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Birthing positions Types of birthing positions RECUMBENT POSITION (LITHOTOMY) Women can choose a variety of positions for birth. Use of non lithotomy positions were natural ways of birth as old as origin of man. In modern times about two centuries ago, the use of lithotomy became the norm because it is easier to apply new technology. It is now advocated that women can choose any comfortable position ranging from standing, sitting, squatty, hand and knees or side lying (left lateral) positions This is more convenient for health workers (midwives and others) to enhance maintenance of asepsis, assessment of fetal heart rate(FHR) and giving of episiotomy and repair. Nevertheless, it has following disadvantages to the comfort of the woman and the fetus LEFT LATERAL POSITION This is a common position some women and birth attendants always use. The woman lies on her left side with the left leg extended and her right knee drawn against her abdomen or flexed by her side. Although frequency of contraction may decrease in this position, the intensity increases leading to greater efficiency Advantages Disadvantages SQUATTING POSITION Squatting primarily common choice for some women because it favours gravity and the abdominal wall is relaxed.  Other advantages: Disadvantages SEMI-FOWLER’S (HALF SITTING) POSITION Most birth attendants advocate for this position. It is halfway between sitting and recumbent positions Advantages SITTING POSITION This can be used where there is availability of delivery chairs. This method can be traced back to ancient Egypt and was widely used in Greek and Roman civilizations.  In the early 19th century use of delivery chairs was discouraged and its use diminished on hygienic grounds due to increase in puerperal fever. A supported sitting position can be achieved by use of a support person in a delivery bed (couch). Advantages  Disadvantage It carries a potential for increased blood loss. HANDS AND KNEES POSITION Advantages Disadvantages Tofort’s Recommendation on choice of birthing positions 

Description of Second stage of labour Second stage of labour starts from fully cervical dilatation to the delivery of the baby. It is also divided into two phases Latent phase of the second stage The cervix is fully dilated but the presenting part is still very high, it has not reach the pelvic outlet Active phase of the second stage The presenting part of the fetus reaches the pelvic outlet and with the presenting part on the perineum, this will stimulate the nerve at the perineum causing expulsive Uterine contraction or urge to bear down during contraction and is also known as Ferguson’s reflex. Physiology of second stage of labour Uterine Action Soft Tissues Displacement Signs and symptoms of second stage The following signs are indicative of second stage of labour. They are classified under presumptive and confirmatory evidence PRESUMPTIVE SIGNS The following signs CONFIRMATORY EVIDENCE Vaginal examination must be taken in the presence of these signs to confirm full dilatation and ensure that the woman is not pushing too early. It also help to time second stage of labour Management of second stage of labour Assessment during second stage of labour Assessment of the woman and the fetus is continuous during second stage of labour. There are four determinants of outcome of second stage and they must be carefully monitored. They are as follows: UTERINE CONDITIONS The midwife should observe the strength duration and frequency of uterine contractions during second stage. It is usually longer and stronger during the first stage of labour with longer resting phase. The position the mother adopt for delivery usually influences the contractions. The midwife observes contractions through maternal response and abdominal palpation. DESCENT, ROTATION AND FLEXION In primigravida, descent may be slow during latent phase of second stage and accelerates during the active phase.  In multigravida,  the descent occurs more rapidly if descent is not progressive despite good uterine contractions and good maternal pushing on abdominal palpation, vaginal examination should be carried out to assess the station of the presenting part, whether or not internal rotation has taken place and rule out excessive caput succedaneum.  The labour is likely to progress well if the occiput has rotated anteriorly ( well flexed head) and there is no excessive caput, the midwife should continue.  