Obstetric And Gynecological Nursing
LECTURE NOTESFor Nursing StudentsObstetric andGynecological NursingMeselech AssegidAlemaya UniversityIn collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education2003
Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.Produced in collaboration with the Ethiopia Public Health Training Initiative, The CarterCenter, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.Important Guidelines for Printing and PhotocopyingLimited permission is granted free of charge to print or photocopy all pages of thispublication for educational, not-for-profit use by health care workers, students orfaculty. All copies must retain all author credits and copyright notices included in theoriginal document. Under no circumstances is it permissible to sell or distribute on acommercial basis, or to claim authorship of, copies of material reproduced from thispublication. 2003 by Meselech AssegidAll rights reserved. Except as expressly provided above, no part of this publication maybe reproduced or transmitted in any form or by any means, electronic or mechanical,including photocopying, recording, or by any information storage and retrieval system,without written permission of the author or authors.This material is intended for educational use only by practicing health care workers orstudents and faculty in a health care field.
PrefaceThis lecture note offers nurses comprehensive knowledgenecessary for the modern health care of women with up-todate clinically relevant information in women’s health care. Itaddresses and contains selected chapters and topics whichare incorporated in the obstetrics and gynecology course fornurses. However, a major focus is provided on the role of thenurse in providing quality maternal and newborn care.The obstetric nurse does a three or four month course ofobstetrics part as part of an integrated training. The nurse ispart of the health team expected to be able to deal withmidwifery. The nurses work among the community and theybear the great responsibility of having to deal with mothers inremote areas and far away from hospitals. The nurses ications.This lecture note is prepared to relieve the shortage ofreference materials in the country even though it does notrepresent the text books. It is organized in a logical manner sothat students can learn from the basics to the complex. It isdivided in to chapters and subtopics. Each chapter containslearning objectives, descriptions and exercises in the form d
glossaries have been included in order to facilitate theteaching learning process. The learning objectives are clearlystated to indicate the required outcomes.ii
AcknowledgementMy deepest appreciation and heart felt gratitude goes to TheCarter Center, EPHTI, Addis Abeba for the financial support,initiation of the lecture note preparation, and provision ofnecessary materials.I also extend my thanks to my colleagues from AlemayaUniversity, Faculty of Health Sciences for their invaluablecomments during the revision of the lecture note.Finally, my special thanks and gratitude goes to Ato AkliluMulugetta for his devoted support and facilitating thepreparation of this lecture note. Last but not least, I thank myuniversity authorities; Acadamic Vice President, Faculty deanand Department for their permission to work on this lecturenote besides my other responsibilities.I would also like to thank my faculty secretaries for theircooperation in writing this lecture note.iii
TABLE OF CONTENTsPrefaceiAcknowledgementiiiTable of ContaintsivList of figuresxiList of TablesxiiAbbreviationsxiiiCHAPTER ONE: INTRODUCTION11.1 Historical development of obstetrics11.2 Magnitude of Maternal Health problem in2Ethiopia1.3 Importance of Obstetrics and Gynecology3nursingCHAPTER TWO: ANATOMY OF FEMALE5PELVIS AND THE FETAL SKULL2.1 Femele Pelvic Bones52.2 Anatomy of the female external genitalia182.2.1 The vulva182.3 Contents of the pelvis cavity202.3.1 The bladder202.3.2 The Ureters212.3.3 Urethra212.3.4 The uterus22iv
2.3.5 Fallopian tube or uterne tube242.3.5 The ovaries252.4 Physiology of the Femel Reproductive Organs262.4.1 Puberty – the age of sexual maturation262.4.2 The menstrual cycle272.4.3 Phases of menstrual cycle292.5 The Breast Anatomy31Review Questions35CHAPTER THREE: NORMAL PREGNANCY363.1 Conception363.2 Development of the Fertilized Ovum373.3 Functions of Placenta403.4 The Fetal Circulation413.5 Anatomical Varations of the Placenta and the46Cord3.6 Physiological Changes Of Pregnancy503.6.1 Gastro Intestinal Tract (GIT)503.6.2 Galbladder513.6.3 Liver523.6.4 Urinary systems523.6.5 Bladder533.6.6 Hematological system533.6.7 Cardiovascular System543.6.8 Plumunary system553.6.9 Changes in the Breast56v
