CHAPTER 1

BLEEDING IN EARLY PREGNANCY

a. Abortions
b. Ectopic pregnancy
c. Molar pregnancy

Bleeding in early pregnancy: This is bleeding from the genital tract before the 24 weeks or
28weeks of pregnancy.
CAUSES OF BLEEDING IN EARLY PREGNANCY

1. Implantation bleeding
2. Abortion
3. Ectopic gestation
4. Hydatidiform mole
5. Incidental bleeding (extra-uterine)
I. Polyps
II. Cervical erosion
III. Carcinoma of cervix
IV. Trauma

IMPLANTATION BLEEDING
As the trophoblast erodes the endometrial epithelium and the blastocyst implants, a small vaginal
blood loss may be apparent to the woman. It occurs around the time of expected menstruation,
and may be mistaken for a period, although lighter. It is of significance if the estimated date of
delivery is to be calculated from menstrual history (Fraser & Cooper 2003).

ABORTION
Abortion can be defined as the termination or expulsion of the fetus either induced or
spontaneously before the 24th (28th) week of pregnancy. The term miscarriage is preferred when
referring to spontaneous abortion especially during history taking. 15% of all pregnancies
terminate as spontaneous abortion, the majority of these occurring between 8 th to 12th week when
the level of progesterone secreted by the corpus luteum falls and placenta hormone have not
reached a high level to sustain the conceptus.

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Causes
Fetal
Chromosomal abnormality
Mal-development of the fertilized ovum
Disease of the fertilized ovum
Malformation of the trophoblast
Poor implantation of the blastocyst

Maternal
Maternal age – the risk of abortion increases with advancing maternal age
Infections or disease accompanied by high fever may precipitate abortion e.g. Rubella,
influenza, malaria, pyelonephritis.
Chronic medical conditions e.g. Hypertension, diabetes, renal disease.
Excessive consumption of alcohol, coffee, cigarette, overexposure to cigarette smoke.
Hormonal imbalance
Drugs e.g. anaesthetic agents, herbs, cocaine, marijuana, cytotoxic drugs, organic solvents
Chemicals e.g. lead, organic solvents and radiation.
ABO / Rhesus incompatibility.
Extreme emotional stress such as hearing bad news, grief, fright, etc.
Extreme physical activities or trauma e.g. accidents, fights, assault, violent exercise and
vigorous intercourse.
Abnormal conditions of the uterus e.g. retroverted uterus, uterine fibroids, infantile or
bicornuate uterus
Cervical incompetence

Paternal
Chromosomal abnormalities
Drugs -cocaine, chemicals or radiation.

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 CLASSIFICATION OR TYPES OF ABORTION

ABORTION SEPTIC

SPONTANEOUS
INDUCED

Threatened Habitual or
recurrent
Therapeutic Criminal

May go to Inevitable Missed

term

Carneous mole
Incomplete Blood mole
Complete
abortion
abortion

SPONTANEOUS ABORTION (MISCARRIAGE)

This is the involuntary loss of the products of conception prior 24 weeks of pregnancy. This may
be group into the following
1. Threatened abortion
2. Inevitable abortion
3. Complete abortion
2. Incomplete abortion

THREATENED ABORTION
It is presumed that a pregnancy is threatening to abort when vaginal bleeding occurs before the
24th week.

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SIGNS AND SYMPTOMS

1. Lower abdominal pain is minimal or absent

2. Size of uterus corresponds with gestational age

3. Scanty vaginal bleeding

4. Uterus is soft and not tender on palpation.

5. Cervix is closed on speculum examination

6. 80% of threatened abortion may continue to term

Management of threatened abortion

1. Reassure client and husband to allay their anxiety.

2. Admit client and ensure bed rest with minimum of disturbance till bleeding stops.

3. All soiled perineal pad should be save to estimate the amount of blood loss and document,

4. Take blood sample for HB, mps, grouping and cross matching and
urine sample for pregnancy test and protein and acetone.

5. Take ultrasound for fetal viability and the gestational age.

6. Conduct abdominal examination for uterine growth and fetal movement.

7. Conduct speculum examination after bleeding to assess the state of the cervical os.

8. 48 hours after the bleeding ceases, encourage the client to ambulate to improve blood
circulation.

9. Check vital signs such as temperature, pulse, respiration and

blood pressure to be taken twice daily.

10. Assist client to maintain her personal hygiene e.g. bathing,

11. Vulva toileting to be done at least twice daily to prevent ascending infection.

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12. Serve client with nutritious diet rich in protein to improve haemoglobin level and high fiber
diet to prevent constipation.

13. Educate client to avoid strainous activities and prevent lighting heavy loads.

14. Administer a mild sedatives to aid in relaxation.

15. If she is hospitalized, she may return home 48hours after bleeding has stopped.

Education on discharge.

1. Counsel client on adequate rest at least 1-2 hours during the day and 8 hours at night

2. Avoid strenuous work e.g. lifting heavy objects.

3. Avoid sexual intercourse for at least 2 months.

4. Avoid strenuous exercises.

5. Taking high fiber diet to prevent constipation.

6. Counsel client to avoid enema.

7. To report back to hospital should bleeding re-occurs.

8. Counsel on regular antenatal attendant.

OUTCOME OF THREATENED ABORTION

✓ 70-80% may go to term

✓ Inevitable abortion
✓ Antepartum haemorrhage

INEVITABLE ABORTION

This is when it is impossible for the pregnancy to continue or go to term because a large section
of the placenta has been detached from the uterine wall. Inevitable abortion may be complete or
incomplete.

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SIGNS AND SYMPTOMS OF INEVITABLE ABORTION

1. Severe lower abdominal pain rhythmic in character

2. The membranes may rupture and amniotic fluid may be seen.

3. Heavy vaginal bleeding with clots

4. Cervix is opened and the content of the uterus is seen protruding through the dilating cervical
os.

5. On abdominal palpation the uterus is tender and may be smaller

than expected

MANAGEMENT

1. Reassure the mother and the partner to allay their fears and anxiety.

2. Admit the client and inform the doctor.

3. Check vital signs such as temperature, pulse, respiration blood pressure to be taken 4 hourly to
rule out shock.

4. All soiled perineal pad should be save to estimate the amount of blood loss and document.

5. Observe the client for shock because of heavy bleeding and treat it.

6. Secure intravenous fluid e.g normal saline or ringer lactate to rehydrate the client to prevent
hypovolaemic shock.
7. Take blood sample for HB, grouping and cross matching for possible blood transfusion and
Rhesus factor.

8. If it is incomplete abortion administer injection oxytocin 40 IU in 1 litre of normal saline or

ringer lactate at 40 drops per minute or according to the hospital protocol to expel the product of
conception and to control bleeding.

9. OR prepare client tor evacuation of the uterus to be performed by the doctor.

10. Prepare the requirement for the evacuation of the uterus and ensure the consent form is
signed by the client.

11. Administer prescribe analgesic for the relief of pain e.g injection pethidine 50mg
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12. Observe infection prevention throughout the care of the client to prevent infections.

13. Administers injection oxytocin 20 IU after the evacuation of the uterus to aid in uterine
contraction to control bleeding or tab misoprostol 400mcg to control bleeding.

14. Inspect the perineal pad for vaginal bleeding after the EOU and report.

15. Transfuse if blood transfusion if necessary.

16. Counsel client on family planning and follow up after discharged.

COMPLETE ABORTION

This occurs when all the contents of the uterus including the embryo, placenta and membranes
are expelled from the uterus spontaneously, and it normally occurs at 8wweks when the placenta
has not fully developed.

SIGNS AND SYMPTOMS

1. Vaginal bleeding subsides

2. Pain ceases

3. Cervical os is closed

4. On palpation the uterus is firm and contracted

5. Uterus is empty on ultrasound scanning

MANAGEMENT

1. All tissue that came out should be saved for inspection to estimate the amount of blood loss.

2. Inspect the flow of lochia to rule out infection.

3. Take blood sample for HB to rule out anaemia, grouping and cross matching for possible
blood transfusion and Rhesus factor.

4. Give blood transfusion if necessary.

5. Counsel client on nutritious diet high in protein to improve the hemoglobin level and high
fiber diet to prevent constipation.
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6. Administer prescribed iron supplements to boost the hemoglobin level of the client.

7. Administer Anti D immunoglobulin for Rhesus negative mother with baby of Rhesus positive
within 72 hours after the expulsion.

8. Counsel client on family planning and follow up after discharge.

INCOMPLETE ABORTION

Incomplete abortion occurs when the uterus retains part or some of the products of conception.
Fetus is usually expelled but the placenta may be retained. This usually occurs in the second
trimester when the placenta is fully develop and embedded.

SIGNS AND SYMPTOMS

1. History of amenorrhea for 12 weeks

2. Severe lower abdominal pains
3. Heavy vaginal bleeding
4. Cervix is soft closed or partly open
5. On abdominal palpation the uterus remain bulky and tender
6. Shock may be present.

MANAGEMENT

1. Reassure the client and admit the client.

2. Inform the doctor and check vital signs to rule out shock.

3. Treat for shock if present

4. Observe the amount of vaginal bleeding record and save all perineal pads for the doctor
inspection and estimation of blood

5. Take blood sample for HB to rule out anemia, grouping and cross matching for possible blood
transfusion and Rhesus factor.

6. Set up intravenous infusion e-g. Normal saline or ringer lactate to rehydrate the client and
maintain intake and output chart.

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7. Give blood transfusion if necessary.
Prepare client for dilatation and curettage (D/C) ensure the consent form is signed.

8. Give injection oxytocin 40IU in 1 litre of normal saline or ringer lactate at 40 drops per minute
or according to the hospital protocol to expel the product of conception and to control bleeding.

9. Administer prescribe analgesic for the relief of pain e.g. inj. pethidine 50 mg.

10. Observe infection prevention throughout the care of the client to prevent infection.

11. Assist client to maintain her personal hygiene.

12. Vulva toileting to be done at least twice daily to prevent ascending infection.

13. Serve client with nutritious diet high in protein haemoglobin level.
14. Counsel client on family planning and followw up after discharge.

15. Examine lochia for the amount, colour and odour.

MISSED ABORTION

This is where the foetus dies and is retained with its placenta in utero.

SIGNS AND SYMPTOMS

1. All Signs of pregnancy cease or regress

2. Uterine enlargement ceases

3. Pain and bleeding may cease

4. There is brownish vaginal discharge which may be offensive

5. Pregnancy test will be negative

MANAGEMENT

1. Iv oxytocin and cytotec is given to induce expulsion of the uterine content or vacuum

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Aspiration may be performed.

MANAGEMENT

- Insertion of Prostaglandin E pessaries into the vagina to soften the cervix and aid dilation

- Iv oxytocin infusion

- Analgesics to reduce pain

-Monitor vital signs

-Maintain personal hygiene to prevent infection.

HABITUAL OR RECURRENT ABORTION

This is when a mother has had at least two or more consecutive spontaneous abortions.
The main cause is cervical incompetence but other cause abortion may be contributory factors

MANAGEMENT

This depends on the cause:

1. Reassure the client

2. Good history taking.

3. Couple need pre-pregancy counseling i.e improvement in general health by eating nutritious
food.

4. Avoidance of smoking, alcohol and drugs

5. Any pre-existing infection i.e UTI, STI should be treated before conception.
6. Avoidance of exposure to hazardous substances e.g. Lead, pesticides, radiation.

7. The woman needs to be investigated to know the cause of abortion

8. Bed rest is very essential. If patient cannot rest at home she should be hospitalised.

9. Cervical Cerclage o Shirodkar is done: This is when the internal os is closed with non-
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absorbable suture.

10. Following the procedure, the mother should rest 3- 5 days.

11. The cervical suture must be removed about 38wks or as soon the woman gets into labour.

INDUCED ABORTION

This is the voluntary termination of pregnancy before the 24th week of pregnancy.

Types of induced abortion;

1. Therapeutic Abortion
2. Criminal Abortion

Therapeutic Abortion
This is evacuation of the uterus before the 24th weeks of pregnancy by a qualified medical
practitioner when the foetus is known to be malformed or where the mother's physical or mental
health is at risk if the pregnancy continues.

SOME INDICATIONS FOR THERAPEUTIC ABORTION

1. To save the life of the woman in cases of worsening of existing medical conditions e,g.
Chronic nephritis, cardiac conditions

2. To prevent harm to the woman physically and mentally.

3. Abnormalities of pregnancy such as Hydatidiform mole.

4. When the baby will suffer from physical or mental abnormalities.

CRIMINAL ABORTION

This is the deliberately evacuation of the uterus by unqualified inexperienced persons with no
medical or obstetric indication. This is illegal and punishable by law.

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METHODS USE TO PERFORM CRIMINAL ABORTION

1. Herbal abortifacients and misuse of prostaglandin E (cytotec)

2. Insertion of sharp tool into the uterus and other organs.

3. Over dose of certain drugs

4. Other traditional methods like having enema with soaps, washing soaps, washing blue,
grinded bottles, herbs etc.

MANAGEMENT

1. Reassure the client

2. Explain the complications or criminal abortion to client.

3. Counsel client on nutritious diet.

4. Take blood sample tor HB to rule out anaemia, grouping and cross matching for possible
blood transfusion and Rhesus factor.

5. Ultrasound to rule out retained product of conception.

6. Conduct vaginal inspection with speculum to rule out vaginal tears and lacerations for possible
suturing.

7. Retained products of concepton managed as incomplete abortion.

8. Counsel client on family planning method to avoid subsequent unwanted pregnancy.

COMPLICATIONS

✓ The operation may be done without aseptic technique: placenta tissue may be left in the uterus
resulting in sepsis and haemorrhage.

✓ There may be injuries to the birth canal and other pelvic organs

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✓Perforation of the uterus

✓Renal damage

SEPTIC ABORTION

This is the abortion which is complicated by infection commonly associated with induced
criminal abortion or incomplete abortion with retained products of conception. Sepsis may result
from ascending if the organism moves from the lower genital tract to the upper genital tract.

The infection may be limited to the uterus or spread to involve the fallopian tubes and other
pelvic organs.

Signs and symptoms

1. Client complains of feeling unwell and looks ill

2. High body temperature above 38° c with rapid pulse 90bpm

3. Headache, nausea and vomiting

4. Lower abdominal pain may or may not be present

5. If pregnancy is after 12 wks uterus will be tender on palpation bulky and soft.

6. Lochia is offensive and pinkish in colour which may be profuse

7. Cyanosis or pallor is present because of excessive blood loss

8. On speculum examination the cervix is closed

Investigations

✓ High vaginal swab for culture and sensitivity

✓ Full blood count

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✓ Blood for culture

✓ Urinalysis

MANAGEMENT

1. Reassure her and the relative if any

Admit client in an isolated place and barrier nursing to prevent infection

2. Monitor vital signs such as temperature, pulse, respiration and blood pressure are recorded.

3. Take blood sample for full blood count, grouping and cross matching for possible blood
transfusion and Rhesus factor

4. Take high vaginal swab to the laboratory for culture and antibiotics sensitivity test to isolate
the causative organism for antibiotic therapy.

5. Set up intravenous infusion  e.g normal saline or ringer lactate to rehydrate the client and
maintain intake and output chart.
6. Perform vulva toileting twice daily and assist client to maintain her personal hygiene.

7. Serve client with nutritious diet high in protein, vitamins, and minerals to build the immune

8. Blood transfusion may be given if patient is anaemic.

9. Broad spectrum antibiotics are given to combat infection eg. iv. Amoxiclav 2g bd, iv
Gentamycin or cap Amoxiciliin 500mg and tab flagyl 400mg

10. Antitetanol serum may be given if the abortion was performed under septic technique.

11. Retained products of conception managed as incomplete abortion.

COMPLICATIONS

✓ Septic shock
✓ Septicaemia
✓Disseminated Intravascular   Coagulation
✓ Anaemia
✓ Infertility

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✓ Pelvic inflammatory diseases
✓ Ectopic pregnancy

b. ECTOPIC PREGNANCY
This is embedment of the fertilized ovum outside the uterus. It is also known as extra-uterine
pregnancy. The commonest site is the fallopian tube (tubal pregnancy) but rarely abdominal or
ovarian can occur. The incidence of ectopic is 1:150 conceptions and is common in the tropics
where there is a high prevalence of pelvic inflammatory and sexually transmitted infections.
Predisposing factors
1. Previous tubal surgery
2. Poor vulval hygiene
3. Ascending vaginal infection
4. Scar within the fallopian tubes from previous inflammatory or infection
5. Blockage (from within or outside of the tube)
6. Women with multiple sexual partners or those who have indiscriminate sex
7. Complications from sexually transmitted infections
8. Septic abortion
9. Women with abnormally long tubes
10. Puerperal sepsis
11. Post abortion sepsis

Tubal pregnancy
The ovum is fertilized in the fallopian tube and the developing zygote is unable to reach the
uterine cavity, and therefore embeds in the fallopian tube where it has been arrested. The
ampulla is the commonest site for embedment and the isthmus the most dangerous site.
The developing zygote may become separated from the wall of the tubes by a layer of blood clot
resulting in a tubal mole. If this occurs near the distal end of the tube the mole may be expelled
into the peritoneal cavity resulting in tubal abortion which will usually regress and be absorbed.
If the zygote continues to grow within the tubes, it expands and ruptures. The ovarian arteries
and veins may be torn resulting in severe haemorrhage.

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Signs and symptoms
1. There is usually a history of amenorrhoea for about 6-8weeks
2. The woman experience sudden feeling of faintness and dizziness
3. There is shock with signs and symptoms such as low blood pressure, rapid pulse, cold
clammy skin
4. She complains of severe abdominal pain which may be felt in the iliac fossa or hypogastrium
and radiates to the tip of shoulder if she lies down.
5. There may be slight vaginal bleeding which is preceded by the pain (because of the decidual
reaction of the uterus)
Diagnosis
 Abdominal tapping is usually done to diagnose the condition
 Blood may be tapped from the pouch of Douglas (Culdocentesis)
 Typical signs and symptoms as above, also helps in diagnosis

Management
 This is a surgical emergency which requires early detection and prompt attention, the doctor
must be informed immediately.
 The woman should be reassured to allay anxiety
 She should be kept quiet in bed
 Vital signs should be checked and recorded ¼ hourly.
 Intravenous fluids e.g. Normal saline should be set up
 Blood should be taken for haemoglobin estimation, grouping and cross matching and
arrangement made for possible transfusion
 Vulval toileting should be done and the pubic area should be shaved.
 Indwelling urethral catheter is passed and connected to urine bag and urine output assessed
 Intake and output should be monitored
 The patient should be given nothing by mouth
 Patients level of consciousness and mental state should be monitored
 Necessary preparation for emergency surgery should be done and the patient assisted to sign
the consent form etc.

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 Laparotomy and salpingectomy is done and auto-transfusion is sometimes given
 Post-operative management is as for any major abdominal surgery. These patients usually
recover very fast.

c. MOLAR PREGNANCY
Pathophysiology
A hydatidiform mole is a pregnancy/conceptus in which the placenta contains grapelike vesicles
(small sacs) that are usually visible to the naked eye. The vesicles arise by distention of the
chorionic villi by fluid. When inspected under the microscope, hyperplasia of the trophoblastic
tissue is noted. If left untreated, a hydatidiform mole will almost always end as a spontaneous
abortion (miscarriage).
Based on morphology, hydatidiform moles can be divided into two types: in complete moles, all
the chorionic villi are vesicular, and no sign of embryonic or fetal development is present. In
partial moles some villi are vesicular, whereas others appear more normal, and embryonic/fetal
development may be seen but the fetus is always malformed and is never viable.
In rare cases a hydatidiform mole co-exists in the uterus with a normal, viable fetus. These cases
are due to twinning. The uterus contains the products of two conceptions: one with an abnormal
placenta and no viable fetus (the mole), and one with a normal placenta and a viable fetus. Under
careful surveillance it is often possible for the woman to give birth to the normal child and to be
cured of the mole

Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants
in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic
disease which grows into a mass in the uterus that has swollen chorionic villi. These villi grow in
clusters that resemble grapes which is due to the over proliferation of chorionic villi. A molar
pregnancy can develop when a fertilized egg does not contain an original maternal nucleus. In
this condition there is abnormal placenta development, resulting in either a complete
hydatidiform mole or a partial mole and there is no viable fetus. The products of conception may
or may not contain fetal tissue. It is characterized by the presence of a hydatidiform mole (or
hydatid mole, mola hydatid

Histopathologic image of hydatidiform mole (complete type).

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TYPES OF MOLAR PREGNANACY

1. A complete mole is caused by a single sperm (90% of the time) or two (10% of the time)
sperm combining with an egg which has lost its DNA. In the first case, the placental
tissue is abnormal and swollen and appears to form fluid-filled cysts.There is also no
formation of fetal tissue.Complete hydatidiform moles have a 2–4% risk of developing
into choriocarcinoma in Western countries and 10–15% in Eastern countries and a 15%
risk of becoming an invasive mole. Incomplete moles can become invasive (<5% risk)
but are not associated with choriocarcinoma. Complete hydatidiform moles account for
50% of all cases of choriocarcinoma.
2. A Partial mole is a type of molar pregnancy where the embryo [fertile egg] has too many
chromosomes. These happens when the egg gets 69 chromosomes when fertilized instead
of 46 chromosomes. In a molar pregnancy, the embryo either develops incompletely or
does not develop at all. It is typically treated by removal of embryo and placenta through
a dilatation and curettage procedure.

Signs and symptoms of molar pregnancy

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 1. Molar pregnancies usually present with dark brown to bright red vaginal bleeding during
first trimester and painless vaginal bleeding in the fourth to fifth months of pregnancy.
2. The uterus may be larger than expected, or the ovaries may be enlarged.
3. There may also be more vomiting than would be expected (hyperemesis) and often
symptoms of pre-eclampsia.
4. Sometimes there is an increase in blood pressure along with protein in the urine. Blood
tests will show very high levels of human chorionic gonadotropin (hCG).
5. Pelvic pressure or pain.
6. Anaemia.
7. Ovarian cysts
8. Increase in abdominal size that occur much faster than a healthy pregnancy
9. No heart beat or foetal movement
10. Grape like cysts coming out from the vagina

Causes

1. The cause of this condition is not completely understood.

2. Potential risk factors may include defects in the egg, abnormalities within the uterus, or
nutritional deficiencies, diet low in protein, folic acid and carotene.
3. Women under 18 or over 40 years of age have a higher risk. Other risk factors include a
previous molar pregnancy. Those with blood type group A.

UTERUS WITH COMPLETE HYDATIDIFORM MOLE

DIAGNOSIS

The diagnosis is strongly suggested by ultrasound (sonogram), but definitive diagnosis requires
histopathological examination. On ultrasound, the mole resembles a bunch of grapes ("cluster of
grapes" or "honeycombed uterus" or "snow-storm"). There is increased trophoblast proliferation
and enlarging of the chorionic villi, and angiogenesis in the trophoblasts is impaired. Sometimes
symptoms of hyperthyroidism are seen, due to the extremely high levels of hCG, which can
mimic the effects of thyroid-stimulating

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TREATMENT
Hydatidiform moles should be treated by evacuating the uterus by uterine suction or by surgical
curettage as soon as possible after diagnosis, in order to avoid the risks of choriocarcinoma.
Patients are followed up until their serum human chorionic gonadotrophin (hCG) level has fallen
to an undetectable level. Invasive or metastatic moles (cancer) may require chemotherapy and
often respond well to methotrexate. As they contain paternal antigens, the response to treatment
is nearly 100%. Patients are advised not to conceive for half a year after hCG levels have
normalized. The chances of having another molar pregnancy are approximately 1%.Management
is more complicated when the mole occurs together with one or more normal fetuses.In some
women, the growth can develop into gestational trophoblastic neoplasia. For women who have
complete hydatidiform mole and are at high risk of this progression, evidence suggests giving
prophylactic chemotherapy (known as P-chem) may reduce the risk of this happening.[18]
However P-chem may also increase toxic side effects, so more research is needed to explore its
effects.More than 80% of hydatidiform moles are benign. The outcome after treatment is usually
excellent. Close follow-up is essential to ensure that treatment has been successful.[20] Highly
effective means of contraception are recommended to avoid pregnancy for at least 6 to 12
months.

