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Guide to the Question Approach for Midwifery Exams

It is important for midwives preparing for the exam to be able to answer questions effectively.

This approach allows you to tackle questions in a systematic manner, ensuring that you cover all important points and provide concise and accurate answers. By following this structured approach, you will be able to effectively demonstrate your knowledge, critical thinking and analytical skills, leading to higher scores and overall success on your midwifery exams.

Whether you are facing questions that require you to EXPLAIN, OUTLINE, DESCRIBE, MENTION, IDENTIFY, STATE, LIST, WHAT and GIVE, this article is all you need!

Explaining Questions: Breaking Down Complex Concepts

When questions require explanations, it is essential to break down complex concepts into understandable parts. Start by introducing the topic you’re discussing and providing a concise definition if necessary. Then, proceed to explain on the key components or factors related to the topic. Use clear and simple language to ensure your explanation is easily understandable.

Example Question: Explain how you would admit a mother who has reported in active phase of first stage?

In response to this question, you can follow the question approach by giving the key points step by step:

Reception: the mother and the relatives are welcomed; mother is taken to the admission room while the relatives are offered seats. Rapport between the mother, attendants and the midwives is created.
History taking: if the mother has been attending ANC, her ANC record is obtained; to get the history and any risk factors like multiple pregnancies. If she has not been attending ANC, a full antenatal history is taken, which involves the mother‘s name, address, tribe, religion, husband‘s name and address, her gravida and parity, obstetrical, surgical, social, and medical history, the time and date of admission are entered in the admission forms of the mother.

Then, history of labour under the following headings is recorded:

Show: the mother is asked if she has seen any blood and mucus, her undergarments examined for any stain, vulva examined for the drainage of show which may appear a few hours before or after beginning of labour.
Uterine contractions: mother is asked when the regular pains began, how often and if she has backache. Her statement about the length, severity, or expulsive character of the contraction should be confirmed by observation and evaluation then
Membranes: She is asked whether her water (amniotic fluid) have ruptured or not; if she has noticed a gush or tickling of water → the amount and time are recorded. If in doubt of whether its liquor or urine, litmus paper is dipped into the draining fluid obtained from the vulva to confirm alkalinity or
Vaginal discharge or bleeding: the mother is also asked if she had any vaginal bleeding/ discharge which should be excluded

General examination of the mother: her general appearance is noted, that is healthy or ill, colour, any deformities like lame, presence of oedema, infections, varicose veins or enlarged neck veins. Breast examination is carried out to identify their sustainability for breast feeding
Observations; Vital signs are monitored like temperature, pulse, respiration and blood pressure to rule out eclampsia in She is also asked for bowel action, sleep and rest
Abdominal Examination: first, the bladder should be empty and this is carried out with the mother lying on the couch on supine position with a pillow under her head and This examination is carried out as follows:
- On inspection: the shape of the abdomen is noted whether round or oval, the size should be correspond with the weeks of gestation, the foetal movements, skin changes like stria gravidarum and linea nigra and any scar are
- On palpation: this can be superficial, fundal, lateral, pelvic, height of the fundus and hypochondriac. They are carried out to note the lie whether its longitudinal, transverse, or oblique; the position of the fetus which can be ROA, LOA, ROP, LOP; and engagement plus enlargement of the spleen and the liver.

On auscultation: the fetal heart is listened, if its heard and regular

Vulva shave, toilet and examination: the shave is done on women whose cultures allow keeping the vulval area with pubic hair. Any abnormal discharges, oedema, or paleness are noted if present
Vaginal examination: this is done to mothers who have no history of APH with the current pregnancy under strict asepsis. It‘s done to confirm the onset of labour, the presentation, position, engagement, station of the presenting part, to confirm whether membranes ruptured or intact, exclude cord prolapsed, assess the pelvis if adequate or inadequate and also progress of labour and it‘s the one that determines the admission of a mother on the partograph
Investigations: routine samples are obtained for example:
- Blood: for routine counseling and testing (RCT), rapid polymerase reaction (RPR), HBsAg, haemoglobin estimation, Grouping and cross matching → rational to confirm presence of any disease so as to prevent mother to child transmission (MTCT) and for blood transfusion (BT) in case of anaemia
- Urine: for analysis to test for albumin, sugar, acetone that might complicate labour

Personal hygiene: a shower is both hygienic and pleasant. If the mother‘s membrane have ruptured or in advanced first stage of labour, she is sponged down on a couch and given a clean

Admission: the mother is then admitted on a partograph, all the necessary information recorded and the continuous observation of the mother takes place accordingly

Outlining Questions: Structuring Information

When faced with outlining questions, it is important to structure your response in a logical and organized manner. Begin by providing an the main points or components related to the topic. Use subheadings to break down the information further, making it easier for the examiner to follow your answer.

Example Question: Outline the changes that take place in the uterus during the first stage of labour?

Before answering the proposed question above, it‘s vital to first define the following terms:

Labour: is the process by which the foetus, placenta and the membranes are expelled out of the birth canal after 28^th weeks of gestation
First stage of labour: is the period of dilatation of the cervix lasting from the onset of true labor till full dilatation.

During the first stage of labour the following occurs:

Effacement or take up of the cervix: this is made possible by the work of muscle fibres surrounding the internal OS which are drawn upward by the retracted upper segment.
Pacemaker / Fundal dominance: each contraction begins from the pace maker situated at the cornua of the uterus. From the fundal region it spreads downwards being stronger and persisting longer in the upper region on reaching the lower region, the wave of contraction weakens and allows the cervix to dilate.
Dilatation of the cervix: this is the opening of the external OS to allow the passage of the fetal head; it occurs as a result of uterine action and the pressure from fore bag of waters and the well fitting presenting part
Contraction and Retraction: is the special ability of the uterine muscle where the contraction does not pass off completely and the muscle fibres, retaining some of the contractions, do not become completely relaxed, instead they become gradually shorter and thicker.
Polarity: is the term used to define the coordination between two poles of uterus throughout labour.
Development of upper and lower segment: the upper uterine segment is the thicker muscular contractile part. The lower part segment is the firm distensible are of 7.5cm – 10cm in length developed from isthmus to the uterus.
Development of retraction ring: is the ridge formed between the upper and the lower uterine segment. It‘s present in labour and normal as long as it‘s not marked enough to be visible above the symphysis pubis. NB: It is called bandl‘s ring in obstructed labour
Show: is the blood stained mucoid discharge seen a few hours within or a few hours after when labour has started.
General fluid pressure: while the membranes remain intact, the pressure of the uterine contraction is exerted on the fluid as the fluid is not compressible the pressure is equalized throughout the uterus.
Rupture of membranes: rupture of membranes may be early or later during the second stage of labour due to the malpresentation and pressure from the presenting part.
Fetal axis pressure: this is when the force of contractions from the uterus is transmitted via the long axis of the canal; this becomes more significant after the rupture of membranes and during second stage.

Describing Questions: Providing Detailed Information

Describing questions require you to provide detailed information about a specific topic or concept. When answering these questions, you have to offer a comprehensive and thorough response, including relevant facts, characteristics, and examples. Use clear language and provide specific details to enhance the depth of your description.

Example Question: Describe the vagina.

Definition: Vagina is a muscular fibrous canal which forms the part of the internal female reproductive organs.

Situation: It is a canal which extends from the vestibule below to the cervix above running in an upward and backward direction between the planes of the pelvic brim.

Shape: It is a potential tube which runs upwards and backwards with its walls in close contact but can be separated during coitus, menstruation, vaginal examination and child birth.

Size: The anterior wall measures 7.5cm. The posterior wall is longer and it measures 10cm.This is because the uterus enters the vagina at an angle of 90 degrees and bends forwards towards the anterior wall hence it encroaches on it

Structure

Gross structure

Superiorly; the upper end of the vagina is known as the vault, where the cervix protrudes into the vault it forms circular recess known as fournices.

The vagina is made up of four fournices that is to say;

The anterior fornix which is smaller and fairly deep The 2 lateral fournices which are shallow
The posterior fornix which is the longest and deepest
The lower end of the vagina is narrow and inferiorly we find the vulva, hymen enclosing the vaginal opening only present in virgins. If hymen is ruptured it leaves tags of membranes referred to as carunculae mytiformes. Vaginal orifice is also called introitus.

Microscopic structure

It is made up of four layers;

Squamous epithelium arranged in folds known as rugae and makes the inner most layer of the vagina, the rugae increase the surface area and offer the vagina ability to stretch when need be for example during coitus and child bearing.
Vascular connective tissue layer which is rich in blood vessels, nerves and lymphatics and is found just beneath the epithelium.
Muscular layer. This is thin but a strong layer which is divided into two; the weak inner circular and strong outer longitudinal fibres.
The pelvic fascial which is made up of loose connective It forms the outer protective coat and is continuous with the pelvic fascia.

Blood supply (arterial): The vagina is supplied by the branches of internal iliac artery which include vaginal artery and uterine artery.

Venous drainage: By the corresponding veins i.e branches of internal iliac veins which include vaginal veins and uterine veins.

