UNIT 10 : MATERNAL AND  uef{j:yfsf] ;ftf} dlxgf b]lv abdominal
CHILD HEALTH (MIDWIFERY)
k|hgg k|0ffnL
(Reproductive system)
k'?if k|hgg\ k|0ffnL
(Male Reproductive system)
 k'?ifsf] k|hgg\ k|0ffnLdf lgDg c+ux? kb{5g M
• Scrotum -1
• Testes-2
• Epididymis-2
• Vas deference-2
• Spermatic cords-2
• Seminal vesicle-2
• Ejaculatory duct-2
• Prostate gland-1
• Penis-1
Scrotum
 Pp6f y}nL h:t} structure xf], h;leq @ j6f
c08sf]ifx? (testes) /x]sf x'G5g .
 of] Ps lsl;dsf] subcutaneous muscle af6
ag]sf] x'G5, h;nfO{ Dartus muscle elgG5 .
 of] inguinal canal sf] dfWodaf6 abdominal
cavity ;Fu hf]l8Psf] x'G5 .
c08sf]if (Testes)
 Scrotum leq @ j6f c08f cfsf/sf testes x?
/x]sf x'G5g , k|To]s c08sf]if spermatic cord
sf] dfWodn] scrotum df c8]sf x'G5g .
 Testes are endocrine glands.
 They are homologous to ovary in female.
 They are about 4.5 cm long, 2.5 cm wide
and 3 cm thick.
 Weight of testis : 10 to 15 gram.
 They are suspended in the scrotum by
spermatic cord.
 Inflammation of the spermatic cord is
known as -Funniculitis.
 o;nfO{ jl/kl/af6 # j6f kqx? (layers) x? n]
3]/]/ /fv]sf] x'G5 .
A. Tunica vaginalis (double layered)
B. Tunica albuginea
C. Tunica vasculosa
 Collection of excessive fluid between two
layers of tunica vaginalis is known as -
Hydrocele.
DN Bhatta Midwifery (MCH)
cavity df testes sf] ljsf; x'g ;'? x'G5 / lz;'
sl/j * dlxgfsf] k'u]kl5 df inguinal canal
sf] af6f] x'b} testes x? scrotum ;Dd cfOk'U5g
.
 Testes develop in the lumber region of
the abdominal cavity, just below the
kidneys.
 k|To]s testes df @))–#)) v08x? (lobules)
x'G5g, k|To]s lobules df ! b]lv $ j6f
seminiferous tubules x? x'G5g . lo
seminiferous tubules leq lgDg k|sf/sf
sf]ifx? /x]sf x'G5g .
A. Spermatogenic cell : Precursor of
sperm (produce sperms /
Spermatogenesis)
B. Sertoli cell/Nursing cell: Helps in
nourishing of sperm.
C. Interstitial cell of leyding/Leyding
cells : Produce Androgens (e.g
testosterone) which maintain
secondary sexual character.
 Cryptorchidism : Undescended testes
 Orchidopexy : Surgical correction of
undescended testes.
 Orchidectomy :Surgical excision of
testes.
 Testes sf] inflammation nfO{ Orchitis
elgG5 .
 Sperm aGg] k|lqmofnfO{ spermatogenesis
elgG5 eg] sperm x? Mature e} o;n]
motility k|fKt ug]{ k|lqmofnfO{
spermiogenesis elgG5 .
 Maturation of spermatids into
spermatozoon, is called
spermiogenesis.
 Spermatogenesis k|lqmof k'/f x'g sl/a ^$
lbg nfUb5 .
 Time taken for spermiogenesis : 14
days.
 Spermatogenesis k|lqmof ;DkGg x'g testes
sf] tfkqmd zl//sf] tfkqmd eGbf 3-50C sd
x'g'kb{5 .
 Sperm aGg] k|lqmofnfO{ anterior pituitary
af6 pTkfbg x'g] Follicle Stimulating
Hormone (FSH) n] Stimulate ub{5 .
Page | 1
 To;}ul/, Anterior pituitary gland af6
pKkfbg x'g] Luteinizing Hormone (LH) n]
interstitial cell of Leyding nfO{ stimulate
u/]kl5 Testosterone (androgen)
hormone sf] pTkfbg x'G5 .
 Testosterone sf] k|efjn] zl//df secondary
sexual character (puberty) sf] ljsf; x'G5 .
 Puberty occurs between the age of 10
and 14.
 Mature sperm have 3 main parts :
Head, Body & tail.
Do you know ?
Spermatozoon = single -Pp6f z'qmls6_
Spermatozoa = multiple -z'qmls6x?_
Testes = multiple -c08sf]ifx?_
Testis= Single -Pp6f c08sf]if_
 Fertilizable life span of the sperm is - 48
to 72 hours
 Sperm is the smallest cell of the human
body.
 Sperm is the only one motile cell of the
body.
 Sperm is the only one cell having
flagellum.
 Number of chromosomes in sperm : 23
(22+X or 22+Y).
 Normal sperm count : 60-120
millions/ml.
 WHO oligospermia : Sperm count
below 15 million/ml.
 Azoospermia: Absence of sperms in
semen.
 Normal sperm motility is 3mm per
minute.
 Capacitation :
• of] sperm df x'g] Pp6f Physiological
process xf], h;af6 sperm n] ovum nfO{
penetrate ug]{ Ifdtf (ability) k|fKt ub{5 .
• Capacitation begins in the female
genital tract (cervix) but major part
takes place in fallopian tube, takes
about 6-8 hours. (7 hours)
DN Bhatta Midwifery (MCH)
Epididymis
 k|To]s testes df /x]sf ; ;fgf gnLx? Testes
sf] dflynnf] 5]pdf cfP/ Pp6f convoluted
gnL agfpb5g, h;nfO{ epididymis elgG5 .
 At the upper pole of the testis the
tubules combine to form a single tubule.
This tubule, about 6 m in its full length,
is repeatedly folded and tightly packed
into a mass called the epididymis.
 It leaves the scrotum as the deferent
duct (vas deferens) in the spermatic
cord.
 Blood and lymph vessels pass to the
testes in the spermatic cords.
 o;nfO{ # efudf af8\g ;lsG5 M
s_ Head v_ Body u_ Tail
 Epididymis df k'u]/ sperm x?n] motility
k|fKt ub{5g, h;nfO{ Spermiogenesis elgG5
.
 Epididymis n] spermatozoa nfO{ testes
af6 vas deference ;Dd k'/\ofpb5g .
Vas deference/The deferent duct
-z'qmaflxgL gnL_
 nDafO{ M $% ;]=dL -!* O{Gr_
 of] gnL epididymis b]lv seminal vesicle
;Dd km}lnPsf] x'G5, o;n] z'qmls6x? nfO{
epididymis af6 ejaculatory duct ;Dd
k'/\ofpb5 .
 vas deference / seminal vesicle af6
cfPsf] gnL ldn]/ ejaculatory duct ag]sf]
x'G5, of] gnL s]lx cuf8L k'u]kl5 urethra ;Fu
hf]l8Psf] x'G5 .
 Ejaculatory duct sf] nDafO : 2 cm
 k|To]s testes af6 !–! j6f spermatic cord
lg:s]sf x'G5g, h;n] h;n] testes nfO{
scrotum df ´'08\ofP/ /fVb5 .+
 k|To]s spermatic cord sf] leq Pp6f vas
deference /x]sf] x'G5 .
 Vasectomy: Excission & ligation of the
vas deference
Page | 2
 Seminal Vesicles -jLo{ y}nL_
 @ j6f v08 k/]sf (lobulate) y}nf cfsf/sf
u|GyLx?nfO{ Seminal vesicle elgG5 .
 Length - 5cm
 o;n] sperm x?nfO{ e08f/0f ug]{ x'gfn]
o;nfO{ store house of sperm klg elgG5 .
 o;n] seminal fluid pTkfbg ug{'sf ;fy}
sperm x? nfO{ fructose k|bfg ub{5 .
 Semen df 60% seminal fluid /x]sf] x'G5 .
Penis -ln+u_
 of] k'?ifsf] ;+ef]u c+u (copulatory organ) xf]
.  o;n] Prostatic fluid pTkfbg ub{5, h;df
 of] ljz]if lsl;dsf pQ]lht tGt'x? (erectile
tissue) / df+;k]zL ldn]/ ag]sf] x'G5 .
 o;df @ j6f corpora covernosa / Pp6f
corpora spongiosum ul/ # j6f erectile
tissue x? /x]sf x'G5g .
 corpus spongiosum df penile urethra
/x]sf] x'G5 .
 ln+usf] 6'Kkf]df cfP/ corpus spongiosum n]
lqsf]0f cfsf/sf] jgfj6 agfpb5, h;nfO{
glans penis elgG5 .
 o;sf] jl/kl/ kftnf] 5fnfsf] vf]n x'G5, h;nfO{
foreskin jf prepuce elgG5 .
 Penis nfO{ /Qm;~rf/ u/fpg] artery sf] gfd
pudendal artery xf] .
 Parasympathetic nerve supply n] penis
nfO{ pQ]lht (erection) u/fpb5 eg]
Sympathetic nerve supply n] jLo{ :vng
(Ejaculation) u/fpb5 .
 Glans penis sf] inflammation nfO{
Balanitis elgG5 .
 Penis is homologous to clitoris in
female.
 Phimosis : Phimosis is defined as the
inability to retract the skin (foreskin or
prepuce) covering the head (glans) of
the penis. It is common in young male.
 Paraphimosis : Tight retracted
foreskin can not be returned to it's
normal anatomical position. It is
common in old male.
DN Bhatta Midwifery (MCH)
 Circumscission : Surgical removal of
foreskin . (Surgical correction for
phimosis & paraphimosis)
Prostate Gland
 of] k'?if k|hgg k|0ffnLsf] ;xfos u|GyL xf], of]
urinary bladder sf] tn rectum sf]
cufl8kl§ /x]sf] x'G5 .
 Adult df o;sf] tf}n sl/a * u|fd x'G5 eg]
%) aif{sf] pd]/kl5 of] $) u|fd ;Dd k'Ug ;S5
 nDafO{ # ;]=dL / rf}8fO{ $ ;]dL x'G5 .
-nDafO{< rf}8fO{_
Prostatic Specific enzyme (PSA) /x]sf]
x'G5 . Prostate sf] SofG;/ ePdf PSA sf]
level a9]sf] x'G5 .
 Prostate 7'nf] x'bf urethra df aflx/af6 rfk
a9\g hfG5, h;n] ubf{ lk;fa /f]lsg]
(retention of urine) ;d:of b]vf kg{ ;S5 .
o;nfO{ Benign Prostatic Hypertrophy
(BPH) elgG5 .
 of] k|foM %) aif{ pd]/ k'/f ul/;s]sf k'?ifx?df
b]vf kb{5 .
 Prostate u|GyL sf] inflammation nfO{
Prostatitis elgG5 .
jLo{ (Semen)
 Composition:
• Seminal fluid : 60%
• Prostatic fluid : 25%
• Sperm: 10%
• Cowper's secretion & mucous : 5%
 Normal volume: 3-5 ml per ejaculation
 pH : 7.35-7.5 (alkaline).
v_ :qL k|hgg k|0ffnL (Female reproductive
System)
:qL k|hgg k|0ffnL nfO{ @ efudf laefhg ul/Psf] 5
.
A) External Genitalia
(vulva/pudendum):
• Mons pubis
• Labia majora
• Labia minora
• Clitoris
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 • Vestibule
• Hymen
B) Internal Genitalia
• Vagina-1
• Uterus-1
• Uterine tubes/Fallopian tubes-2
• Ovaries -2
C) Accessory organs
• Breast
• Bartholin's glands (Vestibular
gland)
Mons pubis : of] external genitalia sf]
;a}eGbf dflyNnf], symphysis pubis cufl8sf]
efu xf] . of}jg cj:yf (puberty) df o;nfO{ pubic
hair n] 9fs]sf] x'G5 .
Labia Majora : Vulva sf] b'a} 5]pdf cjl:yt
af];f]o'Qm afSnf] 5fnfsf] efunfO{ labia majora
elgG5 . of] 5fnf fibrous tissue / fat n] ag]sf]
x'G5 .
Labia Minora :
 Labia majora sf] leqk§L ljgf af];f]o'Qm
5fnfsf kqnfO{ labia minora elgG5 .
 o;sf] dflyNnf] 5]p clitoris sf] 5]p;Fu
hf]l8Psf] x'G5 eg] tNnf] efu dWo/]vfdf cfO{
hf]l8Psf] x'G5, h;nfO{ Fourchette elgG5 .
b'O{ labia minora ljrsf] efunfO{ vestibule
elgG5 .
 There are four opening in the vestibule-
a. Vaginal orifice
b. Urethral orifice
c. Opening of Bartholin's duct.
d. Opening of skene's gland
Clitoris : of] pQ]lht tGt' (most erectile
tissue) n] ag]sf] afXo k|hgg\ cË xf] . of] k'?ifsf]
lnË ;Fu ldNbf] h'Nbf] (homologous) x'G5 .
Hymen : of] kftnf] mucus membrane xf] .
o;n] vaginal orifice nfO{ 9fs]sf] x'G5, /h:jnf
x'bf, of}g;Dks{ ubf{, aRrf hGdfpbf of] gi6 eP/
hfG5 . o;nfO{ s'dfl/Tj sf] lrXg (indicator of
virginity) sf ?kdf klg lnO{G5 .
DN Bhatta Midwifery (MCH)
Perineum
 Perineum is a triangular area extending
from the base of the labia minora to the
anal canal.
 It consists of connective tissue, muscle
and fat.
 It gives attachment to the muscles of
pelvic floor.
 Blood supply to vulva & perineum by
pudendal artery.
 Levator ani is a group of muscles found
in pelvis.
 Size of obstetric perineum : 4cm X 4
cm.
Vagina :
 of] Pp6f fibromuscular canal xf], h;n] :qL
k|hgg k|0ffnLsf] afXo cË (vulva) nfO{
uterus ;Fu hf]8\b5 . of] urinary bladdder
sf] k5fl8 / rectum sf] cufl8k§L /x]sf] x'G5 .
 o;nfO{ non keratinized stratified
squamous epithelium n] lining u/]sf] x'G5
 of] urinary bladder ;Fu 450 sf] sf]0f df
/x]sf] x'G5 .
 o;sf] anterior wall sf] nDafO{ sl/a 7.5 cm
/ posterior wall sf] nDafO{ sl//a 9 cm x'G5
.
 Diameter of vaginal canal : 2.5 cm.
 Vaginal introitus - opening of vaginal
canal.
 Fornix : Space between cervix and
vaginal wall (one anterior, one
posterior & two lateral fornices)
 Vaginal fluid sf] pH ;fdfGotof acidic (4-
5.5) x'G5 t/ dlxgfjf/L rqm sf] ljleGg
r/0fx?df kl/jt{g x'g ;S5 .
(According to some references pH of
vaginal fluid : 3.5 to 4.9)
 Vaginal canal df ljz]if lsl;dsf bacteria
x? kfO{G5g,h:t} lactobacillus
acidophilus, lolgx? n] lactic acid pTkfbg
ul/ clDnokgf a9fp5 / xflgsf/s bacteria
x? af6 ;'/Iff k|bfg ub{5g .
 Colposcopy - Examination of vagina
and cervix.
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 Colposcope - Instrument used for
examination of vagina and cervix.
 Functions of vagina :
- Coitus : Sexual intercourse.
- Provides passage for childbirth.
- Protects pelvic organs from infection due
to it's acidic pH.
Uterus/Womb/Hystera
 of] vf]qmf] dfF;k]zLo cË (Hollow muscular
organ) xf], h'g urinary bladder sf] k5f8L
/ rectum sf] cufl8k§L /x]sf] x'G5 .
 o;sf] nDafO{ sl/a 7.5 cm(3 inch), rf}8fO{
5cm (2 inch) / df]6fO{ 2.5 cm (1 inch) x'G5
. sfo{x?_
 o;sf] tf}n sl/a 50-80 gram (60 gram)
x'G5 .
 The normal length of uterine cavity is
6.5 to 7cm.
 Shape : Pear shaped (Pyriform
shaped)
 Normal position: Anteverted and
antiflexed
 of] urinary blader ;Fu 90o sf] sf]0f agfP/
a;]sf] x'G5 .
 Uterus lgDg 3 j6f kqx? ldn]/ ag]sf] x'G5 .
A. Perimetrium (The outer fibrous layer)
B. Myometrium (The middle muscular
layer)
C. Endometrium (The inner layer of
endothelial cell that takes part in
menstruation, therefore called as
"functional layer of the uterus”)
 Uterus sf lgDg efux? x'G5g M
A. Fundus : of] ;a}eGbf dflyNnf] efu xf] . h'g
uterine tubes hf]l8Psf] efu eGbf dflyNNff] :jtGq
efu xf] . ;fdfGotof fundus sf] posterior efudf
implantation x'g] ub{5 .
B. Body (Corpus): of] uterus sf] dWo / d'Vo
efu (main part) xf] . h'g ;Dk'0f{ efusf] b'O{
ltxfO{ x'G5 . o;sf] b'a} 5]pdf uterine tubes x?
v'n]sf x'G5g .
DN Bhatta Midwifery (MCH)
C. Cervix : of] uterus sf] ;a}eGbf tNnf] efu xf] ,
h'g sl/a @=% ;]=ld hlt nfdf] x'G5 . of] Internal
OS af6 ;'? e} external OS ;Dd k'u]sf] x'G5 .
 Uterus df fallopion tube x? k|j]z ug]{
efunfO{ cornua elgG5 .
 Uterus nfO{ ljleGg ligaments x?n] support
u/]sf] x'G5 h:t} Broad ligament, round
ligament, cardinal ligament, uterosacral
ligament cflb
 log} supportive ligament x? sdhf]/ eP/
k|foM uterine prolapse x'g] ub{5 .
 Uterine prolapse is most common in
multiparous & aged women.
 Functions of the uterus : -kf7]3/sf]
s_ Fertilized ovum nfO{ kf]ifs tTj k|bfg ug{'sf
;fy} z'/Iff ub{5 .
v_ Fetus sf] j[l4, ljsf;sf] nflu cg's'n jftfj/0f
k|bfg ub{5 .
u_ k'0f{ ljsl;t fetus nfO{ aflx/ lgsfNb5 .
(labour)
3_ dlxgfjf/L (menstruation) df e'ldsf lgjf{x
ub{5 .
 Hysterectomy : Surgical excision of the
uterus.
 Hysteritis : Inflammation of the uterus.
 g]kfnL dlxnfx?df b]vf kg]{ k|d'v SofG;/
kf7]3/sf] d'vsf] SofG;/ (cervix cancer) xf]
.
 Hematometra : Collection of blood
within uterine cavity.
 Pyometra : Collection of pus within
uterine cavity.
 Endometriosis - A condition in which
endometrium grows outside of the uterus.
common sites are ovaries, fallopian tubes,
around uterus etc.
 Most common cancer in Nepali females is
'Cervix cancer.'
 Screening tests for cervical cancer : PAP
smear, VIA (Visual Inspection with
Acetic acid
 Cervical cancer screening - 30 b]lv 60
aif{sf] pd]/ leq k|To]s 5/5 aif{df u/fpg'kb{5 .
Page | 5
 Fallopian tube/Uterine tube/Oviduct
 nDafO{ M 10 cm
 o;nfO{ $ efudf ljefhg ul/Psf] 5 .
1. Intramural or interstitial :
(Length : 1.25 cm, Diameter : 1mm)
2. Isthmus :
(Length : 2.5 cm, Diameter : 2mm)
3. Ampulla : 5 cm
-Longest & widest part
- Length : 5 cm, Diameter : 1 cm (10mm)
4. Infundibulum : 1.25 cm
;fdfGotof Ampulla efudf fertilization x'g] ub{5 .
 Ectopic pregnancy x'g] k|d'v efu
ampulla xf] .
 They are highly sensitive to touch or
pain.
 Fallopian tube sf] cGtdf finger like
projections x? x'G5g, h;nfO{ Fimbriae
elgG5 .
 Fallopian tube sf] inflammation nfO{
salphingitis elgG5 .
 Tubectomy: Excision of the part of
fallopian tube.
 Fertilization : Fusion of male gamete
(Sperm) & Female gamete (Ovum) to
form zygote.
 Human body develops from single
cell is called- Zygote.
 Zygote is single cell.
 Number of chromosomes in zygote -
46 (23 pairs)
Ovaries
 lolgx? @ j6f x'G5g h;nfO{ female gonads
klg elgG5 .
 Almond or oval shaped,
 Pinkish gray in color.
 size : 3X2X1 cm
 Lined by single layer of cuboidal cells is
known as Germinal epithelium.
 Ovary x? lgDg b'O{j6f efux? ldn]/ ag]sf]
x'G5 .
DN Bhatta Midwifery (MCH)
A. Cortex :
 Outer part
 Related to sex hormone production &
ovulation.
 Consists of primordial follicles,
maturing follicles, graffian follicles and
corpus luteum.
 Ovary nfO{ FSH n] stimulate ub{5, h;n]
ubf{ Ovary df Ovum sf] ljsf;
(oogenesis) x'G5 / oestrogen xdf]{g sf]
pTkfbg u/fp5 .
 Ovary nfO{ LH xdf]{gn] stimulate ub{5,
kmn:j?k M
a. Corpus luteum af6 progesterone sf]
pTkfbg x'G5 .
b. Ovulation x'G5 .
B. Medulla : Inner part, consists of loose
connective tissue, few unstriped
muscles, blood vessels & nerves.
 Functions of ovary: Production of Ovum,
oestrogen & progesterone.
 Ovary sf] inflammation nfO{ oopharitis
elgG5 .
 Ovum aGg] k|lqmofnfO{ oogenesis elgG5 eg]
ovary sf] graffian follicle af6 ljsl;t
ovum lgl:sg] k|lqmofnfO{ ovulation elgG5 .
 Gametogenesis : Male gamete
(spermatozoon) / Female gamete
(Ovum) aGg] k|lqmofnfO{ elgG5 .
 A female produce about 400 ova in her
reproductive life.
 Ovum is the largest cell of the human
body. (Size of fully matured ovum is
about 130 µm).
 Ovum is non-motile cell while the.
sperm is motile.
 Number of chromosomes in ovum- 23
(22,X).
 The outer transparent mucoprotein
(glycoprotein) layer of the ovum is
called - Zona pellucida
 Oestrogen and Progesterones are
steroid hormones.
Page | 6
 Breast -:tg_ :  Mastitis : Inflammation of the breast.
 of] :qL k|hgg k|0ffnLsf] ;xfos cË  Mastalgia or Mastodynia - Breast pain
(Accessory organ) xf] .  Mastectomy - Surgical
 :tgx? Sternum sf] b'a}k§L bf];|f] rib b]lv excision/removal of breast.
5}7f}+ rib ;Dd /x]sf x'G5g .  Mammogram - Low energy X-ray
 lolgx?sf] ljr efudf r'Rrf] k/]sf] efu x'G5, machine, used for screening of breast
h;nfO{ Nipple elgG5 . o;nfO{ jl/kl/af6 cancer.
sfnf] efu n] 9fs]sf] x'G5, h;nfO{ areola  Mammography - Best Method of Breast
elgG5 . cancer screening using mammogram.
 Round pigmented part of skin at the  Breast self examination (BSE) is
center of the breast - areola another method of screening of breast
 Diameter of areola is about -2.5 cm cancer.
 Muscular projection in breast covered  Best time for Breast self examination is
by pigmented skin- Nipple at the end of menstrual phase.
 About 15-20 lactiferous ducts opens at  Breast tissue is sensitive to the cyclic
Nipple. changes of hormones, oestrogen &
 Milk producing gland in Breast - Progesterone.
Mammary gland.  Women often feel breast tenderness &
 Areola df Ps lsl;dsf modified fullness during the luteal phase of the
sebaceous gland x? /x]sf x'G5g, h;nfO{ menstrual cycle.
Montgomery tubercles elgG5 . ue{jtL
dlxnfdf lolgx? :ki6 b]lvg] (Prominent) Menstrual Cycle/Reproductive cycle
x'G5g . lo u|GyLx?n] Nipple sf] jl/kl/ -dlxgfjf/L jf /h:jnf rqm_ :
Lubrication sf] sfd ub{5g .  Menstruation : k|hgg pd]/ ;d'xsf
 x/]s :tgdf !% b]lv @) j6f lobes x? x'G5g, dlxnfx?sf] kf7]3/af6 ljsf/o'Qm /ut of]lgdfu{
lo lobe x?df y'k|} b'w pTkfbg ug]{ u|GyLx? x'b} aflx/ lgl:sg] k|lqmofnfO{ dlxgfjf/L elgG5 .
(mammary glands) x? /x]sf x'G5g . o;nfO{ weeping of uterus klg elgG5 .
 Thelarche : Development of breast at
puberty.  o;/L periodic ?kdf k|To]s dlxgf e}/xg]
 Pituitary gland af6 pTkfbg x'g] prolactin ePsfn] o;nfO{ dfl;s rqm (menstrual cycle)
xdf]{g n] b'w pTkfbg (production/secretion) klg elgG5 .
df ;xof]u ub{5 eg] oxytocin xdf]{g n] b'w  cjwL (duration) : 28±7 days
lg:sf;g (ejection of milk) df ;xof]u ub{5
.  /Qm>fjsf] cjwL (duration of blood flow) :
 Prolactin -Production/Oxytocin- 3-5 days
Ejection  Normal amount of blood loss : 30-80 ml
 Gynecomastia : Enlargement of breast  klxnf] k6s dlxgfjf/L ;'? x'g'nfO{ Menarche
in male.
elgG5 .
 Galactorrhoea - Discharge of milk from
milk not associated with pregnancy or  klxnf] dlxgfjf/L sl/a !) b]lv !$ aif{sf] pd]/df
childbirth. ;'? x'g] ub{5 .
 Most common cancer in females  $%–%) aif{ kl5 dlxgfjf/L k'0f{tof aGb x'G5,
worldwide - Breast cancer.
h;nfO{ Menopause elgG5 .
 Invasive ductal carcinoma is the most
common type of breast cancer. This type  dlxgfjf/L rqm lgDg cj:yfx?df k'/f x'G5 .
of cancer begins from Milk duct 1.
of the
Menstrual phase : 0-4th day (4 day)
breast. 2. Proliferative phase (Follicular phase) : 5th -14th
 Fibroadenoma is a most common day (10 days)
benign tumor of the breast. (non-
cancerous) 3. Secretory phase (Luteal phase) : 15th -28th day
(14 days)
DN Bhatta Midwifery (MCH) Page | 7
1. Menstrual Phase:
 of] dlxgfjf/L rqmsf] Tof] cj:yf xf] h'g cj:yfdf
of]gLaf6 ljsf/o'Qm /ut aflx/ lgl:sG5 . of]
k|lqmof sl/a # b]lv % lbg ;Dd /xG5 .
 olb ovary af6 lgis]sf] ovum fertilize x'g
g;s]df corpus luteum gi6 x'g yfNb5, h;n]
ubf{ /utdf progesterone sf] dfqf 36\g hfG5,
o;/L progesterone sf] dfqf 36\gfn] kf7]3/sf]
endometrium klg 6'lqmg yfNb5 / /ut ;Fu}
aflx/ lgl:sG5 .
 Composition of menstrual blood -
Secretion of endometrial glands,
endometrial cells, blood and unfertilized
ovum.
 The level of oestrogen & Progesterone is
very low in this phase.
2. Proliferative Phase (Follicular phase) :
 o; cj:yfdf pituitary gland af6 pTkfbg
ePsf] FSH n] ovarian follicle nfO{ graffian
follicle df ljsl;t u/fp5,h;n] oestrogen
xdf]{g sf] pTkfbg ub{5 .
 Oestrogen xdf]{gn] endometrium sf]
k'glg{df{0f u/fO{ fertilized ovum a:g of]Uo
agfp5 . (endometrium becomes thick)
 To;}ul/ Pituitary gland af6} LH xdf]{g klg
pTkfbg e}/x]sf] x'G5, ovulation x'g'eGbf sl/a
24-36 306f cufl8 PSsf;L LH sf] dfqf
pRrtd laGb'df k'Ub5, h;nfO{ LH surge
elgG5 . LH surge kl5 o;sf] dfqf km]/L 36\g
yfNb5 .
 sl/a !$ cf}+ lbgdf LH surge sf] k|efjn]
graffian follicle af6 Pp6f ljsl;t c08f
(ovum) lgl:sG5, h;nfO{ ovulation elgG5 .
o;kl5
 This phase is under the influence of
Oestrogen hormone.
FSH→ Ovarian follicle →Graffian
follicle → Oestrogen
 At the time of ovulation, the cervical
mucous becomes watery, profuse and
slippery and the body temperature
increases by 0.5-10C.
 Ovulation occurs at the end of
proliferative phase.
 Ovulation is due to LH.
DN Bhatta Midwifery (MCH)
3. Secretory phase
 Ovulation e};s]kl5 pituitary gland af6
pTkfbg ePsf] LH xdf]{gn] ovum
lgl:s;s]kl5sf] follicle nfO{ corpus luteum
df kl/0ft ub{5, h'g corpus luteum n]
progesterone xdf]{g pTkfbg ub{5 .
LH→ Corpus Luteum → Progesterone
 Progesterone xdf]{gn] endometrium nfO{
c´ j[l4 ljsf; u/fpg'sf ;fy} ;–;fgf u|GyLx?
/ /QmgnLx?sf] ljsf; u/fpb5 .
 Ovum / sperm sf] fertilization ePdf
implantation sf nflu cfjZos jftfj/0f
k|bfg ub{5, progesterone dfqf lg/Gt/
pTkfbg x'b} uef{j:yf ;'? x'G5 / dlxgfjf/L
/f]lsG5 . (Amenorrhoea).
 olb fertilization gePdf /utdf
progesterone sf] dfqf 36\g uO{ k'gM
menstrual cycle bf]xf]l/G5 .
 The phase is under the control of
Progesterone.
MEDICAL TERMS USED IN
REPRODUCTIVE SYSTEM
 Gametogenesis - Germ cell af6 ovum /
sperm sf] ljsf; x'g] k|lqmofnfO{
Gametogenesis elgG5 .
 Spermatogenesis - Testes sf] Primordial
germ cell af6 Spermatids aGg] k|lqmofnfO{
Spermatogenesis elgG5 .
 Spermiogenesis - Maturation of
spermatids into spermatozoa. OR
Process by which spermatids get motility
and becomes mature spermatozoa, the
process occurs in epididymis.
 Capacitation - A physiological process
that occurs in spermatozoa by which
they are able to penetrate the ovum.
 Ovulation - Release of mature ovum
from ovary is called ovulation.
 Fertilization - Fusion of sperm and
ovum to form zygote.
Page | 8
 Implantation/Nidation - Attachment of NEED TO KNOW
fertilized ovum on the wall of the uterus.
 The cervix are insentive to touch, heat
(Posterior fundus)
and when grasped by instruments.
 Menarche - First menstruation.  The uterus, too is insensitive to
 Thelarche - Beginning of breast handling, and even incision over it's
development. wall.
 Amenorrhoea : Absence of  Narrowest part of fallopian tube is
menstruation. "interstitial" (1 mm)
 Menopause: permanent cessation of  Pouch of douglus also known as
menstruation. rectouterine pouch or Uterovesical
 Dysmenorrhoea : Painful pouch or Cul de sac is the extension of
menstruation. peritoneum between the rectum and
 Menorrhagia : Heavy menstrual posterior wall of uterus.
bleeding.  Aspiration of peritoneal fluid from
 Metrorrhagia : Irregular pouch of douglas (cul-de-sac) is called
bleeding/spotting bleeding between 2 "culdocentesis".
cycles.  Cordocentesis or Periumbilical Blood
 Polymenorrhoea : Menstrual cycle<21 Sampling (PUBS) is blood sample taken
days. (short menstrual cycles) from umbilical cord, most commonly
 Oligomenorrhoea : Menstrual cycle used for evaluation of Rh
>35 days. (long menstrual cycles) Isoimmunization. It is done after >20
 Leucorrhoea : Whitish vaginal weeks of gestation.
discharge.  The purpose of culdocentesis is to
identify Pelvic infections (PID),
 Mastitis- Inflammation of the breast.
ruptured ectopic pregnancy etc.
 Hysteritis -Inflammation of the uterus.
 Salphingitis- Inflammation of the
fallopian tubes.
Homologus Organs
 Oopharitis - Inflammation of the obary.
Male Female
 Orchitis - Inflammation of the testes.
Scrotum Labia Majora
 Ectopic Pregnancy - Implantation
Penile urethra and Labia Minora
occurs outside of the uterus.
prepuce/foreskin
 Endometriosis - Growth of
Penis Clitoris
Endometrium outside of the uterus.
Prostate Paraurethral gland
 WHO Oligospermia - Sperm count<15
(Skene's gland)
millions/ml.
Cowper's gland Bartholin's gland
 Abortion : termination of pregnancy
(Bulbourethral (Vestibular glands)
before the period of viability (i.e 22
glands
weeks of gestation).
Testes Ovaries
 Infertility : Unable to fertilize up to 12
Bulb of penis & Vestibular bulb
month of regular unprotected sexual
Corpus spongiosum
intercourse.
Interstitial cell Hilus cell (Ovary)
 Sterility: Completely unable to fertilize.
(testes)