COMPLICATIONS OF MOLAR PREGNANCY

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 1. Infertility
2. perforated uterus
3. Infection
4. Untreated molar pregnancy can lead to choriocarcinoma
5. Aneamia
6. Pelvic inflammatory disease
7. Birth defect

CHAPTER 2
INCIDENTAL BLEEDING (EXTRA-UTERINE)
I. Polyps
II. Cervical erosion
III. Carcinoma of cervix
IV. Trauma

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 INCIDENTAL BLEEDING (EXTRA- UTERINE)

✓ Cervical erosion
✓ Cervical polyp
✓ Cervical cancer
✓ Incompetent cervix
✓ Trauma

1. CERVICAL EROSION/ ECTROPION

Definition: This is when the cervical epithelium of outgrows and pouts through the external Os.
It usually occurs with pregnancy due to increase levels of oestrogen and progesterone.

- The woman presents with profuse vaginal discharge which may be blood stained due to
ruptured capillaries
- There may be bleeding following sexual intercourse

MANAGEMENT OF CERVICAL EROSION

1. Nothing is done during pregnancy

2. Postnatally, cauterisation may be done using diathermy.
3. Cryosurgery may also be used (use of refrigerated probe to

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remove abnormal tissues).

2. CERVICAL POLYPS

Definition: These are small pedunculated bright red tumours

arising from the cervical canal which may bleed during pregnancy.
Treatment is by torsion postnatally.

CERVICAL CANCER

Definition: Cervical cancer occurs when the cells of the cervix grow abnormally and invade
other tissues and organs of the body.
Cervical intraepithelial neoplasia(CIN) is the precursor to invasive cancerof the cervix.
Approximately 80% of cases of carcinoma of the cervix are diagnosed in the 1st and 2nd
trimester. Carcinoma of cervix is more invasive during pregnancy and management depends on
the degree of invasion and duration of pregnancy. It is the most freguently diagnosed cancer in
pregnancy.

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WOMEN AT RISK

1. Age 35-55 yrs

2. Taking oral contraceptives (birth control pills)

3. Women with multiple sexual parthers e.g. commercial sex workers.

4. Women married to men with multiple sex partners.

5. Women who commence sexual activity at an earlier age.

6. Women with history of sexually transmitted infectious especially Herpes virus (Human
papilloma Virus-HPV)

7. Those married to men in lower socio-economic group. labourers, long distant drivers etc

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 8. All sexual active women are at risk especially those whose husbands have high histone
levels in the coating of their sperm

TYPES
 Squamous cell carcinoma (account for 90% of cervical caner)
 Adenocarcinoma (account for 10%)
 Mixed (rare)

SIGNS AND SYMPTOMS

1. Abnormal bleeding, such as

✓. Vaginal bleeding after sexual intercourse

✓. Vaginal bleeding after a pelvic exam

✓. Vaginal bleeding after menopause

✓. Bleeding or spotting between periods

✓. Longer or heavier menstrual periods than usual.

2. Pelvic pain not related to menstrual cycle

3. Heavy or unusual discharge that may be watery, thick, and possibly have a foul odor

4. Frequency of micturation

5. Painful micturation

STAGES OF CANCER OF THE CERVIX.

The classification is according to the anatomical extent of the disease.

Stage 0/ carcinoma in situ : the cancerous cells remain confined to the epithelial membrane and
have not invaded the deeper tissues.
Stage 1: The cancer is limited to the cervix.
Stage 2: The cancer extends to the vaginal walls

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Stage 3: The cancer extends to the vault
Stage 4: It now involves the whole cervix, bladder, rectum etc.

DIAGNOSIS

1. Vaginal bleeding which is irregular and occurs usually at coitus, micturition or defecation.

2. Offensive blood stained discharge.

3. Lower abdominal pain or backpain, if the cancer has extended to the uterosacral ligament.

4. There may be incontinence of urine and faeces if it is extensive.

5. On vaginal examination the cervix may be immobile with thickening of the fornices

6. Small nodules may be seen around the external os or cauliflower Iike growth may be found at
the lip of the cervix.

NB:
All women who are sexualy active should be screened for cervical cancer.

7. Application of Lugol's iodine to the cervix: precancerous and cancerous tissues are not stained
by the iodine. Normal vaginal and cervical epithelium are stained by the iodine.

8. Cervical smear test: An Ayrels spatula is used to scrape cells from

around the external os at the junction of the cervical canal (squamocolumar junction).

9.The secretion is smeared on a glass slide and sent to the lab for examination.

TREATMENT

Treatment of cervical cancer depends on the kind or cervical cancer and how far it has spread.
Treatments include surgery, chemotherapy, and radiation therapy.

Surgery: for the removal or cancer tissue in an operation.

Chemotherapy: Using special medicines to shrink or kill the cancer. The drugs can be oral or
intravenous or sometimes both
chemo may be cisplatin or cisplatin plus fluorouracil.

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Radiation: Using high-energy rays (similar to x-rays) to kill the cancer. External beam radiation
therapy (EBRT) to the pelvis plus brachytherapy. It depends on the stage of the disease.

- Laser Surgery: Where a laser machine is use to vapourise the abnormal cells. The area heals
by itself and it is suitable for  stage 0/ carcinoma in situ.

- Cautery and diathermy when there is no access to laser.

- Cautery and diathermy when there is no access to laser.

Treatment options for women who want to maintain fertility:

✓ Cone biopsy with removal of pelvic lymph nodes ( pelvic lymph node  dissection).

Treatment for those who don't want to get pregnant.

✓ External beam radiation therapy (EBRT) to the pelvis plus bradycardia.

PREGNANCY
✓ A woman with cancer or cervix n pregnancy may be allowed to continue with the pregnancy if
the cancer is stage IB.

✓ If the doctor decides to continue with the pregnancy, the baby should be delivered by cesarean
section as soon as it is able to survive outside the uterus.

✓ After that total hysterectomy and excision of fallopian tubes, ovaries, perimetrium, upper
vagina and all local lymphatic gland. Sometimes chemotherapy can be given during the
pregnancy (in the second or third trimester) to shrink the tumor.

INCOMPETENT CERVIX

Definition 1: This is failure of the cervix to hold pregnancy to term resulting in mid trimester
abortion.

Definition 2: An incompetent cervix, also called a cervical insufficiency, occurs when weak
cervical tissue causes premature labor or the loss of healthy pregnancy. When the cervix shortens
and opens in the second trimester (16 to 24 weeks) or early in the third trimester without any
other symptoms of labour it is sometimes referred to as cervical incompetence.
The incompetence is at the level ol the internal os. As pregnancy advances (between 16 -

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24weeks) when intrauterine pressure increase, the cervix dilates, membranes rupture and the
foetus is expelled.

CAUSES OF INCOMPETENT CERVIX

1. Congenital anomalies
2  Trauma resulting from dilatation of cervix during dilatation and
curettage for termination of pregnancy.
3. Large cone biopsy for treatment of cancer of cervix.
4. Trauma during difficult delvery e.g. severe laceration of cervix.
5. Uterine abnormalities
6. Client with a weak connective tissue disorder which effects the collagen within the tissues of
the cervix causing it to be weak.

SIGNS AND SYMPTOMS OF INCOMPETENT CERVIX

1. Pelvic pressure within the vagina or rectum.

2. Backache

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3. Mild abdominal cramps
4. Vaginal discharge
5. Slight vaginal bleeding
6. An increase in pelvic pressure
7. Premature rupture of membranes during pregnancy

MANAGEMENT OF INCOMPETENT CERVIX

✓ This is by Cervical Cerclage or Shirodkar suture where a suture of strong non-absorbable

material is inserted at the internal os.
✓ The mother needs to rest for about 3-5 days at the hospital after the procedure.
✓ She will need adequate rest throughout the pregnancy.
✓ The suture ought to be removed by 38 wks or sooner if she gets into labour.
✓ Severe damage will be done to the cervix if the sutures are not removed during labour.

COMPLICATION OF INCOMPETENT CERVIX

✓ Premature labour
✓ Abortion or miscarriage

PREVENTION

CERVICAL CERCLAGE

Definition: A cervical cerclage, also called cervical stitch, is a

surgery to keep the cervix closed during pregnancy. It helps to carry a pregnancy to full term so
the baby can develop properly to prevent miscarriage or premature baby.

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RISK FACTORS

1. Women with recurrent or habitual abortion especially during the second trimester, or given
birth to an extremely pre-term baby without proper labour and contractions in a previous
pregnancy are often suspected to have an incompetent cervix.

2. Trauma to the cervix

3. History of some surgery on the reproductive system

4. Congenital malformation of the uterus or cervix.

5. Congenitally short cervix

WHEN IS THE PROCUDURE IS PERFORMED

Cervical cerclage is often performed between week 12 and 16weeks when the risk of miscarriage
is low and the pressure on the cervix is still not too much to make it difficult to place the suture.

CERVICAL CERCLAGE TYPES

The classification is based on the technique used tor placing the the stitch

. Transvaginal cerclage: Is usualy done through the vagina in one of the following procedures:
1. McDonald cerclage: This 1s the most common form of cerclage
performed these days by physicians. In this method a permanent stitch is placed around the cerix

2. Shirodkar cerclage: this procedure involves making small incisions in the cervical and vaginal
tissues with stitches that hold the cervix closed until full term or gestation. It is usually made
much higher than a McDonald cerclage so the cervix can be more securely closed to prevent
pregnancy loss.

3. Rescue cerclage: this is an emergency cerclage done to rescue the pregnancy when the cervix
has already begun to dilate before term with few or no contractions with the amniotic sac bulges
or drop into the cervical opening

4. Transabdominal cerclage: this procedure is mostly performed for women with congenitally
short cervix, a previous cervical surgery or a severe injury to the cervix. In such cases, the
gynaecologist  may opt for a transabdominal process where the cervix is tied shut  through an
incision made in the women's abdomen.

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Procedure for Cervical cerclage

Before the beginning the surgery, ultrasound scans are used to decide the type of cerclage to be
opted for. The comnmon method invoIves performing

✓ Give local anesthesia before placing the suture through the vagina.
✓  Insert a speculum to visual the vagina during the surgery
✓ Apply a pair of ring forceps or tenaculunm to hold the cervix.
✓ A thick band of thread is then placed around the cervical opening in a manner resembling a
purse -string(suturing with stitches in a circle around a wound that needs closure. Once the circle
is completed  the two ends of the suture are pulled together to cause the stitch are to close ) are
pulled.

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Care after the procedure
1. Administer antibiotics to combat infection and pain medicines.
2. Ensure bed rest for 2-3 days (may be longer in extremely high- risk cases).
3. Encourage client to apply perineal pad and monitor the client for bleeding because a little
spotting or a light bleeding can occur after the surgery which is considered normal.
4. Frequent changing of soiled pad and hand washing before and after changing the pad.
5. Avoid any strenuous activity like pulling something heavy or climbing the stairs too quickly.
6. Counsel client to avoid constipation and straining during bowel movement.
7. Drink lots of fluids (water, sugar-free fruit juices) and add plenty fiber-rich foods (whole grain
bread, cereals) in your diet as these can help prevent constipation
8. Counsel client to avoid douching and she should keep the place around the suture clean.

9. Counsel client to avoid sexual intercourse for at least 7-14days.

10. Extremes exercises should be avoided.

COMPLICATIONS AFTER THE PROCEDURE

✓ little spotting or a light bleeding
✓ whitish/mucusy discharge for a few days
✓ An occasional uterine contraction for a few hours or days, but this usually goes away
on its own.

Cerclage removal
1. The cerclage suture is usually removed around the 37th week of gestation.
2. It may be removed earlier in case of an emergency like the premature rupture of
membranes or a premature labour
3. Removal of a McDonald cerclage is usually a painless procedure performed without
anesthesia, sometimes causing light bleeding.
4.  The stitch may be left in or removed after the delivery in case cesarean section mode
of delivery is performed.
5. In case of a Shirodkar cerclage, the removal procedure has to be carried out in the

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 theater.
6. Shirodkar cerclage may be left in place to prevent any cervical complication in a future
pregnancy in case of a Cesarean section mode of delivery is performed

COMPLICATIONS OF A CERCLAGE
1. Abortion
2. Cervical laceration or a tear in your cervix
3. Early or premature rupture of the membranes
4. Increased chances of a C-section
5. Infection of the cervix or amniotic sac
6. Preterm labour and birth
7. Vaginal bleeding

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 CHAPTER 3
BLEEDING IN LATE PREGNANCY

ANTEPARTUM HAEMORRHAGE

Antepartum haemorrhage (APH) is defined as bleeding from the genital tract after the 28 th week

of pregnancy and before the onset of labour or the birth of the baby.

The bleeding could be from local lesions of the genital tract such as cervical erosions, polyps etc

but bleeding in late pregnancy is usually due to either placenta praevia or placenta abruption

A) PLACENTA PRAEVIA
This is inevitable bleeding from an abnormally situated placenta. In this condition the placenta is
wholly or partially situated in the lower uterine segment. The lower uterine segment grows and
stretches during the latter weeks of pregnancy causing premature separation of the placenta and
subsequent bleeding.
Incidence
 Multiparous women
 Pregnant women with fibroid uterus
 Multiple pregnancy
Diagnosis/ Signs and symptoms

1. The bleeding starts as small recurrent haemorrhages often called warning haemorrhages and

the woman usually ignores the first 2 or 3 episodes.

2. Subsequent bleeding occurs which is more profuse and endangers the woman’s life.
3. The bleeding is not associated with pain
4. There is no history of the bleeding occurring after exertion or strenuous activity, it usually
occurs at rest.
5. The general condition of the woman is proportional to the amount of vaginal bleeding.
6. The presenting part is high and abnormal lie is common.
7. The uterus is not tender or hard on palpation. Palpation is not difficult and the woman does
not resist it.

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8. Ultrasound is a safe and efficient diagnostic method which can locate the situation of the
placenta and helps to give a positive diagnosis of placenta praevia.

Types
 Lateral/ Type I: The placenta is situated mainly in the upper uterine segment with only a tip
of it encroaching on the lower uterine segment. The placenta is not reached unless the cervix
is dilated. Blood loss is mild and maternal and fetal conditions are good and vaginal delivery
may be possible.
 Marginal or Type II: The placenta is situated in the lower uterine segment such that its lower
margin extends to the internal os when the cervix is not dilated. Blood loss is moderate,
vaginal delivery may be possible depending on the maternal and fetal conditions.
 Complete or Type III: In this type the placenta covers the undilated internal os but not
centrally so that it covers it when the cervix dilates up to 6 cm but does not cover it when the
cervix is fully dilated. Bleeding is severe and maternal and fetal conditions are in danger and
C/S will save their lives since vaginal delivery is not possible.
 Central or Type IV: The placenta is located centrally over the internal os even when the
cervix is fully dilated. Profuse bleeding occurs and Caesarean section is recommended to
save the life of the fetus and the mother.

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Management

The management of placenta praevia depends on the amount of blood loss, the condition of the

mother, the condition and maturity of the fetus and the type or degree of placenta praevia.

Conservative
If the gestation is less than 36 weeks and the maternal and fetal conditions are fine, conservative
or expectant management is done to prolong the pregnancy for the fetus to mature and
preventing further bleeding
 The woman is put on strict bed rest and not allowed up for any purpose- special nursing care
should be given.
 Fetal condition and placental functioning is monitored by fetal kick chart and fetal heart rate.
 Ultrasound scan is repeated at intervals to identify the position of the placenta in relation to
the cervical os as the lower uterine segment grows.
 The vulva is swabbed and toileting is done twice daily.
 Perineal pads are applied and inspected at least 4 times a day.
 Gentle abdominal examination is done daily noting pain and tenderness.

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 Vital signs are checked and recorded 4 hourly.
 Haemoglobin estimation and blood grouping is done, 2 pints of blood should be cross
matched for the woman.
 Constipation should be prevented and sometimes magnesium sulphate may be given daily to
avoid straining on defaecation.
 If heavy bleeding should occur or when the fetus is matured (38 weeks) the theater is set and
personnel ready for immediate caesarean section. A vaginal examination is done under
general anaesthesia. Blood should be readily available and I.V fluids set up before
examination. Further management depends on the findings of the obstetrician. If placenta is
felt caesarean section is performed without delay, if not the margins are explored and labour
induced with oxytocin infusion. The mother can then have vaginal delivery.
Active
This is when there is severe bleeding or the bleeding fails to respond to conservative treatment,
or there is intrauterine death. Immediate termination of pregnancy by caesarean section is the
action taken.
 Steps are taken to resuscitate the woman immediately by IV fluids. Oxygen is administered.
 Vital signs are checked ¼ hourly
 Haemoglobin estimation, blood grouping and cross matching are done.
 Necessary preoperative preparation as for any major surgery should be carried out.
 Further management is as outlined above
Complications
1. Massive haemorrhage before delivery which can cause death of mother
2. Fetus may die out of massive blood loss before delivery.
3. Fetal distress
4. Asphyxia neonatorium
5. Neonatal death
6. Post-partum haemorrhage (the lower uterine segment does not have oblique muscle fibers
and so cannot contract and retract efficiently to control bleeding during the third stage).

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B) PLACENTA ABRUPTIO
This also known as accidental haemorrhage, is bleeding from premature separation of normally
situated placenta

Causes
 Conditions that causes sudden reduction in uterine size as in spontaneous rupture of
membrane in polyhydramnios and delivery of first twin in multiple pregnancy
 Severe essential hypertension or pre- eclampsia
 Direct trauma
 Strenuous physical activity/ vigorous exercise or activity
 It may follow external cephalic version

Diagnosis/Signs and symptoms2

1. The mother gives a history as outlined under causes
2. There is bleeding which may be revealed or concealed
3. The bleeding is associated with pain

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4. Concealed bleeding leads to enlarged uterus in excess of gestation
5. The general condition of the mother does not correspond to the blood loss
6. There is no history of recurrent bleeding or previous episodes
7. The presenting part is engaged
8. The uterus is hard (board-like) and guarding on palpation. Palpation is difficult and painful
and the woman may resist it
9. Fetal heart is usually not heard

Types
Revealed haemorrhage: Partial placental separation causes bleeding which is visible. Bleeding
may be slight or profuse and come out through the vagina.
Concealed haemorrhage is the most severe type of placenta abruptio. There is a wide area of
separation usually central and the blood is retained behind the placenta forming a large retro
placental clot which causes further separation. The blood which is retained behind the placenta
may infiltrate between the muscle fibres of the uterus. The uterus appears bruise and
oedematous this is known as Couvelaire uterus or uterine apoplexy. There may be slight
clotted blood or no bleeding from the vagina. The mother will have all the signs and symptoms
of internal bleeding or hypovolaemic shock.
A combination of these two situations above where some of the blood drains and some are
retained behind the placenta can occur and is known as mixed haemorrhage

Management
 Pain should be alleviated using analgesics
 Resuscitation should be done and blood taken for Hb, grouping and clotting time
 The foot end of the bed should not be raised.
 The woman should rest on her side to improve circulation to the fetus and prevent
compression on the vena cava.
 Vital signs should be checked ¼ hourly
 Intake and output should be maintained accurately.
 Urine should be measured and tested for protein
 Fundal height and abdominal girth should be measured hourly.

40 | P a g e
 Fetal heart rate should be monitored closely.
 If the fetus is dead vaginal delivery is contemplated by induction (depending on the state of
the uterus). If the fetus is alive or there is couvelaire uterus, emergency caesarean section is
done to save the life of the mother or the fetus.
 Fresh blood should be given and relatives should be organized and encouraged to donate.

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 CHAPTER 4
MULTIPLE GESTATION
 It is the simultaneously development of more than one fetus in the uterus.
 The average gestation before twins is 37weeks, triplets 34weeks, and quadruplets 32
weeks.

 Two fetus…………twins
 Three foetus……..triplets
 Four foetus………quadruplets
 Five foetus………. Quintuplets
 Six foetus……….. Sextuplets
 Seven foetus……. Septuplets
 Eight foetus………Octuplets

MECHANISM
 The separate fertilization of two or more ova by different spermatozoa
 One ovum is fertilized but undergoes subsequent division into two or more embryos

RISKS FACTORS
 Age
 Ethnicity, higher in Africans
 Multiparty
 Hyper ovulation
 Mode of conception, higher in assisted reproductive techniques
 Family history of multiple gestation
 Use of ovulation- stimulating drugs e.g clomiphene citrate
 Maternal size, tall, averagely built and obesed women

TYPES OF TWIN PREGNANCY

 Monozygotic /identical twins/uniovular
 Dizygotic/biovular/Non-identical/Fraternal twins

OTHER TYPES OF TWINS

 Superfecundation- Twins conceived from different sperms different men in one menstrual
cycle.

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 Superfetation- twins conceived as a result of two coital acts in different menstrual cycle (very
rare)
MONOZYGOTIC/ IDENTICAL
 It is develop from the fusion of one ovum (oocyte) and one spermatozoa, which divides
into two after fertilization.
 It results in one sex, all boys or all girls
 They are genetically identical
 However they have different personalities and are distinct individuals
 Identical twins may have individual placenta and amniotic sacs, but mostly share a
placenta with separate sacs.
 Rarely, identical twins share one placenta and single amniotic sac.
 Have the same blood group

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44 | P a g e
 DIZYGOTIC/ NON-IDENTICAL TWINS
 This occurs when two separate ova (oocyte) are fertilized by two different spermatozoa.
 It can results in all boys, girls or combination of boys and girls
 Fraternal twins are simply siblings conceived at the same time
 They have separate placenta and amniotic sacs

DETERMINATION OF ZYGOSITY AND CHORIONICITY

Knowledge of the differences between the two terms is very important to the midwife.

Determination of zygosity: means determining whether or not the twins are identical.

Chorionicity: This refers to the type of placentation and can either be dichorionic or
monochorionic.

Monochorionic has more higher risk of perinatal mortality and morbidity than dichorionic twin.

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Zygosity: This refers to whether the twin pair resulted from one fertilized ovum or from separate
fertilized ova. Zygosity maybe monozygotic or dizygotic. The most accurate method determining
this is to pertorm DNA test for each baby.

Amnionicity: This refers to whether the fetuses are contained in one sac or separate sacs: Can
Monoamniotic or diamniotic knowledge of chorionicity is very important clinically because
monochorionic twin pregnancies have a three to five times higher risk of perinatal mortality and
morbidity than dichorionic twin pregnancy (Fisk & Bennett 1995 cited by Fraser &
Cooper,2003 in Myles textbook for Midwives 14th edition).

DICHORIONIC MONOCHORIONIC
Two placenta which, may be fused One placenta

Two chorions One chorion

Two amnions Two amnions (one amnion in monoamniotic
twins is very rare

These twins can be either dizygotic or These twins can only be monozygotic
monozygotic

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SIGNS AND SYMPTOMS
 Hyperemesis gravidarum
 Exaggerated pregnancy related symptoms

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  Large for date uterine size
 Two or more fetal poles on palpation
 Two or more fetal heart rates heard on auscultation.
DIAGNOSIS
 Ultrasound examination as early as 6weeks
 Radiography (x-rays) after 28weeks
 Outline of two separate foetuses
 Presence of two foetal heads
 Increased maternal serum alphafetoproteins(AFP) in the presence of neural tube defect.
 Family history
 Abdomen larger than gestational age.

ANTENATAL CARE

Client with multiple gestatons needs support and special care to prevent complications therefore
early diagnosis of twin pregnancy and chorionicity is very important.

✓ Women with twin pregnancy should be counsel to attend antenatal clinic at least nine times for
early detection and prompt management of complication.

✓ Counsel client on exclusive breastfeeding and explain to her that it is the best way for her to
feed her babies nutritionally.

