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Midwifery Nursing Science I
Compiled by: NT Ndjuluwa
Midwifery Nursing Science Tutor: Oniipa Campus-2020
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Unit 1: Introduction to Midwifery/overview
Define related concepts: • Midwifery • Midwife/Accoucher • Community Midwifery • Traditional Birth Attendant (TBA) Discuss the History of Midwifery under: Midwifery History in Namibia pre-independence Midwifery History in Namibia post-independence The scope of practice of enrolled midwife accoucher Negligence Standard of nursing care Ethical framework: Confidentiality Right to privacy Right to information Informed consent
Introduction to Midwifery Nursing Science • Midwifery Nursing Science is one of the three major field of nursing for the enrolled nurse/midwife/accoucher training programme, of which there are four major subjects. • Midwifery is one of the oldest known professions in the world • Midwifery preceded the medical and nursing professions • Midwives were the only caregivers for women in child birth
What is Midwifery?
• Is a field of study where the midwife is trained to offer a comprehensive service to women and families • From before pregnancy to the end of the postnatal period • Continues with the immunization program and the general care of the child until school age
What is a midwife?
• A person who has been regularly admitted to a midwifery educational program, duly recognized in the jurisdiction in which it is located • Has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/ or legally licensed to practice midwifery ( Sellers volume I, 1993: xxxiii )
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What is a Traditional birth attendant? (TBA)
• Is a person without midwifery training and has learnt the art of assisting the birth process from personal experience, or relatives, or neighbor or from known TBA’s in the community Midwifery subject for the EN/M/A program
• It has two components namely: Theory and Practice • To pass the subject the Pupil enrolled nurse midwife PEN/M must meet requirements in both theory and practice The history of midwifery in Namibia pre-independence Work of the Missionaries • In January 1903 Catholic priests moved into the Kavango as far as Andara • In 1907 a Catholic mission established a small hospital at Gobabis, which also provided midwifery services • At Swakopmund a number of sisters from the Fransiscan order took over the health care of the community Work of the Missionaries… • They established a midwifery unit, the Antonius hospital at Swakopmund, which they placed in charge of a trained midwife from Germany • Germany had very strict regulations for the training and regulation of midwives • It was the first country in the world to introduce such legislation (Van Dyk, 1997:20) • On 14 December 1908 Dr. Selma Rainio, a Finnish doctor arrived at Oniipa • The work of Dr. Selma Rainio led to the extension of the Mission services • Between 1908 and 1909 further mission stations with health care facilities were established at Elim, Okahao and Tsandi • By 1910 midwives were appointed in several districts and had to serve as community nurses • Due to the heavy work load of doctors and nurses some indigenous men and women who had received elementary schooling at the missions, were given in-service preparation as health attendants • On 9 July 1911, the first proper hospital was opened in Owambo land, the well known Onandjokwe hospital • Onandjokwe hospital provided the first organized midwifery services in Owambo land, it played a major role in the training of midwives (Van Dyk:21)
Problem of unqualified midwives and regulation of midwifery by law
- The quality of the midwifery services provided by the “folk-midwives of both the indigenous and the settler communities caused a great concern - The authorities endeavored to ensure that midwifery was practiced by certified persons th - Early in the 20 century an effort was made to regulate the practice of midwifery
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History of midwifery in Namibia post independence
st - On 21 March 1990, Namibia gained its independence - The new government of Namibia issued a policy statement which recognized health as a fundamental human right - It committed itself to the WHO target of Health for All by the year 2000 and beyond - The main goal of this policy is the equitable provision of health services with primary health care as the focal point for all health care services - The new health care policy meant that there had to be a complete re-orientation to the concept of primary health care and community-based care
- In addition, plans have to be formulated for slotting medical missions, non- governmental organizations and the private sector into the overall national health plan
- Provision of counseling, advice and care during pregnancy, delivery and puerperium
- Keep simple records of the care given
- Promotion of other health related matter e.g. family planning, immunization and breast feeding
- Provide first aid in emergencies which may occur in pregnancy, labor and puerperium for both mother and baby
- Assist with the identification of families at risk, e.g. acute or chronic illness, alcoholism, childhood handicapped and marital problems
Collaboration between midwives/ accouchers and TBA’s
- Midwives train TBA’s regarding clean and safe home deliveries and notification of births - Train them in primary health care (PHC) activities - Midwives recognize TBA’s by appreciating their work - Give support to TBA’s through support visits and trainings - Involve TBA’s in community based activities such as Expanded program on immunization (EPI) - Assist TBA’s to get identification e.g. badges or uniform Cultural framework
- Many of the ancient cultures had definite customs and taboos relating to childbirth and its attendants - For example only women who had had children themselves were allowed to act as midwives - Men were not allowed to be present - Certain rituals had to be performed before, during and after labour - These factors stress the importance of the midwife to know the cultural history of midwifery in her/ his country as well as the culture of the individual woman she attends in childbirth
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- Midwives working in cross-cultural situations have to be aware that the birth process has always had special significance in all cultures, since it means the continuation of the species - The midwives helping with the birth process have always had a special place in their society, and the birth process has always been associated with a variety of taboos which protect the mother and infant - In the education of the modern midwife and in the assignment of personnel to specific areas, great care has to be taken that the midwives sent are culturally acceptable and that midwives from alien cultures cultivate a particular sensitivity to cultural aspects of the birth process Searle, C. 1987: 8
Legal framework
- The midwife must observe the law, and must be responsible and accountable for her/ his actions - She had to interact in a prescribed manner with mother and child, family and the society - The midwife was always held accountable for her actions - Throughout the course of midwifery history the four core elements of professional practice namely, observance of custom or laws, independent action, interdependent action and accountability are discernible in the role fulfilment of the midwife - The fact that such concepts have survived for millenia, indicates the importance of midwifery in society and the fundamental need for a code of practice - These are characteristics which are essential elements of professional practice in modern midwifery The scope of practice of Enrolled Midwife/Acoucheur
• The midwife shall provide the midwifery care as stipulated in her/ his scope of practice in the Nursing professions Act The scope of practice entails: - Assessment of the health needs of the pregnant woman - Identify health needs and promotion of health care of the mother and child, by means of examination, observations, counseling and health education during pregnancy, labour and puerperium - Handling of normal pregnancy, uncomplicated labour and normal puerperium
- Deliver a normal full term pregnancy, without causing danger to the mother and baby
- Identify abnormalities during antenatal care, delivery and post natal care and refer the patient to a medical practitioner or Registered midwife without delay
- Provide effective care to the newborn baby and mother during puerperium
- Promotion and maintenance of hygiene and physical comfort, and the re-assurance of the mother and child
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- Promotion of exercise, rest and sleep
- Control, promotion and maintenance of respiratory functions, intake and output, blood pressure, temperature, pulse rate and fetal heart rate of the baby
- Promotion, maintenance and improvement of the nutritional status of the mother and child
- Promotion of breast feeding
- Provision of information on health and family planning
- Identifying and establishing a working relationship with traditional birth attendants and community leaders to improve health services in the community
- Plan health care and health promotion activities of mother and child in health facilities as well as in the community
- Care for the dying patient and still born infants
Standards of nursing care Definition: • A standard is a desirable and achievable level of performance against which actual practice is compared (ICN,1984:24 ) • An object or quality or measure serving as a basis or example or principle to which others conform or should conform, or by which the accuracy or quality of others is judged • The degree of excellence required for a particular purpose • A thing recognized as a model for imitation • Standard is also defined as a statement describing the expected level of performance against which the quality can be evaluated • Standards represent the agreed upon level of performance. (SANC, May 1994:32. Record keeping) - A nurse/midwife must observe the standards of care to ensure the safety of patients - The standards of an individual’s practice will be judged against normal, accepted standards for safe practice as observed by the majority of the profession - The setting of desirable standards of practice provides security to the nurse practitioner - For then he/she knows what reasonable members of the profession expect from him/her - Broad macro-standards can be determined by the profession at large, but health care services could have their own detailed explicit standards - Broad macro-standards can be determined by the profession at large, but health care services could have their own detailed explicit standards - The observance of the standard is an integral aspect of responsibility for patient care and accountability to that care - Standards of nursing practice must be based on principles so that they can be applied in any health care situation
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- Standards must enable the practitioner to select the most effective manner in which to apply scientific nursing diagnosis and management and the way in which the nurse carries out her professional responsibilities in the interest of safe care - There is a need to evaluate standards regularly so as to remain abreast of progressive development in health care - The nurse/midwife must be aware that standards of care should always be patient centered - Standards must be realistic, attainable, cost effective and understandable to the practitioner - Standards do not remain static, for they are based on contemporary knowledge of the requirements of health care situation, the individual, family, group or community (Searle, 4th edition 2009: 228) Negligence in nursing practice (Absence of due care) - Occur when nurse/midwife have failed to do (what in the opinion of the plaintiff) could be expected from a reasonable and prudent nurse in similar circumstances - What can be expected of the average reasonable and careful nurse in similar circumstances - The test of the reasonable person is used to establish negligence - (a) Would a reasonable person in the position of the perpetrator - Have foreseen the possibility of damage and - Have taken steps to prevent such damage - (b) Did the perpetrator’s conduct deviate from the above-mentioned standards? - If so, the offender was negligent. If not the offender is not culpable. - The reasonable person comprises all those characteristics which society requires of its members in their conducts towards one another Degrees of negligence • Gross negligence: - Failure to exercise even slight care to protect the right of others. • Criminal negligence: - Crime or an offence against the state, for which the state punishes the individual e.g. negligence resulting in the death of the patient has serious consequences • Contributory negligence: - Where the one who sues may have contributed to his own injury either deliberately or accidentally - Nurses should guard against becoming involved in risky situations (Pera, s & Van Tonder, S 2005:65) - Ethical Concepts
Confidentiality: - A confidential relationship arises whenever one person entrusts confidential information with another person - Where the patient entrusted information to the nurse, the patient has the right to believe that this confidential information will not be conveyed to others
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without the patient’s consent and that it will be used only for the purpose for which it has been given - There are two important aspects of confidentiality namely: - Limiting access to information and - Making provision for communication about intimate and other sensitive, personal matters Right to information - The right of the patient to detailed information extends over a wide area which includes: - Information about available health services to information about diagnosis and prognosis - When a patient admitted to a hospital, he/she receives detailed information about the rules and regulations of the hospital Right to privacy
- The right to privacy include both the right to respect for the dignity of the patient, namely physical privacy and - Respect for the patient secrets, namely confidentiality - Nurses should be continually encouraged to respect the privacy of the patient as a moral duty Informed consent
All procedures in health care require that a patient has given his/her permission To be able to grant consent, the patient must be fully informed about the procedure, as well as any alternatives to the proposed treatment Consent is necessary from a legal point of view because it enables the practitioner to defend him/herself, after consent has been given against a possible charge of assault It is necessary from a moral point of view because it displays respect for the autonomy and right to self-determination There are two meanings of informed consent:
- The first meaning is where the person does not merely express agreement or comply with a proposal, but must actually authorize something through an act of informed or voluntary consent - The second meaning of informed consent is tied up with formal procedures that institutions have to follow before proceeding with diagnostic, therapeutic or research procedures
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Unit 2: Concept Of Holistic Nursing care with cultural diverse childbearing
Psychosocial, spiritual and cultural aspects of child birth: Page126
Pregnancy is not just a physiological change but also psychological adjustment, emotions, thoughts and behaviours go through some variety of changes even before the pregnancy itself. Some babies are planned, others are not. Whether the baby was planned or not, what matter is the acceptance or the rejection of the pregnancy by everyone involved. Much depend on the women’s current family situation, her marital happiness, her reason for wanting or not wanting the baby, the timing and cultural context. Seller: 125
Common feelings experienced in pregnancy include:
Anxiety Fear Sexual activities Emotional liability Siblings, grandparents, friend, etc.
Preparation for parenthood
Several issues are important during early months of parenthood; some related to the mother some to the father and the family and some to the baby. Read sellers page 130-133
The the midwife should facilitate positive parent –infant relationship by providing opportunity for interaction.
The expected father
Transition to fatherhood demand the role of adaptation of men all cultures This is a normal development and sometimes come with stress. Stress is determined by motivation for pregnancy, his expected role and his ability to adapt to new change for the new role.
There are five phases of adaptation in fatherhood
1. Acceptance of pregnancy The first and most important adaptation is to accept the pregnancy. This will also help the woman to adapt positively. Negative feeling from the father also negatively affects the women.
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2. Awareness of mother’s emotional and physical changes during pregnancy. The father should be aware of all physical and emotional changes that happens throughout the pregnancy. Positive adapation will influence his experience. If the father is involve the baby will become real to him and not just in his mind.
3. Anticipation the birth In the last trimester of pregnancy, the father experience some anxiety in terms of his partner, the baby, how the labour will progress and the potential risk of death.
4. Involvement in labour The birth of the baby is a special crisis period and the father’s tension will be high. Just his present at birth doen’t indicate his involvement. Involvement is when he give emotional support to the partner while she is in labour. This will make the woman to rely on him.
5. The father and the postnatal period The postnatal period is also a period of crises for the father. The father may compare the baby to his dreams, imagination and expectatins. He also have to come to term with the sex of the baby. His acceptance of the baby’s gender will influence the mothre’s response. If the baby is sick or premature or abnormal, it will cause more emotional strain and disappointment. Some eeven refuse to support the woman.
