TERMS USED IN REPRODUCTIVE HEALTH FOR NURSES

1. Antenatal: Before birth

2. Antenatal clinic: a special clinic where pregnant mothers attain health care.
3. Amenorrhea: Absence of menstruation/period.
4. Braxton Hicks: Contractions that occur before real labour. Also known as
prodromal labour, false labour, practice contractions.
5. Cephalic: means head.
6. Cervix: is the neck of the uterus.
7. Cervical dilatation: this is the stretching of the neck of the uterus.
8. Chadwicks Sign: Bluish discoloration on cervix, vagina, or labia resulting
from increased blood flow. An early sign of pregnancy. May be observed as
early as 6-8 weeks.
9. Colostrum: is the first secretion from the breast before the true milk (during the
1st 3 days of puerperium) It is high in carbohydrates, protein, and antibodies.
Great for baby.
10.Conception: This is the fusion of the ovum and spermatozoa or the start of
pregnancy when the male germ cell fertilizes the female germ cell.
11.Conjugate: this refers to the antero-posterior diameter of the pelvic brim.
12.Crowning: This is when the presenting part passes the bony pelvis and does not
recede between contractions.
13.Contraction: Temporary shortening of the muscle fibres of the uterus.
14.Dyspareunia: painful or difficult sexual intercourse experienced by a woman.
15.Duration: this is the length of time. A pregnancy which has completed a
normal duration of 40 weeks is called full term.
16.EDD: Estimated Delivery Date
17. Embryo: The fertilized ovum within the uterus up to the eighth week of
development.
18.Engagement of the head: is the largest diameter of the fetal skull that has to
pass through the pelvic brim.
19.Episiotomy: is an incision made into the thinned out perineum or perineal body
to enlarge the birth canal or outlet for the passage of the baby.
20.Fetus: Products of conception from the eighth week of development to birth.
21.Fontanelle: is an area of membrane at a junction of suture line in a fetal skull.
22.Fore water: is the liquor amnii below the presenting part of the fetus.

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23.Full dilatation of the cervix: is when the cervix has completely been drawn up
into the lower segment of the uterus and is no longer felt on vaginal
examination.
24.First stage of labour: this is the period from onset of true labour until full
dilation of the cervix.
25.Fresh still birth: is the fetus that dies in the utero after 28 weeks of pregnancy
within 24 hours.
26.Gestation: means pregnancy.
27.Gravid: This refers to pregnancy
28.Grand mult gravid: A woman who is gravid five or more.
29.Grand Mult Para: A woman who has delivered five babies or more
30.Health: This is a state of a complete Wellbeing of an individual physically,
socially, mentally, psychologically and not merely absence of disease or
infirmity.
31.Hind waters: this is liqour amnii behind the present part
32.Hyperemesis Gravidarum : Extreme, persistent nausea and vomiting during
pregnancy

33.Hysterectomy: this is the surgical removal of the uterus either through an

incision in the abdominal wall or through the vagina.

34.Involution: Is the natural process by which the uterus returns to its pre-gravid
state.
35.Intra partum hemorrhage: Bleeding which occurs during delivery e.g. after
delivery of the 1st baby in twin delivery.
36.Labour: Is the process by which products of conception are expelled from the
uterus after 28weeks of pregnancy.
37.Lightening: this is the sinking of the gravid uterus into the pelvis.
38.Lochia: Is the normal discharge from the uterus following birth or abortion.
39.Linea Nigra: A dark vertical line that appears on the abdomen/belly in a
pregnant female. Very common. Also known as the pregnancy line.
40.Liquor Amnii: this is the fluid contained in the amniotic membrane in which
the baby floats.
41.Low birth weight: This describes both the pre-term and small for dates or light
for dates baby.
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42.Lower segment of the uterus: is the lower part of the uterus and cervix that
stretches and thins out during the 1st and 2nd stage of labour.
43.Lying in period: Is the period after delivery during which the mother is directly
under the care of a midwife (14 days).
44.Macerated still birth: is the fetus that has died in the utero for more than 24
hours. The tissue softens and the skin peels off.
45.Malpresentation: is any presentation deviating from the normal which is
cephalic presentation e.g. breech presentation.
46.Maternal : Means Mother.
47.Mechanism of labour: a series of movements made by the fetus in order to
negotiate the various diameters and curves of the pelvis.
48.Meconium: is the first stool passed by the baby within the first 72 hours of life
and normally it is dark green in colour and odorless.
49.Menarche: This is the initial onset of menstruation where the reproductive
organs become functionally active and may take place at any time between 10-
19 years of age.
50.Menstruation: This is the normal monthly discharge of blood and fragments of
the endometrium from the uterus through the vagina beginning at puberty until
menopause.
51.Moulding: is the normal alteration/ change in the shape of the fetal skull during
its passage through the pelvis.
52.Multi gravid: A woman who has been pregnant more than once.
53.Mult para: A woman who has had more than one delivery.
54.Neonate: A new born up to 28 days of life.
55.Nullipara: A woman who has never given birth to a viable fetus.
56.OS: Is an opening.
57.Ovum: this is a mature female sex cell.
58.Ovulation: This is the process by which an ovum is released from a mature
graafian follicle or the release of an ovum from the ovary.
59.Puerperium
The time from 3rd stage of labour up to 6weeks when the reproductive organs attain
their pre gravid state.
60.Parity : Number of deliveries
61.Parturition: Is the time of giving birth to the baby
62.Postnatal: After birth
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63.Postnatal clinic: a clinic attended by mothers six weeks after delivery
64.Parity: is the number of deliveries a mother has had after 28 weeks of
pregnancy whether alive or dead.
 A gravida 2para1+0 means a woman who is pregnant for the second
time and the first baby was viable.
 Gravida 2para0+1 means a woman pregnant for the second time but
the first pregnancy was not viable.
 Gravida 2para2+0 means a woman who is pregnant for the second
time but the first pregnancy were viable twins.

