OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

EXTERNAL GENITALIA

Female external genitalia (the vulva) include the mons pubis, labia majora, labia minora, clitoris, vestibule, the greater vestibular glands (Bartholin’s glands) and bulbs of the vestibule

Mons Pubis: The mons pubis is a rounded, fatty region located over the pubic bone. It becomes covered with hair after puberty and acts as a cushion during sexual intercourse.

Labia Majora (‘greater lips’): These are two prominent, fatty skin folds that extend from the mons pubis to the perineum. They protect the delicate structures within and typically become thinner with age or after childbirth.

Labia Minora (‘lesser lips’): These are smaller, thinner, and more pigmented skin folds situated inside the labia majora. They encircle the vaginal and urethral openings and contain numerous sweat and oil glands. The labia minora are composed of erectile tissue, which becomes engorged during sexual arousal, and they are highly sensitive to touch. Anteriorly, each labium minus divides into two parts: the upper layer passes above the clitoris to form along with its fellow fold, the prepuce, which overhangs the clitoris. The prepuce is a retractable piece of skin which surrounds and protects the clitoris. The lower layer passes below the clitoris to form with its fellow the frenulum of the clitoris.

Clitoris: This is a highly sensitive and erectile organ located at the top of the vulva, partially hidden beneath the upper junction of the labia minora. It is analogous to the male penis and is a central focus of sexual response, becoming swollen with blood and sensitive to stimulation during sexual arousal. The clitoris is a small rudimentary sexual organ corresponding to the male penis. The visible knob-like portion is located near the anterior junction of the labia minora, above the opening of the urethra and vagina. Unlike the penis, the clitoris does not contain the distal portion of the urethra and functions solely to induce the orgasm during sexual intercourse.

Vestibule: The vestibule is a space or cleft enclosed by the labia minora. It contains the openings to the urethra (the tube that allows urine to exit the body) and the vagina.

Vaginal Opening (Introitus): This is the entrance to the vagina, occupies the posterior two-thirds of the vestibule. In many women, this opening is partially closed by a membrane called the hymen. The orifice is partially closed by the hymen, a thin membrane that tears during sexual intercourse. The remaining tags of hymen are known as the ‘carunculae myrtiformes’ because they are thought to resemble myrtle berries.

The urethral orifice: This lies 2.5 cm posterior to the clitoris and immediately in front of the vaginal orifice. On either side lie the openings of the Skene’s ducts, two small blind-ended tubules 0.5 cm long running within the urethral wall.

The greater vestibular glands (Bartholin’s glands) are two small glands that open on either side of the vaginal orifice and lie in the posterior part of the labia majora. They secrete mucus, which lubricates the vaginal opening. The duct may occasionally become blocked, which can cause the secretions from the gland to accommodate within it and form a cyst.

Blood supply: The blood supply comes from the internal and the external pudendal arteries. The blood drains through corresponding veins.

Lymphatic drainage: Lymphatic drainage is mainly via the inguinal glands.

Innervation: The nerve supply is derived from branches of the pudendal nerve.

Functions of the Vulva

Protection: The labia majora act as a protective barrier for the internal reproductive organs, helping to shield them from injury and infection.
Sexual Arousal: The clitoris and the highly sensitive nerve endings in the labia minora play a crucial role in sexual arousal and pleasure.
Reproduction: The vaginal opening allows for sexual intercourse and serves as the birth canal during childbirth.
Urination: The urethral opening within the vestibule allows for the passage of urine from the bladder to the outside of the body.
Secretion: The vulva contains numerous sweat and oil glands that secrete fluids to keep the area moist and lubricated.
Childbirth: During childbirth, the vulva and vaginal opening stretch to accommodate the passage of the baby.

Scenario for Practical

Mother x has come for a postnatal examination. You are required to do vulva swabbing on her.
Task; Perform Vulva Swabbing
Objectives.
1. Set requirements for Vulva swabbing.
2. Perform the Vulva swabbing procedure.

Requirements

Top shelf	Bottom shelf	Bedside
– A pack containing	– Bed pan	– Screens
– 2 Bowls	– Mackintosh	– Hand washing equipment.
– Receivers	– Sanitary pad
	– 1 drum of swabs
	– 1 drum of drapes

Procedure

Steps	Action	Rationale
1.	Apply soft skills.	To maintain relationship.
2.	Offer a bed pan if necessary	For comfort and accurate procedure
3.	Position the patient in a dorsal position and cover the trunk.	To perform the procedure
4.	Place mackintosh and under the mother’s buttocks.	To protect the bedding.
5.	Assemble the equipment on the top shelf.	To save time.
6.	Wash hands and put on sterile gloves.	To prevent cross infection.
7.	Drape the thighs.	To provide a sterile area.
8.	Inspect the Vulva for any discharge and abnormality	For appropriate interventions.
9.	Place 5 swabs in the dominant bowl and leave a swab in the hand for drying the mother.	To prevent contamination.
10.	For each part in the following order; Left labia majora Left labia minora Right labia majora Right labia minora The vestibule including the vaginal orifice.	To prevent infection.
11.	Dry the vulva and apply a sanitary pad as required.	For promotion of hygiene
12.	Turn the patient on the left side. Dry the perineum.	To prevent irritation.
13.	Leave the mother in a comfortable position.	To promote hygiene.
14.	Clear away the equipment and wash hands.
15.	Document the findings	For proper follow up.

INTERNAL GENITALIA

The internal reproductive system comprises the vagina, cervix, uterus, fallopian tubes, and ovaries, all situated within the pelvic region.

The vagina is a fibro-muscular tube extending from the vulva’s vestibule to the cervix.

The vagina is a fibro-muscular tube which is part of the internal organs of the reproductive system. It extends from the vestibule below to the cervix above, running in an upward and backward direction. The upper end of the vagina is called the vault.

Approximately 10 cm in length, it can extend further during childbirth. The vaginal mucous membranes secrete fluids that cleanse and maintain an acidic environment. The hymen may cover the vaginal opening, breaking during the first penetrative sexual encounter.

Shape:

The vagina is a potential tube.
Its walls are in close contact but can be separated during intercourse, vaginal examination, and childbirth.

Size:

The posterior wall is longer and measures 10cm, but the anterior wall measures 7.5cm because the uterus enters it at right angles and then bends forward, thus encroaching on the anterior wall.

Gross Structure:

The vagina has four fornices:

The posterior fornix, which is the deepest.
The anterior fornix, which is fairly deep.
The lateral fornices( left and right), which are shallow.

Microscopic Structure of the Vagina:

Mucosa: Composed of stratified squamous non-keratinized epithelium which falls into folds known as rugae. These give the vagina an ability to stretch when needed.
Vascular Connective Tissue: Found beneath the epithelium and contains blood vessels, lymph vessels, and nerves.
Muscular Coat: A thin but strong layer (smooth muscle) composed of inner circular and outer longitudinal fibres.
Fascia/Adventitia: This forms the outer protective coat and is continuous with the pelvic fascia.

Contents of the Vagina:

The vagina itself does not contain any glands but is kept moist by mucus and a transudation from underlying blood vessels through the epithelium and Bartholin’s secretions. The vaginal media is acidic (pH 4.5), made possible by the presence of Doderlein’s bacilli which produce lactic acid after the action of glycogen. These are normal lactobacilli that help to prevent infection. The acidic media helps prevent infection.

Lymphatic Drainage: Into inguinal and sacral glands.

Nerve Supply:

By nerves derived from the pelvic plexus.
The vaginal nerves follow the vaginal arteries to supply the vaginal walls and the erectile tissue of the vulva.

Relations to the Vagina:

Laterally: Pubococcygeus muscle below and pelvic fascia above.
Inferiorly: Vulva.
Superiorly: Cervix.
Anteriorly: Upper half of the bladder, lower half of the urethra.
Posteriorly: Upper third – pouch of Douglas; Middle third – rectum; Lower third – perineal body.

Functions of the Vagina:

Exit for the menstrual flow.
Entrance for spermatozoa.
Exit for products of conception.
Supports the uterus.
Prevents ascending infections.
Receives the penis and sperm during sexual intercourse.
Provides the pathway for the foetus during vaginal delivery.

Revision Questions:

List two contents of the vagina.
List four fornices of the vagina.
Describe the microscopic structure of the vagina.
List five organs that are related to the vagina.
Outline five functions of the vagina.

Clinical procedure

A mother reports to the labour ward with labour like pains. You are required to do a vaginal examination to confirm labour.

TASK: CARRY OUT VAGINAL EXAMINATION

Objectives

To carry out Vaginal examination to mother in labour.

Requirement

Same as for internal pelvic assessment.

Procedure

Step	Action	Rationale
1.	Welcome and explain the procedure to the mother. (Apply soft skills)	To allay anxiety and promote corporation
2.	Request mother to empty the bladder.	For comfort and easy examination.
3.	Put on clean gloves.	To protect self.
4.	Assist mother into dorsal position.	Visualization of the parts.
5.	Place a mackintosh and draw sheet under the buttocks.	Protection of beddings.
6.	Remove gloves, wash hands and dry them and Put on sterile gloves.
7.	Observe external genitalia for; * Varicose veins, Oedema, Warts or sores. * Scars from previous episiotomy, tear or excision * Discharge or bleeding. * Colour and odour of discharge or amniotic fluid if membranes ruptured.	To detect abnormalities.
8.	Swab the vulva.	To prevent ascending infection.
9.	Lubricate the index and middle insert them into the vagina.	To assess the state of the vagina.
10.	Feel the vaginal wall with scars, and any abnormality.	To exclude abnormalities.
11.	Locate the cervical as for; * Effacement. * Dilatation. * Fore waters.	To assess the state of the cervix and membranes.
12.	Feel for the vault, sutures and fontanels, Position, Caput and moulding.	To determine the degree of moulding.
13.	Clean the mother. Leave her comfortable and provide a clean pad.	To provide comfort.
14.	Thank and explain findings to her.
15.	Clear away, remove gloves and document findings.	For continuity of care.

Cervix

The cervix, the most inferior part of the uterus, extends into the vaginal canal. It connects the uterus to the vagina, facilitating the passage of menstrual contents, sperm, and the baby during childbirth.

It makes up 1/3 of the uterus from the isthmus above to the vagina below. It is also known as the neck of the uterus.

The cervix has two main portions:

The ectocervix (visible during gynecologic examination) and
The endocervix (a tunnel through the cervix leading to the uterus).
During Childbirth: The cervix undergoes changes, becoming soft and dilating to accommodate the fetus. Cervical dilation is indicative of labor initiation.

Situation:
It is situated in the true pelvis.

Shape:
It is cylindrical in shape, and the canal is spindle-shaped.

Size:
It measures 2.5cm to 3.5cm before pregnancy and 3.5cm to 4cm in women with parity.

Gross Structure of the cervix:
The cervix consists of the following parts:

Supra-vaginal portion: The part above the vagina.
Infra-vaginal portion: Found in the vault of the vagina, and enters it at a right angle provided that the uterus is anteverted and anteflexed.
Internal os/endocervix: Which opens into the cavity of the uterus.
The ectocervix or exocervix: The outer part of the cervix that can be seen during a speculum examination. It has an external os which opens into the vagina.
Endocervical canal: The part between the external and internal os. The overlapping border between the endocervix and ectocervix is called the transformation zone.

Microscopic Structure of the Cervix:
The cervix consists of the following layers of tissue:

An inner lining of the endometrium: Arranged in a pattern of crypts (folds) giving it a tree-like appearance called arborvitae. These folds prevent sperms from flowing back into the vagina. The crypts contain endocervical glands that are lined by columnar epithelium that secretes cervical mucus.
The endometrium: Made up of endocervical glands which are sub columnar basal cells, rasmus glands, mucus-secreting cells, and ciliated columnar cells. The endometrium is not the same as that of the uterus because it does not slough/shed during menstruation.
A middle layer of muscular tissue: Arranged into circular and longitudinal fibres. The circular fibres help in dilatation of the cervical os during labour.
An outer layer of peritoneum: Covering that part of the cervix which lies anteriorly and posteriorly from where it is reflected up over the bladder.

Blood Supply: By uterine arteries.

Venous Drainage: Uterine veins.

Lymphatic Drainage: Into the internal iliac and sacral glands.

Nerve Supply: By sympathetic and parasympathetic nerves from the Lee-Franken Hauser plexus.

Supports:

Cardinal ligaments (transverse cervical ligaments): Extending from the lateral walls of the pelvis.
Pubo cervical ligament: Running forward from the cervix to the pubic bone.
Utero sacral ligament: Extending from the cervix, passing backwards to the sacrum.

Relations to the Cervix:

Anteriorly: By the utero-vesicle pouch and bladder.
Posteriorly: The rectal uterine pouch or pouch of Douglas and rectum.
Laterally: The broad ureters and uterine arteries.

Functions of the Cervix:

Limits microbial access to the uterus: By the mucus and during pregnancy it is sealed by the operculum.
It dilates and withdraws during labour: To enable vaginal delivery of the fetus and placenta.
The tree of life “arborvitae” prevents sperms deposited during sexual intercourse from flowing back: Due to the crypts and cervical mucus.
It is an exit to the menstrual flow.
The cervical glands provide nutrition to the sperms.
Produces fertile mucus that eases movement of the sperms.

Revision Questions:

Explain two functions of the arborvitae.
State two functions of the cervix.
Outline four reasons why the cervix is examined.

Scenario for Practical Procedure:

A 35-year-old mother reports to a gynaecological clinic with a history of dyspareunia.

Task: Performing visual inspection with acetic acid.

Objectives:

To observe any changes in the squamous columnar junction with application of acetic acid.

Requirements:

As for internal pelvic assessment, but in addition, a Cusco speculum and a sponge holding forceps are important in the procedure.

Procedure

Steps	Action	Rationale
1	Welcome and explain the procedure to the mother. (Soft skills apply)	To allay anxiety and Promote corporation.
2	Request mother to empty the bladder.	For comfort.
3	Put on clean gloves and assist mother into dorsal position	Visualization of the parts.
4	Place a mackintosh and draw sheet under the buttocks.	Protection of beddings.
5	Remove the clean gloves, wash hands and dry them then Put on sterile gloves.	To prevent infections
6	Do inspection of the genitalia for: >> Varicose veins, Oedema, Warts or sores. >> Discharge or bleeding.	To detect abnormalities.
7	Swab the vulva.	To prevent ascending infection.
8	Lubricate the cusco’s speculum, insert it into the vagina and lock it.	To view the cervix.
9	Inspect the cervix for discharge, blood, sores or new growth.	For proper management.
10	Clean the cervix gently with cotton using a sponge holding forcep.
11	Apply acetic acid on the cervix and observe. In case of pap smear, obtain the specimen of cervical mucus.	To detect changes in the squamous epithelial junction.
12	Release the screw of Cuscos Speculum and let it out.
13	Clean the mother and make her comfortable.	To prevent infections
14	Clear away and tell the mother findings.
15	Remove gloves and wash hands.
16	Document findings.

Note.

If Pap smear is to be done, follow the same steps but obtain a specimen of cervical discharge for examination,
The epithelium of the cervix undergoes squamous metaplasia at the transformation zone and can form endocervical ectropion and cancer.

Click here for Uterus, Fallopian tubes and Ovaries notes

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THE FETAL SKULL

The fetal skull is a bony compartment forming the head, containing the vital brain, which is susceptible to injury during delivery.

The fetal head’s presentation during normal labor is important; its successful delivery facilitates the delivery of the rest of the body.

Fetal skull is to some extent compressible and made mainly of thin pliable tabular (flat) bones forming the vault. This is anchored to the rigid and incompressible bones at the base of the skull.

Divisions of the Fetal Head:

Face: Composed of 14 bones developing from cartilage. These bones are nearly fully ossified at birth, fused, and firm, protecting the brain. The face extends from the orbital ridges to the chin-neck junction.
Base: Firmly united bones protecting vital centers. Five in number, they develop from cartilage and are fully ossified at birth.
Vault: The area above an imaginary line from the nape of the neck to the orbital ridges. This is the largest part of the head and typically the first to pass through the birth canal. These bones develop from membranes.

Fetal skull showing different regions and landmarks of obstetrical significance

Sinciput is the area lying in front of the anterior fontanel and corresponds to the area of brow and the occiput is limited to the occipital bone.
Flat bones of the vault are united together by non-ossified membranes attached to the margins of the bones. These are called sutures and fontanels. Of the many sutures and fontanels, the following are
of obstetric significance.

Bones of the Vault of the Fetal Skull:

The bony structure of the vault originates within a membrane framework. Over time, a process known as ossification hardens these structures from the center outward.

At birth, ossification remains incomplete, resulting in small gaps existing between the bones referred to as sutures and fontanelles. Each bone features a distinct ossification center, which appears as a noticeable protrusion. The full ossification of the skull takes place only in early adulthood.

The vault’s bony composition encompasses:

(i) Two Frontal Bones: Form the forehead (sinciput). Each has an ossification center (frontal eminence). They are square and fuse into a single bone by age 8.

