√ كتاب تمريض صحة الأم نظري (2023)

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Electronic Module
Maternal & Newborn Health Nursing
Module Code (300N)
By
All the Staff Members of Maternal & Newborn Health
Nursing Department
Menoufia University/ Faculty of Nursing
2022/ 2023
Table of Content
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Table of Content
Faculty of Vision………………………………………………………………………………………….10
Faculty of Mission……………………………………………………………………………………….10
‫ رؤﯾﮫ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬................................................................................ 10
‫ رﺳﺎﻟﮫ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬.............................................................................. 10
Module (1): Anatomy and Physiology of the Female Reproductive System ............ 11
Core Competence of the Module ...................................................................................................... 11
Module Objective .............................................................................................................................. 11
Learning Outcomes ........................................................................................................................... 11
Module Contents................................................................................................................................ 12
(1) Anatomy and Physiology of the Female Reproductive System ........................... 12
(2) Female Reproductive cycle ................................................................................ 12
(3) Preconception care and counseling ................................................................... 12
(4) General follow up activities ............................................................................... 12
(5) References ......................................................................................................... 12
1): Anatomy and Physiology of the Female Reproductive System ............................ 13
Introduction........................................................................................................... 13
External female genitalia ...................................................................................... 14
Figure 2. Structures of the internal female reproductive organs. ...................... 17
Summary ......................................................................................................................... 22
2): Female Reproductive cycle ...................................................................................... 23
Introduction........................................................................................................... 23
The female reproductive hormones .............................................................................. 23
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The ovarian cycle ............................................................................................................ 26

The uterine cycle ............................................................................................................. 27
Summary of study module ............................................................................................. 29
3): Preconception care and counseling ......................................................................... 31
4): General follow up activities ..................................................................................... 42
5). References .................................................................................................................. 50
Module (2): Normal pregnancy .................................................................................... 51
Core Competence .............................................................................................................................. 51
Module Objective .............................................................................................................................. 51
Module Content ................................................................................................................................. 52
(1). Conception and fetal development................................................................... 52
(2). Fetal circulation ................................................................................................ 52
(3). Physiological adaptation of body systems during pregnancy ............................ 52
(4). Diagnosis of pregnancy ..................................................................................... 52
(5). Antenatal care .................................................................................................. 52
(6) Nutrition during pregnancy................................................................................ 52
(6). Minor discomforts and nursing intervention .................................................... 52
(7). Follow up activities ........................................................................................... 52
(8). References ........................................................................................................ 52
Learning Outcomes ........................................................................................................................... 52
1). Conception and Fetal Development ........................................................................ 53
2). Fetal Blood Circulation ............................................................................................ 76
3). Physiological adaptation of body systems during pregnancy ............................... 83
4). Diagnosis of pregnancy ............................................................................................. 92
5). Antenatal Care ........................................................................................................ 100
6) Nutritional requirement for pregnant mother ...................................................... 108
7). Minor Discomforts and Nursing Intervention ..................................................... 112
8). Follow up activities.................................................................................................. 124
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9). References ................................................................................................................ 127
Module (3) Normal Labor…………………………………128

Core Competence of the Module: .................................................................................................. 128
Module Objective ............................................................................................................................ 128
Learning Outcomes ......................................................................................................................... 128
Module Contents: .............................................................................................................................. 128
1). Female Pelvis, Fetal Skull ................................................................................. 129
2). Student Activities ............................................................................................. 129
3). Normal labor .................................................................................................... 129
4). Electronic Fetal Monitoring .............................................................................. 129
5). Immediate care of the newborn ...................................................................... 129
6). General follow up activities.............................................................................. 129
7). References ....................................................................................................... 129
2).Female Pelvis, Fetal Skull........................................................................................ 129
Introduction .......................................................................................................... 129
Learning Outcomes ...................................................................................................... 129
The female bony pelvis ................................................................................................. 130
Summary ....................................................................................................................... 154
2). Student activities ..................................................................................................... 155
3). Normal Labor .......................................................................................................... 158
(1): Links of Normal Labor…………………………………………………………………………………………………………………186
4). Electronic Fetal Monitoring ................................................................................... 193
(2): Links of Normal Labor…………………………………………………………………………………………………………………….194
6). General Follow up activities ................................................................................... 212

7). References ................................................................................................................ 217
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Module (4): Postpartum care 218

Core Competence of the Module .................................................................................................... 218
Module Objectives ........................................................................................................................... 218
Module Content ............................................................................................................................... 219
1). Immediate Postpartum Care ............................................................................ 219
2). Physiological & Psychological Changes during Postpartum Period ................... 219
3). Minor Discomforts during Postpartum Period ................................................. 219
4). Student Activities ............................................................................................. 219
5). General Follow up Activities............................................................................. 219
6). References ....................................................................................................... 219
1)Immediate Postpartum Care.................................................................................... 221
Activities .............................................................................................................. 225
Other Positions .................................................................................................... 239
Counselling on the importance of family planning ........................................... 244
Method options for the non-breastfeeding woman............................................ 245
Method options for the breastfeeding woman ................................................... 245
Lactational Amenorrhea Method (LAM) .......................................................... 245
2) Physiological and Psychological Changes during Postpartum Period ............... 255
 Definition of Puerperium: ...................................................................................................... 256
Characteristics of the Postpartum Period: ......................................................................... 256
Physiological Changes during The Puerperium: ................................................................ 256
3) Minor Discomforts during Postpartum Period ..................................................... 273
4) Student Activities ..................................................................................................... 285
5) General Follow up Activity ..................................................................................... 286
6)References .................................................................................................................. 290
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Module (5): Family Planning ………………………….293

Core Competence of the Module .................................................................................................... 293
Module Objectives ........................................................................................................................... 293
Module Content ............................................................................................................................... 293
1). Counselling Process.......................................................................................... 294
2). Introduction to Family Planning Methods. ....................................................... 294
3). Natural Family Planning Methods. ................................................................... 294
4). Chemical Family Planning Methods. ................................................................ 294
5). Mechanical Family Planning Methods. ............................................................. 294
6). Hormonal Family Planning Methods. ............................................................... 294
7). Emergency Family Planning Methods. ............................................................. 294
8). Surgical Family Planning Methods.................................................................... 294
9). Student Activities. ............................................................................................ 294
10). General Follow up Activities. .......................................................................... 294
11). References. .................................................................................................... 294
1). Family Planning Counselling ................................................................................. 296
2) Introduction to Family Planning ............................................................................ 299
Definition of Family Planning ......................................................................................................... 300
Objectives of Family Planning......................................................................................................... 300
Indications: ..................................................................................................................................... 300
3) Natural Family Planning Methods ......................................................................... 304
Introduction............................................................................................................. 305
Definition of Natural Methods............................................................................... 305
Objectives of Natural Methods.............................................................................. 305
Advantages of Natural Methods............................................................................ 305
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Disadvantages of Natural Methods ......................................................................................... 306

Types of Natural Methods: ...................................................................................................... 306
1-Calendar Method ...................................................................................................... 306
Definition: -................................................................................................................................... 306
Advantages of Calendar Method........................................................................... 307

Disadvantages of Calendar Method ........................................................................................ 307
Nursing Instructions ............................................................................................... 308
2-Safe Period Method ................................................................................................... 308
Description: - ............................................................................................................................. 308

Advantages ................................................................................................................................ 309
Nursing Instructions: ............................................................................................. 310
3-Basal Body Temperature (BBT) .............................................................................. 310
Definition: -It is the body temperature at rest and used to detect ovulation. ..................... 310
Advantages of BBT ................................................................................................. 312
 Disadvantages of BBT ........................................................................................... 312
4- Cervical Mucus Method .......................................................................................... 313
Definition: -................................................................................................................................ 313

 Mechanism: - ............................................................................................................................ 313
 Cervical Mucus Examination ............................................................................... 313
Advantages .............................................................................................................. 314
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5- Symptothermal Method........................................................................................... 315
Definition: -................................................................................................................................ 315

Description: - ............................................................................................................................. 316
Advantages ................................................................................................................................ 316
Disadvantages............................................................................................................................ 316
Nursing Instructions ................................................................................................................. 316
6- Lactational Amenorrhea (Postpartum Infertility)................................................ 317
Definition:-................................................................................................................................. 317
Description............................................................................................................... 318
Advantages .............................................................................................................. 318
7-Withdrawal Method (Coitus Interrupts or Pulling out) ....................................... 319
Definition: -................................................................................................................................ 319

Advantages .............................................................................................................. 320
Disadvantages.......................................................................................................... 320
4) Chemical Family Planning Methods ...................................................................... 323
Introduction............................................................................................................. 324
Definition of Chemical Methods............................................................................ 324
Advantages of Chemical Methods ......................................................................... 325
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Disadvantages of Chemical Methods .................................................................... 325

5) Mechanical Family Planning Methods................................................................... 332
 Introduction............................................................................................................ 333
 Mode of Action ......................................................................................................................... 334
 Types of IUCD.......................................................................................................................... 334
Indications of IUDS ..................................................................................... 336
Contraindications .......................................................................................... 337
Disadvantages............................................................................................................................ 337
Timing of IUCD Insertion & Removal ................................................................. 339
Insertion:- ......................................................................................................................................... 339
Removal:- Can be done at any time during the menstrual cycle ................................................ 339

6) Hormonal Family Planning Methods ..................................................................... 355
7). Emergency Family Planning Methods .................................................................. 371
8) Surgical Family Planning Methods ........................................................................ 373
Sterilization methods include: ........................................................................................................ 375
1- Vasectomy in males. .................................................................................................................... 375
2- Tubal Ligation in females . ......................................................................................................... 375
9). Student Activities .................................................................................................... 384
10). General Follow up Activity .................................................................................. 385
11). References .............................................................................................................. 387
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Faculty of Vision
‫" أن ﺗﻜﻮن اﻟﻜﻠﯿﺔ راﺋﺪة و ﻣﺘﻤﯿﺰة ﻓﻲ ﻣﺠﺎل اﻟﺘﻌﻠﯿﻢ واﻟﻤﻤﺎراﺳﺎت اﻟﺘﻤﺮﯾﻀﯿﺔ و اﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ و‬
‫ﺧﺪﻣﺔ اﻟﻤﺠﺘﻤﻊ ﻟﻸرﺗﻘﺎء ﺑﺎﻟﻤﻨﻈﻮﻣﺔ اﻟﺼﺤﯿﺔ وﺗﺤﻘﯿﻖ اھﺪاف اﻟﺘﻨﻤﯿﺔ اﻟﻤﺴﺘﺪاﻣﺔ ﻋﻠﻲ اﻟﻤﺴﺘﻮي اﻟﻤﺤﻠﻲ‬
." ‫و اﻟﻘﻮﻣﻰ و اﻻﻗﻠﯿﻤﻲ و اﻟﺪوﻟﻲ‬
To be a pioneer and distinguished faculty in the field of nursing

education, practices, scientific research and community services to
contribute in the advancement of health system and achieving sustainable
development goals at the local, national, regional and international level.
Faculty of Mission
‫" اﻋﺪاد ﺧﺮﯾﺞ ﻣﺆھﻞ و ﻛﻒء ﻓﻲ ﻣﺠﺎل اﻟﺘﻌﻠﯿﻢ و اﻟﻤﻤﺎرﺳﺎت اﻟﺘﻤﺮﯾﻀﯿﺔ واﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ وﺧﺪﻣﺔ‬
".‫اﻟﻤﺠﺘﻤﻊ ﻗﺎدر ﻋﻠﻰ اﻻﺑﺘﻜﺎر وﻣﻨﺎﻓﺴﺎ ﻣﺤﻠﯿﺎ و ﻗﻮﻣﯿﺎ واﻗﻠﯿﻤﯿﺎ وﻓﻘﺎ ﻟﻠﻘﯿﻢ اﻟﻤﮭﻨﯿﺔ واﻻﺧﻼﻗﯿﺔ‬
Preparing a qualified and competent graduate in the field of

nursing education, practices, scientific research, and community
services capable to innovate and a competitor locally, nationally, and
regionally taking into consideration professional and ethical values.
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‫رؤﯾﮫ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬

‫ﯾﺴﻌﻰ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده اﻟﻰ ان ﯾﻜﻮن ﻣﻦ اﻻﻗﺴﺎم اﻟﺮاﺋﺪه ﻓﻰ ﺗﻘﺪﯾﻢ اﻟﺨﺪﻣﺎت‬
‫اﻟﺘﻌﻠﯿﻤﯿﮫ و اﻟﺒﺤﺜﯿﮫ واﻟﻤﺠﺘﻤﻌﯿﮫ اﻟﻤﻮﺟﮭﮫ ﺑﺎھﺪاف اﻟﺘﻨﻤﯿﮫ اﻟﻤﺴﺘﺪاﻣﮫ ﻓﻰ ﻣﺠﺎل ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و‬
.‫ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬
Maternal and Newborn Health Nursing Department seeks to be one of

the leading departments in providing education, research and community
services targeted by the goals of sustainable development in the field of
Maternal and Newborn Health Nursing.
‫رﺳﺎﻟﮫ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬

‫ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده ﯾﮭﺘﻢ ﺑﺎﻋﺪاد ﺧﺮﯾﺠﯿﻦ ﻗﺎدرﯾﻦ ﻋﻠﻰ ﺗﻄﺒﯿﻖ اﻟﻜﻔﺎﯾﺎت اﻟﻤﻄﻠﻮﺑﮫ‬
‫ﻟﺘﻘﺪﯾﻢ رﻋﺎﯾﮫ ﺗﻤﺮﯾﻀﯿﮫ ﻗﺎﺋﻤﮫ ﻋﻠﻰ اﻟﺪﻟﯿﻞ و ﺧﺪﻣﺎت ﺑﺤﺜﯿﮫ و ﻣﺠﺘﻤﻌﯿﮫ وﻓﻖ اﻟﻤﻌﺎﯾﯿﺮ اﻟﻤﺮﺟﻌﯿﮫ ﻟﺘﺤﻘﯿﻖ‬
‫اھﺪاف اﻟﺘﻨﻤﯿﮫ اﻟﻤﺴﺘﺪاﻣﮫ‬
Maternal and Newborn Health Nursing Department is concerned with

preparing graduates who can apply the competencies required to provide
evidence -based nursing care, research, and community services in accordance
with reference standards to achieve sustainable development goals.
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Module (1): Anatomy and Physiology of the Female

Reproductive System
Credit Weighting of Module: 3 hours

Teaching Method(s): 3hr(s) Lectures; virtual classes, 18hr(s) Clinical (includes 6hr(s)
for small group clinical skills teaching & 12hrs for labs clinical skills).
Core Competence of the Module:

This module is designed to review the anatomy and physiology of female
reproductive system for basic obstetric care.
Module Objective: To: -

1. Review the anatomy of female reproductive system.
2. Understand the female reproductive cycle.
3. Explain the female reproductive hormones.
4. Explain pre-conception components.
5. Differentiate between pre-conception care and pre-conception counseling
Learning Outcomes
On successful completion of this module, the students should be able to:
1. Identify the basic anatomical features of the external female genitalia and the internal
reproductive organs.
2. Describe the functions of the main anatomical structures in the female reproductive
system and their importance for obstetric care.
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3. Describe the physiological processes and changes during the menstrual cycle.
5. Describe the hormonal regulation of the female reproductive cycle.
6. Provide health teaching during the female reproductive cycle.
7. Define pre-conception care and pre-conception counseling.
8. list objectives of pre-conception care.
9. Explain obstacles of pre-conception counseling.
10. Explain the elements of pre-conception care.
Module Contents:
(1) Anatomy and Physiology of the Female Reproductive System
(2) Female Reproductive cycle
(3) Preconception care and counseling
(4) General follow up activities
(5) References
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1): Anatomy and Physiology of the Female

Reproductive System
Introduction
Applied anatomy and physiology for basic obstetric care is an entry to your studies
in this module and is essential preparation for your practical skills training. Obstetric
care refers to healthcare for women during pregnancy, labor and delivery and their
immediate postnatal care. It requires a good understanding of the anatomy and physiology
of the female reproductive system. Anatomy is the study of the structures of the human
body, i.e. the features of how the organs, tissues and body systems are
constructed. Physiology, on the other hand, is the study of the coordinated functions of
the organs, tissues, and systems in the body. In this Module, you will learn about the
structures that make the external female genitalia and the internal reproductive organs.
We teach you also about the physiology of menstrual cycle (bleeding from the vagina).
You will learn the preconception care and counselling.
The female reproductive system is divided into two broad categories. Structures external
to the vagina are said to be the external female genitalia, whereas structures above the
vagina (including the vaginal canal), and lying internally, are called the internal female
reproductive organs.
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Figure 1: Half section of the pelvic cavity showing the female reproductive
organs, with the body facing to the left.
External female genitalia

Look at Figure 2 carefully. All the structures which are visible externally, surrounding the
urethral and vaginal openings, including the mons pubis, labia majora, labia minora,
vestibule and perineum, make the external female genitalia. Sometimes these structures
are collectively named the vulva.
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Figure 2: The external female genitalia (or vulva).
Mons’s pubis
The mons pubis is a thick, hair-covered, fatty and semi-rounded area overlying
the symphysis pubis. Symphysis is a type of strong and immovable joint between bones.
The two halves of the pubic bone are joined in the middle by the pubic symphysis. The
function of the fatty tissue in the mons pubis is to protect the woman’s pubic area from
bruising during the sex act.
Labia majora and labia minora
The labia majora are two elongated, hair-covered, fatty skin folds that enclose and
protect the other organs of the external female genitalia.
The labia minora are two smaller tissue folds enclosed by the labia majora. They protect
the opening of the vagina and the urethra (the tube that carries urine from the bladder to
the urethral opening in the vulva). The labia minora normally have an elastic nature, which
enables them to distend and contract during sexual activity, and labor and delivery.
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In some countries, the labia minora and the clitoris (described below) may be removed
by female genital mutilation (FGM), one of the harmful traditional practices.
Vestibule
The vestibule is the area between the labia minora, and consists of the clitoris, urethral
opening and the vaginal opening.
The clitoris is a short erectile organ at the top of the vestibule, which has a very rich nerve
supply and blood vessels. Its function is sexual excitation, and it is very sensitive to touch.
Its anatomical position is like the position of the male penis.
If the clitoris and labia minora are removed by female genital cutting, the vaginal opening
will not expand easily during childbirth due to the scarring where tissue has been removed.
This can result in difficulty in labor and delivery, including severe bleeding and rupture
of the scarred tissue, sometimes even causing a fistula — a hole torn in the wall of the
vagina.
Also, the labia minora and clitoris have a rich blood supply, so cutting them leads to severe
bleeding, which may cause fainting and shock.
The urethral opening is the mouth or opening of the urethra, which is a small tubular
structure that drains urine from the bladder.
The vaginal opening is the entrance to the vagina. It is where you will begin to see the
‘presenting part’ of the baby as it stretches wider open near the end of labor.
Perineum and hymen
The skin-covered muscular area between the vaginal opening and the anus is called
the perineum. It has strong muscles and its own nerve supply, and it helps to support the
contents of the pelvic cavity. The hymen is a fold of thin vaginal tissue which partially
covers the vaginal entrance in girls. It can be torn during strenuous exercise, as well as by
the first sexual penetration.
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Internal female reproductive organs
Figure 2. Structures of the internal female reproductive organs.
Fallopian tubes and ovaries
There are two fallopian tubes — one on each side of the uterus — and the finger-like
ends of each tube (called the fimbriae) are close to the ovary on the same side, and open
to the pelvic cavity. This means that if there is an infection in the pelvic cavity, it can get
into the uterus through the fallopian tubes. Similarly, if there is an infection in the uterus,
it can spread along the fallopian tubes and out into the pelvic cavity, and from there all
around the woman’s abdomen, affecting her other organs. This can be very dangerous if
it is not treated early.
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Ovaries
The ovaries are paired female reproductive organs that produce the eggs (ova). They lie
in the pelvic cavity on either side of the uterus, just below the opening of the fallopian
tubes (see Figure 3). They are kept in position through attachment to two
ligaments. Ligaments are the fibrous, slightly stretchy, connective tissues that hold
various internal organs in place; they also bind one bone to another in joints.
Women are born with a fixed number of immature eggs (ova), around 60,000 in number.
The eggs are held in small ‘pits’ in the ovaries, named ovarian follicles. Each ovum has
the potential to mature and become ready for fertilization, but only about 400 ripen during
the woman’s lifetime. Every month, several ovarian follicles begin to enlarge and the
ovum inside it begins to mature, but usually only one will ‘win the race’ and be released
from the ovary. The moment when the ovum is released is called ovulation. The other
enlarging follicles degenerate.
The enlarging ovarian follicles also produce the female reproductive

hormones, estrogen and progesterone, which are important in regulating the monthly
menstrual cycle, and throughout pregnancy.
Hormones are signaling chemicals that are produced in the body and circulate in the
blood; different hormones control or regulate the activity of different cells or organs.
After ovulation, the lining of the empty follicle grows and forms a yellow body in the
ovary called the corpus luteum, which temporarily functions as a hormone-producing
organ.
It secretes estrogen and progesterone for about the next 14 days. Estrogen thickens the
fatty tissues in the wall of the uterus in case pregnancy occurs. Progesterone stops further
ovulation from occurring during the pregnancy.
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If pregnancy does not occur within 14 days after ovulation, the corpus luteum degenerates
and stops producing progesterone. As a result, the blood supply to this additional fatty
tissue in the wall of the uterus is cut off, and it also degenerates and is shed through the
vagina as the menstrual flow. The levels of estrogen can then begin to rise, and the woman
can ovulate again in the following month.
When an ovary releases a mature ovum (ovulation), the fimbriae of the fallopian tube
catch the ovum and convey it towards the uterus. The male sperm swim along the fallopian
tubes, and if they find the ovum, they fertilize it. The lining of the fallopian tubes and its
secretions sustain both the ovum and the sperm, encourage fertilization, and nourish the
fertilized ovum until it reaches the uterus.
The uterus
The uterus is a hollow, muscular organ in which a fertilized ovum becomes embedded
and develops into a fetus. Its major function is protecting and nourishing the fetus until
birth.
During pregnancy, the muscular walls of the uterus become thicker and stretch in response
to increasing fetal size during the pregnancy. The uterus must also accommodate
increasing amounts of amniotic fluid (the waters surrounding the fetus, contained in a
bag of fetal membranes), and the placenta (the structure that delivers nutrients from the
mother to the fetus).
The uterus has four major anatomical divisions, shown in Figure 4:
• Body: the major portion, which is the upper two-thirds of the uterus.
• Fundus: the domed area at the top of the uterus, between the junctions with the two
fallopian tubes.
• Endometrial cavity: the triangular space between the walls of the uterus.
• Cervix: the narrow neck at the upper end of the vagina.
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Figure 3. Structure of the empty uterus, showing the four main

regions.
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The wall of the uterus has three layers of tissue, two of which are shown in Figure 4:
• The perimetrium: the outermost thin membrane layer covering the uterus. (It is not
important for you to know this term for obstetric care.)
• The myometrium: the thick, muscular, middle layer in Figure 4.
• The endometrium: the thin, innermost layer of the uterus, which thickens during the
menstrual cycle. This is the tissue that builds up each month in a woman of
reproductive age, under the influence of the female reproductive hormones.
The cervix
The cervix is the lower, narrow neck of the uterus, forming a tubular canal, which leads
into the top of the vagina (see Figure 4). It is usually about 3 to 4 cm (centimeters) long.
The vagina
The vagina is a muscular passage, 8 to10 cm in length, between the cervix and the external
genitalia. The secretions that lubricate the vagina come from glands in the cervix.
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Summary
In Study module 1, you have learned that:
1. Anatomy is the study of the structures of the human body, and physiology is the study
of the coordinated functions of the organs, tissues and body systems.
2. The female reproductive system is divided into the external genitalia (below the vaginal
opening), and the internal reproductive organs (above the vaginal opening in the pelvic
cavity).
3. The internal reproductive organs are close to the bladder, the large intestine, and the
rectum; the external opening of the vagina is close to the urethral opening and the anus.
These close relationships increase the opportunities for infection to spread in the genital
area.
4. In some traditional societies, the clitoris and labia minora are often removed by female
genital mutilation; this can have serious (even fatal) consequences for the woman,
especially during labor and delivery.
5. The ovaries are female sex organs which usually produce one ovum every month during
the reproductive years. One of the fallopian tubes carries the ovum from the ovary towards
the uterus. If fertilization occurs, it normally happens in the fallopian tube.
6. The uterus is a muscular organ, which gives mechanical protection and nutritional
support to the developing fetus during pregnancy.
7. The female reproductive hormones, oestrogen and progesterone, direct the maturation
of ova in the ovaries, the release of an ovum (ovulation), and the thickening of the
endometrium (the fatty lining of the uterus). If fertilization of the ovum and pregnancy
does not result, the endometrium is shed as the menstrual flow.
8. The vagina functions as a passageway for elimination of the menstrual flow; it receives
the penis during sexual intercourse; and it forms the lower portion of the birth canal.
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2): Female Reproductive cycle

Introduction
In the previous study session, you learned about the anatomy and physiology of the female
reproductive system. The hormones estrogen and progesterone were briefly introduced.
In this study module you will learn much more about the role of these and other important
hormones involved in the regulation of the human menstrual cycle, the monthly
production of mature ova (eggs) by females of reproductive age, and the preparation of
the uterus as a welcoming environment for the start of a pregnancy.
Learning Outcomes: On successful completion of this module, the students should be

able to:
1- Describe the physiological processes and changes during the menstrual cycle.
2- Describe the hormonal regulation of the female reproductive cycle.
3. Provide health teaching during the female reproductive cycle.
The female reproductive hormones

The various functions of the body are regulated by the nervous system and the hormonal
system. Both these systems are involved in controlling the activity of the female
reproductive system in a regular monthly series of events known as the menstrual cycle,
as we will now describe.
A hormone is a signaling chemical produced in the body, which circulates in the blood;
different hormones control or regulate the activity of different cells or organs. The
functions of the five main hormones that regulate the female reproductive system are
described in Box 1, and their interactions are illustrated in Figure 1.
Box 1 Hormones regulating the female reproductive system
Gonadotropin-releasing hormone (GnRH) is produced by a part of the brain called

the hypothalamus. When it circulates in the blood, it causes the release of two important
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hormones (follicle-stimulating hormone and luteinizing hormone) from

the pituitary gland in another specialized part of the brain.
Follicle-stimulating hormone (FSH) is produced by the pituitary gland during the first
half of the menstrual cycle. It stimulates development of the maturing ovarian follicle and
controls ovum production in the female, and sperm production in the male.
Luteinizing hormone (LH) is also produced by the pituitary gland in the brain. It
stimulates the ovaries to produce estrogen and progesterone. It triggers ovulation (the
release of a mature ovum from the ovary), and it promotes the development of the corpus
luteum.
Estrogen is a female reproductive hormone, produced primarily by the ovaries in the non-
pregnant woman. It promotes the maturation and release of an ovum in every menstrual
cycle. It is also produced by the placenta during pregnancy.
Progesterone is produced by the corpus luteum in the ovary; its function is to prepare
the endometrium (lining of the uterus) for the reception and development of the fertilized
ovum. It also suppresses the production of estrogen after ovulation has occurred.
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Figure 4. Hormonal regulation of the female reproductive system.
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The length of the menstrual cycle is typically 28 days, but it can be highly variable. In
some women it may be as short as 21 days or as long as 39 days. The menstrual cycle is
best understood if we focus first on events occurring in the ovaries, and then on events
occurring in the uterus. We are going to describe each of them in turn.
he ovarian cycle
The ovarian cycle refers to the monthly series of events in the ovaries, associated with
the maturation and release of an ovum, and the ‘just in case’ preparation for its fertilization
and implantation in the uterus. You may be wondering why the regulation of the female
reproductive system is so complicated, as shown in Figure 1. The reason is that the ovarian
cycle has to be initiated (switched on) and then suppressed (switched off) in a precisely
regulated sequence every month. In this section, we will explain how this is achieved.
The ovarian cycle consists of two consecutive phases, each of about 14 days’ duration.
Events are measured from ‘day 1’, which is the first day of the last normal menstrual
period (LNMP).
The follicular phase: days 1 to 14
The sequence shown in Figure 1 begins with the secretion of GnRH from the
hypothalamus, which stimulates the pituitary gland to produce FSH and LH, which in turn
act on the ovaries, telling the ovarian follicles to complete the maturation of an ovum.
During this period, a few ovarian follicles containing immature ova develop and mature
under the stimulation of FSH and LH. Usually by day 14, only one follicle has become
fully mature, and the ovum it contains is ready to be released. All other follicles that had
begun maturing during this phase of the ovarian cycle degenerate as soon as ovulation has
occurred.
Note that only one time interval is fairly constant in all females — the time from ovulation
to the beginning of menstruation, which is almost always 14 to15 days. However, the time
of ovulation is variable and difficult to predict accurately.
The luteal phase: days 15 to 28
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This phase is the period of corpus luteum activity, during which the uterus is
prepared ‘just in case’ of pregnancy. After ovulation has occurred, the corpus luteum
begins to secrete progesterone, as well as a small amount of estrogen. Progesterone
maintains the uterus in a state ready to receive and nourish an embryo. The lining of the
uterus (the endometrium) becomes thicker, more richly nourished by blood vessels, and
more receptive to the fertilized ovum. Progesterone also inhibits any further release of
FSH or LH from the pituitary gland.
Thus, ovulation is quickly followed by a rise in the level of progesterone in the

circulation, as the corpus luteum takes over the production of this hormone. As the
progesterone level rises, it circulates around the body in the blood. When a high
concentration of progesterone reaches the hypothalamus in the brain, the effect is to stop
the hypothalamus from producing GnRH.
This type of control system, where the rise in one body chemical (in this case,
progesterone) stops the production of another body chemical (in this case, GnRH), is
called a negative feedback mechanism. But the corpus luteum has a limited lifespan, and
after it stops producing progesterone, the negative feedback on the hypothalamus stops,
and this allows it to begin producing GnRH again. So the ovarian cycle begins all over
again.
The uterine cycle
Next, we turn our attention to the events occurring in the uterus during the same (typically)
28-day period as the events just described in the ovaries. The uterine cycle indicates the
cyclical changes that occur in the uterus in response to the female sex hormones,
progesterone and estrogen.
The menstrual phase: days 1 to 5
If fertilization does not occur after ovulation, the corpus luteum will degenerate and
production of progesterone will decrease, so the stimulus for maintaining the thick
endometrium will disappear. The reduction in progesterone causes the shedding of the
thick endometrial lining. The muscular wall of the uterus (the myometrium) contracts to
help cut off the blood supply to the endometrium, causing it to break away from the uterus.
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The endometrium was richly supplied with blood vessels to nourish the fetus if a
pregnancy occurred, so when it disintegrates and passes down the vagina, some blood is
mixed in with it. The mixture of tissue and blood passes out through the vagina as
the menstrual fluid (or menstrual flow), usually for a period of about three to five days.
Other common names for menstruation are ‘monthly bleeding’ or ‘menstrual period’.
Menstruation usually occurs at monthly intervals throughout the reproductive years,

except during pregnancy when it is completely suppressed, and the woman cannot get
pregnant again until after the fetus is born. Breastfeeding a newborn also suppresses
menstruation, but there is a risk that ovulation and pregnancy may still occur.
The proliferative phase: days 6 to 14
The concentration of estrogen in the blood is rising during this period, following
the end of menstruation, as the ovaries prepare for the next ovulation at around day 14. It
is called the proliferative phase (‘proliferate’ means to ‘multiply or increase’), because in
this period the endometrium grows thicker and becomes more richly fed by blood vessels
in preparation for the possibility of fertilization and pregnancy.
The secretory phase: days 15 to 28
During this phase, the blood concentration of progesterone increases, which causes
even more blood vessels to grow into the endometrium. This makes the endometrium
receptive to the fertilized ovum. If the ovum is fertilized and the embryo implants in the
endometrium and a placenta develops, it produces a hormone called human chorionic
gonadotropin (HCG) throughout pregnancy. The detection of HCG in a woman’s urine is
the basis of most pregnancy tests.
HCG signals the corpus luteum to continue to supply progesterone to maintain the
thick, nourishing endometrium throughout the pregnancy. Continuous levels of
progesterone act as a negative feedback mechanism on the hypothalamus and pituitary
gland, preventing the release of FSH and LH, and hence further ovulation ceases.
The menarche, puberty and the menopause
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You probably know that menarche (the first menstruation) starts on average
between the ages of 12 to15 years. But in some cases, it can start as late as 17 to 20 years,
or as early as 8 to 9 years. Some of the factors that affect the age of menarche are
biological, and some are cultural.
Menarche begins when the hypothalamus in the brain is sensitized to begin producing
GnRH at around the age of 12 to15 years. But evidence suggests that GnRH may begin at
an earlier age in girls who are well nourished and exposed to sexual motivating factors,
such as watching sexual films and talking about sex. In malnourished girls, who have little
exposure to sexual motivating factors, menarche may be delayed until the age of 17 to 20
years. Disease conditions that affect the hypothalamus and pituitary gland, or the ovaries
and uterus, can also affect the age of first menarche.
Around the age of the menarche, the female sex hormones, estrogen and progesterone, are
responsible for the development of secondary sexual characteristics in the female.
These include:
• The development of the breasts

• The broadening of the pelvis
• Increased activity of sweat glands and sebaceous glands (oil glands in the skin)
• The growth of pubic and armpit hair.
Together with the menarche, the appearance of the secondary sexual characteristics marks
the period known as puberty — the period of life (typically between the ages of 10 to15
years) during which the reproductive organs grow to adult size and become functional.
The secondary sexual characteristics are termed ‘secondary’ because they develop after
the primary sexual characteristics, which distinguish females from males.
Menstruation continues every month, except during pregnancy, until the woman reaches
the menopause at around the age of 48 to 50 years, when menstruation ceases.
Summary of study module
In Study module 2, you have learned that:
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1. The hormones controlling the female reproductive system include gonadotropin-

releasing hormone (GnRH), follicle-stimulating hormone (FSH) and luteinizing hormone
(LH), all of which are produced in the brain; estrogen and progesterone produced by the
ovaries and the corpus luteum; and human chorionic gonadotropin (HCG), produced by
the placenta during pregnancy.
2. The menstrual cycle typically lasts 28 days, but it can be highly variable. It is
characterized by menstruation from days 1 to 5 and ovulation at around day 14, but the
date of ovulation is difficult to predict accurately.
3. Menstruation is the monthly shedding from the uterus of the endometrium with some
blood, which emerges through the vagina, typically for a period of three to five days.
Menstruation continues from menarche to the menopause, except during pregnancy. It
may also be suppressed by breastfeeding.
4. The ovarian cycle refers to the regular, repeating events occurring in the ovaries during
the menstrual cycle, characterized by the development of a few ovarian follicles; the
maturation and release of a single ovum (ovulation); and the formation and subsequent
degeneration of the corpus luteum if pregnancy does not occur.
5. The uterine cycle refers to the regular, repeating events occurring in the uterus during
the menstrual cycle, characterized by the thickening of the endometrium and an increase
in its blood supply, followed by its degeneration and shedding as the menstrual flow if
pregnancy does not occur.
6. The menarche and the development of secondary sexual characteristics signal the
period known as puberty, when the internal reproductive organs grow to adult size and a
girl becomes fertile and capable of becoming pregnant.
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3): Preconception care and counseling

Introduction
Preconception health is important for every woman―not just those

planning pregnancy. It means taking control and choosing healthy habits. It means living
well, being healthy, and feeling good about your life. Preconception care should begin at
least three months before you get pregnant. But some women need more time to get their
bodies ready for pregnancy.
Preconception counseling is different from antenatal care and should not be

confused with it. In particular, it is more important than antenatal care, as 30% of pregnant
women begin traditional antenatal care in the second trimester and after the period of
maximal organogenesis (between 3 and 10 weeks’ gestation)1 . Preconception care refers
to interventions that aim to identify and modify biomedical, behavioral and social risks to
women’s health or pregnancy outcome through prevention and management.
Module Objective: To:-

1- Review the anatomy of female reproductive system.
2- Explain pre-conception components.
3- Differentiate between pre-conception care and pre-conception counseling.
Learning Outcomes: On successful completion of this module, the students should be
able to:
- Define pre-conception care and pre-conception counseling.
- Explain objectives of pre-conception care.
- Explain obstacles of pre-conception counseling.
- Explain the elements of pre-conception care.
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- Identify pre-conception components.
- Differentiate between pre-conception counseling and pre-conception care.
Definition
Preconception care is the provision of biomedical, behavioral and social health

interventions to women and couples before conception occurs.
Aim
• Reduce maternal and child mortality
• Prevent unintended pregnancies
• Prevent complications during pregnancy and delivery
• Prevent stillbirths, preterm birth and low birth weight
• Prevent birth defects
• Prevent neonatal infections
• Prevent underweight and stunting
• Prevent vertical transmission of HIV/STIs
• Lower the risk of some forms of childhood cancers
• Lower the risk of type 2 diabetes and cardiovascular disease later in life.
WHICH WOMEN MOST LIKELY TO GET PRECONCEPTION CARE
• Older ones
• Married with unstable relationship
• Low income
• Smokers
• Health problems
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OBSTACLES TO PRECONCEPTION COUNSELING
• Many pregnancies are still unplanned. Globally, 38% of pregnancies are unintended.
Many unintended pregnancies result from failure to use birth control or failure to use it
correctly; if a birth control method fails, there is no opportunity for pre-screening and
assessment
• Most women do not know, realize, or understand the benefits of visiting their physician
before trying to become pregnant.
• The third most common obstacle to pre-conception counseling and assessment may be
the lack of health insurance
COMPONENTS OF PRECONCEPTION CARE
• Physical assessment and risk screening

• Education
• Intervention or modification.
• Preconception counseling
MATERNAL PHYSICAL ASSESSMENT AND RISK SCREENING
• Family and genetic history

• Medical history
• Medication use
• Tobacco use
• Psychoactive substance use
• Environmental health
• Obstetric and reproductive history
• Interpersonal violence
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• Infectious disease
• Vaccine-preventable diseases
• Nutritional assessment
• Financial and emotional concerns
• Tests
• Female genital mutilation (FGM)
Family and genetic history
• Taking a thorough family history to identify risk factors for genetic conditions
• Family planning
• Genetic counselling
• Carrier screening and testing
• Appropriate treatment of genetic conditions
• Community-wide or national screening among populations at high risk
Medical history
• Possible effects of pregnancy on disease

• Possible effects of disease on pregnancy, mother and fetus
• Evaluate for any possible interventions
• Assess for possibility of teratogenic effects of medications
• Hypertension - assess for microvascular disease, severity, underlying etiology
• Hyperthyroidism
• Hypothyroidism
• Previous treatment for cancer
• History of organ transplantation
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• Connective tissue disorders

• Hematological disease
• Inflammatory bowel disease
• Asthma
• Neurological and psychiatric disorders
Special risks
• Primary pulmonary hypertension

• Chronic renal disease
• Complicated coarctation of the aorta
• Sever mitral or aortic stenosis
• Vasculitis syndromes
Medication use
• Type
• Dosage
• Effect on pregnancy
Tobacco use
• Screening of women and girls for tobacco use (smoking and smokeless tobacco) at all
clinical visits using “5 As” (ask, advise, assess, assist, arrange)
• Providing brief tobacco cessation advice, pharmacotherapy (including nicotine
replacement therapy, if available) and intensive behavioural counselling services
• Screening of all non-smokers (men and women) and advising about harm of second-
hand smoke and harmful effects on pregnant women and unborn children
Psychoactive substance use
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• Screening for substance use

• Providing brief interventions and treatment when needed
• Treating substance use disorders, including pharmacological and psychological
interventions
• Providing family planning assistance for families with substance use disorders
(including postpartum and between pregnancies)
• Establishing prevention programs to reduce substance use in adolescents
Environmental health
• Providing guidance and information on environmental hazards and prevention

• Protecting from unnecessary radiation exposure in occupational, environmental and
medical settings
• Avoiding unnecessary pesticide use/providing alternatives to pesticides
• Protecting from lead exposure
• Informing women of childbearing age about levels of methyl mercury in fish
• Promoting use of improved stoves and cleaner liquid/gaseous fuels
Obstetric and reproductive history
• Conditions with recurrence risk:

o Premature delivery
o Preeclampsia/eclampsia
o Placenta previa/abruption
o Gestational diabetes
o Preterm premature rupture of membranes
o Certain birth defects/genetic disorders
• Prior uterine surgery or anomalies
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• Prior pregnancy losses

• Habitual abortion
Interpersonal violence
• Health promotion to prevent dating violence

• Providing age-appropriate comprehensive sexuality education that addresses gender
equality, human rights, and sexual relations
• Combining and linking economic empowerment, gender equality and community
mobilization activities
• Recognizing signs of violence against women
• Providing health care services (including post-rape care), referral and psychosocial
support to victims of violence
• Changing individual and social norms regarding drinking, screening and counselling of
people who are problem drinkers, and treating people who have alcohol use disorders
Vaccine-preventable diseases
– Vaccination against rubella
– Vaccination against tetanus and diphtheria
– Vaccination against Hepatitis B
Infectious diseases sexually transmitted infections (STIs)
– Providing age-appropriate comprehensive sexuality education and services
– Promoting safe sex practices through individual, group and community-level
behavioral interventions
– Promoting condom use for dual protection against STIs and unwanted pregnancies
– Ensuring increased access to condoms
– Screening for STIs
– Increasing access to treatment and other relevant health services
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Nutritional assessment
• Screening for anemia and diabetes

• Supplementing iron and folic acid
• Information, education, and counselling
• Monitoring nutritional status
• Supplementing energy- and nutrient-dense foods
• Management of diabetes, including counselling people with diabetes mellitus
• Promoting exercise
• Iodization of salt
Financial and emotional concerns
 Couples should be aware of maternity coverage provided by their insurance

 Leave benefits
 Stress importance of good family support
 May consult social services
 Emotional issues addressed
Tests
 Physical examination to identify any medical or surgical conditions requiring referred

to members of the multiprotection team.
 Blood pressure measurement
 Cardiac function
 Thyroid function
 Respiratory function
 Review of gastrointestinal activity
 Weight
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 Sexual health status, i.e., vaginal, urethral or anal swabs

 Cervical smear
Serum screening:
 full blood count

 rubella status
 tuberculosis status
 Assessment of vitamin, zinc, and lead levels
 Hair analysis
 nutritional state
 exposure to toxic metals
 Urinalysis for protein, ketones, glucose, and bacteriuria.
Female genital mutilation (FGM)
• Discussing and discouraging the practice with the girl and her parents and/ or
partner
• Screening women and girls for FGM to detect complications
• Informing women and couples about complications of FGM and about access to
treatment
• Carrying out defilation of infibulated or sealed girls and women before or early in
pregnancy
• Removing cysts and treating other complications
EDUCATION
• Patient education regarding pregnancy risks, management options and reproductive

alternatives
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 Results of screening tests should be given to clients as the information becomes

available, taking care not to overload the couple with details. Verbal information is
supported by documents, information via the Internet and referral to others in the
multiprotection team. It is important not to assume a prior level of knowledge, particularly
in relation to issues such as basic anatomy, sexual health, or knowledge of support
services.
INTERVENTION OR MODIFICATION
Initiate the interventions, when possible, to provide optimum pregnancy outcomes.