65.Para: birth of a baby after 28 weeks of pregnancy whether dead or alive.

66.Post-partum hemorrhage: Excessive bleeding from the birth canal after
delivery of the baby amounting 500mls or more or any amount that can
deteriorate the mother’s condition up to 6-8 wks.
67.Placenta/ after birth: is an organ or gland through which the fetus in the utero
gets its nutrients.
68.Postnatal: after delivery
69.Prime gravid: A woman who is pregnant for the first time.
70.Prime para: A woman who has given birth for the first time
71.Pre-term: is a baby born after28 weeks but before 37 completed weeks of
gestation and showing signs of prematurity.
72.Prenatal: before delivery
73.Pre conception: before conception
74.Puerperium: Is the period following labour or abortion up to 6-8 weeks after
delivery when the internal and external organs return to their pre-gravid state.
75.Quickening: this is the first movement of a fetus in the uterus that is felt by the
mother usually after about 16 weeks of pregnancy.
76.Rotation: is the turning of a baby on its long axis.
77.Spermatozoa: This is a mature male sex cell.
78.Still birth: a baby born after 28 weeks of pregnancy without showing any sign
of life
79.Striae : Stretch marks
80.Second stage labour: begins from full dilation of the cervix until when the
fetus is expelled.
81.Show: this is a bloody mucoid discharge at the onset of true labour.
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82.Trimester: is a period of 3 months. The period of 9 months is divided into 3
trimesters
83.Upper uterine segment: is part of the uterus above the lower segment which
contract strongly and progressively retracts in labour.
84.Vernix caseosa: this is a greasy cheesy like material found covering the skin of
the fetus and it is slippery.
85.Zygote: This is the fertilized ovum before it embeds or before cleavage begins.
86.Lie: This is the relationship of the long axis of the fetus to the long axis of the
uterus. Normally longitudinal- cephalic
-Abnormal-transverse and Oblique
113. Attitude: Is the relationship of the fetal head and limbs to its trunk.
Normally it should be of complete flexion which leads to normal vertex
presentation.
 Deflexion (military attitude leading to occipital posterior
position)
 Partial extension (head slightly extended leading to brow
presentation)
 Extension (leads to face presentation)
114. Presentation: Part of the fetus which lies in the lower pole of the uterus
and nearer to the pelvic brim normally the head (cephalic).
 Breech-buttocks
 Face- mentum or chin
 Shoulder-acromial process
 Brow presentation- sinciput
115. Denominator: Part of the presentation which determines the position of
the fetus or it is that part which points to a given part of the mother’s
pelvis E.g.
-Cephalic presentation-occiput
-Face presentation- mentum
-Breech presentation- sacrum
-Shoulder presentation-Acromial process
-Brow presentation-sinciput
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116. Position: Is the relationship of the denominator to one of the 6 areas of the
pelvic brim which are; LOP, ROA,ROL, LOL,ROP,LOA e.g.
 In cephalic the denominator is the occiput if is on the right illio pectineal
eminence the position is ROA. This means the illio pectineal eminence
determines the anterior positions.
 In breech the denominator is the sacrum and if it is on the left sacral iliac
join then the position is LSP. The sacral iliac joint determines the posterior
positions whether right or left.
 In face the denominator is the chin and if it points on the right ilio pectineal
line the position will be RML. The ilio pectineal line determines the lateral
positions.
Left Occipital Anterior (LOA)
This is the normal position where the occiput points to the ilio pectineal eminence
on the left part of the pelvic brim. The sagittal suture is in the left oblique
diamenter of the pelvic brim.
Right Occipital Anterior (ROA)
The occiput points to the ilio pectineal eminence on the right part of the pelvic
brim and the sagittal suture is in the right oblique diameter of the pelvic brim.
Right Occipital Posterior (ROP)
The occiput points to the right sacro-iliac joint in the posterior area of the pelvic
brim and the sagittal suture is in the right oblique diameter of the pelvic brim.
Left Occipital Posterior (LOP)
The occiput points to the left sacro-iliac joint in the left posterior area of the pelvic
brim. The sagittal suture is in the left oblique diameter of the pelvic brim.
NB: Occiputal posterior is an abnormal position and is called malposition.
Right Occipital Lateral (ROL)
The occiput points to the right side of the pelvic brim midway between the right
ilio pectineal eminence and the right sacro iliac joint. The sagittal suture is in
transverse diameter of the brim.
Left Occipital Lateral (LOL)

