SM CMT 05104 obstetrics and gynaecology I

UNITED REPUBLIC OF TANZANIA

Ministry of Health and Social Welfare

CMT 05104
Obstetrics and
Gynaecology I
NTA Level 5 Semester 1
Facilitator Guide
August 2010

CMT 05104 Obstetrics and Gynaecology I NTA Level 5 Semester 1 Student Manual
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Copyright © Ministry of Health and Social Welfare – Tanzania 2010

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Table of Contents
Background and Acknowledgement........................................................................ iv
Introduction.............................................................................................................. ix
Abbreviations........................................................................................................... xi
Module Sessions
Session 1: Comprehensive Obstetric History ............................................................1
Session 2: Physical Examination in Obstetrics..........................................................7
Session 3: Comprehensive Gynaecological History................................................17
Session 4: Physical Examination in Gynaecology...................................................19
Session 5: Normal Pregnancy..................................................................................27
Session 6: Management of Normal Labour.............................................................33
Session 7: Normal Puerperium and Postpartum Care..............................................41
Session 8: Malaria and Anaemia in Pregnancy .......................................................49
Session 9: Urinary Tract Infections in Pregnancy and Puerperal Infection ............55
Session 10: Genital Tract Infections........................................................................59
Session 11: Antepartum Haemorrhage ....................................................................65
Session 12: Postpartum Haemorrhage and Perineal Tears ......................................71
Session 13: Obstructed Labour and Ruptured Uterus..............................................79
Session 14: Obstetric Malpresentation ....................................................................83
Session 15: Premature Rupture of Membranes and Pre-Term Premature Rupture
of Membrane............................................................................................................91

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Background and Acknowledgement
In April 2009, a planning meeting was held at Kibaha which was followed up by a Task
Force Committee meeting in June 2009 at Dodoma and developed a proposal which guided
the process of the development of standardised Clinical Assistant (CA) and Clinical Officer
(CO) training materials which were based on CA/CO curricula. The purpose of this process
was to standardize the entire curriculum with up-to-date content which would then be
provided to all Clinical Assistant and Clinical Officer Training Centres (CATCs/COTCs).
The perceived benefit was that, by standardizing the quality of content and integrating
interactive teaching methodologies, students would be able to learn more effectively and that
the assessment of students’ learning would have more uniformity and validity across all
schools.
In September 2009, MOHSW embarked on an innovative approach of developing the
standardised training materials through the Writer’s Workshop (WW) model. The model
included a series of three-week workshops in which pre-service tutors and content experts
developed training materials, guided by facilitators with expertise in instructional design and
curriculum development. The goals of WW were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials.
The new training package for CA/CO cadres includes a Facilitator Guide, Student Manual
and Practicum. There are 40 modules with approximately 600 content sessions. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders and
experts of different organizations and institutions, from within and outside the country.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these materials for CA /CO cadres. We would first like to
thank the U.S. Centers for Disease Control and Prevention’s Global AIDS Program
(CDC/GAP) Tanzania, and the International Training and Education Center for Health (I-
TECH) for their financial and technical support throughout the process. At CDC/GAP, we
would like to thank Ms. Suzzane McQueen and Ms. Angela Makota for their support and
guidance. At I-TECH, we would especially like to acknowledge Ms. Alyson Shumays,
Country Program Manager, Dr. Flavian Magari, Country Director, Mr. Tumaini Charles,
Deputy Country Director, and Ms. Susan Clark, Health Systems Director. The MOHSW
would also like to thank the World Health Organization (WHO) for technical and financial
support in the development process.
Particular thanks are due to those who led this important process: Dr. Bumi L.A.
Mwamasage, the Assistant Director for Allied Health Sciences Training, Dr. Mabula Ndimila
and Mr. Dennis Busuguli, Coordinators of Allied Health Sciences Training, Ministry of
Health and Social Welfare, Dr. Stella Kasindi Mwita, Programme Officer Integrated
Management of Adults and Adolescent Illnesses (IMAI), WHO Tanzania and Stella M.
Mpanda, Pre-service Programme Manager, I-TECH.
Sincere gratitude is expressed to small group facilitators: Dr. Otilia Gowele, Principal, Kilosa
COTC, Dr. Violet Kiango, Tutor, Kibaha COTC, Ms. Stephanie Smith, Ms. Stephanie
Askins, Julie Stein, Ms. Maureen Sarewitz, Mr. Golden Masika, Ms. Kanisia Ignas, Ms.
Yovitha Mrina and Mr. Nicholous Dampu, all of I-TECH, for their tireless efforts in guiding
participants and content experts through the process. A special note of thanks also goes to

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Dr. Julius Charles and Dr. Moses Bateganya, I-TECH’s Clinical Advisors, and other Clinical
Advisors who provided input. We also thank individual content experts from different
departments of the MOHSW and other governmental and non-governmental organizations,
including EngenderHealth, Jhpiego and AIHA, for their technical guidance.
Special thanks goes to a team of I-TECH staff namely Ms. Lauren Dunnington, Ms.
Stephanie Askins, Ms. Stephanie Smith, Ms Aisling Underwood, Golden Masika, Yovitha
Mrina, Kanisia Ignas, Nicholous Dampu, Michael Stockman and Stella M. Mpanda for
finalising the editing, formatting and compilation of the modules.
Finally, we very much appreciate the contributions of the tutors and content experts
representing the CATCs/COTCs, various hospitals, universities, and other health training
institutions. Their participation in meetings and workshops, and their input in the
development of content for each of the modules have been invaluable. It is the commitment
of these busy clinicians and teachers that has made this product possible.
These participants are listed with our gratitude below:
Tutors
Ms. Magdalena M. Bulegeya – Tutor, Kilosa COTC
Mr. Pius J.Mashimba – Tutor, Kibaha Clinical Officers Training Centre (COTC)
Dr. Naushad Rattansi – Tutor, Kibaha COTC
Dr. Salla Salustian – Principal, Songea CATC
Dr. Kelly Msafiri – Principal, Sumbawanga CATC
Dr. Joseph Mapunda - Tutor, Songea CATC
Dr. Beda B. Hamis – Tutor, Mafinga COTC
Col Dr. Josiah Mekere – Principal, Lugalo Military Medical School
Mr. Charles Kahurananga – Tutor, Kigoma CATC
Dr. Ernest S. Kalimenze – Tutor, Sengerema COTC
Dr. Lucheri Efraim – Tutor, Kilosa COTC
Dr. Kevin Nyakimori – Tutor, Sumbawanga CATC
Mr. John Mpiluka – Tutor, Mvumi COTC
Mr. Gerald N. Mngóngó –Tutor, Kilosa COTC
Dr. Tito M. Shengena –Tutor, Mtwara COTC
Dr. Fadhili Lyimo – Tutor, Kilosa COTC
Dr. James William Nasson– Tutor, Kilosa COTC
Dr. Titus Mlingwa – Tutor, Kigoma CATC
Dr. Rex F. Mwakipiti – Principal, Musoma CATC
Dr. Wilson Kitinya - Principal, Masasi ( Clinical Assistants Training Centre (CATC)
Ms. Johari A. Said – Tutor, Masasi CATC
Dr. Godwin H. Katisa – Tutor, Tanga Assistant Medical Officers Training Centre (AMOTC)
Dr. Lautfred Bond Mtani – Principal, Sengerema COTC
Ms Pamela Henry Meena – Tutor, Kibaha COTC
Dr. Fidelis Amon Ruanda – Tutor, Mbeya AMOTC
Dr. Cosmas C. Chacha – Tutor, Mbeya AMOTC
Dr. Ignatus Mosten – Ag. Principal, Tanga AMOTC
Dr. Muhidini Mbata – Tutor, Mafinga COTC
Dr. Simon Haule – Ag. Principal, Kibaha COTC
Ms. Juliana Lufulenge - Tutor, Kilosa COTC
Dr. Peter Kiula – Tutor, Songea CATC

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Mr. Hassan Msemo – Tutor, Kibaha COTC
Dr. Sangare Antony –Tutor, Mbeya AMOTC
Content Experts
Ms. Emily Nyakiha – Principal, Bugando Nursing School, Mwanza
Mr. Gustav Moyo - Registrar, Tanganyika Nursesand Midwives Council, Ministry of Health
and Social Welfare (MOHSW).
Dr. Kohelet H. Winani - Reproductive and Child Health Services, MOHSW
Mr. Hussein M. Lugendo – Principal, Vector Control Training Centre (VCTC), Muheza
Dr. Elias Massau Kwesi - Public Health Specialist, Head of Unit Health Systems Research
and Survey, MOHSW
Dr. William John Muller - Pathologist, Muhimbili National Hospital (MNH)
Mr. Desire Gaspered - Computer Analyst, Institute of Finance Management (IFM), Dar es
Salaam
Mrs. Husna Rajabu - Health Education Officer, MOHSW
Mr. Zakayo Simon - Registered Nurse and Tutor, Public Health Nursing School (PHNS)
Morogoro
Dr. Ewaldo Vitus Komba - Lecturer, Department of Internal Medicine, Muhimbili University
of Health and Allied Sciences School (MUHAS)
Mrs. Asteria L.M. Ndomba - Assistant Lecturer, School of Nursing, MUHAS
Mrs. Zebina Msumi - Training Officer, Extended programme on Immunization (EPI),
MOHSW
Mr. Lister E. Matonya - Health Officer, School of Environmental Health Sciences (SEHS),
Ngudu, Mwanza.
Dr. Joyceline Kaganda - Nutritionist, Tanzania Food and Nutrition Centre (TFNC),
MOHSW.
Dr. Suleiman C. Mtani - Obstetrician and Gynecologist, Director, Mwananyamala Hospital,
Dar es salaam
Mr. Brown D. Karanja - Pharmacist, Lugalo Military Hospital
Mr. Muhsin Idd Nyanyam - Tutor, Primary Health Care Institute (PHCI), Iringa
Dr. Judith Mwende - Ophthalmologist, MNH
Dr. Paul Marealle - Orthopaedic and Traumatic Surgeon, Muhimbili Orthopedic Institute
(MOI),
Dr. Erasmus Mndeme - Psychiatrist, Mirembe Refferal Hospital
Mrs. Bridget Shirima - Nurse Tutor (Midwifery), Kilimanjoro Chrician Medical Centre
(KCMC)
Dr. Angelo Nyamtema - Tutor Tanzania Training Centre for International Health (TTCIH),
Ifakara.
Ms. Vumilia B. E. Mmari - Nurse Tutor (Reproductive Health) MNH-School of Nursing
Dr. David Kihwele - Obs/Gynae Specialist, and Consultant
Dr. Amos Mwakigonja – Pathologist and Lecturer, Department of Morbid Anatomy and
Histopathology, MUHAS
Mr. Claud J. Kumalija - Statistician and Head, Health Management Information System
(HMIS), MOHSW
Ms. Eva Muro, Lecturer and Pharmacist, Head Pharmacy Department, KCMC
Dr. Ibrahim Maduhu - Paediatrician, EPI/MOHSW
Dr. Merida Makia - Lecturer Head, Department of Surgery, MNH
Dr. Gabriel S. Mhidze - ENT Surgeon, Lugalo Military Hospital
Dr. Sira Owibingire - Lecturer, Dental School, MUHAS
Mr. Issai Seng’enge - Lecturer (Health Promotion), University of Dar es Salaam (UDSM)

