Distance Learning Material

FACULTY OF HEALTH SCIENCES

DEPARTMENT OF NURSING

NRSG 343: REPRODUCTIVE HEALTH NURSING II

KENYA METHODIST UNIVERSITY
SCHOOL OF HEALTH SCIENCES
NURSING DEPARTMENT

AURTHOR: ELIZABETH KIRIINYA

ACKNOWLEDGEMENTS
The writing of this course material would not have been completed without commitment, and a
lot of sacrifice in many ways. I extend my heartfelt gratitude to my family and friends for their
support and encouragement during this period. I would like to thank my colleagues who assisted
me in any way. My thanks also go to .....................read through the unit and gave me many
helpful suggestions and words of advice.

I am very grateful to KeMU for giving me this opportunity to write these Course materials and
for extending time when deadlines were not met due the heavy workloads. Special words of
appreciation go to..........for editing and inclusion of graphics in this course material

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COURSE CONTENT
Physiology of labour and childbirth; Premonitory signs and symptoms, Mechanisms of labour,
Factors affecting labour, Fetal systemic response of labour
1. Fetal assessment; Physiological basis of assessment, Fetal and uterine monitoring, Fetal
heart rate patterns, Other fetal assessment technique: fetal scalp blood sampling
2. Comfort promotion during labour and childbirth; Pain during labour, Behavioural
response to pain, Support during labour, Nursing care during labour, Drugs used to
relieve pain during labour
3. The first stage of labour; Introduction, Nursing care before admission, The admission
process, Nursing care after admission, Monitoring the progress of labour use of a
partograph
4. The second stage of labour; Introduction, Characteristics of 2nd stage of labour,
Preparations for conducting a normal delivery, Procedure for conducting a normal
delivery, Assessing neonate and immediate care, Assigning APGAR Scores to neonate
5. Third and fourth stages of labour; Physiology of third stage of labour, Signs of placental
separation, Delivery of placenta (CCT), Uterine massage and palpation, Inspection of
cervix, vagina and perineum, Birth trauma and its repair; Lacerations, tears, episiotomies
and fistulas, Nursing care during 3rd and 4th stages
6. Prolonged pregnancy, Post-term pregnancy, Induction of labour, Prolonged labour,
Precipitate labour, Trial of Labour, Obstructed labour, Disorders of uterine action
7. Malpositions of the occiput and malpresentations; Occipital posterior positions, Face
presentations, Brow presentations, Breech presentations, Shoulder presentations,
Unstable lie
8. Operative delivery; Caesarean section, Forceps delivery, Ventous/vacuum delivery,
Symphisiotomy
9. Intrapartal complications; Cardiac disease, PIH, Severe eclampsia, Diabetes mellitus,
Infections, Rhesus isoimmunisation/ABO incompatibility, Placenta and cord disorders,
Malaria, Epilepsy, Anaemia.
10. Obstetrics emergencies; APH, Placenta praevea, Placenta abruption, Vasa praevea, Cord
presentation and prolapsed, Shoulder dystocia, Rupture of the uterus, Amniotic fluid
embolism, Inversion of the uterus, Disseminated Intravascular Coagulation (DIC)

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11. The neonate; Immediate care, Adaptation to extra uterine life, Neonatal resuscitation,
First assessment of the neonate, Cord care and breastfeeding
12. The normal puerperium, Physiological changes, body systems, Postpartum assessment,
Transition to parenthood, Family planning, Nursing care
13. The abnormal puerperium, Puerperal sepsis, Birth canal trauma, Deep venous thrombosis,
Mastitis, Puerperal psychosis

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INTRODUCTION

Welcome to Reproductive Health Nursing II.

Before you do this course you are expected to have successfully completed Reproductive Health
I, Pharmacology, Anatomy I, II and III. In the prerequisite courses, you learnt about obstetric
anatomy, normal pregnancy, antenatal care and obstetric pharmacology. It is understood that good
prenatal care is likely to have a good outcome both for the mother, fetus and for the family as a
whole. This course will take you through labour, puerperium and the neonate. You must be
already having a lot of knowledge and skills in this area from your previous midwifery
experience. You are expected to take time to do the activities given in this study guide, as they
will help you understand the learning requirements of this course.
The whole course is divided into (-----) chapters.

Chapter 1 deals with Physiology of labour, premonitory signs and symptoms, factors affecting
labour and fetal and maternal response to labor.
Chapter 2 deals with fetal and maternal assessment, comfort promotion and pain management
during labour.
Chapter 3 discusses the management of 1st, 2nd, 3rd and 4th stages of labour
Chapter 4 discusses abnormal labour and disorders of uterine action.
Chapter 5 covers Obstetric emergencies
Chapter 6 covers operative deliveries
Chapter 7 deals with the Management of Medical conditions complicating pregnancy and labour
Chapter 8 discusses the normal and abnormal peuperium

CHAPTER ONE

NORMAL LABOUR

INTRODUCTION

The process of labour takes different forms. Women have been known to help each other with the
delivery process during childbirth. In the majority of cases, nature takes its own course and the
mother delivers with no serious complications. Generally, a clean and safe delivery is recognized
as one of the pillars of safe motherhood. This is a sure way of preventing the conditions that
cause maternal morbidity and mortality.

Your role as a midwife demands clinical expertise in supervising, caring for and supporting the
pregnant mother during pregnancy, labour and puerperium. You should be able to conduct
deliveries on your own, and be ready to intervene when complications arise. It is also your
responsibility to recognize and act promptly or refer should you be presented with an abnormal
condition, for example, mal-presentation, obstructed labour, or obstetric and neonatal
emergencies. However it is important to note that a mother, who is psychologically well prepared
during pre-natal care, will go through labour and delivery with ease? It is also important to
remember that if a woman in labour has confidence in her caregiver she will experience a
considerable lower level of discomfort and pains during labour. Therefore, professionalism,
calmness and the altitude of the caregiver is a greater tranquilliser to the mother who is in pain
than medicine. (Leeder: 1994).

OBJECTIVES
By the end of this section, you should be able to:

Define labour and normal labour;

Explain the onset of labour;

Describe the physiological changes that occur during labour;

Identify the three stages of labour and the mechanisms that are involved:

Discuss the management of normal labour.

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LABOUR
What is the definition of labour?

Definitions of terms
The word labour is commonly used by both medical and non-medical people. However labour is
described as the process of coordinated uterine contractions leading to progressive cervical
effacement and dilatation, whereby the foetus, placenta and membranes are expelled through the
birth canal after 28 weeks of gestation. Labour can either normal or abnormal.

Normal labour
Normal labour has several important characteristics, which you should always remember. These
are:

Duration - completed within 18hrs;

Occurs at term;

Is spontaneous;

The foetus presents by vertex;

Has no complications to either mother or baby;

The newborn child requires minimal resuscitation.

Precipitate labour - is very rapid labour of less than 3 hours, ending in the delivery of the fetus.
Premature labour - Onset of labour before the 37th completed week of pregnancy dated from
the LNMP.
Parturient - relating to or the process of childbirth.
Antepartum- The period before labour or childbirth
Intrapartum- During labour and delivery or childbirth
Postpartum: The period after childbirth
Peripartum: Including before, during, and after birth

THE ONSET OF LABOUR

Labour can be discussed in terms of the stages the woman moves thro and the mechanisms
involved in the processes. Just before labour begins various changes take place in the womans
reproductive system in the days and weeks preceding labour before the actual true signs of labour
can be identified. A pregnant woman usually diagnoses the onset of labour herself. The presence
of the following signs and symptoms will give evidence that the mother is in labour:

Contractions of the uterus, which are increasingly strong, painful and regular;

The cervix is taken up into the lower segment causing dilatation of the cervix;

There is a mucoid blood stained discharge, which is called a show;

Sometimes there is rupture of membranes with drainage of liquor amnii (amniotic fluid)

Some young women, especially the primigravidae, may fail to recognise true labour.

It is

important that you help them differentiate between false and true labour signs. The contractions of
true labour are regular and intense. In false labour, the contractions are sporadic (Braxton-Hicks
Contractions). False contractions occur during the last weeks of pregnancy. The following table
outlines some factors that can help to differentiate true and false labour.

Table 1: Contrast between True Labour and False Labour

FACTORS

TRUE LABOUR

FALSE LABOUR

Contractions

Regularly spaced

Irregularly spaced

Interval between contractions

Gradually shortens

Remains long

Intensity of contractions

Gradually increases

Stays the same

Location of pain

Back and abdomen

Mostly lower abdomen

Effect of analgesics

Do not alleviates the pain

Often aleviates the pain

Cervical changes

Progressive effacement and No changes

dilatation

The causes that trigger the onset of labour are not known. However, many theories have been
offered which indicate that both hormonal and mechanical factors play a big part. We will now
discuss each of these factors in turn.

Hormonal Factors
It is believed that, close to term, progesterone levels in the body fall, while, at the same time,
levels of oestrogen (which is responsible for sensitising the uterine muscles) rise. The fall in
progesterone levels is important because it has effect on muscle contractions.

The rise in

oestrogen levels, meanwhile, triggers the release of oxytocin, which causes uterine contractions.
The foetal hypothalamus is believed to produce releasing factors, which stimulate the anterior
pituitary gland to produce adrenocorticotrophic hormone (ACTH). ACTH stimulates the foetal
adrenal glands to secrete cortisol, which causes relative levels of placental hormones to rise.
These cause further uterine contractions.

Mechanical Factors
Uterine activity can also result from the mechanical stimulation of the uterus and cervix. This
may be due to over stretching, as in the case of multiple pregnancy and polyhydromnios, or
pressure from the presenting part, when it is well applied to the cervix. It appears that there is,
therefore, a combination of hormonal (from both mother and foetus) and mechanical factors that
set labour in motion.

Pre-Labour or Premonitory Signs of Labour

This is the period two to three weeks prior to the onset of labour when a number of changes take
place. We will now discuss these changes in greater detail.

Lightening
Two to three weeks before labour, the lower uterine segment expands, allowing the foetal head
to sink deep. The descent of the head and the body of the baby gives space to the lungs, heart and
stomach, which enables these organs to function easily. The symphysis pubis widens and the
pelvic floor softens and becomes more relaxed, allowing further descent of the uterus into the
pelvis.
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Frequency of micturation
The descent of the foetal head increases pressure within the pelvis. This limits the capacity of the
bladder, which can cause irritation. The laxity of the pelvic floor muscles gives rise to poor
sphincter control causing a degree of stress incontinence. This pressure results in the congestion
of circulation to the lower limbs. Additionally, the relaxation of the pelvic joint may give rise to
backache.

Taking up of cervix
The cervix is taken up gradually and merges into the lower uterine segment. Shortening of cervix
is looked for when labour needs to be induced.

Contractions
The contractions of the uterus are co-ordinated by two pacemakers in the region of the cornua.
These are located where the fallopian tubes join the uterine body. The muscle contractions start at
the top corner of the uterus, spread to the fundus, and then downward. During normal pregnancy,
the uterus contracts intermittently but the contractions are not strong enough to overcome the
resistance of a normal cervix and do not lead to its dilation. The contractions of pregnancy
become more frequent towards full term and get more painful and noticeable. A multipara may
have such false pains for some days before the onset of true labour. They may come to hospital
too early thinking they are in established labour. This is what we refer to as false labour.

Let us now look at uterine action and how contractions interact with the cervix.
Uterine Action
By the end of pregnancy, the uterus is divided into two anatomically distinct segments, known as
the upper and the lower uterine segments.

The upper uterine segment is a thick muscular, contractile area from where the contractions begin.
The longitudinal fibres retract, pulling on the lower segment and causing it to stretch, which
pushes the head down.

The lower segment is a thin segment, which develops from the isthmus of the uterus about eight
to ten centimetres in length and is prepared for distension and/or dilatation. The lower segment
10

stretches when being pulled by the longitudinal fibres. The force applied by the descending head
or breech also aids the stretching.

Retraction Ring
This is an imaginary ridge that forms between the upper and the lower uterine segment. It is
present in every labour and is perfectly normal as long as it is not marked enough to be visible
above the symphysis pubis.

Fundal Dominance
During a contraction the uterus feels hard to touch. At the beginning of the process, contractions
are painless and involuntary, and are controlled by the nervous system under the influence of
endocrine system.

The contraction starts at the upper part of fundus, spreading across, and by the time they reach the
lower fundus, they last longer and are very intense. The peak of the contraction is reached
simultaneously over the whole uterus and fades from all parts together. This pattern allows the
cervix to dilate and the contracting fundus to expel the foetus.

Polarity
Polarity describes the neuromuscular harmony between the two poles or segments of the uterus
throughout labour. The upper pole contracts strongly and retracts to expel the foetus. The lower
pole contracts slightly and dilates to allow expulsion of the foetus to take place.

Contraction and Retraction

When labour starts, approximately 280 days from the first day of the last Normal menstrual
period, the contractions change in character. They become regular and more painful. Labour
contractions differ from those of pregnancy in that they are followed by retraction. This is
characteristic of uterine muscle in labour. The contracted muscle does not return to its original
length when the contraction passes off. Each succeeding contraction leads to further shortening
of the muscle fibres so that the uterine cavity becomes smaller and smaller. This is what makes
the cervix dilate. This process is illustrated in the figure below.
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Uterine muscle fibre, showing how, by retraction, some of the uterine muscles become shorter
and thicker

When talking about contractions, the midwife is basically concerned with 3 factors, namely;
the strength
the duration
the frequency of the contraction.

The strength of a contraction is identified in 3 categories, that is, weak, fair or fairly strong, and
strong. The strength of a contraction is measured according to the time it has taken. Thus, a
contraction, which takes 10-30 seconds is said to be weak, one that takes 30-40 seconds is said to
be fair.

The duration refers to the time taken by a contraction, for example a weak contraction lasts for 10
to 30 seconds. Frequency, on the other hand refers to the number of intervals between one
contraction and the next. If a mother has one contraction after every 45 minutes, the frequency is
written as 1:45.

The Shortening and Dilation of the Cervix

Before labour begins, the cervix of a primagravida is a thick hard cone, which protrudes into the
vagina. The canal is at least one inch long. When labour begins, the strongly contracting upper
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segment of the uterus starts retracting and getting shorter, while the thinner lower segment of the
uterus gets pulled away from the presenting part. This stretches the lower segment. The latter, in
turn, pulls the internal Os. The dragging away of the internal Os from the presenting part starts
dilating the upper part of the cervical canal. This goes on until the canal is shorter and shorter and
finally there is no canal at all. The canal becomes part of the uterine cavity, with only the un
dilated external Os and the thinly stretched cervix separating this cavity from the vagina. When
this happens, it is said that the cervix has been 'effaced' or 'taken up' (see the Figure below). After
this, further progress in labour leads to dilation of the cervix.

Cervical canal before effacement

Partial effacement

(before labour)

Effacement almost complete

Effacement fully complete

The Effacement of the Cervix

In a primigravida, the cervix usually becomes almost fully effaced before any dilation takes place,
while in multiparous women the two processes take place together. The cervix of a multipara
might be already effaced and be dilated enough to admit a finger up to the internal Os even before
labour starts. These signs of labour are assessed by doing a vaginal examination.
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The 'Show'

Throughout pregnancy, the cervical canal is sealed by a plug of mucus known as an operculum.
Together with the intact membranes this prevents organisms ascending into the uterine cavity.
When labour starts, the internal Os is pulled away from the foetal membranes and the canal is
opened up. This releases the mucous plug, which oozes out of the vagina mixed with a little
blood. This is called the 'show'.

Remember:
It is important to communicate the assessments findings to the mother and reassure her at
every stage as it has great influence on the progress of her labour.

PROCESSES OF LOBOUR
There are four major components that interact to influence childbirth. These are;
-

Powers

Passage

Passenger

Psyche /Placenta

1. POWERS
a) Uterine contractions
b) Maternal pushing efforts
2. PASSAGE- Maternal pelvis
3. PASSAGER- The Fetus
4. PSYCHE; Fear and Anxiety

Antenatal management
It is expected that the learner has enough knowledge of reproductive
Health I, in order to manage the woman in labour effectively which include;

Physiology and Management of pregnancy; to include human conception, fertilization

and fetal and placental development and fetal circulation
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Plan for the labour

Educate the mother

Reassure the mother

Give the mother a reconnaissance tour of the ward and take her through the steps involved

Screen the mother antenatally

Admittance Procedures

Make an accurate diagnosis of labour through;

- History
- Observation
- Physical examination
- Palpation Leopolds Maneuvers
- Vaginal examination

History and Examination

- General condition of mother and fetus
- Blood pressure
- Temperature
- Pulse
- Time when they first become uncomfortable
- Frequency, duration, and intensity of the uterine contractions
- The degree of discomfort that the mother displays
- Fetal heart rate especially at the end of a contraction and immediately thereafter, to identify
- Pathological slowing of the heart rate
- Presentation
- Size of the fetus
- Status of the fetal membranes
- Any vaginal bleeding
- Whether fluid has leaked from the vagina and, if so, how much and when the leakage first
commenced

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Admittance Vaginal Examination

Most often, unless there has been bleeding in excess of bloody show, a vaginal examination
under aseptic conditions is performed 4 hourly.
Amnionic fluid - Meconium stained liquor has 3 grades;
- Tinge
- Mild-consistency
- Thick meconium (fetal distress)
Cervix - Softness
-

Degree of effacement (length) - Expressed in terms of the length of the cervical canal,
compared to that of an uneffaced cervix. When the length of the cervix is reduced by one
half, it is 50 percent effaced; when the cervix becomes as thin as the adjacent lower
uterine segment, it is completely, or 100 percent, effaced. Cervical Effacement "obliteration" or "taking up" of the cervix is the shortening of the cervical canal from
above downward from a length of about 2 cm to a mere circular orifice with almost
paper-thin edges.

Show -Sign of impending labor, characterized by the discharge from the vagina of a small
amount of blood tinged mucus representing the extrusion of the mucous plug which has
filled the cervical canal during pregnancy; - First appearance of blood in beginning
resembling that seen during first menstruation

Extent of dilatation how much the cervix has dilated

The cervix is said to be dilated fully when the average diameter of the cervical opening measures
10cm, because the presenting part of a term-size infant (BPD = 9.5cm) usually can pass through a
cervix that is fully dilated

Location of the cervix with respect to the presenting part and vagina

The relationship of the cervical os to the fetal head is categorized as posterior,

Mid-position, or anterior.

Presenting part - nature

- Position

Station - The degree of descent of the presenting fetal part in the birth canal in relationship to the
ischial spines, which are halfway between the pelvic inlet and the pelvic outlet. The classification
16

of station to delivery divides the pelvis spines into fifths that represent centimeters above and
below the spines.

Thus, as the presenting fetal part descends from the inlet toward the ischial spines, the
designation is, -5/5, -4/5, -3/5, -2/5, -1/5, then 0/5 station at the level of the ischial spines when
most often engagement of the head has occurred; that is, the bi-parietal plane of the fetal head has
passed through the pelvic inlet.

Below the ischial spines, the presenting fetal part passes +1/5, +2/5, +3/5, +4/5, and +5/5
stations when the fetal head is visible at the introitus

Pelvic architecture - Adequacy of the pelvis especially in primigravida

Enema - Early in labor, a cleansing enema e.g. (Examples) often is given to minimize
subsequent contamination by feces, which otherwise may be a problem during the second
stage of labor and delivery.

MANAGEMENT OF LABOR
First stage of lobour
Beginning with the onset of uterine contractions through the period of dilation of the uterine
os (10cm). Average duration of the first stage of labor in nulliparous women is about 8 hours
and in parous women about 5 hours.

First stage of labour is divided into;

Latent phase - 0-3cm cervical dilatation - In primigravida, this phase can last up to 24hrs
and in multiparous mothers up to 12hrs

Active/Established phase - >4cm cervical dilatation - In primigravida, this phase

proceeds at 1.2cm/hr and in multiparous mothers at 1.5cm/hr

Monitoring Fetal Well-being during Labour

Fetal Heart Rate

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During the first stage of labour, in the absence of any abnormalities, the fetal heart
should be checked and recorded on a partogram immediately after a contraction at least
every 30 minutes and then every 15 minutes during the second stage.

Normal fetal heart rate ranges between - 120-160 b/pm (with undulation of 15 b/pm within this
range).