This is done based on the results of risk assessment and tests done.
PRECONCEPTION COUNSELING
Preconception counseling defined as providing information and support to individuals of

childbearing age before pregnancy to promote health and reduce risks.
SUMMARY AND RECOMMENDATIONS
• All women of childbearing age should be offered preconception counseling and

evaluation.
• The goals of preconception counseling are to identify risks to the woman and her
pregnancy, educate the patient and initiate appropriate interventions.
• Good communication between primary and secondary care providers is vital to optimize
a woman’s health prior to conception and ensuring timely referral.
• A thorough history will help in identifying risk factors to the woman and her pregnancy.
• A pregnant woman with a BMI of greater 30kg/m2 should be referred to dietician and
specialist clinic.
• Women who are planning a pregnancy should be on folic acid 400μg/day. Women who
are diabetic or on antiepileptic medications should be given 5mg of folic acid/ day 26–29.
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• An up-to-date cervical smear should have been taken.
• All women should be screened for hepatitis B, HIV, syphilis, rubella, and varicella
immunity.
• All medications should be reviewed, and advice given on the use of over-the-counter
medications.
• If applicable, advice should be given on stopping smoking, reducing alcohol intake,

healthy eating and stopping illicit drug use. Psychosocial and domestic issues should be
identified.
• Ethnic minorities should be screened for hemoglobinopathies and carrier state.
• Family history should be reviewed with referral for genetic counseling, if appropriate.
• Women with a history of recurrent miscarriages, stillbirth, pre-eclampsia or a previous

small baby should be referred to an obstetrician/gynecologist or a specialist center for
further investigations and discussion of recurrence risks.
• Women with chronic medical conditions should receive multidisciplinary care. Women
with diabetes, chronic hypertension, renal or cardiac disease, thyroid problems, epilepsy,
or asthma should be advised to use effective contraception until seen by a specialist and
plans for care have been discussed and put into practice.
• Women with mental health issues should be referred to a psychiatrist.
• Genetic counseling should be offered to all women with a previous abnormal fetus,
personal or family history of genetic problems or a history of three recurrent miscarriages.
• A good occupational and environmental history should be sought to review all potential
health and pregnancy hazards.
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4): General follow up activities

1- Look at Figure 1. Label the anatomical features marked from "a" to "I".
Figure 1 the internal female

reproductive organs to complete follow up activities qestion1.
Answer
The correct labels for Figure 1 are as follows:
a is the vagina
b is the cervix
c is the uterus
d is the ovary
e is the fundus
f is the ovarian suspensory ligament
g is the fallopian tube
h is the fimbriae
i is the ovarian ligament.
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2. The following are the internal organs of the female reproductive system:
a. The uterus, the bladder, vagina, and the appendix
b. The vagina, the cervix, the uterus, the fallopian tubes and the ovaries
c. The cervix, the uterus, the fallopian tubes and the ovaries
d. The vagina, the cervix, the balder, the uterus, the fallopian tubes and the ovaries
3. The clitoris is analogous in the male to the:
a. The foreskin
b. The prostate
c. The glans penis
d. Testicle
4. The Bartholin's glands are:
a. Essential to the menses
b. A pair of egg-shaped glandes
c. A pair of pea sized glands
d. Located in the uterus
5. The cervix is covered with a layer of skin like cells on its outer surface called the:
a. Ectocervix
b. Vagina
c. The mons cervix
d. The pubis
6. Menarche is:
a. The part of the menstrual cycle known as a period
b. The first menstrual period
c. The conclusion of menstrual periods when a woman is around 50
d. An ovulatory menstrual cycle
7. The pudenda are another term for:

a. The external genitals
b. The internal genitals
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c. A collective term for the internal and external genitalia

d. The uterus
8. The mons pubis is also known as:
a. The mons genitalia
b. The mons venereal
c. The mons venus
d. The clitoris
9. The labia majora:
a. Are located at the internal os
b. Provide protection for the urethral and vaginal openings
c. Provide protection for the anus and vaginal openings
d. Have no protective functions
10. A nurse is teaching a class about the reproductive system, and correctly states
that the purpose of the labia minora is to:
a. Lubricate the vulvar skin and provide bactericidal secretions.
b. Secrete substances that enhance sexual stimulation.
c. Lubricate the vaginal vestibule and stimulate release of hormones.
d. Secrete mucus with an alkaline pH that enhances the viability and motility of sperm.
11. The nurse is assessing the pH level of the vaginal environment of a 26-year-old
client. Which of the following would be an expected finding for this client?
a. pH level of 3.4
b. pH level of 4.6
c. pH level of 5.7
d. pH level of 6.9
12. A nurse is teaching a class for adolescents about the female reproductive system.
When the nurse asks the class what the function of the vagina is, she knows that
further teaching is necessary when a student answers:
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a. "It protects the labia minora."

b. "It's a passageway for the sperm and the fetus."
c. "It's a passageway for menstrual flow."
d. "It protects against infections from pathogenic organisms."
13. Which statement best describes the correct order of the four phases of the
menstrual cycle?
a. Menstrual, follicular, secretory, ischemic

b. Luteal, follicular, secretory, menstrual
c. Menstrual, proliferative, secretory, ischemic
d. Luteal, secretory, ischemic, follicular
14. The beginning of the first menstrual cycle during puberty is:
a. The menopause
b. The oligarche
c. The menarche
d. The adrenarche
15. The follicular phase is the first:
a. 16 days of the cycle
b. 12 days of the cycle
c. 19 days of the cycle
d. 14 days of the cycle
16. Post ovulation is also known as:
a. The luteal phase
b. The lunar phase
c. The follicular phase
d. The zonal phase
17. Mensuration is largely a:
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Cervical event
a.
A myometrium events
b.
An endometrium events
c.
A fallopian event
d.
18. The nurse in-charge is reviewing a patient's prenatal history. Which finding
indicates a genetic risk factor?
a. The patient is 25years old.

b. The patient has a child with cystic fibrosis
c. The patient was exposed to rubella at 36 wks gestation
d. The patient has a history of preterm labor at 32wks' gestation
19. A pregnant client is being seen for routine antenatal care. The client is 28wks's
gestation with her first pregnancy and has a history of systemic lupus erythematous.
Choose which outcome is most commonly associated with chronic medical illness in
a pregnant mother?
a. The mother will have difficult time becoming pregnant again.
b. The mother will be at higher risk of postpartum psychosis
c. The mother will have more difficulties attaching to her infant.
d. The mother will be more likely to suffer from anxiety
20. Which of the following common emotional reactions to pregnancy would the
nurse expect to occur during the first trimester?
a. Introversion, egocentrism, narcissism.
b. Awkwardness, Clumsiness, and unattractiveness.
c. Anxiety, passivity, extroversion.
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d. Ambivalence, fear, fantasies
21. Which of the following prenatal laboratory test values would the nurse consider
as significant?
a. Hematocrit 33.5%
b. Rubella titre less than 1:8
c. White blood cells 8000mm
d. one hour glucose challenge test 110mg/dl.
22. One component of preconception care is environmental history. List four items
related to environmental history:
a. Valproic acid-neural tube defects (1-2%)
b. Effect on pregnancy Lithium
c. Tetracycline- deposition in fetal long bones.
d. Vitamin A derivatives
23- Define preconception care
Preconception care is defined as a set of interventions that aim to identify and modify
biomedical, behavioral, and social risks to the woman's health or pregnancy outcome
through prevention and management. Certain steps should be taken before conception or
early in pregnancy to maximize health outcomes.
24- Which women most likely to get preconception care
1. Older ones
2. Married with unstable relationship
3. Low income
4. Smokers
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5. Health problems
25- List Three Items for each of the followings:
1. Barriers or Obstacles to preconception care

2. Many pregnancies are still unplanned. Globally, 38% of pregnancies are
unintended.
3. Most women do not know, realize, or understand the benefits of visiting their
physician before trying to become pregnant.
4. The third most common obstacle to pre-conception counseling and assessment may
be the lack of health insurance.
2. Components of preconception care.
1. Risk assessment
2. Education
3. Intervention or modification
4. Preconception counseling
3- GOALS OF PRECONCEPTION CARE
1-Maximize the health of prospective parents
2-Reduce prenatal and maternal mortality and morbidity.
3- Provide detailed information to prospective parents
4- Evaluate the genetic potential of women and their partners and the need for genetic
counseling.
5. Advise on discontinuation of contraception
6. Inform prospective parents of elements of maternity services
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26. The left-hand column of Table 1 gives the names of the various phases in the
menstrual cycle. Complete the right-hand column by entering the correct period in
days measured from the last normal menstrual period (LNMP).
Table 1
Phase of the menstrual cycle Days (1 = first day of the LNMP)

Follicular phase of the ovarian cycle
Luteal phase of the ovarian cycle
Menstrual phase of the uterine cycle
Proliferative phase of the uterine
cycle
Secretory phase of the uterine cycle
Answer
Table 1 completed.
Phase of the menstrual cycle Days (1 = first day of the LNMP)

Follicular phase of the ovarian cycle 1-14
Luteal phase of the ovarian cycle 15-28
Menstrual phase of the uterine cycle 1-5
Proliferative phase of the uterine 6-14
cycle
Secretory phase of the uterine cycle 15-28
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5). References
1. Adele Pillitteri, Maternal and child health nursing, 6th edition lippincott Williams and
wilkins publication, Philadelphia, 2017, 233-280.
2. Annama Jacob, A Comprehensive Textbook of Midwifery and Gynocological Nursing,
5th Edition, Jaypee Brothers Medical Publishers, 2018, 220-250.
3. Catherin's, A Study to Assess the Effectiveness of selected nursing measures on after
birth pain among postnatal mothers in selected hospital, Punjap. M.Sc Nursing, thesis
of Omayal Achi College of Nursing, submitted to Dr. M.G.R. Medical University,
Chennai, 2019.
4. Brown SJ, Davey MA, Bruinsma FJ., Women's views and experiences of postnatal
hospital care in the Victorian Survey of Recent Mothers, Midwifery, 21 (2). 109-126.
2020.
5. Myles, Textbook for midwives, 14th edition Churchill livingstone, publication, London,
2019, 219-220.
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Module (2): Normal pregnancy

redit Weighting of module: 9 hours
Teaching Method(s): 9hr(s) Lectures; virtual classes, 18hr (s/week) clinical (includes
small group clinical skills teaching, clinical skills lab).
Core Competence
This module is designed to prepare students to provide care for woman during normal
pregnancy.
Module Objective
1. To help student acquire knowledge and understanding skills about the development of
fetus and placenta.
2. To help student acquire knowledge, intellectual and practical skills regarding placental
structure, functions, and examination.
3. To help student acquire knowledge and understanding skills about anatomy and
physiology of fetal circulation.
4. To help student acquire knowledge and understanding skills about the physiological
changes of body systems during pregnancy.
5. To help student acquire knowledge, intellectual, and practical skills regarding the
diagnosis of pregnancy in each trimester.
6. To help student acquire knowledge, intellectual, and practical skills regarding antenatal
care.
7. To help student acquire knowledge, intellectual, and practical skills regarding minor
discomforts during pregnancy and its management.
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Module Content:
(1). Conception and fetal development
(2). Fetal circulation
(3). Physiological adaptation of body systems during pregnancy
(4). Diagnosis of pregnancy
(5). Antenatal care
(6) Nutrition during pregnancy
(6). Minor discomforts and nursing intervention
(7). Follow up activities
(8). References
Learning Outcomes:
on successful completion of this module, students will be able to:
1. Describe process of fertilization
2. Explain phases of conceptus development.
3. Describe process of development of Placenta.
4. List functions of placenta.
5. Explain anatomical and physiological changes of body systems during pregnancy
6. List component of second antenatal visit
7. List minor discomfort of women during third trimester
8. Diagram a graph for mature ova and sperm
9. Diagram Direction of blood flow in the four chambers of the newborn heart.
10.Detect signs and symptoms of pregnancy in first trimester
11.Demonstrate the ability to examine placenta.
12.Use evidence-based nursing intervention to manage minor discomforts during
pregnancy.
13.Value the importance of studying conception and fetal development.
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14.Communicate effectively with pregnant woman during care.
1). Conception and Fetal Development
Outline:
• Introduction
• Process of fertilization and conception.
• Implantation
• Phases of conceptus development.
• Process of development of Placenta.
• Placental circulation
• Function of placenta.
• Examination of placenta.
• Placental barrier
• The development of the cardiovascular system
• Three shunts in the fetal circulation
• Direction of blood flow in the four chambers of the newborn heart.
• Direction of blood flow in relation to the fetus and placenta.
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• Conception is the union of ovum and spermatozoon. It occurs at the ampulla of the
fallopian tube. After intercourse, the spermatozoa ascend and reach the tubes, but
they are not able to fertilize the ovum immediately until capacitation occurs within
2-6 hours.
• Sperm consists of a head, a midpiece and a tail. The head contains the nucleus with
densely coiled chromatin fibres, surrounded anteriorly by an acrosome, which
contains enzymes used for penetrating the female egg. The midpiece has a central
filamentous core with many mitochondria spiraled around it, used for ATP
production for the journey through the female cervix, uterus and uterine tube. The
tail or “flagellum” executes the lashing movements that propel the spermatocyte.
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• Capacitation: The term “sperm capacitation" refers to the process male sperm go
through after being ejaculated into the female reproductive tract. Chemical
processes take place that enable the sperm to penetrate and fertilize an egg. These
processes are not fully understood, but it is believed that they involve the full
maturation of the sperm cells so that they can successfully join with a mature female
egg.
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• The cervical and tubal secretions are mainly responsible for this capacitation,
millions of sperms are ejaculated in the vagina, but only hundreds of thousands
reach the outer portion of the tubes, only few succeed to penetrate the zona pellucida
and only one spermatozoon enters the ovum, after penetration of the ovum by a
sperm, the zona pellucida resists penetration by another sperms.
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• The fertilized ovum “zygote” divides into 2,4,8……the cells called “blastomeres”,
this division “cleavage” starts within 24 hours of fertilization and occurs nearly
every 12 hours repeatedly, the resultant 16 cells mass is called morula and reach
the uterine cavity after about 4 days from fertilization.
 Morula is differentiated into two parts:

• The inner mass consists of embryonic cells
• Outer Layer is the trophoblast.
 The embryonic cells are differentiated into three layers:
1. ECTODERM which will form the skin, nervous system and the special sense
organs as eyes, ears, taste and smell organs.
2. MESODERM which will give muscles, bones, connective tissue, circulatory and
urogenital systems.
3. ENDODERM which will give the digestive and respiratory systems.
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Approximately six to nine days following fertilization, the zygote attaches itself to the
endometrium. This process is called implantation and normally occurs in the upper
uterine segment.
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Definition of placenta:
It is a temporary organ that connects the developing fetus via the umbilical cord to the
uterine wall, allows transferring oxygen and nutrients from the mother to the fetus and
permitting the release of carbon dioxide and waste products from the fetus.
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Placenta development
The placenta begins to develop upon implantation of the blastocyst into the maternal
endometrium.
Blastocyst remains free in the uterine cavity for 3-4 days before implantation.
After implantation, this outer layer (trophoblast) is divided into three layers:
mesoderm, the cytotrophoblast, and syncytotrophoblast. These 3 layers will form the
chorion
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-Spaces appear in synthetiotrophoblast, then these spaces fuse together to form chorion-
decidual space
-Erosion off maternal blood vessels by trophoblast allow blood to flow in this space
-The placenta grows throughout pregnancy. Development of the placenta is complete -
.by the end of the first trimester of pregnancy week
Maternal Placental circulation

-In preparation for implantation of the blastocyst, the endometrium undergoes
decidualization.
Decidua: is the endometrium of pregnancy.
The decidua has three regions:
1-Decidua Basalis: is that part of the decidua deep to the embryo, and adjacent to
chorion frondosum. It will form the maternal part of the placenta.
2-Decidua capsularis: is that part of the decidua, which lies superficial to the embryo
and covers it towards the uterine cavity.
3-Decidua Parietalis/ vera: is the remaining part of the endometrium .
The decidua has three features:

1-endometrium becomes thicker, and its glands are large, tortuous and their cells are
filled with mucous & glycogen.
2-Connective tissue stroma cells enlarge to form decidual cells, which contain large
amount of glycogen and lipids, which provide a source of nutrition for the developing
embryo.
3-The endometrial blood vessels become highly engorged and more spiral to increase
maternal blood flow to the placenta. They are eroded by trophoblast to pour their
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maternal blood into the intervillous spaces of the placenta.
-There is relatively high pressure as the maternal blood fills intervillous space through
these spiral arteries which bathe the fetal villi in blood, allowing an exchange of gases to
take place.
-The maternal blood comes into direct contact with the fetal chorion, though/ but no
fluid is exchanged (placental barrier).
Function of decidua:
It is the site of implantation
Nutrition of the embryo (contain fat and glycogen)
Protection of uterine wall against invasion by chorionic villi
Formation of placenta
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Component of placenta:
-The placenta functions as a feto-maternal organ with two components:
-The fetal placenta (Chorion frondosum), which develops from the same blastocyst that
forms the fetus
-The maternal placenta (Decidua basalis), which develops from the maternal uterine
tissue.
Chorion Frondosum
-is that part of the chorion which adjacent to the decidua basalis of the endometrium of
pregnancy, whose tertiary villi increase in number, size and branching.
-is the base from which the chorionic villi are projecting into the decidua basalis of the
uterus
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Chorionic villi
After 6 days of implantation:
-Primary villi form: strands made up of synthetism and cyto trophoblast
-Secondary villi form: primary villi invaded by mesoderm
-Tertiary villi: when blood vessels appear in mesoderm
At 12 weeks after ovulation:

-The villi related to decidua capsularis disappear and become Chorion laeve (smooth
membrane)
-The villi related to decidua basalis grow to form chorion frondosum which form
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placenta
Microscopic structure of the placenta:

-The placenta is formed of many intervillous spaces filled with maternal blood. -
Each intervillous space lies in between two stem villi.
Structure
-Oval or circular
-500 gm
-15-20cm
-1.5-2cm and tapering at the end
-Upper uterine segment
-2 surfaces: fetal and maternal
1.Maternal surface
-Covered by thin grey layer of decidua called (basal plate)
-Dull red in color
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-Divided by grooves into 15-20 lobes

2. Fetal surface
-Covered by amnion (thin smooth membrane)
-Under amnion there is a (chorionic plate) (few mm in thickness- from which villi rise-
composed of connective tissue- contain branches of umbilical blood vessels which
divide to enter the villi)
-Umbilical cord is inserted in fetal surface (centric- e-centric)
-Vessels branch out over the surface of the placenta and further divide to form a
network covered by a thin layer of cells. (This results in the formation of villous tree
structures).
-On the maternal side, these villous tree structures are grouped into lobules called
cotyledons.
Umbilical cord
-50-70cm
-2cm diameter
-Consists of Warton jelly covered by amnion
-Contains 1 vein (carries oxygenated blood from placenta to fetus) and 2 arteries
(carries deoxygenated blood from fetus to placenta).
Placental barrier
Fetal blood in chorionic villi is separated from maternal blood in intervillious
spaces by placental barrier which is made of 4 layers:
1-Synthetiotrophoblast
2-Cytotrophoblast
3-Mesoderm
4-Wall of blood vessels
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Functions of placenta
1-Nutritive: nutrients (glucose, amino acids and vitamins) are transmitted from the
maternal to fetal blood by active diffusion.
2-Respiratory: placenta acts as fetal lung. o2 and co2 pass by simple diffusion.
3-Excretory: placenta acts as fetal kidney excreting waste products as urea into
maternal blood.
4-Hormonal: the placenta secretes many hormones HCG, HPL, Estrogen, Progesterone,
Relaxing.
5-Hemopoietic: it forms fetal hemoglobin
6-Barrier action: placenta prevents passage of undesirable substances such as some
toxins and organisms
• The term embryo is used during the first 8 weeks of development. It is important to
know the events that occur in the beginnings of life, when all the blueprints of the
human body are laid down in the embryo. The embryonic period is followed by the
fetal period (months 3-9) when there is extensive growth and differentiation and
when the embryo acquires a more human form
 The Zygote—Month 1
• Fertilized egg reaches the uterus and attaches itself to the uterus.
• Cell multiplication begins.
• Internal organs and circulatory system begins to form.
• Cell Division takes place and at the end of two weeks the zygote is the size of a
pinhead
• Heart begins to beat
• Small bumps show the beginnings of arms and legs
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 4 weeks
The Embryo—Month 2
• At 5 weeks the embryo is ¼ inch long
• All major organ systems develop.
• The placenta and Umbilical Cord develop
• Amniotic Fluid surrounds the baby.
• Face, and limbs take shape.
 Two months
6 Weeks 7 Weeks 8 Weeks
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The Fetus—Month 3
• The fetus is about 1 inch long.
• Nostrils, mouth, lips, teeth buds, and eyelids form
• Fingers and toes are almost complete
• Eyelids are fused shut
• Arms, legs, fingers, and toes have developed
• All internal organs are present—but aren’t ready to function
• The genital organs can be recognized as male or female
3 Months
11 Weeks 12 Weeks
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• Fetus is 3 inches long
• Your baby is covered with a layer of thick, downy hair called lanugo.
• His heartbeat can be heard clearly.
• This may be when you feel your baby's first kick.
• The baby can such thumb, swallow and hiccup.
4 months
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18 Weeks
15 Weeks 16 Weeks
• The Fetus is about 6 inches long and weighs 4-5 oz.
• A protective coating called vernix begins to form on baby's skin.
• Hair eyelashes and eyebrows appear
• Organs keep maturing
• Fetus is very active
• The eyes can open and blink
• The fetus is 8-10 inches long and weighs 4-5 oz.
• Your baby's lungs are filled with amniotic fluid, and he has started breathing
motions.
• If you talk or sing, he can hear you.
• Fat is starting to deposit under the skin
6 Months
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• Fetus is 10-12 inches long and weighs about 1-2 pounds.
• Fetus is active and then rests.
• The baby now uses the four senses of vision, hearing, taste and touch
Seven Months
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The Fetus—Month 8
• The fetus is 14-16 inches long and weighs 2-3 pounds
• Layers of fat are piling on.
• Fetus has probably turned head-down in preparation for birth.
• Fetus may react to noises with a jerking action
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Eight Month
The Fetus—Month 9
• Fetus is about 17-18 inches long and weighs 5-6 pounds
• Skin is smooth because of the fat
• Baby’s movement slows down due to lack of room
• “Lightening” occurs when the baby drops in the pelvis
• Disease fighting antibodies are taken from the mother’s blood
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2). Fetal Blood Circulation
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Introduction
Throughout the fetal stage of development, the maternal blood supplies the fetus
with O2 and nutrients and carries away its wastes. These substances diffuse between the
maternal and fetal blood through the placental membrane. They are carried to and from
the fetal body by the umbilical blood vessels.
The development of the cardiovascular system

- Begins to develop toward the end of the third week.
- Heart starts to beat at the beginning of the fourth week.
- The critical period of heart development is from 20 day To day 50 after fertilization.
- Many critical events occur during cardiac development, and any deviation from this
normal pattern can cause congenital heart defects, if development of heart does not
occur properly.
- However, we will concern ourselves with the events surrounding the circulatory
changes at birth.
Three shunts in the fetal circulation

1- Ducts arteriosus
- protects lung against circulatory overload.
- allows the right ventricle to strengthen
- pulmonary vascular resistance, low pulmonary blood flow.
- carries mostly med oxygen saturated blood.
2- Ductus venosus
- fetal blood vessel connecting the umbilical vein to the IVC.
- blood flow regulate via sphincter
- carries mostly high oxygenated blood.
3- foremen oval
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- shunts highly oxygenated blood from right atrium to left atrium.
Adaptations of fetal blood and vascular system.

The concentration of hemoglobin in fetal blood is about 50 % greater than in
maternal blood.
Fetal hemoglobin is slightly different chemically and has a greater affinity for O2 than
maternal hemoglobin.
At a particular oxygen partial pressure, fetal hemoglobin can carry 20-30% more O2 than
maternal hemoglobin.
Fetal Circulation
In the fetal circulatory system, the umbilical vein transports blood rich in O2 and
nutrients from the placenta to the fetal body. The umbilical vein enters the body through
the umbilical ring and travels along the anterior abdominal wall to the liver. About 1/2 the
blood it carries passes into the liver. The other 1/2 of the blood enters a vessel called the
ductus venosus which bypasses the liver. The ductus venosus travels a short distance and
joins the inferior vena cava. There, the oxygenated blood from the placenta is mixed with
the deoxygenated blood from the lower parts of the body. This mixture continues through
the vena cava to the right atrium.
In the adult heart, blood flows from the right atrium to the right ventricle then
through the pulmonary arteries to the lungs.
In the fetus however, the lungs are nonfunctional, and the blood largely bypasses them.
As the blood from the inferior vena cava enters the right atrium, a large proportion of it is
shunted directly into the left atrium through an opening called the foramen ovale.
A small valve, septum primum is located on the left side of the atrial septum overlies the
foramen oval and helps prevent blood from moving in the reverse direction.
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The rest of the fetal blood entering the right atrium, including a large proportion of the
deoxygenated blood entering from the superior vena cava passes into the right ventricle
and out through the pulmonary trunk.
Only a small volume of blood enters the pulmonary circuit, because the lungs are
collapsed, and their blood vessels have a high resistance to flow.
Enough blood reaches the lung tissue to sustain them. Most of the blood in the pulmonary
trunk bypasses the lungs by entering a fetal vessel called the ductus arteriosus which
connects the pulmonary trunk to the descending portion of the aortic arch.
As a result of this connection, the blood with a relatively low O2 concentration which is
returning to the heart through the superior vena cava, bypasses the lungs.
At the same time, the blood is prevented from entering the portion of the aorta that
provides branches leading to the brain. The more highly oxygenated blood that enters the
left atrium through the foramen oval is mixed with a small amount of deoxygenated blood
returning from the pulmonary veins.
This mixture moves into the left ventricle and is pumped into the aorta. Some of it reaches
the myocardium through the coronary arteries and some reaches the brain through the
carotid arteries. The blood carried by the descending aorta is partially oxygenated and
partially deoxygenated. Some of it is carries into the branches of the aorta that lead to
various parts of the lower regions of the body. The rest passes into the umbilical arteries,
which branch from the internal iliac arteries and lead to the placenta. There the blood is
reoxygenated.
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Follow up activities
Activity I: Choose the best answer:
1-The structure which implants in the endometrium is termed as what of the
following?
a. Embryo
b. Zygote
c. Morula
d. Blastocyst
2-Which hormone prevents the second pregnancy during gestation?
a. FSH
b. LH
c. HCG
d. Progesterone
3-In which menstrual cycle phase does implantation occur?
a. Menses
b. Ovulation
c. Secretory
d. Proliferative
4-When does the development heart of the fetus begin?
a. 1st week of gestation
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b. 12th week gestation

c. 5th week gestation
d. 3rd week of gestation
5-Which embryonic cells will formed by mesoderm layer?
a. The digestive and respiratory system
b. Circulatory and urogenital systems
c. the skin, nervous system
d. Skin and special sense organ
6-A natural cleavage plan between the placenta and the uterine wall is formed
when the cotyledons of the maternal surface of the placenta extend into what of the
following?
a) myometrium
b) uterine wall
c) decidua basalis
d) amniotic membrane
7-The 4 cellular layers separating maternal and fetal blood in sequence are what of
the following?
a. Cytotrophoblast, mesoderm, syncitiotrophoblast
b. Syncitiotrophoblast, cytotrophoblast, mesoderm, and fetal capillary endothelium
c. Trophoblast layer, endothelial and fetal red blood cell, mesoderm
d. Fetal capillary endothelium, villi connective tissue, cytotrophoblast and
syncitiotrophoblast
8-Which extra embryonic membrane encloses the embryo in a fluid filled cavity?
a. Allantois
b. Chorion
c. Amnion
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d. Yolk sac
9- Regarding the fetal circulation, pure oxygenated blood can be founded
a. In the placental artery
b. In the fetal lung
c. In the placental vein
d. In the portal circulation
10- the foramen oval is founded between
a. the two atriums
b. the two ventricles
c. the umbilical vein and the inferior vena cava
d. the umbilical vein and the superior vena cava
activity II
determine the level of oxygenation of the blood in each of the following structure, write
"high" if highly oxygenated "low" if deoxygenated and "mix" if a mixture of oxygenated
and deoxygenated blood.
a. ________superior vena cava
b. __________umbilical vein
c. ________inferior vena cava
d. ___________left atrium and left ventricle
e. _____right atrium aorta
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3). Physiological adaptation of body systems during

pregnancy
Outlines:1- Anatomical and physiological changes of body systems during pregnancy.
• Reproductive System
• Cardiovascular System
• Respiratory System
• Urinary System
• Gastrointestinal System
• Musculoskeletal System
• Integumentary System
• Endocrine
• Immunological
• Metabolic changes
2- Diagnosis of pregnancy in first trimester.
3-Diagnosis of pregnancy in second trimester.
4- Diagnosis of pregnancy in third trimester.
Adaptations of the Body Systems During Pregnancy
Body Systems Affected by Pregnancy
Adaptation of Reproductive System Adaptation of Other Body Systems
Uterus Cardiovascular
Cervix Respiratory
Ovaries and fallopian tubes Urinary
Vagina Gastrointestinal
Vulva Musculoskeletal
Breast Integumentary
Metabolic changes
Endocrine
Immunological
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Reproductive System
 Uterus
• Size: increases to 20 times from 7.5×5×2.5 cm in a state of non-pregnant
woman to 35×25×20 cm at term in pregnant woman due to hyperplasia and
hypertrophy.
• Wall: changes from almost a solid globe to a hollow vessel.
• Weight: increases from 50 grams in non-pregnant to 1000 grams at term in
pregnant woman.
• Volume: increases from less than 10 ml to 5000 ml.
• Contractions: Braxton Hicks (irregular, painless contraction).
• Shape: changes from an inverted pear to globular by 8th weeks and pyriform
by 16th weeks still term.
• Endometrium: consists of 3 layers:
• Decidua basalis: uterine lining beneath implantation.
• Decidua capsularis: portion of the decidua that covers the embryo.
• Decidua vera: all of the uterine lining that is not in contact with the fetus.
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 Cervix
• Goodell's sign: violet and softening of the cervix, formation of operculum (mucous
plug).
• Cervical secretions are increased.
• Cervical ectopy is common due to hypertrophy
 Ovaries and Fallopian Tubes

Involution due to suppression of follicle stimulating hormone (FSH).
 Vagina
• Chadwick's sign: bluish discoloration of vagina.
• Hypertrophy and hyperplasia.
• Leukorrhea, acid pH 3.5 to 6.
 Vulva
• Increased vascularity.
• Fat deposit causes labia majora to close and partially cover introitus.
• Edema and vascularity may develop.
 Breasts
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• 3-4 weeks: prickling, tingling sensation.

• 6 weeks: developing ducts and glands.
• 8 weeks: bluish surface veins are visible.
• 8-12 weeks. Montgomery's glands become more prominent, primary areola
become darker.
• 16-18 weeks: colostrum expresses. Secondary areola appears.
Adaptation of Other Body Systems
 Cardiovascular System
• Slight enlargement of myocardium.

• Position: the apex is displaced upward and to the left so that it lies in 4th
intercostal space outside mid-cervical line.
• Heart rate increases by IO to 15 beats/minute.
• Blood volume increases 40-50% → physiological anemia.
• Increase in clotting factors.
• Hemoglobin and hematocrit decrease in relation to increased plasma volume.
• Cardiac output increases mainly by increased stroke volume rather than
increased heart rate by 30% during the first and second trimesters, reaching
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a maximum of 40% above non pregnant at 20 weeks to be maintained till

term.
•
 Respiratory System
• Estrogen causes edema of mucous membranes of upper respiratory tract→

epistaxis.
• Enlarged uterus → prevent the lungs from expanding → shortness of breath.
• Basal metabolic rate increases and oxygen requirement increases by 30 to 40
ml/min.
 Urinary System
• Frequency of micturition due to pressure of the growing uterus.
• Decreased bladder capacity and bladder tone.
 Renal Function Changes

• Changes occur to accommodate an increased workload while maintaining
stable electrolyte balance.
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• Increased glomerular filtration rate by 50%.

• Glucosuria may occur (may not be abnormal, warrants further evaluation).
• Ureter: dilatation of ureter and renal pelvis
 Gastrointestinal System
• Mouth and Teeth
o Gums become hyperemic and have a tendency to bleed.
o Ptyalism is seen in some women.

• Smooth muscle relaxation occurs related to increased progesterone
production.
• Heartburn, slowed gastric emptying and esophageal regurgitation (reflux of
acidic) ·
• Hemorrhoids from the pressure of the gravid uterus, constipation and laxity
of veins by progesterone
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• Constipation due to increased water reabsorption pressure of gravid uterus

and reduced motility of large intestine.
• Gall stone: more tendency to stone formation.
• Appendix: is displaced upward by enlarged uterus.
Appetite usually increases, after a temporary decrease due to nausea and
vomiting.
 Musculoskeletal System
• Alteration in posture can result in lordosis (waddling gait occurs due to

increased level of progesterone and relaxation hormone).
• Diastasis recti is associated with the enlarging uterus in some women.
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• Relaxation and increased mobility of joints occur, because of the relaxing

hormone and steroid sex hormones.
 Integumentary System (Cutaneous Changes)

• Chloasma is the brownish " mask of pregnancy"
• Linea nigra (abdomen).
• Nipples, areolae, axillae, vulva and perineum all darken.

• Striae gravidarum (stretch marks) appear on the breasts and abdomen. This
is caused by increased Fragility of the connective tissue.
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 Endocrine System
• FSH and LH production is suppressed.
• Human placental lactogen production is suppressed.
• Prolactin level increases up to 150 mg/ml at term
• Thyroid and parathyroid gland enlarges, resulting in increased iodine
metabolism.
• Pancreas: Insulin production is increased throughout pregnancy to
compensate for placental hormone insulin antagonism.
• Adrenal gland: hypertrophy particularly cortex.
• Ovaries produce:
o Estrogen.
o Progesterone.
o Relaxing hormone.
 Immunological System
• Resistance to infection is decreased.
• Maternal 1gG levels are decreased.
• Maternal 1gM levels remain unchanged.
 Metabolic Changes
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• Increase metabolic rate.

• Increase the demands for carbohydrate, protein, and minerals.
• Weight gain of 9 -11 kg.
• Water requirement is increased to supply fetus, placenta and amniotic fluid.
4). Diagnosis of pregnancy
The diagnosis depends upon symptoms, signs and investigations
Diagnosis in the first trimester (first 12 weeks)
(I) symptoms:
1. Amenorrhea: It is due to the presence of a height level of estrogen and
progesterone without withdrawal. Il is not a sure evidence of pregnancy because
it may be caused by other conditions as lactation. Also bleeding may occur in
early months of pregnancy and may be mistaken for menstruation. eg. abortion.
2. Morning sickness.
3. Frequency of micturition
4. Breast symptoms as enlargement, heaviness and pain.
5. Change of appetite or longing
6. Some women are sleepy and depressed, others may be irritable and suffer
insomnia.
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(II) signs:
1. Breast signs
2. Uterine signs
3. Cervical signs
4. Vaginal signs
5. vulval signs
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(III) Special investigations

1. Pregnancy tests: detect human chorionic gonadotrophic in maternal urine or
serum
Urine test:
Sensitive urine pregnancy test including home kits are now available. An example is the
ELISA tests (enzyme-linked immunosorbent assay tests) which detect 10-20 m IU\ml of
HCG and can diagnosis pregnancy at the time of missed period in 95% of cases. The
sensitivity of home tests ranges from 10 to 50 m IU\ml.
Blood test:
Detection of beta-subunit of HCG in serum by radioimmunoassay is a very sensitive test
and detects small amounts of the hormone (one mI U\ml of beta-subunit and even
lower). It can diagnose pregnancy before the first missed period by 5-7 days (becomes
positive one day after implantation).
2. Sonography: done for:
1. detect intrauterine pregnancy
2. confirm fetal cardiac activity
3. diagnose multiple pregnancy
It means the use of sound waves above the range of human hearing hence the term
ultrasonic technique. By transvaginal sonography, the pregnancy sac appears as a white
ring at 4 weeks of pregnancy, the fetal pole at 5 weeks, and fetal heart movement at 6
weeks. Transabdominal ultrasound is less sensitive with about one week difference. Also
the fetal heart sounds can be heard after the 10th week by Doppler stethoscope (Doptone
or Sonicaid).
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Diagnosis in the second trimester (13-28 weeks)
(I) Symptoms
1. Amenorrhea
2. Breast symptoms which become more marked.
3. Quickening: it is the first time at which the mother feels movements. In
multigravida, it usually occurs between the 16th and 18th week. In
primigravidae, it usually occurs between the 18th and 20th. This difference is
due to previous experience. The intestinal movements may be mistaken for fetal
movements.
4. Progressive abdominal enlargement.
 Morning sickness and frequency of micturition normally disappear after the 12th
week.
(II) Signs
1. Breast signs
2. Uterine signs:
− The uterus is felt abdominally as a soft or cystic swelling with a convex upper
border. It undergoes intermittent contractions which can be felt by abdominal
palpation (Braxton Hicks contractions).
− Uterine soufflé: it is soft blowing sound synchronous with the maternal pulse.
It is due to flow of blood in the dilated uterine arteries (may be heard in
presence of fibroids). It is usually heard near the lower part of the uterus.
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3. Fetal signs:
− Ballottement: this sign depend on the presence of a solid body, that is the fetus
moving in a fluid medium (the amniotic fluid).
4. Appearance of striae gravidarum and Linea nigra.
(III) Special investigations

Done in doubtful cases because diagnosis of pregnancy is usually easy in the second
trimester.
a. Pregnancy tests.
b. Sonar or X-ray examination: the latter shows parts of fetal skeleton at 16th week
and the whole skeleton at 24th week. Sonar is preferred to avoid hazards of
irradiation. In fact X-ray examination is resorted to if ultrasound is not available.
Diagnosis in the third trimester (29-40 weeks)

The diagnosis is easy because all the sure signs of pregnancy are present and these
are:
1- Palpation of fetal parts
2- Palpation of fetal movements.
3- Hearing of FHS
4- Hearing of umbilical soufflé.
5- Seeing fetal skeleton by sonar or X-ray.
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Follow up activities
Activity I: Choose the best answer
Which of the following physiologic changes are expected during pregnancy?
a. Decreased plasma volume.

b. Deceased minute ventilation
c. Increase in fibrinogen.
d. Increase in glucose utilization
1. What is the major cause of increased cardiac output in the first half of pregnancy?
a. Increased heart rate
b. Increased systemic vascular resistance.
c. Decreased vascular resistance.
d. Increased stroke volume
2. Which of the following causes of leukorrhea during normal pregnancy?
a. Increased metabolic rates
b. Increased production of estrogen
c. Increased functioning of the Bartholin glands
d. Increased supply of sodium chloride to the cells of the vagina
3. which of the following the adaptation of pregnancy is an increased blood supply to the pelvic
region that results in a purplish discoloration of the vaginal mucosa?
a. Hegar’s sign
b. Ladin’s sign
c. Goodell’s sign
d. Chadwick’s sign
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4. A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive.
The physician has documented the presence of a Goodell’s sign. Which of the following indicates
this sign?
a. A softening of the cervix
b. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.
c. The presence of Human Chorionic Gonadotrophin (HCG) in the urine
d. The presence of fetal movement
6- A woman with strong desire for pregnancy falsely believes she is pregnant, this is called what?
a) pseudocyesis
b) factitious disorder
c) dissociative disorder
d) somatoform disorder
7-During the first trimester of pregnancy, what is the source of elevated estrogen
and progesterone?
a) placenta
b) corpus luteum
c) maternal ovaries
d) fetal adrenal gland
8- In assessing Nawal physical condition, the nurse is aware of the fact that a normal
adaptation of pregnancy is an increased blood supply to the pelvic region. The
resulting blush purple discoloration of the vaginal and cervical mucosa is known as
what?
a- Hegar's sign
b- Ladin's sign
c- Goodell's sign
d- Chadwick's sign
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9- What is the meaning of Chadwick’s sign?

a) Vulvar swelling
b) Increased vaginal secretion
c) Softening of the cervix
d) Bluish discoloration of the vagina
10- The nurse suggests a pregnancy test. This is possible because in early
pregnancy the urine contains what?
a- Prolactina
b- Choroinic gonadotropinas
c- Estrógeno
d- Luteinizing hormone
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5). Antenatal Care

Outlines:
1. Definition of antenatal care.
2. Objectives of antenatal care.
3. Components of initial ante partum and return visit.
4. Schedule time of return visits.
5. Nutritional requirement for pregnant mother.
6. Minor discomforts during first trimester of pregnancy and nursing intervention to
each problem.
 Nausea and vomiting
 Nasal stuffiness and epistaxis
 Urinary frequency
 Breast tenderness
 Ptyalism
 Leukorrhea
 Headache
7. Minor discomforts during second and third trimester of pregnancy and nursing
intervention to each problem.
 Heart burn
 Ankle edema
 Varicose veins
 Hemorrhoids
 Constipation
 Backache
 Leg cramps
 Faintness
 Shortness of breath
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 Pain in round ligament
Definitions
- Ante: means before
- Natal: means delivery
- Antenatal: means before delivery
- Antenatal care: comprehensive health supervision of a pregnant women before delivery
Objectives of antenatal care:

1. To ensure that pregnant woman and her fetus are in the best possible
health
2. To prepare the woman for labor, lactation and care of her infant
3. To detect early and treat properly complicated conditions that could
endanger the life of impair the health of the mother or the fetus
4. To foster the delivery of safe, satisfying, and economic maternity care
5. The reproductive experience as an opportunity to promote good health
habits
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I) Initial (First)Antepartum Visit
Purpose
1. Conduct: the initial visit, including a complete medical, OB, and family health
history.
2. Conduct a complete physical exam.
3. Order and evaluate appropriate lab work and additional diagnostic procedures.
4. Establish an estimated date of confinement.
5. Identify deviations from the normal course of pregnancy.
Historical data:
• Biographic data: name, age, marital status, special habits as smoking, social factors
and residence
• Menstrual history
1. Date of last menstrual period (LMP)
2. Menstrual rhythm (regular or irregular)
3. Contraception: as oral contraception pills especially in last 3 months, Intra
Uterine Contraception Devices (IUDS)
• Obstetric history
1. Gravidity= Total numbers of prior pregnancies
2. Parity= Usually expressed in 4 digits numbers
3. Numbers of term deliveries
4. Preterm deliveries
5. Abortion
6. Number of living children
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 In each labor we ask about

- Duration of the pregnancy
- Complications occurred in early or late pregnancy
- Labor if spontaneous or induced
- Date and place of delivery whether vaginal (spontaneous or instrumental or
by forceps) or by cesarean section
- Complications after labor
- Weight of the baby
- Puerperium: for complications as bleeding or fever
- Contraception used
 In each abortion we ask about
- Duration of the pregnancy
- Place
- Date of abortion
- Method of termination (spontaneous or induced)
- If complications occurred (infection, blood transfusion)
• Medical history
- Most obstetric patients are young and healthy, but certain medical
illness may concern. Some diseases may complicate the pregnancy.
Other disease may be aggravated by pregnancy
- care should be taken with; diabetes mellitus; heart disease; hypertension; renal
disease; thyroid dysfunction and serious infections as rubella
• Surgical history
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- prior surgery may affect the conduct of natural delivery as cardiac or

renal surgery
• Family history
- Items of significance are multiple gestation, diabetes mellitus, bleeding
disorders, and hereditary disorders as down's syndrome
• Complaint
- The women may come with complaint asking for antenatal care
• History of present condition
1. analysis of the complaints
2. ask about symptoms of early and late pregnancy
3. Ask about abnormal symptoms as bleeding and pain
4. Escape of any discharge (as liquor)
5. Ask about symptoms of any complications as pre-eclampsia and urinary tract
infection
Physical Examinations
A- General examination
a. Height
b. Weight
c. Gait
d. General appearance or illness
B- Vital signs
-Pulse, temperature and blood pressure
C- Systematic examination
1- Eyes for jaundice
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2- Mouth and teeth

3- Tongue and tonsils
4- Neck for thyroid gland, lymph gland and neck veins for pulsations
5- Chest and heart
6- Lower limbs for edema and varicose veins
D- Abdominal examination
• Inspection
1- Size of abdomen: if excessively large or small
2- Shape and contour as pendulous abdomen
3- Scars of operations
4- Presence of hernias
5- Pigmentation as linea nigra
• Palpation
- Fundal level
- First maneuver (fundal grip)
- Second maneuver (umbilical grip)
- Third maneuver (first pelvic grip)
- Fourth maneuver(second pelvic grip or pelvic palpation)
• Ausculation
- The fetal heart is heard by the fetal or pinard stethoscope or by the Doppler
stethoscope (Sonicaid)
- It is best heard towards the back in vertex and breech and towards the chest in
face presentation.
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Value of auscultation of FHS

1- Sure sign of pregnancy
2- Diagnosis of multiple pregnancies
3- Diagnosis of intra-uterine fetal death
4- Diagnosis of fetal distress
5- Diagnosis of fetal presentation and position
6- follow up progress of labor
E- Pelvic examination
a-Eternal genitalia
Significant lesion during pregnancy as Bartholin’s gland abscess.
b- Vagina
Under hormonal influence of pregnancy, cervical secretion are
increased thus raising vaginal pH which changes the vaginal flora.
Organisms normally present because more abundant producing
discharge are:
- Candida albicance
- Trichomonas vaginalis
- Neisseria gonorrhea
c- Cervix- A pap smear for cytology and bacteriological examination
d- Uterus- Position and size to estimate the gestational age
e- Laboratory data
- Blood grouping
- Complete blood picture
- Complete urine analysis
- Glucose tolerance test
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- Other investigation according to the case
II) Return Ante partum Visit

- The patient is asked about any complaint
- Blood pressure and weight are recorded
- Abdominal examination and edema of lower limbs
- Urine is tested for albumin and sugar
- Pelvic examination at the 36th week is estimate the pelvic capacity and
test for cephalopelvic disproportion
A. Schedule for return visits
1. 1 to 28 weeks gestation: every 4 weeks
2. 28 to 36 weeks' gestation: every 2 weeks
3. 36 weeks gestation until term : every week
4. If the patient is allowed to go past 40 weeks, see her twice a week with
appropriate testing
B. Teaching and counseling
1. Provide opportunity for patient to discuss questions concerns and need.
2. Review checklist for topics to be discussed and procedures to be done at the
appropriate weeks of gestation.
3. Provide individualized health instruction, counselling, and guidance.
4. Review recent laboratory reports.
5. provide relief for minor discomforts or physical complaints.
6. Refer patient other needed services
a) Dietitian
b) Dentist
c) Social services
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d) childbirth education
e) Physical therapist
f) Counselling or mental health
7. Form and revise plan of care after discussing options with patient.
6) Nutritional requirement for pregnant mother

Good nutrition is important during pregnancy and during breast feeding.
a) Calories: Pregnant and breast-feeding women have increased calorie needs.

