THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND
CHILDREN
DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT
FACILITATOR’S GUIDE FOR ORDINARY DIPLOMA
IN NURSING AND MIDWIFERY
NTA LEVEL 6
NMT 06101: Care of a Woman with Abnormal Pregnancy,
Labour and Puerperium
© Ministry of Health, Community Development, Gender, Elderly and Children, Department of Human Resources
Development Nursing Training Section 2018, Dodoma, Tanzania
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Table of Contents
Acronyms................................................................................................................................................. v
Preamble ................................................................................................................................................ vi
Acknowledgement ..................................................................................................................................vii
Background ........................................................................................................................................... viii
Rationale ............................................................................................................................................... viii
Goals and Objectives of the Training Manual ......................................................................................... ix
1.1.
Overall Goal for Training Manual ............................................................................................ ix
1.2.
Objectives for Training Manual ............................................................................................... ix
Introduction ............................................................................................................................................. ix
1.3.
Module Overview .................................................................................................................... ix
1.4.
Who is the Module For?........................................................................................................... x
1.5.
How is the Module Organized? ................................................................................................ x
1.6.
How Should the Module be Used? ......................................................................................... xi
SESSION 1: CARE OF A WOMAN WITH ABORTION ............................................................................ 1
SESSION 2: CARE OF A WOMAN WITH ECTOPIC PREGNANCY ....................................................... 8
SESSION 3:CARE OF A WOMWN WITH HYDATIDIFORM MOLE ...................................................... 16
SESSION 4: CARE OF A WOMAN WITH BLEEDING IN LATE PREGNANCY .................................... 20
(ANTEPARTUM HAEMORRHAGE) ...................................................................................................... 20
SESSION 5:CARE OF A WOMAN WITH PLACENTA PREVIA ............................................................ 26
SESSION 6:CARE OF A WOMAN WITH ABRUPTIO PLACENTA ....................................................... 33
SESSION 7:CARE OF A WOMAN WITH UTI IN PREGNANCY ........................................................... 39
SESSION 8: CARE OF A WOMAN WITH MALARIA IN PREGNANCY ................................................ 44
SESSION 9: CARE OF A PREGNANT WOMAN WITH PULMONARY TUBERCULOSIS .................... 53
SESSION 10: CARE OF A PREGNANT WOMAN WITH SYPHYLIS .................................................... 58
SESSION 11 :CARE OF A WOMAN WITH ANAEMIA IN PREGNANCY .............................................. 62
SESSION 12: HYPERTENSIVE DISORDERS IN PREGNANCY .......................................................... 68
SESSION 13: PRINCIPLES OF CARE OF A WOMAN WITH PRE-ECLAMPSIA AND ECLAMPSIA
ACCORDING TO GUIDELINES AND PROTOCOLS ............................................................................ 73
SESSION 14: CARE OF PREGNSNT WOMAN WITH DIABETES MELLITUS AND CARDIAC
DISEASE ............................................................................................................................................... 82
SESSION 15:CARE OF A WOMAN WITH HYPEREMESIS GRAVIDARUM ........................................ 90
SESSION 16: CARE OF A WOMAN WITH DISORDERS OF AMNIOTIC FLUID (POLYHYDRAMIOUS
AND OLIGOHYDRAMNIOS) ................................................................................................................. 94
SESSION 17:CARE OF A WITH ABNOMAL UTERINE ACTION .......................................................... 99
SESSION 18: CARE OF A WOMAN WITH PROLONGED LABOUR .................................................. 107
SESSION 19: CARE OF A WOMAN WITH OBSTRUCTED LABOUR ................................................ 112
SESSION 20:CARE OF A WOMAN UNDERGOING VACUUM ASSISTED DELIVERY AND
CAESAREAN SECTION...................................................................................................................... 117
SESSION 21: CARE OF A PREGNANT WOMAN DURING INDUCTION AND AUGMENTATION OF
LABOUR .............................................................................................................................................. 124
SESSION 22: CARE OF A WOMAN WITH PRETERM LABOUR ....................................................... 130
SESSION 23: CARE OF A WOMAN WITH PREMATURE RUPTURE OF MEMBRANE (PROM) ...... 135
SESSION 24: CARE OF A WOMAN WITH BREECH PRESENTATION ............................................. 140
SESSION 25: CARE OF A WOMAN WITH BROW PRESENTATION ................................................ 150
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 26: CARE OF A WOMAN WITH FACE PRESENTATION .................................................. 156
SESSION 27: CARE OF A WOMAN WITH SHOULDER PRESENTATION ........................................ 162
SESSION 28: CARE OF A PREGNANT WOMAN WITH OCCIPITAL POSTERIOR PRESENTATION
172
SESSION 29: CARE OF A WOMAN WITH UNSTABLE LIE AND COMPOUND PRESENTATION .... 166
SESSION 30:CARE OF A WOMAN WITH MULTIPLE PREGNANCY ................................................ 180
SESSION 31: CARE OF A WOMAN WITH PUERPERAL SEPSIS ..................................................... 186
SESSION 32: CARE OF A WOMAN WITH PUERPERAL PSYCHOSIS ............................................. 191
SESSION 33: CARE OF A WOMAN WITH BREAST INFECTION AND MASTITIS ............................ 196
SESSION 34: CARE OF A WOMAN WITH UTERINE SUB-INVOLUTION ......................................... 200
SESSION 35:CARE OF A WOMAN WITH VENOUS THROMBOSIS IN PREGNANCY ..................... 205
SESSION 36: CARE OF A WOMAN WITH URINE INCONTINENCE ................................................. 211
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Acronyms
AGYW
AIDS
AIHA
ARV
VMMC
WHO
Adolescents Girl and Young Women
Acquired Immune Deficiency Syndrome
American International Health Alliance
Antiretroviral
Voluntary Medical Male Circumcision
World Health Organization
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Preamble
The Ministry of Health Community Development Gender Elderly and Children among other roles
ensures that Tanzanians receive quality health care and service. This can be achieved through
production of competent nurses and midwives amongst other health cadres. The training of competent
nurses and midwives can be achieved through various teaching and learning materials; one of them being
facilitator’s guides and student’s manual .
Dr. Loishook Saitori
Director for Human Resource Development
Ministry of Health, Community Development, Gender, Elderly and Children
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Acknowledgement
Ministry of Health, Community Development, Gender, Elderly and Children through the Directorate of
Human Resource Development, Nursing training section has reviewed Facilitator’s guide for Nursing
and Midwifery training program. The review was informed by revised curriculum of the same. The
successfully completion of this facilitator’s guide has been made possible by the commitment of the
technical team through a series of writers’ workshops. Understanding the crucial role of the team, the
Ministry would like to express sincere appreciation to all those who involved in the completion of this task.
Special gratitude goes to coordinators of Nursing and Midwifery training, technical expert from NACTE and other
facilitators who tirelessly supported the development of this guide whose names are listed with appreciation:-
SN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
FULL NAME
Nassania Shango
Professor Eliezer Tumbwene
Ramadhani Samainda
Dr. Patrick Mwidunda
Lupyana Kahemela
Joseph Pilot
Mary Kipaya
Paul Magessa
Dominic Daudi
Dr. Beatrice Mwilike
Lilian Wilfred
Upendo Mamchomy
Tito William
Sixtus Ruyumbu
Dr Lenatus Kalolo
Emmanuel Mwakapasa
Salma Karim
Athanas Paul
Dr. Jiyenze Mwangu Kini
Joseph Mayunga
Elizabeth Kijugu
Charles Magwaza
Meshaki Makojijo
Stellah Kiwale
Evance Anderson
Juliana Malingumu
Rehema Mtonga
Masunga Isassero
Mbaruku Luga
INSTITUON/ ORGANIZATION
CDNT -MOHCDGEC-Dodoma
Lecturer -Aga Khan University
NACTE-Dodoma
Program Manager-Amref Health Africa
Program Officer-Amref Health Africa
Program Officer- Amref Hhealth Africa
Principal- Kahama School of Nursing
Ag. Principal –Newala School of Nursing
Tutor –Newala School of Nursing
Lecturer-MUHAS
Tutor KCMC School of Nursing
Tutor KCMC School of Nursing
Nurse Officer Muhimbili National Hospital
Nurse Officer- Mbeya Refferal
Medical Specialist-Mbeya Regional Refferal
Principal Mbeya –OTM
Tutor- Mirembe School of Nursing
Principal- Mirembe School of Nursing
Tutor –CEDHA
Tutor- Kisare
Principal-Kairuki School of Nursing
Principal Njombe School of Nursing
Tutor Bugando School of Nursing
Tutor- PHN Morogoro
Tutor Geita School of Nursing
Tutor Mchukwi School of Nursing
Tutor Assistant Lecturer –MUHAS
Driver-Mirembe School of Nursing
Lastly would like to thank the collaboration and financial support from Amref Health Africa who made
this task successfully completed.
Ndementria Arthur Vermand
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
vii
Assistant Director Nursing Training Section, Ministry of Health, Community Development,
Gender, Elderly and Children
Background
In 2015 the Ministry of Health, Community Development, Gender, Elderly and Children through the
Directorate of Human Resource Development, Nursing training section started the process of reviewing
the nursing curricula NTA level 4-6. The process completed in the year 2017 and its implementation
started in the same year. The rationale for review was to comply with the National Council for Technical
award (NACTE) Qualification framework which offers a climbing ladder for higher skills opportunity.
Amongst other rationale was to meet the demand of the current health care service delivery. The
demand is also aligned with human resource for health strategic plan and human resource for health
production plan which aims at increasing number of qualified human resource for health.
The process of producing qualified human resource for health especially nurses and midwives requires
the plentiful investment of resources in teaching at the classroom and practical setting and the
achievement of clinical competence is acquired in step wise starting from classroom teaching to skills
laboratory teaching. In addition, WHO advocates for skilled and motivated health workers in producing
good health services and increase performance of health systems (WHO World Health Report, 2006).
Moreover, Primary Health Care Development Program (PHCDP) (2007-15) needs the nation to
strengthen and expand health services at all levels. This can only be achieved when the Nation has
adequate, appropriately trained and competent work force who can be deployed in the health facilities
to facilitate the provisions of quality health care services.
In line with the revised curricula, the MOHCDGEC in collaboration with developing partners and team of
technical staff developed quality standardized training materials to support the implementation of
urricula. These training materials address the foreseen discrepancies in the implementation of the
curricula by training institutions.
This facilitator’s guide has been developed through a series of writers’ workshop (WW) approach. The
goals of Writer’s Workshop were to develop high-quality, standardized teaching materials and to build
the capacity of tutors to develop these materials. The new training package for NTA Level 4-6 includes
a Facilitator Guide and Student Manual. There are 33 modules with approximately
520 content sessions
Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a health
system that is responsive to the needs of the people, and leads to improved health status for all.
Skilled and motivated health workers are crucially important for producing good health through
increasing the performance of health systems (WHO, 2006). With limited resources (human and nonhuman resources), the MOHSW supported tutors by developing standardized training materials to
accompany the implementation of the developed CBET curricula. These training manuals address the
foreseen discrepancies in the implementation of the new curricula.
Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels 4-6) aims at
providing a room for Nurses to continue achieving skills which will enable them to perform competently.
These manuals will establish conducive and sustainable training environment that will allow students
and graduates to perform efficiently at their relevant levels. Moreover, this will enable them to aspire for
attainment of higher knowledge, skills and attitudes in promoting excellence in nursing practice.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
viii
Goals and Objectives of the Training Manual
1.1.
Overall Goal for Training Manual
The overall goal of these training manuals is to provide high quality, standardized and
Competence-based training materials for Diploma in nursing (NTA level 4 to 6) program.
1.2.
Objectives for Training Manual
• To provide high quality, standardized and competence-based training materials.
• To provide a guide for tutors to deliver high quality training materials.
• To enable students to learn more effectively.
Introduction
1.3.
Module Overview
This module content has been prepared as a guide for tutors of NTA Level 6 for training students. The
session contents are based on the sub-enabling outcomes of the curriculum of NTA Level 6 Ordinary
diploma in Nursing and Midwifery.
The module sub-enabling outcome as follows:
2.1.1
Provide care to a pregnant woman with bleeding conditions due to abortion, ectopic
pregnancy and hydatidiform mole according to standards
2.1.2
Provide care to a pregnant woman with Antepartum Haemorrhage (placenta praevia and
abruption) according to guidelines and protocols
2.1.3
Provide care to a pregnant woman with Urinary Tract Infections (UTIs) and syphilis according
to protocols and guidelines
2.1.4
Provide care to a pregnant woman with anaemia, cardiac diseases and diabetes mellitus
according to standards and protocols
2.1.5
Provide care to a pregnant woman with Pulmonary Tuberculosis (PTB) and malaria according
to protocols and guidelines
2.1.6
Provide care to a pregnant woman with disorders of amniotic fluid according to guidelines and
standards
2.1.7
Provide care to a pregnant woman with hypertensive disorders of pregnancy according to
guidelines and standards
2.1.8
Provide care to a pregnant woman with Hyperemesis gravidarum according to standards and
guidelines
2.2.1
Provide care to a woman with abnormal uterine action according to standards and guidelines
2.2.2
Provide care to a woman with prolonged labour according to standards and guidelines
2.2.3
Provide care to a woman with obstructed labour according to standards and protocols
2.2.4
Provide care to a woman with precipitate labour according to standards
2.2.5
Conduct vacuum extraction delivery according to standards and guidelines
2.2.6
Provide care to a woman undergoing caesarean section according to standards and protocols
2.2.7
Provide care to a woman during induction, augmentation and trial of labour according to
standards and guidelines
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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2.2.8
2.3.1
2.3.2
2.3.3
2.3.4
2.3.5
2.3.6
2.3.7
2.5.1
2.5.2
2.5.3
2.5.4
2.5.5
2.5.6
Provide care to a woman with preterm labour and premature rupture of membranes according
to standards
Provide care to a woman with breech presentation according to standards
Provide care to a woman with face presentation according to standards
Provide care to a woman with brow presentation according to standards
Provide care to a woman with shoulder presentation according to standards
Provide care to a woman with unstable lie and compound presentation according to standards
Provide care to a woman with occipital posterior position according to standards
Provide care to a woman with multiple pregnancy according to standards
Provide care to a woman with puerperal sepsis according to standards and guidelines
Provide care to a woman with puerperal psychosis according to guidelines and protocols
Provide care to a woman with breast infections according to guidelines and protocols
Provide care to a woman with sub-involution of uterus according to guidelines and protocols
Provide care to a woman with venous thrombosis according to guidelines and protocols
Provide care to a woman with urine incontinence according to guidelines and protocols
1.4.
Who is the Module For?
This module is intended for use primarily by tutors of NTA Level 4 certificate and diploma in nursing
schools.
The module’ sessions give guidance on the time and activities of the session and provide information
on how to teach the session to students. The sessions include different activities which focus on
increasing students’ knowledge, skills and attitudes.
1.5.
How is the Module Organized?
The module is divided into 36 sessions; each session is divided into sections. The following are the
sections of each session:
 Session Title: The name of the session.
 Learning Tasks – Statements which indicate what the student is expected to learn at the end of the
session.
 Session Content – All the session contents are divided into steps. Each step has a heading and an
estimated time to teach that step. Also, this section includes instructions for the tutor and activities
with their instructions to be done during teaching of the contents.
 Key Points – Each session has a step which concludes the session contents near the end of a
session. This step summarizes the main points and ideas from the session.
 Evaluation – The last section of the session consists of short questions based on the learning
objectives to check the understanding of students.
 Handouts are additional information which can be used in the classroom while teaching or later for
students’ further learning. Handouts are used to provide extra information related to the session
topic that cannot fit into the session time. Handouts can be used by the participants to study
material on their own and to reference after the session. Sometimes, a handout will have questions
or an exercise for the participants. The answers to the questions are in the Facilitator Guide
Handout, and not in the Student Manual Handout.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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1.6.
How Should the Module be Used?
Students are expected to use the module in the classroom and clinical settings and during self-study.
The contents of the modules are the basis for learning Care of a Woman with Abnormal Pregnancy,
Labour and Puerperium. Students are therefore advised to learn each session and the relevant
handouts and worksheets during class hours, clinical hours and self-study time. Tutors are there to
provide guidance and to respond to all difficulty encountered by students.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
xi
SESSION 1: CARE OF A WOMAN WITH ABORTION
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define abortion
 State causes of abortion
 Explain the classifications of abortion
 Explain signs and symptoms of abortion
 Give care to a woman with abortion and MVA
 Explain complications of abortion
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
5
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
5
Brainstorming/presentation
3
10
Lecture discussion
Definition of abortion
Causes of abortion
4
20
Lecture discussion
Classification of abortion
5
10
Presentation
Signs and symptoms of abortion
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
1
6
45
Small group
discussion/Lecture
discussion
Care of a woman with abortion and MVA
8
15
Lecture/discussion
Complications of abortion
9
5
Presentation
Key Points
10
5
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and LearningTasks (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of abortion (5 Minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm and give a definition of abortion.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below


Abortion is defined as termination of pregnancy before 24 weeks of gestation or when the fetus
weighs 500 g or less.
In Tanzania, abortion is termination of pregnancy before 28 weeks of gestation or viability.
STEP 3: Causes of abortion (10 Minutes)



Chromosomal abnormalities: cause at least 50% of early abortions e.g. trisomy, monosomy X
(XO) and triploidy.
Blighted ovum (anembryonic gestational sac): where there is no visible foetal tissue in the sac.
Maternal infections: e.g. treponema pallidum , listeria monocytogenes, mycoplasma hominis,
ureaplasma urealyticum, chlamydia trachomatis, neisseria gonorrhoeae, streptococcus
agalactiae, herpes simplex virus cytomegalovirus and toxoplasma gondii which causes abortion
if there is acute infection early in pregnancy.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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








Acute fever for whatever the cause can induce abortion.
Trauma: external to the abdomen or during abdominal or pelvic operations.
Endocrine causes:
o Progesterone deficiency (causes abortion between 8-12 weeks).
o Diabetes mellitus.
o Hyperthyroidism.
o Hypertensive disorders
Drugs and environmental causes: e.g. quinine, ergots, severe purgatives, tobacco, alcohol,
arsenic, lead, formaldehyde, benzene and radiation.
Maternal anoxia and malnutrition.
Immunological causes: e.g. systemic lupus erythematosus, antiphospholipid antibodies,
isoimmunization
Uterine defects e.g. Septum, Asherman's syndrome (intrauterine adhesions) and submucous
myomas.
Nervous, psychological conditions and over fatigue.
Idiopathic.
STEP 4: Classification of abortion (20 Minutes)
The abortion can either be induced or spontaneous.
Induced abortion
Induced abortion is that abortion in which pregnancy was terminated intentionally. There are two types
of induced abortion; criminal and therapeutic abortion.
Spontaneous abortion


Spontaneous abortion occurs without medical or mechanical means to empty the uterus.
Others prefer the term miscarriage to mean spontaneous abortion.
Classification of abortion



Threatened abortion
o If the blood loss is less than a normal menstrual flow and is not accompanied by pain
of uterine contraction there is a reasonable chance for continuing pregnancy. This
occurs in 50% of cases while other half will proceed to inevitable or missed abortion.
Inevitable abortion
o The patient complains of considerable bleeding and severe lower abdominal pain
referred to the back.
o On examination, the products of conception are felt through the dilated cervix.
Incomplete abortion
o Retention of a part of the products of conception inside the uterus. It may be the whole
or part of the placenta which is retained.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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


Complete abortion
o All products of conception have been expelled from the uterus.
Missed Abortion
o Retention of dead products of conception for 4 weeks or more.
Blighted ovum
o Also called anembryonic pregnancy represents a failed development of the embryo so
that only a gestational sac, with or without a yolk sac, is present
STEP 5: Signs and Symptoms of Abortion (10 Minutes)

The following table summarizes the signs and symptoms of abortion (columns) for each type of
abortion (rows).
Table 1.1: Signs and symptoms of abortion
TYPE OF
VAGINAL
ABDOMINAL
ABORTION
BLEEDING
PAIN
CERVICAL
DILATION
TISSUE
PASSAGE
PREGNANCY
TEST
Threatened
Slight
Mild cramping
No
No
positive
Inevitable
Moderate
Moderate
cramping
Yes
No
positive
Incomplete
Heavy
Severe
cramping
Yes
Yes
Positive
Complete
Decreased;
slight
Mild cramping
No
Yes
Positive
Missed
None; slight
None
No
No
Negative
Blighted
ovum
None; slight
Mild cramping
No
No
Positive
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 6: Care of a Woman with Abortion and MVA (45 minutes)
Activity: Small Group Activity (20 minutes)
DIVIDE students depending on the size of the class.
ASK students to explain how to care for a woman with abortion, each group to explain the
care of one category from these:






Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion
Blighted ovum
ALLOW the groups to work together to come up with answers to the question above,
focusing on their assigned category.
GIVE students an example, if necessary. For example, say “Encourage the woman to rest in
bed until one week after stoppage of bleeding”; “Advice the woman not to engage in sexual
intercourse as it may disturb pregnancy by the mechanical effect and the effect of semen
prostaglandins on the uterus.”
ALLOW groups 10 minutes for this exercise.
ASK students to report back the care plan per group. The following part of the presentation
has more details on each of these categories.
APPRAISE the students
Care of a woman with abortion for each category

PROVIDE feedback by summarizing the students’ answers
Threatened abortion
o Encourage the woman to rest in bed until one week after stoppage of bleeding.
o Advice the woman not to engage in sexual intercourse as it may disturb pregnancy by
the mechanical effect and the effect of semen prostaglandins on the uterus.
o Give sedatives if the patient is anxious.
o Medical treatment is usually not necessary but Progestogens: e.g. hydroxy
progesterone is given by some if there is evidence of progesterone deficiency.
o If bleeding stops, advice the woman to continue with follow-up in antenatal clinic.
o Reassess the woman if bleeding recurs.

Inevitable abortion
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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



o Any attempt to maintain pregnancy is useless.
o Resuscitation and oxytocin 10 IU is given by IV route to induce tetanic uterine
contraction and stop bleeding.
 If pregnancy is less than 12 weeks: Termination is done by vaginal evacuation
and curettage or suction evacuation under general anaesthesia.
 If pregnancy is more than 12 weeks:
- Oxytocin is given by intravenous drip to expel the uterine contents.
- If the placenta is retained it is removed under general anaesthesia.
 Counseling before and after the procedure is very important.
Incomplete abortion
o If pregnancy is less than 12 weeks: Evacuation is done by suction evacuation Manual
Vacuum Aspiration under general anaesthesia.
o If pregnancy is more than 12 weeks: evacuation by sharp curettage
o Counselling and reassurance
Complete abortion
o No further medical intervention is required as the products of conception are
completely expelled.
o Mothers should be advised to seek advice if the bleeding recurs or pyrexia develops.
o Counseling and follow-up.
Missed abortion
o The dead conceptus is expelled spontaneously in the majority of cases.
o Evacuation of the uterus is indicated in the following conditions:
 spontaneous expulsion does not occur within four weeks
 there is bleeding
 infection or DIC developed
 patient is anxious.
o It is important to check bleeding indices as this condition may complicate to DIC
Blighted ovum
o A blighted ovum eventually leads to abortion.
o Counseling and reassurance
o Manage accordingly
Perform Manual Vacuum Aspiration(MVA) as evacuation to less than 12 weeks abprtion
Reffer to Handout no1.1
STEP 7: Complications of Abortion (15 minutes)










Severe bleeding that may eventually lead to shock, anemia, and renal failure
Sepsis-septicaemia-infertility-ectopic pregnancy
Depression that may result into marital disharmony
Blood transfusion may predispose patient to HIV or hepatitis
Uterine perforation
Bowel injury
Amniotic fluid embolism- DIC
Bladder injuries
RhD-sensitization
Menstrual irregularities
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 8: Key Points (5 minutes)






The abortion can either be induced or spontaneous.
The term ‘miscarriage’ is used to describe spontaneous loss of pregnancy before 24 weeks
Grieving is an essential part of the recovery process following abortion
Bed rest will not prevent abortion
Blood loss and pain associated with abortion can be profuse and profound and overwhelming
for the mother
Counseling and reassurance is very important for woman who has experienced abortion
STEP 9: Session Evaluation (5 minutes)
 What is abortion?
 What are the causes of abortion?
 What are the signs and symptoms of abortion?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
7
Handout No 1.1 Step by Step in Performing MVA
Step by Step in Performing MVA
Ensure sterility

Ensure that part of the instrument required to
enter in the uterus is sterile.

No part of tip of the tube should be allowed to
touch the vaginal wall.
Steps for performing MVA
1.
Explain the procedure to the client.
2.
Position the patient in lithotomy position.
3.
Clean vulva and perineum with antiseptic e.g.
savlon.
4.
Drape patient with sterile towel
.
Perform bimanual pelvic examination to
ascertain; Size, position of the uterus and extent of
cervical dilatation.
.
.
Insert bivalve speculum into the vagina and
remove blood tissue from the vagina and cervical os
using sponge holding forceps.
.
Clean vagina and cervix with povidone using
gauze or cotton wool swabs.
.
Hold the anterior lip of the cervix using a single
Tenaculum/volsellum at position 12 o’clock.
.
Select appropriate cannula according to the
cervical os.
.
10. Gently apply traction on cervix to
straighten/align the cervical canal and uterine cavity.
.
Create vacuum in the syringe.
.
Gently insert the cannula into the uterine cavity
while holding the cervix steady until it touches the
fundus Note the depth by the dots visible on the
cannula
.
Withdraw the cannula slightly
.
Attach the prepared syringe to the cannula by
holding the end of the cannula in one hand and the
syringe in the other hand; ensure the cannula is
properly attached to the syringe.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
8
.
Release the valve(s) on the syringe to transfer
the vacuum through the cannula to the uterine cavity.
.
Evacuate the contents of the uterus by moving
the cannula gently back and forth and rotating within the
uterine cavity.
.
Check for signs of complete evacuation;
.
Red or pink form,
.
No more tissue in the cannula,
.
Gritty sensations,
.
The uterus contracts around the cannula.
.
17. If the syringe is full with products of conception and
no signs of complete evacuation close the valve,
disconnect syringe from the cannula and empty the
products. Repeat the evacuation procedure.
18. If there are signs of complete evacuation, close the
valve, detach syringe from the cannula, withdraw
syringe and remove the cannula.
19. Clean and inspect the cervix for bleeding, if there is
bleeding apply pressure using a gauze for 5-10
minutes, then remove.
.
Give Oxytocin 10 IU IM or Ergometrine 0.2 mg
IM or Misoprostol 600mcg orally.
20. remove the tenaculum/volsellum and speculum
20. Remove the patient from lithotomy position to rest
for 10 to 20 minutes.
21. Inspect the tissue for product of conceptions,
complete evacuation and molar pregnancy.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
9
SESSION 2: CARE OF A WOMAN WITH ECTOPIC PREGNANCY
Total Session Time:
120 minutes
Prerequisite :None
Learning Tasks
At the end of this session learner is expected to be able to:






Define ectopic pregnancy
State the risk factors for ectopic pregnancy
Identify and explain the common sites for ectopic pregnancy
Explain the sign ,symptoms and the diagnosis of an ectopic pregnancy
Give care to a woman with ectopic pregnancy
Explain the complications of ectopic pregnancy
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Content
1
05
Presentation
Presentation of session title and learning objectives
2
05
Presentation
Definition of ectopic pregnancy
3
10
Lecture/discussion Risk factors for ectopic pregnancy
4
35
Lecture
/discussion
Common sites for ectopic pregnancy
5
15
Presentation
Sign , symptoms and the diagnosis of an ectopic
pregnancy
6
30
Lecture/discussion
Care of a woman with ectopic pregnancy
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
10
7
10
Lecture/discussion
Complication of ectopic pregnancy
8
05
Presentation
Key Points
9
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of ectopic pregnancy (5 Minutes)

An ectopic pregnancy is one where implantation occurs at a site other than uterine cavity. E.g.
uterine tube, ovary, cervix and abdomen.
o Common site (95%):the tubes.
o Rare sites (5%):The ovaries, a rudimentary horn of a bicornuate uterus, broad
ligaments, peritoneum and cervix.
o In other words it is known as extra-uterine pregnancy
STEP 3: Risk factors forectopic pregnancy (10 Minutes)

Any alteration of the normal function of the uterine tube in transporting the gametes contributes
to the risk of ectopic pregnancy;
o Congenital abnormities of the tube.
o Previous infections including Chlamydia, gonorrhea and pelvic inflammatory diseases
o Previous pelvic surgery,particularly reconstructive tubal surgery
o History of infertility or Assisted Reproductive Therapy (ART)
o Failed sterilization i.e. Tubal ligation
o Previous ectopic pregnancy
o Uses of intrauterine contraceptive device
o Smoking
o Adjacent tumors especially in the broad ligament
o Premature implantation of the fertilized ovum in the tube which may occur due
premature shedding of the zona pellucida orPresence of ectopic endometrium in the
tube.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
11
STEP 4: Common sites for ectopic pregnancy (35Minutes)
Activity: Brainstorming (4 minutes)
ASK students to outline the common sites of ectopic pregnancy
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below




Fallopian tube 95% (Tubal pregnancy)
Cervix <2%
Ovary < 2%
Abdomen < 2%
1.1 A diagram showing the sites for ectopic pregnancy


Tubal pregnancy
o In tubal pregnancy, implantation can occur at any point along the tube, although the
ampulla is the most common site, the isthmus is the next in frequency, and the
interstitial site being the least common.
o Tubal pregnancy can either be ruptured or unruptured
Physiology of tubal pregnancy
o The blastocyst rapidly erodes the epithelium and becomes attached to the muscle
layer.
o It grows and expands within the wall,distending the tube.
o Maternal vessels are exposed and the pressure caused by the resultant blood flow can
destroy the embryo.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
12
o The uterus increases in size and changes associated with early pregnancy occur in the
body.
o The endometrium undergoes some degree of change under the influence of hormones.
o Vaginal bleeding associated with ectopic pregnancy is derived from degeneration of
the decidua




Outcome of tubal pregnancy
o Tubal abortion
The developing conceptus separate and is expelled through the fimbriated end of the
uterine tube .this outcome is more common in ampullary implantation
o Tubal mole
Bleeding around the embryo results in its death, and then the blood clots around the
conceptus enclosing it to form a mole, product retain in the tubes and may need to be
removed.
o Tubal rupture
The wall is distended by the pregnancy and penetrated by the trophoblast to such an
extent that it ruptures. This can be gradual or acute
o Abdominal pregnancy
Abdominal pregnancy
o Is always the result of an early tubal pregnancy rupture or abortion into the peritoneal
cavity.
o The fertilized ovum makes the abdomen the site of its primary implantation.
o The fetus develops within the peritoneal cavity but rarely survives
o Pregnancy may proceed to term but very rare
o The placenta remains attached to the uterine tube but expands and attaches
neighboring organs
Ovarian pregnancy
o Is rare
o Vaginal bleeding or sporting may be the presenting complaint.
o Symptoms relate to rupture into the peritoneal cavity and are similar to those of tubal
rupture.
o On examination the midwife may palpate an enlarged ovary or ovarian mass which
may or may not nor be painful.
o Uterus may be slightly enlarged from endometrial response to progesterone and hCG
.
Cervical pregnancy
o Is rare
o Sign and symptoms include painless bleeding soon after the time of implantation.
o Cervical mass may be palpated with distension and thriving of the cervical wall, partial
dilation of the external cervical os.
o Slightly enlarged uterine fundus.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
13
STEP 5: Signs, Symptoms and the diagnosis of ectopic pregnancy (15 Minutes)
Sign and of ectopic pregnancy



Typical sign and symptoms
o Localised/abdominal pain
o Amenorrhoea
o Vaginal bleeding
Atypical sign and symptoms
o Shoulder pain
o Abdominal distension
o Nausea ,vomiting
o Dizziness,fainting
o Apyrexia
Diagnosis of ectopic pregnancy
o Careful history about last normal menstrual period(LNMP) its timing and appearance.
o Always think of tubal pregnancy women with lower abdomen pain in whom there is
possibility of pregnancy should be regarded as having an ectopic until proved otherwise
o Ultrasound - the most reliable method of verification of ectopic pregnancy
o Levels of β-hCG - more often levels are lower than in normal pregnancy
o Laparascopy
o Laparatomy
STEP 6: Care a Woman with ectopic pregnancy(30 minutes)

Nursing management
PRE—OP& POST OP
o If hemorrhage and shock present restore blood volume by the transfusion of red cells
or volume expander
o Or may give the woman normal saline IV and prepare for operation
o Counsel the woman about her condition
o The earlier diagnosis of tubal pregnancy has allowed a more conservative approach to
management where the tube is less damage

Medical Management
o
o
o
o
o
o
Surgical Management
Salpingostomy (incision in tube) hopefully to retain tubal function
Salpingectomy (removal of tube)
Open abdominal incision or laparoscopy (depending on stability of patient
abdominal pregnancy they rarely reach term , and there delivery is by laparatomy
For cervical pregnancy evacuation can be done.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
14
STEP 7: Complications of Ectopic pregnancy (10 minutes)








Severe bleeding
Sepsis
Maternal death
Recurrence of ectopic
Infertility
Shock
Tubal rupture & organ damage
Psychological
STEP 8: Key Points (5 minutes)





Ectopic pregnancy is a life threatening condition
Women need prompt diagnosis and treatment
Not all cases present with a classical picture
Always suspect ectopic pregnancy in a woman of a child-bearing age with abdominal pain
and/or per vaginal bleeding
Information about ectopic pregnancy should be widely available and accessible to all social and
cultural group
STEP 9: Session Evaluation (5 minutes)





What is ectopic pregnancy?
What are the risk factors for ectopic pregnancy?
State the common sites for ectopic pregnancy
What are the signs and symptoms of ectopic pregnancy?
How will you manageectopic pregnancy?
 What are the complications of ectopic pregnancy?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.).London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar esSalaam.
Varny H. (2004) , Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666-667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
15
SESSION 3:CARE OF A WOMAN WITH HYDATIDIFORM MOLE
Total Session Time:
60 minutes
Prerequisite: None
Learning Tasks
At the end of this session a learner is expected to be able to:






Define hydatidiform mole
State the risk factors of hydatidiform mole
Explain the types of hydatidiform mole
Explain signs and symptoms of hydatidiform mole
Explain the management of hydatidiform mole
Explain complications of abortionhydatidiform mole
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Content
1
05
Presentation
Presentation of session title and learning
objectives
2
05
Presentation
Definition of abortion
3
05
Lecture/discussion
Risk factors of hydatidiform mole
4
10
Lecture/discussion
Types of hydatidiform mole
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
16
6
05
Presentation
Signs and symptoms of hydatidiform mole
7
15
Lecture/discussion
Management of hydatidiform mole
8
05
Lecture/discussion
Complications of hydatidiform mole
9
05
Presentation
Key Points
10
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of hydatidiform mole(5 Minutes)


Hydatidiform mole is a benign neoplasm of the trophoblast often the precursor of
choriocarcinoma
It appears like a collection of hydropic vesicles
STEP 3: Risk factors for hydatidiform mole (5 Minutes)




Previous molar pregnancy
Maternal age
o Increasing in women under 20 and over 40 years old
Ovular defect
Nutritional deficiency
STEP 4 : Types of hydatidiform mole (10 Minutes)
Types of hydatidiform mole

Complete mole:
o The whole conceptus is transformed into a mass of vesicles hence contain no
evidence of embryo.
o It is the result of fertilization of anucleated ovum (has no chromosomes) with a sperm
which will duplicate giving rise to 46 chromosomes of paternalorigin only.
 Partial mole:
o A part of trophoblastic tissue only shows molar changes.
o There is a fetus or at least an amniotic sac.
o It is the result of fertilization of an ovum by 2 sperms so the chromosomalnumber is 69
chromosomes.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
17
STEP 5: Signs,symptoms and diagnosis of hydatidiform mole (5 Minutes)
Sign and symptoms of hydatidiform mole



Amenorrhea: usually of short period (2-3 months).
Exaggerated symptoms of pregnancy especially vomiting
Vaginal bleeding which is usually dark brown and may be associated with passage of vesicles
and light pink or brown vaginal discharge due to rupture of the vesicles.
 Abdominal pain : may be ,
o dull-aching due to rapid distension of the uterus,
o colicky due to starting expulsion,
o Sudden and severe due to perforating mole.
 Pre-eclampsia develops in 20% of cases, usually before 20 weeks’ gestation.
 Hyperthyroidism develops in 10% of cases manifested by
o Enlarged thyroid gland,
o Tachycardia and elevated plasma thyroxin level.
Diagnosis of hydatidiform mole




On abdominal examination
o The uterus is larger than the period of amenorrhea
o The uterus is doughy in consistency
Urine pregnancy test: is positive in high dilution.
Serum b -hCG level: is highly elevated ( > 100.000 mIU/m1).
Ultrasonographyreveals:
o The characteristic intrauterine " snow storm" appearance
STEP 7: Care of a Woman with hydatidiform mole (15 minutes)






Resuscitate the woman with IV Ringers lactate or normal saline 3L or more
Emotional support of this patient is very important.
Vacuum aspiration or dilation and curettage is necessary if the mole does not abort
spontaneously
Hysteroctomy may be needed in a large mole to minimise and facilitate control of bleeding
Hysterectomy may be considered to a woman older the 40 years of age to avoiddeveloping
Choriocarcinoma
Advice the woman to avoid
o Getting pregnant during the follow up period
o The use of intrauterine contraceptive device because of the risk of perforation and
infection
o The use of hormonal methods of contraception until the level of HCG have returned to
normal
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
18

The woman should be couselled on the condition and to adhere to the follow up clinic.
STEP8: Complication of hydatidiform mole






Haemorrhage.
Infection due to absence of the amniotic sac.
Perforation of the uterus.
Pregnancy induced hypertension
Hyperthyroidism.
Subsequent development of choriocarcinoma
STEP 9: Key Points (5 minutes)




Gestational trophoblastic disease is a general term covering both bening hydatidiform mole
and choriocarcinoma.
Choriocarcinoma is a malignant neoplasm which can develop as a consequence of a molar
pregnancy.
As soon as the diagnosis of vesicular mole is established the uterus shouldbe evacuated.
Bleeding or blood stained vaginal discharge after a period of amenorrhea is the commonest
symptom
STEP 10: Session Evaluation (5 minutes)
 What is hydatidiform mole?
 What are the sign and symptoms of hydatidiform mole?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.).London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar esSalaam.
Varny H. (2004) , Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666-667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
19
SESSION 4: CARE OF A WOMAN WITH BLEEDING IN LATE
PREGNANCY
(ANTEPARTUM HAEMORRHAGE)
Total Session Time:
120 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define the term Antepartum Haemorrhage
 Explain the causes of Antepartum Haemorrhage
 Identify the classifications of Antepartum Haemorrhage
 Outline the signs and symptoms and Effects of APH
 Identify factors that aid in differential diagnosis in APH
 Explain the assessment of physical condition of the mother and foetus in APH
 Describe the care of a woman with APH
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning objectives
2
10
3
10
Brainstorming
Lecture/discussion
Lecture/discussion
4
10
Lecture/discussion
Signs and Symptoms of Antepartum Haemorrhage
5
05
Lecture/discussion
Factors that aid Differential Diagnosis in
APH
Definition of Antepartum Haemorrhage
Classification of Antepartum Haemorrhage
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
20
6
10
Lecture/discussion
Assessment of Physical Condition of the
Mother and Fetus
7
60
Lecture/discussion
Care of a Woman with APH
Case study
8
05
9
05
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of Antepartum Haemorrhage (10 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the definition of Antepartum Haemorrhage
(APH)
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:


Antepartum haemorrhage refers to bleeding from the vaginal tract in late pregnancy after the
24th week of gestation and before the onset of labour.
This may place the life of the mother and unborn child at risk.
STEP 3: Classification of Antepartum Haemorrhage (10 Minutes)

Placental site bleeding
o Placenta previa:Bleeding from separation of a placenta wholly or partially implanted in
the lower uterine segment.
o Abruptio placenta: Premature separation of a normally implanted placenta.
o Marginal separation: Bleeding from the edge of a normally implanted placenta.

