Unit 3: MATERNAL HEALTH CARE

Specific Objectives:
1.
Outline factors which may influence reproductive health care.
2.
State the focus of pre-conceptual care.
3.
Review the anatomy & physiology of the female reproductive system.
4.
Define terminologies related to fertilization, conception, ovum and foetus development.
5.
Describe the process of fertilization, conception, ovum and foetus development.
6.
State functions of the placenta.
7.
Trace foetal circulation
Factors Influencing Reproductive Health Care
1. Demography
2. Socialization of women
Education
Gender
Culture and ethnicity
Parenting and choices
Family size and spacing
3. Nutrition
4. Health services and programs
Pre-conceptual care
Family planning programs
Community resources
Cancer screening
5. Adolescent sexuality
6. Common health problems
7. Health teaching for mental and physical health
Pre-Conceptual Care
When planning a family you and your partner would want to be in the best of health. Preconceptual care takes all possible steps to ensure that every baby is born in perfect health, free
from physical or mental handicap and other health problems. Pre-conceptual care can help with
overcoming the following issues in connection with conception, pregnancy and birth:

miscarriage

stillbirth

birth defects

unexplained infertility

post-natal depression

health problems in the child

low sperm count

poor resistance to infection

low birth weight

premature birth

malformation

breast feeding difficulties

handicap

hyperactivity

learning problems

asthma

eczema

and other problems relating to conception, pregnancy and birth.

As part of preconceptual care, the above conditions are often preventable by:

Improving nutrition

Combating pollution

Treating allergies, Candida

Treating malabsorption of nutrients

Treating genitourinary infections

Discouraging the use of common social poisons e.g. cigarettes, alcohol and drugs

Avoidance of geopathic stress.

Aims of Pre-conceptual Care

The objective is to optimize the health of both prospective parents well before conception occurs so
that a pregnancy can be started with a normal, strong sperm and ova and the embryo can implant
and develop under optimum conditions in a healthy uterus, with no danger of damage from
nutritional deficiency, toxins or disease.
1.

To secure optimum health and nutritional balance in both parents before

conception.

2.

To instigate research aimed at the identification and removal of potential health

hazards to the developing baby, especially with regard to the environment.

3.

To present the facts and know-how of Pre-conceptual care so that prospective parents
will be motivated to choose to actively contribute to their family's greater health and
happiness.

Pre-conceptual Tips:
Folic Acid - Recent medical research has proved that those women who boost their levels of folic
acid are significantly less likely to have a baby suffering from Spina Bifida. It is now recommended
that all women who are planning a pregnancy should take 400ug of folic acid supplement from the
time they try to conceive up to the 12th week of pregnancy.
Eat foods which are rich in folic acid including spinach, broccoli and brussel sprouts, beef or yeast
extracts and also take folic acid supplements. This will ensure that you are getting the
recommended 400ug of folic acid. Folic acid supplementation is available in our BabyBlend fertility
formulation.
Vianalyse is product from Med-Direct - this is aimed at women planning to conceive and can help
identify the cause of a vaginal infection. This is important for women planning a pregnancy
because vaginal infections can reduce fertility and cause miscarriage.
Cigarettes and caffeine - These can reduce your fertility. If you or your partner are heavy smokers
this can reduce your fertility. Also a heavy caffeine intake can also affect both partners
Diet - Follow a healthy diet and eat regularly. Try not to gain or lose weight over a short period of
time as this may affect your chances of conceiving.

Exercise - Excessive endurance training can affect ovulation. Be fit, but don't over do it !
Stress - If one or both of you are feeling stress or anxiety the chances of achieving pregnancy may
be reduced. Try to find ways of relaxing.
Terminologies:
1. zygote: an ovum that has been fertilized by a spermatozoon
2. morula: an early stage in the development of an embryo, consisting of a solid ball of cells
derived by cleavage of the fertilized egg.
3. implantation: the process by which or stage at which an embryo becomes embedded in the
lining of the womb
4. decidua: a specialized part of the mucous membrane endometrium that lines the womb
during pregnancy and is shed with the placenta at birth
5. embryo: a human offspring in the early stages following conception up to the end of the
eighth week, after which it is classified as a fetus
6. foetus: unborn human offspring after eight weeks of development
7. placenta: a vascular organ that develops inside the uterus to supply food and oxygen to
the fetus through the umbilical cord. It is expelled after birth.
8. chorion: the outer membrane enclosing the embryo. It has a dense concentration of blood
vessels and aids in the formation of the placenta.
9. amnion: the inner of the two membranes enclosing the embryo and its surrounding fluid.
REVIEW A & P OF FEMALE REPRODUCTIVE SYSTEM
Fertilization
Fertilisation occurs when a live sperm penetrates the newly released mature egg successfully and
cell division starts. The woman has now conceived, the embryo is growing!
During sexual intercourse, millions of sperm are released into the vagina. As ovulation approaches,
the cervical mucus becomes watery allowing the sperm to swim up the vagina through the cervix.
At other times the mucus is more viscous and unreceptive to sperm. Only about 2,000 sperm will
be strong enough to reach the uterus and the fallopian tube.
The timing of sexual intercourse is very important for fertilisation to occur. The egg can only be
fertilised for about 18-24 hours after it is released, so sperm must be present in the fallopian tubes
around the time of ovulation. A man's sperm can only survive for about 3-5 days so a woman's
fertile time will only be around 5-6 days every month, with the most fertile time being the 2-3 days
up to and including ovulation.
Research suggests that even if intercourse takes place at the right time a normal healthy couple
may still only have a 30% chance of fertilisation and pregnancy occurring. So don't be discouraged
if pregnancy does not occur in the first of trying.

Once fertilised, an egg normally takes a few days to travel into the womb where it will need to
implant itself in order for a viable pregnancy to begin. If this implantation happens the pregnancy
hormone called Human Chorionic Gonadotrophin (hCG) starts to be produced. This hormone is
vital for the maintenance of the lining of the womb and the new embryo and the amount of
hormone produced rises rapidly, doubling approximately every two days, reaching a peak 60 to 80
days after conception. Soon after conception tiny amounts of this hormone can be detected in a
woman's urine and this is what the early pregnancy.

Conception
Conception is the term used when a mans sperm penetrates a womans egg and a pregnancy is
started. In order for you to become pregnant, the following must happen:
1. OVULATION MUST OCCUR.
2. The fallopian tubes must not be blocked.
3. Intercourse must take place just before or at the time of ovulation
4. The man must be fertile and produce adequate numbers sperm - we have the only
approved home test for men and we provide fertility information and advice for men in the
mens fertility section.
5. Mucus at the mouth of the womb must be receptive and not hostile to sperm.
6. The egg must be fertilized by the sperm and then implant in the womb - 'then conception
has taken place.
Ovum and Foetal Development
When sperm is deposited in the vagina, it travels through the cervix and into the Fallopian tubes.
Conception usually takes place in the Fallopian tube. A single sperm penetrates the mother's egg
cell, and the resulting cell is called a zygote.
The zygote contains all of the genetic information (DNA) necessary to become a child. Half of the
genetic information comes from the mothers egg, and half from the fathers sperm.
The zygote spends the next few days traveling down the Fallopian tube and divides to form a ball
of cells. Further cell division creates an inner group of cells with an outer shell. This stage is called
a "blastocyst". The inner group of cells will become the embryo, while the outer group of cells will
become the membranes that nourish and protect it.
The blastocyst reaches the uterus at roughly the fifth day, and implants into the uterine wall on
about day six. At this point in the mother's menstrual cycle, the endometrium (lining of the uterus)
has grown and is ready to support a fetus. The blastocyst adheres tightly to the endometrium,
where it receives nourishment via the mother's bloodstream.
The cells of the embryo now multiply and begin to take on specific functions. This process is called
differentiation, which produces the varied cell types that make up a human being (such as blood
cells, kidney cells, and nerve cells).
There is rapid growth, and the baby's main external features begin to take form. It is during this
critical period of differentiation (most of the first trimester) that the growing baby is most susceptible
to damage from:

Alcohol, certain prescription and recreational drugs, and other substances that cause birth
defects
Infection (such as rubella or cytomegalovirus)
Radiation from x-rays or radiation therapy

Nutritional deficiencies

The following list describes specific changes by week.

Week 1

fertilization: all human chromosomes are present; unique human life begins;
embryo begins implanting in the uterus

Week 2

heart begins to beat with the childs own blood, often a different type than the
mothers.

Week 3
beginning development of the brain, spinal cord, and heart
beginning development of the gastrointestinal tract
Weeks 4 to 5
o formation of tissue that develops into the vertebra and some other bones
o further development of the heart which now beats at a regular rhythm
o movement of rudimentary blood through the main vessels
o beginning of the structures of the eye and ears
o the brain develops into five areas and some cranial nerves are visible
o arm and leg buds are visible
Week 6
o beginning of formation of the lungs
o further development of the brain
o arms and legs have lengthened with foot and hand areas distinguishable
o hands and feet have digits, but may still be webbed
Week 7
o nipples and hair follicles form
o elbows and toes visible
o all essential organs have at least begun to form
Week 8
o rotation of intestines
o facial features continue to develop
o the eyelids are more developed
o the external features of the ear begin to take their final shape
o
o

The end of the eighth week marks the end of the "embryonic period" and the beginning of the "fetal
period".

