FG Midwifery I

NMT 05111
Midwifery I
NTA Level 5 Facilitator’s Guide for
Certificate in Nursing
September 2013
United Republic of Tanzania

Ministry of Health and Social Welfare
Ministry of Health and Social Welfare
Department of Human Resources Development
Nursing Training Section
© Ministry of Health and Social Welfare 2013
Table of Contents
Goals and Objectives of the Training Manual .......................................................................................vi
Overall Goal for training manual .......................................................................................................vi
Objectives for training manual...........................................................................................................vi
Introduction...........................................................................................................................................vii
Module Overview .............................................................................................................................vii
Who is the Module For? ...................................................................................................................vii
How is the Module Organized? ........................................................................................................vii
How Should the Module be Used? ...................................................................................................vii
Module Sessions
Session 1: History of Midwifery in Tanzania................................................................................... 1
Session 2: Male and Female Reproductive Organs.......................................................................... 5
Session 3: Female Internal Reproductive Organs .......................................................................... 11
Session 4: Anatomy and Physiology of the Female Bony Pelvis............................................... 18
Session 5: Pelvic Diameters Related to Fetal Skull........................................................................ 25
Session 6: Law, Code of Conduct and Standards Guiding Midwifery....................................... 34
Session 7: Cultural and Social Issues ............................................................................................. 40
Session 8: Safe/Good Socio-Cultural Practices.............................................................................. 44
Session 9: Physiology of Pregnancy .............................................................................................. 47
Session 10: Placenta and Foetus....................................................................................................... 54
Session 11: Physiological Changes during Pregnancy..................................................................... 65
Session 12: Signs and Symptoms and Minor Disorders of Pregnancy.......................................... 74
Session 13: Relationship of the Fetus to the Mother’s Uterus and Pelvis.................................... 81
Session 14: Social, Cultural and Economical Aspects with Reproductive and Child Health
Services …….. ...................................................................................................................................... 86
Session 15: Concept and Elements of Focused Antenatal Care (FANC)...................................... 93
NMT 05111 Midwifery I NTA Level 5, Semester 1

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Session 16: Elements of Focused Antenatal Care (FANC) ............................................................. 102
Session 17: FANC Elements 5, 6 and 7 ......................................................................................... 110
Session 18: Physiology of Labour.................................................................................................. 119
Session 19: Use of Partograph in Managing Labour...................................................................... 126
Session 20: Filling and Interpreting the Partograph Findings ........................................................ 132
Session 21: Management a Woman in First Stage of Labour ........................................................ 144
Session 22: Second Stage of Labour .............................................................................................. 154
Session 23: Management of the Third and Fourth Stages of Labour ............................................. 162
Session 24: Management of a Woman with Normal Puerperium .................................................. 170
Session 25: Safe Pharmacological Substances during Pregnancy, Birth and Breastfeeding.......... 177

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Acknowledgement
The development of the training manuals for Certificate and Diploma in Nursing (NTA Level
4 to 6) has been possible and accomplished through involvement of different stakeholders.
The Ministry of Health and Social Welfare (MoHSW) through the Director of Human
Resources Development sends sincere gratitude to the stakeholders including the
coordinating team (Department of Nursing and Midwifery Training), TNI, through AIHA and
the WINONA state University for funding the activity.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these training materials. The ministry of Health would like
to thank the Assistant Director for Nursing Training section Mr. Ndementria Vermand, and
Ms. Vumilia B.E Mmari (Coordinator for Nursing and Midwifery Training) who tirelessly led
this important process.
Sincere gratitude is expressed to main facilitator: Mr. Golden Masika, Tutorial Assistant
University of Dodoma for his tireless efforts and Mr. Nicolaus Ndenzako Programme
consultant of AMCA inter consultant in guiding participants through the process. Special
thanks go to the team of contributors representing the Health Training Institutions, hospitals
and Universities. Their participation in meetings and workshops and their inputs in the
development of the content for each module have been invaluable. It is the commitment of
these participants that has made this product possible.
These participants are listed with our gratitude below:
SN Name Title Institution

1. Mary S. Matembo Nurse Tutor Korogwe NTC
2. Elialilia M. Herman Nurse Tutor MT. Meru Hospital
3. Alice Chifunda Nurse Tutor Mbulu NTC
4. Lilian Wilfreda Nurse Tutor KCMC
5. Aselina Milinga Nurse Tutor KCMC
6. Veronica Mahela Nurse Tutor Kahama
7. Samwel Mwangoka Nurse Tutor Mbeya SOTM
8. Hamza S. Matagira Nurse Tutor Kahama NTC
9. Elikana Wallace Nurse Tutor Kolandoto S/Nursing
10. Anna Sangito Pallangyo Nurse Tutor Kahama NTC
11. David Abincha Nurse Tutor Bukumbi NTC
12. Leon S. Mgohamwende Nurse Tutor Tosamaganga NTC
13. Crescent D. Ombay Nurse Tutor Haydom S/Nursing
14. Kizito B. Tamba Nurse Tutor Ndanda S/N
15. Robert E. Moshi Nurse Tutor IMTU college of Nursing
16. Oresta Ngahi Nurse Tutor Muhimbili S/N
17. Aloyce Ambokile Nurse Tutor Kondoa District Hosp.
18. Helma A. Shimbo Nurse Tutor Mwambani NTC
19. Elizabeth G. Chezue PNO N Tutor MOHSW HIS & QAS
20. Hinju Januarius Obstetrian Dodoma Regional Hosp.
21. Manase Nsunza Principal HLT Singida HLTC
22. Ezekiel Amata IMC Facilitator Mpwapwa Hosp.
23. Sostenes D. Ntambuto HLT Tutor SMLS MUHIMBILI

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24. Anna Sangito Pallanyo N/Tutor Kahama SN
25. Naomi Kagya NT Muhimbili
26. Aloyce Amboikile Nurse Kondoa
27. Golden Masika Lecturer UDOM
28. Vumilia B.E. Mmari CD-NT MOHSW
29. Upendo kilume Nurse PHN
30. Fatuma Iddi Librarian MOHSW
31. Shango Nasania Nurse Newala
32. George Laisser C/Analyst MOHSW
33. Anande Mungure Nurse Tutor Mbulu NTC
34. Robert Masano Nurse Tutor Nkinga NTC
35. Ambokile Dodoma General Hospital
36. Nolasca Mtega Nurse Tutor Tukuyu School of Nursing
37. Asteria Ndomba Senior Lecturer CUHAS
38. Alfreda Ndunguru
39. Elizabeth Chezua MOHSW
40. Magwaza Charles
41. Ellen Mwandemele
42. Robert Mushi IMTU
43. Anna Mangula Nurse Tutor Mirembe NTC
44. Cesilia Mallya Nurse tutor Newala NTC
45. Helma Shimba
46. Kapaya Andrew TNMC
47. Ntambuto Sostenese
48. Joseph Nkungu
49. Anastazia Dinho
50. Eliaremisa Ayo Nurse Tutor MOHSW
51. Grace Mallya Paediatrician RCHS/GBV/VAC-MOHSW
52. Dr. Tecla Kohi Senior Lecturer MUHAS
53. Dr. Lilian Msele Lecturer MUHAS
Supporting staff:
Daniel Muslim Driver, Ministry of Health and Social Welfare
Fatuma Mohamed Health Librarian, Ministry of Health and Social Welfare
Mbaruku A. Luga Driver, Morogoro School of Public Health Nursing
Roselinda RugemaliraAdm. Secretary, Tanzania Nursing & Midwifery Council
Veronica Semhando Secretary Ministry of Health & Social Welfare
George Laizer System Analyst Ministry of Health & Social Welfare
Silvanus Ilomo System Analyst Ministry of Health & Social Welfare
Violet Mrema Adm. Secretary, Ministry of Health and Social Welfare
Walter Ndesanjo System Analyst, Ministry of Health and Social Welfare
Dr. Gozbert Mutahyabarwa

Ag: Director of Human Resource and Development,

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Background
In 2007 the Ministry of Health and Social welfare (MOHSW) started the process of
reviewing the nursing curricula at Certificate and diploma level. In 2008 refined and
developed NTA Level 4 to 6 Nursing Curricula and in the same year 2008 started the
implementation. The intention was to comply with the National Council for Technical award
(NACTE) Qualification framework which offers a climbing ladder for higher skills
opportunity. Advanced Diploma awards are not among the awards of the council and do not
conform to NACTE framework. Therefore, institutions offering Advanced Diploma in
nursing are required to either offer Ordinary Diploma (NTA Level 6) or develop its capacity
to offer Bachelor’s Degree (NTA Level 7&8).
These programs have been developed in line with the above consideration aiming at
providing a room for Nurses to continue to a higher learning and achieve advanced skills
which will enable them to perform duties competently. In addition, WHO advocates for
skilled and motivated health workers in producing good health services and increase
performance of health systems (WHO World Health Report, 2006). Moreover, Primary
Health Care Development Program (PHCDP) (2007-15) needs the nation to strengthen and
expand health services at ALL levels. This can only be achieved when the Nation has
adequate, appropriately trained and competent work force who can be deployed in the health
facilities to facilitate the provisions of quality health care services.
In line with these new curricula, the MOHSW supported tutors by developing quality
standardized training materials to accompany the implementation of the developed curricula.
These training materials will address the foreseen discrepancies in the implementation of the
new curricula. NTA level 8 training materials have been developed after Curricula validation
and verification.
This training material has been developed through writers’ workshop (WW) model. The
model included a series of workshops in which tutors and content experts developed training
materials, guided by facilitators with expertise in instructional design and curriculum
development. The goals of Writer’s Workshop were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders
(NACTE, MOHSW, AIHA and WINONA University) and experts of different organizations
and institutions. The new training package for NTA Level 4-6 includes a Facilitator Guide
and Student Manual. There are 28 modules with approximately 520 content sessions

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Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a
health system that is responsive to the needs of the people, and leads to improved health
status for all. Skilled and motivated health workers are crucially important for producing
good health through increasing the performance of health systems (WHO, 2006). With
limited resources (human and non-human resources), the MOHSW supported tutors by
developing standardized training materials to accompany the implementation of the
developed CBET curricula. These training manuals address the foreseen discrepancies in the
implementation of the new curricula.
Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels
4-6) aims at providing a room for Nurses to continue achieving skills which will enable them
to perform competently. These manuals will establish conducive and sustainable training
environment that will allow students and graduates to perform efficiently at their relevant
levels. Moreover, this will enable them to aspire for attainment of higher knowledge, skills
and attitudes in promoting excellence in nursing practice.
Goals and Objectives of the Training Manual
Overall Goal for training manual

The overall goal of these training manual is to provide high quality, standardized and
competence-based training materials for Diploma in nursing (NTA level 4 to 6) program.
Objectives for training manual

 To provide high quality, standardized and competence-based training materials.
 To provide a guide for tutors to deliver high quality training materials.
 Enable students to learn more effectively.

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Introduction
Module Overview
This module content has been prepared as a guide for tutors of NTA Level 5 for training
students. The session contents are based on the sub-enabling outcomes of the curriculum of
NTA Level 5 Certificate in Nursing.
The module sub-enabling outcome as follows:
2.1.1 Differentiate major parts of female reproductive system
2.1.2 Recognise physiological changes in females pertaining to reproductive health
2.1.8 Interrelate social, cultural and economical aspects with reproductive and child health services
in Tanzania
2.1.3 Describe principles of caring for women during pre, intra and postnatal period
2.3.1 Utilise partograph in identifying abnormalities in labour stages
2.3.2 Comprehend the physiology of labour
2.3.4 Describe the management of 3rd and 4th stages of labour
2.3.3 Differentiate 1st, 2nd and 3rd stages of labour
2.3.7 Utilise Focused Antenatal Care (FANC) in reproductive health
Who is the Module For?

This module is intended for use primarily by tutors of NTA Level 5 in nursing schools.
The module’ sessions give guidance on the time and activities of the session and provide
information on how to teach the session to students. The sessions include different activities
which focus on increasing students’ knowledge, skills and attitudes.
How is the Module Organized?

The module is divided into 25 sessions; each session is divided into sections. The following
are the sections of each session:
 Session Title: The name of the session.
 Learning Tasks – Statements which indicate what the student is expected to learn at the
end of the session.
 Session Content – All the session contents are divided into steps. Each step has a
heading and an estimated time to teach that step. Also, this section includes instructions
for the tutor and activities with their instructions to be done during teaching of the
contents.
 Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
 Evaluation – The last section of the session consists of short questions based on the
learning objectives to check the understanding of students.
 Handouts are additional information which can be used in the classroom while teaching
or later for students’ further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the participants to study material on their own and to reference after the session.
Sometimes, a handout will have questions or an exercise for the participants. The
answers to the questions are in the Facilitator Guide Handout, and not in the Student
Manual Handout.
How Should the Module be Used?

Students are expected to use the module in the classroom and clinical settings and during
self-study. The contents of the modules are the basis for learning Midwifery I. Students are

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therefore advised to learn each session and the relevant handouts and worksheets during class
hours, clinical hours and self-study time. Tutors are there to provide guidance and to respond
to all difficulty encountered by students.

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Session 1: History of Midwifery in Tanzania
Total Session Time: 60 minutes
Prerequisites
 None
Learning Tasks
By the end of this session, students are expected to be able to:
 Explain the history of Midwifery in Tanzania
Resources Needed
 Flipcharts, marker pens, masking tape
 Black/whiteboard and chalk/white board markers
 Projector
 Computer
SESSION OVERVIEW
Step Time Activity /Method Content
1 5 minutes Presentation Presentation of Session Title and Related

Tasks
2 25 minutes Presentation/ History of Midwifery in Tanzania
Brainstorm
3 20 minutes Presentation Major Development in Midwifery
Brainstorm
4 5 minutes Presentation Key Points
5 5 minutes Presentation Evaluation
SESSION CONTENT
Step 1: Presentation of the Session Title and Related Tasks (5 minutes)
READ or ASK students to read the Learning Task and clarify.
ASK Students if they have any questions before proceeding.
NMT 05111 Midwifery I

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NTA Level 5, Semester 1 Session 1: History of Midwifery in
Tanzania
Step 2: History of Midwifery in Tanzania (25 minutes)
 Traditionally, the care of patient and women during pregnancy and child birth was the
function of older women in the community who were known as Traditional Birth
Attendants (TBA) or village local midwife.
 They were highly respected because they were doing their work voluntary although they
were given small present like hens and goats depending on culture of that community.
 In every society they had their own norms, taboos and cultures on how to support and
provide care to women during pregnancy, child birth and postpartum period.
 The Western medicine was introduced in Tanganyika (Tanzania) in 1877 by the Church
Missionaries Society (CMS) initiated by Dr Livingstone. The CMS was followed by
other Mission Societies both from Britain and Germany (UMCA)-(United Mission
Society of Africa). Wherever they established Missions, they also started a dispensary to
which were added beds for Maternity patients.
 At first women were reluctant to change their traditional ways of delivery. They
preferred and trusted their traditional Midwives who attended them at their homes. The
Missionaries made efforts to provide simple teaching to the traditional midwives on
hygiene of using water and soap to wash hands when attending a child birth at home.
 These older women were given some basic knowledge and skills through on the job
training and supportive supervision to provide health services to patients including
assisting women during child birth and they tended to be very good and kind nurses.
Step 3: Major Development in Midwifery (20 minutes)
Activity: Brainstorming (10 minutes)
DIVIDE students in small manageable groups
ASK students in their groups to brain storm schools offering Midwifery in Tanzania
ALLOW few groups to respond
WRITE the responses on the board
CLARIFY and summarize using the information below
Midwifery Training
 In 1937 the first intake of Midwifery started at Tanga. These students qualified in
January, 1940. According to the available records they show the first Midwife to be
registered was called Mary Louise.
 In 1945, Lulindi started to train Midwives
 In 1946, Magila started to train Midwives
 In 1947, Mvumi started to train Midwives
 By 1950, there were all together 8 schools training Midwives. They were Tanga, Lulindi,
Magila, Sumve, Peramiho and Princess Margaret-(Muhimbili Hospital) at famous
“Makuti” area.

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Tanzania
 In 1952, a new course with an annual intake of 12 students was established at Tukuyu to
train Health Nurses. The course took two years, and included Midwifery, Child care,
Nursing, Nutrition, Hygiene, First Aid and Domestic home craft. The Health Nurses on
completion were posted to Rural Maternity and Child Welfare Clinics (now known as
RCH Clinics) where they worked under supervision of health Visitors who were all
foreigners.
 The clinics generally conducted health teaching and school health supervision. Older
women were preferred for this course as it was thought they could exert a greater
influence in the villages although they were intended to act as Midwives.
 In addition to this course, village Midwives were trained for 2 years at Mission Hospitals,
and performed similar functions as for the Health Nurses. A limited number of
“practical” or Village Midwives were trained informally at District Hospitals.
 In 1960-1970, more Midwifery Schools were established and made a total of 12. The
schools were Kilimatinde, Makiungu, Ndolage and Sengerema.
 In 1952, The Tanganyika Nurses and Midwives Council was set up by the act of the
parliament to control and regulates the affairs of the Nurses. In Nurses and Midwives
Registration Regulation, midwives are registered in the following parts:
 Part Two Midwives.......Midwives......Staff Midwife
 Part Eight Midwife Tutor…Midwife Tutors
 In 1975, Maternal and Child Health Aids – Training (MCHA) was established assisted by
Aid from the United States of America.
 By then, only six schools were in full operation. The program expanded, 18 schools were
constructed, which were equipped and in full operation. The 19th school at Mrugwanza
in Ngara District West Lake Region was operated later.
 At first, the MCHA Schools were taking ex-Primary School leavers with working
experience as Nursing or Ward Attendants and were trained for 1 year before they
were sent back to MCH Clinics in the rural areas. This went on up to 1977.
 From 1978, training of the Village Midwives or Ward Attendant was abandoned,
instead young girls were selected from the villages, those with Primary Education.
These were trained for 18 months and qualified as MCHAids. The programme continued
up to 1980 when the duration was raised from 18 months to 2 years.
 In order to unify the service the former Village Midwives who were trained for 1 year
were brought to do the MCH Aids. The programme was conducted by the Ministry of
Health and offered a certificate of qualification and kept the list of qualified MCH Aids.
The course was not recognized by the TNM Council, therefore they were not registered.
 Though the MCH Aids programme was not included in the Register of Nurses – The
MCH Aids had a well defined scheme of service for their progress which did take
them up to higher positions in Nursing. Usually after under taking an in-service
course an MCH Aid took 18 months, in-service course to qualify as a Public Health
Section B, which was eligible to be registered with the TNMC.
 Since 1998, there is no any more training of MCH aid. The schools which were training
the course are now training nurse midwives.

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Tanzania
Step 4: Key Points (5 minutes)
 Traditionally, the care of patient and women during pregnancy and child birth was the
function of older women in the community who were known as Traditional Birth
Attendants (TBA) or village local midwife.
 They were highly respected because they were doing their work voluntary although they
were given small present like hens and goats depending on culture of that community.
 In 1937 the first intake of Midwifery started at Tanga. These students qualified in
January, 1940. According to the available records they show the first Midwife to be
registered was called Mary Louise.
 In 1952 improvement was made by the birth of the Tanganyika Nurses and Midwives
Council, a statutory body to control and regulates the affairs of Nurses. In 1975, Maternal
and Child Health Aids – Training (MCHA) was established assisted by Aid from the
United States of America.
 Though the MCH Aids programme was not included in the Register of Nurses – The
MCH Aids had a well-defined scheme of service for their progress which did take them
up to higher positions in nursing. Usually after under taking an in-service course an
MCH Aid took18 months, in-service course to qualify as a Public Health Section B,
which was eligible to be registered with the TNMC.
 Since 1998, there is no any more training of MCH aid. The schools which were training
the course are now training nurse midwives.
Step 5: Evaluation (5 minutes)
 List midwifery schools in Tanzania

 List two parts of midwives in Tanzania Legislation Regulation
 Explain the major development of midwifery
References
MOH. (1997). Standards for nursing in Tanzania. Dar es Salaam, Tanzania.
Sanga, P. (2004). Basic nursing care (second ed.). Peramiho, Tanzania: Benedictine
Publications.
Tanzania Nursing & Midwifery Council. (1997). Nurses and midwives act no.12 of 1997.
Dar es Salaam, Tanzania.

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Tanzania
Session 2: Male and Female Reproductive Organs
Prerequisites
 None
Learning Tasks
 Explain the anatomy and physiology of male reproductive system
 Explain the anatomy and physiology of the female external genitalia
Resources Needed
 Projector
 Computer
 Anatomical charts
SESSION OVERVIEW

Tasks
2 60 minutes Presentation/ Anatomy and Physiology of the Male
Brainstorm Reproductive System
3 45 minutes Presentation/ Anatomy and physiology of Female
Discussion External Genitalia
SESSION CONTENT
Step 1: Presentation of the Session Title and Learning Tasks (5 minutes)
READ or ASK students to read the learning tasks and clarify.

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NTA Level 5, Semester 1 Session 2: Male and Female
Reproductive Organs
Step 2: Anatomy and Physiology of the Male Reproductive System
(60 minutes)
ASK students to brainstorm on the parts of male reproductive system for 2 minutes.
ALLOW few students to respond.
WRITE their responses on flip chart/board.
CLARIFY and SUMMARIZE their responses using the information below
The Scrotum
 The scrotum forms a pouch in which the testes are suspended outside the body. It lies
below the symphysis pubis and between the upper parts of the thighs behind the penis.
 It is formed of pigmented skin and has two compartments, one for each testis.
The Testes
 They are the male gonads, situated in the scrotum outside the body.
 Each testis is 4.5 cm long and 2.5 cm wide and 3 cm thick.
 Layers
o Tunica vasculosa. Inner layer of connective tissue containing a fine network of
capillaries.
o Tunica albuginea. This is a fibrous covering, ingrowths of which divide the testis into
200 – 300 lobules.
o Tunica Vaginalis. The seminiferous (‘seed carrying’) tubules, they are three of them
in each lobule. Between the tubules there are interstitial cells which secrete
testosterone. The tubules join to form a system of channels which lead to the
epididymis.
 Functions of the testes

o Production of spermatozoa and testosterone hormone
o Testosterone is responsible for the secondary sex characteristics.
o It also joins with follicle stimulating hormone (FSH) to promote production of sperm.
The Epididymis
 It is a coma shaped coiled tube which lies on the superior surface and travels the posterior
aspect to the lower pole of the testis where it leads into the deferent duct or vas deferens.
The Spermatic Cord

 The spermatic cord consists of the deferent duct, the testicular blood vessels, lymph
vessel and nerves.
 The cord passes upwards through the inguinal canal, where the different structure
diverges. The deferent duct then continues upwards over the symphysis pubis and arches
backwards beside the bladder. It emerges behind the bladder with the duct from the
seminal vesicle and passes through the prostate gland as the ejaculatory duct to join the
urethra.

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Reproductive Organs
 Functions
o Transmits the deferent duct up into the body, along with other structures
o The deferent duct carries the sperms to the ejaculatory duct.
 Blood Supply
o The testicular artery, a branch of the abdominal aorta, supplies the testis, scrotum and
attachments. The testicular veins drain in the same manner as the ovarian veins.
 Lymphatic drainage
o To the lymph nodes round the aorta.
 Nerve supply
o From the 10th and 11th thoracic nerves.
The Seminal Vesicles

 They are two pouches situated posterior to the bladder. They are 5 cm long and pyramid
shaped, they consist of columnar epithelium, muscle tissue and fibrous tissue.
 Function
o They produce a viscous secretion to keep the sperms alive and motile.
The Ejaculatory Ducts

 These are small muscular ducts which carry the spermatozoa and seminal fluids to the
urethra.
The Prostate Gland

 It is 4 cm long, 3 cm, wide and 2 cm deep. It is composed of columnar epithelium a
muscle layer and fibrous layer. It surrounds the urethra at the base of the bladder, lying
between the rectum and symphysis pubis.
Function
 It produces a thin lubricating fluid which enters the urethra through ducts
The Bulbo-Urethral Glands

 These are two very small glands which produce another lubricating fluid which passes
into the urethra just below the prostate.
The Penis
 The root lies in the perineum, from where it passes forward below the symphysis pubis.
The lower two third is outside the body in front of the scrotum.
 It is made of 3 columns of erectile tissue
 The corpora cavenosa are two lateral columns, one on either side and in front of the
urethra.
 The corpus spongiosum is a posterior column which contains the urethra; the tip is
expanded to form the glans penis.
 The lower two thirds of the penis is covered with skin. At the end, the skin is folded back
on itself above the glans penis to form the prepuce which is a movable double skin. The
penis is very vascular and during an erection the blood spaces fill and become distended.
 Functions
o It carries the urethra which is a passage both for urine and semen
o During sexual intercourse it stiffens in order to penetrate the vagina and deposit
semen near the woman’s cervix

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Reproductive Organs
Figure 1.1: Male reproductive organs
Source: (WikiBooks, 2013)
The Male Hormones

 The hypothalamus produces gonadotrophin-releasing factors. These stimulate the
anterior pituitary gland to produce follicle stimulating hormone (FSH) and luteinizing
hormone (LH) FSH act on the seminiferous tubules to bring about the production of
sperms while LH acts on the interstitial cells to produce testosterone.
 Testesterone is responsible for secondary sex characteristics, deepening of the voice,
growth of genitalia, growth of hair on the chest, pubis, axilla and face.
Formation of Spermatozoa
 Production of sperms begins at puberty and continues through adult life.
Spermatogenesis takes place in the somniferous tubules under the influence of follicle
stimulating hormone and testosterone. The process of maturation takes some weeks. The
mature sperms are stored in the epididymis and deferent duct until ejaculation, if this does
not happen they degenerate and reabsorbed.
Step 3: Anatomy and Physiology of the Female External Genitalia

(45 minutes)
ASK students to brainstorm on the Parts of Female Genitalia for 2 minutes
ALLOW students to respond
WRITE the responses on the board
CLARIFY and summarize their responses using the information below
The Vulva
 It is the female external genital organ consisting of the following structures:
o The mons pubis or mons veneris (mount of Venus) is a pad of tissue lying over the
symphysis pubis, it is covered with pubic hair from the time of puberty.

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Reproductive Organs
o The labia majora (greater lips) are two folds of fat and areolar tissue, covered with
skin and pubic hair on the outer surface.
o They arise in the mons veneris and merge into the perineum behind.
o The labia minora (lesser lips) are two thin folds of skin lying between the labia
majora. Anteriorly they divide to enclose the clitoris; posteriorly they fuse to form
the fourchette
o The clitoris is a small rudimentary organ corresponding to the male penis.
o It is very sensitive and highly vascular and plays part in the orgasm of sexual
intercourse.
o The vestibule is the area enclosed by the labia minora in which are situated the
openings of the urethra and the vagina.
o The urethral orifice lies 2.5 cm posterior to the clitoris. On either side lies the
opening of Skene’s ducts two small blind ended tubules 0.5 cm long running within
the urethral wall
o The vagina orifice also known as the introitus of the vagina and occupies the posterior
two thirds of the vestibule. The orifice is partially closed by the hymen, a thin
membrane which tears during sexual intercourse or during the birth of the first child,
the remaining tags of hymen are known as carunculae myrtformes.
o Bartholin’s glands are two small glands which open on either side of the vaginal
orifice and lie in the posterior part of the labia majora, they secrete mucous which
lubricate the vaginal opening.
 The Vulval Blood Supply

o This comes from the internal and external pudendal arteries, the blood drains from
corresponding veins.
 Lymphatic Drainage
o Is mainly via the inguinal glands
 Nerve Supply
o This is derived from branches of the pudendal nerve.
Figure 1.2: Female external genitalia
Source: (Stanford Visible Female, n.d.)

9
Reproductive Organs
 The testes are situated in the scrotum. In order to achieve its proper function, they must
be kept below body temperature that is why they are situated outside the body.
 The seminal vesicles produce a viscous secretion to keep the sperms alive and motile
 The control of the male gonads is similar to the female but it is not cyclic.
 Spermatogenesis takes place in the seminiferous tubules under the influence of FSH and
testosterone.
 The term vulva applies to the external female genital organs which extends from the mons
veneris to the perineum
 The vestibule is the area enclosed by the labia minora in which the openings of the
urethra and the vagina are situated.
 List the organs of the male reproductive system?

 Which are the organs of the external female reproductive system?
 State male reproductive hormones?
 What are the functions of testosterone hormone?
References
Fraser, D, M., & Cooper, M. A. (2003). Myles textbook for midwives (1fourth ed.). London:
Churchill Livingstone.
Fraser, D, M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London:
Fraser, D, M., Cooper, M. A., & Nolte, A. G. (2010). Myles textbook for midwives
(African ed.). London: Churchill Livingstone.
Lavine, C. (2011). Urinary & pelvic health. Retrieved from http://www.womentowomen.com
London, M. L., Ladewig, P. W., Ball, J. W., Bindler, R. C., & Cowen, K. J. (2007). Maternal
and child nursing care (second ed.). London: Pearson.
Lookingfordiagnosis.com. (2011). Genitalia, female: Accessory sex organs, female; sex
organs, accessory, female. Retreived from http://www.lookfordiagnosis.com
Pilliteri, A. (2003). Maternal and child health nursing: Care of the childbearing &
childrearing family (fourth ed.). London: Lippincott.
Stanford Visible Female. (n.d.) Vagina. Retrieved from http://lucy.stanford.edu
Tiran, D. (2003). Bailliere’s midwives dictionary (10th ed.). Bailliere Tindall.
Wikibooks. (2013). Human physiology/the male reproductive system. Retrieved from
http://en.wikibooks.org

10
Reproductive Organs
Session 3: Female Internal Reproductive Organs
Prerequisites
 None
Learning Tasks
 Explain the anatomy and physiology of the vagina and uterus
 Explain the anatomy and physiology of fallopian tubes and ovaries
Resources Needed
 Projector
 Computer
 Models
SESSION OVERVIEW

Tasks
2 60 minutes Presentation/ Anatomy and Physiology of the Vagina and
Brainstorm Uterus
3 45 minutes Presentation/ Anatomy and Physiology of the Fallopian
Discussion Tubes and Ovaries
SESSION CONTENT

11
NTA Level 5, Semester 1 Session 3: Female Internal
Reproductive Organs
Step 2: Anatomy and Physiology of the Vagina and Uterus
(60 minutes)
Activity Brainstorming (5 minute)
ASK students to brainstorm on Parts of the Vagina and Uterus for 2 minutes.
ALLOW few students to respond and let others provide unmentioned responses.
WRITE their responses on flip chart.
CLARIFY and summarize their responses using the information below.
The Vagina
 It is a canal running from the vestibule to the cervix, passing upwards and backwards into
the pelvis along a line approximately parallel to the plane of pelvic brim.
 Relations
o The knowledge of the relations of the vagina is essential for the accurate examination
of the pregnant woman and her safe delivery.
o Anterior: In front of the vagina lie the bladder and urethra, which are closely
connected to the anterior vaginal wall.
o Posterior: Behind the vagina lie the pouch of Douglas, the rectum and the perineal
body each occupying at least one third of the posterior vagina wall.
o Lateral: On either side of the upper two thirds are the pelvic fascia and the ureters,
which pass beside the cervix on either side of the lower third are the muscles of the
pelvic floor.
o Superior: Above the vagina lies the uterus.
o Inferior: Below the vagina les the external genitalia.
 Structure
o The posterior wall is 10 cm long where the anterior is 7.5 cm in length because the
cervix projects at right angle into its upper part
o The upper end of the vagina is known as the vault, where the cervix projects into it,
the vault forms circular recess that is described as four arches or fornices.
o The posterior fornix is the largest because the vagina is attached to the vagina at a
higher level behind than in front.
o The anterior fornix lies in front of the cervix.
o The lateral fornices lie on either side.
o The vagina walls are pink in appearance and thrown into small folds known as
ruggae, these allow the vagina to stretch during intercourse and child birth.
 Layers
o The lining is made of squamous epithelium, beneath the epithelium lies a layer of
connective tissue.
o The muscle layer is divided into a weak inner coat of circular fibres and a stronger
outer coat of longitudinal fibres.
 Content
o There are no glands in the vagina. It is moistened by mucous from the cervix and
transudate from the blood vessels of the vaginal wall.
o Inspite of the alkaline mucous, the vaginal fluid is strongly acid (pH 4.5) due to the
presence of lactic acid formed by the action of Doderlein’s bacilli on glycogen found
in the squamous epithelium of the lining.

