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MODULE TITLE: MCH 410
(MATERNAL HEALTH 1)
2 TABLE OF CONTENTS
Title...1
Table of contents...2
Introduction...3
Module objectives...3
Time frame...4
Study skills...4
Need help...4
Assessments...4
Required resources...4
Module units...5
a) UNIT 1: HISTORY OF MATERNAL AND CHILD HEALTH...5
b) UNIT 2: HUMAN REPRODUCTION...9
c) UNIT 3: PREGNANCY...22
d) UNIT 4: LABOUR...36
e) UNIT 5: PUERPERIUM...51
Module summary...70
References...71
3 INTRODUCTION
Welcome to this module “Maternal Reproductive Health”
This is Module 1 of the Maternal, Neonatal and Child Health course (MCH 410). This module has been designed on the assumption that you have some prior training and experience in integrated reproductive health during your diploma training. The aim is to help you consolidate students’ theoretical knowledge and competency in essential details of clinical approaches and evaluation of obstetric patients as well as women with special needs. Nurses can not effectively practice without the required level of competency in managing pregnant women as it has been recommended that all pregnant women should be attended to by skilled attendants. Considering that you are a midwife or may not have done your midwifery you will probably have had problems in delivering quality antenatal, intrapartum and postnatal care and may have wondered how you could improve the care you are giving. Practice is usually informed by research findings and the current trends in terms of disease burden. In this module, you will be required to critically analyse current midwifery practices and issues affecting provision of women’s reproductive health services in Zambia and your area of practice. The module is organized in five study units starting with history of MCH, organization of MCH services, pregnancy, intrapartum, and peurperium. Each of the five units contains a statement of objectives, a textual narrative, self-test activities, assignments and case studies.
Module objectives
At the end of module 1, you should be able to:
1. Describe the history and trends of Maternal and Child Health (MCH) services.
2. Identify factors that affect the provision and delivery of MCH services 3. Describe the Anatomy and Physiology of the reproductive system 4. Discuss the physiology and management of normal pregnancy 5. Discuss the physiology and management of normal labour 6. Discuss the physiology and management of normal pueperium
4 TIME FRAME
We are assuming you will give at least 32 hours of study time and 52 hours clinical practice to this course.
STUDY SKILLS
Learners have different ways of learning and assimilating the material being learnt.
You should be able to identify which ones are the best ways for you. These are some of the tips that would help you (refer to the student’s handbook).
Make a study schedule that specifies the days and times each week and stick to it.
Keep the set aside days free of other activities
Work through the topics in the module systematically
Write short notes as you study
Write the points you think needs clarification at a later stage
NEED HELPIf you have any problems with your studies contact Institute of Distance Education, who will be able to help.
ASSESSMENTS
You will be required to write one individual assignment and one clinical assessment, two written tests for continuous assessments. The final examination will constitute a written and practical examination.
Required resources
You will need a textbook on maternal and child health preferably Myles textbook
for midwives and a book on applied anatomy and physiology to obstetrics, Slyvia
Verralls book may be of great help.
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UNIT 1
UNIT TITLE: HISTORY OF MATERNAL AND CHILD HEALTH
INTRODUCTION
Welcome to unit 1, HISTORY OF MATERNAL AND CHILD HEALTH
This unit should be able to challenge you to assimilate knowledge and develop the technical and critical thinking skills needed to apply that knowledge to practice. Nurses must strive to improve nursing practice on the basis of evidence. Professional nursing practice continues to evolve and adapt to society’s changing reproductive health priorities. The rapidly changing reproductive needs offer new opportunities for nurses to alter the practice of maternity nursing. The unit begins with history, trends and issues in MCH care. We also look at importance of statistics in MCH.
In addition you will undertake several activities to help you understand the evolution of the MCH services.
AIM: To enhance students’ knowledge and competence in identifying current trends in MCH and how to plan for future of MCH services.
UNIT OBJECTIVES
1. Describe the history of MCH
2. Identify current trends and issues in MCH care 3. Discuss the importance of statistics in MCH
4. Describe the organisation and planning of MCH in Zambia
5. Outline services that meet the health needs of mother and children in Zambia LIST OF EQUIPMENT NEEDED FOR STUDYING (Myles Textbook for Midwives) TIME REQUIRED
The total time required for this unit is 4 hours of study time.
6 CONTENT
Organised Maternal and Child Health (MCH) activities date back as far as 1964 when some Netherlands Public Health Nurses started the services. The services provided by then were antenatal care and under five years children services which placed emphasis on child nutrition, growth monitoring and immunisations.
In 1969 the first central MCH unit was established at Ministry of Health (MOH) headquarters.
The family planning and welfare association of Zambia was formed between 1970 – 71. The formation of the association was prompted by the high maternal and infant mortality caused mainly by the unsafe abortions.
In 1972 association was registered as family planning and welfare association of Zambia and later it became Planned Parenthood Association of Zambia (PPAZ). This association was the one that started modern family planning services here in Zambia.
MCH programme was therefore fully established and training of midwives (public Health Nursing) was started in 1972. In 197, family planning was integrated into the MCH services by the government.
In 1976 national immunisation campaigns started which later transformed into the Expanded Programme for Immunisation (EPI). In 1978 the primary health concept was adopted in Zambia at Alma ata conference.
Activity 1.1
Before you read further. What comes to mind when you hear the word Primary Health Care (PHC) in relation to maternal child health.
MCH is one of the concepts of PHC.
In 1979 MoH launched the family health programme with the aim of expanding child health nutrition and family planning services. In service trainings and incorporation of the family planning component in medical training were done.
In 1980 family health unit was formed and the unit had following components; training, IEC, service delivery and research. The training of family health nurses started in 1981. Despite all these developments the maternal mortality rate kept on rising. The safe motherhood initiative was launched in 1987 to address the problem. Their work is to raise awareness, providing technical assistance, mobilising resources and setting priorities.
In 1994 programme of action to improve reproductive health was launched. The reproductive health programme was to broaden the approach to MCH.
7 Assignment 1
From what has been discussed, outline what has evolved in the MCH services from the late 1990s to date. This should include the services introduced to minimise impact of current diseases on women of reproductive age and activities to help the country achieve the mellinuim development goals 4 and 5.
TRENDS AND ISSUES IN MCH CARE
• There has been marked economic, social, technological and environmental changes taking place worldwide. The nurses therefore need to be aware of these changes taking place and their implications for reproductive health care especially in maternal and child health nursing practice.
Assignment 1.3
You could have worked in a health facility offering reproductive health services and may have identified current trends and issues in the provision of these services. Some of them are listed below, for each of them read and explain what could have occurred in the recent past.
