MINOR DISORDERS OF PREGNANCY

These are referred to as minor because they are not life threatening.
The causes can be;-

• Hormonal changes
• Accommodation changes
• Metabolic changes and
• Postural changes

DIGESTIVE SYSTEM

Nausea and vomiting (morning sickness)

This is due to hormonal changes progesterone and Oestrogen and high level of HCG, it occurs from 4-16 weeks. This decreases when the placenta fully takes over.
Management
-Light snacks
-Carbohydratesnack like cassava, a hard crackers
-Avoid sweet things
-Coming out of the bed slowly.

Heart burn

Burning sensation in the media sternal region progesterone relaxes the cardiac sphincter and allows reflux of gastric contents into esophagus most troublesome between 30-40 weeks, because of pressure on stomach from growing uterus.
Management
-Avoid bending
-Small frequent meals
-Sleeping with more pillows
-Persistent heart burn antiacids like magnesium triscilicate.

Excessive salivation (ptyalism)

From 8 weeks, hormones are thought to be the cause. It may accompany heart burn. Counseling is helpful.

Constipation

Progesterone cause relaxation of the plain muscles and decreased peristalsis of the gut.
Management
-Increased intake of water, fresh fruit, vegetables and whole meal foods in diet.
-Glass of warm water in the morning, before tea and breakfast may activate the gut.
– Exercise can be helpful especially walking.
Aperients are only considered as a last resort.

Pica

This is when a mother craves for certain foods or unnatural substances.
The cause is unknown but hormones and changes in metabolism are attributed to it.

MUSCULO SKELETAL SYSTEM

This can be due to hormones Relaxin. Discuss with woman and let her be aware, it will disappear after delivery.

Leg cramps

Cause of leg cramp in pregnancy is unknown may be due to ischemia or a result from changes in PH or electrolyte status.
Management
-Mother to dorsiflex the foot and raise foot of bed.
-Gentle leg movement before sleeping at night.
-Others-use of vit B complements and calcium.

Backache

The weight of the pregnant uterus and altered posture increase susceptibility which is exacerbated by progesterone and Relaxin causing relaxation and softening of ligaments of the pelvis.
Management
-Avoid high heeled shoes.
-Sit on a comfortable chair or support the back on a wall while seated.
-Have extra rest during the day.

CIRCULATORY SYSTEM

Fainting

In early pregnancy, it may occur due to vasodilation under the influence of progesterone before there has been a compensatory increase in the blood volume.
Management
-Avoid long standing periods.
-Quickly sit or lie down if feels slightly faint,
-Mother should avoid lying on her back except during abdominal examination.

Vericose veins

-Progesterone relaxes smooth muscles of veins and results in sluggish circulation. Varicose veins may occur in legs, anus and vulva.
Management
During pregnancy
-Support tights increase comfort eg stockings.
-Avoid constipation.
-A sanitary pad may give support.
-Use a crepe bandage on affected leg from below upwards before getting out of bed in the
morning and remove it at night.
-The affected leg should be elevated when resting.
-Advise mother to see the doctor if varicose veins appear on the vulva.
-In case of severity, book mother for hospital delivery since they can easily rapture and cause severe bleeding.
During labour
-Inform doctor.
-Take off blood for Hb, grouping and x-matching.
-Be careful when shaving the vulva and when performing an episiotomy.
-Sedatives are given to prevent premature pushing.

Hemorrhoids

These are veins of the vulva or rectum and they usually occur due to constipation. They can be painful, edematous and ulcerative.
Management
-Advise mother on diet to avoid constipation.
-Use cold compress gently on the area.
-Doctor may order analgesic like anusol.

Heart palpitations

This occurs due to increased functioning of the heart to meet the demands of the growing fetus and mother.

NERVOUS SYSTEM

Carpal tunnel syndrome

The mother complains of numbness, pins and needles in her fingers and hands.
It’s caused by fluid retention which causes oedema and pressure on the median nerve by compressing it.
Management
-Wearing a splint at night and rising hands on a pillow at night.
-If it persists, refer to doctor who will give diuretics.

Insomnia

This is failure to get sleep and may be caused by worries, anxiety and it shouldn’t be taken lightly.
Emotional instability
Hating, irritation, loving i.e. willing to stay closer to partner.

GENITAL URINARY SYSTEM

Leucorrhoea

This is increased, non- irritant, vaginal discharge.
Management
-Ensure hygiene if distressing.
-Wear cotton under pants for easy absorption.

Frequency of micturition

This occurs in early pregnancy when the growing fetus is still in the pelvic cavity and late pregnancy when the PP descends and competes for space needed by bladder.

INTEGUMENTARY SYSTEM

Itching of the skin

This can be due to Striae gravidurum, poor hygiene, heat rash and minor skin rashes.
Management
-Wear cotton clothes which are non-irritating.
-Advise on personal hygiene.
-Apply calamine lotion in case of skin rash.

Disorders which require immediate action

• Vaginal bleeding.
• Reduced fetal movements.
• Frontal or recurrent headache.
• Sudden swelling or oedema.
• Early rapture of membranes.
• Premature onset of contractions
• Maternal exhaustion at whatever extent.
• Fits.
• Excessive nausea and vomiting.
• Epigastric pain.

PHYSIOLOGY OF PREGNANCY

These are normal natural changes that occur in the body due to pregnancy. These result mainly from alteration of hormones and metabolism.