12
Reproductive Organs
 Function
o It is a passage which allows the escape of menstrual flow.
o Receives the penis and the ejected sperms during sexual intercourse
o Provides an exit for the fetus during delivery.
 Blood supply
o This comes from branches of internal iliac artery and includes the vaginal artery and
descending branch of uterine artery.
o The blood drains through corresponding veins.
o This is via the inguinal, the internal iliac and the sacral glands.
 Nerve supply
o This is derived from the pelvic plexus.
o The vaginal nerves follow the vaginal arteries to supply vaginal walls and also the
erectile tissue of the vulva.
The Uterus
 Position
o It is situated in the cavity of the true pelvis behind the bladder and in front of the
rectum. It leans forward which is known as anteversion and bends forward on itself,
which is known s anteflexion.
o When the woman is standing the uterus is almost horizontal with the fundus resting on
the bladder
 Relations
o Anterior - In front of the uterus lie the uterovesical pouch and the bladder
o Posterior - Behind the uterus are the recto uterine pouch of Douglas and rectum.
o Lateral - On either side of the uterus are the broad ligaments, the fallopian tubes and
the ovaries.
o Superior - Above the uterus lie the intestines.
o Inferior - Below the uterus is the vagina.
 Supports
o The uterus is supported by the pelvic floor and maintained in position by several
ligaments
 The transverse cervical ligament - These fan out from the sides of the cervix to the
side walls of the pelvis. They are sometimes known as the cardinal ligaments or
mackenrodt’s ligaments.
 The uterosacral ligaments - They pass backward from the cervix to the sacrum.
 The pubocervical ligaments - They pass forward from the cervix, under the
bladder to the pubic bones.
 The broad ligaments - These are formed from the folds of peritoneum which are
draped over the fallopian tubes. They hang down like a curtain and spread from
the sides of the uterus to the side walls of the pelvis.
 The round ligaments - Maintain the anteverted position of the uterus,they arise
from the cornua of the uterus in front of and below the insertion of each fallopian
tube and pass between the folds of the broad ligaments, through the inguinal canal
to be inserted into each labium majus.
 The ovarian ligaments - These also begin at the cornua of the uterus but behind
the fallopian tubes and pass down between the folds of broad ligaments to the
ovaries.

13
Reproductive Organs
 Functions
o It is the shelter of the fetus during pregnancy
o It prepares the possibility of pregnancy each month
o Following pregnancy it expels the uterine content.
 Structure
o The non pregnant uterus is a hollow muscular pear shaped organ situated in the true
pelvis, it is 7.5 cm long, 5 cm wide and 2.5 cm in depth, each wall being 1.25 cm
thick. The cervix forms the lower third of the uterus and measures 2.5 cm.
 Parts of the uterus
o The body or corpus - makes up the upper two thirds of the uterus and is the greater
part.
o The fundus - is the doomed upper wall between the insertions of the uterine tubes.
o The cornua - are the upper outer angles of the uterus where the uterine tube joins.
o The cavity - is a potential space between the anterior and posterior walls. It is triangle
in shape; the base of the triangle being uppermost.
o The isthmus - is a narrow area between the cavity and the cervix, which is 7 mm long.
It enlarges during pregnancy to form the lower uterine segment.
o The cervix or neck - this protrudes into the vagina. The upper half which is above the
vagina is known as supravaginal portion while the lower half is the infravaginal
portion
 The internal os (mouth) - the narrow opening between the isthmus and cervix.
 The external os - is the small round opening at the lower end of the cervix. After
child birth it becomes a transverse slit.
 The cervical canal - lies between these two openings and is a continuation of the
uterine cavity.
 Layers
The uterus has three layers
o The endometrium - This layer forms a lining of ciliated epithelium (mucous
membrane) on a base of connective tissue or stroma. In the uterine cavity this
endometrium is constantly changing in thickness throughout the menstrual cycle
o The mayometrium or muscle coat - This layer is thick in the upper part of the uterus
and sparse in the isthmus and cervix. Its fibres run in all directions and interlace to
surround blood vessels and lymphatics that pass to and from the endometrium. The
outer layer is formed of longitudinal fibres that are continuous with those of the
uterine tube, uterine ligaments and vagina.
o The perimetrium - This is a double serous membrane, an extension of the peritoneum
which is draped over the uterus covering all but a narrow strip on either side of the
supravaginal cervix.

14
Reproductive Organs
 Blood supply
o The uterine artery which is a branch of internal iliac artery, it sends a branch to the
upper vagina and runs upwards to meet the ovarian artery and form an anastomosis
with it near the cornua. The ovarian artery is a branch of the abdominal aorta. It
supplies the ovary and fallopian tubes before joining the uterine artery
o The blood drains through corresponding veins
o Lymph is drained from the uterine body to the internal iliac glands and also from the
pelvic area to many other pelvic glands.
 Nerve supply
o Mainly from the autonomic nervous system, sympathetic and parasympathetic via Lee
Franken and Hauser’s plexus or pelvic plexus.
Step 3: Anatomy and Physiology of the Fallopian tubes and Ovaries (45
minutes)
The Fallopian Tubes or Uterine Tubes

 The fallopian tubes extend laterally from the cornua of the uterus towards the side walls
of the pelvis. They arch over the ovaries, there fringed end hovering near the ovary in
order to receive the fertilized ovum.
 Functions
o Propels the ovum towards the uterus
o Receives the spermatozoa
o Provide a site for fertilization
o It supplies the fertilized ovum with nutrition during its journey to the uterus.
 Relations
o Anterior, posterior and superior - In front of, behind and above the uterine tubes are
peritoneum cavity and intestines.
o Lateral - On either side of the uterine tubes are the side walls of the pelvis.
o Inferior - The broad ligaments and ovaries lie below the uterine tubes.
o Medial - The uterus lies below the two uterine tubes.
 Supports
o The uterine tubes are held in place by their attachment to the uterus. The peritoneum
folds over them as the broad ligaments and extend at the sides to form the
infundibulopelvic ligaments.
 Structure
o The tube is 10 cm long. The lumen of the tube provides a pathway from outside to
the peritoneum cavity. The uterine tube has 4 portions
o The interstitial portion is 1.25 cm long and lies within the walls of the uterus. Its
lumen is 1 mm wide.
o The Isthmus it is another narrow part which extends to 2.5 cm from the uterus.
o The Ampulla is the wider portion, 5 cm long where fertilization usually occur.
o The infundibulum is the funnel-shaped fringed end which is composed of many
processes known as fimbriae. One fimbria is elongated to form the ovarian fimbria
which is attached to the ovary.

15
Reproductive Organs
 Layers
o The lining - This is a mucous membrane of ciliated cubical epithelium that are thrown
into folds known as plicae. These folds slow the movement of the ovum on its way to
the uterus. The cells in the lining produce a secretion containing glycogen which
nourishes the ovum.
o Beneath the lining is a layer of vascular connective tissue
o The muscle coat - This consists of two layers of smooth muscles, an inner circular
layer and outer longitudinal layer. The peristaltic movement of the tube is due to these
muscles.
o The tube is covered with peritoneum.
 Blood supply
o This is via uterine and ovarian arteries. Blood drain via corresponding veins.
o This is to the lumber glands.
 Nerve supply
o From the ovarian plexus.
Figure: 1.3 fallopian tubes, uterus and ovaries
Source: (Lookfordiagnosis.com, 2011)
The Ovaries
 The ovaries are the female gonads which produce ova and the hormones estrogen and
progesterone
 Position
o The ovaries are attached to the back of the broad ligaments within the peritoneal
cavity
 Relations
o The ovary is attached to the broad ligaments; it is supported from above by the
ovarian ligament and infundibulopelvic ligament laterally.

16
Reproductive Organs
 Structure
o The ovary is composed of medulla and cortex covered with germinal cells
o The medulla. It is the supporting frame work which is made of fibrous tissue blood
vessels, nerves and lymphatic pass through it
o The cortex. It is the functioning part of the ovary. It consist of ovarian follicles in
different stages of development, surrounded by stroma. The outer layer is formed of
fibrous tissue known as tunica albuginea, over this lies the geminal epithelium.
 Blood supply
o The blood is from ovarian arteries and drains by the ovarian veins. The right ovarian
vein joins the inferior vena cava, the left returns its blood to the left renal vein.
 A knowledge of the relations of the vagina to other organs is essential for the accurate
examination of the pregnant woman and her safe delivery
 The non pregnant uterus lies almost horizontal with the fundus resting on the bladder
when the woman is standing.
 The uterus is supported by the pelvic floor and maintained in position by several
ligaments
 The fallopian tubes propel the ovum towards the uterus, receive spermatozoa as they
travel upwards and provides site for fertilization. It supplies fertilized ovum with nutrition
during its journey to the uterus.
 The ovaries produce ova and the hormones oestrogen and progesterone
 What are the organs of the internal female reproductive system?

 What are the relations of the vagina to other organs?
 What are the functions of the uterus?
 Explain the ligaments that support the uterus.
References
Lavine, C. (2011). Women to women. Retrieved from http://www.womentowomen.com
organs, accessory, female. Retrieved from http://www.lookfordiagnosis.com

17
Reproductive Organs
Session 4: Anatomy and Physiology of the Female
Bony Pelvis
Prerequisites
 None
Learning Tasks
 Describe the anatomy and physiology of the female bony pelvis
 Explain the pelvic joints and ligaments
 Explain the pelvic floor
Resources Needed
 Projector
 Computer
 Models
SESSION OVERVIEW

Tasks
2 40 minutes Presentation/ Anatomy and Physiology of the Female Bony
Discussion Pelvis
3 40 minutes Presentation Pelvic Joints and Ligaments
4 25 minutes Presentation Pelvic Floor
SESSION CONTENT
READ or ASK students to read the learning tasks and clarify
ASK Students if they have any question before proceeding

18
NTA Level 5, Semester 1 Session 4: Anatomy and Physiology of
the Female Bony Pelvis
Step 2: Anatomy and Physiology of the Female Bony Pelvis (45 minutes)
Activity: Small group discussion (10 minutes)
PROVIDE the small groups with the pelvic model
ASK students in their groups to locate the parts of the pelvis for 5 minutes
Female Pelvis
 The female pelvis is the bone compartment which supports the vertebrae column and
articulates with the lower limbs, it permits a person to sit and kneel.
 It forms a bonny passage through which the fetus passes during labour.
 Bones of the pelvis
o Two innominate or unnamed bones
o One sacrum
o One coccyx
Figure 1.4 Female pelvis
Source: (MIDIRS, 2012)

 The innominate bone
o Is made up of three bones: Illium, Ischium and the Pubis
 The illium
o Is the large flared-out part; when the hand is placed on the hip it rests on the iliac
crest, which is the upper border.
o At the front of the iliac crest can be felt a bony prominence known as the anterior
superior iliac spine.
o Below is the anterior inferior iliac spine.
o There are two similar points at the other end of the crest, posterior superior and
posterior inferior iliac spines.

19
 The ischium
o Is the thick lower part which has a large prominence known as the ischial tuberosity,
on which the body rests when sitting.
o Behind and a little above the tuberosity is an inward projection known as, the ischial
spine. During labor the station of the fetal head is estimated In relation to the ischial
spines.
 The pubic bone

o This bone forms the anterior part.
o It has a body and two oar-like projections, the superior ramus and the inferior ramus.
o The two pubic bones meet at the symphysis pubis and the two inferior rami form the
pubic arch, merging into a similar ramus on the ischium.
o The space enclosed by the body of the pubic bone, the rami and the ischium is called
the obturator foramen.
o The innominate bone contains a deep cup to receive the head of femur, called
acetabulum.
o On the lower boarder of the innominate bone are found two curves.
 One extends from the posterior inferior iliac spine up to the ischial spine and is
called greater sciatic notch.
 The other lies between the ischial spine and ischial tuberosity and is the lesser
sciatic notch.
 The sacrum
o The sacrum is a wedge-shaped bone consisting of five fused vertebrae.
o The upper border of the first sacral vertebra juts forward and is known as sacral
promontory.
o The anterior surface of the sacrum is concave and is referred to as the hollow of the
sacrum.
o Laterally the sacrum extends into a wing or ala.
o Four pairs of holes or foramina pierce the sacrum and, through these, nerves from the
cauda equina emerge to supply the pelvic organs.
o The posterior surface is roughened to receive attachment of muscles
 The coccyx
o Is a vestigial tail which consist of four fussed vertebral forming a small triangular
bone.
o The coccyx articulates with the fifth sacral vertebra to form the sacrococcygeal joint,
during birth it is usually forced backwards to allow more room for the fetus to pass.
Step 3: Pelvic Joints and Ligaments (40minutes)
Pelvic Joints
There are four pelvic joints
 One symphisis pubis
 Two sacro iliac joints
 One sacrococcygeal joint.
 The pelvic joints are not very mobile in non pregnant woman, but during pregnancy the
endocrine activity causes the ligaments of the joints to soften which allows the joints to
soften and stretch during labour

20
 The symphisis pubis
o It is formed at the junction of the two pubic bones, which are united by a pad of
cartilage.
o It widens during the last months of pregnancy and, because of its increased mobility
may cause the pregnant woman pain as she walks.
 Sacroiliac joints
o These are the strongest joint in the body.
o They join the sacrum to the ilium and thus connect the spine to the pelvis.
o During pregnancy much stress is placed on these joints and multipara often complain
of backache during pregnancy and for few weeks following delivery.
 Sacrococcygeal joint
o This joint is formed where the base of the coccyx articulates with the tip of the
sacrum.
o The joint allows the coccyx to move backwards during birth, thus widening the outlet
of the pelvis.
 Pelvic Ligaments
Each of the pelvic joints is held together by the following ligaments:-
o Interpubic ligaments at the symphysis pubis
o Sacroiliac ligament
o Sacrococcygeal ligaments.
The other two ligaments important in midwifery are:-
o Sacrotuberous ligaments :- from the sacrum to the ischial tuberosity
o Sacrospinous ligament: - from the sacrum to the ischial spine.
Figure 1.4 Pelvic ligaments

21
Step 4: Pelvic Floor (20 minutes)
The pelvic floor is formed by the soft tissues that fill the outlet of the pelvis.
 Functions
o The pelvic floor supports the weight of the abdominal and pelvic organs.
o Its muscles are responsible for the voluntary control of micturation and defecation and
play an important role in sexual intercourse.
o During child birth it allows the passive movements of the fetus through the birth canal
 Muscle layers
o The superficial layer which is composed of five muscles:-
 The external anal sphincter encircles the anus and is attached behind by a few
fibers to the coccyx
 The transverse perineal muscles pass from the ischial tuberosity to the centre of
the perineum.
 The bulbocavernosus muscles pass from the perineum forward around the vagina
to the copra cavernosa of the clitoris just under the pubic arch.
 The ischial cavernosa muscles pass from the ischial tuberosities along the pubic
arch to the copra cavernosa.
 The membranous sphincter of the urethra is composed of muscle fibres passing
above and below the urethra and attached to the pubic bone.
o The deep layer
 This layer is composed of three pairs of muscles which together re known as
levator ani muscles. Each levator ani muscle (left and right) consist of the
following:
 The pubococcygeus muscle from the pubis to the coccyx
 The iliococcygeal muscle from the fascia covering the obturator intenus
muscle to the coccyx
 The ischiococcygeus muscle from the ischial spine to the coccyx.

22
Figure 1.5: Pelvic floor
Source: (Lavine, 2011)
 The female pelvis forms a bony canal through which the fetus passes during labour.
 The midwife must be competent to recognize a normal pelvis in order to be able to detect
deviations from normal and refer to the doctor.
 There are 4 bones of the pelvis, two innominate bones, one sacrum and coccyx.
 The sacro-iliac joints are the strongest joints in the body.
 During pregnancy the pelvic joints becomes slightly mobile than in non pregnant due to
the effects of the hormones relax and progesterone.
 The pelvic floor is made up of soft tissues which fills the pelvic floor, the superficial layer
consisting of five muscles and the deep layer consisting of lavetor ani muscles
 Explain the bones of the pelvis

 Explain the pelvic joints and ligaments
 Explain the three pairs of muscles known as lavetor ani muscles

23
References
MIDIRS. (2012). The female pelvis. Retrieved from http://www.midirs.org

24
Session 5: Pelvic Diameters Related to Fetal Skull
Prerequisites
 None
Learning Tasks
 Describe the diameters of the pelvis
 Explain the types of pelvis
 Describe the fetal skull
Resources Needed
 Projector
 Computer
 Pelvic models
SESSION OVERVIEW
Step Time Activity/Method Content

Tasks
2 50 minutes Presentation/ Diameters of the Pelvis
Discussion
3 20 minutes Presentation Types of Pelvis
4 35 minutes Presentation/ Fetal skull

Discussion

25
NTA Level 5, Semester 1 Session 5: Pelvic Diameters Related to
Fetal Skull
SESSION CONTENT
Step 2: Diameters of the Pelvis (50 minutes)
DIVIDE the students in manageable groups
PROVIDE the students in their groups with pelvic models
ASK students to locate the diameters of the pelvis for 10 minutes
The True Pelvis

 It is the bonny canal through which the fetus must pass during birth. It has a brim, cavity
and outlet
The Pelvic Brim

 The brim is round except where the sacral promontory projects into it.
 The promontory and wings of sacrum form its posterior boarder, the iliac bones its lateral
boarders and the pubic bone its anterior boarder
 The land marks of the brim are:
o Sacral promontory
o Sacral ala or wing
o Sacro iliac joint
o Iliopectineal line
o Iliopectineal eminence
o Superior ramus of the pubic bone
o Upper inner boarder of the body of pubic bone
o Upper inner boarder of the symphysis pubis
o Diameters of the brim, there are three diameters
 The Anteroposterior Diameter
o It is a line from the sacral promontory to the upper boarder of the symphysis pubis,
When the line is taken to the upper boarder of the symphysis pubis it is called the
Anatomical conjugate and is measures 12 cm, when it is taken to the posterior
boarder of the upper surface 1.25 cm lower is called Obstetrical conjugate and
measures 11 cm, it represents the available space for the passage of the fetus.The
diagonal conjugate is measured from the lower boarder of the symphysis pubis to
the sacral promontory it may be estimated on vaginal examination as part of
pelvic assessment and should measure 12-13 cm.

26
Fetal Skull
 The Oblique Diameter
o It is a line from one sacroiliac joint to the iliopectineal eminence on the opposite side
and measures 12 cm. There are two diameters, left and right oblique diameters each
takes its name from the sacroiliac joint from which it arises.
 The Transverse Diameter
o It is a line between the points further apart on the iliopectineal line and measures 13
cm.
o Another diameter is measured, the sacrocotyloid diameter from the sacral promontory
to the iliopectineal eminence on each side and measures 9-9.5 cm. It is only
important in posterior positions of the occiput.
The Pelvic Cavity

 The cavity extends from the brim above to the cavity below.
 The anterior wall is formed by the pubic bone and the symphysis pubis and is 4 cm long.
 The posterior wall is formed by the curve of sacrum and is 12 cm long. Its lateral walls
are the sides of the pelvis
 The cavity is circular in shape its diameters cannot be measured but are considered to be
12 cm.
The Pelvic Outlet

Two outlets are described, the anatomical and obstetrical.
 The anatomical outlet is formed by the lower border of the pelvic bones and the
sacrotuberous ligaments.
 The obstetrical outlet is the space between the narrow pelvic strait and the anatomical
outlet.
 The narrow pelvis strait lies between the sacrococcygeal joint, the two ischial spines and
the lower boarder of symphysis pubis.
 There are three diameters:
o The anteroposterior diameter
 It is a line from the lower boarder of the symphysis pubis to the sacrococcygeal
joint. It measures 13 cm. the coccyx may be deflected backwards during labour.
The diameter indicates the space available during delivery.
o The oblique diameter
 Between the obturator foramen and the sacrospinous ligaments there are no fixed
points the measurement is taken to be 12 cm.
o The transverse diameter
 This is a line between the two ischial spines and measuers 10-11 cm it is the
narrowest diameter in the pelvis.
The False Pelvis

 The false pelvis is the part situated above the brim. It is formed by the upper flared-out
part of the iliac bones and protects the abdominal organs.

27
Fetal Skull
Figure 1.6: Diameters of the Pelvis
Step 3: Types of Pelvis (15 minutes)

Pelvises are classified according to shape of the brim. Much important is the individual
woman’s pelvic capacity and whether it is adequate for the passage of the child she is
carrying.
The Gynaecoid Pelvis

 It is the ideal pelvis for child bearing
 Its main features are rounded brim, straight side walls, and shallow cavity with broad well
curved sacrum, blunt ischial spines, wide sciatic notch and a pubic arch of 90 degrees.
 It is found in women with average size and height with shoe size of 4 or larger.
 The justor minor pelvis is like a gynaecoid pelvis in miniature. All diameters are reduced
but are in proportion. It is normally found in women of small stature less than 1.5 m in
height with small hands and feet.
Android Pelvis
 It resembles the male pelvis.
 Its brim is heart shaped with a narrow fore pelvis. It is a funnel shape with a deep cavity
and straight sacrum.
 The ischial spines are prominent and the sciatic notch is straight.
 The sub pubic angle is less than 90 degrees, it is found in heavily built women
 The heart shaped brim favors posterior position of the occiput and is the least suited for
child bearing.

28
Fetal Skull
The Anthropoid Pelvis
 It has a long oval brim in which the anteroposterior diameter is long than the transverse.
 The sacrum is long and deeply concave.
 The ischial spines are not prominent, the sciatic notch and sub pubic angle are very wide.
 It is found in women who are tall with narrow shoulders. Labour does not usually present
any difficulties.
The Platypeloid Pelvis

 This flat pelvis has a kidney-shaped brim in which anteroposterior diameter is reduced
and the transverse increased. The sacrum is straight and the cavity is shallow.
 The ischial spines are blunt and the sciatic notch and sub pubic angle are wide.
 The head must engage with the sagittal suture in the transverse diameter but usually
descends without difficulty
Refer students to Hand out 5.1 Types of Pelvis
Step 4: Fetal Skull (40 minutes)
DIVIDE the students in manageable groups.
PROVIDE the students with fetal skull models.
ASK students to locate Diameters of the Fetal Skull for 5 minutes.
CLARYFY and summarize using the information below.
The fetal skull contains the delicate brain which may be subjected to great pressure as the
head passes through the birth in comparison with the true pelvis and some adaptations
between skull and pelvis must take place during labour.
The Bones of the Vault

 There are five main bones in the vault of the fetal skull
 The occipital bone. It lies at the back of the head and form a region of occiput.
 Part of it contributes to the base of the skull.
 At the centre is the occipital protuberance
 The two parietal bones, they lie on either side of the skull, the ossification centre of each
is called the parietal eminence.
 The two frontal bones form the forehead or sinciput, at the centre of each is the frontal
eminence, the frontal bones fuse to form a single bone at the age of 8 years.
 The upper part of the temporal bones forms a small part of the vault.
Sutures and Fontanels

 Sutures are cranial joints and are formed where two bones meet.
 Where two or more sutures meet a fontanel is formed.

29
Fetal Skull
 There are many sutures and fontanels in the fetal skull, those with obstetrical significance
are:
o The lambdoidal suture - Separates the occipital bone from the two parietal bones
o The sagittal suture - Lies between two parietal bones.
o The coronal suture - Separates the frontal bones from the parietal bones, passing from
one temple to the other.
o The frontal suture - Runs between the two halves of the frontal bones
o The posterior fontanel or lambda - Situated at the junction of the lambdoidal and
sagittal sutures. It is small, triangular in shape and can be diagnosed vaginally
because a suture leaves from each of the three angles. It normally closes by 6 weeks
of age.
o The anterior fontanel or bregma - Found at the junction of sagittal and coronal
sutures, it is diamond shaped and is recognized vaginally because a suture leaves at
each of its four corners. It measures 3 – 4 cm long and 1.2 – 2 cm wide and normally
closes by the age of 18 months.
o The sutures and fontanels because they consist of membranous spaces, allow a degree
of overlapping during labour and delivery.
Figure 1.7: Fetal skull
Source: (National BEMONC Training Package, 2010)

Regions and Landmarks of the Fetal Skull
 The skull is divided into the vault, the base and the face.
 Vault
o Is the large dome shaped part above an imaginary line from between the orbital ridges
and nape of the neck its bones are thin and pliable at birth which allows the skull to
alter slightly in shape.
 Base
o is comprised of bones which are firmly united to protect the vital centres in the
medulla
o The face is composed of 14 small bones which are firmly united. And non
compressible
 The regions of the fetal skull are:
o The occiput: It lies between the foramen magnum and the posterior fontanelle. The
area below the occipital protuberance is known as suboccipital region.
o The vertex: It is bounded by the posterior fontanelle, the two parietal eminences and
the anterior fontanelle
o The sinciput or brow: It extends from the anterior fontanelle and the coronal suture to
the orbital ridges.

30
Fetal Skull
o The face: It is small in newborn baby. It extends from the orbital ridges and root of
the nose to the junction of chin and neck. The point between the eyebrows is known
as the glabella. The chin is also known as mentum.
Figure 1.8: Diameters of the fetal skull
Source: (Fraser, Cooper, & Nolte, 2010)
Diameters of the Fetal Skull

 The measurements of the fetal skull are important for the midwife to understand the
relationship between the fetal head and mother’s pelvis
 There are two transverse diameters:
o Biparietal diameter 9.5 cm. – between the two parietal eminences.
o Bitemporal diameter 8.2 cm. – between the furthest points of coronal suture at the
temples.
 The remaining diameters are either antero-posterior or longitudinal.
o Suboccipital bregmatic 9.5 cm. – from below the occipital protuberance to the centre
of the anterior or bregma.
o Suboccipito frontal 10 cm. – from below the occipito – protuberance to the centre of
the frontal suture
o Occipito pfrontal 11.5 cm. – from the occipital protuberance to the centre of frontal
suture.
o Mentovertical 13.5 cm. – from the point of the chin to the highest point on the vertex
o Submento vertical 11.5 cm. – from the point where the chin join the neck to the
highest point of vertex.
o Submento bregmatic 9.5 cm. – from the point where the chin joins the neck to the
centre of the bregma.
 The true pelvis is the bony canal through which the fetus must pass during labour. It is
divided into brim cavity and outlet
 The false pelvis is the part of the pelvis above the pelvic brim
 There are three diameters of the pelvic brim, anteroposterior, transverse and oblique
diameters
 The gynaecoid type of the pelvis is the ideal one for childbearing

31
Fetal Skull
 The fetal skull contains the delicate brain which may be subjected to great pressure as the
head passes through the birth canal
 The sutures and fontanelles because they consist of membranous spaces, allow a degree
of overlapping during labour and delivery
 The measurements of the fetal skull are important for the midwife to understand the
relationship between the fetal head and mother’s pelvis
 Explain the diameters of the pelvic outlet

 Explain the 4 types of pelvis
 Enumerate 8 landmarks of the pelvic brim
 Explain the diameters of the fetal skull
References
organs, accessory, female. Retrieved from http://www.lookfordiagnosis.com
MIDIRS. (2012). The female pelvis. Retrieved from http://www.midirs.org

32
Fetal Skull
Handout 5.1: Types of Pelvis
Source: (Lookingfordiagnosis.com, 2011)

33
Fetal Skull
Session 6: Law, Code of Conduct and Standards
Guiding Midwifery
Prerequisite
 None
Learning Tasks
 Explain law, ethical conduct and standards guiding midwifery practice in Tanzania
 Identify roles and functions of a midwife
 Explain new trends and concepts affecting midwifery practice
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
1 5 minutes Presentation Presentation of Session Title and Related Tasks

Presentation/ Law, Ethical Conduct and Standards Guiding
2 45 minutes
Group discussion Midwifery Practice in Tanzania
3 25 minutes Presentation Roles and Functions of a Midwife
Buzz/ New Trends and Concepts affecting Midwifery
4 35 minutes
Presentation Practice
SESSION CONTENT
Step 1: Presentation of Session Title and Learning Tasks (5 minutes)
 READ or ASK students to read the Learning tasks and clarify
 ASK student if they have any questions before proceeding

34
NTA Level 5, Semester 1 Session 6: Law, Code of Conduct and
Standards Guiding Midwifery
Step 2: Law, Ethical Conduct and Standards Guiding Midwifery Practice
in Tanzania (45 minutes)
Definition of Terms
Law
 Is a system of rules and guidelines which are enforced through social institution to govern
behavior, wherever possible (Wikipedia, 2013).
Ethics
 It is the systematic study of what a persons’ conduct and actions ought to be with regard
to him or her, other human beings and the environment.
 It is concerned with judgment about what is right or wrong conduct in relation to moral
conflicts.
Code of Conduct
 Provide a framework that defines the core value and standards which professional must
follow.
Standard
 An accepted or approved example of something against which others are judged or
measured
 An exact value, a physical entity, or an abstract concept, established and defined by
authority, custom or common consent to serve as a reference, model, or rule in measuring
quantities or qualities, establishing practices or procedures, or evaluating results
Activity: Small Group Discussion (10 minutes)
DIVIDE students into small manageable groups
ASK them to discuss in groups the code of conduct guiding the nursing practice and relate
them to midwifery practice
AFTER small group discussion ask students to present their responses
CLARIFY and summarize by using the information below
 Essentially, the code of ethics for midwives does not vary from the codes for nursing
 Many midwives carry the title of nurse-midwife, and undergo the same level of
professional education and certification as all registered nurses
 Midwives focus on the health of mothers and infants before and during birth
 As with nursing, the midwifery code of ethics focuses on the health care needs of
individual patient and treating each patient with dignity and respect
Principles Guiding Midwifery Practice

 Respect for humankind and the patient/client as an individual
o The midwife provides services with respect for human dignity
 Obtain consent before you provide care
 Obtain patients valid consent for care receiving, respect her autonomy

35
 Maintain professional competence
o Midwives must strive at all times to achieve and maintain high professional standards
in providing quality care through evidence based practice to safeguard the safety of
the client/patient
 Take responsibility and be accountable for your acts.
o Every midwife should be responsible and accountable for his/her midwifery judgment
and actions.
 Be trustworthy and exercise fairness
o Every midwife has the duty to behave in the way that uphold good reputation of the
profession, has to be fair in distributing resources and at all times to tell the truth and
be loyal in whatever form
 Collaborate with others and act as part of the team.
o The midwife collaborates with other members of the health team and other sectors in
promoting community health needs
 Protect confidential information
o Information about patient and clients must be treated as confidential and be used for
the purposes for which it was given
o As it is impractical to obtain consent every time you need to share information with
others, you should ensure that patients and clients understand that some information
may be made available to other members of the team involved in the delivery of care.
 Always the midwife safeguards the client’s right to privacy
o Respect the privacy of a patient/client in such a way that during the procedure privacy
is provided and maintained throughout.
Step 3: Roles and Functions of a Midwife (25 minutes)
Roles
 To be knowledgeable and understand their own values, attitudes, norms and expectations
that affect their professional practice as well as their consumer’s diverse cultures and
religions to enable them to respond equitably.
 To be aware of issues of prejudice, discrimination and racism and how these manifest
themselves in the provision and delivery of health care and may act as a barrier to seeking
health care.
 To take account of the difficulties encountered by women who are less familiar with
health services and less confident and ensure that they are able to create a conducive
environment that will enable the women to explain their views and wishes regarding their
maternity care.
 Midwives should take into account the need for privacy, dignity and clear balanced
evidenced based information that clients can understand and enable them make
appropriate informed choices and exercise control over the care they receive.
 To be change agents
o As advocates of women midwives should ensure that the needs and wishes of
consumers, in particular women who may not be able to effectively communicate are
taken into consideration during the planning and delivery of services.
o They need to utilize skills of adaptability, flexibility and political awareness in the
development and implementation of innovatory practices to ensure that they are
available equitably to all women.
o Midwives should actively participate in raising awareness of the available services
amongst all women.