Current trends
1. Family centered care
2. Millennium development goals 4 and 5 3. Service delivery
4. Advanced technology 5. Decentralisation 6. Cost sharing 7. Early discharge
8. Community participation 9. Follow up care
Importance of statistics in MCH
Vital statistics relate to life and death events and specifically to the systematic collection of numerical data in order that they may be summarized and studied. The collection of these vital statistics allows for analysis of the rates of births and deaths in different population groups Activity 1.2
Identify the vital statistics that are of interest in MCH 1. --- 2. --- 3. --- 4. --- 5. ---
8 Sources of vital statistics relevant to MCH
1. From health institutions (HMIS data) 2. From census
3. Special programmes such as malaria, TB, leprosy as well as school health services 4. Epidemiological surveys
Uses of vital statistics
To measure the health status of the people and quantify their health problems.
It is used to determine populations at risk
Provide basic information about health status, patterns of diseases and factors that affect health.
To determine priority in allocating resources
They are used to measure progress by evaluating to what extent the set objectives are achieved
For local, national and international comparisons of health status.
This information assists in planning at national and local levels.
It forecast the needs of the community for health facilities, schooling, housing and so on.
PLANNING AND ORGANIZATION OF MATERNAL, NEONATAL AND CHILD HEALTH SERVICES
The Maternal, Neonatal and Child health (MNCH) section supports a broad array of programs in order to improve the availability of and access to high quality preventive and primary health care for all children and to reproductive health care for all women and their partners. The concept of an MNCH continuum of care is based on the assumption that the health and well being of women, newborns and children are closely linked and should be managed in unified way. Many things need to be considered when planning and organizing MCH services to make it easy for the mothers and children to access the services without difficulties. Planning and organizing also helps in effective management of the activities.
Organisation is defined as combination of necessary human beings, materials, tools, equipment and working space brought in a systematic and effective coordination to meet the goal (Basavanthappa, 2000). Organization of MCH services depends on the kind and number of staff, equipment, space available and attitude of local people. These will determine the level of care and the pattern of flow of clients, Time, Client flow pattern, Privacy and Equipment
Planning is a process of determining the objectives of administrative effort and devising the means calculated to achieve them (Basavanthappa, 2000).
When planning and organising MCH services the following should be put into considerations:
Personnel
Equipment
Supplies
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Transport
Staff incentives
Before you read any further, reflect on how the above mentioned considerations could help you plan and organise MCH services. Having reflected, what other considerations do you think can be made which could be help in effective planning and organisation of MCH.
Services offered in MCH clinic.
1. Maternal Health Services a) Ante natal care
This care given to pregnant women from the time pregnancy is confirmed up to the onset of labour.
b) Post natal care
This is care given to a woman within 6 weeks after delivery c) Family Planning
This refers to couple’s decision when and how many children they should have.
d) Health education
This is education given to all women attending MCH activities on various topics e.g.
Nutrition, prevention of malaria that promote health and prevent disease.
e) Detection and management of conditions such as anaemia, pre-eclampsia
This is done routinely as a woman comes for any MCH service e.g ANC, F/P etc.
f) Psychosocial counseling
This can be given during any of the services especially in Prevention of Mother To Child Transmission of HIV.
2. Child Health services
a) Growth monitoring and Promotion
This involves weighing and counselling of women on good nutrition practices, hygiene b) Immunizations etc
This involves giving vaccines against all childhood preventable diseases e.g. Polio, measles, tuberculosis etc.
c) Referral of complicated cases for further management
Such conditions include severe pneumonia, complicated malaria etc d) Nutrition demonstration
This is provided to women with under weight children at least once in a week
Food supplements such as High Energy Protein Supplements, cooking oil is also given to malnourished children.
Summary
In this unit you looked at the stages in the evolution of maternal and child health services in Zambia which culminated into the identification of the current trends in reproductive health.
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Additionally, you also looked at use of vital statistics in MCH and finally you went on to describe the planning and organisation of the MNCH services. For you to be able to plan and organise the MNCH services, you went on to look at the services that are offered to mother and children in Zambia to be able to meet their health needs.
Unit 2 : Human Reproduction
Introduction
For you to be able to proceed to this unit you should have successfully completed unit 1 on this module. This unit has been designed on the assumption that you have some prior knowledge on the anatomy and physiology of the human reproductive system in your anatomy and physiology module. It’s aim is to help you review the anatomy of the human reproductive system and how it can be applied to obstetrics.
Aim: To enhance student’s knowledge on the human reproductive system and its importance during antenatal, intrapartum and puerperal care.
Unit objectives
Review anatomy and physiology of the female reproductive system
Review of the anatomy and physiology of the male reproductive system
Discuss the female pelvis
Describe the fetal skull in relation to the female pelvis
Review anatomy of the female breast
Discuss the menstrual cycle
List of equipment needed for studying: Sylvia Verrals Text book Time required
This unit may take a week to work through.
CONTENT
FEMALE REPRODUCTIVE SYSTEM
11 Reading
Before you proceed with reveiw of the human reproductive system. Refer to Sylvia Veralls anatomy and physiology applied to obstetrics for the diagrams of the female and male reproductive organs (internal and external structures).
The external female genetalia (vulva)
Mons veneris – pad of fat lying over symphysis pubis, covered with pubic hair from the time of puberty
Labia majora – two folds of fat and areolar tissue covered with skin and pubic hair on the outer surface.
Labia minora – two thin folds of skin lying between the labia majora. Anteriorly they divide to enclose the clitoris, posteriorly they fuse to form the fourchette
Clitoris – a small rudimentary organ corresponding to the male penis. Extremely sensitive, highly vascular and plays a part in the orgasm of sexual intercourse
Vestibule – area enclosed by the labia minora in which are situated the openings of the urethra and the vagina
Urethra orifice – lies 2.5cms posterior to the clitoris. On either side lie the openings of the skene’s ducts, two small blind ended tubules 0.5cms long running within the urethral wall.
Vaginal orifice – also known as introitus occupies the posterior 2/3 of the vestibule.
Partially closed by hymen, which tears during sexual intercourse carunculae myrtiformes
Bartholins’s glands – two small glands that open on either side of the vaginal orifice and lie the posterior part of labia majora. They secrete mucus and lubricate the vagina openings.
Blood supply comes from the internal and external pudendal arteries. Lymphatic drainage is mainly via the inguinal glands. Nerve supply is from branches of the pudendal nerve.
The nerves supply the erectile tissue of the vestibular bulbs and clitoris and their parasympathetic fibres have a vasodilator effect.
THE INTERNAL FEMALE GENATALIA
The vagina – canal running from the vestibule to the cervix, passing upwards and backwards into the pelvis, almost parallel to the pelvic brim. Anterior – bladder and urethra, posterior – pouch of douglas, rectum and perineal body, lateral – on the either side of the upper 2/3 are the pelvic fascia and ureters, lower 1/3 are muscles of the pelvic floor; superior – uterus, inferior – external genatalia. Posterior wall is 10cm and anterior 7.5cm because the cervix projects at right angle into its upper part. Branches of the internal iliac artery, vaginal artery and descending branch of uterine artery.