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Prof. Charles Kihamia - Professor, Parasitology and Entomology, MUHAS
Mr. Benard Konga - Economist, MOSHW
Dr. Martha Kisanga - Field Officer Manager, Engender Health, Dar es Salaam
Dr. Omary Salehe - Consultant Physician, Mbeya Referral Hospital
Ms Yasinta Kisisiwe - Principal Nursing Officer, Health Education Unit (HEU), MOHSW
Dr. Levina Msuya - Paediatrician and Principal, Assistant Medical Officers Training Centre
(AMOTC), Kilimanjaro Christian Medical Centre (KCMC)
Dr. Mohamed Ali - Epidemiologist, MOHSW
Mr. Fikiri Mazige - Tutor, PHCI-Iringa
Mr. Salum Ramadhani - Lecturer, Institute of Finance Management
Ms. Grace Chuwa - Regional RCH Coordinator, Coastal Region
Mr. Shija Ganai - Health Education Officer, Regional Hospital, Kigoma
Dr. Emmanuel Suluba - Assistant Lecturer, Anatomy and Histology Department, MUHAS
Mr. Mdoe Ibrahim - Tutor, KCMC Health Records Technician Training Centre
Mr. Sunny Kiluvia - Health Communication Consultant, Dar es Salaam
Dr. Nkundwe Gallen Mwakyusa - Ophthalmologist, MOHSW
Dr. Nicodemus Ezekiel Mgalula -Dentist, Principal Dental Training School, Tanga
Mrs. Violet Peter Msolwa - Registered Nurse Midwife, Programme Officer, National AIDS
Control Programme (NACP), MOHSW
Dr. Wilbert Bunini Manyilizu - Lecturer, Mzumbe University, Morogoro
Editorial Review Team
Dr. Kasanga G. Mkambu - Obstertric and Gynaecology specialist, Tanga Assistant Medical
Officers Training Centre (AMOTC)
Dr. Ronald Erasto Msangi - Principal, Bumbuli COTC
Mr. Sita M. Lusana - Tutor, Tanga Environmental Health Science Training Centre
Mr. Ignas Mwamsigala - Tutor (Entrepreneurship) RVTC Tanga
Mr. January Karungula - RN, Quality Improvement Advisor, Muhimbili National Hospital
Prof. Pauline Mella - Registered Nurse and Profesor, Hubert Kairuki Memorial University
Dr. Emmanuel A. Mnkeni – Medical Officer and Tutor, Kilosa COTC
Dr. Ronald E. Msangi - Principal, Bumbuli COTC
Mr. Dickson Mtalitinya - Pharmacist, Deputy Principal, St Luke Foundation, Kilimanjaro
School of Pharmacy
Dr. Janeth C. Njau - Paediatrician/Tutor, Kibaha COTC
Mr. Fidelis Mgohamwende - Labaratory Technologist, Programme Officer National Malaria
Control Programme (NMCP), MOHSW
Mr. Gasper P. Ngeleja - Computer Instructor, RVTC Tanga
Dr. Shubis M Kafuruki - Research Scientist, Ifakara Health Institute, Bagamoyo
Dr. Andrew Isack Lwali - Director, Tumbi Hospital
Librarians and Secretaries
Mr. Christom Aron Mwambungu - Librarian MUHAS
Ms. Juliana Rutta - Librarian MOHSW
Mr. Hussein Haruna - Librarian, MOHSW
Ms. Perpetua Yusufu - Secretary, MOHSW
Mrs. Martina G. Mturano -Secretary, MUHAS
Mrs. Mary F. Kawau - Secretary, MOHSW

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IT support
Mr. Isaac Urio - IT Consultant, I-TECH
Mr. Michael Fumbuka - Computer Systems Administrator – Institute of Finance and
Management (IFM), Dar es Salaam

Dr. Gilbert Mliga
Director of Human Resources Development, Ministry of Health and Social Welfare

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Introduction
Module Overview
This module content has been prepared to enhance learning of students of Clinical Assistant
(CA) and Clinical Officer (CO) schools.. The session contents are based on the sub-enabling
outcomes of the curricula of CA and CO. The module sub-enabling outcomes are as follows:
3.3.1. Take comprehensive obstetric and gynaecological history
3.3.2 Perform proper obstetric and gynaecological examination.
3.3.5. Manage obstetric and gynaecological common conditions: Normal labour, malaria in
pregnancy, pregnancy with urinary tract infections, genital tract infections (monilia,
trichomonas, and gonorrhoea), emesis gravidarum, normal puerperium, Delayed in
placental delivery, Suture 2nd
degree perineal tears. Pueperal pyrexia, Mastitis and
breast abscess,
3.3.6. Manage obstetric emergencies
3.3.8. Monitor progress of labour using a partograph
Who is the Module For?
This module is intended for use primarily by students of CA and CO schools. The module’s
sessions give guidance on contents and activities of the session and provide information on
how students should follow the tutor when he/she teaches the module. It also provides
guidance and necessary information for students to read the materials on his/her own. The
sessions also include different activities which focus on increasing students’ knowledge,
skills and attitudes.
How is the Module Organized?
The module is divided into 15 sessions; each session is divided into several sections. The
following are the sections of each session:
• Session Title: The name of the session.
• Learning Objectives – Statements which indicate what the student is expected to have
learned at the end of the session.
• Session Content – All the session contents are divided into subtitles. This section
includes contents and activities with their instructions to be done during learning of the
contents.
• Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
• Evaluation – The last section of the session consists of short questions based on the
learning objectives to check if you understood the contents of the session. The tutor will
ask you as a class to respond to these questions; however if you read the session by
yourself try answering these questions to evaluate yourself if you understood the session.
• Handouts – Additional information which can be used in the classroom while the tutor is
teaching or later for your further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the students to study material on their own and to reference after the session. Sometimes,
a handout will have questions or an exercise for students to answer.
How Should the Module be Used?
Students are expected to use the module in the classroom and clinical settings and during self
study. The contents of the modules are the basis for learning Obstetrics and Gynaecology I.
Students are therefore advised to learn all the sessions including all relevant handouts and

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worksheets during class hours, clinical hours and self study time. Tutors are there to provide
guidance and to respond to all difficulty encountered by students. One module will be
assigned to 5 students and it is the responsibility of the tutor to do this assignment for easy
use and accessibility of the student manuals to students.

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Abbreviations
ALu Artemether plus Lumefantrine
AMTSL Active Management of the 3rd Stage of Labour
ANC Antenatal Care
APH Antepartum Haemorrhage
ARM Artificial Rapture of Membrene
BCG Bacillus Calmette-Guerin Vaccine
BP Blood Pressure
CCT Controlled Cord Traction
CDKs Cyclins Dependent Kineses
C/S Caesarian Section
CSF Cerebral Spinal Fluid
DM Diabetes Mellitus
DPT Diptheria, Pertusis and Tetanus
EDD Expected Date of Delivery
EmOC Emergency Obstetric Care
ESR Erythrocyte Sedimentation Rate
GA Gestation Age
hCG Human Chorionic Gonadotrophin
HELLP Haemolytic Eleveted Liver enzymes Low Platelet count
HepB Hepatitis B
HPV Human Papilloma Virus
HSG Hystero Salpingealgraphy
HVS High Vaginal Swab
Ig Immunoglobulins
IM Intramuscular
IMCI Integrated Management of Childhood Illness
IPC Infection Prevention and Control
IPT Intermittent Preventive Treatment
ITN Insecticide Treated Nets
IUFD Interuterine Fetal Death
LNMP Last normal menstrual period
M,C,&S Microscopy, Culture and Sensitivity
MVA Manual Vacuum Aspiration
NGT Nasal Gastric Tube
NSAID Non Steroidal Anti Inflammatory Drugs
OPV Oral Polio Vaccine
PNC Postnatal Care
PPH Postpartum Haemorrhage
PPROM Pre Term Premature Rupture of Membrane

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PR Pulse Rate
PROM Premature Rupture of Membrane
PVE Per Vaginal Examination
RBC Red Blood Cells
RCH Reproductive and Child Health
RNAs Ribonucleic Acid
RPR Rapid Plasma Reagin
SFH Fundo-Symphysial Height
TPHA Treponema Pallidum Haemaglutination Assay
TT Tetanus Toxoid
USS Ultrasound
UTI Urinary Tract Infection
VDRL Venereal Disease Research Laboratory
VVF Vescico Vagina Fistula

Session 1: Comprehensive Obstetric History 1
Session 1: Comprehensive Obstetric History
Learning Objectives
By the end of this session, students are expected to be able to:
• Define comprehensive obstetric history
• List steps involved in creation of rapport with a pregnant woman
• Determine expected date of delivery (EDD), gestation age
• Document obstetrical history chronologically
• Summarize the obstetric history (important positives and negatives)
Definition of Comprehensive Obstetric History
• Comprehensive obstetric history is the process of gathering detailed information from the
woman during pregnancy, labour and puerperium.
Creating Rapport
• When attending the patient it is important to build a comfortable connection so that
information can be shared.
• It is important to create a relationship based on trust and respect created through both
verbal and non verbal actions
• It is essential in order to gain acceptability and cooperation from the patient
o Rapport may include the following aspects:
ƒ Greeting by shaking hands
ƒ Welcoming
ƒ Introduce yourself using same language as client
ƒ Offering a seat
ƒ Have time for client
ƒ Do not interrupt
ƒ Say ‘yes’, ‘um-hum’ or use non verbal gestures showing that you care
ƒ Make eye contact
ƒ Do not attend other clients while busy with another
Determination of Expected Date of Delivery (EDD), Gestation Age
• Expected Date of Delivery (EDD): This can be determined using several methods.
Naegele’s Rule and Ultrasound are the most accurate methods.
o Naegele’s Rule:
ƒ The EDD is calculated by taking the Last Normal Menstrual Period (LNMP),
counting forward by nine months; OR
ƒ Adding one year and subtracting three months, and then adding seven days to.
o Last Normal Menstrual Period (LNMP): The first day of the last normal
menstruation.
o Extrapolation from the fundal height at booking (should not be more than 20 weeks)
o Ultrasound – 1st
trimester Ultrasound Scan (USS)
o Extrapolation from quickening (primigravida 18-20 weeks, multigravida 16-18
weeks)
ƒ Quickening: The foetal movement felt by the mother.

