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Puerperal sepsis is an infection of the genital tract that occurs at any time between the rupture of membranes in labour and 42 day following delivery or abortion threatens the well-being of both mother and child in postpartum period. This is may be caused by endogenous bacteria or exogenous bacteria. What is puerperal sepsis? Puerperal sepsis is an infection of the genital tract during the first 6–8weeks of delivery or abortion.  Pyrexia in puerperium is often caused by postpartum sepsis or extragenital causes like pyelonephritis, mastitis, and pneumonia. In some developed countries, puerperal pyrexia is a notifiable case if the temperature gets to 37.7oC within 14 days. Signs and symptoms of postpartum infection Causes of puerperal sepsis In considering the causes of postpartum sepsis, the midwife should ponder of these three factors: The organisms causing puerperal sepsis The microbes responsible for puerperal sepsis are under four groups: Anaerobic streptococci from the patient’s bowel can infect her.  Infection with Clostridium tetani or welchii can occur due to taking delivery in unhygienic environment or use of rusty, unsterile instruments. Risk/predisposing factors to genital tract infection/postpartum infection For better understanding these risk factors for puerperal sepsis include:  Common sites of puerperal infection Women are vulnerable to infection because the placental site is large, warm, dark moist, rich to grow microorganisms very quickly.  During delivery, traumatized tissue or tear in the vagina or perineal area is susceptible to infection. Types of puerperal infection Genital tract Infections or postpartum infections are grouped into: . The source of postpartum infection The source of the infection may be attributed to: Autogenous source of postpartum infection In this case, the source of the infection is from the patient’s respiratory tract. Septic foci in her body can also be a source of infection. Endogenous source of postpartum infection This is often from microbes already present in the patient’s vagina and bowel. These organisms are non-pathogenic in normal conditions but they become virulent and pathogenic if there is laceration of the birth canal. Exogenous source of postpartum infection Organisms from the patient’s respiratory tract and septic foci of the patient’s care provider, the dust in the air of maternity wall from blankets, sheets, and so on are the main sources of this infection.  Unfortunately, most of hospital staff (doctors, nurses and midwives) harbour staphylococci and streptococci in their respiratory tract and would readily infect their patients if proper precautions are not taken. Infections gotten from hospital are called nosocomial infections How to manage postpartum infection Prevention of puerperal sepsis The following tips would be of great help to prevent postpartum infection:

Post-Abortion Care: Nearly 20, 000 women die each year from complications of unsafe abortion and 13 percent of pregnancy-related deaths are attributable to this. It is estimated that one quarter to one-thirds of all pregnancy-related deaths are a consequence of unsafe abortion.  It is unfortunate to know that about 19 million abortions each year are unsafe.  Maternal death has far reached consequences for community motherless children 3 to 10 times more likely to die within 2 years than are children who live with both parents. An estimated 5 to 7.5 million women every year suffer debilitating non-fetal health problems as a result of unsafe abortion. For every maternal death, 10 – 15 women suffer morbidity. What is post-abortion care(PAC)? Post-abortion Care (PAC) consists of medical and related interventions designed to manage the complications of spontaneous and induced abortion, both safe and unsafe. What are objective of PAC?  The aim of post-abortion care is to reduce maternal morbidity and mortality and to improve women’s sexual and reproductive health and lives. What are elements of post-abortion care?  The model for post-abortion care consists of five elements: Does Post-abortion Care involve maintaining patient’s rights? Yes; all women have right to prompt, highly-quality post-abortion medical care and counseling, whether their abortion was spontaneously or induced and regardless of the legal status of the abortion. Women also have the right to information about their medical condition and make informed decisions regarding their medical and reproductive options. What are the sexual and reproductive health rights? The International Planned Parenthood Federation (IPPF) has produced a formal statement declaring women’s sexual and reproductive rights essential components of human rights. The IPPF charter includes twelve rights based on international human rights agreement. How to Provide Post-abortion Care Clinical assessment guides the diagnosis and treatment for each woman. For women presenting for post-abortion care (PAC), these findings and symptoms can generally be organized into four main clinical conditions, each describing a diagnosis and thereafter should be properly addressed.  The bottom line Tofort focuses on providing clear, reliable, respectful and evidence-based facts to ensure the safety of mothers and children. No woman should to die of pregnancy, labour, and puerperium. Therefore, let us unite and improve maternal and child health in wherever you are. Provide post-abortion care with least or no harm always. Safety to all mothers and children! Thanks for reading.