CHANGES IN THE ENDOCRINE SYSTEM

1. Hormonal changes:
   The placenta produces several hormones which cause a number of physiological changes.
   Successful physiological adaptation of pregnancy is due to alterations in hormone production by the maternal endocrine system and the trophoblast.
2.  Human chorionic gonadotrophic hormone.
   It is produced by the trophoblast. H.C.G levels increase rapidly in early pregnancy, maximum levels being attained at 8-10 weeks of gestation. The main function of HCG is to maintain the
   corpus luteum in order to ensure secretion of progesterone and Oestrogen until placental production is adequate after 10-12 weeks after which concentration of HCG gradually decreases until it has completely disappeared 2 weeks after birth.
3.  Progesterone hormone;
   This is produced mainly in the corpus luteum. Its function is to thicken the decidua in order to receive a fertilized ovum. It helps to increase the glandular tissue, ducts of the breasts and muscle
   fibres of the uterus.
4.  Oestrogen;
   It causes growth of the uterus and duct system of the breasts in pregnancy. It is excreted in urine and amount present indicates fetal wellbeing.
5.  Relaxin hormone;
   During the last weeks of pregnancy, it acts on ligaments and joints producing the “give” of the pelvis. It is also produced by decidua and the trophoblast to promote myometrium relaxation and
   may play a role in cervical ripening and rapture of membranes.
6. HPL ( human placental lactogen): It stimulates the growth of breasts and has lactogenic properties that affect a number of metabolic changes. These changes brought about by HPL ensure that glucose is readily available for body and brain growth in the developing fetus, and protects against nutritional deficiencies.
7. Pituitary hormones: The follicle stimulating hormone and L.H are suppressed by the high levels of Oestrogen and progesterone. The adrenal gland increases only slightly in size during pregnancy due to hypertrophy and widening in glucocorticoid area which suggests increased secretion of hormones.
8. Thyroid function: In normal pregnancy, the thyroid gland increases due to hyperplasia of glandular tissue and increased vascularity. There is normally an increased uptake of iodine during pregnancy which may be to compensate for renal clearance of iodine leading to reduced level of plasma iodine.

Changes in the cardiovascular system

The heart
Due to increased work load, the heart hypertrophies particularly in the left ventricle. The uterus pushes the heart upwards and to the left. Heart sounds are changed and murmurs are common.
The cardiac output is increased by 40%. The heart rate increases by an average of 15 beats per minute. The stroke volume increases from 64 to about 71mls.

Effect on blood pressure
During the first trimester, blood pressure remains almost constant. BP drops in 2 nd trimester due to hormone progesterone which causes vasodilation. It reaches its lowest level at 16-20 weeks and towards term, it returns to the level of the first trimester. The decrease may lead to fainting.
Supine position should be avoided in pregnancy as it leads to supine hypotensive syndrome due to compression of the inferior venacava thus reducing venous return. Poor venous return in late pregnancy may lead to oedema in lower limbs, varicose veins and hemorrhoids.

Blood flow
Blood flow increases to uterus, kidneys, breasts and skin but not to liver and brain. Utero placental blood flow increases by 10-15% about 75mls per minute at term. Renal blood flow increases by 70-80%.

Blood volume
Increase in blood volume varies according to the size of the woman, number of pregnancies she has had, parity and whether the pregnancy is singleton or multiple.
The total blood volume increases steadily from early pregnancy to reach a maximum of 35 to 45% above the non- pregnant level. A higher circulating volume is required for the following;
-To provide extra blood flow for placental circulation.
-To supply the extra metabolic needs of the fetus.
-To provide extra perfusion of kidneys and other organs.
-To compensate for blood loss at delivery.
-To counterbalance the effects of increased venous and arterial capacity.

Plasma volume
Increases by 40% where the red cell mass decreases by 20%leading to haemodilution (physiological anaemia). These changes begin at 6-8weeks of pregnancy. The acceptable Hb level in pregnancy is 11-12g/dl.

Iron metabolism
Iron of about 1000g is needed. 500g is to increase the red cell mass, 300g to fetus and 200g for daily iron compensation. In normal pregnancy, only 20% of ingested iron is absorbed. The purpose of iron supplementation is to prevent iron deficiency anaemia not to raise Hb level.

Plasma protein
During the 1st 20 weeks of pregnancy, plasma protein concentration reduces due to increased plasma volume. This leads to lowered osmotic pressure leading to oedema of lower limbs seen in late pregnancy. In absence of disease, moderate oedema is termed as physiological oedema.

Clotting factors
Fibrinogen 7,8,9 and 10 increase leading to a change in coagulation time from 12 to 8 minutes.
The capacity of clotting is increased in preparation to prevent PPH after separation of the placenta.

White blood cells.
These are slightly increased during pregnancy, from 700mm to 10500mm during pregnancy and up to 1600mm during labour. The total count cells rises from 8 weeks and reaches a peak at 30 weeks of gestation. This is mainly because of the increase in the number of neutrophils, polymorphs, nucleus, leucocytes, monocytes and granulocytes are active and efficient phagocytes.

Erythrocytes.
They decrease during pregnancy from 4.5million to 3.7million.

HB.
HB concentration falls from 14g/dl; a falling HB is a physiological. The total iron requirements of pregnancy where as a high HB level can be assign of pathology. The total requirements of
pregnancy is averagely 1000g ,about 500gare required to increase the red cells mass and about 300g are transported to the fetus mainly in the last weeks of pregnancy . The remaining 200g are needed to compensate for insensible loss in skin, stool and urine.

RESPIRATORY SYSTEM.

The basal metabolism rate is increased and the volume of air which enters and leaves the lungs during the normal respiration becomes slightly increased. This is because of increased oxygen consumption by the fetus and the work of maternal heart and lungs.
In the late pregnancy the ribs flare out inhibiting the capacity of the thoracic cavity to expand, the enlarging uterus elevates the diaphragm up wards and compresses the lower lobes of the lungs

CHANGES IN THE URINARY SYSTEM

Renal blood flow and glomerular filtration rate increases by 50%.
There is frequency of micturition in early and late pregnancy. Ureters become elongated and kinked due to progesterone hormone and this results into urine stagnation hence increased favor to UTI in pregnancy.

CHANGES IN THE GIT

-The gums become edematous, soft and spongy and may bleed.
-Increased salivation(ptyalism) is common.
-Nausea and vomiting is common in 70% of the cases.
-Changes in taste becoming metallic.
-Craving for abnormal things like soil or plaster known as pica.
-Increased appetite in most women.
-Heart burn due to of stomach content from decreased space by growing uterus.
-There is reduced GIT motility leading to constipation.

Changes in metabolism
– There is increased metabolism to provide nutrients for the mother and fetus.
-Maternal weight, There is continuing weight increase in pregnancy which is an indication of fetal growth.

Weight gain in pregnancy is as follows;-
4kg in the 1 st 20 weeks(0.2kg/week)
8.5kg in the last 20 weeks(0.4kg/week)
12.5kg approximate total.