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The occiput points out to the left side of the pelvic brim midway between the left
ilio pectineal eminence and the left sacro iliac joint and the sagittal suture is in the
transverse diameter of the brim.
NB: in breech presentation, the position is determined by the sacrum which points
to one of the areas of the pelvic brim.
Positions in breech presentation include;
Left sacro anterior (LSA)
Right sacro anterior (RSA)
Right sacro posterior (RSP)
Left sacro posterior (LSP)
Right sacro lateral (RSL)
Left sacro lateral (LSL)

Face presentation
They are as follows;
Left mento anterior (LMA)
Right mento anterior (RMA)
Right mento posterior (RMP)
Left mento posterior (LMP)
Right mento lateral (RML)
Left mento lateral (LML)
NB:
Anterior position are more favorable than posterior position because when the fetal
back is in the front, it occupies the soft parts of the mother’s abdominal wall and
can therefore flex better.
Anterior positions are also common because there is more room in anterior part of
the pelvis for broad bi-parietal diameter of the head.

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ANTENATAL CARE

This is a planned, methodical care given to a pregnant mother from the time
conception is confirmed until the beginning of labour.

FOCUSED ANTENATAL CARE

Definition

It is personalised care provided to a pregnant woman which emphasises her overall

health, preparation for child birth and readiness for complications that may occur
during pregnancy, labour and puerperium.

GOAL OF FANC

To achieve a good outcome for the mother and baby by preventing, identifying and
appropriately treating complications that may occur in pregnancy / have an effect
in labour, delivery and post-partum.

NOTE

 A pregnant woman should receive at least four thorough Comprehensive,

personalised antenatal visits, spread out during the entire pregnancy (WHO).
 Always view each visit as if it were the only visit the woman may make
(Just in case she does not comeback) many women cannot make four visits.

Four comprehensive, personalised Antenatal visits

1st visit: As soon as a woman thinks she is pregnant to 16 weeks.

2nd visit: 16-28 weeks
3rd visit: 28-32 weeks
4th visit: 32-40 weeks

Objectives of FANC

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 Early detection and treatment of problems
Prevention of complications using safe, simple and cost- effective
interventions
Birth preparedness and complication readiness
Health promotion using health messages and counselling
Provision of care by skilled attendant

1. Early detection and treatment of problems

Service providers should identify existing medical, surgical or obstetrical

conditions during pregnancy such as;
 Severe anaemia (Hb< 7gm/dl)
 Vaginal bleeding (early and late)
 Pre- eclampsia (increased BP, severe Oedema)
 Infections STIS HIV and AIDS, TB, Malaria
 Chronic diseases (Diabetes, Heart or Kidney problems)
 Decreased / absent fetal movements
 Fetal malpresentation after 36 weeks
 Previous operations

2. Prevention of complications by

Immunisation of Tetanus to prevent maternal and neonatal tetanus

Administration of haematenics like Iron/Folate to prevent anaemia
Provision of intermittent preventive treatment of malaria Directly
observed therapy (DOT)
ITN to prevent malaria
Anti-helmenthics like Mebendazole to prevent hook worms
Safer sex practices to prevent STIs, HIV
Administration of ARVS for EMTCT of HIV infection

9
3. Birth preparedness and complication readiness

A. The mother and her family should know the following (Birth
preparedness)

 Date of delivery
 Intended place of delivery
 Skilled attendant
 Transportation
 Adequate funds
 Birth companion (should be welcomed in the clinic and during
labour)
 Requirement for clean and safe delivery and for the new-born
 Blood donor

B. Complication readiness (Emergency plan)

 Knowledge of danger signs (what to be done when they arise)

 Decision making in case of emergency
 Have / arrange for transport in case of emergency

4. Health promotion and counselling

A. Health promotion

 Nutrition
 Rest and hygiene
 Safer sex
 Care of common discomforts
 Use of ITN and IPT
 Avoidance of alcohol and smoking
 Immunization

10
Why Disease Detection & Not Risk Assessment?-I
Every pregnancy is at risk!
 Risk factors cannot predict complications: (e.g. young age alone does not
accurately predict eclampsia.).
 Research showed that the majority of women who experienced
complications were considered low risk and many women designated high
risk have normal pregnancies and childbirth.
 Risk approach is not an efficient or effective strategy for maternal mortality
reduction.

Therefore EVERY PREGNANT woman should be prepared for the

possibility of complications.
THE ANTENATAL CARE CARD
-We shall refer to our national ANC as a guide to the information that you should
gather at each of the 4 antenatal visits.
-At the beginning of each visit, ask the mother if she has developed any danger
symptoms since her checkup.
-Remind her to come to you quickly if she develops vaginal bleeding, blurred
vision, abdominal pain, fever or any other danger symptoms.
OBJECTIVES AND PROCEDURES AT EACH FANC VISIT
History taking (First visit):
 Current complaints/identity danger signs
 Tetanus vaccination status
 Reproductive, medical, surgical, family, social and history
 Interim history( return visit)
Physical exam:
 Physical assessment of general health-first visit and as needed in return
visits.
 Genital inspection, including sexually transmitted infections-first visit and as
needed in return visits.
 Check fundal height after 22 weeks.

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  Proteinuria if available to rule out pre-eclampsia
 Check for anemia at first visit and necessary.
 Check blood pressure at every visit.