Women requiring post-abortion care (PAC) have both physical and emotional needs. Proper and effective counseling is a successful means through which the providers offer emotional care to women. Right to high-quality counseling is a fundamental right of women requiring PAC. Counseling is a way of providing support to patient; helping her to assess her feeling, coping ability, managing her anxiety and understanding information in order to enable her make inform decision. What is counseling? Counseling is defined as structured interaction whereby an individual voluntarily receives emotional support and guidance from a trained person in conducive environment that promote sharing thoughts, feeling and perceptions. Counseling is: Counseling is not: Role of PAC Counselor Benefits of Counseling in a PAC Setting Counseling in PAC Setting In order to provide effective counseling, the provider should give counseling before, during and after medical treatment whenever the woman’s health is not at risk of delay and she is in a state to make an informed decision.  Counseling in PAC helps the woman plan for her future to ensure her wellbeing. All elements of PAC must be employed for effective counseling. Guiding Principles in PAC Counseling The counselor must have these principles as a guide in counseling a woman with post abortion needs. The counselor must assess her biases, beliefs, attitudes. She should separate her beliefs, personal values, attitudes and biases from her professional practices and empathy to all clients regardless of their reproductive behaviours and decision. Health providers’ attitude to patient has great impact. Self-reflection will help her not to oppose her beliefs, values and attitudes to client. She should recognize how their attitudes could negatively or positively affect counseling. Empathy is the ability to understand another person’s feelings and opinion (view) and to communicate at same level with cent. It is putting oneself in another man’s shoes. Empathic provider will always have it in his/her mind to treat others how they would want to be treated. Patients respond most favourable to counselors who: Create a positive rapport between you and the woman which is the bedrock of quality health care. Effective communication skills are necessary in PAC setting because women’s physical and emotional distress may interfere with her ability to accurately explain their physical conditions respond to questions and understand information. She should adapt her behaviour and language to client’s cues especially at the beginning of clinical interactions. She should make patients active participants of their own care through sharing of information. She should provide privacy and treat information confidentially for counseling and that which is essential in promoting woman’s sense of dignity. If patient loose trust, it may be difficult to regain. Therefore, health worker must maintain trust by posting the facility confidential policy in strategic places in PAC setting. Caring areas and sharing it verbally with all clients. Patient’s right to privacy must be respected in PAC setting. It is essential that counseling should take place where nobody can hear and see her. Meeting privately, especially at the initial meet will help the client to be open and give out information. Effective woman-centered care is a two-way communication.  When there is good rapport, patient opens up easily and from her history, proper diagnosis will be made and appropriate treatment would be provided. Conclusion Counseling should be devoid of discrimination, racism and favouritism. The counselor should provide safe and evidence-based facts to enable patients take decision in his or her care. When patients are involved in decision-making, they tend to show maximum cooperation and quick recovery from the ill-health.

Manual Vacuum Aspiration is one of ways to carry out uterine evacuation, which is the removal of the contents of the uterus such as incomplete abortion or other retained products of conception. What is Manual Vacuum Aspiration (MVA)? World Health Organization (WHO) in union with UNPFA, UNICEF and the World Bank and the endorsement by FIGO and ICM approved MVA as an essential technology for uterine evacuation. MVA is typically used in PAC treatment for uterine evacuation in the first trimester.  To perform the MVA procedure, a cannula of the appropriate size (depending on gestation age/uterine size) is inserted through the cervix into the uterus. A hand-held plastic 60ml aspirator that is charged with a vacuum is than attached to the cannula. The vacuum is released by depressing the buttons on the aspirator and then the cannula is gently and slowly rotated while being moved back and forth in the uterus. The aspirator serves as the source of vacuum to pull to tissue through the cannula into the cylinder of the aspirator. What are indications for MVA? What are contra-indications for MVA? Features and Parts of IPAS MVA Plus The IPAS instrument was manufactured by IPAS since 1973.  