Introduction to Midwifery

History of Midwifery The history of midwifery is a long and interesting one. Women of all countries have done noble work as midwives throughout the countries. Socrates mother was a midwife and he considered it a most respected profession. According to Aristotle, a midwife is a most necessary and honourable office, being a helper of nature. idwife carries a huge responsibility in helping women during childbirth. !iblical references to midwives have always been to their honour. There are instances in the "ld Testament to show that midwives play vital role. #ntil the end of the si$teenth century, midwifery was practiced entirely by women. en could be severely punished for attending women in childbirth. %n the seventeenth century male midwives began to take up midwifery. !y the middle of the eighteenth century the number of male midwives had increased, though there was great opposition and competition from the midwives and from the general public. %n &nglish the word midwife means With woman 'the person with the woman who is in labour(. idwives hold an important key to positive care at the time of childbirth that will contribute to a good start for the baby and parents. The midwife is able to do so only by virtue of her e$pert knowledge. The education of the midwife is designed to enable her to fulfill her wide and varied role. )uring the last *+ years of the nineteenth century, several hospitals began to train midwives and to issue certificates. %n ,-.* idwives Act in #nited /ingdom entitled an act to secure better training and supervision of midwives. Terminology

Midwifery is the knowledge necessary to perform the duties of midwife. Obstetrics is that branch of medicine, which deals with the management of pregnancy, labour and puerperium. Gynaecology is that branch of medical science, which treats diseases of the female genital organs. Reproduction means process by which a fully developed offspring of its kind is produced. Pregnancy is a state of carrying fetus inside the uterus by a woman from conception to birth. Gestation means pregnancy. Gravidae is state of pregnancy irrespective of its duration. Multipara refers to woman who has given birth more than once Nullipara is the woman who has not given birth before. Primigravidae is a woman carrying first pregnancy. Multigravidae is a woman carrying pregnancy more than once.

Maternal and C ild Healt Indicators !irth rate0 The number of births per ,,... population. 1ertility rate0 The number of pregnancies per ,,... women of childbearing age. 1etal death rate0 The number of fetal deaths 'over +.. g( per ,,... live births. 2eonatal death rate0 The number of deaths per ,,... live births occurring at birth or in the first *3 days of life. 4erinatal death rate0 The number of deaths of fetuses more than +.. g and in the first *3 days of life per ,,... live births. aternal ortality 5ate0 The number of maternal deaths per ,..,... live births that occur as a direct result of the reproductive process. %nfant ortality 5ate0 The number of deaths per ,,... live births occurring at birth or in the first ,* months of life.

6hildhood ortality 5ate0 The number of deaths per ,,... population in children, , to ,7 years of age.

T"RMINO#OG$ %&"! IN MI!'I("R$

Gestation:pregnancy or maternal condition of having a "mbryo:human

Role of Nurse in Midwifery !efinition of Midwife %n ,--*, The World 8ealth "rgani9ation defined that : A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recogni9ed in the country in which it is located, has successfully completed the prescribed courses or studies in midwifery and has ac;uired the re;uisite ;ualifications to be registered and or legally licensed to practise midwifery. Roles of Midwife The midwife has a uni;ue role in care of mothers and babies. To give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period. To conduct deliveries on her own responsibility and to care for the mother and the newborn. To promote normal birth and detect complications in mother and child, access to medical or other appropriate assistance and the carry out emergency measures. To involve in health counselling and education, not only for the woman, but also within the family and community. To involve antenatal education and preparation for parenthood. To promote women<s health, se$ual or reproductive health and childcare.

developing fetus in the body. conceptus up to the ,.th week of gestation '3th week postconception(. (etus:human conceptus from ,.th week of gestation '3th week postconception( until delivery. )iability:capability of living, usually accepted as *7 weeks, although survival is rare. Gravida *G+:woman who is or has been pregnant, regardless of pregnancy outcome. Nulligravida:woman who is not now and never has been pregnant. Primigravida:woman pregnant for the first time. Multigravida:woman who has been pregnant more than once. Para *P+,refers to past pregnancies that have reached viability. Nullipara:woman who has never completed a pregnancy to the period of viability. The woman may or may not have e$perienced an abortion. Primipara:woman who has completed one pregnancy to the period of viability regardless of the number of infants delivered and regardless of the infant being live or stillborn. Multipara:woman who has completed two or more pregnancies to the stage of viability. #iving c ildren:refers to the number of living children a woman has delivered regardless of whether they were live births or stillborn births. GP#-M %n some institutions, a woman<s obstetric history can also be summari9ed as =4>A . =:represents gravida. 4:represents preterm deliveries, *. to less than ?@ completed weeks. >:represents the number of children living. %f a child has died, further e$planation is needed for clarification.

