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TABLE OF CONTENTS

i.Title Pageii.Dedication

iii. Acknowledgementiv. Introduction

Chapter I - MATERNAL DATABASE

A. Patients Personal Data ----------------------------------------------------------------- 5B. Nursing History ------------------------------------------------------------------------- 6

C. Gordons Eleven Health Functional Pattern ------------------------------------------ 7D. Physical Assessment ------------------------------------------------------------------- 9

E. Knowledge, Beliefs & Practices ------------------------------------------------------- 11

Chapter II HUMANREPRODUCTIVE SYSTEMA. Male Reproductive System ------------------------------------------------------------ 12

B. Female Reproductive System ---------------------------------------------------------- 13C. Illustration of Male & Female Reproductive Organ --------------------------------- 15

Chapter III PREPARTAL PERIOD

A. The Menstrual Cycle ------------------------------------------------------------------- 16

B. Signs of Pregnancy ---------------------------------------------------------------------- 20C. Maternal Physiology Changes During Pregnancy -------------------------------------- 23D. Fetal Development ---------------------------------------------------------------------- 30

E. Pre-natal Care --------------------------------------------------------------------------- 35F. Recommended Exercises During Pregnancy ----------------------------------------- 51

Chapter IV INTRAPARTAL PERIOD

A. Theories of Labor ----------------------------------------------------------------------- 53

B. Signs of Labor -------------------------------------------------------------------------- 54C. Stages of Labor ------------------------------------------------------------------------- 55D. Mechanisms of Labor ----------------------------------------------------------------- 57

E. Essential Factors of Labor -------------------------------------------------------------- 58F. Immediate Care of the Newborn ------------------------------------------------------ 65


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Chapter VI NURSING CARE PLANS

A. Prepartal Period -------------------------------------------------------------------------- 83B. Intrapartal Period ------------------------------------------------------------------------ 87

C. Postpartal Period ------------------------------------------------------------------------- 90

Chapter VII DOCUMENTATIONS ----------------------------------------------------- 93


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DEDICATION

We would like to ex press our gratitude to the following people; without them thecompetition of this book entitled Maternal and Child Nursing: A Family CenteredApproach would not have been possible.

To our parent who are always there with all the burdens and sacrifices carrying

continually and support us, that if they not been there we would not be here to do this maternalbook.

To our relatives who are always there willing to help us out of problems and challengeswe encounter.

To our instructors and friends whose continues encourage and guide us to accomplish thismaternal book that caused us on great deal of work.

Above all, to our Almighty God whom we believe helps and guide us in our worries and

trials in our daily endeavors.

To all of you, we whole heartedly dedicate this book to which you encourage and helpedus to finish it with low and fulfillment in our heart.


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ACKNOWLEDGMENT

Grateful acknowledgement is made to my parents for their unending support andwholeheartedly given their love and concern in many ways.

The author is greatly indebted to my client who shared her understanding and some

classified information necessary for this book. Likewise my deepest appreciation and gratitudefor her cooperation most especially during the documentation, without her this book would not

have been completed.

My sincerest thanks to our Clinical Instructors, without them I will not be able to comeup with this book. They fed us good advice and tons of encouragement all along way because.

They well know how to do this. There insights and thoughtful comments made us dig deeper intoour abilities and made this book far better in the process.

Special acknowledgment to Ms. Lyla Reyes who both assisted me during the prenatal and

in documenting during the delivery and in the newborn care.

And above all, to Almighty God, for the strength, love and grace in writing this book.


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MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Penablanca, Cagayan

Maternaland Child Nursing

A Family Centered Approach

Is Hereby Presented To The

FacultyofCollegeofNursing

PresentedbyChelo Y. Carig


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INTRODUCTION

There are few (if any) other times in a womans life more intensely emotional than whenshe is pregnant. An emotional roller coaster, it is frequently called in magazine articles and

books on pregnancy, and in the sack of literature a woman receives at her first prenatal visit.

That barely does it justice.

Pregnancy in psychological parlance is a time of crisis, an unfortunate word thatsuggests disaster but in meaning is closer to upheaval. After all, pregnancy is a turning point in

a womans life, perhaps her only rite of passage in a society bereft of meaningful rituals forwomen.

The coming of a baby signals a new life for everyone. A woman who may have seen

herself as daughter, wife, friend, coworker, boss, must now make a room for a new identity:mother.And those around her are no longer who they were. Her partner becomes a father; her

parents, grandparents; her siblings, aunts and uncles. These changes may damage or enhance herself-esteem, damage or enhance her sex life, but will almost certainly get her a seat on a crowdedbus. As she becomes more and more preoccupied with her new role, ambition, drive, her career

and even friendships are crowded out of her consciousness. Sad movies will make her sob. A so-so joke will make her laugh uproariously. She struggles with conflicts over her abilities to

mother and rearrange her life to accommodate a child. Shes troubled over mixed feelings towarda pregnancy that at first is nothing more than a missed period and perhaps a bout of what feels

like stomach flu but will end in a paroxysm of pain. Eventually, this gives way to overwhelminglove for a child she cant see but who swells voluptuously and flutters gently under her heart.

It is important to remember that all these feelings, however troubling are normal and

human. Pregnancy is a time of enormous psychological and physiological changes a sheddingof one identity for another and almost everyone experiences some anxiety around those periods

in their lives. For most women, these feeling are productive. They are preparation formotherhood. For most women, these feelings are productive. They are preparation for

motherhood.

Maternal and child health population has the right to grow to ones full potential and thiscan be achieved through giving attention to their comprehensive physical, psychological and

social needs. The Family centered care in the Childbearing Process, shows you the marvelousemotional and physiological changes during pregnancy and how to take charge of your health

during Prenatal, Intranatal and Postnatal periods. This is to avoid complications of pregnancyand childbirth, which are the leading cause of death and disability for childbearing women in


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MATERNAL DATABASE

PATIENTS PERSONAL DATA

Name : R.C

Address : #19 B Sibal St., Caritan Centro, Tuguegarao City

Age : 31

Sex : Female

Civil Status : Married

Religion : Roman Catholic

Date of Birth : July 16, 1974

Nationality : Filipino

Dialect : Ybanag, Ilocano, and Tagalog

Educational Attainment: College Graduate

Occupation : Housewife

Husbands Initial: B.C

Age : 34

Occupation : ConstructionWorker

Date of Marriage: November 8, 1995

Date of Interview: December 28, 2010


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NURSING HISTORY

Past Health History

The patient has allergies on fish, bagoong and chicken. She received completevaccinations during childhood and had malaria when she was 11 years old.

She has 2 children, both boys. Her eldest was delivered by a midwife and the second oneby a Traditional Birth Attendant, both in home setting.

She was previously hospitalized last May 2003 at Cagayan Valley Medical Center due toGastroenteritis.

Present Health Status

The client had cough on her first trimester and took Solmux and Cotrimoxazole.

She is now on her fourth pregnancy. Her third pregnancy was aborted at two months. Sheis planning to deliver at home and expecting to have a baby boy.

Family HistoryofIllness

The client had a history of Arthritis, Hypertension and Asthma on paternal side and

Hypertension on maternal side. Her father died last 1990 due to Hypertension.

Menstrual History

The client had menarche at the age of 14, of moderate flow for three days. The color isdeep red and with an interval of 28-29 days. The patient never ex perienced dysmenorrhea or

other abnormalities in menstruation.

Obstetrical ScoreG4P3 (T2-P0-A1-L2)

G1 - 1996 - F - NSD - Cephalic - Midwife - AliveG2 - 2003 - F - NSD - Cephalic - TBA - Alive

G3 - Aborted at two months

G4 - Present Pregnancy

HistoryofPresent Pregnancy:

Last Menstrual Period: April 6, 2010

Expected Date of Confinement: August 13, 2005


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GORDONS HEALTH EVELEN FUNCTIONAL PATTERN

1. Health Perception-Health Management PatternThe patient has allergies to fish, chicken and bagoong. She brushes her teeth three times a

day and has dental carries but no loose teeth. She does not use prosthesis. She never goes for

dental check-up. She does not smoke nor drink alcoholic beverages. She uses over the counterdrugs to treat simple illnesses like colds, headache and fever. She considered household chores

as a form of her exercise. She practice adequate nutrition and also maintained her health bytaking Enervon C, thus description of health is fair. She has also an adequate background of

medical knowledge.

2. Nutritional-Metabolic PatternThe patient usually eats thrice a day and is not meticulous about the food she eats. Her

meals consist of rice, vegetables and pork. According to her, she has a good appetite. She can

swallow liquid and solid foods, chew and feed her self. She experiences vomiting every morning.She uses dietary supplement. Her present weight is 70 kg and her height is 56.

3. Sleep-Rest PatternShe usually sleeps six hours a day and takes naps during afternoon. She does not have

sleeping problems and does not use any sleeping aids.

4. Elimination PatternThe usual color of her urine is yellow amber, with mild odor. She urinates at least 9-10

times a day, more frequent at night. At present, she has difficulty in defecating and eliminatesevery other day before taking a bath in the morning. Her fecal discharge is color brown and with

a hard consistency.

