OBSTETRIC AND GYNEACOLOGY
OBSTETRIC AND GYNEACOLOGY
Exercise 1.1
a. What is ectopic pregnancy
b. List four clinical presentation of ectopic pregnancy
c. How do you as a midwife help the obstetrician in diagnosing ectopic pregnancy?
d. What is the surgical treatment of choice in ectopic pregnancy
e. What is ruptured ectopic pregnancy
f. Describe the management of ruptured ectopic pregnancy
Answer:
a. Definition of ectopic pregnancy
• This is a pregnancy occurring outside the uterus
• The commonest site is the fallopian tube and the usual cause is blockage of the tube due to previous infection
b. Clinical presentation of ectopic pregnancy
• Intermittent pain in pain in one or either side of the iliac fossa which is often accompanied by faintness and nausea and worsen during defecation
• Slight intermittent vaginal bleeding may occur which might be mistaken for threatened abortion
• Bleeding occurs after pain which is usually dark brown
• Patient has abdominal pain and is anaemic
• Vaginal examination reveals a pelvic mass with tenderness in the pouch of Douglas and pain on moving the cervix
c. How the midwife help the obstetrician to diagnosis ectopic pregnancy.
• Through effective and careful history taking
• Paying keen attention to presenting clinical signs and symptoms.
• Example, noting that
o In ectopic pregnancy bleeding occurs after pain and the opposite in abortion.
o In ectopic pregnancy, blood loss is usually dark brown while it is bright red in abortion
o In ectopic pregnancy, bleeding is usually very slight while it is heavy in abortion
d. Surgical treatment of choice in ectopic pregnancy
• Hysterectomy
• Hysterectomy
e. Classical picture of ruptured ectopic pregnancy
• Ruptured ectopic pregnancy is recognized or identified immediately when:
• The patient complains of severe pain in the iliac fossa, which radiates to the shoulder tip when she lies down as a result of the irritation of the diaphragm by blood.
• The presence of signs of severe internal haemorrhage and shock.
f. Management of rupture ectopic pregnancy
• Treat patient for shock
• Administer 15mg morphine and take blood for test for haemoglobin, packed cell volume, grouping and cross-matching
• Administer intravenous infusion of dextrose or saline
• Commence blood transfusion before surgery
• Prepare patient for surgery/ removal of the affected tube (salpingectomy).
Exercise 1.1
a. Explain the term abortion.
b. Mention four (4) maternal causes of abortion
c. List two (2) fetal causes of abortion
d. Enumerate four (4) general causes of abortion.
e. Unsafe abortion can lead to some complication list four (4) complications
Answer:
a. Explanation of abortion
• This is the interruption of pregnancy before the 24th and 28th week of gestation.
• It is the loss of pregnancy before fetal viability (i.e. 28 weeks of gestation)
• It may be spontaneous or induced.
b. Maternal causes of abortion
• Maternal infection such as rubella, listeria, chlamydia, syphilis and bacteria vaginosis
• Maternal acute illness with high temperature such as malaria, typhoid and influenza.
• Insufficiently prepared endometrium
• Maternal age: - risk of abortion increases with advancing maternal age. For example age above 35 years and also below 18 years
• Hormonal of endocrine disorders
• Extreme emotional state / psychological factor of the mother. For example stress
• Active physical efforts (engaging in strenuous exercise)
• Structural abnormalities of the genital tract. These include retroversion of the uterus, bicornuage uterus, fibroid and incompetent cervix.
• Trauma or lacerations in the genital tract of the mother
c. Fetal causes of abortion
• Chromosomal abnormalities of the fertilized ovum
• Genetic and structural abnormalities of chromosome of the fertilized ovum
• ABO incompatibility between mother and embryo
• Diseased or malformation of the fertilized ovum
d. General causes of abortion
• Hormonal imbalance
• Infection e.g. malaria
• Incompetent cervix
• Severe malnutrition.
