintaining strict confidentiality of all patient information is a paramount legal and ethical duty, given the sensitive nature of psychiatric diagnoses and treatments.
Informed Consent: Obtaining informed consent from patients or their legal representatives for any procedure or treatment is a fundamental requirement. Explanations of procedures must be tailored to the patient's anxiety level, attention span, and capacity to make decisions.
Collaboration: Working effectively with colleagues to determine the best course of action for patient care, ensuring a multidisciplinary approach.
Ethical Practice: Always prioritizing patients’ rights and welfare and developing effective interpersonal relationships with patients and their families.
Reporting: Recognizing and reporting instances of abuse, neglect, or any unsafe practices is a professional and legal obligation.

II. Nursing Malpractice:

Malpractice in nursing signifies a failure by a professional to provide the proper and competent care expected from members of their profession, leading to harm to the patient.

To successfully argue a case of malpractice against a healthcare provider, three conditions typically must be proven by the patient:

Established Standard of Care: There existed a recognized standard of care applicable to the situation.
Breach of Responsibility: The nurse or physician breached their professional responsibility by failing to adhere to this established standard.
Causation and Injury: This breach of responsibility directly caused injury or damage to the plaintiff (patient).

If malpractice is proven, compensatory damages may be awarded to the patient to cover medical expenses, lost wages, and physical or emotional suffering. In cases of gross negligence or extreme carelessness, punitive damages may also be awarded, intended not to compensate the patient but to punish the negligent professional.

III. Common Areas of Liability in Psychiatric Service:

The unique aspects of psychiatric care create specific vulnerabilities for liability. Nurses must be particularly vigilant in these areas:

Patient Committing Suicide: This remains a leading cause of liability. It involves inadequate risk assessment, failure to implement appropriate suicide precautions, or insufficient monitoring.
Failure to Prevent Self-Inflicted Injury: This encompasses situations where patients cause harm to themselves (e.g., cutting, head-banging) without direct suicidal intent, often due to their mental state, and where supervision or protective measures were inadequate.
Patient Assaults: Liability can arise from failure to prevent patients from assaulting other patients or staff. This often links to inadequate risk assessment, poor environmental management, or insufficient de-escalation skills.
Misuse of Psychoactive Prescription Drugs: This includes medication errors (wrong drug, dose, route, time) or inappropriate administration leading to harm.
Failure to Obtain Consent: Providing treatment without proper informed consent, particularly crucial in a setting where capacity to consent may fluctuate.
Failure to Report Abuse: Neglecting to report suspected abuse of a patient is a serious legal and ethical failing.
Inadequate Monitoring of Patients: Insufficient observation or supervision, especially for high-risk patients, leading to adverse events.
Breach of Confidentiality: Unauthorized disclosure of sensitive patient information.
Improper Use of Seclusion and Restraints: Applying these interventions without strict adherence to legal guidelines, clinical necessity, and monitoring protocols.
Failure to Diagnose: While primarily a physician's role, nurses contribute to the diagnostic process through their observations and reporting. A failure to recognize and report critical symptoms that lead to a missed diagnosis and subsequent harm could involve nursing liability.

IV. Steps to Avoid Liability in Psychiatric Nursing Services:

Proactive measures are essential for psychiatric nurses to mitigate legal risks:

Effective Communication: Reporting relevant patient information clearly and thoroughly to co-workers involved in patient care.
Meticulous Documentation: Accurately and thoroughly documenting all assessment data, treatments given, interventions, and evaluations of patient responses.
Confidentiality: Consistently maintaining the confidentiality of patient information.
Scope of Practice: Practicing strictly within the defined scope of state laws and the Nurse Practice Act.
Collaboration: Working collaboratively with colleagues and the interdisciplinary team to determine the best course of action for patient care.
Standards of Practice: Utilizing established practice standards and guidelines to inform and direct clinical decisions and actions.
Patient-Centered Care: Always prioritizing patients’ rights and welfare above all else.
Therapeutic Relationships: Developing effective and professional interpersonal relationships with patients and their families.

MENTAL TREATMENT ACT (MTA)

Legal Documents And Admission Of Civil Patients.

The Mental Treatment Act (MTA), enacted in 1964, is a piece of legislation governing the admission, treatment, and discharge of individuals with mental illness in psychiatric hospitals. It replaced the earlier Mental Treatment Ordinance of 1938, aiming to safeguard persons with unsound mind from harm, protect the public, and legally authorize mental hospitals to detain, treat, and discharge patients. The MTA primarily addresses civil patients, distinguishing them from forensic patients who enter the system via criminal justice proceedings.

I. Orders for Admission of Civil Patients:

The MTA outlines four primary orders under which civil patients can be admitted to mental hospitals, each with specific criteria and durations. While the Voluntary Order is not strictly under the MTA, it is legally accepted as a pathway to admission.

1. Urgency Order (Section 7 of MTA):

Purpose: Designed for the rapid removal of an individual with mental illness from the public into a mental hospital, especially when there is an immediate need for intervention due to potential danger to themselves or others.
Authorization: Can be signed by a licensed medical practitioner (e.g., registered nurse, doctor), a police officer not below the rank of Assistant Inspector, or a gazetted chief (e.g., a Resident District Commissioner - RDC).
Duration: Remains in effect for a period of 10 days. It cannot be renewed; if further detention is required, a new order must be initiated. If the patient is not discharged or a new order is not signed after 10 days, the patient has the right to sue the hospital for illegal detention.

2. Temporary Detention Order (Section 3 of MTA):

Purpose: This serves as the standard initial procedure for detaining patients requiring psychiatric hospitalization. The process begins with the "information of lunacy," which can be made by anyone aware of the patient's condition, though in practice, it is often initiated by the ward in charge.
Duration: Valid for 14 days. It can be renewed once for an additional 14 days, but no further renewals are permitted under this order.

3. Reception Order (Section 5 of MTA):

Purpose: This order is sought if a patient's condition does not improve after the Temporary Detention Order and its renewal expire. It signifies a longer-term commitment to care.
Process: A magistrate appoints two medical practitioners (who are not related to the patient) to thoroughly investigate the patient's behavior and illness. Upon receiving and being satisfied with these medical reports, the magistrate signs the Reception Order.
Duration: Initially valid for one year. If the patient's condition has not improved, it can be renewed for another year. If improvement is still not observed, subsequent renewals are for three-year periods.
Implications: Patients under a Reception Order are considered "satisfied," implying a legal determination of diminished capacity. They are generally not permitted to sign a will, vote, stand as a witness in court, or marry, reflecting a curtailment of certain civil rights due to their mental state.

4. Voluntary Order:

Status: Although not strictly under the MTA, this is a legally accepted pathway for admission.
Process: The patient voluntarily presents themselves to the hospital. The Medical Superintendent or Director examines the patient to confirm their mental health status. The patient agrees to abide by hospital rules and regulations.
Discharge: If a voluntary patient wishes to leave, they inform the ward in charge, who then informs the ward doctor and subsequently the Medical Director or Superintendent. There is typically a 72-hour period within which this notification and processing occurs, allowing for assessment of the patient's decision-making capacity and potential transition planning.

II. Discharge of Civil Patients:

The discharge process for civil patients under the MTA involves several sections, each catering to different circumstances, and nurses play a crucial role throughout.

A. Role of a Nurse in Discharge Procedure:

Nurses are instrumental in ensuring a safe and effective discharge by:

Identifying the patient's fitness for discharge and informing the psychiatrist.
Providing feedback and information about the discharge plan and seeking the patient's input.
Ensuring all paperwork and forms are completed, signed, and copies sent to medical records.
Confirming the patient has returned all hospital property to the ward manager.
Clearly communicating all necessary information, particularly regarding medications and follow-up appointments, to the patient.
Recognizing and addressing any mixed feelings the patient may have about leaving the hospital and returning to the community, offering support and coping strategies.
Preparing the patient's community (family, caregivers) to receive and support the patient, depending on the circumstances.
Escorting the patient out of the ward or hospital compound.

B. Discharge Sections under the MTA:

Section 18: For Recovered Patients:
When a nurse assesses a patient as fit for discharge, they inform the ward doctor (psychiatrist), who then recommends the patient's fitness. The doctor writes to the Director for authorization to discharge the patient with treatment. For patients admitted under Temporary Detention or Reception Orders, the magistrate is informed and authorizes the discharge.
Section 19: Discharge of a Patient Under the Care of Relatives:
If relatives request to take the patient home, they must provide a written statement confirming they will care for the patient. If the patient becomes unmanageable within 28 days of discharge, they can be readmitted using the previous order. After 28 days, a new admission order would be required. In such cases, if the discharge is against medical advice, no medications are provided unless paid for.
Section 20: Discharge for a Paying Patient:
If relatives of a paying patient face increasing medical costs and request discharge, even if the patient is not fully recovered, the Medical Superintendent may grant it. This often comes with a condition that the hospital will not be held responsible for any subsequent incidents at home. Similar to Section 19, no medications are provided without payment if the discharge is against medical advice.
Section 21: Discharge on Trial Leave:
The Director of Medical Services authorizes the Medical Superintendent or ward doctor to discharge a patient on trial leave for a specified period (typically 28 days), during which the patient is expected to return for review. If the patient exceeds this 28-day period without returning, a fresh admission order would be required for readmission.
Section 22: Discharge for Escaped Patients:
If a patient escapes and does not return within 28 days, should they later be brought back, a fresh admission order must be obtained for readmission. This provision addresses safety and management concerns for the hospital.
Section 23: Discharge of a Person of Sound Mind:
If an individual of sound mind is detained against their will, a magistrate, in conjunction with a psychiatrist, will examine the person. If they are indeed found to be of sound mind, the Medical Superintendent or ward doctor will be directed to immediately discharge them.

III. Transfer of Patients:

The MTA also includes provisions for the transfer of patients:

Section 36: Transfer of Patients: This section covers two types of transfers:
- Intra-national Transfer: Allows for the transfer of a patient from one hospital to another within the same country if deemed necessary by the patient, relatives, or medical professionals.
- Inter-national Transfer: Permits the transfer of a mental patient from a hospital in one country to a hospital in another country.
Section 38: Transfer of a Foreigner Back to Their Own Country: This section specifically grants the authority to transfer a foreign mental patient back to their country of origin.

Admission and Discharge Procedures for Criminal Mental Patients

Criminal mental patients, also known as forensic patients, are individuals who interact with the mental health system due to their involvement with the criminal justice system. They are broadly classified into two categories: Remand patients and Class A, B, and C patients, each with distinct admission and discharge protocols governed by specific legal frameworks.

I. Remand Patients (Penal Code Act 106):

Remand patients are individuals who have been accused of an offense and charged, but during court proceedings, they are suspected of being of "unsound mind." They are referred to a mental hospital by a magistrate for observation, investigation, and the preparation of a medical report detailing their mental state, as requested by the court.

A. Admission of a Remand Patient:

Remand patients are admitted to a mental hospital under a warrant of commitment on remand. This warrant is signed by a judge or a magistrate and specifies either a fixed date or an open date for the patient to reappear in court.

Fixed Date Remand: The warrant explicitly states the date for the accused's next court appearance. When this date arrives, the patient is returned to court, accompanied by a medical report indicating their capacity to plead. If found capable, they may be sentenced immediately. If deemed incapable, they are typically returned to the hospital and reclassified as a Class B patient.
Open Date Remand: In this scenario, the warrant of commitment does not specify a date for the next hearing. The patient is recalled to court as needed, upon presentation of a production warrant signed by a magistrate.

II. Class A Patients:

Class A patients are prisoners who develop mental disorders while serving their sentences in a correctional facility.

A. Admission of Class A Patients:

These patients are transferred from prison to a mental hospital based on several orders:

A Temporary Detention Order or Reception Order, similar to those for civil patients, but applied within the context of their incarceration.
A warrant of commitment that specifies the offense they committed.
A warrant slip indicating the expiration date of their prison sentence.

B. Discharge of Class A Patients:

The discharge process for Class A patients depends on their recovery and sentence status:

Recovery Before Sentence Expiration: If a patient recovers while their sentence has not yet expired, they are returned to prison to complete their sentence. This transfer is facilitated by a production warrant signed by a magistrate.
Sentence Expiration While Hospitalized (Recovered): If the patient's sentence expires while they are in the mental hospital and they have recovered, they are discharged directly home under Section 18 of the Mental Treatment Act (which pertains to recovered patients).
Sentence Expiration While Hospitalized (Not Recovered): If the sentence expires but the patient has not shown signs of improvement, they are removed from the forensic register and transferred to a civil hospital, where their care continues under civil orders.

III. Class B Patients:

Class B patients are individuals admitted from court who have been deemed incapable of making their own defense or following court proceedings due to insanity.

A. Admission of Class B Patients:

They are admitted to a mental hospital for observation and treatment under specific warrants:

A warrant of detention for an accused person incapable of making a self-defense, signed by the Minister of Justice or the Attorney General.
Alternatively, a warrant of detention for an accused person incapable of making a self-defense, signed by a magistrate or judge, pending the Minister's order.

B. Discharge of Class B Patients:

When a Class B patient recovers and is deemed able to plead, a psychiatrist issues a certificate of mental fitness. This certificate is submitted to the Director of Public Prosecutions, who then arranges for a court hearing.

If, after pleading, the accused is found guilty, they are sentenced directly.
If found not guilty due to reasons of insanity, they are returned to the mental hospital and reclassified as a Class C patient.

IV. Class C Patients:

Class C patients are those admitted from court after being found not guilty of an offense due to reasons of insanity.

A. Admission of Class C Patients:

Their admission to a mental hospital is based on:

A warrant of detention signed by a judge or magistrate, pending the Minister's order.
A Minister's order, which will explicitly state "ORDER OF DETENTION of a person of unsound mind not found guilty due to reasons of insanity."

B. Discharge of Class C Patients:

Depending on the minister's order the patient after recovery is discharged directly home unless otherwise ordered by the minister.

Law and Mental Illness Read More »

Resuscitation

Neonatal Resuscitation Lecture Notes

Neonatal Resuscitation refers to a series of interventions initiated immediately after birth to support the establishment of breathing and circulation in a newborn who is not breathing effectively or has inadequate circulation.
Resuscitation is a means of restoring life to a baby from the state of asphyxia (Devi, Upendra, and Bard, 2017).

Asphyxia in a newborn refers to a condition where there is impaired blood gas exchange, leading to a progressive decrease in oxygen (hypoxemia) and an increase in carbon dioxide (hypercarbia), often resulting in acidosis.

More simply, it is about "helping a baby to breathe," which is the most critical physiological adjustment required at birth.

The Importance of Neonatal Resuscitation:

High Vulnerability of the Neonatal Period: The first 28 days of life is called neonatal period and incontrovertibly, it is the most vulnerable and high risk time in life because of the highest mortality and morbidity that occur in this period. The day of birth is the riskiest time to a baby" (Sajjad, 2012; and WHO, 2015). A significant proportion of neonatal deaths occur on the first day of life, many of which are attributable to birth asphyxia.
Prevention of Mortality: Effective and timely resuscitation can directly prevent death in newborns who fail to transition successfully from intrauterine to extrauterine life.
Prevention of Morbidity and Long-Term Disability: Prevent brain injury and other organ damage resulting from prolonged oxygen deprivation. Timely resuscitation minimizes the duration of hypoxemia and acidosis, thereby reducing the risk of such devastating outcomes.
Enabling Physiological Transition: Birth involves a physiological transition from relying on the placenta for gas exchange to establishing independent pulmonary respiration and circulatory changes. Approximately 85% of newborns transition successfully without intervention. However, about 10-15% require some assistance, and about 1% require extensive resuscitative measures. Resuscitation provides the necessary support for these babies to make this critical transition.
Global Health Impact: Improving access to and quality of neonatal resuscitation services is a key strategy for achieving global maternal and child health targets, particularly in low-resource settings where the burden of birth asphyxia is highest.

Goals of Neonatal Resuscitation (Aims of Management):

Initiate and/or Restore Respiration/Breathing: This is the most immediate and primary goal, as establishing effective breathing is fundamental to oxygenation.
Establish Adequate Circulation: While not explicitly listed as a separate aim in your text, it's intrinsically linked to respiration. Effective breathing improves oxygenation, which then supports heart function and systemic circulation.
Prevent Infection: Although not a direct resuscitation step, ensuring aseptic technique during resuscitation and appropriate post-resuscitation care are vital to prevent secondary complications in a vulnerable neonate.
Prevent Other Complications: This is a broad goal encompassing the prevention of brain injury (HIE), organ dysfunction, and ensuring overall physiological stability.
Prevent Hypothermia: Maintaining the newborn's temperature is critical from birth, throughout resuscitation, and into post-resuscitation care, as hypothermia can worsen acidosis and impair resuscitation efforts.

Risk Factors for Resuscitation

I. Common Maternal Risk Factors:

These factors are related to the mother's health, pregnancy complications, or circumstances surrounding the birth.

Advanced Maternal Age: (e.g., usually >35 years)

Maternal Illnesses/Conditions:

Diabetes (gestational or pre-existing)
Hypertension (e.g., pre-eclampsia, eclampsia, chronic hypertension)
Cardiac or renal disease
Thyroid disease
Anemia
Infections (e.g., Group B Streptococcus, herpes simplex virus, HIV)

Substance Abuse:

Opioid use (can cause neonatal abstinence syndrome)
Alcohol abuse
Smoking

Medications:

Maternal sedatives/analgesics administered close to delivery (can cause neonatal respiratory depression).
Magnesium sulfate administration (for pre-eclampsia, can cause neonatal respiratory and neuromuscular depression).

Lack of Antenatal Care: Poor or no antenatal care prevents the identification and management of potential risks.

II. Common Fetal/Intrapartum Risk Factors:

These factors are directly related to the fetus or events occurring during labor and delivery.

Prematurity: The most significant risk factor. Premature infants have immature lungs, poor temperature control, and vulnerable brains.

Extremely preterm (<28 weeks)
Very preterm (28-32 weeks)
Moderate to late preterm (32-37 weeks)

Post-term Pregnancy: (>42 weeks gestation), associated with placental insufficiency.

Multiple Gestation: (Twins, triplets, etc.) increases the risk of prematurity, growth restriction, and delivery complications.

Abnormal Fetal Heart Rate (FHR) Pattern:

Persistent bradycardia
Repetitive late decelerations
Prolonged decelerations
Loss of variability, indicating fetal distress.

Meconium-Stained Amniotic Fluid: (especially thick meconium), indicates fetal stress and risk of meconium aspiration syndrome.

Prolonged Rupture of Membranes (PROM): Increases risk of infection.

Chorioamnionitis: (Infection of the amniotic fluid and membranes), leads to neonatal sepsis and respiratory distress.

Abnormal Presentation: (e.g., breech, transverse lie), often requires C-section and can be associated with birth trauma.

Placental Abnormalities:

Placenta previa
Abruptio placentae (premature separation of the placenta)
Vasa previa, leading to fetal hemorrhage and hypoxia.

Cord Complications:

Nuchal cord (cord around the neck)
Cord prolapse (cord falling through the cervix before the baby)
True knot in the cord.

Fetal Anomalies: Congenital malformations affecting respiratory, cardiac, or neurological systems.

Intrapartum Complications:

Prolonged labor
Precipitous labor (very rapid labor)
Forceps or vacuum extraction delivery
Cesarean section (especially elective C-section without labor, as it can be associated with transient tachypnea of the newborn).
Shoulder dystocia.

Fetal Growth Restriction (FGR) / Small for Gestational Age (SGA): Indicates placental insufficiency and compromised fetal reserves.

Lack of Fetal Movement: Reported by mother.

Initial Steps of Newborn Care and Assessment at Birth

This objective focuses on the immediate actions taken when a baby is born, particularly during the critical first minute of life—often referred to as the "Golden Minute." This period is crucial for assessing the newborn's transition and initiating any necessary interventions quickly to prevent adverse outcomes.

Principles of Management.

Temperature regulation. Ensure adequate warmth for the baby to prevent hypothermia which leads to decreased metabolic which cause additional stress to the baby.
Ensure adequate oxygenation to the baby to prevent hypoxia by administration of oxygen and monitoring oxygen perfusion. An endotracheal tube should be inserted and oxygen administered
Prevention of hypoglycemia by regular monitoring blood glucose and if risk for hypoglycemia is identified administer dextrose as per prescription.

I. Preparation for Birth: Ensuring Readiness

Before any birth, and especially when risk factors (as discussed previously) are present, it is paramount to ensure the resuscitation area is prepared and all necessary equipment is immediately available and functional.

A. Essential Equipment and Supplies :

Personal Protective Equipment:

Surgical gloves (minimum for resuscitator).
Other PPE (gowns, masks, eye protection) as per institutional policy.

Warmth Management:

Radiant warmer or heat lamp (integrated into the resuscitation table).
Pre-warmed towels or blankets.
Temperature probe/sensor (to monitor infant's temperature).
Plastic wrap/bag (for extremely preterm infants).

Airway and Suction:

Bulb syringe.
Suction catheters (e.g., 6F, 8F, 10F) with mechanical suction apparatus (set to 80-100 mmHg).
Meconium aspirator (if meconium is present and baby is non-vigorous, though routine use has decreased).

Ventilation Equipment:

Self-inflating bag, flow-inflating bag, or T-piece resuscitator.
Face masks (various sizes: preterm, term, full-term/neonate).
Oxygen source (blender if available to provide specific FiO2, flowmeter).
Nasal prongs/cannula (for oxygen administration post-resuscitation).

Intubation Equipment:

Laryngoscope with straight blades (e.g., Miller 0, 1 for term/preterm).
Spare laryngoscope handle and bulbs.
Endotracheal tubes (ETTs): range of sizes (e.g., 2.5, 3.0, 3.5, 4.0 mm internal diameter).
Stylet (for ETT insertion).
CO2 detector (colorimetric or capnography) for confirming ETT placement.
Scissors, tape/ETT holder for securing ETT.
Naso-gastric/oro-gastric tube (e.g., 8F) for gastric decompression after prolonged PPV.

Circulation and Medication Equipment:

Syringes (various sizes: 1mL, 3mL, 5mL, 10mL, 20mL).
Needles/blunt fill devices.
Umbilical venous catheterization tray (for rapid vascular access if medications are needed).
Sterile water and normal saline (for flushing).
Pediatric stethoscope.

Medications (Prepared and Labeled):

Adrenaline (Epinephrine) 1:10,000 solution:
Volume Expanders: 0.9% Normal Saline or Ringer's Lactate.
Dextrose 10%: For hypoglycemia management post-resuscitation.
Sodium Bicarbonate 4.2%: For prolonged resuscitation with documented metabolic acidosis.

Monitoring and Documentation:

Timer (clock watch).
Pulse oximeter with neonatal probe (pre-ductal placement, right hand/wrist).
Displayed charts for resuscitation steps (e.g., NRP algorithm).
Mothers' chart/patient notes.

B. Resuscitation Environment:

Resuscitation table: Stable, readily accessible, with radiant warmer.
Light source: Adequate, adjustable lighting.
Proximity: Situated near the delivery area for immediate access.

II. Immediate Assessment at Birth: The "Golden Minute"

Upon delivery, a rapid assessment is made to determine if the newborn requires routine care or resuscitation. This assessment should take no longer than 30 seconds to allow for timely intervention within the first minute of life.

A. Three Key Questions for Rapid Assessment:

The decision to proceed with routine care or to initiate resuscitation is based on answering these three questions quickly:

Is the baby term gestation? (i.e., ≥ 37 weeks)
Does the baby have good tone? (i.e., flexed limbs, active movement)
Is the baby breathing or crying? (i.e., strong, regular respiration, not gasping or apneic)

B. Decision Pathway:

YES to all three questions: Proceed with Routine Care (provide warmth, dry, skin-to-skin, observe).
NO to any of these questions: Proceed immediately to the Initial Steps of Stabilization.

III. Steps for Resuscitation: The T-A-B-C's of Resuscitation

If the newborn does not meet the criteria for routine care, the following initial steps of stabilization must be performed quickly and effectively, ideally within the first 30-60 seconds after birth (the "Golden Minute").

A. Step 1: Temperature (T)

Provide Warmth and Dry:

Place the naked newborn under a pre-heated radiant warmer.
Dry the baby thoroughly with pre-warmed towels/blankets. This removes amniotic fluid, which prevents evaporative heat loss, and provides tactile stimulation.
Remove any wet cloth after drying.

B. Step 2: Airway (A)

Position and Clear Airway:

Position baby’s head in a neutral or slightly extended “sniffing position”.
Place a small towel roll under the baby’s shoulders to help maintain this position, ensuring the airway is open.
Clear the airway (if necessary): Suction blood or mucus from the mouth and then the nose using a bulb syringe or suction catheter ONLY if secretions are obstructing breathing or the baby is gasping.