1. Pregnancy: Increase intake by 300 calories.
2. Breast-feeding: Increase intake by 500 calories.
b)Protein: From 80 to 100 g of protein are needed daily.
1. Reasons
a. To enable the body to lay down new tissue
b. To promote fetal growth
c. To prevent edema
2. Daily requirement
a. 1 quart milk (32 g)
b. Three servings of meal, fish, chicken, or rice and beans (60 to 90 g)
Women pregnant with twins need
1. An extra 30g of protein a day
2. An extra 200 calories a day.
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c) Whole grains
1. Reasons
a. They help prevent constipation.
b. They are a good source of B vitamins.
c. They provide complex carbohydrates for energy.
2. Daily requirement :Four servings of whole grain breads, pasta, cereals, or legumes
d)Milk and other daily products
1. Reason : They are a good source of protein and calcium.
2. Daily requirement: Four servings of low-fat milk, cheese. or cottage cheese
e) Fruits and vegetables
1. Reasons
a. They provide many vitamins and minerals.
b. Citrus varieties are high in vitamin C.
c. They help prevent constipation.
2. Daily requirement: Five servings (Lettuce should be the dark green variety)
f) Water
1. Reasons
a. To keep up with expanding blood volume
b. To avoid constipation
2. Daily requirement: Two quarts of fluid
g) Substances to avoid
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1. Artificial sweeteners, especially aspartame, which can be associated with

headaches and dizziness
2. Caffeine
3. Drinks and foods with a high sugar content
Weight Gain
1. Expected weight gain

a. Trimester 1--Two to 4 Ib total
b. Trimester 2—1/4 Ib per week
c. Trimester 3-One pound or- less per week
NB: Ib= 1250 gm
2. Problems with weight gain or loss

a. If the patient is gaining more than 2 lb per week, check for problems.
b. The patient can gain 10% of her original body weight before there is clinical evidence
of edema.
c. Weight loss is most significant in the first trimester, because the baby grows rapidly
and needs nutrients.
d. Weight loss of more than 5 lb in 2 weeks requires a diet history, lab tests, and
consultation with a physician.
3. Management
A. Loss of weight or failure to gain appropriately: try to determine the reason and
treat the patient accordingly.
1. Nausea or vomiting
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2. Heartburn
3. Fear of gaining weight
a. Counsel and reassure patient. Explain distribution of weight gained during
pregnancy.
b. Emphasize the importance of weight gain. Explore the body image and
acceptability of a large body to the patient, partner, or others
c. Offer the patient a referral to a dietitian or mental health counselor
B. Excessive weight gain: try to determine the reason and treat the patient
accordingly.
- Multiple gestations: Suspect this if there is a sudden or continuous large gain, out
of proportion to the woman body build and rating habits.
- Diabetes
- Edema: Check for other signs of pre-eclampsia.
C. Uncontrolled intake of food
a. Counsel patient on diet, explaining that the baby needs nutritious food in
moderate amounts, not junk foods and fats.
b. Stress the importance of regular exercise in controlling weight gain.
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7). Minor Discomforts and Nursing Intervention
During pregnancy a number of minor complaints may arise these are annoying but
don't disable the pregnant woman. The majority of these symptoms are the result of large
amount of placental hormones particularly estrogen and progesterone.
Assessment of common minor discomfort during pregnancy
1) FIRST TRIMESTER:
A) Nausea and vomiting

Generally occur early in pregnancy and subside by the fourth month of pregnancy.
• Causes:
− Increased estrogen level in the blood.
− Decreased glucose levels.
− Fatigue .
− Emotional factors.
• Nursing Management
− Encourage the woman to eat small frequent meals.
− Encourage her to eat a piece of dry toast or some crackers before getting out
of bed.
− Instruct her to avoid foods or situations that worsen the nausea.
− Suggest that carbohydrate containing foods are usually tolerated best.
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− Liquids intake are best consumed between meals.

− Suggest intake of complex carbohydrate with the onset of nausea.
− Vitamin B 6 has been tolerated to relief symptoms.
B) Nasal stuffiness and epistaxis:
• Causes:
− Edema of nasal mucosa from elevated estrogen level.
− Encourage the use of acool moist humidifier .
− Place moist towel on the sinuses and massage the sinuses .
− Increased fluid intake .
C)Urinary frequency:
• Causes:
− Pressure of growing uterus on bladder .
− It is seen again in the later part of the third trimester .
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− Around the 12th weak the uterus rises into the abdominal level, causing
symptoms to disappear.
− Suggest to the woman to void as necessary at least every 2 hours.
− Instruct her to avoid diuretics as caffeine.
− Teach her how to perform kegel exercises.
− Suggest to her to decrease fluid intake at night to minimize noctiuria.
D) Breast tenderness:
Occur early in the pregnancy and continues throughout the pregnancy .
• Causes:
− Increased estrogen level and progesterone level .
− Encourage the use of a well fitting bra with wide shoulder straps for support .
− Advise the woman to wash her breast and nipple area with water only .
− Decrease the amount with caffeine .
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E) Ptyalism :
− Mean Excessive salivation.
• Causes:
− Increased estrogen level.
− Advise woman to use mouth wash and about oral hygiene.
− Chew gum or suck on hard candy.
F) Leukorrhea:
− Mean increased vaginal discharge that is white in color.
• Causes:
− Increase activity of vaginal epithelial cells as they prepare for distention during
the birth process.
− Hyperplasia of vaginal mucosa .
− Increased mucus production by the endocervical glands.
Nursing Management
− Encourage the woman to wear cotton underwear.
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− Encourage the woman to bath daily and avoid using soap on the vulva.
− Reinforce the need to wipe front to back.
− Urge her wear loose, absorbent cotton under wear and to avoid tight pants and
pantyhose .
− Suggest the use of panty liner or perineal pads and frequent changing it.
− Instruct her to notify her health care provider immediately if the discharge in
color or odor.
G) Headache:
• Causes:
− Emotional tension.
− Congestion of sinuses from hormonal stimulation.
− Advise the woman to avoid eye strain and visit ophthalmic physican .
2) SECOND AND THIRD TRIMESTERS:-
A - Heart burn:
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• Causes:
− Regurgitation of acidic gastric content in to the esophagus.
− Relaxation of the cardiac sphincter.
− Decreased GI motility.
− Increased production of progesterone.
− Encourage the woman to eat frequent meals throughout the day .
− Instruct her to avoid over eating as well as spicy, fatty and fried foods.
− Suggest that she remain up right for at least 1 hours after eating.
B) Ankle edema:
• Causes:
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− Poor venous return from the lower extremities aggravated by prolonged

sitting or standing.
− Fluid retention .
− Encourage the woman to rest with her feet elevated.
− Instruct her to avoid standing for long period.
− Advise the women to avoid restrictive garments on the lower half of her of her
body.
− Advise the women to dorsiflex her feet when standing or sitting for long
periods.
− Suggest that she get up and move about every 1 to 2 hours when sitting for
long periods.
C) Varicose veins:
• Causes:
− Poor circulation and weak vessel walls.
• Nursing Management :
− Advise the woman to walk regularly.
− Advise the woman to avoid long periods of standing.
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− Advise the woman to rest with feet elevated.

− Advise the woman not to cross the legs when sitting.
D) Hemorrhoids:
• Causes:
− Pressure on the pelvic veins by the enlarging uterus , which interferes with
venous circulation .
− Increased pressure secondary to constipation.
− Advise the woman to avoid constipation and straining with a bowel movement.
− Encourage the use of a witch hazel compress.
− Caution her against prolonged standing
E) Constipation:
• Causes:
− Decreased intestinal peristalsis.
− Displacement of the intestines from a gravid uterus.
− Insufficient fluid intake.
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− Use of iron supplements.
• Nursing Management:
− Evacuation of the bowel at the same time each day, and do not neglect call to
stool (bowel training).
− Diet rich in fiber in the form of vegetables, fruits, and reduce sugar
− Minimize coffee and tea as they are diuretics and cause dehydration.
− Increase physical activity and avoid sedentary life.
− Mild laxative may be needed.
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F) Backache:
• Causes:
− Altered posture due to increased curvature of the lumbosacral vertebrae from
the enlarging uterus.
• Nursing Management :
− Advise the woman to apply local heat.
− Instruct the woman to avoid long period of standing.
− Advise the woman to stoop for pick up objects.
− Advise the woman to use proper body mechanics and to maintain good
posture.
G) Leg cramps:
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• Causes:
− Spasms of the gastrocnemius muscle.
− May be from insufficient calcium.
− Poor circulation.
− Fatigue.
− Advise the woman to avoid pointing her toes.
− Encourage the woman to wear warm clothes
− Teach the woman what to do during leg cramp, pull the toes up toward the leg
while pressing down on the knee.
− If need, assist the woman with measuring calcium and phosphorus rate.
H) Faintness:
• Causes:
− Change in blood volume .
− Postural hypotension .
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− Advise the woman to move slowly and avoid crowds.
− Advise the woman to remain in cool environment.
I) Shortness of breath:
• Causes:
− Pressure exerted on the diaphragm by the enlarging uterus.
− Encourage the woman to use proper posture.
− Encourage the woman to use pillows behind head and shoulders at night, and
use semi fowlers position.
G) Pain in round ligament:
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• Causes:
− Stretching and hypertrophy of the ligaments.
− Advise the woman to avoid twisting motion.
− Advise the woman to rise to a standing position slowly and use her hands to
support the abdomen.
− Encourage the woman to bend forward to relieve discomfort.
8). Follow up activities

Activity II: Select the best answer
1- A gravida woman at 32 weeks of gestation reports that she has lower back pain.
Which of the following assessment should include by the nurse?
a) Observation of posture and body mechanics
b) Palpation of the lumbar spine
c) Exercise pattern and duration
d) Ability to sleep for at least 6 hours uninterrupted.
2- To relieve a leg cramp, which of the following instruction should be given to the
patient?
a) Massage the affected muscle.
b) Stretch and point the toe.
c) Dorsiflex the foot.
d) Apply a warm pack.
3-What are the most effective methods for preventing venous stasis?
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a. Wear elastic stockings in the afternoons.
b. Sleep with the foot of the bed elevated.
c. Rest often with the feet elevated.
d. Sit with the legs crossed.
4- Return visits for uncomplicated pregnancy routinely include:

a- fetal heart beat
b- Leopold's maneuvers
c- Measurement of fundal height
d- Examination for edema
e- Urine analysis for glucose and protein
Select the number corresponding the correct letters.
1- a,b,c and d
2- c,d,e and e
3- a,b,c and e
4- All of the above
5- Danger signs that should reported immediately to physician during pregnancy:
a- Bleeding from vagina
b-Loss of amniotic fluid
c- Persistent blurred vision or light flashes
d- Abdominal pain and cramping
e- Pain and swelling of the calf
1- a,b,c and d
2- c,d,e and e
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3- a,b,c and e
4- All of the above
6- What is the nursing instructions for hemorrhoids?
a- Adequate dietary roughage to avoid constipation
b- Adequate fluid to prevent dehydration
c- Avoid long period for standing or sitting
d- Adequate exercise for muscle tone
1- a,b,c and d
2- c,d,e and f
3- a,b,c and e
4- All of the above
7- In which trimester the fetus most likely to be damaged by pregnant woman's
ingestion of nonprescribed drugs?
a- First trimester
b- Second trimester
c- Third trimester
d- Entire pregnancy
8- What is the nursing instructions for morning sickness ?
a- Eat nothing until the nausea subsides
b- Take an antacid before bedtime
c- Request her physician to prescribe an anti-emetic
d- Eat dry toast before arising
Activity II Short answer questions?
1- Enumerate 4 nursing management of varicose veins?
2- List nursing management of heart burn?
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9). References
1. Adele Pillitteri, Maternal and child health nursing, 6th edition lippincott Williams
and wilkins publication, Philadelphia, 2017, 233-280.
2. Annama Jacob, A Comprehensive Textbook of Midwifery and Gynocological
Nursing, 5th Edition, Jaypee Brothers Medical Publishers, 2018, 220-250.
3. Catherin's, A Study to Assess the Effectiveness of selected nursing measures on
after birth pain among postnatal mothers in selected hospital, Punjap. M.Sc Nursing,
thesis of Omayal Achi College of Nursing, submitted to Dr. M.G.R. Medical
University, Chennai, 2019.
4. Brown SJ, Davey MA, Bruinsma FJ., Women's views and experiences of
postnatal hospital care in the Victorian Survey of Recent Mothers, Midwifery, 21 (2).
109-126. 2020.
5. Myles, Textbook for midwives, 14th edition Churchill livingstone, publication,
London, 2019, 219-220.
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Module (3) Normal Labor

Credit Weighting of Module: 6hours
Teaching Method(s): 6hr(s) Lectures; virtual classes, 18hr(s) Clinical (includes 6hr(s)
for small group clinical skills teaching & 12hrs for labs clinical skills).

This module is designed to provide nursing care during normal labor
Module Objective: To:-

4- Explain the female pelvic structure bone
5- Identify types of the female pelvic.
6- Describe the main features of the fetal skull, and their importance for labor and
delivery. Discuss the physiology of the four stages of normal labor.
7- Describe the nursing management of the four stages of normal labor.
8- Discuss the physiological changes of mothers during each stage of normal
labor.
9- Recognize the normal characteristics of the newborn baby & identify
abnormalities
10- Appreciate the importance of nursing care during labor & delivery to the
fetus
Learning Outcomes
On successful completion of this module, the students should be able to:
1. Apply the nursing process to the care of women in each stage of normal labor.
2. Explain the normal characteristics of the newborn baby & identify abnormalities
Module Contents:
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1). Female Pelvis, Fetal Skull

2). Student Activities
3). Normal labor
4). Electronic Fetal Monitoring
5). Immediate care of the newborn
6). General follow up activities
7). References
2).Female Pelvis, Fetal Skull

Study Session 1A Female Pelvis
Introduction
▪ In this study session you will learn about the bony structures with the most
importance for the pregnant woman and the fetus she will give birth. The bones
of the skeleton have the main function of supporting our body weight and acting
as attachment points for our muscles. The focus in this study session will be on
the female pelvis, which supports the major load of the pregnant uterus, and the
fetal skull, which has to pass through the woman’s pelvis when she gives birth.
▪ There are certain key landmarks in the anatomy of the female pelvis and the fetal
skull that we will show you in this study session. Knowing these landmarks will
enable you to estimate the progress of labor, by identifying changes in their
relative positions as the fetus passes down the birth canal. You will learn how to
do this in the next Module in this curriculum, which is on Labor and Delivery
Care.
Learning Outcomes for Study Session
When you have studied this session, you should be able to:
1. Describe the female pelvis and identify the important features for obstetric care.
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2. Describe the main features of the fetal skull, and their importance for labor and
delivery.
The female bony pelvis
The pelvis is a hard ring of bone (see Figure 1), which supports and protects the
pelvic organs and the contents of the abdominal cavity. The muscles of the legs, back
and abdomen are attached to the pelvis, and their strength and power keep the body
upright and enable it to bend and twist at the waist, and to walk and run.
Figure 1 the bones of the female pelvis.

The woman’s pelvis is adapted for childbearing, and is a wider and flatter shape
than the male pelvis.
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▪ I-The bony pelvis is composed of :

1- Pairs of bones (Hip bones) 2-Sacrum 3- Coccyx.
Two hipbones which is composed of:
A-Ilium B-Ischium C-Pubis
A-Ilium
The major portion of the pelvis is composed of two bones, each called the ilium — one
on either side of the backbone (or spinal column) and curving towards the front of the
body. When you place your hand on either hip, your hand rests on the iliac crest, which
is the upper border of the ilium on that side. At the front of the iliac crest, you can feel
the bony protuberance called the anterior superior iliac spine (a ‘protuberance’ is
something that sticks out, like a little hill or knob).
B-Ischium
The ischium is the thick lower part of the pelvis, formed from two fused bones — one
on either side. When a woman is in labor, the descent of the fetal head as it moves down
the birth canal is estimated in relation to the ischial spines, which are inward
projections of the ischium on each side. The ischial spines are smaller and rounder in
shape in the woman’s pelvis than in that of the man.
C-Pubic bones and the symphysis pubis

The pubic bones on either side form the front part of the pelvis. The two pubic bones
meet in the middle at the pubic symphysis. (A symphysis is a very strong bony joint.)
The pubic symphysis is immediately below the hair-covered pubic mound that protects
the woman’s external genitalia.
2-Sacrum
The sacrum is a tapered, wedge-shaped bone at the back of the pelvis, consisting of
five fused vertebrae (the small bones that make up the spinal column or backbone). At
the bottom of the sacrum is a tail-like bony projection called the coccyx? The upper
border of the first vertebra in the sacrum sticks out, and points towards the front of the
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body; this protuberance is the sacral promontory — an important landmark for labor
and delivery.
3-Coccyx:
▪ The coccyx consists of four fused vertebrae forming a small triangular bone,
which articulates with the fifth sacral segment
The pelvic canal
The roughly circular space enclosed by the pubic bones at the front, and the ischium on
either side at the back, is called the pelvic canal — the bony passage through which
the fetus must pass. This canal has a curved shape because of the difference in size
between the anterior (front) and posterior (back) borders of the space created by the
pelvic bones. You can see it from the side view in (Figure 2 ).
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Figure 2 the pelvic canal seen from the side, with the body facing to the left.
▪ II-Pelvic Joints:
1-The symphysis pubis (one joint) is
midline cartilaginous joint uniting the ramus of the left and right pubic bones.
2-The sacro-iliac joints (two joints):
Which articulates with the fifth sacral segment.
3-The sacro coccygeal joint (one joint):
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Is formed when the base of the coccyx articulates with the tip of the sacrum.
It permits the coccyx to be deflected backwards during the birth of the fetal head.
 III-Pelvic ligaments:
▪ Function of the ligaments is to connect the pelvic joint together strongely.
▪ Types of ligament in the pelvic are:
A) Sacroiliac Ligament: which connect the ilium with the sacrum.
B) Sacro-coccygeal: which uniting the sacrum &coccyx.
C) Inter- pubic Ligament: between two pubic bone
D) Sacro-spinous Ligament: from sacrum to ischial spines
E) Sacro-tuberous Ligament: from sacrum to ischial tuberosity.
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Figure 2 the pelvic canal seen from the side, with the body facing to the left.
 The size and shape of the pelvis

The size and shape of the pelvis is important for labor and delivery. Well-built
healthy women, who had a good diet during their childhood growth period, usually have
a broad pelvis that is well adapted for childbirth. It has a round pelvic brim and short,
blunt ischial spines (a ‘gynecoid’ pelvis.) It gives the least difficulty during childbirth,
provided the fetus is a normal size and the birth canal has no abnormal tissue growth
causing an obstruction.
There is considerable variation in pelvis shapes, some of which create problems in labor
and delivery. A narrow pelvis can make it difficult for the fetus to pass through the
pelvic canal. A deficiency of important minerals like iodine in the diet during childhood
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may result in abnormal development of the pelvic bones. Stunting (being much shorter
than average for age) due to malnutrition and/or infectious diseases can also result in a
narrow pelvis.
 True pelvis:
Lies below the level of pelvic inlet. It is the bony canal through which the fetus
passes during birth. The true pelvis consists of:1-Inlet or brim 2-Cvity 3-Outlet
 The pelvic inlet:

The pelvic inlet is formed by the pelvic brim, which you saw in ( Figure 3). The pelvic
brim is rounded, except where the sacral promontory and the ischial spines project into
it. The dimensions in centimeters (cm) of the pelvic inlet are shown in Figure 3 in both
directions (top to bottom; and transverse or side to side). When you look at Figure 3,
imagine that you are a fetus in the head-down position, looking down on the pelvis from
above, at the space you must squeeze through! It is just 13 cm wide (on average) and
12 cm from top to bottom.
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Figure 3 Diameters of the pelvic inlet, viewed from above.
 Diameter of pelvic inlet:

• Antero -posterior diameters:
o Anatomice antero-posterior diameter (true conjúgate) = 11cm
• from the tip of the sacral promontory to the upper border of the
symphysis pubis.
o Obstetric conjugate = 10.5 cm
• from the tip of the sacral promontory to the most bulging point on
the back of symphysis pubis which is about 1 cm below its upper
border. It is the shortest antero-posterior diameter.
o Diagonal conjugate = 12.5 cm
• i.e. 1.5 cm longer than the true conjugate. From the tip of sacral
promontory to the lower border of symphysis pubis.
o External conjugate = 20 cm
• from the depression below the last lumbar spine to the upper anterior
margin of the symphysis pubis measured from outside by the
pelvimeter . It has not a true obstetric importance.
• Transverse diameters:
o Anatomical transverse diameter =13cm
• between the farthest two points on the iliopectineal lines.
• It lies 4 cm anterior to the promontory and 7 cm behind the
symphysis.
• It is the largest diameter in the pelvis.
o Obstetric transverse diameter:
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• It bisects the true conjugate and is slightly shorter than the

anatomical transverse diameter.
• Oblique diameters:
o Right oblique diameter =12 cm
• from the right sacroiliac joint to the left iliopectineal eminence.
o Left oblique diameter = 12 cm
• from the left sacroiliac joint to the right iliopectineal eminence.
o Sacro-cotyloid diameters = 9-9.5 cm
• from the promontory of the sacrum to the right and left iliopectineal
eminence, so the right diameter ends at the right eminence and vice
versa.
 The Pelvic Cavity:

The pelvic cavity is the curved bony canal between the pelvic inlet & the pelvic
outlet. The anterior wall is short & is formed by the symphysis pubis &pubic bone.
The posterior wall is formed by the sacrum &the coccyx. Laterally by the sides of
pelvis.
 The pelvic outlet:

The lower border of the pubic bones at the front, and the lower border of the
sacrum at the back form the pelvic outlet. The ischial spines point into this space on
both sides. Figure 4 shows the dimensions of the space that the fetus must pass through
as it emerges from the mother’s pelvis. As you look at Figure 4, imagine that you are
the birth attendant who is looking up the birth canal, waiting to see the fetal head
emerging.
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Figure 4 Diameters of the pelvic outlet, viewed from below.
It is difficult to see from Figures 3 and 4, but the fetus has to rotate in order to
get through the pelvic canal. This is because the pelvic inlet is 13 cm wide, whereas the
pelvic outlet is only 11 cm wide. In order to fit through the pelvic outlet at its widest
dimension (12.5 cm from top to bottom), the fetus must rotate so it ‘presents’ its head
to the widest dimension of the pelvic cavity at every point as it passes through. The
largest part of the fetus is the skull, so the fetus’s head rotates first, and the shoulders
and the rest of the body follow.
 Diameter of pelvic outlet:
• Antero - posterior diameters:
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o Anatomical antero-posterior diameter =11cm

• from the tip of the coccyx to the lower border of symphysis pubis.
o Obstetric antero-posterior diameter = 13 cm
• From the tip of the sacrum to the lower border of symphysis pubis
as the coccyx moves backwards during the second stage of labor.
• Transverse diameters:
o Bituberous diameter = 11 cm
• Between the inner aspects of the ischial tuberosities.
 Types of pelvis
 Pelvis has been classified into four types: (Figure 5)
1) Gynecoid: Rounded brim
2) Android: Heart shape
3) Anthropoid: Oval brim
4) Platy-pelloid: Kidney shaped brim.
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Figure (5) Types of pelvis
 Differences between the four type of pelvis:
Features Gynecoid Android Anthropoid Platy-

pelloid
Brim rounded Heart shape Long oval Kidney

shape
Fore pelvis Wide &Shallow Narrow & narrowed wide

longer
Side walls Straight Convergent divergent divergent
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Ischial Blunt Prominent blunt blunt

spines
Sciatic Rounded narrow wide wide

notch &wider
Sub- pubic 90 <90 90 > 90 >
angle
incidence 50% 20% 25% 5%
The fetus
The Fetal Attitude:
It is the relation of the fetal parts to each other. In most cases the fetus is in an attitude
of general or complete flexion, that is, all joints are flexed.
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Lie:
• It is the relation between the long axis of the fetus and that of the mother. If they
are parallel, the lie is longitudinal but if they cross each other, the lie is oblique
or transverse.
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Presentation:
• It is the first part of the fetus, which meets the pelvic brim, and it is the first part
felt by vaginal examination.
• The presentation may be cephalic (96%), breech (3.5%) or shoulder (0.5%).
Medical-dictionary.thefeedictionary.com
Denominator:
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• It is a bony landmark on the presenting part by which the position of the fetus is
known.
• In vertex presentation--------, the occiput is the denominator.
In face presentation → Mentum is the denominator.
In breech presentation→ Sacrum is the denominator
In Shoulder presentation → Scapula is the denominator
Position:
• It is the relation of the fetal back to the right or left side of the mother it is directed
anteriorly or posteriorly.
It is the relation of the denominator to the maternal pelvis.
In vertex presentation there are 8 positions:
1- Direct occipito-anterior (the occiput points \ towards the symphysis pubis).
2-right occipito-anterior (it points. towards the right ilio-pectineal eminence).
3-right occipito-transverse (it points towards the midpoint of the right iliopectineal
line).
4- right occipito-posterior (it points towards the right sacroiliac joint).
5-direct occipito-posterior (it points towards the sacral promontory).6-
6- left occipito-posterior.
7-left occipito-transverse.
8- left occipito-anterior.
• The commonest is the left occipito-transverse.
• Occipito-anterior positions are commoner than occipito-posterior positions,
because of better accommodation between the concavity of the front of the fetus,
and the convexity of the lumbar spine of the mother.
• Left occipito-anterior is commoner than right occipito-anterior, because in the
former the head descends in the right oblique diameter of the pelvis, while in the
latter the head descends in the left oblique diameter of the pelvis, which is
reduced by the presence of pelvic colon. Also the right oblique diameter is
anatomically slightly longer than the left one due to the more frequent use of the
right leg. For the same reason, ROP is commoner than LOP.
Note: Cephalic presentation is more common than breech because the head is heavier
than the breech and because the breech is larger, it occupies the wide fundus.
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Fetal Skull
INTRODUCTION
The fetal head is large in relation to the fetal body compared with the adult
Adaptation between the skull and the pelvis is necessary to allow the head to pass
through the pelvis during labor without complications.
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 Fetal Skull:
It is divided into vault, face and base.
Vault: is made of soft flat bones separated by sutures and fontanelles.
 Bones of the Vault:
Two frontal bones; 2 parietal bones, 2 temporal bones and 1 occipital bone.
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 Sutures:
Spaces between bones, and made of unossified membranes.
They are six in number:
-Frontal suture: between the two frontal bones.
-Sagittal suture: between the two parietal bones.
-Coronal suture: between the frontal and parietal bones.
-Lambdoidal suture: between the two parietal bones and occipital bone.
-Two temporal sutures: each between the parietal and temporal bone.
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 Fontanelles:
Areas where sutures meet. They are six in number.
Four fontanelles lie at the anterior & posterior end of the temporal sutures on each
side no obstetric importance.
Anterior Fontanelle or Bregma:
▪ It is large, lozenge shaped.
▪ Formed by the meeting of four bones, two frontal and two parietal bones.
▪ Has a soft membranous floor.
▪ Becomes obliterated 1.5 years after birth.
Posterior Fontanelle:
▪ Small, triangular shaped.
▪ Formed by the meeting of three bones, two parietal bones and the occipital
bone.
▪ Has a bony floor.
▪ It is obliterated at full term.
▪ Membranous in the preterm baby.
 NB: The anterior temporal fontanelles are at the junction of the temporal and
coronal sutures. The posterior temporal fontanelles are at the junction of the
temporal and lambdoidal sutures.
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Anterior &Posterior Fontanelles are important to diagnose:

1-Vertex presentation
2-Position of occiput
3-Degree of flexion of the head
Vertex:
It is the area of the vault of the skull between the anterior and posterior fontanelles
and the parietal eminences.
Anteriorly----- by anterior fontanelle & coronal suture.
Posteriorly---- by posterior fontanelle & lamboidal suture.
Brow:
It is an area bounded on one side by the anterior fontanelle and coronal sutures and on
the other side by the root of the nose and supra-orbital ridges of either side.
Face:
is the area from the junction of the chin and neck to the root of the nose.
Diameters of the Fetal Head

A) Transverse Diameters:
1 Biparietal (9.5 cm); between the two parietal eminences.
2 Subparietal-supraparietal (9 cm), from below one parietal eminence to above
the other. It is 0.5 cm less than the biparietal diameter.
3 Bitemporal (8 cm), between the anterior ends of temporal sutures.
4 Bimastoid (7.5 cm), between the tips of the mastoid processes.
B) Longitudinal Diameters or Engaging Diameters
The engaging diameter is the longitudinal diameter of the presenting part.
1-The suboccipito-bregmatic diameter (9.5 cm).
measured from the suboccipital point, i.e. the junction of the head and neck
posteriorly to the center of the anterior fontanelle. It is the diameter of engagement
in occipito-anterior position when the head is completely flexed.
2. The suboccipito-frontal diameter (10 cm).
Measured from the suboccipital point to the anterior end of anterior fontanelle.
It is the diameter of engagement in occipito-anterior position when the head is not
completely flexed.
3.The occipito-frontal diameter (11.5 cm).
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measured from the occipital protuberance to the root of the nose.

It is the diameter of engagement, in occipito-posterior position.
4.The mento-vertical diameter (13.75 cm).
measured from the tip of the chin to the vertical point, which is the point at the
middle of sagittal suture. It is the diameter of engagement in brow presentation.
5.The submento-bregmatic diameter (9.5 cm).
measured from the junction of chin and neck to the center of the anterior fontanelle.
It is the engaging diameter in face presentation when the head is completely
extended.
6.The submento-vertical diameter (11.5 cm).
measured from the junction of the chin and neck to the vertical point.
It is the diameter of engagement in face presentation
When the head is not completely extended. It is also the diameter
Which distends the vulva during delivery of face presentation?
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Caput Succedaneum
It is oedema of the fetal scalp due to prolonged compression of the fetal head against
the maternal tissues! Leading to interference with the venous return.
It occurs in obstructed labor after rupture of membranes.
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The caput is few millimeters in thickness, but it may be large and protrudes from the
vagina giving a wrong impression that the head is low, when actually it is not engaged.
The caput disappears within one or two days after delivery.
The presence of the caput indicates that:
(1) The fetus was alive during labor.
(2) Labor was prolonged and obstructed.
(3) the site of the caput gives idea about the position of the head during labour
because it is formed over the lowest part of the head.
Note: Caput means head and succedaneum means swelling.
Caput Succedaneum(medicine.en.academic.com)
Molding
It means that the flat bones of the fetal skull overlap each other.
one parietal bone overlaps the other and both parietals overlap the occipital bone.
In severe degrees, the parietal bones overlap the frontal bones. Slight molding is
physiological and beneficial because it diminishes the diameters of the head and
facilitates its passage through the birth canal. Severe or rapid molding is dangerous as
it may lead to intracranial hemorrhage.
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Medlineplus.gov
Summary In Study Session 1A&B, you have learned that:
1. The bony pelvis is composed of the ilium, ischium, pubic bones and sacrum.
2. The size and shape of the bony pelvis can affect the ease or difficulty of labor and
delivery; a broad pelvis gives less difficulty than a narrow one, which may obstruct the
descent of the fetus down the birth canal.
3. Certain landmarks in the anatomy of the pelvis are commonly used to estimate the
descent of the fetus during labor and delivery. The two most important landmarks are
the ischial spines and the sacral promontory, which can be felt with the fingers during
a vaginal examination.
4. The pelvic inlet is the space where the fetal head enters the pelvis; it is larger than
the pelvic outlet, where the fetal head emerges from the pelvis. In order to get through
the widest diameter of the inlet and the outlet, the fetus has to rotate as it passes through
the pelvic canal.
5. The skull is formed by several bones joined tightly together by joints called sutures.
In the fetus and newborn, spaces called fontanels exist between some of the skull bones
on the top of the fetal head. The position of the sutures and the fontanels can tell you
about the angle at which the fetal head is presenting during labor and delivery.
6. The vertex presentation (where the top of the fetal head is the presenting part) is the
most common and the safest presentation for a normal vaginal delivery. Other
presentations carry a much higher risk for the mother and fetus.
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2). Student activities

1- What do you notice when you compare the dimensions of the pelvic inlet (Figure
3) and the pelvic outlet (Figure 4)? Which is the narrowest?
- The narrowest diameter for the fetus to pass through is the pelvic outlet, which is only
11 cm wide in the average female pelvis.
2- What do you notice about the diameters given in Figure 6, relative to the
dimensions of the pelvic canal (Figures 3 and 4)?
- At its widest part, the fetal skull is (on average) 9.5 cm wide. This is 3.5 cm less than
the widest diameter of the pelvic inlet, and 1.5 cm less than the widest diameter of the
pelvic outlet.
3- Match each anatomical name with the correct description.
The top of the fetal skull between Fused vertebrae at the back of the
the two fontanels bony pelvis
Joint between the parietal bones in Paired bones forming the front of
the fetal skull the skull
Hip bone in the pelvis
Drag each answer (above) into the correct slot (below).
Ilium
Frontal bones
Sagittal suture
Sacrum
Vertex
Answer
Ilium Hip bone in the pelvis
Frontal bones Paired bones forming the front of
the skull
Sagittal suture Joint between the parietal bones in
the fetal skull
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Sacrum Fused vertebrae at the back of the

bony pelvis
Vertex The top of the fetal skull between
the two fontanels
4. Which of the following statements is false? In each case, say why it is
incorrect.
A The female bony pelvis is broader and flatter than the male pelvis.
B The pelvic inlet is narrower than the pelvic outlet.
C The iliac crest is an important landmark in measuring the progress of the fetus
down the birth canal.
D The sutures in the fetal skull are strong hard joints that hold the skull bones rigidly
in place.
E A newborn baby’s pulse can be seen beating in the anterior fontanel.
Answer
A is true. The female bony pelvis is broader and flatter than the male pelvis.
B is false. The pelvic inlet is wider (not narrower) than the pelvic outlet.
C is false. The iliac crest is the protuberance at the front of each hip bone; it is not
important in measuring the progress of the fetus down the birth canal.
D is false. The sutures in the fetal skull ‘give’ a little under the pressure in the birth
canal, allowing the skull bones to move to a small extent. This makes it easier for the
baby’s head to pass through the mother’s bony pelvis.
E is true. A newborn baby’s pulse can be seen beating in the anterior fontanel.
5. List four possible features of the maternal bony pelvis and/or the fetal skull that
may result in a difficult labor and delivery.
Answer
The possible features of the maternal bony pelvis and/or the fetal skull that may result
in a difficult labor and delivery include (you only had to suggest four):
- A narrow or deformed pelvis
- Abnormal growth of tissue in the pelvic cavity
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- A large fetal skull

- A brow, face, breech or shoulder presentation of the fetus
- A fetus that does not present the widest part of its skull to the widest part of the
pelvic inlet, and then rotate to do the same in the pelvic outlet.
6-Which among the following is referred to as the develop of the bonesof the fetal
head that allows the pelvis to accommodate the fetal head in labor.
a- Moulding c-Engagement
b- Capacitation d- Nodding
7-The bone of the vault that has no significance in obstetrics is.

a-Frontal bone c-Temporal bone
b-Occipital bone d- Parietal bone
8-The suture that is located between the parietal bones divides the skull into left
&right halves is
a-Frontal suture c-Sagittal suture
b- Coronal suture d- Lambdoidal
9-The region of the skull that extends from the anterior fontanelle & the coronal
suture to the orbital ridges.
a-Vertex c- Sinciput
b-Occiput d-Face
10-The fontanelle that is membranous which closes at 18 months & of much

clinical significance is.
a- Bregma/ Anterior fontanelle c- Lambdoidal/ Posterior fontanelle
b- Mastoid fontanelle d- Sphenoid fontanelle
11-The Antero posterior diameter of the skull that is favorable for vertex
presentation is.
a- Suboccipital-bregmatic c- Mento-vertical
b- Occipital-frontal d- Submental-vertical
12-The Parietal diameter that extends between the two parietal diameter
measures.
a-8cm c-8.5
b-9cm d-9.5
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13-The longest diameter of the fetal skull

a-Suboccipital-frontal c- Occipital-frontal
b-Mento-vertical d-Submento-vertical
3). Normal Labor

Aims and intended learning outcomes
1. Overall aims of the course:

Equip the student with necessary knowledge, attitude, skills, and ability to demonstrate
critical thinking and problem solving approach in providing nursing care to the woman
during labor.
2-Intended Learning Outcomes of Course (ILOs):
1- Explain physical and psychological preparation of pregnant women for delivery.