• Misuse of drugs such as strong purgatives
• Fibroids
• Trauma to the abdomen such as criminal interference
• Strong emotion such as grief
• Low implantation of the fertilized ovum
e. Complications of unsafe abortion
• Septicemia (sepsis)
• Infertility
• Ruptured uterus
Exercise 1.3
a. Distinguish between spontaneous abortion (miscarriage) and induced abortion (miscarriage)
b. State the five (5) types of spontaneous abortion, giving their significant features
c. What is septic abortion and in what circumstances is it likely to occur?
d. Describe the clinical features and management of a patient with an inevitable abortion.
Answer:
a. Difference between spontaneous abortion and induced abortion
o Spontaneous abortion may be defined as the involuntary loss of pregnancy before fetal viability
While
o Induced abortion may be defined as a process by which pregnancy is terminated by artificial means before fetal viability.
It is started by artificial means using herbal preparation or other traditional practices which cause the uterus to expel it content.
It may be legal or illegal. A legal induced abortion is carried out in approved manner and approved institution by a medical practitioner approved by the laws of a country for various reasons permitted under the law.
The illegal unsafe induced abortion is carried out by persons lacking the necessary skills and knowledge, and performed under unhygienic condition. This type of abortion may lead to septic or incomplete abortion
b. Types of spontaneous abortions with their significant features
• Threatened abortion.
o In this type the disturbance is so slight that the pregnancy may continue to term if bleeding stops. This is because the internal os remains closed, membrane are not ruptured and the uterus is soft, hence with good management the pregnancy may continue to term.
• Missed abortion.
o This is the term used to describe early death of fetus and is retained in the uterus.
o It is common before 20 weeks of gestation
o There is a risk of hypofibrogeneamia when the fetus has been retained for several weeks.
o The outcome of delay or silent abortion of the dead fetus is blood mole (carneous mole). This is because the fetus in silent abortion is retained for a period and is surrounded by layers of blood clot whose fluid has been extracted leaving a fleshy mass known as blood mole.
• Inevitable abortion
o In this type of abortion, the pregnancy will not continue because the cervical os is dilated and products of conception protruding through the os.
o It is accompanied with heavy bleeding coupled with painful uterine contraction and severe lower abdominal pains.
• Incomplete abortion
o In this type of abortion, the fetus is expelled but placenta and other products may be retained either wholly or partially in a partially opened cervix accompanied with heavy bleeding.
• Complete abortion
o This is when all the products of conception are expelled and bleeding reduces, pain stops, cervix starts to close, uterus firmly contracts and signs and symptoms of pregnancy disappears
c. Description of septic abortion and the circumstance in which it may occur
• Septic abortion is an abortion of any kind which is complicated by infection.
• It often follows an incomplete abortion as a result of illegal abortion
• Infection will first occur in the uterus resulting in an ascending infection by pathogenic organisms to the fallopian tube, pelvic organs and peritoneum leading to septicemia if not properly treated
d. Clinical features and management of inevitable abortion
• Clinical features
o There is heavy bleeding per vaginam accompanied by severe intermittent abdominal pains and backaches
o If uterus is palpated per abdomen, strong uterine contraction may be felt
o On pelvic examination, the internal os is dilated and products may be protruding through the os.
o The general condition of the patient depends on the amount of blood lost, hence the indication of signs of shock
o The degree of shock may be increased if there are products of conception with the cervical canal.
• Management
o In the absence of doctor, the midwife may have to make a presumptive diagnosis of inevitable abortion based on the clinical features of the patient
o If bleeding is heavy administer 0.5mg of ergometrine intramuscularly
o Admit patient to hospital without delay.
o Treat patient showing signs of shock
o Provide complete bed rest
o Allay patients anxiety by reassuring her
o Keep patient warm but not hot
o Give patient the strongest analgesics available
o Commence intravenous infusion as prescribed
o Give oxygen if available and patient in stress
o Repeat 0.5mg of ergometrine after 15minutes
o Attempt to remove products which are lying in the cervical canal to lessening patient’s degree of shock
o Monitor patient’s blood pressure and record all blood lost.