(ii) Two Parietal Bones: Lie on either side of the skull. Each has an ossification center (parietal eminence). They are rectangular.

(iii) Occipital Bone: Lies at the back of the head; part contributes to the skull base, containing the foramen magnum (protecting the spinal cord). It is triangular, with the occipital protuberance as its ossification center.

(iv) Upper segment of the Temporal Bones (both sides): Contribute to the vault(on both sides of the head participates in forming the vault’s structure.)

Development of the Vault:

Five ossification centers develop in the membranes, with calcium deposition (ossification). Chondrocytes contribute to membrane formation. Ossification centers form prominences like frontal bosses, parietal eminences, and the occipital protuberance.

Clinical Notes:

Premature Infants: Bones are not fully ossified, leaving membranous spaces. This lack of support increases the risk of intracranial injury at birth.
Full-Term Infants: Narrow areas remain due to incomplete ossification, allowing for molding (overlapping) during labor to facilitate passage through the pelvis.
Post-Mature Infants: Further ossification leads to harder bones and narrower spaces, hindering molding and making delivery more difficult, with an increased risk of intracranial injury.

Regions of the Fetal Skull:

The fetal skull’s various segments are defined by distinct regions, each marked by significant landmarks(see figure above). These points of reference hold particular importance for midwives during vaginal examinations, aiding in determining the fetal head’s position.

(i) Vertex: The area between the anterior fontanelle (front), posterior fontanelle (behind), and the two parietal eminences (laterally). 95% of babies are present in the vertex position.

(ii) Sinciput (Brow): Extends from the anterior fontanelle and coronal suture to the orbital ridges.

(iii) Face: Extends from the orbital ridges and root of the nose to the chin-neck junction. The chin (mentum) is an important landmark; the face is small in newborns.

• Extending from the orbital ridges and the base of the nose to the junction of the chin, or mentum (landmark), and the neck is the face region. The point situated between the eyebrows is recognized as the glabella

(iv) Occiput: Lies between the foramen magnum and the posterior fontanelle. The area below the occipital protuberance (landmark) is referred to as the sub-occipital region. The protuberance is a prominent point on the skull’s posterior aspect.

SUTURES

Sutures: Membranous lines or cranial joints separating cranial bones. They allow for overlapping during labour.

Important Sutures in Obstetrics:

Frontal (Metopic) Suture: Between the two frontal bone halves; it obliterates over time.
Coronal Suture: Separates the frontal and parietal bones.
Sagittal Suture: Between the two parietal bones.
Lambdoid Suture: Separates the occipital and parietal bones.
Squamous Suture: Separates the temporal and parietal bones.

Importance:

It allows smooth movement of one bone over the other during head molding, which is significant as the head passes through the pelvis during labor.
Palpating the sagittal suture during internal examination in labor provides insight into head engagement (asynclitism or synclitism), the degree of internal head rotation, and head molding.

FONTANELS

Fontanelles: Membranous spaces where sutures meet; they allow for moulding during labour.

A wide gap in the suture line is referred to as a fontanel. Among the numerous fontanels (total of 6), two hold obstetric significance: (1) Anterior fontanel or bregma and (2) Posterior fontanel or lambda.

Anterior fontanel: It results from the fusion of four sutures in the midline. The sutures include the frontal suture anteriorly, the sagittal suture posteriorly, and the coronal sutures on either side. Its shape resembles a diamond, with anteroposterior and transverse diameters of approximately 3 cm each. The floor consists of a membrane, which undergoes ossification around 18 months after birth. If ossification does not occur even after 24 months, it becomes pathological.

Importance:

Palpating it during internal examination indicates the degree of head flexion.
It aids in head molding.
Due to its membranous nature persisting after birth, it accommodates significant brain growth, with the brain nearly doubling in size during the first year of life.
Palpation of the floor reflects intracranial conditions – depressed in dehydration, elevated in raised intracranial pressure.
In rare cases, blood collection and exchange transfusion can be performed through it, via the superior longitudinal sinus.
Although uncommon, cerebrospinal fluid can be drawn through the angle of the anterior fontanel from the lateral ventricle.

Posterior fontanel: It is formed by junction of three suture lines — sagittal suture anteriorly and lambdoid suture on either side. It is triangular in shape and measures about 1.2 × 1.2 cm (1/2″ × 1/2″).
Its floor is membranous but becomes bony at term. Thus, truly its nomenclature as fontanel is misnomer.
It denotes the position of the head in relation to maternal pelvis.

Sagittal fontanel: It is inconsistent in its presence. When present, it is situated on the sagittal suture at the junction of anterior two-third and posterior one-third. It has got no clinical importance.

Diameters of the Fetal Skull:

The engaging diameter of the fetal skull depends on the degree of flexion present. The anteroposterior diameters of the head which may engage are:

Presentation	Diameter	(cm)	Attitude of the Head
Vertex	Suboccipitobregmatic — extends from the nape of the neck to the center of the bregma	9.5	Complete flexion
Vertex	Suboccipito-frontal — extends from the nape of the neck to the anterior end of the anterior fontanel or center of the sinciput	10	Incomplete flexion
Vertex	Occupitofrontal — extends from the occipital eminence to the root of the nose (Glabella)	11.5	Marked deflexion
Brow	Mento-vertical — extends from the midpoint of the chin to the highest point on the sagittal suture	13.5	Partial extension
Face	Submentovertical — extends from junction of floor of the mouth and neck to the highest point on the sagittal suture	11.5	Incomplete extension
Face	Submentobregmatic — extends from junction of floor of the mouth and neck to the center of the bregma	9.5	Complete extension

Diameters are classified as transverse and longitudinal:

(i) Transverse Diameters:

Bi-Parietal: Between the two parietal eminences (9.5cm).
Bi-Temporal: Between the furthest points of the coronal suture and it measures 8.2cm

(ii) Longitudinal Diameters: These are measured from different points on the fetal skull and are important in determining the fetal head’s position and the ease of delivery.

Suboccipito-Bregmatic: From a point below the occipital protuberance to the center of the anterior fontanelle (9.5cm). This is often the smallest diameter and is favorable for vaginal delivery.
Suboccipito-Frontal: From a point below the occipital protuberance to the center of the frontal suture (10cm).
Occipito-Frontal: From the occipital protuberance to the glabella (the smooth area between the eyebrows) (11.5cm).
Mentovertical: From the tip of the chin to the highest point on the vertex (13.5cm). This is the longest diameter and presents in brow presentation, making vaginal delivery difficult or impossible.
Submento-Bregmatic: From the junction of the chin and neck to the bregma (9.5cm).
Submento-Vertical: From the junction of the chin and neck to the highest point on the vertex (11.5cm).

Summary of Diameters in Different Presentations

Diameter	Length	Presentation
Sub occipito-bregmatic	9.5cm	Flexed vertex
Submeto-brigmatic	9.5cm	Face
Suboccipital frontal	10.5cm	Partially deflexed vertex
Occipital-frontal	11.5cm	Deflexed vertex
Submento-vertical	11.5cm	Face not fully flexed
Mento-vertical	13.5-14 cm	Brow

Transverse Diameters

The transverse diameters of the fetal skull;

There are also two transverse diameters,
• The biparietal diameter (9.5 cm) – the diameter between the two parietal eminences.
• The bitemporal diameter (8.2 cm) – the diameter between the two furthest points of the coronal suture at the temples.

Knowledge of the diameters of the trunk is also important for the birth of the shoulders and breech

Bisacromial diameter 12 cm: This is the distance between the acromion processes on the two shoulder blades and is the dimension that needs to pass through the maternal pelvis for the shoulders to be born. The articulation of the clavicles on the sternum allows forward movement of the shoulders, which may reduce the diameter slightly.
Bitrochanteric diameter 10 cm: This is measured between the greater trochanters of the femurs and is the presenting diameter in breech presentation.

ATTITUDE OF THE FETAL HEAD

The attitude of the fetal head refers to the degree of flexion or extension of the head relative to the fetal body.

This is a crucial factor influencing which diameter of the fetal skull presents during labor, impacting labor progression and outcome.

A well-flexed head presents smaller diameters, facilitating easier passage through the birth canal.

Conversely, an extended head presents larger diameters, potentially leading to complications.

Presenting Diameters vs. Engaging Diameters:

The terminology used to describe fetal head diameters during labor needs clarification:

Presenting Diameters: These are the diameters of the fetal skull that are initially oriented at right angles to the curve of Carus (the axis of the birth canal) before the head engages in the pelvis. They are important in determining the initial presentation and lie of the head.
Engaging Diameters: These are the diameters that present after the head flexes and begins to descend into the pelvic brim. These are the diameters that actively distend the perineum during the second stage of labor. Both longitudinal and transverse diameters are considered engaging diameters.

Presenting/Engaging Diameters in Different Presentations:

Some presenting diameters are more favourable than others for easy passage through the maternal pelvis and this will depend on the attitude of the fetal head.

This term attitude is used to describe the degree of flexion or extension of the fetal head on the neck. The attitude of the head determines which diameters will present in labour and therefore influences the outcome.
The presenting diameters of the head are those that are at right-angles to the curve of Carus of the maternal pelvis.
There are always two: a longitudinal diameter and a transverse diameter. The presenting diameters determine the presentation of the fetal head, for which there are three:

The fetal head’s attitude directly determines which engaging diameters present during labor.

1. Vertex Presentation (Optimal):

When the head is well-flexed (chin tucked to chest), the suboccipito-bregmatic diameter (9.5cm) and the biparietal diameter (9.5cm) engage. Given their equal length, the presenting area takes on a circular form, optimally conducive to cervix dilation and successful head birth. This presents a nearly circular area with a circumference of approximately 29cm. This smaller circumference is highly favorable for cervical dilation and vaginal delivery, as it minimizes the forces required to navigate the birth canal.The sub-occipitofrontal diameter (10 cm) is the dimension that expands the vaginal orifice. Conversely, when the head is deflexed, the presenting diameters shift to the occipitofrontal (11.5 cm) and the biparietal (9.5 cm). This circumstance often arises when the occiput occupies a posterior position. In such cases, if the posterior position persists, the diameter expanding the vaginal orifice will be the occipitofrontal (11.5 cm).

2. Brow Presentation (Difficult):

In brow presentation, the head is partially extended (the brow presents). Partial extension of the head results in the mentovertical diameter (13.5 cm) and the bitemporal diameter (8.2 cm) becoming the presenting diameters. These diameters are significantly larger than those seen in vertex presentations. The circumference of the fetal head in this presentation is approximately 38cm. Due to these large diameters, engagement is often difficult or impossible, and vaginal delivery is usually not feasible. Cesarean section is often necessary.

3. Face Presentation (Challenging):

In face presentation, the head is completely extended (the face presents). The submento-bregmatic diameter (9.5cm) engages. While this diameter is relatively small, labor is still often difficult. This is because the bones of the face are less malleable (don’t mold as easily) compared to the vault bones of the skull. While vaginal delivery may be possible, it is often more challenging and may require assistance.

Summary:

The attitude of the fetal head is a critical factor impacting labor. Optimal flexion (vertex) leads to the presentation of smaller diameters, facilitating easier passage through the birth canal. Extension (brow and face presentations) presents larger diameters, significantly increasing the difficulty and risk of vaginal delivery. Understanding the relationships between fetal head attitude, presenting diameters, and the maternal pelvis is crucial for safe obstetrical management.

Examination of the Parts of the Fetal Skull

Task: Description of the sutures and fontanelles.

Objectives:

To identify the sutures and fontanelles.
To explain the importance of fontanelles.

Requirements:

A flat surface
A fetal skull

Procedure:

Step	Action	Rationale
1	Hold the fetal skull with the	To make it firm
2	With a pointer, show the longitudinal sutures i.e. Frontal or metopic suture and sagittal suture. Transverse sutures like coronal and Lambdoid where they start and stop.	To view their location and demarcation
3	Tell the importance of the sutures that: 1. They permit a degree of moulding of fetal bones as the fetal head negotiates the pelvis. 2. They separate the cranial bones.
4	Clear way and record

MOULDING

The term moulding is used to describe the change in shape of the fetal head that takes place during its passage through the birth canal.

This is a physiological adaptation that aids in the process of delivery.

Alteration in shape is possible because the bones of the vault allow a slight degree of bending and the skull bones are able to override at the sutures. This overriding allows a considerable reduction in the size of the presenting diameters, while the diameter at right-angles to them is able to lengthen owing to the give of the skull bones(Fig. 7.13).

The shortening of the fetal head diameters may be by as much as 1.25 cm. The dotted lines in Figs 7.14–7.19 illustrate moulding in the various presentations.
Additionally, moulding is a protective mechanism and prevents the fetal brain from being compressed as long as it is not excessive, too rapid or in an unfavourable direction. The skull of the pre-term infant is softer and
has wider sutures than that of the term baby, and hence may mould excessively should labour occur prior to term.

The Process of Molding:

Moulding involves the overlapping of the fetal skull bones at their sutures. Specifically, the frontal bone is pushed under the anterior portion of the parietal bones, and the occipital bone is pushed under the posterior portion of the parietal bones. The two parietal bones also overlap each other. This allows for a decrease in the head’s overall diameter.

Principles of Molding:

The engaging diameter is pressed by the pelvis so it reduces
Diameter at right angle to the engaging diameter elongates
Frontal bones are pushed under the parietal bones at the coronal suture.
Occipital bone is pushed under the parietal bone at the lambdoidal suture.
The parietal bones overlap each other at the sagittal suture

This leads to reduction of about 1.25cm of the engaging diameter.

In summary,

The primary effect of moulding is to reduce the engaging diameter of the fetal skull (the diameter that presents first to the birth canal) by approximately 1.25 cm.
Simultaneously, the diameter at right angles to the engaging diameter is elongated. For example, in a vertex presentation with a fully flexed head (left or right occipito anterior position), the suboccipito-bregmatic diameter (normally 9.5 cm) is reduced, while the mentovertical diameter (normally 13.5 cm) is lengthened.

Types of Molding:

1. Normal Moulding:

Occurs in normal vertex presentations with a well-flexed head.
Typically takes place over 8-18 hours of labor.
Characterized by a reduction in the suboccipito-bregmatic diameter.
Considered harmless and resolves within one or two days postpartum.
Beneficial because it facilitates vaginal delivery.

2. Abnormal Moulding:

Several types of abnormal molding exist:

(a) Upward Moulding (Sugar Loaf Molding):

Occurs in occipital posterior positions and after-coming head in breech deliveries.
The falx cerebri (a dural fold separating the cerebral hemispheres) is pulled upward, potentially leading to tearing of the tentorium cerebri (another dural fold) at its junction with the falx cerebri. This can involve major blood vessels like the great vein of Galen.
This type of moulding is particularly associated with deflexed heads in vertex presentations.

(b) Excessive Moulding:

Follows the normal direction but is more extreme.
Caused by prolonged labor due to cephalopelvic disproportion (a mismatch between fetal head size and maternal pelvis size), prematurity (soft skull bones and wide fontanelles offer less protection), or other factors.

Involves rapid compression of the fetal head.
Seen in breech deliveries (the after-coming head passes rapidly – usually within 9 minutes – through the birth canal) and precipitate labor (labor lasting less than 3 hours).
Although temporary overlapping of skull bones occurs, significant molding may not be visually apparent.
There’s a risk of cerebral damage in these scenarios.

Absence of Molding:

Moulding does not occur in:

Elective Caesarean sections (because the fetal head does not pass through the birth canal).
Post-mature pregnancies (where sutures are nearly closed, making the skull bones less pliable).

Important Notes on Molding:

Moulding is a result of prolonged compression of the fetal skull during its passage through the birth canal.
It facilitates passage through the birth canal by reducing the head’s diameter.
The bones of the face do not mould due to their rigid structure.
The type of moulding that occurred can be diagnosed.
Some degree of moulding is present in almost all vaginally delivered babies, except those born via Caesarean section.

Revision Questions.

Define a fetal skull.
Describe the bones of the fetal skull.
State four important landmarks of the fetal skull.
Describe the longitudinal diameters of the fetal skull.
Describe the bregma and lambda.
Outline three importances of fontanelles and sutures on the fetal skull.
List three differences between the anterior and posterior fontanelle.
Define moulding.
Explain the process of moulding.
State the principle of moulding.
Explain three types of abnormal moulding.

Examining the Baby’s Head: A Clinical Procedure

Scenario: A mother has delivered her baby. Examine the baby’s head.

Objectives:

To prepare the necessary equipment for the examination.
To systematically examine the baby’s head.