Read futher seller’s midwifery second edition page 135-139
Activity 1. How psycho-social aspect viewed in regards to the following:
1.1 And expected family 126
1.2 The pregnant women, sibling 126
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Unit 3: Anatomy and Physiology of the reproductive system and the fetal skull
The female reproductive organs
DEFINITIONS Ovulation • Is the release of the mature egg/ ovum from the ovary • Occurs approximately 14 days before the onset of menstruation Puberty • The developmental period between childhood and the attainment of adult sexual characteristics and functioning Fertilization • Is the process by which male and female sex cell unite to form a conception(new individual)
Amenorrhoea • An abnormal absence of menstruation Dysmenorrhoea • Is a painful menstruation Menstruation • A non-pregnant woman discharge of blood and other materials from the lining of the uterus at intervals of about 28 days each month Menarche • The first occurring of menstruation
The female reproductive organs
The female reproductive organs is divided into: - External female genitalia and - Internal Female genitalia • The external genitalia extend from the mons veneris anteriorly, to the anus posteriorly The structures of the external genitalia are: • Mons veneris (mons pubis) • The vulva: Labia majora, labia minora, clitoris, vestibuli • The Perineum
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Diagram of external Female Organs
External female genitalia…
The mons pubis: Is a pad of fat lying over the symphysis pubis, covered with hair after puberty The vulva is made up of the following structures: - Labia majora - Labia minora - Clitoris - Vestibuli: External urinary meatus, vaginal orifice, Bartholin’s glands, Vestibular bulbs The openings and structures contained within the vestibuli are:
- The external urinary meatus (urethral orifice)
- The vaginal introitus/orifice
- Bartholin’s gland
- Vestibular bulbs
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The mons veneris (Mons pubis) • Is a protective pad of fibro-fatty tissue • Covered with skin and hair • Is situated anteriorly over the symphysis pubis • It protects the pubic bone The vulva • Extends from the mons veneris anteriorly to the perineum posteriorly
The structures of the vulva
Labia majora • Encloses the vulva on both side. • They are made up of fibro-fatty tissue • Covered with skin and hair. • They are continuous with the mons veneris anteriorly. • And join in the perineum porsteriorly. • The labia majora are homologous with the scrotum in the male. Labia minora • Are two loose folds of skin, enclosed within • and lying parallel to the labia majora • Anteriorly they divide on either side to enclose a structure known as the clitoris • Posteriorly they join to form the fourchette • Which is continuous with the skin of the perineum, and form the posterior border of the vestibule • The area enclosed within the labia minora is the vestibule The clitoris
Is a structure composed of extremely sensitive erectile tissue It is 1.5-2cm in length The body of the clitoris is made up of two crura Which are attached on either side of the symphysis pubis The posterior unattached end of the clitoris is known as the glans The folds of labia minora which surround the clitoris are known as the prepuce anteriorly and frenulum posteriorly The clitoris is homologous with the penis in the male It plays a part in the orgasm of sexual intercourse
The vestibule
• Is the area enclosed within the labia minora • It is bounded by the clitoris anteriorly and the fourchette posteriorly • The vestibule is surrounded by the bulbo-cavernosus muscle, a voluntary muscle • Which forms sphincters to the urethra and the vagina
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The external urinary meatus (urethral orifice)
• The external urethral orifice is situated about 1.5cm below or posterior to the clitoris • Tiny ducts, which have a lubricating function open posteriorly on either side of the orifice are known as Skene’s glands and ducts • The vaginal opening occupies the posterior two thirds of the vestibule • Before puberty the opening may be partially hidden by a membrane known as the hymen • This membrane is teared during first sexual act
The hymen…
• Further tearing of the hymen takes place during the delivery of a child and the remaining tags of skin and fibrous tissue are known as carunculae myrtiformes The Bartholin’s glands • Are situated postero-laterally in the vestibule • They are embedded deep into the labia majora and the bulbo-carvenosus muscle • These glands have a lubricating function especially during coitus
Vestibular bulbs
• They are situated anteriorly to the Bartholin’s glands • Surrounding the vestibule on either side are small collections of vascular erectile tissue, which are continuous with the glans of the clitoris, they are known as the bulbs of the vestibuli • When the clitoris is stimulated, the vestibular bulbs transmit these stimuli to Bartholin’s glands, which secrete a thick mucus
The perineum
• Is the area between the posterior border of the vestibule (the fourchette) and the anterior border of the anal sphincter • It is made up of layers of muscle, covered with skin • It forms the base of the perineal body Sellers volume 1, pg- 5 Dippenaar, pg- 36
The internal female genitalia
Is made up of the following structures: • The vagina, cervix, uterus, uterine tubes and the ovaries. • These organs are all contained within the true pelvis in the non- gravid state
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The vagina
• Is a muscular tube, that connects the vestibule with the uterus • The walls of the vagina are folded with rugae • Which allows the vagina to stretch during birth • The vagina is lined with Stratified squamous epithelium similar to skin but without glands • Lactobacilli or Do”derlein’s bacillus are normal inhabitants of the vagina nourished by large stores of glucogen secreted by squamous cells • Lactobacilli produce lactic acid, which maintains the vaginal pH between 4.0 and 5.5
• The acidic medium helps to reduce vaginal infections
• Before puberty and after menopause, the pH of the vagina is less acidic and vaginal infections are more common
• The blood vessels are full of turns and twists to allow for stretching
Functions of the vagina
• It is the excretory duct for menstrual flow
• It is the organ that receives the penis during sexual intercourse
• It is the birth canal
The cervix
• Opens into the posterior part of the upper vagina
• The upper portion of the vagina is called the fornix
The uterus
• The uterus is a hollow and pear-shaped organ • In its non-gravid state, it is approximately 7.5cm long, 5cm wide and 2.5cm thick • It is made up of a body and neck (cervix), joined at a constricted area, the isthmus • When pregnant the uterus is referred to as gravid • The wide rounded upper portion of the body is called the fundus • The fundus is the muscular part of the uterus • In pregnancy the uterus is divided into the upper and lower uterine segment • The fundus represents the upper segment and the cervix the lower segment • The isthmus divides the two segments • Below the fundus on either side, the fallopian tubes arise at the cornua(horns) of the uterus • The uterine cavity is continuous with the lumen of the uterine tube The position of the uterus
• The uterus is a pelvic organ, in the cavity of the true pelvic • It lies behind and above the bladder and in front of the rectum
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• In the non-gravid state, it lies over the bladder in a position of ante-version and ante-flexion • The uterus is maintained in this position by uterine ligaments, the round and the broad ligament in a non-pregnant woman The structure of the uterus
• The uterus is made up of three layers namely: • endometrium, myometrium and perimetrium - The endometrium consist of three layers: • The compact layer(1st): columnar epithelial tissue • The spongy layer(2nd): connective tissue • If not fertilised, these two layers are shed during menstruation The endometrium
- The third layer is the basal layer: A layer of connective tissue and glands
- This layer is not shed during menstruation
- It forms the basis for regeneration of the two layers (the compact and spongy) that are shed during menstruation
- Oestrogen promotes regeneration
• In pregnancy the endometrium is called the decidua
The myometrium:
• Is the thick middle layer of the uterus
• It is made up of three layers namely:
- An inner layer of circular muscle that keeps the shape of uterine cavity
- A middle layer of criss-crossing fibres, enclosing the numerous blood vessels
- An outer layer of longitudinal muscle fibres extending from the fundus to the external cervical os
The perimetrium
- Is the outer covering of the uterus
- It is a layer of peritoneum that covers the body of the uterus
- It divides the pelvic cavity from the abdominal cavity
- Anteriorly it is reflected forward over the bladder to form the uterovesical pouch
- Posteriorly it is reflected upward over the rectum to form the uterorectal pouch
The cervix
- Is cylindrical and form the lower third of the uterus
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- It is 2.5cm in diameter and 2.5cm long - It consist of a canal which is 2.5cm long - It opens into the uterine cavity at the internal cervical os and into the vagina at the external cervical os - The inner layer of the cervical canal is thrown into folds, made up of ciliated columnar epithelium, interspersed with deep compound racemous glands, which secrete alkaline mucus
- The alkaline medium affords protection to the sperm deposited into the vagina during sexual intercourse
- The acid medium of the vagina is harmful to sperm
- The alkaline mucus of the cervix together with the cilia helps the sperm to move from the vagina into the uterine cavity
- During pregnancy the mucus becomes thick and tenacious forming a cervical plug called opperculum, which helps to protect the content of uterine cavity from ascending infections
- The external cervical os is a small round opening of approximately 0.5cm in diameter in nulllipara and is called primip-os
- After birth it is an oval opening of 2cm or more and is known as multip-os, never completely closed again
The fallopian tubes
• The fallopian tubes stretch from the superior portion of the uterus to the ovaries • Sperm enter the tubes from the uterus and meet with the ovum that has been drawn in by the fimbria of the tubes • Fertilization takes place in the fallopian tube • The cilia in the tube move the fertilised ovum to the uterus
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Internal female reproductive organs
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Internal female reproductive organs
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Female reproductive organs in the pelvis and their associated structures
Activity
Label the above diagram
The Ovaries
• The ovaries lie on either side of the uterus in the true pelvis, attached to the broad ligament • Each one is about the size and shape of an unshelled almond • It is approximately 3cm long, 2cm wide and 1cm thick and is greyish-white in colour • The ovaries are attached to the uterus on either side by strong ligaments, the ovarian ligaments
• The ovaries are also attached to the lateral pelvic walls by the infundibulopelvic (suspensory) ligaments
• And also attached to the infundibulae of the uterine tubes by one of the fimbria
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The structure of the ovary
• The ovary consist of two layers: An inner medulla and an outer cortex • The cortex surrounds the medulla • The medulla is composed mainly of connective tissue • Which forms attachments for the ovarian and infundibulo pelvic ligaments • It contains blood, lymph vessels and nerves • The cortex is the functional part of the ovary consist of theca cells
• Interspersed with primordial and developing ovarian follicles
• Within the follicles are the primary oocytes
• The follicles are responsible for the gradual development of these primary oocytes
• There are between100 000 to 200 000 primordial follicles present in each ovary
• Under the influence of the pituitary and ovarian hormones, oocytes gradually develop and mature
• It is only at puberty that the ovarian follicles begin to reach maturity
• When a mature follicle will burst open at approximately every 14 days of the 28 days menstrual cycle to expel a mature ovum into the peritoneal cavity
• The ovaries appear to lie outside the fold of peritoneum known as the broad ligament
• Attached to it on their anterior surfaces by a fold of the peritoneum known as the mesovarum
• The outer layer of the cortex of the ovary is made up of germinal epithelium which is continuous with the mesovarium
• When menstrual cycle stop at about the age of 50yrs, almost no female sex hormones are secreted, this is known as menopause.
The male reproductive organs
Objectives: • Describe the anatomy and physiology of the male reproductive organs • Describe the male hormones • Describe the changes that takes place in the male and females during puberty
The male reproductive organs are: • One Scrotum • Two Testes • Two Epididymis • Two Spermatic cords/Vas deferens • Two seminal vesicles • Two Ejaculatory ducts
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• Two Prostate glands • One Urethra • One Penis • The male sex cells are called sperm or spermatozoa • The sperm are produced in the testes The Testes • Are two oval shaped organs • Which are suspended in the scrotum by the spermatic cords • They are equivalent to the ovaries
Male reproductive organ
The testes • Testes are surrounded by three layers namely: - Tunica vaginalis (outer covering) - Tunica Albuginea(beneath the tunica vaginalis) - Tunica vasculosa (inner layer) • Testes are about 4.5cm long, 2.5cm wide and 3cm thick • Each testes is made up of about 900 coiled seminiferous tubules
Sperm formation
• The sperm are formed from germinal epithelial cells called spermatogonia • The seminiferous tubules lead into the epididymis
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• The sperm take several days to pass through the epididymis, and become mature • A mature sperm has a head, body and long tail
Functions of the testes
• The testes produce sperm, which are produced in the walls of the seminiferous tubules • By the process called spermatogenesis • The testes produce the hormone testosterone Ross & Wilson P: 448 Dippenaar P: 58
The epididymis
• Is a coiled tube within each testis and is about 6m long • Maturation of sperm takes place in the epididimys and the sperm become motile • The epididymis leads in to the vas deferens
The Scrotum
• Is a loose pouch of pigmented skin • Divided into two compartments, each of which contains one testis and one epididymis • It is situated in the perineal area • Behind the penis and in front of the anus • It is homologous with the labia majora in the female The functions of the Scrotum
• It regulates the temperature of the testes • Required for the production and survival of the sperm • It provides a cooling unit for the testes The vas deferens
• Is a long straight tube that leaves the scrotum and passes through the inguinal canal on either side of the pelvis and in to the abdominal cavity • Then curved over the bladder on either side, back into the pelvis • The vas deferens then joins with the duct of the corresponding seminal vesicle to form the ejaculatory duct Functions of the vas deferens
• Most sperm are stored in the vas deferens and the ampulla of the vas deferens • The sperm maintain their fertility for several months
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The ejaculatory ducts • Are two short ducts about 2cm long • Each formed by the union of seminal vesicle and a deferent duct • They pass through the prostate gland and join the prostatic urethra Function • They carry seminal fluid and sperm to the urethra
The Urethra
• This is a single tube leading from the bladder through the penis to the outside of the body via the external urethral sphincter at the glans penis Function • The urethra transport urine from the bladder and the semen from ejaculatory ducts to the outside of the body via the penis Spermatogenesis or Maturation of the sperm
• Spermatogenesis refers to the whole process of sperm production • In which spermatogonia are transformed into spermatozoa • The whole process requires about 74 days • Spermatogonia grow and develop into spermatocytes • Spermatocytes undergoes a first meiotic division and changes into secondary spermatocytes
• A second meiotic division takes place and four haploid cells are formed known as spermatids which undergoes a final maturation process (spematogenesis)
The structure of a mature sperm
• A mature sperm is possibly the smallest cell in the body • It is a free swimming self propelled cell • It is made up of a head, body and tail • It is made up of the nucleus containing chromosomes • The front of the nucleus is covered with a membrane known as acrosome
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Structure of a mature sperm
The structure of a mature sperm…