Periodic Fetal Heart Rate; deviations observed from baseline related to uterine

contractions includes.
- Acceleration - increase in fetal heart rate above baseline
- Deceleration - decrease in fetal heart rate below baseline rate.
These are classified based on the timing of the deceleration in relation to uterine contractions as;
Early, Late or Variable
-Slope of fetal heart rate change

Clinical sign of;

Gradual - seen in active labour, between 4 -7cm of cervical dilatation, due to head compression.
Begins at or after the peak of the contraction and returning to baseline only after the contraction
has ended;

Causes
- Uteroplacental insufficiency
- Fetal distress
- Fetal compromise

Abrupt and erratic;

Caused by - cord compression.The pattern is that of;
- Fetal distress
- Fetal bradycardia - baseline fetal heart rate <120 beats/min that lasts 15 minutes
- Fetal tachycardia - baseline fetal heart rate >160 beats/min

Uterine Contractions

Charted on a partogram every 30 mins or 15 minutes depending on the status of mother nad
labour;
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- Frequency
- Duration
- Intensity

Maternal Monitoring and Management during Labor

1. Analgesia/Sedation
Analgesia and sedation is initiated on the basis of;

The woman's discomfort,

Uterine contraction pattern of established labor - lasting almost 40secs

Cervical dilatation of at least 2 cm

Drugs used.

Pethidine is use in early labor and should be avoided in advanced labor due to its
effects to the baby. Should have naloxone at hand to use if effects of pethidine pass to
baby.

Trenolol

Epidural block- L3,4, this compromises symptoms characteristic of the second stage of
labor, that is, an urge to bear down or "push," leading to an increased incidence of vacuum
extractions and increased incidence of c/s. Can also lead to HBP thus avoid in heart
disease patients.

2. Maternal Vital Signs

Maternal temperature and pulse are evaluated every 1-2 hours.
Blood pressure usually is taken more frequently and is obtained between contractions,
because it normally rises during a contraction

3. Urinalysis
Ketonuria following hypoglycemia from prolonged labor
Proteinuria Preeclampsia

4. Nutrition and Hygiene

This should be given as necessary of depending on the stage and progress of labour.
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Second stage of labor

Definition
This is the period of expulsive effort, beginning with complete dilation of the cervix (10cm) and
ending with expulsion of the infant.

Identification (Signs and symptoms)

- With full dilatation of the cervix, which signifies the onset of the second stage of labor, the
woman typically begins to bear down, and with descent of the presenting part she develops the
urge to defecate.
- Uterine contractions and the accompanying expulsive forces may last 1 minutes and recur
at times after a myometrial resting phase of 1minute.
Bearing down efforts result in increasing bulging of the perineum and the overlying skin becomes
tense and glistening. At the same time, the anus becomes greatly stretched and protuberant, and
the anterior wall of the rectum may be easily seen through it. When the scalp of the fetus is visible
through the vulvar opening or before in instances where little perineal resistance to expulsion is
anticipated, the woman and her fetus are prepared for delivery.

Duration
The median duration of the second stage is 50 minutes in nulliparas and 20 minutes in
multiparas, but it can be highly variable.

Fetal Heart Rate

For the low-risk fetus, the heart rate should be auscultated during the second stage of labor at
least every 15 minutes, whereas in those at high risk, 5-minute intervals are recommended.

Preparation for Delivery

Position; the woman should not be restricted to any position that she feels comfortable but
following positions are mostly preferred by midwifes.

Dorsal lithotomy position- the woman lies flat on the bed with the legs comfortably placed in
stirrups and the hips flexed and abducted to increase the diameter of the pelvic outlet.

Dorsal position is also.

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Vulva and perineal cleansing

Cleaning and draping must be done as per the procedure manual to avoid infection. A pre- set
trolley with a delivery pack and other requirement for the baby and mother are opened and kept
ready for use. (Refer to procedure manual)

Spontaneous Delivery

Delivery of the Head - Crowning - encirclement of the largest head diameter by the
vulva ring

Episiotomy (See notes on Episiotomy)

Ritgen Maneuver - By the time the head distends the vulva and perineum (during a
contraction) enough to open the vaginal introitus to a diameter of 5 cm, a towel-draped,
gloved hand may be used to exert forward pressure on the chin of the fetus through the
perineum just in front of the coccyx. At the same time, the other hand exerts pressure
superiorly against the occiput. This is important because;
a) It allows the midwife to control the delivery of the head.
b) It favors extension, so that the head is delivered with its smallest diameters passing
through the introitus and over the perineum. The head is delivered slowly with the
base of the occiput rotating around the lower margin of the symphysis pubis as a
fulcrum, while the bregma (anterior fontanel), brow, and face pass successively over
the perineum.

Delivery of Shoulders. After its birth, the head falls posteriorly, bringing the face almost
into contact with the anus. The occiput promptly turns toward one of the maternal thighs
so that the head assumes a transverse position.

The movement of restitution (external rotation) indicates that the bisacromial diameter
i.e. (transverse diameter of the thorax) has rotated into the anteroposterior diameter of the
pelvis. Most often, the shoulders appear at the vulva just after external rotation and are
born spontaneously. Occasionally, a delay occurs and immediate extraction may appear
advisable; - the sides of the head are grasped with the two hands and

Gentle downward traction applied until the anterior shoulder appears under the pubic
arch. Following delivery of the anterior shoulder to try and avoid shoulder dystocia
(Difficult childbirth), suction the nasopharynx and check for a nuchal cord

Next, by an upward movement, the posterior shoulder is delivered.

21

Immediately after delivery of the infant, there is usually a gush of amnionic fluid, often
tinged with blood but not grossly bloody.

Clearing the Nasopharynx - To minimize the likelihood of aspiration of amnionic fluid

debris and blood that might occur once the thorax is delivered and the infant can inspire,
the face is quickly wiped and the nares and mouth are spirated

Nuchal Cord - Following delivery of the anterior shoulder, the finger should be passed to
the neck of the fetus to ascertain whether it is encircled by one or more coils of the
umbilical cord. If a coil of umbilical cord is felt, it should be drawn down between the
fingers and, if loose enough, slipped over the infant's head. If it is applied too tightly to the
neck to be slipped over the head, it should be cut between two clamps and the infant
promptly delivered.

Clamping the Cord - The umbilical cord is cut between two clamps placed 4-5 cm from
the fetal abdomen, and later an umbilical cord clamp (plastic clamp (Hollister, Double
Grip Umbilical Clamp) is applied 2- 3 cm from the fetal abdomen. Clamp the cord after
first thoroughly clearing the infant's airway, all of which usually takes about 30 seconds.
NB The infant is not elevated above the introitus at vaginal delivery or much above the
maternal abdominal wall at the time of caesarean delivery to prevent placental transfusion.
NB Epidural anaesthesia is widely accepted as causative factor in failure of spontaneous
rotation to OA, as well as in slowing second-stage labor and decreasing maternal
expulsive efforts.

Third/placental stage of labour

This is the period beginning at the expulsion of the infant, and ending with the completed
expulsion of the placenta and membranes. This is a stage where

Signs of Placental Separation;

The uterus becomes globular and, as a rule, firmer. This sign is the earliest to appear.

There is often a sudden gush of blood.

The uterus rises in the abdomen because the placenta, having separated, passes down
into the lower uterine segment and vagina, where its bulk pushes the uterus upward.

The umbilical cord protrudes further out of the vagina, indicating that the placenta has
descended.
22

These signs sometimes appear within about 1 minute after delivery of the infant and usually
within 5 minutes.

Physiological management of the third stage

When the placenta has separated, it should be ascertained that the uterus is firmly contracted. The
mother may be asked to bear down, and the intra-abdominal pressure so produced may be
adequate to expel the placenta. If these efforts fail, or if spontaneous expulsion is not possible
because of anaesthesia, and after ensuring that the uterus is contracted firmly, pressure is exerted
with the hand on the fundus to propel the detached placenta into the vagina.

Delivery of the Placenta

Placental expulsion should never be forced before placental separation lest the uterus be turned
inside out - Inversion of the uterus. As pressure is applied to the body of the uterus, the
umbilical cord is kept slightly taut - Controlled cord traction (CCT)/Bradt

Andrew method
The uterus is lifted cephalad (In a direction toward the head) with the abdominal hand. This
maneuver is repeated until the placenta reaches the introitus. As the placenta passes through the
introitus, pressure on the uterus is stopped. The placenta is then gently lifted away from the
introitus. Early delivery of the placenta is believed to decrease blood loss from the implantation
site because it prevents the development of extensive retroplacental bleeding.

Manual Removal of Placenta

Indication
- Applied when the placenta will not separate promptly especially common in cases of preterm
delivery
- If at any time there is brisk bleeding and the placenta cannot be delivered normally then Active
Management of the Third Stage is undertaken.

"Fourth Stage" of Labor (From Delivery to 2hours postpartum)

The placenta, membranes, and umbilical cord should be examined for completeness and
for anomalies.
23

Postpartum hemorrhage as the result of uterine atony is more likely at this time.

The uterus and perineum is evaluated during this time the latter to detect excessive
bleeding.

Observations of the mother and the baby are done at this time.

EPISIOTOMY AND REPAIR

Episiotomy - Surgical incision of the pudenda (external genitals - vulva) to;

prevent laceration at the time of delivery

facilitate vaginal surgery

Perineotomy - Incision of the perineum (commonly described as episiotomy)

Should be individualized and not performed routinely.

Types

Median or midline episiotomy - The incision is made in the midline

Mediolateral episiotomy - The incision begins in the midline but is directed 45o laterally
and downward away from the rectum

Episiotomy characteristic
Midline

Mediolateral

Surgical repair
Faulty healing
Post operative pain
Anatomical results
Blood loss
Dyspareunia
Extensions
Common (3rd & 4th degree)

INDICATIONS FOR AN EPISIOTOMY

24

- Breech delivery
- Cephalopelvic disproportion (CPD)
- Forceps or vacuum extractor operations
- In Occiput posterior positions
- In cases where failure to perform an episiotomy will result in perineal rupture.
- Prevents pelvic relaxation, later resulting to, cystocele, rectocele, and urinary incontinence.

NB Obviously, if the perineal ncision is not made until the time of maximal distension, this
benefit is probably limited.

Timing of Episiotomy
Episiotomy is performed when the head is visible during a contraction to a diameter of 3-4 cm
therefore the head compresses the surrounding blood vessels minimizing blood loss.

If performed unnecessarily early, bleeding from the incision may be considerable during the
interim period between the time performed and delivery.

If performed too late, the muscles of the perineal floor already will have undergone excessive
stretching, and the objective of the operation is defeated.

Timing of the Repair of Episiotomy

Episiotomy repair is deferred until the placenta has been delivered.

Lacerations of the vagina and perineum (Birth Canal)

Such lacerations are often preventable with an appropriate episiotomy and avoidance of
instrumental deliveries.

Classification Lacerations;

First-degree lacerations - involve the fourchette (frenulum of the labia minora.),

perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle.

Second-degree lacerations - involve, in addition to skin and mucous membrane, the

fascia and muscles of the perineal body but not the rectal sphincter. These tears usually
extend upward on one or both sides of the vagina, forming an irregular triangular injury.
25

Third-degree lacerations - extend through the skin, mucous membrane, and perineal
body, and involve the anal sphincter.

Fourth-degree laceration - extends through the rectal mucosa to expose the lumen of
the rectum. Tears in the region of the urethra are also likely to occur with this type of
laceration unless an adequate episiotomy is performed. These periurethral tears may
bleed profusely. Also leads to fistula formation.

Factors associated with an increased risk for third- and fourth-degree lacerations:

Midline episiotomy;
- Increases the risk of posterior tears into the external anal sphincter and/or the rectum.
With a mediolateral episiotomy, the likelihood of a laceration into the rectum is reduced
but not eliminated.

Anterior tears involving the urethra and labia are much more common in women in
whom an episiotomy is NOT cut;

Nulliparity

Second-stage arrest of labor

Persistent occiputo posterior positions

Mid- or low-forceps instead of a vacuum extractor

Use of local anesthetics

Asian race

Nursing Interventions after an Episiotomy

- Hyigien
- Care of episiotomy
- Saline births
- Reasure
- Advice to abstain from sex before the episiotomy is completely healed
MULTIPLE PREGNANCIES
By the end of this topic you should be able to:

Define multiple pregnancies;

26

Explain the two different types of twins;

Diagnose twin pregnancy;

Describe the effect of multiple pregnancy on pregnancy;

Discuss the management of multiple pregnancies during pregnancy, labour, delivery and
puerperium.

State the complications of multiple births

Define multiple pregnancies and list some associated complications.

Definition
Multiple or plural pregnancy is a term applied when there is more than one foetus in the uterus.
The incidence of multiple pregnancies is rare. Twin conception occurs spontaneously once in 90
pregnancies, triplets once in 310,000 while quadruplets occur once in 700,000.

Varieties of Twins
Twins may be binovular or uniovular. Binovular twins are developed from two separate ova,
which may or may not come from the same ovary. Uniovular twins are developed from a single
fertilized ovum, which undergoes division to form two embryos.

Below is the comparison of the two types of twins.

Types Of Twins
Uniovular twin (monozygotic)

Binovular twins (dizygotic)

One ovum

Two ova

One amnion

Two amnions

One chorion

Two chorions

One placenta

Two placentas (may fuse)

One sex

Two sexes

Identical

May be different in appearance and sex.

division is incomplete.

27

Explain how you would diagnose a multiple pregnancy.

Diagnosing a Multiple Pregnancy

The following characteristics may be noted when diagnosing a multiple pregnancy:
On inspection:

The abdomen looks larger than it should at the given date;

Polyhydramnious is common in ultiple pregnancy and if it occurs will add to the size
making it more difficult to diagnosis.

On palpation:

Abdominal girth (circumference) will be 101.5 or more centimetres;

Fundal height is larger than dates from twentieth week of gestation;

You will reveal two foetal poles on fundal palpation;

The size of the head is smaller than the gestational age;

You will palpate an unusual number of foetal parts.

On auscultation:

Two foetal hearts are recorded simultaneously and there is a difference of 10 to 20 beats.

Confirmatory Signs
An ultrasound scan at seventh week can distinguish two separate sacs while from the twelfth
week two foetal bodies can be identified. On the fourteenth week, two heads are detected. Two
skeletons are visible on x-ray at thirty weeks.

Effects of Multiple Pregnancy

State the effects of twins on pregnancy?

The effects of twins on pregnancy include:

Pre- eclampsia - this is three times more common in multiple pregnancies than a single
pregnancy;

Anaemia is more common, due to the increased foetal demand of folic acid and iron
dietary requirement;
28

Polyhydramnios could occur due to more fluid in the two foetal sacs;

Pressure symptoms are more marked, and may include backache, oedema, varicose veins,
indigestion, constipation, dyspnoea and bladder irritability;

Minor disorders of pregnancy are more marked, including, headache, morning sickness
and vomiting;

Pre-mature labour is likely, due to over-stretching of the uterus;

Congenital malformation occurs, twice as much than in single pregnancy;

Intra uterine growth retardation may happen due to placenta insufficiency.

State the complications of twins in labour.

Complications of twins in pregnancy

These include:

Malpresentation; 35 percent of twins will both present by the head, and another 35 percent
by head and breech. 10 percent present by breech and/or 20 per cent present by transverse
lie or cephalic with transverse lie.

Delay in the birth of the second twin;

Cord prolapse, which occurs especially with the second twin, often when there is
malpresentation.

Maternal and foetal distress is common due to prolonged labour;

Locked twins is a rare complication but may prevent spontaneous delivery;

Post partum haemorrhage due to large placental site. And over distension.

Management of Multiple Pregnancy in the Antenatal Period

Intensify the care of the mother of twins by ensuring the following:

See the patient every two weeks from the 20th week;

Check Haemoglobin at 30, 36, 37 weeks before labour to exclude anaemia;

Relieve any discomfort by advising on remedies of minor disorders of pregnancy;

Advise on diet to prevent anaemia;

Advise on the need for at least 2 hours rest in the afternoon and 6 to 8 hours rest during
the night;
29

The practice of admitting the patient between thirty to thirty six weeks is now uncommon,
but it is necessary if home conditions are poor to improve foetal growth by increasing the
placental blood flow by providing enough rest in the hospital;

Improve her nutritional state;

Never allow the patient to go post-mature due to the danger of placenta insufficiency.

Management During, First Stage of Labour

All cases of a multiple pregnancy should deliver in hospitals due to complications that may occur
during labour. The following procedure should be followed:

Take blood for grouping and cross-match;

Avoid over-sedating the mother during labour;

Prepare your delivery trolley pairs of instruments for two babies. You should have a
resuscitation trolley, baby labels, ergometrine or syntometrine in a syringe;

Oxytoxic drip put up if uterine action is not very effective;

Monitor and assess the progress of labour;

Delivery room must be warm;

Time the episiotomy properly;

Take foetal heart between each contraction;

Advise on ambulation if membranes are intact;

Encourage her to empty bladder;

Reassure the mother.

Management of Second Stage of Labour

Ensure that the following procedure is followed when managing the second stage of labour:

It is preferable to have an obstetrician, paediatrician and anaesthetist during the

delivery;

Preparations should be made for resuscitation and special care in case of low birth
weight;

Operation theatres should be ready to receive a mother at a short notice in case of

emergency Caesarean section;

Deliver the head of the first twin slowly, clear the airway and hand the baby to the
assistants;
30

The assistant should label the baby and write first twin or twin one;

The lie of the second twin is checked, that is, if longitudinal, the presenting part is
checked, if high, it is pushed down by fundal pressure and membranes are ruptured;

The mother is encouraged to push with each contraction and the baby should be born
within forty-five minutes;

Oxytoxic drug can be given immediately after delivery of the anterior shoulder of the
second twin. It may also be administered after delivery of the placenta;

As soon as the oxytocin takes effect, the uterus contracts;

Holding both cords the placenta and membranes will be delivered using control cord
traction.

Complications in the Delivery of Twins

There are several complications that may arise with the delivery of twins, including delayed twin
and second twin lying in transverse.

We will now discuss the management of these

complications.

Management of Delayed Twin

Should you be confronted with a case of a delayed twin, the following steps should be taken:

Ascertain if the lie is longitudinal;

Assess the contraction if poor;

Ask your assistant to commence syntocinon drip to stimulate contraction;

Encourage the mother to push during contraction;

Vacuum extraction may be done when the doctor comes.

Management When Second Twin Lies in Transverse

You should ensure that you follow this procedure should you be confronted with a case where the
second twin is lying in transverse:

Send for the doctor;

Attempt external version when the membranes are intact;

If you succeed to perform the external version, rupture the membranes and encourage
the mother to push the baby.
31

Remember:
In case you do not succeed, the doctor will perform an internal version and deliver
the baby in breech.

Expulsion of the Placenta or Bleeding Before Second Twin

If the placenta is expelled soon after the first twin or there is bleeding:

You should deliver the second twin as soon as possible by using fundal pressure in case
of longitudinal lie. If this is not possible, inform a doctor as soon as possible and
prepare the mother for Caesarean section;

Locked twins are very rare but may occasionally be encountered. To facilitate the birth
of the second twin, decapitation of the first twin is necessary, but caesarean section and
delivery of the second twin from above is the easiest and safest method.

Conjoined Twins
A case of conjoined twins usually requires a Caesarean section. At times separation of the
conjoined twins is possible. The parents requires prio preparation so that she can accept the
situation.

Care during Puerperium

For the mother with multiple births, involution is usually slow. The after pain is also often more
troublesome. Care of the babies can be a major problem, so the mother should be initially helped
with the feeding of the babies. Teach the mother how to feed so that she feels competent when
discharged. For more detailed information see the section on Care of Normal Puerperium.

Self Test 1
1. Define multiple pregnancy
2. Differentiate between uniovular and binovular.
3. Plan the antenatal care for a mother with a twin pregnancy
ABNORMAL UTERINE ACTION
By the end of this Unit, you should be able to:

Explain the concept of abnormal uterine action;

Analyse the different types of abnormal uterine action;

32

Discuss causes of various types of abnormal uterine action;

Discuss the management of each type of abnormal uterine action.

Before we begin this section, I would like to recommend that you review the normal uterine
function as you learnt it in the physiology of labor.
Abnormal uterine action is a dysfunction of uterine muscles due to neuromuscular disharmony.
Some types of abnormal uterine action include:

Hypotonic uterine action;

Inco-ordinate uterine action, including hypertonic lower uterine segment, constriction ring
dystocia, colicky uterus and spurious labour;

Cervical dystocia;

Precipitate labour.

We shall now discuss each of these conditions in more detail.

Hypotonic Uterine Action

This is poor tone in the uterine muscle fibres which results from weak /short contractions. The
contractions are infrequent and cause less pain. The uterus may be indented at the height of a
contraction.