5. Activity-Exercise PatternThe client practices full self-care for the following activities: grooming, bathing, and

toileting and leisure activity. She has no difficulty in doing the said activities and does it by

herself. She also does most of the housework and takes care of her two children.

6. Cognitive-Perceptual Pattern


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7. Self Perception PatternShe perceives herself as physically and emotionally healthy. She loves her children and

husband and takes care of them so she considers herself as an adequate mother.

8. Role Relationship PatternThe patient belongs to a traditional close knit family. They live at their own house. She

handles the finances and consults her husband for any decision pertaining to their family.She is able to speak Ybanag, Tagalog and English. She is able to express herself verbally

and with gestures.

9. Sexuality-Sexual FunctionsAccording to the patient, there were no difficulties and problems on their sexual activity.

She had her menarche at 14 with five days duration at 28-29-day interval (7-10 pads for the

whole duration of menstruation), red and with mild odor. There were no difficulties experiencedduring menstruation.

10.Coping-Stress Management PatternWhen she is in stress, the patient diverts her anxiety and anger by busying herself with

household chores and playing the guitar.

11.Value-Belief PatterHer main source of strength is God. She goes to Church with her family every Sunday

and prays everyday.


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PHYSICAL ASSESSMENT

Date of Assessment: March 20, 2005Vital Signs: BP 120/90 mmHg

PR 75 bpmRR 19 cpm

BT- 37CGeneral Appraisal:

The health is good. She is well groomed and her facial ex pression is appropriate. Herlook is within her age. She has a lordotic posture because of her pregnancy.

Area Assessed TechniqueUsed FindingsHair Inspection

Palpation

>Evenly distributed

>Thick hair>No infestation

>Smooth

Head Inspection

Palpation

>Normocephalic

>Absence of nodules>Smooth

Face Inspection >Symmetrical>No lesions

Eyes

Eyebrows

Eyelashes

Conjunctiva

Corneal Reflex

Inspection

Inspection

Inspection

Inspection

>Equally aligned

>Equal movement>Equally distributed

>Intact>Equally distributed

>Pinkish>Shiny

>Blinking

Ears Inspection

Palpation

>Color same as facial skin>No discharges

>Mobile and firm

Nose & Sinuses InspectionPalpation

>Able to smell>Not tender

Mouth Palpation >Soft and moist

Tongue Inspection

Palpation

>Central in position, pink

>Smooth with no palpable nodules


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Palpation

>Breasts are full and tender

Lungs Inspection

AuscultationPalpation

>Normal breathing pattern>No wheezes or crackles

>Lessened diaphragmaticbreathing due to diaphragm cannot

descend fully

Heart Auscultation >Regular rate, no murmurs

Abdomen Inspection >Presence of linea negra and striae

gravidarumGenital Inspection

Palpation>Chadwicks sign>No masses

Skin Inspection

Palpation

>Linea Negra and StriaeGravidarum on abdomen

>Normal Skin Turgor

Extremities InspectionPalpation

>No deformities>Smooth texture

Nails Palpation >Normal CRT

Neurologic Status

LOC

Mental Status

Posture

Balance

Speech

InspectionInspection

InspectionInspection

Inspection

>Alert>Oriented

>Good>Good

>Good

Emotional Status Inspection >Calm


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KNOWLEDGE, BELIEFS & PRACTICES DURING PREGNANCY

Knowledge, Beliefs & Practices Rationale Scientific Basis

Antepartum

Pregnant mother should never eat

dark colored foods like dinuguan& duhat.

Eating dark foods will

cause dark complexion of

the baby.

No scientific basis.

The mother should always bring

garlic and salt when going out atnight.

Garlic and salt serve as a

protection against evil.

Intrapartum

Letting mother or father touch the

abdomen.

This will hasten the

babys delivery.

This can be a means of

emotional support of thefamily.

Throwing rice during delivery. To drive away evil spirit. No scientific basis.

Postpartum

Wear binder or bigkis afterdelivery.

It helps the abdomen toregain its previous shape.

Binder supports the abdomen.

Postpartum mother should sit onbedpan with hot water.

Hot water steam aids inthe healing of perineum.

Steam aids in the healing ofperineum.

Both mother and infant should nottake a bath after two days

Bathing immediately aftertwo days may cause

Dangerous, it may lead toinfection


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HUMAN REPRODUCTIVE SYSTEM

MALE REPRODUCTIVE SYSTEM

Sperm are produced in the testes located in the scrotum. Normal body temperature istoo hot thus is lethal to sperm so the testes are outside of the abdominal cavity where the

temperature is about 2 C (3.6 F) lower. Note also that a womans body temperature is lowestaround the time of ovulation to help insure sperm live longer to reach the egg. If a man takes too

many long, very hot baths, this can reduce his sperm count. Undescended testes (testes aresupposed to descend before birth) will cause sterility because their environment is too warm for

sperm viability unless the problem can be surgically corrected. From there, sperm are transferredto the epididymis, coiled tubules also found within the scrotum, that store sperm and are the site

of their final maturation.

In ejaculation, sperm are forced up into the vas deferens (plural = vasa deferentia).From the epididymis, the vas deferens goes up, around the front of, over the top of, and behind

the bladder. A vasectomy is a fairly simple, outpatient operation that involves making a smallslit in each scrotum, cutting the vasa deferentia near where they begin, and tying off the cut ends

to prevent sperm from leaving the scrotum. Because this is a relatively non-invasive procedure(as compared to doing the same to a womans oviducts), this is a popular method of permanentbirth control once a couple has had all the children they desire. Couples should carefully weigh

their options, because this (and the corresponding female procedure) is not designed to be areversible operation.

The ends of the vasa deferentia, behind and slightly under the bladder, are called the

ejaculatoryducts. The seminal vesicles are also located behind the bladder. Their secretions areabout 60% of the total volume of the semen (= sperm and associated fluid) and contain mucus,

amino acids, fructose as the main energy source for the sperm, and prostaglandins to stimulatefemale uterine contractions to move the semen up into the uterus. The seminal vesicles empty

into the ejaculatory ducts. The ejaculatory ducts then empty into the urethra (which, in males,also empties the urinary bladder).

The initial segment of the urethra is surrounded by the prostategland. The prostate is the

largest of the accessory glands and puts its secretions directly into the urethra. These secretionsare alkaline to buffer any residual urine, which tends to be acidic, and the acidity of the womans

vagina. The prostate needs a lot of zinc to function properly, and insufficient dietary zinc (aswell as other causes) can lead to enlargement, which potentially can constrict the urethra to the

point of interferring with urination. Adding supplemental zinc to the mans diet can often treatmild cases of prostate hypertrophy, but severe cases require surgical removal of portions of the


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The uterus has thick, muscular walls and is very small. In a nulliparous woman, theuterus is only about 7 cm long by 4 to 5 cm wide, but it can expand to hold a 4 kg baby. The

lining of the uterus is called the endometrium, and has a rich capillary supply to bring food toany embryo that might implant there.

The bottom end of the uterus is called the cervix. The cervix secretes mucus, the

consistency of which varies with the stages in her menstrual cycle. At ovulation, this cervical

mucus is clear, runny, and conducive to sperm. Post-ovulation, the mucus gets thick and pasty to

block sperm. Enough of this mucus is produced that it is possible for a woman to touch a fingerto the opening of her vagina and obtain some of it. If she does this on a daily basis, she can use

the information thus gained, along with daily temperature records, to tell where in her cycle sheis. If a woman becomes pregnant, the cervical mucus forms a plug to seal off the uterus and

protect the developing baby, and any medical procedure, which involves removal of that plug,carries the risk of introducing pathogens into the nearly sterile uterine environment.

The vagina is a relatively thin walled chamber. It serves as a repository for sperm (it is

where the penis is inserted), and also serves as the birth canal. Note that, unlike the male, thefemale has separate opening for the urinary tract and reproductive system. These openings are

covered externally by two sets of skin folds. The thinner, inner folds are the labiaminora andthe thicker, outer ones are the labiamajora. The labia minora contain erectile tissue like that in

the penis, thus change shape when the woman is sexually aroused. The opening around thegenital area is called the vestibule. There is a membrane called the hymen that partially covers

the opening of the vagina. This is torn by the womans first sexual intercourse (or sometimesother causes like injury or some kinds of vigorous physical activity). In women, the openings of

the vagina and urethra are susceptible to bacterial infections if fecal bacteria are wiped towardsthem. Thus, while parents who are toilet-training a toddler usually wipe her from back to front,

thus imprinting that sensation as feeling right to her, it is important, rather, that that littlegirls be taught to wipe themselves from the front to the back to help prevent vaginal and bladder

infections. Older girls and women who were taught the wrong way need to make a consciouseffort to change their habits.

At the anterior end of the labia, under the pubic bone, is the clitoris, the female

equivalent of the penis. This small structure contains erectiletissue and many nerve endings in asensitive glans within a prepuce, which totally encloses the glans. This is the most sensitive

point for female sexual stimulation.