• The neck of the sperm is a constricted area between the head and the tail • The tail is divided into a middle piece, a principal piece and an end piece • The tail is responsible for the motility of the sperm • Few sperm survive longer than twenty four hours in the female genital tract Dippenaar P: 60
Male hormones
• Androgens: The main is Testosterone • Follicle Stimulating hormone (FSH) • Luteinizing hormone (LH) • Oestrogen For their functions: Read Dippenaar P: 60
The changes that takes place in males during puberty
Puberty: Is the age at which the internal reproductive organs reach maturity • The age of puberty varies between 10 and 14 Changes in the male • Growth of muscles and bones • Increase in height and weight • Enlargement of the larynx
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• Deepening of the voice Changes in the male…
• Growth of hair on face, axillae, chest, abdomen and pubis • Enlargement of penis, scrotum and prostate gland • Maturation of seminiferous tubules • Production of spermatozoa • Skin thickens and become oilier
Changes in the females during puberty
• The uterus, uterine tubes and the ovaries reach maturity • The menstrual cycle and ovulation begin • The breasts develop and enlarge • Pubic and axillary hair begins to grow • Increase in height and widening of the pelvis • Increased fat deposit in the subcutaneous tissue especially at the hips and breasts
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The Fetal Skull
Learning Outcomes • Outline the three regions of the fetal skull • Identify the bones of the fetal skull • Describe the sutures between the bones of the fetal skull • Make a comparison between the posterior and anterior fontanel of the fetal skull Learning outcomes…
• Describe the anatomical landmarks of the fetal skull
• Describe the measurements of the fetal skull
• Explain different types of movement of the fetal head
Introduction
- The fetus is the passenger who has to negotiate the maternal passage in order to be born
- In about 95% of all labours, babies are born head first
- The head is the least compressible part of the fetus, once the head is born the body usually follows without any problem
Regions of the fetal skull
The skull can be divided into three main regions:
• The base
• The face
• The vault or cranium
Regions of the fetal skull The base: - Is the bony area surrounding the opening known as the foramen magnum - These bones are firmly united in order to protect the vital centres in the medulla The face: - Extends from the root of the nose to the junction of the chin with the neck
The vault or cranium - Is the greater upper dome-shaped part of the fetal skull - Extends above the face in front - To the base of the skull posteriorly and includes the temporal sutures laterally - The bones of the vault are formed from membrane and not cartilage, and the inter- membranuos ossification has started by the tenth week of intrauterine life
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Suture: - Refer to a thin line of membrane between each skull bone - The sutures are useful for identifying the position of the fetal head during labour Fontanel: - Refer to a membranous area which is formed where three or four sutures meet The sutures allow the bones of the fetal skull to overlap or override when the head is compressed, thereby decreasing the dimensions of the presenting diameters Moulding: - Refer to the overriding of the skull bones The bones of the fetal skull - Two halves of the frontal bone - Two parietal bones - One occipital bone The sutures of the fetal skull The frontal suture: - Bisects the frontal bones down the centre of the forehead - It is a forward extension of the sagital suture The sagital suture: - Lies between the parietal bones - Runs in an antero-posterior direction The coronal suture - Separate the frontal bones from the parietal bones - It meets with the sagittal and frontal suture anterior to form the anterior fontanelle Lambdoidal sutures: - Divides the two parietal bones from the occipital bone - It meets with the sagittal suture to form the posterior fontanelle The temporal sutures
- Lie on either side of the fetal skull
- Between the temporal bones laterally and the frontal and parietal bones above
- The temporal suture meet the coronal suture to form a small temporal fontanelle (tempel)
The comparison between the anterior and posterior fontanelle
Anterior (bregma) • Is diamond shaped • It is formed by the junction of four sutures • It is situated at a midpoint on the top of the fetal skull • Close at about 12-18 months after birth
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Posterior (lambda) - Is triangular shaped - It is formed by the junction of three sutures - It is situated posterior of the fetal skull - Close at about 2-3 months after birth - The anatomical landmarks of the fetal skull
Sub-mental area: Is the area below the chin and extends to the angle where the chin meets the neck It is formed by the following areas: - The mentum, the chin - The face - The root of the nose The orbital ridges (above the eye socket)
Sub-mental area: - The glabella (the elevated area between the orbital ridges) - The sinciput, brow or forehead Anterior: Glabella and orbital ridges Posterior: Bregma and coronal sutures
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The vertex: - It is the top of the cranium - It is the lowest area of the fetal skull to enter the pelvic brim in a vertex presentation Anterior: Coronal sutures and bregma Posterior: Lambdoidal sutures and lambda Lateral: Parietal eminences The parietal eminences: - A thickened and raised area in the centre of each parietal bone - This is the area where the greatest amount of ossification has taken place - The diameter between the parietal eminences is known as the biparietal diameter, this is the largest transverse diameter of the fetal skull The occiput:
- -This is the area at the back of the head, formed by the occipital bone
- - It is below the lambdoidal sutures and posterior fontanel
Measurements of the fetal skull
The transverse diameters:
Bi-parietal diameter of 9.5 cm - Measured between the two parietal eminences Bi- temporal diameter of 8.2 cm - Measured between the junctions of the coronal and temporal sutures on either side of the skull
The antero-posterior diameters:
Sub-occipito bregmatic of 9.5 cm - Measured from below the occipital protuberance to the centre of the anterior fontanelle Sub- occipito frontal of 10 cm - Measured from below the occipital protuberance to the centre of the sinciput The occipito- frontal diameter of 11.5 cm - Measured from the occipital protuberance to the glabella
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Sub- mento bregmatic diameter of 9.5 cm - Measured from the angle of the chin with the neck to the centre of the anterior fontanel Sub- mento vertical diameter of 11.5 cm - Measured from the angle of the chin with the neck to the highest point on the vertex The mento- vertical diameter of 13.5 cm - Measured from the tip of the chin/mentum to a point on the vertex above the posterior fontanel. This is the largest diameter of the fetal head
The movements of the fetal head
Flexion: - When the head is completely flexed, so that the chin is in contact with the chest Extension: - When the head is completely extended, so that the occiput is in contact with the back Deflexion (‘Military Attitude’) - Neither flexion nor extension, but somewhere between the two - The fetal back is straight, with the head erect Lateral flexion: - The head is capable of certain amount of flexion to each side (Dippenaar, P 101- 105) Exercise: Define caput succedaneum and cephalohaematoma
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Unit 4: Human Sexuality and sex intervention
THE MENSTRUAL CYCLE
Learning Outcomes: • Interpret related concepts • Describe hormones connected with the menstrual cycle Explain the menstrual cycle under: • Menstrual phase • Proliferative phase • Secretory phase THE MENSTRUAL CYCLE.. Hormone: • A regulatory substance produced by a living organism and transported in tissue fluids to stimulate specific cells or tissues into action Menstruation: • Regular monthly shedding of uterine lining (endometrium) during the reproductive period of the female • Menstruation lasts for about 4 days Hormone: • A regulatory substance produced by a living organism and transported in tissue fluids to stimulate specific cells or tissues into action Menstruation: • Regular monthly shedding of uterine lining (endometrium) during the reproductive period of the female • Menstruation lasts for about 4 days Menarche: refer to first menstruation
Eumenorrhoea: refer to normal menstruation
Menorrhagia: refer to heavy bleeding
Dysmenorrhoea: refer to painful menstruation
Menopause:
• The ceasing of menstruation OR
• Time of the female life span when reproductive function cease
Ovulation
- Is the process whereby the dominant follicle ruptures and discharges the secondary oocytes into the uterine tube ready for fertilization
- Ovulation lasts for about 48 hours
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- Ovulation is stimulated by a sudden surge (increase) in LH which matures the oocytes and weakens the wall of the follicle
Ovarian cycle
- Is the name given to the physiological changes that occur in the ovaries essential for preparation and release of the egg (oocyte)
- The ovarian cycle consists of three phases:
- The follicular phase, ovulation, luteal phase
Hormones connected with the menstrual cycle are:
1. Hormones of the hypothalamus:
- Luteinizing hormone releasing hormone (LHRH)
• Cause the anterior pituitary gland to secrete two gonadotrophic hormones
Hormones connected with the menstrual cycle continue..
2. Hormones of the anterior pituitary gland
- Follicle- stimulating hormone (FSH)
• Stimulate the theca cells of the ovarian follicle to produce oestrogens
- Luteinizing hormone (LH)
• Stimulate the corpus luteum to produce progesterones
Hormones connected with the menstrual cycle continue..
3. Hormones of the ovary
- Oestrogens
• Responsible for growth of the genitalia and breasts
• Bring about secondary sexual characteristics of the female
• Deposition of fat in the breasts and around hips
• Regeneration and proliferation of the endometrium during each menstrual cycle
Hormones of the ovary continue..
- Progesterone
• Prepare uterus for pregnancy
• Prepare breasts for lactation
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• Cause further thickening, vascularity and glandular development of the endometrium
- Inhibin
• Inhibit the production of LH and FSH
Phases of menstrual cycle
1. Menstrual phase
- When the ovum is not fertilized, the corpus luteum degenerates
- The progesterone and oestrogen levels decreases
- Causing the functional layer of the endometrium, to be shed during menstruation
- After degeneration of the corpus luteum, the falling levels of oestrogen and progesterone lead to resumed anterior pituitary gland activity
- LHRH releases the pituitary gland to secrete FSH in the bloodsteam
- Oestrogen affects the basal layer, cause regeneration and proliferation of the endometrium
2. The proliferative phase
- Follows menstruation
- Is similar to follicular phase and lasts until ovulation
- At this stage an ovarian follicle stimulated by FSH, is growing towards maturity
- Producing oestrogen which stimulates proliferation of the functional layer of the endometrium in preparation for the reception of a fertilized ovum
- The endometrium thickens, becoming more vascular and rich in mucus-secreting glands
- This phase ends when ovulation occurs and oestrogen production by the follicle declines
- Ovulation occurs at about the 14th day of the cycle
- The ruptured follicle become known as the corpus luteum (yellow body)
- Luteinizing hormone acts upon the corpus luteum causing it to secrete progesterone in large amounts
- Progesterone acts upon the regenerated endometrium, causing it to become more vascular and secretory ready to receive a fertilized ovum
- In the absence of fertilization, the corpus luteum degenerates and becomes the corpus albicans (white body)
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3. The secretory phase
- Follows the proliferative phase
- Is simultaneous with ovulation
- Immediately after ovulation, the cells lining the ovarian follicle are stimulated by LH and develop into the corpus luteum, which produces progesterone
- If the ovum is not fertilized, menstruation occurs and a new cycle begins
- - If the ovum is fertilized, there is no breakdown of the endometrium and no menstruation
Diagramatic representation of the menstrual cycle.
LHRH Releases pituatary gland (from hypothalamus)
LH secreted into bloodstream
LH increase and FSH decrease
Ovarian follicle rupture - (corpus luteum)
Ovum fertilized Ovulation, ovum released on 14th day
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ovum not fertilized Pregnancy
Oestrogen and FSH decrease
LH act on corpus luteum
Progesterone levels increase and oestrogen decrease
Progesterone acts on regenerated endometrium
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LH level decrease due to progesterone and inhibin
Degeneration of corpus luteum- corpus albicans
Leads to lower levels of progesterone and oestrogen
Results in shedding of endometrium
Menstruation on the 28th day
Decrease oestrogen levels
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Stimulate LHRH from hypothalamus
LHRH release pituitary gland to secrete FSH
Cycle restart
Follicle mature
LH secreted
Increase oestrogen level FSH decrease
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Regeneration of endometrium
END OF THE PHASES OF MENSTRUAL CYCLE
Read more in : Seller volume 1, P: 25 or
Dippenaar P: 45
The changes that take place in females during puberty
Puberty: • Is the age at which the internal reproductive organs reach maturity • The ovaries are stimulated by gonadotrophin hormones namely: follicle stimulating and luteinizing hormone • The age of puberty varies between 10 and 14 years • The uterus, the uterine tubes and the ovaries reach maturity
• The menstrual cycle and ovulation begin (menarche)
• The breasts develop and enlarge
• Pubic and axillary hair begins to grow
• Increase in height and widening of the pelvis
• Increased fat deposited in the subcutaneous tissue, especially at the hips and breasts
Menopause
Occurs between the ages of 45 and 55 years, marking the end of child bearing period • It may occur suddenly or over a period of years • It is caused by a progressive reduction of oestrogen levels • The ovaries become less responsive to FSH and LH Ovulation and menstruation become irregular and eventually cease
Activity
Discuss:
Hormonal changes during pregnancy, labour, puerperium and lactation.
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Unit 5: Conception and fetal development
FETAL DEVELOPMENT
Learning Outcomes Define the following: - Gamete - Gametogenesis - Oogenesis - Fertilization - Embryology - Zygote
- Embryo
- Fetus
- Pregnancy
- Trimester
Describe the process of fertilization
Describe the different stages of fetal development
Describe the placenta at term
Explain the fetal circulation
Describe the anatomical structure of the fefal skull
FETAL DEVELOPMENT
Gamete: - Is a mature male or female sex cell - Which is capable of functioning in fertilization - A gamete contains the haploid number of chromosomes of the somatic cell Gametogenesis: - The process of maturation which occurs in both ovum and sperm - Gametogenesis in the female is know as oogenesis - In the male is known as Spermatogenesis Embryology: - The study of the developing human Fertilization: - The process by which the sperm and ovum unite to form a new individual
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Stages of fetal development Zygote: - A fertilized egg which results from the union of the sperm and the ovum is called a zygote rd - This covers the period from fertilization up to twenty-first days (end of the 3 week) Embryo: nd th - The period from the twenty-second (22 ) to fifty-sixth (56 ) day after fertilization th - From the beginning of the fourth week to the end of the 8 week (5 weeks) Fetus:
th - The period from the beginning of the 9 week after fertilization to term Pregnancy: - The period of gestation in human, divided into three trimesters (first, second and third ) - Each a period of 3 months or + 13 weeks Trimester: - Pregnancy trimester is divided into first, second and third trimesters - Each covers a period of 3 months or approximately 13 weeks The duration of pregnancy and the estimation of the date of delivery
- In order to have a recognisable landmark, the first day of the last normal menstrual period is used in obstetrics
- Fertilization usually takes place within 24 hours of ovulation
- Ovulation takes place about 14 days after menstruation
Estimation of the date of delivery...
- Is calculated as approximately 266 days after fertilization
- Fourteen(14) days are added to 266 days = 280 days
- The estimated date of delivery or term is approximately 280 days, 40 weeks or 9 months after normal menstrual period
Cleavage
- The mitotic division of the zygote is known as cleavage
- The zygote divide into two identical daughter cells, then four, then eight, sixteen and so on...