DN Bhatta Midwifery (MCH) Page | 9

Midwifery : Introduction and history
❖ Midwife :
 Midwife zAb k'/fgf] c+u]|hL efiffsf] Mid /
wif ldn]/ ag]sf] xf], h;df Mid sf] cy{
'With' / wif sf] cy{ 'women' eGg] x'G5 ,
o;cg';f/ midwife sf] zflAbs cy{ "With
women" eGg] a'l´G5 .
 Midwife is a health professional who
care for mothers and newborn around
childbirth.
 ICM n] lbPsf] kl/efiff tn lbPsf] 5, h'g
FIGO / WHO n] klg adopt u/]sf] lyof] .
"A midwife is a person who has successfully
completed a midwifery education
programme that is recognised in the country
where it is located, has acquired the
requisite qualifications to be registered or
legally licensed to practice midwifery.
❖ Midwifery :
 Midwifery is a health science that
deals with nursing care during
Pregnancy, Childbirth and
Postpartum period including
newborn care.
❖ Obstetric :
 Obstetric is a branch of medicine that
include the basic and clinical
approaches during the pregnancy
and childbirth, i.e Changes,
monitoring, evaluation and
management".
 A Nursing staff may be obstetrician
while conducting delivery and s/he
become midwife when s/he care
women.
❖ Gynecology : Gynecology is the medical
practice dealing with the health of female
reproductive system. In general term,
Gynecology is the 'study of women'.
❖ Andrology : Study of male
reproductive health=Andrology
History of Midwifery
 ue{jtL tyf k|;'tL x]/rfx sf] ;'?jft !^ cf}F
;tflAb b]lv ;'? ePsf] dflgG5 .
 ;g !%!# df klxnf] k6s Midwifery sf] klxnf]
k':ts Germany df k|sflzt ePsf] lyof] .
 h'g k':ts ;g !%$) df English df k|sflzt
ePsf] lyof] .
DN Bhatta Midwifery (MCH)
 cfw'lgs obstetric sf] klxnf] cEof; French
Surgeon 'Ambroise pare' n] u/]sf lyP,
h;nfO{ clxn] Father of surgery eg]/ lrlgG5
.
 w]/} jif{ klxnf g]kfndf cg'ejL dlxnfx? 4f/f
k|;'tL u/fOGYof], h;nfO{ ;'8]gL gfd lbO{{Psf] lyof]
.
 kl5 o:tf ;'8]gLx?nfO{ g]kfn /]8qm; ;f];fO6L n]
tflndsf] ;'?jft u/]sf] lyof], To;kl5 :jf:Yo
;]jf ljefu / /fli6«o :jf:Yo tflnd s]Gb| n] klg
tflnd ;'? u/]sf] lyof] .
 o;/L tflnd lnPsf ;'8]gLx? n] cfkm'n] l;s]sf]
l;k / 1fg cfkm\gf kl/jf/sf dlxnf ;b:ox?nfO{
klg l;sfpby] .
 ;g !(@* -lj=; !(*%_ df /f0ff sfndf $ hgf
dlxnfx?nfO{ !* dlxg] Midwifery sf]if{ k9fpg
ef/tsf] cnfxjfb k7fPsf] lyof] / cWoog kZrft
logLx? lj/ c:ktfndf ;]jf lbg yfn]sf x'g .
 ;g !(%@ -lj=; @))(_ df bf];|f] r/0fdf @ hgf
dlxnf -8f= pdf b]jL bf; / ?lSd0fL r/0f >]i7_
nfO{ # jif{ ^ dlxgfsf] tflnd sf nflu ef/t
k7fOof] .
 August 1959 df k/f]ksf/ k|;'tL tyf :qL /f]u
c:ktfn (Maternity hospital) :yfkgf eP;+u}
g]kfndf Midwifery tflndsf] ;'?jft ePsf]
lyof] .
 of] c:ktfn nfO{ k|;'tL u[x eg]/ klg lrlgG5 .
 g]kfn ;/sf/ sf] tkm{af6 :jf:Yo dGqL uug
s'df/ yfkf n] :j=nfd' cdfTo nfO{ g]kfnsf] klxnf]
g;{ eg]/ 3f]if0f ul/ pgsf 5f]/f of]u]Zj/ cdfTo
nfO{ k|df0fkq x:tf/0f u/]sf lyP .
 In 1972 (2029 BS) all academically run
schools were placed under T.U. Institute
of Medicine.
 The nursing program was 3½ years
duration previously (before 1972) & it
was reduced in 3 years later in 1973
(2030 BS).
 School of Nursing in surendra Bhawan
in 2013 (1956).
 School of Nursing in Nirbhawan, Sanepa
2016 (1959)
 ANM Training Center in Bharatpur 2019
(1962)
 ANM Training Center Biratnagar in
2023 (1966),
 upgraded in PCL Nursing in 2044 BS.
 PCL Training Center Nepalgunj in 2026
(1969)
 upgraded in PCL Nursing in 2044 BS.
Page | 10
 SBA Policy was formed in Nepal in
2006.
 SBA training has 27 core skills.
 Duration of SBA training : 2 months.
Florence Nightingale
 hGd (Birth) : 12 May 1820 (Florence
city, Italy)
 d[To' (Death) : 13 August 1910 (England,
UK)
 () jif{sf] pd]/df pgsf] d[To' ePsf] lyof] .
 pgsf] hGdlbg May 12 df k|To]s jif{
International Nurses day dgfpg] ul/G5 .
 pgsf] @)) cf}F hGdhoGtLsf] cj;/ df WHO
n] ;g @)@) nfO{ "Year of the nurse and
midwife" gfd lbO{ dgfPsf] lyof] .
 Theme of International Nurses day
2021(given by ICN) : Nurses : A voice
to lead-A vision for future health
care. .
 March 1854 df ePsf] Crimean war df
pgn] lbPsf] of]ubfg n] pgnfO{ Famous
agfPsf] lyof] .
 She was "statistician and
Researcher".
 Florence Nightingale is also known as :
• Lady with the Lamp
• Founder of Modern Nursing.
• Father of Nursing
• Modern Father of Nursing
• Mother of modern Nursing
TERMINOLOGY
 Gestation : Pregnancy (40 weeks or 280
days or 9 month and 7 days from LMP) -
uef{j:yfsf] cf}ift cjwL $) xKtf jf ( dlxgf &
lbg jf @*) lbgsf] x'G5_
 Gestational age : Duration of pregnancy,
expressed in completed weeks or days. -
uef{j:yfsf] cjwL h;nfO{ xKtf / lbgdf u0fgf
ul/G5, To;nfO{ Gestational age elgG5 ._
 Trimester : 3 month duration of
pregnancy, there are 3 trimesters.-
uef{j:yf nfO{ ltgj6f q}dfl;s df ljefhg
ul/Psf] 5, h'g tn lbOPsf] 5 _
a. klxnf] q}dfl;s (First trimester) - First 12
weeks from LMP (0-12 weeks)
b. bf];|f] q}dfl;s (Second trimester: 13-28
weeks of gestation
DN Bhatta Midwifery (MCH)
c. t];|f] q}dfl;s (Third trimester) : 29-40
weeks
 Natal : Birth
 Antenatal/prenatal : period before
birth.
a. Ovum : 0-2 weeks
b. embryo : 2-8 weeks
c. fetus : 9 weeks to birth
 Perinatal period :
• Period between 28 weeks of gestation
and 7 days after birth.
• According to WHO, From 22 weeks of
gestation to 7 days after birth, which is
also called extended perinatal period.
[Choose answer depending on option
given]
 Post natal period : after birth
• Neonate : 0-28 days
➢ Early neonate : 0-7 days
➢ Late neonate : 8-28 days
• Infant :<1 year
• Toddler : 1-3 year
• Pre-school : 1-4 year
• School children : 5-15 year
• Adolescents : 10-19 years
 Preterm birth : Birth before 37
completed weeks (<259 days)
 Full-term birth : birth between 37-42
completed weeks. (259-294 days)
 Post term birth : birth after 42
completed weeks.(after 294 days)
 Gravid: Pregnant uterus
 Decidua: Endometrium of pregnant
uterus
 Abortion : Expulsion or extraction of of
fetus before the period of viability. (i.e
22 weeks of gestation)
 Intrauterine Fetal Death (IUFD) :
IUFD is death of fetus in uterus after the
period of viability (>22 weeks of
gestation or >500 gm) by WHO.
 Still birth : A baby who dies after 28
weeks of gestation but before or during
birth. [WHO]
 Perinatal mortality = Still birth + Early
neonatal death
 Gravida :
• Gravida eGgfn] dlxnf slt k6s ue{jtL
ePsf] xf], ;f] sf] s'n ;+VofnfO{ hgfp5 .
Page | 11
 • uef{j:yfsf] cGTo lhljt hGd jf d[t hGd
s] af6 eof], o;n] ;/f]sf/ /fVb}g .
• Gravida indicates the number of
times a woman is or has been
pregnant, regardless of the pregnancy
outcome.
• clxn] sf] ue{ klg o;df u0fgf ug{'kb{5 . (
A current pregnancy is included in
this count)
 Primigravida: A women who
conceive for the first time. -klxnf] k6s
ue{wf/0f u/]ls dlxnf nfO{ Primigravidae
elgG5_
 Multi-gravida: A pregnant mother
who has had previously more than one
pregnancy. -Ps k6s eGbf al9 k6s ue{jtL
ePsL dlxnf_
 Grand multi-gravida: A women who
has had previously 4 or more
pregnancy.
-$ k6s jf ;f] eGbf w]/} k6s ue{jtL
ePsL dlxnf_
 Para/Parity :
• Para jf Parity eGgfn] ;DalGwt dlxnfn]
period of viability -@@ xKtf_ kl5 hGdfPsf] -
lhljt jf d[t_ aRrfsf] s'n ;+Vof nfO{ a'l´G5_
• t/, Ps}k6sdf Ps eGbf al9 aRrf -h:t} M
Twins/Triplets) hlGdPdf To;nfO{ Pp6}
Parity df u0fgf ul/G5 . [William’s
obstetrics]
• csf]{ zAbdf eGg'kbf{ slt j6f ue{n] Period of
viability (22 weeks) k'/f u/] To;sf] s'n
;+Vof nfO{ Para/parity elgG5 .
 Nulli para: Period of viability -@@ xKtf_
kl5 aRrf ghGdfPsL dlxnf (A women who
has not deliver baby after the period of
viability, also known as zero para)
 Multi-para: xfn;Dd @@ xKtfkl5 Ps jf al9
k6s hGd -lhljt jf d[t_ lbPsL dlxnf . A
women who has given birth one or more
time after the period of viability.
 Primi-para: A women who has
delivered a baby for first time after the
period of viability. -@@ xKtfkl5 Ps k6s
dfq aRrfnfO{ hGd -lhljt jf d[t_ lbPsL
dlxnf_
 Grand multipara: A women who has
given birth previously 4 times or more. -
$ k6s jf ;f] eGbf al9 k6s aRrf hGdfPsL
dlxnf_
DN Bhatta Midwifery (MCH)
 Low birth weight: birth weight
<2500 gram.
 Very low birth weight: birth
weight<1500 gram.
 Extremely low birth weight birth
weight<1000 gram.
 Precocious puberty: Secondary
sexual character<5 year,
menstruation<10 year.
 Chorioamnionitis/intra-amniotic
infection (IAI) : Inflammation of fetal
membrane (amnion & Chorion), most
commonly due to bacterial infection.
 Amniocentesis :
• Amniotic fluid nfO{ syringe n]
aspiration u/]/ examination ug]{ k|lqmof
nfO{ amniocentesis elgG5 .
 Labour -k|;j_ : A series of event takes
place in the genital organ of female
during child birth, which is a
physiological process. -aRrf hlGdg] a]nfdf
dlxnfsf] hGddfu{df x'g] 36gfx?sf] k|fs[lts
qmdnfO{ k|;j elgG5_
 Delivery: The expulsion or extraction
of fetus out of the uterus. -ue{df /x]sf]
lzz'nfO{ aflx/ lgsfNg'_
 Eutocia: Normal labour.
 Dystocia: Abnormal labour.
 Braxton hicks contraction
- Painless uterine contraction seen
from first trimester.
 Parturient: Women in the period of
labour.
 Parturition: The process of giving
child birth.
 Puerpera: The women in the period of
puerperium.
 Puerperium: k|;j ;dfKt ePkl5 kf7]3/
nufot cGo k|hgg\ c++ux? k'j{ ue{jtL cj:yf
(Non-pregnant state) df kmls{g nfUg] ;do
cjwL nfO{ puerperium elgG5 .
 Involution : k|;j ;dfKt ePkl5 kf7]3/
nufot cGo k|hgg\ c++ux? k'j{ ue{jtL cj:yf
 (Non-pregnant state) df kmls{g] k|lqmofnfO{
involution elgG5
 Ectopic Pregnancy : Uterus eGbf aflx/
cGo 7fpFdf ue{ j:g' .
 ICM
• International Confederation of
midwives
Page | 12
 • Establishment : 1954 AD  Ovulation occurs soon after the
• Members : 143 member formation of the oocytes.
associations of 124 countries.  Secondary oocyte nfO{ g} ovulation e};s]
 FIGO kl5 ovum elgG5 .
• International Federation of  Oogenesis k|lqmof ovary sf] cortex efu df
Gynecology and Obstetrics. x'G5 , h;df germinal epithelium
• Establihsment : 26 July 1954 (Cuboidal cells) x'G5g .
• Head Office : London, UK (Initiatlly  Ovum contains 23 chromosomes (22,X)
in Geneva)  Around 400 ovulation occurs during
• Members : 132 Professional whole reproductive time.
Socities  Maximu number of oogonia in ovary are
 MIDSON seen in 20 weeks (5th month of
• Midwifery Society of Nepal intrauterine life). i.e 6-7 millions
 A fully matured ovum is the largest cell
• Professional forum for Midwives in
of the human body, is about 130 µm in
Nepal
diameter.
• Establishment : 2010 AD
 Ovum sf] aflx/ Ps lsl;dsf] mucoprotein
sf] vf]n (envelope) x'G5, h;nfO{ zona
 IUGR : Intrauterine Growth Retardation pellucida elgG5 .
 SBA : Skilled Birth Attendants
Spermatogenesis Process
FUNDAMENTAL OF REPRODUCTION
 Gametogenesis : Sperm / ovum sf] ljsf;
(maturation) x'g] k|lqmofnfO{ gametogenesis
elgG5 .
 Oogenesis : Ovum sf] ljsf; (maturation)
x'g] k|lqmofnfO{ oogenesis elgG5 .
 Spermatogenesis : Sperm sf] ljsf;
(maturation) x'g] k|lqmof nfO{
Spermatogenesis elgG5 . .
 Spermiogensis : Non motile spermatids
x? motile spermatozoa df ljsf; x'g] k|lqmof
nfO{ spermiogensis elgG5 .
Oogenesis x'g] k|lqmof

Oogenesis
Germ cell
Mitosis
Oogonia

Primary oocyte
(46,XX)

Maturation of graffian follicles  Mitosis sf]if ljefhg df chromosome sf]

Meiosis I ;FVof same /xG5 .
 Meiosis sf]if ljefhgsf] miosis-I df
Secondary oocyte First polar body chromosome df chromosome sf] ;FVof
(23, X) (23, X)
Ovulation
half (Haploid) x'G5 . (reductional cell
Ovum (23, X) dicision)
 Meiosis-II df chromosomes sf] ;FVof
same x'G5 .

DN Bhatta Midwifery (MCH) Page | 13

 Pp6f Spermatogonia af6 16 Primary
spermatocyte aGb5g .
 o;/L Pp6f Spermatogonia af6 16 X 4
=64 sperms x? aGb5g .
 Pp6f Primary spermatocyte af6 4 j6f
sperm sf] ljsf; x'G5 .
 Mature sperm has 2 parts : Head & tail
(tail is further divided into four zones)
 Capacitation : Physiological changes in
the sperm by which it becomes
hypermotile and able to fertilize a ovum.
-z'qmls6x? df b]vf kg]{ kl/jt{g h;df lolgx?
cem al9 motile e} ovum nfO{ penetrate ug]{
zlQm k|fKt ub{5g ._
 Capacitation takes place in genital tract
and takes about 6-8 hours.
 Ovulation : Relase of mature ovum
(secondary oocyte) from the ovary
following the rupture of graffian follicle
is called ovulation.
 Ovulation occurs at the end of follicular
(proliferative) phase of the
menstruation. (14th day of the cycle)
 The mature graffian follicle measures
about 20 mm in diameter, due to
accumulation of follicular fluid.
 Ovulation is due to effect of LH (LH
surge)
 Proliferative phase df LH sf] dfqf pRrtd
ljGb'df k'u]sf] cj:yf nfO{ LH surge elgG5 .
of] cj:yf sl/a 24 hours ;Dd sfod /xG5 .
-Oestrogen sf] level peak level df sl/a 24-36
306f ;Dd /xG5 _
 LH surge ePsf] sl/a 16-24 306f kl5
ovulation x'G5 .
 Fertilize gePsf] ovum, degeneration
process af6 gi6 x'G5g .
 Fertilizable life span of ovum ranges
from 12-24 hours, where as that of
sperm is 48-72 hours.
 Menstruation is unrelated to ovulation.
 Ovulation ge} x'g] dlxgfjf/L nfO anovular
menstruation elgG5 , of] adolescence,
after childbirth, near menopause sf]
a]nfdf common x'G5 .
 Fertilization : Fertilization is the
process of fusion of spermatozoon with
mature ovum to form zygote.
 Zygote is a single cell.
DN Bhatta Midwifery (MCH)
 Human body develops from a single cell
is called zygote.
 Number of chromosomes in zygote : 46
 Most common site of fertilization is
ampulla of the fallopian tube.
 About one hundreds of millions of
sperm deposited into vagina at a single
ejaculation.
 Only 1000 capacitated spermatozoa
enters the uterine tube and only 300-
500 reach the ovum but only one
fertilize.
 It takes only 30 minute for the sperm to
reach the fallopian tube.
 Important events following fertilization
are :
• 0 hour : Fertilization day (Day 15
from LMP)
• 30 hours : 2 cell stage (Blastomere)
• 40-50 hours : 4 cell stage
• 72 hours : 12-cell stage
• 96 hours : 16 cell stage, Morula
enters the uterine cavity.
• 5th day : Blastocyst
• 4-5th day : zona pellucida
disappears. [zona hatching]
• 6th day : Blastocyst attachment to
endometrium, called implantation
or nidation.
• 10th day : Synthesis of HCG by
synctiotrophoblast.
• 13 th day : Primary villi
• 16th day : Secondary villi
• 21th day : tertiary villi
• 21-22 days : Fetal heart, Fetal
circulation.
• 5 weeks : Gestation sac on USG
 Stage which enters uterine cavity is :
Morulla (4th day)
 Zona hatching occurs just before
implantation. (5 days after
fertilization)
 Zona hatching : Implantation x'g' cufl8
zona pellucida Rofltg' .
 Implantation occurs at Blastocyst stage.
(6th days after fertilization)
 Blastocyst contains trophoblast, from
which placenta and membranes are
developed.
Page | 14
 The embryo can be differentiate as  Parts of female pelvis are:
human at 8th weeks A. A basin like structure
 After 8 weeks of fertilization, B. Composed of 4 bones:
Trophoblastic cells differentiated into • 2 innominate bones (nameless) or hip
two layers : bone :
 Cytotrophoblast • 1 sacrum bone
 Synctiotrophoblast • 1 coccyx bone
• Secretes HCG hormone & Human  Each innominate bone has 3 parts.
placental latogen (HPL) (Ilium, Ischium, pubis)
• Also known as 'hormone factory of  Pelvic joints:
placenta'. • 1 symphysis pubis
• 2 sacro-iliac joints
Decidua • 1 sacro-coccygeal joint
 Endometrium of the pregnant uterus.  Pelvic ligaments :
 Well-developed decidua differentiated • Sacro tuberous ligament
into three layers : Compact, spongy • Sacro spinous ligament
and thin basal layers.  Pelvis is divided into 2 parts :
 It's main functions are : • The false pelvis : Part of pelvic above the
• Provide environment for pelvic brim, has no obstetrical
implantation. significance.
• Supplies nutrition to growing • The true pelvis : Part of pelvis below the
ovum. pelvic brim, plays important role in
• Decidua basalis provide basal childbirth & delivery.
plate to placenta.  True pelvis is divided into 3 parts;
pelvic outlet, pelvic brim, and the pelvic
GERM LAYERS cavity.
 A germ layer is primary layer of cells
that forms during embryonic Diameter Antero- Oblique Transverse
development. posterior
 Three germ layers are : Ectoderm, Brim 11 cm 12 cm 13
mesoderm & endoder. (Inlet)
 ECTODERM LAYERS : It forms Central Cavity 12 cm 12 cm 12
and peripheral nervous system, Outlet 13 cm 12 cm 11
epidermis of the skin, hair, nail,
pituitary gland, salivary gland, roof of  There are 4 types of female pelvis:
mouth, paranasal sinuses etc. Gynaecoid, android, anthropoid and
 MESODERM LAYER : It forms Bone, platypelloid.
cartilage, muscles, cardiovascular
system, kidney, testes, ovary, adrenal A. Gynaecoid:
glands, spleen, genital tract, pericardial,  Most common type (Approximately
peritoneal and pleural cavity etc. 50%).
 ENDODERM LAYER : It forms lining of  Shape of brim is round.
gastrointestinal tract, liver, gall bladder,  Cavity is wide and shallow.
pancreas, lining of respiratory tract,  Sacrum is well curved.
mucous membrane of urinary bladder  Ischial spines are blunt.
and urethra, bulbourethral gland etc.  The fetal head often engage in the
transverse diameter of the brim in
The pelvis occipito-anterior position.
 A basin like structure formed anteriorly
and laterally by the innominate bone B. Anthropoid:
and posteriorly by the sacrum and  Approximately 25%.
coccx.  Shape of brim is oval.