3.6.10 Change in Skin563.6.11 Change in Vagina and Uterus563.7 Minor Disorders of Pregnancy573.8 Diagnosis of Pregnancy603.9 Antenatal Care623.9.1. History Taking643.9.2 Examination of the Pregnant Woman At65First Visit3.9.3 Laboratory test74Review Questions76CHAPTER FOUR: NORMAL LABOUR774.1 Mechanism and Stages of Labour794.1.1 Management of 1st Stage of Labour794.1.2 The Second Stage of Labour944.1.3 The Third Stage of Labour984.2 Immediate Care of Mother and Baby1114.3 Discharge Planning (Instructions)1134.4. Episiotomy115Review Questions120CHAPTER FIVE: THE NORMAL PUERPERIUM1215.1 Physiology of Puerperium1225.2 Management of the Puerperium1255.3 Postnatal care (Daily care)127Review Questions129vi
CHAPTER SIX : ABNORMAL PREGNANCY1296.1 Multiple pregnancy1296.1.1 Monozygotic (Uniovular)1296.1.2 Dizygotic (Binovular) Twins1306.2. Hyper Emesis Gravidarum1386.3. Pregnancy Induced Hypertention1406.3.1 Preeclampsia1406.3.2 Eclampsia1466.4. Antepartum Haemorrhage1496.4.1 Placenta praevia1506.4.2 Placental Abruption1556.5 Polyhydramnios1586.6. Rhesus Incompatibility1626.7 Disease Associated With Pregnancy1666.7.1 Infection1666.7.2 Pulmonary tuberculosis1676.7.3 Cardiac Disease1696.7.4 Diabletes Mellitus171Review Question175CHAPTER SEVEN : ABNORMAL LABOUR1767.1. Malpresentation and Malpostion1767.1.1 Breech Presentation1777.1.2 Brow Presentation1847.1.3 Shoulder Presentation1857.1.4 Face Presentation187vii
7.2.7.1.5 Unstable lie1897.1.6. Compound or Complex Presentation1907.1.7 Occupitio- Posteririor Position191Post partum Hemorrhage1937.2.1 Atonic Postpartum Hemorrhage1957.2.2 Traumatic Post Partum Hemorrhage1967.2.3 Hypo Fibrinogenaemia1977.3. Prolonged Labour2007.4 Prolapse of Cord2037.5 Cephalopelvic Disproportion2057.6 Contracted Pelvis2067.7 Retained Placenta2077.8 Adherent Placenta2087.9 Rupture of the Uterus2097.10 Lacerations2137.11 Premature Rupture of the Membrane215(PROM)Review Questions226CHAPTER EIGHT : ABNORMAL PUERPERIUM2188.1 Urinary Complications2188.2 Breast Infections2198.2.1 Acute Puerperal Mastitis2198.2.2 Breast Abscess2208.3 Puerperal Sepsis2218.4. Puerperal Psychosis223viii
8.5 Subinvolution225Review Questions226CHAPTER NINE : INDUCTION OF LABOUR2279.2 Augmentation (Stimulation) Of Labour2329.3 Trial of Labour233Review Questions236CHAPTER TEN : OBSTETRIC OPERATIONS23710.1 Forceps Delivery23710.2 Caesarean Section24310.3 Destructive Operations /Embryotomy/24610.4 Version24810.4.1 Internal Version24810.4.2 External Cephalic Version24910.5 Vacuum Extraction / Ventouse delivery/250Review Questions252CHAPTER ELEVEN : CONGENITAL ANOMALIES253OF THE FEMALE GENITAL ORGANS11.1 Uterine Abnormalities25411.2 Cervix Abnormalities15511.3 Vaginal Abnormalities257Review Questions258ix
CHAPTER TWELVE : INFECTION OF THE259FEMALE REPRODUCTIVE ORGANS12.1 Pelvic Inflammatory Disease26012.2 Vulval Infection26312.3 Candidiasis26612.4 Trichomoniasis26812.5 Trauma of the female genital tract fistulae27012.6 Prolaps Of The Uterus27312.7 Inversion of the Uterus27512.8 Abortion27912.8.1 Types Of Abortion28112.9 Abnormalities Of The Menstrual Cycle290(Menstrual Disorder)12.9.1 Menstral Disordenrs29012.10 Ectopic Pregnancy29312.11 Infertility30012.12 Disorder Of The Breast30212.13. Menopause306Self examination of the breast30712.14. New growths310Review Questions316GLOSSARY317BIBILIOGRAPHY320x
LIST OF FIGURESFiguer 1. Normal Female Pelvis6Figuer 2. Pelvic ligaments(Posterior view)8Figure 3. Types of female pelvis11Figuer 4. Fetal skull16Figuer 5.Diameters of fetal skull17Figure 6 Female external genitalia19Figure 7. Anterior view of female internal reproductive26organFigure 8. Menstrual cycle30Figure 9. Anatomy of female breast34Figure 10. The fetal circulation43Figure 11. Anatomical variation of placenta and cord48insertionFigure 12. Fundal palpation69Figure 13. Lateral palpation70Figure 14. Deep pelvic palpation71Figure 15. Pwelick’s grip72Figure 16. Types of placenta praevia in relation with152cervical osFigure 17. The ventouse or vacuum extractor252Figure 18. Abnormal uterine types255Figure 19. Possible outcomes of tubal pregnancy294Figure 20. Self breast examination309xi