- The progress of the zygote first along the uterine tube, then in the uterine cavity is described in days following fertilization
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The development of the zygote
- On the third (3rd) day following fertilization a cluster of about sixteen (16) blastomeres has formed a solid ball known as the morula
- The morula passes from the uterine tube into the uterine cavity and the cells continue to increase in number
By the fourth (4) day: Fluid from uterine cavity penetrated the morula and form a fluid filled cavity (cyst), pushing the inner cell mass to one side, which will become the embryo - This changes the morula into a blastocyst On the fourth (4) and fifth (5) days: The blastocyst remains free in the uterine cavity, receiving nourishment from uterine secretions
th From about the fifth (5 ) day: The zona pellucida starts to degenerate and the blastocyst attaches to the uterine wall
th On about the sixth (6 )day: The outer cells of the blastocyst become highly specialized and are known as trophoblastic cells - These cells secrete proteolytic enzymes that have the ability to digest and liquefy the cells of the inner lining of the endometrium
th By the end of the seventh (7 ) day: The blastocyst is superficially implanted in the lining of the decidua - The trophoblastic cells develop into two distinct layers together known as Trophoblast/ syncytiotrophoblast - An outer syncytiotrophoblast (syncytial cells) - An inner cytotrophoblast (cytotrophic cells) Syncytiotrophoblast: The inner cytotrophic layer begin to secrete a hormone known as Human chorionic gonadotrophin (HCG), similar to the luteinizing hormone (LH) of the pituitary gland
- On about the eight (8th ) to ninth (9th )day after fertilization: The secretion of HCG can first be measured in the maternal blood
- - The HCG is the basis of the laboratory tests (urine and blood) for the diagnosis of pregnancy
Implantation sites: - Implantation of the zygote into the maternal decidua is completed during the second week after fertilization - The normal site of implantation is in the posterior, anterior or lateral wall of the uterus - The implantation bleed can cause difficulties with the estimated date of delivery (Sellers P: 45-51)
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Development of the zygote: 8-14 days after fertilization th th - From about the eleventh (11 ) to thirteenth (13 ) day after fertilization, the cells of the cytotrophic layer have greatly proliferated, pushing the syncytial layer outwards in finger like processes, which invade the decidua - A third layer of connective tissue, the mesoblast forms within the cytotrophic layer Development of the zygote: 8-14 days after fertilization - Secondary chorionic villi forms consist of three layers namely: syncytiotrophoblast, cytotrophoblast and mesoblast - By the eleventh to thirteen days changes have also occurred in the inner cell mass
Development of the zygote: 8-14 days after fertilization Changes in the inner cell mass The amniotic sac: A narrow slit lined with ectoderm cells develops between the inner cell mass and the outer trophoblast layers The inner cell mass: Has differentiated into an embryonic disc made up of three layers The yolk sac: The cavity of the blastocyst has now developed into the yolk sac lined with endoderm cells
Development of the zygote: 15-21 days after fertilization
- The third week of embryonic life (The period immediately following the first menstrual period) - Is a time of rapid growth Trophoblast - The primary chorionic villi progress to secondary villi then tertiary chorionic villi - These vessels become connected to vessels developing into embryonic heart Trophoblast… - By twenty first day embryonic blood has started to circulate through capillaries in the chorionic villi carries nourishment from maternal blood to the embryo The inner cell mass - Embryonic disc becomes pear shaped and elongated, the cranial expand the caudal area elongates The inner cell mass… rd - By the end of the 3 week after fertilization a neural plate has formed, the edges of the neural plate meet and fuse in the centre of the embryo st - At 21 day the primitive cardio vascular neural tube have formed
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Development of the embryo: 22-56 days after fertilization
- From the beginning of fourth week to the end of the eight week - The gestation sac can be measured with ultrasound to confirm pregnancy - From the fifth week after fertilization fetal heart beat can be located with ultrasound - The cardiovascular is the first system to function in the embryo The growth and development of the fetus
- By the beginning of the ninth week after fertilization, the human embryo has developed into a recognizable human being - Most of the body structures have already started to develop - The fetus is less vulnerable than the embryo to the harmful and deforming effects of teratogenic agents
Factors necessary for fetal growth
Oxygen: Necessary for all metabolic processes Nutrients: Glucose – Is the primary source for energy for metabolism and growth - Amino acids, vitamins and minerals - Particularly iron and calcium are necessary for metabolism and growth - Insulin is required for the metabolism of glucose Factors causing impaired fetal growth
- Placental insufficiency or impaired uteroplacental blood flow - Maternal conditions such as hypertension, hyperpyrexia, chronic infections, cardiac disease and so on… - Genetic factors and chromosomal abberations, Down’s syndrome, achondroplasia - Smoking affects the rate of fetal growth because of its effect upon placental growth
- Alcohol and narcotic addiction can cause growth retardation, congenital abnormalities and addiction in the newborn
- Infections and hyperpyrexia of the mother e.g. viruses such as rubella other pathogenic such as Treponema pallidum
- In multiple pregnancy there is increased nutritional burden on the mother for each additional fetus
- Maternal malnutrition, if the mother is lacking certain necessary nutrients the fetus will also be deprived
- Prolonged pregnancy, results in the degeneration of the placenta increasing risk of fetal hypoxia (Dippenaar P: 75)
(Abnormalities of the placenta ,membranes and cord)- moved to second semester content.
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The structures of the placenta
The umbilical cord - The connecting or body stalk which joins the inner cell mass to the trophoblast develops into the umbilical cord - The body stalk consists of mesoderm cells which develop into fetal blood vessels contained within the umbilical cord - These blood vessels transport nutrient-enriched fetal blood from the chorionic villi in the placenta along the umbilical cord to the heart - Then return the nutrient depleted fetal blood back to the placenta Blood vessels in the umbilical cord One umbilical vein: - Is a thin-walled, wide-bored vessel - Carries 85% oxygenated blood from the placenta to the fetus Two umbilical arteries: - Are thick-walled blood vessels with a narrower bore - Carry deoxygenated blood from the fetus to the placenta - The arteries are usually wound loosely around the vein, along the length of the cord - The vessels are surrounded by a jelly like substance known as the Wharton’s jelly - Wharton’s jelly protects and supports the vessels - Wharton’s jelly sometimes forms lumps known as false knots The Amnion - Is called the amniotic membrane - The small cavity which appears in the ectoderm cells between the embedding trophoblast and the inner cell mass at the end of the first week after fertilization, is the beginning of the amniotic cavity or sac - The membrane surround this cavity or sac is known as the amnion - The sac becomes filled with fluid known as the amniotic fluid or liquor amnii - The amnion comes into contact with the fetal side of the placenta and with the chorionic membrane, where amnion comes into contact with the chorion they adhere - The two membranes the inner amnion and the outer chorion with together with the fetal side of placenta forms the fetal sac The liquor amnii - Is known as amniotic fluid - The amniotic fluid is a clear, pale straw coloured, alkaline fluid - During the later weeks of pregnancy when fetal kidneys are functioning the fetus passes urine into the liquor - The fetus also swallows the liquor which is then absorbed from the fetal intestines, passed into the fetal circulation, back to the placenta and maternal circulation - The whole volume of amniotic fluid is exchanged every 3 hours or half of it every 90 minutes The amniotic fluid - The amount of liquor in the amniotic sac increases as follows: At 10 weeks: about 35ml
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10 – 20 weeks: 300 ml 20 – 30 weeks: 600ml 30 – 38 weeks: 1000ml After 38 weeks: 600ml During Pregnancy: - To permit symmetrical growth of the embryo by equalizing pressures - To prevent the amnion from adhering to the embryo and later the fetus - To protect the fetus from impacts to the maternal abdomen - To maintain embryo, fetus at a constant temperature - To allow the fetus to move freely for the development of muscles - To protect the fetus from infection together with intact amnion During labour: - To equalize the compression on the fetus caused by uterine contractions - To prevent excessive dimunition of the placental site and consequent hypoxia of the fetus - When membranes rupture, the fluid flushes through the birth canal, help to reduce the likely hood of the fetus becoming infected The chorion - Is the outer membrane of the fetal sac - The chorion is an opaque, friable membrane - The chorion has no blood vessels running through it - The hole in the chorion through which the baby has been born is called the fenestrum(Sellers P: 71)
Placenta at term General characteristics of the placenta - The placenta is circular shaped - The diameter is about 20 cm - The central thickness is about 2.5 cm th - It has a mass of approximately one sixth (1/6 ) of the baby’s mass about 500g - It has two surfaces, called maternal and fetal surfaces The maternal surface - Maternal blood is present in the intervillous spaces - Its colour is deep red - It is divided into 16-20 lobules or cotyledons - Separated by deep grooves or sulci Fetal surface - It is covered with amniotic membrane which gives it a smooth shiny appearance - Fetal blood vessels can be seen radiating from the insertion of of the umbilical cord - The two membrane attached to the placenta are the chorion and amnion The functions of the placenta Respiration - The placenta is the respiratory organ for the fetus
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- Oxygen is transferred through the placental membrane from the mother’s blood in the intervillous spaces to the fetal blood and circulation - The oxygen is essential for the development, growth and survival of the fetus Nutrition - Nutrients necessary for normal fetal development, growth and survival e.g. glucose, amino acids, vitamins and mineral salts are transferred from the mother across the placental membrane to the fetus Excretory - Waste products such as creatinine, urea, uric acid are transferred from the fetal blood stream across the placental membrane to the mother’s blood circulation Endocrine - The placenta is a temporary endocrine organ - The hormones produced are essential to the maintenance of pregnancy
Major hormones produced by the placenta are: - Human chorionic gonadotrophin - Oestrogens - Progesterone - Human placental lactogen Barrier - The placenta is a barrier against harmful agents especially in the first trimester Enzymal function - Enzyme found in human body has also been found in the placenta - They are necessary for synthesis of protein, functioning of fetal tissue and so on
THE FETAL CIRCULATION OBJECTIVES: DESCRIBE THE TEMPORARY STRUCTURES OF THE FETAL CIRCULATION. 1. INTRODUCTION - In utero, the fetal lungs do not function. The fetus obtains the oxygen and nutrients from the maternal circulation. The waste products return back into the maternal circulation for disposal. - There are temporary structures that maintain the fetal circulation before birth.
2. The Temporary Structures in the Fetal Circulation: 2.1 The Ductus venosus: (An opening from vein to vein)
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- This vessel is a continuation of the umbilical vein. It connects the umbilical vein to the inferior vena cava. - It joins the Inferior Vena Cava above the level of the umbilicus. The ductus venosus conveys 85% oxygenated blood from the placenta to the fetus. - The Inferior Vena Cava carry de-oxygenated blood from the lower part of the body to the heart. - This causes a mixing of oxygenated blood from the placenta with de-oxygenated blood from the lower half of the fetal body.
2.2 The foramen ovale
- Temporary oval opening between R and L-atrium. - Allow most of the blood from the inferior vena cava to pass directly from the right atrium into the left atrium. - The pressure of the blood volume on the right side of the heart is greater during fetal existence. - The blood which flows through the foramen ovale into the left atrium is mixed blood, but of a high oxygen concentration. The blood then passes into the left ventricle into the ascending aorta, then to the heart muscles and the upper parts of the fetal body.
2.3 The ductus arteriosus (from artery to artery)
-This is a short vessel. It conveys blood from the pulmonary artery to the descending arch of the aorta. - This is mainly deoxygenated blood returning from the head and upper limbs via the superior vena cava. - The blood is directed through the right atrium into the right ventricle from where it is conveyed to the lungs.
- As the lungs are not functioning, most of the blood is diverted through the ductus arteriosus into the descending arch of the aorta, to mix with blood from the left side of the heart. This blood is now only 50% oxygenated.
- As it passes through the superior vena cava, through the right atrium, it picks up some of the oxygenated blood which is being directed into the foramen ovale.
-A small amount of blood is conveyed to the lungs for development, growth and functioning.
2.4 The two hypogastric arteries (umbilical arteries)
- Are branches of the internal iliac arteries, returning deoxygenated blood from the pelvis, back to the placenta for re-oxygenation. - As they enter the umbilical cord they become the umbilical arteries.
The umbilical vein
- This is the only vessel which carries unmixed blood. - Leads from the umbilical cord. - It carries blood rich in oxygen and nutrients.
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3.Changes which take place in the fetal circulation at birth. - At birth the baby take its first breath and the lungs expand. It causes a fall in the pressure on the right side of the heart.
- As blood is drawn into the pulmonary capillaries, it is oxygenated and returned to the left atrium via the expanded four pulmonary veins.
- The pressure on the left side of the heart becomes now greater than the pressure on the right side. - This increase of pressure on the left side of the heart causes the valve of the foramen ovale to close.
- The oxygen tension rises in the blood and prostaglandins are released. This causes contraction of the smooth muscle in the wall of the ductus arteriosus. This brings about the gradual closure of the ductus arteriosus, and the closure becomes permanent by the end of two months.
- When the umbilical cord is severed, no blood enters the ductus venosus, this further reduces the pressure on the right side of the heart.
-The ductus venosus constricts several hours after birth and after some weeks, it is permanently closed. - The Hypogastric/ umbilical arteries also constrict, atrophy and form ligaments.
In short Ductus venosus – ligamentum venosum Foramen ovale – fossa ovale Ductus arteriosus – ligamentum arteriosum
Activity Discuss the cell division: Meitosis & Meiosis
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Unit 6: Pregnancy and Antenatal care
1. DEFINITION OF CONCEPTS
Menarche - Is the beginning of menstruation and reproductive function in the female
Ante-partum - The time between conception and onset of labor, the period during which a woman is pregnant
Gestation - The number of weeks since the first day of the last menstrual period (LMP)
Trimester - The three months period in which pregnancy gestation of nine months is divided
Term - The normal duration of pregnancy (38-42 weeks)
Gravida - Any pregnancy, regardless of duration, including the present one
Primigravida - A woman who is pregnant for the first time (gravida 1)
Multigravida - A woman who is in her second or any subsequent pregnancy (gravida 2, 3 or more)
Parity - Means the number of previous viable pregnancies (either stillborn or alive)
Nullipara - Means a woman who has never carried a previous pregnancy to the point of viability (para o)
Primipara - A woman who has had one previous viable pregnancy (para 1)
Multipara - A woman who had two (2) or more previous viable pregnancies (para 2, 3 or more.)
