Lecture Notes

Signs and symptoms of pregnancy:

 Presumptive
 Probable
 Positive

Presumptive signs
Refers to signs and symptoms that a mother can perceive that resemble pregnancy signs and
symptoms

1. Amenorrhea – pregnancy is suspected if more than 10 days have elapsed since the expected
menstrual period
2. Breast Changes – starting on the fourth week of pregnancy, breast enlarge, feels tender and
heavy, veins become prominent under the skin, areola gets darker and wider, nipples standout
and Montgomery glands become prominent
3. Urinary Frequency – the pressure exerted by the enlarging uterus during the first trimester 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. Quickening – the first fetal movement felt by the mother, felt by primis at 20 weeks and multis
at 16 weeks
5. Easy fatigability
6. Leukorrhea – increase vaginal discharge characterized as white mucoid due to elevated
estrogen levels
7. Nausea and Vomiting/ Morning sickness – commences 6 weeks after the LMP and persists after
12 weeks gestation. This normal disturbance of GIT in the first trimester is believed to be caused
by elevated HCG levels
8. Chadwick’s sign – increase blood supply results in purplish (bluish) discoloration of the vagina
9. Skin changes :
 Striae gravidarum
 Linea Negra
 Cholasma
 Increased Perspiration
 Hair grows more rapidly
Probable signs
Signs that is observed by the examiner. They are more certain that the presumptive signs but
are not definitive.

1. Hegar’s sign – Softening of the lower uterine segment which is felt starting 6-8 weeks after
LMP
2. Uterine growth – the uterus doubles in size as early as 10 weeks and pregnancy becomes
obvious by 14 weeks. Uterine growth is determined by measuring fundal height
 3. Ballotement – refers to rebound that occurs when the examiner’s fingers tap the floating
fetus within the uterus and caused by the fetus floating away and returning back to its
previous position. Ballottement is observable beginning 6 – 8 weeks
4. Uterine suffle – a muffled swishing sound heard over the abdomen in union with the
mother’s heartbeat
5. Goodel’s sign – softening of the cervix can be observed beginning 6-8 weeks after LMP.
6. Braxton – Hicks contractions – they are painless palpable occurring at irregular interval 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 outlie – fetal outline is palpable at 24 weeks
8. Positive pregnancy test – it is the presence of HCG in the woman’s blood and urine that
gives positive result to a pregnancy test. HCG production most probably begins at the time
of implantation. Highest level is attained at 60-70 days of gestation. It decreases thereafter
and reaches its lowest level at 100-130 days of pregnancy. HCG is present beginning 24-48
hours after implantation. The earliest time that it can be detected in maternal serum is:
 8 days after ovulation
 23 days after LMP
 5 days before expected menstrual period

Absolute or Positive signs

1. Fetal heart tone (FHT) – can be detected by Doppler at 12 weeks, by fetoscope at 16 weeks and
by stethoscope by 20 weeks
2. Funic Suffle – a swishing sound synchronous with fetal heart beat caused by blood rushing
through umbilical arteries.
3. Fetal movement can be felt by examiner from 20 weeks onward
4. X-ray visualization of fetal skeleton as early as 14 weeks
5. Ultrasonographic evidence of pregnancy:
 Abdominal pulse echo sonography can detect intrauterine pregnancy at 4-5
weeks
 Small white gestational ring can be detected after 6 weeks
 Fetal brain and heart action demonstrated by 8 weeks using Doppler or real
time sonography
 Fetal head and thorax can be identified by 14 weeks

Concepts of pregnancy

Prenatal care – refers to the health care given to a woman and her family during pregnancy. The
primary goal of the prenatal care is to provide maximum heath to expectant mothers and babies.

Gravida – refers to a pregnant woman, the number of pregnancies regardless of outcome of pregnancy.

Nulligravida – a woman who has never been pregnant

Primigravida – a woman pregnant for the first time

Multigravida – a woman who has two or more pregnancies

Para – the number of pregnancies that reached the age of viability or the number of pregnancies that
reached 20 weeks or more, or the number of fetus delivered with birth weight of 500 grams or more.

Nullipara – a woman who has never delivered a fetus that reached the age of viability. Such woman may
or may not been pregnant before

Primipara – a woman who has completed one pregnancy to age of viability

Multipara - – a woman who has completed two or more pregnancy to age of viability

OBSTETRIC HISTORY

History of Pat Pregnancies – include number of past pregnancy outcome, complications, labor time,
method of delivery, complications of labor, puerperium and complication of puerperium

TPAL

T – number of full term infant born after 37 weeks

P – number of full term infant born before 36 weeks

A - number of spontaneous or induced abortions

L – number of living children

GP

G – number of pregnancies irrespective of age

P – number of pregnancies that reached age of viability

History of Present Pregnancy

Expected Date of Delivery (EDD) – inquire for last menstrual period (LMP) and compute for expected
date of delivery/confinement.