Both mother and baby are affected by the contractions. The effects of weak

contractions bring about very slow or no cervical dilatation. This results in prolonged labour.

There are two types of hypotonia, that is, primary and secondary uterine inertia also respectively
known as primary and secondary hypotonia. Primary hypotonia starts at the onset of labour. The
cause is unknown and it is common in primigravida.

Secondary hypotonia occurs when labour has already been established. The uterus is exhausted
and contractions, slows down, due to the following:

Retained second twin;

Cephalo pelvic disproportion;

Malpresentation or malposition;

Effect after epidural anaesthesia.

33

Management of Hypotonic Uterine Action

Admit the mother in hospital with adequate facility for emergency. Reassure her and then sedate
her to reduce anxiety and calm her down to sleep. You should perform an abdominal and pelvic
exam to exclude cephalo-pelvic disproportion. Determine the cause of the occipito-posterior
position (OPP). If this is present she should be prepared for a caesarean section.

If there are no uterine contractions, these should be stimulated by administering an enema or

repeat administration if it had been given previousily.

Describe the care that would be given to the mother who is experiencing hypotonic uterine
action.
You should check on the following factors:

Frequency, strength and duration of the contractions;

Vital signs, that is, maternal pulse and BP and general condition;

Foetal heart rates;

Descent of the presenting part.

A vaginal examination is done 2 - 4 hourly to determine cervical dilatation. The urine is tested 2
hourly for sugar, acetone and albumin. If there is foetal or maternal distress in the first stage of
labour, the mother is prepared for Caesarean section. However, if the mother is in the second
stage or nearing second stage and contracting and dilating well, the delivery should be assisted by
vacuum extraction.

The possibility of post partum haemorrhage should be kept in mind. Hence an intramuscular
injection of syntocinon 10 units should be within two minutes after the birth birth of the baby.
Over-Stimulation of the Uterus
This may occur as a result of excessive use of syntocinon or prostaglandin, which may cause
tetanic contractions with inadequate periods of relaxation. Complications of over stimulation of
the uterus include foetal hypoxia. If uterine spasms that reduce the transfer from the placenta of
foetal oxygen are not treated, foetal death may occur. Other complications include precipitate
labour and rupture of uterus in cases of disproportion.
34

Methods of management should include the following:

Stop the administration of syntocinon or prostaglandin at once;

In case of tonic contractions, the patient should be given two puffs of ventoline inhaler;

If there is foetal distress, give dextrose IV and oxygen by mask.

Tonic Contractions
This is where the contractions are excessively longer, stronger and more frequent. This results in
almost continuous contractions with short periods of relaxation. Tonic contractions are caused by
cephalo-pelvic disproportion. The uterus attempts to overcome the obstruction and so it increases
its strength and frequency. The condition is common in primigravidae.

Possible complications of tonic contractions include the rupture of the uterus and foetal death due
to prolonged labour.

Management of Tonic Contractions

If the patient is on syntocinon drip, it should be discontinued and the doctor informed. The vital
signs, including observations of pulse and Bp, should be monitored carefully.

There are several factors, which predispose to abnormal uterine action. These include:

Age, with elderly primigravidae more likely to have abnormal uterine action;

Parity - more frequent in primigravidae;

Cephalo pelvic disproportion or malpresentation OPP, which may either cause hypotonic
uterine action or inco-ordinate uterine action;

Post maturity;

Other factors like over distension of the uterus in multiple pregnancy;

Early rupture of membranes;

Emotional tension of the patient.

Inco-ordinate Uterine Action

In cases of inco-ordinate uterine action, there is alteration in the polarity of the uterus with an
increase in the resting tone. The uterus is very irritable. The contractions are strong, painful and
erratic but in spite of strong contractions, the cervix dilates slowly.
35

Clinically, the patient

experiences a lot of pain both before and after contraction. She is exhausted and bears down early
due to severe backache. This may lead to retention of urine. Foetal hypoxia occurs due to the
hypertonic state of uterus, which interferes with the placental circulation.

On vaginal examination (V.E.) the cervix is noted to dilate slowly despite frequent painful
contractions. The cervix is tight, unyielding and oedematous since the mother bears down with
each contraction. There are four varieties of inco-ordinate uterine action, which we will now
discuss in detail.
.
Hypertonic Lower Uterine Segment
This is when the lower uterine segment is hypertonic. There is loss of polarity and intermittent
abdominal pains. The pains occur before and persist long after a uterine contraction. The cervix
fails to dilate.

Colicky Uterus
The upper uterine segment contracts strongly and spasmodically. There is intense clump like
pain, contractions are not effective and the uterus is tender.

The mother may not experience

severe backache.

Constriction Ring or Dystocia

This condition happens in 1:1,000 labours (Myles, 2003). It is a localised spasm of the fibres of
the muscle ring. This is as a result of disorganised uterine action. It is commonly found near the
junction of both the upper and lower uterine segment. It usually embraces a narrow part of the
neck of the foetus. It may happen at any stage of labour but if it occurs in the third stage, it is
known as an hourglass constriction.

The spasm may be triggered by an early rupture of membranes. The hypertonic uterus is irritated
by being moulded round the foetus or by inters uterine manipulation.

The condition can be diagnosed vaginally when there is a delay in labour. There is no advance of
the presenting part and the upper segment feels tender to the touch. Inhalation of amyl nitrate or
10 ml of 2 percent I/V of magnesium sulphate solution may relieve spasms.
36

Spurious Labour
Spurious labour is a condition where contractions occur before the onset of labour, which are
painful and are accompanied by backache. Giving pethidine or morphine 1m to relax the uterine
contractions can abolish them. This differentiates it with true labour.

Management of Inco-ordinate Uterine Action

Cephalo Pelvic Disproportion (CPD) is usually the underlying cause of this condition.
Malpresentation should be ruled out through an abdominal and vaginal examination.

If

malpresentation is present, the patient should be prepared for a Caesarean section. If CPD is not
present, she may be allowed to continue in labour. Close observation is carried out and a record
of observations should be maintained.

Reassure the mother to allay anxiety. Make observations of the foetal heart rate, maternal pulse,
and respiratory rate 1/2 hourly. Blood pressure should be taken every 4 hours and urine testing
should be done 2 hourly. Any signs of maternal/foetal distress, that is, dehydration and ketosis,
should be reported promptly and may be corrected by giving intravenously (IV) 5 % dextrose
alternating with normal saline. You should always maintain an intake and output record.

Sedate the mother to relieve pain, calm her down and enable her to sleep. Epidural analgesia is
very effective in prompting normal uterine action (or Pethidine if added to the drip). A low dose
of 0.5mg syntocinon drip can be given. If, after 4-6 hours, there is still no progress, the mother
should be prepared for a Caesarean section. A small proportion of mothers with inco-ordinate
uterine action may end up in normal delivery or vacuum extraction. The midwife should be able
to make the correct judgement call.

Cervical Dystocia
There are two types of cervical dystocia, that is, primary and secondary. We shall now discuss
each of these in detail;

Primary
37

In primary cervical dystocia, the uterine contractions are normal. The presenting part is low down
in the pelvis but the cervix fails to dilate. The delay is due to the formation of a cartilaginous ring
round the cervix.

This condition occurs mainly in primagravida whereby the first stage is prolonged and there is
severe and persistent backache.

On vaginal examination the cervix feels thin, tight and

unyielding.

Secondary
This type occurs due to previous trauma to the cervix, for example, tears, which were repaired or
scarring from infection. The cervix fails to dilate in spite of good uterine contractions.

There are several types of cervical dystocia. These are:

Rigid cervix;

Annular detachment of the cervix;

Oedematous anterior lip of cervix.

Rigid cervix is a rare condition in which the cervix fails to dilate despite normal uterine
contractions. It is characterised by severe persistent backache. On vaginal examination the cervix
feels thin, tight and unyielding.

Annular detachment of the cervix is characterised by persistent and prolonged pressure on the
rigid cervix, which causes ischemia. The necrosed ring of the cervix is detached and expelled and
constitutes to a uterine rupture.

Oedematous anterior lip of the cervix involves the anterior lip being nipped between the foetal
head and the pelvic brim. It becomes swollen due to pressure. On vaginal examination the
oedematous cervix feels like a firm ridge as thick as a finger. It may also be seen at the vulva as a
bluish glistering cervix. It delays the first stage of labour, as the cervix does not dilate quickly.

Management
38

The management of cervical dystocia involves incision of the cervix to hasten the delivery of the
baby or a Caesarean section by an obstetrician.

MINOR COMPLICATIONS OF CHILD BIRTH AND DELIVERY

PRE-TERM LABOUR
Labour that occurs before the end of 37th completed weeks of pregnancy
Incidence causes 75% to 85% of neonatal morbidity and mortality or 5 10% of all
pregnancies.
A foetus of more than 20 weeks gestation who dies before labour or after delivery is classified as
still birth.
Causes

Unknown but associated with the following: -

Cervical incompetence abortions

Pre eclampsia, Eclempsia

Infections (Maternal)

Multiple births

Placenta disorders

Risky lifestyle e.g. use of and abuse of drugs e.g. heroin

Diagnostic procedure
- Trans-vaginal cervical sonography
- *Immunoassay for alpha- foetal protein****

Medical management
1. Arrest labour to prolong pregnancy by bed rest, side lying position preferably left side
2. Tocolytic therapy directed towards postphonic labour.
a. Betasympathomimetric such as rotodrine (yutopar) and terbutaline sulphate
(Brethine)
b. Magnesium sulphate
c. Prostaglandin inhibitors
d. Calcium, channel blockers such as Nifedipine
39

Refer to pharmacology for mode of Action and side effects of the drugs used
e.g. (*Reverse effects of Beta blocking agent e.g. propranol (inderal) reverses actions of ritodrine
if needed).
3. Glucocoticoid therapy
e. Betamethasone (Celestone)
i. Administer 24 48 hrs before birth if birth appears inevitable
ii. Reduces incidenceof and severity of respiratory distress syndrome in
preterm infants and enhances formation of surfanctant
iii. Celestone is administered unto the mother BD for 2 days and then weekly
until 34 weeks gestation.
4. Home Monitoring

Assessment

Determine the number of like gestation

State of foetus live and viable

Presence of labour

Time contractions

Cervical dilations and effacement

Identify any signs of haemorrhage or infection

Identify presence of ph

Any rupture of membranes

Emotional status

Nurses Diagnosis

Low self-esteem related to failure to carry pregnancy to term.

Fear related to acute status of infant and potential for death or complication.

Compromised family coping related to need for specialised care and continued
hospitalization of the newborn.

40

Implementation

Prevent and decrease risk factors.- Teach importance of early reporting to ANC for
monitoring.

Monitor vital signs, FHR, Contractions and progression of labour

Maintain bedrest

Informs client about medications

Obtain consent

Provide emotional support

Reduce anxiety

Prevent possible loss of baby

Provide special care related to the administration of tocolytic medications.

Obtain database and then monitor

Maintain hydration but monitor for pulmonary oedema.

Monitor hypokalemia and hyperglycaemia

Monitor intake and output and neurological reflexes.

Prepare for glucocorticoid therapy for foetus.

Prepare for preterm birth if labour continues

Provide home instruction for healthy preterm pregnancy

Assessment by health worker
Rest periods
Increased fluid intake
No sexual intercourse or activity that may lead to orgasm
No nipple stimulation
Avoidance of stressful events
Empty bladder regularly and if contraction occurs

PRECIPITATE LABOUR
Definition
41

Precipitate labour is labour that is rapid and childbirth that take a duration of less than three hours.
Contractions are strong and frequent from the onset of labour. Which results in an abnormally
rapid progress of labour and delivery may occur within an hour from the onset of labour.

Assessment

Rapid cervical dilation

Accelerated foetal descent

History of rapid labour (Previous)

Rapid uterine contractions

N/Diagnosis
Risk for maternal injury related to rapid expulsion of foetus resulting lacerations
Risk for foetal trauma related to cranial battering out during rapid birth

Planning and implementation

Remain with mother and monitor closely

Keep emergency birth pack at bed side

Keep mother and partner informed throughout process of labour and birth.

Support and guide foetal head through birth canal when birth occurs.

Complications
There are several types of complications, which can occur with precipitate labour;
Maternal complications include;

Cervical and perenial lacerations.

The uterus may fail to contract during the third stage of labour, leading to a retained
placenta.

Post-partum haemorrhage (PPH)

Uterine inversion,

Shock and collapse may occur due to sudden relief of pressure.

Foetal complications include;

42

Foetal hypoxia which may occur as a result of frequent and strong contractions.

Rapid moulding may result in intracranial pressure and, during delivery leading to,

Intra-cranial haemorrhage

Asphyxia may occur due to rapid expulsion of the babys unmoulded head.

Remember:
Precipitate labour tends to recur. Therefore, with future pregnancies the mother needs to
be admitted to hospital for safe delivery.

43

TRIAL OF LABOUR, INDUCTION OF LABOUR AND PROLONGED LABOUR

By the end of this Section you should be able to:

Define trial of vaginal delivery;

Explain what is maternal and foetal distress

Define induction of labour;

Describe the different methods used in induction of labour and their management;

Define prolonged/obstructed labour;

Discuss management of prolonged/obstructed labour;

Explain the complications of prolonged labour/obstructed labour;

Describe the preventive measures of prolonged labour.

TRIAL OF LABOUR
Trial of labour is a test of labour conducted where there is a minor or moderate degree of Cephalo
Pelvic Disproportion (CPD) in which it is difficult to decide whether delivery per vagina is
possible.

There are several factors influencing good prognosis. These are:

Strength of the uterine contractions;

Flexion of the head;

Degree of moulding of the foetal head, that is, engaging diameters get less;

The giving of pelvic joints. In pregnancy, the joints of the pelvis are relaxed and separate
by half to one cm;

Maternal courage.

Meanwhile, the factors influencing poor prognosis are:

Early rupture of membrane which may be accompanied with prolapsed cord;

Poor moulding of the head;

Maternal or foetal distress which will necessitate intervention on trial of vaginal delivery.

Remember:
Do not hesitate to terminate the trial of labour when there is foetal or maternal distress.
44

You should understand the contraindications for trial of labour. Compare the following list of
contraindications for trial of labour with those you learnt in normal labour:

Grossly contracted pelvis;

Medical or obstetrical complications;

Malpresentations, for example, breech;

Elderly primigravida;

Cases where trial of labour failed before;

Cases of two previous Caesarean sections.

Remember:
Your encouragement and friendly attitude will boost the mothers morale.

Management of Trial of Labour

Explain the situation to the mother and prepare her for possible operative intervention. Assess
patient carefully on admission to ascertain the following:

Whether the mother is in established labour;

Presentation of foetus;

Check for flexion of the head;

State of foetal heart, that is, rate, rhythm and volume;

General condition of mother physically and emotionally;

Confine the mother to bed to prevent early rupture of membranes;

Close observations of temperature and blood pressure four hourly;

Observe

foetal

heart

rate

and

maternal

pulse

quarterly

to

half

hourly.

You should always observe for signs of foetal and maternal distress. Accurately observe and
record for onset, strength, frequency and duration of the contractions. Closely observe the
descent of the head every one to two hours per abdominal palpation by the same midwife if
possible. Encourage the mother to pass urine two hourly and test for acetone to exclude acidosis.

A vaginal examination should be done every four hours to assess the level of the presenting part,
the degree moulding and flexion, the dilation of the cervix (whether progressive or not), the
consistency of the cervix and the presence or absence of caput.
45

You should also check whether the membranes are intact or ruptured. Encourage adequate
hydration by giving intravenous 5% dextrose. Sedate the mother with pethidine or morphia in
early labour to promote rest, and reduce anxiety.

Remember:
The following should be reported to the doctor immediately if any of the following
undesirable factors are observed.

Undesirable occurrences include:

Rupture of membranes;

Colour of liquor is meconium-stained;

Uterine action is abnormal;

Abnormal presentation, that is, a change from vertex to brow.

When the presenting part fails to descend in spite of good uterine contraction;

When there are signs of foetal or maternal distress.

Trial of labour may result in spontaneous vaginal delivery, assisted vaginal delivery by either
forceps or vacuum, or Caesarean section due to complications.

Trial of Scar: Vaginal Birth after Caesarean Section

Trial of scar is a test of labour to a woman with a previous Caesarean section scar, where no
recurrent indication is present.

Studies have shown that a large percentage of previous Caesarean section mothers later deliver
per vagina, involving same or fewer risks than a repeated section. The trial should be in a facility
where, if there is a need for a Caesarean section, it can be performed immediately. The midwife
should be vigilant in making the necessary observations
The main contra-indications include:

Where the reason for the first scar is likely to be repeated, for example, in cephalo-pelvic
disproportion;

Classical type of Caesarean section;

46

Malpresentation, for example, breech;

Two previous Caesarean section scars, regardless of the causes;

Where the previous scar wound did not heal with the first tension;

Where pregnancy occurs within six months of a Caesarean section;

Where there is over-distension due to multiple pregnancy, hydromnious;

Multiparty.

The management of this mother is as for trial of labour with the addition of these few points
below:

Palpate abdomen gently;

Check for any tenderness over the scar;

Observe for any signs of impending rupture of the uterus;

Report any constant pain in abdomen.

Educating the Patient on Avoiding Unnecessary Caesarean Birth

A small percentage of women with conditions that are a threat to the foetal or maternal life need a
Caesarean section. Many other women have a Caesarean section due to a series of events, which
leads to an inevitable section seen as necessary at that particular time. For some, if other options
had been discussed earlier, a Caesarean section may have been avoided.

Some mothers insist on the operation if the month coincides with the previous month of birth of
other children, so as to have same birthday with their babies. Others prefer not to push and go
through the whole process of enlarging the birth canal. If these women were well informed, they
might see the sense of preventing a Caesarean section. Additional contributing factors to the
decision to have a Caesarean section include mismanagement of the syntocinon drip, choice of
obstetrician and/or hospital policy.

MATERNAL AND FOETAL DISTRESS

Maternal and foetal distress is one of the complications of prolonged labour. In this sub-section,
we shall discuss the symptoms, signs and management of maternal and foetal distress.

47

Maternal Distress
This is a serious and life-threatening condition, which should not occur in this era. It happens
when the metabolism and the electrolyte balance of the woman in labour is disturbed and this can
result into keto-acidosis hypotonic uterine inertia. Maternal and foetal distresses usually occur
together after prolonged labour.

In maternal distress, the accumulation of ketoacids and the electrolyte imbalance also affect the
metabolism and function of all the other muscles in the body. The intestines stop contracting,
which is known as intestinal ileus. The large intestine (colon) distends. Emptying of the stomach
is delayed. With large volumes of fluid stagnating uselessly in the stomach, and the small and
large bowel, the woman becomes dehydrated. These disturbances in the mother result in a similar
disturbance in the foetal metabolism. Often maternal and foetal distress present together in
women who have been in labour for a long time at home and are brought to a health centre or
hospital in poor condition.

List the signs and symptoms of maternal distress.

The main symptoms of maternal distress are that the mother is exhausted by severe pain and lack
of sleep and she might have severe abdominal pain because of the prolonged and obstructed
labour.

Prevalent signs to look out for include:

She displays signs of anxiety;

She has a dry and furred tongue;

Her pulse rate is over 120 beats per minute;

Rapid and deep respiration because of acidosis;

She has hot, dry and inelastic skin;

She has a distended abdomen;

There is a reduced output of highly concentrated urine;

Her temperature is 38oC;

She might already have a purulent discharge from an intrauterine infection due to early
rupture of the membranes.
48

The main investigation is testing for the presence of acetone in the urine.

Management of Maternal Distress

Give an infusion of 10 percent glucose to correct dehydration. A Caesarean section is performed
when in the first stage of labour. In the second stage, an episiotomy is given and delivery is
assisted with vacuum extraction.

Foetal Distress
This occurs when the foetus is deprived of oxygen and, as a result, develops hypoxia. The baby
may be born as a still birth or develop asphyxia and suffer brain damage.

Causes of foetal distress include:

Congenital malformation;

Problems with the cord, for example, prolapse, true knot, twisted round the neck;

Obstetric complications;

Mothers condition of pre-eclampsia/eclampsia;

Severe anaemia, ante-partum haemorrhage.