Weeks 9 to 12
o the fetus reaches a length of 3.2 inches
o the head comprises nearly half of the fetus' size
o the face is well formed
o eyelids close and will not reopen until about the 28th week
o tooth buds appear for the baby teeth
o limbs are long and thin
o the fetus can make a fist with its fingers
o genitals appear well differentiated
o red blood cells are produced in the liver
Weeks 13 to 16
o the fetus reaches a length of about 6 inches
o a fine hair develops on the head called lanugo
o fetal skin is almost transparent
o more muscle tissue and bones have developed, and the bones become harder
o the fetus makes active movements
o sucking motions are made with the mouth
o meconium is made in the intestinal tract

the liver and pancreas produce their appropriate fluid secretions

Week 20
o the fetus reaches a length of 8 inches
o lanugo hair covers entire body
o eyebrows and lashes appear
o nails appear on fingers and toes
o the fetus is more active with increased muscle development
o "quickening" usually occurs (the mother can feel the fetus moving)
o fetal heartbeat can be heard with a stethoscope
Week 24
o the fetus reaches a length of 11.2 inches
o the fetus weighs about 1 lb. 10 oz.
o eyebrows and eyelashes are well formed
o all the eye components are developed
o the fetus has a hand and startle reflex
o footprints and fingerprints forming
o alveoli (air sacs) forming in lungs
Weeks 25 to 28
o the fetus reaches a length of 15 inches
o the fetus weighs about 2 lbs. 11 oz.
o rapid brain development
o nervous system developed enough to control some body functions
o eyelids open and close
o respiratory system, while immature, has developed to the point where gas
exchange is possible
o a baby born at this time may survive, but the possibilities for complications and
death remain high
Weeks 29 to 32
o the fetus reaches a length of about 15-17 inches
o the fetus weighs about 4 lbs. 6 oz.
o rapid increase in the amount of body fat
o rhythmic breathing movements occur, but lungs are not fully mature
o bones are fully developed, but still soft and pliable
o fetus begins storing iron, calcium, and phosphorus
Week 36
o the fetus reaches a length of about 16-19 inches
o the fetus weighs about 5 lbs. 12 oz. to 6 lbs. 12 oz.
o lanugo begins to disappear
o increase in body fat
o fingernails reach the end of the fingertips
o a baby born at 36 weeks has a high chance of survival, but may require some
medical interventions
Weeks 37 to 40
o considered full-term at 37 weeks
o may be 19 to 21 inches in length
o lanugo is gone except for on the upper arms and shoulders
o fingernails extend beyond fingertips
o small breast buds are present on both sexes
o head hair is now coarse and thicker
o

Physiology of placenta
The precursor cells of the human placentathe trophoblastsfirst appear four days after fertilization
as the outer layer of cells of the blastocyst. Over the next few days, these same trophoblasts attach
to and invade into the uterine lining, beginning the process of pregnancy and the formation of the
placenta.
The placenta has two surfaces:
Maternal: rough and bluish-red in color; has lobules.
Foetal: smooth white and shiny; two membranes : amnion & chorion; 3 blood vessels: 2
arteries and 1 vein found in umbilical cord.
Functions:

1.
2.
3.
4.

Nutrition
Respiratory
Excretory
Endocrine
Human chorionic gonadotropin (HCG)
Progesterone
Estriol
Human placental lactogen (HPL)
5. Barrier
Amniotic Fluid
Amniotic fluid is a clear, slightly yellowish liquid that surrounds the unborn baby (fetus) during
pregnancy. It is contained in the amniotic sac.
The fetus floats in the amniotic fluid. During pregnancy the amniotic fluid increases in volume as
the fetus grows. Amniotic fluid volume is greatest at approximately 34 weeks of gestation, when it
averages 800 ml. Approximately 600 ml of amniotic fluid surrounds the baby at full term (40 weeks
gestation). This fluid is constantly circulated by the baby swallowing and "inhaling" existing fluid
and replacing it through "exhalation" and urination.
Amniotic fluid accomplishes numerous functions for the fetus, including:

Protection from outside injury by cushioning sudden blows or movements

Allowing for freedom of fetal movement and permitting symmetrical musculoskeletal
development
Maintaining a relatively constant temperature for the environment surrounding the fetus,
thus protecting the fetus from heat loss
Permitting proper lung development

An excessive amount of amniotic fluid is called polyhydramnios. This condition may accompany
multiple pregnancy (twins or triplets), congenital anomalies, or gestational diabetes.
An abnormally small amount of amniotic fluid is known as oligohydramnios. This condition may
accompany postdates pregnancies, ruptured membranes, placental dysfunction, or fetal
abnormalities.
Abnormal amounts of amniotic fluid may trigger additional surveillance of the pregnancy.
Removal of a sample of the fluid is called amniocentesis. This can provide information about the
sex, state of health, and maturity of the fetus.
Umbilical Cord
The umbilical cord is a tube that connects a developing embryo or fetus to its placenta. It normally
contains three vessels, two arteries and one vein, buried within Wharton's jelly, for the exchange of
nutrient- and oxygen-rich blood between the embryo and placenta. The presence of only two
vessels in the cord is sometimes related to abnormalities in the fetus, but may occur without
accompanying abnormalities.
Recently, it has been discovered that the blood within the umbilical cord, known as cord blood, is a
rich and readily available source of primitive, undifferentiated stem cells (i.e. CD34+ and CD38-).
These cord blood cells can be used for bone marrow transplant.
Some parents have opted to have non-clamping of the umbilical cord and extended-delayed cord
cutting or nonseverance Lotus Birth in order to provide for full neonatal transfer of this valuable
cord blood during the most critical time for neonatal health as well as longterm health benefits.
Foetal circulation
During pregnancy, the fetal circulatory system works differently than after birth:

The fetus is connected by the umbilical cord to the placenta, the organ that develops and
implants in the mother's uterus during pregnancy.

Through the blood vessels in the umbilical cord, the fetus receives all the necessary
nutrition, oxygen, and life support from the mother through the placenta.

Waste products and carbon dioxide from the fetus are sent back through the umbilical cord
and placenta to the mother's circulation to be eliminated.

Blood from the mother enters the fetus through the vein in the umbilical cord. It goes to the liver
and splits into three branches. The blood then reaches the inferior vena cava, a major vein
connected to the heart.
Inside the fetal heart:

Blood enters the right atrium, the chamber on the upper right side of the heart. Most of the
blood flows to the left side through a special fetal opening between the left and right atria,
called the foramen ovale.

Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta,
(the large artery coming from the heart).

From the aorta, blood is sent to the head and upper extremities. After circulating there, the
blood returns to the right atrium of the heart through the superior vena cava.

About one-third of the blood entering the right atrium does not flow through the foramen
ovale, but, instead, stays in the right side of the heart, eventually flowing into the
pulmonary artery.

Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2) through
the mother's circulation, the fetal lungs are not used for breathing. Instead of blood flowing to the
lungs to pick up oxygen and then flowing to the rest of the body, the fetal circulation shunts
(bypasses) most of the blood away from the lungs. In the fetus, blood is shunted from the
pulmonary artery to the aorta through a connecting blood vessel called the ductus arteriosus.
Blood circulation after birth:
With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger amount of
blood is sent to the lungs to pick up oxygen.

Because the ductus arteriosus (the normal connection between the aorta and the
pulmonary valve) is no longer needed, it begins to wither and close off.

The circulation in the lungs increases and more blood flows into the left atrium of the heart.
This increased pressure causes the foramen ovale to close and blood circulates normally.

The ANTENATAL/ANTEPARTUM PERIOD

Objectives:
1. Define terminologies.
2. Identify the signs of pregnancy.
3. Describe the physiological changes in pregnancy.
6. Outline areas involved in the first ante-natal visit.
7. Review history taking.
8. Describe areas of physical assessment.
9. Discuss the purpose of subsequent visits.
10. State the schedule for subsequent visits.
11. Outline how patients are classified.
12. Outline educational guidelines for antenatal clients.
13. Discuss nutrition in pregnancy and lactation.
14. Outline the management of minor disorders in pregnancy.
Diagnosis of Pregnancy
Pregnancy: The period from conception to delivery of fetus and placenta.
Usually lasting 266 days, 40 weeks or 9 months of pregnancy.
Possible/Presumptive Signs
1. Amenorrhoea
2. Breast Changes
4-6 wk.: tingling and tenderness
6-8 wk.: breast feels full, superficial veins visible
8-10 wk.: sebaceous glands & Montgomery tubules
10-12 wk.: primary areola becomes pigmented
16 wk.: appearance of secondary areola, straie, expression of colostrum
3. Nausea and Vomiting
Occurs 6-12 wk. and usually in the mornings
Develops a queasiness to odors and distaste to favorite foods
4. Frequency in Micturition & Back pains
6-12 weeks, due to changes in size of uterus and hormonal changes.
5. Skin changes
Cloasma, Linea nigra and straie on buttocks abdomen and arms
6. Quickening
First feeling of feeling of fetal movement by the mother
Primagravida: 18-20 weeks
Multigravida: 16-18 weeks
7. Fatigue and malaise,
Probable Signs
1.
Softening of Cx: @4-5 wk.
2.
Bluish/Purple discoloration of vagina
3.
Enlargement of uterus: @12 wk.
4.
Internal Ballotment
5.
Uterine Souffl
6.
Braxton Hicks Contraction
7.
Positive HCG test
Positive Signs
1.
FH heard: using ultrasound 6 weeks; using doptone 13-14 weeks
2.
Fetal movement felt by examiner: usually 20 weeks
3.
Palpation of fetal parts: @20 wk.
4.
Visualization of fetus on Ultrasound: @6 wk.
5.
X-rays: @13-16 wk. can see bony structures.

Physiological Changes in Pregnancy

Reproductive System
Uterus: increases in weight, shape and size
Non-Pregnant
Weight
60 g (2ozs)
Size
7.552.5 cms
Shape
Pear-shaped

Pregnant
900g (2lbs)
302320 cms
Globular

Cx: increases in width and vascularity

Vagina: under the influence of estrogen blood supply increases and vagina mucosa becomes
thicker.
Ovaries: corpus luteum persists and grows to 12 th wk of pregnancy and then disintegrates as
its fx is taken over by the placenta.
Breast: Review notes possible signs of pregnancy.

