NCM 101 Maternal Health Nursing

Maternal and Child Health Nursing
NCM 101 CMO 14
Mary Lourdes Nacel G. Celeste, RN, MD

Genetic Disorders
Facts
• 1 in 20 newborns has an inherited genetic
disorder
• Over 30% of pediatric admissions are for

genetic-influenced disorders
MLNGCeleste, RN, MD 3
Genetic Disorders
• Inherited or genetic disorders
-disorders that can be passed from one
generation to the next
• Genetics
-Study of why disorders occur
Nature of Inheritance
• In humans, each cell, with the exception of the

sperm and ovum, contains 46 chromosomes
(44 autosomes and 2 sex chromosomes) in the
nucleus
• Each chromosome contains thousands of

genes
• Sex chromosomes 46XX: female
46XY: male
Normal Female Karyotype
Normal Male Karyotype
Nature of Inheritance
• Genes
– Basic units of heredity; structures
responsible for hereditary characteristics
– May or may not be expressed or passed to the
next generation
– According to Mendel’s Law, one gene for each
hereditary property is received from each parent;
one is dominant (expressed); one is recessive
Karyotype
• Chromosomal pattern of a cell including genotype,
number of chromosomes and normality or
abnormality of the chromosomes
Genotype
• Actual gene composition; Sequence and
combination of genes on a chromosome
Phenotype
• Outward appearance or observable expression
of genes (hair color, eye color, body build, allergies)
Alleles
• Pairs of genes located on the same site on
paired chromosomes
• Homozygous alleles (DD or dd)
• Heterozygous alleles are two different
alleles for the same trait (Dd)
CONGENITAL and GENETIC are not synonymous
• Congenital - present at birth because of

abnormal development in utero (teratology)
• Genetic – pertains to genes or chromosomes;

some genetic disorders may be noticeable at
birth and others may not appear for decades
Dominant and Recessive Patterns
• Homozygous - a person who has 2 like genes

for a trait (eg, blue eyes: 1 from the mother
and 1 from the father)
• Heterozygous – if the genes differ (eg, 1 gene

for blue eyes from the mother, 1 gene for
brown eyes from the father)
Dominant and Recessive Patterns
• Dominant genes – genes which are expressed

in preference to others
• Recessive genes – genes that are not

dominant
• Homozygous dominant - an individual with 2
homozygous genes for a dominant trait
• Homozygous recessive – an individual with 2

homozygous genes for a recessive trait
Their children have a 100% chance of being
heterozygous for the trait.
Phenotype – brown eyed (phenotype) ; but
they will carry a recessive gene for blue eyes in
their genotype.
The child will have an equal chance of being
brown eyed (50%) or blue eyed (50%).
All the children will be brown- eyed. Chances
are equal that their children will be
homozygous dominant (50%) like the father or
heterozygous (50%) like the mother.
Both parents are heterozygous. 25% chance of
their children being homozygous recessive
(blue-eyed), 50% chance of being
heterozygous (brown eyed) and a 25% chance
of being homozygous dominant (brown eyed).
Inheritance of Disease
Mendelian or Single gene disorders
A. Autosomal disorders
1. Autosomal dominant disorders
2. Autosomal recessive disorders
B. Sex – linked disorders
1. X-linked dominant inheritance
2. X-linked recessive inheritance
Multifactorial inheritance
Chromosomal aberrations or abnormalities
Autosomal disorders
• Occur in any chromosome pair other than the
sex chromosomes
• Result from a single altered gene or a pair of
altered genes on one of the first 22 pairs of
autosomes
• Autosomal dominant or
Autosomal recessive
Autosomal dominant traits
• Those in which the abnormal gene dominates
the normal gene; thus, the condition is always
demonstrated when the abnormal gene is
present.
• The affected parent has a 50% CHANCE OF
PASSING ON THE ABNORMAL GENE IN EACH
PREGNANCY.
Autosomal dominant traits
Autosomal dominant
• Osteogenesis imperfecta (bones are exceedingly
brittle)
• Marfan syndrome (disorder of connective
tissue; child is thinner and taller than normal;
heart defects)
• Huntington’s disease
• Neurofibromatosis
• Achondroplasia (dwarfism)
Family pedigrees findings
(Autosomal dominant )
• 1 of the parents of the child with the disorder

also has the disorder
• The sex of the affected individual in
unimportant in terms of inheritance
• History of the disorder in other family members
Autosomal recessive traits
• Require transmission of the abnormal gene
from both parents for demonstration of the
defect in the child
• Each child has a 50% CHANCE OF BEING A
CARRIER OF THE DISORDER
• Almost all carriers are free from symptoms
Autosomal recessive
• Albinism
• Sickle cell anemia (chronic intensely painful
episodes caused by obstruction of blood vessels
by odd-shaped RBC’s; precipitated by
dehydration, infection, exposure to cold,
trauma, fatigue, lack of oxygen, strenuous
physical activity)
- The primary nursing action in caring for an
adolescent in sickle cell crisis is directed at
maintaining adequate hydration
- the spleen usually becomes enlarged due to
congestion and engorgement with sickled cells
Autosomal recessive
• Cystic fibrosis (multiple organ disease; the
primary pathophysiologic mechanism in cystic
fibrosis mucus buildup in the lungs and
pancreas; steatorrhea; azotorrhea)
• Inborn errors of metabolism (disorders caused
by the absence of or defect in enzymes that
metabolize proteins, fats or carbohydrates)
• Phenylketonuria or PKU (phenylalanine
hydroxylase) – brain damage and mental
retardation
• Tay Sach’s disease (hexosaminidase)- child is
attentive, passive and regresses in motor and
social development
GROUP Disorder
Blacks/ African Sickle cell Anemia

Americans
Northern European Tay-Sachs disease
descendants of
Ashkenazic Jews
Caucasian/ Non- Cystic fibrosis
Hispanic
Mediterranean Thalassemia
(Autosomal recessive)
• Both parents of a child with the disorder are
clinically free of the disorder
• The sex of the affected individual in
unimportant in terms of inheritance
• History of the disorder in the family is negative
• A known common ancestor between the
parents sometimes exists. This is how both
male and female have come to possess a like
gene for the disorder.
X-linked disorders
• Result from an altered gene on the X
chromosome
• May be dominant or recessive; recessive is
more common
(X-linked dominant)
• All individuals with the gene are affected
• Female children of affected men are all
affected; male children of affected men are
unaffected
• It appears in every generation
• All children of homozygous affected women
are affected.
• EXAMPLE: Hypophosphatemia
X- linked recessive
• More common
• Mother is the carrier of the disorder
• In female children, expression of the disease is
blocked
• In male children, disease will be manifested
(X-linked recessive)
• Only males will have the disorder
• A history of girls dying at birth for unknown
reasons often exists
• Sons of an affected man are unaffected
• The parents of affected children do not have
the disorder
X-linked recessive
• Hemophilia
• Color blindness
• Duchenne-type muscular dystrophy
• Christmas disease
• Fragile X syndrome
• Abnormalities caused by multifactorial reasons
which do not follow the mendelian laws of
inheritance because more than a single gene is
involved
• Environmental influences may be instrumental
in determining whether the disorder is
expressed
• Difficult to counsel parents regarding these
disorders because their occurrence is
unpredictable
• Cleft lip or palate
• Neural tube disorders
• Mental illness
• Pyloric stenosis
• Hypertension
• Heart disease
• diabetes
Genetic Counseling
• Purposes
– Provide accurate information
– Provide reassurance
– Make informed choices
– Educate people about disorders
– Offer support
Nursing Responsibilities
• Alert couple to what procedures they can
expect to undergo
• Explain how genetic screening tests are done
and when they are offered
• Assess for signs and symptoms of genetic
disorders
• Offer support
• Assist in value clarification
• Educate on procedures and tests
Assessing for Genetic Disorders
• History
• Physical assessment
Diagnostic testing
• Karyotyping – visual presentation of
chromosomes (sample: peripheral venous
blood; scraping of cells from buccal membrane)
• Barr body determination – if a child is born with
ambiguous genitalia; scraping of cells from
buccal membrane; stained and magnified;
presence of nondominant X chromosome in
the nucleus- Barr body (chromosomally female)
AFP analysis
• alpha fetoprotein (AFP) is a glycoprotein produced by
the fetal liver
• AFP level in the amniotic fluid or maternal serum will
differentiate from normal if a chromosomal or a spinal
cord disorder is present (eg, in mothers who have
gestational diabetes; infants 10x risk of having a neural
tube defect)
• Serum test is done at 15th week of pregnancy; if result
is abnormal, amniotic fluid will be assessed
• elevated 3-5x in amniotic fluid secondary to leakage
from open neural tube
• low AFP, < 5% Down syndrome
• maternal serum AFP has a false positive rate 30%; use
of triple study (AFP, estriol and hCG) reduces false
positive rate
Chorionic villi sampling
• Retrieval and analysis of chorionic villi for
chromosome analysis
• Transcervical or transabdominal; may be done
as early as 5 weeks, but more commonly done
at 8-10 weeks of pregnancy
• Risks: bleeding/ loss of pregnancy; limb
reduction syndrome; infection
• Diagnosis of Sickle cell disease, thalassemia
Chronic villi sampling
Amniocentesis
• Withdrawal of amniotic fluid from the
abdominal wall for analysis at 14th to 16th
week of pregnancy
• May include karyotyping, analysis of AFP and
acetylcholinesterase
• Used to diagnose potential genetic problems
in the fetus (Down Syndrome), to estimate
fetal lung maturity or to diagnose fetal
hemolytic disease
Amniocentesis
Percutaneous umbilical blood sampling
• removal of blood from the umbilical cord using
an amniocentesis technique
• more rapid karyotyping
Sonography/ Fetal imaging

• assess fetus for general size and structural
disorders of the internal organs, spine and limbs
• may be used concurrently with amniocentesis
Percutaneous
umbilical blood sampling
Fetoscopy
• insertion of a fiberoptic fetoscope through a
small incision in the mother’s abdomen into the
uterus and membranes to inspect the fetus for
gross abnormalities
• can be used to confirm sonography finding,
remove skin cells for DNA analysis or perform
surgery for a congenital defect
Preimplantation diagnosis
• may be possible in the future
• to remove the fertilized ovum from the uterus
before implantation for biopsy or cell analysis
Legal and Ethical Aspects
• Participation must be elective

• Informed consent
• Results must be interpreted correctly
• Confidentiality must be maintained
• Participation must be a free and
individual decision
Common Chromosomal Disorders
• Detected at birth on physical examination

• Most common are nondisjunction syndromes
• Many of these disorders leave children
cognitively challenged
1. Trisomy 13 syndrome
(Patau syndrome)
• Children have extra chromosome 13
• Severely cogitively challenged
• Incidence is low, .45 per 1,000 live births
• Midline body disorders present, microcephaly,
with abnormalities of the forebrain and forehead
• Eyes are smaller than normal (microphthalmos) or
absent
• Cleft lip and palate
• Low set ears
• Heart defects, VSD
• Abnormal genitalia
• Most do not survive beyond early MLNGCeleste, RN, MD
childhood 54
2. Trisomy 18 syndrome
• 3 Number 18 chromosomes
• Severely cognitively challenged
• Incidence .23 per 1,000 live births
• Small for gestational age (SGA)
• Low set ears, small jaw, congenital heart
defects, misshapen fingers and toes (Index
deviates or crosses over other fingers)
• Soles of the feet are rounded not flat (rocker-
bottom feet)
• Do not survive beyond early infancy
3. Cri-du-chat syndrome
• Result of a missing portion of chromosome 5

• Abnormal cry – like a sound of a cat
• Small head, wide-set eyes, downward slant to
the palpebral fissure of the eye
• Severely cognitively challenged
4. Turner syndrome
- female with only 1 X chromosome
• Gonadal dysgenesis, 45XO
• Has only 1 functional X chromosome
• Short in stature
• Hairline at the nape is low set
• Neck may appear webbed and short
• May have edema of the hands and feet
• Congenital anomalies, eg, coarctation (stricture) of the aorta;
kidney disorders
• Streak (small and nonfunctional) gonads; may have pubic
hair in puberty, no other secondary characteristics
• Incidence is 1 per 10,000 live births
• On karyotyping, 1 X chromosome only (no Barr body
present)
• Lack of fertility; learning disabilities; socioemotional
problems
• Growth hormone may help achieve additional height;
Estrogen may induce withdrawal bleeding MLNGCeleste, RN, MD
57
5. Klinefelter syndrome
- male with an extra X chromosome
• Males with XXY chromosome pattern (47XXY) –

may be revealed by karyotyping
• At puberty – poorly developed secondary
characteristics; small testes that produce
ineffective sperm- often infertile
• Usually of normal intelligence or have mental
retardation
• Gynecomastia
• Incidence is about 1 per 1,000 livebirths
6. Fragile X syndrome
• X linked, 1 long arm of the X chromosome is defective
• 1 in 1,000 livebirths
• Most common cause of cognitive challenge in boys
• Before puberty – maladaptive behaviors: hyperactivity
and autism
• Reduced intellectual functioning (speech and
arithmetic)
• Large head, long face with a high forehead, prominent
lower jaw, large protruding ears
• Hyperextensive joints, cardiac disorders
• After puberty – enlarged testicles; fertile
• Folic acid and phenothiazine may improve symptoms
of poor concentration and impulsivity; intellectual
function cannot be improved
7. Down syndrome (trisomy 21)
• Most frequent; 1 in 800 live births

• In pregnancy of women >35 years (1 in 100 live
births); paternal age > 55
• Diagnosis may be possible by sonography in
utero
• Nose is broad and flat; epicanthal fold;
palpebral fissure tends to slant upward; iris of
the eyes may have white speck in it (Brushfield
spots); tongue may be protruding; back of the
head is flat; short neck; extra apd of fat at the
base of the head; low-set ears; poor muscle
tone;simian crease on palm
• Cognitively challenged; educable (IQ 50 – 70) to
profound MR (IQ< 20)
• Prone to upper respiratory infections
• Congenital heart disease (atrioventricular
defects)
• Stenosis/ atresia of the duodenum
• Strabismus; cataract disorders
• Acute lymphocytic leukemia
• Lifespan: 40 – 50 years
• Should be exposed to educational and play
opportunities
Reproductive
and Sexual Health
Reproductive Anatomy and Physiology
• Male reproductive system

–External structures
• Scrotum
• Testes
• Penis
Male internal structures

• Epididymis
• Vas deferens
• Seminal vesicles
• Prostate gland
• Bulbourethral glands
• Urethra
MALE REPRODUCTIVE SYSTEM
MALE REPRODUCTIVE SYSTEM: ANDROLOGY
A. External Structures
1. Penis: the male organ of copulation; a cylindrical shaft consisting
of:
a. corpora cavernosa -two lateral columns of erectile
tissue
b. corpus spongiosum - encases the urethra
-The glans penis, a cone-shaped expansion of the corpus

spongiosum that is highly sensitive in males.
-Erection is stimulated by parasympathetic nerve
2. Scrotum: a pouch hanging below the penis that contains the

testes.
3. Testes: two solid ovoid organs 4-5 cm long and 2-3 cm wide,
divided into lobes containing
Seminiferous tubules -produce spermatozoa
Leydig cells - testosterone production
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Parts of the Penis:
1.The glans penis, a cone-shaped expansion of the

corpus spongiosum that is highly sensitive in males
2. Shaft or body
3. Prepuce or Foreskin – retractable skin covering

the glans & removed during circumcision.
Unretractable or tight foreskin is called PHIMOSIS.
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MALE REPRODUCTIVE SYSTEM:
A. External Structures continued
SPERMATOZOA are produced by:

Hypothalamus Control by
GnRH (+/-) feedback
Anterior Pituitary gland
FSH / LH
Testes
FSH - release of Androgen Binding Protein (ABP) which

promotes SPERMATOGENESIS
LH - release of Testosterone.
“Spermatozoa do not survive at body temperature.

They usually survive at temperature 1°F lower
than body temperature”. Hence, testes are
suspended outside the body.
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MLNGCeleste,
MLNGCeleste, RN, MD RN, MD
70
B. Internal Structures
1. Epididymis: serves as reservoir for sperm storage and

maturation. Approximately 20 ft. it takes 12-20 days for
the sperm to travel the length of Epididymis.
A total of 64 days before the sperm reach maturity.

Aspermia - absence of sperm
Oligospermia- if < 20 million sperm/ ml
2. Vas deferens: a duct extending from epididymis to the

ejaculatory duct and seminal vesicle, providing a
passageway for sperm. Sperm mature as they pass through.
Varicocele- varicosity of internal spermatic cord (may
contribute to infertility)
Vasectomy- severing vas deferens (male birth
control)
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• Beginning in early adolescence, boys
need to learn testicular self-examination.
• Testes should feel firm, smooth, egg-
shaped.
B. Internal Structures continued
3. Seminal vesicles: are two convoluted pouches that lie
along the lower portion of the bladder and empty into the
urethra by the way of the ejaculatory ducts
4. Ejaculatory ducts: the canal formed by the union of the vas

deferens and the excretory duct of the seminal vesicle, which
enters the urethra at the prostate gland.
5. Prostate Gland: located just below the urinary bladder.

Secretes alkaline fluid and most of the seminal fluid.
6. Bulbourethral glands or Cowper’s Gland: adds alkaline fluid

to the semen.
7. Urethra: the passageway for both urine and semen, extending

from the bladder to the urethral meatus. (8 inches long)
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SEMEN:
• Is a thick whitish fluid ejaculated by the male during orgasm,
contains spermatozoa and fructose-rich nutrients.
• During ejaculation, semen receives contributions of fluid from
Prostate gland (60%)
Seminal vesicle (30%)
Epididymis ( 5%)
Bulbourethral gland (5%)
• Average pH = 7.5
• The average amount of semen released during ejaculation is
2.5 -5 ml. It can live with in the female genital tract
for about 24 to 72 hours.
• 50-200 million/ml of ejaculation
• ave. of 400 million/ejaculation
• 90 seconds- cervix
• 5 minutes- end of fallopian tube
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Spermatogenesis
Testes
Contain Leydig cells produces testosterone
Testosterone ALERT: it takes 64 days

for sperm to reach
Stimulates maturity
APG secrete FSH & LH
stimulates seminiferous tubules to produce

spermatozoa
MLNGCeleste, RN, MD
Sperm Pathway
Testes ---produces sperms
Epididymis conducts sperm to Vas deferens
Seminal vesicles ( secretion of fructose & protein)
Ejaculatory duct
Urethra ( 8 inches) ( cowper’s gland secretes

alkaline fluid)
OUT
MLNGCeleste, RN, MD
• Female reproductive system

–External structures
–Internal structures
EXTERNAL REPRODUCTIVE SYSTEM
FEMALE REPRODUCTIVE SYSTEM: GYNECOLOGY
A.External Structures
1. Mons pubis/ Mons veneris – pad of adipose tissues, which

lies over the symphysis pubis, which protects the surrounding
delicate tissue from trauma.
2. Labia majora – longitudal folds of pigmented skin extending

from the mons pubis to the perineum. Contains the Bartholin’s
gland that secretes yellowish mucus that acts as a lubricant
during sexual activity.
3. Labia minora – soft longitudal skin folds between the Labia

majora.
4. Glans clitoris – erectile tissue located at the upper end of

Labia minora; primary site of sexual arousal.
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FEMALE REPRODUCTIVE SYSTEM:
A.External Structures continue
5. Vestibule – a narrow space seen when labia minora are

separated that also contains the vaginal introitus,
Bartholin’s gland and urethral meatus.
6. Urethral Meatus – small opening between the clitoris and

vaginal orifice for the purpose of urination.
7. Vaginal orifice/introitus/opening – external opening of

the vagina that contains the hymen.
8. Hymen – a membranous tissue ringing the vaginal introitus
9. Perineum – tissue between the anus and vagina. Site of

episiotomy
The external genitalia’s blood supply:

Arteries: a. pudendal artery b. inferior rectus artery.
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Vein: Pudendal vein
• FEMALE INTERNAL
STRUCTURES
1. Ovaries
2. Fallopian tubes
3. Uterus
4. Vaginal canal
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Female reproductive system
Internal structures
B. Internal Structures
1. Ovaries – female sex glands located on each side of the uterus

with two ovaries (4 x 2 x 1.5 cm thick).
Ovaries are formed with 3 principal divisions:

a. A protective layer of surface epithelium
b. The cortex filled with the ovarian and graafian follicle
c. The central medulla containing nerves, blood vessels,
lymphatic tissue and some smooth muscle tissue
Functions: -Ovulation (release of ovum) and Secretion of

hormones like estrogen and progesterone.
Estrogen- helps to prevent osteoporosis, and atherosclerosis

and potential risk for breast cancer/ endometrial cancer
84
Ovary - firm almond shaped organ covered by the
peritoneum
3 principal divisions:
a. protective layer of surface
epithelium
b. The cortex filled with

follicles
c. The central medulla

containing nerves, blood
vessels, lymphatic tissue
and some smooth muscle
tissue
85
2. Fallopian Tubes – 4 inches (10 cm) long from each side of the
fundus
Divided into four separate parts:
1. Intramural portion- most proximal (1 cm in length)
2. Isthmus portion- extremely narrow (2cm)

Important: tubal ligation
3. Ampulla- longest portion (5cm) and widest part

Function: site of fertilization
4. Infundibular portion- funnel- shaped with Fimbrae (2cm):

finger like projections.
Function: responsible for the transport of mature ovum from
ovary to uterus
86
Fallopian Tube 4 parts
1. Infundibulum- funnel
shape, with fimbriae
2. Ampulla- wide middle

segment; usual site of
FERTILIZATION
3. Isthmus- narrowest part
•Bilateral ducts extend 4. Interstitial or Intramural-

laterally from the uterus embedded in the uterine
wall
•receive oocyte and
provide site for fertilization
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B. Internal Structures continue
3. Uterus – hollow pear-shaped muscular organ.

