Mother and Child Health: Theories of Procreation and Human Reproduction

UUUUUUUUUUUUUUUUUUUUUUUUUUUNIT
UNIT 11 – MOTHER AND CHILD HEALTH

OBJECTIVES : After given a set of questions, the
students will be able:
de111.define procreation and theories related to

procreation
2. discuss the process of human reproduction
3. Identify risk factors that will lead to genetic disorders
4. Enumerate common tests for determination of
genetic abnormalities
55. 5. explain the utilization of the nursing process in
the prevention of genetic alteration and in the care of
clients seeking services before and during conception..
. Explain the utilization of the nursing process in the
preven
A. PROCREATIVE HEALTH
DEFINITION AND THEORIES RELATED
TO Procreation
Procreative Health – is the
Moral Obligation of the
Parents to Have the
Healthiest Children thru
All Natural and Artificial
Means Available.
DISTINCTION BETWEEN
PROCREATION AND
REPRODUCTION
Reproduction is usually defined as the
action of making a copy of something, or
the production offspring by sexual
intimacy…
In contrast, procreation roots sexuality
and childbearing deeply within with two
relations: that of the man and woman, and
that between the couple and GOD (2006).
THEORIES RELATED TO PROCREATION
1. Theories of conception have to do with far
more than the physical process of human coming
into being. In all times and places, people have
had ideas about the process, and these ideas are
interrelated with ideas about gender, kinship,
property, and religion.
THEORIES RELATED TO PROCREATION
2. Natural Law Theory: with this theory actions in conformity and support
of natural laws are morally correct. A simple summary would be: What is
Consistent with the Natural Law Is Right and What is not in keeping with
the Natural Law is Wrong.
Note: This is NOT what is natural is morally correct and what is unnatural
is morally wrong. The focus is on the natural Laws and not simply natural
acts. Natural La w Theory support doing unnatural deeds such as surgery
for the sake of realizing a restoration of health and the prolongation of
human life which are each consistent with the natural drives of organisms:
survival
Two Types of Natural Law Theory:
Natural Law Theory can be held and applied to human conduct by both
theists and atheists. The atheist uses reason to discover the laws
governing natural events and applies them to thinking about human
action. Actions in accord with such natural law are morally correct. Those
that go against such natural laws are morally wrong.
For the theists there is still the belief that humans have reasoning ability
and with it the laws of nature are discernible. For atheists who accept this
approach to act in keeping with the laws of nature is the morally correct
thing to do.
33. Parent Development Theory: Understanding Parents, Parenting Perceptions
and Parenting Behaviors
-for the importance of parenting, with the long-term implications for children,
families, and society, there is precious little psychological theory specifically on
parents and parent development. And, while there are many parent education
programs available and certainly substantial research on parents (e.g. ,
Baurmind, 1975, 1991), none are based on an overall theoretical model
regarding who parents are and how they develop in relation to the parenting
role. This article provides as theoretical framework, the Parent Development
Theory (PDT) to assist professionals in organizing their thinking, practice, and
research regarding parenting. Originally called the Parent Role Development
Theory (PRDT).
44. Theory for Child Oriented Professionals
5. Theoretical Perspectives on Siblings Relationships
6. Theories of Motivation
- Evolutionary Theory of Motivation-according to evolutionary
psychology, individuals are motivated to engage in behaviors that
maximize their genetic fitness.
MALE REPRODUCTIVE SYSTEM
Mons pubis
clitoris
prepuce
Labia
minora
Urethral
Labia meatus
majora
Vaginal orifice
Anus
Bartholin's glands-(vulvovaginal glands) bean-shaped glands on

either side of the vagina that provide lubrication during
intercourse.
Clitoris -erectile tissue,nerves,and blood vessels located just

above urethral opening; homologous to the penis
Fourchette- ridge of tissue formed by the posterior
joining of the two labia majora and labia minora that's
sometimes cut during vaginal birth
Hymen - thin,vascularized mucous membrane located at

the vaginal orifice
Labia majora-folds of adipose tissue that protect external

genitalia and distal urethra and vagina
Labia minora-lubricate vulva,adding to sexual

enjoyment and providing bactericidal protection
Mons pubis-cushions anterior symphysis pubis
Skene's glands-glands located on each side of the urinary

meatus that lubricate the external genitalia during
intercourse
FEMALE INTERNAL GENITALIA
Cervix - lowest portion of the uterus
Fallopian tubes - long channels that transport the
ovum from the ovary to the uterus
Fundus - portion of the uterus between the points of
attachment of the fallopian tubes
Ovary - almond-shaped glandular structure on either
side of the uterus that produces,matures,and
discharges ova
Uterus - hollow,pear-shaped muscular organ in the
lower pelvis that provides a place for fertilized ovum
to implant and houses growing fetus.
Vagina - vascularized musculomembranous tube that
extends from the external genitals to the uterus and is
the organ of intercourse
66
• Fallopian tubes divided into 4 parts
1. interstitial portion-most proximal
division,lies within the uterine wall.
2.isthmus-portion of the tube that is cut or
sealed in a tubal ligation.
3. the ampulla-third and the longest portion
of the tube.Fertilization of an ovum usually
occurs.
4.infundibular portion-most distal segment of
the tube. Covered by fimbria(small
hairs)that help to guide the ovum into the
fallopian tube.
6
Three Parts of the Uterus:
1. Body or corpus – uppermost portion; bulk
of uterus; expands to accommodate fetus.The
portion of the uterus between the points of
attachment of the fallopian tubes is termed the
fundus.
2. Isthmus – Short segment between corpus
and cervix.It is the portion where the incision
is made when a fetus is born by caesarean
birth.
3. Cervix – Lowest part; 1/3 of total size
6666666666666666666666666
6666666666666666666666666
6666666666666666666666666
66
Uterine Layers:
a. Endometrium – inner mucous membrane

layer of the uterus that sheds during
menstruation
b. Myometrium – three interwoven layers of
smooth muscle that give the uterus its
strength
c. Perimetrium – outer layer that covers the
body of the uterus and part of the cervix
Types of Uterine Deviations
1. Bicornuate uterus-oddly shape