Non-placental site bleeding
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
21
o
o
o
o
o
Vasa previa: Bleeding from ruptured foetal vessels.
Rupture uterus.
Bloody show.
Cervical ectopy, polyp or cancer.
Vaginal varicosity.
STEP 4: Signs and Symptoms of Antepartum Haemorrhage (10 Minutes)
Table 4.1 Signs and Symptoms of APH
Diagnosis
Placenta previa
Abruptio placenta
Signs and symptoms always
present



Painless vaginal bleeding
Painful vaginal bleeding
(may be retained in the
uterus)
Intermittent or constant
abdominal pain
Signs and symptoms sometimes
present









Shock
Bleeding may be precipitated
by intercourse
Relaxed uterus
High presenting part
Normal fetal condition
Shock
Tense/tender uterus
Decreased/absence foetal
movements
Fetal distress or absence fetal
sound
Step 5: Factors that aid Differential Diagnosis in APH (5 minutes)










Location of the placenta is the most critical information which will be needed to make a correct
diagnosis, using ultrasound scans.
Proper history taking
Pain
Onset of bleed, the amount of visible blood loss, colour of the blood
Degree of shock
Consistency of the abdomen
Lie, presentation and the level of engagement
Tenderness of the abdomen
Audibility of the fetal heart
Ultrasound scan
Step 6: Assessment of Physical Condition of the Mother and Fetus (10 minutes)
The midwife will assess the condition of the mother and fetus as follows:
 Maternal condition
o The midwife will look for any pallor or breathlessness which may indicate shock
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
22
o She will weigh up the woman’s emotional state as she greets her and begins to ask for
a history of events and remain calm.
o She must generate the trust of both partners
o Observation of pulse rate, respiration, blood pressure and temperature will be made
and recorded.
o The midwife must assess the amount of blood loss in order to ensure adequate fluid
replacement.
o She will discuss with couples how much has been lost earlier and ask to see all soiled
articles, retained for doctor’s inspection.
o Abdominal examination is made, observing for signs of labour.

Fetal condition
o The mother should be asked if baby is moving as much as normal
o The midwife must attempt to auscultation of fetal heart and may use ultrasound
apparatus to obtain the information
Step 7: Care of the Woman wit Antepaturm Haemorrhage (60 minutes)
A woman with APH can be managed as follows depending on the severity of bleeding.

Mild bleeding
o The women must be kept as quick as possible in a bed
o Regular observation of the women’s condition
o Obtain blood group and cross match and blood for full blood count
o The midwife should try to distinguish the type whether placental abruption or
placentaprevia
o The diagnosis should be confirmed by an ultrasound scan

Severe to moderate bleeding
o Continue to monitor the maternal condition
o Set up an intravenous infusion as soon as possible to treat shock
o Draw blood for hemoglobin and grouping and cross match, if the HB is less
than10mg/100ml a blood transfusion is to started immediately
o Give analgesic or sedatives if necessary
o Catheterize the patient and obtain midstream urine specimen
o Administer oxygen to increase oxygen concentration in the maternal and
fetalcirculation
o Record intake and output chart
o Note the blood loss and the paleness
o Check fetal heart rate and movement every 10-15 minutes
o Other subsequent management will depend on the definite diagnosis
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
23
Activity: Case Study (50 minutes)
DIVIDE students in small manageable groups
GIVE them the case study on Vaginal Bleeding in Later Pregnancy with clear
instructions (20 minutes)
ALLOW them time to present their responses for each group
Refer Handout 4.1: Antepartum Haemorrhage key answer
APPRAISE the students
CLARIFY and summarize using the key answer
Step 8: Key Points (5 minutes)



Antepartum heamorrhage is a bleeding from the placental site due to premature separationof
the placenta which occurs after 28thweeks of pregnancy and prior to the birth of thebaby and it
is life threatening condition to both mother and fetus
The major causes of bleeding in late pregnancy are placenta previa and premature separation
of the placenta (abruptio placenta or placental abruption).
Rapid assessment for and diagnosis of the cause of bleeding are essential to reduce maternal
and perinatal morbidity and mortality.
Step 9: Evaluation (5 minutes)



What is antepartum haemorrhage?
What are the signs and symptoms of Antepartum haemorrhage?
What factors that aid in differential diagnosis in Antepartum haemorrhage?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13thed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14thed.). London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15thed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced lifesaving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric andnewborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar esSalaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
24
Handout 4.1: Case study key answer for APH

Bahati, who is 32 weeks pregnant, gravida three, has two healthy children. She has attended
antenatal clinic regularly and all findings were within normal limits until her clinic visit 10 days
ago. At that visit her blood pressure was noted to be 120/96 mm Hg; there were no other signs
or symptoms of pregnancy-induced hypertension. Bahati was counselled about danger signs
and what to do if they occur and asked to return to the clinic in two weeks. She presents herself
at the health centre two days before her next visit, accompanied by her mother-in-law, with
vaginal bleeding, abdominal pain and a bad headache.

Initial Assessment
o History, Physical Examination, Screening Procedures/Laboratory Tests)

What will you include in your initial assessment of Bahati, and why?
o Bahati and her mother-in-law should be greeted respectfully and with kindness.
o They should be told what is going to be done and listened to carefully.
o In addition, their questions should be answered in a calm and reassuring manner.
o A rapid assessment should be done to check for the following signs to determine ifshe
is in shock and in need of emergency treatment/resuscitation: rapid, weak
pulse;systolic blood pressure less than 90 mm Hg; pallor; sweat or cold, clammy skin;
rapidbreathing and confusion.
o She should also be assessed to determine when vaginal bleeding started, the
amountof blood lost, and whether the blood is bright and contains clots.
o It will also be important to determine:
 When abdominal pain started (e.g., at the same time as vaginal bleeding) and
thenature of the pain
 Whether foetal movement has been felt since the onset of bleeding and pain
 When headache started and whether there has been/is any visual
disturbance(abruptio placenta can be associated with pregnancy-induced
hypertension)

What particular aspects of Bahati’s physical examination will help you make a diagnosisand
identify her problems/needs, and why?
o Palpation should be kept to a minimum, however, to avoid exacerbating thesymptoms.
o An abdominal examination should be done to establish the location and nature ofpain,
to feel the consistency of the uterus and check for guarding, and to detect
foetalmovement (a tense/tender uterus and decreased foetal movements are signs
ofabruptio attempt should be made to detect foetal heart sounds, which may be
absentwith an abruption.

What screening procedures/laboratory tests will you include (if available) in yourassessment of
Bahati, and why?
o No laboratory tests are required to make a diagnosis. However, an ultrasound
scanmay be performed if possible to locate placenta if placenta previa is suspected.
o Diagnosis (Identification of Problems/Needs)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
25

You have completed your assessment of Bahati and your main findings include thefollowing:
o Pulse rate is 120 beats/minute and weak,
o Blood pressure is 110/60 mm Hg.
o Respiration rate is 20 breaths/minute
o Temperature is 37º C.
o Her skin is pale and sweaty.
o Constant abdominal pain,
o Uterus is tender on palpation,
o Foetal heartbeat could not be heard.
o Heavy vaginal bleeding containing some old clotted blood.
o Coagulopathy was not detected.

Based on these findings, what is Bahati’s diagnosis, and why?
o Bahati’s signs and symptoms (e.g., signs of shock, constant abdominal pain,
uterinetenderness, vaginal bleeding and absent foetal heart sounds) are consistent
withabruptio placenta.
o Care Provision (Planning and Intervention)

Based on your diagnosis, what is your plan of care for Bahati, and why?
o Bahati should be treated for shock immediately:
 Position her on her side.
 Ensure that her airway is open.
 Give her oxygen at 6–8 L/minute by mask or cannula.
 Keep her warm.
 Elevate her legs.
 Monitor her pulse, blood pressure, respiration and temperature.
 Start an IV using a large bore needle for rapid infusion of fluids (1 L of normal
salineOr Ringer’s lactate in 15–20 minutes)
SESSION 5:CARE OF A WOMAN WITH PLACENTA PREVIA
Total Session Time:
120 minutes
Prerequisites: None
Learning Tasks
At the end of this session learner is expected to be able to:
 Define placenta previa.
 Explain the physiology of placenta previa.
 Identify the degrees and causes of placenta previa.
 Outline the risk factors for placenta previa.
 Assess maternal and foetal condition of a woman with placenta previa.
 Describe the care of a woman with placenta previa.
 Outline the complications of placenta previa.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
26
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
5
Activity/
Method
Presentation
2
10
Brainstorming/Presentation
Content
Presentation of session title and learning
objectives
3
30
Lecture/discussion
Definition and physiology of placenta previa
Causes and degrees of placenta previa
4
10
Brainstorming
Risk factors and indicators for placenta previa
5
20
Lecture/discussion
6
30
Lecture/discussion
Assessment of maternal and foetal condition of
a woman with placenta previa.
Care of a woman with placenta previa
7
5
Presentation
Complications of placenta previa
8
5
Presentation
Key Points
9
5
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
27
STEP 2: Definition and Pathophysiology Of Placenta Previa (10 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the definition placenta previa.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:

Definition
o Placenta previa is the malposition of the placenta inthe lower uterine segment, either
anteriorly or posteriorly.
o The placenta is partially or totally attached to the lower uterine segment.

Pathophysiology of Placenta Previa
o The lower uterine segment grows and stretches progressively after the 12th week.
o In later weeks this may cause the placenta to separate and severe bleeding can occur.
o The bleeding is caused by shearing stress between the placental trophoblast and
maternal venous blood sinuses.
STEP 3: Causes and Degrees of Placenta Previa (30 Minutes)
Causes of placenta previa
 It occurs in 0.5% of all pregnancy.
 It is more common in multgravida with an incidence of 1 in 90 deliveries and 1 in 250 deliveries
in primigravida.
 The cause is unknown, but the incidence increase with advancing age and parity. It may be
due to:
o Low implantation of the blastocyst.
o Development of the chorionic villi in the decidua capsularis
o Leading to attachment to the lower uterine segment.
o Large placenta as in twin pregnancy.
Degrees of placenta previa
 The degree of placenta previa are classified into four types:
o The 1stand 2nddegrees are marginal
o The 3rddegree is partial placenta previa
o The 4thdegree is total placental previa (see figure 5.1 below)
Figure 5.1: Types of Placenta Previa
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
28
Type 1
Type 2
Type 3
Type 4
Source: https://www.ambulance.qld.gov.au/clinical.html (retrieved on 25th
September 2018)

Type 1 Placenta Previa
o The large part of the placental tissue is situated in the upper uterine segment.
o In this case vaginal delivery is possible, usually blood loss is mild and the mother and
the fetus remains in good condition

Type 2 Placenta Previa
o The placenta is partially located in the lower uterine segment near the internal cervical
os.
o Vaginal delivery is possible particularly if the placenta is anterior.
o Blood loss is usually moderate, although the conditions of the mother and fetus can
vary, fetal hypoxia is likely to be present than maternal shock.

Type 3 Placenta Previa
o The placenta is located over the internal cervical os but not centrally.
o Bleeding is likely to be severe particularly when the lower segment stretches and the
cervix begin to efface and dilate in late pregnancy.
o Vaginal delivery is inappropriate because the placenta preceded the fetus

Type 4 Placenta Previa
o The placenta is located centrally over the internal cervical os and torrential hemorrhage
is very likely.
o Vaginal delivery should not be considered.
o Caesarean section is essential in order to save the life of the mother and fetus
STEP 4: Risk factors and indicators for Placenta Previa (10 Minutes)
Activity: Brainstorming (10 minutes)
ASK students to brainstorm on the risk factors for placenta previa.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
29
Risk factors for placenta previa






Multiparity
Maternal age greater than 35
Previous placenta previa
Previous uterine surgery, including cesarean section (risk increases with increased number of
cesarean sections)
Multiple pregnancy (larger placenta covering the oss)
Smoking (possible larger placenta)
Indicators of placenta previa







Painless per vaginal bleeding
Non tender and tense uterus
The fetal head remain unengaged in a primigravida
There is malpresentation, usually breech
The lie is transverse or oblique
The lie is unstable, usually in a multigravida
Localization of the placenta using ultrasonic scanning will confirm the existence of the placenta
previa and establish it’s degree
Step 5: Assessing the Maternal and Foetal Condition (20minutes)
Assessing Maternal Condition
 The amount of vaginal bleeding is variable
 Some mother may have a history of a small repeated blood loss at intervals
throughoutpregnancy whereas other may have a sudden episodes of vaginal bleeding after the
20thweek
 Severe hemorrhage occurs after 34th weeks of pregnancy
 The color of the blood is bright red denoting fresh blood
 All the blood loss should be quantified

General Examination
o If the bleeding is slight, the blood pressure, respiratory rate and pulse rate may be
normal
o In severe bleeding blood pressure is low and raised pulse rate due to shock
o The degree of shock correlates with the amount of blood lost from the vagina
o Rapid respiration.
o The mother looks pale and her skin cold and moist.

Abdominal Examination
o The midwife may find the lie of the fetus is oblique or transverse and fetal may be
highin primigravida near term
o No pain felt by the mother during palpation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
30
NB:Vagina examination should never be performed because torrential hemorrhage may
resultand worsen the situation
Assessing the Fetal Condition
 Ask the mother if the fetal activity are normal
 In severe fetal hypoxia fetal movements may be diminished or ceased.
 An ultrasound fetal monitor such as cardiotocograph (CTG) may be used
 Pinard fetal scope may also be used
 If fetal hypoxia is marked medical assistance should be called urgently as this is anemergency
condition
 If the facility has no services for resuscitation refer the woman immediately
Step 6: Care of a Woman with Placenta Previa (30 minutes)

The management depends on:
o The amount of bleeding
o The condition of the mother and the fetus
o The location of the placenta
o The stage of the pregnancy
Conservative Management ( NURSING CARE)
 It is appropriate if bleeding is slight and the condition of the mother and fetus are well
 Keep the mother in hospital and rest the mother in bed until bleeding is stopped
 It is usual for the woman to remain in hospital for the rest of her pregnancy
 Monitor placental function by a means of fetal kick chart and antenatal CTG.
 Ultrasound scan to observe the position of the placenta in relation to the cervical os as thelower
segment grows
 Insure physical, social and psychological support is important for those who are admittedfor
some weeks
 If she have other children allow them to visit their mother regularly as they may beanxious
 Some occupational therapy are important to alleviate boredom in long stay to hospital
 The midwife, the obstetrician and the woman may plan for how the birth will bemanaged.
 Vaginal delivery is possible with type 1 and 2, unless the placenta is situated immediatelyabove
the sacral promontory where is vulnerable to pressure from advancing fetal headand may
impede decent
 Correct anemia with oral iron
 Ensure blood is available for transfusion
Active Management
 Severe vaginal bleeding will necessitate immediate delivery by caesarean sectionregardless of
the location of the placenta.
 Take blood for full blood count, cross matching and clotting studies.
 Blood transfusion may be needed to be transfused quickly, blood group O may benecessary
 Insert an intravenous fluids.
 Keep input and output chart and record.
 Reassure the patient all the time as she will be anxious, the partner should be involvedand
supported.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
31



Prepare the patient for theatre but if the condition is worsen the patient will be examinedin the
operating theatre and the caesarean section is done, “double set up”.
In major degree of placenta previa (3rd& 4th) caesarean section is required even if thefetus is
died in utero.
The aim is to prevent torrential hemorrhage and possible maternal death.
Step 7: Complications of Placenta Praevia (5 minutes)





The major maternal complication associated with placenta previa is hemorrhage.
Another serious complication is development of an abnormal placental attachment (e.g.,
placenta accreta, increta, or percreta)
Maternal shock resulted from blood loss and hypovolaemia
Maternal death.
Fetal death.
Step 8: Key Points (5 minutes)


Placenta previa is life threatening emergency obstetric especially for type 3 and 4
Assessment of maternal and fetal condition is important in order to make appropriatedecision
for the management as well as prevention of complication.
Step 9: Evaluation (5 minutes)


What are the degrees of placenta previa?
How will you care a woman with placenta previa?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14th ed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.).London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric andnewborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar esSalaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
32
SESSION 6:CARE OF A WOMAN WITH ABRUPTIO PLACENTA
Total Session Time:
120 minutes
Prerequisites: None
Learning Tasks
At the end of this session learner is expected to be able to:
 Define the term Abruptio placenta
 State the etiology of abruption placenta
 Explain the types of Abruptio placenta
 Assess maternal and fetal condition in abruptio placenta
 Describe the management of a woman with placental abruption
 Outline the complications of placental abruption
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
2
10
3
10
4
50
5
6
Activity/
Method
Presentation
Brainstorming
Presentation
Presentation
Content
Presentation of session title and learning
objectives
Definition and etiology of abruptio placenta
Types of abruptio placenta
Assessment of maternal and foetal condition of a
woman with abruptio placenta.
30
Lecture/discussion
Small group
discussion
Lecture/discussion
05
Lecture/discussion
Complications of abruptio placenta
Management of a woman with abruptio placenta
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
33
7
05
8
05
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
Step 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK student to the Learning Tasks and clarify
ASK student if they have any question before proceeding
Step: 2 Definition and Etiology of Abruptio Placenta (10 minutes)
Activity: Brainstorming (5minutes)
ASK students to brainstorm on:


Definition of abruptio placenta
The etiology of abruptio placenta
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
Definition
 Abruptio placenta (placental abruption) is the premature separation of the placenta, or is the
detachment of part or all of a normally implanted placenta from the uterus.
 Separation occurs in the area of the decidua basalis after 20 weeks of gestation and before the
birth of the infant.
Etiology
 The true cause of this type of hemorrhage is unclear but is associated with:
o Severe pre-eclampsia
o Sudden reduction in the uterine size. e.g. when the membranes ruptured or after birth
of the first twin, and rare in direct trauma to the abdomen perhaps through road traffic
accident ,seat belt injury
o Previous caesarean section increase the risk of placental abruption
o Cigarette smoking
o Poor maternal nutrition
o Chorioamnionitis
o Maternal blunt abdominal trauma
o History of previous abruptio placenta
o External cephalic version
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
34
o Cocaine, particularly crack cocaine, usage
Step 3: Types of Abruptio Placenta (10 minutes)

These can be classified as follows:
o Revealed hemorrhage
 This when the blood escape from the placenta site separates the membranes
fromthe uterine wall and drain through the vagina
o Concealed hemorrhage
 This when blood is retained behind the placenta may be forced into
themyometrium and it infiltrates the muscle fibers of the uterus
 This extravasations cause marked damaged of observed at operation the
uterusappear bruised edematous this is termed as couvelaire uterus or uterine
apoplexy.
 Partial separation of the placenta causes bleeding from the venous sinuses in
the placenta bed
 Further separation continue to separate the placenta to a greater or lesser
degree
 No vaginal bleeding, but the mother will have all sign of hypovolemic
shockcaused by conceal bleeding into the uterine muscle
 The hemorrhage causes uterine enlargement and extreme pain
 It accounts for 20-35% of abruptions
o Mixed hemorrhage
 The combination of both type of hemorrhage
Figure 6.1: Abruptio Placenta (Concealed and Revealed)
Concealed Hemorrhage
Revealed Hemorrhage
Source: Perry et al., (2013). Maternal Child Nursing Care.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
35
Step 4: Assessing Maternal and Fetal Conditions (30 minutes)
Maternal condition
The following should be adhered in assessing the mother
 history taking,
o Ask the mother any history of accident
o Headache, nausea, vomiting, epigastric pain, and visual disturbance may be the
feature
o Mother may feel a slight localized pain or pain free in mildest degree of
placentaabruption

General examination
o The woman may look anxious, has abdominal pain, and the skin may look pale if
themother is in shock.
o Edema of the face, fingers and pretibial area of the lower limbs.
o The blood pressure and pulse rate should be taken immediately.
o Lowered blood pressure and raised pulse rate are signs of shock.
o Temperature may remain normal and respiration may be rapid or normal, but if thereis
reduced oxygenation may lead to air hunger.
o Observe and estimate the visible blood loss, the colour should also be noted.
o Blood that has been retained in utero for any length of time changes to brown colour

Abdominal examination
o Concealed hemorrhage may lead to uterine enlargement in excess of gestation
o The uterus has a hard consistency and there is guarding on palpation of the abdomen
o Palpation may be difficult and should not be attempted if the uterus is rigid
andexcessively painful
o In less severe cases, palpation should be kept to minimum to avoid further pain
anddamage
o Establish the nature and the location of the pain
o Fetal heart is unlikely to be heard with fetal stethoscope
o An ultrasound scanner to confirm the fetal survival
o Fetal parts may not be palpable
Assessing the fetal condition
 Ask the mother if she feels the fetal movements
 A CTG records will give more complete information about the fetal condition as well
asultrasound scan
 Failure to elicit fetal heart sound with a Pinard stethoscope is not confirmation of a fetal death
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
36
Step 5: Management of a Woman with Placenta Abruption (50 minutes)
Activity: Small Group Discussion (20 minutes)
DIVIDE students into small manageable group.
ASK them to discuss in groups on the management of a woman with abruption placenta for 5
minutes.
AFTER small group discussion, ask students to provide their responses.
CLARIFY and summarize using the contents below.



Any women with history of placental abruption needs urgent medical attention, she shouldbe
transferred to obstetric unit for emergency obstetric care.
The mother should be admitted to labour ward and consultant obstetrician is informed.
The midwife should provide physical and emotional comfort to the mother, and keep
herinformed all the time with information’s concerning her condition and progress
Managing Pain
 Pain which exacerbates shock should be alleviated.
 If it is so extreme morphine 15mg or pethidine 100-150mg may be given
 The midwife should differentiate the pain from concealed hemorrhage to that of labourpain
 The nature of the pain should be discussed because labour pain may supervene
followingplacental abruption
Managing Shock
 Set IV line of normal saline or ringer’s lactate
 Maintain Airway, Breathing and Circulation
 Shock may be due to hypovolaemia, to extravasations and consequent pain or toconsumptive
coagulopathy.
 Whole blood is traditionally used to restore the blood volume
 An infusion of fresh frozen plasma for every 4-6 units of blood to replenish the clottingfactors
(i.e. a ratio of 1 FFP to 4-6 units of blood).
 The mother should rest on her side to prevent vena cava occlusion and aortic compressionby
the gravid uterus.
 The legs may be elevated but the body should remain horizontal.
 The foot of the bed may be elevated.
Observations
 Vital signs should be monitored frequently depending on the severity of her condition.
 Check blood pressure 2-hourly or as frequently as necessary.
 Insert an indwelling catheter and monitor urine output.
 The urine should be tested for protein, which may also be linked to pregnancy
inducedhypertension.
 Prepare an intake and output chart and record all fluids.
 Fundal height and abdominal girth are measured hourly, an increase indicate continuebleeding
behind the placenta.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
37


If the fetus is alive, fetal heart rate should be taken continuously with the aid ofcardiotograph.
Any deterioration in the maternal or fetal condition must be reported immediately to
theobstetrician.
Investigations
 Clotting studies should be carried out because of the risk of coagulation defects.
 Blood sample may be needed at intervals in order to monitor the progress of thecondition.
Specific Management of Different Degrees of Placenta Abruption
 Mild separation of the placenta.
o In this case the placental separation and the haemorrhage are slight.
o Mother and the fetus are in a stable condition.

Moderate separation of the placenta.
o This describes placental separation of about one quarter.
o Up to 1000ml of blood may be lost, some may remain behind the placenta as
retroplacental clot or extravasations into the uterine muscles and some will remain per
vaginum.
o The mother will be shocked with raised pulse rate and lowered blood pressure
o There may be uterine tenderness and abdominal guarding.
o The fetus may alive but hypotoxic; intrauterine death is a probability
o The fluid replacement should be monitored.
o The fetal condition should be monitored with an electronic fetal monitor, if the fetusis
alive, immediate caesarian section may be indicated.
o Vaginal delivery may be contemplated if the fetus is in good condition or has
alreadydied.

Severe separation of the placenta.
o This is an acute obstetric emergency; at least two-third of the placenta has
becomedetached and 2000 ml of blood or more are from the circulation.
o The mother will be severely shocked to the degree far beyond what might be
expectedfrom the amount of viable blood loss.
o Whole blood 1500ml should be transfused rapidly and subsequent amounts
calculatedin accordance with the woman’s central venous pressure.
o Labour may begin spontaneously in advance of amniotomy (intentionally breaking
ofamniotic sac with a sterile amnion hook, allis forceps to stimulate or augment labour).
Psychological care
 The patient and her partner should be kept informed for what is happening at all time.
Step 6: Complications of Abruptio Placenta (5 minutes)




Disseminated intravascular coagulation is complication of moderate severe to
placentalabruption.
Postpartum hemorrhage.
Renal failure occur as a result of hypovolemia and consequent poor perfusion of thekidneys
Pituitary necrosis due to prolonged and severe hypotension.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
38
Step 7: Key Points (5 minutes)

Abruptio placenta (placental abruption) is the premature separation of the placenta, or is the
detachment of part or all of a normally implanted placenta from the uterus.
 The blood loss from a placenta abruption may be revealed, concealed or mixedhaemorrhage
 Any woman with history suggestive of placenta abruption needs urgent medical attention.
 Assessment of maternal and fetal conditions is important in order to provide
appropriatemanagement of a woman with abruptio placenta thus to minimize complications.
Step 8: Evaluation (5 minutes)


What are the types of abruptio placenta?
What is the management of a woman with abruptio placenta
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14th ed.). London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care.
Elsevier Health Sciences.
SESSION 7:CARE OF A WOMAN WITH URINARY TRACT INFECTION
(UTI) IN PREGNANCY
Total Session Time:
120 minutes
Prerequisite:
Learning tasks
At the end of this session a learner is expected to be able:
 Outline risk factors of UTIs
 Detect signs and symptoms of UTIs in pregnancy
 Management of UTIs in pregnancy
 Explain the prevention of UTIs
 Explain the impact of UTIs in pregnancy
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
39
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Lecture/discussion
Content
Presentation of session title and learning tasks
2
10
Brainstorming
3
20
Lecture/discussion
Definition of UTI
Causes and Risk factors of UTI
4
15
Lecture/discussion
Signs and symptoms of UTI in pregnancy
5
35
Lecture/ discussion
Management of UTI in pregnancy
6
15
Lecture /discussion
Prevention of UTI
7
15
Brainstorming
Complications of UTI in pregnancy
8
05
Presentation
Key Points
9
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
40
STEP 2: Definition of UTI (10 Minutes
Activity: Brainstorming (5 minutes)
ASK students to brainstorm Definition of UTI
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as below:

Is infection of the urinary tract occurring due to ascending microorganisms due to urine
stasis or trauma during labour or inadequate hygiene leading to ascending infection
Step 3: Causes And Risk Factors Of Uti (20 Minutes)
Causes: The common causative organism is usually Escherichia coli. E. coli is the offending organism
in over 90% cases. Other pathogens are Klebsiella pneumonae and Proteus. To exclude pre-existent
asymptomatic Bacteriuria, all pregnant women should ideally have a urine test at their first antenatal
visit. The overall incidence during pregnancy ranges between 2 and 10%.
Risk factors




Apparently stasis of urine occurs during pregnancy, which results from;
o Hormonal ureteral dilation,
o Hormonal ureteral hypoperistalsis,
o Pressure of the expanding uterus against the ureters
Trauma during labour
Inadequate vulval hygiene
Apparently PH change of vagina to alkalinity reduces clearance of microorganism.
STEP 4: Signs and symptoms of UTI in pregnancy (15 Minutes)

Mild

o
o
Severe
o
o
Mild general body malaise aches and pains in the back and loins.
In some cases painful urination may be apparent.
Acute cystitis- characterized by scalding on urination
Pyelonephritis- causing a sharp raised temperature, pain over the kidney and
haematuria.
o Lower abdominal pain, nausea, vomiting and Dehydration
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
41
STEP 5: Management of UTI in pregnancy (35 Minutes



Investigations: The diagnosis of UTI reached by clinical symptoms and sings and
investigations.
o Urinalysis, culture and sensitivity of the midstream upper urine (MUS) .Urinalysis and
culture are routinely done at initial evaluation to check for asymptomatic bacteriuria.
Diagnosis of symptomatic UTI is not changed by pregnancy.
Treatment:
o Treatment of symptomatic UTI is not changed by pregnancy, except drugs that may
harm the fetus are avoided.
o Because asymptomatic bacteriuria may lead to pyelonephritis, it should be treated with
antibiotics similar to an acute UTI.
o Antibacterial drug selection is based on individual and local susceptibility and
resistance patterns, but good initial empiric choices include the following:
 Cephalexin
 Amoxycilin
 Nitrofurantoin
 Trimethoprim/sulfamethoxazole
o A patient with severe symptoms and signs like fever, vomiting and dehydration Iv
antibiotics may be a best option with iv fluids and hospitalization.
General Nursing care:
o 4 hourly observation of vital signs specifically temperature and pulse rate
o Observation of uterine contractions for preterm labour
o Nursing care should include mobility of the patient and if possible wearing
antithrombotic stocking to avoid deep veins thrombosis(DVT)
o Counselling and reassurance of the patient.
STEP 6: Prevention of Urinary Tract Incfetion (UTI) in Pregnancy (15 Minutes





Routine screening of asymptomatic pregnant mother at first visit to antenatal clinic by doing
urinalysis and if possible doing culture and sensitivity.
Maintaining of vulva hygiene to avoid ascending infections
Enough and regular drinking of water that will help to wash out and clear bacteria in the Urinarr
tract
Prompt treatment at the first indication of the UTI and ensuring that the woman completes the
course of prescribed antibiotic
Re–assessment and repeated treatment is essential until the bacterial count is satisfactory.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
42
STEP 7: Complications of UTI in pregnancy (15 minutes
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on Complications of UTI in pregnancy
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as shown below

Complications
o Miscarriages
o Preterm labour then to premature deliveries
o Anaemia in pregnancy
o Acute renal disease e.g. pyelonephritis
o Chronic renal diseases e.g. Nephritis and Nephrotic Syndrome
o Proteinuria
STEP 8: Keys Points (5 minutes



The causative organism is commonly Escherichia coli.
Prompt treatment at the first indication of the UTI and ensuring that the woman completes the
course of prescribed antibiotic.
Routine screening of asymptomatic pregnant mother at first visit to antenatal clinic by doing
urinalysis and if possible doing culture and sensitivity
STEP 7: Session Evaluation (5 minutes




What are risk factors of UTI in pregnancy?
What are the symptoms and signs of UTI in pregnancy?
How do we prevent UTI in pregnancy?
What are the complications of UTI in pregnancy?
References



Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:
Churchill Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14th ed.).
London: Churchill Livingston
Duttas .D.C,Konar Hiralal.(Nov. 2013). Textbook of Obstetrics including Perinatology and
Contarceptives( 7th ed). New Delh: India
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
43
SESSION 8: CARE OF A WOMAN WITH MALARIA IN PREGNANCY
Total Session Time:
120 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define malaria in pregnancy
 List clinical features of uncomplicated and severe malaria
 Describe the treatment of uncomplicated malaria
 Describe the pre referral management of severe malaria in pregnancy
 Monitor maternal and foetal conditions
 Explain the impact of malaria in pregnancy
 Teach a pregnant woman on prevention and control of malaria
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
2
05
Presentation
Introduction and Definition of malaria in pregnancy
3
10
Lecture/discussion
Clinical features of uncomplicated and severe
malaria
4
20
Lecture/discussion
Treatment of uncomplicated malaria
Presentation of session title and learning
objectives
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
44
5
30
Brainstorming
Lecture/discussion
Lecture/discussion
Management of severe malaria in pregnancy
6
10
7
15
Group discussion
Presentation
Health education for prevention and control of
malaria in pregnancy
8
15
Presentation
How to Reduce Morbidity and Mortality from
Malaria in Pregnancy
9
05
Presentation
Key Points
10
05
Presentation
Session Evaluation
Impact of malaria in pregnancy
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Introduction and Definition of Malaria in Pregnancy (5 minutes)





Malaria in pregnancy is a parasitic infection, the most common causative organism being
plasmodium which is carried by mosquitoes.
The malaria parasites hide in the placenta; therefore routine finger prick blood sample testing
may not detect the parasites. The parasites may thus still be present and cause damage to the
placenta and foetus.
The parasites rarely pass into the blood circulation of the baby but can obstruct the passage of
nutrients and oxygen to the unborn baby hence slowing down its normal growth.
Initially malaria infection can occur without symptoms. Anaemia may be the only recognizable
clinical feature.
Why Pregnant Women are More Vulnerable to Malaria
o The effects of malaria on pregnancy are dependent on the malaria epidemiology and the
immunity of the women.
o There is a decline in immunity which is most pronounced in the first and second
pregnancies and teenage pregnancies.
o Pregnant women tend to get malaria more easily than women who are not pregnant
because of the loss of ability to fight malaria infection (low immunity).
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
45
o Low birth weight prevalence in primigravida adolescents is doubles that of adult
primigravidae.
STEP 3: Clinical Features of Uncomplicated and Severe Malaria(10 minutes)

Uncomplicated malaria
o Headache
o Fever
o Joint pains and malaise
o Poor appetite
o Nausea and/or Vomiting
o Diarrhoea
o Chest pain
o Pallor
o Note: some patients may be asymptomatic

Severe malaria
o Severe malarial anaemia
o Haemoglobinuria
o Cerebral malaria
o Pulmonary oedema.
STEP 4: Treatment of Uncomplicated Malaria(20 minutes)
Case Management of Uncomplicated Malaria
 Early diagnosis and effective management are important to prevent progression of
uncomplicated to severe malaria or death
 Whenever malaria is suspected laboratory confirmation of the parasite should be performed
 Treatment should be commenced immediately if laboratory test is not possible based on clinical
presentation
 A negative result does not exclude malaria infection
 Blood slide can be negative even if parasites are present, as they may be hidden in the
placenta.
 Note:
o During the first trimester of pregnancy Oral Quinine should be used as drug of choice
for treatment of uncomplicated malaria
o Quinine is safe during pregnancy
o Artemether/Lumefantrine (ALu) is not recommended in the first trimester, however if
quinine is not available and the patient is in danger then ALu tablets may still be used.
o During second and third trimesters of pregnancy Artemether/Lumefantrine (ALu)
shouldbe used as drug of choice for treatment of uncomplicated malaria
o ALu is an oral fixed combination tablet of 20 mg Artemether - a derivate of artemisinin,
and120 mg Lumefantrine.
o ALu has a rapid action against Plasmodium falciparum with clearance of the parasites
fromthe blood within 2 days.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
46
o Due to the long body elimination time of Lumefantrine (up to 10 days), ALu is
notrecommended to mothers who are breastfeeding children below 5 kgs
ALu Administration
 The first dose of ALu should be administered at the health facility as DOT
 The second dose should be strictly given 8 hours after the first dose.
 Subsequent doses could be given twice daily (morning-evening) in the second and third day of
treatment until completion of 6 doses.
 Give Paracetamol tablets 1gram 6 hourly for three days to relieve pain and fever when giving
ALu.
 Note:
o If the drug is vomited or spat out within 30 minutes after administration, the dose
should be repeated
o ALu should be taken with meals or drinks such as milk to enhance its absorption.
Side Effects and Contraindications of ALu
 Side effects
o Incidence is low
 Contraindication
o Patients with hypersensitivity to ALu
 Not recommended
o 1st trimester of pregnancy
o Lactating mothers with a child below 5 kgs
o Children below 5 kgs body weight
o Patients with severe malaria.
Management of Failed Response to Malaria Treatment with ALu
 If within 4 to 14 days after treatment with ALu a patient returns to you complaining ofcontinued
symptoms of malaria, a blood smear (and not RDT as does not reveal parasitecount) should be
examined.
 If malaria parasites are not found, other causes of symptoms should be investigated.
 If malaria parasites are present, this indicates drug failure.
 Quinine should be started immediately with strict follow up after a full history andexamination.
 Malaria cases should be followed up on the third day if symptoms persist or immediately ifthe
condition worsens, and cases that fail to respond should be referred.
 Note
o Quinine tablets should be given for 7-10 days, at a dose of 10mg/kg every 8 hours
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
47
STEP 5: Management of Severe Malaria in Pregnancy(30 minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the management of severe malaria in pregnancy.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
Management of Severe Malaria in Pregnancy
 Severe malaria is a medical emergency and demands early diagnosis based on a
completehistory, physical examination and blood smear/RDT
General Management
 Clear and maintain the airway to ensure breathing
 Place the patient in semi-prone position or on her side
 Take vital signs (pulse rate, respiration, blood pressure and temperature)
 Take blood slide for malaria parasites in order to initiate immediate treatment (do not waitfor
results)
 Take blood for urgent Hb estimation and blood for sugar if possible.
Injectable Quinine is the drug of choice for treatment of severe malaria duringpregnancy
 Quinine does not cause abortion at therapeutic doses
 Severe malaria can cause abortion or premature delivery
 Give quinine injection without delay
 Hypoglycaemia is a common problem in severe malaria. Use of quinine may worsen
thecondition.
 Therefore, give 5ml/kg of 10% dextrose solution as bolus, OR give 2.5 ml/kg of 25%dextrose
as bolus, OR give 50ml of water by mixing 20 gm of sugar (4-level teaspoons) with200 ml of
safe water.
 Give glucose solution orally or by Naso-gastric tube if unconscious.
Intra-Muscular (IM) Quinine
 If administration of IV Quinine is not possible, Quinine can be administered intramuscularlyafter
appropriate dilution.
 Use Quinine dihydrochloride injection (300 mg/ml)
 Give a dose of 10 mg of salt/kg bodyweight (maximum 600 mg) every 8 hours until thepatient is
able to take oral therapy.
 Dilute in four-fold of water for injection or normal-saline (1:4) to a concentration of 60mg/ml
 Note:
o Give paracetamol tablets 1 gram 6 hourly for 3 days.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
48
Administration of Intravenous (IV) Quinine
 Quinine dihydrochloride salt 10 mg/kg weight
 Diluted in 5-10 ml/kg weight of 5% dextrose
 Infused over a period of 4 hours, rest for 4 hours, but keep the IV line open, then continuewith
IV Quinine until the patient is able to take orally
 Change to Quinine tablets 10 mg/kg every 8 hours to complete 7 days of treatment or if notin
1st trimester give full course of ALu to complete treatment (ALu administration should bestarted
12 hours after the last dose of quinine)
 Also give 1 gram of paracetamol tablets 6 hourly for 3 days to lower fever and
relieveheadache/pain
 Administration of I/V Quinine may cause hypoglycaemia, therefore close monitoring is vital
 Refer the patient if necessary.
 The drop rate is calculated as follows;
o Drop rate per minute = amount of fluid to be infused (in ml) x 20 (drop factor)time
period to be infused (in minutes)
 Note
o It is important to monitor the rate of Infusion because Quinine if allowed to run
toorapidly may cause hypotension and hypoglyecaemia may develop.
o On the other hand if the Infusion is too slow, inadequate blood levels of the drug may
beachieved.
o Quinine drip (Infusions) should be discontinued as soon as the patient is able to take
oralquinine medication.
o Patients should be properly instructed to complete the 7-day treatment.
o Alternatively, a full course of ALu may be administered to complete treatment
Management of Failed Response to Quinine Therapy
 Persistence of clinical features of severe malaria
o Failure of clearance of parasites after 5 days of treatment
o Other possible causes of illness which have not been investigated.
 Note
o Patients with malaria who have not responded to quinine therapy should be
givenparenteral Artemether 3.2mg/kg weight (loading dose) IM followed by 1.6mg/kg
weightdaily for 6 days.
STEP 6: Impact of Malaria in Pregnancy (10 minutes)
Adverse consequences of malaria during pregnancy
 On the pregnant woman
o Anemia
o Hypoglycaemia
o Cerebral malaria
o Febrile illness
o Puerperal sepsis
o Death
 On the foetus
o Abortion
o Intrauterine growth restriction
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
49

o Stillbirth
o Congenital infection
On the newborn
o Low birth weight
o Premature
o Growth retardation
o Congenital neonatal malaria
o Death
STEP 7: Health education for prevention and control of malaria in pregnancy (15
minutes)
Activity: Small Group Discussion (10 minutes)
DIVIDE students into small manageable group.
ASK them to discuss in groups on the health education for prevention and control of malaria in
pregnancy.
AFTER small group discussion, ask students to provide their responses.
CLARIFY and summarize using the contents below.