Grande multipara - A woman who had five (5) or more previous viable pregnancies (para 5, 6 or more)
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Viability - The ability to live outside the uterus after birth has taken place
Viable - A fetus who had at least six months (26 weeks) of intra-uterine existence
Abortions - The number of pregnancies which have terminated before reaching the point of viability
Birth - The birth of any viable child, whether such child is alive or dead at the time of birth
Stillborn - A child who was viable but showed no sign of life after complete birth
Intra-uterine death (IUD) - A fetus that reaches viability, but died in the uterus before it is born
Preterm or Premature labor - Labor that occurs after 24 weeks, but before the completion of 37 weeks of gestation
Post-term pregnancy - Pregnancy that lasts beyond 42 weeks gestation
Lie - Is the relationship of the long axis of the fetus, to that of the long axis of the uterus
Attitude - Is the relationship of the fetal parts to one another, the relationship of the fetal limbs and head to the fetal trunk
Presentation - Is that part of the fetus which lies in the lower pole of the uterus and which presents at the pelvic brim
Presenting part - Is that part of the presentation which lies over the cervical os during labour, it is upon this portion of the presentation that the caput forms
Denominator - Is that part of the presentation which indicates the position of the presentation in relation to the pelvic brim and gives the position its name
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Position - The position of the fetus is indicated by the relationship of the denominator to six points or landmarks on the pelvic brim
Engagement - The entrance of the fetal presenting part into the pelvic brim and the beginning of the descent through the pelvic canal
Lightening - The descent of the uterus and fetus within the abdominal cavity at 36 weeks gestation, which results in a lowering of the fundal height and a reduction of pressure on the diaphragm
Supine hypotension syndrome - Is a restriction of venous blood flow from the uterus and lower limbs, due to the pressure exerted on the inferior vena cava, when a pregnant woman lies on her back for a long time
The Aims of Antenatal Care - To ensure a normal pregnancy whenever possible by maintaining or where necessary promoting the general health of the pregnant woman - To ensure the early detection, referral and management of complications during pregnancy - To ensure a normal labour whenever possible, by preparing the woman physically and psychological - To provide careful screening of all women, and those who can deliver in health centre or hospital - To prepare the woman for normal puerperium and the care of a healthy newborn baby - To promote and prepare the woman for breast feeding whenever possible - To provide each woman and her family with insight into the possible abnormalities that can occur to the mother and baby for their prompt action and quick arrival at health facility - To promote health education and family planning
Objectives of the first ANC visit (booking visit)
- To assess levels of health by taking a detailed history and to employ screening tests as appropriate - To ascertain baseline recordings of weight, height, blood pressure and haemoglobin level - To identify risk factors by taking accurate details of past and present obstetric and medical history - To provide an opportunity for the woman and her family to express any concerns they might have regarding current pregnancy or previous obstetric experiences
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- To give advice on general health matters and those pertaining to pregnancy in order to maintain the health of the mother and the healthy development of the fetus - To begin building a trusting relationship in which realistic plans of care are discussed
Aims of abdominal examination
- To observe signs of pregnancy - To assess fetal size and growth - To assess fetal health - To diagnose the location of fetal parts - To detect any deviation from normal
2. Signs and symptom of Pregnancy Subjective signs and symptoms of pregnancy - Amenorrhoea - Breast changes - Morning sickness - Bladder irritability - Quickening - Temperature elevation - Changes in body shape Amenorrhoea - Pregnancy is the commonest cause of cessation of menstruation in young women Other causes of amenorrhoea are: - Emotional stress - Change of environment - Some endocrine disorders - Anaemia - After use of contraceptive pill - Poor nutrition (Anorexia Nervosa) Breast changes - Occur from three to four weeks Early symptoms and signs are: - Tingling of the breasts - Breast heaviness and enlargement Morning sickness:
- More than 50% of pregnant women experience nausea and vomiting - Between the fourth and fourteenth week - The cause is thought to be high blood levels of HCG and oestrogens - Vomiting that persist after 14 weeks or excessive vomiting are considered abnormal Bladder irritability - Frequency of micturition without any signs of infection occurs in early pregnancy
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- Between the eighth and fourteenth weeks This is caused by: - Increased blood volume - Resulting in increased renal blood flow and glomerular filtration rate with an increase in urine production Quickening
- When the pregnant woman first notices fetal movement within the uterus - In multigravida quickening occurs at about 16 weeks - In primigravida it occurs at about 18-20 weeks Temperature elevation - When fertilization and implantation have taken place , there is elevation in the woman’s temperature Changes in body shape - A woman may report that her clothes do not fit - And her abdomen feels full Objective signs of pregnancy • Skin changes • Breast changes - Changes in the pelvic organs • Abdominal enlargement • Uterine souffle • Braxton- Hicks contractions
Skin changes - Linea alba changes to linea nigra - The nipples may darkened and secondary areola become present - Chloasma can be noticed from 16 weeks Breast changes - From 8-12 weeks subcutaneous veins become noticeable - There is an increase in the size and pigmentation of the nipple and areola - Montgomery’s/ tubercles appear - From 16 weeks colostrum can be expressed
Changes in the pelvic organ
- Some of these signs are demonstrated during vaginal examination to be carried out by the doctor
Hegar’s sign
- - At 6-12 weeks the embryo only occupies the upper part of the uterus. A bimanual examination done with the two fingers of one hand in the vagina
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- And the fingers of the other hand pressing downwards and backwards on the anterior abdominal wall, the fingers of both hands feel as though they meet because of the soft, elongated isthmus Jacquemier’s/ Chadwik’s sign - From eighth week, there is a dark purplish discolouration of the mucous membranes of the cervix, vagina and vulva - The vagina is warm and blue, and the cervix is soft Osiander’s sign - Increased pulsation felt in lateral fornices of the vagina, due to increase in vascularity - From eighth week (Dippenaar, P: 169)
Uterine enlargement - At about eight weeks the uterus is the size of an orange and more globular in shape - From about week 12, the fundus can be palpated abdominally just above the symphysis pubis and with the gradual increase in size the uterus becomes an abdominal organ Abdominal enlargement - From week 12, the height of the fundus rises and the uterus becomes an abdominal organ Uterine souffle - Is a soft blowing sound that synchronises with the pregnant woman’s pulse - This can be heard from week 16 on auscultation This must not be mistaken with the sound of the fetal heart, which is more rapid and strong Braxton- Hicks contractions - Are painless uterine contractions, present from 20 weeks (Dippenaar P: 171)
3. Diagnosis of pregnancy
Conclusive or Diagnostic signs of pregnancy
Fetal heart beat - The fetal heartbeat can be heard from 20 weeks with a fetoscope (Pinard’s stethoscope) - With ultrasonic, fetal heart can be detected from 15 weeks - With electro-cardiotocograph FH can be detected from 15 weeks Fetal parts: The fetal parts can be felt from 28 weeks - The lie and presentation can be determined
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Fetal movements: Can be felt on abdominal palpation at 22 weeks after LMP Ultrasonic evidence: The fetal sac can be outlined from 5 weeks and the heart beat from 7 weeks after LMP
Signs of previous pregnancy or delivery The breasts: May be flabby with prominent nipples and persistent pigmentation of the areola The abdomen: The muscles may be stretched, with loose skin - There may be scars of ceasarean section - Silver striae gravidarum may be observ Fetal parts are often easier to palpate than in primigravida The vulva: Pigmentation which may have persisted with gaping of the labia and vaginal introitus The vagina: May be lax and roomy or it may have signs of cystocele or rectocele The cervix: With speculum examination, the external cervical os is a transverse slit, which easily admits one finger The perineum: May have scars of episiotomy Pseudocyesis - Is a false or phantom pregnancy - Usually the result of an intense desire for a child
4. Psychology of normal pregnancy
PSYCHOLOGICAL CHANGES DURING PREGNANCY: Pregnancy is always associated with changes in psychological functioning of pregnant women.
It is usually associated with ambivalence, frequent mood changes, varying from anxiety, fatigue, exhaustion, sleepiness, depressive reactions to excitement
It's normal for pregnant women to experience a wide range of emotions, from joy and excitement to bouts of anxiety and mood swings.
Paying attention to any emotional and psychological changes during and after pregnancy can help keep mother and baby safe and healthy.
Depression during pregnancy has been linked with a number of complications for children once they're born.
However, it may not be depression itself, but rather a change in a mother's mental state that is harmful to the baby.
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5. Psychological and Physiological changes during pregnancy Psychological changes during pregnancy Learning outcomes • Explain the psychological changes during pregnancy on the following: - Anxiety - Fear - Emotional changes - Sexuality
PHYSIOLOGICAL CHANGES DURING PREGNANCY
Learning outcomes • Define related concepts • Explain the physiological changes during pregnancy of the following: - Reproductive - Cardiovascular - Respiratory - Digestive - Skin - Immune system - Renal - Skeleton
Physiological changes
Definitions - Leucorrhea - Operculum - Chloasma - Linea Alba/ Linea nigra - Striae gravidarum - Ptyalism - Craving - Pica
Physiology of pregnancy The Uterus - Is the organ that contains and nourishes the conceptus - Therefore is the organ most affected by pregnancy Functions of the uterus - The uterus consist of a body and cervix (neck) During pregnancy: - The body of the uterus must relax and grow to form new muscle fibres to accommodate the conceptus During labour:
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- The body of the uterus must contract and retract to expel the fetus Functions of the cervix During pregnancy: - The cervix must remain firm and become part of uterine cavity in order to maintain pregnancy During labour: - The cervix must relax, stretch and dilate to allow the fetus to pass through the cervical canal The body of the uterus - In pregnancy the uterus is divided into upper and lower uterine segments - The upper portion of the uterus contain the blastocyst enlarges uniformly and is called the upper uterine segment - The lower portion softens and lengthens in early pregnancy and forms the basis for Hegar’s sign of pregnancy - After the first trimester as the fetal sac is filling the uterine cavity, the elongated isthmus is gradually drawn up and this forms the lower uterine segment
The lower uterine segment is less vascular with fewer muscle fibres
The size of the uterus - There is a huge increase in size, weight and volume of the uterus Size:7.5 x 5 x 2.5 cm to 30 x 23 x 20 cm Weight: 50-60 g to 900 – 1000 g Volume: 6 ml to 5000 ml Increase of the uterus… The first 20 weeks of pregnancy - The increase in size is mainly due to an increase in the number of muscle fibres (hyperplasia) - And due to an increase in the size of the muscle fibres (hypertrophy) - Increase of the uterus…
- The second half of the pregnancy
- - The increase in size is mainly due to mechanical stretching of the uterus by the developing and growing fetus
Position of the uterus
- The uterus is a pelvic organ in anteversion and anteflexion
- At 12 weeks the uterus can be felt above the pelvis
- The uterus moves up in the abdomen and displaces the abdominal organs
- At 20 weeks the uterus is dextroverted to lift from the aorta and inferior vena cava
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Braxton – Hicks contractions
- These are painless contractions of uterine muscles which occur throughout pregnancy
- These contractions bring about the formation of the lower uterine segment and play a role in the blood circulation in the uterus
- They prepare the uterus for labour
False labour
- Braxton-Hicks can become intense and frequent in the last two weeks of pregnancy and some pain may be experienced
- False labour is distinguished from true labour by lack of show and absence of changes of the cervix
The cervix - In primigravidae the length of the cervix is about 2.5cm during the first two trimesters - In the second trimester, the cervix widens and softens and there is a marked proliferation of cervical mucosa - A mucus plug is formed which seal off the cervical canal and is known as the operculum
The vagina
- The muscle fibres of the vagina hypertrophy during pregnancy and there is softening of connective tissue
- Causing the vagina to develop a larger lumen and increasing the stretching ability of the vaginal walls
- The vagina becomes more vascular and assumes a dark purplish colour
- The mucosa becomes thicker and there is a larger amount of glycogen in the squamous cells
- An increased desquamation of the superficial vaginal mucosal cells leads to an increased vaginal discharge
- Which may become infected with pathogens
- An increased vaginal discharge may become infected with pathogens, such as bacteria, fungi or parasites
- The resultant vaginitis can be troublesome during pregnancy
The vulva
- There is an increased vascularity of the vulva, resulting in a darker colour
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- Varicosities of the vulva veins may occur
The fallopian tubes
- The uterine tubes together with the broad and round ligaments hypertrophy and become more vascular and pliable
- As the uterus grows and becomes an abdominal organ, the fallopian tubes are lifted out of the pelvis
The ovaries
- The ovaries cease ovum production during pregnancy
- The theca cells become active in hormone production and referred to as interstitial glands of pregnancy
- The blood supply to the ovaries also increases and the ovaries are drawn up into the abdominal cavity with the uterus and uterine tubes
- During the first 12 weeks of pregnancy the corpus luteum increases in size, under the influence of HCG
- - From the third month, there is regression of the corpus luteum as the placenta takes over the function of producing oestrogens and progesterone
The breasts • The breast changes are often the first signs of pregnancy that a woman notices - AT 3-4 weeks there is a prickling and tingling sensation in the breast - The duct and alveolar systems enlarge under the influence of oestrogen and progesterone - From 6 weeks the breast gradually increase in size and have a tense, nodular feel
- At about eight weeks, there is increased vascularity which can be seen under the skin as a network of subcutaneous veins
- By 12 week, the nipples have enlarged and become more prominent together with the primary areola
- By the 12 week, the sebaceous glands in the primary areola enlarge and become more prominent and known as Montgomery’ follicles or tubercles
- By week 16, the areola has extended over a larger area and become known as secondary areola
- From about 16 weeks, colostrum can be expressed from the nipples
- The colostrum only change to milk on about the third day after the birth of the baby
- Colostrum: Is a thin yellow milky fluid secreted from the breasts from 16 weeks of pregnancy up to 3-4 days after birth
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The skin
- There is increase in pigmentation during pregnancy
- When pigmentation is on the face it is called chloasma or the mask of pregnancy
