Deputy Provost MCH

CONCEPT OF MCH/FAMILY HEALTH / REPRODUCTIVE HEALTH and
Menopause end of female reproductive act occene between aged 45-52 can be as early as 42 mean age is
51
It is a normal part of aging
Means ceseasblcovaring are no loyer active changes in the ant & extrepredict organs.
Multifected changes-these chagedanmeuro-endocnnologis, biochemical &metaboilice alteration related
to aging.
S/S
- Ceseasation of means
Nursing managent
- Health education – processes involved means that associated problem to relieve anxiety
- Psychotherapy – Discuses sexuality & sexual
- Physical theory – functions
(1) Kegel exercise
(1) Sexual relationship
II. Atropicvapnallteling can be corrected
(I) Harmonel cream
(II) Hyspence
(III) Avoid chemical imitation
Dyspaunnis – prevent dyness, ask k-yselly
- Alert decrease penal muscle torely exercise 5-10 secs.
- Use emollient cream, lotion to prevent by skin, orinkles,
- Avert ostioporosil – calcium, vit E&D
- Avoid smoking Alcohol, calterisepromotvenphtbeaing exercise under physcologis
- Dinks 6-8 glasses of H2O, take Vit C
- Prevent ST.I. ble of ahopicsente
- Reportancy bleeding afferllyr of meno
-
Medical RX
Use-water soluble lubikant key vaginal cream contingestrosenHomoralreplacenttherepy
Cause of Abdominal pain

Physiological-pregnant specific cause
PAGE \* MERGEFORMAT 35
Round hgament pain
Practon Hick contraction
Sever uterminetorswin
Pathological pains
Ectopic pregnancy
Miscarriage
U.T.I
Preterm labour
Placenta abruption
Severe PET.
Uterine nepture
incidental cause
Heart burns
Excessive vomiting
Constipation
Pathological causes
Appendicitis - Torsion of the ovary
Malignant dx - Rectal haematoma
Bowel obstruction - Sickle cell crisis
Cholecystitil
Reral dx
Acute pancretitis
general topics
a. What is urinary incontinence

b. Categorize urinary incontinence under the following quid line
 Types; 5types
 Description
 Pathology
 Contributory factors
c. Vividly outline the general nursing care for pt with incontinence
ANSWERS
a) DESCRIPTION OF PROSTATE GLAND
Definition: It is an accessory organ of male reproductive system
Location: Its located in the pelvic cavity in front of the rectum, behind the symphisis pubis
encircling the prostatic urethra
Shape/Size : It is wall nut shape and measures 4cm long, 3cm wide and 2cm deep
Structures : Three layers of prostate gland

 Outer fibrous tissue
 A middle layer of smooth muscle
 Glandular substance comprising of columnar epithelial cells
Secretion/Function
It secretes a thin milky fluid that make up about 30% of the semen which give semen milky
colourappearance.
The semen serves as lubricant during sexual intercourse and protects sperm cells
Blood Supply
Arterial
 Inferior vesical artery
 Middle rectal artery
 Inferior pudental artery.
Venous
 Corresponding veins
Lymphatic drainange
 Vesico prostate plexus draining into internal iliac vein
Nerve Supply
 Sympathetic and parasympathetic nerve
b) WHAT IS URINARY INCONTINENCE

ANSWER
Urine escape not under the control of wills any condition causing increate bladder pressure in
lower method resistance can cause incontinence 1.e. pelvic fooor muscle relaxation, impaired
neuron and bladder problem are common contributory factor.
c) CATEGORIZED URINARY INCONTINENCE UNDER THE FOLLOWING
GUIDELINES:
 Types
 Description
 Pathology
 Contributory factors
ANSWERS
Types:Stress Incontinence.
Description:loss of small amount of urine when intra-abdominal pressure increases (sneezing)
laughing, coughing and lifiting.
Pathology:pelvic muscle relaxation, weakness of Urethra and surrounding tissue and decrease
Urethral resistance.
Contributory factor: multiple pregnancy, decrease lestrogalens(metro pains and andro pains
prostate surgery.
ANSWER
Description: Inability to get to toilet facilities to urinate.
Pathology:Self care deficit, with inability to respond to urge to void.
Contributory factor: physical disability, neurological disorders. Diuretic therapy, or sedative,
lack of facility to privacy or care gives assistance.
d) GENERAL NURSING CARE FOR A PT WITH INCONTINENCE
ANSWERS
i. Comprehensive Nursing Assessment;
Physical examination and history taking;
ii. Planning and implementation schedule toiletering
iii. Bladder training, prompted voiding
iv. Combined with practice can reduce the need for diaper, incontinence pad etc.
QUESTION 2
Write briefly on the following
a. Scabies
b. Onchocerciasis
c. Cholera
d. Pertusis (whooping cough)
ONCHOCERCIASIS
Onchocerciasis also known as river blindness is a parasitic disease or infection transmitted through the
bite of a black fly.
Or
Onchocerciasis is a parasitic infection, otherwise known as Ruble’s disease characterize by reduced
visual acuity and blindness.
Causes:
Onchocerciasis is caused by a filarial worm called onchorcerca volvulus.
Incubation period:
3 – 24 months (Range in between is acceptable).
Signs and symptoms:
a. Skin involvement may include:
- Intense itching
- Rashes
- Hyper pigmentation
- Nodules
- Atrophy (loss of elasticity).
b. Occular involvement
- Conjunctivitis
- Atrophy of the eyelids and optic nerve.
- Sub conjunctiva hemorrhage
- Gradual sight loss
- Corneal opacity
c. Others
- Apnoea
- Seizures
- General body malaise.
- Lymphadenopathy
- Fever
- Anorexia
- Bradycardia
Treatment:
- Ivermectin (Mect 1 zan) 2 doses six month apart, repeat every 3 years.
- Antibiotics – Doxcycline used to kill the Wolbachia bacteria.
Prevention:
- Health education on causes
- Personal protective measures against biting insects e.g. wearing insects-repellant on exposed
skin, wearing long sleeves during the day.
- Use of larvicide spray on fast flowing rivers and streams to control black fly population.
- Use of ivermectin to treat infected people.
- Use of insecticide treated nets against flies.
PERTUSIS (WHOOPING COUGH)

Definition:
Pertusis also known as whooping cough is a highly contagious bacterial disease affecting infants and
smaller children.
CAUSE:
It is caused by Bordetellapertusis.
Incubation Period:
7 – 21 days (Range in between in acceptable).
Signs and Symptoms:
- Paroxysmal cough (successive cough)
- Inspiratory whoop
- Coryza
- Vomiting after coughing
- Fever
- Dehydration
- Sinusitis
- Sub conjunctiva hemorrhage.
Treatment:
- Antibiotic e.g. Erythromycin, chloramphenicol as may be prescribed.
- Fluid replacement
- If apnoenic give oxygen
- Trimethoprin – sulfamethaxazole may be used in those with allergies to erythromycin.
Prevention:
Immunization with DPT given at:
- 6 weeks, 10 weeks and 14 weeks respectively.
- Early diagnosis, isolating and treatment of infected cases.
- Prophylactic antibiotic are frequently used in those who have been exposed but without
symptoms
Cholera
Definition:
Cholera is an acute faeco-oral infectious disease of the gestro intestinal tract.
Causes:
It is caused by vibrio cholera (bacteria).
Incubation period:
Few hours – 5 days.
Signs and Symptoms:
- Painless diarrhea ( rice water stool)
- Vomiting of clear fluid.
- Dehydration.
- Tachycardia (rapid pulse)
- Abdominal cramps
- Poor skin tugor (dry skin)
- Dry mouth, mucus membrane.
- Excessive thirst (polydipsia)
- Sunken eyes/fontanels in infants.
- Lethargy.
- Low urine output.
- Low blood pressure.
- Cold and clammy skin.
Treatment:
- Oral rehydration therapy.
- Intravenous fluid (e.g. ringers lactate.)
- Antibiotics e.g. Doxycycline, Cotrimoxazole, Erythromycin and Tetracycline.
Prevention:
- Health education on god personal hygiene, water purification, sterilization, proper sewage
disposal.
- Cholera vaccines.
- Surveillance and prompt reporting of the incidence for the prevention of epidemic occurrence.
RABIES
Definition:
Rabies is a viral dieses, transmitted from rabid animal to man e.g. dog.
Cause:
It is caused by Rabies virus.
Incubation Period:
2 weeks – 3 month, rarely, it may exceed to 6 months.
Signs and symptoms:
- Painful wound with tingling sensation.
- Sensitivity to voices and violent movement.
- Excitability.
- Malaise
- Fever
- Aerophobia
- Hydrophobia
- Excessive salivation
- Forceful laryngeal spasm during swallowing.
- Paralysis of the limbs.
- Coma.
- Photophobia.
Treatments:
- Wash wound with soap and water.
- Virucidal antiseptic e.g. idodine tincture.
- Do not stitch wound.
- Give first doze of rabies vaccines at the abdominal wall as soon as possible after exposure
with additional dozes on day three, seven and fourteen.
Prevention:
- Avoid contact with animal you do not know.
- Get vaccinated if you are at risk.
- Ensure pets receive proper immunization.
- Keep pets under supervision.
QUESTION 3
Briefly explain the following condition in a O/G setting to a junior nurse.
a) Definition
b) S/S
c) Management
d) Complications.
a) Recurrent abortion
b) Induced abortion
c) Septic abortion
d) Incomplete abortion
e) Spontaneous abortion
TYPES OF ABORTION
Incomplete Miscarriage:
Remain of placenta with the items contribution to bleeding that may be heavy and misoprostol
sublingual 1.m Pitocin may be given to control the loss.
Evacuation of the retained under general aesthesis once the pt is in a stable condition use
vacuum aspiration with blunt curretage.
Complete Abortion
Placents/membrane are expelled completely form the uterus. Bleeding stops and sins of
pregnancy regress.
Uterus is firmly contracted on palpath.
Mother should be support after the loss.
Silence/Delayed miscarriage
1. The embryo died despite the presence of a viable placents.
2. The stalk is retained 2CX is closed
3. Embryo dead usually occur before eight weeks but the mother does not usually
recognize it
4. Occasionally a less origination of placenta degeneration of the tissue may present 2
theatre miscarriage may be separated.
5. Woman report cesect of sign of pregnancy.
6. DSS is by USs.
7. Reaction may include postaplat or evacuation of the film.
Septic Abortion
It is mostly a complication of induced abortion or incomplete miscarriage due to ascertain
infection.
s/5
feeding of unwell, headache, N/V, pynsix localized infection or generalized septicearn
with pentoniturital.
Bld culture, V. Serab to identify mcs and intravenous antibodies.
Induced Aboriton
 Them at of pregnancy by 24 aks of getration.
 Reason for medially induced abortion.
Continuation of pregnancy will in more risk greater than if the pregnancy were terminated or
lying to the physical or mental headache of the pregnant woman and existing children of the
feeling.
Uterine Evacuation Method
Vacuum aspiration manual/electric sharp corretage.
Medication or pharmacology method.
Misfepristonceorins
Misoprostol 480m
Mifeprostom 1000meg orally inhibit
Misoprostol 480m taken with 24inhibit depending on the time the woman want the pregnancy to
be expelled.
Misoprostol causes repen of the cervix induce interior contraction
Assesment and Reaction plants
Light to moderate v. bleaching
Severe v. bleeding
Intra abdominal injury
Hx of delay menses craps lower abdplacents v. bleeding
Rapid initial assessment v/s
Early shock
Late shocks
Complete clinical assessment
Medical and surgical Hx
Psychological assessment
Physical assessment
Physical examination
Bi manual examination
QUESTION 4A
Describe the duties of the Public Health Nursing Officer in the industries
SUGGESTED ANSWER - Candidates are to explain these duties namely:-
1) Health Education - Carry out health education activities with respect to personal health hygiene
2) Administrative duties – preparation of work schedules, receiving patients, organizing special
clinics and services, ordering and maintaining medical supplies and equipment and supervising
subordinates.
3) Conducts health interviews and screening procedures e.g. Bp, Visual activity etc.
4) Conduct counseling of workers e.g. (psychological disorders) creates opportunities to discuss in
confidence, workers problems.
5) Supervise vulnerable groups (e.g. young persons, pregnant mothers, the elderly and those
disabled) and render appropriate advice to them.
6) Treat diseases ailments and accident within her professional competence recognize cases clearly
beyond her and refer them to appropriate clinics and specialized centres.
7) Organize and administer immunization programmes for workers and their dependencies
according to factory’s policy and national programme.
8) Keep health records , analyze and prepare reports for management
9) Establish and run Maternal and Child Health (MCH) services including family planning.
QUESTION ANSWER 4A
1. run nutritional programmes especially for the under-fives
2. Conduct Research Conduct simple research to establish priorities in health care and evaluate the
efficiency of health programme.
3. Rehabilitation of workers start at the line of injury and continues until recovery see to gradual
return to full employment, where possible, liase with Disablement resettlement officer and
rehabilitation centres
4. Participate in planning implementing medical measures to deal with disasters (e.g. fire, collapsed
building etc.)
QUESTION 4
VII. Treatment of minor injuries and First Aid Services
VIII. Rehabilitation
IX. Liaison with outside medical agency
X. Planning against major disaster
XI. Research
XII. Development and maintenance of medical records
XIII. Treatment and care of dependants
XIV. Proper implementation of the services.
QUESTION 4B QUESTION ANSWER 4B
a) Define the term Occupational Diseases.
SUGGESTED ANSWER
Candidates to answer as follows:-
Occupational diseases associated with particular process or agents the worker is exposed to in the
course of work. Any other suitable definition is accepted
SCORING : 5 marks
b) List ten (10) Notifiable disease
SUGGESTED ANSWER
Candidates to list the following:
 Anthrax
 Silicosis
 Tuberculosis
 Brucellosis
 Mercury poisoning
 Phosphorous poisoning
 Benzene poisoning
 Ankylostomiasis
 Chronic ulceration of the skin. OR Any other relevant Notifiable diseases
QUESTION 4C describe factors that may affect workers health.
SUGGESTED ANSWER
 Poor working condition poor remuneration of the workers may affect the
productivity of the worker and may also lead to some emotional tensions
 The physical environment of work site. The physical environment may be full of
noise, heat, cold, dust, slippery floor, poor safety devices on, machine.
QUESTION 5
(a) Describe some of the environmental health problems that are likely to be found in an industrial
area.
SUGGESTED ANSWER
Candidate to describe the following
1. Air, Water and soil pollution
2. Rise and slums
3. Refuse disposal problems
4. Housing problems (overcrowding)
5. Sewage disposal problems
6. Inadequate ventilation
7. Malnutrition problem e.g. Malnutrition
8. Increase in crime rate
9. Water borne disease
10. Increase in communicable disease
11. Social problems e.g. cultism, alcoholism, drug addiction
12. Water shortage
13. Mental Health Problems.
(b) What measures would you take to improve the environmental sanitation of an industrial area?
SUGGESTED ANSWER
1. Provision of safe adequate supply of water
2. Provision of good housing
3. Proper disposal of wastes
4. Safe guarding of food
5. Proper health counseling
6. Health education
7. Prevention of atmosphere pollution
8. Elimination of hazards, noise, radiation.
9. Control of insect vectors and pests
10. Control of animal reservoirs of infection
SCORING: I mark for any ten (10) points mentioned. 10 marks. Any other correct points
mentioned should be accepted.
QUESTION 6
(a) Identify three (3) basic laws that regulate health and safety of workers in an industry. (3 marks).
SUGGESTED ANSWER: -Candidate to describe the follows: -

i. Labour Laws
ii. Factory Laws
iii. Workman compensation Laws.
(b) Discuss the operation of each of the Laws mentioned in 4(a) above and their benefits to workers. (
SUGGESTED ANSWER
i. Description
According to the workmen compensation Decree 1987, “a person shall be deemed a
workman if before or after 1987 he has entered into or is working under a contract or an
apprentice with an employer whether by way of manual labour, elerical work or otherwise.
ii. Labour Laws (Labour code ordinance of 1945)

The ordinance reviewed in 1987, into Labour Laws.
Labour Laws prescribe minimum age at employment, age at retirement, and instituted
maternity leave for married women. It also determine the wages paid.
iii. Factory Law (Factory’s Act 1955, revised in 1985

These are laws put in place by a decree in 1987 relating to the Health, Safety and Welfare
of the factory workers. Areas covered under Health include:
 Adequate lighting, ventilation and provision of sanitary conveniences

 Areas of safety covered include
 Safety of powered machine
 Safety rules for the use of cranes and other lifting machine
 Safety means of access and safe places of employment while the welfare area
covered include.
 Supply of drinking water at work
 Washing facilities
 Accommodation for clothing
 Provision of protective wears
iv. Workman compensation law recommends that employer of Labour must provide
adequate facilities to prevent occupation diseases and accidents amongst workers. The
employer should be ready to pay compensation to the worker or his or her relative in the
event of an accident or disability or death. Compensation is graded according to the degree
of disability and the period the worker is incapacitated, it also depends on medical advice
of the medical assessors appointed. Employer must report the death of the workman to the
labour officer within 70 days.
 The nature of the work – The work may carry heavy responsibilities or it may be boring,
non-stimulating and rewarding.
 Lack of patronage of financial returns - Unviable business may lead to anxiety
 Lack of governments policies to safeguard the interest of the workers
 Lack of concern or sensitivity to workers problems by the management
QUESTION 7A
ENDOMETRIOSIS
This is an often painful disorder in which tissue that normally lines the inside of uterus
(endormetrium) grows outside uterus.
It can involve the ovaries, bowel or the tissue lining the pelvis. Rarely, endometrial tissue may spread
beyond pelvic region. Displaced endometrial tissue continues to act as it normally would – it thickens,
breaks down and bleeds with each menstrual cycle.
Because this displaced tissue has no way of exit, it becomes trapped. When endometriosis
involves the ovaries, cysts called endometriomas may form, surrounding tissue can become irritated,
eventually developing scar tissue and adhesions – abnormal that binds organs together.
Symptoms:
- Endometriosis can cause pain (sometimes severe) especially during period.
- Fertility problems may develop.
Signs and symptoms of endometriosis:

- The primary symptoms is pelvic pain, often associated with menstrual period (dysmenorrheal)
- Pain with intercourse
- Pain with bowel movement or urination.
- Excessive bleeding (menorrhagia) heavy period or bleeding between period
(menometrorrhagia)
- Infertility.
- Other are: fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual
periods.
- Endometrisis can be mild or advance.
Causes:
Although the exact cause of endometriosis is not certain, several possible explanations include:
1. Retrograde menstruation – menstrual blood containing endometrial cells flows back through the
fallopian tubes and into the pelvic cavity instead of out of the body. These displaced endometrial
cells sticks to the pelvis walls and surfaces of pelvic organs where they grow and continue to
thickens and bleed over the course of each menstrual cycle.
2. Embryonic cell growth. When one or more small areas of the abdominal lining turn into
endometrial tissue, endometriosis can develop.
3. Surgical scar implanation – after a surgery, such as hysterectomy endometrial cells may attach to
a surgical incision.
4. Endometrial cells transport – the blood vessels or tissue fluid (lymphatic) system may transport
endometrial cells to other parts of the body.
5. Immune system disorder – it’s possible that a problem with the immune system may make the
body unable to recognize and destroy endometrial tissue that’s growing outside the uterus.
Treatments of endometriosis:
- Pain reliever such as nonsteroidal anti-inflammatory drug to relief abdominal cramb.
- Hormone therapy – hormone medication may slow the growth and prevent new implant of
endometrial tissue e.g. hormonal contraceptives, gonadotropin – releasing hormone (Gn-RH)
agonist and antagonist (create artificial menopause) small dose of estrogen and progesterone
can be taken to reduce the side effect of menopause, depo-provera and damazol can also be
used as hormone medication.
- Conservative surgery – this can be done through laparoscopic surgery through small incisions.
- In vitro fertilization to help become pregnant
- Hysterectomy – in severe cases i.e. total hysterectomy
QUESTION 7B
ENDOMETRITIS
Endometritis is an inflammation of the endometrium due to acute or chronic infections.
Causes of endometritis:
Generally caused by infection, foreign bodies, bacteria, viruses or parasite. Infection that can cause
endometritis includes;
- Sexually transmitted infection (STIS) such as Chlamydia and gonorrhea
- Tuberculosis
- Infection resulting from the mix of normal vaginal bacterial in acute phase.
It may occur in the period immediately after child birth (puerperium), miscarriage or caesarean delivery.
After medical procedure that involves entering the uterus through the cervix (hysteroscopy, IUD
incertion, D&C).
Chronic endometritis is women with IUDs may be responsible for the contraceptive action.
Signs and symptoms of endometritis:
1. Abdominal swelling
2. Abnormal vaginal bleeding
3. Abnormal vaginal discharge
4. Constipation
5. Fever
6. Discomfort when having bowel movement
7. General feeling of sickness
8. Pain in the pelvis, lower abdominal area and rectal area.
Diagnosis:
- From signs and symptoms
- Abdominal, uterus and cervix showing signs of tenderness & discharge.
The following test can help to diagnose it

- Specimen from cervix for culture
- Endometrial biopsy
- Laparoscopy procedure
- Blood specimen for WBC and ESR
Complications of endometritis:
- Infertility
- Pelvis peritonitis
- Collection of pus or abscesses in the pelvis or uterus
- Septicemia
- Septic shock
Treatment:
Antibiotics – sexual partner should also be treated if STI is diagnosed serious cases may need bed rest
and intravenous fluids.
Preventions:
- Child birth and other gynecological procedure should be performed with sterile equipment
and techniques
- Prophylactic antibiotics before and after the procedure
- Endometritis caused by STIs can be reduced by:
- Practicing safe sex
- Early diagnosis and prompt complete treatment.
QUESTION 7
Write short notes on the following
1. Needle stick injury
2. Prevention of needle stick injury
3. Post Abortal care
4. Roles of a commonly psychiatric nurse
1. Needle stick injury

a. Explain your Nursing responsibilities to a tunier nurse that sustained needle stick injury
b. Outline prevention strategies that can be employed to prevent needle stick injury.
Needle stick injury QUESTION 1(A) ANSWER
 Allow wound to bleed freely (if it is bleedy)
 Wash with soap and running water
 Alert your Supervisor/Superior Office
 Identify source part
 Immediately report to designated personal facilty
 Document the incident
 GIT Pre and Post Exposure prophases (PED) with 2 hours if possible
 Evaluate injury immediately after 6 week, 3 months and 6 months.
 Conduct follow up in a six monthly basis
 Reassure the student.
2. Prevention of weedle stick injury

 Never carry out 2 assignment at a time that involves handling of sharps
 Employee training capacity building
 Adherence to recommended guild lines
 Effective disposal system
 Improved equipment design.
 Surveillance programme
3. Post Abortal care

It consist of series of medical/midivious care intervention design to manage the complication of
spontaneous and induced abortion.
The Aim of PAC is to reduce mat mobility and mortality, to improve women health and
reproduction health life.
PAC Consist of 5 Element
I. Rx of incomplete and unsaved abortion and its related complication. That are
potentiallylife threaten.
II. Counseling to identify and respond to woman emotional and physical health needs and
this concern.
III. Contraception and family planning services.
IV. To help woman prevent unwanted pregnancy provide birth spacing.
V. Reproduction and the health service that are preferably provided on side or via referred to
other assessable facilities in provide net work.
VI. Commonly and service provide partnership to prevent unwanted pregnancies and unsaved
abortion mobilize resources to help women to seek appropriately upholding parts right
PAC.
Principle That Support Patient Right
1. Value attitude, empathy and respect
2. Interact, communicate
3. Privacy and confidentially
4. Voluntary informs consent
4. Roles of a Commonuty Psychiatric Nurse

The Care of Mentally Challenged Patients
 They enhance continually of care in hospital inpatient and out patient
 They help in administration and supervision of drugs at home and at health centre
 They helps in assisting relations with problem in management and treatment by helping them to
prepare patient return to the community
 They assist in follow up and treatment where fail to attend day hospital or out patient clinic
appointment
 They act as link between the hospitals and the patient by assessing the need for possible re-
admission of the patient.
 They assist in the participation of naming therapartic group, such as social club, that provide
support after discharge.
 They provide consultation capacity to nurse not trained in psychiatry that are work, in the
community.
 They provide health education to the community.
 They serve as Liasing officer with possible involvement in the life and fixing of hostel.
½ marks for 10 = 5marks
Advantage of Community Psychiatry

 It brings health care closer to the people
 It prevents the occurrence of institutionalized neusosis
 Part recover very fast
 The environment is home like and conducing
 It covers a large number of population
 The relative are involved in the care of the part
 It makes reliabilities easy
 It is not too expensive
 It remove the stigma attached to hospitalization.
 It allows for freedom of interaction and brings some of belonging to the part
QUESTION 8
a. Describe step to step protocol of the male genital self- examination
b. Describe step to step female self- breast examination.
a. Step to Step Protocol For The Male Genital Self-Examination (MSGE)

 In a standing position, with one leg on the chair.
 Once undressed, hold your penis in your hand. Start by examining the head of the penis from the
urinary opening down to where it extends out a little just above the shaft.
 Inspect the entire head of the penis in a clockwise motion, notice any lumps and blisters which
may be reddish or fresh coloured. Some may look like pimples.
 Once you have examined the head of the penis, move down the shaft and look for the same signs
and symptons.
 At the base of the penis, try to separate your pubic hair with your fingers so you can get a good
look at the skin underneath. It may be sometimes difficult to see this part clearly, it may be
necessary to use mirror.
 Move down and place your index and middle finger underneath testicle and thumb on the top.
 Gently roll the testicle between fingers and thumb, check all sides of the right testicle and repeat
same for the left.
 Examine the testicle in a mirror while standing; look for unusual contour and swelling.
ECTOPIC PREGNANCY
The term ectopic pregnancy refers to any pregnancy occurring outside the uterine cavity. It occurs
in 1 in 100 pregnancies in the UK and accounted for 3% of pregnancy related death.
Pathology
The commonest site of extrauterine implantation is the uterine tube, usually in the ampullary region.
Ectopic implantation may also occure on the ovary, in the abdominal cavity or in the cervical canal.
Abdominal pregnancy may result from direct implantation of the conceptus or it may result from
extrusion of tubal pregnancy with secondary implantation in the peritoneal cavity.
As with normal pregnancy the conceptus produces hCG which maintains the corpus luteum and
the production of oestrogen and progesterone. This cause the uterus to enlarge and the endometrium to
undergo decidual change.
Trophoblastic cells invade the wall of the tube and erode into blood vessels of the mesosalpinx. This
process will continue until the pregnancy ruptures into the abdominal cavity or the broad ligaments or the
embryo dies, thus resulting in a tubal mole. Under these circumstances, absorption or tubal miscarriage
may occur. Expulsion of the embryo into the peritoneal cavity or partial miscarriage may also occur with
continuing episodes of bleeding from the tube. Vaginal bleeding occurs as a result of shedding of the
decidual lining of the endometrium and progesterone levels fall with the failing pregnancy.
Predisposing factors
- Previous history of ectopic pregnancy
- Congenital malformation
- Sterilization
- Pelvic inflammatory disease
- Scar from tubal surgery
- Sub-fertility
- IUCD – for pregnancies that occur despite the presence of the IUCD – uterine tumors –
smoking-recent in vitro fertilization
Clinical presentation
Acute presentation
The classical pattern of symptoms includes:
- Amenorrhea
- Lower abdominal pain – typically of sudden onset, starting on one side of the lower abdomen,
but rapidly becomes generalized as blood loss extends into the peritoneal cavity.
- Sub-diaphragmatic irritation by blood produces referred shoulder up pain and discomfort on
breathing.
- Vaginal bleeding
- There may be episodes of syncope (temporary loss of consciousness caused by low blood
pressure)
The findings on clinical examination

- Hypotension, tachycardia,
- Signs of peritonism including abdominal distension, guarding and rebound tenderness.
- On pelvic examination, the cervix is closed and acutely tender when moved (cervical
excitation) because of irritation of the pelvic peritoneum caused by the bleeding.
This bleeding of acute presentation occurs in no more than 25% of cases.

Subacute presentation
The majority of ectopic pregnancies present less acutely and some or all of the classic (generally known)
symptoms may be absent. Typically, there is;
- Amenorrhea or of an abnormally light last period followed by irregular vaginal bleeding and
abdominal pain.
- It may be possible to feel a mass in one fornix on vaginal examination.
Diagnosis
The commonest diagnosis to be made in error on clinical diagnosis is threatened or incomplete
miscarriage. It may also be confused with complications or ovarian cysts or acute salpingitis.
- Trnasvaginal ultrasound
- Laparoscopy
The above need to be used together to conform ectopic pregnancy.
Medical treatment
The use of methotrexate, an anti metabolite that transferes with the synthesis of DNA given IM as a
single dose of 1mg/kg body weight or 50mg/m2. Multiple dose regimes have higher success rates but are
associated with more side effects.
Weekly follow-up with serum HCG level is required. Success rates of up to 92% have been
reported but 5% of patents will require surgery for failed treatment. It can be considered as an alternative
to surgical treatment where the serum HCG is <2000IU/L and the ectopic <2cm with no fetal cardiac
activity seen.
Surgical treatment
Laparotomy or laparoscopy can be done whether the laparotomy or laparoscopy is used there are two
main options for surgical removal of the ectopic; partial salpingectomy (removal of part of the tube done
when tube is completely damaged) or salpingotomy (leaving the tube in place and removing the ectopic
through an incision in the wall of the tube).
Nursing management
- Upon arrival at the emergency room, place the woman flat in bed
- Ensure the appropriate physical needs are addressed and monitor for complication.
- Assess vital signs to establish to baseline data and subsequently to determine if the patient is
in shock.
- Maintain accurate intake and output chart. Adequate fluid volume at a functional level (urine
output at 30-60ml/hr).
- Monitor for presence and amount of vaginal bleeding, pain and abdominal distention which
indicate rupture and possible intra abdominalhaemorrage.
- Blood test (full blood count) to determine extent of blood loss.
- Diversional activities which aids in refocusing attention and enhancing coping
- Address emotional and psychological needs.
- Administer prescribed analgesics
ANTEPARTUM HAEMORRHAGE (APH)

Antepartum haemorrhage is the bleeding from the genital tract in late pregnancy after 24 weeks of
gestation and before the onset of labour.
Effect on fetus
- Fetal mortality and morbidity are increased
- Still birth or neonatal death may occur
- Premature placental separation and consequent hypoxial may result in severe neurological
damage in the baby.
Effects on the mother

- In severe bleeding, it may be accompanied by shock and disceminated intravascular
coagulation (DIC).
- The mother may die or be left with permanent ill health
Types of APH
1. Incidental bleeding – bleeding from local lesions of the genital tract: show cervicitis, trauma,
genital tumor, genital infection, haematuria, vasa preaviae.t.c.
2. Due to placental separation as a result of
- Placenta previa
- Placental absruption
PLACENTA PREAVIA
In this condition, the placenta is partially or wholly implanted in the lower uterine segment on either the
anterior or posterior wall.
Degree of placenta preavia
Type 1:- The majority of the placenta is in the upper uterine segment. Vaginal birth is possible. Blood
loss is usually mild. Mother and fetus remain In good condition.
Type 2:- The placenta is partially located in the lower segment near the internal OS (marginal placenta)
vaginal birth is possible, particularly if the placenta is anterior. Blood loss is moderate, although the
condition of the mother and fetus vary, fetal hypoxia is more likely to be present than maternal shock.
Type 3:- The placenta is located over the internal OS but not centrally. Bleeding is likely to be severe
particularly when the lower segment stretches and the cervix begins to efface and dilate in late
pregnancy. Vaginal birth is in appropriate because the placenta precedes the fetus.
Type 4:- The placenta is located centrally over the internal cervical OS and tottrentialhaemorrhage is
very likely. Caesarean section is essential in order to save the lives of the mother and baby.
Diagnosis
1. Painless bleeding from vaginal
2. Uterus not tender or tense
3. The presence of placenta prevea should be considered when the presenting part of the fetus is
above the pelvis and/or the lie is unstable.
4. Ultrasound scanning will confirm the existence of placenta praevia and establish its degree.
Characteristics of placenta praevia haemorrhage

- Some mothers may have small repeated blood loss at intervals throughout pregnancy whereas
others may have a sudden single episode of vaginal bleeding after the 20 th week. However,
severe haemorrhage occurs most frequently after 34th weeks.
- It is not associated with any particular type of activity and may occur at rest.
- The colour of the blood is bright red, denoting fresh bleeding
- The low placental location allows all of the lost blood to escape unimpeded and a retro
placental clot is not formed. For this reason pain is not feature of placenta praevia.
- Sign of shock in severe bleeding:- tachycardia, low BP, increase temperature, air hunger pale
colour, skin cold and moist. She may also lose consciousness.
Assessment
- Abdominal examination – find out if lie is oblique or transverse and fetal head may be high n
a primigravida near term.
- The midwife must not attempt to do a vaginal examination as this can worsen the situation.
- The amount of blood loss should be quantified
- Fetal condition should be assessed – to know if there is diminished or cessation of fetal
movement or excessive movement which denote distress. Ultrasound can also be used.
Management
The management of placenta traevia depends on;
- The amount of bleeding
- The condition of mother and fetus
- The location of the placenta
- The stage of the pregnancy
1. Conservative Management
This is appropriate if bleeding is slight and mother and fetus are well. The woman will be kept in
the hospital until the bleeding has stopped.
- A speculum examination would have ruled out incidental causes. Further bleeding is almost
inevitable is the placenta encroaches into the lower segment. Therefore it is usual to require
the woman to remain in or close to the hospital for the rest of the pregnancy.
- Placenta function is monitored by fetal kick chart. Laudiotocography (LTG), and ultrasound
scans.
- Psychological and social care
- Labour is likely to be indiced from 37 weeks gestation for type 1 and 2.
- The midwife should be aware that there is danger of post partumhaemorrhage. Living ligature
action is poor because of the small amount of oblique muscle fibres.
2. Active Management
Severe vaginal bleeding will necessitate immediate delivery by caesarean section regardless of the
location of the placenta. Type 3 and 4 is to be delivered with CS even if there is IUFD to save the
mother’s life.
- Care for the baby must be arranged for especially is preterm
- Pre and post partum management
- Blood transfusion
- Psychological care for other and relatives
Incidence
- It is high in multip with the parity
- Multigravidae 1 in 90 births
- Primigravida 1 in 250 births
- Common with women who smokes and woman with previous CS
- Women with previous history of placenta praevia
Complications
- Maternal shock
- Anesthetic surgical complication
- Placental accrete map to 15% of women with placenta praevia
- Air embolism
- Post partumhaemorrhage
- Maternal death
- Fetal hypoxia
Fetal death. Description of the skin

- The skin, glands, hairs and nails make up the integumentary system.
- It is the largest organ of the body, provides and external covering and separates the body organs
and tissues from external environment.
- It has a surface area of about 1.5 – 2m2 in adult and weight about 4kg
- It is composed of two layers viz epidermis and dermis.
- The epidermis is the outermost layer of the skin and varies in thickness in different parts of the
body.
- It is thickest on the palms of the hands and soles of the feet, and thinnest on the eyelids.
- Epidermis is composed of 5 layers vizstatumconeum, stratum lucidum, stratum granulosis,
stratum spinosum and stratum germinativum.
- The stratum germinativum is the deepest part of the epidermis and the living part that give rise to
the other strata.
- This deepest layer (stratum germinativum) contains cells that produce melanin and keratin.
- Melanin forms a shield to protect nerve endings in the dermis from the damaging effect of V rays.
- Keratin is a fibrous, water repellent protein that makes epidermis tough and protective.
- The surface of the epidermis is ridged by the projection of cells of the dermis called papillae.
- The dermis, the second and deeper layer of skin is made up of flexible connective tissue.
- The dermis is richly supplied with blood cells, nerve fibres and lymphatic vessels Most of the hair
follides, sebaceous glands sweat glands are located in the dermis Underneath the deepest layer of
the dermis is the areolar tissue and varying amount of adepose tissue.
- The skin performs a number of functions which include protection, temperature, regulation,
formation of Vit D, sensation, absorption and excretion of waste products.
b Face = 3 or 31/2 or 41/2
Both hands and upper limbs = 18
Anterior trunk = 18
39 OR 391/2 Burns = 401/2% Burn
c Nursing Diagnoses
- Ineffective breathing pattern related tracheal oedema and depressed ciling Action from inhalation
injury.
- Pain, acute related to the effect of burns.
- Fluid volume, deficient related to continuous massive oozing of fluid from burnt area.
- Impared skin integrity related to destruction of skin tissues by burns
- Infection (Risk for) related to loss of skin covering.
NURSING CARE PLAN OF MRS BALA WITH SEVERE BURNS
NURSING DIAGNOSIS OBJECTIVE NURSING SCIENTIFIC PRINCIPLES EVALUATION
INTERVENTION/ACTIONS
1. Ineffective Breathing Patient will breathe with 1. Assess patient for signs of 1. This is to detect my deviation Patient breathed
pattern related to tracheal ease (16-20 beats 1 min) respiratory distress. from normal and to facilitate with ease (16 –
oedema depressed ciliaing within 30mins of in situation of prompt and 20min) after 30 mins
action from inhalation intervention. Monitor vital signs1/2 hourly. adequate action. of intervention.
injury.
(1/2mk) 3. Nurse patient in a well ventilated 2. This provides a baseline data (1/2mk)
1
( /2mk) environment and helps in monitoring
improvements.
Put patient in fowlers
Position. 3. This ensure adequate
oxygenation.
5. Administer oxygen as prescribed if
necessary. 4. This facilitates breathing
(mk).
5. This helps to improve tissue
006pygenation.
(1/2mk)
2. Pain, Acute related to effect Patient will verbalise 1. Assess client response to pain. 1. This provides a due to the Patient verbalized a
of burns some relief from pain severity/intensity of pain reduction of pain
within 2-3 hour of nursing 2. Elevate beldclothin’s (with bed 2. This prevent irritations to the after 1 hour of
intervention. cradle) wound surface thereby nursing intervention.
reducing painful sensation.
3. Explain all procedures to the
patient and allow time for 3. This reduce anxiety (anxiety
preparation. reduces pain threshold).
4. Give divertional therapy 4. This provides a non

pharmacologic analgesic.
5. Administer prescribed analgesics
before painful procedures. 5. It blocks pain transmission to
the brain.
3. Fluid volume, Deficient Patient will regain lost 1. Assess the defree and depth of the 1. It established a baseline data Patient became well
related to excessive oozing fluid and electrolytes burns for definitive care. hydrated within 48
of fluid from the burnt area within 2-3 days of nursing house of
intervention and this will 2. Asses vital signs 1/4 hourly, 2. This helps to detect signs of intervention and did
be maintained throughout document and report changes. fluid inadequacies. not manifest any
hospitalization sign of dehydration
3. Give the prescribed IV fluid of N/ 3. This helps to replace lost thereafter.
saline. fluid and electrolytes.
4. Monitor intake and output hourly 4. This helps to detect decrease

and report urine output of less circulating volume and renal
than 50ml per hour perfusion.
5. Weight the patient daily. 5. Body weight is used to

calculate fluid requirements
and to monitor patient’s
progress.
D Complications of burns
- Infection/Sepsis
- Hypovolaemic shock
- Hypertrophic scarring
- Cosmetic deformity/keloids
- Contracture
- Adult respiratory distress syndrome
- Acute renal failure
- Anaemia
- Death
2Depression can be defined as a state of psychomotor retardation. It is characterized by

indecisions, persistent anxiety, sadness, loss of interest in activities around him / her in
psychotic depression delusions and hallucinations are present
B CAUSES OF DEPRESSION
- Loss of a loved one
- Loss of job
- Social stigma
- Desolation of old age
- Menopause
- Physical illness
- Hereditary
- Broken relationship/jiltedness
- Insecurity
- Marital problems/divorce/separation
- Disasters
- Idiopathic
- Premorbid personality
- Unfulfilled dreams
CSIGNS AND SYMPTOMS
- Insomania
- Withdrawal tendency
- Lack of personal hygiene
- Tearful agitations
- Constipation
- Mutism
- Poor/increased appetite
- Loss of libido
- Amenorrhoea
- Lack of insight
- Suicidal thoughts/gesture
- Delusion (unworthiness)
- Hallucinations
- Sighing
- D
- Admit in open ward
- Maintain close observation
- Minimize suicidal tendency by removing sharp and dangerous objects neat the patient.
- Ensure prescribed drugs are administered
- Open suicidal caution card.
- Maintain personal hygiene
- Serve enticing meals and supervise the feeding.
- Chemotherapy served per prescriptione.gtofranil (imipranine), Tryptizol
o (Amitryptiline) zolost chlorpromazine, mellen, Artane, Mogadon
- Severly depressed patient may benefit from electro-convulsive therapy (E.C.T) as
prescribed.
- Psychotherapy – individual and group.
- Take patient to occupational therapy unit for stimulating activities e.g knitting, weaving
and printing.
- Recreational activities ie ward party, organize picnics, ludo, watching I.V etc
Rehabilitation involve psychiatric social worker and significant others around the patient.
This facilitates job rehabilitation.
- Advise on discharge – to always come for check-up and compliance to medications.
(a) Description:
The ovary is one of the internal reproductive organs of the female. They are two
(2) in numbers,one on either side of the uterus in close contact with the fimbriated
end of the fallopian tubes.
The ovary is oval in shape measuring about 3cm long, 2cm wide and 1cm thick.
Structure: Each ovary has two layers of tissue, namely the cortex and medulla.
The medulla: The medulla lies in the centre of the ovary, and consists of fibrow
tissue, blood vessels and neves.
The Cortex: This is a layer of connecting tissue surrounded by germinal epithelium,
it contains ovarian follicles in different stages of development and each follicle
contains an ovum.
Developmental sages of ovarian follicle:
Stage I - Start with primordial follicle formation
Stage II - Ovarian follicle approaching maturity
Stage III - Matured ovarian follicle
Stage IV - Raptured ovarian follicle which is otherwise
Known as ovulation
(b) Stages of cancer of the ovary
Stage I - Cancer is limited to the ovaries
Stage II - Cancer is limited to the true pelvis
Stage III - Cancer is limited to the abdominal cavity
Stage IV - Distant metastasis
(C) Differences between benign and malignant cancers.

Benign Malignant
Usually the cells are encapsulated Rarely encapsulated
The cell are partially differentiated  Poorly differentiated.
Do not metastasize  Frequently metastasize
Only expansive growth  Infiltrative expansive growth
Rarely reoccur  Reoccurrence in common
Can be operated by surgical  Cannot be operated due to
Intervention Massive metastasis
Predisposing factors to development of cancer of Ovary
 Null parity
 Intertility
 Advanced age
 Long history of irregular menses
 High dietary fat intake
 Mumps before menarch
 Use of Telcum powder in the perennial area
 Herediatary
(D) Nursing Diagnosis

1. In effective airway clearance related to effect of anesthesia
2. Pain related to surgical intervention.
3. Risk for infection related to surgical intervention
4. Impaired skin integrity
5. Impaired family fairly role performance
6. Risk for spiritual distress.
7. Fluid volume deficit related to blood loss
8. Knowledge deficit related to the condition
9. Anxiety (moderate) related to unknown prognosis
10. Imbalance nutrition (less than body requirement) related to post-operative nill-per-
oral
11. Sleep pattern disturbance related to pain and anxiety
12. Self care deficit related to post operative drowsiness /narcosis.
4
a Nursing measures to relieve acute retention of urine:
- Definition: Acute retention of urine is a sudden inability of the client to void urine.
Measures:
- Ensure client is in a comfortable position
- Alley anxiety
- Provide privacy to enhance voiding
- Open nearby running tap close to the client which may stimulate client’s voiding urge.
- Apply warm compress on the client’s supra public region.
- Gently massage the supra public region.
- It above measures fail, catheterize the client under aseptic technique
- If all measures fail, prepare and assist for supra public puncture or urethral bouginage
- Make client comfortable after the procedure
- Remove used instruments, wash and sterilize them
b Nurses responsibilities in administration of intra muscular injection:
- Definition: Is a sterile procedure in which drugs are introduced into the muscles of the body.
Responsibilities:
- Explain procedure and obtain informed consent
- Using aseptic technique, set a tray with the needed requirements
- Ensure the client has eaten food.
- Provide privacy
- Cross check the prescription with a qualified nursing officer
- Observe five (5) rules of drug administration – right drug, right patient, right does, right route and the
right time
- If powder injection, constitute with a known volume of diluents and draw the prescribed does in an
appropriate syringe
- Clean the injection site with sterile cotton wool swab and inject deeply into the patient at an angle of
900.
- Gently withdraw the needle and massage with dry swab
- Record the administered drug in the client’s treatment sheet
- Observe for any post injection bleeding, drug adverse effects and report if any.
- Make client comfortable.
- Remove screen, wash and sterilize used instruments.
Post-Opertive Nursing Care Plan of Mrs.Okoh with oophorectomy
NURSING DIAGNOSIS OBJECTIVE NURSING SCIENTIFIC PRINCIPLES NURSING
INTERVENTION RATIONALE EVALUATION
1. Ineffective airway Client will maintain patent  Place client on her back  This prevents the tongue from Patent airway was
clearance related to airway and will not show with head turned to one falling back and obstructing the restore after 1 hour of
effect of anaesthesia signs of hypoxia within 1 side. airway. It also aids drainage of intervention and patient
hour of intervention  Suction airway when secretions thereby maintaining a did not show sign of
necessary. patient airway. hypoxia.
 Observe vital signs 1/4  Suctioning removes secretion and
hourly especially. maintain patient airway.
Respiration and pulse rate.  This helps detect deviation from
 Administer oxygen when normal.
necessary  Oxygen therapy promotes tissue
perfusion and maintains arterial
oxygen saturation levels.
2. Pain related to surgical Client will verbalize relief  Place patient in a  This relieves pressure from Patient verbalized relief
intervention of pain with 30 minute to comfortable position. abdominal bowl and the site of of pain within 1 hour of
1 hour of intervention.  Instruct patient to apply incision thereby reducing pain. Nursing intervention.
light pressure over  This relieves strain on operation
operation site while site thus reducing pain.
courghing.  This relax abdominal muscles and
 Teach client deep breathing relieve pain.
and coughing exercises.  Pentozocin binds with opoid
 Give prescribed analgesics receptors at many sites in the CNS
e.g. pentozocin300mg tdsx entering pain response by
2 as prescribed. unknown mechanism.
 Put on T.V or radio as  This distract her attention from
client desires. perception of pain.
3. Risk for infection Patient will not develop  Maintain aseptic technique  Prevents infection thereby Patient stopped
related to surgical infection throughout the in all sterile procedures. promotes wound healing. vomiting and was able
intervention period of hospitation.  Give prescribed antibiotic  This has bacteriocidal effect which to finish 1/4 of his food
e.g. ciproxm 500mg 12hrly results from inhibiuon of the after 24 hours
48hrs. bacterial DNA and prevents
 Shorten comprograted replication.
dram from 2nd day post  This aids effective drainage and
operation. prevents infection.
 Give warm bed-bath  Warm path aids effective blood
carefully without witting circulation thereby promotes
incuston site. healing.
 Give high protein diet.  Boosts body immunity thereby
promoting healing
(1/2mk) (1/2mk) (1mk) (1/2mk) (1/2mk)
c Preparation of client for surgery:
 Definition: Is the act of ensuring client’s physical, psychological, social and spiritual wellbeing
prior to operation for the purpose of preventing complications during and after surgery.
 Preparation depends on the type of surgery to be performed (emergency of planned operation).
Physical preparation:
 Admit client 2-3 days before surgery
 Monitor and record vital signs in the vital signs’ chart
 Ensure client’s personal hygiene
 Shave and clean the site to be operated upon
 Prepare and assist in I.V. therapy. In some operations psychological preparation allay anxiety by:
 Establish a cordial therapeutic relationship
 Explain the nature of surgery and obtain an informed consent
 Introduce client to the convalescent client with similar condition.
Bowel/Bladder Preparation
 Administer enema in the evening prior to operation
 In some operations, rectal wash out in the morning
 Empty bladder of the patient before leaving for surgery
Nutritional Preparation:
 Last meal in the evening prior to operation
 Nil per oral for 6-8 hours before operation
 It major operation, sustain client whit the intra venous therapy
Drug therapy:
 Administer prescribed pre-medication e.g atropine 0.6mg to drug up respiratory secretions
 Injection Diazepam 10mg to calm client
Spiritual preparation:
 Counsel client about God in relation to the surgery
 Encourage visitation by a clergy for spiritual upliftment
 Apply identification band on the client’s wrist
 Accompany client to the operating theatre and hand over client to the aneasthetist.
d Importance of delegation of duty on the ward:
36
 Definition: Delegation is the transference of responsibility of authority for the performance of an
activity to a competent individual in order to achieve a stated goal.
Importance:
 Enhances achievement of organizational goals
 Ensures continuity of effective and comprehensive client’s care
 Enhances staff supervision and evaluation
 Allowed for acquisition of leadership or managerial skills
 Boost staff morale when the delegated task is properly accomplished
 Gives sense of belonging and direction to the staff assigned with the delegated task.
 Ensure commitment and accomplishment of task within specified time frame
 Reduces job stress and repetition of task.
 Describes the task expectation and monitors performance
 Ensures assignment of specific task to be done for each client
 Provides feedback on the capability and ability of the surbordinate to the delegator.
1
/2mark each x 10 points = 5 marks
37
5(a) DEFINATION OF NURSING AUDIT
Nursing audit is an attempt to improve the quality of health care by a systematic
Critical analysis of the performance of those providing that care
By comparing the performance against designed standards
and improving performance, resulting in better service for consumer.
(1/2mk for each of the underlined points =2 marks)
(b) Important records a nurse must keep during clinical practice are:
- Ward report
- Admission and discharge register
- Inventory book
- Control Drug Act Register (CDA)
- Patient folder
(i) Ward Report (1/4mk)
- Definition:
Ward report is an official document written by a nurse which may be read at any time nursing officers
ward staff and hospital authorities.(1/2)
Description and purposes:

And ideal ward report shows the statistics of each shift in the ward.
- This involves number of in-patients, discharge, transfer, deaths, total beds, occupied beds, and
patients awaiting to settle bills
- It reports on very ill patients, new patients, post-operating patients on blood transfusion and other
special therapies.
- Details in the report involves name of patient, age, time of admission, provisional diagnosis and
nurses observation made during each shift. It also include doctors comment and drugs prescribed,
general complaints, general conditions and vital signs.
- It comments on general condition of all the patients in the ward.
- Comments made by doctors in the ward is usually written by the senior nurse going off duty, and
handed over to incoming staff.
- It should not be read by the patients and their relatives.