36
Functions
 To be alongside and Supporting women giving birth
 Promoting the health and wellbeing of childbearing women and their families before
conception, during antenatal and postnatal, including family planning
 Give the necessary supervision, care and advice to women during pregnancy, labour and
the postpartum period.
 To conduct deliveries
 Give care to the newborn and infant
 Detect abnormal conditions to both mother and child.
 Procure medical assistance and execute emergency measures in the absence of medical
help.
 Provide health counseling and education to the woman, the family and community.
 Provide antenatal education
 Preparation for parenthood and some areas of gynecology including family planning and
child care.
 The midwife practices in hospitals, clinics, health facilities and domiciliary conditions.
Step 4: New Trends and Concepts Affecting Midwifery Practice

(35 minutes)
Activity: Buzzing (10 minutes)
DIVIDE the students in small manageable groups
ASK them to buzz on the new trends and concepts affecting midwifery practice for 2minutes
ALLOW them to present their responses
 Midwifery practice is directly influenced by many factors including legislation, health

funding, demographic trends, professional education and regulation of midwives,
increasing emphasis on evidenced–based practice and clinical effectiveness.
 Some of these factors are considered to have greater focus on women-centered care and
special needs for specific groups including HIV positive mothers, drug misuses, and
women with disabilities
 Demographic Trends
o The delivery of midwifery care and the planning of maternity services are affected by
demographic trends
 Women–Centered Care
o Parents to be are more knowledgeable and informed about pregnancy and birth and
have enhanced expectations of personal involvement in their care
o Focused antenatal care involves mothers in planning where to deliver and preparation
for delivery including care of the newborn baby (Individual birth plan)
o The individual birth plan is an aspect of modern midwifery management designed to
give women/couples more involvement during care
o The right of the mother to make an informed choice includes choice of infant feeding
method and promotion of breastfeeding as the optimal method of infant feeding

37
 Women with Special Needs
o Greater sensitivity is required in the provision of maternity care to mothers with
special needs and care must be given in an equitable, culturally appropriate and in a
quality driven manner
 Refugees
o The absence of information on previous medical and obstetrical histories can impede
the delivery of effective maternity care
o Effective communication is necessary to obtain informed consent for treatment
 Drug Misuses
o The implications for the planning and provision of midwifery and neonatal care are
significant
o Drug misuses require effective supervision and monitoring
 Teenage pregnancies
o Pregnant teenagers are encouraged to attend antenatal care and the preparation for
parenthood programme should be done during early pregnancy
o Care providers should be non-judgmental, empathetic, and reassuring
 Women with Disabilities
o Women with physical or sensory disabilities face many problems in relation to their
health, provision of care to the baby and to themselves
o These include difficulty in accessing services because of physical inaccessibility of
hospitals, health centers, lack of interpreters or sign language users, and poor
communication from health care providers
o Lack of information on health issues and maternity services in non-print format may
prevent women with disabilities being actively involved in decision making regarding
their pregnancy
 HIV Positive Mother
o HIV testing and clinical services for clients with AIDS have been developed.
o Routine screening of pregnant women and anti-retroviral treatment to HIV positive
mothers could reduce the HIV transmission rate from mother to child
o Prevention of mother to child is a service which should be provided to all mothers
attending antenatal clinic
o In clinical practice, standard precautions are applied in the management of all
pregnant women, regardless of HIV status or condition.
o Clear information and confidentiality are central to the management of HIV positive
women.
o If appropriate care is given and advice followed, HIV positive women in the postnatal
period do not pose a risk to other mothers or babies.
o HIV positive mothers are counseled and informed about transmission of the virus
through breast milk, and are advised by the midwife on breast feeding options.
 Responding to Changing Needs
o Midwives are required to be more analytical, thoughtful, responsive, understanding
and able to offer women appropriate sympathetic, sensitive, realistic advice and
skilled care, thus achieving the optimal outcome of pregnancy and childbirth for each
individual mother while being able to provide the necessary psychological and social
support at the time of miscarriage and bereavement
o There is a link between the changing system of continuing professional education and
the quality of patient care.
o Investment in continuing professional education therefore can be seen as an
investment in the future of the Health Services

38
 A midwife should be aware of the guiding principles to midwifery practice to be able to

deliver quality care to patients
 Every midwife should understand his/her roles and function so as to deliver care correctly
within her/his scope of function
 The nurse who knows the new trends and issues affecting midwifery will plan and
practice in the best accepted manner
 Explain the guiding principles to midwifery practice in Tanzania

 List roles and functions of a midwife
 Explain new trends and concepts affecting midwifery
References
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam, Tanzania.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and
newborn care. Dar es Salaam, Tanzania.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es
Salaam, Tanzania.
Wikipedia. (2013). Law. Retrieved from http://www.wikipedia.org

39
Session 7: Cultural and Social Issues
Session Time: 60 minutes
Prerequisites
 None
Learning Tasks
 Explain taboos, customs and beliefs affecting pregnancy and motherhood
 Select recommended taboos, customs and beliefs affecting pregnancy and motherhood
 Encourage woman on avoidance of harmful practices affecting pregnancy and motherhood
Resources Needed
 Projector
 Computer
SESSION OVERVIEW

Group discussion Taboos, Customs and Beliefs Affecting
2 25 minutes
Presentation Pregnancy and Motherhood
Brainstorming Harmful Practices Affecting Pregnancy and
3 20 minutes
Presentation Motherhood
SESSION CONTENT

READ or ASK students to read the related tasks and clarify
ASK student if they have any question before proceeding
NMT 05111 Midwifery I 40

NTA Level 5, Semester 1 Session 7: Cultural and Social Issues
Step 2: Taboos, Customs and Beliefs Affecting Pregnancy and Motherhood
(25 minutes)
Definition of Terms
Taboo
 System, act, of setting apart person or thing as accursed or sacred.
OR
 A cultural or religious custom that does not allow people to do, use, talk about a particular
thing as people find it offensive or embarrassing
OR
 A general agreement about something or to do something
Custom
 An accepted way of doing or behaving in a society or a community, or the way a person
always behaves or a habit or practice
Beliefs
 To be assured that something is true or that somebody is telling you the truth, or think
that something, to think that something is good, right or accepted
DIVIDE the students into groups; each with students from the same zone
ALLOW them time to discuss the taboos, customs and beliefs affecting
pregnancy and motherhood
AFTER small group discussion, ask students to provide their responses
CLARIFY and summarize by using the contents below
Taboos
 A pregnant woman is not allowed to eat eggs, goat meat believing that the baby will be
born without hair
 Avoid eating green vegetables after delivery as it will cause abdominal distension
o Effects
 Pregnant woman needs protein; if she does not get food rich in protein and iron
she may become malnourished and anemic
Customs
 Providing rest with highly nutritious diet to mothers for three months after delivery
o Effect
 Mother is prevented from anaemia
 She gets enough time to recover from labour
 Breast feeding for all mothers
o Effects
 The child gets breast milk which is vital for growth and development
 Stigma for HIV positive women who opted not to breastfeed their babies

 Female genital mutilation (FGM, female circumcision)
 They believe that circumcised women will not be prostitutes thus prevent teenage
pregnancy and married woman will not go out of their wedlock.
o Effects
 It causes unnecessary pain and bleeding
 During delivery it exposes the woman to third degree tear
 It reduces sexual enjoyment to the woman leading to unhappy life
Step 3: Harmful Practices Affecting Pregnancy and Motherhood

(20 minutes)
Activity: Brainstorm (5 minutes)
ASK student to brain storm the harmful practices affecting pregnancy and motherhood for 2
minutes
ALLOW few students to respond and let others provide unmentioned response
WRITE the responses on flip chart/chalkboard
CLARIFY and summarize by using the content below
Beliefs
 It is believed that the use of traditional medicines during pregnancy will make the baby to
be born per vagina easily
o Effects
 Intrauterine fetal death
 Mental retardation to the baby
 Maternal death due to poison in the blood circulation
 Premature delivery
 Precipitate labour
 Rupture of uterus due to excessive contractions
 Packing the vagina with local herbs to prevent episiotomy during delivery
o Effects
 The use of local herbs will encourage ascending infection which may lead to
septicaemia and death.
 Presence of Vernix caseosa on the newborn baby is believed to be caused by sexual
intercourse during pregnancy.
o Effects
 Misunderstanding between the couples leading to deprivation of care during
Puerperium
 It can lead to puerperal psychosis to the mother who will be deprived of love from
the husband
 It may predispose the man to multiple sexual partners which can increase the
incidence of HIV infection
Taboos
 A pregnant woman is not allowed to eat eggs, goat meat believing that the baby will be
born without hair

 Avoid eating green vegetables after delivery as it will cause abdominal distension
o Effects
 Pregnant woman needs protein; if she does not get food rich in protein and iron
she will become malnourished and anaemic
 Female genital mutilation (FGM: female circumcision)
o They believe that by circumcising the women the woman will not be a prostitute thus
prevent teenage pregnancy and married woman will not go out of their wedlock
o Effects
 It causes unnecessary pain and bleeding
 During delivery it exposes the woman to third degree tear
 It reduces sexual enjoyment to the woman leading to unhappy life
 Prohibiting sexual intercourse during pregnancy period
o Effects
 May result to polygamy because many men can not abstain for a long period
 Increases chances of getting HIV/AIDs and STIs as men will go out of their
marriage
 Taboos customs and beliefs depend on particular cultural group of people.

 Some of them are good in pregnancy and motherhood while others are bad.
 Midwives should understand them and how they affect the mothers in order to be in a
position to give appropriate advice to the mothers.
 Identify taboos, customs and beliefs that affect pregnancy and motherhood positively
 Identify taboos, customs and beliefs that affect pregnancy and motherhood negatively
References
Salaam, Tanzania.

Session 8: Safe/Good Socio-Cultural Practices
Session Time: 120 minutes
Prerequisites
 None
Learning Tasks
 Define good social-cultural practices during pregnancy, labour and motherhood.
 Identify good social-cultural practices during pregnancy, labour and motherhood.
 Describe advantages of good social-cultural practices in pregnancy in pregnancy, labour
and motherhood.
Resources Needed
 Projector
 Computer
SESSION OVERVIEW

Presentation/ Social-Cultural Practices during Pregnancy,
2 25 minutes
Group Discussion Labour and Motherhood
Presentation/ Promote Good Social-Cultural Practices during
3 60 minutes
Group Discussion Pregnancy, Labour And Motherhood
Describe Advantages of Good Social-Cultural
4 20 minutes Presentation
Practices in Pregnancy, Labour and Motherhood
SESSION CONTENT

ASK students if they have any question before proceeding

44
NTA Level 5, Semester 1 Session 8: Safe/Good Socio-Cultural
Practices
Step 2: Social-Cultural Practices During Pregnancy, Labour and
Motherhood (20 minutes)
DIVIDE students into small manageable group
ASK them to discuss in groups on social- cultural practices during pregnancy labour and
motherhood
AFTER small group discussion, ask students to provide their responses
CLARIFY and Summarize using the contents below
 Social cultural practice differs from one place to another depending on individual back
ground, geographical environment and ethnic back ground
 Examples of social cultural practices include the following
o During pregnancy
 Some tribes puncture the vein of the cow, draw off blood and consume it after
mixing it with milk
 Traveling is not allowed until delivery, as this may lead to premature delivery
 Limitation of work e.g. is not allowed to carry heavy loads as it may lead to
abortion
o During labour
 Provided with soft nutritious diet.
 Provided with moral and psychological support.
 Having close relative around.
o During motherhood
 Allow her to rest after delivery for varying periods.
 Provision of presents for the mother and newborn.
 Provision of nutritious diet.
Step 3: Promote Good Social-Cultural Practices during Pregnancy, Labour

and Motherhood (60 minutes)
Activity: Clinical visit (40 minutes)
DIVIDE students into manageable groups
ASK students to visit the RCH clinic and discuss with women on social-cultural practices
during pregnancy, labour and motherhood
TELL students to write the information gained in each group
GIVE them time to present in plenary
CLARIFY and summarize their responses

45
Practices
Step 4: Advantages of Good Social-Cultural Practices in Pregnancy,
Labour and Motherhood (20 minutes)
 During pregnancy
o Easy to receive the needs in more satisfying way
o Assistance will be available when the need arise
o There will be a close relative with the mother all the time
 During labour
o Emotional support during labour improve birth outcomes
o Light diet and sweet fluids provides energy during labour provide energy and the
woman is not exhausted
o Changing position during labour and delivery result in good labour outcome
o Exercises during labour facilitate descent of the fetal head and provide adequate
oxygen supply to the fetus
o Proper hygiene practiced during labour protect the womn from getting ascending
infection
 During Motherhood
o Women and community will be happier with the care and the transition to
motherhood will be improved
 Some of the cultures, customs and beliefs are harmful to both the mother and her baby
 The midwife should encourage the useful practices and discourage the harmful practices
 What are the differences between good and harmful socio-cultural practices during
pregnancy labour and delivery?
 List dangers of harmful socio-cultural practices during pregnancy labour and delivery.
 Mention advantages of good socio-cultural practices in pregnancy labour and delivery.
References
Salaam, Tanzania.

46
Practices
Session 9: Physiology of Pregnancy
Prerequisites
 None
Learning Tasks
 Define the common terms used in Midwifery
 Describe the hormonal cycles
 Explain fertilization
 Explain the development of the fertilized ovum
Resources Needed
 Projector
 Computer
 Models
SESSION OVERVIEW

Tasks
2 5 minutes Presentation Common Terms Used in Midwifery
3 40 minutes Presentation/ Hormonal Cycle

Discussion
4 60 minutes Presentation/ Fertilization and Development of the
Discussion Fertilized Ovum
SESSION CONTENT
ASK Students if they have any questions before proceeding

Level 5, Semester 1 Session 9: Physiology of Pregnancy
Step 2: Definitions of Common Terms used in Midwifery (5 minutes)
 Midwife
This is a person who, having been admitted to a midwifery education programme, dully
recognized in the country in which it is located, has successfully completed the prescribed
course of studies in midwifery and has acquired the requisite qualifications to be
registered and/or legally licensed to practice Midwifery.
 Midwifery
Midwifery is the art and science of caring for women undergoing normal pregnancies,
labors or post natal periods. It deals with child birth.
 Obstetrics
This is the branch of medicine that is concerned with management of woman during
pregnancy, child birth and the puerperium.
 Gravid
Means pregnant.
 Gravida
A pregnant woman
 Para
It is the term used to describe a woman who has produced an infant regardless of whether
the child was alive or dead.
 Nullipara
A woman who has never given birth to a viable child, she may however have been
pregnant previously
 Primgravida
A woman who is pregnant for the first time.
 Primipara
A woman who has given birth to a viable child whether alive or stillbirth
 Multipara
A woman who has delivered more than one baby being para 2, 3, 4 etc.
 Grande Multipara
A woman who has had 4 or more previous pregnancies
Step 3: Hormonal Cycles (40 Minutes)
DIVIDE the students in manageable groups.
ASK students to discuss on the Menstrual Cycle for 10 minutes.
AFTER small group discussion ask students to provide their responses.
CLARIFY and summarize by using the content below.
Hypothalamus
 The hypothalamus is the ultimate source of control and it governs the anterior pituitary
gland by hormones pathways.
 The pituitary gland governs the ovary by hormones.
 The ovary produces hormones which control changes in the uterus

The Ovarian Cycle
 The ovarian cortex contains 200,000 primordial follicles at birth. Some of them become
cystic and are known as graafian follicles.
 The ovum is situated at one end of the graafian follicle, under the influence of follicle
stimulating hormone the graafian follicle matures and moves to the surface of the ovary,
and finally, rupturing to release the ovum into the fimbriated end of fallopian tube, this is
known as ovulation,
 The empty follicle is known as corpus luteum (yellow body)
 After ovulation the empty follicle collapses, the granulose cells enlarge and proliferate
over the next 14 days and the structure become irregular in outline and yellow in colour.
 If pregnancy does not occur the corpus luteum will atrophy and become the corpus
albicans (white body).
Ovarian Hormones
 Oestrogen is produced under the influence of follicle stimulating hormone (FSH). It is
responsible for the secondary sex characteristics such as female shape growth of breasts
and uterus and female distribution of hair. It influences the production of cervical mucus
and during the cycle it causes proliferation of the uterine endometrium. It inhibits FSH
and encourages fluid retention.
 Progesterone is produced by corpus luteum under the influence of luteinizing hormone
(LH). Its effects are mainly evident in the second half of the cycle. It acts on tissues
which have been affected by oestrogen. It causes secretory changes in the lining of the
uterus
 Relaxin. It is at its maximum level between 38 and 42 weeks it originates from the
corpus luteum and is known to relax the pelvic girdle. It reduces oxytocin release, soften
the cervix and suppress uterine contractions.
Pituitary Control
 Under the influence of the hypothalamus which produces gonadotrophin releasing
hormone (GnRH), the anterior pituitary gland produces two hormones
o Follicle stimulating hormone (FSH) and Lutenizing hormone
 FSH causes graafian follicle to develop and enlarge one of them more than the
others.
 The matured graafian follicle produces oestrogen.
 The level of FSH rises during the first half of the circle when oestrogen reaches a
certain level its production is stopped.
 LH is produced when the anterior pituitary gland stop producing FHS the follicle
ruptures and ovulation occur.
 The corpus luteum develops and produces both oestrogen and progesterone it is
produced for 14 days then FHS appears and the circle starts again.
 Prolactin is produced in the anterior pituitary gland but does not control the ovary, it
inhibits ovulation during breast feeding.

Figure 1.9: Menstrual Cycle
Source: (Wikimedia Commons, 2012)
The Uterine Cycle (Menstrual Cycle)

 The average length of the circle is taken to be 28 days
 The first day of the circle is the day which menstruation begins
 There are three main phases and they affect the tissue structure of the endometrium.
The Menstrual Phase

 It is characterized by vaginal bleeding, lasting for 3 – 5 days. The endometrium shed
down to the basal layer along with blood from the capillaries and with the unfertilized
ovum.
The Proliferative Phase

 This follows menstruation and lasts until ovulation
 The first few days while endometrium is reforming are described as regenerative phase.
 This phase is under the control of oestrogen and consists of re-growth and thickening of
the endometrium and at the completion of this phase the endometrium consist of three
layers.
o Basal layer immediately above the myometrium it consist of rudimentary structures
for building new endometrium
o Functional layer. It contains tubular glands and changes constantly according to
hormonal influences.
o A layer of ciliated epithelium which covers the functional layer.
Secretory Phase
 Is under the influence of progesterone and oestrogen from the corpus luteum. The
functional thickens and becomes spongy and the glands more tortuous.

Step 4: Fertilization and Development of the Fertilized Ovum (60 minutes)
Fertilization
 It is the fusion of ovum and spermatozoa, it is also known as conception or impregnation.
 Following ovulation, the ovum passes into the fallopian tube and is moved along by the
peristaltic muscular contractions of the tube.
 The cervix under the influence of oestrogen secretes mucous which attracts sperms.
 During sexual intercourse about 300 million sperms are deposited into the vagina, many
will die on the journey through the uterus.
 Thousands will reach the fallopian tube and only one will enter the ovum.
 The sperm and ovum each contribute half the complement of chromosomes to make a
total of 46. The sperm and ovum are known as male and female gametes, the fertilized
ovum is the zygote.
 Neither the ovum nor sperm can survive longer than 2 or 3 days and fertilization is most
likely to occur when intercourse take place not more than 48 hours before or 24 hours
after ovulation.
Development of the Fertilized Ovum
 After fertilization the fertilized ovum continues with its journey through the fallopian tube
and reaches the uterus 3 – 4 days later.
 During this period cell division takes place, the fertilized ovum divides into 2 cells then
into 4, 8, and 16 and so on until a ball of cells formed know as the morula.
 Next a fluid cavity or blastocyst appears in the morula which now becomes blastocyst.
 Around the outside of the blastocyst is a single layer of cells known as the trophoblast,the
remaining cells are clumped together at one end forming the inner cell mass.
 A trophoblast will form the placenta and chorion; while the inner cell mass will form
fetus, amnion and umbilical cord.
 On its journey the ovum is nourished by glycogen from cells of fallopian tubes and later
from secretory glands of the uterus.
 When the blastocyst first reaches the uterus it lies free for 2 – 3 days then the trophoblast
starts to adhere to the uterus and become embedded. Embedding is normally complete by
the 11th day after ovulation.
Figure 2.0: development of the fertilized ovum
Blastocyst Inner cell
cavity mass
Trophoblast
(a)Zygote (b)Early (c)Morula (d)Early (e)Late blastocyst
(fertilized cleavage blastocyst (implanting)
egg) 4-cell stage (b) (c)
Fertilization (a) Ovary
(d
Uterine tube
) (e)
Secondary
oocyte
Ovulatio Uterus
n Endometrium
Source: (Wikimedia Commons, 2012)

The Decidua
 It is the name given to the endometrium during pregnancy
 After conception the endometrium grows 4 times its non pregnant thickness under the
influence of oestrogen
 It divides itself into three layers.
o The basement layer - Immediately above the myometrium and regenerates new
endometrium during the puerperium
o The functional layer - Consists of glands rich in secretions, it provides secure
anchorage for the placenta and allows it to access nutrients and oxygen but as soon as
the baby is born separation occur.
o The compact layer - This layer forms the surface of the decidua. It is composed of
closely packed stroma cells.
 The blastocyst embeds within the spongy layer and different areas of deciduas are
identified. The deciduas underneath the blastocyst is termed basal decidua (decidua
basalis) deciduas which covers the blastocyst is capsular deciduas (decidua capsularis) the
remainder is called parietal (vera or true).
The Trophoblast
 Small projections appear all over the blastocyst and become profuse at the area of
attachment. These trophoblastic cells differentiate into layers the outer synciotrophoblast,
the inner cytotrophoblst and below is a layer of mesoderm.
o Syncitiotrophoblast
 It is capable of breaking tissue in the process of embedding; it erodes walls of
blood vessels of the decidua making nutrients in the maternal blood accessible to
the developing organism.
o The cytotrophoblast
 A single layer of cells which produces a hormone called human chorionic
gonadotrophin (HCG), which is responsible for informing the corpus luteum that
pregnancy has started.
o The mesoderm
 It consists of loose connective tissue
The Inner Cell Mass

 While the trophoblast develop into the placenta which nourish the fetus, the inner cell
mass develop into the fetus
 The cell differentiate into three layers
o The ectoderm - Forms the skin and nervous system
o The mesoderm - Forms bones, muscles, heart, blood vessels and some internal organs.
o The endoderm - Forms mucous membranes and glands.
o The three layers together are known as embryonic plate.
 The inner cell mass undergo development and two cavities are formed
o The amniotic cavity surrounded by ectoderm cells, it is filled with fluid; it enlarges
gradually and folds around the embryo to enclose it.
o The yolk sac surrounded by endoderm cells provides, nourishment to the embryo until
the trophoblast is sufficiently developed to take over.

The Embryo
 It is the name of the developing offspring after implantation up to 8 weeks
 During the embryonic period all the organs and systems of the body are laid down in
rudimentary form.
 The hypothalamus is the ultimate source of control and it governs the anterior pituitary
gland by hormones pathways
 Under the influence of the hypothalamus which produces gonadotrophin releasing
hormone (GnRH), the anterior pituitary gland produces two hormones Follicle
stimulating hormone (FSH) and Luteinizing hormone (LH)
 The sperm and ovum are known as male and female gametes, each contribute half the
complement of chromosomes to make a total of 46
 Which are the hormones formed by the pituitary gland

 What are the ovarian hormones?
 Briefly explain three phases of the menstrual cycle
 How long does it take for a fertilized ovum to reach the uterus?
References.
Wikimedia Commons. (2012) File: Menstrualcycle2.png. Retrieved from
http://en.wikipedia.org

Session 10: Placenta and Foetus
Prerequisites
 None
Learning Tasks
 Describe the placenta and umbilical cord
 Describe the normal placenta
 Explain the fetus
 Explain the amniotic fluid
 Describe the fetal circulation
Resources Needed
 Projector
 Computer
 Models
SESSION OVERVIEW

Tasks
2 45 minutes Presentation/ The Placenta and Umbilical Cord
Demonstration
3 10 minutes Presentation The Amniotic Fluid
4 20 minutes Presentation The Fetus
5 30 minutes Presentation The Fetal Circulation

Level 5, Semester 1 Session 10: Placenta and Foetus
SESSION CONTENT
Step 2: Placenta and the Umbilical Cord (45 minutes)
Placenta
 The placenta is an organ originating from the trophoblastic layer of the fertilized ovum.
 It is closely linked to the maternal circulation and carries out functions which the fetus is
unable to perform during intra-uterine life.
Development
 Initially the ovum is covered with fine hairs which are projections of the trophoblast.
 They proliferate and form branches from about three weeks after 3 weeks after
fertilization, forming the chorionic villi.
 The villi become more profuse at the basal deciduas; this part of trophoblast is known as
chorion frondosum which later form the placenta.
 The villi and the capsular decidua degenerate and form the chorion leave (bald chorion)
which is the origin of the chorion membrane.
 The villi erode the walls of the maternal blood vessels as they penetrate deciduas and
float into the maternal blood. They absorb nutrients and oxygen and excrete waste
products. A few villi are more deeply attached to the deciduas and are called enchoring
villi.
 The placenta is completely formed and functioning from 10th week after fertilisation.
The Normal Placenta
Activity : Brain storming (10 minutes)
DIVIDE the student in manageable groups so that each student can see
Ask students to brain storm different Parts of the placenta.
ALLOW time for them to respond.
CLARIFY and summarize using the information given below
The normal placenta is a round flat mass 20 cm. in diameter and 2.5 cm. thick at the
centre. It weighs 1/6 of the baby’s weight. It has two surfaces, maternal and fetal surface

Figure 2.1: The normal placenta
Source: (Yetter, 1998)
Maternal Surface
 It is dark red in colour due to maternal blood.
 It is made up of chorionic villi, arranged in cotyledons or lobes.
 There are about 20 lobes separated by sulci (furrows), the lobes are made up of lobules,
each lobule contains a single villus with its branches.
 Sometimes deposits of lime salts may be present on the surface.
 It is covered with amnion; it is white shinny in appearance.
Fetal Surface
 Branches of umbilical vein and arteries are visible.
 At the centre there is insertion of the cord.
 The amnion can be peeled off the surface.
Fetal Sac
 It consist of double membrane, the outer membrane is the chorion which is closely
attached to the uterine wall.
 The inner membrane is the amnion which contains the amniotic fluid.
o Chorion
 This is thick opaque, friable membrane derived from the trophoblast
o Amnion
 It is smooth, tough, translucent membrane derived from the inner cell mass.
 It has a role in the formation of amniotic fluid (also called liquor amnii)

Functions of the Placenta
Respiration
 During intra uterine life no pulmonary exchange of gas can take place, the fetus obtains
oxygen and excretes carbon dioxide through the placenta.
 Oxygen from maternal haemoglobin passes into the placenta by simple diffusion and
similarly the fetus gives off carbon dioxide
Nutrition
 The products of nutrition (nutrients) from maternal blood pass to the fetus via the
placenta. The fetus need nutrients such as glucose, amino acids, minerals, vitamins etc.
 Food for the fetus is derived from maternal diet and when it reaches the placenta is
already broken into simpler form
 The placenta also can select what is needed by the fetus and can break complex
substances into compounds that can be used by the fetus.
Storage
 The placenta metabolizes glucose, stores it in the form of glycogen and reconverts it into
glucose as required
 The placenta can also store iron and fat soluble vitamins.
Excretion
 The main substance excreted from the fetus is carbon dioxide
 billirubin will be excreted as red blood cells are replaced frequently
 Tthere is very little tissue break down and there is very little amount of urea and uric acid.
Protection
 The placenta provides a limited barrier to infection.
 With the exception of treponema of syphilis and tubercle bacilli, few bacteria can
penetrate. Virus can cross freely and may cause congenital abnormalities such as in
rubella virus.
 Drugs also can pass freely.
 Towards the end of pregnancy placenta allows small antibodies immunoglobulins G
(IgG) from the mother to pass to the fetus.
Endocrine
 The placenta produces hormones
o Human chorionic gonadotrophin is produced by the chorionic villi.
o Oesrogen and progesterone are produced by the placenta after the activity of corpus
luteum has declined.
o Human placental lactogen has a role in glucose metabolism during pregnancy
The Umbilical Cord

 The umbilical cord or funis extends from the fetus to the placenta and transmits the
umbilical blood vessels to arteries and one vein which are enclosed and protected by
Wharton’s jelly a substance formed by mesoderm.
 The whole cord is covered in a layer of amnion.
 The average length of the cord is about 50 cm. and is termed a short cord if it is below 40
cm. The disadvantages of a very long cord are that it may become wrapped around the
body or neck of the fetus or become knotted

Anatomical variations of the placenta and the cord
Figure 2.2: Succenturiate lobe of placenta
Source: (The International Vasa Previa Foundation, 2012)
 A small extra lobe separate from the main placenta and joined to it by blood vessels,
which run through the membranes
 This small lobe may be retained in utero after delivery and if it’s not removed may lead to
infection and haemorrhage.
Figure 2.3: Circumvallates Placenta
 An opaque ring is seen on the fetal surface, it is formed by a doubling back of the chorion
and amnion

Figure 2.4: Bipartite placenta
 Two complete and separate lobes are present, each with a cord leaving it; the bipartite
cord joins a short distance from the two parts of the placenta.
 Tripartite placenta is similar but with three distinct lobes.
Figure 2.5: Battledore insertion of the cord
The cord is attached to the very edge of the placenta. It is not important unless the
attachment is fragile.

Figure 2.6: Velamentous insertion of the cord
 The cord is inserted into the membranes, some distance from the edge of the placenta.
 If the placenta is situated normally there is no harm to the fetus, the cord may be detached
when applying traction.
 If the placenta is low laying the blood vessels may pass across the internal os and the term
vasa praevia is applied
 In this case there is great danger to the fetus as the blood vessels may be torn during
rupture of membranes.
Step 3: Amniotic Fluid (10 minutes)
 It is the fluid which fills the amniotic sac in which the fetus floats.
Functions
 It distends the sac and allows growth and free movements of the fetus.
 It equalizes pressure and protect the fetus from injury
 The fluid maintains constant temperature for the fetus and provides a small amount of
nutrients.
 During labour, it prevents compression of the placenta and umbilical cord by the
contracting uterus.
 It also aids effacement of cervix and dilatation particularly where the presenting part is
poorly applied.
Origin
 The source of amniotic is both maternal and fetal
 It is secreted by amnion especially the part covering the placenta and umbilical cord
 Some fluid is exudates from maternal and fetal blood vessels
 Fetal urine after the 10th week of gestation also contribute to the volume

Volume
 The amount of amniotic fluid increases throughout pregnancy until 38 weeks gestation
when there is about 1000 ml and then diminishes slightly until term approximately 800 ml
remains. When the total amount exceeds 1,500ml, the condition is called
polyhydramnios and if less than 300ml the condition is called oligohydramnios
 Such abnormalities are often associated with congenital malformation of the fetus
Constituents
 Amniotic fluid is a clear, pale, straw colored fluid consisting of 99% water and 1%
dissolved solid matter including food substances and waste products, in addition the fetus
sheds skin cells, vernix caseosa and lanugo.
Step 4: The Fetus (20 minutes
 For the first 3 weeks following conception the term fertilized ovum or zygote is used
 From 3 – 8 weeks after conception it is known as the embryo and following this is the
fetus until birth when it becomes a baby.
The Summary of Development

 0 – 4 weeks after conception
o Rapid growth, formation of embryonic plate, primitive central nervous system forms,
heart develops and begins to beat, limb buds form.
 4 – 8 weeks
o Very rapid cell division
o Head and facial features develop
o All major organs laid down but in primitive form
o External genitalia present but sex not distinguishable
o Early movements
o Visible on ultra sound from 6 weeks
 8 – 12 weeks
o Eye lids fuse
o Kidneys begin to function and the fetus passes urine from 10 weeks.
o Fetal circulation functioning properly
o Sucking and swallowing begin.
o Sex apparent, moves freely (not felt by the mother)
o Some primitive reflexes present.
 12 – 16 weeks
o Rapid skeletal development – visible in X-ray
o Meconium present in the gut
o Lanugo appears
o Nasal septum and palate fuse.
 16 – 20 weeks
o Quickening - mother feels fetal movements
o Fetal heart felt on auscultation
o Vernix caseosa appears
o Finger nails can be seen
o Skin cells begin to be renewed.

 20 -24 weeks
o Most organs became capable of functioning.
o Periods of sleep and activity
o Responds to sound
o Skin red and wrinkled
 24 – 28 weeks
o Survival may be expected if born.
o Eye lids reopen.
o Respiratory movements.
 28 – 32 weeks
o Begins to store fat and iron
o Testes descend into the scrotum
o Lanugo disappears from the face
o Skin become less pallor and lass wrinkled
 32 – 36 weeks
o Increased fat makes the body more rounded.
o Lanugo disappears from the body.
o Head hair lengthens.
o Nails reach tip of fingers
o Ear cartilage - soft
o Plantar creases - visible
 36 – 40 weeks
o Term is reached and birth is due
Step 5: Fetal Circulation (30 minutes)
Temporary Structures
 The umbilical vein: It leads from the umbilical cord to the underside of the liver and
carries blood rich in oxygen and nutrients. It has a branch which joins portal vein and
supply the liver.
 The ductus venosus (from a vein to a vein): This connects the umbilical vein to the
inferior vena cava, where oxygenated blood is mixed with deoxygenated from the lower
limbs.
 Foramen ovale (oval opening): This is a temporal opening between the two atria which
allows the majority of blood entering from the inferior vena cava to pass across the left
atrium
 The ductus arteriosus (from an artery to an artery): this leads from the pulmonary
artery to the descending aorta, it carries impure blood from and upper limbs bypassing the
pulmonary circulation
 Hypogastric arteries: These branch off from the internal iliac arteries and become
umbilical arteries when they enter the umbilical cord. They return blood to the placenta.
Fetal Circulation
The blood takes about half a minute to circulate and takes the following course.
 Blood from the fetus is carried to the placenta for oxygenation and replenishment.
 From the placenta blood passes through the umbilical vein to the undersurface of the
liver, this is the only vessel which carries unmixed blood.