C. Step 3: Breathing (B)

Assess Breathing and Heart Rate: After completing the initial steps of warmth, drying, positioning, and suctioning (if needed), reassess the newborn.

Look for effective breathing (regular, sustained respiratory effort, no gasping).
Assess Heart Rate (HR): Auscultate the chest with a stethoscope or palpate the umbilical cord stump for 6 seconds and multiply by 10.

Intervention for Breathing Issues:

If the baby is apneic (not breathing) or gasping, OR if the Heart Rate is less than 100 bpm despite initial steps: Begin Positive-Pressure Ventilation (PPV).

Stand at the baby's head.
Apply an appropriately sized mask to the baby’s face, ensuring it covers the mouth and nose to form a good seal.
Give five initial inflation breaths (each 2-3 seconds duration). This aims to establish functional residual capacity in the lungs.
Observe response by looking for chest movements (chest rising) and listen for increasing heart rate.
Troubleshooting: If the chest does not rise, reapply the mask, reposition the baby’s head, and consider suctioning again (MR. SOPA mnemonic: Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase, Alternate airway).
Continue ventilating at a rate of 30-40 breaths per minute.
Intubation consideration: If PPV with a mask is ineffective, prolonged, or if specific conditions require it, intubation should be considered earlier than 20 minutes. Intubation provides a more secure airway for ventilation and allows for direct tracheal suction if needed.

D. Step 4: Circulation (C) / External Cardiac Massage (Chest Compressions)

Indication for Chest Compressions:

Chest compressions should be initiated if the heart rate is less than 60 beats per minute (bpm) AFTER at least 30 seconds of effective positive-pressure ventilation (PPV).

Technique:

The preferred method is the Two-Thumb Encircling Technique: Wrap your hands around the baby’s torso, placing both thumbs over the lower third of the sternum (just below an imaginary line between the nipples).
Alternatively, the two-finger technique can be used if one resuscitator is present or if the encircling method is not feasible.

Rate and Ratio:

Chest compressions are performed at a rate of 90 compressions per minute, coordinated with 30 ventilations per minute.
This provides a ratio of 3 compressions to 1 ventilation, aiming for 120 "events" (compressions + breaths) per minute.

Depth:

Compress the chest approximately one-third of the anterior-posterior diameter of the chest. Allow for complete recoil after each compression.

E. Step 5: Drugs (D)

Indication for Medications:

Medications are generally reserved for when the heart rate remains below 60 bpm despite effective ventilation and chest compressions.
Establish vascular access ( umbilical venous catheter - UVC) prior to medication administration.

Adrenaline (Epinephrine):

Indication: Heart rate remains < 60 bpm despite at least 30 seconds of effective PPV and at least 60 seconds of effective chest compressions coordinated with PPV.
Dose: 0.01 to 0.03 mg/kg IV (intravenous) or IO (intraosseous) of a 1:10,000 solution.
Repeat: May be repeated every 3-5 minutes if needed.

Volume Expanders (e.g., Normal Saline 0.9%):

Indication: Suspected hypovolemia (e.g., pallor, poor perfusion, weak pulse, lack of response to resuscitation efforts) and heart rate remains < 60 bpm despite ventilation, compressions, and epinephrine.
Dose: 10 mL/kg IV over 5-10 minutes.

Dextrose 10%:

Indication: Not typically given during acute resuscitation unless documented hypoglycemia. Administered after stabilization if blood glucose is low (<2.5 mmol/L).
Dose: 2 mL/kg of 10% dextrose solution IV.

Sodium Bicarbonate 4.2%:

Indication: For prolonged resuscitation or documented metabolic acidosis. Not a first-line drug.
Dose: 2 mEq/kg (equivalent to 4 mL/kg of 4.2% solution) IV slowly.

F. Post-Resuscitation Monitoring and Ongoing Care:

Continue to monitor response to resuscitation closely. (This includes heart rate, breathing, oxygen saturation, and clinical appearance).

APGAR Score: The Apgar score is assessed at 1 and 5 minutes after birth, and every 5 minutes thereafter if the score is less than 7, until 20 minutes of age. It's a snapshot of the baby's condition and response to resuscitation.

If the baby responds to resuscitation and stabilizes, keep the baby warm and transfer to a special care unit (e.g., NICU, SCN) for ongoing monitoring and supportive care.

If the baby is breathing well and stable:

Encourage skin-to-skin contact with the mother.
Encourage breastfeeding.
Provide reassurance to the mother and family.

Discontinuation of Resuscitation:

If there is no detectable heart rate after 10-20 minutes of complete and adequate resuscitation efforts, discontinuation of resuscitation should be considered in consultation with the medical team and family.

Principles and Techniques of Positive-Pressure Ventilation (PPV)

Positive-Pressure Ventilation (PPV) is the most critical and frequently performed intervention in neonatal resuscitation. Its primary goal is to establish functional residual capacity (FRC) in the lungs and provide oxygenation and ventilation to newborns who are apneic (not breathing), gasping, or have a heart rate below 100 beats per minute (bpm) despite initial steps. Effective PPV can rapidly improve heart rate, oxygen saturation, and clinical condition, often preventing the need for more advanced interventions like chest compressions or medications.

I. Principles of Effective PPV

The success of PPV hinges on three key principles:

Effective Mask Seal: The mask must form a tight, leak-free seal around the baby's mouth and nose to ensure that the delivered positive pressure enters the lungs and does not escape.
Open Airway: The baby's airway must be properly positioned (sniffing position) to allow air to flow freely into the trachea and lungs. Obstructions (e.g., secretions, incorrect head position) will render PPV ineffective.
Adequate Pressure and Rate: Sufficient pressure is needed to inflate the lungs, but excessive pressure must be avoided to prevent lung injury. The rate of ventilation must be appropriate to ensure both oxygenation and CO2 removal.

II. Indications for PPV

PPV is indicated when a newborn is:

Apneic: Not breathing at all.
Gasping: Irregular, ineffective breaths.
Heart Rate < 100 bpm: Despite the initial steps of warmth, drying, positioning, and clearing the airway (if necessary).

III. Equipment for PPV

The primary equipment used for PPV includes:

Ventilation Device:
- Self-inflating Bag: The most common device. It refills automatically after each squeeze and requires an oxygen source for supplemental oxygen. It will deliver room air if no oxygen is attached.
- Flow-inflating Bag (Anesthesia Bag): Requires a compressed gas source and a tight mask seal to inflate. Allows for precise control of pressure and oxygen concentration but requires more skill.
- T-piece Resuscitator (e.g., Neopuff): A gas-powered, flow-controlled device that delivers consistent peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP). Often preferred for its precision and consistency.
Face Mask:
- Proper size is crucial. Masks are available in various sizes (preterm, term/neonate). The mask should cover the bridge of the nose, the mouth, and the chin without extending over the eyes or compressing the neck.
- Transparent masks allow for visualization of the baby's mouth and color.
Oxygen Source:
- Oxygen blender (if available) allows for delivery of specific oxygen concentrations (FiO2).
- Flowmeter (usually set to 5-10 L/min for resuscitation).
Pulse Oximeter:
- Essential for monitoring oxygen saturation (SpO2) and heart rate during PPV. The probe should be placed on the right wrist or hand (pre-ductal site).

IV. Techniques for Administering PPV

A. Positioning the Baby and Mask Application:

Position the baby: Place the baby on their back under the radiant warmer, with the head in a neutral or slightly extended "sniffing position" (as detailed in Objective 3). A rolled towel under the shoulders can help.
Select the correct mask size: Ensure it covers the nose and mouth without touching the eyes or overhanging the chin.
Apply the mask:
- Position yourself at the baby's head.
- Place the mask gently but firmly on the baby's face.
- Use the "C-E grip" (or similar): The "C" is formed by the thumb and index finger pressing the mask edges to the face, while the "E" is formed by the remaining fingers lifting the jaw forward to maintain an open airway. Avoid pressing on the baby's soft tissues under the chin, which can obstruct the airway.

B. Initial Breaths (Inflation Breaths / Ventilating Breaths):

Initial Breaths: Begin with 5 breaths, each lasting 2-3 seconds. These are sometimes called "inflation breaths" or "ventilating breaths" as they are crucial for clearing fluid from the lungs and establishing functional residual capacity.
Pressure: The initial pressure required can vary.
- For a term baby, initial pressures of 20-25 cm H2O may be sufficient.
- For preterm babies or those with very stiff lungs, higher pressures (e.g., 25-30 cm H2O) may be needed to achieve initial chest rise.
- Many devices have pressure gauges; familiarize yourself with how to achieve the target pressure.
Observe for Chest Rise: The most important indicator of effective ventilation is a gentle, symmetrical rise and fall of the chest with each breath.
- If no chest rise: Immediately re-evaluate the mask seal, reposition the airway, and consider clearing secretions (MR. SOPA mnemonic - discussed below).

C. Ongoing PPV:

Rate: After the initial 5 breaths, continue PPV at a rate of 30-40 breaths per minute (approximately one breath every 1.5-2 seconds).
Pressure: Adjust pressure as needed to achieve gentle chest rise. Once the lungs are open, less pressure is often required.
Oxygen Concentration (FiO2):
- For term infants: Start with 21% (room air).
- For preterm infants (<35 weeks): Start with 21-30% oxygen.
- Adjust oxygen based on pulse oximetry readings. Target SpO2 values increase over the first 10 minutes of life (e.g., 60-65% at 1 min, 80-85% at 5 min, 85-95% at 10 min).

D. Assessing Response to PPV:

Reassess the baby approximately every 30 seconds during PPV.

Heart Rate (HR): The most important indicator. PPV is effective if the HR is increasing, especially if it rises above 100 bpm.
Breathing: Look for spontaneous breathing efforts.
Oxygen Saturation (SpO2): Monitor with a pulse oximeter.
Color: Observe the baby's color (pinker is good).
Tone: Increased activity and muscle tone.

V. Troubleshooting Ineffective PPV (MR. SOPA)

If PPV is not resulting in a rising heart rate or visible chest movement, quickly go through the following troubleshooting steps:

M - Mask adjustment: Reapply the mask to achieve a better seal.
R - Reposition airway: Adjust the head position to ensure an open airway.
S - Suction mouth and nose: Clear any secretions that may be blocking the airway.
O - Open mouth: Gently open the baby's mouth, sometimes just a finger's width, to facilitate airflow.
P - Pressure increase: Gradually increase the inspiratory pressure (e.g., by 5-10 cm H2O increments) until chest rise is observed.
A - Alternate airway: If PPV remains ineffective despite all the above, consider advanced airway interventions such as endotracheal intubation.

VI. Discontinuing PPV

PPV can be gradually discontinued when the baby meets the following criteria:

Heart rate is consistently > 100 bpm.
The baby is breathing spontaneously and effectively.
Oxygen saturation is within the target range for age on minimal or no supplemental oxygen.

Discontinuation can be done by gradually decreasing the rate of PPV while observing the baby's spontaneous breathing, or by stopping completely if the baby is breathing strongly and effectively.

Principles and Techniques of Chest Compressions in Neonatal Resuscitation

Chest compressions are an intervention in neonatal resuscitation, indicated when a newborn's heart rate remains dangerously low despite effective positive-pressure ventilation (PPV). The primary goal of chest compressions is to maintain blood flow to the vital organs, particularly the heart and brain, until the baby's own heart can resume an effective rhythm. This intervention is always performed in conjunction with PPV.

I. Principles of Effective Chest Compressions

For chest compressions to be effective, several principles must be adhered to:

Correct Indication: Compressions are only started after a defined period of effective PPV has failed to raise the heart rate.
Proper Location: Compressions must be delivered over the correct anatomical landmark (sternum) to be effective and minimize injury.
Adequate Depth: Compressions must be deep enough to create adequate blood flow but not so deep as to cause trauma.
Appropriate Rate: The rate must be fast enough to maintain perfusion, but allow for proper coordination with ventilations.
Complete Recoil: Allowing the chest to fully recoil between compressions is essential for adequate cardiac filling and coronary perfusion.
Coordination with Ventilation: Chest compressions must be perfectly coordinated with PPV to ensure both circulation and oxygenation.

II. Indications for Chest Compressions

Chest compressions are indicated when:

The newborn's heart rate is below 60 beats per minute (bpm).
This low heart rate persists despite at least 30 seconds of effective positive-pressure ventilation (PPV), confirmed by visible chest rise.

III. Techniques for Administering Chest Compressions

There are two main techniques for performing chest compressions in newborns:

Two-Thumb Encircling Technique (Preferred):
- Position: The resuscitator stands at the foot end of the baby (or to the side if more convenient for the team). Both hands encircle the baby's torso.
- Hand Placement: Place both thumbs side-by-side or one over the other (depending on baby size and hand size) on the lower third of the sternum, just below an imaginary line connecting the nipples.
- Compression: Use the pads of the thumbs to compress the sternum. The fingers support the baby's back, providing counter-pressure and stability.
- Advantages: This technique generally produces higher peak systolic blood pressure, better coronary artery perfusion pressure, and less fatigue for the resuscitator compared to the two-finger technique. It also allows for continuous ventilation.
Two-Finger Technique (Alternative):
- Position: The resuscitator is positioned to the side of the baby.
- Hand Placement: Place the tips of the index and middle fingers (or middle and ring fingers) of one hand on the lower third of the sternum, just below an imaginary line connecting the nipples.
- Compression: Use the tips of these two fingers to compress the sternum. The other hand can be placed under the baby's back for support.
- Advantages: This technique is often used if there is only one resuscitator or if vascular access is being obtained via the umbilical cord while compressions are ongoing.
- Disadvantages: Can be more tiring, may produce less effective blood flow, and may interfere with effective ventilation if not coordinated properly.

IV. Location, Depth, Rate, and Coordination

A. Location of Compressions:

On the lower third of the sternum, just below an imaginary line connecting the nipples. Avoid compressing over the xiphoid process (bottom tip of the sternum) as this can cause liver injury.

B. Depth of Compressions:

Compress the sternum to a depth of approximately one-third of the anterior-posterior (AP) diameter of the chest.
This depth ensures adequate cardiac output while minimizing the risk of injury. Allow for complete release and recoil of the chest wall after each compression to allow for cardiac refilling.

C. Rate of Compressions:

Compressions should be delivered at a rate of 90 compressions per minute.
This requires a rapid, rhythmic pace: "One-and-two-and-three-and-breathe..."

D. Coordination with Ventilation (3:1 Ratio):

Chest compressions are always coordinated with PPV. The established ratio is 3 compressions to 1 ventilation.
This means 90 compressions and 30 ventilations per minute, totaling 120 "events" (compressions + breaths) per minute.
Technique: "One-and-two-and-three-and-BREATH..." The "BREATH" should coincide with the release phase of the third compression. The resuscitator performing compressions should pause briefly (for approximately 0.5-1 second) to allow the ventilation to be delivered effectively.

V. Assessing Response to Chest Compressions

Heart Rate: Reassess the heart rate after 60 seconds of coordinated chest compressions and PPV.
- If the heart rate is ≥ 60 bpm, chest compressions can be discontinued, and PPV can be continued until the heart rate is ≥ 100 bpm and the baby has effective spontaneous breathing.
- If the heart rate remains < 60 bpm despite 60 seconds of coordinated compressions and PPV (which have been deemed effective), then medications (epinephrine) should be considered and administered as per Objective 3.

VI. Discontinuing Chest Compressions

Chest compressions should be discontinued once the newborn's heart rate is consistently 60 bpm or greater.
Continue PPV until the heart rate is consistently ≥ 100 bpm and the baby has effective spontaneous breathing.

Role and Administration of Medications in Neonatal Resuscitation

Medications are the final step in the neonatal resuscitation algorithm and are rarely needed when ventilation and chest compressions are performed effectively. The primary goal of medication administration in this context is to support cardiovascular function and improve heart rate when other resuscitative efforts have failed. Access for medication administration is established via the umbilical vein.

I. General Principles of Medication Administration

Last Resort: Medications are indicated only after adequate ventilation and effective chest compressions have been performed for a sufficient duration (usually at least 60-90 seconds after starting compressions) and the heart rate remains below 60 bpm.
Vascular Access: Rapid and reliable vascular access is crucial. The preferred route is the umbilical venous catheter (UVC). Intraosseous (IO) access can be an alternative if UVC placement is delayed or unsuccessful. Intratracheal (IT) administration of epinephrine is less effective and not the preferred route, but may be used as a temporizing measure if vascular access is not immediately available.
Dilution and Administration: Medications should be prepared in appropriate concentrations and administered swiftly but carefully. Always flush the line after administration.
Team Communication: Clear communication among the resuscitation team regarding medication preparation, dosage, route, and time of administration is essential to avoid errors.

II. Key Medications in Neonatal Resuscitation

A. Epinephrine (Adrenaline)

Role: A catecholamine that increases heart rate, myocardial contractility, and peripheral vasoconstriction. It is the primary drug used to improve heart rate during neonatal resuscitation.

Indication:

Heart rate remains < 60 bpm despite at least 30 seconds of effective positive-pressure ventilation (PPV).
AND at least 60 seconds of effective chest compressions coordinated with PPV.

Preparation:

Concentration for IV/IO use: 1:10,000 solution (0.1 mg/mL).

Dosage:

Intravenous (IV) / Intraosseous (IO): 0.01 to 0.03 mg/kg.
- This corresponds to 0.1 to 0.3 mL/kg of the 1:10,000 solution.
Intratracheal (IT) (if no IV/IO access): 0.05 to 0.1 mg/kg.
- This corresponds to 0.5 to 1.0 mL/kg of the 1:10,000 solution. Note: The IT route is less reliable, and higher doses are needed due to poor absorption. It should be considered a temporizing measure while obtaining IV/IO access.

Administration: Administer rapidly (over 1-3 seconds) via IV/IO route, followed by a flush (e.g., 0.5-1 mL normal saline).

Repeat Dosing: May be repeated every 3-5 minutes if the heart rate remains < 60 bpm.

B. Volume Expanders (e.g., Normal Saline 0.9% or Ringer's Lactate)

Role: Used to treat hypovolemic shock (low blood volume) and improve blood pressure and perfusion.

Indication:

Suspected acute blood loss (e.g., placental abruption, fetomaternal hemorrhage).
Signs of shock (pallor, poor perfusion, weak pulses, persistent bradycardia) that do not respond to other resuscitative measures, especially if accompanied by evidence of hypovolemia.

Preparation: Normal Saline 0.9% or Ringer's Lactate.

Dosage:

IV/IO: 10 mL/kg.

Administration: Administer slowly over 5-10 minutes. Rapid administration can lead to complications.

Repeat Dosing: May be repeated once or twice if signs of hypovolemia persist and the heart rate remains low.

C. Sodium Bicarbonate (4.2%)

Role: Used to correct severe metabolic acidosis, which can develop during prolonged resuscitation and impair cardiac function.

Indication:

Prolonged resuscitation with documented metabolic acidosis.

Preparation: 4.2% Sodium Bicarbonate (0.5 mEq/mL).

Dosage:

IV/IO: 2 mEq/kg (which is 4 mL/kg of the 4.2% solution).

Administration: Administer very slowly, over at least 5-10 minutes, to avoid rapid shifts in pH and hyperosmolality. Administer only after adequate ventilation has been established.

D. Dextrose (10%)

Role: To correct hypoglycemia (low blood sugar).

Indication:

Hypoglycemia is not typically an acute issue during the immediate resuscitation phase.
Indicated if hypoglycemia is suspected or confirmed after resuscitation, or if the baby has risk factors for hypoglycemia (e.g., prematurity, small for gestational age, maternal diabetes).

Preparation: 10% Dextrose solution.

Dosage:

IV/IO: 2 mL/kg.

Administration: Administer over 5-10 minutes.

III. Medications Generally Not Recommended for Acute Neonatal Resuscitation

Naloxone:

Role: An opioid antagonist.
Why not recommended in acute resuscitation: While it reverses opioid-induced respiratory depression, its onset of action is delayed compared to PPV. PPV is the primary treatment for respiratory depression regardless of cause. Administering naloxone too early or to an opioid-dependent infant can precipitate acute withdrawal and seizures. It should only be considered after successful resuscitation for suspected opioid depression if the baby has a good heart rate but poor respiratory effort.

Calcium Gluconate:

Role: Used to treat hypocalcemia.
Why not recommended: Rarely indicated in acute neonatal resuscitation. Its use is reserved for specific conditions like documented hypocalcemia, hyperkalemia, or magnesium toxicity, which are typically not acute issues in the delivery room.

Atropine:

Role: Anticholinergic, can increase heart rate.
Why not recommended: Not used in neonatal resuscitation. Bradycardia in newborns is almost always due to hypoxia, and correcting hypoxia with PPV is the treatment.

IV. Securing Vascular Access: Umbilical Venous Catheter (UVC)

Procedure: A sterile procedure performed when medications or volume expanders are indicated.

Cleanse the umbilical cord stump.
Cut the cord cleanly about 1-2 cm from the skin.
Identify the umbilical vein (larger, thin-walled, usually at the 12 o'clock position) and the two smaller, thick-walled umbilical arteries.
Insert a catheter (e.g., 3.5F or 5F) into the umbilical vein for a short distance (2-4 cm) until blood can be aspirated easily. Advance no further than necessary to get a free flow of blood, to avoid advancing into the portal circulation.
Secure the catheter.

Importance: Provides a rapid and reliable route for medication administration and volume expansion during ongoing resuscitation.

Post-Resuscitation Care and Monitoring of the Newborn

Post-resuscitation care is a phase aimed at stabilizing the newborn, preventing secondary complications, and optimizing long-term outcomes. Even after successful resuscitation and stabilization of vital signs, newborns remain at risk for various issues related to the initial hypoxic-ischemic event and the interventions performed. Therefore, meticulous monitoring and supportive care are essential.

I. Immediate Post-Resuscitation Stabilization (First Hours)

Once resuscitation efforts lead to stable vital signs (heart rate >100 bpm, effective spontaneous breathing, SpO2 within target range), the focus shifts to maintaining this stability.

A. Thermal Regulation:

Maintain normothermia: Continue to monitor temperature closely and use appropriate warming devices (radiant warmer, incubator). Avoid both hypothermia (which increases oxygen consumption and metabolic acidosis) and hyperthermia.
Target Temperature: Maintain core body temperature between 36.5°C and 37.5°C.

B. Respiratory Support:

Weaning from PPV/Oxygen: If the baby is breathing effectively, gradually wean from supplemental oxygen as tolerated, guided by pulse oximetry.
- Goal SpO2: Aim for age-appropriate target oxygen saturations (e.g., 90-95% by 10 minutes, then >92% once stable).
Monitor for Respiratory Distress: Observe for signs of tachypnea, grunting, retractions, nasal flaring, and cyanosis. Provide continuous positive airway pressure (CPAP) or mechanical ventilation if needed.
Chest X-ray: Consider a chest X-ray to assess lung expansion, rule out pneumothorax, or confirm endotracheal tube (ETT) position if intubated.

C. Cardiovascular Support:

Continuous Cardiac Monitoring: Monitor heart rate and rhythm continuously.
Blood Pressure: Monitor blood pressure. Hypotension may require volume expansion or inotropic support.
Perfusion: Assess capillary refill time, skin color, and peripheral pulses as indicators of systemic perfusion.

D. Fluid and Electrolyte Management:

Intravenous Fluids: Begin IV fluids (e.g., Dextrose 10% at 60-80 mL/kg/day) to prevent hypoglycemia and dehydration, especially if oral feeding is delayed.
Electrolytes: Monitor electrolytes and correct any imbalances.

E. Glucose Management:

Blood Glucose Monitoring: Perform frequent blood glucose checks (e.g., every 1-2 hours initially) to detect and manage hypoglycemia or hyperglycemia.
Treatment of Hypoglycemia: Administer IV dextrose bolus (2 mL/kg of 10% dextrose) followed by a continuous infusion if needed.

F. Acid-Base Balance:

Arterial Blood Gas (ABG): Obtain ABG to assess acid-base status, oxygenation, and ventilation. Correct significant acidosis as needed, although resolution often occurs with adequate ventilation and perfusion.

II. Ongoing Monitoring and Assessment (First 24-72 Hours)

Newborns who have undergone resuscitation require close observation and specialized care in a Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN).

A. Neurological Assessment:

Hypoxic-Ischemic Encephalopathy (HIE): This is a major concern. Assess for signs of neurological injury:
- Level of consciousness: Lethargy, irritability, seizures.
- Muscle tone and reflexes: Hypotonia, hypertonia, abnormal reflexes.
- Feeding difficulties.
Therapeutic Hypothermia: If criteria for moderate to severe HIE are met in term or near-term infants, therapeutic hypothermia (cooling) should be initiated within 6 hours of birth. This neuroprotective intervention aims to reduce brain injury.

