Midwifery

Domiciliary Care

Domiciliary care is an obstetric care given to a mother in her home during pregnancy, labour and puerperium

Types of Domiciliary Care

Type one domiciliary midwifery care “continuity:; In this type the woman is cared for in her home all through during antenatal period delivery and postnatal care. The woman will only visit a health unit or hospital only when there is a problem that requires specialized care or more gadgets to be used. This care is known as continuity of care or fragmented care. In this case one midwife provides all the care to the woman.
Type two, community, integrated or centralized care; In this care service is integrated (mixed) in a way that part of the care may be given at home and some in the health setting like a hospital. Usually antenatal or delivery may be offered in the hospital and puerperium period managed at home. This is the type of care that student midwives and nurses offer as part of their midwifery part two and is compulsory for them.
Employee or independent practitioner in domiciliary; This is a type of care in which a midwife practices as a private midwife in the community but not necessarily on one woman. The midwife may have a maternity Centre for all or part of the care or she may combine it with one to one community midwifery care. This is the commonest type of domiciliary care in Uganda.

Forms of Domiciliary Care
Characteristics of patterns of domiciliary care depend on a number of factors and these can be:

Decision of the midwife
Decision of the woman / family
Location and nature of community
Availability of basic requirements for domiciliary care

Objectives of Domiciliary Care.

Domiciliary midwifery care to take midwifery near to the community thus increasing accessibility to services
To encourage full participation and involvement of male partners and family members in the birth process so as to get their full support
To reduce on maternal / infant morbidity and mortality as the midwife has less workload and concentrates on one woman.
To reduce on hospital/health facility over crowding
To promote midwife-mother relationship and mutual understanding between the woman and the midwife.

Domiciliary Care given by midwives

Care before conception
> Health education to young girls on good nutrition and hygiene
> Teaching young girls about life skills
> Immunization of young girls with tetanus toxoid
> Counselling adolescents on reproductive health and other social issues
Care during pregnancy
> Immunization
> Antenatal check ups
> Treatment of minor problems. > Health education on problems in pregnancy
Care during labour
> Care of mother in Labour
> Use of partograph to monitor labour
> Delivering of the baby
> Infection prevention
Care after delivery
> Immunization
> Care of mother and baby
> Postnatal exercises
> Family planning

Advantages of Domiciliary Services.

Domiciliary services promotes midwife – mother relationships and thus minimizing fears and phobias of childbirth
It promotes continuity of care and close supervision of the mother thus – contributing to the reduction of maternal / infant morbidity and mortality
Increases access to health services as the woman is found in her home instead of herself looking for the services
Domiciliary is cost effective to a certain level as only relevant care will be given to individual women and at the same time the woman will continue her responsibilities especially supervision of the home
It gives peace of mind to the mother, husband children and other house members because the woman remains at home
It promotes woman centered care including choice control over services rendered and also encourages continuity of care.
It promotes privacy and security and respect the mother with less interference and exposure
Promotes good communication and openness. Only relevant information is given to the mother and her family. As the midwife knows the woman personally, she understands better their concerns, lives, and challenges and assists them accordingly.
Promotes autonomy to the midwife and there is job satisfaction
It promotes creativity, problem solving skills and maturity in service with good experience.

Brief History of Domiciliary Care

Throughout the ages, women have depended upon a skilled person, usually another
woman to be with them during child birth
In United Kingdom, the midwives skills are increasingly valued and midwives are being urged to expand their role even further in the field of public health.

In Uganda in 1960’s(May 1968), this is when the midwife would look after the mother in the home environment. Midwives would do antenatal care, deliver mothers in their own homes and continue to give post natal care in the mother’s home.
> This would also give opportunity for the midwife to give health education to the other family members.
> In the 1970s when the political system in Uganda changed, leading to a lot of insecurity, the midwives stopped delivering mothers at home and instead delivered mothers in hospitals and maternity units. Then the midwives continued to nurse the mothers and their babies at the mother’s home.
> These services have continued today and are being practiced by Private Midwives and the student midwives who are undertaking Registered Midwifery Course of Diploma in Midwifery Course.

Types/ Groups of mothers Needing Domiciliary care

Group 1: Women with less risk of getting complications
Women who have ever delivered one baby but have not exceeded five – that is gravid two to four.
This group of women if they did not experience any major complication in pregnancy labour and puerperium, can be care for in the community throughout, pregnancy labour and puerperium
Group 2: These are the women who are suspected of developing a complication, though they may not develop them at all. For examples: primigravida – pregnant for the first time,
Grandmultipara – has delivered more than four times, short women- less than 152cm high, women with previous complications that are likely to occur again e.g. cord prolapsed.
This group of women may be cared for only for antenatal or delivery and puerperium depending on other factors as detected on history and assessment.
Group 3: These are the high Risk Mothers, women who come with obvious complications, or are highly suspected of developing various complications. Examples: Multiple pregnancy – those with medical conditions like cardiac diseases, diabetes mellitus, sickle cell disease.

Common Drugs used in Domiciliary

Ergometrine
Ferrous sulphate
Folic acid
Panadol
Chloroquine

How Domiciliary is carried out.

Booking

A mother who has to be booked must be with the following
> Must be normal with no risk factors like CPD,
> Grandemultparity, multiple pregnancy

Home delivery

The following must be put in consideration
(a). Well ventilated home without without overcrowding
(b). Clean house, good hygiene in and around the house
(c). The house should have more than 4 bedrooms, toilets
and kitchen
(d). The floor must be cemented
(e). There must be tap water
(f). There must be easy means of boiling water

Enough equipment especially for the mother and baby(bathing)
Husband and wife should be willing for the care
The distance from the home to hospital should be less than 2 miles.

QUALITIES OF A MIDWIFE

In normal circumstances the midwife should be a qualified senior student midwife with enough knowledge
(a) She must create a friendly relationship between her, the mother and family
(b) She must remember that she does not belong to the family and is only a guest so she must adopt her behavior in relation to the family routine
(c) No commands or orders should be given but advices, the midwife should be flexible
(d) She should show interest in the family
(e) Avoid embarrassing the mother in the family

(f) She has to apply her professional code of conduct and stay in the home only as a midwife
(g) Quick and correct judgment has to be applied in providing the best care expected

DOMICILIARY BAGS

The midwife must be equipped with the following

Sphyginomanometer
Stethoscope
Urine testing strips
Clinical thermometer
Spirit for baby’s cord
Swabs in the gallipot and cord ligatures
Receivers, dissecting forceps, artery forceps, scissors
Antiseptic lotion
Plastic apron and tape measure
Drugs like Panadol, and iron tablets

Care

Here in Uganda a mother is delivered in the hospital then cared for in her home for seven day including the 1st days in the hospital
ANTENATAL CARE
Normally a mother is booked on her 1st visit at 12wks.It should be during this time when the midwife inspect the home of the mother until the mother is delivered in the hospital and cared for the first 2 days and then 5 days at home
PUEPERIUM
During puerperium the midwife continues to visit the mother daily at her home. If there is any indication of complication arising of the mother requires extra supervision and support additional visits will be made
The midwife observes the mother’s general condition both mentally and physically, ask her how she is feeling. Inquire about the baby particularly feeding, sleeping, passage of urine and stool.
If the mother appears stressed, depressed, or anxious about the baby or any other problem. The midwife should sit, listens and responds. The time spent listening and discussing problems with the mother invariably of great value to her wellbeing
The midwife inquires whether the mother is sleeping and eating well passing urine without difficult or discomfort and has had a bowel action.
She take the mothers vitals and carries out a full postnatal examination of the breast, abdomen to palpate the uterus, vulva to inspect lochia and perineum.
Any abnormality detected should be discussed with the mother and appropriate advice is given. Postnatal exercises are taught on the first day after delivery and the mother is encouraged to practice them dairy throughout puerperium
On the first postnatal visit the midwife usually assists the mother to bath there after the mother should have a bath on her own should be twice or more daily, mother should be advised to change her pads frequently.

Adequate rest and sleep are essential and though ambulating is good but the mother should rest and sleep at appropriate time each day.
The mid wife performs a daily examination on the baby and shows the mother how to bath and dress the baby and attend to the cord.
> She observes its general condition, examine him from head to toe observing the skin, eyes, mouth and cord for any signs of infection or any abnormality.
> Stool should be observed and the passage of urine.
> Baby should be observed whether breastfeeding well
> At the last visit, the mid wife advises the mother when to go back to postnatal clinic and the baby to health clinic.
> Health educate and demonstrates to the mother the postnatal exercises.