2- Identify stages of normal labor.
3- Identify the appropriate nursing management for each stage of labor.
4-Compare between true & false labor pain.
5- Differentiate between different stages of normal labor.
6- Formulate a plan of care to woman during different stages of normal labor & care
of her neonate.
7- Apply nursing process in each stage of normal labor.
8- Demonstrate abilities for immediate neonatal care.
9-Demonstrate instrumental tray of normal labor.
10- Apply nursing care for woman with episiotomy& during vaginal examination.
11-Demonstrate items of preparing mother bag for delivery
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Case Scenario:
Mrs. Heba is 22 years old and had previous vaginal delivery for twins. She is now
38 weeks gestation and presented to the labor ward an hour ago. She was found to
have uterine contractions, 3 in 10 min lasting 50 s each. At the time of arrival,
examination revealed a fundal height of 39 cm, cephalic presentation and 3/5
palpable abdominally. Vaginal examination revealed intact membranes with the
head 1 cm above the ischial spines, occipitoanterior position and the cervix
dilatation 5 cm. There is mild molding and moderate caput succedaneum. She was
commenced on continuous CTG monitoring which showed an initial baseline rate
135 b/m good variability, acceleration and no decelerations. Twenty minutes ago
spontaneous rupture of membranes occurred with clear liquor leaking after doctor
prescribed 2mg prostaglandin suppositories administered into the vagina at 6pm last
night and again at 6am in this morning.
Introduction:
The process of labor and birth involves more than the birth of a new born Numerous
physiologic and psychological events occur that ultimately result in the birth of a
newborn and the creation or expansion of the family. Therefore , labor and birth
require a woman to use all the psychological and physical coping methodsshe was
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available. Regardless of the amount of childbirth preparation or the number of times

she has been through the experience before, family focused nursing care is needed
to support the family as they mark the beginning of a new
Learning Outcomes:
At the end of this this session, the student should be able to:
1-Discuss the physiology of the four stages of normal labor.
2-Describe the nursing management of the four stages of normal labor.
3-Discuss the physiological changes of mothers during each stage of normal labor.
4-Apply the nursing process to the care of women in each stage of normal labor.
5-Recognizethe normal characteristics of the newborn baby & identify abnormalities
6-Appreciate the importance of nursing care during labor & delivery to the fetus &the
mother.
Definition of terms:
Labor is the process by which a viable fetus and placenta are expelled from the uterus
at the end of 28 weeks or more.
Delivery refers to the actual birth of the newborn.
- Preterm or premature labor: It is labor occurring before 38 weeks of pregnancy (37
completed weeks).
- Mature or term infant: It is an infant born between 38 and before 42 weeks of
pregnancy.
- Post term pregnancy (post maturity ): prolongation of pregnancy two weeks or
more beyond the expected date of delivery, i.e., the duration of pregnancy is 42
weeks or more(294 days or more).
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 Characteristics of normal labor

 The fetus is born at full term (>completed 37 weeks)
 The fetus is viable and single
 The fetus presentation is vertex
 The process of labor is completed spontaneously
 through the natural passage ( birth canal)
 The time of labor does not exceed 24 hours
 Without any complication to the mother or to the fetus
 Factors affecting the progress of labor:
There are five essential factors that affect the process of labor :
Fetal factors:
Passengers: Fetus (Size of the fetal head, Attitude, position, presentation,
Engagement, Station) Placenta, membranes, umbilical cord, blood and amniotic fluid
Maternal Factors:.
 Passages: Pelvis, pelvic floor, uterus, cervix , vagina and vulva
 Powers :
• Primary power: contraction and retraction of the uterine muscles
involuntary
• Characteristics of uterine contractions:
• Frequency or interval: The period between the start of one contraction and
the start of the next one.
• Duration: The period between the start of one contraction and its end.
• Intensity: The power or strength of the contraction.
• Phases of contraction: Each contraction has three phases:
A-Increment: A period during which the contraction begins slowly.
B-Acme: A period during which the contraction reaches a peak.
C-Decrement: A period during which the contraction diminishes.
- Secondary power: Refers to the power of the-abdominal muscles and
diaphragm, in the form of bearing down effort, which is partly voluntary and
partly involuntary, or reflex.
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 Position: Maternal position affects her anatomic and physiologic

adaptations to labor. A woman in labor should be encouraged to find
positions that are most comfortable to her.
 Psychological state of the woman and her personality: knowledgeable
and relaxed woman, who is actively participating in the birth process,
usually experiences shorter, less intense labor. The process of labor also
depends on woman's pain threshold.
 Theories of Onset of Labor

1 – Prostaglandins :
* Can induce uterine contractions.
* They are formed in the decidua and membranes.
* Their level increases near term.
2 – Progesterone withdrawal:
* Progesterone supports pregnancy, it decreases the frequency of uterine

contractions . .
* A drop in progesterone level-with subsequent onset of labor could be proved only
in some animals, not in humans.
3 – Estrogen/ Progesterone:
- Estrogen helps the initiation of uterine contractions.

- Estrogen level increases near term.
4 – Estrogen-Oxytocin:
* Estrogen increases the myometrial receptors to Oxytocin “indirect effect’’.
* Oxytocin causes uterine contractions.
5 – Fetal suprarenal:
- The increase production of estrogen by the placenta near term is due to an
increase in the level its precursor: DHEAS. (dehydro- epiandrosterone sulfate)
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which is produced in increased amounts by the fetal suprarenal near term with
fetal maturity.
- Anencephaly is a congenital anomaly in which the fetal vault of the skull is
absent, the brain and pituitary are atrophied. (Incompatible with life).
- In These cases, the fetal suprarenal are not stimulated by ACTH and onset of
labor may therefore, be delayed.
6 – Uterine distension:
Near term, fetal growth continues and uterine growth becomes slower; the result is
increased distension of uterine muscles initiating uterine contractions. Preterm
labour may occur with early distension, e.g.: twins and polyhydramnios.
7 – Placental ischaemia:
- Resulting in lower production of oxytocin’s- an enzyme thought to be

responsible for oxytocin degradation-with subsequent rise in oxytocin level.
8 – Stretch of the lower-uterine segment:
By the presenting part near term may contribute to the onset of labor.
 Premonitory Symptoms and Signs of Labor:

There are symptoms and signs, which may occur in the last week or days of pregnancy
before the actual onset of labor and include:
1-Shelving:
The fundus of the uterus descends slightly &falls forwards; it brings the fetus in the
direction of the axis of the pelvis.
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2- Lightening “after engagement”:

o It is the sinking of the uterus that is observed by descent of the
abdomen. This alteration is brought by engagement, which means
setting of the fetal head into the true pelvis.
o In prime gravidas, lightening usually occurs 2-3 weeks before labor.
o In multiparas, it is more likely to occur after labor begins and even
after the start of the second stage.
o Relief of upper abdominal pressure symptoms (dyspnea Dyspepsia,
palpitation) due
to descent of the uterine fundus &due to shelving.
o Signs of greater lower pressure follow this relief such as shooting
pains in the leg due to pressure on the sciatic nerve and an increase of
the vaginal discharge.
3-Frequency of micturition:
It occurs as a result of engagement. The pressure of the presenting part on the urinary
bladder limits its capacity.
4-Effacement of the cervix:
Is the shortening or slight taking up of the cervical canal from structure of
approximately 2 cm in length to 1 cm
 Relationship of Maternal Pelvis and Presenting Part:

 Engagement of the presenting part occurs when the largest diameter of the
presenting part reaches or passes through the pelvic inlet. Engagement can
be determined by vaginal examination. In Primigravida engagement
usually occurs 2 weeks before term. However, multiparas may experience
engagement several weeks before the onset of labor during the process of
labor. The presenting part is said to be floating or ballottable when it is
movable above the inlet.
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Station:
 Station refers to the relationship of the presenting part to an imaginary line
drawn the ischial spines of the maternal pelvis. The ischial spines as a
landmark have been designated as zero station. If the presenting part is
higher than the ischial spines, a negative number is assigned, noting
centimeters above zero station.
Station –5 is at the inlet, and station +4 is at the outlet. If the presenting part
can be seen at the woman perineum, birth will occur momentarily. During labor,
the presenting part should move progressively from the negative stations to the
midpelvis at zero station to the positive stations.
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The fetus is at -2 station signifying that the leading bony edge of the presenting part is 2
centimeters above the ischial spines. The head is engaged at 0 station.
 Diagnosis of Onset of Labor

*Symptoms:
1-True Labor Pains.
2-Show.
*Signs:1-Dilatation of the internal cervical os. 2-formation of the page of forewaters.
Difference between true and false labor:

False uterine contraction are characterized by:
1-The uterus contract and relaxes.
2-Contractions occur at irregular intervals, duration and intensity.
3-The pain is confined chiefly to the lower part of the abdomen and groin.
4-There is no bloody show.
5-No cervical dilatation.
6- Change of position relieves the discomfort.
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Signs of True Labor pains:

• True uterine contractions are characterized as follows:
o The uterus contracts and retracts.
o Contractions occur at regular intervals or frequency
o Interval between contractions gradually decreases.
o The duration of contractions exceeds 90 seconds.
o Intensity of contractions gradually increases.
o Painful causing colicky pain in the lower part of the back and extend to
the abdomen.
o Show is present.
o Cervical dilatation is present.
o Walking and enema intensify the discomfort.
• Dilatation of the internal cervical Os:
A closed internal os means labor has not started; however, the dilation of the
internal cervical Os from a small opening until it reaches 10 cm, to permit the
passage of the fetus. Dilatation is completed when the cervix cannot be felt
• Show:
The cervical plug that closed the cervical canal during pregnancy to prevent
infection descends during labor in the form of mucus stained with blood. The blood
flows due to separation of the membranes from the lower uterine segment or
rupture of minute capillaries during separation of this plug from the cervical canal.
• Formation of the bag of water:
When the cervix dilates, the lower part of the membranes detaches and bulges
through the dilating cervix. The trickle of amniotic fluid descends in the bulged part
of membranes, and is called fore water The remainder amniotic fluid is called hind
.water
 Stages of Labor
The process of labor is divided into four distinct stages:
• First stage (stage of cervical dilatation): begins with the onset of true labour
pain and ends with fully dilatation of the cervix.
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• Second stage (expulsive stage): begins with complete dilatation of the cervix
and ends with delivery of the fetus.
• Third stage (placental stage): begins with delivery of the fetus and ends with
delivery of the placenta.
• Fourth stage: is the first 2 hours following delivery.
Duration of Labor First Stage Second Stage Third Stage

Primigravida 12 – 16 1-2 10-20
hours hours minutes
Multipara 6-8 hours 10-30 10-20
minutes minutes
 First Stage of Labor:

Definition
begins with the onset of true labor pains and ends with fully dilatation of the cervix.
It takes about 12 hours in the primigravida and 6 hours in the multigravida.
 Factors causing dilatation :

• Uterine contractions and retractions.
• Dilating effect of the bag of forewaters (before rupture of membranes).
• Pressure of presenting part (vertex) on cervix and lower uterine segment
causes reflex augmentation of contractions after rupture of membranes.
• Changes in cervix: During the last days of pregnancy, make it readily dilatable
eg: increased vascularity, edema, changes in ground substances and collagen
fibers.
.
Phases of cervical dilatation:
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The first stage of labor can be divided into two phases:
1- Latent phase: ( initial slow phase)

▪ The cervical dilatation from 0-3 cm.
▪ Contraction duration 20-40seconds.
▪ Contraction intensity mild by palpation.
The uterine contractions are somewhat uncomfortable, but generate force to
cause slow dilatation and some effacement of the cervix.A prolonged latent phase
is greater than 20 hours in the primigravida &14 hours in multipara.
2- Active Phase: (Rapid Phase)
▪ The cervix dilates from 4-7cm.
▪ Characterized by progressive cervical dilation.
▪ Contraction duration 40-60 seconds.
▪ Contraction intensity moderate by palpation.
▪ A prolonged active phase is seen in the primigravida who dilates at less than 1.2
cm/hr. & in the multigravida at less than 1.5 cm/hr.
3-Transitional Phase:
▪ The cervix dilates from 8-10 cm.
▪ Contraction duration 60-90 seconds occurring every 2 -3 minute.
▪ Contraction intensity strong by palpation.
Note:
Active Latent phases of Labor: Normally the cervix dilates slowly to reach 3-4 cm
(latent phase) and then rapidly to reach 9 cm (active phase) and then slowly to full
dilatation (sigmoid curve). A latent phase is considered prolonged if it lasts more than
20 hours in the primigravida and more than 14 hours in the multigravida. During the
active phase, the primigravida usually dilates 1 cm per hour and a multiparous patient
dilates 1.5 cm per hour
Nursing Management of First Stage of Labor

Admission of the Woman
•The nurse should welcome and greet the woman in a kind way. This wi1l be
important in the future relationship. It may be her first admission to hospital, and she
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may be apprehensive about it, particularly if this is her first infant.

•The nurse should ask the woman about her Maternal Health Card, show her the
labor room, and help her undress and get into bed.
•Admission should be carried out as quickly as possible.
Assessment
1-Taking the history of labor:
• Ask the woman why she has come to the hospital and review the history
from her Maternal Health Card.
Determine whether the woman is in labor or not through the presence of the
following signs:
• Uterine contractions: Ask the woman when true contractions began, how
often they are coming and how long they last.
• Show: Ask the woman if she had a blood stained mucous discharge and
examine her underclothes.
• Membranes: Ask the woman if she had a gush of fluid ? If she is not sure,
use litmus papers and smell it to exclude urine. If membranes are ruptured, record
the time of rupture.
• Sleep, rest and food: Ask the woman if she has had enough rest and sleep,
and if she has had food within 6 hours? If yes, it should be recorded and taken
into consideration.
• Ask the woman ·about her previous labor history and her present
pregnancy.
• Bladder and bowel: Ask the woman if she has passed urine or stool?
Examination of woman in labor: Explain all the procedures to the woman and inform
her of the results.
2-General examination:
• The woman's general manner will indicate how she is coping with labor.
• Observe the woman's general condition such as build and stature, limb,
deformity and appearance. Pallor indicates infection and dehydration.
• Temperature, pulse, respiration and blood pressure should be taken
between contractions and recorded. If temperature is high, isolate the woman.
• .Inspect any edema
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• Test urine for protein and sugar after trimming of hair, and before enema.
3-Local examination:
 Examination of the abdomen:
 Inspect the contour of the abdomen.
 Palpate the abdomen gently, and with warm hands, for the height of the
fundus, lie, presentation, position, attitude and station, and record them.
 Observe and record the frequency, duration, and intensity of contractions.
 Auscultate and record the fetal heart sound for one minute using Pinard's
stethoscope, or Sonicaid. A cardiograph machine gives information about fetal
and maternal conditions. The normal range of the fetal heart rate is 120- 160
beats/minute.
 Examinationof the vulva:
 Inspect for gaping of introitus.
 Observe color and odor of liquor amnio, and presence of meconium or
blood. Offensive odor indicates infection.
 Check for edema of the vulva. If present, it indicates pre-eclampsia.
 Examination of the vagina:
Is made by doctor to:
 Make a positive diagnosis of labor.
 Assess the progress of labor.
 Determine the extent of effacement and the degree of dilatation of the
cervix.
 Assess the condition of the membranes.
 Determine position, presentation and degree of descent of head in pelvis
in relation to ischial spine (station).
 Observe the presence of umbilical cord beside the head.
 Check molding, presence of caput succedaneum, and abnormalities.
 Evaluate pelvic capacity and condition of the vagina.
 Examination of the rectum:
A rectal examination is safer than a vaginal examination. It reduces the risk of
infection and gives the same data as a vaginal examination.
 The Partograph:
The partograph is a single page graphic chart designed to record all the important
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information about the woman and fetus during labor.

. OR: It is a graphic representation of the events of labor plotted against time, in hours.
It consists of three components:
 The fetal condition
 The progress of labor
 The maternal condition
Objectives:
1. Record the observations accurately on the partograph
2.Understand the difference between the latent and the active phases of labor
• Interpret a recorded partograph
• Monitor the progress of labor
• Explain to mothers and other members of the
community the significance of the Partograph
Observations and recordings Charted in the Partograph:

 The progress of labor:
- Cervical dilation
- Descent of the fetal head
- Abdominal palpation of the fifths of head felt
above the pelvic brim
 Uterine contractions
- Frequency per 10 minutes
- Duration by differential shading
 The fetal condition
- Fetal heart rate
- Membranes and liquor
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- Molding of the fetal skull

 The maternal condition
- Pulse, blood pressure and temperature
- Urine (volume, protein, acetone)
- Drugs and IV fluids
- Oxytocin regime.
 Nursing Diagnosis
• Alteration in comfort: acute pain related to uterine contraction.
• Anxiety related to impending labor and delivery.
• Alteration in tissue perfusion. Placental perfusion to the
• fetus decreases due to supine position.
• Fluid volume deficit related to decreased fluid intake.
• Sleep pattern disturbances related to labor process.
• Knowledge deficit related to process of labor, appropriate relaxation
techniques, and hospital procedures.
• Alteration in oral mucus membrane related to mouth breathing.
• Alteration in nutrition to less than body requirements related to decreased
oral intake.
• Self-care deficit related to immobility during labor.
• Ineffective individual coping related to lack of support system.
Planning and Implementation

Nutrition and Hydration
• During labor, there is an excessive loss of fluids, and increased tendency
to exhaustion and dehydration due to strong muscular exercise.
• The woman's need for energy is met through nourishing oral fluids at
frequent intervals to maintain the fluid balance.
• Sometimes IV fluids are given to provide energy and prevent dehydration
in case of vomiting, ketosis and possible use of anesthesia.
• During early labor, the woman should receive about 75 ml of fluid per
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hour in the form of juices, soups, or tea with sugar and digestive biscuits.
• Maintain an intake and output chart.
• Diet should be nutritious, easily digestible, and small in amount.
• Solid food is usually avoided during active labor since gastric emptying is
prolonged, and in anticipation of anesthesia, may cause aspiration of vomitus.
• If solid food is permitted, it should be rich in carbohydrates such as jam,
honey and canned fluids. Fats and proteins are not allowed because they are not
easily digested
Rest and Sleep
• Anxiety and painful uterine contractions produce sleeplessness. So, ‫أ أا‬5
important to be with the woman, reassure her, and encourage her to express
her discomfort, fear and anxiety, or help her to sleep by use of hypnotics.
• The nurse helps the woman fo sleep by.
o Have her evacuate the bladder.
o Serving her a warm, nourishing drink.
o Maintaining a quiet room with dim lighting and a comfortable bed.
• Rest is important in the first stage of labor to reserve energy, prevent
exhaustion and anxiety, and maintain mental equilibrium.
• Ambulation may decrease the need for analgesics, shorten labor, and
decrease incidence of fetal heart rate abnormalities.
• The woman is allowed to ambulate if there are no contraindications like
bleeding, premature rupture of membranes with high head, pregnancy-
induced hypertension, cardiac disease, or any other medical problems.
Comfort and Assistance

• Follow the aseptic techniques to prevent infection.
• Provide dry and clean clothes and bed linen for the woman.
• Reassure the woman that vomiting is normal (if it happens).
• Provide mouthwash and sips of water if her mouth is dry.
• Massage the back if she complains of backache.
• Relieve pain by encouraging deep breathing during contractions and use
of analgesics.
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• Make dorsiflexion if cramps of her legs occur.

• Change the pad frequently if there is excessive vaginal discharge.
Preparation of the Woman in Labor
• Trimming of hair: trimming of hair is permitted to clean and disinfect the
vulva to prevent infection. Shaving is not advisable for fear of lacerations and
infection.
• Enema: Prepare and administer enema as ordered to stimulate uterine
contractions. Enema should be given early in the first stage of labor and not
repeated for S hours. (Appendix L)
• Bath: A bath or shower is given following an enema and trimming of hair.
If the time is limited, wash at least from the umbilicus to the knees. Instruct
the woman to wear a clean nightdress or gown, and avoid using cosmetics.
• Hair and nails: Inspect and comb hair, and cut and clean nails.
• Perinea} swabbing: Swab the perineum on admission, then every 6 hours,
before and after vaginal examination, before delivery and before
catheterization. .Cover the vulva with sterile pad (Appendix M)
Posture of Woman in Labor
• The nurse should allow the woman to assume any comfortable position,
except the dorsal recumbent which may result in supine hypotension and lead
to fetal distress.
• The nurse should encourage the woman to walk in the room if she is not
in active labor and to lie down towards the end of the first stage of labor.
•
Care of Bladder
• The woman should be encouraged to pass urine every 2-3 hours during
labor.
• The urine should be tested for the presence of glucose, protein and ketone
bodies.
• A full bladder causes poor uterine contractions, postpartum hemorrhage
and injury or vescio-vaginal fistula when the bladder is nipped between the
fetal head and the pelvis. It prevents the descent of the fetal head, increases
pain and causes unnecessary discomfort.
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• Retention of urine occurs frequently in labor due to:

o Lack of muscle tone of the urinary bladder.
o Uncomfortable use of bedpan.
o Pressure on the urethra.
o Elongation of the urethra, which inhibits relaxation of the urethral
sphincter.
Observation:
Close observation is important for both the woman and fetus. The nurse should
observe the following:
• Reaction of the woman to labor.
• Vaginal discharge, show, amniotic fluid, and meconium.
• Progress of labor through descent of head and cervical dilatation.
• Uterine action: The frequency, duration and intensity of uterine
contractions should be checked and recorded every 30 minutes. .(See table)
Interval minutes 30 minutes 20-15 minutes 3-2
Duration seconds 35-25 seconds 45 -35 sseconds 70-60
Intensity Mild Moderate Strong
 Maternal condition:
o Temperature is checked and recorded every 4 hours.
o Respiration, pulse, and BP are checked and recorded every hour.
Signs of maternal distress:
• Increased pulse rates over 100 b/min.
• Elevated temperature, more than 37.5°C.
• Decreased blood pressure.
• Sweating and pale face.
• Signs of dehydration.
• Dark vomitus.
• Ketone bodies in urine.
• Irritability and restlessness.
• Anxious expression
.
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
 Fetal condition:
Monitor and record fetal heart rate to recognize fetal distress or abnormalities. It should
be heard every 4 hours until rupture of membranes, then every 30 minutes.
Signs of fetal distress:
 Excessive fetal movement.
 Excessive molding of fetal head.
 Excessive formation of caput succedaneum.
 A fetal heart rate increasing to more than 160 b/min, or decreasing to less
than 100 b/m, or becoming irregular.
 Passage of meconium in cephalic presentation.
Complications:
o Powers: Hypotonic or hypertonic uterine action. Passengers: Big infant,
malposition, and malpresentation.
o Passages: CPD/ fetopelvic disproportion (Contracted pelvis), and rigid
cervix.
Evaluation (Expected Outcomes)
• The woman progresses normally.
• She experiences increased comfort.
• The fetal heart rate remains within normal limits.
• The woman's hydration remains with normal limits.
 Second Stage (expulsion of the fetus)

Definition:
It begins with the fully dilatation of the cervix, and ends with delivery of the fetus. It
takes about one hour in the primigravida and half hour in the multigravida
Criteria of the Second Stage of Labor
1- The patient starts to bear down during uterine contractions due to pressure of the
presenting part on the rectum and pelvic floor causing reflex involuntary contraction
of the diaphragm and abdominal muscles.
2- The patient fells the desire to evacuate the rectum or bladder.
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3- Rupture of the membranes and flow of the amniotic fluid. Normally this occurs when
the cervix is fully dilated, however, it may occur early in labor in the first stage or
even before the start of labor( premature rupture of membranes). It may not occur at
all and the fetus is delivered inside the intact amniotic sac.
5- Full dilatation of the cervix: When it is fully dilated, it is 4 inches or 10cm. in
diameter and can admit 5 fingers (this is the sure sign).
 The Mechanism of Normal Labor:

I- Cervical Dilatation
It is due to contraction and retraction of the uterus, which push the head or bag of
forewaters through the cervix. In primigravida, the cervix dilates from above
downwards. The internal os dilates at first, then the cervical canal is taken up or effaced
and finally the external os starts to dilate because it muscle fibers are still intact and
resist dilatation. In multigravida, dilation of the internal os, taking up of the cervix and
dilatation of the external os occur together at the same time.
Note: Effacement means the portio vaginalis of the cervix becomes short and thin.
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II-Expulsion of the Fetus

A- Delivery of the Head: The following movements occur in the head during its
delivery:
1- Descent. 2- Engagement.
3- Increased flexion. 4- Internal rotation.
5- Extension. 6-Restitution.
7-External rotation.
1-Descent:
▪ It refers to the progress of the presenting part through the pelvis.

▪ The degree of descent is measured by the station of the presenting part.
▪ Little descent occurs during the latent phase of first stage of labor &acceleration
in the active phase when the cervix has dilated to 5-7cm
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(Descent of the fetal head-Rule of fifth)
2- Engagement:
▪ It is the passage of the biparietal diameter of the head below the pelvic brim.
3- Increased flexion of the head:
▪ Occur early in the process of descent as the head meets resistance from the
soft tissue of the pelvic, the pelvic floor, and the cervix.
The head may become so flexed that the chin is brought into closer contact with the
fetal chest (ascent of the sinciput and descent of the occiput)
As the consequences, the smallest antero-posterior diameter (the suboccipito-

bragmatic diameter )is presented into the pelvis.
4-Internal rotation of the head:
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▪ The head enter the pelvis in the transverse or diagonal position. When it
reaches the pelvic floor, the occiput is rotated and lies beneath the symphysis
pubis.
5-Extensionof the head:
▪ When the fetal head reaches the perineum for birth. The occiput passes
under the lower border of symphysis pubis first, and then the head emerges
by extension: First the occiput, then the face, and finally the chin.
6-Restitution.
After delivery of the head, the occiput rotates one eighth of a circle in a direction
opposite to that of internal rotation to undo the twist of the neck caused by internal
rotation.
7-External rotation:
The occiput undergoes another external rotation one-eighth of a circle in the same
direction as that of restitution this is due to internal rotation of the anterior shoulder
one- eighth of a circle. This movement is transmitted to the delivered head. So at the
end the occiput is towards one thigh and the face is towards the outer thigh.
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B- Delivery of the Shoulders and Body:
The biacromial diameter descends in the opposite oblique diameter of the pelvis. The
anterior shoulder meets the pelvic floor first and rotates forwards one-eighth of a circle
with further descent, the anterior shoulder appears below the symphysis pubis. The
posterior shoulder is delivered first by lateral flexion of the fetal spine then the anterior
shoulder follows. Finally, the trunk is delivered by lateral flexion of the spine around
the symphysis pubis.
file:///C:/Users/gmail/Documents/My%20Articulate%20Projects/Mechanism%20of%
20Normal%20Labor%20%20-%20Storyline%20output/story.html
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(1): Links of Normal Labor

https://drive.google.com/file/d/1ZROQjhk0DxkdtvRLf2m8NKbyxvp71DLJ/vi
ew?usp=sharing
https://360.articulate.com/review/content/8d5d013a-9333-41d4-b87a-
0acc809087a2/review
file:///C:/Users/gmail/Documents/My%20Articulate%20Projects/Mechanism
%20of%20Normal%20Labor%20%20-%20Storyline%20output/story.html
Nursing Management of the Second Stage of Labor

Assessment
• Assessment should include the following:
• Uterine contractions.
• Maternal physical and emotional status.
• Fetal well-being.
Signs and Symptoms of Second Stage of Labor

• Contractions become strong, and more frequent.
• Show is increased suddenly and becomes more blood tinged.
• Membranes rupture.
• Perineum starts to bulge and the anal orifice starts to dilate.
• Woman starts involuntary bearing down and feels the desire to defecate.
• She may be eager to sleep.
• She is apprehensive, irritable, unwilling to be touched, and may cry if
disturbed.
• She is frustrated, and unable to manage labor alone.
Nursing Diagnosis
• Pain related to descent of the fetus and stretching of vagina
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and perineum.
• Fatigue related to inability to rest and pushing efforts.
• Anxiety related to unknown outcome of labor process.
• High risk of infection

 Transfer to delivery room:
o Primigravida is transferred to the delivery room when the cervix is fully
dilated and the presenting part is seen.
o Multipara is transferred when the cervix is 7-8 cm (3-4 fingers).
 Posture of woman in labor:
The woman lies on the delivery table in one of the following positions:
 Dorsal or lithotomy position:
Woman lies on her back and puts her legs up into the stirrups or leg hold. The
advantages of this position are:
 Change of position is not needed to check FHS and to conduct the 3rd stage
of labor.
 Draping woman and preserving aseptic techniques are easy.
 Left lateral position:
Woman lies on left side, her thighs are partly flexed and another person holds
her knees apart. :The advantages of this position are
 Decrease liability for perineal laceration.
 .Easy removal of feces
 Easy manipulation of shoulders.
 Preparations:
o Preparation of the delivery room:
 Delivery room should always be ready for the conduct of labor. Delivery
trolley and emergency drug tray should be ready.
 The delivery room should be warm enough for the infant.
 All equipment needed for infant's care is present and the resuscitation trolley
should be ready for use at all times.
 Safety of woman should be ensured. She should be transferred between
contractions and supported adequately.
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 Enough privacy should be provided.

 Strict aseptic technique should be maintained.
o :Preparation of the woman
 Place the woman on the delivery table and put her legs in the leg holders.
 The legs and 'thighs should be dressed with sterile leggings. Sterile towels
should be laid over the abdomen and under buttocks leaving only the vulva and
perineum exposed.
 Empty the bladder. Swab external genitalia and. apply a sterile pad.
o Preparation of the attendant:

 The attendant should put on cap and mask, wash and scrub hands and put on a
sterile gown and gloves.
 The attendant starts to scrub up for primigravida when the head is seen in the
vulva during contractions and for multi para towards the end of the
first stage.
o Promotion of comfort:
 Encourage the woman to rest and to let all muscles relax between contractions,
e.g., breathing exercises.
 Give a few sips of water to provide moisture, and relieve dryness of the mouth.
 Sponge the face and hands with cool water.
o Bearing down:
 Prop up the woman with additional pillows to assume a semi-recumbent position.
 Encourage her to push during contractions, and to relax between contractions.
 Teach the woman how to bear down. She takes a deep breath, holds it, closes her
lips, and bears down.
 The woman must not cry out or make any sound because much of the expulsive
force will be wasted.
o Observations:
 Close and frequent observation is .very important for both the woman and fetus.
 The fetal heart should be checked after 2-3 contractions. If fetal distress is
suspected, check it after each contraction.
 The maternal pulse should be taken every 10 minutes.
 The strength and frequency of the contractions, and whether the uterus is
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relaxed between them must be closely watched.

o Protection of perineum:
 Obtain the woman's co-operation. She should only push when instructed and
must desist while the head is actually being born.
 Maintain flexion and control too rapid extension of the head.
 Deliver the head between contractions.
o After delivery of the head:
 Wipe the eyelids with separate swabs of sterile cotton.
 Wipe any mucus from the mouth and nostrils with a gauze swab.
 If the umbilical cord is looped round the infant's neck, slip it over the head if it
is loose, or clamp and cut it, if it is tight.
 Give the woman IM Syntometrine, 1 ml after delivery of the infant's anterior
shoulder, or after expulsion of placenta, to stimulate uterine contractions and
prevent bleeding.
 Note and record the time of birth.
Evaluation (Expected Outcomes)

• The woman is able to push effectively.
• She gains support and comfort from the nursing personnel.
• Her physiological and psychological status has been maintained.
• The infant is born without difficulty.
(Placental stage) Third Stage


Definition:
Starts with delivery of the fetus and ends with expulsion of the placenta, cord and
membranes, takes about 10-20 minutes ( average 10 minutes) and is painless.
 Note : Labour is prolonged when it lasts more than 18 hours.
 Mechanism of the third stage of labor:
Schultz Mechanism:
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Commonest, occurs in 80% of cases. The central part of the placenta separates first as
the placenta is firmly attached at its edges. A retroplacental hematoma forms and the placenta
is delivered by its fetal surface followed by the membranes containing the blood clot. This
mechanism is lees liable to be followed by bleeding or retained fragments. Actually, the
placenta is delivered like inverted umbrella.
Duncan Mechanism:
In 20% of cases. The placenta separates at its lower edge, and is delivered sideways with
the maternal and fetal surfaces appearing together. There is no retro placental hematoma. It
is more liable to be followed by bleeding and retained fragments.
Placenta Expulsion:
After separation of the placenta from the uterine wall, continued uterine contractions cause
the placenta to be expelled and the placenta is delivered either by the natural bearing down
effort of the mother or by gentle pressure on the contracted fundus by a physician or nurse.
 N.B :
- Contraction means temporary shortening of the muscle fibre.
- Retraction means permanent shortening of the muscle fibre.
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A-Schultze Mechanism B-Duncan Mechanism
• Signs of placental separation

o Uterus becomes smaller, globular, harder, higher and more mobile.
o Suprapubic bulge is noticed due to the presence of placenta in the lower
uterine segment.
o Gush of blood from the vagina.
o Lengthening of the umbilical cord outside the vulva.
o Loss of pulsation of the cord when pressure is exerted on the
fundus.
Nursing Management of the Third Stage of Labor

Assessment
• Assess uterine contractions.
• Observe maternal vital signs.
Nursing Diagnosis
• Fatigue related to inability to rest and pushing efforts during labor.
• Alteration of comfort, pain related to episiotomy, perineal distension, and
muscle strain during labor.
• Alteration of fluid to less than body requirements.
• Knowledge deficit related to physiological changes of normal labor, newborn
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care, and self-care.

• High risk of infection secondary to episiotomy during delivery.
Planning and Implementations
• Apply two forceps on umbilical cord and cut in between.
• Carefully inspect vagina, perineum, and labia for lacerations and tears.
• Inspect vulva for bleeding, edema, and hematoma.
• Make sure that the uterus is well contracted. Flabbiness or enlargement of the
uterus indicates bleeding.
• Palpate the height of the fundus. Feeling the fundus above the umbilicus may
be due to presence of another fetus, blood clots, big placenta, or full bladder.
• Avoid vigorous uterine massage because it may lead to irregular contractions,
and cause retained placental parts or membranes.
• Observe signs of placental separation.
• Evacuate the bladder by a catheter if the placenta is not separated within 20
minutes.
• The placenta is expelled by controlled cord traction and use of oxytocic drugs.
It is then received in the hands, and turned through a circle. This method reduces
blood loss and shortens the third stage.
• Examine the placenta and membranes for general appearance, completeness,
cord vessels, and weight.
• Estimate the average blood loss (200-600 ml).
• Clean and dry the vulva, buttocks and thighs and then apply a sterile pad.
Evaluation (Expected Outcome)
• The placenta is expelled without difficulty.
• The physiological status of the woman remains normal.
Care of the newborn include:

Care of the newborn include:
1- Clearance of the air passages (nose, mouth, and pharynx) by a mucus cather or suction
pump.
2- Apgar score is determined 1 and 5 minutes after delivery of the infant
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3- Aplastic clamp is applied 5cm from fetal abdomen to avoid umbilical hernia. The cord is
inspected for bleeding and painted with alcohol. The cord usually falls on the 6th day. If the
cord is thick and the umbilical cord clamp cannot be applied, the cord is ligated by two
thick silk ligatures.
4- The infant is examined for injuries and congenital anomalies as imperforate anus.
5- Vernix caseosa is removed from the neck, maxilla and groins and a bath is not
necessary.
6- The infant is weighted, gestational age is determined, dressed and bracelets is applied
for identification.
7- Penicillin eye drops or ointment is used to protect against gonococcal ophthalmia
neonatorum. Tetracycline or erythromycin ointment can be used.
8- Vitamin k1 is given to all infant immediately after delivery as 1gm IM or is given orally
as 1gm at birth and the dose is repeated at the end of the first and third week (3 oral dose).
In high-risk infants who are liable, to develop hemorrhage as preterm as asphyxiated
infants, the first dose is given IM and then two oral dose are given as above.
Fourth stage of labor:
Definition:
It is the stage of early recovery. Begins immediately after expulsion of the placenta
and membranes and lasts for one hour. During which careful observation for the patient
particularly the signs of postpartum hemorrhage. Uterine massage is usually done every 5
minute during this period.
Nursing Management of the Fourth Stage of Labor

Assessment
• .Check maternal vital sign :
• .Check uterine contraction
• .Observe lochia
• Assess the condition of the urinary bladder.
• Assess the condition of the perineum.
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Nursing Diagnosis
• Alteration in comfort: pain related to uterine involution and
.episiotomy
• .Sleep pattern disturbance
• Alteration in nutrition to less than body requirement.
• Knowledge deficit related to physiological changes of normal postpartum,
newborn care, and self-care.
• Potential for infection related to trauma and episiotomy during delivery.
The nurse should remain beside the patient.
• Check and record the maternal vital signs every 15 minutes, or as necessary.
• Check the uterus to ensure that it is well contracted to prevent bleeding.
• Observe the amount of lochia.
• Inspect the perineum for edema and hematoma.
• Encourage the woman to pass urine. A full bladder will prevent proper uterine
contractions, and cause uterine atony and severe postpartum hemorrhage.
• Clean the woman, change her clothes, swab the perineum and apply clean pad.
• Give the woman a drink or light snack if she is hungry.
• Show the mother her newborn infant.
• Put the infant to the breast as soon as possible because the infant is very alert
and sucking reflex is very strong at this time.
• .Encourage rest and sleep
• Observe the infant's cord clamp, skin color, respiration and temperature.
• Detect and treat complications early.
• Complete the records for woman and infant.
• Transfer the woman to postnatal ward.
Evaluation (Expected Outcome)
The woman's physiological status is within normal limits, she has normal vital signs,
well-contracted uterus, normal lochia, undescended bladder, and she is free from pain
and perineal swelling.
The woman has been able to initiate breastfeeding.
• Woman infant bonding has been enhanced woman to postnatal ward.
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(2)Links of Normal Labor

https://nursingmenofiaedu.sharepoint.com/:p:/s/MNFirstTerm2021/EbQ5su0B
GsFAkwFbNNlXyBsBfDi_PRsiIe8CMbxm_BZt2g?e=y08hLY
https://drive.google.com/file/d/1G0w3Srh4VppipPL0ufV8XSWCtau_pM0M/vi
ew?usp=sharing
4). Electronic Fetal Monitoring
 Overall Aim:
Each student will be able to recognize indication of fetal monitoring and identify
abnormalities of fetal heart rate patterns and their causes.
 ILOs:
I-Knowledge and understanding:
1- Define fetal monitoring.
2- List indication of fetal monitoring.
3- Identify types of fetal monitoring.
4- Identify abnormalities of fetal heart rate patterns, their causes and management.
II-Intellectual skills:
1- Differentiate between internal and external cardiotocography.
2- Differentiate between different methods of assessing fetus during labor.
III- Practical skills:
1- Apply nursing care for woman with abnormal fetal heart rate.
2- Demonstrate procedure of fetal monitoring (internal or external).
IV- General and transferable skills:
1) Cooperate with other health care team to manage woman with abnormal fetal heart rate.
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2) Value importance of fetal monitoring during labor.
Definition:
Electronic fetal monitoring involves the use of an electronic fetal heart rate monitor to
record the baby's heart rate…. Electronic fetal monitoring is performed late in pregnancy
or continuously during labor to ensure normal delivery of health baby.
 Indications for continuous electronic fetal monitoring:

 Antenatal maternal risk factors:
− Previous caesarean section.
− Pre- eclampsia or pregnancy- induced hypertension.
− Recurrent antepartum hemorrhage.
− Prolonged membrane rupture (> 24 hours).
− Diabetes.
− BMI at booking > 35 Kg/ m2
 Antenatal fetal risk factors:
− Suspected fetal grow resistance.
− Suspected oligohydramnios or Polyhydramnios.

− Abnormal presentation breech, transverse oblique
− High or free head in nulliparous woman.
− Reduced fetal move in the previous 24 hours.
− Other significant maternal medical disease or risk Factor requiring obstetric, including
prematurity and multi pregnancies.
 The Goal of Electronic fetal monitoring (EFM) is:

• Reduce fetal death
• Reduce brain injury
• Provide documentation of labor
 Types of fetal monitoring:
1- Internal fetal monitoring
2- External fetal monitoring
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 Internal fetal monitoring:

Definition:
*An electrode is attached to the fetal ECG Invasive
• Internal monitoring can't be used unless the cervix dilated and the membranes are
ruptured to allow replacement of the scalp.
• The ultrasound probe (transducer) is applied to the mother's abdominal wall. It
detects movement of fetal cardiac valves or movement of blood in the fetal heart and
vessels
 Technique:
• Internal monitoring can't be used unless the cervix dilated and the membranes are
ruptured to allow replacement of the scalp.
• It requires cervical dilation at least 2cm to allow replacement of the scalp.
• Presenting part is low enough to allow placement of scalp.
• High skilled practitioner should be present and use aseptic technique.
• Placement a spiral electrode into fetal presenting part usually head to assess FHR and
record uterine contraction.
 Advantage:
1) more accurate in displaying an FHR between 30 and 240 b/min.
 Disadvantages:
1) Perforation of uterus or placenta of fetal damage due to misapplication in fetal
presentation wasn’t recognized.
2) Carry the risk of infection of scalp or amnion.
3) The insertion of electrode may cause bruising on the part of fetus that electrode is
attached.
4) Insertion of electrode may be un comfortable for mother.
5) It isn't recommended for women who have active herpes out breaks when they are in
labor.
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 External fetal monitoring:

*Noninvasive fetal monitoring
• External monitoring doesn't require cervical dilatation or rupture of membranes.
 Technique
Is an in direct monitoring:
• Two ultrasound transducers/each is attached to belt are applied around the woman's
abdomen.
• One of the belts is put against the uterine funds to detect change in uterine pressure
and cover pressure into electronic signal that reordered on graph paper.
• The other belt is put between umbilical and symphysis pubis to record base line of
FHR and if there is any variation
 Advantage:
1)Noninvasive
2) Easy to apply.
3) May be used during the antepartum period.
4) may be used with telemetry.
5) doesn't require ruptured membrane or cervical dilatation.
6) No known risks to woman or fetus.
7) Provide continuous recording of FHR and UA.
8) without hazard.
9) Detects movement of fetal cardiac valves.
10) Doesn't transfer infection to mother and fetus.
 Disadvantages:
1) May limit maternal movement.
2) The ultrasonic transducer may pick up and trace extraneous sound.
3) it may be difficult to obtain a state tracing if the mother is obese or is moving and active
during labor.
4) Not accurate.
5) Disruption of maternal movement.
 Abnormal FHR patterns:
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1. Tachycardia (more than 160 beat/min):

a base line of fetal heart rate for at least 10 minutes. That is greater than 160 beat/min
for at least 10 minutes.
It's degree: - Mild ◊ 161 : 180 beat/minute - Sever ◊ 181 beat/minute.
Causes :- Fetal distress.
- Fetal anemia.
- Maternal anemia.
- Prematurity.
- Maternal fever.
- Maternal or fetal hyperthyroidism.
- Drugs as atropine and beta-sympathomimetic agents.
Management ;
According to causative factor.
- Antipyretic: to slow metabolism and decreased fever.
- Increasing oxygen to treat fetal hypoxia.
- Assess maternal temperature.
- Monitor for change of fetal heart rate pattern.
- Hydrate to improve circulating volume.
- Turn patient to left side.
- Reduce stressors (turn off oxytocin, treat maternal fever).
2-Bradycardia (less than 120 beat/minute):
base line fetal heart rate between 100:120 beat/minute.
Causes:
- Fetal distress.
- Congenital fetal heart block.
- Beta – blockers given to the mother.
- Fetal head compression.
- Fetal hypoxia.
- Fetal acidosis.
- Fetal heart block.
- Umbilical cord compression.
Management:
- Monitor for change of fetal heart pattern.
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- Change maternal position and administer o2.