B. Organ System Monitoring:

Renal: Monitor urine output, creatinine, and electrolytes for signs of acute kidney injury.
Gastrointestinal: Monitor for feeding intolerance, abdominal distension, and signs of necrotizing enterocolitis (NEC), especially in preterm infants or those with severe hypoxia-ischemia.
Hematologic: Monitor for coagulation abnormalities (DIC) and anemia.

C. Infection Control:

Newborns who undergo resuscitation may be at higher risk for infection, particularly if invasive procedures (e.g., UVC placement) were performed.
Monitor for signs of sepsis and consider antibiotic therapy if clinically indicated.

III. Documentation and Communication

Detailed Documentation: Maintain meticulous records of the resuscitation event, including:
- Time of birth and start/end of resuscitation.
- Initial assessment.
- All interventions (PPV, compressions, medications: dose, route, time).
- Baby's response to interventions (HR, SpO2, breathing, tone).
- Personnel involved.
Communication with Parents: Provide timely, empathetic, and clear communication with the parents about the events, the baby's condition, ongoing care plan, and prognosis. Answer their questions honestly.

APGAR Score Reference

SCORE	0 points	1 point	2 points
Appearance (Skin color)	Cyanotic / Pale all over	Peripheral cyanosis only	Pink
Pulse (Heart rate)	0	<100	100-140
Grimace (Reflex irritability)	No response to stimulation	Grimace or weak cry when stimulated	Cry when stimulated
Activity (Tone)	Floppy	Some flexion	Well flexed and resisting extension
Respiration	Apneic	Slow, irregular breathing	Strong cry

IV. Apgar Scoring

Purpose: The Apgar score is a rapid method to summarize the newborn's condition at 1 and 5 minutes after birth. It is a guide to the baby's response to the birth process and resuscitation, not an indicator of long-term neurological outcome.

Scoring:

Appearance (color)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration (breathing effort)

Interpretation:

Scores of 7-10 are generally reassuring.
Scores of 4-6 indicate moderate depression.
Scores of 0-3 indicate severe depression.

Repeat Scoring: If the 5-minute Apgar score is < 7, the score should be repeated every 5 minutes until 20 minutes of age, or until the score is consistently > 7.

V. Transfer and Referral

If comprehensive NICU care or specific therapies (like therapeutic hypothermia) are not available at the birth facility, prompt and safe transfer to an appropriate higher-level facility is crucial.

Resuscitation Read More »

Obstetric Anatomy Q & A

Obstetric Anatomy, Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period

Question 1

(a) Describe the vagina.

(b) Outline indications of vaginal examination.

(d) List contraindications of vaginal examination

SOLUTIONS.

A vagina is a muscular fibrous canal which forms the part of the internal female reproductive organs

Situation

It is a canal which extends from the vestibule below to the cervix above running in an upward and backward direction between the planes of the pelvic brim.

Shape

It is a potential tube which runs upwards and backwards with its walls in close contact but can be separated during coitus, menstruation, vaginal examination and child birth.

Size

The anterior wall measures 7.5cm

The posterior wall is longer and it measures 10cm.This is because the uterus enters the vagina at an angle of 90 degrees and bends forwards towards the anterior wall hence it encroaches on it

Structure

Gross structure

Superiorly; the upper end of the vagina is known as the vault, where the cervix protrudes into the vault it forms circular recess known as fournices.

The vagina is made up of four fournices that is to say; The anterior fornix which is smaller and fairly deep The 2 lateral fournices which are shallow

The posterior fornix which is the longest and deepest

The lower end of the vagina is narrow and inferiorly we find the vulva_hymen enclosing the vaginal opening only present in virgins. If hymen is ruptured it leaves tags of membranes referred to as carunculae mytiformes. Vaginal orifice is also called introitus.

Microscopic structure

It is made up of four layers;

Squamous epithelium arranged in folds known as rugae and makes the inner most layer of the vagina, the rugae increase the surface area and offer the vagina ability to stretch when need be for example during coitus and child
Vascular connective tissue layer which is rich in blood vessels, nerves and lymphatics and is found just beneath the epithelium.
Muscular layer. This is thin but a strong layer which is divided into two; the weak inner circular and strong outer longitudinal fibres.
The pelvic fascial which is made up of loose connective It forms the outer protective coat and is continuous with the pelvic fascia.

Blood supply (arterial)

The vagina is supplied by the branches of internal iliac artery which include vaginal artery and uterine artery

Venous drainage

By the corresponding veins ie branches of internal iliac veins which include vaginal veins and uterine veins.

Lymphatic drainage

Into the inguinal, the iliac and the sacro glands

Nerve supply

By the sympathetic and parasympathetic nerves which are branches from the lee Franken lanser plexus

Contents of the vagina

It doesn‘t contain any glands but its kept moist by cervical mucus and a transudation from the underlying blood vessels through the epithelium.

Its media is acidic (PH 3.8 to 4.5) and this is made possible by presence of lactic acid after action of doderleins bacilli on glycogen

Relationships of the vagina

Anteriorly

Below, the base of the bladder rests on the upper ½ of the vagina and the urethra is embedded in the lower ½.

Posteriorly

Pouch of Douglas above, the rectum medial and perineal body below Laterally

Pubococcygeous muscles below and pubic fascial containing the uterus above Inferiorly

The structure of the vulva Superiorly

The cervix and the fournices

Functions of the vagina

Exit from menstrual flow
Entrance for spermatozoa
Exit for products of conception
Supports the uterus
Prevents ascending infection due to acidic PH
For assessing the pelvis
Drug administration

PART B

Indications of vaginal examination

Indications can be divided into during pregnancy, labour and puerperium

During pregnancy

To confirm pregnancy using hegars, jacquemiers and osianders signs
To rule out abnormalities in genital organs g. polyps, cervical erosion and cancer of the cervix
To rule out causes of bleeding in early weeks

During labour

First stage of labour

To diagnose onset of labour
To determine progress of labour by finding out degree of cervical dilatation
To note state of membranes
To confirm presentation, position and engagement of head
To assess moulding
To exclude cord prolapse when membranes rupture
To note dilatation before giving a narcotic

Second stage of labour

To confirm second stage of labour
To note cause of delay in second stage of labour
To confirm presentation of second twin before rupturing membranes

Third stage of labour

To determine cause of postpartum haemorrhage
Incase of retained placenta, to detect cause of retained placenta and exclude construction ring
To detect condition of birth canal following child birth

During puerperium

To rule out cause of secondary PPH
At 6-8weeks after delivery, to detect if the reproductive organs have gone back to their pregravida state.

Information to note on vaginal examination

On inspection

State of the vulva, note any abnormal discharges like pus, blood, abnormal growths like warts, oedema and scars.

On examination

Note condition of the vagina

Normally the vaginal walls feel warm and moist and dilatable. If dry may be a sign of infection or obstruction.

State of the cervix

If thin, thick, whether soft or rigid and whether its well applied to the presenting part.

Note dilatation and cervical effacement.

State of the membranes

Whether intact or ruptured. If ruptured check colour and smell of liquor

Presentation and presenting part

Note level of presenting part in the pelvis

Confirm position by finding or palpating sutures and fontanelles and relate them to the maternal pelvis.

Note moulding.

Do internal pelvic assessment and note

-sacro promontary if protruding
-hollow of the sacrum if well curved
-sciatic notches if well rounded
-ischial spines if prominent
-sub pubic arch-if it accommodates 2 ½ to 3 fingers
-inter tuberous diameter if it accommodates 4 knuckles

Contraindications of vaginal examination

Ante partum haemorrhage
Threatened abortion
Elective caesarean section

a) Describe

b) Outline the formation of the

c) List variations of the placenta

SOLUTIONS

Describe Fertilization

Fertilization is the fusion of the male gamete (sperm) and female gamete (ovum)

Fertilization occurs when the female gamete fuse to form a zygote during the time of intercourse, about 300 million spermatozoa are deposited into the vagina.

Some sperms cannot survive the acidic media of the vaginal secretions so the weak ones die and only the strong ones survive.

The surviving sperms continue moving forwards this is made possible by the special arrangement of the mucus lining of the cervix (arborvitae) which prevents back flow of sperms.

Sperms continue their journey but still the weak ones continue to die off. Movement is slowed down by the presence of hair like projections called cilia and more eradication of weak sperms continues. And if ovulation had taken place within 48 hours and the ovum is still viable the two gametes will meet in the ampulla and fusion will take place hence fertilization.

b) Outline the Formation of the Placenta

Placenta is a vital organ of communication between the mother and the fetus.

It‘s a maternal-fetal organ which begins developing at implantation of the blastocyst and is delivered with the fetus at birth.

Formations of the placenta

Maternal surface

This is the surface next to the uterus

Its dark red in color due to presence of maternal blood and it has 18-20 lobes which are collections of chronic villi each cotyledon is separated from the other by tissues.

Fetal surface

This is the surface next to the fetus

It has a shiny surface due to presence of amniotic membrane

c). List variations of the placenta / abnormalities of the placenta

Succenturiate lobe

This occurs due to abnormalities in development and it is the most significant abnormality. The additional lobule separates from the main part of the placenta.

Circumvallated placenta

It is an opaque ring seen on the fetal surface of the placenta and this is due to doubling back of the chorion and amnion

Bi-partite placenta or bi-lobed placenta

This placenta has two complete and separate parts each with a branch of umbilical cord vessels which later join to form one cord.

Battledore insertion of the cord

In this the placentas cord is inserted at the edge/margin of the placenta and the placenta has an appearance of a table tennis bat in shape.

Velamentous insertion of the cord

The cord is inserted into the fetal membranes some distance away from the edge of the placenta.

The diagram below shows the different variations of the placenta discussed above.

a) Describe the non-pregnant

b) What changes take place in this organ during pregnancy?

Description of the non pregnant uterus

This is a hollow muscular pear /ovacado shaped

Situation

It is situated in the true pelvis between the urinary bladder and the

Size

It is 5cm, long 5cm wide, and 2.5cm thick so each wall is 1.25cm thick.

Position

The uterus is anteverted (bends forward) and anteflexed (bends on itself)

Shape

The uterus is pear shaped (avocado) with the upper part bigger than the lower part .

Description of the non pregnant uterus

Gross structure

This is made up of the following

The body.

This forms the upper part of the whole uterus.

Fundus

This is a raised area between the insertion of the uterine tubes.

Cornua

Upper outer angles of the uterus where the uterine tubes are inserted. This is made up of the following

Cavity

This is a potential space between the anterior and posterior uterine walls.

It is triangular in shape.

Isthmus

This is a narrow area between the body of the uterus and the cervix.

Cervix or neck

This forms other lower third of the whole uterus into the

Microscopic structure

Endometrium

this is a layer of ciliated mucus
It changes constantly with the menstrual cycle
It lines the uterine cavity and shades off during menstruation up to the basal
The cervical endometrium does not change during menstruations

Myometrium

Middle layer and is formed by different muscle fibres.
Longitudinal fibres ;mainly found in the upper part of the uterus .
Oblique muscle fibres ;mainly found in the fundus
Circular muscle fibres which are located at the cornua and they prevent contractions extending to the uterine tubes.
Some are found around the cervix which help in dilatation during labour.

Perimetrium

It is a serous membrane which is a continuation of the peritoneum
It covers the outer aspect of the uterus.
It bends upwards to form the uterovesco pouch anteriorly and the pouch of dauglous posterioly

Blood supply

By uterine arteries which are the branches of the internal iliac artery and they supply the lower ovarian arteries the branches of the abdominal aorta and supply the upper parts.

Nerve supply

By sympathetic and parasympathetic
Lymph drains into internal illiac glands

Supports

The uterus is supported by pelvic floor muscles and maintained in position by ligaments.
Transverse ligament
Utero sacral ligament
Pubo cervical ligament
Broad ligament
Round ligament and,
Ovarian ligament.

Relations of the Body of the Uterus

Anteriorly:The bladder and vesco-uterine pouch.
Posteriorly: The pouch of douglas
Laterally: The broad ligament on each side uterine tubes and ovaries.
Superiorly: intestines
Inferiorly :vagina

Functions of the uterus

It shades the endometrium during menstruation
To prepare a bed for the fertilized ovum
It shelters the fetus during pregnancy
It expels the products of conception at term
To involute following childbirth

(B) THE PHYSIOLOGICAL CHANGES THAT OCCUR IN UTERUS DURING PREGNANCY

Pregnancy

Is the growth and the development of a fertilized ovum from the time of conception until its expulsion. In normal pregnancy expulsion of the fetus takes place at term. Thus, 38-42 weeks of gestation with an average of 40 weeks.

Physiological changes that take place during and pregnancy are associated with and caused by the effects of specific hormones.
These are temporary adaptations of the body that helps to meet the demands of the fetus.

CHANGE IN THE UTERINE SIZE DURING PREGNANCY.

The body of the uterus

After conception, the body develops to provide a nutritive and a protective environment into which the fetus will grow and develop.

Size: 7.5x5x2.5- 30×23 x20 (cm)

Weight: changes from 60 to 1000gm

Uterine shape and situation.

The uterus changes to a globular shape to accommodate the growing fetus, increasing amounts of liquor and placental tissues.

The lowest part of the uterus elongates 3 times its original length during the first trimester, giving the appearance of a stalk below the globular segment. This is the beginning of the upper and lower uterine
By 12^th week of pregnancy, the uterus rises out of the pelvis and becomes upright. It is no longer anteverted and ante flexed. It is about the size of a grape fruit and may be palpated abdominally above the symphysis pubis.
By 16^th week, the conceptus has grown enough to put pressure on the isthmus, causing it to open out so that the uterus become more globular n shape.
By 20^th week of pregnancy, the uterus becomes spherical in shape and has a thicker, and more rounded fundus. As the uterus continues to rise in the abdomen, the uterine tubes, being ristricted by attachments to the broad ligaments, become progressively more At 20^th week the fundus of the uterus may be palpated at or just below the umblicus.

At 30^th week, the lower uterine segment can be It is the portion of the uterus above the internal os of the cervix. The fundus can be palpated midway between the umblicus and the xiphisternum.

The uterus reaches the level of the xisphisternum by the 38^th A reduction in fundal height , known as lightening, may occur at the end of pregnancy when the fetus sinks into the lower pole of the uterus.

Decidua

The decidua is the name given to the endometrium during pregnancy. Estrogen and progesterone produced by the corpus luteum, causes decidua to become thicker and richer and more vascular at the fundus and in the upper body of the uterus, which are the usual site for implantation.

The decidua provides a glycogen rich environment for the blastocyst until the placenta is formed.

Myometrium.

It is made up of smooth muscle fibres, held together by connective These muscle fibres grow up to 15 to 20 times their non pregnant length.
The hypertrophy and hyperplasia of the uterine muscle is due to the effect of estrogen and
The uterus continues to grow in this way for the first three months, after which the growth is related to the distension by the growing
The wall of the myometrium become thicker during the first few months of pregnancy, and as gestation advances, the walls become thinner owing to the gross enlargement of the uterus being only 5 cm thick or less at term.
These prelabor contractions are associated with the ―ripening of the cervix‖ and eventually becomes the contractions of labor as the effects of estrogen supersede those of progesterone e. progesterone normally suppresses myometrial activity.
During pregnancy, the muscle layers become more differentiated and organized and organized for their part in expelling the fetus.
The thickness of the upper uterine acts as a piston to force the fetus into the receptive, passive lower uterine segment.

Contractions of these muscles fibres is necessary to entrap and enmesh bleeding vessels and ligate them after the placenta is delivered.

The inner circular layer is thin and forms sphincters around the openings at the cornua, and around the lower uterine segment and

Blood vessels

The uterine blood vessels increase in diameter and new vessels develop under the influence of estrogen. the blood supply through the uterine and ovarian arteries increase to about 750mls per minute at term to keep pace with its growth and also to meet its needs of the functioning placenta.

The cervix

The cervix remains tightly closed during pregnancy , providing protection to the fetus and resistance to the pressure from above when the woman is in a standing up
The mucus secreted by the endo cervical cells become thicker and more viscous during The thicken mucus then forms a plug called the operculum, which provides protection from ascending infections.
Cervical vascularity increases during pregnancy, giving the cervix a bluish color if viewed through a speculum.
The cervix remains 5cm long throughout pregnancy.
In late pregnancy, softening or ripening of the cervix occurs making it more distensible. The muscles of the fundus enhance tension in the outer longitudinal layer of muscles of the cervix contributing to the process of effacement.

Obstetric Anatomy Q & A Read More »

Ectopic Pregnancy

ECTOPIC PREGNANCY

Ectopic pregnancy is a gestation that implants outside of the endometrial cavity.

Ectopic pregnancy is an implantation of a fertilized ovum outside the uterine cavity.

An ectopic pregnancy most often occurs in a fallopian tube. This type of ectopic pregnancy is called a tubal pregnancy.

An ectopic pregnancy is estimated to occur in 1 of every 80 spontaneously conceived pregnancies.

ANATOMICAL LOCATION OF ECTOPIC PREGNANCY

Tubal (99%)

Ectopic Pregnancy occurs anywhere in the fallopian tube.
The most common site is the ampulla.
Interstitial (cornual) pregnancies occur in the most proximal tubal segment, which runs through the uterine cornua. This type of ectopic pregnancy can grow to be quite large, and rupture may cause massive haemorrhage.

Ovarian (0.5%)

Ectopic Pregnancy occurs in the ovary.

Abdominal (less than 0.1%)

Ectopic Pregnancy occurs in the abdomen.
With possible adherence to the peritoneum, visceral surfaces, or omentum

Cervical (0.1%)

Ectopic Pregnancy occurs in the cervix.
A cervical ectopic, in which the pregnancy implants on the cervix itself, is very rare. Most cervical pregnancies will result in miscarriage. The risk of bleeding, either with spontaneous miscarriage, or for those which require surgical intervention, is much higher

Heterotopic Pregnancy

This is a very rare type of multiple pregnancy, in which one viable pregnancy develops within the uterus, and another fertilised egg is implanted elsewhere as an ectopic pregnancy.
It occurs in less than 1 in 30,000 naturally occurring pregnancies, and is slightly more common in couples who conceive through assisted conception.
Both intrauterine and ectopic pregnancies may occur concomitantly.

Caesarean Scar Pregnancy

Rarely, the ectopic pregnancy can be located at the site of the scar from a previous Caesarean section. This occurs in 1 in 1,800 pregnancies.

Cornual/Interstitial

Interstitial ectopic pregnancies are those which occur in the tissue of the Fallopian tube that lies within the muscular wall of the uterus.
It can be quite difficult to diagnose through ultrasound, and may need laparoscopic (keyhole) surgery to confirm the diagnosis.

Other less common sites of ectopic implantation are the ovary, or a rudimentary uterine horn. Rarely, an ectopic may be intraligamentous or in the peritoneal cavity

CAUSES AND RISK FACTORS FOR ECTOPIC PREGNANCY

The occurrence of ectopic pregnancy has been associated with abnormal function of the fallopian tubes. Normally, the tubes facilitate collection and transport of the oocyte and embryo into the uterus. The integrity of the fimbria, lumen, and ciliated mucosa appears to be important for transport. Conditions thought to prevent or retard migration of the fertilized ovum to the uterus increase the risk for an ectopic pregnancy.

Abnormal Function of Fallopian Tubes:

Normal function of the fallopian tubes, involving the integrity of fimbria, lumen, and ciliated mucosa, is crucial for the proper transport of the oocyte and embryo into the uterus.
Conditions hindering migration of the fertilized ovum to the uterus elevate the risk of ectopic pregnancy.

Pelvic Inflammatory Disease (PID):

Inflammation and scarring from PID affect intra and extra luminal structures, impairing normal tubal function.
Severe damage may result in complete tubal blockage and infertility.

Tubal Surgery and Related Procedures:

Tubal surgeries, bilateral tubal ligation, and tubal reanastomosis may lead to scarring, narrowing, or false passage formation.
Other pelvic and abdominal surgeries may cause peritubal adhesions, although not directly associated with ectopic pregnancy.

Chlamydia, Gonorrhea, Endometriosis, and Salpingitis:

Infections, especially Chlamydia and gonorrhoea, which causes PID, contribute to inflammation and scarring.
Conditions like endometriosis and salpingitis increase the risk of ectopic pregnancy.

Artificial Reproductive Techniques:

In-vitro fertilization and gamete intrafallopian transfer have been linked to an increased risk of ectopic pregnancy.
Retrograde embryo migration is considered a possible mechanism.

Delayed Fertilization:

Possible transmigration of the oocyte to the contralateral tube and slowed tubal transport can delay the passage of the morula to the endometrial cavity.

Chromosomal and Structural Anomalies of the Conceptus:

Anomalies in the chromosomes or structure of the conceptus may predispose individuals to ectopic pregnancy.

Developmental Abnormalities of the Tube:

Abnormalities like diverticula, accessory ostia, and hypoplasia in the tube can elevate the risk of ectopic pregnancy.
Exposure to diethylstilbestrol increases the risk four to five times.

RISK FACTORS FOR ECTOPIC PREGNANCY:

Increased Maternal Age: Advanced maternal age is identified as a risk factor for ectopic pregnancy.
History of Previous Ectopic Pregnancy: Individuals with a history of ectopic pregnancy have a 15% to 20% risk of recurrence in subsequent pregnancies, in either the same or opposite tube.
History of Infertility: Infertile couples exhibit an increased proportion of ectopic pregnancies compared to the total number of pregnancies, regardless of the cause of infertility.
Contraceptive Methods: Certain contraceptive methods carry a higher risk, including Progestasert IUD (15%), intrauterine devices (5%), and diaphragms. Oral contraceptives have a 1% risk, while intrauterine devices are highly effective at preventing intrauterine pregnancy, making any pregnancy in an IUD user more likely to be tubal.
Progestin-only Contraceptives: Users of progestin-only oral contraceptives and injectable progestins face an increased risk of ectopic pregnancy if pregnancy occurs, possibly due to altered tubal motility.
Peritubal Adhesions: Adhesions following post-abortal or puerperal infections, appendicitis, or endometriosis contribute to the risk of ectopic pregnancy.
Cigarette Smoking: Studies indicate that cigarette smoking causes tubal ciliary dysfunction, contributing to the risk of ectopic pregnancy.
Endometriosis: Endometriosis can make the uterus unsuitable for implantation, increasing the likelihood of ectopic pregnancy.

WHY AN ECTOPIC PREGNANCY HAPPENS?

Pathophysiology of an Ectopic Pregnancy.

Fertilization occurs at the usual distal third of the fallopian tube.
After the union, zygote begins to divide and grow.
However, due to an obstruction by several factors (see Risk Factors), the zygote cannot travel through the length of the tube.
It lodges on that constricted part and implantation takes place at that area instead of the uterus.

In a normal pregnancy, an egg is fertilized by sperm in one of the fallopian tube which connect the ovaries to the womb .The fertilized egg moves and implants itself into the womb lining endometrial ,where it grows and develops

So for an ectopic pregnancy, it occurs when a fertilized egg implants itself outside the womb.

CLINICAL PRESENTATION OF ECTOPIC PREGNANCY

An ectopic pregnancy does not cause noticeable symptoms and is only detected during routine pregnancy testing. However, most women do have symptoms and these usually become apparent between 5 to 14 weeks of gestation.

The Classic Triad of symptoms of ectopic pregnancy consists of

Amenorrhea,
Vaginal bleeding, and
Lower abdominal pain.

Acutely ruptured ectopic pregnancy.

This clinical scenario represents a surgical emergency. The patient who has experienced rupture of her ectopic pregnancy will most likely have:

On History Taking:

History of amenorrhoea 6 – 10 weeks.
Patient complains of a feeling of fainting, dizziness, thirst, light vaginal bleeding and pelvic pain.
Abdominal distension, Guarding and rebound tenderness.
Patient complains of acute abdominal pain localized in the iliac fossa which is colicky in nature.
She may also complain of ipsilateral shoulder pain from phrenic nerve irritation due to hemoperitoneum from the blood in her abdomen and it occurs in up to 25% of patients.

On Examination:

Signs of pregnancy are present.eg darkening of areolar.
Signs of shock e.g. cold clammy skin, rapid thread pulse, low blood pressure and low temperature
Patient is anxious and restless
Pallor of mucous membranes

On Palpation:

Abdominal tenderness especially on the affected side.
Abdominal muscles become rigid due to mother guarding against pain.
Abdominal distention due to presence of blood in the abdominal cavity.

