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LECTURE NOTES For Nursing Students Obstetric and Gynecological Nursing Meselech Assegid Alemaya University In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education 2003 Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. ©2003 by Meselech Assegid All rights reserved. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Preface This lecture note offers nurses comprehensive knowledge necessary for the modern health care of women with up-to- date clinically relevant information in women’s health care. It addresses and contains selected chapters and topics which are incorporated in the obstetrics and gynecology course for nurses. However, a major focus is provided on the role of the nurse in providing quality maternal and newborn care. The obstetric nurse does a three or four month course of obstetrics part as part of an integrated training. The nurse is part of the health team expected to be able to deal with midwifery. The nurses work among the community and they bear the great responsibility of having to deal with mothers in remote areas and far away from hospitals. The nurses must do their best to educate mothers in prevention of complications. This lecture note is prepared to relieve the shortage of reference materials in the country even though it does not represent the text books. It is organized in a logical manner so that students can learn from the basics to the complex. It is divided in to chapters and subtopics. Each chapter contains learning objectives, descriptions and exercises in the form of discussion, case studies. Important abbreviations and i glossaries have been included in order to facilitate the teaching learning process. The learning objectives are clearly stated to indicate the required outcomes. ii Acknowledgement My deepest appreciation and heart felt gratitude goes to The Carter Center, EPHTI, Addis Abeba for the financial support, initiation of the lecture note preparation, and provision of necessary materials. I also extend my thanks to my colleagues from Alemaya University, Faculty of Health Sciences for their invaluable comments during the revision of the lecture note. Finally, my special thanks and gratitude goes to Ato Aklilu Mulugetta for his devoted support and facilitating the preparation of this lecture note. Last but not least, I thank my university authorities; Acadamic Vice President, Faculty dean and Department for their permission to work on this lecture note besides my other responsibilities. I would also like to thank my faculty secretaries for their cooperation in writing this lecture note. iii TABLE OF CONTENTs Preface i Acknowledgement iii Table of Containts iv List of figures xi List of Tables xii Abbreviations xiii CHAPTER ONE: INTRODUCTION 1 1.1 Historical development of obstetrics 1 1.2 Magnitude of Maternal Health problem in 2 Ethiopia 1.3 Importance of Obstetrics and Gynecology 3 nursing CHAPTER TWO: ANATOMY OF FEMALE 5 PELVIS AND THE FETAL SKULL 2.1 Femele Pelvic Bones 5 2.2 Anatomy of the female external genitalia 18 2.2.1 The vulva 18 2.3 Contents of the pelvis cavity 20 2.3.1 The bladder 20 2.3.2 The Ureters 21 2.3.3 Urethra 21 2.3.4 The uterus 22 iv 2.3.5 Fallopian tube or uterne tube 24 2.3.5 The ovaries 25 2.4 Physiology of the Femel Reproductive Organs 26 2.4.1 Puberty – the age of sexual maturation 26 2.4.2 The menstrual cycle 27 2.4.3 Phases of menstrual cycle 29 2.5 The Breast Anatomy 31 Review Questions 35 CHAPTER THREE: NORMAL PREGNANCY 36 3.1 Conception 36 3.2 Development of the Fertilized Ovum 37 3.3 Functions of Placenta 40 3.4 The Fetal Circulation 41 3.5 Anatomical Varations of the Placenta and the 46 Cord 3.6 Physiological Changes Of Pregnancy 50 3.6.1 Gastro Intestinal Tract (GIT) 50 3.6.2 Galbladder 51 3.6.3 Liver 52 3.6.4 Urinary systems 52 3.6.5 Bladder 53 3.6.6 Hematological system 53 3.6.7 Cardiovascular System 54 3.6.8 Plumunary system 55 3.6.9 Changes in the Breast 56 v 3.6.10 Change in Skin 56 3.6.11 Change in Vagina and Uterus 56 3.7 Minor