- This document enhance continuity of care.
(1/2mk each for 5 correct points=11/2mk)
38
(ii) Admission and Discharge Register (1/4 mk)
Definition: (1/2mk)
This is a register that contains data of admitted and discharged clients.

- The register contain the following: name, age sex, hospital number, diagnosis, address, telephone
number, name of next of kin and relationship date of admission and date of discharge.
- Indicate patient’s movement (Discharged, transferred, referred, and death)
- Helps in Keeping hospitals records/statistic
- Important for heath planning and budgeting
- For Continuing of care.
(1/4 mk each for 5 correct ponts = 11/4 mk)
(iii) Inventory Record: (1/4)
This is the record of hospital equipments and instruments used in the health care unit for
management of patients.(1/2mk)
- The inventory record is kept by every ward leader.
- In the book, the list of equipment and instruments are recorded.
- Lost or damaged items are usually recorded while updating the record.
- Any item that needs repair is tagged and placed separately in a place designated for maintenance
so that it can be replaced or repair quickly
The record is also reviewed at the end of every fiscal year while writing annual report.
(1/4mk each for 5 correct points= 11/4mk)
iv. Control Drug Act Register (1/2 mk)
Definition:
It is register that contains detail of control drugs (1/2mk)
The following details are recorded in the register:
- The patient name.
- Name of the drug and dose
- The time of giving the drug
- The name of the nurse giving the drug and signature.
- The name of the registered nurse who checked the drug
- The name of the doctor who prescribed the drug
- The nurse in charge of each shift takes over responsibility for content of the CDA cupboard.
39
Purpose
- For requisition
- It enhances judicious administration of CDA for accountability
- It prevents indiscriminate use.
(1/4 mk each for 4 correct points = 1mk)
v. Patient’s Folder: (1/2mk)
Definition: (1/2mk)
Patients folder (record) is the total of forms accumulated during patient’s stay in the hospital and
contain pertinent information.
Description and purpose.

- It is legal record of account of what happened to the patient during the time he or she was in
hospital.
- The folder is the property of the hospital
- All records and information contained within the folder of each patient are strictly confidential
and must not be read or discussed by anyone except the physician and other who are directly
involved in the patient’s care.
- The face sheet contains patient/information about the patient, such as name, age, se, address,
religion, occupation, next of kin, address of next of kin and hospital number.
Other Content of the folder includes:

- Physician order sheet
- Vital sign chart
- Medication sheet
- Nurses observation sheet
- Glasgow coma scale
- Intake and output chart
- Progress sheet, laboratory investigation sheet, consent forms and other special forms.
(1/2mk each for 4 correct points = 1mk)
(c) Purposes of keeping patient Records

(i) For protection in cases of litigation or allegation of professional misconduct.
(ii) Provides accurate hospital statistics.
(iii) It provides for health related research
(iv) For continuity of patient’s care and advice/follow-up.
(v) Records are vital information for reference purpose or for health planning and budgeting.
(vi) Useful for reimbursement.
40
(vii) For maintenance of professional standard.
(viii) It enhances evaluation of quality and effectiveness services health care
(ix) Enhances evaluation of quality and effectiveness of health care services.
(1 mark each for any correct 5 points – 5 marks)
(d) Instruments for Data Collection
(i) Questionnaire
(ii) Observation
(iii) Interview
(iv) Census
(v) Focus group Discussion
(vi) Rating scale
(vii) Existing records/data
(viii) Case study
(ix) Biophysical measures
(1/2mark each for any 4 correct points – 2 marks)
Questionnaire
Definition A questionnaire is a data collection instrument composed of questions designed for
respondents to answer. (1 mark)
Description/purpose
 It is a prepared question format on certain concept under investigation.
 It is perhaps the most widely used instrument for data collection
 There are two forms of questionnaire schedule, namely, open ended and closed ended questions.
 Each specific objective stands as a unit of the questionnaire
(1/2mk each for any 4 correct points = 2mks)
Advantages
 It is highly flexible
 Easily administered to large groups of people.
 Low cost. Cheaper than interview and observation.
 Reduces biasing errors.
 Offers possibility of complete anonymity. (1/2each x 4 advantage 1 mark)
Disadvantages
 Response rates is very low
 Time consuming in construction
 May not be filled by actual respondents
 Requires permission in order to obtain cooperation.
41
 Offers no opportunity for probing. (1/2mark each 4 disadvantages = 1 mark =5 marks
Observation
Definition: Observation is the process of gathering data using the five senses. It is a conscious and
deliberate skill that is development through effort and organized approach. (1 mark)
 This entails sending observers to observe and record what actually happens while it is
happening.
 Observational techniques can be used to measure a broad range of phenomena and are versatile
along several key dimensions e.g characteristics, and conditions of individual verbal
communication behavior activities skills attainment and performance and environmental
characteristic.
(1/2mark each x any 2 points – 1 mark)
 Types of Interview
(i) Structured
(ii) Unstructured
Structured Interview: Structured interview consists of a set item in which both the questions and
the required alternative response are predetermined.
Unstructured Interview: In an unstructured interview, the interviewer does not specify in
advance the questions or the responses; the researchers encourage the respondent to talk freely
while he records the responses.
(1/2marks each for 2 types of interviews with explanation – 1 mark)
 Advantages:
(i) The response rate tends to be pretty high in face to face interview.
(ii) Confidential/materials are likely to be received.
(iii) It may provide additional data through observation.
(iv) The information received is more likely to be inclusive and complete.
(v) The interviewer has a control over the type of response he receives.
(vi) The interviewer can do more to improve the quality and quantity of response.
(1/4 mark each for any 4 advantages 1 mark)
 Disadvantages
(i) It prevents the respondent’ anonymity.
(ii) It is subject to interviewer’s bias.
(iii) Inter personal relationship between the interview and interviewer are likely to influence the
responses.
(iv) Validity depends on the skills of the interviewer.
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(v) It is more costly than questions.
(vi) Lack of cooperation of and trust from potential respondents can reduce response rate.
(1/2mark each for any 4 disadvantages 1 marks)
Biophysiologic Measures
Definition:Studies of basic biophysiologic process that have relevance for nursing care which involve
normal, healthy participants or subhuman animal species. (1 mark)
TYPES OF BIOPHYSIOLOGIC MEASURES

1. In vivo and in vitro Measures
In vivo measures are those performed directly within or on living organisms e.g. BP. Body
temperature and vital capacity.
In vitro data are gathered from participants by extracting some biophysiologic material from them and
subjecting it to laboratory analysis.
(1 mark each for 2 types with explanation = 2mks)
Advantages
 The information are objective
 The validity of the data is guaranteed
 The information is abundantly available.
 Independent researchers are to get the same result using the same measures.
(1/4 mark for any 4 advantage = 1 mark)
Disadvantages
 It requires specialized technical instrument
 It require special knowledge on training
 The instrument may be faulty giving wrong information
 It requires large sum of money to procure needed instrument.
 It creates artificiality because of experimentation.
(1/4 mark each for any 4 disadvantages = 1 mark)
5. Focus Group Discussion (FGD)

Definition: Is an organized discussion involving some group of people ranging from 5 12 in number
with the aim of getting information in their views concerning a particular issue. (1 mk).
 The group should be homogenous, to allow members to freely express their ideas. (1 mark).
 Those that are selected are brought together in a room. The follow a prepared guide that contain
the questions or issues to be investigated.
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 The discussion should be free flowing with everyone participating. The researcher ensures that no
one dominate the discussion.
 The discussion are recorded on tape or written down on a note book.
(1/2 mark each for any point in explanation x 4 points = marks)
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Advantages
- Less expensive than other methods.
- It can be used to gather data quickly
- Does not enjoy generous funding
- Data from Focus Group Discussion can be used to complement those that are obtained though other
methods.
- Focus Group Discussion can be used to gather baseline data that are needed to design a full blown
study in which another method e.g. Survey will be use.
Disadvantages
- Lack of interest by some respondents
- Time consuming as all the members must contribute to arrive at a vali data.
- Facilitator may hijack the conversation to influence the group.
- Inappropriate selection of participants can influence.
- Some people are uncomfortable expressing their views or experiences in a front of a group.
(1/2mark each for any disadvantages)
MCH services inclues the broad meaning of health promotion and preventive curative and rehabilitative
facility or care of the mother and child.
This deal with the health of women during pregnancy, child birth and post partum period. It
encompasses the health care dimension of family planning.
Complications from child birth were the leading killers of young women and infant, and toddler
mortality was high.
Maternal health was threatened by a lot of complications during pregnancy, labour and
puerperium.
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Mothers and children not only constitute a large group, but they are also vulnerable or special group.
They comprise 71.4% of population in the developing countires.
Children are the foremost priorities of community health program. Their aim is to increase the
nutrition level of mothers and children to ensure the birth of healthy child.
Maternal and child health service were first in India in 1921 by a committee of the lady
Chelmsford league.
Mother and child below the age of 15years make up of majority of the population in almost all
countries. Mothers and children constitute a “special risk” or vulnerable group in the case of illness, death
in terms of pregnancy, child birth of mothers and impaired growth and development in the case of
children.
Reproductive Health (RH) is a state of complete physical, mental and social well being and not
merely the absence of disease or infirmity in all matters realted to reproductive system and to its
functions and processes.
This imples that people are able to have satisfying and safe sex lives and that they have the capacity to
have children and the freedom to decide if, when and how often to do so.
- It is a culturally and politically sensitive issue that requires attitudinal and behavioural cha
nges among individuals, couples, families, communities, policy makers and health care givers.
- It is the group of methods, techniques and services that contributes to Reproductive Health
and well being by preventing and solcing reproductive health problems. It also includes sexual
health, the purpose of which is the enhancement of life and personal relations, and not merely
counseling and care related to reproductive and sexually transmitted disease.
SEXUAL HEALTH AND REPRODUCTIVE HEALTH RIGHTS
Sexual Health:
This is a part of Reproductive Health and includes healthy sexual development, equitable and
responsible relationships and sexual fulfillment, freedom from illness, disease, violence, and other
harmful practices related to sexuality. Sexual health is the result of environment that recognized,
promoted, respected and defended by all societies through all means.
Sexual right:
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These are fundamental and universal right based on the inherent freedom, dignity and equality of all
human beings. Since health is a fundamental human right, health is also a basic human right. In order to
assure respected and defended by all societies through all means.
Reproductive Rights:
There imply that people are able to have satisfying and safe sex lives, capacity to have children
and the freedom to decide if, when and how often to do so. It is implicit here that people have the ability
to reproduce, to regulate their fertility and to practice and enjoy sexual relationship. Additionally, women
can safely go through pregnancy and childbirth without health hazards. It also implies the empowerment
of women and young people in the development and implantation of programs and services, and men
assuming greater responsibility for and actively supporting Reproductive Health.
Reproductive right are the basic right of all couples and individuals to decide freely and
responsibly the number, spacing and timing of their children and to have the information and means to
do, and the right to attain the highest standard of sexual reproductive health. It is the right to make
decisions concerning reproductive that is free of discrimation, coercison and violence, as expressed in
Human Right Documents.
The International Planned Parenthood Federation (IPPF) chapter on Sexual and Reproductive
right is grounded in International Human Right instrument, which include the following rights.
1. Right to Life: Means among other things that no woman’s life should be put at risk by reason of
pregnancy or any ill health.
2. Right to liberty and security of the person: Recognizes that no person should be subjected to
female genital mutilation, forced pregnancy, sterilization or abortion.
3. Right to equality and to be free from all forms of discrimation: This refers to freedom from all
dorms of discrimation regardless of sex, gender, sexual orientation, age, race, social class, religion
of physical and emotional disability (i.e the physically and mentally challenged persons). This
secures the right of all persons to equal treatment, entitlement, and equal employment.
4. Right to good Reproductive Health and services and to preventive and curative health care:
This is a service of physical, psychological, intellectual and spiritual well-being.
5. Right to freedom from torture and ill treatment i.e From inhumane, degrading or cruel
treatments which extend to freedom from domestic and sexual violence as well as the right tp
human dignity.
6. Right to privacy and confidentiality: That all sexual and reproductive health care services
should be confidential and all women have the right to autonomous reproductive choices.
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7. Right to choose whether or not to marry and to form and plan a family: This is the right of
men and women of marriageable age to marry and form a family based on full and free consent.
This encompasses the right to decide whether or not to marry, divorce, have children, the number
and spacing of children and the right to full access to means of fertility regulation.
8. Right to the benefit of scientific progress: It includes client’s rights to new reproductive health
technologies which are safe, effective, accessible and acceptable. That sexual information should
be generated through the process of unencumbered and yet scientifically ethical inquiry, and
disseminated in appropriate way at all societal levels.
9. Right to freedom of assembly and political participation: This includes the right of all persons
to seek to influence communities and governments to prioritize sexual reproductive health and
rights.
10. Right to freedom of thought and opinion: Includes freedom from the restrictive interpretation
of religious texts, beliefs, philosophies and customs as tools to curtail freedom of thought and
choices on sexual and reproductive health.
11. Right to information and education: As it relates to sexual and reproductive health for all,
including access to full information on the benefit, risks, and effectiveness of all method of
fertility regulation, in order that all decision taken are made on the basis of full-free-informed
consent.
12. Right to sexual health care and health protection: Sexual health care should be available for
prevention and treatment of all sexual concerns, problems and disorders. Right to the highest
possible quality health care, and to be free from trafitonal practices which are harmful to health.
OBJECTIVES
1. To reduce maternal morbidity and mortality due to pregnancy and childbirth by 50%
2. To reduce perinatal and neonatal mobility and mortality by 30%
3. To reduce the level of unwanted pregnancies in all women of reproductive age by 50%
4. To reduce the incidence and prevalence of sexuall transmitted infections including the
transmission of HIV infection.
5. To limit all forms of gender-based violence and other practices that are harmful to the health of
women and children.
6. To reduce gender imbalance in availability of reproductive health services
7. To reduce the incidence and prevalence of reproductive cancer and other non-communicable
disease
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8. To increase knowledge of reproductive biology and promote responsible behaviours of
adolescents regarding precention of unwanted pregnancy and sexually transmitted infections.
9. To reduce the gender imbalance in all sexual and reproductive health matters.
10. To reduce the prevalence of infertility and provide adoption services for infertile couples
11. To reduce the incidence and prevalence of infertility and sexual dysfunction in men and women.
12. To promote research on reproductive health issues.
COMPONENTS OF REPRODUCTIVE HEALTH
1. Safe motherhood: this comprises of:

- Parenatal care
- Clean and safe delivery (by Skilled attendant)
- Essential Obstetrc Care (EOC), Life saving Skills
- Prenatal, natal, post partum care and neonatal/child care and breast feeding
2. Family planning information and services
3. Prevention and management of complications of abortions and Post Abortion care
4. Adolescent Reproductive Health
5. Prevetnion and management of STIs, HIV/AIDs and Reproductive tract infections
6. Prevention and appropriate management of infertility and sexual dysfunction in both men and
women.
7. Active discouragement and elimination of harmful practices e.g FGM, Child marriages, domestics
and sexual violence against women.
8. Male involvement and participation in RH issues
9. Cancers of the Reproductive tracts (Male and female)
10. Management of problems associated with menopause and sexual dysfunction in men ans women
11. Gender equity and equality
Benefits of Reproductive Health concept
1. It is a life cycle approach in which RH concerns are not limited to women of reproductive age but
extended to include life time concerns for both men and women from birth to old age.
2. It is a holistic approach to reproductive health needs to the family as it focuses on the needs of
both sexes and all age groups.
3. It has a comprehensice scope of services including family planning, safe pregnancy and delivbery
as well as the prevention and treatment of reproductive tract infection
4. It focuses on entire life cyckle of the human being and coverage of both sexes.
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5. It considers the needs of women before, during and after child bearing age as well as needs of
men.
6. It is critical to peoples well being and central to human development
7. It needs individual Reproductive health needs rather than simply focusing on demographic
targets.
8. It address women’s and men’s RH right and needs throughout their life.
9. It puts individual’s health rights and development at the centre of policies, programmes and
implantation plans.
10. It emphasizes the strategic roles of information, education, community mobilization and
participation, women empowerment and provision of quality cares for all person including the
poor and the marginalized groups.
REPRODUCTIVE HEALTH SITUATION IN NIGERIA

The current indicator of Reproductive Health situation in Nigeria includes the following issues.
i) High maternal mortality: rate is 545 per 100,000 live births (FMOH, 2008). This figure masks widw
regional disparities which ranges frin 339 per 100,000 live births in the South-West to 1,716 per
100,000 live births in the North-East. Maternal mortality rate ranges is 1,100 per 100,000 live births.
- Maternal Mortality Ratio Hospital Data: (Sources: Society of Obstetric and Gynaecology of
Nigeria – SOGON, 2004).
Bornu 727/100,000 live births Enugu 809/100,000 live births
Plateau 846/100,000 live births Cross river 2,977/100,000 live births
Lagos 3,380/100,000 live births Kano 3,523/100,000 live births
ii) High prevalence of unsafe abortions. About 600,000 indcued abortion are believed to take place in
Nigeia annually.
iii) Early Sexual exposure and risky behavior. Over 16 percent of teenage females reported first
sexual intercourse by age 15. Among younf women ages 20 t0 24, nearly half (49.4 percent)
reported first sex by age 18. Among teenage males, 8.3 percent reported first sex by age 15.
Among those 20 to 24,36.3 percent reported first sexual intercourse by age 18.
iv)Adolescent Rh: Median sexual age at first intercourse is 18years and 112 births/1,000 females of
age 15-19 years. Nigerian adolescents have one of the highest level of fertility in the world.
(NDHS, 2004)
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v) High prevalence of harmful practives e.g Female Genital Mutilation (FGM) in adult women at
40.5%
vi)Poor utilization of Reproductive health services: using Family planning methods is 8% for modern
method, 12% for all methods.
vii) HIV/AIDs prevalence is 5.6% 6.1 million Nigerian are living with HIV/AIDS. (WHO, 2009)
viii) Low contraceptive use – prevalence rate is 8.9%
ix)High fertility rate: Total Fertility Rate (TFR) (This is average nu,ber of children per woman’s life
time ) in Nigeria is 4.73 childre/women (2011 Estimate). (Source: CIA World Facebook).
x) Infant mortality rate 100 per 1,000 live births (NDHS, 2004)
Factors associated with cureent Reproductive Health situation in Nigeria: These includes the
indicators highlighted above and other such a gender gaps and rights issues e.g gener inequality and
equity, poor women empowerment, discrimation against girl-child, inequalities in resource and power
sharing; high rate of unprotected sexual activity, teenage pregnancy, unsafe abortion and sexually
transmitted infections.
The situation depicted above clearly indicates a need for the provision of quality reproductive health
information and services, which are comprehensive in scope, and delivered in a user-friendly and
integrated manner.
Strategies to improves Reproductive Health
1. Strengthens outreach services to youth, men and use community based approaches
2. Improves education for girls and women: Improve access to education for girls of poor families in
order to delay early child bearing and improve women empowerment.
3. Targets public sector subsides to poor families and disadvantages areas
4. Developing effective ‘patient-Friendly Referral systems
5. Senstizes communities and private sector on their role e.g improves communication (roads and
telecommunitcation) in rural, poor areas. Strengthens partnerships between Traditional Birth
Attendant (TBAs) and skilled formal providers; build linkage with other Reproductive Health,
nutrtition, gender and adolescent health intervention and build a strong referral system and
establish maternity waiting homes for rural women.
6. Improves quality and availability for Essential and Emergency Obstetric Care (EOC) services for
the poor and address poverty reduction and gender inequality.
7. Strengthens policies and capacity building e.g Training of providers to improved quality of carre.
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8. Ennsures availability of drugs, equipment, suuplies and Emergency Obstetric Care (EOC)
services and improves logistics.
9. Promote affordable maternal health services
10. Scales up adolescent secual and reproductive helath information and services
11. Provides information and services for different age groups and bor both in-school and out-school
programmes.
12. Strengthens Monitoring and evaluation (M&E)
13. Audits ,aternal deaths at health facility and community level
14. Ensures an appropriate array for high quality Consumer-Oriented family planning information
and services through outreach programs to reduces unplanned and poorly timed pregnancies and
the health risks associated with them.
15. Increases the number of skilled providers and ensures that every pregnant woman is attended to
by a trained midwife or qualified health worker.
16. Refer patient to facilities that can manage complications such as hemorrhage, obstructed labour
and sepsis.
17. Provides transport, communication and motivates families and communities.
18. Reduces the risks of STI and HIV/AIDs infection e.g Use of condoms reduces the number of
sexual partners. Screening and counseling of infected people are also effective.
19. Promotes health education and community mobilization
20. Address harmful practives e.g Female Genital Mutilation (FGM)
21. Engage the community practitioners and policy makers and training providers to recognize the
signs of violence using appropriate approaches to treatment and counseling.
FACTORS INFLUENCING MATERNAL AND CHILD HEALTH
1. Parity: - Multiparousity can affect the socioeconomic situation of the family it can affect the
diet, dressing and educational system of the children negatively.
2. Occupation: - Type of job of the mother can affect the growth and development of the
children. It will also determine the income.
3. Educational standard: - formal education improve way of thinking
4. Cultural factor: Cultural taboo will influence diet and the cultural practice like types of food,
cooking method, female genital mutilation, breast feeding, family planning, wife inheritance
and practicing. These have several side effect on reproduction STI,HIV.]
5. Value and belief: Some belief in male preference, some also belief that women should be
separated from their husband during child bearing age.
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6. Some religion (Islam) believe in early marriage, many children and polygamy. Some promote
moral, fear of God, sexual education. It teaches children on premarital sex by the use of threat,
fear and lifestyles.
7. Timing also affect. MCH care service. Some women prefer traditional birth attendant which
can accept them any time of the day for antenatal clinic because of their farm work.
8. Exposure – rural urban disposition.
THE ROLE OF THE FAMILY IN FAMILY HEALTH
 The family provides physical protection and safety by meeting the basic needs of its member
like food, clothing and shelter.
 Provides the economic resources of the family. This is secure by adult members through
employment.
 The family also protects the physical health of its member by providing adequate nutrition and
health care service.
 The family creates an atmosphere that influences the cognitive and psychological growth of its
member. Children and adult in healthy, functional family receives support, understanding and
encouragement as they progress through a predictable development stages, as they move in or
out of the family unit, and as they establish new family units.
 The family is a major educator of its member. The early learning plays influential parts in the
development of a child’s attitudes about family, education, health work and recreation. These
attitude, persist throughout their lives.
 Families play major role in the transmission of religious, cultural and societal values.
 Family health improves interpersonal relationship between family and family members. More
orientation, better information allows family to take informed decision on everything about
child, care of neonate, family planning, Primary focus of family health is promotion of
wellness safety, welfare of father mother and the unborn. It emphasis trusting relationship
between health care provider and the family. Conclusively, there s an issue that stand to be lost
from sight as we focus tightly on the mother and her child. That is the health of the father and
other member of the household. It is beyond argument that priority should be given to mother
and children but paying exclusive attention to them may not serve their best interest and in
many case may not be supportive to the integration of the family unit. Therefore the entire
family should be considered in the program of action.
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For instance, a man with active infectious pulmonary tuberculosis malaria or worse still prematurely
retrenches from service can threaten the well being of his wife and children as surely as though they
themselves were afflicted.
Also, a handicapped child in the family e.g Si+++++ *---------------ckle cell disease mentally retarded
may have impact on other members of the family.
GOAL OF FAMILY HEALTH
Secure good health for the family, antenatal, intranatally, postnally, prompt interventions,
effective teaching, counseling, family adaptation to the newborn, provide cultural competence, care that
recognizes the family cultural and social and religious belief to identify at risk and provide intervention.
Family health is all about the critical studying of all the component of maternal and child health
and including an overview of millennium development goals. Maternal and child health can also be
considered under the following headings;
Obsterics: Is the science of pregnancy and progress of child birth. It is a branch of medicine that deals
with pregnancy, infants and puerperium. This aspect also deal with the period of preparation of
pregnancy whereby the optimum condition required for safe pregnancy such as age of the potential
mothers, interval between pregnancy and parity are also considered in addition to supervision of
pregnancy and puerperium.
Gynaecology: is the branch of medicine that deal with the specific disease that is peculiar to women.
Pediatrics: Is the branch of medicine that deals with the disease and care of infant and children. It deals
with the caring of disease and condition from conception of adolescence.
Family Planning: An action by couples or individual to plan their family in relation to child birth that is
the timing, spacing and the number of children. This simply means children by choice not by chance,
thus is known as fertility-regulation. The individual will be able to feed, cloth, house and educate their
children properly. Family planning programs also include, treatment of infertility, prevention and
treatment of STI.
GIRL-CHILD EDUCATION AND STATUS OF WOMEN

Some decades ago, the status of women in the African society was quite low, that was why in
those days parents felt reluctant to send their young girls to school.
They believed that parents would not benefit from such training since the girl would eventually
find herself in another family after marriage, even now some communities still believes in such naïve
ideas. Educational training of the girl child in such places are neglected. The girl child then becomes
handicapped.
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The Child Right Act provides apprehensive legal framework, for protecting the right of children
in Nigeria.
In some places, the birth of a boy heralds Joy and it is a cause for enjoyment while the birth of a
girl is often a cause for concern or affect the development of our economy adversely.
UNICEF has been trying in one way or other to bridge the gap between booys and girls. They
have sponsored so many conferences on girls education as a priority for educational development in
Africa. Women are being forced to marriage, prostitution and other illegal acts just because they have no
voice, no power to take a stand for themselves.
There is need to abolish all policies that are not conducive to the enhancement of girls education
and the status of women.
Some girls are seen on the streets hawking food items which can expose them to many form of
abuse.
Solution
Effort should be made by all to redress this error
- Traditional rulers, government parent, non government organizations as well as policy-makers

should be set up to address the issue.
- Programmes that can empower girls can be organized through educational and advocacy thereby
improving their literacy level.
IMPORTANCE OF GIRL CHILD EDUCATION
- Educated women are capable of bringing socio-economic changes

- Women have right to education as a citizen of the nation , it is a part of human right to attain
education.
- Women can learn as well as men
- Women have dream just like men
- They can improve life for everyone-starting from their home(children).
THE ROLE OF A NURSE IN FAMILY HEALTH NURSING

Educator: The nurse plays the role of an educator by teaching the primary health workers. Many of the
function traditionally performed by the nurses to guide this new personnel in case finding, disease
prevention, patient and family care, community program development, health education and curative and
related functions.
The impact of this role is evident in PHC Village. Nurses are the key trainers and supervisors of
the village health workers and traditional birth attendants.
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The nurses educates the family on good habit especially breastfeeding, family planning in terms
of number of children and the importance of spacing them, responsible sexual relationship to reduce
STDs, the importance of a clean environment with proper disposal of waste and clean water hygiene and
immunization against communicable disease.
The nurses collaborates with the providers of literacy programs to contributes to the literacy of the
family especially that of women.
Collaborators: The nurse collaborates with the agricultural sector community development sector and
educational sector through close corporation the strengthen the intersectional approach of PHC that is
linking health issues or problem with other socioeconomic issues in the community. For example in an
area where the concern is malnutrition children, education on nutrition can be accompanied by project on
a village food garden. In collaboration with the agricultural and community development agencies
enough food might be grown to provide improved nutrition for the family as well as surplus that can be
sold.
Managerial and supervisory role: - All nursing activities will need planning identification of resources
needed and insurance supervises the primary community workers as well as direct provision of nursing
care which has to be monitored to ensure that expected or intended outcome are being achieved.
A Researcher: - Nurse collects information in an objective based on accepted principle of validity and
reliability. One then interprets the information with the view of nursing the interpretations to improve on
the health care we give families.
FAMILY LIFE EDUCATION
The founder of family life education believed that providing education programs in the family life
education would help to ameliorate or reduce family and societal difficulties such as increased parent-
child strife, juvenile delinquency, shifts in marital roles and an increase divorce rate.
Family life education programs for adolescent are found in schools, although some may also be
offered through youth organization, community agencies and churches. Family life education for
adolescents addresses two important kinds on need:
1. Their current normative needs associated with changing physical, sexual, cognitive, social and
emotional development and
2. Their anticipatory or future family related needs to help prepare them for adult roles and
responsibilities in marriage and parenting.
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CONTENTS OF FAMILY LIFE EDUCATION
1. Understanding one’s self and others

 Creative awareness/knowledge of male and female reproductive system
- Teach the anatomy of male and female reproductive system
- Encourage her to draw diagram of male and female reproductive organs
- Teach the function of these organs
- Discuss
 Stage of development
- Discuss puberty in both sexes
- Highlight the hormones responsible for this
- The age of puberty
 Signs of secondary sexual characteristic in male and female
- Development of glandular tissue of breast
- Increase deposits of subcutaneous fats which gives the female figure its curves
- Bring the structure of the external genital to their adult status.
- Deepening of voice in the males ( vocal cord), presence of hair on the pubic regions e.t.c
2. Building self-esteem
- See good aspect of themselves e.g. height, body size, gait, dressing e.t.c
- Value clarification/norms
- Preserving virginity as a pride in some culture as well as religion values
- Stigma attached to pregnancy out of wedlock
3. Making choice about sexuality
- Fertility awareness/sexuality
- Knowledge of fertile period and the period of ovulation
- Female/male reproductive function
- Human sexual responses
- Sexual dysfunction
- The menstrual cycle mechanism of ovulation
- Sexually transmitted infection and how to avoid them
4. Forming, maintaining and ending relationship
5. Taking responsibility for one’s action
- The legal aspect
6. Understanding family roles and responsibilities
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 Family development
- Definition
- Family structure
- Stages of family development
- Function of the family member/family role
 Nutrition
- Teach on adequate diet for the children for appropriate growth –protein, vitamins and enough
fluid
 Use of contraception
- Reproductive decision making
- Knowledge of contraception method
- Their method of use
- Advantages & disadvantages
7. Improving communication skills
CONCEPT OF SEXUALITY
Sexuality is about your sexual feelings, thought, attractions and behaviors towards other people.
Sexuality does not only refer to intercourse but an expression of who we are, it involve the mind
and the body, how a person thinks, feels & acts. It is shaped by our personal attitude, behavior, physical
appearance, dislikes and the way we have been socialized, internet, mass media, social media, peer
pressure. It is influenced by social norms. Culture and religion, likes and dislikes it includes giving and
receiving sexual pleasure as well as enabling reproduction.
Sexuality also involve physical aspect i.e body growth changes associated with puberty, and
physical processes such as menstruation, ovulation and ejaculation.
Sexuality begins at conception with sex determination, grow through infancy and childhood, as
the infant live to relate with the people and the world around him/her & continue until death. Sexuality is
intrinsic and influence every aspect of a person’s life.
TYPES OF SEXUALITY
Heterosexual – Attraction to opposite sex i.e male and female
Homosexual – Attraction to same sex
Lesbian – Women attracted to women
Gay – Men attracted to men
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Bisexual – People attracted to both men and women (the attraction to one can be stronger than the other)
Asexual – Person who does not experience or experience very little sexual attraction.
Some people may strongly identify with being asexual (different from abstinence which is self
denial)
Semi Sexuality – A form of asexuality in which some people feel sexual attraction only after they
develop a strong emotional bound with someone.
HUMAN SEXUAL CHARACTERISTICS
Sexual characteristics are divided into 2 parts:
- Primary sexual characteristics – are directly related to reproduction and include the sex organs
(genitalia)
- Secondary sexual characteristics –are attributed other than the sex organs that generally
distinguish one sex from the other but are not essential to reproduction such as the larger breast
in women. The facial hair and deeper voices characteristic of men e.t.c.
PRENATAL SEXUAL DEVELOPMENT

About 6 weeks after conception of a X chromosome is present in the embryo’s cells (as it is in
normal males) a gene on the chromosome directs the undifferentiated gonads to become testes. If the Y
chromosome is not present (as in normal female), the undifferentiated gonads will become ovaries. If the
gonads becomes testes, they begin to produce androgens (male hormones, primarily testosterone) by
about eight weeks after conception.
CHILD HOOD
Boys and girls are treated differently from birth onward. Differences in toy and play preferences. The
message about appropriate behavior from boys and girls intensify differences between the sexes as the
child grow older by 6/7years children develop a sense of privacy. By age 8 to 12, the first bodily changes
of puberty begins. The child may become self conscious and more private.
PUBERTY
This marks the second stage of physical sexual differentiation.
This time, both primary and secondary sexual characteristics as well as adult reproductive
capacity develop and when sexual interest surges.
Puberty typically begins in girls from 8 – 12years of age, where as boys start about 2years later.
The hypothalamus initiate pubertal changes by directing pituitary growth hormones and gonadotropins
(hormones that control the ovaries and testes)
Girls – Breasts grow, pubic hair develops and her body grow & takes on the rounded contours of an adult
woman. This is followed by the first menstrual period (menarche) (age of onset ranges from 10-16.5).
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under arm hair growth and increased secretions from oil and sweat producing glands. It may take a year
or two before menstruation and ovulation occur regularly. The hormones responsible are adrenal
androgens, oestrogens, progesterone and growth horomones.
Boys - Testes & Scrotal sac grow, his pubic hair develops, his body grows & develop, penis grows,
voice deepens, facial & underarm hair appear, and secretion from his oil & Swear gland increases.
Penile erections increase in frequency and first ejaculation (thorarche) occur from age 11-15. For a boy
who has not masturbated, a nocturnal emission or so called wet dream may be his first ejaculation.
Ability to produce sperm may take another year or 2. Growth hormones & androgens, particularly
testosterone are responsible for these pubertal changes in boys.
ADULTHOOD
More permanent relationship in the form of marriages peoples in monogamous relationship often engage
in sexual activity more frequently than those who have several partners. The frequency of sexual
intercourse tends to decline as the couple age.
Menopause occur in about 50years, decrease oestrogen leads to thinning of the vaginal walls, shrinking
of the vagina & labia majora & decreased vaginal lubrication. This can cause pain during intercourse.
In men, testes become smaller as testosterone production decline over years. The column & force
of ejaculation decrease & sperm count is reduced. Erection takes longer to attain medication, vascular
disease, diabetes and other medical conditions can cause erectile dysfunction.
PROMOTION OF SEXUAL HEALTH
Sexual health promotion is the process by which individuals achieve the ability to control and
improve their sexual health. The promotion of sexual health should enhance sexual emotional wellbeing
and help people reduce the risk of sexually transmitted disease, HIV, unwanted pregnancies.
- With possibility of having enjoyable & harmless sexual intercourse. Freedom from fear, shame,
guilt, false belief and other psychological factors that inhibits sexual response & impaired sexual
relationship.
- It is the process by which an individual achieves the ability to control & improve their sexual
health.
- It should enhance sexual & emotional well being and help people to reduce the risk of STI and
unwanted pregnancy.
- Pubic policies promoting sexual health
- Development of sexual health supporting environment.
- Remove of barriers to receiving sex related services.
- Increasing access to counseling services through awareness raising.
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- Gaining the support of policy makers
- To get comprehensive sexual education.
- Taking legal action toward sexually abusive.
- Health centre provide sexual health to no to be meant for sexual health alone to prevent
stigmatization.
- Health worker/team should not embarrass teenagers coming for sexual health service
- Economic policy
- Government should report the private sectors so as to reduce the cost of counseling.
- Empowering people & Society.
- Reviewing current health system e.g by integrations of sexual health in primary health care
program.
- A website can be build by the ministry of health for sexual health.
RESPONSIBLE & SAFE SEX

All forms of sexual contacts carry some risk.
Abstinence may be the only true form of “SAFE SEX” especially for the adolescent.
You can reduce your risk of getting a STI with certain precautions and safe behaviors in which
the teaching start from the parents by giving their children sex education.
 Condom – this is said to protect against pregnancy and STIs, it help to prevent certain disease,
Chlamydia and gonorrhea but they may not fully protect against other disease like genital
warts, herpes & syphilis.
 Kissing – some people say it is safe but herpes and other disease can be spread this way.
 Limit your sexual activity to only 1 partner when you are due for that.
 Women should not douche after intercourse. It does not protect against STI rather , it aid the
spread of infection
 Do regular pap smear (if over 21 years), pelvic examination and periodic test for STI.
SEXUAL DEVIATION AND PROBLEMS OF ADOLESCENT SEXUALITY

Abstinence and a delay in the start of sexual intercourse maybe the most effective methods in
preventing the consequences of teenage sexual activity. This is not met as a result of the following;
 Change in social Norms.

 Peer pressure.
 Media influences
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 Premarital sex leading to teenage pregnancy leading to abortion and inability to complete
education. Abortion leading to complications of abortion which people turn the blame to
social circumstances of the mother, the poor nutritional status before pregnancy and poor
attendance at antenatal clinics.
 Early exposure to sex will also make them more prone to contraction of STI and its
complications such as infertility, PID, VVF, Uterine perforation, suicidal attempt e.t.c.
 Family life education can help to prevent unwanted pregnancy.
 Sexually over active adolescent can be exposed to family planning.
 Prompt treatment of STI when contacted.
PROBLEM OF ADOLESCENT SEXUALLITY
 Adolescent/teenage pregnancy
 Abortion and post abortion care
 Contraceptive use
 STI
 HIV/AIDS
SEXUAL DYSFUNCTION
Sexual dysfunction is a disturbance of sexual functioning, they are problems with sexual response
that causes distress.
Erectile Dysfunction: this is a consistent inability to sustain an erection sufficient for sexual
intercourse commonly known as impotence.
Treatment
 Use of medication (notably Viagra)

 Penile implants
 Premature Ejaculation: This is a lack of voluntary control mover ejaculation that interferes with
optimal sexual/psychological well-being in either partner.
 Inhibited male orgasm or retarded ejaculation: occurs when a man cannot have an orgasm
despite being highly aroused.
 Female Orgasmic Dysfunction (anorgasma or inhibited female orgasm) : Orgasmic dysfunction
can be primary, secondary or situational
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 Vaginismus: refers to a spastic contraction of the outer third of the vagina, a condition that can
close the entrance of the vagina, preventing intercourse.
 Cause if unknown, but it may occur in women who fear that penetration will be painful or may
develop in response to a previous traumatic or painful experience.
 It can be managed by kegel exercise to help relax the pelvic floor.
 Vaginal dilator can be very effective.
 Dyspareunia – painful intercourse in either women or man. This can be as a result of vaginal
infections or dryness and vaginal lubricant jelly can be of help.
 Low sexual desire.
 Discrepant sexual desire – refers to a condition in which partners have considerably different
levels of sexual interest. This may be caused by physical problems such as fatigue or illness,
the use of prescription medications other drugs or alcohol or psychological factors, including
learned inhibition of sexual response, anxiety interfering thoughts, spectoring (observing, and
judging one’s own sexual performance) , lack of communication between partners Insufficient
or ineffective sexual stimulation and relationship conflicts.
Treatment is to address the cause.
THE FEMALE PELVIS AND REPRODUTIVE ORGANS

FEMALE PELVIS
Functions:-
(1) It allows the movement of the body especially walking and running.
(2) It permits the person to sit and kneel
(3) It is adapted for childbearing because of its increased with and round brim
(4) It transmits the weight of the trunk to legs, acting as bridge between the femurs
(5) The pelvis also takes the weight of the sitting body on the ischial tuberosities.
(6) Pelvis affords protection to the pelvis organs and to lesser extent and to the abdominal contents.
(7) The sacrum transmits the caudal equine and distributes the nerves to the various part of the pelvis.
(8) It allows the movement of the especially walking and running.
(9) It permits the person to sit and kneel
(10) It is adapted for childbearing because of its increase width and rounded brim
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(11) It transmits the weight of the thrunk to legs, acting as bridge between the femur
(12) The pelvis also takes the weight of the sitting body on to the ischial tuberosities.
(13) Pelvis affords protection to the pelvis organs and to a lesser extent and to the abdominal
contents.
(14) The sacrum transmits the caudal equine and distributes the nerves to the various part of the pelvis
THE FEMALE PELVIS

PELVIC BONES
These are four pelvis bones:-
 Two innominate bone

 One sacrum
 One coccyx
INNOMINATE BONES
Each innominte bone is composed of three parts
The Ilium:- this is the large flatted out part. When the hand is placed on the lip, it rest on the iliac crest
which is the upper border. In front of the iliac crest which is the upper border. In front of the iliac crest is
a bony prominence known as the anterior superior iliac spine.
Inferiority to this being in a short distance below is the anterior inferior iliac spine. On the other
end of the other end of the iliac crest are two similar points namely the posterior superior and posterior
inferior iliac spines. The concave anterior surface of the ilium is the iliac fossae.
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THE ISCHIUM:-This is the thick lower part. It has a large prominence known as the ischial tuberosity
where body rest when sitting down. An inward projection behind and a little above the tuberosity is the
ischial spine.
THE PUBIC BONE:- this is the anterior part that has a body and two projections, the superior ramus
and the inferior ramus symphysis joins the two pubic together and the two inferior ramus forms the pubic
arch. The space enclosed by the body of the pubic bone, the rami and the ischium is called the obstructor
foramen.
The acetabulum is the cup shaped, which is deep to receive the head of the femur. All three inferior iliac
spine up to the ischial spine is called greater sciatic notch which is wide and rounded. The other curve
lies between the ischial spine and the ischial tuberosities and is called the lesser sciatic notch.
THE SACRUM:- This is a wedge shaped bone that consist of five fused sacra vertebra. The upper
border of the first sacral vertebral protrude forward concave and is called sacral promontory. The anterior
surface of the sacrum is concave and is called the hollow of the sacrum.
The sacrum which extends laterally into a wing of other four foramina pierce the3 sacrum which
allows for the passage of nerves from the caudal equine converge to supply the pelvic organs the
posterior surface is roughened for the attachment of muscle.
THE COCCYX: - This is a vestigial tail, it consist of four fused vertebra forming a small triangular
bone.
PELVIC JOINT
There are four pelvic joints:-
(1) One symphysis pubis

(2) Two sacro iliac joints
(3) One sacro coccygeal joints
THE SYMPHYSIS PUBIS: - This is between the junction of the two pubic bones which are united
by a pad of cartilage.
THE SACRO ILIAC JOINTS: - These are the strongest joints in the body. They join the sacrum to
the ilium and connect the spine to the pelvis.
THE SACRO COCCYGEAL JOINTS:- This joint is formed where the coccyx articulates with the
tip of the sacrum. Little movement occur in these joins in a non-pregnant state, but during pregnancy
hormonal activity causes the ligament to soften which allows the joint to move. This provides more
room for fetal head when passing through the pelvis.
The symphsis pubis separates slightly in later pregnancy. These degree of movement give rise to pain
in walking. Nodding of sacrum is a limited backward and forward movement of the tip and
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promontory of the sacrum at the sacro iliac joint. The sacro-coccygeal joint permits the coccyx to be
deflected backward during the birth of the head.
PELVIC LIGAMENTS
Each of the pelvic joints is held together by ligaments:-
- Interpubic ligament at the symphysis pubis

- Sacroiliac ligaments
- Sacrococcygeal ligaments
other ligaments that are important in midwifery are:
- The sacrotuberous ligament

- Sacrospinous ligament
The sacrotuberous ligaments runs from the sacrum to the ischial tuberositites and the sacrospinous
ligaments from the sacrum to the ischial spine. These two ligaments cross the sciatic notch and the
posterior wall of the pelvic outlet.
The inguinal ligaments are of no obstetrical significance. They run from the anterior superior iliac spine
to the pubic tubercles.
THE PELVIS AS A WHOLE
The pelvis is divided into:-
a. The false pelvis

b. The true pelvis
THE FALSE PELVIS

This consists of the iliac fossae laterally, the fifth lumber vertebra posteriorly, the abdominal wall
and the inguinal ligaments anteriorly, the false pelvis is of no obstetrical importance except that it
provides certain landmark for external pelvimetery.
THE TRUE PELVIS
The true pelvis is the most important part of the pelvis in obstetrics; it is made up of three part-
the pelvic inlet or the brim, the cavity and the outlet.
The brim:- This is the area bounded in front by the upper border of the symphysis pubis and the upper
border of the pubis rami, posteriorly by the sacral promontory and the alae of the sacrum and laterally b y
the iliopectineal lines and the iliopectuineal eminences; the brim determines the shape of the pelvis. In a
female or the gyneacoid pelvis, the brim is almost round except where it is encroached upon by the
promontory of the sacrum, the alae of the sacrum, sacro-iliac joint, iliopectineal line, iliopectineal
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eminence, ramus of the pubic bone and sympysis pubis constitutes the plane of the brim and it will be
round.
THE CAVITY: The Cavity lies between the inlet and the outlet, its boundaries are:-
Anteriorly – the pubic bone 3.8cm deep
Posteriorly – the sacral hollow 11.4cm deep
Laterally – the bodies of the ischium and part of the ilium, the greater sciatic notches and the obturator
foramina.
A flat surface cut no fit along the second and third sacral vertebrae, the sacrospinous ligaments, the body
of the ischium on both sides and the mid-parts of the obturator foramina and the symphysis pubis
constitutes the plane of the cavity and this is round.
THE OUTLET: Two pelvic outlets could be described as:
1. The anatomical oulets which is bounded by the landmarks, the tip of the coccyx and the sacro-
tuberous ligament posteriorly, the ischial tuberosity laterally, the pubis arch and the lower border
of the symphysis anteriorly.
2. The obstetrical outlet: This is the area the foetal head negotiate as it is being born. It is segment
of the pelvis between the anatomical outlet and a line drawn along the sacro-coccygeal joint and
sacrospinous ligament, the ischial spine across to the obturator foramen and the lower border of
the symphysis pubis. The flat surface marked by this line is the plane of the outlet.
DIMENSION OF THE PELVIS