Skin Changes: review notes possible signs.

Cardiovascular System
Heart: position changes, displaced upwards and to the L, to accommodate uterus.
Output: increases due to increase in water retention
B/P: No physiological rise in B/P may be slightly lower mid trimester.
Blood Volume: increases by 18%
Respiratory System: increased alveolar expansion, which enhances gaseous exchange.
GI System
Dentition: spongy gums that bleed easily, gingivitis and dental caries.
Pica: cravings for unnatural substances
Peristalsis slowed due to influence of progesterone, resulting in heartburn, gastric reflux, and
constipation leading to hemorrhoids.
N/V
Weight Gain
Expected increase 20-25 lbs.
Fetus: 7.5 lbs.
Placenta: 1lb
Amniotic Fluid: 2 lbs.
Uterus: 2 lbs.
Breast: 3 lbs
Blood volume: 2-4 lbs.
Extracellular fluid: .5-1 lbs.
Fat gain: 1.5 lbs.
Skeletal Changes
Lumbodorsal spinal curve and posture change.
Progesterone relaxes ligaments and muscles reaching maximum effect during the last weeks
of pregnancy.
Endocrine Changes
Increased insulin.
All major glands increase in activity.
Nervous System
Increased mood swings
Irritable

First Antenatal Visit

Involves two (2) areas:
1. History Taking
2. Physical Assessment
History Taking: (refer to Hand-out notes)
Physical Assessment
Clinical Observation
Head to Toe Examination
Abdominal Examination
Laboratory Investigations
Clinical Observation begins as soon as the woman enters the room.
Observe: height, weight, shoe size, gait and height: weight ratio.
Height is important over 5 ft usually has a normal pelvis.
Less than 5 ft may indicate inadequate pelvis.
The nurse needs to ascertain if height is genetic, race, poor nutrition, particularly in
childhood years. Shoe size <3 indicative of small size pelvis.
Weight: increased risk of obesity leading to gestational diabetes, PIH.
Under weight: can result in IUGR, LBWI and prematurely.

Assess V/S: The B/P is of great significance

It provides a baseline for comparison throughout the pregnancy, thus
Importance of early booking.
An increase/decrease in B/P can damage placental tissue.
It is important to take B/P in same position always.

Urinalysis: Done to exclude abnormalities

Ketones may show up due to increase in metabolic rate/vomiting.
Glucosuria may be indicative of gestational diabetes, or renal
dysfunction.
Presence of protein may be due to UTI, PIH, and PET.
Blood may be due to UTI, or vaginal infections or discharge.

Head to Toe
A systemic assessment is done.
HEENT
Chest: Breast (nipples)
Upper Limbs
Abdomen
Lower Limbs
Back
Genitals
Abdominal examination
Inform/explain the procedure to client.
Ask her to empty bladder to prevent false readings when assessing fundal height.
Ask to remove clothing. Provide privacy.
Make sure she is relaxed.
Lie supine with head elevated.
Place arms at side

 Stand at right of client.

Procedure is done using 3 specific skills
inspection
Palpation
Auscultation
Inspection
Size: enlarged uterus may indicate multiple pregnancies, large baby.
Shape: Usually ovoid with a longitudinal lie
Abnormal: low and broader.
Foetal movements.
Skin Changes: straie, linea nigra, and scars.
Hair Distribution: indicative of type of pelvis.
Full bladder.
Palpation
Aims:
1. To observe the signs of pregnancy.
2. Assess fetal size and growth.
3. Determine location of foetus
4. Detect deviation from the norm

Palpate fundus first

Measure fundal height.
12 wks: just above symphysis pubis.
16 wks: midway b/w symphysis and umbilicus.
20 wks: 2 fingers below umbilicus.
24 wks: upper margin of umbilicus.
30 wks: midway b/w umbilicus and xyphi.
36 wks: at xyphi
35/37 wks: 1 finger below xyphi.
34/38 wks: 2 fingers
33/39 wks: 3 fingers
32/40 wks: 4 fingers

Three types of palpation (review notes)

Fundal
Lateral
Pelvic

Auscultation
Examination not completed until FH done.
Normal FH 120-160 bpm.
Use pinnard/sonocaid to auscultate.
Investigations
1. Blood
VDRL: facilities early Rx, contact tracing, prevention of complications.
Syphilis causes congenital defects.
FBC: Rx of Fe deficiency anaemia , elevated WBC may reveal subclinical
infection
Hb Electrophoresis: facilitate prevention of crisis, minimize effects of IUGR.
Blood group and Rh factor: determines need for Rhogram (given within 72 hrs
post delivery.

HIV: not a routine investigation; must obtain consent.

2. MSU
C/S >100,000 count woman is placed on antibiotics.
3. ECS: Clamydia increases susceptibility to abortions. Gonorrhoea may change mode of
delivery.
4. Pap Smear: baseline data to determine changes in postpartum period.
Subsequent Visits
Purpose
1. Observe maternal health.
2. Assess foetal well-being
3. Ensure foetal presentation will allow for vaginal delivery
4. Give advice and allow mother to express fears and concerns.
5. Formulate a birth plan.
6. Evaluate effectiveness of Mx.
Schedule
1-2 week appt. following first visit.
Monthly until 28 wks.
Biweekly until 36 wks.
Weekly until delivered.
Mother is seen by Dr. on 2nd visit or on first visit if booking after 28 wks.
Seen by Dr. at 36 wks.
Seen by Dr. every visit following 36 wks.
(However sees Dr. when not feeling well or requiring prescription Rx)
At 30 wks kick chart implemented.
At 32 wks VDRL and Hb. repeated.
Classification (See handout)
Antenatal Educational Guidelines
First Trimester
1. Importance of ANC
2. Importance of History taking and investigations
3. Significance of passport.
4. Clinic visit schedule
5. Iron therapy during pregnancy
6. Nutrition during pregnancy
7. Minor disorders in pregnancy.
8. Breast feeding
9. Partners role during pregnancy
10. Safe sexual intercourse during pregnancy and sexual alternatives.
11. Use of OTC
12. Physiological changes during pregnancy.
13. Prevention of STDS
14. Effects of alcohol/smoking/drugs on pregnancy
15. Clothing
16. Hygiene and Dental care
Second Trimester
1. Immunization in pregnancy
2. Importance of rest, sleep, and mild exercise.
3. Growth and development of foetus.
4. Signs of labour and type of deliveries.
5. Preparing for the baby (layette).
6. Breathing exercises

7. Pain management options

8. Warning signs during pregnancy
Third Trimester
1. Stages and signs of labour.
2. Family Planning
3. Birth registration.
4. Care of the infant and immunization.
5. The puerperium.
6. Importance of 6wks postnatal visit.
7. Signs of true/false labour
8. When to go to the hospital.
9. Expectations of labour
10. Travel

PATIENT CLASSIFICATION (DPH- CLINICS)

Nutrition during Pregnancy and Lactation

Early Practices: False Assumptions and Folklore
For centuries, in all cultures, a great body of folklore has grown up around pregnancy. Traditional
practices and diet have been followed, many of which have little basis in fact. Early obstetricians
even developed the notion that semi starvation of the mother during pregnancy was really a
blessing in disguise because it produced a small, lightweight baby, easy to deliver. Two
assumptions grew and governed practice:
1. The parasitic theory: whatever the fetus needs it will draw from the stores of the mother
despite the maternal diet.
2. The maternal instinct theory: whatever the fetus needs, the mother will instinctively crave
and consume.
Factors determining Nutritional Needs
Several vital considerations emerge as factors governing nutritional requirements during
pregnancy:
1. Age and Parity: The teenage mother adds her own growth needs to those imposed by her
pregnancy. At the other end of the reproductive cycle, hazards increase with age. The
number of pregnancies, parity and the intervals between them also influence the needs of
the mother and the outcome of the pregnancy.
2. Preconception Nutrition: The mother brings to her pregnancy all her previous life
experiences, including her diet. Her general health and fitness and her state of nutrition at
the time of her infants conception are products of her lifelong dietary habits and genetic
heritage.
3. Complex Metabolic Interactions of Gestation: Three distinctive biologic entities are
involved in pregnancy: the mother, the fetus, and the placenta. Together they form a
unique biologic whole constant metabolic interactions go on among them. Their functions,
while unique, are at the same interdependent.
Positive Nutritional Demands of Pregnancy
The period of gestation is an exceedingly rapid growth period. The human life grows from a single
fertilized egg cell (ovum) to a fully developed infant weighing about 7 lbs. Individual variations such
as body size; activity and multiple pregnancies need to be considered. Also quantitive need for
nourishment of pregnant adolescent must be noted. In considering the needs of the healthy
pregnant woman, we will review here the nutrient elements in terms of:
The general amount of increased intake indicated.
Why this increase is recommended
How it can be obtained from foods.
Energy
Kilocalories must be sufficient to (1) supply the increased energy demanded by the increased
metabolic workload and (2) spare protein for tissue building. A minimum of about 36 kcal/kg is
required for efficient use of protein during pregnancy. This primary emphasis on sufficient kcal. Is
critical to the support of the pregnancy and necessary to ensure nutrient and energy needs.
Appropriate weight gain during the pregnancy will indicate whether sufficient kcal is provided.
Protein
Since protein is the essential growth element of the body, there is an increased essential
requirement.
An additional daily allowance of 30 g of protein is recommended throughout the pregnancy. This
added amount raises the 44g required by the normal no pregnant woman to at least 74g daily. This
represents an increase of about 66%.
Reason for Increased Requirement:
Protein, with its essential constituent nitrogen, is the nutrient basic to growth. Nitrogen
balance studies give some indication of the large amount of nitrogen used by the mother
and the child during pregnancy, More protein is essential to meet tissue demands posed
by:
Rapid growth of fetus: A study of fetal tissue composition indicates the amount of nitrogen
stored by the embryo rises from 0.9g at conception to 55.9g at delivery. The increase in
size of the infant from one cell to multiple cells in a 7lb. child indicates how much protein is
required for rapid growth.