Requirements:

A Tray Containing	At the Bedside
– Tape measure	– Weighing scale
– Receiver	– Apron
– Gloves	– Adequate light
– Gallipot with cotton swabs	– Baby’s clothes
	– Baby’s chart
	– Firm, flat surface

Procedure:

Step	Action	Rationale
1	Use appropriate communication skills when explaining the procedure to the mother.	To build a positive relationship and ensure understanding.
2	Close nearby windows.	To prevent hypothermia (the baby losing body heat).
3	Wash hands and put on gloves.	To prevent the spread of infections.
4	Expose the baby’s head by removing any coverings.	To allow for a clear view during the examination.
5	Examine the head for size, shape, and symmetry.	To rule out prematurity or any abnormalities.
6	Palpate the fontanelles and sutures.	To rule out bulging fontanelles or other issues.
7	Measure the head circumference (33-35cm).
8	Observe the appearance of the face, noting any asymmetry or unusual features.	To exclude paralysis or other neurological conditions.
9	Examine the eyes, noting any discharge, conjunctival hemorrhage, eye setting, eye color, and response to light.
10	Examine the nose.
11	Examine the mouth for color, presence of thrush, and palpate the hard and soft palate. Examine the tongue for size and presence of a tongue tie.
12	Examine the ears for presence of cartilage.	To rule out immaturity or ear deformities.
13	Gently turn the baby’s neck and palpate for any masses.	To avoid injury and to check for neck abnormalities.
14	Place a cup on the baby’s head to make them comfortable and warm.	To provide warmth and comfort to the baby.
15	Share your findings with the mother.	To keep the mother informed about the baby’s health.
16	Clear away, wash hands, and record findings.	To maintain a clean environment and ensure proper documentation.

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Home > Midwifery I > Normal Puerperium

Normal Puerperium

The term "involution" is used to refer to the regressive changes taking place in all of the organs and structures of the reproductive tract following childbirth.

During the puerperium stage, a number of vital physiological changes take place:

The reproductive organs return to the non-gravid (pre-pregnant) state.
Lactation is established, and all other physiological changes that occurred during pregnancy are reversed.
The foundations of the relationship between the infant and the parents are laid.
The mother recovers from the physical stress of pregnancy and delivery, taking on the responsibility for the infant’s care.

Physiological Changes in the Endocrine System

The posterior pituitary gland secretes oxytocin, which stimulates uterine contractions and aids in the expulsion of the placenta during the third stage of labor.
Oxytocin also acts on the breast tissue, facilitating milk production when the baby suckles.
Hormones such as HCG, HPL, estrogen, and progesterone, which were highly increased during pregnancy, gradually decrease to their normal levels.

Changes in the Reproductive System

1. Uterus

Involution of the uterus: The uterus tries to go back to its original size, position, and situation as in a pre-gravid state.

Weight: At the end of labour, the uterus weighs approximately 900g and goes back at the end of puerperium to 60g, representing a reduction of 16 times the weight.
Size: The uterus is about 12.5-15 cm above the symphysis pubis immediately after delivery. It goes back eventually by 1.25 cm daily. A week later, the fundus is 7.5cm above the symphysis pubis. 10-12 days later, the uterus will not be palpable abdominally. The size of the uterus soon after labour is 15 x 12 x 8 to 10 cm in length, width, and thickness. By the end of puerperium, it will be exactly 7.5 x 5 x 2.5 cm.
Shape: When the placenta has been expelled, the uterus contracts and retracts to become globular in shape. As involution takes place, the cavity becomes small, and 6 weeks following delivery, the uterus returns to its normal shape. The decidua continues to shed up to the basal layer, and a new endometrium forms.

The Four Processes of Uterine Involution

Involution of the uterus undergoes four specific processes, namely:

Autolysis: The proteolytic enzymes digest muscle fibres which had increased during pregnancy to 10 times their normal length and 5 times their normal thickness.
Phagocytosis: The end products of autolysis are removed by the phagocytic action of the polymorphs and macrophages in the blood and lymphatic system and are excreted by the kidneys.
Ischemia: This results in the compression of the blood vessels, and there is a reduction in the uterine blood supply producing a relative state of ischemia. The site is gradually covered by glandular tissue then by endometrium.
Contraction and Retraction: Of uterine muscles under the powerful influence of oxytocin.

Other Factors Assisting Involution:

Breast feeding: During breast feeding, the posterior pituitary gland produces oxytocin which assists in the involution of the uterus.
Exercises: (Early ambulation).
Continuous draining of the bladder.

Progression of Changes in the Uterus After Delivery

Period	Weight of Uterus	Diameter of Placental Site	Cervix
End of labour	900g	12.5 cm	Soft and flabby
End of 1 week	450g	7.5 cm	2 cm
End of 2 weeks	200g	5.0 cm	1 cm
End of 6 weeks	60g	2.5 cm	A slit

2. Vulva and Cervix

Vulva: The labia majora and minora become flabby and are less segmented due to decreased vascularity.
Cervix: After delivery, the cervix may be seen protruding into the vagina but is soft and vascular. It loses its vascularity rapidly and normally regains its shape within 2-3 days after delivery. A finger can still be passed through the cervical canal up to 1 week following delivery. The external os closes eventually, leaving a transverse slit which is large enough to admit a finger, known as a multiparous os.

3. Lochia

Lochia is a term used to describe the discharges from the uterus during puerperium. It is alkaline in reaction, and so it favors the rapid growth of micro-organisms as compared to acidic vaginal secretion. The amount varies in different women; it is heavy but not offensive and non-irritant.

Lochia undergoes sequential special changes as involution takes place:

Red lochia (Lochia rubra): It is red in colour and consists of blood from the placental site and debris arising from the decidua and chorion. It is the 1st lochia that starts immediately after delivery and continues for the 1st 3-4 days postpartum.
Serous lochia (Lochia serosa): It is the next lochia. It is paler than lochia rubra and is serous and pink. It contains fewer RBCs but more leucocytes, wound exudates, decidual tissue, and mucus from the cervix. It lasts for 5-9 days.
White lochia (Lochia alba): It is the last lochia. It is pale, creamy white-brown in colour. It consists of leukocytes, decidual cells, mucus, and debris from healing tissue. It lasts up to 15 days.

Note: Some evidence of blood may continue for 2-3 weeks. A slight increase in the amount of lochia may be seen when a mother is active and during breast feeding. The average lochia discharge for the 1st 5-6 days is estimated to be approximately 250ml.

🧠 Memory Aid for Lochia Stages

Remember RSA (Like the country, Republic of South Africa):
R = Rubra (Red, Days 1-4)
S = Serosa (Serous/Pink, Days 5-9)
A = Alba (White, Days 10-15+)

4. Vagina and Breasts

Vagina: Immediately after delivery, the vagina may remain quite stretched, may have some degree of oedema, and gapes open at the introitus. In a day or more, it regains its tone and gaping reduces. It is smooth walled rather than usual and elastic. By the 3rd week postpartum, the vaginal rugae return and it reduces in size. It will always be a little larger than it was before the birth of the 1st child. The torn hymen heals by scar formation leaving several tissue tags called carunculae myrtiformes.
Breasts: No further anatomical changes occur in the breast for the 1st 2 days following delivery. The secretion from the breast called colostrum starts during pregnancy and becomes more abundant during this period. The rise in circulating prolactin acts upon the alveoli of the breasts and stimulates milk production in the 1st 3-4 days, and the breasts become heavy and engorged. As the baby sucks, engorgement is reduced.

Other Systemic Changes

Respiratory System: Breathing returns to normal as the diaphragm and lungs are no longer compressed, as they were during pregnancy.
Urinary System:
- Physiological Diuresis: There is an increase in urinary frequency and volume due to the elimination of retained fluid from pregnancy and labor.
- Bladder Changes: The bladder may be edematous and hypotonic initially, leading to over-distension and incomplete emptying. Proper voiding practices are encouraged to prevent complications.
Circulatory System: Heart size returns to normal after the increased cardiac workload during pregnancy. Blood volume gradually returns to non-pregnant levels by the second week postpartum.
Vital Signs: Blood pressure, pulse rate, respiration, and temperature generally return to normal levels within the first 24 hours postpartum.
Digestive System:
- Increased Thirst: Women may experience increased thirst due to fluid losses during labor and postpartum diuresis.
- Constipation: Constipation may be a concern initially due to the lack of muscle tone in the perineal and abdominal areas.
Musculoskeletal System: Pelvic joints gradually regain their tone over three months. Abdominal walls become flabby but can regain tone with exercises.

Disorders of Puerperium and Relief Measures

These are common discomforts that new mothers may experience after childbirth, but there’s no reason for them to suffer unnecessarily.

1. Afterbirth Pains

Afterbirth pains are the uterus’s sequential contractions and relaxations. They are more common in women with higher parity and those who breastfeed.

Management:

Keep the bladder empty to prevent the uterus from shifting and hindering its contractions.
Advise the mother to lie in a prone position with a pillow under her lower abdomen.
Administer analgesics to alleviate pain.

2. Excessive Perspiration

Excessive sweating occurs as the body eliminates excess interstitial fluid resulting from hormonal changes during pregnancy.

Management:

Ensure the mother stays clean and dry.
Change gowns and bed sheets regularly.
Keep the mother well-hydrated by offering fluids frequently.

3. Breast Engorgement

Caused by milk accumulation and stasis, increased vascularity, and congestion. It typically occurs around the 3rd day postpartum and lasts for approximately 24-48 hours.

Management for Non-breastfeeding Mothers:

Provide good breast support.
Apply ice bags or packs to relieve pain.
Use analgesics like PCM or aspirin, if needed, for pain relief.
Avoid massaging the breasts to express milk.
Avoid applying heat to the breasts, as it may increase milk flow.

Management for Breastfeeding Mothers:

Encourage breast massage, manual expression, and nipple rolling.
Ensure the baby nurses every 2-3 hours without missing any feeds or using supplements.
Alternate between both breasts during feedings to ensure complete emptying.
Apply warmth to the breasts before each feeding to promote milk flow.
Use proper breast support without creating pressure points.
Ice bags may be used between feedings to reduce swelling and pain.
Analgesics can be used if necessary.

4. Perineal (Stitch) Pain

Before providing treatment, examine the perineum to determine whether the pain is normal or if complications like hematoma or infection are present.

Management:

Apply ice packs or bags to reduce discomfort.
Use topical analgesic spray as directed.
Take sitz baths 2-3 times a day after defecation and voiding, as the warmth and motion of the water can soothe and promote healing.

5. Constipation

Can be caused by increased progesterone levels in late pregnancy, decreased bowel motility, and reduced fluid intake during labor.

Management:

Stool softeners or mild laxatives are usually prescribed for women with 3rd or 4th-degree perineal repair.

6. Hemorrhoids

If a woman experiences hemorrhoids, they may be quite painful for a few days.

Management:

Use ice bags or packs.
Administer analgesics.
Apply warm water compresses.
Prescribe stool softeners.
Consider rectal suppositories and creams, such as sediproct suppositories.
Replace external hemorrhoids inside the rectum if necessary.

POSTNATAL EXAMINATION

The puerperal mother should attend the postnatal clinic for a full examination at 6 weeks after delivery to confirm full recovery from the effects of pregnancy, labour, and delivery.

🧠 The BUBBLE-HE Assessment Reminder

The nurse should follow an organized method which provides a consistent, quality approach to nursing care:

Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Homan’s sign
Emotional status

Requirements for Examination

A VE (Vaginal Examination) tray containing:

A gallipot of sterile swabs
2 receivers
Clean pads
Sterile gloves
Sterile bowel of lotion
Antiseptic lotion in a bowel
Clean gloves
Lubricant
Cusco’s vaginal speculum
Sim’s speculum
Sponge holding forceps
Tape measure

At the bedside: Vital observations tray, Acetic acid, Stationary.

General Assessment Procedure:

The mother’s general condition and emotional health are assessed.
Welcome the mother and the spouse if any.
Offer the mother a seat.
Greet the mother.
Introduce yourself and vice versa.
Communicate to the mother about the activities done at the clinic and the reason for any procedure.
Observe for signs of emotional distress or depression and anxiety.
Take history of pregnancy, labor, and puerperium.
Present health statuses e.g. sleep, appetite, breastfeeding habits, and reactions.
Ask how she feels and how she is managing the baby, if breast milk is adequate.
Ask about any discomforts.
Ask about the onset of menstruation or any vaginal bleeding or abnormal discharges.
Give the mother the opportunity to discuss any problems.
Check and record TPR (temperature, pulse rate, and blood pressure).
Screen for any health concerns by performing a systematic examination from head to toe.
Conduct a breast examination, re-examining for signs of infections or lumps, and check for cracks and blisters on the nipples. Instruct the mother on self-breast examination.
Palpate the uterus and lower abdomen for tenderness to confirm involution of the uterus and note the tone of the abdominal muscles.

Bimanual Pelvic Examination and Speculum Vaginal Examination

Examination is done from head to toe systematically.

Speculum Examination:

Follow the general rules for a pelvic examination.
Ask the mother to empty her bladder.
Place the mother in a dorsal position.
Inspect the vulva for any swelling, inflammation, or soreness.
Examine the urethral opening for inflammation and local discharge.
Have the mother cough or strain while separating the labia to check for any prolapse of the uterus or stress incontinence with urine leakage.
If a specimen from the vagina is needed for laboratory examination, pass the speculum before a digital examination.
Place the mother in the Sim’s position and examine the anterior and posterior walls using Sim’s speculum.

Bimanual Examination:

Follow the general rules for a pelvic examination.
Have the mother empty her bladder.
Position the mother in a dorsal position.
Perform vulval swabbing and apply a drape.
Lubricate the gloved fingers of the right hand and gently introduce them into the vagina.
Palpate for any swelling in the labia or adjacent structures.
Note the condition of the vaginal wall.
Examine the cervix for direction (anteverted or retroverted), station (position of external os relative to the ischial spines), texture, shape, movement, and tendency to bleed on touch.
Place the left hand on the abdomen and palpate the uterus between the two hands.
Note the size, consistency, shape, position, mobility of the uterus, as well as possible tumors and areas of tenderness.
Move fingers in the vagina to the left and right fornix, following with the hand on the abdomen to look for any enlargement or tenderness of the tubes and ovaries.
Move the fingers to the posterior fornix to check for any swelling in the pouch of Douglas.
Check the integrity and tone of the perineal body by flexing the internal finger posteriorly and palpating it with the thumb placed externally.
Withdraw the fingers and inspect them for any blood stains or abnormal discharge.

Note: Vaginal examination is done to assess the condition of the pelvic floor and the vagina. Examine for organ prolapse, such as cystocele, urethrocele, and cystourethrocele. A cervical smear (Pap smear) may be taken for cytology to detect cancer cells.

Other Assessments:

Bowel and gastrointestinal system: Assess for dehydration, constipation, and hemorrhoids. Inquire about the mother’s appetite and advise accordingly.
Lochia: Observe the type of discharge, color, odor, and consistency.
Episiotomy: Examine the perineum for healing and good muscle tone.
Extremities: Assess Homan’s sign to check for the presence of thrombophlebitis.
Emotional status: Assess the mother’s response towards her baby, attainment of parental roles, infant care, and family adaptations.

Share the findings with the mother and provide education accordingly. Discuss family planning and advise the mother to attend a family planning clinic. Refer appropriately and document the examination findings appropriately, including a full signature.

TRANSFER OR REFERRAL OF MOTHERS

Transfer or referral involves preparing a mother for relocation to another department within the hospital or to a different hospital or home. This is necessary in obstetric emergencies, such as APH (antepartum hemorrhage), vasa previa, cord prolapse, ruptured uterus, obstetric shock, pre-eclampsia, eclampsia, and other major disorders of pregnancy.

Purposes of Referring:

To obtain necessary diagnostic tests and procedures.
To provide treatment and specialized nursing care.
To access specialized care.
To utilize the most appropriate personnel and services available.
To match the intensity of nursing care based on the patient’s level of needs and problems.

Types of Transfer:

Internal Transfer: This involves moving the patient from one unit to another within the hospital, where special care or specific care suited to her needs is provided. For example, transferring a mother from the maternity ward to the intensive care unit.
External Transfer: This refers to relocating the mother from one hospital to another, usually for the purpose of specialized care. For instance, transferring a patient from a lower facility to a referral center.

Preliminary Assessment:

Assess the method of transport and inform the receiving midwife.
Ensure the patient’s physical well-being during the transfer to the new nursing unit.
Provide a verbal report about the patient’s condition to the receiving unit midwife.
Ensure all necessary documentation and the care plan are completed.
Assist the patient upon arrival at the new unit.
Announce the patient’s arrival to the new unit.
Transport the patient to the new admission room and assist in transferring her to the bed.
Hand over the patient’s investigation records in her file to the receiving midwife.

Requirements for Transfer:

Wheelchair or stretcher
Identification labels
Patient’s belongings
Scans or medical reports

Procedure for Transfer of a Mother to Another Hospital or Department:

Check the doctor’s order for the transfer of the mother.
Inform the mother and her relatives about the transfer.
Inform the ward sister or the hospital where the patient will be transferred.
Arrange for transportation for the mother to the referred hospital.
Check the mother’s chart for complete recording of vital signs, nursing care, and treatment given, and write a referral note.
Collect the mother’s scans, medicines, and other belongings.
Cancel the hospital diet or transfer arrangements if applicable.
Assist the relatives in collecting other belongings.
Make arrangements to settle any due bills if the patient is going to another hospital.
Record the time, mode of transfer, and the general condition of the patient.
Assist in transferring the mother to a wheelchair or stretcher and accompany her to the hospital with proper documentation.
Hand over the mother’s documents and belongings, and give a verbal report to the in-charge or the sister in charge at the receiving unit.
Collect ward articles and take them back.
Clean the unit thoroughly and prepare it for the next patient.