IPAS MVA plusTm aspirator provides vacuum 24 – 26 inches or 609.6 – 660.4 mm of mercury. It is composed of the following parts: Ipas EasyGrip Cannulae Ipas EasyGrip Cannulae have the same dimensions and aperture (openings) as the flexible Karman cannulae. However, Ipas EasyGrip cannulae are slightly more rigid and have a permanently fixed base with a wing design. This helps the base to directly to the IPAS MVA Plus aspirator without requiring a separate adapter. Ipas EasyGrip Cannulae are available in sizes 4, 5, 6, 7, 8, 9, 10 and 12mm. the smaller cannulae (4, 5, 6, 7 and 8mm) have 2 opposing apertures. The larger (9, 10 and 12mm) have a single scoop aperture to allow for removal of thicker tissue. There are dots for calibration on the cannulae at 1cm intervals. How to determine the cannula size to use during MVA This depends on uterine size in relation to Last Menstrual Period (LMP), i.e. the gestational age of the pregnancy What are advantages of MVA? Procedures for Uterine Evacuation with IPAS MVA PLUS To provide woman-centered care, the woman’s safety and comfort during in MVA must be assured. The following ten steps below would guide you to perform uterine evacuation using manual vaccum aspirator effectively STEP 1: Prepare Instruments – Charge the Instrument STEP 2: Prepare the Patient STEP 3: Perform Cervical Antiseptic Preparation Maintain aseptic technique throughout, using sponge – holding forceps, pick sponge (gauze, swab) to clean cervical OS vaginal walls if desired. With each new sponge start at the cervical os to clean and spiral outward without retracting previously cleaned areas. Continue until the cervical os has been completely cleaned with antiseptic. STEP 4: Give Anaesthetics STEP5: Dilate Cervix             Cervical dilation is not required in some cases. Dilation is not required when cannula of appropriate size fits into the OS. If cervix is closed and not efficiently dilated, use a bigger cannula to dilate gently. Do not use force because it can cause cervical tear, injury to pelvic organs and uterine perforation. STEP 6: Insert Cannula STEP 7: Suction Uterine Content What are signs that the uterus is completely empty? Once the manual vaccum aspirator is in uterus and you notice these signs below, and then know that uterus has been evacuated: STEP 8: Inspection of Tissue Inspect the tissue for: STEP 9: Perform Any Concurrent Procedure Other concurrent procedure such as insertion of IUD if consent was obtained when the procedure is complete is allowed. Step 10: Process Instruments Immediately wash the instruments (MVA), rinse in a clean water and insert in a jik solution 1:10 for 10 minutes. Discard needles and sharps appropriately. Other post procedural tasks are: What are challenges arising when using MVA? Vacuum can decrease before completion of the procedure. They following may be the cause. What are the medications to give patient after manual vaccum aspiration? Prescribe necessary drugs for patient such as: Tab Paracetamol twice daily for three days. What are complications of manual vaccum aspiration? Using manual vaccum aspiration is an option to treat missed or incomplete abortion is safe provided it is done by skilled provider and under strict aseptic and antiseptic techniques. However, MVA performed by unskilled provider and without aseptic precautions can result in the following complications:

Precipitate labour is very important for Midwives and Obstetricians to know what to do in such situation. Hence, in this article, we shall discuss precipitate labour, its causes, management and complications. We shall also consider back labour . Most women especially primigravidae do not want to waste time in labour and experience that excruciating pain. They want everything speedily so that they could be free and have their baby. However, they fail to know that labour associated with high speed has many risk factors to both mother and baby. What is precipitate labour? Precipitate labour is a labour that lasts for fewer than three (3) hours. This trial of labour often makes women give birth in the church, market place and so on. Those who thought were smart and started rushing to hospital, would be born on their way or at the hospital gate. Such babies are described as “born before arrival”. Risk factors for rapid labour Effects of the labour on the mother Feto-neonatal complications of precipitate labour How to manage a woman with precipitate labour A woman with needs close monitoring and preparations for emergency delivery to ensure safe outcome for mother and baby. Proper history taking will help the nurse educate the woman on proper birth plan to come to facility as early as possible. Precipitate Labour Vs Back labour About  one-thirds of women in labour report that their backs hurt during labour, more so than their abdomens.  Sometimes, the pain of back labour does not go away during the break in uterine contractions, and this is often blamed on the baby being in an occipitoposterior  position(turned to face the mother’s front).  Ways to manage Back Labour Below are the strategies for ameliorating the pain associated with back labour and also help move a baby out of the posterior position. Therefore, try them if your back is hurting more than your belly during labour.  Sacral massage/counter pressure:  This involves steady, firm pressure or massage on the lower back based on maternal request. It helps to sooth pain through release of endorphins —body’s natural pain killer.

