RSS Feed for the unit 11. Assessing the Fetus

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In this study session, we turn our attention to the physical examination of the mother in order to find out about the position and health of her baby. You will learn how to examine the mother’s abdomen in order to determine whether the fetus is lying head up, head down, or sideways in her uterus. Listening to the fetal heartbeat can also give you information about the baby’s position and its wellbeing. At the end of the study session we guide you about what to do if you suspect that the baby’s position may lead to a difficult or dangerous birth, or if you suspect the woman may be having twins.

Learning Outcomes for Study Session 11

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

11.1 Define and use correctly all of the key words printed in bold. (SAQ 11.1)

11.2 Know how to identify normal and abnormal lie of the fetus using palpation and auscultation. (SAQs 11.1 and 11.2)

11.3 Know how to assess fetal well-being by auscultation and fetal kick. (SAQs 11.1, 11.3 and 11.4)

11.4 Identify fetal conditions that require referral to the nearest health centre. (SAQ 11.4)

11.1 Finding the baby’s position in the uterus

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The position of the baby in the uterus is known as the fetal lie. The purpose of finding the fetal lie is to identify whether there are any danger signs that could make labour and delivery difficult and put the mother and baby at risk.

Healthy signs

There is only one baby in the uterus.
The baby is head down at the time of birth.

Warning signs

The baby is feet or bottom down at the time of birth.
The baby is lying sideways at the time of birth.
The mother has twins or triplets. You already know how to listen for two fetal heartbeats (Study Session 10).

There are two methods for finding the baby’s position — feeling the mother’s abdomen (palpation), and listening (auscultation) to where the fetal heartbeat is strongest. You may need to use both methods to be sure of the position of the baby.

Auscultation is pronounced ‘oss kool tay shun’.

11.2 Feeling the mother’s abdomen

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

It may be difficult to find the position of the baby before the sixth or seventh month of gestation, and it is not important until 36 weeks (eight months) because it is normal for the baby to move around until the final month. Once the pregnancy is at six or seven months, it will be easier to feel the baby and find its position in the uterus.

To begin, help the mother lie on her back and give her support under her knees and head. Make sure she is comfortable. The questions you are trying to answer when you examine her are:

Is the baby vertical (up and down)? This is known as a vertical lie.
Or is it lying sideways across her belly? This is a transverse lie.
Is the baby facing the mother’s front, or her back?
Is the baby head down (cephalic presentation) or bottom down (breech presentation)?

11.2.1 Is the baby vertical?

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Most babies are lying vertically by the seventh month, with the baby’s head towards the cervix of the uterus. This is the safest position for a normal delivery. To find out if the baby is vertical, lay one hand flat on each side of the mother’s abdomen. Press in gently but firmly, first with one hand, and then with the other (Figure 11.1a). Check the shape carefully. Do the ends of the baby seem to be in the mother’s sides (Figure 11.1b)? If so, the baby is probably lying sideways. Many babies lie sideways in the first months, but most turn head down by eight months or so. Babies cannot be born through the vagina from the sideways position. A baby that is sideways and cannot be turned when labour starts must be born by caesarean surgery in a hospital.

If the baby is lying sideways after eight months’ gestation, refer the woman to a Health Centre.

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Figure 11.1 (a) Feel the mother’s belly with your hands on each side, pushing gently with each hand in turn. You should be able to feel the baby lying vertically — ideally head down. (b) If the baby is lying sideways, you can usually feel its head and bottom in the mother’s sides.

It can be difficult to feel the position of the baby if the mother has very strong muscles on her abdomen, or if she has a lot of fat on her abdomen. If you have a hard time feeling the position, ask the mother to take a deep breath and let it out slowly, and to relax her body as you palpate (feel) her abdomen.

11.2.2 Is the baby facing the mother’s front, or her back?

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Next, feel the mother’s abdomen for a large, hard shape (the baby’s back). If you can feel it (Figure 11.2a), the baby is facing the mother’s back. If you cannot feel the baby’s back, feel for a lot of small lumps (Figure 11.2b). If you feel a lot of small lumps instead of a large, hard shape, it probably means that you are feeling the baby’s arms and legs, which tell you that it is facing the mother’s front.

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Figure 11.2 (a) If you can feel a large hard lump, the baby is facing towards the mother’s back. (b) If you can feel a lot of small lumps, the baby is facing towards the mother’s front.

11.2.3 Is the baby head down or bottom down?

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Figure 11.3 (a) Cephalic presentation. (b) Breech presentation.

By the last month before birth, most babies are lying with their head towards the cervix of the uterus (Figure 11.3a). The head down position is called a cephalic presentation, and if the part of the fetal skull called the vertex comes down the birth canal first, it is the easiest presentation for childbirth. Doctors and midwives refer to the part of the baby that is pointing into the cervix of the uterus as the presenting part. In Figure 11.3a, the presenting part is the baby’s head, and in Figure 11.3b, the presenting part is the baby’s bottom. You will learn about other presentations (face, brow, shoulder) in the Module on Labour and Delivery Care.

Which part of the fetal skull is the vertex? (Think back to Study Session 6. You may wish to look again at Figure 6.5, which shows the bones of the fetal skull.)
The vertex is the area of the fetal skull midway between the anterior fontanel (the space between the bones at the front of the baby’s head), and the posterior fontanel (the space between the bones at the back of the baby’s head).

11.2.4 Feeling for the baby’s head

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Figure 11.4 Finding the mother’s pubic bone with your fingers.

By the seventh or eight month, the baby’s head has usually moved down in the mother’s pelvis. Here is how to feel for the baby’s head:

1 Find the mother’s pubic bone with your fingers. You can feel it just under the skin under the mother’s pubic hair (Figure 11.4).

2 As she breathes out, press deeply just above her pubic bone (see Figure 11.5). Be gentle and stop if you hurt her. If you feel a round, hard object that you can move a little from side to side, it is probably the back or side of the baby’s head.

If you do not feel anything in the mother’s lower belly, the baby may be lying sideways.

Figure 11.5 Press firmly with your fingers just above the pubic bone to see if you can feel the baby’s head.

3 If the shape is not clearly round, it may be the baby’s face or the baby’s bottom that you can feel. Or sometimes the baby’s bottom is up, but the head is not straight down (Figure 11.6a and b). The head may be bent to the side, or the chin may be up (Figure 11.6c). These could be signs that the baby will not fit through the mother’s pelvis at birth.

Figure 11.6 If the baby is lying vertically and head down, but you can’t feel the baby’s head, it may be bent to the side (a) facing the mother’s back, (b) facing her front, or (c) with its chin up.

4 If the lower part of the baby is not too deep in the mother’s pelvis, try moving that part of the baby from side to side, using gentle rocking movements with your hands on either side of the lower part of her abdomen (Figure 11.7). If moving the lower part of the baby makes its whole back move, then the baby may be breech. If the back does not move, then the baby may be head down.

Figure 11.7 If the baby’s back does not move when you ‘rock’ the lower part of the abdomen, then the baby may be head down.

5 Now feel the top of the mother’s uterus (the fundus), just below her ribs. Does it feel round and hard, like a head? Or is it a different shape — like a bottom, a back, or legs? If the top of the uterus feels more like a head than what you felt in the mother’s lower belly, the baby may be breech.

6 Put one hand on the baby’s back. At the same time, with your other hand, push the top end of the baby gently sideways (Figure 11.8). If the whole of the baby’s back moves when you move the top end, the baby is probably in the head-down position (Figure 11.8a). If the back stays where it is while you move the upper part of the baby (Figure 11.8b), you may be moving the head. This is because the neck can bend while the back stays in place. If you are moving the head at the top of the uterus, then the baby is breech.

Figure 11.8 (a) If the baby is head down, then you should be able to move its whole back by gently pushing the top of the baby sideways. (b) If you can move the top of the baby without moving its back, then it is probably in the breech position.

7 When you check the baby’s position, you might think you feel two heads or two bottoms. The mother may have twins.

Think back to Study Session 10. What should you do if you suspect that a woman is having twins?
Refer the mother to a health centre immediately.

11.2.5 Asking the mother about the baby’s kicks

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Doctors and midwives refer to fetal kick (not kicks) as an indicator of fetal wellbeing, and it may also indicate the fetal lie.

As you feel the mother’s abdomen, try to imagine the different positions the baby might be in. Imagine where the baby’s hands and legs might be. Imagine how each position would feel to the mother when the baby kicks. Then ask the mother where she feels the strongest kicks and where she feels smaller movements. Is this where you think the legs and hands probably are (see Figure 11.9)?

Figure 11.9 The place where the mother feels the strongest kicks may tell you the position of the baby’s feet and legs.

Refer the woman to a health centre if she no longer feels the baby kicking inside her.

If the baby is healthy and getting adequate nutrients from the mother, it moves in the uterus in such a way that the woman feels it as a kick. Fetal kick is often clearly felt after the mother has eaten a meal, and when she has rested very well and is lying on her side.

If the woman tells you the baby is not moving as it used to, or is not moving at all, it could be sick or it may have died.

11.3 Listening for the baby’s heartbeat

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The baby’s heartbeat gives information about the baby’s position inside the mother, and about the health of the baby. Listen to the heartbeat at each antenatal visit, starting at five months. Doctors and midwives often refer to the fetal heartbeat.

By the last two months of pregnancy, you can often hear the fetal heartbeat in a quiet room by putting your ear on the mother’s abdomen (Figure 11.10a). The heartbeat will be easier to hear if you have a stethoscope (Figure 11.10b) or a fetoscope (Figure 11.10c and d). If you don’t have a fetoscope, you can make a simple one from wood, clay, or a hollow tube of bamboo.

Figure 11.10 Listening to the fetal heartbeat with (a) your ear on the mother’s abdomen, or (b) with a stethoscope, or (c) and (d) with a fetoscope.

The fetal heartbeat is quiet and quick. It may sound like a watch ticking under a pillow, only faster. The fetal heartbeat is about twice as fast as a healthy adult heartbeat — usually 120 to 160 beats a minute. There is no need to count the heartbeats until the woman goes into labour. Hearing a clear fetal heartbeat during an antenatal visit just confirms that the baby is alive.

If you hear a ‘swishy’ sound (shee-oo, shee-oo, shee-oo), you are probably hearing the baby’s pulse in the umbilical cord. Cord sounds tell you how fast the baby’s heart is beating, but they do not help you find the baby’s position.

If the heartbeat sounds slow, you are probably hearing the mother’s pulse instead of the baby’s. Try listening to a different place on her abdomen.

11.3.1 Finding the baby’s position by listening to the heartbeat

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Figure 11.11 The baby’s heartbeat is loudest in its upper chest or upper back, depending on which way the baby is facing.

Think about which way the baby seems to be lying. Then start listening for the heartbeat near the spot where you think the baby’s heart should be. You may need to listen in many places on the mother’s abdomen before you find the spot where the heartbeat is the most loud and clear (Figure 11.11).

Is the heartbeat loudest above or below the mother’s bellybutton? If you hear the heartbeat loudest below the mother’s bellybutton, the baby is probably head down (Figure 11.12a). If you hear the heartbeat loudest above the mother’s bellybutton, the baby may be in the breech position (Figure 11.12b).

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Figure 11.12 (a) If the fetal heartbeat is loudest below the mother’s bellybutton, the baby is probably in the vertex position. (b) If it is loudest above her bellybutton, the baby may be breech.

Sometimes when the baby is facing the mother’s front, the heartbeat is harder to find because the baby’s arms and legs get in the way. Listen near the mother’s sides, or directly in the middle of her abdomen, to hear the fetal heartbeat.

11.4.1 Baby is breech

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Breech babies are often born without any trouble, especially if the mother has had other children and her births were easy. But breech babies are more likely to get stuck, or have other serious problems.

If the baby is breech at 36 weeks (8 months), refer the woman to a health centre. Don’t try to turn a breech baby (see Box 11.1).

Box 11.1 Don’t try to turn a breech baby!

Only a midwife, health officer or physician who has been trained to turn a breech baby should try to do so, and it should be done in a hospital. Trying to turn the baby by pushing on the uterus is very dangerous. Even a midwife, health officer or physician should not try to turn a baby if the mother’s water has broken, or if she has had vaginal bleeding, high blood pressure, surgery on her uterus, or caesarean surgery.

If the baby is not head down when labour starts, it is safer for the mother to give birth in a hospital. The midwife, health officer or physician can use forceps (pulling tools) if the baby gets stuck. Or they can do a caesarean surgery.

11.4.2 Baby is lying sideways

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Sideways babies cannot fit through the mother’s pelvis to be born (Figure 11.13). If you try to deliver the baby without surgery, the mother’s uterus will rupture during labour, and she and the baby will die without medical care. If the baby turns head down at any time — even on the day the mother goes into labour — it is OK for her to give birth at home or at the Health Post.

A baby lying sideways must be delivered by caesarean surgery in a hospital. Do not attempt to turn a sideways baby by hand. This is just as dangerous as trying to turn a breech baby, and should be done only by a doctor in a hospital.

Figure 11.13 If the baby is lying sideways (transverse lie) by eight months, you should make arrangements for a hospital birth by caesarean surgery.

11.4.3 Twins

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Think back to what you learned in Study Session 10 about twin pregnancy.

What are the three signs of twin pregnancy?
The uterus grows faster or larger than normal. You can feel two heads or two bottoms when you feel the mother’s belly. You can hear two heartbeats (this is not easy, but it may be possible in the last few months).

What are the two ways to try to hear the heartbeats of twins?
Find the heartbeat of one baby. Ask a helper to listen for other places where the heartbeat is easy to hear, and both of you tap the rhythm of the heartbeats.
Use a watch to help you count the two heartbeats.

11.5 After the antenatal check-up

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

After you have finished checking the fetus and the mother, and following the instructions for any warning signs, find out if the woman has any more questions, or needs to talk about anything else. If she has any warning signs, carefully explain what the warning sign is, and what she must do to care for herself. If this is a return antenatal check-up, evaluate what you did for her at the previous check-up. Decide what else you may need to do for her. If she needs to be referred to a higher-level health facility, be sure she knows where and when to go.

11.6 Conclusion

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In this session, you have learned how to examine the abdomen of a pregnant woman so that you can determine the position of the baby, its presenting part (head or bottom, or whether it is lying sideways), and how to check the wellbeing of the fetus by listening to the fetal heartbeat and asking the mother about fetal kick.

Summary of Study Session 11

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 11, you have learned that:

It is reassuring to find one baby in the uterus and that the head of the fetus is down in the last month of pregnancy. Most babies are lying vertically by the seventh month with their head towards the cervix of the uterus. By the seventh or eighth month, the baby’s head has usually moved down in the mother’s pelvis. This is the safest position for a normal delivery.
In any other situation, i.e. the baby is bottom down (breech), or lying sideways (transverse), refer the mother to the nearest health facility. Do not attempt to turn a breech or transverse baby.
The position in the mother’s abdomen where she can feel the baby kicking can help you determine its position. Fetal kick is also a sign of fetal health. If the baby stops kicking it may be sick or have died, and the mother needs urgent referral.
The baby’s heartbeat gives information about the baby’s position inside the mother, and whether it is alive. Hearing two heartbeats is a sign of twins. Listen to the heartbeat at each antenatal visit, starting at five months.
By the last two months of pregnancy, you can often hear the baby’s heartbeat in a quiet room by putting your ear on the mother’s belly. The heartbeat will be easier to hear if you have a stethoscope or a fetoscope.
The normal fetal heart rate is usually about 120 to 160 beats per minute.

Self-Assessment Questions (SAQs) for Study Session 11

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 11.1 (tests Learning Outcomes 11.1, 11.2 and 11.3)

Which of the following statements is false? In each case, say why it is incorrect.

A Listening to the fetal heartbeat using a stethoscope is called auscultation.

B When the fetal head is down and the bottom of the fetus is up in the fundus, it is called a vertical lie.

C In a vertex presentation, the presenting part is the baby’s bottom.

D The fetal heart rate is normally 120 to 160 beats a minute.

E If the fetal heartbeat sounds loudest below the mother’s bellybutton, the fetal lie is probably breech.

Answer

A True. Listening to the fetal heart beat using a stethoscope is called auscultation.

B True. When the fetal head is down and the bottom of the fetus is up in the fundus, it is called a vertical lie.

C False. In a vertex presentation, the presenting part is the baby’s head.

D True. The fetal heart rate is normally 120 to 160 beats a minute.

E False. In a breech presentation, the fetal heartbeat sounds loudest above the mother’s bellybutton.

Read the following case study carefully, and then answer SAQs 11.2 to 11.4.

Case Study 11.1 Bekelech

Bekelech came for her antenatal check-up at the eighth month of pregnancy. When you palpated her abdomen, you found a hard, round mass in the fundus of the uterus, and a soft, irregular, bulky mass towards the symphysis pubic. Bekelech told you that in the past week the baby’s kick had decreased, and when you listened to her abdomen with a fetoscope you could not hear the fetal heartbeat.

SAQ 11.2 (tests Learning Outcome 11.2)

Is the fetal lie in Bekelech’s case vertical or transverse? Explain how you reached your conclusion.
What is the presenting part in this case?
What do you call a fetus presenting in such a manner?

Answer

The hard, round mass in the fundus of the uterus is most likely to be the baby’s back, and the soft irregular shapes towards the pubic symphysis are its arms and legs. This is a vertical lie.
The bottom is the presenting part.
This is called a breech presentation.

SAQ 11.3 (tests Learning Outcome 11.3)

Where would you listen to the fetal heartbeat to confirm your diagnosis of how Bekelech’s baby is presenting, and why?

Answer

You would listen for the fetal heartbeat above Bekelech’s bellybutton because, if the baby is breech, its heartbeat will sound loudest there. (Look again at Figure 11.12 if you are not sure why this is so.)

SAQ 11.4 (tests Learning Outcomes 11.3 and 11.4)

What do you suspect is the condition of Bekelech’s baby, and what action should you take?

Answer

The baby may be sick, or even dead, because Bekelech says it isn’t kicking and you can’t hear a fetal heartbeat. You should refer her to a health facility immediately.

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Bleeding after 28 weeks of gestation is considered to be late pregnancy bleeding. You learned about early pregnancy bleeding before 28 weeks in Study Session 20. Late pregnancy bleeding is also referred to as antepartum haemorrhage (APH) by doctors and midwives. It is an important cause of maternal and fetal death and needs the attention of a highly skilled heathcare provider at the earliest time possible in order to save the life of the woman and her unborn baby.

‘Antepartum’ is Latin for ‘before birth’; ‘haemorrhage’ is pronounced ‘hemm-orr-edge’ and means severe loss of blood.

As the first contact provider for pregnant women in your community, you have to work with them on birth preparedness and making a complication readiness plan to address such eventualities as severe bleeding in pregnancy. You must provide obstetric first aid and then make sure that a woman with late pregnancy bleeding can reach a health facility where she can get urgent help. A District Hospital or Health Centre with the ability to perform obstetric operations can save her life.

Learning Outcomes for Study Session 21

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

21.1 Define and correctly use all of the keywords printed in bold. (SAQs 21.2 and 21.3)

21.2 Describe the warning signs and the common causes of late pregnancy bleeding. (SAQs 21.1, 21.2 and 21.3)

21.3 Provide obstetric first aid and know when to make an urgent referral of a woman with late pregnancy bleeding. (SAQs 21.1 and 21.2)

21.1 What causes late pregnancy bleeding?

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The most common causes of late pregnancy bleeding, or ante-partum haemorrhage (APH), are due to bleeding from the placenta, but there are other less common causes arising in the uterus or other parts of the reproductive tract. First, we will list the causes briefly, and then describe placental abruption, placenta previa and ruptured uterus in detail, because these are conditions that require your immediate life-saving intervention.

Placental abruption: this condition occurs if the placenta pulls away prematurely (too soon) from its normal attachment site in the top two-thirds of the uterus.
Placenta previa: this condition is when the placenta has attached too low down in the uterus, very close to, or even covering, the cervix.
Ruptured uterus: this can occur during a prolonged or obstructed labour when the uterus, after a long effort to expel the fetus, gives way and tears or bursts.
Ruptured varicose vein in the genital area: this can occur if a vein becomes twisted and dilated. As a result, it can easily be traumatised and bleed, usually during labour and delivery.
Heavy show: the mucus mixed with bloody fluid that comes from the birth canal at the start of labour is called the show; sometimes, when this mucus plug detaches it may be followed by brisk and heavy bleeding called a heavy show, which often stops on its own without any intervention. But she should always be referred.

21.2 Placental abruption

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Placental abruption refers to the premature separation of the whole or part of a placenta which is implanted in the upper two-thirds of the uterus. Normally the placenta only separates from the uterus after the delivery of the fetus, in the third stage of labour (you will learn all about this in the module on Labour and Delivery Care). The mother and the baby may die if the place where the placenta pulled away from the wall of the uterus starts to bleed a lot.

Why is it likely that placental abruption will result in a lot of bleeding, and why does this pose a serious risk to the mother and the fetus? (Think back to what you learned about the structure of the placenta in Study Session 5, or look again at Figure 5.5 in Antenatal Care, Part 1.)
the mother’s blood flows into large spaces in the placenta which lie close to the fetal blood vessels (Figure 5.5). If the placenta tears away from the wall of the uterus, the mother’s blood will flow out into the cavity of the uterus and she could die from the loss of blood. The supply of oxygen and nutrients from her blood to the fetus will be reduced, so it may die or be severely brain damaged.

Most of the bleeding from the place where the placenta has pulled away from the wall of the uterus may escape through the cervix and flow out of the vagina. This blood is usually dark in colour because it doesn’t contain much oxygen. This is an important warning sign!

Figure 21.1 Bleeding due to placental abruption.

However, in some cases, all the blood from the detachment site may stay inside the uterus cavity, which begins to fill up with blood (Figure 21.1). You will not see external bleeding, as very little of the blood escapes through the vagina. However, the woman will show the typical signs of severe internal bleeding known as haemorrhagic shock, which we already described briefly in Study Session 20 on early pregnancy bleeding. We repeat the information below (Section 21.2.1) because there is even more risk of it happening when a woman bleeds late in the pregnancy.

Other signs of placental abruption include:

If the mother is already in labour, notice if she has pain between contractions, which may get worse and worse as time passes
Her abdomen is hard, sore and tender to the touch
The baby’s heartbeat can be very fast (faster than 180 beats a minute), or very slow (slower than 100 beats a minute), or if you cannot hear a fetal heartbeat the baby could be dead
The baby moves less or not at all.

21.2.1 Haemorrhagic shock

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

All of the conditions resulting from placental abruption require you to take immediate emergency action: see Section 21.5.

Placental abruption with external or internal bleeding may lead to haemorrhagic shock, in which blood is lost in such large amounts that the blood remaining in the woman’s blood vessels is not enough to deliver the nutrients and oxygen required by her body cells.

What are the signs and symptoms of haemorrhagic shock? (Think back to Box 20.3 in the previous study session.)
A woman in shock will be pale and sweating, with a fast but feeble pulse (above 100 beats per minute), fast respiration, low or falling blood pressure (the diastolic pressure — the bottom number — is no more than 60 mmHg and sometimes far less); she complains of dizziness; she seems confused and may even lose consciousness.

You should look for signs such as pallor: her fingernails, the palms of her hands and the inside of her eyelids will turn whiter as she loses blood. She may tell you she feels weak or be unable to lift her head. She appears restless, possibly asking for water to drink, and she seems confused. Confusion happens because her brain is being starved of oxygen. Common consequences of haemorrhagic shock include failure of the kidneys or the heart.

21.2.2 Acute renal failure

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As a result of haemorrhagic shock and the reduced amount of blood flowing to the kidneys, they may stop functioning. As a result, the woman produces very little urine, so toxic material which should have been cleared from her blood by her kidneys and expelled in her urine will build up in her blood. The accumulation of toxic chemicals in her blood rapidly causes her to become severely ill and death follows unless the condition is reversed. This condition is called acute renal failure (‘acute’ means it develops quickly into a life-threatening condition; ‘renal’ is a medical term referring to anything to do with the kidneys).

21.2.3 Heart failure

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If the woman is haemorrhaging, her heart will beat very fast as it tries to pump enough blood to vital body parts like her brain. If the blood loss is severe, her heart may not be able to beat fast enough to compensate for the falling blood volume and the women will develop heart failure. This condition is where the heart is unable to pump enough blood to the tissues and as a result death may occur.

21.3 Placenta previa

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The other common cause for late bleeding is placenta previa. In this situation the placenta is attached very close to the cervix, or is even covering it (Figure 21.2). As the cervix dilates the edge of the placenta may detach and it starts bleeding. A woman with this condition generally has clear, bright red blood coming from her vagina. The amount may be less than with placental abruption, but in some cases it can be severe and life threatening. The bleeding is often painless, so the woman may not have noticed it happening for a while, for example during the night when she was in bed. The bleeding can be set off by sexual intercourse and it may be recurrent (stopping and starting again).

Figure 21.2 Placenta previa is classified on how close the placental edge is to the cervix. (a) Low placental implantation, but not intruding into the cervix. (b) Partial placenta previa. (c) Complete placenta previa.

In a woman with late pregnancy bleeding due to placenta previa, the uterus often feels soft when you palpate her abdomen, in contrast to the hard feeling of the uterus when bleeding is due to placental abruption.

The fetal head is generally not in the lower part of the uterus, which feels empty. This abnormal presentation may be a sign of placenta previa. Usually the fetal condition is normal, so you can detect a fetal heart beat when you listen with a fetoscope, and the mother reports the fetus is moving and kicking normally — but this is not always the case.

The diagnosis of placenta previa can only be confirmed by examining the woman with an ultrasound machine that can reveal the position of the placenta, or by vaginal examination in an operating theatre. Therefore you should refer her to a health facility with the necessary equipment to make a diagnosis.

Women with a suspected placenta previa should be referred to a District Hospital or Health Centre with an ultrasound machine or operating theatre.

Never do a vaginal examination yourself if a woman is bleeding in late pregnancy. This will worsen the situation and increase the risk to her and the fetus.

21.4 Ruptured uterus

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Bleeding from a ruptured uterus may occur from the vagina so you can see the blood flowing out, or the uterus may bleed into the woman’s abdomen where the blood won’t be visible to you. If a woman who has been a long time in labour develops abdominal pain that is constant and gets worse with movement, or if, the uterus stops its contraction in the effort of expulsing the fetus, or she develops vaginal bleeding with associated state of shock, it is likely that the uterus has ruptured. If the uterus stops contracting, the abdomen will become soft and the fetal parts can be felt easily when you do an abdominal examination. If the baby has died the fetal heartbeat will not be evident when you listen with a fetoscope.

You will learn much more detail about the condition of the ruptured uterus in the next module in this curriculum, on Labour and Delivery Care. If you encounter a woman with the signs of a ruptured uterus you should take the emergency actions described below.

21.5 What to do for a woman with late pregnancy bleeding

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If you detect late pregnancy bleeding and you suspect placental abruption, placenta previa, a ruptured uterus or bleeding from any other cause, take the following steps:

Never perform a vaginal examination
Make a rapid evaluation of the general condition of the woman, including vital signs: pulse, blood pressure, respiration and temperature; check her for pallor, weakness, dizziness and confusion.
If you suspect shock, begin treatment immediately by starting a rapid intravenous (IV) infusion with Normal Saline or Ringer’s Lactate solution. (You will learn the theory of how to do this in Study Session 22 and develop this competency in your practical skills training.)
Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, take the actions described above.
Urgently mobilise all available people who can help, inform them how serious the situation is and put into action the complication readiness plan you developed with the woman and as part of focused antenatal care (Study Session 15 of this module). For example, get the village people to assist with transporting her quickly to the higher health facility; make sure that healthy people go with her who can donate blood if she requires a blood transfusion.

Remember that the initial bleeding could be heavy and life-threatening and the woman may arrive at your Health Post carried by relatives. In such a situation, after you do a quick assessment of the condition of the patient, put up the IV line, organise transport and send the woman to the nearest higher health facility as soon as possible.

What is the safest position in which to transport the woman? (Think back to Figure 20.3 in the previous study session.)
Her head should be lying flat — don’t put a pillow under her head. Raise her knees and support her legs with pillows or rolled blankets, so her feet are higher than her head.
In the case of late pregnancy bleeding, even if the bleeding stops on its own before labour begins, the woman should always be referred and preferably deliver her baby in a higher health facility.

Ideally, you should accompany her to maintain the IV infusion and keep the bag of IV fluid held above her. If you cannot go with her, explain the importance to whoever accompanies her of keeping the woman and the fluid bag in the suggested positions; also tell them how to close the IV tubing when the bag of fluid has completely drained. Remember to send a referral note with the woman.

In the final study session in this Module, we teach you the theory of how to set up an intravenous infusion, and also how to insert a urinary catheter in a woman who is unable to urinate due to complications of pregnancy or labour.

Summary of Study Session 21

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In Study Session 21 you have learned that:

Late pregnancy bleeding (ante-partum haemorrhage) can cause maternal and fetal death, and should be treated as a potentially life-threatening emergency.
The most common causes of life-threatening late pregnancy bleeding are placental abruption and placenta previa, or more rarely it can result from a ruptured uterus.
Less serious bleeding can arise from a varicose vein in the genital area, or blood resulting from a heavy show, which usually stops on its own.
Placental abruption can present with both concealed (internal) and revealed (externally visible) bleeding from the vagina; the blood is usually dark and the woman may report abdominal pain.
Placenta previa often presents with painless, bright red bleeding and can be associated with abnormal presentation of the fetus. Usually (but not always) fetal condition is normal.
Never do a vaginal examination in women with late pregnancy bleeding as this may precipitate severe bleeding.
Initial assessment of the woman’s vital signs and initiation of IV fluid therapy are the critical first steps in managing haemorrhagic shock in women with severe late pregnancy bleeding.
After putting up an IV infusion, transfer the patient immediately to a District Hospital or higher health facility with an operating theatre, as most cases require surgical intervention.

Self-Assessment Questions for Study Session 21

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Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 21.1 (tests Learning Outcomes 21.2 and 21.3)

Relatives call you to see a woman who is bleeding from the vagina at the 8th month of gestation.

What will you do as the initial assessment?
Will you initiate emergency treatment for this woman and refer her to the nearest higher health facility? Explain why, or why not.
What will you tell the relatives to do?

Answer

The initial assessment would be a rapid evaluation of the general condition of the woman, including her vital signs: pulse, blood pressure, respiration and temperature; check her for pallor, weakness, dizziness and confusion.
Emergency treatment should begin immediately with rapid intravenous (IV) infusion with Normal Saline or Ringer’s Lactate solution. This may save her life by replacing the fluids and salts lost through the haemorrhage, so her blood pressure does not drop dangerously low.
The relatives should be told to organise transport for the woman to the nearest higher level health facility.

SAQ 21.2 (tests Learning Outcomes 21.1, 21.2 and 21.3)

Which of the following statements is false? In each case, say why it is incorrect.

A You can do a vaginal examination for a pregnant women who comes to you with vaginal bleeding at gestational age of 37 weeks.

B Premature separation of a normally implanted placenta always results in external bleeding.

C Placenta previa is when the placenta is attached close to or covering the cervix.

D You may not need to refer women who present with persistent or recurrent bleeding in late pregnancy if the bleeding stops spontaneously.

Answer

A is false. You should never do a vaginal examination on a woman with late pregnancy bleeding (i.e. after 28 weeks of gestation).

B is false. Premature separation of a normally implanted placenta may result in external bleeding, but it may also cause internal bleeding.

C is true. Placenta previa is when the placenta is attached close to or covering the cervix.

D is false. You should always refer women with persistent or recurrent bleeding in late pregnancy, even if the bleeding stops spontaneously.

Read Case Study 21.1 and then answer the questions that follow it.

Case Study 21.1 Mrs X is brought to the Health Post

Mrs X is brought to your Health Post carried by her relatives on a locally made wooden bed. You are told she is 9 months pregnant. She had severe abdominal pain, which was followed by vaginal bleeding. When you examine her you see her clothes are soaked in blood. She is restless and asking for water. Her pulse is 120 beats per minute and her blood pressure is 80/50 mmHg.

SAQ 21.3 (tests Learning Outcomes 21.1 and 21.2)

What are the possible causes of bleeding in this case? Explain your answer.
Is Mrs X in a state of shock? Justify your diagnosis.

Answer

The possible causes of bleeding in the case of Mrs X are:
- Placental abruption
- Placenta previa
- Ruptured uterus
- Ruptured varicose vein.
Mrs X is in a state of shock: she is restless and thirsty, her pulse is very fast (120 beats/minute) and her blood pressure is dangerously low (80/50 mmHg).