A:represents abortions, elective or spontaneous loss of a pregnancy before the period of viability. :represents the number of ultiple pregnancyA edical Termination of 4regnancy done. A woman who delivered one fetus carried to the period of viability and who is pregnant again is described as =ravida *, 4ara ,. A woman with two pregnancies ending in abortions and no viable children is =ravida *, 4ara .. A woman who is pregnant for the first time is a primigravida and is described as =ravida , 4ara . 'or =,4.(.

by closely monitoring the cost of personnel, use and brands of supplies, length of hospital stays, number of procedures carried out, and number of referrals re;uested. "0panded roles for nurses %ncreasing nursing responsibility for assessment and professional Budgment and providing e$panded roles for nurse practitioners, such as the nurse:midwife. (amily Centered Care ore natural childbirth environment where partners, family members may remain in a homelike environment, and participate in the childbirth e$perience !y adopting a view of pregnancy, childbirth as a family event, nurses can be instrumental in including family members in care and consult family members about a plan of care and provide clear health teaching so that family members can monitor their own care -ccess to Healt Care Strong predictors of access to ;uality health care include having health insurance, a higher income level, and a regular primary care provider or other source of ongoing health care. #se of clinical preventive services, such as early prenatal care, can serve as indicators of access to ;uality health care services. The obBectives selected to measure progress in this area are0 %ncrease the proportion of persons with health insurance. %ncrease the proportion of persons who have a specific source of ongoing care. %ncrease the proportion of pregnant women who begin prenatal care in the first trimester of pregnancy & ortening Hospital &tays Women who have begun preterm labor stay in the hospital while labor is halted and then are allowed to return home on medication with continued monitoring.

TR"N!& IN TH" MI!'I("R$ -N! O.&T"TRIC-# N%R&ING C anges in social structure/ variations in family lifestyle %t has altered health care priorities for maternal and child health nurses. Today, client advocacy, an increased focus on health education, and new nursing roles are ways in which nurses have adapted to these changes. Cost Containment 6ost containment refers to systems of health care delivery that focus on reducing the cost of health care

5outine hospital stay for mothers and newborns after an uncomplicated birth is now * days or less. Short:term hospital stays re;uire intensive health teaching by the nursing staff and follow:up by home care or community health nurses.

Increased %se of -lternative Treatment Modalities There is a growing tendency to consult alternative forms of therapy, such as acupuncture or therapeutic touch, in addition to, or instead of, traditional health care providers. 2urses have an increasing obligation to be aware of complementary or alternative therapies. Increased %se of Tec nology The field of assisted reproduction 'e.g., in vitro fertili9ation(, seeking information on the %nternet, and monitoring fetal heart rates by )oppler ultra sonography are other e$amples. %n addition to learning these technologies, maternal and child health nurses must be able to e$plain their use and their advantages to clients. "therwise, clients may find new technologies more frightening than helpful to them.

C.W. !allantyne : originated concept of prenatal care 4reconception and prenatal care are forms of primary care and prevention "pportunities e$ist in many settings Should target all women of reproductive age &ducation and preparation are key Worldwide maternal mortality approaches one million women annually 5isk of maternal death in the is , in ,.,... live births #nintended pregnancy rate approaches 7.D annually

COMPON"NT& O( PR"CONC"PTION C-R" 5isk assessment &ducation %ntervention or modification 6ounseling GO-#& O( PR"CONC"PTION C-R" To identify pre:e$isting conditions that may affect an anticipated pregnancy This may allow for intervention's( that could lead to more favorable outcome =oal should be realistic %dentification process involves mother and fetus CONTR-C"PTION =ood preconception care begins with appropriate contraceptionEE Should be addressed at each visit, including primary care visits, emergency room visits, and well woman appointments Should be appropriate as regards patientFs lifestyle and medical condition M-T"RN-# RI&1 -&&"&&M"NT 1amily and genetic history 'maternal and paternal( edical history edication use &nvironmental e$posures 'home and work( "bstetric and reproductive history )omestic abuse

PR",CONC"PTION C-R" -N! CO%N&"#ING INTRO!%CTION 6oncept of preconception care has evolved over the last several decades

&motional preparedness %nfectious disease 8%G %mmuni9ation history Se$ually transmitted diseases