Exercise 1.4
a. What is antenatal care?
b. State two reasons why antenatal care is important
c. Mention 3 major activities that takes place at the antenatal clinic during booking visit
d. State any four types of history that can be taken from a pregnant woman who reports to the ANC for visit
e. State 2 advice you will give to a pregnant woman concerning travelling
f. State any 3 components of abdominal examination at ANC
g. List five danger signs of pregnancy
Answer:
a. Definition of antenatal care
Antenatal care is the systematic supervision of the welfare of the woman and her unborn child during the period of pregnancy to ensure safe delivery.
b. Importance of antenatal care
• Reduction of maternal mortality and morbidity rate
• Reduction in neonatal mortality and morbidity rate
• For early detection and treatment of abnormalities
• To reduce complication of labour
• To reduce the ratio of preterm delivery
• To establish a relationship between pregnant patient and health care provider
c. Activities during booking visit
• Reception and registration
• Comprehensive history taking
• General examination and checking of vital signs
• Physical examination (done systematically from head to toe)
• Obstetric examination
• Laboratory investigation
• Treatment
• Health education and health promotion in pregnancy
d. Types of history taking from a pregnant woman
• Social or demographic history
• Medical history
• Family history
• Gynaecological history
• Menstrual history
• Surgical history
• Family planning history
• Drug history
• Obstetric history (past and present obstetric history)
e. Advice concerning travelling for pregnant woman
• Avoid long distance road journey
• Encourage the use of seat belt when driving
f. Components of abdominal examination at ANC
• Inspection
• Palpation
• Auscultation
g. Danger signs of pregnancy
• Bleeding from the vagina.
• Swelling of the feet, hands or face. (oedema)
• Severe abdominal pain.
• Persistent vomiting.
• Jaundice.
• Rapture of membranes.
• Anaemia: Pale conjunctiva, tongue, and palms, nail bed.
• High fever.
• Offensive, discolored discharge from the vagina.
• Frontal headache
• Blurred vision and seeing of flashes of lights
Exercise 1.5
a. List the causes of minor disorders of pregnancy
b. State any four (4) minor disorders of pregnancy associated with pregnancy and two advice you will give a client on each
Answer:
a. Causes of minor disorders
• Hormonal changes
• Metabolic changes
• Accommodation changes
• Postural changes
b. Minor disorders and management
• Minor disorder of GIT
o Morning sickness (nausea and vomiting)
Mgt.
Take small meals at frequent interval
Take carbohydrate diet immediate from bed e.g. crackers
o Constipation
Mgt.
Encourage to eat fruits and vegetables
Encourage to increase fluid intake
Encourage to exercise and empty bowel
o Excessive salivation (ptyalism)
Mgt.
Adapt chewing gum or stick
Encourage the intake of frequent small food
o Pica (carving for non- nutritive diet)
Mgt.
Seek medical advice if substance crave for is potentially harmful
Correct iron deficient anemia
Exercise 1.6
State the physiological changes that takes place in the uterus during pregnancy
Answer:
• Position: The uterus becomes and abdominal organ
• Size: Changes from 7.5cm by 5cm by 2.5cm to 30cm by 23cm by 20cm in size
• Weight: Weighs 1000g
• Shape: Changes from pear shaped to ovoid shape
Exercise 1.7
State two presumptive signs of pregnancy and give one reason why each one is presumptive
Answer:
• Amenorrhea
o Absence of menstruation: It is the first sign and is noticed by the woman herself. Following implantation, of the fertilized ovum, the endometrium undergoes decidual change and menstruation does not occur throughout pregnancy.
o However this can also occur when there is change in diet or geographical location of active woman
• Enlargement of breast
o Discomfort, tingling and a feeling of fullness of the breasts may be noticed as early as third or fourth week of pregnancy due to increased vascularization.
o This characteristics are also typical/ present in certain women during their menses
• Morning sickness
o Nausea and vomiting along with or without indigestion occur due to increased human chorionic gonadotrophic hormone level.
o Some women also experience morning sickness during their menses.
• Bladder irritability
o Frequency of urination increases due to pressure from the gravid uterus and increased vascularity of the bladder.
o This features may also be present in a woman with diabetes.