LIST OF TABLESTable 1. Measurments of the pelvic canal in10centimeterTable 2. Features of different types of female pelvisTable 3. Difference between the true and false78labour contractionTable 4.Postnatal discharge instruction114Table 5. Difference between monozygotic and130dizygotic twinsTable 6. Bishopes score system229Table 7. Proceduers of induction for multipara and230primigravidaxii
ABBRIVATIONSACTH Adreno cortico trophic hormoneADHAnti diuretic hormonesAPHAnti Partum HeamorrageAROM Artificial Rupture Of MemberaneBCGBacillus Calmette GuerineBPBlood pressureCmCentimeterBUNBlood Urea NitrogenCOCardiac OutputCPDCephalo Pelvic DisproportionC/SCeaserian SectionDBPDiastolic blood pressureD&CDlatation and cruttageDICDisseminated intravascular coagulationEDDExpected date of deliveryFHBFetal heart beatFSHFollicle stimulating hormoneHCGHuman Chorionic GonadotrophinGITGastro intestinal tractHPLH Human Placental Lactogenic HormoneHr/sHour/hoursIgGImmuno globuline GIUInternational unitIUCDIntra uterine contraceptive devicexiii
IVIntra venousKgKilogramPF2Prostaglandin Factor 2P.I.HPregnancy induced hypertensionPOPer os/through mouthPPHPost partum hemorrhagePROM Premature Rupture Of MembranePUDPeptic ulcer diseaseRBCRed blood cellRhRhesusSBPSystolic blood pressureV.D.R.L Veneral disease research laboratoryV.EVaginal ExaminationWBCWhite blood cellxiv
CHAPTER ONEINTRODUCTIONCare of childbearing and childrearing families has become amajor focus of nursing practice today. To have healthychildren, it is important to promote the health of thechildbearing women and her family from the time beforechildren are born until they reach adulthood. Prenatal careand guidance is essential to the health of women and fetusand to the emotional preparation of a family for chilbrearing.1.1 Historical development of obstetricsUsually women have cared for other child bearing womenthrough out much of human history. Birth practices in ancientcultures of the world that did not develop written language andrelied only on oral transmission of knowledge have been lostor can be reconstructed only by examining current “Primitive”practices. The routes of maternity care in the Western worldare also ancient; the first recorded obstetric practices arefound in Egyptian records dating back to 1500 B.C Practicessuch as vaginal examination and the use of birth aids arereferred to in writings from the Greek and Roman empires, but1
much of their information was lost in the dark ages. Advancein medicine made during the renaissance in Europe led to icantthdiscoveries and invitations by Physicians in the 16 and 17thcenturies let the stage for scientific progress.1.2Magnitude of Maternal Health problem inEthiopiaMaternal mortality is one of the health indicator which showsthe burden of disease and death; the greatest differentialbetween developing and developed countries. More than 150million women become pregnant in developing countries eachyear and an estimated 500, 000 of them die from pregnancyrelated causes. Other than their health problems most womenin the developing countries lack access to modern health entable problems. Lack of access to modern health careservices has great impact on increasing maternal death. Mostpregnant women do not receive antenatal care; deliver without the assistance of trained health workers etc. The life timerisk of death as a result of pregnancy or child birth isestimated at one in twenty – three for women in Africa,compared to about one in 10,000 for women in NorthernEurope 75% of Maternal morbidity and mortality related topregnancy and child birth are due to five obstetric causes.2
Hemorrhage, sepsis (infection), toxemia obstructed labor andcomplications from unsafe abortion.As Ethiopia is one of the developing countries with inadequatefacilities and resources having highest maternal morbidity andmortality and poor coverage of maternal is estimated to be1000/100,000 live birth. In Ethiopia women get antenatal careare around 905, 283 and overall the national antenatal carecoverage in 34.7%. Among this pregnant woman only 259,083are attended institutional delivery making the nationalcoverage of 10%. Unwanted and unplanned pregnancies areimportant determinants of maternal in health. So from1,769,171 of women child bearing age expected to use familyplanning 635,105 of them use family planning and the nationalcoverage is only 18.7%.Abortion, HIV/AIDS and STIs are alsoanother conditions that increase maternal morbidity andmortality. These all indicated that the maternal health care istoo less in Ethiopia.1.3Importance of Obstetrics and GynecologynursingEnsuring healthy antenatal period followed by a safe normaldelivery with a healthy child and an uneventful post ical