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In this study session you will learn the difference between health promotion, health education, health screening and disease prevention, and learn about different methods of communicating health education messages respectfully and compassionately.

You will also learn how to educate and engage individuals, groups, opinion leaders and community members in the promotion and better utilisation of antenatal care services. Exactly the same principles apply to promoting the uptake of health services for labour and delivery, and postnatal care — as you will see in the next two Modules. Finally, we show you the steps in planning health education activities aimed at reducing maternal and newborn mortality by increasing the antenatal care coverage rate. You can apply these same steps to health promotion activities with other aims, for example increasing the uptake of family planning services.

Learning Outcomes for Study Session 2

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When you have studied this session, you should be able to:

2.1 Define and use correctly all of the key words printed in bold. (SAQ 2.1)

2.2 Discuss the benefits of promoting the antenatal care service in your community. (SAQ 2.2)

2.3 Describe different methods of promoting antenatal care, including through advocacy and social mobilisation, health campaigns, community events, group and individual discussions. (SAQ 2.3)

2.4 Describe the steps in organising a health education event to promote the utilisation of antenatal care services in your catchment area. (SAQ 2.3)

2.1 Health promotion

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Health promotion refers to any activities that result in better health in a community or a country. It includes the process of enabling people to increase control over, and to improve, their own health, but it moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions that increase health and wellbeing. Health promotion includes any actions of individuals, community organisations, district and regional health bureaus, and governments, aimed at improving the health of their population. For example, building more hospitals and health centres, and training more health workers, is a ‘health promoting’ activity at the national level. So too is ensuring that everyone in the population has access to enough food, shelter and clean water.

Health promotion at the community level includes three types of activities (Figure 2.1). We will begin by looking at examples of each of these in turn.

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Figure 2.1 Health promotion at the community level includes health education, health screening and disease prevention activities.

Health education is the effective transmission of accurate, useful, health-related information to community members; it enables individuals and groups to develop their knowledge of health issues, and increase their self-reliance and competence to solve their own health problems through their own initiatives. A major determinant of good or ill health is the knowledge people have about health issues, their beliefs, attitudes and behaviour, and their desire to bring about positive behaviour change in their lives.

A key role for you as a health worker is to provide effective health education to the people in your community, so they can discuss their health problems with you and with each other, and make the right decisions to improve their health, and that of their family members, through their own efforts. Hence, health education is a vital tool for moving people to action. If health education is delivered in a well-planned and coordinated programme, with full community support and participation, there is no better way to encourage positive health behaviours and resolve or prevent many common health problems.

What is behaviour and from where does it originate?
Behaviour is what people do or practise in their daily lives. It originates from our daily living, and from our surroundings and the experiences we have accumulated, informed by our beliefs, culture, tradition and habits.

Positive health behaviour is any action of an individual that results in improvement in his or her health, or in the health of others in the community.

Can you suggest some examples of positive health behaviour?
You may have thought of examples such as eating a balanced diet, taking enough exercise, getting enough sleep at night, and avoiding health-damaging behaviours such as smoking tobacco, drinking a lot of alcohol, or having unsafe sex without using a condom.

The second box in Figure 2.1 refers to health screening — the routine testing of individuals to see if they are at risk of developing a health problem. Health screening is an important health promotion activity that you will conduct as part of your antenatal care service. For example, you will take the temperature, blood pressure and pulse of every pregnant woman at every antenatal visit (we show you how to do this in Study Session 9) to see if she may be developing a health problem that could harm her or her baby.

The last box in Figure 2.1 refers to disease prevention, which means any action taken to prevent a disease from developing. For example, giving pregnant women iron supplements as a routine part of antenatal care is an action to prevent the development of anaemia — a condition in which the body makes too few red blood cells because the woman’s diet does not contain enough iron. (You will learn about the detection and treatment of anaemia in Study Sessions 9 and 18 of this Module.)

You can see from the above discussion that health promotion includes a wide-ranging set of activities. In later study sessions in this Module, you will learn a lot about the specific health education, health screening and disease prevention activities that contribute to the antenatal care of pregnant women in your community. In this study session, we will focus on the general principles of health education as a key aspect of health promotion in antenatal care.

2.2 Educating your community about antenatal care

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Health education enables people to understand and analyse their health problems, and it motivates and leads them in the right direction to effect the desired change. In the context of antenatal care, it helps to educate, motivate and encourage pregnant women to use the service by providing information that helps them to make informed decisions. Moreover, it advocates greater acceptance and uptake of antenatal care by educating the whole community. The result is that everyone understands that the overall benefits of antenatal care are the promotion of maternal and newborn health, and the prevention of common diseases and complications during pregnancy, labour, delivery and the postnatal period. Effective antenatal care helps to detect complications early, and it leads to swift management, including referral to a higher health facility when necessary. It encourages people to make preparations for possible emergencies during pregnancy and childbirth, and it brings about a sustained reduction in maternal and newborn deaths and complications.

Your role is to ensure community awareness of the antenatal care services you provide for pregnant women, and to inform women, their families and community members about the danger signs, and where to seek emergency care. (You will learn about the danger signs in later study sessions.) You need to ensure that everyone in the community is aware of the need to plan in advance for emergency transportation, should the need arise.

You will certainly save lives, even though the overall health of those around you is not in your hands alone. This is because people decide for themselves how to use your advice, and what choices to make about their own health and that of other family members. By teaching and sharing information, you can help people to make their own choices more wisely. Your first task is to educate your community and promote positive health behaviour.

An antenatal care visit is a good opportunity to promote dialogue with your clients, and reinforce positive health messages. Therefore, you need to encourage women to come for the first antenatal visit early in pregnancy. In the next part of this study session, you will learn about the best methods for achieving this aim.

2.3.1 Two-way communication

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To promote improved utilisation of antenatal care services, good communication plays a key role. Communication methods are all the ways in which people exchange ideas, feelings and information, including through conversation, print media such as books and leaflets, posters, radio, television, and increasingly through the internet, where facilities allow. Effective health education involves a two-way dialogue.

What do you understand by two-way communication?
It occurs when information is exchanged between at least two people through participation and discussion.

Two-way communication is the best method to promote health education messages to individuals or groups. There should be a free flow of communication between all participants. Remember, your ears are two of your most important tools! This is particularly important in health education because it enables you to get useful feedback from everyone, and to understand their concerns and resolve them through discussion.

Where and when can the health education of pregnant women happen?
It can happen anywhere and anytime. For example, during an antenatal check-up, while you are asking questions and listening to the woman’s answers, you can discuss the issues that are important to her. At the market, at a community gathering (Figure 2.2), or anytime you meet with pregnant women, or their husbands, you have the chance to discuss the benefits of antenatal care.

Figure 2.2 Community gatherings are good times to get positive health messages across; involve men as well as women in discussing the benefits of antenatal care.

2.3.2 Choose communication methods to suit your audience

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Health promotion is not a one-time affair. It is a continuing process, based on planned and organised activities. It addresses different community members and uses different communication methods as appropriate; it is not limited to a specific audience and one method only. Health promotion involves active and full participation of the whole community, and is based on the reality of the area’s culture, traditions, language and local resources. People learn differently, and everyone learns better when they learn the same thing in different ways. After you talk with individuals or groups about the benefits of antenatal care, they will share their experience with others in the community, so they also become agents of positive change.

2.3.3 Advocacy and community mobilisation

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Advocacy is speaking up for, or acting on behalf of, yourself or another person. Community mobilisation refers to a broad scale movement to engage people’s participation in achieving a specific goal through self-reliant efforts. Advocacy and community mobilisation will help you to gain and sustain the involvement of a broad range of influential individuals, groups and sectors at different levels in the community, who will support the antenatal care programme.

These strategies are covered in detail in the Module on Health Education, Advocacy and Community Mobilisation.

If you are successful in educating advocates to speak up for antenatal care, and in mobilising broad scale support for the service, the outcomes can include:

Improving access to antenatal services for pregnant women, and its acceptance in the community
Providing forums for discussion and coordination of the antenatal care service
Mobilisation of community resources, such as transportation, outreach and emergency funding for pregnant and labouring women with complications that require urgent medical attention.

Opinion leaders as advocates of antenatal care

Engaging the support of advocates who are ‘opinion leaders’ or ‘key persons’ in your locality is an important task. Well-known and respected elders, traditional or religious leaders, and ‘wise persons’ whose advice and words are accepted in the community, can convince others of the benefits of the antenatal care service by exerting social pressure. The tendency of community members to agree with them is important in conveying your health messages and getting acceptance from others.

You can use these community-honoured leaders to communicate positive messages about antenatal care if you give them the right information, and you are ready to use them as advocates. Advocacy by respected leaders can make sure people maintain the positive behaviour changes you have brought about through health education.

Try to get the maximum number of people involved in the promotion of antenatal care, so that the community will really strengthen its support for pregnant women’s health (Figure 2.3).

Figure 2.3 Community mobilisation to support antenatal care involves the whole community, since a pregnant woman’s health can be protected or hurt by everyone.

Men as advocates of antenatal care

Do men have a role in antenatal care?
Yes! Their involvement is very important, because men can influence whether pregnant women in their family attend antenatal care check-ups regularly, and follow your health advice.

As much as possible, encourage men to be partners in improving women’s health. Husbands, fathers, sons, community leaders, spiritual leaders, bosses and other men all play a role in how healthy women will be in relation to pregnancy, labour and delivery. If the men of the community feel responsible for the health of women, the whole community will benefit. So help men to be involved in the promotion of antenatal care.

Build on the roles and skills that men already have. For example, in many communities men are seen as protectors. Help men learn how to protect the health of women. Encourage men to share the responsibilities of pregnancy and parenting. Men can care for children in the same ways that women do — comforting, bathing, feeding, teaching, and playing with them. Invite women and men to community meetings, and encourage women to speak up. Sometimes women feel reluctant to speak about pregnancy and birth issues in front of men.

Work with men who are sympathetic to women’s needs. They can talk to other men who may listen more closely to a man than to a woman. When you discuss antenatal care with them, try to give practical suggestions. Men who care very much about the health of women in their lives may not know where to start. For example:

Explain to a man that his pregnant wife needs help with her daily work (see Figure 2.4).

Figure 2.4 Women need extra help with their work during pregnancy.

Encourage the couple to make a birth plan together, and to be aware of the danger signs during pregnancy, childbirth, and after birth. Advise them to save some money in case of an emergency, and make arrangements for transport if she has to go to a health centre or hospital.
Make sure the man knows he must send for you when his wife goes into labour (if her pregnancy has been normal and she has no danger signs), so you can be there for the delivery.
Make sure he knows where to take his wife for emergency care at a health facility if complications occur.
Show him how a husband supports his wife during labour, for example how and where to rub her back to relieve her pain.
Tell men how they can get tested and treated for sexually transmitted infections. If only a woman is treated, she will quickly be infected again by her partner.

2.3.4 Organising a health campaign

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Health campaigns promote health knowledge, skills, attitudes and values on a particular health issue. They may also be used to accomplish a particular community improvement project. The actual community activities of a campaign often take place during only one week or one month. For this reason, campaigns are often called ‘Health Weeks’.

A health campaign to promote the uptake of antenatal care could be organised around one issue or problem that has been identified by community members themselves. For example, publicising the benefits of antenatal care services for pregnant women would be a priority campaign in a community where the antenatal care coverage rate was low. If there is a health committee in the community, it should be active in identifying issues for health campaigns, and planning the action to be taken.

Figure 2.5 The campaign logo of Ethiopia’s ‘Safe Motherhood Month’ in January 2010.

Health campaigns can also be conducted at a national level. For example, Ethiopia conducted a campaign called ‘Safe Motherhood Month’ in January 2010. The focus of the campaign was ‘No mother should die while giving birth’ (Figure 2.5).

The problem identified was high maternal deaths and complications related to pregnancy and childbirth. At the same time, there was low uptake of maternal health services, such as antenatal care, skilled birth attendance and family planning. Throughout the whole month, advocacy and social mobilisation campaigns were conducted using different communication media, including posters, television broadcasts and radio. There were panel discussions with stakeholders, religious leaders, parliamentarians, and so on, about the magnitude of the maternal health problem and sharing best practice on service provision. Campaigns on family planning and HIV counselling and testing also took place during the month.

2.3.5 Special community events

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Every community has festivals, celebrations and ceremonies, e.g. to mark special seasons of the year, such as planting time, the harvest and the New Year; there are many religious festivals and days in remembrance of national occasions and heroes. Some events are a time for enjoyment and relaxation, such as the coffee ceremony. Others call for serious thinking and quiet devotion. People celebrate in different ways, according to the culture and norm of the community. Whatever the purpose of the ceremony or festival may be, the whole community usually participates. All these events can be useful occasions to disseminate information on antenatal care and conduct activities that promote maternal and newborn health.

2.3.6 Group discussions

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Group discussion is the most commonly employed method of health education. It involves the free flow of communication between a facilitator and two or more participants (Figure 2.6).

View larger image

Figure 2.6 Group discussions create a forum for exchanging experiences.

The advantages of group discussion as a method of health promotion are that it:

Encourages equal participation from all members
Increases motivation to act on the health education message
Helps participants to synthesise knowledge, new ideas and skills
Creates a supportive forum for learning and exchanging experiences
Promotes collective thinking to identify and solve problems by pooling ideas and expertise.

Group discussions are extremely useful as a method of health education if they have a shared goal, and collective planning and implementation of subsequent actions. Box 2.1 gives some steps for facilitating an effective discussion group.

Box 2.1 Steps for effective group discussions

Better results are achieved if it is a small group. If the group is too large, the level of participation of each person will be low. Organise the group to enable full participation of all members.
Begin your presentation with a clear starting point, an introduction, the general and specific objectives, and some useful discussion points to get the conversation going.
Ensure that the discussion is purposeful, i.e. the discussion points are relevant and clear, people don’t interrupt each other, and they keep to the agreed topic.
The effectiveness of group discussions may be enriched or weakened by differences in the participants’ backgrounds, e.g. in their cultures, geographical area, social and economic status, sex and age group. These differences can have a positive or negative influence on the outcome of the discussion, and you should be aware of this.
Your role as facilitator is to motivate and encourage the participants to exchange ideas freely and reach a common decision.
Conclude the discussion by summarising the outcomes, agreeing on next steps, and thanking everyone for their participation.

2.3.7 Individual health education

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Individual health education occurs when you exchange ideas and information with one other person. It is more forceful than any other communication method. It will help you to create mutual understanding with the other person and get to know each other more closely. It promotes frankness between participants and enables them to exchange ideas and give and receive feedback immediately. It also creates the opportunity to discuss problems which are sensitive and need special handling, as is often the case in pregnancy. In individual communication, it is essential to start by building a good relationship. Box 2.2 gives some steps to help you do this.

Box 2.2 Steps for effective individual communication

Greet the other person warmly, in a friendly way.
Then create a good learning environment by making the person feel comfortable and relaxed.
Your message has to be clear, simple and understandable to avoid any confusion.
Use appropriate visual aids if this is helpful.
Encourage participation of the individual by asking him or her to express views on the topic, raise issues and ask questions.
Summarise the message at the end of the session, and invite the other person to say if he or she has any further comments or questions.

2.4.1 Preparation is essential

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Figure 2.7 Books and study help you to prepare for a health education event.

If you are planning a health education event to promote the uptake of antenatal care, or any other health education topic, thorough preparation is essential. Begin by preparing well in advance everything you need to know about the topic, researching the main points and assembling all the necessary information (Figure 2.7).

Think carefully about the audience and pinpoint what they need. For example, if your audience is community leaders, you need to prepare your messages in relation to their knowledge and role. An event for elders will need different messages than an event for new parents, or single mothers, and so on. Consider the needs, feelings and wishes of the specific audience, and identify what points they are likely to want you to focus on.

Choose a place and time that is convenient for as many people as possible to be present. For example, if most people prefer to attend the event on Saturday at the kebele compound at 9:00am, try as much as possible to agree to their choice.

2.4.2 Getting started

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When you conduct a health education event or meeting, ensure that everybody is seated comfortably and is ready for active participation in the discussion. Smile, and try to make eye contact with everybody as you welcome them and introduce yourself. Ask everyone present to introduce themselves.

Start the presentation with what people know already about the antenatal care service, and build on, or add, what people do not know. You may need to tell them about its advantages, how often and at what time a pregnant woman should have antenatal check-ups, and so on.

Choose your presentation method according to the audience’s condition, number, age, sex, etc. For example, a group of pregnant women may like it if you show them pictures of the uterus with a baby growing inside, or demonstrate how a baby moves down the birth canal, using a doll. Community leaders may benefit from seeing data on maternal and newborn mortality rates (as in Study Session 1 of this Module), to convince them of the need for antenatal care.

2.4.3 Keeping everyone involved

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Concentrate on what can be done and achieved in the time available for the event. Don’t try to give out too much new information all at once, or people may feel overloaded and stop listening.

Remember, two-way communication is the best method! Participants should be encouraged to share their knowledge and experiences, and express their ideas and suggestions freely.

Support the active participation of women in particular, since they are the ones who should be encouraged to use antenatal care services. Some people are used to speaking up in groups, and others may be shy or afraid. Therefore, you should encourage those women who usually keep quiet to share their thoughts.

Make sure that everyone gets an equal chance to participate. For example, if a group of women wants to learn about what to eat during pregnancy and after birth, you can first ask each person to share what she knows. Many women will already know about a healthy diet from books or classes, from talking to other women, or from their own experience. But some women may be misinformed, for example about foods they think should be avoided in pregnancy, which are in fact good for pregnant women to eat, if they can afford to buy them (Figure 2.8).

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Figure 2.8 Health education events can reveal many different views, for example about a healthy diet during pregnancy.

2.4.4 Concluding the event positively

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When the time approaches to bring the event to a conclusion, find out what questions, comments or issues anyone still has, and give particular attention to answering questions as much as possible before the meeting ends.

Then summarise the points that have been discussed, and any agreements reached, and bring the meeting to a close.

Thank everyone for their participation and encourage them to tell others what they have learned. They can become good advocates for antenatal care.

In the next study session, we turn our attention to the anatomy and physiology you will need to learn about in order to give good antenatal care.

Summary of Study Session 2

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 2, you have learned that:

The main purpose of promoting the utilisation of antenatal care is to reduce the number of maternal and newborn deaths and complications.
Antenatal care is an opportunity to promote dialogue with clients, to reinforce maternal health messages about danger signs during the antenatal, delivery and postnatal periods, and to ensure everyone knows where to seek appropriate care.
Health promotion covers any activities that result in better health in a community or a country; it can involve the actions of individuals, groups, organisations, institutions and governments. Health education, health screening and disease prevention all contribute to health promotion activities.
Health education enables people to increase control over, and improve, the health of themselves, their families and their communities by their own actions and efforts. It is a continuing process, based on planned and organised activities that take account of the audience’s culture, tradition, language and local resources.
Advocacy and community mobilisation help to gain and maintain the involvement of a broad range of individuals, groups and sectors at different levels in the community, in achieving the desired goal.
Educating influential opinion leaders, religious leaders, husbands and fathers to be advocates and partners in improving women’s health during pregnancy, labour and delivery, is very important.
Health promotion campaigns, education events, discussion groups and communication with individuals should be carefully prepared, and use different communication and presentation media as appropriate.
Group discussion is the most commonly used health education method. It involves two-way communication, in which participants are given an equal chance to express their views freely, and exchange their experiences and ideas.
Individual health education is based on creating trust and mutual understanding, enabling frankness between participants, the free exchange of ideas, and immediate feedback.
A good place to start is by listening to your audience. When you find out what people already know, you can help them build on that knowledge, and when you listen, you will learn from those you are educating.
Provide opportunities to make the antenatal care service the community’s own programme, by promoting the identification of problems and solutions, the planning and implementation of positive actions, and the evaluation of outcomes.

Self-Assessment Questions (SAQs) for Study Session 2

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SAQ 2.1 (tests Learning Outcome 2.1)

Give one example of each of the following:

A routine health screening activity that contributes to antenatal care.
A routine disease prevention activity that contributes to antenatal care.

Answer

You may have suggested routine health screening activities such as taking the pregnant woman’s temperature and pulse, measuring her blood pressure, or testing her urine for the presence of sugar. (You will learn how to do all of these activities in later study sessions in this Module.)
You may have suggested giving pregnant women iron tablets to prevent anaemia, or giving out insecticide-treated bed nets to prevent malaria. There are many other good examples.

SAQ 2.2 (tests Learning Outcome 2.2)

State the main benefits of promoting the utilisation of antenatal care services in your community.

Answer

Promotion of antenatal care benefits the community because it:

Creates awareness in the whole community about the health services provided for pregnant women, and during labour, delivery and the postnatal period.
Enables pregnant women and their male partners to make informed decisions about utilising the service.
Improves the health and well-being of pregnant women and reduces maternal and newborn deaths and complications.

SAQ 2.3 (tests Learning Outcomes 2.3 and 2.4)

Suppose you have a group of pregnant women in your catchment area who want to know about where to go for delivery. What method of health promotion is likely to be the best in this example, and what steps should you take in organising a health education programme for these women?

Answer

Group discussion is the best method in this example. The steps you should take are as follows:

Prepare your presentation to meet the needs of the specific audience — in this case, pregnant women.
Smile, and try to make eye contact with everybody at the start. Introduce yourself, and ask each woman to say who she is.
Start with what the women already know about a safe place to deliver a baby, and build on or add what they do not know; for example, tell them about the danger signs that mean they should have the baby in a health facility.
Concentrate on what can be done and achieved in the time available.
Encourage the women to express their ideas freely. Encourage those women who usually keep quiet to share their thoughts. Keep everyone involved in two-way communication. Listen carefully to what they say.
At the end, summarise the points raised and decisions taken, try to ensure that any remaining questions are answered, and thank everyone for attending.

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In this study session you will learn the definition, classification and risk factors of premature rupture of membranes (PROM). We will describe the potential complications that may end up with serious maternal morbidity and, at the worst, maternal mortality.

This session also tells you about the potential complications that endanger the life of the fetus and the newborn baby. You will learn how to make a clinical diagnosis of PROM and what actions you can take when you have women with PROM, building on your existing knowledge about leakage of fluid from the vagina as one of the danger symptoms in Study Session 15.

Learning Outcomes for Study Session 17

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When you have studied this session, you should be able to:

17.1 Define and use correctly all of the key words printed in bold. (SAQ 17.1, 17.2 and 17.3)

17.2 Describe the classification of PROM. (SAQ 17.1 and 17.3)

17.3 Describe the different risk factors associated with PROM. (SAQ 17.2)

17.4 Define the diagnostic features of PROM. (SAQ 17.2)

17.5 Discuss the possible complications of PROM affecting the mother and the fetus. (SAQ 17.2 and 17.3)

17.6 Explain what action you need to undertake whenever you come across a woman with PROM. (SAQ 17.2 and 17.3)

17.1 Premature rupture of membranes

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Premature rupture of membranes (PROM) is defined as a spontaneous leakage of amniotic fluid from the amniotic sac where the baby swims; the fluid escapes through ruptured fetal membranes, occurring after 28 weeks of gestation and at least one hour before the onset of true labour. PROM can occur before or after 40 weeks’ gestation, so the word ‘premature’ does not mean that the gestational age of the fetus is preterm.

Premature here refers to the premature rupture of fetal membranes before the onset of labour. PROM is of concern because rupture of fetal membranes before the onset of labour is not normal and is associated with many complications (described later in this session). In a normal labour, the fetal membranes usually rupture after the labour has progressed for some time, when the fetal head is deeply engaged and the cervix is near to full dilatation, with no complications in most labouring women. (You will learn in detail about labour progress in the next Module, Labour and Delivery Care.)

You need to know that the majority of people in Ethiopia don’t think of PROM as a problem. Rather, they consider the leakage of fluid as a good symptom about the coming labour. As you will see later in this study session, many serious complications can occur as a result of PROM. Therefore, you need to counsel the woman, her husband/partner and her family very clearly about the actions they should take if her membranes rupture and fluid leaks from her vagina before labour begins. Tell them about the dangers of waiting at home after the rupture of fetal membranes. We begin by describing how you classify cases of PROM, which determines how you handle each case.

17.2 Classifications of PROM

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PROM is classified according to the gestational age at which it occurs and the interval between rupture of the fetal membranes and the onset of true labour.

Preterm PROM occurs after 28 weeks of gestational age and before 37 weeks.

Term PROM occurs after 37 completed weeks of gestational age, including post-term cases occurring after 40 weeks.

Preterm and term PROM are further divided into:

Early PROM (less than 12 hours has passed since the rupture of fetal membranes)
Prolonged PROM (12 or more hours has passed since the rupture of fetal membranes).

The major reason for classifying PROM into term, preterm, early and prolonged PROM is for effective management decisions. The earlier the occurrence (preterm PROM) and the longer the interval between the rupture of fetal membranes and onset of labour, the more complications there are likely to be. We will describe the actions you should take to manage cases of PROM in Section 17.6 of this study session. First, we discuss the risk factors for PROM and then the complications that can result for the mother and the fetus.

17.3 Risk factors for PROM

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Rupture of fetal membranes can occur when the cervix is either closed or dilated. Sometimes, it can occur in a very early pregnancy (before 28 weeks – this leads to inevitable abortion, which you will learn about in Study Session 20), or in early third trimester (between 28 and 34 weeks). It is not exactly known why fetal membranes rupture before the onset of labour. However, there are some known risk factors highly associated with PROM.

Consider the amniotic cavity as a sac (or bag) whose wall is formed by the fetal membranes, enclosing the fetus and amniotic fluid. The sac will rupture at the weakest point, which is the part of the membranes in direct contact with the ‘mouth’ of the cervix. Rupture happens when the sac is either damaged by an infection or external trauma, or it becomes over-stretched (distended) and unable to withstand the internal pressure. These risk factors are described in more detail below.

17.3.1 Infection can cause PROM

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Bacteria that cause infection in the lower genital tract (infection of the cervix or vaginal wall) can travel upwards through the cervix and infect the fetal membranes. This can weaken the membranes enough to allow them to rupture.

Box 17.1 summarises the diagnostic signs of infection in a woman with PROM.

Box 17.1 Evidence of infection in a woman with PROM

Fever: the woman may complain of feeling feverish, or you may record her temperature of 38°C or more.
The vaginal discharge may have an offensive smell and the colour may be changed from watery to cloudy.
She may have an increased pulse rate (more than 100 beats/minute).
The fetal heart beat may increase to 160 beats/minute or more.
She may feel pain in the lower abdomen, particularly when it is touched.

17.3.2 Malpresentation of the fetus

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Rupture of fetal membranes is highly associated with fetal malpresentations in the third trimester. Particularly high risk of PROM is associated with footling breech (feet first) and transverse lie (across the abdomen) with the baby’s back arched upwards and hands and legs pointing down, in direct contact with the weakest point of the membranes.

17.3.3 Multiple pregnancy and excess amniotic fluid

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If the uterus holds two or more babies, or there is excess accumulation of amniotic fluid (polyhydramnios), the fetal membranes become over-stretched and rupture. The membranes can rupture even if the amount of amniotic fluid is small, if there is another cause such as those described below.

‘Poly’ means excess, ‘hydra’ means water, and ‘amnios’ refers to the amniotic fluid. So ‘polyhydramnios’ means ‘too much amniotic fluid’.

17.3.4 Cervical incompetence

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Without uterine contraction, the cervix may dilate spontaneously early in gestation and this can be the cause for an abortion (miscarriage). The cervix may dilate even in late pregnancy before the onset of labour. As the cervix continues dilating, it will allow part of the fetal membranes to pass through it. As a result, the membranes can rupture easily and leak amniotic fluid.

17.3.5 Trauma to the abdomen

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Any blunt or penetrating trauma to the abdominal wall can result in a break in the fetal membranes. Blunt traumas include: uterine manipulation by a doctor or midwife to change the fetal presentation from breech or transverse lie to the normal ‘head down’ or vertex presentation; uterine massage by traditional healers; and blunt abdominal injury (e.g. from a blow or fall). An example of a penetrating abdominal injury is insertion of a hollow needle into the amniotic cavity through the abdominal wall, or through the cervix, to withdraw amniotic fluid or placental tissue for analysis.

17.4 Diagnosis of PROM

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When there is a rupture in the fetal membranes, the woman notices a painless sudden leakage of fluid from her vagina, which is usually excess and watery. However, when the amount of amniotic fluid in the sac is minimal, the leaking fluid may only wet her underwear, and you may be unsure whether to make the diagnosis of PROM from the woman’s complaint.

The mother may be worried, but not be sure whether the leakage is normal or abnormal. A little bit of excess vaginal discharge is normal near to full term, and this may be confused with the leakage of amniotic fluid. So you need to refer any woman complaining of excess vaginal discharge for further evaluation at a higher level health facility, in case the woman is showing signs of PROM.

Box 17.1 summarises the clinical features that can help you to make the diagnosis of PROM.

Box 17.1 Clinical features of PROM

The woman complains of leakage of fluid from her vagina (minimal or excess).
She says she noticed a decrease in the size of her abdomen after leakage of fluid.
You observe watery fluid coming out through the vagina, or the woman’s under clothing is soaked with watery fluid.
When you measure the distance between the pubic symphysis and the fundal height (as described in Study Session 9), you find the baby is small for gestational age. (Note that being ‘small for gestational age’ can also be due to scanty amount of amniotic fluid with intact membranes, intrauterine growth restriction and wrong date for the stated gestational age.)
In PROM, the amniotic fluid remaining in the sac will be minimal, so you may be able to feel (palpate) the fetal parts easily through the mother’s abdomen.
Although not specific, the woman may have an offensive smell due to vaginal discharge, and she may have a fever (see Box 17.1 above); these signs indicate an already established infection, which may be the cause of PROM.
You can give her a dry vaginal pad or Goth and check after some hours whether it is wet or still dry. Note that being dry doesn’t necessarily rule out PROM.

17.5 Complications of PROM

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PROM is associated with several potentially life-threatening complications, as we will now describe.

17.5.1 Infection after PROM

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As stated earlier, the premature rupture of fetal membranes allows bacteria to get into the uterine cavity. They multiply rapidly in the warm, wet environment and, as a result, both the mother and the fetus may develop a life-threatening infection. It can continue even after the birth as uterine or widespread infection in the mother, and cause pneumonia, sepsis (blood infection) or meningitis (infection of the brain) in the newborn.

Infection is one of the most feared complications of PROM because, unless it is quickly treated, it may end up with both maternal and fetal or newborn death. But the good news is that swift treatment with antibiotics is generally successful.

It should be noted that prolonged PROM cases are highly likely to develop a uterine infection unless treated quickly with preventive antibiotics.

Why do you think prolonged PROM is particularly likely to lead to infection?
Over 12 hours have passed since the fetal membranes ruptured, so any bacteria that got into the uterus have enough time to multiply and take hold.

17.5.2 Cord prolapse

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Figure 17.1 Prolapsed cord is a dangerous complication of PROM.

One of the potentially fatal complications of PROM for the baby is umbilical cord prolapse. (The term ‘prolapse’ means ‘pushing out of the proper place’.) When the membranes rupture, the umbilical cord may be washed downwards by the rushing out of amniotic fluid and fall towards the vagina. It may be pushed ahead of the baby and push out into the cervix (see Figure 17.1) through the break in the membranes. In this position, the prolapsed cord is easily compressed, cutting off the blood supply to the fetus and this can be the cause of sudden fetal death.

17.5.3 Fetal hypoxia and asphyxia

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When the ruptured fetal membranes have leaked most of the fluid that keeps the fetus ‘floating’ in the uterus, the membranes collapse around the baby, and the baby can press against the uterine wall. It can lie on and compress the umbilical cord, so the fetus becomes short of oxygen and the waste product carbon dioxide builds up in its body.

Deficiency of oxygen and accumulation of carbon dioxide in the body is called hypoxia (literally ‘low oxygen’), which rapidly leads to asphyxia (brain and tissue damage due to hypoxia) resulting in death if oxygen is not quickly restored.

The fetus can also develop asphyxia and die because of partial or complete placental abruption, as described next.

17.5.4 Placental abruption

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When the cause of the rupture of fetal membranes is an over-stretched uterus, there is a possibility of premature separation of the placenta from the uterine wall (a condition called placental abruption which you will learn more about in Study Session 21). This can happen when a gush of fluid suddenly flows out of the uterus, ripping part of the placenta away from the uterine wall.