Where there is no good rotation and flexion, poor contractions change position, give her nourishing fluid for hydration. Consult more experienced midwife. If fetal or maternal condition is compromised obstetrician should be involved in the management FETAL CONDITION Thick fresh meconium stained liquor when the membrane ruptures indicate fetal compromise (distress) and obstetrician should be called immediately. Fetal heart rate is checked after every contraction in the second stage of labour using pinnard stethoscope or sonicaed. Fetal distress is suspected if the following are observed If this is observed for the first time, change the mothers position because this may be as a result of head compressing the cord.  However if it persists, give episiotomy if delivery is imminent to expedite delivery. Seek an experienced midwife to expediate delivery with use of vacuum extractor MATERNAL CONDITION The midwife observes both psychological and physiologic parameters of the woman during second stage of labour. The woman’s ability to cope emotionally is assessed.  During the second stage there is increased apprehension or irritability. Some women may cry or make a lot of expression. These helps the midwife assesses woman’s coping ability. Also assess physical well being by checking maternal pulse rate ½ hourly and blood pressure. Conduct of normal labour Principles of Delivery These includes Preparation for the birth Before delivery of the baby the midwife should prepare for the birth Promoting maternal comfort in second stage of labour Most mothers feel very hot and exerted during the second stage, they sweat profusely due to pushing, a cool towel should be applied to the face, neck and body and these provide soothing.  The lips and tongue are dried and cracked and saliva sticky. Sips of water or other fluids will be very smoothing.  Ensure that the bladder is empty to avoid trauma to the bladder (pressure of the presenting part on the full bladder) Delivery of the baby The midwife should help position the woman (adopt the position she chooses) Birth of the shoulder Final notes on second stage of labour

Description of first stage of labour The progress of labour has been divided into stages and phases, labour is subdivided into four stages they are as follows:  FIRST STAGE OF LABOUR This begins with the onset of true labour and ends when the cervix is completely dilated at 10cm.  This stage is subdivided into three phases as follows:  Latent phase This begins with onset of irregular Uterine contraction, the cervix begins to dilate and efface little or with no fetal descent. The cervix dilates from 0 – 4 cm, it lasts for 6 – 8 hours in primip gravida and shortens in multigravida.  The cervical canal shortened from 2 – 5 cm to less than 0.5cm. Uterine contraction becomes established during this phase and increases in frequency, duration and intensity Active phase This is characterized by rapid cervical dilatation, initially when two phases of the first stage were recognized. Active phase begins from 4 cm dilation to 10 cm. The cervix dilated 1 cm per hour, fetus descent is progressive, contraction occurs at a frequency of 2-5 times in 10 minutes.  Moderate to strong uterine contractions lasting for 2- 40 seconds progressing to greater than 40 – 60 second s. The woman’s anxiety increases as contraction and pain increases, she may adopt various coping mechanisms Transition phase This is from 8 cm dilation to 10 cm, this is the last part of the first stage and the woman demonstrates significant anxiety.  The contractions becomes more intense and forcefully, the woman becomes restless and frequency changing positions, the contractions are strong about 3 – 5 times in10 minutes lasting for 60- 90 seconds as dilatation approaches 10 cm, there is an increase in rectal pressure and uncontrollable urge to bear down, increase in bloody show, spontaneous rupture of membrane, if membrane has not been ruptured already.  There is a sensation of great pressure at the pick of contraction that it seems that her abdomen will burst open. Physiology of the first stage of labour The events of first stage of labour are divided into two major categories for better understanding, and they include: The duration of labour This varies depending on numerous factors such as parity, birth interval, psychological state, presentation and position of the fetus, maternal pelvis shape and size, and the nature of Uterine contraction. First stage of labour takes the greater part of the labour, especially the latent phase.  Active phase of labour is expected to be completed between 6 – 12 hours, labour last longer in primip gravida woman than multiparous woman, duration of labour should not last longer than 18 hours Note: World Health Organization (WHO) recommended management of the active phase of labour with pantographs, this will help manage the progress of labour and action to be taken if labour is prolonged. Uterine Action Series of event occurs in the Uterus during labour such as Management of first stage of labour