Intra-partum causes include:

Prolonged labour;

Malpresentation and malposition;

Shoulder dystocia;

Foetal tachycardia of more than 160 per minute is an early sign while foetal bradycardia of
pulse less than 120 beats per minute is a late sign of foetal distress. Foetal heart acceleration
related with uterine contraction is another sign of foetal distress.
Management of Foetal Distress
When foetal distress is anticipated, a blood sample is taken, the normal pH being 7.35. If this
falls to 7.2, labour has to be terminated. Below pH 7 the brain cells perish. When there are signs
of foetal distress, call the doctor. If the mother is on oxytocinon drip, stop it immediately.
Change the mothers position and give oxygen by facemask. If the mother is in the first stage of
49

labour, a Caesarean section should be performed. If she is in the second stage, an episiotomy
should be given. Forceps or vacuum hastens the birth. A paediatrician should always be present,
if possible.

POST TERM PREGNANCY

Definition
Pregnancies lasting beyond the end of 42 weeks

Risks of Post Term Pregnancy

Post-term or prolonged pregnancy puts the foetus at great risk due to following;

Decreased placental efficiency resulting in risk of hypoxia and foetal weight loss.

Decreased amount of vernix caseosa which allows the drying of the foetal skin and leaves
the skin patched.

Decreased amniotic fluid which may result in cord compression and reduction of the
placental function.

Big babies weighing over 4,000gms in 10% of cases and 4,500gms in 1% of cases result
in cephalo-pelvic disproportion or shoulder dystocia.

Increased size (Length) and hardening of foetal skull resulting to cephalo-pelvic

disproportion (CPD).

The management of post term usually involves induction of labour (Myles 2003).

Medical management
Medical management is directed towards ascertaining precise foetal gestational age and condition
and determining the foetal ability to tolerate labour and the need for induction of labour or
Caesarean birth.
Assessment

Biophysical propile amount of amniotic fluid

Foetal heart rate result of stress and non stress tests

(Look up to understand the above tests)

Presence of neconium
50

Level of anxiety due to delayed birth

Newborn will have little vernix, long nails, hair, peeling off, wrinkled skin, reduced
subcutaneous fat and meconium staining liquor

Nursing Diagnosis

Fear

Traumatic delivery

Implementation as for induction of labour

INDUCTION OF LABOUR
Induction of labour involves the initiation of uterine muscle contraction by artificial means.
Indications for the induction of labour include:

When the health or well being of the mother or the foetus would be endangered if the
pregnancy continues;

Prolonged pregnancy that continues after 42 weeks because of danger of placental

insufficiency;

Pre-eclampsia, where both mother and baby are in danger, with the mother in danger of
eclampsia and the baby in danger of placental insufficiency;

Signs of intra-uterine growth, retardation, which can be detected by abdominal examination

or serial ultrasound scan;

Placental insufficiency more common in primigravida aged over 35 years;

Poor obstetric history, for example, history of stillbirth or intra uterine growth retardation in
previous pregnancies;

Polyhydramnious, foetal abnormalities;

Spontaneous rupture of membranes. If membranes rupture spontaneously after 36 weeks

gestation and labour does not commence within 12 hours, danger of intra uterine infection is
very high;

Previous large baby, where weight was over 4kg. Induction is indicated between 38-40
weeks. Foetal size tends to increase with successive pregnancies;

51

Diabetes mellitus, noting that intra-uterine death tends to occur near term so induction is
indicated between 36-38 weeks;

Rhesus iso-immunization, where rhesus antibodies are present in the maternal serum and the
titre is high, labour should be induced to save the life of the baby;

Unstable lie when placenta praevia and pelvic abnormalities have been excluded;

Genital herpes, where labour is usually induced after 38 weeks gestation if disease is in
remission;

Previous precipitate labour which tends to recur so induction is indicated at 38 weeks;

Social reasons, which is not common in our community but occurs sometimes;

Intra uterine death.

Remember:
It is important to ensure that when labour is induced results into a viable baby.

Assessment for Foetal Maturity and Viability

To test for foetal maturity amniocentesis, may be performed where possible. The lecithin:
sphingomyelin ratio in the liquor is calculated in order to estimate the foetal pulmonary maturity.
When the ratio is less than 2:1, it means that the lungs are not yet mature and induction of labour
should be delayed. At times, steroids are given to the mother to stimulate the foetal lungs to
produce surfactant to reduce the risk of RDS (Respiratory Distress Syndrome).

Contraindications for induction of labour;

Cephalo-Pelvic disproportion;

Unreliable estimated date of delivery. Confirm estimated date of delivery and maturity by
ultra sound;

Malpresentation;

Oblique or transverse lie;

Foetal compromise, that is, if the foetus could not stand the uterine contractions due to pre
maturity or placenta insufficiency. In such cases, Caesarean section is preferred;

Psychological factors, for example, if the mother is against induction, her decision should
be respected;

Placenta Previa.
52

Favourable factors for induction of labour include:

38 or more weeks of gestation;

Bishops Score of 6 or more;

Where 3/5ths of the head or less is palpable above the pelvic brim.

Methods of Induction
There are different methods of induction as follows:

Medical, where drugs alone are used and the amniotic sac remains intact;

Surgical, where the membranes are artificially ruptured;

A combination of medical and surgical intervention.

Medical Induction
Intra vaginal prostaglandin E2 are used in the form of pessaries (2.5mg), vaginal tablets (3-6mg)
or gel (2.5-5mg). A nelatone urinary catheter is attached to a syringe containing the gel while
membranes are intact in case of intra uterine infection. Introduce the gel to posterior vaginal
phornix. The dose varies from 2.5mg-5mg. If there is no change overnight, prostaglandin may be
added/repeated, but if the cervix ripens overnight, then pessaries of prostaglandin E2 may be
introduced to the vagina.

Care during the Procedure

The following steps should be taken to ensure adequate care of the mother during the procedure:

Maximum of an hour is needed to allow absorption of the prostaglandin, so the mother

should be asked to stay in for this period;

Observations are carried out as in normal labour;

After one hour, if foetal heart is normal, the mother should be allowed to walk around;

After four hours, if labour has not been established, a vaginal examination should be done
to re-assess the cervical dilatation;

If there has been some progress, artificial rupture of the membranes is done and a
syntocinon drip is commenced two hours later to prevent sensitivity of the uterus.

53

Oral Prostaglandin
This is usually used to induce labour where the membranes have ruptured.

One tablet is

swallowed at an hourly interval. A maximum of 10 tablets should be administered. Each tablet

contains 0.5mg of prostaglandin E2. Should it cause diarrhoea, the administration should be
stopped immediately.

You should note, however, that there are several complications associated with prostaglandin.
The mother may suffer discomfort due to painful contractions. The induction may be ineffective.
Over stimulation of the uterus can cause foetal and maternal distress.

Oxytocin Administration
The amount and rate of oxytocin must be carefully calculated and administered. Usually 5 per
cent dextrose in water of 500mls with 5 units of syntocinon is commenced after a vaginal
examination. The drip is started at 15 drops per minute and increased by 10 drops after every
half-hour to a maximum of sixty drops. Using two bottles of the same solution is preferred so that
in the event of discontinuation of oxytoxin, the intravenous line will still be open.

Remember:
It is crucial to record the amount of syntocinon added into the intravenous infusion. The
recommended syntocinon dose for a multiparous is 2.5 units and 5 units for a primigravida.

The following factors should be observed and recorded during the oxytoxin infusion:

Dosage of oxytoxin, the name and amount of solution;

Rate of flow;

Vital signs and foetal heart rate every 15-30 minutes;

Vaginal examination findings four hourly;

Maintain intake and output chart;

Record in the chart any other treatment that is given.

The following may be possible complications of oxytoxin use:

Hypertonic uterine contraction causing foetal distress;

Tetanic and tumultuous contractions, which can result in abruptio placenta;

54

Birth injury due to rapid expulsion of the baby;

Mother may develop hypertension with frontal headache.

Remember:
If any one of the above signs occurs, stop the syntocinon drip immediately and inform the
doctor.
Bishops Score
This is an objective method of assessing whether the cervix is favourable for induction of labour.
Scores
Indelibility features

1 Consistency of cervix

Firm

Medium

Soft

Thin

2 Position of cervix

Posterior

Mid

Anterior

3 Length of cervix in cm

>2

1-2

0.5 -1

< 0.5

4 Dilatation of cervix

Closed

1-2

3-4

-2

-1

+1+2

5 Station of presenting part 1 cm above or -3

below ischial spines

Each score is awarded 0 - 3. A total score of six or over is favourable.

Surgical Induction (Amniotomy)

In the case of an uncomplicated pregnancy, a sweep of the membranes is an effective method of
inducing labour. After a vaginal examination, the index finger is swept through the cervical Os to
detach foetal membranes from the deciduas. The action produces prostaglandin.

What do you understand by the term amniotomy?

Amniotomy is an artificial rupture of the membranes (ARM), which is carried out to induce
labour when the cervix is favourable. A well fitting presenting part is essential to avoid prolapse
of the cord or rupture of the membranes. Allow the descent of the presenting part to the cervical
Os. This raises the level of prostaglandin which stimulates strong contractions to hasten labour.
55

This method of induction may be combined with oxytocin drip and this is referred to as combined
method. This method has likelihood of delivery within 12 hours, requires less analgesia and
reduces the risk of post partum haemorrhage (PPH).

There are, however, several potential hazards associated with Artificial Rupture of Membranes
(ARM). These include:

Intra uterine infection due to contaminated instruments;

Cord prolapse;

Early foetal heart deceleration;

Bleeding due to vasa or placenta previa.

Remember:
Due to the potential risks of this method, it is now being discouraged in this era of
HIV/AIDS.

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CHAPTER 5

EMERGENCY OBSTETRICS

POSTPARTUM HAEMORRHAGE

Objectives

Definition of Postpartum Haemorrhage

Causes and pre disposing factors of PPH

Assessment of condition of a patient with Postpartum Haemorrhage

Management of a woman with PPH

New frontiers in management of a woman with PPH

Appropriate referral of a patient with PPH

Rationale

PPH Worlds leading cause of maternal death.

Mortality occurs within two hours but it is preventable in most cases.

PPH claims the most productive members of the society sometimes leaving behind
neonates and families to suffer the effects.

Early identification, prevention and its management fundermental to the midwife.

Definition of PPH

Postpartum Haemorrhage (PPH) is defined as bleeding from the birth canal after the birth
of the baby until 6 weeks postpartum, amounting to 500ml or more or any amount that
causes deterioration of the maternal condition.

Types

PRIMARY POST PARTUM HAEMORRHAGE is bleeding from the birth canal after the
birth of the baby and within the first 24 hours after delivery.

SECONDARY POSTPARTUM HAEMORRHAGE is bleeding from the genital tract that

occurs after 24 hours of delivery and up to 6 weeks post partum. It is more common
between days 10 and 14.
57

Causes;
a.

Primary PPH

Trauma to the genital tract (perineum, vaginal, cervical or uterine).

Uterine atomy.

Retained placental fragments and membranes.

Bleeding disorders.

b. Secondary PPH

Retained products of conception.

Puerperal sepsis.

Ruptured uterus.

Inadequate repair of genital trauma.

Predisposing Factors

Prolonged labour.

Over distended uterus.

Full bladder.

Grand multiparity.

Uterine fibroids.

APH.

Assessment of a patient with a condition of PPH

Direct observation of excessive vaginal bleeding.

Symptoms and signs of shock. (Rapid pulse, low blood pressure).

Genital condition of mother.

Emergency Management of PPH

Call for help.

Massage uterus to expell clots and encourage contraction.

Empty the bladder.

Give oxytocin 10 units or ergometrine 0.5mg IV stat.

58

Start IV line and infuse fluids.

Blood for grouping and cross matching

Check blood clotting status of the patient (normal clotting time is 6-13 minutes)

Maintain a drip of 20 units of oxytocin per litre of normal saline.

Placenta to be delivered by controlled cord traction if still in situ.

If placenta is already delivered look for the cause of bleeding and manage accordingly.

Management of Traumatic PPH

Get a good source of light and inspect the perineum and vaginal walls and cervix for
laceration and tears.

Repair the tears accordingly.

For ruptured uterus, do urgent laparatomy.

Management of Atonic Uterus

You have inspected the mother and she has no tears.

You have inspected the placenta and membranes and they are complete.

The patient is still bleeding.

Continue to massage the uterus.

Use oxytocic drugs.

Perform bimanual compression of the uterus.

If bleeding persists, attempt compression of the aorta

If bleeding persists then do laparatomy and: - Perform subtotal hysterectomy.

Subsquent Management

Monitor vital signs

- Keep warm

- Continue IV fluids.

Ensure continuous bladder drainage

Correct anaemia.

Broad spectrum antibiotics.

Counsel mothers about what was done e.g. hysterectomy.

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Complications of PPH

Shock.

Puerperal anaemia.

Impaired blood supply to the pituitary gland leading to pituitary necrosis and thus
Sheehan's syndrome.

Acute renal failure due to acute renal cortical necrosis.

Prevention of PPH

Proper antenatal care.

-Identify patients with previous history of PPH and monitor closely in labour.

Proper management of labour

-Avoid prolonged labour.

Active management of third stage of labour.

-Give egometrine 0.5mg IM start with the delivery of the anterior shoulderor syntocinon
10 units IM as per policy

Inspect placenta and membranes for completeness.

Prophylactic antibiotics to prevent infection

Intervene promptly if PPH is diagnosed.

SECONDARY PPH

Also called delayed PPH.

Bleeding usually occurs between day 10 and 14.

Predisposing factors

Retained products of conception.

Puerperal sepsis.

Ruptured Uterus.

Assessment of Secondary PPH

Direct observation of vaginal bleeding.

60

Signs and symptoms.

General condition of the mother.

Level of anemia

Management of Secondary PPH

If in shock resuscitate.

If anaemia is severe transfuse.

If retained POCs evacuate.

Oxytocic drugs

Broad spectrum antibiotics.

Rarely, if bleeding persists, laparotomy may be performed.

Further Problem may due to ;

Refractory uterine atony.

Placenta increte \ percreta

Life saving Procedures

Pack uterine cavity with sterile gauze. Remove after 24 Hrs.

Condom tamponade may be inserted into the uterine cavity: inflate the condom with
300mls of normal saline through giving set and folleys catheter.
Remove after 24Hrs. Deflate gradually 50mls hourly.

Laparatomy is performed if bleeding does not stop.

Patient is covered with antibiotics for infection

OBSTRUCTED LOBOUR
Defination
Labour is considered obstructed when, due to mechanical reasons and despite good uterine
contractions, further progress is impossible without assistance. Obstructed labour is therefore an
absolute and not a relative condition.

61

Obstructed labour- In spite of strong contractions of the uterus, the foetus cannot descend
because of mechanical factors. Obstruction usually occurs at brim, but it can occur in the cavity,
or pelvic outlet.

Prolonged labour-This is active labour with regular uterine contractions and progressive cervical
dilatation for more than 12 hours.

Incindence
- Severely contracted pelvis is prevalent.
- Common in underdeveloped countries (including Kenya) because:
Quality obstetric care, is inaccessible to majority of the women
- Obstructed labour is rare in developed countries because of proper monitoring thro pregnancy
and labour.

Aetiology/ Causes
1. Cephalopelvic Dispropotion
a) Faults in the pelvis: contracted, deformed.
b) Faults in the fetus: too big, macrosomic, deformed (eg hydrocephaly)
2. Malpresentations: breech, shoulder, compound, brow, locked twins, Face-mento posterior etc.
3. Shoulder dystocia
4. Abnormalities of soft tissues: tumors, scars, septae etc

Management of obstructed labour

"Prevention is better than cure"

Anticipation during antenatal period

a. Women of short stature
b. Previous history
c. Routine VE during early and late pregnancy (pelvic abnormality, gross CPD)
d. Abdominal palpation (big baby, malpresentation)
e. Imaging (Xray or U/Sound) studies for selected cases only
62

f. Elective c/s for gross CPD, big breech, transverse lie

g. Trial of labour for others

Anticipation during labour

a. Sluggish uterine activity may be due to CPD: a high presenting part.
b. Presenting part remains high despite adequate uterine activity.
c. Lack of progress"
d. "Prolonged labour
Clinical presentation: History:

prolonged labour,

prolonged rupture of membrane

unsuccessful 2nd stage

Unsuccessful interventions e.g. vacuum

Maternal exhaustion (distress)

Examination

Uterus: Bandl's ring, presenting part high

Bladder: full, displaced upwards

Cervix: oedematous, dilatation not increasing

Vagina: hot and dry, foul smelling discharge

Vulva: oedematous

FETUS: distressed or dead.

Treatment

Relieve Obstruction without delay; however, quickly:

Correct fluid /electrolytes balance: IV fluids

Administer broad spectrum antibiotics as prescribed to control infection

Empty bladder (in-dweling Foley's catheter)

Empty stomach (if necessary)

Cross-match blood

Operations to relieve obstruction

C/S preferred, especially if baby alive
Vacuum: if head can easily deliver, otherwise dangerous
63

Destructive operations: by an experienced gynaecologist/doctor

RUPTURE OF THE UTERUS

"Is an obstetric catastrophe"
Causes
Obstructed labour
Injudicious use of oxytocin
Operations

to relieve obstruction

Perforations during abortion,d&c, evacuation

Predisposing factors
High parity
Previous uterine operations
Abnormal placentation
Malpresentations

Sites
Anterior wall: commonest
Lateral sides: may involve uterine arteries
Posterior: most perforations are of this type
Multiple
Annular detachment

Clinical features
Vary from DRAMATIC to INSIDIOUS

Dramatic:
Profound shock
Maternal distress
Abdomen distended
Fetal parts easily felt
Free fluid
64

VE: presenting part high or not felt

Catheterization: scanty blood stained urine
Insidious
Less dramatic
Shock develops slowly
Pain less intense
Haemorrhage less
Dehiscence of previous scar usually of this type
Impeding Rupture: Local scar pain, PV bleeding, fetal distress, rising maternal pulse/dropping
BP

Goals of management
To arrest bleeding
Resuscitate the mother
Prepare the mother for immediate laparotomy

Nursing diagnoses
Pain
Heamorrhage
Fluid volume deficit
Infection

Management

Laparotomy is mandatory

Prepare quickly: resuscitate

I.V. Line or cutdown

X-match blood

Start operation

Remove fetus and placenta

Inspect uterus and bladder carefully

Repair uterus (&bladder) or do hysterectomy

65

Continuous bladder drainage, monitor urine output carefully

Continue antibiotics,fluids/blood

Future deliveries by elective c/s.

Complications of obstructed lobour

Rupture of the uterus

Urinary/genital tract injuries

Peripheral nerve injuries (foot drop)

Osteitis pubis

Sheehan's syndrome (from pituitary ischaemia)

Infertility

Chronic pelvic pain

High maternal /perinatal morbidity and mortality

Infant/child morbidity including: cerebral palsy, mental retardation, epilepsy, peripheral

nerve injuries, fractures.

Puerperal sepsis

66

MEDICAL CONDITIONS THAT COMPLICATE PREGNANCY & LABOUR

Objectives
By the end of the unit the student will be able to;
1. Define the terminologies used in each condition and state classifications /types of each
that may be seen during pregnancy
2. State the predisposing causes/ aetiology
3. State the signs and symptoms and outline the assessment findings
4. Discuss the pathophysiology of each condition
5. Discuss the effects of each condition on pregnancy, both to the mother and the fetus
6. Discuss the management of each condition
7. List the complications of each condition

MALARIA IN PREGNANCY

Introduction
Malaria is a febrile haemolytic disease caused by protozoa of a genus plasmodium. It is
transmitted by a bite of an infected female anophelen mosquito or rarely by a transfusion of
infected blood products. The mosquito must bite twice in order to transmit the disease. First to
pick it up, and secondly to transmit the disease. The word Malaria comes from an Italian word,
meaning; mala-re-a (bad air), which was believed to be the cause of the disease.
The level and its periodicity determines the level of immunity to it in a community. Pregnant
women with malaria can be therefore divided into two groups;

Immune living in endemic areas

Non-immune / Highly susceptible those living in low risk areas.

Malaria in a community may also be classified into;

High risk areas - These are areas with constant repeated infections (endemic areas) and
the population has a high degree of immunity, e.g. Coast, Nyanza, and parts of Eastern.
67

Low risk areas - Regions with intermittent transmission and therefore, community
immunity is poorly developed and dramatic epidemics with severe attacks of cerebral
malaria, black water fever and pulmonary edema can occur.

Pregnant women are more susceptible to infection with malaria due to their lowered immunity
and therefore they get malaria more easily than non- pregnant women. Many of the pregnant
women may have malaria without signs and symptoms as the parasites have a tendency to hide in
the placenta and if a peripheral blood slide for malaria is taken it may negative. Pregnant women
who come from endemic areas may develop immunity while those from non- endemic areas and
travellers may be non immune.