On Vaginal Examination:

Amount of bleeding does not correspond to the mother’s condition.
Tenderness on movement of the cervix and a mass is felt in the lateral fornix.
Painful mass in the pouch of Douglas.
Dark brown blood on the examining finger.

DIAGNOSIS OF ECTOPIC PREGNANCY

Ultrasound Confirmation: Utilization of ultrasound imaging as a primary diagnostic tool(golden standard).

An ultrasound would reveal an empty uterus and free fluid (blood) in the peritoneal cavity. The diagnosis of ectopic pregnancy may be confirmed by the absence of intrauterine pregnancy (IUP) on ultrasound in a woman with a level of HCG sufficient to normal pregnancy, the absence of intrauterine pregnancy on ultrasound examination is diagnostic for ectopic pregnancy if the gestational age is known for certain or if the HCG level is >2500 IU per ml.
Cordocentesis(Percutaneous umbilical cord blood sampling) , Aspiration of fluid from the cul-de-sac for evidence of intra-abdominal bleeding. It is a technique by which a needle attached to a syringe is inserted transvaginally through the posterior vaginal fornix into the pouch of Douglas to detect any fluid within the peritoneal cavity.

Laparoscopy: Commonly performed surgical procedure for diagnosis. Follows symptoms of bleeding and a positive pregnancy test.
Positive Pregnancy Test: Presence of human chorionic gonadotropin (hCG) in the blood or urine.
Cullen’s Sign: Specific clinical manifestation suggesting a ruptured ectopic pregnancy. Periumbilical bruising due to blood tracking from the ruptured fallopian tube.

Magnetic Resonance Imaging. This is also another way to detect the presence of ectopic pregnancy and it is safer than undergoing a CT scan for pregnant women.
Hematocrit and Haemoglobin Levels: Routine blood tests to assess for signs of anaemia due to internal bleeding.

DIFFERENTIAL DIAGNOSIS OF ECTOPIC PREGNANCY.

Gynecologic problems

Threatened or incomplete abortion
Ruptured corpus luteum cyst
Endometriosis
Gestational trophoblastic diseases
Ruptured corpus luteal cyst
Dysfunctional uterine bleeding
Acute pelvic inflammatory disease
Adnexal torsion
Degenerating leiomyoma (especially in pregnancy)
Salpingitis

Non Gynecologic Problems

Acute appendicitis
Pyelonephritis
Pancreatitis

MANAGEMENT OF ECTOPIC PREGNANCY.

Management has two modalities:

Surgical approach.
Medical approach.

In maternity center

Aims

To prevent shock
To relieve pain
To reassure the patient

Admission: The patient is admitted temporarily in a gynecological ward in a well-made warm bed.
Histories: These are taken including personal, social, surgical, medical, obstetrical history, how the condition started etc
Examination: This is carried out from head to toe to rule out anaemia, dehydration, shocketc
Observation: Temperature, pulse, respiration and blood pressure are taken and recorded to assess functioning of vital organs. The foot of the bed should be raised to allow blood to move to vital centres.
Send for transport as soon as possible and inform the patient and relatives about the decision made and why it is necessary.

Treatment

Put up intravenous infusion of normal saline to prevent or treat shock.. This is to elevate low blood pressure.
Administer morphine or pethidine to relieve pain as prescribed.
Nursing care: The vulva is swabbed and a clean pad is applied.
Send the patient to hospital with a written note stating when the patient reported to the centre, condition on admission and at time leaving and treatment given.

In the Hospital

Aims:

To treat anaemia
To prevent or treat shock
To reassure the patient
To prevent complications

It is a gynaecological emergency, requiring swift action.

Management

Admission: Admit the patient to a well-ventilated room and a warm admission bed. Establish a good nurse-patient relationship.

Histories: Take comprehensive history, including personal data, presenting complaints, and obstetrical and medical history.

General Examination: Perform a head-to-toe examination to rule out anaemia, shock, dehydration, etc.

Observations: Monitor vital signs like temperature, pulse, respiration, and blood pressure. Inform the doctor about the patient.

Investigations: Conduct investigations as required by the doctor, including Hb, grouping and cross-match, ultrasound scan, and urinalysis.

Resuscitation:

Administer intravenous fluids (e.g., normal saline) and maintain a fluid balance chart.
Consider blood transfusion based on haemoglobin results.
Provide pain relief with analgesics like morphine as prescribed by the doctor.
The doctor will determine the operation.

Preparation for Theatre:

Explain the nature of the operation and obtain informed consent.
Reassure the patient to allay anxiety.
Inform theatre staff.
Pass an intravenous line for infusion.
Perform vulva swabbing to minimize infections.
Catheterization is done, and a fluid balance chart is started.
Pass a naso-gastric tube for aspiration of gastric contents or administer an anti-acid like magnesium trisilicate to alkalize stomach contents and prevent aspiration into the lungs.
Pre-medication is given, such as atropine to dry secretions.
Repeat vital observations and compare with baseline observations, recording all findings.
Compile clinical charts and notes, dress the patient in a gown, and transport her carefully to the theatre.
In the theatre, give a full report to the theatre nurse about the patient.
Book about 1-2 units of blood.

SURGICAL APPROACH

Surgical treatment of ectopic pregnancy has the advantage of taking care of the ectopic immediately. It is suitable for emergency care of ectopic pregnancy. It is critical to establish large-bore intravenous lines and to start fluid resuscitation.

Salpingectomy, the removal of the fallopian tube containing the ectopic pregnancy, is the treatment of choice in the following situations:

Future childbearing is not desired.
The tube is severely damaged.
Bleeding cannot be controlled.
The ectopic is in a fallopian tube where an ectopic occurred previously.

Linear salpingostomy, the removal of the gestation through a linear incision in the fallopian tube, may be performed if future fertility is desired.

This procedure is associated with a persistent ectopic pregnancy rate of 3% to 20%.
Therefore, serial quantitative HCG values must be followed to ensure resolution.

Operative laparoscopy may be performed to confirm the diagnosis of ectopic pregnancy and to remove the abnormal gestation via salpingectomy or salpingostomy. This method is used in hemodynamically stable patients. Advantages of this technique over laparotomy include:

Shorter hospital stay
Faster postoperative recovery
Better cosmetic result
Potentially shorter operative time

Laparotomy is reserved for hemodynamically unstable patients who require emergent surgery for a ruptured ectopic pregnancy. This method may also be appropriate when laparoscopy is contraindicated or technically challenging because of extensive adhesive disease from prior surgery.

Cornual resection, may be performed when an interstitial pregnancy occurs. The interstitial portion of the tube is removed via wedge resection into the uterine cornua. Cornual ectopic pregnancies have a higher failure rate with methotrexate and a surgical approach may be more effective.

Oophorectomy is indicated only when an ovarian ectopic pregnancy occurs and salvage of the affected ovary is not possible.

Post-Operative Care:

Post-operative Bed Preparation: Set up the bed with all necessary accessories ready to receive the patient.

Patient Transfer: Inform ward staff, and two qualified nurses go to the theatre to collect the patient. In theatre, receive a full report from the anaesthetist and theatre nurse in a recovery room, reporting the patient’s condition.

Confirm the Report:

Check airway, breathing, and circulation.
Take vital observations.
Observe the site of operation for bleeding.
Observe the catheter to see if it is draining well and in a good position.

Patient Transfer to Ward: After confirming, gently wheel the patient to the ward in a recumbent position with the head turned to one side, observing the airway.

On Ward: Lift the patient from the trolley carefully to a well-made post-operative bed near the nurse’s station for close observations.

Place the patient in a recumbent position with the head turned to one side for drainage of secretions and to prevent the falling back of the tongue.
Conduct observations and record vital signs (temperature, respiration, blood pressure, and pulse) every 1/4, 1/2, 1, 2 hours as per surgeon’s instructions. Adjust the duration based on patient stabilization. Continue observations until the patient is discharged.
Observe the site of operation for bleeding.
Observe the catheter for drainage, color, and the quantity of urine passed.
Maintain a fluid balance chart and balance it every 24 hours to rule out renal failure.
On regaining consciousness, welcome the patient from the theatre, sponge the face, change the theatre gown, conduct mouthwash to remove the anesthetic smell, and offer a pillow.

Fluid/Hydration:

Continue intravenous fluid (e.g., 0.9%) to replace lost fluids.
Observe IV infusion, including cannular site for swelling and drip rate; correct any issues.
Monitor fluid intake and output to avoid overhydration.
Stop IV fluids when bowel sounds are heard, and the patient can take by mouth.
Remove the cannula when necessary, e.g., if the patient has completed intravenous drugs.

Drug Therapy:

Administer prescribed strong analgesics (e.g., pethidine for 48 hours, then switch to mild analgesics like diclofenac 50-100mg tds).
Administer prescribed antibiotics (e.g., x-pen 2mu qid for 72 hours, then change to oral antibiotics if necessary, such as amoxyl 250-500mg tds for 5 days).
Monitor the patient for side effects of the drugs given.
Provide supportive drugs like ferrous and folic acid to prevent anemia.

Wound Care:

Observe the wound for bleeding and add more dressing if needed. Change the dressing if soiled and check for signs of infections.
Conduct daily wound dressing.
Remove stitches on the 7th and 8th day alternately.

Physiology:

Encourage the patient to do deep breathing exercises to prevent chest complications like hypostatic pneumonia.
Encourage passive exercises, such as limb movement, and later active exercises like walking around to prevent deep vein thrombosis.
Provide psychotherapy for continuous reassurance.

Diet:

Conduct a digestion test, and if positive with bowel sounds heard, start the patient on small sips of water.
Introduce soft foods according to tolerance, rich in proteins for tissue repair, roughages to prevent constipation, and carbohydrates for energy.
Note: The nasogastric tube is removed as long as the patient can take orally without any complaint.

Hygiene:

Conduct a bed bath on the first day of operation when the patient is still weak, and later assist her to the bathroom.
Conduct mouth care to prevent neglected mouth complaints like stomatitis, halitosis, etc.
Ensure that the patient’s clothing, bed linen, and the surrounding environment are clean.

Bowel and Bladder Care:

If urine is clear in 24-48 hours, remove the urethral catheter and encourage the patient to pass urine.
Encourage the patient to pass stool, offer privacy, and provide foods rich in roughages to prevent constipation.
In case of constipation and failed conservative measures, give purgatives such as bisacodyl 5-10mg o.d or nocte.

Rest and Sleep:

Keep the patient in a quiet, well-ventilated room.
Restrict visitors, avoid bright light to create a conducive environment for the patient to sleep and rest.

Advice on Discharge: When the patient is fit for discharge, advise on:

Having enough rest at home.
Avoiding heavy lifting to prevent straining the abdominal muscles.
Coming back for review on appointed dates.
Attending ANC clinics when pregnant.
Bringing the husband for treatment if the cause of ectopic pregnancy was PIDs.
Completing the prescribed medications.

In case of Unruptured Ectopic Pregnancy, Medical Approach can be used.

MEDICAL APPROACH

Methotrexate, a chemotherapeutic agent, has been used successfully to treat small, unruptured ectopic pregnancies. This approach has the advantage that it avoids surgery, but the patient must be counselled that it may take 3 to 4 weeks for the ectopic to resolve with methotrexate therapy. Early diagnosis is very paramount for successful management.

Mechanism of action

Methotrexate is a folic acid antagonist that interferes with DNA synthesis. Its action is principally directed at rapidly dividing cells, such as trophoblastic cells.
Once an ectopic pregnancy has been confirmed, 50 mg/m2 is administered intramuscularly in a single or multiple doses with folic acid.
Serial HCG levels are followed every 2 to 4 days after treatment until the HCG level starts to decrease. This is to ensure resolution of the pregnancy
If a 15% reduction is not achieved during the first week, or in subsequent weeks a plateau occurs, then an additional injection of Methotrexate is given or surgical exploration is advocated.
Decreased success has been noted with ectopic pregnancies of greater than 3.5 cm, with fetal cardiac activity, or with high HCG levels (greater than 5000).
After treatment failures, surgical management is usually necessary.
After an ectopic gestation, pregnancy should be avoided for at least 3 months to allow for the fallopian tube architecture to normalize.
Contraception should be provided

Side effects (approximately 5% of patients).

Mild gastrointestinal symptoms such as nausea, vomiting, diarrhoea, and stomatitis are typical.
Potential life-threatening complications include pneumonitis, thrombocytopenia, neutropenia, elevated liver function tests, and renal failure.

Contraindications,

Women who are breastfeeding
Immunodeficiency,
Liver disease, renal disease,
Blood disorders,
Peptic ulcer disease,
Active pulmonary disease should not receive methotrexate.

Criteria for medical management of ectopic pregnancy

Criteria for receiving methotrexate(MTX) (Absolute indications)

Contraindications to medical therapy (Absolute contraindications)

Hemodynamically stable without active bleeding or signs of hemoperitoneum
Non Laparoscopic diagnosis
Patient desires future fertility
General anaesthesia poses a significant risk
Patient is able to return for follow-up care
No contraindications to MTX

Relative indications

Unruptured mass ≤3.5 cm at its greatest dimension
No fetal cardiac motion detected
Patients whose hCG level does not exceed a predetermined value (6000-15,000 mIU/Ml

Breastfeeding
Laboratory evidence of immunodeficiency
Alcoholism, alcoholic liver disease, or other chronic liver disease
Preexisting blood dyscrasias, such as bone marrow hypoplasia, leukopenia, thrombocytopenia or significant anaemia
Known sensitivity to MTX
Active pulmonary disease
Peptic ulcer disease Hepatic, renal, or hematologic dysfunction

Relative contraindications

Gestational sac =3.5 cm
Embryonic cardiac motion

COMPLICATIONS OF ECTOPIC PREGNANCY

The most common complication is rupture with internal haemorrhage which may lead to hypovolemic shock. Death from rupture is rare in women who have access to modern medical facilities.

Infertility
Recurrence
Severe haemorrhage leading to shock
Anaemia due to bleeding.
Infections following operation.
Adhesions due to scar formation during healing process.
Re-occurrence of another ectopic pregnancy.
Infertility if both tubes are affected.

Nursing Diagnosis

Risk for Deficient Fluid Volume related to bleeding from a ruptured ectopic pregnancy.
Fatigue related to early loss of pregnancy secondary to ectopic pregnancy.

Nursing Interventions

Upon arrival at the emergency room, place the woman flat in bed.
Assess the vital signs to establish baseline data and determine if the patient is under shock.
Maintain accurate intake and output to establish the patient’s renal function.

Evaluation

The goal of the evaluation is to ensure that maternal blood loss is replaced and the bleeding would stop.
The patient must maintain adequate fluid volume at a functional level as evidenced by normal urine output at 30-60mL/hr and a normal specific gravity between the ranges of 1.010 to 1.021.
Vital signs, especially the blood pressure and pulse rate, should be stable and within the normal range.
Patient must exhibit moist mucous membranes, good skin turgor, and adequate capillary refill.

Ectopic Pregnancy Read More »

Family Planning Counseling

Family Planning Counseling is a continuous process that you as health care provider, as a counselor provide to help clients and people in the community or health facility make and arrive at informed choices about the size of their family (i.e. the number of children they wish to have)

Counseling is a face to face communication that you have with your client or couple in order to help them arrive at involuntary and informed decisions.

Informed choice is defined as involuntary choice or decision based on the knowledge relevant to the choice or decision.

In order to allow people to make an informed choice about family planning, you must make them aware of all available methods and advantages and disadvantages plus side effects of each .

They should know how to use the chosen method safely and effectively as well as understanding possible side effects.

Aims of Counseling

The primary objective of counseling in the context of family planning is to help people decide the number of children they wish to have and when to have them.
To help clients choose voluntarily, the method that is personally and medically appropriate to them.
To ensure they understand how to use their chosen method correctly for safe and effective contraceptive protection
To clear rumors and misconceptions a client may have about family planning methods

Types of Family Planning Counseling.

There are varieties of approaches for different types of family planning counseling:

Individual counseling
Couple counseling
Group counseling and information sharing

Individual counseling

This is a counseling approach that involves only one client. it involves individual privacy and confidentiality during communication or counseling with you.

It is mostly important when dealing with confidential matters that relate to family planning and other reproductive health issues . E.g.in HIV couples, the woman wants to use family planning but the husband does not.

Couple counseling

Couples counseling refers to counseling sessions in which a woman and her partner are present in discussions with the provider.

However, it must be recognized that couples counseling requires special sensitivity and skills to deal with gender related issues.

Group counseling and information sharing

This is counseling approach involving a group of many people.

It is used when individual counseling is not possible or there are people in the village who are more comfortable in a group.

It is a cost effective of information sharing and answering general questions but people are not likely to share their more personal concerns with you in this situation.

General principles of counseling

Privacy-find a quiet place to talk
Take sufficient time
Maintain confidentiality
Conduct a discussion in a helpful atmosphere
Keep it simple-use words people in your village will understand
First things first –do not cause confusion by giving too much information
Say if again –repeat the most important instructions
Use available visual aids like posters and flip charts etc.

Characteristics of a good counselor

The most important characteristics of a good counselor are:

Respect the dignity of others
Respect the clients’ concerns and ideas
Be non-judgmental and open
Show that you are being an active listener
Be empathetic and caring
Be honest and sensitive

Overview of stages of counseling

General counseling

This is the first contact of family planning counseling .it involves counseling on general issues to address the client’s needs and concerns.

The counselor needs to talk about the following:

To give general information about family planning methods
To clear up any mistaken belief or myths about specific family planning methods
Give information on other sexual and reproductive health issues like; STD’s, HIV and infertility

All these will make the client arrive at the informed decision on the best contraceptive method to use.

Method-specific counseling

The information is given about the chosen method.

The following points are considered:

Examination for fitness (screening) (Blood pressure, weights, age and other health parameters)
Instruct on how and when to use given method
Tell the client when to return for follow-up and ask them to repeat what you have said on key information.

BRAIDED,

Family planning counseling the BRAIDED approach, the acronym BRAIDED can help to remember what to talk about when counseling clients on specific methods.

It stands for:

B-Benefits of the method

R-Risks of the method including consequences of the method failure

A-Alternative to method, including abstinence and no method

I-Inquiries about the method (Individual rights and responsibilities to ask)

D-Decision to withdraw from a method without a penalty

E-Explanation of the method chosen

D-Documentation of the session for your own records

Return follow-up

Follow-up counseling should always be arranged after the counseling process.

The aims;

To discuss and manage any problem and side effects related to the given contraceptive method
It gives the opportunity to encourage the continued use of the chosen method unless problems exist.
It helps to find out whether the client has other concerns and questions

Steps in family planning counseling GATHER approaches

The counseling process should follow a step-by –step process.

GATHER acronym will help you remember the 6 steps for family planning counseling.

G-Greet the client respectfully

A-Ask them about their family planning needs

T-Tell them about different contraceptive options and methods

H-Help them to make decisions about choices of methods

E-Explain and demonstrate how to use the methods

R-Return /Refer, schedule and carryout a return visit and follow-up

It is important to give more emphasis to the points during counseling steps

Greet the client

In the first case give your full attention to your client
Greet them in respective manner and introduce yourself to them often offering seats
Ask them how you can help them
Tell them that you will not tell others what they have told you.
If the counseling takes place in health facility you have to explain what will happen during the visit describing physical examinations and laboratory tests if necessary
Conduct counseling in a place where no one can overhear your conversation

Ask

Help them to talk about their needs, doubts, concerns, and any question they might have
If they are new ,use a standard check list or from your health management information system to write down their names, age ,marital status ,number of pregnancies ,number of births, number of living children ,current and past family planning use and basic medical history
Explain that you are asking them the information in order to help you provide appropriate care
Keep questions simple and brief, and look at them as you speak

Many people do not know diseases, ask specific questions, say<< have you had any headache in the past 2 weeks? or have you had any genital itching? Or do you experience any pain when urinating?>> do not say <<have you had any disease in the recent past?>>

If you have seen the client previously, ask if anything has changed since the last visit.

Tell

Tell them about family planning method
Tel them which methods available
Ask them which methods interest them and what they know about the method
Briefly, describe each method of interest and explain how it works, its advantages, disadvantages and possible side effects.

Help

Help them to choose a method of contraception, ask them about their plans and family situation, if they are uncertain about the future start with the present situation
Ask what the spouse /partner likes and wants to use
Ask if there is anything they cannot understand and repeat information when necessary
When the chosen method is not safe for them explain clearly why the method may not be appropriate and help them choose another method.
Check whether they have a clear decision and ask what method have you decided to use?

Explain

Explain how to use a method after it has been chosen
Give supply if appropriate
If the method cannot be given immediately, explain how, when and where it will be provided
For the method like voluntary sterilization the client will have to sign consent form .the form says that; they want the method, have been informed about it, and understand the consent form.
Explain how to use the method
Ask the client to repeat the instructions
Describe and possible side effects and warning signs and tell them what to do if they occur.
Ask them to repeat this information back to you
Give them printed material about the method to take home if it is available
Tell them when to come back for a follow-up visit and to comeback sooner if they wish, or if side effects or warning signs occur

Appoint a return visit follow-up at the follow-up visit

Ask the client if she is or they are still using a method or whether there have been any side effects or problems
Refer for treatment if severe side effects are present
Re assure the clients’ concerning minor side effects are not dangerous and suggest what can be done to relieve them

Rights of the client

Information : to learn about their reproductive health ,contraception and abortion options
Access : to obtain services regardless of religion, ethnicity, age, marital or economical status
Choice : to decide freely whether to use contraception and which method
Safety : to have a safe abortion and to practice safe, effective contraception
Privacy : to have a private environment during counseling process
Confidentiality : to be assured that any personal information will remain confidential
Dignity : to be treated with courtesy ,consideration and effectiveness
Comfort : to feel comfortable when receiving services
Continuity : to receive follow-up care and contraceptive services and supplies for as long as needed
Opinion : to express views on the service offered.

Factors influencing family planning counseling outcomes

Factor related to the health care provider

Effective communication
Technical knowledge and skills, attitudes and behaviors can influence in effectiveness of counseling process

Factors related to the client

Client’s level of knowledge and understanding, what they choose to do may also be affected by the extent to which they trust and respect a service provider.
Personnel situation (e.g. .if the spouse or another family member has a difference to them)
External programmatic factors
In most health facilities the space or rooms for provision of family planning is integrated with other reproductive health services .This can make it very difficult for you to find a place where privacy and confidentiality can be maintained .

Family Planning Counseling Read More »

Hormonal Contraceptive Methods

HORMONAL CONTRACEPTIVE METHODS

Hormonal family planning refers to the use of hormonal methods to prevent pregnancy.

Hormonal contraceptive refers to birth control methods that act on the endocrine system (hormones).

These methods involve the use of hormones, usually synthetic versions of those naturally produced by the body, to regulate a woman’s menstrual cycle and prevent ovulation (the release of an egg from the ovaries). By preventing ovulation, hormonal methods make it difficult for sperm to fertilize an egg and thus prevent pregnancy.

These include;

Oral contraceptive pills
Implants
Injectable contraceptive
Emergency contraceptive pills

Hormonal Methods:

i. Oral Pills:

Method	Description
Combined Oral Contraceptives	Pills containing both oestrogen and progestin hormones
Progesterone-Only Pills	Pills containing only progestin hormone
Emergency Contraceptive Pills	Pills taken after unprotected sex to prevent pregnancy

ii. Implants:

Method	Description
Implanon (1 Rod Capsule)	Subdermal contraceptive rod
Jadelle (2 Rod Capsules)	Subdermal contraceptive rods
Norplant (6 Rod Capsules)	Subdermal contraceptive rods

iii. Injectable Contraceptives:

Method	Description
Depo Provera	Injectable contraceptive administered every three months
Injector Plan	Injectable contraceptive
Sayana Press	Injectable contraceptive
Noristrate	Injectable contraceptive

iii. Emergency Contraceptives:

Emergency Contraceptive	Mechanism of Action
Lofemenal/Microgynon 4BD for 1 day (Low Dose COC)	Inhibits ovulation, thickens cervical mucus
Eugynon (High Dose COC) 2BD for 1 day	Inhibits ovulation, thickens cervical mucus
Regular POP (Ovrette/Microval) at Recommended Dose	Alters cervical mucus, inhibits sperm function
Levonorgestrel 2 stat	Delays ovulation, inhibits fertilization
Postinar 2 BD for 1 day	Alters cervical mucus, inhibits sperm function
Vikela/Levonelle-2/Norlevo Plan B	Delays ovulation, inhibits fertilization

Oral Contraceptive Pills

There are two main types of hormonal oral contraceptive formulations:

Combined hormonal contraceptive methods which contain both oestrogen and progestin thus, they are called combined oral contraceptives (COCs)
One which contains only progesterone or one of its synthetic analogues (Progestins) thus, it is called progestogen-only pills (POPs) method.