✓ Counsel client on breastfeeding and bottle feeding and introduce her to mothers who have
successfully breastfed babies,

✓ Counsel on nutritious diet rich in protein to prevent anaemia, vitamins and mineral to build the
immunize system and carbohydrates to restore her energy

✓ Encourage client to take in high fiber and roughages to prevent constipation

✓ Encourage her to drink more water to flush the system of toxins and  advise her on rest and
sleep at least 2 hours in the day and 6 or 8  hours at night to restore her energy and health.

✓ Encourage client on exercise e.g. pelvis floor exercise to strengthen the pelvic floor muscle,
walking to improve blood circulation etc.

✓ Laboratory investigations: such as full blood count to rule out anaemia, urine RE for UTI,
grouping and cross matching for possible blood transfusion, hepatitis B, malaria parasite, G6PD

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defect, syphilis, HIV to prevent mother to child transmission etc. should be done.

✓ Counsel client on birth preparedness and complication readiness

MANAGEMENT OF LABOUR

The presentation of the babies  determine the mode of delivery if the first twin is in a cephalic
presentation, labour is usually, allowed to continue normaly to a vaginal birth, but if the first
twin is presenting with other position an elective caesarean section should be considered.

Fetal presentation:

✓ Vertex- Vertex and Vertex-Breech

✓ Breech-Vertex and Breech-Breech
✓ Vertex- transverse and Breech-transverse.

MANAGEMENT OF FIRST STAGE OF LABOUR

1. Welcome client and relatives and offer them a seat.
2. Establish a rapport with the woman and reassure them to allay fear and anxiety.
3. Collect her maternal health record book and glance through the past obstetric history.
4. Take history of onset of labour and enquire about her last meal taken example when the pain
started, show seen, food taken and when membranes ruptured.
5. Collect her items for delivery and assist her to change into light clothing.
6. Admit client into the examination or first stage room for examination and observation.
7.  Serve client with bedpan and collect midstream urine for testing protein and acetone and note
the amount of urine and document any time client pass urine.
8. Perform physical examination from head to toe and document your findings.
9. Performed abdominal examination which includes fundal palpation for the part of the foetus
that occupy the fundus, lateral palpation for the lie, position of the fetal back and pelvic palpation
for the presentation and descent for the engagement of the fetal head.
10. Auscultation for the fetal heart rate using foetal stethoscope every 30 minutes depending on
the condition of the babies every 15 minutes for fetal distress.
11. Continuous electronic fetal heart monitoring of both fetuses is advocated with the use of
Cardiotocography or hand to hand Doppler's for both heartbeats should be monitored
simultaneously to give a more reliable reading.
12. Pinad stethoscope can be used by midwives auscultating simultaneously at the same time so
that the two distinct fetal heart rates are counted over the same minute.
NB: If fetal distress is presence during labour, the birth is expedited , usually by caesarian

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section.
13. Perform vaginal examination every four hours noting the condition of the vulva and cervical
dilatation, vaginal discharges,varicose veins, oedema etc.
14. Monitor the uterine contractions every 30 minutes and note the rhythm and document your
findings on the partograph.
15. Check vital signs such as temperature, pulse, respiration every 30 minutes and blood pressure
every four hours.
16. Secure intravenous line and take blood for HB and grouping and cross matching for possible
blood transfusion.
17. Document all findings on the observation chart if cervical dilatation is less than 4cm and on
partograph if cervical dilation is 4cm or more and communicate findings to the client and
relatives to allay fear and anxiety.
18. Encourage client to walk about provided the membranes are still intact.
19. If membranes rupture note the colour, odour of the liquor and amount should be measured.
Performed vaginal examination to rule out cord prolapse, if present inform doctor. When
prolapse. If present inform the doctor.
20. When membranes rupture, client shift be encouraged to lie in the left lateral position to
improve circulation to the foetus and prevent cord prolapse.
21. Encourage client to empty the bladder frequently to enable the descent of the the fetal head at
least every 2hrs.
22. Frequent changing of perineal pad to prevent infections.
23. Hand washing before and after changing pad to prevent infection
24. Educate client on the progress of labour using the dilation board.
25. Educate client on the stages of labour and inform client that her baby will be delivered onto
her abdomen for bonding and skin to skin contact for warmth.
26. Encourage client to ask questions and answer all her questions in simple language
27. Analgesics and sedatives should be given when necessary for relief of pain and to ensure rest.

NOTE: injection pethidine should not be given when the cervical dilatation is more than 4cm
because it can depress respiratory centre of the baby when given towards the end of 1st stage.
28. Give light nutrition diet in order to maintain her strength and energy.

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29. In severe case intravenous fluid example, ringers lactate etc should be set up when oral feeds
are not tolerated by the client to rehydrate the client to prevent maternal exhausation.
30. If uterine activity is poor the use of intravenous oxygen may be required once the membranes
have been ruptured.

31. Deep breathing exercise should be encouraged to prevent maternal exhaustion and premature
bearing down.
32. Review partograph every four hour or when necessary.
33. Sacral massage should be given to reduce backache.
34. Intake and output chart should be monitored when client is on intravenous infusion to assess
the function of the kidneys.
35 Diversional therapy should be used to reduce pain.
36. Explain to client what is expected of her during second stage.
37. Educate client on personal hygiene not to reapply a fallen pad.
38. Client can have a warm bath when necessary or can wash down.

MANAGEMENT OF SECOND STAGE OF LABOUR

1. Set delivery trolley and infant resuscitation tray ready in the delivery room.
2. Establishes rapport with the client and inform her that she is in 2nd stage and transfer her into
the delivery room or bed and explain to her what is expected from her during delivery.

3. Ensures bladder of client is emptied to prevent trauma to the bladder and provide privacy by
drawing the nearby curtains down.

4. Explain the procedure to her that her babies will be delivered onto her abdomen to initiate
bonding and provide warmth.

5. Assist client to assume preferred position of her choice for delivery

6. Put on protective clothing such as mackintosh apron, boots,face mask and goggles, cap and
wash hands with soap under running water and dry with a clean towel.

7. Put on sterile gloves on both hands.

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8. Clean the vulva/perineum with antiseptic solution example savlon 1:40 to prevent infection.

9. Drape client thighs and abdomen with a sterile towel and confirm full dilatation of the cervical
os to prevent client fron pushing through undilated cervix which can cause cervical tear.

10. Applied clean perineal pad to anal to prevent contamination of the delivery field with faeces
and instruct assistant to check foetal heart rate after each contractions to know the fetal
condition.

11. Check delivery trolley and instruments for completeness

12. Instruct the client to bear down with each contraction and to rest in between contractions
reassuring client to prevent maternal exhaustion

13. ln cephalic presentation maintain flexion as the fetal advances of the first twin /presenting
part becomes visible by gently pressing on the ociput with middle and index fingers to allow the
Bi-parital diameter of 9.5cm of the foetal skull to distend the perinem to prevent tears which
could lead to bleeding.

14. Infiltrate the perineum and makes episiotomy if necessary to expedites delivery.
15. When the head of the first twin crowns (when the ociput doesn't go back with contractions,
ask the woman to pant or give small pushes with contractions in order to prevent rapid expulsion
of the head which can lead to tear and bleeding.

16. Deliver the rest of the head by extension so that the sinciput, face and chin sweep the
perineum.

17. Quickly clean the eyes with dry sterile cotton wool swab from the inner cantus outward using
one swab at a time and clean the face with a sterile gauze to prevent infection and simulate the
baby to cry but if the first twin is asphyxiate suck the mouth and nose with a bulb syringe to clear
airway of mucous.

18 Cord around neck. If loose slip it over baby's head and if tight, 2 artery forceps are applied
3cm apart and the cord cut between 2 clamps covering it with gauze.

19. Wait for restitution and external rotation of the head indicating internal rotation of the
shoulders into the anterior-posterior diameter of the pelvic outlet to prevent perineal tear

20. Deliver the anterior shoulder by downward traction first and posterior shoulder by upward
traction and the rest of the body by lateral flexion onto the mother's abdomen following the curve
of carus.

21. When the first twin is born, note the time of delivery and the sex of the baby and thoroughly
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dry the baby immediately and wrap with dry cloth and maintain skin to skin contact to prevent
hypothermia

22. Apply an identification tag indicating the time and sex of the first twin.
24. After the birth of the first twin, abdominal palpation is made to ascertain the lie, presentation
and position of the second twin and auscultate the fetal heart rate to rule out fetal distress

NOTE: if the presentation of the second twin is vertex delivery of the baby is the same as above
but if it is breech presentation it should be managed as just.

25.NOTE: clamp and cut cord after cord pulsations has ceased or approximately 2-3minutes after
birth of the baby.

26. Give 10 international unit (10 IU) of injection oxytocin intramuscularly on the mother's
thigh.

27. Assess the baby's condition using APGAR SCORE 1 minute and begin resuscitation if baby
is not breathing

28. Clamp the umbilical cord 3cm away from the mother's baby’s abdomen then the second
clamp 2cm from the first clamp, cover with sterilized gauze to prevent the blood from splashing
and cut in between two to separate baby from mother.

29. Show babies to mother to identify the sex of the baby, congratulate her for her effort.

30. Applies identification band with mother's name, baby weight, date and time of birth for easy
identification of the first twin from the second twin

31.Clean the woman up and put the cut end of the cord into a receiver placed near the vulva in
between the thighs for third stage

NOTE: The birth of the second twin should be completed within 45 minutes of the first twin, but
as long as there are no fetal compromise in the second twin, it may be allowed to continue
longer. If there are signs of fetal compromise, the birth must be expedited and the second twin
may need to be delivered by CS.

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ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR.

1. Explain procedure to the mother

2. Palpate the abdomen to rule out undiagnosed twin.

3. Give 10 IU of oxytocin intramuscularly on the mother's thigh for contractions of the uterus to
expel the placenta and also to control bleeding

4. Clamp and cut the cord after cord pulsation has ceased or approximately 1-3 minutes after
delivery after delivery of the baby.

5. Place the cut ends of the cord into a sterile receiver near the vulva in between the thighs.

6. Clamp the cord closer to the perineum using a sponge holding forceps.

7. Place one hand on fundus to feel for contraction

8. Release the forceps and clamps cord closer to the vulva.

9. Place hand just above symphysis pubis with palm facing the
umbilicus.

10 Apply gently counter traction in an upward direction.

11. Hold the forceps horizontaly and apply traction on the cord.

12. Receive placenta into both hands and coaxes membranes out when visible at the vulva.

13. Examine placenta and membranes

14. Examine the genital tract

15. Rub up uterus to expel clots and to initiate contraction. Teach the mother how to massage the
uterus.

16. Measure the amount of blood loss…..tidy up client, apply clean perineal pad and congratulate
the mother.

16. Communicate findings to the woman and thank her.

17. Make client comfortable or move client into 4th Stage room

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18. Record findings and report any abnormalities

REASONS FOR EXAMINATION OF THE PLACENTA

✓ To check for the completeness or the membranes to that, no part of the placenta membranes
has been retained in utero. Placental tissue retained in the uterus is likely to cause postpartum
haemorrnage since the uterus cannot contract and retract effectively.
✓ The umbilical cord should be examined, the number of cord vessels should be noted with
abnormalities.

✓. IF the babies are of different sexes they are dizygotic and if the placenta is monochorionic
they may be monozygotic.

ITEMS FOR THE PROCEDURE

1. Bright light

2  Kidney dish

3. Examination gloves

4. Placenta bucket with 0.5% chlorine solution

PROCEDURE

1. Hold the placenta by its cord allowing the membranes to hang at the eye level.

2. Inspect for the shape and size under good source of light.

3. Inspect the cut end of the cord for the number of vessels (two arteries and one vein).

4. Inspect the foetal surface noting the arrangement of vessels the position for insertion.

5. The amnion should be peeled right up to the umbilical cord to allow the chorion to be viewed.
6. Hold the placenta, maternal surface keep upwards in the palm and remove any clot for
measurement and inspect the surface for any missing cotyledon lobes.

7. If there is a missing lobes massage the uterus to expel it to prevent bleeding. In severe cases

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inform the doctor for EOU.

8. Dispose of the placenta according to the mother's wish. For hospital disposal put in into 0.5%
chlorine solution and dispose it at the hospital incinerator.

9. Normally disposal by burial is not recommended because of preying animals.

10. Assess the amount of blood loss and document.

COMPLICATION ASSOCIATED WITH MULTIPLE PREGNANCY

✓ Malpresentation: due to unlimited space in the uterine cavity movements of the fetuses are
restricted.

✓ Polydramnios: occurs as early as 16 weeks. Which associated with fetal abnormality but is
more likely to be twin to twin transfusion syndrome (TTTS) also known as feto-fetal transfusion
syndrome.

Twin-to-twin transfusion syndrome: it can be acute or chronic. The acute usually occurs during
labour and is the result of blood transfusing from one fetus (donor) to the other ( recipient)
through vascular anastomosis in a monochorionic placenta. Both fetuses may die of cardiac
failure if not treated urgently. This result in anaemia and growth restriction in the donor twin
(stuck twin) and polycythaemia with circulatory overload in the recipient twin (hydrops).

✓ Premature rupture of the membranes: this occurs as a result of malpresentation due to

polyhydramnios.

✓ Cord prolapsed: associated with malpresentation and polyhydramnios which put the second
twin at risk of cord prolapsed,.
.
✓ Prolonged labour: malpresentation do not promote good uterine action and distended uterine
lead to overstretching of uterine muscle which lead to poor uterine contraction.

✓ Fetal malformations: high incident in monochorionic twins e.g

- Conjoined twins: this occurs In monozygotic twins as a result incomplete division of the
fertilized oocyte,
- Twin reversed arterial perfusion: Twin reversed perfusion is a rare disorder that sometimes
occurs in identical twins that share the same placenta, where one twin has a poor functioning
cardiac system receives blood from the healthy twin (pump twin).

✓ Fetus-in fetus: sometimes part of the fetus may be lodged within another fetus.

✓ Post-partum haemorrhage

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 CHAPTER 5
MEDICAL CONDITIONS IN PREGNANCY
HEPATITIS B
Hepatitis B or serum hepatitis is an acute sexually transmitted infection caused by the hepatitis B
virus. It is a disease characterized by jaundice.

 Definition: is an infectious disease caused by the hepatitis B virus (HBV) that affects the
liver.

 The term 'hepatitis simply means inflammation of the liver Hepatitis may be caused by a
variety of viruses or other infections, medications, or a toxin such as alcohol.
Hepatitis viruses that can cause injury to liver cells in addition to hepatitis B include the
hepatitis A and hepatitis C viruses.

 Hepatitis B infection may be either short-lived (acute) or long

lasting (chronic).

 Acute hepatitis B infection lasts less than six months. Acute hepatitis B is determined by
the immune response of the individual. Individuals who develop a strong immune
response to the infection are more likely to clear the virus and recover.

 However, these patients also are more likely to develop more severe liver injury and
symptoms due to the strong immune response that is trying to eliminate the virus. Most
people who get hepatitis B as adults have an acute infection, but it can lead to chronic
infection.

 Chronic hepatitis B infection lasts six months or longer.  A weaker immune response
results in less liver injury and fewer symptoms but a higher risk of developing chronic
hepatitis.

 Hepatitis B is not spread through food, water, or by casual contact.

Incubation period: The virus may be detected within 30 to 60 days after infection but
can vary from 30 to 180 days and can persist and develop into chronic hepatitis B.

FUNCTIONS OF THE LIVER

 The liver is a vital organ that has many functions such follows:
Helps in the immune system.

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  Production of clotting factors

 Producing bile for digestion; storing nutrients including sugars, fats and minerals for use
by the body later; processing medications; and breaking down toxic substances

RISK FACTORS OF HEPATITIS B VIRUS (HBV)

 Health care professionals: Hepatitis B is an important occupational hazard for health

workers.

 Service providers in daycare programs caring for the developmentally disabled etc.

 Patients on hemodialysis

 Patients receiving blood products or transfusions

 Having unprotected sex with multiple sex partners or with someone who's infected with
HBV

 Sharing infected needles during IV drug use

 Living in a regions with high infection rates of HBV

MODE OF TRANSMISSION OF HEPATITIS B VIRUS

 Exposure to infectious blood or body fluids

 Using contaminated needles for injecting illicit drugs, tattooing
body piercing, or acupuncture
 Sharing toothbrushes and razors contaminated with infected fluids or blood.
 Injection given with syringes and or needles contaminated by body fluids of infected
persons or carriers.
 Sexual intercourse with infected person
 Kissing an infected person may spread it since the virus is present in saliva
 Transfusion with infected blood and blood products
 Donated infected livers and other organs.
 Carrier mothers can transmit to their infants during the delivery

MODE OF MOTHER TO CHILD TRANSMISSION OF HBV

The foetus can be infected with the viral through the following ways;

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 DURING PREGNANCY
 Antepartum haemorrhage
 Invasive procedures,
 External cephalic version
 Premature rupture of membranes

DURING LABOUR

 Delivery process such as the passage of the baby through the birth canal.

DURING PUERPERIUM

 Breastfeeding
 Immunization with a an infected needle

SIGNS AND SYMPTOMS OF HEPATITIS B

Most infants and children who acquire acute hepatitis B viral infections have no
symptoms Hepatitis B signs and symptoms may include.
 Dark urine
 Fever
 Joint pain
 Loss of appetite
 Nausea and vomiting
 Weakness and fatigue
 Yellowing of the skin and the whites of your eyes (jaundice)
 Pain in the upper right abdomen (due to the inflamed liver)
 Hepatitis B virus can also cause a chronic liver infection that can later develop into
cirrhosis (a scarring of the liver) or liver cancer

DIAGNOSIS OF HEPATITIS B

 Hepatitis B surface antigen (HBsAG); detects protein that is present on the surface of the
virus .This antigen is the earliest sign of an acute hepatitis B infection and helps to
identify infected people before symptoms appear.

 Hepatitis B surface antibody (anti-HBs); to detect antibody produced in response to HBV

surface antigen. Used to detect previous exposure to HBV and to determine the need for
vaccination (if anti-HBs is absent) or to determine if a person has recovered from an
infection (immune). The presence of this antibody means that the infection is at the end
of its active stage and the patient is no longer contagious.

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  Hepatitis B e-antigen (HBeAG); this antigen is only present during an active hepatitis B
infection. Detects protein produced and released into the blood and t is used to measure
the ability to spread the virus to other people [infectivity).

 Hepatitis B DNA testing to check for hepatitis B viral genetic material in the blood. A
positive test of this DNA means that the virus is multiplying in the patient body and the
patient is highly contagious. This test is also used to monitor the effectiveness of antiviral
therapy in people with chronic hepatitis.

 MANAGEMENT OF HEPATITIS B
Acute hepatitis B:
There is no specific treatment for acute hepatitis B. Therefore,
care is aimed at maintaining comfort and adequate nutritional balance, including
replacement of fluids lost from vomiting and diarrhoea and avoidance of alcohol
consumption because it can cause more danger to the liver.

 Chronic hepatitis B:
Chronic hepatitis B infection can be treated with medicines, including oral antiviral
agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer
and improve long term survival. WHO recommends the use of oral treatments tenofovir
or entecavir, because these are the most potent drugs to suppress hepatitis B virus.

 Patients with evidence of severe disease with encephalopathy, or severe malaise should
be admited to the hospital.

 Liver transplantation should be considered for patients impending liver failure due to
acute (initial) infection or advanced cirrhosis.

NOTE: In most people, however, the treatment does not cure hepatitis B infection, but
only suppresses the replication of the virus. Therefore, most people who start hepatitis
treatment must continue it for life.

POST-EXPOSURE PROPHYLAXIS

 Post-exposure immunization with hepatitis B immunogiobulin HBIG should especially

be considered for neonates born of mothers positive for HBsAg. When HBIG is given
within the first hours, up to 24 hours after birth, the risk of HBV infection can be
reduced. HBIG typically is used as an adjunct to hepatitis B vaccine for post exposure
immune prophylaxis to prevent HBV infection.

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 HBsAg TESTING AFTER IMMUNIZATION
 HBsAg testing may be done at 6 months and, if found positive, shows therapeutic failure.
 Third dose of vaccine should not be given to such cases. HBsAg and anti HBs testing
should be done at 12 to 15 months to see the therapeutic response.
 Persistence of antigeraemia indicates a carrier state. Absence of antigen and presence of
anti HBs (core antibody) indicates protection.

IMPORTANT POINTS TO NOTE: As anti HB (core antibody)

transmitted from the mother to the neonate persists in the neonatal circulation for over a
year, it's testing and interpretation is difficult in neonates. Cesarean section does not
reduce transmission.

COMPLICATION OF HEPATITIS B
 Scarring of the liver(cirrhosis)
 Liver cancer
 Liver failure
 Other conditions like kidney diseases.

EFFECTS OF HEPATITIS B ON PREGNANCY

 Miscarriage
 Premature labour
 Gestational diabetes
 Low birth-weight baby
 Neonatal jaundice
 Perinatal mortality
 It is possible to pass the disease to the baby’s

 PREVENTION OF HEPATITIS B
 Avoid unnecessary casual sexual exposure, that is, anal, oral and
other extra genital sex.
 Use condom for casual sexual intercourse.
 Faithfulness to uninfected partner.
 Visit qualified institutions for health care to prevent contaminated articles.
 Blood should be well screened before used for blood transfusion

 Immunization of babies against hepatitis B with DPT /HibHepB vaccine.

 Care providers and health care workers at risk should be given
Hepatitis B vaccine.
 Promiscuous behavior should be discouraged.

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  Discourage kissing inside the mouth to avoid exchange of saliva.
 All pregnant women should be screened for hepatitis B during antenatal clinic visit to so
that those who are positive screened will be counsel on immunization of the baby after
delivery prevent infection.
 Post exposure immunization with hepatitis B immunoglobulin (HBIG) should especially
be considered for neonates born of mothers positive for HBsAg.
 Wash hands before and after touching blood and body fluids
 Wear disposable gloves if giving someone first aid or cleaning blood or body fluids.
 Avoid sharing tooth brushes needles syringes and personal hygiene items, or any objects
that may come into contact with blood or body fluids,
 Use new and sterile equipment for each injection.
 Cover all cuts and open sores with a water proof dressing.
 Wipe up any blood spills and clean the area with household bleach.

Effects on pregnancy / fetus

 Abortion
 Premature labour
 Pruritus is common
 Low birth weight/ Intrauterine growth retardation
 Stillbirth/IUD
 Bleeding disorders can occur
 Acquired hepatitis B presents later in life with chronic hepatitis, cirrhosis and hepatocellular
carcinoma. Acute hepatitis B in the neonate is rare but serious and has a poor prognosis.

HIV INFECTION
HIV infection is a sexually transmitted infection caused by the Human Immuno-deficiency virus
which destroys the T4 lymphocytes of infected persons and impairs their immunity. The virus is
present in the blood, semen, cervical secretions, breast milk, urine and less in saliva
HIV testing is recommended for all pregnant women. HIV testing is provided to pregnant
women in two ways: opt-in or opt-out testing. In areas with opt-in testing, women may be
offered HIV testing. Women who accept testing will need to sign an HIV testing consent form.
In areas with opt-out testing, HIV testing is automatically included as part of routine prenatal
care.

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Mother-to-child transmission of HIV is when a woman infected with HIV transmits HIV to her
baby during pregnancy, during labor and delivery, or by breastfeeding. Because HIV can be
transmitted through breast milk, women infected with HIV should not breastfeed their babies.