Type of pelvis and their effects on labour The shape and structure of pelvis varies from one woman to another, ut ideal normal pelvis favours vaginal delivery. There are four main types of pelvis are gynaecoid, android, anthropoid and platypelloid. Table of contents GYNAECOID PELVIS This is another name for the female pelvis designed for child bearing. It is found in about 50% of women whose hips are broader than their shoulders with a height over 1.5m and shoe size of about 4 and above.  Characteristics Effects of gnaecoid pelvis on labour The fetal head is always engaged in transverse diameter of the brim in an anterior position, this causes the mechanism of labour normal, therefore the gynaecoid pelvis is the best for child bearing. ANDROID PELVIS This is the male type of pelvis, possessing about 20% of women. The bones are heavier than the gynaecoid pelvis. Characteristics Effects of Android pelvis on labour The available space in this type of pelvis is restricted by the triangular shape of the brim, the head, therefore may engaged transversely in an occipito posterior position, so this type of pelvis favours: ANTHROPOID PELVIS This is an APE type of pelvis possessing about 24–25% of women who have very tall long legs with narrow shoulders. The bones are quite heavy, this type of pelvis is common in women in South Africa. Characteristics Effects of Anthropoid pelvis on labour PLATYPELLOID PELVIS This is a flat pelvis possessing about 5% of women Characteristics Effects of Platypelloid pelvis on labour

General description of bony pelvis The bony pelvis is a strong bony ring linked to a tilted basin which protects and contains the female reproductive organs. The following are found within the pelvis:  It is through these route that a baby passes through during delivery. Structure of the pelvis The bony pelvis is made up of 4 bones these are: INNOMINATE BONES These forms the anterior and lateral walls of the pelvis. Each innominate bones consists of: ILIUM This is the largest flat plate of bone above and part of the acetabulum below. Characteristics Anteriorly: the iliac crest ends in the anterior superior iliac spine Posteriorly: it ends in the posterior superior iliac spine. THE  ISCHIUM This is the lowest of the constituent bone of the innominate bones. The shape is C curved. Characteristics THE PUBIS This is the smallest of the innominate bones and it is the only one that articulate with it’s fellow on the opposite side. Characteristics THE  SACRUM Is situated at the posterior part of the pelvis, therefore it forms the posterior wall of the pelvis. It is waged shaped Characteristics THE  COCCYX This is a small bone which consists of 4 fused coccygeal vertebrae. It is trianglar in shape with it base at the upper most Characteristics PELVIC  JOINT There are 4 in number  The sacroilliac  Joint The joint is formed at the articulates of the sacrum with the ilium in normal condition, very slight movement occurs at this joint. But during cyesis( pregnancy) and labour. This movement increases in range when the ligament becomes softened under the influence of the hormone relaxing The symphysis pubis Joint This joint is formed at the junction of the two pubic bones, which are United by a pad of cartilage. This joint widely appreciably during the later month of pregnancy and the degree of movement permit may give rise to pain on walking The sacrococcygeal Joint This joint is formed where the base of coccyx articulates with the tip of the sacrum and allows the coccyx to bend backwards during the actual birth of the head of the baby PELVIC  LIGAMENTS There are 6 pelvic ligaments which are of important to midwife. Supporting Ligament This is the strongest ligament in the whole body, they binds with the sacrum and ilium at the Sacro Illiac Joint Sacro Tuberous Ligament It is a strong ligament passing from the posterior superior iliac spine and the lateral border of the sacrum and the coccyx to the ischial tuberosity. It bridges across the greater and lesser sciatic notches. Note: the Sacrotuberous and spineous ligament forms the posterior wall of the pelvic outlet. Sacrospineous Ligament This pass from the sides of the sacrum and coccyx across the greater sciatic notch to the ischia spines. It is a strong ligament and lies in front of the Sacro tuberous ligament.  