📋 REFERRAL NOTE

Date of referral: ……………………………..
From: Health unit
To: ………………………………………………………………………………………………………
Referral number: ………………………………………………………………………………….
Patient name: ………………………………………………………………………………………
Patient number: …………………………………………………………………………………..
Date of first visit: ………………………………………………………………………………..

History and symptoms:
…………………………………………………………………………………………………………………………………………………………………………

Diagnosis: ………………………………………………………………………………………………………………..

Treatment given:
…………………………………………………………………………………………………………………………………………………………………………

Treatment or surveillance to be continued:
………………………………………………………………………………………………………

Remarks: ……………………………………………………………………………………………

Name of obstetrician: ……………………………………………………………………. Signature: ………………………………

Postnatal Exercises

Postnatal exercises are a series of physical activities designed to help new mothers recover from childbirth and regain their strength, flexibility, and overall fitness. These exercises are essential for promoting healing, restoring pelvic floor function, and enhancing overall well-being after giving birth.

Kegel Exercises: Kegels target the pelvic floor muscles, which play a crucial role in supporting the bladder, uterus, and rectum. Contracting and relaxing these muscles can help prevent or treat urinary incontinence and pelvic organ prolapse.
Deep Breathing Exercises: Deep breathing helps relax the body, reduce stress, and improve circulation. It is especially beneficial for promoting relaxation and managing stress, which is essential during the postpartum period.
Abdominal Contractions: Gently engaging and releasing the abdominal muscles can aid in toning the core and supporting abdominal recovery after pregnancy. Be cautious not to strain the abdominal muscles, especially if you had a cesarean section.
Pelvic Tilts: Pelvic tilts involve tilting the pelvis forward and backward while lying on your back. This exercise helps strengthen the abdominal muscles and alleviate lower back pain.
Ankle Pumps and Circles: These exercises involve moving the ankles in circles or pumping them up and down to improve blood circulation and prevent blood clots, which can be a concern during postpartum recovery.
Glute Squeezes: Squeezing and releasing the glute muscles while sitting or lying down can help strengthen the buttocks and support the pelvic region.
Leg Slides: Lying on your back with knees bent, gently slide one leg out straight and then back in. Alternate legs to engage the core and strengthen the hip muscles.
Bridge Pose: Lying on your back with knees bent, lift your hips off the floor to create a bridge shape. This exercise targets the glutes, hamstrings, and lower back.
Wall Push-Ups: Standing facing a wall, place your palms on the wall at shoulder height. Bend your elbows and lean in towards the wall, then push back to the starting position. This exercise helps strengthen the upper body.
Gentle Cardio: As you progress in your postpartum recovery, you can incorporate low-impact cardio exercises like walking or swimming. Always start slowly and gradually increase the intensity as your body heals.

💡 Quick Practice Check

Question: A mother reports that her lochia is a creamy white-brown color and she is on day 12 postpartum. Which type of lochia is she experiencing, and is it normal?

Answer: She is experiencing Lochia Alba. Yes, it is completely normal, as this phase typically lasts up to day 15 and consists mostly of healing tissue debris and leukocytes.

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Puerperium Physiology Quiz

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Home > Midwifery I

Normal Puerperium

Overview: The Puerperium (also known as the postpartum period) is the critical time following childbirth or an abortion. It begins immediately after the placenta and membranes are expelled and typically lasts for about 6 to 8 weeks. During this phase, the mother's body—especially the pelvic organs—heals and returns to its pre-pregnant state. A woman going through this phase is medically referred to as a “Puerpera.”

1. Phases, Principles, and Aims of Puerperium

The Three Phases of Puerperium

Immediate Puerperium: The initial phase spanning the first 6 hours after childbirth.
Early Puerperium: The second phase extending up to 6 days postpartum.
Remote Puerperium: The final healing phase continuing up to 6 weeks after childbirth.

Principles of Management

The care provided to a mother during the puerperium is guided by several essential principles:

Restoring the mother’s health and energy to optimal levels.
Preventing infections by ensuring a strictly hygienic environment.
Providing proper care for the breasts to facilitate smooth and successful breastfeeding.
Encouraging the mother to consider contraceptive options to space out future pregnancies (Family Planning).

Aims of Management

The midwife focuses on achieving the following goals:

Establishing the complete physical and emotional well-being of the mother.
Facilitating lactation to promote exclusive breastfeeding.
Educating the mother on the best, safest practices for caring for her newborn baby.
Preventing any life-threatening complications that may arise during this period (e.g., bleeding or sepsis).

2. Management in the 1st Hour (Fourth Stage of Labor)

The fourth stage of labor begins immediately with the birth of the placenta and lasts for exactly one hour. This is a highly critical phase where the mother recovers from the extreme physical stress of labor and delivery. Close monitoring must be conducted.

Evaluation of the Uterus

Palpating the uterus: Feel the abdomen to ensure the uterus is hard and properly contracted (like a firm grapefruit).
Massaging the fundus: Gently rub the top of the uterus to expel any trapped blood clots and promote the shrinking process (uterine involution).
Measuring fundal height: Check the height of the uterus in relation to the mother's umbilicus (belly button).
Emptying the bladder: Encourage the mother to urinate. A full bladder blocks the uterus from contracting tightly and causes heavy bleeding.

Inspection of the Perineum, Vagina, and Cervix

Carefully inspect the perineum for unusual discoloration, heavy swelling (hematoma), lacerations, or deep tears.
When to examine the cervix and upper vagina: A deep examination is required if you notice any of the following factors:
- The uterus is well-contracted and hard, but there is still continuous bright red vaginal bleeding for an hour. (This usually means the cervix or vagina is torn).
- The mother started pushing before the cervix was fully dilated (10cm).
- The labor was unusually rapid and precipitous (very fast delivery).
- There was manual manipulation of the cervix during labor, such as the midwife pushing back a swollen (edematous) anterior lip.
- Traumatic procedures were used, like a forceps delivery.
- The delivery was very traumatic, such as delivering a very large baby or dealing with stuck shoulders (shoulder dystocia).

Inspection of the Placenta and Post-Delivery Care

Placenta, Membranes, and Cord: Examine the placenta carefully to ensure no pieces are left inside the womb. This must be done before any repairs (like stitching a tear or episiotomy) are started.
Cleaning: Wash the perineum gently with warm water, dry it, and position the mother's legs comfortably.
Observations: Continuously monitor and record vital signs: Blood Pressure (BP), Pulse, Temperature, and Respiration (TPR).
Food and Fluids: Provide warm, sweet drinks and nourishing food to restore the mother's energy. Ensure she is covered and stays warm.
Breastfeeding: Help the mother put the baby to the breast immediately. This promotes deep emotional bonding and triggers hormones (oxytocin) that start milk flow and contract the uterus.

At the end of this first hour, repeat all observations. If the mother is stable, she and her baby are transferred to the postnatal ward for ongoing care.

3. Management in the Postnatal Ward (First 6 Hours)

Upon arriving at the postnatal ward, the mother is very tired and highly susceptible to bleeding. The ward must be ready to welcome her and make her comfortable.

Rest and Sleep: Deep rest is crucial for recovery. Visitors must be strictly limited during the day to reduce anxiety, noise, and discomfort. Maintain a calm atmosphere. If the mother cannot sleep at all, a doctor may prescribe mild sedatives to prevent exhaustion and address early signs of puerperal psychosis (severe mental confusion).
Ambulation (Walking): After 6 hours of a normal delivery, the mother must be encouraged to get out of bed and walk around the ward. Walking promotes good blood circulation, helps the heavy vaginal blood (lochia) drain out, and speeds up the shrinking of the uterus (involution). It also improves muscle tone and pumps blood back up from the legs, drastically reducing the risk of deadly blood clots (Deep Vein Thrombosis - DVT).
Diet and Fluids: Provide a well-balanced diet rich in proteins, vitamins, and nutrients to help her regain strength and produce rich breast milk. Encourage her to drink plenty of fluids to prevent hard stool (constipation). Continue giving Vitamin, Iron, and Folic Acid supplements as needed.
Care of the Bladder: The mother excretes very large amounts of urine in the early days of puerperium as the body drops water weight. She might struggle to pass urine because of bruising, pain, or lack of privacy. Ensure she empties her bladder regularly. A full bladder causes a dangerous chain reaction: it stops the uterus from shrinking (subinvolution), which leads to severe Postpartum Hemorrhage (PPH) and Urinary Tract Infections (UTIs).
Hygiene: "Vulval toilet" (cleaning the genital area) should be performed at least 3 times a day. Pads must be changed immediately whenever soiled. Encourage daily warm baths and fresh, clean clothing and bed sheets. Provide a clean, suitable bathroom.
General Examination: The midwife must do a daily head-to-toe check. Look for pale eyes (anemia), swollen legs/face (edema), yellow eyes (jaundice), and dry lips (dehydration). Use a tape measure to check fundal height daily. Inspect the vulva and check the vaginal discharge (lochia) for its color, amount, and smell (a foul smell means infection). Squeeze the calf muscles to check for pain, a sign of Deep Vein Thrombosis (DVT).
Care of Breasts: Breasts should be wiped clean with water before feeding. Immediate and frequent breastfeeding prevents severe bleeding (PPH). The midwife must supervise and assist the mother to ensure the baby attaches (latches) properly. "Demand feeding" (feeding whenever the baby cries) keeps the milk flowing and prevents painful, swollen breasts (engorgement). Advise the mother to wear a well-fitting brassiere for support.
Relief of Pain: Mothers (especially those who have had previous babies) will experience sharp, cramp-like "after-pains" as the uterus aggressively contracts for the first 2-3 days. Provide pain relief like Paracetamol (Panadol).
Perineal Care: Inspect the perineal pad constantly. The mother must avoid sexual intercourse (coitus) for up to 6 weeks, or until the perineum has fully healed. Strongly discourage the application of traditional/native medicines on the wound, as they cause severe infections. Teach postnatal exercises.

4. Vulval Toilet & Postnatal Care Procedure

To prevent infection, cleaning the mother's genital area is treated as a sterile clinical procedure.

Requirements: The Trolley Setup

Top Shelf (Sterile Items)	Bottom Shelf (Clean Items)	Bedside Equipment
Sterile dressing pack containing: - 2 dressing towels - 2 non-toothed dissecting forceps - 2 dressing forceps - 3 gallipots (1 for lotion, 1 for swabs, 1 for gauze) - A pair of stitch scissors / clip remover (if needed) - Probe - Sinus forceps	- Sterile drum of cotton wool - Sterile drum of gauze - 2 flannels - Antiseptic solution & Normal saline - Bathing soap - Dressing mackintosh and towel - Plastic Apron - Clean Gloves - Cheatle forceps - 2 clean sanitary towels - 2 jugs of water (1 hot, 1 cold) - A small jar for pouring water - 2 empty receivers (kidney dishes)	- Privacy Screen - Bedpan and bedpan cover - Hand washing equipment (water and soap) - Linen hamper for dirty clothes/sheets

Step-by-Step Procedure

Request the mother to empty her bladder and bowel before starting.
Fold back the bedclothes to the foot of the bed, leaving the patient covered only up to the waist with a top sheet to preserve dignity.
Put the mother in a dorsal position (lying flat on her back with knees bent and parted).
Wash your hands, put on clean gloves, and carefully remove her soiled sanitary pad, noting its contents before disposing of it properly.
Inspect the genitalia directly for any signs of swelling, broken stitches, or infection.
Examine the lochia (vaginal discharge), noting its exact amount, color, consistency, and odor.
Slide a bedpan securely under the mother's buttocks.
Wash the pubic area (front), the inner parts of the thighs, and the buttocks using warm soapy water and a flannel.
Carefully wash the actual genitalia. Use your dominant hand to gently cleanse with swabs while your non-dominant hand pours the warm water. Pay special attention to skin folds, and always clean from front to back.
Rinse the area with clean water and dry it thoroughly, always moving from the perineum towards the rectum using a clean flannel or sterile swabs.
Carefully remove the bedpan.
Place a fresh, clean sanitary pad in position and ensure the mother’s clothes are pulled down and she is entirely comfortable.
Clear away the trolley, clean the equipment, and wash your hands.
Document the entire procedure, noting the state of the perineum and the lochia in the patient's medical records.

🧼 Patient Education: Self-Cleansing Instructions

Before leaving, clearly instruct the woman on how to cleanse herself after using the toilet:

Always wash hands thoroughly before and after touching the perineal area.
Never touch the stitches with bare fingers.
Always use a wet wipe or water to clean from the front (vagina) to the back (anus). Never wipe back to front, as this drags feces into the healing birth canal.
Apply the sanitary pad firmly so it doesn't slide around when moving.
When removing a soiled pad, pull it downwards and backward (front to back).

5. Ongoing Postnatal Care

Postnatal Exercises: These are critical for proper blood circulation and for bringing strength (tone) back to stretched abdominal and pelvic floor muscles. Exercises include deep breathing, free leg movements in bed, relaxation techniques, and squeezing the pelvic floor (Kegel exercises).
Observations: The mother's Temperature, Pulse, Respiration (TPR), and Blood Pressure (BP) must be checked and recorded twice a day.
Care of the Bowel: Digestion and bowel movements become very slow (sluggish) in the first 2 days. Constipation must be aggressively avoided because a bowel full of hard stool presses on the uterus, contributing to subinvolution. Provide high-roughage foods and plenty of water. If needed, give a mild laxative like Milk of Magnesia.
Prevention of Infection: Strict aseptic (sterile) precautions must be observed. Ensure proper use of gowns, masks, and gloves, and sterilize equipment. No healthcare worker or visitor with a cold, cough, or septic skin spot should be allowed near a puerperal mother. Keep visitor numbers low.
Rooming-In / Bedding-In: The baby should never be kept in a separate nursery. The baby must stay in a cot directly beside the mother’s bed or in her bed when she is awake. This triggers maternal instincts, promotes deep bonding, and helps her learn baby care quickly.
Immunization for the Mother: If the mother is susceptible to Rubella, she should be vaccinated, but must be strictly advised to postpone getting pregnant again for at least 2 years. Give a Tetanus Toxoid (TT) shot at discharge if she missed it during pregnancy. Crucial: If the mother's blood type is Rh-Negative and she just delivered an Rh-Positive baby, she MUST receive an Anti-D injection within 72 hours to protect her future pregnancies.

Uterine Involution Process — Diagram demonstrating the daily descent and shrinking (involution) of the uterus back into the pelvis.

Involution of the Uterus

Involution is the rapid shrinking of the uterus. Daily palpation of the fundus is essential. The uterus should feel smooth, very firm, well-contracted, and should not be extremely painful to touch. The midwife must measure the fundal height daily using a tape measure (it should drop by about 1 finger-width or 1cm per day).

🚨 Warning Sign: Subinvolution

If the uterus remains the exact same size for several days, feels soft and boggy, or is painful, it is failing to shrink. This is called Subinvolution, often caused by a full bladder, retained placental pieces, or infection. It is a major cause of late postpartum hemorrhage.

6. Discharge of the Mother and Baby

Before anyone goes home, both the mother and the baby must be fully examined to confirm they are 100% healthy and stable.

For the Mother, the midwife checks: All vital signs are normal, breasts are soft (not engorged) and milk is flowing, the uterus is involuting properly, the lochia is normal (no bad smell or heavy bleeding), the bladder and bowels are functioning smoothly, and the perineal wound is clean and intact.
For the Baby, the midwife checks: The baby is sucking well at the breast, has a normal sleeping pattern, the umbilical cord stump is clean and dry, and all birth vaccines (BCG for Tuberculosis and Polio 0) have been given.

Comprehensive Advice on Discharge

Advice for the Mother

Personal Hygiene & Breast Care: Continue bathing daily. Keep the perineal area dry. Cleanse the breasts with clean water before and after every single feed.
Diet: Eat a highly nutritious, well-balanced diet rich in proteins, vegetables, and fluids to support rapid tissue recovery and strong milk production.
Rest and Sleep: Sleep whenever the baby sleeps. Exhaustion ruins milk supply and slows down healing.
Postnatal Exercises: Continue doing Kegel exercises and mild walking to tone muscles and boost blood flow.
Avoid Heavy Lifting: Do not lift anything heavier than your baby for the first 2-3 weeks to avoid straining the healing pelvic floor and abdominal muscles.
Medications: Finish all prescribed medications (like antibiotics or iron tablets) exactly as directed.
Vaginal Discharge & Menstruation: Understand that the lochia will change color (red to brown to white) and gradually stop. Her normal menstrual periods may return within 2-3 months, but might be delayed for several months if she is exclusively breastfeeding.
Sexual Intercourse: Strictly avoid sex for about 6 weeks to allow bruised, torn, or stitched tissues to heal safely and perfectly.
Postnatal Clinic: Emphasize that she absolutely must return to the clinic for a final check-up at exactly 6 weeks after delivery.