Development of the placenta: The mature placenta at term has stored about 17 g of
nitrogen. Sufficient protein is required for its complex development during pregnancy as a
vital organ to sustain, support and nourish the fetus.
Enlargement of Maternal Tissues: Increased development of breast and uterine tissue is
required to support the pregnancy. An estimated 17 g of nitrogen is incorporated into the
developing maternal breast tissue and nearly 40 g into the increased uterine tissue. In
addition, a general maternal reserve tissue is required. About 200-300 g of nitrogen is
stored for the approaching loses during labor and delivery. For example, 300-500 mls of
blood (protein) tissue) may be lost during delivery. Also, the increased tissue is required in
preparation for the physiologic demands of lactation to follow.
Increased maternal circulating blood volume: A particular increase of protein is demanded
by the increase in the mothers circulating blood volume of 20-5-% or more above her
normal volume. With this increase comes need for increased synthesis of the constituents
of blood, especially Hg and plasma protein (albumin), both of which are proteins vital to the
support of the pregnancy. Increased plasma protein is required to keep the increased
blood volume circulating by maintaining normal colloidal osmotic pressure and operation of
the capillary fluid shift mechanism. This mechanism prevents accumulation of abnormal
amounts of water in the tissues.
Formation of amniotic Fluid: The fluid surrounding the fetus is designed to protect it from
shock or trauma. The fluid contains protein, hence its formation requires still more protein.
Food Sources: milk, eggs and cheese are complete protein foods of high biologic value. Protein
rich foods also contribute other nutrients such as calcium, iron and B vitamins. Additional protein
may be obtained from legumes and whole grains while lesser amounts are available in nuts and
seeds.
Minerals
The increased need for calcium and iron should be particularly emphasized throughout pregnancy.
Calcium
The pregnant woman should increase her daily intake by 400 mg. Since the suggested intake for
the no pregnant woman is 800 mg, the total daily intake during pregnancy is 1200 mg, about a 50%
increase.
Reason for Increased Requirements: The size of the recommended increase indicates the
importance of calcium to the mother and fetus. Calcium is the essential element for the
construction and maintenance of bones and teeth. It is also an important constituent of the bloodclotting mechanism and is used in normal muscle action and other essential metabolic activities.
The rapid fetal mineralization of skeletal tissue during the final period of growth demands more
calcium.
Food sources: Dairy products are a primary source of calcium. Some increase in milk or
equivalent milk foods such as cheese, ice cream, skim milk powder used in cooking, is
recommended. Additional calcium is obtained in whole or enriched cereal grain and in green, leafy
vegetables.
Iron
A woman should maintain a daily intake of 18 mg of iron throughout her childbearing years. This
amount is necessary to replenish menstrual losses and to restore tissue and liver reserve after
each pregnancy. To meet the iron needs of pregnancy, however, iron supplements (300 mg Ferrous
Sulphate) in addition to dietary sources are usually recommended because the iron cost of a
pregnancy is high. With increased demands of iron, often-insufficient maternal stores, and
inadequate provision through the usual diet, a regular daily supplement of 30-60 mg of iron is
recommended for healthy women. If the woman is anemic at conception a larger therapeutic
amount, 120-200 mg iron (2 tablets) is recommended.
Reason for Increased Requirement: Increased iron is necessary to:
1. Maintain the mothers Hg level given the increased blood volume, thus preventing
Physiologic Anemia caused by Haemodilution.
2. Provide for fetal development, especially a reserve in the fetal liver to last about 6
months after birth, since the infants first food (milk) lacks iron
3. Provide maternal iron stores to fortify the mother against blood losses at delivery.
Food Sources: Liver contains far more iron than any other food. You may encourage its
use by suggesting appetizing ways of serving it. Other meat, dried beans, dried fruit, green
vegetables, eggs and enriched cereals provide additional sources of iron.

Vitamins
Increased amounts of vitamin A, B complex, C and D are needed during pregnancy
Vitamin A: A daily increase of 200 g retinal equivalents (RE) is recommended for pregnancy. This
is about 25% increase over the usual adult intake. Vitamin A is an essential factor in cell
development, maintenance of the integrity of epithelial tissue, tooth formation and normal bone
growth. Liver is an excellent food source. Other good sources include egg yolk, butter or fortified
margarine, dark green and yellow vegetables and fruits.
B Vitamins: There is a special need for B vitamin during pregnancy. These are usually supplied by
a well-balanced diet that is increased in quantity and quality to supply all of the needed vitamins.
The B vitamins are important as coenzyme factors in a number of metabolic activities related to
energy production, tissue protein synthesis, and functions of muscle and nerve tissue. They play
key roles in the increased metabolic activities of pregnancy.
There is an increased demand for folic acid during pregnancy. Folic acid deficiency usually occurs
in conditions of general malnutrition. A specific type of megaloblastic anemia caused by maternal
folate deficiency sometimes occurs and warrants supplementation of the diet with folic acid. This
added amount is particularly needed where such demands are greater, as in multiple pregnancies.
The RDA standard recommends a daily supplement of 400 g of folic acid to prevent such
deficiencies.
Vitamin C: Special emphasis must be given to the pregnant womans need for ascorbic acid. This
vitamin is essential to the formation of intercellular cement substance in developing connective
tissue and vascular systems. It also increases the absorption of iron. A daily increase of 20 mg is
recommended. Added to the adult recommendation of 60 mg, this makes a recommended daily
total of 80 mg during pregnancy or a 25% increase. Additional food sources such as citrus fruit and
other fruits and vegetables should be included in the mothers diet to meet these increased needs.
Vitamin D: adults who lead active lives with adequate exposure to sunlight probably need little
additional source of vitamin D. During pregnancy, however, the increased need for calcium and
phosphorus presented by the developing fetal skeletal tissue necessitates additional vitamin D to
promote the absorption and use of these minerals. The recommended amount for pregnancy is
400 IU (15 g calciferol) daily. Frequently supplementary vitamin D may be used. Food sources
include fortified milk, butter, liver, egg yolk, and fortified margarine.
Weight Gain during Pregnancy
Amount of Weight Gain: Optimal weight gain of the mother during pregnancy is an important
reflection of good nutritional status and contributes to a successful course and outcome. Usually
the amount gained is about 25-30 lbs.
Quality of Weight Gain: The important consideration lies not so much in the quantity of weight
gain but the quality of the gain and the foods consumed to bring it about, rather on a restriction on
the amount of weight gained. Some Drs. Have failed to distinguish between weight gain from
edema and that due to deposition of maternal stores laid down for energy to sustain fetal growth
during the latter part of pregnancy and energy for lactation to follow.
Rate of Weight Gain: About 2-4 lbs is an average gain during the first trimester. Thereafter, about
1 lb per week during the remainder of the pregnancy is usual. The sudden and sharp increase in
weight after the 20th week of pregnancy, which may indicate excessive, abnormal water retention,
should be monitored closely.
High Risk Mothers and Infants
To avoid the consequences of poor nutrition during pregnancy. Mothers at risk should be identified
as soon as possible. Risk factors that identify women with special nutritional needs during
pregnancy are categorized in 2 groups:
1. Risk Factors Presented at the Onset of Pregnancy
Age: 15 yrs or younger and 35 yrs or older.
Frequent pregnancies: 3 or more in 2 yrs.
Poor obstetric Hx. Or poor fetal performance
Poverty
Bizarre or faddist food habits
Abuse of nicotine, alcohol or drugs.

Therapeutic diet required for chronic disorder.

Inadequate weight: <85% of standard weight or > 120% of standard weight

2. Risk Factors Occurring During Pregnancy

Low Hg: < 12 g
Low hematocrit: <35 mg/dl.
Inadequate weight gain:
i. Any weight loss
ii. Weight gain of < 2 lbs per month after the first trimester.
Excessive weight gain: > 2 lbs per week after the first trimester.
These nutrition-related factors are based on clinical evidence of inadequate nutrition. However,
rather than waiting for clinical symptoms of poor nutrition to appear, a better approach would be to
identify poor food patterns that will cause nutritional problems and prevent them from developing.
Look for these 3 types of dietary patterns that will not support optimal maternal and fetal nutrition:
1. Insufficient food intake
2. Poor food selection
3. Poor food distribution throughout the day.
Nutritional Complications of Pregnancy
Anemia: A Hbg concentration of < 10 mg/dl and a hematocrit reading below 32 mg/dl.
Two types of nutritional anemia are common during pregnancy:
1. Iron deficiency anemia: Iron deficiency anaemia occurs when the dietary intake or
absorption of iron is insufficient, and hemoglobin, which contains iron, cannot be formed.
2. Megaloblastic anemia: is an anemia which results from a deficiency of vitamin B12 and
folic acid.
Nutrition during Lactation
An increasing amount of mothers are choosing breast-feeding for their infants. Several factors
have contributed to this:
1. More mothers are informed about the benefits of breast-feeding.
2. Drs. realize the ability of human milk to meet the needs of the infant.
3. Maternity wards and alternative birth centers are being modified to facilitate successful
lactation
4. Community support is more available even in the work place.
Nutritional Needs
Exclusive breast-feeding by a well-nourished mother can be adequate for periods varying from 215 months. Solid foods are usually added to the babys diet at about 6 months of age. The mother
may continue a prenatal nutrient supplement during lactation. Basic dietary nutritional requirements
for lactation include the following additions to the mothers prep regnant needs
Energy
The recommended increase is 500kcal. This additional energy requirement for the overall total
lactation process is based on 3 factors:
1. Milk content; an average daily milk production for lactating women is 850 ml (30 oz).
Human milk has a kcal range of 20-70 kcal/oz or an average of 24 kcal/oz. Thus 30 oz of
milk has a value of about 700kcal.
2. Milk production: the metabolic work involved in producing this amount of milk requires from
400-450 kcal.
3. Maternal adipose tissue storage: The additional energy from lactation is drawn from
maternal adipose tissue stores laid down during pregnancy in normal preparation for
lactation to follow on the maternal cycle. Depending on the adequacy of these stores,
additional energy input may be needed in the lactating womans daily diet.
Protein: An increase of 20 g is needed during lactation.
Minerals: No changes.
Vitamins: Vitamin C: an increase of 40 g and Vitamin A, B complex: slight increased

Fluids: An increased intake of fluid is necessary for adequate milk production.