Inguinal Ligament This ligament runs from the anterior superior iliac spine to the pubic tubercle. Lucuna Ligament This is a small ligament which occupies the angle under the inner end of the inguinal ligament. Obturator Membrane This ligament closes the obturator foramen with the exception of small area in its upper part which transmit the obturator vessels and nerves and also contains the obturator lymphatic glands. THE REGIONS OF THE PELVIS Obstetrically the bony pelvis is divided into two as follows: The False Pelvis This is the part above the brim which consists mainly the flared out iliac bones. It has little obstetric importance. The True Pelvis This is the curved bony canal through which the fetus most pass during birth. It consists of the brim, the cavity and the outlet. . THE AREAS OF THE PELVIC MEASUREMENT (DIAMETERS) THE PELVIC BRIM This is the first part of the Pelvic gland, it is rounded accept where sacral promontory encroaches into it. The promontory and the wings of the sacrum form its posterior border (alae of the sacrum). The iliac bone forms it’s lateral bounder while the pubic bone forms it’s anterior bounder. Obstetrically, the boundaries of the brim also known as its landmarks, are very important to midwife and these includes:  THE  CAVITY This is circular in shape and it’s anterior walls form by the posterior pubic bones and the symphysis pubis. It measures 4cm, the posterior walls measures 12cm and is formed by the curve of the sacrum. Laterally are the greater sciatic notch,body of the sacrum and obturator foramen covered by the obturator internus muscles. THE  OUTLET This is described into two parts The Anatomical outlet The Obstetrical outlet The obstetric outlet is of greater important to midwife because it is the areas in which the fetus must negotiate as passes through the birth canal rather than the wide anatomical outlet. DIAMETERS OF THE PELVIS A diameter is a distance between two points. The study of diameter is of greater important to midwives for the skillful management of labour. DIAMETERS OF THE BRIM Four diameters are measured and they includes:  the sacrocondyloid is the smallest diameter of the brim and it is improtance is concerned with posterior position of the occiput when the pariental eminance of the fetal head may become trapped. DIAMETERS OF THE CAVITY There are 3 diameters of the cavity DIAMETERS OF THE OUTLET 3 diameters are obtained at the outlet and these includes:  TYPES OF CONJUGATE THE PLANES OF THE PELVIS & THEIR ANGLES OF INCLINATION The planes of the pelvis are imaginary flats surface drawn at various levels of the pelvis canal that is:  When a person is standing upright the plan makes an angle of 60 degree to the floor. Because the Pelvis is curved canal. The angles of the brim, cavity and outlet must be different too. Therefore the angle of the plane of the Pelvic brim to the floor is 60 degree. The angle of the plane of the cavity is 30 degree while that of the outlet to the floor is 15 degree. AXIS OF THE PELVIC CANAL This is an imaginary line drawn

Description of Ovaries The Ovaries are the female glands or organs that lie within the peritoneal cavity in a small depression of the posterior wall of the broad ligament. Location: They are situated at the fimbrated end of the Fallopian tube at about the level of the pelvic brim. Shape: They are small almond like organs dull white in colour and with a corrugated surface Size: They measure 3 cm in length 2 cm  in breath and 1 cm in thickness. They weigh about 6 gram Gross structure This varies with the age of the woman. From birth to puberty, the organs are smooth dull white and rather solid in consistency. During the menstrual phase ie from puberty to menopause, the organs are longer and rather on the surface, and in more like a walnut than an almond.  During the post menopausal phase, the ovaries beco smaller and shruken and are covered with scar tissues, where month after month the graffian follicle have ruptured. Microscopic structure The ovaries are composed of the cortex and a medulla surrounded by a germinal epithelium. Changes begin in some of the primordial follicles right from the Uterine life and persist throughout infancy and early girlhood. These changes consist of increase in the number of calls around the ovum and is followed by the appearance of fluid between the cells known liquour folliculi and the primordial follicle is now known as the “graafian follicle” The tunica albuginea is the outer part of the corvex formed by a sense fimbrous coat. The germinal epithelium consists of a layer of low cubical cells which covers the tunica albuginea of the cortex and is continuous with the mesovarian. Therefore the germinal epithelium is the modified form of the peritoneum.   