What is Puerperal psychosis? Puerperal psychosis is a serious or life-threatening mental condition which affects the personality of the woman during puerperium (mostly primipara). Its onset is rapid and usually occurs within the first few days after   delivery.   The   symptoms characterized by this mental illness are similar with those   of   depressive psychosis, manic illness and schizophrenia in some cases. The affected mother shows bizarre behavior, loses touch with reality and may suffer from hallucinations. The onset of these symptoms may be heralded by a time of acute restlessness and inability to sleep. Frequently the mother may deny that her baby belongs to her and in rare cases she may harm the baby. How common is puerperal psychosis? Psychiatric disorders can occur during pregnancy, labour or puerperium. Puerperal psychosis is not common (about 1 or 2 in every 1000 births) but tends to be more common in primigravida.  Most women experience a phase of depression called “maternity blues” during puerperal period, in which its poor treatment can result in a fatal mental state, known as puerperal psychosis or postpartum psychosis Causes of puerperal psychosis The causes of puerperal psychosis are complex and multi-layered. These include genetic factors, environmental factors (social isolation, brain injury/ trauma, and stress), lifestyle (drug or alcohol abuse) and psychological factors (mood disorders, anxiety disorders, schizophrenia or bipolar disorder and personality traits). The cause of puerperal psychosis is likely involves a combination of these factors above. It is believed that some people may be more likely to develop this condition if they are living in an area with high levels of pollution or if they are living in an area with a history of mental illness. However, getting treatment as soon as possible to helps prevent further damage to the individual and their family. Risk factors of puerperal psychosis Signs and symptoms of puerperal psychosis How to treat postpartum psychosis The patient must be treated promptly by admission to a psychiatry unit under the care of a consultant. In most cases, the baby will be allowed to accompany his mother to hospital and this should be encouraged if there is availability of adequate vital and skilled psychiatric nursing care. This involves use of medication (antipsychotic medications and mood stabilizers), psychotherapy, lifestyle changes and electroconvulsive therapy The prognosis of postpartum psychosis With prompt treatment, the prognosis is good. However,  unfortunately, it is likely that further episodes of the illness will occur throughout the woman’s life around  there  is  a  high  risk  of  recurrence  in  subsequent pregnancies. Summary Puerperal psychosis is an illness that affects young adults in their late teens and early twenties after delivery. It is a mental disorder that causes elevated mood, energy and activity levels, delusions, hallucinations, irrational thoughts and other psychiatric symptoms.  It is also known as juvenile schizophrenia. Symptoms of puerperal psychosis can last for months or even years. There is no one cause of puerperal psychosis. It is believed to be caused by a combination of genetic and environmental factors. Some people are more likely to develop puerperal psychosis than others. The prognosis for puerperal psychosis is very uncertain and can vary greatly depending on the individual.  Some people may have a milder form of the disorder and may not require any treatment, while others may have a more severe form and may require long-term treatment. There is no known cure for puerperal psychosis, but it can be managed with medication and therapy.

In this article, I shall discuss abnormality of amniotic fluids such as polyhydramnios, its causes and treatment. But before then, let us see the table of contents for better understanding. What is Polyhydramnios? Polyhydramnios (hydramnios) occurs when there is excess amount of amniotic fluid in the amniotic sac.   It is the amount of amniotic fluid that exceeds 1500ml but it may not be clinically apparent until it gets to 3000ml (that is, 95% above the amniotic fluid index). How common is polyhydramnios? Polyhydramnios is considered to be more common in multiparous than in nulliparous women. And it occurs one in every 250 pregnancy. What are causes of Polyhydramnios?  