Signs and Symptoms

Fever with or without shivering (temp. 37.5 and above)

Headache

Weakness and fatigue

Loss of appetite

Nausea and vomiting

Joint pains and muscular pains

Abdominal discomfort/false labour pains

Dizziness

Signs of anaemia which include; palpitations, breathlessness, fatigue, dizziness etc.

Natural Course of the disease

Malaria parasites hide in the placenta and therefore may not be found in the peripheral
blood samples
The parasites may cause damage to the baby by interfering with the placental function,
hence diminishing oxygen and nutritional supply to the fetus and that may lead to intrauterine fetal growth retardation which can lead to intra-uterine fetal death.
Malaria may cause up to 30% of neonatal deaths as a result of Low birth weight babies
who have a higher perinatal mortality rate as compared to normal babies.

68

 Malaria increases the risk of premature labour, spontaneous abortions and stillbirths.
Anaemia in the mother may occur due to increased destruction of RBCs which may also
lead to jaundice due to high levels of conjugated bilirubin.
Any woman pregnant woman with severe anaemia (Hb <7g/dl) from high risk malaria
areas should be treated presumptively for malaria.

Effects on Pregnancy
-

Pregnancy enhances the severity of falciparum malaria, especially in nonimmune

nulliparous women

Increased fetal loss may be related to placental and fetal infection. Parasites have an
affinity for decidual vessels and may infest the placenta extensively which becomes a
good reservoir for the parasites. The placenta acts like a spleen in malaria with intervillous
spacesand capillaries packed with macrophages and parasites (varying numbers apparently
from the blood stream). This is characteristic of P. falciparum and is seen in the second
half of Pregnancy, especially in the primigravidas and such parasites can eliminated by
use of (Intermittent Preventive/Presumptive treatment during pregnancy ( IPTP).

Cellular reaction in placenta interferes with maternal blood circulation and fetal growth is
impaired leading to LBW babies.

Increased frequency and severity of maternal attacks

Anemia - secondary to hemolysis and destruction of parasitized and non-parasitized RBCs

(the latter process is autoimmune mediated) added to suppression of haemopoiesis.

For mothers from low risk malaria areas, if infected by malaria the anemia is rapidly
progressive and very severe leading to maternal and fetal mortality

Febrile attacks are more common in the last trimester as compared to the first trimester

Effects on Labor

Premature labor may be precipitated by an acute attack

In severe anemia, the onset of labor is of grave significance due to likelihood of CCFand
PPH

69

Severe infections may acutely precipitate labor; parenteral treatment and shortening of
second stage may be required

Avoid PPH by massaging the uterus to ensure that it remains contracted after delivery.

Latent infections may flare up due to stress of labor

Effects on Puerperium

Malaria is an occasional cause of puerperal pyrexia

Can lead to sepsis

Prophylactic antimalarials should be continued until 6 wks to prevent.

Effects on the fetus

Abortion in the 1st trimester due to pyrexia and in the 2nd trimester due to anemia

Still births due to intrapartum asphyxia, severe anemia and placental parasitemia leading
to cessation of cortisol production triggering labor

Neonatal death due to intrapartum asphyxia due to severe anemia, placental parasitemia;
prematurity.

Preterms secondary to pyrexia inducing labor

SGA and Low birth weight due to the cellular reaction in placenta secondary to
parasitemia interfering with maternal blood circulation and fetal growth

IUFD - due to uterine irritation by pyrexia, severe anemia, placental parasitemia, rarely
by transplacental infection especially in non-immune women

Fetal anoxia leading to IUGR, IUFD

Ig G readily crosses the placental barrier and the degree of immunity possessed by the
baby at birth is relative to that of the mum.

Signs and Symptoms of malaria in pregnancy

Symptoms are less severe in immune patients.
o Spleno-hepatomegally in a young primigravida (not common in adults in holoendemic
areas)
o Fever - activates the uterus causing premature labor and abortions below 16 wks
o Flu-like symptoms including chills, headaches, myalgia, and malaise
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o Anemia
o Jaundice

Differential Diagnosis

Eclampsia (if convulsions present), coma, hyperpyrexia and albuminuria (secondary to

nephritis) - differentiated by HBP and massive albuminuria. Coma in the absence of fits is
more likely to be cerebral malaria as compared to repeated epileptiform convulsions with
coma in eclampsia. Hyperpyrexia is present but not invariable in cerebral malaria but
pyrexia, coma and LBP may be in terminal eclampsia

Meningitis - meningism, hyperpyrexia, stupor/coma - Differentiated by a LP

Laboratory tests; peripheral blood slide. Random blood sugar or uristix and CSF test

Management of malaria in pregnancy

STEP I

Prevention of Malaria
Use of mosquito treated bed nets (ITNs)
Indoor Residual spraying (IRS)
Focused ANC (FANC)
Intermittent Presumptive Treatment in Pregnancy (IPTp)
Effective Case Management
Education and communication
Good nutrition
Proper screening procedures

Activity
Describe the drugs used in the treatment of malaria and state their likely side effects

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Refer to the current Ministry of Health Guidelines on Malaria Case Management and Prevention
(2008)

Treatment

Establish the presence of malaria by use of microscopy and Algorithm for management of
fever in adults

Decide whether it is severe or un-complicated malaria

Treatment of uncomplicated malaria

First line in all trimesters- oral quinine for 7 days

Avoid AL in the first trimester ( safety not established yet)

AL in second and third trimester if Quinine is not available

NB
Do not withhold AL in the first trimester if Quinine is completely un- available and malaria
confirmed by laboratory (either Microscopy or RDT)

Treatment of Severe Malaria

In all cases of severe malaria, parasitological diagnosis or confirmation ius recommended

If no parasitological diagnosis or report delayed ; treat for severer malaria on clinical

grounds

Treat with IV quinine in their appropriate doses (loading and maintenance)

IM Quinine diluted according to the guidelines if IV is not possible.

5 % dextrose is preferred for IV infusion

Pregnancy, Anaemia, or hyperparasitemia are is not a contraindication to a loading dose

Supportive care includes prevention of hypoglseamia, monitor the fetus, treat anaemia and
give antiphyretics

Once anemia is established between 20-28 wks, antimalarials alone will not correct it, but folate
supplementation is necessary for hemopoiesis

Hemolysis remits spontaneously especially after treatment but occasionally continues and may
require transfusion and steroid treatment.
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Hemolytic anemia is likely to remit in subsequent pregnancies but can be prevented effectively
with chemoprophylaxis from the 1st trimester.

Complications
o Kidney failure
o Coma
o Death

ANEMIA IN PREGNANCY
Anaemia in pregnancy is a very common condition and especially in the developing countries
especially where social, economic and cultural factors contribute to the wellbeing of women in
reproductive age. Anaemia is the reduction in the oxygen-carrying capacity of the blood; this may
be caused by a decrease in red (RBC) production, or reduction in haemoglobin (HB) content of
the blood or combination of both.

Definition
Anaemia is often fined as haemoglobin concentration < 10 g/dL during pregnancy or the
puerperium. CDC definition - Anaemia in pregnancy is defined as haemoglobin concentration
< 11 g/dL in the first and third trimesters, and < 10.5 g/dL in the second trimester. Anaemia in
nonpregnant women is defined as haemoglobin concentration < 12 g/dL

Pathophysiology
During pregnancy, there is a modest fall in haemoglobin levels observed and not deficient of iron
or folate which is caused by a relatively greater expansion of plasma volume by 46-55%
compared with the increase in haemoglobin mass by 18-25% and red cell volume normally
greatest during the second trimester resulting in physiological decrease in hematocrit due to
hemodilution.

Late in pregnancy; plasma expansion essentially ceases while haemoglobin mass continues to
increase.

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After delivery; the haemoglobin level typically fluctuates to a modest degree around the predelivery value for a few days and then rises to the higher non-pregnant level.

Aetiology
Acquired/ Hereditary
Iron-deficiency anemia
Anaemia caused by acute blood loss
Anemia due to inflammation or malignancy
Megaloblastic anemia
Acquired hemolytic anemia
Aplastic or Hypoplastic anemia
Thalassemias
Sickle-cell hemoglobinopathies
Other hemoglobinopathies
Hereditary hemolytic anemias

Effects of Anaemia on Pregnancy

- Increased risk of preterm birth with mid-trimester anaemia
- Women whose hemoglobin concentration exceeded 13.2 g/dL at 13 to 18 weeks had excessive;
- Perinatal mortality
- Low-birthweight infants
- Preterm delivery
- Preeclampsia in nulliparas

Iron-deficiency Anaemia
The total body iron consists mostly of

Iron in hemoglobin (about 70% of total iron)

Iron stored as ferritin and hemosiderin in reticuloendothelial cells in bone marrow, the
spleen, and parenchymal cells of the liver (about 300 mg)

Small amounts of iron exist in myoglobin, plasma, and various enzymes.

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In a typical gestation with a single fetus, the maternal need for iron induced by pregnancy
averages close to 1000mg which considerably exceeds the iron stores of most women;
- 300 mg for the fetus and placenta
- 500 mg, if available- for maternal hemoglobin mass expansion
- Approximately 200 mg more are shed through the gut, urine, and skin

With the rather rapid expansion of blood volume during the second trimester, iron lack is often
manifested by an appreciable drop in hemoglobin concentration. Although the rate of expansion
of blood volume is not so great in the third trimester, the need for iron is still increased because
augmentation of maternal hemoglobin mass continues, and considerable iron is now
transported to the fetus independent of maternal iron stores.

Etiology
- Nutritional deficiency
- Chronic parasitic infestation - Hookworms cause mucosal bleeding and suck blood from the
patient (0.05- 0.1ml/worm/day) where as other duodenal worms block iron absorption, also
Entamoeba histolytica. Excessive blood loss with its concomitant loss of hemoglobin iron and
exhaustion of iron stores in one pregnancy can be an important cause of iron-deficiency anemia in
the next pregnancy

FOLIC ACID ANAEMIA

Folic acid is needed for the increased cell growth of both the mother and the fetus but there is a
physiological decrease in folate levels in pregnancy. Anaemia is more likely to be found towards
the end of pregnancy when the fetus is growing rapidly

Cause
Reduced dietary intake or absorption or a combination of both. In haemolytic anaemia there is
increased demand for the production of new cells and consequently for folic acid. Some drugs
may interfere with utilization of folic acid e.g. anticonvulsants, sulphonamides and also alcohol.
Clinical Findings
The diagnosis of iron deficiency in moderately anaemic pregnant women usually is presumptive
and based largely on the exclusion of other causes of anemia.
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Signs and Symptoms

The symptoms may be vague and nonspecific;
-

Pallor

General weakness - Easy fatigability, lethargy, malaise

Dizziness

Low grade fever without obvious cause

Palpitations

Tachycardia

Hemic murmur

Dyspnea on slight exertion

Moderate tachypnea at rest

Flabby tongue - large and sluggish

Tinge of jaundice

Albuminuria

Angular stomatitis, glossitis, and koilonychia may be present in long-standing severe

anaemia

In the terminal phase, acute pulmonary edema may supervene and cerebral anoxia may
cause excitement and loss of consciousness

Investigations
- Hb, Hct and red cell indices
- Stool microscopy for ova and cysts
- Sickle-cell tests and Hb and analysis of red cell maturation and morphology and quality
- LFTs - Hypoproteinemia may be a cause
- Urine biochemistry to r/o or confirm underlying kidney disease.
- CXR - r/o TB or malignancy

Lab findings
- The red cells are microcytic and hypochromic
- The reticulocyte count is low
- Platelet counts increased
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- White cell counts normal

- Transferin saturation < 16%
- Serum ferritin concentration < 10 g/dL
- Absence of hemosiderin in the bone marrow
- The serum iron-binding capacity is elevated, but by itself this is of little diagnostic value
because it also is elevated during normal pregnancy in the absence of iron deficiency.

Effects on the fetus

The fetus is a very successful parasite. By the time maternal anaemia is affecting the fetus , the
maternal situation will be very severe.
Severe iron deficiency anemia causes;
- Intrauterine growth retardation
- Preterm labor
- Late abortion (20-28 wks)
- Intrapartum asphyxia - IUFD
- Neonatal death
- Perinatal death
- Infantile anemia 2-3 months postpartum
- Low or absent iron stores in the baby

Differential Diagnosis
Anemia due to chronic disease or an inflammatory process (eg, rheumatoid arthritis) may be
hypochromic and microcytic. A similar type of anemia in thalassemia trait can be differentiated
from iron deficiency anemia by normal serum iron levels, the presence of stainable iron in the
marrow, and elevated levels of hemoglobin A2.

Treatment
The objectives of treatment are;
- Prevention of poor pregnancy outcomes
- Correction of the deficit in hemoglobin mass
- Restitution of iron stores
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Oral Iron Therapy

Ferrous sulphate 1tablet, 3 times a day beginning in the first trimester till delivery and up to the
end of pueperium. Supplemental folic acid 5mg/d. Steroid therapy (Prednisolone 20mg/d)
especially in excess hemolysis e.g. Malaria. When the pregnant woman with moderate irondeficiency anemia is given adequate iron therapy, a hematological response is detected by an
elevated reticulocyte count. The rate of increase of haemoglobin concentration or hematocrit
is slower than in nonpregnant women as newly formed hemoglobin is added to the
characteristically much larger volume blood during pregnancy. Transfusions of red cells or whole
blood (500mL/ 8hrs) seldom are indicated for the treatment of iron deficiency anemia unless
hypovolemia from blood loss coexists or an emergency operative procedure must be
performed on a severely anemic woman.

Labor and puerperium management

The 1st 2 wks of labor and puerperium are the greatest risk to the mother and most maternal
deaths occur during this period in the 1st 12hrs postpartum.
Administer O2 during labour to reduce risk of asphyxia
Use of aseptic techniques and prophylactic antibiotics to reduce chances of infection
Aim to achieve a short 2nd stage of labour

Maternal complications
o Angina pectoris
o Congestive heart failure
o Death

Prevention
During the course of pregnancy and the puerperium;
-

Ferrous sulphate, 300 mg containing 60 mg/d of elemental iron should be prescribed to

prevent anaemia
Supplemental folic acid 5mg/d

Dietary management

Prophylactic malaria treatment and prevention of hookworm infection

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If there are any signs of cardiac failure anti failure regime should be instituted in good
time (digoxin 0.25 mg once daily plus or minus Lasix depending on severity)

Anemia from Acute Blood Loss

Both abruptio placentae and placenta previa may be the sources of serious blood loss cause of
anemia before as well as after delivery. Earlier in pregnancy, anemia caused by acute blood loss is
common in instances of abortion, ectopic pregnancy, and hydatidiform mole.

Anemia Associated with Chronic Disease

Chronic infections, inflammation, and neoplasia cause weakness, weight loss, and pallor,
loss of appetite and reduced food intake.

Blood cells may be hypochromic and microcytic.

During pregnancy, a number of chronic diseases may cause anemia;

Chronic renal disease - Chronic renal insufficiency is characterized by anemia of variable

severity, and usually is due to erythropoietin deficiency.

Suppuration - Women with severe acute pyelonephritis, but not those with asymptomatic
bacteriuria or cystitis

Inflammatory bowel disease

Systemic lupus erythematosus

Granulomatous infections

Malignant neoplasms

Rheumatoid arthritis

As expected, anemia is intensified as plasma volume expands out of proportion to red cell mass
expansion. At least some cases of so-called refractory anemia of pregnancy are the
consequence of one of these diseases which has gone unrecognized.

Megaloblastic Anemia
Megaloblastic anemias; are a family of hematological disorders whose characteristic blood and
bone marrow abnormalities are caused by impaired DNA synthesis. Megaloblastic anemia
beginning during pregnancy almost always results from folic acid deficiency. Women with
79

megaloblastic anemia may have developed troublesome nausea, vomiting, and anorexia during
pregnancy. In some instances, excessive alcohol ingestion is either the cause or contributes to its
development. In normal nonpregnant women, the daily folic acid requirement is 50 to 100
g/day. During pregnancy, requirements for folic acid are increased to 400 g/day. The fetus
and placenta extract folate from maternal circulation so effectively that the fetus is not anemic
even when the mother is severely anemic from folate deficiency.

Etiology

Increased requirements in;

Multifetal pregnancy

Hemolytic anemia

Crohn disease

Alcoholism

Some inflammatory skin disorders

Lab findings

Hypersegmentation of neutrophils

Macrocytic erythrocytes

Nucleated erythrocyte

Bone marrow discloses megaloblastic erythropoiesis

Thrombocytopenia

Leucopenia

Treatment
The treatment of pregnancy-induced megaloblastic anemia should include folic acid, a nutritious
diet, and iron. 1mg. of folic acid OD. By 4 to 7 days after beginning treatment, the reticulocyte
count is increased appreciably, and leucopenia and thrombocytopenia are corrected promptly.
Severe megaloblastic anemia during pregnancy typically is accompanied by an appreciably
smaller blood volume than that of a normal pregnancy, but soon after folic acid therapy has
been started, the blood volume usually increases considerably. Therefore, even though
haemoglobin is being rapidly added to the circulation, the haemoglobin concentration does not
80

reflect precisely the total amount of additional haemoglobin because of the simultaneous
expansion of blood volume.

Prevention
CDC recommends that all childbearing-age women consume at least 0.4 mg of folic acid daily.

81

HYPERTENSIVE DISEASE IN PREGNANCY

Hypertensive disorders complicating pregnancy are common and along with hemorrhage and
infection results in a large number of maternal and fetal morbidity and mortality.

Definition and Classification

Definition and classification of the hypertensive disorders are complex as their pathology remains
poorly understood and their clinical variations are extremely large.

Classification of Hypertensive disorders complicating pregnancy

1. Pregnancy induced Hypertension; Hypertension that develops as a consequence of
pregnancy and regresses postpartum. This type is divided into;
- Hypertension without proteinuria or pathological edema
- Pre-eclampsia - with proteinuria and/or pathological edema
o Mild
o Moderate
o severe
- Eclampsia - proteinuria and/or pathological edema along with convulsions

2. Coincidental hypertension; Chronic underlying hypertension that ante cedes pregnancy or

persist postpartum
3. Pregnancy-aggravated hypertension: Underlying hypertension worsened by pregnancy
- Superimposed preeclampsia
- Superimposed eclampsia
4. Transient Hypertension: Hypertension which develops after the midtrimester of pregnancy
and is characterized by mild elevations of blood pressure that do not compromise the pregnancy.
This form of hypertension regresses after delivery (within 12wks), but may return in subsequent
gestations.

Incidence
The following are the major predisposing factors;

Nulliparity
82

Familial history of preeclampsia-eclampsia

Multiple fetuses

Diabetes

Chronic vascular disease

Renal disease

Hydatidiform mole

Fetal hydrops

Pregnancy-induced Hypertension is more common in;

- Nulliparous women
- Teenagers (<20yrs)
- Multipara with multifetal pregnancy or fetal hydrops

Pregnancy-aggravated hypertension - > 35 yrs

- Multiparas with vascular disease, including chronic essential hypertension and diabetes, or those
with coexisting renal disease.

Diagnosis of Pregnancy-induced Hypertension

The diagnosis of hypertension is made when blood pressure is 140/90 mm Hg.

Preeclampsia is diagnosed by development of hypertension plus;

- proteinuria defined as 300 mg of urinary protein per 24 hours, or 100 mg/dL in at least two
random urine specimens collected 6 hours apart.
- Edema which is pathological and not just dependent; it usually involves the face and hands
and persists even after arising. A useful indicator of nondependent edema is that rings have
become too tight

Mild preeclampsia
- Diastolic BP <100mmHg
- Proteinuria - Trace - 1+
- Normal serum creatinine
- Minimal liver enzyme elevation
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Severe preeclampsia
- Systolic 160mmHg and Diastolic >110mmHg
- Persistent proteinuria of 2+, or 24-hour urinary excretion of 4 g
- Epigastric or right upper quadrant pain frequently accompanied by marked elevated serum
liver enzymes likely results from hepatocellular necrosis, edema, and ischemia that stretches
Glisson's capsule. It usually is a sign to terminate the pregnancy. The pain presages hepatic
infarction and hemorrhage as well as catastrophic rupture of a hepatic sub-capsular hematoma
especially in older and multiparous women.
- Thrombocytopenia (<100*109/L) is characteristic of worsening preeclampsia, and probably is
caused by microangiopathic hemolysis induced by severe vasospasm. There is evidence of gross
hemolysis; such as hemoglobinemia, hemoglobinuria, or hyperbilirubinemia which is indicative
of severe disease.
- Cardiac dysfunction with pulmonary edema
- Fetal growth restriction
- Glomerular filtration may be impaired - Oliguria <400mL/d
- Plasma creatinine may rise - >1.2mg/dL
- Headache
- Visual disturbances

Eclampsia is diagnosed when grand mal convulsions appear before, during, or after labor,
usually preceded by headache, visual disturbances, or epigastric pain, are precipitated by
pregnancy-induced or aggravated hypertension.