Health education messages should focus on the following:
o If malaria symptoms persist after taking right dose of quinine therapy the patient might
be having no response to the treatment. The patient MUST thus go to a higher level of
care for re-evaluation and further management.
o Use of IPTp among pregnant women
o Advise on the use of ITNs
o Advise on environmental sanitation and Indoor Residual Spray (IRS) to control
mosquitoes.
o Closing windows and doors before dark
o Use of mosquito gauze to windows and doors
o Advise pregnant women, family members and other support persons to seek early
treatment when they feel sick.
o Continue with food and fluid intake.
o Importance of compliance to finish the dose.
STEP 8: How to Reduce Morbidity and Mortality from Malaria in Pregnancy (15
minutes)




Intermittent Preventive Treatment (IPT) of malaria with Sulfadoxine/Pyrimethamine (SP)
Preventing malaria transmission due to mosquito bites by using Insecticide Treated Nets(ITNs)
Early diagnosis of malaria and prompt case management
Quality focused antenatal care (ANC)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
50
Intermittent Preventive Treatment (IPTp)
 Intermittent Preventive Treatment (IPT) is the administration of drug (medicine) therapy in full
therapeutic doses at predetermined intervals during pregnancy even if individuals have no
signs of malaria
 The aim of IPT is to prevent the worst effects of malaria infection in pregnancy rather than to
cure a potentially life-threatening illness.
 Women taking IPT can still become sick with malaria
 IPT is not chemoprophylaxis
 Currently SP is the drug of choice for IPT
 IPT assumes that pregnant women in malarial areas are infected with malaria, therefore SP
should be given to reduce the adverse effects of malaria
 The recommended schedule for IPT is four doses that are given four weeks apart from 14
weeks of gestation.
 The health provider should devise an individual schedule for the pregnant woman that ensures
that IPT is given during the second and third trimester and the doses are not given less than 4
weeks apart.
 To get a single dose is better than nothing. Some pregnant women start ANC during the last
trimester of pregnancy.
They can be protected from a single dose of SP
 SP can be given at any point in pregnancy between 14 weeks and the last trimester as long as
they are four weeks apart.
 Evidence shows that, if used as recommended, SP is safe and effective for both the pregnant
woman and foetus.
Sulfadoxine/Pyrimethamine (SP)
 Is a combination of two different drugs - Sulfadoxine and Pyrimethamine which act
synergistically.
 One tablet contains 500 mg of sulfadoxine and 25 mg of pyrimethamine.
 Fansidar® (SP) is the most common brand name, but other brands with the same medicine
are: Falcidin®, Laridox®, Malostat®, Orodar®, and Metakelfin®.
 SP remains the drug of choice for IPTp even though it is no longer the first line drug for
uncomplicated malaria treatment.
 Note
o Chloroquine remains the recommended drug of choice for chemoprophylaxis for
pregnant women with sickle cell disease
Administering SP to Pregnant Woman during ANC Visits
 Always ask about allergy to sulfa drugs before giving SP
 In cases of known allergy to sulfa drugs and no available alternatives to SP for IPT, the use of
ITNs is strongly advised.
 Pregnant women should take SP with clean and safe drinking water, under Direct Observed
 Treatment (DOT) at the antenatal clinic.
 Infection Prevention measures should be adhered to (use clean cups for each client)
 If the pregnant woman vomits SP within 30 minutes, the dose should be repeated
 After giving SP record on the antenatal card and in the register MTUHA Book 6.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
51



Explain to the woman the importance of returning for the second dose, four weeks apart being
the minimum period required.
SP and Tetanus Toxoid may be given during the same visit.
If malaria is confirmed any time after administration of IPTp with SP, a full treatment with
antimalarials should be given according to the national guidelines.
Insecticide Treated Nets
 Insecticide treated nets (ITN) prevent physical contact with mosquitoes through either killingor
repelling them.
 Use of ITN is effective because mosquitoes usually bite at night when the client is asleep.
 ITN kill or repel other insects like:
o Lice, ticks, bedbugs and cockroaches
STEP 9: Key Points (5 minutes)








Early diagnosis and effective case management of malaria are crucial in preventing the
progression to severe disease and death.
Pregnant women with uncomplicated malaria are likely to develop severe malaria.
Treatment should be commenced immediately based on clinical presentation if laboratory test
is not possible
During the first trimester of pregnancy Oral Quinine should be used as drug of choice for
treatment of uncomplicated malaria
During second and third trimesters Artemether/Lumefantrine (ALu) should be used as drug of
choice for treatment of uncomplicated malaria
Injectable Quinine (IM/IV) is the drug of choice for treatment of severe malaria during
pregnancy.
Most pregnant women tend to get malaria more easily than women who are not pregnant
because of the loss of ability to fight malaria infection (low immunity)
In order to reduce malaria in pregnancy, ITN, IPT, early diagnosis of malaria and prompt case
management through quality focused ANC and community health education and promotion are
recommended.
Step10: Session Evaluation (5 minutes)




Why pregnant women are vulnerable to malaria?
What are the effects of malaria in pregnancy to the pregnant woman and the newborn?
What are the strategies to reduce morbidity and mortality from malaria in pregnancy?
How can you prevent malaria in pregnancy?
References
Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives (12th ed.). London: Churchill
Livingstone.
Fraser, D. M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
52
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MoHSW. (2010). Focused antenatal care: Learner’s guide for ANC service providers and supervisors.
Dar es Salaam.
MOHSW. (2006). National guidelines for diagnosis and treatment of malaria. Dar es Salaam.
SESSION 9: CARE OF A PREGNANT WOMAN WITH PULMONARY
TUBERCULOSIS
Total Session Time:
60 minutes
Prerequisite:
Learning Tasks
At the end of this session a learner is expected to be able:





Outline the causes of pulmonary tuberculosis (PTB) in pregnancy
Outline the risk factors pulmonary tuberculosis in pregnancy
Explain the signs and symptoms of pulmonary tuberculosis (PTB) in pregnancy
Describe the management and prevention of pulmonary tuberculosis (PTB) in pregnancy
Discuss the maternal and fetal effects of pulmonary tuberculosis (PTB) in pregnancy
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
53
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
1
05
Presentation of Session Title and Learning
tasks
Brainstorming/presentation The causes of pulmonary tuberculosis (PTB)
in pregnancy
2
05
3
05
Lecture discussion
Risk factors for contacting PTB
4
10
Lecture discussion
Symptoms and signs of PTB and Diagnosis of
PTB
5
15
Lecture discussion
Care of a woman with PTB and prevention in
pregnancy
6
10
Lecture discussion
Maternal and foetal effects of PTB in
pregnancy
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: The Causes of Pulmonary Tuberculosis (PTB) In Pregnancy (5 Minutes)
Activity: Brainstorming (3 minutes)
ASK students to tell the causes of pulmonary tuberculosis in pregnancy
ALLOW time for them to respond
CLARIFY and provide summary using the content below

Pulmonary Tuberculosis (TB) infection is caused by inhalation of viable bacilli, which may
persist in an inactive state (known as latent TB infection [LTBI]) or progress to active TB
disease
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
54
o Individuals with LTBI are asymptomatic and not contagious. Latent TB bacilli remain
viable and may reactivate, causing active symptomatic TB disease, which can be
transmitted via airborne spread.
o This can happen when someone with the untreated, active form of tuberculosis
coughs, speaks, sneezes, spits, laughs or sings
STEP 3: Risk Factors for Contacting PTB (5 Minutes)






Positive family history or past history
Low socioeconomic status
Area with high prevalence of tuberculosis
HIV infection
Alcohol addiction
Intravenous drug abuse
STEP 4: Symptoms and signs of PTB and Diagnosis (10 Minutes)
Symptoms and Signs of active TB include:
 Coughing (productive) that lasts two or more than two weeks
 Coughing up blood
 Chest pain, or pain with breathing or coughing
 Unintentional weight loss
 Fatigue
 Fever mostly in the evening
 Night sweats
 Chills
 Loss of appetite
DIAGNOSIS:
 Tuberculin skin test with Purified Protein Derivative (PPD) when > 10 mm is considered
positive speciallyin presence of risk factors

X-ray chest (after 12 weeks)

Early morning sputum (three samples) for acid-fast bacilli

Gastric washings

Diagnostic bronchoscopy

Extrapulmonary sites—lymph nodes, bones (rare in pregnancy)

Direct amplification tests for 16 S ribosomal DNA and gene probe can detect M. tuberculosis
with greater sensitivity and specificity. ( Currently GN expert)
STEP 5: Care of a woman with PTB and prevention in pregnancy (15 Minutes)

Prophylaxis-a pregnant woman with no evidence of evidence of active disease or HIV positive
are given Isoniazid prophylaxis 300 mg/day is started after the first trimester and continued for
6–9 months and Pyridoxin (Vit B6) 50 mg/ day is added to prevent peripheral neuropathy. No
major adverse fetal or neonatal effects are seen with these anti-tuberculous drugs.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
55






Treatment: Pregnant women with active tuberculosis should receive the following drugs orally
daily for a minimum period of 9 months. (Isoniazid, Rifampicin, Ethambutol , Pyrazinamide) in
fixed dose combination. Streptomycin is not used in pregnant as it causes damage to facial
nerve.
Place of therapeutic termination: Tuberculosis per se is not an indication for termination of
pregnancy.
Obstetric management is no different from other pregnant women, once tuberculosis is well
managed.
Breastfeeding: Breastfeeding is not contraindicated when a woman is taking anti-tuberculous
drugs. Breastfeeding should be avoided if the infant is also taking the drugs (to avoid excess
drug level). In active lesion, however, not only is breastfeeding contraindicated but the baby is
to be isolated from the mother following delivery. Baby should be given prophylactic isoniazid
10–20 mg/kg/day for 3 months when the mother is suffering from the active disease. However,
if the mother is on effective chemotherapy for at least 2 weeks, there is no need to isolate the
baby. BCG should be given to the baby as early as possible.
CONTRACEPTION:
o Pregnancy is to be avoided until quiescence is assured for about two years.
o Spacing can be achieved by any methods acceptable to the couple.
o Oral contraceptives should be avoided when rifampicin is used.
o sterilization should be seriously considered, if the family is completed.
Nutrition assessment and counselling; individuals with active tuberculosis (TB) should
receive
o an assessment of their nutritional status
o appropriate counselling based on their nutritional status at diagnosis and
throughout treatment.
o Pregnant women with active TB and moderate undernutrition, or with inadequate
weight gain, should be provided with locally available nutrient-rich or fortified
supplementary foods, as necessary to achieve an average weekly minimum weight
gain of approximately 300 g in the second and third trimesters.



All pregnant women with TB should be under care of physician who manages the clinical
aspect of the women’s treatment and a specialist midwife with full training in the disease.
It is also important that they collaborate with the obstetrician and HIV specialist to promote
continuity of care.
The key to a successful outcome is to ensure that the woman adheres to the prescribed
treatment.
Postnatal Care
 If negative, the neonate BCG vaccination should be given and drug therapy discontinued
 Antituberculin drugs are considered to be compatible with breastfeeding.
 Caring for a child at home makes great demand on the woman and extra help should be
arranged if possible.
 Long term medical and social follow up is necessary in order to monitor the progress of the
disease and the respond to treatment, also to provide help for the socially and economically
disadvantaged.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
56
STEP 6: Maternal and foetal effects of PTB in pregnancy (10 Minutes)
 Feotal effects
o In active disease, fetus can be affected by transplacental route or by aspiration of
amniotic fluid.
o Neonatal affection is mainly by postpartum maternal contact.
o In untreated patients, the incidence of preterm labor, IUGR and perinatal mortality is
high.
o Low birth from untreated mother
o Increased rate of spontaneous abortion
 Maternal effects
o Low weight gain in pregnancy
o Preterm labour
o Puerperal sepsis
o The onset of primary TB is often insidious and the symptoms are non-specific
fatigue,malaise, loss of appetite, loss of weight alteration in bowel habit and low grade
fever, can be interpreted as usual symptoms occurring in pregnancy
STEP 7: Key Points (5 minutes)




Tuberculosis (TB) infection is caused by inhalation of viable bacilli, which may persist in an
inactive state (known as latent TB infection [LTBI]) or progress to active TB disease.
This can happen when someone with the untreated, active form of tuberculosis coughs,
speaks, sneezes, spits, laughs or sings.
The cardinal symptoms and signs for pulmonary tuberculosis are productive cough for two
weeks or more, sweating and evening fever and un intentional weight loss
Prophylaxis-a pregnant woman with no evidence of evidence of active disease or HIV positive
are given Isoniazid prophylaxis 300 mg/day.
STEP 8: Session Evaluation (5 minutes)



What are the risk factors for contacting PTB?
What are the maternal effects of PTB ?
Why contraception is important to a woman with PTB?
References
WHO. Guideline: Nutritional care and support for patients with tuberculosis. Geneva, World Health
Organization; 2013
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
WHO. (2006). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice (2nd
ed.). Geneva: WHO.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
57
SESSION 10: CARE OF A PREGNANT WOMAN WITH SYPHYLIS
Total Session Time:
60 minutes
Prerequisite:
Learning Tasks
At the end of this session a learner is expected to be able:
 Outline the causes of syphilis in pregnancy
 Explain the signs and symptoms of syphilis in pregnancy
 Describe the management of syphilis in pregnancy
 Explain the prevention of syphilis in pregnancy
 Discuss the maternal and fetal effects of syphilis in pregnancy
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
1
05
2
05
Presentation of Session Title and Learning
tasks
Brainstorming/presentation The causes of syphilis in pregnancy
3
05
Lecture discussion
Risk factors for contacting syphilis
4
10
Lecture discussion
Symptoms and signs of syphilis and Diagnosis
of syphilis
5
15
Lecture discussion
Care of a woman with syphilis and prevention
in pregnancy
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
58
6
10
7
5
8
5
Lecture discussion
Maternal and foetal effects of syphilis
inpregnancy
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: The Causes of Syphilis In Pregnancy (5 Minutes
Activity: Brainstorming (3 minutes)
ASK students to tell the causes of syphilis in pregnancy
ALLOW time for them to respond
CLARIFY and provide summary using the content below



Syphilis is a systemic infection caused by the spirochete bacteria called Treponema pallidum,
is a sexually transmitted disease which is of particular concern during pregnancy because of
the risk of transplacental infection of the fetus.
Congenital infection can be associated with several adverse outcomes, including perinatal
death.
Incidence is rising due to upsurge of HIV infection and the IV drug abuse
STEP 3: Risk Factors for Acquiring Syphilis (5 Minutes)




those having unprotected sex
woman who have sex with men who sex with other men
woman with HIV at high risk
woman with numerous sexual partners
STEP 4: Symptoms and signs of Syphilis and Diagnosis (10 Minutes)

Primary symptom
o syphilis are one or many painless, firm, and round syphilitic sores called chancres.
These appear about 3 weeks after exposure.
o Chancres disappear within 3 to 6 weeks, but, without treatment, the disease may
progress to the next phase.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
59



Secondary symptoms
o a non-itchy rash that starts on the trunk and spreads to the entire body, including the
palms of the hands and soles of the feet. It may be rough, red, or reddish-brown in
color
o oral, anal, and genital wart-like sore
o muscle aches,fever, sore throat ,swollen lymph nodes ,
o patchy hair loss, headaches, weight loss, fatigue
Diagnosis
o Having obstetric performances with classic history shows—late abortion → macerated
stillbirth → fresh stillbirth
o Serological test—This should be done as a routine in the first antenatal visit. VDRL
 Blood tests: These can detect a current or past infection, as antibodies to the
disease will be present for many years.
 Bodily fluid: Fluid from a chancre during the primary or secondary stages can
be evaluated for the disease.
 Cerebrospinal fluid: This may be collected through a spinal tap and examined
to test for any impact on the nervous system.
If there is a diagnosis of syphilis, any sexual partners must be notified of and tested for the
disease.
STEP 5: Care of a woman with Syphilis and prevention in pregnancy (15 Minutes)
Syphilis can be treated successfully in the early stages.
 Early treatment with penicillin is important, as long-term exposure to the disease can
lead to life-threatening consequences.
 So early screening to a pregnant woman during antenatal is very important
 protection even if the treatment is begun late in pregnancy. For primary or secondary or latent
syphilis : benzathine penicillin 2.4 million units intramuscularly single dose. When the duration
is more than a year—benzathine penicillin 2.4 million units IM weekly for 3 doses is given. If
the patient is allergic to penicillin, oral azithromycin 2 gm as a single dose is given.
Baby:
 Positive serological reaction without clinical evidences of the disease —The baby is treated
with a single intramuscular dose of penicillin G 50,000 units per kg body weight
 Infected baby with positive serological reaction:
o Isolation with the mother
o Intramuscular administration of aqueous procaine penicillin G 50,000 units per kg
body weight each day for 10 days.
 An apparently healthy child of a known syphilitic mother: Serological reaction should be tested
weekly for the first month and then, monthly for 6 months.
STEP 6: Maternal and foetal effects of Syhilis in pregnancy (10 Minutes)

Feotal effects
o Abortion
o Preterm birth
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
60
o Intrauterine deaths leading to either a macerated or a fresh stillbirth
o Nonimmune fetal hydrops (ascites, hepatomegaly)
o Delivery of a highly infected baby with early neonatal death
o Survival with congenital syphilis.
 Maternal effects
o Infertility
o Recurrent pregnancy losses
o Preterm deliveries
o Dementia
o Numbness of extremities
o Visual loss
STEP 7: Key Points (5 minutes)





Syphilis is a systemic infection caused by the spirochete bacteria called Treponema pallidum,
It is a sexually transmitted disease which is of particular concern during pregnancy because of
the risk of transplacental infection of the fetus.
Serological test—this should be done as a routine in the first antenatal visit.( VDRL)
Early screening to a pregnant woman during antenatal is very important
An apparently healthy child of a known syphilitic mother: Serological reaction should be tested
weekly for the first month and then, monthly for 6 months.
STEP 8: Session Evaluation (5 minutes)



What are the risk factors syphilis infections?
How does syphilis diagnosed?
List the feotal effects of syphilis.
References
WHO. Guideline: Nutritional care and support for patients with tuberculosis. Geneva, World Health
Organization; 2013
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
WHO. (2006). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice (2nd
ed.). Geneva: WHO.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
61
SESSION 11 :CARE OF A WOMAN WITH ANAEMIA IN PREGNANCY
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define anaemia
 State the factors contributing to anaemia in pregnancy
 Outline the clinical features of anaemia
 Care of a woman with mild, moderate and severe anaemia
 Explain the impact of anaemia, to a pregnant woman and foetus
 Explain the prevention of anaemia in pregnancy
Resources Needed:




 Give care to a woman with abortion
 Explain
complications
of abortion
Flip charts,
marker pens,
and masking
tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
05
Brainstorming/presentation
Definition of anaemia in pregnancy
Factors contributing to anaemia in pregnancy
3
10
Lecture discussion
4
15
Presentation
Clinical features and diagnosis of anaemia in
pregnancy
5
45
Lecture discussion
Care of a pregnant woman with mild,
moderate and severe anaemia
6
15
Lecture discussion
Explain the impact of anaemia, to a pregnant
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
62
woman and foetus
8
15
9
05
10
05
Buzzing/presentation
Explain the prevention of anaemia in
pregnancy
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of anaemia in pregnancy (5 Minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on the defition of anaemia in pregnancy.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below



Anaemia is defined as the reduction of red blood cells or haemoglobin concentration or both
below the normal range.
A pregnant woman with haemoglobin (Hb) less than 11g/dl or haemotocrit less than 33% is
considered anaemic.
Anaemia can be ;
o Moderate anaemia Hb(7.0-10.9)g/dl
o Severe anaemia Hb<7g/dl
o Very severe anaemia Hb<4g/dl
STEP 3: Factors Contributing To Anaemia In Pregnancy (10 Minutes)

Increased nutritional demand for
o Growing foetus and placenta
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
63








o Increased maternal Red blood cell mass
o Nutrients include mainly iron, and folic acid, and other vitamins.
Plasma volume increases by 50%, and RBC mass 25% this leads haemodilution which
reaches maximum about 32-34 weeks.
Inadequate dietary intake –nutritional deficiency
o Poor diet lacking essential nutrients for haemopesis- i.e iron and folic acid
o Poor appetite- e.g.
o excessive vomiting
o Acute & chronic infections
o Inadequate absorption (malabsorption this is rare)
Excessive iron loss ( blood loss)
o parasitic infestations- mainly hookworm, schistosmiasis
o heavy menstrual loss prior to pregnancy
Malaria
 pregnancy women are more susceptible to malaria especially during first
pregnancy
Chronic nutrient depletion
 high parity especially frequent closely spaced births
Multiple pregnancy
 increased demand of nutrients (iron, folic acid vitamin B )
Underlying infections e.g. UTI,HIV,TB
Blood disorders like sickle cell anaemia and leukaemia
STEP 4: Clinical Features And Diagnosis Of Anaemia In Pregnancy (15 Minutes)



Anaemia may be asymptomatic and symptoms appear when the anaemia is already severe
Symptoms and signs are not very specific
The general complaints are
o fatigue,
o lestlessness,
o dizziness,
o palpitations,
o dyspnoea,
o And orthopnoea,

Signs include
o palor of the conjunctiva, tongue, bucalmucosa,palms, and nail beds etc,
Palor of the mucous membranes, and palms
Koilonychia in long standing severe anaemia of iron deficiency type
May be jaundiced



NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
64
 tachycardia,tachypnoea , gallop rhythm
Diagnosis
 Through history taking
 Through physical examination
 Through laboratory investigation
o Full blood count and RBC indices
o Haemoglobin-determine the severity of anaemia
o peripheral blood smear
o Red cell indices- microcytosis, hypochromia- reflects iron deficiency anaemia.
megaobablastic- folic acid deficiency
o Blood slide for malaria parasites
STEP 5: Care Of A Pregnant Woman With Mild, Moderate And Severe Anaemia (45
Minutes)

Mild to Moderate Anaemia (7-10.9g/dl)
o Find and treat the cause of anaemiaGive the following drugs:
 Ferrous sulphate 200 mg three times a day
 Folic acid 5 mg daily
 Antihelminthics : Mebendazole 500 mg (DOT) once after the first trimester
o Treat schistosomiasis after delivery
 Severe anaemia
o Severe at any gestation is an emergency; the pregnant woman should be admitted.
o Thorough history and examination
o Exclude cardiac failure
o Give the pregnant woman blood transfusion
 Precautions-give diuretic before transfusion
 Transfuse slowly
 NB blood transfusion may precipitate cardiac failure
o Monitor vital sign of the mother and fetal heart rate
o Continue with ferrous sulphate and folic acid up to 3 months after delivery
o Follow up patient every 14 days until Hb reaches 11g/dl.

Very severe anaemia
Very severe anaemia – in Cardiac failure is an obstetric emergency
o Transfusion is necessary and urgent
o Use packed cells or sediment cell and discard the serum
o Give a fast acting diuretic- e. g furosemide or ethacranic acid before transfusion
o Monitor the maternal and fetal vital sign
STEP 6: Impacts Of Anaemia To Mother And Foetus(20 Minutes)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
65


Mother
o Severe anaemia may cause cardiac failure and death
 Dangerous time is during labour when there is increased work of the heart
 After delivery when shunting of the blood from placental bed results in volume
overload
o Poor weight gain
o Reduced tolerance to blood loss.
 Minimal blood loss may precipitate hypovolaemia and collapse
o Reduced resistance to infection especially during the puerperium, and thus susceptible
to puerperal infections.
o Decreased work capacity
 Poor ability to lactate
Foetus
o Abortion
o Premature delivery
o Intrauterine growth retardation
o Stillbirth
o Thus anemia in pregnancy causes increased maternal morbidity and mortality and
perinatal morbidity and mortality
STEP 7: Prevention of anaemia in pregnancy(15 minutes)
Activity: Buzzing (2 minutes)
TELL students to pair up and outline the clinical features of anaemia in pregnancy for 2inutes
ALLOW few students to respond and let other pairs provide unmentioned responses
CLARIFY and summarize by using the information below.
PROVIDE possible answers as indicated in the notes below







Prophylactic treatment to all pregnant women
o Iron- ferrous sulphate 1 tablet twice a day
o Folic acid 1 tablet once a day
o Intermittent presumptive treatment (IPT) for malaria with SP twice during pregnancy
o De-worming once during the second trimester
Treatment of any underlying condition
Give nutritional education
o All pregnant women should be advised to take diversified diet and promote use of food
richin iron which are locally available.
Advise the woman on personal malaria protection using ITN
Advise on family planning
Advice pregnant women on the importance of antenatal clinic follow ups
General environmental measures
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
66
o Control malaria, and hookworm
o Promote and ensure adequate nutrition to all women in reproductive age
o Promote adequate food production and thus household food security at national level
STEP 9: Key points (5 minutes)



Anaemia in pregnancy is preventable
In order to treat anaemia treat the underlying cause first
Aetiological type of anaemia includes
o Iron deficiency
o Folic acid deficiency
o Combined deficiencies
o Hemolytic anaemia - due to malaria
o Anaemia of chronic infections e.g. HIV/AIDS,pyelonephritis and TB
o Hemoglobinopathies, eg sickle cell anaemia
STEP 10: Session Evaluation(5 minutes)



What are the contributing factors for anemia in pregnancy?
What are the clinical symptoms and signs of anemiain pregnancy?
What are the complications or effects of anemia to pregnant woman?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
67
SESSION 12: CARE OF A WOMAN HYPERTENSIVE DISORDERS IN
PREGNANCY
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define hypertensive disorders of pregnancy
 Describe different classes of hypertensive disorders of pregnancy
 Explain etiology of hypertensive disorders of pregnancy
 Explain pathophysiology of hypertensive disorders of pregnancy
 Explain signs and symptoms of imminent eclampsia
 Describe haemolysis elevated liver enzymes and low platelets count (HELLP)
syndrome
 Identify principles of managing pre-eclampsia and eclampsia
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
05
Activity/
Method
Presentation
Content
1
2
10
Brainstorming/presentation Definition hypertension in pregnancy
3
10
Lecture discussion
classes of hypertensive disorders of pregnancy
4
30
Lecture discussion
etiology of hypertensive disorders of pregnancy
5
20
Lecture discussion
pathophysiology of hypertensive disorders of
Presentation of session title and learning tasks
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
68
pregnancy
6
20
Presentation
signs and symptoms of imminent eclampsia
7
10
Lecture discussion
Haemolysis elevated liver enzymes and low
platelets count (HELLP) syndrome
8
10
Presentation
Key Points
9
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Hypertensive Disorders of Pregnancy (10 Minutes
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the definitions of hypertension, hypertensive disorders of
pregnancy, pregnancy-induced hypertension, chronic hypertension.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below




Hypertension is one of the medical condition that is diagnosed when a BP is ≥140/90 mmHG
measured 2times apart with at least 4hours or more apart.
The hypertensive disorders of pregnancy include pregnancy induced-hypertension and chronic
hypertension.
Pregnancy induced-hypertension is that occurs after 20 weeks of gestation, during labour
and/or within 48hours of delivery.
Hypertension occurs before 20 of gestation age it is classified as chronic hypertension.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
69
STEP 3: Different Classes of Hypertensive Disorders Of Pregnancy (10 Minutes)
The term, ‘Pregnancy-induced hypertension (PIH)’ is defined as the hypertension that develops as
a direct result of the gravid state. It includes—(i) gestational hypertension, (ii) pre-eclampsia, and
(iii) eclampsia.
 Gestational hypertension: BP ≥ 140/90 mm Hg for the first time in pregnancy after 20
weeks, without proteinuria
 Pre-eclampsia: Gestational hypertension with proteinuria
 Severe pre-eclampsia(imminent eclampsia): Diastollic pressure of 110mmHG or above
after 20 weeks of gestation age with protein in urine of +3 or above, severe headache,
blurred vision, epigastric pain, dizziness but no convulsions and no loss of consciousness.
 Eclampsia: Women with pre-eclampsia complicated with convulsions and/ or coma
 Chronic hypertension: Known hypertension before pregnancy or hypertension diagnosed
first time before 20 weeks of pregnancy
 Superimposed pre-eclampsia or eclampsia: Occurrence of new onset of proteinuria in
women with chronic hypertension.
STEP 4: Aetiology of Hypertensive Disorders of Pregnancy (30 Minutes)



Pregnancy induced hypertension is a multisystem disorder of unknown aetiology
characterized by development of hypertension to the extent of 140/90 mm Hg or more with
proteinuria after the 20th week in a previously normotensive and non-proteinuric woman. Some
amount of edema is common in a normal pregnancy. Edema has been excluded from the
diagnostic criteria unless it is pathological.
The risk factors can be explained rather the causes of pregnancy induced hypertension;
o Primigravida: Young or elderly (first time exposure to chorionic villi)
o Family history: Hypertension, pre-eclampsia
o Placental abnormalities: Hyperplacentosis: Excessive exposure to chorionic villi (molar pregnancy
twins, diabetes)
 Placental ischemia.
o Obesity: BMI >35 kg/M2, Insulin resistance.
o Pre-existing vascular disease
o New paternity. Changing of paternity has been associated with PIH
o Thrombophilias (antiphospholipid syndrome, protein C, S deficiency,
o Preexisting medical conditions such as hypertension, renal disease, thrombophilias
o Age (teens and women older than 35 years)
The common causes of chronic hypertension:
o Essential hypertension
o Chronic renal disease (reno vascular disease)
o Coarctation of aorta
o Endocrine disorders (diabetes mellitus, pheochromocytoma, thyrotoxicosis
o Connective tissue diseases (Lupus erythematosus).
STEP 5: Pathophysiology Of Hypertensive Disorders Of Pregnancy (20 Minutes)

In pre-eclampsia and eclampsia, the following pathophysiologic changes are noted
o BP begins to rise after 20 weeks of pregnancy
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
70
o
o
o
o
o
o
Blood flow is decreased to virtually all organs, which is secondary to intense
vasospasm due to an increased sensitivity of the vasculature to any pressor agent
Blood flow to the kidneys is decreased, resulting in sodium retention that leads to loss
of intravascular plasma volume, increased extracellular volume (oedema) and
increased sensitivity to pressor agents.
Permeability increases and serum albumin filters through into the urine(Tubular
reabsorption is simultaneously depressed) Leading to protein in urine.
Loss of normal vasodilation of uterine arterioles results in decreased placental
perfusion and can affect fetal growth and wellbeing
The liver is affected in severe cases where intravascular haemorrhages and necrosis
occur Oedema of the liver cells produces epigastric pain and impaired liver function
may results in jaundice
Decreased intravascular volume results in increased viscosity of the blood and a
corresponding rise in hematocrit, as well as activation of the coagulation cascade,
especially platelets, with microthrombi formation.
STEP 6: Signs and Symptoms Of Imminent Eclampsia (20 Minutes)

Imminent eclampsia or severe pre-eclapmsia is classified when the diastolic blood pressure is
above 110mmHG on two readings at least 20minutes apart. The following are the symptoms
and signs of immnent eclampsia;o A sharp rise in blood pressure
o Diminished in urine output which is due to acute vasospam
o Increase in proteinuria +3 or more
o Headache which is usually severe persistent and frontal in location( throbbing in
nature) usually does not respond to analgesic
o Drowsiness or confusion due to cerebral edema
o Visual distabances such as blurring vision or flushing lights, due to retinal edema
o Epigastric pain which denotes liver edema and impairment of liver function
o Nausea and vomiting.
STEP 7: Haemolysis , Elevated Liver Enzymes And Low Platelets Count (HELLP)
Syndrome (10 Minutes)

HELLP Syndrome: This is an acronym for Hemolysis (H), Elevated Liver enzymes (EL) and
Low Platelet count (LP)(<100,000/mm3).
o This is a rare complication of pre-eclampsia (10–15%).
o HELLP syndrome may develop even without maternal hypertension.
o This syndrome is manifested by nausea, vomiting, epigastric or right upper quadrant
pain, along with biochemical and hematological changes.
o Parenchymal necrosis of liver causes elevation in hepatic enzymes (AST and ALT >70
IU/L, LDH>600 IU/L) and bilirubin (>1.2 mg/dL).
o There may be subcapsular hematoma formation (which is diagnosed by CT scanning)
and abnormal peripheral blood smear.
o Eventually liver may rupture to cause sudden hypotension, due to hemoperitoneum.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
71
STEP 8: Key Points (10minutes)





Hypertension is one of the medical condition that is diagnosed when a BP is ≥140/90 mmHG
measured 2times apart with at least 4hours or more apart.
The hypertensive disorders of pregnancy include pregnancy induced-hypertension and chronic
hypertension.
Pregnancy induced hypertension is a multisystem disorder of unknown aetiology
characterized by development of hypertension to the extent of 140/90 mm Hg or more with
proteinuria after the 20th week in a previously normotensive and non-proteinuric woman. Some
amount of edema is common in a normal pregnancy.
Imminent eclampsia or severe pre-eclapmsia is classified when the diastolic blood pressure is
above 110mmHG on two readings at least 20minutes apart with proteinuria of +3 or above,
headache and visual disturbance
HELLP Syndrome: This is an acronym for Hemolysis (H), Elevated Liver enzymes (EL) and
Low Platelet count (LP)(<100,000/mm3).
STEP 8: Session Evaluation (5 minutes)




What are hypertensive disorders of pregnancy?
What is pregnancy induced hypertension?
How can you classify pregnancy induced hypertension?
How can you describe the word HELLP syndrome?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Duttas .D.C, Konar Hiralal.(Nov. 2013). Textbook of Obstetrics including Perinatology and
Contraceptives ( 7th ed). New Delh: India
MOHSW. (2010). Learning resource package for basic emergency obstetric and newborn care. Dar es
Salaam
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
72
SESSION 13: CARE OF A WOMAN WITH PRE-ECLAMPSIA AND
ECLAMPSIA
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session a learner is expected to be able:
 Identify principles of managing eclampsia
 Assess a woman to diagnose hypertensive disorders of pregnancy
 Give care to a pregnant woman with mild pre-eclampsia during antenatal
 Give care to a pregnant woman with severe pre-eclampsia/eclampsia during antenatal
 Give care to a pregnant woman with severe pre-eclampsia/eclampsia during itrapartum
and after delivery
 Complications following severe pre-aclampsia and eclampsia intra-partum and after
delivery.
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
2
10
Brainstorming
3
15
Demonstration/
Content
Presentation of Session Title and Learning
Objectives
principles of managing eclampsia
Assessment of a pregnant woman to diagnose
hypertensive disorders of pregnancy
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
73
4
10
Lecture discussion
Care of a pregnant woman with Pre-eclampsia
during antenatal
5
15
Lecture discussion
Care of a pregnant woman with severe preeclampsia & eclampsia during antenatal
6
30
Lecture discussion
Care of a pregnant woman with severe preeclampsia and eclampsia during intra-partum and
after delivery
7
20
Lecture discussion
Complications following severe pre-aclampsia and
eclampsia intra-partum and after delivery.
8
10
Presentation
Key Points
9
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Principles Of Caring A Pregnant Woman With Eclampsia (10Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the principles of care a woman with severe preeclampsia /eclampisa.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below


The management of severe Pre-eclampsia and eclampsia is based on the following principles:
o Antenatal care and recognition of hypertension
o Identification and treatment of Pre-eclampsia/Eclampsia by skilled attendant
o Timely delivery
The treatment objectives ;
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
74
o Control convulsion by giving appropriate drugs.
o Control hypertension by giving antihypertensive accordingly
o The delivery as expectant management should be within 12hrs.
STEP 3: Assessment Of A Pregnant Woman To Diagnose Hypertensive Disorders
Of Pregnancy (15 Minutes)
Activity: Demonstration (10 minutes)
DIVIDE: students in medium-sized manageable group
DEMONSTRATE on how to manage a woman with pre-eclampsia for 5 minutes
Refer students to Handout 13.1: Checking blood pressure
ALLOW one student from each group to do return demonstration and let others comment on it
CLARIFY and summarize by using the information below
STEP 4: Care Of A Pregnant Woman With Pre-Eclampsia During Antenatal (10
Minutes)






Women with PIH or mild Pre-eclampsia can be advised to rest at home and continue to monitor
maternal and fetal condition
Attend Antenatal clinic weekly ensuring that the woman has a birth plan and continue with
antihypertensive
If a woman cannot have
Treatment is aimed at managing symptoms and preventing worsening of the condition and
complications.
Bed rest has the added advantages of reducing oedema by improving the renal circulation,
facilitating kidney filtration and producing a diuresis
Advice diet rich in protein, fibre and vitamins may be recommended and fluids should be
encouraged.
STEP 5: Care Of A Pregnant Woman With Severe Pre-Eclampsia & Eclampsia
During Antenatal (15 Minutes)



Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery
must occur within 24 hours of onset of severe pre-eclampsia versus 12 hours of onset of
convulsions in eclampsia
All cases of severe pre-eclampsia should be managed actively.
Symptoms and signs of “impending eclampsia” (blurred vision, hyperreflexia) are unreliable
and expectant management is not recommended.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
75