The aetiology of polyhydramnios is not known but has been attributed to: Note: Chorioangioma is a small tumor growing from a chorionic villus and consist of enlargement of the blood vessels and connective tissue Classification of polyhydramnios Polyhydramnios is classified based on: Time of its onset Its degree or severity  Acute hydramnios: This is a rare form of polyhydramnios that develops suddenly, usually around 20 week’s gestation. It is characterised by rapid increment of uterine size reaching the level of xiphisterneum within 3 to 4days and the woman’s complaint of severe abdominal ache. Fetal anomalies and monozygotic twins are the commonest risk factors or causes of acute polyhydramnios What are signs and symptoms of acute hydramnios? Acute high liquor amnii is associated with the following: Chronic polyhydramnios: This is a gradual accumulation of amniotic fluid, often noticed in the third trimesters (about 30 weeks’ gestation). It is most common type of amniotic fluid abnormality. What are signs and symptoms of chronic hydramnios? . How to diagnose Hydramnios Maternal history: The woman may complain of abdominal discomfort, over-distension or excessive fetal movements.  In an acute polyhydramnios, she may complain of vomiting, abdominal pain, heartburn, indigestion, constipation and difficulty in breathing —which are all exacerbated by symptoms associated with pregnancy. Abdominal examination:  On inspection: the fundal height is obviously exceeds the expected gestational age. The uterus is globular in shape instead of normal ovoid shape. On palpation: the midwife feels tense uterus and may find it hard to palpate the fetal part. On auscultation: the fetal heart sounds may be hard to hear due to the excessive liquor amnii. Differential diagnosis for hydramnios Multifetal pregnancy, even full bladder and other related causes of large for dates pregnancy like co-existing fibroids, or ovarian cyst should be looked into it. The midwife should also consider hydatidiform mole, fetal macrosomia and wrong dates for their absolute exclusions. Ultrasound screening:  a non-invasive procedure will confirm the diagnosis hydramnios by ruling out or revealing the presence of multiple pregnancy, fetal abnormalities, fetal macrosomia, ovarian cyst, hydatidiform mole and uterine fibroids. The ultrasound scan usually shows that the sum of the liquor depth in each of the four quadrants of the uterus (Amniotic fluid Index, AFI) greater than the 95th centile for gestational age, which is a diagnostic confirmation of hydramnios. Abdominal x-ray: This may reveal skeletal fetal anomalies and exclude multiple pregnancies. However, it must only be used in where ultrasound scan is not available because of the risk factors associated with x-ray radiations. How to manage hydramnios This depends on the condition of the woman and fetus, including the cause and degree of the hydramnios and the gestational age (GA) of the pregnancy. Asymptomatic hydramnios especially where there are no associated fetal abnormalities need no treatment. But when there are gross anomalies of the fetus, the woman has to choose either to electively induced the labour or carry the fetus to term if the fetus has surgicable or operatable deformity like oesophageal atresia which can be managed immediately in neonatal surgical unit. In symptomatic hydramnios where the gestational age is beyond 37weeks with serious maternal distress, labour can be safely induced. Prior to induction, supportive treatment such as encouraging the woman to adopt upright position which relieves any dyspnea and antacids may be administered to alleviate heartburn and nausea. In case of hydramnios where there’s serious maternal distress with GA less than 37 weeks of gestation and no fetal malformation, therapeutic abdominal amniocentesis or amnioreduction could be performed. This may be repeated severally where necessary in order to achieve optimal outcome. The technique is associated with the risks of infections, preterm labour, disseminated intravascular coagulopathy (DIC) and perforation of the fetal vessels with resultant bleeding into the Amniotic sac particularly when performed under poor aseptic techniques and without ultrasound guidance. What are dangers of sudden rupture of membranes in cases of hydramnios? After delivery, the patient may have postpartum haemorrhage because of attendant uterine inertia due to the over-distention of the uterus. Note; abdominal paracentesis should be carefully performed as frequently as the occasion demands. If the fetus is mature, labour may be induced by a slow, controlled forewater or hindwater rupture of membranes. Complications of hydramnios Prevention of hydramnios No specific way for preventing hydramnios. However, the two methods of prenatal treatment of polyhydramnios are amnioreduction and medical treatment with non-steroidal anti-inflammatory drugs (NSAIDs e.g. ibuprofen).  Prenatal administration of NSAIDs such as ibuprofen or Diclofenac has been found to reduce amniotic fluid volumes but these are not without side effects. As per Hamza et al., 2013, some experimental therapeutic studies are still trial that would alter fetal diuresis and in turn control polyhydramnios  The midwife managing woman in labour with hydramnios should anticipate postpartum haemorrhage due to uterine over-distension and get everything handy should emergency arise. The baby should be thoroughly examined at birth to detect any abnormality and initiate prompt care.