R"PRO!%CTI)" HI&TOR$ 6onditions with recurrence risk0 4remature delivery 4reeclampsiaAeclampsia 4lacenta previaAabruption =estational diabetes 4reterm premature rupture of membranes 6ertain birth defectsAgenetic disorders 4rior uterine surgery or anomalies =ood time to discuss trial of labor 4rior pregnancy losses 8abitual abortion ust also deal with associated emotional issues (-MI#$ HI&TOR$ 6oagulation disorders ental retardation "ther conditions 'congenital adrenal hyperplasia, neurofibromatosis, inborn errors of metabolism( -nueploidy Ris2 5isk of any type of aneuploidy increases with maternal age "ffer genetics consultation %mportant to obtain family pedigree 5isk increases with increasing maternal age 5isk of Trisomy *, at age ?+ is ,A?@3 and that of all aneuploidy is ,A,-* 5isk increases to ,A?. and ,A*, respectively, at age 7+ 5isk with increased paternal age probably small RI&1 -&&"&&M"NT , M"!IC-# HI&TOR$ 4ossible effects of pregnancy on disease 4ossible effects of disease on pregnancy, mother and fetus &valuate for any possible interventions

Assess for possibility of teratogenic effects of medications &valuate for presence of microvascular disease and level of glucose control 1re;uency of malformations H:,. D 4ericonceptual control can significantly decrease malformation rate 8emoglobin A,6 crude marker of glucose controlA I Association with anomaly rate 8ypertension : assess for microvascular disease, severity, underlying etiology 8yperthyroidism 8ypothyroidism 4revious treatment for cancer 8istory of organ transplantation

RI&1 -&&"&&M"NT , M"!IC-# HI&TOR$ 6onnective tissue disorders %nflammatory bowel disease Asthma 2eurological and psychiatric disorders &P"CI-# RI&1& 4rimary 4ulmonary 8ypertension 6hronic 5enal )isease 6omplicated coarctation of the aorta Sever mitral or aortic stenosis Gasculitis syndromes RI&1 -&&"&&M"NT , IMM%NI3-TION& 5ubella : should wait ? months before conceiving 8epatitis ! Tetanus antou$ skin test %nfluen9a, pneumova$ as indicated Garicella RI&1 -&&"&&M"NT , &T!4& Assess for high risk behaviors and counsel appropriately

8%G : treatment can decrease transmission to fetus from ?.D to 3D =onorrhea 6hlamydia Trichomonas !acterial Gaginosis : presence associated with increased risk of premature labor and delivery =roup ! beta streptococcus : I 84G : human papillomavirusA4A4Apossible colposcopy in select casesAneonatal infection possible 8SG : as indicated congenital syphilis can occur at any stage of maternal disease To$oplasmosis : cat owners or if handle raw meat 6ytomegalovirus

%ncidence of abuse increases during pregnancy 4hysicians do a poor Bob of screening >ook for0 vague complaintsJ substance abuseJ insomniaJ inBuries to central body areasJ multiple &5 visits )evelop emergency planAreferral numbers

&OCI-# HI&TOR$ %llicit substance use and abuse maBor public health problem Alcohol ost common preventable cause of mental retardation 2o proven safe level of ingestion Tobacco use Associated with numerous pregnancy complications "ne of most common preventable cause of fetal growth restriction %ncreased risk of other health problems %llicit drug use #sually associated with other high risk behaviors 4ossible teratogen %ncreased pregnancy complications Associated with sudden death, infarction, hypertension 4rescription drug dependency &valuate for life stressors that may predispose to substance abuse &ncourage counseling and rehabilitation prior to pregnancy ay have co:e$isting psychological disorders Seen in all social classes !OM"&TIC )IO#"NC"

T"R-TOG"N& &valuate home environment Work e$posure 'plastics, vinyl monomers, heavy metals, viral agents( edication or drug use Alcohol : fetal alcohol syndrome A6& : inhibitors : fetal renal dysfunction 6oumarin derivatives : effects seen in up to *+D e$posed Tegretol : craniofacial abnormalitiesJ limb defectsJ growth and mental retardation )ilantin : fetal hydantoin syndrome Galproic acid : neural tube defects ',:*D( >ithium K congenital anomaly Tetracycline : deposition in fetal long bones Gitamin A derivatives : associated with numerous severe defectsJ L:5aysAradioactive isotopes )&S : reproductive tract abnormalities 1olic acid antagonists Thalidomide : limb defects Should consult specialist, poison control center or teratogen centers Some medications have different safety periods between cessation and conception N%TRITION-# -&&"&&M"NT Assess optimal nutritional needs 5isk factors >ow income Substance abuse 1ad dietingAvegans )epressionAmental illness

=astrointestinal disease 6hronic disorders ust also assess for e$istence of eating disorders 1olic acid supplementation beginning one month prior to conception can greatly reduce incidence of neural tube defects #tili9e nutritionist for full evaluation "besity Adolescence 4re:e$isting conditions : iron deficiency anemia, hyperlipidemia &valuate e$ercise regimen (IN-NCI-# -N! "MOTION-# CONC"RN& 6ouples should be aware of maternity coverage provided by their insurance >eave benefits Stress importance of good family support ay consult social services &motional issues addressed