Domiciliary Care Read More »

Partograph

Partograph is a graph or tool used to monitor fetal condition, maternal condition and labour progress during the active 1st stage of labour so as to be able to detect any abnormalities and be able to take action.
It’s only used during 1st stage of labour. It is used for recording salient conditions of the mother and the fetus.

USES OF A PARTOGRAPH

To detect labour that is not progressing normally.
To indicate when augmentation of labour is appropriate.
To recognize CPD when obstruction occurs.
It increases the quality of all observations on the mother and fetus in labour.
It serves as an “early warning system”
It assists on early decision of transfer and augmentation.

Who should not use a partograph?
Women with problems which are identified before labour starts or during labour which needs special attention.
Women not anticipating vaginal delivery (elective C/S).

A partograph has 3 parts i.e. –
fetal part
maternal part
labour progress part

Observations charted on a partograph:

The progress of labour
> Cervical dilatation 4 hourly
> Descent 2 hourly
> Uterine contractions
Fetal condition
> Fetal heart rate ½ hourly
> Membranes and liquor 4 hourly
> Moulding of the fetal skull 4 hourly.
Maternal condition
> Pulse ½ hourly
> Blood Pressure 2 hourly
>Respiration and > temperature 4 hourly
Urine; – volume 2 hourly, acetone, proteins and sugars.
> Drugs
> I.V fluids 2 hourly and Oxytocin regimen

Starting a partograph:

The partograph should be started only when a woman is in active phase of labour.
Contractions must be 1 or more in 10 minutes.
Cervical dilatation should be 4cm or more.

FETAL CONDITION

Fetal heart;
It is taken 1/2 hourly unless there is need to check frequently i.e. if abnormal every 15 minutes and if it remains abnormal over 3 observations, take action. The normal fetal heart rate is 120-160b/m. below 120b/m or above 160b/m indicates fetal distress.
Molding;
This is felt on VE. It is charted according to grades.
State of moulding Record
Absence of moulding. (-)
Bones are separate and sutures felt (0)
Bones are just touching each other (+)
Bone are over lapping but can be Separated (++)
Bones are over lapping but cannot be separated (+++)
Liquor amnii;
This is observed when membranes are raptured artificially or spontaneously.
It has different colour with different meaning and meconium stained liquor has grades.
State of liquor Record
Clear (normal) (C)
Light green in colour (m+) Moderate green, more slippery (m++) Thick green, meconium stained (m+++) Blood stained (B)
Membranes;

State of membranes Record
Membranes intact (I)
Membranes raptured (R)

LABOUR PROGRESS

5. Cervical dilatation,
The dilatation of the cervix is plotted with an “X”. Vaginal examination is done at admission and once in 4 hours. Usually we start recording on a partograph at 4cm.
Alert line starts at 4cm of cervical dilation to a point of expected full dilatation at a rate of 1cm per hour
Action line– parallel and at 4 hours to the right of the alert line.

6. Descent of presenting part.
Descent is assessed by abdominal palpation. It is measured in terms of fifths above the brim.
The width of five fingers is a guide to the expression in the fifth of the head above the brim.
A head that is ballotable above the brim will accommodate the full width of five fingers.
As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers.
It is generally accepted that the head is engaged when the portion of the head above the brim is represented by 2 or less fingers.
Descent is plotted with an “O” on the graph

7. Uterine contractions This is done ½ hourly for every 30 minutes. The duration, frequency and strength of contraction is observed. Observe the contractions within 10 minutes.

-Mild contractions last for less than 20 seconds.
-Moderate contractions last for 20-40 seconds.
-Strong contractions last for 40 seconds and above.
When plotting and shedding contractions use the following symbols.
Dots for mild contractions
Diagonal lines for moderate contractions
Shade for strong contractions

MATERNAL CONDITION

Pulse; this is checked every 30 minutes. The normal pulse is 70-90b/min.
The raised pulse may indicate maternal distress, infection especially if she had rapture of membranes for 8-12 hours and in case of low pulse, it can be due to collapse of the mother.
Blood pressure; it is taken 2 hourly. The normal is 90/60-140/90mmHg. Any raise of 30mmHG systolic and 20mmhg diastolic from what is regarded as normal or if repeated over 3 times and remains high, test urine for albumen to rule out pre-eclampsia.
Temperature; this is taken 4 hourly. The normal range is between 37.2 0 c to 37.5 0 c. Any raise in temperature may be due to infections, dehydration as a sign of maternal distress or if a mother had early rapture of membranes.
Urine; the mother should pass urine atleast every after 2 hours and urine should be tested on admission.
Fluids; she should be encouraged to take atleast 250-300 mls every 30 minutes. Any type of
fluid can be given hot or cold except alcohol. Thefluid should be sweetened in order to give her
strength.

Further mgt in the normal 1st stage of labour- nursing care

Emotional support:

Midwife should rub the mothers backto relieve pain.
Allow the mother to move around or sit in bed if membranes are still intact.
Re-assure the mother and keep her informed about the progress of labour to relieve anxiety.
Allow her to talk to relatives and husband.
Allow her to read or do knitting.

2. Nutrition;
Encourage mother to take light and easily digested food like bread, soup and sweet tea to rehydrate her and provide energy.

3. Elimination;
Taking care of the bladder and bowel. Encourage mother to empty bladder every 2 hours during labour. Every specimen is measured and tested for acetone, albumen, sugars and findings interpreted and recorded.
Pass catheter if mother is unable to pass urine.

4. Personal hygiene;
Allow mother to go for bath in early labour or on admission if condition allows. If membranes rapture, give a clean pad and ask mother to change frequently to prevent infections.
VE should be done only after aseptic technique.

5. Ambulation and position:
In early labour, mother is encouraged to walk around to aid descent of presenting part.
During contractions, ask mother to lean forward supporting herself on a chair or bed to reduce discomfort.
Allow mother to adopt a position of her choice except supine position.
Mother should be confined to bed when membranes rapture in advanced stage of labour.

6. Prevention of infections
Strict aseptic technique should be maintained when doing a VE and vulval swabbing.
When membranes rapture early, vulval toileting should be done 4 hourly to reduce the risk of infections. Put mother on antibiotics to avoid risk of ascending infections in early raptured of membranes.
Frequent sponging is done, bed linen changed when necessary when a mother is confined in bed.
The midwife should pay attention to her own hygiene and be careful to wash her hands before and after attending to the mother.

7. Sleep and rest
Mother is encouraged to rest when there is no contraction (rest in between contractions).

What to report

Abnormality found in urine.
Failure to pass urine.
Rise in temperature, pulse and BP.
Hypertonic uterine contractions.
Rapture of membranes with meconium stained liquor grade 2 and 3.
Failure of presenting part to descend despite good uterine contractions.
Tenderness of abdomen.
Bleeding per vagina.
Fall in BP.
Raise in fetal heart rate.

Complications

Infections
Early rapture of membranes
Cord prolapse
Supine hypotensive syndrome
Fetal distress
Maternal distress
APH
PET and eclampsia
Prolonged labour
Obstructed labour

Partograph Read More »

Normal First Stage Of Labour

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

Fundal dominance;
Each uterine contraction starts from the fundus near the cornua and spreads across and down wards.
The contraction lasts longer in the in the fundus where it is most intense but the peak is reached simultaneously over the whole uterus and the contractions fade from all parts together.
This permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

Polarity
This is a neuromuscular harmony that prevails between the two poles of the uterus throughout
labour.
During a contraction, these two poles act harmoneously. The upper uterine segment contracts strongly and retracts to expel fetus and the lower pole contracts slightly and dilates to allow expulsion of the fetus. If polarity is disorganized, labour progress is inhibited.

Contraction and retraction
During labour, a contraction does not pass off entirely but muscle fibres retain some of the shortening contractions instead of becoming completely relaxed. This is termed as retraction. This is a unique property of the uterine muscles and because of this,
the upper uterine segment becomes shorter and thicker and diminishes its cavity assisting in expulsion of the fetus.

Formation of the upper and lower uterine segment
By the end of pregnancy, the body of the uterus has divided into two segments;
> The upper segment is mainly for contraction and is muscular and thicker while the lower uterine segment is for distension and dilatation and is thinner.
> The lower segment develops from the isthmus and is about 8-10cm in length.

Retraction ring

This is a ridge formed between the upper and lower uterine segment.
The physiological retraction ring gradually rises when the upper uterine segment contracts and retracts and lower uterine segment thins out to accommodate the descending fetus.
This ring is not usually visible and when cervix is fully dilated and fetus can leave the uterus, it rises no further.
An exaggerated phenomenon of retraction ring in obstructed labour it becomes visible above the
symphysis pubis. This is termed as a bundle’s ring

2. CERVICAL ACTION

Cervical effacement
This is inclusion of the cervical canal. The muscle fibres surrounding the internal os are drawn upwards by the retracted upper uterine segment and the cervix merges into the lower uterine segment.