Theories about the Cause of Pregnancy-induced Hypertension

Immunological Mechanisms
The risk of pregnancy-induced hypertension is appreciably enhanced in circumstances where
formation of blocking antibodies to antigenic sites on the placenta might be impaired.

This may arise;

- during immunosuppressive therapy to protect a renal transplant
- where effective immunization by a previous pregnancy is lacking, as in first pregnancies
- where the number of antigenic sites provided by the placenta is unusually great compared with
the amount of antibody, as with multiple fetuses
84

Genetic Predisposition
Dietary Deficiencies - incidence increases with calcium deficiency, obese women, and with
prepregnancy weight.

Vasoactive Compounds - Nitric oxide, previously termed endothelium-derived relaxing factor

(EDRF), a potent vasodilator whose absence or decreased concentration might play a role in the
etiology of pregnancy induced hypertension. Cigarette smoking has been reported to reduce the
incidence of pregnancy-induced hypertension

Endothelial Dysfunction - Damaged endothelium activates endothelial cells to promote

coagulation, and increases sensitivity to vasopressor agents.

Pathophysiology of preeclampsia-eclampsia

Vasospasm
Vascular constriction causes resistance to blood flow and accounts for the development of arterial
hypertension. It also exerts a damaging effect on vessels. Angiotensin II causes endothelial cells
to contract. These changes lead to endothelial cell damage and interendothelial cell leaks through
which blood constituents, including platelets and fibrinogen, are deposited subendothelially. The
vascular changes, together with local hypoxia of the surrounding tissues, presumably lead to
hemorrhage, necrosis, and other end-organ disturbances that have been observed at times with
severe preeclampsia. With this scheme, fibrin deposition is then likely to be prominent, as seen in
fatal cases.

Increased Pressor Responses in women with early preeclampsia

Supine pressor response - A hypertensive response with increased diastolic pressure of at least
20 mm Hg is induced by having the woman especially at 28 to 32 weeks assume the supine
position after lying laterally Recumbent

Maternal and fetal consequences of preeclampsia-eclampsia

a) Maternal consequences
Hemodynamic Changes- normal left ventricular filling pressures
85

- High systemic vascular resistances

- Hyperdynamic ventricular function.

Blood Volume - Hemoconcentration due to vasoconstriction made worse by increased vascular

permeability

Hematological Changes - thrombocytopenia

- decreased plasma clotting factors
- Erythrocytes may be so traumatized that they display bizarre shapes and undergo
rapid hemolysis

Endocrine Changes - With sodium retention, hypertension, or both, renin secretion by the
juxtaglomerular apparatus decreases. Because renin catalyzes the conversion of angiotensinogen
to angiotensin I (which is then transformed into angiotensin II by converting enzyme),
angiotensin II levels decline, resulting in a decrease in aldosterone secretion.

Fluid and Electrolyte Changes - Commonly, the volume of extracellular fluid in women with
severe preeclampsia-eclampsia has expanded beyond the normally increased volume that
characterizes pregnancy.

The Kidney - renal perfusion and glomerular filtration are reduced

-

Plasma uric acid concentration is typically elevated

Plasma creatinine may be elevated two to three times over nonpregnant normal values due
to a reduction in plasma clearance

Proteinuria develops late in pregnancy

Anatomical Changes - glomerular capillary endotheliosis - the glomeruli were enlarged

with glomerular capillary endothelial swelling, and subendothelial deposits of fibrillary
protein material

Acute renal failure characterized clinically by oliguria or anuria and rapidly developing
azotemia develops from;

Tubular necrosis - it is invariably induced by hypovolemic shock, usually associated

with hemorrhage at delivery, for which adequate blood replacement is not given
86

Renal cortical necrosis develops when the major portion of the cortex of both kidneys
undergoes necrosis

The Liver - Periportal hemorrhagic necrosis in the periphery of the liver lobule. Bleeding from
these lesions may cause hepatic rupture or they may extend beneath the hepatic capsule and
form a subcapsular hematoma.

- HELLP Syndrome. Liver involvement in preeclampsia- eclampsia is serious and is frequently

accompanied by evidence of other organ involvement, especially the kidney and brain, along
with hemolysis and thrombocytopenia - Hemolysis, ELevated liver enzymes, and Low Platelets.

The Brain - edema, hyperemia, focal anemia, thrombosis, and hemorrhage. A regular finding was
fibrinoid changes in the walls of cerebral vessels. The lesions sometimes appeared to have been
present for some time, as judged from the surrounding leukocytic response and hemosiderinpigmented macrophages. These findings are consistent with the view that prodromal
neurological symptoms, visual disturbances and convulsions may be related to these lesions.
It is rare for a woman with eclampsia not to awaken after a seizure. It is also rare for a woman
with severe preeclampsia to become comatose without an antecedent seizure.

b) Placental effects
Compromised placental perfusion from vasospasm is almost certainly a major culprit in the
genesis of increased perinatal morbidity and mortality associated with preeclampsia.

c) Fetal effects
The major cause of fetal compromise occurs as a consequence of reduced uteroplacental
perfusion.

Prematurity - IUGR

Fetal distress

Oligohydramnios

IUFD

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Clinical Presentation
Symptoms of hypertension
-

headache - often frontal but may be occipital, and is resistant to relief from ordinary
analgesics

Epigastric or right upper quadrant pain - probably due to hepatic ischemia or to

stretching of the hepatic capsule, possibly by edema and hemorrhage and may be
indicative of imminent convulsions.

Visual disturbances are also ominous

Diastolic pressure of 90 mm Hg that persists

A sudden increase in weight exceeding > 2 pounds in any given week, or 6 pounds in a
month due almost entirely to abnormal fluid retention (weight gain of 1 pound per week
is normal)

Visible signs of nondependent edema such as swollen eyelids and puffy fingers

Proteinuria almost always develops later than hypertension and usually later than
excessive weight gains

Prophylaxis and Early Treatment

Warning signs;
-

Rapid weight gain any time during the latter half of pregnancy - Normally before 20 wks,
net weight gain is 2Kg and may even have lost 2-3Kg in early pregnancy due to vomiting
and poor appetite; after 20wks, weight increases by Kg/wk

An upward trend in diastolic blood pressure

Early prophylactic treatment with aspirin 75-100mg/d reduces incidence of preeclampsia due to
selective suppression of thromboxane synthesis by platelets and sparing of endothelial
prostacyclin production.

Management
Basic management objectives for any pregnancy complicated by pregnancy-induced hypertension
are

Termination of pregnancy with the least possible trauma to mother and fetus

Birth of an infant who subsequently thrives

88

Complete restoration of health to the mother

Manage conservatively until labour commences

Hospital Management
Hospitalization is considered for women with pregnancy-induced hypertension if thereis a
persistent or worsened elevation in blood pressure or development of proteinuria. With
hospitalization, a systematic study should be instituted that includes the following:
A detailed medical examination followed by daily searches for development clinical
findings such as headache, visual disturbances, epigastric pain, and rapid weight gain.
Admittance weight and every day thereafter

Admittance analysis for proteinuria and at least every 2 days thereafter

Blood pressure readings with an appropriate-size cuff every 4 hours, except between
midnight and morning, unless the midnight pressure has increased
Measurements of plasma creatinine, hematocrit, platelets, and serum liver enzymes, the
frequency to be determined by the severity of hypertension
Frequent evaluation of fetal size and amnionic fluid volume by the same experienced
examiner and by serial sonography if remote from term

Drug therapy
Mild Preeclampsia
The aim of therapy is to maintain BP at about 130/50 mmHg
Sedatives - Phenobarbitone - 30mg TDS
-

Valium - 5mg TDS

Vasodilators - Aldomet - 250mg TDS/750mg/d QID

Hydralazine - 25-50mg/d TDS

Nifedipine - 20mg BD

Severe Preeclampsia - Eclampsia

Termination of Pregnancy
Delivery is the cure for preeclampsia.
Indications for termination of pregnancy;
89

No fetal growth

Severe oligohydramnios

Uncontrolled BP despite antihypertensive drug use

Deteriorating maternal condition - Renal, Liver and CNS

ECLAMPSIA
Eclampsia is characterized by generalized tonic-clonic convulsions that develop in some women
with hypertension induced or aggravated by pregnancy. Coma without convulsions has also been
called eclampsia;however, it is better to limit the diagnosis to women with convulsions and to
regard fatal nonconvulsive cases as due to severe preeclampsia.

Types

Antepartum eclampsia - convulsions appear before labor

Intrapartum eclampsia - convulsions appear during labor

Postpartum eclampsia - convulsions appear after labor. Most cases of postpartum

eclampsia develop within 24 hours of delivery, but otherwise typical cases are seen up to
10 days postpartum. Other diagnoses should be considered in women with the onset of
convulsions > 48 hours postpartum.

Eclamptic Convulsions
a) Preeclampsia - Headache, visual disturbance, and epigastric or right upper quadrant pain precedes the onset of eclamptic convulsions
b) The convulsive movements usually begin about the mouth in the form of facial twitchings.
After a few seconds, the entire body becomes rigid in a generalized muscular contraction. The
face is distorted, the eyes protrude, the arms are flexed, the hands are clenched, and the legs are
inverted. All muscles are now in a state of tonic contraction. This phase may persist for 15 to 20
seconds.
c) Suddenly the jaws begin to open and close violently, and soon after, the eyelids as well. The
other facial muscles and then all muscles alternately contract and relax in rapid succession. Foam,
often blood tinged, exudes from the mouth. The face is congested and the conjunctivae are
injected. This phase, in which the muscles alternately contract and relax, may last about a minute.
90

d) Gradually, the muscular movements become smaller and less frequent, and finally the woman
lies motionless. Throughout the seizure the diaphragm has been fixed, with respiration halted. For
a few seconds the woman appears to be dying from respiratory arrest, but just when a fatal
outcome seems almost inevitable, she takes a long, deep, stertorous inhalation, and breathing is
resumed
e) Occasionally, coma or substantively altered consciousness follows a seizure, or may even
accompany preeclampsia without convulsions. At least in some cases, this is due to extensive
cerebral edema. She will not remember the convulsion or, in all probability, events immediately
before and afterward.

Post convulsive complications

Fever of 39C or more is a very grave sign, because it is probably the consequence of a
central nervous system hemorrhage which is more likely in older women with underlying
chronic hypertension or rarely may be due to a ruptured berry aneurysm or arteriovenous
malformation and may lead to sudden death synchronously with a convulsion or follows
shortly thereafter.

Pulmonary edema, which is a grave prognostic sign, may follow eclamptic convulsions.
There are at least two sources:

- Aspiration pneumonitis may follow inhalation of gastric contents if simultaneous vomiting

accompanies convulsions;
- Cardiac failure may be the result of a combination of severe hypertension and vigorous
intravenous fluid administration.

Blindness may follow a seizure, or it may arise spontaneously with preeclampsia. There are at
least two causes:

- varying degrees of retinal detachment

- occipital lobe ischemia or infarction
Whether due to cerebral or retinal pathology, the prognosis for return of normal vision is good
and usually complete within a week

91

Rarely, eclampsia is followed by psychosis, and the woman becomes violent. This usually
lasts for several days to 2 weeks, but the prognosis for return to normal is good, provided
there was no preexisting mental illness.

Other signs and symptoms

Proteinuria

Oliguria/ anuria

Hemoglobinuria

Edema

Recovery
As with severe preeclampsia, after delivery;

An increase in urinary output is usually an early sign of improvement

Proteinuria and edema ordinarily disappear within a week

Blood pressure returns to normal within 2 weeks after delivery. The longer hypertension
persists postpartum, the more likely that it is the consequence of chronic vascular or renal
disease.

Differential Diagnosis
Until other causes are excluded, however, all pregnant women with convulsions should be
considered to have eclampsia.

Epilepsy

Encephalitis

Meningitis

Cerebral malaria

Poisoning

cerebral tumor

ruptured cerebral aneurysm

hysteria

Treatment
92

Control of convulsions with magnesium sulfate, using an intravenously administered

loading dose and periodic intramuscular injections standardized in dose and frequency of
administration as per prescription.

Intermittent intravenous injections of hydralazine to lower blood pressure whenever the

diastolic pressure is 110 mm Hg or higher.

Avoidance of diuretics and hyperosmotic agents.

Limitation of intravenous fluid administration unless fluid loss is excessive.

Delivery

NURSING IMPLICATIONS
-

Nurse in a calm dark room, side lying to increase fetal oxygenation

Self care deficit

Prevent from injury

Monitor vital signs and blood pressure

Monitor urine output and input

Give prescribed medications and monitor for side effects

Monitor fetal condition

Reassure and provide support

Advice importance of on follow- up

Prognosis
A large percentage of women who develop recurrent hypertension during subsequent pregnancies
will develop chronic hypertension. Outcome for children of pre-eclamptic mothers is usually good
if they are not born hypoxic or acidotic.

DIABETES MELITUS IN PREGNANCY

Definition

Diabetes mellitus is a systemic disorder of carbohydrate, protein & fat metabolism. It is

characterised by hyperglycaemia which results in inadequate insulin production or ineffective of
insulin use at the cellular level.
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Insulin regulates Blood/glucose levels by enabling glucose to enter the adipose & muscle
cells where it is used for energy.

Insulin also stimulates protein synthesis & storage of free fatty acids. When insulin is
insufficient or ineffective, glucose accumulates in the blood.

Pathogenesis
During pregnancy the placenta secretes substances that have an anti-insulin action; These are; Human placental lactogen (hpl)
- Progesterone
- Human chorionic gonadotrophin (hcg)
- Cortisol

Classification

a) Diabetes diagnosed before pregnancy - Overt Diabetes

(Classified according to whether the patient requires exogenous insulin to prevent ketoacidosis)

Type 1 (insulin dependent/Juvenile)

Type 1 diabetes is immune mediated and develops in genetically susceptible persons. This
predisposition is permissive rather than causal and disease presumably is triggered by a viral
infection. There is inflammatory insulitis with lymphocytic infiltration of islets. Subsequently,
there is immune stimulation of antibodies against the -cells. The -cell membrane becomes
susceptible to autoimmune cytotoxic antibodies, which leads to eventual destruction of the cells
and resultant diabetes. As a result the disease manifests itself in youth. Most of the pancreatic
insulin producing tissue is destroyed and the patient therefore needs external insulin, hence the
term insulin dependent diabetes. The patients are usually very fragile.

Type 2 (noninsulin dependent/maturity onset above age 40)

Its pathophysiology is abnormal insulin secretion and insulin resistance in target tissues.
There is still viable insulin producing tissues in the pancreas and often treatment is aimed at
persuading such tissues to produce effective and bioavailable insulin. Most patients are overtly
obese, and there is speculation that peripheral insulin resistance induced by obesity leads to -cell
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exhaustion or consumption of excess or refined carbohydrates.Pregnancy has the effect of

lowering the renal glucose threshold thus making pregnancy a risk factor in the unmasking of
latent diabetes.

Diagnosis of Overt Diabetes during Pregnancy

Glycosuria - Reducing substances - lactose - are commonly found in the urine of pregnant
women and glycosuria in pregnancy most often does not reflect impaired glucose
tolerance, but rather augmented glomerular filtration

Ketoacidosis

Random plasma glucose level > 11.1mmol/L plus classical signs and symptoms such as;
- Polydipsia
- Polyphagia
- Polyuria
- Weight loss
- Weakness

Complications
The likelihood of successful outcomes for the fetus-infant and the overtly diabetic mother are
related somewhat to the degree of diabetes control, but more importantly, to the intensity of any
underlying maternal cardiovascular or renal disease.

Effects on the Fetus

Congenital malformations- Increased severe malformations are the consequence of

poorly controlled diabetes both preconceptionally as well as early in regnancy. Women
with lower glycosylated haemoglobin values at conception have less anomalous fetuses
compared with women with abnormally high values. Fetal anomalies correlated with
diabetic vasculopathy with duration of disease > 10 years.

Skeletal and CNS,

- Caudal regression syndrome
- Neural tube defects
- Anencephaly with/without herniation of neural elements
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- Microcephaly

Cardiomegaly

Renal anomalies includes;

- Hydronephrosis, Renal agenesis
- Urethral duplication

Gastrointestinal;
- Duodenal atresia, Anorectal atresia, Small left colon syndrome

Other; Single umbilical artery

"Unexplained" Fetal Demise - Stillbirths without identifiable cause are a phenomenon

unique to pregnancies complicated by overt diabetes. They are declared "unexplained"
because no factors such as obvious placental insufficiency, abruption, fetal growth
restriction, or oligohydramnios are apparent.

These infants are typically large for age and likely to die before labor, usually at about 35 weeks
or later in severe cases

Spontaneous abortion is associated with poor glycemic control during the first trimester;
type 1 diabetic women with initial glycohemoglobin A1 concentrations > 12% or
persistent pre-prandial glucose concentrations > 6.7mmol/L are at increased risk for
abortion

Macrosomia - The incidence of macrosomia rises significantly when mean maternal

blood glucose concentrations exceed 6.7mmol/L and appears to accrue primarily during
the third trimester, although some macrosomic fetuses can be recognized before 24
weeks

Diabetic pregnancies are often complicated by hydramnios

Hyperglycemia-mediated chronic aberrations in transport of oxygen and fetal metabolites

leads to decreased fetal pH, and increased pCO2, lactate, and erythropoietin in
diabetic pregnancies.

Neonatal complications

Preterm births are associated with advanced diabetes and superimposed preeclampsia
associated with nephropathy

Respiratory distress mostly due to gestational age, rather than overt diabetes
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Hypoglycemia - A rapid decrease in plasma glucose concentration after delivery

attributed to hyperplasia of the fetal -islet cell induced by chronic maternal

Hypocalcaemia - < 7 mg/dL - May be due to magnesium-calcium economy unique to

diabetic pregnancy, asphyxia, prematurity, and preeclampsia

Hyperbilirubinemia - Factors implicated - prematurity and polycythemia (also implicated

in Renal vein thrombosis) with hemolysis

Hypertrophic cardiomyopathy that occasionally progresses to congestive heart failure These infants are typically macrosomic and fetal hyperinsulinemia has been implicated in
the pathogenesis.

Effects on the Mother

Mortality is increased 10-fold, most often as a result of;
- Ketoacidosis
- Underlying hypertension
- Preeclampsia
- Pyelonephritis
- Coronary artery disease (class H)
Diabetic Nephropathy which is the leading cause of end-stage renal disease
Preeclampsia - Women in the more advanced classes of overt diabetes increasingly
developed preeclampsia and indicated preterm delivery especially women with diabetic
nephropathy
Hypertension induced or exacerbated by pregnancy is the major complication that most
often forces preterm delivery in diabetic women. Especial risk factors for preeclampsia
include any vascular complications, pre-existing

proteinuria and/or chronic

hypertension but is not related to glucose control. Plasma creatinine values of 1.5
mg/dL and protein excretion of 3 g /24 hours before 20 weeks' gestation are predictive
for preeclampsia
Diabetic Retinopathy
- Background or nonproliferative retinopathy - small microaneurysms form followed
by blot hemorrhages when erythrocytes escape from the aneurysms. These areas leak serous fluid
that forms hard exudates.
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- Preproliferative retinopathy - With increasingly severe retinopathy, the abnormal

vessels of "background" eye disease become occluded, leading to retinal ischemia with infarctions
that appear as cotton wool exudates.

Diabetic Neuropathy - Although uncommon, some pregnant women will demonstrate

peripheral symmetrical sensorimotor neuropathy due to diabetes. Another form,
diabetic gastropathy, is very troublesome in pregnancy because it causes nausea and
vomiting, nutritional problems, and difficulty with glucose control.

Diabetic ketoacidosis may occur as a result of;

- Hyperemesis gravidarum
- Use of -sympathomimetic drugs for tocolysis
- Infections
- Use of corticosteroids to induce fetal lung maturation

Infections - Sites of these infections include the genital tract (e.g., antepartum candida
vaginitis or pelvic puerperal infection) and the respiratory tract.