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MALE REPRODUCTIVE SYSTEM

FEMALE REPRODUCTIVE SYSTEM


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PREPARTAL PERIOD

THE MENSTRUAL CYCLE

Body Structures PlayingImportant Role inthe PhysiologyoftheMenstrual Cycle:

1. HypothalamusThe hypothalamus is the ultimate initiator of the menstrual cycle. Itsecretes Gonadotropin Releasing Hormones GnRH. It governs the pituitary gland by

hormonal pathways, which in turn governs the ovary in the same manner. It releasesfollicle stimulating hormone releasing factor (FSHRF) during the first half of the cycle

and luteinizing hormone releasing factor (LHRF) during the second half of the cycle.

2. Anterior Pituitary Gland The anterior pituitary gland releases the gonadotropinhormones (GH): follicle stimulating hormone (FSH) and luteinizing hormone (LH)

3. Ovaries The ovary, known as the female gonads, is the site of ovulation and the source

of estrogen and progesterone.

4.

Uterus The organ from which menstrual discharge is formed. The changes that occur inthe uterine endometrial are due to the influence of the ovarian hormones: estrogen andprogesterone.

HormonesInvolved intheMenstrual Cycle:

1. Follicle Stimulating Hormone Releasing Factor (FSHRF) produced by

hypothalamus, stimulates the anterior pituitary gland to release follicle-stimulatinghormone.

2. Follicle Stimulating Hormone (FSH) Produced by the anterior pituitary gland,

stimulates development of several Graafian follicles and their production of estrogen.

3. Estrogen The so-called Hormone ofWomen, which is produced by graafian follicle.It is metabolized by the liver and excreted in the urine. There are three kinds of estrogen:

estradiol, estrone and estriol.

EffectsofEstrogen: Inhibit follicle-stimulating hormone

Stimulates deposition of fat in subcutaneous tissues that gives a female shape anddevelopment of secondary sexual characteristics in female


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4. Luteinizing Horomone Releasing Factor (LHRF) Produced by hypothalamus,stimulates anterior pituitary gland to release luteinizing hormone (LH).

5. Progesterone The so-called Hormone of Mothers, produced by corpus luteum.

EffectsofProgesterone: Thermogenic Effect

Relaxes uterine muscles Promotes growth of the acini cells of the breasts

Causes fluid retention that results in weight gain Is thought to be the cause of Premenstrual Syndrome (PMS)

Causes secretory changes in the endometrium in preparation for implantation Causes tingling sensation and feeling of fullness in the breast before menstruation

Menarche

Menarche refers to the very first menstruation, an event that signifies the end of puberty

and the beginning of the reproductive years of a woman. The average age at which menarcheoccurs is 12 to 13 years; but the onset of menstruation may occur anytime between 9 to 17 years

old depending on nutrition, heredity, race and climate. The first menstrual cycles are usuallyanovulatory, painless and irregular.

PhasesofMenstrual Cycle

The primary purpose of the menstrual cyle is to prepare the uterus for pregnancy. The

average duration of menstrual cycle is 28 days but it may vary between 20 to 45 days. In healthywomen, menstrual cycles continue from puberty to menopause, interrupted only by pregnancy

and lactation.

1. Menstrual Phase Lasts 2-7 days (Begins on the first day of menses) Menstruation is the consequence of progesterone withdrawal

Characterized by desquamation of the superficial layer of endometrium caused bycorpus luteum regression and the consequent withdrawal of progesterone and

estrogen About 2/3 of endometrium is shed off every menstrual period

Lining of the uterus is at its thinnest state


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2. Proliferative Phase

From day 6 to 13 of a 28 day cycle (Lasts for 8-10 days) The very low estrogen level during menstruation stimulates the hypothalamus to

secrete FSHRF, which in turn, stimulates the anterior pituitary gland to secrete FSH.FSH stimulates several primordial follicle to develop into Graafian follicle, but just

one follicle will reach full maturity to release a fully developed ovum while the restwill atrophy and degenerate

Estrogen is lowest on third day and highest a day before ovulation The granulosa cells of the developing graafian follicle secrete estrogen which

stimulates the growth of new cells and capillaries in the endometrium. By the fifthday of the cycle, the endometrium is restored to its usual thickness. Continuous

secretion of estrogen results in continuous growth of the endometrium causing it tobecome highly vascular, with its thickness increasing by eightfolds

Under the influence of estrogen, the genital tract is prepared for sperm migration:cervical secretion becomes abundant, thin and watery to facilitate the journey of

spermatozoa to the uterus This phase is also called follicular, postmenstrual and estrogenic phase

3. Secretory Phase Extends from the 13

thday to the 25

thday

The rising level of estrogen in the blood inhibits the anterior pituitary gland tosecrete FSH. Suppression of FSH, the very high estrogen level and the very low

progesterone level triggers the hypothalamus to release luteinizing hormonereleasing factor (LHRF), which in turn, stimulates the anterior pituitary gland to

secrete LH. LH promotes ovulation. After ovulation, the graafian follicle is termed corpus luteum because of its

yellowish coloration. The corpus luteum produce large amounts of progesteronewhich further increases the vascularity of the endometrium, and which stimulates the

endometrial glands to secrete mucin and glycogen. Because of this, the endometrium becomes very soft, spongy and edematous, very

rich in nutrients making it ideal for implantation. The corpus luteum has an average lifespan of about 7-8 days. If no fertilization

occurs at this time, it regresses and becomes nonfunctional 10-12 days afterovulation resulting in withdrawal of estrogen and progesterone.

If fertilization occurs: The fertilized ovum or zygote will implant in 7-8 days afterfertilization. The trophoblast cells of trhe zygote will secrete human chorionic

gonadotropil beginning on the 7th

day after fertilization to prolong the life of theth


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4. Ischemic Phase

If fertilization does not take place, the corpus luteum shrivels as its lifespan is onlyup to 7 days from the date of ovulation. Degeneration of the corpus luteum results in

withdrawal of estrogen and progesterone. Progesterone withdrawal results in formation and release of prostaglandins and

possibly, of endothelin-1 that causes arteriolar spasms and contraction ofmyometrium.

Arteriolar spasms cuts off blood supply to the uterus causing tisuue necrosis andrupture of blood vessels that would lead to endometrial sloughing. The desquamated

cell together with the blood is discharged from the uterus by muscular contraction. This muscular contraction may cause some degree of discomfort on some women,

commonly known as menstrual cramps or dysmenorrheal when severe. The onset of menstruation signals the beginning of another menstrual cycle.


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SIGNS AND SYMPTOMS OF PREGNANCY

PRESUMPTIVE SIGNS

1. Amenorrhea - Pregnancy is suspected if more than 10 days have elapsed since theexpected menstrual period.

2. Breast Changes Starting on the fourth week of pregnancy, breast enlarge, feels tenderand heavy, veins become prominent under the skin, areola gets darker and wider, nipple

stand out and Montgomery glands become prominent.

3. Urinary Frequency The pressure exerted by the enlarging uterus during the firsttrimester and the pressure of the presenting part during the last weeks of pregnancy create

the same sensation as when the bladder is distended with urine and needs emptying.

4. QuickeningThe first fetal movement felt by the mother, felt by primis at 20 eeks andmultis at 16 weeks.

5. Easyfatigability.

6. Leukorrhea Increase vaginal discharge characterized as white mucoid is due toelevated estrogen levels.

7. Nauseaand Vomiting/Morning Sickness Commences six weeks after the LMP andpersists up to 12 weeks gestation. This normal disturbance of the GIT in the first trimesteris believed to be caused be elevated HCG levels.

8. Chadwicks Sign Increase blood supply results in purplish discoloration of the vagina.9. Skin Changes:

StriaeGravidarum-is a cutaneous condition characterized by stretch marks (Striae

distensae) on the abdomen during and following pregnancy.

Linea Negra-is a dark vertical line that appears on the abdomen during about threequarters of all pregnancies. The brownish streak is usually about a centimeter in

width. The line runs vertically along the midline of the abdomen from the pubis totheumbilicus.


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descent (on the forearms) and in men and women of German/Russian and Jewishdescent (on the face).

Increased

pers

pirat

ion

Hairgrowsmorerapidly

PROBABLE SIGNS

1. Hegars Sign Softening of the lower uterine segment, which is felt? starting 6 to 8

weeks after LMP.

2. UterineGrowth The uterus doubles is size as early as 10 weeks and pregnancy becomesobvious by 14 weeks. Uterine growth is determined by measuring fundal height.

3. Ballotement Refers to the rebound that occurs when the examiners fingers tap the

floating fetus within the uterus and caused by the fetus floating away and returning to itsprevious position. Ballotement is observable beginning 6 to 8 weeks.

4. Uterine Suffle A muffled swishing sound heard over the abdomen in union with the

mothers heart beat

5. Goodels Sign Softening of the cervix can be observed beginning 6-8 weeks after

LMP. In carcinoma of the cervix, the cervix remains firm until the onset of labor.