The following factors influence weight gain during pregnancy:

1. Maternal oedema: Edema, or swelling, can affect weight gain as it involves the accumulation of excess fluid in the tissues of the body.

2. Maternal metabolic rate: The metabolic rate of the mother can impact weight gain. A higher metabolic rate may result in increased energy expenditure and potentially lower weight gain.

3. Dietary intake: The quantity and quality of the mother\’s dietary intake play a significant role in weight gain during pregnancy. Consuming a balanced and nutritious diet supports healthy weight gain.

4. Vomiting or diarrhea: Frequent vomiting or diarrhea can lead to weight loss or inadequate weight gain during pregnancy. These conditions can affect nutrient absorption and overall caloric intake.

5. Amount of amniotic fluid: The volume of amniotic fluid surrounding the fetus can contribute to weight gain. An increased amount of amniotic fluid may contribute to higher weight gain.

6. Size of the fetus: The size and growth rate of the fetus can impact maternal weight gain. A larger fetus may result in increased weight gain during pregnancy.

7. Maternal physical activity level: The level of physical activity and exercise undertaken by the mother can influence weight gain. Regular physical activity can help maintain a healthy weight during pregnancy.

8. Maternal genetics: Genetic factors can influence an individual\’s predisposition to weight gain or weight retention during pregnancy.

CHANGES IN THE MUSCULO-SKELETAL SYSTEM

Progesterone and Relaxin lead to relaxation of pelvic ligaments, joints and muscles. The relaxation allows the pelvis to increase its capacity in readiness to accommodate the presenting part towards term and also during labour. The symphysis pubis and sacroiliac joints soften, the gait of the mother changes as the balance of the body is altered by the weight of the uterus. Allowing the pelvis to increase its capacity towards term is a process known as a give.

SKIN CHANGES

Increased activity of melanin-stimulating hormone from the pituitary causes varying degrees of pigmentation in pregnant women from the end of 2 nd month until term.The areas that are commonly affected are; areolar of the breasts, abdominal mid line, perineum and axilla. This is because of increased sensitivity of the melanocytes to the hormone or because of greater number of melanocytes in these areas.

• -Linea nigra. This is a dark line that runs from the umbilicus to the symphysis pubis and may extend as high as the sternum. It is hormone induced pigmentation. After delivery, the line begins to fade though it may not ever completely disappear.
• -Mask of pregnancy(Cloasma). This is the brownish hyper pigmentation of the skin over the face, fore head, nose, cheeks and neck. It gives a bronze look especially in black complexioned women.
• -Striae gravidurum(stretch marks).
• -Sweat glands. Activity of the sweat glands usually increases throughout the body which causes the woman to perspire more profusely during pregnancy.
• – A rise in body temperature of 0.5 and increase in blood supply causes vasodilation and makes woman feel hotter.

NORMAL PREGNANCY

Normal Pregnancy refers to growth and development of a fertilized ovum and begins from when the ovum is fertilized until the fetus is expelled from the uterus.

Normally the fetus is expelled at term or 9 months or 40 weeks or 280 days.
If the fetus is expelled before 28 weeks, it is called an abortion and if fetus is expelled after 28 weeks but before 37weeks it’s called premature labour and if born after 42 weeks, the post- mature is used.

Pregnancy is said to be normal when;

• The fertilized ovum is growing in the cavity of the uterus.
•  One fetus is forming, one placenta and two membranes.
•  There is about 1000-1500ml of liquor amnii.
•  There is vertex presentation.
•  There is no bleeding until show in first stage of labour.
•  The mother should remain healthy with no serious disorders of pregnancy.

SIGNS AND SYMPTOMS OF PREGNANCY

When a woman misses one or two menstrual periods, she may begin to suspect that she is pregnant, and in most cases, her intuition is correct with an accuracy of about 98%, especially if she has been experiencing regular menstruation.

The signs of pregnancy can be classified into three groups:

1. Presumptive
2. Probable
3. Positive.

Presumptive signs:

1. Amenorrhea: This refers to the absence of menstruation. A woman may report missing one or two periods, which can be a strong indicator of pregnancy. However, amenorrhea can also be caused by factors such as contraceptive use, changes in environment, prolonged illness, or emotional disturbances.

2. Breast changes: Many women experience tingling and prickling sensations, as well as breast enlargement and tenderness. These changes are commonly associated with pregnancy.

3. Morning sickness (nausea and vomiting): Approximately 30-50% of pregnant women experience morning sickness, which typically occurs between the 4th and 14th weeks of pregnancy. While other conditions can also cause nausea and vomiting, the combination of these symptoms with amenorrhea strongly suggests pregnancy. Morning sickness often subsides by the end of the first trimester.

4. Increased frequency of urination: The growing uterus puts pressure on the bladder, leading to more frequent trips to the bathroom. This symptom is usually experienced before 12 weeks of pregnancy and tends to decrease once the uterus rises out of the pelvis at around 12 weeks.

5. Skin changes:

   • Striae gravidarum: These stretch marks appear around the 16th week of pregnancy on the abdomen, thighs, and breasts.
   • Chloasma (mask of pregnancy): Some women develop patches of darkened skin on the face.
   • Linea nigra: A dark line may darken and appear both above and below the umbilicus.
   • Darkening of areolas: The primary areolas become darker, and secondary areolas may form. The hormone responsible for these pigmentation changes is called melanin hormone and is produced by the anterior pituitary gland.

6. Quickening: This refers to the first fetal movements felt by the mother, usually occurring around 18-20 weeks of pregnancy for primigravida (first-time pregnancies) and 16-18 weeks for multigravida (women who have been pregnant before). Quickening can assist a midwife or healthcare provider in estimating the gestational age of a mother who is unsure of her dates.

7. Fatigue: Pregnant women often experience fatigue due to increased blood production, lower blood sugar levels, and decreased blood pressure influenced by progesterone. Sleep disturbances and nausea can also contribute to feelings of tiredness.

8. Mood changes: Physical stress, metabolic changes, fatigue, and hormonal fluctuations, particularly progesterone and estrogen, can lead to mood swings in pregnant women.