Lymphatic drainage: Into the inguinal, the iliac and the sacro glands

Nerve supply: By the sympathetic and parasympathetic nerves which are branches from the lee Franken lanser plexus

Contents of the vagina

It doesn‘t contain any glands but its kept moist by cervical mucus and a transudation from the underlying blood vessels through the epithelium.
Its media is acidic (PH 3.8 to 4.5) and this is made possible by presence of lactic acid after action of doderleins bacilli on glycogen.

Relationships of the vagina

Anteriorly: Below, the base of the bladder rests on the upper ½ of the vagina and the urethra is embedded in the lower ½.

Posteriorly: Pouch of Douglas above, the rectum medial and perineal body below.

Laterally: Pubococcygeous muscles below and pubic fascial containing the uterus above.

Inferiorly: The structure of the vulva.

Superiorly: The cervix and the fournices.

Functions of the vagina

Exit from menstrual flow.
Entrance for spermatozoa.
Exit for products of conception.
Supports the uterus.
Prevents ascending infection due to acidic PH.
For assessing the pelvis.
Drug administration.

Mentioning, Identifying, and Stating Questions: Being Clear and Concise

When faced with questions that require you to mention, identify, or state specific information, it is essential to be clear, concise, and accurate in your response. Avoid unnecessary elaboration and focus on providing the requested information directly.

Example Question: State the major components of a comprehensive birth plan?

To answer this question effectively, you can provide a concise statement listing the major components of a birth plan:

A comprehensive birth plan typically includes the following components:

Preferred birth environment (hospital, birthing center, home birth)
Pain management preferences (medication, natural methods, water birth)
Support people and their roles during labor and delivery(husband, mother)
Positioning preferences for labor and birth(lithotomy)
Preferences for fetal monitoring during labor
Neonatal interventions and care preferences immediately after birth
Feeding preferences (breastfeeding, formula feeding)
Cultural or religious considerations
Preferences for postpartum care and rooming-in with the baby
Contingency plans for unexpected situations or interventions

By providing a clear and concise statement of the major components, you address the question directly and effectively.

Listing and Giving Questions: Providing Comprehensive Information

When asked to list or give information, it is important to provide a response that covers all the relevant points. Ensure that you include all necessary information without leaving out any key details.

Example Question: List and give examples of common obstetric emergencies that midwives may encounter?

In response to this question, here is a comprehensive list of common obstetric emergencies along with examples:

Postpartum Hemorrhage (PPH): This is excessive bleeding following childbirth. Examples include uterine atony (lack of uterine contractions), retained placenta, or trauma to the birth canal.
Shoulder Dystocia: It occurs when the baby’s shoulders become stuck behind the mother’s pubic bone during delivery. This can lead to complications such as brachial plexus injury or fetal hypoxia.
Umbilical Cord Prolapse: The umbilical cord slips through the cervix ahead of the baby, potentially cutting off the baby’s oxygen supply. This requires immediate action to relieve pressure on the cord.
Amniotic Fluid Embolism: This is a rare but life-threatening condition where amniotic fluid enters the mother’s bloodstream, triggering an allergic reaction. It can result in cardiac arrest, respiratory failure, or disseminated intravascular coagulation (DIC).
Pre-eclampsia/Eclampsia: Pre-eclampsia is characterized by high blood pressure and organ damage during pregnancy, while eclampsia is the development of seizures in a woman with pre-eclampsia.
Placental Abruption: This occurs when the placenta separates from the uterine wall before delivery. It can cause severe bleeding and compromise fetal oxygen supply, necessitating emergency delivery.
Fetal Distress: This refers to a compromised fetal condition during labor, usually due to inadequate oxygen supply. It may require interventions such as changing maternal positions, administering oxygen, or performing an emergency cesarean section.
Cord Compression: The umbilical cord becomes compressed during labor, restricting blood flow to the baby. This can occur due to cord entanglement, excessive cord length, or abnormal positioning.
Maternal Infections: Infections such as chorioamnionitis (infection of the placental membranes), sepsis, or genital tract infections can pose risks to both the mother and the baby.
Maternal Hypertensive Disorders: These include gestational hypertension, chronic hypertension, and HELLP syndrome.

Write Short Notes: Concise and Informative Summaries

When encountering “Write Short Notes” questions, the aim is to provide concise yet informative summaries of the given topic. These questions require you to summarize the key points and present them in a clear and organized manner. Avoid excessive details and focus on providing a brief but comprehensive overview.

Example Question: Write short notes on the following

(a) Causes of pain in labour.

(b) Factors that affect pain perception during labour.

(a)CAUSES OF PAIN

There are two major causes of pain

Hormonal factors
Mechanical factors

Hormonal factors These include;

Oxytocin stimulation. This increases the strength, intensity, duration and frequency of the contractions leading to pain.

Progesterone withdrawal. The reduced levels of progesterone lead to an increase in estrogen levels which stimulates the muscles of the deciduae muscles of the uterus to produce prostaglandin which stimulates the smooth muscles of the uterus to contract.

Mechanical factors These include;

Strength and frequency of Braxton hick‘s contractions occurring in late pregnancy which leads to over stretching of the uterus which irritates the uterine muscles to contract leading to pain.

Pressure of the presenting part on the sacro-nerves and lumbar nerves which has pain receptor.

Pressure of the presenting part on the cervix. The presenting part exerts pressure on the cervix muscles hence leading to pain.

Displacement of the pelvic floor muscles. The advancing presenting part distends the vagina and displaces the pelvic floor muscles which are over stretched and the nerves are compressed leading to pain.

(b) PERCEPTION.

Is the process of becoming aware of the environment through the five senses.

Factors that affect pain perception during labour

These factors are emotional experience involving physical and psychological mechanism and can be contributed by the mother, fetus, health workers and structural environment.

Mother

Maternal medical; conditions like pre-clampsia and eclampsia, cardiac conditions which can affect pain perception.
Compromised immunity due to chronic conditions like HIV and cancer which can affect pain perception.
Size of the pelvis. Any pelvic deviation from normal leading to cephalous pelvic disproportion which can affect pain perception.
Age. Young prime gravidae below 18years their pelvic bones are not fully developed and the mother above 35years their pelvic bones are contracted and this hinders normal progress of labour and affects pain.
Parity. Prime gravidae‘s their muscles are still intact and sensitive to pain which leads to strong contractions. The multipara mothers their muscles are laced which leads to uterine itial.
Past obstetrical history like caesarian section which increases the risks of uterine rapture and affects normal labour
Social economic factors for example lack of support which can affect pain perception.
Cultural factors like use of native drugs can affect pain perception.
Past experience can also affect pain perception
Level of education, occupation, religion can also affect pain perception.

Fetus

Fetal abnormalities like hydrocephalous, macrosomic babies can lead to cephalopelvic disproportion hence affecting pain.
Lie, position and presenting pain can affect pain perception during labour
Size of the fetus that is to say big babies which cannot pass through the pelvis hence affecting pain perception
Gestation age. In past maturity the sutures and the fontanels are closing and molding can hot take place hence affecting pain perception.

Health workers

Poor screening of mothers during antenatal Poor management during labour
Poor attitude towards the mother

Structural environment

Hospital setting where there is no privacy for mothers, all stages of labour in one room which can affect pain perception.
Lack of recreation in labour rooms like newspapers, television to occupy the mothers.

What Questions: Providing Clear Definitions and Explanations

“What” questions typically require you to provide clear definitions, explanations, or descriptions of a specific concept, procedure, or pathophysiology These questions aim to test your understanding and knowledge of the subject matter. When answering “What” questions, it is important to be precise and concise in your response, while still providing sufficient information to address the question accurately.

Example Question: What is the role of the midwife in the immediate postpartum period?

To answer this question effectively, you can provide a concise definition and description of the midwife’s role during the immediate postpartum period:

Monitoring maternal and neonatal vital signs: Midwives closely monitor the mother’s blood pressure, heart rate, and bleeding. They also assess the baby’s breathing, heart rate, and overall well-being.
Assisting with breastfeeding initiation: Midwives provide support and guidance to initiate breastfeeding, ensuring proper positioning. They offer education on breastfeeding techniques, addressing any concerns or difficulties that may arise.
Providing emotional support: Midwives offer emotional support to new mothers, addressing any anxieties, fears, or questions they may have. They create a nurturing and supportive environment for the mother and her newborn.
Assessing postpartum recovery: Midwives conduct physical examinations to assess the mother’s postpartum recovery, including uterine involution, healing of perineal tissues, and overall well-being. They provide guidance on self-care practices and postpartum contraception options.
Identifying and managing postpartum complications: Midwives are identify and manage any postpartum complications that may arise, such as postpartum hemorrhage, infection, or breastfeeding difficulties. They collaborate with healthcare providers if further interventions are required.

By explaining the midwife’s role in the immediate postpartum period, you address the “What” question while providing a clear understanding of the topic.

What information must you note on vaginal examination?

On inspection

State of the vulva, note any abnormal discharges like pus, blood, abnormal growths like warts, oedema and scars.