Exercise 1.1
a. What is ectopic pregnancy
b. List four clinical presentation of ectopic pregnancy
c. How do you as a midwife help the obstetrician in diagnosing ectopic pregnancy?
d. What is the surgical treatment of choice in ectopic pregnancy
e. What is ruptured ectopic pregnancy
f. Describe the management of ruptured ectopic pregnancy
Answer:
a. Definition of ectopic pregnancy
• This is a pregnancy occurring outside the uterus
• The commonest site is the fallopian tube and the usual cause is blockage of the tube due to previous infection
b. Clinical presentation of ectopic pregnancy
• Intermittent pain in pain in one or either side of the iliac fossa which is often accompanied by faintness and nausea and worsen during defecation
• Slight intermittent vaginal bleeding may occur which might be mistaken for threatened abortion
• Bleeding occurs after pain which is usually dark brown
• Patient has abdominal pain and is anaemic
• Vaginal examination reveals a pelvic mass with tenderness in the pouch of Douglas and pain on moving the cervix
c. How the midwife help the obstetrician to diagnosis ectopic pregnancy.
• Through effective and careful history taking
• Paying keen attention to presenting clinical signs and symptoms.
• Example, noting that
o In ectopic pregnancy bleeding occurs after pain and the opposite in abortion.
o In ectopic pregnancy, blood loss is usually dark brown while it is bright red in abortion
o In ectopic pregnancy, bleeding is usually very slight while it is heavy in abortion
d. Surgical treatment of choice in ectopic pregnancy
• Hysterectomy
• Hysterectomy
e. Classical picture of ruptured ectopic pregnancy
• Ruptured ectopic pregnancy is recognized or identified immediately when:
• The patient complains of severe pain in the iliac fossa, which radiates to the shoulder tip when she lies down as a result of the irritation of the diaphragm by blood.
• The presence of signs of severe internal haemorrhage and shock.
f. Management of rupture ectopic pregnancy
• Treat patient for shock
• Administer 15mg morphine and take blood for test for haemoglobin, packed cell volume, grouping and cross-matching
• Administer intravenous infusion of dextrose or saline
• Commence blood transfusion before surgery
• Prepare patient for surgery/ removal of the affected tube (salpingectomy).
Exercise 1.1
a. Explain the term abortion.
b. Mention four (4) maternal causes of abortion
c. List two (2) fetal causes of abortion
d. Enumerate four (4) general causes of abortion.
e. Unsafe abortion can lead to some complication list four (4) complications
Answer:
a. Explanation of abortion
• This is the interruption of pregnancy before the 24th and 28th week of gestation.
• It is the loss of pregnancy before fetal viability (i.e. 28 weeks of gestation)
• It may be spontaneous or induced.
b. Maternal causes of abortion
• Maternal infection such as rubella, listeria, chlamydia, syphilis and bacteria vaginosis
• Maternal acute illness with high temperature such as malaria, typhoid and influenza.
• Insufficiently prepared endometrium
• Maternal age: - risk of abortion increases with advancing maternal age. For example age above 35 years and also below 18 years
• Hormonal of endocrine disorders
• Extreme emotional state / psychological factor of the mother. For example stress
• Active physical efforts (engaging in strenuous exercise)
• Structural abnormalities of the genital tract. These include retroversion of the uterus, bicornuage uterus, fibroid and incompetent cervix.
• Trauma or lacerations in the genital tract of the mother
c. Fetal causes of abortion
• Chromosomal abnormalities of the fertilized ovum
• Genetic and structural abnormalities of chromosome of the fertilized ovum
• ABO incompatibility between mother and embryo
• Diseased or malformation of the fertilized ovum
d. General causes of abortion
• Hormonal imbalance
• Infection e.g. malaria
• Incompetent cervix
• Severe malnutrition.