• Gestation Age: Is calculated from the LNMP or EDD and recorded in weeks. Gestation
age is the period of pregnancy from the LNMP reported in weeks.
Documentation of Obstetrical History Chronologically
Introduction
• Name, age in years, place of residence, marital status, gravidity, parity, LNMP, EDD,
GA.
o Gravida: The number of total pregnancies regardless of the outcome.
o Parity: The number of live births at any gestation age or stillbirths after 28 weeks. In
terms of parity, twin counts as two.
o Grand multiparity: Refers to a woman who has had 5 or more deliveries.
Chief Complaints and Duration
• These are main problems that brought the patient to hospital. They should be recorded
chronologically.
o Use the complaints to grade the severity of the problem
o Make sure that you correlate all the complaints so as you have a comprehensive
outcome which will lead you to diagnosis
o Make sure the complaints lead you to the relevant differential diagnosis
History of Presenting Illness
• In this section each main complaint of the patient is expanded by determining its duration,
mode of onset, aggravating and relieving factors, progression and possible aetiological
factors.
• Review of other systems: Ask questions to rule out involvement of other systems
• Past medical history: Ask questions with regards to medical, drugs and surgical history
which could have influence on the current condition.
o Obstetric history: Ask and record the previous pregnancies and their outcomes
o Index Pregnancy: The pregnancy that a client is having (i.e., current pregnancy).
ƒ Inquire when the client reported to the clinic for the first time during the index
pregnancy (booking).
ƒ Ask about the number of visits that the client has made to the clinic, parameters
(weight, blood pressure, haemoglobin levels), screening tests (HIV, syphilis) ,
Iron and folic acid supplements given, IPTp and TT
Gynaecological History
• Gynaecology: Previous diseases of the female genital tract, as well as endocrinology and
reproductive physiology of a female.
o Outline menarche, menstrual cycle and its regularity, periods/ amount of blood loss,
previous infections and their treatment, gynaecological surgery, contraception history.
ƒ Menarche: Establishment of ‘menstrual function’ the time of the first of menstrual
period. men = means month and arche = means beginning.
Medical, Family and Social History
• Ask about familial diseases (e.g. Diabetes Mellitus, hypertension), history of twins
pregnancy in the family, occupation of woman and her husband
• Ask about cigarette smoking and excessive drinking of alcohol during this pregnancy

Refer to Handout 1.1: Performing Obstetric History
Activity: Case Study
Instructions
Read the following scenario and answer the related questions. Each group will briefly present
their answers in front of the class.
Scenario
A woman gives a history of LNMP on the 23rd
(decide on the month and year).
Questions
What will be the expected date of delivery?
What will be gestational age 12 weeks later?
Summary of the Obstetric History - Important Positives and Negatives
• Make sure the complaints assist you in performing physical examinations
• Make sure you are able to identify the urgency of treatment and take action
• Depending on the responses of the patient, identify key findings revealed during history.
• Remember to document both positive and negative findings
• Make sure you are able to interpret moods and body language of the patient during
history taking so that you can probe for more responses as needed
Key Points
• A good history should be comprehensive covering all important components.
• With a good history, a clinician will be able to establish the diagnosis in more than 80%
of the cases.
• With a good history, a clinician will be able to establish the possible aetiology, severity
and prognosis of the disease.
Evaluation
• Define the following terms: obstetrics, gynaecology, gravidity, parity, last normal
menstrual period (LNMP) and menarche.
• Explain the steps in documenting obstetric history chronologically.
• What is the importance of knowing the gestational age of the pregnant woman?
• List steps involved in creation of rapport with a pregnant woman.
References
• Baker, P. Monga, A. (2006). Obstetrics by Ten Teachers (18th Ed.). London: Hodder
Arnold.
• Driessen, F. (1991). Obstetric Problems (A Practical Manual). Nairobi: AMREF.
• Johnson, F. (2006). Lecture Notes Obstetrics and Gynaecology for Clinical Officers.
• Oats, J., Abraham, S. (2005) Llewellyn-Jones Fundamentals of Obstetrics and
Gynaecology. (8th
Ed.). Edinburgh: Mosby.

Handout 1.1: Taking Obstetric History
Introduction
• History-taking and physical examination are essential skills for good clinical practice.
• Competence in this area requires a sound clinical knowledge in order to direct questions
that will help to shape the presentation appropriately.
• The basic framework to history-taking and physical examination can be readily acquired
but the best result can only be achieved by improving these skills through practice and
better knowledge.
Procedure for Taking Obstetric History
Obstetric History
• Greet, welcome the woman and allow her to sit comfortably in a chair
• Create a good interpersonal relationship
• If first visit, start a new Antenatal card. If it is a follow-up visit, ask for the card.
Important issues to note:
• The obstetric history is both a synopsis of a woman’s background risk as well as an
account of the progress of her index pregnancy.
• A carefully taken history provides a clinical guide to the physical examination to follow.
• Further physical signs which are not routinely elicited in a pregnant woman may become
necessary if the history warrants it.
• Use an Antenatal Card for taking a pregnant woman’s history.
• This allows the history to be taken and presented in a logical sequence and avoids
omission of important details.
• The following is a guide to taking an obstetric history.
Taking History of Current Pregnancy
• Personal and Pregnancy History
o Introduce yourself politely. Ask permission to take her history and conduct an
examination.
o Start by asking her name, age, gravidity (i.e. number of pregnancies including the
current one) and parity (i.e. number of births beyond 24 weeks gestation).
o The expected date of delivery (EDD) can be calculated using Naegele’s rule or other
reliable method:
ƒ The EDD is calculated by taking the Last Normal Menstrual Period (LNMP),
counting forward by nine months; OR
ƒ Adding one year and subtracting three months, and then adding seven days to.
o Inquire about her health and that of her fetus (e.g. after 20 weeks inquire about fetal
movements). Ask if there are any current problems/complaints, and obtain detailed
information.
o A chronological and concise account of the events in pregnancy is best obtained by
asking about her pregnancy in the first, second and third trimester.

o If the patient is in the postnatal period, details of labour and delivery are relevant.
o This inquiry should include details of laboratory tests and ultrasound scans.
o The date pregnancy was confirmed by a pregnancy test, results of the routine
antenatal blood tests and the date and details of the first scan are important.
Subsequent antenatal check-ups and tests done (including subsequent scans) should be
noted.
o The details of the results may be asked from the woman and if necessary can be cross
checked against the notes.
o Notes should be organized and logical. At times it may be necessary to revisit an area
of the history as the story unfolds further or during or after clinical examination.
• History of Menstrual Periods
o State the last menstrual period (LMP) and any details that may influence the validity
of her EDD as calculated from the LMP, such as long cycles, irregular periods or
recent use of oral contraceptive pills or injections.
• Past Obstetric History
o Outcome of previous pregnancies and any significant antenatal, intra- or post-partum
events may have influence in the management of the current pregnancy.
o Previous maternal complications, mode of delivery, birth weights and the life and
health of babies may be relevant.
• Past Gynaecological History
o Details of contraceptive history, history of diseases like sexual transmitted infections,
and previous surgical procedures and cervical smears should be noted.
• Past Medical/Surgical History
o Some medical conditions may have a significant impact on the course of the
pregnancy.
ƒ Heart disease, epilepsy, bronchial asthma, thyroid disorders, insulin-dependent
diabetes mellitus and other medical conditions or the medications they take for
these conditions may have significant impact on the pregnancy.
o Alternatively, pregnancy may have an impact on the medical condition.
o The condition may remain the same or get better or worse.
o These may be incorporated under “current pregnancy” if it is of concern in this
pregnancy.
• Drug History
o History of allergies should be highlighted and any use/abuse of drugs during
pregnancy should be noted.
o Arrangements may have to be made to wean off the drug.
• Family/Social History
o History of hereditary illnesses or congenital defects is important and may be of
concern to the couple.
o Appropriate counselling and investigations should be organised. This is a good
opportunity to counsel patient about smoking/tobacco use cessation and/or reducing
alcohol intake, if applicable.
o Relevant social aspects such as childcare arrangements and plans for breastfeeding
and contraception can be discussed at this point.

• Final Summary
o This should include the salient details that will impact the investigations to be carried
out and the proposed plan of management.
o Look at the data on the compiled sections of the antenatal card and identify risk
factors.
o In a woman who has experienced many problems during her pregnancy, it may be
better to provide details of each problem separately rather than a chronological
account of the pregnancy.
After Taking the History
• Inform the patient if you have identified problems or high risk factors
• Educate the client as necessary, addressing harmful beliefs and misconceptions
• Give explanations in clear language, avoiding jargon
• Allow client to ask questions and check for understanding
• Record all the findings in the antenatal card
• The history should form the basis for further investigations if needed and to help focus
the examination.