 The ductus venosus carries blood to the inferior vena cava where it is mixed with blood
from the lower body.
 Blood from the inferior vena cava passes into the right atrium through the foramen ovale
into the left atrium following its normal route through the left ventricle into the aorta.
Large amount supply the brain and heart and upper limbs small amount goes to the
descending aorta.
 Blood collected from the upper part of the body returns to the right atrium through the
superior vena cava. This blood is depleted of oxygen and nutrients; it passes into the
right atrium to the right ventricle.
 Only a small amount of blood goes into the lungs, large amount is carried by the ductus
arteriosus to the descending aorta which supply the abdomen and lower limbs.
 The internal iliac arteries lead into the hypogastric arteries which return blood to the
placenta via umbilical arteries. The remaining blood supplies the lower limbs and returns
to the inferior vena cava
Figure 2.7: Fetal circulation
Source: http://nursingcrib.com
Table 1.0: Adaptation to Extra-Uterine Life
Organs How they adopt

Foramen ovale Closes shortly after birth, fuses completely in first year.
Ductus arteriousus Closes soon after birth, becomes ligamentum arteriousum in about
3 months.
Ductus venosus Ligamentum venosum
Umbilical arteries Medial umbilical ligaments
Umbilical vein Ligamentum teres

Step 6: Key points (5 minutes)
 The placenta is an organ originating from the trophoblastic layer of the fertilized ovum,
and it is completely formed and functioning from 10th week after fertilization
 Umbilical cord extends from placenta to the fetus and transmit blood vessels for the
nourishment of the developing fetus
 When the total amount of amniotic fluid exceeds 1,500ml, the condition is called
polyhydramnios and if less than 300ml is oligohydramnios
 Blood from the inferior vena cava passes into the right atrium through the foramen ovale
into the left atrium following its normal route through the left ventricle into the aorta
 Outline the functions of the placenta

 Outline the functions of the amniotic fluid
 When do nasal septum and palate of the fetus fuse?
 Mention the temporary structures?
References
The International Vasa Previa Foundation. (2012). Velamentous insertion of the umbilical
cord. Retrieved from http://www.vasaprevia.org
Yetter, J. (1998). Examination of the placenta. Retrieved from http://www.aafp.org

Session 11: Physiological Changes during Pregnancy
Prerequisites
 None
Learning Tasks
 Explain the physiological changes in the various body systems
 Explain the changes in skin, breasts and maternal weight
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
1 5 minutes Presentation Presentation of Session Title and related

Tasks
2 20 minutes Presentation/ Changes in Reproductive System
Brainstorm
3 15 minutes Presentation Changes in Cardiovascular System
4 10 minutes Presentation Changes in Respiratory System
5 10 minutes Presentation Changes in Urinary System
6 10 minutes Presentation/ Changes in Gastrointestinal System

Buzzing
7 10 minutes Presentation Changes in Skeletal System
8 10 minutes Presentation Changes in Endocrine System
9 20 minutes Presentation Changes in Skin, Breast and Maternal

Weight

65
Level 5, Semester 1 Session 11: Physiological Changes during
Pregnancy
SESSION CONTENT

Step 2: Changes in Reproductive System (20 minutes)
 Changes in a mother’s body during pregnancy occur to enable the woman to nurture the
fetus and prepare her body for labour and lactation
 The timing and intensity vary between systems.
ASK students to brainstorm on Changes in Reproductive System during pregnancy for 2

minutes
ALLOW few students to respond and let others provide unmentioned responses
WRITE their responses on flip chart/board
The Body of the Uterus

 After conception, the uterus develops to provide nutritive and protective environment for
the fetus
The Decidua
 After embedment of the blastocyst the deciduas become thicker and more vascular at the
upper body of the uterus.
 The decidua provides glycogen rich environment for the blastocyst until the trophoblastic
cells begin to form the placenta.
Myometrium
 Oestrogen is responsible for the growth of uterine muscles,
 Increase in size of the muscle fibers is known as hypertrophy and the increase in number
is known as hypaplasia.
 Increase in weight of the uterus. Prior to pregnancy 60 gm At term 1000 gm
 Increase in size of the uterus prior to pregnancy 7.5x5x2.5 cm at term 30x 22.5x 20 cm
 Hypertrophy and hyperplasia leads to the development of three layers of the myometrium.
 The inner circular layer surrounds the cornua, the lower uterine segment and cervix. It is
involved in stretching the lower uterine segment and cervix during labour.
 The thicker middle oblique layer its fibers are arranged in every direction (figure of eight)
it is involved in the contractions necessary to expel the fetus at the end of pregnancy and
to control bleeding during the third stage of labour.
 The outer longitudinal layer of muscle fibers is thin; they contract and retract during
labour causing the upper segment to thicken.

66
Pregnancy
Blood supply
 The blood supply to the uterus increases to keep pace with its growth also meeting the
needs of the functioning placenta, blood vessels increase in size and number.
Changes in uterine size and shape

 For the first few weeks the uterus maintains its original pear shape but as pregnancy
advances the uterus assume a more globular shape.
 10th week of pregnancy: the uterus is about the size of an orange
 12th week of pregnancy: The uterus is the size of grape fruit; it is no longer anteverted and
anteflexed. It has risen out of the pelvis, it is globular in shape and the fundus may be
palpated abdominally above the symphysis pubis.
 16th week of pregnancy: The fetus has grown enough to put pressure on the uterus. The
isthmus develops into lower uterine segment, which is thinner and contain less muscle
and blood vessels than the corpus.
 20th week of pregnancy: The fundus of the uterus can be palpated at the level of the
umbilicus. From this stage of gestation until term the uterus is ovoid in shape.
 30th week of pregnancy: The lower uterine segment can be defined but it is not yet
complete. The fundus may be palpated midway between the umbilicus and xiphisternum.
 38th week of pregnancy:
o The uterus has reached the level of xiphisternum.
o As the upper segment muscle contractions increase, the lower uterine segment
develop more rapidly which together with cervical effacement and softening of the
tissue of pelvic floor allows the fetal presentation to descend (lightening) relieving
pressure of the upper part of the abdomen.
The Cervix
 During pregnancy the cervix remains full closed providing a seal against external
contamination. It remains 2.5 cm long but becomes soft and swollen under the influence
of oestradiol and progesterone, its increased vascularity makes it looks bluish in colour
 The cervical glands secrete thick mucus which forms a plug called operculum which
provides protection from ascending infection.
 As uterine activity builds up during pregnancy the cervix gradually softens or ripens and
the canal dilates.
The Vagina
 Oestrogen causes changes in the muscle layer, the vagina epithelium become thicker and
more vascular; its violet colour is due to hyperaemia.
 The altered composition of the surrounding connective tissue increases the elasticity of
the vagina making dilatation easier during delivery.
 The epithelium has a marked desquamation of superficial cells which increases the
amount of normal vaginal discharge called leucorrhoea
 The epithelial cells also increase glycogen content which interact with dooderlein’s
bacillus and produce a more acid environment. This provides protection against some
organisms and increase susceptibility to others such as Candida albicans.

67
Pregnancy
Step 3: Changes in Cardiovascular System (15 minutes)
The Heart
 The heart enlarges by about 12% between early and late pregnancy, it is due to increased
myometrial hypertrophy and increased work load to the heart due to increased diastolic
filling (particularly left ventricle) and increasing blood volume.
 The growing uterus elevates the diaphragm and the heart is displaced upwards and to the
left rotating anteriorly
The Cardiac Output

 The increase in cardiac output ranges from 35-50% from an average of 5 l/min before
pregnancy to approximately 7 l/min by the 20th week.
 The increase in cardiac output allows blood flow to the kidneys, brain and coronary
arteries to remain unchanged while the distribution to other organs varies.
 Increased cardiac output is due to increase in resting heart rate of about 15 beats per
minute and increased blood volume.
The Blood Volume

 The two major components of blood - plasma and red blood cells undergo dramatic
adaptation.
 The total maternal blood volume increases 30 – 50%
 A higher circulating volume is required to:
o To protect the mother against the harmful effect of impaired venous return
o Meet the demands of the enlarged uterus with greatly hypertrophied vascular system
and provide extra blood flow for the placenta perfusion
o Supply extra metabolic needs to the fetus
o Provide extra perfusion to the kidneys and other organs
o Counter balance the effect of increased arterial and venous capacity
o Safe guard the mother against adverse effects of excessive blood loss at delivery.
 Plasma volume increase by from the 10th week of pregnancy reaches its maximum level
of approximately 50% by the 3second - 3fourth week and maintains until term.
 The increase in plasma volume reduces the viscosity of the blood and improves capillary
blood flow.
 The red cell mass, which is the total volume of red cells in the circulation, appears to
increase constantly throughout pregnancy.
 There is a total increase of about 18% by the end of pregnancy.
 In spite of the increased production of red blood cells, the marked increase in plasma
volume causes haemodilution effect, this is characterized by lowered hemoglobin (Hb)
level, haematocrit and red cell count.
Iron Metabolism
 The increased red cell mass and the needs of the developing fetus and placenta lead to
increased iron requirements during pregnancy.
 A healthy diet containing 10-14 mg of iron per day provides sufficient iron for the
majority of pregnant women.
 The fetal need for iron is greatest in the last 4 weeks of pregnancy.
 Iron absorption from the gut is therefore enhanced in the latter part of pregnancy.

68
Pregnancy
Plasma Protein
 The total serum content falls during the first trimester and remain reduced throughout
pregnancy.
 Albumin concentration falls leading to a decrease in osmotic pressure, this causes water
to be drawn from the plasma into the cells or out of blood vessels causing oedema of the
lower limbs in late pregnancy which is seen as physiological oedema.
Clotting Factors
 Major changes in the coagulation system, leads to the hypercoagulable state of normal
pregnancy
 The increased tendency to clot is caused by reduced plasma fibrinolytic activity and an
increase in fibrin degradation products in the plasma.
 Fibrinogen factor 7, factor 10 and platelets are all increased leading to a change in
coagulation time from 8 to 12 (approximately) minutes.
 There is risk of thrombosis, embolism and when complications are present, disseminated
intravascular coagulation.
White Blood Cells

 White cell count rises during pregnancy reaching its peak at 30 weeks.
 The main change involves an increase in neutrophils which enhances the blood’s
phagocytic and bactericidal properties
Immunity
 HCG and prolactin suppress the immune response of pregnant women
 lymphocyte function is depressed, and there is also decreased resistance to viral infections
Effects on Blood Pressure

 The increased cardiac output is balanced by reduced peripheral resistance; arterial walls
relax and dilate as progesterone acts on smooth muscles.
 Blood pressure drops by 10% starting in the first trimester reaching its lowest level in
mid-trimester and towards term reach the level of first trimester
 In late pregnancy women should avoid unsupported supine position as it can cause
hypotension. The pressure of gravid uterus compress the vena cava reducing venous
return, cardiac output is reduced which give rise to feelings of faintness and paraesthesia
of the fingers.
Blood Flow
 The majority of increased blood flow is directed to the uterus, and of that 80% goes to the
placenta
 Blood flow to the kidneys is increased by 30-50% enhancing excretion
 In creased flow to the skin is thought to eliminate extra heat generated by fetal
metabolism.
Step 4: Changes in Respiratory System (10 minutes)
 The blood volume expansion and vasodilatation in pregnancy result in hyperaemia and
oedema of upper respiratory mucosa which predispose to nasal congestion, epistaxis and
even change in voice.

69
Pregnancy
 Some pregnant women experience some dyspnoea; it may be that the conscious need to
breath or shortness of breath is influenced by increased sensitivity of the respiratory
centre to carbon dioxide due to effect of progesterone and oestrogen.
 During pregnancy as the uterus enlarges the diaphragm is elevated and the rib cage is
displaced upwards.
 The ribs flare out maintaining the capacity of thoracic cavity by counter-acting the effects
of the enlarging uterus which presses upon the diaphragm.
Step 5: Changes in Urinary System (10 minutes)
 Anatomical changes are seen in the kidneys and ureters.

 The kidneys increase in weight and lengthen by 1 cm under the influence of progesterone
 The ureters also dilate and lengthen this leads to urinary stasis and increased risk of
urinary tract infection during pregnancy.
 Frequency of micturition and stress incontinence in early pregnancy due to pressure of the
growing uterus on the urinary bladder is common
 In late pregnancy due to effect of progesterone on the tissue of the pelvic floor and
pressure of the fetal head to the bladder
Step 6: Changes in Gastrointestinal System (10 minutes)
TELL the students to pair up and explain the Changes in Gastrointestinal System for 2
minutes
ALLOW few students to respond and let other pairs to provide unmentioned responses
CLARIFY and summarize, using the information given below
 The gums become oedematous, soft and spongy due to effects of oestrogen which can
lead to gum bleeding. Dental problems occur due to gingivitis.
 Increased salivation, ptyalism is common due to stimulation of salivary glands. Women
often experience changes in their taste leading to dietary changes and food cravings.
Craving for non-food substances such as coal is termed as pica.
 Effects on digestion
o Progesterone relaxes smooth muscles and therefore gastric emptying and peristalsis
are slowed
o Heart burn is common and is associated with gastric reflux due to relaxation of
cardiac sphincter
o There is constipation due to sluggish gut motility.
o Nausea and vomiting occur mainly during early pregnancy due to increased oestrogen
or human chorionic gondotrophin levels.

70
Pregnancy
Step 7: Changes in Skeletal System (10 minutes)
 During pregnancy, relaxation of pelvic joints and ligaments results from hormonal
changes
 This allows some expansion of pelvic cavity during descent of fetal head in labour
 Relaxation of the symphysis pubis causes severe pelvic pain which occurs more in
multiparous than in primigravid women
 Posture usually alters to compensate for enlargement of the uterus, particularly if
abdominal muscle tone is poor
 A progressive lardosis shifts the woman’s centre of gravity back over her legs, there is
also increased mobility of sacroiliac and sacrococcygeal joint which contribute to change
of posture and low back pain.
Step 8: Changes in Endocrine System (10 minutes)
Placental Hormones
 HGC is produced by trophoblast and can be detected in the maternal circulation within
days and forms the basis for pregnancy test
 The placenta produces progesterone and oestrogen from the 10 and 12th week and
continuous throughout pregnancy its peak being at 38 weeks pregnancy
Pituitary Hormones
 The anterior pituitary gland is enlarged. Adrenocorticotrophic hormone, melanocyte-
stimulating hormone and thyrotrophic hormone increase their activities.
 Follicle stimulating hormone and luteinizing hormone secretions are inhibited by
oestrogen and progesterone. Prolactin secretion increases but its effect of producing milk
is suppressed during pregnancy by high levels of oestrogen and progesterone.
 Posterior pituitary gland produces oxytocin throughout pregnancy but it is not totally
effective until the balance of oestrogen and progesterone changes, before onset of labour.
Thyroid Function
 In normal pregnancy there is reduced level plasma iodine although thyroid activity is not
markedly increased, development of goiter is unlikely
 Rising progesterone levels increases the maternal metabolism but also allow fat
deposition.
 The basal metabolic rate is increased in pregnancy due to increased oxygen consumption
by the fetus
Adrenal Glands
 Corticosteroid production is increased and may be one of the reasons for glycosuria in
pregnancy
 Excretion of sodium and chloride is increased in the presence of progesterone.

71
Pregnancy
Step 9: Changes in Skin, Breasts and Maternal weight (20 minutes)
Skin
 From the third month until term, some degree of skin darkening is observed in 90% of all
pregnant women, this is due to melanocyte –stimulating hormone as well as oestrogen
and progesterone.
 The pigmented linea alba now called linea nigra runs from the pubis to above the
umbilicus. Pigmentation of the face which affects at least half of all pregnant women is
called chloasma or melasma or mask of pregnancy
 As maternal size increases, stretching of the skin occur causing stretch marks called striae
gravidarum
 Itching of the skin may occur but not very common.
 The increased blood supply to the skin leads to sweating, women feel hotter in pregnancy
caused by progesterone induced rise in temperature of 0.5 degrees together with
vasodilatation
Breasts
 Major changes occurs to the breasts because of increased blood supply and stimulation by
oestrogen and progesterone, new ducts and acini cells are formed.
 3-4 weeks: Prickling, tingling sensation due to increased blood supply
 6-8 weeks: Increase in size, painful, tense and nodular due to hypertrophy of alveoli.
Surface veins became visible just beneath the skin.
 8-12 weeks: Montgomery’s tubercles become more prominent on the areola. The
hypertrophic sebaceous glands secrete sebum which keeps the nipple soft. The pigmented
area around the nipple (primary areola) darkens and may enlarge.
 16 weeks: Colostrums can be expressed
 The secondary areola develops which is pigmentation beyond the primary areola.
Colostrums can be expressed
o Late pregnancy.
 Colostrums may leak from the breasts; progesterone causes the nipple to become
more prominent and mobile.
Maternal Weight
 Continue weight gain in pregnancy is considered to be one of the favorable indicators of
maternal adaptation and fetal growth
 Expected increase
o 3.5kg in the first 20 weeks
o 9 kg in the last 20 weeks
o Total 12.5 kg
 Many factors influence weight gain; degree of maternal oedema, dietary intake, vomiting
or diarrhoea, amount of amniotic fluid and size of the fetus.
 Distribution of average increase in weight in pregnancy
o Breasts 0.4 kg
o Adipose tissue 2.5 kg
o Placenta 0.6 kg
o Fetus 3.2 kg
o Amniotic Fluid 0.8 kg
o Uterus 0.9 kg

72
Pregnancy
o Blood volume 1.5 kg
o Extra cellular fluid 2.6 kg
Total 12.5 kg
Step 10: Key points (10 minutes)
 Changes in a mother’s body during pregnancy are designed to enable the woman to
nurture the fetus and prepare her body for labour and lactation
 After conception the uterus develops to provide nutritive and protective environment for
the fetus
 The deciduas provides glycogen rich environment for the blastocyst until the
trophoblastic cells begin to form the placenta
 The cervical glands secrete thick mucus which forms a plug called operculum which
provides protection from ascending infection.
 Increased cardiac output is due to increase in resting heart rate of about 15 beats per
minute and increased blood volume.
 Frequency of micturition and stress incontinence in early pregnancy due to pressure of the
growing uterus on the urinary bladder is common
 Continue weight gain in pregnancy is considered to be one of the favorable indicators of
maternal adaptation and fetal growth
 How does pregnancy affect immunity?

 What is the role of the dooderlein’s bacilli during pregnancy?
 Why the higher circulating blood volume is required during pregnancy?
 What are the effects of progesterone on GIT?
References

73
Pregnancy
Session 12: Signs and Symptoms and Minor Disorders
of Pregnancy
Prerequisites
 None
Learning Tasks
 Explain the sign and symptoms of pregnancy
 Explain the minor disorders of pregnancy
Resources Needed
 Projector
 Computer
 Models
SESSION OVERVIEW

Tasks
2 40 minutes Presentation/ Signs and Symptoms of Pregnancy
Brainstorm
3 65 minutes Presentation/ Minor Disorders of Pregnancy
Group discussion
4 5 minutes Presentation Key points
SESSION CONTENT

74
Level 5, Semester 1 Session 12: Signs and Symptoms and
Minor Disorders of Pregnancy
Step 2: Signs and Symptoms of Pregnancy (40 minutes)
Activity : Brainstorming (10 minutes)
ASK students to brainstorm on the Signs and Symptoms of Pregnancy for 2 minutes
 Possible or Presumptive Signs of Pregnancy

o These are the changes felt by the mother
 Probable signs
o Those changes observed by an examiner but that could be caused by a condition other
than pregnancy
 Positive signs
o Those signs that can be attributed only by the presence of fetus.
 Possible (Presumptive) Signs

o Breast changes 3 – 4 weeks +
 Enlargement of breasts
 Darkening of areola, unreliable in multigravida, pigmentation may persist after
delivery.
o Amenorrhoea 4 weeks +
 In most cases it is a sign of pregnancy, but there are other causes of amenorrhea
such as emotional disturbances, hormonal imbalance, pseudocyesis (false
pregnancy) sometimes slight bleeding may occur during implantation.
o Morning sickness 4 – 14 weeks
 Occurs in 50% of pregnant women but there other causes of vomiting such as
gastrointestinal disorders, pyrexia illness etc.
o Bladder irritability 6 – 12 weeks
 It includes frequency of micturation but there are also other causes e.g. urinary
tract infection, pelvic tumor
o Quickening 16 – 20 weeks +
 Fetal movements felt by the mother. The woman may imagine fetal movements.
 Probable Signs
o Presence of human chorionic gonadotrophin (HCG)
 In blood: 9 – 10 days
 In urine: 14 days
 It can also be found in hydatidiform mole and choriocarcinoma
o Softened isthmus (Hegar’s sign) 6 – 12 weeks
 When two fingers are inserted into the anterior fornix and the other hand is
inserted behind the uterus abdominally, the fingers of both hands almost meet
because of the softness of the isthmus.

75
o Blue vagina (Chadwick’s sign) 8 weeks +
 Violet blue discoloration of the vaginal mucosa due to pelvic congestion may also
be present in pelvic tumor.
o Pulsation of the fornices (Osiender’s sign) 8 weeks +
 Increased pulsation is due to pelvic congestion.
o Uterine growth 8 weeks +
o Changes in skin pigmentation
 Includes skin pigmentation, linea nigra, striae gravidarum
o Uterine soufflé 12 – 16 weeks
 Soft blowing sound felt on auscultation, it is due to increased blood flow to the
uterus.
 It can also occur in uterine tumor.
o Braxton Hicks contractions 16 weeks
 Painless uterine contractions are palpable
o Ballottement of the fetus 16 – 28 weeks
 The fetus can be balloted between two hands
 Positive Signs of Pregnancy

o Hearing fetal heart sounds
o Ultrasound: 6 weeks +
o Fetal scope: 20 – 24 weeks +
o Visualization of fetus by ultrasound: 6 weeks +
o X –ray: 16 weeks
o Fetal parts palpated: 24 weeks +
o Fetal movements palpable: 22 weeks +
o Visible : Late pregnancy
Step 3: Minor Disorders during Pregnancy (65 minutes)
DEVIDE students into small manageable groups
ASK students to discuss in groups on the Minor Disorders of Pregnancy for 10 minutes
AFTER small groups discussion, ask students to present their responses
CLARIFY and summarize by using the content given below
 Minor disorders are the disorders which are not life threatening
 A minor disorder may develop into a serious complication of pregnancy.
 The role of a midwife is to be aware to any developing complication and refer
appropriately, She must always educate women on the changes during pregnancy to allay
unnecessary anxiety; She must provide practical advice to ease the situation as far as
possible.
 Causes of minor disorders can be divided into; hormonal changes, accommodation
changes, metabolic changes and postural changes.
 Every system of the body is affected by pregnancy

76
Digestive System
 Nausea and vomiting
o It occurs between 4 and 16 weeks, it is due to hormonal influences, human chorionic
gonadotrophin, oestrogen and progesterone.
o The sickness is not confirmed to ‘early morning’ but can occur at any time of the day
o The smell of food may cause the mother to retch, The midwife should explain the
probable reasons and encourage the woman to be positive.
o Mothers often find salads and light snacks more tolerable than full meals.
Carbohydrate snacks at bed time and before rising can prevent hypoglycemia which is
also said to cause nausea and vomiting.
o Other conditions unrelated to pregnancy which cause vomiting must be ruled out.
 Heart burn
o It is burning sensation in the mediasternum region
o Progesterone relaxes the cardiac sphincter of the stomach and allows reflux of gastric
content into the oesophagus
o Heart burn is more troublesome at 30 – 40 weeks.
o The advice varies according to the severity
 Avoid bending over when doing house keeping
 Small meals take up less space and are digested more easily
 Sleeping with more pillows than usual
 For persistent heart burn antacids may be prescribed.
 Excessive salivation (ptyalism)
o It occurs from the 8th week and is caused by hormones of pregnancy it may
accompany heart burn.
o Explanation and attentive listening are helpful
 Pica
o It is used when a woman craves certain foods or non-food substances. It may be due
to hormones or metabolic change
o The midwife should seek medical advice if the substance craved is potentially harmful
to the unborn child.
 Constipation
o It is due to relaxation and decreased peristalsis of the gut caused by progesterone
o Management
 Increase water intake, fresh fruits, vegetables and whole meal food in the diet
 A glass of water in the morning before tea or breakfast may activate the gut and
help regular bowel movements.
 Exercises are helpful especially walking.
Musculoskeletal System
 Backache
o This is due to changing of centre of gravity as the fetus grows and which posture to
adopt, hormones also softens ligaments
o Advice the woman on posture, and encourage practice pelvic exercises.
o Reassure the woman that once birth occurs, the ligaments will return to normal
 Cramp
o The cause is unknown it may be due to change in electrolyte status
o Management
 Foot and leg exercises

77
 Raise the foot of the leg about 25cm
 Make gentle leg movement while in warm bath before going to bed
 Vitamin B complex and calcium may be used
Genito-urinary System
 Frequency of micturition
o In early pregnancy due to pressure of the growing uterus on the bladder is common
o In late pregnancy is due to pressure of the fetal head on the bladder.
o The midwife should reassure the mother, exclude other causes of bladder irritability
 Leucorrhoea
o It is the increased white non-irritant vaginal discharge during pregnancy
o The midwife should advise the woman on personal hygiene, wear cotton underwear
and avoid tights, washing with plain water twice daily
o The midwife should exclude the possibility of infection
Circulatory System
 Fainting
o In early pregnancy is due to vasodilatation due to effect of progesterone, the woman
should avoid long periods of standing.
o In late pregnancy the woman may feel faint when lying on her back due to the weight
of the uterus on the inferior vena cava
o Turning the woman on her side will bring a rapid recovery
 Varicosities
o Progesterone relaxes smooth muscles of the veins resulting in sluggish circulation, the
valves of dilated veins become inefficient and varicosities result
o Varicose veins may occur in the legs, vulva and anus (haemorrhoids).
o The midwife should be aware of mothers at risk e.g. those with family history of
varicose veins or those whose work demand long periods of standing
o Management
 Exercises of calf muscles
 In early pregnancy, resting with legs vertical against the wall will drain the veins.
 Support tights increase comfort
 Avoidance of constipation
 In vulva varicosities a sanitary pad may give support and provide comfort
 The midwife should listen to the woman and give appropriate advice. She should
be aware of the risk of haemorrhage from ruptured vein during delivery.
Nervous System
 Carpal tunnel syndrome
o The woman complains of numbness and ‘pins and needles’ in her fingers and hand, it
is caused by fluid retention which creates oedema and pressure on the median nerve.
o Wearing a splint at night and resting the hand on two or three pillows will bring relief
o The condition usually resolves spontaneously after delivery.
 Insomnia
o This may be caused by nocturnal frequency and difficult in getting comfortable due to
the growing fetus.

78
o Increased blood supply to the uterus on lying down often causes the baby to move a
lot just as the mother wishes to sleep, this may be overcome by going to bed earlier.
o Increased anxiety which is brought by pregnancy, the midwife should discuss with the
mother about the common fears of pregnancy and give reassurance.
o In late pregnancy the midwife should advice the woman to rest in the morning or
afternoon when sleep often comes easily.
o Hormonal changes towards the end of pregnancy also contributes to periods of
depression, the midwife should advice the mother and help her to achieve the most
comfortable and safe pregnancy possible.
Skin
The woman observes the changes which occurs on her skin, she should be reassured that this
should be diminished as soon as the baby is born
 Itching of the skin of abdomen and breasts, occasionally it is generalized over the whole
body. It is due to hormones of pregnancy and increased billirubin levels.
 Management of itching includes:
o Local application e.g. Calamine lotion may give comfort
o An antihistamine such as piriton may be prescribed
o Cloths worn next to the skin should be non irritant.
 If the woman complains of vulval irritation; infection such as thrush and glycosuria due to
diabetes, should be excluded and then advice on cotton underwear and adequate washing
with soap and water
 Possible or presumptive signs of pregnancy are the changes felt by the mother
 Probable signs are those changes observed by an examiner but that could be caused by a
condition other than pregnancy
 Minor disorders are the disorders which are not life threatening. A minor disorder may
develop into a serious complication of pregnancy
 Causes of minor disorders can be divided into; hormonal changes, accommodation
changes, metabolic changes and postural changes
 Backache is due to changing of centre of gravity as the fetus grows and which posture to
adopt, hormones also softens ligaments
 Frequency of micturition in early pregnancy due to pressure of the growing uterus on the
bladder is common. In late pregnancy is due to pressure of the fetal head on the bladder.
 Mention the presumptive signs of pregnancy

 Outline the minor disorders of the digestive system
 What can you advice a pregnant woman with heart burn?
 List possible causes of pica
 Outline the common sites for varicosities during pregnancy

79
References

80
Session 13: Relationship of the Fetus to the Mother’s
Uterus and Pelvis
Prerequisites
 None
Learning Tasks
 Explain the relationship of the fetus to the uterus and pelvis
 Explain the role of midwife in ante natal care
 Explain the tasks of expectant father
Resources Needed
 Projector
 Computer
 Doll and pelvis models
SESSION OVERVIEW
2 15 minutes Presentation/ Relationship of the Fetus to the Uterus and

Discussion Pelvis
3 10 minutes Presentation Roles of the Midwife in Antenatal Care
4 20 minutes Presentation/ Development Tasks and Tasks of Expectant

Discussion Father
SESSION CONTENT

81
Level 5, Semester 1 Session 13: Relationship of the Fetus to
the Mother’s Uterus and Pelvis
Step 2: Relationship of the Fetus to the Uterus and Pelvis (15 minutes)
The following is the relationship of the fetus to the uterus and the pelvis lie.
 The lie of the fetus is the relationship between the long axis of the fetus and the long axis
of the uterus
 In 99.5%, the lie is longitudinal
 Others may be oblique or transverse.
Attitude
 It is the relationship of the fetal head and limbs to its trunk. The attitude should be one of
complete flexion.
 The fetus is curled up with chin on the chest and arms and legs flexed forming a compact
mass which accommodates itself to the uterine cavity
Presentation
 It is the part of the fetus which lies at the pelvic brim or in the lower pole of the uterus
 There are five (5) presentation
 Vertex 96.8%
 Breech 2.5%
 Shoulder 0.4% (1:250)
 Face 0.2% (1: 500)
 Brow 0.1% (1: 1000)
 Vertex, face and brow are all head or cephalic presentations.
 When the head is flexed the vertex presents
 When full extended the face presents and when partially extended the brow presents.
Denominator
 It is the name of the part of presentation which is used when referring to fetal position
 Each position has a different denominator
o In vertex presentation, it is the occiput
o In breech presentation, it is the sacrum
o In face presentation, it is the mentum
o In shoulder presentation, it is the acromion process but in practice dorsum is used to
describe the position.
o In brow presentation, no denominator is used.
Position
 It is the relationship between the denominator and the six points on the pelvic brim
 The six points are
o Left anterior Right anterior
o Left lateral Right lateral
o Left posterior Right posterior
Positions of Vertex Presentation

 Left occipito-anterior (LOA): The occiput points to the left ilio-pectineal eminence and
the sagittal suture is in the right oblique diameter of the pelvis
 Right occipito-anterior (ROA): The occiput points to the right ilio pectineal eminence,
sagittal suture is in the left oblique diameter of the pelvis.

82
 Left occipito-lateral (LOL): The occiput points to the left ilio pectineal line midway
between the iliopectineal eminence and sacroiliac joint. The sagittal suture is in the
transverse diameter of the pelvis.
 Right occipito-lateral (ROL): The occiput points to the right iliopectineal line midway
between the iliopectineal eminence and sacroiliac joint. Sagittal suture is in the
transverse diameter of the pelvis.
 Left occipito-posterior (LOP): The occiput points to the left sacroiliac joint, the sagittal
suture is in the left oblique diameter of the pelvis.
 Right occipito-posterior (ROP): The occiput points to the right sacroiliac joint the sagittal
suture is in the right oblique diameter.
 The denominator may be found in the midline either anteriorly or posteriorly especially in
late labour, this position is often transient and is described as direct anterior or direct
posterior.
 Direct occipito-anterior (DOA): The occiput points to the symphysis pubis, the sagittal
suture is in the anteroposterior diameter of the pelvis
 Direct occipito-posterior (DOP): The occiput points to the sacrum, the sagittal suture is in
the anteroposterior diameter of the pelvis.
Figure 2.8 Positions of vertex presentation
Source:(Fraser, Cooper, & Nolte, 2010)
Presenting Part
 The presenting part of the fetus is the part which lies over the cervical os during labour
and on which the caput succedaneum forms.
Step 3: Roles of the Midwife during Antenatal Care (10 minutes)
 To diagnose and monitor pregnancies and carry out examination necessary for the
development of pregnancies.
 To prescribe and advice on the examination necessary for the monitoring the development
of normal pregnancy and the earliest diagnosis of pregnancy at risk.
 To provide a programme of parenthood preparation for child birth including advice on
hygiene, nutrition etc.

83
General Roles of the Midwife
 To respect the patient/client as an individual and be accountable to ensure that he/she
promote and protect the interests and dignity of patients regardless of gender, age, ability,
culture and political beliefs.
 Needs to be knowledgeable and understand her own values, attitudes, norms and
expectations that affect their professional practice.
 Needs to be aware of issues of prejudice and discrimination and racism and how these
manifest themselves in the provision and delivery of health care and may act as a barrier
to seeking health care.
 Ensuring that they are able to create a conducive environment that will enable the woman
to explain their views and wishes regarding their maternity care.
 Ensuring effective and efficient communication that will enable women to make
appropriate informed choices and exercise control over the care they receive.
 To be advocates of women and ensure that the needs and wishes are taken into
consideration during the planning and delivery of services.
 To participate actively in raising awareness of the available services among all women.
Step 4: Development Roles of the Expectant Father and other Support

Persons (20 minutes)
Activity : Brainstorming (10 minutes)
DIVIDE and ASK students to brainstorm on the Roles of the Father and other Support
Person to the Expectant Woman for 5 minutes
ALLOW few students to respond and others to provide unmentioned responses
 Accepting the reality of pregnancy the father may be proud or guilty

 Learn about child birth
 Network with other men to hear their experiences
 Make time to attend prenatal visits and parent education sessions together with the
partner.
 Provide emotional and physical support to his partner throughout all stages of pregnancy
 Get ready to be a major player in the family and show personal leadership when it comes
to raising your new child.
 Develop infant care skills e.g. handling the baby, cuddling, feeding and communicating
with the baby.
 Think about what kind of a father you want to be, the kind of values you want to instill
and the kind of things you want to teach your child.
 To integrate the baby into the family

84
Step 5: Key Point (5 minutes)
 Vertex, face and brow are all head or cephalic presentation. When the head is flexed, the
vertex presents. When fully extended the face presents and when partially extended the
brow presents.
 The denominator may be found in the midline either anteriorly or posteriorly especially in
late labour, this position is often transient and is described as direct anterior or direct
posterior.
 The presenting part of the fetus is the part which lies over the cervical os during labour
and on which the caput succedaneum forms.
 Define presentation, position, denominator and attitude

 Outline the roles of the midwife during antenatal care
 What are the roles of the father/support person to the expectant woman?
References
Sinclair, C. A. (2004). A midwive’s handbook. Philadelphia: Saunders.