Ovarian Attachments Relations of the ovaries Blood supply: by the ovarian and Uterine arteries Venous Drainage: by corresponding veins Nerve Supply: by ovarian plexus Lymphatic Drainage: into lumbar glands. Functions of ovaries Hormonal secretion of the Ovaries The graffian follicles and corpora lutea are not only under the hormonal influence of pituitary gonadotropins, but also secrete hormones on their own account. During the development of the graffian follicle, oestradiol is secreted by the cells of zona granulosa and the theca internal and stored in liquour folliculi. After ovulation it is secreted in lesser amount by the corpus luteum and is also formed in the cortex of the supra – renal glands. It is metabolized in the liver and excreted mainly in the urine in form of oestriol and oestreone and some 8 other related compounds.  These substances are collectively called oestrogen and are responsible for the secondary sex characteristic of puberty in young girls and some changes that occur during the menstrual cycle and pregnancy. Effects of oestrogen Major effects of oestrogens are: Progesterone —Key hormone of ovaries The corpus luteum under the influence of LH produce another hormone known as progesterone and a small quantity of oestrogen. The changes produced in the body by progesterone are mainly manifested in large quantities. Apart from pregnancy, it’s main function is endometrial changes as part of the menstrual cycle. Effects of progesterone During pregnancy it is responsible for:  The Ovarian Cycle This is described in three parts as follows:  Development of graffian follicle During fetal life the cortex of the ovary forms thousands of primitive eggs cells or primordial follicles which are present when the child is born. Every month from age of puberty onwards through child bearing life several follicles begins to develop as a rule, only one becomes fully matured and rises to the surface of the ovary. The one that matured is known as the graffian follicle (named after Dr.Von Graff).  Structure of a mature graafian follicle A mature graafian follicle is about 8-12mm.  Mechanism of ovulation Ovulation means ripening and discharging of an ovum from a graffian follicle into the peritoneal cavity. The reproductive age of a woman begins with menarche (appearance of first menses) to menopause (cessation of menstruation) at about 45-50 years. During this period, one graffian follicle out grows it’s fellow and enlarges in size . It then protrudes to the surface of the ovary with the discus and the ovum. As the follicle enlao it stretches the ovarian capsule (covering) until it becomes so thin and breaks finally. The follicle thus ruptures and the liquor folliculi, Discus and ovum are cast out into the peritoneal cavity. This process is known as ovulation. Ovulation takes place each month in alternate Ovaries so that each individual ovary ovulates at 2 monthly intervals. The corpus luteum After ovulation the walls of the graffian follicle collapses and become wrinkled at the same time some of the cells grow and develop yellowish coloured bodies. This yellowish wrinkled structure is known as corpus luteum, which under the influence of LH produce by the anterior pituitary produce progesterone which thickens the endometrial wall. It remins active for 14 days but if after that period fertilization does not take place, it does ,shrinks and become corpus albicans.  This leaves a whitish scar on the surface of the ovary. On the other hand, if fertilization takes place corpus luteum persist for 12 weeks until placenta is formed to take over the hormonal function of the corpus luteum. Hormonal control of ovulation The growth and ripening of the ovarian follicle are under the hormonal control- Follicular stimulating hormone (FSH) from the anterior pituitary gland. FSH is carried in the bloodstream from the pituitary to the ovary where it causes the follicle to grow and enlarge and at the same time stimulate the cells of th zona granulosa and the theca internal to produce oestradiol. When the amount oestradiol reaches a certain level, the production of FSH is stopped and LH from anterior pituitary gland is produced. When the FSH is falling, LH is rising and at certain ratio , this cause the follicle to rupture and ovulation occurs. After ovulation, the development and growth of corpus luteum occurs due to action of