P ysiology of Reproduction
(unction of t e female reproductive system5 At puberty the ova begins to mature. At the follicular phase, an ovum matures within a cyst called =raafian follicle until it reaches the surface of the ovary where rupture occurs. The ovum is discharged into the peritoneal cavity. This periodic liberation of matured ovum into the peritoneal cavity is referred to as ovulation5 This ovum finds its way into the fimbriated end of the fallopian tube. "n its way to the uterus, if it meets a spermato9oan, the male gamete and union occurs and conception or fertili9ation takes place. The empty =raafian follicle, after ovulation is called as corpus luteum 'yellow body(, which secretes progesterone, a hormone that prepares the uterus for receiving the fertilised ovum. (emale ormones6 The ovaries produce progesterone. steroid hormones, estrogen and

&%MM-R$ Thorough history taking 6omplete physical e$am 2ecessary consultations 6ounseling %nstruct on accurate menstrual history and on contraception 2ecessary laboratory evaluation Ade;uate preconception counseling can decrease risk of pregnancy complications &ducation can lead to healthy habits and realistic e$pectations 6an lead to more efficient and less costly pregnancy care

Oestrogen6 %t is responsible for development and maintenance of the female reproductive organs and the secondary se$ual characteristics associated with the adult female. &strogen also plays an important role in breast development and in monthly cyclic changes 'menstrual cycle( in the uterus.

Progesterone6 4rogesterone regulates the changes that occur in the uterus during the menstrual cycle. %t is secreted by the corpus luteum. 4rogesterone is important for conditioning the endometrium in preparation for implantation of the fertilised ovum. %f the pregnancy occurs, progesterone is essential for maintaining a normal pregnancy. %n addition, it works along with oestrogen in preparing the breast for secretion of milk. P ysiology of reproduction6 Menstrual cycle or uterine cycle6 %t is a series of changes in the uterus resulting in the discharge of blood from the vagina each month. enstruation can be defined as, sloughing and discharge of the lining of the uterus if conception does not take place. This time varies in different women and also from time to time:in same woman. The first day of the cycle is the first day when bleeding begins. The ovarian hormones control the menstrual cycle. There are three main phases and they affect the tissue structures of the endometrium. The average time of menstrual cycle is *3 days and recurs regularly from puberty to menopause e$cept in pregnancy. The three phases are0 75 Proliferative p ase6 1ollicular stimulating hormonal level increases in blood, stimulating oestrogen secretion, which causes the endometrium to thicken and become more vascular. This phase follows menstruation and lasts until ovulation. 85 &ecretary p ase6 The secretary phase follows ovulation and is under the influence of progesterone and oestrogen from the corpus luteum. >eutinising hormone level increases in blood. #nder the combined stimulus of estrogen and progesterone, the endometrium reaches the peak of its thickening and vascularisation. 95 Menstrual p ase6 %t is characterised by vaginal bleeding, lasts for ? K + days. "n absence of fertili9ation, the thickened endometrium is shedded. Two =onadotrophic

hormones are released by the anterior pituitary gland. They are0 ,(ollicular stimulating ormone61S8 is primarily responsible for stimulating the ovaries to secrete oestrogen and for maturation of ovum. ,#uteinising Hormone *#H+6 >8 is primarily responsible for stimulating the corpus luteum for productoin of progesterone. 95 Puberty6 This is the period in which, the reproductive organs develop and reach maturity. The first signs are breast development and appearance of pubic hair. The body grows considerably and takes on the female contour. 4uberty culminates in the onset of menstruation, the first period being called menarc e. The first few cycles are not accompanied by ovulation. 4uberty usually occurs between ,* and ,7 years. Menopause6 %t is the end of a womanF s reproductive life, characterised by the gradual cessation of menstruation. The period first becomes irregular and then ceases altogether. This occurs between the ages of 7+ to +.. %t is the normal part of aging and maturation. enstruation ceases because the ovaries are no longer active. 2o more ovarian hormones are produced. The reproductive organs become atrophied. (ertili:ation6 1ollowing ovulation, the ovum about '..,+ mm( in diameter passes into the fallopian tube and moves towards uterus. %f coitus takes place at this time, the alkaline mucus attracts the spermato9oa. About ?.. million sperms are deposited in the posterior forni$ of the vagina. Those which are propelled by the cervical mucus reach the fallopian tube and others are destroyed by the acid medium of the vagina. The matured sperm is capable of producing the en9yme hyaluronidase, which allows the sperm to penetrate the cell membrane, surrounding the ovum. any sperm are needed for this, but only one will enter into the ovum and fertilisation occurs. After this, the membrane is sealed to prevent the entry of any further sperm and the nuclei of the two cells fuse. The sperm and the ovum each contribute half the