85
Session 14: Social, Cultural and Economical Aspects
with Reproductive and Child Health
Services
Prerequisites
 None
Learning Tasks
 Describe the objectives of National policy/Guidelines on Reproductive and Child Health
Services
 Relate Psychological, emotional and behavioral responses to sexual development
 Describe social and economic inequalities and their impact to Reproductive Health
Services
 Describe Sexuality, gender roles and relationship
Resources Needed
 Projector
 Computer
SESSION OVERVIEW

Tasks
2 10 minutes Presentation/ National Policy/Guidelines on Reproductive
Discussion and Child Health Services
3 35 minutes Presentation Psychological, Emotional and Behavioral
Responses to Sexual Development
4 40 minutes Presentation/ Social and Economic Inequalities and their
Discussion Impact to Reproductive Health Services
5 20 minutes Presentation Sexuality, Gender Roles and Relationship

Level 5, Semester 1 86 Session 14: Social, Cultural and
Economical Aspects with Reproductive
and Child Health Services
SESSION CONTENT
Step 1: Presentation of the Session Title and Related Tasks (5 minutes)
Step 2: National Policy/Guidelines on Reproductive and Child Health

Services (10 minutes)
Goal
 The overall goal of reproductive and child health policy guidelines is to provide
principles for implementation of Reproductive and Child Health services so as to
contribute to the improvement of quality of life of Tanzanians (men, women, youth and
children) with emphasis on gender, equity, quality and women empowerment for
sustainable development.
Objectives
 Provide frame work for planning, decision-making and resource allocation for
reproductive and child health programmes and services.
 Provide directives and uniformity for training, monitoring and evaluation of reproductive
and child health interventions.
 Forster partnership, between public sector, private sector, NGOs, Voluntary agencies and
the community in addressing the RCH services.
 Safeguard health care providers and ensure clients safety on utilization of reproductive
and Child Health services
 Ensure delivery of quality Reproductive and Child Health services including
STIs/HIV/AIDS prevention and care at all levels
 Promote expansion and strengthening of Reproductive and Child Health service provision
outlets
 Promote and strengthen child health, women, adolescent, elderly and male’s reproductive
health.
 Strengthen RCH management information systems and promote its use for quality
services.
 Promote provision of school health services including sexual and reproductive health
education.

Step 3: Psychological, Emotional and Behavioral Responses to Sexual
Development (35 minutes)
ASK students to discuss on psychological and behavioral responses to sexual development

for 10 minutes
LET the groups present their responses
 Adult human sexual behavior results from a long complex and often hazardous
development.
 The anatomical difference between men and women and their sexual responsiveness and
their ability to reproduce does not appear suddenly but result from a slow and gradual
development.
 The outcome of this process depends not only on child’s inherited abilities but also on
social influences such as reaction of parents, teachers, playmate and friends.
 In some cases these influences can be negative, for example an infant boy may be treated
like a girl by his family and thus learn to consider himself female. This early role
assignment may then become irreversible and lead to lifelong difficulties.
 Children whose sex is misdiagnosed at birth learn to identify with the sex that is assigned
to them. This identification is permanent, even if the mistake is discovered it cannot be
corrected.
 After a certain time a boy raised as a girl will continue to consider himself female and in
most cases feel sexually attracted to males, while a girl raised as a boy will continue to
consider himself male and in most cases feel sexually attracted to females.
 A person’s sexual development has 3 aspects
o The male or female characteristics of the body (physical sex)
o The social role as male or female (gender role)
o The preference of male or female sexual partners (sexual orientation).
Physical Sex
 Physical sex is defined as a person’s maleness or femaleness.
 It is determined by five physical criteria: chromosomal sex, gonadal sex, hormonal sex,
internal reproductive structures and external sex organs.
 People are male or female to the degree in which they meet the physical criteria for
maleness or femaleness.
 Most individuals are clearly male or female by all five physical criteria. However a
minority fall short of this test and their physical sex is therefore ambiguous
(hermaphroditism).

Gender Role
 Gender role is defined as a person’s masculinity or feminity
 It is determined on the basis of certain psychological qualities that are natured in one sex
and discouraged in the other.
 People are masculine or feminine to the degree in which they conform to their gender
roles.
 Most individuals clearly conform to the gender role appropriately to their biological sex.
However, a minority partially assume a gender role that contradicts their biological sex
(transvestism), and an even a smaller minority such a role inversion is complete
(transsexualism)
Sexual Orientation
 Sexual orientation is defined as a person’s heterosexuality or homosexuality.
 It is determined on the basis of preference of sexual partners.
 Most people develop a clear preference for partners of the other sex (heterosexuality).
 However a minority are attracted to both men and women and even a smaller minority are
attracted mainly to partners of their own sex (homosexuality)
Step 4: Social and Economic Inequalities and their Impact to Reproductive

Health Services (40 minutes)
ASK students to discuss on the impact of social and economic inequalities to reproductive
and Child Health services for 10 minutes
LET the groups present their responses
 Health inequalities are due to the unequal distribution of health determinants between
people with different positions at the social hierarchy.
 People in lower social economic group are more often exposed to health hazards in the
physical environment.
 They more often experience stressors, and they are more often likely to adhere to
unhealthy behaviors such as smoking, inadequate diet, excessive alcohol consumption
etc.
 As a result of their great exposure to such risk factors, people in lower social economic
groups more often suffer from diseases and disabilities.
 The impact of social economic inequalities on health can be observed at the very start of
life Children from lower social economic families have lower birth weight and are often
born prematurely or with congenital anomalies, death rates are higher, still births,
neonatal mortality and infant mortality.
 Social economic inequalities affect women access to reproductive health care thus
playing a role in the high maternal mortality rate in developing countries

 Profound differences in overall health status exist between developed and developing
countries, this is due to the lack of basic necessities of life such as food, water, sanitation
and primary health care common to developing countries.
Step 5: Sexuality, Gender Roles and Relationship (20 minutes)

Sexuality
 It is how people experience and express themselves as sexual being
Gender
 Gender is defined as the relationship between men and women
 Gender is not only determined biologically, as a result of sexual characteristics of either
men or women but is constructed socially
 Gender issues focus on women and on the relationship between men and women, their
roles, access to and control of resources, division of labour
Gender Relations
 These are the ways in which culture or society defines rights, responsibilities and
identities of men and women in relation to one another.
Gender roles
 Gender roles refers to the set of social and behavioral norms that are widely considered to
be socially appropriate for individuals of a specific sex in the context of a specific culture
which differ widely between cultures over time
 Gender roles are imposed through a variety of social influences
 The first and strongest influence is the parents, parents start treating baby girls and baby
boys differently. Children look to their parents as role models.
 Boys and girls learn the appropriate behavior and attitudes from the family and overall
culture they grow up with, and so non physical gender differences are products of
socialization.
Social role
 The social structure is the underlying force for the gender differences
 The sex differentiated behavior is driven by the division of labor between the two sexes
within a society.
 Division of labor creates gender roles, which in turn lead gendered social behavior.
The Physical Specialization of Sexes

 Men’s unique physical advantages in term of body size and strength provide them
advantage over women in social activities that demand such physical attributes such as
hunting, herding and warfare.
 Women’s biological capacity for reproduction and child bearing explain their limited
involvement in other social activities.
 The activities men involved in were often those that provide them with more access to
control of resources and decision making power, rendering men higher status and
authority in the society.

Social Construction of Gender Differences
 Gender differences are socially constructed
 people do not only internalize gender roles as they grow up but they respond to changing
norms in the society
 Children learn to categorize themselves by gender very early in life
 A part of it is learning how to display and perform gendered identities as masculine or
feminine Boys learn to manipulate their physical and social environment through physical
strength and other skills, while girls learn to present themselves as objects to be viewed.
Changing Roles
 A person gender role is composed of several elements and can be expressed through
clothing, behavior, and choice of work, personal relationship and other factors. These
elements have evolved through time.
 Traditionally only feminine and masculine gender roles existed, however over time many
different acceptable male or female gender roles have emerged
 An individual can either identify themselves with a subculture or social group which
results in them having diverse gender roles
 The overall goal of Reproductive and Child Health is to provide principles for
implementation of child health services in Tanzania.
 Reproductive and Child Health services contribute to the improvement of quality of life
to Tanzanians with emphasis on gender, equity, quality and women empowerment for
sustainable development.
 The differences between men and women and their sexual responsiveness and their ability
to reproduce result from slow and gradual development
 Health inequalities are due to un equal distribution of health determinants between people
with different social positions
 Social economic inequalities affect women access to reproductive health care resulting in
morbidity and mortality.
 Gender is the relationship between men and women. It is not only determined
biologically as a result of sexual characteristics of either men or women but is constructed
socially.
 Explain the overall aim of Reproductive and Child Health policy guidelines
 Explain the three aspects of sexual development
 Explain the relationship between and social economic inequalities and reproductive
health services.
 Give the definitions of sexuality, gender and gender roles

References
Wikipedia. (2012). Gender and sexuality. Retrieved from http://www.wikipedia.org
Wikipedia. (2012). Gender roles. Retrieved from http://www.wikipedia.org

Session 15: Concept and Elements of Focused Antenatal
Care (FANC)
Prerequisites
 None
Learning Tasks
 Explain the concept of FANC
 Explain FANC element 1: early detection and diagnosis and diagnosis of diseases
Resources Needed
 Projector
 Computer
 FANC Job aid
 FANC checklists
SESSION OVERVIEW

Tasks
2 30 minutes Presentation Concept of FANC
3 70 minutes Presentation/ Element 1: Early Detection and Diagnosis of

Group Discussion Disease or Abnormality
SESSION CONTENT

93
Level 5, Semester 1 Session 15: Concept and Elements of
Focused Antenatal Care (FANC)
Step 2: Concept of FANC (30 minutes)
 The vision of MOHSW in regard to RCH is to have a health and well informed Tanzania
population with access to quality Reproductive and child health services which are
accessible, affordable and sustainable.
 To implement this RCHS developed the National Package of Essential Reproductive and
Child Health Interventions (NPERCHI) in 2000.
 A national guideline to promote the provision of quality ANC, services in Tanzania was
developed that is FANC guideline.
 Focused Antenatal Care is one of the interventions and also one of the safe motherhood
pillars
 Safe motherhood means ensuring that all women and their newborns receive the care they
need to be as healthy as possible throughout pregnancy, childbirth and puerperium.
 Pillars of safe motherhood:
o Essential obstetrical care
o Post abortion care
o Targeted postpartum care
o Neonatal care
o Prevention of mother to child transmission of HIV
o Clean and safe delivery
o Focused antenatal care
o Family planning.
Definition of Focused Antenatal Care (FANC)

 Goal oriented care that is client centre, timely, friendly, simple beneficial and safe to
pregnant women.
 The care is provided by a skilled attendant who emphasizes on the woman’s overall
health, her preparations for childbirth and complication readiness.
 The goal is to provide a timely and appropriate care to women during pregnancy; to
reduce the maternal and perinatal morbidity and mortality.
Aims of Focused ANC

 Early detection and provision of treatment for existing diseases.
 Promotion and to maintain wellbeing of the mother and baby physically mentally and
socially.
 Supporting clients in developing individual birth plan (IBP) and complication readiness
plan.
 Prevention of disease and early detection and management of complications during
pregnancy labour delivery and post partum through identification of danger signs.
Characteristic of an Effective ANC

 Well organized and prepared health facility.
 Care from a skilled and well motivated health care provider.
 Preparation for birth and potential complications.
 Focused content of routine antenatal visits based on the mothers needs.
 Promoting health through provision of Tetanus Toxoid (TT) iron and folic acid
supplements, IPTp, ITNs and positive self care practices such as essential nutrition
actions, avoiding tobacco, alcohol and drug abuse, safe sex etc.

94
 Counseling, detection and treatment of diseases including: HIV and AIDS, syphilis (and
other STIs), tuberculosis, malaria, anemia, hypertension and diabetes.
 Early management of complications and prompt referral to the next level of care.
 Promote linkage among providers/facilities, communities and families to ensure
continuity of care.
 Ultimately provides woman-friendly care.
Woman Friendly Care

 Clean and attractive facility, providing kind and supportive care
 Explain what is happening to the woman and family after each evaluation
 Praises the woman/ family for her/their effort
 Help the woman to feel cool when she is too hot or warm when she is cold
 Empower the woman and her family to become active participant in the care.
 The provider
o involves the family, partner or other support person in the care
o includes relevant and feasible advice
o speaks in a language that the clients understands
o Considers rights of the woman
 Respect beliefs, culture, and traditions, permit cultural practices that are not
harmful
 Recognize the right to be informed about her health and what to expect during
visit
 Obtain informed consent prior to exams and procedures
 Assure privacy and confidentiality.
 Considers emotional, psychological and social well being of the woman
Essential Elements of FANC

 Early detection and diagnosis of disease or abnormality
 Counseling on health promotion
 Individual Birth Plan (IBP) and complication preparedness
 Danger signs and symptoms in the mother and newborn
 Focused ANC visits referral and following of ANC clients.
 Prevention of Mother to Child Transmission (PMTCT) of HIV.
 Management of client’s records.

95
Step 3: Early Detection and Diagnosis of Diseases or Abnormality
(80 minutes)
Activity : Demonstration (40 minutes)
ARRANGE students so that everyone can see
DEMONSTRATE to the students on Assessment of an Antenatal Woman
ASK few students to do a return demonstration
LET other students comment on the demonstration
Assessment of Antenatal Woman

 Steps
 Quick Check is performed by health care service provider to identify clients/pregnant
women who need immediate attention through:
o Observation as a woman enters ANC clinic/room
 General appearance, facial expression, pallor, sweating, shivering, difficult
breathing etc.
 Gait (how the woman is walking)
o Asking general screening questions to identify danger signs and symptoms such as
severe headache, per vaginal bleeding or leaking, dizziness, fever, etc.
History Taking
 Ensuring a conducive environment for history taking involves availing the necessary
equipment and offering privacy.
 The following should be addressed
o Personal information
o Details about previous pregnancies
o LNMP, calculate EDD and gestational age
o Use of contraceptives prior to pregnancy
o Use of medications and drug allergies
o Nutrition – dietary habits and locally available foods
o Use of alcohol/tobacco/other substances such as herbal medicine and use of non-food
substances (PICA).
o Tiredness, breathlessness and use of IFA, any side effects
o Immunization status
o Intermittent Preventive Treatment (IPTp) and use of ITN
o History related to STIs including HIV and AIDS
o Present medical and surgical problems
o Social and financial support, etc
o Any other concerns.
 Calculation of EDD
o Know the first date of the Last Normal Menstrual Period (LNMP)
o Add 7 days to the date
o Subtract 3 months from the months (if the month is above March)

96
o Add 9 months to the month if the month is below April
o Add 1 to the year if it is above April.
 Calculation of Gestational Age
o Know the first date of the LNMP
o Add up all the days from the LNMP to the date of visit.
o Divide by 7 to get gestational age in weeks.
Physical Examination
 When conducting physical examination, have the woman remain seated or lying down
and relaxed:
General examination
 Take blood pressure, weight, height, pulse, temperature (if indicated) and respiration
 Check for pallor (conjunctiva, palms)
 Breasts and lymph nodes examination
 Abdominal Examination:
o Inspection:observe the surface of abdomen e.g scars, movement with respiration, and
shape of the abdomen.
o Palpation
 Palpate for fundal height from 12 weeks of gestation age
 Fetal parts and movements from 20 weeks of gestation
 Fetal lie and presentation is of concern from 36 weeks of gestation
 Abnormal lie or/and presentation if observed from 36 weeks is more unlikely to change therefore
decide appropriately for a place of birth)
o Fetal heart sound from 24 weeks of gestation.
 Genital inspection
o Female Genital Mutilation
o Sores, swelling, discharge
o PV Bleeding.
 Fundal height measurement
o Palpate for fundal height from gestation age of 12 weeks (from symphysis pubis to
top of fundus)
o From gestation age of 22 + weeks use tape measure.
o Measure from upper edge of symphysis pubis to top of fundus whereby 1cm
represents one week (see diagram)

97
Figure 2.9: Fundal height measurement
Source: (MOHSW, 2008)
 Palpation of the abdomen

o Palpate to determine fetal parts, lie, presentation and descent of the presenting part.
o There are two methods of palpating the abdomen
o The 3 steps and the 4 steps (Leopold’s Maneuvers)
 Abdominal Palpation – 3 Step Method
o Fundal Palpation
o Palpate to determine which fetal part is at top of uterus:
 Place both hands on sides of fundus at top of abdomen
 Use finger pads to assess consistency/ mobility of fetal parts
Figure 3.0: Fundal Palpation

98
o Lateral Palpation
o To feel for fetal back:
 Move hands smoothly down sides of uterus
 Smooth and firm (back) versus bulge and moveable (legs and arms).
Figure 3.1: Lateral palpation
o Pelvic Palpation (Supra Pubic)

o To feel presenting part:
 Place hands on sides of uterus, palms below umbilicus, fingers toward symphysis
pubis
 Grasp fetal part.
Figure 3.2: Pelvic Palpation

99
 Abdominal Palpation – 4 Step Leopold’s Maneuvers
o There are 4 step and three step technique
 Step 1: Feel what part of the baby is in the upper uterus
 Step 2: Feel for the baby’s back
 Step 3: Feel what part of the baby is in the lower uterus
 Step 4: Feel for descent of baby's presenting part
Figure 3.3: Step 4-Leopolds maneuvres
 Fetal heart examination

o By 24 weeks fetal heart sounds are heard with fetoscope
o Normal fetal heart rate is from 120 to160 beats per minute (during pregnancy only,
not in labor).
Laboratory Investigations
 Urine investigations
 HB
 Blood grouping and RH factor
 VDRC/ RPR for syphilis screening
 HIV testing
 CD4 count if indicated
 Blood examination for malaria parasites where indicate
Decision Making
 Interpret information from client’s history, physical examinations and laboratory
investigations and deciding on the care to be given

100
 Focused ANC is client centered goal oriented services given by a skilled provider
 History taking physical examination and laboratory investigations are important
components of client assessment in the provision of individualized care
 Every pregnant woman is considered at risk of complications and therefore individualized
care is very important
 Define focused antenatal care (FANC)

 What are the aims of FANC?
 Enumerate essential elements of FANC
References
MOHSW. (2008). Focused antenatal care, malaria and syphilis in pregnancy: Learner’s
guide for ANC service providers and supervisors. JHPIEGO: Dar es Salaam.

101
Session 16: Elements of Focused Antenatal Care (FANC)
Prerequisites
 None
Learning Tasks
 Explain FANC element 2: Counseling on Health promotion
 Explain FANC element 3: Individual birth plan and complication preparedness
 Explain FANC element 4: danger signs and symptoms in the mother and newborn
Resources Needed
 Projector
 Computer
 Models
 FANC job aid
SESSION OVERVIEW

Tasks
2 60 minutes Lecture/Discussion Element 2: Counseling on Health Promotion
/Role play
3 15 minutes Presentation/ Element 3: Individual Birth Plan and
Brainstorming Complication Preparedness
4 30 minutes Presentation/ Element 4: Danger Signs and Symptoms in the
Group Discussion Mother and Newborn
SESSION CONTENT

102
Level 5, Semester 1 Session 16: Elements of Focused
Antenatal Care (FANC)
Step 2: Element 2 - Counseling on Health Promotion (60 minutes)
Definition
 Counseling is interpersonal communication (face to face) conversation where one person
helps another (between two people) to make an informed decision and to work on it.
 In focused Ante Natal Care, counseling targets both the pregnant woman and her partner
 It aims at assisting them in developing the individual birth plan and complication
preparedness.
 It includes advice on health promotion aspects such as nutrition, use of ITN personal
hygiene etc.
ASK students to discuss on Counseling for Health Promotion for 10 minutes
Refer students to Handout 16.1: GATHER Steps
AFTER small groups discussion ask students to provide their responses
Health Promotion
 Health promotion is giving health messages to pregnant women and their partners to
enable them improve their health
 Areas of health promotion include
Diet and Nutrition

 Diet, nutrition and use of minerals and vitamins supplementation
 Increased food intake during pregnancy – encourage eating 3 meals and a snack/bite in
between meals every day.
 Take diversified diet i.e. meals containing protein, carbohydrates, vitamins, fats, water,
minerals including iodized salt.
o Reduce energy expenditure by reducing workload and encouraging resting. Provide
iron/folic acid supplements daily.
o Monitor weight gain throughout pregnancy, women should gain at least one kg per
month in the second and third trimesters.
o Take SP for IPTp and use ITN for malaria prevention.
o Take Mebendazole tablets for deworming.
 Diet
o Advise the mother on a balanced diet that includes proteins, high calorie content,
fruits and vegetables for preventing anaemia and ensuring proper growth of the fetus.
o Avoid eating non-food substances such as clay, ashes, charcoal etc.
o Advise the mother on a balanced diet that includes proteins, high calorie content,
fruits and vegetables for preventing anaemia and ensuring proper growth of the fetus.
o Encourage the pregnant woman three meals and a snack to increase energy to take
every day.

103
o Encourage the pregnant woman to have a diversified diet based on locally available
foods.
o Encourage regular taking of iron and folic acid tablets daily throughout pregnancy and
post partum period.
o Take tablets between meals or before going to bed with little water or juice to avoid
possible nausea and vomiting.
o Counsel on compliance and side effects of iron.
o Avoid drinking tea and coffee while taking iron because these drinks contain iron
absorption inhibitors. Tea or coffee should be taken at least one hour apart after taking
the tablets or meal.
o Encourage the pregnant woman to take Vitamin C rich foods such as oranges, guava,
pawpaw, baobab fruits etc. to enhance absorption of iron.
o Avoid overcooking vegetables.
o Use iodized salt only
o Encourage women to take sweet energy drinks when in labour
Rest and Activity

 Encourage the mother to rest (nap in the afternoon).
 Avoid overworking and exhaustion.
 Encourage the mother to carry on with light household work and light exercises such as
walking.
 Avoid lying on back and right side to prevent compression of inferior venacava which
may lead to supine hypotension. Instead the mother should be encouraged to lie on left
side with legs slightly elevated.
Personal Hygiene and Clothing

 Good personal hygiene prevents infections
 Encourage the mother to wear clean comfortable clothing and flat shoes. High shoes may
lead to back pain
 Encourage pregnant mothers to live in a clean environment
 Encourage the mother to wash her body and carry out oral hygiene daily.
Use of Medicine and Immunization

 Encourage pregnant women to speak out about their pregnancy status whenever they are
seeking other healthcare services.
 Medicines are generally discouraged particularly during the first trimester unless advised
by a service provider.
 Routine medicines and vaccine prescribed during pregnancy will include folic acid, iron,
SP, Mebendazole tablets and Tetanus Toxoid.
 Some medicines are not recommended during the first trimester, e.g. SP, Artemether
Lumefantrine (ALu), Metronidazole (flagyl) and warfarin.

104
Harmful Habits during Pregnancy
 Advice the pregnant women to refrain from smoking, drugs, alcohol and herbal medicines
as may cause bad effects on pregnancy.
 Advise the pregnant women to avoid eating non-nutritive substances (PICA)
 Advise pregnant women on dangers of female genital mutilation
 Advice pregnant women on safer sex especially use of condom.
Breast Feeding
 Early and exclusive breastfeeding is beneficial for mother and baby therefore the mother
needs to be prepared psychologically and physically
 Breast milk is the best for the baby because it contains adequate water and nutrients that
the baby requires.
 First yellowish milk (colostrum) protects the baby from diseases and it is rich in Vitamin
A and antibodies
 Is cost-effective/affordable
 Promotes mother-baby bonding
 It is a method of family planning as it prevents the normal status of the reproductive
 Successful breastfeeding depends on diversified diet and increased food intake (three
meals and two snacks/bites), adequate fluid intake and rest.
 Health care providers should provide support to mothers for early initiation (within 1 hour
after delivery) and proper positioning and attachment during breastfeeding.
 Emphasize on exclusive breastfeeding up to 6 months of age and add complimentary
feeding while continuing breastfeeding up to 2 years and beyond.
 Breastfeeding on demand stimulates adequate production of breast milk and prevents
breast engorgement.
 Advice the mother to breastfeed from one breast until it is empty before offering the other
so that the baby gets both foremilk (high content of water) and hind milk (rich in fat and
nutrients).
 For HIV + Mothers counsel on infant feeding options; exclusive breast feeding or
replacement guided by AFASS as per guideline.
Family Planning
 Birth spacing 3 to 5 years apart is recommended for better health of both mother and
child.
 Advise women to use family planning methods which include modern and natural.
 Safe methods for postpartum/lactating mothers are those methods which will not interfere
with breastfeeding such as LAM and barrier methods.
 HIV positive mothers should be advised to use effective family planning methods that
provide dual protection that is prevention of pregnancy and STIs including HIV/AIDS
(use of condoms).
Prevention from STIs/HIV (safer sex)

 Educate the pregnant woman on HIV including other STIs (e.g., syphilis, gonorrhea,
chlamydia) and their effects to woman, her partner and unborn baby.
 Advice the woman on safer sex which include:
o ABSTINENCE or
o BEING FAITHFUL to one partner or
o CONDOM use consistently and correctly

105
Step 3: Element 3 - Individual Birth Plan and Complication Preparedness
(15 minutes)
ASK students to brainstorm on individual birth plan for 2 minutes
ALLOW few students to respond and let others provide the unmentioned responses
 Each pregnant woman must be assisted to develop an individual birth plan (IBP) as part
of birth preparedness because the complications cannot be predicted.
 The plan includes:-
o Reminding the woman on her EDD
o Identifying place of birth
o Identifying someone to take care of her family in her absence
o Preparing essential items necessary for a clean and safe delivery and warmth for
mother and baby.
o Identify at least 2 blood donors
o Prepare transport or funds for transportation in case of emergence
o Identifying decision making family member to accompany her to the hospital or
health facility.
o All these questions must be asked from the mother at each visit.
 IBP and complication preparedness makes it safe for the mother and the baby.
 Ask the mother to plan her birth in the 1st encounter and evaluate progress at each visit.
Step 4: Element 4 - Danger Sign and Symptoms during Pregnancy

(30 minutes)
 A danger sign is a feature experienced by the woman that indicates a life threatening
condition in pregnancy that requires immediate action.
 The midwife should discus with mother all the danger signs that can occur during
pregnancy, labour, post natal period and to the new born
DIVIDE students into small manageable groups for 5 minutes
ASK students to discuss on the Danger Signs during Pregnancy
AFTER small group discussion ask students to provide their responses

106
If any of the following are noted the pregnant woman must to the health facility
immediately
 Vagina bleeding
 Severe headache and/or blurred vision which may indicate imminent eclampsia
 Loss of consciousness or convulsions
 Severe abdominal pain
 Dangerous fever
 Difficult breathing
If any of the following are noted the pregnant woman must to the health facility as soon
as possible
 Lethargy, fatigue, breathlessness that could indicate severe anaemia or haemoglobin less
than 8.5gm/dl or 60%
 Leaking of amniotic fluid from the vagina
 Fever, chills, vomiting which could indicate malaria
 Decreased or absent fetal movements
 Contractions before completed 37 weeks (preterm labour)
The service provider should counsel the client on these danger sign and ensure that the
woman and her family understand them
Note: Every pregnant, delivering or post partum woman is considered to be at risk of serious
life threatening conditions
Danger Signs and Symptoms during Labour

 Vagina bleeding
 Severe headache and/or blurred vision which may indicate imminent eclampsia
 Loss of consciousness or convulsions
 Rupture of membrane in early first stage of labour
 Cord prolapsed
 Labour lasting more than 12 hours
 Fever
 Note:The woman should go to the health facility immediately if she gets the above signs
and symptoms
Danger Signs and Symptoms during the Postpartum Period

 Blood pressure of 140/90 mmHg or more OR a systolic blood pressure rise of 30 mmHg
or diastolic pressure rise of 15mmHg or more from the baseline blood pressure
 Severe headache/blurred vision/fits (convulsions)
 Abnormal vaginal bleeding
 Placenta not delivered within one hour after delivery
 Difficulty breathing
 Fever
 Severe pain in abdomen or around vagina
 Breast or nipple pain; unable to breastfeed
 Foul vaginal discharge.

107
Danger Signs and Symptoms in the Newborn
 Pitched cry and irritability.
 Difficult feeding (unable to suckle)
 Fits (convulsions) or loss of consciousness
 Blueness of lips, tongue or hands
 Hot to touch (hyperthermia) or cold to touch (hypothermia)
 Unable to pass urine and stool or both within 24 hours after delivery
 Low birth weight including prematurity.
 Bleeding from the cord
 Each woman must be assisted to develop individual birth plan (IBP) as part of birth
preparedness
 Any woman who experiences any of the danger signs should be referred to the health
facility for immediate action by a skilled health service provider
 Each pregnant woman should identify a place to deliver and how to reach there
 Children with danger signs should be sent to the health facility for immediate action.
 Explain what is included in counseling for health promotion?

 List the danger signs during pregnancy
 Explain what is included in individual birth plan?
References

108
Handout 16.1: GATHER Model in Antenatal Care
 GREET the woman/couple; thank her/them for coming.
 ASK the woman how she is feeling, ask her about her obstetric history past and present,
and identify any special needs she may have. Use the ANC card to record her answers.
 TELL her about antenatal care, why it is important. Tell her/them what you will do and
why (the physical exam, the tests, the medicines, the vaccines etc).
 HELP her to prepare for a safe birth: to think about where she wants to give birth, with
whom, how she will get there, who to pay, who will stay with the children at home, what
needs to be cooked ahead of time for the children and other family members. Help her to
understand the importance of sleeping under an ITN.
 EXPLAIN to her how to take care of herself during pregnancy. Explain about potential
complications of pregnancy, birth, aftercare and care of the new born. Explain that there
are danger signs that need to be recognised, that are not normal, that need a provider’s
care. Explain why it is important to have a professional at the time of the birth. Explain
to her that every pregnant woman is entitled to one voucher in each pregnancy to assist
her to buy an ITN from a shop. Make sure that every pregnant woman who attends
antenatal clinic for the first time receives an ITN voucher before she leaves.
 REMIND her about the next visit, why it is important, and what will be done.