Effects on Pregnancy/Fetus
 Pregnancy increases the rate of opportunistic infections
 Sexually transmitted infection are common in pregnant HIV positive mothers
 Minor disorders in pregnancy may be exaggerated and HIV positive pregnant mothers do not
usually enjoy pregnancy
 Increased risk of stillbirth
 Preterm labour
 Intra-uterine growth retardation
 Transmission during pregnancy, intrapartum and postpartum period can occur
 Delivery of low birth weight babies commonly occur

Management- Prevention of mother-to-child transmission of HIV

 Voluntary counseling and screening for HIV should be done during the antenatal period.
 Anti-HIV medications are used at the following times to reduce the risk of mother-to-child
transmission of HIV:
During pregnancy, pregnant women infected with HIV receive anti-retroviral drugs zidovudine,
Retrovir, (AZT) by the second trimester of pregnancy.
During labor and delivery, pregnant women infected with HIV receive intravenous (IV) AZT
and continue to take the medications in their regimens by mouth.
After birth, babies born to women infected with HIV receive syrup AZT within 6 to 12 hours
after delivery. AZT helps prevent mother-to-child transmission of HIV. The babies receive AZT
for 6 weeks. for 6 weeks. (Babies of mothers who did not receive anti-HIV medications during
pregnancy may be given other anti-HIV medications in addition to AZT.)
The risk of mother-to-child transmission of HIV is low for women who take anti-HIV
medications during pregnancy and have a viral load less than 1,000 copies/ml near the time of
delivery.
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For some HIV-infected mothers, a scheduled Caesarean section at 38 weeks of pregnancy can
reduce the risk of mother-to-child transmission of HIV. A scheduled caesarean delivery is
recommended for HIV-infected women who: have not received anti-HIV medications during
pregnancy; or has a viral load greater than 1,000 copies/ ml or an unknown viral load near the
time of delivery. If, before her scheduled cesarean delivery, the woman have rupture of
membranes or she goes into labor, a cesarean delivery may not reduce the risk of MTCT.

Breastfeeding after delivery is a controversial issue. HIV is found in breast milk, therefore, if a
woman breastfeed there is a significant chance of passing HIV to the baby. So if the woman has
access to safe breast milk substitutes (formula) then she is advised not to breastfeed.

Mixed feeding is when a baby is fed with breast milk and other liquids such as formula, glucose
water, gripe water or traditional medicine. It is now thought that there is a higher risk of a baby
becoming HIV positive from mixed feeding than exclusive formula feeding alone or
breastfeeding. Mixed feeding may damage the lining of the baby’s stomach and intestines
making it easier for HIV in breast milk to infect the baby.

INFECTION PREVENTION PRECAUTIONS FOR A WOMAN WITH HEPATITIS

B AND HIV/AIDS DURING DELIVERY AND PUERPERIUM
 Protective clothing must be worn e.g. plastic apron, gloves, mask, boots
 Avoid spilling of blood, liquor, and body fluids. In case spillage occurs, decontaminate and
clean immediately
 Avoid unnecessary venipuncture or giving injections
 Surgical gloves should be worn during venipuncture
 Recapping of needles should be avoided but if it is to be done the one hand recapping method
should be used
 Proper disposal of sharps should be done and avoid leaving sharps around and cuts, pricks and
injury should be avoided.
 Wounds if present should be covered, if possible staff with wounds should not come in contact
with body fluids
 Avoid sharing of articles especially toiletries, blades, etc

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 Use syringe and needles for each patient and discard properly
 Proper disposal of pads should be done and mothers educated to dispose of pads in a plastic
bag
 Toilet seats should be decontaminated and cleaned after use and between users
 Disinfect body fluids and placenta before disposal
 Hand washing should be done as often as necessary especially after procedures
 Decontaminate all instruments and equipments used and sterilize properly
 Delivery bed or couch, bed pans, receivers, etc. must be decontaminated and cleaned after use
 Bed clothes should be decontaminated before washing.
 For safety to relatives of the patient, decontaminate items to be washed before giving it to
them. When necessary provide protective clothing for them and educate them on its use
whenever they have to come in contact with body fluids.

ANAEMIA IN PREGNANCY
Anaemia is a reduction in the oxygen carrying capacity of the blood. There may be a reduction in
the number of red blood cells or haemoglobin contents or both. According to WHO’s definition
of anaemia in pregnancy it is the haemoglobin concentration of less than 11g/dl but in Ghana the
accepted value is 10g/dl. In Ghana about 70% of pregnant women are anaemic
 Anaemia is a reduction in the oxygen carrying capacity of the blood. This may be caused
by decrease in the RBC production in the haemoglobin content of the blood or both.
According to WHO, a diagnosis of anaemia in pregnancy is made when the woman’s
haemoglobin level is <11g/dl and haematocrit level is <33%.
 The effects on individual depends on the severity and the speed of onset of the condition
and the degree in which the oxygen carrying capacity of the blood is diminished.
 Haematocrit is specifically a measure of the blood is made of red cells.
 Anaemia can be mild, moderate or severe.
Mild………….10-10.9g/dl
Moderate……..7-10g/dl
Severe………..<7 g/dl

PHYSIOLOGY OF ANAEMIA IN PREGNANCY

 During pregnancy, the maternal plasma volume gradually expand by 50% or an increase of
approximately 1200ml by term while RBC increase by 25%(300ml). This relative

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 haemodilution produces a fall in the haemoglobin concentration, which reduces its lowest
level during the second trimester and rises again in the third trimester.
TYPES OF ANEMIA DURING PREGNANCY
1. Physiological anaemia or hydraemia anemia: This is the increase in the maternal blood
volume in the form of plasma exceeding the level of red blood cells leading to haemodilation óf
the maternal blood around 32 -34 weeks of pregnancy. The normal Hb for pregnant women
should be maintained at 11g/dl and above.

2. Iron-deficiency anemia
Iron deficiency anaemia is a condition in which the body has too
little iron in the bloodstream. This form of anaemia is more common in adolescents and in
women before menopause. This type of anemia occurs when the body doesn't have enough iron
to produce adequate amounts of hemoglobin. That's a protein in red blood cells.

Functions of iron

* Iron is a mineral found in the red blood cells and is used to carry
oxygen from the lungs to the rest of the body.
It helps the muscles store and use oxygen.
When too little iron is produced, the body can become fatigued and have a lowered resistance to
infection.

Causes of Iron-deficiency anemia

 Iron deficiency occurs when the rate of loss or use of iron is more than its rate of absorption
and use. The reasons for this are:
 Chronic blood loss : most commonly due to excessive menstruation or bleeding into or from
the gut as a result of a peptic ulcer, gastritis, haemorrhoids or in children, worm
infestation.
 Increased use of iron : In pregnancy, due to the growth of the foetus or children undergoing
rapid growth spurts in infancy and adolescence.
 Decreased absorption of iron

3. Folic Acid Deficiency Anaemia

This form of anaemia is characterised by a lack of folic acid, one of the B group of vitamins, in
the bloodstream.

CAUSES OF FOLIC ACID DEFICIENCY ANAEMIA

Inadequate intake of folic acid usually found in vegetables or by the overcooking of the
vegetables. Alcoholism can also be a contributing factor in this form of anaemia.
During pregnancy when there is an increase demand of folic acid.

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Symptoms of the disorder include:

1. Weakness
2. Fatigue
3. Memory lapses
4. Irritability

MANAGEMENT OF FOLIC ACID DEFICIENCY ANAEMIA

 This condition can be avoided by including foods with folic acid in
the diet. Such foods include beef liver, asparagus, and red beans.
 Taking folic acid supplement

4. Vitamin B12 deficiency anemia

The body needs vitamin B12 to form healthy red blood cells. When a pregnant woman doesn't
get enough vitamin B12 from her diet, her body can't produce enough healthy red blood cells.
Source: Vitamin B12 can be found in meat, poultry, dairy products, and eggs.

FUNCTION OF VITAMIN B 12

Vitamin B-12 is necessary vitamin for the body for the production of red blood cells.

5. Aplastic Anaemia
Aplastic anaemia is a blood disorder in which the body's bone marrow doesn't make enough new
blood cells. Aplastic anaemia is a rare but serious condition. It can develop suddenly or slowly
and tends to worsen with time, unless the cause is found and treated.

TREATMENT OF APLASTIC ANAEMIA

Treatment for aplastic anaemia includes

Blood transfusions
Transplants of the blood and marrow stem cell to improve quality of life.
Removing a known cause of aplastic anaemia, such as exposure to a toxin, may also cure the
condition.

COMPLICATIONS
Arrhythmias
An enlarged heart
Heart failure

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 Infections
Bleeding disorders
7. Hemolytic Anaemia
Is a condition in which red blood cells are destroyed and removed from the bloodstream before
their normal lifespan is up. There are many types of haemolytic anaemia-some of which
are inherited and others that are acquired.

Inherited haemolytic anaemias include:

 Sickle cel anaemia
 Thalassaemias- are inherited blood disorders which cause the body to make fewer healthy red
blood cells and less haemoglobin.
 Hereditary spherocytosis: is an inherited disease that affect the RBC
 Hereditary elliptocytosis: is an inherited blood condition, where the RBC are abnormally
shaped.
 Glucose-6-phosphate dehydrogenase (G6PD)) deficiency

Acquired haemolytic anaemias include : is a disorder that occurs in individuals who

previously had a normal red blood cell system)
 Immune haemolytic anaemia
 Autoinmune haemolytic anaemia
 Alloimmune haemolytic anaemia (when the body makes antibodies against red blood cells
that you get from a blood transfusion)
 Drug-induced haemolytic anaemia
 Mechanical haemolytic anaemia
 Paroxysmal nocturnal haemoglobinuria (a rare blood disorder that happens when your
immune system attacks and damage your red blood cells and platelet)
 Certain infections and substances can also damage red blood cells and lead to haemolytic
anaemia.

 8. Sickle Cell Anaemia

Definition: Sickle cell anaemia is a serious disease in which the body makes sickle-shaped
("C"-shaped) red blood cells. Normal red blood cells are disk-shaped and move easily
through the blood vessels. Red blood cells contain the protein haemoglobin (an iron-rich
protein that gives blood its red colour and carries oxygen from the lungs to the rest of the
body).

 Sickle cells contain abnormal haemoglobin that causes the cells to have a sickle shape, which
don't move easily through the blood vessels- they are stiff and sticky and tend to form clumps
and get stuck in the blood vessels.

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 The clumps of sickle cells block blood flow in the blood vessels that lead to the limbs and
organs. Blocked blood vessels can cause pain, serious infections, and organ damage.


Sickle cells are fragile and have a short life span of about 10 to 20
days instead of 120 days and the body can't reproduce red blood cells fast enough to
replace the dying ones, which causes anaemia and causes episodes of ischaemia and pains
known as sickle cell crisis.

PREDISPOSING FACTORS FOR SICKLE CELL CRISIS

 Strenuous exercise or work

 Infection
 Cold weather
 Psychological stress
 Fever
 Low oxygen contraction
 Pregnancy
 Respiration diseases

Signs and Symptoms

 Painful bones or joints
 Abdominal pains
 Fatigue
 Shortness of breath
 Dizziness
 Headache
 Coldness in the hands and feet
 Pale skin
 Chest pain

 MANAGEMENT OF SICKLE CELL ANAEMIA

 Treatments of sickle cell anaemia can help relieve symptoms and treat complications. The
goals of treating sickle cell anaemia are to relieve pain, prevent infections, eye damage and
stroke, and control complications.

 Reassure client and the relatives to allay their fear and explain the condition to them.

 Take blood sample for full blood count, grouping and cross matching for possible blood
transfusion.

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 Mobilize donors for possible blood transfusion in severe cases

 Do urine R/E to rule out UTI.

 Administer intravenous fluid replacement and restore circulating volume with plasma
expander's and to prevent dehydration eg normal saline, ringer lactate until the condition
improves.

 Check vital signs as temperature, pulse, respiration and blood pressure every 15 minutes for
the first hour, 30 minutes for the next two hours as the condition improve, l hourly for the
next 3hours and 4hrly till discharge.

 Administer 4 to 6 litres of oxygen by mask if there is respiration distress.

 Serve client with a prescribe analgesia for the relief of pain eg lnj pethidine 100mg when
necessary

 Administer prescribed intravenous antibiotics eg lV Ampicilin 2g 6 hourly for 48 hours or IV

Amoksiklav 1.2g or iv metronidazole 500mg 8 hourly for 48 hours to combat the infection

 Counsel client to avoid all the predisposing factors of sickle cell crisis.

 Monitor the development of the fetus using the ultrasound

 Counsel client on adequate diet and intake of more fluid to flush her system of toxics

 Counsel pregnant women on the importance of antenatal clinic visit

 Iron supplement should be given during pregnancy.

 Bone marrow transplants may offer a cure in a small number of

sickle cell anaemia cases.

9. Pernicious Anaemia

Pernicious anaemia is a condition in which the body can't make enough healthy red blood cells
because it doesn't have enough vitamin B12 (a nutrient found in certain foods). People who have
pernicious anaemia can't absorb enough vitamin B12 due to a lack of intrinsic factor (a protein
made in the stomach).

 GENERAL CAUSES OF ANEMIA DURING PREGNANCY

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 The cause of anemia truly comes down to how many red blood cells are being produced in
the body and how healthy they are.
 A fall in hemoglobin levels during pregnancy is caused by a greater expansion of plasma
volume compared with the increase in red cell volume. This disproportion between the rates
of increase for, plasma and erythrocytes has the most distinction during the second trimester.
 A lack of iron in the diet as a result of not eating enough iron-rich foods or the body's
inability to absorb the iron being consumed.
 Pregnancy itself because the iron being produced is needed for the woman's body to increase
her own blood volume.
 Heavy bleeding due to menstruation
 An ulcer or polyp
 Blood donation causes red blood cells to be destroyed faster than they can be replenished
 Dietary deficiency
 Diarrhoea
 Hyperemesis gravidarum
 Multiple gestation
 Bleeding haemorrhoids
 Antepartum haemorrhage
 Malaria
 Sickle cell disease
 G6PD
 Food taboos
 Hookworms infestation

GENERAL SIGNS AND SYMPTOMS OF ANEMIA DURING PREGNANCY

The tongue may become smooth, shiny and inflamed this is called glossitis
Angular stomatitis (erosion, tenderness and swelling at the corners or the mouth) may also occur.
In some instances, the patient also suffers from pica, a craving for strange foods such as starch,
ice and clay.
 Weakness or fatigue
 Dizziness
 Shortness of breath
 Rapid or irregular heartbeat
 Chest Pain
 Pale skin, lips, and nails
 Cold hands and feet
 Trouble concentrating
 Oedema at the ankle due to salt retention and water

 GENERAL TREATMENT FOR ANEMIA DURING PREGNANCY

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 Anemia during pregnancy can easily be treated by adding iron or vitamin Supplements to the
Client daily routine
 Blood transfusion.

PREVENTION OF ANEMIA DURING PREGNANCY.

 Adding iron supplement to the diet of the client. Medical professionals recommend a
pregnant woman eat 30mg of iron each day
 Counsel client on the intake of nutritious diet
 Early diagnosis and treatment of antepartumhaemorrhage
 Administration of Malaria prophylaxis and the use of insecticide treated net
 Deworming at 2nd trimester
 Screening of all pregnant women for SCD and G6PD at antenatal for proper management.
 Administration of iron supplements to all pregnant women.
 Education on nutrition
 Identification and proper management of conditions like hyperemesis gravidarum.
 Healthy timing and spacing of children.

Examples of iron-rich foods are:

 Lean, red meats and poultry

 Eggs
 Dark, leafy green vegetables (such as broccoli,and spinach
 Nuts and seeds
 Beans, etc

 Foods that are high in vitamin C can actually help the absorption  of more iron, so it is
beneficial to make these additions as well.

 Vitamin C rich foods include:

 Citrus fruits and juices

 Strawberries
 Oranges
 Kiwis
 Tomatoes
 Bell peppers

COMPLICATIONS OF ANAEMIA ON PREGNANCY

 low birth weight

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 premature birth
 still birth
 abortion
 Intrauterine death
 maternal mortality

Causes of Anaemia in Pregnancy

 Reduced dietary intake of iron, folic acid, vitamin.B12, vitamin C and protein. Contributing
factors to this include poverty, ignorance, food taboos, and cooking and eating habits
 Reduce absorption as in gastrointestinal disorders in pregnancy e.g. morning sickness,
hyperemesis gravidarum
 Acute infections e.g. malaria
 Excess demand by fetus or fetuses
 Chronic blood loss from bleeding haemorrhoids or hookworm infestation
 Haemolysis e.g. sickle cell disease, thalassaemia or G6PD

Effects on Mother/Pregnancy
 There is reduced resistance or immunity
 The woman does not feel comfortable due to symptoms of anaemia
 Abortion
 Preterm labour
 Predisposition to post-partum or the slightest blood loss during delivery gives a fatal outcome

Effects on Fetus
 Low birth weight/ Intra-uterine growth retardation
 Stillbirth/intra-uterine death
 Fetal hypoxia

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 CHAPTER 6
DIABETES MELLITUS IN PREGNANCY
Diabetes is a group of metabolic disorders characterized by increased levels of glucose in the
blood (hyperglycemia) resulting from defects in insulin secretion, insulin actions or both. The
major classification of DM are:
Type 1 DM
Type 2 DM
Gestational diabetes
Diabetes associated with other conditions or syndromes.

Except with the type 1 diabetes, patient may move from one category to the other. E.g. someone
with gestational diabetes can move to type 2 DM after delivery.

PATHOPHYSIOLOGY
Insulin is secreted by one of the beta cells, which is one of the cells of the islet of Langerhans in
the pancreas. Insulin is a stored hormone when one eats, insulin secretion increases and moves
glucose from the blood to the muscle, liver, and fat cells. In those cells insulin;
 Transport and metabolizes glucose for energy
 Stimulates storage of glucose in the liver and muscles in the form of glycogen.
 Signals the liver to stop the release of glucose
 Enhances the storage of dietary fat in the adipose tissues
 Accelerates transport of amino acids derived from proteins into cells
 Insulin also inhibits the breakdown of stored glucose into fats and protein.

During fasting, the pancreas continuously releases small amount of insulin (basal
insulin).another pancreatic hormone called glucagon which is secreted by the alpha and beta cells
of the islets of Langerhans when blood glucose is reduced is also secreted. The insulin together

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with the glucagon maintains a constant level of blood glucose by stimulating the release of
glucose from the liver. Initially the liver produces glucose through the breakdown of glycogen
(glycogenesis). After 8-12 hours without food then the liver now forms glucose from the
breakdown of stored fats and proteins

Type 1 DM
There is destruction of beta cells in the islets of Langerhans in the pancreas, stopping insulin
production or decreasing insulin. The glucose released by the liver is unchecked resulting in
fasting hyperglycemia. In addition, glucose derived in foods cannot be stored in the liver but
instead remains in bloodstream and contributes to postprandial hyperglycemia. If the
concentration exceeds renal threshold (9.9-11.1mm/l) then the kidneys fails to absorb all the
filtered glucose so it appears in the urine (glycosuria). When excess glucose is excreted in the
urine, it is accompanied by excessive fluid and electrolyte called osmotic diuresis. Because there
is an impairment in insulin production, glycogenolysis and glyconeogenesis occurs in unstrained
manner contributing to high glucose in the blood and the production of ketones from the
excessive breakdown of fats causing DKA.
Insulin therapy is required in order to prevent the development of ketoacidosis, coma and death.
It presents more commonly in childhood, but can occur at any age in some caes can contribute to
autoimmune process.

Type 2 DM
Affects 90-95% of people with DM and found commonly in those older than 30 and obese
people.
The main problem is with impairment with insulin utilization or secretion. There are special
receptors on cell surfaces that insulin binds to be able to initiate glucose metabolism but in this
type these intracellular reactions are diminished making insulin less effective.
So to overcome insulin resistance the glucose builds up in the blood, increased amount of insulin
must be secreted to maintain the glucose level. If the beta cells are incapable then the glucose
levels in the blood increases and type 2 DM ensues.

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 Clinical manifestation of DM
 Excessive hunger (polyphagia). This is because the body convert food into glucose that
the cells use for energy. But the cells needs insulin to bring the glucose in so if the body
doesn’t make enough or any insulin, or if the cells resist the insulin the body makes,
glucose can’t get into them and there will be no energy. This causes hunger and fatigue
than usual.
 Frequent micturition (polyuria)
 Frequent yeast infection
 Weight loss
 Delayed wound healing
 Glycosuria

Diagnosis of DM by (WHO)
Diabetes symptoms of;
 increased thirst
 increase urine volume
 unexplained weight loss
 A random venous glucose concentration of ˃11mmol/l or fasting plasma concentration
˃11.1mmol/l 2hours after 75g anhydrous glucose in an oral glucose tolerance test
(OGTT).
Without symptoms, diagnosis should not be based on single glucose determination taken on
another day. The OGTT should always be used to diagnose gestational diabetes mellitus and
impaired glucose regulation.

Gestational Diabetes
This refers to glucose intolerance of any degree that develops or is first recognized during
pregnancy, irrespective of whether it resolve after delivery or not. The progressive increase in
insulin demand during pregnancy can make latent diabetes appear. Certain women are at special
risk of developing diabetes during pregnancy and they include:
- those with a history of diabetes in a close family member e.g. mother or father
- obese women

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- those who exceed the normal weight range by more than 20% during pregnancy

Causes /Predisposing of GDM

Prediabetes (blood sugar that’s elevated, but not high enough to be called diaetes)
High blood pressure
Weight ˃100kg
BMI ˃30kg/m2
A history of gestational diabetes
A family history of type 2 diabetes
Hormone disorder, such as polycystic ovary syndrome (PCOS)
Being overweight, or gaining too much weight during pregnancy.
Previously unexplained stillbirth or miscarriage
Previous history of big baby (4kg or more)

Diagnosis
 Urine sugar should be tested at each antenatal visit especially for those at risk
 If glycosuria of + or ++ on two occasions or +++ or ++++ on one occasion the woman must
have a glucose tolerance test
 Blood sugar may also be done i.e. Random Blood sugar or Fasting Blood sugar
 2 hour post-prandial blood sugar
 Oral glucose tolerance test (OGTT)

Effects of Pregnancy on Diabetes

 Diabetes control may be complicated by nausea and vomiting
 Throughout pregnancy there is the tendency to always have glycosuria
 Vaginal infections especially candidiasis are common
 Fetal demands for glucose causes mothers need for carbohydrate to be increased
 A diabetic who is controlled by diet only or tablets may depend on insulin during pregnancy
 Diabetics who already have nephropathy or retinopathy can progress to kidney failure and
blindness

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Effects of Diabetes on Pregnancy
When diabetes is well controlled its effects on pregnancy is minimal
Maternal haemoglobin become bound to glucose i.e. glycoslated haemoglobin
Fertility is reduced
There is increased risk of abortion
The woman is prone to urinary tract infections
Increased incidence of candidiasis
Pre-eclampsia can occur
Polyhydramnios is common among diabetes
Caesarean section is usually indicated since babies are large for age

Effects on Fetus
Stillbirth/intra-uterine death
Perinatal mortality rate is high
Intra-uterine growth retardation occurs due to glycoslated haemoglobin
Fetal polycythaemia
Congenital abnormalities such as sacral agenesis, neural tube defect, kidney and heart defects
are common
Neonatal jaundice
Babies of mothers with poorly controlled Diabetes mellitus may be large for date
(macrosomic) and prone to hypoglycaemia

Care during Pregnancy

1. The woman need to attend ante natal clinic more frequently than the normal schedule i.e.
fortnightly till 32 weeks then weekly till term
2. She would have to attend diabetic clinics as well and be seen by the physician
3. She must be educated to pay attention to her personal hygiene and measures taken to avoid
genitor-urinary infections
4. Maternal health must be monitored closely especially weight
5. Monitor fetal growth and well being

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6. Ensure adequate calorie intake especially if nausea and vomiting is present, the diet must be
reviewed often. Diet high in fibre gives a constant blood glucose
7. Insulin is the best means of control of diabetes in pregnancy.
8. Blood glucose and urine sugar must be estimated during each visit

Care during Labour and Delivery

1. Proper examination should be done and a suitable mode of delivery chosen
2. Dexamethasone is given in case of preterm labour to aid lung maturation.
3. If vaginal delivery, labour should start spontaneously unless there is poor diabetic control,
macrosomia or deterioration in maternal or fetal condition which indicates induction
4. A paediatrician should be present during delivery
5. Fetal condition should be monitored closely throughout labour
6. Resuscitation equipments must be ready since birth asphyxia is common
7. The mother is given oral diet or intravenous fluids depending on the doctors’ orders
8. Hourly blood glucose level estimation is done
9. Soluble insulin is given according to blood sugar results

Care during Postnatal

1. Carbohydrate metabolism returns quickly to normal after delivery of placenta
2. Dose of insulin should be halved immediately after delivery
3. Intravenous infusion should be maintained until the next meal
4. Blood sugar levels should be estimated and insulin adjusted to blood sugar results
5. Diabetic lactating mothers need to increase carbohydrate intake
6. The baby must be examined for congenital abnormalities and birth injuries
7. The baby must be observed closely and resuscitation done if necessary since asphyxia is
common
8. The baby should be fed as soon after delivery as possible and blood sugar monitored.
9. OGTT should be done at 6 weeks post natal

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 JAUNDICE IN PREGNANCY
Jaundice in pregnancy may be a sign or symptom of a severe disease
Causes
 Severe pre-eclampsia or eclampsia
 Haemolysis Elevated Liver Enzymes Low Platelets Syndrome (HELLP)
 Severe hyperemesis
 Cholestatic jaundice of pregnancy
 Acute fatty liver of pregnancy
 Viral hepatitis
 Haemolysis as in malaria, sickle cell disease, G6PD, Septicaemia
 Cholelithiasis/obstructive jaundice

Effects on Pregnancy and Fetus

Pruritus is common
Stillbirth/intra-uterine death
Perinatal mortality rate is high
Intra-uterine growth retardation
Low birth weight
Preterm delivery
Bleeding disorders can occur
Depending on the cause trans placental infection may occur

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 SICKLE CELL DISEASE
Pregnant women with sickle cell disease present with either sickle cell anaemia or sickle cell
crisis.