On examination

Note condition of the vagina. Normally the vaginal walls feel warm and moist and dilatable. If dry may be a sign of infection or obstruction.
State of the cervix. If thin, thick, whether soft or rigid and whether its well applied to the presenting part. Note dilatation and cervical effacement.
State of the membranes. Whether intact or ruptured. If ruptured check colour and smell of liquor
Presentation and presenting part. Note level of presenting part in the pelvis. Confirm position by finding or palpating sutures and fontanelles and relate them to the maternal pelvis. Note moulding.
Do internal pelvic assessment and note

-sacro promontary if protruding
-hollow of the sacrum if well curved
-sciatic notches if well rounded
-ischial spines if prominent
-sub pubic arch-if it accommodates 2 ½ to 3 fingers
-inter tuberous diameter if it accommodates 4 knuckles

Tips for Success:

a. Understand the instructions: Carefully read and follow the instructions.

b. Plan your response: Take a moment to brainstorm and outline your ideas before starting to write. This will help you organize your thoughts and ensure a great structured response.

c. Provide relevant examples: Whenever possible, support your answers with real-life examples, or evidence-based practices to demonstrate your understanding and application of midwifery knowledge.

d. Use clear and simple language: Write in a clear and simple manner, avoiding unnecessary elaboration. Focus on delivering information effectively while maintaining clarity.

e. Practice time management: Allocate time for each question based on its difficulty. This will help you ensure that you have enough time to answer all questions within the given time.

f. Review your answers: Before submitting your answer sheet, review your answers to check for any errors, omissions, or areas that need further clarification or elaboration. Don’t forget to write your NSIN Number!

Question Approach Read More »

Anaemia In Pregnancy

Anaemia means a reduction in oxygen carrying capacity or in quantity of red blood cells.

This may be due to:
> A reduction in number of the red blood cells
> A low concentration haemoglobin
> A combination of both
Degrees

Mild – 80% = 11 g/dl – 12.5 g/dl
Moderate – 70% = 8-10.3
Severe – 60% = 7 g/dl and below

Mild – 9.0g/dl
Moderate – 7.8g/dl
Severe – 6g/dl

Causes

Social and economic factors;

Ignorance about utilization of food
Poverty unable to buy the high protein foods
Native medicine
Unstable country / Insecurity
Beliefs – cultural superstition which forbid women from taking certain foods for example chicken and eggs

Obstetrical causes

Frequent child bearing
Repeated haemodilution
Multiple pregnancy due to high fetal demand
Hyperemesis gravidarum leading to poor absorption of Vitamin B12
Abortions, ruptured ectopic, PPH, APH, and heavy periods

Medical causes

Frequent attacks of malaria
Hookworm infestation
Infections such as septicaemia, TB
Sickle cell anaemia
Drugs like Chloramphenical

Types of Anaemia

Physiological anaemia.
Nutritional anaemia.
Aplastic anaemia.
Haemorrhagic anaemia.
Haemolytic anaemia.
Pernicious anaemia.

Physiological anaemia: This is the type of anaemia that occurs during pregnancy due to haemo-dilution that occurs during pregnancy where the blood plasma is increased by 25-30%.
Nutritional anaemia: This is the type brought about about by poor diet whereby there may be deficiency in:
> Folic acid which is responsible for the RBC development bringing about megoblastic anaemia, (Immature Red blood cells)
> Iron deficiency anaemia which is due to the increased fetal demand from the 28th week of pregnancy or due to excessive morning sickness, vitamin B12 and vitamin c deficiency with lack of protein leading to pernicious anaemia.
Aplastic anaemia: This is due to the damage of the red bone marrow caused by prolonged use of chloramphenical depressing the bone marrow
> Radiation where insufficient protection from the x-rays was not provided
> Diseases such as cancer and leukaemia
> Poison from insecticides
Haemorrhagic anaemia: This when there is increased blood loss as may occur in the following cases
> Frequent child bearing that the mother does not get time to regain her haemoglobin levels
> Worm infestation such as hookworms
> Abortions, PPH and APH
> Ruptured ectopic pregnancy
> Trauma and accidents
> Haematemesis and haemoptysis
Haemolytic anaemia: This is when there is increased blood destruction due to:
> Infections such as septicaemia, Pyelonephritis and Bacterial Streptococcus
> Diseases for example malaria
> Mis-crossmatched transfusion
> Sickle cell disease – big spleen disease
> Drugs for example primaquine
Pernicious anaemia
This is when the intrinsic factor is missing leading to mal absorption of vitamin B12. It may occur in the following conditions:
> Diseases of the stomach for example cancer
> Hyperemesis gravidarum
> Surgical operations for example gastrectomy. However, this condition rarely occurs during child bearing age

Signs and symptoms

On history taking

Patient gives history of general body weakness
Dizziness
Faintness
Palpitations
Loss of appetite (Anorexia)
Headaches
Breathlessness
History of heavy bleeding may be there

On Examination

Pale mucus membranes and conjunctiva for example gums, kips, tongue, soles of the feet and palms of the hands
Distention of the jugular veins
In severe cases oedema of the ankles, feet or it may be generalized
On abdominal palpation, there may be enlarged spleen and liver
Jaundice

Laboratory Tests
Haemoglobin level will be low below 12.5 g/dl

Diagnosis

Based on three factors:

History taken from the patient about her home including the surrounding
diet, parity and hygiene.
Examination of the patient to detect pale mucus membranes and venous return for example oedema of the upper limbs, wedding rings and puffiness of the face.
Investigations: Investigations carried out

(a) . Haemoglobin estimation that any haemoglobin of 10 g/dl or below is regarded as anaemia
(b) . Packed cell volume (Normal is 40%)
(c) . Blood film – thick to identify the shape, maturity and consistency, thin red blood cells.
(d) . BS for malarial parasites
(e) . Sickling test to exclude abnormal cells
(f) . Blood film for the thin:

Microcytosis and hypochromia for iron deficiency
Megaloblastic cells – Normochromic for vitamin B12 and folic deficiency
Sickle cell disease
Target cells
Reticulocytes for haemolysis whether its going on mainly in the spleen, whether it is a mixture of no. 1 and 2 which will be indicating nutritional
anaemia

(g) . Coombs test for haemolytic anaemia to see whether the mother s developing antibodies against the red blood cells. Usually gets recurrent anaemia.
(h) . Bone marrow – to confirm the shape of the cells
(i) . Urinalysis for protein indicating damage to the kidney. Microscopic – for put
cells in case of severe pyenehiritis

(j) . Stool for intestinal parasites, the commonest is hookworm anaemia
(k) . Haemoglobin: Electrophoresis to confirm SCD

Effects of anaemia on pregnancy and labour

General body fatigue with tiredness, breathlessness, palpitations and headache.
Placental insufficiency due to lack of oxygen may lead to:
> Intra-Uterine Fetal Death – intra uterine fetal death
> Small for dates
> Neonatal death
> Abortion and premature labour
Post partum haemorrhage
Stress of labour may not be tolerated by a very anaemic and even minor blood loss may be fatal
Fetal and maternal distress leading to instrumental delivery
May go into heart failure
More likely to have venous thrombosis
Less resistance to infection
Poor lactation

Management

Will depend on the severity of the grade of anaemia, stage of gestation and investigation or cause.

Early pregnancy with mild or moderate anaemia in a maternity centre and hospital
A mother with mild or moderate anaemia treated as an out patient.

Put the mother in bed
Take history from the mother concerning the type of diet way of living and her surrounding to know the cause of anaemia
Carry out general examination for degree of anaemia by use of a tallquist book
The midwife is only allowed to treat mild and moderate anaemia in early pregnancy
The condition is managed according to the cause
If no clinical examination the haemoglobin is found to be below 60% is sent to the hospital for investigations

Active Treatment
For a mother with haemoglobin of 60% and above may be treated with the following:-

Where malaria is common, the mother is given three doses of Fansidar 960 mgs tablets.
Mebendazole 200 mgs bd x 3 days for hookworm
Iron therapy of ferrous Sulphate and folic acid then review after 2 months, ferrous sulphate 200 mgs bd, forric acid 5 mgs od
NB. In the maternity centre moderate anaemia in late pregnancy, refer to hospital.

In the hospital

Admit in the hospital in Antenatal ward
Take history about the diet, environment and hygiene
Observations – temperature, Pulse, Respirations and blood pressure taken
Any underlying cause will be treated accordingly
The mother is given routine nursing care
Proper hygiene
Given a high protein diet

Severe anaemia in early pregnancy and late pregnancy
In maternity Centre – refer to hospital please

In Hospital
The mother is admitted and history taken
Observations and investigations carried out
Patient is resuscitated immediately with:
(a) Blood transfusion or parenteral iron dextran (Inferon) infusion if blood is not available. (N.B Total dose of inferno is given slowly and only in severe anaemia nearly to the time of delivery, and after delivery, should be transfused with packed cells under Lasix.)
Dueretics are given for example lasix 120 mg IV
The patient with severe anaemia should be nursed propped up in bed and given all the care of a very ill patient.
Mouth should be given special attention as stomatitis and glossitis are common in anaemia patients diet – high protein diet with green vegetables plus fresh fruit
Strict fluid balance chart, observe for signs of impending cardiac failure which are raising pulse and respirations. Should report breathlessness if the patient has tuberculosis
N.B. IV inferon – 5 ampoules of 250 mgs each in 100 mls of dextrose 5% or normal saline 500mls.