109
Session 17: FANC Elements 5, 6 and 7
Prerequisites
 None
Learning Tasks
 Explain FANC element 5: Focused antenatal visits and referral
 Explain FANC element 6: Mother to Child transmission of HIV
 Explain FANC element 7: Management of clients’ records
 Explain infection Prevention in the Provision of Ante Natal care.
Resources Needed
 Projector
 Computer
 FANC Job aid
 Antenatal card
 Records form/books
SESSION OVERVIEW

Tasks
2 30 minutes Presentation/ Element 5: Focused Antenatal Visits and
Brainstorm Referral
3 50 minutes Presentation/ Element 6: Mother to Child Transmission of
Brainstorm HIV
4 10 minutes Presentation Element 7: Management of Clients’ Records
5 15 minutes Presentation Infection Prevention in the Provision of Care

Level 5, Semester 1 Session 17: FANC Elements 5, 6 and 7
SESSION CONTENT
Step 2: Element 5 - Focused ANC Visits and Referral (30 minutes)
ASK students to brainstorm on focused Antenatal care visits and referral for 2 minutes
Focused ANC Visits

 It is recommends that each pregnant woman should make four antenatal clinic visits
during her pregnancy
 The first visit within the first trimester and three visits after quickening
 Each pregnant woman should receive at least two doses of IPT from 20 weeks of
gestation
 Women with normal pregnancy should receive at least 4 thorough, comprehensive,
individualized antenatal visits, spread out during the entire pregnancy.
 Pregnant women with complications need more visits depending on individual condition.
 Early referral to appropriate level of care whenever a complication is detected should take
place.
 The minimum recommended number of ANC visits is four:
o 1st visit: before 16 weeks of gestation
o second visit: from 20 to 24 weeks of gestation
o third visit: from 28 to 32 weeks of gestation
o fourth visit: from 36 to 40 weeks of gestation
1st ANC Visit

 During the first antenatal visit, the following services should be offered:
o History taking
o Detecting that the woman is pregnant and detecting diseases, other complications
o Beginning to develop the individualized birth plan and complication preparedness.
o Immunizations - Tetanus Toxoid (TT) vaccine according to schedule
o Counseling and testing for HIV status, syphilis, haemoglobin and other laboratory
investigations
o Advice on the importance of using ITNs and give the ITN voucher.
o Screening, detecting and treating or referring conditions such as anaemia, syphilis and
malaria.

o Give Iron and Folic acid tablets to cover up to the next visit to all pregnant women
regardless of Hb status and explaining how to take and manage side effects
o Advise on dietary diversification i.e. meals containing protein, carbohydrates,
vitamins, fats, minerals and water.
o Give single dose of Mebendazole (DOT) if the pregnancy is more than 12 weeks
o Advise on essential diet and nutrition, personal hygiene, clothing, family planning and
prevention of STIs and HIV/AIDS etc.
second and third ANC Visits

 During the second and third antenatal visit, the following services should be offered:
o SP as Intermittent Preventive Treatment (IPTp) given as DOT, 1st dose between 20
and 24 weeks and second dose between 28 and 32 weeks gestation
o Give single dose of Mebendazole (DOT) after 1st trimester (if not given during the first
visit)
o Confirm fetal heart sounds
o Detect, treat and manage any abnormalities such as multiple gestation, pre-eclampsia
and anaemia
o Confirm lie of the foetus
o Remind about Individual Birth Plan and danger signs.
fourth ANC Visit

 Confirm whether the pregnant woman has received all services which should be
provided in previous visits.
 Confirm lie and presentation of the fetus. In case of any mal-presentation take
appropriate action.
 Detect, manage and refer any abnormalities such as multiple gestations, pre-eclampsia
and anaemia.
 Remind the pregnant woman about the Individual Birth Plan, danger signs and
complication preparedness.
Refer students to Focused Antenatal Care Job aid
Referral and Follow-up of ANC Client

 Referral and follow-up should be given to pregnant women with complications.
o Preparation for referral include:
 Equipment, drugs and supplies for emergency
 Transport preparations
 Skilled service provider
 Family and community at large
o Pregnant woman who need referral includes:
 Those with danger signs and symptoms or
 Those with previous caesarean section
 Those who have had neonatal death.
 Those who are Rhesus factor negative (Rh-)
 Those who get their first pregnancy after thirty five years of age.
 Those who had delivered more than five times.
 Those with abnormality of pelvic

Step 3: Element 6 - Mother to Child Transmission (MTCT) of HIV/AIDS
(50 minutes)
Definition
 Mother to child transmission is the vertical transmission of HIV from an infected mother
to her baby
 MTCT is the main transmission route for HIV infection to babies and children
 Without intervention MTCT is about 40% divided as follows:
o 10% during pregnancy
o 20% labour and delivery
o 10% during breastfeeding.
Factors Increasing chances of MTCT of HIV

 Maternal Factors
o Viral
 High viral load e.g. in mothers with recent HIV infection or advanced
disease/AIDS hence the use of ARV Prophylaxis/Treatment reduce viral load.
o Immune-Suppression
 Compromised immunological status such as when AIDS disease is advanced,
leads to higher transmission rates.
o Nutrition
 Deficiency in micronutrients such as zinc and vitamin A is associated with
increased transmission.
o Clinical status
 AIDS and other chronic conditions such as diabetics or other underlying chronic
infections
o Behavioral
 E.g. smoking, drug abuse and unprotected sex.
o Obstetrical
 Prolonged rupture of membranes (more than four hours)
 Placenta abruption with live baby
 Mode of delivery e.g. instrumental delivery like vacuum due to possible trauma
 Episiotomy at which, blood increases exposure of the newborn to the HIV.
 Infant Factors
o Prematurity:
 Due to fragile skin
 Gastro intestinal tract ulceration
 Undeveloped immune status of the new born
o Twin delivery
 First twin is more at risk in cases of vaginal delivery.
 Breastfeeding Factors
o Mixed feeding – Giving other feeds e.g. water, juice, porridge, artificial milk etc.
while breastfeeding.
o Prolonged breastfeeding for more than 6 months
o Breast conditions:
 Infections such as mastitis
 Cracked nipples
o High viral load in breast milk.

Elements of Prevention of Mother to Child Transmission (PMTCT) of HIV)
 PMTCT elements refer to strategies/intervention used for prevention of the transmission
of HIV from the infected woman to her baby.
 There are four elements to prevent the transmission of HIV from mother to child:
PMTCT Element 1
 Primary prevention of HIV infection among women of childbearing age and their partners
o Behaviour modification to reduce risk:
 Abstinence
 Be faithful
 Condom use - consistently and correctly
 Discourage practices that increase risk of transmission, e.g. female genital
mutilation, wife inheritance, etc
o Use of sterile instruments for invasive procedures
o Improved access to condoms
o Prevention, early diagnosis and proper treatment of STIs.
PMTCT Element 2
 Prevention of unintended pregnancies among women infected with HIV
o Access to counselling and testing for women and their partners
o Effective family planning that provides dual protection of both pregnancy and HIV
o Access to safe and effective contraception including post-exposure contraception in
case of rape (emergency contraception)
PMTCT Element 3
 Prevention of HIV transmission from HIV infected pregnant mothers to their infants
 For women who are already infected and pregnant, PMTCT programmes offer a range of
services and interventions that reduce the risk of MTCT:
 Antenatal care:
o Offer HIV counselling and testing to all pregnant mothers with same day results
o History and physical examination with emphasis on identification of opportunistic
infections and clinical staging of HIV infection
o The use of prophylactic ARVs to reduce MTCT
o Counselling and support for infant feeding options.
o Modified obstetric care
 Avoid artificial Rupture of Membranes (ARM)
 Avoid routine episiotomy
 Avoid vacuum extraction, forceps delivery unless necessary
 Avoid routine suction for newborn
o Use of ARVs during labour and for the newborn.
o Providing Infant feeding options to HIV positive mother/couple
o Exclusive breastfeeding for 6 months and abrupt weaning
o Modified breastfeeding
 Early cessation of breastfeeding before 6 months
 Heated expressed breast milk
o Exclusive Replacement feeding for 6 months if Affordable, Feasible, Accessible, And
Sustainable and Safe (AFASS) applies.
 Commercial infant formula
 Home modified animal’s milk.

PMTCT Element 4
 Provision of treatment, care and support to women infected with HIV and their partners,
infants and families
o Linkages between RCH services and community based programs for follow-up and
ongoing health care
o Linkage to health programmes for special needs such as malaria, STIs, TB, care and
treatment of HIV and AIDS
o Shared responsibility to build community teams.
Step 4: Element 7 - Management of Client’s records (10 minutes)
Tell students to pair up and discuss the importance of record keeping for 2 minutes
ALLOW few students to respond and let other pairs provide unmentioned responses
Importance of Record Keeping

 Planning clients’ care, enabling continuity of care over time
 Facilitating communication among health care workers at different levels and with
community/clients
 Managing health services and making decisions at health facilities, district, regional and
at national levels
 Measuring service uptake, provision of evidence-based practices by providers, and the
health status of women and babies.
Sources of ANC Data

 Antenatal card (RCH card number 4)
 MTUHA Books:
o Book 2: Health Facility Monthly Report
o Book 3: Community Based Data
o Book 4: Ledger (Control and Supplies)
o Book 6: ANC Register
o Book 10: Quarterly Health facility register
o Book 12: Delivery Register
 Tally sheet form for TT and Vitamin A
 Other registers such as ITN vouchers and PMTCT registers
Roles of ANC Health Care Providers

 Ensure all record books are constantly available
 Prepare/update records regularly
 Ensure all data collection tools are recorded accurately, completely and stored properly.
 Review data periodically at staff meetings and make decisions based on the data

Step 5: Infection prevention in the provision of care (15 minutes)
Standard Precautions
 These are simple effective practice guidelines aimed at creating a physical, mechanical
and or chemical barrier to protect health care workers and patients from infection
including blood borne pathogens.
 Standard Precaution Components

o Hard washing and alcohol hand rub
o Use of protective equipments
o Handling of sharps and injection safety.
o Processing instruments
o Health care waste management.
o Traffic flow.
o Housekeeping.
 Hand hygiene is accomplished by:-

o Hand washing with soap and running water
o Use of antiseptic agent
o Surgical hand scrub
o Antiseptic hand rub using a waterless alcohol – based antiseptic agent – is more
effective than hand washing in visibly clean hands.
 Use of personal protective equipments (PPE)

o Proper use of all types of gloves clean, surgical, long sleeved and heavy duty gloves.
o Proper use of caps, eyewear mask, apron, gowns, boots when splashes of blood and
body fluids are anticipated.
 Handling sharp Instruments and injection safety

o Use needle and syringe only once
o Do not recap, bend or break needles
o Dispose needles and syringes in a safety box.
 Processing Instruments
o Decontaminate with 0.5% chloride
o Clean with soap and water
o Rinse in clean water
o Air dry
o Sterile or High level
o Disinfect whichever is appropriate
o Store properly.
 Healthcare waste management

o The purpose of waste disposal is to prevent the spread of infection to providers who
handle the waste, to the local community
o Waste should be separated at the point of generation
o Contaminated waste includes blood and other body fluids, and items that come into
contact with them, such as dressings

o Liquid waste should be disposed off through the sewerage system or pit latrine where
applicable
o Always wear utility gloves when handling healthcare waste
o All waste should be disposed off immediately by incineration, burning or burying
 Traffic Flow
o There should be instructions to direct clients/patients where to go or to exit to obtain
health service in different rooms/places.
o People should be restricted from frequenting all areas where sterile procedures are
being performed. These include:
 Operating theatre
 Central sterilizing unit
 Labour ward
 Intensive care unit
 Neonatal unit
 Laboratory rooms etc.
 Housekeeping
o Housekeeping refers to the general cleaning of hospitals and clinics including floors,
walls, certain type of equipment, furniture and other surfaces.
Logistics Management
 Logistics: Is the coordinated effort of planning, procurement, delivery, and inventory
systems, and working together to bring supplies to clients.
 A logistic system provides effective customer service by fulfilling the seven “rights”:
o The RIGHT goods in the RIGHT quantities in the RIGHT condition, delivered to the
RIGHT place at the RIGHT time for the RIGHT cost and to the RIGHT customer
 The minimum recommended number of ANC visits for a normal pregnancy is four.
However if a pregnant woman comes outside the scheduled visit she should be given
necessary services DON’T send her away.
 Use the stop question to check whether the pregnant woman has received all necessary
care before she leaves the clinic.
 Proper management of ANC Client records is important for the improvement of ANC
services and the decision making.
 Standard precaution practices for infection prevention protect health care
provider/workers, patients/clients and the community from infection with wide range of
pathogens.
 Explain the minimum recommended number of ANC visits

 What are the factors that increase chances of MTCT of HIV?
 Why do you keep accurate records during ANC services?
 How do you manage health care wastes?

References

Session 18: Physiology of Labour
Prerequisites
 None
Learning Tasks
 Differentiate common terms used in labour labour
 Explain the causes of onset of labour
 Identify the duration of labour.
 Describe physiological changes during labour
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
1 5 minutes Presentation Presentation of Session Title and Learning

Tasks
2 10 minutes Presentation Common Terms in Labour
3 10 minutes Presentation/ Causes of Onset of Labour

Brainstorm
4 5 minutes Presentation Definition of First Stage of Labour
5 20 minutes Presentation Physiological Changes during the First Stage

of Labour
SESSION CONTENT

Level 5, Semester 1 Session 18: Physiology of Labour
Step 2: Common Terms in Labour (10 minutes)
Labour
 It is described as the process by which the fetus placenta and membranes are expelled
through the birth canal.
Normal Labour
 It is when labour occurs at term and is spontaneous in onset with the fetus presenting by
the vertex, the process is completed within 18 hours an no complications arise.
First stage of Labour

 Is the stage of dilatation of the cervix, it begins with regular rhythmic contraction and is
complete when the cervix is full dilated
Second Stageof Labour

 Is the stage of expulsion of the fetus, it begins when the cervix is full dilated and is
complete when the baby is born
Third Stageof Labour

 Is the stage of separation and expulsion of placenta and membranes and also involves
control of bleeding. It lasts from the birth of the baby until the placenta and membranes
are expelled.
Show
 It is the term used to describe the blood stained mucoid discharge at the onset of labour,
which comes from the cervical canal plug, the operculum.
Effacement of the Cervix

 It is also called 'taking up' is the progressive merging of the cervix with the lower part of
the uterus.
Dilation of the Cervix

 Dilation, like effacement, mainly occurs due to pulling of the cervix by the contracting
and retracting uterine muscles.
Engagement
 The fetal head is said to be engaged when the largest diameter of the head has passed the
smallest diameter of the maternal pelvis.
Caput Succedaneum
 It is an area of localized edema or collection of fluid on the fetal scalp that develops
during labor.
Molding of the Fetal Head

 Molding is physiological and harmless reduction in the size and shape of the fetal head
during delivery.

Step 3: Causes of Onset of Labour (10 minutes)
ASK students to brainstorm on the Causes of Onset of Labour for 2 minutes
 The exact cause of labour is still uncertain but it appears to be multifactorial in origin,
being a combination of hormonal and mechanical factors.
Hormonal Factors
 Oestrogen level rises in the last weeks of pregnancy therefore opposing the relaxing
effects of progesterone; together with the rise in prostaglandins provoked by changes in
the deciduas and membranes results in uterine contraction.
 High level of oxytocin present in the fetal circulation and that which is released from the
hypothalamus due to maternal emotional and physical stresses together with
prostaglandins initiates rhythmic contractions of true labour.
Mechanical Factors
 This is due to the overstretching of the uterine muscles in cases of multiple pregnancy or
pressure from the presenting part which is well applied to the cervix.
Step 4: Definition of First Stage of Labour (5 minutes)
First Stage of Labour

 It is the stage of dilatation of cervix. It begins with regular rhythmic contractions and is
complete when the cervix is fully dilated.
 The first stage of labour has got two phases
Latent Phase
 This phase is prior to active first stage of labour and may last 6 to 8 hours when the cervix
dilates from 0 to 3 cm, and the cervical canal shortens from 3 cm long to less than 0.5 cm.
Active Phase
 The active first stage is the time when the cervix undergoes more rapid dilatation. This
begins when the cervix is 3 cm dilated and in the presence of rhythmic contractions, is
complete when the cervix is fully dilated.
 From the time the cervix is 8cm dilated until full dilatation is also called the transitional
phase

Step 5: Physiology of the first stage of labour( 20 minutes)
Activity: Brainstorming ( 5 minutes)
ASK students to brainstorm on the Physiological Changes during Labour for 2 minutes
CLARIFY and summarize by the information given below
Duration
 The length of labour varies widely and is influenced by parity, birth interval,
psychological state, presentation and position of the fetus.
 Maternal pelvis shape and size and character of the uterine contractions also affect the
time scale.
 The active phase of labour is completed within 12 hours. On average, the primigravida
will take most of the time while the multigravida might expect to reach second stage
within 6 hours.
Uterine Contractions
 Fundal dominance
o Each uterine contraction starts in the fundus and spreads across and downwards.
o The contraction last longer on the fundus where it is also most intense, however the
pick is reached simultaneously all over the uterus and the contractions fades from all
parts together
o This pattern permits the cervix to dilate and the strongly contracting fundus to expel
the fetus.
 Polarity
o The term used to describe neuromuscular harmony that prevails between the two
poles or segments of the uterus throughout the labour
o The upper pole contracts strongly and retracts to expel the fetus. The lower pole
contracts slightly and dilates to allow expulsion to take place
o If polarity is disorganized, then the progress of labour is inhibited.
 Contraction and retraction

o Uterine muscles have a unique property, during labour the contraction does not pass
off entirely, but muscle fibers retain some of the shortening of contraction instead of
becoming completely relaxed
o This is termed retraction,It assists in progressive expulsion of the fetus; the upper
segment of the uterus becomes gradually shorter and thicker and its cavity diminishes.
 Formation of upper and lower uterine segment

o By the end of pregnancy, the body of uterus has divided into two segments
o The upper uterine segment having been formed from the body of the fundus is mainly
concerned with contraction and retraction, It is thick and muscular

o The lower uterine segment is formed from the isthmus and cervix, and it’s about 8 to
10 cm in length
o The lower segment is prepared for distention and dilatation.
 The retraction ring

o A ridge forms between the upper and lower uterine segments, this is known as
retraction or bundl’s ring
o Normally, the term retraction ring is used to describe the physiological retraction ring
and the term bundl’s ring is used for the exaggerated degree which becomes visible
above the symphysis in obstructed labour.
 Cervical effacement
o This is the taking up of the cervix
o If this has not been taken place during the last days of pregnancy, this process will
take place in labour
o The muscle fibers surrounding the internal os are drawn upwards by the retracted
upper segment and the cervix merges into lower uterine segment
o The cervical canal widens at the level of internal os.
 Cervical dilatation
o This is the process of enlargement of the external os from a tightly closed aperture to
an opening large enough to allow passage of the fetus
o This dilatation is measured in centimeters and full dilatation at term equals to 10 cm.
o Uterine contraction and the counter-pressure applied by the bag of membranes and the
presenting part results into cervical dilatation.
o A well flexed head closely applied to the cervix favors this cervical dilatation.
 Show
o As a result of the dilatation of the cervix, the operculum which formed the cervical
plug during pregnancy is lost
o The woman will see a blood-stained mucoid discharge a few hours before or within a
few hours after labour starts.
Mechanical Factors
 Formation of fore water
o As the lower uterine segment stretches, the chorion becomes detached from it and the
increase intrauterine pressure causes this loosened part of the sack of fluid to bulge
downwards into the internal os.
o The well flexed head fits snugly into the cervix and cuts off the fluid in front of the
head from that which surrounds the body. The former is known as fore water and the
later is known as hind water.
 General fluid pressure

o While the membranes remain intact, the pressure of the uterine contractions is exerted
on the fluid and as the fluid is not compressible, the pressure is equalized throughout
the uterus and all over the fetal body.
o When the membranes rupture and a quantity of fluid emerges the fetal head and the
placenta and umbilical cord are compressed between the uterine wall and the fetus
during contraction and oxygen supplied to the fetus is diminished.

 Rupture of the membranes
o The optimum physiological time for the membranes to rupture spontaneously is at the
end of the first stage of labour after the full cervical dilatation and no longer supports
the bag of fore waters.
o The membranes may sometimes rupture days before labour begins or during the first
stage. Badly fitted presenting part which may lead to not cutting off the fore water,
the membranes may rupture early.
 Fetal axis pressure

o During each contraction the uterus rears forward and the force of the fundal
contraction is transmitted to the upper pole of the uterus down the long axis of the
fetus, and applied to the presenting part to the cervix
o This is known as fetal axis pressure.
Maternal physiological changes
Cardiovascular Changes
 During labour, the labouring women usually feel some changes in their CVS.
 There is about 400 ml of blood emptied from the uterus into the vascular system in each
contraction.
 Blood flowing to the uterine artery decreases due to contractions, it is therefore redirected
to maternal peripheral blood vessels.
 Cardiac output increases by 10 – 15% during the 1st stage of labour. However, it further
increases by 30 – 40% during the second stage
 Blood pressure and pulse rate increases, therefore BP should be monitored between
contractions.
 BP increases even more during the second stage of labour. It is therefore, important to
pay special attention to those known hypertensive women to avoid complications which
may end up with maternal and/or fetal death.
Respiratory Changes
 Because of the increased muscular activity, there is also an increase in oxygen
consumption which is reflected by an increase in respiratory rate.
 However, anxiety also contributes in an increased O2 consumption ( increased BP & PR)
 Often, there is a tendency of hyperventilation leading to decreased CO2 tension. This
may end up with respiratory alkalosis, hypoxia and hypocapnia.
Gastrointestinal Changes
 Gastric mobility and absorption (especially of the solid foods) are affected (reduced) during
labour.
 These reductions in mobility and absorption rate leads to prolonged gastric emptying
time, therefore gastric volume remains over 25 ml.
 These also cause the increased acidity of stomach contents.
 A laboring woman may be nauseated and belching in response to full cervical dilatation.
Some may get diarrhea during the onset of labour.

 The length of labour varies widely and is influenced by parity, birth interval,
psychological state, presentation and position of the fetus.
within 6 hours.
 Blood pressure and pulse rates increases, therefore vital signs need to be monitored
between contractions.
 The upper pole contracts strongly and retracts to expel the fetus. The lower pole contracts
slightly and dilates to allow expulsion to take place
 Uterine muscles have a unique property, during labour the contraction does not pass off
entirely, but muscle fibers retain some of the shortening of contraction instead of
becoming completely relaxed
 Define the stages of labour

 Explain the duration of labour
 Explain the changes which take place in the uterus
 What are the normal physiological changes during labour which occur in cardiovascular
system, and the uterus?
References:

Session 19: Use of Partograph in Managing Labour
Prerequisites
 None
Learning Tasks
 Explain the importance of partograph
 Identify parts of the partograph
 Explain the symbols used during partograph recording
Resources Needed
 Projector
 Computer
 Partograph forms
SESSION OVERVIEW

Tasks
2 15 minutes Presentation Importance of the Partograph
3 40 minutes Presentation/ Parts of the Partograph

Demonstration
4 50 minutes Presentation/ Symbols used during Partograph Recording
Demonstration
SESSION CONTENT

126
Level 5, Semester 1 Session 19: Use of Partograph in
Managing Labour
Step2: Importance of Partograph (15 minutes)
Definition
 Partograph is a chart on which the salient features of labour are entered in a graphic form
and therefore provides the opportunity for early identification of deviations from normal.
Activity Brainstorming (5 minutes)
ASK the students to brainstorm on the importance of partograph for 2 minutes
The Importance of Using Partograph

 Gives a complete picture of how mother, baby and progress of labour are doing
 Provides guidelines on when labour is no longer normal and on management of those
situations.
 Helps give to continuity of care
 Increases the quality of all observations on the mother and fetus in labour
 Serves as an early warning system
 Assists in early decision on transfer, augmentation and termination of labour
 It reduces prolonged labour, need for augmentation, emergency caesarian section and
intrapartum still birth rates.
When to Start a Partograph

 In latent phase if contractions are at least 2 or more in 10 minutes, lasting, 20 seconds or
more to monitor labour progress OR
 In active phase, if contractions are one or more in 10 minutes to monitor labour progress.
OR in early labour to monitor if labour if is stablished
Who should not have a Partograph,

 Women with problems which are identified before labour starts or during labour which
need special attention

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Managing Labour
Step 3: Parts of Partograph (40 minutes)
Activity: Demonstration (20 minutes)
DIVIDE the students in small manageable groups
PROVIDE each student with a partograph form
SHOW to the students the different Parts of the Paragraph
ALLOW students to ask if there are any questions
 The partograph is divided into 4 parts

o General information of the mother
o Fetal monitoring section
o Labour progress monitoring section
o Maternal monitoring section
General Information of the Mother

 The name, gravid, para, registration/hospital number, date of admission, time of
admission and time membrane ruptured
Foetal Monitoring Section

 Foetal heart rate is recorded to monitor the condition of the fetus.
 Liquor or amniotic fluid is observed and write “C” if it is clear or “M” if meconium
stained
 If the membranes are not ruptured record “I” for intact
Labour Progress Monitoring Section

 Cervical dilatation is the most important observation in monitoring progress of labour.
The dilatation is plotted with an “X”.
 Descent of the fetal headis very important in monitoring of labour progress. The descent
is plotted with an “O”
 Time is recorded using the time of admission as zero time. The actual of the day is
recorded below the hours line.
 Progress of labour and contractions- the contractions are recorded below the time line,
along with cervical dilatation and descent of presenting part, they all tell the progress of
labour.
Maternal Monitoring Section

 Blood Pressure, Pulse and Temperature are recorded in the space provided.
 Urine amount is recorded every time urine is passed
 Albumin (protein) and acetone (ketones) every time the woman passes urine or are tested
at least once
 Medications- intravenous fluids (infusion) are recorded in the space provided.

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Managing Labour
Figure 3.4 Example of a Partograph

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Managing Labour
Step 4: Symbols used during Partograph Recording (50 minutes)
USING an enlarged partograph form
DEMONSTATE to the students how the symbols are plotted on the partograph form
ALLOW students to practice
CLARIFY and Summarize using the information given below
Fetal Heart
Liquor I = Intact
C = Clear
M = Meconium stained
B = Blood stained
A = Absent
Moulding O = bones are separated and sutures can be felt easily.
+ = Bones are just touching each other
++ = Bones are overlapping but can be reduced
+++ = bones are overlapping and cannot be reduced.
Dilatation X
Descent O
Contractions ░ dots = mild contractions less than 20 seconds.
Diagonal lines = moderate contractions 20 – 40
seconds.
Completely filled in = strong contractions more than 40
seconds.
Blood Pressure ↕
Pulse ●
 Progress of labour includes cervical dilatation, progress of labour and uterine

contractions.
 Fetal condition includes fetal heart rate, liquor and moulding of the fetal skull
 Maternal condition includes vital signs, urine, drugs and oxytocic regime.
 What is a partograph?
 Why is partograph important?
 How are you going to plot moulding of the fetal skull on the partograph?
 Explain how to plot uterine contractions on the partograph.

130
Managing Labour
References

131
Managing Labour
Session 20: Filling and Interpreting the Partograph
Findings
Prerequisites
 None
Learning Tasks
 Record finding on the partograph
 Explain the interventions based on partograph findings
Resources Needed
 Projector
 Computer
 Plain partograph forms
 Case studies of different situations
SESSION OVERVIEW

Tasks
2 70minutes Presentation Recording Findings on the Partograph
3 35 minutes Presentation Interventions Based on Partograph Findings
SESSION CONTENT

132
Level 5, Semester 1 Session 20: Filling and Interpreting the
Partograph Findings
Step 2: Recording Findings on the Partograph (70 minutes)
Cervical Dilatation
 The first stage of labour is divided into the latent and active phase.
 The latent phase is a period of slow cervical dilatation, is from 0 to 3 cm with gradual
shortening of cervix.
 The active phase is a period of faster cervical dilatation, is from 3 to 10 cm.
 The dilatation of the cervix is measured in cm and is plotted with an X, vaginal
examination are made every 4 hours unless contra indicated. However in advanced
labour women may be assessed frequently especially multipara.
Descent of the Fetal Head

 Descent of the head is measured by palpating the head through the abdomen and
recording the findings every 4 hours.
 The decent is measured in ‘fifths’ of the head palpable above the brim
 Descent of the head can also be assessed by doing vaginal examination and recorded as
fetal stations.
Uterine Contractions
 In order for labour to progress well there must be good uterine contractions
 In normal labour contractions usually become more frequent and last longer, as labour
progresses Contractions are observed hourly in latent phase and half hourly in active
phase.
 Contractions are observed for frequency and duration
 The frequency of contractions is assessed by the number of contractions in a ten-minute
period. The duration is from the time the contraction is first felt abdominally to the time
when the contraction passes off
 Three ways of recording the duration are:
o Below 20 seconds – mild contractions.
o 20 – 40 seconds – moderate contractions,
o More than 40 seconds but should not exceed 60 – strong contractions.
Fetal Heart Rate

 Fetal heart rate should be checked and recorded every hour or half hourly when possible
 When there are problems to be checked after every contraction
 Listen to the fetal heart rate for a full one minute after contraction ends.
 Normally the fetal heart rate is between 120 and 160 beats in a minute, and should be
regular.
Recording Membranes and Liquor

 The state of the liquor can assist in assessing the fetal condition.
 The observations are recorded on the partograph just below the fetal heart recordings
 The observations are made at each vaginal examination.
Moulding of the Fetal Skull Bones

 The amount of molding helps in assessing how well the pelvis is making room for the
fetal head.
 Molding is evaluated at each vaginal examination
 Molding when the head is too high is a sign of disproportion.

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Partograph Findings
Recording Maternal Condition
 All observations on the mother’s condition are recorded at the bottom of the partograph
 Pulse rate half hourly
 Blood pressure temperature and pulse 4 hourly or more frequently when indicated.
 Urine; ask the woman to pass urine every 2 to 4 hours look for amount and concentration.
Concentrated urine is a sign of dehydration
 The protein and acetone should be assessed on admission.
 All entries are made on the line at which the observations are made.
Activity: Small group Exercises (40 minutes)
DIVIDE students into small manageable groups
DISTRIBUTE Plain partograph forms to each groups and provide them with case studies
Refer students to Worksheet 20:1 Partograph exercise.
ASK students to do the exercises in groups.
AFTER small group Exercises ask students to provide responses.
CLARIFY and summarize.
Step 3: Interventions Based on Partograph Findings ( 35 minutes)
Prolonged Latent Phase

If a woman is admitted in labour in the latent phase and remains in the latent phase for more
than 8 hours, progress is abnormal and if she is not in a hospital, she must be transferred to a
hospital for decision about further action.
Moving to the Right of Alert Line

 In active phase the plotting of cervical dilatation is on or to the left of alert line
 When dilatation moves to the right of the alert line and if adequate facilities to deal with
obstetrical emergencies are not available the woman must be transferred for adequate
assessment.
At the Action Line
 The action line is 4 hours to the right of the alert line.
 If a woman’s labour reaches this line, a decision must be made about the cause of the
slow progress and appropriate action taken.
 The decision and action must be taken in a hospital with adequate facilities to deal with
obstetric emergencies.

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Partograph Findings
Management of Abnormal Progress of Labour
 While use of the partograph demands a response from the midwife or doctor the
management of labour when it becomes abnormal the decision is made by the doctor.
When the Cervical Dilatation Moves to the Right of the Alert Line
 In a health centre, the woman must be transferred to hospital immediately unless the
cervix is almost fully dilated
 If the head remains high inspite of good uterine contractions she should be transferred
even if dilatation is satisfactory.
 If the hospital is equipped for operative delivery ,continue with careful assessment of
labour and a decision on further management of labour is done.
When cervical dilatation reaches the action line

 Terminate the labour
 Augment labour
 Observe the woman with supportive therapy.
The latent phase is from 0 to 3 cm and is accompanied by gradual shortening and thinning
(effacement) of the cervix. It should not normally last longer than 8 hours.
 The active phase is from 3 to 10 cm and dilatation should be at the rate of at least1
cm/hour
 When labour progresses well plotting of the cervical dilatation should remain on the alert
line or to the left of the alert line.
 When admission takes place in the active phase the admission dilatation is immediately
plotted on the hour 0 and then transferred to the alert line.
 Immediately before a vaginal examination an abdominal examination must always be
done
 Normal fetal heart rate is between 120 to 160 beats / min.
 All women whose cervicograph moves to the right of the alert line must be transferred
and managed in a facility with adequate facilities for obstetrical interventions, unless
delivery is near.
 At the action line the woman must be carefully re-assessed for the reason for lack of
progress and decision made on further management
 Explain the latent and active phase

 How do you assess the progress of labour?
 What actions to take when cervical dilatation crosses to the right of the alert line
 What actions to take when cervical dilatation reaches the action line.

135
Partograph Findings
References

136
Partograph Findings
Worksheet 20.1: Partograph Exercises
Exercise 1.1: Plot Cervical Dilatation in the LATENT Phase

The latent phase normally may take eight hours. When the woman is admitted in the
latent phase, dilatation of the cervix is plotted with an X on the line marked zero. Vaginal
examination is made every four hours. If the membranes have ruptured and the woman has
no contractions, check foetal heart. If abnormal, exclude cord prolapse.
Cervical dilatation, and the position and descent of the head are also determined.
Figure 19: Recording Dilatation
Fill in the following on the partograph

 Admission was at 2pm and the cervix was 2 cm dilated.
 At 6 pm, the cervix was 6 cm dilated
 At 10 pm, the cervix was 10 cm dilated as she entered the active phase of labour.
Questions:
1. How many hours was the latent phase of labour?
2. How many hours was the active phase of labour?
3. How many vaginal examinations were performed?
4. How long was the first stage of labour at the maternity?

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Partograph Findings
Example of Plotting Cervical Dilatation from Latent to Active Phase.
When dilatation is 0 to 3 cm, plot on the latent phase. When dilatation is above 3 cm,
plotting must be moved by a broken line to the alert line.
Plotting Cervical Dilatation from Latent to Active Phase
Look at the following information

 Admission time was 2 pm and the dilatation was 2 cm.
 At 6 pm, the dilatation was 6 cm (active phase); move the time and dilatation from latent
to active phase on the alert line. Remember to use a dotted line for the move.
 At 10 pm, the cervix was 10 cm.
Answers:
1. Latent phase of labour took 1 hour?
2. Active phase of labour took 7 hours?
3. Three(3) vaginal examinations were performed
4. The first stage of labour took nine (9)hours at the maternity?
Points to Remember:
 The latent phase is from 0 through 3 cm dilatation and is accompanied by gradual
shortening and thinning (effacement) of the cervix. It should normally not last longer
than eight hours.
 The active phase is from 3 to 10 cm, and dilatation should be at the rate of at least 1
cm/ hour.
 When labour progresses very well, the dilatation should remain on or to the left of the
alert line.
 When admission takes place in the active phase, the admission dilatation is
immediately plotted on the hour 0 then transferred immediately to the alert line.
 When labour moves from latent to active phase, the dilatation (X) is immediately
moved (using a broken line) from the latent phase area to the active phase area on the
alert line.