17.5.5 Preterm labour

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Once the fetal membranes rupture, labour usually starts spontaneously in less than one week. If the PROM occurs several weeks before the pregnancy reaches full term, the resulting labour will also be preterm, and this can pose a risk to the newborn. Its development may not be sufficiently mature to sustain life — for example, the preterm baby cannot maintain its body temperature as well as a full term baby, its respiration will be shallow, it may have trouble feeding and its immune system may not be able to protect it from infection.

17.5.6 Deformity of fetal limbs

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Sometimes labour does not start spontaneously after PROM. This is the most risky situation for development of infection and fetal deformity, if it occurs too early in gestation and the pregnancy continues for a long period of time after the membranes have ruptured.

Without the amniotic fluid to keep the fetus ‘floating’, the muscular walls of the uterus closely surround the fetus and compress it. The immature fetal bones are not yet strong enough to resist the pressure, and the chance of developing deformity of the legs, feet, arms or hands is very high if the pregnancy continues in this state for more than 3 weeks.

17.6 Actions in a case of PROM

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Whenever you see a woman with clearly defined or suspected PROM, the questions you need to answer are:

Does the woman have established labour or not?
If the woman has established labour:
- Is it preterm or term PROM?
- How long has she stayed at home after the membranes ruptured?
- How much has the labour progressed?
Is the fetus alive or dead?
Irrespective of labour condition, does the woman have established infection or not?

You need to answer the above questions because they show what actions you need to take, as we will now describe.

17.6.1 When should you conduct the delivery before referral?

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Under certain conditions, it is safer for you to conduct the delivery of a woman with PROM where she is (at her home or your Health Post) before referral.

Can you explain why not?
It greatly increases the risk of infection getting into the uterus.

You should support her through the labour before referral if she is:

Don’t do an internal vaginal examination, even wearing surgical gloves, in a woman with PROM!

already in established labour (yes to Question 1 above)
and she came to you with a history of term PROM, after 37 completed weeks of gestation and the leakage of fluid happened before the onset of labour (Question 2)
and you see no evidence of infection (no to Question 4).

If the labour and delivery was normal and the woman and baby are doing well, check them for the next 24 hours. Tell the family to call you and take her to a health facility immediately if there is any sign of infection in the mother or the newborn.

If the woman comes to you with PROM and she is already in established labour which has progressed a long way (late active first stage, or second stage when the woman is wanting to push), even with evidence of infection, or a preterm labour, or you think the fetus may be dead, it is still preferable to conduct the delivery where the woman is and refer her to a health facility as soon as the baby is born.

17.6.2 When should you refer before conducting the delivery?

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Refer the woman with PROM as soon as possible to a hospital with a surgical facility if she is not in labour, or she is still in the early stage of labour and there is time to get her to the health facility before labour progresses much. Remember that if the case is preterm PROM, the newborn will need special care in a hospital.

Summary of Study Session 17

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 17, you learned that:

Premature rupture of membranes (PROM) is a spontaneous rupture of fetal membranes and leakage of fluid from the vagina after 28 weeks of gestation and at least one hour before the onset of true labour.
PROM is classified as preterm PROM when the leakage of fluid occurs before 37 completed weeks of gestation, and term PROM when it occurs after 37 weeks.
Women with prolonged PROM (12 or more hours passed since the rupture of fetal membranes) are highly likely to develop infection in the uterus unless they get swift antibiotic treatment.
The commonest risk factors for PROM include infection in the reproductive tract, fetal malpresentations (breech or transverse lie), multiple pregnancy, excess amniotic fluid, cervical incompetence, and abdominal trauma.
The diagnosis of PROM is based on a history of sudden and painless leakage of moderate or excess watery fluid from the vagina. You may witness the woman’s soaked underwear, feel easily palpable fetal parts through her abdominal wall, and measure the uterine size as ‘small for gestational age’ because her abdomen has shrunk.
The common complications of PROM are infection in the mother and/or the fetus/newborn, cord prolapse, intrauterine fetal asphyxia/death, placental abruption, preterm labour, and deformity of the fetal limbs.
Fever, foul smelling vaginal discharge, increased maternal pulse rate, increased fetal heartbeat and lower abdominal pain are signs of infection in the uterine cavity, which needs to be treated quickly with antibiotics.
To minimize the risk of infection, gloved digital pelvic examination should be avoided in women with PROM.
Deliver the baby and then refer in cases of term or preterm PROM where the woman is already in advanced labour, even if there is evidence of infection or in cases of term PROM if labour has begun normally and there is no evidence of infection.
Refer as soon as possible all women with PROM coming to you before the onset of labour, or in early labour, with established maternal or neonatal infection; refer all preterm babies immediately after delivery.
Make sure that the woman with PROM and her family are well aware of the risks of waiting at home; counsel them to call you at once and take transport to the health facility.

Self-Assessment Questions (SAQs) for Study Session 17

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SAQ 17.1 (tests Learning Outcomes 17.1 and 17.2)

Complete the missing information in Table 17.1.

Table 17.1

PROM classification	Gestational age
Preterm PROM
Term PROM
	Interval since membranes ruptured
Early PROM
Prolonged PROM

Answer

The completed Table 17.1 should look like this:

Table 17.1

PROM classification	Gestational age
Preterm PROM	After 28 weeks and before 37 weeks
Term PROM	After 37 weeks, including post-term (after 40 weeks)
	Interval since membranes ruptured
Early PROM	Less than 12 hours
Prolonged PROM	More than 12 hours

SAQ 17.2 (tests Learning Outcomes 17.1, 17.3, 17.4 and 17.5)

Which of the following statements is false? In each case, explain what is incorrect.

A Infection in the uterus may cause PROM and may also be a complication following PROM.

B PROM may occur if the uterus is over-stretched by malpresentation of the fetus, multiple pregnancy or excess amniotic fluid.

C Cervical incompetence in combination with PROM can be a cause of umbilical cord prolapse.

D The fetal membranes are so strong that blunt trauma to the abdomen is unlikely to cause PROM.

E Hypoxia and asphyxia of the woman in labour is a common complication of prolonged PROM.

F A sudden gush of clear watery fluid from the vagina is always seen in cases of PROM.

Answer

A is true. Infection in the uterus may cause PROM and may also be a complication following PROM.

B is true. Prom may occur if the uterus is over-stretched by malpresentation of the fetus, multiple pregnancy or excess amniotic fluid.

C is true. Cervical incompetence in combination with PROM can be a cause of umbilical cord prolapse.

D is false. Blunt trauma to the abdomen is a common cause of PROM.

E is false. Hypoxia and asphyxia of the fetus (not the woman in labour) is a common complication of prolonged PROM.

F is false. Some cases of PROM occur without a sudden gush of clear watery fluid from the vagina, so you should always take account of other diagnostic signs such as reduction in size of the abdomen and clearly palpable fetal parts.

Read Case Study 17.1 and then answer the questions that follow it.

Case Study 17.1 Zufan’s story

Zufan’s family contact you to say that her waters broke 24 hours earlier, but they are concerned because her labour has not started yet. They think the baby was due to be born last week. She feels hot to the touch and is becoming restless and complaining of pain in her lower abdomen.

SAQ 17.3 (tests Learning Outcomes 17.1, 17.2, 17.5 and 17.6)

How do you classify Zufan’s case of PROM?
Does she have the signs of any complications?
Is there anything you could have done to prevent her condition from worsening?
What immediate action should you take?

Answer

Zufan’s condition should be classified as post-term prolonged PROM, because the gestational age is already beyond 40 weeks and her membranes ruptured more than 12 hours ago.
She has two clear signs of abdominal infection: fever and lower abdominal pain.
You could have prevented her condition from worsening if you had counselled Zufan and her family more clearly about the risks of waiting at home after the membranes have ruptured.
You should immediately refer her to the nearest hospital or health centre with surgical facilities; she will also need antibiotics quickly to treat the infection.

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Part 1 of the Antenatal Care Module, you have learned mainly about how the human reproductive system is structured anatomically and how it functions, the normal process and adaptation of pregnancy, the general assessment of the progress of pregnancy, and how to identify minor disorders. In Part 2 of the Antenatal Care Module, you will first learn about the basic principles of focused antenatal care (FANC).

This session will start by describing the concepts and principles of FANC and the basic differences between FANC and the traditional approach to antenatal care. It will highlight the other study sessions in Part 2 which all rest under the umbrella of FANC. You will also learn the objectives of each of the four FANC visits. The study session concludes with the preparations you and the pregnant woman should make for the birth, advice about what to do if complications arise, and instructions on how to write a referral note if she has to be transferred to a health facility.

Learning Outcomes for Study Session 13

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

13.1 Define and use correctly all of the key words printed in bold. (SAQ 13.1)

13.2 Discuss the principles of focused antenatal care (FANC) and state how it differs from the traditional approach. (SAQ 13.1)

13.3 Describe the schedule, objectives and procedures covered in each of the four FANC visits for women in the basic component. (SAQs 13.2 and 13.3)

13.4 Advise pregnant women on birth preparedness, including the equipment they will need. (SAQ 13.4)

13.5 Summarise the main aspects of complication readiness and emergency planning, including advising blood donors and writing a referral note. (SAQ 13.3)

13.1 Focused antenatal care: concepts and principles

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Historically, the traditional antenatal care service model was developed in the early 1900s. This model assumes that frequent visits and classifying pregnant women into low and high risk by predicting the complications ahead of time, is the best way to care for the mother and the fetus. The traditional approach was replaced by focused antenatal care (FANC) — a goal-oriented antenatal care approach, which was recommended by researchers in 2001 and adopted by the World Health Organization (WHO) in 2002. FANC is the accepted policy in Ethiopia.

FANC aims to promote the health of mothers and their babies through targeted assessments of pregnant women to facilitate:

Identification and treatment of already established disease
Early detection of complications and other potential problems that can affect the outcomes of pregnancy
Prophylaxis and treatment for anaemia, malaria, and sexually transmitted infections (STIs) including HIV, urinary tract infections and tetanus. Prophylaxis refers to an intervention aimed at preventing a disease or disorder from occurring.

FANC also aims to give holistic individualised care to each woman to help maintain the normal progress of her pregnancy through timely guidance and advice on:

Birth preparedness (described later in this study session),
Nutrition, immunization, personal hygiene and family planning (Study Session 14)
Counselling on danger symptoms that indicate the pregnant woman should get immediate help from a health professional (Study Session 15).

In FANC, health service providers give much emphasis to individualised assessment and the actions needed to make decisions about antenatal care by the provider and the pregnant woman together. As a result, rather than making the traditional frequent antenatal care visits as a routine activity for all, and categorising women based on routine risk indicators, the FANC service providers are guided by each woman’s individual situation.

This approach also makes pregnancy care a family responsibility. The health service provider discusses with the woman and her husband the possible complications that she may encounter; they plan together in preparation for the birth, and they discuss postnatal care and future childbirth issues. Pregnant women receive fundamental care at home and in the health institution; complications are detected early by the family and health service provider; and interventions are begun in good time, with better outcomes for the women and their babies.

Box 13.1 summarises the basic principles of FANC.

Box 13.1 Basic principles of focused antenatal care

Antenatal care service providers make a thorough evaluation of the pregnant woman to identify and treat existing obstetric and medical problems.
They administer prophylaxis as indicated, e.g. preventive measures for malaria, anaemia, nutritional deficiencies, sexually transmitted infections, including prevention of mother to child transmission of HIV (PMTCT, see Study Session 16), and tetanus.
With the mother, they decide on where to have the follow-up antenatal visits, how frequent the visits should be, where to give birth and whom to be involved in the pregnancy and postpartum care.
Provided that quality of care is given much emphasis during each visit, and couples are aware of the possible pregnancy risks, the majority of pregnancies progress without complication.
However, no pregnancy is labelled as ‘risk-free’ till proved otherwise, because most pregnancy-related fatal and non-fatal complications are unpredictable and late pregnancy phenomena.
Pregnant women and their husbands are seen as ‘risk identifiers’ after receiving counselling on danger symptoms, and they are also ‘collaborators’ with the health service by accepting and practising your recommendations.

13.1.1 Advantages of FANC

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FANC is gaining much popularity because of its effectiveness in terms of reducing maternal and perinatal mortality (deaths) and morbidity (disease, disorder or disability). ‘Peri’ means ‘around the time of’, so perinatal means around the time of birth. Perinatal mortality refers to the total number of stillbirths (babies born dead after the 28th week of gestation) plus the total number of neonates (newborns) who die in the first 7 days of life. The perinatal mortality rate is the number of stillbirths and neonatal deaths that occur in every 1000 live births, and is an internationally recognised measure of the quality of antenatal care.

What is the definition of the maternal mortality ratio (MMR)? (You learned this in Study Session 1 of this Module.)
MMR is the total number of women dying from complications due to pregnancy or childbirth in every 100,000 live births.

FANC is the best approach for resource-limited countries where health professionals are few and health infrastructures are limited. In particular, the majority of pregnant women can’t afford the cost incurred by the frequent antenatal visits required by the traditional antenatal care approach. From the logistical and financial point of view, the traditional approach is not practical for the majority of pregnant women and is a burden on the healthcare system. As a result, many developing countries, including Ethiopia, are adopting the FANC approach.

13.1.2 Failings of the traditional approach to antenatal care

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Research studies (for example, see Box 13.2) have shown that the more frequent antenatal visits traditionally practised do not improve pregnancy outcomes. In particular, pregnant women labelled as ‘low-risk’ or ‘not at risk’ in traditional antenatal care may not receive counselling on danger symptoms. As a result, it is very common that these women fail to recognise the danger symptoms and do not report soon enough to health professionals.

Box 13.2 Failure to identify ‘at risk’ pregnancies

Taking obstructed labour occurrence as one of indicators, a study in Zaire in 1984 in 3,614 pregnant women showed that 71% of the women who developed obstructed labour were previously categorised as ‘not at risk’, while 90% of women who were identified as ‘at risk’ did not develop obstructed labour. This is one source of evidence to show that most pregnancy problems are unpredictable and late phenomena.

Other examples of unpredictable pregnancy disorders that appear very late in gestation include the top three killers of mothers:

Hypertensive disorders of pregnancy (hypertension means high blood pressure), specifically eclampsia, which commonly occurs very late in pregnancy, or during labour or after delivery (you will learn about this in Study Session 19).
Haemorrhage (heavy bleeding), which occurs most commonly in the third trimester (Study Session 21 describes late pregnancy bleeding), or the more often fatal postpartum haemorrhage, which occurs after delivery (you will learn about this in the Labour and Delivery Care Module).
Pregnancy related infection (postpartum infection of the uterus), which usually develops after delivery (this is described in the Labour and Delivery Care Module).

The traditional approach to antenatal care is unable to identify accurately women who are ‘at risk’ of developing any of these life-threatening conditions. It identifies some women as being ‘low risk’ who subsequently develop danger symptoms that need urgent professional intervention.

13.1.3 Comparions of traditional and focused antenatal care

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Table 13.1 summarises the basic differences between the traditional and focused antenatal care approaches.

Substance use includes tobacco, alcohol, khat, illegal drugs, hashish, cocaine and others

Table 13.1 Basic differences between traditional and focused antenatal care.

Characteristics	Traditional antenatal care	Focused antenatal care
Number of visits	16–18 regardless of risk status	4 for women categorised in the basic component (as described later in this study session)
Approach	Vertical: only pregnancy issues are addressed by health providers	Integrated with PMTCT of HIV, counselling on danger symptoms, risk of substance use, HIV testing, malaria prevention, nutrition, vaccination, etc.
Assumption	More frequent visits for all and categorising into high/low risk helps to detect problems. Assumes that the more the number of visits, the better the outcomes	Assumes all pregnancies are potentially ‘at risk’. Targeted and individualised visits help to detect problems
Use of risk indicators	Relies on routine risk indicators, such as maternal height <150 cm, weight <50 kg, leg oedema, malpresentations before 36 weeks, etc.	Does not rely on routine risk indicators. Assumes that risks to the mother and fetus will be identified in due course
Prepares the family	To be solely dependent on health service providers	Shared responsibility for complication readiness and birth preparedness
Communication	One-way communication (health education) with pregnant women only	Two-way communication (counselling) with pregnant women and their husbands
Cost and time	Incurs much cost and time to the pregnant women and health service providers, because this approach is not selective	Less costly and more time efficient. Since majority of pregnancies progress smoothly, very few need frequent visits and referral
Implication	Opens room for ignorance by the health service provider and by the family in those not labelled ‘at risk’, and makes the family unaware and reluctant when complications occur	Alerts health service providers and family in all pregnancies for potential complications which may occur at any time

13.2 Important elements of FANC

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FANC has the following three stages:

Thorough evaluation (history taking, physical examination and basic investigations)
Intervention (prevention/prophylaxis and treatment)
Promotion (health education/counselling and health service dissemination).

Box 13.3 summarises the steps in this process.

Box 13.3 Basic steps in the FANC service

Gather information (take history) by talking with the mother, check the mother’s body and check the fetus (physical examination and tests), as you learned in Study Sessions 8 to 11 of this Module.
Interpret the gathered information (make a diagnosis) and evaluate any risk factors.
Make an individualised care plan. If no abnormalities are identified, the care plan will focus on counselling, birth preparedness and complication readiness. If the mother needs specialised care, the plan will be to refer her to a higher health facility.
Follow the care plan — in subsequent visits, you may be able to take care of the woman yourself by providing treatments and counselling, or you may need to refer her.

In provision of the FANC service, important elements to be considered are:

Keeping privacy and confidentiality; effective communication builds trust and fosters confidence, so you should talk with women and their husbands in a manner that encourages communication about birth preparedness, complication readiness, HIV prevention, care and treatment.
Continuous care is provided by the same provider for pregnant women in the community; in the context of this curriculum, you are the skilled health care provider for the pregnant women without identified complications in your community.
Promotion of involvement of the woman’s partner or support person in the process of antenatal care and in preparations for the delivery.
Provision of routine antenatal care services according to the national protocols, which will be described later in this study session).
Linking of antenatal and postnatal care with prevention of mother to child transmission of HIV (PMTCT) and provision of family planning services.

13.3 The basic and specialised components of FANC

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The FANC model divides pregnant women into two groups: those eligible to receive routine antenatal care (called the basic component), and those who need special care based on their specific health conditions or risk factors (the specialised component). Pre-set criteria (described below) are used to determine the eligibility of women to join the basic component. Women selected for the basic component are considered not to require any further assessment or special care at the time of the first visit, regardless of the gestational age at which they start the antenatal care programme.

Women are questioned and examined at the first antenatal visit to see if they have any of the following risk factors:

Previous pregnancy:

Ended in stillbirth or neonatal loss
History of three or more consecutive spontaneous abortions
A low birth weight baby (<2500 g) or a large baby (>400 g)
Hospital admission for hypertension, pre-eclampsia or eclampsia. (You will learn about these conditions in Study Session 19.)

Current pregnancy:

Diagnosed or suspected twins, or a higher number of multiple pregnancies
Maternal age less than 16 years or more than 40 years
Mother has blood type Rhesus-negative: this can result in serious harm to the fetus if it is Rhesus-positive, because the mother makes antibodies which can cross the placenta and attack the baby’s tissues
Mother has vaginal bleeding, or a growth in her pelvis
Mother’s diastolic blood pressure (the bottom number) is 90 mmHg or more
Mother currently has diabetes, heart disease, kidney disease, cancer, hypertension or any severe communicable disease such as TB, malaria, HIV/AIDS or another sexually transmitted infection (STI).

A ‘YES’ to any ONE of the above questions means that the woman is not eligible for the basic component of antenatal care. She is categorised in the specialised component and requires more close follow-up and referral to specialty care.

You will refer women in the specialised component to a higher level health facility for additional monitoring and specialised care determined by specialists in these areas, while you continue to follow the activities of the basic component with these women.

13.4 The Antenatal Care Card

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Figure 13.1 is a guide to the information that you should gather at each of the four antenatal visits. At the beginning of each visit, ask the mother if she has developed any danger symptoms since her last check up. Remind her to come to see you quickly if she develops vaginal bleeding, blurred vision, abdominal pain, fever or any other danger symptoms. You will learn how to counsel her about danger symptoms in Study Session 15.

View larger image

Figure 13.1 Antenatal Care Card from the Ethiopian Federal Ministry of Health’s ‘Integrated Maternal and Child Care Card’.

13.5 Objectives and procedures at each FANC visit

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Sometimes a pregnant woman comes for the first antenatal check-up when the pregnancy is already advanced, but you should cover all the steps in the basic care plan and all of the first visit activities even if she is already in the second or third trimester.

13.5.1 The first FANC visit

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The first FANC visit should ideally occur before 16 weeks of pregnancy. You are expected to achieve the following objectives:

Determine the woman’s medical and obstetric history (using the techniques you learned in Study Session 8) in order to collect evidence of her eligibility to follow the basic component of FANC, or determine if she needs special care and/or referral to a higher health facility.
Perform basic examinations (pulse rate, blood pressure, respiration rate, temperature, pallor, etc.).
If you think the pregnancy is beyond the first trimester, try to determine the gestational age of the fetus by measuring fundal height using the methods you learned in Study Session 10.

Provide nutritional advice and routine iron and folate supplementation (the dosage is in Study Session 14). Advising against misconceptions about diet is also important. For example, in some parts of Ethiopia it is thought that eating eggs and meat during pregnancy will cause vernix (the sticky white substance on the baby’s skin at birth), and that vernix is dirty. In fact, eggs and meat are important sources of protein for the mother and the developing fetus, and vernix is good for the baby because it protects the baby’s skin.
Provide HIV counselling and PMTCT services (you will learn how to do this in Study Session 16).
Give advice on malaria prevention and if necessary provide insecticide-treated bed nets (ITNs). You will learn more about malaria prevention and treatment in Study Session 18.
Check her urine for sugar using the dipstick test you learned about in Study Session 9, or refer her to the health facility if you suspect she may be developing diabetes.
Advise her and her partner to save money in case you need to refer her, especially if there is an emergency requiring transport to a health facility. She may also need money for additional drugs and treatments. Financial help may be available from local community organisations like women’s groups.
Provide specific answers to the woman’s questions or concerns, or those of her partner.

What could it mean if there is a difference of several weeks between the gestational age estimated from fundal height measurement and the estimate based on last normal menstrual period (LNMP)?
As you learned in Study Session 10, this may mean that the woman has not remembered the date of her LMNP correctly, but it could also mean that the fetus is not growing normally (fundal height lower than LNMP estimate), or there could be too much amniotic fluid around the fetus, or a twin pregnancy or very big baby (fundal height larger than LNMP estimate.)

13.5.2 The second FANC visit

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Schedule the second FANC visit at 24-28 weeks of pregnancy. Follow the procedures already described for the first visit. In addition:

Address any complaints and concerns of the pregnant woman and her partner.
For first-time mothers and anyone with a history of hypertension or pre-eclampsia/eclampsia), perform the dipstick test for protein in the urine. (You will learn how to do this in Study Session 19 of this Module.)
Review and if necessary modify her individualised care plan.
Give advice on any sources of social or financial support that may be available in her community.

13.5.3 The third FANC visit

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The third FANC visit should take place around 30–32 weeks of gestation. The objectives of the third visit are the same as those of the second visit. In addition you should:

Direct special attention toward signs of multiple pregnancies and refer her if you suspect there is more than one fetus.
Review the birth preparedness and the complication readiness plan (discussed later in this study session).
Perform the dipstick test for protein in the urine for all pregnant women (since hypertensive disorders of pregnancy are unpredictable and late pregnancy phenomena).
Decide on the need for referral based on your updated risk assessment.
Give advice on family planning (Study Session 14).
Encourage the woman to consider exclusive breastfeeding for her baby (Study Session 14).

Remember that some women will go into labour before the next scheduled visit. Advise all women to call you at once, or come to you, as soon as they go into labour. Don’t wait!

You should also emphasise the importance of the first postnatal visit to ensure that the woman is seen by you either at her home or at the Health Post as soon as possible after the birth. The most critical postnatal period for the mother is the first 4 hours; this is when most cases of postpartum haemorrhage (PPH) occur. (You will learn about PPH in the Labour and Delivery Care Module.)

13.5.4 The fourth FANC visit

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The fourth FANC visit should be the final one for women in the basic component and should occur between weeks 36-40 of gestation. You should cover all the activities already described for the third visit. In addition:

The abdominal examination should confirm fetal lie and presentation, as you learned in Study Session 10 and 11 and in your practical training classes. At this visit, it is extremely important that you discover women with a baby in breech presentation or a transverse lie and refer her to the nearest health facility for obstetric evaluation.

The individualised birth plan (Box 13.4) should be reviewed to check that it covers all aspects of birth preparedness, complication readiness and emergency planning, as described in the next section.
Provide the woman with advice on signs of normal labour and pregnancy-related emergencies (described in Study Session 15) and how to deal with them, including where she should go for assistance.

What is meant by breech presentation, and what is a transverse lie? (You learned this in Study Session 11.)
Breech presentation is when the baby is ‘head up’ in the uterus near the end of gestation, with its buttocks, feet or legs pushing down into the mother’s cervix. A transverse lie is when the baby is lying sideways across the abdomen.

A baby in the breech presentation may be delivered through the vagina in a health facility. A baby in the transverse lie can only be corrected into the normal ‘head first’ or vertex presentation by an obstetric specialist, or it must be delivered by caesarean surgery.

Box 13.4 Individualised birth plan

An individualised birth plan is a guide for healthcare providers developed in discussion with the individual woman and her partner or main support people which reflects their preferences about the planned birth. Some couples choose to have their baby at home under your care because they see birth as a normal part of life. Others choose to have a hospital or health centre birth. The birth plan for HIV positive women should be to deliver in a health facility, according to the National Guideline for PMTCT of HIV (as described in Study Session 16 of this Module).

13.6 Birth preparedness, complication readiness and emergency planning

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Birth preparedness is the process of planning for a normal birth. Complication readiness is anticipating the actions needed in case of an emergency. Emergency planning is the process of identify and agreeing all the actions that need to take place quickly in the event of an emergency, and that the details are understood by everyone involved, and the necessary arrangements are made. First we consider normal birth preparedness.

13.6.1 Normal birth preparedness

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Educate the mother and her family to recognise the normal signs of labour. Delivery may occur days or even weeks before or after the expected due date based on the date of the last normal menstrual period. Knowing what labour means will help the mother know what will happen, and this in turn helps her feel comfortable and assured during the last days or weeks of her pregnancy.

Provide clear instructions on what to do when labour starts (e.g. in the event of cramping abdominal pain or leaking of amniotic fluid). Make sure that someone will call you or another skilled attendant for the birth as soon as possible. Support your verbal advice with written instructions in the local language.

Birth preparedness should also cover:

Honoring her choices. You should give all the necessary information about safe and clean delivery, but ultimately you should respect a woman’s choice of where she wants to give birth and who she wants to be with her.
Helping her to identify sources of support for her and her family during the birth and the immediate postnatal period.
Planning for any additional costs associated with the birth.
Preparing supplies for her care and the care of her newborn baby.

13.6.2 Birthing supplies the mother should prepare

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The birthing supplies that a pregnant woman and her family should be advised to prepare before the delivery are listed below (and see Figure 13.2):

Very clean cloths to put under the mother and for drying and covering the newborn
New razor blade to cut the cord
Very clean and new string to tie the cord
Soap, a scrubbing brush and (if possible) medical alcohol for disinfection
Clean water for drinking and for washing the mother and your hands
Three large buckets or bowls
Supplies for making rehydration drinks, ‘atmit’ or tea
Flashlight if there is no electricity in the area.

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Figure 13.2 Supplies the woman should prepare in readiness for the birth.

13.6.3 Complication readiness and emergency planning

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As noted earlier, complication readiness is the process of anticipating the actions needed in case of an emergency and making an emergency plan (Box 13.5). Pregnancy-related disorders such as high blood pressure and bleeding can begin any time between visits for antenatal check-ups, and any other illness may occur during the pregnancy. If such conditions are suspected at any stage, you should refer the woman immediately, and repeatedly counsel her to report to you or seek medical care quickly if danger symptoms are seen.

Box 13.5 In an emergency

Make sure the woman and her husband and other family members know where to seek help.

Alert them to plan for transportation with vehicle owners.
Advise them to save money for transportation, drugs and other treatments.
Decide who will accompany her to the health facility.
Decide who will care for her family while she is away.
A pregnant woman may bleed massively (haemorrhage) during or after delivery and may need blood to be given to her. You should make sure that she or her husband identifies two healthy adult volunteers who agree to act as blood donors if she needs it. Reassure the potential blood donors that they will not be harmed by giving blood, and their general health will be assessed before donating.

An important aspect of emergency planning is to foresee possible sources of delay that could be overcome by good planning.

13.6.4 Causes of delay in getting emergency help

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There are three types of delay, all of which can be serious for the mother and her baby:

Delay in healthcare-seeking behaviour (delay in deciding to seek medical care),
Delay in reaching a health facility
Delay in getting the proper treatment.

These delays have many causes, including logistical and financial constraints, and lack of knowledge about maternal and newborn health issues. For example, the woman, her family or neighbours may feel that only the husband or another respected family member can give permission for the woman to send for you, or get urgent medical care at a health facility. But delay could threaten her life and that of her baby.

Delays in deciding to seek care may be caused by failure to recognise symptoms of complications, cost considerations, previous negative experiences with the healthcare system and transportation difficulties. Delays in reaching care may be created by the distance from a woman’s home to a facility or healthcare provider, the condition of roads, or a lack of emergency transportation.

Delays in receiving appropriate care may result from shortages of supplies and basic equipment, a lack of healthcare personnel, and poor skills of healthcare providers. The causes of these delays are common and predictable. However, in order to address them, women and families and the communities, providers and facilities that surround them must be prepared in advance and ready for rapid emergency action.

13.6.5 Making a referral

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Finally, you need to know what to do if you are making a referral – sending a client for additional health services and specialised care at a higher level health facility. You should complete a referral form in full and sign and date it, then make sure it goes to the health facility with the patient; it also has a space for feedback to you by the health facility about what treatment they have given.

If you do not have the standard referral form, you should write a note to the health facility that contains the key information (Box 13.6).

Box 13.6 Referral note

Date of the referral and time
Name of the health facility you are sending the patient to
Name, date of birth, ID number (if known) and address of the patient
Relevant medical history of the patient
Your findings from physical examinations and tests
Your suspected diagnosis
Any treatment you have given to the patient
Your reason for referring the patient
Your name, date and signature.

That concludes our discussion of focused antenatal care. In the study sessions that follow in this Module you will learn more about specialised aspects of antenatal care in specific contexts, including health promotion issues in pregnancy, counselling the pregnant woman about danger symptoms, PMTCT of HIV, the diagnosis and management of malaria, anaemia and urinary tract infections, hypertension, abortion and bleeding in early and late pregnancy. The Antenatal Care Module ends by describing how to set up an intravenous (IV) cannula and infusion tubing to give fluids directly into the blood stream, and how to insert a urinary catheter to drain the bladder of a pregnant woman. Your practical training sessions will ensure that you have achieved these competencies.

Summary of Study Session 13

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In Study Session 13, you learned that:

Focused antenatal care (FANC) segregates pregnant women into those eligible to receive routine ANC (the basic component) and those who need specialised care for specific health conditions or risk factors.
FANC emphasises targeted and individualised care planning and birth planning.
FANC makes the pregnant woman, with her husband and the family, participatory in identifying pregnancy related or unrelated complications, planning and decision-making on the future course of pregnancy.
Until proved otherwise, no pregnancy is to be labelled as risk-free.
A pregnant woman has four antenatal visits, each with specific objectives to promote FANC the health of the mother and the fetus, assess risks, and give early detection of complications.
The first FANC visit should be before week 16 of pregnancy; it assesses the woman’s medical and obstetric history, physical examination and test results, to determine her eligibility to follow the basic component.
The second FANC visit is at 24-28 weeks. The additional focus is on measuring blood pressure and fundal height to determine gestational age.
The third FANC visit is at 30–32 weeks. The additional focus is on detecting multiple pregnancies.
The fourth is the final FANC visit between weeks 36 and 40. The additional focus is on detecting breech presentation and transverse fetal lie, and signs of hypertensive disorders. Pay extra attention to informing women about birth preparedness, complication readiness and emergency planning.
Complication readiness and emergency planning anticipates and prepares for the actions needed in case of an emergency, including organising transport, money, support persons and blood donors, and reducing sources of delay in getting to the higher level health facility.
Women who need to be referred at any stage during the pregnancy, or when labour begins, should be accompanied by a referral note with all relevant details of their history, diagnosis and treatment.