DN Bhatta Midwifery (MCH) Page | 15

  Anterioposterior diameter is more
than transverse diameter in
anthropoid pelvis.
 Cavity is wider and side walls are
straight.
 Sacrum is long and narrow.
 Ischial spines are prominent.
 The fetal head may engage with the
occipito-posterior.
 Face to pubis delivery is most
common in anthropoid.
C. Android:
 Approximately 20%.
 Male type pelvis.
 Shape of inlet triangular, like heart.
 Sacrum is straight and inclined
forward.
 Side walls of the cavities are
convergent.
 Ischial spines are prominent.
 The fetal head may engage
transversly or occipito-posterior
position, chance of perineal tears
during delivery.
D. Platypelloid:
 Approximately 5%.
 Least common type.
 Broad flat pelvis.
 Pelvic inlet- oval, like kidney.
 Sacrum is straight and inclined
posteriorly.
 Ischial spines are not prominent.
 The fetal head will engage in the
transverse diameter.
Contracted pelvis
 A contracted pelvis is one in which one
or more diameter are reduced by 0.5
cm or more and interfere with labour.
 The diameter may be reduced by 1 cm
or more.
 Common in women with height <140
cm.
 Management of choice for contracted
pelvis is 'Cesarean section'
 Effect on labor :
(A) Major degree of cephalopelvic
disproportion (CPD)
(B)Obstructed labor
(C) Need C/S delivery
DN Bhatta Midwifery (MCH)
(D) face presentation
(E) Cord prolapsed
Trial Labour :
 Mild to moderated degree sf] CPD df
vaginal delivery sf]lz; ug{' nfO{ Trial
labour elgG5 .
 This is done in hospital settings.
 Trial labour is best management of
CPD at the level of inlet.
 Contraindications of trial labour :
a. Severe degree of contracted pelvis.
b. Previous cesarian section
c. Elderly primigravidae
d. Malpresentation
e. Previous history of trial labour.
f. Severe PIH, diabetes & heart disease
Cephalopelvic Disproportion (CPD)
 Fetus eGbf pelvis ;fgf] x'g' nfO CPD elgG5
.
 of] clxn]sf] pregnancy df 5 eg] csf]{ k6sdf
gx'g ;S5 .
 CPD / contracted pelvis Pp6} xf]Og .
 CPD ePls dlxnfdf Ps k6s C/S u/]klg ;w}
ug{' kb}{g t/ Contracted pelvis ePls
dlxnfdf x/]s ue{df C/S delivery cfjZos
x'G5 .
 Trial labour is best management of
CPD at the level of inlet
Fetal head
 Sutures : Joint between cranial bones of
the skull is called sutures.
a. Frontal/metopic suture : joint
between two frontal bones
b. Coronal suture : Between parietal
and frontal bone.
c. Sagittal suture or longitudinal
suture : Between two parietal bones.
d. Lambdoid suture : Between parietal
and occipital bone.
Page | 16
 Gliding movement -vlK6g'_ overlapping
of one bone of skull over the other bone
is called Moulding.
 Grading of moulding
0-No moulding
1-Bone touching but not overlapping
2-Overlaping but easily separated.
3-Fixed overlaping
 Fontanelles :
• The membranous space (wide gap)
between cranial bone is called
fontanelle.
• At the time of birth , fetal skull has 6
fontanelles, out of which two are of
obstetrical significance.
(A) Anterior fontanelle :
 It is also called Bregma.
 Located at the junction of the
sagittal, coronal and frontal suture.
 Diamond shaped
 Anteroposterior and transverse
diameter : 3 cm
 Ossified (Closed) at 18 months
after birth. (should be closed within
24 months, if not it is pathological)
 It facilitates moulding during labour.
(B) Posterior fontanelle :
 It is also called Lambda
 Located at the junction of the sagittal
and lambdoid suture.
 Shape : like inverted letter 'Y'.
 Closes at 6 to 8 weeks.
Diameter of the skull
• Biparietal diameter -9.5 cm
• Bitemporal diameter -8.0 cm
• Suboccipito-bregmatic diameter -9.5 cm
• Occcipitofrontal diameter -11.5 cm
• Mento-vertical diameter -14 cm
• Submento bregmatic diameter -9.5
DN Bhatta Midwifery (MCH)
AREAS OF SKULL
(Presenting parts of cephalic presentation)
 Vertex : Area between anterior
fontanelle & posterior fontanelle. (Or
between coronal suture and lambdoid
suture)
 Brow : Forehead, the presenting
diameter is occipito-mental or
mentovertical diameter, which is the
longest anterio-posterior diameter of
fetal head. (14 cm)
 Face : From root of the nose to
junction of the chin.
 Occiput : Area limited to occipital
bone.
 Mentum : Chin of the fetus.
Swelling of Fetal Head
 Caput succedaneum
• Formation of swelling due to
accumulation of fluid in scalp.
• Not limited by suture, can cross
suture line.
• Appears at birth.
• Caput disappears after 24 hours.
 Cephalhematoma :
• Collection of blood between the
bones, usually due to forcep delivery.
• It is not develops at birth but
develops after 12-24 hour, the
swelling is limited. The
cephalhematoma may disappear
after 6-8 weeks
Feto-pelvic Relationships
1. Lie
 The relationship between long axis of
the fetus to the long axis of the mother.
 The lie of fetus may be :
a. Longitudinal lie : When fetal axis &
maternal axis corresponds, it is
longitudinal lie, the commonest lie.
(99.5%)
b. Transverse lie : Maternal axis &
fetal axis cross at 450.
c. Oblique lie : Maternal axis & fetal
axis cross at 450.
2. Presentation
 Presentation refers to the part of the
fetus which lies over the pelvic brim
(inlet).
Page | 17
  Presentation may be :
a. cephalic (96.8%) : when Head is
lower pole, Most common
presentation.
b. Breech (2.7-3%%) : When
buttocks are in lower pole.
 When more than one part of the
fetus is present it is called
compound presentation.
3. Presenting part
 The part of the presentation which
overlies the internal os and felt by the
finger on vaginal examination.
 Most dependent part of the fetal body is
called presenting part.
 In cephalic presentation, presenting
parts may be :
• Vertex : Most common (96%)
• Face (0.5%)
• Brow (0.01%) .
4. Attitude
 The relation of the different parts to the
fetus to one another.
 The basic attitude may be : Flexion and
extension
 The universal attitude in uterus is
Flexion.
5. Denominator
 An arbitrary -dgdfgL_ bony
pointschosen for each fetal presenting
part.
Presentation Denominator
Vertex Occiput
Face Mentum
Brow Sinciput
Breech Sacrum
Shoulder Scapula (acromian
process)
6. Position
 The relation of denominator to the
denominator to the different quadrants
of the maternal pelvis.
 The pelvis is divided into 8 equal
segments of 450 each. (total 3600)
 Thus, 8 positions are possible.
 They are :
1. Right occipito-anterior (ROA)
2. Left Occipitoanterior (LOA)
DN Bhatta Midwifery (MCH)
3. Right Occipito-posterior (ROP)
4. Left Occipito-posterior (LOP)
5. Right occipito-lateral (ROL)
6. Left Occipito-lateral (LOL)
7. Right occiput transverse (ROT)
8. Left occiput transverse (LOT)
 Normal Position : Occipito-anterior.
 The commonest position is left occipito
anterior (LOA).
 The commonest position during labour
left occipito-Transverse (LOT).
7. Station :
 Station is the relationship of the
presenting part to the ischial spine.
 If head is at the level of ischial spine,
the station is 0.
 If the head is above the level of ischial
spine, the station is negative.(-ve)
 If the head is Below the level of ischial
spine, the station is positive.
PLACENTA, FETAL MEMBRANES AND
UMBILICAL CORD
PLACENTA
 Also known as 'Fetal lung'
 It occupies 1/4th of the uterine cavity.
 It occupies 30% of the uterine wall.
 Human placenta is :
• Discoid : Disc shaped.
• Hemochorial : Direct contact of the
chorion with maternal blood.
• Deciduate : attached with decidua,
and some maternal tisse shed
during childbirth .
 Establish connection between mother
and fetus through the umbilical cord.
 Weight: 500gm (1/6th of the fetal
weight)
 At 17 weeks of gestation the weight of
the fetus & placenta are equals.
 Ratio of weight of placenta to the weight
of the baby at term - 1:6.
 At term, 15-20 cm diameter and 3 cm
thickness.
 It begins at 6th weeks and formation of
placenta completes by 12th week.
 Maternal blood enters placental
circulation by 15 days after
Page | 18
 fertilization. (uteroplacental
circulation).
 Feto placental circulation is established
by 17 days after fertilization.
 It has 2 surfaces: Fetal and maternal
surface.
(A) Fetal surface (Chorionic
Frondosum):
• Covered by the smooth and glistering
amnion.
• At term, about 4/5 of the placenta is of
fetal origin
• Umbilical cord is attached at center
(B) Maternal surface (Decidua basalis)
• Rough, shaggy and fleshy in
appearance.
• Has many finger like projections,
called Villi.
• Villi have syncytiotrophoblast and
cytotrophoblast.
• Space between the villi, there are
intervillous spaces.
 Villi caries fetal blood. (Volume : 350
ml).
 Intervillous space has maternal blood.
(Volume : 150 ml)
 Thus volume of blood in placenta is
500 ml. (350+150 ml)
 Oxygen saturation of placental blood
: 65-75%
 Oxygen delivery to fetus per minute
is about : 8 ml/kg
 Placenta contains fetal and maternal
blood, but do not mix with each other.
 Functional unit of the placenta is called
fetal cotyledons or placentome or
lobe or lobule.
 Placenta consists of 15-20 lobes.
 Placenta is usually attached to the
upper part of the uterine body.
 Placentomegaly : Thickness of placenta
>40 mm at term
 Most common benign tumor of placenta
is : Chorangioma
 Placenta separates after the birth of the
baby, by two ways
a. Central separation
b. Marginal separation
DN Bhatta Midwifery (MCH)
Placental hemodynamics
 Volume of blood in mature
placenta -500 ml.
 Volume of blood in intervillous
space -150 ml (maternal blood).
 Volume of blood in Villi : 350 ml.
(feta blood)
 Blood flow in intervillous space
-500-600 ml/min
 Fetal blood flow (feto-placental
blood flow) Through the placenta
- 400 ml/min
 Utero-placental blood flow at term,
: 500-750 ml/min (400-600
ml/min in some source)
 Uterine blood flow at term : 750
ml/min (non-pregnant : 50
ml/min)
 Fetal blood volume at term :
125ml/min.
 Pressure in umbilical artery
-60 mm of Hg
 Pressure in umbilical vein
-10 mm of Hg
 Pressure in the uterine artery
-70-80 mm of Hg
 The blood in the intervillous space is
replaced about 3-4 minute.
 The immunoglobulin which can cross
placental barrier is -IgG.
 IgG can cross placental barrier after 12
weeks.
 For placental localization, USG be
should be done in 3rd trimester.
 Functions of the placenta:
• Transfer function : transfer
nutrients, oxygen, antibodies, etc
• Immunological function
• Enzymatic function
• Barrier function : protect from
transfer of drugs, viruses etc.
• Endocrinal function: Produce
progesterone (beta-HCG), Human
placental Lactogen (HPL),
Progesterone, oestrogen.
 Main site of placenta for hormone
production is : Syntiotrophoblast.
(also called Hormone factory of
placenta)
Page | 19
 Main hormone during pregnancy :
Progesterone.
 In first trimester of pregnancy
progesterone is mainly produced by :
Corpus luteum
 During first 6-7 weeks, progesterone is
synthesized by corpus luteum.
 After 8-10 weeks, placenta secretes
progesterone.
 Level of progesterone at term : 300
ng/ml.
 Low progesterone is seen in ectopic
pregnancy, abortion etc.
 High progesterone level is seen in
Molar preganancy, Rh
isoimmunization.
 Human Placental lactogen (HPL), also
secreted by synctiotrophoblast, It
increases insulin resistance during
pregnancy, hence blood glucose is high
during pregnancy.
 Main source of energy for fetus :
Glucose.
Human Chorionic Gonadotropin (HCG)
Hormone
 Secreted by synctiotrophoblast of
Placenta.
 Two subunits : α HCG (non-specific)
& β-HCG (Specific)
 Half life : 24-36 hours
 Doubling time : 2 days
 HCG can be detected :
• 8-9 days following fertilization
or ovulation.
• 3 weeks (DAY 22) of LMP.
• Soon after implantation.
• 5-6 days before missed period.
 Level of HCG at missed period :
100 IU/L.
 Reaches maximum (100,000
IU/L) at : 8-10 weeks (70 days)
 Level of HCG becomes minimum at
: 16 weeks
 HCG disappears from urine after :
48 hours after delivery
 HCG disappears from blood after
1-2 weeks of delivery
 Function of HCG : Maintain corpus
luteum during pregnancy. (similar
as LH)
DN Bhatta Midwifery (MCH)
Abnormalities of Placenta & cord
1. Battledore placenta : Umbilical cord is
attached to the margin of the
placenta.(Racket placenta)
2. Velamentous insertion : Umbilical cord
is attached with membrane.
3. Placenta Succenturiata : one or more
lobe (cotylydon) is placed at varying
distance from main placental margin. (Also
called lobed placenta)
4. Circumvallate placenta : Chorionic
plate is covered by a double fold of amnion
and chorion so between maternal surface
and fetal surface a valve like structure is
seen.
5. Placenta accreta : Chorionic villi are
attached to the superficial myometrium.
6. Placenta increta : Villi penetrates deep
in myometrium.
7. Placenta percreta : Villi penetrates the
full thickness myometrium and reach upto
serosa
FETAL MEMBRANES
A. Amnion
• Innermost fetal membrane
• It is avascular.
• Formed between 10-11days after
fertilization.
B. Chorion
• Formed 8 days after fertilization.
• Placenta is formed from chorion.
C. Yolk Sac : First site of hemopoiesis.
D. Allantosis : umbilical cord is developed
from allantosis. (connecting stalk)
Umbilical cord:
 Length: 35-55 cm (40 cm)
 Long cord > 55 cm.
 Short cord : <32 cm.
 Diameter: 1.5 to 2 cm.
 Develops from allantosis (connecting
stalk)
Page | 20
 Covered only by amnion. (no chorion)  Fetal swallowing of amniotic fluid :
 Structures : 750 ml/day.
A. Covering epithelium  Normal range: 500-1500 ml.
B. Wharton's jelly • 12 weeks -50 ml
C. Blood vessels : • 20 weeks -400 ml
• It consist of Two arteries and one • 36-38 weeks -1000 ml (maximum)
vein. • 40 weeks -600 to 800 ml
• Initially there are four vessels - Two • 43 weeks -200 ml
arteries and two veins, The right
vein disappears by 4th month  Functions of amniotic fluid :
 Cord is attached at the center of the a. The main function is to protect
placenta. fetus.
 When the cord is attached to margin of b. Helps in development of fetal lungs.
placenta, it is called : Battledore c. Maintains even body temperature.
placenta. d. Prevents adhesions between fetal
 Short umbilical cord is associated part and amniotic sac.
with : e. It provides water supply to the
• IUGR fetus during pregnancy.
• Abnormal lie/presentation. f. helps in dilatation of cervix.
• Congenital malformations g. It flushes the birth canal at the end
• Premature separation of placenta of the first stage of labor.
(Abruptio placentae) Amniotic fluid has no role in nutrition.
 Long umbilical cord is associated
with :  Abnormal colors
• Cord prolapse a. Meconium stained (green)
• Cord around neck of fetus -Fetal distress is suspected.
• Fetal distress etc. b. Golden color
-Rh incompatibility
Amniotic Fluid (Liquor amnii) c. Greenish yellow -
 Color : Pale, straw color near term. Post maturity
 Colourless in early pregnancy. d. Dark colored -
 Specific gravity: 1.008 to 1.010. accidental hemorrhage.
 PH : 7.0-7.5 e. Dark brown -
 Osmolarity : 250 mmol Intrauterine death (IUD)
 It is hypotonic to maternal serum.
 Composition : Water 98-99%, Solid  Daily output of fetal urine at term is
1-2% (Protein, glucose, urea, uric acid, about 400-1200 ml.
creatinine, lipids, hormones)  Normal Amniotic Fluid Index (AFI) =
 Replaced in every 3 hours. 5-24 cm
 The precise origin of amniotic fluid is
not well understood. Oligohydrominous
 Amniotic fluid originates from  Amniotic fluid <200 ml or AFI<5cm.
maternal and fetal sources : (AFI= Amniotic Fluid Index)
 In early Pregnancy : From maternal  Causes :
plasma. • Drugs : Indomethacin, ACE
 2nd trimester : Diffusion from fetal inhibitors.
skin. • IUGR
 After 20 weeks : Fetal urine and fetal • Leaking of fluid following
lungs are main contributors. (fetal amniocentesis.
lungs also produce fluid) • Hypertension, pre-eclampsia
 Major contribution of amniotic fluid : • Post term pregnancy
fetal urine. • Premature rupture of membrane
DN Bhatta Midwifery (MCH) Page | 21
 • Renal abnormalities of fetus.
 Complications :
(A) Fetal complications :
• Pulmonary hyperplacia
(undeveloped lungs) - Most
common.
• IUGR
• Meconium aspiration syndrome
• Fetal distress
(B) Maternal complications
• Prolonged labour
• Malpresentations
• Increase maternal morbidity.
 Management
• Supportive management
• Oral administration of water
• Amnioinfusion
Polyhydrominous
 Amniotic fluid >2000 ml or AFI>24 cm.
(25 or more).
 Causes
• Twins/multiple pregnancy (more
fetus→more urine)
• Maternal hyperglycemia or diabetes
• Difficulty in swallowin amniotic
fluid.
 Complications :
• Premature rupture of membrane
• Preterm labour
• Abruptio placenta
• PPH
• Pregnancy Induced Hypertension
(PIH)
• Cord prolapse, malpresentation,
unstable lie
• In fetus : Prematurity, LBW,
congenital abnormalities, increased
perinatal mortality.
 Management : Amniocentesis,
Indomethacin therapy etc.
AMNIOCENTESIS
 Amniocentesis is a medical procedure
used for aspiration of amniotic fluid for
diagnostic or therapeutic purpose.
 Diagnostic Purpose :
(A) Early months (15-20 weeks)
• Genetic abnormalities
• Neural tube defects.
DN Bhatta
(B) Late months
• Fetal maturity
• Lungs development
• Rh isoimmunization
• Meconium stained liquor
• Sex determination
 Therapeutic purpose
• Induction of abortion
• Amnioinfusion
• To dilute meconium stained liquor.
• Management of oligohydroamnios
and polyhydramnios
 The main purpose of amniocentesis is to
detect genetic/chromosomal
abnormalities.
 The best time for amniocentesis is 15-
20 weeks of gestation.
Foetal Circulation (Feto-placental
Circulation):
 cfdfsf] uterus leq /x]sf] aRrfdf x'g]
/Qm;~rf/nfO{ foetal circulation elgG5
 Fetal circulation k|lqmof uef{j:yfsf] s/La !&
lbg b]lv ;'? x'G5 eg] sl/a # xKtfb]lv d'6'n] klg
sfd ug{ yfNb5 .
 Fetal cardiovascular system develops
from mesoderm layer.
 Embryo nfO{ rflxg] cfjZos tTj / clS;hg
Placenta af6 umbilical vein n] n}hfG5 eg]
cz'4 /ut umbilical arteries n] Placenta
;Dd k'¥ofpb5g .
 ha umbilical vein, placenta af6 lg:s]/
umbilicus x'b} fetus sf] zl//df k|j]z x'G5,
To;kl5 of] portal vein ;+u ldNb5, h;n] ubf{
o;n] Nofpg] /utsf] s]lx dfqf sn]hf]df k'Ub5 /
sn]hf]af6 hepatic vein dfkm{t inferior
venacava df k'Ub5 .
 o;sf cltl/Qm umbilical vein l;w} Ductus
venosus dfkm{t inferior venacava ;+u
hf]l8Psf] x'G5 . o;n] Nofpg] w]/}h;f] /ut
Ductus venosus dfkm{t l;w} inferior
venacava x'b} d'6'sf] right atrium df k'Ub5 .
 d'6'sf] right atrium / left atrium sf] leQfdf
Pp6f Kjfn x'G5, h;nfO{ Foramen ovale
elgG5, sl/a 75% /ut olx foramen ovale
x'b} right atrium sf] /ut left atrium df k'Ub5
Midwifery (MCH) Page | 22
 . o;kl5 left atrium sf] /ut left ventricle • Anatomical closing : 7 days.
df k'Ub5 / aorta sf] dfWodaf6 d'6' / • Reminent -cjz]if_ M Ligamentum
dl:tisnfO{ z'4 /ut k|bfg x'G5 . venosum.
 Right atrium sf] sl/a 25% /ut tricuspid 2. Formanen ovale :
valve sf] af6f] x'b} Right ventricle df klg • Connection/shunt between Right
hfG5 . Right ventricle sf] /ut o;kl5 atrium & Left atrium.
pulmonary artery df k'Ub5 . Pulmonary • Bypass the lungs
artery / aorta aLr Pp6f gzf • Physiological change : 5 minute after
(Shunt/connection) x'G5, ,h;nfO{ Ductus birth .
arteriosus elgG5 . olx ductus arterious • Anatomical closure : 1 year.
dfkm{t pulmonary artery sf] ;a} /ut aorta • Reminent -cjz]if_ M Fossa ovalis.
df ldl;G5 .
3. Ductus arteriosus
 Pulmonary artery af6 s]lx /ut kmf]S;f]df
• Connection between Pulmonary
klg k'Ub5, t/ fetus df kmfS;f] n] :jf; gkm]g]{
artery and Aorta. (Artery+artery)
x'bf ;f] /ut Pulmonary vein x'b} d'6'sf] left
• By pass lungs.
atrium →Left ventricle→Aorta df k'Ub5 .
• Physiological closure : 5 minute after
 Aorta af6 ;—;fgf arteries x? lg:s]sf x'G5g
birth.
h;n] zl//nfO{ ;'4 /ut k|bfg ub{5g . o;/L
• Anatomical closure : 3 months after
;'4 /ut k|bfg ug]{ qmddf cz'4 /ut klg cln
birth.
cln hDdf x'b} @ j6f umbilical arteries x?
• Reminent -cjz]if_ M Ligamentum
dfkm{t Placenta df k'Ub5g . Placenta df z'4
arteriosum..
eO k'gM umbilical vein x'b} z'4 /ut Fetus sf]
zl// ;Dd k''Ub5 . 4. Umbilical vein :
• Reminent-cjz]if_ M Ligamentum teres
5. umbilical artery :
• Reminent-cjz]if_ M Median umbilical
Ligament

➢ Umbilical cord consists of two arteries

and one veins.
➢ Initially umbilical cord consists of two
arteries and two veins, after 4 month,
the right vein disappears.
➢ Umbilical vein carries oxygenated blood
(80% saturated) from the placenta.
➢ The mean cardiac output is
Change After Birth
comparatively high in fetus and is
1. Ductus Venosus : estimated to be 350 ml/kg/min.
• Connection between umbilical vein and ➢ Within 1 or 2 hours following birth, the
inferior venacava. (Vein+vein) cardiac output is estimated to be about
• Bypass the liver. 500 ml/min, the heart rate varies from
• Physiological change 5 minute after 120 to 140/minute.
birth.