Probable signs:

1. Hagar\’s sign: This sign can be detected between the 6th and 12th week of pregnancy. It involves performing a vaginal examination where two fingers are inserted into the anterior fornix of the vagina while the other hand presses the uterus abdominally. When the fingers from both hands meet, a softening of the isthmus can be felt, indicating pregnancy.

2. Jacquemier\’s sign: This sign refers to the bluish discoloration of the vaginal walls, which becomes noticeable from the 8th week onwards. It is caused by pelvic congestion, a common indication of pregnancy.

3. Osiander\’s sign: Increased pulsation felt on the lateral vaginal fornices is known as Osiander\’s sign. This sign can be detected from the 8th week onwards and is a result of increased vascularity in the area.

4. Softening of the cervix (Goodell\’s sign): Starting from the 8th week of pregnancy, the cervix of a pregnant woman becomes noticeably softer. It can be compared to the texture of the lower lip, whereas in a non-pregnant state, it is as firm as the tip of the nose.

5. Uterine soufflé: This refers to a soft blowing sound heard on auscultation of the abdomen. It typically occurs from the 16th week of pregnancy due to increased vascularity in the uterus.

6. Abdominal enlargement: The uterus undergoes rapid and progressive enlargement from the 16th week onwards. This enlargement can be observed and felt during abdominal palpation, helping to differentiate it from other causes such as gaseous distension, a full bladder, fibroids, or ascites.

7. Braxton Hicks contractions: These are painless contractions that usually begin from the 16th week of pregnancy. They can be felt during abdominal palpation and occur approximately every 15 minutes.

8. Internal ballottement: This technique involves giving the uterus a sharp tap just above the cervix, causing the fetus to float upward in the amniotic fluid. When the fetus sinks back down, the movement can be felt by fixed fingers within the vagina. Internal ballottement can be detected between the 16th and 28th weeks of pregnancy.

9. Presence of hCG (Human chorionic gonadotropin): The hormone hCG can be detected in the blood as early as 9 days after conception and in urine approximately 14 days after conception. The presence of hCG is a reliable indicator of pregnancy and can also be detected in conditions like hydatidiform mole.

Positive signs:

Positive signs are those that definitively confirm the presence of pregnancy. These signs include:

1. Fetal heart sounds: The fetal heart begins beating around the 24th week after conception. It can be heard using a Doppler device as early as 10 weeks and with a fetoscope by 24 weeks. It is important to distinguish the fetal heart sounds from the uterine soufflé caused by pulsating maternal arteries. The normal fetal heart rate ranges between 120 and 160 beats per minute.

2. Ultrasound scanning of the fetus: Using ultrasound technology, the gestation sac can be visualized and photographed. As early as the 4th week, an embryo can be identified, and by the 10th week of gestation, fetal body parts begin to appear on the ultrasound images.

3. Palpation of the entire fetus: A trained examiner can palpate and feel the various parts of the fetus, including the head, back, and upper and lower body parts. This allows for a comprehensive assessment of the baby\’s position and size.

4. Palpation of fetal movement: Skilled healthcare providers can feel and detect fetal movements through palpation after the 24th week of gestation. This involves perceiving the baby\’s kicks, rolls, and other movements by gently applying pressure on the mother\’s abdomen.

5. X-ray: While an X-ray can identify the complete fetal skeleton as early as the 12th week, it is not a recommended method for confirming pregnancy due to the potential risks associated with radiation exposure. Total body radiation from X-rays in utero can have harmful effects on the developing fetus, leading to genetic or gonadal alterations. Therefore, other non-invasive methods, such as ultrasound, are preferred for assessing pregnancy.

6. Actual delivery of the baby: The ultimate confirmation of pregnancy occurs when the woman delivers the baby. The delivery of a live newborn is the conclusive evidence of pregnancy.

Differential Diagnosis:

Abdominal enlargement can be caused by conditions other than pregnancy, and it is important to consider these possibilities. Some of the potential differential diagnoses include:

1. Ovarian cysts: Enlargement of the abdomen can occur due to the presence of ovarian cysts. When palpated, the swelling caused by ovarian cysts can be distinguished from the uterus, and pregnancy tests will yield negative results.

2. Fibroids: Fibroids are noncancerous growths that can develop in the uterus. They can sometimes be mistaken for pregnancy, as they can cause a hard mass to be felt in the abdomen. However, pregnancy tests will be negative in the case of fibroids.

3. Distended urinary bladder: Abdominal enlargement can also result from a distended urinary bladder due to urine retention. In such cases, a catheter can be inserted to relieve the urine retention, and there will be no other signs indicating pregnancy.

4. Pseudocyesis: Pseudocyesis, also known as false pregnancy or phantom pregnancy, is a condition in which a woman experiences symptoms that mimic pregnancy, including amenorrhea (absence of menstruation) and other signs suggestive of pregnancy. However, upon examination, the typical signs of pregnancy are absent, and pregnancy tests will be negative. Pseudocyesis often occurs in women who have a strong desire to conceive or who experience high levels of anxiety related to pregnancy.

Multiple Choice Questions:

1. Which of the following is a presumptive sign of pregnancy?
   a) Fetal heart sounds
   b) Softening of the cervix
   c) Palpation of fetal movement
   d) Morning sickness
2. Hagar\’s sign is detected by:
   a) Auscultation of fetal heart sounds
   b) Palpation of fetal movement
   c) Vaginal examination
   d) Ultrasound scanning
3. Which sign is a probable sign of pregnancy?
   a) Fetal heart sounds
   b) Ovarian cysts
   c) Presence of HCG
   d) Pseudocyesis
4. What is the normal fetal heart rate?
   a) 60-80 beats per minute
   b) 90-120 beats per minute
   c) 120-160 beats per minute
   d) 180-200 beats per minute
5. Which sign can help in determining the gestational age if the mother is unsure of her dates?
   a) Quickening
   b) Internal ballottement
   c) Jacquemier\’s sign
   d) Amenorrhea
6. Which diagnostic tool can visualize the gestation sac and fetal parts?
   a) X-ray
   b) Ultrasound scanning
   c) Fetal palpation
   d) HCG test
7. What is the most accurate method to confirm pregnancy?
   a) Palpation of fetal movement
   b) X-ray
   c) Actual delivery of the baby
   d) Ultrasonography
8. Which condition can cause abdominal enlargement and yield negative pregnancy test results?
   a) Fibroids
   b) Ovarian cysts
   c) Pseudocyesis
   d) Morning sickness
9. Osiander\’s sign is characterized by:
   a) Softening of the cervix
   b) Increased pulsation in the vaginal fornices
   c) Bluish discoloration of the vaginal walls
   d) Enlargement of the breasts
10. Which sign can be detected by both Doppler and fetoscope?
    a) Fetal heart sounds
    b) Uterine soufflé
    c) Internal ballottement
    d) Quickening
11. What differentiates fibroids from pregnancy?
    a) Positive pregnancy test results
    b) Palpable fetal movements
    c) Presence of uterine soufflé
    d) Hard mass felt on palpation
12. What is the purpose of X-ray in pregnancy?
    a) To visualize the fetal heart rate
    b) To determine the gestational age
    c) To confirm pregnancy definitively
    d) It is not recommended due to radiation risks
13. What differentiates pseudocyesis from a true pregnancy?
    a) Amenorrhea
    b) Fetal heart sounds
    c) Palpation of fetal movement
    d) Negative pregnancy test results
14. What is the primary cause of morning sickness during pregnancy?
    a) Increased blood production
    b) Hormonal changes
    c) Bladder pressure
    d) Emotional upsets
15. Which sign is considered a positive sign of pregnancy?
    a) Morning sickness
    b) Softening of the cervix
    c) Distended urinary bladder
    d) Palpation of fetal movement

Fill in the Blanks:

1. ________ is the absence of menstruation and a presumptive sign of pregnancy.
2. ________ can be detected by performing a vaginal examination and palpating the isthmus.
3. Increased pulsation in the lateral vaginal fornices is known as ________.
4. ________ is a condition in which a woman experiences symptoms resembling pregnancy, but pregnancy tests are negative.
5. Fetal heart sounds can be detected by a ________ or a fetoscope.
6. The normal fetal heart rate ranges between ________ beats per minute.
7. Ultrasound scanning can visualize the ________ and identify the fetal parts.
8. Palpation of ________ is necessary to assess the position and size of the fetus.
9. X-ray is not recommended for pregnancy confirmation due to potential ________ risks.
10. The delivery of a live newborn is the ________ evidence of pregnancy.

Multiple Choice Questions:

1. Answer: d) Morning sickness
2. Answer: c) Vaginal examination
3. Answer: b) Ovarian cysts
4. Answer: c) 120-160 beats per minute
5. Answer: b) Internal ballottement
6. Answer: b) Ultrasound scanning
7. Answer: c) Actual delivery of the baby
8. Answer: a) Fibroids
9. Answer: b) Increased pulsation in the vaginal fornices
10. Answer: a) Fetal heart sounds
11. Answer: d) Hard mass felt on palpation
12. Answer: d) It is not recommended due to radiation risks
13. Answer: d) Negative pregnancy test results
14. Answer: b) Hormonal changes
15. Answer: d) Palpation of fetal movement

Fill in the Blanks:

1. Amenorrhea is the absence of menstruation and a presumptive sign of pregnancy.
2. Hagar\’s sign can be detected by performing a vaginal examination and palpating the isthmus.
3. Increased pulsation in the lateral vaginal fornices is known as Osiander\’s sign.
4. Pseudocyesis is a condition in which a woman experiences symptoms resembling pregnancy, but pregnancy tests are negative.
5. Fetal heart sounds can be detected by a Doppler or a fetoscope.
6. The normal fetal heart rate ranges between ________ beats per minute.
7. Ultrasound scanning can visualize the gestation sac and identify the fetal parts.
8. Palpation of the entire fetus is necessary to assess the position and size of the fetus.
9. X-ray is not recommended for pregnancy confirmation due to potential radiation risks.
10. The delivery of a live newborn is the ultimate evidence of pregnancy.

Terminologies

TERMS USED IN MIDWIFERY

Midwifery: It is the profession of providing assistance and medical care to women undergoing labor and childbirth during the antenatal, prenatal, and postnatal periods.

Obstetrics: This is a branch of medicine dealing with pregnancy, labor, and the postpartum period.

Caesarian section: It is an incision made on the uterus through the anterior abdominal wall to remove products of gestation after 28 weeks of gestation.

Cephalic: Refers to the head.

Cervix: It is the neck of the uterus.

Colostrum: This is a fluid found in the breasts from the 16th week of pregnancy up to the 2nd and 3rd day after delivery.

Crowning: This is when the largest transverse diameter of the fetal skull emerges under the subpubic arch and does not recede back between contractions.

Gestation: Pregnancy or the maternal condition of having a developing fetus in the body.

Fetus: Refers to the human conceptus from the 9th week to delivery.

Viability: The capability of the fetus to live outside the womb, usually accepted between 24 and 28 weeks, although survival is rare.

Gravida: A woman who is or has been pregnant, regardless of pregnancy outcome.

Primigravida: A woman pregnant for the first time.

Multigravida: A woman who has been pregnant more than once.

Nullipara: A woman who is not currently pregnant and has never been pregnant.

Parity: The number of children born alive or dead after 28 weeks of gestation.

Vernix caseosa: A greasy substance that covers the baby\’s skin at birth.

Meconium: This is the stool of the neonate that is present in the lower bowel at 16 weeks of gestation and is passed within 3 days following birth. It is greenish-black in color.

Lightening: This refers to the descent of the baby into the pelvis, resulting in a drop in fundal height.

Show: The bloody stained mucoid discharge seen at the onset of labor.

Additional Midwifery Terms 

1. Lochia: The vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue.

2. Antenatal care: Medical care and monitoring provided to pregnant women before childbirth.

3. Postpartum: The period following childbirth, typically lasting six weeks, during which the mother\’s body undergoes physical and hormonal changes.

4. Perineum: The area between the vagina and anus in females, which may stretch or tear during childbirth.

5. Amniotic fluid: The fluid surrounding the fetus within the amniotic sac, providing protection and cushioning.

6. Placenta: A temporary organ that develops during pregnancy, providing oxygen and nutrients to the fetus and removing waste products.