The management depends upon the severity of the disease so a woman with severe preeclampsia or eclampsia should be admitted for care to multibeded room or single room.
Treatment is aimed at managing symptoms and preventing worsening of the condition and
complications.
She must have continuous care so if staff is few encourage a relative to stay with her who can
alert staff in the event of convulsions.
o Bed rest
 The mother should be nursed in bed and will be encouraged to adopt a sitting
position or to lie on her side in order to encourage uterine blood flow.
 Bed rest has the added advantages of reducing oedema by improving the
renal circulation, facilitating kidney filtration and producing a diuresis.
 Except in severe cases the mother may get up for toilet facilities.
o Diet
 Advice diet rich in protein, fibre and vitamins may be recommended and fluids
should be encouraged.
o Urine
 Urine should be tested for protein daily and a specimen should be sent to the
laboratory if possible so that the levels of protein can be estimated.
o Fluid intake and output
 Fluid should be conscientiously measured.
 Adequate urine output signifies good renal function; oliguria or urinary
suppression may occur if the disease becomes severe.
o Blood pressure
 Blood pressure is ascertained 4 hourly, but will be taken hourly or more
frequently if mother is severely affected.
o Abdominal examination
 It will be carried out at least twice daily.
 Any discomfort, tenderness, or pain experienced by the mother should be
recorded and reported immediately to the doctor.
o The fetal heart rate
 The fetal heart should be elicited when abdominal examination is
performed. Kicks charts
 Are maintained to monitor the degree of fetal movement and serial
ultrasonic scans are undertaken to assess fetal growth and amounts of
liquor if available.
STEP 6: Care Of A Pregnant Woman With Severe Pre-Eclampsia And Eclampsia
During Intra-Partum And After Delivery (30 Minutes)

Once the diagnosis of severe pre-eclampsia (imminent eclampsia) is made, manage as for
eclampsia
o Shout for help
o Keep her in left lateral position
o Protect from injury
o Ensure the airway is clear—insert an airway if needed
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
76
Give oxygen 4–6 Lts/minutes if available
Conduct a rapid evaluation of the general condition including vital signs (pulse, blood
pressure and respiration)
o Administer magnesium sulphate
 Give 4 gms (20 ml of 20% solution) IV slowly over 20 minutes; then draw up
10 gms of 50% magnesium sulphate (2 syringes with 10 ml of 50% solution in
each) and 1ml of 2% lignocaine injection in the same syringe (loading dose)
 Give by deep IM injection in each buttock, ensuring sterile technique.
 If it is not possible to give IV dose, the IM dose should be sufficient.
o Commence IV of normal saline solution.(Do not give Ringer’s Lactate)
o If diastolic BP is > 110 give Hydralazine 10mg IV slowly over 3–5 minutes, if not
possible to give IV, give IM. If hydralazine is not available, give nifedipine 10 mg sub
lingual, recheck BP after 30minutes.
o If diastolic Blood Pressure remains elevated ≥ 110, repeat IV hydralazine 10mg (can
be repeated up to maximum of three doses of hyralazine) continue monitoring BP
closely.
o Aim for diastolic Blood Pressure between 90–100 mm Hg.
o Catheterize with indwelling urethral catheter and commence intake/output chart.
o Quick assessment of the foetus, delivery should be done regardless of gestation age,
mode of delivery SVD is preferred but if following assessment the cervix is
unfavourable caesarean section can be opted.
 Deliver the baby by the quickest and easiest method, within 6–8 hours of onset
of fits.
 Give magnesium sulphate 5 gm (i.e., 10 ml of 50%) solution as deep IM
injection in alternate buttocks with 1 ml of 2% lignocaine in the same syringe
every 4 hours or iv 1gm hourly for 24hrs(maintenance dose)
 Monitor vital signs, respiratory rate, reflexes and foetal heart rate every half an
hour.
o Note; Before repeating administration of medicine, check that:
 Respiratory rate is at least 16 per minute
 Patellar reflexes are present
 Urinary output is at least 25 ml per hour over 4 hours
 Assist second stage of labour by doing vacuum extraction if possible
Specific management of Pre-eclampsia and Eclampsia
o During labour
 The midwife should remain with the mother throughout labor and delivery
 The mother should be made as comfortable as possible which will necessitate
attention to oral, and body hygiene at regular intervals at regular intervals.
 The bed linen should be changed frequently as amniotic fluid usually drain
throughout
 Position the mother on her side will prevent supine hypotension
o
o

NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
77




The midwife should encourage the mother to move her legs.
If she unable to do so, passive leg exercises will stimulate the circulatory
return to the heart
The partograph should be strictly followed with increased monitoring of BP (1/2
hrly); fluid output and checking fetal condition
Consideration of assisting delivery by vacuum extraction

After Delivery
o The blood pressure will be recorded after delivery according to BP.
o The goal is for the diastolic BP to be maintained between 90-100 mmHg.
o If BP is within normal range check at least 4 hourly for 24 hours
o If proteinuria has been present the urine should be tested once or twice daily until it is
clear and urinary output should be recorded
o Any other treatment prescribed should be carried out
o Postnatal care will be as normal
o The woman and her family should be fully informed of what happened and reassured,
answering questions as needed
o She should be counseled on maternal and newborn danger signs and family planning.
STEP 7: Complications Following Severe Pre-Aclampsia And Eclampsia IntraPartum And After Delivery (20 Minutes)
 The Effects on the Woman
o Respiratory problems (pulmonary edema, asphyxia, aspiration of vomit, bronchopneumonia)
o Cardiac problems (heart failure)
o Effects on the brain (hemorrhage, thrombosis, edema, stroke)
o Renal complications (acute kidney failure)
o Hepatic disease (liver failure or subcapsular hematoma/hemorrhage)
o HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)
o Coagulopathy (clotting/coagulation failure)
o Visual disturbances (temporary blindness, lasting a few hours to up to a week, due to
oedema of the retina)
o Injuries during convulsions/fits (fractures, aspiration)
o Abruption placenta.
o Risk of severe pre-eclampsia/eclampsia in subsequent pregnancies
o Long-term cardiovascular morbidity.
o Death
o Note; The main causes of maternal death in eclampsia are intracerebral hemorrhage,
pulmonary complications, kidney failure, liver failure and multi-organ system failure
(e.g., heart + liver + kidney)
 Fetal: The perinatal mortality is very high to the extent of about 30–50%.
o The causes are:
 Prematurity for spontaneous or induced,
 Intrauterine asphyxia due to placental insufficiency arising out of infarction,
retroplacental hemorrhage and spasm of uteroplacental vasculature,
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
78
 Effects of the drugs used to control convulsions,
 Trauma during operative delivery.
STEP 8: Key Points (10 minutes)
 Pre-eclampsia and eclampsia are main cause of maternal death and require quality Antenatal
care as well as increased community awareness
 The main two signs and symptoms of Pre-eclampsia and eclampsia includes hypertension and
proteinuria
 All cases of severe pre-eclampsia should be managed actively
 Treatment is aimed at managing symptoms and preventing worsening of the condition and
complications
 Midwife must give continuous care to the woman so, if number of staff is few encourage a
relative to stay with her who can alert staff in the event of convulsions
STEP 9: Session Evaluation (5 minutes)




What are the principles of caring a woman with eclampsia?
What is the drug of choice to control hypertension in mild pre-eclampsia?
How do we administer magnesium sulphate in a pregnant woman with eclampsia?
What are the maternal complications following eclampsia?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Duttas .D.C, Konar Hiralal.(Nov. 2013). Textbook of Obstetrics including Perinatology and
Contraceptives ( 7th ed). New Delh: India
MOHSW. (2010). Learning resource package for basic emergency obstetric and newborn care. Dar es
Salaam
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Handout No. 13.1 How to measure Blood Presure
Sphygmomanometers
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
79


There are three types of sphygmomanometersused to measure blood pressure: mercury,
aneroid, and digital.
Reading blood pressure by auscultation is considered the gold standard .
Subject




Position: supine, seated, standing.
In seated position, the subject's arm should be flexed.
The flexed elbow should be at the level of the heart.
If the subject is anxious, wait a few minutes before taking the pressure.
Procedures


To begin blood pressure measurement, use a properly sized blood pressure cuff. The
length of the cuff's bladder should be at least equal to 80% of the circumference of the
upper arm.
Wrap the cuff around the upper arm with the cuff's lower edge one inch above the
antecubital fossa.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
80





Lightly press the stethoscope's bell over the brachial artery just below the cuff's edge.
Some health care workers have difficulty using the bell in the antecubital fossa, so we
suggest using the bell or the diaphragm to measure the blood pressure.
Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a moderate rate
(3mm/sec).
Listen with the stethoscope and simultaneously observe the sphygmomanometer. The
first knocking sound (Korotkoff) is the subject's systolic pressure. When the knocking
sound disappears, that is the diastolic pressure (such as 120/80).
Record the pressure in both arms and note the difference; also record the subject's
position (supine), which arm was used, and the cuff size (small, standard or large adult
cuff).
If the subject's pressure is elevated, measure blood pressuretwo additional times,
waiting a few minutes between measurements.
A BLOOD PRESSURE OF 180/120mmHg OR MORE REQUIRES IMMEDIATE ATTENTION!
Precautions







Aneroid and digital manometers may require periodic calibration.
Use a larger cuff on obese or heavily muscled subjects.
Use a smaller cuff for pediatric patients.
For pediatric patients a lower blood pressure may indicate the presence of hypertension.
Don't place the cuff over clothing.
Flex and support the subject's arm.
In some patients the Korotkoff sounds disappear as the systolic pressure is bled down. After
an interval, the Korotkoff sounds reappear. This interval is referred to as the "auscultatory
gap." This pathophysiologic occurrence can lead to a marked under-estimation of systolic
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
81
pressure if the cuff pressure is not elevated enough. It is for this reason that the rapid
inflation of the blood pressure cuff to 180mmHg was recommended above. The
"auscultatory gap" is felt to be associated with carotid atherosclerosis and a decrease in
arterial compliance in patients with increased blood pressure.
Practice



Use our aneroid and mercury sphygmomanometers simulators to practice your blood
pressure measurement skills.
Then take one of our courses that feature blood pressure, auscultation, and other physical
examination skills.
For pediatric patients, the NIH provides tables which use age, sex and height to interpret
blood pressure findings. View our pediatric blood pressure drills for more information.
SESSION 14: CARE OF PREGNSNT WOMAN WITH DIABETES
MELLITUS AND CARDIAC DISEASE
Total Session Time:
120 minutes
Prerequisites

None
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
82
Learning Tasks
At the end of this session a learner is expected to be able:





Define diabetes mellitus and cardiac disease
Explain the risk factors of diabetes mellitus and cardiac diseases
Explain the management of pre-existing diabetes mellitus and gestational diabetes
Describe the management of a pregnant woman with cardiac disease
Explain the maternal and fetal complications of diabetes mellitus and cardiac diseases
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
2
40
Brainstorming
Definitions diabetes mellitus and cardiac disease
3
10
Lecture discussion
risk factors of diabetes mellitus and cardiac
diseases
4
10
Lecture discussion
Care of pregnant woman with pre-existing
diabetes mellitus and gestational diabetes
5
15
Lecture discussion
Care of a pregnant woman with cardiac disease
6
30
Lecture discussion
maternal and fetal complications of diabetes
mellitus and cardiac diseases
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
Presentation of session title and learning tasks
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
83
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definitions Of Diabetes Mellitus And Cardiac Disease (15 Minutes
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on definition of diabetes mellitus and cardiac disease.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below



Diabetes mellitus is a chronic metabolic disorder due to either insulin deficiency (relative or
absolute) or due to peripheral tissue resistance (decreased sensitivity) to the action of insulin.
o The pathophysiology involved are:
 decreased sensitivity of skeletal muscles and liver to insulin (insulin
resistance)
 Inadequate secretion of insulin (β cell dysfunction).
o The defect lies both in insulin secretion and action.
o The ultimate effect is the hyperglycemia.
o Gestation Diabetes Mellitus is defined as carbohydrate intolerance of variable
severity with onset or first recognition during the present pregnancy.
 The entity usually presents late in the second or during the third trimester.
Previously, the definition stipulated that the GTT should come down to normal
following delivery.
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels.
o Cardiovascular disease includes coronary artery diseases (CAD) such as
 angina
 Myocardial infarction (commonly known as a heart attack).
o Other CVDs include stroke, heart failure, hypertensive heart disease, rheumatic heart
disease, cardiomyopathy, heart arrhythmia, congenital heart disease, valvular heart
disease, carditis, aortic aneurysms, peripheral artery disease, thromboembolic
disease, and venous thrombosis.
Peripartum cardiomyopathy is defined as cardiac failure occurring in the last month
of pregnancy or within five months of delivery, in the absence of any identifiable cause
of heart failure.
STEP 3: Risk Factors Of Diabetes Mellitus And Cardiac Diseases (15 Minutes)
Diabetes Mellitus in pregnancy(GDM)
 Positive family history of diabetes (parents or sibling).
o Family history should include uncles, aunts and grandparents
 Having a previous birth of an overweight baby of 4 kg or more
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
84
 Previous stillbirth with pancreatic islet hyperplasia revealed on autopsy
 Unexplained perinatal loss
 Presence of polyhydramious or recurrent vaginal candidiasis in present pregnancy
 Persistent glycosuria
 Age over 30 years
 Obesity
 Ethnic group (East Asian, Pacific island
Cardiovascular Disease
 The cardiac failure occurs during pregnancy around 30 weeks, during labor and mostly soon
following delivery.
 Factors responsible for cardiac failure:
o Advanced age
o Cardiac arrhythmias or left ventricular hypertrophy
o History of previous heart failure
o Appearance of ‘risk factors’ in pregnancy are:
 infection,
 anemia
 hypertension,
 excessive weight gain and multiple pregnancy
o Inadequate supervision.
STEP 4: Care Of Pregnant Woman With Pre-Existing Diabetes Mellitus And
Gestational Diabetes (30 Minutes)

Screening of GDM: Screening strategy for detection of GDM are:
o Low risk—Absence of any risk factor as mentioned, blood glucose testing is not
routinely required
o Average risk—Some risk factors ;perform screening test
High risk—Blood glucose test as soon as feasible.
o The method employed is by using 50 gm oral glucose challenge test without regard to
time of day or last meal, between 24 and 28 weeks of pregnancy. A plasma glucose
value of 140 mg percent or that of whole blood of 130 mg percent at 1 hour is
considered as cut off point for consideration of a 100 gm (WHO – 75 gm) glucose
tolerance test.
Figure 8.1. Criteria for Screening Diabetes and Glucose tolerance in g/dl
Criteria for diagnosis of impaired glucose tolerance and diabetes with 75 gm oral glucose

Time
Normal Tolerance
Impaired Glucose Tolerance
Diabetes
Fasting
<100
≥100 and <126
≥126
2 hours post glucose
<140
≥140 and <200
≥200
Pre Pregnancy and Pre Natal Care
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
85
Diabetes Mellitus increases chances of complications for both mother and foetus and
its incidence is increasing globally.
o It is important therefore that good metabolic control is established before and
throughout pregnancy.
o Women should have access to pre-pregnancy counseling services and ideally meet a
diabetic specialist before becoming pregnant.
o Insulin dosage is reviewed and an explanation given of the adjustment that will be
require during pregnancy.
o Women with Type 2 diabetic mellitus (DM) on oral hypoglycemic will need transfer to
insulin to prevent the possibility of teratogenesis.
o Dietary advice, including weight control and folic acid supplementation, and general
health measures are important throughout pregnancy.
o This woman needs special ANC and will require more frequent visits in particular:
 Close monitoring of BP
 Testing urine at each visit for protein & glucose
 Monitoring foetal growth and wellbeing noting when the foetus is large for
dates which can indicate poor diabetic control
 Counselling for birth preparedness and complication readiness
Intrapartum Care
o Ideally labour should be commenced spontaneously at term for women with
uncomplicated DM during pregnancy.
o Poor diabetes control or deterioration in the maternal or foetal condition may
necessitate earlier, planned birth.
o Induction of labour may be considered where the foetus is judged to be microsomic or
small for dates.
o Routine induction of labour at 37-38 weeks gestation is no longer recommended as it
does not reduce prenatal mortality rate and is more likely to results in respiratory
morbidity.
o It may also contribute to high caesarean section rates for diabetic pregnancies
compared with normal pregnancies.
o The aim of intra-partrum care is to maintain normal-glycaemia in labour (i.e. <
7.0mmol/L).
o Maternal hyperglycemia leads to an increase in foetal insulin production, which will
cause neonatal hypoglycaemia.
o Dehydration must be avoided and a strict input/output chart maintained.
o Foetal distress is more common as placental blood flow is reduced and glycosylated
haemoglobin decreases oxygen carriage in diabetes pregnancies.
o In addition, maternal ketoacidosis may result from dehydration and unstable diabetes.
If mother becomes acidotic, ketones will cross the placenta and affect the foetal acidbase status.
o Continuous electronic foetal monitoring is recommended if available however the most
important activity is close monitoring of the mother and foetus using the partograph.
o If the baby is large care must be taken during birth to prepare for possible
complications such as shoulder dystocia, also ensure equipment and supplies for
newborn resuscitation are available.
Postpartum
o


NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
86
o Immediately after the third stage labour insulin requirements will fall rapidly to prepregnancy levels.
o The insulin infusion rate should be reduced by at least 50%.
o Carbohydrate metabolism returns to normal very quickly and women can assume their
pre-pregnancy insulin regime.
o Women with type 2 DM who were previously on oral hypoglycaemia or dietary control
need to be controlled prior to recommencing therapy.
o Monitoring of blood glucose levels should continue during this interim period.
o Breastfeeding should be encouraged in all women with diabetes.
o An additional carbohydrate intake may be needed therefore adjust insulin accordingly.
o Operative /assisted delivery, together with diabetes, predisposes these women to
infection and delayed healing.
o The administration of antibiotics may be a useful preventive measure in this instance.
o All women should be offered contraceptive advice so that optimum metabolic control is
achieved prior to planning next pregnancy.
o The issue governing choices of contraception for women with DM are similar to those
non-diabetic women.
o Women with DM, gestational diabetes should be reviewed at 6 weeks, ideally as a
combined diabetes clinic or alternatively by their GP (General Practitioner).
STEP 5 Care Of A Pregnant Woman With Cardiac Disease (15 Minutes)


Prenatal Care
o Women with known heart disease should preconception counseling before becoming
pregnant to discuss the risks of condition to pregnancy.
o General health advice can be given by a midwife with regard to diet, weight, exercise,
rest, and the prevention of anaemia and the avoidance of tobacco, drugs and alcohol.
Intra-Partum Care
o The first stage of labour
 In view of the increased cardiac output during labour and immediately after the
birth, it is important to plan for and manage labour carefully
 Optimal management involves monitoring the maternal condition closely; this
includes the measurement of vital signs and urine output
 The partograph must be used to monitor labour and support decision making
 Fluid balance
o Women with significant heart disease require care concerning fluid balance in labour
indiscriminate use of intravenous crystalloid fluids will lead to an increase in circulating
blood volume, which women with heart disease will find difficult to cope with and they
may easily develop pulmonary oedema.
o Positioning; Cardiac output is influenced by the position of the labouring woman
 It is important to remember that woman with heart disease are particularly
sensitive to aortocarval compression by the gravid uterus in the supine
position
 This decreases the cardiac output by inhibiting venous return to the heart
resulting in maternal hypotension and foetal bradycardia
 It is preferably that all labouring women, as well as those with heart disease,
adopt prop-up or left lateral position in labour that is comfortable.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
87



Second stage of labour
o This should be short without undue exertion on the part of mother.
o A vacuum extraction should be considered.
o Prolonged pushing with breath holding such as the valsalva manoeuvre, which is
undesirable for healthy women, may be dangerous for women with heart disease.
o It raises the intrathoracic pressure, pushes the blood out of the thorax and impedes
venous return, with the results that cardiac output falls.
o The midwife should encourage the woman to breathe normally and follow her natural
desire to push; giving several short pushes during each contraction.
o Care should be taken when the woman in lithotomy, where the lower part of the body
is higher than trunk, as this produces a sudden increase in venous return to the heart,
which may result in heart failure.
Third stage of labour
o This is actively managed with oxytocin as the drug of choice due to increased risk of
PPH. ergometrine is contraindicated as this act on smooth muscles and will have a
direct effect on the heart as well as producing a tonic uterine contraction.
o Misoprostol can be used if oxytocin not available.
Post-natal care
o During the first 48 hours following birth the heart must cope with the extra blood from
the uterine circulation and it is important that the midwife monitors the woman’s
condition during this time.
o Close observation should identify early signs of infection, thrombosis or pulmonary
edema.
o Breast feeding is encouraged as cardiac output is not affected by lactation although
drug therapy for specific heart conditions may need to be reviewed for safety during
breastfeeding.
o The midwife provides support with breast feeding similar to that with other women, and
the importance of rest and adequate diet.
o Discharge planning is particularly important for women with heart disease.
o The midwife can evaluate the help and support that will be available in the home during
postnatal period.
o The woman and her partner will need to discuss the implications of a future pregnancy
with the cardiologist and obstetrician.
o Following this, the midwife can provide advice to the woman and her partner about
contraception.
STEP 6: Maternal and Fetal Complications Of Diabetes Mellitus And Cardiac
Diseases (20 Minutes)

Complications of diabetes (Hyperglycemia and adverse pregnancy outcome):
o Maternal :During pregnancy:
 Abortion: Recurrent spontaneous abortion may be associated with
uncontrolled diabetes.
 Preterm labor, may be due to infection or polyhydramious
 Infection: Urinary tract infection and vulvo vaginitis.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
88
Increased incidence of pre-eclampsia
Polyhydramious is a common association with Large baby, large placenta,
fetal hyperglycemia leading to polyuria, increased glucose concentration of
liquor irritating the amniotic epithelium or increased osmosis, are some of the
probabilities.
 Maternal distress may be due to the combined effects of an oversized fetus
and polyhydramious.
 Diabetic retinopathy, microaneurysms, hemorrhages and proliferative
retinopathy
 Diabetic nephropathy—may lead to renal failure
 Ketoacidosis
o During labor: There is increased incidence of:
 Prolongation of labor due to big baby.
 Shoulder dystocia (Shoulder dystocia is due to disproportionate growth with
increased shoulder/head ratio.
 Perineal injuries.
 Postpartum hemorrhage.
 Operative interference.
o Puerperium:
 Puerperal sepsis
 Lactation failure.
o Foetal and neonatal complications:
 Foetal macrosomia (30-40%) due to maternal hyperglycaemia and elevated
free fatty acids
 Congenital malformation due genetic susceptibility and hyperglycemia
 Abortion
 Intrauterine foetal death
 Birth injuries (Shoulder dystocia leads to brachial plexus injury)
Cardiac dieses Complications
o Mternal
 Congenital cardiac failure
 Pulmonary oedema
 Pulmonary Embolism
 Aenaemia
 Maternal Death
o Foetal complication
 Abortion
 Intrauterine growth restriction (IUGR)
 Premature delivery
 Intra-uterine death(IUFD)
 Neonatal death
 Foetal congenital heart disease



STEP 7: Key Points (5 minutes)

Gestation Diabetes Mellitus is a carbohydrate intolerance of variable severity with onset or
first recognition during the present pregnancy.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
89






The entity usually presents late in the second or during the third trimester. Previously, the
definition stipulated that the GTT should come down to normal following delivery.
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels.
Peripartum cardiomyopathy is a cardiac failure occurring in the last month of pregnancy or
within five months of delivery, in the absence of any identifiable cause of heart failure.
Diabetes Mellitus increases chances of complications for both mother and foetus and its
incidence is increasing globally.
It is important therefore that good metabolic control is established before and throughout
pregnancy.
Women should have access to pre-pregnancy counseling services and ideally meet a diabetic
specialist before becoming pregnant.
STEP 8: Session Evaluation (5 minutes)



What are the roles of midwife in caring for a woman with cardiac disease in labour?
What are the aspects of antenatal care need to be adapted for a woman with diabetes
mellitus?
What are foetal complications in woman with gestational diabetes?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Duttas .D.C, Konar Hiralal.(Nov. 2013). Textbook of Obstetrics including Perinatology and
Contraceptives ( 7th ed). New Delh: India
MOHSW. (2010). Learning resource package for basic emergency obstetric and newborn care. Dar es
Salaam
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
SESSION 15:CARE OF A WOMAN WITH HYPEREMESIS GRAVIDARUM
Total Session Time:
60 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define hyperemesis gravidarum
 Explain causes and diagnosis of hyperemesis gravidarum
 Outline signs and symptoms of hyperemesis gravidarum
 Describe the management of a pregnant woman with hyperemesis gravidarum
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
90
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
05
Brainstorming/presentation
Definition of hyperemesis gravidarum
Causes and diagnosis of hyperemesis
gravidarum
3
10
Lecture discussion
4
10
Presentation
Outline the sign and symptoms of hyperemis
gravidarum
5
20
Lecture discussion
Care of a pregnant women with hyperemesis
gravidarum
6
05
Presentation
Key Points
7
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition Of Hyperemesis Gravidarum (5 Minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on the defition of hyperemesis gravidarum
time
them with
to respond
NMT ALLOW
06101: Care
of for
a Woman
Abnormal Pregnancy, Labour and Puerperium
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below
91
 Hyperemesis gravidarum
Is an excessive nausea and vomiting that start between 4-10 weeks gestation, and resolvebefore 20
weeks.
STEP 3: Causes And Diagnosis Of Hyperemesis Gravidarum (10 Minutes)

The causes of hyperemesis is uncertain, with multi-factorial causes such as:
o Hormonal /Endocrine
 High human chorionic ganadotrophin (hCG) stimulates the chemoreceptor
trigger zone in the brain stem including the vomiting center.
o Allergy to the corpus luteum or the released hormones.
o Nervous and psychological due psychological rejection of an unwanted pregnancy
o Deficiency of:
 adrenocortical hormone and /or,
 vitamin B6 and B1
o Hyperemesis occur more often where mothers have a multiple pregnancy, or a
hydatidiform
o Simultaneously occurrence of hyperthyroidism and hyperemesis suggest transient
thyroid dysfunction as a possible cause
STEP 4: Sign And Symptoms (10 Minutes)





The patient cannot retain anything in her stomach.
o Vomiting occurs through the dayand night even without eating.
Thirst, constipation and oliguria.
In severe cases, vomitus is bile and/ or blood stained.
Finally, there are manifestations of Werniche’s encephalopathy as drowsiness,nystagmus and
loss of vision then coma.
Manifestations of starvation and dehydration:
o Loss of weight.
o Sunken eyes.
o Dry tongue and inelastic skin.
o Pulse: rapid and weak.
o Blood pressure: low.
o Temperature: slight rise
STEP 5: Care Of A Pregnant Woman With Hyperemesis Gravidarum (20 Minutes)

The woman should be hospitalized for observation and fluid therapy
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
92













Calm reassurance and sensitive information-giving should be accompanied by competent
attention to physical needs.
On arrival in hospital blood will be taken to determine the plasma electrolytes.
The potassium and sodium levels will be corrected by intravenous infusion( Ringers lactate)
The infusion will continue until hydration and electrolytes return to normal.
Vitamins B12 and C, folic acid and iron will be required to correct anaemia.
The pregnant woman should be given promethazine if vomiting persists and a sedative may be
given to produce rest.
Advice the woman to take small quantity of meals frequently.
Monitor vital sign at least 4 hourly
Test urine twice for specific gravity, acetone, sugar and protein
The intake and output of fluids including vomitus will need insidious monitoring andrecording.
Once vomiting has ceased for a period of 24 hrs, oral fluids may be commenced and if these
are tolerated a light diet may follow.
Normal food is gradually introduced and intravenous therapy discontinued.
Note
o Very occasional the disorder fails to improve with the treatment outlined above and
o The mother will subside into coma and be in danger of dying.
STEP 6: Key Points (5 minutes)




Without dehydration the woman can be treated as an outpatient with the same drugs. If not
Responding admit to the hospital
Morning sickness is the nausea felt by about 50% of pregnant women on getting up in the
morning, actual vomiting is called emesis gravidarum.
These two conditions usually start between the 4th and 6th weeks of pregnancy and improve or
disappear about the 12th week.
In hyperemesis gravidarum the vomiting is not confined to the morning but it is repeated
throughout the day until it affects the general condition of the patient
STEP 7: Session Evaluation (5 minutes)
 What is hyperemesis gravidarum
 What are the possible causes or aetiology of hyperemesis gravidurum
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
93
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
SESSION 16: CARE OF A WOMAN WITH DISORDERS OF AMNIOTIC
FLUID (POLYHYDRAMIOUS AND OLIGOHYDRAMNIOS)
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define the terms polyhydramious and oligohydramnios
 State causes and predisposing factors of polyhydramious and oligohydramnios
 Explain the diagnostic measures for polyhydramious and oligohydramnios
 Describe the management of a pregnant woman with polyhydramious and
oligohydramnios
 State the complications associated with polyhydramious and oligohydramnios
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Content
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
94
1
05
Presentation
Presentation of session title and learning
objectives
2
05
Definition of polyhydramious and oligohydramnios
3
05
Brainstorming
Presentation
Lecture/discussion
4
15
Lecture/discussion
Management of a woman with polyhydramious
5
15
Lecture/discussion
Management of a woman with oligohydramnios
6
05
Presentation
Complications associated with polyhydramious
and oligohydramnios
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
Causes and predisposing factors of
polyhydramious and oligohydramnios
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition Of Polyhydramious And Oligohydramnios (5 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the definitions of polyhydramnious and
oligohydramnios
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
95


Polyhydramious (hydramnios) is an excessive amount of amniotic fluid.
o Is defined as the amount of amniotic fluid which exceeds 1500 ml.
o It may not be clinically apparent until it reaches 3000 ml.
Oligohydramnios is an abnormally small amount of amniotic fluid.
STEP 3: Causes And Predisposing Factors Of Polyhydramious And
Oligohydramnios (5 Minutes)
Causes and predisposing factors of polyhydramious
 Most polyhydramious is of unknown etiology.
 The following conditions are likely to result in a higher incidence of polyhydramious:
o Multiple pregnancy (especially with monozygotic twins)
o Diabetes
o Erythroblastosis
o Fetal malformations (especially of the gastrointestinal tract—e.g., tracheoesophageal
fistula—or central nervous system—e.g., anencephaly, meningomyelocele)
Causes and predisposing factors of oligohydramnios
 The condition is frequently caused by uteroplacental insufficiency, which thereby means that a
decreased fluid volume may be associated with a marked increase in perinatal mortality.
 The following conditions have a higher incidence of oligohydramnios:
o Congenital anomalies (e.g., renal agenesis, Potter’s syndrome)
o Viral diseases
o Intrauterine growth restriction (IUGR)
o Uteroplacental insufficiency
o Early rupture of the fetal membranes (24 to 26 weeks)
o Response to indocin as a tocolytic
o Fetal hypoxia
o Meconium-stained fluid and meconium aspiration
o Postmaturity syndrome
STEP 4: Care of a Woman with Polyhydramious (15 minutes)
Assessing the woman thourough
 On history taking the woman will complain of
o Breathlessness and discomfort
o Abdominal pain in severe cases
o Exacerbation of associated symptoms of pregnancy such as; indigestion, heartburns
and constipation.
o Lower swelling and varicosities of vulva and lower limbs

Abdominal examination
o Inspection
 The uterus is larger than expected for the period of gestation and is globular in
shape
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
96
Abdominal skin appears stretched and shiny with marked stripe gravidarum
and obvious superficial blood vessels
o Palpation
 Uterus feels tense and is difficult to feel the Fetal parts
 Fetal ballottement between the two hands
 Fluid thrill may be elicited by placing a hand on one side of the abdomen and
taping the other side with fingers
 Measurement of abdominal girth
 In cases of acute hydramnios it is done in order to observe the rate of increase
o Auscultation
 May be difficult if the quantity of fluid allows the foetus to move away from the
stethoscope
o Ultrasound
Is used to confirm the diagnosis of polyhydramious

Management of polyhydramious
 The aim of management is to relieve maternal symptoms and optimize the length ofgestation,
prolonging it if safe.
 When the cause is already determined
o The mother will usually be admitted to a consultant obstetric unit.
o Subsequent care will depend on the mother’s condition, the cause of
thepolyhydramious and the stage of pregnancy.
o The mother should rest in bed. An upright position will help to relieve any dyspnea and
she may be given antacids to relieve heartburn and nausea.
o Acute polyhydramious is managed by amniocentesis but the outlook is very poor.
o The mother may need to have labour induced in late pregnancy if the
symptomsbecome worse.
o Labour is usually normal but the midwife should be prepared for the possibility
ofpostpartum haemorrhage.
o The baby should be carefully examined for abnormalities and a wide orogastric
tubemust be passed for about 10-12cm. in order to confirm the patency of
theoesophagus.
STEP 5: Care of a Woman with Oligohydramnios (15 minutes)
Assessment of the mother
 History taking
o The woman who had a previous normal pregnancy may have noticed a reduction in
fetal movements.
o History of vagina leakage

Abdominal Examination
o Inspection
 The uterus appears smaller than expected for the period of gestation.
o Palpation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
97



The uterus is small and compact and fetal parts are easily felt
Breech presentation is possible.
o Auscultation is normal
Diagnosis
o Ultrasonic scan will exclude
 Intra-uterine growth restriction.
 Renal abnormality.
 Coexisting fetal or placental conditions or complications.
o Screen for diabetes and Rh iso-oimmunization.
Care of woman with oligohydramnios
 The woman should be admitted for investigations which will include placental function tests.
 If there is no foetal abnormality the pregnancy will be allowed to continue
 Labour may begin early or may be induced because of the possibility of placental insufficiency.
 Epidural analgesia may be indicated because uterine contractions may be very painful.
 Impairment of placental circulation may result in foetal hypoxia.
 Constriction rings are a possibility due to the small amount of amniotic fluid.
 In rare cases the membranes may adhere to the foetus.
 Reassure the woman and the patner on the condition
STEP 6: Complications of Polyhydramious and Oligohydramnios (5 minutes)

Polyhydramious complications
o Preterm labor (due to over distention of the uterus)
o Maternal dyspnea and shortness of breath
o Fetal malpresentations
o Abruptio placenta
o Cord prolapse
o Uterine dysfunction during labor (due to over distention of the uterus)
o Immediate postpartum hemorrhage as a result of uterine atony from over distention

Oligohydramnios complications
o Lack of amniotic fluid reduces the intra-uterine space and causes compression
deformities.
o The baby has a squashed-looking face, flattening of the nose, micrognathia and
talipes.
o The skin is dry and leathery in appearance.
STEP 7: Key points (5 minutes)




Polyhydramious (hydramnios) is an excessive amount of amniotic fluid.
When polyhydramious is diagnosed, consultation with a consulting physician is indicated.
The woman especially needs emotional support if congenital anomalies are present.
Women with severe polyhydramious have a number of mechanical difficulties and discomforts for
which the midwife can provide relief measures.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
98


Oligohydramnios is an abnormally small amount of amniotic fluid.
Oligohydramnios is a significant finding suggestive of post-maturity syndrome in a postdate
pregnancy.
STEP 8: Session Evaluation (5 minutes)




What are the differences between polyhydramious and oligohydramnios?
What are the predisposing factors of polyhydramious?
What are the complications of polyhydramious?
What are the complications of Oligohydramnios?
References
Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives (12th ed.). London: Churchill
Livingstone.
Fraser, D. M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MoHSW. (2010). Focused antenatal care: Learner’s guide for ANC service providers and supervisors.
Dar es Salaam.
MOHSW. (2006). National guidelines for diagnosis and treatment of malaria. Dar es Salaam.
Varney, H., Burst, V., Kriebs, J. M., &Gegor, C. L. (2004). Varney's midwifery. Jones & Bartlett
Learning.
SESSION 17: CARE OF A WOMAN WITH ABNORMAL UTERINE ACTION
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define abnormal uterine action
 Describe types of abnormal uterine action
 Describe causes of abnormal uterine action
 Care of a pregnant woman with abnormal uterine action
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
99
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time
(min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
05
Presentation
Defintion of abnormal uterine action
3
15
Brainstorming/presentation
Types of Abnormal Uterine action
4
50
Lecture discussion
Care of Woman with Abnormal Uterine Action
5
35
Small group discussion/
Lecture discussion
Cervical dystocia
6
05
Presentation
Key Points
7
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definitio of Uterine Action (5 Minutes)

Abnormal uterine action is any deviation from normal pattern of uterine contractions affecting
the normal course of labour.