Cervical dilatation
This is the process of enlargement of the os from a tightly closed aperture to an opening large enough to permit passage of the fetal head.
It is measured in cm. a full dilatation at term equates to 10cm.
Pressure applied by the bag of fore waters and a well flexed fetal head closely applied to the cervix favors efficient dilatation.

Show
This is blood stained mucus which is seen before or at the onset of labour. The mucus is a thick mucoid substance which forms the cervical plug (opeculum) during pregnancy. Blood comes from raptured capillaries when the chorion has become detouched from the dilating cervix.

3. MECHANICAL FACTORS

Formation of fore waters

As the lower uterine segment stretches, the chorion becomes detouched from it and the increased intra uterine pressure causes this loosened part of the sac of fluid to bulge down wards into the dilating internal os. A well flexed head fits snugly into the cervix and cuts off the fluid in front of the head from that surrounding the body. The water in front is known as fore waters and that
behind is called hind waters.
General fluid pressure
When the membranes are intact, the pressure of the uterine contractions is exerted on the fluid and since the fluid is not compressible, the pressure is applied on the uterus and over the fetal
body. This is termed as general fluid pressure.
When membranes rapture and quantity of fluid escapes, the fetal head, placenta and umbilical cord will be compressed between the uterine wall and body of fetus during contraction resulting in reduced oxygen supply to the fetus.

Rapture of membranes
The optimum physiological moment for membranes to rapture is at the end of 1st stage of labour when the cervix becomes fully dilated and no longer supports the bag of fore water.
The uterine contractions are also applying increasing expulsive force at this time. Membranes may also rapture days before labour begins or during 1st stage of labour especially in a badly
fitting presenting part.
Occasionally, membranes do not rapture even in 2 nd stage and appear at the vulva as a bulging sac covering the fetal head as it is born. This is known as caul(CAL DE SAC)

Fetal axis pressure

During the contraction, the uterus rises forward and the force of fundal contraction is transmitted to the upper pole of the fetus down the long axis of the fetus and is applied to the cervix by the presenting part. This becomes more significant after rapture of membranes and during 2 nd stage of labour.

Descent of the presenting part.

It refers to the downward and outward movement of this part through the pelvis.
The normal well flexed head twists and turns flexes and extends to maneuver through the pelvis.
There are 3 planes or obstacles involved in the process of descent:
– Pelvic inlet/ brim.
When the presenting part is at the level of the ischial spines, a pelvic brim mark, it indicates the largest part of the head has come through the brim. The head is thus engaged.
The presenting part is now at station 0.
– Pelvic cavity.
When the presenting part has descended to the perineum, the largest part has passed the ischial
spines. The head is now at station +2.
– Pelvic outlet.
Delivery of the head brings it past the 3 rd obstacle ( pelvic outlet), which is under the pubic arch, between the ischial tuberosities and over the coccyx.
NB: station is the relationship of the lowermost part of the presenting part to an imaginary line
drawn between the ischial spines and the woman’s pelvis.

MANAGEMENT OF FIRST STAGE OF LABOUR

Aims

To monitor labour progress.
To prevent maternal exhaustion.
To prevent infections.
To give comfort to the mother and maintain patient’s moral.
To relieve pain.
To prevent complications.

Admission of a mother in labour
Welcome the mother and her relatives to allay fear and anxiety, create rapport.
Obtain full history and review the antenatal card while the mother is sitting or lying on
the couch.
The histories taken include;-
-Demographic data
-Date and time of admission
-When contractions started
-Frequency and strength of contractions
-If membranes raptured
Obtain consent from the mother and sign. Make sure mother is given sufficient
information before she decides to give consent.
Vital observations;- pulse ½ hourly if >100b/m indicates pain, anxiety, infections,
ketosis, hemorrhage etc.
– Blood pressure 2 hourly
– Temperature 4 hourly
-Respiration 4 hourly (16-20r/m)
Investigations e.g.- Urinalysis to rule out acetones, glucose and proteins.- Blood for Hb estimation, grouping and cross matching can be obtained depending on mother’s condition.
General examination The midwife examines a mother from head to toe paying more attention to general appearance (health or ill), size, any deformity, signs of anaemia, jaundice, oedema, dehydration, infections, Vericose veins and enlarged glands and veins in the neck. Examine the breasts and notice their suitability for breast feeding.
Abdominal examination: The mother’s bladder should be empty. It’s done following 3 steps.

-Inspection:-for size, shape, scars, signs of pregnancy etc
-Palpation: – Noting tenderness, height of fundus, presentation, lie, position, descent,
contractions, frequency, length and strength.
-Auscultation: – Noting rate, regularity and volume.

Vaginal examination.

This is a sterile procedure carried out on a woman through the vagina to rule out obstetrical or
gynecological abnormalities.

Indications of VE during pregnancy

> To confirm pregnancy
> To exclude abnormalities e.g. fibroids
> For pelvic assessment
> To determine the state of the cervix
> To confirm the type of abortion
> To rule out abnormal discharges
> During labour

During First stage

> To determine cervical dilation

> To exclude cord prolapse when membranes rapture
> To confirm full dilation when mother is bearing down.
> Before induction of labour to determine state of the cervix
> In prolonged labour to rule out obstructed labour.
> To make a positive identification of the presentation.
> To determine if the presenting part is engaged.

–During Second stage
> To confirm full dilation of the cervix
> When there is no descent to determine the delay e.g. face to pubis
> After delivery of the 1st twin to determine the presentation of the 2nd twin.

-During Third stage
> In delayed 3rd stage of labour to know whether the placenta is in the birth canal where it can be
removed quickly.
> To exclude lacerations and expel clots from the birth canal.
> In emergency i.e. manual removal of placenta.
> During puerperium
To find out whether the perineum has healed after 6 weeks.
> To find out whether the reproductive organs have regained their muscle tone and position.
> To obtain a specimen for examination.
> In abnormal vaginal discharge to confirm the type of infection.

Contraindications of VE

In APH and elective caesarian section

Complications of VE
-Infections
-Early rapture of membranes.
-Trauma or lacerations to the birth canal

Requirements
Tray containing;
> Galipot for swabs with antiseptic
> 2 receivers
> Sterile gloves
> Vaginal speculum
> Sterile bowl for lotion.
> Perineal pad/ clean pads
> Sheet and mackintosh.
> Clean gloves.
> Lubricant
At the bed side
> Screen
> Hand washing equipment
> Bed pan

PROCEDURE OF VAGINAL EXAMINATION

Welcome and explain procedure to the mother.
Empty bladder and screen the bed.
Assemble a VE tray.
Ask mother to relax during examination.
Woman’s arms should be down by her sides or across her abdomen to relax her abdominal
muscles.
Assist her into dorsal position and drape her.
Put on clean gloves
Place mackintosh and draw sheet under the buttocks
Remove gloves and wash hands thoroughly and put on sterile gloves.
Observe the external genitalia. Before the midwife cleans the vulva, should observe the
following;-
– Hygiene
– Labia for signs of varicosities.
– Oedema
– Vulval warts
– Sores
– If the perineum has old scars for tears, episiotomy, female circumcision.
– Any discharge from the vaginal opening i.e. blood, raptured membranes, smell of liquor
and colour.
– If liquor smells, it indicates infections. If green or meconium stained, indicates fetal
distress.
Vulva is swabbed using the left hand, swab from the front towards the rectum.
The 2 fingers of the right hand are dipped in the antiseptic cream for lubrication and gently inserted down wards and backwards into the vagina while the labia majora are held apart by the fingers of the left hand.
The fingers are directed along the anterior vaginal wall and should not be withdrawn until the
required information has been obtained. NB: The clitoris should not be touched because it causes discomfort.

Findings:

Condition of the vagina;

The vagina should feel warm and moist. A hot and dry vagina is a sign of obstructed labour and should not be found in modern obstetric care.
If a mother has a high temperature, the vagina will feel correspondingly hot but not dry.
Previous scar from Perineal wound, cystocele or rectocele.

The cervix;
The normal should feel thin and elastic and well applied to the presenting part.
A spongy feeling may show undiagnosed placenta previa.
The midwife should sweep the examining fingers from side to side to locate the os. It is usually felt in the center but sometimes in early labour, it is very posterior.
The length of the cervical canal assessed through a tightly closed cervix shows that labour has not yet started.
In a PG, the cervix can be completely taken up(effaced) but still closed and in this manner, it will be closely applied to the presenting part and it can be confused with a fully dilated cervix. If poorly applied to the presenting part, then it means there is an ill-fitting presenting part.
Assess cervix for; effacement, dilatation, consistency.