7. Episiotomy: A surgical incision made in the perineum during childbirth to enlarge the vaginal opening and facilitate delivery.

8. Postpartum depression: A mood disorder characterized by feelings of sadness, anxiety, and exhaustion experienced by some women after giving birth.

9. Lactation: The production and secretion of breast milk.

10. Umbilical cord: The flexible cord connecting the fetus to the placenta, through which nutrients and oxygen are transferred.

11. Neonate: A newborn baby, typically in the first 28 days after birth.

12. Preterm birth: Delivery of a baby before completing 37 weeks of gestation.

13. Ectopic pregnancy: A pregnancy that occurs outside the uterus, usually in the fallopian tube.

14. Intrauterine growth restriction: A condition in which the fetus fails to grow at the expected rate inside the uterus.

15. Preeclampsia: A pregnancy complication characterized by high blood pressure and damage to organs, usually occurring after 20 weeks of gestation.

16. Fetal distress: A condition in which the fetus is not receiving adequate oxygen, typically detected through abnormal heart rate patterns.

17. Postpartum hemorrhage: Excessive bleeding after childbirth, often caused by the uterus not contracting properly.

18. Neonatal intensive care unit (NICU): A specialized medical unit providing care for newborns with serious health conditions or premature babies.

19. Midwifery-led care: A model of care in which midwives are the primary providers for pregnant women, providing continuity of care throughout pregnancy, labor, and postpartum.

20. Birth plan: A written document created by the pregnant woman outlining her preferences and expectations for labor, delivery, and postpartum care.

Guide to the Question Approach for Midwifery Exams

It is important for midwives preparing for the exam to be able to answer questions effectively.

This approach allows you to tackle questions in a systematic manner, ensuring that you cover all important points and provide concise and accurate answers. By following this structured approach, you will be able to effectively demonstrate your knowledge, critical thinking and analytical skills, leading to higher scores and overall success on your midwifery exams.

Whether you are facing questions that require you to EXPLAIN, OUTLINE, DESCRIBE, MENTION, IDENTIFY, STATE, LIST, WHAT and GIVE, this article is all you need!

Explaining Questions: Breaking Down Complex Concepts

When questions require explanations, it is essential to break down complex concepts into understandable parts. Start by introducing the topic  you\’re discussing and providing a concise definition if necessary. Then, proceed to explain on the key components or factors related to the topic. Use clear and simple language to ensure your explanation is easily understandable.

Example Question: Explain how you would admit a mother who has reported in active phase of first stage?

In response to this question, you can follow the question approach by giving the key points step by step:

• Reception: the mother and the relatives are welcomed; mother is taken to the admission room while the relatives are offered seats. Rapport between the mother, attendants and the midwives is created.
• History taking: if the mother has been attending ANC, her ANC record is obtained; to get the history and any risk factors like multiple pregnancies. If she has not been attending ANC, a full antenatal history is taken, which involves the mother‘s name, address, tribe, religion, husband‘s name and address, her gravida and parity, obstetrical, surgical, social, and medical history, the time and date of admission are entered in the admission forms of the mother.

Then, history of labour under the following headings is recorded:

• Show: the mother is asked if she has seen any blood and mucus, her undergarments examined for any stain, vulva examined for the drainage of show which may appear a few hours before or after beginning of labour.
• Uterine contractions: mother is asked when the regular pains began, how often and if she has backache. Her statement about the length, severity, or expulsive character of the contraction should be confirmed by observation and evaluation then
• Membranes: She is asked whether her water (amniotic fluid) have ruptured or not; if she has noticed a gush or tickling of water → the amount and time are recorded. If in doubt of whether its liquor or urine, litmus paper is dipped into the draining fluid obtained from the vulva to confirm alkalinity or
• Vaginal discharge or bleeding: the mother is also asked if she had any vaginal bleeding/ discharge which should be excluded

• General examination of the mother: her general appearance is noted, that is healthy or ill, colour, any deformities like lame, presence of oedema, infections, varicose veins or enlarged neck veins. Breast examination is carried out to identify their sustainability for breast feeding
• Observations; Vital signs are monitored like temperature, pulse, respiration and blood pressure to rule out eclampsia in She is also asked for bowel action, sleep and rest
• Abdominal Examination: first, the bladder should be empty and this is carried out with the mother lying on the couch on supine position with a pillow under her head and This examination is carried out as follows:
  • On inspection: the shape of the abdomen is noted whether round or oval, the size should be correspond with the weeks of gestation, the foetal movements, skin changes like stria gravidarum and linea nigra and any scar are
  • On palpation: this can be superficial, fundal, lateral, pelvic, height of the fundus and hypochondriac. They are carried out to note the lie whether its longitudinal, transverse, or oblique; the position of the fetus which can be ROA, LOA, ROP, LOP; and engagement plus enlargement of the spleen and the liver.

• On auscultation: the fetal heart is listened, if its heard and regular

• Vulva shave, toilet and examination: the shave is done on women whose cultures allow keeping the vulval area with pubic hair. Any abnormal discharges, oedema, or paleness are noted if present
• Vaginal examination: this is done to mothers who have no history of APH with the current pregnancy under strict asepsis. It‘s done to confirm the onset of labour, the presentation, position, engagement, station of the presenting part, to confirm whether membranes ruptured or intact, exclude cord prolapsed, assess the pelvis if adequate or inadequate and also progress of labour and it‘s the one that determines the admission of a mother on the partograph
• Investigations: routine samples are obtained for example:
  • Blood: for routine counseling and testing (RCT), rapid polymerase reaction (RPR), HBsAg, haemoglobin estimation, Grouping and cross matching → rational to confirm presence of any disease so as to prevent mother to child transmission (MTCT) and for blood transfusion (BT) in case of anaemia
  • Urine: for analysis to test for albumin, sugar, acetone that might complicate labour

• Personal hygiene: a shower is both hygienic and pleasant. If the mother‘s membrane have ruptured or in advanced first stage of labour, she is sponged down on a couch and given a clean

Admission: the mother is then admitted on a partograph, all the necessary information recorded and the continuous observation of the mother takes place accordingly

Outlining Questions: Structuring Information

When faced with outlining questions, it is important to structure your response in a logical and organized manner. Begin by providing an  the main points or components related to the topic. Use  subheadings to break down the information further, making it easier for the examiner to follow your answer.