Its one of the factors causing dystocia (difficult labor) in which uterine forces are insufficiently
strong orinappropriately coordinated to efface and dilate the cervix (uterinedysfunction).
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
100
STEP 3: Types of Abnormal Uterine Action (15 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm describe the types of anormal uterine action.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below
Classifications or Types of abnormal uterine action
 Over-efficient uterine action
o Precipitate labour in absence of obstruction
o Exessive contraction and retraction in presence of obstruction
 Inefficient uterine Action
o Hypotonic inertia
o Hyprtonic inertia
 Colyky uterus
 Hyperctive lower segment
o Constriction ring
 Cervical Dystocia
STEP 4: Care of Woman with Abnormal Uterine Action( 50 minutes)
Over-efficient uterine action

Precipitate labour Is the type of labour due to strong coordinate uterine contractions
from the onset of labour, which results in abnormally rapid progress and delivery within
three hours of its commencement (excessive with or without obstruction)

Causes of precipitate labour
o It is more common in multiparas when there are;
 Strong uterine contractions
 Small sized baby
 Roomy pelvis
 Minimal soft tissue resistance
Diagnosis
o It is a retrospective diagnosis as the patient is usually seen in the second or
third stages of labor

NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
101


o If seen during the 1st stage of the labor, the partograph will show rapid progress
of cervical dilation and effacement
o If seen after delivery, examination of the mother and infant should be perfomed
Care of a woman with precipitate labour
o The with past history of precipitate labour, should be admitted to the hosp at the first
perception of labour pain
o Inhalation anaesthesia as nitrous oxide and oxygen is given to slow the course of
labour.
o Tocolytic agents as ritodrine may be effective
o Episiotomy may be preformed to avoid perineal lacerations and intracranial
haemorrhage
o After delivery exploration of the birth canal for any injury should be done and manage
accordingly
o Give the mother prophylactic antibiotics if delivery occurred in unsuitable conditions
o Proper examination of the fetus for detection of injury and any complications
Complication of precipitate labour
o Maternal
 Lacerations of the cervix, vagina and perineum
 Shock
 Inversion of the uterus
 Postpartum haemorrhage
 Sepsis due to lacerations and inappropriate surroundings
o Foetal
 Foetal Intracranial haemorrhage due to sudden compression and
decompression of the head
 Foetal asphyxia due to strong frequent uterine contractions reducing placental
perfusion and lack of immediate resuscitation
 Avulsion of the umbilical cord
 Foetal injury
Overstimulation of the uterus


Excessive use of syntocinon or prostaglandin may result in titanic contractions with inadequate
periods of relaxation between them
Complications
o Fetal hypoxia due to uterine spasm which reduces the placento-fetal oxygen
o Precipitate labour due to overstimulation of the uterus
o Progress of labour may be slow due to lots of retraction
o Uterine rupture in cases of some degrees of disproportion
 Management
o Inform the doctor for immediate management
o The administration of syntocinon or prostaglandins must be stopped at once
o Nurse the mother on her left side and monitor fetal heart rate frequently
o Puffs of a ventolin inhaler to reduce severe contraction
o Administer oxygen in case fetal bradycardia
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
102
Inefficient uterine contraction
Definition
 Uterine action is said to be inefficient when the contractions do not effectively dilate the cervix.
 Progress in labour is slow and length of labour is prolonged
Classification
 Hypotonic uterine inertia
o The contractions are weak, short and infrequent
o The result is slow dilatation of the cervix or non
o Hypotonic uterine action may be primary; occurring from the onset of labour or
secondary; developing during the course of the previously normal labour
o The cause of primary hypotonic is unknown but it is most commonly found in
primgravida
o Secondary hypotonic uterine actionmay be due to cephalopelvic disproportion,
malpresentation or malposition of the fetal occiput.
o Management of hypotonic uterine action









Encouragement and support from the midwife is necessary
Perform vaginal examination to exclude disproportion or malpresentation or
malposition and manage according to the case
Proper management of the first stage
Prophylactic antibiotics in prolonged labour particularly if the membranes are
ruptured.
Artificial rupture of membrane can be done if still intact providing that;
 Vaginal delivery is amenable
 The cervix is more than 3 cm dilatation
 The presenting part occupying well the lower uterine segment.
Set intravenous infusion of cyntocinon, providing that there is no
contraindication for it.
Maintain fluid and electrolyte balance and give analgesia as required
Perform vaginal examination 2-4hourly interval to assess cervical dilatation
and use the partograph to monitor labour progress
You can perform operative delivery vaginally either by forceps, vacuum or
breech extraction according to the presenting part and its level providing
that:Cervix is fully dilated and vaginal delivery is amenable.
o Complication of hypertonic inertia
 Nervousness and anxiety
 Exhaustion and starvation ketoacidosis
 Prolonged second stage
 Increased liability for instrumental delivery and C/S
 Retention of placenta and postpartum haemorrhage
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
103
 Subinvolution of the uterus
 Risks of abuse of uterine stimulants

Hypertonic uterine inertia ( Incoordinate Uterine action )
o There are of two types
o Colicky uterus: incoordination of the different parts of the uterus in contractions.
o Hyperactive lower uterine segment: so the dominance of the upper segment is lost.
 The condition is more common in primigravidae and characterized by:
 Labour is prolonged.
 Uterine contractions are irregular and more painful. The pain is felt before and
throughout the contractions with marked low backache often in occipitoposterior position
 Slow cervical dilatation.
 Premature rupture of membranes.
 Foetal and maternal distress.
o Care of a woman with hypertonic inertia
 Inform the doctor
 Reassurance to the women is important to promote comfort as possible
 Perform vaginal examination to exclude disproportion or malpresentation
or malposition
 Proper management of the first stage
 Prophylactic antibiotics in prolonged labour particularly if the membranes
are ruptured
 Give intravenous infusion such as Hartmann’s solution to correct
ketoacidoci’s.
 Fluid balance chart is kept and all specimens of urine are tested for
presence of ketones.
 Frequent mouth wash is given so that woman’s mouth remains moist and
fresh.
 Pain relief is essential to rest the woman from pain.
 Monitor fetal heart and uterine contractions continuously to exclude fetal
distress.
 Membranes may be ruptured artificially, and a low-dose of syntocinon
infusion may be commenced to stimulate normal uterine contractions if the
patient is eligible.
 Virginal examinations are performed at 2-4 hourly intervals to assess the
progress
 Plot the findings on the partograph
 Caesarean section may be performed in case of poor progress with
syntocinon, disproportion or foetal distress before full cervical dilatation
STEP 5: Cervical dystocia (35Minutes)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
104
Activity: Small Group Activity (10 minutes)
DIVIDE students depending on the size of the class.
ASK students to explain about cervical dystocia based on the following questions each
group working on one question.




What is cervical dystocia
Types of cervical dystocia
Care of a woman with cervical dystocia
Complication of cervical dystocia
ALLOW the groups to work together to come up with answers to the question above.
ALLOW groups 5 minutes for this exercise.
ASK students to report back the care plan per group. The following part of the presentation
has more details on cervical dystocia
APPRAISE the students
PROVIDE feedback by summarizing the students’ answers



Cervical dystocia is the failure of the cervix to dilate within a reasonable time despite of good
uterine contractions
Types of cervical dystocia
o Organic (secondary) which is due to
 Cervical stances as a sequel to previous amputation, scarring, cone biopsy,
extensive cauterization or obstetric trauma.
 Organic lesions as cervical myoma or carcinoma
o Functional (primary)
 In spite of the absence of any organic lesion and the well effacement of the
cervix, the external os fails to dilate.
 This may be due to lack of softening of the cervix during pregnancy or cervical
spasm resulted from overactive sympathetic tone.
 Also may be due to previous history of failure of external os to dilate in
previous birth, rigid cervix, insufficient uterine contractions, malpresentations
and malposition
Care of a woman with cervical dystocia
o All cases of dystocia are an obstetric emergency
o The woman should be admitted in the labour unit and the obstetrician should be
present.
o Anesthetist and pediatrician should be informed
o Oxytocin can be used if abnormal uterine contraction are the cause of dystocia
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
105
o Assisted delivery may be required.
o The mother may need urgent cesarean section

Complication of cervical dystocia
o Perinatal morbidity and mortality from hypoxia and acidosis
o Brachial plexus injury
o Postpartum haemorrhage
o Perineal tear
STEP 6: Key points(5 minutes)
• Uterine action is said to be inefficient when the contractions do not effectively dilate the cervix.
• Progress in labour is slow and length of labour is prolonged.
• In hypertonic uterine action the fundal dominance is lost and the contractions start and last
longer in the lower segment.
• Progress in labour is slow and length of labour is prolonged
• Cervical dystocia means failure of the cervix to dilate despite good uterine contraction
• Excessive use of syntocinon or prostaglandin may result in titanic contractions with inadequate
periods of relaxation between them
STEP 6: Evaluation (5 minutes)



What is the classification of abnormal uterine action?
What is the most common complication in all the classifications of abnormal uterine action?
What are the general care you can give to a pregnant woman with any abnormal uterine
action?
References
Advanced life saving skills (2005) reproductive child health section Dar-es -Salaam: Tanzania, volume
2
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dares Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
106
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
SESSION 18: CARE OF A WOMAN WITH PROLONGED LABOUR
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define prolonged labour
 Explain prolonged first stage of labour
 State the possible causes of prolonged first stage of labour
 Describe prolonged second stage of labour
 State causes of prolonged second stage of labour
 Explain the management of prolonged labour
Resources Needed:






Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Partograph
Anatomical chart
Session Overview Box
Step Time (min)
Activity/
Method
Content
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
107
1
05
Presentation
Presentation of session title and learning
objectives
2
05
Definition of prolonged labour
3
25
Brainstorming
Presentation
Lecture/discussion
4
15
Lecture/discussion
Prolonged second stage of labour (causes and
care)
5
05
Presentation
Key Points
5
05
Presentation
Session Evaluation
Prolonged first stage of labour(causes and care)
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Prolonged Labour (5 minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on definition of prolonged labour
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
Definition of prolonged labour
 The labor is said to be prolonged when the combined duration of the first and second stage is
more than the arbitrary time limit of 18 hours.
 The prolongation may be due to protracted cervical dilatation in the first stage and/or
inadequate descent of the presenting part during the first or second stage of labor.
 Labor is considered prolonged when the cervical dilatation rate is less than 1 cm/hr and
descent of the presenting part is < 1 cm/hr for a period of minimum 4 hours observation.
STEP 3: Care of a Woman with Prolonged First Stage of Labour (25 minutes)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
108
Causes of prolonged labour in the first stage
 Any one or combination of the factors in labor could be responsible.
 Failure to dilate the cervix is due to:
o Fault in power: Abnormal uterine contraction such as uterine inertia (common) or incoordinate uterine contraction
o Fault in the passage: Contracted pelvis, cervical dystocia, pelvic tumor, or even full
bladder
o Fault in the passenger: Malposition (OP) and malpresentation (face, brow), congenital
anomalies of the fetus (hydrocephalus).
o Too often deflexed head, minor degrees of pelvic contraction and disordered uterine
action have got sinister effects in causing non-dilatation of the cervix.
 Early administration of sedatives and analgesics before the active labor begins.
The first stage of labour is divided into a latent and active phase.
 Prolonged latent phase
o Mean duration of latent phase is about 8 hours in a primi and 4 hours in a multi.
o A latent phase that exceeds 20 hours in primigravidae or 14 hours in multiparae is
abnormal.
o During the latent phase the uterus contracts regularly, and the mother experiences
discomfort and pain.
o The cervix effaces and dilation occurs.
o The duration of the latent phase will vary according to each individual and with parity.
o A prolonged latent phase of labour can be inaccurately diagnosed when the mother is
in false labour.
o The causes include:
 Unripecervix
 malposition and malpresentation
 cephalopelvic disproportion
 premature rupture ofthe membranes.

Prolonged active phase
o The active phase is distinguished by an increased rate of dilatation of the cervix, with
descent of the presenting part.
o Slow progress may be defined either as total duration of hours in labour or as failure of
the cervix to dilate at a fixed rate per hour.
o A prolonged active phase is caused by a combination of factors including the cervix,
the uterus, the fetus and the mother’s pelvis.
o An interval of 4 hours is allowed to diagnose delay in active phase and then
appropriate intervention is done.
o Prolonged active phase may be divided into:
 Protracted active phase: When the rate of cervical dilatation is < 1.2 cm/hr in a
primipara and < 1.5 cm/hr in a multipara.
 A protracted active phase may be due to:
 Inadequate uterine contractions
 Cephalopelvic disproportion
 Malposition (OP) or malpresentation (brow)
 Epidual anesthesia.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
109

Arrest disorder: Arrest of dilatation is defined when no cervical dilatation
occurs after 2 hours in the active phase of labor. It is commonly due to
inefficient uterine contractions. No descent for a period of > 1 hour is called
arrest of descent.
 It is commonly due to CPD.
Care of a woman with prolonged first stage of labour
 Vaginal examination is done to verify the fetal presentation, position and station.
 The causes of slow labour must be identified before deciding on management.
 Oxytocin infusion may be used to stimulate uterine contraction.
 If no progress despite good uterine contraction caesarean section must be done.
 The midwife should help the woman to adopt comfortable position.
 Reassurance and support is necessary.
 Effective pain relief is given by intramuscular pethidine or by regional (epidural) analgesia.
 Give Intravenous infusion to correct fluid and electrolyte balance and to give energy.
 Encourage the woman to empty bladder regularly
 Test urine for ketones
 Monitor Intake and output chart.
 Give sips of water only especially if general anaesthesia is required for delivery
 Observation of Vital signs is Significant.
 High vaginal swab may be taken for laboratory Investigation (if membrane ruptured).
 Broad – Spectrum antibiotics may be offered prophylactically in the hope of preventingmaternal
uterine infection.
Fetal Condition
 Monitor fetal heart continuously.
 Observe the amniotic fluid for the presence of meconeum.
 Prevent aspiration during delivery.
STEP 4:Care of a Woman with Prolonged Second Stage of Labour (15 minutes)



Mean duration of second stage is 50 minutes for nullipara and 20 minutes in multipara.
Prolonged second stage is diagnosed if the duration exceeds 2 hours in nullipara and 1 hour in
a multipara when no regional anesthesia is used.
One hour or more is permitted in both the groups when regional anesthesia is used during
labor
Causes of prolonged labour in the second stage
 Ineffective contractions
 Poor maternal effort
 Loss of or absence of a desire to push cause by epidural analgesia
 A full bladder or a full rectum can also impede progress
 A large fetus, malpresentation or malposition may account for delay
 A reduced pelvic outlet, in association with an occipitoposterior position, may result in deep
transverse arrest.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
110
Care of a woman with prolonged second stage of labour
 A vaginal examination should be carried out to confirm position, attitude and station of the
presenting part.
 The fetal heart should be auscultated after every contraction or electronic monitoring used.
 In the presence of inefficient uterine contractions an infusion of oxytocin should be
commenced.
 Assisted delivery (ventouse) will be utilized where the pelvic outlet is adequate and vaginal
birth can be safely carried out.
 Operative delivery may be necessary where there is evidence of CPD.
 Continue monitoring of maternal and fetal condition
Complications
 Oedema and lacerations caused by prolonged pressure of the fetal head on the vaginal walls
and pelvic floor muscle.
 Uterine prolapse, cystocele or rectocele may occur.
STEP 5: Key points (5 minutes)




The labor is said to be prolonged when the combined duration of the first and second stage is
more than the arbitrary time limit of 18 hours.
The prolongation may be due to protracted cervical dilatation in the first stage and/or
inadequate descent of the presenting part during the first or second stage of labor.
Labor is considered prolonged when the cervical dilatation rate is less than 1 cm/hr and
descent of the presenting part is < 1 cm/hr for a period of minimum 4 hours observation.
Prolonged labor is not synonymous with inefficient uterine contraction. Inefficient uterine
contraction can be a cause of prolonged labor but labor may also be prolonged due to pelvic or
fetal factor.
Step 6: Session Evaluation (5 minutes)




What is prolonged labour?
What are the causes of prolonged labour?
What is prolonged first stage of labour?
What is prolonged second stage of labour?
References
Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives (12th ed.). London: Churchill
Livingstone.
Fraser, D. M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MoHSW. (2010). Focused antenatal care: Learner’s guide for ANC service providers and supervisors.
Dar es Salaam.
MOHSW. (2006). National guidelines for diagnosis and treatment of malaria. Dar es Salaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
111
Dutta, D. C. (2013). Text Book of Obstetrics: Including Perinatology and Contraception 7 th Edition. New
central book agency.Jaypee Brothers Medical Publishers (P) Ltd. India.
SESSION 19: CARE OF A WOMAN WITH OBSTRUCTED LABOUR
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define obstructed labour
 List causes of obstructed labour
 Identify signs and symptoms of obstructed labour
 Explain the management and prevention of obstructed labour
 State complications of obstructed labour
Resources Needed:






Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Pelvic model and fetus
Partograph
Session Overview Box
Step Time (min)
1
05
2
05
3
05
Activity/
Method
Presentation
Content
Brainstorming
Presentation
Lecture/discussion
Definition of obstructed labour
Presentation of session title and learning
objectives
Causes of obstructed labor
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
112
4
10
Lecture/discussion
Signs and symptoms of obstructed labour
5
20
Buzzing
Lecture/discussion
Management and prevention of obstructed labour
6
05
Presentation
Complications of obstructed labour
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Obstructed Labour (5 minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on the defition of obstruced labour
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
Definition of obstructed labour
 Obstructed labor is one where in spite of good uterine contractions, the progressive descent of
the presenting part is arrested due to mechanical obstruction.
 This may result either due to factors in the fetus or in the birth canal or both, so that further
progress is almost impossible without assistance.
 The obstruction usually occurs at the pelvic brim but may occur at the outlet-for example deep
transverse arrest in an android pelvis.
STEP 2: Causes of Obstructed Labour (5 minutes)
The common causes of obstructed labour include:
 Cephalopelvic Disproportion
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
113






o The fetus may be large e.g. in diabetes mellitus mothers.
o Pelvis may be contracted or previously fractured pelvis.
Malpresentation
o Brow presentation
o Persistent mentoposterior position
o Shoulder presentation or arm prolapse
Deep Transverse Arrest
o Outcome of an occipito posterior position
Fetal Abnormalities
o A hydrocephalic fetus
o Conjoin twins (abdominal wall of twins attached together)
o After coming head in breech presentation.
o Locked Twins
Pelvic mass
o Cervical fibroids
o An ovarian tumour
o Tumor of the bony pelvis
Stenosis of the cervix or vagina
Tight perineum
Step 4: Signs and Symptoms of Obstructed Labour (10 minutes)
Early Signs
 The presenting part does not enter the pelvic brim despite of good contractions
 The midwife should exclude full bladder, a loaded rectum and large amount of amnioticfluids;
causes non – engagement.
 The Cervix dilates slowly, hangs loosely like an empty sleeve and presenting part
cannotdescend.
Late Signs
 A woman admitted late in labour ward from home or arise only in a badly management
orneglected labour
 On general examination the woman is:
o Dehydrated-dry tongue and cracked lips
o Ketotic
o Severe pain
o Rapid pulse rate
o Has pyrexia
o Low urine output – contain ketones or blood stained.
o Fetal heart sound cannot be heard.
o Rupture of the uterus can cause maternal shock.
o Signs of fetal distress.
o Uterus mouldedround the fetus and it fails to relax properly between contractions.
o Lower segment becoming progressively thinner and longer, upper segment shorterand
thicker.
o A physiological retraction ring, or Bandl’s ring, it is similar to a full bladder.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
114

Vaginal examination
o a prolapsed arm or shoulder presentation
o The vagina is hot and dry the presenting part is high and feels wedged and immovable
and oedematous
o Excessive molding of the fetal skull and a large caput succedaneum is present
o Cervix is fully or partially dilated, oedematous and hanging.
o The membranes are ruptured.
o The presenting part is high and not engaged or impacted in the pelvis.
Step 5: Care and Prevention of a woman with Obstructed Labour (20 minutes)
Activity: Buzzing (10 minutes)
TELL the students to pair up and discuss on the management and prevention
of Obstructed labour (5 minutes)
ALLOW few students to respond and let other pairs provide unmentioned
responses
CLARIFY and summarize by using the information below
Care of a woman with obstructed labour
 The underlying principles of management are:
o To relieve the obstruction at the earliest by a safe delivery procedure
o To combat dehydration and ketoacidosis
o To control sepsis.
 Midwife should start resuscitating the patient; the doctor who is responsible for the further
management should be called at once.
 Resuscitation
o Put up an IV drip with a large (No 18) needle or cannula
o If she is mainly dehydrated and exhausted give sodium lactate or normal saline one or
two litres in about 6 hours.
o If she is shocked run in saline or sodium lactate as fast as possible.
 Antibiotics
o Most patients will need antibiotics for examples: X-pen 5 MU IV stat, continue 2 MU IV
6 hourly plus streptomycin 1 g IM stat, continue 1 g IM daily or chloramphenicol 1 g IV
stat, followed by 0.5 g IV 6 hourly.
 Delivery
o If the obstruction cannot be overcome by manipulation or instrumental delivery.
o Caesarean section should be performed as soon as possible if the baby is alive; pre
operation and nursing management (To see C/S emergency).
o If ruptured uterus or seems likely do laparatomy. It is lifesaving whether baby alive or
dead.
o If uterus seems intact but the baby is dead, cephalic presentation – cervix 7 cm
craniotomy.
Prevention of obstructed labour
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
115




Proper history taking of previous deliveries e.g. prolonged labour, difficult deliveries babies with
weight over 4.5 kg.at birth.
Antenatal detection of the factors likely to produce prolonged labor (big baby, small women,
malpresentation and position).
Continuous vigilance, use of partographand timely intervention of a prolonged labor due to
mechanical factors can prevent obstructed labor. Failure in progress of labor in spite of good
uterine contractions for a reasonable period (2–4 hours) is an impending sign of obstructed
labor.
If the presenting part fails to advance during second stage of labour despite of good
contractions medical aid should be summoned.
Step 5: Complications of Obstructed Labour (5 minutes)


Maternal :
o Maternal distress and ketoacidosis.
o Rupture uterus.
o Necrotic vesico -vaginal fistula.
o Infections as chorioamnionitis and puerperal sepsis.
o Postpartum haemorrhage due to injuries or uterine atony.
Foetal:
o Asphyxia.
o Intracranial haemorrhage from excessive moulding.
o Birth injuries.
o Infections.
Step 6: Key Points (5 minutes)




Obstructed labor is one where in spite of good uterine contractions, the progressive descent of
the presenting part is arrested due to mechanical obstruction.
Effects of obstructed labor are both on the mother and the fetus.
Management is primarily aimed in prevention.
The actual management is to relieve the obstruction and to deliver the fetus safely .
Step 7: Session Evaluation (5 minutes)



What is obstructed labour?
What are the signs and symptoms of obstructed labour?
What are the complications of obstructed labour?
References
Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives (12th ed.). London: Churchill
Livingstone.
Fraser, D. M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
116
MoHSW. (2010). Focused antenatal care: Learner’s guide for ANC service providers and supervisors.
Dar es Salaam.
MOHSW. (2006). National guidelines for diagnosis and treatment of malaria. Dar es Salaam.
Dutta, D. C. (2013). Text Book of Obstetrics: Including Perinatology and Contraception
7th Edition. New central book agency. Jaypee Brothers Medical Publishers (P) Ltd. India.
SESSION 20:CARE OF A WOMAN UNDERGOING VACUUM ASSISTED
DELIVERY AND CAESAREAN SECTION
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define the term vacuum extraction.
 Explain the indications and contraindications for vacuum extraction.
 Explain the procedure of vacuum extraction.
 List the complications of vacuum extraction
 Define caesarean section
 Describe the types of caesarean section
 Explain the indication and contraindication of caesarean section
Resources Needed:





Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Equipment for vacuum extractions
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
117
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
05
Brainstorming/presentation
Definition of vacuum extraction
The indication and contraindication of vacuum
delivery
3
10
Lecture discussion
4
50
Presentation
/demonstration
Procedure of vacuum extraction
5
10
Presentation
Complication of vacuum extraction
6
30
Lecture discussion
Caesarean section
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of vacuum extraction (5 Minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on the defition of vacuum extraction.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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
Vacuum assisted birth or vacuum extraction is a method of birth involving the attachment of a
vacuum cup to the fetal head and using negative pressure to assist in the birth of the head.
o Vacuum extraction (ventouse delivery) is used when there is delay in the second stage
of labour when the head is engaged and no cephalo pelvic disproportion.
o The cup cleaves to the baby’s scalp by suction and is used to assist maternal effort.
STEP 3: Indication and contraindication of vacuum extraction (10 Minutes)
Indication
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Mild fetal distress
Delay in second stage of labour
Maternal exhaustion
Malposition: occipitolateral and occipitoposterior position
Prerequisites for use
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Vertex presentation
Ruptured membranes
Cervix full dilated
No fetal head palpable above symphysis pubis
Empty bladder
Absence of CPD
The woman is prepared in a lithotomy position to allow sufficient traction.
Contraindications
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No contractions
Cephalo-pelvic disproportion
Foetal skull moulding 2+ or more
Excessive caput
Non-vertex presentation
Incomplete cervical dilatation
Premature fetus
STEP 4: Procedure Of Vacuum Extraction (20 Minutes)
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Watch the following link for video showing the demonstration of vacuum extraction
(https://www.youtube.com/watch?v=8Fq_JR_5vCo)
Equipment
o A delivery tray
o Vacuum extractor tray with various size of cups
o Episiotomy tray
Steps/method
o Ensure bladder is emptied prior to vacuum extraction
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o The woman is positioned in lithotomy
o The position of the fetal head is determined and an appropriately sized cup is selected
o The cup is placed against the fetal head as near to the occiput as possible,
ensuringthat no cervix is trapped beneath
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Assess position of fetal head by identifying the sagittal suture line and fontanelles
Identify posterior fontanelle
Apply largest possible cup
Place centre of the cup as close to the posterior fontanelle as possible
Check no maternal soft tissue in rim of cup
The cup is applied to the fetal head, and a caput develops inside the cup as the pressure is
initiated.
create a vacuum of 0.2kg/cm2(Yellow )
check application of cup
Increase vacuum to 0.8kg/cm2 (Green)
check application of cup
start traction in line of pelvic axis and perpendicular to cup
Vacuum suction pressures of 500 to 600 mmHg have been recommended during traction. .
Between contractions, suction pressure can be fully maintained or reduced to <200 mmHg.
With each contraction ask the mother to push
Place finger on scalp next to cup to assess descent and potential slippage
Between contractions check fetal heart and application of cup
Do not pull if no contraction
Episiotomy if needed
Continue pulls for maximum of 30 minutes
When head delivered release the vacuum and remove cup
Failed vacuum extraction
Classify as ‘failed’ if
o Fetal head does not advance with each pull
o Fetus undelivered after three pulls or after 30 minutes
o Cup slips off the head twice at proper direction of pull with maximum negative
pressure
If vacuum extraction is not successful a forceps assisted or CS is then performed
Post procedure
Examine perineum and repair episiotomy/tear
Write up procedure
Observe baby for complications (12-24hrs)
Neonatal review where available
Inform mother
STEP 5: Complication Of Vacuum Extraction (10 Minutes)
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Maternal complication
o Perineal trauma
o Vaginal lacerations
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o Cervical lacerations
o Soft-tissue hematomas
Fetal complication
o Cephalohematoma
o Scalp lacerations
o Subdural hematoma
o Retinal hemorrhage
STEP 6: Caesarean Section (45 Minutes)
Definition of caesarean section
An operative procedure to deliver a viable foetus or morethrough an abdominal and uterine incision
Indications of caesarean section
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Maternal indication
o Contracted pelvis and cephalopelvic disproportion
o Pelvic tumors especially if impacted in the pelvis or cancercervix.
o Antepartum haemorrhage
o Hypertensive disorders with pregnancy
o Abnormal uterine action.
o Previous uterine scar as hysterotomy or metroplasty.
o Previous successful repair of vesico-vaginal fistula
o Previous caesarean section
Fetal indication
o Malpresentations and malposition ( see before)
o Prolapsed pulsating cord or foetal distress before full cervicaldilatation.
o Diabetes mellitus (see before).
o Bad obstetric history as recurrent intrauterine foetal death in lastweeks of pregnancy or
repeated intranatal foetal death.
o Post-mortem C.S. done within 10 minutes of maternal death tosave a living baby.
Contraindication of caesarean section
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Dead foetus: except in;
o Extreme degree of pelvic contraction.
o Neglected shoulder
o Severe accidental haemorrhage.
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Extensive scar or pyogenic infection in the abdominal wall e.g. in burn
Disseminated intravascular coagulation: to minimize blood loss
.
Types of caesarean section
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According to time
o Elective caesarean section: The operation is done at apre-selected time before onset
of labour, usually at completed 39weeks.
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o Selective caesarean section: The operation is done after onset oflabour.
 According to the site of uterine incision:
o Upper segment caesarean section (classical C.S.): The incisionis done in the upper
uterine segment and it is always vertical.
o Lower segment caesarean section (LSCS) It is the commonertype, the incision is done
in the lower uterine segment and maybe transverse ( the usual) or vertical in the
followingconditions
 Presence of lateral varicosities.
 Constriction ring to cut through it.
 Deeply engaged head.
Pre and post operative care of a pregnant woman undergoing caesarean section
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Preoperative care
o Inform the mother about the procedure and reassure to allay anxiety
o Check vital signs such as Blood pressure, pulse and respiration
o Intravenous infusion should be in situ
o Give iv ceftriaxone 1 g and iv metronidazole 500 mls.
o Insert an indwelling catheter to empty the bladder.
o Any valuables items are placed in safe keeping according to hospital policy
o Laboratory investigation such as hemoglobin, Grouping and cross matching
o Check urea and electrolyte levels and clotting factors
Postoperative care
o Blood pressure and pulse every ¼ hour
o Temperature every 2 hours
o Inspect the wound every ½ an hour
o Inspect lochia (normally it should be small in amounts)
o Nurse the woman in the left lateral or recovery position until fully conscious since the
risk of regurgitation and silent aspiration of stomach contents is still present.
o Give analgesics as prescribed.
o If the mother opts to breastfeed, put the baby to the breast as soon as she recovers.
o Breast feeding can be achieved with minimal disturbance to the mother
Complication of caesarean section
o Uterine rupture in subsequent pregnancy.
o Post-operative infection: Endometritis, wound sepsis, peritonitis and secondarily pelvic
adhesions.
o Paralytic ileus(intestinal obstruction).
o Injury to the urinary system: Bladder, ureters, and secondarily vesico-vaginal fistula
o Injury to the uterine vessels with massive haemorrhage.
o Embolism: Pulmonary, thrombophlebitis and deep venous thrombosis .
o Atelectasis.Partial collapse or incomplete inflation of lung.
o Respiratory distress.
o Prolonged hospitalization.
o Caesarean hysterectomy
STEP 7: Key points (5 minutes)
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Precaution during vacuum derivery
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o Care should be taken to ensure that no vaginal skin is trapped in the edges of
the cup.
o Prolonged or excessive traction should not be used.
Vacuum is also called ventose delivery
Antiseptic measures for vagina , vulva and perineum is important
STEP 8: Session Evaluation (5 minutes)
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What is vacuum extraction?
What are the indication and contraindication of vacuum extraction?
What are the types of caesarean section?
What are the contraindications of caesarean section?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
123
SESSION 21: CARE OF A PREGNANT WOMAN DURING INDUCTION
AND AUGMENTATION OF LABOUR
Total Session Time:
120 minutes
Prerequisites
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None
Learning Tasks
At the end of this session, a learner is expected to be able to:
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Define induction of labour
Explain the indications and contraindications of induction of labour
Explain the methods of induction of labour
Explain pre-induction assessment
Explain the care of a woman during induction of labour
Explain about augmentation of labour
Resources Needed:
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Explain complications of abortion
Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Content
1
05
Presentation
Presentation of session title and learning tasks
2
05
Presentation
Definition of induction of labour
3
05
Lecture discussion
Indication and contraindication of induction of
labour
4
05
Lecture discussion
Pre-induction assessment
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
124
5
15
Brainstorming/Lecture
discussion
Methods of induction of labour
6
10
Lecture discussion
Care of a woman during induction of labour
7
05
Lecture discussion
Augmentation of labour
8
05
Presentation
Key Points
9
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of induction of labour (5 Minutes)
Induction of labour is the initiation of contractions for the purpose of achieving a vaginal birth in a
pregnant woman who is not in labour.
STEP 3: Indication And Contraindication (5 Minutes)
Indication of induction of labour

Maternal
o Hypertensive disorders in pregnancy
o Diabetes
o Medical problem
 Renal ,respiratory or cardiac diseases may require induction of labour
o Placenta abruption after the mother’s condition is stabilised
o Post term pregnancy (defined at or after 42 weeks)
o Premature rupture of membrane
o Previous stillbirth
o Unexplained oligohydramnios
 Foetal indications
o Post-term pregnancy.
o Intrauterine growth retardation.
o Intrauterine foetal death.
o Rh- isoimmunization.
o Gross congenital anomalies
 Contraindication of induction of labour
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o
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o
o
o
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Placenta Praevia
Transverse or compound fetal presentation
Cord presentation or cord prolapsed
Active genital herpes
Previous caesarean section
High parity
Cephalopelvic disproportion
Multiple pregnancy
Polyhydramious
Maternal cardiac disease
Grand multiparty
Breech presentation
Presenting part above pelvic inlet
STEP 4: Pre-Induction Assessment (5 Minutes)
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In order to decide on the methods of induction the assessment of the cervix is required by
using the bishop score.
The key elements in the assessment are the dilatation, effacement (cervical canal length)
,position, consistency and the station of the presenting part.
The five different features are considered and each is awarded a score of between 0 and 3
When a total of 6 or over is reached the prognosis for induction is good.
Figure: Showing the bishop score
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 5: Method Of Induction Of Labour (15 Minutes)
Activity: Brainstorming (3 minutes)
ASK students to brainstorm on the methods of induction of labour
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below
Methods Medical induction

Prostaglandins
o These induce ripening of the cervix and uterine contractions
o Misoprostol (cytotec) is a synthetic prostaglandin E1 which is the most common used.
o Prostaglandins are more effective when administered by intravaginal route.
o Labour will result in 30 to 50% of cases
o Fetal heart rate and uterine contraction should be monitored continuously.
o The side effects of prostaglandins includes
 Uterine hyperstimulation and ruptured uterus
 Systemic side effects includes pyrexia ,diarrhoea and vomiting
 Oxytocin
o The cyntocinon is given intravenously as the oral route is ineffective and the
intramuscular route is dangerous in case of over dosage
o It is used intravenously ,diluted in an isotonic solution such as normal saline
o The infusion should be controlled
o Dosage should be recorded in milli-units per minutes with the suggested dilution being
30 IU in IV 500ml of normal saline.
o Rate of infusion must be titrated against the assessment of strength and frequency of
uterine contractions
o The infusion rate may be reduced as labour becomes established
o It may be used in conjunction with amniotomy and may be commenced at the same
times as ARM or after delay in several hours
o The use of oxytocin for induction of labour has the following side effects
 Hyperstimulation of the uterus
 Prolonged use may predispose to uterine atony postpartum
 Water retention may occur in prolonged use
 Systemic side effects including direct vascular smooth muscle relaxation
leading to transient vasodilatation and hypotension
Mechanical Induction
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Sweeping or stripping of membrane.
o Membrane sweeping means detaching the amniotic membranes of the fore waters
from the lower segment of the uterus.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
127
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o This can be effective method of inducing labour where there is an uncomplicated
pregnancy
Amniotomy
o It is the artificial rupture of membrane (ARM) resulting in drainage of liquor
o However ARM possesses the following hazards:
 Intrauterine infection
 Early deceleration of fetal heart
 Cord prolapsed
 Bleeding from the fetal vessels in the membrane ( vasa praevia) the triable
vessel in the cervix or slow lying placental site (placenta praevia)
 Surgical induction can cause vertical transmission of HIV
Ballooning, a urinary catheter is inserted intracervical and ballooned by 40 cc of water for
injection; the catheter is attached to the thigh by a plaster. The ballon is remained intracervical
until it drop and labour starts.
STEP 5: Care Of A Woman During Induction Of Labour (10 Minutes)
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The midwife should discuss with woman and obtain consent prior to induction of labour
Written information should be available
A record of the woman and partners wishes should be made in the maternity notes
Reassure the woman
Assess the position of the fetus and relationship of the presenting part to the pelvic brim before
commencing the oxytocin
Then induction is done if the cervix is favourable by the appropriate method.
Observe maternal and fetal condition and record on the partograph
Assess the progress of labour and possible side effects
Observe maternal pulse, blood pressure, and temperature and record on the partograph
Observe contraction for frequency, duration and strength every 15 minutes and keep record
Fetal heart should be recorded in the partograph every 15 minutes
Observe for signs of fetal distress such as meconeum stained liquor which may indicate the
presence of fetal distress
Observe and note the mother’s reaction to pain caused by the contraction
Give support and encouragement to the woman to help her cope with the contractions.
Vaginal examination performed to assess the length, consistency position and station of the
presenting part usually in every 4 hours.
STEP 6: Augmentation Of Labour (5 Minutes)
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Augmentation of labour refers to interventions to correct the slow progress in labour.
Correction of ineffective uterine contraction includes
o Amniotomy
o Administration of oxytocin
Care of a woman during augmentation includes
o Obtain consent from the mother prior to augmentation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o
o
o
o
o
Written information should be available
Reassure the mother and her partner
Monitor the progress of labour and the condition of the mother
Monitor the maternal’s vital signs and record in the partograph
Observe for any sign of fetal distress such as meconeum stained liquor which may
indicate the presence of fetal distress
STEP 8: Key Points (5 minutes)
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Induction of labour is the initiation of contractions for the purpose of achieving a vaginal birth in
a pregnant woman who is not in labour.
Augmentation of labour refers to interventions to correct the slow progress in labour
Oxytocin should not be started within 6hours of administration of prostaglandins
Continuous fetal monitoring is recommended when oxytocin is used for inducing or
augmenting labour
STEP 9: Session Evaluation (5 minutes)
 What is the difference between induction and augmentation of labour?
 What are the indications and contraindications of induction of labour?
 What are the methods of induction of labour?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 22: CARE OF A WOMAN WITH PRETERM LABOUR
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define preterm labour
 Explain causes of preterm labour
 Explain signs and symptoms of preterm labour
 Explain the conservative management of a woman with preterm labour
 Explain complications of preterm labour
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
Definition of preterm labour
1
05
Presentation of session title and learning
objectives
2
05
3
05
Brainstorming
Presentation
Lecture/discussion
4
05
Lecture/discussion
Signs and symptoms of preterm labour
5
25
Brainstorming
Lecture/discussion
Conservative management of a woman with
preterm labour
6
05
Presentation
Complications of preterm labour
7
05
Presentation
Key Points
Causes of preterm labor
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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8
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Preterm Labour (5 minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on defition of preterm labour
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
Definition of preterm labour
 Preterm labor is defined as one where the labor starts before the 37th completed week (< 259
days), counting from the first day of the last menstrual period.
o The lower limit of gestation is not uniformly defined; whereas in developed countries it
has been brought down to 20 weeks, in developing countries it is 28 weeks.
o Preterm birth is the significant cause of perinatal morbidity and mortality.
STEP 3: Causes of Preterm Labour (5 minutes)
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Maternal causes
o Medical disorders
 Pre-eclampsia
 Chronic nephritis
 Anaemia
 malnutrition
o Antepartum haemorrhage
 Placenta praevia
 Abruptio placenta
o Uterine anomalies
 Septate uterus
 Incompetent cervix
 Fibroid uterus
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
131
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o Psychological or hormonal.
Foetal causes
o Congenital anomalies
o Intrauterine foetal death
o Polyhydramious
o Multiple pregnancy
o Rh- isoimmunization
o Premature rupture of membranes.
Idiopathic
STEP 4: Signs and Symptoms of Preterm Labour (5 minutes)
Signs and symptoms
 Painful menstrual-like cramps-may be confused with round ligament pain
 Dull low backache-different from the usual low backache a pregnant woman may have
 Suprapubic pain or pressure-may be confused with urinary tract infection
 Sensation of pelvic pressure or heaviness
 Change in character or amount of vaginal discharge (thicker, thinner, watery, bloody, brown,
and colorless)
 Diarrhea
 Unpalpated uterine contractions (painful or painless) felt more often than every 10 minutes for 1
hour or more and not relieved by lying down
 Premature rupture of the membranes
The diagnosis of preterm labour(Assessment of a woman with preterm labour)
 History taking on the pain,Vital signs are very important
 General Examination from head to toe including abdominal examination,Vaginal examination
and Laboratory investigation
 Regular uterine contractions with or without pain (at least one in every 10 minute);
 Dilatation (> 2 cm) and effacement (80%) of the cervix;
 Pelvic pressure, backache and or vaginal discharge or bleeding.
STEP 5: Conservative management to a woman with Preterm Labour (25 minutes)
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
The management includes:
o To prevent preterm onset of labor, if possible
o To arrest preterm labor, if not contraindicated
o Appropriate management of labor
o Effective neonatal care.
Principles of management of women with preterm labour:
o Glucocorticoids to the mother to reduce neonatal Respiratory distress syndrome
o Antenatal transfer of the mother with fetus in utero to a center equipped with NICU
o Tocolytic drugs to the mother for a short period unless contraindicated
o Antibiotics to prevent neonatal infection with Group B Streptococcus (GBS)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o Careful intrapartum monitoring, minimal trauma and presence of a neonatologist during
delivery
o Vaginal delivery is preferred, unless otherwise indicated for cesarean birth
Conservative management
 Prophylactic management:
o Adequate rest for high risk patients.
o Improve health and nutrition.
o Discourage cigarette smoking.
o Treatment of cervical incompetence by circulage in the second quarter of pregnancy.