Effects on Pregnancy/Fetus
Patients who are genotype SC have more problems during pregnancy and delivery than those who
are SS. Crisis and anaemia are common during the last 4 weeks of pregnancy, during labour and
first week of puerperium.
Women with sickle cell disease are usually sub fertile
Those who become pregnant may already have organ damage which complicates the
pregnancy
Pre-eclampsia
Jaundice
Anaemia
Abortion
Premature labour
Stillbirth/intra-uterine death
Perinatal mortality rate is high
Intra-uterine growth retardation
Low birth weight
Fetal hypoxia
Increased maternal mortality
Increased fetal mortality

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Care during Pregnancy and Labour
1. Antenatal care should be more frequent.
2. Sickle cell clinic should be attended and the physician included in the care
3. Provision of psychological support is necessary
4. Education on diet, prevention of anaemia and avoidance of precipitating factor should be
given
5. Frequent haemoglobin check should be done
6. Close monitoring of maternal and fetal condition is necessary
7. Supplements of folic acid and vitamins are given
8. In labour dehydration and starvation must be prevented
9. 2-3 pints of blood should be ready during labour in case crises occur
10. Intravenous fluids e.g. Normal saline should be set up during labour
11. Analgesics should be given
12. Prolonged labour should be avoided i.e. all the 3 stages
13. Prophylactic antibiotic is given before labour
14. Post-partum haemorrhage should be prevented as much as possible

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 CHAPTER 7
MALARIA IN PREGNANCY
Malaria in pregnancy can be very serious and is considered important due to the effects on the
mother and fetus. Pregnant women are vulnerable to malaria due to the lowered immunity
against malaria parasites

MALARIA IN PREGNANCY
 Is a parasite infection transmitted by the female anopheles mosquito. It is the commonest
cause of morbidity in Ghana. It is particularly common and more severe (with
complication in pregnant women and children).
 Pregnant women have been found to attract anopheles mosquito more than the non-
pregnant women due to changes in hormonal levels, increased body surface temperature,
increase released of carbon dioxide and the presence of placenta.
 Malaria is an acute disease of the blood caused by the parasite plasmodium.
 There are four types of plasmodium, which affect humans, these are;

 Plasmodium falciparum
 Plasmodium malariae
 Plasmodium ovale
 Plasmodium vivax

 Most infectious are due to either P. Falciparum or P. Vivax.

 P. Falciparum is the most common and dangerous cause of Malaria infection.

MODE OF TRANSMISSION

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  The bite of an infected mosquito female anopheles mosquito
 Transfusion of an infected blood (rrare.
 Congenital transmission i.e from mother to baby through the placenta (rare)
 Using contaminated needles with malaria parasite.

TYPES OF MALARIA
 Complicated malaria
 Uncomplicated malaria

Uncomplicated malaria: this is when the patient presents with the history of fever with the
absent of an organ dysfunction and life threatening.
SIGNS AND SYMPTOMS OF UNCOMPLICATED MALARIA
 Nausea and vomiting
 Malaise
 Lower abdominal pain
 Headache
 Fever, chills and rigor
 Dry cough
 Pallor dizziness
 Loss of appetite
 Bitterness in the mouth
 Abdominal pain associated with uterine contractions
 Frequent or reduced foetal movement

DIAGNOSIS
 Full blood count.
 Blood film for malaria parasite
 Clinical signs and symptoms
 Rapid diagnostic test (RDT)

MANAGEMENT OF MALARIA IN PREGNANCY

 Counsel client on nutritious diet to build the immune system

 Encourage client on intake of lot of fluid

 Anemia can be treated with oral ferrous sulphate and folic acid

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 Serve client with analgesics e.g tab paracetamol 1g tds for 3days.

First trimester:

 Oral Quinine 600mg 8hrly for 7days OR

 Oral Quinine at 10mg /kg body weight three times per day for 3days plus 300mg of
Clindamycin for 3times daily for 3days is the first line treatment

2nd and 3rd Trimester

 In the 2nd and 3rd trimester first line treatment is an artemisinin-based combination
therapy (ACT)

 Oral Quinine 600mg 8hourly for 7days

 Artesunate- Amodiaquine: Artesunate 4mg /kg body weight and Amodiaquine 10mg / kg
body weight should be together for 3days. OR

 Arthmether-lumefantrine (AL): A- 20mg plus lumefantrine 120mg.

Day 1= 4tablets stat followed by 4tablets 8hrs later.

Day 2= 4 tablets twice daily

Day 3 = 4 tablets twice daily.

Supportive Treatment
 Analgesics for management of pain
 Antipyretic for treatment of fever
 Haematenics for treatment of anaemia
 Antiemetics for vomiting
 Increase fluid intake
 Advice client on nutritious diet
 Repeat ACT if there is vomiting within 30mins

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 Treatment failure
It occurs when a patient with confirmed uncomplicated malaria, who has taken the correct
dosage and followed the regimen of the nationally recommended antimalarial treatment, still
has parasites on a blood smear within 14days of the start of treatment.
NB: Treatment failure must be distinguished from inadequate treatment.
Failure to improve on treatment may be due to a variety of reasons. These includes
1. Symptoms due to a cause other than malaria.
2. Inadequate treatment (dose/compliance)
3. Vomiting the medication
4. Poor quality of drug
5. Resistance malaria parasite
If client complied with treatment and the blood slide is positive for malaria give ;
Quinine -adult dose 600mg 8hrly for 7days OR Quinine+ Doxycycline or
Clindamycin (all for 7days). In case of poor compliance, repeat treatment under
observation.

Complicated malaria / Severe malaria: this is when the patient presents with fever which is
life threatening associated with vital organs dysfunction.

SIGNS AND SYMPTOMS OF COMPLICATED MALARIA

 Hyperpyrexia (greater than 38.5)
 Impaired consciousness
 Respiratory distress
 Jaundice
 Repeated profuse vomiting
 Circulatory failure
 Shock
 Difficulty in breathing
 Unexplained spontaneous heavy bleeding
 Generalized weakness
 Hyper-paracetaemia 3+ or more from blood film
 Signs of haemoglobinuria that is dark or coca-cola coloured urine
 Pulmonary oedema

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 COMPLICATED MALARIA

 Client should be admitted for proper management.

 Treatment should be started as on as possible to prevent complications to mother and
baby. Where quinine is not available or patient cannot tolerate quinine, artemether
injection can be used.
 For severe malaria, in all the trimesters and puerperium
parenteral IM or IV Quinine should be used. 1M Quinine 10 mg/kg BW every 8 hours
OR
 For IV administration the diluents may be 5-10% Dextrose or Dextrose/Saline infusion at
a rate of 5mg/kg wt per hour over 48hours (Hence the IV infusion of 500mls must be
over 4hours). Alternatively, Artemether IM can be use except in the first trimester. OR
 Change to Oral Quinine 1Omg/ kg body weight(max 600mg) 8hourly for 7 days if client
can tolerate.
 Anaemia can be treated with oral Ferrous sulphate (200mg) and
Folic Acid (5mg) daily.

 STRATEGIES FOR MALARIA PREVENTION IN PREGNANCY

 Intermittent preventive treatment (IPT)

 Use of insecticide-treated net and materials (ITNs)
 Iron and folate supplementation
 De-worming
 Environmental hygiene
 Regular monitoring of pregnant women for side effects and putting measures in place
 Creating awareness
 Equipping health facility with the necessary equipment

PREVENTION OF MALARIA IN PREGNANCY

Vector control:
 Indoor residual spray
 Cleaning of the environment
 Care of stagnant waters
 Burying of empty cans
 Application of larvicides
 Insecticide treated net

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 Effect of malaria on the fetus

P. falciparum-infected red cells sequester in the placenta, disrupting nutritional exchange

between mother and fetus and causing
 intrauterine growth retardation/ Low birth weight
 Preterm baby
 Still birth
 Congenital malaria

Effect of malaria on pregnancy maternal

 Abortion
 Anaemia
 Preterm labour
 placental parasitaemia
 Coma
 Convulsion
 Premature labour
 Jaundice
 Increased uterine contractions
 Hypoglycaemia

COMPLICATIONS OF SEVERE MALARIA.

 Cerebral Malaria
 Renal failure
Effects of Malaria on Pregnancy/Fetus
Abortion
Premature labour/ delivery
Haemolysis leading to anaemia
Malaria parasites invade the placenta which leads to placental insufficiency.
Stillbirth/intra-uterine death
Perinatal mortality rate is high
Intra-uterine growth retardation
Low birth weight
Fetal hypoxia
Some parasites may cross the placenta leading to neonatal malaria

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Prevention
1. General measures to prevent malaria must be used
2. Intermittent Preventive Treatment using Sulphadoxine Pyrimethamine as DOT
- 1st dose-after quickening (16-20 weeks) 3 tabs SP (sulphadoxine pyrimethamine)
- 2nd dose-3 tabs SP 1 month after 1st dose
- 3rd dose- 3 tabs SP 1 month after 2nd dose
-4th dose 1 month intervals
-5th dose 1 month intervals
NB. HIV positive women are given 3 tabs SP monthly from 16 to 20 weeks until 36 weeks.

CHAPTER 8
HYPERTENSIVE DISORDERS IN PREGNANCY
Hypertension: This is an abnormally high tension in the blood vessel above 140\90mmHg i.e.
diastolic pressure of 90 mmHg or
Above on 2 consecutive readings taken 4 -6 hours or more apart
This includes:

✓ Chronic hypertension

✓ Gestation hypertension

✓ Pre-eclampsia

✓ Eclampsia

✓ Pre-eclampsia superimposed on chronic hypertension

RISK FACTORS OF HYPERTENSIVE DISORDERS IN PREGNANCY

✓ Multiple pregnancy

✓ Sedentary life

✓ Nuliparity

✓ Family history

✓ Chronic hypertension

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✓ Hydatidiform mole

✓ Obesity

✓ Elderly or young primigravida less than 17 and more than 35 years.

✓ Chronic disease e.g. Diabetes mellitus, hypertension

✓ Previous history

CLASSIFICATION
Chronic hypertension: this is when a woman is a known hypertension before becoming pregnant
or when there is rise in Bp above 140/90mmHg before the 20th week of gestation,which persists
6weeks after delivery.

1. Pregnancy induced hypertension: it occurs after 20 weeks of pregnancy, during labor and
within 48 hours after delivery of a diastolic pressure of 90-110mmHg and disappears most of
the 6weeks after delivery

2. Gestational hypertension: When pregnant women develops HPT without signs of pre
eclampsia for the first time pregnancy. OR  when BP is equal or above 140/90mmHg at risk 
on two or more occasion after 20weeks gestation. OR
Hypertension that is diagnosed for the first time in pregnancy.

4. Pre eclampsia: a pregnant women With high blood pressure of >140/90mmHg plus
proteinuria >1+ on dipstick with severe headache, abdominal or epigastric pain and blurred
vision.

TYPES OF PRE ECLAMPSIA

 Mild Pre eclampsia: Blood pressure of 140/90mmHg, on two or more occasions after 2 to
4hours rest with proteinuria of 1+ on dipstick

 Moderate Pre eclampsia: Blood pressure of 149/99mmHg a diastolic blood pressure

of 90-99mmHg on two or more occasions after 2 to 4hours rest with proteinuria of 2+ on
dipstick.

 Severe Pre eclampsia:Blood pressure of more than or equal 160/110mmhg on two or

more occasions after 2 to 4hours rest with proteinuria of 2+ or 3+ on dipstick.

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  Eclampsia: is the onset of convulsion during pregnancy or postpartum which occurs in
pre_eclampsia which is not related to any cerebral pathological condition.

 Pre-eclampsia superimposed on chronic hypertension: This may occur in women with

pre-existing hypertension before 20 week's gestation who develops proteinuria or sudden
increase in pre-existing hypertension with proteinuria or thrombocytopacnia (low platelet
count) or abnormal liver enzymes. Women with pre-existing hypertension who develop
other signs of Pre-eclampsia:

✓ Proteinuria of 2+ or 3+ on dip stick

✓ Sudden increase in blood pressure above 140/90mmHg
✓ Systolic pressure >160 mmHg
✓ Diastolic pressure of > 110mmHg
✓ Headache
✓ Blurred vision
✓ Abdominal/ epigastric pain
✓ Low platelet level
✓ Abnormal liver enzymes

WHAT IS HELLP SYNDROME

HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant

of preeclampsia. HELLP syndrome was named by Dr. Louis Weinstein in 1982 after its
characteristics:
✓ H- hemolysis, which is the breaking down of red blood cells)
 EL- elevated liver enzymes)
✓ LP- (low platelet count)

SIGNS AND SYMPTOMS

✓ Nausea and vomiting
✓ Malaise
✓ Epigastric pains

COMPLICATION OF HELLP SYNDROME

✓ Renal failure
✓ Pulmonary oedema

DIAGNOSIS OF HYPERTENSIVE DISORDERS

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✓ Through taking of comprehensive history.
✓Blood pressure measurement. The base reading must be taken so that subsequent readings can
be compared to it.
✓ Urinalysis. In the absence of urinary tract infection, protein in urine is an indication of kidney
damage and it must be reported for further investigation

✓ Signs of edema (Sudden severe appearance of edema) and excessive weight gain.

✓ Laboratory investigation such a thrombocytopenia, abnormal liver function, raised serum

creatinine and urea levels etc.

MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION AND CHRONIC

HYPERTENSION AT THE VARIOUS LEVELS

✓ Clients with the mild conditions will be monitored on outpatient basis with frequent antenatal
visit.
✓ They will be educated on signs and symptoms that show that the condition is worsening and
what to do if it occurs. Furthermore they will be educated on reduction of workload. Those with
mild to severe PIH and chronic hypertension will be managed as follows:

COMMUNITY LEVEL (CHO, TBA)

1. Receive woman and accompanying relative and reassure.

2. Take history and assess the condition by checking the blood pressure.
3. If the blood pressure is equal or above 140/90mmHg look for oedema of the feet, hands, face
and ankles.
4. Ask the woman if she is experencing severe headache, blurred vision or epigastric pain.
5. If any of these present refer the woman to the next level accompanied by the health provider
or a support person.

LEVEL B (HEALTH CENTRE)

1. Receive woman and accompanying relative and reassure.

2. Take history and assess the condition by checking the blood pressure in the sitting up position.
✓ If the diastolic blood pressure is equal to or above 90mmHg repeat after one hour rest.

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✓ If it is still equal to or above 90mmHg, ask the woman if she has severe headache, blurred
vision, epigastric pain and protein in urine.
✓ If none is present, counsel the woman to reduce workload and rest.
✓ Administer tablet Methyldopa/ Nifedipine if the diastolic blood pressure is equal or greater
than 110 mmHg.
✓Counsel on danger signs and refer.

HOSPITAL MANAGEMENT (LEVEL C)

1. Receive the woman and accompanying relatives and reassure.

2. Take a comprehensive history
3. Explain the condition to the woman and accompanying relative and the need for admission.
Also explain the prognosis or the condition to them and give the necessary support.
4. Admit into a comfortable bed and ensure rest by ensuring a quiet environment, restricting
visitors and doing of nursing procedures at a go.
5. Observe the following
✓ Weight
✓ Vitals should be monitored every 4hrly and charted especially blood pressure four hourly
✓ Daily checking of protein in urine and record
✓ Abdomninal examination to rule out tenderness which is indicative
Of placental abruption.
✓ Check foetal heart rate during abdominal examination.
✓ Foetal kick count is monitored using the chart.
✓ Client is observed for signs of pre-eclampsia and eclampsia
6. Ensure various requested investigation are done e.g ultrasound
7. Scan is done regularly to monitor placenta function.
8. Ensure her personal hygiene is maintained.
9. Ensure she is able to move her bowel and bladder.
10. Give prescribed oral antihypertensive and other prescribed
Drugs such as methyldopa, hydralazine, Nifedipine, etc.and record.
11. If blood pressure rises that is diastolic pressure equal to or greater than 110mmHg start
hydralazine.

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a. Hydralazine regimen: Give 5mg IV slowly over 5 – 10minutes. If IV
Not possible give IM.
12. Educate her on danger signs, the need for rest and the need to cooperate with care takers.
13. If condition becomes stable and gestation is less than 37wees
Doctor will discharge home. The woman must be monitored and deliver at 37weeks.
14. If condition does not stabilise and there is fetal growth restriction, then delivery must be
expedited.

MANAGEMENT OF MILD PRE-ECLAMPSIA LEVEL A (COMMUNITY LEVEL)

 Same as the management of PIH at level A.

LEVEL B (HEALTH CENTRE)

 Same as the management of PIH at level B.

LEVEL C (HOSPITAL MANAGEMENT)

1. Same as the management of PIH at hospital plus the following:
2. Receive woman and relatives and reassure to allay their fear and anxiety.
3. If gestation is less than 37weeks and her condition normalize,
1. Monitor twice weekly as outpatient and admit when the urine protein increases or no
improvement in condition.
2. ✓ Check for protein and acetone in urine.
3. ✓ Monitor foetal condition.
4. ✓ Counsel woman on danger signs and encourage adequate diet.
5. ✓ If diastolic BP is >100mmHg, start Antihypertensives drugs.
6. If gestation is above 37weeks and foetal conditions are normal, deliver by the safest and
quickest means.
7. If gestation is above 37weeks and there are signs of foetal compromise, inform doctor for
emergency c/s
8. If urinary protein increases or BP worsens inform doctor who will manage as severe pre-
eclampsia .

MANAGEMENT OF SEVERE PRE-ECLAMPSIA/ IMMINENT ECLAMPSIA.

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LEVEL A (CHO /TBA)
1. Receive the wonman and immediately prepare to refer
accompanied by support person and health provider.

LEVEL B (HEALTH CENTRE)

1. Receive the woman, relative and reassure them.

2. Put the woman into bed and start resuscitation with IV ringers lactate at a rate of
30drops/minute.
3. Pass urinary catheter and monitor fluid intake and urine output. Check and record BP
every 15-30 minutes
4. Monitor respiration rate and reflexes.
5. Start sublingual nifedipine stat
6. Start MgS04 (first choice) or diazepam protocol and document.
7. If in labour but not near second stage refer immediately accompanied by the midwife.
8. If in labour and near delivery, deliver by vacuum extraction when second stage.
9. Conduct active management of the third stage (do not give ergometrine)
10. Transfer to the next level after delivery
NOTE: during transfer monitor IV infusion, urine output and keep record of all IV fluids,
medications given, time of administration and the woman's condition.

MAGNESIUM SULPHATE (MGSO4) PROTOCOL REGIMEN. LOADING DOSE

1. Give 4g of MgSO4 (20mls of 20% solution), IV slowly over 5-10mins.
2. Give 10g of MgSO4 IM. Give 5g (10mls of 50%) IM deep in the upper outer quadrant of
each buttocks with 1ml of 2% lignocaine in the same syringe.

MAINTENANCE DOSE
 5g IM every 4hours into alternative buttocks
 Continue MgSO4 until 24hours after delivery or last fit.

If breakthrough fit occurs:

 Give 2-4g IV (as 20% solution) slowly.
Observation/ parameters before maintenance dose.

DIAZEPAM PROTOCOL (10MG IN 2MLS)

 Give 10mg IV slowly over 2mins
 Repeat dose at 10mg if convulsion occurs.

Maintenance dose
 40mg in 500mls IV fluid (N/S or R/L) at 20drops per minute.

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  Stop the maintenance dose if breathing is less than 16bpm.
 Assist ventilation if necessary with ambu bag.
 Do not give more than 100mg in 24hrs.

RECTAL DIAZEPAM REGIMEN- LOADING DOSE.

 Give 20mg (4mls) in 10mls syringe.
 Remove needle
 Lubricate the barrel.
 Insert the syringe into the rectum to half its length
 Discharge the content into the rectum to half its length
 Discharge the content and leave the syringe in place
 Hold the buttocks together for 10mins to prevent expulsion of the drug.

MAINTENANCE DOSE
 10mg (2mls) of diazepam if convulsion occurs.

HOSPITAL MANAGEMENT (LEVEL C)

HOSPITAL MANAGEMENT (LEVEL C)

1. Reassure the mother and explain the condition to her and the relatives to allay their fear and
anxiety.

2. Admit client into a quiet environment on a comfortable bed with side rails to prevent falling
and also to ensure bed rest to reduce the blood pressure.

3. Take comprehensive history of sign of pre-eclampsia such as headache, epigastric pain,

blurred vision etc.

4. Nurse client on the left lateral position to improve blood circulation to the placenta site.

5. Check vital signs such as blood pressure 2 hourly in severe cases and 4 hourly in moderate
cases and maintain a Bp chart. Temperature, pulse and respiration should be monitored 2 hourly.

6. Check the urine output hourly and check for urine protein daily.

7. Check reflexes hourly until patient is stable then check daily.

8. Conduct physical, abdominal examination to monitor the growth of the fetus

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9. Auscultate fetal heart rate at least twice daily to rule out fetal distress.

10. Inform the doctor about the client condition.

11. Monitor fetal kick count and report any problem to the doctor.

12.Monitor for fits.

13. Secure intravenous line and take 10mls of -blood sample for laboratory investigations like
Hb, platelet count, BUN, uric acid, urine protein, LFT, blood grouping and cross-matching , etc .

14. Take midstream urine for protein and acetone.

15. Commence fluid replacement and restore circulating volume with plasma expander's e.g.
normal saline, ringer lactate.

16. Pass foley catheter to monitor intake and output chart to monitor the functions of the kidneys.

17. Educate client on signs of imminent eclampsia such as headaches, epigastric pains and
blurring of vision or flushes of light and report if present for prompt management

18. Daily weighing of the client or alternate day weighing

19. Ultrasound scan should be done to monitor the growth of the fetus and placenta location e.g.
abruptio

20. Serve client with nutritious diet rich in protein to build up the haemoglobin level and high
fiber diet to prevent constipation.

21. Iron supplements and vitamin C and E should be given to prevent

anaemia.

22. Administer sedative to calm the client e.g. valium 5mg when necessary.

23. If the diastolic pressure is above 110mmHg administer antihypertensive drugs such as

Nifedipine 10-20mg bd, Methyldopa 250-500mg 6-8 hours or sublingual nefidipine 10mg
stat OR Hydralazine,

24. Prepare to manage convulsion should it occur (the following should be ready for use: airway
suction apparatus, mask and Oxygen bag, receiver, etc.)

