The outlet of the pelvis is filled with soft tissue, and the strong diaphragm of muscle is the most important. The main function of the pelvic floor is to support the weight of the pelvic and abdominal organs, afford voluntary control over micturition, defecation, and flatulation, diminish the size of the vagina, and cause engorgement of the clitoris during intercourse.
It also influences movement of the fetus during the second stage of labour. The pelvic consists of two layers of muscle: a superficial layer which is smaller than the deep layer. Both combined contribute to the overall strength of the pelvic floor and are likely to become damaged during vaginal delivery.
Bulbocavernosus: This muscle arises from the perineum, passes around the vagina, and embeds in the clitoris. Its function is to cause erection of the clitoris and contraction of the vagina during intercourse.
Ischiocavernosus: This muscle extends from the ischial tuberosities to the clitoris. Its function contributes to the formation of the urethral sphincter and does not become damaged during childbirth.
Transverse perineal muscle: This muscle extends from the ischial tuberosities to the perineum, and the fibres also intermingle with the perineal body and the anal sphincter. Its function provides additional support, however, it will always become damaged during childbirth.
External anal sphincter: This muscle surrounds the anal opening and attaches to the coccyx. Its function is to close the lumen of the anus and prevent fecal incontinence. The deep muscle layer is comprised of three pairs of muscles which are known as the levator ani muscles.
Pubococcygeus muscle extends from the pubic bone surrounding the urethra, vagina, and rectum attaches to the coccyx. Its function supports the lower third of the vagina and rectum, controls the flow of urine, controls defecation, contracts during orgasm, and aids childbirth.
Iliococcygeus muscle extends from the inner aspect of the iliac bone, meets in the perineum, and extends to the coccyx. Its function provides support.
Ischiococcygeus muscle is a triangular sheet of muscle that arises from the ischial spines and passes to the lower sacrum and upper coccyx. Its function stabilizes and supports the sacroiliac joint and sacrococcygeal joint. Damage to the PFM will undermine its overall function. Damage to the PF is classified according to structures involved. CM to advise mom at antenatal clinic of pelvic floor exercises and perineal massage to minimize trauma. Also, to prevent incontinence, prolapse of the pelvic floor, and make birth easier.
The function of the uterus is to prepare monthly to receive a fertilized ovum. The uterus then acts as a shelter for the fetus during pregnancy, providing a suitable environment for growth and development of the fetus. The uterus also assists in the expulsion of the fetus, placenta, and membranes at delivery, followed by the uterus returning to its non-pregnant state. The uterus grows in all dimensions and changes shape. Usually, the blastocyst implants itself in the fundus (upper part) of the uterus. Size increases to 30x23x20 at term. Extra growth results in the uterus walls thickening.
Layers: The uterus has three layers: the endometrium, myometrium, and perimetrium. The endometrium is the lining of the uterus, and it is constantly changing in thickness throughout the menstrual cycle. During pregnancy, the endometrium thickens into the decidua, helped by progesterone and estrogen, and provides the nourishment for the blastocyst.
Progesterone relaxes smooth muscle, allowing the uterus to stretch. Approximately 10 ml/min of blood is passed through the uterus. The blood supply is from the ovarian and uterine arteries. During the first 10 weeks, the isthmus lengthens and later forms the lower segment. By 12 weeks, the fetus has filled the cavity, and the fundus may just be palpated at the pelvic brim. By week 30, the uterus is pear-shaped, with upper and lower segments. At 36 weeks, it is at the xiphisternum level. Pelvic floor muscles soften, and the lower segment encourages the descent of the presenting part into the pelvis. The uterus can weigh up to 900 grams at term, and blood flow increases to 600-800 ml/min.
Nice guidelines (2008) state that the routine care that all healthy women can expect to receive during pregnancy. During an antenatal visit, always introduce yourself, communicate effectively, and listen to the woman. Firstly, ascertain the woman’s well-being and always review her history before commencing any observations. During the 28-week check, primarily start with normal observations: BP is taken to ascertain normality and rule out any abnormalities such as pre-eclampsia. Urinalysis is tested for proteinuria to check for signs of pre-eclampsia, infections, and dehydration.