Membranes;
When membranes are intact, they can be felt through the dilating os; they feel tenser on contraction. When the fore waters are shallow, it is not easy to feel membranes.
If the presenting part does not fit well in or at the cervix, some of the fluid from the hind waters escapes into the fore waters causing the membranes to bulge or protrude through the cervix and are liable to rapture early.

Level or station of presenting part;
The presenting part is that part of the fetus that lies over the internal os during labour.
In order to assess the descent of the fetus in labour, the level of presenting part is assessed or estimated in relation to maternal ischial spines.

Position;
On feeling the features of the presenting part, the position of the fetus can be detected. The vertex is the normal presentation and the midwife must be familiar with it. Commonly the first feature to be felt even in early labour is the sagittal suture. The sagittal suture should be followed with a finger until a fontanel is reached.
If the head is well flexed, the posterior fontanel will be felt. This can be judged by feeling the amount of overlapping of the skull bones and can give additional information on position.
The parietal bones override the occipital bone to reduce the distance of the presenting diameter.

Pelvic capacity (pelvic assessment);
Although the pelvis was assessed during ANC period, the midwife should take opportunity to assure herself of its adequacy as she completes vaginal examination.
At completion of examination, withdraw fingers from the vagina and note any blood or amniotic fluid, cleans up the mother and removes gloves.
Record all findings of what was observed on admission on a partograph and observation chart.

Normal First Stage Of Labour Read More »

Labour

It is described as the process by which the fetus, placenta and membranes are expelled through the birth canal after 28 weeks of gestation.
OR
It is defined as rhythmic contraction and relaxation of the uterine muscles with progressive effacement (thinning) and dilatation ( opening) of the cervix, leading to expulsion of the products of conception.

Normal labour

Labour is said to be normal when;

It occurs at term.
Spontaneous in onset.
Fetus presenting by vertex.
The process is complete within 12-18 hours.
No complications arise.
Both mother and fetus suffer no injury.
No assistance is given in any way.

THREE P’S OF NORMAL LABOUR

Powers – uterine contractions
Passage – pelvis including the size and shape.
Passenger – Size, position and presentation of the fetus as well as bag of fore waters or amniotic sac.

TYPES OF LABOUR

True labour: This is characterized by regular uterine contractions slight at 1 st but increase in severity and frequency causes the cervix to dilate.
False labour: It is characterized by irregular uterine contractions which do not cause the cervix to dilate. They are painful, appear stronger when a mother is in bed and weaker when she is up and moving around.
> No cervical dilatation.
> No show.
> Pain remains stationary in the lower abdomen.
> Pain is continuous without any rhythm.
> Pain reduces after enema.
> No associated hardening of the abdomen.

Signs of impending labour.

These changes occur in the last weeks of pregnancy. This is termed as pre-labour.

Lightening
About 2-3 weeks before the onset of labour, the lower uterine segment expands and allows the fetal head to sink lower. The symphysis pubis widens and pelvic floor becomes more relaxed and softened, allowing the uterus to descend further into the pelvis.
Cervical changes
As labour approaches, the cervix becomes “ripe”. It becomes softer, like a lower lip and there is some degree of effacement and slight cervical dilatation.
False labour: It consists of painful uterine contractions that have no measurable progressive effect on the cervix and this is an exaggeration of the usually painless Braxton hick’s contractions which have been occurring since about 6weeks of gestation. It may occur for days intermittently even 3-4 weeks before the onset of true labour.
Premature rapture of membranes: Normally, membranes rapture at the end of 1 st stage of labour. When rapture occurs before the onset of labour, it is termed as PROM and occurs in about 12% of women. In 90% of women with PROM, labour begins spontaneously within 24 hours.
Bloody show: A mucus plug created by cervical secretions from proliferation of cervical mucosal glands in early pregnancy serves as protective barrier and closes the cervical canal throughout pregnancy. Bloody show is the expulsion of this mucus plug.
Energy spurt: Many women experience an energy spurt approximately 24-48 hours before the onset of labour. After days or weeks of feeling tired (physically tired and tired of being pregnant) they get up one day to find themselves full of energy and vigor.
G.I.T upset: In the absence of any causative factors for the occurrence of diarrhea, nausea, vomiting and indigestion, it is thought that they might be indicative of impending labour and there is no known explanation for this.

SIGNS OF LABOUR

They are divided into two;

Premonitory signs
Actual signs

Premonitory signs
– Lightening
It occurs 2-3 weeks before onset of labour. The lower uterine segment expands and allows the fetal head to sink further so as to engage. The fundus nolonger crowds the lungs and breathing is easier and the mother experiences relief
– Frequency of micturition
Congestion in the pelvis limits the capacity of the bladder requiring it to be emptied more often
– Effacement of the cervix
This is the taking up of the cervix-the cervix is drawn up and gradually merges into the lower uterine segment.
– Braxton hick’s contractions.
They become exaggerated and mother becomes anxious. She experiences backache or pains while walking due to relaxation of pelvic joints. This makes the mother think that she is in labour.

Actual signs
– Regular uterine contractions.
Mother feels painful, rhythmic uterine contractions slight at first but increase in severity and frequency.
– Dilatation of the cervix.
This is enlargement of the external os from a circular opening large enough to permit passage of the fetus.
– Show.
This is a bloody mucoid discharge which comes from the cervical canal. When it dilates, blood
comes from the raptured capillaries.
– Plus or minus rapture of membranes.
This is not so much relied on because it can occur in late 1 st stage or spontaneously at birth of the baby.

Causes of onset of labour.

The exact cause remains unknown but appears to be a combination of hormonal and mechanical
factors.

Hormonal factors.
Theories regarding the initiation of labour include the following;
1. Oxytocin stimulation theory:
– Although the mechanism is unknown, the uterus becomes increasingly sensitive to oxytocin as the pregnancy progresses.
2. Progesterone withdrawal theory:
– A decrease in progesterone production may stimulate prostaglandin synthesis and enhance the effect of Oestrogen which has stimulating effect on muscles. The fall of progesterone reduces the
relaxing effect of the uterine muscles.
3. Oestrogen stimulation theory: Oestrogen stimulates irritability of uterine muscles and enhances uterine contractions.
The raise in estrogen stimulates the decidua to release prostaglandins. Both prostaglandins and oxytocin cause the uterus to contract.
4. Fetal cortisol theory:
Cortisol may affect the maternal Oestrogen levels.
5. Prostaglandin stimulation theory:
Prostaglandin stimulates smooth muscles to contract.
A combination of the above mechanisms is likely to initiate labour.

Mechanical factors
1. over stretching and over distension of the uterus
2. Pressure from the presenting part on the nerve endings of the cervix stimulates the nerve plexus (cervical ganglion)
3. The increase in the strength and frequency of Braxton hick’s contractions may cause labour to begin.

Stages of labour

First stage
It begins with onset of regular, rhythmic uterine contractions and is complete when the cervix
is fully dilated.
It is a stage of dilation of the cervix.
It’s divided into 3 phases
-Latent phase
-Active phase
-Transitional phase
Latent phase:
This is a period of slow dilation of the cervix from 0-3cm.
It may last 6-8hours in first time mothers
Active phase:
This is the time when the cervix undergoes more rapid dilatation. It begins when the cervix is 4cm dilated and ends when the cervix is 8cm dilated.
Transitional phase
It begins when the cervix is 8cm dilated and is complete when Its fully dilated.
–
Second stage
It’s that stage of expulsion of the fetus. It begins when the cervix is fully dilated and is complete when the baby is completely born.
It also has two phases
– The propulsive phase
– The expulsive phase

Propulsive phase: It starts from full dilatation up to the descent of the presenting part to the pelvic floor.
Expulsive phase:
It is distinguished by maternal bearing down efforts and ends with delivery of the baby.

3. Third stage
It’s that stage of separation and expulsion of the placenta and membranes and involves control of bleeding.
OR
It begins with birth of the baby and ends with expulsion of placenta and membranes.
It takes 5-30 minutes. With active management, its completed within 5-15 minutes.

4. Fourth stage
It is also called recovery stage. It is defined as the 1 st one hour after delivery of the placenta.

Labour Read More »

Antenatal Care

This is a planned methodological care and supervision given to a pregnant woman by a midwife or obstetrician from the time the mother starts attending antenatal clinic until beginning of labour.