These are often referred to as diameters which are measurement taken on the brim cavity and the
outlet of the pelvis.
DIAMETER OF THE BRIM
The anteroposterior diameter of the brim is measured from the centre of the sacral promontory to the top
of the symphysis pubis. This can be anatomical conjugate which measure 12cm, and it differs from the
obstetrical conjugate which is measured from the sacral promontory to a point 1.25cm down the
posterior surface of the symphysis pubis. It measure 11cm. the term truwe conjugate could be used to
refer to either of these measurement. In life this obstetrical conjugate is assessed by estimating the
diagonal conjugate on the vaginal examination.
The diagonal conjugate is the distance between the lower border of the symohysis pubis and the
sacral promontory. It measures 12cm – 13cm.
THE OBLIQUE DAIMETER OF THE BRIM
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These are estimated from the sacro-iliac joint on one side to the iliopectineal eminence on the opposite
side-each measure 12cm, they take their names from the sacro-iliac joints hence the right sacro-iliac joint
to the left iliopectineal eminence and vice-versa.
THE TRANSVERSE DIAMETER OF THE BRIM
This is between the farthest point on the iliopectineal lines and it measures 13cm.
THE SACRO-COTYLOID DIAMETER
This is the diameter of the brim which extends from the sacral promontory to the iliopectineal
eminence; it measures 9-9.5cm/
DIAMETER OF THE CAVITY
The anteriposterior diameter of the cavity
This is measured from the midpoint of the symphysis pubis to the junction of the second and third sacral
vertebrae. It measures 12cm. since the plane of the cavity is a cirvle, all the other diameters measure
12cm.
DIAMTER OF THE OUTLET
The anterior-posterior diameter
This is measured from the lower of the symphysis pubis to the sacro-coccygeal joint. It measure 13cm.
during delivery it may be increased by the backward displacement of the coccyx over the sacrococcygeal
joint.
THE TRANSVERSE DIAMETER OF THE OUTLET
These are taken or estimated between the ischial spines or tubersities. Each measure 11cm, if the ischial
spine are prominent, the interspinous diameter is reduced and it is therefore of greater obstetrical
importance than the intertuberous diameter. The intertuberous diameter is easily assessed by the midwife
by placing four knuckles of her hands between the tuberosities.
The oblique diameters and parallel to the other oblique diameters and measures 12cm.
PELVIC INCLINATION
When a woman is standing in the upright position her pelvis is not right angle to her spine, the
inlet slopes at an angle of 600 with the floor. The inclination of the cavity is 300, outlet in chat is 150 in
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some Negro women, and brim in chat is 900, which causes some delay engagement of the head during
labour.
MEASUREMENTS OF THE PELVIC CANAL (IN CENTIMETRES)
Anteroposterior Oblique Transverse

Brim 11 12 13
Cavity 12 12 12
Outlet 13 12 11
DIFFERENT TYPES OF PELVIS
The four basic type of pelvis according to the shape of the brim are;-
1. The gynaecoid or true female pelvis has round brim (inlet)

2. The android has a heart-shaped brim
3. The anthropoid has an oval brim narrow in the transverse
4. The platypelloid or simple flat pelvis has a kidney shaped brim, narrow in the anteroposterior
diameter.
THE GYNAECOID PELVIS
The normal female pelvis is gynaecoid in shape. The brim of the true pelvis is round or oval in
shape. When the patient is standing, the pelvic inlet or brim is inclined at an angle of 50-600 to the
horizontal. The true conjugate should measure at least 11.5cm. the greatest tranverse diameter of the brim
bisects the anteroposterior diameter of the brim at its midpoint. This greatest transverse diameter (also
referred to as available diameter) measures 13cm.
The sacrum is well curved and is concave inward from above downwards and from side to side. The
sacro scsiatic notches are wide and shallow. The entire diameters anteroposterior, transverse and oblique
diameter of the mild cavity are about the same in size and each of them measures approximately 12cm.
The anterposterior diameter of the pelvic outlet is about 13cm. it is measured from the lower
border of the symphysis pubis to the tip the sacrum the transverse diameter of the outlet may be measured
between the tips of the ischial spines or between the inner aspects of the ischial tuberosities. It measures
11cm. The coccys is freely mobile. This further helps to increase the anteroposterior diameter of the
pelvic outlet.
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The sub-pubic is wide and can allow a foetal head whose bipareital diameter is 9.5cm to pass
through the waist space, which is the distance between the circumference of the foetal head and the
highest point of the pubic arch, is usually not more than 1cm.
EFFECT ON LABOUR:- The foetal head often engages in the transverse diameter of the brim in an
anterior position. The course and mechanism of labour are normal. Therefore the gynaecoid pelvis is the
best for child bearing.
THE ANDRIOD PELVIS
This is a male type of pelvis, the brim is triangular or heart-shaped and is roomier posterioely. The pelvic
cavity is deep and funnel-shaped because the sacrum is straight and the side walls converge inwards. The
ischial spines are prominent and the transverse diameter is usually reduced.
EFFECT ON LABOUR:- The foetal head often engages in the transverse diameter of the pelvic brim or
in a posterior position because the biparietal diameter is more easily accommodated in the posterior
segment of the heart-shaped brim. Deep transverse arrest of the head often occurs because of the
prominent ischial space. The acute pubic arch forces the head backwards into the segment of the outlet
causing much bruishing or laceration of the pelvic floor and the perineum.
THE ANTHROPOID PELVIS
This type of pelvis resemble the pelvis of the ape. The brim is oval in shape with an increase in the
anteroposterior diameter and a corresponding decrease in the transverse diameter. The sacrum is long and
narrow and may contain six vertebrae.
EFFECT ON LABOUR: The head often engages in the anteroposterior diameter, sometimes with the
occipitoposterior. The head may descend through the pelvis in the occipitoposterior and be born face to
pubic. Generally the pelvis is large and labour is easy.
THE PLATYPELOID PELVIS
This corresponds to the simple flat pelvis. The anteroposterior diameter is short but transverse
diameter is wide. The sacro-sciatic notch is narrow. The sacrum is flat and displaced forward, therefore
the anteroposterior narrowing of the pelvis continues in the cavity and outlet. The sub-pubic angle is
wide.
EFFECT ON LABOUR: The head will engage in the transverse diameter of the brim. Rotation of the
head may be restricted and deep transverse arrest of the head may occur.
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THE CONTRACTED PELVIS
A contracted pelvis is one in which one or more diameters are much reduced, interfering with the normal
mechanisms of labour. The usual varieties of contracted pelvis are as follows:-
THE JUSTO-MINOR PELVIS
This is a gynaecoid type of pelvis in which all the pelvic measurements are diminished but are in correct
proportion. Women with this type of pelvis are short in nature and are usually not more than 150cm tall.
These women tend to develop pre-eclampsia during pregnancy and their pregnancy may go beyond term.
Occasionally this type of pelvis may be found in a woman of normal stature.
EFFECT ON LABOUR:- The difficulty encountered will depend on the degree of cephalopelvic
disproportion and will persist throughout the first and second stage of labour. The mechanism of labour
proceeds in the ususal way but there will be exaggerated flexion of the head. If vaginal delivery is
thought possible, a trial of labour is carried out. Caesarian section may be necessary, but fortunately these
women often have a small babies.
The funnel-shaped pelvis is a form of contracted pelvis; it usually leads to obstructed labour if there is
cephalopelvic disproportion. The anthropoid and the platypelloid pelvis are also type of contracted pelvis.
DIAGNOSIS OF CONTRACTED PELVIS AND CEPHALOPELVIS DISPROPORTION
Patient whose height is 150cm or less should be suspected of having contracted pelvis; not all
short women have contracted pelvis but the height of the patient is the best yardstick for sorting out
cases.
The diagnosis of contracted pelvis can be confirmed by;
1. External pelvic assessment or external pelvimetry

2. Clinical internal pelvic assessment or internal pelvimetry
3. Radiological pelvic assessment of x-ray pelvimetry.
Midwives should not depend on external pelvic measurement, since the method is grossly inaccurate
and is not used in modern obstertrics.
Internal pelvimetry is carried out by vaginal examination. The best time to assess the pelvis internally
is a time as near to the term as possible. For primigravida internal pelvic assessment should b e carried
out at about 33 week’s gestation. Multigravida who have spontaneously delivered babies weighing 3-4kg
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are not likely to have contracted pelvis. Those who have delivered smaller babies should have a thorough
pelvic assessment at about the 38th week.
THE PELVIC FLOOR
The soft tissue which fill the pelvic constitute the pelvic floor. These are mainly muscles and their fascia
covering. A coronal section of pelvis shows these tissues in the order mentioned below:
a. Peritoneum
b. The pelvic fascia – some of this form the cervical ligaments
c. The levator ani muscles
d. The superficial perineal muscles
e. Some fat
f. Outside covering of skin
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It is important to know the muscular structure of the pelvis floor so that one can appreciate the
damage which may occur to it during labour.
The muscular structure consist of two layers:-
a. Deep layer which comprises the levator ani muscles

b. Superficial layer which comprises the superficial perineal muscles.
LEVATOR ANI MUSCLE
The levator ani is a pair muscles sheets arising from around the brim of the pelvis, they converge
in a downward and inward direction forming a gutter-shaped slope, where these muscle sheet meets in
the middle are three orifice, the urethrea, vagina and anal canal.
The muscle-fibres of the levator anu are arranged in three pairs namely:-
a. The pubo-coccygeus fibres arises from the bodies of the pubic bone pass through the bladder, the
lowest one-third of the vagina and the coccyx.
b. The ilio-coccygeus fibres arise from the white line which is a condensation of the fascia of the
obstructor internus and iliaus muscles.
The white line slightly below the ilio-pectineal line. The ilio-coccygeus muscle fibres are fanned out
along the white line and then pass inwards to be inserted in the sacrum and coccyx.
c. The ischio-coccygeus fibres are situated in front of the sacrospinous ligament. They arise from the
ischial spines and pass downwards and inwards to the coccyx and the lowest part of the sacrum.
The internal or the upper surface of ani muscle is gutter-shaped i.e concave and the posterior
undersurface is convex. The undersurface is occupied posteriorly by the ischio-rectal fat and anteriorly by
the superficial perineal muscles.
THE SUPERFICIAL PELVIC FLOOR MUSCLES
These muscles consist of the following groups:-
a. The transverse perineal muscles:- they originate from the ischial tuberosities and meet
horixontally at the perineum.
b. The bulbocavernosus:- this arises from the perineum and passes forward around the vaginal to be
inserted into the corposal cavernosa (spongy-like bodies on either side of the clitoris).
c. The Ischiocavernosus arises from the ischial tuberosities and passes upwards and inwards along
the oubis arch to end at the corpora cavernosa
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The following groups of muscles fibres are considered part of the pelvic floor;-
d. The external sphincter muscle of the anus: This muscle encircles the anal canal and goes into the
formation of the perineal body.
e. Membranous sphincter of the urethra. This is not a true sphincter, it can occlude the urethral
orifice when contract, it arises from one pubic bone, passes below and above the urethra to the
other bone.
THE PERINEAL BODY
The perineal body is a wedge tissue between the anal canal and vagina in front. Laterally it lies
between the ischial tuberosities, its deeper half consists of fibres from the levator ani and the superficial
half is made up of the bulbo cavernous and the transverse perineal muscle, the outer skin covers the
perineum.
The perineal body is of very great importance during the delivery of a baby, it is likely to be injured
during the delivery. The injury or laceration is described on degree-first, second and third.
BLOOD SUPPLY: Pudendal arteries and vein supply and drain the perineum.
THE LYMPHATICS: The lymphatic’s drain to the inguinal glands.
NERVE SUPPLY: These are aided by the pudendal nerve.
FUNCTIONS:- The levator anu from a hammock across the pelvis and thus give support to the
abdominal organs. Some of the pelvic fascia condenses around the cervix and forms the ligamentory
support of the uterus. This explains why extra strain on the pelvic floor during labour or parturition
weakens these supports and results in prolapsed of the uterus during labour, the pelvic floor contracts
when the foetal head reach it, this action directs the head forward (described as internal rotation of the
head).
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THE PERINEAL BODY
THE EXTERNAL GENITAL ORGANS
The external genital organs of the female are known collectively as the vulva and include the
following structures;
Mons veneris:- A pad of fatty tissue, covered by skin, which lies over the symphysis pubis. After
puberty, a growth of hair develops on it.
Labia Majora:- Two large rounded folds of fatty tissue covered by skin which meet anteriorly at the
mons veneris. As they pass backwards the anus they become flatter and merge into the perineal body.
The terminal portions of the round ligaments are inserted into the fatty tissue. The inner aspects of the
labia are smooth and contain numerous sweat and sebaceous glands while their outer aspects, after
puberty, are covered with hair.
Labia minora;- two folds of pink skin lying longitudinally within the labia majora. They are smooth,
having no covering of hair, but do contain a few sweat and sebaceous glands. They area they enclose is
known as the vestibule. Each labium minus divides into two folds anteriorly. The upper folds surround
the clitoris and unite to form the prepuce. The two lower folds are attached to the undersurface of the
clitoris and are known as the frenulum. Posteriorly, the labia minora unite to form a thin folds of skin, the
fourchete, which is torn when a first-degree perineal tear is sustained during delivery.
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The Clitoris: A small, extremely sensitive, erectile structure, situated at previously explained, within
folds of the prepuce and frenulum. It is composed of two bodies, the corpora cavernosa, which lie side by
side and extend backwards to be attached to the periosteum of the bodies of the pubic bones. The clitoris
is a structure which may be compared with the male penis but, unlike the penis, does not transmit the
urethra.
We are now living in a multiracial society where there is a wide range of different religions,
beliefs and cultural practices. Female circumcision is a traditional practice of which we, in the UK, are
now becoming much more aware. It affects the appearance and function of the vulva in relation to the
degree in which it is practiced.
The Vestibule:- In order to observe the vestibule, the folds of the labia must be separated to bring it the
clitoris.
1. The Urethral meatus:- Known also as the external orifice of the urethra, this lies 2.5cm below the
clitoris.
2. Two Skene’s ducts: The opening of Skene’s tubules which run parallel with the urethra for about
6mm, and then opens, one on each side of the urethra orifice.
3. The vaginal orifice:- Also known as the introitus, this occupies the lower two-thirds of the
vestibule. In a virgin it is covered by the hymen, a thin perforated membrane through which the
menstrual flow can pass. The hymen is ruptured following intercourse and further laceration
occurs during childbirth, the remaining tags of skin being known as carunacula myrtiformes.
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4. Two bartholin’s duct and glands:- The glands lie on the side of the vagina, resting on the
triangular ligmanets. About the size and shape of haricot beans, they are composed of racemose
glands and secrete mucus. The ducts are the opening of the glands and open outside the hymen so
that the glandular secretion keeps the external genitalia moist.
Blood supply: The pudendal arteries, branches of the femoral artery, supply the external genitalis.
Venous drainage is by the corresponding veins.
Lymphatic Drainage: Some drainage is into the inguinal glands and some is into the external iliac
glands.
Nerve Supply: Branches of the pudendal nerve and the perineal nerve provide the nerve supply.
The vulva becomes very distended towards the end of the first stage of labour and even more so
during the second stages when the fetal head is descending quite rapidly. A practical knowledge of the
basic anatomy of these parts is therefore essential in order that the bladder and episiotomy with maximum
of efficiency and minimium of trauma to her patient.
THE VAGINA
Situation: The vagina is a potential canal which extends from the vulva to the uterus. It runs upwards
and backwards parallel to the plane of the pelvic brim. It is surrounded and supported by the pelvic floor.
Shape: Its shape is that if potential tube, the walls normally lying in close contact with each outer but
becoming easily separated.
Size: Because the cervix centers the vagina at right angles, the posterior vaginal wall is longer than the
anterior wall when the uterus is anteverted. The anterior wall is approximately 7.5cm long and the
posterior wall 10cm long. Should the uterus be retroverted, then these measurement will be reversed.
Gross Structure: Four fornices are formed where the cervix projects into vagina. These are named
anterior, posterior or lateral according to their position, the posterior fornix is the largest. At the external
orifice of the vagina, the hymen covers the opening or, if the hymen has ruptured, the carunculate
myrtiforms are found instead.
MICROSCOPIC STRUCTURE
1. Squamous epithelium is a type of modified skin and forms the vaginal lining.
2. Vascular connective tissue
3. Vascular coat is arranged in two layers of involuntary muscle fibres:
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a. Inner circular fibres
b. Outer longitudinal fibres
Although this muscle coat is rather thin, it is nevertheless very strong.
4. Fascia is made up of loose connective tissue which is part of the pelvic cellular tissue.
The walls of the vagina do not lie smoothly but fall into transverse, fold, the rugae, which allow for
distension. In a patient who has borne several children the rugae have been stretched several times, a nd
are therefore not so obvious on inspection.
Blood supply: Vaginal and uterine arteries, branches of the internal iliac artery, form a plexus around the
vagina.
Venous Drainage: Is by Corresponding vessels
Lymphatic Drainage: Drainage of the lower third of the vagina is into the inguinal glands, while the
upper two thirds is into the internal and external iliac glands.
Nerve Supply: Sympathetic and parasympathetic nerve from the Lee Frankenhauser (sacral) plexus
serve the portion of the vagina which lies above the levator and muscles. The pudendal nerve supplies the
lower vaginal area.
Relations
Anterior – Base of bladder rest on upper half of vagina. The Urethra is embedded in lower half.
Posterior – (a) Pouch of Douglas – Superiorly, (b) Rectum – Centrally (c) Perineal body – inferiorly
Lacteral – Pubococcygeus muscle below. Pelvic fascia containing ureter above
Inferior – Structure of the vulva
Superior – Cervix.
FUNCTIONS
- Entrance for spermatozoa

- Exit for menstrual flow and products of conception
- Helps to support the uterus
- Helps to prevent infection
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There is an acid medium in the vagina provided by Doederlein’s bacilli which are normal inhabitants
there. They acts on the glycogen in the vaginal wall and convert it to lactic acid. The amount of glycogen
in the vaginal walls is under the cyclical influence of ovarian hormones and therefore tends to vary –
especially with the onset of pregnancy. The normal PH of vaginal fluid varies between 3.7 and 4.5.
The acid medium destroys pathogenic organism but if the bacilli are absent or reduced in number the
acidity of the vagina is altered, resulting in a consequent vaginitis.
Expectant mothers should therefore be advised not to use antiseptic preparations in the bath or for vulva
or vaginal toilet purposes except under medical supervision.
THE CERVIX
Although the cervix is part of the uterus, its structure and function differs from the main body of
the uterus and it is therefore described separately.
Situation:- It form the lower third of the uterus and is the area below the isthmus which includes the
internal and external os. It enters the vagina at right angles and is sometimes called the ‘neck’ of the
uterus.
Shape:- the cervical canal if fusiform and cervix as a whole tends to be barrel-shaped.
Size:- in adult life the cervix is 2.5cm long and as stated, form one-third of the total length of the uterus.
During intrauterine life, however, it froms the greater part of the uterus and then in the last weeks of
pregnancy there is an accelerated growth of the uterine body brought about by the high levels of maternal
estrogenic hormones. At the time of birth, the cervix and body of the uterus are approximately equal in
size. When the ovarian hormones are activated at puberty there is a further acceleration of uterine body
growth until it is approximately twice the length of the cervix. The diagnosis of an infantile uterus in an
adult woman is made upartly by assessing these relative proportions.
GROSS STRUCTURE
The supravaginal cervix:- is that portion of the cervix which lies outside band above the vagina.
Superiorly, it meet the border of the uterus at the isthmus.
The infravaginal cervix:- is that portion which projects into the vagina.
The internal os:- opens into the cavity of the uterus. Although not a sphincter in the true sense of the
word, it dilates during labor. Incompetence of the cervix at this level result in spontaneous abortion in the
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mid-trimester of pregnancy. Incompetence is sometime due to a congenital anomaly, sometimes
associated with dilatation of the cervix during a dilatation and curettage operation, and is particularly
associated with the surgical termination of pregnancy in young primigravida. It is also sometime
associated with a large cone biopsy carried out when abnormal cervical cells have been found on
cytological examination.
The external os:- opens into the vagina at the lower end of the cervical canal. On pelvic examination it is
found at the level of the upper border of the symphysis pubis. In the multifarious woman it is recognized
on vaginal examination by bening circular in shape, smooth and with a dimple in the centre. After the
36th week of pregnancy, the ‘dimple’ will admit a finger tip. In the multigravida it is a transverse, slit-like
aperture with an irregular edge and will easily admit a finger tip even in early pregnancy. It is know as a
‘multip’s os’.
The cervical canal:- lies between the internal and external os.
There are three layer of tissue:-
Endometrium:- is the inner layer. It contains many recemonse glands, Some of which are criliated to
facilitae the passage of spermatozoa. The tissue is arrange in folds , the arbor vitae, the folds allowing
dilatation of the cerix to occur without trauma. In the multigrain patient, the arbor vitae become flattened
out with successive pregnancies. The cervical endometrial is more glandular than that in the main body of
the uterus and it is not shed during menstruation. Never the less it is affected by oestrogenic hormones
and aty the time of ovulation there is an increase in the glandular seretion, which also becomes less
viscous.
Muscle:- involuntary muscle fibres are mingled with dense collagenous tissue which give the cervix a
fibrous nature. It is not possible to state relative proportions of each, since this appears to be dependence
upon the hormone level of each individual woman. The ‘average’ muscle content is said to be about 10%.
Longitudinal muscle fibres which run in both clockwise and anticlockwise directions and lie in circular
formation in the cervix.
Although the out amount of muscle fiber in the uterine body is increased considerably during
pregnancy, histologic a studies show that there is a negligible increase in the cervix.
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Peritoneum:- covers that part of the cervix which lies above the vagina. It is loosely applied in the area
where it reflects up and over the bladder. This allows both the bladder and uterus to modify their position
as required.
The infravaginal cervix has an outer coat of stratified epithelium which is continuous with that of
the vaginal lining. It continues a short distance into cervical canal to meet the cervical endoetrium at the
squamocolumnar junction- the commonest site of cervical cencer.
Blood supply:- the blood is supple through the uterine areteries, and venous drainage is through the
uterin vein.
Lymphatic drainage:- the lymphatic drainage is into the internal iliac and sacral glands.
Nerve supply:- tsympathetic and parasympathetic nerves from the lee-frankenhauser (sacral) plexus
provide the nerve supply.
THE NON-PREGNANT UTERUS
Situation:- the uterus lies in the true pelvis in an anteverted and anteflexed position. Its actual position is
distended.
Shape:- the shape resembles that of an English pear.
Size:- 7.5cm long, 5cm wide, 2,.5cm in depth, 1.25cm thick. The weight is approximately 60g.
GROSS STRUCTURE
The cervix:- forms the lower third of the uterus and has already been describe in detail.
The isthmus:- is the narrowed constriction about 7mm thick lying between the body of the uterus and the
cervix.
The corpus or body:- forms the upper two-thirds of the uterus and is that portion of the organ lying
above the cervix.
The cornua:- are the areas of the uterus where the fallopian tubes are inserted. The lumen of the tubes
open into the uterine cavity.
The fundus:- is the portion lying above and between the cornua.
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The cavity:- is the triangular – shaped potential hollow in the centre of the organ. The walls of the uterus
normally lie in apposition.
Endometrium:- a mucus membrane lining with secretory activity. Because it is influenced by the
ovarian hormones, its appearance varies with each day of the menstrual cycle. During menstruation it is
shed as far as the basal layer and is renewed on average every 28days from the menarche to the
menopause.
Myometrium:- this is the muscle layer which makes up the chief bulk of the uterus during the period of
active sexual life. Its structure differs before puberty and after the menopause. Involuntary muscle fibres
are intermingled with areolar tissue, blood vessels lymphatic vessels and nerves.
Inner circular and outer longitudinal involuntary muscle fibre are continuous with those of the
fallopian tubes and together with involuntary circular fibres there. These fibres all interlace to form
spirals which pass in both clockwise and anticlockwise directions but forms dense circles around the
cornua and cervix. while it is impossible to define distinct muscle layers because the fibres are so
intermingled, the middle strata, which contains the large blood vassels supplying the uterus, is much
thicker than the layers on the inner and outer sides of it.
It seems that uterine contractions are partially intiated by the peristaltic waves in the fallopian tubes,
and that the interlacing muscle fibres fron the fallopian tubes and the ligaments, together with those of the
uterus, become contractile as the result of oestrogen peaks during the menstrual cycle. Should there be
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any incoordination of muscle fibres act in coordination, the fimbriated end of the fallopian tube is
brought into proximity with the ovary at the time of ovulation.
Perimetrium, or peritoneum:- covers the uterus quite smoothly and almost entirely. The areas which
are excluded are: (1) those areas of cervix previously mentioned, and (2) a narrow strip of the lateral
uterine walls. The peritoneum is attached quite firmly ot the uterus except for an anterior portion of the
isthmus, where its loose attachment allows the bladder to expand, and where it forms the uterovesical
pouch. Posteriorly, peritoneum forms the pouch of douglas.
Blood supply:- ovarian arteries on the right and left from the abdominal aorta supply the fundus of the
uterus. They pass downwards to meet the uterine artery of the corresponding side. Uterine arties on the
right and left reach the uterus at the level of the internal os, and send branches to supply the body of the
uterus as well as the cervix and vagina.
Venous drainage is into the ovarian veins, which drain into the inferior vena cava on the right
hand side, and into renal vein on the left.
Lymphatic drainage:- lymphatic drainage is into the internal iliac and the sacral glands.
Nerve supple:- nerve supply is via sympathetic and parasympathetic nerves from the lee-frankenhauser
(sacral) plexus.
SUPPORTS
The round ligaments:- composed largely of fibrous tissue, maintain the uterus in its position of
anteversion and anteflexion. They extend from the cornia at each side, pass downwards and insert into the
tissues of the labia majora. However, they allow enough movement for the uterus to rise when the
bladder is distended.
The broad ligaments:- are not true ligaments but folds of peritoneum extending laterally between the
uterus and side walls of the pelvis.
The cardinal ligaments, pubocervical ligaments and uterosacral ligaments:- Although described as
supporting ligaments of the cervix, are obviously also uterine supports. Overstretching of these ligaments
will result in prolapsed of the uterus. They are composed of thickened bands of pelvic fascia connective
tissue and muscle fibres from the pelvic floor and uterus. In particular, the pubocervical ligaments are
especially concerned with maintaining the angle between the cervix and the horizontal plane.
FUNCTIONS
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- To prepare a bed for the fertilized ovum
-- To nourish the fertilized ovum for the gestation period
- To expel the products of conception at full term
- To involute following childbirth
RELATIONS
Arterior:- as for the cervix. The intestines lie above the bladder and in front of the body of the uterus.
Posterior:- relations of the cervix and the uterosacral ligaments
Lateral:- relations of the cervix, the fallopian tubes, ovaries and round ligaments.
Superoior:- the intestines
Inferior:- the vagina
FALLOPIAN TUBES (UTERINE TUBE) OR OVIDUCT
These are two tubes which extend from the cornia of the uterus to the ovaries. Each fallopian
tubes is 10-12cm long and has a small lumen which communicates with the uterine cavity medially and
opens into the peritoneal cavity laterally.
Division
a. interstial portion- the narrowest portion,(i.e. within the thickness of the uterine wall. It is 1-2cm long
b. the isthmus – is another narrow portion 2-3cm from the cornua of the uterus
c. the ampulla- the dilated portion is 5cm long
d. the infundibulum- is the last 2.5cm. it is made up of fingerlike processes called fimbrae one of the
fimbrae extends to the ovary and called the fimbria ovarica
STRUCTURE
Outward inside
1. Peritoneum
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2. Muscular coat – with circular fibre inside and longitudinal
3. Vascular connective tissue
4. Mucous lining- thrown into several fold called plicae.
Blood supply
- uterus and ovarian arteries drained by corresponding veins
- Lymphatic drainage to lumbar glands
- Nerve supply – from ovarian plexus
Related Structure
Medially - uterus
Laterally -infundilopelvic ligament and other content of pelvic side wall
Inferiorly - broad ligament and the ovaries are below
THE OVARIES
These are the female sex glands, there are two ovaries one on either side of the pelvic wall. Each ovary is
a solid body measuring about 3.5cm length, 1.5 to 2.5cm in thiclness. It weighs about 48gm
The ovary is attached to the back of broad ligament by the mensovarium. The point of tis attachment to
the ovary is called hilum where blood vessels and nerves enters and live the ovary. Ovaraian ligament
suspend the ovary from the cornuo of the uterus. Ovary is the only abdominal organ not covered with
peritoneum. It is covered by thick connective tissue known as tunica albuginea. The surface looked
scarred in adult but smooth in new born baby. The ovary of menopausal woman is smooth and smaller
than young woman.
Blood supply – Ovarian artery and uterine artery
Venous drainage – By corresponding vein
Lymphatic – Drain to aortic lymph nodes
Structure of the ovary
The ovary has an outer zone is called the cortex and the inner zone the medulla.
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The cortex: - The cortex has a stroma of connective tissue in which graafian follicles are found in their
varying stages of development. The cortex is covered by thick connedtive tissue – tunica albuginea.
The medulla: - The medulla has connective tissue stroma in which numerous blood vessels, nerve and
graafian follicles are found.
Functions of the ovary
a. The production of ova for the purpose of procreation
b. Production of hormones
MALE REPRODUCTIVE SYSTEM

The male reproductive organs are divided into external and internal genitalia. The system is
closely related to the urinary system because of urethra that performs the function of reproduction and
urination.
The external genitalia are; the scrotum while the internal organs otherwise called the gonads are;
the testes/testicles, epididymis, vas deference, ejaculatory duct, the urethra, seminal vesicles, prostate
glnad, bulbo-urethral gland (Cowper’s glands).
PENIS
Penis is the male orgen of copulation; it has a root or the attached portion and a body or free
portion. The root of the penis is found attached to the superficial perineal pouch and made three masses
of erectile tissue. These are the bulb and the two crura (left and right crus). Each of the crus is attached
firmly to the margins of the pubic arch and covered by the ischiocavernosus muscle. The two crura
continue anteriorly to form the body of penis as the corpora cavernosa. In between the two crura there is
bulb that is attached to the perineal membrane. It is covered by the bulbospongiosus e that continues
anterioly into the penis as the corpus spongiosum. The urethra pierced the bulb to form a dilation called
onyra bulber fodda, it then transverses the corpus spongiosum.
The body of ponis composed of three cylindrical bodies (corporal) of erectile tissue that are cnclosed by
dense fibrous tissue, deep fascia and skin. Is very thin with dark colour. At the dorsal part of the penis,
the two of three crectile bodies i.e. the corpora cavernosa are arranged side by side while the third one
corpus spongiosum which contains spongy urethra lies ventrally.
The gland penis is situated at the distal end of the body; it is completely made up of corpus
spongiosum. The concacity of the glans covers the free blunt ends of the corpora cavernossa. The glands
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are highly sensitive to physical stimulation due to its rich innervations. Near the tip of the gland is the
slit-opening of the spongy urethra which is referred” to as the external urethral or meatus.
The skin and fasciae of thr penis are extended to form free fold of skin called the prepuce
(foreskin) that covers the gland. When the penis is flaccid, the root, body and the gland feel spongy due
to the cavernous erectile tissues that have interlacing and intercommunicating spaces. Blood filled those
spaces to make the penis erect when stimulated.
The body of the penis supported by two ligaments, the fundiform ligament and the suspensory
ligament. The fundiform ligament extends from anterior abdominal wall while the suspensory ligament
extends from the symphysis pubis.
Blood supply to the penis
There are three branches of artery arising from the internal pudenal artery that supply blood to the
penis. These are:
1. The deep artery with its branches running a spiral course called helicine arteries in the corpus
cavernosum.
2. The dorsal artery runs on the dorsum and supplies the glands penis, the prepuce and distal part of
the spongiosum.
3. The artery of the bulb supplies the bulb and proximal part of corpus spongiosum.
Venous drainage
The corresponding veins to the arteries mentioned above drain the corresponding parts into the prostatic
venous plexus.
Nerve supply
Sensory supply - dorsal nerve of the penis
Motor supply - perineal branch of pudendal nerve
Autonomic supply – pelvic plexus
Sympathetic fibres are vasocomstrictors and parasympathetic (S2, S3, S4) are vasodilators.
Lymphatic drainage
Lymphatic drainage from glands penis to deep inguinal nodes
Lymphatic drainage from the rest of the penis is to superficial inguinal lymph nodes.
Applied anatomy
a. Congenital anomalies
1. Hypospadias: - This is malformation of penis and urethra where the external urethral orifice opens
on the ventral surface of the glans penis or the body instead of the tip of glans penis.
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2. Phimosis: - in normal penis, the prepuce is usually sufficiently elastic to allow for its retraction
over the glans penis, but in phimosis, the prepuce fits tightly over the glans and cannot be retracted
easily.
b. circumcision: - surgical removal of prepuce
c. The anatomical basis of erectile
sexual stimulation in man is a form of parasympathetic stimulation which makes the smooth muscle in
helicine arteries to relax. The arteries become straightened and their humina are enlarged, thus filling the
cavernous spaces with blood and they become dilated and rigid. The ischio cavernosus and
bulbospongiosus muscles compress the venous plexuses at the peripherty of the corpora cavernosa to
prevent the return of venous blood. Therefor the three corpora become enlarged, rigiod and the penis
erects. After ejaculation and orgasm, the penis gradually returns to ite flaccid status due to sympathetic
stimulation that causes constriction of smooth muscle
The Prostate gland:- Is made up of glandular and muscular tissues and situated around the neck of the
bladder. It secrets a thin, milky and alkaline fluid which aids sperm movement and neutralizes the
acidity of the vagina during intercourse and that of the male urethra just before ejaculation so as not to
kill the sperm,
The nulbo urethra gland:- These are two small gland that are on either side of the urethra. They
secrete clear, thick and alkaline fluid. The fluid lubricates the penile urethra during sexual excitement
thus enhacing sperm motility. It also neutralizes the acid in the male urethra and the vagina.
The urethral glands:- Are small glands found across the lining of the penile urethra. They secrete
mucus that adds to the quantity of the seminal fluid.
The urethra:- A tube-like structure about 20cm (8 inches) long, it runs from the bladder through the
prostate gland beneath the pubic bone and throughout the length of the penis. It serves as an outlet for
urine and semen. The urine from the bladder flows out through the urethra and during sexual
intercourse; the small muscle located at the opening of the bladder closes to allow the semen to pass
through it without urine contamination.
Semen/seminal fluid:- This is composition of sperm and secretions from all the accessory glands.
The spermatozoon:- The sperm/spermatozoon is about 0.05mm long and only visible under a
microscope; it has a head, neck and fine long tail. The head contains the genetic material while the tail is
motility. It is produced in the testes from puberty to old age and may be stored in the male genital tract
for up to 42 days depending primarily on the frequency of ejaculation. The spermatozoon can live for
between 48 and 72 hours in the female genital tract once ejaculated. Averages of about 100 million
spermatozoa per milliliter and they travel at very fast speed.
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Spermatogenesis:- Is the process of production of sperm in the seminiferous tubules under the influence
of follicle stimulating hormone (FSH) and testosterone. This begins in puberty and continues throughout
adult male life. The process of maturation is usually long, it takes some weeks. Following maturation,
the sperm will be stored in the epididymis and the deferent duct until ejaculation. About 2 to 4 mls of
semen are deposited in the vagina at each ejaculation. Out of about 100 million sperm per ml, 20-25% is
likely to be abnormal while the remainder mover at approximately 2-3mm/min . Each spermatozoon has
a head, a body and a long, mobile tail that is contains enzyme to dissolve the covering of the ovum in
order to penetrate it.
HORMONAL ACTIVITY DURING MENSTRUAL CYCLE

Anterior pituitary gland
1. Follicle stimulating hormone (FSH)- ripens the graafian follicle
2. Luteinising hormones (LH) maintains the corpus luteum
3. Prolactin – begins early preparation of the breast for the function of lactation.
Ovary
1. Oestrogen is essential for the development of female characteristics. It produces re-growth of the
endometrium
2. Progesterone is indispensable since it stimulates necessary physiological preparation for
pregnancy.
3. Relaxin ripens the follicle and allows to rupture.
OESTROGENS
At puberty
Oestrogens produce development of the secondary sexual characteristics in the female. They:
1. Increase the length of the long bones and close the epiphysis
2. Develop the glandular tissue of the breast
3. Increase deposits of the subcutaneous fat which gives the female figure its curves
4. Bring the structures of the external genitalia to their female adult status.
At puberty, they:
1. Stimulate the growth of the endometrium and increase its vascularity
2. Promote regeneration of the endometrium after menstruation
3. Increase the cervical mucus and reduce its viscosity at the time of ovulation
4. cause proliferation of the vaginal epithelium and ensure that the cells are packed with glycogen.
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Natural oestrogen from the ovary and the adrenals lower the levels of cholesterol and the
incidence lowers the levels of cholesterol and the incidence of coronary heart disease in women whereas
synthetic oestrogens increase the level of fibrin and therefore the clotting power of blood and cause a
predisposition to thromboembolic disease, as well as coronary heart disease. They also cause rise to
blood pressure.
PROGESTRONE
1. Makes the cervical mucus much more tenacious before and after ovulation
2. Acts on the muscle fibres of the fallopian tube, increasing muscle tone
3. reduces the frequency of peristaltic contractions, causing vaginal epithelium to desquamate, and
depletes epithelial cells of glycogen
4. Increase the vascularity of the breast and cause proliferation of mammary tissue
5. increase water and sodium retention the body tissue
6. The endometrium glands become tortuous and secrete more mucus and fluid which is rich in
glycogen.
THE PRODUCTION OF MATURE OVA

OOGENESIS
The oogenesis takes place in the cortex of the ovary. The primordial germ cell is the oogonium. It
is surrounded by follicular cells to form primordial follicle. The oogenesis is accompanied by
development and growth of the follicles.
The oogonium divides by mitosis and large number of oogonia is formed before birth. Each
oogonium then enlarges to form primary oocyte. The primary oocyte enters the prophase of first meiotic
division before birth. But the division is arrested and resume only at puberty.
After puberty at each cycle few primary oocytes resume the first meiotic division which is
completed just before ovulation. The first meiotic division is unequal, most of the cytoplasm gaining to
one daughter cell forming secondary oocyte, while other daughter cell receives minimal cytoplasm and
forms the first polar body.
The secondary oocyte enters the second meiotic division at the time of ovulation but this division
is completed only after the sperm has penetrated the secondary oocyte. The second meiotic division is
also unequal, so that one daughter cell receives most of the cytoplasm and forms the ovum while the
other daughter cell receives very small amount of cytoplasm and forms the second polar body.
The nucleus of the primary oocyte contains 23 pairs of chromosomes (diploid chromosomes) one
part of chromosomes are sex – determining chromosomes and are designated XX. The other
chromosomes are known as autosomes. Each chromosome is composed of two chromatids. Each pair of
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chromosomes therefore has four cromatids. Chromatids carry the genes genetid Material commonly
called DNA (Deoxyribonucleic Acid) and protein materials. Genetic material conveys inherited
appearance and characteristics from parents to their children.
OVARIAN CYCLE
Ovarian cycle is the physiological changes that occur in the ovary, essentially for the preparation and
release of an oocyte. It consist of three phases all of which are under the control of hormones.
1. The follicular phase 2. Ovulation 3. Luteal phase
1. Follicular phase: - primordial follicles, containing primary occytes, have been developing into
large preovulatory or graafian follicles containing secondary occytes in a process known as
folliculogenesis prior to birth and until puberty in a process known as oogenesis.
Low level of oestrogen and progesterone stimulate the hypothalamus to produce gonadotrophin
releasing hormone (GnRH). This releasing hormone causes the production of follicle stimulating
hormone (FSH) and luteinizing hormone (LH) by the anterior pituitary gland. FSH controls the growth
and maturity of the graafin follicles. The graafin follicles begin to secrete oestrogen. The reduced FSH
secretion causes a slowing inhibin which further suppresses FSH. This dominant follicle prevails and
form a bulge the surface of the ovary and soon becomes competent to ovulate. The time from the growth
and maturity of the graafin follicles to ovulation is normally around 1 week, day 5-14 of a 28- day cycle
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of events.occasionally the follicular phase may take longer if the dominant follicle does not ovulate and
the phase will begin again.
2. Ovulation: - ovulation is the process whereby the dominant follicle ruptures and discharges the
secondary oocyte into the uterine tube where it awaits fertilization. The LH surge occurs around 12-13
of the 28 days cycle and lasts 48hours. Stringly clear mucus appears in the cervix, ready to accept the
sperm from intercourse.
During ovulation there may be mittelschmerz (abdominal pain) there may also be some light
bleeding. Following ovulation, the fertilized oocyte travels to the uterus.
3. Luteal phase: - This is the process whereby the cells of the residual ruptured follicle proliferate
and form yellow irregular structure known as the corpus luteum (yellow body). The corpus luteum
produces oestrogen and progesterone for approximately 2 weeks, to develop the endometrium of the
uterus which awaits the fertilized oocyte. The corpus luteum continue its role until placenta is
adequately developed to take over.
In the absence of fertilization, the corpus luteum degenerates and becomes the corpus albican
(white body) and progesterone, oestrogen, and inhibin levels decrease. In response to low levels of
oestrogen and progesterone the hypothalamus produces GnRH. The rising levels of GnRH stimulate the
anterior pituitary gland to produce FSH and the ovarian cycle commences again.
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PHYSIOLOGY OF MENSTRUATION
This is the physiological changes that occur in the uterus, it is also called menstrual cycle (uterine
cycle or endometrial cycle). It is essential to receive the fertilized oocyte (ovum).
The menstrual cycle consist of three phases.
1. Menstrual phase
2. Proliferative phase
3. Secretary phase
1. Menstrual phase:- (Menstruation, bleeding, menses). Physiologically, this is the terminal phase
of the reproductive cycle of event. The spiral arteies of the endometrium go into spasm withdrawing the
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blood supply to it. Necrosis occur and the endometrium is shed down to the baeal layer along with blood
from the cepillaries and the unfertilized ovum (oocyte). It last 3-5 days.
Day l of the menstrual cycle is the first day endometrial bleeding.
2. Proliferative phase: - proliferative phase follows menstruation and lost until ovulation.
- There is formation of a new layer of endometrium
- It is under the control of oestrogen secreted by graafin follicle
- It consist of the regrowth and thickening of the endometrium in the uterus.
- During the 1st few days the endometrium is reforming described as in the regenerative phase 3
layers are formed
- The basal layer – 1mm thick
- The function layer – 2.5mm tick
- Layer of cuboidal ciliated epithelium
3. Secretory phase: - This phase follows the proliferative phase and it under the influence of
progesterone and oestrogen secreted by the corpus luteum. The functional layer of the endometrium
thicken to approximately 3.5mm become more spongy in appearance because the glands are more
tortuous, increase blood supply to the area, the glands produce glycogen (nutrition secretion).
This condition last for approximately 7 days awaiting the fertilized ova.
MENSTRUAL DISORDERS
1. Dysmenorrhea
2. Amenorrhea
3. Oligomenorrhea
4. Menorrhagia
5. Metrorrhagia
6. Cryptomenorrhoea
(1) DYSMENORRHEA
This means painful menstruation. Characterized by cramping lower abdominal pain radiating to the back
and upper thighs. Which usually start before or along side with the flow.
TYPES OF DYSMENORRHEA
a. Primary dysmenorrheal
b. Secondary dysmenorrheal (spasmodic)
PRIMARY DYSMENORRHEA
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Usually begins with the first period and is heralded by cramping lower abdominal pains starting just
before or with the menstrual flow and continuing during menstruation. It is often assoiciated with:
1. Nausea
2. Vomiting
3. Headache
4. Faintness
5. Symptoms of peripheral vasodilation
Causes: - spasms of uterine muscle. The cause is thought to be related to – excessive
Prostaglandin production.
- Cervical obstruction
- Hormonal inbalance
- Psychological factors
- Blockage of nerve pathways
TREATMENT
Reassure the client
- Worm bath
- Application of heat to the abdomen (hot water bottle)
- Certain exercises such as abdominal muscle strengthening.
- Mild analgesic e.g. paracetamol
- Feldine is very effective
- Anti spasmodic drugs e.g. buscopan
- Suppress ovulation by means of oestrogen
- Progesterone e.g. dydrogesterone 10mg. daily from 5 – 25th day of each cycle treatment continues
for six months to 2years
SURGICAL INTERVENTION
Dilation and curettage (DIC) may be tried, not always with successes and onvolved the risk of an
incompetent cervix in subsequent pregnancies.
Presacral neuredectomy is major operation but the results are good.
SECONDARY (CONGESTIVE) DYSMENORRHEA
Usually affect older women (30-40 years) who complain of a congested ache with lower
abdominal cramps, which usually start from few days to two weeks before menstruation.
CAUSES: -
- Pelvic inflammatory disease e.g. salpngo – oophritis
- Endometriosis (presence of tissue similar to endometrium)
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- Fibroids
- Presence of LUCD
- Malposition of the uterus
- Habitual constipation
SYMPTOMS
The patient complains of headache, backache, pains in the thighs and the symptoms are usually
relieved when theomenstrual period begins.
TREATMENT
Treat any underline cause base on: -
- The severity of the condition
- The age of the patient
- The past obstetric history
- Her desire for more children
2) AMENORRHOEA
Amenorrhoea mean absence or stopping of the menstrual periods. It is normal for the periods to
be absent before, puberty, during pregnancy and milk secretion and menopause.
There are two types amenorrhoea
1. Primary amenorrhoea
2. Secondary amenorrhoea
Primary Amenorrhoea
This is when menstrual period fail to appear at puberty
Causes of primary Amenorrhoea
1. Disorders of endocrine glands.
Cushing syndrome; Addison diseases, myxoedema (a dry firm waxy swelling of the skin and
subcutaneous tissue found in patient with underactive thyroid gland (hypothyroidism),hyperthyroidism,
turner’s syndrome)
2. Developmental abnormalities
Failure of the uterus, vagina, and ovaries to develop,
Absence of the uterus, vagina, and or ovaries
3. Chromosomal abnormality
4. If the uterus is surgically removed or the ovaries are removed of destroyed e.g. by radiarous.
SIGNS AND SYMPTOMS
- Under developed figure
- Small breast
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- Scanty public hair
- Patient are short statured
- Webbing of the neck
- Wide caring angles of the elbow
TREATMENT OF PRIMARY AMENORRHOEA
Hormone therapy, lowdose of estrogen e.g. ethymylstal 0.02mg dail for 21days with norethisterone 5mg
added from days 14-21. If it is due to a defect of the ovaries, it is usually permanent B) secondary
amenorrhoea
The menstrual period stop after establishment at puberty.
CAUSES
- Physiological factors
- Before puberty
The oestrogen levels are not sufficient to cause bleeding from the endomentrium.
- During pregnancy
The space between the decidua capillaries and the decidua vera are fesed after 12 th week of the
pregnancy
- During lactation
Prolaction is secreted in large amount by the auterior lobe of the pituitary gland and there is partial but
not complete suppression of luterinizing hormone so that ovarian follicle may mature but fail to rupture
 Psychological disturbances
Change of environment may produce stress and subsequently amenorrhea. Being away from home,
attending college, tension from school, work, change of occupation or climate, bereavement, grieve and
obesity.
Young women suffering from anorexia nervosa system disease e.g. pulmonary tuberculosis severe
anaemia, renal disease, malnutrition, psychiatric disorders.
Surgical: - hysteratony, removal of ovaries
 Medication e.g. antipsychotics, cancer therapy, antidepresaut
 Contraceptives e.g. depo
 Excessive exercise
INVESTIGATION
- Pregnancy test
- Pelvic examination
- Blood investigation for infecton, anaemia
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- Chest x-ray to rule out TB
- Skill x-ray to exclude pituitary tunour
- Vagina cytology to reveal oestrogen present
- Analysis for 24hrs to estimate hormonal levels
- Chromosomal analysis to exclude chromosomal abnormality
SPECIFIC DIAGNOSIS
An endomentrium biopsy
Ovarian biopsy
Laparoscopy
Hysterosalpingpgraphy (HSG)
TREATMENT
Treatment depend on the cause and include adopting a heathier lifestyle or starting hormone,
antibiotics, iron replacement advice on diet in obesity, and anorexia, surgical reaction psychological
support. In many instances, no treatment is necessary
(3) OLIGOMENORRHOEA
Sparse and or infrequent menstruation.
This can be primary – when the period is always like that or
Secondary – which means at one time the woman had normal menstrual cycl. It may occur two or three
times in a year.
(4) MENORRHAGIA
menorrhagia means heavy bleeding at menstruation. The normal blood loss during menses is 50-
150mls. menorrhagia is an abnormally heavy or prolonged bleeding
CAUSES
- In some cases the causes is unknown
- Hormonal imbalance – if hormonal imbalance occurs ( Oestorogen $ progesterone) the
endomentrium develop in excess and eventully sheds by way of heavy menstrual bleeding
- Dysfunction of the ovaries – if ovulation does not occur, progesterone is not produced. This
causes hormonal imbalance and may result in menorrhagia.
- Uterine fibroids – can cause heavier than normal or prolonged menses
- Polyps: - small benign growths on the lining of the uterine wall as a result of high hormone levels
- Adenomyosis:- this condition occur when glands from the endometrium become embedded in
the uterine muscle, often causing heavy bleeding and painful menses.
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- Intrauterine device (IUD):- menorrhaga is one of the side effects of IUD.
- Pregnancy complications:- miscarriage, ectopic pregnancy
- Cancer – uterine, ovarine,and cervical cancer can cuase excessive bleeding
- Inherited bleeding disorder:- some blood coayulation disorder such as von will ebrand’s disease –
a condition in which an important blood clotting factor is deficient or impaired
- Medication:- certain drugs such as anti-inflammmatory medications and anticoagulants improper
use of hornomone medication can also menorrhagia
- Other medical conditions:- e.g p[elvic inflammatory disease (PID), thyroid problem, end
ometriosis and liver or kidney disease may be associated with menorrhagia.
Treatment
Depending on the cause, severity of the condition and your child bearing plan.
- Iron supplements – when patient is not yet anaemic
- Nonsteroidal anti-inflammatory drugs (NSAIDS) e.g. ibuprofen, naproxen – they help to reduce
menstrual blood loss, and added benefit of
- Oral contraceptives – also help to regulate menstrual cycles.
- Oral progesterone – when taken for 10 or more days of each menstrual cycle, the hormone
progesterone can help correct hormonal imbalance and reduce menorrhagia
- The hormonal IUD (mirena) – this type of intrauterine device releases a type of progestin called
levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and
cramping.
Surgical treatment
- Dilation and curettage (D&C)
- Operative hysteroscopy – the use of hysteroscope to view uterine cavity which can aid the
surgical removal of polyps
- Endometrial ablation – permanent destruction of the entire lining of uterus (endometrium).
- Endometrial resection – the use of electrosurgical wire loop to remove the linig of the uterus
- Hysterectomy – surgical removal of uterus.
When menorrhagia is a sign of another condition, such as thyroid disease, treating that condition
usually result in lighter periods
5) Metrorrhagia
Irregular vaginal bleeding that is not associated with menstruation. The cause may be vaginal in origin
due to foreign bodies in the vagina, inflammations of the vagina such as candidiasis or trachomoniasis, or
occasionally, it may be uterine or cervical in origin.
Management
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- Reassure
- Give symptomatic reaction
- Give analgesics
- Refer to obstetrical and gynaecological teams
6) CRYPTOMENORRHOEA
Cryptomenorrhoea is term used for the absence of blood flow when the internal systems of menstruation
are present.
Causes
1) imperforate hymen – this is when the hymen at the entrance to the vagina lacks an opening
2) it can be as a result of obstruction along the birth canal
Treatment
D&C may help
MENOPAUSE
Menopause took some women unaware while some could be very depressing while other welcome this
change as a natural phenomenon. It has been known that some women who are well prepared for this
change go through this period with mild or no problem at all, while some experience severe and
unbearable problems.
DEFINITION OF MENOPAUSE
It is the time in the life of a women where her ability to reproduce stops naturally.
This change is manifested by complete withdrawal of menstrual bleeding.
Natural menopause occurs about 45-55 years of age for most women (average 48 years).
Premature menopause may occurs before the age of 40 years, late menpouause occurs after 55years of
age.
In other case, menopause may occur artificially due to the following:
1. Use of drugs which may affect hormone production in the ovary
2. Radiotherapy for pelvic cancer
3. Abnormal uterine bleeding or tumour
4. Surgery involving the ovaries
The real cause of menopause is not yet know but could be due to increased rise in the output of pituitary
gonadotrophic hormone. It could also be associated with withdrawal female egg in the ovaries.
Stages of changes
There are three stages to the reproduction change in the body. They are before, during and after.
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SATAGE1: this occur between age40-45. The menstrual period become irregular occurring once every
two or three months. It is not safe to have unprotected sex if pregnancy is not desired.
STAGE 2: this occur between age 45-50. The menstrual period at this stage may stop completely.
Unprotected intercourse is still unadvisable as pregnancy can still occur.
STAGE3: It occurs at the age of 50 and above where there is total ceasation menstrual period. It is now
certain that one is really menopausal, but unprotected intercourse is unwise until 12-18 months after the
after the last period.
Things that happen during reproductive changes
1. The women’s ovaries which are responsible for the production of female hormones, commence
the withdrawal of this function gradually.
2. The secretion of the hormones now becomes more reduced
3. Ovulation becomes irregular
4. Menstruation becomes irregular
Commonest symptoms
Some women enjoy better health during menopause especially women with dysmenorrhoea.
1. Changes in menstrual period which becomes irregular, scanty or excessive.
2. Longer or shorter menstrual cycle occurring at intervals of 2-6 months. This may last for 6
months 5 years until menopause occurs.
3. Hot flushes and sever unprovoked perspiration. This tends to be most disturbing and
uncomfortable. The skin of the bony suddenly becomes flushed, usually from the shoulder up to
the neck and the head, resulting in an uncomfortable heat sensation, which could be momentary or
lasting up to 15 minutes and may occur many times a day.
The body temperature is however usually normal. Other symptoms includes;
1. Nervousness
2. Irritability- respond in a specific way to outside stimuli shown by nerve cells and muscle cells.
3. Depressive mood
4. Headache
5. Dizziness
6. Anaemia
7. Dryurtus of the vagina causing painful intercourse
8. Pruritus (itching of the vulva)
9. Weight gain
10. Scanty pubic hair
11. Indigestion constipation, sleeplessness
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Ovaries shrinks, they become harder and smaller and replaced by small follicular cysts, the
connective tissue increases in quality and the functional activity of the ovaries ceases. The fallopian tube
became narrower and shorter and the lumen is obliterated.
- The uterus becomes smaller, its muscularity decreases and the walls becomes thinner.
- The cervix is shortened and may feel like a button in the vagina roof. The uterine cavity may
becomes partially obliterated.
- The mucosa is thinned and the glands aredestroyed.
- The vagina become shortened and conical in shapes the rugae disappears, the walls lose their
elasticity and become pale in colour and the epithelium snows a tendency to be shed in patches.
- The vulva and labia loss their fat the labia becoming thin folds of skin, the skin becomes dry.
- The breast may become thin and flabby or there may be a great increase in the amount of fat.
There is loss of glandular element.
The uptake of calcium by the body is facilitated by vitamin D, deficiency of vit D may result in
rickets, osteoporosis, osteomalacia.
Management
1. To reduce hot flushes (sudden onset of sweat) nervousness, and sleeplessness.
- To avoid alcoholic drinks, tea or caffeine –they have stimulant action on central nervous system,
promote wakefulness and increase mental activity.
- To avoid high sugar intake and spicy food – aromatic items used to flavor food.
2. Eat well balance diet
- Avoid eating large meal
3. Vegetable and fruits such as carrots, pawpaw, and almond fruits are useful in providing the body
with missing hormones
4. Advise the woman to keep cool by wearing comfortable cotton clothes, not to wear silky or
wooden fabrics.
5. to sleep in a cooler room
6. learn to reduce stress by ignoring hot flushes
- involve in activities such as trekking exercises, deep breathing or massages.
7. advise the woman to attend workshop or meetings on menopause as this help to counteract fear
and uncertainty.
8. for vaginal dryness, which causes discomfort during intercourse, advice the woman to see the
health care provider who will advise on the type of lubricant to use. (vagina cream containing oestrogen).
9. advice the woman to drink plenty of water daily, this will help to add moisture to the body. Feel
free to use handfan or put on electric fan.
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10. vitamin such as vit.B and vit.C can help to reduce stress. Vit.E which is found in vegetable oil,
soya beans, millet will help to minimize or stop hot flushes and vaginal dryness. Calcium + vitamin D
help the bones.
11. avoid insertion of local herbs into the vagina as this may cause serious medical problems.
12. encourage the woman to discusss all these with her partner, this will get him understand better
and supportive.
13. Ethinylestradol – (synthetic oestrogen) 0.01 does is given ones daily for a week. The doses is then
increased until flushes occur only about 4 times daily. Therefore, the dose is gradually reduced over 6
months when further therapy should be unnecessary.
14. Mild sedatives and tranquilizer re necessary to control nervousness and to counteract mental
depressioin.
Menstruation which continues after the age of 55 is pathological and requires investigation. It
may be associate with fibroids, diabetes mellitus, or an oestrogenic tumour of the ovary
Tips the woman should remember
- the client should go to the doctor or nurse for regular checking of blood pressure, weight, breast,
pelvic organs and cervix (pap smear). This will allow early detection and management of any
abnormality.
- self breast examination is important. Its for early detection and prompt treatment of abnormal
lumps
- Report any bleeding after menopause to allow for investigation and early treatment
- Remember “menopause is not a disease condition” it is what every woman will go through in life.
Many have gone through is successfully.
- Be informed that just as women go through their own changes, so do the men. So relax and get
your partner educated about menopause.
ANDROPAUSE
Andropause (sometime called male menopause) refers to a reduction of the production of certain
hormones e.g testoerone.
However by the time men are between the ages of 40 and 55 they can experience a phenomenon similar
to female menopause, called andropause, unlike women, men do not have a cleaer-cut sign post such as
the ceasation of menstruation to mark transition.
Unlike menopause, which gradually occur in women during their id-forties to mid-fitties men’s
transition may be much more gradual and expand over. Many ades. Testosterone level tend to decline an
average of 1% per year after 30 years old in men.
Causes
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1. Andropause is said to be cause by the presence of sex binding hormones globulin that traps much
of the testosterone that is still circulating and make it unavailable to exert its effects in the body’s tissue.
2. Aging
The predisposing factors to early onset of andropause include:
1. Viral infection such as mumps
2. psychological stress
3. Surgical removal or surgical injury to the ts=estis
4. Alcoholism
5. Obesity
6. Medication side effect
7. Type 2 diabetes
8. Other hormonal disorders
9. Infection such as HIV/AIDS
10. Chronic liver or kidney disease
11. Testicular cancer or treatment of testicular cancer
Sign and symptoms
- reduction in libido
- reduced potency (erectile dysfunction)
- fatigue
- Hot flushes and sweating
- insomnia
- joint aches and stiffness of hands
- premature aging
- inability to concentrate
- Changes in hair growth and skin quality
- Depression or sadness
- Nervousness
- impaired memory
- infertility
- Decreased bone density
- Gynaecomastia (development of breasts)
- reduced muscle mass and feelings of physical weakness
- Increased body fat
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- Low energy
Diagnosis
- through signs and symptoms
- Through laboratory investigation such as
a. Free teastosterone blood level
b. Computing the free androgen index (total teastosterone x 100 per sec hormone binding globulin).
c. Prostate specific antigen (PSA)
there are some controversy as to what level of testosterone in men is normal with low end values
ranging from 250 – 400mg/dl.
NORMAL ANDROGEN LEVELS MEAN RANGE