Discuss fetal movements with the woman. Has she experienced the baby’s pattern of movements? If so, advise her to contact the CM of any change in pattern, reassuring the mother at the same time. Abdominal examination: always gain verbal consent, primarily measure fundal height, which is commenced from around 26-28 weeks gestation and taken every 2-3 weeks (preferably by the same midwife), as it is the best first line of assessment. It is taken with a tape from the fundus (top of the uterus) to the top of the symphysis pubis and documented on the woman’s personal growth chart.
Liquor: a gentle examination of the abdomen can give an idea of whether the amount is about right. Record longitudinal, oblique transverse, and which part it presents. NAD. Lie presentation at 28 weeks may be able to be determined, but too early to be definite. The same goes for engagement; however, always document any findings. Secondary bloods are taken at 28 weeks. Offer a repeat hemoglobin level, and if it is below 10.5 g/dl, then consider iron supplementation. Repeat screening for anemia and atypical red-cell antibodies. Also, if the woman is Rh negative, offer Anti-D.
Exchange information and review the care plan. Document and book the next appointment for the 32-week check. The definition of birth is the expulsion of the fetus. It begins when the cervix is fully dilated and is complete when the baby is completely born. NICE guidelines state that healthy women who are giving birth at 37-42 weeks (term) have an active phase in which the baby is visible. Maternal effort is on full dilatation of the cervix without expulsive contractions. Contractions become strong and last about 1 minute. External signs of progress, such as vaginal discharge, show (red blood), and the fundus moves down with contraction on palpation.
Descent of the presenting part is well-engaged and rotated for birth at ischial spines. Maternal signs include being unable to talk, focusing on breathing techniques, slowing down with each contraction, making grunting sounds and cries with expiration. Her mood becomes more focused on herself and withdrawn, with energy withdrawn.
Environment: ensure privacy,room is equipped wbirthing ball, stool facilitate movement&change of position,encourage women to mobilize as much as possible as gravity helps the birthing process.
Every 30 minutes, document the frequency of contractions, hourly check BP and pulse, offer water every 4 hours, and check the temperature regularly. Regularly check if the bladder is empty as a full bladder can impede the baby’s progress down the birth canal. Assess the progress of fetal position and station. If there is no urge to push when fully dilated, assess after 1 hour. Offer water and pain relief and provide support and encouragement.
Physiology: membranes may rupture at this stage, allowing the firm pressure of the presenting part to stretch the tissue. The liquor also warms, cleanses, and moisturizes the vagina. Pressure from the presenting part stimulates the nerve receptors in the pelvic floor, causing the urge to push. The mother naturally contracts her abdominal muscles and uses her diaphragm to exert downwards pressure.
The bladder is drawn up into the abdomen to minimize trauma. The rectum is squashed back into the sacral curve, often expelling fecal matter. The perineal body is flattened, stretched, and thinned, allowing the head (presenting part) to advance until crowning takes place.
The placenta and membranes should be carefully examined by the midwife soon after delivery so that if incomplete, immediate action can commence. The examination is to detect normality and any abnormalities that may suggest any problems in the neonate. Primarily, the placenta is checked for two membranes: the chorion, the outer membrane that lines the uterine cavity, and the amnion, the inner membrane that secretes amniotic fluid or liquor.
Membranes can be ragged and must be pierced to ensure completeness. A hole where the baby has passed through may be seen. The placenta, rounded in shape, is examined; the maternal surface is a large surface area made for active and passive transport of nutrients and gases. The area is cleared of any blood clots and examined to ensure all cotyledons (15-20) are present.
The placenta should be smooth to touch. If gritty, this would signify that the mother smoked during pregnancy. The color should be of a rich red color. The fetal surface should be shiny and covered in amniotic membranes. The placenta edge is examined for blood vessels running into the membranes.