emergencies also prevent so many of complications. Theimportance of the obstetric and gynecology nursing are:-Equip the nurse with the knowledge and understanding ofthe Anatomy and physiology of reproductive organ beable to apply it in practice-With a good knowledge of obstetric drugs including, theeffect of diseases their Complications and know how todeal with them.-Develop skills in carrying out antenatal care and be ableto detect any abnormality, recognize and preventcomplications.-Select high risk cases for hospital delivery and providehealth education.-Develop skills in supporting the women in labour, maintainproper records, and deliver her safely and resuscitate hernew born when necessary.-Be able to care for the mother and baby during the postpartum period and be able to identify abnormalities andhelp them to get-over it.-Be able to educate them on care of the baby,immunization, family guidance and family spacing.-Be ready to offer advice to support the mother andunderstand her problems as a mature, kind and helpfulnurse.4
CHAPTER TWOANATOMY OF FEMALE PELVISAND THE FETAL SKULLLearning ObjectivesAt the end of this chapter the students will be able to:-Describe anatomy of the Female pelvis and Femaleexternal genitalia-Mention parts of fetal skull with its features.-Differntiat organs contained in the pelivic cavity.-Describe characteristic of menustral cycle and its disorder-List anatomy of female breast-Define puberity and its featuers.2.1 Female Pelvic BonesThe female pelvis is structurally adapted for child beaing anddelivery.There are four pelvic bones-innominate or hip bones-Sacrum-Coccyx5
Figure 1. Structure of the pelvis (Adele Pilliter, 1995)A. Innominate bonesEach innominate bone is composed of three parts.1. The ilium the large flared out part2. The ischium the thick lower part. It has a largeprominance known as the ischial tuberosity on which thebody rests when sitting. Behind and a little above thetuberosity is an inward projection, the ischial spine. Inlabour the station of the fetal head is estimated in relationto ischial spines.3. The pubis - The pubic bone forms the anterior part.The space enclosed by the body of the pubic bone therami and the ischium is called the obturator foramen.B.The sacrum - awedge shaped bone consisting of fivefused vertebrae. The upper border of the first sacral vertebrais known as the sacral promontary. The anterior surface of the6
sacrum is concave and is referred to as the hallow of thesacrum.C. The coccyx: - is avestigial tail. It consists of four fusedvertebrae forming a small triangular bone.Pelvic JointsThere are four pelvic joints-One Symphysis pubis-Two Sacro illiac joint-One Sacro coccygeal joint-The symphysis pubis is a cartilgeous joint formed byjunction of the two pubic bones along the midline. The sacro iliac joints are the strongest joints in thebody.-The sacro coccygeal joint is formed where the base of thecoccyx articulates with the tip of the sacrum.In non pregnant state there is very little movement in thesejoints but during pregnancy endocrine activity causes theligaments to soften which allows the joints to give & providemore room for the fetal head as it passes through the pelvis.Pelvic ligamentsEach of the pelvic joints is held together by ligaments-Interpubic ligaments at the symphysis pubis (1)7
-Sacro iliac ligaments (2)-Sacro coccygeal ligaments (1)-Sacro tuberous ligament (2)-Sacro spinous ligament wllyn, 1990)The True PelvisThe true pelvis is the bony canal through which the fetus mustpass during birth. It has a brim, mid cavity and an out let. Thepelvic brim is rounded except where the sacral promontoryprojects into it. The pelvic cavity is extends from the brimabove to the out let below. The pelvic out let are two anddescribed as the anatomical and the obstetrical. Theanatomical out let is formed by the lower borders of each ofthe bones together with the sacrotuberous ligament. It is8