Nagele’s Rule – Add 7 days to the first day of last menstrual period count 3 months backward and add
one year.

*if the woman cannot remember her LMP, ask her when she first felt the fetus move.
To get the EDC for primigravida, add 22 weeks to date of quickening

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

Assesment of Fundic Height – is measured to estimate age of gestation (AOG), EDC and fetal growth rte.
Measure fundic height from the top of symphysis pubis to the top of the fundus the bladder empty.
Mc Donald’s Rule – is used to calculate AOG
Fundic height (cm) X 2/7 = AOG in Lunar months
Fundic height (cm) X 8/7 = AOG in weeks

Bartolomew’s 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, symphysis pubis, xiphoid process.

12 weeks – level of symphysis pubis

16 weeks – halfway between umbilicus and symphysis pubis
20 weeks – level of umbilicus
24 weeks – 2 fingers above umbilicus
30 weeks – halfway between umbilicus and xiphoid process
34 weeks – just below xiphoid process
36 weeks – level of xiphoid process
40 weeks – at 34 weeks due to lightening

Johnson’s Rule – is used to calculate fetal weight in grams

Fundic Height (cm) – N + K = fetal weight

N =155 grams (constant)

K = 12 if engaged (do Leopold’s Manuever)
N = 11 if not yet engaged

Haase’s Rule – used to determine length of fetus

a. During the first half of pregnancy, square the number of months

b. During the second half of pregnancy, multiply the number of months by five

Greater Fundic height indicates:

 Multiple Pregnancy
 Miscalculated due date
 Polyhydramnios
 Hyatidiform mole

Lesser Fundic height indicates:

 Feta growth rate retardation

 Fetal death
 Error in estimating AOG
 Oligohydramnios
Psychosocial/Emotional Adaptation of Pregnancy

Acceptance of pregnancy (First Trimester)

“I am pregnant” – Acceptance of reality of pregnancy is the first psychological task that a
woman who is about to become a mother faces. The doctor’s confirmation of pregnancy often helps the
woman accept the fact that she is pregnant, aside from the signs and symptoms of pregnancy that she
feels. At this stage, the unborn child is incorporated as part of herself.

Acceptance of the Fetus as a Separate, Individual (Second Trimester)

“I am going to have a baby” – quickening by 20 weeks gestation can be very significant in

helping the woman realize that the fetus inside her womb is not just a part of her body but a real and
separate individual to care for. As the woman realizes the individuality of her unborn child, she begin to
fantasize about the child’s sex and appearance. In this manner she gives the fetus an identity. The
woman becomes more introspective during this stage because she is preoccupied with fantasies about
her unborn child.

Acceptance of motherhood/ The woman prepares for the birth of the baby and her role as a mother
(Third Trimester)

“I am going to be a mother” – the woman begins to plan about the birth of the baby. She
selects baby’s layette, choose names for her baby, make plans on how the baby will be fed, where the
baby will sleep at home, etc.

Nutrition During Pregnancy

Nutritional Assessment

1. Taking a diet history:

a. 24 hour diet recall
b. Cultural and religious practices that influence food selection and preparation
c. Eating habits and preferences
2. Laboratory test for hemoglobin, hematocrit count at first clinic visit repeated a 28 weeks to
detect anemia
3. Take weight and height
4. General physical assessment

Weight gain

1. Recommended weight gain during pregnancy is 22 – 35 lbs.

a. First trimester expected weight gain 2-4lbs
b. 2nd and 3rrd trimester – 1lb a week or 10-12lbs per trimester
 c. Abnormal weight gain
- Weight gain of less than 2 lbs a month on the 2 nd and 3rd trimester is a sign
of malnutrition
- Weight gain of more than 2 lbs a week is a sign of hypertension of
pregnancy, this is due to fluid retention.