Secondary: the cord, twisted to increase strength, is examined, noting its insertion (should be central), any true knots, which can reduce blood flow to the fetus, and the number of vessels: two arteries and one vein, which are protected by Wharton’s jelly. After birth, vessels constrict, and blood starts to clot. The placenta is usually weighed, and at term should weigh at least 1/6 of the baby’s birth weight.
Finally, any blood loss is measured and added to the estimated loss soaked into pads. Findings should be documented in the mother’s notes, and any referrals needed should be made immediately to the doctor if concerns of any tissue that has been retained. From the birth of the baby to the delivery of the placenta and membranes and the control of bleeding could also add to perineal repair.
This lasts anything from 1-60 minutes. The reaction of the uterine muscles begins with the contraction that delivers the baby’s body. Contraction and retraction continue, and there is also a reduction in the size of the uterus and placenta site shrinks. When this occurs, the placenta becomes compressed.
However, if the cord is not clamped, some transfer of fetal blood is forced from the placenta to the baby. Uterine walls thicken further, causing the placenta to come away. There are two ways in which the placenta is expelled. Schultze is where the fetal surface appears first with membranes trailing and blood loss will be encased in the membrains.
Matthew Duncan is where the placenta slips from the vagina sideways and maternal surface appears first. This is associated with slower separation. To control bleeding, the uterus must fully contract. Contraction and retraction continue, and living ligatures constrict torn blood vessels. Management: Physiological: use no oxytocic drugs. Women adapt position with cord left intact and placenta expelled by maternal effort and contraction. Active: oxytocic drug IM, early clamping of cord, controlled cord traction, skin-skin, immediate breast feeding releases natural hormone oxytocin which can help the process.
Delivery of placenta: guard uterus, control cord traction downward motion. When the placenta is visible, apply upward motion and deliver placenta into a bowl, and carefully deliver membranes. Check and document.
Jaundice that requires treatment around day 3 to day 7 is a common condition in newborns. Jaundice refers to the yellow color of the skin and whites of the eyes caused by excess bilirubin in the blood. Bilirubin is produced by the normal breakdown of RBCs. Bilirubin passes through the liver and is excreted as bile through the intestines. Jaundice occurs when bilirubin builds up faster than the liver can break it down and pass it from the body.
This is because newborns make more bilirubin than adults. Adults last 120 days, whereas fetal lasts 80. The liver is still developing and, therefore, unable to remove enough bilirubin from the blood and unable to change bilirubin from fat-soluble to water-soluble. Occurring in most newborns, this mild jaundice is due to immaturity of the baby’s liver. Generally appears at around 2 days and usually fades within 1-2 weeks. Plenty of feeds and light therapy can help clear the condition and break down RBCs and be excreted via urine and feces.
Blood pressure (BP) should be checked to detect pregnancy-induced hypertension/pre-eclampsia. BP may cause severe headaches or flashing lights. Advice the lady to inform the midwife/dry immediately. Urine. Midstream urine sample checked for leukocytes, which is a sign of infection, dehydration, or protein, a sign of pre-eclampsia.
Fetal movement should be explained. FHHR 110-160. Palpate lie/pres longitudinal, oblique, transverse, and which part presents towards the birth canal cephalic/breech. Engaged presenting part is measured by the proportion that can still be felt through the abdomen. Also, birth preferences, where, who, length of stay, what to take, students, signs of labor contractions 3:10 lasting 60-70 seconds, water breaking.
Methods inducing 42w+ y! assessment during labor mom/baby posture, labor/birth pain relief, Entonox, peth up to 7cm epidural. C-section. Assisted delivery, forceps, vacuum, perineum tear, 3rd stage physiological maternal up to an hour, active Syntocinon injection to minimize bleeding. Vit K to prevent bleeding disorder, IM/3 drops.
Initial examination is a screening tool and should be undertaken by the midwife. This is to confirm normality as well as any abnormalities, identify any problems that may need a referral. APGAR score should be commenced at 1 minute and 5 minutes after birth, which is primarily used for the decision to resuscitate a neonate. HR absent 0r slow.