- Correct maternal hypotension.
- Look for causes such as prolapsed cord.
- Put mother in knee – chest position.
3. Early decelerations (type I dips):

decrease in fetal heart rate which begins and ends at the same time at uterine contraction,
causing a consistent V-shaped wave from that mirrors the contractions on an electronic
fetal monitoring tracing.
Causes:
Head compression during labor and this leading to increasing intracranial tension and
vaginal stimulation and slowing of the heart slowing at the onset of contraction, the lowest
point correspond with the peak of contraction.
It doesn't indicate fetal distress.
Management:
- Relieve head compression is indicated. - Monitor for change for heart rate pattern.
4. Late decelerations (type II dips):

it indicates fetal hypoxia and distress due to reduced placental blood flow caused by
uterine contractions. Deceleration begins at or near the peak of contraction is completed
when late deceleration occurs when 50% or more of uterine contractions, we suspect fetal
hypoxia.
Causes:
- Placental interruption as placenta previa and abruptio placenta.
- Internal hypotension.
- Excess uterine activity.
- Maternal DM.
- Maternal severe anemia.
- Maternal cardiac disease
Management:
- Turn patient to left side.
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- Administer o2 by tight face mask.

- Correct hypotension.
- If oxytocin used, turn off.
- Infuse rapidly intravenous fluid
. - Expect expeditious delivery if not corrected in 30 min.
5. Variable deceleration:
variable decelerations are irregular, often jagged dips in the fetal heart rate that look more
dramatic than late decelerations.
Causes:
- Intermittent compression of umbilical cord by fetal head.
- Oligo hydrominos.
- Cord between fetus and mother's uterus or pelvic without obvious prolapse.
Management:
- Change maternal position to decrease cord compressive (turn sides to side or knee chest
position).
- Give O2 at 8 – 10 L/min by tight face mask.
- Improve circulating volume.
- Amnion per fusions.
- Monitor for change fetal heart pattern dis continue oxytocin if it being administered.
- Perform vaginal examination to assess for prolapsed cord
6. Prolonged deceleration:
there are isolated deceleration which last longer than 60 – 90 seconds.
Causes:
- Tetanic uterine contractions.
- Placental abruption.
- Umbilical cord prolapse.
- Maternal hypoxia.
Management: - Notify physician or mid wife of first occurrence.
- Check for cord prolapse.
- Examine the cervix.
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- Check progress of dilation and descent.

- Correct maternal hypotension increase intravenous fluids.
- Continuous observation until delivery be prepared for emergency delivery.
7-Sinusoidal pattern:
it indicates fetal anemia as in case of ruptured vasa praevia, feto maternal haemorrhage,
twin-to-twin transfusion syndrome, and Rh-immunization.
Causes:
- Acute intra partum asphyxia.
- Fetal maternal hemorrhage.
- Chronic fetal anemia.
Management:
-Continuous, careful, fetal assessment including direct ultrasound observation of fetal
abnormalities or placental abnormalities.
- Assessment for active fetal movement is important in assessing fetal status.
- Percutaneous umbilical blood sampling under ultrasound guidance is a technique that
permits fetal hemoglobin levels to be assessed.
- Preparations for a possible emergent delivery should be initiated if intrauterine
resuscitation is not appropriate.
 Method of electronic fetal monitoring
I-External fetal monitoring

Equipment:
1- Bedside monitor unit
2- Two transducer or sensor (one sensor for FHR and the other one for uterine activity)
3- Paper strip
4- Belts to hold the sensors or transducer.
5- Ultra sound Gel.
1) Hand washing
2) Prepare equipment
3) Keep privacy
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4) Explain the procedure and teach the mother that using electronic monitoring does not
mean that you or the baby has a problem- it's a common way we assess the baby's response
to labor contraction.
5) Verify doctor order.
6) use Leopold’s maneuver or grips To locate the fetus back
7) Apply ultra sound gel to the transducer as gel improues the transmission of ultra sound
wave.
8) Place the transducer on the woman's abdomen at approximately of fetal back, move the
sensors until a clear signal's heard.
9) Place the uterine activity sensor in the fundal area or the area where contraction feel
strongest when palpate
10) Apply belts; slide both belts under the women's back
11) Observe the strip for baseline fetal heat rate and contraction frequency and duration
12) Record any abnormalities
II-Internal monitoring:
• There are two electrode (fetal spiral electrode and intrauterine pressure catheter)
• fetal spiral electrode (FSE) application occur once the amniotic membranes have been
ruptured.
Contraindication:
1- Planned application to fatal head, fontanels, or genitilia
2- Presence or suspicions of placenta previa
3- Presence of active herpes lesion or HIDV
4- Maternal infection with hepatitis B or C
5-Inability to identify the portions of the fetus where the applications id applied.
Equipment:
1) Two transducer "fetal scalp electrode and intrauterine pressure catheter " 42 Fetal
monitoring
2) Paper strip
3) Electronic fetal monitoring
4) Gloves
5) Kocher's forceps
Procedure:
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1-Hand washing
2-Keep the privacy
3- Facing the mother
4- Explain the procedure 
5- Ask the patient to undress completely and put on a hospital gown and lie on labor
bed with her feet separated and knee flexed as for pelvic exam
* If the amniotic sac still intact, the doctor use Kocher and rupture the membranes but
we should make sure that there is cervical dilatation through PV to insert the sensors.
* tell the women that she will feel worm water in vagina
* the nurse will insert the fetus electrodes on fetal scalp. The nurse should avoid apply
the electrodes on fontanelle or gentile area.
*the nurse will insert the other catheter "intra uterine pressure catheter. * Fix the
electrodes around the thigh with a bond.
* Observe fetal heart rate and Record.
Nursing responses to non-reassuring fetal heart rate patterns

• Stop oxytocin or other uterine stimulants. Tocolytic such as terbutaline may be
ordered.
• Reposition the woman, avoiding the supine position for patterns/ cord compression -
Repositioning of ten improves other non-reassuring patterns as well.
• Increase the rate of perfusion of a non-additive iv fluid. - To expand the mother's
blood volume and improve placental perfusion.
• Administer oxygen by facemask at 8 to 10 L/min to increase maternal blood oxygen
saturation, making more oxygen available to the fetus. 44 Fetal monitoring - Maternal
pulse oximetry, available on many fetal monitors, allows ongoing assessment of
maternal oxygen saturation and documentation on the strip if the information is crucial.
• Consider starting continuous internal devices. - If no contraindication exists.
• Notify the physician or ask another nurse to notify Report and document the
following. - The pattern that as ID'd
• Nursing interventions taken in response to the pattern - The fetal response after
nursing intervention Response of doctor or other response.
• If non reassuring pattern is severed, other staff members should be alerted to the
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possibility of immediate delivery usually cesarean, unless operative vaginal birth is

possible and quicker. - Birth prep should include staff prepared for neonatal
resuscitation. 45 Fetal monitoring
2) Immediate Care of the Newborn

ABCW Principles of Delivery
• Remember the following ABCW principles of delivery to ensure adequate
resuscitation of the infant:
o Airway
o Breathing
o Circulation
o Warmth
Objectives of Immediate Care of the Newborn

• To establish and maintain respiratory function.
• To provide warmth and prevent hypothermia.
• To ensure safety from injury and infection.
To identify actual and potential problems that might require immediate action
Assessment of the Infant's Condition
• The airway: To clear the airway, hold the infant upside down for few seconds
and perform gentle suction to establish breathing, and improve infant's color.
• The APGAR Score: APGAR Score involves consideration of 5 signs, and the
degree to which they are present or absent. It is recorded at 1 and 5 minutes after
birth
The APGAR Score

Sign 0 1 2
Hear rate Absent Slow blew 100 Fast above 140
Respiration Absent Weak crying Good crying
Reflex irritability No response Grimace Good response
Color Blue and pale Body pink Completely pink
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extremities blue
Total Score = 10 Normal= 7 – 10

Mild asphyxia = 4-6 Severe asphyxia = 0-3
• Warmth: It is very important to keep the infant warm at birth because he will
lose heat rapidly through evaporation. So, the labor room should be warm and the
infant should be dried gently and wrapped in a warm dry towel to avoid exposure.
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• Umbilical cord
o Double ligation may be used. The first at 5 -cm from umbilicus to
prevent strangulation of a congenital umbilical hernia. The second at 2 cm
further for security.
o A disposable plastic clamp may also be used and placed 3-5 cm from
the umbilicus.
o The excess cord is cut off.
o Nowadays, alcohol gauze and bandage are not applied to the stump.
• Weight and measurements:
o Weigh the infant after birth. The normal weight is 2.5- 3.5 kg.
o Measure its length. The average length is 50 cm.
o Measure its circumferences. The head and chest circumferences are I 3
inches.
• Care of eyes:
o The eyes are washed with sterile warm water.
o Erythromycin ointment is the drug of choice now.
• Vitamin K: should be given to prevent bleeding.
• identification:
o It is very important to identify the infant by its sex, and its mother's
name.
o An identity bracelet is placed around the infant's wrist or ankle.
o A wrist or ankle band or a foot print may be used.
• Position:
o The head of the infant should be placed lower than the body in order to
drain mucus and secretions by gravity, stimulate the brain centers, and
improve circulation. This is done only to the full term babies. ·
• Examinations: It is very important to examine the infant properly to
determine whether any abnormalities are present.
o General appearance:
 Color.
 Respiration.
 Muscle tone.
 Temperature.
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206
o Assessment of head and neck:

 Observe and palpate head for moulding and caput succedaneum.
 Palpate fontanels for fullness or depression.
 Observe ears for shape and position.
 Observe eyes for size, shape and presence of hemorrhage.
 Observe mouth for cleft lip and/or cleft palate. Observe neck for length,
webbing and mobility.
 Check skin for abrasions, spots, pustules and birthmarks.
 Observe nose for symmetry, septum, patency and flaring of nostrils.
o Assessment of body:
 .Measure weight and length
 Observe general activity, posture and response.
 Observe skin for lanugo, vernix, texture, rash, pigmentation and.
meconium staining.
o Thorax:
 Observe size symmetry and shape.
 Observe breath sounds and respiratory rate.
 Observe heart sound, rhythm and rate.
 Check breasts for engorgement.
o Abdomen:
 Observe
 .shape
 Observe umbilicus and cord vessels.
 .Check femoral pulse
o Genitalia:
 Observe for appropriateness of sex.
 Observe female labia and discharge.
 Observe male urethral opening, scrotum and testes.
 Observe urine for amount and color
o Back:
 Observe spine for symmetry of vertebrae.
 Check anus for patency and meconium.
o Extremities:
 Observe for symmetry, movement and abnormalities.
 Observe digits of hands and feet for number and webbing.
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207
 Observe hips for range of motion.

 Observe feet for abnormalities.
o Neurological assessment:
 Observe rooting and sucking reflex.
 Observe grasp reflex of hands and feet.
 Observe Moro reflex.
 Observe startle reflex, hold the infant with head supported and allow
the head to drop back, the response will be lateral extension of arms and
opening of hands.
 Observe stepping reflex, when the infant is held upright, he makes
stepping movements.
o Breastfeeding:
 The infant should be given to the mother for breastfeeding. Early
breastfeeding is recommended to prevent hypoglycemia, promote mother
infant bonding, and stimulate milk secretion.
Duties of the Nurse in the Labor Room
Duties of the Scrub Nurse
• Scrubs and wears cap, mask, sterile gown and gloves.
• Arranges the instruments on the delivery table.
• Assists in draping the woman.
• Hands the instruments and catheter to the doctor as called for.
• Assists in perinea! repair, and prepares proper length sutures on proper
needles.
• Massages the uterus as needed.
• Assists in holding the newborn infant.
Duties of the Circulating Nurse
• Assists the woman during her transfer from the labor bed, and
positions her properly on the delivery table.
• Opens packs or drums, and ties the gowns of doctor and assistant.
• Prepares and administers routine medications as ordered, and records
its time.
• Prepares resuscitation and emergency equipment.
• Observes and records FHR.
• Receives the infant from the doctor and takes care of him.
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208
• Resuscitates the infant and observes him at regular intervals.

• Records the time of birth and sex of the infant. ·
• Observes and records the time of placental expulsion.
• Records the location and extent of episiotomy or tear, and type of
repair.
• Records the amount of blood loss.
• Observes and records any unusual conditions.
• Prepares and places the identification measure of the infant.
• Assists in giving anesthesia and emergency drugs if needed
Neonatal Care in the Delivery Room
The very first minutes of the neonatal life are critical. Anticipation of problems and
preparation are key for the neonatal resuscitation.
The nursing care for the newborn can be classified into three stages:
Stage Theme
Before delivery Preparation
During delivery Identify risk
After delivery action
Before Delivery
o As soon as the mother is admitted to the labor room, the following
items for infant care should be checked:
o The bed warmer is working appropriately.
o There is a resuscitation bag and an appropriate size mask.
o Oxygen tubing is available and attached to the bag. Suction system is
working appropriately. Different sizes suction catheters are available.
o Different sizes endotracheal tubes are available. Laryngoscope is
available. Attach the blade to ensure the bulb is working. Do not leave the
blade on. The bulb will get hot and can bum the infant.
o Once the mother is progressing in labor:
o Tum the bed warmer on the non-servo (manual) mode and set it at
pre-heat.
o Attach the oxygen tubing to the flow meter and set the flow at 10 min.
o Ensure that an infant mask is attached to the resuscitation bag.
o Attach an appropriate size suction catheter to the suction canister
tubing.
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209
o Make sure the suction pressure does not exceed 100 mmHg
o Attach the laryngoscope blade to the handle and do not turn it on
o Make sure the resuscitation cart is in place. Check the contents of the
cart daily.
o Put gloves on
During Labor
Deliveries can be classified into three categories according to the expected risk to
the newborn.
o Low risk delivery:
o Identification:
 Mothers with uncomplicated pregnancy, labor and delivery.
o Personnel:
 Labor room nurse will provide the care to the normal infant in the
labor room.
 If the infant is unexpectedly ill, resuscitation should start while
awaiting the arrival of the pediatric staff.
o Equipment:
 The labor room nurse is responsible for ensuring that the following
infant care equipment is present and operating properly:
 Infant bed warmer.
 Oxygen unit.
 Infant suction apparatus.
 Infant resuscitation bag and masks.
 Laryngoscope with appropriate endotracheal tubes.
o Mild to moderate risk delivery
o Identification
 Premature delivery from 32 - 36 weeks gestation.
 Post-term delivery greater than 42 weeks gestation.
 Meconium stained amniotic fluid.
 Cesarean section.
 Fetal distress as determined by obstetrician. Expected fetal growth
retardation.
 Multiple pregnancy.
 Breech delivery.
 Mild Rh disease as determined by obstetrician.
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 Maternal illnesses, such as:

 Diabetes mellitus.
 Pre-eclampsia.
 Thyroid disease.
 Suspected infection, including:
 Maternal fever during labor.
 Rupture of membranes > 18 hours.
 Other findings identified by the obstetrician.
o Personnel:
 Pediatric resident.
 Intensive care nursery nurse.
 Assistant specialist or specialist (only if the obstetrician or the
pediatric resident feels necessary).
o Equipment:
 Infant care equipment as indicated above.
 Emergency cart or the NICU should be ready for immediate use:
 The Emergency cart: contains several drawers that have all the
required emergency medications (such as: epinephrine, NaHC03, calcium
gluconate, saline, etc.) and tools (such as: IV catheters, endotracheal tubes,
chest tubes, etc.). This cart is physically located on each floor or unit and can
be moved to the bedside
o High risk delivery
o Identification:
Premature delivery less than 32 weeks gestation.
 Severe Rh disease.
 Several antepartum or intrapartum hemorrhage.
 Suspected asphyxia (such as: cord prolapsed or loss of fetal heart
rate).
o Personnel:
 The most senior resident or assistant specialist in house.
 NICU nurse.
 Specialist should be available as necessary.
Equipment: As in mild to moderate.
 Conclusion:
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• Labor is a crucial time for the mother, family member and the fetus. This
is the most perilous journey under taken by the fetus in utero. For the
clinician it is equally important to know and identify any deviation from
the normal pathway.
• Despite immense development in imaging techniques to assist in making
the right decision for the patient nonetheless in labor management the
clinical assessment still has a key role.
 Recommendation
• Precise assessment of onset of labor is crucial to identify any deviation from

normal course.
• Latent phase of labor is when there is painful uterine contraction and some
cervical effacement; dilatation up to 4 cm. The duration may vary days to
weeks.
• The progress of first stage labor: progressive cervical dilatation 2 cm/4 h,
frequency of uterine contraction, progressive descent and rotation of the
head.
• There is no substantial evidence to support the imaging: CT/MRI for routine
pelvic assessment. Clinical trial (labor) is still accepted for pelvic
assessment. Imaging may assist in decision making for labor in woman to
evaluate the pelvis with history of pelvic fracture.
• Monitoring of fetal heart rate should be a routine practice to ensure fetal well
being during the process of labor.
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6). General Follow up activities

1-Which of the following fetal positions is most favorable for birth?
a- Vertex
b- Transverse lie
c- Frank breech presentation
d- Posterior position of the head
2-In vertex presentation , the position is determined by the relationship

Of what fetal part to the mother’spelvis:
a-Mentum
b-Sacrum
c-Sinciput
d-Occiput
3-A client is admitted in active labor. The nurse palpates her abdomen to
determine the fetal presentation, which of the following defined it?
a-Position of the fetal body parts
b-Portion of the fetus that enters the pelvis first
c-Relationship of the fetal presenting part to the mother's pelvis
d-Relationship of the long axis of the fetus to the long axis of the mother.
4-Which of the following terms is used to describe the thinning and shortening
of the cervix that occurs just before and during labor?
a-Ballottement
b-Dilation
c-Effacement
d-Multiparous
5-True labor can be differentiated from false labor because in true labor
contraction will:
a-Bring about progressive cervical dilation.
b-Occur immediately after membrane rupture
c-Stop when the client is encouraged to walk around
d-Be less uncomfortable if client is in a side-lying position
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6-Progress in labor is determined by which of the following?

a-Dilation &intensity of contraction
b-Dilation &effacement
c- Dilation &descent
d-Frequency of contraction & descent
7-The client's vaginal examination reveals: 4 cm dilated, 80% effaced, vertex

at -1 station. The woman is talkative and appears excited. The nurse
determines the client to be in which stage and phase of labor?
a-First stage, latent phase.
b-First stage, active phase.
c-Second stage, latent phase.
d-Third stage, transition phase
8-Which of the following hormones would be administered for the

stimulation of uterine contraction?
a. Estrogen
b. Oxytocin
c. Progesterone
d. Fetal cortisol
9-According to priority, which of the following is the FIRST step in

management of magnesium sulfate toxicity?
a. Inform the physician
b. Turn the patient on left side
c. Stop the infusion
d. Give oxygen therapy
10- During which of the following stages of labor would the nurse assess
crowning?
a. First stage
b. Second stage
c. Third stage
d. Fourth stage.
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11-The breathing technique that the mother should be instructed during

crowning is:
a-Blowing
b-Slow chest
c-Shallow
d-Accelerated-decelerated
12-The clinical features of second stage of labor include

a-Mild backache radiating to the legs
b-Decreased in blood flow though vagina
c-Strong irregular contractions of the uterus
d-Sensation of bearing down & the cervix is fully dilated
13-Which of the following is the most important characteristic of fetal heart

tracings to determine fetal well-being?
a-Baseline
b-Variability
c-Presence of Accelerations
d- Presence of Decelerations
14-What is considered to be the normal range of fetal heart rates?

a-100-150 bpm
b-120-170 bpm
c-110-160 bpm
d-120-160 bpm
15-Which of the following is the cause of late deceleration?

a. Head compression
b. Cord compression
c. Oxytocin induction
d. Placental insufficiency
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16-Variable decelerations in FHR during labor are severe dips occurring at the
peak of contraction. This FHR problem is associated with which one of the
following conditions?
a. Utero-placental insufficiency
b. Fetal head compression
c. Uterine insufficiency
d. Pressure on the umbilical cord
Case study:
A primigravida at term is admitted to a primary-care perinatal clinic at 06:00 with

a history of painful contractions for several hours. She received antenatal care and
is known to be HIV negative. The maternal and fetal conditions are satisfactory.
On abdominal examination a single fetus with a longitudinal lie is found. The
presenting part is the fetal head, and 4/5 is palpable above the brim of the pelvis. 2
contractions in 10 minutes, each lasting 15 seconds are noted. On vaginal
examination the cervix is 1 cm long and 2 cm dilated. The fetal head is in the right
occipito-posterior
1. Is the patient in the active phase of labour?

Yes, as the cervix is more than 5 cm dilated.
2. How should you record your findings?

As the patient is in the active phase of labor, the findings must be entered on the
active phase part of the portogram. The X (cervical dilatation) is recorded on the
alert line, opposite the 5 on the vertical axis indicating 5 cm dilatation. The O
(number of fifths palpable above the pelvic brim) is recorded below the X opposite
the 4 on the vertical line. The length of the cervix is recorded by a 1 cm column on
the base line, vertically below the X and O.
3. How should you manage the patient further?

The routine observations (e.g. pulse rate, blood pressure, fetal heart, and urine
output) must be performed at the usual intervals. The patient must be offered
analgesia. Pethidine 100 mg and promethazine 25 mg or hydroxyzine 100 mg
should be given by intramuscular injection as soon as the patient requests pain
relief. A second complete examination should be done at 12:00, i.e. 4 hours after
the first complete examination.
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At the second complete examination the maternal and fetal conditions are
satisfactory. On abdominal examination the head is 3/5 palpable above the brim of
the pelvis. 3 contractions in 10 minutes, each lasting 25 seconds, are noted. On
vaginal examination the cervix is 5 mm long and 6 cm dilated with bulging
membranes.
The presenting part is in the left occipito-transverse position. Poor progress is

diagnosed and a systemic assessment of the patient is made in order to determine
the cause. Intact membranes and inadequate uterine contractions are diagnosed as
the causes of the poor progress.
4. How should you record these findings on the partogram?

The X must be recorded on the horizontal line corresponding to 6 cm cervical
dilatation, 4 hours to the right of the record at 08:00. The position of the fetal head
and length of the cervix are recorded on the same vertical line as the X. The correct
way of recording these observations is shown in figure 8C-8.
5. Is the progress of labor satisfactory?

No. This is immediately apparent by observing that the second X has crossed the
alert line. For labor to have progressed satisfactorily, the cervix should have been
at least 9 cm dilated (5 cm initially plus 1 cm per hour over the past 4 hours).
6. How should you manage this patient further?

The membranes must be ruptured. Rupture of the membranes will result in stronger
uterine contractions. Because there has been inadequate progress of labour, a third
complete examination should be performed at 14:00, i.e. 2 hours after the second
complete examination.
At the third complete examination the maternal and fetal conditions are
satisfactory. On abdominal examination the head is 1/5 palpable above the pelvic
brim. 4 contractions in 10 minutes, each lasting 50 seconds are observed. On
vaginal examination the cervix is 1 mm long and 9 cm dilated. The presenting part
is in the left occipito-anterior position. The findings are recorded as shown in
figure 8C-8.
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7. What is your assessment of the progress of labor at 14:00?

Labor is progressing satisfactorily. This is shown by the third X having moved
closer to the alert line. The head, which has rotated from the left occipito-posterior
to the left occipito-anterior position, is also engaged. A spontaneous vertex
delivery may be expected within an hour.
7). References:
• http:// nursekey.com/intrapartum-fetal surveillance.
• http:// quizlet.com/14658971/ch-17- nursing responses to nonreassuring fetal-
heat-rate-patterns – flash – cards/.
• Alfirevicz, devaned, gyte GM; continuous
cardio tocography (CTG) as a form of electronic fetal monitoring (EFM) for
fetal assessment during labour, Cochrane database syst Rev-2013 may 315:
CD006066. Doi: 10.1002/14691858. CD CD006066.
• Hasee BF, (2007): Basic obstetrics eighth edition, Cairo, University book
center, 145-148
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Module (4): Postpartum care
Course: Maternity& Newborn Health Nursing

Code: 300(N)
Module (4): Postpartum care
Teaching Method(s): 3hr(s) Lectures; virtual classes, 12hr(s) Clinical (includes
6hr(s) for small group clinical skills teaching & 6hrs for labs clinical skills).
This module is designed to prepare students to provide basic postpartum, and
newborn care.
Module Objectives: To:-

1. To influence in a positive way the attitude of the students toward globally
accepted, evidence-based practices in postpartum, and newborn care.

2. To provide the students with the knowledge and clinical skills needed to ensure,
support, and maintain maternal and fetal/newborn well-being throughout the

postpartum period.
3. To enable the students to recognize and respond to a woman or newborn when
life-threatening complications are experienced during the postpartum period.
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Module Content:
1). Immediate Postpartum Care

2). Physiological & Psychological Changes during Postpartum Period
3). Minor Discomforts during Postpartum Period
5). General Follow up Activities
6). References
Learning Outcomes:
On successful completion of this module, students should be able to:
1. Identify the characteristics of the postpartum period.
2. Recognize the objectives of immediate care during the postpartum period.
3. Explain the components of immediate postpartum care of the newborn.
4. Identify women and newborns with common discomforts/concerns or special
needs during the postpartum period and respond to these needs appropriately.
5. Provide ongoing assessment and supportive care of the mother and newborn
during the fourth stage of labor.
6. Perform the first complete physical examination of the newborn.
7. Perform a postpartum physical examination including general well-being, of
the mother and newborn.
8. Provide basic postpartum care regarding a scheduled a return visit.
9. Identify the specific nursing activities, which provided in each postpartum
visit and the rationale of these activities.
10.Recognize the importance of postpartum visits and the different nursing
activities provided through these visits.
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11.Formulate nursing care plan for the women and newborn during postpartum
period.
12.Apply nursing activities during the postpartum visits.
13.Counsel of women during postpartum period.
14.Appreciate the importance of care of women and neonate during postpartum
period.
15.Manage common complications of the immediate postpartum period for the
mother and the newborn.
16. Illustrate the physiological and psychological changes which occur during
postpartum period.
17. Classify changes that occur during postpartum period.
18. Perform general & local examination to detect body system changes during
postpartum period.
19. Appreciate the emotional needs of the women during postpartum period.
20. Perform nursing activities effectively as regard to these changes in an aim to
restore the mother’s health and to avoid any deviation from normal course of
postpartum period.
21. List types of minor discomfort during postpartum period.
22. Identify the most common postpartum minor discomforts.
23. Clarify the mother needs and complains
24. Apply a simple nursing measures which needed to alleviate mothers
complains and meet their needs.
25. Reassure the mother and the family and explain to them the type of
discomfort and the nursing management needed to relief it.
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1)Immediate Postpartum Care
 By the end of the lecture every student should be able to:

 Recognize the objectives of immediate care during the postpartum period.
 Explain the components of immediate postpartum care of the newborn.
 Identify women and newborns with common discomforts/concerns or special
needs during the postpartum period and respond to these needs appropriately.
 Provide ongoing assessment and supportive care of the mother and newborn
during the fourth stage of labor.

 Perform the first complete physical examination of the newborn.
 Perform a postpartum physical examination including general well-being, of
the mother and newborn.

 Provide basic postpartum care regarding a scheduled a return visit.
 Identify the specific nursing activities, which provided in each postpartum
visit and the rationale of these activities.

 Recognize the importance of postpartum visits and the different nursing
activities provided through these visits.

 Formulate nursing care plan for the women and newborn during postpartum
period.
 Apply nursing activities during the postpartum visits.
 Counsel of women during postpartum period.
 Appreciate the importance of care of women and neonate during postpartum
period.
 Manage common complications of the immediate postpartum period for the
mother and the newborn.
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Outline
1. Introduction.
2. Goals of postpartum care
3. Components of care during the postpartum period
4. Objectives of care during the postpartum period.
A. Immediate postpartum care for the mother:
B. Immediate postpartum care for the newborn
C. Late postpartum care for the mother and newborn (activities of
postpartum visits).
5. Nursing care for the postpartum woman.
Introduction
 Nursing care during the postpartum provides means by which the parturient can
restore her physical and emotional health, as well as gain experience in caring
for her newborn infant.
Goals of postpartum care:

1- Promote normal uterine involution.
2- Prevent or minimize postpartum complications.
3- Promote comfort & healing of pelvic & perineal tissue.
4- Assist in restoration of normal body functions.
5- Increase understanding of physiologic & psychological changes.
6- Facilitate newborn care & selfcare by new mother.
7- Promote the newborn successful integration into family unit.
8- Provide effective discharge planning.
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Components of Care during the Postpartum Period

• Care of the mother:
• Immediate care.
• Subsequent daily care.
• Care of the newborn infant.
Objectives of Care during the Postpartum Period.
A- Immediate postpartum care for the mother:
 Check funds frequently and massage gently if not firm.
 Inspect perineum frequently for visible signs of bleeding.
 Check vital signs and blood pressure frequently.
 Instruct about breast feeding which should start within the first hour
after delivery.
Record all data about the mother.

 Secure physical and mental rest, restore normal good muscle tone and
maintain normal body functions.
 Provide proper adequate nutrition.
 Guard against infection.
 Teach the mother how to care for herself and the infant.
 Foster and maintain family ties and adjust the parents to their new role.
B- Immediate postpartum care for the newborn
Importance of immediate postpartum care for the newborn

1. Period of transition from intrauterine to extrauterine condition.
2. Changes in the cardiovascular system and respiratory system.
3. Immaturity of the body in thermoregulation.
4. Loss of heat through conduction, convection, and evaporation.
5. Check for bleeding.
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Immediate newborn care involves:
1. Drying the baby with warm towels or cloths, while being placed on the
mother's abdomen or in her arms. This mother-child skin-to-skin contact is
important to maintain the baby's temperature, encourage bonding and
expose the baby to the mother's skin bacteria.
2. Ensuring that the airway is clear, removing mucus and other material from
the mouth, nose, and throat with a suction pump.
3. Taking measures to maintain body temperature, to ensure no metabolic
problems associated with exposure to the cold arise.
4. Clamping and cutting the umbilical cord with sterile instruments,
thoroughly decontaminated by sterilization. This is of utmost importance for
the prevention of infections.
5. A few drops of silver nitrate solution or an antibiotic is usually placed into
the eyes to prevent infection from any harmful organisms that the baby may
have had contact with during delivery (e.g. maternal STDs ).
6. Vitamin K is also administered to prevent hemorrhagic disease of the
newborn .
7. The baby's overall condition is recorded at 1 minute and at 5 minutes after
birth using the Apgar Scale .
8. Putting the baby to the breast as early as possible. Early suckling/breast-
feeding should be encouraged, within the first hour after birth and of nipple
stimulation by the baby may influence uterine contractions and postpartum
blood loss.
9. About 6 hours or so after birth, the baby is bathed, but the vernix
caseosa (whitish greasy material that covers most of the newborn's skin) is
tried to be preserved, as it helps protect against infection.
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C- Late postpartum care for the mother and newborn (activities of

postpartum visits)
1. A new mother should visit the health center, for her first postpartum visit, or
be visited by a health worker at home within 7-10 days of delivery.
2. This is especially true if she delivered at home.
3. This is important to make sure that the woman and the infant are recovering
from the labor and delivery.
4. If all is well, the next visit should be at the 40th day. Both the mother and
infant will have a thorough physical examination, the infant will be
immunized.
5. All mothers’ questions about breast feeding, family planning and any other
worries will be answered
6. The MOHP /maternal and child health department has set a schedule of five
home visits for postpartum care to be done by the nurse or midwife
The Following Activities Will be Emphasized in Each Visit in Addition to the

Routine Postpartum Care
No. of Visits Time Activities

1 2nd day For the mother
 Check vital signs and blood pressure
 Estimate the fundal level
 Ask about lochia, bleeding, urine and bowel
movement
 Episiotomy care
 Check the condition of the lower extremities
 Assess the condition of breast and perineum
For the newborn
 Take the temperature
 Weight the newborn
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 Assess the eye and cord condition
 Cord dressing
Health education
 Early ambulation
 Nutrition
 Breast feeding
 Postpartum exercises
 Hygiene
 Newborn care
Record the findings and referral if needed
2 4th day For the mother
 Assess the mother general condition
 Check vital signs
 Check lochia, fundal level and perineal
condition
 Check flow of milk
For the newborn
 Cord dressing
 Baby bath
Health education
 Personal hygiene
 Rest and sleep
 Postpartum exercises
 Breast feeding
 Nutrition
 Check the lochia
 Check the breast condition
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 The mother should assume her normal
activities
For the newborn
 Weight the child
 Check the cord drop
Health education
 As the second visit
 Check the uterus for involution
 Check lochia and breast condition
For the newborn
 Weight the baby
 Newborn care
Health education
As above and family planning
5 During the For the mother
sixth week  Assess the mother general condition
 Complete postpartum examination
 Family planning
For the child
 Assess the chills growth and development
 BCG immunization
Health education
 The importance of breast feeding
 Nutrition
 Hygiene
 Family planning
 Obligatory vaccination
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Nursing Care for the Postpartum Woman

Fourth Stage of Labor
 The first two hours after birth.

 Maternal organs start to undergo readjustments to the nonpregnant state.
Nurse’s role during the fourth stage of labor is:
1- Identify and manage promptly any deviations from the normal

processes that may occur
2- Promote and support parent-infant attachment
Assessment during the fourth stage of labor
 During the first hour in the recovery room, physical assessments
of the mother are frequent.
 All factors but temperature is assessed every 15 minutes for the
first hour and then every thirty minutes in the second hour.
 Temperature is assessed at the beginning and end of the recovery
period.
 Postpartum women experience intense tremors or shivering.
 Provide warm blankets.
Physiologic Assessments
Temperature
- First 24 hours every 4 hours
- Every 8 hours after that till discharge
Pulse, Respirations, and Blood Pressure
- Every 15 minutes-first hour of delivery.

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- Every 30 minutes for the next 2 hours after delivery.
- Then every 4 hours for the first 24 hours.
- Then every 8 hours till discharge.
Fundus, Lochia, and Bladder
- Assess every 15 minutes for the first hour.
- Assess every 4 hours for the next two hours after delivery.
- Then assess every 8 hours until discharge.
Perineum
- Assess once the first hour after delivery.
- Then assess every four hours for the first 24 hours.
- Then after 24 hours of delivery assess every 8 hours until discharge.
Breasts& Legs
- Assess every four hours in the first twenty-four hours.
- Then assess every 8 hours thereafter until discharge.
Routine Laboratory Test
- Hemoglobin
- Hematocrit
- Rubella
- Rh status
Early needs of the mother:
1- Observation and recording to:
A. Vital signs
 Check vital signs 2 times daily "morning and evening".
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 Observe for symptoms of hypovolemic shock and hemorrhage.

 A temperature of 38°c or above, for two consecutive days.
 After the first 24hr(s) is considered an early sign of puerperal infection.
 Bradycardia is a normal physiological phenomenon.
B. Subsequent Postpartum Assessment:
1. Check firmness of the fundus at regular intervals. Perform fundal massage if the
uterus is boggy (not firm).
2. Assessment of involution of uterus after childbirth– 2 days after childbirth
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3. Assessment of involution of uterus after childbirth– 4 days after childbirth.

4. Perineum:
 Observe perineum and suture line if present, for redness, ecchymosis, and
edema or gapping. Check healing and cleanliness
 During the examination hemorrhoids may be noted and appropriate treatment
advised.
5. Lochia
 Check lochia for color, amount, odor, consistency, and blood clots.
6. Urine out put
 The urine output is usually recorded for the first 24 hours after delivery to
ensure that the woman is passing and adequate amount of urine. Assess bowel
and bladder elimination. offer the opportunity to void within the first 4 to 8
hrs. after delivery and every 2 to 3 hrs. thereafter.
7. Legs
 The nurse examines the patient's leg for pain and edema.
8. Assess for breast engorgement and condition of the nipples if breast-feeding.

9. Assess incisions for signs of infection and healing.
10.Postpartum Vaccination :If the woman is not rubella immune, a rubella vaccination
may be given, and pregnancy must be avoided for at least 3 months.
11.Psychological Assessment:
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 Focuses on mother’s general attitude, feelings of competence, support systems,

caregiving skill.
 -Describe level of attachment to infant
 Determine mother’s phase of adjustment to parenting.
 Evaluate interaction and care skills of the mother and family with infant.
2. Rest and sleep:
 Provide for sufficient periods of rest and sleep to maintain physical and mental
health, as to promote lactation (8hrs nighttime sleep and 2hrs after noon-nap
are needed).
3. Diet:
 Provide diet high in proteins and calories to restore tissues.
 A daily requirement of 3000-3500 cal/day is needed in the form of a well-
balanced diet rich in 1st class proteins, calcium, iron, vitamins, thiamine,
riboflavin, and ascorbic acid
 Liberal amounts of fluids are required "the daily fluid intake should be 2.5-3
liters" (e.g. milk, juice ….ect."
4. Hygiene:
The women should be taken shower daily.
The vulva and perineal care include washing or swabbing with warm water
and antiseptic solution, the area must be kept clean and dry and free from
infection.
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The perineum must be inspected daily if there are sutures to see that healing
is taking place. Non-absorbable sutures are removed on the fifth or sixth day.
Breast care should be done before and after feeding. The nurse teaches the
mother the technique of breast care and encourages her to initiate breast-
feeding.
Patient Education Guidelines

1. Breast feeding :
 Breast feeding :is the best possible source of nutrition for your infant. It provides
an immunologic boost for the infant, protects against breast cancer, hastens
postpartum healing, and serves as a wonderful bond between the infant and
mother.
Advantages of Breast Feeding
For the baby:
 Immunological properties help prevent infections.

 Provides nutritional needs.
 Easily digested.
 Less sodium and protein than in cow's milk; puts less stress on
newborn's kidneys.
 Calcium is better absorbed.
 Least allergenic food for infant.
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 Promotes development of facial muscles, jaw, and teeth.

 Less likely to be overfed, less obesity.
 Has natural laxative effects.
 Fulfilling psychological needs.
For the mother:
 Oxytocin release aids uterine involution.

 Strong mother-infant relationship.
 Convenient; always available; no preparation.
 Cost effective.
 Less incidence of cancer breast.
 Natural contraception.
Ways for successful breastfeeding

 Immediately after birth, keep the baby in the bed with the mother, or within
easy reach.
 Start breastfeeding within 1 hour of birth.
 The baby's suck stimulates the milk production. The more the baby feeds, the
more milk the mother will produce.
 At each feeding, let the baby feed and release the breast, and then offer the
second breast. At the next feeding, alternate and begin with the second breast.
 Give the baby the first milk (colostrum). It is nutritious and has antibodies to
help keep the baby healthy.
 At night, let the baby sleep with the mother, within easy reach.
 While breastfeeding, the mother should drink plenty of clean, safe water. The
mother should eat more and healthier foods and rest when she can.
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Technique of Breast Feeding
 Tell the mother to help the baby to her breast when the baby seems to be ready,
usually within the first hour.
 The mother should begin breast feeding in a quiet, comfortable place that is
free from interruption. She may need a pillow to help support the infant and
a footstool to use to elevate her leg.
 Make sure the infant is awake and dry before the feeding started. If awake and
comfortable, the infant will settle down and feed better. The infant should also
be hungry.
 Dress the infant appropriately so that the infant is not too warm or too cool
during the feeding . If too warm, the infant may fall asleep after the first few
sucks of milk. A sleepy infant will not nurse well. If too cool, the infant may
be fussy and restless.
 Have the mother wash her hands before feeding to help prevent infection.
 Position infant at the breast by placing the infant in a semi-sitting position
with face close to the breast and supported by one of your arms and hand. A
pillow may be used under the infant for support. The mother may need to
support her breast with your other hand.
 Proper positioning will provide the infant with comfort and security and make
it easier for the infant to suck and swallow. This makes the nipple more easily
accessible to the infant's mouth and prevents obstruction of nasal breathing.
 When the feeding to start, let the breast touch the infant's cheek. Do not hold
the cheek but try to help the infant find the nipple. The rooting reflex will take
over and the infant will turn head toward breast with mouth open. If you touch
the cheek, the infant will become confused, perhaps turning toward your hand.
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 The infant's lips should be out over the areola and not just around the nipple
before beginning to suck. Because the nipple is so small, suction cannot be
achieved merely by grasping it. The areola must be in the infant's mouth to
establish suction and make the suck effective.
 The mother may notice the let-down reflex during the nursing period. Milk
flowing from the other breast during nursing is quite normal.
 The length of feeding time may vary from 5 to 30 minutes. Let the infant nurse
until satisfied. When the infant is satisfied and has nursed well, the infant is
relaxed and usually falls asleep. The infant will stop sucking.
 Burp the infant during and at the end of the feeding to prevent abdominal
distention or regurgitation from air swallowed during the feeding .
 One or both breasts may be used at each feeding. It makes no difference if the
infant is satisfied at the end of the breast and one breast is completely emptied
at the breast . If both breasts were used, the second breast is not usually
emptied and should be used first at the next feeding. Regular and complete
emptying of the breast is the only stimulation to produce milk.
 When the infant has stopped sucking, the infant typically likes to cling to the
breast. To break this suction, insert a finger to the corner of the infant's mouth
and gently pull.
 When the infant has finished feeding , change the diaper if it is wet or soiled.
Position the infant on the right side in bed. Note whether the infant appears
satisfied or still seems to be hungry.
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 To continue successful breast feeding adequate rest and nutrition. The mother
should be comfortable and relaxed and her baby is correctly attached can help
to make breastfeeding easier and more enjoyable.
 The mother can try to feed in a chair that offers good back support; use
cushions or pillows to prop up her arms; and if necessary, rest feet on a
telephone book or footstool.
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Breastfeeding positions
1. The classic 'front hold' or 'cradle position'.
2. The 'underarm position'

shown above is also known as the 'footy hold'. It’s possible to feed twins
together in this position.
3. The 'lying down' position is particularly good for mums who’ve had
caesareans or if your bottom is sore after the birth.
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4. Cross-cradle Hold: This position is similar to the cradle hold breast feeding
position except that the mother hold the baby’s head in her hand to direct it
toward the nipple.
Other Positions
• In the first few weeks, it may be easier to feed twins separately. However,
once the mother has got the hang of her twins, she can try feeding them
together using the 'twin hold'.
• If the mother feels uncomfortable or self-conscious when breastfeeding in
public, drape a light muslin wrap over your shoulder so it covers your breast
and baby.
Breastfeeding and family planning
• During the first 6 months after birth, if the mother breastfeeds exclusively,
day and night, and her menstruation has not returned, the mother is protected
against another pregnancy.
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2. Promoting Proper Bowel Function
 Teach the woman that bowel activity is sluggish because of decreased abdominal
muscle tone, anesthetic effects, effects of progesterone, decreased solid food
intake during labor, and pre-labor diarrhea.
 Inform the woman that pain from hemorrhoids, lacerations, and episiotomies may
cause her to delay her first bowel movement.
 Review the woman's dietary intake with her.
 Encourage daily, adequate amounts of fresh fruit, vegetables, fiber, and at least
eight glasses of water.
 Encourage frequent ambulation.
 Administer stool softeners as indicated.
3. Reducing Fatigue
• Provide a quiet and minimally disturbed environment.