INTRAPARTUM CARE
Objectives:
1. Define labour or parturition period.
2. Explain the theories of labour.
3. State the principles of care during labour.
4. Identify the stages of labour.
5. Outline the nursing management of a hospitalized client during the stages of labor.
6. Outline the mechanism of labour.
7. Describe common complications of labour.
8. Explain common disorders/conditions associated with labour.
Labor or Parturition
Definition: The process by which regularly occurring uterine contractions result in progressive
effacement and dilatation of the cervix.
Onset of labor begins when the fetus is mature and capable to exist outside uterus
Theories of Labor
Estrogen Progesterone Theory
Proposes that Estrogen and progesterone is necessary to maintain pregnancy and initiate
parturition (labor).
Progesterone and estrogen regulate the concentrations of oxytocin receptors in uterus.
As progesterone levels fall prostaglandin level rises initiating labor
Oxytocin Theory
This theory suggest that oxytocinon stimulates contractions by acting directly and indirectly on
the myometrium to increase production of prostaglandin in the decidua on the myometrium
Uterus becomes increasingly sensitive to oxytocinon as pregnancy advances.
The increase of oxytocinon levels is linked to the onset of labor.
Fetal Endocrine Control Theory:
This theory proposes that at the appropriate time of fetal maturity fetal adrenal glands secrete
corticosteroids that trigger mechanisms leading to labour.
Prostaglandin Theory:
This theory suggests that human labor be initiated by a sequence of events including:
Release of lipid precursors triggered by steroid action
Release of arachidonic from these precursors in fetal membranes
Increased prostaglandin synthesis from arachidonic acid act upon uterine muscles
Increase uterine contractions.
Premonitory Signs of Labor:
Symptoms that appear before the onset of true labor
Lightening: occurs about10-14 days before birth (primigravida)
Relief of abdominal tightness and diaphragmatic pressure experienced by the pregnant woman
Caused: by presenting part settling in the pelvis
Braxton Hicks contractions increase and occur more frequently
Cervical softening, effacement and sometimes dilatation
Increased vaginal discharge
Show: passage of a mucoid plug from the cervix may be mixed with blood from the cervix as the os
dilates
Sciatic nerve pressure resulting in low backache
Greater frequency of micturition
Spurt of energy
Occasional rupture of membranes
True Versus False Labor:
False Labor
Begins 3-4 weeks before actual delivery of the fetus
Exaggeration of Braxton Hicks contractions now accompanied by discomfort
Restlessness and sleeplessness from intensity of Braxton Hicks contractions
Tension and fatigue

Low abdominal and loin discomfort

No or little change in cervix
Discomfort relieved by walking
True Labor
Has four stages
First stage of labor: (Dilating stage)
Period from true contractions begin to complete dilatation of the cervical os (10 cms.)
First stage further divided into:
Latent phase: Onset of contractions
Softening of cervix
Cervical dilatation
Longest period
Active phase: Increase in intensity and duration of uterine activity
Ends with cervical dilatation 7cms.
Transition Phase: The cervix undergoes full dilatation (8-10 cms.)
When the os is 5cms. Dilated the woman has progressed half way point in labor
Cervical effacement is the thinning and shortening of the cervical canal from a structure of 2-3 cms
and icm. thick to no canal at all.
The terms obliteration and taken up is synonymous with effacement.
Second Stage of Labor:
The period from full dilatation to delivery of the baby
Contractions increase in intensity lasting 50-70 seconds duration at two to three minute intervals
The membranes rupture at this time with a gush of liquor (amniotic fluid) from vagina
Straining or the urge to bear down occurs with overwhelming intensity
Face becomes flushed neck veins bulge
Perspires profusely
Expiratory vocalizations
Bulging of perineum occur
Presenting part becomes visible at vaginal orifice
All ENERGY IS DIRECTED AT GIVING BIRTH:
Contractions occur rapidly with scarcely a break in between
Last 1hour in nulliparous woman and5 30 minutes in the multipara
Third stage of Labor: (Placental Stage)
The period from delivery of the newborn to delivery of the placenta and membranes
Duration 5-30 minutes
Uterus changes to globular shape
Intra-abdominal pressure exerted
Fourth Stage of Labor:
Period from delivery of placenta and membranes
To first 4 hours post-partum

Admission of Patient to Labor Ward

Reception
It is important to establish rapport with client to foster co-operation.
Greet client warmly.
Nurse should make an immediate assessment as the client enters LW.
To determine if delivery is eminent.
Ascertain reason for hospital visit.
Ask for passport.
Get ANC notes and look for abnormalities.
If client is under 18yrs, parents/guardian needs to sign consent form for surgical procedures. If an
emancipated adult may sign for herself.
History Taking
Once client presents, obtain Hx.
If having contractions
Onset, frequency, duration of contractions.
Determine if presence of show
Determine if membranes rupture.
Determine if fetal movements felt today
General Examination
Physical assessment
Begins with clients arrival
Look at general appearance
Compare height: weight ratio
Observe facial expressions (pain, anxiety)
Observe gait
Collect specimen of urine
Check for blood, ketones, glucose and proteins.
Instruct client to empty bladder once specimen collected.
Assess V/S
Ask client to undress, and lie on examination table.
Perform a physical assessment.
Abdominal examination done
Inspect, palpate, and auscultate.
Place hand on fundus for 10 mins and time the frequency, duration, and intensity of
contraction.
<20 slight, 20-40 moderate, >40 strong
If in labor place ID band
Inform relatives
ALL CLIENTS WITH NO ANC, PRIMAGRAVIDA NEEDING PELVIC ASSESSMENT AND THOSE
NOT IN LABOUR MUST BE SEEN BY THE DR.
Prepare for Vaginal Examination.
Sterile procedure done by M/W or Dr.
Record Findings:
Condition of vulva
Condition of vagina
Cervix: Dilatation and Effacement
Membranes: If intact or ruptured
Presentation
Station of presenting part
Position
Moulding
Type of P.V. loss
Abnormalities

Once it has been ascertain that the client is in true labor she is taken to a bed.
Preparation for labor
Perineal shave (optional)
Administer enema (at M/Ws discretion)
Early labor 3-4 cms.
Explain to client that she needs to remain in bathroom for at least 30 mins.
Identify needs of client
Provide adequate relief of pain.
Ensure client is as comfortable as possible.
Ensure delivery room is prepared
Resuscitation cot, Trolley, ID bands for infant, Oxygen tanks, Drugs (oxytocin,
erythromycin, vitamin K)

Management of Labor
First Stage
1. Conduct admission procedures.
Review SPCR form
Physical examination.
2. Maternal monitoring q30 mins.
V/S q30 mins except T, which is q4h unless, indicated.
Contractions q30 mins.
Ensure bladder empty. Encourage woman to void q2h.
Observe color of liquor if membranes ruptured.
Assess need for analgesics.
Perform V/E q4h, may be done sooner based on maternal condition.
Usually NPO
IV heploc insitu
Fluid given TKVO
May be placed on regime i.e. sicklers.
3. Fetal monitoring
FHR Q30 mins or sooner depending on maternal condition. Sometimes placed on
continuos monitoring.
4. Reinforce breathing and Relaxation exercises
5. Provide back massage
6. Provide use of cool damp cloth to forehead
7. Reassure client
8. Prepare delivery room
Second Stage: NEVER LEAVE CLIENT ALONE DURING THIS STAGE.
1. Confirm that woman in 2nd stage by performing VE.
2. Place in Lithotomy position.
3. Ensure bladder is empty.
4. Monitor contractions
5. Assess FHR after each contraction.
6. Observe color of liquor.
7. Give clear, precise, timely instructions
8. Keep close watch of time.
9. Maintain asepsis.
10. Reassure and encourage
11. Keep woman informed of progress.
12. Give oxytoxic drug following delivery of infant.
Third Stage
1. Mechanism of placental Separation
Signs of separation: gushing of blood, lengthening of cord and rise of fundus.
Methods of placental separation: Schultz and Matthew Duncan.
Methods of delivery: controlled cord traction, maternal effort and fundal pressure.