Size: 3 inches long (5-7cm), 2 inches wide(5cm) and 1 inch thick
(3x2x1)
Wt: 60 gms. in non pregnant Location: lower pelvis
Parts: Corpus, Isthmus, and Cervix
Position: anteverted and anteflexed
Layers: perimetrium, myometrium and endometrium
Functions:
1. receives the ova to fallopian tube; place for implantation and
nourishment during fetal growth; furnishes protection to a growing
fetus
2. aids in labor and delivery
Cervix (2-5cm long)

Internal cervical os - an impt. relationship in estimating the
External cervical os level of dilatation of the fetus
in the birth canal before birth.
88
3 main parts of the Uterus
1. Fundus- rounded portion superiorly
2. Corpus or Body- major portion
3. Cervix- outlet which protrudes into vagina
• Isthmus- junction between the body and the cervix
• POSITION: Anteverted and Anteflexed
Layers of Uterine wall
1. endometrium (or mucosa) – inner layer
2. myometrium – thick, middle circular layer
(stratum vasculare)
3. epimetrium- superficial part surrounded
by the perimetrium
Layers of the Endometrium
1. Stratum Functionale
– Stratum compactum
– Stratum spongiosum
2. Stratum basale or germinativum
Uterus continue
Nerve Supply:
Efferent (motor) nerve- spinal ganglia (T5 to T10)
Afferent (sensory) nerve - hypogastric plexus (T-11 & T-12)
Impt: Controlling pain in labor ( Epidural anesthesia)
Uterine Ligaments:
1. Broad Ligaments – from the sides of uterus to pelvic walls
2. Round Ligaments – from sides of uterus to mons pubis.
3. Cardinal and uterosacral ligaments- provide middle support
4. Pelvic muscular floor ligaments- provide lower support
93
3. Vaginal Canal – 3-4 inch long dilatable canal between the bladder
and the rectum; contains rugae that permits stretching without
tearing.
Anterior Vaginal wall- 6-7 cm (anterior fornices)

Posterior Vaginal wall- 8-9 cm (posterior fornices)
Functions: 1. passageway for menstrual discharges

2. receives penis during intercourse and
3. serves as birth canal.
- lined with stratified squamous epithelium
- Bulbocavernosus: a circular muscle acts as voluntary sphincter

(Kegel exercises)
Blood supply to the vagina:

Arteries: vaginal artery branch of internal iliac artery
Vein: pudendal vein 94
Vagina continued…
The external genitalia’s blood supply: mainly from the

a. pudendal artery and
b. a portion of inferior rectus artery.
Nerve supply: has both parasympathetic & sympathetic

(S-1 to S-3 levels)
Nerve supply of the anterior portion: (L1)

a. Ilio-inguinal nerves b. Genito-femoral nerves
Nerve supply of the posterior portion: (S3)
Pudendal nerves
“This is the reason why one type of anesthesia used for

childbirth is called Pudendal block.”
95
Vaginal canal
• Connects the cervix to the vestibule
• Fibromuscular walled tube lined with mucus and
covered with hymen
• hymen – vascular and tends to bleed when ruptured
• The remnant of hymen is called CARUNCULAE
MYRTIFORMIS
• Bulbocavernosus: a circular muscle acts as voluntary
sphincter (Kegel exercises)
Function: organ of copulation and passageway of

menstrual flow and baby
Variations of Uterine Formation
NORMAL Bicornuate Septum- Double

UTERUS Uterus dividing uterus uterus
Uterine Deviations
Bicornuate – oddly shaped horns at the junction of
the fallopian tubes
Retroversion – fundus is tipped back
Retroflexion – body of the uterus is bent sharply
back just above the cervix
Normal : Anterted and Anteflexed

Anteversion – fundus is tipped forward
Anteflexion – body of the uterus is bent sharply
forward at the junction of the cervix
Anteversion Anteflexion
Retroversion Retroflexion

• Female internal structures

– Vagina
– Breasts
– Pelvis

Analogous Structures
Female Male
Glans Clitoris Glans penis
Labia majora Scrotum
Vagina Penis
Ovaries Testes
Fallopian tubes Vas deferens
Skene’s glands Prostate glands
Bartholin’s glands Cowper’s glands
Ovum Spermatozoa

Mammary glands
- MODIFIED SWEAT GLAND
- glands consist of 20 individual compound
alveolar glands w/ separate openings
(lactiferous ducts) at nipple
- internally 15-25 lobes
- under effects of estrogen and progesterone for
development; prolactin for milk secretion;
oxytocin - milk ejection reflex

• HORMONES THAT INFLUENCE THE MAMMARY
GLANDS:
– ESTROGEN – STIMULATES THE DEVELOPMENT OF
THE DUCTILE STRUCTURES OF THE BREST
– PROGESTERONE – STIMULATES THE DEVELOPMENT
OF THE ACINAR CELLS
– HUMAN PLACENTAL LACTOGEN – PROMOTES
BREAST DEVELOPMENT DURING PREGNANCY
– OXYTOCIN – LET DOWN REFLEX
– PROLACTIN – STIMULATES MILK PRODUCTION
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Reproductive Development
• Intrauterine development
-sex of an individual is determined at the moment of
conception
• Gonad- body organ that produces sex cells (ovary, testis)
Week 5: primitive gonadal tissue is formed

- Mesonephric (wolffian) and paramesonephric
(mullerian) ducts are present
Week 7 or 8 - in choromosomal males: primitive testes;
formation of testosterone
Week 10 - ovaries in females; oocytes formed
Week 12 – external genitalia

REPRODUCTIVE AND SEXUAL HEALTH
PUBERTAL DEVELOPMENT:
Puberty is the stage of life at which the

secondary sex changes begin.
Girls- age 9 to 12 years
Theory: must reach a critical weight of

approx. 95 lbs (43kgs) or develop a critical
mass of fat before the hypothalamus is
triggered to stimulate the anterior
pituitary gland to begin gonadotropic
hormone formation.
Boys- age 12 to 14 years

The role of Androgen- hormones
responsible for :
1. Muscular development
2. Physical growth
3. Increase sebaceous gland secretion
(acne)
Androgen- produced by the adrenal cortex
and testes in the males; by the adrenal
cortex and the ovaries in the females

“Testosterone -1° androgenic hormone”

In girls, testosterone influences the
development of labia majora, clitoris, and
axillary & pubic hair latter termed as
(adrenarche)
In males, it influences the development of

testes, scrotum, penis, prostate and
seminal vesicle; the appearance of pubic,
axillary hair; facial hair; laryngeal
enlargement; voice change; maturation of
spermatozoa and closure of growth in long
bones.
• Estrogen – excreted by the ovarian

follicles (3 compounds: estrone, estradiol
and estriol)
- Influences the development of the
uterus, fallopian tubes and vagina at
puberty; typical female fat distribution
and hair patterns; breast development
and end of growth of long bones

Secondary sex characteristics of
boys occur in the following order:
1. increase in weight
2. growth of testes
3. growth of face, axillary and
pubic hair
1. voice changes
2. penile growth
3. increase in height
4. spermatogenesis
Secondary sex characteristics of girls
occur in the following order:
1. growth spurt
2. increase in the transverse diameter
of the pelvis
3. breast development (thelarche)
4. growth of pubic hair (adrenarche)
5. onset of menstruation (menarche
12.5 y/o ave.)
-Ovulation occurs 1 – 2 years after
menarche
6. growth of axillary hair (adrenarche)
7. vaginal secretion

Menstruation
• Episodic uterine bleeding in response to cyclic
hormonal changes
• Brings an ovum to maturity and renews uterine
tissue bed
• PERIODIC, SLOUGHING OFF OF THE
ENDOMETRIUM WHICH OCCURS EVERY 28
DAYS BUT COULD BE ANYWHERE FROM 25 TO
35 DAYS & LASTS FOR 3-5 DAYS.

Characteristics of Menstrual Blood:
1.Does not appear to clot
2.Dark red as that of venous blood
3.Offensiveness ( Fleshy stale odor)
MLNGCeleste, RN, MD
MENSTRUAL CYCLE / FEMALE REPRODUCTIVE CYCLE
= EPISODIC UTERINE BLEEDING IN RESPONSE TO
HORMONAL CHANGES
= PERIODIC SERIES OF CHANGES THAT RECUR IN THE
UTERUS AND ASSOCIATED ORGANS BEGINNING AT
PUBERTY AND ENDING AT MENOPAUSE
= TAKEN FROM THE FIRST DAY OF MENSTRUATION TO
THE FIRST DAY OF THE NEXT MENSTRUATION
118
Basis for menstrual cycle is 6-12 month graphing.
Menarche – first menstrual period that occurs
typically at age 12 but may occur as early as 9 or as
late as 17
Thelarche – development of the breast buds that
occur at puberty
Adrenarche – development of pubic & axillary hair
due to androgen stimulation
119
BODY STUCTURES INVOLVED IN MENSTRUATION
1. HYPOTHALAMUS – ultimate initiator of menstrual
cycle. Secretes GnRH. Releases FSHRF during the
first half of the cycle & LHRF during the second half
of the cycle.
2. ANTERIOR PITUITARY GLAND – releases the
gonadotropin hormones (GH) FSH & LH
3. OVARIES- site of ovulation & releases estrogen &
progesterone.
4. UTERUS – the organ from which menstrual
discharge is formed. The changes in the uterine
endometrium are due to ovarian hormones
120
PITUITARY HORMONES ( GONADOTROPIC HORMONES)
WHICH REGULATE MENSTRUAL CYCLIC ACTIVITIES:
1. FOLLICLE STIMULATING HORMONE ( FSH)
2. LUTEINIZING HORMONE ( LH )
OVARIAN HORMONES WHICH REGULATE MENSTRUAL
CYCLE ACTIVITIES:
1. ESTROGEN – hormone of women; produced by the
graafian follicle
2. PROGESTERONE – hormone of mothers; produced by
the corpus luteum
121
HORMONES
Estrogen - female secondary sexual

characteristics, such as breast
development, increased adipose
tissue deposition, and increased
vascularization of the skin, widening
and lightening of pelvis

HORMONES
Progesterone - triggers uterine

changes during the menstrual cycle

Characteristics of Normal
Menstrual Cycles
• Beginning (menarche) – average of onset 12 -13 yrs;
average range 9 -17 years
• Interval between cycles – Average 28 days; cycles of 23
– 35 days not unusual
• Duration of menstrual flow – Average flow 2-7 days;
ranges 1-9 days not abnormal
• Amount of menstrual flow –difficult to estimate;
average 30-80 ml
• Color of menstrual flow – dark red; combination of
blood, mucus and endometrial cells
• Odor- similar to that of marigolds

FEMALE REPRODUCTIVE
FUNCTIONS AND CYCLES
OOCYTES
• in utero - 5 to 7 million
• at birth - 2 million
• 7 yrs of age only - 500,000/ovary
• Reproductive age only - 400–500 oocytes
• Menopause - none

Uterine cycle
3 phases
1. Menstrual phase
2. Proliferative phase
3. Secretory phase

Menstrual Phase
• Day 1- day 5
• First day of bleeding is the first day of
cycle
• Stratum functionale (compactum and
spongiosum) are shed
• Around 60 ml average

Proliferative Phase
• Days 5- day 14
• Eptihelial cells of functionale
multiply and form glands
• Due to the influence of estrogen

Secretory Phase
• Day 15- day 28
• Endometrium becomes thicker and
glands secrete nutrients
• Uterus is prepared for implantation
• Due to progesterone
• If no fertilization constriction vessels
menstruation

Ovarian cycle
3 phases
1. Pre-ovulatory : follicular phase
2. Ovulatory phase
3. Post-ovulatory : Luteal phase

Ovarian Cycle;
preovulatory/follicular
• Variable in length: day 6- day 13

• Dominant follicle matures and
becomes graafian follicle with primary
oocyte
• FSH increases initially then decreases
because of estrogen increase

Ovarian cycle: Ovulatory phase
• Day 14
• Rupture of the graafian follicle
releasing the secondary oocyte
• Due to the LH surge
• MITTELSCHMERZ- pain during
rupture of follicle

OVARIAN cycle:
Post-ovulatory: luteal phase
• Day 15- day 28
• MOST CONSTANT 14 days after ovulation
• Corpus luteum secretes Progesterone
• If no fertilization, corpus luteum will become
corpus albicans then degenerate
• Decreased estrogen and progesterone
production

Hormonal cycle
1. Menstrual phase
– Decreased Estrogen, decreased
progesterone, decreased FSH and decreased
LH
2. Proliferative/Pre-ovulatory phase
– Increased FSH and Estrogen in small amounts

3. Ovulatory phase
– Increased LH (surge); Increased Estrogen
4. Post ovulatory/luteal Phase

– Increased Estrogen, increased progesterone
until corpus luteum degenerates

‘

SUMMARY OF MENSTRUAL CYCLE
- monthly changes in the uterine lining that
lead to menstrual flow as the endometrium
is shed
STEPS:
1. Corpus luteum of previous cycle fades,
progesterone decreases, FSH rises
(proliferative phase)

SUMMARY OF MENSTRUAL CYCLE
2. FSH stimulates follicular growth and
differentiation and stimulate Estrogen
secretion
3. Estrogen stimulates endometrial growth
and differentiation along w/ follicular
growth

4. Rising Estrogen levels exert a
negative feedback on the pituitary
gland and hypothalamus to decrease
secretion of FSH
5. Dominant follicle is destined grow

for ovulation

6. Sustained high Estrogen level
cause the LH surge w/c triggers
ovulation 24-36 hours later,
progesterone production and shift to
luteal/secretory phase
7. Estrogen level decreases until the

midluteal phase when it rises d/t
corpus luteum secretion

8. Progesterone also rises because of corpus
luteum secretion; protein rich secretory
products in glandular lumen (secretory
phase)
9. If pregnancy does not occur, the corpus

luteum degenerates, hormone levels decline,
and the uterine lining disintegrates and shed
(menstrual phase)
*time from ovulation to the onset of the next
menstrual period is usually constant (2
weeks)

10. If fertilization and implantation occur, ovary
continues producing progesterone and the
endometrium remains intact to support
embryo daevelopment and pregnancy.

Education

Menopause
• Cessation of menstruation for at least one year
occurring at the age of 45-52 due to cessation
of ovarian function
• Decreased estrogen and progesterone
• Genetically determined
• May occur earlier in smokers, nulliparous and
patients who underwent hysterectomy

A. MENSTRUAL CYCLE CHANGES:
- changes in menstrual cycle regularity
- remaining follicles in both ovaries become
less sensitive to GnRH stimulation which
results to:
1.increased level of fsh
2.reduction in estrogen concentration

- the limited follicle maturation leads to either a decrease
in cycle interval or lapses of cycles, with
oligomenorrhea
B. CESSATION OF MENSES:
- menses usually cease between Ages of 45 and 52
years,
(reduced level of estrogen from the remaining follicles
is no longer sufficient to induce endometrial
proliferation / changes capable of producing visible
menstruation)

C. PREMATURE MENOPAUSE:
- manifested by permanent amenorrhea
before 35 years of age due to:
1.genetic predilection
2.ovarian failure due to auto-
immune reaction

Concerns
1. Loss of childbearing capacity
2. Loss of youth
3. Skin changes-related to estrogen deficiency that has a
role in collagen storage and restoration
4. Depression-related to changes in relationship w/
children, spouse and other life events
5. Anxiety and irritability –”climacteric syndrome”;
psychocial
6. Loss of libido-related to vaginal atrophy secondary to
decreased estrogen

7. Abnormal bleeding – irregular, heavy or prolonged
related to to anovulatory cycles
* rule out pregnancy, malignancies and polyps
8. Hot flashes/flushes – recurrent, transient flushing,
sweating, palpitations, anxiety, chills
9. Urinary symptoms – dysuria, urgency and recurrent
UTI
10. Difficulty in concentration and short term memory
loss
11. Cardiovascular disease
12. osteoporosis

TARGET ORGAN RESPONSE TO
DECREASED ESTROGEN:
• VAGINA
- becomes smaller and the size of the upper vagina
diminishes
- epithelium becomes pale, thin, and dry
- labia minora has a pale , dry appearance; reduction in fat
content of labia majora
• Uterus
- endometrial tissue become sparse, with numerous small
petecchial hemorrhages, has atrophic appearance
- myometrium atrophies, uterus decreases in size
• Breast
- general loss of turgor, form, fullness of the breast
• Bones
- gradual loss of calcium, lading to osteoporosis,
characterized by reduction in bone density and fracture
• Hair
- with the loss of estrogen, there is relative decrease in
circulating androgens; increase quantity of hair with
male pattern distribution

Sequelae of reduced estrogen:
Vasomotor symptoms:
- Hot flash/ flush, is the hallmark of the
menopausal woman
- last for a few seconds or several minutes
- more frequent and severe at night or during
time of stress
- coincides with a surge of luteinizing
hormones

• Altered menstrual function:
– Oligomenorrhea followed by amenorrhea
– Amenorrhea for 6 to 12 months
– If vaginal bleeding occurs after 12 months of
amenorrhea, endometrial biopsy must be
ruled out
• osteoporosis:
– Main health hazard associated with
menopause
Menopausal syndrome:
-Such as fatigue, headache, nervousness, loss of libido,
insomnia, depression, irritability, palpitation, muscle
pain
•Atrophic changes:
- atrophy of the vaginal mucosa leads to atrophic
vaginitis, pruritus of vulvovaginal area, dyspareunia and
stenosis
- urethral changes
- increased frequency of cystitis
- vaginal, urethral and bladder symptoms

Treatment:
Estrogen replacement therapy
• Advantages:
– Eliminate hot flashes
– Reversal of atrophic vaginitis, dyspareunia,
affective symptoms
– Prevention and treatment of osteoporosis
– Prevention of cardiovascular disease
– Retention of youthful skin

•Disadvantages
-can cause acute liver disease
-Acute vascular thrombosis
-Seizure disorder
-Hypertension
-Migraine headache
-Breast cancer
-Endometrial cancer

Menstrual Disorders
Dysmenorrhea
Primary – due to prostaglandin excess or increased

sensitivity to prostaglandin w/ no pathologic pelvic
disorder
Secondary – with underlying disease

ie, PID (Pelvic inflammatory disease)
Endometriosis, Adenomyosis, Uterine prolapse, Uterine
myomas, Polyps

Dysmenorrhea
Pathophysiology
Prostaglandin myometrial
contractions muscle spasm
constricts blood vessels ischemia
and pain

Clinical Manifestations
• Primary – within 1-2 yrs after menarche in conjunction

with ovulatory cycles
- pain few hours before menses up to 72 hours thereafter
- Nausea and vomiting, diarrhea, syncope, headache, back
pain
• Secondary – years after menarche

- 1-2 wks prior to menses and persist few days after
menstrual cessation
Diagnosis
History and PE
Medical Management
1. combination OCP – inhibit ovulation, decrease
prostaglandin and uterine activity
2.promote exercise
3.administer prostaglandin synthesis inhibitors –
ibuprofen, mefenamic acid
Nursing Management
1. Education and reassurance
2. adequate nutrition and rest
3. stress management

Menstrual cycle irregularities
Oligomenorrhea – infrequent, irregular bleeding at

intervals > 35 days
Polymenorrhea – frequent, regular bleeding at intervals
< 21 days
Amenorrhea – cessation of menses x 6 months
Menorrhagia – regular bleeding that is excessive in
amount and duration > 5 days
Metrorrhagia – irregular bleeding
Menometrorrhagia – excessive prolonged bleeding at
irregular intervals

PREMENSTRUAL SYNDROME
- emotional and physical manifestations that

occur cyclically before menstruation and
regress thereafter
- peak 30-40 yo
- mood and behavioral changes
- No specific hormone, treatment or markers
- inherent to menstrual cycle

Etiology and Risk Factors
- Caffeine
- Smoking
- Lack of exercise
- Improper diet
- Inadequate sleep
- Stress
Management:
supportive

Sexuality
• Includes feelings, attitudes and actions
• Has both biologic and cultural components
• Encompasses and gives direction to a person’s physical
emotional social, and intellectual responses throughout
life
• Each person is born a sexual being.
• Gender identity and gender role behavior evolve from
and usually conform to societal expectations within a
person’s culture.

Sexuality and Sexual Identity
Terms
• Biologic gender – denotes chromosomal
development: XX, XY
• Gender identity or sexual identity: inner sense a

person has of being male or female
• Gender role - behavior a person conveys about

being male or female (may or may not be the same
as biologic gender or gender identity)

Human Sexual Response
Sexual response cycle (Masters and Johnson)
• Excitement
• Plateau
• Orgasm
• Resolution

Mechanisms involved in response to sexual stimulation:
1. Vasocongestion – the engorgement of blood

vessels and increased influx of blood into the tissues.
Congested tissues, because of its excess blood
content, become swollen, red and warm
2. Myotonia – increased muscles tension affecting

both smooth and skeletal muscles and occurs both
voluntarily and involuntarily

Excitement
• occurs with physical and psychological (sight,
sound, emotion, thought) stimulation that causes
parasympathetic nerve stimulation
• Arterial dilation and venous congestion in the
genital area
• Vasocongestion:
-clitoris in women increases in size, mucoid fluid
appears in vaginal walls as lubrication, vagina
widens/ increase in length, nipples become erect
• In men, erection occurs; scrotal thickening,
elevation of testes
• Increase in PR, RR and BP

Plateau
• just before orgasm
• Women: clitoris is drawn forward and retracts
under the clitoral prepuce; lower part of the
vagina becomes extremely congested (formation
of the orgasmic platform), increased nipple
engorgement
• Men: vasocongestion leads to full distention of
the penis
• HR increases to 100 to 175 beats per minute and
RR to approximately 40 respirations per minute

Orgasm
• Occurs when stimulation proceeds
through the plateau stage to a point at
which the body suddenly discharges
accumulated sexual tension
• Vigorous contractions of muscles in the
pelvic area expels or dissipates blood and
fluid from the area of congestion

• Shortest stage in the sexual response
cycle
• Usually experienced as intense pleasure
affecting the whole body not just the
pelvic area
• Highly personal experience; vary greatly
from person to person

Resolution
• Period during which the external and internal
genital organs return to unaroused state
• Males: refractory period – during which further
orgasm is impossible
• Females: no refractory period; may have
additional orgasms immediately after the first
• Generally takes about 30 minutes

The Growing Fetus
Stages of Fetal Development
During pregnancy, the fetus undergoes 3

major stages of development:
1. PRE-EMBRYONIC PERIOD – fertilization

to week 2
2. EMBRYONIC PERIOD –
week 3 – week 8
3. FETAL PERIOD – week 8 to birth

Fertilization
• Beginning of pregnancy
• Union of the ovum and spermatozoon
• Usually occurs at the outer third of
fallopian tube

Implantation
• Contact between growing structure
and uterine endometrium
• Occurs 8-10 days after fertilization

Embryonic and Fetal Structures
• Decidua
• Chorionic villi
• Placenta

Umbilical Cord
• From fetal membranes
• Provides circulatory pathway
• Contains one vein and two arteries

Amniotic Membranes
• Chorionic membrane
• Amniotic membrane

I. PREGNANCY
• refers to condition of carrying an
offspring within the body.
• a form of reproduction that unites the
cell of 2 individuals to form a unique
new individual who embodies
characteristics of both parents
II. FERTILIZATION
• union of ovum and spermatozoa
• union generally occurs in the distal third
of the fallopian tube
• Cells of the human body develop from
chromosomes
• Normal human cell tissue contains 46 chromosomes-
22 pairs of homologous autosomes (any chromosome
other than sex chromosome) and one pair of sex
chromosomes; one chromosome of each pair of
chromosomes is received from the mother and the
other one from the father
• Sex determination occurs at the moment of conception
as a result of the sex chromosome contributed by the
male; an X-carrying sperm fertilizing the ovum
produces a female (XX), a Y-carrying sperm produces a
male (XY)
• Aberration in the number of chromosomes result in
abnormal offspring or spontaneous abortion
Process of fertilization (conception)
– only one sperm penetrates ovum