• Organize nursing care to keep interruptions to a minimum.
• Encourage the woman to minimize visitors and phone calls.
• Encourage the woman to sleep while the baby is sleeping, and specifically to
nap or lie down and get off her feet at least 30 minutes per day.
4. Preventing Infection
 Observe for elevated temperature above (38° C).

 Evaluate episiotomy/perineum for redness, edema, ecchymosis, discharge
(color, amount, odor) and approximation of the skin (REEDA).
 Assess for pain, burning, and frequency on urination.
 Administer antibiotics as ordered.
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5. Postnatal exercise:
 Encourage postpartum exercise which promotes circulation.
 Lessen the possibility of venous thrombosis and restore the muscle tone of
the abdominal wall and pelvic floor.
 Postnatal exercises help to give the patient a sense of wellbeing.
 Certain patients, such as those suffering from heart lesions, should not be
allowed to perform all the exercises, though even they may be encouraged,
on medical advice to take gentle exercise.
 Deep breathing and free movements in the bed should be encouraged from
the day of the delivery. On the second day the following exercises may be
done provided the labor has been normal and the patient is in health.
 In prescribing exercises discretion must be used and the exercises must be
adapted to the individual. In hospital the exercises will probably be directed
by a physiotherapist.
Breathing exercises:
 Deep-breathing exercises should be performed as described for antenatal
period, with the patient lying flat in be stretch, stiffen and reflex the muscles of
the right and left leg alternately.
Pelvic floor tone. Several exercises may be performed:

1. Lie flat on the back with body relaxed. Tighten the anus for ten seconds as
though trying to control a loose motion or retain an enema. Repeat six times,
and then rest for one minute. Carry out the same procedure eight times.
2. Lie flat on the bed and forcibly abduct the thighs against resistance (the nurse
attempts to hold the thighs together while the patient pushes them apart. Repeat
slowly six times. Later the same exercise may be carried out, but with the nurse
holding the patient’s Knees together instead of the thighs.
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3. Lie flat upon the back with the hands upon the hips and elevate the feet
alternately, counting one to six, up, and one to four, down.
4. Lie flat with the hands resting lightly on the abdominal wall. Then slowly raise
the head and shoulders. The patient must not push the chin forwards, or the
abdominal wall will be pushed outwards instead of contracting, nor must any
weight be rested on the elbows.
5. Sit up in bed with the hands clasped round the flexed knees and endeavor to
touch the knees with the chain. The nearer the head and knees approach the
greater the contraction of the abdominal muscles.
Strengthening the muscles generally:

 The patient, sitting up in bed and bedding forward with legs outstretched places
her hands on her ankles. The trunk is then stretched backwards, and the arms
drawn up and bent to imitate rowing, the knees are slightly flexed at the same
time.
Late needs of the mother

Health education and counseling
The nurse plays an important role as health educator and counseling which should
provide the woman health education and counseling about:
1. Breast feeding, definite, technique and position.
2. Resumption of sexual relations. Include information about when to expect
menstruation.
3. Postnatal exercise, hygiene, rest, sleep, and nutrition. Advice and explain
to the mother:
 To always have someone near her for the first 24 hours to respond to any
change in her condition.
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 Not to insert anything into the vagina.
 To have enough rest and sleep.
 The importance of washing to prevent infection of the mother and her baby:
→ wash hands before handling baby.

→ wash perineum daily and after faecal excretion.
→ change perineal pads every 4 to 6 hours, or more frequently if heavy lochia
and dispose of them safely.
→ wash the body daily.
 To avoid sexual intercourse until the perineal wound heals.
 To sleep with the baby under an insecticide-treated bed net.
 Advise the woman to eat a greater amount and variety of healthy foods, such
as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to
help her feel well and strong (give examples of types of food and how much
to eat).
 Reassure the mother that she can eat any normal foods – these will not harm
the breastfeeding baby.
 Spend more time on nutrition counselling with very thin women and
adolescents.
 Talk to family members such as husband and mother-in-law, to encourage

them to help ensure the woman eats enough and avoids hard physical work.
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4. Family planning methods for spacing of pregnancy.
Counselling on the
importance of family planning
– Counsel the woman that her husband should be included in the counselling
session.
– Explain that after birth, if she has sex and is not exclusively breastfeeding, she
can become pregnant as soon as 4 weeks after delivery. Therefore, it is
important to start thinking early about what family planning method they will
use.
– Counsel the woman if she plans for having more children waiting at least 2
years before trying to become pregnant again is good for the mother and for
the baby's health.
– Information on when to start a method after delivery will vary depending on

whether a woman is breastfeeding or not.
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Method options for the non-breastfeeding woman

Methods can be used – Condoms
immediately postpartum – Progestogen-only oral contraceptives
– Progestogen-only injectables
– Implant
– Spermicide
– Female sterilization (within 7 days or delay 6 weeks)
– Copper IUD (immediately following expulsion of
placenta or within 48 hours).
Delay 3 weeks – Combined oral contraceptives

– Combined injectables
– Fertility awareness methods
Method options for the breastfeeding woman

Methods can be used – Lactational Amenorrhea Method (LAM)
immediately postpartum – Condoms
– Spermicide
– Female sterilization (within 7 days or delay 6 weeks)
– Copper IUD (within 48 hours or delay 4 weeks)
Delay 6 weeks – Progestogen-only oral contraceptives
– Progestogen-only injectables
– Implants
– Diaphragm
Delay 6 months – Combined oral contraceptives
– Combined injectables
– Fertility awareness methods
Lactational Amenorrhea Method (LAM)

 A breastfeeding woman is protected from pregnancy only if:
→she is no more than 6 months postpartum, and,
→she is breastfeeding exclusively (8 or more times a day, including at least
once at night: no daytime feedings more than 4 hours apart and no night
feedings more than 6 hours apart; no complementary foods or fluids),
and,
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→her menstrual cycle has not returned.
 A breastfeeding woman can also choose any other family planning method,
either to use alone or together with LAM.
5. Stress the importance of postpartum examination. Visits and follow up to

assess involution, general health, and wellbeing of the mother before
discharge.
6. The care of the newborn which includes:
A. Hygiene
 Wash the baby's face and neck daily. Bathe her/him when necessary. After
bathing, thoroughly dry the baby and then dress and keep her/him warm.
 Wash baby's bottom when soiled and dry it thoroughly.
 Wash your hands with soap and water before and after handling the baby,
especially after touching her/his bottom.
B. Care for the newborn's umbilical cord

 Keep cord stump loosely covered with a clean cloth. Fold diaper and clothes
below stump.
 Do not put anything on the stump. If the birth at home without a skilled
attendant, apply chlorhexidine to the stump daily until it separates.
 If stump area is soiled, wash with clean water and soap. Then dry completely
with clean cloth.
 Wash your hands with soap and water before and after care.
C. Maintain warmth of the newborn

 In cold climates, keep at least an area of the room warm.
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 Newborn need more clothing than other children or adults.
 If cold, put a hat on the baby's head. During cold nights, cover the baby with
an extra blanket.
D. Let the baby sleep on her/his back or side.
E. Keep the baby away from smoke.
F. Prevention of infection, good feeding and giving him love and sense of
security.
7. Counsel on danger signs for the mother:

Advise the mother to go to a hospital or health center immediately, day or night,
without waiting, if any of the following signs:
1. Vaginal bleeding: more than 2 or 3 pads soaked in 20-30 minutes after

delivery or bleeding increases rather than decreases after delivery.
2. Convulsions.
3. Fast or difficult breathing.
4. Fever and too weak to get out of bed.
5. Severe abdominal pain.
6. Calf pain, redness or swelling, shortness of breath or chest pain.
Go to health center as soon as possible if any of the following signs:

1. Fever
2. Abdominal pain
3. Feels ill
4. Breasts swollen, red or tender breasts, or sore nipple
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5. Urine dribbling or pain on micturition

6. Pain in the perineum or draining pus
7. Foul-smelling lochia
8. Severe depression or suicidal behaviour (ideas or attempts).
8. Counsel on danger signs for the newborn:

Advise the mother to go to hospital or health center immediately, day or night, do
not wait, if the baby has any of the following signs:
1. Difficulty breathing
2. Fits
3. Fever
4. Feels cold
5. Bleeding
6. Stops feeding
7. Diarrhoea.
Go to the health center as soon as possible if your baby has any of the following
signs:
1. Difficulty feeding.
2. Feeds less than every 5 hours.
3. Pus coming from the eyes.
4. Irritated cord with pus or blood.
5. Yellow eyes or skin.
6. Ulcers or thrush (white patches) in the mouth.
Nursing Diagnosis
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 Alteration in comfort (pain) related to afterpains, episiotomy, laceration,

hemorrhoids, breast engorgement, surgical incision
Alteration in skin integrity related to episiotomy, or perineal lacerations.
 Altered urinary elimination related to postpartum diuresis and urinary retention

from postdelivery edema of perineal area, or due to effect of anesthesia.
 Altered bowel elimination related to decreased bowel motility and abdominal

muscle tone, dehydration, and painful defecation.
 Fluid volume deficit related to decreased oral intake and/or blood loss.
 Altered nutrition related to inadequate intake of food (increased body needs for
protein for tissue repair and lactation).
 Sleep pattern disturbance related to discomfort, parenting activities and anxiety.
 High risk of infection related to impaired skin integrity and tissue trauma, as
well as lowered body resistance.
 Knowledge deficit regarding self-care, infant care, health maintenance,

prevention of infection and complications related to lack of experience.
 Disturbance in self-concept related to body changes or parenting abilities and

role transition.
 Potential altered parenting related to lack of support from significant others,

interruption in bonding process, lack of knowledge, or unrealistic expectations
for self, infant, or partner.
 Impaired breastfeeding related to improper positioning, inverted nipples, or

absence of infant sucking.
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Nursing Care Plan and Implementation

 After admission to the postnatal ward, subsequent daily care is implemented
as follows:
General Aspects of Care
• Check vital signs 2 times daily (morning and evening); observe for symptoms of
hypovolemic shock and hemorrhage (fainting).
• A temperature of 38°C, or above, for two consecutive days after the first 24 hrs.
is considered an early sign of puerperal infection.
• Bradycardia is a normal physiological phenomenon.
• Palpate the uterus to assess firmness, level of fundus, and rate of involution of
the uterus.
• Administer oxytocic medication as ordered to promote involution.
• Check lochia for color, amount, odor, consistency, and presence of blood clots.
• Observe perineum and suture line - if present - for redness, ecchymosis, edema,
or gapping. Check healing and cleanliness.
• Provide for sufficient periods of rest and sleep to maintain physical and mental
health, as well as to promote lactation (8 hr. night-time sleep and 2 hr.
afternoon-nap are needed).
• Proper positioning. During the first 8 hours after labor, the mother is allowed to
sleep in any comfortable position. After that, prone position or either lateral
position should be encouraged to facilitate involution, and to help drainage of
lochia. Sitting position is also recommended since it promotes contraction of
the abdominal muscles, aid pelvic circulation, and helps drainage of lochia.
Knee-chest.
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• Position is indicated in certain conditions because it prevents retroversion and

retroflexion (RVF) of the uterus and hastens its involution.
• On the other hand, both supine and semi-sitting positions should be avoided.
• Prevent infection: complete aseptic and antiseptic precautions should be

followed during the early postpartum period to prevent infection.
• Promote bladder and bowel function:
Bladder: marked diuresis is expected for 2-3 days following delivery: voiding
should be encouraged within 6-8(hrs) after labor. If no urine is passed after 12
hrs., initiate simple nursing measure to induce voiding. If failed, catheterization,
under complete aseptic technique is performed.
Bowel: there may be no bowel action for a couple of days because the bowel
has probably been emptied during labor. Glycerin suppository may be used to
relieve constipation. /
• Provide diet high in proteins and calories to restore tissues. A daily requirement
of 3000-3500 Cal/day is needed in the form of a well-balanced diet rich in 1st
class proteins, calcium, iron, vitamin A, thiamine, riboflavin, and ascorbic acid.
Liberal amounts of fluids are required (e.g. milk, juice ... etc.). Roughage and
green vegetables are provided to prevent constipation.
• Encourage early ambulation to prevent blood stasis. However heavy activities are
avoided to prevent complications.
• Encourage postpartum exercises (appendix) particularly Kegel's exercises. To

strengthen pubococcygeal muscles.
• Provide treatment for afterpains as ordered.
• Monitor laboratory reports for Hb, HCT, and WBC.
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• Observe for postpartum blues, which may be caused by a drop in hormonal levels
on the 4th or 5th day.
• Meet the mother's needs to enable her to meet the infant's needs.
• Assist the mother with self-care and care of the infant as needed.
• If Rh negative mother, assess need for administration of RhO GAM.
• Give rubella vaccine if indicated.
• Discuss resumption of sexual relations. Include information about when to expect

menstruation.
• Discuss most suitable family planning methods for spacing of pregnancy, (e.g.,
immediate post-delivery contraceptives).
• Stress the importance of postpartum examination, visits and follow up to assess

involution, general health, and wellbeing of the mother.
• Evaluate client's response and revise plan as necessary.
• Discuss community resources that provide maternal services.
Special Aspects of Care
• Breast care: (plan and implementation)
Encourage early initiation of breastfeeding: The first feed should be given as soon
as possible after birth, as the infant is alert and sucks well at birth. Lactation and
emotional bonding is enhanced. Exclusive, and on demand breastfeeding are
encouraged. There should be no limit to the length of time that s/he sucks.
Check the breasts:
o Should be soft until milk conies in.
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o Daily cleansing in shower.
o Regular and frequent examination for early detection of complications

such as engorged breast, cracked nipples, mastitis, and breast abscess.
• Care of the perineum:
o Inspect and observe for presence of episiotomy, lacerations, edema,

pain, or ulceration.
o Keep the area clean and dry by employing perineal care
o Teach the mother principals of self-care:-

– Pouring a stream of water over the vulva and perineum after voiding or
defecation.
– Wiping from front to back after voiding or defecation.
– Change peri-pad with each voiding or defecation.
– Cold therapy for 24 to 48 hours (Ice packs & Cold packs).
– Heat therapy
• Ambulation
o Early ambulation is successful in reducing the incidence of

thromboembolism and in promoting the woman’s more rapid
recovery of strength
• Prevention of excessive bleeding by maintenance of uterine tone:
o Fundal massage.
o Teaching patient to do fundal self- massage.
o IV oxytocin, such as Pitocin.
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o Oral or IM medications (drugs that stimulate contraction of the

uterine smooth muscle) such as methergine, Cytotec, and
hemobate.
• Prevention of Bladder Distention
o Full bladder causes the uterus to be displaced above the umbilicus well to one
side of the midline of the abdomen and prevents uterus from contracting
normally.
o Focus on helping the woman to empty her bladder

spontaneously as soon as possible.
o Assist woman to the bathroom.
o Have woman listen to running water.
o Pouring water from a squeeze bottle over her perineum.
o Assisting woman into the shower or sitz bath.
• Care of the newborn infant: Nursing assessment:
o Observing the general condition.
o Checking the cord.
o Checking the infant's physical needs: cleanliness, feeding, warmth, sleep,

protection from unsuitable environment.
o Checking psychological needs: bonding and attachment.
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2) Physiological and Psychological Changes

during Postpartum Period
 Overall objectives:
By the end of the lecture every student should be able to:
• Identify the characteristics of the postpartum period.
• Illustrate the physiological and psychological changes which occur during
postpartum period.
• Classify changes that occur during postpartum period.
• Perform general & local examination to detect body system changes during
postpartum period.
• Appreciate the emotional needs of the women during postpartum period.
• Perform nursing activities effectively as regard to these changes in an aim to
restore the mother’s health and to avoid any deviation from normal course of
postpartum period.
Outline:
- Introduction
- Definitions of puerperium.
- Characteristics of the postpartum period
- Physiological changes occurring during postpartum period.
1. Changes in reproductive organs
2. General physiological changes
3. Psychological changes
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Introduction :
 The postpartum period, also known as the puerperium, refers to the
time after delivery when maternal physiological changes related to

pregnancy return to the nonpregnant state. In addition to physiologic
changes and medical issues that may arise during this period.
 The nurses should be aware of the physical, psychological needs of the
postpartum mother and sensitive to cultural differences that surround childbirth.
 Definition of Puerperium:
 It is a period that begins upon delivery of the infant to the end of the six to eight
weeks after delivery during which the maternal body in general, and the genital
organs in particular return to the pre-pregnant condition.
 Puerperium is divided into:
1. Immediate postpartum (first 24 hours).

2. Early postpartum (first week).
3. Late postpartum (from second week till end of six weeks).
Characteristics of the Postpartum Period:

 Involution: of the reproductive organs or regressive changed.
 Lactation: is initiated.
 Recovery: from physiological effort & emotional symptoms"Recuperation".
Physiological Changes during The Puerperium:

The major maternal physiological during puerperium:
1. Changes in Reproductive Organs
1) Uterus:
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1- Involution of the uterus:-
 Involution is the rapid decrease in the size of the uterus as it returns

to the non-pregnant state and the breast feed may experience a more
rapid involution.
 After delivery, the weight of the uterus is 1000 grams, and its length is
20cm. By the end of 6 weeks, it is 50 grams weights and 7.5cm length.
 The fundus or uterine involution is usually midline and approximately

at the level of the woman's umbilicus (belly button) after delivery(6-
12hrs).
 Within 12 hours of delivery, the fundus may be (1 cm) above the

umbilicus.
 After this, the level of the fundus descends approximately 1
fingerbreadth each day, until by the 10th to the 14th day, it has
descended into the pelvic cavity and can no longer be palpated and must
be firm on palpation.
 It's return to near its non- pregnant size by 4 to 6 postpartum weeks.
 Uterine involution is due to autolysis of the excess of the muscle fibers.

Old blood vessels thrombose, and newer vessels develop within the
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thrombosed old ones. Remnants of old vessels are detected as elastic

tissue.
 The deciduas (except the basal portion) are cast off.

 The site of placental attachment requires 6-7 weeks to heal. In process
called Exfoliation
Assessment:
a. Weight of the uterus decreases
b. Endometrium regenerate.
c. Fundus descends into the pelvis.
d. Fundus height decreases about 1 finger (1 cm)/day.
e. By 10 days postpartum the uterus cannot be palpated abdominally.
f. Note that a flaccid fundus indicates uterine atony and should be massaged until
firm a tender fundus indicates an infection.
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 Factors that enhance involution include:

• Uncomplicated labor and birth.
• Breast-feeding.
• Early, frequent ambulation.
 Factors that slow uterine involution include:

• Prolonged labor.
• Incomplete separation and expulsion of placenta.
• Previous labors.
• Distended (full) bladder.
• Anesthesia.
2- Vaginal discharge from the uterus (Lochia):-
 The lochia is the vaginal discharge from the puerperal uterus during the
first part of the puerperium (3-4 weeks).
Stages: It progresses through three stages.

1. Lochia rubra (red color): is consisting mainly of blood , deciduas, fatty
epithelial cells, shreds of membrane and leukocyte, presents in the first 4
days.
2. Lochia serosa (pink or more brownish color): is due to relative
decrease in RBCs and predominance of leucocytes, presents between
5th and 10th day. lochia serosa has strong odor
3. lochia alba (whitish or yellowish color and is almost colorless): is
consisting mainly of leucocytes, cervical mucus, deciduas, bacteria and
should not has odor. Lochia alba occurs from days 10 to 14.
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 The Lochia usually ceases by 3 weeks. Persistence of red lochia occurs in

subinvolution. Offensive lochia indicates infection but in severe infection
with septicemia the lochia is scanty and not offensive.
Classification of lochia according to the amount:
a. Scant lochia: less than 2-5 cm blood on the perineal pad.

b. Light or mild lochia: less than 10cm blood on the perineal pad\hrs.
c. Moderate lochia: less than 15cm stain perineal pad\hrs.
d. Heavy lochia: 1 saturated pad\hrs.
e. Sever lochia : more than 1 saturated pad \hrs.
Assessment:
a. Rubra is a bright red discharge that occurs from delivery day to day 4.
b. Serosa is brownish pink discharge that occurs from days 5 to 10.
c. Alba is white discharge that occurs from days 10 to 14.
d. The discharge should smell like normal menstrual flow.
e. Discharge decreases daily in amount.
f. Discharge may be increase with ambulation.
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g. Breast feeding may increase lochia.
h. Foul – smelling lochia and scant may indicate an infection.
i. Bright red blood indicates cervical or vaginal laceration.
2) Cervix:
 Immediately after delivery of the placenta the cervix has little tone and
become thicker and firmer.
 The cervix is closed by the end of the first week
 Complete cervical involution may take 3-4 months and childbirth result in a
permanent change in the cervical OS from round to elongated.
 The uterine ligaments involute but subinvolution predisposes to prolapse and
retroversion.
3) Vagina:
 The vagina becomes smooth and swollen with poor tone after delivery.
Vaginal rugae reappear by 3 – 4 postpartum weeks.
4) Perineum:
 The perineum appears edematous and bruised after delivery.

 The perineum regains its tone by the end of puerperium.
5) Vulva:
 Edema, minute, or frank laceration may be seen immediately after labor.

 Edema disappears gradually in a few days while lacerations, if not properly
mended by sutures, may lead to the formation of a postpartum ulcer.
 The gaping of the vulva disappears.
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6) Breasts:
 Increase their activity during the puerperium.



 Colostrum is a yellowish fluid that contains more minerals and protein but

less sugar and fat than mature breast milk, and has a laxative effect on the
infant, is secreted for the first 3 to 4 days postpartum.
 Mature milk secretion is usually present after the third postpartum day but
may be present earlier if a woman breast-feeds immediately after delivery.
 With the establishment of milk secretion, the breasts become engorged, larger,
painful, and tender. Suckling relieves the discomfort and stimulates prolactin
secretion (which causes milk production) and stimulates oxytocin secretion
(which increases milk expulsion).
2. General Physiological Changes
1) Vital signs:
 Should be assessed at least twice daily and more frequently if indicated:
a. Temperature : may increase in the first 24 hrs. reach to 38°c after delivery
because of the dehydration during labor, may occur after difficult labor so
encourage fluid intake. Slight rise may occur at the third day due to
engorgement of the breasts.
b. Pulse : pulse rate decreases during the 1st week to 60-70 beat/mint (24-48
hrs.), if increase you should think of hemorrhage, infection, anxiety,
excitement, pain, or visitor.
c. Blood pressure : should be unchanged , if BP >140/90mmhg may indicate
postpartum hemorrhage.
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d. Respiratory rate: unchanged, respiratory function returns to normal by

approximately 6 to 8 weeks postpartum.
2) Cardiovascular function
 Most dramatic changes occur in this system.

 Cardiac output decreases rapidly and returns to
normal by 2 to 3 weeks postpartum.
 Hematocrit increases by the 3rd -7th P.P day and
the increased red blood cell (RBC) production
stops.
 Leukocytosis with increased white blood cells (WBCs) common during the first
postpartum week.
 If the patient is Rh negative, evaluate her need for RhO(D) immune globulin
(RhoGAM). If indicated, administer the RhoGAM within 72 hours of delivery.
 Following delivery, despite 300 to 500 ml of blood loss during normal vaginal
delivery, and 500-1000 ml is lost in cesarean births, excess blood volume,
which was necessary during pregnancy, remains in the intravascular
compartment and in interstitial spaces.
• The body rids itself of the excess fluids by two methods:
1. Diuresis: "increased excretion of urine" is facilitated by a decline in the

adrenal hormone aldosterone, which is increased during pregnancy to
counteract the salt-wasting effect of progesterone. urinary output of 3000 ml
per day is not common for the first few days of the postpartum period.
2. Diaphoresis "profuse perspiration" also rids the body of excess fluids
through skin "sweating often occurs at night"
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 Coagulation: During pregnancy, plasma fibrinogen necessary for coagulation

increased as a protection against postpartum hemorrhage. As a result, the
mother’s body has a great ability to form clots and thus prevent excessive
bleeding
 Blood values: The white blood cells count increasing 10.000/mm up to 20.000
or even 30.000/mm during postpartum. A moderate increase in the fibrinogen
and sedimentation rate occurs during the first postpartum period, and then
gradually gets back to normal values.
3) Respiratory function
 Returns to normal by approximately 6 to 8 weeks postpartum.
4) Musculoskeletal function
 Generalized fatigue and weakness is common.

 Decreased abdominal tone is common.
 Diastasis recti heals and resolves by the 4th to 6th week postpartum until
healing is complete, abdominal exercises are contraindicated.
5) Gastrointestinal tract
 Women are usually hungry& thirst after delivery.

 Constipation can occur.
 Hemorrhoids are common.
6) Renal & urinary system changes:
 Urine: Diuresis & diaphoresis occurs to excrete the water retained in

pregnancy within the first 24 hrs. after delivery.
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There is a tendency to retention of urine due to:

1. Atony of the bladder and abdominal wall.
2. Inability to micturate while recumbent
3. Reflex inhibition from stitched perineum.
4. Compression of the urethra by edema or hematoma.
 Urinary retention and over distention of the bladder may cause two
complications:
1. Urinary tract infection.

2. Postpartum hemorrhage. loss of sensation
 Bladder tone returns between 5 and 7 days.

 Mild proteinuria is common for 1 to 2 days after delivery in 50% of postpartum
women.
 The urine may also test positive for acetone / ketonuria resulting from
dehydration during a prolonged labor.
 Over distention of the bladder is common due to increase bladder capacity.
 A full bladder displaces the uterus and can cause postpartum hemorrhage.
 Dilated ureter and renal pelvis return to their non-pregnant state within 6-10
weeks after delivery.
7) Bowel function
 Gastrointestinal tone and motility decrease in the early

postpartum, commonly causing constipation.
• Constipation may be present due to:
1. Intestinal atony.
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2. Anorexia after labor.

3. Loss of body fluids.
4. Laxity of the abdominal wall.
5. Hemorrhoids, perineal trauma, and episiotomy.
6. Reflex inhibition enema in labor.
 Normal bowel function returns approximately 2 to 3

days postpartum
 women feel hungry and thirsty.
 Inform the woman that pain from hemorrhoids,
lacerations, and episiotomies may cause her to delay her
first bowel movement
 Women may return to her prepregnant weight in 6-8
weeks if weight gain during pregnancy within normal
range
 Gall bladder contractility increases to normal, allowing
for expulsion of small gallstones.
 After cesarean section, bowel tone returns in few days
and flatulence causes abdominal discomfort.
8) Integumentary function
 Striae lighten and melasma is usually gone by 6 weeks

postpartum.
 Hair loss can increase for the first 4 to 20 weeks
postpartum and then re-growth will occur, although the
hair may not be as thick as it was before pregnancy.
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9) Neurological function
 Discomfort and fatigue are common.

 Frontal and bilateral headaches are common and are
caused by fluid shifts in the first week postpartum.
10) Endocrine/Metabolic function:
 Thyroid levels are normal by 4 to 6 weeks postpartum.

 Glucose levels are low secondary to decreased human
placental lactogen and decreased growth hormone.
11) Body weight:
 Loss of weight is observed during the first l0 days

particularly in the non-lactating mothers. There is about
a 4 – 5 kg loss of body weight (sometimes 8 kg) due to
evacuation of uterine contents and diuresis.
12) Resumption of Ovulation and Menstruation:
 Most non-nursing mothers resume menstruation within

6 to 8 weeks after childbirth.
 In lactating mothers, menstruation usually reappears not
earlier then 3-4 months, and sometimes as late as 24
months.
 The first period is generally profuse and prolonged.
 It should be mentioned that ovulation can commence in
the absence of menstruation, and another pregnancy can
occur.
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13) Ovarian function:
 Estrogen and progesterone levels decrease rapidly after

delivery of the placenta.
 Estrogen reaches the follicular phase by 3 weeks after
birth, if the woman is not lactating.
 Ovulation may occur as early as 27 days after delivery.
The average time is 70 to 75 days post-delivery and 190
days post-delivery if breast-feeding.
 The start of menses after delivery is individualized.
Usually, the first menses occurs approximately 3
months after delivery, although breast-feeding women
may not start their first menses until 8 months.
14) Physiology of lactation
Lactation consists of two distinct processes

1. Milk production After labor, sudden fall of estrogen and progesterone levels
leads to marked rise of prolactin level. This hormone stimulates the alveolar
cells leading to milk secretion.
2. Milk ejection: Stimulation of the nipple and areola (by suckling), leads to
increased production of oxytocin from posterior pituitary. This hormone acts
on the myoepithelial cells which line the ducts causing its contraction. Milk
is ejected into the lactiferous ducts, where it is readily available to the suckling
infant (Let down reflex).
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• Nipple erection reflex" results also from stimulation of the nipple by

suckling or tactile stimulation of the nipple. This is of great help to the baby
during suckling.
Factors Affecting Milk Production
2. Regular complete breastfeeding.
3. Suckling abilities of newborn.
4. Maternal health, and Nutrition.
5. Psychological factors.
6. Hormones : Prolactin, Oxytocin, Thyroxin,
Growth hormone, in addition to
Progesterone and estrogen. Normal levels of
these hormones are essential for initiation &
maintenance of lactation.
3. Psychological Changes (Emotional response)
Phases of maternal role:

Emotional changes in the mother during the postpartum period (restorative
process) as described by Reva Rubin pass through three phases. They are:
o Taking –in phase
o Taking –hold phase
o Letting-go phase
 The first phase: Taking –in phase (turning in)
- It takes 2-3 days, during which time the mother’s first concern is with her own
needs (sleep and food).
- The woman reacts passively, mostly depends on others to meet her.
- She initiates little activity on her own. She is quite talkative during this phase
about every detail of her labor and delivery experience.
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 The second phase: Taking –hold phase (turning in)

- It starts the 3rd day postpartum.
- The emphasis is placed on the present.
- She becomes impatient and is driven to organize herself and her life.
- She progresses from the passive individual to the one who is in command of
the situation.
- This phase lasts about 10 days. Once the mother has taken control of her
physical being and accepted her role as a mother, she is able to extend her
energies to her mate and other children.
 The third phase: Letting –go phase (turning in)
- As her mothering functions become more establishment the mother enters the
letting-go phase.
- This generally occurs when the mother returns home.
- In this phase there are two separations that the mother must accomplish. One
is to realize and accept physical separation from the infant.
- The other is to relinquish her former role as a childless person and accept the
enormous implications and responsibilities of her new situation.
- She must adjust her life to the relative dependency and helplessness of her
child.
- This is the phase where postpartum depression may set in.
Postpartum Blues (Depression)
■ It is the gap between the ideal and reality: the new mother’s self-
expectation may exceed her capabilities, resulting in cyclic feelings of
depression.
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■ This condition is usually temporary and may occur in the hospital. The
condition is partly due to hormonal changes, and partly due to the ego
adjustment that accompanies role transition.
■ Up to 10% of women can experience postpartum depression. Usually,

reassurance and education are sufficient therapy, but sometimes a
psychiatric consultation is required. Antidepressant therapy may need to
be initiated. Postpartum depression can recur with subsequent
pregnancies.
■ Many women may experience temporary mood swings during this period
because of the discomfort, fatigue, and exhaustion following labor and
delivery, and because of hormonal changes after delivery. If this continues
after 10 day this called postpartum depression
Manifestations of emotional changes

 Disturbed appetite and sleeping patterns
 Discomfort, fatigue, and exhaustion
 Episodes of crying for no apparent cause
 The mother may experience a letdown felling accompanied by
irritability and tears which often relieves the tension
 Guilt felling at being depressed
Predisposing factors of emotional changes

 The first pregnancy
 A pregnancy in late childbearing years
 Ambivalence toward the woman’s own mother
 Social isolation
 Long or hard labor
 Anxiety regarding finance
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 Marital disharmony
 Crisis in the extended family
Nursing management
 Recognition of the effort made during labor: approval of behavior
during labor as well as in the immediate postpartum period.
 Support and encouragement in her care for the infant.
 Attention from family members particularly from the husband: this is
very significant as most of the attention in the immediate postpartum
period is directed suddenly toward the newborn.
 Someone to listen and help them solve their dependency –
independency conflict.
 Physical needs of comfort, nourishment and hygiene should be properly
fulfilled.
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3) Minor Discomforts during Postpartum Period

• List types of minor discomfort during postpartum period.
• Identify the most common postpartum minor discomfort.
• Clarify the mother needs and complains
• Apply a simple nursing measures which needed to alleviate mothers
complains and meet their needs.
• Reassure the mother and the family and explain to them the type of discomfort
and the nursing management needed to relief it.
Out line
 Definition.
 Most common postpartum minor discomforts.
1- After pain
2- Uterine subinvolution
3- Breast engorgement
4- Urinary Retention
5- Constipation
6- breast mastitis
7- Cracked Nipple
8- Insufficient milk supply
9- Leaking of breast milk:
10- Perineal Discomfort
11- Postpartum Blues (Depression)
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Definition of Minor Complains:

 They are minor complaints felt by the parturient during postpartum period.
Simple nursing measures (interventions) are needed to alleviate these complaints.
Most Common Postpartum Minor Discomforts

1) After pain
 It is a spasmodic colicky pain in the lower abdomen during the early postpartum
days due to vigorous contractions of the uterus.
 It is more common and more severe in multiparas due to weak muscle tone.
Conditions with increased intra-abdominal pressure e.g., polyhydramnios,
multiple pregnancy, large size infant
Predisposing factors
 Presence of blood clots, piece of membranes or placental tissue.
 Breastfeeding increases after-pain.
Managements:
1. Reassurance and simple explanation of the cause

2. Encourage relaxation , breathing exercise, and abdominal muscle exercises
3. bladder should be kept empty.
4. Simple uterine massage.
5. Mother is advised not to used hot water bottle.
6. Advice the mother to lie in a comfortable position (prone or sitting position).
7. Offering warm drinks
8. Ordering analgesia
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2) Uterine subinvolution
 It is failure of the uterus to regain its normal non-pregnant size within 6-8 weeks
after labor.
Causes of subinvolution:
 Retained placental fragment
 Infection
 Retroversion resulting in congestion
 Over distension of the uterus during pregnancy as in twins and
hydramnios.
 Fibroids
 Non –suckling
 Bad general condition and anemia as in cases of antepartum and
postpartum haemorrhage.
Managements:
1. Prevent excessive blood loss, infection, and other complications.

2. Massage uterus, facilitate voiding, and report blood loss.
3. Monitor blood pressure and pulse rate.
4. Administer prescribed medications.
5. Be prepared for possible D&C.
6. Early ambulation postpartum.
7. Daily evaluation of fundal height to document involution.
3) Breast engorgement
 It is an accumulation of increased amount of blood and other body fluids as well

as milk in the breasts. This condition occurs in frequently about the 3rd day
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postpartum, especially in primiparas. It is due to lymphatic and venous

engorgement and is relieved when milk comes out.
Causes
 Inadequate and\or infrequent breastfeeding
 Inhibited milk ejection reflex
 Congestion and increased vascularity
 Over production of milk.
Signs and symptoms
 Breasts are firm, heavy (due to blocked ducts), swollen, tender and
hot (37.8 C).
 Areola is firm, flattened nipple if engorgement involve the areola in
severe cases.
 Pain may be present leading to irritability and insomnia. The mother
may refuse the nurse and the infant.
Nursing management
1. Apply moist warm packs to the involved breast 2-3 minutes before each
feeding.
2. Massage and manual expression of milk to relieve areolar engorgement before
feeding. This facilities attachment.
3. Cold application after feeding.
4. A well-fitting bra should be used to provide support and comfort.
5. frequent breast feeding every 2 hours for 15- 20 min /side , if not breast feed
uses a manual or electronic pump.
6. The application of cool cabbage leaves to the breast, left in place for 20
minutes, may reduce symptoms of engorgement.
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7. Mild analgesics may be ordered. Syntocinon inhalation may be prescribed. In

severe cases, administration of 2 doses of diuretic (as Lasix 40 mg) is effective.
8. Anti-inflammatory medication.
Prevention:
 Frequently breastfeeding every 2-3 hours for 15-20 min /side.
 Begin breastfeeding as soon as possible after the birth.
 Avoid early use of bottles and pacifiers.
 Ensuring that baby is correctly latchet on at each feed.
4) Urinary Retention
 It is inability to excrete urine. The urine accumulated within the urinary bladder.
It is a common complaint during the first few days after labor.
Causes:
 Laxity of the abdominal muscles
 Inability to micturate in the recumbent position
 Reflex inhibition due to stitched perineum or bruised urethra
 Atony of the bladder
 Compression of the urethra by edema or hematoma.
Nursing management:
 Urine should be passed approximately 8-12 hours after delivery. If not,
the following measures should be attempted:
 Perineal care with warm water
 Privacy and reassurance
 Warm bedpan
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 Listening to the sound of running water

 Hot-water bottle over the symphysis pubis
 If these measures fail, catheterization should be performed using
complete aseptic technique
5) Constipation
 An abnormal infrequent and difficult evacuation of feces may occur during the
first few days postpartum.
Health teaching should consider the following:
 Diet rich in roughage.
 Increase fluid intake.
 Milk before bedtime.
 Exercises.
 After 72 hrs. a glycerin suppository, or mild laxative, may be administered as
ordered.
6) Breast mastitis
 It is an inflammation of the breast duct It is common and usually occurs in

women who are breast-feeding. characterized by Sadden onset of flu-like
symptoms
 It is usually affecting only one breast, but may affect both breasts, most
common in upper outer quadrant of the breast.
Most Common organisms:
 Staphylococcus aurous
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 Streptococcus
 Escherichia Coil
 Symptoms
 Mastitis affects 1% of women after Childbirth
Source of infection may be from hands of patient, personnel caring for patient,
baby's nose, or throat, or blood-borne.
Symptoms:
 Fever
 Fatigue
 headache
 Aches, chills, or other flu-like symptoms
 Redness, tenderness, warm , and edema of the breast
 A burning feeling in the breast
 A hard feeling or tender lump in the breast
 Pus draining from the nipple
 Swollen lymph glands in the arm
 Localized breast pain
Predisposing factors :
 Obstructed milk duct

 Engorgement
 Cracked, sore nipple
 Poor nutrition
 Trauma
 Tight bra
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 Managements:
 Provide warm compresses to resolve tissue reaction; may cause increased milk
production and worsen symptoms.
 May apply cold compresses to decrease tissue metabolism and milk
production.
 Continue breast feeding with appropriate and correct feeding position , may
have patient stop breast-feeding (controversial).
 Massage of the breast.
 Wear a well-fitting bra.
 Avoid wash breast with soap.
 Eat well balanced diet (Vitamin C)
 Increase fluid intake
 Antibiotic medications as (Cloxacillin , Cephalosporin)
 Analgesia to relieve pain
Cracked Nipple
 Fissured nipple occurs in about half of the nursing mothers at one time or
another. Nipple tenderness and soreness are usually the result of trauma and
irritation.
Causes:
• Improper antenatal care.
• Improper technique of breastfeeding.
• Unnecessary prolonged lactation.
• Flat or large size nipple → excoriation
• The use of irritating substances e.g., soaps, lotions.
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• Conditions as candidiasis, and contact dermatitis.

• Engorgement of the breast.
Signs and symptoms:
• Irritation of the nipple in the form of minute blisters or petechial spots.

• Persistent pain and tenderness.
• Bleeding.
• Inflammation signs.
 Nursing management:
• Proper technique of breast-feeding should be followed.

• Apply moist heat and massage before feeding (3-5 min).
• Frequent, short feedings.
• Air/sun exposure.
• Avoid engorged breast.
• Avoid irritating materials.
• Use supportive bra.
• Mild analgesic and panthenol ointment may be used.
• Treatment of candidiasis and dermatitis.
7) Insufficient milk supply
 Physiological variations in milk secretion are often perceived as milk

insufficiency.
• Encourage the mother to follow frequent breast-feeding.
• Mother should drink more fluids.
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• Reduce outside activities that are strenuous.