Preventive management:
o The aim is to inhibit labour till completed 37 weeks’ gestation or at least till the foetal
lung maturity is ensured. This may be achieved by acting on one or more of the
following theories of labour.
o Neuromuscular:
 Sedation such as diazepam.
 Ethyl alcohol (Ethanol).
 Sympathomimetic drugs such as ritodrine and isoxuprine.
 receptor blockers: as phenoxybenzamine
o Hormonal :
 Betamethazone:4 mg betamethazone IM every 8 hours for 48 hours can
cause:
 Decreaseoestrogen synthesis by depressing the production of its
precursor from thefoetal adrenal gland.
 Inhibition of prostaglandin synthesis.
 Acceleration of foetal lung maturity.
 Prostaglandin inhibition: e.g. endomethacin.
 Oxytocin inhibition by :
 Hydration with a rapid IV infusion of 0.9% Nacl (normal saline) in a
rateof 120 ml/hour. This will decrease the release of oxytocins as well
asantidiuretic hormone from the posterior pituitary.
 Ethyl alcohol.
o Mechanical:
 Rest in bed: to reduce the mechanical stimuli from the pressure of the
presentingpart on the lower uterine segment.
 Cervical cerclage: it is of value in prevention of abortion and preterm labour
ifdone at 14-16 weeks’ gestation but not so later on.
 Amniocentesis: was advocated by some authors to reduce the
mechanicaldistension of the uterus in polyhydramious.
Management in the first stage
 The patient is put to bed to prevent early rupture of the membranes
 To ensure adequate fetal oxygenation by giving oxygen to the mother by mask
 Epidural analgesia is of choice
 Labor should be carefully monitored prefer-ably with continuous EFM
 Cesarean delivery is done for obstetric reasons only
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
133
Management in the second stage
 The birth should be gentle and slow to avoid rapid compression and decompression of the
head
 Episiotomy may be done to minimize head compression if there is perineal resistance
 The cord is to be clamped immediately at birth to prevent hypervolemia and hyperbilirubinemia
 To shift the baby to neonatal intensive care unit under the care of a neonatologist
STEP 6: Complications of Preterm Labour (5 minutes)
Maternal.
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
Fetal
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
Maternal side effects of tocolytics e.g. nausea, vomiting, tachycardia etc
Sepsis
Preterm labor and delivery of a low birth weight baby results in high perinatal mortality and
morbidity
Birth asyphxia and development of respiratory distress syndrome
Fetal side effects of tocolytics e.g. tachycardia, hypoglacemia
STEP 7: Key points (5 minutes)
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


Preterm labor is defined as cervical changes and uterine contractionsoccurring between 20 and
37 weeks of pregnancy.
Preterm birth is any birth that occurs before the completion of 37 weeks of pregnancy,
regardless of birth weight.
Complications related to preterm birth account for more newborn and infant deaths than
anyother cause.
Although preterm birth often is not preventable, early recognition of preterm labor is still
essential to implement interventions that have been demonstrated to reduce neonatal and
infant morbidity and mortality.
STEP 8: Session Evaluation (5 minutes)



What is preterm labour?
What are the causes of preterm labour?
What are the signs and symptoms of preterm labour?
References
Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives (12th ed.). London: Churchill
Livingstone.
Fraser, D. M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
134
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MoHSW. (2010). Focused antenatal care: Learner’s guide for ANC service providers and supervisors.
Dar es Salaam.
MOHSW. (2006). National guidelines for diagnosis and treatment of malaria. Dar es Salaam.
Dutta, D. C. (2013). Text Book of Obstetrics: Including Perinatology and Contraception 7th Edition. New
central book agency. Jaypee Brothers Medical Publishers (P) Ltd. India.
SESSION 23: CARE OF A WOMAN WITH PREMATURE RUPTURE OF
MEMBRANE (PROM)
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define premature rupture of membrane(PROM)
 Explain causes of PROM
 Explain the diagnosis of PROM
 Explain the conservative management of a woman with PROM
 Explain complications of PROM
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
Definition of PROM
1
05
Presentation of session title and learning
objectives
2
05
3
05
Brainstorming
Presentation
Lecture/discussion
4
05
Lecture/discussion
Diagnosis of PROM
5
25
Buzzing
Lecture/discussion
Conservative management of a woman with
PROM
6
05
Presentation
Complications of PROM
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
Causes of PROM
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Premature Rupture of Membranes (PROM) (5 minutes)
Activity: Brainstorming (2 minutes)
ASK students to brainstorm on the definition of premature rupture of
membranes (PROM)
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
136
Definition of premature rupture of membranes (PROM)
 It is defined as rupture of membranes before onset of labour.
o Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but
before the onset of labor is called premature rupture of the membranes (PROM).
STEP 3: Causes of PROM (5 minutes)

The causes are mostly unknown.
o PROM can be brought about iatrogenically either during induction of labour or
accidentally during membranes sweeping.
o A weak point in the amniotic membranes could rupture before labour starts.
o It is common in multiple pregnancy, polyhydramious and if the presenting part of fetus
is poorly fitted into the pelvis.
o After PROM, labour may set in within 6 hours or the leaking of liquor may continue for
days or weeks or the rupture may close spontaneously.

The following factors are incriminated:
o Cervical incompetence.
o Polyhydramious.
o Multiple pregnancy.
o Malpresentations as the presenting part is not fitting against the loweruterine segment.
o Chorioamnionitis
o Low tensile strength of the membranes.
STEP 4: Diagnosis of PROM (5 minutes)



The only subjective symptom is escape of watery discharge per vagina either in the form of a
gush or slowleak.
This is often confused with:(a) Hydrorrheagravidarum—a state where periodic watery discharge
occurs probably dueto excessive decidual glandular secretion; (b) Incontinence of urine
especially in the later months.
Confirmation of diagnosis:
o Speculum examination is done taking aseptic precautions to inspect the liquor
escaping outthrough the cervix;
o To examine the collected fluid from the posterior fornix (vaginal pool) for: (a) Detection
of pH bylitmus or Nitrazine paper. The pH becomes 6–6.2 (Normal vaginal pH during
pregnancy is 4.5–5.5 whereas that of liquoramnii is 7–7.5). Nitrazine paper turns from
yellow to blue at pH > 6; (b) To note the characteristic ferning pattern when asmeared
slide is examined under microscope; (c) Centrifuged cells stained with 0.1% Nile blue
sulfate showing orange bluecoloration of the cells (exfoliated fat containing cells from
sebaceous glands of the fetus)
o Ultrasonography is to be donenot only to support the diagnosis but also to assess the
fetal wellbeing.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 5: Conservative Management of a Woman with PROM (25 minutes)
Activity: Buzzing (10 minutes)
TELL the students to pair up and discuss on the conservative
management of a woman with PROM (5 minutes)
ALLOW few students to respond and let other pairs provide
unmentioned responses
CLARIFY and summarize by using the information below
 All women with PROM should be reffered to hospital.
 Before reffering such a patient to hospital ascertain that what is coming out per vaginum is
liquor and not urine or pus by:
o History. The patient will complain of sudden watery vaginal discharge.
o Observations of;
 Odour of the discharge. Urine has ammonical smell, while liquor smells like
seminal fluid.
 Alkalinity. Liquor is alkaline so it will change litmus paper blue.
 Liquor contains lanugo hair from the fetus.
 Fern test. In liquor fern test is positive. If the discharge is smeared on a
microscope slide and examined under microscope it will form a fern-like
structure.
Conservative management of PROM
 Bed-rest.
 Prophylactic antibiotics.
 Corticosteroids can be given to the mother so as to mature the baby’s lungs. Dexamethasone
12 mg, intramuscularly, 12 hourly for 24 hours.
 Frequent monitoring of maternal pulse, temperature and the fetal heart rate.
 Monitoring vital signs especially temperature and pulse rate for monitoring infections
 In hospitals where culture can be done, frequent culturing of the liquor should be done.
 During conservative management avoid unnecessary vaginal examinations.
 The management of PROM depends on the gestational period.
 Cord prolapse should be ruled out. If the cord is prolapsed then woman should be delivered
regardless of the gestational age.
 If there is no cord prolapse then:
o If the gestational period is 34 weeks or above, the dangers of the fetus staying in utero
are more than if delivered. Thus at this gestation period the woman should be
delivered and care of the baby is done accordingly.
o If the gestation period is less than 34 weeks then conservative management can be
tried.
o If gestation age is less than 24 weeks salvaging the pregnancy is not easy.
o If there is a lot of liquor draining out salvaging the pregnancy is not easy.
o If there is none of the above conservative management can be tried.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 6: Complications of PROM (5 minutes)





Dry labour. If most of the liquor drains out the fetus will be in close contact with the uterine
walls, thus labour will be dry.
Ascending infection is common after 24 hours. The ascending infection can cause amnionitis,
neonatal pneumonia and even peritonitis if the infection spreads.
o Signs of infection will include smelly liquor, high temperature and pulse rate of the
woman and the fetal heart bear will be raised (tachycardia).
Cord prolapse.
Abruptio placenta.
Choriomnitis
STEP 7: Key Points (5 minutes)




When rupture of membranes occur beyond 37th week but before the onset of labor it is called
term PROM and when it occurs before 37 completed weeks, it is called preterm PROM.
Rupture of membranes for > 24 hours before delivery is called prolonged rupture of
membranes.
It is common in multiple pregnancy, polyhydramious and if the presenting part of fetus is poorly
fitted into the pelvis.
After PROM, labour may set in within 6 hours or the leaking of liquor may continue for days or
weeks or the rupture may close spontaneously.
STEP 8: Session Evaluation (5 minutes)


What is PROM?
What are the complications of PROM?
References
Bennett, V. R., & Brown, L. K. (1993). Myles textbook for midwives (12th ed.). London: Churchill
Livingstone.
Fraser, D. M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers and midwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MoHSW. (2010). Focused antenatal care: Learner’s guide for ANC service providers and supervisors.
Dar es Salaam.
MOHSW. (2006). National guidelines for diagnosis and treatment of malaria. Dar es Salaam.
Dutta, D. C. (2013). Text Book of Obstetrics: Including Perinatology and Contraception 7th Edition. New
central book agency. Jaypee Brothers Medical Publishers (P) Ltd. India.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
139
SESSION 24: CARE OF A WOMAN WITH BREECH PRESENTATION
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define breech presentation
 Explain the types of breech presentation
 Describe causes and diagnosis of breech presentation
 Explain mechanism of breech delivery
 Give care to the woman with breech presentation
 Outline complications of breech delivery
Resources Needed:





Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Models
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
05
Brainstorming/presentation
3
10
Lecture discussion
Definition breech presentation
Types of breech presentation
4
10
Lecture discussion
Causes and Diagnosis of breech presentation
5
20
Lecture discussion
Mechanism of breech delivery
6
55
Lecture
discussion/demonstration
Care to the woman with breech presentation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
140
8
05
9
05
10
05
Lecture discussion
Complication of breech presentation
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Breech Presentation (5 Minutes)
Activity: Brainstorming (2 minutes)
ASK students to define breech presentation
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below

It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs
while the head occupies upper pole of uterus.
o In the breech presentation the baby enters the birth canal with the buttocks or feet first
as opposed to the normal head first presentation.
o Compared with a fetus with cephalic presentation, a breech fetus faces increased risk
during labor and delivery of asphyxia from cord compression and of traumatic injury
during delivery of the shoulders and head
STEP 3: Types of Breech presentation (10 Minutes)
There are two types of breech presentation which are
 Complete breech presentation
o Is this type the normal attitude of full flexion is maintained.
o The thighs are flexed at the hips and the legs at the knees

Incomplete breech presentation
o This is due to varying degrees of extension of thighs or legs at the podalic pole.
o Three varieties are possible:
 Breech with extended legs (Frank breech):
 In this condition, the thighs are flexed on the trunk and the legs are
extended at the knee joints.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
141



The presenting part consists of the two buttocks and external genitalia
only.
It is commonly present in primigravidae, about 70%.
The increased prevalence in primigravida is due to a tight abdominal wall,
good uterine tone and early engagement of breech
o Footling presentation (25%)
 Both the thighs and the legs are partially extended bringing the legs to present
at the brim.
o Knee presentation:
 Thighs are extended but the knees are flexed, bringing the knees down to
present at the brim.
 This is very rare
Figure: Showing varieties of breech presentation
STEP 4: Cause and Diagnosis of Breech Presentation (15 Minutes)
Causes of breech presentation
 Prematurity which is due to
o relatively small foetal size,
o relatively excess amniotic fluid, and
o more globular shape of the uterus
 Multiple pregnancy
o One or both will present by the breech to adapt with the relatively small room.
 Poly-and oligohydramnios
 Hydrocephalus
 Intrauterine foetal death.
 Bicornuate and septate uterus.
 Uterine and pelvic tumours.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
142



Placenta praevia
Anencephaly
Contracted pelvis
Diagnosis of breech presentation

The diagnosis of breech presentation is mainly by physical examination and investigation
though sometimes the mother may admit that she feels the baby kicking in her lower abdomen
but this is unreliable ,the diagnosis includes
o Abdominal examination
 Lie is longitudinal with a soft presentation which is more easily felt using
pawlik’s grip
 On palpation of the uterus the fundus will be found to be occupied by a firm,
smooth, round and ballottable mass which indicates the head.
 A woman may complain of discomfort under the ribs due to the pressure of the
head on the diaphragm
o Auscultation
 The foetal heart rate may be heard clearly above the umbilicus.
 If already descended in to the pelvis, the fetal heart sounds tend to be
heard at a lower level.
o Vagina examination
 On vaginal examination done at proper time will reveal soft and irregular mass
instead of smooth and round mass with palpable sutures indicating the head.
 Anus may be felt and fresh meconium on the examining finger is usually
diagnostic
 If the legs extended, external genitalia (vulva/scrotum) are very evident though
it may become edematous
o Ultrasound
 It is used to confirm the diagnosis
STEP 5: Mechanism and of breech presentation(20 Minutes)

Positions in breech presentation
o Left Sacro Anterior
o Right Sacro Anterior
o Left Sacro Posterior
o Right Sacro Posterior
o Left Sacro Transverse
o Right Sacro Transverse
Mechanism of breech presentation

Example in Left sacro- anterior position
o The lie is longitudinal
o The attitude is one of complete flexion
o The presentation is breech
o The position is left sacroanterior
o The denominator is the sacrum
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
143
o The presenting part is the anterior (left) buttock
o The bitrochanteric diameter, 10cm, enters the pelvis in the left oblique diameter of the
brim.
o The sacrum points to the left iliopectineal eminence.








Compaction
o Descent takes place with increasing compaction due to increased flexion of the limbs
Internal rotation of the buttocks
o The anterior buttock reaches the pelvic floor first and rotates forwards 1/8 of a circle
along the right side of the pelvis to lie underneath the symphysis pubis.
o The bitrochanteric diameter is now in the anteroposterior diameter of the outlet.
Lateral flexion of the body
o The anterior buttock escapes under the symphysis pubis, the posterior buttock sweeps
the perineum and the buttocks are born by a movement of lateral flexion.
Restitution of the buttocks
o The anterior buttock turns slightly to the mother’s right side
Internal rotation of the shoulders
o The shoulders enter the pelvis in the same oblique diameter as the buttocks, the left
oblique.
o The exterior shoulder rotates forwards 1/8 of a circle along the right side of the pelvis
and escapes under the symphysis pubis, the posterior shoulder sweeps the perineum
and the shoulders are born.
Internal rotation of the head
o The head enters the pelvis with the sagittal suture in the transverse diameter of the
brim.
o The occiput rotates forwards along the left side and the sub occipital region (the nape
of the neck) impinges on the undersurface of the symphysis pubis.
External rotation of the body
o At the same time the body turns so that the back is uppermost.
Birth of the head
o The chin, face and sinciput sweep the perineum and the head is born in a flexed
attitude
STEP 6: Care of a Woman with breech presentation (55 minutes):
The care of a woman with breech presentation according to the stages of labour includes
Care during first stage of labour




Basic care during this stage is the same as in normal labour.
It is usual to monitor the fetal heart and uterine contractions continuously once labour is
established.
Although the breech with extended legs fits the cervix quite well, the complete breech is a less
well-fitting presenting part and the membranes tend to rupture early.
There is an increased risk of cord prolapse and a vaginal examination is performed to exclude
this as soon as the membranes rupture
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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
If not ruptured spontaneously at early stage, it is safer to leave them until labor established and
the breech is in the level of ischial spines
Care during the second stage of labour




Full dilation of cervix should be always confirmed by vagina examination before the woman
commences active pushing because
o in footling presentation, a foot may appear at the vulva when the cervix is only partially
dilated
o Also when legs are extended, particularly if the fetus is small, the breech may slip
through an incompletely dilated cervix
o Hence, head may be trapped by the cervix when the fetus is partially delivered
Types of breech delivery includes
o In spontaneous breech delivery
 Birth occurs with little assistance from the midwife.
Assisted breech delivery
o The buttocks are born spontaneously, but some assistance is necessary for delivery of
extended legs or arms and the head.
Breech extraction.
o This is a manipulative delivery carried out by an obstetrician and is performed to
hasten birth in an emergency situation such as fetal compromise (Distress)
Conducting delivery



Delivery of the buttocks and legs
o Once the buttocks has entered the vagina and cervix is full dilated tell the woman that
she can bear down with contractions and the buttocks are delivered spontaneously
o If the perineum is very tight perform an episiotomy
o If the legs are flexed, the feet disengage at the vulva, and the baby is born
If the legs do not deliver spontaneously,
o Deliver one leg at a time through Pinard maneuver
 Leg abducted and flexed at knee by pressing popliteal fossa
 Foot and leg are brought down and delivered
 Procedure repeated for other leg and foot
 Do not pull the baby while the legs are being delivered
 Do not hold the baby by the flanks or abdomen as this may cause kidney or
liver damage
 If there is a loop of cord it should be gently pulled down to avoid traction on the
umbilicus
Delivery of the Shoulder/Arms
o Wrap the baby’s with small towel around the hips to preserve warmth and improves the
grip on the slippery skin
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
145
o The uterine contractions and weight of the body will bring the shoulders down in to the
pelvic floor where they will rotate in to anterior posterior diameter of the outlet
o Let the descent continue until the shoulder blades are seen
o If the arms are felt on the chest, allow them to disengage spontaneously
o After spontaneous delivery of the first arm, lift the buttocks toward the mother’s
abdomen to enable the posterior shoulder and arm to deliver spontaneously.
o If the arm does not deliver spontaneously, place one or two fingers in the elbow and
bend the arm, bringing the hand down over the baby’s face.
o If the arms are stretched above the head or folded around the neck (extended arms)
o Use the lovset’s manouvure
 Hold the baby by the hips and turn half a circle keeping the back uppermost
and applying downward traction at the same time so that the arm that was
posterior become anterior and can be delivered under the pubic arch
 Assist delivery of the arm by placing one or two fingers on the upper part of the
arm draw the arm down over the chest as the elbow is flexed, with the hands
sweeping over the face.
 To deliver the second arm turn the baby half circle keeping the back
uppermost and applying downward traction and deliver the second arm in the
same way under the pubic arch
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
146
Figure; Showing the illustration of Lovset maneover

Delivery of the head
o When the back has been turned the infant is allowed to hang from the vulva without
support.
o His weight brings the head onto the pelvic floor on which the occiput rotates forwards.
o The sagittal suture is now in the anteroposterior diameter of the outlet.
o If rotation of the head fails to take place, two fingers should be placed on the molar
bones and the head rotated.
o The baby can be allowed to hang for 1 to 2 minutes.
o Gradually the neck elongates the hairline appears and the suboccipital region can be
felt.
o Control delivery of the head to avoid any sudden change in intracranial pressure and
subsequent cerebral haemorrhage.
o Delay in delivery of the head (Extended head)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
147





When the body has been allowed to hang, the neck and hairline are not
visible, it is probable that the head is extended.
This may be dealt with by the use of forceps or the Mauriceau Smellie veit
If the head is trapped in an incompletely dilated cervix, an air channel can be
created to enable the baby to breathe pending intervention.
This is done by inserting two fingers or a Sim’s speculum in front the baby’s
face and holding the vaginal wall away from the nose
Complete steps as normal delivery after delivering the baby, including active
management of third stage of labour and immediate newborn care.
Figure; Showing mauriceau smellie veit maneuver
Activity: Demonstration (30 minutes)
DIVIDE students depending on the size of the class.
Demonstrate: On how to conduct breech extraction delivery
ALLOW One student from each group to do return demonstration and let others
comment on it
CLARIFY and summarize.
.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
148
STEP 7: Complications of Breech presentation (5 minutes)












Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of
delivery.
Deaths most often are associated with difficult delivery, malformations, prematurity and
intrauterine fetal demise
Premature separation of the placenta
Fetal hypoxia/Birth asphyxia
Incidence of prolapsed umbilical cord: Footling 17%, Complete 5%, Frank 0.5
Superficial tissue damage
Fracture of the humerus, clavicle or femur or dislocation of the shoulder or hip
Spinal cord damage or fracture of the spine
Birth trauma ; intra-cranial haemorrhage, trauma of internal organs
Lower Apgar scores
Impacted breech/An entrapped head
Cervical spine injury
STEP 8: Key Points (5 minutes)




Breech presentation is a longitudinal lie in which the buttocks is the presenting part with or
without the lower limbs while the head occupies upper pole of uterus.
There are two types of breech complete and incomplete
Pinard maneuver is used to deliver the extended legs
Lovset maneuver is used to deliver the extended arms

Encourage the woman to push with contractions and the buttocks are delivered spontaneously.

Excessive delay in delivery of the head may cause severe hypoxia in the fetus
STEP 9: Session Evaluation (5 minutes)
 What is breech presentation?
 What are the causes of breech presentation?
 What are the the complications of breech presentation?
References
. Advanced life saving skills (2005) volume 2 reproductive child health section Dar-es -Salaam:
Tanzania
Bennett V.R., & Brown L, K. (1996) Myles text book for midwives (14th ed)
Callahan, T., & Caughey, A. B. (2013). Blueprints obstetrics and gynecology (Vol. 6). Lippincott
Williams & Wilkins.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
149
.
Dutta, D. C. (2004). Text Book of Obstetrics: Including Perinatology and Contraception. New central
book agency.
Diane, M.F., & Margaret, A.C. (2003). Myles Textbook for Midwives (14th ed). London: Churchill
Livingston.
El Mowafi, D. M.(2002) .Obstetric Simplified
Fraser, D.M., & Cooper, M.A. (2009). Myles text book for midwives (15th ed).London Churchill
Livingston
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667
SESSION 25: CARE OF A WOMAN WITH BROW PRESENTATION
Total Session Time:
120 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define brow presentation
 Explain causes of brow presentations
 Explain the diagnosis of brow presentation
 Give care to a woman with brow presentation
 Complication of brow presentation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
5
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
5
Brainstorming/presentation
3
10
Lecture discussion
Definition of brow presentation
Causes of brow presentation
4
10
Lecture discussion
Diagnosis of brow presentation
5
20
Lecture discussion
Care of a woman with brow presentation
6
15
Lecture discussion
Complications of abortion
7
5
Presentation
Key Points
8
5
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
151
STEP 2: Definition of Brow presentation (5 Minutes)
Activity: Brainstorming (3 minutes)
ASK the leaner to define brow presentation
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below

It is a cephalic presentation in which the head is midway between flexion and extension.
o In Brow the fetal head is partially extended with frontal bone, which is bounded by the
anterior fontanel and orbital ridges lying in the pelvic brim
o The presenting diameter is mentovertical (13.5cm). This diameter exceeds all the
diameters in an average pelvis.
Figure: showing brow presentation
STEP 3: Causes of Brow presentation(10 Minutes)
During the process of extension from vertex to face presentation, the brow will present temporarily and
in a few cases it will persist.
 Anterior obliquity of the uterus
o Multiparous women with slack muscles and a pendulous abdomen will have a uterus
that leans forward and alters the direction of the uterine axis.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
152



o This causes the fetal buttocks to lean forward and the force of the uterine contractions
are directed towards the chin rather than the occiput resulting in the extension of the
head
Contracted pelvis
o The parietal eminences are held in the obstetrical conjugate, the head then becomes
extended.
o Alternatively, in an android pelvis, the occipital posterior head does not descend. The
head is extended and the brow may present
Polyhydramnious.
o Sudden rupture of the membranes results in the extension of the head as it descends.
Congenital abnormalities
o Tumour of the fetal neck and anencephaly
STEP 4: Diagnosis of Brow presentation (10 Minutes)
 Not diagnosed before the onset of labour.
 Abdominal exam
o Head is high, appears unduly large and does not descend into the pelvis despite good
contractions
 On vaginal examination
o Presenting part is high and may be to reach
o Anterior fontanelle may be felt on one side of the pelvis and the orbital ridges and the
root of the nose may be felt on the other side.
o A large caput may mask these landmarks if the woman has been in labour for a while
STEP 6: Care of a Woman Brow presentation (20minutes)
 Inform the doctor immediately if this presentation is suspected
 Vaginal delivery is very rare and obstructed labour usually results.
 When the brow reaches the pelvic floor, the maxilla rotates forwards and the head is born by a
mechanism similar to that of the occiput posterior
 Although this is the exception from the rule
 The mother should be warned about the possible course of labour and that a vaginal birth is
unlikely
 If there is no evidence of foetal compromise, the doctor may allow labour to continue for a short
while in case further extension of the head converts the brow presentation to a face
presentation
 Occasionally spontaneous flexion may occur, resulting in a vertex presentation.
 If the head fails to descend and the brow presentation persists, a caesarean section is
performed, with maternal consent.
 The mother will be given the normal pre operative care before caesarean section and then
taken to the operating theatre.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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
Preoperative care
o Inform the mother about the procedure and reassure to allay anxiety
o Check vital signs such as Blood pressure, pulse and respiration
o Intravenous infusion should be in situ
o Give IV ceftriaxone 1 g and IV metronidazole 500 mls.
o Insert an indwelling catheter to empty the bladder.
o Any valuables items are placed in safe keeping according to hospital policy
o Laboratory investigation such as hemoglobin, Grouping and cross matching
o Check urea and electrolyte levels and clotting factors
 Postoperative care
o Blood pressure and pulse every ¼ hour
o Temperature every 2 hours
o Inspect the wound every ½ an hour
o Inspect lochia (normally it should be small in amounts)
o Nurse the woman in the left lateral or recovery position until fully conscious since the
risk of regurgitation and silent aspiration of stomach contents is still present.
o Give analgesics as prescribed.
o If the mother opts to breastfeed, put the baby to the breast as soon as she recovers.
Breast feeding can be achieved with minimal disturbance to the mother
STEP 7: Complications of Abortion (15 minutes)
 Maternal complications
o Obstructed labour
o Maternal trauma
 Extensive perineal laceration may occur during delivery due to large
submental and biparietal diameters
 There is increased incidence of operative delivery either forceps or
caesarean delivery
 Foetal complications
o Facial bruising
o Cord prolapse
o Cerebral hemorrhage
STEP 8: Key Points (5 minutes)




Brow presentation is a cephalic presentation in which the head is midway between flexion and
extension
The presenting diameter is mentovertical (13.5cm).
This diameter exceeds all the diameters in an average pelvis.
It cannot be diagnosed before the onset of labour
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 9: Session Evaluation (5 minutes)
 What is brow presentation?
 What are the causes of brow presentation?
 What are the complications of brow presentation?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 26: CARE OF A WOMAN WITH FACE PRESENTATION
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define face presentation
 Describe causes of face presentation
 Explain mechanism of face presentation
 Explain the course and outcome of labour in face presentation
 Give care to the woman with face presentation
 Describe complications of face presentation
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
Definition of face presentation
1
05
Presentation of session title and learning tasks
2
05
3
05
Brainstorming
Presentation
Presentation
4
10
Lecture discussion
Mechanism of face presentation
5
10
Lecture discussion
Course and outcome of labour in face presentation
6
10
Lecture discussion
Care of the woman with face presentation
Causes of face presentation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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7
05
8
05
9
05
Presentation
Complicationsof face presentation
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Face Presentation (5 minutes)
Activity: Brainstorming (3 minutes)
ASK students to define face presentation
ALLOW time for them to respond
CLARIFY and provide summary using the content below:
Face presentation
 Face is a rare variety of cephalic presentation where the presenting part is the face.
 Face presentation is when the attitude of the head is one of the complete extensions, the
occiput of the foetus will be in contact with its spine and the face will present.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 3: Causes of Face Presentation (5 minutes)
 The actual cause is unknown.
 It can either be primary (occurs during pregnancy) or secondary (occurs during labour).
 Primary face is less common and it is usually due to foetal causes which may be:
o Anencephaly: due to absence of the bony vault of the skull and the scalp while the
facial portion is normal.
o Loops of the cord around the neck.
o Dolichocephalic head with long anteroposterior diameter
o Tumours of the foetal neck e.g. congenital goiter
o Increased tone of the extensor group of neck muscles
o Dead or premature foetus.
 Secondary face is more common and it may be due to:
o Contracted pelvis particularly flat pelvis which allows descent of the bitemporal but not
the biparietal diameterleads to extension of the head.
o Pendulous abdomen or marked lateral obliquity of the uterus.
o Further deflexion of brow or occipito - posterior positions.
o Other causes of malpresentations as polyhydramious and placenta praevia.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 4: Mechanism of face presentation (10 minutes)






The principal movements are like those of corresponding occipitoanterior position.
The exceptions are increasing extension instead of flexion and delivery by flexion instead of
extension of the head.
Engagement: The diameter of engagement is the oblique diameter, with the mentum related to
one ilio-pubic eminence to the opposite sacroiliac joint. The engaging diameter of the head is
submento-bregmatic 9.5 cm in fully extended head or submento-vertical 11.5 cm in partially
extended head. Engagement is delayed because of long distance between the mentum and
biparietal plane (7 cm). Descent with increasing extension occurs till the chin touches the
pelvic floor.
Internal rotation—Internal rotation of the chin occurs through 1/8th of a circle anteriorly,
placing the mentum behind the symphysis pubis. Further descent occurs till the submentum
hinges under the pubic arch.
Delivery of the head—The head is born by flexion delivering the chin, face, brow, vertex and
lastly the occiput.
The diameter distending the vulval outlet is submentovertical 11.5 cm. Restitution occurs
through 1/8th of a circle opposite to the direction of internal rotation. External rotation occurs
further 1/8th of circle to the same side of restitution so that ultimately the face looks directly to
the left thigh in LMA and right thigh in RMA. This follows delivery of the anterior shoulder
followed by the posterior shoulder and the rest of the trunk by lateral flexion.
STEP 5: Course And Outcome Of Labour In Face Presentation. (10 Minutes)


Antenatal diagnosis
o Antennal diagnosis is rare since face presentation develop during labour in majority of
cases.
Intrapatrum diagnosis
o On abdominal palpation
 Face presentation may not be detected especially if mentum is anterior.
 The occiput feels prominent, with a groove between head and the back, but it
may be mistaken for the sinciput.
 The limbs may be palpated on the side opposite to the occiput and the foetal
heart is best heard through the foetal chest on the same side as the limbs.
 In ment- posterior position the foetal heart is difficult to hear because the foetal
chest is in contact with the maternal spine
o On vaginal examination
 The presenting part is high, soft and irregular.
 When the cervix is sufficiently dilated, orbital ridges, eyes, nose and mouth
may be felt.
 Confusion between mouth and anus could arise, but the moth will be open,
and the hard gums.
 The foetus may suck the examining fingers.
 As the labour progresses the face becomes oedematous, making it more
difficult to distinguish from breech presentation.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
159



To determine position the mentum must be located and if it is posterior, the
midwife should decide whether it is lower than the sinciput, if so, it will rotate
forwards if it can advance.
In left mento anterior position, the orbital ridges will be in the left oblique
diameter of the pelvis.
Care must be taken not to injure or infect the eyes with the examining finger.
STEP 5: Care to the woman with face presentation (10 minutes)
 Overall assessment of the case is to be done
o Counseling and reassuring of the woman on the condition
o Should be kept on iv fluids and blood investigation be done
o Pelvic adequacy (clinical),
o size of the baby,
o associated complicating factors, if any, like elderly primigravidae, severe preeclampsia, postcesarean pregnancy and postmaturity,
o congenital fetal malformation
o position of the mentum.
 Indications of elective or early cesarean section:
o Contracted pelvis,
o Big baby,
o Associated complicating factors.
 Vaginal delivery
o MENTOANTERIOR
 First stage: In uncomplicated cases, a wait and watch policy is adopted. Labor
is conducted in the usual procedure and the special instructions, as laid down
in occipitoposterior positions, are to be followed.
 Second stage: One should wait for spontaneous delivery to occur. Perineum
should be protected with liberal mediolateral episiotomy.
o MENTOPOSTERIOR
 First stage: In uncomplicated cases, vaginal delivery is allowed with strict
vigilance hoping for spontaneous anterior rotation of the chin.
 Second stage: If anterior rotation of the chin occurs, spontaneous delivery
with episiotomy is needed. In incomplete or malrotation: Early decision for the
method of delivery is to be taken soon after full dilatation of the cervix.
 The following methods may be employed to expedite the delivery. Cesarean
section is the preferred method and is commonly done these days.
 Delay of labor, in all the stages, is common. The causes ar
o weak uterine contractions,
o Absence of moulding of the facial bones
o delayed engagement—the distance between the biparietal plane to chin is 7 cm and to
occiput is only 3 cm
o late internal rotation
 Birth of the head
o When the face appears at the vulva, extension must be maintained by holding back the
sinciput and permiting the mentum to escape under the symphyisis pubis before the
occiput allowed sweeping perineum. Because the perineum is distended by the the
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
160
parietal diameter an elective episiotomy may be performed to avoid extensiveperial
lacerations.
o If the head does not descend in the second stage the doctor should be informed for
further management.
STEP 6: Complications of Face Presentation (5 minutes)


Maternal—In mentoanterior, the maternal risk is not much increased. However,
o there is increased morbidity due to operative delivery and
o vaginal manipulation.
o In neglected cases, the risks of impacted ment-oposterior leading to obstructed labor
and ruptured uterus
o Chance of perineal damage is more because of a wide biparietal diameter—9.5 cm (3
3/4”) stretches the perineum and submento-vertical diameter
o Postpartum hemorrhage is more likely due to atonic uterus and trauma following
operative delivery.
o Obstructed labour
Fetal complications
o cord prolapse,
o increased operative delivery,
o cerebral congestion due to poor venous return from the head and neck and
o Neonatal infection due to bacterial contamination within the vagina.
STEP 7: Key Points (5 minutes)




Face is a rare variety of cephalic presentation where the presenting part is the face
It can either be primary (occurs during pregnancy) or secondary (occurs during labour).
The exceptions are increasing extension instead of flexion and delivery by flexion instead of
extension of the head.
In mento-anterior, the maternal risk is not much increased. However, there is increased
morbidity due to operative delivery
STEP 8: Session evaluation (5 minutes)


What are the causes of face presentation?
What are common complications of face presentation?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:Churchill
Livingston.
Konar, H. (Ed.). (2011). DC Dutta's Textbook of Obstetrics Including Perinatology and Contraception.
New Central Book Agency.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.).London: Churchill
Livingston.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers andmidwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric andnewborn care.
Dar es Salaam.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
161
SESSION 27: CARE OF A WOMAN WITH SHOULDER PRESENTATION
Total Session Time:
60minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:
 Define shoulder presentation
 Explain causes of shoulder presentation
 Assess for shoulder presentation
 Give pre and post-operative care to the woman
 Outline complications of shoulder presentation
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
Presentation of session title and learning tasks
2
05
Brainstorming/presentation Definition of shoulder presentation
3
05
Lecture discussion
Causes of shoulder presentation
4
10
Lecture discussion
Diagnosis of shoulder presentation
5
20
Lecture discussion
Pre and post-operative care to the woman with
shoulder presentation
6
05
Lecture discussion
Complications of shoulder presentation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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7
05
8
05
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Shoulder presentation (5 Minutes)
Activity: Brainstorming (2 minutes)
ASK students to define shoulder presentation
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below


Is when the fetus lies with its long axis across the long axis of the uterus (transverse lie) and
the shoulder is likely to present.
Or when the long axis of the fetus is approximately perpendicular (90°) to the long axis of the
mother
o Occasionally the lie is oblique but this does not persist as the uterus contractions
during labour make it longitudinal or transverse
o Shoulder of the fetus come in to lower uterine segment and lie over the pelvic inlet
o Head-in one iliac fossa/on one side of the abdomen
o Breech-in the other iliac fossa/with the breech at a slightly higher on the other side
o The feta back may be anterior or posterior
STEP 3: Causes of Shoulder presentation (5 Minutes)
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
163


Maternal factors
o Contracted pelvis as may prevent the head from entering the pelvic brim
o Lax abdominal and uterine muscles especially in multigravidae.
o Uterine causes as bicornuate, subseptate and fibroid uterus.
o Pelvic masses as ovarian tumours.
Foetal factors
o Multiple pregnancy
o Polyhydramious
o Placenta praevia
o Prematurity
o Intrauterine foetal death due to lack of muscle tones
STEP 4: Diagnosis of Shoulder Presentation ( 10 Minutes)


On abdominal examination
o The uterus appears broad/wide abdomen and the fundal height is less than
expected for the period of gestation.
o Fundus extends to only slightly above umbilicus
o On pelvic and fundal palpation neither head nor breech is felt.
o The mobile head is found on one side of the abdomen and the breech at a slightly
higher level on the other.
o But when the membranes have ruptured the irregular outline of the uterus is more
marked
o If the uterus is contracting strongly and becomes moulded around the foetus,
palpation is very difficult.
o The pelvis is no longer empty, the shoulder being wedged into it
On vaginal examination
o This should not be performed without first excluding placenta praevia
o In early labour the presenting part may be may not be felt as the lower uterine
segment is imperfectly filled
o Late in labor, the membranes usually ruptured early because of the ill-fitting
presenting part with a high risk of cord prolapse
o Then if the cervix is sufficiently dilated, scapula, acromion, clavical, axilla and ribs
can be felt.
o If possible to palpate the ribs, their characteristics grid-iron pattern being
diagnostic
STEP 5: Pre and Post Operative care of a Woman with Shoulder Presentation (10
Minutes)

There is no mechanism for delivery of shoulder presentation
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
164


Spontaneous delivery is impossible with a persistent transverse lie
If this persists in labour delivery must be by caesarean section to avoid obstructed labour and
subsequent uterine rupture

Preoperative care
o Inform the mother about the procedure and reassure to allay anxiety
o Check vital signs such as Blood pressure, pulse and respiration
o Intravenous infusion should be in situ
o Give IV ceftriaxone 1 g and IV metronidazole 500 mls.
o Insert an indwelling catheter to empty the bladder.
o Any valuables items are placed in safe keeping according to hospital policy
o Laboratory investigation such as hemoglobin, Grouping and cross matching
o Check urea and electrolyte levels and clotting factors
Postoperative care
o Blood pressure and pulse every ¼ hour
o Temperature every 2 hours
o Inspect the wound every ½ an hour
o Inspect lochia (normally it should be small in amounts)
o Nurse the woman in the left lateral or recovery position until fully conscious since the
risk of regurgitation and silent aspiration of stomach contents is still present.
o Give analgesics as prescribed.
o Monitor the condition of the baby as well
o If the mother opts to breastfeed, put the baby to the breast as soon as she
recovers.Breast feeding can be achieved with minimal disturbance to the mother

STEP 6: Complications of Shoulder Presentation (5minutes)



Neglected Shoulder presentation (Impacted shoulder)
o After rupture of membrane, labor continue
o Fetal shoulder is forced into the pelvis, the corresponding arm frequently prolapse
o After some descent, shoulder is arrested in pelvis, with the head is in the one iliac
fossa and breech in the other
o As labor continues, the shoulder is impacted firmly in the upper part of the pelvis
o Contracts vigorously
o After a time, a retraction ring rises increasingly higher
o If not promptly managed, uterine rupture, mother & fetus dies.
o So once diagnosed emergency caesarean section should be done
Cord prolapse
Prolapsed arm
o Occurs when the membrane have ruptured and e emergency caesarean section
should be done
STEP 8: Key Points (5 minutes)
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165



Shoulder presentation occurs when the fetus lies with its long axis across the long axis of the
uterus (transverse lie) and the shoulder is likely to present.
The lie is transverse ,though sometimes can appear oblique
The complication of shoulder presentation includes
o Neglected Shoulder presentation (Impacted shoulder
o Cord prolapse
o Prolapsed arm
STEP 9: Session Evaluation (5 minutes)
 What is shoulder presentation?
 What are the causes of shoulder presentation?
 What is the diagnosis of shoulder presentation?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
SESSION 28: CARE OF A WOMAN WITH UNSTABLE LIE AND
COMPOUND PRESENTATION
Total Session Time:
120 minutes
Prerequisite: None
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
166
Learning Tasks
At the end of this session a learner is expected to be able:
 Define unstable lie and compound presentation
 Explain the causes of unstable lie and compound presentation
 Explain complication unstable lie and compound presentation
 Explain how to diagnose unstable lie and compound presentation
 Give pre and post operative care to woman with unstable lie and compound presentation
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time
(min)
1
05
Activity/
Method
Presentation
Content
2
05
Brainstorming/presentation
Definitions of unstable lie and compound presentation
3
05
Lecture discussion
The causes of unstable lie and compound presentation
4
10
Lecture discussion
Complication unstable lie and compound presentation
5
10
Lecture discussion
Diagnose unstable lie and compound presentation
6
15
Lecture discussion
Pre and post operative care to woman with unstable lie
and compound presentation
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
Presentation of session title and learning tasks
SESSION CONTENTS
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
167
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definitions of Unstable Lie And Compound Presentation (5Minutes)
Activity: Brainstorming (3 minutes)
ASK students to brainstorm on the definitions of unstable lie and compound
presentation of the feotus.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below.