25. Start anticonvulsants magnesium sulphate (MgSo4 as per protocol.

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 26. Administer prescribe dexamethasone 12mg bd for 24hrs to client with less than or equal to
34weeks gestation to mature foetal lungs.

27. If maternal and fetal condition is stable conservative management is continued till pregnancy
is more than 37weeks, then labour is induced.

28. Severe pre-eclampsia where the mother life is in danger, pregnancy should be ended no
matter the gestational age of the pregnancy to save the life of the mother.

29. If maternal and or foetal condition is poor or cervix is unfavorable is unfavorable deliver by
c/s.

30. If in labour but not near second stage monitor progress of labour closely, deliver by vacuum
extraction when in second stage.
31. Conduct active stage of 3rd stage (do not give ergometrine).

SIGNS OF MAGNESIUM SULPHATE (MgSo4) TOXICITY.

SIGNS OF MAGNESIUM SULPHATE (MGSs04) TOXICITY

✓ Oligouria; urinary output<10Oml per hour

✓ Slow or arrested breathing
✓ Slow heart rate
✓ Absence of patella or deep tendon reflexes
NOTE: If respiratory depression occurs (i.e. respiration less than16bpm) after MgSo4
administration, or absence of patella reflexes or oliguria, discontinue MgSo4, Give the antidote
of MgSo4, calcium gluconate 1g intravenously (10mls  of 10% solution slowly for about 10min)
and give oxygen.

PARAMETERS BEFORE GIVING MgSo4

 Respiration of > 16cpm
 Urinary output of 100mls in 4hours
 Present of patellar or other deep tendon reflexes.

COMPLICATIONS OF PRE-ECLAMPSIA

MOTHER

✓ Eclampsia
✓ Disseminated Intravascular coagulation (DIC) due to increased
consumption of platelets.
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✓ Thrombocytopaenia (decrease level of platelets in blood)
✓ Placenta abruption: Occurs due to vasoconstriction. This reduces the uterine blood flow and
vascular lesions occur in the placental site.
✓ Acute renal failure
✓ HELLP syndrome
✓ Retinal damage leading to blindness.
✓ Cerebral oedema
✓ Intracerebral haemorrhage (stroke)
✓ Heart failure
✓ Pulmonary oedema
✓ Liver failure: Vasoconstriction of the hepatic vascular bed causing hypoxia and oedema of the
liver cells.
✓ Epigastric pain as a result of oedematous swelling of the liver due vasoconstriction of the
hepatic vascular bed.
✓ Ruptured liver
✓Intracellular oedema as a result of decreased plasma colloid pressure due to leakage of plasma
protein from the damaged blood vessels.
✓ Reduced intravascular plasma volume will cause hypovolaemia
and haemoconcentration.
✓ Pulmonary oedema develops as the lungs become congested with fluid.
✓ Maternal death.

FETAL
 Hypoxia as a result of decrease placenta perfusion
 Cerebral damage due to hypoxia
 Stillbirth
 Foetal growth restriction
 Preterm labor
 Placenta insufficiency.

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 CHAPTER 9
ANXIETY AND DEPRESSIVE DISORDERS WITH PERIPARTUM ONSET
MOOD DISORDERS DURING PREGNANCY
 Definition 1: is a mental state of impaired mood characterized by feelings of anger, sadness,
irritability, guilt, lack of Interest in the baby, changes in eating and sleeping habits, trouble
concentrating, thoughts of hopelessness and sometimes even thoughts of harming the fetus or
herself.

 Definition 2: Depression that occurs during pregnancy or within a year after delivery is called
perinatal depression. It can be difficult to diagnose mood disorders during pregnancy because
some of the symptoms can overlap with symptoms of pregnancy, such as changes in appetite,
energy levels, concentration, or sleep etc.

However, while mild mood changes during pregnancy are common, mood symptoms can
sometimes become severe enough to require treatment by a health provider. If feelings of
depression or anxiety persist for a few weeks or interfere with daily activities, it is time to ask
for help. Depression and anxiety during pregnancy can worsen and continue into the
postpartum period.

ANXIETY IN PREGNANCY
Definition: Anxiety is a normal response to threat or danger and part of the usual human
experience, but it can become a mental health problem if the response is exaggerated, lasts
more than three weeks and interferes with daily life.
Definition 2: Anxiety arises when the person makes a mental assessment of some type of
threat

 Pathophysiology
Anxiety often occurs because the brain is unable to properly produce and regulate two

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 important neurotransmitters called GABA and Serotonin (remember these are your calm
happy chemicals).
Basically, stress hormone levels become elevated and the brain is unable to produce the
proper amounts of GABA and Serotonin which tell the brain to "SLOW DOWN".

WHAT IS GABA AND SEROTONIN

GABA and Serotonin are the two main inhibitory neurotransmitters.
Gamma-aminobutyric acid, or GABA, is a neurotransmitter that sends chemical messages
through the brain and the nervous system, and is involved in regulating communication
between brain cells.

 Function

✓  The role of GABA is to inhibit or reduce the activity of the neurons or nerve cells.

✓ GABA plays an important role in behavior, cognition, and the body's response to stress.

✓ Research suggests that GABA helps to control fear and anxiety when neurons become
overexcited.

Symptoms of GABA deficiency:

Physical - Carbohydrate craving, skin flushing, butterflies in stomach, ringing in ear, muscle
tension (especially in neck and back), numbness or tingling fingers, hyperventilation (not the
emergency kind, but the everyday breathing  too fast and too shallow), blurred vision etc.

Psychological: Restlessness, dread, emotional immaturity, short temper, phobias, anxiety or

panic, obsessive thinking rapid pulse.

WHAT IS SEROTONIN

Serotonin is a chemical nerve cells produce. It sends signals between your nerve cells.

Function:
Serotonin is considered a natural mood stabilizer. It's the chemical that helps with sleeping,
eating, and digesting. Serotonin also helps:

heal wounding

maintaining bone health

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 reduce depression

regulate anxiety

stimulate nausea

Symptoms of Serotonin Deficiency:

 Psychological - Impulsiveness, hyper vigilance, lack of common sense, rage

✓ Attention Issues - Slow reactions, restlessness, lack of concentration

✓ Conditions/diseases of serotonin deficiency- PMS, phobias, insomnia, depression, etc

✓ Physical - Salt cravings, backache, headache, cold or clammy hands, shortness of breath,
drug reactions, sleep disturbances

TYPE OF DISORDER
Generalized anxiety disorder:  is characterized by excessive, exaggerated anxiety and worry
about everyday life events with no obvious reasons for worry. They are overly concerned
about money, health, family, work etc.
 Compulsive disorder (OCD): 1s an anxiety disorder in which time people have recurring,
unwanted thoughts, ideas or sensation(obsessions) that make them feel driven to do
something repetitively (compulsions). The repetitive behaviors, such as hand washing.
checking on things or cleaning.

Panic disorder: panic disorder occurs when one experience recurring unexpected panic
attacks and fears that peak within minutes. Panic attacks are accompanied by physical
manifestations, such as heart palpitations, sweating, and dizziness as well as the fear of dying
or becoming insane.

CAUSES OF DEPRESSION AND ANXIETY

✓ Hormonal imbalance

✓ Worry over the health of the pregnancy

✓ Miscarriage

✓ High maternal levels of the stress hormone cortisol during pregnancy increase anxious and
depressive.

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 ✓ Congenital malformation of the fetus

✓ Birth trauma to newborn

✓ Newborn's inability to effectively initiate breathing

✓ Unsuccessful breastfeeding initiation

✓ Attitude of health providers

✓Body changes during pregnancy

✓ Poor diet

✓Excess stress

✓Minor disorders in pregnancy, like nausea, mood swings

Constipation, being tied etc.

RISK FACTORS FOR PREGNANCY DEPRESSION AND ANXIETY

Factors that may increase  the likelihood of depression and anxiety during or after pregnancy
can include:

 A personal or family history of a mood disorder, such as depression or anxiety

 Being a young mother (under the age of 20)

 Living alone

 Experiencing marital conflict

 Being divorced, widowed, or separated

 Having experienced traumatic or stresstul events in the past year

 Feeling ambivalent about being pregnant

 Pregnancy complications

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 Having a low income

 Having more than three children

 History of substance abuse

 lnadequate support from family and friends

 Anxiety about the fetus or unknown outcome of labour

 Problems with previous pregnancy

 Tiredness, problems sleeping

 Stronger emotional reactions

 Changes in body weight normally occur during and after pregnancy

Symptoms of Depression During Pregnancy

 Feeling sad, depressed, and/or crying a lot

 Diminished interest in becoming a mother

 Feeling worthless or guillty, especially about not being a good mother

 Strong anxiety, tension, and/or tear either about your future child or other things

 Sleep problems (not being able to sleep despite feeling very or sleeping more than usual but
not feeling rested)

 Thoughts of wanting to be dead or wanting to kill yourself

 Having low energy

 Loss of or increase in appetite or weight

 Trouble focusing, remembering things, or making decisions

SYMPTOMS OF ANXIETY DURING PREGNANCY

Generalized Anxiety Disorder Symptoms
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✓ Excessive worry that is difficult to control

✓ Irritability

✓ Tension/muscle aches

✓ Disrupted sleep pattern

✓ Feeling restless inside

✓ Fatigue

✓ Poor concentration

Obsessive-Compulsive Disorder Symptoms

✓ Recurrent, persistent, intrusive thoughts

✓ Compulsions to relieve those thoughts through repetitive thoughts or behaviors

Panic Disorder Symptoms

✓ Recurrent panic attacks

✓ Persistent fear of having a panic attack.

TREATMENT OF DEPRESSION AND ANXIETY IN PREGNANCY

Non-medicinal Approaches

The following treatments have been shown to help pregnant women with mild to moderate
depression

Psychotherapy, such as cognitive behavioral therapy (CB), In which a skilled therapist teaches
new approaches to managing thoughts and emotions

Omega- 3 essential fatty acids, which are found in foods such oily fish and walnuts, and can act
as a natural mood- booster.

Light therapy, in which patients are exposed to artificial sunlight at specific times of the day to
help relieve depression symptoms.

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Antidepressant Medication

Level 1
Initial Treatment: Mild to moderate depression may respond to non-pharmacological treatment
alone, but severe depression should be treated with effective medication monotherapy with a
selective serotonin reuptake inhibitor (SSRI)
Is preferred (with the exception of paroxetine, which may have an increased risk of cardiac and
other Malformations).
Consider bupropion in smokers who are trying to quit/abstain during pregnancy

Level 2
If Level 1 is ineffective and/or not well tolerated: Switch to different SSRI Consider
monotherapy with a serotonin-norepinephrine reuptake Inhibitor (SNRI) (good efficacy but less
data on birth defects). Consider Augmenting with a second generation antipsychotic (SGA)

Level 3
If Levels 1 and 2 are ineffective and/or not well tolerated: Consider electroconvulsive therapy
(ECT): it has proven efficacy. In severe depression and can be done with proper safeguard in
pregnant women

COMPLICATIONS OF ANXIETY AND DEPRESSION ON PREGNANCY

Stress-related hormones may play a role in causing certain pregnancy complications. Serious or
long-lasting stress may affect the immune system, which protects the client from infection.
Stress also may affect how you respond to certain situations. Some women deal with stress by
smoking cigarettes, drinking alcohol, which can lead to pregnancy problems.

Effect on the baby includes:

✓ Low birth weight

✓ Premature birth (before 37 weeks)
✓ Low APGAR score
✓ Poor adaptation outside the womb, including respiratory distress
✓ Growth restriction

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✓Fetal distress
✓ Increase abnormalities such as cleft lip and cleft palate

Effect on the mother includes;

✓Suicide
✓Pregnancy termination
✓Postpartum depression or anxiety
✓ Use of substances such as alcohol or drugs.
✓ Impaired attachment to the baby.
✓ Not taking good care of her physical health.
✓Pre-eclampsia
✓ Preterm labour
✓ Having a C-section

PREVENTION

 Screening of anxiety disorders in prenatal care is necessary.

 Pregnant women living alone and feeling a lack of support need to receive more attention
from midwives and health care professionals.

 Counsel client on stress management.

 Eating a well-balanced diet nutrient-dense, whole and unprocessed foods (including fruits,
vegetables, fish, nuts, dairy and whole grains)- instead of  processed and fast foods is thought
to support healthy bacteria in the gut, which in turn may help lessen anxiety.

 Women who are pregnant and have severe depression or anxiety should remain on
medication, as they are at high risk for relapse.

 Regular exercise e.g. walking for 10 minutes.

 Take a childbirth education class so you know what to expect during pregnancy and when
your baby arrives. Practice the breathing and relaxation techniques you learn in your class.

 If you're working, plan ahead to help you and your employer get ready for your time away
from work.

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 Counsel client on rest and sleep at least 6 to 8 hours at night.

 Build a good support network, including your partner, family and friends.

 Find out what's making you stressed and talk to your partner, friend or your health care
provider about it.

 Counsel client on the minor disorders that, the discomforts of pregnancy are only temporary.

 Try relaxation activities, like prenatal yoga or meditation.

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 CHAPTER 10
PREGNANCY INDUCED CONDITIONS
 HYPEREMESIS GRAVIDARUM:
 Definition: The term Hyperemesis gravidarum' is derived from the Greek word hyper-
meaning excessive, emesis means vomiting, gravida is also a Latin word which means being
pregnant. Hyperemesis gravidarum therefore means "excessive or severe form of vomiting in
pregnancy. Most women have some nausea or vomiting (morning sickness), particularly
during the first 3 months of pregnancy. This condition occurs from the 4 to 8 weeks of
gestation and ceases between 16 and 20 weeks but may go beyond it which needs to be
investigated further for possible termination of tne pregnancy especially when complications
set in.

CAUSES OF HYPEREMESIS GRAVIDARUM

1. Rising levels of HCG (Human Gonadotrophin Hornmone

2. Hormonal imbalance between oestrogen and progesterone

3. Hyperthyroidism suggest transient thyroid dysfunction

4. Infections with Helicobacter pylori. The organism implicate gastric ulcers.

5. Women with previous history of hyperemesis are likely experience it in subsequent

pregnancy.

6. Hydatidiform mole

7. Multiple gestation

8. Psychological factor
NB: Causes of vomiting not due to pregnancy such as thyroid problems, urinary tract
infection or gastroenteritis need to be excluded.

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 SIGNS AND SYMPTOMS OF HYPEREMESIS
 Mother’s suffering from hyperemesis are unable to retain food or fluid
 Signs of dehydration; rapid pulse, dry skin, low BP and dry furred tougher.
 Clint breath may smell acetone which is a sign of ketosis.
 Elevated haematocrit, alteration in electrolyte level and ketonuria associated with
dehydration
 Severe nausea and Vomiting
 Weight loss
 Decrease urination/ Oliguria
 Headaches
 Confusion
 Fainting
 Jaundice
 Loss of skin elasticity
 Secondary anxiety/depression
 Epigastric pain
 Low blood pressure
 Sunken eyes
 Thready and rapid pulse

DIFFERENTIAL DIAGNOSIS:
 Urinary tract infection
 Molar pregnancy
 Disorders of the gastrointestinal tract
 Malaria

MANAGEMENT HYPEREMESIS GRAVIDARUM

Aim of management of the mother is to stabilize and prevent complications.
 Client look miserable and sad, so reassure client by educating client and family members
about client condition that it will be resolved to allay anxiety.
 Client should be admitted to the hospital at the side ward for assessment and management to
prevent further infections.
 Monitor the vital signs 4 hourly or frequently depending the severity of the vomiting to rule
out shock

 Encourage client to have adequate rest and sleep by maintaining a calm environment

 History of the frequency and severity of the bouts of vomiting is taken.

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 Perform physical examination to assess the general appearance of the woman for signs of
dehydration, jaundice, pain, dizziness etc.

 Perform abdominal examination to rule out enlarge uterus with the gestational age which
may be due to hydatiform mole.

 Initially nothing is given by mouth, to allow time for the vomiting to be controlled.

 Take blood sample for FBC, grouping and cross matching, rhesus factor factor for possible
blood transfusion.

 Daily monitoring of urine for protein and acetone.

 Daily weighting of the client and record to monitor the weight or loss

 Intravenous fluids like dextrose saline and lactated Ringer's solution for hydration to replace 
lost electrolytes or correct dehydration.

 Maintain strict intake and output chart to monitor the functions of the kidneys.

 In nasal secretions N.G tube may be passed to aspirate the gastric secretions.

 In severe cases enteral nutrition like tube feeding is necessary

 Gradual introduction of fluids and diets as her condition improves is closely monitored.

 As the conditlon improve serve food attractively to promote appetite

 Remove all nauseating items from the ward to prevent inducing vomiting.

 Assist client to maintain personal hygiene bathing twice daily to prevent infection and body
odour, changing of bed linen to promote rest and sleep, grooming and oral hygiene twice
daily to improve aappetite

 Teach client on how to do fetal kick count to monitor the wellbeing of the fetus.

 Vulva toileting twice a day to prevent infection.

 Order for ultrasound to monitor the fetal heart rate and development

 Encourage mild exercise as the condition improves to prevent DVT.

 Administer routine drugs such as fersolate, folic Acid and vitamin C to correct anaemia

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 Vitamin supplement can be given parenterally, particularly where hyperemesis has been
prolonged

 Antiemetics may be prescribed to control the vomiting e.g injection phenergan 25 mg 1.M.

 Mild sedative if the client appears agitated e.g. valium 5mg bd x 5 days may be given to
promote rest and sleep.

 Antihistamines are recommended for pharmacological treatment for nausea and vomiting

NB: Hyperemesis persisting into the third trimester should be further investigated as it may
be symptomatic of serious illness such as acute fatty liver of pregnancy

COMPLICATION OF HYPEREMESIS GRAVIDARUM

MOTHER:

1. Hypoglycemia: when the blood sugar level is less than normal

2. Hypovolemic shock: a reduction in the circulating blood volume due to external loss.

3. Malnutrition or anemia

4. Decrease levels of vitamins or hypernatremia which causes confusion and seizures

5. Anxiety/ Depression

6. Hypoproteinaemia

7. Hypokalemia

8. Deep vein to thrombosis due to immobility

9. Renal failure

10. Pre-eclampsia

11. Death

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 BABY

1. Low birth weight

2. Preterm delivery
3. Stillbirth
4. Abortion
5. Intrauterine growth restriction.

Different between morning sickness and hyperemesis gravidarum

Morning Sickness Hyperemesis

Nausea sometimes accompanied by vomiting Nausea accompanied by severe vomiting

Nausea that subsides at 12weeks or soon first Nausea that does not subside
trimester

Vomiting that does not cause dehydration Vomiting that causes severe dehydration

Vomiting that allows foods to be retained Vomiting that does not allow food to be retained.

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 CHAPTER 11
COMPREHENSIVE ABORTION CARE
INTRODUCTION
Over the past two decades, maternal mortality has begun to decline, though progress has
remained too slow to achieve targeted reductions.
Many women in Ghana seek illegal abortions, which vary widely in terms of safety;
complications from unsafe abortions contribute substantially to Ghana’s high maternal
mortality

• Key objectives of comprehensive abortion care for women are:

• To prevent unwanted pregnancies through family planning services, including counseling
and method provision.
• To ensure that the abortion services provided to women, as permitted by law, are safe,
affordable and accessible.
• To reduce morbidity and mortality from abortion complications through effective
management and referrals.
• To reduce morbidity and mortality due to unsafe abortion through public awareness on
the availability of safe abortion services and the dangers of unsafe abortion
• To ensure that every woman in Ghana is able to exercise her rights to safe abortion.

WHO’s Definition of Safe &Unsafe Abortion

Safe abortion refers to abortion that is done with a method recommended by WHO (i.e. medical
abortion, vacuum aspiration, or dilatation and evacuation), is appropriate to the pregnancy\
duration, and is provided by a trained health-care provider.
Unsafe abortion: is defined as a procedure for terminating a pregnancy performed by persons
lacking the necessary skills or in an environment not in conformity with minimal medical
standards or both

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Less safe abortion: refers to abortion that only meets one of two criteria – i.e. either the abortion
is done by a trained health-care provider but with an outdated method (e.g. sharp curettage) or a
safe method of abortion (e.g. misoprostol) is used but without adequate information or support
from a trained individual
Least safe abortion: refers to abortion that is provided by untrained individuals using dangerous
methods (i.e. ingestion of caustic substances, insertion of foreign bodies, or use of traditional
concoctions
COMPREHENSIVE ABORTION CARE
Is a comprehensive approach to providing abortion services that takes into account the
various factors that influence a woman’s individual health needs both physical and
mental as well as her personal circumstances and her ability to access services.
Providing comprehensive abortion care includes a range of services that support women
in exercising their sexual and reproductive rights
Comprehensive abortion care (CAC) includes all of the elements of PAC as well safe
induced abortion for all legal indications (i.e as allowed by national law). These elements
all contribute to reductions in maternal mortality.
An approach to abortion-related services that takes into account women’s individual
physical, mental and social health needs and circumstances and ability to access care. It
includes:

1. Compassionate counseling
2. Treatment of incomplete, missed or unsafe abortion
3. Related sexual and reproductive health services provided onsite or via
referrals to accessible facilities and community-service provider
partnerships
4. Safe abortion
5. Contraceptive services
6. A range of health services that help women exercise their sexual and
reproductive rights
7. Abortion and postabortion care services for young and unmarried
women

POSTABORTION CARE
Post-abortion care includes a series of medical and related interventions designed to
manage the complications of

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 • spontaneous and induced abortions,
• both safe and unsafe and
• address women’s related health-care needs

Objectives of CAC in Ghana

1. To ensure that the abortion care services provided to women, as permitted by law, are
affordable and accessible.
2. To reduce morbidity and mortality due to unsafe abortion
3. To reduce deaths and disability from abortion complications through effective
management and/ or stabilization and referral
4. To prevent unwanted pregnancies through contraceptive services, Including counseling
and method provision.
5. To improve women and girls broader reproductive health by integrating

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CHOICE
• . Choice means the right and opportunity to select among options others should not
interfere in a woman’s individual right to make choice about her body and her health
• The opportunity to make choices , however, depends on various factors, Including the
policy environment, a well-functioning health system , social and cultural beliefs and
practices, and economic resources
• With regards to pregnancy and abortion, choice means a woman’s right.
Women and girls have the choice to decide:
• If and when to become pregnant
• Whether to continue or terminate a pregnancy
• Which available abortion or postabortion care procedures, contraceptives,
providers and facilities she will use
Health-care providers support a woman's choice by:
• giving complete and accurate information
• offering the opportunity to ask questions and express concerns
• recognizing her right to a choice, regardless of age, marital status or other
characteristics

ACCESS:
• It is the medical and ethical responsibility of appropriate professional to provide abortion
care for legal indications.
• A woman’s access is determined in part by the availability of trained, technically
competent providers who use appropriate clinical technologies and who are easily
reached- preferably in local communicaties and at as many service-delivery points as
possible
• Accessible Services should be delivered in timely manner, respectful and confidential,
easily reach in the communities and affordable
Accessible services are:
• Affordable
• Delivered in timely manner
• Easily reached in local communities

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 • Respectfully and confidentially provided

QUALITY
High quality abortion care includes many factors that will vary somewhat within local contexts
and available resources, some fundamental components of high quality care are:
• Providing accurate, appropriate information and counseling that supports women in
making fully informed choices.
• Utilizing internationally recommended medical technologies particularly manual vacuum
aspiration (MVA) and medical abortion as well as appropriate clinical standards.
• Appropriate clinical standards and protocols for infection prevention, pain management
and managing complications.
• Offer information and counseling to support fully-informed choices
• Provide services tailored to individual needs and social circumstances, including for
young and unmarried women
• Use recommended uterine evacuation methods and protocols
• Provide desired contraceptive methods and services
• Offer other related sexual and reproductive health services
• Ensure confidentiality, privacy, and respectful interactions
• Monitor services, including adverse events, for quality improvement, with participation
from community members

The Five Elements of Post-abortion Care

1. Treatment of incomplete, missed or unsafe abortion
2. Compassionate counseling to identify and respond to women’s emotional and physical
health needs and other concerns
3. Contraceptive and family-planning services to help women prevent an unwanted
pregnancy or practice birth spacing
4. Related sexual and reproductive health services that are preferably provided onsite or
via referrals to accessible facilities
5. Community-service provider partnerships to help women prevent unwanted pregnancies
and unsafe abortion, mobilize resources to help women receive appropriate and timely

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 care for abortion-related complications and ensure health services reflect and meet
community expectations and needs.