Description of third stage of labor Third stage of labour is defined as the period between birth of the baby to complete expulsion of placenta and membranes. It is the shortest but most dangerous stage of labour since there is for postpartum haemorrhage, uterine inversion and rupture. Physiology of third stage of Labour This involves separation, descent, expulsion and control of haemorrhage. The time the placenta actually separates from the uterine wall varies. Separation may start during final expulsive contraction of the second stage or may remain attached some time.  Third stage of labour lasts between 5 – 15 mins but up to 1 hour is still normal. It comprise of mechanical factors and control of haemorrhage (haemostasis) Mechanical factors Management of the third stage of labour Placenta could be delivered using physiologic and active management of third stage of labour Physiologic management or Expectant management Routine administration of uterotonics is withheld. Signs of separation of cord are observed.  Active management of Third stage of labour The active management of Third stage of labour is discussed in three (3) steps Step 1: Give oxytocin Give oxytocin 10 I.U I.M within one minute of birth of the baby after checking for a second baby Step2: Controlled cord traction to delivery of placenta Step 3: Massaging the uterus and control of bleeding Procedure for Active management of Third stage of labour Advantages of Active management of Third stage of Labour STEP TO STEP IMMEDIATE CARE OF THE NEWBORN Stimulation The baby that is active does not need stimulation. Rough handling of newborn children should be discouraged. If the baby is not breathing. Stimulate the baby after suctioning by gently rubbing the back. Most babies start to breathe very well after stimulation. Handling a baby roughly like beating the back, turning upside down can cause injury to internal organs and brain Assess the Apgar Score at 1 minute and 5 minutes after delivery Apply Olive oil This helps to maintain warmth. Clean off any blood stain on the baby’s skin. Do not remove vernix  caseosa because it also help to keep baby warm and will later be absorbed Weigh the baby, measure height, length and head circumference Complications of third stage of labour  Final Notes

What is the menstrual cycle? Menstruation is a monthly physiological bleeding from the endometrium that lasts from about 4 days from the time of menarche to menopause. The occurrence of monthly menstrual flow is known as menstrual cycle. Physiology of menstruation The uterine changes which relate to menstruation occur in the corpora endometrium, as a result of its stimulation of the ovarian hormones; oestrogen and progesterone. These takes form of: The  Proliferative Phase This begins at the end of menstrual phase and lasts for about 10 days ie until ovulation. During this period, a graffian follicle starts to develop in the ovary. FSH from anterior pituitary stimulates the cells of the graffian follicle to secrete oestrogen which is responsible for the growth of the endometrium from unchanged deeper layer. At the conclusion of these phase, the endometrium consist of three layers:  A basal layer: lies immediately above the myometrium about 1mm in thickness. This layer never alter during the menstrual cycle. It contains all the necessary rudimentary structures for building up new endometrium  A functional layer: which contains tubular glands and is 2.5mm thick. This layer changes constantly according to the hormonal influences of the ovary. A layer of cuboidal: ciliated epithelium Covers the functional layer. It deeps down to line the tubular glands. The Secretory Phase After the proliferative phase, ovulation takes place and corpus luteum is formed. The corpus luteum is under the influence of luteinizing hormone(LH) from anterior pituitary, secretes progesterone. This cause the endometrium which was being growing under the influence of oestrogen to undergo further growth and glands increase in size, become more tertous and secrete more mucus. Blood supply is also increased giving a red corrugated surface. This is in preparation for the fertilized ovum. The Menstrual Phase Should fertilization not take place the ovum dies, the corpus luteum disintegrates. The secretion of oestrogen and progesterone falls. The endometrium shows degenerative changes which is followed by bleeding lasting for 3-4 days. Disorders of Menstrual Cycle