(i) Combined Oral Contraceptive Pills (COC)

Combined oral contraceptives contain both oestrogen and progesterone. It achieves effects of both hormones. Oestrogen suppresses ovulation and progesterone creates unfavourable conditions for egg transport and thickening of the cervical mucus to impair sperm entrance into the canal.

Examples

Lo-femenal
Pill Plan (Duofen)
Microgynon

Mechanism of Action:

Combined methods work by:

Suppressing ovulation (estrogenic effect)
Thickening cervical mucus, making it difficult for sperm to penetrate the uterus
Making the endometrium unsuitable for implantation of a fertilized egg (thin and atrophic due to constant progestogenic action)
Reducing sperm transport in the upper genital tract (fallopian tubes).

Effectiveness:

92 – 99.9% effective, depending on user compliance.
In very young women, typical effectiveness can be as high as 95.3%.
Failure rates decline with the duration of use and age of the user.
Failures may be due to method failure, client error, incomplete information from service providers, drug interactions, severe vomiting/diarrhoea, or expired pills.

Advantages:

Very effective if taken correctly.
Effective immediately.
Easily reversible.
Few side effects.
Convenient and easy to use.
Does not interfere with intercourse.
Causes regular and predictable periods.
May improve anemia.
Reduces dysmenorrhea and premenstrual tension.
Protects against ovarian and endometrial cancer, and some causes of PID.
Reduces the risk of ovarian cysts, benign breast disease, and ectopic pregnancy.
Can be provided by trained non-medical staff.

Disadvantages:

Effectiveness depends on daily pill intake, requiring strong motivation.
Increases chances of promiscuity.
Can cause Candida vulvitis and vaginitis.
May lead to thromboembolism and benign/malignant liver tumors.
Requires regular and dependable supply.
Reduces breast milk, especially in the first 6 months after delivery.
Not the most appropriate choice for lactating women unless no other method is available and there is a high risk of pregnancy.

Indications:

Women requiring a highly effective method.
Women wanting an easily reversible method.
Non-breastfeeding women or breastfeeding women after 6 months.
Women who are anaemic with heavy menstrual bleeding.
Women with a history of ectopic pregnancy.
Nulliparous women.
Women with a history of benign, functional ovarian cysts.
Women with a family history of ovarian cancer.
Women with menstrual cycle symptoms or irregular menstrual cycles.

Contraindications:

Absolute contraindications include cardiovascular diseases, liver disease, pregnancy, undiagnosed per vaginal bleeding, and oestrogen-dependent neoplasms.
Relative contraindications include obesity, varicosities, epilepsy, asthma, mood disorders, nursing mothers in the first 6 months, smoking, and gallbladder disease.

Side Effects:

Major side effects include hypertension, venous thromboembolism, and cholestatic jaundice.
Minor side effects can be due to oestrogen, progestin, or both, including nausea, vomiting, headache, leg cramps, weight gain, chloasma & acne, breakthrough bleeding, hypomenorrhea, amenorrhea, leucorrhea, and decreased libido.

Danger Signs of COCs:

Acute abnormal pain.
Severe headaches with blurred vision.
Pain in the chest with difficulty in breathing.
Pain in the calf muscles.

Indications for Withdraw:

Severe migraine.
Visual disturbance.
Sudden chest pain.
Severe cramps.
Excessive weight gain.
Severe depression.
Patient wanting pregnancy.
Awaiting major surgery.

Drug Interaction:

Decreases effectiveness of methyldopa, oral anticoagulants, and oral hypoglycemics.
Increases effectiveness of B blockers, corticosteroids, diazepam, aminophylline, and alcohol.
Other drugs that increase COC metabolism include phenobarbitone, antiepileptics (except sodium valproate and clozapine), rifampicin, griseofulvin, spironolactone, and ketoconazole.

WHO Medical Eligibility Criteria for Contraceptive Use.

Category 1: A condition for which there is no restriction for use of the contraceptive

Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks

Category 3: A condition where the theoretical or proven risk outweigh the advantages of using the method.

Category 4: A condition that represents unacceptable health risk if the contraceptive is used.

Who can use only if more appropriate methods are not available (WHO class3)

Women with high BP (greater than 160/100 but less than 180/110) and no vascular disease.
Women with symptomatic gall bladder disease.
Women age 35 yrs or older and light smokers (under 20 cigarettes a day)
Women taking drugs for epilepsy or anti-TB.
Women with unexplained vaginal bleeding (only if serious problem suspected)
Women who are fully b/feeding (6 wks to 6 months postpartum)
Women who are not b/feeding who are less than 3 weeks postpartum.
Women with h/o breast cancer and no current evidence of the disease.

Who should not use COCs (WHO Class 4)

Women with hypertension: blood pressure diastolic above 110 mm Hg. The health risk/benefit ratio is dependent upon the severity of the condition
Women with current or history of cardiac disease (heart disease or stroke). Among women with underlying vascular disease due to thrombosis, the increased risk of thrombosis with COCs should be avoided;
Women with thrombo-embolic disease (current and a history of or major surgery with prolonged immobilization). The increased risk of venous thromboembolism associated with COCs should have little impact on healthy women, but may have a big impact on women otherwise at risk for it;
Women within 2 weeks of child birth (Postnatal) and within 4 weeks or elective surgery;
Women with known or suspected cervical cancer. Theoretical concern that COC use may affect prognosis of the existing disease. In general, treatment of these conditions renders a woman sterile;
Women who are pregnant. As no method is indicated, any health risk is considered unacceptable. However, there is no known harm from COCs;
Women with undiagnosed breast lumps or breast cancer. Breast cancer is a hormonally sensitive tumor. The risk for progress of the condition may be increased among women with current or past history of breast cancer;
Women who are taking long-term drugs that could affect the pill’s efficacy. Commonly used liver enzyme inducers are likely to reduce the efficacy of COCs. Drugs which affect liver enzymes are the antibiotic rifampicin (note that other antibiotics will not affect pill efficacy), other drugs where another method should be used are: —griseofulvin, and anticonvulsants (such as phenytoin, carbamazepine, barbiturates, and primidone).
Women with severe headache (recurrent, including migraine with focal neurological symptoms). Focal neurological symptoms may be an indication for an increased risk of stroke( or cerebrovascular accident (CVA) is sudden damage to brain tissue caused either by a lack of blood supply or rupture of a blood vessel . The affected brain cells die and the parts of the body they control or receive sensory messages from ceaseto function.)
Women who are retarded or forgetful.
Women with sickle cell disease, as they have increased risk of thrombosis;
Women with trophoblast disease (current trophoblastic tumor)
Women who are to undergo major elective surgery with prolonged bed rest.

Client Information

Start between 1^st and 7^th day of monthly period
Take pills daily at the same time – at bed time if possible
Do not miss taking the pill any day
If you start after the 7^th day of monthly period; you need to use another FP method such condoms or to abstain from sex for one week.
Contraception is 7 days after initiation
You will have your monthly period when you are taking the brown pills. Do not stop taking the pills.

If a client misses, they should do the following:

If you miss one white pill, take it as soon as you remember, then continue normally.
If you miss 2 white or more days in a row; take two pills each day until all missed pills are taken and you are back on schedule. You must also use a condom for the next 7 days.
If you miss the brown pill, no worry. Just skip and continue
If you keep forgetting – may need to change method

ii) Progesterone Only Pills (POP)

Progestin-Only Pills are oral contraceptive pills which contain synthetic progestin and are taken orally every day at the same time of day to prevent pregnancy.

Mechanism of Action:

Reduces the frequency of ovulation.
Thickens cervical mucus, making it difficult for sperm to penetrate the uterus.
Partially inhibits ovulation.

Types of POPs available in Uganda:

Microval: 35 white pills, each containing 0.03 mg Levonorgestrel.
Ovrette: 28 yellow pills, each containing 0.075 mg Norgestrel.

Effectiveness:

Depends on user compliance.
Very effective if used correctly (83%-99%).
Crucial to take POPs at the same time every day, as effectiveness decreases even with a few hours’ delay.
In lactating women, POPs are nearly 100% effective, and they do not alter the quantity of milk.

Advantages of POPs:

Do not suppress lactation.
No estrogenic side effects.
Suitable for women with hypertension, thrombotic, cardiac, and sickle cell diseases.
Can be started at any time of the menstrual cycle and in the early postpartum period.
Decreased menstrual cramps.
Decreased amount of bleeding during periods.
Decreased severity of anaemia.
Do not increase blood clotting.
Some protection against pelvic inflammatory disease (progestins make cervical mucus thicker, reducing the likelihood of infection reaching the uterus and tubes).

Disadvantages of POPs:

Amenorrhea.
Must be taken at the same time every day.
Irregular periods, including spotting or bleeding between periods.
Prolonged or heavy vaginal bleeding.
For women who have had ectopic pregnancy, POPs do not prevent ectopic pregnancy as well as intrauterine pregnancy.
For women with a history of ovarian cysts, POPs do not protect against the development of future ovarian cysts.

Indications:

Women of any reproductive age or parity seeking pregnancy protection.
Breastfeeding women (6 weeks or more postpartum).
Post-abortion women (may start immediately).
Women who smoke.
Women with high blood pressure, blood clotting problems, or sickle cell disease.
Women unable to take Combined Oral Contraceptives (COCs) but want to take Pills.

Who should not use POPs (Class 3):

Women breastfeeding and less than 6 weeks postpartum.
Women with jaundice.
Women taking anti-epileptic and anti-TB medication.
Women with unexplained vaginal bleeding.
Women with breast cancer.
Women concerned about changes in their menstrual bleeding pattern.
Women unable to remember taking a pill every day (no more than 3 hours late).

Who should not use POPs (Class 4):

Women known or suspected to be pregnant.
Women who are known or suspected to be pregnant. POPs should not be initiated if a woman is pregnant. However, there is no known harm to mother or fetus if POPs are used during pregnancy;
Signs of problems from POPs warranting immediate return to clinic
Severe lower abdominal pain.
Heavy bleeding (twice as long and as much).
Migraine headaches, repeated very painful headaches, or blurred vision.

Signs of problems from POPs warranting immediate return to clinic:

Severe lower abdominal pain.
Heavy bleeding (twice as long and as much).
Migraine headaches, repeated very painful headaches, or blurred vision.

Client Instructions:

Start between the 1st and 7th day of the monthly period.
If started after the 1st day of bleeding, abstain from intercourse or use another method for the next 48 hours.
Take pills daily at the same time.
Do not miss taking the pill any day.
Return to the clinic for more pills before finishing the last pack.
Severe diarrhoea or vomiting reduces pill effectiveness. Use a backup method or abstain from sex while taking the pills and for 48 hours after.
If client misses taking pills:

If more than 3 hours late, take it as soon as remembered and the next pill at the usual time. Use a backup method or abstain for the next 48 hours.
If miss two or more days, take one as soon as remembered, continue as usual, and use a backup method or abstain for the next 48 hours.
If consistently forgetting, consider another method and seek counseling.

Contraindications:

Pregnancy: Progestin-Only Pills (POPs) should not be initiated if a woman is pregnant.
Unexplained vaginal bleeding: POPs are contraindicated in cases of unexplained vaginal bleeding, and immediate medical attention is advised to determine the cause.
Recent history of breast cancer: Women with a recent history of breast cancer are advised against using POPs due to potential hormonal interactions that could affect cancer progression.
Arterial diseases: Individuals with arterial diseases, such as a history of stroke or cardiovascular issues, should avoid POPs as they may pose additional risks to vascular health.
Thromboembolic diseases: Those with a history of thromboembolic diseases, involving blood clotting, are at an increased risk when using POPs, making it a contraindicated option.
Active hepatic diseases: Presence of active liver diseases is a contraindication, as POPs can impact liver function, and their use might exacerbate hepatic conditions.
Hypertension: Women with hypertension are advised against using POPs, as the hormonal components may contribute to increased blood pressure.

Side Effects:

Amenorrhea: Some women may experience amenorrhea (absence of menstruation) as a side effect of POPs, which is generally considered a normal response to hormonal changes.
Spotting: Spotting, or irregular bleeding between periods, can occur, and individuals should be aware that this is a common side effect that usually diminishes with time.
Prolonged or heavy bleeding: While some may experience prolonged or heavy bleeding, this side effect should be discussed with a healthcare provider to ensure it is not indicative of an underlying issue.
Lower abdominal pain: Lower abdominal pain may occur.
Weight gain or loss: Changes in weight, either gain or loss, may be observed.
Jaundice: Jaundice, characterized by yellowing of the skin or eyes, is a rare but serious side effect.
Nausea and vomiting: Nausea and vomiting may occur initially but often subside.
Headache with blurred vision: Headaches with blurred vision may be experienced.
Excessive hair growth: Some individuals may notice changes in hair growth patterns.
Breast fullness or tenderness: Breast fullness or tenderness is a common side effect that usually resolves over time.
High blood pressure: An increase in blood pressure may occur in some individuals

Implants

Implants are small, flexible rods or capsules that are inserted under the skin of a woman’s upper arm.

These implants release a steady, low dose of hormones (usually a progestin hormone) into the bloodstream over an extended period. The most common types of contraceptive implants include Implanon, Jadelle, and Norplant.

Implants are considered a reversible form of contraception, and their effectiveness is not dependent on user compliance once inserted. They are suitable for women who want a reliable, long-term birth control option without the need for daily or frequent intervention.

Types:

Implanon: A single rod capsule effective for 3 years.
Jadelle: Two rods of levornogestrel each 75mg capsules providing protection for 5 years.
Norplant: Consists of 6 rods each with 36mg levornogestrel capsules labelled for 5-7 years.

Modes of Action:

The hormonal release from these implants serves to prevent pregnancy by thickening the cervical mucus within 24 hours, hindering sperm entry into the uterus, inhibiting ovulation (the release of eggs from the ovaries), and altering the uterine lining to make it less receptive to a fertilized egg. Implants are highly effective and offer long-term contraception, ranging from three to seven years, depending on the specific type.

Insertion: Inner aspect of non dominant arm, 6 – 8 cm above elbow fold under local anesthesia. This is at day1, immediate after abortion or 3weeks postpartum.

Removal: Approximately 3 to 5 years

Advantages:

Very effective within 24 hours after insertion.
Easily reversible with no delay in returning to fertility after removal.
Reduces frequency and intensity of sickle cell crises.
Highly effective for long-term contraception.
Shares benefits with Depo Provera.

Common Side Effects and Disadvantages:

Changes in menstruation patterns.
Spotting.
Rare instances of heavy bleeding.
Amenorrhea.
Does not protect against STIs, including HIV/AIDS.
Discomfort in the hand after insertion.
Possible weight changes (overweight or weight loss).
Minor surgical procedure required for both insertion and removal.

Indications:

Breastfeeding post-partum mothers.
Adolescents.
Post-abortion contraception.
Women with sickle cell disease.
Women awaiting surgical contraception.
Women on treatment, e.g., ARVs.

Contraindications:

Serious problems with the heart or blood vessels.
Breast cancer history.
Liver diseases leading to jaundice.
Pregnancy.

Signs and Problems Requiring Medical Attention:

Soreness at the site of insertion.
Capsules coming out.
Severe headaches.
Heavy bleeding, exceeding the usual amount and duration.
Pregnancy.
Missed period after several regular cycles.

Injectable Contraceptives

Examples

Depo Provera (Depo Medroxyprogesterone acetate (DMPA), single dose of 150 mg I.M every 12 weeks. (Injecta Plan)
Sayana Press 104mg, 0.65ml Subcutaneously
Noristerat (Norethisterone) 200mg every 8 weeks for 24 weeks, then every 12 weeks.
Norigynon/Mesigyna (50 mg norethindrone enanthate plus 5 mg estradiol valerate) ; Both given monthly.

These contraceptives contain a single type of hormone, progestin.

Depo Provera

Depo Provera is a hormone used for contraception. It is given by injection and its effects will last for three months at a time.

Mode of Action

Inhibits ovulation.
Thickens cervical mucus, hindering sperm entry.
Thins the uterine lining, reducing chances of fertilized egg implantation.

Indications

Breastfeeding mothers after 6 weeks or immediately if not breastfeeding.
Women needing long-term contraception.
Known/suspected HIV-positive women.
Women with sickle cell disease.
Women unable to use COC due to oestrogen content.
Women awaiting surgical contraception.

Advantages

Very effective.
Does not suppress lactation.
Easy to remember return dates.
Private usage.
No oestrogen-related side effects.
Reduces sickle cell crisis frequency.
Non-interference with sex.

Disadvantages

Changes in menstrual bleeding.
Spotting (common in the first 3 months).
Amenorrhea (common after 1st injection and after 9-12 months).
Prolonged heavy vaginal bleeding.
Weight changes.
Irreversible injection.
Delayed return of fertility.
Loss of libido.
Does not protect against STIs/HIV/AIDS.

Management

Depo Provera 150mg deep IM into deltoid or buttock muscle.
No rubbing to avoid increased absorption.
Advise abstinence or backup FP method for the first 7 days after injection.
Return for the next dose 12 weeks after the injection.

Sayana Press

Sayana Press is a contraceptive injection that women can give to themselves to prevent pregnancy. It’s given under the skin, at the front upper thighs or abdomen. The injection releases medication that runs through your bloodstream over a period of 13 weeks.

Sayana press ® is a single-dose container with 104 mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension (104mg) formulated for subcutaneous.
It is administered subcutaneously into the anterior thigh or abdomen or arm.
The efficacy of Sayana press depends on adherence to the recommended dosage schedule of administration.

Composition

Single-dose container with 104 mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension.

Administration

Subcutaneously into the anterior thigh, abdomen, or arm

Mechanism of Action

Suppresses ovulation.
Renders endometrium unsuitable for implantation.
Increases cervical mucus viscosity, impeding sperm penetration.

Indications

Nearly all women can use it safely & effectively including women:-

Women whose partners have undergone vasectomy until vasectomy is effective.
Have or have not had children.
Any age including adolescents & women over 40 years old.
Have just had an abortion/miscarriage.
Breastfeeding women 6 weeks postpartum.
HIV infected whether or not on ART.

Advantages and Non contraceptive benefits.

New formulation for S/C injection.
30% low side effects compared to Depo-Provera.
Do not interfere with sex.
Private & no one else can tell that a woman is using it.
May help women gain weight.
Do not require daily action.
Prevents pregnancy.
Protects against endometrial cancer, uterine fibroids.
Reduces sickle cell crisis among women with sickle cell anaemia.
Protects against symptomatic PID & iron deficiency anaemia.

Disadvantages

Weight changes.
No protection against STIs/HIV/AIDS.
Delayed fertility return.
Potential side effects like hypersensitivity reactions, decreased/increased appetite, loss of libido, dizziness, headache, and more.

Problems that may need medical attention

Loss of bone mineral density.
Menstrual irregularities.
Thromboembolic disorders.
Anaphylaxis & anaphylactoid reactions.
Sudden partial or complete loss of vision.

Disadvantages & Side effects

Weight gain or loss
Does not protect against STI/HIV/AIDs
Delayed fertility return
Hypersensitivity reactions
Decreased/increased appetite
Loss of libido & irritability
Dizziness, headache & migraine
Thromboembolic disorders
Nausea & vomiting
Jaundice
Alopecia & urticaria
Loss of bone mineral density
Back & leg pains
Mood changes
Abdominal bloating & discomfort

Emergency Contraception / Post-Coital Contraception

Emergency contraception (EC) serves as a preventive measure for unintended pregnancies following unprotected sexual intercourse, condom rupture, missed pills, or sexual assault.

It should be regarded as an emergency measure and not as a routine contraceptive method. EC does not terminate pregnancy. It encompasses hormonal, anti-progestin, and other methods.

Types

Emergency Contraceptive Pills (ECP)
Progesterone-Only Pills Regimen

When to Start?

EC should be initiated within 3 -5 days or 72 -120 hours, with earlier administration being more effective, following unprotected sexual intercourse. Intrauterine contraceptive devices (IUCDs) with copper introduction, within a maximum period of 5 days, can prevent conception after accidental unprotected sexual exposure.

Mechanism of Action

Prevents implantation
Failure rate is about 1%
Effectiveness is over 99% in preventing pregnancy

NOTE:

Post-coital contraception is solely for emergency use and is not effective if used regularly, except for copper IUCDs.
Women seeking emergency contraception should also be counselled about regular contraceptive options, promoting consistent and correct usage.
Referral to relevant services, such as HIV counselling, testing, post-exposure prophylaxis (PEP), and treatment for sexually transmitted infections (STIs), is essential.
Specialized services for sexual and gender-based violence should also be considered.

Basic Steps of Client Care for ECP

Greet and introduce yourself.
Maintain a respectful attitude.
Ensure confidentiality of the discussion.
Explain different ECP options, including usage, side effects, and the need for referral or follow-up.
Encourage questions from the client.
Discuss regular contraception options.
Conduct counselling with active client involvement, reassurance of confidentiality, and in a private and supportive environment.

Examples of ECP:

Ethinyl estradiol 2.5mg b.d X 5/7
Conjugated oestrogen 15mg b.d X 5/7
Levonorgestrel 0.75mg stat and after 12 hours.
Mifepristone 600 mg stat – single dose.
Copper IUDs inserted within 5 days.
Others: Postinor, Microgynon, Eugynon.

Indications

Unprotected sexual intercourse
Rape survivors
Contraceptive method failure
Missed contraceptive pills or injections
Delay in taking pills
Sexual assault or first-time intercourse

Contraindications

Pregnancy
After 120 hours or 5 days of unprotected sex

Emergency Contraceptive	Dosage	Mechanism of Action
Lofemenal/Microgynon 4BD for 1 day (Low Dose COC)	4 tablets once	Inhibits ovulation, thickens cervical mucus
Eugynon (High Dose COC) 2BD for 1 day	2 tablets twice	Inhibits ovulation, thickens cervical mucus
Regular POP (Ovrette/Microval) at Recommended Dose	As recommended	Alters cervical mucus, inhibits sperm function
Levonorgestrel 2 stat	2 tablets at once	Delays ovulation, inhibits fertilization
Postinar 2 BD for 1 day	2 tablets twice	Alters cervical mucus, inhibits sperm function
Vikela/Levonelle-2/Norlevo Plan B	As recommended	Delays ovulation, inhibits fertilization

NON HORMONAL METHODS click here

Hormonal Contraceptive Methods Read More »

Family Planning

FAMILY PLANNING

Family planning is defined as the practice of having children by choice and not by chance.

Family planning is defined as a process through which individuals, couples make an informed choice on how many children to have, when to have and how often to have so that each child born is expected and properly catered for in all ways.

Family planning policy does not discriminate against men; they also have great roles to play for the success of care.

Unplanned pregnancies constitute major public health problems .The United Nations International Children’s Emergency Fund (UNICEF) estimates that over 800,000 women worldwide die each year as a result of pregnancy and pregnancy-related causes and an additional 15 million women are severely disabled by pregnancy. Countries in which women utilize contraception have lower birth rates and the lowest rates of maternal mortality. Every method of birth control prescribed is safer than pregnancy.

Benefits/Importances of Family Planning

To the Mother

Physical and Mental Recovery: Allows the mother to recover physically and mentally from the effects of previous pregnancies.
Participation in Productive Activities: Offers ample time for a woman to actively participate in productive activities like farming and business.
Enhanced Social Bondage: Increases social bondage between the mother and her baby.
Reduced Maternal Mortality and Morbidity: Helps to reduce maternal mortality and morbidity due to pregnancy-related complications.
Promotion of Marital Happiness: Promotes a happy marital life and enjoyment between the couples without fear of unwanted pregnancy.
Preparation for Pregnancies: Family planning enables sexually active couples to prepare for pregnancies, optimizing fetal and maternal outcomes.
Avoidance of Unwanted Pregnancies: Family planning helps avoid unwanted pregnancies, reducing complications associated with childbirth.
Reduction of Maternal Complications: Reduces incidences of complications such as anaemia, poor maternal health, caesarean section, and maternal-child deaths.

To the Child

Emotional and Social Support: The child receives adequate emotional and social support, contributing to emotional maturity and stability.
Healthy Nutrition: Allows adequate nutrition for the baby in the womb, resulting in a healthy newborn.
Reduced Malnutrition: Reduces malnutrition by preventing early weaning and ensuring enough food for the child.
Fewer Infections: The child experiences fewer infections due to a strengthened immune system.
Love and Care for the Child: Enables families to concentrate on other income-generating activities, ensuring love and care for the child.
Ensuring Breastfeeding: Ensures adequate breastfeeding for the child, promoting child health.