Four Key Rights Related to Abortion and Postabortion-Care Services

• The right to life
• The right to privacy
• The right to information and education
• The right to decide whether or when to have children

Support Rights in an Abortion-Related Care Setting

• Have empathy and respect for all women, regardless of age or marital status
• Maintain positive interactions
• Respect privacy and confidentiality
• Adhere to the voluntary, informed consent process

Guiding Principles For The Implementation Of CAC Services

• The guiding principles on how the services should be implementated in order to ensure
women’s access to Comprehensive abortion care are as follows:
1. Each client has the rights to access abortion care as an integral part of comprehensive,
integrated reproductive health services.
2. A good history must be taken from each client.
3. Each client must be evaluated as an individual based on her own circumstances.
4. Parental, partner or spouse consent us encouraged but not mandatory when request CAC
Services
5. Pre and post- counseling are integral components of Comprehensive abortion care.
6. After the client has made a decision to terminate the pregnancy, the service should be
provided as soon as possible
7. Each client has the right to privacy and confidentiality.
8. No psychiatric assessment is required in order to obtain a legal abortion.

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 9. NB: A minor is a person below the age of 18yrs (Reference Children’s Act of Ghana
1998, Act 560).
 The service provider should encourage minors to consult a parent or trusted adult
if they not done so already, provided that doing so will not put the minor in
danger or physical or emotional harm. However abortion services shall not be
denied because, such chooses not to consult them.
 A parent, next of kin, another adult or trained services provided acting in loco
parentis (in place of the parent) can give consent on behalf of the minor.
 The confidentiality of the minor should be respected, should be respected, and
subjected to the usual exceptions that apply to patient-provider confidentiality.

GENERAL WOMEN RIGHTS

Health care providers must help women to exercise their reproductive rights and must respect
that right.
1. Right to information
2. Right to access to service
3. Right to safe services
4. Right to privacy and confidentiality
5. Right to dignity, comfort and expression of opinion
6. Right to Continuity of care
7. Right to freedom of opinion and expression
8. The right to the benefits of scientific progress
9. Right to freedom from discrimination
10. Right to life and health
11. Right to freedom from inhuman and degrading treatment.

Rights Related To Abortion And Post Abortion Care Services

1. The right to life
2. The right to privacy
3. The right to information and education
4. The right to decide whether or when to have children
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MEDICOLEGAL ISSUES ON ABORTION IN GHANA AND CAC SERVICES
STANDARDS AND PROTOCOLS

Where abortion is not against the law, health systems should train and equip health-service
providers and should take other measures to ensure abortion is safe and accessible

Legal Definition of Abortion

• It is “the premature expulsion or removal of conception from the uterus or womb before
the period of gestation is completed.”

Abortion Law in Ghana

• Abortion is a criminal offence pursuant to Act 29, section 58 - 59 of the Criminal code of
1960, amended by PNDCL 102 of 1985
• However, there are legal indications for abortion
• The Ministry of Health/Ghana Health Service has developed Standards and Protocols for
Comprehensive Abortion Care
• The Law and Standards/Protocols should be read and used together

Who is Liable Under Sec 58?

When abortion is performed outside of the legal indications
• The woman causing the abortion
• Any person who administers the drug or uses the instrument for the abortion (e.g. doctor,
midwife)
• Any person who induces a woman to cause an abortion (e.g. partner)
• Any person who aids and abets a woman to cause an abortion (e.g. friend)

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 • Any person who attempts to cause an abortion (e.g. the woman)
• Any person who supplies the poison, drug, instrument for the abortion knowing it was
going to be used for an abortion (e.g. chemist)

What Does the Law Say?

• A woman who intends to cause an abortion or miscarriage
• Administers to herself a drug, a poison, uses an instrument or any other means
• Any person who administers the poison/drug/instrument on the woman to cause an
abortion
• Commits an offence under the law and is liable to a term of imprisonment of not more
than five years.

Is Abortion Criminal Under all Circumstances?

• NO!
• When abortion is performed under certain circumstances it is not a crime and not covered
under our criminal law
• Anyone who performs or assists to perform an abortion under the circumstances listed in
the law will be acting legally within the parameters of the law.

Legality of Abortion trends in Ghana

• Only 11% of women age 15-49 who know what abortion is (including women who have
had an induced abortion) know that abortion is legal in Ghana
• The percentage of women age 15-49 who know what abortion is and know that abortion
is legal in Ghana increased from 4% in 2007 to 11% in 2017

Who Can Perform An Abortion?

• Registered medical practitioner specializing in gynaecology
• Any other registered medical practitioner
• Trained Midwife

Where Can Abortion Be Performed?

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 • Government hospital
• Private hospital
• Clinic registered under the Private Hospital and Maternity Homes Act, 1958 (No. 9)
• Place approved by the Minister of Health by a Legislative Instrument (eg. Marie Stopes
clinics)

Legal Indications for Abortion

• Risk to life or injury to physical or mental health of woman
• Rape, incest, defilement of female idiot (mentally challenged woman)
• Substantial risk that foetus has or will have serious abnormality or disease

Who Can Consent to Abortion?

• Woman or girl seeking abortion
• Liberated minors
• Next of kin or person acting in loco parentis if woman is underage or lacking capacity

Minor Consent
A minor is a person below the age18 years (ref children’s act of Ghana 1998, act 560)
• The service provider should encourage minors to consult a parent or a trusted adult if
they have not done so already, provided that doing so will not put the minor in danger of
physical or emotional harm. However, abortion services shall not be denied because such
minor chooses not to consult them.
• Liberated/emancipated and matured minors are allowed to consent for themselves.
• A parent, next of kin, another adult or trained service provider acting in loco parentis (in
place of the parent) can give consent on behalf of the minors.
• Providers should recognize the in cases where pregnancy occurs in a minor under 16
years of age and is as result of defilement (statutory rape) such client are entitled to
abortion services
• In case of defilement, rape or incest, no legal evidence is not required in order for the
client to obtain an abortion
• In mental illness, consent should be given on behalf of such client by the guardian

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Pregnancy as a Result of Rape, Incest or Defilement
• Rape: Carnal knowledge of a girl or woman above the age of 16 years without her
consent (according to Ghana law, wives cannot be raped)
• Defilement: carnal knowledge of a boy or girl below 16 years whether with or without
her/his consent
• Sex with imbecile or mental patient: It will be rape whether she consented or not
• Incest: sex with blood relation

Mental Health
Mental health refers to a state of emotional, psychological and social wellbeing and not merely
the absence of disease in matters relating to mental function. A continuing pregnancy may put a
client's mental health at risk. Mental health is essential to personal welfare, family and
interpersonal relation-ships and the individual's contributions to the community or society
• No psychiatrist assessment is required in order to obtain legal abortion.
• The service provider should determine the client’s emotional status in relationship to the
pregnancy. A woman’s or a girl’s social circumstances may be taken into account in
assessing the current and future risks to her mental health

Risk to Life or Injury of Physical or Mental Health

• Where continued pregnancy would be a risk to the physical health of the woman
• Where continued pregnancy would involve a risk to the mental health.
• Mental health refers to the state of emotional, psychological and social wellbeing and not
merely the absence of disease in matters relating to mental function Woman has to
consent to the termination
• If she lacks the capacity to consent due to mental illness it can be given on her behalf by
her parents, next of kin, or person in loco parentis
• According to the GHS protocols, no psychiatrist assessment is required

Substantial Risk of Foetal Abnormality

• Termination can be ordered/requested if there is a substantial risk that if the child were
born it may suffer from, or later develop serious physical abnormality or disease

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Conscientious Objection (1)
• The subject of induced abortion generates many conflicts of opinion based on religious
and other beliefs. Though individuals have a right to their own beliefs and moral
perspectives on abortion. Their personal objectives should not hinder access to care for
others. Health care providers must note the following:
• Management of all government health facilities and facilities supported by government
have the obligation to ensure that services are provided within those facilities, except
those excluded through specific agreements with government
• Management must have a recruitment policy which ensures the provision of services

Conscientious Objection (2)

• Service providers working in a public institution are mandated to provide the services, as
stipulated by law
• Although many health workers are involved in providing care for abortion clients, only
those directly performing the abortion procedure can claim conscientious objection
• A service provider validly claiming conscientious objection has a duty to provide
information to the client about her rights to the service and refer her to an accessible
provider

Conscientious Objection (3)

• No provider has the right to conscientious objection in an emergency situation.
• No individual may claim conscientious objection if the client is below 18 years of age,
according to the following constitutional provisions:
• “(4) No child shall be deprived by any other person of medical treatment,
education or any other social and economic benefit by reason only of religious
or other beliefs.
• (5) For the purposes of this Article, ‘child’ means a person below the age of 18
years”.
{Article 28 of the Constitution of the Republic of Ghana, Clauses (4) and (5)}

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COMPREHENSIVE ABORTION CARE SERVICES STANDARDS AND PROTOCOLS

Components of CAC S&Ps – Protocol Sections

• Safe Induced Abortion: Pre-Procedure Care
• Medical Abortion Procedure ≤ 13 weeks of pregnancy

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 • Surgical Abortion Procedure for ≤ 13 weeks of pregnancy
• Medical Abortion Procedure for Pregnancies >13 Weeks
• Dilatation and Evacuation Procedure for Pregnancies > 13 weeks
• Management of Abortion Related-Complications and Post-Abortion Care
• Post Procedure Care and Counselling
CHAPTER 12
ABORTION METHODS
1. Surgical Abortion Method
• Dilatation and Curettage
Dilatation and Evacuation
2. Non-surgical Abortion Method.
• Vacuum Aspiration
• Medical abortion
• Manual Vacuum Aspiration

Dilatation And Curettage (D&C)

• Is also known as sharp Curettage, it refers to the dilatation ( widening /opening) of the
cervix and surgical removal of the part of the lining of the uterus and/ or contents of the
uterus by scraping and scooping
• It is used when the fetal skeleton begins to calcify at 14weeks and fetus can’t be removed
by suction alone.

Procedure:
• Client lie on the back on an examination table while the heels rest in supports called
stirrups
• The first step in a D&C is to dilate the cervix with Hegar dilators.
• A curette, a metal rod with a handle on one hand and a sharp loop on the other hand, is
then inserted into the uterus through the dilated cervix.
• The curette is used to gently scrape the lining of the uterus and remove the tissue in the
uterus
This tissue is examined for completeness

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After the procedure
• Client may spend a few hours in a recovery room after the D&C for monitoring of heavy
bleeding or other complications and recovery from the effects of anaesthesia.
• Normal side effect after D&C
Mild cramping
• Spotting or light bleeding
• Uses of D&C:
1. To diagnose abnormal uterine bleeding
2. To take endometrial cells during a routine test for cancer cells.

Complications of Dilatation And Curettage.

• Perforation of the uterus
• Damage to the cervix
• Scar tissue on the uterine wall: Asherman’s syndrome (abnormal, absent or painful
menstrual cycles.
• Infection

Dilatation and Evacuation (D&E)

• It also called dilatation and extraction, is the dilatation of the cervix and surgical
evacuation of the contents of the uterus. It is a method of abortion as well as a therapeutic
procedure used after miscarriage to prevent infection by ensuring that the uterus is fully
evacuated.
• A D&E is done to completely all the tissues in the uterus for an abortion in the second
trimester of pregnancy.
• Is usually recommended in women diagnosed in the second trimester with the fetus that
has severe medical problems or abnormalities. Abnormalities such as severe neural tube
defects or congenital heart anomaly.

Procedure
• D&E is performed under general anesthesia

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 • It may be performed with or without ultrasound guidance
• Before the procedure, the cervix is usually softened and passively dilated using osmotic
dilators and /or misoprostol. This facilitates cervical dilation.
• The first step in the procedure itself is the dilatation of the cervix
• The second stage is insertion of a vacuum curette through the cervix. Under ultrasound,
the tip of that currette is placed up against the fetal chest or abdomen.
• The suction is turned on. Amniotic fluid is is removed and the fetus dies instantly.
• This leaves the fetal cranium and skeleton with soft tissues to be removed. The thorax,
pelvis, cranium and each arm and leg are removed separately using surgical instruments.
• The fetal cranium will be usually have to be crushed in order to be extracted.
• After removal of all fetal tissues, the uterine cavity is thoroughly curetted to ensure that
all products are removed
• The uterus will then be massaged to ensure it is firmly contracted to minimize post-
operative bleeding.
• The entire procedure usually takes less than 30mins and is well tolerated.

Common Sides Effect

• Bleeding
• Cramping
• Nausea and Vomiting
Sweating
• Feeling faint.
Disadvantage
• Can’t be used after 20 weeks gestational age due to the tough ess of the fetal tissues.

Vacuum ASPIRATION
• Vacuum aspiration may be used as a method of induced abortion,as a therapeutic
procedure after miscarriage, to aid in a mentrual regulation, and to obtain a sample for
endometrial biopsy. It is used to terminate molar pregnancy.

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 • It can be used alone with cervical dilatation anytime in the first trimester( up to 12
weeks)

Procedure
• The clinician must first used local anesthetic to numb the cervix.
• Then dilators are used to dilate the cervix, or sometimes medically induced dilatation
with drugs.
• Finally, a sterile cannula is inserted into the uterus and attached through tubing to the
pump. The pump creates vacuum which empties uterine content.
• After the procedure for abortion or miscarriage treatment, the tissue removed from the
uterus is examined for completeness.
• Expected contents includes the embryo, or fetus, as well as the decidua, chorionic villi,
amniotic fluid etc.

MANUAL VACUUM ASPIRATION

• Is a quick non- surgical procedure that uses gentle suction to naturally release the
pregnancy tissue into a handheld device.
• It is the safest abortion procedure, because it does not use scraping, electric suction, or
general anaesthesia, so there are no major complications.
• Many women may feel mild to moderate cramping during the procedure, and is reduced
when the tube is removed from the uterus.

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Before the MVA Procedure
• Provide counseling to the woman and obtain written consent
• Perform a clinical assessment, including bimanual examination
• Discuss her contraceptive needs
• Ensure adequate medication and equipment are available
• Discuss the type of pain she may experience related to the uterine evacuation
• Discuss options available to reduce pain
• Describe available medications, their effects and potential side effects.
• Offer support measures that can be used in addition to pain medication.
• Ask her to state her preferred support measures.
• Help her decide on a pain-management plan

Pain Management During MVA

• All women undergoing uterine evacuation by any method will need pain control
• Reducing pain and/or anxiety, minimizes risks of complications

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 • Women’s response to pain vary but all women should be offered pain management
• Providers consistently underestimate the amount of pain a woman experiences
• Anxiety and depression increase pain perception
• Cervical dilatation, Uterine manipulation, and provider Clinical technique affect pain
perception
• General anesthesia is not routinely recommended

Physical Aspects Associated with Increased Pain with VA

• Nulliparity
• Higher gestational age
• Dysmenorrhea
• Young age

Support Measures
• Respectful interaction and communication
• Companion during procedure
• Verbal and physical support and reassurance
• Gentle clinical technique
• Non-pharmacological pain relief such as a heating pad or hot water bottle to the lower
abdomen.
• Calming environment
• Can supplement but not replace medications

Non pharmacological pain management

• Heating pad or hot water bottle to the lower abdomen.
These measures can supplement but not replace pain medication

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 Antibiotic Prophylaxis
• Women with active signs of infection are given appropriate specific antibiotics
• Prophylactic antibiotics are given to reduce the risk of infection
• Either of the following prophylactic antibiotic regimes can be given before the procedure
(not more than 2 hrs before): 
– Doxycycline 200mg orally OR
– Azithromycin 500 mg orally

MVA for Uterine Evacuation

• Many women will require uterine evacuation at some time in their lives.
• World Health Organization (WHO): Vacuum aspiration is a preferred method.

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 STEPS OF THE MVA PROCEDURE
1. Prepare instruments.
2. Assess the woman.
3. Perform cervical antiseptic prep.
4. Perform paracervical block.
5. Dilate cervix.
6. Insert cannula.
7. Suction uterine contents.
8. Inspect tissue.
9. Perform any concurrent procedures.
10. Take immediate post-procedure steps, including instrument processing.

• NB: Remain alert for changes in the woman's emotions and physiology throughout
procedure

Step 2: Prepare the Woman

• Ensure pain medication is given at the appropriate time.

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 • Administer antibiotics.
• Ask the woman to empty her bladder.
• Help her onto the table.
• Wash hands and put on appropriate barriers
• Alert her that you are about to start
• Perform a bimanual exam
• Select and insert speculum

Pre-Procedure Provision of Antibiotics

• Prophylactic: reduces risk of infection
• Administer prophylactic antibiotics to all women
• Therapeutic: for current infection
• Administer therapeutic antibiotics to women with signs and symptoms of infection
• Monitor for allergic reaction

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Step 4: Perform Paracervical Block

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 • Recommended for all MVA procedures.
• Usually 10 to 20mL of 1.0% lidocaine (Xylocaine)
• Always aspirate (pull back on the plunger) slightly before injecting to prevent
intravascular injection.
• Inject 2mL of anesthetic where tenaculum will be placed (12 o’clock).
• Place tenaculum.
• Apply slight traction to move cervix, exposing transition from cervical to vaginal tissue

Step 5: Dilate Cervix

• Dilatation required in some but not all cases.
• Women with inevitable or incomplete abortion may require minimal or no dilatation
• Cannula should fit snugly in os
• Use gentle operative technique
• Use progressively larger cannulae or mechanical dilators
• After 12 to 14 weeks, cervical preparation with osmotics or misoprostol should be
routinely used

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Signs That the Uterus is Empty
• Red or pink foam without tissue passing through cannula
• Gritty sensation over surface of uterus
• Uterus contracting around cannula
• Increased uterine cramping or pain

When the Procedure is finished

• Depress buttons down and forward to close valve then disconnect cannula from aspirator
• OR withdraw cannula and aspirator from uterus without depressing buttons.
• Keep instruments ready to evacuate again after inspecting POC, if needed.

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Step 8: Inspect Tissue
• Empty contents of aspirator into container
• Look for POC; villi and decidua should be visible
• Inspect Tissue For:
 Quantity and presence of POC
 Complete evacuation
 Molar pregnancy

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Possible Reasons That No POC Visible
• A spontaneous abortion has already completed itself
• Uterine cavity still contains POC
• Ectopic pregnancy
• Uterine anatomical variation prevented evacuation

Possible Reasons for Less Than Expected POC

• Incomplete procedure; re-evacuation necessary
• Incorrect estimation of length of pregnancy

Step 9: Perform Any Concurrent Procedures

If POC inspection results satisfactory:
• Wipe the cervix with swab to assess additional bleeding.
• Perform concurrent procedure.
Step 10: Immediately Post-Procedure

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 • Process or discard instruments.
• Remove barriers and wash hands
• Reassure the woman that the procedure is finished.
• Help her into a comfortable position.
• Ensure she is escorted to the recovery area.
• Record information about procedure
Reasons for Decrease in MVA Vacuum
• Aspirator is full.
• Cannula is withdrawn past os.
• Cannula is clogged.
• Aspirator is incorrectly assembled.
When Aspirator is full
• Close the valve buttons.
• Detach the cannula and leave in os.
• Replace aspirator OR
• Empty aspirator into a container by pressing buttons and pushing plunger into cylinder
• Establish new vacuum, attach aspirator to the cannula and resume.
When Cannula is Withdrawn Past Os
• Remove cannula and aspirator; don’t touch vaginal walls.
• Detach and empty aspirator.
• Reestablish vacuum.
• Reinsert cannula if it has not been contaminated.
• If contaminated, insert another sterile or HLD cannula instead.
• Reconnect aspirator to cannula, release vacuum and resume.

When Cannula Is Clogged

• Ease cannula back toward, but not through, the external os OR

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 • Depress buttons and withdraw aspirator and cannula out of uterus, avoiding
contamination.
• Remove tissue clogging cannula using sterile or high level disinfected (HLD) forceps.
• Reinsert cannula using no-touch technique
• Reattach aspirator and continue aspiration.

If Aspirator Does Not Hold Vacuum

• Reassemble and test aspirator

Post-Procedure Care
• Care provided after uterine evacuation completed
• Any physical complications addressed
• Woman informed about her condition and self-care
• Woman is provided with contraceptive method, if desired
• Ends when she is discharged

Elements of Post-Procedure Care

• Physical monitoring
• Other physical health issues
• Pain management
• Emotional monitoring and support
• Contraceptive counseling and provision
• Scheduling follow-up care and providing referrals
• Providing discharge instructions

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Types of MVA Instruments
There are different types of the MVA instruments in the market any can be used for uterine
evacuation. The following are some of the types:
• IPAS MVA double valve
• MSLMVA1 single valve
• MVA Double punch valve
• GYNASUCK MVA KIT
• MANUAL VACUUM ASPIRATOR SYRING-BENWAY

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About the Cannulae
• Same dimensions, apertures (openings) as Karman cannulae
• Slightly more rigid
• Permanently affixed base with wings
• Sizes 4, 5, 6, 7 and 8mm have two opposing apertures
• Sizes 9, 10 and 12mm have one larger, single-scoop aperture
• Dots on each cannula at 1cm intervals indicate location of main aperture

Disassembling the Aspirator

• Remove cannula by twisting its base and pulling it out of valve.
• Pull cylinder and remove from valve.
• Press cap-release tabs to remove cap
• Open hinged valve by pulling open clasp
• Remove valve liner
• Disengage collar stop by sliding under retaining clip, or remove completely

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 • Pull plunger completely out of cylinder
• Displace O-ring by squeezing its sides and roll down into groove below

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Assembling the MVA
• Place valve liner in valve by aligning ridges.
• Close valve; ensure that it snaps into place.
• Snap cap onto end of valve.
• Push cylinder straight into base of valve.
• Place O-ring into groove near tip of plunger.
• Spread one drop of lubricant around O-ring with finger.
• Squeeze plunger arms, push straight into cylinder.
• Move plunger in and out to lubricate.
• Insert collar stop tabs into holes in cylinder.

When Assembling the Aspirator

• Introduce plunger straight into cylinder.
• Do not introduce plunger at an angle.

Creating a Vacuum
• Begin with valve buttons open, plunger all the way in and collar stop locked in place.

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 • Close valve by pushing buttons down and forward until they lock.
• Pull plunger back until plunger arms catch on wide sides of cylinder.
• Ensure that both arms are extended and secured over edge of cylinder.
• Incorrect positioning of plunger arms can allow plunger to slip back into cylinder.

Check Aspirator for Vacuum

• Charge aspirator.
• Leave charged aspirator for several moments.
• Push buttons to release vacuum.
• A rush of air indicates vacuum was retained.

Checking Why Vacuum Fails

• Check that instrument is properly assembled.
• Inspect O-ring for proper positioning and lubrication.
• If damaged, replace O-ring.
• Ensure no foreign bodies are present.
• Check cylinder is firmly seated on valve.
• Charge and test again.
• If vacuum is still not retained, use another aspirator.

Selection of Cannulae
Depends on uterine size and amount of dilation of cervix select the appropriate cannula to use:
• Uterine size 4–6 weeks LMP: suggest 4–7mm
• Uterine size 7–9 weeks LMP: suggest 5–10mm
• Uterine size 9–12 weeks LMP: suggest 8–12mm

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MVA ASPIRATORS CARE AND PROCESSING
• Should be put in decontamination soak promptly after use to ease removal of tissue.
• Must be cleaned with soap, under running water and high level disinfected (HLD) or
sterilized between patients
• Does not have to be HLD or sterile at time of use (like speculum)

Replace MVA When…

• Cylinder is cracked or brittle.
• Mineral deposits inhibit plunger movement.
• Valve is cracked, bent or broken.
• Buttons are broken.
• Plunger arms do not lock.
• Aspirator no longer holds a vacuum.