6. Braxton Hicks Contractions They are painless palpable contractions occurring atirregular interval and felt by the mother as sensation of tightness over her abdomen. They begin

as early as 8 weeks gestation and tend to become stronger as pregnancy advances.

7. Fetal Outline Fetal outline is palpable at 24 weeks.

8. Positive Pregnancytests It is the presence of HCG in the womans blood and urinethat gives a positive result to a pregnancy test. HCG production most probably begins at the time

of implantation. Highest level is attained at 60 to 70 days of gestation. It decreases thereafter andreaches its lowest level at 100-130 days of pregnancy. HCG is present beginning 24 to 48 hours

after implantation. The earliest time that it can be detected in maternal serum is:

8days after ovulation 23days after LMP

5 days before the expected menstrual period


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3. Fetal movement can be felt by the examiner from 20 weeks onward.

4. Ultrasonographic evidence of Pregnancy:

Abdominal pulse echo sonography can detect intrauterinbe pregnany at 4

to 15 weeks. Small white gestational ring can be detected after six weeks.

Fetal brain and heart action is demonstrated by eight weeks usingDoppler or real time sonography.

Fetal head and thorax can be identified by 14

th

week.


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MATERNAL PHYSIOLOGY CHANGES DURING PREGNANCY

Reproductive System

Uterus

Changes in Uterine Measurement:

Uterine Prepregnacy Term Pregnancy

Weight 50gm 1100gm

Thickness 2cm 0.5cm

Length 6.5cm 32cmDepth 2.5cm 20cm

Width 4cm 24cm

Capacity 10m 5000ml

Blood Flow: Uterine blood flow increases from 20 ml before pregnancy to 700 to 900 ml at the

end of pregnancy. Three fourths of blood supply to the body goes to the placenta.

Shape: From pear-shape before pregnancy to spherical and later on to ovoid shape in the lastmonths of pregnancy.

Position:After 12 weeks gestation, the uterus loses its anteflexed position.

Dextrorotation of the Uterus: As the uterus rises out of the pelvic cavity after 12 weeks

gestation, it rotates to the right because of thepresence of rectosigmoid on the left side of the

pelvis. As it grows larger and occupies much of the space in the abdominal cavity, the uterusdisplaces the intestines to the sides of the abdomen.Location of the Fundus:

12 weeks at the level of symphisis pubis 16 weeks halfway between symphisis pubis and umbilicus

20 weeks at the level of umbilicus 24 weeks - two fingers above umbilicus

30 weeks midway between umbilicus and xiphoid process

36 weeks at the level ofxiphoid process 40 weeks two fingers below umbilicus, drops at 34 weeks level because of

lightening

Contractility: Being muscular, the uterus is a highly contractile organ. Beginning on the first

trimester the uterus undergoes irregular contractions Late in pregnancy these contractions


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Cervix

Color:Color of the cervix change from pinkish to purplish due to increased blood supply.

Leukorrhea: Estrogen stimulation results in increase mucus production that leads to theformation of operculum, the mucus plug of the cervix that protects against bacteria and infection.

The discharge of operculum at term, called show, is an important sign of labor.

Beading:The pattern showed by a pregnant womans dried cervical mucus under the microscopewhich is an effect of progesterone.

Consistency: Softening of the cervix, known as Goodels sign, is observable by 6 to 8 weeks

gestation.

Isthmus

During pregnancy, the isthmus softens and elongates up to 25mm. it will later formthe lower segment, together with the cervix.

Hegars sign softening of the lower uterine segment begins as early as 5 weeksgestation

Vagina

Increase blood supply results in:

Chadwick Sign vaginal mucosa change in color from pinkish to purplish or dark-bluish.

Increased sensitivity and heightened sexual responsiveness.Vaginal pH: 3.5 to 6, acidic

The vaginal tissues become soft to allow for easier distension during labor

Ovaries

No graafian follicles develop and no ovulation occurs during pregnancy. Corpus luteum of pregnancy the corpus luteum is the chief source of hormone

progesterone during the first 12 weeks of gestation. The corpus luteum also producesestrogen, relaxin, inhibin and sometimes oxytocin.

Breast

Increased breast size due to alveolar tissue growth, fat deposition and increased


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Cardiovascular System

Blood Volume

Total blood volume increases by 45 to 50% for which 75% is plasma and 25% isRBC. Unequal proportion in the increase of blood constituents results in

hemodilution that lowers hematocrit leading to physiologic anemia. Increase blood volume results in the increase in cardiac output by 25 to 50%.

The increase in the blood volume reaches its peak at about 24 weeks; cardiacworkload also reaches its peak during the second trimester.

Regional blood flow

There is an increased supply of blood in several areas of thebody such as the kidney and the skin to make them more efficient in excreting waste

products.

Blood Constituents

There is increased production ofRBC by the bone marrow. RBC increase as muchas 33% and hemoglobin levels by 15% to compensate for the increase in plasma

volume. Hemodilution occur (increase in plasma portion of the blood) causing pseudoanemia.

The rise of the plasma volume of the blood precedes the rise in erythrocytes. Moreplasma is added to the blood than erythrocytes.

Increased protein requirement of the fetus and hemodilution contribute to thereduction in maternal plasma protein levels. Reduction in protein level lowers down

osmotic pressure within intravascular spaces which causes fluid shift fromintravascular to interstitial spaces. This contributes to the normal ankle and foot

edema of pregnancy. Blood lipids and cholesterol levels increase to provide an available supply of energy

for the fetus. Increased level of clotting factors making woman prone to thrombus formation.

Instruct to avoid massage.

Heart

The heart is displaced to the left and upward as the diaphragm is progressivelypushed upward elevated by enlarging uterus.

Slight cardiac enlargement by a little more than 10%. Increased blood volume meansan increased in cardiac workload, because of this slight hypertrophy of the heart

occurs.


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The following are normal during pregnancy:a. Splitting third sound is due to lowered blood viscosity

b. Systolic murmurs in about 90% of pregnant womenc.

Diastolic murmur in 20%

d. Benign pericardial effusion on x-ray Pulse rate increases about 10-15 beats per minute.

Blood Pressure

Blood pressure remains the same as pre-pregnancy level. It may drop slightly on the

second trimester but returns to normal levels on the third trimester. Arterial blood pressure is highest in sitting position, intermediate in supine and

lowest in left lateral position. Supine Hypotensive Syndrome When the women lies on her back, the gravid

uterus lies on the inferior vena cava and interferes with blood flow from the lowerextremities, resulting in blood returning to the heart to be greatly reduced. The

decreased amount of blood going back to the heart results in decreased cardiacoutput that leads to:

e.

Decreased blood pressuref. Decreased blood supply to the brain causing dizziness, faintness and

lightheadedness.

Respiratory System

Changes in respiratory system during pregnancy are chiefly caused by:

Increased oxygen requirement as the mother must supply not only for herself but forthe baby, too.

Effect of progesterone and estrogen. Mechanical effect of the enlarging uterus that reduces the space in the chest.

Hyperventilation:

The mother ex perience hyperventilation in an effort to blow off the extra carbon

dioxide from the fetus. Increased ventilation prevents respiratory acidosis(accumulation of carbon dioxide in the body) which is dangerous to the fetus but it

results in respiratory alkalosis (accumulation of oxygen) which is compensated byincreased renal excretion of bicarbonate.


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Tidal volume (amount of air inspired) increased by as much as 40% to meet increased oxygenrequirements:

Total body consumption of oxygen increase by 15-20%

Nasal congestion occurs due to estrogen stimulation. Advice the woman that this isnormal during pregnancy and that there is no need to take medications.

Urinary System

Urinary frequency during pregnancy is due to:

First Trimester uterus exerts pressures on the bladder as it rises out of the pelvic

cavity. Second Trimester pressures of the presenting part on the bladder after lightening.

Increased blood flow to the kidney which increases glomerular filtration rate andconsequently, urinary output

Lactosuria:

Presence of sugar or lactose in the urine is considered normal. Lactose is secreted by

the mammary glands but since it is not yet used during pregnancy, it normally spillsin the urine.

The following are increased during pregnancy:

Increased urinary output as the mother must excrete her metabolic waste products

and those of the fetus, too. With the increase in the volume of urine, specific gravitydecreases.

Glomerular filtration rate (GFR) and renal plasma flow by as much as 40%. Concentration of renin, angiotensin I & II.

The kidney increases slightly in size. Greater loss of amino acids and water-soluble vitamins in the urine of pregnant

women

Effects of Progesterone:

Dilatation of the ureters particularly on the right side Increased urine capacity of the bladder for about 1,500ml due to decrease bladder

tone


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Dilatation and kinking of the ureters due to the relaxant effect of progesterone andthe compression caused by the enlarged uterus at the level of the pelvic brim leads to

urinary stasis. Urinary stasis predisposes the pregnant woman to infection.

Nocturia:

During the day, the pregnant woman tends to accumulate water in the form ofdependent edema. This fluid is mobilized and excreted via the kidney (urine) at

night.

Gastrointestinal System

Nausea and vomiting on the first trimester is attributed to:

Increased HCG levels Increased estrogen levels

Decreased maternal glucose levels as glucose is being utilized for fetal braindevelopment.