• Usually occurs in the outer third of the fallopian
tube
• Implantation usually occurs in the upper part of
the uterus about 7-10 d after fertilization when
the developing zygote burrows into the
endometrium, which has undergone changes to
provide for its nourishment and is now called the
deciduas

There are three groups of cells in the developing embryo:
• Outer layer (ectoderm) – develops into the following

structures; hair, nails, sebaceous glands, sweat glands,
epithelium of nasal and oral passages
• Middle layer (mesoderm)
– develops into the following structures: muscles, bones,
sexual structures, heart, kidneys, teeth dentin
• Inner layer (endoderm) – develops into the following:
epithelium of digestive tract, respiratory tract, bladder

• Zygote- fertilized ovum
• Cell division:
- occurs as the zygote travels the fallopian tube to the
uterus.it takes 3 to 4 days of cell division or mitosis for the
zygote to become morula( resemble mulberry), this
morula entering the uterus is now
called a blastocyst
Blastocyst- differentiates into

1. inner mass of embryonic cell which becomes the EMBRYO
2. outer layer called the TROPHOBLAST, which is involved in
implantation, hormone secretion, and membrane and
placental formation

III. IMPLANTATION - 7 days or 5 days
after fertilization, the trophoblast
burrows into the endometrium (upper
part of uterus), embedding the
fertilized egg into the uterine lining
decidua - what the endometrium is

called after implantation

Formation of twins:
• Fraternal or dizygotic
- 2 ova are being
fertilized by 2 sperm,
they are nonidentical,
there are 2 amnion, 2
chorion, 2 placenta
195
Formation of twins:
• Identical or monozygotic
twins:
- one ovum is fertilized by
one sperm and the inner
cell mass of the
blastocyst splits into 2 to
form two embryos
- maybe 2 males or 2
females, there are 2
amnion , one chorion
and one placenta
196
• Chorion - outer fetal membrane,
formed from the trophoblast
( maternal side of placenta)
• Amnion - originates in the blastocyst
during early stages of development,
expands as the fetus grows until it
slightly adheres to the chorion ( fetal
side of placenta)
• Amniotic sac - formed by 2 fetal
membranes (chorion, amnion)

IV. AMNIOTIC FLUID - formed by the secretion of:
1. amniotic cells
2. lungs and skin of fetus
3. fetal urine
- 98% water, but also contains glucose, protein,
sodium, urea, creatinine, lanugo, vernix caseosa
- slightly alkaline, replaced approximately every 3
hours
- amniotic cells and the fetus urinating and
swallowing regulate the secretion and
reabsorption of the fluid

Functions of amniotic fluid:
Never stagnant
Serves to protect fetus
• - Shields against pressure; equalizes the
pressure around the fetus; cushions the
fetus from external compression
- Protects from temperature changes; .
provides constant temperature and fluid for
the fetus to swallow
- Protects umbilical cord
- allows freedom of movement for the fetus
- lubricates the membrane and the fetus
yolk sac - cavity in the blastocyst
- forms primitive red blood cell until the
liver is able to take over the process in
about 6 weeks

V. PLACENTA AND UMBILICAL CORD:
placenta- formed by the :
1. chorionic villi at the base of the
implanted fertilized ovum and the
decidua basalis
2. endometrium at the side of
implantation

Placenta - membranous vascular organ
connecting the fetus to the mother,
supplies the fetus with oxygen and food
and transports waste product out of fetal
system
- development is stimulated by
progesterone secreted by corpus luteum
( 3rd wk after fertilization)
- fully functional by the 12th week

2 sides of placenta:
1.maternal side which is irregular and is
divided into subdivisions called cotyledons
2. fetal side covered by amnion, so it is
smooth and shiny

Placental Circulation

umbilical cord - a structure that connects the fetus
to the placenta.
- has 2 arteries and 1 vein (AVA)
- 2 arteries carry deoxygenated blood from the
fetus to the placenta
- 1 vein carries oxygenated blood to the fetus,
along with nutrients, hormones etc

Circulatory system of the mother and
fetus are separate
- maternal blood enters the intervillous
spaces of the placenta
- fetal blood is in the vessels of chorionic
villi

Functions of placenta:
1.Transport: ( substances)
a. by diffusion from an area of higher
concentration to area of lower concentration
(oxygen, carbon dioxide, electrolytes, fat soluble
vitamins, gases and drugs)
b. facilitated diffusion uses carrier system to

move molecules ( some glucose and oxygen)

c. active transport – allows molecules to move
from lower concentration to area of higher
concentration (amino acids, iron, calcium,iodine
and water soluble vitamins)
d.Pinocytosis - transfers larger molecules

(albumins, globulins, antibodies, viruses)
e. osmotic pressure and hydrostatic pressure

Insulin, heparin IgM, and blood cell do not move
across the placenta unless there is tear

2. Endocrine:
secretes 5 hormones
1. hCG- basis of pregnancy test
2. human placental lactogen
3.estrogen.
4.progesterone
5.relaxin

HCG- secreted by trophoblast, during early
pregnancy
- prevents involution of corpus luteum,
stimulates it to continue producing
progesterone and estrogen for 11-12
weeks
- 8 to 10 days after fertilization, hCG is
present in maternal blood
- few days from missed menses, (+) in urine

Human placental lactogen
- makes sufficient amount of protein,
glucose, and minerals
- an insulin antagonist (maternal
metabolism of glucose)
- ensures that the mother’s body is
prepared for lactation

Estrogen - stimulates development of
uterine and breast tissues in the mother
- increases vascularity and vasodilation in
the villous capillaries

Progesterone - after 11 weeks of pregnancy,
placenta takes over the production of
progesterone from the corpus luteum
- it is a smooth muscle relaxant, prevents

uterine contraction by decreasing its
contractility
- also maintains the endometrium
relaxin - causes changes in collagen

3. Metabolic:
- produces fatty acid, glycogen and
cholesterol for fetal use and
hormone production

DEVELOPMENT OCCURS IN SYSTEMATIC
MANNER FROM HEAD TO TOE
- from proximal to distal and from general to

specific
- or described in general term of trimester
(1st trimester -12 wks, 2nd trimester-13 to
27 weeks, 3rd trimester-28 to 40 weeks)

week 4 - (wt 0.4g, length is 4- 6mm), half the size of a
pea, brain differentiates, G.I. tract begins to form
limbs buds appear

week 5 - cranial nerves present, muscles have
innervation ( L 6-8mm)
week 6 - fetal circulation established. liver

produces red blood cells, CNS forms, primitive
kidney forms, lung buds present, cartilage
forms, primitive skeleton forms, muscles
differentiate
week 7 - eyelids form, palate and tongue form

stomach formed, diaphragm formed, arms and
legs move (L 22-28mm)
MLNGCeleste,
219
week 8 - resembles human being, eyes move to face front,
heart development complete, hands and feet well
formed; bone cells begin to replace cartilage, all body
organs have begun forming
(wt-2g, L 3cm,) MLNGCeleste, RN, MD 220
Fetal Stage
week 9 - fingers and toenails form; eyelids fuse

shut
week 10 - head growth slows, islets of langerhans

differentiated, bone marrow forms, rbc
produced; bladder sac forms, kidneys make
urine
( wt-14g,L 5-6cm C – H )
week 11 - tooth buds appear, liver secretes bile;

urinary system functions, insulin forms in
pancreas MLNGCeleste,
221
week 12 - lungs takes shape, palate fuses, heart
beat heard with Doppler, ossification
established, swallowing reflex present; external
genitalia, male or female distinguished

week 16 - meconium forms in bowels, scalp hair
appears, frequent fetal movement, skin thin
and pink ,sensitive to light, 200 ml of amniotic
fluid
MLNGCeleste,
223
week 20 - myelination of spinal cord begins, peristalsis
begins, lanugo covers body; vernix caseosa covers
body, brown fat deposit begins, swallows and sucks
amniotic fluid, heart beat heard by fetoscope,
hands can grasp, regular schedule of sucking ,
kicking and sleeping ( wt 435 g L 19cm)

week 24 - alveoli present in lungs/ begin
producing surfactant , eyes completely
formed, eyelashes and eyebrows appear,
many reflexes appear, (+) chance of survival if
born MLNGCeleste,
225
week 28 -subcutaneous fat deposits begin; lanugo
begins to disappears, nails appear, eyelids open
and close ; testes begin to descend
week 32 - more reflexes present, CNS direct

rhythmic breathing movement/ partially controls
body temperature, begins storing iron, calcium
phosphorus; ratio of lungs surfactant lecithin and
sphingomyelin is 1.2:2
week 36 - a few creases on soles of feet, skin less

wrinkled, fingernails reach fingertips, sleep-wake
cycle fairly definite, transfer of maternal
antibodies

week 38 - L/S ratio 2:1
week 40 - lanugo only on shoulders and upper
back; creases cover sole, vernix mainly in folds
of skin, ear cartilage firm, less active, limited
space, ready to be born
MLNGCeleste,
227
System development:
-all systems in the fetus begin forming by the 8th
week
• cardiovascular system -primitive heart begins to
beat on the 21st day following conception ,the
1st to function in the embryo; congenital
malformation may develop during the 6th to 8th
weeks
228
Fetal
Circulation

Fetal circulation:
oxygenated blood(placenta)
umbilical vein
liver ductus venosus
inferior vena cava
right atrium
foramen ovale( flap opening in the atrial septum

that allow only R-L movement of blood)

• Continuation:
left atrium
left ventricle right ventricles( small amount)
aorta pulmonary arteries

ductus arteriosus
supply the body aorta
supply blood to the body

Continuation:
superior vena cava
right atrium
right ventricle
pulmonary arteries
( ductus arteriosus)
aorta
supply blood to the body

Special Structures:
Foramen Ovale
Connects the left and right atria
Bypassing fetal lungs
Obliterated after birth to become fossa ovalis
Umbilical Vein
Brings oxygenated blood coming from the placenta to the heart and liver
Becomes ligamentum teres
Umbilical arteries
Carry unoxygenated blood from the fetus to placenta
Become umbilical ligaments after birth
Ductus venosus
Carry oxygenated blood from umbilical vein to IVC
Bypassing fetal liver
Becomes ligamentum venosum after birth
Ductus arteriosus
Carry oxygenated blood from pulmonary artery to aorta
Bypassing fetal lungs
Becomes ligamentum arteriosum; closes after birth
• Hematologic development:
- day 14 , primitive blood cells are formed in
the yolk sac.
- fifth week of gestation before the fetal liver
begins hematopoiesis
- fetal hemoglobin ( Hgb F ) found only
during gestation and early neonatal
period, has great attraction for oxygen
- blood type is genetically determined at
conception

• Gastrointestinal system:
- 4th week of gestation ,G.I.T. begins to
form
- 20th week fetus begins to swallow
amniotic fluid, but there is no coordination
of the swallow and suck reflexes until
about the 34th week
meconium - fecal material stored in the fetal

intestine, begins to form about week 16
- if the fetus encounters hypoxic stress
anal sphincter may relax and meconium
may be passed
• Musculoskeletal system:
- limb buds appear late in the 4rth week and
development is complete by the 8th week
- growth of skeleton is determined by
genetics and maternal supply of calcium and
phosphorous
- cartilage is noted about the 5th week
- ossification begins about the 12th week but not
completed until after puberty
- end of 12th week skeletal muscles begin
involuntary movement ( depend s on volume
amniotic fluid)

• Genitourinary system:
- kidneys begin forming about 3 weeks
- 12th week -begins to produce hypotonic urine
( all nephrons are in the kidneys at birth)
• Reproductive system:
- testes seen on abdomen by 7 weeks, and
begin to descend to the scrotum about 30 weeks;
ovaries develop in the abdomen and stay in the
pelvic cavity

• Integumentary sytem:
- creases form on the palms, fingers, soles, during
week 11, permanent design formed by week 17
- lanugo appears during week 20 and slowly
dissappears
- mammary glands develop during the 6th week
• Respiratory system:
- lung buds form during the 6th week
- bronchi form by week 16

-surfactant production begins between weeks 20-24
- primitive lungs formed by week 23
- surfactant production matures between
weeks 35 and 37
• Immunologic system:
- between 12-15th weeks immune capability
begins to develop
- fetus produces small amount of immunoglobulin
IgA, IgG, and IgE

Fetal development:
- preembryonic or germinal stage:
weeks 1 and 2 - rapid cell division and differentiation
- germinal layers form
-embryonic stage:
week 3 - primitive nervous system, eyes, ears,
rbc present, heart begins to beat day 21

Teratogens
Any factor that adversely affects
fertilized ovum, embryo or fetus

Teratogenic Fetal Exposure
• Maternal infections
• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes simplex virus
• Syphilis

• Lyme disease
• Infections
• Vaccines
• Drugs
• Alcohol
• Cigarettes

Drugs Teratogenic Effects
• Androgen, Estrogen Musculinization of female
infants
• Progesterone
• Thalidomide Phocomelia, cardiac & lung
defect
• Anticonvulsant left lip & palate; CHD
• Lithium CHD
• Tetracycline yellow staining of teeth,
inhibits bone growth
• Vitamin K Hyperbilirubinemia
• Salicylates ( aspirin) neonatal bleeding,
decreased IUG
• Streptomycin Nerve defects
• Vitamin A CNS defects
• Barbiturates Bleeding disorders
• Environmental
• Metal and chemical
• Radiation
• Hyperthermia and hypothermia
• Maternal stress

Assessing Fetal and Maternal
Health: Prenatal Care
PRENATAL CARE (ANTEPARTUM CARE)
3 PHASES:
1. PRE-CONSULTATION = HISTORY TAKING, FAMILY,

MEDICAL, OB HISTORY
2. CONSULTATION = PHYSICAL ASSESSMENT
3. POST CONSULTATION = HEALTH TEACHINGS
247
COMPONENTS OF PRE NATAL VISIT
1.PRE- CONSULTATION PHASE:
PERSONAL DATA: AGE, SEX, CIVIL STATUS, WEIGHT,
HEIGHT
1 AGE : UNDER 17 OR ABOVE 35 (GREATER RISK IF
OVER 40)
** PREGNANT ADOLESCENTS HAVE A HIGHER
INCIDENCE OF PREMATURITY, PIH, CEPHALOPELVIC
DISPROPORTION, POOR NUTRITION & INADEQUATE
ANTEPARTAL CARE.
** WOMEN OVER 35 YEARS OLD ARE AT RISK FOR
CHROMOSOMAL DISORDERS IN INFANTS, PIH &
CESARIAN DELIVERY.
248
** THE DURATION OF A NORMAL PREGNANCY
IS 266 – 280 DAYS OR 38-42 WEEKS ( AVERAGE IS 40
WEEKS) ; OR 9 CALENDAR MONTHS OR 10 LUNAR
MONTHS.
** BOTH OVULATION & GESTATIONAL AGE ARE
ALSO SOMETIMES MEASURED IN LUNAR MONTHS ( 4
WEEK PERIODS) OR IN TRIMESTERS ( 3 MONTH
PERIOD) RATHER THAN IN WEEKS.
IN LUNAR MONTHS, A PREGNANCY IS 10

MONTHS ( 40 WEEKS OR 280 DAYS) LONG; A FETUS
GROWS IN UTERO 9.5 LUNAR MONTHS OR THREE
FULL TRIMESTERS ( 38 WEEKS OR 266 DAYS)
249
MLNGCeleste, RN, MD
Health Assessment
• Initial interview
– Health history
• Demographic data
• Chief concern • History of family illness
• Family profile • Gynecologic history
• History of past • Obstetric history
illnesses • Review of systems
251
Health Assessment
• Initial interview
– Support person’s role
– Physical exam
• Baseline height/weight, vital signs
• Assessment of systems
252
• Assessment of systems
– General appearance and
mental status
– Neck
– Head and scalp
– Eyes – Lymph nodes
– Nose – Heart
– Ears – Lungs
– Sinuses – Back
– Mouth, teeth and throat
– Rectum
– Extremities and skin
253
OBSTETRICAL DATA:
MENSTRUAL HISTORY: INCLUDES MENARCHE,
LENGTH & REGULARITY OF MENSES, INTERVAL
BETWEEN PERIODS, AMOUNT OF FLOW,
DYSMENORRHEA
HISTORY OF PAST PREGNANCIES:
GRAVIDA = ALL PREGNANCIES REGARDLESS OF
DURATION OR OUTCOME
PARA = PAST PREGNANCIES RESULTING IN
VIABLE FETUS ( 20 WEEKS) WHETHER BORN DEAD
OR ALIVE. ( TWINS, TRIPLETS ETC. CONSIDERED
AS ONE).
254
History
1. Initial visit
a. Obstetrical history (TPAL)
Gravida – the total number of pregnancies regardless of

duration (includes present pregnancy)
Nulligravida – a woman who has never been pregnant
Primigravida – a woman who is pregnant for the first time
Multigravida – a woman who has two or more pregnancy
MLNGCeleste, RN, MD
• Para – number of past pregnancies that have gone
beyond the period of viability (capability of the fetus to
survive the outside of the uterus; currently considered
any time after 20-wk gestation), regardless of the
number of fetuses or whether the infant was born alive
or dead
• Nullipara – a woman who has never delivered a fetus
that reached the age of viability
• Primipara – a woman who has completed one
pregnancy to viability
• Multipara – a woman who has completed two or more
pregnancy to the age of viability
MLNGCeleste, RN, MD
• Term infant – an infant born between 38 and 42
weeks of gestation
• Preterm – an infant born before 38 weeks
• Post term – an infant born after 42 weeks
• Abortion – pregnancy that terminates before
the period of viability (20 wks)
• Live birth – a live birth is recorded when an
infant born shows sign of life

• Other terms to know:
Stillbirth – infant born without signs of
life
Parturient – a woman in labor

Puerpera – a woman who just delivered
(within six weeks after delivery)
MLNGCeleste, RN, MD
• Low birth weight < 2500 grams
• Normal Birth weight 2500 – 4000 grams
• Large birth weight > 4000 grams

PRENATAL ASSESSMENT
A. VERIFYING PREGNANCY
• Signs and Symptoms
Presumptive
Probable
Positive
• Pregnancy Test
B. LMP
Estimated Date of Delivery/ Confinement
EDD/ EDC/EDB
Age of gestation
Measure Fundic Height

Last Menstrual Period (LMP)
• First day of the last menstrual period

EDC/ EDD/ EDB

AOG
COMPUTATION OF AGE OF GESTATION
Example: LMP: January 1, 2010
Date of consult: August 31, 2010
AOG: Total # of days from LMP up to date of consult

7
January 30 days
February 28 Total = 242 days
March 31 AOG = 242
April 30 7
May 31 34 to 35 weeks
June 30
July 31
August 31 MLNGCeleste, RN, MD 264
Obstetrical History/ Number
G__ P__ (T, P, A, L)
• Gravida – the total number of pregnancies regardless of
duration (includes present pregnancy)
• Para – number of past pregnancies that have gone
beyond the period of viability (capability of the fetus to
survive the outside of the uterus; currently considered
any time after 20-wk gestation), regardless of the
number of fetuses or whether the infant was born alive
or dead
• Term infant – an infant born between 38 and 42 weeks
of gestation
• Preterm – an infant born before 38 weeks
• Post term – an infant born after 42 weeks
• Abortion – pregnancy that terminates before the period
of viability (20 wks)
• Live birth – a live birth is recorded when an infant born
shows sign of life MLNGCeleste, RN, MD 265
OTHER COMPUTATIONS (Nice to know):
MC DONALD’S RULE = ( ESTIMATION OF AOG IN
MONTHS & WEEKS BY FUNDIC HEIGHT
MEASUREMENT)=
FORMULA :
FUNDIC HEIGHT IN CMS X 2/7
EXAMP[LE:
FUNDIC HEIGHT IS 21 CMS
21 CMS X 2 =42
42/ 7 = 6 ( AOG IN MONTHS)
6 MONTHS X 4 = 24 ( AOG IN WEEKS)
266
HAASE’S RULE = ESTIMATION OF FETAL LENGTH
RULE:
**DURING THE FIRST HALF OF PREGNANCY, SQUARE
THE NUMBER OF THE MONTH ( EX. FIRST LUNAR
MONTH: 1X1 = 1CM.
**DURING THE SECOND HALF OF PREGNANCY,
MULTIPLY THE MONTH BY 5
( EX. 6TH LUNAR MONTH: 6X5 = 30 CM.)
FORMULA: 1 TO 5 MONTHS = MONTHS SQUARED
267
EXAMPLES:
5 MONTHS X 5 = 25 CMS LENGTH
8 MONTHS X 5 = 40 CMS LENGTH
268
JOHNSON’S RULE = ESTIMATION OF WEIGHT IN GRAMS
FORMULA: FUNDIC HEIGHT IN CM – N X K
“K” IS CONSTANT, IT IS ALWAYS 155
“N” IS MINUS 11 IF PART IS NOT YET ENGAGED
MINUS 12 IF PART IS ALREADY ENGAGED
EXAMPLE: 21 CM, NOT ENGAGED

21 – 11 = 10 X 155 = 1,550 GMS
269
BARTHOLOMEW’S RULE = ESTIMATION OF AOG BY
THE RELATIVE POSITION OF THE UTERUS IN THE
ABDOMINAL CAVITY.
** BY THE 3RD LUNAR MONTH, THE FUNDUS IS
PALPABLE SLIGHTLY ABOVE THE SYMPHYSIS PUBIS
** ON THE 5TH LUNAR MONTH, THE FUNDUS IS AT THE
LEVEL OF THE UMBILICUS
** ON THE 9TH LUNAR MONTH , THE FUNDUS IS
BELOW THE LEVEL OF THE XIPHOID PROCESS
270
2. CONSULTATION PHASE = PHYSICAL ASSESSMENT
A. PHYSICAL EXAMINATION = A REVIEW OF SYSTEMS
IS INDICATED, INCLUDING INSPECTION OF THE
TEETH BECAUSE THEY ARE A COMMON CAUSE OF
INFECTION.
B. PELVIC EXAMINATION
(CARDINAL RULE: EMPTY THE BLADDER FIRST)
** INTERNAL EXAMINATION (IE) = TO DETERMINE
CHADWICK’S, GOODEL’S, HEGAR’S
271
Physical assessment
Initial visit – complete physical exam
• Breast exam – nipple formation using “pinch test” in

which the areola is pinched gently and pushed in with
the examiner’s thumb and forefinger; an everted or
normal nipple protrude, an inverted nipple will look flat
or turned inward, indicating potential difficulty with
breastfeeding
• Pelvic exam – Pap smear; culture for gonorrhea and

herpes if appropriate; smear for chlamydia; bimanual
(palpation of reproductive organs between abdominal
and vaginal hands) to establish uterine size, consistency,
and contour; pelvic measurements