Placenta praevia: Bleeding in late pregnancy (antepartum haemorrhage) is a disheartening condition that threatens the wellbeing of both mother and fetus. This bleeding condition that occurs during the lasts two trimesters of pregnancy may be due to may be due to placenta previa or placenta abruptio What is placenta praevia? Placenta praevia refers to the placenta situated/ implanted wholly or partially in the lower uterine segment on either anterior or posterior wall which causes unavoidable bleeding from the genital tract. Bleeding from placenta praevia is said to be unavoidable and inevitable because the placenta will definitely separates and haemorrhage must follow as the uterus stretches and dilates in the late pregnancy and early labour. Signs and symptoms of placenta praevia Patient’s condition depends on the amount of blood loss. If the bleeding is slight, your blood pressure, respiratory rate and pulse rate tend to be normal. But if there is severe haemorrhage, hypotension and rapid pulse may be present — suggestive of shock. What are classic signs of placenta praevia? The only sign is vaginal bleeding that is painless. Other signs that will cause a midwife to suspect placenta previa in addition to bleeding are presenting part remains above the pelvis and unstable lie. Causes of placenta praevia The main aetiology of placenta previa is unknown but is associated with the following condition: Note: Multiparous women are more likely to suffer placenta praevia than primiparous women. This is because, in a new pregnancy, the placenta tends to look for a fresh surface to implant avoiding the previous placenta site scan. This may then result in implantation of the placenta in the lower uterus. Who are at higher risk of placental praevia? How common is placenta praevia? Placenta previa occurs 2.8 per 1,000 in every singleton pregnancy and 3.6 per 1,000 in multiple pregnancies. Placenta praevia Diagnosis The degree of shock is associated with amount of bleeding. If there is shock other signs may be present such as rapid respiration (air hunger).  The mother is pale with cold clammy skin. There may be loss of consciousness in a torrential bleeding. General Examination: Check the woman’s general appearance. The woman may be apprehensive due to bleeding. Check the vital signs: If the haemorrhage is slight blood pressure, pulse, respiration may be normal. In severe bleeding there may be hypotension, rapid pulse indicating shock. Abdominal examination: The midwife finds that the fundal height usually corresponds with the gestational age. The consistency of uterus is also normal with no tenderness and no pain. The fetal heart is also heard on auscultation. The fetal lie may be oblique or transverse. No engagement: the fetal head will still be very high near term in a primigravida. Obstetric ultrasonography:  The confirmatory diagnosis of placenta praevia is ultrasonic scanning because it determines its location.  However, X-ray (soft tissue placentography) carried out in the third trimester (after 34th week’s gestation) will show soft tissue radiography and outlining a low-lying placenta. Currently, obstetric ultrasonography is recommended for detecting the placental site. Midwife’s Assessment This would be divided into maternal and fetal assessment: Assessment of mother’s condition: Assess amount of vaginal blood loss. Take history of bleeding which is variable, some may have repeated small bleeding at interval, some may have repeated small bleeding at interval while some may experience sudden single episode after 20th week. Severe bleeding may occur after 34th week and is usually associated with the following which the midwife must take note of: Assessment of fetal condition: What are differences between placenta praevia and abruptio placenta? S/N Placental previa Abruptio placenta 1. Warning bleeding present Absent 2. Usually there is an abnormal lie or malpresentation Usually normal lie and presentation 3. Abdomen not likely to be tender Abdomen is likely to be tender 4. No associated abdominal pain There is associated abdominal pain 5. Blood is usually bright red Blood  may be dark or bright red 6. Mother is usually compromised Fetus is usually compromised 7. Uterus is soft on palpation Uterus is woody-hard on palpation 8. No particular association with pre-eclampsia May be associated with pre-eclampsia 9. No coagulation defect initially coagulation defect occurs early 10. Presenting part is high(unengaged) Presenting part may be  high or engaged Types of Placenta Previa Placenta praevia is classified into four degrees as follow: Type I placenta praevia: This occurs when the whole or majority of your placenta is situated in the upper uterine segment. There may be vaginal bleeding but blood loss is usually mild. Mother and fetus are in good condition and vaginal delivery is possible. Type II placenta praevia:  Thisis also called marginal placenta praevia. Marginal placenta praevia occurs when the placenta is partially situated or located in the lower uterine segment near the internal cervical os.  Blood loss is often moderate but the conditions of both mother and fetus may vary.  