Effects of Progesterone:

Decreased GIT motility and longer emptying time which leads to constipation.

Pyrosis/Heartburn relaxation of cardiac sphincter results in reflux of acidic gastriccontents 9due to hydrochloric acid) into the lower esophagus which irritates the

esophageal mucosa. Instruct to avoid gastric irritants such as coffee, tea, andchocolates.

Slowed bile movement from gallbladder results in the reabsorption of bilirubin intomaternal blood stream which causes generalized itching and increased predisposition

to gallstone formation.

Effects of estrogen:

Ptyalism increased salivation. Epulis hypertrophy or swelling of the gums, advised to use soft toothbrush to avoid

gum bleeding.


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Integumentary System:

Increased melanin production:

During pregnancy, the anterior pituitary gland produce more melanotropinstimulating hormone which stimulates the melanocytes in the skin to produce more

melanin. This results in darker skin coloration in certain parts of the body:

a. Melasma facial discolorationb. Linea negra dark line from umbilicus to symphisis

c. Darker areolaEffect ofEstrogen:

Palmar erythema redness and itching of the hands Vascular spider nevi prominent capillaries under the skin

Activation of sweat and sebaceous glands result in increased perspiration and oilyskin.

Striae Gravidarum:

Enlargement of the uterus results in stretching and tearing of the elastic fibers of the

abdominal skin that results in striae. Striae appear pinkish during pregnancy and turnsilvery white after delivery. Pruritus or severe itching of the abdominal skin is due to

the stretching of the skin. Striaes may also appear in the thighs and breasts.

Endocrine System

Thyroid Gland slight enlargement of thyroid gland due to increased metabolic rate. Pancreas elevated glucocorticoid levels stimulate increase insulin production.

Parathyroid gland enlargement of parathyroid to meet increased needs for calciumto be utilized for the development of fetal bones and teeth.

Adrenal Gland increased corticosteroid production and aldosterone productionpromote sodium reabsorption and water retention.

Pituitary Gland The pituitary gland enlarges but this is not essential to pregnancy. High estrogen and progesterone levels inhibit LH and FSH production.

Increased secretion of growth hormone and melanocyte stimulating hormone Posterior pituitary gland secretes increasing amounts of oxytocin and prolactin as

pregnancy nears term.

Skeletal System


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FETAL DEVELOPMENT

When sperm is deposited in the vagina, it travels through the cervix and into the

Fallopian tubes. Conception usually takes place in the Fallopian tube. A single sperm penetratesthe mother's egg cell, and the resulting cell is called a zygote.

The zygote contains all of the genetic information (DNA) necessary to become a child.

Half of the genetic information comes from the mothers egg, and half from the fathers sperm.

The zygote spends the next few days traveling down the Fallopian tube and divides to

form a ball of cells. Further cell division creates an inner group of cells with an outer shell. Thisstage is called a "blastocyst". The inner group of cells will become the embryo, while the outergroup of cells will become the membranes that nourish and protect it.

The blastocyst reaches the uterus at roughly the fifth day, and implants into the uterinewall on about day six. At this point in the mother's menstrual cycle, the endometrium (lining of

the uterus) has grown and is ready to support a fetus. The blastocyst adheres tightly to theendometrium, where it receives nourishment via the mother's bloodstream.

The cells of the embryo now multiply and begin to take on specific functions. This

process is called differentiation, which produces the varied cell types that make up a humanbeing (such as blood cells, kidney cells, and nerve cells).

There is rapid growth, and the baby's main external features begin to take form. It isduring this critical period of differentiation (most of the first trimester) that the growing baby is

most susceptible to damage from:

y Alcohol, certain prescription and recreational drugs, and other substances that cause birthdefects

y Infection (such as rubella or cytomegalovirus)y Radiation from x-rays or radiation therapy

y Nutritional deficiencies

The following list describes specific changes by week.

y Week3

o beginning development of the brain, spinal cord, and hearto beginning development of the gastrointestinal tract

y Weeks 4 to 5


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o the brain develops into five areas and some cranial nerves are visibleo

arm and leg buds are visible

y Week6

o beginning of formation of the lungs

o further development of the braino arms and legs have lengthened with foot and hand areas distinguishable

o hands and feet have digits, but may still be webbed

y Week7

o

nipples and hair follicles formo elbows and toes visible

o all essential organs have at least begun to form

y Week8

o rotation of intestineso facial features continue to develop

o the eyelids are more developedo the external features of the ear begin to take their final shape

The end of the eighth week marks the end of the "embryonic period" and the beginning of the

"fetal period".

y Weeks 9 to 12

o the fetus reaches a length of 3.2 incheso the head comprises nearly half of the fetus' size

o the face is well formed

o

eyelids close and will not reopen until about the 28th weeko tooth buds appear for the baby teetho limbs are long and thin

o the fetus can make a fist with its fingerso genitals appear well differentiated

o red blood cells are produced in the liver

y Weeks 13 to 16

o the fetus reaches a length of about 6 incheso

a fine hair develops on the head called lanugoo fetal skin is almost transparento more muscle tissue and bones have developed, and the bones become harder

o the fetus makes active movementso sucking motions are made with the mouth


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o nails appear on fingers and toeso the fetus is more active with increased muscle development

o "quickening" usually occurs (the mother can feel the fetus moving)o

fetal heartbeat can be heard with a stethoscopey Week24

o the fetus reaches a length of 11.2 inches

o the fetus weighs about 1 lb. 10 oz.o eyebrows and eyelashes are well formed

o all the eye components are developedo the fetus has a hand and startle reflex

o footprints and fingerprints formingo alveoli (air sacs) forming in lungs

y Weeks 25 to 28o the fetus reaches a length of 15 inches

o the fetus weighs about 2 lbs. 11 oz.o rapid brain development

o nervous system developed enough to control some body functionso eyelids open and close

o

respiratory system, while immature, has developed to the point where gasexchange is possible

o a baby born at this time may survive, but the possibilities for complications anddeath remain high

y Weeks 29 to 32o the fetus reaches a length of about 15-17 inches

o the fetus weighs about 4 lbs. 6 oz.o rapid increase in the amount of body fat

o

rhythmic breathing movements occur, but lungs are not fully matureo bones are fully developed, but still soft and pliable

o fetus begins storing iron, calcium, and phosphorus

y Week36

o the fetus reaches a length of about 16-19 incheso the fetus weighs about 5 lbs. 12 oz. to 6 lbs. 12 oz.

o lanugo begins to disappearo increase in body fat

o

fingernails reach the end of the fingertipso a baby born at 36 weeks has a high chance of survival, but may require some

medical interventions

y Weeks 37to 40

o considered full-term at 37 weeks


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LEOPOLDS MANEUVER

FirstManeuver (Upper uterinesegmentorthe uterinefundus)

Nurse faces woman's head. Palpate uterine fundus.

Determine the height the uterine fundus. Determine what fetal part is in the uterine fundus.

Palpation of the uterine fundus will usually indicate the fetal part situated in the fundus;usually a fetal head; infrequently a fetal breech. Place hands on either side of the fundal area so

that the fingersof both hands almost tough each other (face the woman's head). A somewhat hard and roundish

shape, which when moved back and forth between the finger pads, also moves the entire fetus

usually indicates a fetal breech. Press gently and firmly with finger pads. A very hard roundwell-defined shape which can be moved back and forth (balloted) usually indicates a fetal head.

SecondManeuver (Determines small partsandbackof fetusalong the sidesofmaternal

abdomen)

Examiner faces woman's head. Palpate with one hand on each side of abdomen.

Palpate fetus between two hands. Assess on which side is the fetal back or spine and which side has small parts or

extremities.

Lateral Palpation of the Uterus generally provides information regarding the location of


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ThirdManeuver (Lower uterinesegmentor uterine pole)

Face the woman's head and spread your hands widely apart. Grasp the uterine contents just above the symphysis pubis (firmly but gently). Hold presenting part between index finger

and thumb. Assess for cephalic versus Breech Presentation. Move the fetal presenting part gentlyback and forth in your hand. Fetal head will shift more easily back and forth. Fetal breech will

move the whole body.

Fourth Maneuver (pelvic palpationofthe uterus-assessthe presenting part)

Provides information about the presenting part: breech or head,

attitude (flexion or extension), and station (level of descent of thepresenting part).

Examiner faces woman's feet.Place hands on either side of the lower abdomen with finger pads at the lower uterine pole


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If there is a head palpated in the pelvis, the fetal presentation is referred to as a cephalicor vertex presentation. Assess if a prominence on one side of the abdomen can be palpated

higher than a prominence on the other side. The first prominence felt indicates the sinciput

(forehead) of the infant and is on the same side as the fetal small parts. Therefore, the sinciput ison the side opposite the fetal back. The prominence felt further down the pelvis is the fetalocciput back of the head) and is on the same side as the fetal back.