Management
Preconception

Particular emphasis should be placed on normalizing blood glucose levels before

conception and during early pregnancy to reduce the risks of major birth defects. The
most significant risk for malformations is with levels >10%

Folate, 400 g/day, given periconceptually and during early pregnancy, decreases the risk
of neural-tube defects

First Trimester
Maternal glycemic control can usually be achieved with multiple daily insulin injections and
adjustment of dietary intake. Oral hypoglycemic agents are not used because they may cause
fetal hyperinsulinemia and congenital malformations. The goals of self-monitored capillary
blood glucose control recommended during pregnancy must be maintained. Diabetes tends to be
unstable in the first trimester, followed by a stable period, and then by an increase in insulin
requirement from about 24 weeks (3rd trimester) due to the increased production of
pregnancy hormones, which are insulin-antagonists
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Second Trimester
Maternal serum alpha-fetoprotein concentration at 16 to 20 weeks is used in association with
targeted ultrasound at 18 to 20 weeks in an attempt to detect neural-tube defects and other
anomalies

Third Trimester
A weekly visit to monitor glucose control and to evaluate for preeclampsia is a typical
recommendation. Serial ultrasonography at 3 to 4 week intervals is performed to evaluate both
excessive and insufficient fetal growth as well as amnionic fluid volume.

Delivery
Ideally, delivery of the diabetic woman should be accomplished near term - after 37 completed
weeks. Typically the lecithin-sphingomyelin ratio is measured at about 37 weeks and, if 2.0,
delivery is effected. Indications for cesarean section to avoid traumatic delivery of a large infant
at or near term;

If severe hypertension develops even though the lecithin-sphingomyelin ratio is < 2.0.

In the overtly diabetic woman with vascular disease.

If preterm labor occurs, tocolytic therapy with -sympathomimetic drugs is best avoided in
women with diabetes. These medications may significantly worsen maternal glucose control,
causing ketoacidosis. Caution is advised in the use of corticosteroids to promote lung maturation.
It is important to considerably reduce or delete the dose of long-acting insulin given on the day
of delivery. Regular insulin should be used to meet most or all of the insulin needs of the mother
at this time, because insulin requirements typically drop markedly after delivery. During and after
either cesarean section or labor and delivery, the mother should be hydrated adequately
intravenously as well as given glucose in sufficient amounts to maintain normoglycemia.
Infection must be detected quickly and treated promptly.

Contraception

Diabetes carries a risk of vascular disease, and the estrogens in oral contraceptives
statistically increase the risk of thromboembolus, stroke, and myocardial infarction.
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Use of low-dose oral contraceptives should probably be restricted to women without

vasculopathy or additional risk factors such as a strong history of ischemic heart disease.

Progestin-only oral or parenteral contraceptives may be used because of minimal effects

on carbohydrate metabolism.

Intrauterine devices in diabetic women are associated a possible increased risk of pelvic
infections

b) Diabetes diagnosed during pregnancy - Gestational Diabetes

Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy
regardless of whether or not insulin is used for treatment. Gestational diabetes is maturityonset/type 2 diabetes unmasked or discovered during pregnancy. Importantly, more than half
of women with gestational diabetes ultimately develop overt diabetes in the ensuing 20 years.

Carbohydrate Metabolism in pregnancy

Normal pregnancy is diabetogenic as characterized by;

mild fasting hypoglycemia due to

hyperinsulinemia secondary to -cell hypertrophy, hyperplasia, and hypersecretion

probably mediated by; estrogen, progesterone, and human placental lactogen

postprandial hyperglycemia

After an oral glucose meal, to ensure a sustained or maintained postprandial supply of glucose to
the fetus, there is;

prolonged hyperglycemia

-cell sensitivity to a glucose challenge is increased but that the -cell sensitivity to a
glucose stimulus is unaltered leading to;

- Hyperinsulinemia
- Suppression of glucagon

Pregnancy-induces a state of peripheral resistance to insulin, which is suggested by;

increased insulin response to glucose (increased plasma level and duration)

reduced peripheral uptake of glucose (increased plasma level and duration)

suppressed glucagon response

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Accelerated starvation - pregnancy-induced switch in fuels from glucose to lipids; The pregnant
woman, changes rapidly from a postprandial state characterized by elevated and sustained glucose
levels to a fasting state characterized by decreased plasma glucose and amino acids such as
alanine and higher plasma concentrations of free fatty acids, triglycerides, and cholesterol.

Predisposing factors of Gestational Diabetes

familial history of diabetes (1st degree relative)

demonstrate persistent glycosuria on at least 2 tests

age > 30yrs

a prior macrosomic (> 4.5 Kg), malformed (renal tube defects), or stillborn infant

obesity - > 85Kg/BMI 30

hypertension

Detection of Gestational Diabetes

Gestational diabetes is typically a disorder of late gestation, hyperglycemia during the first
trimester usually means overt diabetes.

Screening
All pregnant women should be screened using a Mini-GTT - 50-g oral glucose tolerance test
between 24 and 28 weeks without regard to time of day or last meal, and that a plasma value at 1
hour > 7.8mmol/L be used as the cutoff for performing the diagnostic 100-g 3-hour oral glucose
tolerance test performed after an overnight fast.

Adverse fetal consequences of gestational diabetes

Macrosomia - Insulin secreted by fetal pancreatic -cells (fetal hyperinsulinemia)

primarily during the second half of gestation resulting from maternal hyperglycemia, is
believed to stimulate excessive somatic growth (except for the brain) and adiposity. This
may result in birth trauma due to shoulder dystocia. Similarly, hyperinsulinemia in the
infant may provoke hypoglycemia within minutes of birth.

Diabetes, has been associated with unexplained stillbirth

Long-range complications includes;- obesity and development of diabetes in the offspring

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Management
The goals of therapy are;
-

To provide the necessary nutrients for the mother and fetus

To control glucose levels

To prevent starvation ketosis

Women without persistent fasting hyperglycemia (class A1), are usually treated by diet
alone. They are typically seen at 1- to 2-week intervals, and fasting and/or postprandial
plasma glucose levels are measured to ensure that the glucose thresholds for insulin
therapy have not been exceeded.

Insulin therapy is usually recommended when standard dietary management does not
consistently maintain the fasting plasma glucose at < 5.8mmol/L or the 2-hour
postprandial plasma glucose at < 6.7mmol/L -

A total dose of 20 to 30 units given once daily, before breakfast, is commonly used to initiate
therapy. The total dose is usually divided into 2/3 intermediate-acting insulin (NPH or Lente)
and 1/3 short-acting insulin (regular).

A liberal exercise program

A woman diagnosed to have gestational diabetes should undergo a 2-hour 75-g oral
glucose tolerance at the first postpartum check up at 6 to 8 weeks after delivery, or
shortly after she stops breast feeding. This recommendation is based on the 50%
likelihood of women with gestational diabetes developing overt diabetes within 20 years
of delivery. If fasting hyperglycemia develops during pregnancy - Class A2 - diabetes is
more likely to persist postpartum.

Nursing implications
Health education on self care and Nutrition prevention of infection and follow up

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CARDIAC DISEASE IN PREGNANCY

INTRODUCTION
Heart disease complicates about 1% of all pregnancies - of which majority are due to; Rheumatic
heart disease and mitral stenosis. Mortality rate is high in clients with heart conditions.
Knowledge about clinical presentation, pathophysiology and management of heart conditions is
essential for the midwife in order to achieve a good outcome both for the mother and the baby.

Physiological Considerations
Significant hemodynamic alterations are apparent early in pregnancy and maximized by midpregnancy.
Cardiac output is increased by as much as 30-50% due to augmented stroke volume that
apparently results from decreased vascular resistance and is accompanied by diminished blood
pressure.
Later in pregnancy, there is also an increased resting pulse (10-15 beats), and stroke volume is
even more increased, presumably related to increased diastolic filling from the augmented blood
volume. Maintenance of normal left-ventricular filling pressures comes about as the result of
ventricular dilatation.

Diagnosis of Heart Disease

Symptoms

Severe or progressive dyspnea secondary to reduced perfusion to the brain and pulmonary
edema

Progressive orthopnea

Paroxysmal nocturnal dyspnea

Tachypnea

Hemoptysis secondary to pulmonary edema

Syncope with exertion

Chest pain related to effort or emotion due to reduced perfusion of the myocardium

Epigastric pain due to tender hepatomegaly stretching its capsule

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Nausea, anorexia and vomiting secondary to backflow of mesenteric circulation leading to

edema in the mesentery; can also be a side effect of furosemide and digoxin.

Clinical findings
o Persistent neck vein distension
o Systolic murmur > grade 3/6
o Diastolic murmur
o Cardiomegaly
o Sustained arrhythmias due to increased strain on the myocardium - tachycardia that is
compensatory or an irregular pulse.
o Persistent split second sound
o Displaced apex beat laterally and inferiorly
o Criteria for pulmonary hypertension - increased JVP, reduced air entry at the lung bases
when the patient is ambulatory and at the base posteriorly when the patient is in bed; basal
crepitations
o Pitting pedal edema
o Smooth tender hepatomegaly - fluid in the interstitium enlarges the capsule which is
smooth with pain (CCF)
o CCF - The first warning sign is likely to be persistent basilar rales, frequently
accompanied by a cough.
o Sudden diminutions in ability to carry out usual duties, increasing dyspnea on
exertion, or attacks of smothering with cough are symptoms of serious heart failure.
Clinical findings may include hemoptysis, progressive edema, and tachycardia.

New York Heart Association Clinical Classification

Class I - Uncompromised: Patients with cardiac disease and no limitation of physical

activity. They do not have symptoms of cardiac insufficiency, nor do they experience
anginal pain.

Class II - Slightly compromised: Patients with cardiac disease and slight limitation of
physical activity.

These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort
results in the form of excessive fatigue, palpitation, dyspnea, or anginal pain.
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Class III - Markedly compromised: Patients with cardiac disease and marked limitation
of physical activity.

They are comfortable at rest, but less than ordinary activity causes discomfort by excessive
fatigue, palpitation, dyspnea, or anginal pain.

Class IV - Severely compromised: Patients with cardiac disease and inability to perform
any physical activity without discomfort.
Symptoms of cardiac insufficiency or angina may develop even at rest, and if any physical
activity is undertaken, discomfort is increased. Past or present CCF classifies her as Grade
IV unless cardiac correction has been done

Management
Concepts that affect management;
-

The is 50% increase in blood volume and cardiac output by the early third trimester
with further fluctuations in volume and cardiac output in the peripartum period.

There is a decline in systemic vascular resistance, reaching a nadir in the second

trimester, and then rising to peak at 20 percent below normal by late pregnancy.

Hypercoagulability, is of special importance in women requiring anticoagulation in the

nonpregnant state.

Antenatal Management

Grade I and II can be managed as out patients.

Grade III and IV should be admitted on first visit.

Adequate bed rest - minimum of 10hrs at night and 2hrs at daytime

Prop up in bed

Allay anxiety - use anxiolytics prepartum and narcotic analgesics during labor

Hematinics - Iron salts and folic acid - to increase hemoglobin to reduce strain on the heart

Manage pregnancy induced hypertension within normal BP ranges

Screen for and treat infections promptly - avoid contact with persons who have respiratory
infections, including the common cold as infection leads to tachycardia

Cigarette smoking is prohibited, both because of its cardiac effects as well as the
propensity to cause upper respiratory infections.
105

Regular/weekly urinalysis to r/o asymptomatic bacteriuria

Minor heart surgery can be done e.g. closed valvotomy but major heart surgery is
contraindicated because of increased risk to the mother

Post datism is not allowed

Grade III and IV should get frusemide 40mg OD and digoxin 0.25mg OD

Women with a mechanical prosthetic valve generally take;

- Conception - 13wks - heparin 5000IU QID SC
- 13-36wks - warfarin 2.5-5mg OD PO
- 36wks-delivery - Heparin
- 2wks postpartum - Warfarin

Warfarin Heparin crosses the placenta, has Teratogenic effects - especially on bone, cartilage
and connective tissue leading to congenital malformations thus - should be administered after 1st
trimester (13wks)
-

Administered PO

Warfarin has a long half life- given from 13-36wks,

Not used during labor as it also can have an anti-coagulant effect to the fetus causing
intracranial hemorrhage and in the event of PPH, its antidote takes long to act i.e.

Antidote - Vitamin K - takes long to act; Fresh frozen plasma can be used

Heparin
Doesnt cross the placenta
Non-teratogenic thus administered during the 1st trimester (13wks)
Administered SC which is painful
Administered in the first 13wks and after 36wks when in labor
Antidote - Protamine sulphate IV is quick acting

Management of labor
All cardiac patients must deliver in the hospital setup

1st stage
106

The patient is propped up in bed throughout labor to prevent pulmonary edema

Oxygen is administered by mask PRN

Allay anxiety with narcotic analgesics - Morphine 15mg IM or Pethidine 100mg IM

No IV fluids should be given

Limit the number of pelvic examinations to minimize risk of infection

Delay the rupture of membranes to minimize risk of infection

Use broad spectrum IV antibiotics to cover for infection - Augmentin

Labor is augmented/induced with oxytocin pump and IV frusemide is given to reduce

fluid overload

Prepare a resuscitation tray containing;

- Adrenaline (MI)
-

Aminophylline (pulmonary edema)

Hydrocortisone (MI)

Sodium Bicarbonate (Acidosis)

Calcium gluconate (Acidosis)

Oxytocin

Morphine/Pethidine (anxiety/analgesia)

Naloxone (antinarcotic)

Digoxin (CCF, MI)

Frusemide (CCF)

2nd Stage
-

Patient remains propped up

The patient should not bear down

Vacuum extraction is done easily as the babies are usually small

Cesarean section is avoided due to increased risk to the mother except for obstetric
reasons which are however rare in cardiac patients

3rd Stage
-

Patient remains propped up

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Frusemide 40mg IV stat irrespective of whether it had been administered before as during
uterine contraction after delivery, 1L of blood goes back into circulation and may lead to
fluid overload.

DO NOT give ergometrin as this causes severe uterine contraction which hastens the
return of blood into the circulation which may lead to a sudden fluid overload; instead
massage the uterine to facilitate its gradual contraction

If massage is insufficient, give IV Oxytocin 40U in 500mL fluid to run slowly

(20drops/min)

4th Stage
-

Patient is at risk of postpartum hemorrhage, anemia, infection, and thromboembolism

Keep the patient in the acute room for 24hrs then the postnatal ward till the 10th day

Post delivery
Monitor vital signs, lung fields, uterus, and lochia and for signs of DVT in the calf muscles and
the femoral
-

Restart anticoagulants after 48hrs (if patient was on them)

Continue antibiotics for 1wk

Continue hematinics for up to 6 weeks

Prognosis
The likelihood of a favorable outcome for the mother with heart disease depends upon the;
-

Functional cardiac capacity

Other complications that further increase cardiac load

Quality of medical care provided

Due to a high MMR, the mother should limit the family to 1-2 children by use of contraception;
-

BTL/Vasectomy

Progesterone only drugs (Estrogen increases blood volume)

Barrier methods - high failure rate

Natural method - high failure rate

Avoid IUCD due to increased risk of sepsis endometritis

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PUERPERIUM

Objectives

Define puerperium

Describe the changes that occur in the body systems during pueperium.

Describe the physiological aspects of puerperium

Discuss the management of a during puerperium

Identify the minor and complications of puerperium

Definition
Peuperium is defined as a period of confinement during and 6 subsequent weeks (42 days) just
after birth during which normal pregnancy involution occurs and the reproductive tract returns
anatomically to a normal non-pregnant state. It is characterized by;

General organs return to their pre-gravida state;

Initiation of lactation;

Recuperation.

The period of puerperium is a stressful and emotional moment to mother. It is a time of great
physiological change, accompanied by some anatomical and psychological changes as well. This
is a time of change in the body in general with the exception of the breasts. The breasts continue
to develop so as to establish and maintain lactation. Each mother should be taken as an individual
based on her maternal experience, educational background, maturity and parity. The midwife
should be observant, kind, patient, and compassionate towards the mother and give her the
necessary support and education /information concerning herself and the baby. She should be
allowed to cuddle her baby and express her love as she wishes. This maternal instinct is at times
delayed.

Rooming is the term given when a hospital plans for the mother to stay with the baby for most of
the 24 hours in a day.

It is highly recommended because it has been seen to have great

psychological advantages for both mother and baby. Bonding commences immediately and

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demand breast-feeding can be successfully practised. Most baby-friendly hospitals in this country
encourage rooming in.

General Involution

Corpus
Immediately after placental expulsion, the fundus of the contracted uterus is slightly below the
umbilicus. The uterine body then consists mostly of myometrium covered by serosa and lined by
basal decidua (because separation of the placenta and membranes involves the spongy layer) that
has striking variations in thickness, an irregular jagged appearance, and is infiltrated with blood,
especially at the placental site. The anterior and posterior walls, in close apposition, each measure
4 to 5 cm in thickness. Because its vessels are compressed by the contracted myometrium, the
puerperal uterus on section appears ischemic when compared with the reddishpurple hyperemic
pregnant organ.

After the first 2 days, the uterus begins to shrink. Within 2 weeks it has descended into the
cavity of the true pelvis. It regains its previous non-pregnant size within about 4 weeks.
Uterine weight;

Immediately postpartum - 1000 g

1 week later - 500 g

Second week - 300 g

Soon thereafter - 100 g

The total number of muscle cells does not decrease appreciably; instead, the individual cells
decrease markedly in size. The involution of the connective tissue framework occurs equally
rapidly.

Endometrial Regeneration
Within 2 or 3 days after delivery, the remaining decidua becomes differentiated into two layers;
- The superficial layer becomes necrotic, and it is sloughed in the lochia
- The basal layer adjacent to the myometrium remains intact and is the source of new
endometrium which arises from proliferation of the endometrial glandular remnants and the
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stroma of the interglandular connective tissue. Endometrial regeneration is rapid, except at the
placental site which within a week or so, becomes covered by epithelium, and the entire
endometrium is restored during the third week.

Placental Site Involution

Complete extrusion of the placental site takes up to 6 weeks. When this process is defective, late
puerperal hemorrhage may ensue. Immediately after delivery, the placental site is about the size
of the palm of the hand, but it rapidly decreases thereafter. By the end of the second week, it is 3
to 4 cm in diameter. Within hours of delivery, the placental site normally consists of many
thrombosed vessels that ultimately undergo the typical organization of a thrombus.

Involution is not effected by absorption in situ, but rather by a process of exfoliation which is in
great part brought about by the undermining of the implantation site by growth of endometrial
tissue. This is affected partly by extension and downgrowth of endometrium from the margins
of the placental site and partly by the development of endometrial tissue from the glands and
stroma left in the depths of the decidua basalis after placental separation.

Changes in the Uterine Vessels

Successful pregnancy requires a great increase in uterine blood flow; arteries and veins within the
uterus, and especially to the placental site, enlarge remarkably, as do transport vessels to and
from the uterus. Within the uterus, growth of new vessels also provides for the marked increase in
blood flow. After delivery, the caliber of extrauterine vessels decreases. Within the puerperal
uterus, blood vessels are obliterated by hyaline changes, and vessels that are smaller replace them.

Changes in the Cervix and Lower Uterine Segment

The outer cervical margin, which corresponds to the external os, is usually lacerated, especially
laterally. The cervical opening contracts slowly, and for a few days immediately after labor it
readily admits two fingers. By the end of the first week, it has narrowed. As the opening narrows,
the cervix thickens, and a canal reforms. At the completion of involution, however, the external os
does not resume its pregravid appearance completely. It remains somewhat wider, and typically,
bilateral depressions at the site of lacerations (fishmouth appearance) remain as permanent
changes that characterize the parous cervix (parous os).
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The markedly thinned-out lower uterine segment contracts and retracts but not as forcefully as the
body of the uterus. Over the course of a few weeks, the lower segment is converted from a clearly
evident structure. The markedly thinned-out lower uterine segment contracts and retracts but not
as forcefully as the body of the uterus. Over the course of a few weeks, the lower segment is
converted from a clearly evident structure,

Vagina and Vaginal Outlet

Early in the puerperium, the vagina and vaginal outlet form a capacious, smooth-walled passage
that gradually diminishes in size but rarely returns to nulliparous dimensions. Rugae reappear by
the third week. The hymen is represented by several small tags of tissue, which during
cicatrisation (The process of scar formation) are converted into the myrtiform caruncles.