complement of chromosomes to make a total of 7H. The sperm and ovum are known as the male and female gametes. The fertili9ed ovum is known as the :ygote5 %mplantation of the fertilised ovum 'embedding( into the uterine cavity 'endometrium( is called as nidation or nesting. 2ormally this occurs by the ,,th day after ovulation and the endometrium closes over it completely. !evelopment of t e fertilised ovum6 1ertilised ovum reaches the uterus by ?:7 days. 6ell division takes place as * into 7,3,,H, etc, till a cluster of cells formed known as morula 'mulberry(. 2e$t a fluid filled cavity, a blastocele appears in the morula and it is known as blastocyst. "utside of blastocyst there is a single layer of cells known as trop oblast/ while the remaining cells are clumped together forming an inner cell mass5 The trophablast forms the placenta and c orion while the inner cell mass become fetus and amnion5 (ormation of fetal membrane and placenta6 The trophoblast has two layers, "uter syncitiotrop oblast, which erodes the endometrium in the process of embedding. The inner cytotrop oblast produces a hormone called uman c orionic gonadotrop in '86=( which reacts on corpus lutuem to continue the pregnancy by producing oestrogen and progesterone.The trophoblast develops as placenta which will nourish the fetus until delivery. The inner cell mass differentiates into three layers. 1rom the ectoderm skin and nervous system are formed. 1rom the mesoderm bones and muscles, heart and blood vessels and certain internal organs are formed. 1rom the endoderm mucous membranes and glands are formed. )uring the first three weeks following conceptual the fertilised ovum is termed as :ygote5 1rom ?:3 weeks, it is termed as embryo. The organs and systems are developed by @th week. After 3 weeks, till birth it is termed as fetus. ("T-# GRO'TH -N! !")"#OPM"NT

4reviously, methods used to determine how well the fetus was growing and maturing consisted of evaluating uterine growth and listening to fetal heart sounds. Advances in knowledge and technology have provided newer methods for assessing fetal well:being and maturity. %mproved methods for assessment and diagnosis enable early intervention for improved outcome. &tages of Growt and !evelopment The growth and development of the fetus is typically divided into three stages. Preembryonic &tage0 1ertili9ation to * to ? Weeks o 5apid cell division and differentiation o )evelop embryonic membranes and germ layers "mbryonic &tage6 7 to 3 Weeks< =estation o ost critical stage of physical development o "rganogenesis (etal &tage0 - Weeks to !irth o &very organ system and e$ternal structure present. o 5efinement of fetus and organ function occurs. !evelopment by Mont (irst #unar Mont 1ertili9ation to * weeks of embryonic growth. %mplantation is complete. 4rimary chorionic villi forming. &mbryo develops into two cell layers 'trophoblast and blastocyst(. Amniotic cavity appears. &econd #unar Mont ? to H weeks of embryonic growth. At the end of H weeks of growth, the embryo is appro$imately M inch ',.* cm( long. Arm and leg buds are visibleJ arm buds are more developed with finger ridges beginning to appear. 5udiments of the eyes, ears, and nose appear. >ung buds are developing. 4rimitive intestinal tract is developing. 4rimitive cardiovascular system is functioning.

2eural tube, which forms the brain and spinal cord, closes by the 7th week.

&i0t

T ird #unar Mont @ to ,. weeks of growth. The middle of this period '- weeks( marks the end of the embryonic period and the beginning of the fetal period. At the end of ,. weeks of growth, the fetus is appro$imately * M inches 'H.? cm( from crown to rump and weighs M o9 ',7 g(. Appearance of e$ternal genitalia. !y the middle of this month, all maBor organ systems have formed. The membrane over the anus has broken down. The heart has formed four chambers 'by @th week(. The fetus assumes a human appearance. !one ossification begins. 5udimentary kidney begins to secrete urine. (ourt #unar Mont ,,: to ,7:week:old fetus. At the end of ,7 weeks of growth, the fetus is appro$imately 7 N inches ',* cm( crown:rump length and ? N o9 ',,. g(. 8ead erectJ lower e$tremities well developed. 8ard palate and nasal septum have fused. &$ternal genitalia of male and female can now be differentiated. &yelids are sealed. (ift #unar Mont ,+: to ,3:week:old fetus. At the end of ,3 weeks of growth, the fetus is appro$imately H O inches ',H cm( crown:rump length and ,, O o9 '?*. g(. "ssification of fetal skeleton can be seen on $:ray. &ars stand out from head. econium is present in the intestinal tract. 1etus makes sucking motions and swallows amniotic fluid. 1etal movements may be felt by the mother 'end of month(.