This maneuver provides information related to fetal descent into the pelvis. How much

of the fetal head can be palpated above the pelvic brim? Is the head fixed into pelvis? Can thehead be easily moved from side to side? When moved from side to side does the presenting part

move by itself back and forth (balloted)? Does the whole fetal body move when palpating thepresenting part side to side?

PRENATAL CARE

Objectives:

The objective of prenatal care is to reach all pregnant women, to give sufficient care to

ensure a healthy pregnancy and the birth of a full term healthy baby. With the present staffavailable, it is not possible to give optimum prenatal care to every pregnant woman. An attempt

should therefore be made to see every woman as she knows she is pregnant. This examinationcan be used to screen out the women at risk for closer prenatal supervision leaving the

remainder on a program of minimal care. A special care of highly risk women should be kept;this can be done very simply by tagging the prenatal record or by writing the letters HR in

red ink against the entry in the prenatal register.Based upon the initial evaluation and screening of pregnant women, they maybe

classified as follows:

Normal PatientsFollowing the initial evaluation they will be given healthy instructions and

counseling. These will advice for prompt prenatal care examination.

Patients with Serious or Potentially Serious ComplicationsFollowing the initial evaluation, these patients shall be referred to the most skilledsource of medical and hospital care. As a first choice they will be referred if at all

possible for continuing care or consultation. Ass a second choice they will befollowed carefully bay the rural health unit, city health or puericulture center

where they should be seen frequently by the physician


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COMPONENTS OF PRENATAL CARE (DOH):

History Taking

Begin history taking by asking the woman of her CHIEF Concern for coming to thehealth care for facility. Inquiring about the main reason of the woman for seeking

health care enables the midwife to know the need that is uppermost in the womansmind and conveys a message of concern on the patients well-being. This helps to

establish rapport between the patient and the midwife who will work closely togetherfor the entire length of pregnancy and puerperium, sometimes longer than that.

Do the interview in private setting so that the woman will not be inhibited fromvoicing out all her concerns and other information, which might be embarrassing for

her to say in front of many people. The interview should be conducted unhurriedlyand in a relaxed manner. All information obtained from the patient should be treated

confidential and must be known only by the people involved in the care of thepatient. Doing otherwise will violate the patients right to privacy.

PersonalData The personal data is often the first information gathered during the interview,

which includes name, age civil status, weight, height, religion and occupation.y Age Women below 15 years are at increased risk for anemia, preeclampsia,

prematurity, cephalopelvic disproportion, and congenital anomalies. Advanced maternal

age, above 35 years old, increases the risk for hypertension, diabetis nellitus, placenta previa and abruption placenta, caesarian section, ectopic pregnancy, fetasl growth

retardation, macrosomia, Down Syndrome, abortion, perinatal, and infant mortality.

y WeightLow prepregnancy weight, below 95 lbs or 43.2kg is high risk for prematurity,

low birthweight infant, still born, and congenital defects. O bese women are prone todevelop diabetes mellitus, hypertensive disorders and thrombophlebitis.

y HeightWomen who are less than 5 feet tall are at risk for cephalo-pelvic disproportion.

y OccupationHandling toxic substances and highly stressful work places the woman atrisk.

y

CivilStatusUnwed and unwanted pregnancy is considered high risk pregnancy.

y Menstrual History This include menarche, length and regularity of menses, intervalbetween periods, amount of flow by asking the number of sanitary pads consumed everymenstrual period, dysmenorrheal, and other discomforts associated with the monthly


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y Contraceptive Use What is the family planning method used? An IUD in place shouldbe removed during pregnancy to avoid abortion. Contraceptive pills should be stopped

once pregnancy is diagnosed. IUD and contraceptive pills may cause development of

certain vitamin deficiencies.

y Medical History Included in the medical history are childhood diseases, drug allergies,past surgeries, existing medical conditions, family history, immunizations, alcohol intake,

cigarette smoking and use of drugs.

y Obstetric History:

History of Past Pregnancies Include number of past pregnancies, outcome,

complications, labor time, method of delivery, complications of labor, puerperium andcomplications of puerperium.

TPAL

T - number of full term infants born after 37 weeks.

P number of preterm infants born before 37 weeksA number of spontaneous or induced abortions

L number of living childrenGP

G number of pregnancies irrespective of gestational ageP number of pregnancies that reached viability (20 weeks)

Signs of Previous Pregnancies:

Pendulous and lax abdominal wall

Abdominal striae Labia gapes wider

Hymen is transformed to myrtiform carunculae Cervix admits tip of cervix

Sites of healed laceration of the cervix can be identified

Signs of first Pregnancy:

Uterus is firm and tense Frenulum is intact

Labia majora in close apposition Vagina is narrow with numerous rugae

Cervix is soft but do not admit tip of finger until very end of pregnancy


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History of Present Pregnancy:

ExpectedDate ofDelivery Inquire for the last mesnstrual period (LMP) and

compute for expected date of delivery/confinement (EDD/EDC).Naegeles Rule Add7daystothe firstdayof LMP, countback3 months

andaddoneyear.

If the woman cannot remember her LMP, ask hew when she first felt thefetus move.

To get EDC for primigravida, add 22 weeks to the date of quickening.

To get EDC for multigravida, add 24 weeks to the date of quickening.

Determination of the Age of Gestation/Duration of Pregnancy:The clinically most appropriate unit of measure of gestational age is weeks

of gestation completed. Two methods are the:

Menstrual Age/Gestational Age Measures from LMP. The averageduration of pregnancy using the menstrual age is 280days.

Ovulatory Age/Fertilization Age Measures from the date of ovulation orfertilization. The average duration of pregnancy from ovulation is 267 days.

The clinical parameters that can be used to measure the duration of

pregnancy are the following:

Last Menstrual Period This involves calculating the span of time from the lastmenstrual period up to the present. Problems encountered with the use of the LMP are the

following.

Failure to record LMP Menstrual cycles maybe irregular and variable

Pregnancy may follow immediately without menstruation in betweengestation

Implantation bleeding maybe mistaken as menstruation Ovulation that occurs after cessation of ovulation inhibition method of

contraception may be delayed. Basal Body Temperature Record or Single Coitus If an isolated coitus

can be dated or BBT record is available, the precise onset of pregnancy can bedated.

Quickening Noted at 20 weeks at primis and 16 weeks in multis.


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McDonalds Rule is used to calculate AOG.Height of fundus is used to determine AOG. Fundic height is determined

by palpation and by relating to the different landmarks in the abdomen: umbilicus,

symphisis pubis, xiphoid process.12 weeks level of umbilicus16 weeks halfway between umbilicus and symphisis

Pubis20 weeks level of umbilicus

24 weeks 2 fingers above umbilicus30 weeks halfway between umbilicus and xiphoid

Process34 weeks just below xiphoid process

36 weeks level ofxiphoid process40 weeks at 34 weeks level due to lightening

Johnsons Rule is usedtocalculate fetalweightingrams.

Fundic Height 9cm) Nx K = fetal weightK = 155 (constant)

N= 12 if engaged (do Leopolds to find out) and 11 ifnot yet engaged.

Haases Ruleis used to determine length of fetus

During the first half of pregnancy, square the number of months During the second half of pregnancy, multiply the number of

months by 5

Greater Fundic Height Indicates: Multiple Pregnancy

Miscalculated Due Date Polyhydramnios

Hyaditiform Mole

Lesser Fundic Heaight Indicates: Fetal Growth Rate Retardation

Fetal death Error in estimating AOG

Oligohydramnios


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PHISYCALEXAMINATION:

Blood Pressure No significant changes in blood pressure occur during pregnancy. In the

second trimester, it may drop slightly but return to normal in the third trimester. Blood pressureis highest when the woman is sitting; intermediate in supine position and lowest in left lateralposition.

Su pine Hypotensive Syndrome When a pregnant woman lies on her back, the gravid uterus

compresses the blood vessel that drains blood freom the lower extremities. This results indecrease amount of blood going back to the heart which consequently decreases cardiac output

resulting in less blood supply to the brain. These chain of events leads to hypotension anddizziness.

Pulse Rate Pulse Rate increases by aboput 10 beats per minute due to increased cardiac

workload. Respiratory Rate Increases in depth, no significant change in rate. Shortness of breath and

dyspnea late in pregnancy is common.

Temperat

ure

There is slight elevation of temperature early in pregnancy due to thethermogenic effect of progesterone. It drops to normal after 16 weeks.

PHYSICAL ASSESSMENT Physical Assessment should be performed systematically. One

technique is by the cephalocaudal method.

Head & Scalp Hair tends to grow faster during pregnancy. Oily hair is not alsouncommon. Excess dryness indicates poor nutrition.

Eyes Pale conjunctive indicates anemia. Edema of the eyelids accompanied by visual

disturbances are sign of PIH.

NoseNormal nasal congestion occur as a result of estrogen stimulation.

Ears Nasal stuffiness results in blockage of Eustachian tube which may affect apregnant womans hearing.

Mouth & Teeth It is normal to find swollen gums (epulis) due to estrogen stimulation.