Aims of antenatal care

To monitor the progress of pregnancy in order to support maternal health and normal fetal development.
To prepare the mother for labour, lactation and subsequent care for her baby.
To detect early and treat appropriately high risk conditions be it medical or obstetrical that would endanger the life of the mother and the baby.
This is achieved by;
Developing a partnership with the woman.
Providing a holistic approach to the woman’s care that meets her individual needs.
Promoting awareness of the public health issues for the woman and her family.
Exchanging information with the woman and her family enabling them to make informed choices.
Being an advocate for the woman and her family, supporting her right to choose care that is appropriate for her own needs and those of the family.
Recognize complications of pregnancy and appropriately referring women within the multi- disciplinary team.
Facilitating the woman to make an informed choice about methods of infant feeding and giving appropriate and sensitive advice to support her decision.
Facilitating the woman and her family in their preparations to meet the demands of birth and making a birth plan.
Offering health education for parenthood.

Activities done in ANC

Registration
Booking (history taking)
Special tests and investigations
Health education
Immunization
Treatment of minor disorders
Provision of supplements
Examination i.e. physical and abdominal
Orientation of mothers
Formulating a birth plan
counseling.
Referral of cases

INITIAL ASSESEMENT (BOOKING DAY)

Objectives for initial assessment(booking visit)
– To assess the level of health by taking a detailed history and to offer appropriate
screening tests
– To ascertain a base line data of blood pressure, urinalysis, uterine growth and fetal
developmentto be used as standard for comparison as pregnancy progresses.
– To identify risk factors by taking accurate details of the past and present obstetric,
medical, family and personal history.
– To provide an opportunity to discuss any concerns the woman has.
– To give advice pertaining to pregnancy in order to maintain the health of the mother and
the developing fetus.
– To build the foundation for a trusting relationship in which the woman and the midwife
are partners in care.
– To make appropriate referral when additional health care or support needs have been
identified.

HISTORY TAKING

Demographic data
Name
Age
Address
Occupation
NOK; relationship, occupation, contacts.
LOE
Tribe
Religion
Nearest health facility and distance from home.

Social history
Habits
-Smoking; Cigarettes have nicotine which constricts blood vessels leading to placental
insufficiency, which can result in fetal hypoxia, small for dates, abortions etc. The woman should be advised to reduce on the number of sticks gradually to avoid withdrawal syndrome.
-Alcohol; There is a risk of trauma which can result into abortion, placenta abruption, loss of appetite thus malnutrition and small for dates.
Marital status; -Married or single, number of years spent in marriage, find out if she’s happy or not.
Home environment
-House; – Rented or own, number of rooms and number of occupants.
-Environmental hygiene
-Source of water and food.

Family history
Health status of woman’s parents and her siblings (if deceased, note cause of death).
Familial diseases e.g. h/o cancer, diabetes, cardiac diseases, allergies etc.
Other serious illnesses like mental illnesses or complications with pregnancy.

History of multiple pregnancies.
Past surgical history
History of accidents involving the spine, pelvis and lower limbs which would reduce the pelvic diameters.
History of major operations like C/S, and pelvic operations.
History of blood transfusion(risk of exposure to HIV/AIDS and iso immunization)

Past medical history
-Medical conditions that may complicate or be complicated by pregnancy, labour and
puerperiume.g. sickle cell, DM, HTN.
-Child hood illnesses e.g. rickets, polio myelitis which can reduce pelvic diameters, hence
contracted pelvis.
-Infectious diseases like TB, HepB
-Infections like syphilis, gonorrhea,

Gynecological history
Gynae conditions like abortions, ectopic pregnancy, fibroids etc.
Gynae operations like myomectomy, D and C, evacuation etc.
Menstrual history
Menarche, length, interval, amount of flow.
Dysfunctional uterine bleeding (DUB).
Pre- menstrual spotting.
Family planning
Method of F/P ever used any complaint about it, reason for stopping it.

Past obstetrical history
Previous pregnancies; ask about any abnormalities e.g. abortions, still births, living children
and their health status and immunization status.

Interval between pregnancies, length of gestation, birth weight, fetal outcome, length of labour,
presentation and type of delivery. Prenatal and post natal complications, if baby was breast fed
and for how long.
Labour; Any operations, induction, assisted delivery, PPH.
Puerperium; If it was normal, any h/o sepsis, PPH.

Present obstetric history
Gravidity
Parity
LMNP
EDD. This is calculated by adding 9 calendar months and 7 days to the date of the 1 st day of the
woman’s last menstrual period (Naegele’s rule). This method assumes that:
The woman takes regular note of regularity and length of time between periods.
Conception occurred 14 days after the first day of the last period. If the woman has a regular
cycle of 28 days.
The last period of bleeding was true menstruation. Implantation can cause slight bleeding.
Break through bleeding and anovulation can be affected by contraceptive pill thus impacting on
the accuracy of LNMP.
WOA

Present health
– Appetite; It is important to know because poor appetite leads to malnutrition and anaemia.
– Sleep; Find out if the mother sleeps well, if not, find out the cause which could be due to
worries, insects in bed, pain and any signs of illness.
– Micturition; It’s good to know whether the woman passes urine well because UTI is
common in pregnancy due to stagnation of urine in dilated and kinked ureters. In case of
increased frequency without pain, mother is counseled in relation to physiology of pregnancy.

– Bowel action; as constipation is very common in pregnancy, the mother is re assured and
advised to take plenty of fluids and roughages.
NB: Conclude history by asking mother if she has anything else she would like to tell you.

INVESTIGATIONS

On the first day, every woman should receive the following investigations
Blood pressure
Weight
Height
Urinalysis; – for albumen, acetone and sugars.
Albumen is indicative of PET, acetone-
dehydration, sugar- diabetes.
RPR/VDRL; done to exclude syphilis.
HIV screening to ensure
Emtct
Blood grouping
Hb level; It should be done on booking day, then at 32-34 weeks and lastly at 36weeks to rule out anaemia.
Comb’s test; It’s done to detect anti bodies in blood.

Clinical Tests

Weight; this is taken on every visit to ANC. The mother is expected to gain 12.5kg during
pregnancy, 4kg in the first 20 weeks and 8.5kg in the last 20 weeks. Excessive weight gain could be due to twins, big baby, polyhydramnios etc. Failure to gain weight could be due to poor fetal growth.
Height; It’s done on the booking visit or in labour if the mother has not been attending ANC. The normal height should range 152-170cm, below 150cm indicates a small
pelvis and above 170cm indicates a narrow pelvis.
Shoe size; if below 5 indicates a small pelvis. Normal shoe size ranges between 5 and 8
Blood pressure; this is done on every visit to ANC. The BP of a pregnant mother ranges from 90/60 to 140/90mmhg.A raised BP is a danger sign and may be due to PET and eclampsia. Any rise of 30mmhg (systolic) and15-20mmhg (diastolic) from what has been considered normal is dangerous and the mother’s urine should be tested for proteins. The mother is asked how she feels generally especially her sight (blurred vision), then referred to the doctor.

PHYSICAL EXAMINATION

This includes a review of the physical systems to ascertain the woman’s general health. The breasts, pelvis and abdomen receive particular attention. The examination is carried out systematically beginning with the head and ending with the pelvis and abdomen.

General appearance;
Body type, weight, energy level, grooming, posture. This is noted when the mother is entering the room or when she is sitting.
Head;
Scalp, hair whether treated and hair pattern distribution.
Eyes; conjunctiva- check for anaemia, sclera- check for jaundice, visions, discharge.
Nose; Sense of smell, bleeding, obstruction, abnormal growth and discharge.
Oral cavity; Toothache, denture, state of lips, chewing or swallowing problems, tongue and gums for anaemia, sense of taste.
Ears; Check for discharges, any hearing loss.
Neck;
Movement, Palpate for swelling or enlarged salivary glands i.e parotid, sub mandibular, sublingual, thyroid, lymph nodes i.e. superficial cervical and deep cervical glands, sub clavicles.
Palpate and observe jugular veins and pulsation of the thyroid gland. Swelling of the thyroid gland may be due to iodine insufficiency though during pregnancy there is a slight enlargement of the glands may be due to chronic cough. Extended jugular veins may be due to cardiac problems or anaemia.
Upper limbs;

They should be two with the same size and length, skin texture and muscle wasting. Palms examined for the colour, finger nails if capillary refill is good and oedema.
Chest; see how the mother is breathing to detect if the mother has problems with respiratory
system like pneumonia.

Breasts;
– Inspection.
Observe for size, equality, shape, pulling of breasts.
Signs of pregnancy, signs of abnormalities like changes in skin e.g. redness, orange like discoloration.
Nipple for prominence, dimpling retraction, size, flat, well protracted or not.
Presence of scars, cracks, sores, axillary extension.