• Avoid supplementary hour feeds.
• Nurse the baby every hour if necessary.
• Nurse in a relaxed position.
• Try to avoid distracting or up- setting situation while breast-feeding.
• Breast-feed just as the baby wakes up before he can begin crying from
hunger.
• Have a warm or cool drink each time the baby is breast-fed.
8) Leaking of breast milk
 Women who have active ejection reflexes often find that breasts leak milk
during the first few weeks after delivery.
 The mother should put clean pieces of gauze or cloth inside the bra to soak up
the milk.
 Change the clothes frequently.
 Breast care frequently.
9) Perineal Discomfort
 It usually occurs due to presence of tears, lacerations, episiotomy, and edema.
• Frequent perineal care under aseptic technique. (the area should be kept
clean and dry).
• Soaks of magnesium sulfate compresses in case of edema
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• Expose to dry heat (electrical lamp) will help the healing process
• Episiotomy is assessed for (REEDA):
1. R: Redness.
2. E: Edema.
3. E: Ecchymosis (purplish patch of blood flow).
4. D: Discharge.
5. A: Approximation, or the closeness of the skin edge.
Health education that includes:

 Perineal self-care
 Position (lateral with a pillow between thighs)
 Diet rich in protein
 Sources of strain such as coughing, constipation and carrying heavy objects
should be avoided
 Encourage pelvic floor muscle exercises
 Avoid infection & The use of cotton under wear
10) Postpartum Blues (Depression)
 Rev a Rubin defined postpartum blues as "the gap between the ideal and reality:
the new mother's expectations may exceed her capabilities, resulting in cyclic
feelings of Depression". This condition is usually temporary and may occur in
the hospital. The condition is partly due to hormonal changes, and partly due to
the ego adjustment that accompanies role transition.
 Signs and symptoms:
 Disturbed appetite and sleeping patterns.

 Discomfort, fatigue, and exhaustion.
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 Episodes of crying for no apparent cause.

 The mother may experience a letdown feeling accompanied by irritability
and tears which often relieves the tension.
 Guilt feeling at being depressed.
Predisposing factors:
• The first pregnancy or pregnancy in late childbearing age.
• Social isolation.
• Ambivalence toward the woman's own mother.
• Prolonged, hard labor.
• Anxiety regarding finances.
• Marital disharmony. Crisis in the family.
• Reassurance, understanding, and anticipatory guidance will help the
parents become aware that these feelings are a normal accompaniment to
this role transition.
• Recognition of the effort made during labor: approval of behavior during
labor as well as in the immediate postpartum period
• Support and encouragement in her care for the infant
• Attention from family members particularly from the husband: this is very
significant as most of the attention in the immediate postpartum period is
directed suddenly toward the newborn.
• Someone to listen and help them solve their dependency –independency
conflict.
• Physical needs of comfort, nourishment and hygiene should be properly
fulfilled.
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4) Student Activities
Activity (1) Case Scenario
A 20 year old woman gave birth to her first baby 10 days ago. Her pregnancy,
labor, and birth were uncomplicated. The nurse who attended the birth checked the
woman and her baby the day after the birth. She has not seen a healthcare provider
since then. This is her first postpartum clinic visit. The woman has come to the
clinic because she has sore, red nipples. Her baby is with her.
Answer the following questions:-
1. Before beginning your assessment, what should you do for the woman?
2. What history will you include in your assessment of the woman?
3. What physical examination will you include in your assessment of the woman?
4. What laboratory tests will you include in your assessment of the woman?
5. Based on your assessment, what is the diagnosis (problem/need) and why?
6. Based on your diagnosis (problem/need identification), what is your plan of
care and why?
Activity (2)
1. List schedule of postpartum visit.
2. Discuss activities and nursing care which is given for mother and newborn
in each visit.
Activity (3)
1. Explain objectives of the immediate care of the mother and newborn during the
postpartum period.
2. Formulate nursing care plan for the postpartum period
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5) General Follow up Activity

1. A nurse has provided discharge instructions to a woman who delivered a
healthy infant by cesarean delivery. Which statement made by the woman
indicates a need for further instructions?
a. I will begin abdominal exercises immediately.

b. I will notify the physician if I develop a fever.
c. I will turn on my side and push up with my arms to get out of bed.
d. I will lift nothing heavier than the newborn infant for at least 2 weeks.
2. A nurse is monitoring the amount of lochia drainage in a woman who is

2 hours postpartum and notes that the woman has saturated a perineal pad
in 1 hour. The nurse reports the amount of lochia flow as:
a. Scanty
b. Light
c. Heavy
d. Excessive
3. A nurse is teaching a postpartum woman about breast-feeding. Which of the

following instructions should the nurse include?
a. The diet should include additional fluids
b. Prenatal vitamins should be discontinued
c. Soap should be used to cleanse the breasts.
d. Birth control measures are unnecessary while breast-feeding.
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4. It has been 12 hours since the woman's delivery of a newborn. The nurse
assesses the woman for the process of involution and documents that it is
progressing normally when palpation of the woman's fundus is noted at
which level?
a. At the umbilicus
b. One fingerbreadth below the umbilicus
c. Two fingerbreadths above the umbilicus
d. Two fingerbreadths below the umbilicus
5. A nurse is performing an assessment on a 2-day postpartum mother. The

mother complains of severe pain and an intense feeling of swelling and
pressure in the vulvar area. After hearing these complaints, the nurse
specifically checks the client's.........
a. Episiotomy for drainage

b. Rectum for hemorrhoids
c. Vulva for a hematoma
d. Vagina for lacerations
6. When does postpartum depression usually happens?
a. During the birth of the baby

b. One week after the delivery
c. Immediately after the delivery
d. During the letting go phase
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7. What happens during the taking in phase?
a. The woman easily adjusts to her new role as a mother.

b. The woman is passive and relies mostly on the people around her.
c. The woman is very active in the care of her new-born.
d. The woman undergoes postpartum depression.
8. What is the most important player during involution?
a. Medications
b. Support persons
c. Contractions
d. Comfort measures
9. How could a woman regain the strength and tone of her vagina post birth?
a. Through pelvic rocking exercises.

b. Do Kegel’s exercises.
c. Have a hot sitz bath.
d. Apply cold compress to the area.
10.What would you advise a woman who has a urinary output of 3000 mL per
day postpartum?
a. It is a normal occurrence after birth.

b. She should visit her physician and have it consulted.
c. It is a very dangerous complication postpartum.
d. She should restrict her fluids to decrease her output.
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11.Enumerate 4 Goals of postpartum care:

1- ………………………………………………..
2- ………………………………………………..
3- ………………………………………………..
4- ………………………………………………..
12.List 4 Special Aspects of Postpartum Care

1………………………………………………...
2……………………………………………….
3……………………………………………….
4……………………………………………….
13.Enumerate 4 nursing interventions of after pain

1………………………………………………...
2……………………………………………….
3……………………………………………….
4……………………………………………….
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6)References
6. Adele Pillitteri, Maternal and child health nursing, 6th edition lippincott
Williams and wilkins publication, Philadelphia, 2017, 233-280.
7. Annama Jacob, A Comprehensive Textbook of Midwifery and Gynocological
Nursing, 5th Edition, Jaypee Brothers Medical Publishers, 2018, 220-250.
8. Catherin's, A Study to Assess the Effectiveness of selected nursing measures on
after birth pain among postnatal mothers in selected hospital, Punjap. M.Sc
Nursing, thesis of Omayal Achi College of Nursing, submitted to Dr. M.G.R.
Medical University, Chennai, 2019.
9. Brown SJ, Davey MA, Bruinsma FJ., Women's views and experiences of
postnatal hospital care in the Victorian Survey of Recent Mothers, Midwifery, 21
(2). 109-126. 2020.
10.Myles, Textbook for midwives, 14th edition Churchill livingstone, publication,
London, 2019, 219-220.
11.Thomas, M., A study to assess the effectiveness of structured teaching program
on knowledge and practice regarding management of minor disorders of
pregnancy among primigravida mothers in district hospital, Tumkur, 2020, 2-11.
12.WHO Recommendations on Postnatal Care of the Mother and Newborn.,
Geneva, WHO, 2017.
13. Kansky C (July 2019). "Normal and Abnormal Puerperium: Overview, Routine
Postpartum Care, Hemorrhage". Medscape.
14. "Childbirth recovery and postpartum care". www.aboutkidshealth.ca.
Retrieved 2018-04-22.
15.WHO (2019). "WHO recommendations on postnatal care of the mother and
newborn". World Health Organization. Archived from the original on 22
December 2020. Retrieved 22 December 2020.
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16.^ Thom DH, Rortveit G (December 2019). "Prevalence of postpartum urinary

incontinence: a systematic review". Acta Obstetricia et Gynecologica
Scandinavica. 89 (12): 1511–22. doi:10.3109/ 00016349 526188.PMID
. 21050146 . S2CID 18385231.
17. "Postpartum care: After a vaginal delivery". Mayo Clinic. Retrieved 2020-05-
18.
18. N. H. S. Choices (2018). "How soon can I use tampons after giving
birth?". N.H.S. Choices. Retrieved 2018-04-22.
19. "Statistics on Postpartum Depression - Postpartum Depression
Resources". PostpartumDepression.org. Retrieved 2020-05-18.
20.Dennis CL, Fung K, Grigoriadis S, et al. Traditional postpartum practices and rituals: a
qualitative systematic review. Womens Health (Lond) 2017; 3:487.
21.Timilsina, R. Dhakal, Knowledge on postnatal care among postnatal mothers.
Med. Pharm. Sci., 1 2017, 88.
22.Kumbani and Mclnerney A study to assess the effectiveness of video teaching
programme on postpartum primigravida mothers admitted in urban health
maternity centers, Coimbatore, Tamilnadu. Reviews of progress. 1(8). 2019. 19.
23.Missiriya, utilization of postnatal care among rural women in Nepal; Dentocafe:
16(3). 2018. 103-67.
24.Adam, L.A., Assessment of knowledge and practice of mothers regarding self-
care during puerperium, Ribat University, 2017, 22.
25.Kirandeep Kaur, Avinash Kaur Rana, ShaliniGainder, Effect of video on
postpartum minor discomfort Among Primigravida Mothers, Nursing and
Midwifery Research Journal, 9(1). 2020.
26.Nigai, F.W., A quasi experimental study on effects of a postpartum minor
discomfort education using videos. International Journal of Obatetrics and
gynaecology, 23(1). 2019. 412-23.
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27.Wan, Postpartum urinary retention: A systematic review of adverse effects and

management. IntUrogynecol J. 2019.
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MM., Effectiveness of Planed Teaching Program on Episiotomy care: a
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29.Santhi MD, Kokilavani, Best practices in management of postpartum minor
discomfort. J Perinat Neonatal Nurs, 31. 2018. 126-36.
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Module (5): Family Planning
Course: Maternity& Newborn Health Nursing

Code: 300(N)
Module (5): Family Planning
Teaching Method(s): 3hr(s) Lectures; virtual classes, 18hr(s) Clinical (includes
6hr(s) for small group clinical skills teaching & 12hrs for labs clinical skills).

This module is designed to learn students about the most used family planning
services and aspects of family planning programme management including planning,
monitoring and evaluation that can improve the health of both mothers and children.
Module Objectives: To:-

4. To list the main principles of family planning counselling.
5. To recognize key concepts of reproductive rights relating to family planning.
6. To identify concepts of gender issues and relations in family planning.
7. To list key indicators of quality of care in family planning.
Module Content:
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1). Counselling Process.

2). Introduction to Family Planning Methods.
3). Natural Family Planning Methods.
4). Chemical Family Planning Methods.
5). Mechanical Family Planning Methods.
6). Hormonal Family Planning Methods.
7). Emergency Family Planning Methods.
8). Surgical Family Planning Methods.
9). Student Activities.
10). General Follow up Activities.
11). References.
Learning Outcomes:
On successful completion of this module, students should be able to:
1. Describe aspects of family planning counselling.
2. List principles of the counselling process.
3. Explain objectives of family planning methods.
4. Describe the health benefits of using family planning.
5. Enumerate advantages of natural family planning methods.
6. Explain mode of action of chemical methods.
7. List indications of chemical methods.
8. Explain mode of action of an intrauterine device (IUCD).
9. Enumerate types of hormonal methods.
10.Describe methods of tubal ligation.
11.Identify uses of emergency contraception.
12.Describe the mechanism of action, effectiveness, advantages, disadvantages,
and indications for use of family planning methods.
13.Distinguish between stages of counselling process.
14.Differentiate between mechanical and chemical methods.
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15.Interpret different types of hormonal methods.

16.Plan nursing care for male after vasectomy.
17.Plan visits for women after an intrauterine device insertion.
18.Apply the counselling process by using the GATHER Approach.
19.Demonstrate the benefits of using family planning methods.
20.Demonstrate nursing instructions while using different methods of family
planning.
21.Apply nursing instructions while using vaginal spermicidal.
22.Follow steps of applying different mechanical methods as male and female
condoms, vaginal diaphragm, and cervical cap.
23.Evaluate importance of family planning for improving the health of both
mothers and children.
24.Value the importance of regular follow up while using contraceptive methods.
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1). Family Planning Counselling
 Short Story:
History
A 21 year- old a married woman presents to the family planning center because
she had unprotected intercourse related to broken condom and worried about
pregnancy. She had unprotected intercourse 36(hrs) ago, and 4 days before that. Her
last menstrual period started 13 days ago, and she bleeds for 4 days every 27 days.
She is generally heathy and has no significant medical history.
Examination
- Abdominal Examination is unremarkable and internal examination is not

indicated.
Investigations
- Urinary pregnancy test: Negative

Questions
- What options are available to this woman and how should be managed?

• Describe aspects of family planning counselling.
• List principles of the counselling process.
• Distinguish between stages of counselling process
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Outline
1. Introduction
2. Definition of Counselling Process
3. Principles of Counselling Process
4. Stages of Counselling Process
5. Counselling Using the GATHER Approach
Introduction
Counseling is one of the critical elements in the provision of quality family
planning services. Through counseling, providers help clients make and carry out
their own choices about reproductive health and family planning. Good counseling
leads to improved client satisfaction. A satisfied client promotes family planning,
returns when she needs to and continues to use a chosen method.
Definition of Counseling Process

 It is a process whereby a person purposefully assists another to better handle
his or her problems.
How to use counseling at family planning choice?

 Ideally, family planning counseling should start during antenatal care.
 Providers can help women by prescribing family planning methods through
counseling process.
Principles:
1. Being in a private room and quiet place.
2. Taking sufficient time.
3. Maintaining confidentiality.
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4. Using direct and simple words.
5. Using good interpersonal communication skills.
6. Telling the most important messages first.
7. Using available visual aids.
Stages of counseling process

Stage One: Relationship building
Stage Two: Assessment and diagnosis
Stage Three: Formulation of counseling goals
Stage Four: Intervention and problem solving
Stage Five: Termination and Follow Up
Stage Six: Research and evaluation
Counselling Using the GATHER Approach

Counselling of family planning using the acronym GATHER to remember all the
six steps:
1. G → Greet in a friendly, helpful, and respectful manner.
2. A →Ask about family planning needs, concerns, and previous use.
3. T→ Tell about different contraceptive options.
4. H → Help to make a decision about which method prefers.
5. E→ Explain how to use the method chosen; ask to repeat the instructions.
6. R →Arrange a return visit and follow-up.
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2) Introduction to Family Planning
• Explain objectives of family planning methods.
• Describe the health benefits of using family planning.
• Demonstrate the benefits of using family planning methods.
• Evaluate importance of family planning for improving the health of both
mothers and children.
Outline:
1. Introduction
2. Definition of Family Planning Methods
3. Objectives of Family Planning Methods
4. Indications of Family Planning Methods
5. Benefits of Using Family Planning Methods
6. Qualities of Contraceptive Methods
7. High Risk Group of Family Planning
8. Types of Family Planning Methods
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Introduction :
Family planning is the planning of when to have children, and the use
of birth control and other techniques to implement such plans. Other techniques
commonly used include sexuality education, prevention and management
of sexually transmitted infections, pre-conception counseling and management,
and infertility management.
Definition of Family Planning

• Involves personal, social economic, religious and cultural decision about
completing pregnancy, it will mean seeking a way to prevent or postpone
pregnancy.
• Proper birth spacing is having children 3 to 5 years apart, which is best for the
health of the mother, her child, and the family.
Objectives of Family Planning

1. To avoid unwanted births.
2. To bring about wanted births.
3. To regulate the intervals between pregnancies.
4. To control the time at which births occur in relation to the ages of the parents.
5. To determine the number of children in the family.
6. To prevent pregnancy for women with serious illness in whom pregnancy
would pose a health risk.
7. To avoid pregnancy women's who are carrier of genetic disease.
Indications:
1. Limitation of population.
2. Limitation of family
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3. Chronic maternal illness as cardiac or renal disease.

4. Previous obstetric complications as repeated caesarean section.
5. Transmissible diseases to the fetus as epilepsy.
6. Early years of marriage when adjustment to the new life may be needed.
7. Later years of marriage when the family is completed.
Benefits of Using Family Planning Methods:

Family planning provides many benefits to mother, children, father, and the family.
1. Benefits to the Mother:-

• Enables her to regain her health after delivery and maintenance of good health
standard.
• Enjoyment of maternal life and provide attention to her husband and children.
• When suffering from an illness, gives enough time for treatment and recovery.
• Avoidance of hazards and complications (mortality and morbidity).
2. Benefits to the Child:-

• Healthy mothers produce healthy children.
• Will get all the attention, security, love, and care they deserve.
• Adequate breast feeling and proper weaning.
• Improve general life welfare due to better nutrition and health.
• Decrease infant mortality rate.
3. Benefits to the Father and Family:-
• Lightens the burden and responsibility in supporting his family.
• Enables him to give his children their basic needs (food, shelter, education,
and better future).
• Gives him time for his family and own personal advancement.
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• When suffering from an illness, gives enough time for treatment and recovery.
Qualities of Contraceptive Methods

• Cheap
• Available
• Easy to use
• Independence from coitus
• Total safety
• Total effectiveness
• Availability to everyone
• Instant reversibility
• Used with minimum of advice & care from the health provider
High Risk Group of Family Planning:

1- Woman with sexual transmitted disease
2- Woman with chronic disease
3- Old age woman over 45 years
4- Woman with complete family members
5- Woman with low socioeconomic status
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1. Natural Methods→ (1-Calendar Method, 2- Safe Period, 3-Basal Body

Temperature, 4- Cervical Mucus Method, 5- Symptothermal Method, 6-
Lactational Amenorrhea, 7- Withdrawal Method (coitus interrupts), 8-Abstinence
and 9- Vaginal Douching).
2. Chemical Method→ (1-Vaginal Contraceptive Sponges, 2- Vaginal Spermicides
such as: - Foams, Cream, Jell & Suppositories).
3. Mechanical Methods→ (1-Intrauterine Contraceptive Devices (IUCD), 2-

Condoms (Male & Female), 3- Cervical Cap, and 4- Vaginal Diaphragm).
4. Hormonal Methods→ (1-Oral Contraceptive Pills (Combined Pills,

Progesterone Only Pills), 2- Injectable Contraceptive (Combined, Progesterone
Only), 3-Subcutaneous Implants (Norplant, Implanon), 4- Skin Patches, and 5-
Vaginal Rings).
5. Surgical methods→ (1-Tubal Ligation, and 2- Vasectomy).
6. Emergency Method→ (1-Natural methods,2- Hormonal Methods(Combined
contraception, Estrogen, Progesterone),3- Intrauterine devices (IUDS), and 4-
Menstrual Regulation).
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3) Natural Family Planning Methods
• Enumerate advantages of natural family planning methods.
• Describe the mechanism of action, effectiveness, advantages, disadvantages,
and indications for use of natural family planning methods.
• Demonstrate nursing instructions while using different methods of natural
family planning methods.
• Evaluate importance of natural family planning for improving the health of
both mothers and children.
Outline
1. Introduction
2. Definition of Natural Methods
3. Objectives of Natural Methods
4. Advantages of Natural Methods
5. Disadvantages of Natural Methods
6. Types of Natural Methods
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Introduction
Natural methods of contraception are considered "natural" because they are not
mechanical and not a result of hormone manipulation. This method is based on
knowing when woman ovulates each month to use this method . It is necessary to
watch for signs and symptoms that indicate ovulation has occurred or is about to
occur.
Definition of Natural Methods

• Natural methods of contraception are considered "natural" because they are not
mechanical and not a result of hormone manipulation.
• This method is based on knowing when woman ovulates each month in order
to use this method. It is necessary to watch for signs and symptoms that indicate
ovulation has occurred or is about to occur.
Objectives of Natural Methods

1. Enable couples to time sexual intercourse in relation to the fertile and infertile
phases of the menstrual cycle.
2. Natural family planning method is particularly attractive to individuals who
are unable to use other contraceptive methods
3. Useful to woman who wish to learn more about their body's responses
throughout her reproductive cycle.
Advantages of Natural Methods

1. It doesn't cause any side effects.
2. It is acceptable to all cultures.
3. It can be used to avoid pregnancy or to become pregnant according to women's
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wishes.
4. It doesn't involve chemicals or physical products secretions, so women can be
aware of possible infection.
5. It involves partner in the process which increase feeling of closeness and trust.
Disadvantages of Natural Methods

1. It takes 3-6 menstrual cycles to learn effectively.
2. It doesn't protect against sexually transmitted disease as HIV.
3. You will need to avoid sex during the time you might be pregnant, which
some couples can find it difficult.
4. It can be much less effective than other methods of contraception.
5. It will not work without cooperation of both partners.
6. You will need to keep a daily record of your fertility signs.
7. It is not suitable if you have persistent irregular period.
8. High failure rate (effectiveness about 68%).
Types of Natural Methods:

1-Calendar Method
Definition: -
• The rhythm or calendar method is the best and safest method to avoid
pregnancy. It is based on a record of the woman's menstrual cycle during the
previous 6 months.
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Prediction of Fertile Days in Your Current Cycle

 Tell the woman to calculate her cycle for 6m and know the shortest cycle.
 Find the shortest cycle.
 Subtract 18 from the shortest cycle to know the first day of fertile days.
 Find the longest cycle.
 Subtract "11" from the longest cycle to know last day of fertile days.
An Example for Prediction of Fertile Days in Your Current Cycle
 Predicting the first fertile day if the shortest cycle 26 day.
 Subtract 18 from that leave 8.This is the first fertile day.
 Predicting the last fertile day. if the longest cycle 30 day.
 Subtract 11 from 30 it leaves 19.This is the last fertile day.
 In this example from 8 to 19 are unsafe days, all other safe day.
Advantages of Calendar Method

1. There are no side effects.
2. In expensive.
3. Encourage communication between couples.
4. It is acceptable to all cultures.
Disadvantages of Calendar Method

1. There is restriction on sex.
2. Take long time to learn and use it properly.

3. If one does not have regular menstrual cycle miscalculation for dates can
occur. Resulting in not knowing what safe time for inter.
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Nursing Instructions
1. Teach women how to calculate her safe period.
2. Avoid Sexual intercourse during fertile period.
3. If woman has irregular cycle, advise her to use other type of contraception.
4. Keep record of the length of each menstrual cycle to determine when you are
fertile.
5. Use an ordinary calendar.
6. Circle day one of each cycle which is the first day of your period.
7. Count the total number of days in each cycle for at least 6- 8 cycle" 12 months
is better“.
8. Don't use the calendar method if all your cycle are shorter than 17 days.
9. Don’t have unprotected intercourse on any day the calendar method say is
unsafe.
2-Safe Period Method
Description: -
 This method requires a regular menses.
 The menstrual cycle is 28 days long.
 Ovulation usually occur about 14 days.
 Human ovum can be fertilized for about 48 h after ovulation and sperm can
survive up to 72 h.
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 In this method the couple abstain from intercourse for 2 days before and 2
days after expected ovulation.
Advantages
2. In expensive and convenient.
3. Encourage communication between coupes.
 Signs and Symptom of Ovulation

1. LH surge
2. Positive result on an ovulation predictor
test.
3. Changes in cervical mucus (fertile quality
cervical mucus.)
4. Increased sexual desire.
5. Sustained basal body temperature
increase.
6. Fertile cervical position.
7. Breast tenderness.
8. Mittelschmerz Pain (Ovulation Pain).
9. Mild cyclic pain many be caused expelling
of the follicular contents.
10.Mild cyclic spotting

11.Edema of limbs.
12.Change in a petite and mode.
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13.Abdominal pain and cramps.

14. Weight gain
15.Fertile Saliva Ferning Pattern.
Estrogen and progesterone alter the consistency of dried saliva before or during
ovulation, causing patterns to form. These patterns in the dried saliva may look
similar to crystals or ferns in some women.
Nursing Instructions:
1. If the woman has irregular cycle advise her to have other type of contraception.
2. Nurse should explain that ovulation take place 12 to 16 days before start of the
next menstrual flow, so she must have a barrier to protect herself from
pregnancy.
3-Basal Body Temperature (BBT)
Definition: -It is the body temperature at rest and used to detect ovulation.
Description
1. This method is based on the fact that the basal body temperature Lower during
the first 2 weeks of the menstrual cycle, before ovulation.
2. Immediately after ovulation, corpus luteum progesterone raises BBT by 0.2 -
0.4°C and maintained until the next menstruation.
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3. This method is based on the fact that the basal body temperature Lower during
the first 2 weeks of the menstrual cycle, before ovulation.
4. Immediately after ovulation, corpus luteum progesterone raises BBT by 0.2 -

0.4°C and maintained until the next menstruation.
5. The rise in temperature indicates that progesterone has been released into the
system.
6. It also means that the patient has ovulated.
7. Just before the day of ovulation, a patient's BBT falls about 1°C.
8. At the time of ovulation, the BBT rises a full degree because of progesterone
influence.
9. The couples have safe unprotected intercourse from the 3rd day after
temperature rise until the beginning of the next period.
10. To use the BBT method of contraception the woman records her temperature
daily at basal condition (in the early morning,
→ just after a walking

→ before any physical activities
→ by oral or rectal route in a special chart through the cycle.
11. BBT method can be affected by many variables, which may lead to mistaken
interpretations of a fertile day as a safe day such as illness, activity, stress,
hydration, and emotions.
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Advantages of BBT
1. Its inexpensive
2. Has no side effects
3. Encourage communication between couples
4. Acceptable in all culture
 Disadvantages of BBT
1. If intercourse take place night before drop in temperature pregnancy is
possible.
2. Typical temperature can be disrupted by stress, anxiety, illness and fatigue.
3. Some couples abstain from intercourse for several day before the anticipated
time of ovulation and then 3days after ovulation.
1. Ask woman to take her temperature every morning before she gets out of bed.
2. This should be done before eating or drink anything
3. This should occur at the same time everyday
4. Recommended a special thermometer that's more accurate and sensitive than

typical oral thermometer must be use.
5. Daily temperature variations carefully noted.
6. Teach woman refrain from having intercourse from the time her temperature
drops until at least 72 hours after her temperature increase again.
7. Teach woman to recognize other factor that may rise temperature.
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4- Cervical Mucus Method
Definition: -
 Called billing or ovulation method this is based on
changes in cervical mucus as the result of influence of estrogen and
progesterone on the mucus gland of the cervix.
 This mucus is generally thick and various in color similar to raw egg white.
This type of mucus increases permeability to sperm.
 Mechanism: -
1. Changes into consistency of cervical mucus occurs 2-3 days before ovulation.
The woman checks her cervical mucus if it is sticky, ovulation is about to occur
or has occurred.
2. This method defends on the ability of the women to judge relative sickness of
cervical mucus and abstain from intercourse for at least 6 days the sickness
first is noticed.
 Cervical Mucus Examination

1. Fern test:
 Take a drop of cervical mucus on a glass, left to air dry for 3-5 minutes and
examined under microscope.
 Sodium chloride crystals form a palm leaf appearance under estrogen effect
and mean anovulation.
2. Spinnbarkeit test:
 Minimally stretched cervical mucus between 2-glasses slides → Anovulation.
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Cervical Mucus Changes before and after or during Ovulation
Cervical mucus Before ovulation During ovulation
1. Colour Creamy white Clear
2. Amount Decreased Increased
3. Content Low amount High amount
4. Elasticity Stretch from 3:5 cm Stretch from 5-10
5. Consistency Thick Thin
6. Hormone Under effect of estrogen. Under effect of progesterone
Advantages
2. In expensive and convenient.
3. No controversial
Disadvantages
Vaginal infection can affect the quality of cervical mucus.
Presence of semen interfere with assessment of cervical mucus.
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1. The woman can check by gently placing the middle finger into vagina and
pushing it up to around her finger.
2. For the first few days after period, she will probably find the vagina and can't
feel any mucus.
3. As the levels of hormones rise to prepare the body for ovulation, she will
probably find that her cervix now producing mucus.
5- Symptothermal Method
Definition: -
 It is a method that Combines the BBT method with the cervical mucus method.
 Combining the two methods is more effective than if either is used alone.
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Description: -
 The woman takes her daily temperature and watches for the rise in temperature
that signals the onset of ovulation.
 She also assesses her cervical mucus daily.
 The couple abstains from intercourse until 3' days after the rise in basal
temperature or the fourth day after the peak day (indicating ovulation) of cervical
mucus because these symptoms indicate the woman's fertile period.
Advantages
1. It is inexpensive
2. Provide the couple with more information
3. Encourage communication
4. Has no sides effects
5. Require few days of abstinence of intercourse because it allows the fertile

period to be more easily identified.
Disadvantages
1. It is more complex
2. Difficult to learn
3. Require regular and daily efforts
1. Woman should take her temperature every morning before getting out of
bed.
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2. This should be done before eating or drinking anything.

3. This should occur at the same time every day.
4. Uses specific thermometer for this method.
5. The increase in temperature is very small, this likely that you are no longer
fertile at this time.
6. You should recognize difference in the quality and quantity of cervical

mucus be examined it is appearance on her under wear.
7. Teach the women choose to have intercourse between the time of her last
menstrual period and the time of change in the cervical mucus.
8. Teach the mother not to have intercourse at all for 3 to 4 days after notice
the change in cervical mucus.
6- Lactational Amenorrhea (Postpartum Infertility)
Definition:-
 is a modern, temporary family planning method that has been developed as a
tool to help support both breastfeeding and family planning use and occurs when
a woman is amenorrheic and fully breastfeeding.
Lactational Amenorrhea Method

↓ ↓ ↓
means related to means not having means a technique
breastfeeding menstrual bleeding for contraception
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Description
1. The stimulation of the nipples by infant suckling sends nerve impulses to
hypothalamus causing release of prolactin and disruption the release of "FSH"
and "LH" by pituitary gland.
2. Reduction of these hormones affects follicular development and suppress

ovulation.
LAM is defined by three criteria:

1. The woman’s menstrual periods have not resumed, AND
2. The baby is fully or nearly fully breastfed, AND
3. The baby is less than six months old.
When any one of these three criteria is no longer met, another family planning
method must be introduced in a timely manner to ensure healthy birth spacing.
 LAM is a contraceptive method, based on the physiology of breastfeeding.

 Breastfeeding is a feeding practice.
 Amenorrhea, or the absence of menstrual bleeding, reflects a reduced risk of

ovulation, but neither breastfeeding nor amenorrhea is a family planning
method.
Advantages
1. Available to all breast-feeding women.
2. At least 98% effective.
3. Has no side effect.
4. Inexpensive and convenient.
5. Encourage communication between partners.
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6. Protection being immediately postpartum.

7. Can be used temporarily when woman decides other contraception to use.
Disadvantages
1. Full or nearly full breast feeding may be difficult for some women to
maintain due to social circumstance.
2. No sexual transmitted disease or HIV protection.
3. The Duration of the method is limited.
1. Women should use this method within the first 6 months postpartum.
2. Women use this method should be fully or nearly fully breast feeding.
3. Teaching women about effective breast-feeding technique.
4. Women should breastfeed exclusively for the first six months: no water, other
liquids, or solid foods.
5. The infant must breastfeed at least every four hours during the day and at
least every six hours at night.
6. Counsel women about alternative methods of birth control.
7-Withdrawal Method (Coitus Interrupts or Pulling out)
Definition: -
 Is a method of contraception in which the man withdraws his penis from the
vagina before ejaculation.
 Fertilization is prevented because the sperm do not enter the vagina
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 The practice requires the man to be able to recognize when he is about to

ejaculate.
 Withdrawal is often used by couples as a back method to condoms or hormonal

method.
Advantages
1. It can be used for people with objection to other forms of contraception
2. It has no side effect
3. It can be practiced without prescription or medical consultation
Disadvantages
1. Man, my release small amount of sperm before actual ejaculation.
2. Man needs self-control and precise sense of timing to be able to withdrawal

his penis from woman's vagina before ejaculation.
3. It only about 75% -80% effective in preventing pregnancy.
4. Pelvic congestion syndrome related to withdrawal method.
1. The man must be able to predict ejaculation and to control the urge to remain
in the vagina.
2. Before intercourse, the man should urinate to removal any sperm that may be
present from previous ejaculation.
3. Before insertion, he should wipe the penis clean of any ejaculatory fluid.
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8-Abstinence
Definition and Description: -

 is the practice of not doing or not having any sexual intercourse for long time.
 No sexual intercourse with a member of the opposite sex means that there is no
chance that man's sperm can fertilize woman's egg.
 It’s essentially 100% effective method that prevent pregnancy.
 Man and woman can practice abstinence from sexual activity for specific
period or continuously through one's lifetime.
 It also reduces the like hood of contracting a sexually transmitted infection.
 Advantages
1. It is good method for birth control.
2. It also prevents sexual transmitted disease.
3. It is %100 effective in preventing pregnancy.
Disadvantages
1. Continuous abstinence for long period of time difficulty for many people to
maintain.
2. Woman and man who have been abstinent for long time tend to be less safe
and protected for sex when they choose to end their abstinence.
Nursing Instructions
1. You should have method and resources available to protect yourself against
pregnancy in case you stop abstinence.
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2. Talk with your partner about the boundaries you have established and how to
maintain them.
9-Vaginal Douching
Definition: -
 It is the use of a liquid solution to wash out mucus and other types of bodily
debris from a woman's vagina after intercourse, many women choose to make
regular douching as a part of their routine for maintaining vaginal hygiene.
Disadvantages
1. Douching is not enough effective, as during intercourse, active sperm can reach
a woman's cervix and even the upper port of her uterus within five minutes of
ejaculation.
2. Douching could even force sperm higher up into uterus.
3. If a woman douches within 6-8 period after using spermicidal, she may reduce
the effectiveness of this contraceptive.
 Teach the women that, this method isn't effective and increase liability to have
unwanted pregnancy.
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4) Chemical Family Planning Methods
• Explain mode of action of chemical methods.
• List indications of chemical methods.
and indications for use of different chemical family planning methods.
• Demonstrate nursing instructions while using different methods of chemical
family planning methods.
• Apply nursing instructions while using vaginal spermicidal.
• Evaluate importance of chemical family planning for improving the health of
 Outline
1. Introduction
2. Definition of Chemical Methods
3. Mechanism of Action of Chemical Methods
4. Indications of Chemical Methods
5. Contraindications of Chemical Methods
6. Advantages of Chemical Methods
7. Disadvantages of Chemical Methods
8. Types of Chemical Methods
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Introduction
 Chemical methods of contraception as sponges, creams, jell, foams and
suppositories are substances administered into the vagina before intercourse.
 After insertion of them, there is burning sensation ,irritation of vaginal mucosa

and change vaginal fluid "PH" to strong acid (acidity) that is inappropriate to
sperm life.
Definition of Chemical Methods

 It's a chemical substance which interfere with sperm viability and prevent sperm
from entering the cervix.
Mechanism of Action of Chemical Methods

 Chemical methods provide physical and chemical barrier that prevent viable
sperm from entering the cervix as blocking the passages of sperm.
 Effect is local within the vagina once the spermicidal placed deep in the vagina
before each incidence of coitus.
Indications of Chemical Methods

1. Adjacent to mechanical contraceptive method: e.g: diaphragm and cervical
cap.
2. Woman who uses temporary hormonal method such as: pills.

3. Woman Who needs to increase vaginal lubricant or secretion.
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Contraindications of Chemical Methods

1. Known or suspected pregnancy.
2. Undiagnosed vaginal bleeding.
3. Genital ulcer.
4. Hypersensitivity.
5. Allergy.
6. Vaginal epithelial irritation.
Advantages of Chemical Methods

1. Safe and easy to use.
2. Has no side effects.
3. Low cost.
4. Available without prescription.
5. Aid in lubrication of the vagina.
6. Useful when other methods are contraindication.
7. Provide some protection against sexually transmitted disease.
Disadvantages of Chemical Methods

1. Burning sensation.
2. Has short term effectiveness.
3. They have a lower effectiveness than other methods.
4. May produce allergic reaction or tissue irritation.
5. New application is required when more intercourse.
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Types of Chemical Methods
1-
Vaginal Contraceptive Sponge
Definition
 The contraceptive sponge available without prescription, is a round piece of
white plastic material with a little dimple on one side, inserted into vagina to fit
over the cervix which blocks passage of sperm.
Advantages and Disadvantages

1. STD protection → No protection.
2. Benefits → Safe , easy to use and may be inserted 12-24H before intercourse.
3. Risks → (1) Yeast infection, (2) UTI, (3) rarely toxic shock syndrome, (4)
irritation, (5) allergic reaction, (6) Difficult removing sponge, (7) cost and
short-term effectiveness and (8) Less effective with multiparas.
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Contraindications of Sponges
1. Inability of women to insert or remove device.
2. Inability to remember to use the sponge.
3. Allergy to spermicide of polyurethane.
4. History of toxic shock syndrome.
5. Vaginal colonization of staphylococcus aureus.
6. Abnormalities of pelvic structure that would interfere with its placement,
retention, or removal.
Side Effects & Complications of Sponges

1. Redness, irritation and itching of the vulva.
2. Tearing of the device during insertion or removal or during intercourse.
3. Dryness of the vagina, resulting from absorption of vaginal secretion by the
sponge.
For Insertion: Teach women about:
1. Hand washing
2. Perineal care
3. Sponge is used only one time
4. Wet it and then squeeze it
5. Insert it into the vagina.
6. Effective for 24 hours and should be left into vagina about 6 hours after
intercourse.
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For Removal: Teach women about:

1. Hand washing
2. Perineal care
3. Put finger inside the vagina.
4. Then pull sponge put slowly.
5. Then throw it.
2-Vaginal Spermicidal
Definition: -
• Chemical materials inserted into the vagina for killing the sperm before entering
cervix and preventing pregnancy such as (cream- jell – suppositories – foam-
films).
Mode of Action
1. Provide a physical and chemical barrier that prevents viable sperm from
entering the cervix.
2. Effect is local within the vagina.
3. Placed deep in the vagina in contact with the cervix before each incidence of
coitus.
4. Nonoxynol 9:- active material, attract sperm and kill it.
5. Change vaginal fluid "PH" to strong acid that inappropriate to sperm viability.
Advantages
1. Safe and easy to apply.
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2. Low cost.
3. Aid in lubrication of vagina.
4. Increase effectiveness of condoms and other forms of contraception.
5. Back up when women forget her oral contraceptive.
6. Alternative without prescription or previous medical examination.
Disadvantages
1. Maximum effectiveness lasts no longer than 1 hour.
2. If intercourse is to be repeated, reapplication of additional spermicide must
precede it.
3. Allergic response or irritation of vaginal or penile tissue may occur.

4. Possible decreased tactile sensation.
Types of Vaginal Spermicidal

• Creams, Foams, and Jells are placed high up in the vagina, near the cervix, with
a plastic plunger-type applicator.
• Suppositories are capsules that dissolve in the vagina. They’re inserted into the
vagina like a tampon and pushed up to the cervix. It takes about twenty minutes
for a suppository to become effective.
 Nursing Instructions
1. Give women information on anatomical model to practice insertion into the
vagina.
2. Give information about importance of hand washing and perineal care before
usage of spermicidal.
3. For Cream Insertion:

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• Explain how to use it.

• Fill the applicator with cream.
• Insert it into the vagina and press on plunger to release it.
• Insert it 30 minutes before intercourse.
• Douching must be avoided for at least 6-8 hrs. after coitus.
4. For Insertion of Suppositories:
• Suppository need to be moisted prior to insertion.

• Insert it deep into the vagina 30 minute before intercourse.
• Avoid using soap when washing vagina. Just warm water to avoid reducing
its effect.
5. Give Instruction about Foam Usage:
• The foam must be used every time, you have a sex.