Cracked corners of the mouth may be caused by vitamin deficiency which pregnantwoman is prone to develop. Dental carries should be treated during pregnancy as they

may become site of infection. Major dental operations such as tooth extraction should be


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BreastNormal findings include enlargement of the breast with wider and darker areola, prominent veins and Montgomery tubercles. Breast masses, nodules and bloody nipple

discharge are abnormal findings and should be reported to the physician right away.

Colustrum, a thin watery fluid, can be ex pressed from the nipple as early as the firsttrimester.

Skin Linea negra, mask of pregnancy, spider nevi, palmar erythema are commonfindings. Pallor, jaundice, rashes and skin lesions are abnormal findings.

BackExxagerated lumbar curve late in pregnancy occurs as a result of the shifting of

the pregnant womans center of gravity.

RectumHemorrhoids may be present especially in the last months of pregnancy.

ExtremitiesAnkle swelling is a normal finding in the second half of pregnancy. Legedema especially in the late afternoon is common to pregnant women. Waddling gait is

due to relaxation of pelvic joint. Edema of upper extremities, face and hands are dangersigns.

ABDOMINAL EXAMINATION Abdominal palpation of pregnant women or Leopolds

maneuver is preferably performed after 24 weeks gestation when fetal outline can already bepalpated.

Preparation:

Cardinal Rule Instruct woman to empty her bladder first.

Place woman in dorsal recumbent position, supine with knees flexed to relaxabdominal muscles. Place a small pillow under the head for comfort.

Drape properly to maintain privacy. Explain procedure to gain patients cooperation.

Warm hands first by rubbing them together before placing them over the womansabdomen. Cold hands may stimulate uterine contractions.

Use the palm for palpation not fingers.

INTERNAL EXAMINATIONOR VAGINAL EXAMINATION

Purpose:


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PatientPreparation:

Provide explanation.

Let woman empty her bladder first Provide good lighting Place woman in lithotomy position with buttocks extended slightly beyond

examining table. Drape properly

Let support person stay at the head of bed Instruct woman not to hold or squeeze your hands or that of her husband, hold her

breath, close yes tightly, clench fist or contract perineal muscles.

Explain the procedure. It may be slightly uncomfortable. After the procedure, provide tissue to wipe perineum of lubricant.

Laboratory Test:

Urinalysis

Collect urinary specimen by midstream or clean catch technique.

Benedicts test to detect glycosuria.

Heat and Acid Test to detect proteinuria. Urinalysis in the first trimester is also performed to detect asymptomatic bacteuria.

Bacteuria can lead to abortion early in pregnancy and can cause premature labor latein pregnancy.

Blood Tests

Hematocrit& Hemoglobincount is done at initial clinic visit and repeated at 28-32 weeks

to detect anemia.

Normal Hemoglobin level is between 12-16 mg/dl Normal hematocrit count is between 37 47 %

Determinationof Blood Typeand Rh Factor

Rh factor determination early in pregnancy is important for detection and prompt

treatment ofRh incompatibility which occurs when the mother is Rh negative andthe fetus is Rh positive.

VDRL & Kahnand Wasserman Test detect syphilis


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Between 8 to 18 weeks, it is best to perform:

Ultrasound

Amniocentesis Chorionic Villus Sampling Maternal Serum Alphafetoprotein

Between 26-28 weeks:

Diabetic screening for all pregnant women using the 50 gm one hour glucose screen.

Repeat hemoglobin and hematocrit.

Repeat antibody test for unsensitized Rh-negative women.

TreatmentofDisease

In malaria infested areas, all pregnant women shall de given prophylaxia in the form

of choloquine (150mg) 2 tablets per week during the entire week of pregnancy.

Dental Care

The pregnant woman should have a dental check-up early in pregnancy to give plenty of time for repairs and treatment of infected teeth and for instructions on

proper dental care. Dental carries should be treated during pregnancy for they are potentially dangerous

because they are foci of infection. Dental x-ray is allowed as long as the woman wears lead apron over her abdomen to

protect the fetus from the damaging effects of radiation. Alkaline mouthwash can be used to counteract the acidic saliva during pregnancy

that serves as favorable medium for growth of enamel destroying bacteria.

Immunizations

Immunization with vaccines containing live viruses is contraindicated duringpregnancy because of the danger of the virus crossing the placenta and infecting the

fetus. Examples of vaccines contraindicated during pregnancy are: Measles(Rubella) vaccine, Sabin Poliomyelitis Vaccine and Mumps Vaccine.

Hepa B Vaccine is given only if risk factors are present. Typhoid vaccine and plaguevaccine is given if there is possibility of ex posure or if the woman will travel to

endemic areas.


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The immunization recommended to all pregnant women in the Philippines is tetanus

Toxoid vaccine given in the following schedule:

TT1 anytime during pregnancy (usually on the second)

TT2 one month afterTT1TT3 six months afterTT2TT4 one year afterTT3

TT5 one year afterTT4

Health Teachings

Schedule ofClinic Visit Prenatal Visits should begins as soon as possible after the first missed

period. Subsequent clinic visits for normal pregnancy are scheduled as follows:

From first visit to 32 weeks every 4 weeks

From 32 weeks to 36 weeks every 2 weeksFrom 36 weeks until delivery every week

The desirable number of clinic visits according to WHO is 5 clinic visits during the entire

length of pregnancy and the minimum is 3 clinic visits.

Clothing Characteristics of Good Maternity Clothes

Lightweight, non constrictive and loose fitting Absorbent and washable because of increased perspiration.

Reasonably priced because they will be used only during pregnancy. Advice the woman to avoid using constricting garters around the legs, abdomen, and

breasts as these interferes with circulation. Panty girdles and tight clothing over the perineum may contribute to vaginitis. Maternity girdles maybe used for backache

and lordotic posture. Flat heeled shoes that provide good support are recommended during pregnancy

because of the altered balance of the woman especially when the abdomen hasgrown large enough.

Bathing

The woman perspires more heavily because she needs to excrete the waste products

of her body and that of the fetus, too. Due to increased perspiration, the pregnantwoman is encouraged to have a daily bath to keep fresh and clean.

Tub bath is discouraged because alteration in the womans balance makes getting in


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BreastCare

Well fitting and larger sized brassiere is recommended for the increased breast mass

and pendulous breast. Bras should provide adequate support, with wide straps anddeep cups toprevent loss of breast tone.

If woman plans to breastfeed, nipple rolling between thumb and forefinger and

drying of nipples with rough towel is encouraged to help toughen the nipple. Wash breast with water only. No soaps and alcohol should be used as these causes

drying and cracking.

Employment

Pregnant women can continue working as long as their job does not involve liftingheavy objects, standing and sitting for long periods of time, excessive physical; and

emotional strain and exposure to toxic substances. When deciding whether a pregnant woman should continue working or not, safety

and rest should be the primary consideration. Thus, it is important to emphasize thatthey should avoid:

exhaustion discomfort

strenuous exercise extreme temperature

smoking areas ladder climbing

lifting heavy objects, pushing, straining, running overtime

prolonged standing and walking because of greater risk for preterm labor

crossing the legs at knees while sitting

Classification of Jobs for Pregnant Women: Standing Jobs jobs which required standing for the same position for

more than 3hours a day such as cashier, bank teller and dentist. Active Job job which require continuous or intermittent walking such as

physician, waitresses, real estate agent. Sedentary Job jobs which requires less than as hour of standing per day

such as librarian, bookkeeper and bus driver Studies have shown that continued employment during pregnancy resulted in low

birth weight infants.

Travel


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A 15 to 20 minute rest period every 2 hours on long rides to move aboutand empty the bladder.

Use of shoulder and lap belts should be emphasized for safety.

The place should be pressurized, exposure to low oxygen concentration athigh altitudes when traveling by nonpressurized plane can cause fetalbrain damage.

Sexual Relations

Sexual desires continue during pregnancy but sexual drive and responsiveness vary

among women at different stages of pregnancy:

First trimester decreased sexual desire due to discomforts of pregnancy(nausea & vomiting), it may also be due to the womans preoccupation tothe changes occurring in her body.

Second Trimester increased sexual desire because the woman hasalready adjusted to pregnancy and this is the period when she is most

comfortable. Third Trimester decreased sexual desire because of the fear of hurting

the fetus and the discomfort caused by enlarged abdomen and deep penilepenetration.

Contraindications to sexual intercourse: Deeply presenting part

Rupture bag of water Vaginal spotting or bleeding

Incompetent cervical os During the last six weeks of pregnancy (36 weeks onward) coitus is discouraged by

some physicians because it has been related to increase incidence of postpartalinfection, preterm labor, premature rupture of membrane and bleeding

Alcohol

The safest minimum amount of alcohol that can be ingested during pregnancy

without causing any harm to the fetus has not yet been established. For this reason, itis safer for the woman to refrain from drinking any alcoholic beverage of any

amount during pregnancy to protect her baby from the damaging effects of alcohol. Infants born with fetal alcohol syndrome are mentally deficient, possess congenital

anomalies and usually are low birth weight. Other effects of alcohol are abortion and prematurity.