diamond in shape. The obstretrical out let is of the spacebetween the narrow pelvic strait and the anatomical outlet.Important land marks of female pelvisA. Pelvic brim-Sacral promentary posteriorly-Superior ramus of the pubic bone antro lateral-Upper inner boarder of the body of the pubic bone-Upper inner boarder of the symphysis pubis anteriorlyB. Mid pelvis-Ischial spineC. Out let-Inferior pubic rami antero laterally-Sacrotuberous ligament postro laterally-Ischial tuberosity laterally-Inferior border of symphsis pubis anteriorly.-Tip of coccyxImportant diameters of the pelvisInletDiagonal conjugate - a line from the sacral promontory towardthe lower boarder of the symphysis pubis and measures 12.5centimeter. It is measured by pelvic examination.9
Mid cavityInterspinous diameter-a line between the two ischial spinesand measures 11 centimeter.The pelvic out let-Pubic arch-Intertuberous diameterTable 1. Measurements of the pelvic canal in 13Cavity121212Out let131211The four types of female pelvis1. The gynacoid pelvis (female type)2. The android pelvis (male type)3. The anthropoid pelvis4The platypelloid pelvis10
Table 2 .Features of the four types of female dBrimRoundHeart shapedLong ovalKidneyshapedFore- pelvisGenrousNarrownarrowedWideSide wallsStraightconvergentdivergentDivergentisctial spinesBluntProminentbluntBluntsciatic notchRoundedNarrowwideWidesub- pubic angle90Incidence50%o 90o20% 90o25% 905%Figure 3 Types of female pelvis (Alan H. Decherney l.pemoll, 1994)11o
Pelvic floor Or Pelvic diaphragmThe pelvic floor or diaphragm is amuscular floor thatdemarcates the pelvic cavity and perineum. Its strength isinforced by its associated condesed pelvic fascia, therefore, itis important for pelvic organs protection.Functions: It supports the weight of the abdominal and pelvic organsThe muscles are responssible for the voluntary c
nurse in providing quality maternal and newborn care. The obstetric nurse does a three or four month course of obstetrics part as part of an integrated training. The nurse is part of the health team expected to be able to deal with midwifery. The nurses work among the community and they bear the great responsibility of having to deal with .
cation of its concept and structure. Hence, this study was conducted to explore the perception of health care providers involved in obstetric triage about their concept and structure of obstetric triage. The results of this study can help improve the design and implementation of the obstetric triage system in Iran. Methods Study design and setting
open-forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for Obstetric Anesthesia: An Updated Report by the ASA Task Force on Obstetric Anesthesia,” adopted by ASA in 2006 and published in 2007.† Methodology Definition of Perioperative Obstetric Anesthesia
delineated (e.g. specific training in obstetric anesthesia, several years of practice with a focus on obstetric anesthesia, and/or evidence of expertise based on academic contributions). Please provide the curriculum vitae of the lead obstetric physician anesthesiologist with your application. 3. Staffing education
who experiences dural puncture with an epidural needle or obstetric post-dural puncture headache. Based on available evidence, a proposed outline for treatment of obstetric PDPH is presented in Appendix A. CONSERVATIVE TREATMENT Bed rest Although most women gain some relief from obstetric post-dural puncture headache when supine, the
Diploma in Nursing (GNM) Duration: 3 Years Bachelor of Nursing Duration: 4 Years Post Basic B.Sc. Nursing Duration: 2 Years Master of Nursing Duration: 2 Years Specialisations: 1. Medical-Surgical Nursing 2. Obstetric & Gynaecological Nursing (OBG) 3. Child Health Nursing 4. Community Health Nursing
First Year 13. Nursing Education 14. Advance Nursing Practice Clinical Speciality Medical Surgical Nursing Obstetric & Gynaecological Nursing Child Health (Paediatric) Nursing Mental Health (Psychiatric) Nursing Community Health Nursing 15. N
for Nursing (69) Delaware Board of Nursing (12) District of Columbia Board of Nursing (75) Florida Board of Nursing (70) Georgia Board of Nursing (31) Guam Board of Nurse Examiners (87) Hawaii Board of Nursing (37) Idaho Board of Nursing (82) Illinois Board of Nursing (49) Indiana State Board of Nursing (48) Iowa Board of Nursing (60)
interface (API) used in a GEANT4 application. A simple application will use concrete classes provided with the toolkit, the developer will provide the detector description a primary generator (possibly using one of the general purpose ones provided with the toolkit), define the physics for the application (the physics list, possibly one of the few provided with the toolkit) and optional user .