Fetal hypoxia is far more likely to present than maternal shock. Vaginal birth is possible only when your placenta is positioned anteriorly because posterior position impedes the fetal descent. Type III placenta praevia: This occurs when placenta is situated over the internal os but not centrally. The patient is far more likely to experience severe bleeding especially when the lower uterine segment stretches and the cervix starts to efface and dilate in the late pregnancy. You can’t have vaginal birth because the placenta precedes the fetus (i.e. the placenta lies before the fetus) Type IV placenta praevia: This is also called Central placenta praevia, which occurs your placenta is located centrally over the internal cervical os. Vaginal delivery is NOT possible because torrential haemorrhage is very likely to occur. Caesarean section is the only way to save your life and that of your baby. Pathophysiology of bleeding in placenta praevia Bleeding with placenta praevia happens when the lower uterine segment starts to grow progressively after 12th weeks and also differentiates from the upper uterine segment during late pregnancy (at about 30 weeks gestation) while the cervix begins to dilate. Bleeding occurs due to placenta’s

Abruption placenta is the separation of normally located placenta resulting in bleeding occurring after 28 weeks gestation or before the third stage of labour.  It is the premature separation of a normally situated placenta occurring after the 28th week of pregnancy Simply, abruptio placenta is defined as the cause of bleeding in late pregnancy (after 28 weeks gestation), or prior to onset of third stage of labour due to earlier separation of the placenta abruptio. Placental abruption is also the cause of antepartum haemorrhage, postpartum haemorrhage, obstetric shock and maternal mortality. The partial separation of the placenta results in bleeding from the maternal venous sinuses in the placental bed. In this article, I shall consider the causes, types, treatment and prevention of placental abruption. I urge you to exercise patient and read through entire article for better understanding. It is my desire to see that maternal and child morbidity and mortality rate is reduced to its lowest level globally. What is an abruptio placenta? Simply, abruptio is a Latin word that means “breaking away from a mass”. Therefore, abruptio placenta is the process of placental detachment from its site or separation of normally situated placenta after 22nd week of pregnancy. Signs and symptoms of placental abruption These are the clinical manifestations: Pathophysiology of abruptio placentae  Initially there is vasospasm followed by relaxation of the vessels, and then vascular engorgement occurs followed by rupture of vessels. This leads to bleeding into decidua basalis. Decidual haematoma is formed, eventually blood escape through the vagina as revealed bleeding or escape into amniotic cavity causing blood stained liquour. If large volume of blood accumulates under placenta, it will be absorbed into the myometrium causing the uterus to be very tense, rigid and oedematous a condition known as (Couvelaire uterus or uterine apoplexy or uteroplacental apoplexy). It is common with conceal type and causes severe pain and uterine contraction. With placental separation, utero-placental circulation is impaired resulting in fetal hypoxia and eventually death. Decidual degeneration and necrosis may release thromboplasm into maternal circulation causing Disseminated Intravascular Coagulation (DIC). How common is abruptio placenta in pregnancy? Placental abruption occurs in about 10% of all pregnancies and remains the most common cause of prenatal death. It remains an accidental cause of antepartum haemorrhage or the cause of inevitable bleeding in late pregnancy apart from placenta praevia, bleeding from sources such as cervical lesion or cancer of the cervix. What are key signs of Abruptio placenta? The diagnosing cues for placenta abruption are the dark vaginal bleeding with abdominal pain, tender/rigid uterus, uterine contraction and back pain. However, these symptoms can occur without vaginal bleeding especially when the blood is trapped behind the placenta. What are causes and risk factors of placental abruption? The actual cause of early separation of placenta prior to labour is not known. However, the predisposing factors of placenta abruptio are: How is a placental abruption diagnosed? A thorough history-taking from the patient may reveal incidence of pregnancy induced hypertension or external cephalic version. The patient’s uterus has a hard consistency and there is a guarding on palpation of the abdomen. The fetal parts may be difficult to palpate or not palpated at all and the fetal heart is unlikely to be heard with a fetal stethoscope. The key diagnosing cues for placenta abruption is the dark vaginal bleeding withabdominal pain, tender/rigid uterus, and back pain. But these symptoms can occur without vaginal bleeding especially when the blood is trapped behind the placenta. Ultrasound scan performed at this time helps to differentiate placenta praevia from abruptio placenta. However, placenta praevia tends to occur at rest but placenta abruption is often associated with history of trauma or active procedures. Lab Investigations Midwife’s Assessment during management of abruptio placentae Assessment maternal condition Ascertain maternal history, probably history of pre-eclampsia, recent history of headaches, nausea, vomiting epigastric pain, visual disturbances. General Examination Abdominal Examination Assessing Fetal Condition Observations Fetomaternal conditions are assessed and help to determine mode of management. Maternal vital signs should be taken at frequent intervals depending on the severity. What are differences between abruptio placenta and placenta previa? S/N Placental previa Abruptio placenta 1. Warning bleeding present Absent 2. Usually there is an