Free testosterone in men 700ng/dl 300-1100
Free testosterone in women 40ng/dl 15-70
Free androgen index 70 – 100
Nursing management
1. couple counseling, career refocusing and spiritual support
2. Exercise, dietary changes and stress reduction
3. treatment for depression through diversional therapy
4. Chemical dependency treatment, sexual compulsitivity treatment
5. Finding and engaging one’s calling in the second half of life.
Medical management
Testosterone replacement therapy, this can be in form of pills, e.g. metheltesterone transdrmal
preparations, injection subdermal pellets, implant.
Side effects of hormone therapy
Synthetic testosterone can have damaging side effects e.g it can cause cancer cells to grow in
prostate gland with cancer.
GYNAECOLOGICAL POSITION AND PROCEDURES
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GYNAECOLOGICAL POSITION PROCEDURES
1. Lithotomy position-spine, flings, flexed and Vaginal examination, IUD insertion and removal.
abducted (knee up) Normal delivery
2. semi-recumbent or supported sitting position Labour/ delivery
with thigh abducted
3. Dorsal position “
4. Upright positions “
5. Squatting position “
6. Kneeling position “
7. All fours (relief back pain, especially occipito Another name is Gaskin maneuver (for shoulder
posterior, but tiring to maintain dystocia)
8. standing “
9. Using birthing ball “
10. Knee – chest position pressure on the umbilical Management of cord prolapsed
cord is relieved as the fetus gravitates towards the
fundus
11. trendelenburg position when the foot of the bed “
is raised to relieve compression on the cord
12. Eccaggerated sims position – the woman is For shoulder dystocia
helped to le on her left side with a wedge or pillow
elevating her hips to relieved pressure on the
umbilical cord
13. Mc Roberts with manoeuvre position – this This pressure will relate the angle of the symphysis
involves helping the woman lie pubis superiorly and use the weight of the mother’s
leg to create gentle pressure on her abdomen
releasing the impaction on her anterior shoulder
DILTATION AND CURETTAGE (D&C)

Ditatation and curettage is a brief surgical procedure in which the cervix is dilated and the uterine
is scraped or suctioned.
It is an operation in which the cervix dilated with dilator and the endometrium is slightly scraped
off with a curette.
Indication for D&C
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1. To remove retained tissue in the uterus during or after a miscarriage or abortion or to retained
placenta and/or membrane after childbirth. This helps to prevent infection and heavy bleeding
(PPH)
2. To diagnose or treat abnormal uterine bleeding. Uterine tissue can be taken and examined by
pathologist. It may help diagnose or treat growth such as fibroids, polyps, hormonal inbalances, or uterine
cancer, D&C may be done with other procedure such as hysteroscopy
Management
The procedure is done by a medical doctor. It is performed under anaesthesia, either local, spinal or
general anaesthesis.
D&C involves no stitches or –cuts. The doctor cleanses the cervix with an antiseptic solution. It can be
done in health care provider’s office, a surgery centre or a hospital.
Patient can watch out and report the following:-
-- heavy bleeding from the vagina
-- fever
-- pain in the abdomen
-- foul-smelling discharge from the vagina
Risks and complications
1. haemorrhage – when instrument injure the uterine wall or if an undetected fibroid is cut during
curettage
2. infection
3 perforated uterus- though rare, is common to women with uterine infection, in elderly, post
menopausal is carried on miscarriage.
4. asherman syndrome
This is also rare and involves formation of scar tissue in the uterus caused by aggressive scrap in
or abnormal reaction to the scraping. Thick scars can result, which can fill up the uterus completely, this
can lead to infertility and cessation of menstrual periods. Asherman syndrome can be treated successfully
with surgery.
5. missed disease- since the procedure cannot remove all the endometrium, there is a chance that
disease could go undetected, this is why the procedure should be done with nysteroscopy.
Contraindication for D&C
-- pelvic infection
-- blood clotting disorder
-- serious medical problems e.g. heart and lung disease, which can be general and sometimes local
anaesthesia more risky.
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Preparation for D&C
-- avoid unnecessary drugs few days before D&C- e.g. aspirin which can cause increased risk of
bleeding and any over-the-counter medication such as laxatives, avoid alcohol and tobacco, stop taking
any herbal supplements at least two weeks before surgery.
-- any chronic condition should be stabilized e.g. high blood pressure.
-- patient should be on nil per oral 12 and 8 hours for general and local anaethesia respectively.
-- preliminary test – a day before surgery test like routine blood, urine and other tests to be sure no
medical problems have been missed. Other pre operative care should be done.
Procedure
-- patient will be put on lithotomy position.
-- proper cleaning of vulva
-- uterine sound will be passed to determine the depth and angle of the uterus
-- different sizes of metal dilator can be used to dilated cervix to scrape or suction the uterine wall.
The tissue can be sent to the lab for analysis as necessary.
-- the entire procedure takes about 20minutes
-- the patient can experience cramps for about 30minutes, or longer.
After the surgery
Patient may have some light bleeding for several days
-- she should be in recovery room for one hour
-- arrange for transport home but not to drive herself for the next 24hours because of side effect of
anaesthesia
-- ibuprofen are usually given for cramping pain
SALPINGECTOMY
Salpingectomy is a surgical procedure for removal of one or both diseased fallopian tubes in females.
Types of salpingectomy
1. partial salpingectomy – where only a part of the fallopian tube is removed.
2. complete or total salpingectomy – where the entire fallopian tube is removed
3. bilateral salpingectomy – where both the fallopian tubes are removed.
4. uniteral salpingectomy – where only one fallopian tube is removed
5. salpingo – oophorectomy – where the ovaries are removed along with the fallopian tubes.
Indications for salpingectomy
1. ectopic (tubal) pregnancy- when the fertilized egg settles outside the uterus.
2. hydrosalpinx – accumulation of fluid within the fallopian tube. It can result in fertility.
3. infection and stricture of the tube due to organism like gonoorhea, syphilis, or Chlamydia.
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4. cancer of the fallopian tube
5. as a prevention of ovarian cancer, at women of high risk, ovaries are removed along with fallopian
tube.
6. A long with the removal of uterus, a procedure referred to as total abdominal hysterectomy with
bilateral salpingo-oophorectomy
Pre operative tests done before salpingectomy
- Abdominal and pelvic ultrasound
- Hysatersalpingogram (HSG) – contrast medium (also called as a dye) is introduced into th uterus
via the vaginal, this is visualized through imzaging test as it passes through the uterus to the tube to th]e
abdomen. With obstruction the contrast is unable to pass through the tube and its seen as a narrow section
on the x-ray,.
- Diagnostic laparocopy –used to directly visualize thye fallopian tubes.
- routine tests – blood test (hemoglobin level blood group, electrolytes and kidney function test,
ECG chest x-ray
Pre and post operative management – as for patient with other abdominjal surgery
Complications
- complication due to anesthesia
- bleeding
- injury to surrounding structures
- infection
- chronic pain
- Bilateral salpingectomy result in infertility
VASICO-VAGINAL FISTULA (VVF)

VVF is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending
between the bladder and the vagina that allows the continuous involuntary discharge of urine into the
vaginal vault.
Cause of VVF
1. It is often caused by child birth (obstetric fistula) when prolonged labour passes the unborn child
tightly against the pelvis cutting off blood flow to the vesico vaginal vault. The affected tissue
may neutrotize (die) leaving a hole.
2. Particular violent cases of rape – especially those involve multiple rapists and/or foreign objects.
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3. It can be associated with hysterectomy, cancer, operations, radiation therapy and cone biopsy ( a
surgical removal via a vaginscope colposcope) of a cone-shaped segment of tissue from the cervix
of the uterus).
4. Inflammatory bowel disease ( including crohn’s disease and ulcerative colitis) or diverticulitis
(pouches that form in the wall of large intestine get inflamed).
5. A deep tear in the perineum or an infected episiotomy after child birth.
Predisposing factor
1. Very young mothers’
2. When there is no health care facility nearby
Symptom
- Urine incontinence flowing
Diagnosis
- Through symptom
- History of trauma, any surgery or disease that could have caused a fistula
- Speculum vaginal examination
- The use of dye in the vagina and bladder to find all signs of leakage
- Urinalysis to check for infection
- Blood test (complete blood count) to check for infection
- X-ray endoscope or MRI (Magnetic Resonance Imaging) to get a clear look for all possible tissue
damage.
Management
- The fistula closes spontaneously after ½ to 2months of urethral catheterization and anticholergic
medication, especially if the fistula is of small diameter, is detected early or there is no
epithelization of the fistula.
- Simple fistula are treated using simple vaginal approaches while complex fistula are commonly
treated either vaginally using a myocutaneous flap or through an abdominal approach.
- A delay approach to surgery may be considered to take care of the sanitary protection and the
skin
- It is vital to consider the nutritional and rehabilitative needs to patient.
- The laparoscopic (minimally invasive) approach of the VVF repair has become more prevalent
due too its greater visualization, high success rate and lower rate of complication
Prevention
- Political approach are needed as in child marriage control
- Reduction of risk factor
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- Post natal examination services should be intensified to promote early diagnosis, prompt
treatment and rehabilitation.
- Upgrading standard to institutional care
- Developing and applying better method of comprehensive medical care including PHC.
Care of catheter
1. All continuous catheter drainage for 8 days then spigot the catheter and release hurly x 12 hours
and then 2 hourly x 6hours x 24hours. This procedures, however really depends on the doctor’s
instruction.
2. Finally, remove the catheter on the 14th day and offer the patient a bed pa every hour. This special
care of the catheter helps the bladder to gradually return to its normal tone and allows the wound
to heal.
RECTO VAGINA FISTUAL

This is an opening between the rectum and the vagina in which there is constant escape of flatus
and faecal matter through the vagina.
Causes
- Congenital
- Damage to the supporting muscles as a result of prolonged labour
- Post vaginal surgery.
Signs and Symptoms
- Faecal incontinency
- Flatus is discharged through the vagina
Nursing management
- As for any surgery
- Diet should be low residual to control
- Proper cleaning of the rectum and vagina
- Temporary colostomy may be performed. This is to keep the vagina dry and clean.
- Repair of fistula should be done by gynaecologist.
Post-operative care
- Warm perineal irrigation
- Give psychological support
- Colostomy care (as need may arise)
- Care of catheter
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- Diet – as condition improves, encourage patent to take clear fluids, light diet on the next day and
particularly on protein, vitamin, moderate fat and CHO until she can diet as tolerated.
- Encourage fluid intake
- Active and passive exercise should be encouraged
- Health education should be given.
Complications
Immediate – 1st 24hours
- Respiratory failure
- Urinary retention
- Haemorrhage
- Shock
- Vomiting
Later
- Chest infection e.g Bronchitis
- Abdominal distention
- Paralytic ileus
- Deep vein thrombosis
- Urinary tract infection
Health promotion activities aimed at Primary Prevention
- Elimination
- Reduction of risk Factor
- Modification of life style pattern
- Post natal examination services should be intensified to promote early diagnosis and prompt
treatment.
Nursing care
- Catheterization – proper monitoring of the catheter
- Irrigation – bladder and vaginal irrigation are done gently with manual procedute
- Baby care – general cleanliness of the body to prevent skin excoriation sits bath should be done
twice daily.
- Deodourizing douches may be required
- Use of desirable pads and rubber pants at all time in desirable
- Light dusting powder
- Psychological care – encourage patient to accept her condition. Try as to please the patient.
Assists as need be.
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- Effective measures to assist the woman those fistula cannot be repaired must be planned on an
individual basis.
- Give appropriate antibiotics.
CERVICITIS
This is the inflammation of the cervix. The cervix is a narrow passage that connects the uterus and
vagina, if something irritates the cervix and it becomes inflamed.
Signs and symptoms
- Bleeding between periods
- Pain when having sex (dyspareuria)
- Dysuria
- Unusual grey or white discharge that may smell
- Lower back pain
- Abdominal pain
Causes
- Allergies:- if someone is allergic to these material such as spermicides, douches or latex condoms,
it may cause the cervix to be inflamed.
- Pregnancy:- this can affect hormones levels and lead to cervicitis as the cervix is much more
sensitive as this time.
- Cancer or cancer treatment:- Treatment for cancer or advanced stages of cervical cancer itself
may affect cervical tissue. This is rare but may lead to symptoms or cervicitis.
- Irritation such as tampons, pessaries or diaphragms may irritate or injure the cervix especially left
in place for long as directed.
- Sexually transmitted disease such as chlamdia, gonorrhea, trichonomiasis e.t.c
Prevention
- Wearing of loose cotton underwear which reduces the build up of moisture and bacteria that can
lead to infection.
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- Using of condoms during sex: This reduce the risk of sexually transmitted disease.
- Avoiding irritants such as tampons, douches, scented soaps.
- Expectant mothers should avoid use of antiseptics preparations for vulva or vaginal toilet.
Management
Cervicitis can either be Acute or Chronic form. And is treated medically with Antibiotics such as
Azithromycin 1g and Doxycycline 100mg.
1. Erosion of cervix
Cervix ectropin or cervical ectopy is when the soft cell (grandular cells) that line the inside of the cervical
canal spread to outer surface of the cervix.
Incidence
It is fairly common in women who are in their childbearing year and it is usually nothing to worry about
it is not a sign of another health problem.
Risk factor and causes
- You may have been burn with cervical ectropion or may develop it later in life, most likely when
your hormone level change and estrogen level go up such as during puberty, pregnancy or when
you take birth control pills, women who have STD like Chlamydia may be more likely to have
erosion of cervix
- Menstruating age
Symptoms
Many women with erosion don’t have symptom. But some have.
- Vaginal discharge sometimes with streaks of blood
- Bleeding or spotting during or after sex
- Pain during or after sex.
Investigation
The main role of any investigation is to exclude other potential diagnosis.
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- Pregnancy test
- Triple swabs- if there is any suggestion of infection endocervical and high vaginal swabs should
be taken.
- Cervical smear- to rule out cervical intraputherlial neoplasia
Management
Cervical ectropien is regarded as a normal variant, and does not require treatment unless symptomatic
- First line treatment is to stop any oestrogen containing medications-most commonly the combined
oral contraceptive pill.
- If symptoms persist the columnar epithelium can be ablated, typically using cryotherapy. This
will result in significant vaginal discharge until healing is completed.
POLYPS OF THE CERVIX

Cervical polyps are growth that usually appears in the cervix where it opens to the vagina, they are
usually chemy-red or reddish purple or grayish white. They vary in size and often looks like bulbs on thin
stems.
Symptoms
About 2 or 3 women who cervical polyps don’t have symptoms; Doctor may find out this growth deep a
pap test or other procedure. This symptoms include.
1. Period that are heavier than usual
2. Bleeding after sex
3. Bleeding after menopause
4. Vaginal discharge, which may stink due to infection
Cause
This may be linked to
1. Cervical infection
2. Chronic inflammation
3. At abnormal response to the hormone estrogen
4. Clogged blood vessels near the cervix
Diagnosis
1. Pelvic examination
2. Pap smear, take some sample to the laboratory (biopsy) to rule out cancer.
Complication
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Complication of polypectomy are rare but include
1. Infection
2. Haemorrhage
3. Uterine perforation
Management
Cervical polyps have a small (less than 0.5%) risk of indignant transformation and so it is common
practice to remove them whenever they are identified (even if asymptomatic).
Small polyps can be removed in the primary care setting. The polyp is graped with polypectomy forceps,
and twisted several times. The polpy is avulsed as the pedicle becomes twisted. The polyp should not be
pulled off as it will result in more bleeding. Any resulting bleeding can be cauterized with silver nitrite.
Larger polyps, or those that are more difficult to access can be removed by diathermy loop excision in the
colposcopy clinic or under general anesthesia if the base of poly is broad.
Any excised polyp should be sent for histological ecamination to exclude malignancy. They have
recommence rate of 6-12%.
CERVICAL CANCER
Abnormal cells on the cervix growing out of control
Six leading cancer in women
- Breast 719000
- Cervix 437000 (80% of cases are from developing countries)
- Colorectal 346000
- Stomach 282000
- Lung 219000
- Ovary 16200
Profile of femal genital tract cancer (OOUTH SAGAMU Cancer Records)
- Cervical cancer 55%
- Ovary 20%
- Corpus uteris 15%
- Vulva 8%
- Vagina 2%
- Fallopian tube Nil
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Clinical Presentation
Normal cervical cell changes rarely symptoms but occur if the cell changes grow into cancer
- Vagina bleeding – (abnormal) bleeding between menstrual period, after sex or after menopause.
- Malodourous vagina discharge ( smelling like rotten meat and non- itchy)
- Deep seated pelvic pain, this may radiate to the lower back and upper part of the thigh, pain
during sex
- In the advance stage patient is very ill- looking and weak due to anemia/ureamia
- Pallor
- Evidence of fecal incontinence or urinary incontinence, if RVF orVVF has complicated the Dx
- Speculum examination of the cervix shows
Craggy mass/ fleshy out- growth
Contact bleeding
Breakage of fleshy mass on contact
Staging
Stage IA- cancer confined to the cervix
Stage IB1 diameter cancer < 4cm
Stage IIA – cancer beyond the cervix extending to 1/3 vagina
Stage IIB – cancer beyond the cervix extending to parametrium
Stage IIIA – cancer beyond the cervix extending to distal portion of the vagina
Stage IIIB – cancer beyond the cervix extending to pelvic sidewall
Stage IVA/IVB – cancer has spread to bladder/rectum and can involve distance metastasis
Cause of cervical cancer/ risk factor
1. Most cervical cancer is caused by virus called human papilloma virus (HPV). It can be contacted
through sexual intercourse with an infected person. Not all types of HPV can cause cervical
cancer, some may not cause any symptoms while some cause genital warts.
- Smoking- this is linked to lowering immune system thus lowering body ability to eliminate HPV,
also harmful substance in tobacco damage the DNA of cells in the cervix and contribute to the
development of cervical cancer.
- Pregnancy – the risk rises with parity
- Social class
Cervical smear test – sexual active woman should be a cervical smear test every 5 years.
Diagnosis of cervical cancer
Cervical cancer develops over 5-10 years through a well-recognized pre-cancerous phase. The
changes can be detected through screening. There are now two popular method of screening.
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- Pap smear and cytology (papanicolaous smear)
- Visual Aid techniques
- Pap smear and cytology is the internationally acceptable and most advanced method of screening.
The drawbacks are cost & technicalities. Result read by a cytotechnologist and/or pathologist.
- Sample taken from of the cervix to look for cell changes
- Visual aids techniques are cheap and sensitive but are not as specific as the pap smear. This may
be desirable for countries of low resources e.g. visual inspection with acetic acid (VIA)
- Chest x-rays, CT scan, MRI, and a PET scan may be used to determine the stage of cervical
cancer
- Cone biopsy/ tissue biopsy – cone biopsy removes the entire circumference of the transformation
zone and most if the cervical cana – helps to confirm the cancer cell know the extent of the
cancer and possible treatment.
- Colposcopy- wash cervix with 3-5% acetic acid solution inspect cervix under magnification (4x
to 20x ) assess the entire TZ and any ace to white area.
Prevention
- Prevent HPV though; HPV type 16 is the main organism linked to the development of cervical
cancer.
- Immunization – two vaccines GARDASIL and CERVARIX are vaccines available to prevent
HPV
- Prevent multiple sexual partner
- Prompt treatment of STI
- Educating women (and men) that screening by pap smear or visual inspection with acetic acid
(VIA) is important
- Precancerous change in the cervix may be treated with: Cryotherapy- this is freezing of abnormal
areas of the cervix with very cold disc/probe – 600c eliminate precancerous cell, it is highly
effective for small lesions. A simple procedure done in outpatient department for about 15
minutes, usually caused some crampting / mild pain.
- Cauterization - Destruction of tissues by direct application of heated instrument, as it is used to
stop bleeding from small levels, removal of warts or other growth.
- Laser surgery – The use of a device that produce a very thin beam of light in which high energies
are concentrated
- LEEP/LLETZ – (Loop electrical excision procedure, Large-loop excision of TZ). This choice is
made when lesion is too large for cryoprobe, when it involve endocervical canal, and when
histology is needed.
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Need intensive training, anaesthesia, electricity, sophisticated equipment, post operative bleeding 2.
An excision method, using a thin electric wire to remove the entire transformation zone (TZ)
Treatment
- Surgery – such as hysterectomy and removal of pelvic lymph node with or without removal of
both ovaries and fallopian tubes
- Chemotherapy
- Radiation therapy. Combination of therapy may be necessary.
- Palliative care for advance cases
- Psychological, social and spiritual care
- Laser or cryotherapy
- Cone biopsy – this is both diagnostic and treatment
- Management of cervical intraepithelial neoplasia (CIN) which is the precursor for invasive
cancer of the cervix, i.e. the early removal of precancerous cells
The prognosis of cervical cancer depends upon the stage and type of cervical cancer as well as the
tumor size
Procedure for visual inspection with acetic acid
(VIA/Visual inspection with lugol’s iodine (VILI)
- Explain the procedure to patient, insert the speculum
- Gently clean cervix with dry swab, if necessary
- Wash the cervix with a 3-5% acetic acid solution, carefully inspect the cervix, especially the TZ
for acetowhite.
VILI – After Via, wash the cervix with lugos’s iodine solution, inspect the cervix carefully, paying
attention to areas that were Via. Positive, VILI positive if there are dense bright, banana yellow non-
uptake areas in TZ. VILI is useful for confirming VIA finding.
Types of cervical cancer
There are two main types:
1. Squamous Cell Carcinoma – Most Common (90%) of all cancers of the cervix. They arise from
squamous cells in cervix and screening tests detect abnormalities in squamous cells.
2. Adenocarcinoma – these are rare, accounting for around 10% of cervical cancers, diagnosis is
problematics as cells are to be found within the cervical canal.
ENDOMETRITIS
Endometritis is an inflammation of the endometrium due to acute or chronic infections.
Causes of endometriris
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Generally caused by infection, foreign bodies, bacteria, viruses or parasite. Infection that can cause
endometrittis includes;
- Sexually transmittnd infection (STIS)such as Chlamydia and gonorrhea
- Tuberculosis
- Infection resulting from the mix of normal vaginal bacteria
In acute phase
It may occur in the period immediately after child birth (puerperium), miscarriage or caesarean delivery.
After medical procedure that involves entering the uterus through the cervix (hysteroscopy, IUD
incertion, D&C)
Chronic endometritis in women with IUDs may be responsible for the contraceptive action.
Signs and symptoms of endometritis
1. Abdominal swelling 2.Abnormal vaginal bleeding
3. Abnormal vaginal discharge 4. Constipation 5. Fever
6. Discomfort when having bowel movement
7. General feeling of sickness 8. Pain in the pelvis, lower abdominal area and rectal area.
Diagnosis
- Abdominal, uterus and cervix showing signs of tenderness & discharge.
The following test can help to diagnose it
- specimen from cervix for culture
- Endometrial biopsy
- Laparoscopy procedure
- Blood specimen for WBC and ESR
Complications of endometritis
- Infertility
- Pelvis peritonitis
- Collection of pus or abscesses in the pelvis or uterus
- Septicemia
- Septic shock
Treatment
Atibiotics - sexual partner should also be treated if STI is diagnosed
Serious cases may neeed bed rest and intravenous fluids.
Prevention
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- Child birth and other gynaecological procedure should be perfomed with sterile equipment and
techniques
- Prophylactic antibiotics before and after the procedure
- Endometritis caused by STIs can be reduced by:
- Practicing safe sex
- Early diagnosis and prompt complete treatment
ENDOMETRIOSIS
This is an often painful disorder in which tissue that normally lines the inside of uterus
(endometrium) grows outside uterus.
It can involve the ovaries, bowel or the tissue lining the pelvis. Rarely, endometrial tissue may
spread beyond pelvic egion. Displaced endometrial tissue continue to act as it normally would – it
thickens, breaks down bleeds with each menstrual cycle.
Because this displaced tissue has no way of exit, it becomes trapped. When endometriosis
involves the ovaries, cysts called endometriomas may form, surrounding tissue can become irritated,
eventually developing scar tissue and adhesions – abnormal tissue that binds organs together.
Symptoms
- Endometriosis can cause pain (sometimes severe) especially during period.
- Fertility problems may develop
Signs and symptoms
- The primary symptom is pelvic pain, often associated with menstrual period (dysmenorrheal)
- Pain with intercourse
- Pain with bowel movement or urination
- Excessive bleeding (menorrhagia) heavy period or bleeding between period (menometrorrhagia)
- Infertility
- Others are: fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual
periods.
- Endometrisis can be mild or advance.
Causes
Although the exact cause of endometriosis is not certain, several possible explanations include:
1. Retrograde menstruation – menstrual blood containing endometrial cells flow back through the
fallopian tubes and into pelvic cavity instead of out of the body. These displaced endometrial cells
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stick to the pelvis walls and surfaces of pelvic organs where they grow and continue to thicken
and bleed over the course of each menstrual cycle.
2. Embryonic cell growth. When one or more small areas of the abdominal lning turn into
endometrial tissue, endometriosis can develop.
3. Surgical scar implantation – after a surgery, such as a hysterectomy endometrial cells may attach
to a surgical incision.
4. Endometrial cells transport – the blood vessels or tissue fluid (lymphatic) system may transport
endometrial cells to other parts of the body.
5. Immune system disorder – it’s possible that a problem with the immune system may make the
body unable to recognize and destroy endometrial tissue that’s growing outside the uterus.
Treatment of endometriosis
- Pain reliever such as nonsteroidal anti-inflammatory drug to relief abdominal cramb.
- Hormone therapy – hormone medication may slow the growth and prevent new implant of
endometrial tissue e.g. hormonal contraceptives, gonadotropin – releasing hormone (Gn-RH) agonists
and antagonist (create artificial menopause) small dose of estrogen and progesterone can be taken to
reduce the side effect of menopause, depo-provera and damazol can also be used as hormone medication.
- Conservative surgery – this can be done be done through laparoscopic surgery through small
incisions.
- In vitro fertilization to help become pregnant
- Hysterectomy – in severe cases i.e. total hysterectomy
ECTOPIC PREGNANCY
The term ectopic pregnancy refers to any pregnancy occurring outside the uterine cavity. It occurs
in 1 in 100 pregnancies in the UK and accounted for 3% of pregnancy related death.
Pathology
The commonest site of extrauterine implantation is the uterine tube, usually in the ampullary region.
Ectopic implantation may also occur on the ovary, in the abdominal cavity or in the cervical canal.
Abdominal pregnancy may result from direct implantation of the conceptus or it may result from
extrusion of a tubal pregnancy with secondary implantation in the peritoneal cavity.
As with normal pregnancy the conceptus produces hCG which maintains the corpus luteum and
the production of oestrogen and progesterone. This causes the uterus to enlarge and the endometrium to
undergo decidual change.
Trophoblastic cells invade the wall of the tube erde into blood vessels of the mesosalpinx. This
process will continue until the pregnancy ruptures into the abdominal cavity or the broad ligament or the
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embryo dies, thus resulting in a tubal mole. Under these circumstances, absorption or tubal miscarriage
may occur. Expulsion of the embryo into the peritoneal cavity or partial miscarriage may also occur with
continuing episodes of bleeding from the tube. Vaginal bleeding occurs as a result of shedding of the
decidual lining of the endometrium and progesterone levels fall the failing pregnancy.
- Previous history of ectopic pregnancy
- Congenital malformation
- Sterilization
- Pelvic inflammatory disease
- Scar from tubal surgery
- Sub-fertility
- IUCD – for pregnancies that occur despite the presence of the IUCD – uterine tumors – smoking
– recent in vitro fertilization
Clinical presentation
Acute presentation
The classical pattern of symptoms includes
- Amenorrhoea
- Lower abdominal pain – typically of sudden onset, starting on one side of the lower abdomen, but
rapidly becomes generalized as blood loss extends into the peritoneal cavity.
- Sub-diaphragmatic irritation by blood produces referred should tip pain and discomfort on
breathing.
- Vaginal bleeding
- There may be episodes of syncope (temporary loss of consciousness caused by low blood
pressure)
The findings on clinical examination
- Hypotension, tachycardia,
- Signs of peritonism including abdominal distension, guarding and rebound tenderness.
- On pelvic examination, the cervix is closed and acutely tander when moved (cervical excitation)
because of irritation of the pelvic peritoneum caused by the bleeding.
This type of acute presentation occurs in no more than 25% of cases.
Subacute presentation
The majority of ectopic pregnancies present less acutely and some or all of the classic (generally
known) symptoms may be absent. Typically, there is;
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- Amenorrhoea or of an abnormally light last period followed by irregular vaginal bleeding and
abdominal pain.
- It may be possible to feel a mass in one fornix on vaginal examination.
Diagnosis
The commonest diagnosis to be made in error on clinical diagnosis is threatened or incomplete
miscarriage.
It may also be confused with complications or ovarian cysts or acute salpingitis.
- Transvaginal ultrasound
- Laparoscopy
The above need to be used together to conform ectopic pregnancy.
Medical treatment
The use of methotrexate, an anti metabolite that transferes with the synthesis DNA given IM as a single
dose of 1mg/kg body weight or 5mg/m2. Multiple dose regimes have higher success rates but are
associated with more side effects.
Weekly follow-up with serum hCG level is required. Success rates of up to 92% have been
reported but 5% of patients will require surgery for failed treatment. It can be considered as an alternative
to surgical treatment where the serum hCG is <2000IU/L and the ectopic <2cm with no fetal cardiac
activity seen.
Surgical treatment
Laparotomy or laparoscopy can be done whether the laparotomy or laparoscopy is used there are two
main options for surgical removal of the ectopic; partial salpingectomy (removal of part of the tube done
when tube is completely damaged) or salpingotomy (leaving the tube in place and removing the ectopic
through an incision in the wall of the tube).
Nursing Management
- Upon arrival at the emergency room, place the woman flat in bed
- Ensures the appropriate physical needs are addressed and monitor for complication.
- Assess vital signs to establish the baseline data and subsequently to determine if the patient is in
shock.
- Maintain accurate intake and output chart. Adequate fluid volume at a functional level (urine
output at 30-60ml/hr).
- Monitor for presence and amount of vaginal bleeding, pain and abdominal distention which
indicate rupture and possible intra abdominal haemorrhage.
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- Blood test (full blood count) to determine extent of blood loss.
- Diversional activities which aids in refocusing attention and enhacing coping
- Address emotional and psychological needs
- Administer prescribed analgesics
- PREVENTION AND MANAGEMENT OF SEPSIS
- Sepsis is a major cause of death in mothers and foetus (or newborn) during pregnancy,
labour and the puerperium.
- In Nigeria, sepsis accounts for 17% maternal mortality. Sepsis can lead to shock, failure of
kidneys and death. And where the woman does not die, it can lead to chronic pelvic infection,
ectopic pregnancy and infertility.
- Sepsis can be defined as the invasion of germs into the body system leading to serious ill-
health. It can also be defined as an introduction of harmful micro-organisms into the body, which
multiply and cause disorders to the body system.
- CAUSES OF SEPSIS
- - Germs in the lower birth canal
- - Germs from the nose, mouth and hands of those providing care for mother and baby
- - Germs from blood and body fluids. Such opportunities arise when there is:
- - Prolonged/premature rupture of membranes
- - Prolonged labour
- - Episiotomy, laceration or traumatic delivery
- - Poor hand-washing technique
- - Frequent or unclean vaginal examinations
- - Unsafe abortion
- - Retained tissue of placenta or membranes
- - Improper care of perineum during and after delivery
- - Sickness of mother such as anaemia, tuberculosis, pre-existing STI
- PREVENTION OF SEPSIS
- - Give advice on diet during pregnancy to prevent anaemia
- - Discourage introduction of foreign bodies e.g. herbs into birth canal
- - Conduct delivery under aseptic technique
- - Use clean linen to wrap baby
- - Encourage early breast feeding
- - Avoid female circumcision and scarification
- - Male circumcision should be done under hygienic conditions.
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- - Use of very clean or sterile procedure when doing vaginal examination and wound care
- - Do vagina examination ONLY when it is necessary
- - Proper hand washing before and after caring for each mother and baby
- - Maintain perinea hygiene
- - Teach all pregnant mothers the importance of her coming back to the midwife as soon as the
membrane rupture.
- - Teach pregnant mothers the reasons why they should not have sexual intercourse after rupture
of leaking of the membranes.
- - Teach clean cord care and tetanus immunization.
- - Treat all STI and other infections in timely manner during the antenatal period
- - Monitor the mother’s temperature postnatally and ACT if the temperature is high
- - Monitor the mother’s lochia postnatally and ACT if smelly or abnormal
- - Check fundal height to make sure this is below the umbilicus and the uterus is firm
- MANAGEMENT OF SEPSIS IN THE MOTHER
- The midwife should use her PSM skills and take appropriate action based on identified problems.
- Action to be taken can include the following:
- - Give copious fluids
- - Give sponge baths
- - Give analgesic e.g. paracetamol or dispirin 2 tablets 6 hourly
- - Give antibiotics e.g. septrin tabs 500mg bd or Flagyl 400mg tds or Ampiclox caps 500mg qds
for 7 days
- - Severe cases of infection may require parental antibiotics e.g. metronidazole (Flagyl) 100mls to
run for 1 hour every 8hours x 48 hours and then change to oral
- - Refer immediately
- Note: - A postnatal or antenatal raised temperature can also be caused by Malaria
OVARIAN CYST
Ovarian cyst are fluid sacs or pockets within or on the surface of an ovary. The majority of it is
benign, the commonest being functional ovarian cysts (follicular cysts, corpus luteum). Symptoms
always arise as a result of complication.
SIGNS AND SYMPTOMS
- Most cysts don’t cause any symptoms and go away on their own
- A large ovarian cysts can cause abdominal discomfort
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- If a large cyst presses on the bladder it can cause frequent urination due to reduced bladder
capacity.
- Menstrual irregularity.
- Pelvic pain – a constant or intermittent dull pain that may radiate to the lower back and thighs.
- Pelvic pain before period, during intercourse, during bowel movement
- Nausea, vomiting or breast tenderness. Similar to that experience during pregnancy
- Fullness or heaviness in abdomen
- Pressure on rectum
TREATMENT
Medical – Pills
Surgical – Cystectomy (removal of the cyst)
Oophorectomy (removal of ovary)
Hysterectomy can also be done as the case may be
COMPLICATIONS
- Ovarian torsion – ovary move out of its usual place
- Rupture – causing severe pain and lead to internal bleeding
- May be cancerous (malignant) the cyst thatdevelop after menopause
DERMOID CYST
This is the commonest solid benign ovarian cysts found in pregnancy. they are mature cystic
teratomas.
It is a cystic teratoma that contains developmentally mature skin complete with hair follicles and
sweat glands, sometimes clumps of long hair and often pockets of sebum, blood, fat, bone, nails, teeth,
eyes, cartilage and thyroid tissue.
Because it contains mature tissue, a dermoid cyst is almost always benign. The rare malignant
dermoid cyst usually develops squamous cell carcinoma in adult in infants and children it usually
develops an endodermal sinus tumor.
TREATMENT
Complete surgical removal. If detected during pregnancy (which is very common) the surgery
(laparatomy) should preferably be done in the second trimester.
BARTHOLIN’S CYST
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Bartholin’s gland produce fluid that lubricate the vagina, sometimes the opening of the gland
becomes obstructed, causing fluid to back up into the gland. the result is relatively painless swelling
called a bartholin’s cyst. At times the fluid within the cyst may become infected, resulting in pus
surrounded by inflamed tissue (abscess).
TREATMENT
It depends on the ssize of the cyst, the pain and whether the cyst is infected.
- Antibiotics may be needed to treat infected bartholin’s cyst
- Surgical drainage of the bartholin’s cyst.
CYSTOCELE
Cystocele is also known as prolapsed, herniated, dropped or fallen bladder. This occur when ligaments
that hold that bladder up and the muscle between vagina and bladder stretches or weakness allowing the
bladder to sag or presses into the vagina.
There are three grade of cystocele;
 Grade 1 (mild) – the bladder drops only a short way into the vagina
 Grade 2 (Moderate) – The bladder drops to the opening of the vagina
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 Grade 3 (Severe) – the bladder buldges through the opening of the vagina
Risk factors for a Cystocele;
1. Vaginal birth which involve straining of pelvic floor muscle.