During FANC visits, the following must be accomplished-II

Provision of:
 Iron, folate,
 IPT,
 Tetanus toxoid
 Mebendazole
 ARV if indicated
Counseling on:
Danger signs,
Individual birth plan (IBP)
Complication readiness
Nutrition, breast feeding, family planning, safer sex, hygiene, etc.
E MTCT core intervention:
 HIV testing and counseling
 ARV prophylaxis and treatment
 Safe delivery practices
Return date

During FANC visits, the following must be accomplished-III

Laboratory investigations:
Most of the lab work should be done during the first visit.
 Hb, Grouping &Rhesus factor
 HIV
 VDRL/RPR,
 Hepatitis B( if indicated)

NOTE
-Advise her and her partner to save money in case you need to refer her, especially
if there is an emergency requiring transport to a healthy facility.
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-Provide specific answer to the woman’s questions or concerns, or those of her
partner.
THE SECOND FANC VISIT
-Follow the procedures already described for the first visit.
- Screen abnormalities
-Review and if necessary modify her individualized care plan.
THE THIRD FANC VISIT
-The objectives are the same as above. In addiction you should:
-Direct special attention towards signs of multiple pregnancies and refer if you
suspect there is more than one fetus.
-Review the birth preparedness and the complication readiness plan
-Decide on the need for referral based on your updated risk assessment.
-Give on family planning
THE FOURTH FANC VISIT (To prepare mother for child birth)
- You should cover all the activities described for the 3rd visit. In addition:
- The abdominal examination should confirm fetal lie and presentation.
- The individual birth plan should be reviewed to check that it covers all
aspects of birth preparedness, complication readiness and emergency
planning.
- Provide the woman with advice on signs of normal labor and pregnancy –
related emergencies and how to deal with them, including where she should
go for assistance.
Individual Birth Plan (IBP)
Individual Birth Plan (IBP) is the preparation/ plan that a family makes for the
expected baby with the service provider.
Importance of IBP
 15% of pregnant women develop life threatening complications requiring
specialized care.
 These women could die if:
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  Nobody is there to make timely- decisions at home and in the health
facility.
 No plans for referral or transport have been made.
 No plans on how to meet new financial demands are made.
IBP Checklist-I
Health worker should discuss with mother, preferably in presence of spouse
or person she lives with if acceptable to her.
 Whom do you live with?
 Who will accompany you to the health facility when labour starts?
 What means of transport will you use to come to the health facility?
 Who will you leave at home to look after your family while you are
away?
 Who will stay with you at the health facility during labour?
 Would you like us to place the after birth in our placenta pit or would
you like to take it home?

IBP Checklist-II
 Where will you deliver?
 Where you go in case of an emergency?
 Where is it located?
 How will you get there?
 How far is it from your home?
 How long will it take to get there?
 Have you made this journey before?
 How much will it cost to arrange for transport?
 How will you raise the funds for this transport?

IBP Checklist III

 What family planning method will you use after delivery before your
next pregnancy?
 Name of health workers with whom the birth plan has been
made……….

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 IBP Supplies checklist.

 Health worker should discuss supplies for the birth plan

 4 pairs of gloves
 Gauze: ( this is a special material for dressing that can be
bought from drug shop/pharmacy)
 Plastic sheet(ekiveera)
 Cotton wool
 Needles and syringes.
 Razor blade
 Personal effects
 Sanitary pads
 Baby clothing
 Money for emergency transport.
 Basin
 Soap
 Sugar and tea leaves
 Clean clothing for herself.
IBP: The Mama Kit
 New unused razor blade
 Thread or string
 Money/funds
Family members can help purchase the items in the mother-baby package and can
help pay transport, or the delivery costs.
 Cotton wool
 Soap
 Gloves
Transport options for the patient;
o Train
o Motorcycle
o Motor vehicles
o Wheelbarrow
o Bicycle

15
A birth partner/companion;
 Is the father of the baby, a sister, a mother-in-law, mother or an auntie?
 Should be chosen by the woman and involved in making the individual birth
plan ( IBP)
 Should provide support to the woman during pregnancy at the antenatal
clinic and during delivery.
 Should know that signs of life-threatening complications and what to do if
these arise.

Danger signs in pregnancy –I

 Any vaginal bleeding
 Severe headache or blurred vision
 Swelling of the face and hands
 Convulsions or fits
 High fever
 Laboured breathing
 Premature labour pains
 Baby moving less or not moving at all.

TAKE ACTION----MOVE!
Danger signs in pregnancy-II
 Feeling very weak or very tired
 Abnormal vaginal discharge
 Abdominal pain
 Genital ulcers
 Painful urination
 Persistent vomiting

TAKE ACTION ---MOVE

Danger signs during labour and delivery
 Severe headache/ visual disturbances
 Severe abdominal pain
 Convulsions or fits during labour
 High fever with or without chills

16
  Foul vaginal discharge
 Labour pains for more than 12 hours
 Ruptured membranes Without labour
 Excessive bleeding during delivery
 Cord, arm or leg protruding from the birth Canal.