What is an abnormal pelvis? Abnormal pelvis is a pelvis with disruption in its structure or function.  It is the main cause of prolonged or obstructed labour that necessitates cesarean delivery.  There are different types of abnormal pelvis which are classified under two main groups. Congenital abnormalities of the pelvis Justo Minor: This is like gynaecoid in shape but all the diameters of the brim cavity and outlet are proportionately reduced, it is seen in women of small status. The shoe size is less than 4. Effects of Justo Minor pelvis  on labour  Naegele’s pelvis: Here the sacrum has only one wing or alae. This can occur in a woman who has limping gait for many years Roborth pelvis: The sacrum has no wings or alae at all and so it is contracted in all directions High Assimilation: In this type of pelvis, the last lumbar vertebra is fused to the upper part of the sacrum producing a large promontory with a subsequence reduction of anterior posterior diameter of the brim, because of this the head may fail to engage Achondroplastic pelvis: Failure of the growth of both the long bones leading to dwarfism. This condition also affects the shape and inclination of the pelvis Contracted pelvis: This is the type of pelvis in which the one or more essential diameter like anteroposterior position (AP), transverse, or oblique diameter of the brim, cavity and outlet of the brim is reduced by 1 cm or more. Acquired abnormalities of the pelvis Rachitic Pelvis: the pelvis is deformed due to ricket in early childhood. Ricket is due to lack of vitamin  D, causing non-absorption of calcium and phosphorus. The incidence of this type of pelvis is now reduced due to infant welfare facilities and health care. Osteomalacia Pelvis: Deformity here is due to deficiency of minerals, vitamin A and D in diet. This makes the bones to be soft on the side walls of the pelvis canal, squashed together until the brim becomes a mere slit shape. Spondylolytic  Pelvis: This is a condition where the lower lumbar vertebra slight forward to over hanged the sacral promontory thus markedly reduced the anterior posterior diameter of inlet Fractured Pelvis: Badly healed fracture of the pelvis reduces the diameter of the brim, cavity and outlet. Kyphotic Pelvis: This is when there is curvature of the vertebrae the shape of the pelvis(hunch back). The shape and inclination of the pelvis are always affected because the diameters are all reduced and squashed Effects of abnormal pelvis on labour If the degree of contraction is sereve elective C/S is carried out. But where there is  minor or moderate contraction of the pelvis, trials of labour may be carried out, as fortunately these women often have small babies (law of compensation is observed). Conclusion Normal(gynaecoid) pelvis is ideal for pregnancy and parturition.   However, abnormal pelvis does not favour vaginal delivery and is usually associated with operative delivery.  We encourage that all women during pregnancy receives adequate nutrition and take their prescribed routine drugs(vitamins and minerals) to ensure that the baby in-utero obtains good supply of nutrients from maternal bloodstream.  Again, all girl children should be placed on balaced diets, encouraged to engage in moderate and regular exercises and prevent them from engaging in anything capable of causing trauma or injury.

The essential functions of umbilical cord cannot be over emphasized. Therefore, any  abnormal umbilical cord  predisposes to rupture, mechanical failure, entanglement, disruption of labour, uterine malfunction, and premature labor.  What are abnormalities of umbilical cord?  Cord abnormalities are silent and invisible but can be diagnosed prenatally with meticulous ultrasound scan. Sometimes, may not be diagnosed until in labour/delivery. The followings are abnormalities with their accompanying risks: False knots:  This is also known as Pseudoknots, resulting from merely a varicosity or redundancy of an umbilical blood vessel (usually the vein) within the cord substance and cannot be physically released in an intact cord. This cord anomaly has no clinical significance. Nuchal Cords:   Dr. J. Selwyn Crawford of the British Medical Research Council in 1962 was first  to define this  as the condition in which the umbilical cord is wound at least once around the neck of the fetus.  Simply, whenever a fetus’s umbilical cord crosses itself 360 degrees  around the neck, it’s called a nuchal cord. This increases the risk for entanglement, fetal distress and neonatal depression, and possibly prolonged labour or even fetal death. Thin or ‘lean” knot:  This is called Thin-cord syndrome which is characterised by reduced or completely absent Whartonʼs jelly.Whartonʼs jelly surrounding the three umbilical vessels offers a flexible protective layer against vessel compression, kinking and other mechanical forces, and hence, assuring the fetal blood supply and removal of metabolic waste products. With deficient or absent Wharton’s  jelly, the umbilical cord is drastically exposed to dangers.  Thick knot: Umbilical cord is naturally designed in a way to regulate blood flow. Therefore, the thickness of the cords can disrupt circulation. Single umbilical artery (SUA):  This tends to cause disturbance in the fetal blood flow leading to fetal distress and stillbirth. SUA occurs in two forms: a helical form and a straight form.  