2. Control bleeding
Ensure oxytoxic agent given.
Syntometrine: routine drug of choice.
Syntocinon: multiparas and woman with Hx of HTN.
Assess fundus: if soft and boggy may have RPOC. MASSAGE fundus to ensure well
contracted, should be hard like a baseball.
3. Examination of placenta and membranes completes the stage.
4. Assess PV loss.
Fourth Stage
1. V/S done following delivery.
2. Assess fundus
3. Assess PV loss.
4. Allow client to rest for 1 hr.
5. Give bed bath
6. Give warm tea or meal before transfer.
7. Document all information in record book.
Mechanism of Labor
Definition: Series of passive movements of the fetus as it negotiates through the birth canal. These
movements include:
1. Engagement: the fetal head passes through the pelvic brim.
2. Flexion of head: Usually flexed @ the beginning of labor, but increases in flexion with descent.
3. Internal rotation of head: The turning forward of the head as it meets the resistance of the
pelvic floor (this creates a twist in the neck).
4. Crowning: When the head (occiput) escapes from under the symphysis and distends the vulva.
5. Extension of the head: flexion is undone pushing the head forward.
6. Restitution of head: The turning of the head to undo the twist of the head that took place during
internal rotation of the head.
7. Internal rotation of shoulders the anterior shoulder meets the resistance of the pelvic floor and
rotates forward.
8. External rotation of the head: This occurs simultaneously with internal rotation of the shoulders.
9. Lateral flexion: Sideways bending of the spine while body is being expelled. Infant is carried
forward over/towards the abdomen
Complications of Labor
First Stage Complications
Maternal
1. Maternal distress
2. Ante-partum hemorrhage: bleeding from genital tract >15mls after 28 th wk of pregnancy and
before the birth of the baby.
3. Eclampsia
4. Uterine anomalies
Prolong labor
Obstructed labor
Precipitate labor: when labor occurs within 4 hrs.
5. Cervical anomalies
Failure to dilate
Slow to dilate
6. Placental anomalies: separation or infarcts may lead to fetal distress.
7. Pelvis i.e. CPD (cephalopelvic disproportion)
Fetal
1. Large head (hydrocephalous)
2. Large baby
3. Obstruction form multiple pregnancies i.e. Locked twins.
4. Malposition i.e. occipito-posterior (OP)
5. Malpresentation i.e. Breech /face.

6. Cord anomalies
Prolapse (obstetrical emergency)
Knots/kinking
7. Liquor anomalies
Meconium stained
Amount:
Polyhydramnious : too much
Oligohydramnious: too little.
2nd Stage Complications
1. Delay
2. Obstruction of labor
3. Hypoxia
4. CPD
5. Severe perineal lacerations
6. Unyielding pelvic Floor i.e. previous perineal lacerations.
3rd Stage Complications
1. Post Partum Hemorrhage (PPH): (blood loss>500mlsfollowing expulsion of placenta)
2. Retained placenta.
3. Vulval haematoma
4. Inversion of uterus
5. Rupture of uterus
6. Hypovolemic Shock
Induction of Labor
Induction of labor: process by which labor is initiated by artificial means; may be surgical or
medical.
Augmentation of labor: the artificial stimulation of labor, that has began spontaneously.
Indications:
1. Preeclampsia
2. Eclampsia
3. Diabetes
4. Maternal infections
5. Previous precipitated labor
6. Marked polyhydramnious
7. Post-maturity
8. Evidence of diminished fetal well-being
9. Abruptio placentae
10. IUGR
11. Rhesus isoimmunization with antibodies.
12. Premature rupture of membranes
13. Fetal anomalies.
14. Unstable lie
15. IUD
16. Poor obstetrical Hx.
17. Social reasons
Types
1. Medical: use of syntocinon, or prostaglandin.
Prostan inserted PV q4-6hrs depending on progress
Syntocinon given IV 5u in 1L/D5W @10 dpm increasing by 5dpm q30 mins.
Until contracting 4:10 strong.
2. Surgical: puncture of membranes.
Contraindications
1. CPD
2. Previous C/S
3. Extensive myomectomy
4. Unfavourable presentation

5. Maternal Cardiac Disease

6. Grand multiparity.
7. Fetal distress.
8. Preterm fetus
Pre-term Labor
Labor before 37 weeks of gestation, if the os is dilating and the cervix effacing.
Cause: unknown
Predisposing Factors
1. Low socio -economic status
2. Smokers
3. High parity
4. PIH
5. Pylenephritis
6. Structural defects
7. Renal disease
8. Cervical incompetence
9. Fibroids
10. Hx of abortions
11. Placental causes
12. Multiple pregnancy
13. Fetal anomalies
14. Polyhydramnious
15. APH
16. Trauma
17. Dehydration
Management
Prevention
1. Identify woman @ risk
2. Educate on signs of pre-term labor
3. Treat ALL infections promptly.
4. Stabilize ALL medical conditions in ANC
5. Ensure early USS
Actual Mx
1. Initial Mx on LW
2. IVI
3. Pharmacotherapy
Sedatives: Pethidine and Phenergan or Valium
Ventolin: causes relaxation of the smooth muscles of the myometrium.
IVI : 5mgs of ventolin in 500 of D5W/hartmans
Titrate starting @ 10dpm increasing @ 5dpm to a maximum of 60 based on uterine activity.
Assess V/S q15 mins
Monitor uterine activity q30 minutes
Decrease if P.100
D/C if woman c/o chest pains
NPO
If contractions cease taper off ventolin infusion and give oral ventolin 4mgs q8h
MgSO4: blocks Ca from entering muscles.
4. Investigations
5. Hospitalize on bed rest on ANW
Surgical Mx
1. Shirodkir suture
2. McDonald's suture

Post-partum Care/Puerperium
Objectives:
1. Define post-partum period.

2.
3.
4.
5.
6.
7.
8.

State the principles of care during the puerperium.

Outline the nursing management of a hospitalized client during the puerperium.
Outline the criteria for discharge of postpartum patients from Maternity Ward @ PMH.
Discuss the physiological changes of the puerperium.
Identify factors that affect psychological adjustments in the puerperium .
Describe common complications of the puerperium.
Explain common minor disorders that occur during the puerperium.

Definition
A 6 8 week period that begins once the placenta has been expelled and includes:
Anatomical, physiological and psychological changes.
Reproductive organs return to their non-pregnant state.
Lactation is established.
Relationship between mother and infant is established/fostered.
Mother recovers from stressors of delivery/labor.
Principles of care
1. Promoting the physical well-being of mother and infant.
2. Establishing feeding methods of infant.
3. Encouraging the development of good maternal-child relationship.
4. Support and strengthen mothers confidence in self and abilities to care for infant.
5. Encourage the mother to fulfill her role in the family.
Immediate care
Begins on LW aka 4th stage of labor.
Made comfortable and given a bath
V/S taken.
Uterus assessed for contractility.
Blood loss assessed.
Ensure bladder is empty.
A light meal/tea may be given
Once stable, transfer to PNW.
Admission to PNW
Inform PNW
Unit prepared prior to arrival.
Welcome patient and introduce self.
Accompany LW nurse to bed with patient to establish data.
Uterus contracted.
Lochia
Passed urine.
Inform patient of risk of early ambulation.
Enquire if patient needs analgesic for pain.
Receive report from nurse.
Personal data.
Obstetrical History.
ANC.
Recent Hb and date.
STD results, Rx given.
Details of labor.
Type of delivery.

Any tears.
Amount of blood loss.
Infant
Condition , gender and A/S
Transfer location.

Subsequent Care
1. Assess general well being of client.
Ask client how she is feeling
Observe behavior of client.
2. Review History of patient to identify any risk factors and inform Dr.
Review Antenatal History
Note duration of labor, progress, and outcome of labor.
1. Assess V/S
T & P taken bd. unless indicated otherwise, if during/following delivery T >100 degrees,
then T is to be done q4h.
If other symptoms accompany elevated T, inform Dr.
Respiration are assessed only if evidence of abnormality.
Pulse is normally <80bpm, elevated pulse may be indicative of hemorrhage/infection.
B/P is assessed bd., if normotensive.
Known hypertensive or hypertensive episodes during last visits @ clinic or during labor
should be monitored q4h.
RECORD AND DOCUMENT ALL FINDINGS.
2. Perform Physical Assessment
BREAST
Expose breast and note size and shape.
Lightly palpate to determine if, soft, filling, or engorged.
Assess T.
Assess nipples for cracks, bleeding, ability to breast-feed etc.
UTERUS
Assess FH, to determine if rate of involution follows a normal pattern.
Note consistency (firmness), tenderness, and position.
Firmness indicates good contraction, if not firm massage fundus lightly until firm.
Simultaneously while assessing fundus observe lochia for:
Characteristics: presence of clots, membranes etc.
Amount: Should not exceed 4-8 partially saturated pads/day.
Color: determined based on time lapsed since delivery.
Odor: Offensive lochia indicative of infection.
PERINIUM
Provide privacy.
Examine in Sims position. Lift buttocks to expose perineum.
Assess perineum and episiotomy for:
Redness
edema
ecchymosis
discharge/drainage
approximation of suture line.
Lightly palpate area for presence of haematoma.
Observe for hemorrhoids
LOWER EXTREMITIES
Expose legs and observe both together. Note for:
Edema

3.

4.

Redness
Tenderness
Elevated T.

Early ambulation
Essential to decrease infection, and prevent complications.
Provide assistance when patient goes to bathroom for first time.
Instruct client to rise slowly from a lying position.
Explain that a gush of blood will be felt on rising.
Nutrition
A well balanced meal is essential, and dairy intake should increase
Three complete meals are given

5. Rest/Sleep
Is necessary in order to facilitate recovery from labor process.
Mother allowed to rest 1-2 hrs before infant is brought from nursery.
Ensure analgesics are given.
6. Education
Vital component and should include the following:
Relief of perineal/hemorrhoid discomfort
Use of sitz baths and topical agents.
Relief of minor discomforts.
Initiation of breast-feeding
Suppression of lactation
Resumption of physical activity
Avoid strenuous activity
Advise not to return to work for 6 wks
Resumption of sexual activity
Discourage sexual intercourse for 6 wks. , and until episiotomy healed.
Advise re family planning.
Birth registration.
Clinic Visits
9.