Prevention of anaemia

Good antenatal care – by detecting anaemia and malaria early and treat them.
Health education about diet, personal hygiene, environmental, sanitation by proper use of latrines
Protection against malaria
Reduce blood loss in 3rd stage even after by good management of all the stages of labour
Replace proteins at least during lactation by giving extra protein
Administration of extra Iron and folic acid
To carry out the routine examination of blood for haemoglobin

Advice to the mother

Explain to the mother the reason why she has become anaemic, dangers of anaemia and how to prevent it.
Rest to avoid overworking
Diet and types of food
Advise the mother to take any treatment ordered regularly
The need to prevent mosquitoes to avoid malaria
To avoid frequent child bearing (family planning)
To deliver in the hospital

In labour

Good management of 3rd stage of labour to prevent much blood loss
Administration of iron during puerperium

On discharge

Tell the mother to report immediately when they become pregnant in order to receive appropriate prophylactic treatment of iron therapy

Anaemia in Pregnancy Read More »

Normal First Stage of Labour

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

Fundal dominance;
Each uterine contraction starts from the fundus near the cornua and spreads across and down wards.
The contraction lasts longer in the in the fundus where it is most intense but the peak is reached simultaneously over the whole uterus and the contractions fade from all parts together.
This permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

Polarity
This is a neuromuscular harmony that prevails between the two poles of the uterus throughout labour.
During a contraction, these two poles act harmoneously. The upper uterine segment contracts strongly and retracts to expel fetus and the lower pole contracts slightly and dilates to allow expulsion of the fetus. If polarity is disorganized, labour progress is inhibited.

Contraction and retraction
During labour, a contraction does not pass off entirely but muscle fibres retain some of the shortening contractions instead of becoming completely relaxed. This is termed as retraction. This is a unique property of the uterine muscles and because of this,
the upper uterine segment becomes shorter and thicker and diminishes its cavity assisting in expulsion of the fetus.

Formation of the upper and lower uterine segment
By the end of pregnancy, the body of the uterus has divided into two segments;
> The upper segment is mainly for contraction and is muscular and thicker while the lower uterine segment is for distension and dilatation and is thinner.
> The lower segment develops from the isthmus and is about 8-10cm in length.

Retraction ring

This is a ridge formed between the upper and lower uterine segment.
The physiological retraction ring gradually rises when the upper uterine segment contracts and retracts and lower uterine segment thins out to accommodate the descending fetus.
This ring is not usually visible and when cervix is fully dilated and fetus can leave the uterus, it rises no further.
An exaggerated phenomenon of retraction ring in obstructed labour it becomes visible above the
symphysis pubis. This is termed as a bundle’s ring

2. CERVICAL ACTION

Cervical effacement
This is inclusion of the cervical canal. The muscle fibres surrounding the internal os are drawn upwards by the retracted upper uterine segment and the cervix merges into the lower uterine segment.

Cervical dilatation
This is the process of enlargement of the os from a tightly closed aperture to an opening large enough to permit passage of the fetal head.
It is measured in cm. a full dilatation at term equates to 10cm.
Pressure applied by the bag of fore waters and a well flexed fetal head closely applied to the cervix favors efficient dilatation.

Show
This is blood stained mucus which is seen before or at the onset of labour. The mucus is a thick mucoid substance which forms the cervical plug (opeculum) during pregnancy. Blood comes from raptured capillaries when the chorion has become detouched from the dilating cervix.

3. MECHANICAL FACTORS

Formation of fore waters

As the lower uterine segment stretches, the chorion becomes detouched from it and the increased intra uterine pressure causes this loosened part of the sac of fluid to bulge down wards into the dilating internal os. A well flexed head fits snugly into the cervix and cuts off the fluid in front of the head from that surrounding the body. The water in front is known as fore waters and that
behind is called hind waters.

General fluid pressure
When the membranes are intact, the pressure of the uterine contractions is exerted on the fluid and since the fluid is not compressible, the pressure is applied on the uterus and over the fetal
body. This is termed as general fluid pressure.
When membranes rapture and quantity of fluid escapes, the fetal head, placenta and umbilical cord will be compressed between the uterine wall and body of fetus during contraction resulting in reduced oxygen supply to the fetus.

Rapture of membranes
The optimum physiological moment for membranes to rapture is at the end of 1st stage of labour when the cervix becomes fully dilated and no longer supports the bag of fore water.
The uterine contractions are also applying increasing expulsive force at this time. Membranes may also rapture days before labour begins or during 1st stage of labour especially in a badly fitting presenting part.
Occasionally, membranes do not rapture even in 2 nd stage and appear at the vulva as a bulging sac covering the fetal head as it is born. This is known as caul(CAL DE SAC)

Fetal axis pressure

During the contraction, the uterus rises forward and the force of fundal contraction is transmitted to the upper pole of the fetus down the long axis of the fetus and is applied to the cervix by the presenting part. This becomes more significant after rapture of membranes and during 2 nd stage of labour.

Descent of the presenting part.

It refers to the downward and outward movement of this part through the pelvis.
The normal well flexed head twists and turns flexes and extends to maneuver through the pelvis.
There are 3 planes or obstacles involved in the process of descent:
– Pelvic inlet/ brim.
When the presenting part is at the level of the ischial spines, a pelvic brim mark, it indicates the largest part of the head has come through the brim. The head is thus engaged.
The presenting part is now at station 0.
– Pelvic cavity.
When the presenting part has descended to the perineum, the largest part has passed the ischial spines. The head is now at station +2.
– Pelvic outlet.
Delivery of the head brings it past the 3 rd obstacle ( pelvic outlet), which is under the pubic arch, between the ischial tuberosities and over the coccyx.
NB: station is the relationship of the lowermost part of the presenting part to an imaginary line drawn between the ischial spines and the woman’s pelvis.

MANAGEMENT OF FIRST STAGE OF LABOUR

Aims

To monitor labour progress.
To prevent maternal exhaustion.
To prevent infections.
To give comfort to the mother and maintain patient’s moral.
To relieve pain.
To prevent complications.

Admission of a mother in labour. Welcome the mother and her relatives to allay fear and anxiety, create rapport.
Obtain full history and review the antenatal card while the mother is sitting or lying on the couch.
The histories taken include;-
-Demographic data
-Date and time of admission
-When contractions started
-Frequency and strength of contractions
-If membranes raptured
Obtain consent from the mother and sign. Make sure mother is given sufficient
information before she decides to give consent.
Vital observations;- pulse ½ hourly if >100b/m indicates pain, anxiety, infections,
ketosis, hemorrhage etc.
– Blood pressure 2 hourly
– Temperature 4 hourly
-Respiration 4 hourly (16-20r/m)
Investigations e.g.- Urinalysis to rule out acetones, glucose and proteins.- Blood for Hb estimation, grouping and cross matching can be obtained depending on mother’s condition.
General examination The midwife examines a mother from head to toe paying more attention to general appearance (health or ill), size, any deformity, signs of anaemia, jaundice, oedema, dehydration, infections, Vericose veins and enlarged glands and veins in the neck. Examine the breasts and notice their suitability for breast feeding.
Abdominal examination: The mother’s bladder should be empty. It’s done following 3 steps.

Inspection:-for size, shape, scars, signs of pregnancy etc
Palpation: – Noting tenderness, height of fundus, presentation, lie, position, descent, contractions, frequency, length and strength.
Auscultation: – Noting rate, regularity and volume.

Vaginal examination.

This is a sterile procedure carried out on a woman through the vagina to rule out obstetrical or
gynecological abnormalities.

Indications of VE during pregnancy

> To confirm pregnancy
> To exclude abnormalities e.g. fibroids
> For pelvic assessment
> To determine the state of the cervix
> To confirm the type of abortion
> To rule out abnormal discharges
> During labour

During First stage

> To determine cervical dilation

> To exclude cord prolapse when membranes rapture
> To confirm full dilation when mother is bearing down.
> Before induction of labour to determine state of the cervix
> In prolonged labour to rule out obstructed labour.
> To make a positive identification of the presentation.
> To determine if the presenting part is engaged.

-During Second stage
> To confirm full dilation of the cervix
> When there is no descent to determine the delay e.g. face to pubis
> After delivery of the 1st twin to determine the presentation of the 2nd twin.

-During Third stage
> In delayed 3rd stage of labour to know whether the placenta is in the birth canal where it can be
removed quickly.
> To exclude lacerations and expel clots from the birth canal.
> In emergency i.e. manual removal of placenta.
> During puerperium
To find out whether the perineum has healed after 6 weeks.
> To find out whether the reproductive organs have regained their muscle tone and position.
> To obtain a specimen for examination.
> In abnormal vaginal discharge to confirm the type of infection.