Advice for the Baby

Exclusive Breastfeeding: Feed the baby ONLY breast milk for the first 6 full months. No water, no porridge. This provides optimal nutrition and heavy immune protection.
Bottle Feeding (If medically necessary): Teach the mother exactly how to prepare formula safely. Explain how to boil and sterilize bottles, nipples, and spoons. Demonstrate holding the bottle tilted so the nipple is always full of milk, preventing the baby from swallowing painful air.
Burping: Always hold the baby upright against the shoulder and gently pat the back after every feed to release swallowed gas.
Bathing and Dressing: Show her how to gently sponge bathe the baby, keeping the baby warm. Teach her to carefully clean the baby's genital area (wiping front to back for girls).
Cord Care: Keep the umbilical cord stump exposed to air, clean, and completely dry to prevent deadly tetanus or sepsis. Do not apply dung, herbs, or ash.
Diaper Rash: Teach her to change wet/soiled diapers immediately, wash the buttocks with water, dry thoroughly, and apply a barrier cream (like Vaseline) to treat or prevent rashes.
Baby's Temperature: Teach her how to feel the baby's chest or back to check for fever, and keep the baby warmly wrapped but not overheating.
Recognizing Cues: Help the mother understand the different ways her baby cries to signal hunger, need for sleep, a wet diaper, or pain.
Immunization Schedule: Stress the massive importance of returning to the clinic at 6 weeks, 10 weeks, and 14 weeks for the baby's routine vaccinations to protect against childhood diseases.

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Home > Midwifery I > Examination of the Placenta

Examination of the Placenta

The word Placenta is derived from the Greek word "plakuos," meaning "flat cake," which perfectly describes its typical shape. It is a vital fetal organ responsible for providing nutrition, oxygen, and excretory functions to the growing fetus.

Embryology: It is formed by both maternal and fetal components:

Maternal Component: Decidua placentalis (formed by trophoblastic invasion of the endometrium).
Fetal Component: Chorion frondosum (formed by branches of the umbilical artery protruding into intervillous spaces).

A quick, one-minute clinical examination in the delivery room provides crucial information for the immediate care of both the mother and the newborn.

1. Aims of Placenta Examination

Every midwife must carefully examine the placenta immediately after it is delivered to achieve two primary goals:

To determine completeness: Ensuring that no part of the placenta, cotyledons, or membranes is left inside the mother's uterus, which could cause fatal postpartum hemorrhage (PPH) or sepsis.
To detect abnormalities: Identifying any structural defects, tumors, nodules, or signs of infection that are associated with abnormal fetal development and perinatal morbidity.

Gross Anatomy of a Normal Term Placenta

Before looking for abnormalities, a midwife must know what a normal, healthy placenta looks like:

Size and Weight: A fresh, term placenta measures approximately 15 to 22 cm in diameter and weighs between 470g and 600g (roughly 1/6 of the baby's total birth weight).
Thickness: It is normally 2.0 to 2.5 cm thick. Interestingly, placental thickness is directly proportional to the gestation age (e.g., a 21-week placenta will be about 21 mm thick).
Maternal Surface: Should be a dark maroon color, consisting of around 20 lobes (cotyledons) that fit perfectly together with no missing gaps.
Fetal Surface: Should be shiny, gray, and translucent (clear) enough that the underlying maroon tissue can be seen.

2. Requirements and Preparation

To safely examine the placenta without causing blood spillage or infection, the midwife must organize the following equipment:

Location	Equipment Required
Top Shelf	Clean examination gloves. Measuring jar (to accurately measure blood clots/loss). The freshly delivered placenta inside a receiver. A syringe and needle (if cord blood samples are required).
Bottom Shelf	Weighing scale. 3 designated buckets (for placenta disposal and clinical waste). Protective plastic apron.
At the Side	Protective gumboots. Hand washing equipment. A flat work surface covered with protection to avoid blood spillage. Adequate Lighting: (If lighting in the delivery room is dim, the placenta must be moved to an area with excellent lighting).

3. Procedure for Examination

The examination should be done systematically. Always begin by explaining the procedure to the mother and guardian, and ask if they wish to observe.

Step 1: Inspecting the Fetal Surface and Membranes

Initial Lay Out: Wear your protective gear. Lay the placenta flat on the surface with the fetal side uppermost. Note the overall size, shape, smell, and color.
Check for Irregularities: Look for fatty deposits, infarctions (dead tissue), or the presence of large (velamentous) blood vessels running unprotected through the membranes.
Lift and Inspect Holes: Hold the placenta up by the umbilical cord. This allows the membranes to drop down like a bag. There is normally only a single hole where the baby passed through. If you see extra holes or torn vessels leading nowhere, suspect a missing Succenturiate lobe (an extra accessory lobe left in the uterus).
Separate the Layers: Return the placenta to the flat surface. Gently pull the inner membrane (amnion) back over the base of the umbilical cord to separate it from the outer membrane (chorion). Ensure both layers are fully present.

Step 2: Examining the Umbilical Cord

Length and Insertion: Note the total length of the cord and exactly where it inserts into the placenta (central, marginal/battledore, or velamentous).
Count the Vessels: Inspect the freshly cut end of the cord. The normal cord contains two arteries and one vein. Clinical Tip: Count the vessels in the middle or fetal third of the cord, because arteries sometimes fuse near the placenta, making them difficult to differentiate.
Look for Abnormalities: Check the cord for true knots, thromboses (blood clots blocking the cord), and the healthy presence of Wharton's jelly (the protective jelly around the vessels).

🧠 Memory Aid for Umbilical Cord Vessels

Remember the word AVA to recall the normal blood vessels in the umbilical cord:
A = Artery
V = Vein (The single, largest one)
A = Artery

Step 3: Inspecting the Maternal Surface

Turn it Over: Carefully turn the placenta over to inspect the dark maroon maternal surface.
Piece it Together: Gently push the lobes (cotyledons) together. A complete placenta will fit neatly together without any gaps, with the edges forming a uniform circle. Broken fragments must be carefully replaced to make an accurate assessment.
Check for Missing Tissue: Ensure all roughly 20 cotyledons are present. Tissue may be retained inside the mother due to abnormal lobation or conditions like placenta accreta (where the placenta grows too deeply into the uterine wall).
Remove Clots: Remove any blood clots from the maternal surface and place them in the measuring jar to accurately assess the mother's total blood loss.

4. Clinical Interpretations of Abnormal Findings

A trained midwife uses the placenta to read the story of the pregnancy. Any of the following abnormal findings must be documented, and the placenta should be submitted for pathologic evaluation.

Placental Size and Thickness

Less than 2.0 cm thick: Strongly associated with Intrauterine Growth Retardation (IUGR) of the fetus.
More than 4.0 cm thick: Associated with maternal diabetes mellitus, fetal hydrops (fluid buildup in the baby), and severe intrauterine fetal infections.

Surface Abnormalities

Pallor (extreme paleness) of the maternal surface: Indicates fetal anemia, which may be a sign of active fetal hemorrhage (such as in vasa previa). With prompt recognition, a lifesaving blood transfusion can be arranged for the newborn.
Clots on the maternal surface: Adherent, centrally located clots usually represent Placental Abruption (premature separation of the placenta).
Thick ring of membranes on the fetal surface: Represents a Circumvallate Placenta. This is dangerously associated with prematurity, prenatal bleeding, multiparity, and early fluid loss.
Thin ring of membrane tissue: Represents a milder condition called a Circummarginate Placenta.

Umbilical Cord Abnormalities

A normal umbilical cord measures between 40 cm and 70 cm.

Short Cord (Less than 40 cm): Associated with a less active fetus, fetal malformations, Down syndrome, neuropathic diseases, and oligohydramnios (low amniotic fluid).
Risks during labour: Cord rupture, bleeding, prolonged second stage of labour, uterine inversion, and placental abruption.
Long Cord (More than 70 cm): Associated with fetal hyperkinesis (excessive movement).
Risks: Severe entanglements around the baby's neck, torsion (twisting), true knots, and thromboses.
Missing a Vessel (Single Umbilical Artery): If only one artery and one vein are grossly visible, the fetal anomaly rate is nearly 50 percent. These anomalies heavily affect the newborn's cardiovascular, genitourinary, and gastrointestinal systems.

Fetal Membrane Odors

Normal membranes are thin, gray, and glistening. Thick, dull, discolored, or foul-smelling membranes indicate strong possibilities of infection. The specific smell gives the midwife a clue to the bacteria:

Fecal odor (smells like stool): May indicate infection by Fusobacterium or Bacteroides.
Sweet odor: May indicate infection by dangerous bacteria like Clostridium or Listeria.

⚠️ Attention: Incomplete Placenta

Where there is any suspicion that the placenta and/or the membranes are incomplete, they must be kept for further inspection and the duty obstetrician/doctor must be informed immediately. Inform the mother of the findings and complete the documentation in her health care record.

5. Disposal of the Placenta

Cultural Considerations: Always politely inquire from the mother if she would like to take the placenta home, as many cultures have specific burial traditions for it.
Medical Disposal: If the mother declines, dispose of the placenta by taking it directly to the hospital's incinerator or the designated biological placenta pit. Wash hands thoroughly and sanitize the work area.

💡 Quick Practice Check

Question: While examining the cut end of an umbilical cord, the midwife notices there is only one large vein and one artery present. What is the immediate clinical concern?

Answer: A Single Umbilical Artery carries a 50% risk of fetal anomalies, specifically affecting the baby's cardiovascular, gastrointestinal, and genitourinary systems. A thorough pediatric assessment of the newborn is required.

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Home > Midwifery I > Normal Third Stage of Labour

Normal Third Stage of Labour

The Third Stage of Labour is a very critical phase that begins immediately after the baby is born. It involves three main steps: the separation of the placenta from the uterine wall, its descent down the birth canal, and its final expulsion along with the membranes.

A major goal of the midwife during this stage is to ensure the complete removal of the placenta and to prevent heavy bleeding (postpartum hemorrhage).

Physiology of the Third Stage of Labour

Understanding how the body naturally separates and pushes out the placenta helps the midwife manage this stage safely. The process involves four main actions:

1. Contraction and Retraction

Placental separation is started by the continuous contraction (tightening) and retraction (shortening and thickening) of the uterine muscles.

These contractions make the wall of the uterus much thicker.
As the wall thickens, the inside space (capacity) of the upper part of the uterus becomes very small.
This causes the area where the placenta is attached to shrink. Because the placenta itself cannot shrink, it begins to tear away from the wall, usually starting from the center.
As the blood vessels (sinuses) tear, a pool of blood called a retroplacental clot forms behind the placenta. This clot pushes and helps to separate the placenta even more.

2. Descent of the Placenta

Once separated, the placenta must move down. The force of gravity and the weight of the blood clot act like a heavy piston. This heavy weight pushes the loose placenta down from the upper part of the uterus into the lower part of the uterus.

3. Separation of Membranes

The membranes (the bag that held the baby and fluid) are peeled off the wall of the uterus (the decidua) by the heavy weight of the falling placenta. However, these membranes might stay stuck around the cervix until the whole placenta is pushed completely out of the vagina.

4. Haemostasis (Preventing Hemorrhage)

When the placenta separates, it leaves behind open, bleeding blood vessels. The body must quickly control this blood flow to prevent serious bleeding. The body achieves haemostasis (stopping the bleeding) through four vital steps:

Living Ligatures: The unique crossed (oblique) muscle fibers of the uterus contract and thicken. They act like strong clamps or tight ropes (ligatures) that tightly squeeze and close the torn blood vessels.
Vigorous Uterine Action: After the placenta separates, the empty uterus contracts very strongly. The walls press tightly against each other, putting direct pressure on the bleeding site.
Clot Formation: A strong protein net called a fibrin mesh quickly covers the bleeding site. The body uses about 5% to 10% of its circulating fibrinogen to form solid blood clots to stop the bleeding completely.
Oxytocin from Breastfeeding: If the mother starts breastfeeding immediately, her brain releases the natural hormone oxytocin. This hormone makes the uterus contract even harder, which greatly helps to stop the bleeding.

Separation of the Placenta — Visual demonstration of how the placenta separates from the uterine wall and descends.

Methods of Placental Separation

The placenta can separate from the uterine wall and come out in two different ways. These are known as the Schultze method and the Mathew Duncan method.

1. Schultze Method

This is the most common and preferred way for the placenta to separate.

The separation starts deeply in the center of the placenta.
A large pool of blood (retroplacental clot) forms behind it. This clot pushes the middle part down and helps to strip the edges of the placenta off the wall smoothly.
The weight of the placenta easily peels the membranes off the wall, creating a neat bag that holds the blood clot inside.
As the placenta comes out, the shiny, smooth fetal surface comes out first.
Advantage: This method is very quick and clean. Because the blood is trapped inside the membrane bag, there is less visible blood loss, and both the placenta and membranes come out completely without tearing.

2. Mathew Duncan Method

This method is less common and a bit messier.

The separation starts from the sides (edges) of the placenta, not the center.
Because there is no central blood clot to trap the blood, the blood escapes continuously from the sides during the whole process.
The placenta slides down sideways, and the rough, fleshy maternal surface comes out first.
Disadvantage: This method takes a longer time. It is associated with ragged, torn, and incomplete membranes, and it causes a higher amount of visible blood loss.

🧠 Easy Memory Aid for Placental Delivery Methods

Shiny Schultze: The smooth, shiny fetal side comes out first. (Clean and common).

Dirty Duncan: The rough, dark red maternal side comes out first. (Messy and bleeds more).

Signs of Placenta Separation

Before a midwife can safely deliver the placenta, she must observe for clear signs that it has fully detached from the wall. These signs include:

The uterus becomes hard, round, and mobile: It feels like a firm ball in the abdomen.
The fundus rises: The top of the uterus (fundus) moves up to the level of the umbilicus (belly button) or slightly above it.
Lengthening of the cord: The umbilical cord hanging outside the vagina appears to suddenly grow longer as the placenta drops down.
A gush of blood: A sudden, small flow of dark blood escapes from the vagina as the placenta detaches.
Placenta felt on VE: The placenta can be physically felt if a vaginal examination is done.
Placenta visible at the vulva: The placenta can be seen resting at the vaginal opening.
Cord does not recede: If the midwife presses firmly just above the pubic bone (suprapubic pressure), the umbilical cord will not pull back inside the vagina. This means it is completely free.

Mechanism of Placental Separation

The natural process of the placenta falling away relies heavily on uterine contractions and a process called involution (the shrinking of the uterus).

Immediately after the baby is born, the uterus does not stop working. It continues to contract strongly about every 3 to 4 minutes.
These contractions, combined with the rapid shrinking (involution) of the uterus, force the site where the placenta is attached to shrink drastically.
Usually, within 10 to 15 minutes after the baby is delivered, the majority of the placenta successfully detaches from the wall.
When it detaches, the open blood vessels bleed, causing the classic "gush of blood" that signals the midwife.
As the placenta is delivered, the uterus continues to clamp down hard, closing the small bleeding arteries (spiral arterioles) and ensuring the mother does not bleed to death.

⚠️ Attention: Normal Blood Loss

It is important for every midwife to note that the average normal blood loss from a healthy vaginal delivery is approximately 250ml to 300ml. Any bleeding significantly above this amount (500ml or more) is considered a dangerous Postpartum Hemorrhage (PPH).

Management of the Third Stage of Labour

There are two main methods a midwife can use to deliver the placenta safely. These are Active Management and Passive Management.

1. Active Management (Controlled Cord Traction)

This is the most recommended method because it is faster and significantly reduces the risk of heavy bleeding. It involves the midwife taking an active role using drugs and controlled pulling. The steps are:

Palpate the abdomen: Immediately after the baby is born, feel the mother's stomach to make sure there is no second baby (undiagnosed twin) still inside.
Administer Oxytocin: Give the mother an injection of Oxytocin 10 IU intramuscularly (IM). This forces the uterus to contract quickly and strongly.
Prepare the cord: Move the clamp on the umbilical cord closer to the mother's vulva so you can get a strong, comfortable grip.
Apply counter-traction: Wait for the first strong contraction. Place your left hand flat over the mother's lower abdomen (just above the pubic bone). Push firmly upwards towards the mother's head to support the uterus and prevent it from turning inside out (inversion).
Apply traction: With your right hand holding the cord clamp, pull the cord steadily downwards and outwards. When the placenta appears at the vulva, pull gently upwards to catch it in your cupped hands.
Deliver the membranes: Carefully roll or twist the placenta as it comes out. This twists the fragile membranes into a strong rope, preventing them from tearing and leaving pieces inside. Deliver them using a gentle upward and downward motion.
Record the time: Note exactly what time the placenta and membranes were completely delivered.
Massage the uterus: Rub the fundus (top of the uterus) until it feels hard like a stone. This promotes continuous contractions to stop bleeding.
Examine the placenta: Quickly spread the placenta out in a receiver to check that all parts (lobes and membranes) are complete.
Check for tears: Clean the mother's vulva with warm water or antiseptic. Examine the vagina and cervix carefully for any tears, lacerations, or bleeding episiotomies, and repair them immediately.
Make the mother comfortable: Provide a clean sanitary pad, cover her with a warm blanket, and ensure she is resting well.