– Palpation
Examined for breast abnormalities and deep seated masses.
This is done to promote proper breast feeding and exclude abnormalities.
Back; Check for any fungal infections, scars, sacral oedema( may indicate PET or Eclampsia)
Lower limbs
Size, muscle wasting, pain or stiffness of joints, pain in the calf muscles, oedema, varicose veins, extra digits, any infections, tibia and ankle oedema.
Feet; Hygiene, any fungal infections, nails check for venous return and colour. Sole of the feet for cleanliness and colour.
Perform a Homan’s test
Assess for maternal efforts.
Vulva;
Check for sores, warts, varicose veins, abnormal discharges etc.

Request mother to cough while observing for discharges.

Abdominal examination

It is carried out from 24 weeks gestation to establish and affirm that fetal growth is consistent
with gestational age during pregnancy.

AIMS

To observe signs of pregnancy.
To assess fetal size and growth.
To assess fetal health by auscultating the fetal heart.
To detect any deviations from normal
To diagnose the location of fetal growth.
To locate fetal parts.

Preparation/ procedure:
> Ensure mother has emptied the bladder within the last 30 minutes before abdominal examination.
> Ensure privacy
> Mother should be on a couch.
> Wash hands and expose only the area of the abdomen that needs to be palpated and cover the remainder of the woman to provide her privacy and protect her dignity.

STEPS

Inspection
Palpation
Auscultation

Inspection

Stand at the foot of the bed while mother is on her back with abdomen exposed from the xymphy sternum up to the symphysis pubis. Look at the size, shape, operational scars, signs of pregnancy like darkening of linea nigra below and above the umbilicus, fetal movements,
Striae gravidurum etc.

Palpation

> Abdominal palpation is also known as leopold’s maneuvers.
Stand at the right side of the mother, pads and not tips of fingers are used and palpate
as follows;-
> Superficial palpation for localized tenderness.
> Hypochondriac palpation for enlarged organs.
> Height of fundus estimation
Pelvic palpation for presentation
> Fundal palpation for the lie
> Lateral palpation for position
NOTE: During a deep pelvic palpation, a midwife grips the fetal head between the thumb and fingers to check for engagement, this maneuver is termed as pawlik’s grip/second pelvic grip.

Auscultation

This is the way of listening the fetal heart to determine fetal wellbeing by use of feto- stethoscope.
Abdominal summary
-Height of fundus
-Presentation
-Lie
-Position
-Fetal heart.
Case summary

Comment on all histories, general and abdominal examination.
> Feed back
> Advice
> Return date

ONGOING ANC

PURPOSE

To continue to observe for maternal health and freedom from infections.
To assess fetal wellbeing.
To ascertain that fetus has adopted a lie and presentation that will allow vaginal delivery.
To offer an opportunity to express any fear or worries about pregnancy and labour.
To ensure that mother and family are confident to decide when labour starts.
To discuss any views about the conduct of labour and formulate a birth plan if required.
Risk factors arising during pregnancy
Change in fetal mov’t pattern- increased or reduced
Hb less than 10g/dl
Poor weight gain or weight loss
Proteinuria
Bp above 140/90mmhg
Uterus large or small for dates
Excess or decreased liquor
Malpresentation
Any vaginal bleeding
Premature contractions
Vaginal infection
Head not engaged by 38weeks in PGs

On each visit, do the following
> Review the card and assess any past complaints
> Take BP, weight and test urine
> Carry out general and abdominal examination.
> Give drugs accordingly.

Indicators of fetal wellbeing

Increased maternal weight in association with increasing uterine size.
Fetal movements which follows a regular pattern throughout pregnancy.
Fetal heart rate between 120-160b/m

FOCUSSED ANC

FANC is goal oriented care that is client centered, timely, friendly, simple beneficial and safe to
pregnant women.
> It emphasizes quality over quantity of antenatal visits.
> It also looks at a woman as an individual and schedules the visits according to her needs.
The aim of FANC is to provide timely and appropriate care to women during pregnancy to
reduce the maternal morbidity and mortality as well as achieving the good outcome for the baby.

Goals of FANC

Early detection and treatment of existing diseases.
Prevention of diseases.
Promotion and maintenance of physical, mental and social health of the mother and the baby.
Early detection and management of complications during pregnancy, labour, delivery and puerperium.
Supporting clients to develop an individual birth plan and readiness plan for possible complications.

Elements of FANC

Identification and management of obstetric complications e.g. pre- eclampsia.
TT immunization.
IPT for malaria.
Identification and management of infections including HIV and other STIs.
Counseling for healthy behavior including nutrition, breastfeeding and family planning.

Characteristics of effective ANC

Well organized and prepared healthy facility.
Provision of care from a skilled and motivated health care provider.
Preparations for birth and potential complications.
Individualized based on mother’s needs.
Promotes linkage among providers and facilities to ensure continuity of care.
Woman- friendly care and inclusive of her partner or family to become active participants in the care.
Culturally appropriate.

FANC VISITS

Women with normal pregnancy should receive atleast 4 thorough, comprehensive, individualized
antenatal visits, spread out during the entire pregnancy.

1st visit: before 16 weeks of gestation.
2nd visit: from 20-24 weeks of gestation.
3rd visit: from 28-32 weeks of gestation.
4th visit: from 36-40 weeks of gestation.

Women of high risks should make 8 visits to ANC and different activities should be done on different visits.

STEPS OF FANC

Quick check:
Observation as the woman enters antenatal clinic/ room.
-General appearance i.e. facial expression, weight, energy, gait and stature.
Asking general screening questions to identify danger signs and symptoms such as severe
headache , PV bleeding, fever etc.
History taking:
This helps the service provider gather information about a woman.
It is important to ensure comfort and keeping privacy and keeping the information confidential.
Physical examination:
– General appearance
– Blood pressure
– Pulse and respiratory rates
– Weight, height
– Head to toe assessment
Investigations
– Hb, blood group and RH factor.
– Urinalysis for UTIs, albuminuria and glucosuria
– Stool for ova
– VDRL/ RPR for detection of syphilis
– VCT for HIV
Health education:
– Danger signs

For any of the following, seek immediate attention at the health facility

Mother	Fetus
Heavy bleeding	Breathing difficulties or no breathing
Severe headache	Yellowness of skin and eyes
Swelling of the feet and hands	Conulsions, twitching
High fever	Poor sucking /failure to feed
Placenta not delivered 30 minutes of the baby’s birth	Inactive child
Offensive vaginal discharge	Diarrhea or constipation
Blurred vision	Red swollen eyes
Convulsions	Redness or pus from umbilicus
Loss of consciousness	------------------------------------------------------------

Individual birth plan

The plan includes

A birth place where there is a skilled birth attendant
Identifying someone to take care of the family in her absence
My EDD
Her choice of birth companion.
Identifying a blood donor.
Her choice of clothes for labour.
Strategies for labour pain relief.
Position for labour and child birth.
Place of delivery.
Transportation to use and how it will be available
How to raise funds for transport and cost of delivery.
Family security and feeding provisions.
Family planning goals after baby is born.
Where to go after delivery.
Next appointment.

NB: Involve the partner in the birth planning process. Teach mother how to recognize onset of labour.
– Nutrition
– Sleep and resting
– Sexual counseling
– Hygiene
– Daily activities
– Weight gain
– Postnatal follow-up

6. Immunization:
– TT

RECORD AND INTERPRETE FINDINGS

After taking proper history, done a thorough physical examination and relevant investigations, record all findings in the antenatal card.
Interpret the findings so as to identify the risk factors.
Give care and management accordingly.
Give appointment for the next visit accordingly.

Assignment
Discuss the goal oriented antenatal protocol.

PELVIC ASSESSMENT.

This is estimation of the pelvic cavity so as to see whether its adequate for that particular baby to pass through.
OR It is an examination done by a doctor or midwife on a pregnant woman at or after 36weeks to
see that both the mother and baby are out of danger at the time of delivery.

It is always done at 36weeks because of the relaxation of the pelvic joints due to Relaxin hormone.

Aims
> To rule out poor obstetric history
> To ensure normal delivery of the mother without any assistance.
> To rule out abnormalities like prominent ischial spines, narrow sub pubic arch.
> To reduce infant and maternal mortality rate.
> To reduce injuries to both mother and fetus.