Contraindications of VE

Active vaginal bleeding: If a patient is currently experiencing active vaginal bleeding, a vaginal examination may worsen the bleeding or lead to further complications.
Recent pelvic surgery or trauma: Patients who have undergone recent pelvic surgery or trauma may have delicate or healing tissues that can be easily damaged during a vaginal examination.
Suspected or confirmed pregnancy with threatened miscarriage or ectopic pregnancy: Vaginal examination may increase the risk of complications, such as miscarriage or rupture of an ectopic pregnancy, in patients with these conditions.
Known or suspected cervical incompetence: Cervical incompetence refers to a weakened or structurally defective cervix that is unable to maintain a pregnancy. In these cases, a vaginal examination may increase the risk of cervical dilation or premature rupture of membranes, potentially leading to preterm labor or miscarriage.
Active pelvic infection or history of pelvic inflammatory disease (PID): Vaginal examination in the presence of an active pelvic infection or PID can potentially spread the infection or cause further complications.
Severe pain or discomfort: If a patient experiences severe pain or discomfort during a vaginal examination, it should be stopped immediately.
Patient refusal or lack of consent: Patients have the right to refuse any medical procedure, including vaginal examinations.
In APH and elective caesarian section

Complications of VE

Discomfort or pain: Vaginal examinations can cause discomfort or mild pain, particularly if the pregnant mother is anxious.
Vaginal bleeding: Following a vaginal examination, some pregnant mothers may experience light spotting or minimal bleeding. This is generally considered normal and should resolve on its own. However, if the bleeding is heavy, persistent, or accompanied by abdominal pain, it could indicate a potential complication such as placenta previa or placental abruption. Can also cause Trauma or lacerations to the birth canal.
Infection: there is risk of introducing bacteria into the vaginal canal during a vaginal examination, which could lead to infection.
Premature rupture of membranes (PROM): vaginal examination can accidentally cause the membranes surrounding the baby (amniotic sac) to rupture prematurely. This can lead to premature labor and delivery.

Requirements
Tray containing;
> Galipot for swabs with antiseptic
> 2 receivers
> Sterile gloves
> Vaginal speculum
> Sterile bowl for lotion.
> Perineal pad/ clean pads
> Sheet and mackintosh.
> Clean gloves.
> Lubricant
At the bed side
> Screen
> Hand washing equipment
> Bed pan

PROCEDURE OF VAGINAL EXAMINATION

Welcome and explain procedure to the mother.
Empty bladder and screen the bed.
Assemble a VE tray.
Ask mother to relax during examination.
Woman’s arms should be down by her sides or across her abdomen to relax her abdominal muscles.
Assist her into dorsal position and drape her.
Put on clean gloves
Place mackintosh and draw sheet under the buttocks
Remove gloves and wash hands thoroughly and put on sterile gloves.
Observe the external genitalia. Before the midwife cleans the vulva, should observe the following;-
– Hygiene
– Labia for signs of varicosities.
– Oedema
– Vulval warts
– Sores
– If the perineum has old scars for tears, episiotomy, female circumcision.
– Any discharge from the vaginal opening i.e. blood, raptured membranes, smell of liquor and colour.
– If liquor smells, it indicates infections. If green or meconium stained, indicates fetal distress.
Vulva is swabbed using the left hand, swab from the front towards the rectum.
The 2 fingers of the right hand are dipped in the antiseptic cream for lubrication and gently inserted down wards and backwards into the vagina while the labia majora are held apart by the fingers of the left hand.
The fingers are directed along the anterior vaginal wall and should not be withdrawn until the required information has been obtained. NB: The clitoris should not be touched because it causes discomfort.

Findings:

Condition of the vagina;

The vagina should feel warm and moist. A hot and dry vagina is a sign of obstructed labour and should not be found in modern obstetric care.
If a mother has a high temperature, the vagina will feel correspondingly hot but not dry.
Previous scar from Perineal wound, cystocele or rectocele.

The cervix;
The normal should feel thin and elastic and well applied to the presenting part.
A spongy feeling may show undiagnosed placenta previa.
The midwife should sweep the examining fingers from side to side to locate the os. It is usually felt in the center but sometimes in early labour, it is very posterior.
The length of the cervical canal assessed through a tightly closed cervix shows that labour has not yet started.
In a PG, the cervix can be completely taken up(effaced) but still closed and in this manner, it will be closely applied to the presenting part and it can be confused with a fully dilated cervix. If poorly applied to the presenting part, then it means there is an ill-fitting presenting part.
Assess cervix for; effacement, dilatation, consistency.

Membranes;
When membranes are intact, they can be felt through the dilating os; they feel tenser on contraction. When the fore waters are shallow, it is not easy to feel membranes.
If the presenting part does not fit well in or at the cervix, some of the fluid from the hind waters escapes into the fore waters causing the membranes to bulge or protrude through the cervix and are liable to rapture early.

Level or station of presenting part;
The presenting part is that part of the fetus that lies over the internal os during labour.
In order to assess the descent of the fetus in labour, the level of presenting part is assessed or estimated in relation to maternal ischial spines.

Position;
On feeling the features of the presenting part, the position of the fetus can be detected. The vertex is the normal presentation and the midwife must be familiar with it. Commonly the first feature to be felt even in early labour is the sagittal suture. The sagittal suture should be followed with a finger until a fontanel is reached.
If the head is well flexed, the posterior fontanel will be felt. This can be judged by feeling the amount of overlapping of the skull bones and can give additional information on position.
The parietal bones override the occipital bone to reduce the distance of the presenting diameter.

Pelvic capacity (pelvic assessment);
Although the pelvis was assessed during ANC period, the midwife should take opportunity to assure herself of its adequacy as she completes vaginal examination.
At completion of examination, withdraw fingers from the vagina and note any blood or amniotic fluid, cleans up the mother and removes gloves.
Record all findings of what was observed on admission on a partograph and observation chart.

Sample Questions

Formulate 3 actual and 2 potential nursing diagnoses for a mother in first stage of labour.
Outline 10 nursing intervention for this mother giving rationale for each.

Answer.

Actual Nursing Diagnoses:

Pain related to uterine contractions and cervical dilation as evidenced by patient verbalization of pain.
Anxiety related to uncertainty and anticipation of labor as evidenced by the mother asking a lot of questions if she will deliver well.
Fluid volume deficit related to increased fluid loss during labor as evidenced by frequent urination by the mother.

Potential Nursing Diagnoses:

Risk for fetal distress related to maternal physiological changes during labor
Risk for ineffective coping related to labor pain and emotional stress

2. Ten nursing interventions for this mother, along with their rationales:

Assess and monitor the mother’s pain level using a pain assessment scale (e.g., 0-10 scale): This intervention helps in determining the intensity of pain experienced by the mother, allowing appropriate interventions to be implemented.
Encourage and assist the mother with relaxation techniques, such as deep breathing and progressive muscle relaxation: These techniques can help the mother cope with labor pain by promoting relaxation and reducing anxiety.
Provide information and education about the labor process, including what to expect during the first stage of labor: This intervention helps to reduce anxiety by providing the mother with knowledge and understanding about the process, empowering her to participate actively and make informed decisions.
Offer emotional support and reassurance throughout labor: Emotional support from healthcare providers can help alleviate anxiety and provide a sense of comfort and security to the mother.
Encourage the mother to change positions frequently and ambulate if possible: Changing positions and walking during labor can help improve maternal blood circulation, relieve discomfort, and facilitate well fetal positioning.
Promote adequate hydration by offering frequent sips of clear fluids: Maintaining hydration is essential to prevent fluid volume deficit, particularly as the mother experiences increased fluid loss through sweating and exertion during labor.
Monitor maternal vital signs regularly, including blood pressure, pulse, and temperature: Regular monitoring of vital signs helps identify any deviations from normal, enabling prompt intervention if necessary.
Assess fetal well-being by monitoring fetal heart rate using continuous electronic fetal monitoring or intermittent auscultation: This intervention allows healthcare providers to evaluate the baby’s condition and detect any signs of distress promptly.
Administer pain relief measures as indicated, such as non-pharmacological methods (e.g., warm compresses) or pharmacological interventions (analgesics): Pain relief interventions should be offered based on the mother’s preferences, pain intensity, and the progress of labor, aiming to provide optimal pain management and enhance maternal comfort.
Collaborate with the healthcare team to make decisions regarding the need for medical interventions, such as augmentation of labor or cesarean section: Collaboration and communication among the healthcare team members are vital to ensure timely and appropriate interventions, promoting the well-being of both the mother and the baby.

Normal First Stage Of Labour Read More »

Labour

Labour is described as the process by which the fetus, placenta and membranes are expelled through the birth canal after 28 weeks of gestation.
OR
Labour is defined as rhythmic contraction and relaxation of the uterine muscles with progressive effacement (thinning) and dilatation ( opening) of the cervix, leading to expulsion of the products of conception.