2. Passive Management (Maternal Efforts)

This method allows the body to work entirely on its own without pulling the cord. It is only used if the placenta has already separated naturally. The steps are:

Wait for the signs: Carefully observe the mother for the clear signs of placental separation (gush of blood, lengthening of cord, hard round uterus).
Encourage pushing: Once you are sure the placenta has separated, ask the mother to bear down and push exactly when she feels a contraction.
Provide resistance: Place your flat hand over her abdomen to give her something firm to push against.
Receive the placenta: Catch the placenta gently in both hands as it is pushed out to ensure it comes out complete.
Administer Oxytocin: Even after natural delivery, give Oxytocin 10 IU intramuscularly to keep the uterus contracted and prevent late bleeding.

⚠️ Attention: Prevent Hypothermia

The mother has just gone through hours of strenuous physical exercise during the first and second stages of labour. This causes extreme heat loss. It is strictly essential to keep the mother warm with dry sheets and blankets during and immediately after the third stage to prevent shivering and cold shock.

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Home > Midwifery I

Episiotomy and Perineal Tears

Overview: An Episiotomy is a surgical cut (incision) made on the perineum—the area of skin and muscle between the vagina and the anus. This procedure is done to widen the vaginal opening just before the baby is born. This helps the baby come out easier and protects the mother's body from tearing badly. Below is a detailed breakdown of why it is done, the types, and the exact step-by-step repair process.

1. Indications for an Episiotomy

A midwife does not cut the perineum for every delivery. It is only done for specific medical reasons. These reasons are divided into three main categories:

A. To Quicken the Delivery (Speed up childbirth)

In certain emergencies, the baby must be born as fast as possible:

1. Pre-eclampsia and Eclampsia: Dangerous conditions involving very high blood pressure where the mother could get a stroke or seizures.
2. Cardiac (Heart) Diseases: Pushing for a long time puts too much dangerous strain on a mother with a weak heart.
3. Maternal Distress: When the mother is extremely exhausted, weak, and physically cannot continue pushing anymore.
4. Fetal Distress: When the baby is lacking oxygen (shown by a dropping heart rate) and needs to be born immediately to prevent the baby from dying.
5. Cord Prolapse in the Second Stage: When the umbilical cord falls out before the baby. If the baby is still alive, a quick cut is made to deliver the baby before the cord is completely crushed.

B. To Prevent Excessive Trauma (Severe Tearing)

Sometimes the mother's tissues are at risk of tearing apart violently:

1. Rigid Perineum: When the mother's tissues are very stiff, tight, and refuse to stretch easily (common in older first-time mothers).
2. Forceps Delivery: When the doctor needs extra room to insert metal forceps to help pull the baby out safely.
3. Face to Pubis Delivery: When the baby comes out facing upwards (Occipito-Posterior position). The baby's head takes up much more space in this position.

C. To Reduce the Risk of Cerebral (Brain) Damage to the Baby

1. Premature Births: A premature baby has a very soft, fragile skull. Pushing hard against a tight vagina can cause bleeding inside the baby's brain.
2. Postmaturity (Overdue Baby): The baby’s skull bones have become very hard and do not fold or mold easily to fit through the birth canal.
3. Breech Deliveries: In a breech birth, after the body is out, the head (which is the biggest part) comes last. The cut ensures the head comes out fast without getting trapped.
4. Narrow Subpubic Arch: When the mother's front pelvic bones are too narrow, it forces the baby’s head backward toward the anus, causing dangerous pressure.
5. Previous Third-Degree Tears: If the mother had a severe tear into her anus in a past pregnancy, an episiotomy protects that old, weak scar from tearing open again.

2. Types of Episiotomy

1. Medial Lateral (Mediolateral):
This is the most common and highly recommended type, especially for midwives. The cut starts from the bottom center of the vaginal opening (the fourchette) and extends diagonally downward and outward (medial lateral direction) for about 2-3cm.

Advantages:
- 1. It usually heals very well.
- 2. It is much easier for a midwife to perform and repair.
- 3. It minimizes damage to large blood vessels.
- 4. It strongly reduces the risk of the cut extending into an excessive perineal tear.
- 5. It shortens the total duration of the second stage of labor.
- 6. It helps avoid serious injuries to the Bartholin’s glands (lubrication glands) and the anal sphincter muscle.
2. Medial, Central, or Midline:
This cut begins directly at the center of the fourchette and goes straight down the middle toward the anus.

Advantages:
- 1. Results in much less bleeding.
- 2. Provides greater comfort and less pain for the mother afterward.
- 3. Very simple to perform and easy to stitch back up.
Disadvantages:
- 1. It may accidentally tear further downwards and involve the anal sphincter.
- 2. A poor repair could lead to a Rectovaginal Fistula (RVF)—a hole where feces can leak into the vagina.
3. Lateral Incision:
This cut is made completely sideways across the outer lips (labia majora). It is rarely done today.

Disadvantages:
- 1. It is very challenging and difficult to repair.
- 2. It may lead to severe, excessive bleeding.
- 3. High risk of permanently damaging the Bartholin’s glands.
- 4. Causes extreme discomfort to the mother and takes much longer to heal.
4. J-shaped:
This is usually performed only by a doctor. It starts from the center of the fourchette and goes straight down, but then curves away from the anal sphincter at a distance of about 2.5cm, forming a "J" shape.
5. Bilateral:
This is similar to the lateral incision but is done on both the left and right sides. It starts from the fourchette to the lateral walls.

Note: Bilateral episiotomy is strongly discouraged because it carries a massive potential risk of destroying both Bartholin’s glands.

3. Precautions When Giving an Episiotomy

Timing: Avoid making the cut too early (causes heavy bleeding) or too late (the tissues will have already torn naturally).
Presentation: In a normal head-first (cephalic) presentation, wait until the baby's head is visibly stretching the perineum. In a breech presentation, wait until the anterior (front) shoulder is stretching the perineum before cutting.
Contraction Height: You must only make the cut exactly during a strong contraction. This ensures the tissues are tight, providing better control, precision, and less pain for the mother.

4. Basic Principles of Perineal Repair

Basic Principles Prior to (Before) Repairing the Perineum

1. Timely Repair: Perform the stitching as soon as possible after the placenta is out. This minimizes the risk of heavy bleeding and prevents the area from swelling up (perineal edema).
2. Aseptic Technique: Ensure the entire repair is done using proper, clean, sterile methods to highly reduce the risk of dangerous infections.
3. Equipment Check: Verify that all necessary equipment is ready. You must strictly count your swabs, gauze, and needles before and after the procedure to avoid accidentally leaving any foreign objects inside the mother's body.
4. Anesthesia: Make sure the wound is fully numb (anesthetized) before starting the repair so the mother does not feel sharp pain.

Basic Principles After the Repair is Completed

1. Hemostasis: Ensure complete hemostasis (meaning all bleeding has completely stopped) to prevent blood loss.
2. Post-repair Examination: You must gently perform a rectal and vaginal examination with your fingers to confirm the repair is good, ensure no other hidden tears were missed, and verify that you did not accidentally stitch the rectal mucosa to the vagina.
3. Removal of Swabs: Double-check and look inside to ensure that all tampons or swabs used to block blood during the procedure have been completely removed.
4. Detailed Documentation: Make clear, detailed notes in the mother's file describing your findings, the size of the tear, and the exact repair procedure for accurate medical records.
5. Post-repair Care: Inform the woman about how to take pain relief (analgesia), how to wash the area properly (hygiene practices), the importance of maintaining a good diet, and performing pelvic floor exercises to help the muscles recover fast.

5. Method of Infiltration and Performing the Episiotomy

Requirements (Equipment Needed)

A sterile episiotomy pack containing exactly the following:

1. Pair of episiotomy scissors.
2. Needle and suture material (like catgut).
3. Needle holder.
4. Sterile gauze and cotton swabs.
5. Sterile gloves.
6. A syringe.
7. Lignocaine (local anesthesia).
8. Hibicet (antiseptic cleaning solution).

Method of Infiltration and Cutting (Step-by-Step)

Step 1: Ensure the entire procedure is performed under strict sterile conditions.
Step 2: Explain the procedure to the mother to keep her informed, calm, and cooperative.
Step 3: Draw the required amount of Lignocaine or local anesthesia into the syringe (usually 10mls of 0.5% Lignocaine, or 5-7mls of 1% Lignocaine).
Step 4: Clean (swab) the vulva with antiseptic to maintain cleanliness.
Step 5: Wait for a contraction. When the baby's head or presenting part is pushing hard and distending the vulva, place two fingers of your left hand firmly between the fetal head and the mother's perineum. This ensures you do not accidentally inject medicine into the baby's scalp.
Step 6: Introduce the needle into the perineum. Pull back on the syringe (withdraw the piston) to check for any blood aspiration. If blood enters the syringe, it means you are in a vein. Reposition the needle and repeat until no blood is withdrawn. Then inject the medicine.
Step 7: Keep your two fingers inside the vagina. Position your scissors, and at the absolute peak of the next contraction, make a single clean cut approximately 3cm in length in a medial-lateral direction.
Step 8: Immediately control the hemorrhage (bleeding) by pressing a sterile swab firmly on the cut area.

6. The Repair Technique (Step-by-Step)

This is the exact sequence of actions a midwife takes to stitch the wound back together. Do not skip any of these steps:

Step 1: Ensure the proper setting before you start:
- a. Place the mother in a comfortable position.
- b. Remove any dirty or soiled linen from under her genitalia.
- c. Adjust your light source so you have a very clear, bright view deep inside the vagina.
- d. Communicate with the mother, explain the repair procedure, and provide reassurance.
Step 2: Put on a fresh, clean pair of sterile gloves.
Step 3: Check whether the previously administered local anesthesia is still effective. If the mother feels sharp pain when you touch the wound, administer more anesthesia before starting the repair.
Step 4: Carefully remove all blood clots from the birth canal.
Step 5: Open the vagina to assess the true extent of the damage. Locate the very top end of the cut inside the vagina, which is called the apex of the episiotomy.
Step 6: Insert a roll of sterile gauze (vaginal pack) deep inside to stop blood from dripping down over your work area. Secure the end of this pack with an artery forceps so it is not lost inside.
Step 7: Start suturing (stitching) the episiotomy directly from the apex.
Step 8: Suture the vaginal inner lining (vaginal mucosa) using the continuous stitch technique. Pass the needle through the vaginal mucosa from behind and bring it out on the perineum wound.
Step 9: Continue using the continuous suturing method all the way down to the bottom of the wound to close the deep, thick muscle layer. The same continuous technique can be used to close the outside skin nicely.
Step 10: Remove the vaginal pack. Inspect the vagina carefully, and insert one finger into the rectum to ensure perfect closure and to exclude any accidental involvement of the rectum.
Step 11: Clean the mother gently with warm water after completing the repair.
Step 12: Provide a clean sanitary pad for the mother’s comfort and hygiene.
Step 13: Advise the mother on how to properly care for the episiotomy at home and provide all necessary instructions.
Step 14: Clear away all your tools and properly dispose of all used and bloody materials in the correct bins.

⏳ Healing Time

The healing time for an episiotomy is around 4 to 6 weeks. This depends largely on the size of the incision and the type of suture material (thread) used to close the wound.

7. Classification of Perineal Trauma (Tears)

When the perineum tears naturally during birth, the damage is classified into different degrees of severity.

Classification of Perineal Tears — Diagram showing the anatomy and degrees of perineal tearing.

Classification	Clinical Description
First Degree Tear	A very mild injury to the perineal skin only. The muscles underneath are perfectly safe.
Second Degree Tear	A deeper injury to the perineum that involves the perineal muscles, but it completely stops before hitting the anal sphincter.
Third Degree Tear	A severe injury to the perineum that goes deep enough to involve and tear the anal sphincter (the circular muscle that controls the anus).
Fourth Degree Tear	The most severe and dangerous injury. It involves the total destruction of the perineum, the anal sphincter complex, and tears completely into the inner lining of the rectum (anal epithelium).
Isolated Buttonhole Injury	A rare injury where there is a direct hole punched into the rectal mucosa (the wall of the rectum), but the anal sphincter muscles at the bottom remain intact without injury.

Complications of Perineal Trauma

If tears or cuts are not managed well, the mother can suffer the following problems:

1. May become a 3rd degree tear: A smaller cut can accidentally rip further into the anus if the baby comes out too fast.
2. Bleeding: Heavy, continuous bleeding (hemorrhage) from torn blood vessels.
3. Infections: The wound is very close to the anus, making it highly susceptible to bacterial infection and pus.
4. Swelling: Severe swelling and blood collecting under the skin, causing immense pain.
5. Defect in wound closure: The stitches may break or dissolve too early, causing the wound to open up again.
6. Local pain and sexual dysfunction: The mother may experience severe short-term pain, making sexual intercourse difficult or painful for a while.

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Home > Midwifery I > Normal Second Stage of Labour

Normal Second Stage of Labour

Overview: The Second Stage of Labour is the "pushing stage." It officially begins when the mother's cervix is fully open (fully dilated to 10cm) and ends when the baby is completely born. This stage is highly active, requiring strong uterine contractions, voluntary pushing from the mother, and close monitoring by the midwife to ensure a safe delivery.

1. Signs of the Second Stage

A midwife must closely observe the mother to know exactly when the second stage has started. The signs are divided into early warnings and one absolute confirmation.

Early Warning Signs (Premonitory Signs)

Expulsive Uterine Contractions: The mother feels an uncontrollable urge to bear down and push. Note: This can sometimes happen before she is fully dilated, especially if the baby's head is facing her back (occipito-posterior) or if her rectum is full of stool.
Rupture of Fore Waters: The bag of waters (amniotic sac) may break at this time, though it can happen earlier in labor.
Dilatation and Gaping of the Anus: As the baby's head drops deep into the pelvis, it presses on the bowel, causing the anus to open wide (gape).
Appearance of the Presenting Part: The baby's head becomes visible at the vaginal opening. Sometimes, heavy pressure causes a soft swelling on the baby's head (caput succedaneum) which can be seen even before the cervix is fully open. (In a breech birth, the buttocks might be seen when she is only 7-8cm dilated).
Show: A sticky, blood-stained mucus plug comes out. The midwife must carefully check that this is a normal "show" and not dangerous bleeding from a tearing placenta.
Congestion of the Vulva: The private parts become swollen, dark, and full of blood because of heavy pressure and early pushing.
Bulging of the Perineum: The skin between the vagina and the anus stretches and bulges outward as the baby's head pushes against it.

Confirmatory Sign

No Cervix is Felt: When the midwife does a Vaginal Examination (VE), she can no longer feel the edges of the cervix. It is completely out of the way (full dilatation of 10cm). This is the only 100% sure sign.

Phases of the Second Stage

Passive Phase: The cervix is fully open, but the mother's body is not yet forcing her to push (no involuntary expulsive contractions). In a healthy labor, this resting period can last up to one hour.
Active Phase: The cervix is fully open, the body forces strong pushing contractions, and the baby is visible.
Time limits: You must inform a doctor if the baby is not born after 2 hours for a first-time mother (primigravida) or 1 hour for a mother who has delivered before (multigravida).
Propulsive Phase: The baby's head moves from the fully open cervix down to the bottom of the pelvis (pelvic floor).
Expulsive Phase: The mother actively pushes with all her strength until the baby is completely delivered.

2. Physiology of the Second Stage

This explains exactly how the mother's body physically changes and reacts to push the baby out.

Descent: The baby continues its rapid, downward journey through the pelvis until it hits the pelvic floor muscles.
Uterine Action: Contractions become much stronger and longer. However, the breaks between them might get longer, giving the mother and baby time to recover (this rest can last up to an hour, especially for first-time mothers).
- When the water breaks, the hard round head of the baby presses directly on the vaginal tissue, which helps it stretch.
- The pressure of the baby's body pushing down bends the baby's neck (flexion), making the head smaller so it fits through the bones faster and safer.
- When the baby's head presses on the nerve receptors in the pelvic floor, it sends a powerful message to the mother's brain, causing an overwhelming urge to push. She responds by naturally tightening her stomach muscles and breathing muscle (diaphragm).

Soft Tissue Displacement (Moving Organs Out of the Way)

As the hard baby's head moves down, the soft organs inside the mother's pelvis are squeezed and pushed out of the way to prevent injury:

Anteriorly (Front): The bladder is pushed high up into the abdomen to protect it from being crushed. This stretches the urine tube (urethra), making it very thin.
Posteriorly (Back): The rectum (bottom bowel) is flattened flat against the backbone (sacrum). The heavy head pushes out any leftover stool (feces) as it passes.
Pelvic Floor: The strong levator ani muscles stretch, thin out, and are pushed to the sides. The perineal body (skin between vagina and anus) stretches until it is paper-thin.
Birth: The baby's head appears with each contraction and slips back slightly when the contraction stops, until it stays out (crowning). The head is born, followed by the shoulders and body, usually with a large splash of amniotic fluid and some blood.