138
Partograph Findings
Descent of the Foetal Head
For labour to progress well, dilatation of the cervix should be accompanied by descent of the
head. Measuring the descent of the baby’s head helps the health care provider follow the
progress of labour.
Descent of the head is measured by palpating the head through the abdomen and recording
the findings every two hours. The descent is measured in “fifths” of the head palpable above
the pelvic brim. See Figure 21.
Diagram Showing Descent of the Foetal Head through the Brim
Descent of the head can also be assessed by doing a vaginal examination and recorded as
foetal station. Before doing the vaginal examination, always assess the descent of the head
abdominally in order to compare the findings.
Exercise 1.2: Plot Descent

To plot descent of the head, look on the left side of the graph and see the word descent
with lines going from 5 to 0. Plot the descent with a 0 on the graph.
Plot Descent of the Head

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Partograph Findings
Exercise 1.3
Record the following on the graph (Figure 23):
 On admission at 1 pm, the head is 5/5 (five-fifths) above the pelvic brim and the cervix
is 1 cm dilated.
 After 4 hours, the head is 4/5 (four-fifths) above the brim and the cervix is 5 cm
dilated. Labour is now in the active phase. Cervical dilatation, descent of head and
time recordings are transferred to the alert line.
 After 3 more hours, the head is 1/5 (one-fifth) above the pelvic brim and the cervix is
10 cm dilated.
 How long was the first stage of labour in the labour ward?
 The first stage of labour took 7 hrs in the labour ward?

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Partograph Findings
Exercise 1.4: Plotting Foetal Heart Rate on a Partograph
Plotting Observations
Fill in the following on the above partograph:

 The woman was admitted at 2 pm in the active phase of labour
 The cervix was 3 cm dilated; the head was 4/5 (four-fifth) above the pelvic brim
 Contractions were three in 10 minutes, each lasting between 20 to 40 seconds
 At 6 pm the cervix was 7 cm dilated, the head 3/5 (three-fifth) above the brim and
contractions were 5 in 10 minutes, lasting over 40 seconds
 At 9 pm, the cervix was 10 cm; the head 0/5 (no fifth) above the brim, contractions were
5 in 10 minutes, lasting over 40 seconds

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Partograph Findings
 The foetal heart rate is recorded at the top of the partograph, Figure 25. There are spaces
to record the foetal heart rate every half hour. Each square represents 30 minutes. Take
and record the foetal heart rate at least every hour, or every half hour when possible.
The lines for 120 and 160 beats per minute are darker to remind the health care provider
that these are the normal limits of the foetal heart rate. When there are problems, you may
listen to the foetal heart after every contraction.
Points to Remember:
 Listen to the foetal heart rate (FHR) for a full minute immediately after the contraction
ends, with the woman lying in semi-recumbent position.
 Record the foetal heart rate at least every 30 minutes in the first stage of normal
labour.
 Record FHR every 5 minutes in the second stage of labour.
 Normally, the foetal heart rate is between 120 and 160 beats in a minute, and should be
regular.
Membranes and Liquor
The state of the liquor, or amniotic fluid, can assist in assessing the foetal condition. The
following observations are recorded on the partograph immediately below the foetal heart
rate recordings, Figure 4.1.10. The observations are made at each vaginal examination.
If the membranes are intact:

 Write the letter “I” for intact.
If the membranes are ruptured and:

 Liquor is clear; write the letter “C” for clear.
 Liquor is blood-stained; write the letter “B.”
 Liquor is meconium-stained, write the letter “M+ for light meconium, M++ for thick
meconium.”
 Liquor is absent; write the letter “A” for absent.
 If liquor is absent or meconium–stained, the foetus may be in distress.
 Monitor foetal heart rate every 30 minutes.

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Partograph Findings
Recording Status of Membranes and Liquor

143
Partograph Findings
Session 21: Management a Woman in First Stage of
Labour
Prerequisites
 None
Learning Tasks
 Explain the signs and symptoms of labour
 Describe vaginal examination
 Explain the management of a woman during the first stage of labour
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
1 5 minutes Presentation Presentation of Session Title and learning

Tasks
2 10 minutes Presentation Signs and Symptoms of Labour
3 50 minutes Presentation Vaginal Examination

Demonstration
4 45 minutes Presentation Management of the Woman in 1st of Labour
Group Discussion
SESSION CONTENT

144
Level 5, Semester 1 Session 21: Management a Woman in
Step 2: Signs and Symptoms of the First Stage of Labour (10 minutes)
TELL the students to pair up and discuss the signs and symptoms of first stage of labour for
2 minutes
ALLOW few students to respond and the other pairs provide unmentioned responses
Recognition by the Mother

It is the woman herself who usually diagnose the onset of labour and many women are
apprehensive in case they misdiagnose this process.
Show
This is a pink jelly-like discharge lost at the beginning of labour. It is the sign that labour
is either imminent or underway. It may be lost after a vaginal examination.
Contractions
 True labour contractions exhibit a pattern of rhythm and regularity usually increasing
in length. When the woman first feels contraction, she may only be aware of
backache but if she places a hand on her abdomen, she may perceive simultaneous
hardening of the uterus
 Contractions will be short initially, lasting 30 to 40 seconds and may be as much as
half an hour apart.
Rupture of membranes
The woman may have little difficult in recognizing a sudden gush of fluid as rupture of
membranes and she should be instructed to inform the midwife immediately if this
happens.
Recognition by the Midwife

The midwife will examine the abdomen to evaluate the character of the contractions and
during a vaginal examination she can assess the state of the cervix and cervical os.
Step 6: Vaginal Examination (50 minutes)
Activity : Demonstration (20 minutes)
DIVIDE students into medium sized manageable groups
DEMONSTRATE to the students on how to perform Vaginal Examination
ASK one student from each group to do a return demonstration and let other students
comment on it
ENCOURAGE students to practice in skills laboratory

145
 A vaginal examination should be preceded by an abdominal examination, an explanation
and the obtaining of verbal consent from the woman
 This is done in 4 hourly intervals and must be recorded on the partograph
 The woman’s bladder should be empty as the head may be displaced by a full bladder as
well as being very uncomfortable for the woman.
 Indications of vaginal examination
o Make a positive identification of presentation
o Determine whether the head is engaged in case of doubt
o Ascertain whether the fore water have ruptured, or to rupture them artificially
o Exclude cord prolapse after rupture of fore waters, especially if there is an ill-fitting
presenting part or fetal heart rate changes
o Assess progress or delay in labour
o Confirm full dilatation of the cervix
o Confirm the axis of the fetus and presentation of the second twin in multiple
pregnancies and if necessary in order to rupture the second amniotic sac.
Note: The midwife should avoid unnecessary vaginal examinations. Under no circumstances
should a midwife do vaginal examination if there is any frank bleeding unless the placenta is
positively known to be in the upper uterine segment.
 Method
 Vaginal examination is an aseptic procedure
 The midwife should explain the procedure to the woman and give her an opportunity to
ask questions.
 Vaginal examination is an aseptic procedure.
 In order for the midwife to avoid exogenous infections she should adhere to aseptic
techniques.
 She should wash her hands with soap and water before preparing the equipments.
 Prepare a tray with:
o Sterile bowel with antiseptic solutions.
o Sterile swabs
o Sterile gloves.
o Perineal pad
o Lubricant cream.
o Sterile hand towel.
o A receiver for soiled swabs
o A cocher forceps if the indication is to rupture the membranes
Procedure
 Explain the procedure to the mother.
 Let her ask the questions to alley anxiety.
 Ask her to empty the bladder.
 Screen the bed and perform abdominal examination.
 Record the findings of abdominal examinations.
 Ask the woman to lie on her back.
 If she is dirty wash her thighs and the vulva with soap and water.
 Scrub hands and put on sterile gloves.
 Ask the woman to flex her knees and separate the thighs.

146
 Swab the vulva using the left hand while the picking the swabs with the right hand. The
number of swabs depends on the condition of the vulva i.e. with much show etc
 Swab the left labia minora then the right labia minora.
 Separate the labia minora with the first finger and thumb and swab the vestibule and the
vaginal orifice with the right hand without contaminating the hands.
 Use only one strip.
 Do not remove the left hand
 Dip the first two fingers of the right hand into a lubricant and gently insert them into the
vaginal in a downward and backward direction avoiding touching the anus.
 While exploring avoid pressing the clitoris as it may cause discomfort to the mother.
 Do not remove the fingers until you have obtained all necessary information about the
following;
o Condition of the vagina
o The cervix and cervical os
o The bag of waters
o The level of the presenting part
o Presentation and position
o Degree of moulding
o Abnormalities
Findings on Vaginal Examination

 The external genitalia: This is obtained by observation, normal findings include
discharges i.e. liquor and show.
 Abnormal findings include:
o Varicose veins
o Blood or pus or meconeum stained discharges
o Warts and ulcers
o Old scars from tears and episiotomy or clitoridectomy
o Smell (offensive smell)
 Condition of the vagina

o Normal findings:
 The walls should feel soft and stretchable.
 Vagina should feel warm and moist
o Abnormal findings:
 Hot and dry vagina is a sign of obstructed labour. In high temperatures it will feel
warm but remains moist.
 Firm rigid walls may indicate type 3 female genital mutilation (FGM) and it
indicates prolonged labour
 Acystocel may be felt anteriorly in multparous and loaded rectum may be felt on
the posterior
 The cervix and cervical os

o Normal findings:
 In established labour the effacement is complete and is closely applied to the
presenting part.
 The consistency of the cervix should be soft and elastic in established labour
 The degree of dilatation of the uterine os is estimated by centimeters across the
opening. A diameter of 10 cm indicates fully dilatation of the cervix.

147
o Abnormal findings:
 If the cervix is 2.5 cm long and is closed labour is not established.
 A tough hard un-dilatable cervix indicates unyielding cervix (rigid) especially if
the woman has been in labour for some time.
 Edematous cervix which may be found on anterior part may be due to obstructed
labour.
 Dilatation less than 1 cm per hour in active phase.
 Fore waters
o Normal finding;-
 Intact membranes
o Abnormal findings;-
 Rupture of membranes in early labour
 Bulging membranes/elongated membranes. This may indicate that the membranes
will rupture early or badly fitting presenting part
 Level or station
o It is assed in relation to the maternal ischial spines to determine descent of the
presenting part.
o The midwife should bear in mind about caput succedaneum and moulding which may
give wrong interpretation of the level of the presenting part in relation to the level of
 Excessive caput
 Excessive moulding
 Undescending presentation in spite of good contractions
 The ischial spines
 Identification of the presentation

o In 99% of all pregnant women present their fetuses by vertex.
o This is recognized by feeling the hard cephalic bone, the fontanelles and sutures.
 Feeling the buttocks, the limbs, face, shoulder or brow in the lower pole of the
uterus
 The position
o The position is detected by feeling the features of the presenting part.
o The vertex has the fewest diagnostic features, and is the most common presentation
the midwife should be able to make diagnosis
o The 1st feature is the saggital suture. It is commonly felt in the right or left oblique
diameter of the pelvis.
o In few cases during the process of labour it may be felt in the transverse diameter.
o Towards the end of the 1st stage after rotation of the head it may be felt in the anterior
posterior diameter.
o Following the suture the midwife can detect the fontanelles. The anterior by feeling a
diamond shaped membranous space with 4 sutures leaving it.
o In a well flexed head the posterior fontanel will be detected by its triangular shape
with 3 sutures leaving it.
o Identification of the fontanels will make the midwife to know where the occiput is and
thus detecting the position.

148
 The moulding
o Moulding is judged by the degree of overlapping of the fetal skull bones e.g. parietal
bones to override the occipital bones and the right parietal override the left.
 The pelvic capacity

o If the pelvic capacity was not assessed before, the midwife should do it during vaginal
examination during labour.
o She tries to reach the sacropromontory to assess the anterior posterior diameter of the
brim.
o The ischial spines should be blunt
o The sacral curve should be straight and curved.
o Check the pubic angle; it should accommodate the two examining fingers that is 90
degrees angle.
o On completion of the examination the midwife withdraws her fingers and checks the
discharge from the vagina.
o She places her 4 knuckles between the ischial tuberosities and sees if all can be
accommodated.
o After the examination the results should be explained to the woman.
o Remove the gloves and put them in the dust bin marked highly infectious.
o Immerse the used equipments in chlorine 0.5% for 10 minutes.
o Remove them and wash them in soapy water.
o Rinse them in clean water, air dry then sterilize ready for another use next time.
o Immediately record the findings before forgetting.
 Contraindications for Vaginal Examination

o A woman with history of repeated vaginal bleeding during pregnancy or obvious
vaginal bleeding during labour.
o A woman for elective caesarian section
o A woman with genital warts and or genital herpes
Step 7: Management of a woman during the first stage of labour

(45 minutes)
Activity: Group Discussion (20 minutes)
ASK students to discuss in groups the management of a woman in the first stage of labour
AFTER small group discussion ask students to provide their responses.
CLARIFY and summarize by using the contents below
Admission of a Woman in Labour

When a woman comes to your labour ward:
 Welcome her together with her companion
 Create a good therapeutic interpersonal relationship with her and the companion

149
 Once you have welcomed the woman and her companion;-
o Review the woman’s antenatal records (if available), if not, take her history
o Perform quick assessment
o Perform physical examination and per vaginal examination (if signs of true labour are
present)
o Record all findings of the latent 1st stage on a woman’s card. If the woman comes
after the latent phase of the 1st stage (cervix dilated 3 cm and above), during active
phase record all findings in the partograph.
o Allow a companion to remain with the woman (if possible), and continue monitoring
the progress of labour, fetus and the woman (using partograph)
Note:
 Skills in inspiring confidence and establishing a trusting relationship with a woman is an
integral part of good midwifery care, as is an understanding that each individual couple
will respond differently to the onset of labour.
 A welcoming attitude and a comfortable environment will encourage the couple to relax
and respond positively to the forces of labour, and the labour is likely to progress
normally until the end.
 The midwife must make an immediate assessment of whether delivery is imminent and, if
so, admission procedures are curtailed and preparation is made for the birth.
 Continue with the following care through delivery
Table 1.2 cares during labour
Element 1st stage – Latent phase 1st stage – Active phase

(cervical dilatation 1 – 3 cm) (cervical dilatation 3 – 10 cm)
Communication/ • Attend the woman as needed at • Never leave the woman alone for
Attendance least every 4 hours. more than 30 minutes
• Periodically engage her in • Closer attendance may be necessary
conversation even if briefly if woman is having difficulty copying
• Encourage the birth companion to or fetal or maternal condition requires
stay with her (if possible) close monitoring.
• Periodically engage her in
conversation even if briefly
• Provide continuing information and
reassurance about her progress
• Never make false promises
• Encourage the birth companion to
stay with her (if possible)

150
Rest & Activity/ • Allow the woman to remain as • Allow the woman freedom to choose
Positions active as she desires from a variety of positions while
• Encourage rest or sleep as she guiding her to find a position that
desires so that she is well rested easies her discomfort and promotes
when active labour begins labour
• Assist her in relaxing between
contractions in order to conserve her
energy
• Encourage position changes (e.g.
sitting, sporting, side lying, hands and
knees) as well as walking, pacing,
standing, rocking and leaning of a
chair.
Comfort • Give the woman a back rub or • Lightly massage, rub her back or
massage. apply pressure to the lower back as
• Teach hear to breath out more she desires
slowly than usual during • Provide a cool cloth for the face and
contractions and relax with each chest as she desires
breath • Continue to coach her to breathe
through her mouth during contraction
in deliberate slow breath
•
Nutrition • Encourage food as tolerated, there • Encourage light meals/food as
are no restriction on intake as tolerated. There are no restrictions on
long as the woman has no nausea intake as long as the woman has no
and/or vomiting nausea and/or vomiting
• Provide the woman with • Provide the woman with nutritious
nutritious drink to maintain drink to maintain hydration. Two
hydration. Two liters of oral liters of oral fluids per 24-hour period
fluids per 24-hour period is a is a minimum amount
minimum amount
Elimination • Encourage the woman to empty • Encourage the woman to empty her
her bladder every two hours and bladder every two hours and empty
empty her bowels as needed. her bowels as needed.
• Do not give the woman an enema • Record urine output on partograph
• Do not give the woman an enema

151
Hygiene/ • Maintain cleanness of the woman • Maintain cleanness of the woman and
Infection and her environment her environment
Prevention - Encourage her to bath - Encourage her to bath before
before active labour active labour begins
begins - Cleans the genital area if
- Cleans the genital area if necessary before each
necessary before each examination
examination - Do not shave the vulva
- Do not shave the vulva - Before and after each
- Before and after each examination wash hands
examination wash hands - Clean up spills immediately
- Clean up spills - Replace soiled linen
immediately
- Replace soiled linen
Observations • Maternal condition • Maternal condition
- Blood pressure - Blood pressure - 4 hourly
- Pulse rate - Pulse rate - ½ hourly
- Temperature - Temperature - 4 hourly
• Fetal condition • Fetal condition
- Fetal heart rate - Fetal heart rate - ½ hourly
- Molding - Molding - 4 hourly
- Liquor amnii - Liquor amnii - 4 hourly
• Progress of labour • Progress of labour
- Descent of the fetal head - Descent of the fetal head – 4
- Contractions hourly
- Cervical dilatation - Contractions – ½ hourly
Note: The above observations are - Cervical dilatation – 4 hourly
performed 4 hourly and be • Note: The above observations are
recorded on the woman’s ANC recorded on the partograph
card.

152
within 6 hours.
 The midwife should avoid unnecessary vaginal examinations.
 Under no circumstances should a midwife make a vaginal examination if there is any
frank bleeding unless the placenta is positively known to be in the upper uterine segment
 Recording and reporting findings to the appropriate person is mandatory
 After the examination the results should be explained to the woman.
 During admission, the midwife must make an immediate assessment of whether delivery
is imminent and, if so, admission procedures are curtailed and preparation is made for the
birth
 Outline the hormones that play role in initiation of labour

 What are the indications of vaginal examination?
 How can a midwife recognize 1st stage of labour?
 Where do you record the observation of the latent 1st stage of labour?
References
Green, C. J., &Wilkinson, J. M. (2004). Maternal newborn nursing care plans. St. Louis:
Mosby.
Kenzie, B., & Gomez, P. (2006). Basic maternal and newborn care: A guide for skilled
providers. Baltimore: JHPIEGO Corporation.
WHO. (2008). Preservice initiatives basic emergency maternal and neonatal care: Lesson
plans. JHPIEGO: Dar es Salaam.

153
Session 22: Second Stage of Labour
Prerequisites
 None
Learning Tasks
 Explain Physiological changes In the second stage of labour
 Explain Signs and symptoms of second stage of labour
 Explain the management of a woman in the second stage of labour
Resources Needed
 Projector
 Computer
 Models
 Check list
SESSION OVERVIEW
Step Time Activity/ Method Content

Tasks
2 10 minutes Presentation Physiological Changes in the Second Stage
of Labour
3 5 minutes Presentation/ Signs and Symptoms of Labour
Brainstorm
4 5 minutes Presentation Duration of the Second Stage of Labour
5 25 minutes Presentation/ Mechanism of Normal Labour

Demonstration
6 60 minutes Presentation/ Management of a Woman in the Second
Demonstration Stage of Labour
SESSION CONTENT

Level 5, Semester 1 Session 22: Second Stage of Labour
Step 2: Physiological Changes during Second Stage of Labour (10 minutes)
 The second stage of labour is that of expulsion of the fetus. It begins when the cervix is
fully dilated and is complete when the baby is completely born.
 The physiological changes results from continuation of the same forces which have been
at work during the 1st stage of labour, but activity is accelerated once the cervix has
become fully dilated
 These physiological changes include;-
Uterine Action
 Contractions become stronger and longer but may be less frequent allowing both mother
and fetus regular recovery periods
 There is continued progressive contraction and retraction of the upper uterine segment
while the lower segment and cervix passively dilates and thin
 The membranes often rupture spontaneously towards the end of the 1st stage or during
transition to the second stage.
 The drainage of liquor allows the hard round fetal head to be directly applied to the
vaginal tissue and aid distension
 Fetal axis pressure increases flexion of the head which result in smaller presenting
diameter, more rapid progress and fewer traumas to the mother and fetus
 Contractions become more expulsive as pressure is exerted on rectum and pelvic floor
 The mother feels an urge to push.
Soft Tissue Displacement

 As the fetal head descends, the soft tissue of the pelvis becomes displaced.
 Anteriorly, the bladder is pushed upwards into the abdomen where it is at less risk to
injury during fetal descent
 Posteriorly, the rectum becomes flatted into the sacral curve and the pressure of the
advancing head expels any residual fecal matter
 The lavetor ani muscles dilate, thin out and are displaced laterally and the perineal body is
flatted, stretched and thinned.
 The fetal head becomes visible at the vulva, advancing with each contraction and
receding during the resting phase until crowning occur
 The shoulders and body follow with the next contraction.
Step 4: Signs and Symptoms of the Second Stage of Labour (5 minutes)

Presumptive signs
 Expulsive uterine contractions
It is possible for a woman to feel strong desire to push before the cervix is fully
dilated especially if the fetus is in occipitoposterior position, full rectum or the woman
is higher porous.
 Rupture of forewaters
This may occur at any time during labour
 Dilatation and gapping of the anus
Deep engagement of presenting part may produce this during the later part of the first
stage.

 Appearance of the presenting part
o Excessive molding may result in the formation of large caput succedaneum which can
protrude through the cervix prior to full dilatation
o Similarly, a breech presentation may be visible when the cervical os is only 7 to 8 cm
dilated.
 Show
o This is the loss of blood stained mucous which often accompanies rapid dilatation of
the cervical os towards the end of the1st stage of labour
o It must be distinguished from frank fresh blood loss caused by partial separation of
the placenta.
 Congestion of the vulva
Premature pushing may also cause this.
Confirmatory Evidence (positive signs)

This is only available when no cervical rim can be felt on vaginal examination.
Step 5: Duration of Second Stage of Labour (5 minutes)
 The exact duration of this stage is still uncertain

 However, the second stage is considered to be prolonged if the fetal head has not
descended onto the pelvic floor after 2 hours of dilatation or if delivery has not taken
place after 45 minutes of pushing in a primigravida or 30 minutes of pushing in a
multipara.
 Two phases in the progress may be recognized as follow:
o Latent phase
 It begins at full cervical dilatation, although the presenting part may not yet have
reached the pelvic floor
 The woman may experience little expulsive urge until the head has descended
sufficiently to exert pressure on the rectum and perineal tissues
 Passive descent of the fetus can continue with good midwifery support until the
head is visible at the vulva.
o Active phase
 Once the fetal head is visible, the woman will experience a compulsive urge to
push
Step 6: Mechanism of Normal Labour (25 minutes)

DIVIDE students in medium sized manageable groups
DEMONSTRATE to the students on the mechanism of normal labour using doll and pelvis
models
ALLOW one student from each group to do a return demonstration and let other students
comment on it.
ENCOURAGE students to practice in skills laboratory

Definition
 Mechanism of labour is a series of passive movement of the fetus through the birth canal
 Knowledge and recognition of normal mechanism enable the midwife to anticipate the
next step the process of descent which in turn will dictate her conduct of the delivery
 Principles common to all mechanisms are;-
o Descent takes place throughout
o Whichever part leads and first meets the resistance from the pelvic floor should rotate
forward until it comes under the symphysis pubis
o Whichever pert emerge from the pelvis will pivot around the pubic bone
o At the onset of labour, the most common presentation is vertex and the most common
position is left or right occipitoanterior
o Mechanism is described in the following instance:
 The lie is longitudinal
 The presentation is cephalic
 The position is right or left occipitoanterior
 The attitude is one of good flexion
 The denominator is the occiput
 The presenting part is the posterior part of the anterior parietal bone
Main Movements
 Descent:
o descent of the fetal head into the pelvis often begins before onset of labour
o For a primigravida, this usually occurs during the later weeks of pregnancy
o In multigravida, descent and engagement of the fetal head may not occur until labour
begins.
 Flexion:
o This increases throughout labour.
o At the onset of labour, the suboccipitofrontal diameter 10 cm is presenting
o With greater flexion, the suboccipitobregmatic diameter 9.5 cm presents
o The occiput becomes the leading part.
 Internal rotation of the head:
o During a contraction, the leading part is pushed downwards onto the pelvic floor.
o The resistance of the pelvic diaphragm brings about rotation
o In a well flexed vertex, the occiput leads and meets the pelvic floor first, and rotates
anteriorly through 1/8 of a circle until it comes under the symphysis pubis.
 Crowning:
o The occiput slips beneath the subpubic arch and crowning occurs when the head no
longer recedes between contraction and the widest diameter (biparietal) is born.
o The subocipitobregmatic diameter 9.5 cm distends the vaginal orifice.
 Extension of the head:
o Once crowning has occurred, the fetal head can extend, pivoting on the subocipital
region around the pubic bone
o Sinciput, face and chin sweep the perineum and they are born by movement of
extension.
 Restitution:
o The twist in the neck of the fetus which resulted from internal rotation is now
corrected
o The occiput rotates 1/8 of the circle towards the side from which it started.

 Internal rotation of the shoulders:
o The shoulders undergo the similar rotation to that of the head
o The anterior shoulder is the first to reach the pelvic floor, and rotates anteriorly to lie
under the symphysis pubis.
 External rotation of the head:
o It accompanies the internal rotation of the shoulders
o It occurs in the same direction as restitution and the occiput now lies laterally.
 Lateral flexion:
o The anterior shoulder slips beneath the sub-pubic arch and the posterior shoulder
passes over the perineum
o The body is born by lateral flexion as the spine bends sideway through the birth canal.
Step 7: Management of the Woman during the Second Stage of Labour

(60 minutes)
Communication and Attendance

 Never leave the woman alone during the second stage
 Focus on woman; look for none verbal cues of her needs and preferences
 Use and expect minimal verbal interaction. Be direct and clear.
 Give her verbal encouragement and praise.
 Provide continue information and reassurance about her progress and the wellbeing of the
baby
 Never give false promises
 Encourage birth companion in support of the woman (if possible)
Rest, Activity and Position

 Allow the woman freedom to choose from a variety of positions while guiding her find a
position that eases her discomfort and promotes labour.
 Assist her in relaxing between contractions to conserve energy
 If a position is tiring, assist the woman in changing position to facilitate progress and to
provide some relieve of discomfort
 Encourage position changes e.g. sitting, squatting, side lying, hands and knees.
Comfort
 Lightly massage or rub her back as she desires
 Apply lower back pressure to relieve back pain
 Stretch legs out and flex foot upwards to relieve muscle cramps in legs and foot
 Provide cool cloth for the face and chest as she desires
 Continue to coach her to breathe during contractions until she has the urge to push, and
then coach her to push when she has the urge, acknowledging her good efforts.
 Do not encourage her to push when she has no urge nor to sustain pushing longer than she
desires.
Nutrition
 Offer sips of cool sweetened fluids between contractions

Assisting in Normal Birth
DIVIDE students in medium sized manageable groups.
DEMONSTRATE to students on how to conduct a delivery using he child birth model
Refer students to Checklist: Assisting normal birth
ALLOW one student from each group to do a return demonstration and let others comment
on it
ENCOURAGE students to practice more until they become competent
 Once the cervix is fully dilated and the woman is in second stage, encourage the woman
to assume the position she prefers and encourage her to push when the urge is felt.
 Continually assess the speed at which the baby is descending through the birth canal
 Have the woman continue spontaneous bearing down efforts until the baby’s head crowns
 Coach the woman to push and/or breathe so that the birth of the head will be slow, steady
and controlled.
 If the baby is coming fast, help the woman stop pushing by asking her to blow repeatedly
or breathe steadily which make it easier to refrain from pushing.
 Birth of the head
o Clean the woman’s perineum with antiseptic solution
o Ask the woman to pant or give only small pushes with contractions as the baby’s head
is born
o As the pressure of the head thins out the perineum, one way to control the birth of the
head is with fingers of one hand applying a firm gentle downward (but not restrictive)
pressure to maintain flexion, allow natural stretching of perineal tissues and prevent
tears.
o Use the other hand to support the perineum using a compressor or cloth and allow the
head to crown slowly and be born spontaneously
o Do not manipulate the labia or perineum over the baby’s head because this increases
the risk of tears.
o Wipe the mucus from the baby’s mouth and nose with clean swab
o Feel around the baby’s neck to ensure that the umbilical cord is not around it
 If the cord is around the neck but loose, slip it over the baby’s head
 If the cord is loose but cannot reach over the head, slip it backward over the
shoulders
 If the cord is tight around the neck, tie or clamp a cord in two places 2 cm apart
and
cut the cord between the ties/clamps
 Unwind the cord from around the baby’s neck and proceed

 Delivery of the shoulders
o Restitution and external rotation of the head must occur in order to deliver the
shoulders safely and avoid the perineal lacerations
 Allow the baby’s head to turn spontaneously
 After the head turns, place a hand on each side of the baby’s head over the ears,
avoiding pressure around the neck.
 Advice the woman to push gently with the next contraction
 Then, apply slow gentle pressure downward and outwards until the anterior
shoulder slips under the pubic bone (figure below).
 When the axilla is seen, guide the head upwards towards the woman’s abdomen as
the posterior shoulder is born over the perineum
 Support the baby’s head with one hand and the rest of the baby’s body with the
other hand as it is slides out and place the baby on the woman’s abdomen
Figures3.5 : (A – F) Illustration of the Second Stage of Labour
Source: http//www.pub.com/content/army medical
Immediate Care of the Newborn Baby

 After placing the baby on the woman’s abdomen
 Thoroughly dry the baby and cover with clean and dry cloth, while wiping the baby’s
eyes and assessing the general condition of the baby (Apgar score).
o If the baby does not start breathing immediately, start newborn resuscitation
o If the baby is crying or breathing, leave the baby with the woman
 Clamp the umbilical cord in two places and cut between the clamps
 Ensure that the baby is kept warm (skin to skin contact with the woman’s chest) and
encourage breast feeding.

 Cover the baby with a cloth or blanket, ensure that the head is covered to prevent heat
loss
 Palpate the abdomen to rule out the presence of an additional baby and proceed with
active management of the third stage of labour.
 The second stage of labour is that of expulsion of the fetus. It begins when the cervix is
fully dilated and is complete when the baby is completely born.
 Two phases in the progress may be recognized as latent and active phase.
 Mechanism of labour is a series of passive movement of the fetus through the birth canal.
 At the onset of labour, the most common presentation is vertex and the most common
position is left or right occipitoanterior
 Once the cervix is fully dilated and the woman is in second stage, encourage the woman
to assume the position she prefers and encourage her to push when the urge is felt
 If the baby is coming fast, help the woman stop pushing by asking her to blow repeatedly
or breathe steadily which make it easier to refrain from pushing
 Outline the signs of second stage of labour

 How long does the second stage take to a primigravida woman?
 Outline the common principles to all mechanisms
 Outline main movements taken during the mechanism of labour.
References
Mosby.