C. VITAL SIGNS = TEMPERATURE, PULSE AND
RESPIRATORY RATES ARE IMPORTANT ESPECIALLY
DURING THE INITIAL PHASE OF THE PRENATAL VISIT .
BUT CERTAINLY MORE IMPORTANT ARE THE WEIGHT &
BLOOD PRESSURE AS BASELINE DATA TO DETERMINE
ANY SIGNIFICANT INCREASE.
D. BLOOD STUDIES
** BLOOD TYPING
** CBC, INCLUDING HgB, & HcT TO DETERMINE
ANEMIA
273
E. URINE EXAMINATIONS:
** HEAT & ACETIC ACID TEST TO DETERMINE
ALBUMINURIA. ANY SIGN OF ALBUMIN ( PROTEIN) IN
THE URINE SHOULD BE REPORTED IMMEDIATELY
BECAUSE IT IS A SERIOUS SIGN OF TOXEMIA ( PIH).
** BENEDICT’S TEST FOR GLYCOSURIA, A SIGN
OF POSSIBLE GESTATIONAL DIABETES.SPECIMEN
SHOULD BE TAKEN BEFORE BREAKFAST TO AVOID
FALSE POSITIVE RESULT
274
Laboratory screening
• Initially and at routine visits, urine dipstick for glucose,
protein (pregnancy induced hypertension and UTI), CBC,
rubella IgG antibody
• Repeat GC culture late third trimester (more often if
indicated)
• Maternal serum alpha-fetoprotein (AFP) at 16-18 wk to
identify risk of neural tube defect in fetus
• Glucose screening between 24-28 wk to detect
gestational diabetes
• Repeat CBC at 24 –28 wk
• Rh antibody titers for Rh woman at 24, 28, 32, and 40 wk
• ultrasound

• Fundal height
• Fetal heart sounds
• Pelvic exam
– External genitalia
– Internal genitalia
• Pap smear
• Vaginal inspection
• Exam of pelvic organs
• Rectovaginal exam

THE APPEARANCE OF THE CERVIX
1. NULLIGRAVID 2. AFTER CHILDBIRTH 3. AFTER MILD CERVICAL TEARING

(Stellate)

278
Assessment of Fetal Growth
Estimating fetal growth
FUNDIC HEIGHT ( in cm)
McDonald’s Rule – determining during
midpregnancy, that the fetus is growing in utero
by measuring the fundal (uterine) height
- typically, the distance from the fundus to the
symphysis in centimeters is equal to the week
of gestation between the 20th and 31st weeks of
pregnancy

• Measure from the notch of
the symphysis pubis to over
the top of the uterine fundus
using a tapemeasure in
centimeters as the woman
lies supine
• inaccurate during the 3rd
trimester
• Typical measurements
- Over the symphysis pubis: 12
weeks
- At the umbilicus: 20 wks
- At the xiphoid process:
36 wks
 Rises about 1cm per week;
after which it varies
280
Location of the fundus:
• 12 weeks  at the level of the symphysis pubis

• 16 weeks  halfway between symphysis pubis and
umbilicus
• 20weeks  at the level of the umbilicus
• 24 weeks  two fingers above umbilicus
• 30 weeks  midway between umbilicus and xiphoid
process
• 36 weeks  at the level of xiphoid process
• 40 weeks  two fingers below umbilicus,
drops at 34 weeks level because of
lightening

Assessment of Fetal Growth
Assessing fetal well-being
• Fetal heart rate • Maternal serum alpha-

fetoprotein
• Fetal movement
• Triple screening (AFP,
• Ultrasound estriol and hCG)
• Nonstress Test • Chorionic villi sampling
• Electrocardiography • Amniocentesis
• MRI • Percutaneous umbilical
• Amnioscopy blood sampling
• Fetoscopy • Biophysical profile
283
Fetal heart rate
• FHR should be 120-160
beats per minute
• Can be heard with a

Doppler : 10 – 11th week
of pregnancy
• Fetoscope: 18-20 weeks
284
Fetal heart rate
• Assist the patient to a supine position.
• Drape her with a blanket to minimize exposure.
• Apply water soluble lubricant to her abdomen or the
monitoring device.
• To assess FHR in a fetus 20 weeks or younger, position
Doppler/Stethoscope/ fetoscope on the abdominal midline
above the symphysis pubis. After 20 weeks AOG, when you
can palpate fetal position, use Leopold’s maneuvers and
position the listening instrument over the fetal back.
• Place the earpieces in your ears and press gently on the
patient’s abdomen. If there are no earpieces, turn the
device on and adjust the volume. As needed. Start listening
at the midline, midway between the umbilicus and the
symphysis pubis.
• Move the instrument from side to side to locate the
loudest heart tones then palpate the maternal pulse.
Fetal heart rate
• If the maternal radial pulse and FHR are the same, try to
locate the fetal thorax/ back by Leopold’s maneuver, then
reassess FHR for 60 seconds. Record FHR.
• During labor, monitor FHR during the relaxation period
between the contractions to determine baseline.
• In a low-risk labor, assess FHR every 60 minutes during the
latent phase, every 30 minutes during the active phase and
then every 15 minutes during the 2nd stage of labor. In
high risk labor, assess FHR every 30 minutes during the
latent phase, every 15 minutes during the active phase,
and every 5 minutes during the 2nd stage of labor.
• Auscultate FHR during a contraction and for 30 seconds
afterward to identify the response to the contraction.
• Auscultate FHR before administration of medications,
ambulation, and artificial rupture of membranes, changes
in the characteristics of contractions, vaginal examinations
and medications.
LOCATING FETAL HEART SOUNDS BY FETAL POSITION
FHT – heard best at the FETAL BACK

Fetal Heart Rate Patterns Indicative of… Intervention
Tachycardia (>160 bpm) Maternal or fetal infection Depends on the cause

Fetal hypoxia (ominous sign)
Bradycardia (<120 bpm) Fetal hypoxia or stress Place client on her left side
Maternal hypotension after Increase fluids to counteract
epidural initiation hypotension
Stop oxytocin (Pitocin) if in
use
Early deceleration Head compression :not None required
(deceleration begins and ends ominous
with uterine contraction) Vagal stimulation
Late deceleration Fetal stress and hypoxia Change maternal position
(HR decreases after peak of Deficient placental perfusion Correct hypotension
contraction and recovers after Supine position Increase IV fluid rate as
contraction ends) Maternal hypotension ordered
Uterine hyperstimulation Discontinue oxytocin
Administer oxygen as
ordered
Variable deceleration Cord compression Change maternal position
(transient decrease in HR Hypoxia or hypercarbia Administer Oxygen
anytime during contraction
Decreased variability Fetal sleep cycle Depends on the cause
Depressant drugs
Hypoxia
CNS anomalies
Fetal movement
• Fetal movement that can be felt by the mother :

QUICKENING begins at approximately 18 – 20
weeks of pregnancy;peaks at 28-38 weeks
• Primigravid- quickening:20 weeks
• Multigravid- 16 weeks
• Ask the mother to observe fetal movement.
• A healthy fetus moves at least 10x a day.

• Sandovsky method
- mother is in a left lateral recumbent position;
fetus normally moves a minimum of twice every
10 minutes or an average of 10 -12x an hour
• Cardiff method – Count to ten

- records the time it takes for her to feel 10 fetal
movements; usually within 60 minutes

LEOPOLD’S MANEUVER
• systematic method of observation and
palpation to determine fetal position
• woman empties her bladder; lies supine with
her knees flexed slightly
• examiner warms hands to avoid contraction of
abdominal muscles
• gentle but firm touch

LEOPOLDS MANEUVER
• First Maneuver Palpation of the Uterine
Fundus
• Will usually indicate the fetal part situated in
the fundus; usually a fetal head; infrequently a
fetal breech.
Place hands on either side of the fundal area so
that the fingers of both hands almost touch
each other (face the woman's head).
• A somewhat hard and roundish shape, which
when moved back and forth between the finger
pads, also moves the entire fetus usually
indicates a fetal breech.
• Press gently and firmly with finger pads.
A very hard round well-defined shape that can
be moved back
and forth (balloted) usually indicates a fetal293
MLNGCeleste, RN, MD
head.
First Maneuver
Palpation of the Uterine Fundus

Second Maneuver
Determines small parts and back of fetus
along the sides of maternal abdomen
• Lateral Palpation of the Uterus

• Examiner faces woman's head
• Palpate with one hand on each side of
abdomen
• Palpate fetus between two hands
• Assess on which side is the fetal back or
spine and which side has small parts or
extremities

• Generally provides information regarding the
location of the fetal back and the fetal small
parts consisting of arms and legs.
Hands should alternately apply pressure against
the opposite hand.
Directing alternating pressure against each
hand is the technique.
• Alternating hands using firm resistance while
the other hand gently and firmly applies
pressure and rotates in a circular fashion.
This technique can be used up and down the
entire length of the uterus.

Second Maneuver
Determines small parts and back of fetus
along the sides of maternal abdomen

Third Maneuver
(Lower uterine segment or uterine pole)
• Face the woman's head and spread your hands

widely apart.
• Grasp the uterine contents just above the
symphysis pubis (firmly but gently).
• Hold presenting part between index finger and
thumb.
• Assess for cephalic versus Breech Presentation
Move the fetal presenting part gently back and
forth in your hand Fetal head will shift more
easily back and forth Fetal breech will move the
whole body.

• The 3rd Leopold's Maneuver (Pawlick's grip) will
provide either initial information or confirm
prior data gained from the previous steps of
Leopold's maneuvers.
• Anchoring the uterine fundus with the non-
dominant hand assist
in identifying the location of the fetal back and
small parts.

Third Maneuver
(Lower uterine segment or uterine pole)

Fourth Maneuver
(pelvic palpation of the uterus
- assess the presenting part)
• Provides information about the presenting part:
breech or head, attitude (flexion or extension),
and station (level of descent of the presenting
part).
• Examiner faces woman's feet .
• Place hands on either side of the lower
abdomen with finger pads at the lower uterine
pole (bikini line) and thumbs directed toward
the umbilicus.
• Carefully move fingers of each hand towards
each other in a downward and inward manner
using gentle pressure. MLNGCeleste, RN, MD 301
• The nurse's thumbs should point towards the
woman's umbilicus.
• If there is a head palpated in the pelvis, the
fetal presentation is referred to as a cephalic or
vertex presentation.
• Assess if a prominence on one side of the
abdomen can be palpated higher than a
prominence on the other side. The first
prominence felt indicates the sinciput
(forehead) of the infant and is on the same side
as the fetal small parts. Therefore, the sinciput
is on the side opposite the fetal back. The
prominence felt further down the pelvis is the
fetal occiput back of the head) and is on the
same side as the fetal back.
Fourth Maneuver
(pelvic palpation of the uterus
- assess the presenting part)

1st What is at the uterine fundus?
MANEUVER HeadMANEUVER
LEOPOLD’S is more firm, hard and round that moves independently of
the body.
Breech is less well defined that moves only in conjunction with
the body.
nd
2 Where is the fetal back?
MANEUVER Fetal back is smooth, hard, resistant surface.
Knees and elbows of fetus feel with a number of angular
nodulation.
rd
3 What is at the inlet of the pelvis?
MANEVER By grasping the lower portion of the abdomen (just above the
symphisis pubis.
Not engaged (not firmly settled in the pelvis) if the presenting
part moves upward so an examiner’s hands can be pressed
together.
4th What is the fetal attitude? (degree of flexion)
MANEUVER Fingers on both sides of the uterus (2 inches above inguinal
ligaments) pressing down and inwards. The fingers of the hand
that do not meet obstruction above the ligament palpates the
fetal brow.
Good attitude if brow corresponds to the side (2nd maneuver)
that contained the elbows and knees.
Poor attitude if examining fingers will meet an obstruction on
the same side as fetal back (hyperextended head).
Also palpates infant’s anteroposterior position. If brow is very
MLNGCeleste,
easily palpated, fetus is at posterior position RN,pointing
(occiput MD 304
• Estimating pelvic size
• Type
• Measurements
• Diagonal conjugate
• True conjugate or conjugate vera
• Ischial tuberosity diameter

Passage (maternal) – size and type of pelvis, ability of the cervix
to efface and dilate, and distensibility of vagina and introitus
• Pelvis – the bony ring through which the fetus

passes during labor and delivery; consists of
four united bones (two hip or innominate
bones, the sacrum, and the coccyx) between
the trunk and thighs
• Measurements – may be obtained by internal

and external pelvic examination (using
pelvimeter), x-ray pelvimetry (used rarely in
pregnancy and only late in third trimester or in
labor), and ultrasound

Pelvic types:
a. Gynecoid – classic female pelvis inlet, well rounded
(oval); ideal for delivery
- most ideal for childbirth (50% of women)
b. Android – resembling a male pelvis, narrow and heart-
shaped; usually requires cesarean section or difficult
forceps delivery (20% of women)
c. Platypelloid – flat, broad pelvis; usually not adequate
for vaginal delivery (5% of women)
d. Anthropoid – similar to pelvis of anthropoid ape; long,
deep, and narrow; usually adequate for vaginal delivery
(25% of women)

TYPES OF PELVIS

PELVIS:
• provides protection to the organs found within
the pelvic cavity
• provides attachment to muscles, fascia and
ligaments
• supports the uterus during pregnancy
• serves as birth canal

Division of the pelvis:
a. False
• “ SUPERIOR HALF”
 upper flaring portion of the ilia
 provides support to the uterus during
pregnancy
 to direct the fetus to the true pelvis during
labor
b. True
• “INFERIOR HALF”
• FORMED BY THE PUBIS IN FRONT, THE ILIA &
THE ISCHIA ON THE SIDES & THE SACRUM &
COCCYX BEHIND
forms the passageway of the fetus during labor
312
** THE FALSE PELVIS IS DIVIDED FROM THE TRUE
PELVIS ONLY BY AN IMAGINARY LINE: THE LINEA
TERMINALIS DRAWN FROM THE SACRAL PROMINENCE
AT THE BACK TO THE SUPERIOR ASPECT OF THE
SYMPHYSIS PUBIS AT THE FRONT OF THE PELVIS. **
313
a.PELVIC INLET / pelvic brim= ENTRANCE TO
THE TRUE PELVIS, OR THE UPPER RING OF
BONE THROUGH WHICH THE FETUS MUST
FIRST PASS TO BE BORN VAGINALLY. ITS
TRANSVERSE DIAMETER IS WIDER THAN ITS
AP DIAMETER. THUS:
** TRANSVERSE DIAMETER = 13.5 CM
** AP DIAMETER = 11 CM
314
315
• Consists of the following parts:
1. Inlet/ pelvic brim – entrance to true pelvis
• AP diameters:
– Diagonal Conjugate = 12.5 cm
– Obstetric Conjugate = 11 cm
(Substract 1-1.5cm from diagonal conjugate)
– True Conjugate/ Conjugate Vera = 11.5 cm
(or 10.5 – 11cm)
(Substract 1-1.5 cm (or 1.2-2cm) from
diagonal conjugate)
• Transverse diameter = 13.5 cm
• Right and left oblique diameter = 12.75 cm
DIAGONAL CONJUGATE
• The distance between (the anterior surface of)
the sacral promontory of the sacrum and (the
anterior surface of the inferior margin of) the
symphysis pubis
• Measured clinically
• Most useful measurement for estimating the
pelvic size (AP diameter of pelvic inlet)
• AVERAGE = 12.5 TO 13 CMS
• >12.5 cm adequate for birth

Measurement of Diagonal Conjugate

320
Obstetric conjugate
• Shortest anteroposterior diameter
between the sacral promontory and the
symphysis pubis
• Can only be measured radiographically
• AVERAGE = 11 CM
• Normal > 10 cm

TRUE CONJUGATE/ CONJUGATA VERA
THE DISTANCE BETWEEN THE MIDPOINT
OF THE SACRAL PROMONTORY TO THE
UPPER MARGIN OF THE SYMPHYSIS
PUBIS.
• VERY IMPORTANT MEASUREMENT
BECAUSE IT IS THE DIAMETER OF THE
PELVIC INLET.
• AVERAGE = 11.5 CM

323
2. Pelvic canal - situated between inlet and outlet
MIDPELVIS/ PELVIC CAVITY = THE SPACE BETWEEN
THE INLET & THE OUTLET. THIS IS NOT A
STRAIGHT BUT A CURVED PASSAGE
-Interspinous (smallest diameter of pelvic)= 10
cm
-AP diameter at level of ischial spines = 11.5 cm
-Posterior sagittal diameter = 4.5 cm
324
MLNGCeleste, RN, MD
3. Pelvic Outlet –most important diameter of the
outlet is its transverse diameter or Bi-ischial
diameter =11.5 cm
AP diameter = 9.5 to 11.5 cm
Posterior sagittal diameter = 7.5 cm

3.POST – CONSULTATION PHASE =
HEALTH TEACHINGS
• Schedule of clinic visits

• Exercises
• Dental hygiene
• Clothing
• Traveling
• Bathing
• Employment
• Sexual relation
• Immunization

Routine visits
• every 4 weeks until 32 weeks
• then every 2 weeks until 36 weeks
• weekly until delivery
- to monitor vital signs, weight, fetal heart
tones, fundal height and outline

HEALTH TEACHINGS
NUTRITION = MOST IMPORTANT ASPECT
FOOD SOURCES:
** PROTEIN RICH FOODS = MEAT, FISH, EGGS, MILK, POULTRY,
CHEESE, BEANS, MONGO
** VIT. A = EGGS, CARROTS, SQUASH, CHEESE, BEANS, VEGETABLES
** VIT. D = FISH, LIVER, EGGS, MILK ( EXCESS VIT.D DURING
PREGNANCY CAN LEAD TO FETAL CARDIAC PROBLEMS)
**VITAMIN E = GREEN LEAFY VEGETABLES, FISH
330
**VITAMIN C= TOMATOES, GUAVA, PAPAYA
**VITAMIN B= PROTEIN RICH FOODS
**CALCIUM/PHOSPHORUS=MILK, CHEESE
**IRON= ESPECIALLY IMPORTANT DURING THE LAST TRIMESTER
WHEN THE PREGNANT WOMAN IS GOING TO TRANSFER HER IRON
STORES FROM HERSELF TO HER FETUS SO THAT THE BABY HAS
ENOUGH IRON STORES DURING THE 1ST 3 MONTHS OF LIFE WHEN
ALL HE TAKES IS MILK(WHICH IS DEFICIENT IRON). IRON HAS A
VERY LOW ABSORPTION RATE: ONLY 10% OF THE IRON INTAKE
CAN BE ABSORBED BY THE BODY. THUS, FOR OPTIMUM
ABSORPTION, GIVE VITAMIN C.
331
IRON SHOULD BE GIVEN AFTER MEALS BECAUSE IT IS IRRITATING
TO THE GASTRIC MUCOSA.
SOURCES: LIVER AND OTHER INTERNAL ORGANS, CAMOTE TOPS,

KANGKONG, EGG YOLK, AMPALAYA, MALUNGGAY, SALUYOT.
**MALNUTRITION DURING PREGNANCY CAN RESULT IN

PREMATURITY, PREECLAMPSIA, ABORTION, LOW BIRTH
WEIGHT BABIES, CONGENITAL DEFECTS OR EVEN STILL BIRTHS.
332
** FOLIC ACID – TO PREVENT NEURAL TUBE DEFECTS ( SPINA
BIFIDA, MENINGOCOELE )
SOURCES:
** GREEN LEAFY VEGETABLES
** FRUITS
** RDA FOR SALT IN A PREGNANT WOMAN IS 3g/DAY BECAUSE
OF INC IN BLOOD VOLUME TO MAINTAIN F & E BALANCE.
333
TT IMMUNIZATION:
• TT1 GIVEN ANYTIME DURING PREGNANCY
• TT2 ONE MONTH AFTER TT1 ( 3 YEARS
PROTECTION)
• TT3 SIX MONTHS AFTER TT2 ( 5 YEARS
PROTECTION)
• TT4 ONE YEAR AFTER TT3 ( 10 YRS)
• TT5 ONE YEAR AFTER TT4 OR NEXT PREGNANCY
( LIFETIME PROTECTION)
334
** THE PROVISION OF PRENATAL CARE IS THE
PRIMARY FACTOR IN THE IMPROVEMENT OF MATERNAL
MORBIDITY & MORTALITY STATISTICS. “”
335
ANTENATAL FETAL TESTING

Ultrasound• Response of sound waves
against objects
• Allows visualization of the
uterine content
• Transabdominal UTZ
- full bladder
- client lies on her back
• Transvaginal UTZ
- probe is inserted in the
vagina
- lithotomy position
- empty bladder
337
• Diagnose pregnancy as early as 6 weeks
• Confirm the presence, size and location of the
placenta and amniotic fluid
• Establish that the fetus is growing and has no gross
defects (eg, hydrocephalus, anencephaly, spinal
cord, heart, kidney and bladder defects)
• Establish the presentation and position of the fetus
(sex can be diagnosed)
• Predict maturity by measurement of the biparietal
diameter (BPD)
• discover complications of pregnancy / fetal
anomalies
Estimation of Fetal Age
• Gestational sac – 5 – 6 weeks
• Crown rump length – 7 – 14 weeks
• Femoral length – 12 – 22 weeks
• Biparietal Diameter 17 -26 weeks

Biophysical profile (BPS)
• Assesses 4 to 6 parameters (fetal breathing
movement, fetal movement, fetal tone,
amniotic fluid volume, placental grading, and
fetal heart reactivity/ reactive NST)
• Each item has a potential for scoring a 2; 12
highest possible score
• BPS 8 – 10: fetus is doing well
• BPS 4 – 6: fetus is in jeopardy

Nonstress Test
• Measures the response of

fetal heart rate to fetal
movement
• Determines fetal well-
being
• Performed to assess
placental function and
oxygenation
341
• An external ultrasound transducer and the
tocodynamometer are applied to the mother
and a tracing of at least 20 minutes’ duration
is obtained so that the FHR and the uterine
activity can be observed.
• Obtain baseline blood pressure and monitor
blood pressure frequently.
• Position mother in semi-fowler’s or side- lying
position or left lateral position to avoid vena
cava compression.
• The mother may be asked to press a button
every time she feels fetal movement; the
monitor records a mark at each point of fetal
movement, which is used as a reference point
to assess FHR response.
RESULTS OF NST:
• REACTIVE NONSTRESS TEST:Normal/Negative
- indicates a healthy fetus
- requires 2 or more FHR accelerations of at least 15 beats
per minute, lasting at least 15 seconds from the
beginning of the acceleration to the end, in association
with fetal movement, during a 20-minute period.
• NONREACTIVE NONSTRESS TEST: Abnormal

-No accelerations or accelerations of less than 15 bpm or
lasting than 15 seconds in duration occur in a 40 minute
observation.
• UNSATISFACTORY – The result cannot be interpreted

because of the poor quality of the FHR tracing.