Example Question: Outline the changes that take place in the uterus during the first stage of labour?

Before answering the proposed question above, it‘s vital to first define the following terms:

• Labour: is the process by which the foetus, placenta and the membranes are expelled out of the birth canal after 28^th weeks of gestation
• First stage of labour: is the period of dilatation of the cervix lasting from the onset of true labor till full dilatation.

During the first stage of labour the following occurs:

1. Effacement or take up of the cervix: this is made possible by the work of muscle fibres surrounding the internal OS which are drawn upward by the retracted upper segment.
2. Pacemaker / Fundal dominance: each contraction begins from the pace maker situated at the cornua of the uterus. From the fundal region it spreads downwards being stronger and persisting longer in the upper region on reaching the lower region, the wave of contraction weakens and allows the cervix to dilate.
3. Dilatation of the cervix: this is the opening of the external OS to allow the passage of the fetal head; it occurs as a result of uterine action and the pressure from fore bag of waters and the well fitting presenting part
4. Contraction and Retraction: is the special ability of the uterine muscle where the contraction does not pass off completely and the muscle fibres, retaining some of the contractions, do not become completely relaxed, instead they become gradually shorter and thicker.
5. Polarity: is the term used to define the coordination between two poles of uterus throughout labour.
6. Development of upper and lower segment: the upper uterine segment is the thicker muscular contractile part. The lower part segment is the firm distensible are of 7.5cm – 10cm in length developed from isthmus to the uterus.
7. Development of retraction ring: is the ridge formed between the upper and the lower uterine segment. It‘s present in labour and normal as long as it‘s not marked enough to be visible above the symphysis pubis. NB: It is called bandl‘s ring in obstructed labour
8. Show: is the blood stained mucoid discharge seen a few hours within or a few hours after when labour has started.
9. General fluid pressure: while the membranes remain intact, the pressure of the uterine contraction is exerted on the fluid as the fluid is not compressible the pressure is equalized throughout the uterus.
10. Rupture of membranes: rupture of membranes may be early or later during the second stage of labour due to the malpresentation and pressure from the presenting part.
11. Fetal axis pressure: this is when the force of contractions from the uterus is transmitted via the long axis of the canal; this becomes more significant after the rupture of membranes and during second stage.

Describing Questions: Providing Detailed Information

Describing questions require you to provide detailed information about a specific topic or concept. When answering these questions, you have to offer a comprehensive and thorough response, including relevant facts, characteristics, and examples. Use clear language and provide specific details to enhance the depth of your description.

Example Question: Describe the vagina.

Definition: 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;

1. 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 bearing.
2. Vascular connective tissue layer which is rich in blood vessels, nerves and lymphatics and is found just beneath the epithelium.
3. Muscular layer. This is thin but a strong layer which is divided into two; the weak inner circular and strong outer longitudinal fibres.
4. 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 i.e 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

1. Exit from menstrual flow.
2. Entrance for spermatozoa.
3. Exit for products of conception.
4. Supports the uterus.
5. Prevents ascending infection due to acidic PH.
6. For assessing the pelvis.
7. Drug administration.

Mentioning, Identifying, and Stating Questions: Being Clear and Concise

When faced with questions that require you to mention, identify, or state specific information, it is essential to be clear, concise, and accurate in your response. Avoid unnecessary elaboration and focus on providing the requested information directly.

Example Question: State the major components of a comprehensive birth plan?

To answer this question effectively, you can provide a concise statement listing the major components of a birth plan:

A comprehensive birth plan typically includes the following components:

1. Preferred birth environment (hospital, birthing center, home birth)
2. Pain management preferences (medication, natural methods, water birth)
3. Support people and their roles during labor and delivery(husband, mother)
4. Positioning preferences for labor and birth(lithotomy)
5. Preferences for fetal monitoring during labor
6. Neonatal interventions and care preferences immediately after birth
7. Feeding preferences (breastfeeding, formula feeding)
8. Cultural or religious considerations
9. Preferences for postpartum care and rooming-in with the baby
10. Contingency plans for unexpected situations or interventions

By providing a clear and concise statement of the major components, you address the question directly and effectively.

Listing and Giving Questions: Providing Comprehensive Information

When asked to list or give information, it is important to provide a  response that covers all the relevant points. Ensure that you include all necessary information without leaving out any key details.

Example Question: List and give examples of common obstetric emergencies that midwives may encounter?

In response to this question, here is a comprehensive list of common obstetric emergencies along with examples:

1. Postpartum Hemorrhage (PPH): This is excessive bleeding following childbirth. Examples include uterine atony (lack of uterine contractions), retained placenta, or trauma to the birth canal.
2. Shoulder Dystocia: It occurs when the baby\’s shoulders become stuck behind the mother\’s pubic bone during delivery. This can lead to complications such as brachial plexus injury or fetal hypoxia.
3. Umbilical Cord Prolapse: The umbilical cord slips through the cervix ahead of the baby, potentially cutting off the baby\’s oxygen supply. This requires immediate action to relieve pressure on the cord.
4. Amniotic Fluid Embolism: This is a rare but life-threatening condition where amniotic fluid enters the mother\’s bloodstream, triggering an allergic reaction. It can result in cardiac arrest, respiratory failure, or disseminated intravascular coagulation (DIC).
5. Pre-eclampsia/Eclampsia: Pre-eclampsia is characterized by high blood pressure and organ damage during pregnancy, while eclampsia is the development of seizures in a woman with pre-eclampsia. 
6. Placental Abruption: This occurs when the placenta separates from the uterine wall before delivery. It can cause severe bleeding and compromise fetal oxygen supply, necessitating emergency delivery.
7. Fetal Distress: This refers to a compromised fetal condition during labor, usually due to inadequate oxygen supply. It may require interventions such as changing maternal positions, administering oxygen, or performing an emergency cesarean section.
8. Cord Compression: The umbilical cord becomes compressed during labor, restricting blood flow to the baby. This can occur due to cord entanglement, excessive cord length, or abnormal positioning.
9. Maternal Infections: Infections such as chorioamnionitis (infection of the placental membranes), sepsis, or genital tract infections can pose risks to both the mother and the baby. 
10. Maternal Hypertensive Disorders: These include gestational hypertension, chronic hypertension, and HELLP syndrome. 