Session 23: Management of the Third and Fourth
Stages of Labour
Prerequisites
 None
Learning Tasks
 Explain Physiological changes In the third stage of labour
 Explain active management of third stage of labour
 Describe examination of the placenta
 Explain fourth stage of labour
Resources Needed
 Projector
 Computer
 Models
 Check list
SESSION OVERVIEW
1 5 minutes Presentation Presentation of Session Title and Learning

Tasks
2 20 minutes Presentation Physiological Changes in the Third Stage of
Labour
3 40 minutes Presentation/ Active Management of the Third Stage of
Demonstration Labour
4 30 minutes Presentation/ Examination of the Placenta
Demonstration
5 15 minutes Presentation Management of the Fourth Stage of Labour

162
Level 5, Semester 1 Session 23: Management of the Third and
Fourth Stages of Labour
SESSION CONTENT
Step 2: Physiological Changes in the Third Stage of Labour (20 minutes)
Definition
The third stage of labour is that of separation and expulsion of placenta and membranes
and also involves the control of bleeding. It lasts from the birth of the baby until the
placenta and membranes have been expelled.
Physiology of the third stage

During this stage, separation and expulsion of placenta and membranes occur as the
results of mechanical and haemostatic factors.
Mechanical Factors
 The unique characteristic of uterine muscles still lies on the retraction, thus by the
beginning of the third stage, the placenta has already began to diminish in size
 The placenta itself becomes squeezed and the blood in the intervillous spaces is forced
back into the spongy layer of the deciduas.
 Retraction of the oblique uterine muscle fibers exerts pressure on the blood vessels so
that blood does not drain back into the maternal system.
 The vessels during this process become tense and congested
 With the next contraction, the distended vessels burst and a small amount of blood sips
in between the spongy layer and the placental surface stripping it from its attachment
 As the surface area of the placental attachment reduces, the non-elastic placenta begins
to detach from the uterine wall.
 Separation usually begins centrally so that a retroplacental clot is formed
 The weight of this clot may further aid the separation
 The increased weight also helps to peel the membranes off the uterine wall
 This process of separation was first described by Schultze (see figure below) and is
associated with more complete shearing of both placenta and membranes and less fluid
blood loss.
 Alternatively, the placenta may begin to detach unevenly at one of its lateral borders.
 The blood escapes so that the separation is unaided by the formation of the
retroplacental clot.
 The placenta descends slipping sideways maternal surface first
 This process (first described by Mathews Duncan) takes longer and is associated with
rugged incomplete expulsion of the membranes and higher fluid blood loss (see figure
below)

163
Figure 3.6: Placental separation
Source: http://www.tpub.com/content/army/medical
Homeostasis
 The normal volume of blood flow through the placental site is 500 – 800 ml per minute
 At placental separation this has to be arrested within seconds or serious hemorrhage
will occur. The three factors within the normal physiological processes that control
bleeding are:
o Retraction of oblique uterine muscle fibers in the upper uterine segment through
which the tortuous blood vessels intertwine, the resultant thickening of the muscles
exert pressure on the torn muscles acting as clamps so securing a ligature action.
o The presence of vigorous uterine contractions following separation brings the
uterine walls into opposition so that further pressure is exerted on the placental site.
o There is a transitory activation of the coagulation and fibrinolytic systems during
and immediately following placenta separation. This protective response is
especially active at the placental site so that clot formation in the torn vessels is
intensified.
Signs of Placenta Separation

 The uterus rises upward in the abdomen
 As the placenta moves downward, the umbilical cord lengthens
 A sudden trickle or spurt of blood appears
 Uterus becomes globular in shape and firmer
Step 3: Active Management of Third Stage of Labour (40 minutes)

Importance of Active Management of Third Stage of Labour
 Will prevent up to 60% of uterine atony
 Decreases length of third stage, so placenta delivery is approximately 5 to 7 minutes
 Decrease prolonged third stage; if a woman has a prolonged third stage (30 minutes)
she has a 6 times greater chance of having post partum haemorrhage (PPH)
 Decreases the average blood loss

164
 Decreases the number of cases of PPH
 Decreases need for blood transfusion
Steps of Active Management of Third Stage of Labour

 Give 10 International units (IU) of oxytocin intramuscular (IM) within one minute of
birth of the baby after excluding an additional fetus. If not available, give Ergometrine
or Misoprosol
 Assist delivery of the placenta by controlled cord traction while supporting the
contracted uterus
 Massage the uterus immediately after delivery of the placenta
DEMONSTRATE to students on how to conduct active management of third stage using the
child birth model
on it

Performing Active Management of Third Stage of Labour
 Within 1 minute of birth, palpate the abdomen to rule out the presence of an another
baby/babies) and give oxytocin 10 IU, IM.
 Perform controlled cord traction
o Clamp the cord close to the perineum. Hold the clamped cord at the end of the
clamp in one hand
o Place the other hand just above the pubic bone and apply counter traction to
stabilize the uterus and prevent uterine inversion
o Keep light tension on the cord and await a strong contraction (2 – 3 minutes)
o When the uterus becomes rounded or the cord lengthens, very gently pull
downward on the cord to deliver the placenta.
o Do not jerk on the cord or pull on it between contractions. Do not wait for a gush
of blood before applying traction on the cord.
o Continue to apply counter traction (push upward on the uterus) with the other hand
 If the placenta does not descend during 30-40 seconds of controlled traction,
relax the tension and repeat with the next contraction
 If the placenta does not deliver in 30 minutes, immediately report to the in-
charge for further management.
o As the placenta delivers, hold it with both hands and twist it slowly so that the
membranes are expelled intact
o If membranes do not slip spontaneously, gently twist them into a rope and move
them up and down to assist separation without tearing them
o If the cord is pulled off, immediately report to the in-charge for further management
o Rapidly inspect the placenta, cord and membranes for general completeness
o Inspect the vagina and perineum for tears

165
Massage the Uterus
 Immediately, massage the uterus through the woman’s abdomen until it is contracted.
Show the woman how to massage her fundus to maintain contraction.
 Repeat uterine massage every 15 minutes for the 1st two hours
 Ensure that, the uterus does not become relaxed after you stop uterine massage
 Inspect the vagina and perineum for tears
 Gently cleanse the perineum
 Apply a clean pad
 Remove all wet and soiled bed linen
 Ensure the woman is comfortable and cover her with a blanket
 Help initiate breast feeding
Step 4: Examination of the Placenta (30 minutes)
DEMONSTRATE to students on how to examine the placenta
on it
Refer students to Hand Out 23.1: Examination of the placenta
 The examination of the placenta and membranes is performed as soon after delivery as
possible check for their completeness.
 The midwife should make every attempt to piece the membranes together to get the
overall picture of completeness.
 Assess membranes, hold the placenta by the cord and allow the membranes to hang.
Identify the hole through which the baby was delivered and spread hand out inside the
membranes to aid inspection.
 After that, lay the placenta on a flat surface and under good lighting minutely examine
both placental surfaces.
 Peal the amnion from the chorion right up to the umbilical cord to fully view the chorion.
 During the examination of the placenta, any clots on the maternal surface should be
removed and kept for measurement.
 Broken cotyledon must be carefully replaced before an accurate examination is possible.
 Recent infarction looks bright red, old infarction forms grey patches whereas localized
calcification can be seen as flattened white plaques feeling gritty to touch.
 Normally, lobes are neatly fitted and edges forms uniform circle. Blood vessels should
not radiate beyond the edges of the placenta, otherwise denote succenturiate lobe. If this
lobe has retained, you will see the tissue abruptly ending at a hole in the membrane.
 On the fetal surface, note the position of the insertion of the cord.

166
 Normally, two umbilical arteries and one vein are present, therefore absence of one or
more of these mean congenital fetal abnormality, particularly renal agenesis.
 Placenta is also weighed; its weight may vary depending on the time of clamping. In
early clamping, there is an increase of one fifth of the baby’s weight whereas in a delayed
clamping, placenta weigh approximately one sixth of the baby’s birth weight.
 Disposal of the placenta is done in respect of the mother’s choice; however that choice
must not be against healthy way of handling the placenta. (See appendix)
Record the Following Information

 Time the placenta is delivered.
 Method of placenta delivery
 Type, amount, time and route of administration of oxytocin.
 If the placenta is delivered complete and intact or in fragments.
Step 5: Care of a Woman During Fourth Stage of Labour (15 minutes)

 The fourth stage of labor is the period from the delivery of the placenta until the uterus
remains firm on its own
 This is usually a 1 to 2 hours period. In this stabilization phase, the uterus makes its
initial readjustment to the non pregnant state
 The primary goal is to prevent hemorrhage from the uterine atony and the cervical or
vaginal lacerations.
Management
 The midwife should attend the woman, check vital signs: Blood Pressure, Pulse and
Respiration every 15 minutes for an hour, then every 30 minutes for the next hour.
 Care of the perineum and apply clean perineal pad between the legs and change
accordingly.
 Ensure that the woman and baby has enough blankets to maintain warmth
 Maintain calm environment conducive to rest for the woman to facilitate bonding with
her baby and initiation of breastfeeding.
 Encourage early and exclusive breast feeding
 Encourage the woman to eat and drink as she desires
 Encourage the woman to pass urine when the urge is felt, or if bladder is palpable, as a
full bladder may actually cause postpartum hemorrhage because it prevents the uterus
from contracting appropriately.
 Evaluate fundal height from the umbilicus to the symphysis pubis using tape measure.
The fundus should remain in the midline. If it deviates from the middle, identify this and
evaluate for distended bladder.
 Massage the fundus every 15 minutes during the first hour, every 30 minutes during the
next hour.
 Ensure emergency equipments are available in the recovery room or post natal ward for
possible complications.
 Observe the mother for chills. The cause of the mother being chilled following birth is
unknown. However, it refers primarily to the result of circulatory changes after delivery.
The best means of relief is to cover the mother with a warm blanket.

167
 Transfer the patient to the recovery room or postnatal ward, this is done after cleaning the
woman and dressing a clean gown on the patient, obtaining a complete set of vital signs,
evaluating the fundal height and firmness, and the lochia.
 Record all findings and report any abnormality detected
 The separation and expulsion of placenta and membranes occur as the results of
mechanical and haemostatic factors.
 Never apply cord traction without applying counter-traction above the pubic bone with
the other hand
 As the placenta delivers, hold it with both hands and twist it slowly so that the
membranes are expelled intact
 Massage or pressure to the fundus before the placenta delivers is dangerous, it can
cause partial separation of the placenta
 The examination of the placenta is performed as soon after delivery as possible so as to
get information that may be important to the care of both mother and infant
 The fourth stage of labour is concerned with the immediate observation and care to the
woman and fetus within the first 1 to 2 hours post delivery.
 What is the purpose of the active management of the third stage of labour?
 What are the steps of the active management of the third stage of labour?
 Explain two methods of placenta separation
References
Mosby.

168
Handout 23.1: Examination of the Placenta
 The examination of the placenta is performed as soon after delivery as possible so as to get
information that may be important to the care of both mother and infant.
 During the examination, the size, shape, consistency and completeness of the placenta should
be determined, and the presence of accessory lobes, placental infarcts, hemorrhage, tumors
and nodules should be noted
 The umbilical cord should be assessed for length, insertion, and number of vessels,
thromboses, knots and the presence of Wharton's jelly
 The color, luster and odor of the fetal membranes should be evaluated, and the membranes
should be examined for the presence of large (velamentous) vessels.
 Tissue may be retained because of abnormal lobation of the placenta or because of placenta
accreta, placenta increta or placenta percreta
 Numerous common and uncommon findings of the placenta, umbilical cord and membranes
are associated with abnormal fetal development and perinatal morbidity
 The placenta should be submitted for pathologic evaluation if an abnormality is detected or
certain indications are present
 The findings of this assessment should be documented in the delivery records.
 Most of the time, membranes are the most difficult to examine as they become torn during
delivery and may be raged
 The midwife should make every attempt to piece the membranes together to get the overall
picture of completeness
 To assess membranes, hold the placenta by the cord and allow the membranes to hang.
Identify the hole through which the baby was delivered and spread hand out inside the
membranes to aid inspection.
 After that, lay the placenta on a flat surface and under good lighting minutely examine both
placental surfaces. Peal the amnion from the chorion right up to the umbilical cord to fully
view the chorion.
 During the examination of the placenta, any clots on the maternal surface should be removed
and kept for measurement
 Broken cotyledon must be carefully replaced before an accurate examination is possible.
 Recent infarction looks bright red, old infarction forms grey patches whereas localized
calcification can be seen as flattened white plaques feeling gritty to touch
 However, at this stage none of these is of great significance other than providing retrospective
evidence of intrauterine problems.
 Normally, lobes are neatly fitted and edges forms uniform circle
 Blood vessels should not radiate beyond the edges of the placenta, otherwise denote
succenturiate lobe. If this lobe has retained, you will see the tissue abruptly ending at a hole
in the membrane.
 On the fetal surface, note the position of the insertion of the cord
 Normally, two umbilical arteries and one vein are present, therefore absence of one or more
of these mean congenital fetal abnormality, particularly renal agenesis
 Placenta is also weighed; its weight may vary depending on the time of clamping. In early
clamping, there is an increase of one fifth of the baby’s weight whereas in a delayed
clamping, placenta weigh approximately one sixth of the baby’s birth weight
 An average length of the cord is 50 cm.
 Disposal of the placenta is done in respect of the mother’s choice; however that choice must
not be against healthy way of handling the placenta.

169
Session 24: Management of a Woman with Normal
Puerperium
Prerequisites
 None
Learning Tasks
 Explain the Physiology of normal purperium
 Explain the Management during normal puerperium
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
2 50 minutes Presentation/ Physiology of Normal Puerperium

Group discussion
3 55 minutes Presentation Management of Normal Puerperium
SESSION CONTENT
NMT 05114 Community Health Nursing I

NTA Level 5, Semester 1 170 Session 24: Management of a Woman
with Normal Puerperium
Step 2: Physiology of Normal Puerperium (50 minutes)
Definition
Puerperium is the period of 6 weeks which begins as soon as the placenta is expelled, during
this time a number of physiological changes take place which includes:
 The reproductive organs return to their non pregnant state
 Other physiological changes which occurred during pregnancy are reversed
 Lactation is initiated
 The foundation of the relationship between the infant and his parents are laid
 The mother recovers from the stresses of pregnancy and delivery and assumes
responsibility for the care and nurture of her infant
Physiology of Puerperium
 Changes in endocrine activity
o Oxytocin
 Oxytocin is secreted by posterior pituitary and acts upon uterine muscles and
breast tissue
 During the third stage of labour the action of oxytocin is to stimulate contraction
of the uterus which helps in separation of the placenta. It then continues to act
upon the uterine muscles maintaining their contraction
o During breast feeding the suckling of the infant stimulates further secretion of
oxytocin and this aids the continuing involution of the uterus and expulsion of milk.
o Prolactin
 The fall of oestrogen allows prolactin which is secreted by the anterior pituitary
gland to act upon the alveoli of the breast to stimulate the production of milk.
 The fall in oestrogen and progesterone brings about several other physiological
changes:
 Pelvic floor perineum, vagina, vulva and bowel
o The fall in circulating progesterone allows its effect upon the smooth muscle fibers of
the pelvic floor, perineum, vagina, vulva and bowel to be reversed
o This process aids the recovery of normal muscle tone in these areas
o This is a gradual process which is aided by early ambulation, postnatal exercises and
avoidance of constipation.
 Bladder urethra and ureters
o The effect of progesterone diminishes after delivery of the placenta but many women
remain prone to urinary tract infection during the first weeks of puerperium
o During labour the bladder is displaced into the abdomen, stretching of the urethra and
this frequently leads to bruising of the urethra and loss of muscle tone of the bladder
o The bruising of the urethra makes micturition painful and the bladder easily become
over distended, retention of urine may occur.
 The cardiovascular system
o The withdrawal of oestrogen allows a diuresis to take place reducing the plasma
volume to normal proportions within the first 24 – 48 hours following the birth of the
baby, during this period the woman pass large amount of urine.
 The kidneys
o Renal action is increased in early part of puerperium because of reduction of blood
volume and excretion of waste products of autolysis
o This occurs within the first 7 days of puerperium

 The breasts
o The rise in circulating prolactin acts upon the alveoli of the breasts and stimulate milk
production
o During the first 3 to 4 days of puerperium the breast become heavy and engorged,
they are tender and must be handled gently
o Engorgement is reduced as the baby continues to suckle
o In women who do not breast feed engorgement is gradual reduced by the fall in
prolactin which occurs when its secretion is no longer stimulated by suckling
 The involution of the uterus
o At the completion of labour the uterus weighs almost 1 kilograms, and by the end of
the puerperium it has returned to its non pregnant weight of 60 grams
o This physiological phenomenon is brought about by the process known as autolysis
during which proteolytic enzymes digest the muscle fibres which have increased
during pregnancy to 10 times their normal length and 5 times their normal thickness.
o The end products of autolysis are removed by the phagositic action of ploymorphs
and macrophages in the blood lymphatic system.
o This process is further assisted by the contraction and retraction of the uterine muscles
under the influence of oxytocin.
o The most marked reduction occurs in the 1st 10 days of puerperium and is complete
six weeks later.
o Immediately after delivery the fundus is at or just below the mother’s umbilicus, one
week after delivery it is palpable just above the symphysis pubis and by the 10th or
12th day it is no longer palpable
 The Lochia
o Lochia is the term used to describe the discharges from the uterus during the
puerperium.
o The lochia undergoes sequential changes as involution progresses as follows
 Red lochia (lochia rubra) it is the name given to the lochia during the first 3 to 4
days of puerperium. It is red in colour and consists of blood from the placental site
and debris arising from the deciduas and chorion.
 Serous lochia (lochia serosa) it is pinkish, yellowish or pale brownish in colour, it
is discharged from 5th to 9th day and contains leucocytes, wound exudates, mucus
from cervix and micro organisms.
 White lochia (lochia alba). It is paler creamy- brown in colour and contains
leucocytes, cervical mucus and debris from healing tissue. Some evidence of
blood may continue to be seen for a further 2 or 3 weeks.
 The puerperium is a time of transition during which both parents but especially the
mother adjust their pattern of leaving to meet the needs of a small infant
 Many women have little or no experience of caring for a new born infant and may feel
overwhelmed by the responsibility
 They will be very sensitive to any suggestion that they are not copying, and are easily
confused and distressed by conflicting or ill considered advice.
 The midwife should provide help, encouragement and advice, and should praise he
mother for her effort both in her act of giving birth and in mothering her infant

Maternal Child Relationship
 Maternal attachment of the mother to her baby begins during pregnancy and birth is the
transition period to the motherhood
 Maternal/ child relationship begins following delivery of the baby and develop rapidly
during the puerperium. The mother and father should be left in peace with their baby to
rejoice in his birth and delight in his perfection.
 The role of the midwife is to facilitate positive parenting skills through support, education
and early recognition of problems which may indicate poor psychological adaptation.
This is especially important in young women or women whose pregnancies were
unplanned/unwanted (e.g. sexual assault,forced marriages).
 Close physical and eye contacts should be encouraged throughout the puerperium. Eye
contact between mother and baby is achieved when the baby is held in the- en face
position in her arms
Mood Changes
 With rapid changes occurring during the puerperium many women experience some
degree of mood changes during the first few days of puerperium and sometimes
tearfulness, anxiety and irritability which is usually called third day or baby blues’.
 Some women however this distress may last longer than usual and may indicate that the
woman needs more support and care than she is present receiving. It may also lead to
more prolonged period of emotional distress or depression.
 The role of the midwife is to provide the kind of consistent, kindly and relevant support
which each individual mother requires in order to recover from physical stress of labour
and to grow in confidence in caring for her baby
Step 3: Management of a Postnatal Woman (55 minutes)
Activity: Small group discussion
DIVIDE the students in small manageable groups - students to discuss in their groups
management of a woman during puerperium
ALLOW them write their responses on flip charts and present their work
CLARIFY and summarize using the information below.
 The care given to the mother and baby is based on three principles:
o Promoting the physical well being of the mother and baby
o Encouraging proper methods of feeding of infant and promoting the development of
maternal – child relationship
o Supporting and strengthening the mother’s confidence in her and enabling her to
fulfill her mothering role within her particular personal family and cultural situation.
Daily Examination
 General well being
o The mother should be greeted and asked how she is feeling, the midwife should take
particular note if the mother complains of not feeling well.
o Any woman who is developing an infection or who is anaemic will not feel well

 Vital signs
o Temperature, pulse and blood pressure should be checked
o Temperature may rise as a result of engorged breasts but should not exceed 37.3
degrees
o The pulse rate is normally at or belows 80 beats/minute, any rise in pulse may indicate
excessive bleeding or developing puerperal infection.
o Blood pressure is checked during the first 24 hours following a normal delivery and
for a longer period if there has been history of bleeding, hypertension or the mother
has had caesarean section.
 Breasts
o A complete breast examination should be performed
 The uterus
o The abdomen should be palpated daily; the uterus should be well contracted and not
painful
o Sub involution is identified if the uterus remains the same size for several days,
tenderness of the uterus suggests infection
o Bladder should be empted prior to examination.
o Perineum, vulva and anus
o The perineum, vulva and anus should be inspected to ensure that any trauma is
healing satisfactory the midwife should ensure that vulva pads are changed frequently.
 The lochia
o The character and amount of lochia are noted and the midwife should expect to see
gradual Change in the colour and amount of the lochia as the puerperium progresses.
 The legs
o The mother’s legs should be examined for any tenderness which may suggest
thrombosis of the superficial veins. Thrombophlebitis of superficial veins is
characterized by swelling, hardness and redness of the affected veins.
o Deep vein thrombosis which may predispose to pulmonary thrombosis should be
suspected if there is any tenderness on working or when he deep veins of the calf of
the leg are pressed.
Promoting Physical and Emotional Well-being

 Prevention of infection
o Puerperal infection is one of the five of maternal deaths it must be prevented by strict
infection prevention practices throughout pregnancy, labour and post partum
o The uterus provides an ideal environment for multiplication of organisms,any degree
of trauma will increase the tendency for development of infection.
o Possible foci of puerperal infection are:
 Breast infection
 Infection of genital tract
 Infection of urinary tract
 Upper respiratory infection.
o Infection can be prevented by careful attention to the mother’s hygiene,
encouragement of drainage by early ambulation and by the prevention of cross
infection.
o The mother’s hygiene is maintained by; daily shower or bath, vulval toilet, vulval
pads should be changed frequently, the woman should be advised not to contaminate
the vulva and perineum with organisms from the anus when changing pad.
o Midwives should wear gloves when handling pads and should maintain aseptic
technique when applying any treatment.
 Ambulation and exercises
o Ambulation increases muscle tone and venous return from the legs and lower
abdomen, it also increases drainage of lochia and voiding of urine
o Ambulation should be encouraged as soon as possible after delivery
o Mothers are encouraged to walk around not just sit by the bed side.
o Post natal exercises help increase muscle tone and are usually commenced during the
first three days of delivery.
 Rest and sleep
o Ensuring adequate rest and sleep is a vital part of post natal care, the healing of
trauma and emotional well being is aided by physical rest and sufficient sleep
o When he woman returns home the need for adequate rest should be emphasized and
the family encouraged to take over the care of the baby for a period of time each day
to allow the mother to rest.
 Care of the breasts
o The breasts should be well supported
o Engorgement if present may be relieved by expressing small quantities of milk and
breast feeding the baby. Discomfort may be relieved by the use of paracetamol and
providing firm support.
 Nutrition
o The diet of a puerperal woman should be nourishing, balanced and varied
o It should include adequate protein to aid tissue renewal and milk production, iron and
vitamins to counteract anaemia, fibre to aid excretion and plenty of fluids.
 Prevention of anaemia
o Any degree of anaemia will reduce the body resistance to infection and its capacity of
healing. Therefore any degree of anaemia should be identified and reported for
treatment.
 Follow up visits
o The postnatal mother should be followed up in the post natal clinic on the 7th day, 28th
day and at 6 weeks.
 Puerperium is the period of 6 weeks which begins as soon as the placenta is expelled
during this time a number of physiological changes takes place:
 During breast feeding the suckling of the infant stimulates further secretion of oxytocin
and this aids the continuing involution of the uterus and expulsion of milk.
 Maternal - child relationship begins following birth of the baby and develop rapidly
during the puerperium. The mother and father should be left in peace with their baby to
rejoice in his birth and delight in his perfection
 Purperal infection can be prevented by careful attention to the mother’s hygiene,
encouragement of early ambulation increases muscle tone and venous return from the legs
and lower abdomen, it also increases drainage of lochia and voiding of urine.
 Explain the principles of care in the management of a woman during the puerperium.
 What is included in the daily examination of a post natal mother.
 How is infection prevented during the postnatal period.

References
Venes, D., Thomas, C. L., & Taber, C. W. (2001). Taber’s cyclopedia medical dictionary
(19th ed.). Philadelphia: F. A. Davis.

Session 25: Safe Pharmacological Substances during
Pregnancy, Birth and Breastfeeding
Prerequisites
 None
Learning Tasks
 List pharmaceutical substances restricted in pregnancy
 Explain the Management of ADR during pregnancy
 List pharmaceutical substances used during Pregnancy and labour
SESSION OVERVIEW
1 5 minutes Lecture Presentation of Session Title and Related

Tasks
2 10 minutes Individual Exercise Pharmacological Substances Restricted in
on Filling of the Pregnancy
Partograph
3 10 minutes Lecture/Discussion Management of Adverse Drug Reaction
(ADR) during pregnancy
4 25 minutes Lecture/Discussion Pharmacological Substances Used During
Pregnancy and Labour
5 5 minutes Questions/Answers Key Points
SESSION CONTENT

NTA Level 5, Semester 1 177 Session 25: Safe Pharmacological
Substances during Pregnancy, Birth and
Breastfeeding
Step 2: Pharmacological Substances Restricted during Pregnancy
(15 minutes
TELL the students to pair up and mention pharmacological substances restricted during
pregnancy for 2 minutes
ALLOW few students to respond and let other pairs to provide unmentioned responses
Introduction
 A drug administered to a pregnant woman or abreast feeding mother will be present in the
blood circulating around her body
 Drugs will pass across into the fetus or neonate in greater or lesser quantity depending on
the characteristics of the drug molecules
 Many drugs have adverse effects during pregnancy
 These vary depending on the stage of pregnancy. The effects are referred as “teratogen”
(a substance that causes physical defect in the developing embryo).
Table 1.3 Commonly used drugs that are Teratogens

Drug Effect
Lithium Cardiac defects
Warfarin Facial anomalies
CNS anomalies
Phentoin Craniofacial anomalies
Sodium valporate Neural tubes defects
Carbamazepine Craniofacial anomalies.
Neural tube defects
Retinoic acid derivatives Craniofacial, cardiac and CNS
anomalies
 Where possible, above drugs should be avoided in the first trimester.
Examples of antibiotics that can cause adverse effects in pregnancy

 Tetracyclines (tetracycline, oxytetracycline, doxycycline)
 A minoglycosides (gentamicin, netilmicin)
 Chloramphenicol
 Nitrofurantoin
 Quinolones (Ciprofloxacin, ofloxacin)
Step 3: Management of ADR during Pregnancy (10 Minutes)

Introduction
 Generally, drugs should not be administered to a woman during pregnancy unless the
potential benefit to the mother outweighs the risk to the fetus
 Drugs taken in pregnancy may not harm the mother but may still lead to disordered
development of the fetus especially during the first trimester.
Breastfeeding
Definition
 Adverse Drug Reaction can be defined as a response to a drug which is noxious,
unintended and occurs at doses used in humans for prophylaxis, diagnosis or therapy.
 The management of a woman with ADR includes the following key aspects;
o Maintenance of respiration; physical methods such as room with adequate ventilation
and fanning may be used.
o Maintain circulation by physical methods and drug treatment.
o Maintenance of body temperature by physical methods
o Maintenance of fluid and electrolyte levels in accordance with biochemical tests
o Remove of the poison (gastric lavage/emetics/active elimination)
o Inactivation of the poisons- the use of activated charcoal to absorb the poison
o Correction of metabolic complications such as metabolic acidosis
 If adverse drug reaction occurs in remote area the woman should be referred to hospital as
some poisons have specific antidotes.
 However it is clearly better to prevent Adverse Drug Reactions than to treat the symptom
of an ADR.
Prevention of ADR:
 Study/ evaluate published work; the clinical significance of ADR is not always apparent
 Adjust doses; avoid certain combinations
 Utilize skills of clinical pharmacist
 Improve communication between doctor/pharmacist/nurse/ and patient
 Ensure that information is communicated in a timely way on suspected defects in
specifications and quality of manufactured products.
Step 4: Pharmacological Substances Used during Labour (25 minutes)
ASK students to brainstorm on pharmacological substances used during pregnancy and

labour for 2 minutes
WRITE their response on the flip chart/board
Drugs Used During Pregnancy

Folic Acid
 It is a vitamin that is involved in the process of cell growth and division, folic acid
deficiency leads to maternal anaemia
 The recommended dose is 400mg daily, there are no risks associated with this dose.
 It is recommended that all pregnant women should take folic acid

Breastfeeding
Iron Preparations
 There are many preparations, ferrous sulphate or gluconate, some are combined with folic
acid
 Commonly experienced side effects are constipation ( occasionally diarrhea) and
indigestion
 Obsorbtion of iron is reduced by antacids and by some foods
Antacids
 Antacids are alkalis that act by reducing the acidity of stomach acid.
 Modern antacids are based on magnesium and aluminium salts which are relatively non
absorbable.
 They are safe to use in pregnancy
Antiemetics
 Women with mild morning sickness should be encouraged to use non pharmacological
methods in controlling nausea
 If vomiting is severe antiemetis should be used
 There are three main categories
o Antihistamins e.g.Cyclizine, common side effect is drowsinesy
o Anticholinergic drugs e.g.prochlorperazine may cause a side effect known as
‘dystonic’ reaction(uncontrolled spasms of muscles of face and neck)
o Antidopaminergic drugs e.g. metoclopramide, these may also cause dystonic reactions
Analgesics
 Many of the available analgesic preparations are not considered safe in pregnancy
 Paracetal
o It should be recomended as first line analgesic during pregnancy, over dose can be
dangerous to the mother and fetus, it causes liver damage
Antibiotics Considered Safe in Pregnancy

 Penicillins
o Benzyl penicillin
o Ampicillin
o Amoxillin
o Flucloxacillin
 Cephalosporins
o Cephradine, cephlaxen
o Cefuroxime, cephtaxime
o Erithromycin
o Trimethropin Avoid in first trimester
Drugs Used During Labour
Prostaglandins
 Are lipid molecules responsible for multiple physiological sub cellular reactions
 These can be administered by any route but have significant side – effects hen given
orally.

Breastfeeding
 Classifications/groups
o Prostaglandin E2
 Given by the vaginal route used for Induction of labour and have action on both
the cervix and the myometrium.
Misoprostol
 Misoprostol is a prostaglandin E analogue.
 It is used for cervical ripening and for management of PPH.
 Is administered vaginally
Prostaglandin F2a
 Is used to treat PPH
 Acts on the myometrium as a powerful contractile agent
 Can be given intramuscularly or Intra myometrially in cases of uterine atony.
Dangers of Prostaglandings
 These are very similar to those associated with oxytocin
o Hypertonic contractions
o Asphyxia of the fetus
o Injuries to the mother such as rupture of the uterus
Oxytocin
 Oxytocin is a naturally occurring hormone that exerts a stimulatory effect on myometrial
contractility.
 This can be given by any parenteral route.
 In labour it is generally given by intravenous infusion
 It takes 20 – 30 minutes for oxytocin to reach a steady state and the rate of Infusion of
oxytocin should therefore not be increased at time interval 30 minutes.
Side Effect/Dangers
 Maternal
o The major side effect of oxytocin is water retention and hyponatraemia which is
o relevant in women with pre eclampsia
o Rupture of the uterus
o Cervical and Vaginal lacerations due to atonic postpartum with PPH.
o Anoxia caused by over stimulation of the uterus.
 Fetus
o Brain damage because the fetus is delivered too quickly
o Hyper bilirubinaemia.
Ergometrine
 This is used in the treatment and prevention of postpartum haemorrhage it is a powerful
constrictor of smooth muscles.
 Can be given 0.5 mg combined with oxytocin 5IV/ml intramuscular for the third stage.
 Side Effects
o Nausea
o Vomiting
o Hypertension (it is contraindicated for women with pre-eclampsia)
o Route: Can be given intramuscularly or intravenously

Breastfeeding
 The session discusses management of ADR

 Appropriate use of uterotonics can save the life of mother and baby
 Outline drugs restricted during pregnancy

 Explain the side effects of uterotonic agents
 List antibiotic which are safe to use in pregnancy
 Many of the available analgesics are not considered safe in pregnancy
References
Venes, D., Thomas, C. L., & Taber, C. W. (2001). Taber’s cyclopedia medical dictionary
(19th ed.). Philadelphia: F. A. Davis.

Breastfeeding

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NMT 05111

United Republic of Tanzania

Overall Goal for training manual .......................................................................................................vi

Objectives for training manual...........................................................................................................vi

Module Overview .............................................................................................................................vii

Who is the Module For? ...................................................................................................................vii

How is the Module Organized? ........................................................................................................vii

How Should the Module be Used? ...................................................................................................vii

Session 2: Male and Female Reproductive Organs.......................................................................... 5

Session 3: Female Internal Reproductive Organs .......................................................................... 11

Session 4: Anatomy and Physiology of the Female Bony Pelvis............................................... 18

Session 5: Pelvic Diameters Related to Fetal Skull........................................................................ 25

Session 6: Law, Code of Conduct and Standards Guiding Midwifery....................................... 34

Session 7: Cultural and Social Issues ............................................................................................. 40

Session 8: Safe/Good Socio-Cultural Practices.............................................................................. 44

Session 9: Physiology of Pregnancy .............................................................................................. 47

Session 10: Placenta and Foetus....................................................................................................... 54

Session 11: Physiological Changes during Pregnancy..................................................................... 65

Session 12: Signs and Symptoms and Minor Disorders of Pregnancy.......................................... 74

Session 15: Concept and Elements of Focused Antenatal Care (FANC)...................................... 93

NMT 05111 Midwifery I NTA Level 5, Semester 1

Session 17: FANC Elements 5, 6 and 7 ......................................................................................... 110

Session 18: Physiology of Labour.................................................................................................. 119

Session 19: Use of Partograph in Managing Labour...................................................................... 126

Session 21: Management a Woman in First Stage of Labour ........................................................ 144

Session 22: Second Stage of Labour .............................................................................................. 154

Session 24: Management of a Woman with Normal Puerperium .................................................. 170

NMT 05111 Midwifery I NTA Level 5, Semester 1

These participants are listed with our gratitude below:

SN Name Title Institution

NMT 05111 Midwifery I NTA Level 5, Semester 1

Dr. Gozbert Mutahyabarwa

NMT 05111 Midwifery I NTA Level 5, Semester 1

NMT 05111 Midwifery I NTA Level 5, Semester 1

Goals and Objectives of the Training Manual

Overall Goal for training manual

Objectives for training manual

NMT 05111 Midwifery I NTA Level 5, Semester 1

Who is the Module For?

How is the Module Organized?

How Should the Module be Used?

NMT 05111 Midwifery I NTA Level 5, Semester 1

NMT 05111 Midwifery I NTA Level 5, Semester 1

Step Time Activity /Method Content

1 5 minutes Presentation Presentation of Session Title and Related

5 5 minutes Presentation Evaluation

Step 1: Presentation of the Session Title and Related Tasks (5 minutes)

READ or ASK students to read the Learning Task and clarify.

ASK Students if they have any questions before proceeding.

NMT 05111 Midwifery I

Step 3: Major Development in Midwifery (20 minutes)

Activity: Brainstorming (10 minutes)

DIVIDE students in small manageable groups

ALLOW few groups to respond

WRITE the responses on the board

CLARIFY and summarize using the information below

NMT 05111 Midwifery I

NMT 05111 Midwifery I

Step 5: Evaluation (5 minutes)

 List midwifery schools in Tanzania

NMT 05111 Midwifery I

Step Time Activity /Method Content

5 5 minutes Presentation Evaluation