3. Mechanism of Normal Labour

The mechanism of labour refers to the series of passive turns and movements the baby must make to successfully fit through the curves and tight spaces of the mother's pelvis.

🔑 Core Principles of the Mechanism

Descent happens continuously throughout the whole process.
Whichever part of the baby hits the pelvic floor muscles first will automatically rotate forward until it sits right under the pubic bone (symphysis pubis).
The baby will pivot (swing) around the pubic bone to get out.
The baby always turns its body to use the widest space available in the mother's bones.

Important Terms Used to Describe the Baby's Position

Attitude: How the baby's head, arms, and legs are folded. The best attitude is "complete flexion" (chin tucked tightly to the chest), making the head as small as possible.
Presentation: The part of the baby that is sitting lowest in the womb. The normal, safest presentation is "Vertex" (the top of the head).
Lie: How the baby's spine lines up with the mother's spine. Normal labour requires a "Longitudinal" lie (spines are parallel), which happens 99.5% of the time.
Presenting Part: The exact part of the baby sitting directly over the opening of the cervix.
Denominator: The specific name of the bone used to describe the baby's position.
- Vertex presentation = Occiput (back of the head).
- Breech presentation = Sacrum (tailbone).
- Face presentation = Mentum (chin).

The 8 Main Movements of Labour

In a normal delivery (Cephalic presentation, Occiput denominator), the baby performs these steps in order:

1. Engagement: The widest part of the baby's head passes into the top of the pelvic brim. (Happens weeks before labour in first-timers, but late in labour for mothers who have delivered before).
2. Descent: The baby moves deeper down. This is pushed by strong uterine contractions, the mother bearing down, and the baby's body straightening out when the water breaks.
3. Flexion: The baby's head hits the walls of the pelvis, forcing the chin to tuck deeply into the chest. This reduces the presenting size from 10cm to a perfect 9.5cm.
4. Internal Rotation of the Head: The baby's head hits the pelvic floor muscles and turns slightly (1/8 of a circle) forward so the back of the head (occiput) sits under the mother's pubic bone.
5. Crowning: The widest part of the head pushes through the vaginal opening. It no longer slips back when the contraction stops. The head is about to be born.
6. Extension of the Head: The back of the baby's head pivots under the pubic bone. The baby lifts its chin, and the face, nose, and chin sweep over the perineum and are born.
7. Restitution: As soon as the head is completely out, it naturally untwists itself to realign with the shoulders still inside. The head turns exactly 1/8 of a circle back to where it started.
8. Internal Rotation of Shoulders & External Rotation of Head: The shoulders inside rotate to fit the widest part of the exit. As the shoulders turn inside, the baby's head (which is already outside) visibly turns to the side (External Rotation).
9. Lateral Flexion: The top shoulder slips under the pubic bone, the bottom shoulder sweeps out over the perineum, and the rest of the baby's body easily bends to the side (lateral flexion) and slides out.

The Mechanism of Normal Labour — Diagram showing Descent, Flexion, Internal Rotation, Extension, Restitution, and Lateral Flexion.

4. Factors Influencing the Length of the 2nd Stage

Not every mother will push for the same amount of time. The speed depends on:

Maternal Parity: Mothers who have given birth before usually have stretched tissues, so the baby comes out much faster than a first-time mother.
Fetal Size: A very large baby takes much longer to squeeze through the pelvic bones.
Force of Uterine Contractions: Weak contractions (uterine inertia) make the stage very long.
Presentation & Position: If the baby is facing the mother's stomach instead of her back, it takes longer for the head to rotate.
Pelvic Size: A narrow or deformed pelvis creates heavy resistance.
Method of Anesthesia: Epidurals or heavy painkillers can numb the pelvic nerves, stopping the mother from feeling the urge to push strongly.
Maternal Effort: How hard the mother is physically able to push, push correctly, and her emotional stamina.

5. Management & Nursing Care of the Second Stage

Basic Midwifery Care

Bladder Care: Always encourage the mother to empty her bladder at the start of the second stage. A full bladder blocks the baby from dropping down and can be easily torn or crushed during birth.
Hygiene and Comfort: Wipe away any stool or blood gently. Place a sterile pad over the vulva between contractions. If she gets leg cramps from pushing, massage the leg and gently bend it to relieve the pain.
Emotional Support: Do not leave the woman alone. Praise her constantly, tell her she is doing a good job, and keep her updated ("I can see the baby's hair!"). Keep the room quiet, private, and calm to reduce her fear.
Positioning: Let her choose the most comfortable position. This can be lying on her back (dorsal), squatting, kneeling, all fours, standing, or lying on her left side. Upright positions use gravity to help the baby come down faster.
Observations: Constantly check her blood pressure (hourly) and pulse (every 30 mins). Watch the baby's heart rate, the color of the amniotic fluid (green means danger), and how well the mother is coping emotionally.

Requirements: Preparing the Delivery Trolley

The midwife must set up the delivery room long before the baby arrives. A sterile trolley is arranged in three areas:

Top Shelf (Sterile Pack)	Bottom Shelf (Medicines & Supplies)	Beside the Bed / Room Setup
6 delivery swabs 2 cord clamps 1 pair of cord scissors 1 pair of episiotomy scissors 2 gallipots (for swabs/lotion) 2 sterile receivers Bulb syringe (mucus extractor) 2 syringes Perineal pad 4 delivery towels Cord ligatures Sterile gloves	Vial of Lignocaine (local anesthetic) Ampoule of Oxytocin (to prevent bleeding) Measuring jar Plastic Apron 2 extra pairs of sterile gloves Episiotomy repair pack Disinfectant solution Extra syringes and needles Mackintosh (waterproof sheet) and towel Clean maternity pads Safety box for sharp needles	A warm cot with clean baby clothing Newborn resuscitation equipment Gum boots for the midwife 2 buckets (one for dirty swabs, one with disinfectant for tools) Laundry hamper for dirty linen IV Drip stand

6. Conducting the Delivery (Active Management)

Responsibilities of the Assistant Midwife

While the primary midwife delivers the baby, the assistant plays a massive role:

Reassure and comfort the mother constantly.
Help hold the mother in the correct pushing position.
Instruct the mother *exactly* when to push (during the contraction) and when to pant/rest.
Listen to the fetal heart rate immediately after every single contraction to ensure the baby is surviving the pressure.
Give an injection of Oxytocin in the mother's thigh within 1 minute of the baby being born to stop heavy bleeding (Active Management of Third Stage).
Show the sex of the baby to the parents.
Score the baby's health (APGAR score) at 1 minute and 5 minutes.
Dry the baby, keep it warm, and put it on the mother's chest for skin-to-skin contact and early breastfeeding.

Various Birth Positions during Labour — Delivery positions: Squatting, kneeling, left lateral, and dorsal positions can all be used depending on maternal comfort.

Step-by-Step Delivery Procedure

Preparation: Explain everything to the mother. Put on your protective gear (gum boots, plastic apron, and face mask). Position the mother properly.
Scrubbing: Wash your hands thoroughly with soap and clean water to remove all bacteria. Put on two pairs of sterile gloves.
Draping: Clean the mother's vulva with an antiseptic swab. Cover her legs and abdomen with sterile towels. Place a sterile pad tightly over her anus to prevent stool from dirtying the delivery area.
Delivery of the Head:
- As the head pushes out, press two fingers gently on the top of the baby's head to keep the chin tucked to the chest (maintain flexion). This stops the head from bursting out too fast and tearing the mother.
- When the head stays out between contractions (Crowning), shout to the mother to STOP pushing and start panting like a dog. This allows the head to slide out smoothly and slowly.
- Gently guide the head upward toward the pubic bone to deliver the face and chin.
- Immediately wipe the baby's face, clean the eyes from the inside to the outside, and use a bulb syringe to suck mucus out of the nose and mouth.
- Quickly check if the umbilical cord is wrapped around the baby's neck. If it is loose, slip it over the head. If it is very tight, clamp it in two places and cut it immediately.
Delivery of the Shoulders:
- Wait for the baby's head to naturally turn to the side (restitution/external rotation). This means the shoulders have turned into the correct position inside.
- Place your hands flat on the sides of the baby's head (over the ears).
- Pull gently downward to deliver the top (anterior) shoulder under the pubic bone.
- Then lift gently upward to deliver the bottom (posterior) shoulder over the perineum.
- The rest of the wet, slippery body will slide out easily. Place the baby directly onto the mother's belly or chest.

Immediate Care of the Newborn (The First Hour)

Note the exact time of delivery.
Clamp and cut the cord (if not already done). Tie it tightly with a clean ligature.
Ensure the airway is totally clear. A strong, lusty cry is excellent as it forces the baby's lungs to pop open and expand.
Dry the baby instantly to prevent heat loss. Wrap the baby in a sterile, warm towel.
Place the baby on the mother’s bare breast (skin-to-skin) to bond and start breastfeeding.
Calculate the APGAR score at 1 minute and again at 5 minutes.
Show the mother the baby’s face and sex.
Put a name tag on the baby's arm or leg showing the mother's name, sex, time, date, and weight.
Cover the mother with a blanket to keep her warm.

7. Possible Complications of the Second Stage

The second stage is high-pressure. If it takes too long or if the baby gets stuck, severe emergencies can occur. The midwife must be ready to identify and manage:

⚠️ Danger Signs & Complications

Deep Transverse Arrest: The baby's head gets completely stuck halfway turning inside the pelvis and refuses to rotate further.
Obstetrical Shock: The mother collapses due to overwhelming pain, severe bleeding, or extreme exhaustion.
Uterine Inertia: The uterus becomes entirely exhausted and the contractions become weak or stop completely.
Maternal Distress: The mother becomes dehydrated, feverish, panicked, and physically unable to continue.
Shoulder Dystocia: A terrifying emergency where the baby's head is born, but the shoulders get stuck behind the mother's pubic bone.
3rd-Degree Perineal Tear: The baby bursts out so fast or is so large that it tears the mother's vagina all the way down through the anal sphincter muscle (where stool comes out).
Amniotic Fluid Embolism: A rare but deadly event where the baby's water (amniotic fluid) is pushed backward into the mother's bloodstream, causing her heart and lungs to collapse.
Ruptured Uterus: The contractions are so violent, or the baby is so blocked, that the muscular wall of the uterus actually tears open.
Fetal Distress: The baby runs out of oxygen. The fetal heart rate drops dangerously low or the baby passes green stool (meconium) into the water.

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Home > Midwifery I > Domiciliary Care

Domiciliary Care in Midwifery

Domiciliary Care is specialized obstetric care given to promote the health and well-being of childbearing women and their families in their own homes. It covers the entire cycle: before conception, during pregnancy, during labour, and after delivery (including family planning).

Who can be a domiciliary midwife? Any midwife who has acquired practical experience of not less than two years and has fulfilled all the strict requirements of setting up a domiciliary home/practice.

1. Brief History of Domiciliary Midwifery Services

Throughout the ages, women have depended upon a skilled person, usually another woman, to be with them during childbirth.
In the United Kingdom, midwives' skills are increasingly valued, and they are urged to expand their roles in public health.
In Uganda (1960s): Midwives routinely looked after mothers in the home environment. They conducted antenatal care, delivered mothers in their own homes, and continued with postnatal care. This gave them the opportunity to provide health education to the entire family.
In Uganda (1970s): Political instability and insecurity forced midwives to stop delivering mothers at home. Instead, mothers were delivered safely in hospitals and maternity units. However, midwives continued to nurse mothers and babies at home during the postnatal period.
Today: The service continues and is heavily practiced by Private Midwives and student midwives undertaking their Diploma in Midwifery.

2. Types and Forms of Domiciliary Care

Domiciliary care can be organized in several ways depending on the midwife's decisions, the family's choice, the community's nature, and the availability of basic requirements.

Types of Domiciliary Care

Type One (Continuity of Care): The woman is completely cared for in her home throughout the antenatal, intrapartum (delivery), and postnatal periods. She only visits a hospital if a complication requires specialized gadgets. One midwife provides all the care.
Type Two (Community Integrated / Centralized Care): This is a mixed service. Antenatal care or delivery may occur in the hospital, while the puerperium (postnatal) period is managed at home. This is compulsory for student midwives during their training.
Independent Practitioner: The midwife works privately in the community. She may own a maternity center for part of the care and combine it with home visits. This is the most common type in Uganda.
Midwifery Autonomy / Medicalized Approaches: The midwife acts as part of a team in a health setting but maintains a high level of autonomy over her practice in the community, under professional control.

3. Objectives and Advantages

Objectives of Domiciliary Care

To take midwifery services near to the community, drastically increasing accessibility.
To encourage full participation and involvement of male partners and family members for maximum support.
To reduce maternal and infant morbidity/mortality, as the midwife has a lesser workload and concentrates on one woman.
To reduce severe overcrowding in hospitals and health facilities.
To promote a strong midwife-mother relationship and mutual understanding.

Advantages of Domiciliary Services

Minimizes fears and phobias of childbirth by keeping the mother in a familiar environment.
Promotes strict continuity of care and close supervision.
Highly cost-effective because only relevant, tailored care is given.
Allows the mother to continue her household responsibilities and supervision without disruption.
Provides complete peace of mind to the mother, husband, and children because they remain together.
Ensures privacy, security, and respect with much less interference and physical exposure.
Promotes autonomy, creativity, and job satisfaction for the independent midwife.

4. Advantages and Disadvantages of Early Discharge

In modern settings, mothers often deliver in the hospital and are discharged early to be cared for at home by a domiciliary midwife.

Advantages of Early Discharge	Disadvantages of Early Discharge
Encourages more mothers to deliver in the hospital initially.	The mother may be discharged before lactation (breastfeeding) is well established.
Leaves more hospital beds available for high-risk cases and emergencies.	Household duties and other children will take up the mother's time, preventing adequate rest.
The mother is more relaxed at home, making it easier to establish a good nurse-patient relationship.	Poor sanitary facilities in some homes may predispose the mother and baby to dangerous infections.
Significantly reduces the risk of acquiring hospital-acquired infections.	Puerperal complications (like secondary PPH or sepsis) may not be diagnosed early enough.
The midwife assesses the actual home condition, so advice on diet, hygiene, and rest is highly relevant.

5. Selection of Mothers (Risk Groups)

A midwife cannot safely deliver every mother at home. Mothers must be assessed and placed into one of three risk categories:

Group 1: Low Risk: Para 2 to 4. Women who have delivered at least one baby but not more than five. If they have no history of major complications, they can be cared for in the community throughout pregnancy, labour, and puerperium.
Group 2: Suspected Risk: Primigravida (1st pregnancy), Grand multipara (more than 4 deliveries), short stature (less than 152cm), or a history of previous complications (e.g., cord prolapse). These mothers are only managed at home for antenatal or puerperium, but must deliver in a hospital.
Group 3: High Risk: Mothers with obvious complications (e.g., multiple pregnancy) or underlying medical conditions like cardiac disease, diabetes mellitus, or sickle cell disease. Must be referred immediately to a well-equipped Health Centre IV or Hospital.

6. How Domiciliary is Carried Out

Booking Criteria & Home Delivery Requirements

A mother booked for a home delivery must have no risk factors (no CPD, no multiple pregnancy). The midwife must inspect the home to ensure it meets strict safety standards:

Housing: Well-ventilated, no overcrowding, highly hygienic. Must have more than 4 rooms (bedrooms, toilet, kitchen) and a cemented floor.
Utilities: Must have tap water and an easy means of boiling water for sterilization.
Distance: The home must be less than 2 miles away from a referral hospital in case of an emergency.
Consent: Both husband and wife must willingly agree to the care.

Domiciliary Midwifery Kit — A fully stocked, sterile domiciliary kit is essential for safe home practice.

7. Equipment for Domiciliary Care (The Kit)

The midwife must carry a light metal kit or a suitable bag containing specific, sterile items for the mother, the baby, and herself.

For the Mother

Sterile bowl and gallipot.
Sterile cotton wool for swabbing the vulva and perineum.
An antiseptic lotion (such as Savlon or Dettol).
A sterile urinary catheter.
An antiseptic drying agent (such as mercurochrome) for sutured perineums.
A clinical thermometer, pulsometer (or a watch with a second hand), and a tape measure.
Syringes, needles, and ampoules of Oxytocin.
Plastic bags for the disposal of used swabs.
Basic treatments for minor complaints (e.g., Antibiotics, Paracetamol, Antimalarials, Ferrous sulphate, Folic acid).

For the Baby

Sterile cotton swabs specifically for the baby's eyes.
Mucus extractor (for clearing the airway).
Baby's weighing scales and a clean towel.
A separate baby thermometer.
An ampoule of Vitamin K.

For the Midwife & Delivery

Plastic apron, sterile gloves.
Bowl for water, soap, towel, and a nail brush for scrubbing.
Fetal scope (Pinard horn).
Sterile scissors and two artery forceps.