- Linea Alba: Is a thin line extending from the symphysis pubis to the umbilicus
- Linea alba darkened during pregnancy and become known as Linea nigra (black line)
- Striae gravidarum: Are small pinkish – brown streaks or scars that develop over the abdomen, thighs and breasts
- They may become quite dark in multigravid brunettes and dark – skinned women
- They result from high level of circulating hormones and the rapid stretching of the skin of the abdomen, thighs and breasts
- Striae- gravidarum or stretch marks fade after the pregnancy and later appear as silvery streaks on a white skin or as shiny dark streaks on a dark skin
The cardiovascular system - There is an increase volume of blood to almost all the organs of the body The blood - The blood volume increases by about 1.5 litres - This is referred to as hydraemia of pregnancy th th - The plasma volume increases from 10 week to 34 week to reach about 3800ml - The red cell volume increases to about 30% more than in the non-gravid state
- As the plasma volume is greater than the red cell volume, it causes a reduction in the concentration of red blood cells, therefore a reduction in haemoglobin concentration, this is known as physiological anaemia of pregnancy
- The white blood cells increase, but there is a slight decrease in platelets
- There is a decrease in the stored quantity of iron
- Total protein, albumin and gamma globulin levels fall in the first trimester, than rises slowly to term
- Serum lipids increases especially cholesterol
The heart
- The cardiac output increases by 30-50% due to increase in blood volume
- The increased output is managed by an increase in stroke volume
- There is an increase in the heart rate of about 15% (90-100 beats per minute)
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The blood pressure
- In a normal pregnancy there is little change in the blood pressure until the end of the second trimester
- The peripheral resistance of blood vessels is reduced
- The blood viscosity is reduced
- Varicose veins and haemorrhoids are common findings
Supine hypotensive syndrome
- It is caused by the pressure of the enlarged uterus on the inferior vena cava, when the pregnant woman lies too long on her back
- It results in the patient feeling faint, pale and sweaty
- The blood pressure may be low or unrecordable
The blood coagulation factors
- There is an increase in coagulation components such as fibrinogen
- Together with factors VII, VIII, IX and X
- There is a decrease in anti-coagulation components- the fibrinolytic system
- During labour the hypercoagulable state protects the woman from excessive blood loss
The immune system - The immune system and defences are altered in the pregnant woman, causing increased risk of infection during pregnancy • Consist of immunological and non-immunological factors • Non-immunological factors include: - The skin, mucosal barriers, digestive enzymes, pH, temperature, proteins, enzymes, lysozymes, transferrin and interferon - Serum levels of IgG fall as pregnancy progresses, except in intra-uterine death (IUD) And intra-uterine growth retardation (IUGR) - IgA and IgM decrease or remain stable in pregnancy - IgE changes little and IgD increases to term
The respiratory system
- There is a relaxation of the muscles in the thorax that broadens the ribcage by about 6cm - This increase the air volume by 50% per minute - The diaphragm is pushed upwards and breathing becomes diaphragmatic
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- Due to pressure by the enlarged uterus, the movement of the diaphragm is reduced - Pregnant woman breath more deeply and tidal volume increases - There is greater mixing of gases during pregnancy and an increased oxygen consumption - Due to pressure by the enlarged uterus, the movement of the diaphragm is reduced - Pregnant woman breath more deeply and tidal volume increases - There is greater mixing of gases during pregnancy and an increased oxygen consumption - The increased blood volume causes engorgement of the pulmonary vessel - There is an increased oxygen tension(Pa02) and a decrease in carbon tension (PaC02) - Dyspnoea may be experienced by some pregnant women - Women may be more prone to upper respiratory infections and viral pneumonia
The Renal system
- Sodium retention, increased extracellular volume with altered renal functioning - The renal length increase by about 1cm - The capacity increases from 10 – 40ml - The kidney enlarge by 1cm and renal volume increases by 30% - Dilatation of the ureters may result in kinking in the middle portion - The bladder muscle becomes relaxed due to the effect of progesterone, this together with the dilatation of the renal pelvis and ureters can lead to stasis of urine - The result of this changes is increased risk of urinary tract infection - The neck of the bladder remain in pelvis and is pushed forward against the symphysis pubis
- Because of the increased blood volume, there is an increase in renal blood flow and glomerular filtration rate - This results in increased urine production which cause frequency of micturition - Tubular re-absorption remains unaltered - The capacity of tubular cells to reabsorb certain substances is exceeded
- There is increased clearance of certain substances particular sugar, amino acids, folic acid, water soluble vitamins, iodine and waste products such as urea, uric acid and creatinine
- This accounts for the frequency of glucosuria found during pregnancy
- Protein in the urine after 20 weeks is of diagnostic value for pre-eclampsia
The Alimentary system
- Increased appetite and alteration in the type of food desired, including cravings and pica
- Gingivitis and tooth decay during pregnancy are caused by hormones in the saliva
- The gums becomes highly vascular, oedematous and hyperplastic
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- Saliva becomes more acidic in pregnancy
- Some women may experience ptyalism (excessive salivation)
- The relaxing effect of progesterone on the musculature, causes delayed emptying of the stomach, intestines and colon
- This permits greater absorption of foodstuffs, but also leads to constipation
- Relaxation of cardiac sphincter may lead to oesophageal reflux and heartburn
Musculo-skeletal system
- Pregnancy is characterised by changes in posture and gait
- External rotation of the femurs cause a waddling gait to compensate for redistribution of body mass
- The symphysis pubis may widen by 10cm
- Lower limp pain may develop due to increased load on the lateral side of the foot
- The risk of ligament injury increases in pregnancy
- Muscle cramps are common in the third trimester and at night
- Compensatory lordosis develops due to a shift in the centre of gravity
Activity
Explain the psychological changes during pregnancy on the following:
a) Anxiety
b) Fear
c) Emotional changes
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d) Sexuality
6. Common Minor disorder/ discomfort in pregnancy
Learning outcomes • Identify common minor disorders of pregnancy • Demonstrate competency in the interventions for each condition • Explain the education to give to women for each condition Common minor disorders of pregnancy
Fainting:
Definition :
Causes:
- Progesterone induced, general vasodilatation of pregnancy - Standing for long, especially in hot over crowded place - Tight clothing, over exertion, lack of sleep, excitement and shock
Care and Education :
- Take blood pressure - Check haemoglobin - Reassure that the condition resolves itself after the first trimester - Avoid standing for long periods - Lie down when feel dizzy or sit with head between the knees - Avoid sitting or standing up quickly from a lying position - Eat small regular meals a day - Avoid lying in supine position for more than 15 minutes
Nausea and Vomiting/ Emesis gravidarum
Causes - Increasing levels of oestrogen and HCG - Changes in the thyroid function Care and Education - Observe signs of weight loss and dehydration - Check urine SG and ketones
Education
- Reassure that the condition usually disappears after the first trimester
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- Revisit daily food intake, low glucose levels seem to aggravate the nausea and vomiting - Have more frequent smaller meals with plenty of protein - Avoid fatty, spice foods or large meals - Do not take over the counter medication or self medication - Admit to hospital when necessary: Unable to tolerate food, significant loss of weight, ketones in urine
Frequency of micturition
Causes - Increased urine production by the kidneys in early pregncy - Pressure on the bladder from the enlarged uterus Care and Education - Take temperature to exclude infection - Test urine for pH, protein, leukocytes Education
- Reassure the woman that it is caused by the pressure of the uterus on the bladder
- Reduce intake of fluids in the evenings and before bed time
- Avoid standing for longer periods
- Empty the bladder regularly
- Leaning forward during the final stage of passing urine will help to void residual urine
Fatique
Causes - Metabolic processes of pregnancy and hormones circulating - Cumulative effect of too little sleep - Increased weight of the enlarged uterus
Headaches
Causes - Effects of oestrogen and progesterone on the circulatory system Care and Education - Take the temperature, blood pressure, oedema - Check urine for
Education
- Reassure the headache will pass after the first semester - If headaches are severe or persist, see a doctor
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- Only take prescribed medications - Protein
Varicose veins
Causes - Effects of progesterone on the circulatory system with increased blood volume - Pressure of the enlarging uterus - Inherited tendency to poor veins - Increase in parity and age
Care and Education
- Observe legs and vulva for haemorrhoids - Do not cross legs when sitting - Do not maintain same position for more than half an hour - Rest in left lateral position - Do gentle exercises - Rest with legs and hips elevated for an hour twice a day - Wear supporting anti-thrombosis stockings - Avoid tight garments around the legs
Haemorrhoids
Care and Education - Observe haemorrhoids - Prevent constipation and straining - Take some rest during the day - Elevate the foot-ent of the bed - If bleeding, cold astringent packs can be applied
Heartburn and oesophageal reflux
Education - Small frequent meals should be taken - Avoid fatty, oily, spice or indigestible foods - Last meal should not be taken after 6 pm - Use extra pillow when sleeping or resting - If smoking, reduce or stop smoking - An antacid may be prescribed by a doctor
Constipation
Education - Take a good balanced diet - Take food high in roughage/fibre and low in carbohydrates
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- Drink plenty of fluids, particularly plain water - Take high bran biscuits, wholewheat cereals and wholewheat bread - Perform light exercise such as a short walk - Bowel training, to use the toilet at specific times
Oedema
Causes - Increased blood volume - Distension of the veins - Mechanical pressure of the enlarged uterus - Standing for long periods
Care and Education
- Check blood pressure - Check haemoglobin - Test urine for protein - Avoid standing for long periods - Take frequent rests with legs elevated - The foot of the bed should be elevated - If no improvement after good rest see doctor
Backache
Causes - Increased lumbar curve - Lax abdominal muscles - Pendulous abdomen
Care and Education
- Do not stand for long periods - Take frequent rests - Do not wear high-healed shoes - Do light antenatal exercises - If backache is troublesome, see a medical practitioner
Muscle Cramps Education - Take frequent rest during the day - During spasm the foot should be flexed by pulling the toes up - The calf muscles should be gentle massaged - Rest in the knee chest position to lift pressure from the pelvic floor - Calcium or magnesium supplementation may help
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Insomnia
Care and Education - Take good balanced diet - Have adequate amounts of exercise and rest - If severe refer to medical practitioner - Do not take medication not prescribed by doctor
Activity
7. Evidence –based care : Dippenaa,173-178
Evidence –based care (Sellers Second edition page 29-31)
Good care is based on procedures and interventions that have been justified by scientific research in other words,evidence- based care.
Evidence-based aspects AND Application
Pregnancy
Magnesium- Sulphate for treating eclampsia
Studies have shown it to be much more effective than other anticonvulsants. In addition it is relatively cheap and easy to use
Magnesium sulphate should be used routinely to treat all women with eclampsia following the protocols.
Corticosteriod therapy
To prevent hyaline membrane disease of the newborn
Give IM injection to the mother between 32-34 weeks when at risk for premature birth following a protocol
Folic Acid
Prevention of neural tube abnormalities of the newborn.
All pregnant women to take folic acid orally before pregnancy
Labour
Position for labour
A number of studies suggest that an upright, or semi-upright position shows more benefits than a supine position
Allow women to take the position that feels comfortable in first and second stage unless containdicated
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Mobility during labour
Several studies show that the supine position affects blood flow in the uterus ,and can reduce the intensity of contractions
Standing or lying on the side can be more beneficial to the woman as long as there are no complications. Women should be encourage to walk around,choose other more comfortable positions, even take baths or showers during labour.
Fluids and food during labour
Labour requires lots of energy and can last for hours. Women need to maintain their energy levels,Ristriction of oral intake can lead to dehydration and ketosis- this is usualy treated with IV infusion.
Women are able to monitor their own intake and will intuitively avoid heavy meals
For normal and low- riskbirths,avoid interfering with women’s wishes for food and drink during labour,
Encourage companionship during labour
There is evidence to suggest that women who are supported throughout labour by a partner, friend,relative or carer enjoy several benefits
Encourage women to bring someone they trust or feel comfortable with; a partner,relative or friend,Alternatively, establish a child birth companionship system at your hospital/clinic.
Enemas are not always necessary
There is insufficient evidence to recommend the routine use of enemas. Further medical trials need to be conducted before the benefits and harms can be properly evaluated
An enema should be given only if the women requests it.
Stop pubic shaving
Shaving is an unnecessary procedure
Ifyou stop shavingyou will reduce the discomfort and embarrassment for women
Avoid Episiotomy
Episiotomy carries a number of risks,and the evidence suggests that routine use does not reduce perineal trauma or improve healing.
There is clear evidence to recommend restricted use of routine episiotomy. Only done when indicated.
Reduce use of early amniotomy
Routine erly amniotomy is associated with both benefits and harms.
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Until there is more evidence,amniotomy should be reserved for women with abnormal or slow progress and avoided in HIV-positive women
Suction of newborns
Routine nasopharyngeal suction of all newborn is unnescessary, and costly
It is recommended that only those babies with meconium present should undergo suction on delivery.
HIV- POSITIVE WOMEN PMTCT
Antiretroviral therapy
Triple therapy is evidence-based best practice in developed,well –resourced settings
Neverapine ,one tablet to the mother during labour, and one dose of syrup to the baby after bith,is highly effective in reducing the risk of transmission in low resource settings
Artificial rupture of membranes
Risk of MTCT increased.
Avoid the artificial rupture of membranes
Breastfeeding
12% risk of contracting HIV from breast milk
If women are in a position to provide safe alternative feeding,they may be encouraged not to breast feed,they should should be encouraged to give their baby only breat milk for 6 monts then introduce complementary feeds and continue breastfeeding for 12 months
Mode of delivery
Evidence suggest that caesarean delivery can reduce mother to child transmission of HIV.
Caesarean section is only indicated under safe conditions
Vaginal cleansing
Highest risk for MTCT is during vaginal birth
Vaginal disinfecting before and /or during laboir may help to prevent transmission of HIV. Disinfective agents such as chlorhexidine,may be particularly useful because of their activity against HIV.