Smoking


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Smoking affects the appetite of the mother resulting in decreased caloricintake which in turn leads to limited maternal weight gain. Decreased

maternal weight gain leads to low birth weight infants.

Because of the above mentioned effects of cigarette smoking, pregnant womenshould absolutely avoid cigarette smoking.

Caffeine

Caffeine is found in coffee, tea and colas. Pregnant women should not take more than4cups of caffeine containing foods and beverages because it has the following deleterious effects

on the body:

y Diuretic depletes water from the bodyy Filling and satisfying without being nutritious

y Causes mood swings thus it may interfere with rest and sleepy Interfere with absorption of iron

y Baby may develop diabetes later in life

Drugs

The pregnant woman should not take any drug not prescribed by physician. A number ofover the counter (OTC) drugs are known to have teratogenic effects to the fetus.

Drugs Teratogenic Effects

Androgen, estrogen, progesterone MAsculinization of female infants

Thalidomide Phocomelia, cardiac and lung defect

Anticonvulsant (Dilantin) Cleft palate, congenital heart defects

Lithium Congenital Heart Defects

Tetracycline Yellow staining of teeth, inhibit bone growth,

not given to children below 7

Vitamin K Hyperbiliribinemia

Salicylates (Aspirin) Neonatal bleeding, decreased intrauterine

growth

Sodium Bicarbonate Fetal metabolic alkalosis

Streptomycin Nerve deafness

Vitamin A Central Nervous System defects


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DANGER SIGNS OF PREGNANCY:

The pregnant woman should be instructed about the reportable danger signs and

symptoms of pregnancy during the first clinic visit. They are:

y Vaginal Bleeding of any amount

y Persistent vomitingy Chills and fever

y Sudden escape of fluid from the vaginay Swelling of face and fingers

y Visual disturbances (Blurring of vision, spots before the eyes)y

Painful urination or dysuriay Abdominal painy Severe or Continuous headache

MINORDISCOMFORTS OF PREGNANCY

Nausea andVomiting

Nausea and Vomiting also known as morning sickness because it usually occur in the

morning commence 6weeks after the last menstrual period and disappears by the end of the firsttrimester. The exact cause is not known but it has been attributed to HCG. It may also by

psychologic in origin: ambivalence or nonacceptance of pregnancy. Most women experiencenausea and vomiting in the morning but it may occur anytime of the day.

Management:

y Eat dry toast or crackers before rising from bed.

y Eat small frequent meals rather than 3 large ones.

Frequent Urination

First appears on the first trimester when the enlarging uterus exerts pressure on the

bladder as it rises out of the pelvic cavity. It disappears on the second trimester when the uterushas become an abdominal organ. Frequency of urination returns late in pregnancy when the

presenting part exerts pressure on the bladder.Management:

y Limit fluid intake before bedtime.y Kegels exercise to improve tone of muscles that controls urination.

Fatigue

M


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Management:

y Take at least 8 hours of sleep at night and frequent rest periods during the day.

y

Avoid standing for long periods, work while seated as much as possible.y Eat a well balanced diet to provide enough energy.

BreastTenderness andNipple irritation

Breast discomfort occurs throughout pregnancy. It is due to alveolar celld development asstimulated by increased levels of estrogen.

Management:

y Wash breast with water only, no soaps and alcohol to prevent drying and irritation.

y Wear supportive maternity brassiere

Leukorrhea

High level of estrogen causes hyperactivity of cervical glands throughout pregnancy.

Management:

y Proper perineal hygiene,, flush perineum with water after each voiding, no douching isnecessary.

y Use of sanitary pad for excessive vaginal discharge.

Nasal

Stuffiness

Elevated estrogen levels results in hyperemia of mucous membranes, occurs throughoutpregnancy.

Management:

y Avoid allergens and smoke-filled rooms.

y

Normal saline nose drops (1/4 tsp salt in 1 cup water).y Breathe steam from pot of boiling water.

Heartburn or Pyrosis

Progesterone slows down gastric motility resulting in reflux of gastric contents into the

V i V i


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Varicose Veins

Varicosities caused largely by hereditary predisposition, advancing age, prolonged

standing and exaggerated by pregnancy. It usually becomes apparent during the second and thirdtrimester when the uterus is enlarged enough to impede return of blood from the lowerextremities.

Management:

Leg Varicosities

y Periodic rest with elevation of the legs, lie with feet against the wall.y

Avoid prolonged sitting or standing, constricting garters, knee high socks.y Wear support hose.y Apply elastic bandage before getting up in the morning starting at the distal ends but

dont wrap toes.

Vulvar Varicositiesy Rest with pillows under the hips.

y Modified knee-chest position.Anal Varicosities or Hemorrhoids:

y Sims position several times a day.y Avoid constipation.

y Hot sitz bath 15 to 20 minutes.y Avoid bearing down.

y Observe good bowel habits.y Use of topically applied anesthetics, use of stool softeners and warm soaks.

Backache

The major part of the gravid uterus rests on the anterior abdominal wall when the woman

stands altering her center of gravity. In order to maintain her balance, the woman walks withhead and shoulders thrown backwards with the chest and abdomen forward. This posture is

exaggerated inward curve of the spine called lordosis. The relaxation of the sacroiliac jointsthrows greater strain on the surrounding muscles causing low backaches during pregnancy.

Management:

y Pelvic Rocking Exercise to relieve low backache.

y Frequent rest and avoidance of fatigue.

Management:


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Management:

y For immediate relief, push toe upward while applying pressure on the knee to straighten

the leg.y One quart of milk a day to meet calcium needs or oral calcium supplements as prescribed

by physician.

y Exercise regularly but avoid pointing of toes.

Headache

Normal headache of pregnancy is common during the first trimester. Some causes lead to

sinusitis or ocular strain caused by refractive errors. The cause is unknown. By midpregnancy,these headaches have decreased in severity or are gone. Headache in the third trimester,especially if frontal and accompanied by visual disturbances should be investigated as this

maybe caused by pregnancy induced hypertension (PIH).

RECOMMENDED EXERCISES DURING PREGNANCY

Exercise done during pregnancy increases circulation, improves muscle tone, aid in the

prevention of fatigue, promote physical comfort and encourage good posture. Exercise should bedone smoothly, avoiding exaggerated o jerky movement. The woman should not do any exercise

that causes pain or discomfort. Breathing should be coordinated with exercise, generally exhalingwhile doing the effort of the exercise.

Different Types ofExercise:

1. Pelvic Floor Contraction

Buttocks are tucked under to flatten out the hollow of the lower back. Hold for 3

seconds, and then relax, allowing the hips to move back to former position. Repeatseveral times. This exercise may be done sitting, standing on the hands arch on

knees, or lying on the floor. This exercise can promotes perineal healing, increase sexual responsiveness and

prevents stress incontinence. While sitting at desk or working around the house, thewoman can tighten the muscles surrounding her vagina, relax, tighten the muscles

surrounding her rectum, relax, tighten her perineum, and relax.

2. Tailor Sitting

3 Squatting


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3. Squatting

It helps to stretch muscle of the pelvic floor. It should be done 15 minutes a day. The

woman must keep her feet flat on the floor.

4. Knee-Chest

Lying on the back of the knees is pulled to the chest and arms stretched straight to

the sides. The knees are rolled to one side, while the head is turned to the oppositeside. Sides are twisted. This exercise stretches the spine and relieves backache.

5. Ribcage Lifting

The right arm is lifted with elbow slightly lifted and flexed above the head while the

chest ex pands with exhaling. During the second inhalation the arm is returned toinitial position. The exercise is repeated with the other arm. This exercise is helpful

in relieving shortness of breath and can be performed in standing, sitting or tailorsitting.

6. Shoulder Circling

With back neck hand straight throughout the exercise, arms are allowed to hangloosely at the sides. Shoulders are routed slowly up and back as far as they will

comfortably go in circular motion. Inhaling occurs as the shoulders are returned tostarting position. This exercise is useful in strengthening the muscle of the upper

back and may achieve upper backache and numbness in the arms and fingers.

7. CalfStrengthening

Calf strengthening is helpful in providing o relieving lower leg cramps with footslightly apart, hands are on the back of an object that offers security.

8. Knee Bends

Deep bend knee using a chair for stabilization will strengthen back muscle and will

keep leg and hip joint supple.

9. AbdominalMuscle Contraction

10. Pelvic Rocking


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10. Pelvic Rocking

Helps relieves backache during pregnancy. It can be done on hands and knees, lying

down or standing. If the woman lies supine, she tightens her buttocks and flattens herlower back against the floor trying to lengthen her supine. She holds the position for1 minute then hollows her back or raises the lumbar spine of the floor.

INTRAPARTAL PERIOD

THEORIES OF LABOR

Oxytocin Stimulation Theory - Studies have shown that as pregnancy near terms, oxytocinproductions by posterior pituitary gland increase while the production of oxytocinase (a hormonethat counteracts the effect of oxytocin) by the placenta decrease. As a result the uterus becomes

increasingly sensitive to oxytocin. Oxytocin stimulates uterine contractions.

Uterine Stretch Theory According to this the

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