Session 2: Physical Examination in Obstetrics 7
Session 2: Physical Examination in Obstetrics
Learning Objectives
• List essential tools for physical examination in obstetrics
• Describe the systematic approach in examining a pregnant woman
• Document obstetric examination findings systematically
• Present obstetric examination findings systematically
• Interpret the examination findings and make the diagnosis and differentials
• Demonstrate ability to perform obstetric examination systematically
Physical Examination Tools
Physical examination tools include:
• Examination room
• Weighing scale
• Height measurement facility
• Sphygmomanometer
• Stethoscope
• Thermometer
• Speculum
• Sterile gloves
• Swabs and disinfectants
• Foetoscope
Systemic Approach in Examination of a Pregnant Woman
General Examination
• Height, weight, pallor, jaundice, cyanosis, state of the tongue, angular stomatitis, finger
status (clubbing, koilonichia), physical deformities, enlarged lymph nodes, skin condition,
oedema, neck swellings, blood pressure, pulse rate and temperature
Cardiovascular System
• Pulse, blood pressure, look for engorged neck veins, precordial examination (inspection,
palpation, and auscultation)
Respiratory system
• Respiratory rate, position of the trachea, percussion, auscultation
• Breasts should be examined separately- nipple (retraction and discharge)
Abdominal examination
• Inspection
o Configuration of the abdomen, movement of the abdomen with respiration, surgical
scars
• Palpation

o Fundal height, fundal palpation (which foetal parts occupies the fundus), lie,
presenting and level of the presenting part, foetal heart beats, then assess other
internal organs (liver, spleen, kidneys).
Note: In normal pregnancy the fundus is just palpable above the symphysis pubis at 12
weeks, between symphysis pubis and umbilicus is 16 weeks, at the umbilicus is 22 weeks,
between the umbilicus and xiphoid process is 28 weeks and at the xiphoid is 36 weeks.
Vaginal Examination
• Only recommended for specific conditions
• If necessary perform sterile speculum examination
Document of Obstetric Examination Findings
• Remember to document the findings systematically after examination:
o Have a plain paper and pen
o Write down the findings obtained from the general, systemic and vaginal examination
o Write the comments for specific conditions
o Document for any action taken
ƒ Controlling haemorrhage
ƒ Stopping convulsions
ƒ Inserting the NGT (Nasal Gastric Tube)
ƒ Inserting Intra Venous Fluid
Interpretation of Findings, Diagnosis and Differentials
• Interpret the examination findings in order to establish the most likely diagnosis and
differentials:
o Use the list of findings to grade the severity
o Correlate all the findings to have the comprehensive outcome which will lead to
diagnosis
o Make sure the findings will direct you to the relevant differential diagnosis and
investigation
Demonstration of Systemic Examination of a Pregnant Woman
Activity: Demonstration and Return Demonstration
Instructions
Tutor will demonstrate examination of a pregnant woman using a model.
REFER to:
• Handout 2.1: Performing Obstetric Physical Examination
• Handout 2.2: Performing Vaginal Examination
Key Points
• Be well-mannered and gentle when performing physical examination.
• Always ensure the patient is comfortable and warm.
• Always have an assistant, preferably a female midwife, present when you examine a
patient.

• Link the history and your examination findings to arrive at the diagnosis.
• Always remember to document the examination findings.
• Inform the client on any relevant findings and educate as necessary.
Evaluation
• What equipment is necessary for the obstetric examination?
• How do you create a good interpersonal relationship with a client?
• What are the important aspects of abdominal examination?
References
• Association of Professors of Gynaecology and Obstetrics (APGO) (2008). Undergraduate
Medical Education Committee. (8th
Ed.).
Arnold.
• DeCherney, A.H. Nathan, L. (2002). Current Obstetrics and Gynaecology (9th
Ed.).
McGraw Hill.
• Parisaei, M., Shailendra, A., Dutta, R., Broadbent, J.A. (2008). Crash Course: Obstetrics
and Gynaecology. (2nd
Ed.) Mosby.
• Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. (2007). Pelvic examination.
NEJM (26th
Ed.).
• Lynn S. Bickley and Peter G. Szilagyi (2007) Bates’ Guide to Physical Examination
History Taking, (9th
Ed.). Lippincott Williams Wilkins.
• Mark H. Swartz, (2006). Textbook of Physical Diagnosis – History and Examination. (5th
Ed.). W.B. Saunders Company.
Gynaecology. (8th

Introduction
Many aspects of the obstetric physical examination are unique. There are several necessary
techniques and skills which are not required in other specialities.
General Examination
The assessment should begin with a general examination.
• The general examination should include the woman’s height and weight.
o From these, the body mass index (BMI) can be calculated as follows:
BMI =
Weight
=
kg
(Height)2
m2
ƒ The metric BMI formula accepts weight measurements in kg, and height
measurements in either cm or meters
o Some antenatal and perinatal complications are associated with a BMI 20 or 25.
• The thyroid gland and breasts should be examined at a booking visit and auscultation of
the heart sounds and lungs is essential.
• More detailed examinations are indicated when a sign is detected (e.g. multinodular of the
goitre, bruit over the mass, ophthalmic signs, tremors) or in specific situations
o For example, examination of the eyes with an ophthalmoscope to look for retinopathy
in a diabetic or hypertensive woman.
• The measurement of maternal blood pressure is of great importance in pregnancy.
o It is not appropriate to measure this in the supine position as pressure from a gravid
uterus on the inferior vena cava impedes venous return resulting in a falsely low blood
pressure. This is often referred to as the supine hypotension syndrome.
o The correct position is ‘semi recumbent’ – a 45° tilt. When auscultating the brachial
artery in measuring the diastolic blood pressure, the value at which the sounds
disappear is currently accepted as it gives the closest reading to the direct arterial
blood pressure measurement.
o An appropriate size cuff should be utilised with a larger cuff for those with a larger
upper arm circumference – the smaller cuff in these women would give a falsely high
reading.
Performing Abdominal Examination
• The fundamental steps in abdominal examination, namely inspection, palpation and
auscultation apply to the pregnant woman and occasionally the art of percussion to elicit
fluid thrill when polyhydramnios is suspected.
• The specific manoeuvres and techniques vary in an obstetric examination.
• The clinician may be guided by the preceding history and general examination to conduct
this more specific part of the physical examination.
• For instance, a history of abdominal pain should prompt a careful palpation for uterine
contractions (suggestive of labour) or localised tenderness (associated with red
degeneration of a fibroid, accident of an adnexal mass, dehiscence of a previous scar or
rarely placental abruption).
Handout 2.1: Performing Obstetric Physical Examination

Abdominal Inspection
• Note the distension of the abdomen that may indirectly indicate the shape and size of the
uterus. Any asymmetry of the abdomen and foetal movements should be recorded.
• It is important to note any surgical scars, particularly a low transverse incision that may
be obscured by pubic hair and a laparoscopic scar within the umbilicus. The scars
observed should be correlated to previous surgical and gynaecological history.
• Coetaneous signs of pregnancy such as linea nigra (dark pigmented line stretching from
just below the xiphi sternum through the umbilicus to the supra-pubic area) or striae
gravidarum (recent striae are purplish in colour) are often present though they are of no
clinical significance.
• Old striae (striae albicans) are silvery-white and are evidence of previous parity.
• The umbilicus may be flat with the surface or everted due to increased intra-abdominal
pressure.
• Superficial veins may be seen denoting alternate paths of venous drainage due to pressure
on the inferior vena cava by the gravid uterus.
Abdominal Palpation
• Uterine size: The uterine size is objectively measured and expressed as fundo-symphyseal
height.
• First the highest point of the fundus of the uterus should be palpated.
• One should bear in mind that the uterus may be displaced to the left or right of the
midline.
• Use the ulnar border of the left hand and move it downwards from below the xiphi
sternum and from below each subcostal margin until the fundus is located.
• Once the highest point of the uterine fundus is identified the fundo-symphysial height
(SFH) can be measured with a tape measure.
• The upper margin of the bony pubic symphysis is located by palpating downwards in the
midline starting from few centimetres above the pubic hair margin.
• The SFH in centimetres ± 2 cm should approximate the gestation of the pregnancy in
weeks from 20 until 36 weeks gestation.
• From 36 to 40 weeks this could be ± 3 cm and at 40 weeks it is ± 4 cm.
• The decrease in height is due to reduction in the amniotic fluid volume and descent of the
foetal head.
• On the contrary, the increase in size may be due to further growth of the foetus, increase
of amniotic fluid and non descent of the foetal head.
• It is important at this stage that the number of foetuses is determined.
• Palpation of a larger uterus than that expected for that gestation, two heads, three poles,
multiple foetal parts, excessive amniotic fluid, and auscultation of two foetal heart rates
with a difference of greater than 10 beats per minute suggests the presence of multiple
pregnancies.
Checking for Foetal Presentation
• Presentation is the part of the foetus that overlies the pelvic brim and is of importance
especially after 37 weeks gestation when the majority of women go into labour.
• This is determined by placing both hands on either side of the lower pole of the uterus
while facing the woman’s feet.
• Approximate the hands firmly but gently towards the midline to ascertain the presenting
part.

• A hard rounded presenting part suggests a cephalic presentation while a broader, soft
object suggests breech presentation.
• In cephalic presentation, it is usual to report the number of fifths of the head palpable.
o This is a rough approximation of how many finger breadths are necessary to cover the
head above the pelvic brim.
• When touching the abdomen look at the woman’s face, as palpation of the foetal head
may be tender. The clinician should detect any signs of discomfort from her facial
expression and be gentle with the palpation.
o Paulik’s grip is a one-handed technique to feel for the presenting part.
o The cupped right hand is used to grasp the lower pole of the uterus and it is possible to
feel the hard rounded foetal head in nearly 95% of pregnancies at term.
o It can cause discomfort and is not a necessary part of the examination if the head can
be palpated with ease by the two hands.
• If the hands on the sides of the head converge above the pelvic brim then the head is not
engaged as more of the head is above whilst if the hands diverge then it is suggestive of
engagement i.e. more than half the head has descended below the pelvic brim.
Checking for Lie of the Foetus and Location of the Foetal Back
• Lie of the foetus describes the relationship of the longitudinal axis of the foetus to the
longitudinal axis of the uterus.
• This is best done by facing the woman and placing one hand on each side of the uterus
and applying gentle pressure when one should be able to perceive the resistance of the
firm foetal back and on the opposite side it may be possible to feel the foetal limbs.
• This can be confirmed by alternately palpating with one hand while using the opposite
hand to steady the foetus.
• If the presentation is cephalic or breech (the buttocks of the foetus) it has to be a
longitudinal lie as the lower pole of the longitudinal lie of the uterus is occupied by one
pole of the longitudinal axis of the foetus.
• If no presenting part was palpable in the lower pole and if the head or a breech was in one
of the iliac fossa then it is an oblique lie and if the longitudinal axis of the foetus straddles
right across the horizontal axis of the uterus then it is a transverse lie.
• Once the foetal lie is determined the anterior shoulder should be palpated as the foetal
heart sounds are best heard over this area.
• A shallow groove palpable between the presenting part and the rest of the foetus helps to
identify the prominent anterior shoulder in most cases.
Estimation of Foetal Weight and Quantity of Amniotic Fluid
• Assessing foetal weight can be difficult but it is important to determine whether the foetus
is small, average or big.
• It is usually assessed by placing one hand over each pole of the foetus and by guessing
the approximate weight.
• With experience and by checking the guessed weight to the actual weight after delivery
the clinician is able to improve his/her performance although many a times the error
would exceed more than 10% especially with the very small and the very large fetuses.
• The ease with which the foetal parts are palpable, ballotment of the fetal parts and the
‘cystic’ feeling for the fluid in the uterus should give some idea of the amniotic fluid.