Vitamine and nutritional supplements
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Studies suggest that the risk of MTCT of HIV infection is associated with Vitamine A deficiency in the mother
Give Vitamine A to pregnant women
Safe motherhood
Learning outcomes: • Provide a brief background information on the initiation and development of the Safe Motherhood Initiative (SMI) • Interpret related concepts: - Safe motherhood - Maternal morbidity - Maternal mortality - Perinatal periodon - Neonatal period
- Postnatal/ Postpartum
- Puerperium
• Identify the causes of maternal illnesses and deaths in Namibia
• Explain the contributing factors of poor maternal health
• Discuss the intervention measures for safe motherhood • Describe the human rights that promote safe motherhood • Describe the situation of safe motherhood in Namibia Safe motherhood background information
- Safe motherhood initiative (SMI) was first launch in 1987 in Nairobi- Kenya - The initiative was developed with the aim to reduce the burden of maternal deaths and illnesses resulted from complications of pregnancy, child birth and puerperium and to make pregnancy and childbirth safer Safe Motherhood Initiative: - Is a World Health Organization campaign - To reduce maternal and child mortality and morbidity world wide - Safe motherhood is an international effort to raise awareness of the scope and dimensions of maternal mortality and to stimulate commitment among Governments, Donor agencies, United Nations agencies and other relevant stake holders to take steps to address this public health problem
- Safe motherhood programmes seek to address direct and indirect causes of maternal morbidity and mortality and undertake related activities to ensure women have access to comprehensive reproductive health services From the health data monitored by the World Health Organization, maternal mortality shows the greatest disparity between poor and rich countries
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- Safe motherhood is based on the implementation of simple, appropriate, cost- effective strategies - To enable mothers to have access to high-quality care during pregnancy and child birth and related events such as fetal loss - Safe motherhood aims to improve the health, nutrition and general wellbeing of girls and women of reproductive age before conception and into parent hood - In 1987 when health experts development professionals and policymakers gathered in Nairobi to inaugurate the global initiative, maternal mortality was not a major national or international priority - It was often the overlooked component of maternal and child health (MCH) - Making motherhood safer benefit not only the woman but also the health of the newborns and children and the wellbeing of the entire family and societies - The health of newborns is closely linked to the health of their mothers - Evidence suggest that a mother’s death also harms the overall wellbeing of the surviving children - A woman’s death affects her family’s wellbeing and that of society as a whole
DEFINITION OF CONCEPTS
Safe motherhood - Safe motherhood include a series of initiatives, practices, protocols and service delivery guidelines designed to ensure that women receive high quality gynaecological, family planning, prenatal, delivery and postpartum care, in order to achieve optimal health for mother, fetus and infant during pregnancy, childbirth and postpartum - Safe motherhood also means: To create circumstances within which a woman is able to choose whether, when, and how often she will become pregnant - And if a woman become pregnant, ensuring that she receives the care for prevention and treatment of pregnancy complications - And ensuring that pregnant women has access to skilled birth attendants and access to emergency obstetric care if needed
Safe motherhood also means:
- Ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and child birth
Maternal morbidity:
- - Refers to sickness or disability as a result of complications of pregnancy and child birth
Maternal mortality or maternal death:
- Is the death of a woman while pregnant, or within fourty two (42) days of termination of pregnancy - Irrespective of the duration and site of the pregnancy from any cause related to or aggravated by the pregnancy or its management
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- But not from accidental or incidental causes
Perinatal period th • The period extending from the 28 week of pregnancy to the end of the first week of life Neonatal period • The period starting at birth and ends after a month (28 days), the first four (4) weeks after birth • Early neonatal period • - The period from birth up to seven (7) completed days after birth • Late neonatal period • - Extends/begins from day eight (8) after birth and ends on the 28th day after birth • Postnatal/Postpartum • - After child birth Postnatal examination - Maternal examination undertaken frequently during the first ten (10) days of puerperium - To ensure that the involution is taking place, lactation is becoming established and mother is adapting physically, emotionally and psychologically to motherhood
Medical/Midwifery postnatal examination - Examination at the end of the six (6) weeks of puerperium - To ensure that mother’s body has returned to the non-pregnant state without complication Puerperium - Six weeks period following child birth during which the uterus and other organs are returning to the non-pregnant state, the fourty two (42) days period following delivery of the baby Live birth - A live born baby who is over 500g in weight, irrespective of gestation who shows signs of life after delivery, i.e. heart beats, respirations, muscle movements Still birth - Refer to an infant over 500g in weight, that shows no signs of life after delivery irrespective of gestation Abortion - Refers to a fetus of less than 500g in weight who may or may not show evidence of life after delivery - It also refers to the expulsion or extraction of the placenta or membranes without an identifiable fetus - Perinatal death - - Stillborn infants and babies who die within the first week of life - Neonatal death
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- - Infants who die within 28 days of birth - Early neonatal death - - Refer to the death of an infant within the first week of life - Late neonatal death - - The death of an infant between 8 and 28 days
- Perinatal mortality rate
- - The number of stillbirths plus death of babies under one (1) week old per 1000 total births
- Neonatal mortality rate
- - Number of deaths of infants up to four (4) weeks after birth per 1000 live births
The components of safe motherhood
• Preconception care • Antenatal care/Prenatal care • Clean safe delivery • Essential obstetric care (EOC) and emergency obstetric care (EMOC) • Perinatal care, Neonatal care • Postnatal care • Breastfeeding • Family planning
Direct causes of maternal illness and death
• The three delays: Delay to make a decision to seek care Delay to get transport to health facility Delay to be attended to at the facility • Haemorrhage due to: Obstructed labour, Prolonged labour, Ruptured uterus • Pregnancy induced hypertension (PIH): Severe-pre-eclampsia and eclampsia • Infection, Abortion, Septicemia, Puerperal sepsis
Indirect causes of maternal deaths
• Human immunodeficiency virus (HIV) and Aquired immunodeficiency deficiency syndrome • Sexually transmitted infections • Malaria • Tuberculosis • Meningitis • Pneumonia
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Contributing factors of poor maternal health
• Heavy work load • Low standard of living resulting from poverty • Early marriage and early child bearing • Teenage /Adolescent pregnancy • Poor education • Violence against women • Poor nutrition, Poor general health • Lack of access to health care
Intervention measures for safe motherhood
• Problem solving approach during antenatal care • Educate girls and women on matters related to reproductive health • Ensure skilled attendants during pregnancy and birth • Essential obstetric care • Emergency obstetric services for life threatening complications • A functional referral system to ensure timely access to appropriate care and outreach to community
• Improve family planning services
• Training of traditional birth attendants
Includes the fulfillment of several key human rights such as:
• Right to reproductive freedom: Delay early age marriage and child birth
• Rights to education and information: Including education and information relating to sexual and reproductive health without any discrimination
• Improving nutrition of girls and women
• Right to health including sexual and reproductive health: Care during pregnancy and child birth by trained and skilled health care professionals
• To have access to maternal and neonatal health care treatment in emergency situations including obstetric interventions when needed
• Building linkages with other stakeholders, which involve decision makers at the national and local levels, UN-agencies, civil society, mass media, religious bodies, schools, non-governmental and community-based organizations • Involvement of men as husbands/partners, neighbours, leaders etc, need to become more actively involved in supporting women to improve their health
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Eight health care delivery functions identified by WHO to reduce maternal deaths are:
1. The administration of parenteral antibiotics 2. The administration of parenteral oxytocics 3. The administration of parenteral anti- convulsions for pre- eclampsia/eclampsia 4. Perform the removal of retained placenta 5. Perform the removal of retained products 6. Perform an instrumental assisted vaginal delivery
7. Perform safe blood transfusions
8. Perform surgery/ ceasarean delivery
Health facilities offering functions 1-6 are classified as basic emergency obstetric care(BEmoC)
Health facilities offering functions 1-8 are classified as comprehensive emergency obstetric care(BEmoC)
The situation of maternal health in Namibia
- According to Demographic Health Survey of 2006, the Maternal Mortality Ratio (MMR) in Namibia is 449 deaths per 100,000 live births. - Of concern is that the MMR shows an increasing trend, from 225 per 100,000 live births in 1992 to 271 per 100,000 live births in 2000. Women are particularly more at risk during delivery - In 2000 the Government of Namibia adopted the Millenium Development Goals (MDGs). These consist of eight goals to be met in 2015.
- MDGs 4 and 5 focus on maternal and child health.
- Millenium Development Goal 4 focus on the reduction of under-five mortality rate by 2/3
- Millenium Development Goal 5: Improve maternal health. Reduce maternal mortality by 3/4
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Unit 7: Antenatal care
Definitions
Viability: Means the ability to live outside the uterus after birth has taken place • Viable: In relation to a child means it has had at least six months (26 weeks) of intra-uterine existence • Parity: Means the number of previous viable pregnancies ( stillborn or alive ) • Ante-partum: The time between conception and onset of labor, the period during which a woman is pregnant • Gestation: The number of weeks since the first day of the last menstrual period (LMP) • Trimester: The three months period in which pregnancy gestation of nine months is divided • Term: The normal duration of pregnancy (38-42 weeks)
Aims of antenatal care
- To support and encourage a family’s healthy psychological adjustment to child bearing - To promote an awareness of the sociological aspects of childbearing and influences that these may have on the family - To monitor the progress of pregnancy in order to ensure maternal health and normal fetal development - To recognize deviation from the normal and provide management or treatment as required - To ensure that the woman reaches the end of her pregnancy physically and emotionally prepared for her delivery - To help and support the mother in her choice of infant feeding; to promote breast feeding - To give advice about preparation for lactation when appropriate - To offer the family advice on parenthood either in a planned programme or on an individual basis - To build up a trusting relationship between between the family and their caregivers which will encourage them to participate in the care they receive
Objectives of the first ANC visit (booking visit)
- To assess levels of health by taking a detailed history and to employ screening tests as appropriate - To ascertain baseline recordings of weight, height, blood pressure and haemoglobin level - To identify risk factors by taking accurate details of past and present obstetric and medical history - To provide an opportunity for the woman and her family to express any concerns they might have regarding current pregnancy or previous obstetric experiences
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- To give advice on general health matters and those pertaining to pregnancy in order to maintain the health of the mother and the healthy development of the fetus - To begin building a trusting relationship in which realistic plans of care are discussed
Aims of abdominal examination
- To observe signs of pregnancy - To assess fetal size and growth - To assess fetal health - To diagnose the location of fetal parts - To detect any deviation from normal
The duration of pregnancy and expected date of delivery (EDD).
Calculation of expected date of delivery Several methods can be used: - Obstetric calendar, when LMP is determined - The obstetric wheel, give both the EDD and current gestational age based on the LMP - EDD can be determined by using naegle’s rule - The normal duration of pregnancy (38-42 weeks)
HISTORY TAKING OF A PREGNANT WOMAN Learning objectives: Interview and take history of a pregnant woman without physical medical risks within 20 minutes Demonstrate practical competence in the interviewing technique Keep accurate records Interpret findings and notice abnormalities Give appropriate health education to the client
Antenatal • Before birth • A care provided by midwives and obstetricians during pregnancy • To ensure that the fetal and maternal health are satisfactory • To enable early detection and treatment of any abnormality (deviations) from normal
• Complete the antenatal record card • Physical examination, weight, bloodpresure, urinalysis, blood test in pregnancy • Taking History, general health, menstrual history, past obstetric, medical/surgical, family history • The midwife/ Acchoucheur’s examination of pregnant woman • Abdominal examination( leopards manoeuvre) • The relationship of the fetus in utero • Indication of fetal wellbeing
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• Antenatal exercises & Postnatal exercises
SUBSEQUENT ANTENATAL VISITS
Frequency of ANC visits.
If pregnancy is normal, the woman can attend ANC as follows:
0-20 weeks: After 2 months
21-28: 6 weeks
29-35: 4 weeks
36-42: Every after 2 weeks
Pregnancy with problems or complications are seen 1-2 weeks or whenever necessary.
MANAGEMENT OF A WOMAN DURING ANC FOLLOW-UPS.
- Ensure a warm welcome and encourage the client to talk out anything that is troubling her.
- Re-assess the psychological state of the client.
- Any existing problem should be attended to or if necessary refer to the Dr. or other relevant services.
- Re-assess previous history for any changes and adjust accordingly, attend to the needs of the client and keep accurate records.
- Take the necessary parameters and examinations e.g. Bp, urine test, abdominal examination etc.
- Give out routine medications if applicable.
- Health education should be a continuous process at each visit.
- Give a date for return follow-up.
CONDITIONS WHICH ARE OF PARTICULAR IMPORTANCE FOR IMMEDIATE REFERRAL TO A DOCTOR
- Any problem regarding the fetal heart beat or fetal wellbeing. - Vaginal bleeding. - Blood pressure of 130/90mmHg or more. - Excessive weight gain, oedema of hands, legs, face and/ or protein-uria. These clinical features may indicate severe pre-eclampsia.
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- Sugar in urine may indicate diabetes mellitus. - Any cardiac conditions. - Pre-term labour. - Any abnormalities noted on abdominal palpation e.g. mal-presentations after 36 weeks. - Multiple pregnancy and/ or polyhydramnios. - Excessive vomiting and/ or diarrhoea.
THE ANTENATAL VISIT AT OR AFTER 36 WEEKS OF PREGNANCY
Re-assess the client psychological state with emphasis on her preparedness for delivery and motherhood. - If mother is RH- negative re-check antibody titre - Assess engagement of the head. Re-assess HB.