2. Family history
3. Obesity
4. Intense physical acitivty including lifting heavy objects
5. Hysterectomy or pelvic surgery
6. Constipation and / or repeated muscle straining during bowel movement
7. Frequent coughing
8. Aging and a drop in the hormone estrogen at menopause (estrogen helps keep muscles around the
vagina strong)
Symtopms
1. Feeling or seeing something bulging through the vagina opening

2. Diffculty urinating / urinary incontinence
3. Frequent urinary tract infections
4. Feeling of fullness, heaviness or pain in the pelvic area or lower back
This feeling may get worse when the person is standing, lifiting, coughing or as the day goes on.
5. The bladder bulging into or out of vagina.
6. Painful sex
7. Problems inserting tampons or applicators.
Diagnosis
 Grade 2 or 3 cystocele can be diagnosed through history or signs and symptoms and by vagina
examination
 Urodynamic: Measures the bladder’s ability to hold and release urine.
RECTOCELE
Rectocele occurs when the thin wall of tissue that separates the rectum from the Vagina weakens,
allowing the vagina wall to bulge. This bulge may be uncomfortable but it’s rarely painful.
Non-surgical options are often effective. Severe rectocele might require surgical repair.
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Symptoms
 A small rectocele (Posterior vaginal prolapsed) may cause no signs or symptioms

 A soft bulge of tissue in the vagina that might protrude through the vagina opening.
 Difficulty having a bowel movement,
 Sensation of rectal pressure or fullness
 A feeling that the rectum has not completely emptied after a bowel movement
 Sexual concerns such as feeling embarrassed.
 Constipation.
Causes
 Chronic constipation or straining with bowel movement

 Chronic cough or bronchitis
 Repeated heavy lifting
 Being overweight or obese
 Cystoscopy (Cystourethroscopy) – to examine the bladder and urinary tract for malformation,
blockages, tumors or stones.
Management
A Mild cystocele may not require any treatment other than avoiding heavy lifting or straining that
could cause the problem to get worse
Other potential treatment options include the following;
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 Weight loss
 Estrogen replacement therapy
 Kegel exercises – To strength the opening of the urethra, vagina and rectum. These exercises
involve tightening the muscles that are used to stop the flow of urine, holding for 10seconds, and
then releasing.
 If symptoms are modest, a device called a Pessary may be placed in the vagina to hold the bladder
in place.
Pessaries are available in a number of shape and sizes to ensure a proper fit. A pessary has to be
removed and cleansed on a regular basis in order to avoid infection or ulcers.
 Surgery – Anterior repair – the tissue that separate vagina from bladder is tightened or by placing
a synthetic material with robotic or laparoscopic approach through the abdomen. This method is
used in more severe cases and gives more support to the tissue and helps prevent reoccurrence.
The patient usually goes home the day of surgery or 1-3days after surgery as the case may be.
Complete recovery typically takes four to six weeks.
Complications
 Recurrent urinary tract infection

 Urinary retention
Prevention
 Avoid heavy lifting

 Avoid Prolong labour, bearing down before time, too frequent pregnancy, too many child birth.
 Avoid constipation
 Regulate your weight, BMI (Body Mass Index) Work Towards maintaining ideal BMI (20-
25kg/m square)
Specific Nursing Care (Post-Operative)
 Monitor Catheter drainage

 Apply and care for sanitary pad
 Don’t have secual intercourse or put anything in your vagina (such as tampoons) for six (6)
weeks after surgery.
 Avoid strenuous exercise such as jogging and running
 Don’t lift any heavy thing more than 10pounds for 6weeks.
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Take Prescribed medication such as Antibiotics, Pain reliever, laxative (stool softner).
 Pregnancy and Child birth – the more pregnancies you have, the greater you chances of
developing rectocele.
Risk Factors
 Aging – because of loss of muscle mass
 Childbirth – multiparity and perineal tear have higher risk.
 Obesity.
Prevention
 Perform Kegel’s exercises regularly
 Treat and prevent constipation
 Avoid heavy lifting and lift correctly
 Control coughing – prompt treatment
 Avoid Weight gain
Diagnosis
 Through signs and symptoms
 MRI or X-ray
 Defecography
Treatment
 If mild; simple – care measures such as Kegel’s exercises to strengthen the pelvic muscles
 Pessary; A plastic rubber ring inserted into the vagina to support the bulging tissue. A pessary
must be removed regularly for cleaning.
 Surgical repair.
UTERINE PROLAPSR/RELAPSE (PROCIDENTIA)

Uterine prolapse occurs when pelvic floor muscle and ligaments stretch and weaken providing inadequate
support for the uterus. The uterus slips down into or protrudes out of the vagina.
Symptoms of uterine prolapses
Uterine prolapse varies in severity, one may have mild uterine prolapse and experience no sign or
symptoms. If there is moderate to severe prolapse the individual may experience;
1. Sensation of heaviness or pulling in the pelvis
2. Tissue protruding from the vagina
3. Urinary problems such as urine leakage or urine retention, urgency
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4. Problem with defeacation (constipation)
5. Low back pain
6. Feeling as if one is sitting on a small ball or as if something is falling out of the vagina.
7. Sexual concern such as sensation of looseness in the tone of the vagina tissue, decrease libido,
dyspareunia.
8. Symptoms that are less bothersome in the monitoring and worsen as the day goes on.
9. Discharge, bleeding and ulceration may occur though very rare.
Causes
Weakening of pelvic muscle and supportive tissues contribute to uterine prolapse. This may happen as a
result of:
1. Pregnancy
2. Trauma during child birth
3. Delivery of a large baby
4. Difficult labour and delivery
5. Loss of muscle tone
6. Less circulating oestrogen after mfnopause
Risk Factor
1. One or more pregnancies and vaginal birth
2. Giving birth to a large baby
3. Increasing age
4. Frequent heavy lifting
5. Chronic coughing
6. Prior pelvic surgery
7. Frequent straining during bowel movement
8. Genetic predisposition to weakness connective tissue
9. Being Hispanic or white.
10. Some conditions such as obesity, chronic Obstructive pulmonary disease (COPD) and chronic
constipation can place a strain on the muscles and may play a role in the development of uterine
prolapse.
Complication
1. Ulcers – friction on underwears may lead to vagina sores (ulcers).
2. Infection – in rare cases the sores could become infected
3. Prolapse of other pelvic organs including bladder (cystocele) and recto (rectocele)
Treatment or Drug
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- Mild prolapse with or without symptom may probably not need treatment
- Performing exercises such as kegels exercise to strengthen the pelvic muscle
- Maintaining a healthy weight and avoiding heavy lifting.
For Advance cases
- Vaginal possary – this device fits inside the vagina and hold the uterus in place. This may
sometimes cause ulceration on vagina tissue and it may interfere with sexual intercourse.
- Surgery – This can be through vagina or abdominally. This can be tissue grafting through donor
or self or some synthetic material onto weakened pelvic floor.
- Hysterectomy may be recommended.
INJURY TO THE PEVIC FLOOR MUSCLE

1. Premature bearing down result in excessive strain on the transverse cervical ligament and
paracervical tissue.
2. The uterus may sag and become reboverted.
3. In the second stage, the fascia supporting the bladder become over-stretched.
4. The anterior vaginal wall prolapse and forms a sac containing the bladder (cystocele)
5. With obstructed labour when the fetal head exerts prolonged pressure on the perineum and the
pelvic floor, this can lead to fistula formation (VVF & RVF)
6. Laceration – first, second or third degree tears.
Perineal Trauma
Stretching of muscle – all the tissue are subjected to compression, dilatation and elongation during the
second stage of labour.
Minor Laceration – This affect only the fourchettee ad perineal skin
Second Degree tear – Extend to mucous membrane and superficial pelvic floor muscles and will quite
possibly be accompanied by laceration of the labial or vaginal walls. If the tear is deep, and levatories ani
muscles are involved.
Third degree tear – Tear Extend so far posteriorly that the anterior area of the external anal sphincter is
involved.
Fourth Degree tear – The tear extend to the anterior wall of the rectum is involved the internal sphincter
of the anus.
If 1st and 2nd degree tear is not treated skillfully, they can result in faecal and flatus incontinence.
The pudendal nerve which supplies both the pubococygeus muscle and the external sphincter of the
urethra and anus, is commonly damaged during child birth.
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A lax Pubococcygeous muscle will also alter the angle of the urethrovesical and anorectal junction,
contributing to incontinence or stress incontinence of urine and/ or faeces.
Prevention of pelvic floor injuries

1. Good prenatal care
- General health including prevention or treatment of anaemia
- Maintain well-nourished body
- Muscle strengthening exercise not to be dangerous nor too strenuous e.g Walking, swimming,
dancing, cycling, riding.
- Perineal awareness should be taught and as well as contracting and relaxing these muscles
regularly.
- The mother should be encouraged to stretch her perineum as much as possible by squatting and
sitting cross legged on the floor for as long as pregnancy allows
- Oiling and massaging of the perineum currently believed to be beneficial in making the tissues
nor supple
2. The basic knowledge of the process of labour should be taught or revised. The mother should also
be shown how she can carry out special breathing technique in the 1st and 2nd stages.
- Good delivery technique
- Empty bladder hourly during 1st stage of labour
- Episiotomy when need be
- Prevent prolonged and obstructed labour
3. Take special precautions in cases of complication
PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease is an inflammatory condition of the pelvic cavity that may begin from the
vagina or cervix to the uterus; fallopian tubes, ovaries, broad ligaments and pelvic peritoneum.
Causes
 Neisseria gonorrhea.
 Chlamydia trachomatis
 Staphylococcoci
 Tuberculosis
 Cytomegalovirus
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 Strepocococci
 Diphtheroids
 Chlamydiae
 Coliforms
 Pseudomonas
 Escherichia Coli
Risk Factors
 Early age at first intercourse

 Multiple sexual patners
 Frequent intercourse
 Intercourse without condoms
 Sex with a partner with an STD
 History of STDs or previous pelvic infection
 Puerperal infection
 Appendix perforation
 Pelvic peritonitis
 Endometrial biopsy
 Surgical abortion
 Hysteroscopy
 Intrauterine device (IUD) insertion
Signs and Symptoms of this disease
 Severe abdominal and pelvic pain

 Malaise
 Nausea and vomiting
 Elevation of temperature
 Anorexia
 Headache
 Lecucycytosis
 Foul smelling; purulent vaginal discharge
 Menstrual irregularities
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 Pain during sexual intercourse (dyspareunia)
 Pain during urination or defecation
Investigation
 History taking
 Physical Examination
 Full blood count
 Laparoscopy
 Ultrasoundgraphy
 Computed tomography scan
 Culdocenthesis for culture and sensitivity
 Gram stain of secretions from the endocervix or cul-de-sac
 Culture and sensitivity of vaginal swab and urethral and rectal secretions.
The Nursing and Medical Management of a patient with Pelvic Inflammatory Disease
 Admission: Admit patient for bed rest, Investigations and treatment

 Position: Place patient in a semi-fowlers position to facilitate drainage of pus into the vagina
and the cul-de-sac.
 Observation: Observe the vital signs – temperature, pulse, respiration and blood pressure 4
hourly and record.
 Monitor fluid intake and output for signs of dehydration
 Observe the patient’s level of pain and effectiveness of analgesics
 Observe the characteristics, any change in the amount, appearance, or odour and amount of
vaginal discharge as a guide to therapy.
 Watch for abdominal rigidity and distension possible sign of developing peritonitis.
 Assess the patient for adverse reactions to administered medications and other complications.
 Relief of Pain: Apply heat to the abdomen, either a hot-eater bottle or an electric heating pad,
or a hot vaginal douche twice daily. This relieve pain and discomfort by improving circulation
to the involved parts thereby allays the discomfort caused by stasis of blood
 Administer prescribed analgesic agents for pain relief.
 Restoring fluid balance
 Monitor vital signs and intake and output closely
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 Administer antiemetics as indicated
 Maintain Iv infusion of fluids until oral intake is adequate
 Provide clear fluids, soft, bland diet as tolerated
 Hygiene: Assist patient in daily baths and oral toilets
 Encourage patient to take part in plans to prevent contamination of others as well as
protect herself from infection.
 Provide frequent perineal care if vaginal drainage occurs
 Use Meticulous hand-washing technique; follow wound and skin precautions if
necessary.
 Hand perineal pads with gloves
 All items that come in contact with the patient (utensils, bedpans, toilet seats, and linens)
should be properly disinfected by the correct procedures for controlling the specific
organism responsible for the infection.
 Discharge the soiled pad according to hospital guidelines for disposal of
biohazardous material.
 Drugs: Commence antibiotic therapy immediately after culture specimens are obtained
 Psychotherapy: Reassure the patient
 Encourage her to discuss her fellings.
 Offer her emotional support and help her develop effective coping strategies.
Complication of Pelvic inflammatory Disease
 Chronic pelvic discomfort

 Disturbance of menstruation
 Constipation
 Septicaemia
 Periodic exacerbation of acute symptopms
 Infertility due to scar tissue that closes the fallopian tube
 Ectopic Pregnancy due to structures of the salpinges
 Adhesions due to chronic inflammation
 Thrombophlebitis with possible embolization.
Advice Discharge
 Encourage compliance with antibiotics therapy for full length of prescription

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 To wash hands carefully with a good germicidal soap after visiting the toilet.
 To maintain her personal and environmental hygiene
 To avoid multiple sexual partners and frequent sexual intercourse
 To use condoms during sexual intercourse
 To send sexual partner(s) to physician for examination and treatment
 To abstain from sexual intercourse and rest the pelvic (nothing in vagina, including douching or
use of tampons) until follow-up visit and testing ensure cure.
Prevention of Pelvic Inflammatory Disease
 Examine and treat sexual partner(s)

 Use condoms before intercourse or any penile-vaginal contact if there is any chance of
transmitting infections.
 Avoidance of multiple sexual partners and early age at first sexual intercourse and frequent
sexual intercourse.
 Use condoms during sex
 To avoid sexual intercourse, tub baths, and the use of douches and tampons after tumor
gynaecological procedures such as dilation and curettage, and when the cervix is dilated for any
reason example, childbirth, abortion, and miscarriage.
 To check with her doctor before resuming any of these activities
 Early treatment if she suspects that she may have gonorrhea of Chlamydia.
THE BREAST/ MAMMARY GLAND
The breast is accessory gland of the female reproductive system. They are situated on the
superficial fascia of the pectoralis major and seratus anterior muscle in the anterior chest wall. The size
and shape of the breast vary in individuals. They are usually hemispherical in young nulliparous girls but
are often flat and pendulous in the multiparous women.
The breast extends vertically from the second to the sixth rib. Horizontally, it extends from the
axilla to the lateral margin of the sternum. The part of the breast which extends up into the axilla reaching
as high as the third rib is called the axillary tail of Spence.
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STRUCTURE
The breast consists of a central protuberance called the nipple. The nipple is made up of erectile
tissue. It is covered and surrounded by a pigmented area called the areola. The areola extends for a
distance of about 2.5cm around the nipple. There are sebaceous glands at the edges of the areola.
These sebaceous gland secrete sebum to keep the nipple supple. The other gross structure of the breast
are glands, some fat and smooth muscle and an outer skin covering.
MICROSCOPIC STRUCTURE: The breast is divided into 18-20 lobes which radiate outwards from
the areola. Each lobes is a complete unit and is separated from the next lobes by fibrous connective
tissue. A lobe consist of glandular tissue and ducts, each gland is called acini cells. A little duct empties
each alveolus. The small duct run into one another uniting to form bigger duct. The bigger ducts also
unite to form lactiferous duct which runs along the lobes. The lactiferous duct dilates underneath the
areola to form a reservoir for milk. This reservoir is called ampulla (lactiferous sinus). The ampullae
narrow as they enter the nipple and terminate into minutes openings on its surface.
THE BLOOD SUPPLY: The breast is supplied with blood by the following:-
- The internal mammary artery which is a branch of the subclavian artery.

- The external mammary artery- a branch of the axillary artery
- The intercostals arteries which originates from the aorta.
THE VEINOUS DRAINAGE:- veins from a circular network around the nipple and drain to the
internal mammary and axillary veins.
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LYMPHATIC DRINAGE: The lymphatic nodes which drain the breast are:-
- The axillary gland in both axillae

- The glands in the anterior mediastinum
- The glands in the portal fissure of the liver
NERVE SUPPLY:- The cutaneous branches of the forth and sixth thoracic nerve supply the skin of the
breast for sensation but the functions of the breast are controlled by hormones like oestrogen,
progesterone and prolactin.
PHYSIOLOGY OF LACTATION
During pregnancy, the hormones oestrogen and progesterone activate the breast. The breast
becomes larger and produces some fluid called colostrums. During the pueperium, they are expected ti
secrete milk which is different from the colostrums. The secretion or production of milk is known as
lactation.
The hormone which initiate lactation is called prolactin. It is a secretion of the anterior pituitary
gland.
Prolactin is antagonized by the hormone oestrogen, for this reason, prolactin does not function
until level of oestrogen in the blood is low. The reduction in the level of oestrogen occurs within the first
two days of pueperium. This explains why milk is secreted from about the third day of the pueperium.
The effect of prolactin weard off after eight days. Further production and maintenance of lactation is by
factors discussed below.
MAINTENANCE OF LACTATION
The breast should be able to produce enough milk for full or partial feeding of the baby for nine
months’ post-partum in order to achieve this. The following factors are necessary;
1. Maternal good health: - physical and mental well being of the mother in the absence of anxiety.
2. Stimulation of the breast by the sucking of the baby:- The baby should suckle the breast at
regular intervals.
3. Adequate emptying of the breast by baby sucking on them or by manual expression of the breasts.
The sucking action of the baby on the breast stimulates the posterior pituitary gland to release an oxytocic
or pressor factor causes the plain muscles of the breast to contract thereby propelling the milk from the
alveolae along the lactiferous ducts into the ampullae.
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The rhythmic compression of the baby’s sucking action of the ampullae will empty the breast. As
the breasts are emptied the acini cells are stimulated to produce more milk.
The drought “let down reflex” is a term used to describe the effect of the oxytocic factor on the
breast. Let down reflex is demonstrated by the dripping of the milk from one breast as the baby sucks on
the other breast, if one removes the baby’s mouth from the breast during feeding, a shower of the milk
will escape through the nipples.
Oxytocic released during breast feeding causes uterine contraction, cause ‘after pain’. During
feeding times, thus breast feeding aid involution of the uterus.
MASTITIS (INFLAMMATION OF THE BREAST)

Mastitis means inflammation of the breast. In the majority of cases, it is the result of milk – stasis, not
infection, although infection may supervene.
Signs and symptoms
- one or more adjacent segments are inflamed (as a result of milk being forced into the connective
tissue of the breast) and appear as a wedge – shaped area of redness and swelling).
- If milk is also forced back into the blood stream the woman’s pulse and temperature may rise.
- In some cases flu-like, including shivering attacks or rigors may occur.
TYPES OF MASTITIS
1. Non-infective (Acute inflammatory) mastitis
2. Infective mastitis
Non-infective (Acute inflammatory) mastitis result from milk stasis. It may occur during the early days
as the result of unresolved engorgement or at any time when poor feeding technique results in the milk
from one or more segment of the breast not being efficiently removed by the baby. It occurs much more
frequently in the breast that is opposite the mother’s preferred side for holding her baby.
Pressure from fingers or clothing has been blamed for causing the comdition.
Management
Breast feeding from the affecting breast should conmtinue otherwise milk stasis will increase further and
provide ideal conditions for pathogenic bacteria to replicate. An infective condition may then arise which
could, if untreated lead to abscess formation.
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- Feeding technique should be improved, the woman should be encouraged to allow the baby to
finish the first breast first.
- If no improvement antibiotics should be given prophylactically e.g erythromycin, cephalexia,
flucloxacillin.
Active mastitis
The main cause of superficial breast infection is damage of the epithelium, which allows bacteria
to enter the underlying tissues – damages usually results from incorrect attachement of the baby to the
breast, which has caused trauma to the nipple.
- Infection may also enter the breast via the milk duct if milk stasis remains unresolved.
Management
Antibiotics
BREAST ABSCESS
Here a fluctuant swelling develops in a previously inflamed area.
- Pus may be discharged from the nipple.
Management
- Simple needle aspiration may be effective or
- Incision and drainage may be necessary
- It may not be possible to feed from affected breast for a few days. However, milk removal should
continue and breastfeeding should recommence as soon as possible because this has been shown
to reduce the chances of the further abscess formation (WHO 2000).
BREAST ENGORGEMENT
Breast engorgement occurs in the mammary glands due to expansion and pressure exerted by the
synthesis and storage of breast milk.
Engorgement usually happen when the breast switch from colostrum to mature milk around the 3 rd
to 4th day postpartum. However, engorgement can also happen later is lactating woman miss several
nursing and not enough milk is expressed from the breast. It can be exacerbated by insufficient
breastfeeding and/or blocked milk ducts.
Sign and symptom
Engorged breast may swell, throb, hard, painful (mild to extreme pain) and sometime flushed
- The mother may be pyrexial
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- The women will often feel a lump in one part of the breast. The skin flat area may be red and or
worm. If it continue unchecked, the plugged duct can become a breast infection at which point
she may have fever or further flu-like symptom
- The condition may cause edematous and flushed nipples. In case when breast is greatly engorged
the nipple is likely to retract into the alveolar
- Commonly, patients experience loss of appetite, fatigue, weakness and chills. Fever is typically
less than 39oc and last for less than one day.
Causes of breast engorgement
- It is caused by imbalance between milk supply and infant demand. It often occur in women who
decided not to breastfeed.
Engorgement can occur due to the following factors
- A suddenly increased milk
- When the mother does not nurse or pump the breast as much as usual or the baby is not correctly
attached.
- Severe breast engorgement can lead to the flattering of the nipples or it can result in inverted
nipples which make it impossible for the baby to suck out all the milk from the breast. This is one
of one the common causes of the stagnation of the milk in the breast.
- Overfilled breast can lead to severe engorgement due to waiting too long to begin breastfeeding
the baby, not feeding often enough or due to small feeding that do not empty the breast. Very
common in cases when the baby is fed formula or water. Severe engorgement of the breast can
lead to breast infection.
Diagnosis
The symptoms of breast engorgement are similar to the symptoms caused by the inflammatory breast
cancer for this reason, it is very important to seek medical attention if the condition does not completely
clear within 2 weeks.
Treatment
- Regular breastfeeding should be continued, supportive treatment and hot and cold compresses
can help.
- Wearing a well fitting maternity bra with wide straps that do not scratch and with a cup that
comfortably holds the entire breast usually helps in easing the discomfort and other symptoms.
- If the symptoms do not improve after a few days, the patient is advised to seek a doctor.
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- In severe cases the only solution will be the gently use of a pump. This will reduce the tension in
the breast and will not cause excessive milk production.
- The mother’s fluid intake should not be restricted as this has no effect on milk production.
BREAST SELF – EXAMINATION

Breast self examination is a check – up a woman does at home to look for changes or problems in
the breast tissue.
There are 3 methods of breast cancer detection
1. Mammography – It’s an X-ray examination of the breast that should be done every 1-2 years after
age 40, annually after age 50.
2. Clinical breast examination – Done by a Dr. or a nurse every 3years between the ages of 20 and
40 and every year thereafter.
3. Breast self examination. This is to be done monthly.
For pregnant and post-natal menopausal women – they should pick a date that is easy to remember which
can be marked on their calendar.
Step 1
Look at your breast in the mirror with shoulders straight and your arms on your hips.
Look for the size shape and colour, if your observe the following, report to your doctor.
Visible distortion or swelling, dimpling, puckering or bulging of the skin, nipple that has changed
position or an inverted nipple, redness, soreness, rashes or swelling.
Step 2
Raise your arms and look for the same changes
Step 3
While you are at the mirror, look for any signs of fluid coming out of the nipple (this could be a yellow
fluid or blood)
Step 4
Feel breast while lying down, using your right hand to feel your left breast, and left hand on the right
breast. Use a firm, smooth touch with the middle 3 finger pads of your hands, keeping the finger flat and
together, use a circular motion about the size of the quarter.
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Cover the entire breast from top to bottom, side to side, from clavicle to upper part of abdomen, and from
armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast.
Step 5
Finally, feel your breast while you are standing or sitting, some women prefer their skin to be wet so
they do the examination under shower like 4 above.
SEXUALLY TRANSMITTED INFECTIONS (STIs)

These are infections that are passed on from one person to another through unprotected sex or
genital contact formally known as veneral disease or STDs.
Types of STI
1. Chlamydia (Causative organism Chlamydia Trachomatis)
In women, it can cause pain or a burning sensation when urinating, a vaginal discharge, pain in lower
abdomen, during or after sex and bleeding during or after sex or between periods. It can also cause
heavy period.
In men, it cause pain or a burning sensation when urinating, a while cloudy or watery discharge from
the penis and pain or tenderness in the testicles.
It is also possible to have chlamydia infection in the rectum (bottom) throat or eyes
Diagnosing chlamydia
Through urine test or taking a swab from the affected area.
Treatment
it is treated with antibiotics but can lead to serious longterm health problems is left untreated,
including infertility.
2. Genital warts (causative organism – Epidermotrophic Human papilomaviruses (HPVs)
These are small fleshy growths, bumps or skin changes that appear on or around genital or anal area.
They are caused by the human papilloma virus (HPV). They are usually painless, buy you may
notice some itching or redness occasionally, they can cause bleeding.
You don’t need to have penetrative sex to pass the infection on because HPV is spread by skin to
skin contact.
Treatment
Creams and cryotherapy (freezing the wats)
3. Genital herpes (causative organism – Herpes Simplex Virus HSV)
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Caused by the herpes simplex virus (HSV), it is the same virus that causes cold sores.
Signs and symptoms
Small painful blister or sores usually develop which may cause itching or tingling or make it painful to
urinate.
There is no cure for genital herpes; the symptoms can usually be controlled using antiviral
medicines.
4. Gonorrhea (causative organism – Neisseria Gonorrhoeae bacterium)
This is a bacteria STI easily passed on during sex. About 50% of women and 10% of men don’t
experience any symptoms and are unaware they are infected
Signs and symptoms in women
Pain or a burning sensation when urinating, a vaginal discharge (often watery, yellow or green),
pain in the lower abdomen during of after sex and bleeding during or after sex or between periods
sometimes causing heavy periods. It is a cause of opthalmia neonatorum.
There may be enlargement of bartholin’s gland with pus coming out from the external orifice of
the duct of the gland. In advance cases, the joints to the body and the eyes can involved in men. Pains or
burning sensation when urinating, a white, yellow or green discharge form the tip of the penis or
tenderness in the testicles. It is also possible to have gonorrhea infection in rectum, throat or eyes.
Diagnosis
It can be diagnosed using a urine test or by taking a swab of the affected area.
Treatment
The infection is easily treated with antibiotics e.g procaine penicillin daily x 7 to 10 days lead to serious
longterm health problems if left untreated, including infertility.
5. Syphilis (causative organism –Spirochaete Treponema Pallidum)
This is a bacteria infection that in the early stages causes a painless but highly infectious sore on
genitals or around the month. The sore can last for up to six weeks before disappearing.
Symptoms:- such as a rash, flu-like illness or patchy hair loss may they develop. These may disappear
within a few weeks after which you have a symptoms free phase.
The late or tertiary stage of syphilis usually occurs after many years and can cause serious
conditions, such as heart problems, paralysis and blindness.
Diagnosis
A simple blood test can usually be used to diagnose syphilis at any stage.
Treatment
It can be treated with antibiotics, usually penicillin injection. When treated properly, the later stages can
be prevented.
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6. Trichomonas vaginitis: ( Causative organism - Trichomonas vaginalis (TV)
This is an STI caused by a tiny parasite. It can be easily passed on through sex and most people are
unaware they are infected.
Signs and symptoms in women
TV can cause a frothy yellow or watery vaginal discharge with has an unpleasant smells soreness or
itching around the vagina and pain when passing urine.
Signs and symptoms in men
Pain or burning after passing urine, whitish discharge or an inflamed foreskin.
Diagnosis
Difficult to diagnose, you can be referred to specialist clinic for urine or swab test once diagnosed. TV
can usually be treated with antibiotics.
7. HIV/AIDS
HIV is most commonly passed on through unprotected sex. It can also be transmitted by coming into
contact with infected blood/body fluid, e.g. sharing needles for injection, blood transfusion, guts
during nail and hair cutting.
HIV virus attacks and weakens the immune system, making it less able to fight infection and disease
there is no cure for HIV but there are treatments that allow most people to live a long and otherwise
healthy life.
Trichomonas vaginitis: - Causative organism-trichomonas vaginalis
Signs and symptoms
Yellow or greenish-yellow, frothy, foul smelling discharge accompanied by puritus vulvae.
When the discharge is cleaned off the vagina and vagina protion of the cervix, small raised red spots
are seen in the vagiva and on the cervix.
The vagina may be sore and vulva may be sore and swollen as a result of excessive scratching.
Treatment
Flagyl tds x one to two weeks and husband should also be treated to prevent reoccurrence.
MONILIASIS
Causative organism-candida (monila) albicans a fungus
Signs and symptoms
Thick chessy discharge which comes out in flakes
Prutitus vulvae
Sometimes urine may contain sugar though very common in pregnant diabetic women, may also be
seen in non-diabetics.
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On scraping, the chessy material from the vagina small red confluent area are seen and there many
bleeding from these areas.
The scratching of the vulva man causes it to be abraded and sore.
Treatment
Nystatin pessaries (ii nocte) may be inserted into the vagina for 3 weeks.
Nystatin cream for local application or precent gentian violet may be applied locally to the vagina.
Canesten application daily x 6 days or
Travogen cream (schering) applied twice daily or gyno-travogen vaginal tablet has been highly
successful.
INFERTILITY
Infertility is a failure to conceive after regular unprotected sexual intercourse for two years in the
absence of known reproductive pathology. (NICE 2004).
Sub-fertile couples are couples who have been unable to achieve a conception after one years.
Primary infertility is when there has been no prior conception and
Secondary infertility is when there is previous pregnancy irrespective of the outcome.
WHO defines subfertility as the inability of a couple to achieve conception or bring pregnancy to
term after a year or more of regular, unprotected intercourse.
Causes of infertility
Male
1. Defective spermatogenesis
a. Endocrine disorder
i. Dysfunction of
- Hypothalamus
- Pituitary
- Adrenals
- Thyroid
ii. Systemic disease
- Diabetes mellitus
- Coeliac disease
- Renal failure
b. Testicular disorder
i. Trauma
ii. Environment (high temperature)
-congenital (hydrocele, undescended testes)
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- occupational (furnaceman, long distance lorry driver)
- acquired (varicocele, tight clothing)
Iii cancer treatment
2. Defective transport
A. Obstruction or absence of seminal duct
- Infection
- Congenital anomalies
- Trauma
B. Impaired secretion from prostate or seminal vesicles
- Infection
- Metabolic disorder
3. Ineffective delivery
A psychosexual problem (impotence)
B drug- induced (ejaculatory dysfunction)
C physical disability
D physical anomalies
- Hypospadias
- Epispadias
- Retrograde ejaculation (into bladder)
Causes of infertility
Female
I. Defective ovulation
A endocrine disorder
I dysfunction of
- Hypothalamus
- Pituitary
- Thyroids
ii. Systemic disease
- Diabetes mellitus
- Coeliac disease
- Renal failure
2 . Physical disorders
A obesity
B anorexia nervosa or strict dieting
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C excessive exercise
3. Ovarian disorders
A hormonal
B ovarian cyst or tumours
C polycystic ovary disease
D ovarian endometriosis
4. Defective transport
A. Ovum
Tubal obstruction
- infection (gonorrhea, peritonitis, pelvic inflammatory disease)
- previous tubal surgery
- fimbrial adhesions
- endometriosis
b. sperm
I vagina
- psychosexual problems (viginismus)
- infection (causing dyspareunia)
- congenital anomaly
ii cervix
- cervical trauma or surgery (cone biopsy)
- infection
- homonal (hostile mucus)
- antisperm antibodies in mucus
3 defective implantation
- hormonal imbalance
- congenital anomalies
- fibroids
- infection
Initial Management
Investigation
The investigate process is aimed at achieving an accurate diagnosis and definition of any cause,
an accurate estimation of the chance of conceiving without treatment and a full appraisal of treatment
options.
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- Both partners should be involved in the management of their infertility and full explanation be
given to them
- A detailed drug history should be taken including any history of drug abuse, occupational factoes
should be noted.
- General advice regarding smoking and alcohol should be given to both partners.
- Weight control advice, if appropriate for the female partner
- Folic acid supplementation commenced for the female partner
- The couple should be advised that sexual intercourse every 2-3 days optimize the chance of
pregnancy.
- The male partner should have semen analysis undertaken as part of the initial assessment
- Women with regular menstural cycle are likely to be ovulating but women with regular cycles
and a history of more than 2 years infertility should have measurement of serum progesterone
levels to confirm ovulation.
- Women with irregular or prolonged irregular cyucles should have serum progesterone and serum
gonadotrophin levels measured.
- Tubal patency should be ensured (HSG)
- Assisted conception techniques can be adopted such as:
i. Ovulation induction
The principles of management of ovulation disorder include diagnosis and treatment of underlying
causes and once an adequate sperm count and tubal patency have been conformed ovulation induction
can be commened e.g clomifene citrate and taxomifen.
ii. Intrauterine insemination (IUI)
Sperm is prepared to maximize its fertility ability and inserted high into the uterus. IUI is indicated as
first-line management where there are problems such as hostile cervical mucus, antisperm antibodies
or low sperm count or premature ejaculation in male.
iii. In vitro fertilization/embryo transfer (IVF/ET)
IVF describes the laboratory technique where fertilization occur outside the body. IVF is indicated in
cases where the female partner has uterine tube occlusion, endometriosis, or cervical mucus problems
or where male factors are the main problem.
iv. Intracytoplasmic sperm injection
Is a highly specialized variant of IVF treatment that involve the injection of a single sperm into the
cytoplasm of an egg needle.
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Psychosocial and Psychological case of infertility
Common reported feelings of the couples and individuals are feelings of guilt, anger, depression,
anxiety, inadequacy, grief, loss of control and low self-esteem. Many of these symptoms persist over
extended period of time.
Fertility clinics should aim to address the psychological and emotional needs of their patients.
SORROGACY
Legal arrangement for surrogacy require the commissioning couple to both be over the age of 18, married
to each other and the child genetically related to at least one of them.
Either a fertile woman can be artificially inseminated with the sperm of the husband of the
commissioning couple or the commissioning couple can undergo an IVF procedure and produce an
embryo. The surrogate mother then act as a host as the embryo is placed in her uterus. The
commissioning couple can then apply for a parental order within 6 months of the birth though the consent
to the parental order can not be given until 6 weeks after the birth of the child.
FEMALE GENITAL MUTILATION

Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of
the external female genitalia or other injury to the female genital organ for non-medical reasons.
The practice is mostly carried out by traditional circumcisers, who often play other central role in
communities attending childbirths. In many settings, health care providers performs FGM due to
erroneous belief that the procedure is safer when medicalized. WHO strongly urged health professional
not to perform such procedures.
FGM is recognized internationaly as a violation of the human right of girls and women. It reflect
deep rooted inequality between the sexes and constitutes an extreme form of discrimation against women.
It is nearly always carried out on minors and is a violation of the right of children, the practice also
violate a person’s right to health, security and physical integrity.
The right to be free torture and cruel
- Inhuman or degrading treatment and
- The right to life when the procedure result in death.
Types of FGM
It is classified into 4 major types
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Type 1 – often referred to as clitoridectomy. This is partial or total removal of the clitoris and in very rare
cases, only the prepuse (the fold of skin surrounding the clitoris).
Type 2 – often referred to as Excisive. This is the partial or total removal of the clitoris and the labia
minora with or without excision of the labia majora.
Type 3 – often referred to as infibulation. This is the narrowing of the vaginal opening through the
creation of a covering seal. The seal is formed by cutting and repositioning the labia minora or labia
majora, sometimes through stitching with or without removal of clitoris (Clitoridectomy).
Type 4 – This including all other harmful procedures to the female genitalia for non medical purposes e.g
Pricking, piercing, incising, scrapping and cauterizing the genital area.
Deinfibulation – Refers to the practice of cutting open the sealed. Vaginal opening in a woman who has
been infibulated which is often necessary for improving health and well-being as well as to allow
intercourse or to facilitate childbirth.
Effect of FGM
It has no health benefit and it harm girls and women in many ways.
- It damages the normal female genital tissue
- It interferes with the natural function of girls and women’s bodies
Complication of FGM (immediate)
- Severe pain
- Excessive bleeding
- Genital tissue swelling
- Fever
- Infections e.g tetanus
- Urinary problem – painful urination, UTI
- Wound healing problems
- Shock
- Death
Long term
- Vaginal Problem ( discharge, itching, bacteria vaginosis and other infection.
- Menstrual problems (painful menstruation, difficulty in passing menstrual blood e.t.c
- Scar tissue and Kleoid
- Sexual Problem (pain during intercourse, decreased satisfaction e.t.c
- Increased risk for child birth.
- Need for later surgery especially type 3
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- Psychological problems (depression, anxiety, post traumatic stress, disorders, low self esteem
e.t.c
FGM is a global concern:- The practice is most common in the western, eastern, and north-eastern region
of Africa. In some countries in the middle east and Asia as well as among migrants from these areas.
Cultural and social factors for performing FGM
This carry from one region to the other. The most commonly cited reasons are:
1. Social norm and the need to be accepted socially
2. FGM is considered a necessary part of raising girls and a way to prepare her for adulthood.
3. It aims to ensure premarital virginity and marital fidelity, it is believed to reduce woman’s libido.
4. Some people believed that FGM increases marriage ability.
5. FGM is associated with cultural belief of ferminity and modesty which include the notion that
girls are clean and beautiful after removal of body parts that are considered unclean, unfeminine
or male.
International response
Building on works from different decades WHO, UNICEF and United Nations Population Fund
(UNFPA) issued a joint statement against the practice of FGM
Inseminated Intravascular Coagulation
(DIC) – A condition resulting from overstimulation of the blood clotting mechanism in response to
disease or injury, such as severe infection, malignancy, acute leukaemia, burns, severe trauma, abruption
placentae, or intrauterine fetal death. The overstimulation result in generalized blood coagulation and
excessive consumption of coagulation factors. The resulting deficiency of these may lead to spontaneous
bleeding.
Transfusion of plasma are given to replace the depleted clotting factors, and treatment of the underlying
cause is essential.
LIFE SAVING SKILLS (LSS)
SAFE MOTHERHOOD
Safe motherhood is an initiative that guarantees a woman’s successful completion of the physiological
processes of pregnancy and childbirth without suffering any injury or loss of her life or that of her baby.
It comprises of prenatal care, clean and safe delivery, post-partum care including family planning,
emergency obstetric care, STIs/PMTCT and post abortion care. The goal of safe motherhood is reduction
of maternal morbidity and mortality by 50% within a stipulated period of time.
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Globally, about 600,000 women die every year from pregnancy-related causes. In addition to this, over
50 million more suffer different kinds of morbidity. Almost 99% of these deaths occur in developing
countries especially sub-saharan Africa. In Nigeria, the maternal mortality ratio is estimated to be about
800 per 100,000 live births (multiple indicator cluster survey (MICS) by FOS).
In nigeria, the main causes of maternal mortality are:
- Haemorrhage
- Sepsis
- Pregnancy induced hypertension
- Obstructed labour
- Unsafe abortion
- Anaemia
- Malaria
- some key factors that contribute to maternal and newborn deaths are as follows:
- Socio-economic and cultural factors (poor educational status, harmful practices, low status of
women, poverty and weak community support).
- Institutional poor logistics, lack of basic and emergency obstetric care
- Pre-existing health condition (sickle cell disease, diabetes, cardiac disease e.t.c.)
- Infrastructure: poor transportation and communication network
Strategies for reducing Maternal Mortality
These include the following:
- Routine maternal care for all pregnancies and skilled care during and after childbirth
- Management of complications during pregnancy , delivery and following childbirth.
- Post-partum family planning and basic neomatal care
- Training and equipping midwives and community physicians to provide basic and emergency
obstetric services.
- creating awareness and mobilizing community towards safe motherhood.
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MATERNAL MORTALITY
World Health Organization WHO estimates that about 600,000 women die every year as a direct result of
child bearing and most of these deaths occur in the developing countries and many of them are
preventable (WHO,1996). In Nigeria, the maternal mortality ratio is about 800/100,000 live births.
The loss of these women is a great trategy to their immediate families in particular, their communities
and countries in general. The fact that the great majority of maternal deaths are preventable low to
moderate technology and education also add to the tragedy. It has been documented that for every
maternal death are sixteen cases of maternal illness.
MATERNAL MORBIDITY
Any symptom or condition resulting from made worse by pregnancy. The quality of care often
determines whether complication is effectively treated or continue unto death.
Midwives can play a major role in decreasing maternal mortality at family, community, national and
global levels.
Home (Family)/Community Level:
- Works with the TBA (Traditional Birth Attendant), women and other community
members/groups.
- Provides information to increase understanding on nutrition, personal hygiene. Family planning,
recognition of danger signs, the need to seek medical attention promptlt.
- Influences decision making in the family and community
- Motivates, shows love and concem to every one
- Orgaizes the community into groups for self help programmes e.g. transportation committee in
cases of emergencies.
- In birth preparedness, the midwife plans the community in readiness for any emergency
complications.
- Encourages literacy for women and children especially the girl-child.
- Encourages empowerment of women
Health Facility Level
- Works in collaboration with other members of the health team.
- Trains, supervises other midwives and any other cadre under her
- develops emergency plans and delegates to the team members as and when necessary
- In birth preparedness, the midwife plans with the community members in readiness for any
emergency complications.
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- Seeks, organizes continuing education programmes to update her knowledge and that of other
staff.
- Uses data on maternal health to analyze, evaluate seek ways to improve her service and care.
National Level
- Influences policies that affects her practice.
- Keeps date in her facility and submits same for the government to use in identifying needs.
- Plans and implements necessary programmes that with be beneficial to the community.
ANTENATAL CARE (Prenatal care)