Self-Assessment Questions (SAQs) for Study Session 13

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SAQ 13.1 (tests Learning Outcomes 13.1, 13.2 and 13.4)

Which of the following statements is false? In each case, explain what is incorrect.

A Focused antenatal care focuses on the pregnant woman alone.

B Women in the basic component receive only 4 FANC visits, unless warning signs or symptoms are detected at any stage.

C Pregnant women do not need to prepare any equipment for labour and delivery.

D The birth plan in FANC is essentially the same for every woman and she is told about it at the fourth visit.

E Prophylaxis in FANC focuses on prevention of sexually transmitted infections, including mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia and tetanus.

Answer

A is false. Focused antenatal care does not focus on the pregnant woman alone (this used to happen in the traditional approach). FANC includes the woman’s partner and if possible the whole family in caring for her during pregnancy, watching for danger symptoms, and preparing for the birth, complication readiness and emergency planning.

B is true. Women in the basic component receive only 4 FANC visits, unless warning signs or symptoms are detected at any stage.

C is false. A pregnant woman should prepare for labour and delivery by assembling very clean cloths, a new razor blade, very clean new string, soap and a scrubbing brush, clean water for washing and drinking, buckets and bowls, supplies for making drinks, and a flashlight.

D is false. The birth plan in FANC is individualised for every woman and her partner and respects her wishes and preferences. It is discussed at the third visit and revised if necessary at the fourth visit.

E is true. Prophylaxis in FANC focuses on prevention of sexually transmitted infections, including mother to child transmission of HIV, malaria, nutritional deficiencies, anaemia, urinary tract infections and tetanus.

SAQ 13.2 (tests Learning Outcomes 13.3 and 13.5)

Suppose a 27-year-old pregnant woman called Aster comes to see you. She tells you that this is her first pregnancy and the last time she saw her menstrual period was 25 weeks ago. What actions do you take during this first visit? When would you normally see her for the next visit?

Answer

As Aster is already 25 weeks pregnant, you should cover all the services of the first and the second FANC visits. Give close attention to investigating her medical and obstetric history and do a complete physical examination, including blood pressure, pulse, temperature, respiration rate, abdominal examination to measure fundal height, listen to the fetal heart beat, check for presentation and lie of the fetus, and check the results of urine tests. The purpose is to determine Aster’s eligibility to follow the basic component of FANC. Also advise her on nutrition, hygiene and rest.

If she is healthy and the pregnancy appears to be progressing normally, tell her that the next visit should be at 30-32 weeks of pregnancy - but she must seek help at once if she experiences any of the danger symptoms such as bleeding or foul smelling discharge from her vagina, fever, blurred vision, or feeling dizzy and confused.

SAQ 13.3 (tests Learning Outcomes 13.3 and 13.5)

Suppose Aster comes to you at 32 weeks of her pregnancy. You discover that her blood pressure is 120/60 mmHg, she has mildly pale conjunctiva and the fundal height is measured as the 38 week size. What do these signs suggest and what actions would you take?

Answer

Pale conjunctiva suggests that Aster may be anaemic, so ask her about her nutrition - what does she eat and how much food does she get each day? Perform a multiple dipstick test on a sample of her urine to see if it contains excess sugar or protein. If her urine test is normal, counsel her on improving her nutrition and provide her with iron and folate tablets.

As the fundal height is much more than you would normally expect at 32 weeks, it may indicate twins or a pathological condition and Aster should be referred for evaluation at a higher level of care. Therefore you should write a referral note and advise her to go to the nearest health centre or hospital. She may need help in arranging transportation or money for the trip. Advise her about birth preparedness, complication readiness and emergency planning.

Introduction to the Antenatal Care Module

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According to WHO estimates, more than 1,500 women die from pregnancy or childbirth-related complications every day. Annually, about half a million maternal deaths occur worldwide, and most of these deaths are in developing countries. Globally, there is not much improvement in the maternal mortality ratio (MMR, the proportion of women dying due to complications of pregnancy or childbirth), primarily because of the high maternal deaths in less developed countries. The maternal mortality ratio is less than 10 per 100,000 live births in Western countries and above 1,000 per 100,000 live births in very poor countries. As the Ethiopian Demographic and Health Survey reports showed, the maternal mortality ratio was 871 per 100,000 live births in 2000 and 673 per 100,000 live births in 2005 (European calendar). In short, a woman’s lifetime risk of maternal death is 1 in 7,300 in developed countries, versus 1 in 75 in less developed countries.

The most common causes (about 80%) of maternal mortality in developing countries (unsafe abortion, haemorrhage, eclampsia, infection and obstructed labour – described in detail either in this Module, or in the next one) are either avoidable or treatable. With that understanding, improving maternal health is one of the eight Millennium Development Goals (MDGs) adopted by the international community at the United Nations Millennium Summit in 2000. The Ethiopian government has expressed its commitment to deliver the MDGs, including improving maternal health and reducing maternal mortality by three-quarters (MDG5), and reducing mortality of children aged under 5 years by two-thirds (MDG4).

To make a difference to maternal and newborn health in developing countries, or anywhere else, health promotion, disease prevention and effective healthcare have to begin even before the occurrence of pregnancy. This helps to evaluate the physiological maturity and psychological readiness of the mother, and also her medical fitness to conceive and carry the pregnancy. As a continuum of preconception care, effective antenatal care is a very crucial aspect of the health service. It can detect established medical problems and reduce the occurrence of some pregnancy-related complications; it gives the opportunity for pregnant women and their families to become familiar with the health facility environment and accept home visits by health professionals, such as the Health Extension Practitioners of Ethiopia; it alerts pregnant women to possible danger signs, so that they are aware of pregnancy and delivery-related problems that may arise later, and thus can make practical and financial preparations for possible emergencies ahead of time.

The goal of antenatal care is to have a healthy mother and healthy baby by monitoring the well-being of both the woman and the fetus during pregnancy, and helping them make a smooth transition to labour and delivery. To achieve this goal, your role of providing optimal antenatal care at the Health Post or in the home is immense. Therefore, understanding the concepts and competencies of antenatal care as recommended in this Module, and taught in your practical skills training programme, is crucial for the better health and survival of the pregnant women and newborns in your catchment area, and for the general wellbeing of Ethiopian mothers and their children.

This Module is formulated to equip you with the basic principles and practice of antenatal care at Health Post and home level. It has 22 Study Sessions divided into two parts. In Part 1, you will learn about antenatal care planning and promotion, the anatomy and physiology of the female reproductive system, physiologic changes during pregnancy, routine assessment of the pregnant woman and fetus, and methods of evaluating and identifying the progress of a normal pregnancy and some common maternal and fetal problems. In Part 2, you will learn what focused antenatal care is, and about counselling pregnant women on staying healthy, eating well at low cost, the danger signs to watch for, pregnancy from the perspective of HIV and prevention of mother-to-child transmission, premature labour, hypertensive disorders of pregnancy, abortion, and latepregnancy bleeding, and other common medical problems in pregnancy. Part 2 ends with the theory of two major practical procedures: setting up pre-referral intravenous therapy for women in shock, and inserting a catheter to drain the bladder of a pregnant woman.

Introduction

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Health promotion refers to any activity that aims to achieve better health in a community or a country. It includes the health education of individuals to enable them to control and change their lifestyles so that their health is improved. This is the main focus of this study session, in the context of your role as a health educator of pregnant women during antenatal care visits. But as you know from Study Session 2 of this Module, health promotion activities go far beyond this focus on individual behaviour, and include a wide range of social and environmental interventions that increase health and wellbeing in populations as well as individuals. Health promotion also includes disease prevention — actions taken to prevent a disease from developing, and health screening — the routine testing of individuals to see if they are at risk of developing a health problem. The relationship between health promotion, health education, disease prevention and health screening is represented in Figure 2.1 in Study Session 2.

Antenatal care (FANC, Study Session 13) provides a key entry point for a broad range of health promotion and disease prevention services. It is essential for healthcare providers and women to talk about important issues affecting the woman’s health and her pregnancy.

During the antenatal period, you can promote the health of the women in your care and the health of their babies before and after birth, by educating mothers about the benefits of good nutrition, adequate rest, good hygiene, family planning and exclusive breastfeeding, and immunization and other disease prevention measures. Your aim is to develop women’s knowledge of these issues so they can make better informed decisions affecting their pregnancy outcome — but you should never lose sight of the difficulties some women will face in being able to improve their lifestyles.

Learning Outcomes for Study Session 14

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When you have studied this session you should be able to:

14.1 Define and use correctly all of the key words printed in bold. (SAQs 14.2 and 14.4)

14.2 Describe the major dietary constituents for good health in a pregnant woman, advise women on eating well with little money, and explain the problems resulting from a poor diet. (SAQs 14.1 and 14.2)

14.3 Explain the benefits of good hygiene and other self-care activities in pregnancy. (SAQ 14.3)

14.4 Explain the benefits of immunization against tetanus. (SAQs 14.3)

14.5 Explain the benefits of early and exclusive breastfeeding for the mother and for her baby. (SAQs 14.3 and 14.4)

14.6 Explain the benefits of family planning to achieve birth spacing and discuss postpartum contraception with pregnant women. (SAQ 14.4)

14.1 Nutrition during pregnancy

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In this section (the biggest in this study session) we describe the nutritional requirements in pregnancy in detail and explain how you can advise women about eating well, even if they have very little money for additional food.

14.1.1 Eating well

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Eating well means eating a variety of healthy foods and also eating enough food. This combination helps a pregnant woman and her baby stay healthy and strong because it:

Helps a woman resist illness during her pregnancy and after the birth
Keeps a woman’s teeth and bones strong
Gives a woman strength to work
Helps the baby grow well in the mother’s uterus
Helps a mother recover her strength quickly after the birth
Supports the production of plenty of good quality breast milk to nourish the baby.

Eating a variety of foods

It is important for pregnant women (like everyone else) to eat different kinds of food (see Figure 14.1): main foods (carbohydrates), grow foods (proteins), glow foods (vitamins and minerals), and go foods (fats, oils and sugar), along with plenty of fluids. We will describe each of these food groups in more detail later in the study session.

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Figure 14.1 Eating well means eating a variety of foods to get all the right nutrients, especially during pregnancy and breastfeeding, and eating enough food for good health.

Eat more food

Pregnant women and women who are breastfeeding need to eat more than usual. The extra food gives them enough energy and strength, and helps their babies grow. They need to increase their usual food intake by at least 200 calories per day, or even more than this if they were underweight before they became pregnant. There are many ways to increase daily food intake by this amount: for example, one more serving of maize porridge and 12 groundnuts a day would meet this additional requirement.

Some pregnant women feel nauseated and do not want to eat. But pregnant women need to eat enough — even when they do not feel well. Simple foods like injera or rice can be easier for these women to eat. For women who suffer from nausea, encourage small and frequent meals.

Problems from poor nutrition

Poor nutrition can cause tiredness, weakness, difficulty in fighting infections and other serious health problems. Poor nutrition during pregnancy is especially dangerous. It can cause miscarriage or cause a baby to be born very small or with birth defects. It also increases the chances of a baby or a mother dying during or after the birth.

14.1.2 Talking to women about food

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When you see pregnant women for antenatal care, or at village meetings and celebrations, in the market, try to find ways to enquire sensitively about the food they eat. The earlier pregnant women start eating healthier foods, the better chance they have to stay healthy, to have normal births and to have healthy babies.

To find out whether a woman is eating well, ask her what she usually eats, and how much. For example, ask her: ‘What did you eat yesterday?’ Be sure to tell her what is healthy about what she eats, reinforce the positive efforts she is making to eat well. Then, if it is appropriate, make a suggestion for how she could eat better.

Remember that education about food is not enough on its own to change eating behaviour. Even if a woman knows the best foods for health, she may not eat them. Many families cannot afford to buy enough food or a wide variety of foods. Some women may simply not like the taste of some healthy foods. To help a woman eat better, suggest healthy foods that she can afford and will choose to eat.

14.1.3 Eating well with little money

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The biggest cause of poor nutrition is poverty. A very poor family can eat better by spending money wisely and not wasting what little they have. A father who buys alcohol, tobacco and ‘chat’ (or khat) could instead buy nutritious food or he could buy a hen to lay eggs. A mother who buys her children sweets or soda pop could instead buy eggs, beans or other low-cost, healthful foods. Here are some ideas that families can use to eat better with little money.

Figure 14.2 Grow beans this year and plant maize in the same earth next year.

Beans, peas and lentils

Beans, peas and lentils belong to a family of vegetables called legumes. All legumes have a lot of protein and vitamins, and they usually do not cost much. They have even more vitamins if they are sprouted before being eaten. Planting legumes makes soil richer. Other crops such as maize will grow better in a field where legumes once grew (Figure 14.2).

Less expensive meats and animal products

Blood and organ meats like liver, heart and kidney have a lot of iron and may cost less than other meats. Fish and chicken are as healthy as other meats, and usually cost less — especially for a family that fishes or raises their own chickens. Eggs have a lot of protein, iron, and vitamin A. Eggs give more protein for less money than almost any other food.

Whole grains

Grains like teff, wheat, rice and corn are more nutritious when they have not been refined (processed to take out the colour). Taking out the colour takes out healthy things too. White bread and white rice have fewer vitamins, minerals and proteins than brown bread or brown rice. Dark teff and brown injera are more nutritious than the light-coloured ones.

Vegetables and fruits

When vegetables are boiled or steamed, some of the vitamins from the foods go into the cooking water. Use this water to make soups.

The outside leaves of plants are usually thrown away, but sometimes they can be eaten. The leaves of the cassava plant have more vitamins and protein than the root. Many wild fruits and berries are rich in vitamins and natural sugars that give energy.

Breast milk

Breast milk costs nothing, and has all the nutrition a baby or young child needs. Young children who are on exclusive breastfeeding do not need fortified milks or other foods until after the age of 6 months.

14.2 Food groups and their nutrients

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Main foods (carbohydrates)

In most parts of the world, people eat one main food at each meal. This main food may be injera, rice, maize, wheat, millet, cassava, plantain, kocho, bulla, godere, shenkora, gishta, breadfruit or another low-cost, starchy food which is rich in carbohydrates. These foods give the body energy. But to grow and stay healthy, the body needs other types of food too.

Grow foods (proteins)

Meat, fish and cheese are nutritious foods but they can carry parasites or disease when they are eaten raw. Pregnant women should eat fish, meat or cheese only when it is well cooked or pasteurised.

Grow foods contain protein, which is needed for the growth of muscles, bones, and strong blood. Everyone needs protein to be healthy and to grow. Some grow foods that are high in proteins are:

Legumes (beans, peas, soybeans, and lentils)
Eggs
Cheese, milk and yogurt
Nuts and seeds
Cereal, wheat, corn and rice
Meat, poultry and fish.

Go foods (sugars and fats)

Go foods contain sugars and fats, which give the body energy. Everyone needs these foods to be healthy. Some healthy go foods that are high in sugars are:

Fruits
Honey.

Some ‘go foods’ that are high in fats are:

Some nuts (e.g. peanuts) and some seeds (e.g. sunflower)
Avocados
Vegetable oils, butter and lard
Fatty meat
Milk and cheese
Eggs
Fish.

These days, many people eat more sugars and fats than they need. That is because more people drink sugary soda pop, or eat foods that come from packages instead of foods made at home. These packaged, sugary and fatty foods are expensive and not as healthy as fresh products. They also damage the teeth. It is better to eat go foods that are natural, not packaged.

Glow foods (vitamins and minerals)

Glow foods contain vitamins and minerals, which help the body fight infection and keep the eyes, skin and bones healthy and strong. Vitamins and minerals are known as micronutrients because they are very small. Fruits and vegetables are high in vitamins and minerals. It is important for pregnant women to eat as many different fruits and vegetables as they can. In the next section, we discuss the five most important vitamins and minerals that pregnant and breastfeeding women should eat every day.

14.2.1 The five most important vitamins and minerals

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Pregnant and breastfeeding women need more of these five vitamins and minerals than other people do — iron, folic acid, calcium, iodine and vitamin A. They should try to get these vitamins and minerals every day.

Why do you think that a pregnant woman needs more of these vitamins and minerals?
The baby needs them to grow and be healthy and to prevent birth defects. A pregnant woman needs them to have enough energy to look after herself and her family, to fight infections and to keep her strong for completing the pregnancy, giving birth safely and breastfeeding the baby afterwards.

Iron

Iron helps make blood healthy and prevents anaemia (you will learn about diagnosing and treating anaemia in Study Session 18 of this Module). A pregnant woman needs a lot of iron to have enough energy, to prevent too much bleeding at the birth, and to make sure that the growing baby can form healthy blood and store iron for the first few months after birth. It is also important in the production of good breast milk.

Figure 14.3 Pregnant and breastfeeding women should try to eat at least one iron-rich food every day.

These foods contain a lot of iron (Figure 14.3):

Poultry (chicken)
Fish
Dark leafy green vegetables
Meat (especially liver, kidney and other organ meats)
Whole grain products
Dried fruit
Nuts
Iron-fortified bread
Egg yolk.

Taking iron pills

It can be difficult for a pregnant woman to get enough iron, even if she eats iron-rich foods every day. She should also take iron pills (or liquid iron drops) to prevent anaemia. These medicines may be called ferrous sulfate, ferrous gluconate, ferrous fumerate or other names (ferrous comes from the Latin word for iron).

Iron pills or drops can be obtained from pharmacies and health institutions, but throughout Ethiopia you will give iron pills routinely to pregnant women as part of focused antenatal care. She should receive 300 to 325 mg (milligrams) of ferrous sulphate once a day taken by mouth, preferably with a meal. This dosage is usually supplied in a single tablet combined with folate (see below).

The iron pills may cause nausea, make it hard for the woman to pass stool (constipation), and her stool may turn black, but it is important for the woman to keep taking the iron pills because anaemia can cause complications during pregnancy, during delivery, and after the baby is born. It is helpful for the woman to take the iron pill with a meal, drink plenty of fluids, and eat plenty of fruits and vegetables to avoid nausea and constipation. The black colour of the stool is a normal side-effect from the iron and is not harmful.

Folate (folic acid)

Lack of folate can cause anaemia in the mother and severe birth defects in the baby. To prevent these problems, it is important if possible for a woman to get enough folic acid in her diet before she becomes pregnant and she should certainly do this in the first few months of pregnancy.

Foods rich in folate that pregnant and breastfeeding women should try to eat every day (Figure 14.4) include:

Figure 14.4 These foods contain a lot of folate.

Dark green, leafy vegetables
Whole grains (brown rice, whole wheat)
Meat (especially liver, kidney and other organ meats)
Fish
Peas and beans
Eggs
Sunﬂower, pumpkin and squash seeds
Mushrooms.

As well as eating as many of these foods as she can, all pregnant women should also take 400 mcg (micrograms) of folic acid tablets orally every day during pregnancy. She should be able to get these tablets from you as part of Focused Antenatal Care.

Calcium

Figure 14.5 Calcium-rich foods.

A growing baby needs a lot of calcium to make new bones, especially in the last few months of pregnancy. Women need calcium for strong bones and teeth. These foods (Figure 14.5) contain a lot of calcium:

Yellow vegetables (hard squash, yams)
Lime (carbon ash)
Milk, curd, yogurt and cheese
Green, leafy vegetables
Bone meal and egg shells
Molasses and soybeans
Sardines.

Women can also get more calcium in these ways:

Soak bones or eggshells in vinegar or lemon juice for a few hours. Then use the liquid to make soup or eat with other foods.
Add lemon juice, vinegar or tomatoes when cooking bones.
Grind eggshells into a fine powder and mix into food.
Soak maize in lime (carbon ash) before cooking it.

Iodine

Figure 14.6 Iodized salt is the easiest way to get enough iodine in the diet.

Iodine prevents goitre (swelling of the neck) and other problems in adults. Lack of iodine in a pregnant woman can cause her child to have cretinism, a disability that affects thinking and physical features.

The easiest way to get enough iodine is to use iodized salt instead of regular salt (Figure 14.6). It is available in packet form labelled ‘Iodized salt’ in many market places.

Vitamin A

Vitamin A prevents poor vision at night or when light intensity is low and helps to fight infections. Lack of vitamin A also causes blindness in children. A woman needs to eat plenty of vitamin A-rich food during pregnancy and while breastfeeding.

Dark yellow and green leafy vegetables and yellow fruits contain lots of vitamin A. Name some of these vegetables and fruits.
Carrots, mangoes, spinach, cabbage. (You may have suggested other good examples.)

Other sources of vitamin A are liver, fish liver oil, milk, eggs and butter.

Fluids

Along with eating healthy foods, women should drink plenty of clean water and other healthy fluids every day. Fruit juices, animal milks and many herbal teas are all healthy fluids to drink.

14.3 Hygiene during pregnancy

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During pregnancy, women should be especially careful about personal hygiene. Pregnant women sweat more and have more vaginal discharge than non-pregnant women (due to hormonal changes), and they may be more vulnerable to infection by germs in the environment. Keeping the body clean helps prevent infection. Hand washing with soap is the most important hygiene action she can take, especially before preparing food and after going to the toilet. If possible, a pregnant woman should wash her body every day with clean water — especially her genital area.

Dental hygiene is especially important during pregnancy because increased oestrogen levels can cause swelling and increased sensitivity in gum tissues. Whether she cleans her teeth with a dental stick or a toothbrush and toothpaste, the pregnant woman should do so regularly.

14.4 Living a healthy lifestyle

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As well as eating well and keeping clean, pregnant women need to get enough sleep and rest every day. This will help her to avoid developing high blood pressure (discussed in detail in Study Session 19 later in this Module), and oedema (swelling of the feet and ankles due to fluid collecting in the tissues). Good rest also helps her to stay strong and gives the fetus a better chance of being born healthy.

Figure 14.7 Families who encourage a pregnant woman to rest often are helping her and the baby to be healthy.

Many women have to work throughout their pregnancy in the fileds, factories or shops, as well as in their own homes. This can be especially hard for women during pregnancy, because they get more tired than usual — especially in the last few weeks. Explain to them and their families that the woman should try to rest for a few minutes every 1 to 2 hours (Figure 14.7). This will also help her to enjoy her pregnancy.

Figure 14.8 Whatever a mother puts into her body passes to her baby.

Make sure that women know that whatever they put into their body will pass across the placenta and into the baby (Figure 14.8). Cigarette smoke, alcohol and illegal drugs such as opium, heroin, cocaine and barbiturates are dangerous for anyone, but especially harmful to the developing fetus. Even one or two alcoholic drinks a day during pregnancy can result in the baby being born too small, or with birth defects or disabilities that affect the brain.

She should also be advised to avoid:

Lifting heavy things
People who are sick, especially if they have vomiting, diarrhoea or rashes
Strong chemicals or their fumes (e.g. chemicals used to kill pests in the fields)
Non-essential medicines
Medicines such as cough syrups, laxatives and pain relievers that have not been prescribed for her by a health worker (Figure 14.9).

Figure 14.9 Pregnant women should take only medicines that are safe in pregnancy and that are truly needed.

14.5 Immunization against tetanus

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Tetanus is a very serious, life-threatening infection, which damages the nervous system and is caused by bacteria in the environment, for example in soil. Tetanus toxoid immunization is the best protection against tetanus for the woman and her baby. Therefore, it is very important for her to be immunized according to the schedule on her card, and to bring her card to every antenatal care visit (Figure 14.10).

Figure 14.10 Make sure all pregnant women are immunized against tetanus.

In the Module on Postnatal Care, you will learn that to prevent tetanus in the newborn, the stump of the baby’s umbilical cord should be kept clean and dry after birth and until it falls off. This is one reason why it is so important for the woman and her family to plan and prepare for a clean and safe childbirth attended by a skilled health provider such as you.

14.6 Benefits of early and exclusive breastfeeding

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Breastfeeding positions and good attachment of the baby are described in detail in the Postnatal Care Module, but you should lay the foundations during your antenatal care visits with pregnant women — especially those having their first baby. Whether the mother chooses to breastfeed her baby or she feeds a substitute for human milk, you should respect her decision. But she cannot make this choice if she has not been well informed by you about the benefits of early and exclusive breastfeeding. Explain to her that it:

Provides the best nutrition for the newborn
Is easily digested and efficiently used by the baby’s body
Protects against infection and other illnesses
Offers some protection against allergies
Is cost-effective and affordable
Promotes mother-baby bonding
Provides the woman with a degree of contraceptive protection (though less than 100% effective) if she is exclusively breastfeeding until her first menstrual period returns after the birth.

14.6.1 Unhealthy beliefs and practices about feeding newborns

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In some countries, there are beliefs about feeding newborn babies that are dangerous to the baby’s health. For example, in some places the baby is given food or liquids, such as water with sugar, honey, herbs, spices and animal milks, during the first 3 days after the birth before the woman begins breastfeeding. The thin, watery fluid called colostrum that her breasts produce during these 3 days may be thrown away because it is considered unclean.

What are the benefits of feeding colostrum to newborns? (You learned about this in Study Session 7 of this Module.)
Colostrum is rich in proteins and antibodies (special proteins produced by the mother’s immune system that help to protect her and the baby from infection).

Even after the woman’s breastmilk begins to flow, some people go on feeding other liquids and honey to the baby, in addition to breastfeeding.

What do you think are the reasons for this and what are the risks in doing so?
Breastfed babies may demand feeding frequently, so the mother may think that her breastmilk is not enough on its own. Feeding other liquids and honey to the baby is not necessary for nutrition and it increases the risk of infection from the spoon or feeding bottle.

14.6.2 General principles of early and exclusive breastfeeding

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For mothers who are HIV-negative:

Babies should begin breastfeeding as soon as possible after birth (preferably within the first hour) and continue for at least the first 6 months of life.
Colostrum, the first milk should be given to the baby, not thrown away.
The baby should be breastfeed exclusively for the first 6 months of life. Nothing else should be given to the baby to drink or eat during that time.
The baby should be breastfeed whenever s/he wants, day and night (on demand), which stimulates the breasts to produce an adequate supply of breast milk.

You will learn how to advise mothers who are HIV-positive in Study Session 16 of this Module, on prevention of mother to child transmission (PMTCT).

14.7 Postpartum family planning

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During the antenatal period, discussions should begin concerning postpartum contraception options. Family planning information and services are important components of good quality antenatal care. These occasions provide an opportunity for health providers to discuss with women the benefits of birth spacing (leaving at least 2 years between births) for their health and the health of their current and future children. Help pregnant women and new mothers decide how they will avoid pregnancy after childbirth.

14.7.1 Breastfeeding and contraception

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The return of fertility after birth is not entirely predictable, and conception can occur before the woman resumes her first menstrual period. A woman who is not fully and exclusively breastfeeding is able to become pregnant again as soon as 4 to 6 weeks after childbirth, and she should plan to begin some sort of contraception before starting to have sexual intercourse again. Full and exclusive breastfeeding gives good protection against conception, but cannot be relied on as 100% effective. A breastfeeding woman is usually protected from pregnancy only if:

She is no more than 6 months postpartum
She is breastfeeding exclusively (8 or more times a day, including at least once at night; no daytime feedings more than 4 hours apart and no night feedings more than 6 hours apart; no complementary foods or fluids given to the baby)
Her menstrual cycle has not returned.

Numerous safe methods of contraception are available for the breastfeeding woman.

14.7.2 Benefits of birth spacing

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For maximum protection, women after childbirth should not wait until the return of monthly bleeding to start a contraceptive method, but start as soon as safe guidance for her chosen method allows. (Some basic principles of contraception after miscarriage or induced abortion are given in Study Session 20 of this Module. Detailed discussion of all contraceptive methods and guidelines are given in the Family Planning Module in this curriculum.)

Intervals of at least 2 years have health benefits for both the woman and baby (Box 14.1).

Box 14.1 Appropriate birth spacing lowers the risk of:

Maternal mortality
Fetal death (miscarriage or stillbirth), neonatal mortality
Anaemia in the mother during subsequent pregnancies
Postpartum inflammation of the endometrium lining the uterus
Premature rupture of the amniotic membranes surrounding the fetus
Premature birth
Intrauterine growth retardation and a low birth-weight baby
Malnutrition of newborns and infants due to insufficient breastmilk.

Coordinate your family planning visits with an infant’s immunization schedule. And remember that optimal breastfeeding offers triple value: important improvements in child survival and health, better health for mothers, and temporary contraception.

In the next study session, you will learn about the principles of effective counselling, so you can communicate the health promotion messages to pregnant women sensitively during antenatal care, and address their concerns and beliefs about pregnancy and childbirth.

Summary of Study Session 14

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In Study Session 14 you learned that:

Eating well during pregnancy and breastfeeding means eating a variety of foods and enough foods — at least 200 additional calories every day.
Eating well with little money is possible by buying cheap nutritious foods like beans and organ meats, growing legumes, keeping chickens, using whole grains, and making soups.
Pregnant and breastfeeding women need to eat a variety of main foods (carbohydrates), grow foods (proteins), go foods (sugars and fats), and glow foods (vitamins and minerals, particularly iron, folate, calcium, iodine and Vitamin A).
Iron pills and folate (folic acid) tablets should be provided to pregnant women as part of routine antenatal care.
Personal hygiene, especially hand washing and keeping the genital area clean, helps to prevent infection during pregnancy (and at all times).
Getting plenty of rest and sleep, and avoiding alcohol, cigarettes, illegal drugs, strong chemicals and infectious persons helps to protect the pregnant woman and her unborn baby.
Immunization against tetanus should be a routine part of antenatal care.
Feeding colostrum, followed by full and exclusive breastfeeding, is the best and only nourishment a baby needs in the first 6 months of life.
Full and exclusive breastfeeding may protect the woman from becoming pregnant again up to 6 months after the birth, but only if feeding is very frequent and her menstrual periods have not returned.
Birth spacing of at least 2 years is good for the health of the woman, her baby and any older children — in fact for all her family.

Self-Assessment Questions (SAQs) for Study Session 14

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SAQ 14.1 (tests Learning Outcomes 14.2)

Suggest some ways to help women who cannot afford to buy a lot of different foods how they can get enough calories and a variety of foods.

Answer

Beans, peas and lentils are cheap and nourishing and quite easy to grow. Organ meats like liver, heart and kidney have a lot of iron and may cost less than other meats. Brown bread or brown rice and dark teff are more nutritious than the light-coloured grains and are usually cheaper to buy if she cannot grow her own.

SAQ 14.2 (tests Learning Outcomes 14.1 and 14.2)

Complete Table 14.1. Some of the categories have been left blank for you to write your answers.

Table 14.1 for SAQ 14.2.

Food group	Contains	Three examples
Main foods	Carbohydrates
	Proteins
Go foods
	Vitamins and minerals

Answer

The table below is the completed version of Table 14.1. We do not know exactly which three examples you chose for each food group, so you may have mentioned other good examples.

Table 14.1 Completed.

Food group	Contains	Three examples
Main foods	Carbohydrates	Injera, rice, maize, etc.
Grow foods	Proteins	Beans, eggs, meat, etc.
Go foods	Sugars and fats	Fruits, honey, nuts, etc.
Glow foods	Vitamins and minerals	Fish, dark green leafy vegetables, meat, etc.

SAQ 14.3 (tests Learning Outcomes 14.3, 14.4 and 14.5)

What advice should you give a pregnant woman on how to avoid infection in herself or her newborn baby? Think of at least three different actions she can take.

Answer

Some actions that you can advise a pregnant woman to take to avoid infection in herself and her newborn baby:

Washing her hands with soap, particularly before preparing food and after using the toilet.
Washing her body every day with clean water, especially her genital area.
Cleaning her teeth every day with a dental stick or toothbrush.
Getting an immunization with tetanus toxoid.
Keeping the stump of the newborn baby’s umbilical cord clean and dry until it falls off.

SAQ 14.4 (tests Learning Outcomes 14.1, 14.5 and 14.6)

Which of the following statements is false? In each case, explain what is incorrect.

A Breastfeeding is 100% effective at preventing a further pregnancy.

B Colostrum should be fed to the newborn baby, not thrown away.

C Early and exclusive breastfeeding means feeding only breastmilk from the first hour of the baby’s life until at least 6 months of age.

D Even if menstrual periods return during exclusive breastfeeding, a woman does not need to begin another form of contraception.

E The benefits of birth spacing of at least 2 years include reduced risk of maternal and fetal death.

Answer

A is false. Breastfeeding is not 100% effective at preventing a further pregnancy; full and exclusive breastfeeding gives good protection from pregnancy but cannot be relied on as 100% effective —especially not after 6 months from the birth or if menstrual periods return.