Abdominal Auscultation
• The foetal stethoscope or any other device can be placed over the anterior shoulder and
the foetal heart can be heard. The rate can be determined by auscultation over one minute.
Abdominal Percussion
• Percussion is generally not used in an obstetric examination.
• If the quantity of amniotic fluid is felt to be excessive (shining, stretched abdomen with
difficulty in feeling foetal parts) then the sign of ballottement is useful to identify the
head.
• Fluid thrill may be elicited by tapping in the midpoint of the uterus on one side and trying
to feel it with the hand placed on the opposite side at the same level.
• The passage of surface vibrations should be damped by an assistant or patient keeping the
ulnar border of the hand firmly in the midline on the abdominal wall.
After Taking the History
• Inform the woman of identified problems or high risk factors
• Educate the client as necessary addressing harmful beliefs and misconceptions
• Give explanations in clear language avoiding jargon
• Record all the findings in the antenatal card
• The examination should add to information gathered during history taking in order to
assist in making clinical judgements for further investigations if needed, and to help
further management.

Handout 2.2: Performing a Vaginal Examination
Introduction
• Vaginal speculum and digital examinations are not a routine part of the obstetric physical
examination but are performed when indicated
o For example, a speculum examination to confirm leaking amniotic fluid in cases of
pre-labour rupture of membranes, or to carry out inspection and take swabs in cases
with abnormal vaginal discharge.
The Procedure
• Introduce yourself and explain the procedure to the client
• Establish names/relationship of family
• Start with an open-ended question
• Use appropriate eye contact, body language
• Use facilitative listening skills
• Demonstrate empathy
• Describe each step of exam to patient prior to performing it
• Maintain patient privacy
• Attend to patient’s comfort throughout the procedure
• Perform exam in a gentle and professional manner
Preparation
• Prepare all the needed equipment and supplies
• Prepare the examination table and the light prior to gloving
• Wash hands in running water with soap
General Techniques/Exam Skills
• Demonstrate concern for the patient’s comfort and maintain client’s privacy
• Explain to patient/client about the procedure
• Ask for the patient’s/client’s cooperation during the exam
• Follow a logical sequence of exam from one region to another
• Emphasize areas of importance as suggested by interview
• Modify the examination to adapt to patient limitations (imposed by illness, age or
temperament of patient)
• Position patient on the examination couch, making sure that you maintain privacy, hips to
end of table and heels on foot rests or stirrups
• Wash hands and wear gloves throughout the examination
External Examination of the genitalia
• Examine the external genitalia:
o Inspect mons pubis
o Inspect labia majora
o Inspect labia minora
o Inspect clitoris
o Inspect urethal meatus
o Inspect introitus

o Inspect Bartholin’s gland
o Inspect perineum
o Inspect anus
Speculum Examination
• Hold speculum at 45-degree angle
• Insert speculum properly
• Rotate speculum at full insertion
Angle at full insertion: 45 degree angle
Source: APGO, 2008.
• Open speculum slowly
Source: APGO, 2008.
• Identify cervix
• Secure speculum in open position
• Inspect cervix
• Inspect vaginal walls while removing speculum
• Handle speculum appropriately
• Remove speculum appropriately

Bimanual Pelvic Examination
• Change gloves and inform the woman that you are going to insert fingers to inspect the
inside of the vagina
• Introduce fingers into vagina
Source: APGO, 2008.
• Palpate cervix and cervical os
• Palpate uterine body, apex of fundus
• Note uterine size
• Describe position of uterus
• Palpate right adnexa/ovary
• Palpate left adnexa/ovary
Bimanual Rectovaginal (RV) Examination
• Change gloves for rectal examination
• Explain the procedure to the client saying that you are going to insert a finger in the anus,
being sensitive to culture
• Ask patient to bear down as finger is inserted
• Insert middle finger into rectum
• Palpate uterus
• Palpate right adnexa/ovary
• Palpate left adnexa/ovary
• Remove finger smoothly
After the Examination
• Assist the woman to a sitting position
• Inform the woman the identified problems or risks
• Educate the client as necessary addressing harmful beliefs and misconceptions
• Give explanations in clear language avoiding jargon

Session 3: Comprehensive Gynaecological History 17
Session 3: Comprehensive Gynaecological History
Learning Objectives
• Define comprehensive gynaecology history
• Demonstrate skills on creating rapport with a woman with gynaecological condition
• Document gynaecological history chronologically
• Summarize the history (important positives and negatives)
Definition of Comprehensive Gynaecological History
• Comprehensive gynaecology history includes a summary of a patient’s information on
o Menstrual, obstetrical, and sexual history
o Contraceptive use (past and current),
o Gynaecologic history
ƒ Pap smears examination,
ƒ Reproductive health problems such as infections and other diseases of the female
genital tract and endocrine disorders)
Creating Rapport
• Creating rapport is important in order to gain toleration and cooperation from the patient.
• Rapport may include the following aspects:
o Greeting by shaking hands
o Welcoming
o Introduce yourself using same language as client
o Offering a seat
o Have time for client, and do not interrupt
o Say ‘yes’, ‘um-hum’ or use non verbal gestures to show that you care
o Make eye contact
o Do not attend to other clients while busy with another
Systematic Documentation of Gynaecological History
Activity: Small Group Discussion
Instructions
You will work in small groups to discuss the following:
• What steps and components are important during a systematic gynaecological history?
• What information do you need to ask the patient to provide?
Record your answers, and be prepared to share with the class.
• Introduction, age, place of residence, parity, LNMP
• Chief complaint and duration
• History of presenting illness (refer the contents under the obstetric history)
• Review of other systems (i.e., probe for involvement of other systems).
• Past medical history

Session 3: Comprehensive Gynaecological History 18
o Ask questions with regards to medical, drugs and surgical history which could have
influence on the current condition.
• Gynaecological history
o Indicate age at menarche, menstrual cycle and its regularity, periods/amount of blood
loss, previous infections and their treatment, gynaecological surgeries, contraception
history.
o Menstruation: The periodical flow of blood from the uterus commences at the age of
13 and ceases at the age of 45years (it may occur earlier or later respectively).
o The flow of blood may vary from three to five days.
ƒ Menstrual cycle: The periodic cycle from day one of menstruation to the onset of
the next menstruation. The duration varies from 21 up to 35 days.
ƒ Dysmenorrhoea: Pain occurring during menses.
ƒ Menopause: Physiological cessation of menstruation (menstrual cycles).
• Family and social history
o Note: for additional information on family/social history, refer to Session 1: Obstetric
History
Summary of History - Important Positives and Negatives
• Depending on the responses of the patient, identify key findings revealed during history
taking.
• Remember to document both positive and negative findings.
• Make sure you are able to interpret moods and body language of the patient during
history taking so that you can probe for more detailed responses as needed.
Key Points
• A good history should be comprehensive, covering all important components.
• With a good history, a clinician will be able to establish the possible aetiology, severity
and prognosis of the disease.
Evaluation
• Define menarche, menstruation, menopause and gynaecology.
• Explain the steps in documenting gynaecological history chronologically.
• Mention three hints that you need to remember during establishing the cause of the
gynaecological problem.
References
• Baker, P. Monga, A. (2006). Obstetrics by Ten Teachers (18th
Ed.). London: Hodder
Arnold.
• Johnson, F. (2006). Lecture Notes Obstetrics and Gynaecology for Clinical Officers
Gynaecology. (8th

Session 4: Physical Examination in Gynaecology 19
Session 4: Physical Examination in Gynaecology
Learning Objectives
• List essential tools needed to conduct a physical examination in gynaecology
• Describe the systematic approach for examining a woman with a gynaecological
condition
• Document and present examination findings systematically
• Interpret examination findings and make the diagnosis and differentials
Physical Examination Tools
• In order to conduct a physical examination, a healthcare provider will need:
o Examination room with gynaecological bed and a source of light
o Blood Pressure machine
o Stethoscope
o Thermometer
o Speculum (Auvards, Sims, Cuscos and Furgerson)
o Gloves
o Swabs and disinfectant
Systematic Physical Examination
General Examination
• Look for pallor, jaundice, cyanosis, state of the tongue, angular stomatitis, finger status
(clubbing, koilonichia), physical deformities, enlarged lymph nodes, skin conditions,
oedema, neck swelling, and temperature
• Pulse rate ,blood pressure, engorged neck veins, precordial examination (inspection,
palpation, and auscultation)
Respiratory System
• Respiratory rate, position of the trachea, percussion, auscultation
• Breasts- examine the nipple, look for masses, axilla lymphnodes
Abdominal Examination
• Inspection- Contour of the abdomen, movement of the abdomen with respiration, surgical
scars.
• Palpation- Before palpation, ask the patient for any site of pain. Do superficial
examination to elicit tenderness and swellings, deep palpation for masses, liver, spleen
and kidneys.
• Percussion- Recommended if free fluid is suspected – assess for shifting dullness and
fluid thrills.
Pelvic Examination
• External Exam- Inspect external genitalia in lithotomy position.