Antenatal care is the advice, supervision and attention a woman receives to ensure;
1. Good health and where applicable, early detection and treatment of abnormalities which may
affect her health or that of her baby.
2. A pleasant child-bearing experience and adequate preparation for labour and lactation.
3. A live healthy baby at the end of pregnancy
The nurses/midwives, doctors, health visitors and social workers should make women, their
husbands and relatives understanding the necessity for, and value of early and regular antenatal care
which usually take place in the health centre, private maternity home or in a hospital.
The care should be efficient and should provide health education for the patient.
Aims of ANC
1. To promote and maintain good health and good nutrition during pregnancy
2. To ensure good health of infant
3. To prepare pregnant women for successful labour, lactation and puerperium.
4. To detect early and treat any abnormalities
At each clinic, weighing, urine test, BP are recorded except height that is done at first visit only.
Inspection, palplation, auscultation are carried out at each first visit on mother and fetus, fetal
heart rate is checked for strength, frequent rhythm.
At first visit, detail history is taken and at 30th week haemoglobin estimation is done to find out
any abnormalities and at 36th week pelvic assessment is done for all primigravida to determine adequacy
of birth canal.
All other needs including health education in all aspect is given.
Screening measure: Mother
History taken
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This should be a friendly discussion with the patient in order to be able to elicit the correct information in
assessing her emotionally, socially, medically and obstetrically.
Social history
This provides facts for tracing the patients’
- Full name and address
- Occupation – to know the socio-economic status
- Age
- Marital status
- Religion
Medical history
Some medical conditions which affect pregnancy adversely and some are aggravated by pregnancy
condition like; anaemia, diabetes, hypertension, kidney and heart disease, syphilis, pulmonary and bone
tuberculosis and accident involving the pelvis.
Surgical history
History of operations and hospital at which they were performed, any accident, blood transfusion to rule
out the possibility of development of antibodies.
Family history
History of twins in family should be noted, heredity conditions such as psychosis, hypertension, diabetes.
Obstetrical history
The history of previous pregnancies, labours and puerperium often decides how the present pregnancy
should be managed and where the patient should be delivered.
- Previous pregnancy
- Previous labour
- Previous puerperium
- Previous babies – the state of baby at birth and present, any still birth, neonatal death, jaundice
call for more attention
- Present pregnancy – duration of pregnancy LMP and EDD
EDD – date of last menstrual period plus 7 days plus nine months or by counting back 3 months after the
addition of 7 days.
- Menstrual history e.g. age at which menstruation began, the duration of the period and number of
the cycle.
General examinations
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The start as patient walk to the clinic the height, gait and vitality.
- Height – 150cm tall or less is likely to have small pelvis or contracted pelvis
- Weight – recorded as base line data
- Blood pressure
- Urinalysis – for protein, sugar and acetone in urine, it is noted for reaction and specific gravity
Physical examination
- Head – hair, eyes, mouth, nose, mouth, neck (enlarge lymph gland and thyroid gland)
- Breast
- The arms
- The vulva – abnormal discharges presence of warts, ulcers, varicose veins, and oedema
- The legs
- Abdominal examination
- Vertebral column – to examine the spinal column for any abnormality such as scoliosis
orkyphosis, if present it can affect the pelvic size, sacra oedema.
Blood investigation
a. Blood group and rhesus factor
b. Venereal dieases, research laboratory (VDRL) test
c. Hepatitis B test
d. Haemoglobin level and/or packed cell volume
the above examination and investigations are kept to serve as basis for assessment of patients
future progress.
POSITION OF THE FETUS
Lie: - This is the relation of the foetal spinal column or long axis to that of the mother. This could be
longitudinal, transverse, or oblique.
Presentation:- this refers to the part of the foetus lying lower in the birth canal. The area of the
presentation directly over the cervical is called the presenting part.
Attitude:- attitude is the relation of the foetal limb and head to it trunk e.g. flexion.
Position:- this is the relation of the presentation of the four quadrants of the pelvic brim.
Denomination is the leading part of the presentation part e.g. LOA, ROA, LSA, RSA
Occiput is the denominator in cephalic presentation
Engagement or station of the presentation:- this is the relation of the presentation to the pelvic brim.
When the greatest circumference of the head has passed the pelvic brim it is said to be engaged.
Method of abdominal examination
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Inspection, palpation and auscultation are the three ways used in obtaining the required information.
Inspection
Note the shape and size of uterus
Longitudinal lie – uterus is ovoid in shape
A big round uterus with full flank – may be due to multiple pregnancy transverse lie, hydramnois or
obesity. Foetal movement, skin pigmentation, striae gravidarum e.t.c.
Palpation
Gestational age is assessed on the basis of the last menstrual period and the height of fundus. So the
height of the uterus is assessed by placing the ulnar border of the left hand on the fundus.
a. pelvic palpation – this is to know the part of the baby that is presenting and engagement.
b. lateral palpation – this is done to know the position of the foetus
c. fundal palpation – the two hands are placed on the fundus to feel what is presenting there, 95 of
cases the buttocks are found at the fundus.
Auscultation
The foetal heart sounds are listened to, it is like a ticking of a clock under a pillow, and faster than the
maternal pulse rate. Foetal stethoscope can be used i.e pinard’s fetal stethoscope or ultrasound equipment
(e.g. a sonicaid or Doppler) with Doppler the woman can hear the fetal heartbeat.
DIAGNOSIS OF PREGNANCY
Presumptive signs
- Early breast changes at around 3-4 weeks in primigravidae but not significant in multigravidae
- ammenorrhoea – cessation of menstruation is most significant at 4 weeks
- Morning sickness – this nausea with or without vomiting between 4 – 14 weeks.
- Bladder irritability (6 – 12 weeks_ frequency of micturition without pain.
- Quickening – movement of the foetus first recognized by the mother between 16-20weeks.
Probable signs
Majority of these signs are elicited by the doctor and mainly by vaginal examination and
laboratory investigations such as presence of human chorionio gornadotrophin in blood and urine at
around 9-14days. Others include;
- Hegar’s sign (softened isthmus) 6-12 weeks
- Osianders sign (pulsation of the fornices, 8 weeks +)
- Uterine soufflé
- Cladwick;s sign (blueing of the vagina)
- Braxton Hicks contraction at the 16th week
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Positive signs
Hearing the foetal heart rate (20th weeks)
- Palpation of foetal parts from 24th weeks
- Foetal movements from the 22nd weeks
- Demonstration of the foetal skeleton by the x-ray
- Visualization by ultra-sonic sound at 4 – 6 weeks or by x-ray at 16 weeks
Some of the pregnancy signs and symptoms may be found in conditions not associated with
pregnancy, the following are few examples;
1. Amenorrhoea – may occur in chronic general illness such as tuberculosis, emotional upset and a
change in environment.
2. Morning sickness may be due to gastritis, pyrexia, illness, cerebra irritation e.t.c
3. Enlarge abdomen – may be associated with tumours such as an ovarian cyst or fibroids or ascites
and an increase in abdominal fat.
4. Foetal movements – flatulence may be mistaken for foetal movement
5. Pseudocyesis – in this condition amenorrhoea and other symptoms suggesting pregnancy may be
volunteered by the patient who is anxious to have a child. The abdomen may be enlarged but the patient
is not pregnant because there is no positive signs of pregnancy.
6. Presence of human chorionic gonadotrophine – is also present in hydatidiform mole and chorioc-
arcinoma.
7. Early breast changes – can be seen in contraceptive pills uses
Immunological tests for pregnancy
a. Gravindex test
b. Pregnostricon test
c. Prepuerin test
d. Therapeutic test (the use of oestrogen and progesterone for few days then withdraw if there is no
pregnancy, patient will bleed).
PHYSIOLOGICAL CHANGES IN PREGNANCY
The presence of pregnancy causes menstruation to cease and returns to function some weeks or
months after delivery. Pregnancy is a state in which changes occurs in all parts of the body.
Growth of the uterus
The most outstanding change is the growth of the uterus. Before the 12th week of pregnancy –
uterus remain a pelvic organ. Uterus palpable at upper border of symphysis pubis, uterus assumes an
upright position.
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At 16th week – it is spherical in shape. End of 22 week – uterus can be palplated at the level of the
umbilicus.
At 24weeks – the fundus has risen to a finger breath above the level of umbilicus
At 30 weeks – the fundus may be palplated mid-way between the imbilicus and the xiphisternum.
36weeks at the level of xiphisternum
40week – midway between the umbilicus and the xiphisternum
The size of the uterus changes from 7.5 by 5cm by 2.5cm (deep) to 30cm by 25cm by 20cm at
term weight changes from 60g to 900g up to 1kg at term.
2. The cervix: - This becomes highly vascularized and thus becomes softer. The cervical glands
secreted plug of mucus called operculum.
3. Vagina: - becomes highly vascularised with enlarge lumen. The secretion is increased and
becomes more acidic (4.5-5.0). there is increased vaginal secretions called leucorrhoea of pregnancy.
4. Vulva -- more pigment because of increased blood supply
5. Fallopian tubes -- are lifted with the uterus as it grows.
6. Ovaries: - becomes dormant, no ova is produced.
7. Cardiovascular system – there is hypertrophyof the heart muscles cardiovascular disease tend to
get worse in pregnancy due to increased circulation and extra body weight.
Blood pressure – blood pressure falls stiffly in second trimester but often back to normal about 30th
week. The total blood volume is increased by 40-50%, this is marked between the 12th and 32nd week and
the volume is mainly in the plasma with no corresponding increase in the red blood cells thus red cell
count and HB estimation reduces by 10% due to haemodilution of the blood causing physiological
anaemia of pregnancy.
8. Respiratory system: - The volume of tidal air which enters and leaves the lungs during normal
respiration becomes slightly increased. Late in pregnancy the bases of the lungs are compressed by the
rising uterine fundus and the respiration becomes costal in type.
9. Urinary system: - in early and late pregnancy there is increase micturition due to uterine pressure
on the bladder.
- Full bladder is easily displaced into abdominal cavity.
- Hormone progesterone causes dilation and kinking of the ureter, peristalsis is also slowed down
and stasis of urine occurs. This predispose to urinary tract infection e.g. pyelonephritis.
- The kidney work harder, therefore kidney disease becomes worse.
- Possibility of urine reflux from bladder, this can predispose the patient to UTI.
10. Digestive system: - plain muscle of GIT are affected by progesterone, there is possibility of
nausea and vomiting, indigestion, heart burn and constipation.
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11. Skeletal system: - Relaxing effect of hormones on the ligaments cause joints to show an
increased range of movement. Weight of uterus also changes the patient gait, there may be back pain.
12. Nervous system: - Emotional instability, anxiety, fear and even depression have been manifested
during pregnancy.
13. Skin changes: - There are changes in skin colours, hair, nails, sebaceous and sweat gland, striae
gravidarum – caused by stretching of the abdominal skin in which small tears in the deeper layers of the
skin, the scar from these tears are seen on the thighs and breast.
- “Chloasma” or mask of the pregnancy – is a pigmentation of the skin over the face.
- Linea nigra – the line extending from the pubis to the xiphisternum becomes darker and is called
linea nigra.
14. Breast changes: - Estrogen and progesterone stimulate the glandular tissue of the breast to grow,
increase blood supply, veins and striae gravidarum are visible on breast, nipple prominent primary and
secondary areola formed, enlarges sebaceous gland called Montgomery tubercles in patient areola,
colostrums can be expressed from the breast from about 16th weeks.
15. Maternal weight: - There is weight gain during pregnancy which is attributed to the uterus and
its contents, the breasts, increase in blood volume and extracellular fluid. The normal weight gain is
about 3kg (fat accumulation) in the first 20 weeks of pregnancy and about 0.4kg to 0.45kg/week for the
remainder of the pregnancy. (growth of fetus and maternal supportive tissues) resulting in about 12.5kg
increase in weight throughout pregnancy.
16. Endocrine changes: - Human chorionic gonadotrophin (hCG) levels increase rapidly in early
pregnancy doubling every 2 days maximum levels being attained at about 8-10 weeks gestation,
thereafter level begin to decline and a lowest is reached by around 20 weeks, after which this lower level
is maintained for the remainder of pregnancy. hGC is also synthesized in the fetal kidney so it is also
found in fetal blood and amniotic fluid, so it is almost always indicative of pregnancy.
- It also maintain corpus luteum in order to ensure secretion of progesterone until placenta
production is adequate around 12 weeks of gestation, after which it gradually decline until completely
disappeared 2 weeks after birth.
- It stimulates maternal thyroid gland
Human placenta lactogen (hPL) – plasma level hPL steadily rise until its peak around 34-36 weeks
gestation.
- It regulate glucose available for the foetus. It reduce glucose uptake by the maternal cells. As a
result more glucose is available for transport to the fetus.
Oestrogen
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The level increases progressively until 38 weeks gestation. It is produced by syncytiotrophoblast.
Majority is excreted through maternal urine.
- Oestrogen act to increase the number of glandular ducts of the breast
- It enhance myometrial activity
- promote myometrial vasodilation
- Increase sensitivity of the maternal respiratory centre to carbondioxide.
- Soften fibres in the cervical collagen tissue
- Increase pituitary secretion of prolactin
- Increase serum binding protein and fibrinogen
- Increase plasma proteins and increase the increase the sensitivity of the uterus to progesterone in
late pregnancy
Progesterone
- Is the principal pro-pregnancy factor, placenta (syncytiotrophoblast) production of progesterone
increase steadily throughout pregnancy until it reaches maximal levels around 38 weeks. Initially
produced by corpus luteum under the influence of hCG, during pregnancy progesterone.
- Acts to maintain myometrial state of inactivity
- Constrict myometrial vessels
- Inhibit prolactin secretion
- Help suppress maternal immunological responses to fetal antigens and therefore prevent rejection
of the fetus.
- Relax smooth muscle in the gastrointestinal and urinary systems
- Increase basal body temperature and increase sodium and chloride excretion
- It stimulates appetite, fat storage and the respiratory centres.
FSH
Pituitary FSH secretion is inhibited by the negative feedback of progesterone and oestrogen and
also by inhibin (glycoprotein hormone produced in the corpus luteum and placenta) and thus ovulation is
prevented during pregnancy. level of FSH is low in 6-7 weeks and are undetectable by mid pregnancy.
Prolactin – most of it is produced by anterior pituitary, it is also produced by the breast, the decidua and
found in high concentrations in amniotic fluid.
- It promote mammary development
- It stimulate lactation
The posterior pituitary gland produces vasopressin oxytocin.
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- Vasopressin modulate blood pressure, electrolyte balance and adrenocorticotrophic hormone
release (ACTH)
Oxytocin is also produced by posterior fetal pituitary glands, myometrium, deciduas, placenta and fetal
membranes
As oxytocin receptor of myometrium increases, the uterus is increasingly sensitive to oxytocin
throughout pregnancy. it rises during the expulsive stage of labour when it stimulates the contraction of
myometrium.
It causes the contraction of myoepithelia cells of the breast, resulting in milk ejection.
Thyroid function
There is moderate enlargement of thyroid gland in pregnancy due to relative iodine deficiency and
increased thyroid volume and blood flow in the intra-thyroid vessels. There is therefore, increase
metabolic rate during pregnancy.
PSYCHOLOGICAL CHANGES IN PREGNANCY
Many women cheerfully carry their pregnancy to term. They often cooperate with the midwives during
antenatal and intranatal periods.
Causes of adverse emotional reaction in pregnancy
1. Minor discomfort associated with pregnancy e.g. early morning sickness dyspepsia, frequency of
micturition e.t.c.
2. Poor socio-economic status i.e. lack of financial support
3. poor relationship with the husband
4. Unmarried pregnant mother
5. Anxiety over normalcy of the body
6. Poor environmental or living conditions
7. Fear of the unknown based on superstitious and old wife’s tales
Adverse emotional reaction seen in pregnancy
1. Irritability:- Irritable woman is usually quarrelsome and exhibit temper tantrums.
2. Insomnia or sleeplessness- this is often associated with fear
3. Anxiety-may cause the woman to be restless and she often cries readily
Management of adverse emotional reaction seen in pregnancy
- A friendly and understanding attitude of the nurse/midwife with encouragement from her can go a
long way to calm the patient.
- Mild hypnotic could be given in cases of insomnia
- Social medical workers assistance could be sought in cases where the anxiety o r distress is due to
unfavourable socio-economic factors
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- Patients should be referred to doctors if the symptoms persist
DISORDERS OF PREGNANCY
These are minor ailments of pregnancy complained by most pregnant women. They may distress them
but may not necessarily endanger life.
The pregnant women should not be ignored but should be reassured and advised on a simple remedy to
alleviate her symptoms.
1. MORNING SICKNESS: - The patients feels nauseated on rising in the morning, she may vomit
or have nausea wit excessive salivation. It may sometimes persist throughout the day and may
impair patient’s appetite. Begin between 4 and 7 weeks and usually resolve by 16-20weeks.
CAUSES
- Unkown
- Nausea is frequently triggered by hypogycaemia, hence its occurrence on wakening in the
morning
- It may be due to the effect of hormone progesterone
- Psychological effects
MANAGEMENT
- Taking easily digestible food before bed
- Getting out slowly from bed has been helpful
- Taking slightly bitter taste substance cleanses and refreshes the mouth
- Avoid starvation and dehydration- take rich food and little at frequent interval, with adequate
fluid intake (food rich in vitamin and mineral salt) non sedative can be helpful
- If the condition persist and severe it can progress to hyperemis gravidarum
PTYALISM
Excessive salivation
CAUSES
- May be associated with gastro oesophageal reflux or stimulation of salivary gland by ingestion of
starch.
- Due to difficulty in swallowing saliva during the period of nausea and vomiting in early
pregnancy
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- Psychology
MANAGEMENT
- Taking slightly bitter taste substance
- Rehydration
- Hygiene
3. CONSTIPATION
Passing smaller stool with lower water content (hard stool)
CAUSES
- Progesterone enhances absorption of sodium and water in the colon resulting in constipation
- Relaxing effect of progesterone on the progesterone on the plain muscle of intestinal wall
- Iron supplement may also aggravate constipation (the type used can be changed to another type)
MANAGEMENT
- Adequate intake of fluid, fruits and vegetables should prevent it
- Increase intake of bran and wheat fibre
- Take gentle exercise
- A mild aperients (not stronger purgatives) can be used e.g. milk of magnesia
4. VERICOSE VEIN AND HAEMORRHOID
Haemorhoids are varicose veins in anal canal
- When rupture especially in the vulva it can cause haemorrhage
- The risk of venous thrombosis is increased with varicosity
CAUSES
- The effect of progesterone on plain muscles
Prolong standing can aggravate it
MANAGEMENT
- Avoid standing for long period
- The affected leg should be bandaged with crepe bandage from below upward before getting out of
bed in the morning and the bandage must be removed at night.
- Leg can be elevated when patient is resting
Others are:
5. Glossitis and gingivitis – occur as a result of inadequate vitamin especially vitamin B
6. Faining and giddiness – can occur as a result of anaemia, cardiac impairment, sudden change in
posture, crowed and stuffy rooms could also predispose to fainting.
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7. Itching – can be caused by striae gravidarum, poor personal hygiene, heat rash and minor skin
disease. Itching of the vulva (pruritis vulvae) can be as a result of trichomonas vaginitis and
moniliasis.
8. Backache and joint pains – this is more common in tired multiparous women with bad posture
Management
- Rest
- Assumption of good posture
- Use of sensible sheos – patient should be reassured. Nurse/midwife should also note that
backache is also associated with pyelonephritis, retroved gravid uterus and may be an early sign
of labour.
9. Frequency of micturition
10. Insomnia
11. Leg cramp – caused by deficiency in vitamin B, calvium and chlorides
12. Heartburn – This is burning sensation in the mediaternum due to the effect of hydrochloric acid
on the oesophagus. The cardiac sphincter of the stomach is relaxed as a result of the effect of
progesterone om plain muscles, thus there is a reflux of the stomach contents into the oesophagus
especially when the patient adopt a recumbent position.
Management
- Pateint should be reassured and advise to sit up for sometimes after meals
- Sleep with pillow at night
- Sucking of peppermint and sips of milk and hot water also help.
- Antacids such as magnesium tricillicate and milk of magnesia are prescribed in stubborn cases
- The patient should be advised to eat little food at frequent intervals avoid overdistension of the
stomach or the eating of greasy indigestible food.
HYPERTENSIVE DISORDERS OF PREGNANCY
The blood pressure disorder in pregnancy includes:

- Chronic and gestational hypertension
- Pre eclampsia and eclampsia
Pre eclampsia and eclampsia are leading cauaea of death; all pregnant, laboring and post partum women
are at risk.
Classification
After 20 weeks of pregnancy:
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Pre-eclampsia (PE)
Systolic BP (SBP) >140mmHg or diastolic BP (dBP)>90mmHg
Plus
Proteinuria >300mg of protein in a 24 hours urine collection or 2+of dipstick
Severe pre-eclampsia (BPE)
1. New onset high BP of systolic BP (SBP)>160mmHg or diastolic BP (dBP)> 110mmHg with
proteinuria as anove. Or
2. PE as defined above plus any one of the following:
Danger signs reported by the women
- severe headache unrelieved by analgesics
- visual changes such as blurred vision or seeing lights or spots
- Rilght upper quadrant pain
- Difficulty breathing, pulmonary edema, abnormal ratting heard when listening to lungs or.
Danger signs that can be measured:
- pulmonary oedema
- Oliguria<400ml of urine output in 24 hours
- Low platelets, elevated creatinine, or elevated liver enzymes
Eclampsia (E)
PE as defined above plus convulsions or unconsciousness
- If SPE is suspected, do not wait for hours to repeat BP. Begin treatmee immediately.
- If you cannot check for protein, begin treatment immediately for women who otherwise meet the
definition of SPE.
- Women with less than 2 + proteinuria but with danger signs or BP in severe category, begin
treatment at once.
- women with PE- (meaning no danger signs should be seen twice a week until 37weeks at each
visit.
- Check BP
-- Monitor the fetus
-- Assess for SPE danger signs
-- Listen to lungs
- Check reflexes
- Check laboratory tests weekly
Any woman with PE who cannot return for visits twice a week must be admitted or transferred for
advanced care.
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If at any time SPE develops act quickly
The cure for NPE is delivery
A woman with PE and reliable GA (gestational age) should deliver within 24-48hours after reaching
37weeks and 0 day. But if a woman does not know her LMP or have a reliable first trimester ultrasound
and maternal and fetal status are reassuring labour should not be induced. If labour must be induced
transfer woman to advanced care
Women with PE are at risk for progressing to SPE or E during labour, birth and post partum.
Continue close monitoring.
For women with PE, continuing pregnancy after 37weeks puts both women at fetus at risk.
-- labour induction and birth should take place at facilities with ability for cesarean delivery.
-- using partograph, monitor women with PE as you would any woman in labour according to WHO
guidelines.
-- assess regularly for danger signs
-- check BP at least every 4 hours
-- continue to listen to lungs for pulmonary edema.
-- perform active management of the 3rd stage of labour. Give all women 101u oxytocin im or
600mg misoprostol by mouth within one minute of birth.
-- do not give ergometrine
-- monitor the woman at least 72 hours after delivery as much as 40% eclampsia begins in the post
partum period.
-- follow up in one week
-- all babies should receive essential new born care. Also
-- provide skin-to-skin care for at least an hour after birth and encourage breastfeeding within 1st
hour.
-- provide additional care for small babies
-- weigh the baby
-- under 2500 gram need special care
-- under 200 gram should receive prolonged skin-to-skin care.
-- babies under 1500 grams should receive advanced care
-- insert urinary catheter and monitor intake and output
-- once you have begun treatment for a pregnant woman, confirm gestational age. The woman will
be in one of three categories (1) pre-viable, (2) viable to 37 weeks or (3) 37 weeks or more. With SPE or
E.
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-- IF pre-viable-end pregnancy within 24hours to save the woman’s life (pre-viable fetus is too
premature to survive, the timing of viability depends on facility and country recourses.
-- if viable but less than 34weeks give Dexamethasone, this is an antenatal, corticosteroid (ACS) to
increase lung maturity and protect fetal intestines and blood vessels in the brain. This woman must
deliver within 7 days and there must not be any suspicion of maternal infection and there must be
adequate pretern new born care.
Medical management
Anti-convulsant
-- magnesium sulphate (MgSO4) is best anticonvulsant for SPE/E.
-- the preferred leading dose includes both:
4g mgso4 20% solution iv and
10g mgso4 50% solution im 5g in each buttock prepare and maintain a PE/E emergency kit with
all supplies needed for SPE/E.
1. Give 4g MgSO4 20% solution iv
-- Draw 8ml (4g) MgSO4 50% in 20ml sterile syringe
-- Add 12ml sterile water in same syringe
-- 20ml of 20% solution or 4g MgSO4
-- Give IV over 5 – 20minutes
2. Give 5g MgSO4 50% Solution
- Draw 10ml (5g) MgSO4 50% in each buttock

- Add 1ml 2% lignocaine in each syringe
- Give deep Im injection in upper outer quadrant of each buttock
If convulsions recur after 15minutes give 2g MgSO4 20% iv.
- Draw 4ml (2g) of MgSO4 50% into 10ml sterile syringe
- Add 6ml sterile water in same syringe
- Give iv over 5minutes
- Record information on MgSO4, monitoring sheet
If advanced care will not be reached within 4hiurs, administer first maintenance dose (5g MgSO4, 50%
solution + 1ml Lignocaine 2% im injection in single buttock) 4hiurs after loading dose.
Withhold dose if any of the 3 signs of toxicity are present.
- Respiratory rate < 16 breaths per minute
- Patella reflexes are absent
- Urine output < 30mls per hour over preceding 4 hours
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Then continue to check hourly and document, restart when there is no sign of toxicity.
Use of MgSO4 with IV infusion (Zuspan)
Benefit
- A faster onset of therapeutic effect
- No need of im injections, which can be painful and cause inflammation at the injection site.
The loading dose for a Zuspan regimen is 4g MgSO4 in 20ml (20%) solution) administered by iv
infusion over 5-20minutes.
The continuation dose is 1g MgSO4 per hour by iv infusion i.e
500ml Saline or lactated ringer solution + 10g 50% MgSO4 and infuse at 50ml/hr by gravity infusion or
infusion pump or 1000ml iv saline or lactated ringer solution + 20g 50% MgSO4 and infuse at 50ml
1hour by infusion pump only.
- Always check hourly for sign of toxicity, if present discontinue iv infusion
- MgSO4 must be continued for 24hours after birth but if she has convulsion after birth, MgSO4
must be continue for 24hours after last convulsion.
PE/E Emergency Kit
Place all supplies below in a box labeled “PE/E Emergency Kit”
MgSO4 at least 14g
Lignocaine 2%
Sterile water iv for dilution
20cc syringe at least 3
IM needle at least 3
IV normal saline or lactated ringer solution
IV giving set and IV needles
Alcohol swabs, tourniquet gloves
Calcium gluconate 10%
Antihypertensive
Target BP 140-55/90 – 100mmHg achieve in 12hours.
- Lower than the target may be decrease blood to the fetus, causing distress
- Higher than the target may cause a stroke solution of antihypertensive is based on total
availability.
1. Nifedipine immediate-release only: 5-10mg PO or bitten then swallowed repeat q 3omin until
goal achieved. Maximum initial dose 30mg. (Nifedipine is available in more than one
formulation: immediate release, intermediate-release, sustained release) other immediate-release
Nifedipine.
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2. Hydralazine – 5mg iv slowly, repeat 5mg q 5min until goal achieved max 20mg in 24hours.
Repeat hourly as needed or give 12.5mg im every two hours as needed.
3. Labetalol Oral: 200mg PO, repeat q 1hour if needed to achieve goal, maximum dose is 1200mg
in 24hours.
- Labetalol IV; 10mg iv, double dose q 10min to 80mg until goal achieved maximum dose 30mg
then switch oral labetalol.
Note:
If urine output is less than 30ml/hour administer IV fluids (normal saline or lactated ringer solution at 1L
in 8hours and monitor for pulmonary edema.
If rates are heard: withhold fluids and give furosemide 40mg iv once
In case of respiratory arrest:
- Shout for help
- Ventilate with bag and mask
- Give calcium gluconate 1g (10ml of 10% solution ) iv slowly over 3minutes
Dexamethasone (antenatal corticosteroid (ACS) give 12mg dexamethasone im as soon as possible
followed by another 12mg im 12hours later. Do not delay birth in order to give the 2nd dose if quick
delivery is needed to protect the woman or fetus. Never give more than wo courses, can only be given to
viable age but less than 34weeks.
Expectant management for woman with SPE is an option if a women and her fetus are stable and
less than 37weeks and if continuous monitoring is available.
If at any time a woman experience a contraindication to expectant management the baby should
be delivered within 24hours.
- A woman with SPE > 37 weeks should deliver within 24 hours.
- A woman with SPE of any GA who is not stable should deliver within 24hours
- A woman with severe PE of any gestation age who cannot be closely monitored should deliver
within 24hours.
- A woman with E of any gestational age should deliver within 12hours. Vaginal birth is preferred
if possible.
ECLAMPSIA
Eclampsia is an acute and life threatening complication of pregnancy, characterized by the
appearance of tonic-clonic seizures, usually in a patient who has developed pre-eclampsia (pre-
eclampsia and eclampsia are collectively called “hypertensive disorder of pregnancy” and toxaemia
of pregnancy).
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Eclampsia includes seizures and coma that happens during pregnancy but are not due to pre-
existing or organic brain disorders.
SIGN AND SYMPTOMS
- Typically patients shows sign of pregnancy induced hypertension and protein uria before the
onset of hallmark of eclampsia.
- Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and
cortical blindness, weakness, slurred speech, double vision, patellar reflexes, muscular----------
- Other organs symptoms may be present including abdominal pain, liver failure, signs of HELLP
syndrome, pulmonary edema, and oliguria, respiratory and cardiac arrest.
- For the foetus, there may be intrauterine growth retardation, they may suffer retal distress,
placental bleeding and placental abruption may occur.
Stages of eclampic event
1. Stage of Invasion – facial twitiching can be observed around the mouth
2. Stage of Contraction – ionic contractions, or sustained muscular contractions without intervals of
relaxations, render the body rigid, this stages may be last about 15 – 20 seconds Tonic
contractions are also known as titanic contractions
3. Stage of Convulsion – when involuntary and forceful muscular movements occur, the tongue may
be bitten, foam appears at the mouth, the patient stops breathing an become cyanotics, this stages
last about one minutes.
4. Stage of Coma – is a more or less prolonged stage, when the patient awakens, she is unlikely to
remember the event.
In some rare cases there are no convulsion and the patient falls directly into a coma. Some patients
may experience temporary blindness upon awaking for the coma.
During a seizures, the patient may experience bradycardia
Risk Factors
- More common in first pregnancies and young mothers it is thought that novel exposure to
paternal antigens is involved.
- Women with pre-existing vascular disease (hypertension, diabetes and nephropathy) or
thrombophilic disease such as the antiphospholipid syndrome are at higher risk.
- Having a large placenta (multiple gestation hydatidiform mole)
- Genetic component; patient whose mother or sister had the condition are at higher risk.
- Patients who have experienced eclampsia are at increased risk in later pregnancy.
PATHOPHYSIOLOGY
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Multiple theories shows that pre-eclampsia occur in the presence of placenta and is involved by
its removal.
Placental hypoperfusion is a key features of the process. It is accompanied by increased sensitivity of the
maternal vasculature to pressor agents leading to vasospasm and hypoperfusion of multiple organs.
Further, an activation of the coagulation cascade leads to microthrombi formation and aggrevates the
perfusion problem. Loss of plasma from the vascular tree with the resulting edema additionally
compromise the situation. These events lead to sign and symptoms of toxaemia including hypertension,
renal, pulmonary and hepatic dysfunction, and in eclampsia specifically cerebral dysfunction, preclinical
markers of the disease process are signs of increased platelets and endothelial activation.
Placental hypoperfusion is linked to abnormal modeling of the fetal-maternal interface that may
be immunologically mediated. The invasion of the trophoblast appears to be complete.
Adrenomwulin, a potent vasodilator, is produced in diminished quantities by the placenta in pre-
eclampsia (and thus eclampsia).
Other vasoacitive agents are at play including prostacyclin, thromboraneAz, initric oxide, and
endothelins leading to vasoconstriction.
May studies have suggested the importance of a woman’s immunological tolerance to her baby’s
father, whose gene are present in the young fetus and its placenta and which may pose a challenge to her
immune system.
There is reduced cerebral vascular leading to increase blood flow to the brain. In addition to
abnormal function of the endothelium, this leading to cerebral oedema. Typically an eclampsia seizure
will not lead to lasting brain damage, however, intracranial haemorrhage may occur.
Prevention
Defection and management of pre-eclampsia is critical to reduce the risk of eclampsia
This can be done with appropriate management of patient with pre-eclampsia generally involve the use of
magnesium sulphate as an agent to prevent convulsion and thus preventing eclampsia.
Treatment of eclampsia
The treatment of eclampsia requires prompt intervention and aims to prevent further convulsion,
control the elevated blood pressure and immediately deliver the baby if possible.
The aims of immediate care are to
- Summon medical aid
- Clear and maintain the mother’s airways, this may be achieved by placing the mother in a
semiprone position in order to facilitate the drainage of saliva/vomit.
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- Ensure maternal oxygenation during the convulsive episode, hypoventilation and respiratory
acidosis may occur therefore oxygen should be administered via a face mask at 8-10l/min and
oxygen saturation monitoring commenced.
- Prevent maternal injury
- Determine the fetal heart rate – fetal compromise secondary to maternal hypoxaemia or placental
abruption will indicate the need for an emergency caesarean section under general anaesthesia
once the maternal condition has been stabilized.
- Antihypertensive management – this may consist hydralazine or labetalol
- Delivery – stabilize mother’s condition, deliver the baby speedily even if the baby is premature
(often a caesarean section) unless the patient is already in advanced labour.
- Anti convulsant therapy- magnesium sulphate (MgSO4) is the recommended drug of choice. It is
thought to aid vasodilation thereby reducing cerebral oedema and preventing seizure. A loading
dose of 4g is given over 5-10mibn. IV followed by a maintenance dose of 5g-500ml normal
saline given as an IV infusion at a rate of 1-2g/hr until 24hours following delivery or the last
seizure. Recurrent seizure should be treated with a further bolus of 29 continuous infusion of
MgSO4 can be toxic particularly in women with renal insufficiency.
In the event of toxicity, the MgSO4 infusion should be stopped and ventilator and circulatiory
support given as required. Calcium gluconate (10-20ml of 10% solution is the antidote for
magnesium toicity and should be readily available.
- Intake and output monitoring.
Post-natal care
As almost half of eclampticseiure occur following child birth intensive care should be given to the
mother such as: blood pressure, urine output, proteinuria, oedema, monitoring.
Antithrombotic agent and antihypertensive agents should be continued as necessary
- .
FEOTAL DEVELOPMENT
This is the mechanism by which the ovum and the spermatozoon meet, fuse and start as a new
individual.
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Fertilization is the union of an ovum and a spermatozoon. It occurs at the ampulla of the fallopian
tube 36-48 hours after ovulation. A zygote is formed from the union and it contains 46 chromosomes in
its nucleus, the ovum contributes 23 chromosomes and the spermatozoon 23 chromosomes. The male
chromosomes can be combination of either
a. 22 + X chromosomes or
b. 22 + Y chromosome. The chromosomes of the ovum are always
c. 22 + X chromosomes.
If the zygote is the combination of (a) and (c) that is 44 + X chromosomes the child will be a
female, but if the zygote is a combination of (b) and (c) that is 44 + Y chromosomes, the child will be a
male.
DEVELOPMENT OF THE ZYGOTE
The zygote travels towards the uterus aided by ciliary and peristaltic movements of the fallopian
tube. It is nourished by the secretions in the tube and food previously stored around the ovum. During
this journey it takes the zygote three days to divide and subdivided to form a mass of cells called morula.
A cavity develops at one end of the morula and this cavity collects some fluid. The structure then become
the blastocyst by the fourth to fifth day, the blastocyst arrives at the uterus. The outer layer of the cell of
the blastocyst is called the hydrocele. The layer of the cells connecting the inner cell mass and the
trophoblast is in contact with the secetary endometrium. At this stage, the simultaneous events occur in
the uterus namely: -
1. The formation of the deciduas
2. The embedding of and further development of the blastocyst
FORMATION OF THE DECIDUA

As a result of the conception, the corpus luteum continues to grow and more progesterone is
produced. The trophoblast produces an anterior pituitary hormone called chorionic gonadotrophic
hormone that helps to maintain the level of progesterone produce by the corpus luteum. The chorionic
gonadotrophic hormone is excreted in the pregnant women urine and forms the basis for the pregnancy
test.
The abundant progesterone promotes the growth and development of the secretary endometrium
into the deciduas. The endometrial gland become dilated, more tortuous and filled with more secretion.
The endometrium becomes more vascular and thickens and becomes more rosy nourishing bed for the
developing feotus.
EMBEDDING OF THE ZYGOTE
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The blastocyst usually rest on the deciduas of the fundus uteri. The trophoblast secretes an
enzyme which erode the deciduas and some blood vessels. The blastocyst becomes embedded in the
deciduas with the inner cell mass. After fully embedded, the blastocyst is surrounded by a pool of
maternal blood.
The deciduas underneath the blastocyst is called decidua bassalis and the one surrounding it is
called deciduas capsularis. The undisturbed decidua is called deciduas vera.
The trophoblast develops into the placenta and chorion, while the inner cell mass forms the
feotus, the umbilical cord and the amnion.
DEVELOPMENT OF THE PLACENTA AND CHORION
The trophoblast cells multiply and arrange themselves into three distinct layer: -
a. Synccytium (syncytiothrophoblast) – The outer layer
b. Lang Han’s layer (cytothrophoblast) – The semi permeable middle layer
c. Primitive mesenchyme (mesoderm) – The inner layer
The three layers arrange themselves in finger-like projection which are embedded in the
surrounding decidua. The finger like projection multiplies or proliferates to invade the decidua and
eventually surrounded by maternal blood vessels. These projections are primitive chorionic villi which
make the trophoblast to become primitive chorion.
Feotal capillaries appear in the mesenchymal core of each villus. Three weeks after fertilization,
the partition of the primitive chorion next to the deciduas bassalis outgrows the other is called the chorion
fondosum and other portion which atrophies is known as chorion laeve.
The collection of villi of the chorion fondosum forms the placenta. The remains of the placenta
form the chiorion. The placenta is completely developed at about 12th week of pregnancy.
DEVELOPMENT OF THE FOETUS & AMNION
The inner cell mass develops into the feotus and the amnion. The inner cell mass is a collection of
cells inside the blastocyst and it is attached to the trophoblast by another collection of the mesenchymal
cells. The feotal blood vessels pass through mesenchymal cells to and from the placenta. The cells body
stalk elongate and later becomes the umbilical cord. The differentiation of the cells of the inner cell mass
results in the formation of two cavities, the amniotic cavity and the yolk sac.
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The amniotic cavity contains fluid called liquor amnii. This amniotic cavity rapidly outgrows the
yolk sac and fills the cavity of the blastocyst. Its lining called the amnion adhere to the chorion and lines
the feotal surface of the placenta and the umbilical cord. The cavity of the blastocyst is filled with a
delicate net of cells known as the primary mesoderm. The endodermal cells and the primary mesoderm
form a small sac called the primary yolk sac. The rapid growing endodermal cells replace or displace the
entire mesoderm of the primary yolk sac. Therefore secondary or definite yolk sac is formed lined with
endodermal cells.
The cells at the embryonic plate are designed to form different organs and parts of the body. The
ectodermal cells form the skin, hair, nails, nervous system, and lens of the eye and the enamel of the
teeth. The mesodermal cells form the heart, blood and its vessels, the lymphatic, bones, muscles, kidneys,
ovaries or the testicles. The endodermal cells form the alimentary tract, liver, pancreas, lungs and the
thyroid glands.
As the embryo develops, the yolk sac is enveloped to form the alimentary tract and part of the
umbilical cord.
SUMMARY OF THE DEVELOPMENT
0-4 weeks after conception
- Rapid growth
- Formation of the embryonic plate
- Primitive central nervous forms
- Heart develops and begins to beat
- Limb buds form
4-8 weeks
- Very rapid cell division
- Head and facial features develop
- All major organs down in primitive form

- External genitalia present but sex not distinguishable
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- Early movements
- Visible on ultrasound from six (6) weeks
8-12 weeks
- Eyelids fuse
- Kidney begin to function and feotus urine from 10 weeks
- Feotal circulation functioning properly
- Sucking and swallowing begins
- Sex apparent
- moves freely (not felt by mother)
- Some primitive reflexes present
12-16 weeks
- Rapid skeletal development visible on x-ray
- Meconium present in gut
- Lanugos appears
- Nasal septum and palate fuse
16-20 weeks
- Quickening, mother feels foetal movement
- Foetal heart heard on auscultation
- Vernix caseosa appears
- Fingernails can be seen
- Skin cells begin to renewed
20-24 weeks
- Most organs becomes capable of functioning
- Periods of sleep and activity
- Responds to sound
- Skin red and wrinkled
24-28 weeks
- Survival may be expected if born
- Eyelids reopen
- Respiratory movement
28-32 weeks
- Begins to store fat and iron
- Testes descend into scrotum
- Lanugos disappears from the face
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- Skin becomes paler and less wrinkled
32-38 weeks
- Increased fat makes the baby more rounded
- Lanugos from body
- Head hair lengthen
- Nails reach tips of the fingers
- Ear cartilage soft
- Plantar creases visible
36—40 weeks after conception (38-42 after LMP)
- Term is reached and birth is due
- Contours rounded
- Skull firm
FOETAL CIRCULATION (fetus/British)

The foetal receives its oxygen, nutrient and eliminates its waste through the placenta. There are
some temporary structure in addition to the placenta and the umbilical cord that enable the fetal
circulation to take place.
Temporary structures
1. The umbilical vein – carries oxygenated blood from the placenta to the under surface of the liver
connect to ductus venosus.
2. The ducts venosus – which connects the umbilical vein to the inferior vena cava.
3. The foramen ovale – which is an opening between the right and left atria.
4. The ductus arteriosus – which leads from the bifurcation of the pulmonary artery to the
descending aorta.
5. The hypogastric arteries – which branch off from the internal iliac arteries and become the
umbilical arteries when they enter the umbilical cord.
Course of Fetal Circulation
Umbilical vein: - carried blood, rich in oxygen, from the placenta to the under surface of liver supply the
liver with the richest blood i.e. the umbilical vein divide into two branches, one that supplies the portal
vein in the liver, the other ductus venosus.
Ductus venous: - This is a branch from the umbilical vein and transmits the greater amount of
oxygenated blood into the inferior vena cava.
Inferior vena cava: - Returning deoxygenated blood from lower part of the body and trunk. Receives
blood from hepatic vein and ductus venous and takes it to the right atrium.
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Foramen ovale: -Allows greater part of the oxygenated blood in the right atrium to pass on to the left
atrium, from where it pass through the left atrioventricular valve to the left ventricle and then through the
aorta into its ascending branch to supply the head and upper extremities.
Superior vena cava: Returns blood from the head and upper extremities to the right atrium, this with the
remainder of the stream of blood brought in by the inferior vena cava passes through the tricuspid valve
into the right ventricale, this is pumped through the pulmonary arteries.
Pulmonary artery: - Shunts some of this supply of mixed blood to non-functioning lungs, for its
nourishment.
Ductus arteriosus: - Shunts the greater part of the blood from right ventricle to descending aorta. Giving
part of the blood coming from arc of aorta to supply the abdomen, pelvis and lower extremities.
Hypogastric arteries: - Carry blood back to the umbilical arteries and then the placenta for oxygenation
and more nutrients.
Changes at Birth
- At birth, there is dramatic alteration to the fetal circulation and an almost immediate change
occurs. The cessation of umbilical blood flow causes a cessation flow in the ductus venosus, a fall
in pressure in right atrium and closure of the foramen ovale.
- As baby takes the first breath, the lung inflate and there is a rapid fall in pulmonary vascular
resistance.
- The ductus arteriosis constructs due to bradykinin released from the lungs on initial inflation. The
effect of bradykinin is dependent on increase in arterial oxygen.
In the term baby, the ductus arteriosus closes within the 1st few days of birth. These structural changes
become permanent and becomes as follows:
- Umbilical vein become ligamentum teres
- Ductus venous become ligamentum venosum
- Ductus arteriosus become ligamentum arteriosum
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A DIAGRAM OF FETAL CIRCULATION
- Foramen ovale become fossa ovale

- Hypogastric arteries: - Obliterated hypogastric arteries except for the first few centimeters
which remains open as the superior vesical arteries.
CIRCULATION THROUGH THE PLACENTA
Foetal blood low in oxygen is pumped by the foetal heart towards the placenta along the umbilical
arteries and transported along their branches to the capillaries of the chorionic villi. After releasing CO2
and absorbing oxygen, the blood is returned to the foetus via the umbilical veins.
The maternal blood is delivered to the placenta bed in the deciduas by spiral arteries and flows
into the blood spaces surrounding the villi. It is similar to a fountain; the blood passes upward and bathes
the villus as it circulates around it and drains back into a branch of the uterine vein.
PLACENTA AT TERM
Placenta is a flat circular organ with a diameter of 20 to 25cm; it weighs approximately 500 grams or one
sixth of the baby’s weight. The umbilical cord and the membranes are attached to the placenta. The
placenta has two surfaces.
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i. The dark red irregular surfaces is called the maternal surface.
ii. The grayish surface with blood vessels running in different directions is called the foetal surface.
The maternal surface is attached to the deciduas, it consists of 18 to 20 lobes called cotyledons. The
grooves separating the cotyledons are called sulci. The cotyledons are also referred to as lobes and each
lobe is made. Up of masses of chorionic villi. The reddish colour is due to the blood in the villi and the
intervillous spaces. The foetal surface of the amniotic cavity is covered by the amnion and the
umbilicalcord is inserted into it, the blood vessels which are mainly fetal radiate from the point of the
cord insertion to the edge of the placenta where they disappear into the placenta tissue.
The maternal surface is attached to the deciduas; it consist of the amnion which is a tough
transparent membrane and the chorion. The amnion forms the bag that encloses the foetus, and lones the
foetal sueface of the placenta and the umbilical cord. The amnion is often referred to as the foetal
membrane
THE CHORION
The chorion is attached to the edge of the placenta and it is adherent to the amnion it the membrane
which is in direct contact with the deciduas.
- The chorion is soft and friable
- It is thicker than the amnion
- It can be stripped from the amnion to the edge of the placenta but it is not continuous with the
cord.
THE UMBILICAL CORD (FUNIS)
The umbilical cord at about 50cm long and varies in thickness from 1.2 to 2cm short cord less than
40cm
a. One large umbilical vein through which too long cord lead to cord rapped round the neck or body
of the foetus or become knotted which result in occlusion of the blood vessels during labour”.
Oxygenated blood flows from the placenta to the foetus.
b. Two umbilical arteries which carry deoxygenated blood from the foetus to the placenta
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The vessels are wrapped in a jelly-like material known as Wharton’s jelly. The umbilical is covered on
the outside with a layer of stratified cubical cells, continuous with the foetal epidermis at one end of the
cord and the amniotic epithelium at the other.
The cord is not sometimes present. True knot rarely occur and are invariably due to foetal movements in
the liquor.
LIQUOR AMINII
This is the fluid that fills the amniotic fluid in which the foetus swims, its origin is not known but
it’s believed to be a secretion of the amniotic cells. The foetal matures and translates from the foetal and
maternal vessel, the cord; placenta and decidua are supposed augment the quantity of the liquor amnii.
The quantity of the liquor amnii increases steadily as pregnancy advances but relative to the
foetus, it is most abundant in mid-pregnancy
About 1 to 1.5 litres of liquor is regarded as normal, especially towards the end of pregnancy the
liquor is not stagnant, it is continually changed during pregnancy. The volume change every two to three
hours it is removed by the swallowing action of the foetus and it is absorbed into foetal circulation and
carried to the placenta. At term it remains 800ml. polyhydramnios – if the total amount exceeds
1500mls.
Oligohydramnoios – if less than 300ml:- congenital abnormalities.
FUNCTIONS OF THE LIQUOR AMNII

a. It permits foetal movement and uniform development of the feotus
b. It maintains equal pressure and provides constant temperature for the foetus.
c. It protects the foetus from trauma
d. During labour it prevents compression of the foetus by the contracting uterus; it acts as a sterile
douche when the membranes rupture.
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FUNCTIONS OF THE PLACENTA
1. Respiration: - During intrautine life no pulmonary exchange of gases can take place so the foetus
must obtain O2 and excrete CO2 through the placenta; O2 from the mothers Hb passes into the foetal
blood via the simple diffusion and the foetus gives off CO2 into the maternal blood.
2. Nutrition: - Nutrition are transferred across the placenta. Protein is transferred across the placenta
as amino acids, CHO as glucose, and fats as fatty acids. H2O, vitamins and minerals also pass to
the foetus. Fat and fat-soluble vitamin(A,D and E) cross the placenta only with difficulty and
mainly in the later stages of pregnancy some substances including amino acids are found at higher
level in the foetal blood than in the maternal blood.
3. Storage:- The placenta metabolizes glucose, stores it in the form of glycogen and reconverts it to
glucose as required. The placenta can also store iron and fat soluble vitamins.
4. Excretion:- The main substances excreted from the foetus is CO2 Bilirubin will also be excreted
as red blood cells replaced raletively frequently. There is a very little tissue breakdown apart from
this and the amunt of urea and uric acid excreted are very small.
5. protection:- placenta provides a limited barrier to infection. With the exception of the treponema
of syphilis and the tubercle bacillus few bacterial can penetrate; virus can cross to the foetus
except heparin and others. Some dugs cause damage and many drugs are harmless and other are
positively beneficial e.g antibodies administer to pregnant women. Towards the end of pregnancy
small antibodies immunoglobulin G (lgG) will be transferred to the foetus and these confer
immunity on the baby for the first three (3) months after birth only those that the mother possess
he can pass on.
6. Endocrine
i. Human chorinic gonadotrophin (hCG):- this is produce by the Cytotrophoblastic layers of the
chorionic villi. hCG is present initially I every large quantity, it reaches peak advances. hCG from
the basis of the many pregnancy test as it is excreted in the mother’s urine. Its function is to
stimulate the growth and activity of the corpus luteum.
ii. Oestrogen:- as the activity of the corpus luteum declines, the placenta over the production of
ocstrogn which are secreted in large amounts through out pregnancy. The amount of oestrogen
produced (measured as urinary or serum oestrid ) is an increasing placental well-being.
iii. progesterone:- This is peoduced in the syncytial layer of the placenta in increasing quantities
until immediately before the onset of labour when its leved all. It may be measured in urine as
pregnanediol.
iv. Human Placental Lactogen (HPL):-This has role glucose metabolism in pregnancy.
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It has a connection with the activity of human growth hormomes although it does not promote
grwth. As the level of HCG falls, the level of HPL rises and continues throughout pregnancy.
7. Transfer:- Through transport mechanism.
a. Simple diffusion of gases and lipid soluble substance.
b. Water pores transfer water soluble substances as a result of osmotic and potentially hydrostatic
forces.
c. Facilitated diffusion of glucose using carrier proteins.
d. Active transport against concentration gradients of oins, calcium (Ca) and phosphorus
e. Endocytosis (pinocytosis) of macromolecules
ABNORMALITIES OF THE PLACENTA