Unstable lie is a condition where the presentation of the fetus is constantly changed even
beyond 36th week of pregnancy when it should have been stabilized.
o Lie refers to the relationship between the longitudinal axis of the feotus and that of its
mother, which may be longitudinal, transverse or oblique.
Compound presentation is when a cephalic presentation is complicated by the presence of a
hand or a foot or both alongside the head or presence of one or both hands by the side of the
breech.
o The commonest one being the head with hand and the rarest one being the presence
of head, hand and a foot. The incidence is about 1 in 600. As in figure
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
168
Figure showing Compound presentation
STEP 3: The Causes of Unstable Lie and Compound Presentation (10 Minutes)


Causes of unstable lie: The causes are those which prevent the presenting part to remain
fixed in the lower pole of the uterus. Such conditions are:
o Grand multipara with lack of uterine tone and pendulous abdomen—commonest
cause,
o Hydramnios
o Contracted pelvis
o Placenta previa
o Pelvic tumor.
Causes of compound: Conditions preventing engagement of the head can result in slipping of
either upper or lower limbs by the side of the head.
o Prematurity (commonest),
o contracted pelvis, pelvic tumours,
o multiple pregnancy,
o macerated fetus,
o high head with premature or early rupture of the membranes and hydramnios are the
known etiological factors.
STEP 4: Complication Unstable Lie and Compound Presentation (10 Minutes)


Complications unstable lie: Cord entanglement is a possible risk.
o Risk of cord prolapse is there once the membranes rupture.
o Birth asyphyxia
o Operative delivery
o Perinatal death is high.
Compound presentation
o Foetal compilcations;
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
169
 Premature delivery
 Fresh still birth
 Sepsis
 Birth injuries
 Cord prolapse
o Maternal complication
o Operative deliveries
o Haemorrhage(PPH)
o Shoulder dystocia and shoulder presentation
o Chorioamnitis
STEP 5: Diagnose Unstable Lie and Compound Presentation (110 Minutes)


Diagnosis of unstable lie Unstable lie can be diagnosed after 32 weeks’ gestation and not
before, because before that period foetus can assume any position without being abnormal.
However, diagnosis can be made during labour, as the lie change from time to time.Unstable
lie is commonly found in multigravida of high parity (grand maltigravida) and polyhydramnious.
Diagnosis in compound presentation: The diagnosis is not difficult when the cervical os is
sufficiently dilated to feel the limb by the side of the presenting part, especially after rupture of
the membranes. Premature or early rupture of the membranes occurs in about one-third of the
cases. Cord prolapse is to be excluded because of its frequent association—10–15%.
STEP 6: Pre and Post Operative Care of Woman with Unstable Lie And Compound
Presentation (15 Minutes)




Unstable lie the woman is to be admitted at 37th week. Premature or early rupture of the
membranes with cord prolapsed is the real danger with the lie remaining oblique.
The mode delivery is preferable cesarean section, so if the woman not in labour elective
cesarean section is done in majority of the cases or emergency caesarean is planned.
Pre-operative care
o Counsell the woman on the condition and tell the mode of delivery
o Inserting canular for IV fluids and taking blood for haemoglobin and blood grouping and
cross-matching
o Catheterization of the patient
o Labeling the patient (name ward from, operation and site)
o Consent signing for the patient
o Check and record vital signs the morning before the patient is sent to theatre
o Escort the patient to theatre and hand her to the theatre nurse
Post-operative care
o Receive the patient and make sure she is safe
o Check and record the vital signs
o Observe the wound and note its safety
o Administer prescribed medications like strong analgesics to reduce pain, antibiotics,
blood transfusion if ordered
o Taking part in nursing process by charting vitals, intake and output
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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
o Turning the patient accordingly
o Considering early ambulation to the woman
Compound presentation
o Caring a woman with compound presentation the factors to be considered are:
 stage of labor,
 maturity of the fetus,
 singleton or twins,
 pelvic adequacy
 Associated cord prolapse.
o The indication of cesarean section in compound presentation Mature singleton fetus
associated with contracted pelvis or cord prolapse with the fetus alive
o During second stage of labour if midwife sees a hand out she should try to hold the
back towards the chest.
STEP 7: Key Points (5 minutes)




Unstable lie is a condition where the presentation of the fetus is constantly changed even
beyond 36th week of pregnancy when it should have been stabilized.
Compound presentation is when a cephalic presentation is complicated by the presence of a
hand or a foot or both alongside the head or presence of one or both hands by the side of the
breech.
Grand multipara with lack of uterine tone and pendulous abdomen is the commonest cause of
unstable lie.
In compound presentation conditions preventing engagement of the head can result in slipping
of either upper or lower limbs by the side of the head.
STEP 8: Session Evaluation (5 minutes)



What is unstable lie?
What are predisposing factors for unstable lie?
What are the complications of compound presentation?
References
Callahan, T., & Caughey, A. B. (2013). Blueprints obstetrics and gynecology (Vol. 6). Lippincott
Williams & Wilkins.
Konar, H. (Ed.). (2011). DC Dutta's Textbook of Obstetrics Including Perinatology and Contraception.
New Central Book Agency.
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care.
Elsevier Health Sciences.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 29: CARE OF A WOMAN WITH OCCIPITAL POSTERIOR
PRESENTATION
Total Session Time:
120 minutes
Prerequisite: None
Learning Tasks
At the end of this session a learner is expected to be able:
 Define Occipital Posterior Position
 Explain the cause of Occipital Posterior Position
 Explain the mechanism of labour in Occipital Posterior Position
 Explain the course and outcome of labour in Occipital Posterior Position
 Explain how to diagnose Occipital Posterior Position
 Give general care and delivery to a woman with Occipital Posterior Position
 Give care to a woman with deep transverse arrest.
 Give management of 3rd and 4th stage of labour
 Explain the complications of Occipital Posterior Position
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
2
10
Brainstorming/presentation Definitions of Occipital Posterior Position
3
10
Lecture discussion
Presentation of session title and learning tasks
The causes of Occipital Posterior Position
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
172
4
30
Lecture discussion
The mechanism of labour in Occipital Posterior
Position
5
25
Lecture discussion
The course and outcome of labour in Occipital
Posterior Position
6
25
Lecture discussion
Diagnosis of Occipital Posterior Position
7
30
Lecture discussion
General care and delivery of a woman with
Occipital Posterior Position
8
10
Lecture discussion
Care of a woman with deep transverse arrest.
9
10
Lecture discussion
Give management of 3rd and 4th stage of labour
10
10
Lecture discussion
The complications of Occipital Posterior
Position
11
05
Presentation
Key Points
12
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of the Occipital Posterior Position (10 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the definitions of Occipital posterior position.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below.

Occipito-posterior position is a vertex presentation where the occiput is placed posteriorly
over the sacroiliac joint or directly over the sacrum.
NB: When the occiput is placed over the right sacroiliac joint, the position is called right
occipito-posterior (ROP), traditionally called 3rd position of the vertex and when placed over the
left sacroiliac joint, is called left occipito-posterior (LOP), traditionally called 4th position of the
vertex (Fig. below) and when it points towards the sacrum, is called direct occipito-posterior.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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(Occipito-posterior is an abnormal position of the vertex rather than an abnormal presentation)
Figs (A) Right occipito-posterior position
(B) Left occipito-posterior position
STEP 3: The Cause of Occipital Posterior Position (10 Minutes)



In majority, the cause of the abnormal position is not clear.
The following are the responsible factors:
o Shape of the pelvic inlet: The shape of the inlet significantly determines the position of
the head at the onset of labor. In more than 50%, the occipito-posterior position is
associated with either an anthropoid or android pelvis.
o Fetal factors: Marked deflection of the fetal head, too often favors posterior position of
the vertex. The causes of deflexion are:
 High pelvic inclination.
 Attachment of the placenta on the anterior wall of the uterus—This favors the
well flexed fetus ovoid looking towards the anterior wall of the uterus, i.e.
remains in dorso-posterior position.
 Primary brachycephaly—This shortens the length of the lever from the frontal
to atlanto-occipital joint, and thereby diminishes the effective movement of
flexion.
Uterine factor: Abnormal uterine contraction which may be the cause or effect, leads to
persistent deflexion and occipito-posterior position.
STEP 4: The Mechanism of Labour in Occipital Posterior Position (30 Minutes)


The head engages through the right oblique diameter in ROP and left oblique diameter in LOP.
The engaging transverse diameter of the head is biparietal (9.5 cm) and that of anteroposterior
diameter is either suboccipitofrontal (10 cm) or occipitofrontal (11.5 cm).
Because of deflexion, engagement is delayed.

In Favorable Circumstances (90%)
Flexion: Good uterine contractions result in good flexion of the head. Descent
occurs until the head reaches the pelvic floor.
o Internal rotation of the head: As the occiput is the leading part, it rotates 3/8
th of a circle (135°) anteriorly to lie behind the symphysis pubis. As the neck
cannot sustain such amount of torsion, the shoulders rotate about 2/8th of a
o
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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
circle to occupy the right oblique diameter in ROP and the left oblique in LOP
with 1/8th of a circle torsion of the neck still left behind. Thus, the rest of the
mechanism is like that of right occipito-anterior in ROP and that of left occipitoanterior in LOP.
o Further descent and delivery of the head occurs like that of occipito-anterior
position
o Restitution: There is movement of restitution to the extent of 1/8th of a circle
in the opposite direction of internal rotation of the head.
o External rotation: The external rotation of the head occurs through 1/8th of a
circle in the same direction of restitution as the shoulders rotate from the
oblique to antero-posterior diameter of the pelvis
o Birth of the shoulders and trunk: The process of expulsion is the same as
that of occipit-oanterior.
In unfavorable circumstances: (Non-rotation or mal-rotation)—10%.
o In certain circumstances, the occiput fails to rotate as described previously.
o The causes are deflexion of the head,
 weak uterine contraction,
 faulty shape of the pelvis such as flat sacrum,
 prominent ischial spines or convergent side walls and weak pelvic floor
muscles.
 Big baby and immobility of the fetal trunk consequent to the drainage of liquor
amnii also contribute to faulty rotation.
o Incomplete forward rotation: In this condition, the occiput rotates through 1/8th of a
circle anteriorly and the sagittal suture comes to lie in the bispinous diameter.
Thereafter, further anterior rotation is unlikely and arrest in this position is called deep
transverse arrest.
o Non-rotation: Both the sinciput and the occiput touch the pelvic floor simultaneously
due to moderate deflexion of the head resulting in non-rotation of the occiput. The
sagittal suture lies in the oblique diameter. Further mechanism is unlikely and the
condition is called oblique posterior arrest.
o Malrotation: In extreme deflexion, the sinciput touches the pelvic floor first resulting in
anterior rotation of the sinciput to 1/8th of a circle and putting the occiput to the sacral
hollow. This position is termed as occipitosacral position. This is, in the true sense,
“Persistent Occipito-Posterior Position” (POP) of the vertex.
STEP 5: The Course and Outcome of Labour in Occipital Posterior Position (25
Minutes)


Unlike the occipitoanterior, the course of events in labour is likely to be modified in
occipitoposterior position. The average duration of both the first and second stage of labor is
increased.
First stage: There is tendency to delay.
o Engagement: Engagement is delayed due to:
 Persistence of deflexion of the head thereby increasing the diameter of
engagement
 The driving force transmitted through the fetal axis is not in alignment with the
axis of the inlet.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
175
o Membrane status: Deflexed head becomes ovoid and this cannot fit well the spherical
lower segment
 loss of ball valve action during uterine contraction
 Early rupture of the membranes and drainage of liquor.
o Uterine contraction: Because of ill fitting of the deflexed head to the lower uterine
segment, there is lack of stimulus for uterine contraction. This results in abnormal
uterine contraction with slow dilatation of the cervix. Pressure on the rectum by the
wide occiput results in premature desire of bearing down effort even in the first stage.
The patient, as a result, becomes exhausted. ( There is prolongation of the first stage).
 Second stage: the second stage is often delayed due to long internal rotation or malrotation,
with at times, arrest of the head. This may happen in android pelvis or in mid pelvic
contraction. If felt uncared for, arrest of the head may lead to obstructed labor.
 Third stage: There is increased incidence of postpartum hemorrhage and trauma of the genital
tract.
Step 6: Diagnose Occipital Posterior Position (20 Minutes)
Abdominal Examination
 Inspection: The abdomen looks flat, below the umbilicus.
 Palpation
o Fundal soft mass palpable
o Lateral palpation the findings are:
 The fetal limbs are more easily felt near the midline on either side.
 The fetal back is felt far away from the midline on the flank and often difficult to
outline clearly.
 The anterior shoulder lies far away from the midline.
o Pelvic palpation the findings are:
 The head is not engaged.
 The cephalic prominence (sinciput) is not felt so prominent as found in well
flexed occipito-anterior.
 In direct occipitoposterior; the small sinciput is confused with breech.
 Auscultation: The maximum intensity of the fetal heart sounds is heard on the flank and often
difficult to locate especially in LOP. However, in direct occipito-posterior, the FHS is distinctly
felt in the midline.
Vaginal Examination
 The findings in early labor are:
o Elongated bag of membranes which is likely to rupture during examination.
o The sagittal suture occupies any of the oblique diameters of the pelvis.
o Posterior fontanelle is felt near the sacroiliac joint
o The anterior fontanelle is felt more easily because of deflexion of the head and at
times, is felt at a lower level than the posterior one
 In late labor, the diagnosis is often difficult because of caput formation which obliterates the
sutures and fontanelles. In such cases, the ear is to be located and the unfolded pinna points
towards the occiput. Simultaneous assessment of the pelvis should be done.
NB:Imaging: Ultrasonography is rarely done. It is helpful to know the descent, attitude of the head
and its relation to the pelvic walls (position).
A
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 7: General Care and Delivery of A Woman With Occipital Posterior Position
(30 Minutes)







The underlying principles in the management of the occipitoposterior position are—
o early diagnosis,
o strict vigilance with watchful expectancy hoping for descent and anterior rotation of the
occiput and
o judicious and timely interference, if necessary.
Diagnosis and evaluation: After diagnosed OPP (mentioned earlier).
o The overall assessment of the woman should be done, the pelvic assessment is
mandatory. Pelvic adequacy is assessed clinically.
 Inclination of the pelvis,
 configuration of the inlet, sacrum,
 ischial spines and the side walls are to be noted.
First stage: In otherwise uncomplicated cases, the labor is allowed to proceed in a manner
similar to normal labor. The following are the special instructions:
o In anticipating prolonged labor, intravenous infusion line is sited and Ringer’s
solution drip is started.
o Progress of labor is judged by—
 progressive descent of the head
 rotation of the back and the anterior shoulder towards the midline
 increasing flexion of the head,
 position of the sagittal suture on vaginal examination and
 cervical dilatation.
o Weak pain, persistence of deflexion and non-rotation of the occiput are the triad
too often coexistent. In such a situation, oxytocin infusion is started for augmentation of
labor.
Indication of cesarean section:
o Arrest of labor (failure of rotation),
o incoordinate uterine action and
o fetal distress.
Second stage: In majority, anterior rotation of the occiput is completed and the delivery is
either spontaneous or can be accomplished by low forceps or ventouse.
In minority (unrotated and malrotated): Provided the fetal and maternal conditions permit,
one should take a watchful expectancy for the anterior rotation of the occiput and descent of
the head. In occipitosacral position, spontaneous delivery as face-to-pubis may occur. In such
cases, proper conduction of delivery and liberal episiotomy should be done to prevent complete
perineal tear.
Third stage: Because of prolongation of labor, tendency of postpartum hemorrhage can be
prevented by prophylactic intravenous oxycitocin 20 IU in 500mils of Ringers Lactate with the
delivery of anterior shoulder. Following vaginal operative delivery, meticulous inspection of the
cervix and lower genital tract should be made to detect any injury and the woman should be
counseled for hygiene including sitz bath with dettol.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP8:Care of A Woman With Deep Transverse Arrest(DTA). (15 Minutes)





The head is deep into the cavity; the sagittal suture is placed in the transverse bispinous diameter
and there is no progress in descent of the head even after 1/2–1 hour following full dilatation of the
cervix.
The arrest in occipito-transverse position may be the end result of incomplete anterior rotation
(1/8th of circle) of oblique occipitoposterior position, or it may be due to non-rotation of the
commonly primary occipito-transverse position of normal mechanism of labor.
Causes:
o Faulty pelvic architecture such as prominent ischial spines, flat sacrum and convergent
side walls,
o Deflexion of the head
o Weak uterine contraction,
o Laxity of the pelvic floor muscles.
Diagnosis:
o The head is engaged,
o The sagittal suture lies in the transverse bispinous diameter,
o Anterior fontanelle is palpable
o Faulty pelvic architecture may be detected.
Management: The fetal condition and pelvic assessment give the guide as to the line of
management (mentioned earlier).
o Vaginal delivery is found not safe (big baby and or inadequate pelvis): Cesarean section.
o Vaginal delivery is found safe (any of the methods may be employed):
 Ventouse—Excessive traction force should not be used
 Manual rotation and application of forceps
 Operative vaginal delivery for DTA should only be performed by a skilled
obstetrician. Otherwise cesarean delivery is always preferred.
STEP 9: Care Of 3rd And 4th Stage Od Labour(15 Minutes)
Third stage: It begins after expulsion of the fetus and ends with expulsion of the placenta and
membranes
(after-births). Following delivering a difficult labour of an OPP there is risk of:
 Uterine atony
 Cervical tear
 Perineal tear
During managing third stage of labour Im oxytocin 10IU is given, massaging the uterus,
controlled cord traction the placenta is delivered while IV fluids ringers lactate in situ.
Then asses the placenta and the perineum while helping the woman to massage the uterus.
Fourth stage: It is the stage of observation for at least 1 hour after expulsion of the after-births.
 During this period, general condition of the patient and the behavior of the uterus are to be
carefully monitored. Including checking vital signs( Pulse rate,blood pressure, temperature,
respiratory rate)
 Assess the perineum if any tear and cervical then repair bedside a 1st and 2nd degree perineum
tear ,in case there was an episiotomy should be repaired .
 If woman had significant bleeding blood for Haemoglobin and grouping and cross-matching
should be done
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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



Analgesics and prophylactics antibiotics should be given.
Counseling and reassurance to the woman should be done.
Counseling the woman to continue breastfeeding if the baby was alive, in case of FSB give
reassurance for future delivery and family planning
The woman to use sitz barth for perinal hygiene
STEP 10: The complications of Occipital Posterior Position (10 Minutes)


Maternal complication
o Operative deliveries
o Uterine rupture
o Haemorrhage(PPH)
o Perineum injury
o Cervical tear and uterine perforation
o Sepsis
o May lead to cervical incompetence to future pregnancies
Foetal compilcations;
o Increase operative delivery (Ventouse delivery)
o Superficial scalp abrasion
o Sloughing of the scalp
o Fresh still birth
o Birth asyphyxia
o Sepsis ( Neonatal infection due bacteria contamination during delivering )
o Birth injuries
STEP 11: Key Points (5 minutes)



Occipito-posterior position is a vertex presentation where the occiput is placed posteriorly over
the sacroiliac joint or directly over the sacrum
The shape of the pelvic inlet, fetal factors and uterine factors are main factors responsible for
the Occipital posterior position.
Ocipito-posterior per se is not an indication of cesarean section however pelvic inadequacy or
its unfavorable configuration, along with obstetric complications such as, pre-eclampsia, postcesarean pregnancy, big baby usually need cesarean section.
STEP 12: Session Evaluation (5 minutes)



What are the causes of occipital posterior position?
What is the course of labour in OPP?
What are the complications of OPP?
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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References
Callahan, T., & Caughey, A. B. (2013). Blueprints obstetrics and gynecology (Vol. 6). Lippincott
Williams & Wilkins.
Konar, H. (Ed.). (2011). DC Dutta's Textbook of Obstetrics Including Perinatology and Contraception.
New Central Book Agency.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers andmidwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric andnewborn care.
Dar es Salaam.
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care.
Elsevier Health Sciences.
SESSION 30:CARE OF A WOMAN WITH MULTIPLE PREGNANCY
Total Session Time:
120 minutes
Prerequisite
 Note
Learning Tasks
At the end of this session a learner is expected to be able:
 Define the term multiple pregnancy
 Explain types of multiple pregnancy
 Describe the method of delivery of a woman with multiple pregnancy
 Explain complications associated with multiple pregnancy
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Session Overview Box
Step Time (min)
1
2
05
10
Activity/
Method
Presentation
Brainstorming
Content
3
20
Presentation
Explanation on types of multiple pregnancy
4
40
Lecture discussion
Method of delivering a woman with multiple
pregnancy
5
35
Lecture discussion
complications associated with multiple pregnancy
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
Presentation of session title and learning tasks
Define the term multiple pregnancy
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Define the Term Multiple Pregnancy (10 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the defition of multiple pregnancy and twins pregnancy
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers if necessary:

When more than one fetus simultaneously develops in the uterus, it is called multiple
pregnancy.
o Simultaneous development of two fetuses (twins) is the commonest; although rare,
development of three foetuses (triplets), four fetuses (quadruplets), five fetuses
(quintuplets) or six fetuses (sextuplets) may also occur.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o Simultaneous development of two fetuses in the uterus is the commonest variety of
multiple pregnancies.
VARIETIES:
 Dizygotic twins—It is the most common (80%) and results from the
fertilization of two ova.
 Monozygotic twins (20%) results from the fertilization of a single ovum.
STEP 3: Explain Types of Twin Pregnancy (20 Minutes)
o This is to help identify whether the babies share a placenta and it is important because
babies who share a placenta have a higher risk of complications.
o Twins can be:
 Dichorionic diamniotic (DCDA) – if two eggs are fertilised or if one egg splits
soon after fertilisation, each baby has its own placenta with its own outer
membrane called a ‘chorion’ and its own amniotic sac (Dizygotic)
 Monochorionic diamniotic (MCDA) – if the fertilised egg splits a little later, the
babies share a placenta and chorion but they each have their own amniotic sac;
these babies are always identical(monozygotic)
 Monochorionic monoamniotic (MCMA) – much less commonly, the fertilised egg
splits later still and the babies share the placenta and chorion and are inside the
same amniotic sac; these babies are always identical; this is rare and carries
additional risks
STEP 4: Management of a Woman with Multiple Pregnancy ( 40 Minutes)
Antenatal Review:
o The successful outcome of a twin pregnancy is to make an early diagnosis.
o High index of clinical suspicion and thorough ultrasound examination are the keys to the
diagnosis.
o It is useful to make early diagnosis and to detect chorionicity, amniocity, fetal growth
pattern and congenital malformations.
o Antenatal services:o Diet: Increased dietary supplement is needed for increased energy supply than
that needed in a singleton pregnancy.
o Increased rest at home and early cessation of work is advised to prevent preterm
labor and other complications.
o Supplement therapy: (i) Iron therapy is to be increased (ii) Additional vitamins,
calcium and folic acid above those prescribed for a singleton pregnancy
o Interval of antenatal visit should be more frequent to detect at the earliest, the
evidences of anemia, preterm labor or preeclampsia.
o Fetal surveillance Assessment of fetal growth, amniotic fluid volume and AFI
o The woman may be admitted to hospital from 30th – 36th weeks to avoid pre-term
labour by providing rest
During labour:
 The twin pregnancy is considered a ‘high risk’; the patient should be confined in an equipped
hospital preferably having an intensive neonatal care unit.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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
Vaginal delivery is allowed when either the twins are or at least the first twin is with vertex
presentation.
 First stage of Labour
o The 1st stage tends to be longer than in single fetus due to the large size of the uterus
o Carry out routine observation and care of 1st stage
o The fetal heart rate sound should be auscultated by two midwives at the same time
o Lie and presentation of 1st twin should be found out
o Prepare to conduct delivery if 1st twin should be found out
o Inform the doctor when the 1st twin present by breech.
o After rupture of membranes perform per vaginal examination in order to:
 Exclude cord prolapse
 Detect presentation and presenting part of 2nd twin
o Prepare equipment at the end of 1st stage of labour.
 Second stage of labour
o Additional swabs, gauzes, cord tie and forceps, scissors, mucous extractor episiotomy
scissors plus the rest to be added to the delivery trolley
o Extra cots, identification bands, labeled number 1 and 2, extra clothes
o Equipment for resuscitation of the babies should be at hand to combat asphyxia
neonatorum if it should occur
o Syntocinon or Syntometrine 1ml should be drawn up in redness to be given after the
delivery of last baby or soon after delivery of the placenta
o Fetal Heart Rate should be checked continuously until delivery
o As soon as the first twin has been delivered, clamp the cord and cut, note the time,
clear the baby’s airway and identify the baby as twin one, handle the baby to the
assistant to continue with other management e.g. putting the baby in a warm towel
o Another assistant should perform abdominal palpation to diagnose lie, presentation
and position of 2nd twin o If longitudinal confirm lie, presentation and position by
vaginal examination
o Check fetal heart rate
o Rupture the 2nd bag of waters at the highest point of contraction
o Exclude cord prolapse.
o Deliver the baby, note the time and identify by no. 2
o Give oxytocino IV/IM within one minute of delivery of the second Twin
 Delivery of delayed 2nd Twin
o Re-assessment by abdominal examination,vaginal examination
o Oxytocin drip is administered if delay was due to hypotonic uterine action and aid
delivery of baby by vacuum extraction if the presentation is vertex.
 Management of the third stage:
o The risk of postpartum hemorrhage can be minimized by routine administration of
oxytocin 10 IU IM with the delivery of the anterior shoulder of the second baby.
o The placenta is to be delivered by controlled cord traction. It is a sound practice to
continue the oxytocin drip for at least one hour, following the delivery of the second
baby.
o A blood loss of more than average should be immediately replaced by blood
transfusion, already kept at hand.
o The patient is to be carefully watched for about 2 hours after delivery,multiple birth puts
an additional stress and strain on the mother as well as on the family members.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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o Mother should be given additional support at home to look after both the babies.
STEP 5: Complications Associated With Multiple Pregnancy (30 Minutes)
MATERNAL
 During pregnancy:
o Nausea and vomiting occurs with increased frequency and severity.
o Anemia is more due to increased iron and folate requirement by the two fetuses
Deficiency of folic acidleads to increased incidence of megaloblastic anemia.
o Preeclampsia (25%) is increased three times over singleton pregnancy. Exposure to
superabundance of chorionic villi is the possible explanation.
o Hydramnios (10%) is more common in monozygotic twins and usually involves the
second sac. It is perhaps due to increased renal perfusion with consequent increased
urinary output which may accompany the hypervolaemia in the larger twin.
o Antepartum hemorrhage may occur with slight increased frequency. The increased
incidence of placenta previa is due to the bigger size of the placenta encroaching on to
the lower segment. The separation of normally situated placenta may be due to
 increased incidence of preeclampsia
 sudden escape of liquor following rupture of the membranes of the
hydramniotic sac
 deficiency of folic acid and
 following delivery of the first baby due to sudden shrinkage of the uterine wall
adjacent to the placental attachment.
o Malpresentation is quite common in twins compared to singleton pregnancies.
o Preterm labor (50%) frequently occurs and the mean gestational period for twins is 37
weeks. (Over distension of the uterus, hydramnios and premature rupture of the
membranes are responsible for preterm labor).
o Mechanical distress such as palpitation, dyspnoea, varicosities and hemorrhoids
may be increased compared to a singleton pregnancy.
 During Labor
o Early rupture of the membranes and cord prolapse are likely to be increased due to
increased prevalence of malpresentation. Cord prolapse is five times more common
than in singleton pregnancy and is more common in relation to the second baby.
o Prolonged labor though theoretically expected, is practically not met with. This is
because of parous women with smaller babies.
o Increased operative interference is due to high prevalence of malpresentation with
its associated complications.
o Bleeding (intrapartum) following the birth of the first baby, may at times be alarming
and is due to separation of the placenta following reduction of placental site.
o Postpartum hemorrhage is the real danger in twins. It is due to:
 Atony of the uterine muscle due to overdistension of the uterus
 A longer time taken by the big placenta to separate
 Bigger surface area of the placenta exposing more uterine sinuses
 Implantation of a part of the placenta in the lower segment which is less
retractile.
 During puerperium:
o There is increased incidence of:
 Subinvolution—because of bigger size of the uterus
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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

Infection because of increased operative interference, pre-existing anaemia
and blood loss during delivery
Lactation failure—this is minimized by reassurance and giving her additional
support.
FOETAL
 Abortion
 Vanishing twin
 Preterm birth
 Fetal anomalies
 Discordant growth
 Intrauterine death of one fetus
 Twin transfusion syndrome
 Cord prolapsed
 Locked twins
 Increased perinatal mortality
STEP 6: Key Points (5 minutes)




Multiple pregnancy refers to the development of more than one foetus in utero.
The 1st stage tends to be longer than in single fetus due to the large size of the uterus.
Multiple pregnancies are at risk and should preferably be managed at facilities that have
ultrasound, theatres and facilities for the care of premature babies
Mother should be given additional support at home to look after both the babies
STEP 7: Session Evaluation (5 minutes)




What is multiple pregnancy?
What are the types of multiple pregnancies?
What is the differences between monozygotic and dyzagotic pregnancy.
What are the complications associated with multiple pregnancy?
References
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14th ed.). London:
Churchill Livingston
Duttas .D.C,Konar Hiralal.(Nov. 2013). Textbook of Obstetrics including Perinatology and
Contarceptives( 7th ed). New Delh: India
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 31: CARE OF A WOMAN WITH PUERPERAL SEPSIS
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define puerperal sepsis
 Outline predisposing factors of puerperal sepsis
 Identify causative organisms of puerperal sepsis
 Explain signs and symptoms of puerperal sepsis
 Describe the nursing care to a woman with puerperal sepsis
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
Definition of puerperal sepsis
Causative organisms of puerperal sepsis
1
05
2
05
3
05
Brainstorming
Presentation
Presentation
4
10
Buzzing
Presentation of session title and learning
objectives
Predisposingfactors of puerperal sepsis
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Presentation
5
10
Presentation
Signs and symptoms of puerperal sepsis
6
15
Presentation
Nursingcare to a woman with puerperal sepsis
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Puerperal Sepsis (5 minutes)
Activity: Brainstorming (3 minutes)
ASK students to define puerperal sepsis
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:
Puerperal sepsis
 Puerperal sepsis is defined as a genital tract infection resulted from bacterial invasion during or
after labour.
o This is still a major cause of maternal death if undetected or untreated.
STEP 3: Predisposing Factors of Puerperal Sepsis (5 minutes)
The predisposing factors for puerperal sepsis includes;
 Antepartum factors:
o Malnutrition and anemia
o Preterm labor
o Premature rupture of the membranes
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
187

o Chronic debilitating illness
o Prolonged rupture of membrane > 18 hours.
Intrapartum factors:
o Repeated vaginal examinations
o Prolonged rupture of membranes (> 18 hours)
o Dehydration and keto-acidosis during labor
o Traumatic operative delivery
o Hemorrhage during antepartum or postpartum
o Retained bits of placental tissue or membranes
o Placenta praevia - placental site lying close to the vagina
o Cesarean delivery
STEP 4: Causative Organisms of Puerperal Sepsis (10 minutes)
Activity: Buzzing (5 minutes)
TELL the students to pair up and discuss on the causative organisms of puerperal sepsis
ALLOW few students to respond and let other pairs to provide unmentioned responses
CLARIFY and summarize by using the information below
Causative Organisms
 Haemolytic streptococcus group A
o Are the most dangerous organism for the postpartum woman as they are able to
invade the blood stream
o However if treated promptly the infection can usually be brought under control
o Are very sensitive to certain antibiotics otherwise the spread of infection can be
controlled through infection prevention and control including; Scrupulous domestic
cleanliness, ventilation and dust control and proper application of aseptic and
antiseptic techniques
 Staphylococcal Infection
o This tends to be localized, and abscess formation is common, but fatal as septicemia
may occur
 Clostridium Welchii
o Occasionally found in the vagina and in the presence of bruised or necrosed tissue.
o May become aggressive and cause septicaemia
o Other features includes, haemolysis of red cells resulting to anaemia, anuria and death
 Escherichia Coli
o Genital urinary tract infection by this organism is usually confined to the uterus and
treatment and management give rise to foul smelling lochia
o Septicemia sometimes occurs
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STEP 5: Signs and Symptoms of Puerperal Sepsis (10 minutes)
The signs and symptoms of puerperal sepsis depends on the site of infection. The sites can be:
 Local infection (Wound infection)
 Uterine infection
 Extra uterine spread infection
Local infection (wound infection):
 There is slight rise of temperature, generalized malaise or headache,
 The local wound becomes red and swollen,
 Pus may form which leads to disruption of the wound. Whensevere (acute), there is high rise of
temperature with chills and rigor.
Uterine infection:
 Mild uterine infection
o There is rise in temperature and pulse rate.
o Lochial discharge becomes offensive and copious.
o The uterus is sub-involuted and tender.
 Severe uterine infection
o The onset is acute with high rise of temperature, often with chills and rigor
o Pulserate is rapid, out of proportion to temperature
o Lochia may be scanty and odorless
o Uterus maybe sub-involuted, tender and softer. There may be associated wound
infection (perineum, vagina or thecervix).
Extra uterine spread:
o Is evident by presence of pelvic tenderness (pelvicperitonitis), tenderness on the fornix
(parametritis), bulging fluctuant mass in the pouch of Douglas (pelvicabscess).
o Parametritis - The onset is usually about 7–10th day of puerperium.
 Constant pelvic pain
 Tenderness on eithersides on the hypogastrium
 Vaginal examination reveals an unilateral tender indurated mass pushing the uterus
tothe contralateral side
 Rectal examination confirms the induration specially extending along the uterosacral
ligament.
 Steady rise of spikytemperature with chills and rigor
 Intense pain
 Gradual deterioration of the general condition
o Pelvic peritonitis – The signs and symptoms include
 Pyrexia with increase in pulse rate
 Lower abdominal pain and tenderness.
 Vaginal examination reveals tenderness on the fornix and with the movement of the
cervix
 Collection ofpus in the pouch of Douglas is evidenced by swinging temperature,
diarrhea and a bulging fluctuant mass felt through theposterior fornix.
o General peritonitis – the signs and symptoms include
 High fever with a rapid pulse
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
189
 Vomiting
 Generalised abdominal pain
 Patient looksvery ill and dehydrated
 Abdomen is tender and distended. Rebound tenderness is often present.
o Septicemia- the signs and symptoms include
 There is high rise of temperature usually associated with rigor. Pulse rate is usually
rapid even afterthe temperature settles down to normal
 Blood culture is positive
 Symptoms and signs of metastatic infection in thelungs, meninges or joints may
appear.
STEP 6: Nursing Care to a Woman with Puerperal Sepsis (15 minutes)
The nursing care to a woman with puerperal sepsis includes the following:
 Set up an IV infusion and start Iv fluids
 Keep the woman in a semi sitting position to help drain of discharge from the uterus and vagina
 Start antibiotics such penicillin/ampicillin 2 grams every 6 hours and gentamycin 5 mg/kg body
weight every 24hours.
 Drug therapy may change depending on the progress of the patient and response to initial
treatment
 Administer analgesics
 In case of perineal or abdominal wound, the wound will be dressed with a damp dressing which
should be changed every 24 hours
 Monitor for vital signs including hydration and urinary output
 Regardless of the location of care, postpartum women and health care professionals should be
aware of how infection can be acquired and should pay particular attention to
 Effective hand washing techniques
 Adhere to accepted practices for aseptic techniques when in contact with wound care
 Use of gloves appropriately
STEP 7: Key Points (5 minutes)



Puerperal sepsis is an infection of the genital tract by organisms that is occurring within 14
days after child birth.
Aseptic techniques are very important to prevent cross infection.
Untreated puerperal sepsis can progress to septic shock resulting to death.
STEP 8: Session Evaluation (5 minutes)


What is puerperal sepsis?
What are the predisposing factors of puerperal sepsis?
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
190
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14th ed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.).London: Churchill
Livingston.
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric andnewborn care.
Dar es Salaam.
SESSION 32: CARE OF A WOMAN WITH PUERPERAL PSYCHOSIS
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define puerperal psychosis
 Explain the etiological factors of puerperal psychosis
 Outline clinical features of a woman with puerperal psychosis
 Describe the nursing care to a woman with puerperal psychosis
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
191
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
Brainstorming
Presentation
Presentation
Definition of puerperal psychosis
1
05
Presentation of session title and learning
objectives
2
05
3
05
4
10
Buzzing
Presentation
Clinicalfeatures of a woman with puerperal
psychosis
5
25
Presentation
Nursingcare to a woman with puerperal psychosis
6
05
Presentation
Key Points
7
05
Presentation
Session Evaluation
Etiological factors of puerperal psychosis
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Puerperal Psychosis (5 minutes)
Activity: Brainstorming (3 minutes)
ASK students to define puerperal psychosis
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
CLARIFY and provide summary using the content below:

Puerperal psychosis is a severe mental illness characterized by extreme difficulty in responding
emotionally to a newborn baby; it can even include thoughts of harming the child.
o Puerperal psychosis is the most severe form of postpartum affective disorder that tend
to show onset within two weeks postpartum.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
192
STEP 3: Etiological Factors of Puerperal Psychosis (5 minutes)