344
Contraction Stress Test
• Assesses placental oxygenation and

function
• Determines fetal ability to tolerate
labor and determines fetal well-being
• Fetus is exposed to the stressor of
contractions to assess the adequacy of
placental perfusion under simulated
labor conditions.
• External fetal monitor is applied to the
mother, and a 20 to 30 minute baseline
strip is recorded.
• The uterus is stimulated to contract by the
administration of a dilute dose of oxytocin
or by having the mother use nipple
stimulation until 3 palpable contractions
with a duration of 40 seconds or more in a
10 minute period have been achieved.
• Frequent maternal BP readings are done,
and the mother is monitored closely while
increasing doses of oxytocin are given.
RESULTS OF CST:
• NEGATIVE CST/ NORMAL
- no late or variable decelerations of FHR
• POSITIVE CST/ ABNORMAL

- late or variable decelerations of FHR with 50%
or more of the contractions in the absence of
hyperstimulation of the uterus.
• EQUIVOCAL – with decelerations but with less

than 50% of the contractions, or the uterine
activity shows a hyperstimulated uterus.
• UNSATISFACTORY – adequate uterine

contractions cannot be achieved, or the FHR
tracing is not of sufficient quality for adequate
interpretation. MLNGCeleste, RN, MD 347
Amniocentesis
- Withdrawal of amniotic fluid from the
abdominal wall for analysis

Amniocentesis
- amniotic fluid is aspirated by a needle inserted through
the abdominal and uterine walls; indicated early in
pregnancy (14-17 wk) to detect inborn errors of
metabolism, chromosomal abnormalities, open NTD
(neural tube defect); determine sex of fetus and sex-
linked disorders after 28 wk
- Used to diagnose potential genetic problems in the

fetus (Down Syndrome), to estimate fetal lung
maturity or to diagnose fetal hemolytic disease
• Indicated for pregnant women 35 years and older;

couples who already have had a child with a genetic
disorder; one or both parents affected with a genetic
disorder; mothers who are carriers for X-linked
disorders
• Prior to the procedure, the patient’s bladder
should be emptied; ultrasonography (x-ray
only if necessary) is used to avoid trauma
from the needle
• Post procedure, monitor for signs and

symptoms of hemorrhage, labor, premature
separation of placenta, fetal distress,
amniotic fluid embolism, infection,
inadvertent injury to maternal
intestines/bladder or fetus; RhoGam is
indicated for Rh- mothers
Chorionic villi sampling
-transcervical (or transabdominal) aspiration of
chorionic villi

Chorionic villus sampling (CVS)
• Retrieval and analysis of chorionic villi for
chromosome analysis
• Transcervical or transabdominal; may be done
as early as 5 weeks, but more commonly done
at 8-12 weeks of pregnancy
• Risks: bleeding/ loss of pregnancy; limb
reduction syndrome; infection
• Diagnosis of Sickle cell disease, thalassemia
• diagnosing of genetic disorders comparable to
amniocentesis (except for NTD); preprocedure:
there should be full bladder; ultrasound is used
as in amniocentesis; post procedure:
precautions as for amniocentesis
Percutaneous umbilical blood sampling
(PUBS)
– second- and third-trimester method to aspirate

umbilical cord blood (location identified by
ultrasound) to test for genetic conditions,
chromosomal abnormalities, fetal infections,
hemolytic or hematological disorders

Percutaneous
umbilical blood sampling

Estriol levels
– serial 24-h maternal urine samples or serum

specimens to determine fetoplacental status;
falling levels usually indicate deterioration

Lecithin/ Sphingomyelin ratio (2:1)
– important components of surfactant, a

phosphoprotein that lowers surface tension of
the lungs that facilitates extrauterine expiration

Perinatal Exercises

PRE-EXERCISE POINTERS
1. Always let breath flow freely. Let abdomen
and ribcage expand and compress naturally
as you inhale and exhale.
2. Warm up with gentle stretching before
exercise program - increase blood flow to
muscles and loosen them up.
3. When you finish, take time to relax fully; lie
in comfortable position on floor for 10
minutes with eyes closed; let breathing slow
down.
4. As strength improves, add one repetition of
each exercise until you’re up to 10; also, try
holding positions from 3 to 5 counts.
PRE-EXERCISE POINTERS
5. Do each exercise slowly and thoroughly. Allow
rest between each exercise.
6. Avoid extreme motions like deep lunges or
twisting movements.
7. Avoid lying flat on your back for prolonged
periods; it may become uncomfortable and the
position allows less blood flow to the uterus.
Lying on your side increases blood flow.
8. Think of opportunities for exercises during day;
Kegel’s while standing in line at grocery store,
squatting while peeling potatoes, talking on the
phone, watching television, etc.
9. If there is a prenatal exercise class in your area,
join it. It is fun to get into shape with other
pregnant women. MLNGCeleste, RN, MD 359
A. Tailor Sitting
1. It strengthens the thigh and
stretches the perineal
muscles
2. Done at least 15 min/day
• Sit on floor with thighs apart,
knees bent, legs parallel to
each other, one ankle should
NOT be on top of the other,
push knees gently towards
the floor until you feel the
perineum stretch. Use this
when watching TV, reading or
entertaining friends. Do this
for 15 minutes daily.
360
B. Squatting
1. Helps to stretch muscle
of the pelvic floor.
2. Done at least
15min/day
• When lifting something
from the floor, bend
knees rather than the
back; do not squat on
tiptoes but keep feet
flat on the floor;
incorporate this into
daily activities; practice
for 15 minutes daily
361
C. Pelvic Floor Contractions
(Kegel’s Exercise)
• It is designed to strengthen pubococcygeus
muscle.
• It may lead to increased sexual enjoyment.
• Each is a separate exercise and should be done
3x a day.
1. Squeeze the muscle surrounding the vagina as
if stopping the flow of urine, hold for 3 seconds
then relax. (10x)
2. Contract and relax the muscles surrounding
the vagina as rapidly as possible 10 – 25x
3. Imagine that you are sitting in the bath tub of
water and squeeze muscles as if sucking water
into the vagina. Hold for 3 seconds then relax.
10x MLNGCeleste, RN, MD 362
D. Abdominal Muscle Contractions
1. strengthen the abdominal muscles
2. help prevent constipation
3. may be done as often as she wishes
• Tighten abdominal muscles, then relax and

repeat as often as you can; can be done on lying
or standing position along with pelvic floor
contractions.

E. Pelvic Rocking
1. Helps to relieve backache during pregnancy and

early labor
2. Makes the lumbar spine more flexible
3. Can be done on a variety of positions
The woman arches her back, trying to lengthen

or stretch her spine. She holds the position for
1 minute, and then hollows her back.
- do this at the end of the day (5x)

F. Pelvic Tilt
1. PELVIC TILT – SUPINE
Do daily and after delivery.
Position: Backlying, knees bent.
Exercise: Press small of back against floor by
tightening abdominal muscles and buttocks
muscles.

F. Pelvic Tilt
2. PELVIC TILT – STANDING
Position: Stand with back to

wall, feet about three inches
from base of wall.
Exercise: Tighten stomach and

buttocks and press low back
against the wall so that your
back is touching the wall.
Your knees must be relaxed or
slightly bent to do this.
366
F. Pelvic Tilt
3. PELVIC TILT - ALL FOURS
Position: On hands and

knees.
Exercise:Tighten stomach
muscles and arch back
toward the ceiling. Hold.
Tighten buttocks, pelvic
floor and back muscles
and arch
back to produce hollow.
Hold. 367
G. Sit ups
1. SIT-UPS - Modified
Purpose: Strengthen abdominal
muscles. Good muscle tone is
important for maintaining good
posture, for effective pushing,
and for early return of figure
postpartum.
Position: Backlying, knees bent,

low back flat (pelvic tilt).
Exercise: Lift head and shoulders off floor, reaching hands toward
knees (lift trunk to about 45° angle). Slowly return to starting
position; do not drop back. 368
G. Sit ups
2. OBLIQUE (DIAGONAL)
SIT-UPS - Modified
Purpose: Strengthen
oblique abdominal
muscles.
Position: Backlying, knees

bent, low back flat.
Exercise: As above, but

reach up and across to
the outside of the
opposite knee. 369
H. GLUTEAL / PELVIC FLOOR
SETTING
Position: Backlying, legs straight, ankles crossed,
arms at sides.
Exercise: Pinch buttocks, squeeze pelvic floor

muscles, squeeze thighs together, raise head
off floor.

I. ADDUCTOR LENGTHENING
Position: Sit on floor with legs straight and slightly

apart.
Roll knees outward.
Exercise: Slowly lean body forward towards the

floor with arms stretched out in front of you.
Your knees may bend slightly. Do not jerk or
bounce. Hold forward for 3 to 5 seconds.

SPECIFIC ACTIVITIES
To the pregnant Client
1. Jogging:
Wear good shoes; supportive bra. Keep pelvic floor
muscles strong with Kegel exercises. Jog at a
slower pace, shorter distances, less frequently.
Remember: Increased weight and laxity of

ligaments means more strain on lower body
(lower spine, hip joints, knees, ankles and feet).
Do not overexert yourself.
2. Bicycling and Swimming:

Excellent activities with reasonable limitations.
Don’t push yourself!
3. Tennis, Basketball, other “sudden stop and
start” Activities.
More awkward as bulk increases; listen to your
body and slow down when necessary.
4. Skating, Horseback Riding:

Danger of falling! Advise against. Consult your
obstetrician as needed.
5. Walking:
Most highly recommended for the pregnant
woman; ideal alternative to more strenuous
exercise. Walk uphill, downhill, and at different
speeds.
MLNGCeleste,
373
Patient Teaching:
Consult your obstetrician early in your
pregnancy. In general, you can continue your pre-
pregnant routine of exercising. Stop when
something hurts, or when you become fatigued.
Know your limits, and avoid exercising to the
point of exhaustion. It is generally advised that
you do not begin any new sport or activity during
pregnancy. You may want to taper off your sports
participation during the last few months, but you
may still continue to exercise gently. Avoid
exercising in very hot or humid weather, or at
high altitudes if you’re not used to it.

Psychological and
Physiologic Changes of
Pregnancy
Diagnosis of Pregnancy
• Presumptive signs of pregnancy
• (subjective) – experienced by the woman; (+) suspicion
of pregnancy, not proof, could easily indicate other
conditions
• Amenorrhea
• Nausea/ vomiting
• Breast sensitivity and increased size/fullness
• Fatigue
• Quickening (maternal perception of fetal movement
occurring between 16-20 weeks
• Abdominal (uterine) enlargement
• Skin pigmentation changes (melasma, chloasma, linea
nigra, striae gravidarum)
• Frequent urination
Probable signs of pregnancy – objective, can
be documented by examiner; increased suspicion of
pregnancy but still not the true diagnostic proof
• Serum Laboratory tests (hCG)
• Home pregnancy tests
• Chadwick’s sign (color change of the vagina from pink to
violet)* - presumptive in some references
• Goodell’s sign - softening of the cervix
• Hegar’s sign - Softening of the lower uterine segment
• Ballotement -when LUS is tapped on a bimanual exam, fetus
can be felt to rise against abdominal wall or rebound caused by
the fetus floating away and returning back to its previous
position
• Fetal outline or contour palpated by examiner
• Braxton hicks sign -periodic uterine tightening/ contractions
occurs; painless palpable contractions occurring irregular
interval and felt by the mother as sensation of tightness over
her abdomen
• Sonographic evidence of gestational sac
• Uterine soufflé – a muffed swishing sound over the abdomen
in
union with the mother’s heart beat
• Pregnancy test
- HCG (human chorionic gonadotropin)
- Immunologic test that can detect HCG in
woman’s urine by 2 weeks after missed period;
cannot measure the amount of HCG; false
readings may occur inappropriate timing,
handling error, or some medications

Positive signs of pregnancy
- definite signs of pregnancy; not subjective
data
• Fetal heart separate from the mother’s
(Doppler, auscultation)
• Fetal movements felt by examiner
• Visualization of fetus: fetal outline can be
seen and measured by sonogram

Psychological Tasks
Emotional responses
• Ambivalence
• Grief
• Narcissism
• Introversion vs extroversion
• Body image and boundary
• Stress
• Couvade syndrome – men experience
physical symptoms
• Emotional lability
• Changes in sexual desire
• Changes in the expectant family
MATERNAL ADAPTATIONS
IN PREGNANCY
A.Anatomical
Uterus
•changes in size, structure, and position to become
a thin-walled, muscular abdominal organ capable of
containing the fetus, placenta, and amniotic fluid
•In the early months of pregnancy, growth is partly
due to formation of new muscle fibers and
enlargement of preexisting muscle fibers
•After the first trimester, the increase in size is partly
mechanical due to the pressure of the developing
fetus
•The full-term pregnant uterus and its contents
weigh about 12 lb
Location of the fundus:
12 weeks  at the level of the symphysis pubis
16 weekshalfway between symphysis pubis and
umbilicus
20weeks  at the level of the umbilicus
24 weeks  two fingers above umbilicus
30 weeks  midway between umbilicus and
xiphoid process
36 weeks  at the level of xiphoid process
40 weeks  two fingers below umbilicus,
drops at 34 weeks level
because of lightening
FUNDIC HEIGHT AT VARIOUS AGES OF GESTATION

Contractility:
• Being muscular, the uterus is a highly
contractile organ.
• Beginning on the first trimester, the uterus
undergoes irregular contractions.
• Late in pregnancy, these contractions, known as
Braxton-Hicks, become more intense and
frequent causing some discomfort on the
pregnant woman.
• It is the cause of false labor.

Vagina and external genital organs
enlarge, soften, thicken, and develop blue-violet
hue as a result of increased vasculature
Vaginal secretions become alkaline, causing an
increased risk of vaginitis
Connective tissue loosens in preparation for
labor and delivery
A blue-violet color (Chadwick’s sign) about 6-8
wk

• Cervix
• undergoes increased blood supply, edema, and
hyperplasia of the cervical glands contributing
to:
– Softening (Goodell’s sign) about 6 wk
– Increased friability (bleeds easily after Pap smear
and intercourse)
– Distention of cervical mucosa glands with mucus,
creating a tenacious “mucous plug” that seals the
endocervical canal and inhibiting the ascent of
bacteria and other substances into the uterus

• Isthmus
• During pregnancy, the isthmus softens and
elongates up to 25 mm. It will later form the
lower uterine segment, together with the cervix
• Hegar’s sign  softening of the lower uterine
segment begins as early as 5 weeks gestation
• Ovaries
• No Graafian follicles develop and no ovulation
occurs during pregnancy
• Corpus luteum of pregnancy  the corpus
luteum is the chief source of hormone
progesterone during the first 12 weeks of
gestation. The corpus luteum also produces
estrogen, relaxin, inhibin and sometimes
oxytocin MLNGCeleste, RN, MD 388
• Breasts
• enlarge early in pregnancy, causing progressive
feelings of heaviness, fullness, and tenderness;
the nipple and areola become larger, darker in
color; blood vessels enlarge and become
prominent beneath the skin

Body mass
changes with weight gain; total desirable weight
gain in pregnancy (for average woman) is about
23-28 lb (11-13 kg); 3-4 lb (1.36-1.81 kg) during
the first trimester, followed by an average of
slightly less than one pound per week for the rest
of the pregnancy
1st trimester: 3-4 lbs
2nd trimester: 12-14 lbs
3rd trimester: 8-12 lbs

• Skin
• Pink or reddish streaks (striae gravidarum) may
occur on breasts, abdomen, buttocks, and/or
thighs as a result of fat deposits, which cause
stretching of the skin
• Increased pigmentation can occur on the face as
blotchy brown areas on the forehead an cheeks
(chloasma or “mask of pregnancy”) and on the
abdomen as dark line from the symphysis pubis
(linea nigra)
• Minute vascular spiders may occur
• The umbilicus is pushed outward, and by about
the seventh month its depression disappears
and becomes a darkened area on the abdominal
wall
• Sweat and sebaceous glands are more active
• Musculoskeletal
• Change in the center of gravity, decreased
muscle tone, and increased weight-bearing
cause in accelerated lumbosacral curve, which
may lead to lower back pain and difficulty with
locomotion
• Progesterone – produced relaxation and
increased mobility of the pelvic joints may
cause discomfort and difficulty in walking
• The vertical abdominal muscles may separate
(diastasis recti)

B.Physiological
• Hormonal
• Placental
• Estrogen – enlargement of uterus, breasts,
genitals; growth of glandular tissue, ducts,
alveoli, and nipples of breasts; fat deposition;
increased elasticity of connective tissue; altered
thyroid function; altered nutrient metabolism;
sodium and water retention by kidneys;
hypercoagulability of blood; vascular changes

• Progesterone – development of decidua;
decreased contractility of the uterus; decreased
gastric motility (sphincters relaxed); increased
sensitivity to CO2 in respiratory center;
decreased tone of smooth muscle;
development of secretory portions of lobular-
alveolar system in breasts; sodium excretion

• Human chorionic somatomammotropin and
human placental lactogen; anabolic effect;
insulin antagonist

Pituitary gland
Anterior lobe secretes prolactin hormone

after delivery of the placenta
Posterior lobe secretes oxytocin during labor

and lactation

• Blood
• total blood volume in body increases during
pregnancy by about 30%; normal blood
pressure is maintained by peripheral
vasodilatation
• RBC production increases; WBC count
increases; clotting factors increase while
fibrolytic activity decreases
• Hemoglobin and hematocrit levels decrease
slightly in response to hemodilution
(increased plasma content); hemoglobin <10
g/dL or hematocrit <35% may indicate
anemia

• The increased blood volume creates the need
for the heart to pump more blood through the
aorta (about 50% more blood per minute)
resulting increased heart rate; occasional
palpitations (possibly due to sympathetic
nervous imbalance in the early months of
pregnancy or to intra-abdominal pressure of
the enlarged uterus toward the end of the
pregnancy)

• Respiration
• in the later months of pregnancy, the enlarged
uterus causes the diaphragm to be displaced
upward, putting pressure on the lungs and
causing shortness of breath

• Digestion
• Nausea and vomiting may occur in the first
trimester; vomiting that is excessive or
persists beyond this time (hyperemesis
gravidarum) may require medical
management; appetite usually improves as
pregnancy advances
• Progesterone – induces relaxation of smooth
muscle tone, reduction in total acidity of
gastric juices, and pressure from the growing
uterus may cause heartburn, flatulence, and
constipation

• Aversion or cravings for certain foods or
unusual substances (e.g., pica) may occur
• Carbohydrate metabolism is profoundly
affected to meet growth and development
needs of fetus and the metabolic needs of
mother to support tissue expansion

• The first half of pregnancy
• -Maternal glucose is moved across the placenta
by active transport; causing maternal glucose
levels to fall slightly; her pancreas responds by
decreasing production of insulin
• -Maternal insulin does not cross the placenta
• -By 8 wk the fetus’s own insulin production is
consistent with the amount of glucose received
from the mother

• The second half of pregnancy – the placental
hormones impede the mother’s ability to utilize
insulin; the resulting demand for added insulin
can be met by a normally functioning pancreas

• Urinary system
• Urinary output is increased and has a low specific
gravity; possible tendency to excrete glucose;
reabsorption of sodium and decreased water output
(latter half of pregnancy) is a compensatory
mechanism to maintain increased blood volume
• Ureters become dilated (especially the right ureter)
due to the pressure of the enlarged uterus; the
dilated ureters are unable to propel urine as
efficiently, resulting in stasis of urine and possible
urinary tract infection
• Bladder – urinary frequency may occur early in
pregnancy and later again when “lightening” occurs
as a result of increased pressure on the bladder from
the enlarged uterus

C. Psychological
• First trimester –ACCEPTING THE
PREGNANCY
• maternal ambivalence, even in planned
pregnancy, is usual; there may be some
anticipation and concern related to fears
and fantasies about the pregnancy

• Second trimester
• ACCEPTING THE BABY
• usually increased maternal feelings of physical
and emotional well-being; mother is often
described as self-absorbed and introverted

• Third trimester –PREPARING FOR
PARENTHOOD
• possible new fears related to labor and delivery
and fantasies about the appearance of the
baby; feelings of awkwardness, clumsiness, and
decreased femininity related to changes in body
image

• Paternal reactions – may parallel those of
mother; some may experience physical
symptoms of pregnancy (couvade syndrome)
• Adaptation of siblings – age and experience

related

Promoting Fetal
and Maternal Health
Nursing Process
• Nursing Diagnosis
• AnxietyHealth-seeking behaviors
• Risk for deficit fluid
• Constipation
• Disturbed body image
• Risk for altered sexuality patterns
• Disturbed sleep pattern
• Fatigue
• Risk for fetal injury
Health Promotion During Pregnancy
• Self-care needs
• Bathing
• Breast care
• Dental care
• Perineal hygiene
• Sexual activity
• Exercise
• Sleep
• Employment
• Travel

First-Trimester Discomforts
• Breast tenderness • Hypotension
• Palmar erythema • Varicosities
• Constipation • Hemorrhoids
• Nausea, vomiting • Heart palpitations
and pyrosis • Frequent urination
• Fatigue • Abdominal
• Muscle cramps discomfort
• Leukorrhea
414
• Middle to Late Pregnancy Discomforts

• Backache
• Headache
• Dyspnea
• Ankle edema
• Braxton Hicks contractions

Discomforts associated with pregnancy
1. First trimester
• Nausea and vomiting (“morning sickness”)

related to altered hormone levels and
metabolic changes; advise small snacks of dry
crackers before arising, small feedings of bland
food, milk
• Urinary frequency and urgency without dysuria;
fluid intake should not be restricted
• Increased vaginal discharge; manage with good
hygiene (but no douching) and loose-fitting
cotton underwear; report signs or symptoms of
vaginitis

• Breast soreness due to hormonal changes;
suggest wearing a well-fitting, supportive
brassiere
• Headache due to tension from emotional and
physical stresses at any time during pregnancy;
provide reassurance, suggest relaxation
techniques; inform patient to report persistent
and/or severe episodes

Second and third trimester
• Heartburn may be related to tension and
vomiting in early pregnancy, progesterone-
induced decreased motility and relaxation of the
cardiac sphincter; displacement of the stomach
by the growing uterus; encourage small,
frequent meals and discourage overeating,
ingesting fried/fatty foods, lying down soon
after eating, avoid use of sodium bicarbonate
(would interfere with sodium balance)

• Constipation related to progesterone-induced
hypoperistalsis, compression/displacement of
the bowel by the enlarging uterus, poor food
choices, lack of fluids, and/or iron
supplementation; advise bulk foods, fruits and
vegetables, exercise, and generous fluid intake;
avoid laxatives
• Hemorrhoids due to pelvic congestion related to

pressure from enlarged uterus; suggest
regulation of bowel habits, gentle reinsertion
into rectum with use of lubricant, relief
measures, e.g., ice packs, topical ointments, sitz
baths, lying down with legs elevated
• Uterine contractions (Braxton-Hicks) due to
tension on the round ligaments as a result of
displacement of the uterus; instruct patient to
rest, change position or activity
• Backache due to increased spinal curvature;

educate the patient on the importance of
good posture
• Faintness related to vasomotor lability or

postural hypotension; instruct the patient to
use slow, deliberate movements when rising,
avoid prolonged standing and warm, stuffy
environments; elastic hose may be needed

• Leg cramps related to pressure on the nerves
supplying the lower extremities aggravated by
poor peripheral circulation or fatigue; instruct
the patient to increase calcium and decrease
phosphorus intake; encourage dorsiflexion of
feet
• Ankle edema related to decreased venous

return from lower extremities, instruct the
patient to avoid wearing anything that
constricts blood flow, elevate legs when sitting
or resting, and dorsiflex feet when sitting or
standing for any length of time; medical
management if edema persists in AM, is
pitting, involves the face, or associated with
elevated BP, proteinuria, persistent headaches
• Varicosities of extremities or vulva related to
uterine compression of venous return,
increased vein wall distensibility from
progesterone-initiated relaxation, or inherited
tendency; suggest elevating legs frequently,
avoid sitting with legs crossed, standing/sitting
for long periods of time, or wearing constrictive
clothing; support/elastic stockings may be
helpful.

DISCOMFORTS OF PREGNANCY
Assessment Nursing Considerations
May occur any time of day
Nausea and vomiting (morning
Eat dry crackers on arising
sickness)
Eat small, frequent meals
Bulk foods, fiber
Constipation, hemorrhoids
Generous fluid intake
Increase calcium intake
Leg cramps
Flex feet, local heat
Well-fitting bra
Breast soreness
Bra may be worn at night
Emphasize posture
Backache Careful lifting
Good shoes
Small, frequent meals
Antacids – avoid those containing phosphorous
Heartburn
Decrease amount of fatty and salty foods
Slow, deliberate movements

Dizziness Support stockings
Vena cava or supine hypotensive syndrome

Vertigo, light-headedness
Turn on left side
Kegel exercises
Urinary frequency Decrease fluids before bedMLNGCeleste, RN, MD
Report signs of infection 423
DANGER SIGNS OF PREGNANCY
SIGN POSSIBLE CAUSE
Swelling of face. fingers; legs Hypertension of pregnancy, thrombophlebitis

(for leg swelling)
Headache, continuous and severe Hypertension of pregnancy
Blurring of vision Hypertension of pregnancy
Abdominal/ chest pain Ectopic pregnancy, uterine rupture, pulmonary embolism
Vaginal bleeding Placental problems (previa, abruption, premature

separation)
Vomiting, persistent Infection (also with fever and chills), hyperemesis

Gravidarum
Visual changes Hypertension of pregnancy
Escape of vaginal fluids Premature rupture of membrane
Others: change or decrease in movements; dysuria

fetal MLNGCeleste, RN, MD 424
Preparing for Labor
• Lightening
• Show
• Rupture of membranes
• Excess energy
• Uterine contractions

Promoting Nutritional Health
During Pregnancy
THE FOOD PYRAMID
Maternal Diet and Infant Health
• Recommended weight gain
• Components of healthy nutrition
• Calorie needs
• Protein needs
• Fat needs
• Vitamin needs

Total desirable weight gain in pregnancy
(for average woman)
•about 23-28 lb (11-13 kg)
•3-4 lb (1.36-1.81 kg) during the first trimester,
followed by an average of slightly less than one
pound per week for the rest of the pregnancy
1st trimester: 3-4 lbs
2nd trimester: 12-14 lbs
3rd trimester: 8-12 lbs

• Mineral needs
• Calcium and phosphorus
• Iodine
• Iron
• Fluoride
• Sodium
• Zinc

• Fluid needs
• Fiber needs
• Foods to avoid
• Alcohol
• Caffeine
• Artificial sweeteners
• Weight loss diets

• Nutritional status
1. Weight gain should be within expected parameters
2. increased nutrient requirements
a. Calories – 300 kcal/d; may need adjustment for

prepregnant under/overweight
b. There should be no attempt at weight reduction during

pregnancy
c. Carbohydrates – needed to prevent unsuitable use of

fats/proteins for added energy needs; important to avoid
“empty” calorie sources
d. Proteins to 60 g/d; additional increase for

adolescent/multiple pregnancies; efficient use of requires
complete protein (contains all essential amino acids; animal
sources) or complemented with other protein sources, e.g.,
legumes, grains, nuts
e. Iron – to a total of 30 mg/d of elemental iron;
usually requires supplement
f. Calcium to 1,200/d; best obtained from dairy

products; if milk is disliked or poorly tolerated,
calcium supplement may be necessary
g.Sodium – should not be restricted without

serious indication; excess should be discouraged
3. 24-h recall/diet diaries may be used to

evaluate high-risk woman

RDAs for Pregnant Women
(Recommended Dietary Allowances)
• Calories 2,500 kcal • Water-soluble Vitamins
• Protein 60 g Ascorbic Acid (Vit C) 75 mg
Folic Acid 400 μg
• Minerals Niacin 17 mg
Calcium 1,200 mg Riboflavin 1.6 mg
Phosphorous 1,200 mg Thiamine 1.5 mg
Iodine 175 μg Vitamin B6 2.2 μg
Iron 30 mg Vitamin B12 2.2 μg
Zinc 15 mg
• Fat-soluble vitamins
Vitamin A 800 μg
Vitamin D 10 μg
Vitamin E 10 μg
436
Assessment: Nutritional Health

Assessment: Nutritional Health

Preparation for
Childbirth and Parenting
CHILDBIRTH PREPARATION CLASSES
• Bradley
• Dick-Read
• Lamaze Method
• Leboyer Method

CHILDBIRTH PREPARATION CLASSES
1. Bradley (Partner-Coached) Method
• stresses the important role of the husband
during pregnancy, labor and early newborn
period
• woman uses muscle toning exercises
• limits or omits food that contain preservatives,
animal fat and high salt content
• abdominal breathing exercise
• woman is encouraged to walk during labor
• use of dissociation technique

2. Dick-Read Method
• tension (psychic and muscular) is aroused by
fear and anticipation of pain
• sympathetic stimulation brought about by fears
causes contraction of the circular muscle of the
cervix
• prenatal courses and training reduce fear,
educate and boost self-confidence
• Covers: fetal development and childbirth; pain
relief methods; muscle strengthening exercises;
breathing techniques; physical and emotional
health for children; mother gets emphatic
understanding from partner, nurse, physician
• fear >>> tension >>> pain
• abdominal breathing contraction
3. Lamaze Method
(Psychoprophylactic method)
• based on stimulus – response conditioning
(Pavlov Theory of Classical Conditioning) where
unfavorable responses are replaced by
favorable conditioned responses
• high level of activity can excite higher brain
centers to inhibit other stimuli as pain
• woman is taught to replace responses of
anxiety, fear and loss of control with more
useful activity

• Conscious relaxation
• Cleansing breath
• Conscious controlled breathing
• Effleurage
• Focusing
• Second-stage breathing

• Covers: practice of breathing techniques
during labor; controlled perception;
relaxation of involved muscles; mouthing
silently words or songs with rhythmical
tapping of fingers; supportive person nearby
in a calm environment
• Use 3 Gate Control Method of pain relief
»education and relaxation
»use of imagery and focusing
(breathing patterns)
»conditioned reflex

4. Leboyer Method
• The contrast of intrauterine environment and

the external world causes infant to suffer
psychological shock at the time of delivery
• Gentle controlled delivery
• Covers: Relaxing the craniosacral axis by
supporting the head, neck and sacrum
• Restoring body heat loss by warm bath
• Allowing infant to breathe spontaneously
• Delaving cutting of cord to permit placental
blood flow
• Bonding mother and infant by skin to skin
contact
• Conscious Relaxation – learning to relax muscles
deliberately
• Cleansing Breath – woman breathes in deeply
and exhales deeply
• Consciously Controlled Breathing (Set breathing
Patterns)
Level 1 – full respiration, 6 – 12cpm,
early contraction
Level 2 – lighter, 40cpm, 4-6cm dilated
Level 3 – more shallow, 50 - 70cpm,
transition contraction
Level 4 – pant blow pattern, 3-4 quick
breaths then forceful expiration
Level 5 – continuous chest panting (60cpm),
strong contraction and 2nd stage
of labor MLNGCeleste, RN, MD 448
• Leboyer method
• Birthing room is darkened
• Soft music
• Infant placed immediately into a warm-water
bath
• Hydrotherapy and water birth

Caring for a Woman
During Vaginal Birth
LABOR AND DELIVERY
• Labor is a process whereby with time regular
uterine contractions bring about progressive
effacement and dilatation of the cervix,
resulting in the delivery of the fetus and
expulsion of the placenta.
Critical factors affecting the process of labor:

• Passage
• Passenger
• Power

THEORIES OF LABOR ONSET
1. Uterine Stretch Theory – Any hollow muscular

organ when stretched to the capacity will
contract and empty
2. Oxytocin Theory – Increased production of

oxytocin by the anterior pituitary increases as
pregnancy nears term while production of
oxytinase by the placenta decreases

3. Progesterone Deprivation Theory – as
pregnancy nears term, progesterone level
drops, hence uterine contraction occurs
4. Prostaglandin Theory – when pregnancy
reaches term, the fetal membranes produces
high levels of arachidonic acid
5. Theory of the aging Placenta – as the placenta
ages it becomes less efficient

Components of Labor
• Passage
• Passenger
• Power
• Psyche

I. Passage (maternal)
– size and type of pelvis, ability of the cervix to
efface and dilate, and distensibility of vagina
and introitus
• Pelvis – the bony ring through which the fetus

passes during labor and delivery; consists of
four united bones (two hip or innominate
bones, the sacrum, and the coccyx) between
the trunk and thighs
• Measurements – may be obtained by internal

and external pelvic examination (using
pelvimeter), x-ray pelvimetry (used rarely in
pregnancy and only late in third trimester or in
labor), and ultrasound MLNGCeleste, RN, MD 456
Pelvic types:
a. Gynecoid – classic female pelvis inlet, well
rounded (oval); ideal for delivery
- most ideal for childbirth (50% of women)
b. Android – resembling a male pelvis, narrow and
heart-shaped; usually requires cesarean section
or difficult forceps delivery (20% of women)
c. Platypelloid – flat, broad pelvis; usually not
adequate for vaginal delivery (5% of women)
d. Anthropoid – similar to pelvis of anthropoid
ape; long, deep, and narrow; usually adequate
for vaginal delivery (25% of women)
II. Passenger (fetal)
• Size – primarily related to fetal skull
• Fetopelvic relationships
• Lie – relationship of spine of fetus to spine of
mother;
longitudinal (parallel)
transverse (right angles)
oblique (slight angle off a true transverse
lie)

460
Presentation
• part of fetus that presents to (enters)
maternal pelvic inlet
– Cephalic/vertex – head presentation
(>95% of labors)

MLNGCeleste,
462
Breech presentation
• Complete – flexion of hips and knees
• Frank (most common) – flexion of hips and
extension of knees
• Footling/incomplete – extension of hips and
knees

Attitude/ habitus
• relationship of fetal parts to each other;
usually flexion of head and extremities on
chest and abdomen to accommodate to
shape of uterine cavity
• Vertex – head is maximally flexed
• Military – head is partially flexed
• Brow – head is partially extended
• Face – head is maximally extended

Position
- relationship of fetal reference point to mother’s
pelvis
Fetal reference point

• Vertex presentation – dependent upon
degree of flexion of fetal head on chest; full
flexion–occiput (O); full extension–chin (M);
moderate extension–brow (B)
• Breech presentation – sacrum (S)
• Shoulder presentation – scapula (SC)

Position
• Relation of the presenting part to a specific

quadrant of a woman’s pelvis
• Right anterior
• Left anterior
• Right posterior
• Left posterior

• Maternal pelvis is designated per her right/left
and anterior/posterior
– Expressed as standard three letter
abbreviation; e.g., LOA = left occiput anterior,
indicating vertex presentation with fetal
occiput on mother’s left side toward the
front of her pelvis
– Fetal position reflects the orientation of the

fetal head or butt within the birth canal.

• Anterior Fontanel
The bones of the fetal scalp are soft and meet at "suture
lines." Over the forehead, where the bones meet, is a
gap, called the "anterior fontanel," or "soft spot." This
will close as the baby grows during the 1st year of life,
but at birth, it is open.
• The anterior fontanel is an obstetrical landmark because
of its' distinctive diamond shape. Feeling this fontanel
on pelvic exam tells you that the forehead is just
beneath your fingers.
• Early in labor, it is usually difficult (if not impossible) to
feel the anterior fontanel. After the patient is nearly
completely dilated, it becomes easier to feel the
fontanel.
• When attaching a fetal scalp electrode, it is better to not
attach it to the area of the fontanel.

• Posterior Fontanel
The occiput of the baby has a similar obstetric
landmark, the "posterior fontanel."
• This junction of suture lines in a Y shape that is
very different from the anterior fontanel.
• In cases of fetal scalp swelling or significant
molding, these landmarks may become
obscured, but in most cases, they can identify
the fetal head position as it is engaged in the
birth canal.

472
Left occiput anterior (LOA)

Right occiput anterior
(ROA)

Left occiput transverse
(LOT)

Right occiput transverse
(ROT)

Occiput posterior
(OP)

Occiput Anterior
(OA)

Left occiput posterior (LOP)

Right occiput posterior (ROP)

FETAL POSITION

Station
- level of presenting part of fetus in
relation to imaginary line between
ischial spines (zero station) in midpelvis
of mother
• –5 to –1 indicates a presenting part above
zero station (floating); +1 to +5, a
presenting part below zero station
• Engagement – when the presenting part is
at station zero

STATION or DEGREE OF ENGAGEMENT

III. Power – force expelling the
fetus and placenta
1. Primary – involuntary uterine
contractions
• Three phases
• Increment – steep crescent slope from
beginning of a contraction until its peak
• Acme/peak – strongest intensity
• Decrement – diminishing intensity

Characteristics of contractions
• 1. Frequency – time frame in minutes from the
beginning of one contraction to the beginning of the
next one; frequency of less than every 2 min should be
reported
• 2. Duration – time frame in seconds from the beginning

of a contraction to its completion; more than 90 s should
be reported because of potential risk of uterine rupture
or fetal distress
• 3.Intensity – the strength of a contraction at acme; may

be assessed by subjective description from the woman,
palpation (mild contraction would feel like the tip of the
nose, moderate like the chin, strong like the forehead),
or electronic intrauterine pressure catheter (IUPC)

2. Secondary – voluntary bearing-down efforts
• Psychological state of the woman – fear and

anxiety may lead to increased perception of
pain and impede progress of labor;
preparation and support for childbirth may
enhance coping efforts
• Preparation for childbirth education about
the birthing process and methods to
decrease discomfort and tension
• Relaxation of voluntary muscles
• Distraction, focal point, imagery
• Breathing techniques with each contraction

• a.Always begin and end with “cleansing” or
“relaxing” breath (inhale deeply through nose
and exhale passively through relaxed, pursed
lips)
• b.Hyperventilation – may cause maternal
respiratory alkalosis and compromise fetal
oxygenation; characterized by light-
headedness, dizziness, tingling of fingers
and/or circum-oral numbness; managed by
having woman breathe into her cupped hands
or a paper bag
• Support person/”coach” should be involved in
the formal preparation
• Position (maternal)
• Side-lying enhances blood flow to the utero-
feto-placental unit and maternal kidneys
• Upright (standing, walking, squatting) enlists
gravity to aid in fetal descent through the birth
canal
• Frequent changes relieve fatigue and improve
circulation

• Cardinal mechanisms/ movements of
labor in vertex presentation
• usually flow smoothly and often overlap; failure
to accomplish one or more usually requires
obstetrical intervention
(ED FIrE ErE)

Cardinal mechanisms/ movements of labor
in vertex presentation
• Engagement*
• Descent
• Flexion
• Internal rotation
• Extension
• Restitution and external rotation
• Expulsion
• Engagement - movement of the presenting part
below the plane of the pelvic inlet
• Descent – progress through the maternal pelvis;
continuous throughout labor
• Flexion – as a result of resistance from maternal
pelvis and musculature, the head flexes so that a
smaller diameter enters pelvis
• Internal rotation – head rotates from occiput
transverse or oblique position (usual position as
it enters the pelvis) to anterior/posterior at
pelvic outlet; head is under symphysis pubis and
neck is twisted

• Extension – the head is moved backward as it
proceeds under the symphysis pubis and
baby is born by extension over the perineum
• Restitution and external rotation –
movement of head to align itself with face
and shoulders (restitution) and then rotation
bringing shoulders into anteroposterior
diameter appears as one movement
• Expulsion – first the anterior shoulder under
the symphysis pubis, then the posterior
shoulder over the perineum, followed rapidly
by the rest of the body; time of birth is
recorded at this time

Signs of Labor
• Preliminary signs of labor
• Lightening
• Increase in level of activity
• Braxton Hicks contractions
• Ripening of the cervix

Signs of Labor
• Signs of true labor
• Show

Signs and symptoms of labor:
1. Impending – may begin several weeks prior to

labor
• Lightening “the baby dropped”
• settling of uterus and fetal presenting part into
pelvis
• sensation of decreased abdominal distention
• Increase Braxton-Hicks contractions
• mild, intermittent, irregular, abdominal
contractions
 decrease/disappear with activity

• May be heightened anxiety, and anticipation,
fatigue
• Weight loss of about 2-3 lb 3-4 d before onset of
labor; related to changes in estrogen and
progesterone levels
• Increased vaginal mucus discharge
• Fetal movements may appear less active
• May be episodes of false labor

2. Onset
• Expulsion of mucous plug; pink/brown-tinged discharge
(bloody show)
• Regular contraction increasing in frequency, duration,
and intensity
• Spontaneous rupture of membranes (SROM) may occur
before or during
• Check FHR by auscultation for 1 min and with next
contraction
• May be a gush or trickle; report strong/foul odor
(infection), meconium-stained (in vertex presentation,
may indicate fetal anoxia) or wine-colored (indicative of
premature separation of placenta)

• Questionable leakage of amniotic fluids
should be tested for alkalinity to
differentiate from urine:
– Nitrazine tape turns blue/gray/green
(alkaline); urine (acidic) does not change
the yellow color
– A mixture of cervical mucus and amniotic
fluid dried on a slide looks like crystallized
ferns by microscopic examination

Cervical changes
• Effacement – thinning and shortening of the
cervix during late pregnancy and/or labor;
measured in percentages (100% is fully effaced)
• Dilation – opening and enlargement of the

cervical canal; measured in centimeters 0-10
cm (10 cm is fully dilated)

EFFACEMENT AND DILATION OF CERVIX

TRUE VERSUS FALSE
LABOR
True False
Contractions – Contractions –
regular with irregular with
increasing usually no change
frequency in frequency,
(shortened duration, or
intervals), intensity
duration, and
intensity
Discomfort Discomfort is
radiates from usually
back around the abdominal
abdomen
Contractions do Contractions may
not decrease lessen with
with rest activity or rest
Cervix Cervical changes
progressively do notMLNGCeleste,
occur RN, MD 503
effaced and
DIVISIONS OF LABOR/ FRIEDMAN’S CURVE

Stages of Labor
• First stage
• Latent phase
• Active phase
• Transition phase

Stages of Labor
• Second stage
• Period from full dilatation and cervical
effacement to birth of the infant
• Third stage
• Placental separation
• Placental expulsion

Friedman’s Division of Labor
Stages of Labor:
First stage (dilating/ Cervical stage) – from onset of
regular contraction to full cervical dilation
AVE: 13-18 h for nulliparas
8-9 h for multiparas
A. Latent phase (0-4 cm) – the cervix begins effacing

and dilating and contractions become increasingly
stronger and more frequent
DURATION: nulliparas 7-10 h
multiparas 5-6 h

B. Active phase (5-7 cm) – more rapid dilation of
cervix and descent of presenting part
DURATION: approximately 3-4 h for both
C. Transition (8-10 cm) – contractions may be

every 1.5 to 2 min and last 60-90sec
DURATION: should not > 3 h for nulliparas
1 h for multiparas

• May be accompanied by irritability and
restlessness, hyperventilation, and dark heavy
show, as well as leg cramps, nausea/vomiting,
hiccups, belching
• Possible rectal pressure creating a desire to
push; should discourage before full dilation
because it may cause maternal exhaustion
and cervical and fetal trauma

• * Monitor vital signs and FHR
• *Provide comfort measures (ambulate if
tolerated and if BOW is not ruptured yet; side
lying is usually most comfortable, sacral
pressures, back rubs)
• *Breathing technique during transition phase:
Take a deep breath and exhale slowly and
completely. At beginning of contraction, take a
fairly deep breath. Then engage in shallow
breathing. If there is an urge to push, puff out
every 3rd, 4th, or 5th breath. Take deep breath
at the end of contraction.

2. Second stage (stage of expulsion) – from
complete dilation of cervix to delivery of
the baby
AVE: 2 h for nulliparas
20 min for multiparas
Contractions are now severe, lasting 60-
90sec at 1.5 to 3 min intervals

• Bearing down/pushing increases intra-
abdominal pressure from voluntary contraction
of maternal abdominal muscles and pushes the
presenting part against the pelvic floor, causing
a stretching, burning sensation and bulging of
the perineum; “crowning” occurs when the
presenting part appears at the vaginal orifice,
distending the vulva
• Timing of transfer to delivery room
• Nulliparas – during second stage when the
presenting part begins to distend the perineum
• Multiparas – at the end of first stage when the
cervix is dilated 8-9 cm

• Third stage (placental stage) – from delivery
of the baby to delivery of the placenta; if more
than 30 min, placenta is considered retained
• AVE: < 30mins
• Separation of placenta from the uterine wall
evidenced by a change in the fundus from
discoid to globular shape as it becomes firm
and rises in the abdomen, a sudden
gush/trickle of blood and lengthening of the
umbilical cord
• Expulsion of the placenta through the vagina
by uterine contractions and pushing by
mother or by gentle traction on the umbilical
cord
Placental delivery make take 5-10 minutes
(maximum 30 minutes) Either by
• Duncan – margin of the placenta separates first
and the dull, red, rough maternal surface
emerges from from the vagina first (dirty
presentation)
“dirty by Duncan”
• Schultze – center portion of the placenta
separates first and the shiny and glistening fetal
surface emerges from the vagina
“shiny by Schultz”

• *Crede’s maneuver – gentle pressure on the
contracted uterine fundus (never on a
noncontracted uterus; uterus may evert and
lead to hemorrhage)
• Contraction of the uterus following delivery

controls uterine hemorrhage and produces
placental separation: if necessary, Pitocin
(oxytocin) or Methergine (methylergonovine
maleate) may be administered to help contract
the uterus

• Fourth stage – immediate recovery period
from delivery of placenta to stabilization of
maternal systemic responses and contraction
of the uterus
• DURATION: from 1 to 4 h
– Mother begins to readjust to non-pregnant state
– Areas of concern include discomfort due to
contraction of uterus 9after pain) and/or
episiotomy, fatigue or exhaustion, hunger, thirst,
excessive bleeding, bladder distention, parent-
infant interaction

STAGES OF LABOR
STAGE PHASE Dilatation Duration/Interval Intensity
First Phase1- 0-4 cm 10-30 sec/ 5-30 Mild to
Stage Latent min moderate
Phase 2- 5-7 cm 30-40 sec/ 3-5 Moderate
Active min to strong
Phase 3- 8-10 cm 45-90sec/ 2-3 min strong
Transition
Second From full cervical dilatation (10 cm) up to the
Stage expulsion of the fetus
-in the later phase of this stage, station becomes (+);
+4 to birth
-contraction becomes 1-2 minutes apart; fetal head
visible; increased urgency to bear down
3rd Placental Delivery- sudden gush of blood,
Stage lengthening of the cord, rising of the fundus,
globular uterus
4th First 4 hours after delivery of the placenta (monitor
Stage VS, fundus and lochia until stable)MLNGCeleste, RN, MD 517
Maternal and Fetal Responses to Labor
• Danger signs of labor - fetal

• Heart rate
• Meconium staining
• Hyperactivity
• Fetal acidosis

Maternal and Fetal Responses
• Danger signs of labor - maternal

• Blood pressure
• Abnormal pulse
• Inadequate or prolonged contractions
• Pathologic retraction ring
• Abnormal lower abdominal contour
• Apprehension

Maternal and Fetal Assessment
• Assessment of stage one
• History
• Physical exam
• Leopold’s maneuvers
• Vaginal exam
• Pelvic adequacy

Assessment
• Laboratory analysis
• Blood
• Urine
• Length
• Intensity
• Frequency

LOCATING FETAL HEART SOUNDS BY FETAL POSITION

Electronic Monitoring
• External and Internal Monitoring
• Telemetry
• FHR and uterine contractions
• FHR patterns
• Baseline FHR
• Periodic changes

Fetal Heart Monitoring
• Labor is stressful for the fetus; therefore,
continual assessment of fetal well- being
through fetal heart rate monitoring is essential.
• Fetal well-being is determined by the response
of the fetal heart rate to uterine contractions.
• Fetal anoxia resulting from stressful labor must
be avoided to prevent intrauterine death or
neurological damage.

NORMAL FHR: 120 – 160 bpm
Fetal monitoring during labor and delivery
Methods
1. Periodic auscultation of the fetal heart by fetoscope
(stethoscope adapted to amplify sound or Doptone
(ultrasound stethoscope) during contractions and for
30sec beyond; best heard over fetal back
Electronic fetal monitoring (EFM) – continuous monitoring
providing audio and visual recordings as well as tracing
strips
External – indirect, noninvasive method using a lubricated
(water-soluble gel) ultrasound transducer attached to
the abdomen
Internal – small electrode attached to the fetal scalp;
indicated for high-risk maternity patient, problematic
labor, or with oxytocin use; requires ROM, cervical
dilation of at least 2 cm, and presenting part can be
reached
Alterations in fetal heart rate
a. Normal – 120-160 BPM

b. Tachycardia (>160 BPM) – associated with
prematurity, maternal fever, fetal activity, or
fetal hypoxia/infection, drugs; if continued for
an hour or more, or accompanied by late
deceleration, indicates fetal distress
c. Bradycardia (<120 BPM) – associated with fetal
hypoxia, maternal drugs/hypotension,
prolonged cord compression, congenital heart
lesions; persistent bradycardia or persistent
drop of 20 beats per min below baseline may
indicate cord compression or separation of the
placenta MLNGCeleste, RN, MD 527
Variability – beat-to-beat fluctuations;
measured by internal EFM only
a. Normal (6-25 BPM) – significant indicator of

fetal well-being
b. Absent (0-2 BPM) or decreased (3-5 BPM) may
be associated with fetal sleep state, fetal
prematurity, reaction to drugs, congenital
anomalies, hypoxia, acidosis; if persists for
more than 30 min is indicator of fetal distress
c. Increased (>25 BPM) – significance is not known
d. Loss of the baseline (beat-to-beat variation) or
“smoothing out” of the baseline is often
prelude to infant death
Periodic changes
1.Accelerations – rise above baseline followed by a return;
usually in response to fetal movement or contractions
2.Decelerations – fall below baseline followed by a return
Early – occurs before peak contraction; most often uniform
mirror image of contraction on tracing; associated
with head compression, commonly in second stage
with pushing
Late – onset after the peak with slow return to baseline;
indicative of fetal hypoxia because of deficient
placental perfusion
Variable deceleration – transient U/V/M-shaped reduction
occurring at any time before, during, or after
contraction; indicative of cord compression, which
may be relieved by change in mother’s position;
ominous if repetitive, prolonged, severe, or has slow
return to baseline
• Nursing interventions
– None for early decelerations
– For late decelerations (at the first sign of
abnormal tracing) – position mother left
side-lying (if no change, move to other
side, Trendelenburg or knee/chest
position); administer oxygen by mask, start
IV or increase flow rate, stop oxytocin if
appropriate; if the pattern persists, fetal
scalp blood sampling for acidosis (pH >7.25
is normal, 7.20-7.24 is considered
preacidotic – repeat in 10-15 min; 7.2 or
less indicates serious acidosis; prepare for
cesarean section)

Fetal Heart Rate Patterns Indicative of… Intervention
Tachycardia (>160 bpm) Maternal or fetal infection Depends on the cause
Fetal hypoxia (ominous sign)
Bradycardia (<120 bpm) Fetalhypoxia or stress Place client on her left side
Maternal hypotension after Increase fluids to counteract
epidural initiation hypotension
Stop oxytocin (Pitocin) if in use
Early deceleration Head compression :not ominous None required

(deceleration begins and ends with Vagal stimulation
uterine contraction)
Late deceleration Fetal stress and hypoxia Change maternal position

(HR decreases after peak of Deficient placental perfusion Correct hypotension
contraction and recovers after Supine position Increase IV fluid rate as ordered
contraction ends) Maternal hypotension Discontinue oxytocin
Uterine hyperstimulation Administer oxygen as ordered
Variable deceleration Cord compression Change maternal position

(transient decrease in HR anytime Hypoxia or hypercarbia Administer Oxygen
during contraction
Decreased variability Fetalsleep cycle Depends on the cause

Depressant drugs
Hypoxia
CNS anomalies
Nursing Care: First Stage
• Respect contraction time
• Change positions
• Voiding and bladder care
• Support
• Pain management

Nursing Care: Second Stage
• Preparing for birth
• Positioning for birth
• Pushing
• Perineal cleaning
• Episiotomy
• Birth
• Cutting and clamping the cord

Perineal cleaning

EPISIOTOMY

RITGEN’S MANEUVER

A child is considered born when the whole body is delivered.

UMBILICAL CORD CLAMP APPLIED TO CORD
541
Providing Comfort During
Labor and Birth
Intapartal nursing management
• Stage 1
• Maternal
• Monitor vital signs, fluid and electrolyte balance,
frequency, duration, and intensity of uterine
contractions and degree of discomfort (hourly, at
minimum); urine protein and glucose with every
voiding; laboratory results; preparedness; ROM
• Provide comfort measures – e.g., positioning,
back massage/effleurage (light abdominal
stroking in rhythm with breathing during a
contraction to ease mild/moderate discomfort),
warm/cold compresses, ice chips

1. Support coping measures – reassure,
explain procedures, reinforce/teach
breathing techniques, relaxation, focal
point
2. Assist support person
• Fetal – monitor status

• Stage 2
• Maternal
– Monitor physical status; assess progress of
labor, perineal and rectal bulging, increased
vaginal show
– Assist in techniques to foster expulsion –
encourage bearing down focus on vaginal
orifice (discourage breath holding for more
than 5sec), position squatting, side-lying,
Fowler’s as appropriate
– Provide comfort measures; support coping
measures; assist support person

• Fetus/neonate
• Monitor fetal heart rate and regularity
• Provide immediate neonatal care
– Assist M.D./nurse/midwife in newborn care
– Please refer to ESSENTIALS OF NEWBORN
CARE

• Stage 3
• Maternal – observe for signs and symptoms of placental
separation; assess amount of blood loss; monitor blood
pressure, pulse, and fundus frequently
• Neonate
• Apgar scores at 1 and 5 min to evaluate condition at
birth
– Based on five signs: heartbeat, respiratory effort,
muscle tone, reflex irritability, color
– Each sign rated 0-2 2 is top score); all the scores are
added for total score
– 7-10 (good condition) should do well in normal
neonatal nursery; 4-6 (fair condition) may require
close observation; 0-3 (extremely poor condition)
resuscitation and intensive care are acquired

Assessment for Well-Being
• Apgar scoring
• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability
• Color

APGAR SCORE
0 1 2
Cardiac tone Absent Slow (<100 BPM) Normal (>100 BPM)
Respiration Absent Slow, irregular Good cry
Muscle tone Flaccid Some flexion Active
Reflexes No response Cry Vigorous cry
Color Blue, pale Body pink, Completely pink
extremities blue

• Maintain temperature – minimize exposure to
environmental heat loss (evaporation,
radiation, conduction, convection); skin-to-
skin with mother or at 36.4°C skin
temperature
• Weigh and measure infant
• Place identification band on infant
• Record time of first void and stool
(meconium) after delivery; monitor physical
status

• Initiate parent-child interaction
• Instill prophylactic eye drops/ointment –
legally required to prevent conjunctival
gonococcal infection that could lead to
blindness in the neonate; 1% silver nitrate or
0.5% erythromycin
• Administer intramuscular vitamin K – for first
34 d of life the neonate is unable to
synthesize vitamin K, which is necessary for
blood clotting and coagulation

• Stage 4
• Monitor maternal blood pressure and pulse;
uterine contractility tone and location; amount
and color of lochia, presence of clots; condition
of episiotomy every 15 min x 4
• Monitor bladder function
• Provide comfort
• Evaluate parenteral interaction

FOURTH STAGE OF LABOR
First 1-2 h Nursing Considerations
Vital signs (BP, pulse) q 15 min Follow protocol until stable
q 15 min Position – even to 1 cm/finger breadth above the
umbilicus for the first 12 h, then descends by one
Fundus
finger breadth each succeeding day, pelvic usually by
day 10
q 15 min Lochia (endometrial sloughing) – day 1-3 rubra (bloody
Lochia with fleshy odor; may be clots); day 4-9 serosa
(color, volume) (pink/brown with fleshy odor); day 10+ alba (yellow-
white); at no time should there be a foul odor
(indicates infection)
Urinary Measure first void May have urethral edema, urine retention
Bonding Encouraged interaction Emphasize touch, eye contact
Delivery
1. Normal spontaneous vaginal delivery
• The mother is encouraged not to push as the

head is delivered; the infant cries (or is
encouraged to do so to expand the lungs); if the
cord is encircling the neck (nuchal cord), it is
gently slipped over the head
• Episiotomy (a surgical incision of the perineum)
may be done at the end of the second stage of
labor to facilitate delivery and to avoid
laceration of the perineum
Types of Episiotomy
• Median – rare faulty healing, easier to
make and repair
• Mediolateral – tearing in the anus and
rectum is rare

Classification of Perineal Laceration
• First Degree – involves the perineal mucosa

• Second Degree – involves the muscle of the
perineal body but does not involve the rectal
sphincter
• Third Degree – involves the rectal sphincter but
not the rectal mucosa
• Fourth Degree – involves the rectal mucosa

Operatives deliveries
2.Forceps delivery
forceps - two doubled-curved, spoonlike
articulated blades used to extract the fetal head;
indicated if mother cannot push fetus out or
compromised maternal/fecal status in late
second stage; contraindicated in cephalopelvic
disproportion (CPD)
•

• Classification:
–Outlet – fetal head is on the pelvic floor
–Low – fetal head is below station +2 but
not reached the pelvic floor
–Mid – fetal head is below station 0 but
not reached station +2
–High – fetal head is above station 0

Indications:
• Prolonged second stage (most common)
• Non reassuring EFM strip
• Avoiding maternal pushing
• Breech presentation
Complications
• Maternal – lacerations
• fetal – neonatal – soft tissue
compression or cranial injury

2. Vacuum extractor – delivery with use of
suction device that is applied to the fetal
scalp for traction; used in prolonged second
stage; contraindicated in CPD and
face/breech presentation
Indications:
• Prolonged second stage (most common)
• Non reassuring EFM strip
• Avoiding maternal pushing
• Breech presentation

Complications
• Maternal – lacerations
• fetal – neonatal – cephalhematoma and
scalp laceration, subgluteal hematoma
and intracranial hemorrhage (>10min)

4. Cesarean delivery
(next chapter)

Comfort and Pain Relief
• Support from doula or coach
• Alternative therapies
• Relaxation
• Focusing and imagery
• Breathing
• Herbal preparations

Comfort and Pain Relief
• Pharmacological Measures
• Goals
• Preparation
• Narcotic analgesics
• Intrathecal
• Regional anesthesia

Nursing Care: Promoting Comfort
• Reducing anxiety
• Coping strategies
• Comfort measures
• Positioning
• Childbirth method
• Pharmacologic pain relief

Pharmacological control of discomfort
• Principles of use – minimize pain without

increasing risk to mother or fetus; type of
pain relief is influenced by length of
gestation, mother’s emotional status,
response to pain, previous history with
analgesics or anesthesia, and general
character of labor process

Analgesia – alleviation of the sensation of pain or
the elevation of one’s thresshold for perception of
pain
• Narcotic analgesics – effective for relief of
severe, persistent pain
- with no amnesic effect
- adverse effects: nausea and vomiting, maternal
respiratory depression, neonatal CNS depression
(blocking nerve impulses to the brain) requiring
stimulation or resuscitation at delivery
- cross the placental barrier and affect the
neonate
EX: Meperidine HCl (Demerol); Morphine sulfate

Anesthesia- includes analgesia, amnesia, and
relaxation; abolishes pain perception by CNS
depression
• epidural block –most common; local anesthetic
such as lidocaine or bupivocaine is injected into
the epidural space surrounding the spinal cord;
a catheter is placed for continuous epidural
anesthesia
- - if hypotension occurs, woman should be
placed on her left side; IV rate should be
accelerated as ordered; oxygen support should
be administered if ordered and doctor should
be notified

Regional Anesthesia
• Injection of local anesthesia to block specific
nerve pathways
• Epidural anesthesia
• Nursing care
• Administration
• Spinal anesthesia

Medication for Pain Relief: Birth
• Local anesthesia
• Local infiltration
• Pudendal nerve block
• General anesthesia
• Preparation
• Aspiration of vomitus

• Timing of administration
• 1. Before 5 cm (latent phase) – may retard or
stop labor
• From 5 to 7 cm (early active phase) – may aid
relaxation
• After 8 cm (transition phase) – may result in
respiratory depression requiring resuscitative
measures in sedated neonate
• - Because most medications cross the placental
barrier, FHR is taken frequently before and after
administration of medication

• Obstetrical analgesia – functions through
alleviation of sensation of pain or enhancement
of threshold for pain
• Sedatives/hypnotics – used less frequently than
previously because of incidence of side effects
• Narcotics
– Morphine sulfate – used rarely because of adverse
reactions
– Meperidine hydrochloride (Demerol) – most
commonly used; mother and infant interaction may
be limited in immediate postpartum period because
infant may still be sluggish and less alert
– Alphaprodine (Nisentil) – may be given IV/SC but
never IM because of unpredictability by this route

– Mixed narcotic agonist-antagonist compounds
(Stadol [IM/IV/SC], Talwin [IV/IM] but not SC, which
can cause severe tissue damage) – analgesia while
decreasing side effects but can still produce
respiratory depression, nauseas and vomiting, light-
headedness
– Narcotic antagonist (Narcan) – counteracts
respiratory depressant effects; may be administered
to mother IM/IV 5-15 min prior to delivery or to
neonate IV via umbilical vein immediately after birth
• Note: Narcotic antagonist given to a woman
who is addicted to narcotics may cause
immediate withdrawal symptoms.

• Analgesic potentiator/ataractic (Phenergan,
Largon, Vistaril, Sparine) – tranquilizing effect,
decreasing apprehension and anxiety as well as
the nausea and vomiting associated with many
analgesics; fetal and neonatal problems are rare

• Anesthetics
• Inhalation
– Nitrous oxide and oxygen – used
intermittently with each contraction;
patient is able to cooperate in bearing
down; increased danger of neonatal
depression with continued use after 15-20
min
– Trilline/Penthine – self-administered by
mother with inhaler (under supervision);
may cause maternal and fetal narcotic
depression
• Regional blocks – allow mother to be awake and
participate in process; can increase incidence of
maternal hypotension and fetal bradycardia; need for
forceps delivery, prolonged labor or uterine atony,
necessity for catheterization, and sometimes post spinal
headache
1. Lumbar epidural block –affects the entire pelvis by
blocking impulses at level of T12 through S5; may be
administered continuously through tubing left in
place; incidence of maternal hypotension may be
minimized if 500-1000 ml of IV fluids is infused at a
rapid rate prior to administration and mother is
maintained in side-lying position
• There must be vigilant monitoring of maternal
BP and FHR every 1-2 min x 15 min and every 10-
15 min thereafter MLNGCeleste, RN, MD 582
• Treatment of maternal hypotension includes
– Mild/Moderate – place mother in left lateral
position, increase the rate of IV fluid;
administer oxygen by mask
– Severe/prolonged – place mother in
Trendelenburg position for 2-3 min
2. Caudal – administered during second stage just
before delivery; not commonly used
3. Subarachnoid block/ “saddle block” (nerves from S1
to S4) – anesthetizes perineum, lower pelvis, and
upper thighs; diminishes pushing efforts; high
incidence of maternal hypotension and potential for
fetal hypoxia

3. Spinal block – now used primarily just prior to
cesarean delivery
4. Paracervical block analgesics – injection of an
anesthetic solution into region around cervical area
to relieve pain caused by cervical dilation; thought
to have a depressing effect on infant’s respiratory
center
5. Intravenous anesthesia (Pentothal) – rarely used,
can cause fetal depression, maternal laryngospasm,
vomiting and aspiration, postpartal uterine atony

COMMON ANALGESICS AND ANESTHETICS OF LABOR AND DELIVERY
Medication Side Effects Nursing Considerations
Meperidine hydrochloride Hypotension Increases pain tolerance
(Demerol) Respiratory depression Do not administer within 2 h of
Gastric irritability expected delivery
Constipation
Bradycardia
Constricted pupils
Secobarbitol sodium (Seconal) Drowsiness Sedates
Lethargy Anxiety relief
Respiratory depression
Angioedema
Naloxone hydrochloride Tachycardia IV into umbilicus vein for neonates
(Narcan) Hypertension (0.01 mg/kg)
Tremors Reverses narcotic depression
Thiopental sodium (Sodium Respiratory depression Induction anesthesia for cesarean
pentothal) secretion
Tetraccaine hydrochloride Confusion If subarachnoid space used, keep
(Pontocaine; lidocaine) Tremors patient flat for 6-8 h
Restlessness Regional nerve block
Hypotension Relieves uterine or perineal pain
Dysrhythmias
Tinnitus
Blurred vision
Cesarean Birth
Nursing Care:
Anticipating a Cesarean
• Immediate preoperative care
• Informed consent
• Hygiene
• GI tract preparation
• Baseline intake and output
• Hydration
• Preoperative medication
• Checklist
• Transport
• Role of support person

Nursing Care:
Cesarean Birth
• Intraoperative care
• Anesthesia
• Skin preparation
• Surgical incision
• Types of incisions
• Birth

Nursing Care:
Cesarean Birth
• Postpartal care
• Pain control
• Fluid volume
• Output
• Circulation
• Parenting
• Infection

Cesarean Birth
Birth accomplished through an abdominal incision
into the uterus

Cesarean section
– fetus is delivered through an incision in
anterior abdominal and uterine wall
Indications:
• Cephalopelvic disproportion
• Fetal malpresentation
• non reassuring EFM strip

Complications:
• hemorrhage
• Infection
• Visceral injury
• Thrombosis

Uterine Incisions
1. Low segment Transverse
- incision is made in the non contractile portion
of the uterus
- low chance of uterine rupture, may have trial
of labor
- fetus must be in longitudinal lie
2. Classical
- incision is made in the contractile portion of
the uterus
- risk uterine rupture
- lower segment varicosities and myomas can be
bypassed

Anesthesia in C/S
Most popular:
• Regional block
• Epidural
• Spinal anesthesia
• Because the mother is awake and aware of the
birth of her infant
• When time is of the essence or when an
epidural or spinal cannot be used, general
anesthetic is used.

Scheduled or Unscheduled C/S
• Scheduled Cesarean Birth
- If it is to be a repeat cesarean birth
(eg, cephalopelvic disproportion)
- If labor is contraindicated (eg, complete
placenta previa, hydrocephaly)
- If labor cannot be induced and birth is
necessary
Clients have some time to prepare for the
cesarean birth

• Unscheduled/ Emergency Cesarean Birth
- Usually a result of some difficulty in the labor
process/ failure to progress in labor
- Placenta previa
- Abruptio placenta
- Fetal distress

• Vaginal Birth after Cesarean (VBAC)
- When the reason for the initial cesarean is a
nonrecurring situation such as placenta previa,
prolapsed cord, or breech presentation, the
client may be able to have a vaginal birth with
the next pregnancy
- Low transverse uterine incision: trial of labor is
recommended
- Classic uterine incision: trial of labor is CI

Nursing Care of a Postpartal
Woman and Family
Postpartum
• FROM STAGE 4 UNTIL 6 WEEKS AFTER
DELIVERY

POSTPARTUM ASSESSMENT
B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
S - sex
H - Homan’s sign
E - emotion

BREAST ASSESSMENT
• Breasts – Soft, engorged, filling, swelling,
redness, tenderness.
• Nipples – Inverted, everted, cracked, bleeding,
bruised, presence of colostrum or breastmilk.