Normal labour

Labour is said to be normal when;

It occurs at term.
Spontaneous in onset.
Fetus presenting by vertex.
The process is complete within 12-18 hours.
No complications arise.
Both mother and fetus suffer no injury.
No assistance is given in any way.

THREE P’S OF NORMAL LABOUR

Powers – uterine contractions
Passage – pelvis including the size and shape.
Passenger – Size, position and presentation of the fetus as well as bag of fore waters or amniotic sac.

TYPES OF LABOUR

True labour: This is characterized by regular uterine contractions slight at 1 st but increase in severity and frequency causes the cervix to dilate.
False labour: It is characterized by irregular uterine contractions which do not cause the cervix to dilate. They are painful, appear stronger when a mother is in bed and weaker when she is up and moving around.
> No cervical dilatation.
> No show.
> Pain remains stationary in the lower abdomen.
> Pain is continuous without any rhythm.
> Pain reduces after enema.
> No associated hardening of the abdomen.

Signs of impending labour.

These changes occur in the last weeks of pregnancy. This is termed as pre-labour.

Lightening
About 2-3 weeks before the onset of labour, the lower uterine segment expands and allows the fetal head to sink lower. The symphysis pubis widens and pelvic floor becomes more relaxed and softened, allowing the uterus to descend further into the pelvis.
Cervical changes
As labour approaches, the cervix becomes “ripe”. It becomes softer, like a lower lip and there is some degree of effacement and slight cervical dilatation.
False labour: It consists of painful uterine contractions that have no measurable progressive effect on the cervix and this is an exaggeration of the usually painless Braxton hick’s contractions which have been occurring since about 6weeks of gestation. It may occur for days intermittently even 3-4 weeks before the onset of true labour.
Premature rapture of membranes: Normally, membranes rapture at the end of 1 st stage of labour. When rapture occurs before the onset of labour, it is termed as PROM and occurs in about 12% of women. In 90% of women with PROM, labour begins spontaneously within 24 hours.
Bloody show: A mucus plug created by cervical secretions from proliferation of cervical mucosal glands in early pregnancy serves as protective barrier and closes the cervical canal throughout pregnancy. Bloody show is the expulsion of this mucus plug.
Energy spurt: Many women experience an energy spurt approximately 24-48 hours before the onset of labour. After days or weeks of feeling tired (physically tired and tired of being pregnant) they get up one day to find themselves full of energy and vigor.
G.I.T upset: In the absence of any causative factors for the occurrence of diarrhea, nausea, vomiting and indigestion, it is thought that they might be indicative of impending labour and there is no known explanation for this.

SIGNS OF LABOUR

They are divided into two;

Premonitory signs
Actual signs

Premonitory signs

– Lightening: It occurs 2-3 weeks before onset of labour. The lower uterine segment expands and allows the fetal head to sink further so as to engage. The fundus no longer crowds the lungs and breathing is easier and the mother experiences relief
– Frequency of micturition: Congestion in the pelvis limits the capacity of the bladder requiring it to be emptied more often
– Effacement of the cervix: This is the taking up of the cervix-the cervix is drawn up and gradually merges into the lower uterine segment.
– Braxton hick’s contractions: They become exaggerated and mother becomes anxious. She experiences backache or pains while walking due to relaxation of pelvic joints. This makes the mother think that she is in labour.

Actual signs

– Regular uterine contractions: Mother feels painful, rhythmic uterine contractions slight at first but increase in severity and frequency.
– Dilatation of the cervix: This is enlargement of the external OS from a circular opening large enough to permit passage of the fetus.
– Show: This is a bloody mucoid discharge which comes from the cervical canal. When it dilates, blood comes from the raptured capillaries.
– Plus or minus rapture of membranes: This is not so much relied on because it can occur in late 1 st stage or spontaneously at birth of the baby.

Causes of onset of labour.

The exact cause remains unknown but appears to be a combination of hormonal and mechanical
factors.

Hormonal factors.
Theories regarding the initiation of labour include the following;

Oxytocin stimulation theory: Although the mechanism is unknown, the uterus becomes increasingly sensitive to oxytocin as the pregnancy progresses.
Progesterone withdrawal theory: A decrease in progesterone production may stimulate prostaglandin synthesis and enhance the effect of Oestrogen which has stimulating effect on muscles. The fall of progesterone reduces the relaxing effect of the uterine muscles.
Oestrogen stimulation theory: Oestrogen stimulates irritability of uterine muscles and enhances uterine contractions.The raise in estrogen stimulates the decidua to release prostaglandins. Both prostaglandins and oxytocin cause the uterus to contract.
Fetal cortisol theory: Cortisol may affect the maternal Oestrogen levels.
Prostaglandin stimulation theory: Prostaglandin stimulates smooth muscles to contract.

A combination of the above mechanisms is likely to initiate labour.

Mechanical factors

Over stretching and over distension of the uterus
Pressure from the presenting part on the nerve endings of the cervix stimulates the nerve plexus (cervical ganglion)
The increase in the strength and frequency of Braxton hick’s contractions may cause labour to begin.

Stages of labour

1. First stage
It begins with onset of regular, rhythmic uterine contractions and is complete when the cervix is fully dilated. It is a stage of dilation of the cervix.
It’s divided into 3 phases

-Latent phase
-Active phase
-Transitional phase

Latent phase: This is a period of slow dilation of the cervix from 0-3cm. It may last 6-8hours in first time mothers
Active phase: This is the time when the cervix undergoes more rapid dilatation. It begins when the cervix is 4cm dilated and ends when the cervix is 8cm dilated.
Transitional phase: It begins when the cervix is 8cm dilated and is complete when Its fully dilated.

2. Second stage
It’s that stage of expulsion of the fetus. It begins when the cervix is fully dilated and is complete when the baby is completely born.
It also has two phases
– The propulsive phase
– The expulsive phase

Propulsive phase: It starts from full dilatation up to the descent of the presenting part to the pelvic floor.
Expulsive phase: It is distinguished by maternal bearing down efforts and ends with delivery of the baby.

3. Third stage
It’s that stage of separation and expulsion of the placenta and membranes and involves control of bleeding.
OR
It begins with birth of the baby and ends with expulsion of placenta and membranes.
It takes 5-30 minutes. With active management, its completed within 5-15 minutes.

4. Fourth stage
It is also called recovery stage. It is defined as the 1 st one hour after delivery of the placenta.

Labour Read More »

Antenatal Care

Antenatal care is a planned methodological care and supervision given to a pregnant woman by a midwife or obstetrician from the time the mother starts attending antenatal clinic until beginning of labour.

Aims of antenatal care

To monitor the progress of pregnancy in order to support maternal health and normal fetal development.
To prepare the mother for labour, lactation and subsequent care for her baby.
To detect early and treat appropriately high risk conditions be it medical or obstetrical that would endanger the life of the mother and the baby.

This is achieved by;

Developing a partnership with the woman.
Providing a holistic approach to the woman’s care that meets her individual needs.
Promoting awareness of the public health issues for the woman and her family.
Exchanging information with the woman and her family enabling them to make informed choices.
Being an advocate for the woman and her family, supporting her right to choose care that is appropriate for her own needs and those of the family.
Recognize complications of pregnancy and appropriately referring women within the multi- disciplinary team.
Facilitating the woman to make an informed choice about methods of infant feeding and giving appropriate and sensitive advice to support her decision.
Facilitating the woman and her family in their preparations to meet the demands of birth and making a birth plan.
Offering health education for parenthood.

Activities done in ANC

Registration
Booking (history taking)
Special tests and investigations
Health education
Immunization
Treatment of minor disorders
Provision of supplements
Examination i.e. physical and abdominal
Orientation of mothers
Formulating a birth plan
counseling.
Referral of cases

INITIAL ASSESEMENT (BOOKING DAY)

Objectives for initial assessment(booking visit)
– To assess the level of health by taking a detailed history and to offer appropriate
screening tests
– To ascertain a base line data of blood pressure, urinalysis, uterine growth and fetal
developmentto be used as standard for comparison as pregnancy progresses.
– To identify risk factors by taking accurate details of the past and present obstetric,
medical, family and personal history.
– To provide an opportunity to discuss any concerns the woman has.
– To give advice pertaining to pregnancy in order to maintain the health of the mother and
the developing fetus.
– To build the foundation for a trusting relationship in which the woman and the midwife
are partners in care.
– To make appropriate referral when additional health care or support needs have been
identified.

HISTORY TAKING

Demographic data
Name
Age
Address
Occupation
NOK; relationship, occupation, contacts.
LOE
Tribe
Religion
Nearest health facility and distance from home.

Social history
Habits

Smoking; Cigarettes have nicotine which constricts blood vessels leading to placental insufficiency, which can result in fetal hypoxia, small for dates, abortions etc. The woman should be advised to reduce on the number of sticks gradually to avoid withdrawal syndrome.
Alcohol; There is a risk of trauma which can result into abortion, placenta abruption, loss of appetite thus malnutrition and small for dates.
Marital status; -Married or single, number of years spent in marriage, find out if she’s happy or not.