Corresponding veins. Inguinal, internal iliac and the sacral glands. Pelvic plexus.
The uterus – well supported by transverse cervical ligaments, uterosacral ligaments, pubocervical ligaments, broad ligaments and round ligaments at the level of the cervix.
Non- pregnant uterus is hollow, muscular, pear shaped and situated in the true pelvis.
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7.5cm long, 5cm wide, 2.5cm depth and 1.25cm thick. It constists of the body, fundus, cornua, cavity, isthmus (narrow area between the cavity and cervix; 7mm long and in pregnancy becomes lower uterine segment; cervix protrudes into the vagina, upper ½ is supravaginal portion and lower is infravaginal portion. Endometruim, myometruim and perimetruim.
The fallopian tubes – extend laterally from the cornua of the uterus towards the sidewalls of the pelvis. They arch over the ovaries; fringed ends hovering near the ovaries. Anterior, posterior and superior – peritoneal cavity and intestines; lateral sidewalls of pelvis; inferior – broad ligaments and fallopian tubes; medial – uterus lies in between.
The ovaries – attached to the back of the broad ligaments within the peritoneal cavity.
Produce ova oestrogen and prgestrone. Anterior – broad ligaments; posterior – intestines;
superior – fallopian tubes and medial – uterus and ovarian ligaments.
The breasts – linked with the female reproductive system. It has the medulla and cortex.
MALE REPRODUCTIVE SYSTEM
Penis – carries the urethra, which is a passage for both urine and semen. Root lies in the perineum, from where it passes forwards below the symphysis pubis. The lower 2/3 is outside the body in front of the scrotum
Scrotum – forms a pouch in which the testes are suspended outside the body. It lies below the symphysis pubis and between the upper parts of the thighs behind the penis. The scrotum has two compartments for each testis.
Testes – male gonads and produce spermatozoa and testosterone situated in the scrotum
Spermatic duct – passes upwards through the inguinal canal, continues upwards over the symphysis pubis, arches backwards beside the bladder. Behind the bladder it merges with the duct from the seminal vesicle and passes through the prostate gland as the ejaculatory duct to join the urethra.
Seminal vesicle – two pouches situated posterior to the bladder. Produces viscous secretion to keep the sperm alive and motile
Ejaculatory ducts – two small muscular ducts that carry spermatozoa and seminal fluid to the urethra.
Prostate gland – surrounds the urethra at the base of the bladder, lying between the rectum and the symphysis pubis. Produces a thin lubricating fluid that enters the urethra through ducts Bulbo urethral glands – two very small glands, which produce a lubricating fluid that passes into the urethra just below the prostate gland
13 THE FEMALE PELVIS
Reading
Refer to the Myles texbook for midwives for the diagram of the pelvic bones, pelvic floor muscles and the features of the four types of pelvis.
The pelvis forms a bony canal through which the fetus must pass during the process of birth, and if the canal is of average shape and dimensions the baby of normal size will negotiate it without difficulty. Knowledge of pelvic anatomy is also needed in the conduct of labour, progress of labour is estimated by the relationship of the presenting part to certain pelvic land marks.
PELVIC BONES
The pelvis is composed of four bones;
Two innominate bones
Sacrum
Coccyx
1. The innominate bone consist of the ilium, ischium and os pubis a) The ilium
It is the large flared out part, its anterior concave surface is known as the iliac fossa.
The iliac crest is the upper curved border and the terminal points are known as iliac spines.
b) The ischium
It is the lowest part of the innominate bone, the body rests on the ischial tuberosities when in a sitting position.
Posterior and superior to the tuberosity is a projection known as the ischial spines, a useful land mark when making a vaginal examination during labour.
c) The os pubis
Consist of a body, superior and inferior ramus.
The two inferior rami form the pubic arc.
The two pubic bones meet at the symphysis pubis.
2. The sacrum
It is a wedged shaped bone composed of five vertebrae.
The centre of the upper surface of the first sacral vertebra is known as the sacral promontory.
It is an important land mark when assessing engagement of the fetal head.
The anterior surface of the sacrum is concave and is referred to as the hollow of the sacrum
3. The coccyx
It is a small bone consisting of four coccygeal vertebrae fused together.
14 THE PELVIC JOINTS
There are four pelvic joints:
a) Two sacral iliac joints
It is formed at the articulation of the sacrum with the ilium and allows limited backwards and forward movement of the sacral promontory.
b) The symphysis pubis
It is formed at the junction of the two pubic bones. The joint widens appreciably during the last months of pregnancy.
c) Sacro-coccygeal
It is formed where the base of the coccyx articulates with the tip of the sacrum. It allows the coccyx to bend backwards during the actual birth of the fetal head.
The pelvic ligaments
The ligaments binding the sacrum and the ilum at the sacro iliac joint are strongest in the whole body.
The interpubic ligaments strengthen the symphysis pubis.
The sacro- tuberous ligaments form an attachment between the sacrum and the ischial tuberosities.
The sacro spinous ligament connects the sacrum with the spine of the ischium.
The bony pelvis
It is divided into two parts
The false pelvis
The true pelvis.
The false pelvis is the part above the brim and consists of the flared out iliac bones. It has little obstetric importance.
THE TRUE PELVIS The Brim
It is round except where the sacral promontory projects into it. The promontory and wings of the sacrum form its posterior border, lateral border is formed by the iliac bones and anteriorly it’s the pubic bones. The landmarks are
Sacral promontory
Sacra ala
Sacroiliac joint
Iliopectineal line
Iliopectineal eminence
Superior ramus of the pubic bone
Upper in border of the body of the pubic bone
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upper inner body of the symphysis pubis Diameters of the brim
1. Anteroposterior diameter
This diameter is from the sacral promontory to the upper border of the symphysis pubis.
when the line is taken from the uppermost point of the symphysis pubis – anatomical conjugate (12cm)
when it is taken from the posterior border of the upper surface (1.25cm lower) – obstetrical conjugate 11cm
Measurement from the lower border of the symphysis pubis to the sacral promontory – diagonal conjugate 12- 13 cm.
2. Oblique diameter
This is a diameter measured from one sacroiliac joint to the iliopectineal eminence on the opposite side of the pelvis – 12cm
3. Transverse diameter
This is a line between the points furthest apart on the iliopectineal lines- 13cm.
The cavity
It extends from the brim above to the outlet below and is circular – 12 cm. the anterior wall is formed by the pubic bones and symphysis pubis and its depth is 4cm. the posterior wall is formed by the curve of the sacrum, which is 12cm in length. Laterally are the sides of the pelvis.
The outlet There are two
The anatomical outlet
The obstetric outlet.
The anatomical outlet is from the lower border of each of the bones together with the sacrotuberous ligament.
The obstetric outlet is of greater practical significance. It lies between;
sacrococcygeal joint
the two ischial spines
Lower border of the symphysis pubis.
It is diamond shaped and has three diameters.
Diameters
Anteroposterior diameter
it is from the lower border of the symphysis pubis to the sacrococcygeal joint 13cm.
Oblique diameter between the oburator foramen and sacrospinous ligament 12
cm. Transverse diameter between the two ischial spines 10 – 11cm. it is the narrowest diameter in the pelvis
16 TYPES
The classification of the pelvis into four major types (gynecoid, android, anthropoid, and platypelloid) helps you as a student to understand the possible difficulties that may arise in a laboring patient. A quote that should be remembered is: "No two pelves are exactly the same, just as no two faces are the same. For each pelvis there is an optimum mechanism that may be wholly different from the so-called normal mechanism of labour that will be described later.
An important principle is that most pelves are not purely defined but occur in nature as mixed types. Regardless of the shape, the baby will be delivered if size and positioning remain compatible. The narrowest part of the fetus attempts to align itself with the narrowest pelvic dimension (e.g., biparietal to interspinous diameters) which means the occiput generally tends to rotate to the "most ample portion of the pelvis."
GYNAECOID
This is the ideal pelvis for child bearing. It has a rounded brim, generous fore pelvis, straight side walls converge, making it a funnel shape with a broad, well curved sacrum, blunt ischial spines, a rounded sciatic notch and a sub pubic angle of 90 degrees.
ANDROID
This is a male pelvis. The brim is heart shaped with narrow fore pelvis, has transverse diameter that is towards the back, side walls converge, making it a funnel shape with deep cavity and a straight sacrum. The ischial spines are prominent, the sciatic notch is narrow and sub pubic angle is less than 90 degrees. This type of the pelvis predisposes to occipitoposterior position of the fetal head.
ANTHROPOID
This has a long oval brim in which the anteroposterior diameter is longer than the transverse. The side walls diverge, the sacrum is long and deeply concave, ischial spines are not prominent and the sciatic notch is very wide as is the sub pubic angle.
PLATYPELLOID
This flat pelvis has a kidney shaped brim in which the Anteroposterior diameter is reduced and the transverse diameter increased. The sidewalls diverge, the sacrum is flat, the cavity is shallow, the ischial spines are blunt and the sciatic notch and the sub pubic angle are both wide.
PELVIC INCLINATION
When a woman is standing in an upright position, her pelvis is on an incline. The brim is tilted and if the line joining the sacral promontory and top of the symphysis pubis were to be extended, it would form an angle of 60 degrees with the horizontal floor. Similarly, if a line joining the centre of the sacrum and the centre of the symphysis pubis were extended, the resultant angle with the floor would be 30 degrees. The angle of inclination of the outlet is 15 degrees. A line drawn exactly between the anterior wall and the posterior wall of the pelvic canal would trace a curve – the curve of carus.
17 ASSESSMENT OF PELVIC CAPACITY
Measuring of diagonal conjugate per vaginum
Intertuberous diameter
Prominence of the ischial spines
Ultra sound to measure pelvic size by pelvimetry
X ray pelvimetry.
PELVIC FLOOR
The soft tissues that fill the outlet of the pelvis form the pelvic floor. The most important of these is the strong muscle slung like a hammock from the walls of the pelvis, through which the vagina and anal canal pass.
FUNCTIONS
Supports the weight of the abdominal and pelvic organs.
Its muscles are responsible for the voluntary control of micturation and defecation.
Plays an important part in sexual intercourse
During labour it influences the passive movements of the fetus through the birth canal and relaxes to allow the exit of the fetus from the pelvis.
MUSCLE LAYERS Superficial layer
External anal sphincter – encircles the anus and is attached behind by a few fibres to the coccyx.
Transverse perineal muscles – pass from the ischial tuberosities to the centre of the perineum.
Bulbocavernosus muscles – pass from the perineum forwards around the vagina to the corpora cavernosa of the clitoris just under the pubic arch.
Ischiocavernosus muscles – pass fro the ischial tuberosities along the pubis arch to the corpora cavenosa.
Membranous sphincter of the urethra – composed of muscles fibres passing above and below the urethra and attached to the pubic bone. It is not true sphincter since it is not circular but it acts to close the urethra.
Deep layer (levator ani muscles)
Pubococcygeus muscles – passes from the pubis to the coccyx, with a few fibres crossing over in the perineal body to from its deepest part.
Iliococcygeus muscle – passes fro the fascia covering the obturator internus muscle to the coccyx
Ischiococcygeus muscle – passes from the ischial spine to the coccyx, in front of the sacrospinous ligament.
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Between the muscles layers and also above and below them, there are layers of pelvic fascia. The tissue that fills the triangular space between the bulbo cavernosus, the ischio cavenosus and the transverse perineal muscles is known as the triangular ligament.
PERINEAL BODY
This is a pyramid of muscle and fibrous tissue situated between the vagina and the rectum. It is made up of fibres described above. The apex is the deepest part and is formed the fibres of the fibres of the pubococcygeus muscle, which cross over at this point.
The base is formed from the transverse perineal muscles, which meet in the perineum together with the bulbocavernosus in front and the external anal external anal sphincter behind. Each direction of the perineal body measures 4cm.
THE FETAL SKULL
The fetal skull contains structures which may be subjected to great pressure as the head passes through the birth canal.
It is larger in comparison with the true pelvis.
The head is the most difficult part to deliver whether it comes first or last.
The bones of the fetal head originate in two different ways.
1. The face is laid down in cartilage and is almost completely ossified at birth.
2. The bones of the vault are laid down in membranes and are much flatter and pliable.
They ossify from the centre outwards and the process is in complete at birth Bones of the vault
There are five main bones in the vault of the skull.
1. The occipital bone
It lies at the back of the head.
Part of it contributes to the base of the skull
It contains the foramen magnum which protects the spinal cord 2. The parietal bones
They lie on either side of the skull
The ossification centre of each is called the parietal eminence 3. Frontal bones
The two frontal bones form the forehead or sinciput.
At the centre of each is a frontal boss or frontal eminence.
The frontal bones fuse into a single bone by 8 years
In addition to the five is the temporal bone is also flat forms a small part of the vault.
Sutures and Fontanelles
Sutures are cranial joints and are formed where the bones adjoin.
Where two or more sutures meet, a fontanelle is formed.
Sutures of obstetric importance
Lambdoidal suture: - it separates the occipital bone from the two parietal bones.
Sagittal suture:- lies between the two parietal bones
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Coronal suture: - separates the frontal bones from the parietal bones, passing from one temple.
Frontal suture: - runs between the two halves of the frontal bone.
Posterior fontanelle
It is situated at the junction of the lambdiodal and sagital sutures.
It is small and triangular in shape
It can be recognised vaginally because a suture leaves from each of the three angles.
It closes by 6 weeks of age.
Anterior fontanelle
It is found at the sagittal, coronal and frontal sutures
It is broad and kite shaped
It normally closes by the time the child is 18 months old
Pulsation of the celebral vessels can be felt through it.
The sutures and fontanelles allow overlapping of bone during labour and delivery Regions and Landmarks
The skull is divided into 1. Vault
2. Base 3. Face Vault
It is large and dome shaped part
It lies above an imaginary line drawn between the orbital ridges and the nape of the neck
The bones are thin and pliable at birth which allows the skull to alter during labour and delivery.
The base
It is comprised of bones which are firmly united to protect the vital centres in the medulla.
The face
It is comprised of 14 small bones which are also firmly united and non compressible Regions of the skull
The occiput: - lies between the foramen magnum and the posterior fontanelle.
The vertex: - is bounded by the posterior fontanelle, the two parietal eminences and the anterior fontanelle.
The sinciput or brow: - extends from the anterior fontanelle and suture to the orbital ridges.
The face : - is small in the newborn baby.
It extends from the orbital ridges and the root of the nose to the junction of the chin and the neck.
The point between the eyebrows is known as the gabella, the chin is termed the mentum ANATOMY AND PHYSIOLOGY OF THE BREAST
Knowledge of anatomy and physiology of the breast is important to understand the fact that during breast feeding not only the breasts are affected, but the mother’s whole body and emotions become involved. This knowledge will assist you as a nurse to teach pregnant women
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and post natal mothers on milk production. Breastfeeding for the first 6 months of life is the ideal start for babies and nurses have a key role in supporting mothers who are unable to or choose not to breastfeed. As a nurse you have an important role in ensuring families safely and appropriately feed their babies.
How would you describe the breast? To help you with the description, refer to the cross section of the breast diagram in the Myles textbook for midwifives.
In the diagram you have just referred to, you can come up with a description such as this one.
The breasts are compound secreting glands, composed of two parts, the parenchyma (glandular tissue) and the stroma.
Take note that the anatomy and physiology of the breast will help you understand the physiology of lactation in the module you will be looking at postnatal. You are therfore required to read futher in the book syvia veralls, anatomy and physiology applied to obstetrics.
MENSTRAUAL CYCLE
The biological cycles of a woman follow a monthly pattern and have a profound influence on her life and behaviour. When a woman is sexually active and no fertility control is used, recurring pregnancies will intervene and may obliterate the pattern for most of her fertile life. The hypothalamus is the ultimate source of control and it governs the anterior pituitary gland by hormonal pathways. The anterior pituitary gland in turn governs the ovary by hormones, the ovary produces hormones that control changes in the uterus. All these changes occur simultaneously and in harmony. A woman’s mood may change along with the cycle because of the close relationship between the hypothalamus and the cerebral cortex.
The ovarian cycle
The ovarian cortex contains 200 000 primordial follicles at birth. Form puberty on wards, certain follicles enlarge and one matures each month to liberate an ovum. The ovum is situated at one end of the Graafian follicle. The whole follicle is lined with granulose cells and contains follicular fluid. The outer coat of the follicle is the external limiting membrane and around this lies an area of compressed ovarian stroma known as the theca.
Under the influence of follicle stimulating hormone (FSH) and later, luteinising hormone (LH) the Graafian follicle matures and moves to the surface of the ovary. At the same time it swells and becomes tense, finally rupturing to release the ovum into the fibriated end of the uterine tube, which is cupped underneath the ovary in readiness. This is what is known as ovulation,
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some women feel pain at this time, and this may be related to small loss of blood into the peritoneal cavity.
After ovulation the follicle collapses, the granulose cells enlarge and proliferate over the next 14 days and the whole structure becomes irregular in outline and yellow in colour. The ovary contains a number of these white bodies in varying stages of degeneration.
Ovarian hormones Oestrogen
This comprises a number of compounds including oestriol, oestradiol and oestrone. They are produced under the influence of FSH by the granulose cells and the theca in increasing amounts until the degeneration of the corpus lutuem when the levels fall. During the cycle, estrogen causes the proliferation of the uterine endometrium. It inhibits FSH and encourages fluid retention.
Progesterone
It is produced by the corpus luteum under the influence of LH. It acts only on tissues that have previously been affected by estrogen. The effects of progesterone are mainly evident during the second half of the cycle. It causes secretory changes in the lining of the uterus, when the endometrium develops tortuous glands and enriched blood supply in readiness for the possible arrival of a fertilized ovum. It causes the body temperature to rise by 0.5 degrees Celsius after ovulation and gives a tingling and sense of fullness in the breasts prior to menstruation.
Pituitary control
Under the influence of the hypothalamus which produces gonadotrophin releasing hormone (GnRH), the anterior pituitary gland secretes two gonadotrophins: LH and FSH. The gonadotrophin activity of the hypothalamus and the pituitary is influenced by positive and negative feedback mechanism from ovarian hormones.
FSH. The hormone causes several Graafian follicles to develop and enlarge, one of them more than all the others. FSH stimulates the granulose cells and theca to secrete oestrogen. The level of FSH rises during the first half of the cycle and when the oestrogen level reaches a certain point its production is stopped.
LH. This is first produced a few days after the anterior pituitary starts producing FSH. Rising oestrogen causes a surge in both FSH and LH levels, the ripened follicle ruptures and ovulation occurs. Levels of both gonadotrophins then fall rapidly. Progesterone inhibits any new rise in LH in spite of high oestrogen levels rise again to begin a new cycle.
The uterine or menstrual cycle
Each woman has an individual cycle that varies in length, the average is 28 days long and recurs regularly from puberty to menopause except when pregnancy intervenes. The first day of the cycle is the day on which menstruation begins. There are three main phases and they affect the tissue structure of the endometrium, controlled by the ovarian.
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The menstrual phase This phase is characterized by vaginal bleeding which lasts for 3-5 days.
The endometrium is shade down to the basal layer along with the unfertilized ovum.
The proliferative phase This follows menstruation and lasts until ovulation. The first few days while the endometruim is reforming are described as regenerative phase. This phase is under the control of oestrogen and consists of the regrowth and thickening of the endometrium. At the completion of this phase the endometrium consists of three layers, the basal, functional and the layer of cuboidal ciliated epithelium which covers the functional layer which contains tubular glands and is 2.5 mm thick.
The secretory phase This phase follows ovulation and is under the influence of progesterone and oestrogen from the corpus luteum. The functional layer thickens to 3.5 mm and becomes spongy in appearance because the glands are more tortuous.
summary
You have worked so hard to reach this far. In this unit you have looked at the male and female reproductive system, the female pelvis and the fetal skull. You went on to look at the female breast and menstruation. The knowledge you have acquired will help you understand the following unit. Continue working hard and proceed to the next unit.
Unit 3 Pregnancy
INTRODUCTION
In this unit you will discuss fertilization, early development of the fetus and physiological changes in pregnancy. The content of this unit has been developed with an assumption that you have successfully finished the module on anatomy and physiology of the human reproductive
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system. After you understand the process of fertilization you will be required to manage a pregnant woman. The last part will involve you discussing the management of normal labour.
unit objectives
1. Discuss the fertilization and early development of a fetus 2. Identify physiological changes in pregnancy
3. Review the diagnosis of pregnancy
4. Discuss antenatal care of a pregnant woman
5. Provide a rationale for common disorders in pregnancy
You have to dedicate at least about 8 hours to this unit for you to be able to understand the concept of management of a pregnant woman.
CONTENT
Fertilization and development Activity
What comes to mind when you hear the term, fertilisation?
Human fertilization, known as conception, is the fusion of the sperm with the secondary oocyte, to form the zygote. This process occurs in the ampulla of the fallopian tube and it takes approximately 24 hours.
After ovulation the ova is wafted along by cilia and the peristaltic muscular contraction of the uterine tube. Approximately 300 million sperms are deposited in the posterior fornix of the vagina at intercourse. Once the sperm reaches the fallopian tubes they undergo a process known as capacitation. Influenced by secretions from the uterine tube the sperm undergo changes to the plasma membrane, resulting in the removal of the glycoprotein coat. The acrosomal layer of the sperm becomes reactive and releases the enzyme hyaluronidase known as the acrosome reaction, which disperses the corona radiate allowing access to the zona pellucida.
The first sperm that reaches the zona pellucida penetrates it. Penetration of the zona pellucida penetrates oocurs with aid of several enzymes processed by the sperm which break down the
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proteins of the zona layer. Upon penetration a chemical reaction known as the cortical reaction occurs. The cortical reaction alters the zona pellucida making it impermeable to other sperm.
After the plasma membranes of the sperm and the ova fuses the ova completes its second meiotic division and become mature. The pronucleus now has 23 chromosomes, refered to as haploid.
The male and female pronuclei fuse to form a new nucleus that is a combination of the genetic material from both the sperm and oocyte. The male and the female gametes each contribute half the complement of chromosomes to make a total of 46. This new cell is called a zygote.
Development of the zygote
The development of the zygote can be divided into three periods. The first 2 weeks after fertilization referred to as the pre-embryonic period includes the implantation of the zygote into the endometruim; weeks 2 -8 are known as the embryonic period and weeks 8 to birth, are known as the fetal period.
The zygote divides into two cells at 1 day, then four at 2 days, eight by 2.5days, 16 by 3 days, now known as the morular.
Cavitation occurs whereby the outermost cells secrete fluid into the morular and a fluid – filled cavity or blastocele appears in the morula. This results in the formation of the blastocyst, comprising 58 cells.
The blastocyst possesses an inner cell mass and outer cell mass or trophoblast. The trophoblast becomes the placenta and chorion, while the embroblast becomes the embryo, amnion and umbilical cord.
During week 2, the trophoblast proliferates and differentiates into 2 layers: the outer syncytiotrophoblast and the inner cytotrophoblast.
The syncytiotrophoblast layer invades the deciduas by forming finger like projections called the villi
The villi begin to branch, and contain blood vessels of the developing embryo thus allowing gaseous exchange between the mother and embryo.
The cells of the embryoblast differentiate into two types of cells: the epiblast and the hypoblast. The epiblast cells give rise to cells of the embryo.
Each layer of epiblast cells, of which there are three, will form particular parts of the embryo. The first appearance of these layers, collectively known as the primitive streak, is around day 15.
The ectoderm is the start of tissue that covers most surfaces of the body: the epidermis layer of the skin, hair and nails. Additionally it forms the nervous system.
The mesoderm forms the muscle, skeleton, dermis of skin, connective tissue, the urogenital glands, blood vessels and blood and lymph cells.
The endoderm forms the epithelia lining of the digestive, respiratory and urinary systems, and glandular cells of organs such as the liver and pancreas.
The mature placenta
The placenta is completely formed and functioning 10 weeks after fertilization. Between 12 and 20 weeks’ gestation, the placenta weighs more than the fetus because the fetal organs are insufficiently developed to cope with the metabolic processes of nutrition.
25 The following are the functions of the placenta
1. Respiration
During the intrauterine life, no pulmonary exchange of gases can take place so the fetus must obtain oxygen and excrete carbon dioxide through the placenta.
2. Nutrition
The fetus needs nutrients for growth and development. The nutrients are actively transferred from the maternal to the fetal blood through the walls of the villi. The placenta is able to select those substances required by the fetus.
3. Storage
The placenta metabolises glucose, stores it in the form of glycogen and reconverts it to glucose as required.
4. Excretion
The main substance excreted from the fetus by the placenta is carbon dioxide. Amounts of uric acid and urea are also excreted though in very small amounts.
5. Protection
The placenta provides a limited barrier to infection. This is so because some few bacteria e.g Treponema of syphilis, tubercle bacillus and some substances like alcohol can cross the placenta barrier.
6. Endocrine
The placenta produces the following hormones human chorionic gonadotrophin, oestrogen, progesterone which helps maintain the pregnancy, while human placenta lactogen has a role in glucose metabolism during pregnancy.
The membranes
There are two membranes, an outer one (chorion) and the inner one (amnion). The chorion is a thick opaque friable membrane derived from the trophoblast. The amnion is a smooth tough translucent membrane derived from the inner cell mass. It lines the chorion and the surface of the placenta continuing over the outer surface of the umbilical cord.
Amniotic fluid
This is a clear, alkaline and slightly yellowish liquid contained within the amniotic sac. The fluid is said to have originated from both fetal vessels in the placenta and maternal vessels in the decidua. Some of it is secreted by the amnion covering the placenta and umbilical cord and urine from the fetus also contributes. The amniotic fluid distends the amniotic sac allowing the growth and free movement of the fetus it permits symmetrical musculoskeletal development. It maintains a constant intra uterine temperature and it protects the fetus from jarring and injury. It also protects the placenta and the umbilical cord from the pressure of the uterine contractions during labour.
26 Reading
Read and take some notes from Myles textbook for midwives on the constituents and the volume of the amnoitic fluid. After reading before you proceed to the next topic. In the same book, look at a diagram of the cross section of the umblical cord.
The umbilical cord
The umbilical cord extends from the fetal surface of the placenta to the umbilical area of the fetus, it is formed by the 5th week of pregnancy. The umbilical cord contains two arteries and one vein, which are continuous with the blood vessels in the chorionic villi of the placenta. The cord transports oxygen and nutrients to the developing fetus and removes waste products. A normal cord is approximately 1-2cm in diameter and 40 – 50cm in length.