• Speculum Examination- Perform speculum examination to visualize the cervix and
vaginal walls. Take specimens when indicated, like vaginal swabs and cervical smears.
• Bimanual Digital Examination- Palpate the cervix, uterus, adnexae (parametrium,
fallopian tubes, and ovaries). Note the size, shape, position, mobility and tenderness of
these structures.
• In a virgin or a child, only a rectal examination should be performed.
• Note: Pelvic examinations, if done by a male clinician, should be conducted in the
presence of a female nurse.
Rectal Examination
• May be performed in case of specific conditions, such as cancer of cervix.
Demonstration of Essential Tools for Gynaecological Physical Examination
The essential examination tools for gynaecological examinations include:
sphygmomanometer (BP machine), stethoscope, thermometer, gloves, swabs, tape measure
and speculums (Auvards, Sims, Cuscos and Furgerson).
Figure 1: Auvard Weighted Vaginal Speculum
Source: Oats et al, 2005.
Uses:
• Visualizing the cervix
• Taking cervical biopsy
• During performing the sharp curettage
• During MVA (Manual Vacuum Aspiration)
• Removing products of conceptus e.g. retained placenta for
repairing cervical tear
Figure 2: Cuscos
Uses
• In visualizing the cervix
• For taking cervical biopsy
• During performing the MVA (Manual Vacuum Aspiration)
• For inserting the Loop (a long term family planning
method)
• For introducing the dye (Radio opaque) when preparing the
client for HSG (Hystero Salpingeal Graphy)

Figure 3: Sims
Uses:
• In visualizing the cervix
• Performing gentle vagina inspection
• During MVA (Manual Vacuum Aspiration)
• For removing products of conceptus e.g. retained placenta
• For repairing cervical tear can be used together with
Auvard
Activity: Demonstration
Instructions
Tutor will demonstrate the examination sequentially, starting with general examination then
systemic/regional examination which will include pelvic examination.
REFER to Handout 4.1: Procedure for Gynaecological Physical Examination.
Documentation of Findings
• Document the findings after examination
o Write down the findings obtained from the:
ƒ General examination
ƒ Systemic/regional examination
ƒ Pelvic examination
ƒ Bimanual digital examination
o Write the comment for specific conditions
o Document for any action taken
ƒ Controlling haemorrhage
ƒ Stopping convulsions
ƒ Inserting the NGT (Nasal Gastric Tube)
ƒ Inserting Intra Venous Fluid
• Remember to document both positive and negative related findings
Interpretation of Findings, Diagnosis, and Differentials
• Interpret the examination findings in order to establish the most likely diagnosis and
differentials:
o Use the list of findings to grade the severity
o Make sure the findings will direct you to the relevant differential diagnosis
o Make sure the findings are assisting you in requesting the relevant investigation
o Correlate all the findings to have the comprehensive outcome which will lead to
diagnosis
o Make sure you are able to identify the urgency of treatment and take action

Key Points
• Be well-mannered and gentle during all interactions and examinations with patients.
• Always ensure that the patient is comfortable and warm.
• Ensure privacy
• Always have an assistant, preferably a female nurse, present when performing pelvic
examination.
• Link the history and your examination findings to arrive at a diagnosis.
Evaluation
• Why is it necessary to have a female nurse present while performing a pelvic
examination?
• What is bimanual digital examination intended to elicit?
References
• Clayton, S. Monga, A. (Ed.). (2000). Gynaecology by Ten Teachers (17th
Ed.). London:
Arnold.
• Oats, J., Abraham, S. (2005). Llewellyn-Jones Fundamentals of Obstetrics and
Gynaecology. (8th
Ed.) Mosby.

Handout 4.1: Procedure for Gynaecological Physical Examination
Procedure for Physical Examination
• Start with the general examination of the patient, followed by cardiovascular and
respiratory systems.
• The gynaecological examination encompasses both an abdominal as well as a vaginal
pelvic examination (including bimanual palpation).
• A bimanual examination should be preceded by inspection of the vulva, vagina and cervix
using a speculum. In specific circumstances, a rectal examination may be indicated.
Abdominal Examination
The fundamental steps in an abdominal examination are:
• Inspection, palpation and percussion
• Auscultation may be relevant especially in cases of acute abdomen and post-operative
examinations.
• Inspection:
o Abdominal distension, if any, should be noted and if present look for visible
evidence of masses. If surgical scars are present they should be correlated to the past
history.
• Palpation:
o Guarding, tenderness and rebound tenderness are important signs to elicit in
anyone presenting with an acute abdomen.
o After performing a routine light palpation of the whole abdomen with the right
hand, it is important to switch to the left hand and feel for pelvic masses.
• Percussion/auscultation
o Percussion is useful to distinguish between a solid mass (dull) and distended
bowel (tympanic).
o In the presence of a vague mass on palpation in an obese individual or when one is
tensing the abdominal wall percussion is useful to identify the possibility of the mass
and also in defining the borders of a mass.
o It is useful to demonstrate ascites or collection of blood. Shifting dullness and
fluid thrill need to be demonstrated appropriate to the situation.
The Pelvic Examination
• The pelvic or vaginal examination is the most challenging part of the gynaecological
physical examination.
• It is a potential source of embarrassment to the woman and should be conducted in a
sensitive manner in privacy accompanied by a suitable chaperone (i.e., a female nurse).
• Exposure should be in a manner needed to carry out the examination.
• The abdomen should be covered up to just below the knees.
• The exam should be performed gently, otherwise it can be uncomfortable. A well
performed pelvic examination gives good information about the genital tract and pelvic
organs. It is thus an indispensable part of the gynaecological assessment and is to the
gynaecologist the equivalent of a rectal examination to the surgeon.

Position
• The pelvic examination can be performed in the dorsal, lithotomy or Sim’s position.
o Sim’s position is a modification of the left lateral position and is ideal for
examination of a woman with utero-vaginal prolapse or vesico-vaginal fistulae.
o The lithotomy position, in which both thighs are abducted and feet suspended
from lithotomy poles is usually adopted when performing vaginal surgery.
o The dorsal position is most commonly used for routine outpatient
gynaecological examinations such as when obtaining a cervical smear.
Technique
The steps in performing a pelvic examination are:
• Inspection of the external genitalia
• Speculum examination of the vagina and cervix
• Bimanual examination of the uterus and adnexae.
Inspection
• Inspect the vulva and external genitalia. It is useful to imagine a series of circles
surrounding the vaginal introitus and then to describe your findings from the outermost to
the innermost circle. For example, one could begin with describing the mons pubis and
pubic hair distribution, the labia majora and minora, the clitoris, urethral meatus and
vaginal introitus.
Speculum Examination
• Two vaginal speculae are commonly used – the Sim’s (duck-billed) speculum and
Cusco’s (or bivalve) speculum.
o Sim’s speculum is used in the Sim’s position and is most useful for the
examination of utero-vaginal prolapse.
o Cusco’s speculum is most frequently used and is described below.
Introduction of the Speculum
• The labia minora are parted with the index and middle fingers of the left hand to obtain a
good view of the introitus.
• A well-lubricated and warm bivalve speculum is held in the right hand with the main
body of the speculum in the palm and the closed blades projecting between the index and
middle fingers.
• This grasp is intended to keep the blades opposed and prevent inadvertent opening of the
speculum while it is being inserted.
• In the lithotomy position, the speculum is usually inserted with the handle inferior while
in the dorsal position, the handle should be superior.
• The speculum is advanced gently along with gentle pressure on the posterior wall of the
vagina to open the potential space.
• Take note that the axis of the vagina is directed slightly towards the rectum.
• Open the speculum only when it cannot be advanced further.
• The cervix may be visualised. If it cannot be seen, the speculum is either above or below
the cervix as the blades are in the anterior or posterior fornix of the vagina.
o It will then be necessary to close the speculum, withdraw it slightly, change its
direction and advance it before opening it again.
• The vaginal skin is rugose and that over the cervix is smooth. Usually there is mucus
close to the cervical os. There will be a convex anterior vaginal fornix or a concave

posterior fornix – one or more of these features may come into view that may help to
change the direction of the speculum.
Removal of the Speculum
• Removal of the speculum requires as much care as insertion. It is essential that the blades
are held open as the speculum is withdrawn until the ends of the blades are distal to the
cervix. Otherwise, closing the blades on the cervix will cause pain. The speculum must be
completely closed as the ends of the blades come out through the introitus.
Digital Examination
• The digital bimanual examination helps to identify the pelvic organs.
• The bladder should be emptied prior to this examination.
• The index and middle fingers of the right hand are inserted into the vagina with the
palmar aspect facing upwards.
• Feel the consistency of the cervix. The left hand is placed on the abdomen and bimanual
palpation commenced.
• The purpose of bimanual palpation is to bring the abdominal wall close to the pelvic
organs by pressing on the appropriate place on the abdominal wall and also by shifting
the pelvic organs or masses towards that hand.
• One should feel these organs or masses between the vaginal and abdominal hands. First,
the uterus is felt with the vaginal fingers placed on the cervix and the hand on the lower
midline above the uterine fundus.
• Then, the adnexae can be palpated between the vaginal fingers placed in the lateral
fornices and the abdominal hand over the respective iliac fossa.
• An anteverted uterus is easily palpated bimanually but a retroverted one may not be.
• Retroverted uteri can be assessed by feeling the body of the uterus with the vaginal
fingers via the vaginal wall of the posterior fornix.
• If a pelvic mass is discovered, its size, consistency and mobility are determined. Uterine
masses may be felt to move with the cervix when the uterus is shifted upwards while
adnexal masses will not.
• If adnexal masses are suspected there should be a line of separation between the uterus
and the mass and the mass should be felt distinctly from the uterus.
• Pedunculated masses from the uterus may give the impression of an adnexal mass and an
adnexal mass adherent to the uterus may give the impression of a uterine mass.
• The consistency of the mass may be of help to distinguish the origin in some cases. An
ultrasound examination may be necessary to define it better.

Session 5: Normal Pregnancy 27
Session 5: Normal Pregnancy
Learning Objectives
• Explain the process of fertilization
• Describe essentials for establishing a diagnosis of normal pregnancy
• Describe the physiological changes in pregnancy
• Describe minor disorders of pregnancy
Processes of Fertilization
Fertilization
• This is the fusion of the male and female gametes, which results in the formation of a
zygote.
• This process usually takes place in the ampulla of the fallopian tubes.
• In humans, fertilization is completed within 20 hours.
Implantation
• The embryo remains in the fallopian for six days before reaching the uterine cavity.
• When it reaches the uterine cavity, the embryo orients itself towards the decidua and
begins to penetrate the epithelial surface by piercing its basement membrane.
Placenta Formation
• The trophoblast is characterized by its invasiveness that provides attachment to the
endometrial tissue.
• Differentiation of trophoblasts results into cytotrophoblasts and syncytiotrophoblast.
• The placenta is formed from the syncytiotrophoblast and is complete by 12 weeks.
• The foetus develops from the inner cell mass and organogenesis is almost complete by 12
weeks.
Figure 1: Summary Process of Fertilization

Source: Obstetrics by Ten Teachers (18th
Ed.)
Key
1. Fertilization
2. Division of fertilized ovum into a zygote of two cells
3. Morula with 16 – 32 cells
4. Compaction of cells and cavitation
5. The stage of blastocyst
6. Implanting blastocyst
Diagnosis of Normal Pregnancy
• The diagnosis of pregnancy can be made using three main diagnostic tools.
Symptoms of Pregnancy
• Amenorrhea during childbearing age
• Nausea and vomiting (morning sickness), especially in the first trimester
• Breast enlargement and tenderness (first trimester)
• Marked fatigue (first and third trimesters)
• Urinary frequency (first and third trimesters)
• Foetal movements
Physical Examination (Elicit Signs)
• Chadwick's sign (blue discoloration of the cervix and vagina)
• Breast changes (darkening of the areola)
• Enlarged uterus
• Palpation of foetal parts and two foetal poles
• Skin changes and discoloration
• Identification of heart beats by foetostethoscope (from 19 weeks)
Investigations
• Pregnancy tests (hCG assays in urine or serum)
• Ultrasound
Physiological Changes in Pregnancy
Haematological Changes
• Plasma volume increases by 45-50%, beginning by the sixth week-marked in the second
trimester
• RBC mass increases by 20-35%. Moderate erythroid hyperplasia in bone marrow.