B is true. Colostrum should always be fed to the baby because it is very nutritious and gives protection against infection.

C is true. Early and exclusive breastfeeding means feeding only breast milk from the first hour of the baby’s life until at least 6 months of age.

D is false. A woman who is breastfeeding exclusively does need to begin another form of contraception if her menstrual period returns.

E is true. Birth spacing of at least 2 years reduces the risk of maternal and fetal death.

Introduction

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In this study session, you will learn how to carry out an important measurement that should be done at every antenatal visit — measuring the height of the top of the mother’s uterus as a way of assessing whether her baby is growing normally. We teach you two ways of doing this — using your fingers, and using a soft measuring tape. This will enable you to estimate the stage of pregnancy she has reached, and check the accuracy of the due date calculated from the mother’s last normal menstrual period. Then we discuss possible reasons for the uterus growing too quickly or too slowly, and what actions you should take if you suspect that something may be wrong.

Learning Outcomes for Study Session 10

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When you have studied this session, you should be able to:

10.1 Define and use correctly all of the key words printed in bold. (SAQ 10.1)

10.2 Know how to measure fundal height using the finger method and a soft measuring tape. (SAQ 10.1)

10.3 Interpret fundal height measurements to assess normal fetal growth in relation to gestational age. (SAQ 10.2)

10.4 Identify possible causes of abnormal fundal height measurements and take the appropriate actions. (SAQ 10.3)

10.1 What does measuring the height of the mother’s uterus tell us?

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The purpose of measuring the height of the mother’s uterus is to determine if the baby is growing normally at each stage of the pregnancy. When you measure the uterus, you check to see where the top of the uterus is.

Healthy signs

The height of the uterus matches the gestational age of the fetus, i.e. the number of weeks or months of pregnancy (gestation).
The top of the uterus rises in the mother’s abdomen by about two finger-widths, or 4 cm every month.

Warning signs

The height of the uterus does not match the number of weeks or months of pregnancy.
The top of the uterus rises more than, or less than, two finger-widths or 4 cm every month.

Do you remember what the domed region at the top of the uterus is called? (You learned this in Study Session 3.)
It is called the fundus.

When you measure how high the top of the uterus has reached in the mother’s abdomen, you are measuring the fundal height. This is a much more accurate way of estimating fetal growth than weighing the mother. Measuring the fundal height will show you three things:

How many months the woman is pregnant now.
The probable due date. If you were able to figure out the due date from the mother’s last monthly bleeding, measuring the height of the top of the uterus can help you see if this due date is probably correct. If you were unable to figure out her due date from her last normal menstrual period (LNMP), measuring the fundal height can help you figure out a probable due date. This should be done during the first antenatal check-up.
How fast the baby is growing. At each antenatal check-up, measure the fundal height to see if the baby is growing at a normal rate. If it is growing very fast or very slowly, there may be a problem.

As the baby grows inside the uterus, you can feel the uterus grow bigger in the mother’s abdomen. The top of the uterus moves about two finger-widths or 4 cm higher each month (Box 10.1).

Box 10.1 Changes in fundal height in a normal pregnancy

At about three months (13-14 weeks), the top of the uterus is usually just above the mother’s pubic bone (where her pubic hair begins).

At about five months (20-22 weeks), the top of the uterus is usually right at the mother’s bellybutton (umbilicus or navel).

At about eight to nine months (36-40 weeks), the top of the uterus is almost up to the bottom of the mother’s ribs.

Babies may drop lower in the weeks just before birth. You can look back at Figure 7.1 in Study Session 7 to see a diagram of fundal height at various weeks of gestation.

10.2 How to measure the fundal height

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To feel the uterus, have the mother lie on her back with some support under her head and knees. Explain to her what you are going to do (and why) before you begin touching her abdomen. Your touch should be firm but gentle. Walk your fingers up the side of her abdomen (Figure 10.1) until you feel the top of her abdomen under the skin. It will feel like a hard ball. You can feel the top by curving your fingers gently into the abdomen.

View larger image

Figure 10.1 With the woman lying on her back, begin by finding the top of the uterus with your fingers. Then see how many months pregnant the woman is by comparing the number of fingers with Figure 10.2 (each line is about the width of two fingers).

10.2.1 How to measure fundal height using the ﬁnger method

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If the top of the uterus is below the bellybutton, measure how many fingers below the bellybutton it is. If the top of the uterus is above the bellybutton, measure how many fingers above the bellybutton it is.

View larger image

Figure 10.2 Measuring fundal height using the finger method. The woman is lying on her back. Each line represents the width of two fingers.

Look carefully at Figure 10.2. If the baby is growing normally, by how many finger-widths should the uterus rise in the second trimester (3-6 months of pregnancy, or 15-27 completed weeks of gestation)?
Figure 10.3 Fundal height at 7 months’ gestation.
Fundal height should increase by 6 finger-widths (two finger-widths every month) in the second trimester.

How many fingers above the bellybutton should the top of the uterus be at 7 months’ gestation?
See Figure 10.3 for the answer.

How do you explain the position of the dotted line at 9 months in Figure 10.2, which is below the line showing fundal height at 8½ to 9 months?
Babies may drop lower in the weeks just before birth (look back at Box 10.1).

Look at the diagrams in Figure 10.4 (a) and (b). How many weeks pregnant is the woman in each case, based on the finger method of measuring fundal height shown in Figure 10.2?
View larger image
Figure 10.4 (a) and (b) How many months of pregnancy do you think each of these diagrams shows?
In Figure 10.4(a) the woman is about 4½ months pregnant. In Figure 10.4 (b) she is about 6½ months pregnant (three fingers above the bellybutton).

When you measure fundal height at every antenatal visit, write down the number of fingers you used to measure the height of the uterus on the woman’s antenatal record card. Put a ‘+’ (plus) sign in front of the number if the top of the uterus is above the bellybutton. Put a ‘–’ (minus) sign in front of the number if the top of the uterus is below the bellybutton.

How would you record the measurements shown in Figure 10.4(a) and (b)?
The measurement in Figure 10.4(a) would be recorded as -2. The measurement in Figure 10.4(b) would be +3.

Limitations of the finger method

You need to be aware that the finger method for estimating gestational age (the number of weeks/months of pregnancy) has some limitations that affect its accuracy.

Look at your own hands. Can you suggest why the finger method might give a different estimate of gestational age if two different health workers used this method to measure the same woman’s fundal height?
Because of the big variation in the thickness of our fingers, there could be up to three weeks difference between the fundal height measurement of the same woman made by two different people. (This is known as ‘inter-observer variation’, i.e. variation between different observers.)

Even if the same health worker measures the fundal height of the same woman several times on the same day, the answer may be different each time, because the finger method is not very precise. (This is known as ‘intra-observer variation’, i.e. variation by a single observer at different times.)

Finally, you might have realised that the distance between the symphysis pubis (pubic bone) and the umbilicus (bellybutton) varies between women when they are not pregnant, and this variation affects the accuracy of the fundal height measurement using the finger method. For example, it assumes that the distance between the pubic symphysis and the umbilicus is 20 cm at 20 weeks’ gestation, but it can be as long as 30 cm and as short as 14 cm.

To overcome these limitations, it is recommended that you measure fundal height using a soft tape measure if you have one, as described next.

10.2.2 How to measure fundal height using a soft tape measure

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You can use this method when the top of the uterus grows as high as the woman’s bellybutton.

During the second half of pregnancy, the size of the uterus in centimetres is close to the number of weeks that the woman has been pregnant. For example, if it has been 24 weeks since her last normal menstrual period, the uterus will usually measure 22-26 cm. The uterus should grow about 1 cm every week, or 4 cm every month.

Lay a cloth or soft plastic measuring tape on the mother’s abdomen, holding the 0 (zero) on the tape at the top of the pubic bone (see the arrow in Figure 10.5a).
Follow the curve of her abdomen, and hold the tape at the top of her uterus (Figure 10.5b).
Write down the number of centimetres (cm) from the top of the pubic bone to the top of the uterus.

View larger image

Figure 10.5 (a) The arrow points to the top of the pubic bone. Place the 0 (zero) of the tape measure here. (b) Follow the curve of the woman’s abdomen and hold the tape at the top of her uterus.

Doctors, nurses and many midwives are taught to count pregnancy by weeks instead of months. They start counting at the first day of the last normal menstrual period (LNMP), even though the woman probably got pregnant two weeks later. Counting this way makes most pregnancies 40 weeks long (or you can say a normal gestation is 40 weeks).

10.3 What if the size of the uterus is not what you expected?

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If you are measuring correctly and you do not find the top of the uterus where you expect it to be, based on the date the woman gave you for her LNMP, it could mean three different things:

The due date you got by counting from the LNMP could be wrong.
The uterus (and the baby) could be growing too fast.
The uterus (and the baby) could be growing too slowly.

10.3.1 The due date you got by counting from the LNMP is wrong

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There are several reasons why a due date figured from the LNMP could be wrong. Sometimes women do not remember the date of their LNMP correctly. Sometimes a woman misses her menstruation for another reason, and then gets pregnant later. This woman could really be less pregnant than you thought, so the uterus is smaller than you expect. Or sometimes a woman has a little bleeding after she gets pregnant. If she assumed that was her LNMP, this woman will be one or two months more pregnant than you thought. The uterus will be bigger than you expect.

Remember due dates are not exact. Women often give birth up to 2 or 3 weeks before or after their due date. This is usually safe.

If the due date does not match the size of the uterus at the first visit, make a note. Wait and measure the uterus again in two to four weeks. If the uterus grows about two finger-widths or 1 cm a month, the due date that you got from feeling the top of the uterus is probably correct. The due date you got by counting from the LNMP was probably wrong.

10.3.2 The uterus is growing too quickly

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If the uterus grows more than 2 finger-widths a month, or more than 1 cm a week, several different causes are possible:

The mother may have twins.
The mother may have diabetes.
The mother may have too much water (amniotic fluid) in the uterus.
The mother may have a molar pregnancy (a tumour instead of a baby).

If you think there might be twins, even if you can find only one heartbeat, refer the woman to the nearest health centre.

The mother may have twins

It can be very difficult to know for sure that a mother is pregnant with twins. Signs of twins are that:

The uterus grows faster or larger than normal.
You can feel two heads or two bottoms when you feel the mother’s abdomen.
You can hear two heartbeats. This is not easy to detect, but it may be possible in the last few months.

We will show you how to listen to the fetal heartbeat through the mother’s abdomen in Study Session 11. For now, we are focusing on twins as a possible reason for the uterus being larger than expected. Here are two ways to try to hear the heartbeats of twins:

Figure 10.6 Tapping the rhythm of the fetal heartbeats may tell you if there is one baby or two.

Find the heartbeat of one baby. Ask a helper to listen for other places where the heartbeat is easy to hear. If she hears a heartbeat, ask her to listen to one place while you listen to the other. Each of you can tap the rhythm of the heartbeat with your hand. If the rhythms are the same, you may be listening to the same baby. If the rhythms are not exactly the same, you may be hearing two different babies (Figure 10.6).
If you do not have a helper, but you have a watch with a second hand, or a homemade timer, try timing each heartbeat separately. If the heartbeats are not the same, you may be hearing two different babies.

Because twin births are often more difficult or dangerous than single births, it is safer for the woman to go to a hospital to give birth. Since twins are more likely to be born early, the mother should try to have transportation ready at all times after the 6th month. If the hospital is far away, the mother may wish to move closer in the last months of pregnancy. Be sure to have a plan for how to get help in an emergency.

The mother may have diabetes

You learned about the warning signs of diabetes in Study Session 9.

If a woman had all the warning signs of diabetes, what would you expect to find?
Refer the woman to a health centre if you suspect she may have diabetes.
She had diabetes in a past pregnancy. One of her past babies was born very big (more than 4 kilograms), or was ill or died at birth and no one knows why. She is fat. She is thirsty all the time. She has frequent itching and a bad smell coming from her vagina. Her wounds heal slowly. She has to urinate more often than other pregnant women. Her uterus is bigger than normal for how many months she has been pregnant. She has sugar in her urine when you do the dipstick test (Section 9.8.1 of Study Session 9).

Too much water in the uterus

Too much water (amniotic fluid) is not always a problem, but it can cause the uterus to stretch too much. Then the uterus cannot contract enough to push the baby out, or to stop the bleeding after the birth. In rare cases, it can mean that the baby will have birth defects. Try to refer the woman to the nearest health facility that can give her a sonogram (ultrasound examination) if the uterus is measuring too big and you do not suspect twins.

Molar pregnancy (tumour)

Sometimes a woman gets pregnant, but a tumour grows instead of a baby. This is called a molar pregnancy (Figure 10.7). Blood spotting and tissue (sometimes shaped like grapes) may be discharged from her vagina.

Figure 10.7 A molar pregnancy (tumour) growing in the uterus instead of a baby.

If you detect the signs and symptoms of a molar pregnancy, refer the woman to a hospital as soon as possible. The tumour can become a cancer and kill her, sometimes very quickly. A surgeon can remove the tumour to save the woman’s life.

Other signs of a molar pregnancy are that:

No fetal heartbeat can be heard.
No baby can be felt.
The woman has had nausea all through the pregnancy.
She has spotting of blood, and tissue shaped like bunches of grapes coming from her vagina.

10.3.3 The uterus is growing too slowly

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Slow growth can be a sign of one of these problems:

The mother may have too little water (amniotic fluid) in the uterus. Sometimes there is less water than usual, and everything is still OK. At other times, too little water can mean the baby is not normal, or will have problems during the labour.
The mother may have a poor diet. Find out what kind of food the mother has been eating. If she is too poor to get enough good food, try to find some way to help her and her baby. Healthy mothers and children make the whole community stronger.
The mother may have high blood pressure (hypertension). High blood pressure can keep the baby from getting the nutrition it needs to grow well. You learned how to check her blood pressure in the previous study session.
The mother may be drinking alcohol, smoking, or using drugs. These can cause a baby to be small. Try to find some way to help her to stop these damaging behaviours.
The baby may be dead. Dead babies do not grow, so the uterus stops getting bigger.

If you do not have the right equipment to check her blood pressure, and the uterus is growing too slowly, refer her to the nearest health centre for evaluation.

How to tell if the baby is dead

If you suspect that the baby may have died, refer the mother to a health centre for the stillbirth.

If the mother is five months pregnant or more, ask if she has felt the baby move recently. If the baby has not moved for two days, something may be wrong. If the mother is more than seven months pregnant, or if you heard the baby’s heartbeat at an earlier visit, listen for the heartbeat again.

If the woman reports no fetal movements and you cannot hear the heartbeat, the baby may have died. If so, it is important for a dead baby (stillbirth) to be delivered soon, because the woman may bleed more than other mothers, and she is at more risk of infection.

When a mother loses a baby, she needs love, care and understanding (Figure 10.8). Make sure that she does not go through labour alone. If she gives birth to a dead baby in the hospital, someone she trusts should stay there with her during the birth.

Figure 10.8 When a mother loses a baby, she needs love, care and understanding.

10.4 Conclusion

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In this study session, you have learned how to measure the fundal height, using your fingers and a measuring tape. You have also learned to interpret of your measurements and take the appropriate actions. In the next study session you will learn how to assess the position of the baby by palpating (feeling) the mother’s abdomen and listening to the position of the fetal heartbeat.

Summary of Study Session 10

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In Study Session 10, you have learned that:

Measuring the fundal height tells you the duration of the pregnancy, how fast the baby is growing, and the probable due date.
Remember to position the woman correctly before measuring the fundal height. The fundus of the uterus grows on average two finger-widths for each month of pregnancy.
If the fundal height is not equal to the gestational age, you need to check the duration of pregnancy from the last normal menstrual period (LNMP). Having the wrong date is one of the main reasons for discrepancy between fundal height and gestational age.
If the fundal height is bigger than expected for gestational age, the mother may have given you the wrong LNMP, or she may have twins, diabetes, too much water in the uterus, or a molar pregnancy.
If the fundal height is smaller than expected for gestational age, the mother may have given you the wrong LNMP, she may have too little amniotic fluid surrounding the fetus, raised blood pressure, poor nutrition, she may be drinking alcohol or taking other harmful drugs, or the baby may be dead.

Self-Assessment Questions (SAQs) for Study Session 10

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Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below Case Study 10.1. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

Case Study 10.1 Abebech

Abebech is a pregnant woman, whose duration of gestation based on her last normal menstrual period (LNMP) is six months. When you examine her, you can feel that the fundus is four finger-widths above her bellybutton and you can hear a fetal heartbeat clearly.

SAQ 10.1 (tests Learning Outcomes 10.1 and 10.2)

What is your assessment of the gestational age of Abebech’s baby using fundal height measurement?
How many centimetres would Abebech’s abdomen measure from her pubic bone to the top of her uterus in order to confirm your fundal height measurement?

Answer

The gestational age based on the fundal height measurement is seven months.
If Abebech is really seven months pregnant, you would expect her abdomen to measure about 28 cm from her pubic bone to the top of the uterus, i.e. approximately one centimetre for each week of pregnancy dated from the LNMP. Remember the measurement may range from 26-30 cm.

SAQ 10.2 (tests Learning Outcome 10.3)

Is the gestational age of Abebech’s baby based on fundal height measurement consistent with the gestational age calculated from her LNMP?

Answer

The gestational age based on fundal height is one month more than expected from the date of the LNMP. Therefore, the uterus is bigger than expected from the date of the LNMP.

SAQ 10.3 (tests Learning Outcome 10.4)

What possible explanations can you give for your findings in Abebech’s case, and what actions should you take?

Answer

The uterus may be bigger than expected because the date of the LNMP may be incorrect, and Abebech is really seven months pregnant. This is not a problem, but it is important to investigate other possible explanations. For example, she may have too much amniotic fluid (water) surrounding the baby in the uterus; you should refer her to a health facility where she can have an ultrasound examination to find out if this is the problem. Or she could have a twin pregnancy. You can hear one fetal heartbeat clearly, so get someone else to help you listen to Abebech’s abdomen to see if you can hear two fetal heartbeats. If you suspect she is having twins, refer her to the nearest health facility.

Introduction

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Hypertensive disorders of pregnancy are one of the three leading causes of maternal morbidity and mortality (together with haemorrhage and infection). The contribution of hypertension (high blood pressure) to mortality and morbidity of the fetus and newborn is also immense. Hypertensive disorders may complicate up to 10% of all pregnancies, with the highest proportion occurring in women who are pregnant for the first time (primigravida). Hypertension is usually defined as blood pressure above 140/90 mmHg, where the top number is the systolic pressure and the bottom number is the diastolic pressure.

Blood pressure is measured in millimetres of mercury (mmHg) because the original instruments contained a column of mercury.

Do you remember what systolic and diastolic pressure refer to?
The systolic pressure is the pressure of blood in the blood vessels at the moment when the heart contracts. The diastolic pressure is measured when the heart relaxes between beats.

A major purpose of your antenatal care service is to make pregnant women aware of the danger symptoms of hypertensive disorders, to check their blood pressure at every antenatal visit (you learned how to do this in Study Session 9), and to make a timely diagnosis of hypertension and refer affected women as early as possible.

In this study session you will learn about the changes in the woman’s body as a result of hypertension and how this affects the mother and the fetus, the classifications of hypertension, the common risk factors for developing it, how to diagnose the different types and what actions to take in order to prevent worsening complications and even death.

Learning Outcomes for Study Session 19

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After studying this session you should be able to:

19.1 Define and use correctly all of the key words printed in bold. (SAQs 19.1, 19.2 and 19.3)

19.2 Briefly describe what happens in blood vessels and body fluids in women with hypertension, and how this can damage the fetus. (SAQs 19.1 and 19.2)

19.3 Define the different types of hypertensive disorders of pregnancy. (SAQ 19.2 and 19.3)

19.4 List the common risk factors for developing pregnancy-related hypertension. (SAQ 19.3)

19.5 Describe the common clinical features of severe pre-eclampsia. (SAQ 19.3)

19.6 Identify the common maternal and fetal/neonatal complications of hypertensive disorders of pregnancy. (SAQ 19.3)

19.7 Provide basic supportive treatment and facilitate early referral, in particular for women with severe hypertensive disorders of pregnancy. (SAQ 19.3)

19.1 How does hypertension affect pregnancy?

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The underlying cause of hypertension related to pregnancy remains unclear. However, hypertension is known to contribute to disorders in different parts of the body; in particular, it affects the brain and spinal cord, the heart and blood vessels, the blood, the kidneys and the liver.

19.1.1 Effects on blood vessels and body fluids

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A well-known phenomenon in a woman who develops hypertension during pregnancy is that the muscular walls of the blood vessels all over her body contract, so the space inside the vessels becomes smaller. (The technical name for this is generalised vasoconstriction.) The constriction causes high blood pressure in the blood vessels, and this is one reason why fluid from the blood is pushed out through the vessel walls and collects in the woman’s tissues.

What is the name for the swelling due to fluid collecting in the tissues and where is the swelling most often visible in pregnant women with hypertension? (You learned about this in Study Sessions 7 and 8, particularly Box 8.2.)
The swelling is called oedema and is a warning sign of hypertension in pregnancy. It is most often see in the lower legs, ankles and feet; also the hands, and in the most severe cases in the face and back.

19.1.2 Effects of maternal hypertension on the fetus

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Any form of hypertension during pregnancy has a significant effect on fetal growth and survival. This happens because of the marked reduction in the mother’s blood volume, which will in turn reduce the blood supply from the endometrial arteries into the placenta. The endometrial arteries bring the mother’s blood into the placenta, delivering oxygen from her lungs and nutrients from her digestive system to the fetus. (You can see them if you look back at Figure 5.5 in Study Session 5.)

If the maternal blood flow into the placenta is reduced, what effect will this have on fetal development?
The transfer of oxygen, nutrients and fluids to the baby will be reduced, so it will not develop normally. Fetal growth is likely to be restricted (hypertension during pregnancy is one of the common causes of intra-uterine growth restriction, IUGR).

The amount of amniotic fluid surrounding the fetus will also be much less than normal, because the blood flow to the baby’s kidneys is reduced, so it makes less urine. In late pregnancy, most of the amniotic fluid comes from the baby’s urine. The fetus may die due to deficiency of oxygen and nutrients, or due to significant reduction of amniotic fluid. If the fetus lives very long in the uterus with a reduced oxygen supply, the growing brain is very likely to be dangerously affected. As a result, if the baby is born alive and survives early childhood, mental retardation can appear when it is older.

The fetus may also die because the placenta gets aged too early and the blood supply is inadequate, so there can be early separation of the placenta from the wall of the uterus. (Early detachment is called placental abruption and you will learn all about it in Study Session 21. Preterm labour may begin spontaneously (Study Session 17), and the mother’s life can also be at risk due to severe placental abruption where much blood may be lost.

19.1.3 Common complications of severe pre-eclampsia for the mother

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Complications of any type of hypertensive disorder for the mother are highly related to the generalised vasoconstriction and body fluid redistribution (more outside the blood vessels and less inside the vessels). These phenomena result in:

Inadequate blood supply to her vital organs (brain, heart) and less vital organs for short survival (kidneys, gastrointestinal tract including liver, skeletal muscles and skin).
Fluid accumulating in her organs (liver, brain, abdominal cavity, eyes, lungs), which swell and can even rupture.
Narrow or constricted blood vessels, which contributes to blood cell damage, particularly platelets (essential for blood clotting if there is a tear or wound in the tissues), and red blood cells.

If a significant proportion of the woman’s red blood cells are damaged, what condition will she develop?
She will develop anaemia.

19.1.4 Summarising maternal and fetal complications of severe pre-eclampsia

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Asphyxia is pronounced ‘ass-fix-ee-ah’.

‘Acute’ refers to a condition that begins suddenly and rapidly becomes very serious.

Table 19.1 Common complications of severe pre-eclampsia in the mother and the fetus.

Maternal complications	Fetal complications
Eclampsia	Placental abruption
Intracranial haemorrhage (bleeding inside the skull)	Intrauterine asphyxia (severe shortage of oxygen in the uterus)
Anaemia	IUGR (intrauterine growth restriction)
Low platelet count, poor blood clotting and risk of bleeding	Premature delivery
Acute kidney failure	IUFD (intrauterine fetal death)
Acute liver failure, maybe even liver rupture	Respiratory distress after birth(early neonatal asphyxia)
Fluid in the lungs (pulmonary oedema)	Mental retardation
Heart failure
Temporary total blindness

19.2 Classification of hypertension during pregnancy

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Hypertension during pregnancy can be a new development, or a continuation or worsening of hypertension that existed before the pregnancy. If the hypertension is diagnosed before pregnancy or during the first 20 weeks of gestation, or if the hypertension persists for six weeks after the baby is born, it is defined as chronic hypertension.

‘Chronic’ describes a condition that has been going on for a long time.

The reason for classifying hypertension during pregnancy is to enable you to decide what actions to take in each case. Some types (e.g. mild pre-eclampsia and gestational hypertension — see Table 19.2 below) have fewer and less severe complications for the mother and the fetus: other types (e.g. severe pre-eclampsia and eclampsia) can have fatal complications unless managed quickly.

19.2.1 Classification of pre-eclampsia

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Pre-eclampsia is the commonest type of hypertensive disorder of pregnancy and the focus of much of the discussion in this section (see Table 19.2). It usually occurs in the second half of pregnancy (after 20 weeks of gestation, but most commonly after 28 weeks). The appearance of protein in the woman’s urine (proteinuria) is a danger sign. Significant proteinura is defined as a positive urine dipstick test for protein with a result greater than or equal to +2 on the scale supplied with the dipsticks.

Proteinuria is pronounced ‘proh-teen-you-ree-ah’.

You will learn about these symptoms of severity in Section 19.4 later.

Table 19.2 Characteristics of types of hypertension and pre-eclampsia

Type	Raised blood pressure (measured twice, 6 hours apart)	Proteinuria	Symptoms of severity
Gestational hypertension (develops during pregnancy, resolves afterwards)	Above 140/90 mmHg	No significant proteinuria	None
Mild pre-eclampsia	Between 140/90 and 160/110 mmHg	No significant proteinuria	None
Severe pre-eclampsia	Greater than or equal to 160/110 mmHg	With or without significant proteinura (urine dipstick test result greater than or equal to +2)	Headache, blurred vision, epigastric burning pain, decreased urine output, decreased or absent fetal kick
Superimposed pre-eclampsia	Higher than before the pregnancy in a known chronic hypertensive woman	Significant or worsening proteinuria	With or without symptoms of severity

19.2.2 Diagnostic signs of eclampsia

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Figure 19.1 Convulsion is a characteristic sign of eclampsia in pregnancy.

Eclampsia is the most severe type of hypertensive disorder. The diagnosis is made when a woman with pre-eclampsia (most commonly), or any other type of hypertensive disorder, develops convulsions (fits or seizures, Figure 19.1) or coma (complete loss of consciousness). The convulsion looks like the seizure you might have witnessed in a person with epilepsy (in Amharic: Yemitil Beshita). You will learn more about this type of convulsion later in this study session.

19.3 Risk factors for pre-eclampsia/eclampsia

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In the majority of cases, the occurrence of pre-eclampsia or eclampsia is unpredictable and the cause is unknown. However, there are some risk factors which are known to be associated with hypertensive disorders of pregnancy (Box 19.1).

Box 19.1 Common risk factors for hypertensive disorders in pregnant women

First time pregnancy before the age of 20 years or after 35 years
Multiple pregnancy (twins or more)
Family history of pre-eclampsia/eclampsia in close female relatives
History of pre-eclampsia/eclampsia in the previous pregnancy
Diabetes currently
Obesity currently (woman is very overweight for her height)
Kidney disease currently.

Knowing these risk factors will help you to:

Anticipate the possibility of a hypertensive disorder and its complications developing before they actually happen.
Offer counselling to the woman and her partner and family about the danger symptoms of severe pre-eclampsia/eclampsia, so they can take action quickly if needed.
Make antenatal care visits more frequently in late pregnancy to women with known risk factors.

Equally important, you need to know that any woman (regardless of age and number of previous deliveries) can develop a hypertensive disorder in any pregnancy. Therefore, although it is good to anticipate its occurrence in those who have one of the risk factors, you should assume that all pregnant women have the potential to develop hypertension.

19.4 Clinical features of severe pre-eclampsia.

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As you saw in Table 19.2, mild pre-eclampsia is an incidental finding of raised blood pressure in a woman who doesn’t have any other hypertensive symptoms. However, a woman with severe pre-eclampsia can have one or more complaints of severe symptoms. From observations and research studies, the following are the common clinical features.

19.4.1 Headache

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Although there are many causes of headache during pregnancy, till proved otherwise, you should first consider that a headache could be due to the severe form of hypertension. Brain oedema (swelling due to fluid collecting around the brain) and increased pressure inside the skull (the medical name for the skull is the cranium, so doctors call this intracranial pressure) are the major reasons for the headache in severe pre-eclampsia.

19.4.2 Blurred vision/visual disturbance

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Blurred vision and visual disturbances are also because of increased intracranial pressure, coupled with oedema in the brain and in the retina (the structure at the back of the eyeball).

19.4.3 Epigastric pain

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Oedema in the liver can become very painful because the liver is covered by a capsule, which becomes tense and painful when the liver accumulates too much fluid in its tissues. The liver lies behind the epigastric area of the abdomen, which you learned to identify in Study Session 15 (look back at Figure 15.4). Other causes of epigastric pain are rare during pregnancy, so the message is: first think of hypertension in a pregnant woman (particularly after 28 weeks of gestation) complaining of epigastric pain.

19.4.4 Decreased urine output

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Urine production decreases very significantly in severe types of pregnancy-related hypertension. The reduction in maternal blood volume (described in Section 19.1.1) results in markedly reduced blood flow to the kidneys, and as a result, there will be a significant decrease in urine output. The woman may stop producing urine altogether.

19.4.5 Decreased or absent fetal kick

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This happens because the fetus receives a reduced supply of oxygen and nutrients due to the decreased blood flow through the placenta, as described above.

19.4.6 Generalised (pathologic) oedema

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Generalised oedema is characterised by the widespread development of oedema in the woman’s back, abdomen, hands and face. The oedema is considered pathologic if the mother’s weight gain per week is above 1.0 kg. The normal weight gain per week during pregnancy is in the range of 0.25 kg to 0.75 kg (average 0.5 kg).

19.5 Clinical features of eclampsia

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Eclampsia occurs when the woman hasn’t been able to get adequate treatment when she had severe pre-eclampsia. It is the most life-threatening complication of severe pre-eclampsia. It can occur before labour, during labour and after delivery. Sometimes, eclampsia can occur as long as 24 hours after the delivery, even in women who gave birth with normal blood pressure and without any danger symptoms before and during labour. Therefore, if a woman comes to you with a history of convulsion, after a normal labour and delivery and even some time at home, the first clinical problem you need to consider is eclampsia. But you should also know that there are other medical causes of convulsion, such as blood sugar being too low or too high (hypo or hyperglycaemia), malaria affecting the brain, bacterial infection in the brain (e.g. meningitis), stroke, drugs, or poisoning.

As you learned above, the diagnosis of eclampsia is made when the clinical features of pre-eclampsia are present, plus:

Convulsion/fits
Coma in the absence of other causes.

The convulsion in eclampsia is usually sudden in onset, but in some cases there may be warning signs and symptoms that make the occurrence of eclampsia inevitable (see Box 19.2).

Box 19.2 Warning signs and symptoms that eclampsia is developing

Intractable/severe headache
Severe epigastric pain
Markedly blurred vision or total visual loss (temporary)
Lethargic or very irritable
Disoriented about the time, people and places in her environment
Disconnected with the environment
Shows some abnormal behaviour.

19.5.1 Convulsions in eclampsia

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The convulsion in eclampsia is similar to the seizure in people with epilepsy. Like an epileptic fit, it has four phases:

The quiet stage

The typical feature of the first stage is a period of quiet (it may not take more than 20 seconds) when the person has generalised weak muscles, stiffness and twitch, and staring eyes.

The tonic stage

This may last up to 30 seconds and is characterised by a severe form of generalised muscle spasms, where the muscles of the legs and hands contract very severely and may seem as strong as a dry stick. During the tonic stage, the woman stops breathing and becomes short of oxygen. There is also rolling of the eyes where you can see the upper part of the sclera (the white part of the eye).

The clonic stage

The third stage may take up to 2 minutes and is classically a jerky movement of the whole body as a result of vigorous muscle contraction and relaxation. At this stage, the woman can breathe and she will also salivate and urinate spontaneously.