Summary
Having gone through fertilisation, early development of the fetus and development of the placenta and its function, you could have realised that these alter the woman’s normal physiological functions. The knowledge you have gained will help you understand the next topic; physiological changes in pregnancy. For a woman to be able to cope with the physiological and emotional stressess during pregnancy, she needs support from you as nurse who has an understanding on what is happening with her.
Physiological changes in pregnancy
Physiological and anatomical alterations develop in many organ systems during the course of pregnancy and delivery. Early changes are due to metabolic demands and later changes are anatomic in nature.
• Skin changes
• Usually present in the 5-6th month
• Chloasma “mask of pregnancy”
• These are irregular brownish discoloration of the forehead, nose, cheeks and neck.
• Darkening of the midline of the lower abdomen from symphysis pubis to the umbilicus (linea nigra).
• This is due to the hormones estrogen and progesterone which increases melanin.
Breast
• 3 – 4 weeks pricking and tingling sensation due to increased blood supply around the nipple.
• 6-8 weeks. Increase in size, painful, tense and nodular due to hypertrophy of the alveoli.
Surface veins become visible
• 8 – 12 weeks. Montgomery’s tubercles become more prominent on the areola.
• 16 weeks. Colostrum can be expressed.
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• Late pregnancy. Colostrum may leak from the breast.
Reproductive tract
• Amenorrhoea
• Uterine enlargement- it increases in size and number of uterine blood vessels.
• Enlargement of the cervical glands (6wks).
• jacquemier’s sign.
• Hegar’s sign.
Urinary system
• There increase in glomerular filtration of about 50 -60%.
• Impaired tubular reabsorptive capacity may lead glycosuria.
• Increased creatinine clearance leading to reduced serum creatinine.
• Sodium filtered is increased but reabsorbed due to an increase in aldosterone secretion.
Enlarging uterus can compress the ureters causing obstructing the follow. This contributes to the frequency of urinary tract infections.
• Pressure from the enlarging uterus on bladder usually in the first and 3rd trimester.
Cardio vascular changes
• Blood volume
• Increases progressively from 6-8 weeks gestation and reach maximum at approximately 32-34 weeks.
• The increase in plasma volume (40-50%) is greater than the red cell mass (20-30%)
• This facilitates maternal and fetal exchanges of respiratory gases, nutrients and metabolites.
• Secondly it reduces the impact of maternal blood loss at delivery.
Cardiac output
• Increases to a similar degree as the blood volume.
• It increases from 6.7 litres/ minute at 8 – 11weeks to about 8.7 litres/minutes flow at 36-39 weeks
Blood pressure
• Remains constant although in some women it can be lower than due to vaso dilatation.
• There is supine hypotensive syndrome Cardiac size
• There are both size and position changes. The heart is enlarged by both chamber dilatation and hypertrophy.
• Dilatation across the tricuspid valve can initiate mild regurgitation flow causing a normal grade 1 and II systolic murmur
• Upward displacement of the diaphragm by the enlarging uterus causes the heart to shift to the left and anteriorly.
• The apex beat is outward and upward Aortal caval compression
• From mid pregnancy, the enlarged uterus compresses both the inferior vena cava and the lower aorta when the patient lies supine.
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• Obstruction of the inferior vena cava reduces venous return to the heart leading to a fall in cardiac output by as much as 24% towards term.
• Obstruction to the aorta and its branches causes diminished blood flow to kidneys, uteroplacental unit and the lower extremities.
Gastrointestinal system Mechanical changes
• The enlarging uterus causes a gradual displacement of stomach and intestines.
• The stomach at term attains a vertical position.
• The change of the gastro esophageal junction leads to greater esophageal reflux.
Physiological changes
• Gastric emptying time and intestinal transit time are delayed due to hormonal and mechanical factors.
• Delay in gastric emptying and peristalsis leads to nausea, heartburn, constipation and hemorrhoids.
Metabolism
• All metabolic functions are increased during pregnancy.
• Optimal blood glucose levels in pregnant women range between 4.4 to 5.5 mmol/l (80 – 100mg/dl).
• In pregnant women hypoglycemia is defined as concentration below 3.3 mmol/l (60mg/l).
• Weight gain
• 0.5kg per week is normal.
• Water retention
• It increases, women retain on average 6.5 litres extra water on a minimum during pregnancy.
Musculoskeletal system
• Relaxation of smooth muscles leads to aching and numbness.
• Relaxation of pelvic joints.
• Progressive lordosis shifts the woman’s centre of gravity back over her legs.
• The muscles of the abdominal wall may strecth and lose some tone, further aggravating back pain.
Diagnosis of pregnancy
The signs and symptoms of pregnancy are often enough to cause a woman to suspect pregnancy.
Diagnosis of pregnancy usually begins when a woman presents with the following signs and symptoms. Some of the signs and symptoms to be discussed are just suggestive of pregnancy but are not conclusive of pregnancy. As a nurse taking care of these women you should therefore be aware of the other conditions that presents in the same way as pregnancy would.
Sign Time of occurence Differential diagnosis
Presumptive signs
Early breast changes
Amenorrhoea 3 – 4 weeks+
4 weeks+ Contraceptive use
Hormonal imbalance Emotional stress Cerebral irritation
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Morning sickness
Bladder irritation
Quickening
4 – 14 weeks
6 – 12 weeks 16 -20 weeks +
Gastrointestinal disorders Pyrexia illness
Cerebral irritations Urinary tract infection Pelvic tumour
Intestinal wind Probable signs
Presence of hCG in blood
Presence of hCG in urine
Hegars sign
Chadwick’s sign
Osiander’s sign
Changes in skin pigmentation
Uterine soufflé
Braxton hicks
Ballottement of fetus
9 – 10 days 14 days 6 – 12 weeks 8 weeks 8 weeks + 8 weeks + 12 – 16 weeks
16 weeks 16 – 28 weeks
Hydatidiform mole Choriocarcinoma
Pelvic congestion Tumours
Increased blood flow to uterus as in large uterine myomas or ovarian tumours
Positive signs
Visualization of gestational sac by ultrasound
Visualization of heart pulsation by ultrasound
Fetal heart sounds by Doppler
Fetal heart sounds by fetal scope
Fetal movements palpable
Fetal movements visible
Fetal parts palpable
Visualization of fetus by x- ray
4.5 Weeks 5.5 Weeks 5 weeks 6 weeks 11 – 12 weeks
20 weeks 22 weeks 24 weeks + 16 weeks +
The positive signs of
pregnancy have no alternative diagnosis.
Antenatal care
Antenatal care refers to care given to a pregnant woman from the time conception is confirmed until the beginning of labour. It is important in helping to ensure that women and newborns survive pregnancy and childbirth. The traditional approach to antenatal care, which is based on European models developed in the early 1900s, assumes that more frequent visits to the antenatal clinic is better in care for pregnant women.