What the Mother Must Provide: A basin and towel for bathing the baby, clean soap and warm water, and clean baby clothes.

⚠️ Attention: Care of the Domiciliary Kit

The equipment must be checked and restocked daily. Metal kits must be emptied, cleaned, and boiled daily. All used equipment must be washed and sterilized daily upon returning to the hospital. If the midwife visits an infectious patient, ALL contents and the bag itself must be fully sterilized on return.

8. Roles of the Midwife & The Daily Visit

The midwife is responsible for comprehensive care across the reproductive cycle. Her roles involve highly detailed assessments of both the mother and the newborn.

General Roles During Domiciliary Care

Care Before Conception: Health education on nutrition/hygiene, life skills, giving tetanus toxoid, and counseling adolescents.
Care During Pregnancy: Immunizations, antenatal check-ups, treating minor problems, and educating on danger signs.
Care During Labour: Monitoring via partograph, delivering the baby, and maintaining strict infection prevention.
General Postnatal Roles: Checks vitals (BP, pulse, temp, respiration). Notes uterine involution, inspects lochia and perineum. Examines breasts and legs. Instructs on diet, personal hygiene, and vulval swabbing. Gives iron/folic acid. Re-emphasizes the importance of the 6-week postnatal clinic and Young Child Clinic (YCC) attendance.

The Postnatal Daily Visit Routine

During the puerperium, the midwife visits daily. If complications arise, she makes additional visits. The daily routine includes:

Assessment of the Mother

History & Coping: Ask how she is feeling, sleeping, and eating. Ask if she is passing urine and stool normally. Ask how she is coping with the baby, if breast milk is adequate, and if breastfeeding is satisfactory. Sit, listen, and respond to her anxieties.
Vital Signs: Check temperature, pulse, BP, respiration, and look for any signs of pallor (anemia).
Breast Examination: Examine for signs of severe engorgement, cracked nipples, or sore nipples. Give immediate advice on breast care and feeding techniques.
Abdominal & Pelvic Check: Have the mother completely empty her bladder. Palpate the lower abdomen for tenderness and measure the fundal height to accurately assess uterine involution.
Perineal Check: Check the lochia and perineum for proper healing, signs of infection, oedema, or breaking down of stitches. Encourage strict hygiene and correct self-vulval swabbing.
Leg Examination: Examine the legs (calves) for any tenderness or swelling to rule out deep vein thrombosis (DVT). Encourage early ambulation and postnatal exercises.

Assessment of the Baby

General Observation: Observe the baby's overall color, respirations, cry, and movements.
Infection Check: Look very closely for any signs of infection in the eyes, skin, mouth, and specifically the umbilical cord.
Physical Care: Help the mother with bathing the baby and supervise her for the first few days. Check the baby's temperature and weight.
Feeding & Elimination: Inquire if the baby is feeding well, sleeping properly, and passing normal stool and urine. Encourage exclusive breastfeeding.
Immunization: Inspect the BCG site and give advice accordingly.

9. Qualities of a Domiciliary Midwife

Because the midwife is operating outside a hospital, her professional behavior must be impeccable.

She must remember that she does not belong to the family; she is only a guest. She must adapt her behavior to respect the family's routine.
No commands or orders should be given—only professional, persuasive advice. She must be highly flexible.
She must create a friendly, trusting relationship but maintain strict professional boundaries.
Avoid embarrassing the mother in front of the family.
She must have the ability to make quick, correct judgments independently in the event of an emergency.

💡 Quick Practice Check

Question: During a daily postnatal home visit, the midwife palpates the mother's abdomen but notices the uterus is displaced to the right and higher than expected. What must the midwife ask the mother to do before re-assessing?

Answer: Empty her bladder. A full bladder will displace the uterus and make it impossible to accurately assess uterine involution or tenderness.

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Home > Midwifery I > The Partograph & 1st Stage of Labour

The Partograph & Management of 1st Stage of Labour

Overview: The Partograph is a highly visual, life-saving graph used by midwives to monitor the mother, the baby, and the progress of labor during the active first stage. By plotting findings on this graph, a midwife can easily detect if labor is abnormal, serving as an "early warning system" to prevent prolonged labor, fetal distress, or maternal exhaustion.

1. Introduction to the Partograph

A partograph is a graphical tool used strictly during the active first stage of labor. It is used to record important (salient) conditions of both the mother and the fetus to quickly detect any abnormalities so that immediate action can be taken.

Uses of a Partograph

Detect Abnormal Progress: It helps the midwife quickly see if labor is not progressing or moving forward normally.
Indicate Need for Augmentation: It shows exactly when it is appropriate to speed up (augment) labor using drugs like Oxytocin.
Recognize CPD: It helps recognize Cephalopelvic Disproportion (CPD) when an obstruction occurs (meaning the baby's head is too big for the mother's pelvis).
Improve Observation Quality: It increases the quality and accuracy of all observations made on the mother and fetus.
Early Warning System: It serves as a strict visual alarm system for complications.
Decision Making: It assists midwives in making early decisions to transfer the mother to a higher-level hospital or to assist the labor.

Who Should NOT Use a Partograph?

The partograph is for normal, active vaginal labor. It should not be used for:

Women with major problems identified before or during labor who need special, constant doctor attention (e.g., severe bleeding, severe pre-eclampsia).
Women who are not planning to have a vaginal delivery (e.g., those scheduled for an elective Caesarean Section).

A Standard Partograph for Monitoring Labor — The Partograph: A complete visual tool for monitoring fetal condition, labor progress, and maternal condition.

2. Starting the Partograph

The partograph must only be started when the woman enters the Active Phase of Labour. You know she is in the active phase when:

Her cervical dilatation is 4cm or more.
She is having 1 or more true contractions in 10 minutes.

The 3 Main Parts of a Partograph

Every standard partograph is divided into three distinct sections that must be closely monitored:

1. Fetal Condition Part: Monitors the baby's wellbeing.
2. Labour Progress Part: Monitors how fast the cervix is opening and the baby is dropping.
3. Maternal Condition Part: Monitors the mother's vital signs and strength.

3. Monitoring the Fetal Condition

This section is purely to ensure the baby is surviving the stress of labor contractions safely.

Fetal Heart Rate (FHR): Taken every ½ hour (30 minutes). The normal FHR is 120-160 beats per minute. If it is below 120 or above 160, it indicates fetal distress. If it is abnormal, you must check it more frequently (every 15 minutes). If it remains abnormal over 3 observations, you must take immediate action.

Moulding of the Fetal Skull (Checked 4-hourly)

Moulding is the normal overlapping of the baby's skull bones to allow the head to fit through the narrow birth canal. It is felt during a Vaginal Examination (VE) and plotted using specific grades:

State of Moulding	Record Symbol	Midwife Interpretation
Absence of moulding	(-)	Normal. The head fits easily.
Bones separate, sutures felt	(0)	Normal. Bones are not touching yet.
Bones just touching	(+)	Normal moulding has started.
Bones overlapping but separable	(++)	Moderate. The bones can still be pushed apart with a finger.
Bones overlapping, inseparable	(+++)	Danger (Severe Moulding). Indicates the baby's head is completely stuck (CPD).

State of Liquor Amnii & Membranes (Checked 4-hourly)

When the bag of waters (membranes) breaks either naturally (spontaneously) or by the midwife (artificially), the water (liquor) is observed.

State of Liquor (Water)	Record Symbol	State of Membranes	Record Symbol
Clear (Normal)	(C)	Membranes Intact	(I)
Light green (Meconium stained)	(m+)	Membranes Ruptured	(R)
Moderate green, more slippery	(m++)
Thick green, heavily stained	(m+++)
Blood stained	(B)

*Note: Meconium is the baby's first stool. If the baby passes it inside the womb (green liquor), it is a major sign that the baby is struggling to breathe or is in distress.

4. Monitoring Labour Progress

This section tracks the physical work of labor: the cervix opening, the baby dropping, and the uterus squeezing.

Cervical Dilatation (Checked 4-hourly): Measured in centimeters. It is plotted with an "X" on the graph. A vaginal examination is done on admission and once every 4 hours. Recording starts exactly at 4cm.

⚠️ The Alert and Action Lines

Alert Line: Starts at 4cm and goes diagonally upward at a rate of 1cm per hour. If the plotted "X" crosses to the right of this line, it is an alert that labor is slowing down.
Action Line: Drawn parallel to the Alert line, exactly 4 hours to the right of it. If the plot reaches this line, medical action (like a C-Section or giving Oxytocin) MUST be taken immediately.

Descent of Presenting Part (Checked 2-hourly): Checked by feeling the mother's abdomen (abdominal palpation). It is measured in "fifths" above the pelvic brim using the width of the midwife's five fingers. It is plotted with an "O" on the graph.
- If the head is loose (ballotable) above the brim, it accommodates all 5 fingers (5/5).
- As the head drops down (descends), fewer fingers can feel it above the pelvic bone.
- The head is considered fully engaged when only 2 or fewer fingers can feel it above the brim (2/5 or less).
Uterine Contractions (Checked every 30 mins): The midwife must feel the mother's belly for exactly 10 minutes to count how many contractions happen, how long they last (duration), and how strong they are.
- Mild: Lasts for less than 20 seconds. (Plotted using Dots).
- Moderate: Lasts for 20-40 seconds. (Plotted using Diagonal lines).
- Strong: Lasts for 40 seconds or more. (Plotted using full Dark Shading).

5. Monitoring the Maternal Condition

The mother works extremely hard during labor. Her physical signs must be tracked to ensure she does not collapse from exhaustion or infection.

Pulse (Every 30 mins): Normal is 70-90 beats/min. A raised pulse may indicate maternal distress, bleeding, or infection (especially if her waters broke 8-12 hours ago). A very low pulse can mean the mother is collapsing.
Blood Pressure (Every 2 hours): Normal is between 90/60 and 140/90 mmHg. If the top number (systolic) rises by 30 or the bottom (diastolic) rises by 20 above her normal, or stays high for 3 readings, test her urine for albumen to check for dangerous Pre-Eclampsia.
Temperature (Every 4 hours): Normal is 37.2°C to 37.5°C. A high fever means infection, dehydration, or maternal distress, especially common if the membranes ruptured very early.
Urine (Every 2 hours): The mother should pass urine at least every 2 hours. Test the urine on admission for Volume, Acetone (shows starvation/dehydration), Proteins (shows Pre-Eclampsia), and Sugars (shows Diabetes).
Fluids and Drugs: Record any IV fluids given (2-hourly), the Oxytocin regimen (if used to speed up labor), and any pain drugs given. The mother should be encouraged to drink 250-300 mls of sweetened fluid every 30 minutes to keep her energy up (no alcohol).

6. Further Management in the Normal 1st Stage of Labour

Proper nursing care is critical during the active first stage to keep the mother comfortable, safe, and progressing normally.

Comprehensive Nursing Care

1. Emotional Support & Pain Relief: The midwife should rub the mother's lower back to relieve contraction pain. Keep the mother reassured and constantly informed about her progress to reduce fear and anxiety. Allow her to move around, talk to her relatives or husband, or do light activities like reading or knitting.
2. Nutrition: Labor burns massive amounts of energy. Encourage the mother to take light, easily digested foods like bread, soup, and warm sweet tea. This prevents dehydration and gives the uterine muscles the energy they need to contract strongly. Heavy foods should be avoided as the stomach empties very slowly during labor.
3. Elimination (Bladder and Bowel Care): A full bladder blocks the baby's head from dropping down. Encourage the mother to urinate every 2 hours. Every single urine sample is measured and tested for acetone, albumen, and sugars, and the results are recorded. If the mother absolutely cannot pass urine herself, the midwife must carefully pass a catheter to empty it.
4. Personal Hygiene: Allow the mother to take a warm bath in early labor to relax. Once her waters (membranes) rupture, give her a clean sanitary pad and ask her to change it frequently to stop bacteria from entering. Vaginal examinations (VE) must strictly be done using sterile, aseptic techniques.
5. Ambulation (Walking) and Position: In early labor, encourage the mother to walk around. Gravity helps the baby's head drop down (descent). During strong pains, ask her to lean forward on a chair or the bed to reduce back discomfort. She can choose any comfortable position except the flat supine (flat on her back) position, which drops her blood pressure. Once the membranes rapture deeply into advanced labor, she should stay in bed.
6. Prevention of Infections: Strict cleanliness (aseptic technique) must be maintained when checking the cervix or swabbing the vulva. If the waters break early, clean the vulva every 4 hours. The doctor may start antibiotics to stop bacteria from traveling up to the baby (ascending infection). Wash the mother with a sponge and change dirty bed sheets to keep her comfortable. The midwife must always wash her hands before and after touching the mother.
7. Sleep and Rest: Labor is exhausting. Strongly encourage the mother to rest, close her eyes, and breathe deeply in between the contractions to save her energy for the final pushing stage.

7. What to Report (Danger Signs)

The midwife must immediately report any of the following warning signs to the doctor in charge:

Any abnormal substances found in the urine (high protein, high acetone).
Total failure of the mother to pass urine.
A sudden spike in the mother's temperature, pulse, or blood pressure.
Hypertonic uterine contractions (contractions that are too strong, too long, and never give the uterus time to rest).
Membranes rapturing with thick, meconium-stained liquor (Grade 2 and Grade 3).
Failure of the baby's head to drop down (descend) even though the mother has strong, good contractions.
Severe, constant tenderness over the abdomen (warning sign of a tearing uterus).
Fresh bleeding from the vagina (Bleeding per vagina).
A sudden, dangerous drop in blood pressure (Fall in BP).
A highly raised or severely dropped fetal heart rate.

Complications of the 1st Stage of Labour

If the first stage is not managed well, the following severe complications can arise:

Complication	Brief Explanation (Extra Midwifery Detail)
Infections	Bacteria entering the open cervix, especially if membranes ruptured hours ago.
Early Rupture of Membranes	The water breaking way before the cervix is fully open, risking infection.
Cord Prolapse	The umbilical cord slips out of the cervix before the baby, cutting off the baby's oxygen.
Supine Hypotensive Syndrome	Mother's blood pressure crashes because she is lying flat on her back.
Fetal Distress	The baby is running out of oxygen, shown by abnormal heart rate and green liquor.
Maternal Distress	The mother is totally exhausted, dehydrated, and has a high pulse/fever.
APH (Antepartum Haemorrhage)	Severe bleeding before the baby is born (e.g., placenta separating early).
PET and Eclampsia	Extremely high blood pressure leading to dangerous maternal seizures (fits).
Prolonged Labour	Labor taking much longer than normal, crossing the Partograph Alert Line.
Obstructed Labour	The baby physically cannot pass through the bones, crossing the Partograph Action Line.

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Midwifery

OVERVIEW OF ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

EXTERNAL GENITALIA

Functions of the Vulva

Scenario for Practical

INTERNAL GENITALIA

Contents of the Vagina:

Clinical procedure

Cervix

Scenario for Practical Procedure:

Female Reproductive Quiz

Female Reproductive Quiz

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THE FETAL SKULL

Bones of the Vault of the Fetal Skull:

Regions of the Fetal Skull:

SUTURES

FONTANELS

Diameters of the Fetal Skull:

Transverse Diameters

ATTITUDE OF THE FETAL HEAD

Presenting/Engaging Diameters in Different Presentations:

Examination of the Parts of the Fetal Skull

MOULDING

Types of Molding:

Examining the Baby’s Head: A Clinical Procedure

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Fetal Skull Quiz

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Normal Puerperium

Physiological Changes in the Endocrine System

Changes in the Reproductive System

1. Uterus

The Four Processes of Uterine Involution

Other Factors Assisting Involution:

Progression of Changes in the Uterus After Delivery

2. Vulva and Cervix

3. Lochia

🧠 Memory Aid for Lochia Stages

4. Vagina and Breasts

Other Systemic Changes

Disorders of Puerperium and Relief Measures

1. Afterbirth Pains

2. Excessive Perspiration

3. Breast Engorgement

4. Perineal (Stitch) Pain

5. Constipation

6. Hemorrhoids

POSTNATAL EXAMINATION

🧠 The BUBBLE-HE Assessment Reminder

Requirements for Examination

General Assessment Procedure:

Bimanual Pelvic Examination and Speculum Vaginal Examination

Speculum Examination:

Bimanual Examination:

Other Assessments:

TRANSFER OR REFERRAL OF MOTHERS

Purposes of Referring:

Types of Transfer:

Preliminary Assessment:

Requirements for Transfer:

Procedure for Transfer of a Mother to Another Hospital or Department:

📋 REFERRAL NOTE

Postnatal Exercises

💡 Quick Practice Check

Puerperium Physiology Quiz

Puerperium Physiology Quiz

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Normal Puerperium

1. Phases, Principles, and Aims of Puerperium

The Three Phases of Puerperium

Principles of Management

Aims of Management

2. Management in the 1st Hour (Fourth Stage of Labor)

Evaluation of the Uterus

Inspection of the Perineum, Vagina, and Cervix

Inspection of the Placenta and Post-Delivery Care