Lecturer: JHORAM F. NUFABLE, M.D.

A. Two hip bones (right and left innominate:

Sacrum, coccyx).
B. Innominate bones are consists of the:
1. Ilium
2. Ischium
3. Pubis
1. False pelvis – upper portion above pelvis
brim, supportive structure for uterus
during last half of pregnancy.
2.True pelvis – below brim; pelvic inlet,
midplane, pelvic outlet. Fetus passes
through during birth
PELVIS
Four Types:
1.Gynecoid Pelvis
2. Android Pelvis
3. Anthropoid Pelvis
4. Platypelloid Pelvis
1.Gynecoid Pelvis
 Inlet is round
 Wide
 This is the typical FEMALE PELVIS
 Most favorable for normal spontaneous

delivery
2. Android Pelvis
 Wide
 HEART-SHAPED
 This is the typical MALE PELVIS
3. Anthropoid
Pelvis
 Wide
 Narrow
 This is the typical
APE PELVIS
4. Platypelloid Pelvis
 Opposite of Anthropoid Pelvis
 Wide
 Narrow
A. Diagonal conjugate – 12.5 cm or greater is
adequate size, evaluated by examiner

C. Conjugate vera – 11 cm is adequate size;

can be measured by x-ray (not commonly
performed)
C. Obstetric conjugate – measured by x –ray
(not commonly performed)

D. Tuber-ischial diameter – 9 -11 cm indicates

adequate size; evaluated examiner.
DIAMETERS OF THE PELVIS
 Sagittal section
 Obstetric Conjugate

◦ A conjugate that CANNOT BE MEASURED

CLINICALLY
◦ Distance from posterior surface of symphysis
pubis up to the most prominent portion of sacral
promontory
 Subtract 1.5 – 2.0 cm from diagonal
conjugate
 Therefore, Obstetric Conjugate (OC) is equal

to Diagonal Conjugate (DC) minus 1.5 to 2.0

centimeters.
 In equation form:

◦ OC = DC – 1.5 or 2.0 cm
Diagonal Conjugate
 Distance from posterior surface of

symphysis pubis and the inferior margin of

symphysis pubis up to the most prominent
area of the sacrum
 Only conjugate that can be measured

clinically
 Normal value is 11.5 cm to 12.5 cm.
A. Mons veneris – protects symphysis
B. Labia majora – covers, protects labia minora
C. Labia minora – two located within labia
majora
D. Clitoris – small erectile tissue
E. Hymen – thin membrane at opening of
vagina
F. Urinary meatus – opening of urethra
G. Bartholins glands – producer of alkaline
secretions that enhances sperm motility,
viability.
Vagina – outlet for menstrual flow, depository
of semen, lower birth canal
Cervix – cone-shaped neck of the uterus that
protrudes into the vagina
OVARY
 Ovulation is the

most important
function of the
ovary
 Production of the

female hormone
 Situated

retroperitoneally
 Contained in the
OVARIAN FOSSA
 In times of
abdominal new
growth in the ovary
– these are always
detected late due to
anatomical location
 Example:

◦ Ovarian carcinoma
◦ Ovarian
malignancy
Not easily palpable
UTERUS
 Changes occurring

during pregnancy
 Endometrium lining

during pregnancy
becomes deciduas (lining
of the pregnant uterus)
 Endometrium is the

lining of the NON-

PREGNANT UTERUS
2. Decidua Basalis
 Decidua immediately beneath the
implantation of the blastocyst
2. Decidua Capsularis
 Decidua covering the blastocyst
3. Decidua Vera
 This is the remaining portion of the decidua
 Decidua that is not Basalis nor Capsularis
 Desidua Basalis
◦ Most important among the deciduas
◦ Limits invasion of CHORIONIC VILLI into the
MYOMETRIUM
◦ Placenta will not be delivered spontaneously if
basalis is NOT WELL DEVELOPED
◦ This will result into a condition known as
PLACENTA ACCRETA
 Placenta Accreta
◦ Presence of faulty attachment of the chorionic villi
of the placenta into the myometrium
◦ The main problem in Placenta Accreta is
HEMORRHAGE
◦ Therefore, the decidua basalis should be
well developed
FALLOPIAN TUBE
 Site of fertilization

 More specifically, the

AMPULLA of the Fallopian

Tube is the site of
fertilization
 Distal Third of the

Fallopian Tube
 Composed of the

◦ Ampulla and Fimbriae

 Ampulla
◦ Has the widest diameter among the segments of
the fallopian tube
 Middle Third of the Fallopian Tube
◦ Composed of the ISTHMUS
 Proximal Third of the Fallopian Tube
◦ Composed of the INTERSTITIAL SEGMENT or the
INSTERSTITIAL PART
a. Health history
1. menarche; onset and duration
2. menstrual problems
3. contraceptive use
4.Pregnancy history fertility problems
lifestyle
B. Physical examination
1. external, internal reproductive organs
2. breast examination
3. mammography – every 1-2 years for
women beginning 40 annually beginning
age 50 more frequently if have risk factors
for breast cancer.
C. Pap smear – first Papaniculaou smear at
age 18 or earlier if sexually active; then
annually until 3 consecutive normal Pap
smear.
D. Test for sexually transmitted disease.
1. Follicle stimulating hormone (FSH) – secreted
during the first half of cycle; stimulates
development of graafian follicle; secreted by
anterior pituitary gland.
2. Interstitial cell- stimulating hormone, or
leuteinizing hormone (ICSH, LH)
- stimulates ovulation and development of
corpus luteum; secreted by pituitary
gland.
3. Estrogen – assists in ovarian follicle
maturation; stimulates endometrial
thickening; responsible for development of
secondary sex characteristics; maintains
endometrium during pregnancy. secreted
by ovaries and adrenal cortex during cycle
and by placenta during pregnancy.
4. Progesterone – aids in endometrial
thickening; facilitates secretory changes;
maintains uterine lining for implantation
and early pregnancy; relaxes smooth
muscle. Secreted by corpus luteum and
placenta.
5. Prostaglandins – substances produced by
various body organs that act hormonally on
the endometrium to influence the onset and
continuation of labor. Used to efface the
cervix before induction of labor in term
pregnancies.
 Puberty
◦ Begins with the first menstrual bleeding
(menarche)
◦ Begins when GnRH, FSH, LH, estrogen, and
progesterone levels increase
◦ Increased estrogen and progesterone promote
the development of the female primary and
secondary sexual characteristics
 Menstrual Cycle
◦ Consists of the periodic changes occurring in
the ovaries and uterus of a sexually mature,
nonpregnant female that result in
The production of a secondary oocyte
Preparation of the uterus for implantation
◦ Days 1-5: Menstrual phase: uterus sheds all
but the deepest part of the endometrium
◦ Days 6-14: Proliferation phase: endometrium
rebuilds itself
◦ Days 14-28: Secretory phase: endometrium
prepares for implantation of the embryo
 First half of the ovarian cycle
 Always variable in length
 Follicles of ovaries are growing Uterus lining

(endometrium) is proliferating
 Elevated Hormones
 Anterior Pituitary INCREASES SECRETION OF
FOLLICLE STIMULATING HORMONE
◦ Therefore, the follicle in the ovary ENLARGES
◦ As it enlarges, it becomes more mature
 GRAAFIAN FOLLICLE
◦ Most mature of all follicles
◦ With cavity
◦ With ovum ready to be extruded
◦ With clear fluid rich in ESTROGEN
◦ Only one (1) follicle matures per menstrual cycle
 Approximate number of growing follicles:
◦ At twenty-eight (28) weeks Age of Gestation
6,000,000
◦ At Term
1,000,000
◦ At menarche
400,000
◦ At forty (40) years of age
8,000
 Thickens the uterine lining
 Usually eight-fold of previous

◦ From one millimeter to eight millimeter

 Peak of uterine lining coincides with
ovulation
 Peaking of Estrogen will signal Leutinizing

Hormone surge or increase in blood levels

of Leutinizing Hormone
LH Surge
 Coincides with ovulation
 Extrusion of ovum from the Graafian Follicle
 Signal for Ovulation
 Ovum stays in the Fallopian tube for one (1)

to three (3) days

 Peak is twenty-four hours
Second half of the ovarian cycle
 Constant part

◦ Always fourteen (14) days in length

 Production of Corpus Luteum
◦ Uterus / uterine lining is secretory in nature
 Because of the secretion of Leutinizing
Hormone
◦ Leutinizing Hormone influences follicle
◦ Cavity is left inside the follicle
◦ Stimulates change in fluid in Graafian follicle
◦ Yellowish, milky white fluid high in
PROGESTERONE
Progesterone
 Maintains uterine lining
 Organizes uterine lining

◦ If only estrogen is present, the uterine lining

would continue to thicken and thicken and thicken
 PRO-VERA
◦ Progesterone
◦ For dysfunctional uterine bleeding
◦ For organization of the uterus
 Anticipates possible fertilization
 If there is pregnancy, to MAINTAIN

PREGNANCY
 If ovum degenerates,
◦ LH and Progesterone no longer needed
◦ Therefore, there is menstruation
If there is coitus and fertilization
 Corpus Luteum must persist up to twelve

(12) weeks of gestation

 After twelve (12) weeks, it degenerates and

the placenta produces hormones

 Approximate menstrual cycle
 NORMAL is 28 days
 28 + or – 7 days or 21 – 35 days is also

NORMAL
 If the menstrual period is short (i.e. 21

days), a person can menstruate twice in a

month – this is still NORMAL
 If a person’s menstrual cycle is 28 days, 14
days for the proliferative or follicular phase
and 14 days for the secretory or luteal
phase, then OVULATION IS ON THE 14TH
DAY
 If a person’s menstrual cycle is 35 days, the

OVULATION IS ON THE 21ST DAY

Given the following:
 Last Menstrual Period (LMP) is January 1,

2005
 Menstrual Cycle is 35 days
January 2005
01 02 03 04 05 06 07
08 09 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
February 2005
xx xx xx 01 02 03 04
05 06 07 08 09 10 11
The LAST MENSTRUAL PERIOD or LMP is the
FIRST DAY OF THE PERIOD
◦ Therefore, counting of the MENSTRUAL CYCLE,
starts from this same date
◦ Thus, February 4, 2005
Is the 35th day
Is the expected start of the next cycle
 Is the LMP of the next cycle
Thus, February 3, 2005
Is the 34th day
Is the end of the cycle that started on
January 1, 2005
This is WHERE YOU START COUNTING
BACK FOURTEEN DAYS TO GET THE DAY
OF OVULATION
 Therefore, count fourteen (14) days, starting
February 3 going backward
 Thus, the expected OVULATION DAY is
February 21, 2005
 If the cycle is irregular, do not do this
procedure
 If the Menstrual Cycle is not given, it is

UNDERSTOOD THAT IT IS 28 DAYS

CONSTANT OF 11 AND 18
 Another way of getting the ovulation period

if the cycle is variable is by the use of the

constant of 11 and 18
Example:
◦ Menstrual Cycle is 22 – 35 days
◦ Monitor the menstrual cycle in one year’s time
◦ Subtract higher number (18) from shortest cycle
22 – 18 = 4
◦ Subtract lower number (11) from the longest
cycle
◦ 35 – 11 = 24
 Therefore, from the 4th to the 24th day of the
cycle, there is NO COITUS
◦ There is 80% failure in the rhythm method
 If menstrual cycle is 28 – 35 days
◦ 28 – 18 = 10
◦ 35 – 11 = 24
Therefore, from the 10th to the 24th day of the
cycle, there is NO COITUS
Egg –approximately 24 hours after
ovulation.

Sperm – approximately 72 hours

after ejaculation into female
reproductive tract.

Implantation (nidation) – occurs

within 7 -9 days of conception, or
about day 21 – 23 of a 28 day
menstrual cycle.
Conception (fertilization) – usually occurs
within 12 -24 hours after ovulation, within
fallopian tube.

Ovum – period of conception until primary

villi have appeared; about 12 – 14 days
EMBRYO
 Product of Fertilization
 Approximately 3 cm; 54 – 56 days
 Pre-embryonic Period

◦ Zero (0) to two (2) to three (3) weeks

 Embryonic Period
◦ Two (2) to three (3) weeks to eight (8) to ten (10)
weeks
FETUS
 Period from end of embryo stage until birth.
 Eight (8) to ten (10) weeks up to time of

delivery
VIABILITY
 A fetus can be delivered
 Capable of living outside utero
 Period of Viability is TWENTY (20) WEEKS

AND ABOVE
GRAVIDA
 Number of pregnancies REGARDLESS OF
THE OUTCOME
 PREGNANT WOMAN
d. Nulligravida – never been pregnant
e. Primigravida – first pregnancy
f. Multigravida – a woman with a second or
later pregnancy
PARITY
 Number of pregnancies THAT REACH THE

AGE OF VIABILITY REGARDLESS OF THE

OUTCOME OF PREGNANCY (should be
delivered)
 Refers to the past pregnancies ( not number

of babies) that reached viability (20-22 wk

whether or not born alive)

NULLIPAROUS
 A woman who has not carried a pregnancy

to viability (may have had one or more

abortions)
 Pregnancy did not reach age of viability

◦Therefore, PRIMIGRAVID, NULLIPAROUS

Primipara – a woman who has carried one
pregnancy to viability.

Multipara – a woman who had two or more

pregnancies that reached viability.

Grandmultipara – woman who has had six or

more viable pregnancies.
GTPAL
 G - describes number of gravida
(pregnancy)
 T is for Term (37 weeks and above)
 P is for Pre-term (20 to 36 weeks)
 A is for Abortion (any terminated pregnancy
less than 20 weeks; 19 wks and below)
 L is for Living children
 Presumptive
◦ More of a symptom rather than a sign
 Possible
 Positive
PRESUMPTIVE SYMPTOMS – subjective
experiences
2. Amenorrhea
 more than 10 days past missed menstrual
period.
 Breast tenderness, enlargement
 Nausea and vomiting
 Quickening (wk 16-18)
 Urinary frequency
 Fatigue
 Constipation (50% of women)
Presumptive signs
 Striae gravidarum linea negra, chloasma

(after 6 week)
 Increased basal body temperature
Probable signs - examiner’s objective findings
 positive pregnancy test
 Enlargement of abdomen/uterus
 Reproductive organ changes (after six

week)
3. Changes in Urination
 Urinary frequency

◦ Present in First and Third Trimester

◦ No Urgency
 Second Trimester
◦ This disappears
◦ Uterus starting to enlarge in First Trimester
◦ Uterus becomes abdominal organ in the second
trimester
◦ This releases pressure on the bladder
Third Trimester
 Uterus enlarges and presses again against

the bladder in the Third Trimester

4. Nausea and Vomiting
 Human Chorionic Gonadotropin

◦ Primigravida
Mostly manifests this
 Peaks at FIRST TRIMESTER
◦ At two (2) to three (3) months of pregnancy
◦ At eight (8) to twelve (12) weeks of pregnancy
 Provide:
Dry unsalted crackers
Ice chips
Small, frequent feedings
Six (6) times a day
This is the best among all the options
Split food into two halves and give meals after every
two (2) hours
Less fatty foods in diet
Do not lie supine after eating
Encourage ambulation
Progesterone decreases gastric emptying!
 If nausea and vomiting is severe consider

◦ Hydration
◦ Vomiting
◦ Hypokalemia, presenting as generalized
weakness
◦ Electrolyte Balance
 Therefore, client needs to be admitted
5. Fatigue
 Diaphragm does not descend upon

inspiration
6. Skin Changes
 Brought about by hormonal changes -

ESTROGEN
◦ Cloasma
Mask of pregnancy
Visible at the cheek
◦ Melasma
Darkening of the neck
◦ Linea Negra
From the symphysis pubis to the umbilicus
◦ Striae Gravidarum
Silvery in color
Due to distention of the collagen of the abdomen as
the uterus enlarges
PROBABLE SIGNS
 More of the signs
 1. Abdominal Enlargement
 Symmetrical and globular
 High risk
 Less than eighteen (18) weeks
 See different Landmarks:If uterus is at the
level of the symphysis pubis
◦ Age of Gestation = 12 weeks
 If uterus is midway between umbilicus and
symphysis pubis
 Age of Gestation = 16 weeks
If uterus is at the level of the umbilicus
◦ Age of Gestation = 20 weeks
 Then, increase of one centimeter (1 cm) in
FUNDIC HEIGHT = Additional Four (4) weeks
in Age of Gestation
◦ 1 cm above the umbilicus = 24 wks
◦ 2 cm above the umbilicus = 28 wks
◦ 3 cm above the umbilicus = 32 wks
◦ 4 cm above the umbilicus = 36 wks
At the LEVEL OF THE XIPHOID PROCESS, Age
of Gestation is 36 weeks
 If one centimeter (1cm) below the xiphoid

process, Age of Gestation is 40 weeks due

to LIGHTENING (presenting part enters the
true pelvis) or DESCENT
Lightening or Descent occurs
◦ In Primigravida
Two weeks earlier
◦ In Multigravida
Occurs during the time of labor
2. BALLOTTEMENT
When you tap the uterus, there is a
sensation that something is sinking
and floating
Sinking and floating of fetus in the
uterus
Appreciated at sixteen (16) to twenty-
four (24) weeks only
After twenty-four weeks (> 24 weeks),
NO BALLOTEMENT OCCURS
 This is because the size of the baby is
greater in respect to the amniotic fluid
3. BRAXTON HICKS
 False labor
 Palpable uterine contraction
 Starts at approximately twenty-eight (28)

weeks and above

 This is okay unless it does not give

progressive cervical dilatation

4. CHADWICK’S SIGN
 Bluish-purple coloration of the vagina due to

increase in vagina’s vascularity

 Vagina becomes swollen due to estrogen

and progesterone
 purple hue in vulvar/ vaginal area.
 Increase in acidity of vaginal pH due to
lactobacillus acidophilus
 Lactobacillus acidophilus protects the

vagina from ascending infection but favors

increased growth of candidiasis
 Candidiasis

◦ This problem increases in pregnancy

5. GOODEL’S SIGN
 Softening of the cervix to ready cervix for

dilatation and effacement

 Increased vascularity (red and bluish cervix)
 Hyperplasia and hypertrophy of cervical

glands (uterus hypertrophy only)

 – cervical softening.
 Increased cervical glands
 Increased cervical secretions
 Leukorrhea or white secretions
 Cervical secretions coagulation or clumping
resulting into MUCOUS PLUG or OPERCULUM
 Operculum
◦ Protects the baby and the placenta from
ascending infection
Hegar’s sign – softening of the lower uterine
segment
POSITIVE PREGNANCY TEST
 HCG levels determine this
 Ten (10) days after missed period, this can

be detected
 Peak of level of HCG is ten (10) weeks Age
of Gestation or 2½ months
 Then it goes down
 Therefore, yield of positivity of pregnancy

tests to go down after ten (10) weeks

1. FETAL HEART TONE
 1.1) Ultrasound

◦ Cardiac pulsation as early as six (6) to eight (8)

weeks
1.2) Doppler
Fetal heart tone at ten (10) to twelve (12) weeks
1.3) Fetoscope / Stethoscope
Fetal heart tone at eighteen (18) to twenty (20)
weeks
1.4) External Electronic Fetal Monitor
Fetal heart tone at twenty-four (24) weeks Age of
Gestation
2. QUICKENING
 Quickening felt by the examiner is a
positive sign of pregnancy
 Quickening felt by the mother is a
presumptive sign
 In Primigravida
◦ This occurs later than twenty (20) weeks
 In Multigravida
◦ This occurs earlier than sixteen (16) weeks
3. X-RAY / FETAL SKELETON
APPRECIATED
 X-ray on pregnant mother is okay as long as

there is ABDOMINAL SHIELD

 This is done on the SECOND (2nd) or THIRD

(3rd) TRIMESTER but NEVER DURING THE

FIRST (1st) TRIMESTER
4. PULSATION OF HEART OF BABY
THROUGH ULTRASOUND
 MATERNAL PHYSIOLOGY
 Pregnancy Duration

◦ 280 days
- 40 weeks
- 10 lunar month
s
1. WEIGHT GAIN
 Twenty-five (25) to thirty-five (35) pounds
 First Trimester

◦ Four pounds (4 lbs.)

◦ Only organogenesis occurs
◦ No muscle growth
 Second Trimester
◦ Eleven pounds (11 lbs.)
 Third Trimester
◦ Eleven pounds (11 lbs.)
One (1) to two (2) pounds per week is the
allowable weight gain during the FIRST (1st)
and SECOND (2nd) TRIMESTER
 On the LATE THIRD TRIMESTER (36 weeks
and above), allowable weight gain is one
pound per week (1 lb. / week)
2. WATER METABOLISM
 Four (4) to six (6) liters of water are

retained during pregnancy

 Thirty to fifty percent (30% to 50%) of this

amount can enter into the circulation

(approximately 2 – 3 liters) to intravascular
space
 This INCREASES the CARDIAC OUTPUT
 Therefore, pregnant people with HEART

CONDITIONS are AT-RISK!!!

 Increased Progesterone
◦ Relaxes smooth muscles
◦ Decreases peripheral resistance
 Therefore, Blood Pressure should REMAIN
THE SAME or should DECREASE DURING
PREGNANCY
 Sodium
◦ Dilutional Hyponatremia occurs in pregnancy due
to increased water retention
◦ Therefore, DO NOT RESTRICT SALT INTAKE
DURING PREGNANCY
 Just maintain sodium intake of three (3)
grams per day
3. PHYSIOLOGIC ANEMIA
 Due to increase in plasma value

◦ Dilutes circulating Red Blood Cells

◦ Therefore, take the Complete Blood Count in the
initial assessment to get the blood picture of the
client
 Give iron supplementation
◦ Do this in the second trimester because this is the
time when iron stores are depleted
◦ Best taken at night
◦ Metallic taste is
◦ Give with food
 A gastric irritant
◦ Followed by orange juice
◦ Acidic environment provides greater absorption
◦ Advise that client will have black stool
◦ Client taking iron is constipated
Therefore, increase oral fluid intake and iron
4.CARBOHYDRATE METABOLISM
 Pancreas is enlarged

◦ Increased insulin secretion

◦ Pregnancy is a diabetogenic state
◦ A paradox!!!
 If pre-pregnant mother is diabetic
◦ Two to three percent (2% to 3%) chance of having
gestational diabetes
◦ Placenta COUNTERACTS INSULIN by INSULINASE
◦ Insulinase breaks insulin
 Human Placental Lactogen
◦ Secreted only during pregnancy
◦ Promotes lipolysis
 INSULINASE and HUMAN PLACENTAL
LACTOGEN
◦ Increased sugars in blood prevents starvation of
baby in case of maternal starvation
5. PROTEIN METABOLISM
 Increase in need of protein during

pregnancy
 Additional ten grams (10 g) of protein per

day to be added to non-pregnant diet

 Placenta is made up of fatty acids
 FAT METABOLISM

◦ Add to diet
◦ A little increase in fat in the diet is necessary
 Iron supplementation in pregnancy is
DOUBLED
 In pre-pregnancy

◦ Fifteen grams per day (15 g / day)

 In pregnancy
 Thirty grams per day (30 g / day)
 1. HISTORY
 2. PHYSICAL EXAMINATION
 2.1) Take Blood Pressure
 Well rested mother for fifteen (15) minutes
 Blood Pressure Variations with Position
 Sitting
◦ BP is slightly higher
◦ Highest reading of the three positions
 Supine
◦ Intermediate reading
 Left Lateral
 Lowest reading among the three positions
2.2) IPA
 In pregnant women, assessment would

consist of:
◦ Inspection
◦ Palpation
◦ Auscultation
 NO PERCUSSION
 2.3) FOCUS ON ABDOMEN
 Inspection
◦ Look for striae
◦ Look for hernia of umbilicus
 Palpate
◦ Take the fundic height
◦ Supine position with both legs flexed
◦ Use centimeter scale of tape measure
◦ Place at TIP OF SYMPHYSIS PUBIS up to the level
of FUNDUS AND NOTE THE MEASUREMENT
 2.4) PERFORM LEOPOLD’S MANEUVER
 Purpose of Leopold’s Maneuver

◦ To know where the fetal back is

◦ To get Fetal Heart Tone
 Let patient void before performing
Leopold’s Maneuver
 In the first three maneuvers, the nurse

FACES THE HEAD PART OF THE MOTHER

 2.4.1) LEOPOLD’S 1
 Performed to know. . .
 What part of the baby occupies the fundus

of the uterus?
 FUNDAL GRIP
 How is Leopold’s 1 done?
 Use both hands
 Palpate the fundus of the uterus in a

circular manner
 Locate if the fundus has:
◦ HEAD
Round
Hard
Ballottable mass
◦ BREECH (buttocks)
Soft
Irregular
With nodulations
(coccyx, bilateral aspect of buttocks)
 Question:
 What Leopold’s maneuver will you use to

know the presentation of the fetus?

 Answer:
 Leopold’s 3
 In Leopold’s 1, we know what is the LIE of
the baby
 FETAL LIE

◦ Is the relationship of the long axis of the mother

to the long axis of the baby
 Types of Fetal Lie
 Transverse Lie

◦ Baby is perpendicular to the long axis of the

mother
◦ HORIZONTAL ORIENTATION
 Longitudinal Lie
◦ Baby is parallel to the long axis of the mother
 VERTICAL ORIENTATION
 If baby is in a TRANSVERSE LIE, LEOPOLD’S
1 is NEGATIVE
 LEOPOLD’S 2
 Performed to know. . .
 Where is the FETAL BACK?
 Where is the UMBILICAL GRIP?
 How is Leopold’s 2 done?
 Use both hands
 Palpate the side of the mother
 If at longitudinal lie
◦ Fetal Back
Bony, convex mass represents the vertebral column
◦ Fetal Small Parts
Small, irregular mass represents the knuckles and
knees
 If at transverse lie
◦ Head or Buttocks will be located
 If you locate the back, place stethoscope at
the back where FETAL HEART TONE is MOST
AUDIBLE
 LEOPOLD’S 3
 Performed to know. . .
 What part of the baby lies just above the

pelvic inlet
 PAWLIK’S GRIP
 How is Leopold’s 3 done?
 Use dominant hand
 Grasp area just above the symphysis pubis
 If you grasp the head

◦ Round
◦ Hard
◦ Ballotable mass
 If breech
◦ Soft
◦ Irregular
◦ With nodulations
(coccyx, bilateral aspect of buttocks)
 You will ALSO KNOW if PRESENTING PART IS
ENGAGED or NOT ENGAGED
 If head is engaged,
◦ If head is already descended, you will not feel the
head
◦ If head has not descended fully to the pelvic inlet
(partial descent), you can feel for the shoulders of
the baby
◦ If head is unengaged, you can grasp head and
you can move it sideways
 FETAL PRESENTATION is best determined by
LEOPOLD’S 3 because IT IS DIRECT.
 LEOPOLD’S 1 is INDIRECT
 LEOPOLD’S 4
 Performed to know. . .
 What is the ATTITUDE of the fetus?
 FETAL ATTITUDE
◦ This is the degree of flexion of the baby in utero
 Types of Fetal Attitude
 Flexed
 Suboccipitobregmatic
 diameter is presented
Approximately nine centimeters (9cm)

Note: Bregma is anterior

 Extended
It cannot pass through suboccipitomental diameter,
which is greater than thirteen centimeters (>13 cm)
Thus, there will be LONG LABOR
Cervical Dilatation will not proceed
Therefore, CAESARIAN SECTION is PERFORMED
 You also note the DEGREE OF FLEXION or
ATTITUDE of the fetus or PELVIC GRIP
 How is Leopold’s 4 done?
 Face the foot part of the mother
 Use both hands
 Palpate the side of the mother going to the

midline of the symphysis pubis

 If in extension attitude
◦ There is RESISTANCE
◦ This occurs when you hit NAPE AREA
 Note: Your hand will feel a depression and
then will feel the ascending curve going
towards the head
 If in complete flexion
◦ Cephalic prominence is on the same side as fetal
small parts (feet and knees)
 If in complete extension
◦ Cephalic prominence is on same side of fetal back
 Two (2) things to know from LEOPOLD’S 4
◦ Fetal Attitude or the degree of flexion
◦ Cephalic Prominence
 Prepare mother psychologically during pre-
natal check-up
 FIRST TRIMESTER
 Mother should accept that she is pregnant

(though ambivalence may be present)

 Concern of the mother towards herself is

greater than her concern towards the baby

SECOND TRIMESTER
 Acceptance of baby is the main task
 Concern towards the self is EQUAL to
concern for the baby
 THIRD TRIMESTER
 Acceptance of parenthood
 Concern for the self is LESS than concern

for the baby

a. Once monthly – until week 28.
b. Every 2 week – week 28 – 36
c. Weekly – week 36 until labor
THEORIES OF PARTURITION
FETAL SIGNAL
 The baby feels that it is already capable of

living outside utero

 Example:
◦ Fetus with Normal Spontaneous Delivery go into
Post Maturity, delivered 42 – 43 weeks
◦ This is because fetus feels something is still
lacking in his or her body
OXYTOCIN THEORY OF PARTURITION
 Receptors for oxytocin in the uterus

increases as term approaches

 Level of progesterone assayed in pre-term
and term pregnancy
 Pre-term

◦ Progesterone level is still high

 Approaching Term
◦ Level of progesterone DECREASES causing
CONTRACTION OF THE UTERUS
 Premature
◦ Low levels of prostaglandin
 Term / Post Term
◦ High levels of prostaglandin
 Important Concepts!
 Prostaglandin causes uterine contraction
 COITUS is CONTRAINDICATED if you have a
history of PREMATURITY since SEMEN
CONTAINS PROSTAGLANDIN
 1. PELVIC DIMENSION
 2. FETAL DIMENSION
 A) Fetal Size
 Correlation of size of baby to pelvic size
 Cephalopelvic Disproportion (CPD)
 Head of baby is INCONGRUENT with the

pelvis
 Head Size is greater than the Pelvis
 B) Fetal Posture or Attitude
 If in complete extension, labor will not

progress
 C) Fetal Lie
 If fetus is in TRANSVERSE LIE, DILATATION

will NOT PROGRESS

 D) Fetal Presentation
 If breech and PRIMIGRAVIDA
 NO NORMAL SPONTANEOUS DELIVERY
 If breech and MULTIGRAVIDA
 POSSIBLE NORMAL SPONTANEOUS

DELIVERY
 E) Fetal Position
 Relationship of the four (4) quadrants of the

pelvis of the mother to the presenting part

 F) Fetal Station
 Relationship of presenting part to ISCHIAL

SPINES
 If head of baby descends in the pelvis, the

head of the baby is AT THE LEVEL OF THE

ISCHIAL SPINE
 THEREFORE, STATION IS ZERO
 1 cm above ischial spine = -1
 2 cm above ischial spine = -2
 3 cm above ischial spine = -3
 4 cm above ischial spine = -4
 At station of –4, head is still floating
 The presenting part is in the FALSE PELVIS
 The LINEA TERMINALIS is an imaginary

dividing line that

 divides the FALSE and TRUE PELVIS
 Above the linea terminalis is the FALSE

PELVIS
 Below the linea terminalis is the TRUE

PELVIS
 If engaged, head is not necessarily at
STATION ZERO
 From STATION –3, the head is ALREADY

ENGAGED!!!
 Below the Ischial spine, the reckoning is

POSITIVE
 1 cm below ischial spine = +1
 2 cm below ischial spine = +2
 3 cm below ischial spine = +3
 4 cm below ischial spine = +4
 At station +4, head is already CROWNING or
SHOWING AT THE INTROITUS
3. FETAL HEAD
 Fontanelles

◦ Give rise to molding

 Molding
◦ Overlapping of sutures to accommodate head
through the pelvis
 Anterior Fontanelle
◦ Diamond shaped
◦ Closes at nine (9) to eighteen (18) months
 Posterior Fontanelle
 Triangular shaped
 Closes at two (2) to three (3) months
TRUE LABOR
 Starts at lumbar area or the back
 Regular interval
 Progressive cervical dilatation and
effacement
 Intensity is increasing
 Ambulation intensifies uterine contraction in
true labor
 Sedation has no effect
FALSE LABOR
 Confined to hypogastric area or lower
abdomen
 Irregular interval
 No cervical dilatation and effacement
 No change or decreasing intensity
 Ambulation stops uterus contraction
 Sedation stops false labor
 UTERINE CONTRACTION
 Timing is done by the nurse
 Use balls of the finger and palpate fundus of

the uterus
 In the United States, the mother is hooked

to an external monitor
Example:
 Contraction starts 7:00 AM
 Lasts 60 seconds 7:01 AM
 Second contraction 7:04 AM
 Duration is 60 secs 7:05 AM
 Third contraction 7:08 AM
 Interval
◦ From end of first contraction to the beginning of
the next contraction
◦ 7:01 AM to 7:04 AM
◦ Therefore, three (3) minutes
 Frequency
◦ Beginning of one contraction to beginning of next
contraction
◦ 7:00 AM to 7:04
◦ Therefore, four (4) minutes
 Duration
◦ From the beginning to end of one contraction
◦ 7:00 AM to 7:01 AM
◦ Therefore, one (1) minute
 Intensity
◦ This is a subjective term
◦ May be classified as:
Mild Contraction
Examining finger can be indented but uterus is still
contracting
Moderate Contraction
Examining finger can be indented but uterine
contraction is more than in mild
◦ Strong Contraction
You cannot indent examining finger because the
abdomen is board-like in consistency (hard)
 1. LIGHTENING
 In Primigravida

◦ Two (2) weeks prior to labor

 In Multigravida
◦ At time of labor
 2. BRAXTON HICKS CONTRACTIONS
Starting at twenty-eight (28) weeks Age of Gestation
This is normal, provided there is NO CERVICAL
DILATATION
 3. INCREASE IN VAGINAL SECRETION
 An attempt to remove mucous plug
 4. SOFTENING OF THE CERVIX
 HEGAR’S SIGN
 For effacement and dilatation
 5. BLOODY SHOW
 Secondary to descent of presenting part
 Capillaries in the floor of pelvis are ruptured

by presenting part or pressing on the pelvis

STAGE 1
 TRUE UTERINE CONTRACTION TO FULL

CERVICAL DILATATION (10 cm)

 For Primigravida (in normal circumstances)
 First Stage lasts for eight (8) to twelve (12)

hours
 For Multigravida (in normal circumstances)
 First Stage lasts for six (6) to eight (8) hours
 In Precipitate Labor
 Entire labor is through within three (3)

hours
 PHASE 1
 LATENT PHASE OF FIRST STAGE OF

LABOR
 Cervical Dilatation

◦ Zero centimeters (0 cm) to three (3 cm)

 Uterine Contraction
◦ Duration
Twenty (20) to Forty (40) seconds
◦ Interval
Five (5) to ten (10) minutes
◦ Intensity
Mild Intensity
 PHASE 2
 ACTIVE PHASE OF FIRST STAGE OF
LABOR
 Cervical Dilatation
◦ Four centimeters (4 cm) to Seven (7 cm)
 Uterine Contraction
◦ Duration
Thirty (30) to Fifty (50) seconds
◦ Interval
Two (2) to Five (5) minutes
◦ Intensity
Moderate Intensity
 PHASE 3
 TRANSITIONAL PHASE OF FIRST STAGE

OF LABOR
 Cervical Dilatation

◦ Eight centimeters (8 cm) to ten (10 cm)

 Uterine Contraction
◦ Duration
Up to sixty (60) seconds
◦ Interval
Two (2) to three (3) minutes
◦ Intensity
Strong Intensity
 FROM FULL CERVICAL DILATATION UP TO
DELIVERY OF THE FETUS
 In Primigravida

◦ One (1) to four (4) hours long

 In Multigravida
◦ Twenty (20) to forty-five (45) minutes only
 In a client in labor – A primigravida client,
when will you transfer the client from the
labor room to the delivery room?
a.if cervix is fully dilated
b.if in active labor
c.if in transitional labor (8 – 10 cm)
d. Anytime
 Answer:
◦ Letter A
 ◦ If patient is Multigravida
 Best time to transfer patient from the labor
room to the delivery room is the
TRANSITIONAL PHASE
 Transfer the client even while she is at eight

centimeters (8 cm) dilatation

MECHANISMS OF LABOR IN VERTEX OR HEAD
PRESENTATION
POSITION OF FETUS
 Relationship of the four (4) quadrants of

mother to the presenting part

 Mother is facing you
 Symphysis pubis is ANTERIOR
 Vertebra of mother is POSTERIOR
 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion
Common Board Questions
 Give the correct sequence of the

mechanisms of labor
DELIVERY OF BABY TO DELIVERY OF
PLACENTA
 Lasts for five (5) to ten (10) minutes
 Maximum waiting time is thirty (30) minutes
 Beyond thirty (30) minutes is ALREADY

ABNORMAL
1. Calkins’s Sign
◦ Uterus becomes firm and globular
2. Lengthening of the Cord
3. Sudden Gush of Blood

4. Rising of the Uterus into the Abdomen

◦ Up to the level of the umbilicus or one centimeter
(1 cm) after umbilicus after the delivery of the
placenta
 Two (2) Types of Placental Expulsion
 Shultz
 Duncan
 Shiny
 Cotyledon is not seen
 Total membrane covers this
 Placental separation starts at fetal side of
the placenta
◦ This is the membrane
 Central separation is the start
 Less chances of bleeding
 Nursing Responsibility for the Assessment
of the Placenta
◦ Expose all cotyledons
If one is missing, IT REMAINS INSIDE
Look for the PUNCHED-OUT AREA
◦ Measure the placental diameter
◦ Weigh the placenta
Remove the clamp
Normal placental weight
Less than 500 grams
If greater than 500 grams, there is PLACENTO-MEGALY
related to congenital anomaly
◦ Measure umbilical cord
Measure portion of the cord remaining with the
placenta
Measure portion of the cord remaining with the baby
 If this is less than fifty centimeters (<50 cm), there
may be SHORT CORD SYNDROME related to
ABRUPTIO PLACENTA
◦ Expect Blood Vessels
Artery
Small round lumen
Vein
Bigger lumen
More collapsed
◦ Two (2) arteries and one (1) vein
◦ Mnemonic is AVA
◦ If there is only one (1) artery and one (1) vein,
there is a congenital problem – A GUT PROBLEM –
Genitourinary Tract Anomalies
 Placental separation starts at SIDE /
PERIPHERY – on the lower end of the placenta
 Placenta slides down to the introitus
 Maternal side presents (attached to
myometrium)
 Cotyledons are easily visible
 Associated with more bleeding and
hemorrhage
 Normal Range of Number of Cotyledons
◦ Sixteen to twenty (16 – 20)
 When is the best time to clamp the cord?
 Best time to clamp the cord is when THE

CORD STOPS PULSATING

 When is the best time to cut the cord?
◦ Best time to cut the cord is when THE CORD
STOPS PULSATING
Pulsation means blood still flows
These drugs cause contraction of the
uterus
1. ERGOTRATES
 Includes METHERGINE I.V. or I.M.
 Best given immediately after delivery of

placenta
 Massive contraction of the uterus traps

placenta inside
 Therefore, do not give before placental
expulsion
2. OXYTOCIN
 Given prior to expulsion of placenta to add

to contraction
 Given at minimal amounts
 Normally at a rate of eleven to twelve drops

per minute (11-12 gtts / min)

 After delivery of placenta, give oxytocin at
GREATER AMOUNTS
Important Nursing Considerations!
 Methergine

◦ Prior to administration, check blood pressure

◦ If BP is greater than 140/90, WITHHOLD
METHERGINE
 Oxytocin
◦ Never given in direct bolus
◦ Never push
 ◦ Causes UTERINE HYPERTONUS
Tetanic contractions of the uterus or UTERINE ATONY
◦ Always dripped
Ten (10) units with one (1) liter
 Duration and Interval of Contraction in
Uterine Atony / Hypertonus
◦ Duration of Contraction
Greater than seventy seconds (>70 secs)
In Transitional Phase of First Stage of Labor, duration
of contraction is about sixty (60) seconds
◦ Interval
Less than two (2) minutes
This means that rest period is decreased
 Maximum interval must be maintained at
two (2) to three (3) minutes
 Therefore, STOP INFUSION OF OXYTOCIN AS
SOON AS POSSIBLE
 DO PROCEDURES IN LATE DECELERATION
 Oxytocin
◦ A potent vasoconstrictor
◦ Side effect
Initially is HYPERTENSION
◦ If given in bolus
Hypertension will be REVERSED TO HYPOTENSION
 Therefore, DO NOT GIVE OXYTOCIN IN
BOLUS
 Also causes WATER INTOXICATION
◦ Therefore, assess lungs of client
◦ Crackles will be present due to pulmonary edema
due to water retention by oxytocin
Bleeding or Hemorrhage
 Uterus must be at level of umbilicus or

about one centimeter (1 cm) above

 If it is three centimeters (3 cm) above the
umbilicus, UTERUS IS NOT CONTRACTED
◦ There would be BLEEDING
 First thing to do:
◦ Massage the uterus to attempt contraction
◦ Increase the rate of oxytocin drip
Nurse does this
 Rate is increased from ten drops per minute
(10 gtt/min) to twelve to fifteen drops per
minute (12 – 15 gtt/min)
◦ Place icepack over the abdomen
Remove compress every ten minutes and replace
This prevents necrosis and blackening of the tissues
 Inspect Perineum
◦ How to measure amount of bleeding?
◦ Utilize the PADS
Count and Weigh
Guide: One gram is equivalent to one milliliter (1 g =
1 ml)
◦ Qualitative Approach
Mild Bleeding
One (1) pad saturated in one (1) hour
Moderate Bleeding
One (1) pad saturated in thirty (30) minutes
Heavy Bleeding
One (1) pad saturated in fifteen (15) minutes
Heavy Bleeding
Perineal pads saturated at one (1) hour and if blood clots
are present
◦ Palpate Abdomen
Uterus contracted
Perineum has bleeding
Bleeding from episiotomy (done if there is crowning
or +4 station)
Laceration not appraised
Bleeding from cervical laceration
Most common cause of bleeding
Vaginal wall bleeding
 DO NOT ENCOURAGE PUSHING IF CERVIX IS
NOT FULLY DILATED
 Question
 When is the best time to ask client to push?
 Answer

◦ Second Stage of Labor

◦ Main purpose of pushing
To shorten the Second Stage of Labor
Ask client to PANT-BREATHE if there is an urge to push
This prevents VALSALVA MANEUVER
Remember, FIRST STAGE PUSHING IS
NOT ADVISABLE
In the Third Stage of Labor, the NURSING
RESPONSIBILITY is to PROVIDE MEASURES TO PREVENT
HEMORRHAGE
 Other Causes of Bleeding
 Bladder Distention

◦ Therefore, MOTHER MUST VOID AFTER GIVING

BIRTH
◦ Offer bedpan every hour or accompany the
mother to the bathroom (patient has
HYPOTENSION)
First twelve (12) hours post partum
It is NORMAL for mother to go into DIURESIS
Absorbed water must be eliminated
◦ After twelve (12) hours, there is difficulty in
voiding due to FATIGUE BLADDER because of
CONSTANT PRESSURE EXERTED BY CONTRACTING
UTERUS
This results to a DISTENDED BLADDER
Therefore, UTERUS CANNOT CONTRACT EFFECTIVELY
This causes UTERINE ATONY (Uterus is deflected
either to the LEFT or to the RIGHT)
Therefore, assure voiding so uterus stays at center
 Place warm water in container
◦ Do not place warm water in abdomen or at the
hypogastric area
◦ This will cause bleeding
 Nursing Responsibility
◦ Do alternate pouring of warm and cold water over
the perineum to promote uterine contraction
FIRST ONE (1) TO TWO (2) HOURS AFTER
DELIVERY OF THE PLACENTA
 Crucial Problem or Main Problem at this
stage
◦ BLEEDING
 All the retained water retained previously
will be reabsorbed into the circulation
◦ Increase in Cardiac Output
◦ Increase in Oxygen Consumption
 Therefore, it is the most detrimental or
difficult stage of labor in GRAVIDOCARDIAC
PATIENTS!!!
 ABORTION
 Two (2) types of Abortion
 Spontaneous Abortion
 Induced Abortion
 SPONTANEOUS ABORTION
 Spontaneous miscarriage oocurs in 15 to 30% of
all pregnancies.
 Early miscarriage occurs before 16 weeks; late if
it occurs 16 to 24 weeks
 Most common cause of spontaneous abortion is
teratogenic factor and Chromosomal in nature
 Embryo is defective
 Immunologic, Implantation, Progesterone is too
low, Infection, Ingestion of drugs.
 Assessment:
 Vaginal spotting.
 Woman’s action is important.
 Therapeutic management:
 TYPES OF SPONTANEOUS ABORTION
 Threatened Abortion
 Incomplete Abortion
 Inevitable / Imminent Abortion
 Complete Abortion
 Missed Abortion
Threatened – mild bleeding, spotting,
cramping; cervix closed.
Inevitable – moderate bleeding, painful
cramping cervix dilated
Imminent – profuse bleeding, severe
cramping , urge to bear down
Incomplete – fetal parts or fetus expelled;
placenta and membranes retained.
Complete – all products of conception
expelled; minimal vaginal bleeding
Habitual/recurrent – history of spontaneous
loss of three or more successive
pregnancies.
Missed – fetal death with no spontaneous
expulsion within 4 weeks.
Elective abortion – (intentionally introduced
loss of pregnancy
 Threatened abortion:
 Blood is drawn to monitor human chorionic

gonadotropin hormone
 Sonogram is done to assessed viability of

fetus.
 Avoiding strenuous activity for 24 to 48

hours is the key intervention.

 Imminent(Inevitable abortion).
 For dilation and evacuation
 Complete Abortion
 entire product of conception are expelled spontaneously
without any assistance.
 Incomplete Abortion
 Danger of maternal hemorrhage.
 Dilation and curettage should be done.
 Missed Abortion
 Early pregnancy failure
 Died 4 to 6 weeks before the onset of miscarriage
symptoms
 Over 14 weeks may perform induced labor
 Disseminated intravascular coagulation.
 Recurrent Abortion
 Occurs in 1% of pregnant women.
 Possible causes:

4. Defective spermatozoa or ova

5. Endocrine factors
6. Deviations of uterus.
7. Infection
8. Autoimmune disorder
 Danger in MISSED ABORTION is SEPSIS
 Particularly if products of conception stay for more than
two (2) weeks, there is INFECTION and DISSEMINATED
INTRAVASCULAR COAGULOPATHY (DIC)
 DIC may also occur from induced abortion (abortion with
catheterization)
 Offending organism is gram negative anaerobe
 Other complications:
6. Hemorrhage
7. Septic abortion
8. Isoimmunization
9. Anxiety
◦ Gram negative organism secretes ENDOTOXINS
Causes destruction of capillaries
Results in turbulence in blood flow
Blood will seep out through the capillaries
Platelets will go to site of destruction
Platelets consumed
Therefore, also called CONSUMPTIVE
COAGULOPATHY
 Disseminated Intravascular Coagulopathy
patients:
◦ Die of continuous bleeding
◦ Have patches of hematoma
◦ Have hypotension leading to SEPTIC SHOCK due
to dilatation caused by ENDOTOXIN
◦ Fibrinogen level are too low.
◦ Associated with premure separation of
placenta, pregnancy induced hypertension,
placental retention, septic abortion, retention of
dead fetus.
 In septic shock, the extremities are warm
◦ All other forms of shock have COLD EXTREMITIES
ECTOPIC PREGNANCY
 Implantation outside the uterus

 Mostly tubal in nature (95%): 80% Ampulla, 12%

isthmus, 8% fimbria.
 2nd most common cause of bleeding in early

pregnancy
 Can be abdominal pregnancy

 Can be ovarian pregnancy

 Abdominal and ovarian pregnancy account for

five percent (5%)

 Most common predisposing factor
◦ PELVIC INFLAMMATORY DISEASE or PID
◦ Others chronic salpingitis, congenital
malformation, scars, uterine tumor.
 Other factors:
◦ Previous Surgery
May lead to adhesion
Peritoneum may adhere to fallopian tube
◦ Presence of Intrauterine Device
◦ History of previous ectopic pregnancy (on
opposite side)
 TRIAD OF MANIFESTATIONS
 Amenorrhea
 Vaginal bleeding or SPOTTING
 UNILATERAL ABDOMINAL PAIN or

TENDERNESS
◦ Usually lower abdomen
 CLINICAL MANIFESTATIONS OF
ECTOPIC PREGNANCY
 Severe, sharp knife-like abdominal pain

◦ Unilateral pain
 Abdominal rigidity
◦ Bleeding inside
◦ Hemoperitoneum
◦ Peritonitis
 Positive (+) for Cullen’s Sign
◦ Ecchymosis around the umbilicus due to
hemoperitoneum
◦ Sign of peritoneal irritation
 Decreased Blood Pressure
◦ About 80 / 50
 Excruciating Pain when the cervix is moved
 In ectopic pregnancy, blood goes to the
peritoneum
◦ Blood ruptures and pools at CUL DE SAC or the
POUCH OF DOUGLAS or URETERORECTAL POUCH
 When internal examination is done and cul
de sac is palpated, WRIGGLING SENSATION
arises
 DIAGNOSIS FOR ECTOPIC PREGNANCY
 CULDOCENTESIS
 You get something from the cul de sac
 How is Culdocentesis done?
 Consent
 Lithotomy position
 Prepare Perineum
 Speculum introduced
◦ Held in place
To visualize the cervix
◦ No anesthetic is given
 Spinal needle directed towards posterior
portion of the cervix
 Aspirate
 If blood is present in the cul de sac, it is a
RUPTURED ECTOPIC PREGNANCY
 If there is blood. . .

◦ It is tested to make sure it comes from ectopic

pregnancy and NOT MATERNAL BLOOD
◦ Blood is placed in a test tube / disk and observed
for clotting
 If NON-CLOTTING OR LAKED BLOOD
◦ It comes from ectopic pregnancy
 If BLOOD CLOTS
 It is maternal blood
 MANAGEMENT FOR ECTOPIC
PREGNANCY
 MEDICAL MANAGEMENT
 METHOTREXATE
 A sclerosing agent

◦ To shrink and absorb products of conception and

eventual absorption to the circulation
 If ectopic pregnancy is less than three
centimeters (3 cm)
◦ Given I.M. to the mother
 SURGICAL MANAGEMENT
 Salphingostomy
 Limited to UNRUPTURED (less than three

centimeter (3 cm))
 “binubutas, tinatanggal”
 Left to heal
Salphingotomy
 Limited to UNRUPTURED
 “binubutas, tinatanggal”
 Sutured

Salphingectomy
 For a ruptured ectopic pregnancy
Conditions Associated with second-
Trimester bleeding
Hydatidiform mole (H-MOLE)
 Predisposing Factors:

◦ Low socio-economic status

◦ Low protein intake
◦ Age
Less than eighteen (<18)
Greater than thirty-five (>35)
PROBLEM IN H-MOLE
 There is an abnormal degeneration of the

chorionic villi
 Vesicle-like structure is formed instead of

placenta
 May be antecedent to choriocarcinoma
 Genetic base of complete mole (sperm
enters empty egg and its chromosomes
replicates; 23 pairs of chromosomes are all
paternal).
 More common in women over 45 years of

age and women who are Asian.

A. uterus – rapid enlargement; fundal height
inconsistent with gestational estimate.
B. Brownish discharge – beginning about wk
12; may contain vesicles.
C. Signs and symptoms of
preeclampsia/eclampsia (before third
trimester), increased incidence of
hyperemesis gravidarum.
1. sonography, x-ray, amniography – no fetal
parts present; “snowstrom”
2. Laboratory test – for elevated human
chorionic gonadotropin (HCG) levels.
NURSING RESPONSIBILITIES IN H-MOLE
 SUCTION CURETTAGE
 “Sinisipsip”
 “Ayaw kayudin ang uterine lining”
 Purpose of Suction Curettage
◦ To prevent cancer of CHORIONIC CARCINOMA
◦ To prevent bleeding
◦ Sinuses Open
Early dissemination of tissues or METASTASIS to the
lungs, brain
 Lungs are the MOST common site of
METASTASIS IN H-MOLE
 Inability of cervix to support growing weight
of pregnancy; associated with repeated
spontaneous second trimester abortion.
Etiology
 Unknown
 Congenital defect in cervical musculature
 Cervical trauma during previous birth,

abortion; aggressive, deep or repeated

dilation and curettage
INCOMPETENT CERVIX / CERVICAL OS
 Most common cause of Habitual Abortion
 Habitual Abortion

◦ Three (3) consecutive abortions

 PREDISPOSING FACTORS IN INCOMPETENT
CERVIX
 Developmental Factors

◦ Defective collagen formation in the cervix

 Repeated Trauma to the Cervix
◦ Repeated Dilatation and Curettage
MANIFESTATIONS OF INCOMPETENT
CERVIX
 Minimal uterine contraction
 Vaginal Spotting
 Progressive dilatation of the cervix
 Already evident in the FIRST TRIMESTER
MANAGEMENT OF INCOMPETENT CERVIX
 McDonald’s Procedure
 Shirodkar / Barter Procedure
MC DONALD’S PROCEDURE
 Purse string suture applied to cervical

opening
◦ Purpose is to make the cervix tense
 Done if products of conception IS LESS
THAN TWELVE (12) WEEKS OLD
 Mother is allowed to deliver by NORMAL

SPONTANEOUS DELIVERY if pregnancy

persists
 SHIRODKAR / BARTER PROCEDURE
 Cervix is closed
 But menstrual blood is allowed to come out
 Delivery is via CAESARIAN SECTION
NURSING RESPONSIBILITIES IN
INCOMPETENT CERVIX
 Bed Rest
 Position of choice

◦ Modified Trendelenberg
◦ Lumbar area is elevated and feet are lowered
 Coitus is temporarily restricted
 Tocolytic therapy is employed if there is
contraction
◦ RITODRIN, TERBUTALLINE is administered to STOP
CONTRACTION
 Conditions Associated with Third-
Trimester bleeding
 PLACENTA PREVIA
 Important Concept!
 All previa types are CAESARIAN

DELIVERIES !!!
 FOUR (4) TYPES OF PLACENTA PREVIA
 1. Low Lying Placenta Previa;
 Example: Gravida 7
 Predisposing Factors
 Multiparity, Advanced maternal age, past

cesarean, uterine curettage, multiple

gestation, male fetus.
◦ Tumor or mass in the uterus
◦ Previous Caesarian Section
Scar is avoided by the placenta
◦ Developmental Anomaly in the Uterus
Bicornuate uterus
 2. Marginal Placenta Previa
 Lower end of Placenta is TOUCHING THE

INTERNAL OS
 3. Partial Placenta Previa
 Part of placenta is OBSCURING THE

INTERNAL OS
 4. Total Placenta Previa
 Also called Placenta Previa Totalis
 Placenta TOTALLY COVERS THE INTERNAL

OS
◦ Definitely a Caesarian Section!
 Localization of Placenta
◦ Done on the second / third trimester
 PLACENTAL MIGRATION
 Placenta moves and may move up
 Can occur up to thirty-two (32) weeks
 Establish that the placenta is NOT PREVIA in
ALL INSTANCES OF SECOND OR THIRD
TRIMESTER BLEEDING
◦ Wait for the ULTRASOUND result
 DO NOT DO INTERNAL EXAMINATION!!!
 DOUBLE SET-UP
 Client with placenta previa

◦ If Internal Examination is done

◦ A stand-by team for operation is set up
Due to the advent of the Ultrasound, a Double Set-up
is NO LONGER DONE!!!
 ABRUPTIO PLACENTA
 Normal Placement
 EARLY SEPARATION OF THE PLACENTA

PRIOR TO DELIVERY OF THE FETUS

 Remember that separation of placenta

normally occurs on the THIRD STAGE OF

LABOR
 Frequent cause of perinatal death
 In abruptio placenta, the abnormal
separation OCCURS ON THE SECOND STAGE
OF LABOR
 If baby has SHORT CORD SYNDROME or
TRAUMA, consider ABRUPTIO PLACENTA
 Pregnancy Induced Hypertension

◦ A common cause of Abruptio Placenta

◦ Advanced maternal age
◦ Vasoconstriction from cocaine or cigarette use
PERIPHERAL SEPARATION
 Better
 Safer
 Blood goes out of introitus
 Tachycardia
 Hypotensive
 Increases degree of separation
 Increases degree of fluctuation of vital

signs
CENTRAL SEPARATION
 More dangerous
 Blood does not seep off through the

introitus but enters MYOMETRIUM

 Results to difficulty in contraction of the

Myometrium
 Uterus remains soft and boggy

◦ Uterine Atony
 Therefore, HYSTERECTOMY IS DONE
 Called COUVELAIRE
 Uterus is COPPER-COLORED or BLUISH in

color due to BLOOD THAT SEEPED INTO THE

MYOMETRIUM
 Degree of separation:
 Grade 0: no symptoms of separation were apparent from
the maternal or fetal signs, the diagnosis that a slight
separation did occur is made after birth.
 Grade 1: Minimal separation, but enough to cause vaginal
bleeding and changes in maternal vital sigs. No fetal
distress
 Grade 2: Moderate separation, there is evidence of fetal
distress.
 Grade 3: Extreme separation, without intervention maternal
shock and fetal death will result.
 Preterm Labor
 Occurs before the end of week 37 of gestation.

 Responsible for almost two thirds of all infant

deaths in the neonatal period.

 Associated with dehydration, urinary tract

infection, chorioamnionitis, inadequate pre-natal

care.
 Symptoms:

6. Dull, low back pain

7. Vaginal spotting

8. Feeling of pelvic pressure

9. Menstrual like cramping

10.Increased vaginal discharge

 PREMATURE RUPTURE OF MEMBRANES
 Membranes rupture PRIOR TO ONSET OF

LABOR
 No contractions yet
 PROBLEMS IN PREMATURE RUPTURE
OF MEMBRANES
 1. INFECTION
 Gold Standard is twenty-four (24) hours
 If more than twenty-four hours, there will be

SEPSIS
 2. CORD PROLAPSE
 Umbilical cord goes out
 Position the client to TRENDELENBERG

POSITION
◦ Lower the head part
◦ NICHE’S POSITION
 Do not reinsert!!!
 Moisten OS with NSS and cover
 Push the PRESENTING PART BACK and NOT
THE CORD
 Transport client to the OPERATING ROOM
 Provide oxygenation
 Get Fetal Heart Tone
 Then Caesarian Section is started
 Never Normal Spontaneous Delivery
 MANAGEMENT OF PREMATURE
RUPTURE OF MEMBRANES
 Pregnancy can still be prolonged if PRE-
TERM PREMATURE RUPTURE OF
MEMBRANES (PPROM)
◦ Pre-term Premature Rupture of Membranes (i.e.
35 weeks)
 Problems are:
◦ Infection
◦ Cord Prolapse
◦ Prematurity
 Provided
◦ There is no maternal infection
◦ There is no fetal distress
◦ Mother is not in labor
 Termination of Pregnancy
◦ Caesarian Section
◦ Normal Spontaneous Delivery
 PREMATURE LABOR
 Most common cause of neonatal morbidity
and mortality
◦ Eighty five percent (85%)
 Preventable
◦ How?
Modify lifestyle of the mother
Resolve on-going infection
Ascending infection affects fetus, uterus (goes into
contraction)
 Management is similar to Placenta Previa
 Except coitus restriction throughout
 POST TERM LABOR
 Pregnancy extends beyond forty-two (42)

weeks
 1. Cephalopelvic Disproportion (CPD)
 This leads to babies with

◦ Long nails
◦ Wrinkled Skin
 2. Oligohydramnios
 Amniotic fluid is less than 1,000 ml
 Polyhydramnios is amniotic fluid level

greater than 2,000 ml

 Related to congenital anomaly
 This gives rise to babies with BANDS OR

CONSTRICTIONS ON BODY
 3. Inadequate blood supply to the baby due
to calcification of the placenta
 Placenta tends to harden
 There are whitish specks instead of black

specks
 4. Meconium Staining
 Due to distress
 Meconium Aspiration Syndrome
 PRECIPITATE LABOR
 Course of labor is ABRUPT
 Labor lasts for LESS THAN THREE (3) HOURS
 DANGERS OF PRECIPITATE LABOR
 Non-institutionalized Delivery

◦ Exposes baby to sepsis

 Expose mother to laceration
◦ Head of baby bumps to pelvis
This results to hemorrhage
 Intracerebral hemorrhage of the head of
baby
◦ Baby bumps to bony pelvis
 BREECH DELIVERY
 1. COMPLETE BREECH
 Baby assumes a position similar to sitting
 Thighs flexed to abdomen
 Legs flexed to thigh
 2. FRANK
 Thighs are flexed to abdomen
 Legs are extended
 3. INCOMPLETE BREECH
 Thighs are flexed to abdomen
 Either leg is extended outside

◦ Single Footling
 Double Footling
 MAIN PROBLEM
 Cord Prolapse

◦ Space in cervical opening

◦ Therefore, cord goes with presenting part
 Head Entrapment
 Shoulder Dystocia

◦ Difficulty in bringing out shoulder

 Normal to see Meconium Staining
◦ Buttocks get stuck
Less blood supply to the gut
Stress present
Therefore, there is meconium
 MULTIPLE PREGNANCY
 Two (2) types of Multiple Pregnancy
 Monozygotic
 Dizygotic
 MONOZYGOTIC
 One (1) ovum and one (1) sperm
 Fertilized by single sperm
 Problem in cell division
 Two (2) individuals
 Most of the time, of the same sex
 One (1) placenta
 Two (2) umbilical cords
 One (1) chorion (vascular outer covering)

◦ In contact with maternal side

 Two (2) amnions (avascular inner
covering)
◦ In contact with the fetus
 DIZYGOTIC
 Two (2) ova and two (2) sperms fertilizing
them
 Identical or twin of opposite sex
 Two (2) placenta
 Two (2) umbilical cord
 Two (2) amnions
 Two (2) chorions
 MONOZYGOTIC TYPE OF MULTIPLE
PREGNANCY
◦ More common
 Increased chance of twin to twin transfusion
◦ Donor twin and recipient twin
Blood of donor twin goes to recipient twin
Because they share one vascular channel
◦ Donor Twin
Survives
Usually thin
Would normalize and be okay after blood transfusion
◦ Recipient Twin
Dies
Develops Congestive Heart Failure
Usually stout
Dystocia
– difficult labor
- Due to effects of factors that affect the
FETUS. (3 P’s)
a. Power: forces of labor (uterine
contractions, use of abdominal muscles0.
1 premature analgesia/anesthesia
2. uterine overdistension (multifetal
pregnancy, fetal macrosomia).
3. uterine myomas
4. grandmultiparity
b. PASSAGEWAY: resistance of cervix, pelvic
structure.
1. rigid pelvis
2. distended bladder
3. dimensions of the bony pelvis: pelvic
contractures
c. PASSANGER: accommodation of the presenting
part to pelvic diameters.
1. fetal malposition/malpresentation
a. transverse lie
b. face, brow presentation
c. breech presentation
d. persistent occiput posterior position
e. CPD
2. fetal anomalies
a. hydrocephalus
b. conjoined (“Siamese”) twins.
c. meningomyelocele
Maternal:
2. fatigue, exhaustion, dehydration – due to prolonged labor
3. Lowered pain threshold, loss of control- due to prolonged
labor, continued uterine contractions, anxiety, fatigue,
lack of sleep.
4. Intrauterine infection- due to prolonged rupture of
membranes and frequent vaginal examination
5. Uterine rupture – due to obstructed labor,
hyperstimulation of uterus
6. Cervical, vaginal, perineal lacerations – due to obstetric
interventions
Fetal:
2. hypoxia, anoxia, demise – due to
decreased oxygen concentration in cord
blood.
3. Intracranial hemorrhage – due to changing
intracranial pressure.
Hypertonic dysfunction
 Increased resting tone of uterine
myometrium; diminsihed refractory period;
prolonged phase;
 Unknown etiology
 Theory- ectopic initiation of incoordinate
uterine contractions.
a. nullipara – more than 20 hours
b. multipara – more than 14 hours
Assessment:
1.Onset – early labor (latent phase)
2.Contractions:
a. continuous fundal tension, incomplete
relaxation
b. painful
c. ineffectual – no effacement or dilation
 Signs of fetal distress

a. meconium stained
b. FHR irregularies
3. Maternal vital signs
4. Emotional status
Medical management:
2. Shorting acting barbiturates – to
encourage rest, relaxation.
3. Intravenous fluids – to restore/maintain
hydration and fluid-electrolyte balance.
4. If CPD, cesarean birth.
Nursing management:
2. Emotional support – assist coping with
fear, pain, discouragement
a. encourage verbalization of anxiety, fear
concern.
b. explain all procedure
c. reassure, keep couple informed of
progress.
2. Comfort measure
a. position: sidelying – to promote
relaxation and placental perfusion.
b. bath, back rub, linen change, clean
environment
c. environment: quiet, darkened room – to
minimize stimuli and encourage relaxation
and warmth.
d. encourage voiding – to relieve bladder
distension; to test urine for ketones.
Hypotonic dysfunction during labor
 After normal labor at onset, contractions

diminish in frequency, duration and

strength; lowered uterine resting tone;
cervical effacement and dilation slow/cease.
Etiology
 Premature or excessive analgesia (epidural

block/spinal block)
 CPD
 Overdistention (polyhydramnios, fetal

macrosomia, multifetal pregnancy).

 Fetal malposition/alpresentation
 Maternal fear/anxiety.
Assessment:
2. Onset – may occur in latent phase, most
common during active phase
3. Contractions: normal previously,
demonstrate:
Decreased frequency
Shorter duration
Diminished intensity (mild to moderate)
Less uncomfortable
3. Cervical changes – slow/ cease.
4. Signs of fetal distress
Uterine rupture
 Stress on uterine muscle exceeds its ability to
stretch.
Etiology
 Overdistention – due to large baby, multifetal
gestation
 Old scars – due to previous cesarean births or
uterine surgery
 Contractions against CPD, fetal malpresentation,
pathological
 Tetanic contraction – due to hypersensitivity to
oxytocin( or overdose) during
induction/augmentation of labor.
 Injudicious obstetrics-malaaplication of forceps
(application without full effacement/dilation.
Assessment:
2. Identify predisposing factors early.
3. Complete rupture:
a. pain: sudden, sharp, abdominal; followed by
cessation of contractions; tender abdomen.
b. signs of shock; vaginal bleeding
c. fetal heart tones – absent
d. presenting part – not palpable on vaginal
examination.
2. Incomplete rupture
a. contractions: continue, accompanied by
abdominal pain and failure to dilate; may
become dystonic
b. signs of shock
c. may demonstrate vaginal bleeding
d. fetal heart tone absent/bradycardia
Amniotic Fluid Embolus
 Acute or cor pulmonale – due to embolus

blocking vessels in pulmonary circulation;

massive hemorrhage due to DIC resulting
from entrance of thromboplastin-like
material into bloodstream.
Etiology:
 Amniotic fluid (with any meconium, lanugo,

or vernix) enters maternal circulation

through open venous sinuses at palcental
site; travels to pulmonary arterioles.
Triggers cardiogenic shock and
anaphylactoid reaction.
Prognosis:
Poor; often fatal to the mother
Assessment:
2. May occur during labor, at time of rupture of
membranes, or immediately postpartum
3. Sudden dyspnea and cyanosis
4. Chest pain
5. Hypotension, tachycardia
6. Frothy sputum
7. Signs of DIC
a. purpura – local hemorrhage
b. increased vaginal bleeding – massive
c. rapid onset of shock
Medical management:
2. IV heparin, whole blood
3. Birth, immediately, by forceps, if possible;
or cesarean birth
Fetus in Jeopardy
 Maternal hypoxemia, anemia, ketoacidosis,

Rh isoimmunization,or decrease
uteroplacental perfusion
Etiology
Maternal:
1. preeclampsia/eclampsia, PIH
2. heart disease
3. diabetes
4. Rh or ABO incompatibility
5. insuffient uteroplacental/cord circulation due
to:
a. maternal hypotension/hypertension.
b. cord compression
1. prolapsed
2. knotted
c. hemorrhage; anemia
Placental Problem;
1. malformation of the placenta/cord
2. premature “ aging” of placenta
3. Placental infarcts
4. abruptio placentae
5. placenta previa
Prolapsed umbilical cord
 Cord descent in advance of presenting part;

compression interrupts blood flow,

exchange of fetal/maternal gases leads to
hypoxia, anoxia, death (if unrelieved)
Etiology:
b. Spontaneous or artificial rupture of
membranes before presenting part is
engaged.
c. Excessive force of escaping fluid, as in
polyhydramnios.
d. Malposition – breech, compound
presentation transverse lie.
e. Preterm or fetus who is SGA
PREGNANCY INDUCED HYPERTENSION
(P.I.H.)
 Unknown cause
 Vasospasm
SCREENING PROCEDURE FOR
PREGNANCY INDUCED HYPERTENSION
 1. ROLL-OVER TEST
 Done when mother is

◦ Twenty-eight (28) to thirty-two (32) weeks Age of

Gestation
 With increased cardiac output
◦ Mother is rested for fifteen (15) minutes
◦ Take the blood pressure in sitting position
(assuming BP is 100/60)
◦ Rest mother for fifteen (15) minutes
◦ Get blood pressure at left lateral position
(assuming BP is 90/60)
◦ Place mother in supine position
◦ Take the BP in supine position (assuming BP is
120/80)
 Then compare values at left lateral and
immediately supine
◦ Implication
Positive Roll-over test if there is an:
Increase in SYSTOLIC BP of 30 mmHg
Increase in DIASTOLIC BP of 15 mmHg
 Base line BP = 100/60
 Left Lateral BP = 90/60
 Supine BP = 120/80
 Difference = 30/20
 Therefore, this is positive for roll-over test
 Either systolic or diastolic, positive is

positive
 Therefore, client has increased chance of

developing Pregnancy Induced

Hypertension
 TRIAD OF PREGNANCY INDUCED
HYPERTENSION
 Hypertension after twentieth (20th) week
of Age of Gestation
 Proteinuria
◦ Greater than two-hundred fifty milligrams per
deciliter (>250 mg/dl)
 Edema
◦ Pathologic
◦ Physiologic
 Two (2) General Classifications
 Pre-eclampsia
 Eclampsia
 PRE-ECLAMPSIA
 Mild
 Severe
 Mild Pre-eclampsia
 Blood Pressure
◦ Positive to roll-over test
◦ But blood pressure can go as high as 140/90 to
150/100
 Proteinuria
◦ Level of protein in urine is 500 mg/dl
 Edema
 No associated signs and symptoms
 Management of Mild Pre-eclampsia
 Bed Rest

◦ To conserve oxygen
◦ Due to constriction of vessels
 Limit intake of salty foods
◦ Up to three (3) grams per day
 Closer follow-up
◦ Weekly check-up
 Severe Pre-eclampsia
 Blood Pressure

◦ 160/110 or more
 Proteinuria
 Five (5) grams per liter
 Measured in twenty-four (24) hour urine

output
 Edema
 Other signs and symptoms:

◦ Severe headache
◦ Blurring vision due to retention of water going
up to optic discs
◦ Fundoscopic examination
Looking for papilledema
◦ Pulmonary edema
Crackles
Cough
◦ Oliguria
Urine Output
Less than four-hundred milliliters (< 400 ml) in a day
Less than thirty thirty milliliters (< 30 ml) in an hour
◦ Epigastric pain
Aura of an impending seizure
 ◦ Reason for Presence of Epigastric Pain
Distention of capsule of liver due to edema
Necrosis of pancreas
Enzymes release digesting contents of intestine
◦ Vomiting
 Due to increased
 intracranial pressure (▲ICP)
 Management of Severe Pre-eclampsia
 Prevention of seizures
 PHARMACOLOGIC MANAGEMENT
 Give Magnesium Sulfate (MgSO4)

◦ Drug of choice
◦ Can also cause decrease in Blood Pressure
◦ (Hydralazine is drug of choice for hypertension)
◦ Check deep tendon reflex
◦ Knee jerk
If no reflex, hold magnesium sulfate
Hyporeflexia
◦ Magnesium sulfate causes depression
◦ Check Respiratory Rate
If less than twelve (12) to fourteen (14) respirations
per minute, HOLD
Magnesium sulfate causes INCREASED RESPIRATORY
DEPRESSION
◦ Check Urine Output
Magnesium Sulfate is eliminated through the urine
If urine output is low, Magnesium sulfate cannot be
eliminated
Loading Dose of Magnesium Sulfate
Fourteen grams (14 g)
Four grams (4 g) via I.V. infusion pump
Given for a duration of thirty (30) minutes
This is painful to the blood vessels
Ten grams (10 g) via I.M. injection
Five grams (5 g) on each buttock / gluteus
◦ Maintenance Dose
Give at one to two grams (1 – 2 g) in one to two
hours (1 hr. – 2 hrs.)
Given via I.V. drip
Continue forty-eight (48) hours after delivery
Because there is post partum pre-eclampsia
◦ Antidote
Calcium Gluconate
One gram (1 g) via direct I.V.
 Provide dim light room
 Limit Visitors
 Put up side rails
 Suction machine by bedside
 Don’t put anything in mouth if there is
seizure
 Open collar
 Turn patient to side to eliminate saliva
 Concern is safety
 ECLAMPSIA
 Positive for seizures
 Give additional medications:

◦ Diuretics
Furosemide is the drug of choice
 ◦ Digitalis (digoxin)
To promote contractility of heart without increasing
heart rate
Inotropic
 Check pulse rate
 ◦ In Adults:
If pulse rate is less than sixty beats per minute (< 60
BPM) – HOLD THE MEDICATION
◦ In children less than ten (10) years old
 If pulse rate is less than eighty beats per
minute
(< 80 BPM) – HOLD THE MEDICATION
In both cases, patient will go into BRADYCARDIA IF
MEDICATION IS NOT WITHHELD
 ◦ Potassium (K+)
Prevents DIGITALIS TOXICITY
 And USE OF POTASSIUM WASTING
FUROSEMIDE
 Before giving Potassium (K+)
◦ Before I.V. is in the vein, test for backflow
◦ Subcutaneous tissue necrosis
◦ Tissues get burned due to Potassium (K+)
 Barbiturates
 Fast acting sedatives
 To arrest seizure
 Hydralazine
 For hypertension
 HELLP SYNDROME
 HEMOLYSIS, ELEVATED LIVER ENZYMES,

LOW PLATELET
 Due to necrosis of the liver
 Disseminated Intravascular Coagulopathy
 Because of increased pressure in the blood

vessels
 GESTATIONAL DIABETIS MELLITUS
 Two (2) values elevated in OGTT
 DIET
◦ Maintain daily calorie intake of 1,800 to 2,200
kcal/day
◦ Refrain from eating simple sugars and
saturated fats
 EXERCISE
◦ Appropriate for Age of Gestation
 PHARMACOLOGIC THERAPY
◦ Insulin
Drug of Choice
◦ Oral hypoglycemic agent is teratogenic
 Insulin given is based on the weight of the
client
 If client is sixty kilograms (60 kg)

◦ Give 1ų / kg / day
◦ Therefore, give sixty units
 In a B.I.D. dosing
◦ Bigger portion is given in the morning
◦ 2/3 of 60 units = 40 units
 Smaller portion is given in the evening
◦ 1/3 of 60 units = 20 units
 The bigger portion – 2/3 portion or 40 units
is composed of
◦ Regular Insulin
Brief onset
For immediate need
Thirty (30) minutes to one (1) hour onset of action
 Comprises 1/3 of 40 units
◦ Intermediate Insulin
For later need
Comprises 2/3 of the 40 units
 Note: The bigger portion is given thirty (30)
minutes prior to breakfast
 For the smaller portion – 1/3 portion or 20
units
◦ 1 : 1 ratio of the regular : intermediate for 20
units
10 units for regular
10 units for intermediate
 In drawing insulin
 Vacuum air
 First introduced to regular (clear)

◦ Draw this first

 Then draw on the intermediate type
 Hypoglycemia causes COMA
 HEART DISEASE IN PREGNANCY
 Four (4) Functional Classifications of Heart
Disease
 Class I
◦ Heart Disease is present
◦ But uncompromised
 Class II
◦ Heart Disease is present
◦ Slightly compromised
 Class III
◦ Heart Disease is present
◦ Markedly compromised
 Class IV
◦ Heart Disease is present
 Severely compromised
 If you belong to Class I and Class II
◦ You can go through normal pregnancy
 If you belong to Class III and Class IV
◦ You cannot go through normal pregnancy
◦ You are not a good candidate
 In Heart Disease In Pregnancy
 Labor and delivery should be:
 Effortless
 Painless
 Pushless

◦ A vaginal delivery
 EPIDURAL ANESTHESIA
 Upon active labor (3 cm)
 Check Blood Pressure
 Side effect is hypotension
 No Oxytocin
 No Methergine
 No augmentation of labor
 All natural labor
 General Anesthesia only given when
crowning occurs
◦ If given early, this crosses the placenta and the
effect is a decrease in the APGAR SCORE
POSITION OF CHOICE DURING LABOR
 Will deliver at these positions:
 Semi-sitting
 Semi-Fowler’s position

◦ Not lithotomy
 Femoral vessels are obstructed
 DELIVERY OF CHOICE
 Outlet forceps extraction – Vaginal
 In Caesarian Section

◦ Normal blood loss is 800 – 1,000 ml

◦ 1,000 ml blood loss is hemorrhage
In Normal Spontaneous Delivery
◦ Normal blood loss is 500 ml
 500 ml blood loss is hemorrhag
 PUERPERIUM
 Main Responsibility

◦ Achieve INVOLUTION
Return of reproductive organs to pre-pregnancy
state
 Usually achieved after six (6) weeks
 PRINCIPLES
 1. PROMOTE HEALING
 Uterus

◦ At level of umbilicus
◦ After the delivery of the placenta
 One (1) day after
◦ One (1) finger breadth below the umbilicus
 Two (2) days after
◦ Two (2) finger breadths below the umbilicus
 Three (3) days after
◦ Three (3) finger breadths below the umbilicus
 Four (4) days after
◦ Four (4) finger breadths below the umbilicus
 Five (5) days after
◦ Five (5) finger breadths below the umbilicus
 Six (6) days after
◦ Six (6) finger breadths below the umbilicus
 Seven (7) days after
◦ Seven (7) finger breadths below the umbilicus
 Eight (8) days after
◦ Eight (8) finger breadths below the umbilicus
 Nine (9) days after
◦ Nine (9) finger breadths below the umbilicus
 Ten (10) days after
◦ Ten (10) finger breadths below the umbilicus or at
the level of the symphysis pubis
 Eleven (11) days after
- Uterus at the pelvic cavity
 After six (6) weeks, upon Internal
Examination. . .
◦ If Uterus is midway between the umbilicus and
symphysis pubis, this is ABNORMAL
This means that there is something left inside
 SUB-INVOLUTION or POST PARTUM
HEMORRHAGE
 Uterus has not gone back to original size
 Caused by retained placental fragment
 Rubra
 Day one (1) to day three (3)
 Day two (2) to day three (3)
 Bright red in color
 Serosa
 Day three (3) to day ten (10)
 Pinkish in color
 Actually, brown in color
 Alba
 Day ten (10) until third (3rd) week up to

sixth (6th) week post-partum

 After six (6) weeks, THERE IS NO MORE
LOCHIA
 CHARACTERISTICS OF NORMAL LOCHIA
 Normal Odor

◦ Musty but not FOUL SMELLING

◦ Foul smell indicates infection
 Color
◦ Should not be YELLOWISH
◦ Yellowish color indicates infection
 Order of Appearance
◦ Should never be reversed
◦ Reversal in appearance indicates RETAINED
PLACENTAL FRAGMENTS
 LACTATIONAL AMENORRHEA
 Lactating Fully
 Not ovulating
 Six (6) months effectivity
 TO BE EFFECTIVE
 There must be complete emptying of the

breast without supplementation (baby

receives no bottle feeding)
 Four (4) to six (6) months
 Start Supplementation
 Normally, after eight (8) weeks or two (2)
months, MENSTRUATION RETURNS
 If the mother is breastfeeding, it would take

six (6) months BEFORE MENSTRUATION

RETURNS
 After three (3) to four (4) weeks, COITUS IS
ALLOWABLE
2. PROVIDE EMOTIONAL SUPPORT
 TAKING IN
 First two (2) days post-partum
 Mother is very dependent for care for

self and the newborn

 Rejecting rooming-in is NORMAL
 TAKING HOLD
 After second day

◦ Mother is now independent of self care and

newborn care
◦ Time of evidence of POST PARTUM BLUES /
DEPRESSION IS OVERT
◦ If poor support system is present, this predisposes
to POST PARTUM BLUES / DEPRESSION /
PSYCHOSIS
◦ Brief Psychotic episode lasts for three (3) months
 LETTING GO
 Completely accepted role as a new mother
 3. PREVENTION OF POST-PARTUM. . .
 3.1) MATERNAL HEMORRHAGE
 Early post-partum hemorrhage
 Occurs within the first twenty-four (24)

hours after delivery

 Uterine atony is most common cause
 Lacerations are the second most common

cause
 Inherent clotting disorders occur:
 Thrombocytopenia
 Leukopenia
 Late post-partum hemorrhage
◦ Occurs after first twenty-four hours of delivery
 Common causes:
◦ Primary Cause
Retained placental fragment/s
◦ Secondary Cause
Hematoma (vaginal)
 3.2) INFECTION
 Endogenous infection
 Normal flora causes infection
 These travel up the uterus
 3.3) PERINEAL INFECTION
 On site of episiotomy

◦ Management involves antibiotic therapy

 Surgical Management
◦ Remove suture
◦ Drain pus
 Position in Semi-Fowler’s position
 3.4) ENDOMETRITIS
 Infection of the lining of the uterus

◦ With maternal fever > 38°

C (37.5°C is common due to dehydration)
◦ With foul-smelling vaginal discharge
 With uterine or abdominal tenderness
 Management for Endometritis
 Antibiotics
 Position

◦ Semi-Fowler’s position
 Oxytocin is given
◦ Promotes contractions
◦ Promotes release of secretion
 ENDOMETRITIS is a PRELUDE to
THROMBOPHLEBITIS
 3.5) THROMBOPHLEBITIS
 Most common site are the vessels of the

LOWER EXTREMITIES
 Positive (+) for HOMAN’S SIGN
 How is Homan’s Sign elicited?
◦ Ask patient to dorsiflex foot
◦ Upon lying supine, legs extended
◦ Stretching of the blood vessels causes pain on
calf muscle (gastrocnemius muscle)
 Management of Thrombophlebitis
◦ Antibiotics
◦ Anticoagulant
Heparin
Larger molecule than warfarin
Less likely to enter breast milk
 Discontinue breastfeeding whether heparin
or warfarin is administered
 Antidotes

◦ For Heparin
Protamine Sulfate
◦ For Warfarin
Vitamin K
 ESTABLISHMENT OF SUCCESSFUL
LACTATION
 La leche Method

◦ When placenta is delivered

◦ There is decreased estrogen and progesterone
 This indicates production of PROLACTIN
◦ Stimulation of acinar cells to produce milk and
stored in the lobules
◦ Upon sucking, OXYTOCIN IS RELEASED
This is the hormone responsible for the EJECTION OF
MILK
 HOW TO BREASTFEED
 Offer entire breast up to the areola
 Assume side lying position
 Hype up to suck whole nipple and areola
 Pull breast tissue away from the NOSE of

the baby
 Day 1
 Start breastfeeding for five (5) minutes on

each breast
 Day 2
 Provide breastfeeding for six (6) minutes on

each breast
 Day 3
 Provide breastfeeding for seven (7) minutes

on each breast
 Day 4
 Provide breastfeeding for eight (8) minutes

on each breast
 Day 5
 Provide breastfeeding for nine (9) minutes
on each breast
 Day 6
 Provide breastfeeding for ten (10) minutes
on each breast
 Stop and maintain ten (10) minute feeding
per breast
 This would give a total of twenty (20)
minutes of breastfeeding time
Important Concept!
 Breastfeeding is done on a per demand

basis
 1. CARDIOVASCULAR SYSTEM
 HEART
 As diaphragm rises, the heart is displaced

laterally
 Point of Maximum Impulse
◦ Normally located at Fifth Intercostal Space Mid-
clavicular Line on the Left Side {5th ICS-MCL (L)}
◦ This shifts to Fourth Intercostal Space Lateral
Axillary Line on the Left Side {4th ICS-LAL (L)}
 ◦ Exaggeration of first and second heart sounds
{S1 (Lub) and S2 (Dub)} due to INCREASED
CARDIAC OUTPUT
 Appreciation of S3 (third heart sound;
ventricular filling) due to INCREASED
CARDIAC OUTPUT
 Appreciation of a MURMUR, which is almost
always SYSTOLIC (all pathologic) in
natureInnocent in nature
◦ As soon as mother delivers placenta, excess fluid
is absorbed or excreted, then the MURMUR
DISAPPEARS
 Blood Volume is INCREASED due to
INCREASE IN WATER RETENTION
 HIGHEST CARDIAC OUTPUT IN
PREGNANCY
 Twenty-eight to thirty-two weeks (28-32

wks) Age of Gestation

 During labor and delivery
 Immediately postpartum
 Therefore, be careful and monitor pregnant

cardiac patient
 Supine Hypotensive Syndrome
◦ When mother assumes supine position, she
develops hypotension
◦ Weight of uterus presses on the VENA CAVA
This results into DECREASED VENOUS RETURN
This results into DECREASED CARDIAC OUTPUT
End result is HYPOTENSION
 Therefore, SUPINE POSITION IN PREGNANCY
IS NOT ALLOWABLE (particularly in the
second and third trimester)
 POSITION OF CHOICE
◦ Side-lying Left (so as not to impede the Vena
Cava
◦ Left Lateral Position
◦ Sim’s Left Position
With arm flexed
Leg flexed
Weight of uterus would be ON THE BED
 2. HEMATOLOGIC CHANGES
 HEMODILUTION
 Due to increase in PLASMA VOLUME
 CHANGES IN PLATELET
 Expected during Postpartum
 Due to blood loss, there is TRANSIENT

INCREASE IN PLATELET COUNT

 This predisposes to THROMBOSIS due to

platelet aggregation
 This would then predispose to EMBOLISM
 Therefore, EARLY AMBULATION is NEEDED
 WHITE BLOOD CELL LEVELS INCREASE
(particularly in labor)
 LEUKOCYTOSIS is STRESS-INDUCED

◦ Increased by 20K to 30K

 Therefore, DO NOT CORRELATE THIS TO
INFECTION
 NO FEVER
 NO abdominal / uterine infection
 3. RESPIRATORY SYSTEM
 Diaphragm is prevented from descending in

inspiration on second and third trimester

 Tidal Volume is increased

◦ Lungs are easily filled

◦ Client tends to hyperventilate
◦ Therefore, RESPIRATORY ALKALOSIS OCCURS
 This is manifested by:
◦ Tingling sensation on the lower ends of
extremities
◦ Lightheadedness
 Nursing Management
◦ Breathe through a paper bag or through cupped
hands
 During labor, there is increase in oxygen
consumption by three-hundred percent
(300%)
◦ When exhaling, pursed lip breathing is practiced
during labor
 Swelling of mucosa during estrogen
◦ Prone to epistaxis
◦ Therefore, caution in picking nose!
 4. GASTROINTESTINAL TRACT
 4.1) PICA
 Craving for food
 Unedible (i.e. rice grains)
 No reason for this
 May be due to hypersalivation
 If not checked, this causes vomiting
 4.2) EPULIS OF PREGNANCY
 Effect on gums
 Swelling of gums due to INCREASED

ESTROGEN
 Therefore, CONTINUE TO USE SOFT BRISTLE
TOOTHBRUSH
 4.3) ESOPHAGUS
 Progesterone is a relaxant of smooth

muscle
◦ Effect is on lower esophageal sphincter
◦ It is more relaxed
 Pressure of Lower Esophageal Sphincter
(LES) is less than pressure on Cardiac
Sphincter (CS)
◦ If LES pressure is > CS pressure
No regurgitation
◦ If LES pressure is < CS pressure
◦ There is HEARTBURN OR PYROSIS;
SUBSTERNAL PAIN related to eating
 Most common surgical complication of
pregnancy is ACUTE APPENDICITIS!
 Right Upper Quadrant pain is not expressed

during pregnancy or on flank as the

appendix rises in pregnancy
 Nursing Management
 Do not assume supine position after eating
 Gradual ambulation
 Small Frequent feeding
 Due Progesterone’s relaxing effect on
smooth muscles, there IS INCREASED
GASTRIC EMPTYING TIME
◦ Water and electrolytes absorbed by walls
◦ This gives rise to hard stools
◦ This eventually leads to constipation
 Management
◦ Increase fluid intake
◦ Provide high fiber diet
 Tendency is to do valsalva maneuver
◦ This leads to hemorrhoids
 Progesterone also decreases stretchability
of vessels.
◦ This also causes hemorrhoids
 5. RENAL OR EXCRETORY SYSTEM
 5.1) Due to Progesterone
 There is relaxation of renal pelvis and the

ureter
 Therefore, URINE STAGNATION occurs in the
URETER (no longer peristaltic)
 Therefore, the PATIENT IS PRONE TO
URINARY TRACT INFECTION
 5.2) Glomerular Filtration Rate in
Pregnancy
 Increased Cardiac Output
 Increased Glomerular Filtration Rate
 But absorptive capacity of nephrons is not

increased (NO CHANGE IN ABSORPTION)

 Therefore, the following will be spilled in the
urine:
◦ Sugar
◦ Carbohydrates
◦ Protein
 Carbohydrates in the urine is NORMAL
 Acceptable level of Carbohydrates in the
urine
◦ Qualitative analysis
◦ Trace = +1 sugar
 Protein in the urine is NORMAL
 Acceptable level of Proteins in the urine
◦ Trace = +1 Protein
◦ Or less than 250 mg / dl
 If Protein level in the urine is greater than
250 mg / dl, CONSIDER PREGNANCY
INDUCED HYPERTENSION
 If you LOSE PROTEIN and RETAIN WATER,
this leads to EDEMA
◦ This is Physiologic Edema
◦ This type of edema is normal and expected in
pregnancy
 No management for PHYSIOLOGIC EDEMA
◦ Supportive
◦ Leg raises
 For Pathologic Edema
◦ Identify the cause of the edema
◦ Most common cause is PREGNANCY INDUCED
HYPERTENSION
 6. ENDOCRINE SYSTEM
 Hypertrophy is present in most of the

endocrine system organs

 Thyroid Gland is hyperthrophied
 Increased production of thyroid hormones
 Therefore, there is RISK FOR
HYPERTHYROIDISM
◦ Patient may die when in labor with
hyperthyroidism
◦ Thyroid Storm leads to arrhythmia
◦ Arrhythmia leads to DEATH
 Therefore, monitor so that client goes
EUTHYROID (with normal thyroid hormonal
level)
 7. NEUROLOGIC SYSTEM
 This is the only system UNAFFECTED during

pregnancy
 The following are normal during pregnancy:

◦ Blurring of vision
 Headache
 8. MUSCULOSKELETAL SYSTEM
 8.1) PLACENTA IS CAPABLE OF

PRODUCING RELAXIN
 Relaxes pelvic joints
 Therefore, the pelvis is more movable
 8.2) DIASTASIS RECTI
 Separation of rectus abdominis muscle
 Only fascia remains in between
 This is normal
 Rectus abdominis muscle goes back after

pregnancy (coarctate)
 8.3) PHYSIOLOGIC LORDOSIS
 Known as the PRIDE OF PREGNANCY
 Increased outward curvature

◦ There is back pain

 Nursing Management
◦ Do PELVIC ROCKING
Place direct pressure on lumbar area
◦ Prevent supine position
Increases pressure on the spine
◦ No analgesics
 FETAL CIRCULATION
 PLACENTA
 Functions of the Placenta
 Mnemonic is NIMEE
 N is for:
 NUTRITION or NIDATION

◦ Supplying nutritional requirements of the fetus

◦ Nutrients and oxygen exchanged
◦ THE BLOOD IS NOT EXCHANGED
◦ Modes of Exchange
Active transport from mother to baby
Diffusion
Pinocytosis
I is for:
 IMMUNOLOGIC

◦ If not pregnant, all foreign matter – antigens are

rejected
◦ Baby is a foreign matter
◦ But immunologic function of the placenta
removes the MAJOR HISTOCOMPANITIBILITY
COMPLEX TYPE 2 (MHC TYPE 2)
◦ This is responsible for rejecting the foreign body
M is for:
 METABOLIC FUNCTION

◦ In Fetal Circulation
Nutrient exchange occurs
NO PORTAL CIRCULATION EXISTS
Liver is bypassed as METABOLISM (by the liver) is
NOT NEEDED
E is for:
 ENDOCRINOLOGIC

◦ Hormones are secreted only during pregnancy:

Human Placental Lactogen
Human Chorionic Gonadotropin
Relaxin
E is for:
 EXCRETORY
 Metabolites excreted by Placenta and NOT

BY THE KIDNEY NOR THE LIVER

FETAL CIRCULATION
 Starts from the placenta
 Connected to the uterus
 Decidua is bathed by UTERINE ARTERY
 Uterine Artery ► Sinuses of the Placenta

►Exchange of nutrients ►Umbilical vein

 Placenta
 ▼▼▼
 Umbilical vein (composed of two arteries
and one vein – AVA)
 ▼▼▼
 Liver
 ▼▼▼
 Ductus Venosus (First Shunt)
 ▼▼▼
 Inferior Vena Cava
 ▼▼▼
 Right Atrium
 ▼▼▼
 Foramen Ovale (Second Shunt)
 ▼▼▼
 Left Atrium
 ▼▼▼
 Left Ventricle
 ▼▼▼
 Aorta
 ▼▼▼
 ▼▼▼
 To upper half of the fetal body only
 Upper Extreme
 Brain
 Heart
 Pulmonary
 Upper part of the GUT
 ▼▼▼
 ▼▼▼ Then this blood is recollected ▼▼▼

with less oxygen and then it ▼▼▼ goes to

the
 ▼▼▼
 Superior Vena Cava
 ▼▼▼
 Right Atrium
 ▼▼▼
 Right Ventricle
 ▼▼▼
 Pulmonary Artery (but lungs are collapsed;
Surfactant inadequate and amniotic fluid
is present)
 ▼▼▼
 Ductus Arteriosus
 ▼▼▼
 Descending Aorta
 ▼▼▼
 Supply the lower half of the fetal body
 ▼▼▼
 ▼▼▼ Blood is recollected
 ▼▼▼
 Hypogastric Artery
 ▼▼▼
 Umbilical Artery
 ▼▼▼
 Placenta
SHUNTS
 When the baby is delivered, the shunts are

normally removed
◦ Ductus Venosus
◦ Foramen ovale
 Two (2) types of Closure
 Functional Closure
 Anatomic Closure
FORAMEN OVALE
 Closed functionally immediately after birth

or IMMEDIATELY AFTER CORD IS CLAMPED

 Anatomically, it can persist up to one (1)

year after delivery

◦ Therefore, in auscultation in twenty-eight (28) day
old baby
There is a MURMUR
This is Normal
This is NOT A PATHOLOGIC MURMUR
It is a SYSTEMIC / INNOCENT MURMUR
◦ A PHYSIOLOGIC MURMUR IN NEONATES
DUCTUS ARTERIOSUS
 Functional Closure

◦ Ten to ninety-six hours (10 – 96 hrs) after birth or

approximately four (4) days
 Anatomically
◦ Two to three months (2 – 3 mos.)
DRUGS TAKEN DURING PREGNANCY
 NSAIDs

 Indomethacin

◦ Not advisable
◦ Causes premature closure of the Ductus Arteriosus
◦ Not compatible with life
◦ No supply to the lower half of the body of the fetus
 PARACETAMOL IS ALLOWED
 ASPIRIN
 Causes persistence of Ductus Arteriosus

even after delivery

 No functional / anatomic delivery of Ductus

Arteriosus
 Important Concept!

◦ Stop taking about four (4) weeks prior to

confinement
 ASSESSMENT OF FETAL MATURITY AND
WELL-BEING
 1. MATERNAL HISTORY AND PHYSICAL

EXAMINATION
 1.1) First thing to ask is the LAST

MENSTRUAL PERIOD
 Purpose is to IDENTIFY THE AGE OF

GESTATION
 1.2) What are History of Previous
Pregnancy:
 NSAID?
 Postpartum complication?
 Infection?
 1.3) Past Medical History
 Diabetes Mellitus?
 Gestational Diabetes?
 Hypertension?
 2. FETAL HEART TONE
 Easiest method to assess for fetal well-

being
 Very reliable indicator of oxygenation of the

fetus
 If FHT is heard

◦ Fetus is alive
◦ THIS IS AN ALL OR NONE RESPONSE
 NORMAL
◦ 120 –160 beats per minute
 If greater than 160
◦ Tachycardia
 If less than 120
◦ Bradycardia
 Be able to assess that sound you hear in
the mother is the FHT
 In the mother’s abdomen, you can hear:
◦ BORBORYGMIC SOUNDS
 Hunger sounds
 ◦ UMBILICAL SOUFFLE
When the blood in the placenta enters the umbilical
vein, this coincides with the Fetal Heart Tone
 But FHT should be DISTINCT
Fetal Heart Tone sound
TUG – TUG – TUG
Umbilical Souffle Sound
SHHH – SHHH – SHHH
This is the sound of the gush of blood
◦ UTERINE SOUFFLE
Sound heard when blood enters uterine artery
This coincides with the heartbeat of the mother
 IDEAL WAY TO TAKE THE FETAL HEART
TONE
 Use the bell of the stethoscope

◦ Purpose is for greater amplification

 Hand / Dominant Hand
◦ On area being auscultated
 Non-Dominant Hand
 ◦ Palpates radial pulses for the mother
 Therefore, you can correlate
◦ FETAL HEART TONE IS DISTINCT
TUG – TUG – TUG – TUG
◦ Radial pulse of the Mother is
 Tug - - - - - - Tug - - - - - - Tug
 FETAL MOVEMENT
 Two (2) schools of thought

◦ Cardiff Count to Ten

◦ Sandovsky Method
 CARDIFF COUNT TO TEN
 Normal Fetal Movement

◦ At least one (1) movement every five (5) to six (6)

minutes
◦ About ten (10) to twelve (12) movements per
hour
 First Instruction
◦ Instruct the client to eat LIGHT MEAL one (1) hour
before monitoring for fetal movement
 Have short walk or massage abdomen as baby
may be asleep or is hungry
 Ask mother to assume left lateral position
 A clock must be at the bedside with pencil and
paper
 Dominant hand of mother palpates most
prominent part of abdomen
 Note for any fetal movement
 FETAL MOVEMENT SHOULD BE ASSESSED
WHEN THERE IS QUICKENING (AT TWENTY-
FOUR MONTHS AGE OF GESTATION
ONWARDS)
 Mother notes for ten (10) fetal movements
and NOTES THE TIME THAT THE TEN (10)
FETAL MOVEMENTS HAVE BEEN COMPLETED
◦ Should be completed in one (1) hour
◦ Approximately five (5) movements in thirty (30)
minutes
 You MUST get at LEAST ONE HALF OF
NORMAL
 Therefore, AT LEAST FIVE (5) FETAL
MOVEMENTS PER HOUR IS ACCEPTABLE
 SANDOVSKY METHOD
 Same procedure as in Cardiff Count to Ten
 Mother monitors fetal movement three (3)
times a day
 These are done:
◦ After breakfast
◦ After lunch
◦ After dinner
 Normal
 You should appreciate two (2) to three (3)
fetal movements in one hour
 OTHER WAYS TO ASSESS:
DIAGNOSTICS
 AMNIOCENTESIS
 Best done at sixteen to eighteen (16 – 18)

weeks Age of Gestation or during second

(2nd) trimester
 This is the time when the baby is SMALL

and there is MUCH AMNIOTIC FLUID

 Information Obtained:
 A) FETAL LUNG MATURITY
 Analyzed for lung surfactant: Dipalmytoyl
Phosphatidylcholine
 L : S Ratio
◦ Lecithin : Sphingomyelin Ratio
 Lecithin is a specific component of lung
surfactant
◦ Lecithin should be greater than Spinglomyelin
◦ Normal Ratio is 2L : 1S
 If there is anticipated premature delivery,
amniocentesis is done to know if delivery is
viable
 PHOSPHATIDYL GLYCEROL (PG)
 Most potent of all lung surfactants
 Usually appreciated at amniotic fluid at

THIRTY-FOUR to THIRTY SIX (34 – 36)

WEEKS AGE OF GESTATION
 Therefore, it is safe to deliver fetus if
Phosphatidyl Glycerol is present
 There is decreased risk of respiratory

distress
 POLYHYDRAMNIOS
 Amniotic fluid greater than 2,000 ml

◦ A teratogenic effect
 Therefore, remove part of amniotic fluid
 IDENTIFICATION OF GENETIC OR
CHROMOSOMAL PROBLEM
 HOW TO PREPARE THE CLIENT FOR

AMNIOCENTESIS
 Explain what to do to the client
 Get Consent
 Remember, CONSENT IS NEEDED as this

procedure is INVASIVE!
 Client must have I. V. fluid

◦ Plain Normal Saline Solution

◦ Side drip of Tocolytic to relax the uterus
 Ask client to void before the procedure so
as not to puncture bladder
◦ Ultrasound-guided procedure
◦ Needle should not puncture the placenta
 Abdomen is prepared aseptically
 Specific Site
◦ Pocket of abdomen containing highest amount of
Amniotic Fluid
◦ Done by OBSTETRIC SONOLOGIST
 Needle Inserted
◦ Local anesthesia
◦ Abdominal wall through the uterus to amniotic sac
 Post Procedure
◦ Check Vital Signs (every fifteen (15) minutes)
◦ Check Blood Pressure
◦ Check Fetal Heart Tone
◦ Client then rests for two (2) to three (3) hours
◦ Mother is then sent home
 DISCHARGE INSTRUCTIONS
◦ Note for UTERINE TONE
◦ Note for Fetal Activity
◦ Client may be:
Hyperactive
In distress
Hypoactive
In distress
◦ Note for vaginal bleeding or spotting
◦ Vaginal spotting is acceptable
 DANGER SIGNS
 Persistent uterine contraction
 Hyper / Hypoactive
 Vaginal Spotting to Bleeding

◦ Therefore, ask mother to come back if she

observes any of the above signs
 MATERNAL SERUM ALPHA
FETOPROTEIN
 A special kind of protein produced in the

yolk sac of the liver of baby / fetus

 Specimen is blood
 Consent is needed
 Normal value of Maternal Serum Alpha Feto
Protein (MS AFP)
◦ 2.0 – 2.5 MOM (measurements of the mean)
 If MS AFP is higher than normal, THERE IS A
NEURAL TUBE DEFECT:
◦ Spina bifida
◦ Meningocoel
◦ Myelomeningocoel
 Anencephaly
 If MS AFP is lower than normal, THERE IS
DOWN’S SYNDROME
 Therefore, you must be able to know exact

Age of Gestation
 Fifteen to Twenty (15 – 20) weeks Age of
Gestation is the IDEAL TIME FOR MS AFP or
during the SECOND (2nd) TRIMESTER, not
on the First or the Third Trimesters
 If early high result
◦ Yolk sac and liver gives false elevated result
 If late low result
◦ Liver only gives false low result
 CHORIONIC VILLUS SAMPLING (CVS)
 Get part of chorionic villi from the placenta
 Done at nine to twelve (9 – 12) weeks Age

of Gestation
 Approach is INTRAVAGINAL
 Ultrasound-guided
 A part of chorionic villi near maternal
attachment will be suctioned to the catheter
for KARYOTYPING and GENETIC ANAL
 Purpose of this procedure is for detection of
genetic and chromosomal problems
 Nursing Responsibility

◦ Bleeding is common in CVS

◦ Instruct mother to observe SPOTTING to
BLEEDING
◦ Ask mother to come back if bleeding occurs
 Therefore, not much done; increases
chance of abortion or fetal loss
 PERCUTANEOUS UMBILICAL BLOOD
SAMPLING (PUBS)
 Also known as CORDOCENTESIS
 Get sample
 Ultrasound-guided
 Sonologist identifies umbilical vein

◦ Vein has larger lumen than the artery

 Catheter is inserted
 Approach is through the abdomen
 Information obtained:
◦ For identification of blood incompatibilities
◦ For exchange transfusion
◦ For isoimmunization
Needed in instances of an Rh+ baby and an Rh-
mother
 ULTRASOUND
 Types of Ultrasound
 Transabdominal Ultrasound
 Transvaginal Ultrasound
 TRANSABDOMINAL ULTRASOUND
 Ask the client to FILL BLADDER
 Full bladder will push uterus to pelvic cavity

for better visualization at abdomen

 ULTRASOUND IN FIRST TRIMESTER
 Information obtained:
 Confirmation of Pregnancy

◦ (+) cardiac movement

◦ (+) yolk sac
◦ (+) Fetal Heart Tone
 Identification of Ectopic Pregnancy
◦ Fallopian tube is PERISTALTIC
◦ Therefore, look at the uterus
◦ If the uterus is empty and positive (+) for
pregnancy test, then there is pregnancy outside
or ECTOPIC PREGNANCY
 Identification of Intrauterine Device (IUD) in
Place
◦ Intrauterine Device
Has 97% protection
Has 3% failure rate
◦ If IUD is in place and pregnancy occurs, advice
the client to LET THE IUD STAY IN PLACE
◦ IUD will attach to the fetal membrane
◦ If taken out, there is greater chance of
SPONTANEOUS ABORTION
 Identification of the H-MOLE
◦ Ultrasound characteristic of H-Mole
SNOW STORM APPEARANCE
In a dark background there is a speck of white
 There are vesicles
 ULTRASOUND IN THE SECOND AND THIRD
TRIMESTER
 Information obtained:
 Location of Placenta
◦ Placental Localization
 Growth of the Fetus
 Amount of Amniotic Fluid
 Fetal Position and Fetal Presentation
 Sex / Gender of the baby
◦ Determinable at sixteen (16) weeks of gestation
◦ Ideal time is twenty-eight (28) weeks
 Congenital / Chromosomal Problems
◦ Determined by three-dimensional (3D) ultrasound
 TRANSVAGINAL ULTRASOUND
 Ask client to void
 BIOPHYSICAL SCORE
 Has five (5) parameters (including Non-

Stress Test or NST)

 Modified Biophysical Score

◦ Has four parameters only

 Uses ULTRASOUND
 Criteria / Parameters observed
◦ Fetal Breathing
Two (2) is the highest score for this parameter
◦ Fetal Movement
Two (2) is the highest score for this parameter
◦ Fetal Muscle Tone
Flexion and extension in utero
Two (2) is the highest score for this parameter
◦ Amniotic Fluid Index
Done for a period of thirty (30) minutes
Baby’s breathing is not spontaneous
Two (2) is the highest score for this parameter
 Perfect score is 8/8
◦ This means that the baby is in the best possible
health
 Before, Biophysical Score includes the Non-
Stress Test
 Non-Stress Test
◦ For fetal heart activity
◦ With this parameter added, the perfect score in
BPS becomes 10/10
NON-STRESS TEST
 Uses CARDIOTOGORAPH (CTG) TRACING
 No stressor on part of the baby
 Stressor is the contraction of the uterus
 There should be NO CONTRACTION
 Compare

◦ Fetal Heart Tone and Fetal Movement

If baby moves, FHT INCREASES!
 With two (2) transducers placed near FHT at
fundus of uterus
 Leopold’s maneuver
 Water soluble lubricant

◦ KY jelly amplifies FHT

CRITERIA TO SAY NST IS NORMAL
 Period of Observation should be

◦ Greater than or equal to twenty (20) minutes

 You must get at least two (2) accelerations
in twenty (20) minutes
 Acceleration should be at least fifteen (15)

beats above baseline

 Duration of acceleration should be
◦ Greater than or equal to fifteen (15) seconds
◦ One (1) small square = one (1) second
 Therefore, IF ALL CRITERIA ARE MET, NON-
STRESS TEST IS NORMAL
 If NST is NORMAL – IT IS REACTIVE
 Therefore, the chances of fetal survival is

greater than 99% in the next week

 You can assure the mother
 If NOT ALL CRITERIA ARE MET
 (i.e. Criteria No.3 with 10 beats per minute

only),
 Repeat NST after two (2) to three (3) hours
 If NST is NON-REACTIVE, it is ABNORMAL
 CONTRACTION STRESS TEST (CST)
 Best done when mother is at thirty-eight (38)
weeks Age of Gestation
 Done when NST is NON-REACTIVE
 Then, proceed with Contraction Stress Test
 If CST could not be withstood by baby, IT NEEDS
IMMEDIATE DELIVERY
 Introduce a STRESSOR – CONTRACTION if
ABNORMAL CST
 OXYTOCIN CHALLENGE TEST
 Rub nipples

◦ Nipple stimulation if uterus is NOT contracting

 When assessing
◦ Hide your thumb
 If you are a male so as not to be sued for
sexual harassment
 TWO (2) ABSOLUTE
CONTRAINDICATIONS FOR
CONTRACTION STRESS TEST
 If client is premature (Biophysical Score is

used instead)
 History of problem in the placenta

(placentation)
 NIPPLE STIMULATION
◦ Give warm pack / warm soaks for ten (10)
minutes prior to stimulation to increase circulation
/ vascularity
◦ Explain procedure
◦ Start
◦ Four (4) cycles per stimulation
◦ 1, 2, 3, 4 stimulations REST x4
 First Cycle
◦ If after these and there are NO CONTRACTIONS
◦ Stop and rest for two (2) to four (4) minutes
◦ Then stimulate
Up to four (4) cycles
◦ If NO CONTRACTIONS AFTER THE FOURTH (4th)
CYCLE
Stop stimulation
Proceed with Oxytocin Challenge Test
 OXYTOCIN CHALLENGE TEST
 Give diluted form of oxytocin

◦ Five units (5U) or ½ampule + 1 liter D5LR or

D5H2O
 Give at a titrating dose
 Start at ten to twelve (10-12)

drops per minute to a maximum

of forty (40) drops per minute
 Observe for Uterine Contraction
 Wait for two (2) consecutive uterine
contractions
 Stop Oxytocin Challenge Test if two (2)

uterine contractions are obtained

 Now compare Uterine Contractions with

Fetal Heart Tone

 NEGATIVE
◦ In the presence of uterine contraction, tracing is
NEGATIVE FOR DECELERATION
 Vagus Nerve
◦ Parasympathetic Stimulation gives rise to
bradycardia
 Carotid Stimulation results into
◦ Bradycardia
◦ Hypotension
 Abnormal if POSITIVE (+) FOR
DECELERATION
INTERVENTIONS
 If in labor:
 Turn client to left lateral position
 Stop oxytocin immediately

◦ No contractions are wanted

 Give oxygen to mother
◦ Rate is 8 – 10 liters per minute
 Hydrate with plain water
◦ No incorporation of oxytocin to increase
circulating blood volume
◦ Mother is on NPO during labor and there could be
DEHYDRATION
 ADH secretion is increased to conserve
water
◦ ADH is released from the posterior pituitary
◦ Oxytocin is released from the posterior pituitary
◦ Cross reaction of ADH and Oxytocin in the
Uterus
◦ ADH binds in OXYTOCIN RECEPTORS in Uterus
resulting to CONTRACTION
◦ Therefore, hydrate so as not to increase ADH
secretion
 If variable deceleration is >10 minutes,
then CAESARIAN SECTION may be
NECESSARY
LATE DECELERATION
 Occurs before contraction ends
 Has a late recovery
 Baseline is changed
 Lower than original baseline
 Significance:

◦ UTEROPLACENTAL INSUFFICIENCY is present

 Management
◦ Hydrate
◦ Give oxygen
◦ Stop oxytocin
 Placenta and Uterus are compromised
◦ Therefore, this is an indication for OUTRIGHT
ABDOMINAL DELIVERY
◦ Do outright Caesarian Section
 PRE-NATAL ASSESSMENT
 In the Ideal Setting:
 At zero to twenty-eight weeks (0 – 28) Age

of Gestation
◦ Ask client to come back every four (4) weeks
 At twenty-eight to thirty-six weeks (28 – 36)
Age of Gestation
◦ Ask client to come back every two (2) weeks
 At thirty-six (36) weeks onwards
 Ask client to come back every week
 DOH RECOMMENDATION
 One (1) pre-natal check-up per TRIMESTER
 Three (3) pre-natal check-ups during the

entire course of pregnancy

 If high risk
 Below 18 years old
 Above 35 years old
 Greater than Gravida 5

◦ Due to higher chances of maternal bleeding after

delivery
 Problem in placentation (location)
 History of Maternal illness
◦ Hypertension
◦ Diabetes mellitus
◦ Cardiac Problems
 Clinical check-up should be performed
every week!
 Auscultate the lungs on the first visit
 Nursing history has physical examination

◦ This is done by the nurses

◦ Not weigh
◦ Baby is sleeping contentedly
◦ Baby will cry
 Changes in heart rate
 NO IPPA IN PEDIATRIC PATIENTS
 Get Maternal History of Client
 Laboratory Examinations
 COMPLETE BLOOD COUNT
 Hemoglobin
 Hematocrit
 Platelet
 Rh and ABO blood typing
 Important Concepts!
 Asians NOT COMMONLY Rh-
 Caucasians are COMMONLY Rh-
BLOOD NOMENCLATURE
 ABO Typing

◦ Type A, B, O
◦ A or B antigens
 Rh Typing
◦ Rh (C, D, E)
◦ Three antigens
C
D
E
◦ In incompatibility, the concern is the D antigen
 Rh
 Mother is Rh- Father is Rh+
 No D antigens ▼▼▼
 Rh- or Rh0 ▼▼▼
 (zero for D) ▼▼▼
 ▼▼▼▼▼▼▼▼▼▼▼▼▼
 Baby is Rh+ or Rh(D)
 Antigen D is present in the blood
 The first pregnancy is spared
 The first baby is born
 Blood enters mother’s circulation
 Therefore, mother PRODUCES ANTI-D
antibody
 Interaction
 During time of delivery when the placenta

starts to detach from maternal attachment

 Abortion / Dilatation and Curettage
 Some fragments of placenta are retained

in the uterus
 Ancillary Procedures like AMNIOCENTESIS
 Interaction of blood of baby entering

mother occurs and stimulates antigen-

antibody reaction
 Second Pregnancy
 Anti-D antibody of mother hemolyzes the

Antigen D of second baby

◦ This results into erythroblastosis fetalis or death
of the RED BLOOD CELLS
◦ Second baby would have SEVERE ANEMIA ►
HEART FAILURE ►ANASARCOUS►DEATH
 RHOGAM
 Gamma globulin
 A pre-formed antibody
 Given within seventy-two (72) hours
 If to undergo amniocentesis

◦ Rhogam is given before the procedure

 If mother undergoes abortion
◦ Rhogam is given within seventy-two (72) hours
after abortion
 If pregnant now
◦ Give at twenty-eight to thirty-two
(28 – 32) weeks Age of Gestation
◦ to Rh- mother REGARDLESS OF Rh
of Baby
 RhoGam is repeated prior to
term at forty (40) weeks
 RhoGam has a half life
 Rhogam may be out of

circulation
 COOMB’S TEST
 Two (2) types
 Direct Coomb’s Test
 Indirect Coomb’s Test
 DIRECT COOMB’S TEST
 Concerns the Baby
 Identify if RBC of baby has hemolysis and

has attached antibody

 Therefore, sensitization has occurred on the

mother
 INDIRECT COOMB’S TEST
 Concerns the mother
 Identify for titer of antibody

◦ Get blood sample

◦ Identify titer of Anti-D
◦ Zero titer if Rh+
◦ If Rh- individual
1 : 8 or 1 : 16
 If titer is less than 1 : 8 this means that
MOTHER IS NOT YET SENSITIZED
◦ Therefore, blood of the mother is FREE OF ANTI-D
antibody
 There is a need for RhoGam
 Iftiter is greater than 1 : 16 this
means that there is
SENSITIZATION
◦ It has ANTI-D antibody
◦ Then, RhoGam is NOT needed
◦ RhoGam CANNOT REVERSE
SENSITIZATION
Situation
 Mother is Type O Rh-
 Baby is Type A Rh+
Question
 What type of blood do you give?
Answer
 Give type A blood
 Rationale
 Hemolysis is present
 Baby has anti-D that is why there is

hemolysis
 If Rh+ is given

◦ There is continuous antibody given – there is

confirmed hemolysis
◦ Therefore, give Rh-
 ALWAYS GIVE THE BLOOD TYPE OF THE
MOTHER (as far as Rh is concerned)
 If mother is Rh+ and father is Rh+, then the
baby is Rh+ and there is no problem
 Type O blood causes hemolysis
 If baby is type A, B, AB
 Question
 What type of blood in mother will cause
hemolysis in ABO?
 Answer
 Type O
 Question
 What type of blood will be given to the
baby if there is ABO incompatibility?
 Answer
 Blood type of mother
 Most common cause of PATHOLOGIC
JAUNDICE is ABO INCOMPATIBILITY
 Pathologic Jaundice is prolonged jaundice
 Normal Value of Bilirubin
◦ 15 mg / dl
 If greater than 15 mg / dl, transformation
is needed
 ABO INCOMPATIBILITY is protective
against Rh INCOMPATIBILITY
◦ If Mother is type O
 ◦ If Baby is type A
 RBC carries Rh(D)
◦ RBC of baby contains D antigen
◦ Since hemolysis has already occurred, Anti-D of
mother will no longer hemolyze any RBC with
Anti-D
APGAR – SCORING
SIGN O 1 2
HR absent <100 >100

Respirator absent Slow and Good and strong,

effort irregular loud cry
Activity: flaccid Some flexion of Active motion.
muscle tone extremities General flexion
Reflex No response to Weak cry or Cry: vigorous
irritability stimuli grimace
appearance Blue, pale Body pink, Completely pink
extremities
Fetal anatomy and physiology
1. Fetal circulation – four intrauterine
structures that differ from extrauterine
structures.
a. umbilical vein – carries oxygen and
nutrient-enriched blood from placenta to
ductus and liver.
b. ductus venosus – connects to inferior
vena cava; allows most blood to bypass
liver.
c.Foramen ovale – allows fetal blood to
bypass fetal lungs by shunting it from right
atrium into left atrium.
d. Ductus arteriosus – allows fetal blood to
bypass fetal lungs by shunting it from
pulmonary artery into aorta.
e. Umbilical arteries – allows return of
deoxygenated blood to the placenta.
2. Umbilical cord – extends from fetus to
center of placenta: usually 50 cm (18-22
inches) long and 1-2 cm (1/2 – 1 inch) in
diameter. Contains:
a. Wharton’s jelly – protects umbilical
vessels from pressure, cord “kinking” and
interference with fetal-placental circulation.
b. umbilical vein – carries oxygen and
nutrients from placenta to fetus.
c. Two umbilical arteries – carry
deoxygenated blood and fetal wastes from
fetus to placenta.
*absences of one artery indicates need to
rule out intraabdominal anomalies.
3. Characteristics of fetal blood
b. Fetal hemoglobin (HbF)
a.1 higher oxygen-carrying capacity than
adult hemoglobin
a.2 releases oxygen easily to fetal tissues
a.3 ensures high fetal oxygen
a.4 normal range at term: 85ml/kg body
wt. Hct: 38%-62%, average 53%: RBC 3-7
million, average 4.9 million/U.
Extrauterine adaptation: task
2. Establish and maintain ventilation,
successful gas transfer- requires patent
airway and adequate pulmonary
surfactant.
3. Modify circulatory patterns – requires
closure of fetal structures.
4. Absorb and utilize fluids and nutrients
5. Excrete body wastes
6. Establish and maintain thermal stability
A. Admission assessment of normal,
termneonate
1. color and reactivity
2. general appearance, symmetry
3. length and weight
4. head and chest circumferences
5. vital signs:
Criterion Average values
Vital signs
Heart rate 120-140/min, irregular, especially
when crying, and functional murmur
respiratory 30-60/min with short periods of
apnea, irregular; vigorous and loud
cry.
temperature Stabilizes about 8-10 hr after birth;
36.5 -37 degree centigrade
Blood pressure 60-80/40-50; varies with change in
activity level
Criterion Average values
Measurements
weight 3400g(71/2 lbs); range: 5 lb 8 oz – 8
lbs 13 oz

Length 50 cm (20 inches); ranges: 18 – 22

inches

Chest circumference 2 cm (3/4 inch) less than head

circumference

Head circumference 33 – 35 cm (13 -14 inches)

Criterion Average values
General assessment
Muscle tone Good tone and generalized flexion;
full range of motion; spontaneous
movement
Skin color Mottling, acrocyanosis, and
physiological jaundice; petechiae,
milia, mongolian spotting, lanugo, and
vernix caseosa
Head Moulding of fontanels and sutute
spaces; one-fourth of body length
Hair Silky, single strands, lies flat; grows
towards face and neck
eyes Edematous eyelids,
nose Appears to have no bridge
1. Altered health maintenance related to
separation from maternal support system
2. Impaired skin integrity related to
umbilical stumps; incontinence of urine
and meconium stool.
3. Ineffective airway clearance related to
excessive mucus
4. Pain related to environmental stimuli
5. Ineffective thermoregulation related to
immature temperature regulation
mechanism
1. Goal; promote effective gas transport
a. maintain patent airway – to promote
effective gas exchange and respiratory
function.
b. Position: right side-lying, head
dependent (gravity drainage of fluid,
mucus)
c. suction prn with syringe for mucus
2. Goal: establish/maintain thermal stability
a. Avoid chilling – to prevent metabolic
acidosis
b. dry, wrap
c. place in heated crib
d. monitor vital signs hourly until stbale
3. goal: promote bonding.
a. encourage parent-infant interaction
(holding, touching, eye contact, talking to
infant)
b. encourage breastfeeding within 1 hr of
birth
c. encourage parent participation in infant
care to develop confidence and competence
in caring for newborn
Sleeping – almost continual (wakes only to
feed) or 12 – 16 hr daily
Feeding – from every 2-3 hr to longer
intervals; establish own pattern
Weight loss – 5% - 10% in first few days
regained in 7-14 days
Cord care – drops off in 7 – 10 days
Physiologic jaundice – occurs 24- 72 hr after
birth. Non pathologic, need for hydration
Age Bottle-fed breastfed implications
1 day Meconium Meconium Absences may indicate
obstruction or atresia

2-5 days Greenish Greenish At any time

yellow, loose yellow, loose,
frequent
> 5 days Yellow to Bright golden Dairrhea – greenid\sh,
brown, firm, yellow, loose, mucus
2 -4 daily foul 6 -10 daily Constipation – dry, hard
odor stools
 GOOD DAY!

THANK YOU..GOOD LUCK..

1.Which phase of the menstrual cycle is
characterized by a surge in luteinizing
hormone (LH) from the pituitary gland?
A.Proliferative C. Ichemic
B.Menstruation D. Secretory
2. At the beginning of menstruation, the
following physiologic changes occurs,
except.
A. an ovulation begins to mature in the graafian
follicle
B. estrogen and progesterone are at their lowest
level
C. luteinizing hormone are at its peak
D. follicle stimulating hormone has just begun to
rise.
 Situation: Mrs. Flor de Luna is on her fifth
month of pregnancy.
3Which of the following fetal development
has been achieved during the fifth month of
gestation?
A. ossification of the bone is completed
B. Mrs. De Luna can feel her baby’s movement
C. Vernix caseosa is developed
D. Heartbeat is audible by Doppler
4. When Mrs. De Luna enters the seventh
month of pregnancy, how often will be her
pre-natal check- up?
A. once a week c. once a month
B. as often as she desires
D. twice a month
5. What level of the abdomen can be fundic
height be palpated at 5 months gestation?
A. midpoint between the symphysis pubis
B. symphysis pubis
C. midpoint between umbilicus and xiphoid
D. umbilicus
Situation: Mrs Brenda Mage, 24 year old,
consulted at the health center because of
nausea and vomiting. She claimed that she
missed her menstruation for 2 months and
her LMP was March 1.
6. Which of the following is a probable sign
that Mrs. Mage is pregnant?
absence of menstruation
softening of the cervix
C. nausea and vomiting
D. Breastc hanges
7. Which of the following terms refers to the
first pregnancy?
A. Primipara c. primigravida
B. Nullipara d. nulligravida
8.How many weeks AOG will Mrs. Mage be on
her next prenatal visit, which is scheduled
on may 15.
A. 13 – 14 C. 10 – 11
B. 12 – 13 D. 11 – 12
9. When will be the EDC of Mrs. Mage?
A. December 8 c. December 9
B. December 7 d. January 8
10. Which sign refers to the softening of the
lower uterine segment?
A. Chadwick’s c. Culkin’s
B. Hegar’s d. Goodel’s
 Situation: Nicole claims to be amenorrheic
for 1 month. She consults at the lying –in
clinic.
11. What hormone is excreted in the urine
that serves as the basis for most tests for
pregnancy?
A. HCG c. progesterone
B. FSH d. estrogen
12. Nicole complains of urinary frequency.
Which of the following be the best
response of the nurse?
A. “ limit your fluid intake to 2 liters per day”
B. “ I would not worry if I were you, it is not
unusual.”
C. “ just use panty shields so you will be dry and
comfortable.”
D.“ this is expected because of the compression of
your ascending uterus.”
13.Which of the following intervention will be
the most helpful to Nicole in adapting to
her pregnancy?
A. encourage her to attend pregnant mothers’
classes
B. advise to have a regular pre-natal check-up
C. involve her husband in planning for her needs
D. assist her in exploring and expressing her
feelings
 Situation: Marla is 25 year old G2P1, full
term is rushed to the ER due to passage of
watery vaginal discharge.
14. Which of the following interventions will
be the immediate action of the nurse?

◦ take her fetal heart tone c. start an

intravenous fluid
B. monitor her vital signs d. place her on left
lateral position
15. The nurse observes the vaginal discharge
of Marla. Which characteristics of the
amniotic fluid that the fetus is in distress?
volume is about 1 liter c. greenish
mucus - tinged d. colorless
16. Which of the following is not a sign of true
labor?
A. intensity of contractions increases gradually
shorten
B. intervals between uterine contractions increases
C. cervical dilation and effacement increase
D. uterine contractions are more frequent and of
shorter duration
17.What is the most fatal complication of
PROM to the fetus?
A. delayed onset of labor c. dehydration
B. ascending infection d. cord prolapsed
18. Marla is instructed to count and record
fetal movement every hour. How many
movement per hour indicates that Marla’s
baby has a healthy status/
A. 2 c. 5
B. 4 d. 3
Situation: Aurora is on her 3rd post normal
spontaneous delivery.
19. She complains of inability to defecate
inspite of taking regular meals and
frequent ambulation. The following are
recommended to reestablish her regular
defecation, which one is least priority/
A. milk of magnesium 45 ml c. high roughage
diet
B. adequate fluid intake d. do manual
extraction
20. She must report to the nurse if she
observes that her lochial discharge:
A. contains mucus and particles of cellular debris
B. is bright red on the 5th day post partum
C. has a musty odor
D.disappears after the third week
21. She remarks, “Do you think I have milk for
my baby?” This signals what phase of the
puerperium ?
A. post partum blues c. taking -hold
B. post partum psychosis d. taking –in
22. which of the following will best initiates
the secretions of milk?
A. use of breast pump in expressing milk
B. manual breast expression
C. adequate intake of fluid
D. allow infant to suck each breast alternately
23.In the physiology of lactation, the oxytocin
hormone functions to:

A. stimulates lactogenesis c. suppression of

milk
B. produces more milk d. alters
secretion of milk
 Situation: Andrea is a newly registered
nurse who is assigned at the OB ward where
some nursing students are having their
related learning experience on the concept
of pregnancy.
24. One student asks Andrea to discuss what
a zygote is. Her answer will likely be a:
A. daughter cell
B. cell that results from the fertilization of the
ovum by a spermatozoa
C. union of an egg by a sperm
D. matured ovum
25. Which of the following will best describe
mitosis?
A. Fertilization of an ovum
B. Cell division of the fertilized ovum
C. Rupture of the ovum from the graafian follicle
D. Implantation of the fertilized egg
26. Andrea discusses how the zygote enters
the uterus which usually takes place in
how many hours after fertilization?
A. 180 hours c. 48 hours
B.72 hours d. 150 hours
27. The mulberry-like ball of cells that results
from cleavage is called?
A. Blastocyst c. blastomore
B. Trophoblast d. Morula
28. The zygote is normally implanted in what
part of the uterus?
A. Corpus c. Cornea
B. Fundus d. Cervix
Situation: Lisa, 19 year old single and
pregnant for the first time is admitted to the
labor room due to the passage of watery
vaginal discharge, one hour PTA. I.E
revealed 3 – 4 cms. Cervical dilation, 80%
effaced, station 0 and (-) BOW.
29. What is the rationale for placing Lisa on
complete bed rest upon admission? This
will prevent:
A. Infection c. fetal distress
B. Fatigue d. cord prolapse
30. Which of the following heartbeats per
minute is indicative of fetal distress?
A. 159 c. 135
B. 121 d. 165
31. What position is best for Lisa in order to
prevent fetal hypoxia?
A. left lateral c. trendelenburg
B. dorsal recumbent d. semi- fowlers
32. Which of the following best describes
effacement?
A. cervix becomes thinner
B. presenting part has descended at the level of
the ischial spine
C. diameter of the presenting part of the fetus has
passed through the pelvic inlet
D. opening of the cervix becomes wider.
33. Station 0 means that the presenting part
of the fetus is:
A. still floating
B. one centimeter above the ischial spine
C. at the level of the ischial spine
D. one cm below the ischial spine
Situation: Nurse Jane is assigned at the
nursing unit at 6-2 shift.
34. She admitted girl Reyes, full term whose
mother has a history of PROM. Jane
anticipates that girl Reyes will b;

A. Exposed to bili light c. given I.V fluids

B. Placed inside the incubator d. given doses of
antibiotics
35. Boy Santoyas, 36 weeks AOG, has
cryptorchidism, which refers to:
A. undescended testes
B. unretracted foreskin of the penis
C. ventral location of the urinary meatus
D. presence of fluid in the scrotal sac.
36. Girl Pablo develops jaundice. When does
physiologic jaundice occur?

A. after the 7th day c. twenty four hours after

birth
B. upon birth d. between the 2nd and 5th day
37. Boy Malonzo demonstrated a tonic neck
reflex, which is described as:
A. fanning of the toes when a sharp object is
pressed in the sole of his foot
B. extension of his leg on the same side to which
his head is turned
C. turning of the head towards the side of the
cheek that was touched.
D. Grasping of any object placed in his hand
38. When the crib of girl Liboon is jarred, she
develops sudden outward extension of her
arms then slowly release. What reflex is
this.
A. Parachute c. Landau
B. Babinski d. Moro
39. What part of the mother will be the source
of nourishment for the baby?

A. Uterus c. Amniotic fluid

B. Chorionic villi d. placenta
Situation: Janice a community health nurse is
attending a home delivery a primigravida
client.
40. A probable sign of pregnancy
characterized by painless, irregular,
abdominal; false labor contractions is
called:

A. Goodel’s sign c. Braxton Hicks contraction

B. Leukorrhea d. Ballotment
41. I. E of 4 cm indicates:
A. cervical canal is 4 cm in diameter
B. the cervix is 4 cm thick
C. the cervical external OS is 4 cm wide
D. the cervical internal OS is 4 cm in diameter
42. The meaning of station +1 is:

A. the level of ischial spine c. 1 cm below level of

ischial spine
B. 1 cm above level of ischial spine d. 1 cm above the
pelvic inlet
43. It also known as the organ of
menstruation.
A. Ovaries c. Fallopian tube
B. uterus d. vagina
44. The average lifespan of ovum is:

A. 12 hours c. 36 hours
B. 24 hours d. 48 hours
45. The process of implantation takes place
in:
A. uterus c. ampulla
B. ovaries d. tunica albuginea
46. The non pregnant uterus is lined by the:

A. Endometrium c. deciduas vera

B.Myometrium d. deciduas capsularis
47. Which terms refers to the externally
visible structure of the female
reproductive system extending from the
symphysis pubis to the perineum?
A. mons pubis c. vulva
B. vestible d. labia majora
Situation: Rowena is admitted at the ER with
the following findings: Cervical dilation is 6
cm; fully effaced; cephalic presentation; 40
weeks AOG.
48. The nurse observes that Rowena’s
abdomen has irregular scar lines as a
result of stretching of the skin. This refers
to;
A. linea negra c. striae gravidarum
B. chloasma d. melasma
49. The obstetrician remarks that the fetus is
dipping, which means that the fetus is;
A. still floating
B. reached the ischial spine
C. in station +1
D. descending but has not reached the ischial
spine
50. Rowena asks if she can take her meal.
What should be the appropriate response
of the nurse?
A. “ your IV fluid is enough to give you
nourishment.”
B. “ you can take a light meal”
C. “ no, the doctor orders you to be kept NPO”
D. “ you cannot take food nor fluids because you
are now in active labor.”
1. If a woman is pregnant for the second
time, but her first pregnancy did not reach
viability, what would be her parity using
the four digit scoring system?
b. 1 –0-0-1
c. 0-0-1-0
d. 0-1-0-0-
e. 0-1-0-1
Answer: B
The formula for determining parity is TPAL
T- term pregnancies = 38 weeks
P- preterm =20-37 weeks
A- abortion = pregnancy that do not reach
viability 20-22 weeks
L – number of living children
2. In providing health teaching for an
expectant couple, what should the nurse
tell them is a probable sign of pregnancy?

c. Fetal heart sound

d. Positive pregnancy test
e. Fetal movements felt by examiner
f. Outline of fetus on sonogram
Answer: C
Positive pregnancy test results are
considered among the probable signs of
pregnancy.
3. A woman in labor has a history of
undiagnosed vaginal bleeding. Which
procedure may be contraindicated on her
arrival in the labor room?

c. Initiating an intravenous therapy

d. Taking her blood pressure
e. Examining her vaginal canal
f. Monitoring FHR
Answer: C
Examining her vaginal canal is
contraindicated initially because of her pre
admission history of bleeding. The problem
may be placenta previa or other bleeding
abnormalities in pregnancy.
4. A primipara at term has experience
lightening. The nurse should anticipate
which sign of discomfort that would
normally accompany lightening?

c. Urinary frequency
d. Dyspnea
e. Heartburn
f. constipation
Answer: A
Lightening or descent of the fetus puts added
pressure on the bladder, causing frequency.
5. A client is in active labor, the baby’s head
is crowning, the client is bearing down,
and delivery appears imminent. The nurse
should:

c. Transfer her immediately by stretcher to

the delivery room.
d. Tell her to breath through her mouth and
not to bear down
e. Instruct the client to pant during
contractions and to breath through her
mouth
f. Support the perineum with the hand to
prevent tearing and tell the client to pant.
Answer: D
Gentle pressure is applied against the baby’s
head as it emerges so it is not delivered too
rapidly. The head is never held back, and it
should be supported as it emerges to
prevent a vaginal laceration.
1. The labor room nurse decides to intervene
when the fetal heart rate pattern
indicates:
b. A baseline range of 110 to 160 bpm
c. Absence of variability
d. Early deceleration
e. Mild variable deceleration
2. A primipara at term has experienced
lightening. The nurse should anticipate
which sign of discomfort that would
normally accompany lightening.
b. Urinary frequency
c. Dyspnea
d. Heartburn
e. constipation
3. A newborn who weighed 7 lbs at birth now
weighs 6 lbs 8 oz. Implementing health
teaching, the nurse tells the mother the
percentage of birth weight usually lost by
normal, healthy babies. Which represents
the maximum amount of normal weight
loss for this newborn?
b. 6 oz (170g)
c. 8 oz (227g)
d. 11 oz (317g)
e. 16 0z (454g)
4. Of the following findings in full-term
newborn, which is not an expected
outcome of maternal hormone influence,
and therefore should be reported?
b. “witch milk”
c. Slight vaginal bleeding
d. Undescended testicles
e. Linea negra
5. A woman who is a primipara at term is in
active labor and is complaining of severe
backache with contractions. Which of the
following is not an effective comfort
measure?
b. Massage to the lower back between
contractions
c. External pressure to the sacrum during
contractions
d. Assistance with ambulation
e. Position on side with pillows between legs.
Answer:1. b
Sign of potential fetal distress. It can result
from fetal hypoxia and acidosis and certain
drugs that depress the central nervous
system. A baseline range of 110-160 bpm is
within normal limits
Answer 2. a
Lightening or descent of the fetus puts added
pressure on the bladder, causing frequency.
Answer 3 c.
Term infants may lose 5%-10% of their birth
weight
Answer 4 c.
Undescended testicles is a condition
unrelated to maternal hormonal influence.
By 36 – 38 weeks of gestation, they should
be descending through the inguinal canal
and into the scrotal sac.
Answer 5 c.
Ambulation would increase back discomfort
by increasing fetal descent.