DN Bhatta Midwifery (MCH) Page | 23

 Physiological Changes During
Pregnancy:
1. General consideration
 Basal metabolic Rate (BMR) increases
by 10-20%.
 Total amount of water retained during
pregnancy : 6.5 Liter (Hypervolemia)
 Extra calorie requirement : +350 Kcal
 Weight gain : 10-12 kg.
 Ideal weight gain : 11 kg (24 Ib)
• First trimester : 1 kg
• Second trimester : 5 kg
• Third trimester : 5 kg
 Insulin secretion is increased.
 But insulin resistance occurs during
pregnancy, due to oestrogen,
progesterone, cortisol, HPL.
 HPL is main hormone causing insulin
resistance during pregnancy.
 Gestational diabetes is due to insulin
resistance.
 Best time for screening of gestational
diabetes is 24-28 weeks, when the
insulin resistance is maximum.
 During fasting : Hypoglycemia (due to
glucose used by fetus)
 Post prandial : Hyperglycemia occurs
due to insulin resistance.
 Oral Glucose tolerance test (OGTT) is
best method for screening gestational
diabetes mellitus.
 Glycosurea may be seen in 50% of
pregnancies.
 Total iron required during whole
pregnancy is about 1000 mg
 Daily requirement of Iron :
• Adult male : 0.84 mg
• Adult women : 1.65 mg
• Pregnant women : 2.80 mg (K. Park
psm 24th edt)
• Daily requirement in second half of
pregnancy : 6-7 mg (DC Dutta)
• Lactating : 1.65 mg
• Daily loss : 1 mg/day
 Increased level of steroid hormones
(Porgesteroen & oestrogen)
 Increased level prolactin hormone.
2. Changes in Genital organs
(A) Vagina
DN Bhatta Midwifery (MCH)
 Becomes oedematous, more vascular,
becomes bluish (Jacquimer's
sign/Chadwick's sign)
 Secretion becomes copius, thin and
curdy white.
 pH becomes more acidic. (3.5-6)
(B) Uterus
 At term, uterus weighs about 900-
1000 gm. (Non pregnant : 60 gm)
 Lenghth measures about 35 cm (
non pregnant : 7.5 cm)
 Capacity becomes 5000 ml. ( non-
pregnant -10 ml)
 Change in Shape :
• Globular : 8-12 weeks
• Pyriform : 12-36 weeks
• Spherical : 36 weeks after
 Size of uterus :
• Hen's egg size : 6 weeks
• Cricket ball size : 8 weeks
• Fetal head size : 12 weeks
 Increase in fundal height
• Within pelvic cavity : <12 weeks
• At symphysis pubis : at 12 weeks
• Between symphysis pubis & umbilicus :
18 weeks
• At umbilicus : at 24 weeks
• Between umbilicus & Xiphisternum :
30 weeks
• At Xiphisternum : 36 weeks
 Uterus becomes palpable after 12
weeks.
 Increased uterine blood flow : 500-750
ml/min (non-pregnant -50 ml/min)
 Change in position : rotate on it's long
axis to right (dextroroatation), uterus
lies on bladder, hence cause frequency
of micturition.
 Braxton Hicks contractions :
irregular, painless contractions, not
related to cervical dilatation. (felt from
second trimester)
 Braxton hiicks contractions are not felt
in abdominal pregnancy.
 The endometrium in pregnancy, called
decidua.
 Softening of the cervix (Goodel's sign)
 Forms lower uterine segment (LUS)
(C) Ovary
 No ovulation during pregnancy.
 Corpus luteum is non-functional 6-7
weeks.
Page | 24
  Placenta takes over the function of  Maximum cardiac output during
corpus luteum by 8-10 weeks. pregnancy is seen in : 28-32 week.
3. Breast Changes  During pregnancy, uterus presses on
 Increased size (marked hypertrophy & inferior venacava→femoral venous
proliferation) pressure increases→may cause pedal
 Nipple becomes larger, erectile and oedema/varicose vein,
deeply pigmented. Hemorrhoides.
 Montgomery's tubercles are  Postural hyptension is common due to
prominent. venous compression.
 Irregular pigmented area around  Pregnancy is a state of hypervolemia.
nipple : Secondary areola  Erythropoietin level is raised.
 Colostrum can be squeezed at about 12  Increase plasma volume results into
weeks which is sticky, after 16 weeks hemodilution and causes physiological
it becomes thick yellowish. anemia.
4. Skin Changes  At term, Hb is reduced by about 2gm%.
 Hyperpigmentation on cheek, forehead  ESR increases by 4 folds.
and around eyes, called cholasma.  pH increased, respiratory alkalosis.
(Also known as 'Pregnancy mask'), (7.42)
disappears after delivery.  There is overall decrease in blood
 Linea nigra : Brownish black pressure, due to reduced Systemic
pigmented straight line in the midline Vascular Resistant (SVR). BP=COX SVR
from xiphisternum to symphysis pubis.  Systolic murmur can be heard at apical
(Sometime seen in OCP users) region.
 Striae gravidarum : Linear stretch
marks with varyin length on abdominal DIAGNOSIS OF PREGNANCY
wall below the umbilicus, during  The total duration of pregnancy is 9
pregnancy they are pinkish in color. months and 7 days, or 40 weeks or
 After delivery, striae gravidum 280 days.
becomes white, called striae albicans.  This is also called 'gestational age'.
 Pseudocyesis : False pregnancy
5. Change in cardiovascular system (women has some sign/symptoms of
Which increases Which decreases pregnancy but no positive signs)
Blood volume (30- Packed cell  Expected Date of Delivery can be
60%) volume (PCV), calculated by Naegele's formula :
Viscosity of blood. EDD= LMP + 9 month & 7 days
Plasma volume Viscocity of blood  The entire duration of pregnancy is
divided into three trimesters.
RBC count Hematocrit,
• First trimester : 0-12 weeks
Hemoglobin (gm) Hemoglobin
• Second trimester : 13-28 weeks
or total (gm/dl), or % due
to hemodilution • Third trimester : 29-40 weeks
WBC count Platelet count
(A) FIRST TRIMESTER (0-12 weeks)
Plasma proteins Serum albumin  Symptoms :
(gm) U = Incresed urinary Frequency
Cardiac output Peripheral Are = Amenorrhoea
(40%) resistance My= Morning sickness
Heart rate (by 10- Blood pressure Best = Breast tenderness
15bpm) Friend = Fatigue
 PCV (Packed cell volume) : % of cells
in blood.
 Hematocrit : % of RBC in blood.

DN Bhatta Midwifery (MCH) Page | 25

 Signs :
• Jacquemier's sign/Chadwick's sign :
Bluish discoloration of vulva & Vagina.
(8 weeks)
• Goodel's sign : Softneing of cervix (6
weeks)
• Osiander's sign : increased pulsation
at lateral fornices. (8 weeks)
• Hager's sign : On bimanual
examination, lower uterine segment
feels empty and soft while mass
palpable in upper segment. (6-10
weeks)
• Palmer's sign : on bimanual
examination, rgular & rhythemic
contraction felt on palm. (4-8 weeks)
• FHS can be recorded by USG after 6
weeks.
• FHS can be recorded by Doppler
after 10 weeks.
• Enlarged abdomen
(B) SECOND TRIMESTER (13-28 weeks)
 Symptoms
• Quickening : Active fetal movement
felt by mother after 16-20 weeks
pregnancy. (Primi = 18 weeks, Multi
= 16 weeks)
• Cholasma
• Secondary areola
• Secretion of Colostrum
• Braxton hicks contractions
• Fetal parts palpable (after 20 weeks)
• Ballotement of uterus : Finger n]
cervix df tap ubf{ Fetus dfly jump
u/]h:tf] x'g' . (When lower uterine
segment is tapped by examiner's
finger, the fetus floats upwards)
• Ballotement can be felt at 16-20
weeks of pregnancy.
• Ausculatation of fetal heart sound
by stethoscope after 18-20 weeks.
(C) Third Trimester (29-40 weeks)
 Lightening : After 36 weeks, fetal head
settles into pelvis, called lightening, also
known as 'welcome sign of labour'.
 Amenorrhoea, enlarged abdomen,
frequency of micturition, quickening etc
also persists in 3rd trimester.
DN Bhatta Midwifery (MCH)
 The first sign of pregnancy on USG is
appearance of gestatitonal sac.
 Earliest abnormality to be detected on
USG : Anencephaly. (<10 weeks)
Signs & symptoms of pregnancy
s_ uef{j:yfsf cg'dflgt nIf0fx?
(Presumptive signs)
 dlxgfjf/L aGb x'g' (Amenorrhoea)
 ljxfg ljxfg jfsjfsL nfUg' (morning
sickness)
 w]/}k6s lk;fa nfUg' (frequency of
micturation)
 cToflws ysfg nfUg' (unexplained fatigue)
 :tg 7'nf] x'b} hfg' / b'vfO{ dz;'; x'g' (Breast
enlargement and tenderness)
 5fnf lrnfpg' (itchy skin), rfofF kf]tf] cfpg'
(Cholasma)
 aRrf rn]sf] dx;'z x'g' (Sensation of
quickening)
v_ uef{j:yfsf ;Defljt nIf0f tyf lrXg x?
(Probable signs)
 Goodell’s sign : Softening of cervix (6
weeks)
 Chadwicks sign/Jacquimer’s sign:
Bluish discoloration of vulva & vagina.
(about 8 weeks)
 Hager’s sign : Lower uterine segment
feels soft and empty.(6-10 weeks)
 Osiander’s sign : increased pulsation at
lateral fornices. (at 8 week)
 Palmer’s sign : during bimanual
examination (at 4-8 weeks) regular
uterine contraction can be felt.
 Ballottement : A method of diagnosing
pregnancy, in which the uterus is
pushed with a finger to feel whether the
fetus moves away and returns.
 Positive pregnancy test (HCG +ve) :
HCG positive in Urine after 3 weeks from
LMP (8-9 days following fertilization,
soon after implantation).
 Enlargement of abdomen
 Braxton hicks contraction.
u_ uef{j:yfsf ;sf/fTds nIf0f tyf lrXgx?
(Positive signs)
 USG jf X-ray df fetus visible x'g' .
 Fetal Heart Sound (FHS) ;'lgg' .
 lzz'sf] zl//sf] efu 5fDbf cg'ej ug{ ;Sg'
.
Page | 26
  hl6ntfx? sf] pkrf/ ug{' (To treat the
Signs Time of complications)
occurrence  uef{j:yf / k|;jsf] af/]df dlxnfnfO{ lzIff
1. Amenorrhoea 4 weeks + k|bfg ug{' . (To educate the pregnant
2. morning sickness 4-14 Weeks women about the physiology of
4. Quickening 16-20 weeks pregnancy and labour)
5. HCG Positive (urine) 3 weeks+ (from  k|;'tLsf] ;do, 7fpF / k|;'tLsf] tl/sf af/]
LMP) 5nkmn ug{' jf k'j{tof/L ug{' . (Birth
8-9 days after preparedness and complication
fertilization.
readiness)
6. Braxton hicks 16 weeks
 uef{j:yfsf] cGTodf Pp6f :j:y cfdfaf6 Pp6f
contraction
7. Ballottement of fetus 6-28 weeks
:j:y aRrf k|fKt ug{' g} o;sf] d'Vo p4]Zo xf] .
(The main objective of ANC is to have
8. Visualization of fetus 6 weeks+
on USG normal pregnancy, delivery of a healthy
9. Visualization of fetus 16-28 weeks baby by a healthy mother)
on X-ray
10. FHS by USG 6 weeks + Antenatal visits
11. FHS by Doppler 10 weeks +  Ideal number of ANC visit is 11.
11. FHS by fetal 20 weeks+  Ideally the mother should attend the
stethoscope (Fetoscope) ANC visit once a month during first 7
12. Uterus palpable 12 weeks + month; twice a month, during next
13. Fetus movement 22 weeks + month; and thereafter once a week.
palpable
14. fetal parts palpated 24 weeks  New WHO ANC model 2016 ;
15. Fetal movement Late pregnancy
visible WHO FANC 2016 WHO ANC
model (old) model (new)
HIGH RISK PREGNANCY First Trimester
 Maternal age 35 years and <18 years. Visit 1 : 8-12 Contact 1 : upto 12
 Height <140 cm, Weight<40kg weeks weeeks
 Rh Negative mother Second trimester
 Breech presentation. Visit 2 : 24-26 Contact 2 : 20 weeks
 Poor weight gain (Normal weight gain weeks Contact 3 : 26 weeks
is: 10-12 kg).
Third trimester
 Twins pregnancy
Visit 3 : 32 Contact 4 : 30 weeks
 H/O previous Caesarian section.
weeks Contact 5 : 34 weeks
k'j{k|;'tL ;]jf÷Antenatal care (ANC) Visit 4 : 36-38 Contact 6 : 36 weeks
weeks Contact 7 ; 38 weeks
 Systemic supervision (examination and
Contact 8 : 40 weeks
advice) of a women during pregnancy is
called antenatal care. (prenatal care). Source : WHO recommendation on antenatal
uef{j:yfdf dlxnfsf] :jf:Yo ;DalGw ;'kl/j]If0f care for a positive pregnancy experience
-hfFr / ;Nnfx_ k'0f{?kn] ug]{ k|lqmofnfO{ (FANC : Focused ANC Visit)
“k'j{k|;'tL ;]jf” elgG5 .
 gofF k|:tfljt ANC Visit cg';f/ * k6s
❖ Objectives of Antenatal care -k'j{k|;'tL
ue{hfFr ug{'kg]{5 .
ue{ /x]sf] cjwL
;]jfsf p4]Zox?_
klxnf] k6s !@ xKtf
 pRr hf]lvd ue{ kQf nufpg' (To detect high
bf];|f] k6s !^ xKtf
risk pregnancy)
t];|f] k6s @) b]lv @$ xKtf
 uef{j:yfsf hl6ntfx? kQf nufpg' (To Rff}yf] k6s @* xKtf
detect the complications of pregnancy) kfFrf} k6s #@ xKtf

DN Bhatta Midwifery (MCH) Page | 27

 5}7f}F k6s #$ xKtf b. Obstetric grip palpation (Leopold
;ftf}F k6s #^ xKtf maneuver) :
cf7f}F k6s #* b]lv $) xKtf
There are four maneuvers.
i. Fundal grip(First Maneuver):
How to Provide ANC care? • Palpation by facing the women’s face.
1. History taking • Use : What fetal parts lies in uterine
• LMP fundus. (to know fetal lie)
• Obstetric history of all pregnancies. • Broad, soft, irregular mass : Buttocks
• Write gestational age in weeks in • Smooth, hard, globulllar mass : head
each visit. ii. lateral grip (Second Maneuver):
2. Examination • Palpation by facing the women’s face.
• Measure vital signs • To find out Position of the back, limbs &
• Measure height, weight, MUAC anterior shoulder.
• Abdominal examination iii. Powlik's grip/pelvic grip-2 (Third
• Check fundal height and compare maneuver):
with weeks of gestation. • Palpation by facing the women’s face
• If uterus is small than date, consider • To determine the what fetal parts are
➢ Wrong dates lying above the inlet.
➢ Miscarriage • Determine the fetal presentation and
➢ Growht retardation enagagement.
• If uterus is larger than date, consider iv. Pelvic grip-1 (Forth Maneuver) :
: • Palpation by facing the women’s feet.
➢ Wrong date • Determines the presenting part, fetal
➢ Multiple pregnancy attitude, engagement, degree of fetal
3. Screening of risk factors : extension and flexion.
• Rheumatic Heart Disease (RHD)
• DM, HTN 3. Auscultation : Listen for FHS
• Kidney disease • Below umbilicus : in cephalic
• Anemia • Around the umbilicus : in breech
• Mental Health problems • FHS normal : 120-160/min
• Sexually Transmitted infections 4. Lab examination during pregnancy:
(STIs) • Hb%, Blood grouping
• HIV • Rh determination
• Age <18 years or over 35 years • Urine examination : albumin & sugar
• Grandmultipara • PMTCT/HIV test
• Rh Negative • VDRL/Hepatitis
• Previous history of C/S delivery • HBsAg
• Previous still birth • Blood sugar at 24-28 weeks : If
• Habits : Smoking, alcohol FBS >126 mg/dl or RBS >200 mg/dl,
• Maternal malnutrition or obesity refer to higher center for
• Weight < 40 kg management of diabetes mellitus.
➢ Molar pregnancy • Ultrasound (before 24 weeks) : To
➢ Polyhydramnios estimate gestational age, for
detection of fetal anomalies, multiple
Antenatal Abdominal examinations pregnancy
It is done through : 5. Drugs and immunization during
1. Inspection : Look for Striae, linea nigrae, pregnancy:
scars, skin changes etc.  Tab. Folic acid 5 mg OD : ue{sf] of]hgf
2. Palpation agfPb]lv ue{ /x]sf] klxnf] # dlxgf ;Dd .
a. Measurement of fundal height

DN Bhatta Midwifery (MCH) Page | 28

 ue{ /x]sf] # dlxgf b]lv ;'Ts]/L x'g] a]nf ;Dd M 4. USG : USG can be performed. Time for
180 tablets (during pregnancy) USG scan is :
 ;'Ts]/L ePsf] $% lbg ;Dd M 45 tablets • At booking visit : First trimester
 Total IFA required during a pregnancy & • To detect fetal abnormality : 18-20
postpartum period : 180 +45 = 225 weeks (Most important time)
tablets • To localize placenta : third trimester
 Tab. IFA contains 60 mg elemental 5. Diet: high protein, Iron and calcium
iron + folic acid 400 mcg containing balance diet, plenty of fluid,
dietary fiber. Folic acid required most in
 Advice for iron : first trimester to prevent Neural tube
➢ Take IFA after food at night to avoid defect.
nausea. 6. Rest: Pregnant women needs at least 10
➢ Do not take iron tablet with milk or tea. hours rest (8 hours at night and 2 hours
➢ If constipation, drink more water and at day). Sleep in Left lateral position is
take fiber diet. comfortable.
➢ Donot worry about black tarry stool, 7. Sexual intercourse/coitus: Avoid in
this is normal. first and 3rd trimester, especially in first
 Give calcium supplementation if low trimester.
intake of dairy products. 8. Drugs: Use only safe drugs as
 Tab. Albendazole, 400 mg single dose prescribed by obstetrician.
after first trimester.
 Danger Signs in Pregnancy:
 Injection TD : at first visit, second -uef{j:yfdf b]vf kg]{ vt/fsf nIf0fx? _
dose after 1 months. • PV bleeding
Dose When to give Expected • Severe headache
of TD duration of
protection • Blurring vision
1st At first contact None • Swelling of face and upper limbs
(TD1) • Severe vomiting
2nd 1 month after 1st 1-3 years • Premature rupture of membrane
dose (TD2) • Decreased or absent FHS.
3rd At least 6 weeks At least 5
after TD2 or during year
subsequent Disorders of pregnancy:
pregnancy (TD3) 1. Minor disorders:
4th At least 1 year At least 10 • Morning sickness (nausea, vomiting)
after TD3 or during years • Heart burn (common during 30-40
subsequent
weeks)
pregnancy (TD4)
5th At least one year All
• Constipation, indigestion,
after TD4, or childearing hemorrhoids
during subsequent age • Excessive salivation (Ptylism)
pregnancy (TD5) • Backache and cramps
• Frequency of micturation
 Antenatal Advice: • Leucorrhoea, itching, fainting,
1. Smoking: Avoid it; smoking in insomnia
pregnancy may cause LBW, still birth, • Varicose vein
placental insufficiency etc. 2. Major disorders of pregnancy:
2. Alcohol: Avoid it; it may cause Fetal A. Hyperemesis gravidarum
Alcohol Syndrome (FAS)-FAS is B. Pregnancy Induced Hypertension
characterized by poor growth and (PIH) : Pre-eclampsia, eclampsia
development, prematurity and poor C. Bleeding
nutrition. a. Bleeding in early pregnancy:
3. X-ray: Frequent x-ray may cause • Implantation bleeding
leukemia, malformations.
DN Bhatta Midwifery (MCH) Page | 29
 • Abortion
• Ectopic pregnancy
• Hydatiform mole
b. Bleeding in late pregnancy:
• APH
• Placenta previa Abruptio placenta
• abortion elgG5 .
Abortion (ue{ktg_
 @@ xKtf leqsf] ue{ s'g} klg sf/0f n] v]/
uPdf jf kmflnPdf To;nfO{ ue{ktg elgG5 .
 Abortion is defined as termination of
pregnancy or expulsion of fetus before
the period of viability." (i.e 22 weeks
of gestation or 154 days, according to
WHO).
 Or abortion is defined as when the fetus
is expelled out from the uterus when it's
weight is below 500 gm.
Types of abortion -ue{ktgsf k|sf/x?_
1. Spontaneous abortion/ Miscarriage -
ue{ t'lxg'_
A. Threatened abortion :
B. Inevitable abortion :
C. Incomplete abortion
D. Complete abortion
E. Missed abortion
F. Septic abortion : (Less common)
2. Induced abortion :
A. Legal abortion : sfg'gL dfkb08 cg';f/ u/fO{g]
ue{ktg .
B. Ilegal abortion : sfg'g ljkl/t u/fO{g] ue{ktg
. (Septic abortion is most common in illegal
abortion)
3. Septic Abortion : ;Fqmd0f sf] hl6ntf ePsf]
ue{ktg, of] Spontanous jf Induced h'g klg
x'g ;S5 .
.
4. ;'/lIft ue{ktg (safe abortion) : ;/sf/ af6
;'lrs[t :jf:Yo ;F:yfdf, ;'lrs[t :jf:YosdL{4f/f,
;'lrs[t cf}ifwL jf ljwLsf] k|of]u ul/g] ue{ktgnfO{
;'/lIft ue{ktg elgG5 .
5. c;'/lIft ue{ktg (Unsafe abortion) :
;'/lIft ue{ktgsf] dfkb08 lakl/t u/fO{g] ue{ktg
nfO{ c;'/lIft ue{ktg elgG5 .
6. Medical abortion : cf}ifwLsf] k|of]u af6
u/fO{g] ( xKtf jf ^# lbg ;Dd -!) xKtf leq_ sf]
ue{ktg nfO{ medical abortion elgG5 .
DN Bhatta Midwifery (MCH)
7. Surgical abortion : pks/0f tyf surgical
procedure sf] k|of]u 4f/f ul/g] ue{ktg nfO{
surgical abortion elgG5 .
8. Recurrent miscarriage or habitual
abortion : nuftf/ # k6s jf ;f] eGbf al9 k6s
x'g] abortion nfO{ Habitual or recurrent
Threatened abortion :
 The type of abortion In which
pregnancy can be continued. (recovery
is possible).
 h'g ue{kgtdf ue{ nfO{ lg/Gt/tf lbg ;lsG5,
To:tf] ue{ktgnfO{ Threatened abortion
elgG5 .
 nIf0f tyf lrXgx? (Sign and symtoms) :
• of]gLaf6 /ut aUg' (Spotting PV
bleeding : Light, brownish or red,
usually painless
• Abdominal pain (-/+)
• kf7]3/sf] d'v aGb x'G5 . (Cervical OS
closed)
• kf7]3/ sf] prfO{ uef{j:yfsf] cjwL hlt g}
x'G5 . (Height of uterus = period of
gestation)
• e|'0f sf] s'g} klg efu aflx/ lg:s]sf] x'b}g .
(No expulsion of product of
conception)
• USG : Live fetus
 Joj:yfkg (Management) :
• s'g} cf}ifwL tyf ;Nolqmof cfjZos x'b}g
(No medical or surgical treatment
required)
• ufx|f] sfdx? gug{ / of}g ;Dks{ g/fVg
;Nnfx lbg] (Avoid heavy work and
sex)
• k|z:t cf/fd ug]{ (Adequate rest) : BED
REST is not necessary.
Inevitable abortion
 In this abortion, pregnancy will not
continue, recovery is not possible.
-of] ue{ktg df uef{j:yfnfO{ lg/Gt/tf lbg
;lsb}g_
 of] vfnsf] ue{ktg kl5 Complete or
incomplete abortion df kl/0ft x'g ;S5 .
 Clinical features:
• of]gL af6 /ut aUg' (Heavy PV bleeding)
+ Abdominal pain
Page | 30
• kf7]3/sf] d'v aGb v'nf x'g' (Cervical os
Open/dilated)
• kf7]3/sf] cfsf/ ue{sf] cjwL hltg} x'G5 .
(Height of uterus = Period of gestation)
• No expulsion of POC (product of
conception)
 Management -Joj:yfkg_
• olb heavy bleeding ePsf] 5 / ue{sf] cjwL
!@ xKtf eGbf sd 5 eg] MVA ug]{ / ue{ktg
kZrft x'g] /Qm>fj (post abortal
hemorrhage) x'g glbg 800 mcg
misoprostol lbg] .
• ue{sf] cjwL !@ xKtf eGbf al9 ePdf
Dilatation & evacuation ug]{ .
Incomplete abortion
 e|'0f tyf kf7]3/ leq /x]sf Products of
conception cfFlzs ?kdf dfq aflx/ lg:s]sf]
ue{ktg nfO{ incomplete abortion elgG5
 Clinical features :
• of]gLaf6 cToflws /Qm>fj x'G5 . (Heavy
PV bleeding)+ Abdominal pain.
• kf7]3/sf] d'v v'nf x'G5 . (Cervical OS
dilated/Open)
• kf7]3/sf] cfsf/ ue{sf] cjwL eGbf sd x'G5 .
(Height of the uterus : less than
period of gestation)
• Partial expulsion of product of
conception (POC).
 Joj:Yffkg (management) :
• ue{sf] cjwL !@ xKtf eGbf sd ePdf M
A. Medical management : Misoprostol
400 mcg sublingual or 600 mcg by
mouth for one dose.
B. Surgical management : Mannual
vacuum Aspiration (MVA)
( Note : MVA sf] ;'ljwf pknAw gePsf]
cj:yfdf dfq D & C (Dilatation and
curettage) ug{'kb{5 )
• ue{sf] cjwL !@ xKtf eGbf al9 ePdf
A. Medical management : Misoprostol
200 mcg by vagina every four hours
until expulsion, maximum 800 mcg OR
Oxytocin 40 units in 1L IV fluids at 40
drops per minute.
B. Surgical management : Dilatation
and evacuation (D & E)
Complete Abortion
 Clinical Features :
• Light PV Bleeding
DN Bhatta Midwifery (MCH)
• Mild abdominal pain or cramps
• Height of uterus is less than period of
gestation.
• Closed cervix.
• History of expulsion of POC.
 Management :
• Usually no treatment required.
• If heavy bleeding : MVA for <12
weeks or D & E for >12 weeks.
• Give 800 mcg misoprostol to prevent
post abortal hemorrhage.
Missed Abortion
 When the fetus is dead and retained
inside the uterus for variable period.
 Clinical features (almost similar to
threatened abortion but fetus is dead)
• Brownish vaginal discharge
• Subsidance of pregnancy
symptoms.
• Uterine growth stops. (smaller than
gestational age)
• FHS Absent
• Firm cervix
• Cervical OS closed
 Management
A. Uterus<12 weeks
• May be expelled spontaneously.
• Misoprostol 800 mcg per vaginally,
repeated after 24 hours if needed.
• MVA can be used.
B. Uterus >12 weeks
• Oxytocin induction : 10-20 units
oxytocin in 500 ml NS at 30
drops/min.
• Surgical induction : Dilatation &
Evacuation.
Septic abortion
 ;Fqmd0f sf] hl6ntf ePsf] ue{ktg, of]
Spontanous jf Induced h'g klg x'g ;S5 .
(Septic abortion is defined as abortion
complicated by infection. Sepsis may
result from infection if organisms rise
from the lower genital tract following
either spontaneous or unsafe abortion)
 Clinical features :
• Fever with chills and rigors.-Hj/f] cfpg'_
• Lower Abdominal pain -tNnf] k]6 b'Vg' _
• Rebound tenderness -k]6 lyr]/ 5f]8\g]
a]nfdf b'vfO{ dxz'; ug{' _
Page | 31
 • Tachycardia -gf8L sf] ult a9\g'_
• Offensive, purulent, vaginal discharge,
tender uterus -of]gLaf6 uGxfpg] vfnsf]
;]tf] kfgL] aUg'_
•Cervical motion tenderness
 Management -Joj:yfkg_ M
• Hospitalization
• Examination of cervical fluid
• Broad spectrum antibiotic
• Evacuation of the uterus.
Legal aspects of Abortion In Nepal
(g]kfndf
ue{ktg ;DaGwL sfg'gL k|fjwfg)
❖ z'/lIft dft[Tj tyf k|hgg :jf:Yo clwsf/ P]g
@)&% cg';f/ b]xfosf] cj:yfdf ue{jtL dlxnf (A) Simple vomiting
nfO{ ;'/lIft ue{ktg ug{ kfpg] clwsf/ x'g]5 .  o;nfO{ Morning sickness jf emesis
 ue{ktg u/fpg] dlxnfsf] dGh'/Ldf !@ xKtf
;Ddsf] ue{ .
 hj/hl:t s/0fL -anTsf/_ / xf8gftf s/0fLsf]  Common during early pregnancy.
xsdf ue{jtL dlxnfsf] dGh'/Ldf @* xKtf
;Ddsf] ue{
 ue{ktg gu/fPdf cfdfsf] :jf:Yodf ulDe/
c;/ kg]{ ePdf Ohfht k|fKt lrlsT;ssf]
/fodf @* xKtf ;Ddsf] ue{
 Pr=cfO=le jf To:t} k|sf/sf] lgsf] gx'g] /f]u
nfu]sf] dlxnfsf] dGh'/L df @* xKtfsf] ue{ .
 e|'0fsf] sdhf]/Lsf] sf/0f e|'0f ue{d} gi6 x'g
;Sg] jf hGd]/ klg afFRg g;Sg] ul/ e|'0fdf
v/faL /x]df pkrf/df ;+nUg :jf:YosdL{sf]
/fodf @* xKtf ;Ddsf] ue{ .
 z'/lIft dft[Tj tyf k|hgg :jf:Yo clwsf/ lgodfjnL • Avoid Fatty and spicy food.
@)&& cg';f/ ;'/lIft ue{ktgsf] nflu lgDg ljlwx? • Vitamin B1 100 mg daily is helpful.
;'lrs[t ul/Psf 5g .
xKtf k|ljwL
!) xKtf leq MA or MVA
!) xKtf ;Dd MA or MVA
!@ xKtf ;Dd MVA
!# b]lv !* xKtf MI or D & E
!( b]lv @* xKtf MI
MA = Medical Abortion
MVA = Mannual Vacuum Aspiration
MI = Mannual Induction
D & E = Dilatation & Evacuation
gf]6 M
 Medicine used in MA : Misoprostol 800 mcg
+ Mifepristone 200 mg
 g]kfndf 26 September 2002 af6 ue{ktgnfO{
sfg'gL dfGotf lbO{Psf] lyof] . (Abortion was
legalized in Nepal on 26th Sept. 2002)
 ue{ktg eP kl5 tTsfn} ue{jtL x'g' x'b}g .
k'0f{tof recover ePkl5 jf ue{ktg ePsf] #
b]lv ^ dlxgf kl5 ue{jtL x'g' /fdf|] dflgG5
 Ovulation may occurs 2 weeks (14 days)
after abortion.
Vomiting In Pregnancy
 Severeity sf] cfwf/df uef{j:yfdf x'g]
vomiting @ k|sf/sf] x'G5 .
(A) Simple vomiting (Milder type)
(B) Hyperemesis gravidarum (Severe type)
gravidarum klg elgG5 .
 common at morning.
 o;nfO complication ge} uef{j:yfsf]
symptom sf] ?kdf lnOG5 .
 lagf s'g} pkrf/ klg 12-14 weeks kl5 of]
cfkm} lgsf] eP/ hfG5 .
 HCG / oestrogen xdf]{gsf] a9\bf] dfqfsf sf/0f
jfGtf x'G5 .
 Most commonly due to HCG.
 Management :
• Assurance is important.
• Take dry toast or biscuits.
• Vitamin B6 25 mg +Doxylamine 25 mg
is also safe & effective.
• Anti-emetic drugs can be used : e.g
Metoclopramide, promethazine,
ondansetron etc.
• Advice to take plenty of fluid .
(B) Hyperemesis Gravidarum
 uef{j:yfsf] sf/0fn] x'g] severe vomiting
h;n] cfdf sf] :jf:Yodf k|lts'n c;/ ub{5
jf b}lgs ls|ofsnfkx?nfO{ c;xh agfp5,
To;nfO{ hyperemesis gravidarum elgG5
.
 The effect of vomiting may be :
Dehydration, metabolic acidosis (if
starvation), or metabolic alkalosis