The causes of postpartum psychosis are not well understood.
The most important etiological factors for this condition are biological factors (neuroendocrine
and genetic)
It's possible that the abrupt shift in hormones after delivery could trigger the condition.
Some women will have suffered from a similar illness following the birth of a previous child.
Some women may have suffered from a non-postpartum bipolar affective disorder from which
they have long recovered.
Family history of bipolar illness.
Marked psychosocial adversity.
STEP
4: Clinical
Features
Activity:
Buzzing (5
minutes)of Puerperal Psychosis (10 minutes)
TELL the students to pair up and discuss on the clinical features of puerperal
psychosis
ALLOW few students to respond and let other pairs provide unmentioned
responses
CLARIFY and summarize by using the information below
















Puerperal psychosis is an acute, early onset condition.
Characteristically, the woman begins to complain of fatigue, insomnia, and restlessness and
can have episodesof tearfulness and emotional lability.
Sudden thoughts of throwing the baby or harming it in some way
Delusions (beliefs that have no basis in reality)
Hallucinations (seeing or hearing things that aren't there)
"Flat affect," or a lack of emotional response or blank facial expression
Difficulty responding emotionally to the baby
Difficulty sleeping beyond the normal interrupted sleep of new motherhood
Changes in appetite or eating
Irritability
Confusion
Agitation
An inability to bond with baby
Thoughts of suicide, or the belief that the baby or the family would be better off without the
mother
In extreme situations, a woman with postpartum psychosis may exhibit behaviors such as
staring off into space, muttering to herself, refusing to eat, or making seemingly irrational
statements.
The woman may be unable to attend to her own personal hygiene and nutrition and unable to
care for her baby.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
193
STEP 5: Care to a Woman with Puerperal Psychosis (20 minutes)
Care of a woman with puerperal psychosis involves the following:
 A woman with puerperal psychosis will almost always need to be admitted to a psychiatric
hospital setting.
 Hospital admission facilitates stabilisation of symptoms and initiation of medications with
ongoing monitoring by health professionals.
 Admission to a psychiatric setting with a mother and baby unit is preferable to enable continued
contact between mother and baby.
 Because mothers with puerperal psychosis can harm their infants,extra precaution is needed in
assessment and intervention.
 The nurseneeds to ask specifically if the mother has had thoughts about harmingher baby.
 Due to the high risk of suicide or infanticide, management of puerperal psychosis needs to be
ongoing, often for many weeks or months.
 Assessment and monitoring of the mother–infant interactionis a key part of care of both mother
and infant.
 Treatment with medication is essential.
 Antipsychotics and mood stabilizers such as lithium are the treatments of choice.
 Antidepressants should be used verycautiously in treating postpartum psychosis, even when
depressivesymptoms are present, because of the risk for precipitating rapidcycling.
 Because of potential risks to the breastfeeding infant,informed consent regarding the risks and
benefits of exposing thenewborn to a psychotropic agent and maternal mental illness mustbe
discussed and documented.
 It is usuallyadvantageous for the mother to have contact with her baby if she sodesires, but
visits must be closely supervised.
 Psychotherapy is indicatedafter the period of acute psychosis has passed.
 Mood stabilisers are used to treat manic episodes and psychotic symptoms and help reduce
relapse. Antipsychotics and antidepressants may also be of benefit, depending on the range of
symptoms.
 A psychiatrist should be consulted when medications are prescribed, changed or ceased, and
the potential risks and benefits to the woman and baby should be considered.
Medication should not be ceased suddenly.
 Given the need for medication and maximising sleep in women with puerperal psychosis, the
advantages and disadvantages of breastfeeding for mother and baby need to be discussed
with the woman and her partner.
 Sodium valproate and clozapine should not be used without consultation with a psychiatrist.
 Lithium should be used cautiously. Advice should be sought from a psychiatrist if
breastfeeding, and it is important to ensure close monitoring of the baby by a specialist (e.g.
neonatologist/paediatrician).
 A woman’s physical activity levels and diet need to be considered if she is taking antipsychotics
(due to their association with weight gain).
 Electroconvulsive therapy (ECT) may be used or even essential to treat acute mania,
psychosis and severe depression. This treatment is only used in major hospital settings, with
close monitoring of the woman.
 Psychological therapiescan assist women to develop effective coping strategies as they
recover.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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

Mother-infant therapy can be useful in promoting mother-infant bonding.
Counselling/support is also recommended for the partner and key support people.
STEP 6: Key Points (5 minutes)






It is rare, affecting approximately 0.1% to 0.2% of postpartum women.
Once a woman has had one episode of postpartum psychosis, she has a 30% to 50%
likelihood of recurrence with each subsequent birth.
The overwhelming majority of cases present in the first 14 days postpartum.
They rarely arise within 48 hours following birth and most commonly develop suddenly between
day 3 and day 7.
Because mothers with puerperal psychosis can harm their infants, extra precaution is needed
in assessment and intervention.
The nurse needs to ask specifically if the mother has had thoughts about harming her baby.
STEP 7: Session Evaluation (5 minutes)


What is puerperal psychosis?
What are the clinical features of puerperal psychosis?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13thed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15thed.). London: Churchill
Livingston.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones &BarteltPg 666-667.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
195
SESSION 33: CARE OF A WOMAN WITH BREAST INFECTION AND
MASTITIS
Total Session Time:
60 minutes
Prerequisites: None
Learning Tasks
At the end of this session a learner is expected to be able to:
 Define breast infection and mastitis
 Identify causes of breast infections
 Explain two types of mastitis
 Explain preventive measures of mastitis
 Explain complications of breast infections
 Explain the management of breast infection and mastitis
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
Definition of breast infection and mastitis
1
05
Presentation of session title and learning
objectives
2
05
3
05
Brainstorming
Presentation
Presentation
4
10
Presentation
Types of mastitis
5
05
Presentation
Preventive measures of mastitis
Causes of breast infection
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
196
6
05
Presentation
Complicationsof breast infections
7
15
Buzzing
Presentation
Managementof breast infection and mastitis
8
05
Presentation
Key Points
9
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Breast Infection and Mastitis (5 minutes)
Activity: Brainstorming (3 minutes)
ASK students to define breast infection and mastitis
ALLOW time for them to respond
CLARIFY and provide summary using the content below:
Breast infection
 Breast infections are usually caused by bacteria and the infection takes place in the fatty tissue
of the breast and causes swelling.
Mastitis
 Is painful inflammation of the breast, usually accompanied by an infection.
 Mastitis most commonly affects women who are breast-feeding (lactation mastitis).
STEP 3: Causesof Breast Infection (5 minutes)



Bacterial infection
o The cause of most breast infections is Staphylococcus aureus bacteria.
o The second most common cause is Streptococcus agalactiae.
o Bacteria from the baby’s mouth can enter and cause an infection.
Obstruction of a milk duct
o For breastfeeding mothers, a plugged milk duct can cause milk to back up and an
infection to begin.
Cracked nipples also increase the risk of breast infection.
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STEP 4: Types of Mastitis (10 minutes)
There are two types of mastitis namely Non-infective and Infective mastitis.
Non infective (acute intramammary) mastitis
 This condition results from milk stasis.
 It may occur during the early days as the result of unresolved engorgement.
 It occurs as a result of a poor feeding technique whereby the milk from one or moresegment of
the breast is not sufficiently emptied after breast feeding.
 It most frequently occurs in the breast that is opposite the mothers preferred side forholding the
baby.
Infective mastitis
 This is an infection of the breast caused by damage to the epithelium, which allowsbacteria to
enter the underlying tissues.
 The damage results from incorrect attachment of the baby to the breast which hascaused
trauma to the nipple.
 Infective mastitis if left untreated may lead to abscess (Breast Abscess).
 A cracked nipple will also let micro-organisms to into the breast.
STEP 5: Preventive measures of Mastitis (5 minutes)
The following measures may help prevent mastitis:
 Avoid sudden changes in feeding schedules.
 Avoid using soap and intense cleaning of the nipple. The areola has self-cleaning and
lubricating ability.
 Taking care to prevent irritation and cracking of the nipple
 Frequent breast-feeding and emptying at least one breast very well every feeding, and
alternate breasts.
 Avoiding tight-fitting bras that can dig in and impede natural milk flow.
 Massaging the breasts, especially if you feel a thickening or lump.
 Using a proper breast-feeding technique that allows for good latching by the infant
 Weaning the baby over several weeks, instead of suddenly stopping breast-feeding
STEP 6: Complications of Breast Infection (5 minutes)
The complications of breast infection includes:
 If the blocked milk ducts that occur in milk stasis become infected with bacteria, a woman is at
risk of forming a breast abscess.
 Chronic infection can result if an abscess is not completely drained.
 Women with abscesses may be told to temporarily stop breastfeeding.
 Undergoing surgical procedure to drain abscess that may result into scarring of the breast.
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198
STEP 7: Management of Breast Infection and Mastitis (15 minutes)
Activity: Buzzing (5 minutes)
TELL the students to pair up and discuss on management
ALLOW few students to respond and let other pairs to provide unmentioned responses
CLARIFY and summarize by using the information below
Management of breast infection and mastitis
 It is extremely important that breast feeding from the affected breast continues, toprevent milk
stasis which is ideal condition for pathogenic bacteria to replicate.
 Educate the mother to improve her feeding technique by allowing her baby to finish thefirst
breast first.
 A sample of breast milk is sent for bacteriological examination.
 A broad spectrum antibiotic is given until the causative organism is known.
 Breast feeding should be suspended if pus is found in the milk, and the breast is emptiedby the
gentle use of breast pump or hand expression.
 The breast must be gently and firmly supported by large pad of cotton wool to protect thepainful
infected area.
 Apply a warm, moist cloth to the affected area several times a day
 If the infection is mild, breast feeding may be continued.
 For babies who are difficult to attach:
o If the breast is engorged, gently manipulate the tissue that lies under the areola
toreduce oedema.
o Hand expression or the use of breast pump, may relieve fullness to the point where
thebaby can draw in the inner tissue to create necessary teat from the breast.
o If attachment is still difficult, ask the mother to lie on her side with a short edge of
apillow under her ribs to raise the breast off the bed.
o If attachment is still difficult despite of the measures above, teach the mother how
tohand express and how to give colostrum to her baby.
STEP 8: Key Points (5 minutes)




Breast infections are usually caused by bacteria and the infection takes place in the fatty tissue
of the breast and causes swelling.
Mastitis is is painful inflammation of the breast, usually accompanied by an infection.
There are two types of mastitis namely Non-infective and Infective mastitis.
In the majority of women, mastitis is the result of milk stasis, not infection although infection
maysupervene.
STEP 8: Session Evaluation (5 minutes)


What is mastitis?
What are the preventive measures of mastitis?
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London:Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives (14th ed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.).London: Churchill
Livingston.
Mbilu, J. N. K. (2010). Essentials of obstetrics and gynaecology for clinical officers andmidwives:
Obstetrics (2nd ed., Vol. 1). Dar es Salaam: Matai & Company Limited.
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric andnewborn care.
Dar es Salaam.
SESSION 34: CARE OF A WOMAN WITH UTERINE SUB-INVOLUTION
Total Session Time:
60 minutes
Prerequisites

None
Learning Tasks
At the end of this session, a learner is expected to be able to:





Define sub-involution of the uterus
Outline causes of sub-involution of uterus
Outline signs and symptoms of a woman with uterine sub-involution
Describe the care to a woman with uterine sub-involution
State complications of uterine sub-involution
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Content
1
05
Presentation
Presentation of session title and learning tasks
2
05
Presentation
Definition of uterine sub-involution
3
05
Lecture discussion
Causes of uterine sub-involution
4
05
Lecture discussion
Signs and symptoms of uterine sub-involution
5
25
Small group
discussion/Lecture
discussion
Care of a woman with uterine sub-involution
6
10
Lecture discussion
Complications of uterine sub-involution
7
05
Presentation
Key Points
8
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definition of Uterine Sub-involution (5 Minutes)

Uterine sub-involution is a condition after child birth in which the uterus does not return to its
normal pre-pregnant size.
o It occurs when the process of uterine contraction does not take place as it should and
is either prolonged or stops
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 3: Causes of Uterine Sub-involution (5 Minutes)









Retained products of conception
Uterine sepsis (endometriosis)
Retroversion causing congestion
Uterine myomas.
Antepartum over distension e.g. multiple pregnancy
Prolapse of the uterus,
Maternal ill health
Caesarean section
Urine stasis
STEP 4: Sign and symptoms of uterine sub-involution (5 Minutes)


Symptoms
o Abnormal lochial
o Discharge either excessive or prolonged
o Irregular or at times excessive uterine bleeding,
o Irregular cramp like pain in cases of retained products
o Rise of temperature in sepsis
Signs
o The uterus feels boggy and softer.
o Uterus does not decrease in size
o Fundal height remains stationary rather than descending.
STEP 5: Care Of A Woman With Uterine Sub Involution (25Minutes)
Activity: Small Group Activity (15 minutes)
DIVIDE students depending on the size of the class.
ASK students to explain how to care for a woman uterine sub-involution
ALLOW the groups to work together to come up with answers to the question above.
GIVE students an example, if necessary. For example, say “Give the woman antibiotics.”
ALLOW groups 10 minutes for this exercise.
ASK students to report back the care plan per group. The following part of the presentation
has more details about the care.
APPRAISE the students
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
PROVIDE feedback by summarizing the students’ answers
202
Care of a woman with uterine sub-involution









Give broad spectrum antibiotics treat any underlying infection
Catheterize the patient in order to rule out full bladder or urine stasis
Exploration of the uterus in retained products followed by the evacuation of the retained
products a
Give fluid infusions to replace fluid loss
Give uterotonics to help in uterine contraction after
o Emptying the bladder
o Evacuation of the retained products
Take blood for grouping and cross matching
Encourage the mother to maintain hygiene by sitz bath
Encourage the mother to take proper nutrition.
Encourage the woman to empty the bladder frequently
STEP 6: Complications of Uterine Sub-involution (5minutes)





Severe bleeding
Sepsis-septicaemiaAnaemia
Infertility
Can lead to hysterectomy
STEP 8: Key Points (5 minutes)




Uterine sub-involution is a condition after child birth in which the uterus does not return to its
normal pre-pregnant size.
Sub-involution occurs when the process of uterine contraction does not take place as it should
and is either prolonged or stops.
The process of involution may be hampered by retained placental fragments, myomata, or
infection
Giving the woman antibiotics is important to treat infection or as a prophylaxis
STEP 9: Session Evaluation (5 minutes)



What is uterine sub-involution
What are the sign and symptoms of uterine sub-involution
What are the complications of uterine sub -involution
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
203
References
Advanced life saving skills (2005) volume 2 reproductive child health section Dar-es -Salaam: Tanzania
Bennett V.R., & Brown L, K. (1996) Myles text book for midwives (14th ed)
Callahan, T., & Caughey, A. B. (2013). Blueprints obstetrics and gynecology (Vol. 6). Lippincott
Williams & Wilkins.
Dutta, D. C. (2004). Text Book of Obstetrics: Including Perinatology and Contraception. New central
book agency.
Diane, M.F., & Margaret, A.C. (2003). Myles Textbook for Midwives (14th ed). London: Churchill
Livingston.
El Mowafi, D. M.(2002) .Obstetric Simplified
Fraser, D.M., & Cooper, M.A. (2009). Myles text book for midwives (15th ed).London Churchill
Livingston
MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
Tanzania Nurses and Midwives Council. (2009). Nursing ethics: A manual for nurses. Dar es Salaam
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666667
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 35:CARE OF A WOMAN WITH VENOUS THROMBOSIS IN
PREGNANCY
Total Session Time:
Prerequisite :
120 minutes
None
Learning Tasks
At the end of this session a learner is expected to be able:
 Define venous thrombosis, thrombophlebitis, phlebothrombosis and pulmonary embolism
 Outline predisposing factors for venous thrombosis
 Identify signs and symptoms of venous thrombosis
 Explain the management of a woman with venous thrombosis
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
Activity/
Method
Presentation
Content
1
05
Presentation of session title and learning tasks
2
20
Brainstorming/presentation Definitions of venous thrombosis, thrombophlebitis,
phlebothrombosis and pulmonary embolism
3
20
Lecture discussion
Predisposing factors for venous thrombosis
4
15
Presentation
signs and symptoms of venous thrombosis
5
40
Lecture discussion
Care of a pregnant woman with venous thrombosis
6
05
Presentation
Key Points
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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7
05
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Definitions of Venous Thrombosis, Thrombophlebitis, Phlebothrombosis
and Pulmonary Embolism ( 20 Minutes)
Activity: Brainstorming (10 minutes)
ASK students to brainstorm on the definitions of venous thrombosis, thrombophlebitis,
phlebothrombosis and pulmonary embolism.
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below.
Pregnancy is generally considered a ‘hypercoagulable’ state with its pathogenesis not been described
but several mechanisms have been proposed including increased coagulation factors, endothelia
damage, and venous stasis.

Definitions;
o A venous thrombus (thrombi) is a blood clot (thrombus) that forms within
a vein. Thrombosis is a term for a blood clot occurring inside a blood vessel. A
common type of venous thrombosis is a deep vein thrombosis (DVT), which is a
blood clot in the deep veins of the leg.
o Thrombophlebitis is inflammation of a vein caused by a blood clot. It typically occurs
in the legs. A blood clot is a solid formation of blood cells that clump together.
o Phlebothrombosis occurs when a blood clot (thrombosis) in a vein (phlebo) forms
independently from the presence of inflammation of the vein (phlebitis) or thrombosis
of a vein without prior inflammation of the vein; associated with sluggish blood flow (as
in prolonged bed rest or pregnancy or surgery) or with rapid coagulation of the blood.
o Pulmonary embolism (PE) occurs when a pulmonary artery becomes blocked—
usually by a blood clot that has broken free from its site of origin and embolized or
migrated to the lungs. If misdiagnosed, unrecognized, or untreated, PE can cause
death quickly.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
206
STEP 3: Predisposing Factors for Venous Thrombosis (20 Minutes)




Risk factors for venous thrombosis are
o Vascular stasis,
o Hyper coagulability of blood,
o Vascular endothelial trauma (Virchow’s triad 1856).
NB: Virchow's triad or the triad of Virchow describes the three broad
categories of factors that are thought to contribute to thrombosis.
Other pregnancy specific risk factors are as mentioned below:
o Venous thrombo-embolic diseases include:
 Deep vein thrombosis (ileofemoral).
 Thrombophlebitis (superficial and deep veins)
 Pulmonary embolus.
Pathophysiology of venous thrombosis can explain the risk factors:
o In a normal pregnancy there is rise in concentration of coagulation factors I, II, VII, VIII,
IX, X,XII and plasma fibrinolytic inhibitors are produced by the placenta and the level of
protein S is markedly (40%) decreased can increase the chance of thrombosis
o (Alteration in blood constituents—increased number of young platelets and their
adhesiveness.
o Venous stasis is increased due to compression of gravid uterus to the inferior vena
cava and iliac veins. This stasis causes damage to endothelial cells and may caus
thrombosis.
o Thrombophilias are hypercoagulable states in pregnancy that increase the risk of
venous thrombosis. It may be inherited or acquired:
 Inherited thrombophilias are the genetic conditions associated with the
deficiencies of antithrombin III, protein C, and protein S. Others are factor V
Leiden mutation and hyperhomocysteinemia.
 Acquired thrombophilias are due to the presence lupus anticoagulant and
antiphospholipid antibodies.
Other acquired risk factor for thrombosis are;
o Advanced age and parity
o Operative delivery
o Obesity
o Anemia
o Heart disease
o Infection-pelvic cellulitis
o Trauma to the venous wall
o Cancer: Some forms of cancer increase substances in blood that cause blood to clot.
Some forms of cancer treatment also increase the risk of blood clots.
o Inflammatory bowel disease: Bowel diseases, such as Crohn's disease or ulcerative
colitis, increase the risk of DVT
o Immobility
o Smoking,
o Prior DVT or PE.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
207
STEP 4: Signs and Symptoms of Venous Thrombosis (15 Minutes)
Deep vein thrombosis signs and symptoms can include:
 Swelling in the affected leg. Rarely, there's swelling in both legs.
 Painful in affected leg. (The pain often starts in calf and can feel like cramping or soreness)
 Red or discolored skin on the leg.
 A feeling of warmth in the affected leg.
NB: Deep vein thrombosis can occur without noticeable symptoms.
The warning signs and symptoms of a pulmonary embolism include:





Sudden shortness of breath
Chest pain or discomfort that worsens when you take a deep breath or when you cough
Feeling lightheaded or dizzy, or fainting
Rapid pulse
Coughing up blood
STEP 5: Care of A Pregnant Woman With Venous Thrombosis (40 Minutes)
Care of the pregnant woman with venous thrombosis should start from diagnosis of the condition.
Clinical diagnosis is unreliable. In majority it remains asymptomatic.
However pain in the calf muscles, swelling of legs and rise in skin temperature, difference in
circumference between the affected and the normal leg more than 2 cm may be significant. These
investigations may help a proper care:




Doppler ultrasound to detect the changes in the velocity of blood flow in the femoral vein by
noting the alteration of the characteristic ‘whoosh’ sound which is audible from a patent vein
Venography by injecting nonionic water soluble radiopaque dye to note the filling defect in the
venous lumen is a reliable method, if carefully interpreted. Venogram is restricted in pregnancy;
due to the risk of radiation and contrast allergy
Magnetic resonance imaging (MRI) is found superior to VUS and equivalent to contrast
venography in the diagnosis of DVT. The sensitivity and specificity of MRI in the diagnosis of
DVT is 100 percent and the accuracy is 96 percent.
Full Blood count shows polymorphonuclear leucocytosis.
Preventive measures for venous thrombosis:
Women at risk of venous thromboembolism during pregnancy have been grouped into different
categories depending on the presence of risk factors. Thrombo prophylaxis to such a woman depends
on the specific risk factor and the category.
 A low risk woman has no personal or family history of VTE. Such a woman need no
thromboprophylaxis will need the following preventive measures;
o Prevention of trauma, sepsis, anemia in pregnancy and labour. Dehydration during
delivery should be avoided.
o Use of elastic compression stocking and intermittent pneumatic compression devices
during surgery.
o Leg exercises, early ambulation are encouraged following operative delivery.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
208

A high risk woman is one who has previous VTE or VTE in present pregnancy, or
antithrombin–III deficiency.
o Such a woman needs low molecular weight heparin prophylaxis throughout pregnancy
and postpartum 6 weeks.
o Women with antithrombin-III deficiency can be treated with antithrombin-III concentrate
prophylactically.
Imminent care to a woman with venous thromboembolism
 The patient is put to bed rest with the foot end raised above the heart level.
 Pain on the affected area may be relieved with analgesics.
 Appropriate antibiotics are to be administered.
 Anticoagulants—
o Heparin 15,000 units are administered intravenously followed by 10,000 units, 4–6
hourly for four to six injections when the blood coagulation is likely to be depressed to
the therapeutic level. Heparin is continued for at least 7–10 days or even longer if
thrombosis is severe. Prolongation of activated partial thromboplastin time (APTT) to
1.5–2.5 times indicate effective and safe anticoagulation.
 Low molecular weight heparin (LMWH), can be used safely in pregnancy.
Enoxaparin 40 mg daily is given. It does not cross the placenta.
 A drug of coumarin series—warfarin is commonly used orally with an overlap
of at least three days with heparin. The initial daily single dose of 7 mg for 2
days is adequate for induction.
 Subsequent maintenance dose depends upon international normalised ratio
(INR) which should be within the range of 2.0–3.0.
 The daily maintenance dose of warfarin is usually 5–9 mg to be taken at the
same time each day. The anticoagulant therapy should be continued till all
evidences of the disease have disappeared which generally take 3–6 months.
 The anticoagulant should not prevent the mother from breast-feeding.
 As soon as the pain subsides, gentle movement is allowed on bed by the end of first week.
High quality elastic stockings are fitted on the affected leg before mobilization..
 Fibrinolytic agents like streptokinase produce rapid resolution of pulmonary emboli.
 Venous thrombectomy is needed for massive illiofemoral vein thrombosis or for massive
pulmonary embolus.
Nursing care for a woman with pulmonary embolism includes:
 Prevent venous stasis by encourage ambulation and active and passive leg exercises to
prevent venous stasis.
 Monitor thrombolytic therapy and anticoagulant therapy through INR or PTT.
 Manage pain
 Manage oxygen therapy
 Relieve anxiety.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
209
STEP 6: Key Points (5 minutes)




Pregnancy is generally considered a ‘hypercoagulable’ state which increase coagulation
factors, and venous stasis.
Thrombosis is a term for a blood clot occurring inside a blood vessel. A common type
of venous thrombosis is a deep vein thrombosis (DVT), which is a blood clot in the deep veins
of the leg.
Risk factors for venous thrombosis are Vascular stasis, Hyper coagulability of blood and
Vascular endothelial trauma
Encouraging ambulation and active and passive leg exercises will prevent venous stasis.
STEP 7: Session Evaluation (5 minutes)
 What are the predisposing factors for venous thrombosis?
 What are prevent measures to a low risk pregnant woman with suspected venous thrombosis?
 Can you list the warning signs of pulmonary embolism?
References
Kozek-Langenecker, S. A. (2011). New anticoagulants: perioperative considerations. Wiener
Medizinische Wochenschrift, 161(3-4), 63-67.
Chiu, J. J., & Chien, S. (2011). Effects of disturbed flow on vascular endothelium: pathophysiological
basis and clinical perspectives. Physiological reviews, 91(1), 327-387.
Callahan, T., & Caughey, A. B. (2013). Blueprints obstetrics and gynecology (Vol. 6). Lippincott
Williams & Wilkins.
Konar, H. (Ed.). (2011). DC Dutta's Textbook of Obstetrics Including Perinatology and Contraception.
New Central Book Agency.
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care.
Elsevier Health Sciences.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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SESSION 36: CARE OF A WOMAN WITH URINE INCONTINENCE
Total Session Time:
120 minutes
Prerequisite
 Note
Learning Tasks
At the end of this session participants are expected to be able:
 Define urine incontinence, stress incontinence and vesico-vagina fistula
 Classification of urine incontinence
 Identify predisposing factors of stress urine incontinence and Vesico-vagina fsitula
 Outline signs and symptoms of stress urine incontinence and vesico-vagina fistula
 Explain the management of a woman with incontinence and vesico-vagina fistula
Resources Needed:




Flip charts, marker pens, and masking tape
Black/white board and chalk/whiteboard markers
LCD Projector and computer
Note Book and Pen
Session Overview Box
Step Time (min)
1
05
Activity/
Method
Presentation
Content
2
10
Brainstorming
Define the term Urine incontinence, stress
incontinence, vesico-vagina fistula
3
15
Presentation
Classification of urinary incontinence
4
25
Lecture discussion
Identification of predisposing factors for stress
urinary incontinence vesco-vagina fistula
5
20
Lecture discussion
signs and symptoms of stress urine incontinence
and vesico-vagina fistula
Presentation of session title and learning tasks
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
211
6
30
7
10
8
05
Lecture discussion
Management of a woman with stress urinary
incontinence and vesico-vagina fistula
Presentation
Key Points
Presentation
Session Evaluation
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK participants to read the learning tasks
ASK participants if they have any questions before continuing
STEP 2: Define the term Urine incontinence (10 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm definitions of



Urine incontinence
Stress urine incontinence
Vesco-vagina fistula
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as below.



Urinary incontinence is the involuntary leakage of urine or person cannot prevent urine from leaking
out. Urinary incontinence is more common among women than men. An estimated 30 percent of
females aged 30-60 are thought to suffer from it.
Stress urine incontinence, also known as effort incontinence, is due essentially to insufficient strength
of the pelvic floor muscles to prevent the passage of urine, especially during activities that increase
intra-abdominal pressure, such as coughing, sneezing, or bearing down.
Vesico-vaginal fistula or VVF, is an abnormal opening tract extending between the bladder (or vesico)
and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
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STEP 3: Classification of Urine Incontinence (15 Minutes)
Urinary incontinence is defined as objectively demonstrable involuntary loss of urine so as to cause
hygienic and/or social inconvenience for day to day activity. Urinary insentience can be classified as
urethral or extra-urethral.


Urethral classification;
o Urge incontinence is a condition where there is a frequent feeling of needing
to urinate to a degree that it negatively affects a person's life.
o Stress incontinence due to poor closure of the bladder (also known as stress urinary
incontinence (SUI) or effort incontinence. It is due to insufficient strength of the closure
of the bladder.
o Overflow incontinence due to either poor bladder contraction or blockage of the
urethra (characterized by the involuntary release of urine from an overfull urinary
bladder, often in the absence of any urge to urinate. This condition occurs in people
who have a blockage of the bladder outlet or when the muscle that expels urine from
the bladder is too weak to empty the bladder normally.
o Functional incontinence due to medications or health problems making it difficult to
reach the bathroom (is a form of urinary incontinence in which a person is usually
aware of the need to urinate, but for one or more physical or mental reasons they are
unable to get to a bathroom.
Extra-urethral classification;
o Acquired urinary incontinence e.g vesco-vagina fistula and other fistulas.
o Congenital like ectopic ureter.
STEP 4: Predisposing Factors for Stress Urinary Incontinence Vesco-Vagina
Fistula (25 Minutes)


Stress urinary incontinence its pathogenesis is strictly an anatomic problem.
o In the normal continent woman, the bladder neck and the proximal urethra are intraabdominal and above the pelvic floor in standing position.
o Normally the urethral pressure exceeds that of intravesical pressure. So when there is a
descent of the bladder neck and proximal urethra which normally lies above the urogenital
diaphragm, hinders rise of intraurethral pressure during straining leading to incontinence.
The following are the predisposing factors of stress urinary incontinence:
o Developmental weakness of the supporting structures maintaining the bladder neck and
proximal urethra in position. There may be genetic variations in collagen and other
connective tissues which normally maintain anatomic and physiologic aspect of the vesicourethral unit.
o Childbirth trauma causing damage of the pelvic floor and pubocervical fascia. The injury is
more common in gynecoid and least in android pelvis.
o Pregnancy—It is probably functional in nature and related to high level of progesterone
o Postmenopausal—Estrogen deficiency leads to atrophy of the supporting structures along
with diminished periurethral vascular resistance.
o Trauma—Injury to symphysis pubis due to fracture or following symphysiotomy.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
213
o Following surgery like anterior colporrhaphy, local repair of VVF or bladder neck surgery,
there may be fibrosis of the urethra and urethral musculature.
o Age: Although stress incontinence isn't a normal part of aging, physical changes
associated with aging, such as the weakening of muscles, may make you more susceptible
to stress incontinence
o Body weight: People who are overweight or obese have a much higher risk of stress
incontinence. Excess weight increases pressure on the abdominal and pelvic organs.

Vesco-vagina fistula: There is communication between the urinary bladder and the vagina and the
urine escapes into the vagina causing true incontinence .This is the commonest type of
genitourinary fistula.The following are the predisposing factor for VVF:
o Obstetrical factors;
 Obstructed labour this is the commonest one, about 80-90% causes obstetric
fistula.
 Instrumental vagina delivery such as destructive delivery and forceps delivery
 Abdominal operations such as hysterectomy following ruptured uterus or
caesarean section from a previous caesarean section
o Gynaecological factors; though are very rare in developing countries.
 Operative injury likely to produce fistula includes operations like anterior
colporrhaphy, abdominal hysterectomy for benign or malignant lesion
 Traumatic—the anterior vaginal wall and the bladder may be injured following fall
on a pointed object, by a stick used for criminal abortion, following fracture of
pelvic bones or due to retained and forgotten pessary.
 Malignancy—Advanced carcinoma of the cervix, vagina or bladder may produce
fistula by direct spread.
 Radiation—Following malignancy treatment, apart from overdose or
malapplication, it may occur even with accurate therapy. It takes usually long time
(1–2 years to produce such fistula.
 Infective—Chronic granulomatous lesions such as vaginal tuberculosis,
lymphogranuloma venereum, schistosomiasis or actinomycosis may produce
fistula.
STEP 5: Signs and Symptoms of Stress Urine Incontinence and Vesico-Vagina
Fistula (20 Minutes)

Stress Urinary Incontinence;
o Symptoms: The only symptom is escape of urine with coughing, sneezing or laughing.
The loss of urine has got the following features
 Brief and coincides precisely to the period of raised intra-abdominal pressure.
 Un-associated with a desire to pass urine.
 Rarely, occurs in supine position or during sleep.
 Patients are fully aware of it.
 The amount of loss is small
o A woman with stress urinary incontinence she may experience urine leakage when:
 Cough, sneeze, laugh, stand up, get out of a car, lift something heavy, exercise,
have sex.
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium
214

Vesco-vagina Fistula(VVF);
o Symptoms
 Continuous escape of urine per vaginum (true-incontinence) is the classic
symptom. The patient has got no urge to pass urine.
 There is associated pruritus vulvae/ vagina itching.
o Signs
 Escape of watery discharge per vaginum of ammoniacal smell is characteristic.
 Evidences of sodden and excoriation of the vulval skin.
 Varying degrees of perineal tear may be present
STEP 6: The Management Of A Woman With Stress Urinary Incontinence And
Vesico-Vagina Fistula (30Minutes)
Stress urinary incontinence
Management of stress urinary incontinence is divided into preventive and definitive
Preventive management:



Avoiding repeated childbirth trauma and delaying second stage of labour
Proper monitoring of labour and proper assessment of the mother in labour to avoid neglected
obstructed and prolonged labour
Counselling the mother to avoid overweight and obesity
Definitive management: It is also divided into conservative and surgical management and the
principles for definitive are, restoration of the function of the muscles of urethrovesical junction and
strengthening the support of the urethra.
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Conservative management;
o To improve the pelvic floor muscles by counselling and training the mother to do a pelvic
muscle exercises this will strengthen the muscular part of pelvic floor muscles.(The pelvic
floor muscles training are in the form of drawing up the anus and tightening the vagina for
stopping micturition) This should be done about 100 times a day for several months.
o Use of vaginal devices ; pessaries ring for bladder neck support
o Use of vagina cone
o Electrical stimulation activation of the pelvic floor muscles by stimulation of pudendal
nerves.
o Diet control in obese
o Use of drugs;
 Estrogen use in postmenoposal woman may be useful and improve pelvic
muscle strength
 Impramine (10-25)mg or Ephedrine (15-30)mg twice daily may be of effective
Surgery—The principles of surgery are:
o Restoration of normal anatomy to maintain bladder neck and proximal urethra as
intraabdominal structures. So that it lies within the abdominal pressure zone
o Strengthening the support of bladder neck and proximal urethra. This prevents the
funneling of vesicourethral junction in response to raised intravesical pressure.
o To increase the functional urethral length.
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Surgery for Stress urinary incontinence may be vaginal (anterior colporrhaphy) or abdominal
(elevation of the bladder neck) or combined.
Vesical-vagina fistula ; Management a woman with VVF is of preventive and operative.
 Preventive: Obstetric fistula in the developing world can be prevented with safe motherhood
initiative (WHO-1987). Women with obstetric VVF is considered as a ‘near-miss’ maternal death.
Gynecological fistula—can be prevented with better anticipation and improved surgical skill. The
following preventive measures:
o Adequate antenatal care is to be extended to screen out ‘at risk’ mothers likely to develop
obstructed labor.
o Anticipation, early detection (partograph) and ideal approach in the method of delivery in
relieving the obstruction.
o Continuous bladder drainage for a variable period of about 5–7 days following delivery
either vaginally or abdominally in a case of longstanding obstructed labor.
o Care to be taken to avoid injury to the bladder during pelvic surgery—obstetrical or
gynecological.
o Immediate management: Once the diagnosis is made, continuous catheterization for 6–8
weeks is maintained. This may help spontaneous closure of the fistula tract. Unobstructed
outflow tract helps epithelialization, provided the tissue damage is minimum.
o The management of genitourinary fistula needs a team approach both by the
gynecologists, nursing staff and the urologists. These socially neglected women need
realistic counseling. Other-wise treatment failure may cause further devastation.
 Operative: local repair of the fistula is the surgery of choice. So preoperative assessment,
preoperative preparations and definitive surgery should be considered.
o Preoperative Assessment
 Fistula status—Assessment is done as regards the site, size, number, mobility
and status of the margins of the fistula.
 Urethral involvement is assessed by introducing a metal catheter through
external urethral meatus into the bladder.
 To ascertain the position of the ureteric openings in relation to a big fistula,
cystoscopy is indicated.
 Some blood investigations like FBC, urea and creatinine (renal function)
estimation are done.
o Preoperative Preparations
 As the patients are usually from poor socioeconomic status, and socially neglect
the improvement of the general condition is essential prior to surgery.
 Local infection in the vulva should be treated by application of silicone barrier
cream or glycerine and general vulva bathing is important.
 Urinary infection, if any, should be corrected beforehand. It is difficult to collect
urine for culture and sensitivity. It is preferable to collect
 It is advised to start urinary antiseptics at least 3–5 days prior to surgery.
Definitive surgery
 Time;
o The ideal time of surgery is after 3 months following delivery. By this time, the general
condition improves and local tissues are likely to be free from infection.
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o Further delay is likely to produce more fibrosis and unnecessary prolongs the misery of
the patient.
o Early repair may compromise the success.
o Surgical fistula if recognized within 24 hours, immediate repair may be done provided it
is small. Otherwise it should be repaired after 10–12 weeks.
o Radiation fistulae should be repaired after 12 months.
STEP 7: Key Points (5 minutes)
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Stress urine incontinence, also known as effort incontinence, is due essentially to insufficient
strength of the pelvic floor muscles to prevent the passage of urine, especially during activities
that increase intra-abdominal pressure, such as coughing, sneezing, or bearing down.
Vesico-vaginal fistula or VVF, is an abnormal opening tract extending between the bladder
(or vesico) and the vagina that allows the continuous involuntary discharge of urine into
the vaginal vault.
Stress Urinary Incontinence;
o Symptoms: The only symptom is escape of urine with coughing, sneezing or laughing.
The loss of urine has got the following features
Vesco-vagina Fistula(VVF);
o Symptoms
 Continuous escape of urine per vaginum (true-incontinence) is the classic
symptom. The patient has got no urge to pass urine.
Stress urinary incontinence
o Management of stress urinary incontinence is divided into preventive and definitive
Vesical-vagina fistula ; Management a woman with VVF is of preventive and operative
STEP 8: Session Evaluation (5 minutes)
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What is urine incontinence?
What is the similarity between stress urinary incontinence and vesico-vagina fistula?
Give the classification of urine incontinence.
What are the predisposing factors of stress urine incontinence?
What are preventive measures of vesico-vagina fistula?
References
Bennett, V. R., & Brown, L. K. (1999). Myles’ textbook for midwives (13th ed.). London: Churchill
Livingston.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Duttas .D.C, Konar Hiralal.(Nov. 2013). Textbook of Obstetrics including Perinatology and
Contraceptives ( 7th ed). New Delh: India
MOHSW. (2010). Learning resource package for basic emergency obstetric and newborn care. Dar es
Salaam
MOHSW. (2005). Advanced life saving skills (Vol. 2). Dar es Salaam.
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MOHSW-RCHS. (2010). Learning resource package for basic emergency obstetric and newborn care.
Dar es Salaam.
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