Pelvic assessment is done in 2 ways;-
-External Pelvic assessment
-Internal Pelvic assessment

EXTERNAL PELVIC ASSESSMENT /EXTERNAL PELVIMETRY

This is done on the 1st visit. It includes;-

History taking;

Age – Awoman of the age of 18 years is expected to have a mature pelvis but below 18 years, the bones are not fully ossified. A PG 35 years and above is expected to have difficult delivery because the ligaments of the pelvis are already fused there4 her give of the pelvis is impossible.
Tribe – it’s important to know the tribe because different tribes have different types of pelvis.
The Bakiga and Banyankole have a large normal pelvis but the Basoga and Baganda are at risk of contracted pelvis.
Marital status – It’s important to know the size of the husband because small women marrying giant men may carry big babies which can lead to CPD(Cephalopelvic Disproportion)
Medical history – It’s important to know because some diseases like poliomyelitis may affect the
growth of the pelvic bones and muscles.
Surgical history – Ask mother if she has ever had any accident involving her spine, pelvis and lower limbs.
Past obstetrical history – If the previous labour and delivery were normal, and if the baby weighed atleast 3kgs and over, she is expected to have an adequate pelvis. Hx of instrumental delivery or C/S may give a suspicion of an inadequate pelvis.

2. Observations

Gait;– always be alert on a woman who walks with a limp or who has muscle wasting of the legs.
A poor gait means a deformed pelvis hence reduced diameter. It indicates congenital hip deformity.
Height;– the normal average height in women is between 152-170 cm, below 152cm, may indicate a contracted pelvis and if above 170cm indicates a narrow birth canal.
Palms;-Those with short palms indicate a small pelvis
Shoe size;– the normal shoe size is 4-8. Shoe size below 4 indicates small pelvis.
Stature;- A woman of small stature and tiny waist is not expected to have an inadequate pelvis.

3. Abdominal examination

ENGAGEMENT OF THE FETAL HEAD(Head fitting)
NB: It’s no longer being practiced for fear of HIV transmission.
Procedure

Explain the procedure to the woman.
The bladder should be emptied.
The mother is relaxed flat on the bed with support on the pillow.
The midwife with the right hand locates the symphysis pubis while the other hand is under the mother’s head.
The mother takes a deep breath in and out
The head is pushed downwards and inwards
The fingers of the right hand should feel if the largest diameter of the fetal head is passing through the brim as the mother is supported to sit upright without relaxing the elbows.
The transverse diameter can be pushed through the pelvic brim. This test is called head fitting.

NB: It’s important that from 36weeks onwards, the abdomen is palpated to see if the head is engaged or can be made to engage.

INTERNAL PELVIC ASSESSEMENT(DIGITAL PELVIMETRY)

It’s done under aseptic technique. The midwife should know the measurement of her fingers.

Procedure:

Explain procedure and ask mother to empty bladder and rectum.
Prepare a VE tray and put it on the side of the bed.
Screen the bed
Ask mother to lie on her back and carry out abdominal examination.
The midwife measures the length of her fingers.
Position mother in dorsal and drape her.Right hand is gloved and two fingers of the gloved hand are lubricated, introduced and passed high into the vagina. The following are assessed.
Sacral promontory;
An attempt is made to reach the sacropromontory by assessing the diagonal conjugate which is 12-13cm. If short fingers less than 12-13cm reach it that shows it’s prominent.
Hollow of the sacrum;
It should be well curved and smooth. It should not be too long, if it’s flat the cavity is reduced and internal rotation of the fetal head will be difficult.
Pelvic walls;
These are felt and theyshould be smooth and flat. If they converge down wards, the mid cavity is
reduced.
Greater sciatic notches;
These should feel wide. If reduced, internal rotation of the head will be difficult.
Ischial spines;
They are palpated to see whether they are prominent. The distance between them is estimated.
Sub pubic arch;
Is measured and should not be less than 90 degrees. It should accommodate 2-3 fingers. A narrow sub pubic arch reduces the AP diameter of the pelvic outlet. Inter tuberous diameter; The distance between 2 ischial tuberosities can be assessed by inserting a closed fist between them, it should admit 4 knuckles.

NB: After the assessment, record findings and give feedback to the mother.

Antenatal Care Read More »

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 a period or two, she may suspect pregnancy and in most cases she is 98% correct if she has been menstruating regularly.

Signs of pregnancy are divided into 3 groups.

Presumptive
Probable
Positive

Presumptive signs

1. Amenorrhea; This is absence of menstruation. Mother may give a history of missing a period or two.
Amenorrhea may also be due to;- use of contraceptives, change of environment, long term illness and emotional upsets.

2. Breast changes; Mother may feel tingling and prickling sensations, breast enlargement and tenderness.

3. Morning sickness(nausea and vomiting); Occurs to 30-50% of the cases, it usually occurs from 4 th -14 th week of pregnancy. Other conditions may give raise to nausea and vomiting but vomiting in conjunction with amenorrhea is suggestive of pregnancy.(may disappear at end of first trimester).

4. Frequency of micturition; Caused by pressure of growing uterus on the bladder usually before 12weeks and decreases when
the uterus rises out of the pelvis at 12 weeks.

5. Skin changes; –
– Striae gravidurum appears on the 16 th week on the abdomen, thighs and breasts.
-Chloasma(mask of pregnancy).
-Linea nigra darkens and can be found below and above the umbilicus.
-Darkening of primary areolar and formation of secondary areolar.
The hormone responsible for the pigmentation of skin is produced by anterior pituitary gland and
it’s called melamine hormone.

6. Quickening; These are the first fetal movements experienced by the mother usually at 18-20 weeks in a PG
and 16-18 in a multi gravida. This helps a midwife to calculate the weeks of gestation if a mother does not know her dates.

7. Fatigue; due to increased blood production, lower blood sugar levels, and lower BP under the influence of progesterone.
Sleep disturbances and nausea may also contribute

8. Mood changes; Due to physical stress, metabolic changes, fatigue or by hormones progesterone and oestrogen.

Probable signs

1. Hagar’s sign;
This is detected from 6th -12th week. It is detected by performing a vaginal examination where 2 fingers are inserted into the anterior fornix of the vagina and another hand presses the uterus abdominally, when the fingers of both hands meet, softening if the isthmus is felt.

2. Jacquemier’s sign;
Is the bluish discoloration of the vaginal walls. It takes place from the 8th week onwards and is due to pelvic congestion an indication of pregnancy.

3. Osiander’s sign;
Its increased pulsation felt on the lateral vaginal fornices due to increased vascularity detected from the 8th week onwards.

4. Softening of the cervix (goodel’s sign)
This happens from the 8 th week onwards. The cervix of a pregnant woman is as soft as the lower lip and in a non- pregnant state is as soft as a tip of the nose.

5. Uterine soufflé;
This is a soft blowing sound heard on auscultation. It usually occurs from the 16th week due to increased vascularity of the uterus.

6. Abdominal enlargement;
The uterus enlarges rapidly and progressively from the 16 th week. This excludes gaseous distension, full bladder, fibroids and ascites.

7. Braxton hick’s contractions;
These are painless contractions which usually occur from the 16th week and are felt on abdominal palpation every 15 minutes.

8. Internal ballottement;
The uterus is given a sharp tap just above the cervix which causes the fetus to float upwards in amniotic fluid. The fetus sinks back again and it is felt by the fingers fixed in the vagina. Its detected from 16th-28th week of pregnancy.

9. Presence of HCG(Human chorionic gonadotrophin);
It can be detected in blood for 9 days and in urine 14 days. HCG can be detected in conditions like hydatid form mole.

Positive signs.

Those are signs that are definitely confirmed as pregnancy. They include;-

1. Fetal heart sounds; fetal heart begins beating by the 24th week following conception. It is audible with a Doppler by 10weeks and with a fetoscope by 24weeks. It should not be confused with uterine soufflé from pulsating fetal arteries. The normal fetal heart rate is 120-160 beats per minute.

2. Ultra sound scanning of the fetus; the gestation sac can be seen and photographed. An embryo as early as the 4th week can be identified. The fetal parts begin to appear by the 10th week of gestation.

3. Palpation of the entire fetus; Palpation must include fetal head, back, upper and lower body parts.

4. Palpation of fetal movement; this is done by a trained examiner. It is elicited after 24weeks of gestation.

5. X-ray; It will identify the entire fetal skeleton by the 12 th week. In utero the fetus receives total body radiation that may lead to genetic or gonadal alterations .An x-ray is not a recommended test for identifying pregnancy.

6. Actual delivery of the baby.

DIFFERENTIAL DIAGNOSIS

Enlargement of the abdomen may be caused by other conditions other than pregnancy, these
include;-

Ovarian cysts.
They may cause abdominal enlargement and when palpated abdominally, the swelling can be separated from the uterus and pregnancy tests will be negative.
Fibroids.
These may be mistaken for pregnancy and normally a hard mass is felt and when pregnancy tests are done, results are negative.
Distended urinary bladder.
In case of urine retention, the catheter will be passed and there will be no other signs of
pregnancy.
Pseudocyesis. In this condition, amenorrhea and other signs suggesting pregnancy will be given by a mother who is anxious to have a baby. When examination is carried out, signs of pregnancy are absent.