To the Father

Reduced Domestic Violence: Family planning reduces domestic violence in a home.
Meeting Basic Needs: Enables the father to meet basic needs like food, medical care, etc.
Cost of Living Reduction: Reduces the cost of living in a home, allowing the father to invest in productive activities.
Preparation for Children: Assists couples in preparing for their children, ensuring they can provide love, care, and adequate support.
Protection Against STIs: Some family planning methods are protective against HIV and other sexually transmitted infections (STIs).

To the Community

Healthy and Productive Population: Family planning contributes to a healthy and productive population, enhancing community stability and harmony.
Reduced Overcrowding: Reduces overcrowding, maximizing available land for productivity.
Increased Socio-economic Development: Leads to increased socio-economic development within the community.
Prevention of Negative Behaviours: Reduces the presence of negative characters in the community, as parents have adequate time to provide for their children.
Improvement in Standards of Living: Family planning contributes to the improvement of standards of living within communities.

To the Nation

Control of Population Growth: Reduces the rapid population growth rate at a national level.
Reduced Dependence on Foreign Aids: Reduces the country’s dependence on foreign aids.
Improved Government Services: Enables the government to provide better social services and infrastructures like roads and health facilities.
Effective Resource Allocation: Facilitates easy budgeting for the people, as the number of resources to the population is manageable.
Population Growth Prediction: Helps predict population growth, allowing for better planning and resource allocation.

Components of Family Planning Services

Counselling: Counselling is an important need for the initiation and continuation of a family planning method. Service providers must undergo training to provide comprehensive counselling about all available family planning methods. Importantly, there should be no incentives or coercion to adopt family planning or a specific contraceptive method.
Provision of Contraceptives: Contraceptives should be provided to clients based on approved method-specific guidelines. Service providers delivering these methods must undergo training to ensure competency in their provision. This ensures that clients receive family planning services that align with their needs and preferences.
Follow-Up and Referral System: Clients choosing a family planning method should be informed about appropriate follow-up requirements. They should be encouraged to return to the service provider if they have any concerns or issues. The established referral system should be followed by service providers when making client referrals for further assistance.
Record Keeping: Family planning service providers are required to maintain comprehensive records. These records help identify each client, specify the type of contraception provided, and note any special circumstances associated with its provision. Effective record-keeping contributes to the overall management and evaluation of family planning programs.
Supervision: Supervision is an essential component of program evaluation. It ensures that client needs are met, and service delivery guidelines are adhered to. Supervisors act as team members who promote staff motivation, assist in problem-solving, and ensure the rights of both service providers and clients are observed throughout the delivery of family planning services.
Logistics: Maintenance of an effective organization and supply system is crucial to prevent both understocking and overstocking of family planning commodities. Staff at service delivery points must adhere to proper procedures for the storage and handling of contraceptives and other supplies to maintain the quality of services provided. This ensures that family planning services are consistently available and accessible to those in need.

Characteristics of an Ideal Family Planning Method

Effectiveness: A good family planning method should demonstrate high efficacy in preventing unintended pregnancies.
Minimal Side Effects: The method should have minimal or no adverse effects on the health and well-being of the individual using it.
Independence from Sexual Intercourse: The effectiveness of the method should not be relying on specific timing related to sexual activity.
User Autonomy: The method should empower individuals to manage their reproductive health without requiring constant supervision or intervention from health professionals.
Accessibility: It should be widely available, ensuring that individuals, regardless of geographic location or socioeconomic status, can access and utilize the method.
Ease of Distribution: The method should have a distribution system that allows for easy accessibility, ensuring convenience for users.
Affordability: Cost-effectiveness is crucial. A good family planning method should be affordable to a broad range of individuals, regardless of income.
Cultural and Religious Acceptance: The method should be culturally and religiously sensitive, respecting diverse beliefs and practices.
Reversibility: Individuals should have the option to discontinue the use of the method easily, with a quick return to fertility if desired.
Educational Support: The method should come with educational resources to ensure users are well-informed about its proper use, benefits, and any potential risks.
Long-Lasting: Ideally, the method should offer a duration of protection that aligns with the user’s family planning goals, whether short-term or long-term.
Compatibility with Health: The method should not compromise overall health, and individuals with specific health conditions should have suitable alternatives available.
Privacy and Confidentiality: The use of the method should be discreet, respecting the user’s privacy and maintaining confidentiality.
Community and Partner Support: It should encourage open communication and support from partners, families, and communities.
Research-Backed: The method’s safety and efficacy should be supported by scientific research and continuous monitoring.
Inclusivity: The method should be inclusive, addressing the diverse needs of different populations, including adolescents, women, and men.

Classification of family planning methods

There are 2 broad types of family planning:

Natural or Traditional or Non-hormonal methods.
Artificial or Hormonal methods.

Natural/Traditional Methods

Method	Description
Calendar/Rhythm	Tracking menstrual cycles for fertility awareness. This is the only method approved in the Roman Catholic Church
Basal Body Temperature	Monitoring temperature variations during the menstrual cycle
Cervical Mucus Method	Observing changes in cervical mucus for fertility awareness
Lactation Amenorrhea Methods	Reliance on breastfeeding as a natural contraceptive during postpartum period
Abstinence	Refraining from sexual activity
Withdrawal/Coitus Interruptus	Withdrawing the penis before ejaculation

Artificial Methods

a) Barrier Methods:

Method	Description
Spermicides	Chemical substances that kill sperm
Condoms	Barrier devices worn over the penis or inserted into the vagina to prevent sperm from reaching the egg
Intrauterine Contraceptive Devices (IUCDs)	Devices placed inside the uterus to prevent pregnancy
Diaphragm	Shallow, dome-shaped cup placed over the cervix with spermicide

b) Hormonal Methods:

i. Oral Pills:

Method	Description
Combined Oral Contraceptives	Pills containing both oestrogen and progestin hormones
Progesterone-Only Pills	Pills containing only progestin hormone
Emergency Contraceptive Pills	Pills taken after unprotected sex to prevent pregnancy

ii. Implants:

Method	Description
Implanon (1 Rod Capsule)	Subdermal contraceptive rod
Jadelle (2 Rod Capsules)	Subdermal contraceptive rods
Norplant (6 Rod Capsules)	Subdermal contraceptive rods

iii. Injectable Contraceptives:

Method	Description
Depo Provera	Injectable contraceptive administered every three months
Injector Plan	Injectable contraceptive
Sayana Press	Injectable contraceptive
Noristrate	Injectable contraceptive

c) Permanent Methods:

Method	Description
Tubal Ligation (Tubectomy) for Women	Surgical procedure to block or cut the fallopian tubes
Vasectomy for Men	Surgical procedure to block the vas deferens in the male reproductive system

NON-HORMONAL FAMILY PLANNING METHODS

They are so-called because they are not manufactured with hormone basis.

NATURAL NON-HORMONAL

These include:

Fertility awareness methods of family planning which involve identification of the fertile days of the menstrual cycle (when pregnancy is most likely to occur) and avoiding sexual intercourse (or using barrier methods ) during these days. The fertile days of the menstrual cycle can be determined by one of the following methods:

Calendar/Rhythm or Standard Days method, including cycle beads.
Basal Body Temperature
Cervical Mucus Method
Symptom- thermal ( a combination of cervical mucus and BBT methods).

Other Non Hormonal/traditional include;

Lactation Amenorrhea Methods
Periodic abstinence, abstaining from sexual intercourse during a woman’s fertile time.
Withdrawal/Coitus Interruptus

These methods, also known as fertility awareness methods, are based on understanding key physiological conditions related to reproduction, Such as;

Lifespan of Sperm and Ovum:

The lifespan of a sperm is approximately 3 – 5 days in the female reproductive tract.
The lifespan of an ovum (egg) is around 12- 24 hours.
Menstrual cycles can range between 23 to 35 days, but usually 28 days.

General Advantages:

Safety and Lack of Side Effects: FAMs are generally considered safe with minimal or no side effects.
Cost-Effectiveness: They are affordable, requiring no ongoing financial commitment.
Acceptability Across Groups: Often acceptable to individuals and religious groups opposing modern contraceptive methods.
Educational Benefits: These methods empower women with knowledge about their menstrual cycles and fertility.
Couples’ Control: Couples have direct involvement and control over the method, promoting shared responsibility.
Facilitates Pregnancy Planning: FAMs can be used for both family planning and to facilitate pregnancy when desired.
Non-Invasive: FAMs do not involve invasive procedures or the use of synthetic substances.
No Hormonal Interference: They do not interfere with hormonal balances, making them suitable for those sensitive to hormonal contraceptives.
Long-Term Relevance: Useful throughout a woman’s reproductive life, fostering awareness and informed decision-making.

General Disadvantages:

Learning Curve: Some methods require substantial education and learning before effective use.
Record Keeping: Users must maintain accurate records over several menstrual cycles for proper reference.
Challenges with Irregular Periods: Effectiveness diminishes when menstrual cycles are irregular.
Behavioural Adjustments: Requires adjustments to sexual behaviors during fertile periods.
Dependency on Partner Cooperation: Success depends on the level of cooperation between partners, which can be challenging.
Risk of Error: Inconsistencies in recording or misinterpretation may lead to unintentional pregnancies.
Limited Protection from STIs: FAMs provide no protection against sexually transmitted infections (STIs), including HIV/AIDS.
Intensive Monitoring: The method demands continuous and intensive monitoring, which may be burdensome for some users.

Indications:

Fertility awareness methods are suitable for any woman or couple who is willing and committed to observing, recording, and interpreting fertility signs on a daily basis. This includes:

Women who find other contraceptive methods unacceptable due to reasons such as religious beliefs.
Women who cannot use certain contraceptive methods for health reasons.
Couples who are open to abstaining from sexual intercourse (or using condoms) for more extended periods during each menstrual cycle.

Contraindications:

While there are no medical conditions that worsen with the use of fertility awareness methods, some conditions may make their application more challenging. In the presence of these conditions, the method may either be postponed or require specialized counselling to ensure correct utilization. These conditions include:

Breastfeeding, especially until the return of menstruation.
Less than three postpartum menstrual cycles.
Irregular vaginal bleeding.
Abnormal vaginal discharge.
Diseases that influence body temperature.

Barrier methods

Barrier methods work by preventing the passage of sperm into the female genital tract.

Female barrier methods include the diaphragm, cervical cap, FemCap, and the condom to both females and males and Spermicides

Condoms

A condom is a latex sheath put on an erect penis before coitus and worn during coitus.

Indications for Condom Use:

Men Engaging in Family Planning: Condoms are an excellent choice for men who wish to actively participate in family planning.
Sexually Active Adolescents: Adolescents engaging in sexual activity can benefit from the use of condoms as a reliable contraceptive and STI prevention method.
Infrequent Sexual Intercourse: Couples who engage in sexual intercourse infrequently may find condoms to be a practical and effective choice.
Casual Sexual Relationships: Individuals in casual sexual relationships where pregnancy is not desired can use condoms to prevent both unwanted pregnancies and sexually transmitted infections (STIs).
Back-Up Contraception: Couples waiting for another contraceptive method to become effective can use condoms as a reliable back-up method.
Temporary Contraception: Couples awaiting the initiation of another contraceptive method can use condoms as a temporary solution to prevent unintended pregnancies.

Mechanism of action of condom

Acts as a barrier, preventing sperm from entering the female genital tract.
For condoms that are coated with spermicide, the spermicide immobilizes and kills sperm.

Advantages of male and female condom

Effectiveness: When used correctly, condoms provide a high level of effectiveness (95 – 97%) in preventing pregnancy.
STI and HIV Prevention: Condoms are crucial in preventing the spread of sexually transmitted infections (STIs), including HIV.
Accessibility: Condoms are easy to obtain and can be distributed widely by Community Based Health Workers and the commercial sector.
Dual Purpose: They serve a dual purpose of family planning and STI/HIV prevention.
Potential Cervical Cancer Protection: There is a probable protective effect for women against the development of Intra-epithelial Neoplasm, i.e., cervical cancer.
Ease of Use: Condoms are easy to use, usually inexpensive, safe, effective, and portable.
Sexual Enhancement: They can help some men with premature ejaculation maintain an erection.
Convenient Short-Term Contraception: Condoms are convenient when short-term contraception is required.
Safety and Lack of Side Effects: Condoms are considered safe with minimal side effects.

Disadvantages:

Allergic Reactions: Some individuals may experience allergic reactions to latex or other materials used in condoms.
Sexual Enjoyment: Condoms may reduce the quality of sex for some individuals.
Male Partner Cooperation: Requires cooperation from the male partner for effective use.
Vulnerability to Damage: Can be damaged by exposure to oil-based lubricants, heat, humidity, or light.
Decreased Sensitivity: May decrease sensitivity for men, impacting the enjoyment of intercourse.
Slipping or Tearing: There is a small possibility of slipping or tearing during sexual intercourse.
Storage Requirements: Condoms can deteriorate if not properly stored, e.g., in too much heat, sunlight, or humidity.
Erection Challenges: Some men may struggle to maintain an erection with a condom on.

Spermicides

Vaginal spermicides come in the form of foam, cream, jelly, tablet or suppository and are inserted into the vagina just before sexual intercourse to prevent pregnancy.

Mechanism of action of spermicide

Inactivates and kills sperm;
Blocks the path of sperm to the uterus.

Effectiveness of spermicides

Fairly effective, depending on the user (79-97%);
If used with condom, effectiveness is 99%;
Effectiveness lasts only 30 to 40 minutes after insertion.

Advantages of spermicides

Over-the-Counter Availability: Spermicides can be obtained without a prescription, making them easily accessible.
Immediate Protection: Spermicides can be kept available for immediate use whenever needed, providing on-the-spot protection.
Additional Lubrication: Spermicides can offer additional lubrication during intercourse, enhancing comfort.
Enhanced Effectiveness with Condoms: When used in conjunction with condoms, spermicides can increase their overall effectiveness in preventing pregnancy.
Back-Up Option for Contraceptive Delays: Spermicides serve as a simple back-up option for women waiting to start oral contraceptives or have an IUD inserted. They are also useful for women who forget multiple contraceptive pills or run out of pills.
Emergency Use: In cases of a condom breakage, spermicides can be applied quickly as an emergency measure.

Disadvantages and Side Effects:

Sexual Interruption: Some forms of spermicides, such as suppositories or foaming tablets, may require a waiting period of 10 minutes for dissolving before becoming effective, potentially interrupting sexual intercourse.
Application Before Each Act: Spermicides must be used before each act of sexual intercourse, requiring consistent and timely application.
Post-Intercourse Wetness: Spermicides may cause increased vaginal wetness for several hours after intercourse.
Sensitivity or Allergic Reactions: A few women may be sensitive or allergic to spermicides, leading to irritation and discomfort, especially with frequent use.
Lower Effectiveness Rates: Spermicides are generally less effective in preventing pregnancy compared to more modern methods such as IUDs and hormonal contraceptives.
Risk of Candida Vaginitis: Some women may develop Candida Vaginitis as a side effect of using spermicides.
Increased Infections: Spermicides can potentially increase the risk of urinary and yeast tract infections in women.
Messiness and Discomfort: Spermicides can be messy and may cause mild discomfort or minor allergic reactions in some individuals.

Vaginal Diaphragm

Diaphragm is a mechanical barrier placed between the vagina and cervical canal .They are designed to fit in the cul-de-sac and cover the cervix.

The contraceptive jelly or creams should be placed on the cervical side of the diaphragm before insertion because the device itself is ineffective. Again, this medication serves as lubricant for insertion of a device.

The device is inserted 6 hours prior to intercourse and should be left in place 6-24 hours after intercourse

Advantages

Easy to use
It offers some protection against STDs
Well used, it protects from conception with the failure rate as low as 6% of women per year of exposure.

Disadvantages

It require fitting by a well trained medical professional
Fitting may loose during intercourse
It cannot be effective in women with significant pelvic relaxation,a sharply retroverted or anteverted uterus or shortened vagina.

Side effects

Vagina irritation
Increased risk of urinary tract infection due to pressure of the rim against the urethra and alterations in the composition of vaginal normal flora.

Cervical Cap (CAP)

Cervical caps are small cuplike diaphragms placed over the cervix that are held in place by suction.

To provide a successful barrier against the sperms, they must be tightly fit over the cervix therefore, individualization is essential because of variability in cervical size.

It has few advantages because;

Unpleasant odour often develops after approximately 1 day of use
Dislodgment (as in diaphragm)
The cup should remain in place 1 or 2 days before intercourse and should be left in place for 8 -48 hours after intercourse.

Intrauterine Contraceptive Devices (IUCDs):

Intrauterine Contraceptive Devices, or IUCDs, are flexible plastic devices inserted into a woman’s uterus to prevent pregnancy, usually renewed every 3-5 years. These devices are often made of copper impregnated with gold, silver, and stainless steel.

Various Design Types:

Copper T 380A:

T-shaped device with copper on the stem and arms of the T.
Duration of effectiveness: 10 years.
Shelf life: 7 years.

Multiload 375:

Lasts for 5 years.

Mechanism of Action:

Renders the endometrium unsuitable for the implantation of a fertilized ovum.
Copper emits metal ions with spermicidal properties.

Advantages:

Very Effective: Provides high efficacy, ranging from 99-99.5%.
Immediate Effectiveness: Works instantly upon insertion.
Long-Term Method: Offers a long duration of effectiveness.
No Interference with Intercourse: Does not interfere with sexual activity.
Quick Return to Fertility: Fertility returns immediately upon removal.
Few Side Effects: Mild side effects compared to other methods.
No Client Supplies Needed: Does not require additional supplies by the client.

Disadvantages and Side Effects:

Mild Cramps: May experience mild cramps in the first 3-5 days post-insertion.
Menstrual Changes: Longer and heavier menstrual blood loss in the initial 3 months.
Increased Cramping Pain: Increased cramping pain during menstruation.
Provider-Dependent: Insertion and removal depend on a healthcare provider.
String Checks: Need to check for strings after menstruation.
Increased Bleeding: May experience increased bleeding in the first few months.
Spontaneous Expulsion: There is a possibility of spontaneous expulsion, especially in the first 6 months.
Uterine Perforation: Very rare, occurring in 1 out of 1000 cases.
Pelvic Inflammatory Diseases (PID): May increase the risk of PID.
Pain and Discomfort: Pain, especially with larger devices.
Menstrual Changes: Increased menstrual loss; intermenstrual spotting may occur.
Expulsion Risk: Higher risk of expulsion during the first 6 months, especially during menses.
Translocation Risk: Possibility of translocation to the peritoneal cavity or broad ligament.
Pregnancy Risks: May increase the risk of pregnancy and ectopic pregnancy.
No Protection Against STIs/HIV or Cancers: Does not provide protection against STIs, HIV, ovarian, endometrial, or cervical cancers.

IUCDs users who develop PID should be treated with the IUCD in place if they want to continue using it. If no improvement within 72 hours, remove it.

When to Insert an IUCD:

During or immediately after menstruation.
At a postnatal examination.
Immediately following delivery or any time within 46 hours after childbirth.
After termination of a pregnancy.
During the caesarean section.

Insertion of an Intrauterine Contraceptive Device (IUD): Procedure

Aseptic Technique: Implement aseptic techniques, including hand washing and wearing sterile gloves.
Device Preparation: Place the IUD in an introducer and plunger.
Straightening: The device straightens inside the introducer.
Visualization of Cervix: Insert a Cusco’s vaginal speculum to clearly visualize the cervix.
Cleaning: Clean the cervix and vaginal vault with sterile swabs.
Uterine Measurement: Measure the length of the uterus with a uterine sounder.
Introducer Insertion: Insert the introducer into the uterus through the cervix.
Plunger Action: Gently push the plunger to force the device out of the introducer into the uterus.
Device Lodging: In the uterus, the device resumes its original shape and lodges against the uterine walls.
String Placement: The two small strings attached to the device hang down through the cervical opening.
String Cutting: Cut the string with scissors to reduce the size, leaving approximately 3cm hanging out of the cervix.
Post-Insertion: After insertion, the client rests and can remain on the procedure table until ready to get dressed.
String Check: The woman can feel the strings in the vagina to ensure the device is in position.

Post-Insertion Instructions:

Backup Use: Use backup contraception for a minimum of 3 days.
Mild Pain: Slight pain may occur but usually does not require medication.
String Check: Check the string during menstruation to ensure it is in place; return if removed or dislodged.
Immediate Return for Discomfort: Return to the facility immediately in case of any discomfort.

Removing the IUDs:

Discussion with Client: Discuss side effects with the client and weigh the option of managing the problem or immediate removal.
Timing for Removal: Removal is simple and can be done any time of the month, with monthly bleeding making it easier.

Removal Procedure:

Explain the removal procedure to the client.
Ensure privacy and confidentiality.
Visualize cervix and UID strings with a vaginal speculum.
Clean cervix and vagina with antiseptic solution.
Instruct the client to relax and take slow breaths.
Gently pull the IUD strings until it comes completely out of the cervix.
Show the removed IUD to the client for assurance.
Thank the client for cooperating throughout the procedure.

Reasons for Missed Threads in IUDs:

Coiled thread inside.
Thread torn through.
Device expelled outside unnoticed by the client.
Device perforated the uterine wall and is lying in the peritoneal cavity.
Device pulled by the growing uterus in pregnancy.

Methods of Identification:

History taking (exclude pregnancy).
Ultrasonography.
Hysterectomy.
Hysteroscopy.
Straight x-ray.

Contraindications:

Pregnant women or those suspected to be.
Women with menorrhagia or abnormal bleeding.
Women with PID, current, or in the past 3 months.
Purulent per vaginal discharge, gonococcal, or chlamydial infection.
Malignant trophoblastic disease.
Pelvic tuberculosis.
Women with genital tract cancer.

Surgical methods

Male Vasectomy

Male vasectomy is a permanent operation in the male where a segment of vas deferens of both sides are resected and the cut ends are ligated.

Vasectomy is a voluntary surgical procedure for permanently terminating fertility in men.

Mode of Action

Blocking the vas deferens (ejaculatory duct) to prevent sperm presence in the ejaculate.

Indications

Men certain about achieving their desired family size, seeking a highly effective permanent contraceptive method, or whose partners face unacceptable pregnancy risks.

Contraindications

Vasectomy should be delayed in the case of local or systemic infections.

Benefits

Highly effective
Permanent
Simple surgery under local anesthesia
No further expense or concerns about conception
No long-term side effects
Does not interfere with sexual intercourse

Side Effects

Wound infection
Scrotal hematoma
Granuloma
Excessive swelling
Pain at incision sites

Explain to Clients

When to come back for follow-up visits
Common side effects of the method
What to do if there are changes in menstrual periods
How soon the method is effective
How to protect against STIs
How to care for the wound postoperatively

General Instructions to Clients Using Permanent Methods

Inform about follow-up visit schedules
Explain common side effects in simple language
Share warning signs or possible problems requiring medical attention
Guide regarding changes in menstrual periods
Emphasize the method’s lack of protection against HIV/AIDS and STIs, advocating for backup methods like condoms
Provide instructions on wound care postoperatively

Female -Tubal ligation

Female Tubal Ligation is the interruption of continuity of fallopian tubes.

Tubal ligation is a voluntary surgical procedure for permanently terminating fertility in women. It can be done by a mini-operation (laparatomy/laparoscopy).

Mode of Action

Blocking fallopian tubes by cutting, cautery, rings, or clips, preventing sperms from reaching the ovum.

Indications

Women certain about achieving desired family size, seeking a highly effective permanent contraceptive method, or facing unacceptable pregnancy risks. Family planning should be delayed in specific cases, such as pregnancy, postpartum complications, or certain health conditions.

Timing of the Tubal Ligation

Immediately after childbirth or within the first seven days (if chosen in advance)
Six weeks or more after childbirth
Immediately after abortion (if chosen in advance)
Any time, provided pregnancy is ruled out (between seven days and six weeks postpartum)
During cesarean section

Benefits

Highly effective
Immediate effectiveness
Permanent
Simple surgery under local anesthesia
No contraception-related concerns
No long-term side effects
Does not interfere with sexual intercourse

Disadvantage

Does not protect against STIs/AIDS
Irreversible

Side Effects

Wound infection
Post-operative fever
Rare bladder and intestinal injuries
Hematoma
Pain at the incision site
Superficial bleeding

Challenges associated with Tubal Ligation

Desire for more children after the operation
Excessive desire for reversal
Disagreement to sign the informed consent form
External pressures
Depression
Marital problems

General Complications

Obesity
Psychological upset
Chronic pelvic pain
Congestive dysmenorrhea
Menstrual abnormalities

General Advantages

Simple Surgical Procedure: The procedure is straightforward and uncomplicated.
Out-Patient Procedure: It can be performed as an outpatient procedure, avoiding the need for a hospital stay.
Few Complications: The surgery has a low incidence of complications.
Reversal Anastomosis: Reversal procedures, known as anastomosis, have a 50% chance of success.
Highly Effective: The failure rate is minimal, at 0.15%.
No Interference with Sexual Life: Vasectomy does not interfere with the sexual life of the individual.
Performed Under Anesthesia: The operation is conducted under anaesthesia, ensuring a painless experience.