The coma stage

After the clonic stage is over, in typical cases the woman becomes deeply unconscious for an uncertain period of time. However, a woman can be comatose even from the outset (i.e. without even a single convulsion). The duration of the coma state is dependent on:

The number of previous convulsions: The higher the number, the longer the duration of coma, which may even end in death. Having a history of more than ten convulsions is one of the poor outcome indicators. Therefore, the earlier the convulsion episodes are controlled, the better the prognosis for the mother and the baby.
Severity of brain oedema: The space between the skull and the brain is very limited. Thus, even a minimal increase in the mother’s brain size due to oedema or haemorrhage will have a serious effect on the brain cells, because the pressure on the brain (the intracranial pressure) rises so high.
Extent of intracranial haemorrhage (see below in this session): As already described for brain oedema, any bleeding in the intracranial space will increase the intracranial pressure on the brain cells. Additionally, it may aggravate further bleeding and can create a vicious cycle.
Associated hypoglycaemia (low blood sugar level): Each convulsion requires energy. This is because, during the tonic-clonic stages, almost all the skeletal muscles contract and relax many times. Frequent convulsion means consumption of much energy, which comes from stored sugars in the blood, liver and tissues. The woman with eclampsia cannot replace the sugars used by her muscles quickly enough, so she develops very low blood sugar (severe hypoglycemia), which in turn may manifest in coma. Because her blood sugar is low, the woman with eclampsia invariably will be getting some energy from proteins in her muscles to keep her alive. Breaking down proteins produces ketone bodies that can be used as an energy source and some will appear in her urine. You can test for the presence of ketone bodies with a dipstick.

19.6 What can you do if you diagnose a hypertensive disorder in a pregnant woman?

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Your primary role in the management of hypertensive disorders of pregnancy is early identification of warning signs and symptoms, and immediate referral to a hospital or health centre. If possible ensure rapid transportation and reception of the woman at the higher health facility. Your actions should be based on your clinical diagnosis and the severity of the hypertension.

19.6.1 Actions if pre-eclampsia is not severe

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Pregnant women diagnosed to have:

mild pre-eclampsia,
chronic hypertension
gestational hypertension

should be referred without any intervention by you, preferably on the day of diagnosis.

Why do you think referral is necessary, even though the hypertension is not severe?
This is because sometimes the mild form of hypertension may progress to the severe type in a very short period of time.

19.6.2 Persuading affected women to go for medical treatment

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You should offer counselling to the woman and her family about the danger of maternal and fetal complications and the advantage of getting specialist medical treatment urgently. In cases of eclampsia, people in many parts of rural Ethiopia believe that convulsions/fits are related to an evil spirit. A pregnant woman who has had a fit in these cultures may not want to go to a health facility, because she may prefer to go to the holy water, to a priest or other religious leader, or to local healers. You have a very important role to make sure that the woman and her family understand that the fits are caused by the very high blood pressure she is experiencing. Reassure her that the convulsions will stop progressively after the baby is delivered.

19.6.3 Supportive pre-referral treatment for severe pre-eclampsia

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Your second role is providing supportive treatment to avoid worse complications before the woman reaches the health facility. When your clinical diagnosis is as defined in Table 19.2 earlier:

severe pre-eclampsia
superimposed severe pre-eclampsia

you should be able to prevent the occurrence of eclampsia by taking the supportive actions in Box 19.2 below.

Box 19.2 Actions to prevent superimposed and severe pre-eclampsia progressing to eclampsia

Make the referral to the higher health facility as soon as possible.
Communicate with the receiving hospital or health centre to alert the medical team that a pregnant woman with severe pre-eclampsia is coming for urgent treatment.
Reassure the woman and her family that when she arrives at the health facility, the doctor will give her drugs to reduce her high blood pressure (anti-hypertensive drugs) and to prevent her from developing convulsions (anti-convulsant drugs).
While transport is being arranged, insert an intravenous (IV) line into a vein in the woman’s hand or arm, as you will learn to do in Study Session 22 of this Module and in your practical training sessions. Connect the IV line to a bag containing at least 1 litre of IV fluid: either Normal Saline (N/S) or Ringer Lactate (R/L). Never give dextrose in water IV fluid (D/W).

19.6.4 Emergency referral for eclampsia

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Figure 15.2 It is safest to transport the mother to hospital lying on her side.

If you discover a pregnant woman with eclampsia, you should take the actions already described in Box 19.2. Refer her urgently unless she is already in advanced labour — in this case you should deliver the baby and refer her and the baby to a hospital as soon as possible after the birth.

When you transport a woman with eclampsia to the health facility, make sure she is lying on her side with her airway open (Figure 15.2). Don’t let her lie on her back because she may find it difficult to breathe if she has another fit. Lying on her side also means that if she vomits during a fit, she is less likely to breathe the vomit into her lungs.

In the next study session you will learn about another potentially life-threatening situation: abortion and early pregnancy bleeding.

Summary of Study Session 19

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 19, you learned that:

Hypertensive disorders of pregnancy are one of the common causes of maternal and perinatal morbidity and mortality.
Generalised constriction of blood vessels is a fundamental phenomenon of pregnancy-related hypertension. It brings about a marked reduction in the woman’s blood volume, as fluids leave the blood vessels and accumulate in the tissues. Oedema occurs in different tissues and organs (including the brain, liver and kidneys), and leads to a significant reduction in blood supply to different parts of the mother’s body, and to the placenta.
Known risk factors for pregnancy related hypertension include: being primigravida before the age of 20 years or after 35 years, multiple pregnancies, personal or family history of pre-eclampsia or eclampsia, having diabetes or kidney disease, or being obese.
Pre-eclampsia (raised blood pressure + significant proteinuria) is the most common type of hypertension during pregnancy. Severe pre-eclampsia is characterised by clinical manifestations such as headache, visual disturbance, epigastric pain, decreased urine output, decreased fetal kick and development of generalised oedema.
Eclampsia is diagnosed when the pregnant woman develops convulsion or coma in the absence of other causes. It is the leading cause of maternal and fetal death among all types of hypertensive disorders of pregnancy.
In classical cases, eclampsia has four stages: quiet, tonic, clonic and coma stages.
The coma stage can be long if there is recurrent convulsion, significant brain oedema, much intracranial haemorrhage or associated hypoglycaemia.
The very common complications of severe pre-eclampsia include eclampsia, anaemia, low platelet count, multiple and acute failure of organs (kidneys, liver, heart, lungs, and eyes).
The fetal complications include placental abruption, intrauterine and early neonatal asphyxia (due to low oxygen levels in the blood), intrauterine growth restriction (IUGR) and intrauterine fetal death (IUFD).
In the management of hypertensive disorders of pregnancy, your primary role is facilitating early referral.

Self-Assessment Questions (SAQs) for Study Session 19

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SAQ 19.1 (tests Learning Outcomes 19.1 and 19.2)

Which of the following statements is false? In each case, explain what is incorrect.

A When the muscular walls of the blood vessels all over a woman’s body contract, the space inside the vessels becomes larger so her blood pressure falls.

B Hypertension during pregnancy reduces the blood supply from the endometrial arteries in the mother’s uterus to the fetus via the placenta.

C Hypertension reduces the amount of amniotic fluid surrounding the fetus, because the blood flow to the baby’s kidneys is reduced so it makes less urine.

D Fetal growth is not restricted in a pregnant woman with hypertension.

Answer

A is false. When the muscular walls of the blood vessels all over a woman’s body contract, the space inside the vessels becomes smaller so her blood pressure rises.

B is true. Hypertension during pregnancy reduces the blood supply from the endometrial arteries in the mother’s uterus to the fetus via the placenta.

C is true. Hypertension reduces the amount of amniotic fluid surrounding the fetus, because the blood flow to the baby’s kidneys is reduce so it makes less urine. In late pregnancy, most of the amniotic fluid comes from the baby’s urine.

D is false. Fetal growth is very likely to be restricted in a pregnant woman with hypertension, because the transfer of oxygen, nutrients and fluids to the baby via blood from the placenta is reduced.

SAQ 19.2 (tests Learning Outcomes 19.1 and 19.3)

Complete Table 19.3 with the measurements you would expect to find in women classified with the types of hypertension shown in the left-hand column.

Table 19.3 for SAQ 19.2

Type	Raised blood pressure	Proteinuria	Symptoms of severity
Gestational hypertension
Mild pre-eclampsia
Severe pre-eclampsia
Superimposed pre-eclampsia

Answer

The completed version of Table 19.3 appears below.

Type	Raised blood pressure	Proteinuria	Symptoms of severity
Gestational hypertension	Above 140/90 mmHg	No significant proteinuria	None
Mild pre-eclampsia	Between 140/90 and 160/110 mmHg	No significant proteinuria	None
Severe pre-eclampsia	Greater than or equal to 160/110 mmHg	With or without significant proteinura (urine dipstick test result greater than or equal to +2)	Headache, blurred vision, epigastric burning pain, decreased urine output, decreased or absent fetal kick
Superimposed pre-eclampsia	Higher than before the pregnancy in a known chronic hypertensive woman	Significant or worsening proteinuria	With or without symptoms of severity

Read the following case study and then answer the questions that follow it.

Case Study 19.1 Zewditu’s story

Zewditu is a 37-year-old primigravida woman who is pregnant with twins. She is very overweight for her height. She was in good health until she reached gestational week 22, when she began to complain of headaches and swollen feet and ankles.

SAQ 19.3 (tests Learning Outcomes 19.1, 19.2, 19.3, 19.4, 19.5 and 19.6)

Does Zewditu have any of the common risk factors for hypertension? If yes, what are they?
Does she have any of the clinical features of hypertension? If yes, what are they and what is the underlying cause?
What complications could affect Zewditu’s baby if she has untreated hypertension?
What action should you take in Zewditu’s case and why?

Answer

Zewditu has three of the common risk factors for hypertension: she is having her first baby after the age of 35 years; she is expecting twins; and she is obese.
She has two clinical features of hypertension: headaches and swollen feet/ankles. Both are caused by oedema (swelling due to fluid collecting in the tissues). The headaches are due to oedema around the brain, and the swollen feet and ankles are due to oedema in the tissues of the lower limbs. The underlying cause of the oedema is because the high blood pressure is pushing fluid from the blood out through the vessel walls and into the surrounding tissues.
The complications that could affect Zeditu’s baby if she is not treated quickly are: placental abruption, intrauterine asphyxia, intrauterine growth restriction, intrauterine fetal death, or mental retardation in later life.
The first action is to measure her blood pressure and test her urine for the presence of protein. Even if the results are close to normal, she should be referred without any intervention from you to a higher health facility for further assessment, preferably on the day of the assessment. This is because even if her hypertension is currently mild, it may progress to severe pre-eclampsia in a very short period of time.

Introduction

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In this session you will learn about two very important techniques for emergency care of the pregnant woman who is either:

haemorrhaging (losing blood very quickly from her uterus), for reasons already described in Study Sessions 20 and 21; or who
cannot urinate (pass urine) because there is an obstruction preventing her from emptying her bladder. Usually this is because the pressure of the baby is blocking the urethra – the tube that brings urine down from her bladder.

This study session is preparation for the practical skills training in both these techniques, which you will receive during an attachment in a health centre or hospital. Here we introduce you to the equipment you will need, and describe how to start and maintain IV fluid therapy and how to catheterise the bladder of the pregnant woman. You will also learn to follow infection control procedures while performing these techniques.

Before you begin either of these techniques, explain to the woman in local language what you are going to do and why she needs this procedure. Tell her that as soon as you have finished doing it, she must go to the higher health facility for further treatment.

Make sure that transportation is being arranged while you are setting up the IV fluid therapy or bladder catheterisation.

Learning Outcomes for Study Session 22

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22.1 Define and use correctly all of the key words printed in bold. (SAQs 22.1, 22.2 and 22.3)

22.2 Explain the reasons for giving IV fluid therapy or catheterising the bladder of a pregnant woman. (SAQ 22.1 and 22.3)

22.3 Describe the equipment, the preparation and the procedure for starting intravenous (IV) fluid therapy, including selecting a suitable venipuncture site, and inserting and removing a cannula from a vein. (SAQs 22.1 and 22.2)

22.4 Describe how you would monitor IV fluid therapy. (SAQ 22.1)

22.5 Describe the equipment, the preparation and the technique of how to insert and remove a urinary catheter. (SAQs 22.1 and 22.3)

22.6 Describe the infection control procedures required to reduce the risk of infection resulting from IV fluid therapy or catheterising the bladder. (SAQ 22.1 and 22.2)

22.1.2 When to start IV fluid therapy

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A pregnant woman who is haemorrhaging will rapidly develop a state of shock; unless you take action quickly she will soon become unconscious and die.

What are the signs of shock? (You learned this in Study Session 20.)
The woman will look pale, especially inside her lower eyelids and the palms of her hands; her diastolic blood pressure (the bottom number) is below 60mmHg – sometimes much lower; and her pulse is high, often more than 100 beats per minute.

In order to save her life, you need to know how to start intravenous (IV) fluid therapy (also known as IV fluid resuscitation or IV infusion). This means getting special fluids into her blood circulation through a hollow needle called a cannula inserted into a vein, to replace the fluid part of the blood she is losing. You should do this before you urgently refer her to a hospital or health centre, where they will give her a blood transfusion. Women in labour, or soon after delivery of the baby, may also haemorrhage (as you will learn in the Labour and Delivery Care Module). You should start IV therapy quickly whenever you detect that a woman is haemorrhaging.

22.1.2 Setting up the IV fluid therapy equipment

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The first step in the process of initiating IV fluid therapy is to assemble and check the equipment you need (see Figure 22.1). You can place everything on a very clean large dish or locally available tray. We will describe the equipment in detail after you have looked at Figure 22.1.

Figure 22.1 Equipment needed for IV fluid therapy. The numbers in the list below correspond to the number beside the equipment on the tray.

Sterile IV fluid in a plastic bag; the main types are called Normal Saline (NS) and Ringer’s Lactate (RS) solution.
Sterile IV tubing (sometimes called an IV line) with a connector at one end to join it to the IV fluid bag, and a connector at the other end to join it to the cannula. It comes sealed in a sterile plastic package (not shown in Figure 22.1).
Sterile IV cannula. It comes sealed in a sterile plastic package (not shown in Figure 22.1). There is a larger diagram later in this study session (Figure 22.6).
Roller clamp, which you attach to the IV tubing and tighten or loosen to control the flow of fluid along the tube.
Bottle of alcohol to use with the cotton swabs (9) to clean the area of skin where the cannula is inserted; if alcohol is not available you can use soap and water.
Sterile surgical gloves in a sealed bag. If you open the bag carefully (as shown in Figure 22.1), you can lay the sterile paper on the tray with the inside facing upwards, and use the paper as a sterile surface. If you do not have sterile gloves, you should use very clean gloves swabbed with alcohol or scrubbed with soap and water.
A belt or rope, or a piece of cloth or bandage, to use as a tourniquet (Tourniquet is pronounced ‘torn-ee-kay’)– something you tie around the person’s arm to obstruct the flow of blood for a short time while you insert the needle at the end of the cannula into a vein.
A plaster to stick over the cannula when it is in the person’s arm to keep it securely in place. If you do not have a plaster you may use a clean bandage or locally available material, e.g. a piece of clean cloth.
Cotton swabs or small pieces of very clean cloth, to use with the alcohol for cleaning the person’s skin before you insert the cannula.

22.1.3 Sterile techniques for IV fluid therapy

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you prepare to give a person IV fluid therapy you have to keep everything clean and use sterile techniques (free from germ contamination) as much as possible. This may be difficult in a rural home, but you can reduce the risk of infection if you follow the instructions in Box 22.1.

Box 22.1 Preventing infection during IV fluid therapy

The most important precaution is to wash your hands thoroughly with soap and clean water for at least two minutes before and after you handle patients or sterile equipment.
Use alcohol to clean the tray or dish for your equipment, or (if not available) use soap and water and make sure it is thoroughly air-dried before using it.
Put on sterile or very clean gloves. You must wear gloves all the time because you will be coming in contact with the patient’s blood.
The cannula, the IV tubing and the surgical gloves come sealed in sterile plastic or paper packages. The inside surface of these sterile packages can be opened out and laid flat to serve as a sterile surface for the equipment until you need it.
The patient should be lying down in a comfortable position. Swab her skin with alcohol or soap and water around the area where the cannula will be put into a vein.
Open the sterile package holding the IV tubing and connect it to the fluid infusion bag. Hang the bag on hook in a wall above the patient, or ask someone to hold it up for you. Make sure the tip of the tubing which will be connected to the cannula is kept untouched and sterile.

22.1.4 Selecting the IV cannula

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Gauge is pronounced ‘gage’. The largest commonly available cannula is gauge 18 or 20.

You must choose a cannula with the appropriate size of needle for the required purpose. The size is referred to as the gauge of the cannula, and each size is given a number – the larger the number, the bigger the cannula.

Why do you think you should choose a large gauge cannula if you are giving IV fluid therapy to a pregnant woman who is haemorrhaging?
The woman has lost a significant amount of blood. Therefore, you need to get replacement fluids into her blood system as quickly as possible. You need a large gauge cannula so you can infuse a large amount of fluid into her vein in a short time.

22.1.5 Selecting the venipuncture site

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Figure 22.2 Common venipuncture sites in the hand and forearm.

The next step is identifying a good venipuncture site, that is the site where you will ‘puncture a vein’ by inserting the IV cannula. Figure 22.2 shows some commonly used sites in the hand and forearm.

In selecting the site for venipuncture:

Ask the patient which is the hand she most often uses, e.g. to hold a knife or a tool. If she says she is ‘right handed’, this is her ‘dominant’ hand and her left is her ‘non-dominant’ hand.
Look first at possible venipuncture sites on her non-dominant hand and then look higher up the arm.
Select a vein which is large enough for the cannula, avoiding sites near to joints like the wrist or the elbow.
Make sure that when you insert the cannula, it will not interfere with woman’s ability to move her hand or arm.
Avoid a site which is painful to touch.

The visibility of the veins can be improved by encouraging the woman to close her hand into a fist and then open it again several times, lowering the arm and stroking the chosen venipuncture site. As you become more experienced, you will find it easier to choose a suitable vein which is easily visible, not twisted, where you think you can enter your cannula easily.

22.1.6 Inserting the IV cannula

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Once you decide where to insert your IV cannula, apply a tourniquet about three finger-widths above the chosen venipuncture site (Figure 22.3a). Then feel for the vein with your gloved finger (Figure 22.3b). Clean the site with alcohol (Figure 22.3c) or soap and water.

Figure 22.3 Steps in inserting an IV cannula. (a) Tie the tourniquet above the chosen venipuncture site. (b) Feel for a good vein with your gloved finger. (c) Clean the area with alcohol or soap and water.

Then stretch the skin taut and stabilise the vein with your non-dominant hand — meaning keeping it stretched so that it does not move easily and you miss your target with the needle. Pierce the skin with the IV cannula over vein at a 45 degree angle; first you push the needle into the skin and then aim at the vein (Figure 22.4). As you approach the vein, lower the angle to about 10 degrees and insert the cannula into the vein.

Figure 22.4 Stretch the skin with your non-dominant hand and insert the cannula into a vein (a) in the patient’s hand; (b) in the forearm.

Look for blood ‘flash back’ (blood shooting back along the barrel of the cannula), which tells you that the needle is in the vein. Release the tourniquet at this point, then push the cannula further into the vein until you are well into the vein.

The cannula is a metal needle with plastic over it, and it is the plastic part that remains in the vein. Gently remove the metal needle part of the cannula, leaving the plastic part in the vein.

Figure 22.5 The cannula is held in place with a plaster (or similar) and connected to the IV tubing.

You then stabilise the plastic part of the cannula with a plaster, or clean rope or cloth wrapped around the venipuncture site (Figure 22.5).

Connect the IV tubing to the IV fluid bag and open the roller clamp to let fluid flow down the tube. Do this before connecting the other end of the tubing to the cannula. Flushing with fluid ensures there are no air bubbles in the tube before you begin infusing fluid into the patient.

22.3 Monitoring during IV therapy

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Once the IV tubing has been connected to the cannula, push the roller to the top of the clamp (see Figure 22.6). This allows the fluid to run down the tube and into the woman’s vein as quickly as possible. The flow rate should be as fast as you can run it because the woman is losing a lot of blood. Maintain this high flow rate at all times, including during transportation to the health facility. Make sure the IV fluid bag is kept higher than the woman’s arm, or the flow rate will slow down even if the roller clamp is fully ‘open’.

Figure 22.6 The roller clamp can be ‘closed’ (middle picture) or ‘opened’ to adjust the flow rate of IV fluid down the IV tubing and into the vein through the cannula.

22.3.1 Establishing a monitoring routine

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A routine has to be established for monitoring the progress of IV fluid therapy, beginning at the bag of fluid and ending at the venipuncture site. The flow rate should be checked every 15 minutes for as long as the woman is with you. If the flow has slowed down, check if the IV tubing has twisted, or if the position of the woman’s hand or arm has twisted to obstruct the flow, and straighten them out. The flow rate in emergency fluid replacement should run as fast as possible.

Make sure you monitor the woman’s pulse and blood pressure every 15 minutes.

If you are giving IV fluid therapy to treat shock due to blood loss, what would you expect to happen to the pulse rate and blood pressure as the IV fluids are infused?
With adequate infusion the pulse rate will decrease and blood pressure will increase. (After infusing two to three bags of IV fluid, the expectation is for the pulse to slow down and the blood pressure to start rising towards normal.)

As soon as you have completed the IV fluid therapy set up, refer the woman to a higher health facility as quickly as possible. Go with her if you can.

22.3.2 When to stop IV infusion

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Look for any swelling around the venipuncture site compared with the other hand (or arm), as this may signal that the cannula has moved and the fluid is running into the soft tissue instead of into the vein. If you see swelling, loosen the plaster and remove the IV cannula. Choose a new venipuncture site and use a new sterile IV cannula to enter a new vein and reconnect the IV fluid bag.

IV fluid therapy is stopped when the woman does not need additional fluid any more, or when the venipuncture site has developed an infection (the skin around the site will be red and will feel painful to the patient if you touch it). Sometimes patients may be given too much IV fluid in a short time and this may put stress on the heart because the blood volume has become too large. Fluid can also get into the lungs and in such cases the patient will have difficulty breathing, cough and sometimes become confused. This is not likely to happen while the patient is with you because you will refer her immediately after you started the IV infusion. But in case you encounter this situation, stop the infusion and refer the woman to the next higher facility immediately for further treatment.

You can stop the infusion by closing the roller clamp so no more fluid runs down the tube. Leave the cannula in place for someone at the health facility to remove under sterile conditions.

To stop an infusion you need sterile or very clean gloves, a clean dry swab, an antiseptic wipe or swab soaked in alcohol, and a new plaster.

Explain what you will be doing to the patient, put on your gloves and turn the roller clamp to the ‘off’ position. Check that the flow of fluid along the tube has stopped. Remove the plaster or other stabilising material over the cannula while holding the cannula in place with your other gloved hand. With a clean dry swab held over the venipuncture site, withdraw the cannula and apply pressure with your fingers to the site for a minute or two. Then swab the site with antiseptic or alcohol to remove any germs that may be near the puncture hole. When the skin is dry, cover the site with a plaster if you have one.

Always make sure the cannula is intact and dispose of it safely in a puncture-proof container.

22.4 Bladder catheterisation

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

A pregnant woman in labour who cannot urinate as a result of compression on the outflow tube (urethra) from the bladder, will have great discomfort. At the same time, the full bladder will further obstruct the passage of the unborn baby by occupying space in the pelvis. She needs to have a catheter (sterile rubber or plastic tube) inserted into her bladder to let the urine out before you refer her to a higher health facility. The technique is called catheterisation. This procedure may even allow the birth of the baby to progress. Without it, if labour begins, she may be unable to give birth normally. Women who are a long time in labour may also need catheterisation if their bladder becomes obstructed. If the woman’s bladder is distended it will feel like a soft bag of water lying above her pubic bone. When she is lying flat on her back, you may see the full bladder as a rounded mass.

Tell her what you are going to do and why she needs the procedure. Then ask her to lie on her back with her head lifted and her legs flexed, with feet wide apart. Cover her lower body except the genital area with a clean cloth to reduce embarrassment for her if other people are present.

22.4.1 Bladder catheterisation equipment

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Assemble the necessary equipment for the procedure and lay them on a very clean dish or tray (see Figure 22.7). We will describe the equipment in detail after you have looked at Figure 22.7.

Figure 22.7 Equipment needed for bladder catheterisation. The numbers in the list below correspond to the number beside the equipment on the tray.

Sterile drainage tubing with a collection bag to hold the urine draining from the bladder. It will come in a sterile plastic package (not shown in Figure 22.7).
Alcohol or antiseptic cleaning solution to clean the genital area; if you do not have it, use soap and water.
Cotton swabs or small pieces of very clean cloth.
Sterile gloves; if you do not have them use very clean gloves.
Tube of lubricant (slippery gel to help the catheter go in more easily).
Syringe containing sterile water to inflate the catheter balloon.
Sterile catheter of the correct size; the size in common use is 16FC (FC or Foley Catheter, is the unit used to indicate the size of the catheter). It will come in a sterile plastic package (not shown in Figure 22.7). Notice the side tube which connects to an inflatable balloon at the tip of the catheter.
Good light source; a battery operated torch may serve the purpose, but you will need to ask someone to hold it for you.
Cloth to drape over the woman’s lower body.

22.4.2 Steps in the catheterisation procedure

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What is the first thing you should do before you open any of the sterile equipment packages?
Wash your hands thoroughly with soap and water for at least 15 seconds.

Once your patient is prepared and informed and your equipment is ready, put on the sterile or very clean gloves and clean around the woman’s vulva and perineal area with antiseptic solution or alcohol, starting from the urethral opening and swabbing outwards (Figure 22.8a). If you don’t have antiseptic solution, clean the area thoroughly with soap and water.

Figure 22.8 (a) Clean the area around the vulva and perineum with an alcohol swab. (b) Gently pull back the labia majora to expose the urethral opening and insert the catheter.

Why do you think it is important to clean the area starting with the urethral opening and swabbing outwards?
This avoids wiping germs from the perineal area towards the urethral opening; they could be carried inside when the catheter is inserted.

Use your non-dominant hand to carefully pull back the labia majora to fully expose the urethral opening. (You may wish to look back at the detailed drawing of the female external genitalia in Figure 3.2 in Study Session 3.) Lubricate the 16FC catheter if you have proper lubricant (don’t use anything else) and slowly insert the catheter into the urethral opening (Figure 22.8b).

Once well into the bladder, you will see urine flowing out through the end of the catheter. Use the syringe to inject 5 ml of sterile water into the tube leading to the catheter balloon; this makes the balloon swell up and anchors the catheter in the bladder so it won’t pull out when the patient moves (see Figure 22.9). Pull on the catheter very gently to feel the resistance.

View larger image

Figure 22.9 Half section of the pelvic cavity of a woman showing a urinary catheter anchored in the bladder by the inflated catheter balloon.

Then connect the catheter to the sterile drainage tubing so the urine flows into the collecting bag. Make sure the collecting bag is placed below the level of the bladder, or the urine will not flow into it. If you do not have a sterile collecting bag, then let the urine drain into a very clean container. This is called an ‘open’ system and it carries a bigger risk of infection passing up the drainage tube and into the bladder. Ideally, the drainage should be a ‘closed’ system with the urine draining into a sterile bag.

As soon as you have completed the procedure, refer the woman to a higher health facility as quickly as possible. Go with her if you can.

22.4.2 General care for the catheterised person

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When you are providing care to the woman who is catheterised, understand that she may feel some discomfort in her bladder area. Reassure her to reduce anxiety by explaining why you want to keep the catheter in place.

You should also keep her clean by wiping away any urine that might have leaked from the catheter; this may make her wet and embarrass her, or irritate her skin and also increase her anxiety.

22.4.3 Removing the catheter

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When it is time to remove the catheter, prepare the necessary items on a very clean tray or dish.

The equipment you will need are sterile or very clean gloves, and a syringe to remove the water from the catheter balloon.
Tell the patient you are going to remove the catheter and this may cause a little discomfort. Put on the gloves and without disconnecting the drainage tube use the syringe to collapse the balloon by sucking the sterile water back into the syringe. When all the water has been withdrawn, slowly pull out the catheter.

Explain to the woman that she may feel some soreness or slight burning pain when she urinates normally for the first few times, but her bladder will soon be functioning normally.

22.5 In conclusion

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

This concludes the Antenatal Care Module. You have learned many things in the 22 study sessions about looking after the pregnant woman who is healthy and whose pregnancy is progressing normally, and also about the interventions you should make if you detect danger signs and symptoms. Your knowledge and skill can prevent many complications and save the lives of women and their unborn babies who get into difficulties. In the next Module, you will learn about Labour and Delivery Care.

Summary of Study Session 22

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 22 you have learned that:

Intravenous (IV) fluid therapy is required to replace lost fluids in a pregnant woman who is losing a lot of blood.
Giving IV fluid therapy includes knowing how to assemble the necessary equipment, identify a suitable venipuncture site, insert a cannula into a vein and stabilise it, and maintain a rapid flow rate of fluid into the woman’s circulation.
Reasons for stopping IV fluid therapy include: the woman’s blood pressure and pulse return to normal, fluid leaks into the tissues around the venipuncture site instead of running into the vein, there are signs of infection around the venipuncture site, or the woman has received too much fluid and is showing signs that her heart or lungs may be affected.
Catheterisation of the bladder involves introducing a sterile rubber or plastic tube through the urethra and into the bladder to drain excess urine. The procedure is necessary when the bladder is distended due to an obstruction preventing the woman from urinating normally, e.g. during a long or obstructed labour.
The catheter is anchored in the bladder by injecting sterile water into the catheter balloon to inflate it and hold the catheter in place.
A closed drainage system is important for collecting the urine; an open system can result in infection travelling back up the tubing into the bladder.
Infection control procedures should be observed at all times when giving IV fluid therapy or catheterising the bladder; wash hands thoroughly before and after the procedure, wear sterile or very clean gloves, and swab the surrounding area of skin with antiseptic solution or alcohol before inserting the IV cannula or the urinary catheter.
Make sure you inform the patient what you are going to do before you begin these procedures and explain why it is necessary to help her in this way.
Refer the woman to a higher health facility immediately you have completed the procedure. Go with her if you can.

Self-Assessment Questions (SAQs) for Study Session 22

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions that follow below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 22.1 (tests Learning Outcomes 22.1, 22.2, 22.3, 22.4, 22.5 and 22.6)

Which of the following statements is false? In each case, explain what is incorrect.

A A woman who is in shock due to loss of blood should be referred immediately without beginning IV fluid therapy.

B Remove and reposition the IV cannula if the venipuncture site swells and is painful.

C If you don’t have a plaster to put over the venipuncture site there is no need to stabilise the IV cannula in the vein.

D You can stop giving IV fluid if the woman’s blood pressure and pulse return to normal and she is no longer bleeding.

E The syringe is for injecting sterile water into the bag collecting urine from the drainage tube in the bladder.

F Wash your hands thoroughly with soap and water before you touch the patient or the equipment.

G The flow rate should be as fast as possible when you start IV fluid therapy for a woman who is in shock.

Answer

A is false. A woman who is in shock (low blood pressure and rapid pulse) due to blood loss needs IV fluid therapy to be started before referral.

B is true. You should remove and reposition the IV cannula if the venipuncture site swells and is painful. This indicates that the fluid is going into the tissues instead of into the vein.

C is false. If you don’t have a plaster to put over the venipuncture site, you should stabilise the IV cannula by tying very clean cloth around it. If the cannula is not stabilised it can pull out of the vein.

D is true. You can stop giving IV fluid if the woman’s blood pressure and pulse return to normal and she is no longer bleeding.

E is false. The syringe is for injecting sterile water into the catheter balloon (not the collecting bag) to inflate the balloon so it anchors the catheter in the bladder.

F is true. You should wash your hands thoroughly with soap and water before you touch the patient or the equipment.

G is true. The flow rate should be as fast as possible when you start IV fluid therapy for a woman who is in shock.

SAQ 22.2 (tests Learning Outcomes 22.1, 22.3 and 22.6)

Rearrange the following list into the correct sequence of actions when you start IV fluid therapy.

Interactive content appears here. Please visit the website to use it.

SAQ 22.3 (tests Learning Outcomes 22.1, 22.2 and 22.5)

Define what catheterisation means and why it may be necessary in the pregnant woman in labour. List at least five items of equipment you need to conduct this procedure.