The absent left or right umbilical artery is linked with increased risk of fetal abnormalities. SUA is found  to be common in twins and diabetic pregnancies, and also with long cords and small placentas. Single umbilical artery may indicate  kidney abnormalities.  Abnormal insertions of the cords: These may occur as:  True Knots:   True knots is a rare cord anomaly occurring in 0.5% of all pregnancies. True knot is the abnormal twisting of the cord leading to disturbances in blood flow and it may be single, double, or triple. True knots are associated with hematomas.  Fetuses with true umbilical knots are at high increased risk of fetal hypoxemia and intrauterine death due to constriction of blood vessels.  Probably, true knots develop early in pregnancy when intrauterine space is available for excessive fetal movement As the fetus grows, a true knot may tighten or tightening may occur at delivery when the umbilical cord undergoes traction. The constriction or hematoma development may lead to fetal hypoxia, neurologic impairment or fetal demise. Etiologically, true knots are linked with conditions(risk factors) that allow for increased fetal movement including multigravidae, long cord length, male fetuses,small fetuses, monoamniotic twins and increased amniotic fluid(polyhydramnios). Cord torsion:  Torsion is an anomaly of umbilical cord where twists are  superimposed on the cord itself like an overly twisted telephone cord. Note that torsion is not a natural state of the umbilical cord and hence,torsioned cords must never be likening to naturally helical, coiled, or spiraled cords. Knots and nuchal cords do not usually accompany torsion, but they can be observed with torsion.   The  harmful effect of torsion on the fetus ranges from heart failure to stillbirth owing to disrupted blood flow.  Absent umbilical cords:  This is a rare cord anomaly. If the umbilical cord does not develop, the fetus can develop but can be malformed. The fetus is directly attached to the placenta at the abdomen and usually develops defects. Fetuses without cords have been born by C-section. Without an umbilical cord, life is usually not possible. Short cord (<40):  A short cord has found to be associated with increased risk for fetal malformations, umbilical vein and arteries to tears, which can lead to hematomas (vessel rupture of the cord, fetal distress and death, stillbirth risk especially with  relatively short cords which can be more heightened in the presence of other factors like toxemia,  maternal labor and delivery complications, including retained placenta, uterine inversion(inside out and a medical emergency) can occur from traction on a short cord, placental abruption and  prolonged  labour due to  poor fetal descent seen in short cord accruing operative vaginal delivery (forcep, vacuum extractions or even cesarean section).  Short cords and cigarette smoking tend to result in small babies, called IUGR  (intrauterine growth retarded).  Moreover, restricted  fetal movements and when they occur,  may predispose the cord vessels to compression/constriction, thrombosis, hemorrhage, or hematoma formation.  Relatively short cords interfere with the mechanics of labor and delivery while exhibiting changes in fetal heart rate patterns.  Short cord is  believed  to be associated with placental trisomy 16. Long cord (>60):  Excessive lengthy cords are found to be associated with cord entanglements around the neck and body, cord prolapse (slip out of the womb), emergency deliveries and fetal thrombotic vasculopathy in the placenta, fetal death and increased risk of neurological complications. Long cords can enter  the fetal mouth acting as ”pacifier” or the fetus handles the cord like a toy.  This may result in cord blockage  during the sucking and handling thereby affecting the fetus. Risk factors associated with long umbilical cords: Naturally, male cords tend to be longer than female cords, and term vertex fetuses may have longer lengths than term breech fetuses (with the duration of presentation unknown).  Multigravida cord length may be longer than primigravida cord length (the first pregnancy having a shorter length than the third, this may imply more room for movement-tension or more blood supply/hormone production/fetal and maternal weight gain).  Multifetal pregnancies may have fetuses with discordant lengths and shorter lengths than singletons.   Patent urachus: This results in fistulous or abnormal connection of the bladder with umbilicus.  Variable umbilical cord-vessel number: These are rare though reports had shown presence of