• Misuse of drugs such as strong purgatives
• Fibroids
• Trauma to the abdomen such as criminal interference
• Strong emotion such as grief
• Low implantation of the fertilized ovum
e. Complications of unsafe abortion
• Septicemia (sepsis)
• Infertility
• Ruptured uterus
Exercise 1.3
a. Distinguish between spontaneous abortion (miscarriage) and induced abortion (miscarriage)
b. State the five (5) types of spontaneous abortion, giving their significant features
c. What is septic abortion and in what circumstances is it likely to occur?
d. Describe the clinical features and management of a patient with an inevitable abortion.
Answer:
a. Difference between spontaneous abortion and induced abortion
o Spontaneous abortion may be defined as the involuntary loss of pregnancy before fetal viability
While
o Induced abortion may be defined as a process by which pregnancy is terminated by artificial means before fetal viability.
It is started by artificial means using herbal preparation or other traditional practices which cause the uterus to expel it content.
It may be legal or illegal. A legal induced abortion is carried out in approved manner and approved institution by a medical practitioner approved by the laws of a country for various reasons permitted under the law.
The illegal unsafe induced abortion is carried out by persons lacking the necessary skills and knowledge, and performed under unhygienic condition. This type of abortion may lead to septic or incomplete abortion
b. Types of spontaneous abortions with their significant features
• Threatened abortion.
o In this type the disturbance is so slight that the pregnancy may continue to term if bleeding stops. This is because the internal os remains closed, membrane are not ruptured and the uterus is soft, hence with good management the pregnancy may continue to term.
• Missed abortion.
o This is the term used to describe early death of fetus and is retained in the uterus.
o It is common before 20 weeks of gestation
o There is a risk of hypofibrogeneamia when the fetus has been retained for several weeks.
o The outcome of delay or silent abortion of the dead fetus is blood mole (carneous mole). This is because the fetus in silent abortion is retained for a period and is surrounded by layers of blood clot whose fluid has been extracted leaving a fleshy mass known as blood mole.
• Inevitable abortion
o In this type of abortion, the pregnancy will not continue because the cervical os is dilated and products of conception protruding through the os.
o It is accompanied with heavy bleeding coupled with painful uterine contraction and severe lower abdominal pains.
• Incomplete abortion
o In this type of abortion, the fetus is expelled but placenta and other products may be retained either wholly or partially in a partially opened cervix accompanied with heavy bleeding.
• Complete abortion
o This is when all the products of conception are expelled and bleeding reduces, pain stops, cervix starts to close, uterus firmly contracts and signs and symptoms of pregnancy disappears
c. Description of septic abortion and the circumstance in which it may occur
• Septic abortion is an abortion of any kind which is complicated by infection.
• It often follows an incomplete abortion as a result of illegal abortion
• Infection will first occur in the uterus resulting in an ascending infection by pathogenic organisms to the fallopian tube, pelvic organs and peritoneum leading to septicemia if not properly treated
d. Clinical features and management of inevitable abortion
• Clinical features
o There is heavy bleeding per vaginam accompanied by severe intermittent abdominal pains and backaches
o If uterus is palpated per abdomen, strong uterine contraction may be felt
o On pelvic examination, the internal os is dilated and products may be protruding through the os.
o The general condition of the patient depends on the amount of blood lost, hence the indication of signs of shock
o The degree of shock may be increased if there are products of conception with the cervical canal.
• Management
o In the absence of doctor, the midwife may have to make a presumptive diagnosis of inevitable abortion based on the clinical features of the patient
o If bleeding is heavy administer 0.5mg of ergometrine intramuscularly
o Admit patient to hospital without delay.
o Treat patient showing signs of shock
o Provide complete bed rest
o Allay patients anxiety by reassuring her
o Keep patient warm but not hot
o Give patient the strongest analgesics available
o Commence intravenous infusion as prescribed
o Give oxygen if available and patient in stress
o Repeat 0.5mg of ergometrine after 15minutes
o Attempt to remove products which are lying in the cervical canal to lessening patient’s degree of shock
o Monitor patient’s blood pressure and record all blood lost.