Answer

Catheterisation of the bladder means introducing a sterile rubber or plastic tube into the urethra and then into the bladder to drain urine when the bladder is obstructed. Bladder obstruction can happen in a long or obstructed labour when the baby presses down on the urethra and blocks the normal flow of urine. The items of equipment you need are:

Sterile catheter of the correct size (16FC)
Sterile drainage tubing with a urine collection bag
Syringe containing sterile water to inflate the catheter balloon
Sterile or very clean gloves
Alcohol or antiseptic cleaning solution and swabs
Tube of lubricant
A good light source
Cloth to drape over the woman’s lower body.

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

During pregnancy, a woman’s body changes in many ways — as you learned in Study Session 7. These changes can sometimes be uncomfortable, but most of the time they are normal. They can occur at any time during the pregnancy. In this study session, you will learn about some of the most common minor disorders of pregnancy, and discuss ways to help women feel better, or at least to stop worrying about them. We will also explain how to tell when a woman’s discomfort may be a sign that there could be a problem that requires further investigation and management, or even that something dangerous is happening with her pregnancy. Most of the minor disorders during pregnancy can be minimised with good education and prompt treatment. You should also know about some remedies that are dangerous for pregnant women and may hurt the baby.

Learning Outcomes for Study Session 12

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

12.1 Define and use correctly all of the key words printed in bold. (SAQ 12.1)

12.2 Identify minor disorders or problems that women could develop during pregnancy and describe their relevant management. (SAQs 12.2 and 12.3)

12.1 Digestive and food-related disorders

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

There are several very common disorders of pregnancy that relate to food, or the digestion of food. Another way of classifying these disorders is to think of them as affecting the gastrointestinal system.

12.1.1 Nausea, vomiting and hyperemesis gravidarum

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Many women have nausea and vomiting in the first trimester (3 months) of pregnancy, which is often called morning sickness. It happens commonly in the morning when the woman gets out of bed. Excessive salivation is an infrequent but troublesome complaint which is associated with a condition called hyperemesis gravidarum — caused by severe and frequent nausea and vomiting during pregnancy.

Hyperemesis is pronounced ‘hye-pur-em-ee-sis’ and means ‘excessive vomiting’. Gravidarum is pronounced ‘gra-vid-ah-room’ and means ‘during pregnancy’.

Hyperemesis gravidarum is a serious disorder, for which the woman needs to be admitted to hospital or a health centre.

The diagnosis of hyperemesis gravidarum is made if the woman loses 5 kg or more of her body weight due to frequent vomiting, loss of body fluids and nausea, making her fearful of eating, and is confirmed by the appearance of acidic chemicals (called ketone bodies) in her urine. The body starts to produce ketone bodies when it begins to break down proteins in a person’s muscles because there is no other energy source to keep them alive. The ketone bodies can be detected in urine by a dipstick test, which you can do in the woman’s home or at the Health Post if you have been provided with the appropriate dipsticks and shown how to ‘read’ the colour change if ketone bodies are present. A positive test result means she must be referred immediately to get replacements for the nutrition, body fluids and essential chemicals that she has lost, and receive preventive treatment to avoid further occurrence.

Management of mild nausea

If the nausea is mild, encourage the woman to try any of these remedies:

Before bed or during the night, eat a food that contains protein, such as beans, nuts or cheese.
Eat a few bananas, dry bread, dry kita, or other grain food upon waking up in the morning.
Eat many small meals instead of two or three larger ones, and take small sips of liquid often.
Drink a cup of mint, cinnamon or ginger tea two or three times a day, before meals. Put a teaspoon of mint leaves, or a stick of cinnamon, in a cup of boiling water and let the tea sit for a few minutes before drinking it. To make ginger tea, boil crushed or sliced ginger root in water for at least 15 minutes.

12.1.2 Food dislikes and food cravings

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

A pregnant woman may suddenly dislike a food that she usually likes. It is OK not to eat that food, and she will probably begin to like it again after the birth. She should be careful that the rest of her diet contains a lot of nutritious food. You will learn what advice to give women about good nutrition during pregnancy in Study Session 14.

A food craving (also known as pica) is a strong desire to eat a certain food, or even something that is not food at all, like black soil, chalk or clay (Figure 12.1). If a woman gets a craving for nutritious foods (like beans, eggs, fruits or vegetables), it is OK for her to eat as much as she wants.

Pica is pronounced ‘pye-kah’.

Figure 12.1 Food cravings are common in early pregnancy.

A woman who craves to eat things that are not food, like soil or clay, should be advised not to eat them. They may poison her and her baby. They may also give her parasites, like worms, that can make her sick. Encourage her to eat iron-rich and calcium-rich foods instead (see the advice in Figure 12.1).

12.1.3 Heartburn

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

A burning feeling or pain in the stomach, or between the breasts, is called indigestion or heartburn. Heartburn happens because the growing baby crowds the mother’s stomach and pushes it higher than usual (Figure 12.2). The acids in the mother’s stomach that help digest food are pushed up into her chest, where they cause a burning feeling. Reassure her that this is not dangerous and usually goes away after the birth.

Figure 12.2 Heartburn in pregnancy may be due to the baby crowding the mother’s stomach.

Management

Here are some things a woman can try to make herself feel more comfortable:

Keep her stomach less full by eating smaller meals more often, and by eating foods and drinking liquids separately.
Avoid eating spicy or greasy foods, drinking coffee, or smoking cigarettes, as all of them can irritate the stomach.
Regularly eat papaya or pineapple, which have enzymes (special chemicals) that help the stomach to digest food.
Keep her head higher than her stomach when lying down or sleeping. This will keep her stomach acids in her stomach and out of her chest.
Calm the acids in the stomach by drinking milk, or taking a low-salt antacid (stomach-calming liquid or tablet) that contains no aspirin, but advise her to try other methods before using drugs like antacids.

12.1.4 Constipation

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Some pregnant women have difficulty in passing stools. This is called constipation. It is caused by hormonal changes that decrease the rhythmic muscular movements of the gut (peristalsis), which push food along the intestines. This results in an increase in ‘emptying time’, how long it takes for a meal to be digested and the waste matter expelled as stools.

Management

To prevent or treat constipation, a pregnant woman should:

Eat more fruits and vegetables.
Eat whole grains (brown rice and whole wheat, instead of white rice or white flour).
Drink at least eight cups of clean water a day.
Walk, move and exercise every day.
Try home or plant-based remedies that will soften the stool or make it slippery, e.g. remedies made from telba seed, certain fruits, or fibre plants like gomen.

12.2 Swollen veins

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

There are many reasons why pregnant women may develop swollen veins in different parts of the body. Here are two of the most common.

12.2.1 Varicosities (varicose veins)

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Genital varicosities can cause bleeding if they tear during birth, so refer a woman who has this problem to a health centre.

Swollen blue veins that appear in the legs are called varicosities, or varicose veins, and are very common in pregnancy. Sometimes these veins hurt. Pressure by the enlarging uterus on the veins that return blood to the heart from the legs is a major factor in the development of varicosities in the leg veins. Very rarely, swollen veins may develop in the external genitalia and these are very painful.

Management

If the swollen veins are in the legs, they may feel better if the woman puts her feet up often. Strong stockings or elastic bandages may also help. If the swollen veins are around the genitals, a panty-girdle or sanitary pad may help to support them.

12.2.2 Haemorrhoids (piles)

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Haemorrhoids (also known as piles) are swollen veins around the anus. They may burn, hurt, or itch. Sometimes they bleed when the woman passes a stool, especially if she is constipated. Sitting or standing a lot can make haemorrhoids worse.

Management

The woman should try to avoid getting constipated by eating a lot of fruit and vegetables and drinking plenty of fluids. Straining to pass hard stools makes haemorrhoids worse. Sitting in a cool bath or lying down can help.

12.3.1 Back pain

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Many pregnant women get back pain. The weight of the baby, the uterus and the amniotic fluid, changes her posture and puts a strain on the woman’s bones and muscles. Too much standing in one place, or leaning forward, or hard physical work, can cause back pain. Most kinds of back pain are normal in pregnancy, but it could also be caused by a kidney infection.

Management

Encourage the woman’s husband, children, other family members or friends to massage the woman’s back. A warm cloth or hot water bottle on her back may also feel good. Her family can also help by doing some of the heavy work, such as carrying small children, washing clothes, farming, and milling grain. A tight girdle, or a belt worn about the hips, together with frequent bed rest, may relieve severe back pain.

12.3.2 Joint pain

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Hormones in the third trimester (six to nine months of pregnancy) act on the woman’s joints so they get softer and looser. This makes her joints more flexible, including the joints between the bones in her pelvis (recall the anatomy of the pelvis in Study Session 6, particularly Figure 6.1).

Why do you think this natural loosening of the joints in the pelvis is beneficial in late pregnancy?
It helps to create a more flexible space in the pelvis for the baby to pass down the birth canal during labour and delivery.

Sometimes a pregnant woman’s joints get too loose and uncomfortable, especially the hips, and she may develop an unstable pelvis, which produces pain. Joint pain is not dangerous, but the woman can more easily sprain her ankles or other joints.

12.3.3 Leg cramps

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Many pregnant women get foot or leg cramps — sharp sudden pain and tightening of a muscle. These cramps especially come at night, or when women stretch and point their toes. To stop the cramp, flex the foot (point it upward) and then gently stroke the leg to help it relax (do not stroke hard).

Management

To prevent more cramps, a woman should not point her toes (even when stretching), and she should eat more foods high in calcium and potassium, which can help.

Can you list some calcium-rich foods?
Yellow vegetables such as yams and carrots, lime, milk, curd, yogurt, cheese, green leafy vegetables, bone meal and egg shells, molasses, soybeans and sardines.

12.3.4 Sudden pain in the side of the lower belly

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The uterus is held in place ‘suspended’ by ligaments on each side. Ligaments are like ropes that attach the uterus to the mother’s abdomen. A sudden movement will sometimes cause a sharp pain in these ligaments. This is not dangerous. The pain will usually stop in a few minutes. It may help to stroke the belly gently, or to put a warm cloth on it.

12.3.5 Abdominal cramps in early pregnancy

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The woman may have an ectopic pregnancy implanted in a fallopian tube, or she may be having a miscarriage. She should get medical help immediately.

It is normal to have mild abdominal cramps (like mild monthly bleeding cramps) at times during the first trimester of pregnancy. These cramps happen because the uterus is growing. However, cramps that are regular (come and go in a pattern), or constant (always there), or are very strong or painful, or come with spotting or bleeding from the vagina, are warning signs.

12.3.6 Headaches and migraines

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Headaches are common in pregnancy, but are usually harmless. Headaches may stop if the woman rests and relaxes more, drinks more juice or water, or gently massages her temples. It is OK for a pregnant woman to take two paracetamol tablets with a glass of water once in a while. However, headaches late in pregnancy may be a warning sign of pre-eclampsia, especially if there is also high blood pressure, or swelling of the face or hands. Pre-eclampsia is discussed in detail later in this Module, in Study Session 19.

If you suspect pre-eclampsia, refer the woman to the nearest health facility immediately.

Some women have migraine headaches. These are strong headaches, often on the side of the head. The woman may see spots and feel nauseated. Bright light or sunshine can make them worse. Migraines may get worse in pregnancy.

Management

Unfortunately, migraine medicine is very dangerous in pregnancy. It can cause labour to start too soon, and it may also harm the baby. It is better for a pregnant woman with a migraine to take 500 to 1,000 mg (milligrams) of paracetamol with a glass of water, and rest in a dark room. Although coffee and black tea are usually not healthy in pregnancy, they are OK occasionally, and they may help to cure a migraine.

12.4.1 Oedema

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

If you suspect that oedema might be a sign of pre-eclampsia, refer the woman to the nearest health facility immediately.

Swelling of the feet and ankles is very common in pregnancy, especially in the afternoon, or in hot weather. It is due to oedema, the retention of fluids in the body tissues. Under the force of gravity, the retained fluid tends to sink down the body and collect in the feet. Advise the woman to sit with her feet raised as often as possible, to allow the fluid to be absorbed back into the circulatory system. Swelling of the feet is usually not dangerous, but severe swelling when the woman wakes up in the morning, or swelling of the hands and face at any time, can be signs of pre-eclampsia, which is a very serious (even life-threatening) condition.

Management

Swelling in the feet may improve if the woman puts her feet up for a few minutes at least two or three times a day, avoids eating packaged foods that are very salty, and drinks more water or fruit juices.

12.4.2 Frequency of urination

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Urinary frequency is a common complaint throughout pregnancy, especially in the first and last months. This happens because the growing fetus and uterus presses against the bladder. It will stop once the baby is born. If urinating hurts, itches, or burns, the woman may have a bladder infection. The diagnosis and management of urinary tract infections are discussed in Study Session 18.

12.4.3 Vaginal discharge

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Discharge is the wetness all women have from the vagina. A woman’s body uses this discharge to clean itself from the inside. For most women, the discharge changes during their monthly cycle. Pregnant women often have a lot of discharge, especially near the end of pregnancy. It may be clear or yellowish. This is normal. However, the discharge can be a sign of an infection if it is white, grey, green, lumpy, or has a bad smell, or if the vagina itches or burns.

You should refer all suspected cases of vaginal infection to the nearest health facility.

12.4.4 Feeling hot or sweating a lot

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Feeling hot is very common in pregnancy, and as long as there are no other warning signs (such as signs of infection), the woman should not worry. She can dress in cool clothes, bathe frequently, use a paper fan or a large leaf, and drink plenty of water and other fluids.

12.4.5 Dyspnoea (shortness of breath)

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Many women get short of breath (cannot breathe as deeply as usual) when they are pregnant. This condition is called dyspnoea.

Dyspnoea is pronounced ‘dissp-nee-ah’.

Why do you think shortness of breath is a common problem, especially later in pregnancy?
Breathlessness is because the growing baby crowds the mother’s lungs, and she has less room to breathe.

Management

Reassure women who are breathless near the end of pregnancy that this is normal. But if a woman is also weak and tired, or if she is short of breath all of the time, she should be checked for signs of sickness, heart problems, anaemia, or poor diet. Get medical advice if you think she may have any of these problems.

12.4.6 Difficulty in getting up and down

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

It is better if a pregnant woman does not lie flat on her back, because it can be difficult for her to get up again, and because when a woman is on her back, the weight of the uterus presses on the big blood vessels that return blood to her heart. This can temporarily reduce the supply of oxygen to her brain, and she may feel dizzy. If the woman wants to be on her back, she should put something behind her back and under her knees so she is not lying completely flat.

A pregnant woman should also be careful how she gets up. She should not sit up like the woman in Figure 12.3(a). Instead, she should roll to the side and push herself up with her hands, as in Figure 12.3(b).

View larger image

Figure 12.3 (a) Getting up without turning onto one side first can tear the muscles of the abdomen. (b) Turning to the side and pushing up with the hands is much safer and more comfortable.

12.4.7 Chloasma (the mask of pregnancy)

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

You already know what chloasma looks like from Study Session 8. Reassure the woman that the dark colouration is not harmful and that usually most of the colour goes away after the birth. A woman may be able to avoid developing dark areas on her face by wearing a hat when she goes out in the sun.

12.5 Changing feelings and emotions

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Pregnancy is an important time in a woman’s life. Her baby is growing inside her, her body is changing, and she needs more food and more rest. As a woman’s body changes, her relationships, her sexuality, and her work life can change too.

12.5.1 Sudden changes in feelings

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Pregnancy can make women very emotional. Some women laugh or cry for no clear reason. Some feel depressed, angry, or irritable. Odd laughing or crying, and other sudden mood changes or strong feelings, are normal. They usually pass quickly. But do not ignore a woman’s feelings simply because she is pregnant. Her feelings are real.

12.5.2 Worry and fear

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Many women worry when they are pregnant, especially about the baby’s health and about giving birth. A woman’s worries about other problems in her life may also become stronger when she is pregnant. Such worries are normal. They do not mean that something bad will happen. Women with these feelings need emotional support, like someone to listen to their worries and encourage them to feel hopeful. They may also need help to solve the problems they are having in their lives, like problems with their partners, money, drugs or alcohol, or other issues.

12.5.3 Sleep problems

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Some pregnant women feel sleepy much of the day. This is normal during the first three months. Their bodies are telling them to slow down and rest. There is no need to intervene unless the woman also feels weak, which may be a sign that she has a more serious problem, like a sickness, depression or anaemia.

Sometimes pregnant women have problems in sleeping; they may find it difficult to get to sleep, or they wake up after a short time and cannot get back to sleep. This problem is called insomnia.

Management of insomnia

If a pregnant woman cannot sleep because she is uncomfortable or restless, it may help if:

She lies on her side with something comfortable between her knees and at her lower back. She can use a pillow, a rolled-up blanket, banana leaves, or some other padding.
Someone gives her a massage.
She drinks herbal teas that help her sleep.

12.5.4 Strange dreams and nightmares

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Pregnant women may have strong, vivid dreams. They can be beautiful, strange, or frightening. For many people, dreams are an important way of understanding themselves and the world. Some people believe that dreams can tell us about the future, or give us messages from spirits. But usually, when something happens in a dream, it does not mean that it will happen to us in life. The events in the dream may be telling us what we are afraid of, or what we desire. Or they may simply be stories our minds make up while we sleep. Pregnant women who are having frightening dreams may need someone to talk to about their hopes, fears and feelings.

12.5.5 Forgetfulness

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Some women are more likely to forget things when they are pregnant. For most women, this is not a big problem. But some may worry if they do not know it is normal. No one knows why women become more forgetful when they are pregnant, but it is common.

12.5.6 Feelings about sex

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Some women do not want much sex when they are pregnant. Others want sex more than usual. Both feelings are normal. Having sex, and not having sex, are both OK for the woman and her baby. Sex is not dangerous for the baby. Sometimes sex is uncomfortable in pregnancy. A woman and her partner can try different positions for making love. It may feel better with the woman on top, or in a sitting or standing position, or with the woman lying on her side. When a pregnant woman has sex, it is important to avoid infection by advising her to have safe sex by using condoms to prevent HIV/AIDS and other sexually transmitted infections.

12.6 Conclusion

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The techniques you learned earlier (in Study Session 8) will enable you to ask sensitive questions when women come to you for antenatal care, so you can discover if they have any minor disorders that you can help them to manage. Effective questioning will also reveal danger signs that require referral to a health facility. In the next study session, you will increase your skills in dealing with clients when we teach you about the health promotion issues you will need to discuss with pregnant women in your community.

Summary of Study Session 12

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 12, you have learned that:

A woman’s body changes during pregnancy. These changes can sometimes cause discomfort, but mostly they are normal and will resolve themselves after the baby is born.
You can minimise most of the minor disorders during pregnancy with advice on diet, exercise, and with simple home remedies that are known to be safe and help women feel better.
Sometimes these minor problems may become more serious, or signal a serious underlying health problem that needs referral to a health facility.
Some remedies (e.g. migraine medicine) are dangerous for pregnant women, and may hurt the baby as well as the mother.
Minor disorders of pregnancy that you may encounter in dealing with pregnant women can be categorised according to which of the body systems is involved.

Gastrointestinal disorders include nausea and vomiting, dislike of some foods, heartburn, pica (food cravings), constipation and haemorrhoids (piles).
Musculoskeletal and skin disorders include back pain, aches and pains in the joints, difficulty in getting up and down, feeling hot or sweating a lot, the mask of pregnancy (chloasma), sudden pain in the side of the lower belly, cramps in early pregnancy, and leg cramps.
Cardiovascular disorders include varicosities, and dyspnoea (shortness of breath).
Genitourinary disorders include frequency of urination, and vaginal discharge (wetness from the vagina).
Nervous system disorders include sleepiness and insomnia, headaches, changing feelings and emotions, worry and fear, strange dreams and nightmares, forgetfulness, and changing feelings about sex.

Self-Assessment Questions (SAQs) for Study Session 12

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

SAQ 12.1 (tests Learning Outcomes 12.1 and 12.2)

A 22-year old pregnant woman at 34 weeks of gestation tells you that she craves to eat clay soil. She also tells you that she has developed darker brown patches on her face, and that her feet and ankles swell up during the day.

Identify the minor disorders of pregnancy this woman is displaying, using their medical names.
What advice should you give her to manage her symptoms?

Answer

The medical names for the minor disorders of pregnancy that this woman is displaying are pica, chloasma, and oedema.
Management:
Pica: Clay soil is not food, and it may give her parasites that can make her sick. You should advise her not to eat clay, but encourage her to eat iron-rich foods (like chicken, fish, pumpkin, beans, peas, meat — especially liver, kidney, and other organ meats — and whole grain products) and calcium-rich foods (like yellow vegetables, milk, curd, yogurt, cheese, and green leafy vegetables).
Chloasma: Reassure her that the brown patches are normal and they will fade after the baby is born. She can minimise them by wearing a hat when she is in bright sunlight.
Oedema: Advise her to put her feet up for a few minutes at least two or three times a day. This will help the fluid in her lower legs to be absorbed back into her circulation. Encourage her to eat fewer packaged foods that are very salty and to drink more water or fruit juices.

SAQ 12.2 (tests Learning Outcomes 12.1 and 12.2)

Match the correct management with each of the disorders.

Interactive content appears here. Please visit the website to use it.

Federal Democratic Republic of Ethiopia Ministry of Health

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The Ethiopian Federal Ministry of Health (FMOH) and the Regional Health Bureaus (RHBs) have developed this innovative Blended Learning Programme in partnership with the HEAT Team from The Open University UK and a range of medical experts and health science specialists within Ethiopia. Together, we are producing 13 Modules to upgrade the theoretical knowledge of the country’s 33,000 rural Health Extension Workers to that of Health Extension Practitioners, and to train new entrants to the service. Every student learning from these Modules is supported by a Tutor and a series of Practical Training Mentors who deliver the parallel Practical Skills Training Programme. This blended approach to workplace learning ensures that students achieve all the required theoretical and practical competencies while they continue to provide health services for their communities.

These Blended Learning Modules cover the full range of health promotion, disease prevention, basic management and essential treatment protocols to improve and protect the health of rural communities in Ethiopia. A strong focus is on enabling Ethiopia to meet the Millennium Development Goals to reduce maternal mortality by three-quarters and under-5 child mortality by two-thirds by the year 2015. The Modules cover antenatal care, labour and delivery, postnatal care, the integrated management of newborn and childhood illness, communicable diseases (including HIV/AIDS, malaria, TB, leprosy and other common infectious diseases), family planning, adolescent and youth reproductive health, nutrition and food safety, hygiene and environmental health, non-communicable diseases, health education and community mobilisation, and health planning and professional ethics.

In time, all the Modules will be accessible from the Ethiopian Federal Ministry of Health website at www.moh.gov.et; online versions will also be available to download from the HEAT (Health Education and Training) website at www.open.ac.uk/africa/heat as open educational resources, free to other countries across Africa and anywhere in the world to download and adapt for their own training programmes.

Dr Kesetebirhan Admasu

State Minister of Health

Ethiopian Federal Ministry of Health

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Applied anatomy and physiology for basic obstetric care is an entry to your studies in this Module and the next four Modules, and is essential preparation for your practical skills training. Obstetric care refers to healthcare for women during pregnancy, labour and delivery, and their immediate postnatal care. It requires a good understanding of the anatomy and physiology of the female reproductive system. Anatomy is the study of the structures of the human body, i.e. the features of how the organs, tissues and body systems are constructed. Physiology, on the other hand, is the study of the coordinated functions of the organs, tissues and systems in the body.

In this study session, you will learn about the structures that make the external female genitalia and the internal reproductive organs. In Session 4, we teach you about the hormonal regulation of the internal female reproductive organs and the female monthly menstrual cycle (bleeding from the vagina). In Study Session 5, we describe ovulation, fertilisation and implantation of the embryo in the mother’s uterus (womb), and the development of the fetus, the placenta and fetal nutrition. In Study Session 6, you will learn the anatomy of the female bony pelvis, and also of the fetal skull, which has to pass through the mother’s pelvis during delivery.

Learning Outcomes for Study Session 3

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

3.1 Define and use correctly all of the key words printed in bold. (SAQs 3.1 and 3.2)

3.2 Identify and describe the basic anatomical features of the external female genitalia and the internal reproductive organs. (SAQs 3.2, 3.3 and 3.4)

3.3 Describe the functions of the main anatomical structures in the female reproductive system and their importance for obstetric care. (SAQs 3.3 and 3.4)

3.1 Some common terms in anatomy and physiology

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In learning anatomy and physiology for the first time, you will be exposed to a large number of new terminologies. Some of these may be familiar to you from your previous biology course at high school. In this study session, we have tried to use simple terms as much as possible to help you understand the study material. Defining most of the terms used in anatomy and physiology is beyond this study session, but defining the most important terms used in obstetric care will help you achieve the learning outcomes of this study session and Study Sessions 4 to 6.

The terminologies used in human anatomy often include a directional term, i.e. a term that indicates the position of one anatomical structure in relation to another one, or in relation to the body as a whole (see Box 3.1). You will encounter directional terms many times in this Module.

Box 3.1 Some common directional terms used in anatomy

Superior: above

Inferior: below

Medial: towards the midline of the body

Lateral: away from the midline (sides, edges)

Anterior: in front of

Posterior: behind, at the back of

3.2 Anatomy and physiology of the female reproductive organs

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The reproductive role of females is far more complex than that of males:

Women produce ova (eggs), which can be fertilised by the male.

Ova (plural) is pronounced ‘oh vah’. Ovum (singular) is pronounced ‘oh vumm’

After fertilisation, women also carry and protect the developing fetus in the uterus.
After childbirth, the breasts (mammary glands) produce milk to nourish the baby.

By nature, every one of us is eager to know how we develop in our mother’s uterus, how a fetus (the growing baby inside the uterus) develops during the nine months of pregnancy, how it is nourished, and how the female menstrual cycle is controlled. To understand these and other related questions about female reproductive functions, you have to learn about the anatomy (structure) of the female reproductive organs, and understand the physiology (function) of each organ.

We begin with the anatomical positions of the female reproductive organs in relation to the urinary system (the kidneys and bladder), the gastrointestinal system (the ‘gut’ where digestion of food occurs), and other nearby structures in the pelvic cavity, (see Box 3.2 and Figure 3.1 below).

Box 3.2 Cavities in the human body

A cavity is a space in the human body which contains different organs, fluids and other structures. For example, the cranial cavity contains the brain; the chest cavity contains the lungs and the heart; the abdominal cavity contains the stomach, intestines, liver, kidneys and some other organs; and the pelvic cavity contains the reproductive organs and bladder. Note that the pelvic cavity is actually the lower part of the abdominal cavity, and that there is no barrier between them.

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Figure 3.1 Half section of the pelvic cavity showing the female reproductive organs, with the body facing to the left. You will learn more about the anatomical terms labelled in this diagram as this study session proceeds.

Look carefully at Figure 3.1 for about two minutes, taking note of the position of the labelled structures. Choose the correct directional terms from Box 3.1 to describe the position of the uterus in relation to the bladder.
The bladder is in front of (anterior to) the uterus, or you could say instead that the uterus is behind (posterior to) the bladder. The top part of the uterus is bending over the bladder and is above (superior to) it, or you could say that the bladder is below (inferior to) the top of the uterus.

Behind (posterior to) the uterus, cervix and vagina in Figure 3.1, you can see part of the large intestine (colon) and the rectum, where solid waste is directed out of the body through the anus. Knowing about the anatomical position of all these structures is very important during pregnancy, labour and delivery. For example, in the pregnant woman, the enlarging uterus containing the growing fetus will push down on the bladder and large intestine. This can often result in decreased urine-carrying capacity of the bladder, so the woman has to urinate (pee) more frequently, and she may also experience constipation (drying and difficulty of passing stools).

When you are studying the female reproductive system, you have to bear in mind that structurally it is divided into two broad categories. Structures external to the vagina are said to be the external female genitalia, whereas structures above the vagina (including the vaginal canal), and lying internally, are called the internal female reproductive organs. You have already seen some structures in both categories from the side view in Figure 3.1. Now we will look at each of them in more detail.

3.3 External female genitalia

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Look at Figure 3.2 carefully. All the structures which are visible externally, surrounding the urethral and vaginal openings, including the mons pubis, labia majora, labia minora, vestibule and perineum, make the external female genitalia. Sometimes these structures are collectively named the vulva.

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Figure 3.2 The external female genitalia (or vulva).

Structures in the external female genitalia have a nerve supply, which can respond to different sensory stimuli (touch, pain, pressure and temperature). This makes these structures sensitive and active to sexual arousal during touch, especially by the male partner. Following this, the sexual act between the male and female facilitates the ejaculation of male sex cells into the female internal reproductive organs, initiating the process of fertilisation, pregnancy, labour and delivery.

Notice in Figure 3.2 that the urethral opening, the vaginal opening and the anus are all close together in the vulva. What do you think is the clinical importance of this close relationship for the pregnant woman?
As you know, the area around the anus is contaminated with bacteria from waste matter emerging from the gastrointestinal tract. So, direct bacterial contamination of the urethral and vaginal openings easily occurs.

Advising the pregnant woman to keep this area clean through good personal hygiene is very important. Infections of the bladder and vagina are common in pregnancy, and if bacteria get into her uterus, she could lose the baby.

Now we will look at each of the structures in Figure 3.2, beginning with those on the outer edges of the diagram, and ending with those in the centre.

3.3.1 Mons pubis

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The mons pubis is a thick, hair-covered, fatty and semi-rounded area overlying the symphysis pubis. Symphysis is a type of strong and immovable joint between bones. As you will see in Study Session 6 (Figure 6.1), the two halves of the pubic bone are joined in the middle by the pubic symphysis. The function of the fatty tissue in the mons pubis is to protect the woman’s pubic area from bruising during the sex act.

Symphysis is pronounced ‘simm feh siss’.

3.3.2 Labia majora and labia minora

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The labia majora are two elongated, hair-covered, fatty skin folds that enclose and protect the other organs of the external female genitalia.

The labia minora are two smaller tissue folds enclosed by the labia majora. They protect the opening of the vagina and the urethra (the tube that carries urine from the bladder to the urethral opening in the vulva). The labia minora normally have an elastic nature, which enables them to distend and contract during sexual activity, and labour and delivery.

How is this elasticity helpful during delivery?
The labia minora can stretch to let the baby’s head out.

In some countries, including parts of Ethiopia, the labia minora and the clitoris (described below) may be removed by female genital mutilation (FGM), one of the harmful traditional practices.

Female genital mutilation is discussed in the Module on Adolescent and Youth Reproductive Health.

3.3.3 Vestibule

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The vestibule is the area between the labia minora, and consists of the clitoris, urethral opening and the vaginal opening.

The clitoris is a short erectile organ at the top of the vestibule, which has a very rich nerve supply and blood vessels. Its function is sexual excitation and it is very sensitive to touch. Its anatomical position is similar to the position of the male penis.

If the clitoris and labia minora are removed by female genital cutting, the vaginal opening will not expand easily during childbirth due to the scarring where tissue has been removed. This can result in difficulty in labour and delivery, including severe bleeding and rupture of the scarred tissue, sometimes even causing a fistula — a hole torn in the wall of the vagina.

Female genital mutilitation that involves the labia minora and clitoris is usually performed without an anaesthetic. What will be the consequence of this for the female?
There will be severe pain due to the nerve supply to this area, which can lead to fainting (becoming unconscious).

Also, the labia minora and clitoris have a rich blood supply, so cutting them leads to severe bleeding, which may cause fainting and shock.

The urethral opening is the mouth or opening of the urethra, which is a small tubular structure that drains urine from the bladder. In Study Session 22, at the end of this Module, and in your practical training classes, you will learn how to insert a small tube (called a catheter) into this opening to drain urine from the bladder. This may be necessary during emergency care for a pregnant woman, or during labour and delivery, if she cannot pass urine for herself because the tissues of the vestibule have swollen and squashed the urethra flat.

The vaginal opening is the entrance to the vagina. It is where you will begin to see the ‘presenting part’ of the baby as it stretches wider open near the end of labour.

3.3.4 Perineum and hymen

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The skin-covered muscular area between the vaginal opening and the anus is called the perineum. It has strong muscles and its own nerve supply, and it helps to support the contents of the pelvic cavity. The hymen is a fold of thin vaginal tissue which partially covers the vaginal entrance in girls. It can be torn during strenuous exercise, as well as by the first sexual penetration.