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Therefore frequent routine visits were a norm, and pregnant women were classified by risk category to determine their chances of developing complications and the level of care they needed. This is the approach which was being used in Zambia before the adoption of the world health organization focused antenatal model.
This approach, focused antenatal care, recognizes that, frequent visits do not necessarily improve pregnancy outcomes and many women who have risk may not develop complications, while women without risk factors often do. This approach is for the view that every pregnant woman is at risk for complications and that all women should therefore receive the same basic care and monitoring for complications. It is therefore organized in such a way that each focused antenatal care visit includes interventions that are appropriate to the woman’s stage of pregnancy and that address her overall health and preparation for birth and care of the newborn.
Goal-Directed Interventions 1. Detection and Prevention
For you to achieve this goal, you are expected to interview and examine the woman to detect problems that might affect the woman’s pregnancy and require additional care. Conditions that could severely affect the mother or baby if they are left untreated include HIV, syphilis and other sexually transmitted diseases, malnutrition and tuberculosis. Also, conditions such as severe anemia, vaginal bleeding, pre-eclampsia/eclampsia, fetal distress and abnormal fetal position after 36 weeks may cause or be indicative of a life-threatening complication. As a nurse you will realize that early treatment of these conditions can mean the difference between death and survival for the woman and her newborn. It will in the long run help us reduce the maternal and neonatal deaths in Zambia.
In addition to early detection and treatment of problems, the following preventive interventions have been implemented. Tetanus toxoid is given to pregnant women to prevent neonatal and maternal tetanus which causes about 500,000 neonatal deaths and 30,000 maternal deaths each year. Iron
and folate supplementation, helps to prevent iron deficiency, the single most prevalent nutritional deficiency affecting pregnant women. Iron deficiency can lead to severe anemia, which is associated with preterm delivery, inadequate intrauterine growth, and maternal and fetal deaths.
In countries like Zambia with malaria epidermic the programme also supports intermittent preventive treatment for malaria, presumptive treatment for hookworm and vitamin A supplementation.
Activity
Before you proceed to look at the next goal for focused antenatal care, the first gaol you have just finished has highlighted most of the diseases you are able to detect. Identify the
laboratory investigations you will have to carry out in order for you to detect those diseases.
1. ...
2. ...
3. ...
31 4. ...
5. ...
6. ...
Counseling and Health Promotion
Focused antenatal care visits should include time for you and women to talk about important issues related to nutrition and health during pregnancy. The following topics should be included as they equip the women with knowledge to make informed choices and avoid some of the delays in seeking care:
a. Danger signs of complications during pregnancy and labor How to recognize them, what to do and where to get help b. Nutrition:
The importance of good nutrition to the health of the mother and baby; how to get enough calories and essential nutrients for a healthy pregnancy; micronutrient supplements;
importance of iron intake
c. Risks of using alcohol, medications and local drugs d. Importance of Rest and avoidance of heavy physical work
e. Family planning: benefits of child spacing to the mother and child; options for family planning services following the baby’s birth
f. Breastfeeding: exclusive breastfeeding; importance of immediate breastfeeding after birth g. HIV and other sexually transmitted diseases: The use of condoms for dual protection
from pregnancy and disease; availability and benefits of testing; and specific issues related to mother-to-child transmission and living with AIDS (after a positive test result).
Birth Preparedness and Complication Readiness
Focused antenatal care includes attention to a woman’s preparations for childbirth, such as family and community, and making arrangements for her newborn. As a nurse attending to this woman, you should plan with her for the following:
Items needed for the birth
ransport to the health facility and any needed medications
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the birth, including someone to accompany the woman during the birth and someone to take care of her family while she is away
A person designated to make decisions on her behalf, in case of an emergency and she is unable to make them.
HISTORY TAKING
History taking is a very important aspect of antenatal care and serves as a screening procedure, which can identify factors that can be detrimental to the normal course of pregnancy.
Comprehensive history is taken on the first visit where the following information is taken from the patient. Having completed a module in medical and surgical nursing on physical examination, you will have knowledge on what information you will collect under the listed headings.
Demographic data
Social history
Family medical history
Past medical history
Personal surgical history
Past obstetric history
Parity and gravid
Year when the children where born, if it is not the first pregnancy
Health during pregnancy
Duration of pregnancies
Outcome of pregnancies
Birth weight
Find out if the children are alive or not
Present obstetric history
Ask the woman for the following information
Last normal menstrual period so as to ascertain the expected date of delivery using the neagele’s rule.
Age at menarche
Health during pregnancy
Any minor disorders of pregnancy
Dietary habits
Physical examination of an antenatal mother Initial prenatal
As a nurse attending to pregnant women you are responsible for the following assessment at initial prenatal examination.
Vital signs
Height and weight
Urinalysis
Blood investigation
33 Prenatal examination
Skin – color noted (to detect anemia, cyanosis and jaundice) edema noted (may be normal or could indicate pre eclampsia); changes normally associated with pregnancy noted such as chloasma, linea nigra and spider nevi.
Neck – thyroid assessed (may enlarge slightly during pregnancy); marked enlargement, nodules, and so forth could indicate hyperthyroidism or goiter and are assessed further.
Lungs – inspection, palpation and auscultation should be normal, with no adventitious sounds.
Breasts – inspection and palpation performed. Normal changes of pregnancy noted. Orange – peel skin and palpable nodule suggest possible carcinoma; redness indicates mastitis.
Heart – rate, rhythm and heart sounds noted. Short systolic murmur is common because of increased blood volume.
Abdomen – inspection and palpation performed. Liver and spleen should not palpable. Skin changes of pregnancy should be seen including enlargement depending on duration of pregnancy. On palpation determine the lie and the presentation.
a) Fundus – palpable as follows
10- 12 weeks: slightly above symphysis
16 weeks: half way between symphysis and umbilicus
20 weeks: at umbilicus
28 weeks: three finger breadths above the umbilicus
36 weeks: just below ensiform cartilage b) Fetal heart auscultated as follows
10 – 12 weeks: heard with Doppler (rate 110 – 160 beats per minute)
17 – 20 weeks: heard with stethoscope
c) Examiner can palpate fetal movements at 20 weeks’ gestation Take note
Measurement of fundal height after the first trimester when the uterus is palpable in the abdomen. Its height – the distance from the top of the symphysis pubis to the top of the fundus – can be measured with a centimeter tape measure. Fundal height corresponds well with weeks of gestation, especially between 20 and 31 weeks. For example, 24 cm would suggest 24 weeks’
gestation.
Reflexes – at least brachial and patellar assessed. Hyperreflexia could indicate developing pre eclampsia (refer to unit 5 for details on pre eclampsia).
Scheduling of visits