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

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.
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 weeksof 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.
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.
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.
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.
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.
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.
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 REPRODUCTIVE SYSTEM

CHANGES IN THE UTERUS:

It stretches and expands to accommodate and nurture the growing fetus. This occurs in the
myometrium. The body grows to provide a nutritive and protective environment in which the fetus will develop and grow.

Uterine muscle layers;
1. Endometrium;
– Menstruation stops.
-It becomes the decidua during pregnancy.
-It becomes thick, soft, spongy and readily supplied with blood.

2 . Myometrium.

The enlargement of the body of the uterus is due to 2 factors.
1. The actual muscle fibres enlarge increasing in length about 10 times and in width about 3 times.
This process is called hypertrophy (increase in size).
2. The new muscle cells make their appearance and grow alongside the original muscle cells. This process is called hyperplasia (increase in number).
The size; as pregnancy advances, the uterus grows from its normal size. The length being 7.5cm,
width 5cm and thickness 2.5cm. So it becomes 30cm in length, 23cm in width and 20 cm in
thickness. The weight increases from 60g to 960g.
The shape; Health growth of the uterus requires adequate space to accommodate the growing fetus, increasing amount of liquor and placental tissue. After conception, the uterus enlarges
because of Oestrogen. At the beginning of pregnancy, it is pear shaped organ, at the end of 12 weeks, it is globular, from 12-38weeks its oval shaped and when lightening takes place after 38weeks, it turns back to globular.

Muscle layers of the myometrium;

Outer most longitudinal layer,
This layer begins in the anterior wall of the upper uterine segment, passes over the fundus and down the posterior wall. It is by contraction and retraction of this muscle layer that the fetus is expelled from the uterus during labour.
Middle oblique layer,
In this case, muscles are arranged in criss cross manner; the muscle cells surround the blood vessels in the figure of 8 pattern. After separation and expulsion of the placenta, they compress the blood vessels and help to prevent PPH. They are sometimes referred to as living ligatures.
Inner circular layer,
This is the weakest of the 3 layers, the muscle fibres pass transversely around the uterus. They are more developed around the cervix, lower uterine segment and the fallopian tubes. They help in cervical dilatation.

3. The perimetrium;
This is the layer of the peritoneum which does not totally cover the uterus, its deflexed over the bladder anteriorly to form the utero vesicle pouch and posteriorly forming pouch of Douglas. After 12 weeks, the uterus rises out of pelvis and becomes an abdominal organ. It loses its ante-version and ante flexed position and becomes erect and leans on its axis on the right.

CLINICAL OBSERVATIONS OF THE GROWING UTERUS

At 12 weeks

The uterus is out of the pelvis and becomes upright; it is no longer anteverted and ante flexed. The uterus is palpable just above the symphysis pubis and is about the size of a grape fruit.

At 16 weeks

Between 12 and 16 weeks, the fundus becomes dome shaped. As it rises, it rotates to the right (dextrorotation) due to the recto sigmoid colon in the left side of the pelvis and exerts tension on the broad and round ligaments.
The conceptus has grown enough to put pressure on the isthmus causing it to open out so that the uterus becomes more globular in shape.

At 20 weeks

The fundus of the uterus may be palpated at the level of the umbilicus. The uterus becomes more rounded around the fundus.

At 30 weeks

The fundus may be palpated midway between the umbilicus and ximphoid sternum. Enlarging uterus displaces the intestines laterally and superiorly. Abdominal wall supports the uterus and maintains the relationship btn the long axis of the uterus and axis of the pelvic inlet.
In supine position, the uterus falls back to the vertebral column, aorta and inferior venacava.

At 36 weeks

By the end of 36 weeks, the enlarged uterus fills the abdominal cavity. The fundus is at the tip of the ximphoid cartilage.

At 38 weeks

Between 38 and 40 weeks, there is increase in smoothening and softening of the lower uterine segment. Uterus becomes more rounded with a decrease in fundal height. The reduction in fundal height is known as lightening.

Changes in blood supply: The uterine blood vessels increase in diameter and new vessels develop under the influence of Oestrogen. Blood supply to the uterine and ovarian arteries increases to about 750ml/ min at term to keep pace with its growth and meet the needs of the functioning placenta.

Changes in the fallopian tubes: On either side are more stretched out and are more vascular in pregnancy. Uterine end of the tube is usually closed and fimbriated end remains open.

Changes in the isthmus;
It softens and elongates from 7mm to23mm and forms the lower uterine segment during late pregnancy.

Changes in the ovaries:
The follicle- stimulating hormone {FSH} ceases its activity due to the increased levels of estrogen and progesterone secreted by the ovaries and corpus luteum .This prevents ovulation and menstruation. As the uterus enlarges, the ovaries are raised out of the pelvis. Also both ovaries are enlarged due to increased vascularity and become edematous particularly that containing the corpus luteum.
The corpus luteum enlarges during early pregnancy and may even form a cyst on the ovary. The corpus luteum produces progesterone to help maintain the lining of the endometrium in early pregnancy. It functions until about the 10th and 12th week of pregnancy when the placenta is capable of producing adequate amounts of progesterone and estrogen. It slowly decreases in size and function after the 10th to 12th week.

Changes in the cervix:
It remains tightly closed during pregnancy, providing protection to the fetus and resistance to pressure from above when the woman is in standing position. There is slight growth on the cervix during pregnancy, it becomes softer and this is due to increased vascularity and relaxing effects of hormones.
Under the influence of progesterone racemose glands secrete thicker and more viscous mucus which fills the cervical canal and prevents entry of infection in the uterus. The plug of mucous is called opeculum
Towards the end of pregnancy or at the onset of labour the cervix becomes part of the lower
uterine segment, this is called effacement of the cervix. The external os of the cervix also admits a finger. A short softened cervix or os which admits the
tip of a figure at term is referred to as ripe cervix.

Changes in the vagina:
The muscle layer hypertrophies and capacity of vagina increases and it becomes more elastic
allowing it to dilate during 2 nd stage.
The epithelium becomes thicker with increased desquamation of the superficial cells which
increase the amount of normal white virginal discharge known as leucorrhea. The epithelial cells have high glycogen content. The cells interact with Do-derlein’s bacillus and produce a more acidic environment providing extra degree of protection against some organism and increasing susceptibility to others such as candida albicans. The vagina is more vascular and appears violet in colour.

Changes in the vulva:
The vulva appears bluish in colour due to increased vascularity and pelvic congestion.

Breast changes:
-In early pregnancy, breasts may feel full or tingle and increase in size as pregnancy progresses.
-The nipples become more erectile.
– The areolar of the nipples darken and the diameter increases.
– The sebaceous glands become the Montgomery’s tubercles which enlarge and tend to
protrude.They secrete sebum to lubricate the breast throughout pregnancy and breast feeding.
– The surface vessels of the breast become visible due to increased circulation and turns to bluish
tint on the breasts.
-A little clear, sticky fluid(colostrum) may be expressed from the nipples after the 1 st trimester
which later becomes yellowish in colour.

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.

Maternal weight gain
Content weight
Uterus 1kg
Breasts 0.4kg
Fat 3.5kg
Blood volume 1.5kg
Extra cellular fluid 1.5kg
Total7.9kg
Fetal weight gain
Fetus 3.4kg
Placenta 0.6kg
Amniotic fluid 0.6kg
Total4.6kg
GRAND TOTAL12.5kg

The following factors influence weight gain.
Maternal oedema.
Maternal metabolic rate.
Dietary intake.
Vomiting or diarrhea.
Amount of amniotic fluid.
Size of the fetus.

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.

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 deliverysince 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, anxietyand 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.

Normal Pregnancy Read More »

Terminologies

TERMS USED IN MIDWIFERY

Midwifery: It is profession of providing assistance and medical care to women undergoing labour and child birth during antenatal, pre-natal and postnatal period.

Obstetrics: This is abranch of medicine dealing with pregnancy, labour and puerperium.

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

Cephalic: Means head.

Cervix: Is the neck of the uterus

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

Crowning: This is wherethe largest transverse diameter of the fetal skull escapes under the sub pubic arch and does not recede back between contractions.

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

Fetus: Human conceptus from the 9 th week to delivery.

Viability: Capability of living usually accepted 24weeks-28 weeks although survival is rare.

Gravida: Woman who is or has been pregnant regardless of pregnancy outcome.

Prime gravida: Woman pregnant for the first time.

Multi gravida: Woman who has been pregnant more than once.

Nuli Para: Woman who is not now and has never been pregnant.

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

Vernix caseosa: Is a greasy substance that covers the baby’s skin at birth.

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

Lightening: This is drop in fundal height.

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

Terminologies Read More »