Tests carried out at the first antenatal visit or at follow up visits
Urine test: Glucosuria, associated with the following conditions: - Lowered renal threshold - Diabetes mellitus Proteinuria, associated with the following conditions:
- Hypertension
- Pre-eclampsia
- Pyelonephritis
- Chronic nephritis
- Urinary tract infection
Ketonuria - Diabetes mellitus - or starving (hunger) Blood Tests - Blood grouping (Type of blood group) - Rhesus factor (If negative refer to doctor) - Haemoglobin - Rapid Plasma Reagin (RPR): Test for syphylis - If RPR is positive it must be confirmed with Treponema Pallidum Haemagglutination (TPHA) - Antigen HIVirus (AIDS) - Antigen Hepatitis B (Hepatitis)
Weight, physical examination (done from head to toe) &
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Blood pressure measurement are also done during the first vist and also at every visit. History Taking
• Is a guide not a rigid structure • Pay attention to your relationship with the client and the information you want for history • Be friendly and show respect for the patient • Choose a comfortable setting and help the patient get settled • Maintain eye contact and use a conversational tone • Begin by introducing yourself and explain your role • Help the patient understand why you are taking the history and how it will be used • Be sensitive to the patient’s emotions at all times • Avoid confrontation and leading questions
Procedures to be done:
• Complete the antenatal record card • The midwife/ Acchoucheur’s physical examination of pregnant woman • Abdominal palpation • Health Education
Abdominal examination ( leopards manoeuvre)
ABDOMINAL EXAMINATION
Aims of abdominal examination - To observe the signs of pregnancy - To assess fetal size and growth - To assess fetal health/ wellbeing - To diagnose the location of fetal parts - To detect any deviation from normal (Bennett, P: 128)
- Abdominal examination is a guide to be used during pregnancy and labour - The examination is more useful from 28 weeks - The woman should empty her bladder before the examination - The examination is done with the woman lying in the supine position - the examination must be done quickly and efficiently The procedure is carried out in the following order: - Determine EDD and estimated gestational age - Inspection - Assessment of the fundal height - Palpation - Auscultation of the fetal heart
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Inspection: - Note the following: - Skin changes - Striae gravidarum: extensive distribution and deep pigmentation in the abdomen skin due to excessive stretching - Old striae gravidarum indicate previous pregnancy - Skin changes, note the following - Linea alba and nigra - Rashes or skin lesions - Sores or any evidence of trauma e.g.bruises or wound scars - Operation scars, enquire about C/S and reason
Size of the abdomen
- Rough estimate can be made on the period of gestation, bearing in mind the estimate date of delivery calculated
Shape of the abdomen
- Oval shaped: Indicate a longitudinal lie with the fetus well flexed
- Round shaped: Suggest polyhydramnios and/ or multiple pregnancy
- A narrow, elongated abdomen: Suggest a frank breech (extended legs)
- A heart-shaped abdomen: Suggest a bicornuate uterus
- An abdomen that is wider than it is long: Suggest a transverse lie
- A very flabby and shapeless abdomen: Suggest grande multiparity
- A saucer-shaped depression in the centre of the abdomen near term: Indicate fetal back lying posterior (Occipito-posterior position)
- A saucer-shaped depression in the centre of the abdomen near term: Indicate fetal back lying posterior (Occipito-posterior position)
- Fetal movement: Indicate the side of the small parts and that the fetus is well
- (Dippenaar, P: 200)
Abdominal palpation
Assessment of fundal height - The tape measure method is only accurate between 20 – 35 weeks. The height that the fundus has reached at certain weeks using abdominal landmarks 12 weeks: Just above the symphysis pubis
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16 weeks: Half- way between the upper border of the symphysis pubis and lower border of the umbilicus
The height that the fundus has reached at certain weeks using abdominal landmarks..
- 20 weeks: The lower border of the umbilicus
- 22 weeks: The centre of the umbilicus
- 24 weeks: The upper border of the umbilicus
- 30 weeks: Half-way between the upper border of the umbilicus and the lower border of the xiphisternum
- The height that the fundus has reached at certain weeks using abdominal landmarks
- 36 weeks: The lower border of the xiphisternum
- 38 weeks: The height of fundus drop about 2 fingers breadth and remain at the level at
- which it was at about 32- 34 weeks
- Measuring the height of fundus can give an indication of fetal growth
Types of pelvic grips Pawlik’s grip - Determine which part of the fetus is lying over the pelvic brim - Determine presentation (presenting part) The head will feel hard and round If not engaged mobile and ballotable Combined grip: Fundal palpation and pawlik’s grip - Determine the part of the fetus lying in the fundus (comparison is made on what is in the lower and upper uterine segment) - This is likely to lead to a correct diagnosis of the Lie and Presentation) The breech feel bulkier and softer than the head - Bimanual fundal palpation: - Using two hands on the fundus - Determine what is in the funds - Fetal limbs and feet may be felt and this will help to verify that the breech is in the fundus - Two poles in the fundus indicate twins Lateral grip: - Used to locate the fetal back
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-In a vertex presentation the back of the fetus should be on the same vertical plane as the occiput -Locating the fetal back help to determine the position of the fetus Walking the fingers over the abdomen: A continuation with the lateral grip The deep pelvic grip - Used in late pregnancy or during labour - To determine the level of descent of the fetal head or presenting part - Help to verify which part of the fetus lies at the pelvic brim - When the head is deeply engaged (no fifths of head above the pevic brim), cannot be felt on abdominal palpation
Abdominal examination
Auscultation - The fetal heart can be heard from 20 weeks with Pinard’s stethoscope or from 14 weeks with doppler - The normal fetal heart beat is between 120 – 160 beats per minute
Information that can be obtained on abdominal examination
- The shape and size of the abdomen - The height of the fundus and if this corresponds to the EDD - The lie of the fetus - Which part of the fetus is lying over the pelvic brim Which part of the fetus is in the fundus
- Which part of the abdomen can the back of the fetus be felt and the limbs - Whether the head is engaged and how many fifths of head are above the pelvic brim - Are there fetal movements - Is the fetal heart rate present and normal - Is there any uterine contractions
Causes of non – engagement of the fetal head
- Inaccurate calculation of EDD - Full bladder, prevent head from entering - Large presenting diameters - Contracted pelvis - Polyhydramnios - Multiple pregnancy - Breech presentation - Placenta praevia - Tumors or abnormalities of the uterus - Pendulous abdomen - Unknown causes
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The relationship of the fetus in utero: page 191
This relationship indicate the part of the fetus that will the pelvic brim first, and will indicate the mechanism by which the fetus will pass through the birth canal during labor.
It is very important for a student to know which one is normal and which one is abnormal in this relationship to be able to continuation of pregnancy and labor.
Lie- is the relationship of the long axis (spine) to that of the mother. The lie can be longitudinal or transverse or obligue. Attitude – is the relationship of the fetal parts to each other, such the fetal limbs and fetal trunk. Attitude can be flexion, deflexion and extension. Presentation - is that part of the fetus that lies in the lower pole of the uterus and which present in the pelvic brim. The presentation can be vertex, breech, a face, and a shoulder or brow presentation. 96% of presentation are cephalic (head, face and brow). The breech presentation are podalic (pelvic) Denominator is that part of the presentation that indicated the position of the presentation in relation to the pelvic brim and give the position its name. The part that is felt on vaginal examination. Occiput is the denominator in vertex, mentum (chin) in face presenation, etc. Position – the relationship of the denominator to sixpoints or landmarks on the pelvic brim. This could be anteriorly, posteriorly, laterally. In vertex presentation with occiput as a denominator, the position is either LOA/ROA Presenting part – is that of the presentation that liesover the cervical os during labor and is where caput is formed.
Descent /engagement of presenting part –the amount of descent of the presenting part (fetal head/sacrum) in the mother’s pelvis. Page197
Activity
Study all positions also for breech presentation. Page 197
Indication of fetal wellbeing
One of the aim of ANC is to monitor fetal wellbeing in the uterus.
The wellbeing of the fetus is linked to the wellbeing of the fetus. Amy infection of the mother put also the fetus at risk.
Maternal weight gain SFH measure increasing and correlate with LMP & EDD Abdominal palpation, indicating, fetal parts, fetal movements, fetal heart rate Fetal movement is the most reliable indication of fetal wellbeing. Mothers should be able to monitor fetal movements as from 26 weeks. Non stress test, Ultra sound and ECG can be used to check the fetal wellbeing.
Activity:Read Antenatal exercises & Post natal exercises Dippenaar 2013:218
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Unit 8.Management of Lactation /breastfeeding
• Anatomy of the breast
Structure of the female breast
The breast is made up of glandular tissue, fibrous tissue, adipose tissue and is covered on the outside by skin 1.The skin of the breast - Is covered with skin and sub- cutaneous tissue - The nipple is covered with primary areolar tissue - The areola is pigmented and is less smooth 1. Skin of the breast continue
- During pregnancy and lactation, the primary areola becomes more darker and is known as secondary areola
- The glands in the areola is made up of sebaceous, sweat and montgomery’s glands
- The oily secretion from the glands provide a protective lubricant for the areola and nipple
The adipose tissue
- Forms the bulk of the breast tissue
- Surrounds the breast and lobes of the glandular tissue
- The amount of adipose tissue present determine the size of the breast
3.The fibrous tissue
- The fascia on which the breast rest
- Sends out extensions in the form of fibrous processes
- From the back of the breast forwards to the sub-cutaneous tissue
- These processes are the suspensory ligaments of cooper
The glandular tissue
- There are fifteen to twenty lobes in each breast
- Made up of glandular tissue and ducts
- Each lobe is made up of thirty to forty lobules
- When fully developed each lobule consist of cluster of specialized alveoli
- Making up the secretory units of the glands
- The alveoli open up in tiny ducts which are the smallest ducts of the breast
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The nipple
• Is a small conical eminence at the centre of the breast
• It is surrounded by a pigmented area called the areola
• On the surface of the areola are numerous sebaceous glands (Montgomery’s tubercles), which lubricate the nipple during lactation
Functions of the breast
• After the baby is born the hormone prolactin, stimulates the production of milk • Oxytocin stimulates the release of milk in response to the stimulation of the nipple by the sucking baby Seller volume 1, P: 119 Dippenaar Page: 114 Study the diagram of the breast in your books
The diagram of a female breast
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Defi
Exclusive breast-feeding: - Means to give an infant only breast milk; including expressed breast milk, with exception of drops or syrups consisting of vitamins; mineral supplements or medicines. The exclusively breast feed infant receives no drinks; (not even water) or food.
Replacement feeding. - Is feeding the baby with any other food apart from breast milk.
Colostrum Is the first breast milk which can be expressed from the breasts from the 16th week of pregnancy.
It is a clear; yellowish; alkaline fluid. Colostrum is high in protein and low in carbohydrates and fat. The fluid content is less than that of breast milk, but the kilo-joule value is 300 kJ/100ml; which is high than that of breast milk
The functions of colostrum for the newborn baby - Provides adequate kilojoules for the baby’s needs during the first few days of life - Satisfies the baby’s hunger; because it has a high protein value - Provides antibody protection from infection as it has a high level of immune-globulin A (IgA) - Bonding with the mother in the first days of life appears to be facilitated through breast feeding - Colostrum is thought to have a laxative action facilitating the passing of the sticky meconium
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Advantages/benefits of breastfeeding
For the baby: - It is always fresh - It is safe and free from bacteria - Breastfed babies are more healthy than bottle-fed babies - Breast milk is naturally designed for babies, contains all the nutrients needed by the baby in the right proportion - It is easy to digest - It has the right temperature - Protect the baby against some diseases such as diarrhea and pneumonia - Help baby to receive love from his/her mother - Facilitates bonding between mother and baby For the mother - No costs involved - It saves time - Sucking helps the uterus to contract - Help to prevent breast abscesses - Helps mother to express love to he baby - Delays ovulation and pregnancy
Disadvantages of breast milk - If mother is HIV-positive, the baby will be exposed to HIV infection - Exclusive breastfeeding is not adhered to sometimes - Feeding on demand is difficult for women who work outside the house - Mother requires a balanced diet with additional 500-750 kilo calorie per day to practice exclusive BF-in the first 4-6 months
Tips for successful breastfeeding - Initiate breastfeeding within ½ hour of birth with skin to skin contact - Reinforce exclusive breastfeeding, no water, tea or food for the first 4-6 months for every baby - Explain dangers of mixed feeding and HIV transmission - Demonstrate correct positioning and attachment to the breast - Explain feeding on demand 8-12 times(both breasts) every 24 hours - Remind to alternate breasts when starting to feed - Teach mother to wake baby at night if enough feeds haven’t occurred - Review health hazard of bottles, dummies, artificial teats, and cups with spouts - Demonstrate how to express milk and feed with cup if breast problems occur
Ten steps to successful breastfeeding
Ten steps to successful breastfeeding
- Have a written breastfeeding policy that is routinely communicated to all health care staff - Train all health care staff in skills necessary to implement breastfeeding policy
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- Inform all pregnant women about the benefits and management of breastfeeding - Help mothers initiate breastfeeding within half-hour of birth - Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants
- No food or drink be given to newborn infants other than breast milk, except vitamins or medications
- Practice rooming-in, allow mothers and infants to remain together 24 hours a day
- Encourage breastfeeding on demand
- Give no artificial teats or pacifiers to breastfeeding infant
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the health facility
Activity
How to promote baby- mother -friendly initiative in community, home, workplace and health facilities.
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Unit 9. Nutrition in pregnancy, birth and lactation
Define Nutrition
Is the science that interprets the nutrients and other substances in food in relation to maintenance, growth, reproduction, health and disease of an organism. the process of providing or obtaining the food necessary for health and growth
Nutrition- related physiology of pregnancy
Maternal nutrition during pregnancy, and how this impacts placental and fetal growth and metabolism, is of considerable interest to women, their partners and their health care professionals.
In developing countries, maternal undernutrition is a major factor contributing to adverse pregnancy outcomes.
On the other hand, with the increased prevalence of high calorie diets and resulting overweight and obesity issues in developed countries, the impact of this overnutrition situation upon pregnancy outcome is highlighted as a contributing factor for adverse metabolic outcomes in offspring later in life.
Undernutrition, overnutrition, and diet composition negatively impact fetoplacental growth and metabolic patterns, having adverse later life metabolic effects for the offspring
Nutritional requirement during pregnancy
Eating right during pregnancy - Eating a well-rounded diet with all of the right nutrients and getting at least 30 minutes of exercise per day is important for a healthy pregnancy. For most normal-weight pregnant women, the right amount of calories is: o About 1,800 calories per day during the first trimester. o About 2,200 calories per day during the second trimester. o About 2,400 calories per day during the third trimester
Most pregnant women can meet these increased nutritional needs by choosing a diet that includes a variety of healthy foods. A simple way to ensure you’re getting all the necessary nutrients is to eat different foods from each of the food groups every day. In fact, all meals should include at least three different food groups.
Each food group has something to offer your body. For example:
Grains are a good source of energy. Fruits and vegetables are packed with antioxidants, fiber, and water-soluble and fat- soluble vitamins. Meats, nuts, and legumes provide your body with protein, folate, and iron. Dairy products are great source of calcium and vitamin D.
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Nutrition needed for HIV-positive and lactating women.
Pregnant, HIV-positive women should be encouraged to obtain needed nutrients from a balanced diet. At this time, no specific RDAs are available for pregnant, HIV-positive women.
A prenatal multivitamin or micronutrient supplementation is likely to be beneficial and is an easy, cost-effective means to improve maternal and neonatal health in addition to nutrional requirements for a pregnant woman.
Activity
Define Lactation
Indicate the nutritional needs for a lactating woman.
Reference
1. UNICEFNamibia/2015/L/Narib- Promoting exclusive breastfeeding as a standard practice for countering malnutrition in Namibia Retrieved February 19 2020 2. Pauline M. Sellers, 2006: Midwifery volume 1. Juta & Co. S.A 3. Depp
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