#unar Mont ,-: to **:week:old fetus. At the end of ** weeks of growth, the fetus is appro$imately 3 O inches '*, cm( crown:rump length and , lb H O o9 'H?. g(. Gerni$ caseosa covers the skin. 8ead and body 'lanugo( hair visible. Skin is wrinkled and red. !rown fat, an important site of heat production, is present in neck and sternal area. 2ipples are apparent on the breasts. &event #unar Mont *?: to *H:week:old fetus. At the end of *H weeks of growth, the fetus is appro$imately ,. inches '*+ cm( crown:rump length and * lb ? O o9 ',,... g(. 1ingernails present. >ean body. &yes partially openJ eyelashes present. !ronchioles are presentJ primitive alveoli are forming. Skin begins to thicken on hands and feet. Startle refle$ presentJ grasp refle$ is strong. "ig t #unar Mont *@: to ?.:week:old fetus. At the end of ?. weeks of growth, the fetus is appro$imately ,, inches '*3 cm( crown:rump length and ? lb ,* o9 ',,@.. g(. &yes open. Ample hair on headJ lanugo begins to fade. Skin slightly wrinkled. Toenails present. Testes in inguinal canal, begin descent to scrotal sac. Surfactant coats much of the alveolar epithelium. Nint #unar Mont ?,: to ?7:week:old fetus. At the end of ?7 weeks of growth, the fetus is appro$imately ,* M inches '?* cm( crown:rump length and + lb 3 o9 '*,+.. g(. 1ingernails reach fingertips. Skin pink and smooth. Testes in scrotal sac.

Tent

#unar Mont ?+: to ?3:week:old fetusJ end of this month is also 7. weeks from onset of last menstrual period. &nd of ?3 weeks of growth, fetus is appro$imately ,7 M nches '?H cm( crown:rump length and @ lb 3 o9 '?,7.. g(. Ample subcutaneous fat. >anugo almost absent. Toenails reach toe tips. Testes in scrotum. Gerni$ caseosa mainly on the back. !reasts are firm.

(etal circulation )uring intra uterine life placenta is the sourse of nutrition and site of elimination of waste. There are several structure in addition to the placenta and umbilical cord. T e umbilical vein 0 leads from umbilical cord to the underside of the liver and carries blood rich in o$ygen and nutrients. %t has branch that Boins the portal vein and supply the liver. !uctus venosus 'from vein to vein( this connects the umbilical vein to the inferior vena cava. At this point the blood mi$es with the deo$ygenated blood returning from the lower parts of the body. T e foramen ovale6 temporary opening between the atria that allows the maBority of the blood to pass across the left atrium 'no respiration( T e ductus arteriosis 'from artery to an artery( this leads from the bifurcation of the pulmonary artery to the descending aorta,entering it Bust beyond the point where the carotid and subclavian arteries leave. T e ypogastric arteries6

these arteries off from the internal iliac arteries and become umbilical arteries when they enter the umbilical cord they return blood to the placenta. 1rom placenta the blood passes along the umbilical vein through the abdominal wall to the undersurface of the liver, gives off branches to the left lobe of the liver and receives deo$ygenated blood from the portal vein,. 'unmi$ed blood( The ductus venosus carries blood to the inferior vena cava which mi$es with the blood from the lower body. 1rom here the blood passes into the right atrium ost of it is directed across through the foramen ovale in to the left atrium. 1ollowing its normal route it enters left ventricle and passes into aorta. The heart and brain gets a supply relatively well o$ygenated. 'coronary and carotid arteries are early branches of aorta.( !lood collected from the upper parts of the body returns to the right atrium in the superior vena cava. This blood is depleated of o$ygen and nutrients. This stream of blood crosses the stream enteringfrom the inferior vena cava and passes into the right ventricle. the two streams remain separate because of the shape of the atrium. !ut there is a mi$ing of *+ D of the blood allowing a little o$ygen and food to be taken into the lungs through pulmonary arteries. 'necessary for the development( Adaptation to the e$tra uterine life At birth the baby breath and blood is drawn to the lungs through the pulmonary arteries. %t is then collected and returned to the left atrium via pulmonary veins. The placental circulation ceases soon after birth. 'less blood returns to the right side of the heart.( 4ressure in the left side is greater

This result in the closure of flap over foramen ovale. 'stops blood flow from right to left( &stablishment of pulmonary respiration result in the rise of o$ygen concentration in the blood stream. 6auses the ductus arteriosus to constrict and close. The cessation of the placental circulation result in collapse of the umbilical vein, ductus venosus and hypogastric arteries. #mbilical vein:ligamentum teres. ) G: ligamentum venosum ) A: ligamentum arteriosum 8ypogastric arteries :obliterated hypogastric arteries 1 ":fossa ovalis Closure of 0 umbilical artery:functional closure: instantaneousP.anatomical closure * to ? months # G:obliteration little later than # A ) A fun :soon after establishing pul circulation 1 ": fun soon after birth Anatomical , year