2. Components of maternal weight gain

FETAL PART lb kg
Fetus 7 3.4
Placenta 1.5 .6
Amniotic fluid 1.70 .8
Uterus 2.1 .97
Breast .9 .4
Blood 3.2 1.45
Extravascular 3.2 1.48
fluid
Maternal store 7.3 3.33
(fat)
TOTAL 26.96 12.5

Food Servings

Taking into consideration her lifestyle, income, eating patterns, culture and religion have the
woman plan a daily menu that include the following food servings to meet maternal requirements:

3 (2oz) servings of protein foods (2 eggs/day)

4 servings of milk and milk products
6 servings of bread and cereals
5 servings of fruits and vegetables containing Vitamin C
1 serving of other fruits and vegetables
1 serving of yellow fruit or vegetables
6-8 glasses of fluid

Essential Nutrients during Pregnancy

Carbohydrates
Recommended daily intake: Prepregnant – 2,000 – 2400 kcal
Pregnant – 2,300 – 2,700 kcal

Food sources: cereals, grains, starchy vegetables

Protein
Recommended Daily Intake: Prepregnant – 50 grams
Pregnant – 60-80 grams

Food sources: milk, meat, and meat products, egg, cheese, legumes, nuts
Fats
Food sources: margarine, butter, lard, milk, animal fat, chocolates

Iron
1. During the latter half of pregnancy, iron requirements totals about 7mg a day, however, the
woman may ingest more than this amount because only 10% of iron is absorbed by the body.
2. Total iron requirement during pregnancy is about 1 gram About 300mg us transferred to the
fetus and placenta and 50mg is utilized for expanding maternal blood volume the remaining 200mg is
excreted.
3. Iron stores and amount of iron is absorbed from the diet is generally insufficient to meet iron
requirements of pregnancy. Thus, it is advised that all pregnant women take simple iron tablet especially
during the second half of pregnancy when iron stores are transferred from mother to fetus and
maternal blood volume increases.
4. Recommended daily intake: Nonpregnant: 18mg
Pregnant: 30-60mg
5. Food sources: pork liver is the best source, organ meats, soy beans, clam peanuts

Calcium

1. Calcium is necessary for the formation of fetal bones and teeth. Calcium is especially needed
during last months of pregnancy because 2/3 of calcium deposition in the fetus occurs
during the last trimester. Calcium is also important for the maintenance of good muscle
tone.
2. Recommended Daily Allowance: Nonpregnant – 800mg
Pregnant – 1,200mg
3. Food sources: one quart of milk a day provides full allowance of calcium and vit D, cheese

Phosphorus

1. The function of phosphorus is for the development of fetal bones and teeth. If calcium
requirements are met, phosphorus needs of the body will also be met adequately
2. Recommended daily allowance: Nonpregnant – 800mg
Pregnant – 1200mg
3. Food Source: Food source of protein and calcium are also good source of phosphorus, eggs,
oatmeal, seafoods (dilis and sardines)

Iodine

1. Increased iodine requirements during pregnancy is due to:

a. Increased metabolic rate
b. Fetal requirements
c. Increased maternal renal looses
a. Recommended daily allowance: Nonpregnant: 150ug
Pregnant: 175ug
Vitamins

Vitamin RDA Function Food Sources

A Pregnancy -800ug Normal vision. Fish, liver oil, eggyolk,
Lactation – 1300ug Maintenance of skin yellow and green fruits
and mucous and vegetables
membrane, promotes
bone and teeth growth
D Pregnancy -10ug Promotes calcium Milk, liver, eggyolk,
Lactation – 12ug absorption, bone and exposure to sunlight
teeth absorption
E Pregnancy -10ug Antioxidant, prevents Vegetables, fats, nuts,
Lactation – 12ug hemolysis of RBC green leafy vegetables,
eggyolk, milk ,legumes
K Pregnancy -65ug Antihemorrhagic Liver, green leafy
Lactation – 65ug formation of clotting vegetables, eggyolk,
factors in liver soybean, tomato
B1 – thiamine Pregnancy -1.5ug Carbohydrate Glandular organs, nuts,
Lactation – 1.6ug metabolism, normal eggyolk, legumes, meat
function, promote
appetite
B2 – Riboflavin Pregnancy -1.6ug For carbohydrate Cheese, milk, eggs,
Lactation – 1.8ug metabolism, healthy glandular organs, green
skin, converts leafy, lean meat
tryptophan to niacin
B6 – Pyridoxine Pregnancy -2.2ug For protein metabolism Meat lover, whole
Lactation – 2.1ug grains, green leafy
vegetables
B12 – cyanocobalamine Pregnancy -2.2ug Maturation of RBC, Read meat, milk, nuts,
Lactation – 2.6ug prevents megaloblastic legumes, eggs, green
anemia, normal nerve leafy vegetables
function, GIT function
Folic Acid Pregnancy -400ug Maturation of RBC, Liver, green leafy,
Lactation – 80ug prevents megaloblastic legumes nuts, oranges
anemia, normal cell
division, prevents
neural tube defects
C –Ascorbic Acid Pregnancy -70ug Promotes iron Citrus Fruits, tomatoes
Lactation – 95ug absorption, tissue
integrity, resistance
against infection,
promotes healing,
antioxidant