This may be structural abnormalities or as a result of disease.
BATTLEDORE PLACENTA:- Here the cord is inserted at the margin of the placenta in the manner of
a table tennis bat. It is unimportant unless the attachment is fragile.
PLACENTA SUCCENTRIATA:- This is the most significant of the variation in conformation of the
placenta. A small extra lobe is present, separate from the main placenta, and joined to it by blood vessels
that run through the membranes to reach it. The danger is that this small lobe may be retained in uterus
after the placenta is born and if it is not removed it may lead to infection and hemorrhage. The midwife
must examine every placenta for evidence of a retained succenturiate lobe, a hole in the membranes with
vessels running to it.
CIRCUMVALLATE PLACENTA:- In this type an opague ring is seen at the foetal surface of the
placenta, it is formed by a doubling back of the chorion and amnion and may result in the membranes
leaving the placenta nearer the center instead of at edge.
VELAMENTOUS INSERTION OF THE CORD:- The cord is inserted into the membranes some
distance form the edge of the placenta. The umbilical vessels run through the membranes from the cord
to the placenta. If the placenta is normally situated no harm will result to the foetus but the cord is likely
to become detached upon applying traction during active management of the 3rd stage of labour.
vessels may pass across the uterine OS. The term applied to the vessels lying in this position is vasa
praevia. Here there is danger to the foetus when the membrane rupture and even during artificial rupture
as the vessels may be turn, leading to rapid exsanguinations of the foetus.
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EXSANGUINATION:- This is the process of blood loss. If the onset of hemorrhage coincides with the
rupture of the membranes, foetal hemorrhage should be assumed and the birth expedited. Foetal blood is
distinguished from maternal blood by singer’s alkali – denaturation test, in practice the time is so short
that it may not be possible to save the life of the baby. If the baby survives, Hb levels should be
estimated after birth.
BIPARTITE PLACENTA:- Two complete and separate parts are present each with a cord leaving it.
The bipartite cords joins a short distance from the two parts of the placenta. This different from the two
placentas in a twin pregnancy where there are also two umbilical cords but these don’t join at any point
where there is a succenturiate lobe, the vessels are attached to the placenta directly and never join the
cord.
A TRIPARTITE PLACENTA:- This is similar but with three distinct parts except for the dangers
noted above these varieties of conformation have no clinical significances.
PLACENTA MEMBRANACEA: - The result form the failure of the chorion leave in contact with the
deciduas capsularis to degenerate. The bulk of the chorion leave takes part in the formation of the
placenta. The placenta is not limited to the decidua bassalis, but becomes a thin membranous structure
occupying the entire periphery of the chorion.
There is no interface with the nutrition of the ovum. During the 3rd stage of labour the placenta
does not limited separate easily and manual removal may be necessary, post partum hemorrhage may
result.
PLACENTA FENESTRATA: - Here the placenta is oblong with an aperture of varying sizes near its
centre. This is a rare condition, the division of the placenta into two lobes frequently happens.
DISEASES OF THE PLACENTA
1. Hydatidiform Mole: - this is proliferative cystic degeneration of the chorionic villi which leads
hemorrhage in early pregnancy (ante partum hemorrhage).
2. Calcareous Degeneration :- this is associated with normal degenerative process of the placenta.
The maternal surface is rough to touch and white gritty substances like broken egg shell form plagues
are found on it.
3. Infarets:- These are necrosed or dead chorionic villi. They are whitish in colour and appears as
white patches on the maternal Surface. Infarcts result from placental insufficiency.
Oedematous placenta:- This is associated with hydrops foetalis. The placenta is large and pale.
5. Syphilitic placenta:- This is greas- looking and may weigh as much one quarter of the weight of
the foetus. Normal placense is 1/6th of the baby’s weight.
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POLYHYDRAMNIOS (HYDRAMNIOS)
Excessive amniotic Fluid
To calculate the amniotic fluid volume (AFV) the liquor in each of the four quadrants around the
fetus is measured to establish the amniotic fluid index (AFI).
When the deepest vertical pool of liquor exceeds 8cm or the calculated AFI is above the 95th
centile for gestational age.
Causes/Predisposing Factors
- Oesophageal atresia
- Open neural tube defect
- Multiple pregnancy, especially monozygotic twins
- Maternal diabetes mellitus
- Rarely an association with rhesus isoimmunization
- Chorioangioma, a rare tumor or placenta.
- Anencephalic fetus
Sign and symptoms
- Uterus larger than gestational age
- Uterus tense and difficult to feel fetal part
- Breathlessness and discomfort
- Severe abdominal pain
- Exacerbation of symptoms associated with pregnancy, such as indigestion, heartburn and
constipation.
- Oedema and Varicosities of the vulva and lower limb may be present.
Management
- The cause of the condition should be determine if possible
- The woman may be admitted
- Subsequent care will depend on the condition of the woman and fetus, the cause and degree of
hydroramnios and stage of pregnancy.
- If gross abnormality is present, labour may be induced.
- In mild hydramnios, she should be reassured that the outcome is likely to be good.
- Watch out for rupture membrane
- Upright position help to relieve dyspnea
- Antacid given for heart burn and nausea
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- If discomfort from swollen abdomen, amniocentesis or amnior education can be done ( through
infection may be introduced or onset of labour provoked). This must be done repeatedly and
since fluid accumulation increases.
- Administration of drugs such as indomethacin and sulindac reduce fetal urine production and
consequently amniotic fluid.
- Labour may be induced in late pregnancy if the need arises
- Midwife should be prepared for the possibility of PPH
- Amniotic fluid should be allowed to drain slowly to avoid placenta abruption, cord prolapse and
alteration of lie.
- Baby should be carefully examined for abnormality
OLIGOHYDRAMNIOS
This is an abnormally small amount of amniotic fluid.
- When diagnosed in the 1st half of pregnancy, it is found to be associated with absence of kidney
or potter’s syndrome.
- When diagnosed at any time in pregnancy before 37 weeks it may be due to fetal abnormality or
preterm pre-labour rupture of membrane and fluid fail to reaccumulate.
- It can cause compression deformities, baby has a squashed looking face, flattering of the nose
micrognathia (a deformity of the jaw) and talipes. The skin is dry and leathery in appearance
- It sometimes occur in the post-term pregnancy and is believed to be linked with the development
of placental insufficiency, leading to decrease urine formation.
- Uterus smaller than expected for egstational age and fetal part easily palpated
- Breech presentation is possible.
Management
- Find the cause if possible
- Where fetal anomaly is not the cause or not known, prophylactic amnioninfusion with normal
saline, ringer’s lactate or 5% glucose may be performed to prevent compression deformity and
hypoplastic lung disease and prolong the pregnancy
- Epidural analgesia because of the unusual pains of labour.
Complications
Cord compression which may result in fetal hypoxia
HYPEREMESIS GRAVIDARUM
Hyperemesis gravidarum is one of the major complications of pregnancy. it is an excessive
vomiting in pregnancy occurring in the first trimester. The patient may vomit throughout the day till she
empties both the stomach and duodenal contents. In such circumstances the vomitus contains bile. She
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may feel continuously nauseated and can scarcely eat. Nausea and anorexia can produce a state of
malnutrition, dehydration and metabolic disturbances which may fatal. Ojo & Briggs 2013
CAUSES
- The cause of vomiting in 50% of pregnant women is not known
- It has been suggested that the vomiting could be of psychological origin i.e when pregnant
woman seeks sympathy and attention
- It is more common among educated and nervous women
- It is known to be associated with multiple pregnancy, hydatidiform mole, acute hydramnios,
infective hepatitis and pyelonephritis
- Histamine-related substances are said to have an aetiological note in hyperemesis. This is the
reason why hyperemesis gravidarum is treated with autihistamines
SIGNS AND SYMPTOMS
- Patient cannot eat to retain food, this coupled with the effort of retching and vomiting
- Patient will be weak, emaciated, dehydrated and miserable
- Eyes are sunken, and skin is dry and inelastic
- The tongue is coated or red or raw with sordes on the teeth
- Scanty urinary output, concentrated and contains acetone
- The patient is often constipated
- In severe cases, there is gross acidosis with consequent electrolyte disturbance
- Hypotension and proteinuria may occur
- The patient may eventually become jaundiced, delirious and comatose
- Death may supervene
MANAGEMENT
- There is necessity for prompt and adequate treatment
- The patient is admitted in private room or side ward where she can have adequate rest
- A thorough examination of patient to exclude other causes of vomiting
- The management is based on replacement of lost fluid and electrolyte to provide hydration,
energy and correct acidosis. Vitamin B complex is usually added.
- Serum electrolytes are estimated daily and corrected as necessary
- Antiemetic drugs (some of which also have a sedative effect) such as Largactil (25-50mg) or
Phenegan (25-50mg) are given intramuscularly twice daily.
- Oral fluid are withheld till vomiting abated
- Further vomiting may be prevented by the administration of oral, Avomine (25mg) or Ancoloxin
(25mg) once or twice a day
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- Multivitamins, iron and Daraprim are also given
NURSING MANAGEMENT
The nurse/midwife must be tactful understanding, kind but firm in her approach and management
of patient because patient is usually miserable and feels sorry for herself.
- Complete bed rest
- Daily bed bath, pressure area care at least twice daily
- Mouth toilet is done daily using using glycerine to keep the lips moist and free from cracks
- Patient should be made to rinse her mouth with diluted lemon juice to keep the mouth fresh and to
prevent excessive salivation
- An accurate intake and output chart is kept and urine should be tested daily for acetone, protein,
bile and chloride
- Constipation can be managed with suppositories
- Vital signs are done 4 hourly and recorded
- Any abnormalities should be reported for quick action
The following should be reported if noted
1. Jaundice
2. Undue excitement or excessive drowsiness
3. Lower abdominal pain which may denote onset of abortion
COMPLICATIONS
- Encephalopathy
- Renal failure
- Hepatic failure
ANTEPARTUM HAEMORRHAGE (APH)

Antepartum haemorrage is the bleeding from the genital tract in the late pregnancy after 24 weeks
of gestation and before the onset of labour.
Effects on fetus
- Fetal mortality and morbidity are increased
- Still birth or neonatal death may occur
- Premature placenta separation and consequent hyporexia may result in severe neurological
damage in the baby.
Effects on the mother
- In severe bleeding, it may be accompanied by shock and disceminated intravascular coagulation
(DIC)
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- The mother may die or be left with permanent ill health
Types of APH
1. Incidental bleeding – bleeding from lesions of the genital tract: show, cervicitis, trauma, genital
tumor, genital infection, haematuria, vasa preavia e.t.c.
2. Due to placental separation as a result of
- Placental preavia
- Placental absruption
PLACENTA PRAEVIA
In this condition, the placenta is partially or wholly implanted in the lower uterine segment on either the
anterior or posterior wall.
Degree of placenta praevia
Type 1: - The majority of the placenta is in the upper segment. Vaginal birth is possible. Blood loss is
usually mild. Mother and fetus remain in good condition
Type 2: - The placenta is partially located in the lower segment near the internal OS (marginal placenta)
vaginal birth is possible, particularly if the placenta is anterior. Blood loss is moderate, although the
condition of the mother and fetus vary, fetal hypoxia is more likely to be present than maternal shock.
Type 3: - The placenta is located over the internal OS but not centrally. Bleeding is likely to be severe
particularly when the lower segment stretches and the cervix begins to afface and dilate in late
pregnancy. Vaginal birth is in appropriate because the placenta precedes the fetus.
Type 4: - The placenta is located centrally over the internal cervical OS and torrential haemorrhage is
very likely. Caesarean section is essential in order to save lives of the mother and baby.
Diagnosis
1. Painless bleeding from vaginal
2. Uterus not tender or tense
3. The presence of placenta praevia should be considered when the presenting part of the fetus is
above the pelvis and /or the lie is unstable.
4. Ultrasound scanning will confirm the existence of placenta praevia and establish is degree.
Characteristics of placenta praevia haemorrage

- Some mothers may have small repeated blood loss at intervals throughout pregnancy whereas
others may have a sudden single episode of vaginal bleeding after the 20th week. However, severe
haemorrhage occurs most frequently after 34th weeks.
- It is not associated with any particular type of activity and may occur at rest.
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- The colour of the blood is bright red, denoting fresh bleeding
- The low placental location allows all of the lost blood to escape unimpeded and a retroplacental
clot is not formed. For this reason pain is not feature of placenta praevia.
- Sign of shock in severe bleeding: - tachycardia, BP, increase temperature, air hunger, pale colour,
skin cold and moist. She may also loss consciousness.
Assessment
- Abdominal examination – find out if lie is oblique or transverse and fetal head may be high in a
primigravida near term.
- The midwife must not attempt to do a vaginal examination as this can worsen the situation
- The amount of blood loss should be quantified
- Fetal condition should be assessed – to know if there is diminished or cessation of fetal movement
or excessive movement which denote distress. Ultrasound can be used.
Management
The management of placenta traevia depends on;
- The amount of bleeding
- The condition of mother and fetus
- The location of the placenta
- The stage of the pregnancy
1. Conservative Management
This is appropriate if bleeding is slight and mother and fetus are well. The woman will be kept in the
hospital until the bleeding has stopped.
- A speculum examination would have ruled out incidental causes. Further bleeding is almost
inevitable is the placenta encroaches into the lower segment. Therefore it is unusual to require the
woman to remain in or close to the hospital for the rest of the pregnancy.
- Placenta function is monitored by fetal kick chart. Laudiotocography (LTG), and ultrasound
scans.
- Psychological and social care
- Labour is likely to be indiced from 37 weeks gestation for type 1 and 2.
- The mid/wife should be aware that there is danger of post partum haemorrhage. Living ligature
action is poor because of the small amount of oblique muscle fibres.
2. Active management
Severe vaginal bleeding will necessitate immediate delivery by caesarean section regardless of the
location of the placenta. Type 3 and 4 is to delivered with CS even if there is IUFD to save the mother’s
life.
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- Care for the baby must be arranged for especially is preterm
- Pre and post management
- Blood transfusion
- Psychological care for mother and relatives
Incidence
- It is high multip with the parity
- Multigravida 1 in 90 births
- Primigravida 1 in 250 births
- Common with women who smokes and women with previous CS
- Women with previous history of placenta praevia
Complications
- Maternal shock
- Anaesthetic surgical complication
- Placenta accrete map to 15% of women with placenta praevia
- Air embolism
- Post partum haemorrage
- Maternal death
- Fetal hyporexia
- Fetal death
PLACENTA ABRUPTION
Placental abruption is a premature separation of a normally situated placenta occurring after the
22nd week of pregnancy.
Aetiology/predisposing factors
Not always clear, but often associated with;
- Severe pre-eclampsia (not chronic hypertension)
- It can follow a sudden reduction in uterine size, for imbalance when the membranes rupture or
after the birth of a first twin.
- Rarely is a result of direct trauma to the abdomen, perhaps through a road traffic accident.
- Seat-belt injury or deliberate violence
- High parity
- Caesarean section in the previous delivery increased the risk by 40%
- There is a correlation between placental abruption and cigarette smoking
- Severe infection
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Incidence
It occurs in 0.49 – 1.8% of all pregnancies
Types of placental abruption
The blood loss from a placental abruption may be defined as;
1. revealed – when the bleeding from the placental escapes by separating the membrane and drain
through the vagina.
2. concealed – blood that is retained behind the placenta may be forced into the mymetrium
3. mixed haemorrage – combination of the above 1 & 2 is called mixed haemorrhage.
An alternative classification can be based on the degree of separation and related to the condition
of mother and the baby.
- Mild, moderate and severe haemorrhage. The most severe is when it is totally concealed.
Signs and symptoms/diagnosis
- There may be history of pre-eclampsia, a recent history of headaches, nausea, vomiting, epigastric
pains and visual disturbances.
- There may be physical domestics violence
- External cephalic version in judiciously perfomed may be cause.
- The bleeding is most of the time associated with pains.
- The mother may have eodema of face, fingers and pretibial area of the lower limbs attributable to
pre-eclampsia.
- Signs of shock should be checked for
- Temperature should be checked since infection can be one of the causes of placental abruption.
- Conceal haemorrhage may lead to uterine enlargement in excess of gestation. Palpation may be
difficult and should not be attempted if the uterus is rigid and excessively painful. In less severe cases
when palpation is possible, it should be reduced to the nearest minimum.
- The fetal heart is unlikely to be heard with fetal stethoscope if there has been any concealed
haemorrhage. An ultrasound, CTG or hand-held device should be used. Fetal death is common with
severe haemorrhage.
Mild type management of placental abruption
It is difficult to differentiate the mild type of placental abruption from placenta praevia and form an
incidental cause of vaginal bleedings except with ultrasound scan which can help to determine the
placental location and identify any degree of concealed bleeding.
- Monitoring of fetal heart rate
- If pregnancy is above 37 weeks induction can be offered but further heavy bleeding or evidence
of fetal compromise may indicate that a caesarean section is necessary.
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- Moderate separation describes placental separation of about one-quarter.
- Patient should be observed for chock and adequately managed
- If the fetus is in good condition or has already died, vaginal birth may be contemplated.
Severe separation
It is an acute obstetric emergency at least 2/3 of the placenta has become detached and a life
threatening amount of blood is lost from the circulation.
Most or all of the blood can be concealed behind the placenta. The woman will be severely
shocked perhaps to a degree for beyond what might be expected from the amount of visible blood loss.
C/S as soon as the condition is stabilized
Pain relief – with morphine or pethidine
Blood transfusion
Care of the baby – preparation should be made for an asphyxiated baby with the effect of shock
the baby may also be a premature baby.
Psychological care
Complications
- DIC
- PPH
- Renal failure
- Pituitary necrosis
- Maternal mortality rate (1%)
POST PARTUM HAEMORRHAGE

PPH is the loss of blood following childbirth resulting in hypovolaemia or otherwise causing a woman to
become symptomatic due to the blood loss.
PPH is blood loss greater than 500mls following vaginal birth 1000mls of blood following
caesarean section. It is one of the most common causes of perinatal maternal death in developing world
and is major morbidity worldwide. Any blood loss however small, that adversely affect the mother’s
condition constitute PPH.
Causes and incidence of PPH
Causes Incidence
Uterine atony 70%
Trauma 20%
Retained tissue 10%
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Coagulopathy 1%
Types of PPH
Primary PPH: - This is excessive bleeding from the genital tract at any time following the baby’s birth
up to 24 hours following the birth.
Secondary PPH: - Is any abnormal or excessive bleeding from the genital tract occurring between 24
hours and 6weeks post natally. (some books say 12 weeks)
Atonic uterus
This is the failure of the myometrium at the placental site to contract and retract and to compress
tone blood vessels and control blood loss by a living ligature action.
Causes of atonic uterine action
- Incomplete separation of the placenta
- Retained cotyledon, placental fragment or membrane
- Precipitate labour
- Polyhydramnios or multiple pregnancy causing over-distension of uterine muscle.
- Prolonged labour resulting in uterine inertia
- Placenta praevia
- Placenta abruption
- General anaesthesia especially halothane or cycloprepane
- A full bladder
- Aetiology unknown
- Mismanagement of the third stage of labour
A full bladder, manipulation of the uterus may precipitate arrhythmic contractions
Factors that increase the likelihood of PPH
- Previous history of PPH or retained placenta
- High parity
- Fibroid (fibromyomata)
- Anaemia – anaemia is associated with debility which is a direct cause of uterine atony.
- HIV/AIDS – minor blood loss may cause severe morbidity or death
- Multiple pregnancy
- Ketoacidosis – 40% of women had ketonuvia at some time during labour. There was a significant
relationship between ketosis and the need for oxytocin augmentation, instrumental delivery and
PPH when labour lasted >12hours
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Signs of PPH
- Visible bleeding
- Maternal collapse
- However, more subtle signs may present, such as
- Pallor
- Rising pulse rate
- Falling blood pressure
- Altered level of consciousness, may be restless or drowsy
- An enlarged uterus as it fills with blood or blood clot; it feels “boggy” on palpation (i.e. soft and
distended and lacking tone); there may be little or no visible loss of blood.
Treatment of PPH (primary)
1. Call for medical aid
2. Stop the bleeding
- Rup up for contraction – message the fundus in a smooth, circular motion.
- Give uterotonic – oxytocin 5 or 10 units or syntometrine 1ml, ergometrine 0.5mg can be repeated
not more than 2 doses.
- Empty the uterus – deliver the placenta, expel any clot
3. Resuscitate the mother – IV fluid, oxytocin infusion or fluid replacement.
- Elevate the legs (not the foot of the bed)
- Catheterize to empty the bladder
- Grouping and cross matching of blood
Secondary PPH
This is most likely to occur between 10 and 14 days after birth
Causes
- Retention of a fragment of the placenta or membranes
- Presence of large uterine blood clot
Signs and symptoms
- Lochia is heavier than normal and will have changed from a serous pink or brownish loss to a
bright red blood loss.
- Lochia may be offensive if infection is a contributory factor
- Subinvolution
- Pyrexia and tachycardia
Management
- Call a doctor
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- Reassure the woman and her support person(s)
- Rup up a contraction by messaging the uterus if it is still palpable
- Express any clots
- Encourage the mother to empty her bladder
- Give a uterotonic drug such as ergometrine maleate by the intravenous or intramuscular route.
- Keep all pads and linen to assess the volume of blood lost.
- If bleeding persists discuss a range of treatment options with the woman and if appropriate
prepare the woman for theatre.
FOETAL DISTRESS
Foetal distress refers to foetal hypoxia in uterio. This occurs when conditions which interfere with the
supply of oxygen to the foetus are present.
Condition which predispose to foetal distress
1. Maternal condition which can lead to placental insufficiency. E.g Pre-eclampsia, Eclampsia,
severe hypertension, chronic nephritis, chronic pyelonephritis and diabetes.
2. Other condition like severe anaemia in pregnancy, severe cardiac disease and pulmonary T.B
result in deficient oxygen supply to the mother.
3. Abnormal uterine action, especially of the hypertonic type.
4. Prolonged labour, especially with ruptured placenta.
5. Antepartum haemorrhage due to premature placental separation
6. Cord presentation and cord prolapse
7. True knots the umbilical cord
8. Prematurity
9. Postmaturity- this is associated with placental degenerate
10. Congenital abnormality- experience has shown that abnormal fetuses do not withstand labour
well.
Sign and symptoms
1. Tachycardia – fetal heart rate of 160 beat and above per minutes give cause for concern.
2. Bradycardia – This usually follow tachycardia and is a sign of severe hypoxia. A decrease of 20
beat in the normal rate is significant i.e 100 beat or below which can lead to death
3. Irregular heart rate (arrhythmia) follow the slow heart rate.
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4. Passage of meconium – in a cephalic presentation.
5. Convulsive movement of the fetus – this sometimes precede intra-uterine death. Treatment of
fetal distress at this stage is usually fruitless.
Prevention of foetal distress
- Patients pregnancy complications as above should be referred for hospital delivery and should
not be allowed to have prolonged labour.
- Patients with ruptured membrane should be confined to bed to prevent prolapse of the cord.
- Early detection of early signs of foetal distress by auscultating the fetal heart at quarter hourly
intervals in susceptible cases.
Treatment
- The physician should be informed
- Immediate delivery of baby
- Give oxygen to the mother by mask
- Administration of Nikethamide or Coramine (2ml) and 10-40ml of 10 percent glucose in
conjuction with oxygen has yielded good results.
- If possible, find out the cause of the distress
- Determine the degree the vaginal dilation through V.E and exclude cord prolapse.
- If patient is in 2nd stage and the head is being held up by right perineum, episiotomy can be given.
- Forceps delivery under pudendal block may be necessary.
- Caedarian section should be anticipated and the necessary preparations made if fetal distress
occurs in the first stage of labour.
MATERNAL DISTRESS
Maternal distress means maternal exhaustion that is, the strain and stress of labour have proved too much
for the mother the exhaustion is not necessarily related to the duration of labour, for maternal distress can
occur at any stage of labour, though it is unusual in early labour. Maternal distress is an indication that
the labour should be terminated.
Signs of maternal distress’

a. Increase pulse rate (90 to 120 beat or more / minutes)
b. Increase temperature of 37.20c and more in an umcomplicated condition
c. Increase respiration rate of 24c/m and above
d. Sign of dehydration such as dry furred tingue. Dry ski, presence of acetone in the breath and in
urine.
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e. Distension of the bowel with gas
f. Vomiting occurrence at times
g. Restlessness, weakness and sweating
h. The patient looks ill, anxious and worried.
Management
Adequate rest, sedation, hydration an avoidance of prolonged labour are preventive measures against
maternal distress.
Treatment
- IV fliud of 5-10% glucose to correcr dehydration and ketosis
- Labour is usually terminated
- If OS is less than 6cm dialted, caesarean section is usually performed.
- Forceps delivery or episectomy is performed to shorten the 2nd stage of labour in cases in which
full dilatation of the cervix has been achieved.
Maternal distress should be anticipated in certain labour e.g trial of labour, induction of labour with
Pitocin drip, when there is mal-presentation and abnormal position of foetus.
Others are:
Elderly primigravidae and those with cardiac disease, pulmonary tuberculosis, diabetes, severe
hypertension, pre-eclampsia and eclampsia and severe anaemia.
Patient with the above condition must be closely watched, well managed during labour and
delivered in a hospital.
MULTIPLE PREGNANCY
The term multiple pregnancy is used to described the development of more than one fetus in utero
at the same time. The incidence is much more higher in west Africa and much more lower in Japan.
Causes/Predisposing Factors
- Hereditary
- The increasing age of mothers at the time infants’ birth
- Increasing use of fertility treatment such as ovulation-stimulating drugs.
Types of Twin Pregnancy
1. Monozygotic or uniovular or identical twins: - They develop from fusion of one ovum and one
spermatozoon which after fertilization split into two.
Characteristics
Same sex, same genes, blood groups and physical features such as eye and hair colour ear shapes and
palm
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creases. However, they may be of different sizes and sometimes have different personalities. At birth,
they tend to have greater weight variation.
2. Dizygotic or binovular or non-identical twins: - They develop from separate ova that are fertilized
by two different spermatozoa, they are only alike just like brothers and sisters and can be of the
same or different sex. ½ of dizygotic twin will be boy-girl pair, ¼ will be both boys and ¼ will be
both girls.
Superfecundation: - This is the term used when twins are conceived from sperm fromdifferent men
during a menstrual cycle.
Superfetation: - The term used for the twins conceived as the result of two coital acts in different
menstrual cycle (very rare).
Placentation of Twins
1. Dizygotic: - Usually have separate placenta, 2 chorions and 2 amnions
2. Monozygotic: - (split occur at 2-cell stage first 3-4 days) separate placenta, 2 chorion and 2
amnion.
Monozygotic: fused placenta, 2 chorion and 2 amnion
Monoxygotic: (division occurs approximately 10-12 days). Single placenta, 1 chorion and 2 amnion
Single placenta: (occurs when embryo divide after 12 days). This occur in 1% of cases. 1 chorion and 1
amnion.
Diagnosis of Twin Pregnancy
1. Family history of twins should alert the midwife to the possibility of a multiple pregnancy.
2. Abdominal examination
a) Inspection: - size of uterus may be large than expected for the period of gestation
- Fetal movement may be seen over a wide area fresh
- Striae gravidarum may be apparent
- Up to twice the amount of amniotic fluid is normal
b) Palpation
- Fundal height may be greater than expected for the period of geastation
- Presence of two fetal poles (head or breech) in the fundus of the uterus may be revealed on
palpation.
- Multiple fetal limbs
- Head may be small in relation to uterine size
- Lateral palpation may reveal two fetal backs or limbs on both sides.
c) Auscultation
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- Hearing two fetal hearts over a wide area in a singleton pregnancy
- The pregnancy is shorter than a single pregnancy, average gestation for twins is 37weeks, for
triplets 34 weeks 34 weeks and for quardruplets 33weeks.
Effects of Pregnancy
- Exacerbation of minor disorder e.g. nausea, heartburn, e.t.c due to higher of circulating hormone
- Anaemia e.g. iron deficiency and folic acid deficiency
- Polyhydramnios – particularly associated with monochromic twins and fetal abnormalities
- Pressure symptoms – due to increased weight and pressure of the fetuses
- Impaired venous return from lower limbs increases the tendency to varicose veins and oedema of
legs
- Backache
- Increased uterine size may lead to marked dyspnoea and to indigeation.
Others
There can be increase in complication of pregnancy
3. Ultrasound examination
Complications associated with multiple pregnancy
- Poly hydramnios
- Twin-to-twin transfusion syndrome (TTTS): - This can be acute or chronic, acvute occur during
labour through blood transfusion from one fetus to the other through vascular anastomosis in a
monochromic placental. Both fetus may die.
- Conjoined twins
- Twins reversed arterial perfusion (TRAP): - one twin present without a well-defined cardiac
structure and is kept alive through placental anastomoses to the circulatory system of the viable
fetus.
- Fetus-in-Fetus: part of the fetus may be lodged within another fetus
- Malpresentations
- Premature rupture of the membranes
- Prolapsed of the cord because of distended uterus leading to poor uterine activity. Malpresentation
are poor stimulus to good contraction.
- Locked twins
- Delayed in the birth of the second twin
- Premature expulsion of the placenta (before the birth of second twins in dichorionic twins).
- Postpartum haemorrhage
- Undiagnosed twins
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ANAEMIAS
Anaemia is a reduction in oxygen carrying capacity of the blood, this may be caused by decrease
in red blood cell (RBC) production, or reduction in haemoglobin (Hb) content of the blood or a
combination of these.
It is often defined by a decrease in Hb levels to below the normal range of 13.5g/dl (men)
11.5g/dl (women) and 11.0g/dl children and pregnant women.
Signs and symptoms of anaemia
- Pallor of the mucous membranes
- Dizziness and fainting, headache, exertional shortness of breath, tachycardia and palpitations.
- Severe anaemia Hb<7g/dl – requires medical attention
- Very severe anaemia Hb<4g/dl – medical emergency of pregnancy
Physiological anaemia of pregnancy
During pregnancy the maternal plasma volume gradually expands by 50%, or an increase of
approximately 1200ml by term the total increase in RBCs is 25% or approximately 300mls. This relative
haemodilution produces a fall in Hb concentration, which reaches its lowest level during the second
trimester in pregnancy and then rise again in the third trimester. This represent a psychological alteration
of pregnancy necessary for the development of the fetus.
A low Hb level is ikely to affect the ability of the maternal system to transfer sufficient oxygen
and nutrients to the fetus. High Hb levels are considered to reflect poor pH volume expansion as found in
some pathological such as pre-eclampsia.
Iron deficiency anaemia in pregnancy
This is the most common cause of anaemia in pregnant women worldwide. No mobilizable iron
stores and compromised supply to body tissues.
- More severe stages – there are associated with anaemia
- Mild – moderate iron deficiency – these also have adverse consequences.
Iron deficiency increase the risk of haemorrhage, sepsis, maternal mortality, perinatal mortality and low
birth weight.
Causes of iron deficiency anaemia

- Reduced intake or ansorption of iron (diarrhea, hyperemesis, celiac disease e.t.c)
- Excese demand such as frequent, humorous or multiple pregnancy.
- Chronic infection particularly of urinary tract
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- Acute or chronic blood loss.
- Others are hookworm, infestation onfections such as amoebic dysentery, malaria e.t.c
Management
1. Oral iron preparation 120-40mg/day in divided doses e.g. ferrous sulphate, ferrous gluconate to be
taken after meal.
2. Intramuscular or intravenous iron injection for women who can not take or tolerate oral intake 1m
iron is given in from of iron sarbitol injection should be given deep to the muscle to prevent
staining and irritation at the injection site.
Iron dextran is given as total dose intravenous infusion, dosage is calculated by taking account of
body weight and the HB concentration deficit. Side effect – allergic reaction which may take the form
anaphylactic shock.
Oral, IM and IV administrations of iron result in similar rates in Hb concentration.
An increase of 0.8g/dl per week is usual irrespective of the route of administration.
Folic acid deficiency anaemia

Folic acid is needed for the increased cell growth of both mother and fetus. Anaemia is more likely to be
found towards the end of pregnancy when fetus is growing rapidly and in area social, economic and
nutritious deprivation.
Causes
- reduced dietary intake and reduced absorption
- When there is excessive demand and loss of folic acid e.g. multiple pregnancy, ahemolytic
anaemia
- Some drugs interfere with the utilization of folic acid e.g. anticonvulsants, sulphonamides and
alcohol
Signs and symptoms
Pallor, lassitude, weight loss, depression, nausea and vomiting, glossitis, gingivitis, and diarrhea. These
may be mistaken for minor disorders of pregnancy.
Examination of the red cell indices will reveal that the red cells are reduced in number but enlarge
in size (macrocytic or megaloblastic).
Management
The recommended daily supplement is 5-10mg orally in the following circumstances
- Diagnosed folate deficiency
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- Malabsurption syndrome
- Haemoglobinopathy
- Epilepsy requiring anticonvulsant treatment
- Multiparity
- Multiple pregnancy
- Adolescence
Vit. B12 deficiency anaemia
It produces a megaloblastic anaemia. B12 falls during pregnancy but anaemia is rare because the body
draws on its stores. Deficiency is most likely in vegans who eat no animal product at all. And should take
Vit. B12 supplements during pregnancy.
NORMAL LABOUR
Labour is the sequence of actions by which a baby and the placenta are expelled from the uterus at
child birth which is after 28th weeks of pregnancy.
Causes of labour
The cause of labour is said to be unknown. Among the theories offered are listed below
1. Overdistension and overstretching of uterus this explains why multiple pregnancy and
polyhydramnius tend to go into premature labour.
2. Low level of oestrogen and progesterone towards term as a result of diminish placental efficiency.
The uterus become sensitive to the effect of oxytocin from posterior pituitary and she goes into
labour.
3. The Braxton Hicks’ contractions increase in amplitude and may bring about the onset of labour.
4. Onset of labour has also been associated with hyperpyrexia, cyanosis and emotional upset
Premonitory signs of labour
This predict the approach of labour
1. Lightening – occur two weeks before term. After 36weeks in primp
2. Frequent micturition occur, urgency & stress incontinence
3. Braxton Hick’s contractions become more intensified with back pain due to relaxation of pelvic
joints.
4. Cervix is soft, almost attached, OS admit one or two finger tips.
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5. Weight loss due to reduction in liquor amnii at term.
6. Mood swing, and a surge of energy may be experienced
Stages of Labour
For descriptive purposes, labour is divided into 3 stages.
1. 1st stage of labour:- Onste of regular uterine contractions to full dilatation of the cervical os. It
comprises of:-
- Painful uterine contraction
- Progressive dilatation of the cervix
- Formation of the forewaters
- Rupture of the membranes
2. 2nd stage of labout: - start from full dilatation of cervical os to the complete expulsion of the baby.
It last abour one hour in a primigravida and 5-30 minutes in a multigravida.
3. 3rd stage of labour: - Entails complete expulsion of the placenta and membranes, usually within 5-
15 minutes birth.
During 1st stage of labour, we also have
- Latent phase: - This last 6-8 hours in first time mothers when cervix dilate from 0cm to 3-4cm
and cervical canal shortens from 3cm long to <0.5cm.
- Active first stage: - this is the time when cervix undergo more rapid dilation, when the cervix is 3-
4cm till full dilationof cervix. Average of 7.7 hours in primp and 5.6 hours in multip.
- Transitional phase: - when cervix is from around 8cm until it is fully dilated (or until the
expulsive contraction during 2nd stage are felt by the woman)
PHYSIOLOGICAL OF FIRST STAGE OF LABOUR

1. Uterine action: - Each uterine contraction start in the fundus near one of the cornua and spread
across and downward. Contraction is most intense and last longer around the fundus.
2. Polarity: - The term describe the neuromuscular harmony that takes place between the two poles
of uterus throughout labour. The upper pole contract strongly and retract expel the fetus the lower pole
contract slightly and dilate to allow expulsion to take place.
3. Contraction and retraction: - Uterine muscle does not completely relax after contraction but
muscle fibre retain some of the shortening of contraction upper segment of uterus becomes
gradually shorter and thicker and its cavity diminishes, this assist in progressive expulsion of
fetus. The contraction usually occur as rhythmic regularity and interval between them gradually
lesson. Meanwhile, the length and strength gradually increase. They start by occurring every 15-
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20 minutes lasting for about 30 seconds, often fairly week at the end of 1st stage, they occur at 2-3
minute intervals last for 50-60 seconds and are very powerful.
4. Formation of upper and lower uterine segment: - Upper uterine segment is formed by the body
and fundus while the lower uterine segment is formed by isthmus and the cervix. The muscle content
reduces from fundus to cervix. When labour begins, the retracted longitudinal fibres in the upper segment
pull on the lower segment causing it to stretch, this is aided by the force applied by the presenting part.
Retraction ring:- this is a ridge that form between the upper and the lower uterine segments. When the
ridge is exaggerated, it is known as bandl’s ring. This is when it becomes visible above the symphysis in
mechanical obstructed labour when the lower segments thins abnormally.
The retraction ring continue to rise until the fetus descend down the cervix when it will rise no
more.
Cervical effacement:- this is the shortening of the cervix and it is drawn into lower uterine segment.
Cervical dilatation:- dilation of the cervix is the process oe enlargement of the os uteri from a tightly
closed aperture to an opening large enough to permit passage of the fetal head. Dilatation occur as a
result of uterine contraction and counter-pressure applied by the presenting part and/or the bag of
membrane (intact).
Show:- a blood stained mucoid discharge seen at the dilatation of os. Cervical plug (operculum) during
pregnancy with blood from parietal decidual around the cervix where chorion has detached from dilating
cervix.
MANAGEMENT OF LABOUR
Admission of the woman:- the nurse/midwife should welcome the woman happily, giving her the
impression of her readiness to care, both for her and her relatives.
Admission of patient:-
-- general condition and progress of labour
-- history taken: previous and present pregnancy, full social medical and obstetrical history from
booked patient.
-- time of onset of labour, ‘show’ or vaginal bleeding
-- vital signs
-- urine testing for sugar and albumin
Abdominal examination:- this is done to determine the lie, presentation and position as well as the
engagement of head. Fetal heart sounds, intensity and frequency of uterine contractions and patient
reaction to these contractions are noted.
Vaginal examination:- this will confirm if this woman is in true labour. Vaulava should be inspected to
exclude and abnormalities such as vaginal discharge , bleeding, oedema, sore, warts and varicose veins,
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color and odour of liquor (if rupture). Vaginal examination should be kept at a minimum to avoid
ascending information.
Indication for VE
1. to exclude prolapse of cord after rupture of membrane
2. to confirm the onset of second stage
3. to determine the degree of cervical dilatation
4. To find out the cause of delay in prolonged labour especially in the second stage of labour.
5. To determine fetal presentation and engagement of head.
presentation:-presentation is often assessed in relation to the ischial spines. A head that is at or below
the level of the ischial spines is well engahed.
Further management include
- Making the patient as comfortable as possible
- Providing appropriate nourishment and fluid intake
- Taking care of bladder and bowels
- Keeping accurate record and making intelligent observations to assess the condition of the mother
and the foetus as well as the progress of labour.
MANAGEMENT OF THE SECOND STAGE OF LABOUR
Preparation for delivery
1. The delivery room and equipment should be got ready
2. The baby’s cot is warned and the head of the cot is lowered. Equipment for delivery trolley should
be ready.
3. The delivery trolley should be set under aseptic precaution.
The basic equipments are: - 2 clamps or artery forceps, 1 pair of blunt end or cord scissors, 1 pair of
episiotomy scissors, 2 urethral catheters, 1 dish to receive the placenta, mucus extractor, 2 cord ligatures,
a pair of sterile gloves, sterile linen and dressings, namely gown for the nurse and delivery sheet, 3
dressing towels, 2 anal pads, 2 perineal pads, wool swabs, a gallipot with four sterile swabs and water for
the baby’s eyes, 1 hand lotion bowl with Hibitane (1:2ooo), 1 swabbing lotion bowl.
4. Oxytocic drugs. Ergometrine 0.5mg or syntometrin 1ml, same should be drawn in syringe and
kept with the ampoule in a covered bowl. Or misoprosol 600mcg tablet orally or vaginally.
5. The baby’s identification band bearing the mothers name
Signs of 2nd stage
- Full cervical dilation (10cm)
- Expulsive uterine contraction
- Gaping anus
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- Bulging of the perineum
- Rupture of membrane
- Presence of fetal head in the vagina
Observation and care
- Encourage patient to empty her bladder
- Put patient in lithotomy position
- She is asked to take deep breath and bear down during contraction and rest in between
contractions.
- The patient pulse rate and BP is measured and recorded every 5 minutes
- Sips of cold water may be given
- If 2nd stage exceed 30 minute for multip and 1 hour for primit, the cause of the delay should be
sought and corrected.
Aseptic precaution: - This is to prevent infection, the nurse/midwife should wear a plastic apron, clean
cap, and mask. She should scrub her hand and arms under running water or in a bowl of antiseptic lotion.
The perineum, vulva and thighs are cleaned with swabs. Sterile dressing towels or delivery sheets
are placed under the patient’s buttocks and over lower abdomen and thighs. The anus is covered with anal
pad.
Delivery of the baby
The patient can be placed in dorsal position left lateral, lithotomy and squatting attitude is adopted
among some tribes
Delivery of the head
Flexion of the head is maintained till the occipital protuberance is free; then the head is crowned. The
patient is asked to pant or breathe quickly through the mouth while the midwife actively extend the head.
Sudden expulsion of the head should be prevented because it can predispose to intracranial injury and
perineal laceration.
After the delivery of the head, the eye is cleaned with sterile wet swab and the nose and mouth
with guaze swabs.
The cord is felt for around the body and neck when it is felt and loop is loose, it is made to slip
over the body and head of the foetus, when it is tight, the cord is double clamped and cut.
Shoulders
when there is extemal rotation of the head there will also be internal rotation of shoulder, gentle
downward pull on the baby can aid in the expulsion of the anterior shoulder, after which the baby is
carried upward over the mother’s abdomen so that the posterior shoulder, can escape over the perineum.
The baby usually glides out smoothly following the escape of the posterior shpulder.
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The nurse/midwife note the time of delivery, the airways are cleared, cord double clamped and
cut, identification wristlet is tied on the baby’s wrist, which should include name and sex. The baby is
wrapped warmly, shown to the mother for identification, then lay to rest.
MANAGEMENT OF 3RD STAGE OF LABOUR
- Put the patient in lithotomy/dorsa position
- Ensure the bladder is emptied to prevent PPH
- Ensure the uterus is contracting
- Observe for signs of placental separation
- Adjacent of placenta leading to lengthening of cord.
- Oozing out of blood vaginally
- Appearance of placenta on the vulva
- The midwife should observe for and manage excessive bleeding
- Deliver the placenta on a curved hands and drop it inside a kidney dish, same should be observed
under running water.
Modes of placental delivery
1. Maternal effort: - A natural method when uterus contracts, the woman is instructed to hold her
breath and bear down. The palm of nurse/midwife can be placed on the abdomen and placenta removed
on curved hands,
2. Fundal pressure
3. Brandt Andrews Manouvre: - This method entails the lifting of an already separated and
descended placenta from the vaginal or the lower uterine segment by pulling on the cord. The cord is
wound round the hand-twice and a gentle downward pull will deliver the placenta.
4. Controlled cord traction: - This is a modified Brandt Andrew’s Manouvre. The separation of
placenta is hastened by the administration of syntometrine/ergometrine.
The left hand is used bracing the utery (pressing the uterus downward and upward). The right hand gasp,
the cord and apply traction to expel the placenta.
5. Crede’s method and manual removal: -This is used in abnormal types of labour.
TRADITIONAL METHOD OF FAMILY PLANNING
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INTRODUCTION: before the advent of scientific method, our forefathers and fore mothers were aware
of need for child spacing. Traditional medicine men have prescribed and operated some method of F/P.
The mode of action may vary from one herbalist to another herbalist who may refuse to discuss the mode
of action of family planning. An inexhaustible list of mentioned below;
1. WAIST BAND: a form of leather panel worn around the woman’s waist during ciotus
2. ARM BAND: a leather band worn around woman’s arm during coitus.
3. INCANTATION PARCHMENT: Incantation written in parchments folded and tied with black
and white thread round it. It is worn by the woman before and during coitus. Another type is
Leopard Skin and six children are afraid of Leopards, the spirit of leopard will drive aaway
children, thereby preventing pregnancy.
4. SACRIFICATION:
Black powder applied every 3months are incision on the Mon’s veneris of the woman, the powder is
prepared from used burnt menstrual cloth of the woman. The powder is rubbed on the 16th incision mark
on mon’s veneris. It is assumed that this prevent ovulation or menses.
5. WOODEN DOLL:
A wooden doll expected to be placed under the pillow of the woman during coitus. It is assumed that the
spirit of the wooden doll will prevent pregnancy.
6. RING:
A ring maintained with native concortion to be worn everytime by the woman.
7. PARROT’S FEATHER:
A Parrot’s feather maintained with native drug. It is used for wayward teenager who will walk over or
across it. The feather is kept until the teenager gets married and the feather is then neutralized
8. LOCKED PADLOCK:
A locked pad lock which in that should remain locked throughout the period the couple donot wait
pregnancy.
9. SPECIFIC VEGETABLE:
Specific vegetable cooked for only the woman to eat.
10. BARK OF TREE:
A specific bark of tree steamed and the liquid given to the woman to drink periodically.
11. KAUN (POTASH):
Potassium sulphate dissolve in water to be taken orally immediately after ciotus
12. LIME JUICE:
Taken immediately after coitus and also used for vaginal douching.
13. BLUE POWDER:
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Blue powder us poisonous to the body. It is drank by the women immediately after coitus. It is assumed
that it stimulates uterine contraction thereby preventing inplantation.
14. WATER FROM CORPSE:
Water from dead body rubbed into cuts made in the body of the woman.
15. ABSTINENCE:
Refraining from penis-invagina intercourse. It is obviously the most effective of all the traditional
methods.
16. POLYGAMY:
Having more than one wife. It is practiced as a means of achieving abstanances.
17. VERSE FROM:
Verses from ‘Kuran’ are written on a piece of paper and rapped with leather and thread. This is word and
the head around the waist of woman.
18. PROLONGED BREAST FEEDING:
This is common practice throughout Nigeria. It may last up to 3yrs post partum.
ADVANTAGE OF TRADITIONAL METHOD OF FAMILY PLANNING
1. It is the method use even when modern method were not available.
2. The methods are assessable to the grass roots.
3. Supports the belief system already held by men.
4. Does not require change in behavior
5. Some methods such as breast feeding and abstinence are effective and beneficial to mothers and
babies.
DISADVANTAGES
1. The mechanism of actions are not clearly defined.
2. Effectiveness cannot be measured
3. Some of the articles are injurious to the body e.g Pottassium powder and blue powder.
4. Some of the methods are irreversible, especially when there is a mistake from the operation.
5. Some of the articles are difficult to get e.g Leopard skin.
6. Some methods can only be operated by traditional medicine men.
7. The woman that use the method may be at the mercy of the traditional medicine men.
8. Some methods are excited in unhygienic ways.
9. No dosage: mode of action is not known and the adverse effect.
NATURAL METHOD OF FAMILLY PLANNING
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Natural method of FP are otherwise known as fertility awareness. Fertility awareness method have been
in use since 1930s to predicts woman’s fertile days. Thus both partners can avoid unwanted pregs or
minimize the chances of ‘planned preg’.
Fertility awareness includes these methods
1. Rhythm or calendar method.
2. Bowel body T0 (BBT)
3. Cervical mucus method or “Billings method” or oculation method.
4. Synthothermal method.
5. Lactational Amoneerrohea method
6. Coitus interruption (withdrawal)
7. Total abstianance.
ADANTAGES
- It can be used at will by the couples
- It involves the two partners.
- It is free from artificial means (in-expensive)
- Fairly effective (63-98%) depending on use.
- No physical side effect.
- Is acceoted by many religious group that does not accept methods of Fp.
- Trained volunteers contrain others to woe method:- without assistance from the health workers.
- It may increase number of initial FP acceptors.
DISADVANTAGES
- Does not protect against STDs including HIV/AIDs up to 3months of instruction and continuous
counseling is needed for beginners. Is a but difficult from non-literate women as they need to
keep daily records.
- Both couples must be co-operate so as not result In wanted pregnancy.
- Couples must avoid sexual intercourse between 10-15days.
- Long period of abstinence may cause marriage problems
- Women with irregular periods may not be able to use the calendar and BBT method.
- Vagina infections may interfere with normal mucus symptoms.
- Fear of unwanted pregnancy.
- Require strong commitment and operation.
FERTILITY AWARENESS
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This mean knowing about the female and male reproductive processes and how to determine the fertile
and unfertile phases of the menstrual cycle.
When fertility awareness is used for FP it requires the couple to abstain from sexual intercourse during
the fertile days around the time of ovulation.
A. RHYTHM (Calendar) METHOD
This woman calculates the onset and duration of her fertile period; i.e the time awhich a viable egg is
available for fertilization by the sperm. Calculation of fertile period rests on these three assumptions.
i. Ovulation occurs on day 14( + or – 2days) before the onset of the next menses.
ii. Sperm remains viable for 2-3days.
iii. The ovum survives for 24hours.
To use this method, the woman must maintain a menstrual calendar recording the length of each of her
menstrual cycles over a period of six months. The first day of menses is day1 of the cycle. The earliest
day likely to be fertile is by substracting 20days from the shortest cycle. The latest day on which is likely
to be fertile is by subtracting 10days from the longest cycle e.g if her shortest cycle is 25days and the
longest cycle is 30days.
First fertility day = 25-20 = day 5
Last fertility day = 30-10 = day 20
Days likely to be fertile is Day 5 -20 of the flow.
However temperature or mucus changes or both may give clear idea of the end of fertility days more than
the calendar method does so that the fertile period may be shorter while the safe period longer.
MECHANISM OF ACTION
The calendar/Rhythm method does not reflect physiological changes associated with ovulation and
fertility. Any variation in the woman’s cycle can result in miscalculation of the safe period which can
lead to unplanned pregnancy. Furthermore, the prolonged period of an ovulation such as occur in post
partum period especially with lactation. Many NFP providers belief it should not be taught alone.
B. BASAL BODY TEMPERATURE (BBT) METHOD
BBT can be used in the home to detect ovulation.
BBT is defined as the highest body temperature of a healthy person during working hours.
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A woman can determine her time of ovulation after she has recorded her chart for 3 or 4 successive
months. A drop in BBT sometimes proceeds ovulation by about 12-24hours and sustained rise almost
follows for several days.
MECHANISM OF ACTION
Ovulation is detected by identifying a shift in temperature 0.2-0.50c or 0.4-1.0 of body temp. rises under
the influence of progesterone produced by corpus luteum temp. can be taken orally, rectally or vaginally
but same time should be used for consistency. However if temperature are checked daily and correctly,
temp changes will be observed and that denotes that ovulation has occurred.
C. BILLING METHOD (CERVICAL MUCUS)
In this method, the sequence of changes in the quality of cervical mucus is observed ton determine the
fertile and infertile periods. After menstruation and before ovulation, normal vaginal discharge is either
absent or white cloudy or yellowish colour, scarity and thick, close to or during ovulation becomes clear,
abundant, elastics, thin and slippery (spina barkett) as a result of low saline content and a high oestrogen
level. Ovulation most likely occur abut 24hours after the last day of abundant slippery discharge. To use
cervical mucus charting for FP a woman should assume that ovulation could occur anytime in the 2days
before and 2days after her mucus peak she can assume that her fertile period is over 4days after the last
abundant slippery discharge day.
MECHANISM OF ACTION
The cervical mucus method (CMM) is based on the woman’s observation of a sequence of changes in the
quality of cervical mucus.
As the time of ovulation approaches and the oestrogen concentration increases to it’s highest level in the
cycle, the mucus thins out and produce a wet slippery lubricature sensation and appear as a clear (egg
white) like substances which when placed between two fingers stretches so as to hang in strings (spin
barkeit) without breaking. The last day of the wet slippery sensation is called “The peak day” following
ovulation, the progesterone produced by corpus luteum in the presence of oestrogen inhibits the
production of the mucus especially the type on the peak day to predict and detect the time of ovulation
and the fertile period through careful daily observation of the cervical mucus.
D. SYMPTOTHEMAL METHOD (Cmm +BBT)
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This is a method of FP which involves a combination of cervical mucus changes and BBT to indicate of
time of ovulation and determine the beginning and end of the fertile period. Sometimes other s/s of
ovulation are noticed by the woman, such as breast tenderness, mid cycle pain or spotting and opening of
the cervix in addition to calendar calculation, Rhythm symptothermal(S.I) method involves abstinences
during fertile periods (unsafe) as determined by a combination of the method listed above.
E. LACTATIONAL AMMENORRHEA METHOD (LAM)
The use of exclusive breast feeding as contraceptives method because:
 It causes lactational amenorrhea and ovulation.
 Very effective, give adequate information as follows;
- Breastfeeding exclusively for 1st 6months
- Breastfeed on demand.
- Refrain from given (domies) passifier.
- Allow at least (15min) on each breast.
- Breast feed both day and night (at least 8times) in a day and at least twice at night.
- Give no other drink or food, water before 6months.
- Return to clinic, if breast feeding pattern changes or menses resume.
 Can use other method after counseling accordingly.
F. COITUS INTERUPTION (WITHDRAWAL)
1. When penis is withdrawn from the vagina before ejaculation.
2. Instruct client to wipe off any fluid at the tip of the penis before sex.
3. Withdraw penis from vagina before ejaculation.
4. Do not use if partner is not in dull control of ejaculation.
5. Do not use for repeated sexual act.
6. In case of failure, use a quick acting spermicide e.g foaming tablet or jelly and use emergency
contraceptive within 72hrs.
G. TOTAL ABSTAINANCE
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This means avoiding having sexual intercourse totally.
- The only method encouraging for youth and adolescent.
- It is morally and culturally accepted.
- 100% effective in the prevention of STI,HIV/AIDS.
- It bestows on young people a sense of self worthy.
ADVANTAGES
Since use of natural method of FP does employ drugs or devices. The only potential medical side effect is
the risk of unplanned pregnancy with the attendant possibilities of maternal mortality.
1. Training in method increases, knowledge of production and may help couples become pregnant
when so desire.
2. Effectiveness and acceptability can be increased for some couple when calendar and BBT is used
in combination with barrier method.
DISADVANTAGES
1. Require strong commitment and co-operation from both partners.
2. Fairly effective (63-98%) dependency on use. Responsibility for planning is shared by both
partner’s leading to better co-operation between the couples.
SURGICAL METHODS OF F/P
STERILIZATION:
It is the permanent birth control method for both women and men who do not want to have any more
children, vasectomy is done for men while tubal ligation is done for women.
The two methods are permanents and irreversible. Therefore the couple must be sure they have
completed their family before intervention is done; usually they are to sign the consent form before the
operation is performed and usually admitted to hospital for close observation prior to surgery.
1. TUBAL LIGATION
A permanent for women who do not want to have any more children, can be done under local or general
anaesthesia.
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The tube are tied/ligated thereby preventing pregnancy.
NOTE: Ovulation and menstrual flow is not affected.
ADVANTAGE AND BENEFITS.
1. More than 99% effective.
2. Give permanent protection against pregnancy.
3. It is a safer, simple and quick operation.
4. No need for other birth control measure.
5. It is done once and is effective for the woman’s life.
6. In expensive over the long time.
7. Gives husband and wife chances to enjoy sex life without fear of pregnancy.
8. No long term side effects.
It is done by trained Doctor’s in the hospital or health centres.
POSSIBLE SIDE EFFECTS
Following the operation there may be
a. Possible bleeding or swelling at the incision site.
b. Slight tenderness of the incision site.
c. Slight soreness for few days.
REPORT: severe fever, dizziness, severe abdominal pain, bleeding, severe pain or pain at incision site
heavy bleeding from the womb through the vagina.
Tube ligation is not recommended for women who
(1) May want more children
(2) Is less than 35yrs old and has never had child
(3) Not on stable relationship but might be at some future time
(4) Is emotionally unprepared or psychologically unstable
(5) Expects to have the operation reversed. If she change her mind.
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Follow up visit: Client should visit the hospital health center seven days after surgery for review and
follow up instruction.
2. VASECTOMY:
Normally done for men under general and local anesthesia. The vas-deferense (the tube through which
sperm passes) is tied and ligated or cut. It prevents sperm from reaching the penis during ciotus.
ADVANTAGES
1. More than 90% effective
2. Men with vasectomy will not be able to have children again but can still enjoy sexual life/sex with
ejaculation.
3. It is simple, safe and quick operation.
4. It is done once and effective through life.
5. There is no need for other FP method
6. Couples can wnjoy their sexual life without fear of unwanted pregnancy.
7. It is unexpensive over the long time.
8. It gives men the chances to participate in family size decision.
9. No longer term side effect. It is done by the trained DR. in the hospital/health centre.
POSSIBLE SIDE EFFECT AFTER SURGERY
- Possible bleeding from the incision site
- Possible swelling of the scrotum.
- Fever of slight pain
- A reaction to the local anaesthesia.
FOLLOW UP VISIT
- Visit hospital/health care for check up in 1-6wks after operations.
- Must use other birth control method until the doctor indicates that pregnancy can no longer occur
after 3negative seminal fluid analysis is result (within 6months).
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3. TOTAL HYSTERECTOMY
It is a permanent method of birth control. This term refers to the total removal of the uterus incase of
disease, the whole uterus may be removed. This resulting in permanent stericity e.g Cancer of the uterus.
NOTE: It is a major surgery which can be done under general spinal anaesthesia.
- Consent of both husband and wife is very necessary.
- The woman will not be able to mensurate after surgery.
PRE AND POST OPERATIVE CARE
As for other major surgical cases,
 Review subtotal hysterectomy and vaginal hysterectomy.
IUCD
DEF: The IUCD are small flexible article made of plastic or stainless steel which are inserted into the
uterus to prevent pregnancy. They are of various size and shape.
HISTORY
Development of Modern IUCD begin in 1909 when Richter(R)X craftenberg device intra uterine devices
is made of silk worm gut, since then IUCD were made in various shape e.g ring spiral, T-Shape, 7 shapes
e.t.c. the material used varied including silver or plastic, some contain progesterone.
1. (MOA) inhibition of sperm, fertilization, implanatation impairment by distruption of proliferative,