3.4 Internal female reproductive organs

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In learning about pregnancy and delivery, understanding the anatomical structures involved in production of eggs (ova), fertilisation and fetal development is fundamental. In this section, you will learn how to identify and describe the internal female reproductive organs involved in these processes. Knowledge of the position and function of these organs is also essential for the accurate examination of pregnant women, and a safe labour and delivery.

3.4.1 Fallopian tubes and ovaries

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Begin by looking carefully at Figure 3.3. As you can see from the diagram, there are two fallopian tubes — one on each side of the uterus — and the finger-like ends of each tube (called the fimbriae) are close to the ovary on the same side, and open to the pelvic cavity. This means that if there is an infection in the pelvic cavity, it can get into the uterus through the fallopian tubes. Similarly, if there is an infection in the uterus, it can spread along the fallopian tubes and out into the pelvic cavity, and from there all around the woman’s abdomen, affecting her other organs. This can be very dangerous if it is not treated early.

Fallopian is pronounced ‘fah loh pee ann’. Fimbriae is pronounced ‘fimm bree aye’.

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Figure 3.3 Structures of the internal female reproductive organs.

The ovaries are paired female reproductive organs that produce the eggs (ova). They lie in the pelvic cavity on either side of the uterus, just below the opening of the fallopian tubes (see Figure 3.3). They are kept in position through attachment to two ligaments. Ligaments are the fibrous, slightly stretchy, connective tissues that hold various internal organs in place; they also bind one bone to another in joints.

Women are born with a fixed number of immature eggs (ova), around 60,000 in number. The eggs are held in small ‘pits’ in the ovaries, named ovarian follicles. Each ovum has the potential to mature and become ready for fertilisation, but in actuality only about 400 ripen during the woman’s lifetime. Every month, several ovarian follicles begin to enlarge and the ovum inside it begins to mature, but usually only one will ‘win the race’ and be released from the ovary. The moment when the ovum is released is called ovulation. The other enlarging follicles degenerate.

What could happen if two ova are released at the same time?
The woman could become pregnant with twins.

The enlarging ovarian follicles also produce the female reproductive hormones, oestrogen and progesterone, which are important in regulating the monthly menstrual cycle, and throughout pregnancy. You will learn a lot more about these hormones in Study Sessions 4 and 5.

Oestrogen is pronounced ‘ee stroh jenn’. Progesterone is pronounced ‘proh jest err own’.

Hormones are signalling chemicals that are produced in the body and circulate in the blood; different hormones control or regulate the activity of different cells or organs.

After ovulation, the lining of the empty follicle grows and forms a yellow body in the ovary called the corpus luteum, which temporarily functions as a hormone-producing organ.

Corpus luteum is prounounced ‘korr puss loot ee umm’.

It secretes oestrogen and progesterone for about the next 14 days. Oestrogen thickens the fatty tissues in the wall of the uterus in case pregnancy occurs. Progesterone stops further ovulation from occurring during the pregnancy.

Why is it beneficial to prevent further ovulation once a woman is pregnant?
It means she cannot get pregnant again during this pregnancy, so all her resources can go towards nourishing and protecting the first fetus developing in her uterus.

But if pregnancy does not occur within 14 days after ovulation, the corpus luteum degenerates and stops producing progesterone. As a result, the blood supply to this additional fatty tissue in the wall of the uterus is cut off, and it also degenerates and is shed through the vagina as the menstrual flow. The levels of oestrogen can then begin to rise, and the woman can ovulate again in the following month.

When an ovary releases a mature ovum (ovulation), the fimbriae of the fallopian tube catch the ovum and convey it towards the uterus. The male sperm swim along the fallopian tubes, and if they find the ovum, they fertilise it (as you will see in Study Sessions 4 and 5). The lining of the fallopian tubes and its secretions sustain both the ovum and the sperm, encourage fertilisation, and nourish the fertilised ovum until it reaches the uterus.

3.4.2 The uterus

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The uterus is a hollow, muscular organ in which a fertilised ovum becomes embedded and develops into a fetus. Its major function is protecting and nourishing the fetus until birth.

During pregnancy, the muscular walls of the uterus become thicker and stretch in response to increasing fetal size during the pregnancy. The uterus must also accommodate increasing amounts of amniotic fluid (the waters surrounding the fetus, contained in a bag of fetal membranes), and the placenta (the structure that delivers nutrients from the mother to the fetus). You will learn a lot more about this in Study Session 5.

Why do you think the muscular walls of the uterus become thicker during pregnancy?
A thicker layer of muscle has the strength to support the growing fetus and the other contents of the uterus, which get much heavier as pregnancy proceeds.

The uterus has four major anatomical divisions, shown in Figure 3.4:

Body: the major portion, which is the upper two-thirds of the uterus.
Fundus: the domed area at the top of the uterus, between the junctions with the two fallopian tubes.
Endometrial cavity: the triangular space between the walls of the uterus.
Cervix: the narrow neck at the upper end of the vagina.

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Figure 3.4 Structure of the empty uterus, showing the four main regions.

The wall of the uterus has three layers of tissue, two of which are shown in Figure 3.4:

The perimetrium: the outermost thin membrane layer covering the uterus. (It is not important for you to know this term for obstetric care.)
The myometrium: the thick, muscular, middle layer in Figure 3.4.
The endometrium: the thin, innermost layer of the uterus, which thickens during the menstrual cycle. This is the tissue that builds up each month in a woman of reproductive age, under the influence of the female reproductive hormones.

What happens to the endometrium if the hormones stop circulating after ovulation?
The blood supply to the endometrium is cut off, and it sheds from the body through the vagina as the monthly menstrual flow.

3.4.3 The cervix and the vagina

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The cervix is the lower, narrow neck of the uterus, forming a tubular canal, which leads into the top of the vagina (see Figure 3.4). It is usually about 3 to 4 cm (centimetres) long.

The vagina is a muscular passage, 8 to10 cm in length, between the cervix and the external genitalia. The secretions that lubricate the vagina come from glands in the cervix.

The vagina has three functions. Can you suggest what they are?
It is a receptacle for the penis, where sperm are deposited during sexual intercourse. It is the outlet for the menstrual flow every month in the non-pregnant woman. And it is the passageway down which the baby passes at birth.

Pregnant women should be encouraged to strengthen the muscles of the vagina by contracting (squeezing) them as hard as they can at least 10 times, and repeating this exercise at least four times a day. A woman can learn to do this exercise while she is urinating. As the urine comes out, she should contract the muscles in her vagina until the urine stops, then relax the muscles so the urine flows again. Once she learns how to squeeze these muscles, she should only do it when she is not urinating. Doing the squeezing exercises can help to:

Prevent leaking of urine
Prevent the vagina and perineum from tearing when they are stretched during childbirth
Speed healing after birth
Increase sexual pleasure.

In this study session you have studied the structures and functions of the organs in the female reproductive system and their importance in obstetric care. In the next study session you will look at the hormonal regulation of the reproductive cycle in women.

Summary of Study Session 3

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 3, you have learned that:

Anatomy is the study of the structures of the human body, and physiology is the study of the coordinated functions of the organs, tissues and body systems.
The female reproductive system is divided into the external genitalia (below and exterior to the vaginal opening), and the internal reproductive organs (above the vaginal opening in the pelvic cavity).
The internal reproductive organs are close to the bladder, the large intestine and the rectum; the external opening of the vagina is close to the urethral opening and the anus. These close relationships increase the opportunities for infection to spread in the genital area.
In some traditional societies, the clitoris and labia minora are often removed by female genital mutilitation; this can have serious (even fatal) consequences for the woman, especially during labour and delivery.
The ovaries are female sex organs which usually produce one ovum every month during the reproductive years. One of the fallopian tubes carries the ovum from the ovary towards the uterus. If fertilisation occurs, it normally happens in the fallopian tube.
The uterus is a muscular organ, which gives mechanical protection and nutritional support to the developing fetus during pregnancy.
The female reproductive hormones, oestrogen and progesterone, direct the maturation of ova in the ovaries, the release of an ovum (ovulation), and the thickening of the endometrium (the fatty lining of the uterus). If fertilisation of the ovum and pregnancy does not result, the endometrium is shed as the menstrual flow.
The vagina functions as a passageway for elimination of the menstrual flow; it receives the penis during sexual intercourse; and it forms the lower portion of the birth canal.

Self-Assessment Questions (SAQs) for Study Session 3

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

SAQ 3.1 (tests Learning Outcomes 3.1 and 3.2)

Look at Figure 3.5. Label the anatomical features marked from ‘a’ to ‘i’.

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Figure 3.5 Label the internal female reproductive organs to complete SAQ 3.1.

Answer

The correct labels for Figure 3.5 are as follows:

a is the vagina

b is the cervix

c is the uterus

d is the ovary

e is the fundus

f is the ovarian suspensory ligament

g is the fallopian tube

h is the fimbriae

i is the ovarian ligament.

SAQ 3.2 (tests Learning Outcome 3.1)

Choose the correct directional terms from Box 3.1 to describe the relative positions of the uterus and the rectum in Figure 3.1.

Answer

The uterus is anterior to (in front of) and superior to (above) the rectum. An alternative way of expressing the same positions is to say that the rectum is posterior to (behind) and inferior to (below) the uterus.

SAQ 3.3 (tests Learning Outcomes 3.2 and 3.3)

Which structures are removed in female genital mutilation, and what harm can come to a woman during labour and delivery as a result?

Answer

The structures removed in female genital mutilation are usually the clitoris and the labia minora. The scarring that results as the cuts heal interferes with the normal ability of the vulva to stretch during childbirth to allow the baby to pass through the birth canal. As a result, the birth can be obstructed and the vagina can tear, causing severe pain and loss of blood. In some cases, a fistula (hole in the vaginal wall) can tear open, and blood loss can put the woman’s life at risk.

SAQ 3.4 (tests Learning Outcomes 3.2 and 3.3)

Which of the following statements is false? In each case, state why it is incorrect.

A Infection in the uterus can get into the pelvic cavity through the vagina.

B The perineum is a muscular area between the vaginal opening and the anus.

C The maturation of an ovum is controlled by the female reproductive hormones.

D Glands in the cervix produce secretions which lubricate the vagina.

E The fundus is the narrow ‘neck’ at the bottom of the uterus.

Answer

A is false. Infection in the uterus can get into the pelvic cavity by passing outwards through the fallopian tubes, which are open at the ends. Infection in the uterus can pass down the vagina, and usually appears as a bad-smelling discharge from the vaginal opening in the vulva.

B is true. The perineum is a muscular area between the vaginal opening and the anus.

C is true. The maturation of an ovum is controlled by the female reproductive hormones.

D is true. Glands in the cervix produce secretions which lubricate the vagina.

E is false. The fundus is the name for the domed top of the uterus. The narrow neck at the bottom of the uterus is called the cervix.

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In the previous study session you learned about the anatomy and physiology of the female reproductive system. The hormones oestrogen and progesterone were briefly introduced. In this study session you will learn much more about the role of these and other important hormones involved in the regulation of the human menstrual cycle, the monthly production of mature ova (eggs) by females of reproductive age, and the preparation of the uterus as a welcoming environment for the start of a pregnancy.

Learning Outcomes for Study Session 4

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

4.1 Define and use correctly all of the key words printed in bold. (SAQ 4.1)

4.2 Describe the physiological processes and changes during the menstrual cycle. (SAQs 4.1 and 4.2)

4.3 Describe the hormonal regulation of the female reproductive system. (SAQs 4.3 and 4.4)

4.1 The female reproductive hormones

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

As you will probably remember from your previous high school biology course, the various functions of the body are regulated by the nervous system and the hormonal system. Both these systems are involved in controlling the activity of the female reproductive system in a regular monthly series of events known as the menstrual cycle, as we will now describe.

You should remember from Study Session 3 that a hormone is a signalling chemical produced in the body, which circulates in the blood; different hormones control or regulate the activity of different cells or organs. The functions of the five main hormones that regulate the female reproductive system are described in Box 4.1, and their interactions are illustrated in Figure 4.1.

Box 4.1 Hormones regulating the female reproductive system

Gonadotropin-releasing hormone (GnRH) is produced by a part of the brain called the hypothalamus. When it circulates in the blood, it causes the release of two important hormones (see below, and Figure 4.1) from the pituitary gland in another specialised part of the brain.

Gonadotropin is pronounced ‘gonn add oh troh pinn’. Hypothalamus is pronounced ‘hy poh thah lah mooss’. Pituitary is pronounced ‘pitt yoo itt ary’.

Follicle-stimulating hormone (FSH) is produced by the pituitary gland during the first half of the menstrual cycle. It stimulates development of the maturing ovarian follicle and controls ovum production in the female, and sperm production in the male.

Leutenizing hormone (LH) is also produced by the pituitary gland in the brain. It stimulates the ovaries to produce oestrogen and progesterone. It triggers ovulation (the release of a mature ovum from the ovary), and it promotes the development of the corpus luteum.

What is the corpus luteum? (Think back to Study Session 3.)
The name means ‘yellow body’, and after ovulation it develops in the ovary from the enlarged ovarian follicle that released the ovum.

Oestrogen is a female reproductive hormone, produced primarily by the ovaries in the non-pregnant woman. It promotes the maturation and release of an ovum in every menstrual cycle. It is also produced by the placenta during pregnancy.

Progesterone is produced by the corpus luteum in the ovary; its function is to prepare the endometrium (lining of the uterus) for the reception and development of the fertilised ovum. It also suppresses the production of oestrogen after ovulation has occurred.

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Figure 4.1 Hormonal regulation of the female reproductive system.

The length of the menstrual cycle is typically 28 days, but it can be highly variable. In some women it may be as short as 21 days or as long as 39 days. The menstrual cycle is best understood if we focus first on events occurring in the ovaries, and then on events occurring in the uterus. We are going to describe each of them in turn.

4.2 The ovarian cycle

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The ovarian cycle refers to the monthly series of events in the ovaries, associated with the maturation and release of an ovum, and the ‘just in case’ preparation for its fertilisation and implantation in the uterus. You may be wondering why the regulation of the female reproductive system is so complicated, as shown in Figure 4.1. The reason is that the ovarian cycle has to be initiated (switched on) and then suppressed (switched off) in a precisely regulated sequence every month. In this section, we will explain how this is achieved.

The ovarian cycle consists of two consecutive phases, each of about 14 days’ duration. Events are measured from ‘day 1’, which is the first day of the last normal menstrual period (LNMP).

4.2.1 The follicular phase: days 1 to 14

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The sequence shown in Figure 4.1 begins with the secretion of GnRH from the hypothalamus, which stimulates the pituitary gland to produce FSH and LH, which in turn act on the ovaries, telling the ovarian follicles to complete the maturation of an ovum. During this period, a few ovarian follicles containing immature ova develop and mature under the stimulation of FSH and LH. Usually by day 14, only one follicle has become fully mature, and the ovum it contains is ready to be released. All other follicles that had begun maturing during this phase of the ovarian cycle degenerate as soon as ovulation has occurred.

Note that only one time interval is fairly constant in all females — the time from ovulation to the beginning of menstruation, which is almost always 14 to15 days. However, the time of ovulation is variable and difficult to predict accurately.

4.2.2 The luteal phase: days 15 to 28

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This phase is the period of corpus luteum activity, during which the uterus is prepared ‘just in case’ of pregnancy. After ovulation has occurred, the corpus luteum begins to secrete progesterone, as well as a small amount of oestrogen. Progesterone maintains the uterus in a state ready to receive and nourish an embryo. The lining of the uterus (the endometrium) becomes thicker, more richly nourished by blood vessels, and more receptive to the fertilised ovum. Progesterone also inhibits any further release of FSH or LH from the pituitary gland.

Thus, ovulation is quickly followed by a rise in the level of progesterone in the circulation, as the corpus luteum takes over the production of this hormone. As the progesterone level rises, it circulates around the body in the blood. When a high concentration of progesterone reaches the hypothalamus in the brain, the effect is to stop the hypothalamus from producing GnRH.

What will happen when the hypothalamus stops producing GnRH? (Look back at Figure 4.1.)
The pituitary gland will stop producing FSH and LH.

What effect will this have on the ovaries?
The maturation of more ova will stop at that point.

This type of control system, where the rise in one body chemical (in this case, progesterone) stops the production of another body chemical (in this case, GnRH), is called a negative feedback mechanism. But the corpus luteum has a limited lifespan, and after it stops producing progesterone, the negative feedback on the hypothalamus stops, and this allows it to begin producing GnRH again. So the ovarian cycle begins all over again.

4.3 The uterine cycle

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Next, we turn our attention to the events occurring in the uterus during the same (typically) 28-day period as the events just described in the ovaries. The uterine cycle indicates the cyclical changes that occur in the uterus in response to the female sex hormones, progesterone and oestrogen.

4.3.1 The menstrual phase: days 1 to 5

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

If fertilisation does not occur after ovulation, the corpus luteum will degenerate and production of progesterone will decrease, so the stimulus for maintaining the thick endometrium will disappear. The reduction in progesterone causes the shedding of the thick endometrial lining. The muscular wall of the uterus (the myometrium) contracts to help cut off the blood supply to the endometrium, causing it to break away from the uterus. The endometrium was richly supplied with blood vessels to nourish the fetus if a pregnancy occurred, so when it disintegrates and passes down the vagina, some blood is mixed in with it. The mixture of tissue and blood passes out through the vagina as the menstrual fluid (or menstrual flow), usually for a period of about three to five days. Other common names for menstruation are ‘monthly bleeding’ or ‘menstrual period’.

Menstruation usually occurs at monthly intervals throughout the reproductive years, except during pregnancy when it is completely suppressed and the woman cannot get pregnant again until after the baby is born. Breastfeeding a baby also suppresses menstruation, but there is a risk that ovulation and pregnancy may still occur.

4.3.2 The proliferative phase: days 6 to 14

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

The concentration of oestrogen in the blood is rising during this period, following the end of menstruation, as the ovaries prepare for the next ovulation at around day 14. It is called the proliferative phase (‘proliferate’ means to ‘multiply or increase’), because in this period the endometrium grows thicker and becomes more richly fed by blood vessels in preparation for the possibility of fertilisation and pregnancy.

4.3.3 The secretory phase: days 15 to 28

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

During this phase, the blood concentration of progesterone increases, which causes even more blood vessels to grow into the endometrium. This makes the endometrium receptive to the fertilised ovum. If the ovum is fertilised and the embryo implants in the endometrium and a placenta develops, it produces a hormone called human chorionic gonadotropin (HCG) throughout pregnancy. The detection of HCG in a woman’s urine is the basis of most pregnancy tests.

Chorionic is pronounced ‘korr ee onn ik’. Gonadotropin is pronounced ‘gonn add oh troh pinn’.

HCG signals the corpus luteum to continue to supply progesterone to maintain the thick, nourishing endometrium throughout the pregnancy. Continuous levels of progesterone act as a negative feedback mechanism on the hypothalamus and pituitary gland, preventing the release of FSH and LH, and hence further ovulation ceases.

What happens if fertilisation of the ovum does not occur?
The corpus luteum degenerates and the level of progesterone declines; the endometrium disintegrates and the woman menstruates — a signal that she did not become pregnant during that menstrual cycle.

4.4 The menarche, puberty and the menopause

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

You probably know that menarche (the first menstruation) starts on average between the ages of 12 to15 years in Ethiopia. But in some cases it can start as late as 17 to 20 years, or as early as 8 to 9 years. Some of the factors that affect the age of menarche are biological, and some are cultural.

Menarche is pronounced ‘menn ark’.

Menarche begins when the hypothalamus in the brain is sensitised to begin producing GnRH at around the age of 12 to15 years. But evidence suggests that GnRH may begin at an earlier age in girls who are well nourished and exposed to sexual motivating factors, such as watching sexual films and talking about sex. In malnourished girls, who have little exposure to sexual motivating factors, menarche may be delayed until the age of 17 to 20 years. Disease conditions that affect the hypothalamus and pituitary gland, or the ovaries and uterus, can also affect the age of first menarche.

Around the age of the menarche, the female sex hormones, oestrogen and progesterone, are responsible for the development of secondary sexual characteristics in the female. These include:

the development of the breasts
the broadening of the pelvis
increased activity of sweat glands and sebaceous glands (oil glands in the skin)
the growth of pubic and armpit hair.

Together with the menarche, the appearance of the secondary sexual characteristics marks the period known as puberty — the period of life (typically between the ages of 10 to15 years) during which the reproductive organs grow to adult size and become functional. The secondary sexual characteristics are termed ‘secondary’ because they develop after the primary sexual characteristics, which distinguish females from males.

Name some of the primary sexual characteristics of females.
You already learned about them in Study Session 3 — they are the anatomical structures of the external female genitalia (e.g. the labia minora and clitoris), and the internal female reproductive organs (e.g. the ovaries, uterus and vagina).

Menstruation continues every month, except during pregnancy, until the woman reaches the menopause at around the age of 48 to 50 years, when menstruation ceases. You may recall from Study Session 3 that at birth a female baby’s ovaries already contain about 60,000 immature eggs, and she cannot produce any more in her lifetime. By the time she reaches the menopause, her ability to bring ova to maturity has come to an end.

In Study Session 5, we describe what happens when an ovum is fertilised and it implants in the uterus and develops into a fetus.

Summary of Study Session 4

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

In Study Session 4, you have learned that:

The hormones controlling the female reproductive system include gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH) and leutenizing hormone (LH), all of which are produced in the brain; oestrogen and progesterone produced by the ovaries and the corpus luteum; and human chorionic gonadotropin (HCG), produced by the placenta during pregnancy.
The menstrual cycle typically lasts 28 days, but it can be highly variable. It is characterised by menstruation from days 1 to 5 and ovulation at around day 14, but the date of ovulation is difficult to predict accurately.
Menstruation is the monthly shedding from the uterus of the endometrium with some blood, which emerges through the vagina, typically for a period of three to five days. Menstruation continues from menarche to the menopause, except during pregnancy. It may also be suppressed by breastfeeding.
The ovarian cycle refers to the regular, repeating events occurring in the ovaries during the menstrual cycle, characterised by the development of a few ovarian follicles; the maturation and release (ovulation) of a single ovum; and the formation and subsequent degeneration of the corpus luteum if pregnancy does not occur.
The uterine cycle refers to the regular, repeating events occurring in the uterus during the menstrual cycle, characterised by the thickening of the endometrium and an increase in its blood supply, followed by its degeneration and shedding as the menstrual flow if pregnancy does not occur.
The menarche and the development of secondary sexual characteristics signal the period known as puberty, when the internal reproductive organs grow to adult size and a girl becomes fertile and capable of becoming pregnant.

Self-Assessment Questions (SAQs) for Study Session 4

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

SAQ 4.1 (tests Learning Outcomes 4.1 and 4.2)

The left-hand column of Table 4.1 gives the names of the various phases in the menstrual cycle. Complete the right-hand column by entering the correct period in days measured from the last normal menstrual period (LNMP).

Table 4.1 for SAQ 4.1.

Phase of the menstrual cycle	Days (1 = first day of the LNMP)
Follicular phase of the ovarian cycle
Luteal phase of the ovarian cycle
Menstrual phase of the uterine cycle
Proliferative phase of the uterine cycle
Secretory phase of the uterine cycle

Answer

Table 4.1 completed.

Phase of the menstrual cycle	Days (1 = first day of the LNMP)
Follicular phase of the ovarian cycle	1-14
Luteal phase of the ovarian cycle	15-28
Menstrual phase of the uterine cycle	1-5
Proliferative phase of the uterine cycle	6-14
Secretory phase of the uterine cycle	15-28

SAQ 4.2 (tests Learning Outcome 4.2)

Why do you think that a woman may feel cramping pains in her abdomen when she is menstruating?

Answer

A woman may feel cramping pains in her abdomen when she is menstruating because the muscular walls of the uterus (the myometrium) contract to help cut off the blood supply to the endometrium, causing it to break away from the uterus.

SAQ 4.3 (tests Learning Outcome 4.3)

Can you suggest how the relatively high concentration of artificially produced oestrogen and progesterone in contraceptive pills prevents pregnancy in women who take the pills regularly as prescribed?

Answer

The relatively high concentration of artificially produced oestrogen and progesterone in contraceptive pills prevents pregnancy by activating a negative feedback mechanism on the hypothalamus in the brain. High levels of oestrogen and progesterone mimic the situation that occurs in pregnancy. They suppress the production of gonadotropin-releasing hormone (GnRH) from the hypothalamus, so the pituitary gland stops producing FSH and LH. This in turn stops the ovaries from maturing any more ova, so ovulation does not occur, and the woman cannot get pregnant as long as she takes the contraceptive pills regularly as prescribed.

SAQ 4.4 (tests Learning Outcome 4.3)

Explain why menstruation stops during pregnancy.

Answer

In a pregnant woman, the placenta continuously produces the hormone HCG, which causes the corpus luteum in the ovary to produce progesterone throughout the pregnancy. Progesterone maintains the endometrium as a thick fatty layer, so menstruation ceases during pregnancy because the endometrium remains attached to the uterus, where it assists in nourishing and protecting the growing fetus.

Introduction

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

This study session shows you how to conduct a general assessment of the pregnant woman’s health status during an antenatal visit. You should make all of these assessments every time you see her for antenatal care. For each assessment, we first describe the signs and symptoms that indicate the pregnant woman is in good health. Then we describe the warning signs and symptoms that may indicate health problems that may lead to a serious complication of pregnancy, including anaemia, diabetes, poor nutrition, iodine deficiency, hypertension, fever, infection, lung and kidney problems.

Later in this module, you will learn about the most serious complications of pregnancy in more detail — HIV infection in Study Session 16; premature rupture of the fetal membranes in Study Session 17; anaemia, malaria and urinary tract infections in Study Session 18; hypertension, pre-eclampsia and eclampsia in Study Session 19; and bleeding in early and late pregnancy in Study Sessions 20 and 21.

Learning Outcomes for Study Session 9

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you have studied this session, you should be able to:

9.1 Define and use correctly all of the key words printed in bold. (SAQ 9.1)

9.2 Know how to assess a pregnant woman for pallor, nutritional status, pulse rate, blood pressure, temperature, shortness of breath, and sugar in the urine. (SAQs 9.2 and 9.3)

9.3 Identify the healthy signs and symptoms of pregnancy and the possible warning signs and symptoms of pregnancy complications, based on these assessments. (SAQs 9.2 and 9.3)

9.1 Checking for symptoms of poor nutrition or lack of iodine

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

When you begin an antenatal visit, one of the first things you should ask the pregnant woman is if she has any symptoms that suggest poor nutrition or lack of iodine in her diet. This is very important, because poor maternal nutrition is associated with poor pregnancy outcomes like a small baby, and the child may be short in stature. The questions you ask her should aim to find out if she has any of the following warning symptoms (i.e. things she notices herself):

Warning symptoms

Not wanting to eat
Not gaining weight
Weakness and general ill-health
Sores, rashes, or other skin problems
Sore or bleeding gums
Stomach problems or diarrhoea
Burning or numbness of the feet.

The effects of iodine deficiency are:

Figure 9.1 Goitre may be a warning sign of lack of iodine in the diet.

Goitre (swelling in the front of the neck caused by iodine deficiency; Figure 9.1)
Short children
Children with deafness

Children with cretinism, a disability that affects thinking.

If you suspect that a pregnant woman’s health is poor due to inadequate nutrition, or lack of iodine in her diet, advise her about good nutrition and iodine supplementation. You will learn how to do this in Study Session 14 of this Module.

9.2 Checking her weight

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Healthy weight gain

A woman in good health steadily gains between 9 to 12 kilograms during pregnancy. This is the same as 1 to 2 kilograms each month. However, routine weight measurement is not necessary for antenatal care because it is not a reliable indicator of pregnancy outcome. A woman with only a little weight gain can have a normal pregnancy outcome, though this is unusual.

Warning sign A pregnant woman who gains weight suddenly near the end of her pregnancy should be referred to the nearest health centre.

If a woman gains weight suddenly near the end of her pregnancy, it may be a sign of twins, or pre-eclampsia (high blood pressure and protein in the urine appearing for the first time during pregnancy).

9.3 Checking her temperature

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Body temperature is a measurement of how hot or cold the internal tissues of the body are. Although it varies a little bit in hot or cold weather, or if the person is wearing too many or too few clothes, or doing heavy physical work, it generally stays close to a value known as ‘normal’ temperature, unless the person is ill. Body temperature is measured using an instrument called a thermometer (Figure 9.2a), which has a ‘bulb’ at one end, usually filled with a silver liquid metal called mercury. (Some glass thermometers contain a red dye instead, and some use digital technology — see Figure 9.2b.) In a glass thermometer, when the bulb of mercury is warmed by a person’s body, the mercury expands and rises up the thin glass tube, which is marked with numbers showing the person’s body temperature.

View larger image

Figure 9.2 (a) Glass thermometers may measure temperature in degrees Celsius (top) or Fahrenheit (below). (b) A digital thermometer shows the temperature as a number in a window.

Healthy temperature

Normal temperature is close to 37°C, or just under 98°F. The woman does not feel hot to touch.

Warning sign

The woman has a fever — a temperature of above 37.5°C (or 100°F) or above. She feels hot to touch.

Figure 9.3 You can easily feel if she is hotter than you.

9.3.1 How to check her temperature

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

If you don’t have a thermometer, put the back of one hand on the woman’s forehead, and the other on your own, or that of another healthy person (Figure 9.3). If the woman has a fever, you should be able to feel that her skin is hotter than that of a healthy person.

Figure 9.4 Shake the mercury to below 36°C.

If you have a glass thermometer, clean it well with soap and clean water, or alcohol. Hold the thermometer with the ‘bulb’ containing the silver mercury pointing away from your hand. Shake it with a snap of the wrist (Figure 9.4), until the top of the thin column of silver mercury falls well below ‘normal’ body temperature, i.e. less than 36°C (or 96°F).

Put the bulb end of the thermometer under the woman’s tongue or in her armpit, and leave it there for three minutes. The woman should keep her mouth closed, or her arm close to her body.

Take the thermometer out and turn it until you see the silver line. The point where the silver stops marks the temperature. There is usually a little arrow at the ‘normal’ point.

What temperature is showing in Figure 9.2a?
The mercury has risen to about 39.6°C – a high fever.

Always clean the thermometer with soap and cool water, or with alcohol, after you use it. Do not use hot water — it can break the thermometer! Mercury is a very poisonous metal. Be careful with glass thermometers, and if they break, do not pick up the mercury with your bare hands. Sweep the mercury into a jar and bury it. Do not let children play with thermometers or mercury. Get a digital thermometer if you can (Figure 9.2b).

9.3.2 What to do if the woman has a fever

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

A fever can be caused by:

Sickness — for example, flu or malaria
An infection of part of the body — like a bladder infection, or an infection of the uterus
A mild fever can also be caused by dehydration (loss of body fluids due to not drinking enough water).

If the fever does not come down in 8 hours, refer her to a health centre.

A high fever needs to be lowered right away. To lower a fever:

Give 500 to 1,000 mg (milligrams) paracetamol by mouth every four to six hours
Have her drink one cup of fluid every hour
Wash her body with a cloth dipped in cool water.

9.4 Checking her pulse

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

View larger image

Figure 9.5 Use two or three fingers (never your thumb) to feel the pulse in the neck or inside of the wrist.

The pulse tells you how fast the heart is beating. Every time the heart beats (contracts) it pushes blood out into the arteries. You can feel each ‘pulse’ by pressing gently on an artery with your fingers. Everyone’s pulse is different. That is normal. You can find the pulse in the throat or wrist, as shown in Figure 9.5.

Healthy pulse

The normal pulse rate is about 60 to 80 beats a minute when the woman is resting.

Warning sign

The pulse rate is 100 or more beats a minute when the woman is resting.

9.4.1 How to measure her pulse rate

The Open University — Mon, 11 Jul 2011 09:03:18 GMT

Wait until the woman is resting and relaxed. Put the pads of two fingers on the pulse (Figure 9.6). Do not use your thumbs, because there is a little pulse in your own thumbs which could confuse you.

Figure 9.6 Make sure the woman is sitting in a relaxed position when you measure her pulse rate.

If you have a watch with a second hand, or there is a clock with a second hand, count the number of beats in the mother’s pulse for one minute. Write the number down.

At first, have someone look at the watch or clock for you, and tell you when one minute has passed. Many people find it hard to count accurately while looking at a watch. They tend to count one pulse beat every second, no matter how fast the pulse is really beating.

If you do not have a watch with a second hand, check the pulse anyway. You can learn to tell if it is slow, normal, or fast compared to your own pulse, and to other women’s.