Ensure the mother has appointments for episiotomy or B/P check.

CRITERIA FOR DISCHARGE OF POST PARTUM PATIENTS FROM MATERNITY WARD

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

The patient looks feels and sleeps well.

The patient is eating.
The patient has passed urine normally and no residual urine is palpated in the
bladder.
the uterus is central, well contracted and at or below umbilical level.
The lochia is normal, consistency, color and odor.
Normal temperature for 24 hrs.
Pulse rate below 100/min.
B/P below 140/90 mm Hg.
If B/B above 140/90 mm Hg medication has been prescribes and a return
appointment given.
Instruction regarding personal hygiene, breast and perineal care, advice on care and
feeding of the infant has been given.
Full ambulation has been established.
Mother does not complain of headache, undue abdominal comfort, pain or swelling
of legs.
Hb level is normal, and treatment prescribed where necessary.
Physical assessment of mother by Dr.
Blood group and Rhesus factor known, and appropriate measures taken if Rh
negativity exists.
VDRL/STIs results known and appropriate measures taken.

17.
18.
19.
20.

Mother is knowledgeable about what immunization is required and where to take the
infant.
Knowledge of birth registration.
Medications such as sedatives or hypotensive agents given immediately prior to
discharge.
Nursing records completed and current.

Physiological Changes in Puerperium

Endocrine system
Oxytocin increases
Aids in placental separation.
Affects uterine and breast muscles.
Maintains contraction of the uterine muscles after the 3 rd stage to prevent
hemorrhage.
hCG decreases.
Estrogen and progesterone levels fall rapidly.
Prolactin is secreted.
Reproductive System
Uterus
Involution: process by which the uterus returns to its pregravid state.
Immediately after delivery, the fundus is hard, globular and contracted.
Usually felt below the umbilicus, then rises to the umbilicus.
As the uterus involutes it descends into the pelvic cavity 1 cm per day. By 10 th 12th day
the fundus is not palpable.
Involution occurs more rapidly in primagravadas due to muscle tone and women
breastfeeding due to release of oxytocin.
Factors causing delay in Involution
Multiparity
Polyhydramnious.
Multiple pregnancy
Large babies
Infection
Prolong labor
Cervix
Immediately after delivery is soft, flabby and partially open.
Loses its vascularity in 2 3 days and returns to its hard consistency.
External os is now a transverse slit vs. a pinhole I non-parous women.
Lochia: Discharge during puerperium, which contains:
Blood from placental site
Cervical secretions
Epithelial cells
Decidua
Placental tissue
Membranes
Lanugo
Vernix caseouses
Meconium (sometimes).
Types/Stages
1.
Lochia rubra
Bright red
First 4 days of puerperium
2.
Lochia Serosa
Pink in color
5 9 days of puerperium
3.
Lochia Alba
Creamy white in color
10 14 days of puerperium
The pH of lochia is alkaline.
Scanty lochia suggestive of infection.
Excessive lochia with clots after 24 hour and accompanied by pain is indicative of RPOC.
Offensive lochia may indicate poor vulval hygiene or infection.

Breast
Post delivery the breast is soft and may contain colostrum.
Increase prolactin stimulates the production of milk by 2 3 days and the breast become
full.
Primary areola never regains its color.
Secondary areola fades at 3months.
Perineum
Vagina
Decrease progesterone, allows for recovery of normal muscle tone.
Rugae reappear around the 3rd week.
Rectum
Hemorrhoids shrink.
Normal defecation pattern.
Urinary System
Increase in urinary output for the first 2-5 days.
Presence of nitrogen and albumin in the urine.
Cardiovascular System.
Decrease blood volume due to blood loss.
Leucocytosis occurs during labor and post delivery to fight infection.
Fibrinogen level increases.
Pulse rate slows.
Gastrointestinal System
Women loses 10 12 lbs. @ delivery and then 5 lbs one week later
Integument System
The marks of pregnancy eventually fade.
Linea negra fades, but does not disappear.
Striae gravidarium fades, but never goes away.
Psychological Changes in Puerperium
The arrival of an infant causes major adjustments.
Social life and finances.
Expectations of father, in-laws and siblings.
Recovery of mother vs. caring for infant.
Sibling rivalry.
Mothering Skills:
Mother may feel overwhelmed.
Sensitive to criticism.
Needs to build self-confidence.
Quality contact with infant.
Note:
It is important for the nurse to identify 3rd Day Blues and signs of Post-partum Depression.

Complications of the Puerperium

Vaginal Tears:
1st degree: involve vaginal mucosa and perineum.
2nd degree: involves deeper layers of perineal muscles.
3rd degree: extends to the anal margin.
4th degree: involves anal muscles and mucosa.
Management:
Anesthesia and suturing in layers of traumatized areas.
Pain relief: panadols, or IM/IV pethidine.
Warm sitz baths.
Infra red heat.
Physiotherapy: intensive pelvic floor exercise.
Proper hygiene
Avoid retention of urine: catheterize if necessary and retrain bladder.
Puerperal Infection:
Causes: E. coli. Streptococcus faecalis, Clostridium welchii
Clinical Manifestations: pyrexia (first sign), increase pulse rate, uterus tender on palpation, sudden
collapse.
Management: IV antibiotics, analgesics, Strict I & O., V/S q4h, proper hygiene- vulval swabbing.
Breast Infections
Infection may enter the breast via cracked nipples and spread through interlobular tissue.
Clinical Manifestations: sharp rise in temperature, throbbing pain and tenderness in affected
breast, rapid pulse, wedge shape reddened area of affected breast.
Management: Abscess: I & D., Antibiotic therapy.

Minor Disorders in the Puerperium

a.

After-pains
Pain is in the uterus during the first few days after childbirth, due to the contraction of the
muscles, due to the release of oxytocin.
Pains are strongest during breast-feeding, and in multiparous women and women with
large babies.
Management:
Palpate the uterus and assess lochia to ensure that the uterus is not attempting to
expel clots/retained products.
Relieve pain by administering oral analgesics i.e. Panadol, Baralgin or Tylenol
Position/advise client to lie in prone position with a small pillow under the
abdomen. Initially the pain intensifies then disappears

b.

Retention of Urine
Traumas as a result of fetal head on urethra and bladder may result in loss of muscle
sphincter tone seen immediately after delivery. Cause considerable discomfort and may
result in retention with overflow if not relieved
Management:
Encourage mother to void frequently to regain muscle tone
Encourage early ambulation and post natal pelvic floor exercises.
Insert catheter to empty bladder if above fails:
Maintain catheter for 24hrs.
Bladder training to recover muscle tone
Educate: importance of voiding

c.

Engorgement
Occurs on 2-4 day, due to filling of breast lobules with milk. The breast is usually hard,
shiny, and painful and skin is lumpy.
Management
Early establishment of breast-feeding
Use of warm compressors to breast
Gentle expression of milk.
Relieve pain with analgesics

d.

Sore Nipples: Commonly seen in primagravida.

Cause:
Poor preparation of breast during pregnancy
Poor technique in breast-feeding.
Infection ex. Thrush (infant)
Poor development of breast/retracted nipples.
Management: Treat the cause
Adequate antenatal preparation.
Prevention of trauma by wearing proper bra. Bra should avoid compression of
nipples.
Relieve pain

e.

Hemorrhoids: Engorgement of the hemorrhoid plexus of veins at the lower ends of the
bowels.
Etiology: Bearing down during the 2nd stage of labor results in prolapse.
Management:
Education in ANC. re: diet, fluid intake, pushing technique in labor.
Use of sitz baths and cold compressors.
Use of anesthetic agents.
Use of astringents
Avoid prolong sitting.
Use of stool softeners if constipated.
May be reduced digitally and client placed on bed-rest

Please read the following:

Constipation
Backaches
Varicose Veins of vulva and legs.
Urinary stress incontinence
Galactorrhoea
Hypogalactia

MANAGEMENT OF THE NEWBORN

Objectives:
1.
Outline the immediate and subsequent care of the newborn.
2.
Explain APGAR.
3.
Discuss the nursing management of minor disorders in the newborn.
4.
Identify common congenital anomalies in the newborn.
Immediate Care of Infant
INFANT SHOULD BE HANDLED WITH GLOVES UNTIL FIRST BATH.
Resuscitar should be on before delivery.
Once the infant is delivered, note time of delivery.
The mouth then the nostrils are suctioned for excessive mucous.
The cord is clamped in two places and cut.
Ensure respiration is present.
Dry the infant thoroughly to prevent hypothermia. Discard blanket and place infant on a clean,
dry, warm blanket.
Assess infant @ 1 minute.
Perform initial Head to toe assessment
Weigh and measure infant
Place Identification tags on infant after mother has confirmed.
Give routine Rx
Erythromycin eye ointment applied to infants conjunctiva. Apply from inner cantus to
outer.
Vit. K 1mg given IM into thigh (promotes prothrombin formation)
Perform apgar @ 5 minutes.
Infant is wrapped in blanket. Avoid over exposure when not under resuscitar.
Bonding with mother is encouraged and breast-feeding is initiated if infant is active and alert.
Pay attention to color, respiration, and cord clamp.
Note if infant passes urine or had a bowel movement.
Confirm identification of infant with mother before transferring to Ward Nursery.
Apgar Score
A five part scoring system used to assess the neonate at 1 minute and 5 minutes of life.
If the infant is critically ill the apgar is done at 10 minutes.
Scores range from 0-10.
8-10: indicates neonate is in no apparent distress.
5-7: indicates mild respiratory, metabolic or neurological depression.
< 5: indicates more resuscitative measures may be needed.
Five areas are assessed:
Appearance: Note the color
Pulse: Assess apical heart rate.
Grimace: Assess reflexes/irritability.
Activity: Assess muscle tone/coordination of movements.
Respiration: Assess rate of breathing.
Table demonstrating Apgar Score System
Area
0