Disorders of Pregnancy 57 3.8 Diagnosis of Pregnancy 60 3.9 Antenatal Care 62 3.9.1. History Taking 64 3.9.2 Examination of the Pregnant Woman At 65 First Visit 3.9.3 Laboratory test 74 Review Questions 76 CHAPTER FOUR: NORMAL LABOUR 77 4.1 Mechanism and Stages of Labour 79 4.1.1 Management of 1st Stage of Labour 79 4.1.2 The Second Stage of Labour 94 4.1.3 The Third Stage of Labour 98 4.2 Immediate Care of Mother and Baby 111 4.3 Discharge Planning (Instructions) 113 4.4. Episiotomy 115 Review Questions 120 CHAPTER FIVE: THE NORMAL PUERPERIUM 121 5.1 Physiology of Puerperium 122 5.2 Management of the Puerperium 125 5.3 Postnatal care (Daily care) 127 Review Questions 129 vi CHAPTER SIX : ABNORMAL PREGNANCY 129 6.1 Multiple pregnancy 129 6.1.1 Monozygotic (Uniovular) 129 6.1.2 Dizygotic (Binovular) Twins 130 6.2. Hyper Emesis Gravidarum 138 6.3. Pregnancy Induced Hypertention 140 6.3.1 Preeclampsia 140 6.3.2 Eclampsia 146 6.4. Antepartum Haemorrhage 149 6.4.1 Placenta praevia 150 6.4.2 Placental Abruption 155 6.5 Polyhydramnios 158 6.6. Rhesus Incompatibility 162 6.7 Disease Associated With Pregnancy 166 6.7.1 Infection 166 6.7.2 Pulmonary tuberculosis 167 6.7.3 Cardiac Disease 169 6.7.4 Diabletes Mellitus 171 Review Question 175 CHAPTER SEVEN : ABNORMAL LABOUR 176 7.1. Malpresentation and Malpostion 176 7.1.1 Breech Presentation 177 7.1.2 Brow Presentation 184 7.1.3 Shoulder Presentation 185 7.1.4 Face Presentation 187 vii 7.1.5 Unstable lie 189 7.1.6. Compound or Complex Presentation 190 7.1.7 Occupitio- Posteririor Position 191 7.2. Post partum Hemorrhage 193 7.2.1 Atonic Postpartum Hemorrhage 195 7.2.2 Traumatic Post Partum Hemorrhage 196 7.2.3 Hypo Fibrinogenaemia 197 7.3. Prolonged Labour 200 7.4 Prolapse of Cord 203 7.5 Cephalopelvic Disproportion 205 7.6 Contracted Pelvis 206 7.7 Retained Placenta 207 7.8 Adherent Placenta 208 7.9 Rupture of the Uterus 209 7.10 Lacerations 213 7.11 Premature Rupture of the Membrane 215 (PROM) Review Questions 226 CHAPTER EIGHT : ABNORMAL PUERPERIUM 218 8.1 Urinary Complications 218 8.2 Breast Infections 219 8.2.1 Acute Puerperal Mastitis 219 8.2.2 Breast Abscess 220 8.3 Puerperal Sepsis 221 8.4. Puerperal Psychosis 223 viii 8.5 Subinvolution 225 Review Questions 226 CHAPTER NINE : INDUCTION OF LABOUR 227 9.2 Augmentation (Stimulation) Of Labour 232 9.3 Trial of Labour 233 Review Questions 236 CHAPTER TEN : OBSTETRIC OPERATIONS 237 10.1 Forceps Delivery 237 10.2 Caesarean Section 243 10.3 Destructive Operations /Embryotomy/ 246 10.4 Version 248 10.4.1 Internal Version 248 10.4.2 External Cephalic Version 249 10.5 Vacuum Extraction / Ventouse delivery/ 250 Review Questions 252 CHAPTER ELEVEN : CONGENITAL ANOMALIES 253 OF THE FEMALE GENITAL ORGANS 11.1 Uterine Abnormalities 254 11.2 Cervix Abnormalities 155 11.3 Vaginal Abnormalities 257 Review Questions 258 ix CHAPTER TWELVE : INFECTION OF THE 259 FEMALE REPRODUCTIVE ORGANS 12.1 Pelvic Inflammatory Disease 260 12.2 Vulval Infection 263 12.3 Candidiasis 266 12.4 Trichomoniasis 268 12.5 Trauma of the female genital tract fistulae 270 12.6 Prolaps Of The Uterus 273 12.7 Inversion of the Uterus 275 12.8 Abortion 279 12.8.1 Types Of Abortion 281 12.9 Abnormalities Of The Menstrual Cycle 290 (Menstrual Disorder) 12.9.1 Menstral Disordenrs 290 12.10 Ectopic Pregnancy 293 12.11 Infertility 300 12.12 Disorder Of The Breast 302 12.13. Menopause 306 Self examination of the breast 307 12.14. New growths 310 Review Questions 316 GLOSSARY 317 BIBILIOGRAPHY 320 x LIST OF FIGURES Figuer 1. Normal Female Pelvis 6 Figuer 2. Pelvic ligaments(Posterior view) 8 Figure 3. Types of female pelvis 11 Figuer 4. Fetal skull 16 Figuer 5.Diameters of fetal skull 17 Figure 6 Female external genitalia 19 Figure 7. Anterior view of female internal reproductive 26 organ Figure 8. Menstrual cycle 30 Figure 9. Anatomy of female breast 34 Figure 10. The fetal circulation 43 Figure 11. Anatomical variation of placenta and cord 48 insertion Figure 12. Fundal palpation 69 Figure 13.
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