=rayish areas are calcium deposits =reyish tinge is due to placental separation &ach cotilidon has fissures which contain decidual

septum (etal &urface 1etal surface is grey and glistening 6ord is the continuation of the mesoderm %t is also called funis '+.:,..cm( %t consists of two arteries and one vein At the cut end of the cord, vein appears collapsed and arteries are protruded and down. 6ord is +.:,..cm in length White Belly life substance called WhartonFs Belly present on the cord %nner layer is amnion and the outer layer is the chorion (unctions of t e Placenta ,. The fetus obtains amino acids, glucose, vitamins, calcium, phosphorus, iron and other minerals from the maternal blood through the placenta. *. The placenta also stores glucose in the form of glycogen. %t also stores iron and fats soluble vitamins. ?. The waste products such as carbon dio$ide, bilirubin and urea are e$creted from the fetus through the placenta. 7. The placenta prevents passing of microorganisms from the mother to the fetus to some e$tent. +. The placenta also produces hormones like the human chorionic gonadotrophic hormone, oestrogen, progesterone and human placental lactogen '84>(. -mniotic fluid The fluid medium in which the fetus grows and develops inside the uterus. (unctions of amniotic fluid !uring pregnancy Acts as a shock absorber protecting the fetus from the possible e$traneous inBury aintains even temperature

-natomy and (unctions of Placenta Gross -natomy of t e Placenta %t consists of two surfaces0 ,. 1etal surface *. aternal surface Maternal &urface 4lacenta is attached to the upper side of the fundus ,+:*.cm in diameter ?.D of uterus covered by the placenta 6enter part is *.+cm in thickness Thickness reduced at the periphery 6onve$ polygonal areas called 6otilidons ,H:*. cotilidons in a placenta

1luid distends the amniotic sac and there by allows for growth and free movement of the fetus %t helps to prevent adhesion between the fetal parts and Amniotic sac. %ts nutritive value is negligible as there is only small amount of protein and salt. 'water supply is ;uite ade;uate(

7.. ml at *.th week. 5eaches the peak amount at ?H to ?3 th week Kthat is appro$imately ,...ml. Thereafter amount diminishes at term the it measures aboutH.. to 3.. ml.

!uring labour Amnion and chorion combined to form hydrostatic wedge which helps in the dilation the uterine os and effacement of cervi$. )uring # 6 it prevent marked interferance with the placental circulation so long as the membranes remains intact. 6ontP. 1lushes the birth canal at the end of the first stage of labour. Antiseptic and bactericidal action protects the fetus from the ascending infection. origin (etal and maternal5 %t is secreted by amnion especially the part covering the placenta and umbilical cord. Transudate from maternal serum across the fetal membranes or from the maternal circulation. 6ontP Transudate of fetal plasma through highly permeable fetal skin before it is keratini9ed at *.th week. 1etal urine also contributes to the volume from ,. th week. 'water of the A 1 is e$changed every ? hrs.( Clinical importance As a measure of fetal wellbeing 2ormal amount at term appro$imately ,...ml %f more than *...:poly ydramnios %f less than *.. ml:oligo ydramnios )olume of - ( +. ml at ,*th week.

C emical property 1aintly alkaline with low specific gravity.of ,..,.. Colour Straw coloured'e$foliated epidermal cells and lanugo( Turbid 'presence of verni$ caseosa( -bnormal colours =reen coloured =olden coloured =reenish yellow 'saffron( )ark coloured )ark brown -natomical variation of placenta and cord Succenturiate lobe of placenta 6ircumvallate placenta !attledore insertion of the cord Gelamentous insertion of the cord. !ipartite tripartite

T e %mbilical Cord -natomy Origin 6 %t develops from the connecting stalk. #engt 6 At term, it measures about +. cm.

!iameter6 * cm.

*C+ 1nots of t e cord6 ,.True knot0 when the foetus passes through a loop of the cord. %f pulled tight, foetal asphy$ia may result. *. 1alse knot0 locali9ed collection of WhartonFs Belly containing a loop of umbilical vessels. A long umbilical cord may more easily become twisted, or even form a knot *!+ Torsion of t e cord6 may occur particularly in the portion near the foetus where the Wharton<s Belly is less abundant. *"+ Haematoma 6 )ue to rupture of one of the umbilical vessels. *(+ &ingle umbilical artery 6 may be associated with anomalies other foetal congenital