Color

Blue/pale

Blue extremities

Pink

Heart rate

Absent

<100

>100

Slow/irregular

Lusty cry

Respiratory Effort

Absent

Tone

Flaccid

Minimal flexion

Active motion

Reflex

No response

Weak response

Vigorous response

PLEASE READ: Reflexes in the Newborn

Subsequent Care of Infant

Infant is kept under heating lamp for 2-3 hours.
Allows warming up and provides a period of rest.
Infant is bathed, dressed and may be fed.
A full physical examination is preformed by the physician.
Infant may be discharged to postnatal ward.
Nurse assists the mother with breast feeding and demonstrates how to clean the cord.
Infants of C/S, hypertensive mothers may be kept in nursery longer to allow the mother to rest.
Infants will low apgar score or ill may remain in nursery for observations.
Transfer of Infant to Nursery
1. Name and Age of mother
Name: confirms identification.
Age: may have implications in relation to education re: breast-feeding.
2. Gender of infant
Verifies identification of infant, when comparing identification bands
3. Gestational age of infant.
Directs level of care given. Ex. Preterm and post-term infants monitored closely for
hypoglycemia.
Overweight/big babies of diabetic mothers are big but still preterm. Monitor closely.
4. Place and time of delivery
Place: if delivered @ home Vs hospital so as to channel level of care.
5. Type of delivery.
Directs level of care given Ex. Infants delivered by forceps/vacuum must be nursed in
isolette and observed for cerebral irritation
6. Weight of infant
Overweight/LBW infants tend to be poor suckers and usually the mother needs assistance
with breast-feeding.
7. Apgar score
Gives an indication of infant well-being post delivery. Infants with low Apgar score need
closer monitoring for complications, such as apnea.
8. Response to resuscitation (if required).
Directs level of care given. Infants who may have required resuscitative interventions, for
ex. Infants with slow onset to breathe should be nursed in an isolette with oxygen.
9. Choice of feeding
The nurse should inform the receiving nurse if breast-feeding was initiated and method of
feeding.
This allows for mothers wish to be complied with, especially if she does not wish to use
cows milk.
10. Blood group of mother
If Mother Rh gives indication for follow-up, checking of SB levels early feeds.
If cord blood was saved, so that Dr. can take blood for testing.

11. Rx given
If Routine Rx given, if not given the nurse may give.
If infant received Narcan, they need to be monitored for reoccurrence of respiratory
depression.
12. Complications
If birth injuries sustained, so Dr may examine promptly,
Directs nursing care, Ex. Infants with cephalahaematoma must be monitored for shock.
13. VDRL/HIV status of mother.
Provides guidelines for the type of Care/Rx given to infants.
14. Risk factors in mother.
If mother had any factor that may have placed infant at risk for problems post- delivery, so
these may be addressed or observed for to prevent complications.
15. If infant passed Urine or Meconium
Provides information about patency of urethra and anus.
CRITERIA FOR DISCHARGE OF INFANT
1.
Identification has been clearly established.
2.
Feeding routine established an infant observed while feeding on at least two
occasions.
3.
Infant has passed urine and feces.
4.
There is no vomiting.
5.
Appearance and general condition are satisfactory.
6.
Physical examination completed by Pediatrician.
Minor Disorders of the Newborn
a. Physiologic Jaundice
Most common type of Jaundice seen in newborns.
Occurs in term and preterm infants. Usually presents in 2-3 days.
Disappears within7 days of birth.
Causes: Increased production of bilirubin due to rapid breakdown of unwanted RBC.
Liver immaturity.
Management:
Early feeding encourages gut motility and supplies glucose for manufacture of liver
enzymes.
Ensure feeds are given q2-3 hrs.
Monitor SB levels (Normal: 0.2-7 mmol/L) if >9mmol/L infant remains hospitalized.
Undress infant and expose to sunlight 2-3 times daily for 15 mins.
b. Vomiting
Common in newborns and differs from regurgitation.
Cause: Irritation of the stomach lining due to swallowed blood or meconium.
Feeding technique may be too slow or rapid/over feeding/failure to burp infant.
Weakness of cardiac sphincter muscle.
Management: Treat the cause
Educate the mother
Refer where necessary
c. Sore Buttocks:
Common complaint.
Varies from slight redness to excoriation.
Causes: Infrequent changes of diaper
Frequent stools
Improper cleansing of skin
Allergy to pampers

Fungal or microbial infections

Management: Ascertain cause
Change diapers frequently
Wash, rinse, and dry skin properly
Expose buttocks to air and sunshine
Use barrier crmes or healing agents.
d. Pseudomenstration
Characterized by bloodstain vaginal discharge.
Cause: due to withdrawal of the influence of maternal hormones
Management: Nil. Disappears spontaneously
e. Engorged Breast
Breast is hard and exudes a watery milk fluid.
Management:
Advise mother not to squeeze.
Condition subsides in 2-3 wks.
f.

Skin rashes
Milia: white spots located on cheeks and chin.
Cause: retention of secretions in sebaceous glands.
Management: Nil. Disappears within 2 wks.
Mongolian spots: Bluish discoloration formed over lower spines, legs and buttocks
Cause: Unknown
Management: Nil. Disappears eventually.

g. Hydrocele
Accumulation of fluid in sac surrounding testes, characterized by painless enlargement of
scrotum.
Management: Nil. Disappears within 6 wks.
h. Vasomotor instability
Bluish discoloration of hands and feet with good color over remainder of the body, which last
for a few minutes then disappear. Common in the preterm infant.
Management: Nil.
i.

Sucking blister: harmless blister on upper lip due to improper attachment disappears without
scarring.
Management: Nil.

j.

Cranial cyanosis
Bluish discoloration of the head and pink bodies.
Causes: delay in the delivery of the shoulder.
Cord tight around the neck.
Management: Nil.

k. Abnormalities of stool
Diarrhea: >3 extra loose watery stools.
Management:
Advise mother re: breast-feeding
Proper hand-washing
Constipation: NO stools are passed for 48hrs.
Cause: thick, sticky meconium.
Imperforated anus
Intestinal obstruction
Under-feeding
Management:
Give extra fluids
Avoid giving laxatives.

Encourage breast-feeding.

Congenital Anomalies
Definition: Any defect of form, structure, or function during conception or in fetal life.
Causes: May be inherited due to genetic factors or acquired due to damage during development.
1. Drugs
2. Maternal age
3. Radiation
4. Nutrition
5. Infection
6. Inherited
7. Hypoxia
Inherited Anomalies: spermatozoa and ovum carries the flaw. Usually results in abortion.
May be: autosomal dominant, ex. Deafness
autosomal recessive. Ex. Sickle cell
polygenetic, ex. Cleft palate
x-linked, ex. Hemophilia
CNS anomalies
1. Hydrocephaly: excessive CSF in ventricles of brain.
2. Anencephaly: cranial vault missing and /or cerebral hemispheres small or missing.
3. Microcephaly: small vault of skull, indicating a decrease in brain tissue.
4. Encephalocele: tumors covered by meninges that protrude through the lamboidal suture,
normally contains brain tissue.
5. Meningiocele: meninges protruding on spinal column, usually lumbar region.
GI. Tract anomalies
1.
Cleft palate/lip: non-union of hard or soft palate /lip.
2.
Pierre Robins Syndrome: characterized by small lower jaw, cleft palate
and displacement of tongue.
3.
Esophageal Atresia: absence of the normal opening of the esophagus.
4.
Diaphragmatic hernia: a protrusion occurring at the diaphragm.
5.
Omphalocele/exomphalus: herniation of abdominal contents through the umbilical opening.
6.
Hirshsprung disease: an obstruction caused by reduced motility in the colon.
Musculo-skeletal anomalies
1.
Congenital hip dislocation
2.
Talipes: a deformity in which the foot has developed at an abnormal angle of the leg
3.
Polydactyl: excessive digits.
4.
Syndactyl: webbing of digits.
Genitourinary anomalies
1.
Hypospadios: urethral opening on the underside of the penis in males.
Urethral opening into the vagina.
2.
Epispadios: abnormal opening of the urethra on the dorsal surface of the penis.
Importance of Early detection
1.
Early detection gives team time to plan the course of the pregnancy.
2.
Prepares the mother, and broadens her options.
3.
Proper referral.
4.
Proper delivery Management.

References:
Amniotic fluid: http://www.nlm.nih.gov/medlineplus/ency/article/002220.htm
Bennett, V.R., & Brown, L.A. (1996). Myles textbook for midwives. Churchill Livingston: New York.
Fetal development: http://www.nlm.nih.gov/medlineplus/ency/article/002398.htm
Lowdermilk, D.L. Perry, S.E. (2004). Maternity & womens health care. (8 th ed.). St. Louis: Mosby
Elsevier.
Murray, S. S., & McKinney, E. S. (2006). Foundations of maternal-newborn nursing. (4 th ed.). St.
Louis: Mosby, Saunders & Elsevier.
Orshan, S. A. (2008). Maternity, newborn, and womens health nursing: Comprehensive care
across the lifespan. Philadelphia: Lippincott, Williams & Wilkins.
Reeder, S.J., & Martin, L.L. (2004) Maternity nursing: Family, newborn, and womens health care.
J.B. Lippincott: Philadelphia.
Scott - Ricci, S. (2007). Essentials of maternity, newnorn and womens health nursing.
Philadelphia: Lippincott, Williams & Wilkins.