secretory maturation process.
2. Mechanical dislodgment of implanted blastocycst from the endometrium.
3. Increase local production of prostaglandins with inhibition of carbolic anydrase and possibly
alkaline, Phosphate activity.
4. Copper may also interfere with oestrogen up take and its intracellular effect on the endometrium
5. Immobilization of sperm.
6. Decrease motility of the ovum in the fallopian tube.
EFFECTIVENESS
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Seems to be between 97%-99% with very minimal failure rate, the difference in effectiveness for
different IUCD can be attributed to such IUCD, such as size, shape, presence of copper or progesterone,
also age and parity e.t.c
SCREENING
One of the main concern about the use of IUCD is that woman who use it are more likely to develop PID.
Through screening must be done to eliminate those who are predisposed to risks.
TYPE OF IUCD
- Non – medicated and
- Medicated
A. NON-MEDICATED IUCD.
They are made up of inner plastic material e.g lippes loop
LIPPES LOOP: of various size which could be identified by the colour string.
1. Lippes lopp A is with blue colon strings (small size for para 1-2 client)
2. Lippes loop B – is with black colour string (small size for para 2-3 client)
3. Lippes loop C – is with yellow colour string (medium size for para 3-4 clients)
4. Lippes loop D – is with white cololur string (Large size for para 5-7 and above clients).
B. MEDICATED: it includes
- Copper T (CuT 200B, CuT 380A, CuT 2209)
- Copper 7 ( Graviguard)
- Multiload (Cu -250 – Cu-375)
- Progestorsert – contains progesterone
- Norgesterial T: contain levonorgestrel
ADVANTAGE
- Highly effective not messy
- Reversible
- Independent of intercourse
- No day to day action required.
- Easily available
- No effect on lactation.
DISADVANTAGES
- Increase risk of infection.
- A slight increase risk of ectopic pregnancy or intra-uterine preg.
- Expulsion may lead to pregnancy.
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- Abnormal menstruation may occur
- Backache, uterine cramps during and after insertion.
- Faintung attack may occur at time of insertion.
INDICATION
- When hormonal contraceptive are contra-indication.
- Child spacing
- The client has completed child bearing, but does not wish to be sterilized.
- The client has menorhhagia (use of progestin bearing IUCD) where available.
- Clients preferences, in the absence of contra-indication.
CONTRA-INDICATION
ABSOLUTE CONTRAINDICATIONS
- Pregnancy (known or suspected)
- Active, recent or recurrent infection or known or suspected gonorrhea.
- Malignancy of the genital organ
- Abnormal vaginal bleeding
- Acute Pelvic Inflammation disease (PID)
- Abnormal vagina bleeding.
STRONG / RELATIVE CONTRA INDICATION
- Treatment of ectopic pregnancy

- Treatment of acute P.D (with in last 3months)
- Chronic P.D
- Severe dysmenorrhea
- Recurrent heavy periods
- Cervicitis or cervical erosion.
- Anaemia PCU less than 30%
- Uterine Fibriods
- Congenital anomalies of uterus e.g Bi-cornual uterus, cervical stenosis.
- Nulligravida
- Multiple sexual partner
- Age under 16years except in special circumstances
- Sickle cell diseases
- Heart diseases
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- Clotting disorders
- Corticosteroid therapy
- Allergy to copper (for copper IUCD or people that reacts to earing of jewelries that peel off their
skins).
EQUIPMENT OF INSERTION
TIME OF INSERTION
- Anytime during the menstrual cycle provided pregnancy has been excluded.
- Insertion is preferably performed because;
1. Uterus is less irritable
2. There is little chance of pregnancy
3. Cervical cannal is more open thus making dilatation unnecessary and insertion less painful
4. Fainting during insertion are reduced
5. Immediately after evacuation of an abortion if there is no infection.
6. Six (6) week of post partum
- 3months after a
- 3months – 6months after a successful,
COUNSELING/PREPARATION
The client must be counseled properly or allowed to choose a method.
- The procedure must be explained to her
- Pre or post insertion counseling are very important physical examination from head to toe to
detect any abnormality.
- Brest examination to rule out breast lump or CA (cancer) of the breast.
- V.E or cervical smear to rule out CA cervix
- The weight, B/P, should be noted at 1st and subsequent visit.
- Insertion should be done during the third to 4th day of menses, because it is easier done, rule out
pregnancy.
- In absence of menses or incase where pregnancy is suspected. Pregnancy test must be done if
negative IUCD can be inserted.
PROCEDURE STEPS
Explain the procedure to the patient to ensure her cooperation and relaxation, demonstrate the procedure
with a pelvic model (where applicable) the above examination are normal.
- Leave cosco’s speculum in the vagina

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- Clean vagina or cervix with anti-septic lotion (Savlon or mixture of chlorhexidine and salvon)
- Grasp anterior lip of the CX with a tenaculum (at 10am 2 dock position to minimize bleeding).
- Gently place traction and the CX with the tenaculum to reduce the angle between the uterine body
and the cervix.
- While maintaining traction on the tenaculum gently pass on uterine sound in the uterine cavity
until contact is made with the external Os.
- Measure the distance from the external Os to the top of the fundus by withdrawing the sound and
looking the level of blood on the sound or by marking the level on the Os on the uterine sound
with your index finger.
- Put on sterile glove.
- Load the device in the inserter (introducer)
- Using of recommended insertion technique gently introduce the loaded inserter using the
technique for the particular device.
- Withdraw the plunger and insert tube
- Trim the vagina end to the tails(string so that only 5cm/2inches is left beyond the external cervical
Os).
- Release and withdraw the tenaculum
- Inspect the cervix for any bleeding from the tenaculum site and apply gentle pressure with swab
on a sponge holder for a few minutes.
- Removes the speculum.
- Clean the client and offer sanitary pad.
INSERTION OF COPPER T
After sounding the uterus load copper T as follows;
- Open copper T wrapper carefully
- Wear sterile gloves on both hands
- Bend the horizontal arm of the device so that the tips are forced into the top of the inserter.
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- Adjust the flanges so it lies the same horizontal plane as the arms of the T.
- Introduce the loaded inserter through the cervical canal and upward until the flangers rest on the
external Os. The Tip of the inserter should be at the uterine fundus.
- Release the copper T by holding the plunger and the tenaculum steady with the left hand
withdrawing the inserter a little (about ½ inches) with the right hand. This release the arm of the
T-withdraw the plunger with left hand while holding the inserter stationary with the right hand.
Now push the inserter upward until the resistance of the fundus is felt this ensuring fundal placement.
- Then withdraw the inserter
- Trim the string to the length of about 5cm.
INSERTION OF MULTILOAD
The multiload come with vertical stem already preloaded in the inserter. After sounding the uterus insert
as follows;
- Pick up the inserter tube bearing the pre-loaded device and adjust the movable cervical flange to
the numbered mark corresponding to the uterine sound length in cm.
- Carefully insert the multiload into the uterus until it touches the fundus or the cervical flanges rest
against the external Os.
- Withdraw inserter to release the device into the uterine cavity.
- Trim the string to about 5cm external Os.
POST INSERTION INSTRUCTION
Allow patient rest on the couch for a few minutes and then help her down.
- Record finding and give bulk appointment
- Inform her that there might be increase bleeding and cramping for a few days and that these are
normal.
- Advise her to use sanitary pad during menstruation rather than tampons or clothes, wool or toilet
rolls as many get entangled with the string causing the device to be removed and may cause
infection.
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- Inspect all sanitary pad as expulsion is common during the menstruation.
- Check for the string after each period
- Avoid intercourse, in the 1st few days after insertion while still bleeding
- Report to the nearest family planning clinics if you notice the following;
Pelvic pain, dyspareunia, offensive vagina discharge, missed period or sign of pregnancy, fever, missing
strings.
- Inform your doctor of the presence of IUCD if you are going of surgery.
- Advice on personal hygiene.
DURING FIRST VISIT FOLLOW UP
- Ask about her health generally
- Ask about complication
- Ask about variation in her menstrual cycle this should include inter menstrual bleeding or spotting
excessive blood loss and painful menstruation.
- Ask her when last she felt the string of the device (this is to ascertain clients complies with
instruction to check the string)
- Carry out abdominal and pelvic examination
- Inspect of cervix into confirm presence of string
- No any discharge, erosion, cervicitis
- Palpate for pelvic tenderness
- Advise client on personal hygiene.
SUBSEQUENTLY FOLLOW UP
Next visit, 3months, 6months, subsequently yearly until she wished the device removed or the life of the
device expires
Lippes loop – Indefinite
Copper T 200 – 3yrs
Copper 1, 350A – 5yrs

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Multiload 250 – 3yrs
Multiload 375 – 5yrs
Repeat the activities of 1st visit of each such subsequent visits. Do a pap smea at the yearly visits.
REMOVAL OF IUCD
Indication for removal are
- Desire for pregnancy
- Menopause deserve another method
- Life of IUCD expires
- Accidental pregnancy
- Unusual bleeding or pain
- Genital tract malignancy
- Dyspareuria (painful intercourse)
- Partial expulsion of the device
- Cervical perforation
- Uterine perforation
- Remove IUCD whenever the client insist on its removal, the best time is during menses because
cervix is slightly dilated, soft and removal is less comfortable.
- Prepare equipment and material as for insertion but include alligator forceps and retrieval hook.
- Explain the procedure to the patient to ensure her co-operation and relaxation
- Ensure that client has emptied her bladder
- Place patient in a dorsal position with the legs flexed at the heep and knees
- With sterile gloves left hand, part the labia and gently pass a coscos.
- Visualize the cervix
- Clean the cervix and fornix with antiseptic solution
- Apply a perrineal pad.

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- Explain to the client that slight vagina spotting may continue for a few days
- If patient wish to use another method of contraceptives counsel and or initiate according.
DIFFICULTY IN REMOVING OF IUCD
Removal should be done by family planning trained Dr and traction as described above does not result in
the removal of the device and string are still visible or snaped, proceed as follows;
- Probe the cervical canal – a narrow artery forceps and attempt removal (if this fails, device is
probably embedded in endometrium).
- Explore the uterine cavity with alligator forceps, sharman’s curette or loop retriever
- If this fails, dilate the cervix with small dillotors or attempt, removal again (cervical block may be
necessary).
- X-ray or scan with ultrasound to exclude partial extrusion through uterine wall if this is found;
explore the uterine cavity under general anaesthesia.
COMPLICATION AND MANAGEMENT
1. PERFORATION: X-ray of the pelvic, prepare patient for surgery.
2. PID: Begin antibiotics immediately, probenecid. 1g daily and Empicillin 3.0mg orally 5times
followed by tetracycline 500mg orally two (2) days or doxycyline 100mg orally bd for 7-10days.
3. Remove IUCD follow up in 48hrs – refers to doctor if no improvement. If improved tell her to her
to return to clinic 4-7days after competing antibiotic.
- If no more infection, wait for 3months before re-insertion of IUCD after PID has been treated.
Mean while use other alternative contraceptive method.
4. Tubal infertility – Refer for investigation and treatment
Cramping pain (back ache e.t.c: if severe IUCDE should be removed, if mild, give analgesic drug e.g
PCM 2tab, PrN for pain.
5. Spotting bleaching, haemorrhagia and anaemia (esp. in the 1st 3months give haematenic).
- Reassure client that the uterus will adjust to the device
- Give proteinous diet
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- Refer to Dr. for treatment if no improvement
- Remove IUCD immediately.
6. EXPULSION:
- Partial or complete
- Perform speculum examination
- Rule out pregnancy
- If partial, remove and re-insert
- If complete re-insert if no infection
7. LOST OF IUCD STRING
- Perform speculum examination to visualize string removal under anaesthesia or hysterasal

pingogram in some cases.
Do bi-manual examination to assess consistency and size of uterus.
- Assess Adnexa (lateral fornix) and uterus for ectopic or PID if treatment indicate that:
1. Pregnancy test could rule out pregnancy
2. Reassure patient
3. If string are neither visible nor palpable and patient is not pregnant.
4. Gently explore endocervical canal with a narrow artery forceps or spiral tail extractor
5. If tail found, bring it down gently in the vagina taking care not to pull it.
- If string is not found. After cervical exploration refer to the doctor for “trace” IUCD insertion (or
uterine sound insertion).
- X-ray later view will be helpful. If the IUCD is located within the uterine cavity extract it by
means of a loop retriever, long fine artery or alligator forceps. (A sharman’s curette is excellent
for this procedure e.g Lippes loop.
- Re-insert another of client desire, if X-ray shows that the IUCD is no more in utero and has been
expelled, suggest to patient to use other type of IUCD or other contraception.
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- If patient is pregnant with IUCD in situ reassure her, inform her the potential out come for
keeping and removing the IUCD when pregnant.
If patient consents for removal do so and refer to antenatal clinic, counsel her to report to the clinic,
counsel her to report to the clinic if there is abdominal pain and bleeding or spotting.
6. Ectopic Pregnancy- refer immediately for surgery.
7. Spontaneous Abortion – Diagnose pregnancy remove IUCD, evacuate uterus and rule out ectopic
pregnancy.
8. Mechanical diathermy performed as it may cause injury to the surrounding tissue e.g patient with
CuT 3804; should not had diathermy.
9. REACTION TO COPPER T 380A; May predispose to undiagnosed disease in some women.

Also patients who react to earing jewelries should not have CuT 380A.
10. PREGNANCY RELATED COMPLICATION: E.g Intra-uterine pregnancy, diagonosed and

refer to prompt attention.
11. SECONDARY AMENORRHOEA
MIXED PERIOD
- Assess for sign for pregnancy
- Do bi-manual examination for string consistency of uterus, adenexia.
- Do speculum examination for string and colour for cervix
- Order for pregnancy test if possible.
ABORTION
Abortion is termination of pregnancy before the fetus i.e. before 24 weeks of gestation in the UK.
Bleeding in pregnancy, however slight is abnormal.
Abortion
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Spontaneous Induced
Threatened Therapeutic Criminal
Missed Inevitable Septic
Blood mole
Incomplete Complete
Carneous mole
Habitual
May go to term
Abortion may be spontaneous or induced
Causes of spontaneous abortion

1. Maternal
General ill health and debility, especially those associated with hyperpyrexia such as in malaria, anaemia,
diarrhea and dysentery, tuberculosis, pylonephritis and chronic nephritis, hypertension, untreated syphilis
and diabetes
Others are
- Hormonal imbalance
- Extreme emotional stress e.g. grief or fight, accident, violent, exercises and certain drugs.
Some local conditions in the birth canal such as submucous fibroids, infantile uterus and
incompetent internal OS of the cervix.
Threatened abortion
The pregnancy may continue to term if the disturbancy is slight, that is with good management.
The damage may also be progressive resulting in the termination of pregnancy.
Signs and symptoms of threatened abortion
- Slight vaginal bleeding which is preceeded by a period of amenorrhoea
- May complain of backache and intermittent low abdominal pain.
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- A spectrum examination done by doctor will reveal a closed cervical OS. The membranes are
intact.
MANAGEMENT OF THREATENED ABORTION
- Bed rest till bleeding stops
- Reassure patient
- Patient should put sanitary pad
- Vulva toilet with aseptic precaution
- Good feeding with addition of supplement e.g. ferrous sulphate folic acid and vit. C with
profilatic anti malaria should be given, phenoberbiton can be given to relax the patient mentally
and physically.
- On discharge advise patient to continue adequate rest at home
- Avoid lifting heavy objects, strenuous exercise and intercourse for at least one month.
- Avoid constipation, mild aperients such as two Dulcolax suppositories or magnesium hydroxide
(30mls) can be given but avoid enema and strong purgatives it can stimulate contraction.
- Good feeding is encouraged and supplement e.g. ferrous sulphate, folic acid and vitamin C
INEVITABLE ABORTION
With inevitable abortion, the pregnancy cannot be saved because a good portion of the placenta as
been detached and the cervical OS is dilating. The vaginal bleeding is severe and some clots may be
passed.
- Backache
- Intermittent lower abdominal pain
- Strong uterine contraction may be felt, if palpable
- The membrane may rupture and part of the product of conception may be visible vaginally
POSSIBLE RESULTS OF INEVITABLE ABORTION
1. Complete abortion: - In this case, the whole product of conception is expelled, pain and vaginal
bleeding will decrease, more common before 8 weeks of pregnancy.
2. Incomplete abortion: - Part of the product of conception, usually the foetus is passed and the
placenta and membrane are retained, it occur mostly after 12 weeks, the uterus fail to contract because of
the retained product and patient continue to bleed. Signs of shock may be eminent.
Management
- Ergometrin 0.5mg or syntometrin 1ml can be given, same can be repeated after 10-20minutes if
haemorrhage is profuse
- Pethidine 100mg can be given for pain
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- Evacuation may be done
- Manage if in shock
- Blood transfusion in severe bleeding
- Adequate rehydration
- Pre and post operative management
HARBITUAL/RECURRENT ABORTION
This is a condition in which a patient has had 3 or more consecutive spontaneous abortions.
Causes
- Unknown
- Can be result of incompetence of the internal cervical OS resulting from previous trauma to the
cervix
- It can be complication of disease like diabetes, nephritis, and tuberculosis
- Local lesions such as cervical erosion,
- Abnormalities and displacements of the uterus and fibroids.
Clinical features of abortions due to incompetence of the internal cervical OS
1. The abortion occur late in second trimester, usually between the 22nd and 24th weeks of pregnancy.
2. There may be no previous warning such as bleeding, the membranes may rupture suddenly
followed by expulsion of the products of conception
3. The abortus looks fresh
Management of habitual abortion
1. Patient are encouraged to improve their health by taking adequate diet.
2. Coitus should not take place during her subsequent pregnancy
3. Hospital admission is recommended in the 1st ½ of the pregnancy if patient cannot have enough
rest at home
4. the treatment if incompetent cervix is the shirodkar operation. A purse-string stitch of mersilence
tape or any non absorbable suture materials is tired round the cervix at the level of recorded in
patient case notes. The suture must be removed at about 38 weeks or as soon as the labour start.
The implication and possible uterine rupture should be stressed if suture is not remove in time.
MISSED ABORTION
This is a condition when the foetus is dead and is retained in utero.
- the signs of threatened abortion subsides expect for some brownish discharge which is not
associated with pain.
- the uterus fail to grow
- other signs of pregnancy disappear
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- the dead foetus may be retained for 3 to 4 weeks and its prolonged retention may occasionally
lead to profuse vaginal bleeding as a result of hypofinogenamia.
Management
- medical induction of labour is usually adopted in form of castor oil, enema, and bath followed by
the use of pitocin.
- if there is bleeding after conceptus has been expelled, curettage of the uterus and administration of
oxytocic drugs.
BLOOD AND CARNEOUS MOLE
Blood mole may arise in cases of missed abortion in which the decidual eapsularis remain intact
and permit the zugote to be surrounded by layer of blood. When fluid is exhausted from the blood
the fleshy, firm, hard mass is known as carneous mole. The management is the same as for missed
abortion.
THERAPEUTIC ABORTION
This is evacuation of the uterus done by a qualified practitioner in the interest of mother’s life or
her total well-being.
Indication
- Medical condition threatening the mother’s life or likely to cause good abnormalities e.g cardiac
disease, chronic nephritis and germen measles contracted in the 1st 12 weeks of pregnancy.
- The uterus is usually evacuated vaginally following dilatation of the cervix under a general
anesthetic
- Suction evacuation is advised before the 12 week
CRIMINAL ABORTION
This abortion is illegally procured. Such abortion are often done by unqualified person having
little regard for the consequencies such as risk of sepsis, uterine perforations, cervical laceration and
haemorrhage are associated with criminal abortions. Others are acute renal failure, infertility, maternal
morbidity and sudden death
SEPTIC ABORTION
Septic abortion usually occur after incomplete abortion. Often criminally induced.
Signs and symptoms
237
- Patient is ill with a high temperature
- Rapid pulse, headache. Vomiting, lower abdominal pain, lochia are profuse and offensive.
The patient become jaundiced.
Nursing care
- Patient should be nursed in isolation room are barrier-nurse
- pethidine injection to relieve her pain
Vital signs and if temperature is above 390c tepid sponging should be done.
- Vulval toilet twice daily and change pd PRN
- Replace blood loss and treat infection with heavy broad borad antibiotics
- Administration of anti tetanus
- Adequate diet
- Routine haematinics and antimalari should
UNSAVE ABORTION
An abortion performed by persons lacking necessary skill or in an environment tacking minimal
medical standareds or both
Method used
- Drugs used of ergometrine, qunine/blue or potash
- Vaginal interference such as inserting knitting pin of bicycle spoke into the vagina
Dangers
- Perforation of the pouch of douglas
- Perforation or laceration of the uterus
- Sepsis
- haemorrhage
- Acute renal failure
- Death from air embolus
Causes of unsafe abortion
There are:
- Unwanted pregnancy
- Lack of information to public
- Financial difficulties
- Desire to continue schooing
- Fear of parent’s reaction to a pregnant teenager at school
- Lack of knowledge about reproductive system
- Single marital status
238
- Too many children
- Lack of access to contraceptives
- Abandonment by the partner responsible for the pregnancy
- Pregnancy outside wedlock
Facts about Unsafe Abortion
- 20 million unsafe abortions occur worldwide yearly
- More than 70,000 women die each year as a result of unsafe abortion 23,000 of these occur in
sub-saharan Africa.
- 1 out of 8 deaths related to pregnancy is due to unsafe abortion
- Unsafe abortion accounts for 13% of all maternal death worldwide
- 40% of maternal deaths occur in Nigeria
- For every maternal death, 15-20 maternal morbidities occur
- Up to 50% of the hospital resources are used in treating women admitted for complications of
unsafe abortion.
POST ABORTION CARE
This is an approach for reducing morbidity and mortality from incomplete and unsafe abortion and
resulting complications and for improving women’s sexual and reproductive health lives.
Elements of PAC:
There are 5 elements of PAC which are:
- Treatment of incomplete and unsafe abortion and abortion related complications that are
potentially life threatening.
- Counseling to identify and respond to women’s emotional and physical health needs and other
concerns.
- Contraceptive and family planning services to help women prevent unwanted pregnancy
- Encourage the practice of birth spacing
- Reproductive and other services that are provided on site, provided via referrals to other facilities
in provider’s networks.
- Community and service provider partnerships to prevent unwanted pregnancies and unsafe
abortion
- Mobile resources for timely care for complications from abortion
- Ensure health services reflect and meet community expectations and needs
Potential Difficulties in Providing PAC
- Lack of adequate staff
- Inadequate infrastructure
239
- Lack of necessary equipment and medical supplies
- Poor communication system
- Lack of political wall
- Lack of support from policy makers
- Inadequate infection prevention control programmes
- Inadequate referral systems
- Inadequate monitoring and follow up of training processes.
- Administrative policy separating emergency and routine contraceptive processes within the
facility
- Resistance to the use of manual Vacum Aspiration (MVA)
Principle that Support patients’ Rights in Pac Setting
- Having empathy and respect for patient
- Maintaining positive interaction and communication with patient
- Respecting privacy and confidentiality
- Adhering to the voluntary, informed consent process.
Roles of the midwife in PAC
- The medwife is the general overseer of the totality of MVA service within the facility.
- The midwife has the responsibility of ensuring that the facilities and the necessary equipments are
always available at the MVA room. Portable water should be made available.
- All sterile items for the procedure should always be available
- The general cleanliness of the room must not be assumed. She should ensure proper cleaning and
setting up of the trolley. She must also ensure completenesss of the item on both shelves of the
trolley.
- She is to ensure availability of the stock for the procedure
- There should be no “out of stock syndrome”.
- Pre and post procedure care of the patient is an important responsibility of the midwife
- Her role in the actual MVA procedure depend on whether she is permitted to carry out the
procedure or to assist the doctor during a procedure. In which ever situation, she must have a
good grip of the procedure.
- she must possess a proper understanding of cleaning and sterilization/or disinfecting of equipment
used during the procedure and disposal of wastes, aspirates and sharp instrument in order yo
prevent infection especially HIV/AIDS.
- She is responsible for keeping record of details of the procedure.
240
THE FEOTAL SKULL
The feotal head is the most important part of the feotus because it contains the brain which is a
vital organs. About 95% of the babies present by the head. The midwife must know which area of the
feotal head causes least problem during labour and delivery. The knowledge of the landmarks on the
feotal head helps to diagnose abnormal presentation and positions as well as conducting delivery with
minimal injury to the mother.
THE SCALP
- This is the outer soft part of the head. It consists of the following
- The skin on some hair grows
- Connective tissue on which the skin rests
- Aponeurosis with some muscle fibres which are situated mainly to sides of the head.
- Loose connective tissue
- Periosteum which covers the bones of the skull

241
THE SKULL
The skull is the skeleton of the feotal head and consists of the dome-shaped portion called the
vault, underneath which is the base of the skull and the face.
The constituent bones of the feotal skull are the same as those of the adult. The bones of the face
and the base of the skull are ossified and fixed before birth. These are the sphenoid, the ethmoid and the
temporal bones which form the base of the skull while the orbital bones; the maxillae and the mandibles
constitute the bones of the face.
The bones of the vault are not well ossified before birth. The vault starts as sheet of membrane in
which five centers of ossification appear. These centers develop to form the occipital bones, the two
parietal bones and the two frontal bones.
A portion of the temporal bone forms part of the vault. The membranous ends of these bones are
known as sutures and where two or more suture meet fontanelle is formed.
The five original centers of ossification are the eminences on the skull, namely; one occipital
protuberance, two parietal eminences, two frontal eminences.
THE SUTURES
The suture are of great obstetrical importance in that they allow for the overlapping of the bones
of the vault during labour and birth of the baby.
The overlapping of the bones is known as moulding. The suture close gradually after birth. The
important of suture are listed below: -
- Frontal suture lies between the two frontal bones and extend from the root of the nose to anterior
frontanelle.
- Sagital suture extends from the anterior to the posterior fontanelle lies between the two parital
bones
- Coronal suture runs transversely between the frontal and the parietal bones and extend from on
temporal bone to the other.
- Lambdoidal suture seperates the parietal and the occipital bones.
FONTANELLES
242
Fontanelles are membranous spaces at the point of junction of the suture. There are two
fontanelles that are obstetrical significance: -
1. The anterior fontanelle or the bregma formed at the junction of frontal, coronal and sagittal
sutures. It is diamond –shaped measure 2.5cm in length and 1.25cm in breadth. The pulsation of
the cerebral vessels can be felt on the bregma; it is usually not closed till the baby is 18months old
after which it decomes completely ossified.
2. The posterior fontanelles or lambda is triangular in shape with less definite shape than the anterior
fontanelle. It is formed at the junction of the lambdoidal and sagittal sutures, it closes when the
baby is 6weeks old.
The attitude of the feotal head determines which area of the head lies lowest to birth Cana, when the head
completely flexed; the area which presents is the vertex which is the presentation that is common and
favourable. The vertex is that position of the head which lies between the anterior and the posterior
fontanelles and is bounded laterally by parietal eminences. The face presents when the head is completely
extended. This areas lie between the bridge of the nose and the chin.
The brow or sinciput comprising the two frontal bones is present where the head is partially extended. The
sinciput extended from the bridge of the nose to the anterior fontanelle.
The occipital area comprises the occipital bone only and it extends from the posterior fontanelle to the
foramen magnum.
DIAMETERS OF THE FEOTAL HEAD
Diameters are straight distances between any two points to the foetal head, some diameters are more
favourable than other for easy passage through the pelvic canal and this will depend on the attitude and
presentation of the head. The largest diameter lying across the pelvic in a presentation called the engaging
diameters.
There two transverse diameters:-
1. Biparietal;- this is 9.5cm – that diameter between the two parietal eminences.
2. Bitemporal diameter is 8.2cm long. It passes through the lower ends of the coronal suture.
243
Other diameter of the foetal head are anteroposteriro or longitudinal.
1. sub-mento vertical diameter is 11.5cm and is take from where the chin join the neck to highest
point on the vertex.
2. sub-occipito bregmatic diameter is 9.5cm and is estimated from below the occipital protuberance
to the midpoint of the bregma, here the attitude of the head is complete flexion and presentation is vertex.
3. Sub-occipito frontal diameter is 10cm from below the occipital protuberance to the midpoint of
the frontal suture
4. Occipito fronta; 11.5 from occipital protuberance to the midpoint of the glabela. Here the attitude
of the head is military attitude associated, the presentation is crow persistent occipito-posteriror.
5. mento vertical diameter (13.5cm) from the chin to the highest point on the vertex and head is
partially extended in brow presentation.
6. Sub-mento bregmatic (9.5cm) from where the chin joins the neck to the bergma and the head is
fully extend with face presentation.
ATTITUDE OF THE FOETAL HEAD
Attitude id defined as the degree of flexion or extension of the head on the neck. The attitude of
the head determines which diameter will present in labour and therefore influenced the outcome attitude
associated head partially extended, head fully extended.
244
PRESENTING DIAMETERS
The diameter of the head which are called the presenting diameter are those that are at right angle to the
curve of carus. There are always two presenting diameter namely an antero posterior or longitudinal
diameter and a transvers diameter. The diameter presenting in the individual cephalic or head presentation
are:-
1. Vertex presentation:- Whan the head is well flaxed the suboccipito bregmatic diameter and
biparietal diameter present. These two diameter have the same lengtgh 9.5cm. the presening area is
circular which is the most favourable shape for dilating the cervix the diameter the distends the vaginal
orifice is the sub occipito fronatal, diameter, 10cm whwn the head is not flexed but erect, the presenting
diameter are the occipito frontal, 11.5cm and biparietal 9.5cm this occurs when the occiput is in a
posterior position, which makes the diameter distending the vaginal orifice to be occipitofrontal 11.5cm.
2. brow presentation:- when the head ia partially extende, the mentovertical diameter 13.5cm and
the bitemporal diameter, 8.2cm present in this persistence presentation vaginal deginal delivery extremely
unlikely.
3. face presentation:- When the head is completely extended, the presenting diameters are the
submento bregmatic 9.5cm and the bitemporal 8.2cm the sunmento vertical diameter, 11.5cm will distend
the vaginal orifice.
245
DIAMETER OF THE FOETAL TRUNK
1. Bisacromial diameter 12cm
This is the distance between the acromion processes on the two should blader and is the
dimension that need to pass throughthe pelvic for the shoulder to be born. The articulation of the clavicles
on the sternum allows forward movement of the shoulders which may reduce the diameter slightly.
2. Bitrochanteric diameter 10cm
The is measured between the greater trochanters of the femure and is the presenting diameter in breech
presentation.
MOULDING
The term moulding is used to describe the change in shape of the fetal head that takes place during its
passage through the birth canal.
Alteration in shape is possible because of the bones of the vault allow a slight degree of bending and
the skull bones area able to override at the sutures. This overriding allows considerablereduction in the
size of the presenting diameters while the diameter at right angles lengthen.
It is a protective mechanism and prevents the fetal brain from being compressed as long as its not
excessive, too rapid or in an unfavorable direction.
Dangerous/complicated types of moulding
1. Excessive moulding e.g. in prematurity, prolonged labour
2. Rapid moulding e.g. in precipitate labour
3. Upward Moudling e.g. in sugar loaf head
NORMAL TYPES OF MOULDING
PRESENTATION PRESENTING DIAMETER ELOGATING DIAMETER

(AT RIGHT ANGLE)
1. Vertex presentation
- head well flexed SOB – 9.5CM MV – 13.5CM
- Deflexed head OF – 11.5CM SMB – 9.5CM
- partially flexed head SOF- 10CM SMV – 11.5CM
246
2. face presentation Head SME – 9.5CM OF – 11.5CM
completely extended
3. Brow presentation Head MV – 13.5CM SOB – 9.5CM
partially extended
CAPUT SUCCCDANEUM
This is a collection of tissue fluid (or oedema) under the scalp. It occurs as a result of pressure on
the part of the foetus which lies over the cervical os, it is thus persent at birth and could be present on any
presenting part-head or beech and tends to shrink in size after birth. It pits on pressure, it is usually
unilateral, it usually disappears within 24hours of birth without treatment.
CEPHAL HAEMATOMA:- This is a collection of blood of damage to the capillaries under periosteum.
It occurs as a result of damage to the fine capillaries under the periosteum.
COMPLICATIONS OF MOULDING
CAPUT SUCCEDANEUM CEPHAL HAEMATOMA

1. an oedematous swelling of A swelling due to bleeding between the skull bone
subdSDAsdacutaneous tissue of fetal skull and the periosteum
2. occur following early rupture of membrane in Occur as a result of the friction between the skull
firt stage of lobur bone as overriding of the bone takes place during
moulding
3. It is present at birth and occur on the part of the It is not present at birth (take 6 week to disappear)
head which lie over the internal os, but disappears but appers 2-3 days when the amount of blood is
within 24-48hours sufficient to form an obvious swelling
4. It may lie over the suture line Can be bilateral
5. It pit on pressure Does not pit in appearance
247
6. Does not need treatment except its complicate. Treatment is only required if haematoma
Infants should be cut-nursed and observed for increases in size over a number of days.
signs of cerebral irritation - vit.k injections are then give to raise
prothrombin level and assist clotting
- Haemoglobin level to be estimated and bady to
be treated for anaemia if need be
INTERNAL STRUCTURE OF THE HEAD
The brain and the meninges occupy the skull. A double layer of the meanings called the falx
cerebri divides the cerebrum into two hemispheres. The falx cerebri extends from the root of the nose,
along the frontal and sagittal sutures to the occipital protuberance. It is sickle shaped and contain large
blood sinuses.
Tentorium cerebelli separates the cerebri form the cerebellum it lies horizontally across the occiput
extending form one temporal bone to the other. It is attached in its midpoint to the posterior part of the
falx cerebri. Blood vessels are present in the tentorium.
The blood sinuses in the meanings are as listed below.
1. The superior sagittal sinuses which lies along the upper edge of the falx cerebri.
2 The inferior sagittal sinuses which lies along the lower boarder of the falx cerebri.
3. The straight sinus is found at the base of the falx cerebri.
4. The confluence sinus is at the junction of the superior sagittal sinus and the straight sinus.
5. The great veins of Galen join the inferior sagittal and the straight sinus at a point where the union
of the tentorium and falx is weak. This sinus drains the substance and is the most susceptible to injury
because of its situation.`
FERTLIZATION
Fertilization is the process by which male and female gamete fuse, this occur in the ampullary
region of the uttering tube.
248
Following ovulation, the ovum (oocyte) which is about 0.15mm in diameter, passes into the
uterine tube and is moved along towards the uterus i.e wafted along by the cilia and by the peristaltic
muscular contraction of the tube.
At this time, the cervix under the influence of oestrogen, secrets a flow of alkaline mucus that
attracts the spermatozoa. At intercourse about 300 million sperm are deposited in the posterior fornix of
the vagina, many are destroyed by the acid medium of the vagina. More will die on the journey through
the uterus and only thousands reach the uterine tube (ampulla). Movement of the sperm from cervix to
the uterine tube occurs by muscular contractions of the uterus and uterine tube and very little of their own
propulsion.
Before spermatozoa can fertilize the oocyte they must undergo:
1. Capacitation: during which which a glycoprotein coat and serminal plasma proteins are removed
from the spermatozoon head. It is a period of conditioning which involves epithelial interactions between
sperm and the mucosal surface of the tube.
2. Acrosome reaction: during which acrosin and trypsin-like substances (called zona-lysin) are
released to penetrate the zona pellucid. The sperm is also capable to releasing anzyme hyaluronidase
which also allow penetration of the zonal pellucid and cell membrane surrounding the ovum.
Many sperm (300-500 sperm) are needed for this to take place but only one will enter the ovum.
After this, the membrane is sealed to prevent entry of any further sperm and the nuclei of the two cells
fuse. The sperm and the ovum each contribute half of the complement of chromosomes to make a total of
46. The sperm and ovum are known as the male and female gametes, and the fertilized ovum as the
zygote. Fertilization is most likely to take place when intercourse takes place not more than 48 hours after
ovulation. Conception will take place about 14days before the next period is due.
Note: zona reaction
As the spermatozoa penetrates the zona pellucid, there is release of cortical oocyte granules that
contain lysosomal enzymes.
These enzymes
- Alter the properties of zona pellucid making it impermeable to other spermatozoa (zona
reaction).
- Inactivate the species specific receptor site of spermatozoa on the oocyte.

249
OBSERVATION OF NEW BORN BABY
A quick overall examination should be performed in the labour ward as soon as possible after birth to
ascertain that externally at least, the baby is normal and to assess adaption to normal extra uterine life.
Such examinations as colour changes, patency of airway and haemorrhage from the umbilical cord,
temperature should also be monitored.
Before the examination, the midwife should ensure that the environment is warm and draught-
free. Diligent hand-washing is essential.
The face, head and neck
Face:- General examination of face, eyes and mouth each eye should be confirmed that it is present and
the lence shold be clear. The normal space between the 2 years is up to 3cm.
Mouth- mouth can be opned by pressing against the angle of the jaw,observe the tongue, gums, palate,
vulva must be central, preocious teeth coveed with epithelial which may be loose, requiring extraction in
early neonatal period to prevent inhalation. A normal baby should be able to suck.
Epithelial pearls (cluster of several white spots in the mouth). It is of no significance but occasionally are
mistaken for infection and they disappear spontaneously. Midwife will observe for cleft lip/palate at
glance.
The Ears
Note: Position the upper notch of the finna should be level with the canthus of the eye.
- Patency of aternal auditory meatus
- Accessory uricles (small tags of tissuer) in front of our abnormalities associated with
chromosoma anomalies.
250
The Head
Degree of moulding (overriding of the bones of the suture) should be noted.
Fontanelle – a wode fontanelle indicate, hydrocephalus or immaturity.
Shape of Head – an indication for presentation at birth.
Caput succedneum may be noted.
Neck – should be examined to exclude swellings and to ensure that rotation and flexion of the head are
possible. Meningocele may be present at the back of the neck.
The Chest and the Abdomen
Chest and abdominal movements should be synchronous through the respiration may still be irregular
- The space between the nipples should be noted. Widely spaced nipple being associated with
chromosome abnormality.
- That shape of the abdomen should be rounded scaphoid (boat-shaped) abdomen indicate a
malnourished fetus or diciphragmatic hernia.
- Observe for protrusion at the base of the umbilical cor. Protrusion of the intestines through a
defect in the anterior abdominal wall is called exomphalos.
- Absence of one of the arteries of the cord is occasionally associated with renal abnormality and
must be reported.
Genitalia and Anus
If not certain of sex, paediatrician will initiate investigations.
- Baby’s temperature may be checked rectally to observe the temperature and the patency.
The Limbs and Digits
- Note the length and movement of the limbs
- Count the digits and separate them to ensure webbing is not present
- Observe for any accessory digits
- Observe the feet for talipes equinovarus
- Normal flexion and rotation of the wrist and ankle joints should be confirmed
- The axillae, elbows, groins and popliteal spaces should be examined for abnormalities.
Spine
With baby lying prone, the back should be examined and palpated – any swellings, dimples, or hairy
patches may signify an occult spinal defect. Spinal bifida.
Measurement
251
The baby’s head circumference, length and weight are measured to provide parameters against which
future growth can be monitored. Average length at birth 50cm. head circumference 35cm.
Documentation
All findings should be documented
APGAR SCORE
The midwife at 1 minutes and 5 minutes after the birth will make an assessment of the baby’s ge neral
condition using the apgar score.
Sign 0 1 2
1. Heart rate Absent < 100 b.p.m > 100 b.p.m
2. Respiratory Effort Absent Slow irregular Good or crying
3. Muscle tone Limb not firm Some flexion limbs Active
4. Reflex response to None Minimal grimace Cough or Sneeze
Stimulus
5. Colour Blue, Pale Body Pink completely pink
Extremities blue
Mnemonic for the Apgar score is
A Appearance (colour)
P Pulse (Heart rate)
G Grimace (response to stimuli)
A Active (Tone)
R Respiration (Breathing)
252

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CONCEPT OF MCH/FAMILY HEALTH / REPRODUCTIVE HEALTH and

Cause of Abdominal pain

a. What is urinary incontinence

Structures : Three layers of prostate gland

b) WHAT IS URINARY INCONTINENCE

PERTUSIS (WHOOPING COUGH)

SUGGESTED ANSWER: -Candidate to describe the follows: -

ii. Labour Laws (Labour code ordinance of 1945)

iii. Factory Law (Factory’s Act 1955, revised in 1985

 Adequate lighting, ventilation and provision of sanitary conveniences

Signs and symptoms of endometriosis:

The following test can help to diagnose it

1. Needle stick injury

2. Prevention of weedle stick injury

3. Post Abortal care

4. Roles of a Commonuty Psychiatric Nurse

½ marks for 10 = 5marks

Advantage of Community Psychiatry

a. Step to Step Protocol For The Male Genital Self-Examination (MSGE)

The findings on clinical examination

This bleeding of acute presentation occurs in no more than 25% of cases.

The above need to be used together to conform ectopic pregnancy.

ANTEPARTUM HAEMORRHAGE (APH)

Effects on the mother

Characteristics of placenta praevia haemorrhage

Fetal death. Description of the skin

4. Give divertional therapy 4. This provides a non

4. Monitor intake and output hourly 4. This helps to detect decrease

5. Weight the patient daily. 5. Body weight is used to

2Depression can be defined as a state of psychomotor retardation. It is characterized by

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(D) Nursing Diagnosis

Description and purposes:

- It should not be read by the patients and their relatives.

Description and purposes:

Description and purpose.

Other Content of the folder includes:

(c) Purposes of keeping patient Records

TYPES OF BIOPHYSIOLOGIC MEASURES

5. Focus Group Discussion (FGD)

SEXUAL HEALTH AND REPRODUCTIVE HEALTH RIGHTS

COMPONENTS OF REPRODUCTIVE HEALTH

1. Safe motherhood: this comprises of:

Benefits of Reproductive Health concept

REPRODUCTIVE HEALTH SITUATION IN NIGERIA

Bornu 727/100,000 live births Enugu 809/100,000 live births

Plateau 846/100,000 live births Cross river 2,977/100,000 live births

Lagos 3,380/100,000 live births Kano 3,523/100,000 live births

Strategies to improves Reproductive Health

FACTORS INFLUENCING MATERNAL AND CHILD HEALTH

THE ROLE OF THE FAMILY IN FAMILY HEALTH

GIRL-CHILD EDUCATION AND STATUS OF WOMEN

- Traditional rulers, government parent, non government organizations as well as policy-makers

IMPORTANCE OF GIRL CHILD EDUCATION

- Educated women are capable of bringing socio-economic changes

THE ROLE OF A NURSE IN FAMILY HEALTH NURSING

FAMILY LIFE EDUCATION

1. Understanding one’s self and others