&tructure6 %t consists of mesodermal connective tissue called Wharton<s Belly, covered by amnion. It contains6 "ne umbilical vein carries o$ygenated blood from the placenta to the foetus Two umbilical arteries carry deo$ygenated blood from the foetus to the placenta, 5emnants of the yolk sac and allantois. ost of the cord consists of a loose mesenchyme with intercellular ground substance 'Wharton<s Belly(. Insertion6 The cord is inserted in the foetal surface of the placenta near the center Qeccentric insertionQ '@.D( "r at the center Qcentral insertionQ '?.D(. -bnormalities of t e %mbilical Cord *-+ -bnormal cord insertion6 arginal insertion 0 in the placenta ' battledore insertion(. Gelamentous insertion0 in the membranes and vessels connect the cord to the edge of the placenta. Gasa praevia0 %f these vessels pass at the region of the internal os , the condition is called Q Gasa praeviaQ. Gasa praevia can occur also when the vessels connecting a succenturiate lobe with the main placenta pass at the region of the internal os *.+ -bnormal cord lengt 6 & ort cord w ic may lead to 6 o i:%ntrapartum haemorrhage due to premature separation of the placenta, o ii:)elayed descent of the foetus druing labour, o iii:%nversion of the uterus. #ong cord w ic may lead to6 o i:6ord presentation and cord prolapse, o ii:6oiling of the cord around the neck, o iii:True knots of the cord.

-bnormalities of t e Placenta

The placenta develops from the chorion frondosum 'foetal origin( and decidua basalis 'maternal origin(. -natomy -t Term Shape 0 discoid. )iameter 6 ,+:*. cm. Weight 0 +.. gm. Thickness0 *.+ cm at its center and gradually tapers towards the periphery. 4osition 0 in the upper uterine segment '--.+D(, either in the posterior surface '*A?( or the anterior surface ',A?(. &urfaces 1oetal surface aternal surface (oetal surface Smooth, glistening and is covered by the amnion which is reflected on the cord. The umbilical cord is inserted near or at the center of this surface and its radiating branches can be seen beneath the amnion. Maternal surface )ull greyish red in colour and is divided into ,+:*. cotyledons. &ach cotyledon is formed of the branches of one main villus stem covered by decidua basalis -bnormalities of t e Placenta *-+ -bnormal & ape6 ,. 4lacenta !ipartite *. 4lacenta Succenturiata ?. 4lacenta 6ircumvallata 7. 4lacenta 1enestrata The placenta consists of two e;ual lobes connected by placental tissue 75 Placenta .ipartite6 The placenta consists of two e;ual parts connected by membranes.

The umbilical cord is inserted in one lobe and branches from its vessels cross the membranes to the other lobe. 5arely, the umbilical cord divides into two branches, each supplies a lobe. The placenta consists of a large lobe and a smaller one connecting together by membranes. The umbilical cord is inserted into the large lobe and branches of its vessels cross the membranes to the small succenturiate 'accessory( lobe. 85 Placenta &uccenturiata6 The accessory lobe may be retained in the uterus after delivery leading to postpartum haemorrhage. This is suspected if a circular gap is detected in the membranes from which blood vessels pass towards the edge of the main placenta. A whitish ring composed of decidua, is seen around the placenta from its foetal surface. This may result when the chorion frondosum is two small for the nutrition of the foetus, so the peripheral villi grow in such a way splitting the decidua basalis into a superficial layer ' the whitish ring( and a deep layer. 95 Placenta Circumvallata6 %t can be a cause of 0 Abortion, Ante partum haemorrhage, 4reterm labour and %ntrauterine foetal death. ;5 Placenta (enestrata6 A gap is seen in the placenta covered by membranes giving the appearance of a window. <5 Placenta membranacea6 A great part of the chorion develops into placental tissue. The placenta is large, thin and may measure ?.:7. cm in diameter. %t may encroach on the lower uterine segment i.e. placenta praevia. *.+ -bnormal 'eig t6

The placenta increases in si9e and weight as in 0 6ongenital syphilis, 8ydrops foetalis )iabetes mellitus. Placenta Praevia The placenta is partly or completely attached to the lower uterine segment %n this gravid uterus, the placenta implanted over the os. This is called placenta previa. %mplantation in this low lying position can lead to e$tensive hemorrhage as the dilation of the cervi$ disrupts the placenta. *C+ -bnormal -d esion6 Placenta -ccreta6The chorionic villi penetrate deeply into the uterine wall to reach the myometrium,due to deficient decidua basalis. Placenta increta0When the villi penetrate deeply into the myometrium, it is called Qplacenta incretaQ Placenta percreta0 When they reach the peritoneal coat it is called Qplacenta percretaQ. *!+ Placental #esions Seen in placenta at term, mainly in hypertensive states with pregnancy. White infracts0 due to e$cessive fibrin deposition. '2ormal placenta may contain white infracts in which calcium deposition may occur(. 5ed infarcts 0 due to haemorrhage from the maternal vessels of the decidua. '"ld red infarcts finally become white due to fibrin deposition(. *"+ Placental Tumour6 6horioangioma 0 is a rare benign tumour of the placental blood vessels which may be associated with hydramnios.