• Disproportionate increase in plasma volume over RBC volume leads to haemodilution
• Despite erythrocyte production there is a physiologic fall in the haemoglobin and
haematocrit readings. (Physiological anaemia of pregnancy.)
• There is an increase in white cell count, erythrocyte sedimentation rate (ESR), and
fibrinogen concentration.
• Heart rate increases by 10-20%
• Stroke volume increases by 10%
• Cardiac output (HR X SV) increases by 30-50%
• Mean arterial blood pressure decreases by 10%
• Peripheral resistance decreases by 35%
Respiratory System
• Pco2 decreases by 15 – 20%
• Po2 increases slightly
• Oxygen availability to the placenta and tissues improves
• pH alters little
• Bicarbonate excretion increases
Renal System
• Renal blood flow increases 60 – 75%
• Glomerular filtration rate increases by 50%
• Clearances of most substances is enhanced
• Plasma creatinine, urea and urate are reduced
• Glycosuria is normal
Reproductive System
• Increased vascularity and hyperaemia in the vagina, perineum and vulva
• Increased cervical secretions
• Blue coloration of the vagina (Chadwick’s sign)
• Hypertrophy of the papillae of the vaginal mucosa
• Softening of the cervix (Hegar’s sign)
• Hypertrophy of the uterine muscles
Endocrine System
• Oestrogen and progesterone increase
• Prolactin concentration increases markedly
• Human chorionic gonadotrophin hormone is increased
• Insulin resistance develops
• Corticosteroid concentrations increase
Minor Disorders of Pregnancy
• There are some minor disorders of pregnancy of which sometimes may need attention of
medical personnel.
• These disorders include emesis gravidarum and hyperemisis gravidarum

Emesis Gravidarum
• Emesis gravidarum refers to mild to moderate nausea and vomiting during pregnancy.
• It occurs in 70-85% of all gravid women especially in early 16 weeks of pregnancy.
• It is sometimes referred to as morning sickness of pregnancy
• Usually commences during the early part of the day but passes in a few hours, although
occasionally it persists longer and may occur at other times
Hyperemesis Gravidarum
• Refers to severe and intractable form of nausea and vomiting in pregnancy, leading into
weight loss, dehydration and electrolyte imbalance
• Occurs in 0.5 - 2% of pregnancies.
• The peak incidence is 8-12 weeks and symptoms usually resolve by week 20 in all but
10% of patients.
Predisposing Factors for Hyperemesis Gravidarum
• Both aetiology and pathogenesis are unknown. No conclusive evidence implicating any
specific substance
• Appears to be associated with high or rapidly rising levels of HCG in circulation
• Predisposing factors include:
o Multiple pregnancy
o Molar pregnancy
o Familial predisposition
ƒ Sisters and daughters of women with hyperemesis have a higher incidence.
• Other medical disorders: Pre-gestational diabetes, hyperthyroidism.
Complications of Hyperemesis Gravidarum
• May affect health and well-being of both the pregnant woman (maternal) and the foetus
Maternal Complications
• Haematemesis: Mallory-Weiss tears
• Dehydration
• Malnutrition → e.g. weight loss and anaemia
• Electrolyte imbalance
o Acidosis from starvation
o Alkalosis loss of hydrochloric acid in vomitus
o Hypokalaemia
• Wernicke’s encephalopathy
o Due to vitamin B-1 deficiency
o Presents with confusion, disorientation and nystagmus for example
• Acute tubular necrosis
• Psychosocial morbidity
Foetal Complications
• Abortion - mainly due to severe form
• Prematurity
• Low birth weight
Diagnosis of Hyperemesis Gravidarum
• Diagnosis must always start with confirmation of pregnancy.

• Investigations
o Blood screen for malaria parasites
o Electrolyte levels
o Urinalysis for ketones R/O DM; cells R/O UTI
o Liver function tests - R/O hepatitis: LFTs can be slightly elevated with hyperemesis
o USS - R/O molar or multiple gestations
Management of Hyperemesis Gravidarum
• Depends on severity
o Mild-moderate form
ƒ Counselling
ƒ Encourage fluid intake between the meals
ƒ Encourage frequent small meals - high-protein snacks. Avoid fatty foods
o Severe form
ƒ Admit
ƒ IV fluids preferably RL, NS
ƒ Antiemetics: metoclopramide, promethazine, prochlorperazine or chlorpromazine
ƒ Vitamin B1 (thiamine) to prevent Wernicke encephalopathy, Pyridoxine (vitamin
B6)
Key Points
• Pregnancy is a result of fusion of the male and female gametes, which results in the
formation of a zygote, this process is call fertilization.
• The zygote changes to embryo which remains in the fallopian for six days before reaching
the uterine cavity.
• The placenta is formed from the syncytiotrophoblast and is complete by 12 weeks.
• The foetus develops from the inner cell mass. Organogenesis is almost complete by 12
weeks.
• Hyperemesis gravidarum is one of the common obstetric problems in early pregnancy.
• Hyperemesis gravidarum complications may occur in both mother and foetus.
• The management of emesis gravidarum depends on severity.
Evaluation
• What is the process of fertilization?
• What are the predisposing factors for hyperemesis gravidarum.
• What are the complications of hyperemesis gravidarum in maternal as well as foetal side?
• Explain the management of hyperemesis gravidarum.
References
Arnold.
Ed.).
McGraw Hill.
• Hanretty, K.P. (2003). Obstetrics Illustrated (6th Ed.). London: Churchill Livingstone.
Gynaecology. (8th
and Gynaecology. (2nd Ed.) Mosby.

Session 6: Management of Normal Labour 33
Session 6: Management of Normal Labour
Learning Objectives
• Define the mechanisms of labour
• Explain features of true labour
• Explain the stages of normal labour
• Describe the mechanisms of labour
• Describe the management of normal labour
Features of Normal/True and Mechanisms of Labour
Features of Normal/True Labour
• Spontaneous painful regular uterine contractions associated with effacement and
dilatation of the cervix and descent of the presenting foetal part, rupture of membranes
and show.
• Single cephalic presentation
• 37–42 weeks of gestation
• Unassisted spontaneous vaginal delivery (no vacuum, no forceps)
• Duration of 12 hours or less in nulliparous women, and eight hours or less in multiparous
women
• The process results in the delivery of the baby and other products of conception
• A labour which deviates from these key features can be described as abnormal
Mechanism of Labour
• The mechanism of labour is the series of changes in position and attitude that the foetus
undergoes to accommodate itself to and through the maternal pelvis.
• They include:
o Engagement: When the largest diameter of the presenting part has just passed the
pelvic inlet.
o Lie: The relation of the long axis of the foetus to that of the mother.
o Position: Is the relationship of the denominator to the six parts of the pelvis. The
denominator refers to reference point of the presenting part, i.e. occiput (in vertex),
sacrum (in breech), mentum (chin).
o Presentation: The portion of the body of the foetus that is foremost within the birth
canal or closest proximity to it.
o Descent: Progressive movement of the presenting foetal part into the maternal pelvis.
Description of Stages of Labour
• There are three stages of labour.
First Stage
• Commences with the onset of labour and terminates when the cervix has reached full
dilatation (i.e. 10 cm).
• There are two phases of first stage of labour:
o Latent phase: The cervical canal shortens (effaces) and dilates to 3cm.

o The duration is usually variable.
o Active phase: The cervix dilates from 3 cm to full dilatation.
o The average duration in primigravida is eight to ten hours, and multipara is six to
eight hours.
Second Stage
• Begins at full dilatation and ends with the delivery of the baby.
• Normally this stage should not exceed one hour.
Third Stage
• Begins after delivery of the baby and ends with the delivery of the placenta and
membranes.
• The length of this stage is usually within ten minutes of birth; however, up to 30 minutes
is considered normal.
Mechanism of Normal Labour
• The process involves engagement, descent, flexion, internal rotation, extension,
restitution and external rotation.
• Knowledge of the mechanisms of labour gives us the ability to evaluate the progress of
the foetus through the maternal pelvis.
• The mechanism of labour is the series of passive movements of the foetus as it passes
through the birth canal.
o Descent: Descent takes place throughout labour.
o Flexion: Bending forward.
o The chin is brought into contact with foetal thorax and these changes the presenting
diameter from occipital-frontal to sub-occipital bregmatic diameter 9.5cm.
o Internal Rotation of the Head: The occiput gradually rotates 1/8 of the circle towards
the symphysis when it reaches the pelvic floor.
o Crowning: The occiput slip beneath the sub-pubic arch and crowning occurs-the
widest transverse diameter (biparietal) is born.
o Extension of the Head: The sinciput, face and chin sweep the perineum and the head
is born in the movement of extension.
o Restitution: The occiput turns 1/8 of the circle towards the side from which it started.
o Internal Rotation of the Shoulder: When the shoulder reaches the pelvic floor, the
anterior shoulder rotates 1/8 of the circle towards the symphysis pubis.
o External Rotation of the Head: The occiput turn further as the shoulders rotates thus
making the occiput of the foetal head now lies laterally.
o Lateral Flexion: The anterior shoulder escape under the symphysis pubis and posterior
shoulder pass over the perineum.
o The remainder of the body is born by lateral flexion.
Activity: Demonstration
Instructions
Refer to Worksheet 6.1: Mechanism of Normal Labour.
Tutor will demonstrate the mechanisms of normal labour using the foetus and pelvic model in
front of the class. Make sure you can see/hear the demonstration.