abnormal lie or malpresentation Usually normal lie and presentation 3. Abdomen not likely to be tender Abdomen is likely to be tender 4. No associated abdominal pain There is associated abdominal pain 5. Blood is usually bright red Blood  may be dark or bright red 6. Mother is usually compromised Fetus is usually compromised 7. Uterus is soft on palpation Uterus is woody-hard on palpation 8. No particular association with pre-eclampsia May be associated with pre-eclampsia 9. No coagulation defect initially coagulation defect occurs early 10. Presenting part is high(unengaged) Presenting part may be  high or engaged What are activities contraindicated during placenta abruption? Activities contraindicated for women with placental detachment before labour (placenta abruption) are: What are types of placenta abruption? Specifically, there are three types of abruptio placenta: Revealed placental abruption This accounts for about 48% of all cases of abruption placenta and occurs when there is bleeding from the genital tract which may be mild or severe.  In Revealed abruption, there isblood flow to the external and no blood is accumulated behind the placenta.Patient often experience mild abdominal pain with some degree of tenderness as well as presence of fetal distress depending on the degree of separation. Revealed haemorrhage treatment Management of bleeding in revealed abruptio placenta depends on: Specific care for revealed abruptio placenta is: What is Concealed placental abruption? Concealed placental abruption accounts for about 27% of all cases of abruption placenta. Here, there is bleeding in-utero from the separation of the placenta and blood clots tend to accumulate in the uterus.  That’s, concealed placental abruption is a type of abruption where blood is retained behind the placenta.  This makes the uterus to be greater than gestational age and appears more globular. The patient tends to present with all the signs and symptoms of hypovolemic

Antenatal exercises plays a very important role in pregnancy. Pregnancy is a time of great physical and mental changes for both the mother and the fetus. There are a variety of exercises that pregnant women can do to maintain their health and well-being, both during and after pregnancy. These  exercises help pregnant women to maintain a healthy weight, improve circulation, and reduce stress. In this article, we  shall discuss : What are the benefits of antenatal exercises? Exercise in pregnancy not only improves the overall health of the mother, but also influences the fetal health positively as well as fostering a favourable birth experience. Specifically,  antenatal exercises can: Generally, exercises  increase strength and flexibility as well as breastfeeding success; better breathing and circulation, better balance and coordination. Contraindications for Exercise during Pregnancy What are the best exercises for pregnant women according to the American College of Obstetricians and Gynecologists(ACOG)? ACOG and National Institutes of Health recommended the following for  exercise in pregnancy:  Mayo Clinic also recommended these tips for exercises in pregnancy: What are safe exercises during pregnancy? 1.Walking: A moderate amount of walking is beneficial for pregnant women. ACOG recommends at least 150 minutes of moderate-intensity aerobic activity per week, including at least 30 minutes of walking.  Walking can help improve your circulation, help you maintain your weight, and help you get pregnant. It also helps improve your mood, increase your endurance, and help you keep up with your daily routine. 2.Strength Training:  ACOG recommends at least 30 minutes of strength training per week, including at least two days of resistance training that includes mild weightlifting and two days of aerobic activity. Strength training can help you maintain your weight, improve your posture, and help you get pregnant. 3.Yoga:  Yoga has been shown to reduce stress and  anxiety. It improves your flexibility, balance,strength and endurance, which can help you maintain your pregnancy and improve your overall health. 4.Swimming:  Swimming can help improve your flexibility and balance, which can help you maintain your pregnancy and improve your overall health. It helps your body to release endorphins, which can improve your mood and reduce stress. 5.Dancing:  Dancing has been shown to improve your cardiovascular health, which can help you maintain your pregnancy and improve your overall health. 6.Prenatal massage:  Prenatal massage can help to improve relaxation, circulation, and overall health. 7.Strength training: Strength training can help you maintain your pregnancy weight, build muscle, and reduce your risk of pregnancy-related complications. 8.Aerobic exercises: moderate-intensity aerobic exercise such as brisk walking, running, biking and using an elliptical machine, is beneficial for pregnant women. It can help to improve heart health, blood pressure, and blood sugar. 9.Kegels: This is a pelvic floor strengthening exercise, which helps improve childbirth experiences, lower the need for episiotomy or risk of lacerations during delivery. Tofort’s Recommendations for exercise in pregnancy We at Tofort via our experts make the following tips for prenatal exercises: The bottom line Antenatal exercises have been shown to have many benefits for both mother and baby. There are a variety of exercises that pregnant women can do, and the best way to find the ones that are best for them is to ask their doctor or health care provider for recommendations.