Peritoneum and Abdominal Wall

The broad and round ligaments are much more lax when nonpregnant, and they require
considerable time to recover from the stretching and loosening that occurred during pregnancy.
As a result of the rupture of elastic fibers in the skin and the prolonged distention caused by
the pregnant uterus, the abdominal walls remain soft and flabby. Except for silvery striae, the
abdominal wall usually resumes its prepregnancy appearance; but when muscles remain atonic,
the abdominal wall also remains lax. There may be a marked separation, or diastasis, of the rectus
muscles. In this condition, the abdominal wall in the vicinity of the midline is formed only by
peritoneum, attenuated fascia, subcutaneous fat, and skin.

Urinary Tract Changes

The puerperal bladder has an increased capacity and a relative insensitivity to intra-vesical
fluid pressure. Overdistention, incomplete emptying, and excessive residual urine are common
due to the paralyzing effect of anesthesia, especially conduction analgesia, and the temporarily
disturbed bladder neural function. Residual urine and bacteriuria in a traumatized bladder,
coupled with the dilated renal pelves and ureters, create optimal conditions for development of
urinary infection. Dilated ureters and renal pelves return to their pre-pregnant state from 2 to 8
weeks after delivery.Avoiding prolonged labors and catheterization promptly for bladder
distention, prevents bladder hypotonia. Stress incontinence after delivery is associated with;
-

the length of second-stage labor

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infant head circumference

birthweight

episiotomy

Impaired muscle function in or around the urethra during vaginal delivery

Normal micturition resumes by 3 months postpartum

Changes in Mammary Glands

Colostrum is the deep lemon-yellow colored liquid secreted by the breasts by the second
postpartum day persisting for about 5 days, with gradual conversion to mature milk during the
ensuing 4 weeks. Compared with mature milk, colostrum contains more minerals and protein,
much of which is globulin, but less sugar and fat. Immunoglobulin A protects the newborn
against enteric pathogens and also other host resistance factors such as complement,
macrophages, lymphocytes, lactoferrin, lactoperoxidase and lysozymes.

Onset of Lactation
Lowered oestrogen levels trigger the production of prolactin from the anterior pituitary gland,
which initiates lactation. The maintenance of lactation depends on putting the baby on the breast,
but secretion of milk commences on the third to fourth day. The baby should be put on the breast
immediately, which leads to oxytocin release and assists in keeping the uterus well-contracted.
(You should revise the anatomy and physiology of the breast in done earlier).

Clinical and Physiological Aspects of the Puerperium

Temperature
- Vascular and lymphatic engorgement of the breasts with milk, which is common on the third
or fourth day, causes milk fever but it does not last > 24 hours.
Any fever in the puerperium implies an infection - most likely somewhere in the genitourinary
tract until proven otherwise.

Afterpains
- In primiparas the puerperal uterus tends to remain tonically contracted. Particularly in
multiparas, the uterus often contracts vigorously at intervals, giving rise to afterpains. Afterpains
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are noticeable particularly when the infant suckles, likely because of oxytocin release. Usually,
they decrease in intensity and become mild by the third postpartum day.

Lochia
-

Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of

mucus, blood, and tissue debris of variable quantity; this is termed lochia.
Microscopically, it consists of erythrocytes, shreds of decidua, epithelial cells, and
bacteria.

Lochia rubra/cruenta/sanguinolenta - For the first few days after delivery, blood in the
lochia is sufficient to produce thick, dark red vaginal discharge

Lochia serosa - After 3 or 4 days, lochia becomes progressively pale in color, thin and
watery

Lochia alba/purulenta - After about the 10th day, because of an admixture of leukocytes
and reduced fluid content, lochia assumes a white or yellowish-white color. This is the last
discharge no longer tinged with blood.

Urine - Normal pregnancy is associated with an appreciable increase in extracellular water, and
puerperal diuresis between the second and fifth days is a physiological reversal of this process.

Blood- Rather marked leukocytosis and thrombocytosis occur during and after labor. There is
also a relative lymphopenia and an absolute eosinopenia. By 1st week after delivery, the blood
volume has returned nearly to its non-pregnant level.

Cardiac output remains elevated for at least 48 hours postpartum. Most likely this is due to
increased stroke volume from venous return, because the heart rate falls at the same time. By 2
weeks, these changes have returned to normal non-pregnant values. Pregnancy-induced changes
in blood coagulation factors persist for variable periods during the puerperium. Elevation of
plasma fibrinogen and hence the sedimentation rate are maintained at least through the first
week.

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Weight Loss - In addition to the loss of about 5 to 6 kg due to uterine evacuation and normal
blood loss, there is usually a further decrease of 2 to 3 kg through diuresis - Factors that
increased puerperal weight loss included;
-

Weight gain during pregnancy

Primiparity

Early return to work outside the home

Smoking.

Most women approach their self-reported prepregnancy weight 6 months after delivery but still
retain an average surplus of 1.4 kg (3 lbs)

Care of the Mother during the Puerperium

The aim of managing the puerperium is to:

Maintain the mothers good health;

Aid involution of the pelvic area;

Promote breast-feeding;

Prevent infection and other puerperium complications;

Educate the mother on the proper care of her own health and the baby.

Attention Immediately After Labor

For the first hour after delivery;

blood pressure and pulse should be taken every 15 minutes

amount of vaginal bleeding is monitored

the fundus should be palpated to ensure that it is well contracted

If relaxation is detected, the uterus should be massaged through the abdominal wall until it
remains contracted.

Because the likelihood of significant hemorrhage is greatest immediately postpartum, even in

normal cases, a trained attendant should remain with the mother for at least 1 hour after
completion of the third stage of labor.

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Early Ambulation
Early ambulation has also reduced the frequency of;

Bladder complications

Constipation

Puerperal venous thrombosis

Pulmonary embolism

Care of the Vulva

The patient should be instructed to cleanse the vulva from anterior to posterior (vulva toward
anus). An ice-bag applied to the perineum may help reduce edema and discomfort during the first
several hours after episiotomy repair. Beginning about 24 hours after delivery, moist heat as
provided with warm sitz baths can be used to reduce local discomfort.

Bladder Function
As a consequence of infused fluid and the sudden withdrawal of the antidiuretic effect of
oxytocin, rapid bladder filling is common. Moreover, both bladder sensation and its capability to
empty spontaneously may be diminished by anesthesia, especially conduction analgesia, as well
as by painful genital lesions, such as extensive episiotomy, lacerations, or hematomas. Prevention
of over distention demands observation after delivery to ensure that the bladder does not overfill
and that with each voiding it empties adequately. If the woman has not voided within 4 hours
after delivery, it is likely that she cannot. Whenever the bladder becomes over distended, an
indwelling catheter should be left in place until the factors causing the retention have abated. A
short course of antimicrobial therapy after catheter removal is indicated to prevent UTIs.

Bowel Function
Lack of a bowel movement is no more than the expected consequence of an efficient cleansing
enema administered before delivery. With both early ambulation and early feeding, constipation
has become much less of a problem.

Subsequent Discomfort
During the first few days after vaginal delivery, the mother may be uncomfortable due to;
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Afterpains

Episiotomy

Lacerations

Breast engorgement

Post spinal puncture headache

Post C/S Management

The amount of bleeding from the vagina must be monitored closely

The uterine fundus must be identified frequently by palpation to assure that the uterus is
remaining firmly contracted

Give an effective analgesic intramuscularly or intravenously

An anti-emetic is usually given

The patient is now evaluated at least hourly for 4 hours at the minimum/until
conscious, and blood pressure, pulse, urine flow, amount of bleeding, and status of the
uterine fundus are checked at these times. Thereafter, for the first 24 hours, these are
checked at intervals of 4 hours, along with the temperature.

Fluid Therapy and Diet

- 3 L of fluid should prove adequate during the first 24 hours after surgery. If urine output falls
below 30 mL/hr, however, then the woman should be reevaluated promptly. The cause of the
oliguria may range from unrecognized blood loss to an antidiuretic effect from infused
oxytocin.

Bladder and Bowel Function

The bladder catheter most often can be removed by 12 hours after operation. In uncomplicated
cases, solid food may be offered within 8 hours of surgery. In most instances, by at least the day
after surgery the woman, with assistance, should get out of bed briefly at least twice.
Ambulation can be timed so that a recently administered analgesic will minimize the discomfort.

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Wound Care - The incision is inspected each day, and the skin sutures (or clips) are removed on
the fourth day after surgery. By the third postpartum day, bathing by shower is not harmful to
the incision.

Laboratory - The hematocrit is routinely measured the day after surgery. It is checked sooner
when there was unusual blood loss or when there is oliguria or other evidence to suggest
hypovolemia.

Breast Care - Breast feeding can be initiated by the day after surgery

Discharge from the Hospital

Unless there are complications during the puerperium, the mother is generally discharged from
the hospital on the third postpartum day. An initial postpartum evaluation should be performed
on the third week after delivery and then 6 weeks. Antibiotic prophylaxis

Mild Depression
Postpartum Tears or Fourth Day Blues
This is the transient depression or postpartum blues which is characterized by mild depression
and mood swings due to a temporary endocrine hormonal imbalance following childbirth. It
occurs in fifty percent of post-natal mothers on around the fourth day and usually remits after 2 to
3 days, although it sometimes persists for up to 10 days. It is thought to be most likely
exacerbated by the consequence of the emotional letdown that follows the excitement and fears
that most women experience during pregnancy and delivery and the discomforts of the early
puerperium, fatigue from loss of sleep during labor and postpartum in most hospital settings.
There is also anxiety over her capabilities for caring for her infant after leaving the hospital,
including fears that she has become less attractive.

Management
Postpartum blues should be prevented by; Anticipation, recognition, and reassurance and support.
Educate the mother during, pre-natal period on how to take care of herself and the baby to build
up her confidence. Involve the partner in these teachings so that the partner can give moral
support.
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Teach the mother how to check for minor discomfort and the relevant remedies to reduce the
feeling of anxiety that the baby is ill whenever she/he cries.

Abdominal Wall Relaxation

Exercises to restore abdominal wall tone may be started any time after vaginal delivery and as
soon as abdominal soreness diminishes after caesarean delivery.

Diet
The diet of lactating women, compared with that consumed during pregnancy, should be
increased in calories and protein.

Immunizations
The D-negative woman who is not iso-immunized and whose baby is D-positive is given 300 g
of anti-D immune globulin shortly after delivery. Women who are not already immunized may
vaccination before discharge. Unless it is contraindicated, a diphtheria-tetanus toxoid booster
injection may be administered at this time.

Time of Discharge
Following vaginal delivery, if there are no complications, hospitalization is warranted for 48
hours. Following an uncomplicated postoperative cesarean delivery, women usually are ready
for discharge on the third or fourth day. Before discharge, the woman should receive
instructions concerning the anticipated normal physiological changes of the puerperium, including
lochia patterns, weight loss due to diuresis, and when to expect milk let down. She also should
receive instructions concerning what to do if she becomes febrile, has excessive vaginal bleeding,
or develops leg pain, swelling, or tenderness. Any shortness of breath or chest pains should be
assessed immediate.

Contraception - immediately post partum if needed

Coitus - There is no definite time after delivery when coitus should be resumed, however,
hemorrhage and infection are less likely 14 to 21 days postpartum. Resumption of intercourse
early may prove to be unpleasant, if not frankly painful, due to incomplete uterine involution
and incomplete healing of the episiotomy and lacerations.
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Return of Menstruation and Ovulation - If the woman does not nurse her child, menses usually
return within 6 to 8 weeks. In lactating women, the first period may occur as early as the second
or as late as the 18th month after delivery. Ovulation is identified as early as early as 42 days
after delivery

Activity
Define Peuperium.
Describe the changes that take place in a woman immediately after delivery and during
puerperium?

Daily Observation of the Baby

You should observe the baby daily for the following:

The colour should be pinkish in a fair baby and brownish chocolate in a dark skinned
baby;

Breathing, with respiration at a rate of about 40 per min;

Eyes should be checked for any discharge, or yellow discolouration or any subconjunctival bleeding. The eyes should not be touched except to wash them if there is any
discharge;

Motion of bowels should be checked for meconium or greenish stools, which are normally
passed within 24 hours of birth. The stool changes to greenish yellow on the second day
to yellowish and soft on the third day. The bowels should be opened one to four times a
day;

Cord should be dried and cleaned daily with hibitane. If the cord is wet or septic, you
should report it to the doctor. You will learn about the management of ompholitis in
greater detail when we deal with infections of the newborn;

Skin should be observed for rashes and if these are present, they should be reported to the
doctor;

Feeds should be monitored. The baby is fixed on the breast as soon as he is hungry
provided his breathing and colour are satisfactory and there is no excessive mucus. Soon
after delivery, most babies are ready for breastfeeding. Self-regulated or demand feeds are
more satisfying to the baby. Eventually the baby regulates his feeding pattern.

Major complications of the puerperium include:

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Venous thrombosis;

Pulmonary embolism;

Retention of urine or retention with overflow;

Urinary tract infection;

Puerperal sepsis and pyrexia;

Engorgement of the breasts;

Cracked nipples or mastitis;

Puerperal psychosis.

Activity
Discuss the management of each of the above stated complications of puerperium following

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NORMAL PUERPERIUM
Psychology of the Mother during Puerperium

General Involution
Every system in the body is affected during this process, including the heart and circulatory
system.

With the cessation of the utero-placental circulation, the work done by the heart

decreases. The quantity of blood required also gradually returns to normal. The renal and
musculo-skeletal systems also return to normal.
Involution of the Uterus

The size of the pregnant uterus is 30 x 22 x 20 cm and it weighs 100gms at the end of labour. It is
15 x 11 x 7.5 cm by the end of puerperium. Involution takes place, by which point it measures
7.5 x 5 x 2.5 cm and weighs 60gms. Involution is the return of the uterus to its normal size,
position and tone and is brought about by autolysis and ischaemia.

Autolysis is a process by which muscle fibres are digested by the proteolytic enzyme. Lysome
cells are responsible for autolysis. The muscle fibres have to dissolve a large amount of their
protein in order to achieve this reduction in size. This means that a great deal of nitrogen is
excreted by the body in the urine together with the excess fluid retained during pregnancy. This
is why a lot of urine containing large amounts of nitrogen is excreted during the first few days
after delivery. In addition, the epithelial lining of the uterus, other cellular debris, and red blood
cells are expelled as lochia from the uterus.

Ischaemia is localised anaemia of the uterus, which occurs when the placenta is expelled. Blood
vessels are constricted, which results in the reduction of the blood supply to the uterus. The
phagocytes dispose of the redundant muscle fibre and elastic tissue. The vagina, ligaments of the
uterus and muscle of the pelvis also return to their pre-gravida state. If not, prolapse of the uterus
may occur later. At the completion of labour, the uterus measures 12.5 centimetres above the
symphysis pubis. It decreases at a rate of 0.5 1 centimetres daily. After a week, the fundus
measures 6.7 weeks. The fundus is usually not palpable.

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Lochia is a discharge from the uterus during the puerperium. It consists of bloodshed of deciduas,
epithelium cells and debris from the uterus, for example, liquor amni, vanix casaeosa and
meconium. It is alkaline in nature with a heavy odour, which is not unpleasant. The amount is
slightly more than what is lost during the menstrual flow. It changes in colour as follows:

From day 1 4 it is reddish in colour and is known as lochia rubra;

From day 5 9 it is pinkish in colour and is known as lochia serosa;

From day 10 15 it is whitish in colour and is known as lochia alba. When there is an
infection the lochia persists and becomes red and offensive.

Onset of Lactation

Lowered oestrogen levels trigger the production of prolactin from the anterior pituitary gland,
which initiates lactation. The maintenance of lactation depends on putting the baby on the breast,
but secretion of milk commences on the third to fourth day. The baby should be put on the breast
immediately, which leads to oxytocin release and assists in keeping the uterus well-contracted.
(You should revise the anatomy and physiology of the breast in done earlier).
Management of Normal Puerperium

The aim of managing the puerperium is to:

Maintain the mothers good health;

Aid involution of the pelvic area;

Promote breast-feeding;

Prevent infection and other puerperium complications;

Educate the mother on the proper care of her own health and the baby.

The mother and the baby should be examined daily and if any abnormality is noted, the doctor
should be informed. When noting the mothers general condition, you should check for the
following points:

Assess happiness, sadness, worries and fears and address them appropriately;

Ambulation is important to prevent deep venous thrombosis;

Take her temperature, pulse, respiration and blood pressure twice daily;
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Check the breasts, if she is not lactating, express colostrum;

Increase expressing on the second day and milk should be established on the fourth day;

Advise the mother on how to feed the infant. When fixing the baby on the breast she
should put the whole areola in the babys mouth;

She should initially breast feed the baby for three minutes to prevent cracked nipples and
empty the breast in cases where the baby does not feed a lot. This is especially important
in the first days to prevent engorgement.

Measure the fundal height and record the measurement daily. Assess whether the involution is
taking place satisfactory. The fundal height should reduce by 0.5 1 centimetres daily. Check on
lochia loss, noting the colour. This should change as per the schedule we noted earlier. If there is
persistent red lochia, this points to the need for further investigation. Offensive lochia odour
denotes infection.

You should also check the perineum to see if there was episiotomy and note its state. Advise the
mother to wash the episiotomy at least four times a day with salt water and change the pad as
soon as it is soiled and after she goes to the toilet. Check on the calf muscles and exclude any pain
that may indicate deep venous thrombosis. You should also exclude oedema and anaemia. Ensure
that the mother gets enough sleep and rest. If she cannot sleep, she should be given a sedative.
Take note of any pain and administer analgesics. Ask the mother to report if lochia is heavy. Also
encourage her to pass urine when her bladder is full. Encourage her to continuously check on the
babys cord and to report any bleeding, especially in the first 12 hours.

Note her bowel action and check for constipation. On the third day, if the mother has not opened
bowels, give a mild laxative. Blood should be tested for haemogram on the third day. The mother
should be given a well balanced diet. She should continue with her iron tablets during the
puerperal period. She should also be encouraged to take plenty of fluids (at least two litres and
whenever possible one litre of milk). Post-natal exercise should be encouraged. Stress the
importance of family planning and share advice on different methods of family planning. Let her
discuss these methods with her partner and advise her to start practising her method of choice on
the fourth week.
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Remind the mother to take the baby to the child welfare clinic and give the date for the post-natal
examination. Emphasise the importance of taking the baby to the clinic and of attending postnatal clinics. Finally the importance of proper hygiene for both the mother and her baby to
prevent infection should be stressed.

Daily Observation of the Baby

You should observe the baby daily for the following:

The colour should be pinkish in a fair baby and brownish chocolate in a dark skinned
baby;

Breathing, with respiration at a rate of about 40 per min;

Eyes should be checked for any discharge, or yellow discolouration or any subconjunctival bleeding. The eyes should not be touched except to wash them if there is any
discharge;

Motion of bowels should be checked for meconium or greenish stools, which are normally
passed within 24 hours of birth. The stool changes to greenish yellow on the second day
to yellowish and soft on the third day. The bowels should be opened one to four times a
day;

Cord should be dried and cleaned daily with hibitane. If the cord is wet or septic, you
should report it to the doctor. You will learn about the management of ompholitis in
greater detail when we deal with infections of the newborn;

Skin should be observed for rashes and if these are present, they should be reported to the
doctor;

Feeds should be monitored. The baby is fixed on the breast as soon as he is hungry
provided his breathing and colour are satisfactory and there is no excessive mucus. Soon
after delivery, most babies are ready for breastfeeding. Self-regulated or demand feeds are
more satisfying to the baby. Eventually the baby regulates his feeding pattern.

Let us now have a look at the minor and major complications of puerperium. Minor complications
of the puerperium include:

After pains;

Soreness of the perineum;

Haemorrhoids.
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Major complications of the puerperium include:

Venous thrombosis;

Pulmonary embolism;

Retention of urine or retention with overflow;

Urinary tract infection;

Puerperal sepsis and pyrexia;

Engorgement of the breasts;

Cracked nipples or mastitis;

Puerperal psychosis.

Post Natal Examination

This is carried out during the 6th post-partum week. You should inquire about the general health
of the mother and baby. You should also do haemoglobin estimation and if you find that it is low,
embark on treatment.
You should inquire and note any gynaecological symptoms. Examine the mothers general
condition, with specific emphasis on the breasts. Find out if the breasts are active. Examine the
abdomen for tone of muscle and any masses. Also examine the vulva and vagina to ascertain the
healing of the repaired episiotomy or tear. Pass a speculum (sims) to see the state of the cervix
and if there is any discharge. Do a Pap smear at this stage. If possible, you should carry out a
bimanual examination of the uterus to ascertain that the uterus has involuted to its normal size.
Finally, remind the mother of the various family planning methods discussed and re-emphasise
the importance of attending maternal and child health clinics.

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