General Disadvantages

Lack of Protection Against HIV and STDs: Vasectomy does not provide protection against HIV and sexually transmitted diseases (STDs).
Costly Reversal: Reversal procedures can be expensive.
Consent Requirements: Obtaining consent may involve important family members in decision-making.
Risk of Injury to Internal Organs: There is a potential risk of injury to internal organs during the procedure.
Anaesthesia Risks: The use of anaesthesia carries inherent risks.
Post-Surgical Complications: Possible complications include infection and bleeding.
Additional Contraception Required: Additional contraception is needed for about 2-3 months until semen becomes free of sperm.
Potential for Impotency: There is a rare risk of impotence.
Frigidity: Frigidity, especially sexual unresponsiveness in women and an inability to achieve orgasm during intercourse, may occur.
Stigma: Societal stigma may be associated with the decision to undergo vasectomy.

Important points to think about before the use of a permanent contraception

Because male and female sterilization are permanent methods of contraception, thorough counselling procedures must be followed to ensure that the client fully understands his or her choice and to minimize chances of regret.

Counselling: Thorough counselling sessions to ensure informed decision-making.
Reasons for Choosing Permanent Methods: Understand and evaluate the motivating factors behind the choice of permanent contraception.
Screening for Risk Indicators for Regret: Identify potential risk indicators such as:

Young age
Low parity
Single-parent status
Marital instability

Completion of Informed Consent Process: Ensure the individual fully comprehends the implications and consequences of the procedure.
Details of the Procedure: Provide comprehensive information about the surgical process involved in permanent contraception.
Possibility of Failure: Acknowledge the rare but existing possibility of the procedure not being 100% effective.
Positive Pregnancy Test Result: In case of a positive pregnancy test post-tubal ligation, rule out ectopic pregnancy.
Condom Use for STD Protection: Emphasize the continued need for condom use to safeguard against sexually transmitted diseases.

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Menstruation Disorders

MENSTRUATION DISORDERS

Menstrual disorders are abnormalities in menstruation during reproductive life.

Common disorders associated with menstruation are as follows;

Amenorrhoea
Dysmenorrhoea
Menorrhagia
Metrorrhagia
Polymenorrhagia (epimenorrhoea)
Dysfunctional uterine bleeding
Endometriosis

MENSTRUATION

Menstruation is defined as the periodic physiological discharge of blood from the uterus through the vagina.

The normal period of menstruation usually lasts 2-7 days with a total blood loss of

10 – 80 ml is considered normal.

The normal menstruation cycle has a length of 21-35 days.

THE MENSTRUATION CYCLE

The menstrual cycle is a sequence of physiological events that occur periodically (on average every 28 days) from puberty until menopause.

The events occur under the influence of hormones produced by pituitary glands(Follicle Stimulating Hormone – FSH and Luteinizing hormone – LH) and the ovaries (Progesterone & Oestrogen).

The menstrual cycle is divided into 3 phases namely:

Follicular phase
Ovulatory phase
Luteal phase

Follicular phase (proliferative phase)

This is marked by the beginning of menstruation.

Bleeding results from the decrease in the levels of oestrogen and progesterone from the luteal phase.
The reduction in oestrogen and progesterone leads to the shedding of the endometrium.
During this phase, Follicle stimulating hormone (FSH) from the anterior lobe of the pituitary gland rises to stimulate the growth of several ovarian follicles with each follicle containing an ovum.
Later, FSH levels reduce which leads to only one dominant follicle developing.
The dominant follicle then produces oestrogen hormone.

The Ovulatory phase

This begins with a sharp rise in the levels of LH and FSH.

The luteinizing hormone stimulates ovulation at about the 14th day of the menstrual cycle (between the 7th – 21st day depending on the cycle length).
The oestrogen levels reach a peak and progesterone levels begin to rise once the ovum has been released.
What is left behind of the dominant follicle after ovum release is referred to as the corpus luteum and it is the one that produces progesterone.

Luteal phase (Secretory phase)

Luteal phase usually occurs after ovulation.

During this phase, the endometrium begins to thicken in preparation for nourishment of an embryo in case fertilization takes place.
If fertilization doesn’t occur, the increasing levels of oestrogen and progesterone decrease the production of both luteinizing and follicle stimulating hormones.
Since the maintenance of corpus luteum depends on the luteinizing hormone, a decrease in its production causes the corpus luteum to atrophy leading to a reduction in the production of oestrogen and progesterone.
The thickened uterine lining then begins to slog off and menstruation begins.
And the follicular phase begins to complete the menstrual cycle.

Factors that may interfere with menstrual cycle thereby causing menstrual disorders

1. Physical conditions such as trauma, tumors, and diseases of the glands, ovaries, and uterus can impact the normal functioning of the reproductive system, potentially causing menstrual irregularities.

2. Debilitating diseases such as tuberculosis (TB) and HIV/AIDS can affect overall health, potentially disrupting the menstrual cycle.

3. Malnutrition can lead to hormonal imbalances, affecting the regularity of menstrual periods.

4. Dysfunctional uterine bleeding, which involves abnormal bleeding patterns, can be a contributing factor to menstrual disorders.

5. Age plays a role, as menstruation can be irregular in young girls after menarche (the first occurrence of menstruation).

6. Pregnancy naturally alters the menstrual cycle, and complications during pregnancy can lead to menstrual irregularities.

7. Certain drugs and exposure to X-rays, especially radiography, can impact hormone levels and disrupt the menstrual cycle.

8. Menopause, with its gradual onset, marks the end of the reproductive years and can cause significant changes in menstrual patterns.

9. The use of intrauterine contraceptives (IUCs) can also affect menstrual regularity in some women.

10. Extreme stress and worries, such as those experienced during times of war or conflict, can disrupt hormonal balance and impact the menstrual cycle.

11. Anxiety and mental health conditions can influence hormone levels, potentially leading to menstrual irregularities.

12. Environmental changes, such as transitioning to a new school or significant shifts in routine, can impact stress levels and, in turn, affect the menstrual cycle.

13. The stage of adolescence is a period of significant hormonal changes, and this transition can lead to menstrual irregularities as the body adjusts to these fluctuations.

AMENORRHOEA

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Anatomy and Physiology of the Musculo-skeletal System

Anatomy and Physiology of the Musculoskeletal System

The muscular-skeletal system is the system that is mainly important in locomotion, body support and makes bodies’ frame work. It consists of skeletal muscles, bones and joints.

I. MUSCLES (ANATOMY AND PHYSIOLOGY)

Skeletal, Smooth, and Cardiac Muscle

Our bodies contain three distinct types of muscle tissue, each uniquely adapted to perform specific roles. While all muscle tissues share the ability to contract, they differ significantly in their location, microscopic appearance (histology), and physiological function.

1. Skeletal Muscle:

Location:
- Attached to bones (or to skin, as in facial muscles).
- Forms the bulk of the body's muscle mass.
Histology (Microscopic Appearance):
- Striated: Appears striped or banded under a microscope due to the arrangement of contractile proteins (actin and myosin).
- Very long, cylindrical cells (fibers): Can be several centimeters long.
- Multinucleated: Each muscle fiber contains many nuclei, located peripherally (just under the sarcolemma, or cell membrane).
- Voluntary: Contraction is under conscious control.
Function:
- Movement: Responsible for all voluntary movements of the body (e.g., walking, lifting, speaking, facial expressions).
- Posture: Maintains body posture.
- Stabilize Joints: Helps stabilize joints by exerting tension.
- Heat Generation: Produces heat as a byproduct of contraction, helping to maintain body temperature.

2. Cardiac Muscle:

Location:
- Found exclusively in the wall of the heart (myocardium).
Histology (Microscopic Appearance):
- Striated: Like skeletal muscle, it also appears striped due to the arrangement of contractile proteins.
- Branched cells: Individual cells are shorter than skeletal muscle fibers and branch, forming an intricate network.
- Uninucleated (or occasionally binucleated): Each cell usually has one (sometimes two) centrally located nuclei.
- Intercalated Discs: Unique to cardiac muscle, these are specialized junctions between adjacent cardiac muscle cells. They contain desmosomes (to prevent cells from pulling apart) and gap junctions (to allow ions to pass quickly, enabling rapid communication and synchronized contraction).
- Involuntary: Contraction is not under conscious control; it's regulated by the heart's intrinsic pacemaker and influenced by the autonomic nervous system.
Function:
- Pump Blood: Responsible for pumping blood throughout the body, maintaining blood pressure and circulation.

3. Smooth Muscle:

Location:
- Found in the walls of hollow internal organs (viscera), except the heart.
- Examples: Walls of the digestive tract (stomach, intestines), urinary bladder, respiratory passages (bronchi), arteries, veins, uterus, arrector pili muscles in the skin (causing "goosebumps").
Histology (Microscopic Appearance):
- Non-striated: Lacks the visible banding pattern seen in skeletal and cardiac muscle because the contractile proteins are arranged more randomly.
- Spindle-shaped cells: Elongated cells with tapered ends.
- Uninucleated: Each cell contains a single, centrally located nucleus.
- Involuntary: Contraction is not under conscious control; it's regulated by the autonomic nervous system, hormones, and local factors.
Function:
- Peristalsis: Propels substances along internal passageways (e.g., food through the digestive tract).
- Regulation of Organ Volume: Can maintain prolonged contractions, regulating the size of organs (e.g., constricting blood vessels, emptying the bladder).
- Movement of Fluids: Moves fluids and other substances within the body.
- Regulates Airflow: Adjusts the diameter of respiratory passages.

1. The Skeletal Muscle

Skeletal muscles are truly fascinating structures, responsible for all voluntary movements, from the subtlest facial expressions to powerful athletic feats. They are unique among muscle types due to their voluntary control and striated appearance.

Gross Anatomy of a Skeletal Muscle

Skeletal muscles are organs composed predominantly of muscle tissue, but they also contain connective tissues, nerves, and blood vessels. They are typically attached to bones, and this attachment is crucial for their function in generating movement.

Muscle Belly: This is the fleshy, contractile part of the muscle. It contains thousands to hundreds of thousands of individual muscle fibers (cells).
Attachments to Bones: Skeletal muscles connect to bones, usually at two points:
- Origin: This is typically the less movable (or stationary) attachment point of the muscle. It often lies closer to the trunk or center of the body.
- Insertion: This is the more movable attachment point of the muscle. When the muscle contracts, the insertion point is pulled towards the origin, causing movement at a joint.
Example: For the biceps brachii muscle in your upper arm:
- Origin: Scapula (shoulder blade)
- Insertion: Radius (forearm bone)
- When the biceps contracts, it pulls the radius towards the scapula, causing the elbow to bend (flex).
Connective Tissue Attachments: Muscles attach to bones via specialized connective tissues:
- Tendons: These are cord-like bundles of dense regular connective tissue. They are continuous with the connective tissue sheaths within and around the muscle and then with the periosteum (the fibrous membrane covering the bone). This direct continuity ensures that the force generated by muscle contraction is effectively transmitted to the bone, causing movement. Tendons are incredibly strong and relatively inelastic.
- Aponeuroses: These are broad, flat sheets of dense regular connective tissue. They function similarly to tendons, serving as a flat attachment site, especially where muscles are broad and require a wide area of attachment, or where they connect to other muscles. Examples include the aponeurosis of the external oblique muscle in the abdomen, or the plantar aponeurosis in the sole of the foot.

Hierarchical Organization of Skeletal Muscle

Understanding the hierarchical organization of skeletal muscle is key to appreciating how force is generated and transmitted. It's like a cable, where smaller strands are bundled together to form larger, stronger cables.

Entire Muscle (Organ Level):
- This is what we commonly recognize as "a muscle" (e.g., biceps brachii, quadriceps femoris).
- It is composed of many bundles of muscle fibers, along with connective tissue, blood vessels, and nerves.
- The entire muscle is typically enclosed by a dense, irregular connective tissue sheath called the epimysium.
Fascicle (Bundle of Muscle Fibers):
- The entire muscle is divided into numerous smaller bundles called fascicles.
- Each fascicle consists of anywhere from 10 to 100 or more individual muscle fibers.
- Each fascicle is wrapped in its own connective tissue sheath, the perimysium. This compartmentalization allows for independent neural control of different parts of a muscle.
Muscle Fiber / Muscle Cell (Cellular Level):
- Within each fascicle are the individual muscle cells, which are often referred to as muscle fibers due to their elongated, cylindrical shape.
- These are unique cells: they are very long (can be up to 30 cm in large muscles), multinucleated (containing many nuclei), and are the actual contractile units.
- Each muscle fiber is surrounded by a delicate connective tissue layer called the endomysium.
- The plasma membrane of a muscle fiber is called the sarcolemma, and its cytoplasm is called the sarcoplasm.
Myofibril:
- Inside each muscle fiber (muscle cell), the sarcoplasm is packed with hundreds to thousands of rod-like structures called myofibrils.
- Myofibrils are the actual contractile elements of the muscle cell. They are composed of even smaller structures called myofilaments.
- The characteristic "striated" or striped appearance of skeletal muscle under a microscope is due to the repeating arrangement of these myofilaments within the myofibrils.
Myofilaments (Actin & Myosin):
- These are the protein filaments that make up the myofibrils. They are the actual contractile proteins.
- Thick filaments are primarily composed of the protein myosin.
- Thin filaments are primarily composed of the protein actin, along with regulatory proteins troponin and tropomyosin.
- These myofilaments are organized into functional repeating units called sarcomeres.

Hierarchical Flowchart:
Entire Muscle ↓ (enclosed by Epimysium) Fascicle (bundle of muscle fibers) ↓ (enclosed by Perimysium) Muscle Fiber / Muscle Cell ↓ (enclosed by Endomysium, plasma membrane is Sarcolemma) Myofibril (contains myofilaments) ↓ Myofilaments (Actin & Myosin) ↓ (organized into) Sarcomere (functional unit)

Connective Tissue Sheaths Associated with Skeletal Muscle

Skeletal muscles are not just bundles of contractile cells; they are highly organized structures held together and protected by various layers of connective tissue. These sheaths play vital roles in transmitting force, providing pathways for nerves and blood vessels, and maintaining the structural integrity of the muscle.

Sheath	Location	Tissue Type	Main Function(s)
Epimysium	Surrounds the entire muscle	Dense Irregular CT	Binds all fascicles, overall protection, forms tendons/aponeuroses, major vessel/nerve pathways
Perimysium	Surrounds fascicles (bundles of fibers)	Dense Irregular CT	Divides muscle into fascicles, provides pathways for smaller vessels/nerves
Endomysium	Surrounds individual muscle fibers	Areolar (Loose) CT	Electrically insulates fibers, supports capillaries/nerves, transfers force

These connective tissue layers are continuous with each other and ultimately with the tendons, forming a continuous network that effectively transmits the force generated by the contracting muscle fibers to the bones, enabling movement.

Microscopic Anatomy of a Skeletal Muscle Fiber (Cell)

A skeletal muscle fiber, or muscle cell, is a highly specialized and elongated cell designed for contraction. It has several unique features that distinguish it from a typical animal cell.

Sarcolemma (Plasma Membrane):
- Description: This is the specialized plasma membrane of a muscle fiber. It is a thin, elastic membrane that encloses the sarcoplasm.
- Function:
  - Electrical Excitability: It has voltage-gated ion channels that allow it to generate and propagate action potentials (electrical signals).
  - Invaginations (T-tubules): At numerous points, the sarcolemma invaginates deep into the muscle fiber to form structures called Transverse Tubules (T-tubules).
Sarcoplasm (Cytoplasm):
- Description: This is the cytoplasm of a muscle fiber. It contains the usual organelles found in other cells, but also has some specialized components.
- Specialized Components:
  - Glycosomes: Granules of stored glycogen, which provide glucose for ATP production.
  - Myoglobin: A red pigment that stores oxygen, similar to hemoglobin in blood. Myoglobin efficiently stores oxygen within the muscle cell, providing an oxygen reserve for aerobic respiration during periods of high activity.
  - Mitochondria: Numerous mitochondria are packed between the myofibrils, reflecting the high energy demand of muscle contraction (producing ATP).
  - Myofibrils: The most prominent component, myofibrils are rod-like contractile elements that make up about 80% of the muscle fiber volume.
Sarcoplasmic Reticulum (SR) (Endoplasmic Reticulum):
- Description: This is a highly specialized, elaborate network of smooth endoplasmic reticulum that surrounds each myofibril like a loosely woven sleeve. It runs longitudinally along the myofibril. At the A-I band junction, it forms larger, perpendicular channels called terminal cisternae.
- Function:
  - Calcium Storage and Release: The primary function of the SR is to store and regulate the intracellular concentration of calcium ions (Ca2+). It contains a high concentration of Ca2+ pumps that actively transport Ca2+ from the sarcoplasm into the SR, and Ca2+ release channels that open in response to electrical signals.
  - Excitation-Contraction Coupling: The release of Ca2+ from the SR is the critical step that initiates muscle contraction.
T-Tubules (Transverse Tubules):
- Description: These are deep, invaginations (inward extensions) of the sarcolemma that run perpendicular to the long axis of the muscle fiber. They are located at the A-I band junction of each sarcomere.
- Function:
  - Rapid Impulse Transmission: T-tubules act as rapid communication channels, allowing the electrical impulse (action potential) generated on the sarcolemma to quickly penetrate deep into the muscle fiber, reaching every sarcomere.
  - Coupling with SR: Each T-tubule runs between two terminal cisternae of the SR, forming a structure called a triad. This close anatomical arrangement is crucial for excitation-contraction coupling, as the electrical signal in the T-tubule directly triggers Ca2+ release from the adjacent SR terminal cisternae.
Nuclei (Multinucleated):
- Description: Unlike most cells, skeletal muscle fibers are multinucleated, meaning they contain many nuclei. These nuclei are typically located just beneath the sarcolemma (peripherally).
- Function: Protein Synthesis: The large number of nuclei allows for the efficient production of the vast amounts of proteins (especially contractile proteins like actin and myosin) needed for the maintenance and repair of the very long muscle fiber, as well as for muscle growth (hypertrophy).

Structure of a Myofibril

Myofibrils are the long, cylindrical, contractile organelles found within the sarcoplasm of a muscle fiber. It's their precise arrangement of protein filaments that gives skeletal muscle its characteristic striated appearance and enables contraction.

Myofibrils and Sarcomeres:
- Each myofibril is composed of a chain of repeating contractile units called sarcomeres.
- A sarcomere is the fundamental functional unit of a skeletal muscle, extending from one Z disc to the next Z disc. It is the smallest unit of a muscle fiber that can contract.
- The precise arrangement of two types of myofilaments within each sarcomere creates the striations.
Myofilaments:
- Thick Filaments (Myosin Filaments): Composed primarily of the protein myosin. Each myosin molecule has a "rod-like" tail and two globular "heads." The heads are crucial for muscle contraction, as they bind to actin and possess ATPase activity. They are found in the center of the sarcomere and do not extend the entire length of the sarcomere.
- Thin Filaments (Actin Filaments): Composed primarily of the protein actin, which forms a double helix. Also contains two regulatory proteins:
  - Tropomyosin: A rod-shaped protein that spirals around the actin core, blocking the myosin-binding sites on actin in a relaxed muscle.
  - Troponin: A three-polypeptide complex that binds to actin, tropomyosin, and calcium ions (Ca2+). Its binding of Ca2+ causes a conformational change that moves tropomyosin away from the myosin-binding sites.
  Thin filaments extend from the Z disc toward the center of the sarcomere.
Bands and Zones within a Sarcomere: The alternating dark and light bands give skeletal muscle its striated appearance.
- Z Disc (Z Line): A coin-shaped sheet of proteins (primarily alpha-actinin) that anchors the thin filaments and connects myofibrils to one another. It defines the lateral boundaries of a single sarcomere.
- I Band (Light Band): A lighter region on either side of the Z disc. Contains only thin filaments (actin). During contraction, the I band shortens.
- A Band (Dark Band): A darker, central region of the sarcomere. Contains the entire length of the thick filaments (myosin). Also contains the inner ends of the thin filaments that overlap with the thick filaments. The A band's length does not change significantly during contraction.
- H Zone (H Band): A lighter region within the center of the A band. Contains only thick filaments (myosin); there is no overlap with thin filaments in a relaxed muscle. During contraction, the H zone shortens and can even disappear as thin filaments slide past.
- M Line: A dark line in the exact center of the H zone (and thus the A band). Consists of proteins (e.g., myomesin) that anchor the thick filaments in place and keep them aligned.

During muscle contraction, the thin filaments slide past the thick filaments, pulling the Z discs closer together. This causes the sarcomere to shorten, and the I bands and H zones to narrow or disappear, while the A band's length remains relatively constant. This mechanism is known as the Sliding Filament Model of Contraction.

Physiology of a Skeletal Muscle (Muscle Contraction)

"Sliding Filament Model" of muscle contraction.

The Sliding Filament Model is the universally accepted explanation for how skeletal muscles contract. It states that during contraction, the thin filaments (actin) slide past the thick filaments (myosin), causing the sarcomere to shorten. The myofilaments themselves do not shorten; rather, their overlap increases.

Here's a breakdown of the key principles:

Relaxed State:
- In a relaxed muscle fiber, the thick and thin filaments overlap only slightly at the ends of the A band.
- The H zone (containing only thick filaments) and the I band (containing only thin filaments) are at their maximum width.
- The myosin heads are "cocked" and energized, but they are prevented from binding to actin by the regulatory protein tropomyosin, which covers the myosin-binding sites on the actin molecules.
Initiation of Contraction (The Signal):
- A nerve impulse (action potential) arrives at the neuromuscular junction (which we'll detail later).
- This electrical signal is transmitted down the sarcolemma and into the T-tubules.
- The signal in the T-tubules triggers the release of calcium ions (Ca2+) from the sarcoplasmic reticulum (SR) into the sarcoplasm.
Role of Calcium (Ca2+) and Regulatory Proteins:
- When Ca2+ is released into the sarcoplasm, it binds to the regulatory protein troponin.
- Binding of Ca2+ causes troponin to change shape.
- This shape change in troponin, in turn, pulls the tropomyosin molecule away from the active (myosin-binding) sites on the actin filament.
- With the binding sites now exposed, the myosin heads are free to attach to actin.
Cross-Bridge Formation (Myosin-Actin Binding):
- The energized myosin heads (which have already hydrolyzed ATP into ADP and inorganic phosphate, storing the energy) bind to the exposed active sites on the actin filament, forming cross-bridges.
The Power Stroke:
- Once the myosin head is attached to actin, the stored energy is released, causing the myosin head to pivot or "bend." This bending motion is called the power stroke.
- The power stroke pulls the thin filament (actin) toward the M line (the center of the sarcomere).
- As the myosin head pivots, it releases ADP and inorganic phosphate.
Cross-Bridge Detachment:
- A new ATP molecule then binds to the myosin head.
- The binding of ATP causes the myosin head to detach from the actin filament. This detachment is crucial; without new ATP, the cross-bridges would remain attached, leading to a state known as rigor mortis (stiffening after death due to lack of ATP).
Cocking of the Myosin Head:
- The newly bound ATP is immediately hydrolyzed (broken down) by the ATPase enzyme on the myosin head into ADP and inorganic phosphate (Pi).
- This hydrolysis provides the energy to "re-cock" or re-energize the myosin head, returning it to its high-energy, ready-to-bind position.
Repetition of the Cycle:
- As long as Ca2+ is present and bound to troponin (keeping the actin binding sites exposed) and sufficient ATP is available, the cycle of cross-bridge formation, power stroke, and detachment will repeat multiple times.
- Each cycle pulls the thin filament a little further toward the M line.
Sarcomere Shortening:
- With each power stroke, the thin filaments slide further inward.
- This sliding action shortens the sarcomere (the distance between Z discs).
- As all the sarcomeres in a myofibril shorten simultaneously, the entire myofibril shortens, which in turn causes the entire muscle fiber and ultimately the entire muscle to shorten, generating force and producing movement.

Visualizing the Change during Contraction:

Z discs: Move closer together.
I bands: Shorten (may disappear in maximal contraction).
H zone: Shortens (may disappear in maximal contraction).
A band: Remains the same length (myosin filaments don't shorten).