Cannulae Care and Processing

• Manufacturer-sterilized with ethylene oxide
• Should be sterilized or high-level disinfected (HLD) before reuse
• Should be sterile or HLD at time of use.
• After use, process promptly to ease cleaning

Discard and Replace Cannula If…

• It is brittle
• Tissue cannot be removed with cleaning
• It is cracked, twisted or bent, especially near the aperture

Four Steps for Processing Instruments

1. Decontamination soak
2. Cleaning
3. Drying and Sterilization or high-level disinfection
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 4. Storage

Steps in Decontamination Soak

• Fill a plastic container with solution. Use 0.5% chlorine solution.
• Wearing gloves, submerge instruments completely
• Then draw solution into cannula and aspirator.
• Soak instruments for 10 minutes to decontaminate.
• Use utility gloves or forceps to remove instruments.

Cleaning Instruments
• The process to physically remove visible foreign materials (such as dirt, dust bunnies,
and body fluids) which may contain microorganisms from an object or surface.
• For instruments it involves scrubbing with a brush, detergent and water
• Clean all crevices and inside cylinder, valve and plunger. ° Use a soft brush; nothing
sharp or pointed
• You can’t kill microbes if you don’t clean first

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Steps in Manual Cleaning
Manual cleaning - refers to cleaning of devices with the hands
• Routine cleaning of soiled instruments is done immediately after the procedure
• Manual cleaning must be done with extreme caution by adhering to the following steps:
1. Wear the appropriate utility gloves, plastic apron and eye protection
2. Fill sink or bowl with water (2/3 full) and add detergent as per supplier’s direction
3. Dismantle all items and place gently in the sink (avoid splashing)
4. Thoroughly brush all items, keeping the brush below the surface of the water
5. Rinse items in clean, warm or tap water
6. Allow to air-dry or dry with clean absorbable material before disinfection or sterilization.
Failure to remove water from trapped areas will cause corrosion.
7. Decontaminate brush after use by soaking in 0.5% chlorine solution for at least 10 minutes,
clean and dry
• Do not clean items under running water.
• Instruments that will be further processed with chemical solutions must dry completely to
avoid diluting the chemicals.
• Items that will be boiled or steamed do not need to be dried first

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Manual Vacuum Aspirator
• Must be high level disinfected (HLD) or sterilized between patients
• This prevents potential blood borne pathogens from being transmitted between patients in
case of problems during the procedure where aspirator contents may make contact with a
woman’s body
• The aspirator does not need to remain HLD or sterilized before the next patient.

MVA CANNULAE
• Must be HLD or sterilized between patients
• Must be HLD or sterile at time of use

Steps in HLD by Boiling

1. Decontaminate and clean all instruments and other medical devices to be boiled
2. Open all hinged instruments and disassemble those with sliding or multiple parts
3. Place bowls and containers upright, not upside down, and fill with water
4. Completely submerge all instruments and other items in the water in the pot or boiler.
This is because water must touch all surfaces for HLD to be achieved
5. Cover the pot or boiler and bring the water to a gentle, rolling boil.
6. When the water comes to a rolling boil, start timing for 20 minutes. (From this point on,
do not add any water or Item to, or remove any water or item from, the pot or boiler).
7. Lower the heat to keep the water at a gentle, rolling boil
8. After 20 minutes, remove the items using dry high-level disinfected pickups (e.g. lifters,
Cheatle’s forceps).
9. Place items on a high-level disinfected tray or in a high-level disinfected container
10. Allow items to air dry before use or storage.
11. Use items immediately or keep them in a covered, sterile, or HLD container for up to one
week.

Option: 0.5% Chlorine (HLD)

• Use a plastic (non-metal) container.

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 • Fully immerse and ensure that solution fills instruments.
• Soak for 20 minutes.
• Remove using HLD or sterile gloves or forceps.
• Rinse with boiled or sterile water.
• Dry with sterile cloth, if desired.

Option: Steam Autoclave (Sterilization)

• Wrap clean, disassembled items in paper or linen.
• Arrange items so steam penetrates all surfaces.
• Ensure instrument openings are not obstructed and parts do not touch.
• Cool before use.

Steam Autoclave: Caution

• Process at 121°C (250°F) with 106 kPa (15lbs/in2) pressure for 30 minutes.
• Be sure the autoclave is set to these parameters.
• Do not use other autoclave settings or “flash” the instruments.

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 • Higher temperature settings can damage instruments.

Storing MVA Instruments

• Ideally, reprocess cannulae every day if boiled or soaked.
• Storing items even slightly wet invites microbial growth.
• Keep just a few cannulae in each container.
• Avoid touching cannulae tips; grasp cannulae by base.

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 CHAPTER 13
MEDICAL ABORTION
• Medical abortion is a client focused, simple, safe and effective method using medicine
for the termination of pregnancy.
• A combination of mifepristone and misoprostol or misoprostol alone is used to interrupt
pregnancy and expel the products of conception from the uterus.
• It is used from 4weeks up to 7weeks or nine weeks.
• Mifepristone is also known as the abortion pill or RU486. Either mifepristone or
methotrexate is taken together with another medication, called misoprostol, to induce and
abort the pregnancy.
• Mifepristone is the most common medical abortion used. Is the best medication for
ending early pregnancy.
• It is 95-99% effective .

Misoprostol OR Cytotec
• Where mifepristone is not available misoprostol, or cytotec can be used for abortion.

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 • Is less effective than the mifepristone, is about 80% successful.
• It can induce abortion in early pregnancy but repeated doses are needed 800mcg
vaginally or sublingually repeated every 12 hours up to 3 doses.
• Misoprostol alone, however is less effective than mifepristone and misoprostol combined
and generally causes side effects like birth defects.

Client Preparation
Before administering any medications:
• Provide counseling to the woman and obtain informed consent.
• Maintain privacy, communicate in simple language
• Perform a clinical assessment, including physical examination and bimanual examination
• Discuss the woman’s contraceptive needs

Essential Information for the woman undergoing medical abortion

• What she may experience
• What pills to take, when and how to take them
• When to follow up, if required
• When and where to seek medical help in case of a problem

Confirm Client’s Eligibility for MA

• Confirm that the pregnancy is thirteen weeks or less since the LMP.
• Date pregnancy through medical history, pregnancy test (if available) and bimanual
exam.
• Using ultrasound to date pregnancy can be helpful but should not be a routine.
Additional Eligibility for Misoprostol for Incomplete Abortion
• Gestational Age from last menstrual period ≤ 13
• Cervical os is opened
• No signs of sepsis
• Haemodynamically stable

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 • Not bleeding profusely (2 pad/hour / 2 consecutive hours)
Contraindications
• Ectopic pregnancy (confirmed or suspected)
• Allergy to Mifepristone, misoprostol or other prostaglandin
• Chronic adrenal failure (only for Mifepristone with misoprostol)
• Inherited porphyria (only for Mifepristone with Misoprostol)
• For PAC: Signs of pelvic infection and/or sepsis
• For PAC: Hemodynamic instability or shock
• IUD in place.

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Effectiveness
• Combination of the two drugs is more effective than either used alone
• Combined regimen is more than 96-98 % effective in pregnancies ≤ thirteen weeks since
last menstrual period (LMP)
• Misoprostol only results in successful abortion in approximately 85% -90% of cases
• Misoprostol for incomplete abortion is more than 91-99 % effective up to 13 weeks
uterine size
• Administer 200mg Mifepristone orally.
• Most women will feel no change after taking the pill.
• Some women (8-25%) will begin bleeding before taking the next pill (Misoprostol).
Administer misoprostol at the required time even if bleeding occurs.

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Advice client to report back to the clinic if any of the following occur:
 No vaginal bleeding 48 hours after taking the second medication
 Vaginal bleeding soaking more than 2 maxi pads in an hour for two hours in a row
 Prolonged vaginal bleeding or cramping for more than 14 days
 Offensive vaginal discharge
 Fever more than 38.ºC - more than 24 hours after taking misoprostol
 She feels persistent symptoms of pregnancy after 14 days

NB:
• To avoid infection, client should not have sexual intercourse for 14 days. If sexual
intercourse cannot be avoided, then a condom should be used.
• Client should not use tampons. She should use absorbent sanitary towels until the
bleeding has stopped
• Regular pain medications (e.g. Ibuprofen) for 2-3 days can be taken
• Provide contraceptive counselling to clients who choose PAFP and help them choose a
method that meets their needs

Expected Effects
• Bleeding
• Cramping
BLEEDING
• Usually begins within three hours, can last about 7 - 14 days, on and off bleeding can
continue for up to 6 weeks
• Moderate/heavy bleeding with blood clots. Normal bleeding is saturating less than two
sanitary pads per hour with decreasing flow over time
• Saturating more than two pads per hour for two consecutive hours or passing large
fist sized clots could indicate a complication such as an incomplete abortion which
requires surgical evacuation
• Women should be told about the expected bleeding so they can seek prompt medical
attention if necessary

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 • If the client does not have any bleeding within 48hrs she should return, as this could
indicate a continued pregnancy or ectopic

PAIN MANAGEMENT

Non-Pharmacological Pain Management Options

• Verbal support
• Counseling about what to expect
• Reassurance during the abortion
• Low heat to the abdomen or lower back
• Hot-water bottle
• Warm cloths
• Music may be helpful

Possible Side Effects

• Nausea, vomiting and diarrhoea in 4 in 10 women
• Shivering

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 • Headaches
• Side effects can continue for 4 – 6 hrs after taking misoprostol
• Women must know in advance what effects to expect and be able to distinguish between
expected effects and signs of complications

Complications of Medical Abortion

Uterine evacuation with medical methods is associated with few serious complications.
Rare complications include:
• Incomplete abortion
• Heavy bleeding
• Infection
• Continuing pregnancy

Risk of Continuing Pregnancy

• Small risk that medical abortion will not work and pregnancy will continue.
• Very small risk that Misoprostol could cause birth defects if the pregnancy continues.
• If medical abortion does not work, women should be willing to undergo vacuum
aspiration to complete abortion.

Contraception after Medical Abortion

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ADVANTAGES OF MEDICAL ABORTION
• It avoids a medical procedure where a doctor inserts instruments into the uterus.
• You can be at home instead of at the clinic, during the actual abortion, which feels more
comfortable or provide a sense of more privacy and control- in particular, for survivors of
sexual abuse.
• It seems like a miscarriage, which for some reason can feel more natural.
• Some people prefer to consciously experience the process of ending the pregnancy at
home rather than being sedated as during aspiration.

DISADVANTAGES
• It can only be done up to 7-9 weeks after first day of your last menstrual period.
• It takes longer time than the aspiration.
• Failure rates are higher than with the aspiration abortion.
• There is typically more pains with medical abortion, cramping maybe more stronger than
the aspiration abortion.
• Bleeding is typically heavier, and may last longer than with aspiration.
• Misoprostol, one of the medication used, can cause flu-like symptoms such as nausea,
vomiting, diarrhea, fever etc.
• During the abortion itself, you will not be at the facility to get support from medical staffs
an Viewing the pregnancy tissue can be difficult for some , especially when the weeks os
over 7weeks.
• It more expensive than the aspiration.
• Those with severe vomiting and anaemia are not eligible for medical abortion.

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ABORTION CARE COUNSELLING, OPTION COUNSELLING AND
INFORMED CONSENT

WHAT IS COUNSELING
Definition: Counseling is the provision of advice or guidance in decision-making, in particularly
in emotionally significant situations. Clients seen by counselors have demoralized,
developmental or situational concerns that require help in regard to adjustment or remediation.
Counselors focus on their clients' goals. Thus, counseling involves both choice and change.
Counseling is provided in a timely and appropriate manner based on each individual's situation.
Counseling can be for one person or a group (typically couples and families) and may be
delivered through a number of methods, from face-face dialogue, group work, telephone, email
and writen materials.

CHALLENGES TO ABORTION COUNSELING

1. Lack of privacy and confidentiality

2. Lack of adequate time

3. Increase of work load on the care provider

4. Women's conflicting feelings and emotional state

5. Cultures, norms and languages barriers

STEPS TO SUCCESFUL COUNSELING

1. Be actve listener
2. Maintain eye contact
3. Show caring
4. Create a friendly atmosphere
1. Respond to client question honestly using a simple language.
6. Be nonjudgmental
7. Be genuine and provide privacy and ensure confidentially
8. Use both verbal and non verdal communication skills

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WHAT IS OPTIONS COUNSELING:

1.  This type of counseling that support people and their choices of where to live and receive
services.

2. Options Counselors empower people to make informed decisions about their long term
supports, and help people easily acces public and private long term supports and services
programs.

3. It's a person centered approach that ensures the consumer's personal goals and preferences are
honored.

4. Pregnancy option counseling is a form of counseling that provides information and support
regarding a women's pregnancy. Woman seeking pregnancy options counseling are typically
doing so in the case of an unintended pregnancy. Pregnancy options counselors educate women
about the different options that are available and help guide therm to a decision on how to
proceed with their pregnancy.

ABORTION RELATED COUNSELING OPTIONS

1. Continue the pregnancy to term

-Parent
-Adoption

2. Termination of the pregnancy, adoption, or parenting

WHAT IS INFORMED CONSENT

This is the process of informing a client of the risks, benefits expected outcome of a medication,
medical procedure,or therapeutic approach in which they have agreed to take part.

✓ Client seeking abortion service should be given informed consent forms to sign before
beginnmg treatment or altering abortion plan.
✓ Various methods for abortion should be made known to the women
✓ Counsel client on what to expect during the procedure, duration.
Complications, side eftect, pain management option and the need for follow up.

PERSONAL BELIEFS VERSES PROFESSIONAL RESPONSIBILITIES

1. The subject of Induced abortion generates many conflicts of opinion based on religion and

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other beliefs. Though individual have the right to their own beliefs and moral perspectives on
abortion, their personal beliefs should not hinder access to care for others.

2. Health care administrators, providers and workers must note the following

✓ Managers of all health facilities have the obligation to ensure that services are provided within
those facilities for all women in Ghana.

✓ Correct information about client's right to abortion care and provide or refer for abortion
service.

✓ No provider has the right to refuse to perform an abortion procedure that is needed to preserve
a woman's health or life.

✓ No provider may refuse if the client is below 18 years of age according to the following
constitutional provision,

3. Physicians must have the patient's interests as paramount. Abortion is often the test case when
a physician refuses to do something she believes is harmful to her patient .
4. The rights of a religious medical provider to refuse to terminate pregnancy must be balanced
against the similarly compelling rights of the patient to follow her conscience in choosing
abortion. The religious rights of a small group of medical professionals do not trump" those held
by the remainder of the citizen compromise between the two is required.

5. Emergency abortion care must be provided and, in non-urgent cases, medical professionals
must disclose their conscientious objection to the patient as soon as possible and ensure an
effective referral is made

6. Institutions and healthcare systems must guarantee the availability of full-service staff to meet
patients' demand and there must be consequences for an lndividual or institution where
conscience claims result in women being denied the care to which they are entitled.

BARRIERS WOMEN FACE TO ACCESSING ABORTION SERVICES

✓ Refusal by medical practiioners and healthcare institution on grounds of rellgion or

conscience.

✓ Distance

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✓ Lack of accessibility to the service.

PREVENTION OF TETANUS

Women who have had unsafe abortions with non-sterile instruments are at risk of tetanus.
Provide or refer the patient for tetanus prophylaxis if this is known or suspected, particularly in
communities where tetanus after abortion has been reported. A booster injection of tetanus
diptheria (TD) should be given to women who have been previously vaccinated.

MANAGING COMPLICATIONS

Ensure that women have ongoing access to emergency Care during their treatment. If the woman
requires treatment beyond the capability of the facility where she is seen, stabilize her condition
before she is transferred to a higher-level referral service.

FOLLOW-UP AFTER ABORTION

The client should report to the hospital approximately two weeks after abortion. These would
tend to include tests for infection in case any biological material was not properly removed.

POST ABORTION FAMILY PLANNING COUNSELNG AND CONTRACEPTIVE

SERVICES

WHAT 1S FAMILY PLANNING: Practice of controlling the number of children in a family

and the intervals between their births, particularly by means of artificial contraception or
voluntary sterilizaton: family-planning clinics. All women receiving abortion care must
understand that ovulation can occur as early as 10 days after an abortion resulting in  pregnancy
even before menses returns. Contraception, including an IUD or hormonal methods, may be
started immediately after uterine evacuation. Sexual intercourse should be avoided for a few days
after bleeding has stopped because of the risk of infection.

COMPLICATIONS AND ADVERSE EVENT REPORTING

Types of Complications
• Presenting
• Procedural
• Pregnancy-related

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ASSESSMENT AND MANAGEMENT OF COMPLICATIONS
The provider needs to:
• Do rapid initial assessment and management of shock, if woman is presenting for
postabortion care
• Continually assess the woman for complications
• Manage complications by providing pain management then treating immediately
or stabilizing and referring

Incomplete Abortion: Immediate signs and symptoms

• Heavy vaginal bleeding
• Less tissue than expected
• Sometimes severe abdominal
Delayed signs and symptoms
• Uterine tenderness
• Fever, pain, infection
• Elevated white blood cell count

Management of Incomplete Abortion

• Usually treat with vacuum aspiration
• May use misoprostol or expectant management with close monitoring
• If woman has heavy bleeding or signs and symptoms of infection, use immediate vacuum
aspiration and appropriate antibiotics.

Uterine infection after VA or MA (signs and symptoms)

• Lower pelvic or abdominal pain
• Bleeding
• Fever and chills
• Uterine or lower abdominal tenderness on exam
• Cervical motion tenderness

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Management of uterine infection
• Stabilize if not stable
• Evacuate RPOC if present
• Manage with appropriate antibiotics
• Refer to the next level if necessary

Continuing Pregnancy (signs and symptoms)

• On vacuum aspiration, smaller amount of ‘’POC” than expected
• Persistent pregnancy symptoms
• Less vaginal bleeding than expected
• Uterine size increasing after uterine evacuation
Also known as “failed abortion”
• Pregnancy continues due to:
 Ineffective uterine evacuation
 Failure to evacuate gestational sac
 Extra uterine pregnancy
• Early gestational age (<6 weeks), operator inexperience and uterine anomalies may make
it more difficult to evacuate gestational sac using VA

Management of continuing pregnancy

• Request for Scan to determine location of pregnancy
• Re evacuate or give MA to complete evacuation
• Refer if patient cannot be handled at this level

Hemorrhage
• Rare after safe abortion
• May occur because of incomplete abortion, infection or uterine atony

Uterine Atony (signs and symptoms)

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 • Copious vaginal bleeding
• Large, boggy, softened uterus
Factors Contributing to Uterine Atony
• Loss of muscle tone and uterus cannot stop bleeding
• Multi parity
• Advanced gestation
• Multiple pregnancy
• More common in multiparous and advanced pregnancies
Cervical, Uterine or Abdominal Injury (signs and symptoms)
During procedure:
• Excessive vaginal bleeding
• Sudden excessive pain
• Instrument passes further than expected
• Aspirator vacuum decreases
• Fat or bowel contents in aspirate
Post-procedure:
• Persistent abdominal pain
• Rapid heart rate
• Falling blood pressure
• Pelvic tenderness
• Labs: raised WBC
• Minor cervical lacerations from tenaculum or cannula, or anything inserted in the vagina
during an unsafe abortion
• Uterine perforation caused by:
o Excessive force used to dilate (such as with stenotic cervix)
o Unusual uterine position (for eg. Retroverted uterus)

o Actual uterine size different than expected

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Management of Cervical or Vaginal Laceration
• Ensure adequate pain control and proper positioning and lighting
• Apply antiseptic solution to the cervix and vagina
• Check for more than one laceration
• Stop the bleeding by one or a combination of the following:
o Clamping a ring forceps over the tear

o Suturing with absorbable suture

o Apply silver nitrate
Uterine perforation
• May occur during vacuum aspiration
• May occur due to things inserted in the uterus during unsafe abortion

Management of Uterine Perforation

If:
• Perforation occurred during aspiration
• Woman is stable
• No other signs of intra-abdominal injury, and
• Evacuation is complete
Then:
• Admit her and closely observe for signs and symptoms of intra-abdominal injury
or hemorrhage.
• Administer antibiotics
Medication-Related Complications (signs and symptoms)
• Dizziness
• Muscular twitching or seizures
• Loss of consciousness
• Drop in blood pressure or pulse

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 • Respiratory depression

Management of Medication-Related Complications

• Reversal agents
• Treating respiratory and cardiac depression
• Stabilizing convulsions
Hematometra (signs and symptoms)
• Enlarged, firm, tender uterus
• Pelvic pressure
• Intense cramps and pain
• Lightheadedness
• Mild fever
• Scanty vaginal bleeding
Management of Hematometra
• Give appropriate antibiotics
• Evacuate uterus
• Give sublingual misoprostol and refer
Vaso vagal Reaction (signs and symptoms)
• Fainting, loss of consciousness
• Cold or damp skin
• Dizziness
• Nausea
• Moderate drop in blood pressure, pulse
• The cause is as a result of vagal nerve stimulation during vacuum
aspiration.
Management of vasovagal reaction
• Give IV fluids
• Perform a speculum examination and remove any POC in the cervical os

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 • Continue monitoring vital signs and
• Refer if necessary

Allergic Reactions
• Symptoms may include swelling of hands or feet, rashes or wheezing.
• Manage conventionally, such as with an antihistamine.
• Severe allergic reactions (very rare) should receive emergency treatment.
Management of allergic reactions
• Give IV fluids
• Monitor vital signs
• Give antihistamines and corticosteroids
• Give oxygen in severe cases and refer

Care after Treatment for Abortion Complications

The woman must be:
• Physically monitored
• Emotionally supported
• Provided verbal and printed information about:
• her condition including long-term changes
• use of medications
• contraceptive methods
• follow-up care
• what to expect, and what to do if emergency care is needed

Adverse Events
• Complications that a patient suffers during treatment that are not a result of her
presenting condition
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 • 1 in 10 patients in the hospital for any reason suffers some adverse event
• Rare in routine abortion-related and contraceptive care
• Serious adverse events may result in life-threatening injury or death

Types of Adverse Events

• Adverse event (AE)/complication – problem requiring intervention or management
beyond what is normally necessary for a procedure or anesthesia
• Serious adverse event (SAE) – may results in life-threatening injury, permanent
impairment, or requires medical or surgical intervention to prevent permanent
impairment or death
• Near miss – has potential to harm a patient but does not due to chance, prevention or
mitigation

Adverse Event Reporting

• Once the woman has been cared for, the event should be:

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 • Documented – complete information in the woman’s chart and facility logbook
• Reported – to local authorities according to established guidelines
• Analyzed - so that the experience can be used to improve care.
REFERENCES
1. Cooper, M. A and Fraser D. M (2003). Myles Textbook for Midwives 14th Edition.
London. Churchill Livingstone.
2. Doyle, R. M. et al. (2005). Nursing2005 Drug Handbook. 25th Anniversary
Edition. Philadelphia. Lippincott William and Wilkins.
3. Ojo, O.A. & Briggs, E.B. A Textbook for Midwives in the Tropics. London: Edward
Arnold
4. Sweet, B. R. (1982). Maye’s Midwifery-A Textbook for Midwives .10th Edition. London.
Bailliere Tindall.
5. Sweet, B. R. (1990). Bailliere’s Midwives Dictionary .8th Edition. London. Bailliere
Tindall.
6. Hagar B. (2020) Introduction to Abnormal Pregnancy handbook, 1st edition
7. Ghana Health Service, 2021. Comprehensive Abortion Care Services Standards and
Protocols handbook, 4th edition.

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