Home environment

–House; – Rented or own, number of rooms and number of occupants.
–Environmental hygiene
–Source of water and food.

Family history

Health status of woman’s parents and her siblings (if deceased, note cause of death).
Familial diseases e.g. history of cancer, diabetes, cardiac diseases, allergies etc.
Other serious illnesses like mental illnesses or complications with pregnancy.

History of multiple pregnancies.
Past surgical history

History of accidents involving the spine, pelvis and lower limbs which would reduce the pelvic diameters.
History of major operations like C/S, and pelvic operations.
History of blood transfusion(risk of exposure to HIV/AIDS and iso immunization)

Past medical history

Medical conditions that may complicate or be complicated by pregnancy, labour and
Puerperium e.g. sickle cell, DM, HTN.
Child hood illnesses e.g. rickets, polio myelitis which can reduce pelvic diameters, hence
Contracted pelvis.
Infectious diseases like TB, Hep B
Infections like syphilis, gonorrhea,

Gynecological history

Gynaecological conditions like abortions, ectopic pregnancy, fibroids etc.
Gynaecological operations like myomectomy, D and C, evacuation etc.
Menstrual history
Menarche, length, interval, amount of flow.
Dysfunctional uterine bleeding (DUB).
Pre- menstrual spotting.
Family planning
Method of F/P ever used any complaint about it, reason for stopping it.

Past obstetrical history

Previous pregnancies; ask about any abnormalities e.g. abortions, still births, living children and their health status and immunization status.
Interval between pregnancies, length of gestation, birth weight, fetal outcome, length of labour,
Presentation and type of delivery. Prenatal and post natal complications, if baby was breast fed and for how long.
Labour; Any operations, induction, assisted delivery, PPH.
Puerperium; If it was normal, any h/o sepsis, PPH.

Present obstetric history

Gravidity
Parity
LMNP
EDD. This is calculated by adding 9 calendar months and 7 days to the date of the 1 st day of the woman’s last menstrual period (Naegele’s rule).

This method assumes that:

The woman takes regular note of regularity and length of time between periods.
Conception occurred 14 days after the first day of the last period. If the woman has a regular cycle of 28 days.
The last period of bleeding was true menstruation. Implantation can cause slight bleeding.
Break through bleeding and anovulation can be affected by contraceptive pill thus impacting on the accuracy of LNMP.
WOA

Present health

Appetite; It is important to know because poor appetite leads to malnutrition and anaemia.
Sleep; Find out if the mother sleeps well, if not, find out the cause which could be due to worries, insects in bed, pain and any signs of illness.
Micturition; It’s good to know whether the woman passes urine well because UTI is common in pregnancy due to stagnation of urine in dilated and kinked ureters. In case of increased frequency without pain, mother is counseled in relation to physiology of pregnancy.
Bowel action; as constipation is very common in pregnancy, the mother is re assured and advised to take plenty of fluids and roughages.

NB: Conclude history by asking mother if she has anything else she would like to tell you.

INVESTIGATIONS

On the first day, every woman should receive the following investigations

Blood pressure
Weight
Height
Urinalysis; – for albumen, acetone and sugars.
Albumen is indicative of PET, acetone-dehydration, sugar- diabetes.
RPR/VDRL; done to exclude syphilis.
HIV screening to ensure
EMTCT
Blood grouping
Hb level; It should be done on booking day, then at 32-34 weeks and lastly at 36weeks to rule out anaemia.
Comb’s test; It’s done to detect anti bodies in blood.

Clinical Tests

Weight; this is taken on every visit to ANC. The mother is expected to gain 12.5kg during pregnancy, 4kg in the first 20 weeks and 8.5kg in the last 20 weeks. Excessive weight gain could be due to twins, big baby, polyhydramnios etc. Failure to gain weight could be due to poor fetal growth.
Height; It’s done on the booking visit or in labour if the mother has not been attending ANC. The normal height should range 152-170cm, below 150cm indicates a small pelvis and above 170cm indicates a narrow pelvis.
Shoe size; if below 5 indicates a small pelvis. Normal shoe size ranges between 5 and 8.
Blood pressure; this is done on every visit to ANC. The BP of a pregnant mother ranges from 90/60 to 140/90mmhg.A raised BP is a danger sign and may be due to PET and eclampsia. Any rise of 30mmhg (systolic) and 15-20mmhg (diastolic) from what has been considered normal is dangerous and the mother’s urine should be tested for proteins. The mother is asked how she feels generally especially her sight (blurred vision), then referred to the doctor.

PHYSICAL EXAMINATION

This includes a review of the physical systems to ascertain the woman’s general health. The breasts, pelvis and abdomen receive particular attention. The examination is carried out systematically beginning with the head and ending with the pelvis and abdomen.

General appearance;

Body type, weight, energy level, grooming, posture. This is noted when the mother is entering the room or when she is sitting.

Head;

Scalp, hair whether treated and hair pattern distribution.
Eyes; conjunctiva- check for anaemia, sclera- check for jaundice, visions, discharge.
Nose; Sense of smell, bleeding, obstruction, abnormal growth and discharge.
Oral cavity; Toothache, denture, state of lips, chewing or swallowing problems, tongue and gums for anaemia, sense of taste.
Ears; Check for discharges, any hearing loss.

Neck;

Movement, Palpate for swelling or enlarged salivary glands i.e parotid, sub mandibular, sublingual, thyroid, lymph nodes i.e. superficial cervical and deep cervical glands, sub clavicles.
Palpate and observe jugular veins and pulsation of the thyroid gland. Swelling of the thyroid gland may be due to iodine insufficiency though during pregnancy there is a slight enlargement of the glands may be due to chronic cough. Extended jugular veins may be due to cardiac problems or anaemia.

Upper limbs;

They should be two with the same size and length, skin texture and muscle wasting. Palms examined for the colour, finger nails if capillary refill is good and oedema.

Chest;

Observe how the mother is breathing to detect if the mother has problems with respiratory system like pneumonia.

Breasts;
– Inspection.

Observe for size, equality, shape, pulling of breasts.
Signs of pregnancy, signs of abnormalities like changes in skin e.g. redness, orange like discoloration.
Nipple for prominence, dimpling retraction, size, flat, well protracted or not.
Presence of scars, cracks, sores, axillary extension.

– Palpation

Examined for breast abnormalities and deep seated masses.
This is done to promote proper breast feeding and exclude abnormalities.

Back;

Check for any fungal infections, scars, sacral oedema( may indicate PET or Eclampsia)

Lower limbs

Size, muscle wasting, pain or stiffness of joints, pain in the calf muscles, oedema, varicose veins, extra digits, any infections, tibia and ankle oedema.

Feet;

Hygiene, any fungal infections, nails check for venous return and colour. Sole of the feet for cleanliness and colour.
Perform a Homan’s sign: Homans’s sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans’s sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis.
Assess for maternal efforts.

Vulva;

Check for sores, warts, varicose veins, abnormal discharges etc.
Request mother to cough while observing for discharges.

Abdominal examination

It is carried out from 24 weeks gestation to establish and affirm that fetal growth is consistent
with gestational age during pregnancy.

AIMS

To observe signs of pregnancy.
To assess fetal size and growth.
To assess fetal health by auscultating the fetal heart.
To detect any deviations from normal
To diagnose the location of fetal growth.
To locate fetal parts.

Preparation/ procedure:

> Ensure mother has emptied the bladder within the last 30 minutes before abdominal examination.
> Ensure privacy
> Mother should be on a couch.
> Wash hands and expose only the area of the abdomen that needs to be palpated and cover the remainder of the woman to provide her privacy and protect her dignity.

STEPS

Inspection
Palpation
Auscultation

Inspection

Stand at the foot of the bed while mother is on her back with abdomen exposed from the xymphy sternum up to the symphysis pubis. Look at the size, shape, operational scars, signs of pregnancy like darkening of linea nigra below and above the umbilicus, fetal movements,
Striae gravidurum etc.

Palpation

> Abdominal palpation is also known as leopold’s maneuvers.

Stand at the right side of the mother, pads and not tips of fingers are used and palpate as follows;-
> Superficial palpation for localized tenderness.
> Hypochondriac palpation for enlarged organs.
> Height of fundus estimation
> Pelvic palpation for presentation
> Fundal palpation for the lie
> Lateral palpation for position

NOTE: During a deep pelvic palpation, a midwife grips the fetal head between the thumb and fingers to check for engagement, this maneuver is termed as pawlik’s grip/second pelvic grip.

Auscultation

This is the way of listening the fetal heart to determine fetal wellbeing by use of feto- stethoscope.
Abdominal summary

-Height of fundus
-Presentation
-Lie
-Position
-Fetal heart.