DN Bhatta Midwifery (MCH) Page | 32

 (loss of HCL), electrolyte imbalance
(Hypokalemia) & weight loss.
 Incidence : <1 in 1000 pregnancies.
 Aeteology : exact cause is unknown.
 Risk factors :
• More common in first pregnancy.
• More common in first trimester.
• Younger age.
• Low body weight.
• History of motion sickness.
• Family history
• Hydatiform mole, multiple
pregnancy.
• Psychogenic
• Dietary defeiciency of Vitamin B1,
B6 & protein.
 Some theories explained about
hormonal cause.
• High level of B-HCG hormone.
• High oestrogen & Progesterone.
 Clinical features :
• Severe vomiting, may occurs throughout
the day.
• Features of dehydration : Dry &
coated tongue, sunken eyes, loss of skin
elasticity, hypotension, tachycardia,
Oligurea etc.
• Features of ketoacidosis : Fruity
smell breath, kussmaul
breathing.(Deep and labored
breathing)
• Epigastric pain, constipation may
occurs.
• Investigations : USG (to confirm
pregnancy), Urine examination (Ketone
bodies) , Electrolyte (Na+, K+), ECG (To
assess potassium level, hypokalemia).
 Management
Principles of management are :
• Maintenance of hydration.
• To control vomiting.
• To correct fluid and electrolyte
imbalance.
• To correct acidosis or alkalosis.
• To provide nursing care.
1. Hospitalization :
2. IV fluid : RL + D5%
DN Bhatta Midwifery (MCH)
3. Antiemetic drugs : Promethazine
(Phenergan) or Prochlorperazine (Stemetil)
or Metoclopramide (perinorm)
4. Vitamin B6 25 mg +Doxylamine 25 mg
is also safe & effective
5. Nutritional supplementation : Protein,
vitamin B1, B6 diet.
6. Good nursing care, psychological and
social support.
Ectopic pregnancy
 kf7]3/ eGbf aflx/ ue{ j:g'nfO{ Ectopic
pregnancy elgG5 . (An ectopic pregnancy
is one in which implantation occurs
outside the uterine cavity.)
 The fallopian tube (ampulla) is the
most common site of ectopic pregnancy.
(greater than 90%).
 Risk factors are:
• Pelvic inflammatory disease (PID)
• Use of IUCD
• Previous exposure to DES
(Diethylstibestrol)
• Tubal surgery
• Intrauterine surgery. eg. D & C
• Smoking
• Previous ectopic pregnancy.
• Endometriosis (growth of
endometrial tissue outside of the
uterine cavity)
 Clinical features :
A) Unruptured ectopic pregnancy :
• Signs of early pregnancy
(amenorrhea, morning sickness,
frequency of micturation, bluish
vagina and cervix, softening of cervix)
• Positive pregnancy test
• lower abdominal pain
• Slight Vaginal bleeding
• Tender cervix
B) Ruptured ectopic pregnancy :
• Collapse and weakness
• Fast, weak pulse (110 beats per
minute or more)
• Hypotension
• Hypovolaemia
• Acute abdominal (one sided) and
pelvic pain
• Abdominal distension
• Rebound tenderness
Page | 33
 • Pallor • Vasa previa (When fetal blood vessel
 Diagnosis : crosses the near the internal OS of
• HCG (pregnancy test) the uterus, it is difficult to diagnose)
• USG abdomen • Cervical polyps
• Culdocentesis (cul-de-sac puncture) is • Local trauma
an important tool for the diagnosis of Differences Between Placenta Previa &
ruptured ectopic pregnancy. Abruptio Placentae
 The most common differential diagnosis
for ectopic pregnancy is 'Threatened Placenta Previa Abruptio
abortion'. (other D/D are PID, ovarian placentae
cyst, acute appendicitis) 1. Placenta is implanted 1. Detachment of
 Management : partially or completely normally located
over lower uterine placenta from the
• Cross-match blood and arrange for
segment. uterus before
immediate laparotomy (Do not wait delivery.
for blood before performing surgery) (premature
• If there is extensive damage to the separation of
tube, perform salpingectomy (the placenta)
bleeding tube and the products of 2. Painless vaginal 2. Bleeding occurs
bleeding present. with sharp
conception are removed together) – abdominal pain.
most common cases 3. Repeated bleeding. 3. Single sudden
• Rarely, if there is little tubal damage, bleeding
perform salpingostomy (the products 4. Bright red blood. 5. Dark red blood.
of conception can be removed and the 5. FHS can be heard 6. FHS difficult to
tube conserved). normally, normal fetal hear or absent.
condition. (fetal distress)
• Blood transfusion or auto-transfusion.
6. PV examination 7. Can be
• Correct anaemia with ferrous sulfate or should not be performed PV
ferrous fumarate 60 mg by mouth daily performed. examination.
for three months
Placenta Previa
Antepartum hemorrhage (APH)  When the placenta is implanted
partially or completely over the lower
 APH is defined as bleeding from or into uterine segment, it is called placenta
the genital tract after 22 weeks of  Most common in multiparous women
gestation but before birth of the baby. (80%).
(uef{j:yfsf] @@ xKtf kl5 / k|;j ;'? x'g'eGbf  Common in >35 years of age.
cuf8L of]gLaf6 x'g] /Qm>fj nfO{ APH elgG5  Other risk factors : Previous history of
.) C/S, smoking etc.
 Limitation and spacing of birth may
 If bleeding is stained with mucous reduce the risk of placenta previa.
(show) at term, suspect labor.  Exact cause is unknown.
 Causes:
A. Placental bleeding (70%): Most Degree of placenta previa
common cause
• Abruptio placentae (35%)
• Placenta previa (35%
B. Unexplained -25% (Placental & local
cause afx]s_
C. Extra-placental cause (5%) or local
cause
• Ruptured uterus

DN Bhatta Midwifery (MCH) Page | 34

(A) Type-I (Low lying) : Placenta sf] d'Vo
efu upper segment df /x]sf], Placenta sf]
tNnf] 5]p lower segment ;Dd k'u]sf] t/
Cervical OS ;Dd gk'u]sf] .
(B) Type-II (Marginal) : Placenta n]
cervical os 5f]Psf] t/ g9fs]sf] .
(C) Type-III (Incomplete or partial centr
al) : Placenta n] cervical os fully dilate x'bf
cf+lzs (partially) ?kdf 9fs]sf] .
(D) Type-IV (Central or total or
complete) : Cervix fully dilate x'bf klg
placenta n] cervix nfO{ completely cover u/]sf]
.  Immediate delivery indicated if the
 Clinically, type-I / type-II (anterior) nfO{
mild degree / type-II posterior, Type-
III & type-IV nfO{ major degree elg
grading ul/G5 .
 Most dangerous placenta previa : Type-
II posterior placenta previa
 Clinical features :
• Vaginal bleeding : sudden onset,
painless, commonly causeless,
recurrent. Bright red blood.
• Anemia
• Height of uterus = Gestational age.
• Persistence malpresentations :
Breech or transverse or unstable
• FHS usually present.
Management of Antepartum
hemorrhage
1. General management :
 SHOUT FOR HELP
 Rapid evaluation of patient (BP, Pulse,
level of consciousness, volume of blood
loss, color of skin)
 Open IV line
 If shock is suspected: Manage
immediately.
 Listen FHS :
• If FHS abnormal (<100 or
>180/min) : Suspect fetal distress
• Absent FHS : Suspect fetal death.
 Blood grouping & cross matching
 Blood transfusion if required.
2. Specific management :
(A) Abruptio placentae :
 Perform bed side clotting test
 Heavy bleeding + Fully dilated cervix
: vaccum or C/S delivery
DN Bhatta Midwifery (MCH)
 If bleeding is light to moderate &
FHS normal or absent : Oxytocin
augmented vaginal delivery or C/S
delivery.
 If bleeding is light to moderate &
FHS abnormal : Perform rapid
vaginal birth, if not possible plan for
C/S.
(B) Placenta previa :
 Assessment of mother and fetus.
 Hospitalization.
fetus is mature or fetus and mother
are in distress.
 Mode of delivery:
• For type-I and type-II : Vaginal
delivery
• Type III and Type-IV : C/S is
indicated
 Blood volume replacement.
 Corticosteroids are indicated at 24-
34 weeks of gestation.
 Do not perform per vaginal
examination in placenta previa.
Ufef{j:yfdf pRr /Qmrfksf] ;d:of
(Hypertension during pregnancy )
$ 306f jf ;f] eGbf a9L ;dosf] cGt/fndf
nuftf/ @ k6s olb /Qmrfk !$)÷() mm of Hg
jf ;f] eGbf a9L ePdf pRr /Qmrfk
(Hypertension) ePsf] dflgG5 . uef{j:yfdf x'g]
pRr /Qmrfk @ k|sf/sf x'G5g .
s_ uef{j:yf ;Fu ;DaGw gePsf] bL3{sflng pRr
/Qmrfk (Chronic Hypertension in
pregnancy)
 olb ue{ /x]sf] @) xKtf eGbf cufl8 pRr
/Qmrfk (Hypertension) b]vf k/]df To;nfO{
uef{j:yf ;Fu ;DaGw gePsf] bL3{sflng pRr
/Qmrfk (Chronic hypertension) elgG5 .
v_ uef{j:yfsf] sf/0fn] x'g] pRr /Qmrfk
(Pregnancy Induced Hypertension-PIH) :
olb ue{ /x]sf] @) xKTff kl5, k|;j Joyf nfu]sf]
a]nf jf k|;'tL ePsf] $* 306f leqdf pRr /Qmrfk
b]vf k/]df To; k|sf/sf] /QmrfknfO{ uef{j:yfsf]
sf/0fn] x'g] pRr /Qmrfk (Pregnancy Induced
Hypertension, PIH) elgG5 .
Page | 35
 Sign & symptoms

Hypertension

proteinurea

Severe pre-

Eclampsia
eclampsia

eclampsia
Mild pre-
Pregnancy Chronic HTN

without
Induced HTN
(PIH)
HTN occurs due to Hypertensive
pregnancy women becomes Diastolic 90- 90- ≥110 >90
(Placental pregnant. BP 110 110
pathology) (mm of Hg)
No past history Past H/O HTN Proteinure x'b}g Trace 3+ or 2+ or
Present a (Nill to 2+ more more
)
Increase BP after Rise in BP seen
Others dflyNnf] sDkg
20 weeks of before 20 weeks. -xft / cg'xf/ k]6 b'Vg', cfpg' /
pregnancy. ;'lGgg]_ 6fpsf] a]xf];
b'Vg', cfFvf x'g'
May associated No proteinuria. wldnf] (Conv
with proteinurea. b]Vg', ulsion
BP Backs normal BP does not come lk;fa sd s and
cfpg',
before 12 weeks of back to normal jfsjfsL uncon
delivery. after delivery. nfUg', scious
jfGtf x'g' )
PIH klg # k|sf/sf x'G5g . • Epigastric pain
!= k|f]l6go'l/of lagfsf] pRr /Qmrfk • Nausea, vomiting
(Hypertension without proteinurea) • Headache & Dizziness
@= lk|–OSn]Dkl;of (Pre-eclampsia) • Blurring of vision, diplopia
s_ ;fdfGo (Mild) • Oligurea
v_ ulDe/ (Severe)
#= OSn]Dkl;of (Eclampsia) jf uef{j:yf sf] Management of severe pre-eclampsia
laiffQmtf (Toxemia of pregnancy) and eclampsia
A. Management During Convulsion
 Risk factors for pre-eclampsia  ;xof]usf] nflu u'xfg]{ (SHOUT FOR HELP)
• Previous history of pre-eclampsia.  Vital Signs, x?sf] l;3| cg'udg ug]{ .
(reccurance rate : 15-25%)  :jf; lng ;lhnf] kfg{ tyf
• Primigravida Secretions/blood/vomiting cflb nfO{
• Obesity Aspiration x'g glbg afofF sf]N6] (left lateral)
• Diabetes kN6fP/ ;'tfpg] .
• Chronic renal disease  Never leave women alone, prevent
• Extreme of maternal age. (<18 years or injuries.
>35 years)
• Rh negative pregnancy B. If convulsion stops,
• Heridity  Check airway, Suctioning if necessary
 Less chance in smoker. (Protective  O2 inhalation : 4-6 liter/min
factor)  Open IV line, give IV fluid slowly (RL)
 PIH is a placental pathology.  Urinary catheterization, maintain fluid
balance chart, check for proteinurea.
PIH sf nIf0f tyf lrGxx?  Bed side clotting test
(Sign and symptoms of PIH)  Anticonvulsant: Magnesium sulphate
 Pre-eclampsia = HTN+ Proteinurea ± is Drug of choice .
Oedema  Diazepam is used if magnesium sulphate
 Eclampsia = Severe pre-eclampsia + is not available.
Convulsion ± unconsciousness  Regular monitoring of Vital signs,
 C/F of severe pre-eclampsia are patellar reflex, urine output, FHS.

DN Bhatta Midwifery (MCH) Page | 36

 If diastolic BP>110 mm of Hg, give
antihypertensive drug.
 Hydralazine is the drug of choice.
 Give 5 mg hydralazine IV in every 5
minutes till BP falls to normal.
 If hydralazine not available, give
labetalol 10 mg IV.
 Conduct delivery, within 12 hour of
starting convulsion or within 24 hour of
severe pre-eclampsia.
Ante-Hypertensive drugs in pregnancy
Safe Contraindicated
• Methyl-Dopa • ACE
• Labetalol Inhibitors
• Nifedipine (For (Enalapril,
emergency captopril)
management) • Diuretics
• Hydralazine • Losartan
(Drug of choice) • Diazoxide
Source : MNH Update manual,
Governement of Nepal.
Magnesium Sulphate Dose for severe pre-
eclampsia & Eclampsia
50% MgSO4 1 Ampule = 1 gm =2ml
!= nf]l8Ë 8f]h (Loading dose)
klxnf] r/0f M 4 gm 50% MgSO4 nfO{ 20%
agfP/ IV lbg' kb{5 .
• 20 ml syringe lng'kb{5 .
• 4 ampule (4 gm or 8 ml) 50% MgSO4 df
12 ml distilled water jf normal saline
ld;fO{ hDdf 20 ml agfpg] .
• To;nfO{ % ldg]6 eGbf al9 ;do nufP/ IV
lbg'kb{5 .
bf];|f] r/0f M t'?Gt} !) u|fd (20 ml) 50%
MgSO4 IM lbg'kb{5 .
• @ j6f 10 ml sf] syringe lng] / b'a}df 1/1
ml 2% Lignocaine nf]8 ug]{ .
• To;kl5 b'a}df 5/5 Ampule -k|To]s df 10
ml) 50% MgSO4 /flv 11 ml agfpg] .
• To;nfO{ b'a} buttocks df deep IM lbg] .
@= Joj:yfkg dfqf (Maintenance Dose)
5 gram 50% MgSO4 IM lbg'kb{5 .
 10 ml syrine lng'kb{5 .
 To;df 1 ml 2% Lignocaine nf]8 ug]{ .
 5 ampule (10 ml) MgSO4 ldnfO{ hDdf 11
ml agfpg] .
DN Bhatta Midwifery (MCH)
 To;nfO{ k|To]s $ 306fdf kfn} kfnf]
buttocks df deep IM lbg'kb{5 .
 aRRff hGd]sf] jf clGtd k6s sDkg cfPsf]
@$ 306f ;Dd k|To]s $ 306fdf
Maintenance dose lbO{ /fVg' kb{5 .
MgSO4 sf] ljifQmtf (Toxicity) sf] cg'udg
 MgSO4 sf] maintenance dose lbg'eGbf
cufl8 lgDglnlvt s'/fx?sf] hfFr ug{'kb{5 /
• Patellar reflex (Reflex b]lvg'k5{ _
• cl3NNff] $ 306fdf lk;fasf] dfqf -!
306fdf slDtdf #) ld=ln x'g'kb{5 ._
• Zjf;k|Zjf;b/ -! ldg]6df !^ jf Tof]
eGbf al9 x'g'kb{5 _
 DofUg]l;od ;Nkm]6sf] toxicity b]vf k/]df
antidote sf] ?kdf Calcium gluconate
k|of]u ug{'kb{5 . (10% calcium gluconate
1gm/10ml IV)
Prevention of Pre-eclampsia &
eclampsia
 Focused ANC
 Calcium supplementation : After first
trimester 1 gm/day for at least 90 days.
(3 month)
 Regular exercise decreases the chance
of PIH.
 Drugs : Aspirin, Heparin
 Should not restrict salt, calories, fluid
etc.
KEY POINTS
 Proteinurea is excretion of urine >300
mg in 24 hours or >30 mg/dl of urine.
 In Mild pre-eclampsia, BP is more than
140/90 but less than 160/110 mm of
Hg.
 In severe pre-eclampsia, BP is more
than or equals to 160/110 mm of Hg.
 Placenta is most important/common
pathology of PIH.
 PIH is multi-system disorder.
 Definitive management of PIH is
'Termination of pregnancy'
irrespective of gestational age.
 Most common cause of death in
eclampsia & Pre-eclampsia is :
Intracranial bleeding.
 Magnesium sulphate is anti-convulsant.
 Incidence of eclampsia : 1 in 2000
deliveries.
Page | 37
 First line management of eclampsia
is : airway management.
 First sign of MgSo4 Toxicity : absent
patellar reflex.
 Most severe hematological complication
of severe pre-eclampsia is 'HELLP
Syndrome'.
 Most common cause of convulsion in
eclampsia : Cerebral anoxia due to
arterial spasm.
HYDATIDIFORM MOLE
 Hydatidiform mole is benign neoplasm
of chorion. (Placenta)
 It is due to hyperproliferation of
gestational trophoblastic cells.
 It is the most common gestational
trophoblastic disease.
 Abnormal condition of placenta,
characterized by multiple grape like
appearance.
 RISK FACTORS :
• Age >35 years or <18 years.
• Low socioeconomic status.
• Past history of molar pregnancy.
• Deficiency of Protein, folic acid &
Vitamin A.
• Blood group A mother & O group
father.
 Types
A. Partial mole : Some fetal parts
grow.
B. Complete Mole : No fetal parts
grows.
 Pathology : abnormally Increased
number of chromosomes in zygote.
 Clinical Features :
• Per vaginal bleeding in first
trimester. (Most common)
• Raised HCG Level
• Positive Pregnancy test
• Excessive nausea, vomiting due to
High HCG. (hyperemesis
gravidarum).
• Height of the uterus is same or less
than POG (in partial mole)
• Height of uterus is more than POG.
(in complete mole)
• FHS absent.
 Diagnosis : USG + Clinical features
 Management :
DN Bhatta Midwifery (MCH)
• Spontaneous expulsion may occurs at
around 16 weeks.
• Treatment of choice for H. Mole :
Suction evacuation. (MVA)
• Hysterecomy can be done, if patient
has completed family size or age >40
years.
• Anti-D is given to all Rh-Negative
women after suction evacuation.
• Regular follow up
• Drug of choice for prophylactic
chemotherapy : Methotrexate.
 Complications : Most common in
complete mole.
• Hyperthyroidism
• Pre-eclampsia (PIH)
• Hyperemesis gravidarum
• Choriocarcinoma (Benign neoplasm
or trophoblastic cancer of placenta)
•
Rh incompatibility
 Rh system was discovered by Karl
Landsteiner in 1940.
 RBC df lgDg antigen x? x'G5g .
Antigen-A, Antigen-B, Antigen-D
 D-antigen nfO{ Rh factor klg elgG5 .
 lo antigen sf] lj?4df @ lsl;dsf antibody
x? /utdf aGb5g .
IgM : for Anti-A, Anti-B
IgG : acts as anti-Rh antibody
 IgM ;a}eGbf klxn] aGg] antibody xf], o;n]
placental barrier cross ug{ ;Sb}g . / o;n]
fetus nfO{ s'g} xfgL k'/\ofpb}g .
 IgG eg] placenta cross ug{] / fetal
damage ug]{ vfnsf] x'G5 . o;nfO{
incomplete or bloking antibody klg
elgG5 .
 olb fetus sf] group klg negative ePdf
o;n] fetus nfO{ c;/ ub}{g . jf Mother /
father b'a} Rh-negative ePdf Rh
incompatibility x'b}g .
 t/ cfdf sf] group negative / fetus sf]
Positive ePdf, klxnf] pregnancy sf] labor
sf] a]nfdf Fetus sf] Rh -positive RBC cfdf
sf] /utdf k'Ug ;S5 . h;af6 mother
Rh+ve blood ;Fu sensitize dfq x'G5g . t/
klxnf] aRrf ;'/lIft x'G5 .
 csf]{ k6ssf] ue{ ;Dd cfdfsf] /utdf Anti-
RhD antibody (IgG) x? alg;s]sf x'G5g . /
lolgx? placenta cross ul/ fetus sf] zl//df
Page | 38
 k'lu Toxf hemolytic disorder jf fetal
damage u/fpb5g, h;nfO{ Rh-
Incompatibility elgG5 .
 Effects of Rh incompatibility
(A) Fetal effects
• Distruction of red cells
/Erthroblastosis fetalis
(Hemolytic anemia)
• Hyperbilirubinemia (Jaundice)
• Kernicterus (Brain damage due
to hyperbilirubinemia)
• Hydrops fetalis (Heart failure,
fluid overload or may cause still
birth)
(B) Maternal effects : Maternal effects
are rare, sometime cause Pre-
eclampsia, polyhydraminous, PPH
etc.
 Diagnosis
• Antenatal investigation for Rh-factor
& Blood grouping.
• Obsteteric history of abortion, still
births etc.
• History of Anti-D antibody
administration
• Indirect coomb's test.
• USG for fetal damage.
• New born & placenta
examination.
 When to do indirect coomb's test ?
DN Bhatta Midwifery (MCH)
• Primigravidae : 12 weeks, if
negative, repeat at 20 weeks & 28
weeks.
• Multigravida : Monthly, after 24
weeks of gestation.
 Prevention
• Administration of Anti-D antibody
(IgG)
• Given intramuscularly within 72
hours of delivery or abortion (>12
weeks) or before or during
pregnancy.
• Dose
 After delivery/postpartum
prophylaxis (sensitized) : 300 mcg
(1500 IU)
 After 12 weeks of pregnancy
(Antepartum prophylaxis) : 300 mcg
(1500 IU)
 Before 12 weeks of pregnancy
(unsensitized) : 50 mcg (200 IU)
• Not given for abortion <12 weeks.
 Rh-antigen develops in fetus 30-40
days after fertilization. (7.5 weeks)
k|;j (Labour)
 Labour is defined as the physiological
process by which the fetus, placenta and
membranes are expelled through birth
canal. -k|;j Pp6f k|fs[lts k|s[of xf], h;4f/f
kf7]3/ leq /x]sf] aRrf, ;fngfn / l´NnL
of]gL4f/sf] af6f] x'b} aflx/ lgl:sG5g ._
 Delivery -k|;'tL_ : is expulsion or
extraction of a viable fetus out of the
uterus. (kf7]3/ leq /x]sf] lzz' aflx/ lgl:sg'
jf lgsfNg' nfO{ k|;'tL elgG5 ._ Labour /
delivery sf] cy{ s]xL km/s 5 . lagf labour
klg Caesarean section ljlw4f/f delivery
u/fpg ;lsG5 .
 Normal Labour (eutocia) : The labour
is called normal if it fulfill the following
criteria.
a. Spontaneous onset at term.
b. With vertex presentation.
c. Without undue prolongation.
d. Natural termination with minimal
aid.
e. Without having any complication to
mother and fetus.
Page | 39
 Abnormal labour (dystocia) eGgfn] In some references :
To:tf] k|;j xf] h;n] normal labour sf] Latent phase 0-3 cm
criteria k'/f u/]sf] x'b}g Active phase 4-7 cm
Transitional phase 8-10 cm
;fFrf] k|;j / ´'6f] k|;j lar km/s (Differences
between true labour and false labour)
@_ bf];|f] r/0f (Second stage of labour)
nIf0f tyf ;frf] k|;j ´'6f] k|;j  Cervix k'/f v'n]b]lv aRrf ghlGdP ;Ddsf]
lrGxx? (true (False
cj:yf nfO{ k|;jsf] bf];|f] r/0f elgG5 .
(Sign and labour) labour)
symptoms)
 of] cj:yfdf aRRffsf] hGd x'G5 .
1. Painfull Regular Irregular
 o;sf] cjwL primipara df ! b]vL @ 306f (1
hour) nfdf] x'G5 eg] multipara df #) b]lv
uterine
contraction
^) (30 minute) ldg]6sf] x'G5 .
2. Severity of Increases Same
 It is divided into two phases :
A. Propulsive phase : No urge to push
pain
B. Expulsive phase : Urge to push & fetal
3. Cervical Present Absent
delivery.
dilatation
A.
4. Cervical Present Absent #_ t];|f] r/0f (Third stage of labour) :
effacement
 aRRff hlGdPb]]lv ;fngfn / l´NnL k'/}
5. Pain relief Not relieved Pain glg:sP;Ddsf] cjwL nfO{ k|;jsf] t];|f] r/0f
by enema or relieved by elgG5 .
sedatives. enema and
 o;sf] cjwL primipara / multipara b'a}df
sedatives.
al9df #) ldg]6;Ddsf] x'G5 . #) ldg]6 eGbf
6. Show Present Absent al9 ePdf Retained placenta elgG5 .
 Effacement : Shortening and thinning of (WHO : >15 min, retained placenta)
cervix during labour.  Average duration : 15-20 minute.
 Show : Blood stained mucus that can be  t/, active management u/]df % ldg]6
observed in first stage of labour. ;Dd 5f]6\ofpg ;lsG5 .
 Placenta sf] delivery of] r/0f df x'G5 .
k|;jsf r/0fx? (Stages of labour)
k|;jsf $ j6f r/0fx? x'G5g . $_ rf}yf] r/0f (Fourth stage of labour) :
!_ klxnf] r/0f (First stage of labour) :  ;fngfn / l´NnL k'/} lgl:s;s]kl5sf] klxnf] @
 k|;j Joyf ;'? ePb]lv kf7]3/sf] d'v 306f ;Ddsf] cjwL nfO{ k|;jsf] rf}yf] r/0f
(Cervix) k'/f -!) ;]=dL_ v'Ng] a]nf ;Ddsf] elgG5 . (in some source : 1 hour also
cjwL nfO{ First stage elgG5 . mentioned)
 o;sf] cjwL klxnf] k6s k|;'tL x'g] dlxnf
(primipara) df * b]lv !) 306f -!@ 306f_
;Dd nfdf] x'G5 eg] Ps eGbf al9 k6s k|;'tL Prelabor
x'g] dlxnf(Multipara) df ^ b]lv * 306f -^  It is premonitory stage of labour and
306f_ nfdf] x'G5 . begins 2-3 weeks before onset of true
 o;nfO{ cervical state of labour klg elgG5 . labour.
 of] stage nfO{ @ efudf ljefhg ul/Psf] 5 .  The signs of pre-labour stage are :
s_ ;'?sf] cj:yf (Latent phase) : ;frf] Joyf ;'? • Lightening : Sinking (descend) of
ePb]lv cervix $ ;]=dL eGbf sd v'n]sf] cj:yf presenting part into true pelvis or
nfO{ latent phase elgG5 . (0-3 cm) decrease in fundal height seen at term.
v_ ;lqmo cj:yf (Active phase) : Cervix $ b]lv • Cervical ripening : Softeneing of
!) ;]=dL ;Dd v'nsf] cj:yf nfO{ active phase cervix.
elgG5 . o; cj:yfdf kf6f]{u|fkm eg{ ;'? ug{'kb{5 . • False labour pain.
(4-10 cm)
IMPORTANT POINTS

DN Bhatta Midwifery (MCH) Page | 40

 During labour the contractions are :  Pain during early stage of labour is due
painful and leads to dilatation of to : Uterine contractions
cervix.  Pain during later stage of labor is due to
 Uterine contraction ;'? x'g] 7fpF M Cornua : Cervical dilatation.
of the uterus or uterine horns. (also
known as pacemaker of uterine
contraction)
 Cornua or uterine horns : Uterus sf] Mechanism of labor
fudus part hxfF Uterus / fallopian tube  There are 8 cardinal movements of
hf]l8G5g . head in normal bour.
 Contractions are predominant over 1. Engagement
the fundus. 2. Descent
 Adequate contraction means : 3 3. Flexion
contractions in 10 minute each lasting 4. Internal rotation
for 45 seconds. 5. Crowning
 Uterine contractions are measured in 6. Extension
mm of Hg. 7. Restitution
 Uterine contraction excessive ePdf 8. External rotation
precipitate labour x'g ;S5 .
 Precipitate labour : @ 306f eGbf sd Induction of labor
;dodf delivery sf] ;Dk'0f{ k|lqmof k'/f x'g' . • Inductuction of labour means initiation
(DC Dutta : <3 hours) of uterine contraction by any method
 Normal labour x'g rflxg] # dxTjk'0f{ (medical, surgical or combined) for the
s'/fx? (3P) : purpose of vaginal delivery
• Push/Power (uterine contraction)
• Passage (Normal pelvis) Indications for induction of labour:
• Passanger (fetus) • Post maturity
 Normal or minimum rate of cervical • IUFD
dilatation during active phase of labour • Premature rupture of membrane
should be : (PROM)
• 1.2 cm/hour for primigravidae • Rh-Isoimmunization
• 1.5 cm/hour for multigravidae. • Congenital malformation of the fetus
 According to WHO, minimum dilatation • Pre-eclampsia & Eclampsia
should be 1 cm/hour. • Maternal distress
 Normal rate of descend of fetal head :  Contraindications of induction of
• Primigravidae/Nulliparous : 1cm/hr labour:
• Multigravidae/multiparous : 2 cm/hr • Contracted pelvis.
 If head is engaged, the station is 'O'. • Cephalopelvic disproportion (CPD)
 Most common position during labour : • Malpresentation
Left occipito-transverse. (LOT>LOA) • Heart disease
 Most imporatant step in delivery is : • Previous C/s, Grand multipara,
Delivery of head. Carcinoma of cervix
 Modifeid ritgen Maneuver is used for
delivery of head.  Bishop Score :
 When the duration of first & second • labour induction ug{' cuf8L induction
stage of labour is >18 hours, it is called ug{' pko{Qm 5 5}g elg ul/g] Scoring nfO{
Prolonged labour. Bishop score elgG5 .
 Best method to assess the progress of • o;nfO{ cervical scoring klg elgG5 .
labor : Partograph • Dr. Edward Bishop n] ;g 1964 df o;sf]
 Main purpose of use of partograph is : ljsf; u/]sf lyP .
To avoid Prolonged labor.

DN Bhatta Midwifery (MCH) Page | 41

 • o;df lgDg % j6f component x? /x]sf
5g .
A. Cervical position
B. Cervical consistency
C. Cervical dilatation
D. Cervical effacement
E. Fetal station
• Most important parameter is :
Cervical dilatation
• k|To]s component df minimum 0 /
maximum 2 score /fv]sf] x'G5 .
• Minimum score : 0
• Maximum score : 10
• Score 6 or less : indication of
induction.
• Before induction, Bishop score should
be at least 8 or more.
• Score >9 : chance of spontaneous
delivery.
Augmentation of labour
 Process of stimulation of uterine
contraction that is already present but
found to be inadequate.
 Cervical Dilation and Measurement
through finger:
• If the index finger can insert, then
dilatation is 1.5 cm.
• One finger loose=2cm
• Two finger tight=3cm
• Three fingers=4.5cm
• Four fingers=6cm
• No feel of cervix=10cm.
 Personal protective measures
include:
• Gloves, footwares (Rubber boot or
lather shields)
• Eyeware (Goggles, glasses or face
shield)
• Apron of rubber or plastic.
FIRST STAGE OF LABOUR
 Sign and symptom of First stage of
labour:
1. Painful Uterine contraction
2. Dilatation of cervix up to 10 cm.
3. Bulging of the membrane during
contraction.
4. Rupture of the membrane.
DN Bhatta Midwifery (MCH)
5. Formation of active (lower) and
passive(Upper) segment.
❖ Physiological Changes in First stage
of labour:
 Involuntary Uterine contraction
 Fundal dominance : Each contractions
starts in the fundal region and spread
downwards
 Formation of upper and lower uterine
segment
 Development of the retraction ring or
bandl’s ring.
 Cervical effacement (shortening and
thinning of cervix during labour)
 Cervical dilatation
 Presence of show (Blood stained mucoid
discharge seen in few hours before or
within a few hours)
 Formation of bag of water
 General fluid pressure
 Fetal axis pressure
 Rupture of the membrane
❖ Nursing management of the women
in First stage of labour:
1. Position and posture:
 There is no hard and fast rule for
position of women in labour but left
lateral position is commonly used.
 In early stage, women should encourage
for ambulation.
2. Diet:
 Tea, digestive biscuits, soup, fruits can
be given.
 Only fluid and liquid diet is given by
mouth as labour starts.
 No intravenous fluid is needed in
normal labour.
 If food is not taken by women for many
hours, dextrose 5% or 10% should be
given.
3. Bowel and bladder:
 Encourage to pass urine every 2 hours,
 Catheterization if can not pass urine.
 Enema should not be given in first stage
of labour.
4. Rest and sleep:
• The women need adequate rest and
sleep, In early stage of labour mild
sedation and analgesics can be given.
Page | 42
5. Encourage and reassurance. —k|;jsf] ;lqmo r/0f (active phase) df h;df
6. Teaching about bearing down effect. kf7]3/sf] d'v $ ;]=dL= v'n]sf] x'G5 To; cj:yf
7. Medications: Buscopan, oxytocin b]lb kf6f]{uf|km eg{ ;'? ug{'k5{ .
8. Prevention of infection • Kff6f]{uf|km s;/L eg]{ <
9. Examination & monitoring != dlxnfsf] ljj/0f M gfd, s'g k6ssf] ue{ slt
• Monitor FHS half hourly. aRrf hGdfPsf], :jf:Yo ;+:yf btf{ gDa/, egf{
• Filling of partograph started when ePsf] ldlt / ;do, kfgLsf] kmf]sf km'6]sf] ;do
cervical dilatation is 4 cm. cflb ljj/0f eg{'k5{ .
• Vaginal examination in every 4 hours. • Gravida eGGffn] slt k6s ue{jtL ePsf] xf]
• Monitor color of amniotic fluid ;f] sf] s'n ;+VofnfO{ hgfp5 .
• Assess umbilical cord, prolapsed or not.
• Para eGGffn] ;DalGwt dlxnfn] slt k6s @@
• Monitor Frequency, duration and
xKtf eGbf al9sf] aRrf hGdfPsf] -lhljt jf
intensity of uterine contraction.
d[t_ xf] ;f] sf] s'n ;+Vof nfO{ hgfp5 .
Phase or Frequency of Duration of @= aRrfsf] d''6'sf] w8sg M k|To]s #) ldg]6df
stage contraction contractions
Latent 5-10 minutely 20-35 seconds
aRRffsf] d''6'sf] w8sg ;'Gg] / -●_ lrXg nufO{
phase kf6f]{u|fkmdf eg{'kb{5 .
Active 3-5 minutely 40-55 seconds #= Amniotic fluid M k|To]s $ 306fdf PV hfFr
phase u/L kfgL kmf]sf km'6]÷gkm'6]sf] x]g{'k5{ / km'6]sf] eP
Second 2-3 minutely 55-65 seconds fluid sf] /Fu x]/L lgDg cg';f/n] kf6f]{uf|kmdf eg{'k5{
stage .
• Record contractions in every 30 minute C : Clear -;kmf_
intervals for 10 minutes and record in M : Miconium stained -aRrfsf] lb;f ldl;Psf]_
partograph. B : Blood stained -/ut ldl;Psf]_
• If contraction within 10 minutes I : Intact -kfgL kmf]sf gkm'6]sf]_
remains for : A : Absent -kfgLsf] kmf]sf km'6]sf] t/ kfgL gePsf],
a. <20 seconds : Mild contractions ;'Vvf_
b. 20-40 Seconds : Moderate $= Moulding (Overlappig of skull bone) :
contractions aRrfsf] 6fpsf] sf] moulding kgL PV hfFr u/L
c. >40 Seconds : strong contractions
lgDgfcg';f/ /]s8{ ug{'kb{5 .
 Adequate uterine contraction refers
:- 3 contractions in 10 min each lasting O M Suture ;fdfGo cj:yfdf ePsf]
for 40 seconds. + : Suture hf]l8Psf] .
++ : Suture vlK6Psf] t/ km6\ofpg ;lsg]
+++ : Suture vlK6Psf] t/ km6\ofpg g;lsg] .
WHO PARTOGRAPH %= Cervical dilatation:
• Kff6f]{Uff|km s] xf] < • kf6f]{uf|km eg{ ;'? ubf{ kf7]3/sf] d'vsf] v'nfO -
• ljZj :jf:Yo ;+3 (WHO) n] s]lx ;dfof]hg x_ lrXg k|of]u u/L hlxn] kgL cn6{ nfOgaf6}
u/L k|sflzt u/]sf] of] o:tf] uf|km xf] h;n] z'? ug{'kb{5 .
Labour sf] progress , k|;jsf] a]nfdf cfdf
/ aRRffsf] cg'udg ub{5 . • x/]s k6s of]gLsf] hfFr ubf{ kf7]3/ sf] d'v sf]
• Best method to assess the progress of v'nfO{ kf6f]{uf|kmdf /]s8{ ug{'k5{ .
labor : Partograph • k|To]s $ 306fdf PV ug{'kb{5 .
• Main purpose of partograph is : To • Alert Line : kf7]3/sf] d'vsf] v'nfO{ olb alert
avoid Prolonged labor. line sf] afofFlt/ /x]df k|;j Joyfsf] k|utL
• Action line n] alert line nfO cross u/]df ;Gtf]ifhgs ePsf] dfGg'k5{ . olb of] line cn6{
Prolonged labor elg diagnose ul/G5 . nfOgsf] bfofF lt/ k/]df k|;j Joyfsf] k|ult
• Peripheri level df action line n] alert line c;Gtf]ifhgs ePsf] jf nfdf] Joyf nfu]sf] eg]/
cross u/]df dflyNnf] :t/df l/km/ ug{'kb{5 . d'Nof+sg ug{'kb{5 .
• Action Line : kf7]3/sf] d'vsf] v'nfO{ olb
• Kff6f]{u|fkm slxn] k|of]u ug]{ < action line df k/]df t'?Gt nfdf] k|;j Joyfsf]
Joj:yfkg ug{'kb{5 . olb cfkm\gf] :jf:Yo
DN Bhatta Midwifery (MCH) Page | 43
 ;F:yfdf ;f] sf] Joj:yfkg ug{ g;lsg] eP
action line df k'Ug' cufj} dlxnf nfO t'?Gt
plrt 7fpF (CEONC service site) df k]|if0f
ug{'kb{5 .
^= aRRffsf] 6fpsf] tn ´g]{ k|lqmof (Descend of
head ) :
• aRRffsf] 6fpsf] tn ´g]{ k|lqmofnfO{ (O) lrXg
nufO{ kf6f]{uf|kmdf /]s8{ ug{'k5{ .
• o;sf] hfFr k]6df 5fd]/ ul/G5 . aRRffsf] 6fpsf]
nfO{ % efudf af8]/ % efusf] slt efu k]6sf
5fDbf Symphysis pubis eGbf dfly e]l6G5 ,
To;nfO{ /]s8{ ug{'k5{ .
• )÷% x'bf aRrfsf] 6fpsf] k]6df 5fDbf e]l6b}g
eg] %÷% x'bf k'/} 6fpsf] Symphysis pubis
eGbf dfyL e]l6G5 .
• !÷% jf Tof] eGbf sd -%÷% ;Dd_ x'bf aRRffsf]
6fpsf] Abdominally palpable x'G5 .
&= kf7]3/sf] v'DrfO{ (uterine contraction)
• k|To]s #) ldg]6sf] km/sdf !) ldg]6;Dd
uterine contraction hfFrL partograph
df eg'{kb{5 .
• Methods of recording uterine
contraction:
A. Duration : how long they lasts.
B. Frequency: Time interval between 2
contractions.(How often they come)
C. Strength : The degree of hardness of
the uterus. (how strong they come)
• Full effacement
• Uterine contractions
• Rupture of membrane
• Anal gaping
• Bulging of perineum
• Desire of bearing down.
• Crowning
 Nursing care of the women during
second stage of labour:
• Never leave the women alone.
• Empty the bladder every 2 hourly,
catheterized if necessary.
• Provide hot or cold drinks in between
contractions.
• Check FHS every 10-15 minutes.
• Liquor amnii is checked for meconium
staining because it indicates fetal
distress.
• Check pulse of mother every 15 minute
and BP every hourly.
• Check and record the Uterine
contractions every 15 minute.
• Encourage for bearing down effects.
• Recheck the delivery equipments,
resuscitation set, essential drugs, O2
cylinder.
• Toileting the external genitalia and
inner side of the thigh with cotton swab
soaked in antiseptics.

*= cGo cf}ifwL / IV fluid sf] dfqf .  k|;jsf] bf];|f] r/0fdf b]vf kg{ ;Sg] ;Defljt
• s'g} cf}ifwLx? clS;6f]l;g, PlG6afof]l6s, hl6ntfx? (Complications of Second
;nfOg x? lbPsf] eP o; uf|kmdf eg{'k5{ . stage of labour)
• Maternal distress
(= cfdf sf] cj:yf M • Fetal distress
s= gf8Lsf] ult (pulse) M k|To]s #) ldg]6df • Cord prolapsed
cfdfsf] gf8Lsf] utL x]/L -●_ lrXg n] hgfpg'kb{5
. Maternal Distress
v= /Qmrfk (Blood pressure) M k|To]s $ 306fdf • Maternal condition is a of mental and
physical exhaustion of the women
cfdfsf] /Qmrfk hfFr]/ partograph df /]s8{ ug{'5{
during labour usually caused by
. prolonged labour characterized by
u= tfkqmd (Temperature) M x/]s $ 306fdf maternal dehydration, altered vital sign,
tfkqmd hfFrL /]s8{ ug{'k5{ . ketoacidosis.
3= lk;fk (Urine) M k|To]s $ 306fdf lk;fasf] • It is an indication of that labour should
dfqf hfRg] / lk;fkdf k|f]l6g / Pl;6f]g ePsf] be terminated.
gePsf] hfFrL x]g'{k5{ . • Causes:
A. Prolonged labour:
SECOND STAGE OF LABOUR
• Contracted pelvis
 Signs of second stage of labor • CPD
• Full dilatation of cervix (10cm) • Big baby

DN Bhatta Midwifery (MCH) Page | 44

 • Malpresentation
• Regid cervix
• Regid pelvic floor & perineum in
primigravidae.
B. Insufficient uterine contraction
C. Low maternal bearing down effect
 Sign & Symptoms:
• Increased pulse rate (>120/min)
• Increased respiration (24-26/min)
• Increased temperature
• Looking ill & worried
• Marked restlessness, weakness,
sweating
• Severe dehydration: dry lips, tongue,
presence of acetone in breath and
urine.
• Abdominal distension
• Dark vomitus
• Women may died if not managed
properly
 Management
• Adequate rest, sedative.
• Good nursing care, monitor vital signs.
• Encourage to empty bladder every 2
hours.
• Provide reassurance and emotional
support.
• Provide plenty of fluid orally.
• Inform to doctor immediately when the
sign of maternal distress seen.
• Give IV fluid : RL & 5% dextrose.
• Definitive management : Labour
should be terminated by C/S.
• Complete rest after delivery.
Fetal distress:
 Causes:
• Malpresentation and position of the
fetus
• Maternal distress
• Pre-eclampsia & eclampsia
• Prolonged labour
• Pre-term and post term labour.
• Weak uterine contraction
• Placenta previa & Abruptio placenta
• Cord prolapsed, Short umbilical cord
• Excessive moulding
 Sign & Symptoms :
• Fetal tachycardia (FHS>160/min)
DN Bhatta Midwifery (MCH)
• Persistent bradicardia(<110/min) after
tachycardia
• Irregular heart rate
• Meconieum stained liquor amnii.
(Green colored liquor amnii)
• Excessive fetal movement in early
stage.
• Very slow or absent fetal movement in
late stage.
• Increasing caput succedaneum.
(swelling of the scalp during labour)
 Management:
• Place the women in left lateral
position, which helps to improve
placental circulation.
• Stop oxytocin drip, if giving.
• IV fluid: RL & 5% dextrose.
• Give O2 inhalation to mother 6-8
liter/min.
• Check uterine contraction: strength,
frequency and duration.
• FHS should be recorded every 15
minute.
• Make ready the resuscitation set.
• If there is sign of infection, give
antibiotic.
• If cord is prolapsed, manage it.
• If the cervix is fully dilated, and the
fetal head is not more than 1/5 above
the symphysis pubis or fetal head is
at ‘0’ station, deliver by vacuum or
forceps.
• If cervix is not fully dilated , and the
fetal head is more than 1/5 above
symphysis pubis or fetal head is at
above ‘0’ station, deliver by cesarean
section.
• With miconeum stained, baby’s
mouth and throat should be
suctioned.
Cord prolapsed:
 The umbilical cord lies in the birth canal
below the fetal presenting part.
 The umbilical cord is visible at the
vagina following rupture of membrane.
 Incidence : 1 in 300 deliveries.
 Clinical types:
A. Occult prolapse: The cord is placed by
the side of the presenting part and is
Page | 45
 cannot be seen & felt by fingers PV
examination.
B. Cord presentation: The cord cannot be
seen but can be felt as pulsating mass on
PV examination.
C. Complete cord prolapsed: The cord is
seen outside the vulva after rupture of
membrane.
 Causes:
• Malpresentation : transverse lie, breech
or foot presentation
• Malposiition: Occipito-posterior
• Multiparity
• Contracted pelvis
• Ployhydrominos
• Prematurity
• Placenta previa
• Long umbilical cord
 Clinical features:
• Umbilical cord may palpate or seen
during PV examination.
• FHS decreased
• Excessive fetal movement
• Miconium stained liquor
 Management:
• Treatment of choice :Cesarean
delivery.
• Keep the patient in Exaggerated and
elevated Sim’s position or Knee chest
or trendelenberg position.
• Immediately inform the obstetrician.
• Stop oxytocin infusion immediately.
• Give 02 inhalation at 4-6 liter/minute.
• Immediately do PV examinations to
check the cord for pulsating or not.
• If the cord is pulsating, fetus is alive, if
the cord is not pulsating, fetus is dead.
• For pulsating cord:
A. If women is in first stage of labour,
give salbutamol 0.5 mg IV slowly to
reduce contractions and perform
immediately C/S delivery.
B. If the women in second stage of
labour, delivery with episiotomy and
vacuum or forcep delivery. If not
possible, prepare for C/S.
• If the cord is not pulsating, the fetus is
dead. (Confirm by USG) Perform
delivery in the manner that is safest
DN Bhatta Midwifery (MCH)
method or can be wait for spontaneous
delivery. .
• Prepare for resuscitation.
• C/S delivery is the choice of
managemet for cord prolapsed.
THIRD STAGE OF LABOUR
 k|;jsf] t];|f] cj:yfsf] ;lqmo Joj:yfkg
(Active management of third stage of
labour) : k|;jsf] t];|f] r/0fsf] ;lqmo
Joj:yfkg eGGffn] x/]s aRRff hGd] nuQ}
cfdfnfO{ PPH af6 arfpg ul/g] # j6f sfo{
a'l´G5 .
1. clS;6f]l;g (Oxytocin) :
• aRRff hGd]sf] ! ldg]6 leq csf]{ aRRff gePsf]
;'lgl:rt ul/ klxn] g} tof/ Ul/ /fv]sf !)
o'lg6 clS;6f]l;g IM lbg'k5{ .
2. Delayed cord clamping (≥1-3 minute) :
80 ml of blood (50 mg iron) present in the
cord goes to fetus, prevent anemia.
3. lgolGqt ?kdf tfGg] ljlw (Controlled Cord
Traction) : CCT ul/ ;fngfn k'/f lgsfNg' kb{5
.
kf7]3/sf] xNsf ;Fu dfln; (Uterine massage) :
• o;nfO{ WHO New guideline n] Third
stage sf] active management sf] r/0f
af6 x6fPsf] 5 . cyf{t PPH sf]
prevention sf] nflu of] r/0f k|of]u gug]{ .
• t/, PPH sf] treatment sf] ?kdf eg]
uterine massage nfO{ k|of]u ug{ ldNg]
elgPsf] 5 .
• ;fn lgl:s;s]kl5 kf7]3/nfO{ k]6 dfyLaf6 s8f
;Fu gv'lDrP ;Dd sxNsf dfln; ug{'kb{5 . o;f]
ug{ cfdfnfO{ klg l;sfpg'k5{ / a]nf a]nfdf
kf7]3/sf] dfln; ug{ nufpg'k5{ .
• ;fnsf] t'?Gt kl/If0f u/L ;fngfn / l´NnL
;fdfGo lx;fan] k'0f{?kdf lgl:sPsf] olsg
ug{'kb{5 .
• aRrf hlGdPsf] @ 306f ;Dd k|To]s !%–!%
ldg]6df kf7]3/ s8f ;Fu gv'lDrP ;Dd of]
k|lqmof bf]xf]/\ofpg' kb{5 .
 The earliest sign of placental
separation : Uterus becomes globular &
firm.
 Most commonly placenta should be
separated from it's center. (80%)
Page | 46
 Third stage of labour is the most
crucial/critical/most important one
for women.
Average Blood loss During labor
 After vaginal delivery : 500 ml
 After Cesarean section : 1000 ml
 After twin vaginal delivery : 1000 ml
 After cesarean hysterectomy : 1500
ml
k|;jsf] t];|f] / rf}yf] cj:yfdf b]vf kg{ ;Sg]
hl6ntfx?
(Complications of third & fourth stage of
labour)
• Post partum Hemorrhage
• Retained placenta
• Inversion of the uterus
• Ruptured uterus
• Vulval hematoma
• Amniotic fluid embolism
k|;'ltkl5sf] cToflws /Qm>fj
(Post partum hemorrhage, PPH)
 aRrf hlGdPkl5 olb of]gLaf6 %)) ld=ln eGbf
al9 /Qm>fj ePdf To;nfO{ k|;'ltkl5sf]
cToflws /Qm>fj (PPH) elgG5 .
 t/ /ut slt au]sf] 5 eGg] af/]df cg'dfg ubf{
k|foM h;f] Tof] jf:tljs gf]S;fgL sf] cfwfh:tf]
dfq} x'g] ub{5 . lsgsL /ut Amniotic fluid
jf lk;fa ;Fu ldl;Psf] x'g ;S5 . To;}ul/ /ut
Sponges, perineal towel, bedsheet, floor
cflbdf ;d]t nfu]sf] x'g ;S5 .
 ;DalGwt dlxnfsf] /utdf ePsf] hemoglobin
sf] dfqf (Level) cg';f/ /Qm>fjsf] c;/df
leGGftf x'g ;S5 . Pp6f /QmcNktf ePsf]
dlxnfsf] lglDt clnslt /Qm>fj -%)) ld=ln
eGbf sd_ n] klg c;fdfGo l:ylt pTkGg x'g
;S5 .
 To;}n] aRrf hGdfPkl5 b]lv $@ lbg -^ xKtf_
;Ddsf] cjlwdf s'g} klg kl/df0fsf] /Qm>fj
h;n] ;DalGwt dlxnfsf] :jf:Yodf ulDe/ c;/
kf5{, To;nfO{ klg PPH elgG5 .
 PPH @ k|sf/sf x'G5g .
A. Primary PPH : aRrf hGdfPsf] @$ 306f
leqdf of]gLaf6 x'g] cToflws /Qm>fjnfO{
Primary PPH elgG5 .
B. Secondary PPH : aRrf hGdfPsf] @$
306fb]vL ^ xKtf;Dd of]gLaf6 x'g] cToflws
/Qm>fjnfO{ Secondary PPH elgG5 .
DN Bhatta Midwifery (MCH)
 PPH x'g] k|d'v sf/0fx? lgDglnlvt 4T sf]
?kdf ;lD´g ;lsG5 .
T1 = TONE
T2 = TRAUMA
T3 = TISSUE
T4 = THROMBIN
s_ Tone /Atonic Uterus : aRrfsf] hGdkl5
kf7]3/ s8f;Fu v'lDrPg eg] ;fn 6fl;Psf] 7fpFaf6
x'g] /Qm>fj nfO{ atonic PPH elgG5 . Post
partum hemorrhage sf] k|d'v sf/0f atonic
uterus xf] . sl/a &) k|ltzt PPH o; sf/0fn]
x'G5 . kf7]3/ atonic x'g] k|d'v sf/0f x? tn
lbO{Psf 5g .
 ;fn k'/f g5'l§Pdf
 ;fnsf] 6'qmf jf l´NnL c8\lsPdf
 Pricipitate labour ePdf .
 Nffdf] k|;'tL Joyf nfu]df
 Polyhydroamnious or multiple pregnancy
or grand multipara
v_ Trauma /Traumatic PPH : of]gLdfu{df 3fp,
rf]6 nfu]/ x'g] /Qm>fjnfO{ Traumatic PPH elgG5
. Traumatic PPH kf7]3/sf] d'v, of]gL, k]l/lgod
RofltP/ jf kf7]3/ km'6]/ klg x'g ;S5 . sl/a
@)% PPH o; sf/0fn] x'G5 .
u_ Tissue/Retained tissue : cfFlzs ?kdf
;fngfn (placenta), lemNnL (Membrane) jf
/utsf l9Ssf (clots) afFsL eP/ To;n] kf7]3/
v'lDrg glbO{ x'g] /Qm>fjnfO{ o; sf/0fn] ePsf]
PPH elgG5 . sl/a !) k|ltzt PPH o; sf/0fm]
x'G5 .
3_ Thrombin sf] sldn] x'g] PPH
/ut hDg] k|ls|ofdf c;/ ug]{ cj:yf
(Coagulopathy) sf] sf/0fn] x'g] /Qm>fjnfO{
o;sf/0f n] ePsf] PPH elgG5 . sl/a ! k|ltzt
PPH o; sf/0f n] x'G5 .
k|;'tLkl5sf] cToflws /Qm>fj sf] Joj:yfkg
(Management of PPH)
!_ ;fdfGo Joj:yfkg (General management)
 ;xof]usf] nflu u'xfg]{ (SHOUT FOR HELP)
 dlxnf ;'t]sf] a]8sf] tNNff] efu -v'§flt/sf] efu_
clnslt prfn]/ /fVg] h;n] ubf{ vital organ
x? df /ut ;Grfng x'gdf dbt u5{ .
 dlxnfsf] vital sign x? -Pulse, Respiration,
temperature, BP) af/]df rapid assessment
ug]{ .
 olb shock ePdf tTsfn To;sf] Joj:yfkg
yfngL ug]{ .
Page | 47
@_ PPH sf] j:t'ut Joj:yfkg (Specific
management) :
 kf7]3/ 5fDg] / s8f;Fu v'lDrPsf] 5 , 5}g hfFr
ug]{ . kf7]3/ s8f;Fu gv'lDrPsf] eP xNsf
 dfln; ug]{ . To;n] /ut / /utsf] l9Ssf
(blood clots) aflx/ lgsfNg / kf7]3/nfO{
k|efjsf/L tl/sfn] ;+s'rg (contraction)
u/fpg d4t u5{ .
 !^ u]hsf] canula n] IV line vf]Ng] / IV fluid
rnfpg ;'? ug]{ . /utdf Hemoglobin sf]
dfqf hfFr ug{ tyf cross match ug{ t'?Gt
k7fpg] . /utsf] cfjZostf kg]{ s'/fnfO{ klxn]
af6} cg'dfg ug{'kb{5 / cfjZos eP /ut
r9fpg] Joj:yf ug]{ .
 Foley’s catheter nufpg] (Bladder vfln ug{
/ input/output monitor ug{_
 klxn] glbPsf] eP oxytocin 10 IU IM lbg] .
klxn] lbPsf] eP 20 IU oxytocin 1 liter RL
jf NS df (500 ml RL jf NS df 10 unit
oxytocin ) /flv 60 drops/min sf] b/n] ;'?
ug]{ . o:tf] oxytocin ePsf] IV fluid # ln6/
;Dd lbg ;lsG5 . (Maximum dose)
 ;fngfn (placenta) k'/f lgl:sPsf] 5, 5}g eGg]
s'/f lgl:rt x'g] ul/ km]/L /fd|/L hfFr ug]{ /
c8\lsPsf] eP ltgnfO{ kf7]3/af6 lgsfNg] .
 RofltPsf]÷3fp (tears) ePsf] 5, 5}g af/]df
hfGgsf] lglDt kf7]3/sf] d'v (cervix) (vagina)
, Perineum sf] hfFr ug]{ . RofltPsf] eP t'?Gt
l;Nffpg] .
 To; kZrft klg /Qm>fj hf/L /x]df, Bedside
clotting test sf] dfWod af6 /ut hDg] l:ytL
(clotting status) sf] hfFr ug]{ . Bedside
clotting test ubf{ & ldg]6 ljlt;Sbf klg /ut
ghd]df coagulopathy ePsf] cfz+sf ug{'k5{ ,
o:tf] l:yltdf blood transfusion ug]{ jf ;f]
;]jf lbg ;Sg] 7fFp (CEONC service site) df
t'?Gt k|]if0f ug]{ .
 dfly pNn]v ul/Pcg';f/sf] Joj:yfkg ubf{ ub}{
klg /Qm>fj g/f]lsPdf b'a} xft k|of]u ul/
kf7]3/nfO{ RofKg] ljlw (Bimannual
compression) ckgfP/ kf7]3/nfO{ s8f;Fu
v'Drfpg d4t ug{‘'kb{5 jf To;sf] ljsNkdf
aortic compression ug{'kb{5 .
DN Bhatta Midwifery (MCH)
 PPH is bleeding more than 500 ml
following vaginal delivery & 1000 ml
following C/S delivery.
 The most common cause of PPH is Atonic
uterus.
 The most common cause of Primary PPH
is : Atonic uterus.
 The most common cause of secondary
PPH is : Retained placenta
 Misoprostol nfO{ dft[ z'/Iff rlSs elgG5, h'g
PPH sf] prevention jf treatment sf] ?kdf
k|of]u ug{ ;lsG5 . of] pregnancy df lbg' x'b}g
-k|of]u ug{' x'b}g_ .
 Dose and route of Misoprostol in PPH
a. For prevention of PPH : 600 mcg orally
b. For management of PPH : 800 mcg
sublingually
 Delivery kl5 shock df hfg] k|d'v sf/0f M PPH
RETAINED PLACENTA
Retained placenta is called when placenta is
not expelled out even 30 minutes after the
birth of the baby. [WHO > 15 minutes]
 Signs of Placenta Separation
1. The uterus becomes firm and globular.
2. umbilical cord lengthen at the vulva.
3. A gush of blood usually comes out from
vagina.
4. Lower abdominal pain
5. The uterus rises in the abdomen.
 There are three methods of placenta
delivery :
1. Control Cord Traction (CCT)
2. Fundal Pressure (FP)
3. Maternal Effort (ME)
 Naturally, there are two methods of
placenta separation :
A. Central separation (Schultz method) :
More common.
B. Marginal separation (Mathews Duncan
Method)
Page | 48

 Causes of Retained Placenta
1. Atonic uterus : Most common
2. Adherent placenta
3. Full bladder
4. poor voluntary effort
5. separated placenta hold by Constriction
ring.
 Complications/Effects of retained
placenta :
1. Hemorrhage
2. Shock
3. Peurperal sepsis
4. Risk of reccurance
5. Thrombophlebitis
6. Embolism
 Management of retained placenta :
1. empty bladder by rubber catheter
2. Manage bleeding as PPH
3. if placenta is separated : Express placenta
by Controlled cord traction.
4. Unseparated placenta : Manual removal
of placenta under general anesthesia.
INVERSION OF UTERUS
 Inversion means ‘turn inside out’
 Inversion of uterus means the uterus is
partially or completely turns inside out.
 Incidence : 1:20,000 deliveries
 Degree of inversion :
A. First degree : Dimpling of the fundus
, which still remains above the internal
os.
B. Second degree : The fundus passes
through the cervix but lies inside the
vagina.
C. Third degree (Complete) : the
endometrium with or without the attached
placenta is visible outside the vulva.
 Causes :
A. Spontaneous (40%)
B. Induced (60%) : Iatrogenic
a. Pulling the cord (CCT) when uterus is
atonic
b. Faulty technique in manaual removal
c. Fundal pressure when uterus is atonic.
d. Adherent placenta
e. Sudden emptying the distended bladder
 Risk factors
a. short umbilical cord
b. uterine malformations
c. prolonged labor
DN Bhatta Midwifery (MCH)
d. fetal macrosomia
 Dangers
a. shock : Neurogenic
b. Hemorrhage
c. Pulmonary embolism
d. Infection
 Clinical features
a. Sudden onset of shock due to severe pain.
b. Anemia : Mild to severe.
c. persistent vaginal bleeding.
d. Pelvic pain
e. history of something coming down per
vagina
 Diagnosis : USG
 Management
A. General care : Open IV line, Give IV
fluid and prophylactic antibiotic.
B. Food end of the bed elevated.
[Trendelenburg position]
C. Replace the first part which is inverted
last.
D. After replacement, the hand should
remain inside the uterus until the uterus
becomes contracted.
E. Hydrostatic replacement is quite effect.
F. If not successful with hydrostatic
correction : reposition of uterus under
General anesthesia or refer.
G. Treatment of shock.
PROLONGED LABOR
 Prolonged labor is defined when the
first and second stage of labour last
more than 12 hour without including
false labor. (Source : WHO IMPAC &
Roshani tuitui, textbook of obstetric)
 According to DC Dutta : >18 hours
 Labor is considered prolonged when
the cervical dilatation rate is less than
<1 cm/hour and descend of the
presenting part is less than 1 cm/hour
for a period of minimum 4 hour
observation. [WHO 1994]
 Prolonged latent phase : If the cervix
is not dilaeted 4 cm after 8 hour of
regular contraction is called prolonged
latent phase.
 Causes of prolonged labor :
1. Fault in Power
a. Hypotonic uterine dysfunction (uterine
inertia)
Page | 49
b. hypertonic uterine dysfunction After 3 weeks 100 gm
- incordinate, asymemetrical uterine After 6 weeks 60 gm
contraction.
 The rate of uterine involution is about
- Hyperactive lower segment
1.25 cm (1/2 inch) per day.
- constriction ring, Bandl’s ring
 Soon after birth of the baby fundal
- cervical dystocia
height is just below umbilicus.
2. Fault in Passage
 At 10 days of delivery, fundal height is
a. Contracted pelvis
just above symphysis pubis & after 10
b. Cephalopelvic disproportion (CPD)
days it reaches below symphysis
c. Pelvic tumor
pubis.
d. rigid perineum
 Best time for post-partum tubectomy
e. cervical dystocia (rigid cervix)
(Post-partum sterilization or post
f. Full bladder
partum minilaparotomy) is : within 1
3. Fault in Passanger
week of delivery.
a. Malposition : Occipito posterior
 Delayed involution is called :
b. Malpresentation
Subinvolution
c. Macrosomia (big baby)
d. Fetal malformation : hydrocephalus
2. Puerperium :
 Most common cause of prolonged  Puerperium is the period following
labor is : CPD
childbirth during which pelvic organs
 Dangers or effects of prolonged labor reverts back approximately to the non-
a. Maternal distress pregnant state. (Puerperium eGGffn] ;'Ts]/L
b. Fetal distress kl5sf] Pp6f cj:yf xf], h;df ;Dk'0f{ k|hgg
c. Post partum hemorrhage c+ux? k'j{ ue{jtL cj:yfdf kmls{G5g ._
d. increased chance of C/S delivery
 jf, involution k|ls|of k'/fx'g nfUg]
e. subinvolution
;docjwLnfO{ Peurperium elgG5 .
f. Peurperal sepsis
 Management  Placenta delivery ePb]lv sl/a ^ xKtf -$@
a. Early detection of causes during ANC
lbg_ sf] cjlwnfO{ Puerperium elgG5 . of]
b. Use of Partograph
cj:yfnfO{ # efudf ljefhg ul/Psf] 5 .
(A) Immediate puerperium : Within 24
c. Treatment of maternal and fetal distress
hours following delivery.
d. treatment of acidosis with RL
(B) Early puerperium : upto 7 days
e. Find the cause and treat the cause
(C) Late puerperium : upto 6 weeks
f. Termination of pregnancy with C/S.
3. Lochia Formation:
POSTPARTUM PERIOD
 Discharge from the uterus following
1. Involution
childbirth or abortion. -;'Ts]/L ePsf]
 Delivery kl5 uterus nufot cGo k|hgg
c+ux? non-pregnant cj:yfdf kmls{g'nfO{ ;'?sf] !% lbg ;Dd b]vf kg]{ vaginal
discharge nfO{ Lochia elgG5 ._
involution elgG5 . (involution is a
 The discharge originates from uterine
process by which the reproductive
body, cervix and vagina.
organs returns to their non-pregnant
 It has offensive fishy smell.
state).
 It is of 3 types.
 of] k|lqmof sl/a ^ xKtfdf k'/f x'G5 .
(A) Lochia rubra :
 Labour sf] cGtdf uterus sf] tf}n sl/a ())-
• Color : Red,
!))) u|fd x'G5 eg] ^ xKtf kl5 o;sf] tf}n
• Seen on first 1-4 days of puerperium.
^) u|fd hlt x'G5 .
• Composition : Blood (RBCs main),
Postpartum period Weight of uterus
Shreds of fetal membranes &
At delivery 1000 gm deciduda, vernix caseosa, lanugo &
After 1 week 500 gm meconium
After 2 weeks 300 gm

DN Bhatta Midwifery (MCH) Page | 50

 • Vernix caseosa : Waxy white
substance found on the skin of
newborn babies.
• Lanugo : Very thin, soft, unpigmented
hair found on the body of new born
babies.
(B) Lochia serosa
• Color : Yellowish or Pink
• Seen during 5-9 days of puerperium.
• Composition : Less RBCs but more
leucocytes, wound exudate, mucus
from the cervix, micro-organisms
(Streptococci, staphylococci)
(C) Lochia alba :
• Color : pale white
• Seen upto 10-15 days of puerperium.
• Composition : Plenty of decidual cells,
leucocytes, mucus, epithelial cells &
micro-organisms.
4. Other Changes after delivery
 Delivery ePnuQ} zl//sf] tfkqmd 0.5 F n]
a9\g ;S5 h'g 12 hour leq normal df
cfp5 .
 t/, Delivery ePsf] @$ 306f leq zl//sf]
tfkqmd 990F eGbf al9 x'g' x'b}g .
 Overdistended bladder→incomplete
emptying→UTI may be common.
 Constipation is common.
 Delivery nuQ} sl/a 5 kg weight loss x'G5
/ ^ xKtfsf] cGTodf yk 4 kg weight loss
x'G5 .
 About 2 liter fluid loss occurs in first
week.
 1.5 Liter fluid loss occurs in next 5
weeks.
 Female should be adviced for coital
activity (sex) minimum after 6 weeks
of delivery.
 Menstruation occurs after 36 weeks of
delivery if mother is lactating
 In non-lactating mother, menstruation
usually returns betweens 6-12 weeks.
 Delivery kl5 @$ 306f;Dd ;'Ts]/L cfdfnfO{
Close observation df /flv @$ 306f kl5 dfq
discharge ug]]{ .
 Postnatal visit $ k6s ug{'kb{5 .
s+_ klxnf] k6s M hGd]sf] @$ 306fdf .
v_ bf];f| ] k6s M @ jf # lbgdf . (48-72 hours)
u_ t];|f] k6s M & lbgdf . (7-14 days)
DN Bhatta Midwifery (MCH)
3_ rf}yf] k6s M ^ xKtfkl5 . (Near after 42
days)
Peurperal Pyrexia
 ;'Ts]/L ePsf] !) lbg leq @$ 306fsf]
cGt/fndf Hj/f] gfKbf 100.40F (380C) eGbf
al9 ePdf o;nfO{ Peurperal pyrexia elgG5
.
 Causes : Peurperal sepsis, UTI, Mastitis,
breast abscess, wound infections etc.
 Most common cause of puerperal
pyrexia : Endometritis.
 Commonest organism : group A
streptococci.
 Highest chance of endometritis occurs
in : C/S delivery.
Puerperal Sepsis
 An infection of genital tract which
occurs as a complication of delivery is
called puerperal sepsis.
 Peurperal sepsis is commonly due to :
(A) Endometritis (Most common) or
(B) Endomyometritis or
(C) Endoparametritis : Combination
of these, also called Pelvic
cellulitis.
 Causative agents :
• Group A beta hemolytic streptococcus
(Most common)
• Group B Beta hemolytic
streptococcus. (Main cause of
neonatal sepsis/deaths)
• E. Coli
• Others : Staphylococcus,
Pseudomonas, proteus, chlamydia etc.
 Commonest site of infection is
'Placental implantation site at
endometrium'
 Clinical features :
• Rise in body temperature (>100.40F)
• Chills & rigor
• Tachycardia
• Lochia becomes offensive & copious.
• Uterus may be subinvoluted, tender &
soft.
• Wound infections.
 Management :
• Hospitalization & isolation
• Adequate fluid & calorie by IV infusion.
• Correct anemia
• Catheterization.
Page | 51
• Monitor intake output & Vitals.
• Antibiotics based on Culture &
sensitivity report.
• Without culture report, IV antibioics :
Ampicillin + Gentamycin +
Metronidazole can be used.
 Prevention :
• Prophylactic antibiotic at the time of
Cesarean section.
• Full surgical asepsis during delivery.
• Screening for Group B streptococcus in
high risk patient.
• Postpartum prophylactic antibiotic.
Psychiatric Disorders during pregnancy
1. Peurperal Blues
 Seen in 50-60% of postpartum
mothers.
 Most common psychiatric disorder in
postpartum period.
 Occurs after 4-5 days after delivery and
lasts for few days.
 Gradual onset
 Mildest psychiatric disorder in
postpartum period..
 Clinical features : Depression, anxiety,
tearfulness, insomnia, helplessness and
negative feelings towards the infant.
 Due to progesterone withdrwal.
 Treatment : reassurance &
psychological support by the family
members.
2. Post-Partum Psychosis
 Seen in <1% (0.14-0.26%) of
postpartum mothers.
 Sudden onset, usually within 4 days of
delivery.
 Most dangerous psychiatric disorder in
peurperium.
 Breastfeeding is contraindicated in
this case.
 Chance of reoccurance is 20-25%.
 Clinical features :
• Fear, restlessness,
• Hallucinations, delusions
• Confusion, disorientation.
• Suicidal, infanticidal attempts.
 Treatment :
• Psychiatric consultation
• Hospitalization
DN Bhatta Midwifery (MCH)
• Antipsychotic drugs : Chlorpromazine
.
• Temporary separation and nursing
supervision needed.
3. Post-partum Depression
 It is observed in 10-20% of mothers.
 Moderate type.
 Gradual onset, usually over the first 4-6
months after delivery.
 Characterized by : loss of energy &
appetite, insomnia, social withdrawl,
irritability & suicidal attitude.
 Treatment : Fluoxetine or paroxetine.
 Need psychological support.
 If no improve, refer for psychiatric
consultation.
 Highest chance of reccurance : 50-
100%.
Oxytocin
 Oxytocin is a oxytocic agent, which
have the power to excite contractions of
the uterine muscles.
 Discovery : de Vigneaud (in 1950)
 Oxytocin hormone is secreted by
posterior pituitary.
 Mode of action : It stimulates amniotic
& decidual Prostaglandin production.
 Indications : can be used during
pregnancy, labour & postpartum for
following purpose :
(A) During pregnancy :
• To accelerate abortion
• To treat post abortal hemorrhage.
• To induce labour
• To ripen the cervix before
induction.
• Augmentation of labour.
(B) During labour
• Active management of third stage of
labour.
(C) During puerperium
• To control PPH or to minimize blood
loss.
 Oxytocin : responsible for milk ejection
& involution.
 Method of administration : IM or IV
infusion.
 Preparation most commonly used :
Syntocinon 5 IU/ml (ampule) OR
Pitocin 5 IU/ml
Page | 52
 Contraindications of Oxytocin : Degree Description
• Grand multipara First Tear involving vaginal
• Contracted pelvis epithelium or skin only
• History of cesarean section or Second Tear involving both vaginal
hysterectomy skin and muscles.
• Malpresentation (Mediolateral episiotomy hltg}
• Obstructed labor level df Rofltg]_
• Precipitate labor Third Involvement of anal sphincter.
• Fetal distress Fourth Involvement of anorectal
• Hypovolemic state mucosa (anal epithelium)
• Cardiac disease  Prevention of perineal tears : ritgen
maneuver (Head delivery u/fpg] ljlw_,
EPISIOTOMY Episiotomy.
 Delivery sf] a]nfdf perineum jf vulva df
lbO{g] surgical incision nfO{ episiotomy MULTIPLE PREGNANCY
elgG5 .  When more than one fetus develops
 ofgLdfu{ (vulval outlet) nfO{ v's'nf] kfg{ simultaneously in the uterus, called
k|;jsf] bf];|f] r/0f (Second stage of multiple pregnancy.
labour) df of] lbOG5 . • Two fetus : Twins (most common)
 Ideal time of episiotomy : Bulging • 3 fetuses : Triplets
thinned perineum during contraction • 4 fetuses : quadruplets
just prior to crowning of head. (When • 5 fetuses : quintuplets
3-4 cm head is visible) • 6 fetuses : Sextuplets
 Perineal tear x'g glbg' episiotomy sf]  Types of twins :
k|d'v p4]Zo xf] . (A) Dizygotic twins :
 Indications of episiotomy : • Most common (80%).
(A) Inelastic (rigid) perineum • Results from the fertilization of two
(B) Chance of perineal tears ova.
• Big baby (B) Monozygotic twins (20%)
• Face to pubis delivery • Also known as 'identical twins'.
• Breech delivery • Results from the fusion of single
• Shoulder dystocia ovum.
(C) Operative delivery : Forcep, ventouse
delivery etc.
(D) Previous perineal surgery : pelvic floor Monozygotic Dizygotic
repair. 1. One uvum 1. Two ova
 Types of episiotomy : fertilized. fertilized.
• Median/midline 2. One placenta 2. Two placenta
• Mediolateral (most common) 3. Two amnions, 3. 2 amnions &
• Lateral No chorion two chorion
• 'J' Shaped 4. Sex : Same 4. Sex : differ
 Most common type of episiotomy: Right 5. Blood 5. Blood
Mediolateral (first answer), median group/fingerprint group/fingerprint
(second answer). : Same : differ
 Muscles also cut in mediolateral 6. Skin grafting : 6. Skin grafting :
incision. Acceptance Rejection.

PERINEAL TEAR  In twins pregnancy :

 Tear involving the perineum are • Increased nausea, vomiting in early
perineal tears. pregnancy.
 Classification
• Unusual weight gain

DN Bhatta Midwifery (MCH) Page | 53

 • Barrel shaped abdomen.
• The height of the uterus is more than
the period of gestation.
• Palpation of too many fetal parts.
• Two diferrent FHS herd at separate
region.
 Complications of multiple pregnancy :
(A) Maternal :
• Nausea, vomiting
• Anemia
• PIH
• Oligohydramnios/polyhydramnios
• Preterm labour
• APH, PPH
• Malpresentations
• Prolonged labour etc.
(B) Fetal
• Abortion
• Preterm birth
• Low birth weight
• IUFD
• Cord prolapsed etc
Miscellaneous
 Contraindications of breastfeeding
(A) Maternal conditions
• Acute puerperal illness
• Acute breast complications : Cracked
nipple, mastitis or breast abscess
• Herpes simplex lesion of the breast.
• Active untreated pulmonary
tuberculosis.
• Peurperal psychosis.
• Mother taking high dose of anti-
epileptic, anti-thyroid, anti-psychotic
or anticancer drugs.
(B) Neonatal Conditions
• Very low birth weight baby
• Asphyxia
• Acute illness
• Severe degree of cleft palate.
• Galactosemia : High galactose in
blood.
================================
 Indications of Cesarean Section
(A) Absolute indications:
• When vaginal delivery is not possible
even in dead fetus,
• Central placenta previa
• Contracted pelvis
DN Bhatta Midwifery (MCH)
• Cephalopelvic disportion (CPD)
• Pelvic mass causing obstruction
• Advanced carcinoma of cervix.
• Vaginal obstructions (stenosis etc)
(B) Relative indications
• Vaginal delivery may be possible but
risk to mother & fetus are high.
• Cephalopelvic disproportion
• Previous history of C/S delivery
• Dystocia due to Large fetus (passanger),
small pelvis (passage), insufficient
uterine contractions. (power).
• Malpresentations : Breech, shoulder etc.
• Hypertensive disorders : Pre-eclampsia,
eclampsia.
• Antepartum hemorrhage (APH)
• Failed to induction
• On patient request.
 g]kfndf dft[ d[To'sf sf/0fx?
(Causes of maternal mortality in Nepal)
1. Hemorrhage : 24%
• PPH : 19%
• APH : 5%
2. Eclampsia (Toxemia) : 21%
3. Abortion complications : 7%
4. Obstructed labour : 6%
5. Peurperal sepsis : 5%
6. Other causes : 37%
NEW BORN CARE
 New borne danger signs -gjhft lzz'df
b]vf kg]{ vt/fsf lrGxx?_
• cfdf sf] b'w r':g g;Sg' .
• ;':t jf a]xf]; sd rnfO{ .
• l56f] l56f] :jf; km]/]df .
• s8f l;t sf]vf xfg]df .
• Hj/f] cfPdf .
• l;tf+u (hypothermia ) : Temp <36.50C
• gfO{6f] kfs]df jf 5fnfdf kmf]sfx? cfPdf .
 Immediate essential new born care -
gjhft lzz' hlGdg] ljlQs} ul/g] cTofjZos
:ofxf/x?_ : o; cGt{ut lgDg % j6f sfo{x?
kb{5g .
!_ g/d, ;kmf / ;'Vvf sk8fn] k'5\g' kb{5 / .
(Dry, stimulate and wrap the baby)
@_ gfeL nfO{ sterile wfuf] jf cord clamp n] afwLF
sterile cf}hf/n] sf6\g] .
Page | 54
• ;fdfGotof % b]lv !) leqdf gfle ´g]{ ub{5 .
(5-8 days or 7-10 days also mentioned
in various sources)
• Cord clamp ug{ cl3 ev{/} hGd]sf] aRrfnfO{
sk8f n] a]l/ tray df /flv cfdfsf] @ v'§fsf]
aLrdf /fVg'kb{5 . (should be placed lower
level than uterus). o;f] ubf{ gravity n]
placenta / cord df ePsf] /ut fetus lt/
hfg ;xh x'G5 .
#_ lzz'sf] ;Dk'0f{ zl//nfO{ ;kmf sk8fn] a]/]/
cfdfsf] 5ftLdf Gofgf] kf/]/ /fVg'kb{5 .
$_ hjhft lzz'nfO{ hGd]sf] ! 306fleq cfdf sf]
b'w r';fpg]
%_ lzz'nfO{ hGd]sf] @$ 306f leq g'xfpg' x'b}g .
 gjlzz'sf] k|f/lDes :ofxf/ (Initial care) :
o;cGt{t lgDg s'/fx? kb{5g .
!= lzz'nfO{ Stimulation ug]{ M ;kmf, ;'Vvf
sk8fn] aRrfsf] lk7\o' d';fg]{ .
@= Zjf;gnLaf6 >fj lgsfNg] (Suction)
• /ut / >fj (mucus) nfO{ ;kmf sk8f jf
gauge n] k'5\g] .
• lzz'n] lb;f (Meconium) lgn]sf] eP
suction ug]{ .
Neonatal Resuscitation
 hGdbf lg;fl;Psf] lzz'nfO{ Neonatal
resuscitation sf] cfjZos x'G5 . tnsf dWo]
s'g} klg Pp6f cj:yf ePdf lzz' lg;fl;Psf]
dflgG5 .
s_ hGdbf g/f]Psf] jf ;f; gkm]/]sf]
v_ l3l6Ss l3l6Ss ;f; km]/]sf] (gasping) :
Zjf;k|Zjf;b/ ult #) ldg]6 k|lt ldg]6 jf ;f] eGbf
sd ePsf] gjlzz' .
 Steps of Newborn Resuscitation
1. Immediate Essential Newborn Care
(hlGdg] lalQs} ul/g] cTofjZos :ofxf/x?_
+ (Common causes of neonatal
2. Initial Care -gjlzz'sf] k|f/lDes :ofxf/_
+ A. Globally :
3. Ventilation -s[lqd Zjf; lbg] tl/sf_
 tflnd k|fKt :jf:YosdL{n] dfq Neonatal
resuscitation ug{'kb{5 .
Eight steps of immediate new born care:
Step 1: Dry, stimulate and wrap the baby.
Step 2: Assess the baby’s breathing and
color
DN Bhatta Midwifery (MCH)
Step 3 : Decide the baby need
resuscitation.(breathing<30/min or
gasping)
Step 4: Tie and cut the cord, take birth
weight, note APGAR score, record sex
and time of birth.
Step 5: Place the baby in skin to skin
contact with the women.
Step 6: Start breastfeeding within one
hour of birth.
Step 7: Give eye care within one
hour of birth.
Step 8 : Explain both normal and abnormal
findings to the mother
 Tie the first one 3 cm away from the
baby’s abdomen and second tie 5cm
away from the baby’s abdomen and cut
the cord between two ties.
 Do not put anything on the curd stump
except NAAVI MALAM (4%
chlorhexidin ointment)
 Use silver nitrate 1% solution or
tetracycline 1% ointment for eye care.
 Do not bath baby for first 24 hours.
 Post-natal visit (PNC)
• First visit : within 24 hour of
delivery (at health facility before
discharge)
• Second visit : on day 3 (48-72
hours)
[At mother’s home]
• Third Visit : 7 days (7-14 days)
[At mother’s home]
• Fourth Visit : 42 days. (6 weeks)
[At Health facility or vaccination
center, with DPT]
 gjhft lzz' d[To' x'g'sf sf/0f x? :
mortality)
• Preterm Birth (28%)
• Severe infections (26%)
• Asphyxia (23%)
• Neonatal tetanus (7%)
B. In Nepal
• NDHS 2006 : Infection (39%)
• NDHS 2016 - Respiratory &
cardiovascular disorder (31%)
Page | 55
Physical examination of Newborn Infant
 Term baby eGGffn] #& xKtf k'/f ePb]lv b]lv
$@ xKtf leq hGd]sf] aRrfnfO{ elgG5 .
 New born baby sf] normal weight 2.5 b]lv
3 kg x'G5 .
• <2500 gm : low birth weight
• <1500 gm : very LBW.
• <1000 gm : extremely LBW
 Length of new born baby : 50 cm
 The newborn baby should cry
immediately after birth and quickly
adapts to the changed environment.
1. Examination of Vital signs :
 Temperature : Recorded from axillary,
rectal or oral.
 Respiration : 30-60 breaths/min
 Pulse/heart rate :
• 100-160 beats/min (Sources : DC
Dutt's textbook of obstetrics/Standard
treatment protocol, 2078 Nepal, CBIMNCI
Guideline 2078)
• 120-140/min, (Source : Nelson's
textbook of Pediatric)
 Blood pressure : 45-60/25-40 mm of
Hg.
2. Examination of Skin
 It is the single Most important
parameter of cardiovascular
function.
 Normal Color : Pink
 Pallor : /QmcNktf, lg;fl:;g', ;F3ft cflb
sf/0f n] lzz'df pallor b]lvg ;S5 .
 Cyanosis : 5fnf / Do's; l´NnL lgnf] x'b}
hfg' nfO{ Cyanosis elgG5 . Reduced
hemoglobin sf] dfqf 3-5 gm/dl eGbf al9
x'bf ;fdfGotof Cyanosis b]lvG5 .
 Jaundice : Bilirubin sf] dfqf /utdf 5mg
/dl eGbf al9 ePdf ;fdfGotof Jaundice bvf
kb{5 .
 Vernix caseosa : Waxy white
substance found on the skin of
newborn babies. This forms around 21
weeks of gestation.
 Lanugo : At 16th weeks, downy, thin,
soft, colorless hair appears, which
almost disappears at term.
DN Bhatta Midwifery (MCH)
 Milia : Seen in nose, cheeks & forehead
due to plugged sweat glands. -3df}/f h:t}
b]lvg]_
 Mongolian spot : Bluish spot, seen
commonly in back, buttocks or thigh.
Disappears by 4 years of age.
 Erythema toxicum : Papular lesions
with erythromatous base seen after 48
hours of birth. Resolves spontaneously.
 Diaper rash : It is a form of irritant
contact dermatitis, usually the skinfolds
are involved.
3. Examination of the Head :
 Head circumference : 34 cm
 Chest circumference : 32 cm
 At birth : HC>CC
 At 12 months (6-9 months) : HC=CC
 After 12 months = CC>HC
 Large fontanels: Hypothyroidism,
Down’s syndrome
 Small fontanels : Hyperthyroidism
 Bulging fontanels : Meningitis,
Increased ICP, Hydrocephalus
 Depressed fontanels : Dehydration
 Molding : Seen in prolonged labor,
subsides within 5 days.
 Caput succedaneum : Formation of
swelling due to accumulation of fluid in
scalp, not limited by suture. Appears at
birth. Caput disappears within 24
hours.
 Cephalhematoma : Collection of blood
between the bones, usually due to
forcep delivery.It is not develops at
birth but develops after 12-24 hour, the
swelling is limited. The
cephalhematoma may disappear after
6-8 weeks.
4. Examination of Chest :
 Any asymmetry , tachypnoea, grunting,
Breath sounds etc
 The newborn’s breast may be enlarged
due to maternal oestrogen. (Normal 1
cm in diameter)
 The white discharge from infant’s breast
is known as “Witch milk”.
5. Examination of Abdomen :
Page | 56
 Look for hepatomegaly (Sepsis),  v'§fsf] k}tnfdf (Plantar surface df_ s'g}
Spleenomegaly (Rubella, CMV infection) xNsf ltvf] j:t'n] k5f8L b]lv cuf8L sf]bf{
 Omphalocele (Liver & Intestine remains v'§fsf] cf}nfx? Pscfk;af6 separate x'b}
outside of abdomen) (fanning out) a'l9 cf}nfsf] extention x'g' -
 Umbilicus for any redness, discharge or toes up_ nfO{ Babinski reflex elgG5 .
infection.  of] normal Planter reflex sf] l7s pN6f] xf] .
 A greenish yellowish cord suggest  Infant df of] normal xf] eg] adult df
meconium aspiration. (fetal distress) pathological x'G5 . adult df of] sign n]
upper motor neuron damage sf] ;+s]t
 Genitalia : ub{5 .
• Male : Size of penis (Normal>2cm), 7. Planter reflex : v'§fsf] k}tnfdf (Plantar
testes within scrotum, Hydrocele, surface df_ s'g} xNsf ltvf] j:t'n] k5f8L b]lv
• Female : enlargement of clitoris, cuf8L sf]bf{ v'§fsf] cf}nfx? Pscfk;af6 separate
blood stained vaginal discharge. ge} cf}nfx? e'Olt/ kmls{g' (Toes down).
(due to maternal oestrogen 8. Tonic neck reflex : olb aRrfsf] 6fpsf] nfO{
withdrawal) bfFof jf afofF k§L kmsf{pbf, 6fpsf] kms]{sf] side sf]
 Rectum and anus : arms & leg sf] extension x'G5 eg] csf]{ k§Lsf]
• Checked for any imperforation and arm & leg sf] flexion x'G5 . o;nfO{ Fencing
position. reflex klg elgG5 .
• Stool & Urine :
A. Urine : Pass by 24 hours after APGAR Score
birth. (Ghai Essential Pediatrics)  Used for rapid assessment of new born
B. Stool (meconium) : Passed baby.
within 24 hours after birth.  Components of APGAR score
(Reference : A textbook of Child health APGAR Score
Nursing, Kamala Uprety,First edition, Signs 0 1 2
2018, page 59) - Best Answer for Appearance Blue, Body pink, Complete
PSC (color) pale extremities pink
• First urine & stool should be blue
passed within 48 hours, if not Pulse Absent Below 100 Above
occurs further investigation needed (Heart 100
rate)
Grimace No Grimace Cry/
Neonatal reflexes (reflex) response cough or
1. Rooting reflex : d'vsf] 5]plt/ cf}nfn] sneeze
la:tf/} rnfpbf aRrf 5f]Psf] lb;ftkm{ kmls{G5 / Activity Flaccid Some Active
(Muscle Flexion of flexion of
d'v v'nfp5 . tone) extremities extremitis
2. Glabellar reflex : aRRffsf] lgwf/df cf}nfn] Respiration Absent Slow, Good
lj:tf/} lyRbf aRrfn] cfFvf aGb ub{5 . irregular crying
3. Grasp reflex : aRrfsf] xTs]nfdf s'g} s'/f -
h:t} M cf}Fnf_ /fVbf ;dfTg vf]H5 .  APGAR score aRrf hGd]sf] ! ldg]6 / %
4. Moro reflex : ldg]6df lng'kb{5
 aRrfsf] 6fpsf] nfO{ lj:tf/} dfly p7fP/ 5f]8\bf  o;sf] Go'gtd c+s (minimum score) ‘0’ x'G5
aRrfn] xft v'§fx? PSsf;L k5f8L n}hfG5 . eg] clwstd c+s (Maximum score) ‘10’
 Extension of extremities due to CNS.
x'G5
 Startle reflex is also known as
 Most important component of APGAR :
moro reflex. Pulse (heart rate)
5. Sucking and swallowing reflex : aRrfsf]  Total score : 10
d'vleq s'g} s'/f h:t} Nipple /fv]df p;n] To;nfO{  No depression : 8-10
r':g yfN5 / d'vdf b'w el/Pdf lgNg] ub{5 .  Mild depression : 5-7
6. Babinski reflex :  Moderate depression : 3-4
 Severe depression : 0-2

DN Bhatta Midwifery (MCH) Page | 57

 Growth and development
1. Prenatal periods :
• Ovum : 0-2 weeks (0-14 days)
• Embryo : 2-8 weeks
• Fetus : 9 weeks to birth
2. Perinatal periods :
• 22 weeks of gestation to 7 days after
birth
3. Postnatal periods :
• Neonate : first 4 weeks (up to 28 days)
• Infant : less than 1 year
• Toddler : 1-3 years
• Pre-school : 1-4 years (Source : K. park
PSM 24th edt. Page 566)
• School children : 5-15 years
• Childhood : 1-15 years
• Adolescenets : 10-19 years -
lszf]/fj:yf_
 Preterm baby : uef{j:yfsf] #& xKtf k'/f
x'g'eGbf cuf8L hGd]sf] aRrf (Before 259
days)
 Full term baby : uef{j:yfsf] #& xKtf
k'/fePkl5 t/ $@ xKtf k'/f x'g'eGbf cuf8L
hGd]sf] aRrf (Born between 259-293 days
of gestation)
 Post- term baby : uef{j:yfsf] $@ xKtf k'/f
ePkl5 hGd]sf] aRrf (After 294 days)
 Normal birth weight : 2.5-3 kg
 Low birth weight (LBW) : hGdbfsf] tf}n
@%)) u|fd eGbf sd ePsf
 Very low birth weight : hGdbfsf] tf}n !%))
u|fd eGbf sd ePsf] .
 Extremely Low birth weight : hGdbfsf]
tf}n !))) u|ffd eGbf sd ePsf] .
Weight for age
 Weight is the best single parameter to
assess the physical growth.
 aRRffsf] hGdbfsf] cf}ift tf}n 2.5 to 3 kg x'G5 .
 Weight initially decreases but regains
after 7-10 dayss.
 aRRffsf] tf}n % dlxgfdf bf]Aa/ x'G5 eg] !@
dlxgf df # u'0ffn] / @$ dlxgfdf $ u'0ffn] j[l4
x'G5 .
 “Road to health chart” sf] k|of]u aRrfsf]
j[l4 cg'udg(Growth monitoring) sf nflu
k|of]u ul/G5 .
 Road to health chart was first designed
by David morley and later modified by
WHO.
DN Bhatta Midwifery (MCH)
 Growth chart df aRrfsf] pd]/ cg';f/sf] tf}n
/]s8{ ul/G5 .
 Community level df aRrfx?sf] tf}n gfKg
salter’s scale sf] k|of]u ul/G5 .
 kxlnf] Ps aif{df aRrfsf] j[l4 (growth)
;a}eGbf al9 x'G5 eg] klxnf] @ jif{df sl/a *)
k|ltzt dlit:s sf] ljsf; x'G5
 Increase of weight in children :
• 0-3 months : 200 gm per week
• 4-6 month : 150 gm per week
• 7-9 months : 100 gm per week
• 10-12 months : 50-75 gm per week
• 1-2 year : 2.5 kg per year
• 3-5 year 2.0 kg per year
Height (Length) for age
 aRrf hlGdg] a]]nfsf] nDafO{ sl/a %) ;]=dL
x'G5 .
 $ aif{df aRrfsf] prfO{ bf]Aa/ x'G5 .
 klxnf] % aif{df aRrfsf] prfO{ lgDgcg';f/ j[l4
x'G5 .
• First year : 25 cm/year
• Second year : 12 cm/year
• Third year : 9 cm/year
• Fourth year : 7 cm/year
• Fifth year : 6 cm/year
 Lenghth of baby <2 year is measured
by : Infantometer
 Height of the baby >2 years is
measured by : Stadiometer
Head and chest circumference
 At birth head circumference(HC) is about
34 cm and chest circumference (CC) is 2
cm less than head circumference (i.e 32
cm). [HC>CC]
 HC & CC becomes equals at 1 years.
References :
: 1) : A textbook of Child health Nursing,
Kamala Uprety,First edition, 2018, page 59
2)Dr. Y.R Bhattarai, Quick review of HEALTH
SCIENCE, 7th Edition (2016), page 294,
Samikshya Publication
 At 6-9 months, HC=CC, according to
K.Park, Preventive and social medicine)
Page | 58
 MUAC (Mid Upper Arm Circumference)
 Measured by Shakir’s tape
Color MUAC sf] gfk kf]if0fsf]
cj:yf
/ftf] <115 mm (<11.5cm) SAM
kx]nf] ≥115 mm to <125 MAM
cm
xl/of] ≥125 mm (≥12.5cm) Normal
Developmental Milestones
 1 month : Alert to sound, turn head to
sound, strong grasping
 2 month : Social smile
 3 months : Neck holding, recognize
mother
 5-6 month : sitting with supports,
Mono-Syllables (ma, ma)
 8 months : Sitting without support
 9 months : stand with support
 9 months : starts crawling -afd] ;5{_,
waves (Bye-Bye), Bi-syallables (mama)
 10 Months : Standing without support
 12 months : walking with support.
 13 months : walking without support,
two words with meaning.
 15-18 months : Runs
 36 months : Rides tricycles, Knows
his/her gender
Better to Know !!
 Most common cause of uterine
inversion is : Mismanagement of
third stage of labour.
 Most common cause of postpartum
shock (After delivery) : PPH
 aRrfsf] hGd ePsf] #) ldg]6 ;Dd klg
placenta delivery ePg eg] To;nfO{
'Retained Placenta' elgG5 . (WHO,
>15 minute)
 When fetus frequently changed lie &
presentation even after 36 weeks of
pregnancy is called : Unstable lie
 Diabetic mother may give birth to :
Big baby
 Baby Friendly Hospital Initiatives
(BFHI) created and promoted by
WHO & UNICEF in 1991.
DN Bhatta Midwifery (MCH)
 The main focus of Baby friendly
hospital initiative is “To promote
breastfeeding”
 g]kfndf ;g !(($ af6 BFHI sfo{qmd sf]
;'?jft ePsf] lyof] .
 There are Ten steps of successful
breastfeeding.
 Rooming in : Keeping the baby by the
side of the mother.-rf}la;} 306f cfdf /
aRrfnfO{ ;Fu;Fu} /fVg'_
 Breastfeeding nfO{ infant feeding sf]
gold standard dflgG5 .
 The most common organism causing
diarrhea in infants and children :Rota
virus
 gjhft lzz'df @$ 306fkl5
Physiological jaundice b]vf kb{5, rf}yf]
/ kfFrf} lbgdf ;a}eGbf al9 Jaundice
b]lvG5 eg] *–!) lbg kl5 x/fP/ hfG5 .
 aRrfn] hGd]sf] t];|f] / rf}yf] lbgdf u/]sf]
lb;fnfO{ Transitional stool elgG5 .
 ;fdfGotof aRrfx?df :tgkfg u/fO{;s]kl5
af8'NsL (hiccup) nfUg] ub{5, Stomach
el/Pkl5 o;n] Diaphragm nfO{ irritation
u/fp5 / af8'NsL nfU5 .
 Prolonged labour is duration of :
First + Second stage : ≥12 hours
[IMPAC], >18 hours [DC Dutta]
 SBA core skills contains : 27 skills
Page | 59