TAKE ACTION---MOVE
Danger signs after delivery
 Placenta not delivered within 30 minutes of baby’s birth.
 Excessive bleeding after delivery
 Severe abdominal pain
 Convulsions or fits after delivery
 High fever with or without chills
 Foul-smelling vaginal discharge

TAKE ACTION---MOVE
Importance of recognizing danger signs.
Acting quickly is important because a woman could die in a short period of
time.
 With antepartum hemorrhage she can die in just 12 hours.
 With postpartum hemorrhage she can die in just 2 hours.
 With complications of eclampsia in as few as 12 hours and
 With sepsis in about 3 days.

Group work
a) Why do clients decide to deliver at home rather than at a health facility?
b) Discuss myths, traditional beliefs and cultural practices that hinder a woman
from delivering at a health facility.
Barriers contributing to home deliveries.
Barriers for the clients;
 Perceived lack of facilities providing high quality essential obstetric
care.
 Services not accessible
 Services not affordable
 Services not acceptable
17
  Negative staff attitudes
Barriers for the staff
 Unskilled staff
 Frequent shortage of essential equipment and supplies and staff.
 Poor infrastructure
 Poor referral system

PREGNANCY

INTRODUCTION

The diagnosis of pregnancy is done depending on the changes which the mother
undergoes usually due to hormonal changes and physical development of the fetus
as well as the body’s adaptation to this new experience. These vary in regard to the
period of conception.

Definition

Pregnancy is the growth of a fertilized ovum from conception to expulsion of the

fetus.

CLASSIFFICATION OF THE SIGNS OF PREGNANCY

 Presumptive signs
 Probable signs
 Positive signs

Presumptive signs of pregnancy

These are maternal physiological changes which a woman experiences and which
in most cases indicate to her that she is pregnant. They are:
 Breast changes. like tingling, tenderness, enlargement
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  Amenorrhea
 Nausea and vomiting(morning sickness)
 Colour changes of the cloasma.
 Appearance of the Montgomery’s tubercles.
 Colostrum expression
 Cloasma (pregnancy mask)
 Increased urine frequency
 quickening
Probable signs

These are maternal physiological changes other than presumptive signs which are
detected upon examination and documented by the examiner.
These signs include:
 Jacquemeire’s sign/chadwicks sign (violet blue discoloration of the vaginal
membrane due to increased vascularity)

 Uterine changes (change in shape, size i.e. enlargement)

 Presence of HCG in blood (4th -12th) and in blood.

 Hegar’s sign (softening of the isthmus of the uterus)

 Braxton hicks contraction on palpation(16th week)

 Osiander’s sign(pulsation in the lateral fornices)

 Ballottement of the fetus (16th -28th week). This can be internal or external.

Positive signs

These are directly attributed to the fetus as detected and documented by the
examiner.

19
 They are:
 Visualization of the fetus by ultrasound scan (6th wk.)
 Visualization of the fetal skeleton by X-ray(16th week)
 Fetal heart sounds by ultrasound(6th week)
 Fetal heart sound heard with a fetoscope
 Palpable fetal movements (22wks)
 Visible fetal movements(late pregnancy)
 Palpation of the fetal parts (24th week)
CONCLUSION

It should be noted that a number of the above signs should be considered before
diagnosing pregnancy since there are other conditions which present with some of
the above signs

MINOR ALMENTS/DISODERS OF PREGNANCY

The body goes through allot of un pleasant / or normal changes

Minor disorders

• Tiredness; in early and late pregnancy. due to extra weight mother is

carrying
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-Treatment, rest, accept offers
• Constipation; Cause hormonal changes, (progestone)

-Treatment

-Eat plenty of fiber in diet e.g.

-Exercise regularly (yoga and swimming) to keep muscle toned up

Plenty of water, fluids and fruits.

-Laxatives to stimulate the bowel into action.

• Headache; cause, hormonal changes

Treatment
- Rest and relaxation
- A brisk walk may be all that you need

Advice, it is wise to avoid drugs but some ocational cetamol can be used

If headaches are not relieved by cetamol suspect high blood pressure.

• Faintness; Causes , poor supply of blood / or food to the brain

-low oxygen levels

- Hormonal changes
- Too much lying at the back apart from supine hypotensive syndrome
Treatment
- Adjust the position, if standing sit
- Reassurance

-Try to get off slowly from where you are

21
 • Ingestion; causes, Pregnancy hormones, leading to low peristaltic
movement.
• The growing uterus presses on the stomach.

Treatment

-Try to eat smaller meals more often

- Sit up straight when eating to relieve pressure off your stomach

- Avoid particular foods that make symptoms worse like fatty and spiced foods.

 Heartburn; this is more than ingestion

Cause, the cardiac reflux causes regurgitation of acid stomach contents due to
that reflux.

Treatment, sleep well dropped up (use pillows)

- Try drinking a glass of milk
- Avoid eating or drinking a few hours before sleep
- Anti-acids can be taken to reduce reflux if contra indications are read
• Leaking from nipples; colostrum leaks in mid to late pregnancy

Causes, hormones

Management, do not squeeze them out

-See Dr/ or midwife

- Breast pad

 Backache; due to

22
(i) Softened and stretched ligaments in preparation for labor.

(ii) Lumber lordosis which puts a strain on the lower back and pelvis

-Management, avoid lifting heavy load

-Bend knees; keep back straight, when carrying something heavy.

-Work at a surface high enough to avoid stooping

-Balance weight to carry

-Sit with back supported, use firm mattress

• Cramps; a sudden sharp pain on calf muscle and feet

-Cause, pressure of the growing fetus compromising blood supply to the cuff
muscles with minimal oxygen resulting to relies of lactic acid which causes pain
during a contraction.

Management, plenty of calcium rich foods eg vegetables, dairy products, sun

flower seeds dried beans, magnesium rich foods

-Elevating foot of bed

-Exercises, particularly leg movement to aid circulation

• Pururitis valvae / itching

Causes, increased blood supply to skin, stretching of abdominal skin

-cholestasis (not common) due to a buildup of bile acids in blood

Giant urticarial (large itchy red rash)

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Management

Wear loose clothes, some medication to reduce bile acid level.

• Nose bleeds

Cause, hormonal changes

Treatment
- Press sides of nose between thumb and fore finger for ten minutes
- Avoid explosive sneezes
- Try a steam inhalation.

• Frequency of micturition; early pre: developing and enlarging fetus

Late: fetal head pressing bladder

Try to find out how many times she empties the bladder in the night.
• Stress incontinency due to abdominal pressure and increased intra-
pelvic flow exercises
• Sudden spurt of urine when coughing, sneezing laughing

Management reassurance, tighten up muscle around vagina

• Piles/ hemorrhoids swollen veins

Cause, relaxed veins under the influence of progesterone

Management, regular gentle exercise to improve circulation

- Use of ice packs covered in clean cloth
- If they stick out, observe infection prevention and push them back using
a lubricant

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 • Respiratory distress; women feel breathless due to the growing uterus
and as pregnancy advances

Patient`s information, reassurance

• Ptyalism; increased salivation, it is due to failure of the mother to
swallow

Intervention

Dental hygiene, ant cholinergic to induce dryness

• Symphysis pubis dysfunction
- This is collection of discomfort and pain in the pelvic area radiating to
the upper thighs and perineum.

Management, pain relief, reassurance, resolves 6 months after delivery

• Peripheral paresthesia (tingling sensation of the fingers)

Causes, fluid retention leading to compression of nerves

It may often lead to carpal tunnel syndrome

Interventions

Wrist prints, steroid injection analgesics

• Insomnia / or sleeplessness

Due to strange dreams, night mares about baby and birth, change in hormones

Patient`s information

Restful music before bed time, rest during the day, lie on one side with a pillow
under your bump and on other between the knees
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 • Leucorrhea/Vaginal discharge

Cause, hormonal changes, excess estrogen production

It should be clear and smell unpleasant

Intervention

Use of loose cotton underwear

Medication
• Varicose veins of the legs and vulva

If severe rule out deep venous thrombosis

Information
- Avoid standing for long
- Elevate legs, sit with legs crossed
- Avoid putting on much weight
- Exercise like walking
- Support tights

Others
• Nausea and vomiting, anticholinergic drugs can be prescribed to act on
higher centres e.g. fenagan, plasil (metachromide) parentolite (multi
vitamins), periactine dompeldol (motilium motinon).

The side effects of the drugs are lack of concentration.

• Stretch marks
• Gingivitis; this is inflammation of the gum,
mother`s information, hygiene is very important.

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THE PHYSIOLOGICAL CHANGES DUE TO PREGNANCY.

This refers to the changes that take place during pregnancy in all the system of the
body.

These changes are a natural part of pregnancy and a better understanding will help
you to cope with them. These changes are due to hormonal production namely
oestrogen and progesterone.

I) THE REPRODUCTIVE SYSTEM (CHANGES TO THE SEX

ORGANS)
CHANGES TO THE BREASTS.

 Stimulated by the hormones oestrogen, Progesterone and human placental

lactogen.
 There will be gradual increase in size of the breast due to growth of the
glandular tissue and the ducts.
 In the 3rd to 4th week, prickling, tingling sensation and sense of fullness.
 Due to increase in blood volume, circulation and vascularity increase, the
breasts are tensed and nipples become pronounced.
 Surface veins become visible because of the increased blood supply.
 At 12 weeks the primary Areolar darkness.
 At 16 weeks Montgomery tubercles become visible. These are developed
sebaceous gland (to lubricate Nipples).
 At 16 to 18 weeks the secondary Areolar appears.
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  A thin clear fluid called pre-colostrum is produced at approximately 6
weeks.
 Thick yellow liquid called colostrum is produced during the third trimester.
 There will be suppression of lactation until birth. (oestrogen-Progesterone
level drop)
 Elevation of prolactin at birth will start lactation cycle.
 Upon palpation, breasts are Nodular.

CHANGES IN THE UTERUS

 Menstruation ceases during pregnancy and returns some weeks or months

after delivery because the hormones FSH and LH are suppressed.
 The changes are influenced by the oestrogen and progesterone activity and
the growth of the fetus.
 Size- this increases from 7.5×5×2.5 to 30×23×20cm. the average increase is
3.5cm per month.
 Weight- this increases from 60gms to 1kg.
 Position- from ante-flexed and ante-verted to an erect organ or vertical.
 Shape- from avocado shape to globular.
 Muscle coat- it increases 10 times in length and 5 times in thickness new
muscle fibres develop and the walls become thicker up to 0.5cm to 1cm at
term.
 In the late pregnancy the uterus becomes divided into two parts;
i) Upper uterine segment- this is the upper 3.4of the body of the uterus and
it is the part which contracts and retracts.

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 ii) Lower uterine segment – this develops from the Isthmus to the cervix
during the last few weeks of the pregnancy. It becomes soft and stretches
in preparation for labour.
 The muscular area of the uterus rises depending on the weeks of pregnancy.
 Endometrium or the uterine lining becomes very thick and highly vascular.
This allows for implantation and it is then called the decidua.
 Myometrium- hypertrophy i.e. grows in length and thickness. There will
also be Hyperplasia (new muscle fibres are developed)
 Perimetrium – it becomes thick and rough in order to accommodate growing
uterus.

THE CERVIX.

 It becomes more vascular which gives it a bluish colour in appearance.

 The cervix produces more mucus which forms the plug to close off the
cervical OS. This plug is known as Operculum. This is expelled during
labour together with some blood from the dilating cervix and this forms
what is known as Show. The Operculum acts as a barrier against the
infections from the growing fetus.
 Towards the end of pregnancy the cervix becomes soft and shortened and it
is then known as the ripe cervix. In this case the external OS allows a tip of
the finger.

THE GROWTH OF THE UTERUS.

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  In the clinical assessment of the uterus, the height of the fundus is estimated
using 1 figure=2 weeks.
 At 1-8 weeks the uterus is not palpable abdomen.
 At 12 weeks the uterus is the size of an orange. The shape is more ovoid
than round. It is palpable just above the symphysis pubis.
 At 16 weeks the fundus is half way between the symphysis pubis and the
umbilicus.
 At 16 -18weeks, quickening and Braxton hicks’ contractions starts.
 At 20 weeks the fundus is 1 figure below the umbilicus,(1.5cm above the
symphysis pubis )
 At 22 weeks the fundus is at the umbilicus.
 At 24 weeks the fundus is 1 figure above the umbilicus. The girth is about
20cm in circumference.
 At 30 weeks the fundus is midway between the umbilicus and the
xiphisternum.
 At 34 weeks the fundus reaches the coastal margins.
 At 36 weeks – the fundus reaches the xiphisternum.
 At 36 weeks, the height of the fundus begins to shrink up to level of 34
weeks. Engagement takes place leading to what is called lightening (release
of pressure from the fundus)
 At 40 weeks the fundus is at the level of 34 weeks due to lightening.
 Note at 38-40 weeks ossification of the fetal skull has taken place and
abdominal girth is about 90-100cm.

QUICKENING

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  This is when the woman starts feeling the fetal movements at 16-18 weeks
in multigravida and 18-20 in prime gravida.
 By then the uterus enlarges and is in contact with the abdominal wall so the
woman feels fetal movement.
BRAXTON HICKS CONTRACTION

 These are painless contraction which starts at 16-20 weeks onwards.

 They do not cause the cervical dilatation.
FUNCTIONS

 It assists in the circulation of the blood to the placental site with each uterine
contraction and relaxation.
THE VAGINA, VULVA AND PERINEUM

 The blood supply is increased

 The colour of the vagina turns bluish due to increased blood supply.
 The colour of the vulva also become purplish.
 Glands in the vagina ad cervix produce more mucus called leucorrhea.
 There will be less acidic discharge in the vagina, there is increased risk for
vaginal infection especially yeasts.

THE FALIOPPIAN TUBES.

 They are lifted out of the pelvis as the uterus grows, straightened and they
become abdominal organs.
THE OVARIES.

 They are lifted out of pelvis and they also become abdominal organs.
THE CHANGE IN THE CIRCULATORY SYSTEM.

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 Progesterone reduces systemic vascular resistance by about 20% early in
pregnancy and this may result in postural hypotension. (Progesterone relaxes
the blood vessels).
 Blood volume increases by 30-50% at about 10-12 weeks and peaks at 20-16
weeks. It is only the plasma volume that increases while the solid part
remains (blood cells) the same. This leads to dilution of blood known as
Haemodilution, this leads to physiological anemia in some mothers (those
on poor diet)
 The diastolic and systolic blood pressure tends to fall during the mid-
pregnancy and the return to normal by weeks 36. Normal blood pressure in
pregnancy varies between 70/50-120/80 mmHg above 130/90 is considered
high.
 The heart enlarges slightly due to the increased activity (increased blood
volume, venous return and output) but the blood pressure does not rise due
to relaxation of the blood vessels.
 The venous return in the IVC can be compromised in late pregnancy if the
woman lies on her back. This is relieved by lying in the left lateral position.
 Increased circulating angiotensin. It encourages water and sodium retention,
leading to an increased plasma volume (to 50% by 30weeks). Predisposing
the woman to oedema. This enables increased uterine blood flow to meet the
growing nutritional and oxygenation needs of the fetus. It also enables
blood loss (average of 500ml) at delivery too without physiological
compensation.
 The heart rate will be increased by 10-15 beats per minute during 14-20
weeks.

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CHANGES IN THE DIGESTIVE SYSTEM.

 Appetite is usually increased, sometimes with specific cravings (pica).