Case summary

> Comment on all histories, general and abdominal examination.
> Feed back
> Advice
> Return date

ONGOING ANC

PURPOSE

To continue to observe for maternal health and freedom from infections.
To assess fetal wellbeing.
To ascertain that fetus has adopted a lie and presentation that will allow vaginal delivery.
To offer an opportunity to express any fear or worries about pregnancy and labour.
To ensure that mother and family are confident to decide when labour starts.
To discuss any views about the conduct of labour and formulate a birth plan if required.
Risk factors arising during pregnancy
Change in fetal movement pattern- increased or reduced
Hb less than 10g/dl
Poor weight gain or weight loss
Proteinuria
Bp above 140/90mmhg
Uterus large or small for dates
Excess or decreased liquor
Malpresentation
Any vaginal bleeding
Premature contractions
Vaginal infection
Head not engaged by 38weeks in PGs

On each visit, do the following

> Review the card and assess any past complaints
> Take BP, weight and test urine
> Carry out general and abdominal examination.
> Give drugs accordingly.

Indicators of fetal wellbeing

Increased maternal weight in association with increasing uterine size.
Fetal movements which follows a regular pattern throughout pregnancy.
Fetal heart rate between 120-160b/m

The MOH Goal Oriented Anc Protocol
Goals are different depending on the timing of the visit. Minimum 8 Contacts are aimed for an uncomplicated pregnancy.
If a woman books later than in first trimester, preceding goals should be combined and attended to. At all visits address any identified problems, check the BP and measure the Symphysio-Fundal Height (SFH) women must receive Hb, HIV testing and Syphilis testing (RPR) routinely.

Individual birth plan

The plan includes

A birth place where there is a skilled birth attendant
Identifying someone to take care of the family in her absence
My EDD
Her choice of birth companion.
Identifying a blood donor.
Her choice of clothes for labour.
Strategies for labour pain relief.
Position for labour and child birth.
Place of delivery.
Transportation to use and how it will be available
How to raise funds for transport and cost of delivery.
Family security and feeding provisions.
Family planning goals after baby is born.
Where to go after delivery.
Next appointment.

NB: Involve the partner in the birth planning process. Teach mother how to recognize onset of labour.
– Nutrition
– Sleep and resting
– Sexual counseling
– Hygiene
– Daily activities
– Weight gain
– Postnatal follow-up

6. Immunization:
– TT

RECORD AND INTERPRETE FINDINGS

After taking proper history, done a thorough physical examination and relevant investigations, record all findings in the antenatal card.
Interpret the findings so as to identify the risk factors.
Give care and management accordingly.
Give appointment for the next visit accordingly.

Assignment
Discuss the goal oriented antenatal protocol.

PELVIC ASSESSMENT

This is estimation of the pelvic cavity so as to see whether its adequate for that particular baby to pass through.
OR
It is an examination done by a doctor or midwife on a pregnant woman at or after 36weeks to
see that both the mother and baby are out of danger at the time of delivery.

It is always done at 36 weeks because of the relaxation of the pelvic joints due to Relaxin hormone.

Aims

> To rule out poor obstetric history
> To ensure normal delivery of the mother without any assistance.
> To rule out abnormalities like prominent ischial spines, narrow sub pubic arch.
> To reduce infant and maternal mortality rate.
> To reduce injuries to both mother and fetus.

Pelvic assessment is done in 2 ways;-

External Pelvic assessment
Internal Pelvic assessment

EXTERNAL PELVIC ASSESSMENT /EXTERNAL PELVIMETRY

This is done on the 1st visit. It includes;-

History taking;

Age – A woman of the age of 18 years is expected to have a mature pelvis but below 18 years, the bones are not fully ossified. A PG 35 years and above is expected to have difficult delivery because the ligaments of the pelvis are already fused there4 her give of the pelvis is impossible.
Tribe – it’s important to know the tribe because different tribes have different types of pelvis. The Bakiga and Banyankole have a large normal pelvis but the Basoga and Baganda are at risk of contracted pelvis.
Marital status – It’s important to know the size of the husband because small women marrying giant men may carry big babies which can lead to CPD(Cephalopelvic Disproportion)
Medical history – It’s important to know because some diseases like poliomyelitis may affect the
growth of the pelvic bones and muscles.
Surgical history – Ask mother if she has ever had any accident involving her spine, pelvis and lower limbs.
Past obstetrical history – If the previous labour and delivery were normal, and if the baby weighed at least 3kgs and over, she is expected to have an adequate pelvis. Hx of instrumental delivery or C/S may give a suspicion of an inadequate pelvis.

2. Observations

Gait;– always be alert on a woman who walks with a limp or who has muscle wasting of the legs. A poor gait means a deformed pelvis hence reduced diameter. It indicates congenital hip deformity.
Height;– the normal average height in women is between 152-170 cm, below 152cm, may indicate a contracted pelvis and if above 170cm indicates a narrow birth canal.
Palms;-Those with short palms indicate a small pelvis
Shoe size;– the normal shoe size is 4-8. Shoe size below 4 indicates small pelvis.
Stature;- A woman of small stature and tiny waist is not expected to have an inadequate pelvis.

3. Abdominal examination

ENGAGEMENT OF THE FETAL HEAD(Head fitting)
NB: It’s no longer being practiced for fear of HIV transmission.
Procedure

Explain the procedure to the woman.
The bladder should be emptied.
The mother is relaxed flat on the bed with support on the pillow.
The midwife with the right hand locates the symphysis pubis while the other hand is under the mother’s head.
The mother takes a deep breath in and out
The head is pushed downwards and inwards
The fingers of the right hand should feel if the largest diameter of the fetal head is passing through the brim as the mother is supported to sit upright without relaxing the elbows.
The transverse diameter can be pushed through the pelvic brim. This test is called head fitting.

NB: It’s important that from 36weeks onwards, the abdomen is palpated to see if the head is engaged or can be made to engage.

INTERNAL PELVIC ASSESSEMENT(DIGITAL PELVIMETRY)

It’s done under aseptic technique. The midwife should know the measurement of her fingers.

Procedure:

Explain procedure and ask mother to empty bladder and rectum.
Prepare a VE tray and put it on the side of the bed.
Screen the bed
Ask mother to lie on her back and carry out abdominal examination.
The midwife measures the length of her fingers.
Position mother in dorsal and drape her. Right hand is gloved and two fingers of the gloved hand are lubricated, introduced and passed high into the vagina. The following are assessed.
Sacral promontory;
An attempt is made to reach the sacro-promontory by assessing the diagonal conjugate which is 12-13cm. If short fingers less than 12-13cm reach it that shows it’s prominent.
Hollow of the sacrum;
It should be well curved and smooth. It should not be too long, if it’s flat the cavity is reduced and internal rotation of the fetal head will be difficult.
Pelvic walls;
These are felt and they should be smooth and flat. If they converge down wards, the mid cavity is reduced.
Greater sciatic notches;
These should feel wide. If reduced, internal rotation of the head will be difficult.
Ischial spines;
They are palpated to see whether they are prominent. The distance between them is estimated.
Sub pubic arch;
Is measured and should not be less than 90 degrees. It should accommodate 2-3 fingers. A narrow sub pubic arch reduces the AP diameter of the pelvic outlet.

Inter tuberous diameter; The distance between 2 ischial tuberosities can be assessed by inserting a closed fist between them, it should admit 4 knuckles.

NB: After the assessment, record findings and give feedback to the mother.

Antenatal Care Read More »

Guide to the Question Approach for Midwifery Exams

Explaining Questions: Breaking Down Complex Concepts

Outlining Questions: Structuring Information

Describing Questions: Providing Detailed Information

Mentioning, Identifying, and Stating Questions: Being Clear and Concise

Listing and Giving Questions: Providing Comprehensive Information

Write Short Notes: Concise and Informative Summaries

What Questions: Providing Clear Definitions and Explanations

Tips for Success:

Anaemia In Pregnancy

Causes

Types of Anaemia

Signs and symptoms

Diagnosis

Effects of anaemia on pregnancy and labour

Management

Prevention of anaemia

Advice to the mother

Normal First Stage of Labour

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

2. CERVICAL ACTION

3. MECHANICAL FACTORS

Descent of the presenting part.

MANAGEMENT OF FIRST STAGE OF LABOUR

Vaginal examination.

Indications of VE during pregnancy

Contraindications of VE

PROCEDURE OF VAGINAL EXAMINATION

Findings:

Sample Questions

Labour

THREE P’S OF NORMAL LABOUR

TYPES OF LABOUR

Signs of impending labour.

SIGNS OF LABOUR

Causes of onset of labour.

Stages of labour

Antenatal Care

Activities done in ANC

INITIAL ASSESEMENT (BOOKING DAY)

HISTORY TAKING

INVESTIGATIONS

Clinical Tests

PHYSICAL EXAMINATION

Abdominal examination

AIMS

Inspection

Palpation

Auscultation

ONGOING ANC

Indicators of fetal wellbeing

Individual birth plan

RECORD AND INTERPRETE FINDINGS

PELVIC ASSESSMENT

EXTERNAL PELVIC ASSESSMENT /EXTERNAL PELVIMETRY

INTERNAL PELVIC ASSESSEMENT(DIGITAL PELVIMETRY)

Procedure: