Normal Midwifery for students enrolled and registered midwives.pptx

INTRODUCTORY BLOCK MIDWIFERY WELCOME 9 th September 2016

COURSE OUTLINE- MONTH 1 INTRODUCTION: History of midwifery Basic A &P of female reproductive system. Breasts. Bony pelvis & pelvic floor. Fetal skull & Fetal circulation. Basic Terminologies used in midwifery. The Menstrual cycle. Fertilization ,Development & Decidua .

Embryology & Fetal Development. Placenta & Membranes. Umbilical cord & Liquor amnii . Examination of the placenta. Practical session, using real placenta .. C . A . T . 1 (ONE )

BROAD OBJECTIVE By the end of the learning sessions, the KRCHN students will be able to describing the basic anatomy and physiology of the reproductive system and the associated functions.

HISTORY OF MIDWIFERY . KARIBUNI .

“ The longer you look back, the further you can look forward’’ (Sir Winston Churchill, 1994) MIDWIFERY , refers to dealing with a woman during pregnancy , labour and puerperium . MIDWIFE , is the title or legal term describing a person who is trained, certified and licenced by the respective professional body to practice midwifery.

WHO (1992) describes a MIDWIFE as: “a person who, having been regularly admitted to a midwifery educational programme , duly recognized in the country in which it is located, has successfully completed the prescribed courses or studies in midwifery and has acquired the requisite qualifications to be registered and or legally licensed to practice midwifery”. MAIN OBJECTIVE/ ROLES OF A MIDWIFE To help in the delivery of life healthy neonate and have a healthy mother. To alleviate the undue anxiety and discomfort during the 3 periods (Pregnancy, labour & puerperium ).

ROLES OF A MIDWIFE CT’ The midwife has a unique role in care of mothers and babies. To conduct deliveries on her own responsibility and to care for the mother and the newborn. To promote normal birth and detect complications in mother and child, access to medical or other appropriate assistance and the carry out emergency measures. To involve in health counseling and education, not only for the woman, but also within the family and community.

Roles of a midwife ct’ To involve antenatal education and preparation for parenthood. To promote women's health, sexual or reproductive health and childcare.

MIDWIFERY PRACTICE Mid , means Together with . Wife , means Woman. As early as 3000 BC , the practice of midwifery is recorded in Egypt, in fact, no branch in medicine can claim a longer history than the Art of midwifery. Exodus 1: 15-22 records pharaoh’s order, to midwives to kill all the male offsprings of the Hebrews

EUROPE Midwifery training started as early as second(2) century A.D Sarous wrote a m.w manual, which was used for 14 centuries. 1513,Rosin E wrote a book “The Garden of Roses” for pregnant woman.

1663 ,king Louis the 13 th was delivered, by a graduate / trained midwife at Diue in Paris. 1580 a law was passed in Germany prohibiting anyone but a trained m.w , to be in attendance to a mother in labour . In some (English speaking) countries, males were forbidden to practice or train as midwives in 18 th & 19 th centuries. E.g Canada, U.S.A, Australia & Britain.

In 1847 Ambrose P. introduced Podalic Version as a way of managing malpresentations . Ignaz Phillip reduced maternal mortality rate by emphasizing on thorough hand washing practice during and after vaginal examination procedure. 1867 , Florence Nightgale started the kings college hospital and school of Nursing . The Nurses were licensed by the Bishops.

1890 the British midwifery bill was introduced in the parliament , but it never became an act until 1902. Thereafter central midwifery board was established to set rules and regulations for the practice of midwifery. 1905 the central m.w board set its 1 st examination following which they issued certificates. 1936 the Act required that all the local authorities provide Domiciliary midwifery services to its resident women in need of a midwife.

IN KENYA At the end of the 19 th century, missionaries arrived in Kenya and started building schools as well as hospitals. Local girls were given instructions in vernacular on how to assist mothers in labour . Charitable organizations, local authorities and the government built hospitals e.g Maseno , Pumwani ( Lady Grigg African

cont Maternity), Indian Maternity hospital( Lady Grigg Maternity Mombasa), P.C.E.A Tumutumu , Consolata Nyeri (Mathari) , Kisumu and Murang’a hospital. Training started respectively , entry requirements being ability to read and write ,instructions were basically in vernacular for 1 year. By 1960 to 1970 new m.w training schools were opened, for a 2 years Enrolled midwife programme , later reverted to 1 year postgraduate programme . Examples of such schools are;

Consolata , Thika , Ortum ,Lourdes, Kendu Bay among others. 1940- 1950 Kiswahili was widely used as a media of instruction. As from 1951 to date English is the language of instructions in training schools. Entry requirement was, O-Level 3 rd division for a registered midwife , 2 years programme . Permitted schools were , Pumwani , Ortum , Lourdes( Motomo ) ,St. Claire Kaplong and Thika .

Nurses and Midwives of Kenya Nurses and midwives council of Kenya was founded in 1950. In 1951 the council set the first examination to students at P.C.E.A Tumutumu . 1957 ,the council formulated a syllabus for enrolled midwives ( EM )training. 1963 , Kenya Registered Midwives (KRM) training started at Ngara (Nairobi) in Lady Grigg Asian maternity. The first class comprised of 6 students, who graduated in 1965. The school also offered upgrading program from EM to RM. Dec. 1965 midwifery training started in Medical Training Centre , school of nursing Nairobi. Other schools followed e.g Mater- Misericordiae , June 1972 and Pumwani February 1973.

June 1973 the first male student was trained as a midwife in KMTC NRB. Cap 257: Nurses Act , a revision of 1983 . The law governs:- The practice and conduct of nursing as well as nurses. Prescription of the syllabus / program for training. Licensing of nurses who have undergone a prescribed course of training( in knowledge & skills). The conduct of nurses, in order to protect the public ( clients / patients ) from untrained persons and unethical practices by nurses, with offences and punishment.

Midwifery Regulations 1965: Legal Notice No. 299 of 1983. Applies for both registered midwives and enrolled midwives. Requires that your name must be in the current register or roll of midwives kept by registrar of the Nursing Council of Kenya (NCK) . Takes the role of review of offences in terms of omission or commission , and the appropriate punishment. END

BASIC ANATOMY& PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM It’s grouped into 2 (two) namely:- External genitalia Internal genitalia

DIAGRAM OF THE VULVA- (Page 84)

1.EXTERNAL GENITALIA/VULVA Vulva is the collective term given/applied to the external structures of the female genitalia. Specific structures are:- Mons veneris /pubis. It’s a firm, cushion like formation (i.e. pad of fat) over the symphysis pubis. The area is covered by hair as from puberty. The main role is sensuality and also protects the symphisis pubis during copulation

contd ii. Labia majoral / majus or greater lips They are two (2) prominent, longititudal folds of fat and areolar tissue They arise from the lower margin of the mons veneris , extends/runs downwards and backwards to merge into the perineum posteriorly. Pubic hair covers their outer aspect/surface as from puberty while the inner surface /aspect is smooth and moist. Precisely, the labia majora forms the anterior border of the perineal body and protects the inner surfaces of the vulva.

contd iii .Labia minora /minus or lesser lips Are two (2) thin longitudinal folds of hairless skin entirely covered with a thin membrane. Their outer surface joins with the inner edge of the L. majora , such that they lie between the L. majora . Anteriorly and superiorly they separate to enclose the clitoris, while posteriorly they fuse to form the fourchette . NB: Fourchette is the posterior part of the vaginal orifice (opening).

cntd Vestibule It is an oval-shaped area enclosed by the L. minora . Extends from the clitoris site superiorly to the fourchette inferiorly. The external urethra meatus , vagina introitus and bartholin glands outer opening are located on it. NB: Bartholin glands secretions lubricate the vulva. Skene’s glands ducts, opens on either side of the urethra, just above the meatus , hence lubricate the urethra opening.

Clitoris It’s a small undeveloped/rudimentary sexual organ. Comprises of erectile tissues, covered by a thin epidermis and highly vascular, hence extremely sensitive. The visible knob-like part is located above the urethra meatus near the anterior junction of labia minora . It comprises of a prepuce superiorly and frenulum / frenum inferiorly.

contd Each results from the separation of the respective labia minora into 2 pairs of folds, grouped as upper and lower folds. *The two (2) i.e. right and left, upper folds forms the prepuce while the lower folds forms the frenulum . The main purpose of the structure / organ is:- *Sexual excitement (arousal) and response (orgasm). *Facilitates maximum stretching of the vulva during childbirth hence tears rarely occur.

ct Hymen. It is a thin membrane which partly occludes (closes)the vaginal opening. Its presence in adulthood indicates virginity. Normally torn during first copulation experience, vigorous exercises and use of tampon. The remaining tags following the tear are referred to as Carunculae myrtiformes or hymenal caruncies .

Perineum. It is a triangularly shaped area. On the anterior, superior aspect is the fourchette while posteriorly - inferiorly is the anus. Comprises of muscles which make the pelvic floor, fat and connective tissues. Injury/trauma is almost inevitable during delivery.

Blood supply Main source is internal and external pudendal arteries, drainage is through corresponding veins. Lymphatic drainage Main route is through the inguinal glands which later join the iliac glands.

Nerve supply Derived from branches of pudendal nerve. The vaginal nerves supplies the erectile tissue of the vestibular bulbs and clitoris. The nerves have parasympathetic fibres hence have vasodilator effect. Other back up is from lumbar 1 (one) nerve root.

II INTERNAL GENITALIA Comprises of structures/organs located in the pelvic cavity namely: The vagina The cervix The uterus Two uterine tubes Two ovaries

SAGITTAL VIEW OF INTERNAL GENITALIA STRUCTURES ( PAGE 86)

1.VAGINA It’s a distensible fibromuscular tubular structure connecting the external and internal genital. It is approximately 10cm in length & 2.5cm in diameter (although there’s a wide anatomical variation) Its canal passes at an upwards and backwards direction in the pelvic cavity hence comprises of an anterior and posterior wall. RELATIONS/NEIGHBOURING STRUCTURES Anteriorly: are the urinary bladder and the urethra

Posteriorly : are the pouch of Douglas (recto-uterine pouch), rectum and perineal body each occupying 1/3 of the posterior vaginal wall Superiorly cervix and uterus Inferiorly – external genitalia Laterally – The upper 2/3 are the pelvic fascia and lower portion of urethra, lower 1/3 is the pelvic floor

ct STRUCTURE Refers to description of the various parts Vault The term given to the upper end of the vagina. Walls The anterior wall measures about 7.5 cm long hence closely related to the adjacent structures anteriorly. The posterior wall measures 10cm long The difference in length is because the cervix is attached to the vagina at a higher level posteriorly

contd Fornices or arches These are circular recess/deeps formed as the cervix projects/hangs into the vault. They are four (4) namely. Anterior fornix (singular) Located between the anterior vaginal wall and the anterior aspect of the cervix. It is in contact with the base of the bladder Posterior fornix. Situated between posterior vaginal wall and posterior part of the cervix. It is the largest The two (2) lateral fornices . Each lies on either side of the cervix .

cont LAYERS Refers to tissues comprising the vaginal wall. ( i ) Mucosa is the most innermost layer Consists of stratified squamous epithelium,which allows exudates/oozes from the blood vessels to sip out and moist the vagina (ii) Muscle layer :- Comprises of a weak inner coat of circular fibres and a stronger outer coat of longitudinal fibres .

contd This arrangement facilitates stretching and dilatation as need arises. (iii) Pelvic fascial outermost layer Surrounds the vagina externally as well as the adjacent pelvic organs. Allows independent expansion and contraction as necessary. Generally, the walls are thrown (arranged) into tranverse folds referred to as Rugae . These folds allow maximum stretching and distension vagina yet no or minimal injuries occurs

contd NORMAL VAGINAL STATE In health, its warm, moist and pinkish in appearance Increased vascularity brings about the pinkish colouration and warmth Cervical glands secretions and exudates from vaginal wall brings about the moisture. Vaginal fluid (discharge) media is acidic (PH 4.5) in reaction. The acidity results from the interaction of Dorderleins bacilli on glycogen.

ct The increased acidity aims at preventing growth of some pathogenic organisms during the entire childbearing period. NB: Dordeleins bacilli/lactobacilli are normal inhabitants of the vagina. The action of oestrogen hormone produces glycogen in the vagina cells. Before menarch , and after menopause the acidity levels are quite low hence vaginitis occur easily.

contd BLOOD SUPPLY Originates from branches of the internal iliac artery which includes descending branch of uterine artery as well as vaginal artery. LYMPHATIC DRAINAGE Through the inguinal, internal iliac and the sacral glands. NERVE SUPPLY Derived from the Lee Frankenhauser Plexus, i.e. pelvic plexus . Supplies the vaginal wall and the erectile tissues of the vulva.

contd FUNCTIONS Allows menstrual fluid to flow out during the entire procreation period. OR Serves as an excretory duct for the uterus. Receives the penis and the ejected sperms during copulation. OR It is the female organ for copulation. Provides an exit for the fetus during the process of birth .

2. CERVIX Also referred to as the neck of the womb. Situated between the uterine cavity and the upper end of the vagina. The attachment site of the uterine cervix to the vaginal vault divides the cervix into two (2) namely :- ( i ) Supravaginal portion . The part above the vagina (ii) Infravaginal portion . That part which protrudes/hangs into the vault.

Cont’d AREAS Are three (3) namely: Internal cervical os: The narrow opening between isthmus and the cervical canal, in the cervix. Cervical canal: Lies between the two (2) oral (openings). It is shaped like a spindle i.e. narrow at each end and wider in the middle. External cervical os: Forms the opening at the lower end of the cervix to the vagina. **Before childbirth the opening is small and circular. **Thereafter it becomes a transverse slit, that has an anterior and a posterior lip.

LAYERS Are basically two (2) namely:- ( i ) The cervical endometrium / inner lining It is a mucous membrane lining, with tall columnar shaped epithelial cells and mucus secreting glands. The coat is thinner than that of the uterine body and is folded into a pattern known as the arbor vitae (tree of life) ,which is thought to assist the passage of sperms. (ii) Muscle/middle layer It is a continuation of the uterine muscle, though the coat is thinner. The fibres are arranged in longitudinal and circular patterns, as well as embedded in collagen fibres to facilitate stretching and dilatation of cervix during labour .

Cont’d FUNCTIONS Remain closed in non pregnancy state hence prevents easy ascend of infectious organisms to the uterus. Remain closed prenatally for fetus to develop to term. Produces a plug of mucus prenatally at the cervical canal hence prevent ascend of infectious organisms.

Cont’d Allows passage of bloody mucoid discharge as it dilates which indicates true labour . Facilitate expulsion of the fetus during the birth process as the cervix progressively dilate. NB :* Caution regarding cancer of the cervix. Yearly, pap smear screening is recommended from age of 18 years, for early diagnosis . * Preventive measure is a vaccine against human papilloma virus ( Hpv ) as from age of 9yrs.

THE UTERUS

A CORONAL SECTION DIAGRAM OF THE UTERUS

A DIAGRAM OF THE CORONAL VIEW OF THE UTERUS

3. UTERUS space for coronal section diagram……… Also referred to as the womb. Definition It’s a thick-walled hollow muscular organ, pear in shape but flattened anteriorly as well as posteriorly and situated in the pelvic cavity. Measurements :- Diagram: measurements of non-pregnant uterus ( PAGE 88) Basically weighs about 30-40gm before the first pregnancy and about 60gm thereafter.

contd NB : Average weight, depends on the parity ie number of deliveries. It measures 7.5cm long, 5cm wide and 2.5cm in depth. Each wall thickness being 2.5cm. Physiologically, cervix forms the lower third (1/3) of the uterus and measures 2.5cm all through.

Cont’d Position It is located between the urinary bladder and the rectum respectively. On lateral view, it leans forward, collectively referred to as anteversion and bends forward upon (on) itself, collectively referred to as anteflexion . **Therefore the normal position is that of anteversion – anteflexion

SPECIFIC PARTS (AREAS) Are basically four , namely:- Fundus :- Refers to the dome-shaped upper wall, situated above the levels of uterine tubes insertion to the cavity. Cornua ( cornu singular) :- Are upper outer angles, where uterine tubes join.

Corpus (Body):- The part/area directly below the cornua upto where the uterus starts to narrow. In the outer aspect it measures 4cm long. The inner aspect forms the uterine cavity which is triangularly shaped with the base uppermost. Isthmus :- It is a narrow area located between the uterine cavity and the cervix. It is about 0.7cm/7mm long.

LAYERS/WALL They are three (3) layers namely:- PERIMETRIUM It is the outermost layer, made up of a double serous membrane, an extension of the peritoneum. Anteriorly, covers the uterus up to the level of the internal cervical os . Then it is reflected back over the upper surface of the urinary bladder forming a small pouch known as: uterovesical pouch/ vesico -uterine pouch.

contd Posteriorly covers the uterus completely to include the supra-vaginal portion of the cervix. * Then reflected onto the rectum forming recto-uterine pouch of Douglas . Laterally covers the fundus only and continues to form the broad ligaments.

2.MYOMETRIUM The middle(muscular) layer Thickest at the fundus and body while thinner at the isthmus and cervix. At the fundus and body the fibres interlace i.e. run in all directions to surround the blood and lymphatic vessels passing to and from the endometrium. At the isthmus and cervix, circular fibres are more. Generally the outermost part of this layer comprises of longitudinal fibres , which are continuous with those of uterine tubes ligaments and the vagina.

ENDOMETRIUM The innermost layer. Formed of ciliated epithelium, whose base has a connective tissue capable of rapid regeneration following every menstrual phase. The epithelial cells are cuboidal shaped and have glands which secrete alkaline mucus .

RELATIONS Anteriorly is the uterovesical pouch and the urinary bladder. Posteriorly , is the recto-uterine pouch of Douglas and the rectum. Superiorly is the intestines. Inferiorly – The cervix and vagina. Laterally – the broad ligaments, uterine tubes, the ovaries, uterine blood vessels, and lower portion of ureters .

FUNCTIONS Prepares for possibility of pregnancy every month. Shelters and facilitates the nourishment of the fetus. Nourishment is from the mother through the placenta. Expels the products of conception through the labour process.

Blood supply Through uterine artery, a branch of the internal iliac artery. Ovarian artery, a branch of abdominal aorta provides supply back up. venous drainage follow the same course. This excellent network of supply from major vessels, makes the uterus highly vascular.

Cont’d Nerve supply Mainly from the autonomic nervous system. Sympathetic and parasympathetic through the pelvic plexus. LYMPHATIC DRAINAGE Uterine body drains to the internal iliac glands while cervical areas drains into various pelvic lymph glands. Uterine infection under normal circumstances, does not occur because of the good drainage network.

UTERINE SUPPORTS Pelvic floor is the main supportive factor , through various ligaments maintain the position. Those attached to the cervical level are the most important. They are:- THE TRANSVERSE CERVICAL LIGAMENTS Also referred to as cardinal or mackenrodt’s ligaments. Spreads out from the lateral aspect of the cervix to the side walls of the pelvis. Results from thickening of the broad ligaments lower margin.

contd THE PUBOCERVICAL Originates from the anterior aspect of the cervix. Passes forward, under the bladder to be inserted to the anterior aspect of the pubic bones. Pulls the cervix forward. THE UTEROSACRAL Spreads from the posterior surface of the cervix, passes backwards, to be inserted to the sacrum. Pulls the cervix backwards. Therefore pubocervical and uterosacral ligaments maintains the uterus in position.

contd THE BROAD LIGAMENTS Are formed from a double fold of the peritoneum draping over the uterine tubes. Hangs like wings/curtains extending from the entire lateral margin of the uterus to be inserted to the lateral aspect of the pelvic side walls. THE ROUND LIGAMENTS They originate from the cornua , but anteriorly and inferiorly to the insertion of each uterine tube. Passes between broad ligaments folds, through the inguinal canal to be inserted into each of the labia majora . Maintains the uterine anteverted position though minimally.

ct THE OVARIAN LIGAMENTS Originates from the cornua , but posterioly to the uterine tubes. Inserted to each of the ovaries after passing between broad ligament folds. NB: Round, ovarian ligaments and uterine tubes originate from the cornua and resemble closely on inspection. For successful bilateral tubal ligation (BTL) specific identification is mandatory.

A DIAGRAM OF THE SUPPORTS OF THE UTERUS…..(pg 87)

4.UTERINE TUBES Synonymes :- Fallopian tubes, Salpinges and Oviducts, Definition Are 2 thin tubular structures running laterally from the cornua to the ovaries and each measures about 10cm long. AREAS (PARTS) Based on location in relation to the cornua . 1.Interstitial (intramural)

contd It is the first part, lying within the uterine walls, i.e. between the fundus and the body. Measures about 1.25cm long with a lumen diameter of 1mm. 2.Isthmus It is the narrowest part immediately adjoining the uterus. Measures 2.5cm long. 3.Ampulla It is about 5cm long and lumen diameter 2-3cm.

4. I nfundibulum( fimbriated / fringed end) A funnel shaped fringed end which overhangs near the ovaries. Comprises of many finger-like projections referred to as fimbriae . The longest of all is known as ovarian fimbria. Its purpose is to direct the ovum to the specific tube since the fimbria is attached to the ovary.

RELATIONS Peritoneal cavity and intestines lies anteriorly, posteriorly and superiorly. Inferiorly are the broad ligaments and ovaries Laterally are the side walls of the pelvis. Medially Uterus located between the two(2) tubes

LAYERS Are three (3) namely: i ) Innermost lining It is a mucous membrane made of ciliated cuboidal epithelium thrown into folds known as plicae . The purpose of plicae is to slow down the ovum’s passive movement hence some development processes occur. Presence of goblet cells on the same lining sustains the ovum since they produce glycogen containing secretions.

contd ii) Middle layer Comprises of a thin muscular coat similar to that of the uterus Inner fibres arranged in circular and longitudinal form to produce peristaltic movements. Therefore, in conjunction with ciliated lining and plicae, the peristaltic action convey to ovum to the uterine cavity on time. iii)The outermost layer It is a continuation of the peritoneum though the inferior surface is uncovered. However, the infundibulum portion passes through the peritoneum to open into the peritoneal cavity.

FUNCTIONS Facilitates passive movement of the ovum from ovary to uterine cavity. Provides a site for conception ,i.e. fertilization to occur. Provides nourishment of the fertilized ovum as it travels through Receives the spermatozoa (male gametes) from the uterine cavity as they travel upwards and eventually direct them to the ampulla .

contd Blood supply and lymphatic drainage Through uterine and ovarian arteries. Venous drainage follows the same course. Lymph drains to the lumber glands. Nerve supply It’s from the ovarian plexus.

5. OVARIES DESCRIPTION They are two (2) glandular organs, located in the peritoneal cavity, but attached to the broad ligaments. Each weighs 4-8gms ,and the right one is slightly larger. DEVELOPMENT At birth, each ovary contain/holds between 200-400,000 (2-4 hundred thousand) of primordial follicles . As the child grows and develop, some of these follicles undergo developmental processes such that they are eventually referred to as graafian follicles . Then as from puberty, each undergoes further development and finally release the ovum monthly.

RELATIONS Anteriorly - Broad ligaments. Superiorly - Uterine tubes Posteriorly - Are intestines Laterally, Infundibulo -pelvic ligament and pelvic side walls. Medially, Uterus and ovarian ligament , 2.5 cm long. NB: Since the ovaries and uterine tubes are closely related, together with their mesentries , they are collectively known as Adnexa or appendages

STRUCTURE Each ovary comprises of a medulla and cortex respectively. MEDULLA It is the innermost zone/supporting framework in which the ovarian blood and lymphatic vessels as well as nerves passes through. The site (area) of their entry to the ovary is referred to as Hilum Since at this site, the ovary is attached to the broad ligament, then the area is collectively known as mesovarium .

contd CORTEX It is the outer zone and the functional part, because it has ovarian follicles. They are surrounded by a connective tissue while the outer layer of the zone comprises of a fibrous tissue referred to as Tunica albuginea Over it is a modification of peritoneum known as Germinal epithelium .

contd FUNCTIONS Production of ova throughout the procreation period. Production of estrogen and progesterone hormones in preparation of the endometrium for pregnancy. BLOOD SUPPLY Ovarian arteries. Drainage is via ovarian veins in which the right ovarian vein empties into the inferior vena cava while the left one into the left renal vein.

LYMPHATIC DRAINAGE & NERVE SUPPLY As for the uterine tubes . ASIGNMENT: Read & make notes on the anatomy and physiology of the male reproductive system ( page 93-96) END QUESTION !

Twendelee …………. BREASTS

CROSS-SECTION OF THE BREAST

Also referred to as mammary glands DESCRIPTION Are compound secreting glands comprising of glandular parenchyma, fibrous and adipose. The latter serves as supporting tissues. Lie on the anterior aspect of the chest over the pectoral muscle.

Are accessory glands of the female reproductive system. NB: The amount of fat deposit determines the size. DEVELOPMENT As from a gestation of five (5) weeks. Mammary structures are located over the entire right and left anterior aspect of the body, from clavicle to inguinal region.

As fetal development progresses, normally most of them degenerate such that only two (2) remain on the anterior aspect of the chest. So at birth consist of a nipple and few vestigial ducts. As from puberty, the high levels of oestrogen and progesterone stimulates their growth & development as follows:- a. Generally they enlarge and assumes a characteristic hemispherical shape.

b. When mature, they extend from the 2 nd to the 6 th rib vertically, and from the sternum to the anterior axillary folds horizontally. c. Radiates upwards and outwards in a tail-like structure referred to as the Axillary tail. d. The nipple comprises of smooth muscle, erectile tissues and at the base is a hyperpigmented area, referred to as Areola .

STRUCTURE Each comprises of about 20 lobes . Lobes are separated by fibrous tissues known as septae . It runs from behind the nipple towards pectoral muscle. Also serves to localize infection. Each lobe consists of numerous lobules and each lobule ,opens into a small duct. Within a lobule is a collection of alveoli. Every alveolus consists of Acini cells , which produce milk under the influence of Prolactin hormone.

contd Lobules are connected to network of small duct that unites to form a centrally large excretory duct, known as Lactiferous duct The various lactiferous ducts converge towards the centre of the breasts just behind the nipple and each empties into a temporary milk reservoir known as Lactiferous sinuses ( ampulla ).

ct Milk is propelled to the ampulla due to the effect of oxytocin hormone acting on myoepithelial cells which lines the alveoli, ducts, sinuses and tubules. As the infant suckles, milk is led to its mouth through lactiferous tubules. However as milk accumulates at the ampulla, it’s prevented from automatically flowing out, by the action of the plain muscles which makes the terminal ducts contract.

contd NB: Adipose tissues are also located between lobes behind the breasts & under the skin hence the hemispherical shape is maintained. Acini cells are the functional part of the breasts BLOOD SUPPLY Arterial – mainly from internal mammary and upper intercostal (thoracic) arteries. Other source is Axillary arteries which is a branch of the sub- clavian arteries.

contd Venous drainage is through circular veins behind the nipple, which eventually empty to the internal mammary and axillary veins. Generally they are richly supplied prenatally and during the entire breast feeding period for adequate production of milk.

LYMPH DRAINAGE It is extensive and communicates between the two breasts. Therefore metastasis i.e. spread of malignant cells is very common. Main route is either the superficial or deep through internal mammary nodes and finally into the axillae and media sternum lymph vessels and nodes.

NERVE SUPPLY Sensory nerve endings are more around the nipple, hence facilitates ejection of milk. Supply is from the 4 th , 5 th and 6 th thoracic nerves which contains the sympathetic fibres . FUNCTION Nourishment of the infant for the first 4-6 months since breast milk is the deal food.

CAUTION Breast cancer is the 2 nd malignant killer disease in females. Ladies are encouraged to carry out, Self breast examination a week after menses. Gents: – To also have regular breast tissue examination. Breast cancer is usually fatal because of late diagnosis. QUESTIONS !! END

THE BONY PELVIS KARIBUNI

THE BONY PELVIS NORMAL FEMALE PELVIS ( Page 74 )

THE BONY PELVIS

1. Sacrum 2. Ilium 3. Ischium 4. Pubic bone 5. Pubic symphysis 6. Acetabulum 7. Obturator foramen 8. Coccyx Red line: Terminal line/pelvic brim.

DEFINITION It is a basin-like structure, connecting the vertebrae column to the lower limbs. SPECIFIC BONES Pelvis comprises of four bones (4) namely:- 1)INNOMINATE BONES Also referred to as the hipbone, ie a right &left. They are 2 (two) and forms the anterior and lateral aspect of the pelvis. Each comprises of 3 ( three) completely fused bones which meet at a socket known as Acetabulum . NB. Complete fusion is expected to occur at the age of 20-25 years. They are:-

LATERAL VIEW OF THE INNONIMATE BONES

a ) ILIUM It is the largest, uppermost and flared out part. Landmarks (important fixed points) are:- i )ILIAC CRESTS They are two (2) i.e. the right and the left, upon which the hands rests when placed on the hip (akimbo). ii ) ILIAC FOSA Are concave anterior surfaces just below the iliac crest. They form the false pelvis (not important in obstetrics) . iii ) ILIOPECTINEAL EMINENCE Roughened area at the junction of ilium and superior pubic rami .

iv ) ILIOPECTINEAL LINE Each is located on the inner aspect of the ilium as a ridge between the sacro -iliac joint and the respective iliopectineal eminence. NB. At each extreme of the iliac crest, are sharp pointed areas referred to as iliac spines. -Specific naming depends on the site. Anterior- superior, posterior- superior, Anterior-Inferior, Posterior-Inferior .

b ) ISCHIUM Forms the lowest part of each of the innominate bone. Landmarks are:- i ) Ischialtuberosities - Right and left tuberosity . They are large prominences upon which the body rests on sitting position. ii) Ischial spines Located posteriorly and superiorly to the tuberosities . Are two(2) inward projections, very important during the monitoring of the labour process.

c) PUBIS (PUBIC BONE) Makes the anterior aspect . C onsists of a body , two oar-like projections , as well as the superior and inferior rami respectively. Important landmarks are:- i ) Symphysis pubis A joint at which the 2 pubic bones meet anterior. ii) Pubic arch (angle) Formed at the junction of the two (2) inferior pubic rami . iii) Obturator foramen It is a hollow space enclosed by the pubic body , rami and ischium .

CONCLUSION Posteriorly of each innominate bone are 2 curves namely; Great sciatic notch :- Located between the posterior inferior iliac spine and ischial spine. Lesser sciatic notch:- Located between the ischial spine and the tuberosity on each side.

2.SACRUM Forms the upper middle posterior aspect of the pelvis. Comprises of 5 fused vertebrae. Land marks are:- i ) SACRAL PROMONTORY / PROMONTORY OF THE SACRUM It is a forward protrusion on the anterior surface of the first (1 st ) sacral veterbra . ii) HOLLOW OF THE SACRUM It is the concave shaped anterior aspect of the sacrum immediately below the sacral promontory. Wings / alae are formed by lateral extension of the sacrum. iii)SACRAL ILIAC JOINT Located at the junction of the alae and the ilium .

CONCLUSION Sacrum has 4( four) pairs of foramina (holes) through which nerves of cauda equina passes to supply the pelvic organs/ structures. It’s posterior aspect is rough to provide attachment to muscle. 3.COCCYX Comprises of 4(four) fused vertebrae forming the vestigial tail. The only landmark is:- Sacrococcygeal joint . Situated at the junction of 5 th (fifth) sacral vertebra and 1 st (first) coccygeal vertebra.

PARTS OF THE PELVIS True pelvis Comprises of brim ,inlet, cavity and outlet . This provides the ideal bony canal which the fetus passes in order to be born . In upright position gynaecoid pelvis inclination is:- Brim 60 , cavity 30 and outlet 15 .

AREAS OF THE BRIM / INLET (PAGE 79)

BRIM/ INLET Determines the shape of the pelvis since it is the upper most area/part. Comprises of eight (8) landmarks. Anteriorly are :- Upper inner borders of symphysis pubis (8) Upper inner borders of body of pubic bone. (7) Superior ramus of the pubic bone (6)

Laterally :- iliopectineal eminence (5) iliopectineal line (4) Posteriorly :- sacral- iliac joint (3) alae of sacrum (2) sacral promontory (1)

CAVITY Lies between the inlet and the outlet . Generally circular in shape. The anterior aspect comprises of symphysis pubis and bodies of ischium and part of ilium . Posteriorly- hollow of sacrum The anterior aspect is shallow hence measures 4cm deep, while posterior aspect measures 12cm because of the well curved hollow of the sacrum.

OUTLET Described in two (2) aspects as follows:- i ) THE ANATOMICAL Formed by lower borders of each of the bones together with the sacrotuberous ligaments. Anteriorly - pubic arch and the inferior pubic rami . Laterally – ischial tuberosities , sacrotuberous ligaments, sciatic notches and ischial spines. Posteriorly - the coccyx.

ii) THE OBSTETRICAL It is the most important part because it describes the space available for the fetal passage. Includes the narrow pelvic strait which lies between sacrococcygeal joint, ischial spines and pubic arch. Therefore the obstetrical outlet is the space between the narrow pelvic strait and the anatomical outlet, hence diamond in shape. NB : i) Ischial spines level, forms the upper transverse border. ii) Intertuberous space, forms the lower transverse border.

DIAMETERS

DIAMETERS OF THE PELVIC BRIM They are imaginery straight distances between two standardized points. 1.BRIM – There are four as follows a) Anteriorposterior Also known as the Obstetrical conjugate because the fetal head must pass through it, to enter the pelvis. It is measured from the centre of the sacral promontory to the upper inner border of the symphysis pubis. It excludes the bones thickness. measures 11cm .

contd b)Oblique There are two (2) and each is measured from one sacro -iliac joint to the iliopectineal eminence on the opposite side. They are named according to the specific sacro -iliac joint. Each measures 12cm . c)Transverse It is measured between the points furthest apart on each of the iliopectineal line, i.e. right and left. It measures 13cm.

d) Sacro-cotyloid They are two and each is measured from sacral promontory to the ileopectineal eminence on each side. Measures 9.0-9.5cm. NB . Important only in occipitoposterior position ( malposition ). 2.CAVITY All diameters are estimated to measure 12cm each because the area is circular.

3.OUTLET They are normally three (3) a) Anterior posterior Measured from the lower border of symphysis pubis to the sacrococcygeal joint. It measures 13cm. The diameter represents the pelvic strait. b) Oblique They are two and each is estimated to measure 12cm. c) Transverse Measured between the ischial spines hence referred to as bispinous diameter. Measures10-11cm. It is universally accepted to measure 11cm .

OTHERS All, aims at estimating anterior posterior diameter of the brim/inlet. They are:- 1.DIAGONAL CONJUGATE Measured from the lower border of symphysis pubis (pubic arch) to the sacral promontory during digital pelvic assessment. It measures approximately 13cm. 2.TRUE(ANATOMICAL) CONJUGATE Measured from the centre of the sacral promontory to the highest point (summit) of the symphysis pubis, through an x-ray. It includes the bones thickness hence measures 12cm.

SUMMARY- DIAMETERS FUNCTIONS – PELVIS Protection of its organs and to a lesser extent abdominal contents. Transmission of the trunk’s weight of the sitting body to the ischial tuberosities . A-P OBLIQUE TRANSVERSE INLET 11 12 13 CAVITY 12 12 12 OUTLET 13 12 11

CONTD The sacrum facilitates the distribution of nerves to various parts of pelvis and lower limbs. Allows movement of the body especially walking, running etc. Forms a bony passage through which the fetus passes during labour .

TYPES/CLASSIFICATION – PELVIS Are grouped into two (2) namely l .INHERITED : Occurs due to genetical link and racial characteristics. They are determined mainly by the shape of the brim. 1) GYNAECOID Normal pelvis designed for child birth purposes. Found in 50% of women, who are of average height and build, wears shoe size 4 or larger. Clinical features. Rounded brim i.e. brim is round Fore pelvis generous i.e. spaceous .

contd Side wall straight Cavity shallow and round Sacrum broad and well curved Ischial spines blunt/flattened not prominent Sciatic notch rounded/wide Sub-pubic angle 90 NB: Pelvic bones are light Labour – normal

2. JUSTO MINOR A gynaecoid pelvis in which all the diameters are reduced proportional. Found in those whose height is less than 150cm and shoe size less than 4. Labour outcome depends on the size of the fetus.

3.ANDROID Referred to as the male pelvis Found in 20% of female/women, who are short, heavily built and tend to be hirsute( hairly ) Clinical features . Brim is heart-shaped such that the anterior aspect is angulated while the posterior is spaceous . Forepelvis is narrow. Side walls are convergent.

Cavity funnel shaped and deep. Ischial spines prominent. Sciatic notch narrow and deep. Sacrum is straight hence A-P diameters of cavity and outlet are reduced respectively. Sub-pubic angle is less than 90 i.e the acute. NB: Bones generally heavy. Labour very difficult – caesarean section.

contd 4. ANTHROPOID So, called because it resembles the apes pelvis. Found in 25% of women who are tall i.e. height above 158cm and have narrow shoulders clinical features Brim is long, oval in shape hence anterior posterior diameter is longer than the transverse.

Forepelvis is narrowed. Side walls are divergent. Sacrum narrow, long because it has six (6) vertebrae instead of five (5) but well curved. Rest, as in gynaecoid pelvis. NB: Labour is very easy – precipitate labour

5.PLATYPELLOID Also referred to as flat pelvis. Found in 5% of women clinical features Brim is kidney shaped such that the anterior posterior diameter is reduced and transverse increased.

Side walls diverge Cavity is shallow Sacrum is flat Rest, as in gynaecoid pelvis NB Labour is prolonged & it’s aided by use of instruments

Summary of features of inherited pelvis

II ACQUIRED/DEFRORMED PELVIS Results from either intra uterine developmental anomalies, dietary deficiency , disease during childhood as well as trauma/injury. The general effect is reduction of one or more diameters hence normal delivery is impossible

They are:- 1. RACHITIC Brought about by rickets during childhood Sacral promontory is forced downward and forward towards the symphysis pubis as the weight of the trunk gets transmitted to the softened pelvic bones. The lower end of the sacrum swings backwards such that, ischial tuberosities get further apart and pubic angle widens.

contd The brim becomes grossly deformed depending on the severity of the disease hence caesarean birth . Precisely, mode of delivery depends on the severity and size of the fetus. 2. OSTEOMALACIC Results from deficiency of calcium in adulthood. It leads to gross pelvic contraction since the pelvic brim becomes a Y-shaped slit.

contd It’s a rare deformity ,caesarean section is the only mode of delivery. 3. ASYMMETRIAL (NAEGELE’S) Results from intra-uterine developmental anomalies in which one sacral ala is missing hence sacrum is fused to the ilium directly. Can also result from exertion of unequal pressure on the growing pelvis.

Associated with either poliomyelitis , uncorrected congenital hip dislocation as well as trauma during childhood, in form of either pelvis or femur fracture . Bony fusion occurs on the side of intense pressure ,such that the brim becomes obliquely contracted since only one ala develops. 4. ROBERTS It is a rare deformity in which there is either congenital absence or poor development of the alae bilaterally leading to a too small brim.

PELVIC FLOOR DESCRIPTION It is formed by the soft tissues that fill the outlet of the pelvis. Muscles hang from the pelvis side walls to meet at the centre of the perineal body forming a sling-like hammock. Are penetrated by three (3) canals namely, anal posteriorly , vagina medially and urethra anteriorly .

contd

CLASSIFICATION Refers to the muscle layers which are grouped into two (2) namely. I . SUPERFICIAL LAYER Comprises of five (5) muscles. 1) THE EXTERNAL ANAL SPHINTER It surrounds the anus hence voluntarily control defecation. Then its attached behind to the coccyx by a few fibres . 2) THE TRANSVERSE PERINEAL:- They are a pair. Each originates from the respective ischial tuberosity to be inserted to the centre of the perineum.

contd NB: They can be damaged during birth process. 3) THE BULBOCAVERNOSUS:- Are a pair. Originates from the perineum, passes forward around the vagina. Finally are inserted to the corpora cavernosa of the clitoris just under the pubic arch. NB: They are highly succeptible to trauma during delivery

4)THE ISCHIOCAVERNOSUS:- A pair. Each originates from the respective ischial tuberosity , pass along inferior pubic rami , pubic arch,eventually inserted to the corpora cavernosa . 5) THE MEMBRANEOUS SPHINCTER OF THE URETHRA Comprises of muscle fibres passing above and below the urethra, from one pubis bone to be attached to the other pubic bone. Its not a true sphinter , because the muscle doesn’t encircle the urethra but closes the urethra as the muscle contract.

II. DEEP LAYERS Comprises of three (3) pairs of muscles namely: 1. THE PUBOCOCCYGEUS Together with puborectalis , they originate from the posterior aspect of the inferior pubic rami . Then passes ( pubococcygeus ) around the rectum to be inserted on the coccyx and lower part of the sacrum. A few fibres cross over to be inserted to the perineal body forming its deepest part.

2. THE ISCHIOCOCCYGEUS Begins from the Ischial spines and the adjacent sacroiliac fascia. Then are attached to the coccyx, lower sacrum and medium portion of sacrotuberous ligaments. 3. THE ILIOCOCCYGEUS Starts from the fascia covering the obturator internus muscle, then directed posteriorly and medially. They converge with the pubococcygeus and finally gets inserted into the coccyx.

NB: Pubococcygeus , puborectalis and iliococcygeus are collectively known as levatores ani . They stabilise the pelvic structures into their respective positions and give support against exertion of increased abdominal pressure e.g. cough, defecation, urination etc Ischiococcygeus and levatores ani form the pelvic diaphragm .

Triangular ligament refers to the tissue that fills the triangularly space between bulbocavernosus , Ischiocavernosus and transverse perineal muscle. FUNCTIONS Supports the weights of pelvic and abdominal organs/structures. Plays a major role during copulation, in that ischiocavernosus muscle contracts leading to arousal while bulbocavernosus contraction and diminishes the size of the vaginal orifice.

ct Controls acts of micturition and defecation. Facilitates passive movements of fetus through the birth canal and eventually delivery. END! QUESTIONS?

THE FOETAL SKULL

AERIAL VIEW OF THE FOETAL SKULL Fetal head viewed from above( ariel view)

DEFINITION Refers to the bony structure of the fetal head which basically comprises of vault, face and base. RATIONALE FOR LEARNING Skull encloses the delicate brain, among other structures which may be subjected to trauma during labour process.

ct Head is slightly larger naturally, compared to the true pelvis, hence some adaptation must occur during the labour process. Head is the most difficult part, to be born whether it comes first or last, irrespective of its size. Some universal standardized areas helps to diagnose the course of labour hence intervene as necessary.

SKULL DEVELOPMENT Bones of the vault originates from membranes while those of the face are from cartilage. Ossification starts as from the 8 th week of intra uterine life. At birth, face bones are completely ossified, fused together and firm, while those of the vault are much flatter and more pliable.

Vault bones, ossify from the centre outwards such that at birth the process is incomplete hence small membranes spaces are present at the edges. Centres of ossification becomes important landmark known as eminences or protuberance . NB: The small membraneous spaces facilitate slight overlapping of the skull bones hence reduce the size of the fetal head during the labour process.

REGIONS AND LANDMARKS

Lateral view of the fetal skull

1 . THE VAULT It is the largest, dome-shaped compressible part. Anteriorly there is the orbital ridges. Laterally temporal bones . Posteriorly the nape of the neck. ** The area is compressible due to presence of small membraneous spaces.

It is made up of three (3) areas namely:- SINCIPUT/BROW Forms the anterior aspect of the vault. Extends from the anterior fontanelle and coronal suture to the orbital ridges. VERTEX It is the middle aspect. Bounded anteriorly by the anterior fontanelle , laterally by parietal eminence and posteriorly by posterior fontanelle . THE OCCIPUT Forms the posterior aspect, hence entirely over the occipital bone i.e. between posterior fontanelle and foramen magnum.

2.THE FACE Located on the anterior, inferior aspect of the skull. Extends from orbital ridges and root of the nose, to the junction of chin and neck, collectively referred to as submento region . Face is small in newborn and comprises of 14 small bones, which are firmly united hence non-compressible. NB: -Chin is also known as mentum . - Glabella refers to the central point between the eyebrows.

3. THE BASE Comprised of firmly united bones to protect the vital centres in the medulla. MAIN VAULT BONES They are five (5) namely: The occipital :- Lies at the back of the head. At the centre is the occipital protuberance. .Contribute to the formation of the base, since it contains foramen magnum.

The two (2) parietal bones :- Lies at the middle part of the skull. Each has an ossification centre known as parietal eminence when referring to both are biparietal eminences .

The two (2) Frontal bones:- Located on the anterior aspect, hence form the forehead or sinciput or brow. Frontal eminence is located at the centre of each . The two bones fuse into one by the age of 8years. NB: The upper part of the temporal bone on each side, also forms a small part of the vault.

SUTURES DEFINITION Are membraneous spaces between bones of the vault, i.e. where two (2) bones adjoin. Sutures are cranial joints and are formed where two bones adjoin. Where two or more sutures meet, a fontanell is formed. The important sutures are four (4) namely:- 1. THE FRONTAL Runs longitudinally, between the two (2) frontal bones, as from the glabella to the anterior fontanelle .

2. THE CORONAL Runs transversely from one temporal bone to the other, hence separates the frontal bones from the parietal bones. 3.THE SAGITTAL Extends from anterior fontanelle to posterior fontanelle , such that it lies between the two parietal bones. 4.THE LAMBDOIDAL SUTURE Shaped like the Greek letter lambda & runs transversely hence separates the occipital bone from the parietal bones. NB: Apart from the frontal suture, the others fuse during infancy stage and become fixed joints.

FONTANELLES DEFINITION They are membraneous spaces where two (2) or more sutures meet. Those of importance are 2 namely:- 1.THE ANTERIOR FONTANELLE (BREGMA) Located at the junction of frontal, coronal and sagittal sutures.

CLINICAL FEATURES Its broad (large) with average measurements of 3-4cm long and 1.5-2cm wide. Kite/diamond shaped and easily recognized on vagina examination since a suture leaves each of its 4 corners. Cerebral vessels pulsation is observed and felt through it. Particularly during infancy stage. Normally closes (fuses completely) by the age of eighteen (18) months i.e. 1 ½ years.

2.THE POSTERIOR FONTANELLE (LAMBDA) Situated at the junction of sagittal and lambdoidal sutures. CLINICAL FEATURES Its triangularly shaped. Quite small compared to anterior fontanelle . Identified per vaginally, because a suture leaves each of its three (3) angles/corners. Spontaneously/uneventfully closes by the age of six (6) weeks. NB// The sutures and fontanelles , because they consist of memberanous spaces, allow for a degree of overlapping of the skull bones during labour and delivery ( Moulding ).

DIAMETERS OF THE FOETAL SKULL Diagrams (page 138)

ILLUSTRATION OF A-P DIAMETERS

TRANSVERSE DIAMETERS

DIAMETERS CT’ Refers to measurements of the skull at specific landmarks, in order to understand the relationship between fetal head and maternal pelvis. Grouped into two (2) namely: 1.ANTERIOR POSTERIOR DIAMETERS They are six (6) , three (3) relate to the occiput and the rest to the mentum hence named respectively.

1. SUBOCCIPITOBREGMATIC (SOB) = 9.5cm Measured from below the occipital protuberance to the center of the anterior fontanelle . 2.SUBOCCIPITOFRONTAL (SOF) = 10CM It’s measured from below the occipital protuberance to the center of the frontal suture or sinciput 3.OCCIPITOFRONTAL (O.F.) = 11.5cm Measurements are taken from the occipital protuberance to the glabella .

4. SUBMENTOBREGMATIC (SMB) = 9.5cm Measured from the junction of the chin and neck (submento region) to the center of the bregma . 5. SUBMENTOVERTICAL (SMV) = 11.5cm Measurements are from the junction of the chin and neck to the highest point on the vertex. 6. MENTOVERTICAL (M.V.) = 13.5cm Measured from the tip of the chin ,to the highest point on the vertex.

II.TRANSVERSE DIAMETERS They are two namely:- 1. BITEMPORAL DIAMETER = 8.2cm Measured between the furthest point of the coronal suture at the temples. 2. BIPARIETAL DIAMETER = 9.5cm Measured between the two (2) parietal eminences. END

FETAL CIRCULATION Diagram - Fetal circulation

WHY FETAL CIRCULATION IS SPECIAL Blood becomes oxygen saturated at the placental bed. The heart, brain and upper body receives blood from the left ventricles while the rest of the body receives blood from both ventricles.

NB Blood have to pass through temporary structures which is not the case after birth. Fetal haemoglobin ( HbF ) is produced by the yolk sack between the 3 rd -13 th week and the liver between the 5 th -36 th week . It’s ( HbF ) different from adults ( HbA ), so that it obtains adequate oxygen levels from the placental bed.

Bone marrow begins to manufacture haemoglobin from the 12 th week and CT life long At term, the ratio of HbF to HbA is 80:20. By six months of age, HbF is highly haemolysed such that it is only 1% i.e. the infants haemoglobin is HbA .

TEMPORARY STRUCTURES Apart from the placenta and the umbilical blood vessels, there are four (4) other temporary structures within the fetal body which facilitates fetal circulation . Namely :- 1.DUCTUS VENOSUS Connects the umbilical vein to the inferior Vena Cava after the vein branches to supply the liver.

contd Therefore, the liver receives the purest oxygenated blood hence, early maturity. At the inferior vena cava, the oxygenated blood mixes with the deoxygenated blood returning from the lower parts of the body, then it is emptied into the Right atrium.

contd NB. ( i ) The umbilical vein is the only structure that carries unmixed blood. However, the oxygen content is approximately 80% ,because 20% as been used up for the placental active metabolism. (ii)The oxygen content of the blood in the right atrium is approximately 65%.

contd 2. FORAMEN OVALE (OVAL OPENING) It is an opening between the right and the left atria. Located between the two (2) atria. It allows most of the blood entering the right atrium from inferior vena cava to be diverted (channeled) to the left atrium, then to the left ventricle and pumped to the aorta. So pulmonary circulation is bypassed, because blood is already oxygenated ,and lungs are non-functional.

contd 3. DUCTUS ARTERIOSUS It leads from bifurcation of the pulmonary artery to the descending aorta thus connects the pulmonary artery to the aorta. It is situated between the bifurcation (division) of the pulmonary artery and the descending aorta, precisely just below where subclavian and carotoid arteries leave.

contd Deoxygenated blood from the head and upper limbs is channeled straight to the right ventricle due to:- i ) The high pressure within the superior vena cava. ii) The shape of the right atrium. Irrespective of the mentioned about 25% mixing, with the fairly oxygenated blood from the inferior vena cava occurs.

contd As the ventricles contract, blood is pushed into the pulmonary artery ,where only a little gets into the lungs to supply its tissues. Most of it gets channeled to the aorta. By this time, the oxygen content is about 60% hence still good enough to supply the rest of the body parts.

4. HYPOGASTRIC ARTERIES They are two (2) vessels which branch off from internal iliac arteries. They carry completely deoxygenated blood and become umbilical arteries on entering the umbilical cord. These convey the deoxygenated blood to the placental bed through specific terminal vessels, then the circulation restarts.

NB i ) The heart, brain and upper limbs are the 2 nd areas to be supplied with more oxygenated blood with about 65% oxygen content. ii) Upper limbs are more developed at birth compared to the lower ones. iii) The circulation takes half a minute to occur hence higher rate of the F.H.S. iv) Direct mixing of fetal and maternal blood doesn’t occur.

PLACENTAL CIRCULATION The maternal blood is delivered to the placental bed in a pulsatile rhythm, by spiral arteries. It flows into a pool, known as the blood or intervilli space. The direction of flow is likened to a fountain. It is so because, blood passes upwards and baths each of the villus as it circulates around it slowly.

contd Simultaneously, fetal blood which is low in oxygen content and loaded with waste products of metabolism, flows through the umbilical arteries initially, then their branches and finally to the capillaries of the chronic villi . Through simple diffusion :- i ) Carbon dioxide and waste from the fetus are given off to the maternal circulation

contd ii)Then oxygen and nutrients are absorbed. The blood thereafter returns to the fetus through the umbilical vein.

In summary, the fetal circulation takes the following course: Oxygenated blood from the placenta travels to the fetus in the umbilical vein. The umbilical veins divide into 2 branches; one that supplies the portal vein in the liver, the other ductus venosus joining the inferior vena cava Most of the oxygenated blood that enters the right atrium passes across the foramen ovale to the left atrium & from here into the left ventricle, & then the aorta The head & upper extremities receive approximately 50% of this blood via the coronary & carotid arteries & the subclavian arteries respectively

Deoxygenated blood collected from the upper parts of the body returns to the right atrium in the superior vena cava. Blood that has entered the right atrium from the superior vena cava & inferior vena cava passes into the right ventricle Most blood passes through the ductus arteriosus into the descending aorta & supplies the lower body & consequently, deoxygenated blood travels back to the placenta via the internal iliac arteries, which lead into hypogastric arteries, which later lead into umbilical arteries.

ADAPTATION TO THE EXTRA UTERINE LIFE At birth, when the baby takes the 1 st breath, blood is drawn to the lungs through the pulmonary arteries. It is then collected and returned to the left atrium via pulmonary veins. The placental circulation ceases soon after birth. (less blood returns to the right side of the heart.) Pressure in the left side is greater than on the right side This results in the closure of flap over foramen ovale . (stops blood flow from right to left)

Establishment of pulmonary respiration results in the rise of oxygen concentration in the blood stream. This Causes the ductus arteriosus to constrict and close. The cessation of the placental circulation results in collapse of the umbilical vein, ductus venosus and the hypogastric arteries.

The structural changes become permanent and become as follows: Umbilical vein becomes the ligamentum teres . D V- ligamentum venosum D A- ligamentum arteriosum FO - fassa ovalis Hypogastric arteries - obliterated hypogastric arteries

Adaptation to extra-uterine life also involves: Maintenance of a nutritional state thru the establishment of breastfeeding Elimination of waste via the kidneys & gastro-intestinal system Temperature control Communication developed thru parent-child interactions END , QUESTIONS?

COMMON TERMINOLOGIES IN MIDWIFERY WELCOME

1.Midwife A trained & qualified person, who has been licensed by the state’s legal body of Nurses and Midwives (NCK), to care for a woman during pregnancy, labour and after delivery.

2. REPRODUCTIVE HEALTH WHO defines RH as the ability to have a responsible and satisfying sexual relationship and the ability to reproduce and decide when and how often to do so. It also includes unrestricted access to safe, acceptable and affordable information and reproductive health-care options.

3 .Traditional birth attendant(TBA) A woman mostly elderly and has given birth before, selected by the community to care for women during pregnancy, labour and after delivery. ** Commonly used in areas where health care facilities are sparsely located.

4. Prenatal ( Antenatal) It’s the period between conception and onset of true labour . 5.Gravid ( Cyesis ) Refers to pregnancy. E.g gravida 4, means on the 4 th pregnancy ever since she started conceiving. 6.Primigravida A woman who is pregnant for the very first time in her life.

contd 7.Multigravida A pregnant woman, who has previously, had more than one(1) pregnancy. 8.Parity Refers to the status of a woman in regard to the number of children (viable babies) , she has borne. For example:- Para 4(four) means, she has had 4 deliveries ,and each baby has been born as from a gestation of 24 weeks.

contd 9.Nullipara A woman who has never given birth to a viable baby. 10.Primipara A woman who has delivered only once in her life time. 11.Multipara A woman who has delivered more than one viable baby , but less than 4 times.

12.Grandmultipara Refers a woman who has delivered 4 or more children. Alternatively , a woman of high parity. 13.Intrapartum It’s the period of labour . That is, from onset of 1 st stage to completion of 3 rd stage. 14.Postnatal A period of not less than 10 or more than 28 days , after the end of labour . The mother and her newborn are continuously attended to, by the midwife.

15.Puerperium A period of 6-8 weeks after completion of 3 rd stage of labour , during which the uterus, and other structures affected by pregnancy, return to their non-gravid / pre-gravid state. 16.Pregnancy It’s a state in which, a living fertilised ovum is embedded/implanted into the uterus or elsewhere, and continues to develop as well as grow.

17.Normal pregnancy It’s pregnancy which lasts for 40(forty) weeks or 280 day or nine(9) calendar months and 1(one) week. No complications have occurred during the entire period. 18.Prolonged pregnancy(Post maturity) Refers to pregnancy that continues beyond 42 weeks or 294 days.

19.Presentation Refers to the part of the fetus which lies at the pelvic brim , during labour and in the lower pole of the uterus , prenatally. 20.Presenting part Part of presentation that lies over the dilating cervical os . 21.Leading part It’s part of presentation that touch the pelvic floor first and escapes from under the symphysis pubis.

22.Lie Refers to the relationship between the long axis of the fetus ,and the long axis of the uterus. 23.Attitude Relationship of the fetal limbs and head , to its trunk. **Normal is that of complete flexion and indicates vertex presentation.

24.Denominator Refers to the part of presentation that indicates the position. Or Part of presentation, used when referring to a fetal position. ** E.g , In vertex presentation, denominator is the occiput . 25.Position It’s the relationship of the denominator to the 6(six) areas of the brim.

26.Menarch Refers to the first ever occurrence of reproductive system cyclic events in a female. Or Onset of menstruation. 27. a) Eumenorrhoea Refers to normal, regular menstruation that basically lasts, for 3-5 days , although 2-7 days is also considered normal. b) MENORRHAGIA - denotes heavy menstrual bleeding i.e. >150 mls c) DYSMENORRHOEA: - denotes uterine cramps that women experience during menstruation. They are caused by uterine muscular contractions to expel the tissue

28.Abortion or miscarriage Expulsion of products of conception ( conceptus ) from the uterus before a gestation of 24 complete weeks . E.G , a woman who had an abortion with her 1 st pregnancy, and is now in her 2 nd pregnancy, is denoted as:- Gravida 2 Para 0 +1.

29.Show It’s a bloody mucoid discharge from the birth canal , that accompanies onset of true labour . 30.Labour Refers to the process by which the uterus expels its products of conception, as from 24 weeks of pregnancy.

31.Normal Labour Labour that occurs at term, spontaneuosly and fetus presents in vertex. The whole process is completed within 18 hours , through unaided maternal efforts. Minimal injuries or sometimes none, occurs to the mother and her newborn.

contd 32.Preterm (Premature) Labour It’s labour that occurs , as from the 24 th week, but before end of the 37 th week. 33.Precipitate Labour Labour that takes less than 3 hours for the whole process to be completed. It’s accompanied by extremely quick delivery.

34.Prolonged Labour It’s labour that takes more than 24 hours for the whole process to be completed. 35.First stage of labour Refers to the period , marked as from onset of true labour , to full dilatation of the cervix. 36.Second stage of labour The period marked from, full dilatation of the external cervical os , to complete expulsion of the fetus.

37.Third stage of labour Period marked from, birth of the baby, to expulsion of placenta, membranes and control of the intial excessive bleeding. 38.Fourth stage of labour It’s a period of 1(one) hour following completion of third stage , during which the mother and her neonate are closely observed for signs of shock. It is the first part of puerperium .

39.Low birth weight baby Refers to a baby whose birth weight is 2500gm or less, despite of the gestation period. 40.Preterm(Premature)baby A baby born as from the 24 th week, but before 37 complete weeks of pregnancy. 41.Light(Small) for gestation This is a baby born at term, but , birth weight is below the 10 th centile . **Common causes are intra-uterine growth restriction and genetical factors.

42.Asphyxia neonatorum It’s a condition whereby the baby failures to establish normal respirations or to cry at birth. 43.Stillbirth(SB) A baby born after 24 weeks gestation , but does not show any sign of life. 44.Fresh stillbirth(FSB) A baby who has died during the process of labour , due to a sudden complication.

45.Macerated stillbirth(MSB) This is a baby who has died before the onset of labour , and has been retained for sometime. At birth the body has decomposed. 46.Perinatal death Refers to either stillbirth or neonatal death within the 1 st week of birth. **NB Perinatal , means around birth.

47.Neonate(Newborn) This is a newly born baby, whose age ranges between 0-28 days. 48.Infant A baby who is less than one(1) year old. 49.Antepartum haemorrhage Bleeding from the genital tract after 24 weeks of pregnancy, but before the onset of true labour .

50.Intrapartum haemorrhage Refers to bleeding through the genital tract after the onset of labour , but before completion of 2 nd stage of labour . 51.Postpartum haemorrhage Excessive bleeding from the genital tract , at any time following the birth of the baby, up to six(6) weeks after delivery. 52.Lochia Normal bleeding through the genital tract, after conclusion of 3 rd stage. It continues for the 1 st , 2-3 weeks of puerperium .

53.Quickening Refers to the first fetal movements, felt by the mother. 54.Lightening It’s a relief experienced in late pregnancy, i.e , after 36 weeks , as the presenting part sinks into the lower uterine segment. The fundus ceases to press on the diaphragm. Specific causes of sinking of presenting part are:- - Complete development of the lower uterine segment. - Relaxation of the pelvic floor.

55.Engagement A situation where the widest transverse diameter, of the presentation passes through the brim. This indicates brim adequacy. 56.Caput succedaneum A birth trauma characterised by an oedematous swelling on the fetal/newborn’s head. Results from pressure between the presenting part and the dilating cervical os . Haemoserous fluid accumulates under scalp tissues.

57.Cephalhaematoma A birth trauma characterised by a hard swelling which develops on the newborn’s head. Results from friction between the bony pelvis and the specific skull bone(s). Blood collects under the periosteum .

Miscellaneous Ante = before Intra = within Post = after Neo = new Parturition = giving birth to a child. Parturient = being in labour or relating to child birth. END HAPPY!

THE MENSTRUAL CYCLE WELCOME

REPRODUCTIVE CYCLE

ct

Also referred to as the endometrial cycle . DESCRIPTION Refers to physiological changes that occur in the uterus/endometrium due to hormonal influence. They prepare it for reception of fertilized ovum at an average of every 28 days during the procreation period . It comprises of three phase , namely:- contd

1.THE MENSTRUAL PHASE Also referred to as menstruation/ bleeding/ menses or a period . Generally dwells for an average of 3-5days though 2-7days is also considered normal. The average blood loss ranges between 50-150mls . It should not be in clots, or capable of clotting, because of presence of plasmin enzymes from the endometrium.

The loss consists of endometrial shed , blood from torn capillaries and the dead unfertilized ovum/oocytes . Physiologically , it is the last phase. Follicle stimulating hormone release inhibitor (FSHRI) from hypothalamus is responsible for this phase. It influences the anterior pituitary gland (adenohypophysis) to stop secreting Luteinizing hormone. contd

2.THE PROLIFERATION PHASE Also referred to as regenerative phase . Occurs simultaneously with the follicular phase of the ovarian cycle. Last for about 10 days from the end of menses until ovulation occurs. The phase is highly influenced by oestradiol and other oestrogens. This hormone is secreted by the graafian follicle under the stimulation of follicle stimulating hormone from the anterior pituitary gland.

The specific activity of the phase is regrowth and thickening of the endometrium . Eventually, endometrium comprise of three layers namely:- i)BASAL LAYER Lies immediately above the myometrium and it is about 1mm thick. ii)FUNCTIONAL LAYER Contains tubular glands. Lies on top of the basal layer and it is approximately 2.5mm thick. It is highly influenced by ovarian hormones . contd

iii)CUBOIDAL CILIATED EPITHELIUM :- It is the uppermost layer. Covers the functional layer and dips down to line the tubular glands in the previous layer. In the ovary the dominant follicle ruptures releasing the ovum, and process is collectively referred to as OVULATION . This marks the end of the phase.

NB. As the endometrium regrows , the graafian follicle is steadily maturing. Some women experience a sharp abdominal pain on the side of the specific ovary and the pain is known as Mittelschmerz . It results from irritation of the peritoneal cavity by the small amount of blood loss which collects there. The empty shell following ovulation is referred to as corpus luteum (yellow body). ct

The phase dwells for 14 days (2 weeks). The luteinizing hormone from the anterior pituitary gland, influences the corpus luteum to secrete progesterone and oestrogen hormones. 3. THE SECRETORY PHASE

The functional layer, increases in thickness to about 3.5mm. It becomes spongy in appearance since the glands are more tortuous. Blood supply is increased and nutritive secretions e.g. glycogen, are available. ct

If fertilisation does not occur, then the cycle restarts. Menstruation always occurs 14 days after ovulation. Prolonged or shortened cycle, results from the response of the proliferative phase. CONCLUSION

contd Pregnancy (physiological amenorrhoea ) is the only factor which interrupts the cycle in a healthy woman, during the childbearing period. Corpus luteum becomes a white body known as corpus albican and remains in the ovary while it degenerates steadily.

NB. The following incidences are abnormal. Heavy menses all through to the extent of developing anaemia , in the absence of artificial FP methods and the lady is below 24years. Flow duration of over 5days in the same age bracket. ct

Severe dysmenorrhoea which is incapacitating. Amenorrhoea for 2-3 months as from the age of 20years for no just cause. This is highly suggestive of hormonal imbalance which compromises fertility. contd

Involved hormones and source Monthly physiological changes occur in the ovaries and uterus due to hormonal regulation. These hormones are from hypothalamus, pituitary glands and ovaries. Hypothalamus secretes: i) Gonadotrophin Release Hormone (GnRH) ii) Follicle stimulating hormone release inhibitor

Pituitary secretes: FSH & LH. Ovaries secretes: Oestrogen & progesterone . ct END ! QUESTIONS?

FERTILISATION (CONCEPTION)

DEFINITION It is the process by which the male and female gametes fuse or unite. The process takes about 24 hours to occur i.e. as from ovulation and deposition of sperms .

BASIC ANALYSES OF GAMETES i ) Ovum It is the largest cell in the body ,with a diameter of about 0.15mm. It consists of three (3) layers namely; corona radiata ‘externally zona pellucida , medially cell membrane , innermost. It is released from the graafian follicle through ovulation .

ct ii) Spermatozoon (Sperm)/ Spermatozoa (Sperms) Spermatogenesis , occurs in the seminiferous tubules of the testes (testicles), by cells referred to as spermatogonia ,as from puberty. A mature sperm is very small as compared to the ovum because of presence of, sperm specific proteins known as protamines .

contd The protamines bring about compaction in the sperm. The benefit of the compaction is that a normal sperm is able to move fast on its own, as long as other environmental factors are favourable . Each sperm consists of 3 parts namely:- i ) Head It has a pointed end referred to as Acrosome . The Acrosome carries an enzyme known as hyaluronidase ( Hyalase ). A nucleus with chromosomes (genetic material) are also present.

ct ii.Body (Mid piece) It carries the mitochondria which provides energy for movement. iii.Tail It produces a whip-like movement hence propels the sperm quickly (fast) , at a speed of 2-3 mm per minute. ** Precisely , the generally purpose of the tail, is propulsion and motility.

CONCLUSION Each gamete undergoes a reduction process known as haploid . So, before fertilization each has 23 chromosomes, ie , 22 somatic and 1 (one) sex chromosome. The female’s sex chromosomes are xx ( gynaecogenic) and the male’s are xy ( androgenic) chromosomes. After fertilization, the two (2) gametes fuse to a single cell hence maintains the 46 chromosomes.

contd The coming together of the 2 (two) haploid sets of chromosomes is refered to as syngamy . It signifies the final stage of fertilization process. NB. The male (man) determines the sex of the fetus involuntarily.

FERTILISATION PROCESS During the first 7-10 hours after copulation ,as the sperms ascend the uterus and enter the uterine tubes, they mature ,hence capable of fertilization. In the uterine tubes they undergo a process known as Capacitation .

ct The process is initiated by uterine enzymes known as proteolytic . Together with some tube’s secretion, the glycoprotein coat on sperm is removed. This reactivates the acrosomal layer of the sperm, to release hyaluronidase enzyme.

contd The release process is known as acrosome reaction and the enzyme acts as a solvent. Simultaneously the ovum is passively propelled to the ampulla and also matures. At the ampulla the 2 (two) gametes meet and the process begins in that:-

contd The enzyme hyaluronidase disperses the corona radiata cells allowing access to zona pellucida layer. The head of the first sperm to reach the zona pellucida , penetrates the layer. **This is after many sperms have released adequate enzymes to break down the proteins of the zona .p layer. Thereafter, a chemical reaction referred to as cortical reaction occurs.

contd It alters the zona pellucida layer, through production of a sticky substance around it. The layer becomes impermeable to other sperms. The penetration process takes less than 20 (twenty) minutes. The sperm nucleus is released into the cytoplasm of the ovum and the 2 (two) nuclei fuses forming a single diploid cell, known as ZYGOTE .

FACTORS THAT F AVOUR CONCEPTION Timing of the fertile phase, 2 days in each cycle. Patency and healthy of the uterine tubes. Deposition of adequate sperm, in which ¾ are healthy in morphology and are motile. NB: i ) Normal Sperm count ranges between 200-400 millions, per ejaculate , since (N) amount of semen is between 2-4 mls . ii)On average , a health/ fertile male, deposits 300 million sperms per ejaculation.

contd iii) The semen should be healthy to facilitate coagulation immediately , hence assists to overcome the acidity of the vaginal media. iv)Thereafter semen should liquidify within 20 minutes. v) Persistent coagulation of semen = infertility because the sperms are held in (trapped). Vagina media should not be too acidic because it will kill most of the sperms.

DEVELOPMENT OF ZYGOTE The Zygote begins mitotic cell replication and division at a rate of once every 12 (twelve) hourly. The replication and division is referred to as cleavage . By the 3 rd -4 th day of cell division, a small cluster of cells forms, and it is known as the Morula . These cells bind tightly together in a process known as Compactation .

contd Thereafter the zona pellucida layer is shed off. Then a small fluid cavity appears inside the morula through a process known as cavitation . A small cluster of cells is pushed to one end, while a single layer surrounds the cavity forming a blastocyst/blastula . The process from development of morula to development of blastocyst is referred to as blastulation .

contd So, a blastocyst comprises of:- Inner cell mass ( E mbryoblast) , which forms, embryo, amnion membrane and umbilical cord. Cystic cavity ( blastocele ) , a small fluid cavity. Outer cell mass ( Trophoblast ) , which forms placenta and chorion membrane. During all these developments, the group of cells is being propelled towards the uterine cavity.

contd They are fed by goblet cells on the inner lining of uterine tubes. In the uterine cavity and before implantation occurs, blastocyst is nourished, by mucus from the secretory glands of the uterus. It lies freely in the cavity for 2-3 days, choosing the site for implantation purposes.

IMPLANTATION Also referred to as nidation /embedding. The process commences on about 6 th day after fertilization i.e. approximately 20 th days of the menstrual cycle. The area of blastocyst overlying the inner cells mass produces a sticky substance, which erodes the functional layer of the endometrium .

contd NB. - Slight (scanty) bleeding may be reported/observed by some women, and confused with scanty menstrual period. Thereafter the blastocyst burrows into that area. So, by the 11 th (eleventh) day after fertilization nidation is complete. Then the endometrium closes over it, leaving a small bulge at the site.

DEVELOPMENT OF THE BLASTOCYST It comprises of 2 (two) important areas namely:- I.TROPHOBLAST (OUTER CELL MASS) It’s a single layer of flattened cells ,located on the outer aspect of the blastocyct . Cells are grouped (differentiated) into 3 (three) layers namely:-

ct 1.Syncytiotrophoblast ( Syncytium ) It’s the outer most layer and comprises of nucleated photoplasm . Some root-like structures known as chorionic villi development on it. They open up maternal blood vessels ,making nutrients and oxygen, accessible to the developing embryo and later fetus.

ct 2.Cytotrophoblast It is a middle layer and comprises of a well defined single layer of cells. Its main role is production of Human chronic gonadotrophin (HCG) hormone. This hormone maintains pregnancy, by influencing corpus luteum ,to continue with production of oestrogen and progesterone hormones till placenta is fully functional.

NB: Oestrogen suppresses production of follicle stimulating hormone hence no other graafian follicle matures. Progesterone hormone maintains the prepared layer on the decidua . 3.Mesoderm (Primitive Mesenchyme ) It’s the innermost layer and comprises of loose connective tissue in which blood vessels of the cord grows. Inner cell mass has a similar tissue ,and the two are continuous forming the umbilical cord and its vessels.

II. INNER CELL MASS (EMBRYOBLAST) Develops concurrently with the trophoblast & are closely placed. Basically comprises of :- 1.Embryonic plate/ Epiblast Visible by the 4 th day after fertilization. It’s a cellular area where cells are grouped into three (3) primitive layers namely:- i )Ectoderm It’s the outer layer from which the skin, its appendages and nervous system forms.

ii) Mesoderm (middle layer) Bones, muscles, heart , blood vessels, blood and some internal organs forms from it. iii) Endoderm / Entoderm (innermost layer) Mucous membrane , of respiratory, digestive tract, urinary tract, various organs ,like liver & pancrease as well as some glands develop from it. Generally the embryo develops from these layers.

2. The two (2) sacs Each located on either side of the embryonic plate. i ) Amniotic sac (cavity) It lies on the side of the ectoderm( ie closely related to ectoderm). Its filled with fluid hence enlarges very fast to contain and protect the embryo. The amnion membrane forms from its lining. ii) Yolk sac / Hypoblastic layer Is closely related to the endoderm ( entoderm ). Its main role is to nourish the embryo until the placenta is fully developed.

contd Part of it, contributes to the formation of the primitive gut (intestines). The rest floats in front of the embryo like a balloon. As the placenta becomes fully formed the york shrinks and is enclosed under the amnion on the fetal surface of the placenta. At birth the remnants (York sac) is a vestigial structure known as vitelline duct , located at the base of the umbilical cord.

NB: The first two (2) weeks after fertilization (conception), until the appearance of the primitive streak ,is known as the pre-embryonic period . Primitive streak :- Refers to the first appearance of the 3(three) layers, observed as a long thin band of tissues ,at around the fifteenth(15 th ) day after fertilisation . Basically, pre-embryonic period is very crucial, hence determines the health of the fetus and the mother to some extent .

First 3 weeks development

SUMMARY – FLOW CHART FERTILISATION ZYGOTE MORULA BLASTOCYST TROPHOBLAST EMBRYOBLAST PLACENTA, chorion membrane FETUS, Amnion membrane and part of umbilical cord and part of umbilical cord .

QUESTIONS??? THANK YOU.

DECIDUA DEFINITION It’s the name given to the endometrium during pregnancy, because it is normally shed off, after delivery except, for the basal layer.

DEVELOPMENT The endometrium , increases four (4) times, its non-pregnant thickness, due to increased secretion of oestrogens . New blood vessels are formed and become functional in order to increase the blood supply. Progesterone hormone activates the secretory glands of the decidua and also relaxes the blood vessels.

contd Finally the decidua becomes a soft, highly vascular and spongy bed, in which the blastocyst implants. LAYERS -They are three (3) namely; 1.Basal Lies immediately above the myometrium and remains unchanged throughout pregnancy.

contd New endometrium regenerate from it during puerperium , for menstrual cycles to start and continue. 2.Functional (spongy ) Consists of torturous glands, rich in secretions. Its main role is to:- i ) Limit the invasion of the outer most layer of the placenta.

contd ii) Facilitates secure anchorage of the placenta. secretions of cytokines and protease inhibitors modulate the invasion also. The foundation cells are enlarged throughout pregnancy, to form a fibrous tissue known as decidua reaction .

contd Finally nutrients and gases are accessed from the mother, and during the 3 rd stage of labour placenta separation normally. 3. COMPACT Forms the uppermost surface of the decidua . Comprises of closely packed stroma cells and necks of glands. AREAS Based on how, each relates to the embryo.

contd i ) Basal or Basalis Lies immediately underneath ,the embryo ii Capsular or capsularis It is on top of the embryo. As growth and development continues it is pushed outwards. By the 16 th week of pregnancy it is in contact with parietalis decidua .

As pregnancy advances, finally capsularis thins and disappears. iii) Parietalis /True/Vera Refers to the rest of the decidua which is not in immediate contact with the embryo. END

EMBRYOLOGY

DEFINITIONS It’s the scientific study of embryo development. Embryo :- Refer to the developing offspring as from the 3 rd to the 8 th week after conception (fertilization).

LEARNING OBJECTIVES To understand when particular body parts start forming . To identify ways in which developmental abnormalities occurs.

HUMAN EMBRYO IN VARIOUS STAGES

DEVELOPMENTAL STAGES THREE (3) WEEKS The embryo is basically surrounded by the amniotic sac. On the sac’s outer aspect ,are chorionic villi , in a direct contact with the capsularis decidua .

contd On the inner aspect of the sac, the primitive streak becomes a prominent feature, hence identification of cephalic and caudal ends of the embryo. So no human characteristics are recognizable.

FOUR (4) WEEKS Also known as differentiation phase . Characteristic by rapid growth which continues through the next two (2) weeks. The embryo measures about 1 cm in length. Weighs about one (1) gramme . Amniotic sac measures about 2.5cm in length.

contd The embryo is curved and this helps to locate organs/structures in their correct positions . Specific developments includes:- Presence of a primitive nervous system, mainly in terms of visible forebrain, midbrain and hindbrain. Underdeveloped eyes, nose and ears identified as dots.

contd Small limb buds. The formative heart begins to function, though not fully developed anatomically. Its an S-shaped tubular organ known as embryonic bulbar trunk . Has only 2 vessels ,ie, inferior venacava and aorta.

contd Cardiac activities are recordable using a highly powered ultrasonic machine either trans-vaginal or trans-abdominally. The later is the most common route. NB: Exposure to teratogens (drugs or some organism) increases the risk of congenital abnormalities hence various cardiac malformations.

SIX (6) WEEKS The laid down parts continues to grow and develop, hence upper and lower limbs are correctly identified. Eyes are visible, grooves on the side of the head where external ears will develop are obvious. Oral and nasal cavities/structures begins to form.

contd Gonads develop as well, though differentiation occurs from the 7 th week. By the end of the 6 th week the head and trunk begins to straighten, though the head is much larger. EIGHT (8) WEEKS Embryo measures about 3cm long and weighs about 4gm

contd The amniotic fluid is about 5 to 10 ml. specific developments are:- Chorionic villi degenerate except for the area the sac is attached to the decidua . Degenerated chorionic villi forms the chorion membrane . Embryo begins to move but the movements cannot be perceived by the mother .

contd Human feature are obvious though it is impossible to identify the sex. Head persists, being larger than the trunk/body. Finally all the parts are laid down awaiting growth and development in the next 32 weeks. NB: The most crucial period for organs/systems development is between 4 th -8 th week. END

THE FOETUS

Definition Term applied to the unborn baby from the 9 th week of pregnancy, until delivery occurs. Objectives Enables age estimation, of a baby born before term. Explanation of how developmental abnormalities arise.

STAGES OF DEVELOPMENT Ten(10) weeks Kidneys are functional, ie, is making little urine, though anatomically immature. There is rapid growth of the liver, hence fill most of the abdominal cavity. Nails on the fingers start forming.

ct Twelve(12) weeks It’s about 10 cm long and weighs about 6o gm . Eyelids are fused . Sucking and swallowing begins , since digestive tract is formed and lumen patent. Fingers and toes are visible , though toe nails are abscent. Lanugo (fine downy hair) begins to appear on the skin. Gender is apparent, through radiological examination.

ct Sixteen (16) weeks Measures about 15 cm long and weighs about 170 gm . Meconium is present in the intestines. Quickening is reported by multipara. Nasal septum and the palate fuses, because of rapid skeletal development. There is rapid muscle coat development as well, particular that of the abdomen.

ct Twenty (20) weeks Fetus measure about 20 cm long and weighs about 300 gm . Vernix caseosa (greasy whitish substance) is present in small amount on the skin. In the lungs, production of surfactant begins , hence assists in gaseous exchange. Hair on the head and eyebrows begin to form. Skin cells begin to be renewed.

contd Auscultation of fetal heart sound using pinard fetalscope is possible. Quickening is reported by primigravidae . Twenty four (24) weeks Measures about 30 cm and weighs about 700 gm . The fetus is viable ,though survival rate is very poor , because of inadequate facilities and specialist personnel.

contd Skin is wrinkled because of lack of cutaneous tissue. Respiratory movements are present though gaseous exchange occurs at the placental bed. Eyelids are open, eye brows and eye lashes present. Various ear structures continue to develop .

ct Twenty eight(28) weeks Measures about 36 cm and weighs about 1100 gm (1.1 kg). Iron stores and subcutaneous tissue begins to form. For male, testes begin to descend from the abdominal cavity. In female, labia minora are prominent. Ear structures are fully formed, though pinnae is quite soft. Hair on the head is short , but different in texture compared to lanugo .

ct Thirty two(32) weeks Measures about 40 cm long and weighs about 1500 gm . Wrinkles have disappeared, skin less reddish and body more rounded, because of increased fat store. Lanugo disappears from the face. Testes starts descending to the scrotal sac. Planter creases begins to appear.

contd Nails reach the tip of fingers and toes. Survival rate is fair , with basic facilities of life support. Thirty six (36) weeks Measures about 45 cm and weighs about 2500 gm (2.5 kg). Vernix caseosa is plenty ie baby appears whitish coated at birth, and thereafter , for about 4 hours.

Measures about 45 cm and weighs about 2500 gm (2.5 kg). Vernix caseosa is plenty ie baby appears whitish coated at birth, and thereafter , for about 4 hours. Skin is pink because of increased layer of fat. Lanugo disappear from the body. Palmer creases are present. Ear cartilage is medially soft. Hair is long. Labia minora are slightly exposed. Survival rate is very high, since respiratory system is almost mature physiologically.

ct Forty (40)weeks Average measurements ranges between 45-55 cm and weight is between 3200-3500 gm (3.2-3.5 kg). Vernix caseosa is quite scanty. Skull bones firm (hard) and ear cartilage firm. Testes have descended to scrotal sac , and labia majora completely covers the minora respectively. The fetus is ready to be born.

ct NB Term , means as from the 38 th week. However, it’s normal for delivery to occur either 2 weeks before or after 40 th week of pregnancy. Exert weight and length, of baby at term depends on the genetical link.

contd Length is a better criteria for maturity than weight , due to immediate effect intrauterine malnutrition has on weight increase. Males are slightly heavier than females. HAPPY! END

THE PLACENTA

Also referred to as the afterbirth . DESCRIPTION It is a flat organ (spongy disc) at term, whose diameter is approximately 20cm. Thickness at the middle, approximately 2.5 cm, though thinner at the edges. Its almost round in shape. Weighs approximately 1/6 th of the baby’s birth weight. ct

DEVELOPMENTAL STAGES 3 rd -11 th week Chorionic villi i.e. minute, roots- like projection from the trophoblastic layer, covers the embryo completely externally. Those below the embryo, proliferate very fast due to excellent perfusion ,and become known as Chorion frondosum .

Those on top of the embryo, gradually degenerate forming chorion laeve , which eventually forms chorion membrane . Among the chorion frondosum, some of them erode the maternal blood vessels as they penetrate the decidua, and they are referred to as nutritive villi . The rest penetrate deeper into the spongy decidua, to firmly secure the placenta and they are known as anchoring villi . contd

As the nutritive villi erode, the opened up blood vessels become known as sinuses . The area surrounding the villi is referred to as blood or intervillous space . The maternal blood circulates slowly to facilitate various placental functions. STRUCTURE OF CHORIONIC VILLI Diagram:- It’s the functional part of the placenta. contd

CHORIONIC VILLI

Each villus comprises of four (4) layers of tissues, which are semi-permeable to allow placental functions to occur. However mixing of maternal and fetal blood never happen ,except tear(s) of a villus /villi have occurred. Specific layers are: contd

i )Fetal capillary :– Consists of the terminal vessels of umbilical arteries and vein. ii)Mesoderm :- Provides connective tissue to the fetal capillary ,so together they form the innermost layer. iii) Cytotrophoblastic (middle) layer :- Comprises of a single layer of cells and completely cover the innermost layer. contd

iv) Syncytiotrophoblastic layer/outer most layer :- Covers the villus externally. Together with the cytotrophoblastic layer, provide limited barrier to some substances and facilitates production of most hormones. As from the 10 th week, placenta is fully formed and functional, though loose in texture. contd

12 th – 27 th week Its larger than the fetus up to a gestation of 20 weeks (twenty weeks), because it metabolises and stores some nutrients needed by the fetus. It is so ,since most of the fetal organs are under developed. ct

28 th -37 th week Flat, almost round in shape and medially firm in consistency. Most of the fetal organs have fully developed. So metabolism and storage of nutrients , is taken over by the liver. ct

Towards term, the syncytium and cytotrophoblastic layers degenerate gradually . This allows ,easy exchange of gases, passage of antibodies and nutrients, hence fast growth. contd

The placenta is completely developed in all aspects. On delivery it is noted to have two (2) distinctive surfaces namely:- 1.MATERNAL SURFACE (SIDE) The side attached to the decidua. clinical features Bluish red or dark red in appearance , due to maternal blood and parts of the separated basal decidua. AT TERM

Has about 20 lobes / cotyledons , separated by lines referred to as sulci or furrows . It’s firm to touch, because cotyledons are fully developed. Calcaneous degeneration has occurred . It’s characterised by, sandy feeling ,on gentle palpation due to deposits of lime salts and calcium. Sometimes ,a fat tissue(s) may be present but they don’t have any significance.

2.FETAL SURFACE Side that was on direct contact with liqour and fetus. clinical features Whitish and shiny in appearance, due to present of amnion membrane. D istribution of the umbilical blood vessels is noted on inspection. Cord insertion is identified , normal being either central or lateral. Fetal membranes (Amnion and chorion) adheres to each other as from the placenta edge.

Main aim is to facilitate fetal growth and development. 1.NUTRITION Fetus receives all its nutrients from the mother’s diet ,already in simplified form. The placenta selects the required substances ,to an extent of depleting the mother ,if there are deficiencies. FUNCTIONS

Some substance e.g. amino acids, levels are higher in fetal blood than in maternal circulation. However fats and fat-soluble vitamins (A,D,E & K) cross the placenta barrier with difficulties and mainly in later stages of pregnancy. Hence need for supplementation during infancy stage. contd

2. STORAGE It stores glucose in form of glycogen and only reconverts as required. Other storage is of iron and fat-soluble vitamins. 3. RESPIRATION Gaseous exchange occurs at the placental bed through simple diffusion . ct

4. EXCRETION The main substances excreted from the fetus is carbon dioxide and bilirubin . Small amounts of urea and uric acid too, since tissue breakdown is minimal. 5. ENDOCRINE Hormones produced by the placenta are:- ct

i ) Human chorionic gonadotrophin (HCG) Produced by the cytotrophoblastic layer of the chorionic villi. Peak levels are achieved between the 7 th and 10 th week of pregnancy. Its function is to stimulate the growth and activity of corpus luteum , hence maintain pregnancy till the placenta is fully formed and functional. contd

ii) Oestrogens They are growth stimulating hormones secreted in large amounts throughout pregnancy. The fetus provides the placenta with the vital precursors for the secretion. Therefore the amount of oestrogen either in urine or blood is an indicator of feto -placental health. ct

iii) Progesterone Made in the syncytial layer of the placenta. The levels increases steadily until, just, before onset of labour ,when they fall drastically. It is measured in urine as pregnanediol . Its main role ,is to act on tissues that have already been receptive to oestrogen ,leading to relaxation effect. ct

iv) Human placental lactogen (HPL) Its levels rises as HCG levels falls, and continues throughout pregnancy. Its main role, is in glucose metabolism prenatally . It weakens, the insulin in the maternal circulation so that more glucose, is readily available for fetal use. contd

Therefore, glucose levels are persistently high in the circulation, hence control of diabetes mellitus prenatally is a big challenge. Others released in small amounts are:- a) Human chorionic thyrotropin ; Produced by the syncytium layer. has similar functions to thyroid stimulating hormone (TSH). b) Human placental growth hormone ; Ensures that fetus has adequate nutrient supply. c) Relaxin hormone ; Softens cervix and pelvic ligaments in preparation of child birth. contd

6. PROTECTION Provides limited barrier ,to most of the organisms ,and other harmful substances, from the mother to fetus. However some do cross, and lead to either congenital abnormalities or infections to fetus/neonate. Such are:-

i ) Bacteria , e.g treponema pallidum which causes syphilis ,and tubercle bacillus organism for tuberculosis ,among others. ii)Viruses e.g. Human cytomegalovirus, Rubella and Human immunosuppressive virus, etc. iii) Substances e.g. alcohol, carbon monoxide from cigarettes smoking, drugs taken by the mother.

However, some drugs are beneficial ,like those , in treatment of syphilis. In late pregnancy , i.e. from 37 weeks antibodies in form of immunoglobin G (IgG), comprising of tetanus & measles among other antibodies are transferred. They (antibodies) confer passive immunity to the baby for sometimes . contd

Are grouped into two. A. STRUCTURAL RELATED 1. Succenturiate lobe It the commonest, characterized by presence of a small, extra lobe, separate/away from the main placenta. Diagnosis is based on finding, blood vessels that run through the membranes to join it. ANATOMICAL VARIATIONS/ABNORMALITIES

Potential dangers/risks The extra lobe may be retained, on delivery of the placenta and membranes, leading to:- Puerperal infection. Postpartum haemorrhage. So , it affects the mother only. contd

Succenturiate lobe, Battledore insertion& Velamentous insertion

2.Circumvallata Characterized by presence of an opaque ring observed on the fetal surface . Its formed by doubling back of the fetal membranes hence the blood vessels distribution does not extend beyond the ring. Therefore, functional part of the placenta is smaller . Cord is inserted centrally.

ct

Potential dangers/risks Generally interferes with normal placental functions, leading to:- Intrauterine growth restriction, hence low birth weight baby. Sometimes it can bring placental abruption. So, effect is on the fetus, and rarely on the mother. contd

3.Membranacea placenta Results from inadequate degeneration of the chorionic villi ,under the capsularis decidua. The placenta is thin, and occupies most of the entire periphery of chorion membrane. At the same note, it is also poorly limited on the functional layer of the decidua.

Potential dangers/risks In most cases manual removal is the way out leading to; Puerperal sepsis. Postpartum haemorrhage. Affects the mother only. contd

4.Fenestrata Placenta is oblong in shape. It has a gap/window of varying size near the centre,which is covered . Potential dangers/risks Placental insufficiency, leading to LBW. So effect, is on the fetus only. ct

5 .Bipartite/Tripartite Two (2) or three (3) separate placentae are present, with each its own cord. The cords later join to form one, a short distance from the respective placenta. Potential dangers/risks One or more cords may cut during the process of labour leading to:-

Fresh still birth. Asphyxia neonatorum from fetal hypoxia. Postpartum haemorrhage. Puerperal sepsis. 6 . Accreta , increta , percreta Each characterized by abnormality in the adherence of anchoring villi. Invades the myometrium superficially, deeply or penetrate all the uterine layers respectively. contd

Diagnosis is based on failure of the placenta to separate. So, anatomically and physiologically the placenta is normal . Potential risks/dangers Postpartum haemorrhage due to partial separation. Puerperal sepsis because of invasive procedures + retention of some parts. Secondary infertility , for increta and percreta cases. Affects the mother only contd

DIAGRAMATIC PRESENTATION

B. DISEASE RELATED 1.Infarcts Characterised by presence of dead chorionic villi . They are whitish in appearance , smooth to touch and on the maternal surface. contd

They result from inadequate blood supply to the placental tissues. Mainly due to hypertensive disorders prenatally. Potential dangers/risks Depends on the severity and the stage of pregnancy (maturity by dates) :- Abortion – severe before viability contd

Low birth weight baby Either fresh or macerated stillbirth 2 .Syphilitic Its large and weighs a ¼ (quarter) of the baby’s birth weight. Oily looking in appearance. Potential dangers/risks Low birth weight baby. contd

Fetal hypoxia which may lead to asphyxia. 3 .Oedematous Results from severe consequences of Rhesus – D incompatibility. Mostly hydrops fetalis, occur due to high levels of fluid retention, leading to various degree of cardiac failure. ct

Simultaneously placenta is large, pale and marshy i.e. oozes out fluid. DANGERS/RISKS Severe fatal hypoxia leading to asphyxia neonatorum .

Fresh/macerated stillbirth, where either the hypoxic levels are too high, or there is delay in seeking medical attention. The latter is the commonest outcome. ct END . QUESTIONS?

welcome THE MEMBRANES

Also referred to as the fetal sac. DEFINITION Are two (2) thin tissues ,which extends beyond the placental edge forming a bag containing, the fetus, cord and amniotic fluid.

CLASSIFICATION 1.CHORION Develops from the outer cell mass ( trophoblast ), hence attached to the chorionic plate, which forms the base of the placenta. Lines the decidua on its outer surface, and adheres to the amnion on it inner aspect.

contd Clinical feature Its opaque and translucent. Friable, that is, tears easily. On the maternal surface. Can be stripped off from the amnion up to the placenta edge.

2.AMNION Develops from the inner cell mass ( embryoblast ). In direct contact with liquor on the inner aspect, and adheres to chorion on the outer surface .

ct Clinical features Transparent and shiny. Tough to tear. On the fetal surface. Stripped off up to the cord insertion. END

THE UMBILICAL CORD R U THERE?????????

Also referred to as the funis . Originates from the duct that forms between the amnion and York sac by the 5 th week of pregnancy. ct

Extends from the fetus to the placenta. Has an average measurement of 50cm in length, thickness ranges between 1.5 – 2cm ,since its not evenly distributed. Consists of 3 blood vessels wrapped/ enclosed in a gelatinous materials referred to as Wharton’s jelly from mesoderm. DESCRIPTION

Externally covered by a layer of amnion, continuous with that covering the placenta ,but adherent to the gelatinous material. Has a characteristic spiral twist ,which gives it some protection from pressure. It does not have nerves, hence no pain is perceived on cutting it. contd

They are two (2) arteries and one (1) vein. Arteries carry deoxygenated blood and wind spirally around the vein all along. The vein is wider , and carries oxygenated blood from placenta to the fetus. NB Absence of one (1) artery, is highly associated with renal agenesis i.e. incomplete development of the kidneys. THE BLOOD VESSELS

1.True knot(s) Occurs where the cord is abnormally long such that the fetus pass over the loop of the cord as it turn/moves within liquor amnii. Dangers/Potential risks Fetal hypoxia as the knot tightens during the labour process. Fresh stillbirth due to complete cut off, of the blood supply to the fetus . ANATOMICAL VARIATIONS /ABNORMALITIES

FALSE KNOT

2. False knot(s) Identified as lumps of Wharton’s jelly on a specific parts of the cord. In most cases the blood vessels are normal. In some cases the blood vessels are longer than the actual length of the cord . So they double back inside the cord leading to false knot(s). ct

The later leads to some degree of intrauterine growth restriction ,hence low birth weight. 3.Very short cord Measures less than 40 cm in length. Potential dangers/Risks Intrapartum haemorrhage due to placental abruption. Fetal hypoxia due to blood loss hence asphyxia neonatorum . contd

Fresh still birth , as the cord cuts. Anaemia to the mother, which could be fatal. NB:- All this results due to cord traction during labour. INSERTION RELATED 4. Battledore Cord is attached to the very edge of the placenta, so may easily cut during 3 rd stage hence manual delivery of the placenta . CONTD

Battledore insertion

P otential risks/Dangers Postpartum haemorrhage Puerperal sepsis 5.Velamentous It’s a situation in which the cord is inserted into the membranes, some distance from the placental edge. The unprotected cord vessels, run through the membranes before they reach the placenta. contd

If the placenta is low-lying , the vessels may pass across the internal cervical os. This is collectively referred to as Vasa Praevia. For normally situated placenta no harm may occur to the fetus, but the cord may cut off during active management of labour. CONTD

P otential dangers/Risks Fresh stillbirth ,following either spontaneous or artificial rupture of membranes, in vasa praevia . Severe anaemia to the mother , as cord cuts. Severe asphyxia to the neonate if some blood vessels rupture during 2 nd stage of labour. END CONTD

LIQUOR AMNII

ct Also referred to as amniotic fluid DEFINITION It’s a clear alkaline and slightly yellowish (straw- coloured ) fluid/liquid contained within the amniotic sac/fetal sac.

ct SOURCE Are two (2) namely:- Maternal Vessels in the decidua . Fetal Vessels in the placenta. Amnion covering the placenta and cord. Urine passed as from the 10 th week.

COMPOSITION 99% is water, exchanged approximately every 3 hourly. The remaining 1% ,are dissolved solid matter such as food substances, waste products, lanugo , vernix caseosa and skin cells shed from the fetus. Normally: Its alkaline in reaction, turbid or milky coloured due to vernix caseosa shed on it at term.

contd Abnormal compositions are:- Meconium stained , becomes greenish coloured , facilitates diagnosis of the fetal status. Muddy coloured , indicates that, fetus has been hypoxic previously, but the condition has resolved spontaneously . Golden coloured , indicates hyperbilirubinaemia .

VOLUME/AMOUNT Normally , fluid volume increases gradually as fetal growth progresses. Maximum volume is attained at approximately 38 weeks , and it ranges between 1000-1500ml. Thereafter ,reduces slightly by approximately 200ml.

contd Amount, more than 1500ml is referred to as Polyhydramnious. Less than 300ml (0.3 litre ) is collectively known as Oligohydramnious . Such abnormalities are highly associated with congenital malformations of the fetus such as spinal-bifida.

FUNCTIONS Distends the amniotic sac such that fetus grows and moves freely, hence symmetrical musculoskeletal development. Maintains equal pressure, because the fluid is not compressible, hence offers fetal protection from mechanical/physical trauma.

contd Maintains constant intrauterine temperature conducive for fetal growth and development. Provides small amounts of nutrients to the fetus. Helps/assists in cervical effacement, and subsequent cervical dilatation, especially where the presenting part is poorly applied.

contd Protects the placenta and umbilical cord, from pressure of uterine contractions, as long as membranes are intact . QUESTION?

It’s carried out soonest possible after delivery, so that prompt interventions are taken appropriately. EXAMINATION OF A PLACENTA

OBJECTIVES To confirm completeness of placenta and membranes. To detect abnormalities. To assess blood loss. To assess the weight of placenta. PREPARATION 1. Equipment:-

At least 2(two) pairs of surgical gloves. Measuring jug. Polythene bag. Weighing scale Improvised tape measure or ruler. Placenta in a container. contd

2. Environment. Have a flat surface. Good lighting, preferably natural. Coded bins. 3. Self (midwife). Wear protective gear ,ie plastic apron and gloves. Ensure all requirement are within reach.

PROCEDURE Separate blood from the placenta and pour it into measuring jug. Allow the jug to rest on a flat surface. Hold placenta by the cord and check for completeness of membranes. Place it on a flat surface.

Inspect the cord for :- Number of blood vessels ,normally ,one(1) vein and two(2) arteries. Thickness, determined by distribution of Wharton's jelly. Presence of knots and establish the type. Measure length ,using either an improvised tape measure or your spread out fingers. contd

Fetal surface :- Note the appearance/ colour. Cord insertion. Distribution of the blood vessls,ie,whether they all end at the placenta edges or otherwise. Maternal surface :- Turn the placenta to face upwards and inspect for;

Colour /appearance. Status of the cotyledons, ie completeness and texture. Calcaneous degeneration and infarcts. Thickness and presence of oedema . Membranes for :- Presence of blood vessels running beyond placental edge.

Separate amnion from chorion to confirm presence of both membranes and identify them correctly. Establish ,whether they are complete or ragged. Finally :- Place the placenta in a polythene bag and weigh. Come up with total blood loss ,by adding up the measurable loss and estimates from soiled linen, as well as blood soaked swabs.

Clearing:- Discard placenta and blood respectively. Clean equipments as per infection control guidelines. Remove gloves and discard safely. Handle the plastic apron correctly. Record findings appropriately ,for future reference as care continues.

REPORT State of placenta in terms of whether :- - Complete or Incomplete and rationale of each. - Health ,ie whether normal or abnormal and specify the abnormality. State of membranes:- -Complete ,indicated by presence of one(1) regularly edged hole. -Ragged , means ,the edges are irregular and the two(2) ,

membranes don’t completely fit together. State of the cord:- - Normal. - Abnormal, due to absence of 1(one) artery , presence of a knot(s), being too short or too long and anomalous insertion. Weight of placenta in grammes or kilograms. contd END THANKYOU

Normal Midwifery for students enrolled and registered midwives.pptx

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