Breasts – progress from soft filling with potential
for engorgement (vascular congestion related to
increased blood and lymph supply; breasts are
larger, firmer, and painful)
• Non-nursing woman – suppress lactation
• Mechanical methods – tight-fitting brassiere, ice
packs, minimize breast stimulation
• Nursing woman – successful lactation is
dependent on infant sucking and maternal
production and delivery of milk (letdown/milk
ejection reflex); monitor and teach preventive
measures for potential problems
Nipple – irritation/cracking
• Nipple care – clean with water, no soap, and dry
thoroughly; absorbent breast pads if leaking
occurs; expose to air
• Position nipple so that infant’s mouth covers a
large portion of the areola and release infant’s
mouth from nipple by inserting finger to break
suction
• Rotate breastfeeding positions

Engorgement
• nurse frequently (every ½-3 h) and long enough to
empty breasts completely (evidenced by sucking
without swallowing)
• warm shower or compresses to stimulate letdown
• alternate starting breast at each feeding
• mild analgesic 20 min before feeding and ice packs
between feedings for pronounced discomfort
• Plugged ducts – area of tenderness and lumpiness often

associated with engorgement; may be relieved by heat
and massage prior to feeding

Expression of breast milk
• to collect milk for supplemental feedings
• to relieve breast fullness or to build milk supply
• may be manually expressed or pumped by a
device and refrigerated for no more than 48 h or
frozen in plastic bottles (to maintain stability of
all elements) in refrigerator freezer for 2 wk and
deep freezer for 2 mo (do not thaw in
microwave or on stove)
• Medications – most drugs cross into breast milk;
check with physician before taking any
medication

LACTATION PRINCIPLES
Breast Care – Antepartum Initiating Breast Feeding
and Postpartum
Soap on nipples should be Relaxed position of mother is
avoided during bathing to essential – support
prevent dryness dependent arm with pillow
Nipples can be “prepared” Both breasts should be offered
antepartum by exposure to at each feeding
sun, air, and by wearing Five minutes on each breast is
loose clothing sufficient at first – teach
Redness or swelling can proper way to break suction
indicate infection and should Most of the areola should be
always be investigated infant’s mouth to ensure
proper sucking
Uterus
FUNDAL ASSESSMENT
• Location in relation to umbilicus
• Degree of firmness
• Midline or deviated to one side

ASSESSING THE UTERINE FUNDUS
• The uterus is best evaluated
with the patient in a supine
position and with an empty
bladder.
• The nurse should support
the lower uterine segment
just above the symphysis
pubis with the non-
dominant hand and palpate
the uterine fundus for
degree of involution.
• Fundal descent is measured
in relationship to the
umbilicus in fingerbreadths
or centimeters. 615
• Involution – (uterus reduced to prepregnant
size)
• Fundus – midline, firm
• Position – even to 1 cm/finger breadth above
the umbilicus for the first 12 h, then descends
by one finger breadth each succeeding day,
pelvic organ usually by day 10
• If with deviations, check bladder and have
patient void; if deviations continue, massage
fundus
Bowels
• GI – bowel sluggishness, decreased abdominal
muscle tone, perineal discomfort may lead to
constipation; managed by early ambulation,
increased dietary fiber and hydration, stool
softeners

• After pains – cramps due to uterine
contractions lasting 2-3 d; more common in
multipara and with nursing; may be relieved by
lying on abdomen with small pillow, heat,
ambulation, mild analgesic (if breast feeding, 1 h
before nursing)
• Rubella vaccine – for susceptible woman;
RhoGam as appropriate

BLADDER ASSESSMENT
• Voiding pattern, complete
emptying, pain burning
on urination
• Record first three voids
with the amount and
times voided
• A full bladder displaces
the uterus upwards and
laterally and prevents
contraction of the uterus
= UTERINE ATONY = > risk
of postpartum
hemorrhage.
621
• Elimination
• Urinary – increased output (postpartum
diuresis), urethral trauma, decreased bladder
sensation, and inability to void in the recumbent
position may cause bladder distention,
incomplete emptying and/or urinary stasis
increasing the risk of uterine relaxation and
hemorrhage and/or UTI; monitor I and O
encourage voiding every 24 h (early ambulation
and pouring warm water over perineum);
catheterization may be necessary if no voiding
after 8 h

Lochia
• Lochia – (endometrial sloughing)
– day 1-3 rubra (bloody with fleshy odor; may
be clots)
– day 4-9 serosa (pink/brown with fleshy
odor)
– day 10+ alba (yellow-white); at no time
should there be a foul odor (indicates
infection)

EPISIOTOMY/
PERINEAL ASSESSMENT
• Assessment of the
episiotomy/perineum should
occur with the woman in lateral
Sims (side lying) position.
Use the acronym REEDA
(redness, edema, ecchymosis,
discharge, approximation of
edges of episiotomy) to guide
assessment.
• Even if there is no episiotomy,
the perineum should still be
assessed.
• Unusual perineal discomfort
may be a symptom of
impending infection or
hematoma.
Hemorrhoids ?
625
• Perineum – possible discomfort, swelling,
and/or ecchymosis
• Managed with analgesics and/or topical
anesthetics, ice packs for first 12-24 h and then
20 min sitz baths 3-4 times/d, tightening
buttocks before sitting
• Monitor episiotomy/laceration – teach
techniques to prevent infection, e.g., change
pads on regular basis, peri care (cleaning from
front to back using peri-bottle or surgigator after
each voiding and bowel movement), and sitz
baths

SEX
• Sexual activities – abstain from intercourse until
episiotomy is healed and lochia has ceased
(usually 3-4 wk); may be affected by fatigue,
fear of discomfort, leakage of breast milk,
concern about another pregnancy; assess and
discuss couple’s desire for and understanding
about contraceptive methods; breastfeeding
does not give adequate protection, and oral
contraceptives should not be used during
breastfeeding.

• Psychosocial adjustment
• Attachment/bonding – influenced by maternal
psychosocial-cultural factors, infant health
status, temperament, and behaviors,
circumstances of the prenatal, intrapartal,
postpartal, and neonatal course; evidenced
initially by touching and cuddling, naming, “en
face” positioning for direct eye contact, later by
reciprocity and rhythmicity in maternal-infant
interaction

Psychological Changes
• Phases
• Talking-in
• Taking-hold
• Letting-go

Phases of adjustment
• “Taking in”/dependency (day 1-2 after
delivery) – preoccupied with self and own
needs (food and sleep); talkative and
passive; follows directions and is hesitant
about making decisions; retells
perceptions of birth experience

• “Taking hold”/dependency-
independency (by day 3) – performing
self-care; expresses concern for self and
baby; open to instructions

• “Letting go”/independence (evident by
weeks 5-6) – assuming new role
responsibilities; may be grief for
relinquished roles; adjustment to
accommodate for infant in family

• “Postpartum blues” (day 3-7) – normal
occurrence of “roller coaster” emotions,
weeping, “let-down feeling”; usually
relieved with emotional support and
rest/sleep; report if prolonged or later
onset

Pregnant Adolescent
• Complications
• Pregnancy-induced hypertension
• Iron-deficiency anemia
• Preterm labor

Pregnant Adolescent
• Complications and concerns of labor, birth and
postpartum
• Cephalopelvic disproportion
• Postpartal hemorrhage
• Inability to adapt
• Lack of knowledge

Over Age 40
• Complications
• Pregnancy-induced hypertension
• Complications and concerns of labor, birth and
postpartum
• Failure to progress
• Difficulty accepting event
• Postpartal hemorrhage

Reproductive Life Planning
Reproductive Life Planning
• Includes all decisions an individual or couple
make about having children:
- If and when to have children
- How many children to have
- How children are spaced
- Conception, fertility and counseling

Responsible Parenthood
• A responsible person is a man or woman who

is able and willing to give the proper response
to the demands of a given situation.
• With specific reference to marriage and family

life, the responsible spouse is one who gives
the proper responses to the needs of his/ her
spouse, as well as his own, and of their life
together. Similarly, responsible parents give
proper responses to the needs of their
children.
• Although some people object to the idea, we

tend to equate family planning with responsible
parenthood.
• Family planning refers more specifically to the
voluntary and positive action of a couple to
plan and decide the number of children they
want to have and when to have them.

The concept of family planning includes these
elements:
• Responsibility of parents to themselves and to

each other
• Responsibility to their present and future

children
• Responsibility to their community and country

Purposes of Family Planning
• improvement of health
• promotion of human right to determine
reproductive performance
• relation of demographic change to economic
development

The ultimate goal of family planning is directed
towards:
• Birth spacing, to allow the mothers time to rest

and regain their health before the next
pregnancy
• Birth limitation, when the desired number of

children is reached
• Helping those who do not have children to

have children
Contraceptive
• Any device used to prevent fertilization of
an egg

Considerations:
• Personal values
• Ability to use method correctly
• How method will affect sexual enjoyment
• Financial factors
• Status of couple’s relationship
• Prior experiences
• Future plans
• Contraindications

CONTRAINDICATIONS OF CONTRACEPTIVE USE

Contraceptives
1. Abstinence
• 0% failure rate
• Most effective method to prevent STDs
• Difficult to comply with

Contraceptives
2. Natural Family Planning
• No chemical or foreign material into the
body
• Failure rate of approximately 25%

Contraceptives
Fertility Awareness Methods
• Calendar (rhythm) method
• Basal body temperature
• Cervical mucus (Billings) method
• Symptothermal method
• Ovulation awareness
• Lactation amenorrhea method
• Coitus interruptus

Calendar/ Rhythm
(Natural Family Planning)
• Action – periodic abstinence from

intercourse during fertile period; based on
the regularity of ovulation; variable
effectiveness

Calendar/ Rhythm (Natural
Family Planning)
• Teaching – fertile period may be determined by a
drop in the basal body temperature before and a
slight rise after ovulation and/ or by a change in
cervical mucus from thick, cloudy and sticky
during nonfertile period to more abundant, clear,
thin, stretchy and slippery as ovulation occurs

1. Calendar (rhythm) method
• Entails keeping a day-by-day record of your
cycle for 6 consecutive months
• noting the onset of bleeding as day 1 and the
last day before your next menstrual bleeding as
the final day of your cycle
• This 6 month record will show you your longest
and shortest cycles- from which you can
calculate your FERTILE days


• The first day of menstrual bleeding (day
1 of your period) counts as the first day
of the cycle.
• Approximately 14 days (or 12 to 16 days)
before the start of the next period, an
egg will be released by one of the
ovaries.

• While the egg from the woman lives for
only around 24 hours, sperm from the
man can survive for up to 3 days,
possibly longer.

• First unsafe day: subtract 18 from the number of
days in your shortest cycle
• Last unsafe day: subtract 11 from the number of
days in your longest cycle
• Ex: shortest: 26 – 18 = day 8
longest: 31 – 11 = day 20
UNSAFE PERIOD!! Days 8 -20
-avoid coitus or use a contraceptive

SHORTEST CYCLE
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
1
18 DAYS
LONGEST CYCLE
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1
11 DAYS
UNSAFE TIME
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
UNSAFE TIME

2. Basal Body Temperature
• Involves taking the temperature every morning
BEFORE the woman gets out of bed and
recording it
• The temperature drops slightly 24 hours before
ovulation, then rises to about half a degree
higher than normal and remains thus for up to
three days: UNSAFE period!
• Not a very efficient method unless combined
with calendar and mucus methods

3. Cervical Mucus
(Billings) Method
• Involves becoming aware of the normal
changes in the cervical secretions that
occur throughout your cycle by inserting
the forefinger into the vagina first thing in
the morning

3. Cervical Mucus
(Billings) Method
• A few days after menstrual bleeding: little
secretion, vagina is dry
• Gradually, secretion increases and becomes
thicker, cloudy white and sticky
• As ovulation approaches, this secretion or
mucus becomes copious, clear, thin, less
viscous, more liquid, slippery or stringy; as soon
as this change begins and for 3 full days later:
UNSAFE PERIOD!!

3. Cervical Changes
• Spinnbarkeit test
• Cervical mucus is
thin, watery and can
be stretched into long
strands
• high level of
estrogen: ovulation is
about to occur
664
3. Cervical Changes
• Ferning or
arborization of
cervical mucus
• At the height of
estrogen stimulation
just before ovulation
• Ferning- due to
crystallization of
sodium chloride on
mucus fibers
665
Symptothermal method
• Combines BBT and cervical mucus
methods

Ovulation awareness
• Use of over-the-counter OTC ovulation
test kit which detects the midcycle LH
(luteinizing hormone) surge in the urine
12 to 24 hours before ovulation
• 98 to 100% accurate

Lactation amenorrhea method
• As long as a woman is breastfeeding an
infant, there is some natural suppression
of ovulation
• Not dependable- woman may be fertile
even if she has not had a period since
childbirth
• After 6 months, she should another
method of contraception

Coitus interruptus
• Oldest method
• Couple proceeds with coitus until the moment
of ejaculation, then the man withdraws and
spermatozoa are emitted outside the vagina
• Offers little protection because ejaculation may
occur before withdrawal is complete and
despite the care used, spermatozoa may be
deposited in the vagina

Contraceptives
3. Oral Contraceptives
• Composed of varying amounts of
estrogen combined with small amount
of progesterone
99.5% effective

• Estrogen suppresses
FSH and LH, thereby
suppressing ovulation
• Progesterone
decreases the
permeability of
cervical mucus
671
• Monophasic - Fixed doses of estrogen and
progesterone ; 21-28 day cycle
• Biphasic - Constant amount of estrogen
with increased progesterone
• Triphasic - Varying levels of estrogen and
progesterone

Benefits of OC’s:
DECREASED incidences of:
• Dysmenorrhea
• Premenstrual dysphoric syndrome
• Iron deficiency anemia
• Acute PID with tubal scarring
• Endometrial and ovarian cancer and ovarian
cysts
• Fibrocystic breast disease

Side Effects
• Nausea
• Weight gain
• Headache
• Breast tenderness
• Breakthrough bleeding
• Monilial vaginal infections
• Mild hypertension
• Depression

Absolute Contraindications to OC’s
• Breastfeeding
• Family history of CVA or CAD
• History of thromboembolic disease
• History of liver disease
• Undiagnosed vaginal bleeding

Possible Contraindications to OC’s
• Age 40+
• Breast or reproductive tract malignancy
• Diabetes Mellitus
• Elevated cholesterol or triglycerides
• High blood pressure
• Mental depression

• Migraine or other vascular type headaches
• Obesity
• Pregnancy
• Seizure disorders
• Sickle cell or other hemoglobinopathies
• Smoking
• Use of drug with interaction effect

Other Contraceptives
• Continuous or extended regimen pills
• Mini-pills
• Estrogen-progesterone patch
• Vaginal rings

Estrogen-progesterone patch

• Highly effective, weekly hormonal birth control
patch that’s worn on the skin
• Combination of estrogen and progestin
• Absorbed on the skin and then transferred into
the bloodstream
• Can be worn on the upper outer arm, buttocks,
upper torso or abdomen
• Worn for 1 week, replaced on the same day of
the week for 3 consecutive weeks. No patch-4th
week

Emergency Postcoital Contraceptives
• “Morning-after pills”
• High level of estrogen
• Must be initiated within 72 hours of
unprotected intercourse

4. Other Contraceptives
Subcutaneous implants (eg, Norplant)

• 6 nonbiodegradable Silastic implants with
synthetic progesterone embedded under the skin
on the inside of the upper arm
• Slowly release the hormone over the next 5 years
• Suppress ovulation, stimulating thick cervical
mucus and changing the endometrium so
implantation is difficult
4. Other Contraceptives
• Intramuscular injections
-administered every 12 weeks
Medroxyprogesterone (depo-provera)
-100% effective

Contraceptives
5. INTRAUTERINE DEVICES
• T-shaped plastic device with copper
• With progesterone
• Mechanism of action not fully understood
• Must be fitted by physician, nurse practitioner or
midwife
• Insertion performed in ambulatory setting after pelvic
examination and pap smear
• Device is contained within uterus – string protrudes
into vagina
• Effective for 5-7 years (mirena type) or 8 years
(Copper T380)

INTRAUTERINE DEVICE
686
5. INTRAUTERINE DEVICES
Side Effects:
• Spotting or uterine cramping
• Increased risk for PID
• Heavier menstrual flow
• Dysmenorrhea
• Ectopic pregnancy

6. Barrier Methods
• Vaginally inserted spermicidal products
• Diaphragms
• Cervical caps
• Condoms

6. BARRIER METHODS
• SPERMICIDAL AGENT
goal: to kill the sperm
before the sperm
enters the cervix
-Nonoxynol-9
-gel, creams,
films,foams,
suppositories
689
6. BARRIER METHODS
• DIAPHRAGM
-mechanically blocks sperm
from entering the cervix
-soft latex dome supported by
a metal rim
-can be inserted 2 hours
before intercourse; removed
at least 6 hours after coitus
or within 24 hours
-size must fit the individual
-washable, may be used for
2-3 years
690
6. BARRIER METHODS
• CERVICAL CAP
-similar to diaphragm
but smaller
-thimble-shaped
rubber cap held onto
the cervix by suction
691
6. BARRIER METHODS
MALE CONDOM FEMALE CONDOM
692
• MALE CONDOM
Action – prevents the ejaculate and sperm from entering
the vagina; help prevent venereal disease; effective if
properly used; OTC
• Teaching – apply to erect penis with room at the tip every

time before vaginal penetration; use water-based
lubricant, e.g., K-Y jelly, never petroleum-based lubricant;
hold rim when withdrawing the penis from the vagina; if
condom breaks, partner should use
contraceptive foam or cream immediately

7. Surgical Methods
• Tubal Ligation
-28% of all women in US
-fallopian tubes are
cut,tied/ cauterized to
block passage of ova and
sperm
ABDOMINAL INCISION
MINILAPAROTOMY
LAPAROSCOPY
FOR TUBAL
STERILIZATION
694
7. Surgical Methods
• Vasectomy
- 11% of all men in US
-incisions are made in
the sides of scrotum; vas
deferens is cut and tied,
then plugged or
cauterized
-blocks passage of sperm
-viable sperm for 6
months post op
-reversible 95%
695
8. Elective Termination of
Pregnancy
Procedure to deliberately end a pregnancy
before fetal viability
• Induced
(mifepristone-progesterone antagonist;
misoprostol-prostaglandin analog
• Medically induced
D&C, D&E, saline induction, hysterotomy

Cycle Beads
• an easy way to plan or prevent pregnancy naturally
• color-coded string of beads which enables a woman
to track her cycle and know if she is on a day when
pregnancy is likely or not
Advantages
• Effective - more than 95%*
• Side-Effect Free
• Easy to use
• Inexpensive
• Educational & Empowering
MLNGCeleste,
697
• To use CycleBeads a woman simply moves a
ring over the series of color-coded beads
that represent the days of her cycle.
• The color of the beads lets her know

whether she is on a day when she is likely to
be fertile or not. The one medical criterion
for using CycleBeads to prevent pregnancy is
that a woman should have cycles between
26 and 32 days long.
MLNGCeleste,
698
CycleBeads are a color-coded string of
beads that represent a woman's
menstrual cycle. Each bead represents a
day of the cycle and the color helps a
woman to determine if she is likely to be
fertile that day.
MLNGCeleste,
699
The day a woman starts her period she puts
the rubber ring on the red bead.
MLNGCeleste,
700
• When the ring is on the red bead or a
dark bead, there is very low likelihood of
pregnancy, so she can have intercourse
on these days without getting pregnant.
• When the ring is on a white bead - Days 8

through 19 - there is a high likelihood of
getting pregnant if a woman has
unprotected intercourse.
MLNGCeleste,
701
MLNGCeleste,
702
MLNGCeleste,
703
Health Teaching
1. Remembering to move the ring
2. Checking to make sure that the ring is on the
right day.
3. Making sure that no one else moves the ring.
4. Talking to the partner about Cycle Beads and
how it works
MLNGCeleste,
704
CycleBeads
• based on a natural method of family
planning called the Standard Days Method
• developed by the Institute for Reproductive
Health at Georgetown University
• The Standard Days Method works best for
women who have regular menstrual cycles
between 26 and 32 days long.
• Days 8 through 19 of their cycles are the
days these women are likely to get pregnant
if they have unprotected intercourse. On
other days of their cycles, pregnancy is very
unlikely.
MLNGCeleste,
705
The Newborn
MLNGCeleste, RN, MD

NCM 101 Maternal Health Nursing

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Maternal and Child Health Nursing

NCM 101 CMO 14

Mary Lourdes Nacel G. Celeste, RN, MD

• Over 30% of pediatric admissions are for

• In humans, each cell, with the exception of the

• Each chromosome contains thousands of

• Congenital - present at birth because of

• Genetic – pertains to genes or chromosomes;

• Homozygous - a person who has 2 like genes

• Heterozygous – if the genes differ (eg, 1 gene

• Dominant genes – genes which are expressed

• Recessive genes – genes that are not

• Homozygous recessive – an individual with 2

• 1 of the parents of the child with the disorder

Blacks/ African Sickle cell Anemia

Sonography/ Fetal imaging

• Participation must be elective

• Detected at birth on physical examination

• Result of a missing portion of chromosome 5

• Males with XXY chromosome pattern (47XXY) –

• Most frequent; 1 in 800 live births

• Male reproductive system

Male internal structures

-The glans penis, a cone-shaped expansion of the corpus

-Erection is stimulated by parasympathetic nerve

2. Scrotum: a pouch hanging below the penis that contains the

1.The glans penis, a cone-shaped expansion of the

3. Prepuce or Foreskin – retractable skin covering

SPERMATOZOA are produced by:

FSH - release of Androgen Binding Protein (ABP) which

“Spermatozoa do not survive at body temperature.

1. Epididymis: serves as reservoir for sperm storage and

A total of 64 days before the sperm reach maturity.

2. Vas deferens: a duct extending from epididymis to the

4. Ejaculatory ducts: the canal formed by the union of the vas

5. Prostate Gland: located just below the urinary bladder.

6. Bulbourethral glands or Cowper’s Gland: adds alkaline fluid

7. Urethra: the passageway for both urine and semen, extending

Contain Leydig cells produces testosterone

Testosterone ALERT: it takes 64 days

stimulates seminiferous tubules to produce

Epididymis conducts sperm to Vas deferens

Seminal vesicles ( secretion of fructose & protein)

Urethra ( 8 inches) ( cowper’s gland secretes

• Female reproductive system

1. Mons pubis/ Mons veneris – pad of adipose tissues, which

2. Labia majora – longitudal folds of pigmented skin extending

3. Labia minora – soft longitudal skin folds between the Labia

4. Glans clitoris – erectile tissue located at the upper end of

5. Vestibule – a narrow space seen when labia minora are

6. Urethral Meatus – small opening between the clitoris and

7. Vaginal orifice/introitus/opening – external opening of

8. Hymen – a membranous tissue ringing the vaginal introitus

9. Perineum – tissue between the anus and vagina. Site of

The external genitalia’s blood supply:

1. Ovaries – female sex glands located on each side of the uterus

Ovaries are formed with 3 principal divisions:

Functions: -Ovulation (release of ovum) and Secretion of

Estrogen- helps to prevent osteoporosis, and atherosclerosis

b. The cortex filled with

c. The central medulla

Divided into four separate parts:

1. Intramural portion- most proximal (1 cm in length)