Management of Labour
• Management of labour includes monitoring of the progress of labour.
• The progress of labour is monitored using a partogram.
• The partogram is a graph used during labour to monitor the parameters for labour
progress, maternal and foetal wellbeing, and drugs/treatment given during labour.
• It can help birth attendants determine when an intervention is necessary.
Importance of using a Partogram in Labour
• The partogram is an important tool during labour and delivery.
o Offers an objective basis for monitoring the progress of labour, and of maternal and
foetal wellbeing over time.
o Enables early detection of abnormalities during labour, and assists providers in
knowing when to take appropriate and timely action.
o Has proved to be extremely useful in reducing maternal complications from
prolonged labour (postpartum haemorrhage, sepsis, uterine rupture, etc.) and perinatal
complications (death, anoxia, infections, etc.).
Use of the Partograph in Decision Making
• In basic health facilities:
o Used to monitor labour which is expected to be normal
o Those patients with risk factors should already have been referred prior to onset of
labour.
o Referral is decided when the progress line of the cervical dilatation deviates to the
right of an alert line.
o Management of labour between alert and action lines (referral zone)
ƒ Transfer the woman to hospital unless the cervix is almost fully dilated
ƒ ARM may be performed if membranes are still intact and first stage of labour is
advanced and delivery is expected soon.
• In health facilities with comprehensive emergency obstetric care (EmOC):
o Used to monitor both high and low risk labour
o Management of labour between alert and action lines (referral zone)
ƒ Perform ARM at vaginal examination
ƒ Continue routine monitoring
ƒ Repeat vaginal examination four hours or earlier if delivery is expected sooner
o Do not intervene or augment – unless complications develop
• Parameters to be plotted in a partograph:
o The key parameters include:
ƒ Maternal information: gravidity, parity and age
ƒ The rate of cervical dilatation
ƒ Frequency and strength of uterine contraction
ƒ The descent of the head in fifth palpable
ƒ The amount and colour of the amniotic fluid
ƒ Foetal heart rate
ƒ Moulding
ƒ Basic observation of maternal wellbeing such as PR, BP, temperature, urine for
(acetone, protein, volume)
• Key parameters plotted in a partogram

Parameter
Ideal in both
phases (hrs)
Minimum acceptable
Latent phase Active phase
Foetal heart rate ½ 4 1
Liquor 4 8 4
Moulding 4 8 4
Dilatation of the cervix 4 8 4
Descent of head 4 8 4
Contractions ½ 4 2
Drugs and IV fluids given 1 1 1
PR, BP ½ 4 4
Temperature 1 4 4
Urine (acetone, protein, volume) 1 4 4
Activity: Small Group Exercise
Instructions
You will practice how to record progress of labour on a partograph.
REFER to Worksheet 6. 2: Recording Progress of Labour on a Partograph.
Read the instructions for activity on the worksheet. You will briefly present your responses
to the class.
Management during First Stage of Labour
• Latent phase: Observation and reassurance
• Active phase: Start the partograph and monitor the progress of labour using parameters
indicated on the partogram.
Management during Second Stage of Labour
• Continue monitoring labour, prepare delivery kit, oxytocics then deliver the baby.
Management during the Third Stage of Labour
• Active management of third stage (controlled cord traction) to reduce blood loss
• Oxytocin 10 IU IM or Ergometrine 0.5mg im, given within one minute after delivery of
the baby.
• Massage of the uterus every 15 minutes for two hours if you find the uterus is flabby (not
contracted) to prevent post-partum haemorrhage.
• Make sure the woman is left clean and comfortable
Immediate Care of the Baby
• Make sure the baby breathes normal, that is has cried during delivery
• Observe at the cord stump to make sure is well tied and there is no bleeding
• Cover the baby well and give the baby to the mother immediately to be latched on breast
for breastfeeding.

Key Points
• Features of normal labour include:
o Spontaneous onset
o Single cephalic presentation
o 37–42 weeks of gestation
o Unassisted spontaneous vaginal delivery (no vacuum, no forceps)
o Duration of 12 hours or less in nulliparous women, and eight hours or less in
multiparous women
• A labour which deviates from these key features can be described as abnormal.
• The primary objective of using a partogram is to detect abnormalities during labour, and
to reduce maternal and perinatal mortality and morbidity.
• The partogram should be used in all labour wards, and with every patient in labour.
Evaluation
• What are the mechanisms of a normal labour?
• What is a partograph?
• What is the importance of using a partograph?
• What parameters are tracked in the partogram?
References
Arnold.
Ed.).
McGraw Hill.
Gynaecology. (8th
Ed.) Mosby.
• MOHSW. (2005). Advanced Life Saving Skills Trainee Manual, Volume 2. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare.
• WHO. (2005). Managing Complications in Pregnancy and Childbirth: A Guide for
Midwives and Doctors. Geneva: World Health Organization.

Worksheet 6.1: Mechanism of Normal Labour

Worksheet 6.2: Recording Progress of Labour on a Partogram
Instructions
The table below represents the progress of labour of Mrs. Hadija Jumbe, a primigravida,
admitted at your local labour ward at 0600 hours. She was assessed several times.
Time (hours)
Cervical
Dilatation (cm)
Descent FHR Liquor Status
0600 2 5/5 144 Intact
1000 4 4/5 140 Intact
1400 7 3/5 132 Ruptured – clear
1800 10 1/5 140 Clear
Plot these results on the partograph in the next page.

Session 7: Normal Puerperium and Postpartum Care 41
Session 7: Normal Puerperium and Postpartum
Care
Learning Objectives
• Define terms puerperium and postpartum
• Describe the physiological changes following delivery
• Describe the importance of postpartum (puerperium) care
• Describe postpartum (puerperium) care
• Describe postpartum follow-up visits
Definition of Puerperium and Postpartum
• Puerperium: The interval between delivery and six weeks post delivery. It involves
reversal of the changes of pregnancy into a pre-pregnancy state.
• Postpartum Period: The time between expulsion of the placenta and membranes to 42
days (six weeks) after delivery. This period is critical for the mother and the newborn.
Physiological Changes in Puerperium
• Uterine Involution
o The fundus is palpable 10-12cm above the symphysis pubis within 24 hours after
delivery.
o In seven days it is reduced by 50% in size, abdominally impalpable by day 10 – 14.
Thus the height of the fundus reduces by approximately 1cm per day.
o The internal cervical os closes two to three weeks after delivery.
• Placental Site and Lochia
o Placental site repair requires six weeks.
o This is accompanied by shedding of the decidual debris and necrotic material known
as lochia.
ƒ Normal lochia, is on average, red for four days (lochia rubra), pink for four days
(lochia alba), and serous for four days (lochia serosa).
• Urinary Tract
o Bladder during puerperal has an increased capacity and is relatively insensitive to
intravesical fluid pressure.
o Overdistention, incomplete emptying, and excessive residual urine are common.
o About 10% of women experience urinary incontinence.
• Reversal Hormonal Changes
o Progesterone and oestrogen return to the pre-pregnant levels within 72 hours.
• Breasts
o Lactation is initiated mainly under the influence of prolactin and human placental
lactogen.
o The first milk produced is deep lemon-yellow coloured liquid known as colostrum.
o It is rich in high concentrations of protein with less sugar and fat than subsequent
breast milk.
o The proteins are mainly in the form immunoglobulins (Ig) A which are important for
protection of the newborn against infection.
• Bowel Function
o Constipation is common in first three to four days of puerperium.

• Weight Loss
o An average weight gain during pregnancy is 12.5kg. Delivery reduces weight by 6 kg.
Importance of Postpartum Care
Postpartum Care
• Is a set of activities such as observation, treatment, counselling, and advice provided
during the postpartum period that can prevent, identify, and treat complications that may
arise for the mother or baby.
Importance of Postpartum Care
• Postpartum Care is crucial for both mother and newborn
• Ensure that any complications arising from the delivery are detected and treated
• Mothers are provided with important information on how to care for themselves and their
newborn.
Care of the Mother and Baby during the Puerperium (Postpartum Care)
Postpartum Examination
• Immediately after delivery, the woman is still in great danger of getting serious
complications like haemorrhage and eclampsia; therefore close monitoring during this
period is important.
• The health care provider should conduct postpartum examinations as follows:
o Examination of the mother
ƒ Check vital signs: Blood pressure, pulse rate, and respiration rate hourly in the
first six hours, then every four hours. Check temperature every 12 hours.
ƒ Check for pallor (palms, tongue and conjunctiva) to rule out anaemia.
ƒ Abdominal palpation hourly in the first six hours, then every four hours to make
sure the uterus is well contracted and feels firm. Instruct the mother to observe
and report excessive vaginal bleeding.
ƒ Inspect the genitalia for perineum for oedema, lacerations, or/and episiotomy
immediately after delivery
ƒ In case of delivery by Caesarean section, check wound for bleeding.
o Examination of the baby
ƒ Check for colour (palms, tongue and conjunctiva) to rule out cyanosis
ƒ Check the umbilical cord for any abnormality (such as bleeding)
ƒ Look for the movement activity
ƒ Asses for primary reflexes
ƒ Ensure that the mother is able to breastfeed the baby correctly
ƒ Check, document and take action for any congenital malformations
• Care of the mother involves monitoring of normal changes, detection and treatment of
problems, facilitation of infant feeding and provision of emotional support.
• Advise on:
o Perineal hygiene
o Exercise abdominal muscles
o Pelvic floor exercises
o Diet containing high protein and adequate fluid intake

o Contraception
o Child feeding options
o Psychological changes (depression, etc.)
Postpartum Follow-Up Visits
• Postnatal Care (PNC) follow-up visits should be scheduled at the following intervals to
monitor the mother and baby’s condition:
o 7 days after delivery
Postnatal Visits for the Mother
At every visit, do the following:
• Check vital signs. BP, Temperature, respiratory rate, and pulse rate
• Take thorough history:
o Ask about breastfeeding
o Check for bladder and bowel action
ƒ Ask for any abnormal conditions/problems
o Ask and examine the breasts
• Perform thorough physical examination
o Assessment of the baby to identify problems
o Check baby’s weight and assess growth
o Observation of breastfeeding, or alternative feeding
o Counsel and advise the mother and family on baby care and danger signs
o Counsel and advise the mother on family planning
o Vaccinate the baby according to national immunization schedules
o Manage any problems appropriately
Refer to Handout 7.1: Postpartum Follow-Up Visits.
Common Postpartum Conditions
Mother
• Excessive vaginal bleeding
• Severe pain in the genitalia
• Fever
• Headache
• Convulsions/fits
• Abdominal pain
• Foul smelling lochia/vaginal discharge
• Pain in the calf muscles
• Emotional/psychological changes and/or abnormal behaviour (depression, psychosis)
• Pallor (palms, tongue and conjunctiva)
• Painful, engorged breasts
Baby
• Convulsion/fits
• Difficulty breathing

SM CMT 05104 obstetrics and gynaecology I

SM CMT 05104 obstetrics and gynaecology I

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