Write Short Notes: Concise and Informative Summaries

When encountering \”Write Short Notes\” questions, the aim is to provide concise yet informative summaries of the given topic. These questions require you to summarize the key points and present them in a clear and organized manner. Avoid excessive details and focus on providing a brief but comprehensive overview.

Example Question: Write short notes on the following

(a) Causes of pain in labour.

(b) Factors that affect pain perception during labour.

(a)CAUSES OF PAIN

There are two major causes of pain

• Hormonal factors
• Mechanical factors

Hormonal factors These include;

Oxytocin stimulation. This increases the strength, intensity, duration and frequency of the contractions leading to pain.

Progesterone withdrawal. The reduced levels of progesterone lead to an increase in estrogen levels which stimulates the muscles of the deciduae muscles of the uterus to produce prostaglandin which stimulates the smooth muscles of the uterus to contract.

Mechanical factors These include;

Strength and frequency of Braxton hick‘s contractions occurring in late pregnancy which leads to over stretching of the uterus which irritates the uterine muscles to contract leading to pain.

Pressure of the presenting part on the sacro-nerves and lumbar nerves which has pain receptor.

Pressure of the presenting part on the cervix. The presenting part exerts pressure on the cervix muscles hence leading to pain.

Displacement of the pelvic floor muscles. The advancing presenting part distends the vagina and displaces the pelvic floor muscles which are over stretched and the nerves are compressed leading to pain.

(b) PERCEPTION.

Is the process of becoming aware of the environment through the five senses.

Factors that affect pain perception during labour

These factors are emotional experience involving physical and psychological mechanism and can be contributed by the mother, fetus, health workers and structural environment.

Mother

• Maternal medical; conditions like pre-clampsia and eclampsia, cardiac conditions which can affect pain perception.
• Compromised immunity due to chronic conditions like HIV and cancer which can affect pain perception.
• Size of the pelvis. Any pelvic deviation from normal leading to cephalous pelvic disproportion which can affect pain perception.
• Age. Young prime gravidae below 18years their pelvic bones are not fully developed and the mother above 35years their pelvic bones are contracted and this hinders normal progress of labour and affects pain.
• Parity. Prime gravidae‘s their muscles are still intact and sensitive to pain which leads to strong contractions. The multipara mothers their muscles are laced which leads to uterine itial.
• Past obstetrical history like caesarian section which increases the risks of uterine rapture and affects normal labour
• Social economic factors for example lack of support which can affect pain perception.
• Cultural factors like use of native drugs can affect pain perception.
• Past experience can also affect pain perception
• Level of education, occupation, religion can also affect pain perception.

Fetus

• Fetal abnormalities like hydrocephalous, macrosomic babies can lead to cephalopelvic disproportion hence affecting pain.
• Lie, position and presenting pain can affect pain perception during labour
• Size of the fetus that is to say big babies which cannot pass through the pelvis hence affecting pain perception
• Gestation age. In past maturity the sutures and the fontanels are closing and molding can hot take place hence affecting pain perception.

Health workers

• Poor screening of mothers during antenatal Poor management during labour
• Poor attitude towards the mother

Structural environment

• Hospital setting where there is no privacy for mothers, all stages of labour in one room which can affect pain perception.
• Lack of recreation in labour rooms like newspapers, television to occupy the mothers.

What Questions: Providing Clear Definitions and Explanations

\”What\” questions typically require you to provide clear definitions, explanations, or descriptions of a specific concept, procedure, or pathophysiology These questions aim to test your understanding and knowledge of the subject matter. When answering \”What\” questions, it is important to be precise and concise in your response, while still providing sufficient information to address the question accurately.

Example Question: What is the role of the midwife in the immediate postpartum period?

To answer this question effectively, you can provide a concise definition and description of the midwife\’s role during the immediate postpartum period:

1. Monitoring maternal and neonatal vital signs: Midwives closely monitor the mother\’s blood pressure, heart rate, and bleeding. They also assess the baby\’s breathing, heart rate, and overall well-being.
2. Assisting with breastfeeding initiation: Midwives provide support and guidance to initiate breastfeeding, ensuring proper  positioning. They offer education on breastfeeding techniques, addressing any concerns or difficulties that may arise.
3. Providing emotional support: Midwives offer emotional support to new mothers, addressing any anxieties, fears, or questions they may have. They create a nurturing and supportive environment for the mother and her newborn.
4. Assessing postpartum recovery: Midwives conduct physical examinations to assess the mother\’s postpartum recovery, including uterine involution, healing of perineal tissues, and overall well-being. They provide guidance on self-care practices and postpartum contraception options.
5. Identifying and managing postpartum complications: Midwives are  identify and manage any postpartum complications that may arise, such as postpartum hemorrhage, infection, or breastfeeding difficulties. They collaborate with healthcare providers if further interventions are required.

By  explaining the midwife\’s role in the immediate postpartum period, you address the \”What\” question while providing a clear understanding of the topic.

What information must you 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

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

Tips for Success:

a. Understand the instructions: Carefully read and follow the instructions.

b. Plan your response: Take a moment to brainstorm and outline your ideas before starting to write. This will help you organize your thoughts and ensure a great structured response.

c. Provide relevant examples: Whenever possible, support your answers with real-life examples, or evidence-based practices to demonstrate your understanding and application of midwifery knowledge.

d. Use clear and simple language: Write in a clear and simple manner, avoiding unnecessary elaboration. Focus on delivering information effectively while maintaining clarity.

e. Practice time management: Allocate time for each question based on its difficulty. This will help you ensure that you have enough time to answer all questions within the given time.

f. Review your answers: Before submitting your answer sheet, review your answers to check for any errors, omissions, or areas that need further clarification or elaboration. Don\’t forget to write your NSIN Number!