 Progesterone causes the relaxation of the lower oesophageal sphincter while
the growing uterus presses on the stomach. This leads to the regurgitation of
the acidic stomach contents into the esophagus causing what is known as
heart burn.
 As progesterone, causes the relaxation of the gut muscles, the
gastrointestinal motility is reduced and the transit time is consequently
longer, this allows for increased nutrient absorption however it always leads
to constipation.
 Gum disease- gums become spongy, friable and prone to bleeding. Good
dental care is important.
 Haemorrhoids- Haemorrhoids occur due to the expansion and congestion of
the blood vessels. In order to prevent hemorrhoids try avoid constipation by
drinking plenty of fluids and consuming enough fiber.
 There will be decreased bowel sounds due to decreased peristaltic
movements because of the increased stimulation of the progesterone
Hormone.
CHANGES IN THE URINARY SYSTEM.

 Urinary elimination- there is increased frequency and urgency of urinary

elimination because of decrease in the bladder capacity due to the pressure
from the growing uterus. This happens in the early pregnancy when both the
uterus and the bladder are still occupying the pelvic cavity.
 After 12 weeks the uterus comes out of the pelvic cavity and less
micturition.
 At 36 weeks fetal head engages and exerts pressure on the bladder again.
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  Mild glycosuria and proteinuria may occur because of the increase in
Glomerular Filtration rate may exceed the ability of the renal tubules to
absorb glucoses and protein.
 Increased water retention causes reduction of the plasma osmolality.
 Bladder smooth muscle also relaxes, increasing the capacity and the risk of
UTIS.
 Sleep disturbance – this can be caused by frequent urination, the mobility to
find comfortable sleeping position in bed, fetal movements, stress and
worry.
 There is kinking of the ureters which causes stagnation (urinary stasis) of
urine in them hence predisposing to UTIs.
THE CHANGES IN THE ENDOCRINE SYSTEM.

 The pituitary and the thyroid gland may enlarge due to the increased body`s
general metabolism.
 The ovaries become dormant and the placenta takes over and becomes active
producing estrogen, progesterone and chorionic gonadotrophic hormone by
the trophoblastic from the time of embedding to 13 weeks. This helps to
maintain the corpus luteum until the placenta takes over and the corpus
luteum shrinks. It’s the hormone which is found in the urine of pregnant
woman upon which a pregnancy test is done.

CHANGES IN THE NERVOUS SYSTEM.

 Due to high levels of female hormones progesterone, estrogen and anxiety

about upcoming birth, irritability, mood swings, depression are common in
pregnant women as often it occurs in many women prior to the menstruation.

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CHANGES IN THE SKELETAL SYSTEM.

 There may be changes in gait due to the abdomen which is enlarged.

 The shoulders are thrown backwards.
 Increased joint and ligament cavity caused by increased levels of relaxation.
This relaxes the joint around the pelvic during the later weeks of pregnancy.
 Shift in the posture with the exaggerated lumbar lordosis leading to the
typical gait of late pregnancy.
 Back pain is caused by change in the center of gravity, weight gain and
muscle tension due to need to maintain stability of the body pressure from
the fetal head over the sacrum, sacral vertebrae may as well lead to the
backache.
 Leg cramps- leg cramps occur when there is poor absorption of calcium or
local deficiency of the blood supply.

CHANGES IN THE GENERAL METABOLISM

 The basal metabolic rate increases slowly over the course of pregnancy by
15-20% due to the increasing demand from the fetus and the maternal tissue.
 Active energy expenditure tends to fall over pregnancy.
 In pregnancy a mother may have a track of glucose in urine and will be
considered normal. (less of catabolism and more of Anabolism)

CHANGES IN THE WEIGHT

A pregnant woman is expected to have a steady weight of 500gms monthly for the
first 20 weeks and 500gm weekly for the last 20 weeks.

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This weight gain results from the following;

 Fetus 3.5kg
 Fats 3.5kg
 Blood volume 1.5kg
 Extra cellular fluids 1.0kg
 Uterus 0.9kg
 Placenta 0.5kg
 Amniotic fluid 0.6kg
 Breast 0.5kg
Total 12.0kg.

CHANGES IN THE INTEGUMENTARY SYSTEM (SKIN)

 There is increased secretion of sweat and sebaceous glands.

 There is increase in the basal body temperature.
 Striae gravidarum or reddish- purple stretch marks on the breasts, abdomen,
buttocks, thighs they begin to occur in the second half of pregnancy.
 Linear nigra- this is marked abdominal midline pigmentation that can be
seen externally from the symphysis pubis to above umbilicus.
 There can be pigmentary changes such as chloasma or brownish
discoloration of the face (pregnancy mask) and disappears after pregnancy.

CHANGES IN THE RESPIRATORY SYSTEM

 The tidal volume increases by about 200ml, increasing the vital capacity and
decreasing the residual volume.

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  Increased oxygen consumption by approximately 20%
 Many women complain of feeling short breath in pregnancy because the
respiratory canter are more sensitive to any increase in carbon dioxide due to
the effect of progesterone without explanatory pathology. The mechanism of
this is not fully understood.
CONCLUSION

It is true that being pregnant is not easy, your body changes as you progress with
pregnancy.

There are changes that bring risk, but most of the changes happen in order to adopt.
It is important that you know the difference between normal changes and changes
that require medical attention.

If you are at high risk, it is important consult your doctor regularly because some
changes can endanger the baby and mother.

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