Exercise 1.4
a. What is antenatal care?
b. State two reasons why antenatal care is important
c. Mention 3 major activities that takes place at the antenatal clinic during booking visit
d. State any four types of history that can be taken from a pregnant woman who reports to the ANC for visit
e. State 2 advice you will give to a pregnant woman concerning travelling
f. State any 3 components of abdominal examination at ANC
g. List five danger signs of pregnancy
Answer:
a. Definition of antenatal care
Antenatal care is the systematic supervision of the welfare of the woman and her unborn child during the period of pregnancy to ensure safe delivery.
b. Importance of antenatal care
• Reduction of maternal mortality and morbidity rate
• Reduction in neonatal mortality and morbidity rate
• For early detection and treatment of abnormalities
• To reduce complication of labour
• To reduce the ratio of preterm delivery
• To establish a relationship between pregnant patient and health care provider
c. Activities during booking visit
• Reception and registration
• Comprehensive history taking
• General examination and checking of vital signs
• Physical examination (done systematically from head to toe)
• Obstetric examination
• Laboratory investigation
• Treatment
• Health education and health promotion in pregnancy
d. Types of history taking from a pregnant woman
• Social or demographic history
• Medical history
• Family history
• Gynaecological history
• Menstrual history
• Surgical history
• Family planning history
• Drug history
• Obstetric history (past and present obstetric history)
e. Advice concerning travelling for pregnant woman
• Avoid long distance road journey
• Encourage the use of seat belt when driving
f. Components of abdominal examination at ANC
• Inspection
• Palpation
• Auscultation
g. Danger signs of pregnancy
• Bleeding from the vagina.
• Swelling of the feet, hands or face. (oedema)
• Severe abdominal pain.
• Persistent vomiting.
• Jaundice.
• Rapture of membranes.
• Anaemia: Pale conjunctiva, tongue, and palms, nail bed.
• High fever.
• Offensive, discolored discharge from the vagina.
• Frontal headache
• Blurred vision and seeing of flashes of lights
Exercise 1.5
a. List the causes of minor disorders of pregnancy
b. State any four (4) minor disorders of pregnancy associated with pregnancy and two advice you will give a client on each
Answer:
a. Causes of minor disorders
• Hormonal changes
• Metabolic changes
• Accommodation changes
• Postural changes
b. Minor disorders and management
• Minor disorder of GIT
o Morning sickness (nausea and vomiting)
Mgt.
Take small meals at frequent interval
Take carbohydrate diet immediate from bed e.g. crackers
o Constipation
Mgt.
Encourage to eat fruits and vegetables
Encourage to increase fluid intake
Encourage to exercise and empty bowel
o Excessive salivation (ptyalism)
Mgt.
Adapt chewing gum or stick
Encourage the intake of frequent small food
o Pica (carving for non- nutritive diet)
Mgt.
Seek medical advice if substance crave for is potentially harmful
Correct iron deficient anemia
Exercise 1.6
State the physiological changes that takes place in the uterus during pregnancy
Answer:
• Position: The uterus becomes and abdominal organ
• Size: Changes from 7.5cm by 5cm by 2.5cm to 30cm by 23cm by 20cm in size
• Weight: Weighs 1000g
• Shape: Changes from pear shaped to ovoid shape
Exercise 1.7
State two presumptive signs of pregnancy and give one reason why each one is presumptive
Answer:
• Amenorrhea
o Absence of menstruation: It is the first sign and is noticed by the woman herself. Following implantation, of the fertilized ovum, the endometrium undergoes decidual change and menstruation does not occur throughout pregnancy.
o However this can also occur when there is change in diet or geographical location of active woman
• Enlargement of breast
o Discomfort, tingling and a feeling of fullness of the breasts may be noticed as early as third or fourth week of pregnancy due to increased vascularization.
o This characteristics are also typical/ present in certain women during their menses
• Morning sickness
o Nausea and vomiting along with or without indigestion occur due to increased human chorionic gonadotrophic hormone level.
o Some women also experience morning sickness during their menses.
• Bladder irritability
o Frequency of urination increases due to pressure from the gravid uterus and increased vascularity of the bladder.
o This features may also be present in a woman with diabetes.
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