This repetitive cycle of binding, pulling, and detaching is the fundamental mechanism behind all skeletal muscle contractions.

Roles of actin, myosin, tropomyosin, and troponin in muscle contraction.

These four proteins are the molecular machinery that directly drives and regulates muscle contraction.

Actin (Thin Filament Component):
- Structure: Actin forms the "backbone" of the thin filaments. It's a globular protein (G-actin) that polymerizes to form long, fibrous strands (F-actin), which then twist together into a double helix.
- Role in Contraction: Actin contains the active (myosin-binding) sites. It is the protein that the myosin heads attach to and pull on during the power stroke. Actin essentially provides the "track" along which myosin travels.
- Key Action: Binds to myosin heads to form cross-bridges.
Myosin (Thick Filament Component):
- Structure: Myosin is a large motor protein that makes up the thick filaments. Each myosin molecule has a long tail and two globular heads. The heads contain an actin-binding site and an ATPase (enzyme that breaks down ATP) site.
- Role in Contraction: Myosin is the "motor" protein. Its heads bind to actin, pivot (power stroke) to pull the actin filament, and then detach. The ATPase activity in the heads hydrolyzes ATP, providing the energy for these movements.
- Key Action: Forms cross-bridges with actin, pulls actin filaments, hydrolyzes ATP for energy.
Tropomyosin (Regulatory Protein of Thin Filament):
- Structure: A rod-shaped protein that spirals around the actin filament, covering the active (myosin-binding) sites on the actin molecules in a relaxed muscle.
- Role in Contraction: Its primary role is to block the myosin-binding sites on actin in a relaxed muscle. This prevents myosin from binding to actin and initiating contraction when the muscle is not stimulated.
- Key Action: Blocks actin's active sites, preventing contraction in the absence of calcium.
Troponin (Regulatory Protein of Thin Filament):
- Structure: A complex of three globular polypeptides, each with a specific function:
  - TnI (inhibitory): Binds to actin, holding the troponin-tropomyosin complex in place.
  - TnT (tropomyosin-binding): Binds to tropomyosin, helping to position it on the actin filament.
  - TnC (calcium-binding): Binds to calcium ions (Ca2+).
- Role in Contraction: Troponin is the calcium sensor that initiates the unblocking of actin. When calcium ions become available (released from the sarcoplasmic reticulum), they bind to the TnC subunit. This binding causes a conformational change in troponin, which then pulls tropomyosin away from the myosin-binding sites on actin.
- Key Action: Binds calcium, causing tropomyosin to move off the actin binding sites, thereby allowing myosin to bind.

How they interact during a full cycle:

Relaxed: Tropomyosin (held by troponin) blocks actin's binding sites. Myosin cannot bind.
Stimulated (Ca2+ present): Ca2+ binds to troponin. Troponin changes shape, pulling tropomyosin away from actin's binding sites.
Contraction: Myosin heads bind to exposed actin sites, perform the power stroke, and pull the actin filament.
Relaxation (Ca2+ removed): Ca2+ detaches from troponin. Troponin returns to its original shape, allowing tropomyosin to once again cover the actin binding sites. Myosin detaches, and the muscle relaxes.

These four proteins work in a highly coordinated fashion, driven by the presence or absence of calcium ions, to control the fundamental process of muscle contraction and relaxation.

Events at the neuromuscular junction (NMJ)

The neuromuscular junction (NMJ) is the specialized synapse where a motor neuron communicates with a skeletal muscle fiber. It's the critical link that translates a nerve impulse into a muscle action potential.

Here's the sequence of events at the NMJ:

Action Potential Arrives at the Axon Terminal: A nerve impulse, or action potential (AP), travels down the motor neuron axon and reaches the axon terminal (also called the synaptic knob or terminal bouton), which is the enlarged end of the motor neuron.
Voltage-Gated Calcium Channels Open:
- The arrival of the action potential at the axon terminal depolarizes the membrane, opening voltage-gated calcium (Ca2+) channels in the presynaptic membrane (the membrane of the axon terminal).
- Ca2+ ions, which are in higher concentration outside the cell, rush into the axon terminal.
Acetylcholine (ACh) Release:
- The influx of Ca2+ into the axon terminal triggers the fusion of synaptic vesicles (which contain the neurotransmitter acetylcholine, ACh) with the presynaptic membrane.
- Acetylcholine (ACh) is then released into the synaptic cleft (the tiny space between the axon terminal and the muscle fiber). This release occurs via exocytosis.
ACh Binds to Receptors on the Motor End Plate:
- ACh diffuses across the synaptic cleft and binds to specific nicotinic acetylcholine receptors located on the motor end plate of the muscle fiber. The motor end plate is a specialized region of the sarcolemma that is highly folded to increase surface area and contains a high density of these receptors.
- These receptors are ligand-gated ion channels.
Ion Channels Open and Local Depolarization (End Plate Potential):
- The binding of ACh to its receptors causes the ligand-gated ion channels to open.
- These channels allow both sodium ions (Na+) to flow into the muscle fiber and potassium ions (K+) to flow out.
- However, more Na+ enters than K+ leaves, resulting in a net influx of positive charge. This causes a local depolarization of the motor end plate, called an end plate potential (EPP).
Generation of Muscle Action Potential:
- If the end plate potential reaches a critical threshold, it triggers the opening of voltage-gated sodium channels in the adjacent sarcolemma (the sarcolemma immediately outside the motor end plate).
- A rapid influx of Na+ through these voltage-gated channels generates a full-blown muscle action potential.
- This action potential then propagates (travels) along the entire sarcolemma and deep into the muscle fiber via the T-tubules.
Termination of ACh Activity:
- To prevent continuous muscle contraction, the effects of ACh must be rapidly terminated. This is achieved by the enzyme acetylcholinesterase (AChE), which is located in the synaptic cleft and on the sarcolemma.
- AChE breaks down ACh into its components (acetic acid and choline), rendering it inactive.
- This rapid degradation ensures that each nerve impulse produces only one muscle action potential.

Summary of Events at the NMJ:
Nerve AP ➔ Ca2+ Influx into Axon Terminal ➔ ACh Release ➔ ACh Binds to Receptors on Motor End Plate ➔ Ligand-gated Channels Open (Na+ Influx > K+ Efflux) ➔ End Plate Potential ➔ Voltage-gated Na+ Channels Open (if threshold reached) ➔ Muscle Action Potential ➔ ACh broken down by AChE.
This sequence ensures precise and controlled communication between the nervous system and the musculoskeletal system.

2. BONES

The skeletal system, comprised of bones, cartilage, ligaments, and other connective tissues, is far more than just a rigid framework. It's a dynamic and vital organ system with several critical functions.

Five Main Functions of the Skeletal System:

Support:
- Description: The skeletal system provides a rigid framework that supports the body's soft tissues and organs. It acts as the internal scaffolding that holds the body upright and maintains its overall shape.
- Example: Our legs and vertebral column support the weight of the trunk, and the rib cage supports the thoracic wall.
Protection:
- Description: Bones form protective enclosures for many of the body's vital organs, shielding them from external forces and trauma.
- Example: The skull protects the brain, the vertebral column protects the spinal cord, and the rib cage protects the heart and lungs.
Movement:
- Description: Bones serve as levers for muscles. When muscles contract, they pull on bones, causing movement at the joints. The joints themselves act as fulcrums for these levers.
- Example: The biceps muscle contracts to pull on the forearm bones (radius and ulna), causing the arm to flex at the elbow. Without bones, muscles would have nothing firm to pull against.
Mineral Storage:
- Description: Bone tissue acts as a reservoir for several important minerals, most notably calcium and phosphate. These minerals are essential for numerous physiological processes, including nerve impulse transmission, muscle contraction, blood clotting, and ATP production.
- Example: When blood calcium levels drop, calcium can be withdrawn from the bones to restore homeostasis. Conversely, excess calcium can be stored in the bones. This dynamic storage helps maintain mineral balance in the blood.
Hematopoiesis (Blood Cell Formation):
- Description: Inside certain bones, primarily in the red bone marrow, the process of hematopoiesis occurs. This is the production of all blood cells, including red blood cells, white blood cells, and platelets.
- Example: In adults, red bone marrow is found in the flat bones (like the sternum, ribs, and hip bones) and the epiphyses of long bones (like the femur and humerus).

Classification of Bones Based on Their Shape

Bones come in a variety of shapes and sizes, and their classification by shape often reflects their primary function. There are five main categories:

Long Bones:
- Description: Characterized by being significantly longer than they are wide. They typically have a shaft (diaphysis) and two expanded ends (epiphyses). They are primarily compact bone with some spongy bone at the ends.
- Function: Act as levers to aid in movement and support the body's weight.
- Examples: Femur (thigh bone), Humerus (upper arm bone), Tibia and Fibula (lower leg bones), Radius and Ulna (forearm bones), Phalanges (finger and toe bones).
Short Bones:
- Description: Roughly cube-shaped, with their length, width, and height being approximately equal. They primarily consist of spongy bone surrounded by a thin layer of compact bone.
- Function: Provide stability and some movement, often articulating with multiple other bones.
- Examples: Carpals (wrist bones), Tarsals (ankle bones).
Flat Bones:
- Description: Thin, flattened, and often curved. They are typically composed of two parallel plates of compact bone, with a layer of spongy bone (diploe) sandwiched between them.
- Function: Provide broad surfaces for muscle attachment and often protect underlying soft organs.
- Examples: Cranial Bones (skull bones, e.g., frontal, parietal), Sternum (breastbone), Scapulae (shoulder blades), Ribs.
Irregular Bones:
- Description: Have complicated, unique shapes that do not fit into the other categories. Their structure is typically a mix of compact and spongy bone.
- Function: Serve various specialized roles, including protection, support, and providing attachment points for muscles.
- Examples: Vertebrae (spinal bones), Pelvic Bones (hip bones, e.g., ilium, ischium, pubis), Facial Bones (e.g., sphenoid, ethmoid).
Sesamoid Bones:
- Description: Small, round, or oval bones that are embedded within tendons, often found at joints. They vary in number among individuals.
- Function: Act to protect tendons from excessive wear and tear, and can alter the angle of muscle pull, increasing the mechanical advantage of the muscle.
- Examples: Patella (kneecap) - the largest sesamoid bone. Small sesamoid bones are often found in the tendons of the thumb and big toe.

Gross Anatomy of a Long Bone

Long bones, like the femur or humerus, are exemplary for studying bone anatomy due to their distinct and easily identifiable regions.

Diaphysis (Shaft):
- Description: This is the main, elongated cylindrical shaft of a long bone. It forms the long axis of the bone.
- Composition: Primarily composed of a thick collar of compact bone that surrounds the medullary cavity.
- Function: Provides strength and structural support, withstands stresses along the longitudinal axis of the bone.
Epiphyses (Bone Ends):
- Description: These are the expanded, knob-like ends of a long bone, located at both proximal and distal extremities.
- Composition: The exterior consists of a thin layer of compact bone, while the interior is filled with spongy (cancellous) bone.
- Function: Articulate with other bones to form joints; provide an increased surface area for joint stability and muscle attachment.
Metaphyses (Growth Plate Region in growing bone):
- Description: This is the region where the diaphysis joins the epiphysis. In a growing bone, this area contains the epiphyseal plate (growth plate), a layer of hyaline cartilage where longitudinal bone growth occurs.
- Composition: Primarily cartilage in growing bones; in adults, after growth has stopped, the epiphyseal plate ossifies and becomes the epiphyseal line, a remnant of the growth plate.
- Function: Site of longitudinal bone growth during childhood and adolescence.
Articular Cartilage:
- Description: A thin layer of hyaline cartilage that covers the articular (joint) surfaces of the epiphyses.
- Composition: Hyaline cartilage, a smooth, slippery tissue.
- Function: Reduces friction and absorbs shock at movable joints, allowing for smooth movement between bones. It lacks a perichondrium and is avascular (receives nutrients from synovial fluid).
Periosteum:
- Description: A tough, fibrous membrane that covers the outer surface of the entire bone, except where articular cartilage is present. It is richly supplied with blood vessels, lymphatic vessels, and nerves.
- Composition:
  - Outer fibrous layer: Dense irregular connective tissue, providing protection and attachment for tendons and ligaments.
  - Inner osteogenic layer: Contains osteoprogenitor cells (bone stem cells), osteoblasts (bone-forming cells), and osteoclasts (bone-resorbing cells).
- Function: Protects the bone. Serves as an attachment point for tendons and ligaments. Plays a crucial role in bone growth in width (appositional growth) and in bone repair. Contains nerve fibers, which makes bone pain very acute.
Endosteum:
- Description: A delicate connective tissue membrane that lines the inner surfaces of the medullary cavity, covering the trabeculae of spongy bone and lining the canals that pass through compact bone.
- Composition: Contains osteoprogenitor cells, osteoblasts, and osteoclasts.
- Function: Involved in bone growth, repair, and remodeling.
Medullary Cavity (Marrow Cavity):
- Description: The hollow central cavity within the diaphysis of long bones.
- Composition: In adults, it contains yellow bone marrow, which is primarily adipose (fat) tissue, serving as an energy reserve. In infants and children, and in some adult bones (like the sternum and hip bones), it contains red bone marrow, which is the primary site of hematopoiesis (blood cell formation).
- Function: Stores bone marrow.

Compact (Cortical) Bone and Spongy (Cancellous/Trabecular) Bone

All bones are made of both compact and spongy bone, but their relative proportions and arrangements differ depending on the bone's shape and function.

Feature	Compact Bone	Spongy Bone
Appearance	Dense, solid, smooth	Porous, network-like, trabecular
Structural Unit	Osteon (Haversian System)	Trabeculae (no osteons)
Location	Outer layer of all bones; diaphysis of long bones	Interior of bones; epiphyses of long bones
Marrow	Medullary cavity (in diaphysis)	Spaces between trabeculae
Weight	Heavier	Lighter
Function	Strength, protection, withstands stress	Lightness, marrow storage, stress distribution

Microscopic Anatomy of Compact Bone

The microscopic structure of compact bone is highly organized around its fundamental unit: the osteon.

Osteon (Haversian System): The primary structural and functional unit of compact bone. It is an elongated cylinder oriented parallel to the long axis of the bone, acting like a tiny weight-bearing pillar.
Central Canal (Haversian Canal): Runs through the core of each osteon. Contains blood vessels (arterioles and venules), nerve fibers, and lymphatic vessels that supply nutrients to and remove waste from the bone cells.
Lamellae: Concentric rings (like growth rings on a tree trunk) of bone matrix that surround the central canal.
- Concentric Lamellae: Form the main bulk of the osteon.
- Interstitial Lamellae: Found between intact osteons.
- Circumferential Lamellae: Extend around the entire circumference of the diaphysis.
Lacunae: Small, hollow spaces or cavities located at the junctions between the lamellae. Each lacuna houses a single mature bone cell called an osteocyte.
Canaliculi: Tiny, hair-like canals that radiate out from the lacunae, connecting them to each other and to the central canal. They allow osteocytes to communicate and facilitate transport of nutrients.
Osteocytes: Mature bone cells, derived from osteoblasts, that reside in the lacunae. They maintain the bone matrix and act as stress sensors.
Osteoblasts: Bone-forming cells found on the surface of bone tissue. They synthesize and secrete the organic components of the bone matrix (osteoid).
Osteoclasts: Large, multinucleated cells found on bone surfaces. They resorb (break down) bone matrix by secreting acids and enzymes.

Organic and Inorganic Components of Bone Matrix

1. Organic Components (Approx. 35% of bone mass):

Primary Substance: Osteoid – the unmineralized organic part of the matrix.
Composition:
- Collagen fibers (Type I): Provide flexibility and tensile strength (resist stretching).
- Ground substance: A gel-like material contributing to resilience.
Contribution to Bone Properties: Flexibility and Tensile Strength.

2. Inorganic Components (Approx. 65% of bone mass):

Primary Substance: Mineral salts, primarily calcium phosphates.
Composition:
- Hydroxyapatite: Calcium phosphate crystals that are extremely hard and dense.
- Other mineral salts: Calcium carbonate, magnesium phosphate, etc.
Contribution to Bone Properties: Hardness and Compressional Strength (resist squeezing).

Analogy for Bone Structure:
Think of reinforced concrete:
- The steel rebar provides the tensile strength and flexibility (like collagen fibers).
- The concrete provides the compressional strength and hardness (like hydroxyapatite crystals).

Intramembranous and Endochondral Ossification

Ossification (osteogenesis) is the process of bone tissue formation.

Feature	Intramembranous Ossification	Endochondral Ossification
Initial Structure	Fibrous connective tissue membrane	Hyaline cartilage model
Bones Formed	Flat bones of skull, mandible, clavicles	Most other bones (long, short, irregular bones)
Mechanism	Bone forms directly from mesenchymal tissue	Cartilage model is replaced by bone tissue
Growth Plates	Not directly involved	Involves epiphyseal plates for longitudinal growth

Process of Bone Remodeling

Bone remodeling is a lifelong process involving bone resorption (removal) and bone formation. It occurs in packets called basic multicellular units (BMUs).

Resorption Phase (Osteoclast Activity): Osteoclasts migrate to the bone surface, create a sealed compartment, and secrete lysosomal enzymes and hydrochloric acid to dissolve the bone matrix.
Reversal Phase: Osteoclasts undergo apoptosis or detach. Macrophages clean up debris.
Formation Phase (Osteoblast Activity): Osteoblasts arrive, secrete osteoid, and mineralization occurs. Osteoblasts become trapped and differentiate into osteocytes.

Key Hormones Involved in Calcium Homeostasis

Hormone	Source	Stimulus for Release	Effect on Bone	Overall Effect on Blood Calcium
PTH	Parathyroid Glands	Low blood Ca²⁺	Stimulates osteoclast activity	Increases
Calcitonin	Thyroid Gland (C cells)	High blood Ca²⁺	Inhibits osteoclast activity	Decreases

Stages of Bone Fracture Repair

Hematoma Formation (Immediate - Days 1-5): Blood vessels rupture, forming a clot (hematoma). Inflammation initiates.
Fibrocartilaginous Callus Formation (Days 3-21): New capillaries grow. Fibroblasts and chondroblasts create a soft callus of collagen and cartilage to bridge bone ends.
Bony Callus Formation (Weeks 3-4): Osteoblasts convert the soft callus into a hard, bony callus (spongy bone).
Bone Remodeling (Months to Years): Excess material is removed by osteoclasts. Compact bone is laid down to restore the original shape and strength.

3. JOINTS (ARTICULATIONS)

Joints are the sites where two or more bones meet. They bind bones together and allow mobility.

Structural Classification

1. Fibrous Joints:

Bones joined by dense fibrous connective tissue. No joint cavity.
Most are immovable (synarthrotic).
Subtypes: Sutures (skull), Syndesmoses (tibia/fibula), Gomphoses (teeth).

2. Cartilaginous Joints:

Bones united by cartilage. No joint cavity.
Allow limited movement (amphiarthrotic) or are immovable.
Subtypes: Synchondroses (epiphyseal plates), Symphyses (pubic symphysis).

3. Synovial Joints:

Bones separated by a fluid-filled joint cavity.
All are freely movable (diarthrotic).
Examples: Shoulder, elbow, hip, knee.

Features of a Synovial Joint

Articular Cartilage: Hyaline cartilage covers bone ends. Reduces friction, absorbs shock.
Joint (Synovial) Cavity: Potential space filled with synovial fluid.
Articular Capsule: Double-layered (Outer fibrous layer, Inner synovial membrane).
Synovial Fluid: Viscous fluid for lubrication, nutrient distribution, and shock absorption.
Reinforcing Ligaments: Connect bone to bone, providing stability.
Nerves and Blood Vessels: Detect pain/position and supply nutrients.

Additional Structures: Articular Discs (Menisci), Bursae, and Tendon Sheaths.

Types of Movements Allowed by Synovial Joints

Gliding (Translational): Flat surfaces slip over one another (e.g., wrist bones).
Angular: Flexion, Extension, Hyperextension, Abduction, Adduction, Circumduction.
Rotation: Turning of a bone around its own long axis.
Special Movements: Supination/Pronation, Dorsiflexion/Plantar Flexion, Inversion/Eversion, Protraction/Retraction, Elevation/Depression, Opposition.

Major Types of Synovial Joints

Joint Type	Articulating Surfaces	Movement Type	Axes	Examples
Plane	Flat/slightly curved	Gliding	Nonaxial	Intercarpal, vertebral facets
Hinge	Cylinder in trough	Flexion/Extension	Uniaxial	Elbow, knee, fingers
Pivot	Rounded in ring	Rotation	Uniaxial	Proximal radioulnar, atlantoaxial
Condylar	Oval condyle in depression	Flexion/Ext, Abd/Add	Biaxial	Wrist, knuckles
Saddle	Saddle-shaped	Flexion/Ext, Abd/Add	Biaxial	Carpometacarpal of thumb
Ball-and-Socket	Spherical head in cup	Universal movement	Multiaxial	Shoulder, hip

Main Joint Disorders and Diseases

Arthritis:
- Osteoarthritis (OA): Wear-and-tear, degenerative. Breakdown of articular cartilage.
- Rheumatoid Arthritis (RA): Autoimmune. Immune system attacks synovial membranes.
- Gouty Arthritis (Gout): Uric acid crystals deposit in joints.
Bursitis: Inflammation of a bursa.
Tendonitis: Inflammation of a tendon.
Sprains: Ligaments stretched or torn.
Dislocations: Bones forced out of alignment.

DISEASES AFFECTING SKELETAL MUSCLES

1. Muscular Dystrophies

Description: Genetic diseases characterized by progressive weakness and degeneration of skeletal muscles due to lack of specific proteins (like dystrophin).
Types:
- Duchenne (DMD): Severe, early onset, primarily affects males.
- Becker (BMD): Milder, later onset.

2. Myasthenia Gravis

Description: Autoimmune disease characterized by fluctuating muscle weakness and fatigue.
Pathophysiology: Antibodies attack acetylcholine receptors at the NMJ.
Symptoms: Drooping eyelids, double vision, difficulty swallowing.

3. Fibromyalgia

Description: Chronic disorder characterized by widespread musculoskeletal pain, fatigue, and sleep issues.

4. Muscle Spasms/Cramps

Causes: Dehydration, electrolyte imbalance, fatigue, nerve compression.

5. Strains (Pulled Muscles)

Definition: Injury to a muscle or tendon (overstretched or torn).
Grading: Mild, Moderate, Severe (rupture).

6. Rhabdomyolysis

Description: Rapid breakdown of damaged skeletal muscle tissue releasing myoglobin into the bloodstream.
Clinical Implication: Myoglobin is toxic to kidneys, leading to acute kidney injury.

7. Compartment Syndrome

Description: Painful condition caused by pressure buildup within a confined muscle compartment.
Intervention: Fasciotomy (surgical emergency) to relieve pressure.

DISEASES AFFECTING SKELETAL MUSCLES

MYASTHENIA GRAVIS

This is another autoimmune disease predominantly affecting females. There is un usual fatigue due to lack of acetylcholine receptor at the myoneural junctions which impair muscle contraction.

Signs and symptoms

The onset is gradual.
Excessive fatigue particularly towards end of the day with drooping of eye lids
Frequent falls
Difficult in chewing and swallowing
Involvement of respiratory muscles may lead to respiratory failure
A weak cough reflex may lead to accumulation of secretions and infections

Treatment and management

Short acting anticholine esterase drugs like edrophonium
Long acting ant cholinesterase drugs e.g. neostigmine or pyrisostigmine
Thymectomy and steroids also provide relief.
Exercises

MYOSITIS (MYOPATHY)

Myositis or myopathy refers to a group of primary diseases of muscles; Myositis (inflammation of muscles) can be genetically diseases.

Progressive muscular atrophy is a group of hereditary disorder characterized by progressive delegation of muscles without involvement of bones.

The wasting and weakness of muscles is symmetrically without any sensory loss. The affected muscles are large, firm but weak.

The child walks with a waddling giant like that of the duck

When rising from a supine lying position, in bed, the child rolls on his face (prone position) and then uses his arms to push his body up (tripod sign). Death in second decade is usual due to involvement of respiratory muscles.

Fibrositis – rheumatism (fibrocystic)

Fibrositis and muscular Rheumatism are terms used to describe recurring pains, stiffness in the muscles or the back, various parts of the body being involved from time to time.

The disease does not progress and such vague symptoms are attributable to emotional stress.

Treatment

Is usually symptomatic, heat and massages may be helpful and aspirin or one of the NSAIDS can be prescribed.

Anatomy and Physiology of the Musculo-skeletal System Read More »