• Read the instructions on the can foam.
• Insert it 30 minutes before intercourse.
• Shake the can of foam vigorously to ensure complete mixing and foaming
action before use.
• Place the applicator on the can and fill by applying pressure to the top of the
can.
• Remove it by douching or hygiene after 8 hours from intercourse.
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6. For Jell Insertion:

• Fill the applicators with jell by squeezing it into applicator.
• Insert it into vagina until reach to the cervix.
• Wait for 30 minutes to dissolve.
• Another one “dose” needed when you have sex again.
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5) Mechanical Family Planning Methods
• Explain mode of action of an intrauterine device (IUCD).
and indications for use of different mechanical family planning methods.
• Differentiate between mechanical and chemical methods.
• Plan visits for women after an intrauterine device insertion.
• Demonstrate nursing instructions while using different mechanical methods
of family planning.
• Follow steps of applying different mechanical methods as male and female
condoms, vaginal diaphragm, and cervical cap.
• Evaluate importance of mechanical family planning for improving the health
of both mothers and children.
• Value the importance of regular follow up while using contraceptive
mechanical methods.
 Outline
1. Introduction
2. Definition of Mechanical Methods
3. Types of Mechanical Methods
• Intrauterine Contraceptive Devices (IUCD)
• Condoms (Male & Female). Cervical Cap. Vaginal Diaphragm
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 Introduction
• Mechanical methods of birth control, also known as barrier method, are among
the most common forms of contraception, some of them, like condoms, are
also the only methods that reduce risk of sexually transmitted disease such as
HIV.
• All mechanical methods of birth control rely on preventing sperm and ovum
from meeting.
 Definition of Mechanical Methods

• Mechanical barriers are devices that provide a physical barrier between the
sperm and the ovum.
• Examples of mechanical barriers include the male condom, female condom,

vaginal diaphragm, cervical cap, and IUCD.
• The condom is the only contraceptive method that helps to prevent sexually
transmitted infections (STIs).
Types of Mechanical Methods

1- Intrauterine Contraceptive Devices (IUCD)
 Definition: -
 It is a small flexible appliance T shaped made of polyethylene carrier with
copper wire wounded around its vertical arm and 2 nylon threads attached to the
lower end of the vertical arm for removal.
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• It is inserted into the uterine cavity and remains in the uterus for as long as
contraception is desired.
• Cupper Release Rate: 60-100 mg /day
• Pregnancy Rate : 1-3/HWY (Hundred Women Year).
• Failure Rate (Require removal): 1.5/HWY.
 Mode of Action
IUCD act as foreign body (copper) in the uterine cavity:
1. Attract macrophages: - Attack and phagocyte sperms or fertilized ova.
2. Unfavorable endometrium: - ↑Leucocyte infiltration and hyperemia.
3. Increase immunoglobulin: - IgM and IgG.
4. Increase tubal peristalsis → Ova reach the uterus unsuitable for implantation.
 Types of IUCD
1. Most Common Types of IUCD (1st Generation)
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1- Lippe’s loop
• Double S shaped device
• Made up of polyethylene
• Inert, nontoxic, and durable

Most Common Types of IUCD (2nd Generation)
1- Cu T 380 A: -
• The copper surface area: 380 mm²
• Length: 36 mm, width 32mm
• Duration of use: Up to 10 years
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2- Multiload Cu 375: -
• 2 flexible curved transverse arms
• Length: 35 mm, width 20 mm
• Duration of use: 5 years
• More commonly used for multipara women

3- Nova T: -
• The copper surface area: 380 mm² with silver core.
• Length: 32 mm, width 32 mm
• Duration of use: 5 years

2. Most Common Types of IUCD (3rd Generation)
1. Mirena IUCD (Hormonal): -
• The vertical arm contains reservoir of 52 mg

levonorgestrel, which release 20mg/day.
• Length: 36 mm
• Width: 32mm
Benefits:- Related to the local action of IUCD progestins on the endometrium which
causes:
1. Reduce menorrhagia in 70%of users.
2. Reduce or shrink uterine fibroid size.

3. Treatment of endometrial hyperplasia.
Indications of IUDS
1. Women who desire along acting high constant contraceptive method.
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2. Women who do not tolerate pills and to use other methods of contraception.
3. Women who desire a method that not need to be remembered daily.
4. Women who desire a method not related to intercourse.
5. Women see their husbands sporadically.
Contraindications
1. Known or suspected pregnancy.
2. Active pelvic inflammatory diseases (PID).
3. Previous ectopic pregnancy.
4. Undiagnosed abnormal uterine bleeding (Menorrhagia →heavy
menstruation)
5. Suspected malignancy of genital tract.

6. Sever dysmenorrhea (painful menstruation).
7. Abnormal shape of uterine cavity as in fibroid or congenital malformation.
Advantages
1. Low cost and long acting (Up to 10 years).
2. Very safe and highly effective (more than 99%).
3. Easy to use no action at time of intercourse.
4. No systemic side effects.
5. Complication as perforation or expulsion are rare.
6. Can be used safely by breastfeeding women.
7. In place all time.
8. Reversible contraceptive effect (return to fertility after removal).
Disadvantages
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1. Trained health care provider is needed for insertion and removal of IUCD.
2. Offer no protection against (STD) such as (HIV).
3. High initial cost especially for hormonal type
4. Spontaneous expulsion in about 2% - 15% of client.
Side Effects and Complications

1- Bleeding: In the form of:-
• Heavy or prolonged period (menorrhagia).
• Inter-menstrual bleeding.
• Pre or post menstrual spotting.
• Post insertion bleeding that may require removal of IUCD.

2- Expulsion:
• Occur in 2- 15 % of users, more in the first 2 months especially in multiparous.
3- Pain: Pain associated with IUCD: -
• Spasmodic dysmenorrhea.
• Lower abdominal heaviness.

4- Pelvic Infection:-
• Either acute or chronic PID.

5- Pregnancy: -
1-Intrauterine Pregnancy: -
• Pregnancy may go successfully to term.
• Presence of IUCD: No increase in congenital anomalies.
• ↑ Incidence of spontaneous and septic abortion, preterm labor and premature

rupture of membrane.
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2- Extrauterine (ectopic) Pregnancy: -
• IUCD don’t protect against ectopic pregnancy.

Lost threads and Lost device:-
1- Causes: - Due to spontaneous expulsion of IUCD or uterine perforation
during insertion with escape of IUCD into the peritoneal cavity.
2- Diagnosis:-Detection of IUCD by ultrasound , MRI, or pelvic X-ray with

uterine sound.
3- Treatment: - Removal of IUCD by laparoscopy or laparotomy.
Timing of IUCD Insertion & Removal

Insertion:-
1- Follow the end of menses (at the 5th day)
2- 40 days postpartum.
3- Immediately after abortion.
4- 12 weeks after C.S
5- Immediately after removing IUCD if there is no contraindication.
Removal:- Can be done at any time during the menstrual cycle
1- Inform the woman about type of IUD, duration of action , give her a card with
date of insertion and removal and telephone number in case of emergency
questions.
2- Inform her that she may experience mid pelvic cramps and mild bleeding after
few days from insertion.
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3- Told woman that menorrhagia is frequent during the first 3 months after
insertion.
4- Woman is instructed to examine herself periodically after each period to feel the
threads to be sure that the device is in place.
5- Tell her to keep record of her period if she misses one she may be pregnant and
should have a pregnancy test.
6- She should report if threads not felt, if period is missed or if there is sever pelvic
pain and fever to exclude pelvic infection.
7- The client should be instructed to report any signs of infection.
8- The nurse should teach the clients about (PAINS) system or recognize early
signs of IUD as:
P → Period late or skipped period

A → Abdominal pain (severe)
I → Increased temperature (fever) &chills
N → Noticeable vaginal discharge & foul-smelling discharge
S →Spotting, bleeding, heavy periods, clots (unusual) may signal complications
9- The nurse should be aware of IUD procedure side effect as it may induce enough
pain and stimulation result in syncope so be ready to place the client in
recumbent position if there is any signs of light headiness, sweating or nausea.
10- Inform the woman if there is excessive bleeding should be examined routinely
for anemia and given iron supplement.
11- Tell her not to try to remove the IUD by herself or make her partner removed
it. If she needs to remove it at any time, it can be done by health care provider.
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12- Remind her to have an annual gynecologic examination.
13- Tell her that IUD must be replaced periodically as it loss it's effectiveness.
14- Follow-up after 1mounth, 3, 6 and then every 1 year.
2- Condoms
Definition: -
• Is a rubber sheath-shaped barrier used during sexual intercourse to reduce the
probability of pregnancy or sexually transmitted infection (STI).
• There are both male and female condoms.
1- Male Condom
Definition: -
• It is a rubber sheath that prevent deposition of semen in the vagina .
• Male condom is placed over the penis in male.
• Diameter (3- 3.5 cm) and from 15- 20 long .
Mechanism of Action:-
• The rubber sheath is covering the man's erect penis to prevent the sperm
transposition into the vagina, so it prevents the pregnancy and transmission of
sexually transmitted infection.
Indications
1. Prevent immature ejaculation
2. Prevent sexual transmitted disease (STDS)
3. Birth control method
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4. Improve sexual experience
1. Urinary tract infection
2. Allergies
3. Surgical procedure in penis
4. Right or left hypochondrium pai
Advantages
1. Safe and has no hormonal side effects.
2. Effective against pregnancy when used correctly
3. Widely available
4. Prevent transmission of sexual transmitted diseases

5. Inexpensive
6. Quick and easy to use

7. Can be stopped at any time and the fertility can return shortly after each
use.
Disadvantages
1. Require male partner cooperation.
2. Can be used only once.
3. Interruption of sexual fore play to apply the condom.

4. Can be damaged by exposure to the heat , light or oil- based lubricants.
5. There is small possibility that condom will slip off during sex.
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Side Effects
• No side effect except in male who have allergy.
Condom Failure
The most common cause of the condom failure is: -
1. Breaking of the condom: - to prevent breaking due to dryness the user

should make sure that there is enough lubricant inside the condom such as
KY Jelly.
2. Slipping of the condom: - to prevent it the user should be certain that the
rim stay near the base of the penis during intercourse
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1. Teach the man how to do the procedure of insertion.
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2. Use a new condom for each act of sexual intercourse.

3. Check the expire date every time.
4. Place the condom after erection of penis and before initiate contact.
5. Place the condom on the head of penis and unroll it all the way of the base.
6. Leave an empty space at the tip to remove the air.
7. Don't tear the condom with the fingernail.
8. Male condom and female condom shouldn't be used at the same time.
9. Used condom should be thrown away after each sex act.
10.The condom should be used from starting to finishing with every act at
intercourse.
11.Don't use two condoms at once because placing two condoms on the penis can
raise the chance of tearing.
12.Store unused condom in cool and dry place.
13.Put lubricant during use like KY Jelly.
14.Don't use condom that are sticky or damaged.
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2- Female Condom
Definition: -
• It is a rubber sheath that prevent deposition of semen in the vagina.
• Female condom fits into the vagina.
• One size: 15- 17 cm. Long and 7 cm diameter.
Mechanism of Action:-
• Prevent deposition of sperm in the vagina (prevent pregnancy).
• Female condoms protect the entire vaginal and urethral area from contact
with shaft and base of penis reducing the risk of pregnancy and STDs.
Indications: -
1. Birth control method.
2. Used to prevent sexual transmitted diseases.
Contraindications: -
1. Dysurea and urinary tract infection
2. Surgical procedure in vagina
3. Allergies
Advantages:
1. Safe, quick, and easy use
2. Available
3. Vaginal condoms increase woman’s control over contraceptive use and
protecting STDs.
4. Can be inserted several hours before continuing.

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Disadvantages
1. Sensation may be altered.
2. Necessity for manual insertion of female condom.
3. If used improperly spillage of sperm can result in pregnancy
4. Can be used only once.
5. Interruption of sexual fore play to apply the condom.
Side Effects: - No side effects of condom except the allergy.

How to use Female Condom
1. Female condom can be inserted up to 8 hours before intercourse are only
effective when placed prior to intercourse.
2. All first female condom can be uncomfortable to use, but they become easier
with practice.
3. Female condom and a male condom shouldn't be used at the same time.
Steps
1. The woman must squeeze the ring at the closed end of the tube.
2. She can use the other hand to spread the outer tip, then insert the squeezed
condom into vaginal canal.
3. It should be pushed just post pubic bone over the cervix.
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1. Teach woman how to do the procedure of insertion.
2. Teach her to use a new condom every intercourse.
3. Teach the woman to cheek expired every time.
4. Tell her to put lubricant during using like KY Jelly.
5. Store unused condom in cool, dry place.
6. Don't use condoms that are sticky or obviously damaged.
3- Cervical Cap
Definition: -
• It is a small dome, shaped latex cup with flexible ring that fists over cervix by
suction.
• It's remained at least six hours and not more than 48 hrs. after last act of
intercourse.
• Size:-22-31 mm
• Action: Blocks sperm from entering the cervical canal.
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Indications
1. Woman who doesn't tolerate with another method
2. For woman have never been pregnant or given birth vaginally (86% effective).
3. For women at childbearing age as a barrier method of contraception.
1. Some women aren't good candidates for wearing cervical cap such as:
2. Women who can't be fit properly with existing cap sizes.
3. Women who find the insertion and removal of devices too difficult.
4. Women with history of toxic shock syndrome.
5. Women with virginal or cervical infection.
6. Women who experience allergic response to cap or spermicides.
 Advantages
1. Smaller than diaphragm and may fit women who can't wear diaphragm.
2. Requires less spermicide.
3. No pressure against bladder
4. Can remain in place for 48 hrs.
5. Reversible.
 Disadvantages
1. Sizes are limited.
2. Initially expensive.
3. Requires nurse practitioner or physician to fit size.
4. Requires education on proper use.
5. Difficult to apply than diaphragm
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6. Can be dislodged during intercourse.

7. If left in place for long period leads to toxic shock syndrome "fever chills"
Side Effects
• Although there is little published information on safety and side effects of
cervical cap, problem may arise due to prolonged cervical exposure to secretion.
1. Bacteria tapped within the cap.

2. Trauma could result to the cervix or vagina from insertion or removal and
prolonged retention of the cap.
Insertion of Cervical Cap: -
1. Wash your hand with soap and water
2. Put one quarter teaspoon of spermicide in the dome of the cervical cap and
spread a thin layer on the rim.
3. Put one half teaspoon in the flooded area between the rim and the dome.
4. Find a comfortable position as stand with one foot on a chair, sit on the edge of
a chair, lie down or squatting position.
5. Put your index and middle fingers in your vagina to locate your cervix. That
way, you will know where to place the cap.
6. Separate the labia with one hand and squeeze the rim of the cap together with
the other hand.
7. Slide the cervical cap dome – side down into the vagina , with the long rim
entering first.
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8. Push down toward the anus and then up and onto the cervix , make sure the
cervix is completely covered it is easier to insert before you are sexually
aroused.
Removal of Cervical Cap: -

1. Wash your hand with soap and water.
2. Hook your finger under the removal strap and pull the cap out.
4-Vaginal Diaphragm
Definition: -
• It is a shallow, dome, shaped rubber device with flexible rim that lay across the
cervix, vault and anterior vaginal wall.
• Size: - 70-80 mm
• Action: - Prevent the meeting of sperm with the ovum. The diaphragm holds
spermicide in place against the cervix for 6 hours, the time it takes to destroy
the sperm.
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Advantages
1. It won't change the menstrual cycle
2. Woman can put it in any time before having sex.
3. It can be washed and used again
4. It lasts for up to one year.
Disadvantages
1. Expensive
2. Require practitioner, certified, nurse midwife or physician to choose suitable
size.
3. Require education of proper use.

4. Possibility of toxic shock syndrome.
5. Pressure against bladder may cause infection.
Women who:-
1. Have given birth in last 6 weeks
2. Have history of urinary treat infection.
3. Have recent cervical surgery
4. Have history of toxic shock syndrome
5. Have poor vaginal muscle tone
6. Have recent abortion
Side Effects
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1. Toxic shock syndrome manifested by vomiting diarrhea, sum burn type rash,
dizziness, sudden high fever, faintness, weakness.
2. UTIs: reduced by urination before insertion of diaphragm.

3. Vaginal irritation
4. Trauma to vagina or cervix from insertion or removal
5. Pelvic inflammatory disease.
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Position of using the Diaphragm

1. Squatting: is the most commonly used position and most women find is
satisfactory.
2. Leg up method: another position is to raise the left foot.
3. Chair method: another practical method for diaphragm insertion to sit

forward on the edge of chair.
4. Recailing: You may prefer insertion while lying down in bed.
1. Instruct the women about how to use the diaphragm.
• Hand washing with water and soap.

• Insert diaphragm as long as 30 mins before intercourse.
• Diaphragm must be left in place for at least 6hrs after last intercourse.
• The women who engage in intercourse infrequently may choose this barrier
method. The spermicide adds additional lubricant it may be interfere with
normal flow of cervical mucus.
2. The fit size of diaphragm should be assed every year.

3. Instruct her that device should be refitted after weight loss or gain.
4. Inspect diaphragm for holes or tears by holding it up to a light source or fill it
with water and check for a leak.
5. Select the most comfortable position for insertion.

6. Wash the diaphragm with soap and water after use.
6) Hormonal Family Planning Methods
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6) Hormonal Family Planning Methods

• Enumerate types of hormonal methods.
and indications for use of hormonal family planning methods.
• Interpret different types of hormonal methods.
• Plan nursing care for male after vasectomy.
• Demonstrate nursing instructions while using different hormonal methods of
family planning.
• Evaluate importance of hormonal family planning for improving the health of
• Value the importance of regular follow up while using hormonal
contraceptive methods.
 Outline
1. Definition of Hormonal Family Planning Methods
2. Uses of Hormonal Family Planning Methods
3. Types of Hormonal Family Planning Methods
4. Woman instructions for Using of Hormonal Family Planning Methods
5. Nursing care of Hormonal Family Planning Methods
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Introduction
Hormonal contraception refers to birth canal control methods that act on the
endocrine system. Almost all methods are composed of steroid hormones, although
in India one selective estrogen receptor modulator is marked as contraceptive. The
combined oral contraceptive pill- was the first marketed as a contraceptive in 1960.
Definition:
Hormonal methods refer to birth control methods that act on the endocrine
system.
Methods of Hormonal Contraception:

- Oral contraceptive pills.
- Inject able contraceptive.
- Implant.
- Transdermal Contraceptive Patch.
- Vaginal ring
- Progestin releasing IUCD(Mirena)
Oral Contraceptive Pills.

There are two types of hormonal contraceptives:
1- Combined Pills:-
• It is a combination of estrogen and progestin and the most widely used.

2- Progestin Only Pills (Minipill)
- Contain no estrogen. - The amount of progestin is less than combined
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Mechanism of action of estrogen as contraceptive*

- Inhibition of ovulation by inhibits production of pituitary gonadotropin.
- Inhibition of egg utilization.
- Acceleration of ovum transport.
Mechanism of action of progestin's as contraceptive*

- Inhibition of ovulation.
- Increase thickness of cervical mucus, which interfere with sperm transport and
decrease sperm ability to penetrate cervical mucus.
- Delay ovum transport.
- Interference with implantation.
1. Progestin only pills (minipill)
- It consists of a small dose of a progestogen as norethisterone.It is taken daily

without interruption. The tablets should be taken at the same time every day
with no more than 3 hours delay as it remains effective for only 27hours.
Mechanism of action:
l - Thick cervical mucus (most important)
2- Atrophic endometrium
3- Inhibit tubal motility & sperm capacitation
4- Suppression of ovulation (50% only)
Advantages
• ASER "available, safe, effective (failure rate 1-2%), reversible"
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• No special acts during sexual acts
• Can be used in:-
1. Lactating women
2. Women with contraindication of E: liver or CVS, diabetics, hypertensive,
smokers, old & obese as no salt & H2O retention, or androgenic side effects
Disadvantages
• Doesn't prevent against STD,
• Menstrual irregularities:
• Ectopic pregnancy
• Specific: require resupply, incorrect use
• Amenorrhea or suspected pregnancy
• Undiagnosed genital bleeding
• Previous ectopic pregnancy
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2- Combined oral contraceptive (COC)
Mechanism of action:
• Suppression of ovulation (negative feedback on hypothalamus & pituitary)
• Thick cervical mucus (most important)
• Inhibit tubal motility
• Atrophic endometrium
• Inhibition of sperm capacitation
Advantages
• ASER "available, safe, effective (failure rate 1-2%), reversible"
• Extra contraceptive benefits
1. Decrease Bleeding, PID, Benign breast disease
2. Decrease cancer endometrium I ovary,
3. Decrease Dysmenorrhea
4. Decrease Ectopic pregnancy, treat endometriosis
Disadvantages
• Doesn’t prevent sexually transmitted disease
• Strokes
• Gall stones
• Diabetogenic
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• Hypertension, atherosclerosis
Indication for the combined oral contraceptive:

Combined oral contraceptive is appropriate for women who:-
• Desire highly effective method of contraception.
• Has anemia from heavy menstrual bleeding.
• Has sever Menstrual cramping.
• Has History of ectopic pregnancy.
• Has strong history of ovarian cancer
Contraindication
The combined contraceptive is not used by women who:
• Has known or suspected pregnancy by history of positive pregnancy test.
• Abnormal vaginal bleeding between periods after intercourses.
• Has a benign or malignant liver tumor or acute or sever active liver gall-
bladder disease.
• Woman who has family history of hypertension, D. M, stroke, Heart disease,

osteoporosis, carcinoma of genital tract or breast.
Client instruction
1. The first pill should be taken on any of the first 5 days of menstrual cycle,
preferably on the first day, which is easier to remember.
2. A pill should be taken every day at the same time of day preferably at night
after meals for 21 days; withdrawal bleeding usually starts 2or3days after
stopping the tablets.
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361
3. If vomiting occurs within one hour of pill intake, another pill is taken.
4. missed pills:
 If forget one pill: she should take it as soon as possible them the next pill at
the regular time.
 If forget two pills: she should take two pills as soon as possible she remember,
then take 2 pills at its usual time.
 If forget three pills: barrier methods of contraception should be used and wait
for the next period before restarting the pill.
Drug Interaction:
Certain drugs reduce the efficacy of the combined tablets as sedatives,

tranquillizer, anticonvulsants, antihistaminic, antibiotics as ampicillin and
rifampicin.
The pills may reduce effect of anticoagulants, hypoglycemic agents,

corticosteroids, and other drugs
Warning symptoms of hormonal Contraceptive (ACHES)

 A: severe abdominal pain
 C: sever chest pain ,cough, and shortness of breath
 H: severe headache
 E: eye problems, vision loss or blurring, speech problem
 S: sever leg pain.
Injectable contraceptive:-
Types:-
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362
• Progestin only injectable.
• Combined injectable.
Action:
• Change in cervical mucus. Increase viscosity, decrease volume inhibition
sperm transport.
• Atrophic change in endometrial.
• Inhibition of ovulation.
• Tube effect: decrease tubal mobility.
Types of injectable contraceptive

1-Progesterone only injectable
A-Depot- medroxy progesterone acetate, (DMPA)
– It's injected in dose 150 mg every 3 months subsequent
– Injection must be given no more than 2 weeks early or 2 week after
B-Norethisterone - Enanthate:
– It's injected in dose of 200mg every 2 months
2- Combined injectable contraceptive
• Mesgyna: DMPA 50 mg +5 mg Estradiol valerate / 1 month
• Cyclofem: DMPA 25 mg + 5 mg Estradiol cypionate / 1 month
362
363
The injectable contraceptive is given deeply into the deltoid muscle or the upper
outer quadrant of the gluteus muscles. The injection site is not massaged to avoid
rapid absorption of the drug.
Mechanism of action: as COC (high progesterone can suppress ovulation)

Advantages of Progestin only Injectable:
• ASER "available, safe, effective (99%), reversible", long acting
• No E side effects, can be given for old, CVS, liver diseases, & lactating
women
• Protects against PID (but not STD)
• Combined Injectable: as (Progestin only) but for shorter duration (1 month)
Disadvantage
Progestin only Injectable:
• Menstrual irregularities
- Amenorrhea, oligo / hypo menorrhea: exclude pregnancy then
- Heavy bleeding or spotting
• Once started can’t be stopped & return of fertility may be delayed (9 months)
• Weight gain, no protection against STD
• Combined injectable: as Progestin only + Estrogen side effects (headache,

breast tenderness)
363
364
Implants
Silastic capsules of Progesterone are inserted under the skin (subdermal) of medial
side of the upper arm
• 1-Norplant (6 cap ) of levonorgestrel for 5 years
• 2-Implanon (1 cap of etonogesterol for 3 years)
Norplant
• 6 capsules of progesterone are inserted under the skin (subdermal) of medial
side of the upper arm in a fan shaped manner.
Action
• Thickening of cervical mucus making it difficult for sperm to enter the uterine
cavity
• Preventing ovulation
• Cause atrophic changes in the endometrial
Advantage
• Safe and preventing pregnancy
• Easy to use no action needs taken at time of inter course
• It's long acting but reversible
• It contains no estrogen so can be used by women who are breast feeding
Disadvantage
1-Insertion and removal be carried out by health professional
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365
2-special training is needed for health workers
3-more expensive than short term method
4- Often changes bleeding pattern
Side effect :-
1- Bleeding irregularities are most common
* Irregular light bleeding or spotting
* Prolonged bleeding which usually decreased after the first few months
* Amenorrhea
2- Ovarian cysts occur in about 10% of users
3- Local infection or bleeding at insertion site
4- Other side effect as:
- Headache
- Weight gain
Increase blood pressure
Indications
• women who desire a long acting contraceptive
• women who don't tolerate IUD or pills
• Women who desire a method that not need to be remember daily take
• Client who desire a method not related to intercourse
Client instruction and follow up:
365
366
1-Noplant should be inserted during the first day of first week of menstrual cycle
2- Avoid trauma to area of insertion
3-Norplant capsules should be replaced after 5 years
4- Irregular bleeding or amenorrhea may occur in first year but don't effects the
women's health
5- the women should return to clinic after 1 month 3 months 6 months 1 years
then annually for checks up
Implanon
• Implement is a progestin only sub dermal implant
• The hormone provides protection from pregnancy for 3 years
• The mechanism of action for implanon is similar to the mechanism of action

for other hormone method.
Advantages
• Women can use it during lactation and within breastfeeding
• Don't need to take every day
366
367
• Fix it under the skin of the women's arm and don't remove it every day
• Safe and preventing pregnancy
• No action needs at time of intercourse
• It's long acting but reversible
Disadvantage
• It is a surgical procedure and need special professional
• Special training is needed for health workers
• More expensive than short term method
• Change bleeding pattern
Side effects
• Similar to other progestin – only contraceptives
• Implanon can have effects on bleeding patterns
– Women who are using this method often experience irregular bleeding or spotting
some women may develop amenorrhea
– Headache, nausea, breast tenderness and mood swings. this returns soon after
removal of the implant with ovulation taking place within the first month after
removal.
Contraindication
Progesterone – only contraceptive shouldn't be used in the presence of any of the
condition
1. Known or suspected pregnancy

367
368
2. Venous throb embolic disorder
3. Liver disease
4. Un diagnosed vaginal bleeding
Client instruction
• Implanon should be inserted in the first day of the first week of menstrual
cycle
• It should be replaced every 3 years
• The women should return to clinic after 1 month 3 month 6 month 1 years
then annually for checks up
• The arm should be kept from trauma
• Keep area for insertion clean
• Avoid carrying having objects
• Avoid measuring blood pressure of the arm of insertion
• A void giving injection in the arm of implanon
Transdermal Contraceptive Patch (OrthoEvra)
Definition: The birth control patch is a thin, plastic patch that sticks to the skin
releases estrogen and progestin through skin for 7 days.
Site of Transdermal Contraceptive Patch
368
369
Advantages
 high efficacy
 regulation of menstrual cycle
 shorter, lighter periods with less cramping
 unlike the pill, you only need to think about it once a week
 Extra protection: if a women forgets to remove the patch after a week, serum
hormone levels will remain in the contraceptive range for up to 2 additional
days
369
370
Vaginal rings (NuvaRing).

 The combined hormonal contraceptive vaginal ring is self-administered once
a month. Leaving the ring in for three weeks slowly releases hormones into
the body, mainly vaginally administered estrogen and progesterone
 Worn continuously for three weeks followed by a week off.
370
371
7). Emergency Family Planning Methods

• Identify uses of emergency contraception.
and indications for use of emergency family planning methods.
• Demonstrate nursing instructions while using emergency methods of family
planning.
• Evaluate importance of emergency family planning for improving the health
of both mothers and children.
• Value the importance of regular follow up while using emergency
contraceptive methods.
 Outline
1. Definition of Emergency Family Planning Methods

2. Indications of Emergency Family Planning Methods
3. Types of Emergency Family Planning Methods
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372
Definition
Emergency contraception (EC) are birth control measures that may be used
after sexual intercourse to prevent pregnancy.
Indications
 Unprotected sexual intercourse at any time during the menstrual cycle
 Rape
 Failure of barrier methods , as when condom ruptures or vaginal diaphragm
or cervical cap is displaced
Types of Emergency Methods

1. Natural methods:
• Immediate postcoital douching to dispel deposited semen from the vagina.
2. Hormonal methods:
• Combined oral contraceptive(COC): 2tablets taken at once and repeated
after 12 hours
• Estrogens: Premarin 5 mg taken in divided doses within 24hours.
• Progestins: levonorgestrel (Postinor-2)1tablet taken within 24hours after
coitus and repeated after 12 hours.
3. Intrauterine Devices
• It prevents implantations by changing the endometrial pattern
4. Menstrual regulation:
• It is an outpatient procedure using aspiration cannula to remove the pregnancy
sac. It is an early induced abortion.
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373
8) Surgical Family Planning Methods

1. Describe methods of tubal ligation.
2. Plan nursing care for male after vasectomy.
3. Demonstrate nursing instructions while using surgical family planning
methods.
4. Evaluate importance of surgical family planning for improving the health of
Outline
1. Introduction.
2. Indications
3. Types
4. Vasectomy:
• Definition.
• Advantage
• Disadvantage.
• Management of pain.
• Complications.
• Nursing implications.
5. Tubal ligation:
• Definition.
• Types.
• Laparoscope & mechanism of action.
• Advantage & disadvantage.
373
374
• Complications.
• Contraindications.
• Nursing instructions.
• Nursing care.
Introduction:
Surgical methods of reproduction life planning include sterilization (tubal
ligation for women and vasectomy for men). Many people choose these surgical
methods because they are the most effective methods of contraception besides
abstinence and because they have no effect on sexuality.
Although procedures for the reversal of both male and female sterilization do
exist, such techniques are much more complicated and expensive than sterilization
itself, and success rates vary great for this reason surgical methods should be chosen
with great thought and care should be considered permanent. Counseling should be
especially intensive for the possibility younger than 25 years of age, because the
possibility of divorce, death of asexual partner, loss of a childbearing in the future.
In addition, sterilization isn't recommended for individuals whose fertility is
important to their self-esteem.
Indications of surgical family planning:

1- Man, who wants to participate in the prevention of pregnancy.
2- Woman who wants pregnant method.
3- Women with heart disease.
4- Women with liver disease at end stage.
5- Women who want not to be pregnant.
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375
Sterilization: Female sterilization and male vasectomy are permanent method of

contraception and highly effective
Sterilization methods include:
1- Vasectomy in males.
2- Tubal Ligation in females .
1- Vasectomy:
Definitions:
In vasectomy, a small incision is mode on each side of the scortum. The vas
deferens at that point is then cut and tied, cauterized, or plugged blocking the passage
of spermatozoa.
Advantage of vasectomy:
1- It can be done as an outpatient procedure with little anesthesia and minimal
pain.
2- It's 99.6% effective.
3- It doesn't interfere with male erection and the male still produce seminal fluid
it just doesn't contain sperm.
Disadvantage of vasectomy:
1- Misconceptions about the procedure may lead some men to resist it.
2- Some reports indicate that vasectomy may be associated with the development
of renal calculi.
375
376
3- The procedure is contraindicated in individuals who aren't entirely certain of

their decision to choose permanent sterilization and those with specific
surgical risks such as anesthesia allergy.
How it works:
• The vas deferens from each testicle are clamped, cut, or otherwise sealed
which prevents sperm from mixing with the semen that is ejaculated from
the penis.
• Wait two months after vasectomy or 15 to 20 ejaculations in order to clear
semen completely
Type of anesthesia:
 Vasectomy can be done under local anesthesia in an ambulatory setting such
as a physician's office or reproductive life planning clinic.
376
377
Management of pain and effectiveness of procedure of procedure:

 The man experiences a small amount of local pain afterward, which can be
managed by taking a mild analgesic and applying ice to the site.
 The procedure is 99.5% effective. Spermatozoa that were present in the can
deferens at the time of surgery can remain viable for as long as 6 mouths
therefore, although the man can resume sexual intercourse within 1 week. An
additional birth control method has been obtained (proof that all sperm in the
vas deferens have been eliminated, usually requiting 10-20 ejaculations).
377
378
Complications:
1- Hematoma: at surgical site may occur, because men who have vasectomy
seek a reversal of the procedure unfortunaty the success rate for
reanastomosis id only 70% to 80%.
2- Some men develop autoimmunity of form antibodies against sperm, so that

even if reconstruction of the vas deferens is successful at a later date.
3- Urolithiasis (kidney stones). A few men develop chronic pain after vasectomy
(post vasectomy pain syndrome) having the procedure reversed relieved this
pain.
2- Tubal ligation:
Definition
Sterilization of women could include removal of the uterus or ovaries
(hysterectomy), but it usually refers to a minor surgical procedure, such as tubal
ligation, whereby the fallopian tubes are occluded by cautery, crushing, clamping or
blocking and thereby preventing passage of both sperm and ova. Tubal ligation has
a 99.5% effectiveness rate.
Types:
1- Laparoscopy.
2- Culdoscopy: tube inserted through posterior fornix of the vagina.
3- Colostomy: incision through vagina.
Laparoscopy and mechanism of action:

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• The most common operation to achieve tubal ligation is laparoscopy. After

menstrual flow and before ovulation, an incision as small as 1 cm is woman
under general or local anesthesia. Alighted laparoscope is inserted through
the incision to lift abdominal wall upward and out of the line of vision the
surgeon located the fallopian tubes by viewing the field through the
laparoscope. An electrical current to coagulate tissue is then passed through
the instrument for 3-5 seconds.
• The tubes are clamped and cut or filled with a silicone gel to seal them.
379
380
Note:
The procedure can also be done by Culdoscopy (a tube inserted through

posterior fornix of the vagina) or colostomy (incision through vagina). But the
incident of pelvic infection is higher with these procedures and visualization is less.
Advantage of tubal ligation:

1- It can be performed on an outpatient basis, and the patient is usually
discharged within a few hours after the procedure.
2- It's 99.6 effective.
3- It has been associated with decreased incidence of ovarion cancer.
4- Patient can return to having intercourse 2 to 3 days after having the procedure.
Disadvantage of tubal ligation:

1- Some patients may be reluctant this type of procedure because it requires a
small surgical incision and general anesthesia.
380
381
2- Complications include a risk of bowel perforation and hemorrhage and risks

of general anesthesia (Allergy, arrhythmia) during the procedure.
3- Post tubal ligation syndrome may occur which include vaginal spotting and
intermittent vaginal bleeding as well as sever lower abdominal cramping.
4- This form of contra caption isn't recommended for individuals who aren't
certain of their decision to choose permanent sterilization.
Complications:
- Bowel perforation.
- Hemorrhage.
- Risks of general anesthesia.
Contraindications of laparoscopy:
1- Umbilical hernia because bowel perforation might result.
2- Extensive obesity, which would probably require a full laparotomy to allow

adequate visualization.
3- Vaginal spotting.
4- Intermittent vaginal bleeding.
5- Sever lower abdominal cramping.
Effect on sexual enjoyment:

Both tubal ligation and vasectomy may lead to increased sexual enjoyment,
be pregnancy they largely eliminate possibility of pregnancy.
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382
Use by the adolescent:

Sterilization isn't advised for adolescents because their future goals may
change. Adolescents should be counseled to use more temporary forms of birth
control to have the option available.
Preoperative Nursing Care for Patient with Surgical Family Planning

Methods.
1- Ensure informed consent before the procedure.
2- Assess patient's understanding of procedure, provide explanation and

emotional support is very important .
3- Reassure that anesthesia will eliminate pain during surgery and all
medications will be administered post operatively to decrease comfort.
4- Caution patient not to have unprotected intercourse before procedure.
5- Advice patient with vasectomy to use an additional form of contraception until

two negative sperm reports have been obtained.
6- Caution patient with vasectomy that sperm remain viable for as long as 6
months in the vas deferens after surgery.
7- Obtain perineal care if asked.
8- If ordered administer enema and ask patient to empty bladder before

procedure.
9- Administer preoperative medications as ordered.
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383
Postoperative Nursing Care for Patient with Surgical Family Planning

Methods.
1- Obtain clear airway.
2- Assess for signs symptoms of hemorrhage.
3- Monitor vital signs every 4 hours, auscultate heart and lung sounds measure
intake and output to obtain homodynamic status.
4- Encourage turning, coughing and deep breathing exercise and early

amputation to prevent complication.
5- Assess level of consciousness.
6- Encourage fluid intake and monitor output.
7- Instruct patient to restrict physical activity at least 2-3 weeks.
8- Assess for complications
9- Infection and hemorrhage are the greatest postoperative risks, restrict

activities and prevent introduction of any foreign material into vagina.
383
384

Activity (1) Case Scenario
A married primipara from a rural area has just been delivered in a district
hospital. She has a stable relationship with her husband, and they decide to have
their next infant in five years’ time. The patient would like to have an intra-uterine
contraceptive device inserted.
Answer the following questions:-
3. Is this an appropriate method for this patient?
4. When should the device be inserted?
5. The patient decides to come back after 6 weeks for the insertion. Could she, in
the meantime, rely on breastfeeding as a contraceptive method?
6. The patient asks if the intra-uterine contraceptive device could be inserted
before she is discharged from hospital. Would this be appropriate
management?
Activity (2)
1. List 4 different types of chemical methods and outline 3 nursing care
regarding one method.
Activity (3)
3. Differentiate between Cervical mucus changes before and after or during
ovulation.
4. Explain nursing instruction for woman using combined oral contraceptive
pills.
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385
10). General Follow up Activity

1. Injectable progestins (DMPA, Depo-Provera) are a good contraceptive
choice for women who:
a. Want menstrual regularity and predictability.

b. Have a history of thrombotic problems or breast cancer.
c. Have difficulty remembering to take oral contraceptives daily.
d. Are homeless or mobile and rarely receive health care.
2. A woman will be taking oral contraceptives using a 28-day pack. The nurse
should advise this woman to protect against pregnancy by:
a. Limiting sexual contact for one cycle after starting the pill.
b. Using condoms and foam instead of the pill for as long as she takes an
antibiotic.
c. Taking one pill at the same time every day.
d. Throwing away the pack and using a backup method if she misses two pills
during week 1 of her cycle.
3. When counselling a woman about vaginal ring for birth control method of
contraception, the nurse should assess for the woman as regards:
a. Should remember to insert the device every morning.
b. Should insert the device before sexual intercourse.
c. Should change of the vaginal ring every 3 weeks.
d. Should return to the clinic once a week for reinsertion.
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386
4. A woman tells the nurse that she plans to use the rhythm method of birth
control. The nurse is aware that the success of the rhythm method depends
on the:
a. Age of the client
b. Frequency of intercourse
c. Regularity of the menses
d. Range of the client’s temperature
5. The nurse would tell the woman to expect what after she had an intrauterine
device (IUD) inserted?
a. Menstrual flow will be lighter.
b. Menstrual cramps will be eliminated.
c. String should be felt in the vagina.
d. The device should be changed every 2 years
6. The woman using a diaphragm correctly would tell the nurse that the
diaphragm:
a. Does not require the use of a spermicidal cream or jelly with it.
b. Should be left in place for at least 6 hours after intercourse.
c. Is removed immediately after intercourse for douching.
d. Is effective for up to 48 hours if positioned properly.
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387
11). References
1. Why reproductive rights must be a critical part of our arsenal to fight
pandemics". forbesafrica.com. 2020-04-29.
2. Population planning 4 Pakistani couples use contraceptives". tribune.com.pk.
2019-05-10.
3. Calls for universal access to family planning services". thejakartapost.com.
2020-11-17.
4. Nigerian women girls use contraceptives study". vanguardngr.com. 2021-02-
10.
5. Maternal infant mortality rate to 2020 target". m.guardian.ng. 2019-05-10.
6. 139 million Women and girls now Use Modern Methods of
Contraception". m.timesofindia.com. 2019-05-10.
7. Kenyas-adolescents-lag-behind-as-contraceptive-use-increases". standard
media.co.ke. 2019-05-10.
8. African Women Embrace Contraceptives". m.dw.com. 2019-05-10.
9. Contraception use on the rise in 69 Poorest Countries report". aljazeera.com.
2018-11-18.
10. Global health women and girls family Planning". telegraph.co.uk. 2019-05-1
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388
388

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The ovarian cycle ............................................................................................................ 26

9). References ................................................................................................................ 127

Module (3) Normal Labor…………………………………128

6). General Follow up activities ................................................................................... 212

Module (4): Postpartum care 218

Module (5): Family Planning ………………………….293

Disadvantages of Natural Methods ......................................................................................... 306

Advantages of Calendar Method........................................................................... 307

Description: - ............................................................................................................................. 308

Definition: -................................................................................................................................ 313

Nursing Instructions ............................................................................................... 315

Definition: -................................................................................................................................ 315

Definition: -................................................................................................................................ 319

Disadvantages of Chemical Methods .................................................................... 325

Nursing Instructions ................................................................................................................. 339

To be a pioneer and distinguished faculty in the field of nursing

Preparing a qualified and competent graduate in the field of

‫رؤﯾﮫ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬

Maternal and Newborn Health Nursing Department seeks to be one of

‫رﺳﺎﻟﮫ ﻗﺴﻢ ﺗﻤﺮﯾﺾ ﺻﺤﮫ اﻻم و ﺣﺪﯾﺜﻰ اﻟﻮﻻده‬

Maternal and Newborn Health Nursing Department is concerned with

Module (1): Anatomy and Physiology of the Female

Credit Weighting of Module: 3 hours

Core Competence of the Module:

Module Objective: To: -

1): Anatomy and Physiology of the Female

External female genitalia

Figure 2: The external female genitalia (or vulva).

Labia majora and labia minora

Perineum and hymen

Internal female reproductive organs

Figure 2. Structures of the internal female reproductive organs.

Fallopian tubes and ovaries

The enlarging ovarian follicles also produce the female reproductive

The uterus has four major anatomical divisions, shown in Figure 4:

Figure 3. Structure of the empty uterus, showing the four main

2): Female Reproductive cycle

Learning Outcomes: On successful completion of this module, the students should be

2- Describe the hormonal regulation of the female reproductive cycle.

3. Provide health teaching during the female reproductive cycle.

The female reproductive hormones

Box 1 Hormones regulating the female reproductive system

Gonadotropin-releasing hormone (GnRH) is produced by a part of the brain called

hormones (follicle-stimulating hormone and luteinizing hormone) from

Figure 4. Hormonal regulation of the female reproductive system.

The follicular phase: days 1 to 14

The luteal phase: days 15 to 28

Thus, ovulation is quickly followed by a rise in the level of progesterone in the

The uterine cycle

The menstrual phase: days 1 to 5

Menstruation usually occurs at monthly intervals throughout the reproductive years,

The proliferative phase: days 6 to 14

The secretory phase: days 15 to 28

The menarche, puberty and the menopause

• The development of the breasts

Summary of study module

In Study module 2, you have learned that:

1. The hormones controlling the female reproductive system include gonadotropin-

3): Preconception care and counseling

Preconception health is important for every woman―not just those

Preconception counseling is different from antenatal care and should not be

Module Objective: To:-

- Define pre-conception care and pre-conception counseling.