“horns” at the junction of the
fallopian tubes.
2. Septum-Dividing Uterus
3. Double Uterus
Deviations in Uterine Position:
Deviations in Uterine Position
That Are Commonly Seen:
1. Anteversion-the entire uterus tips far
forward.
2. Retroversion-the entire uterus tips far
back
3. Anteflexion-body of uterus bends
sharply forward at the junction with the
cervix
4. Retroflexion-body of uterus bends
sharply backward just above the cervix.
Anteversion anteflexion
Retroversion Retroflexion
Types of Pelvis pg.267
• Gynecoid - round shaped
– Transversely rounded and slightly
ovoid
• Android – wedge-shaped / heart-
shaped
– Angulated, resembles male pelvis;
• Anthropoid - inlet oval-shaped
– Oval, wider anteroposterior diameter
• Platypelloid -oval shaped
transversely
– Flat anteroposterior diameter; wide
transversely
FEMALE REPRODUCTIVE CYCLE-
menstrual cycle
 Purpose is to mature ovum and renew the
uterine tissue bed
 Menarche usually occurs between ages 9 and
17
 Average length of menstrual cycle is 28 days
 Average length of menses is 2 to 9 days
 Initiated by the release of LHRH, also known
as GnRH, from the hypothalamus

 Under the influence of LHRH ,the anterior
lobe of the pituitary produces two hormones

( FSH and LH) that act on the ovaries to
further influence the menstrual cycle
The MENSTRUAL
CYCLE
– Periodic uterine bleeding in response to cyclical
hormonal changes
– Begins at puberty, ends at menopause
– Structures involved:
• Hypothalamus
• Pituitary gland
• Ovaries
• Uterus
– 1. Uterine Phase
– A. Menstrual Phase
 Days 1 to 5
 Endometrial lining is shed
 LH, Estrogen, & Progesterone at their lowest
level
 FSH increases  Graafian follicle begins
maturing
– B. Proliferative Phase
 Days 5 to 14
 Uterine lining grows due to increased Estrogen;
thickens by 8 to 10-folds
 Glands and vascularization are developed 3 to 4 days
before ovulation
– C. Ovulation
 Days 12 to 16
 Estrogen is high & Progesterone is low
 LH stimulates the release of mature, non-fertilized
ovum
 Spinnbarkeit – stretchable cervical mucus
– D. Secretory or Luteal Phase
 Days 15 to 26
 Uterus prepared for implantation
 Estrogen level drops, Progesterone level is high
(produced by corpus luteum)

 Increased uterine vascularity
 Tissue glycogen levels increase
– E. Ischemic Phase
 Days 27 to 28
 Estrogen & Progesterone levels declines
 Arterial vessels constrict
 Endometrium prepares to shed
 Blood vessels rupture  Menstruation begins

– 2. Ovarian Response
– A. Follicular Phase
 Days 1 to 14
 Follicle matures due to FSH
 Ovulation occurs due to LH surge
– B. Luteal Phase
 Days 15 to 22
 Corpus luteum develops from a ruptured
follicle
 Corpus luteum produces large quantities
of progesterone
*If conception occurs, ovum proceeds down
the fallopian tube and plants on the
endometrium of the uterus.
*If conception does not occur the unfertilized
ovum atrophies after4-5 days.
*The corpus luteum remains only 8-10 days
and gradually regresses and turns into
corpus albican or white body.
• The first day of menstrual flow is used to
mark the beginning days of a new
menstrual cycle.
• Menstrual cycle begins with the first day of
bleeding which is counted as day 1, the
cycle ends just before the next menstrual
period.
• For example if your period starts on Oct
6th, that is day 1,if your next period starts
on the nov 3, the 2nd of nov was the 28th
day of your last cycle and the 3rd day of
Nov is the first day of the next menstrual
cycle.
The Menstrual
Cycle
Menstrual Cycle
• Purpose:
1. To bring ovum to maturity
2. Renew a uterine tissue bed that will be
responsible for ova’s growth should it be
fertilized.
* Interval: Ave: 28 days, 23-35 days not unusual
*Duration: Ave:4-6 days, may be 1-9 days
*Amt. Of menstrual flow: ave: 30-80 ml
*Color- Dark red, made up of blood, mucus and
endometrial cells
Determination of Ovulation
 Mittelschmerz
 Spinnbarkeit
 Basal Body Temperature
 Ferning
 Glycogen content of vagina and the cervical
cells
 To compute for the exact date of ovulation, count back

14 days from the first day of menstruation.
*Spinnbarkeit
• First half of the cycle- cervical mucus is thick
and scant
• At the time of ovulation, when the estrogen level
is high- cervical mucus become thin and copious
• During the second half of the cycle, the cervical
mucus again becomes thick and sperm survival
is poor.
• *Fern Test- mucus can be examined at mid
cycle to detect ferning
• Cervical mucous forms “fernlike “ patterns when
it smeared and dried on a glass slide.The
pattern are due to crytallization of sodium
chloride on mucus fibers.
• If increased progesterone fern pattern is no
longer discernible.
*Basal Body Temperature
• The basal temp. drops before the day of
ovulation and rises on the day after
ovulation
• * The temperature remains at this level
until approximately day 24 of the
menstrual cycle when the level of the
progesterone drops.
Process of Conception chapter 9
• Fertilization
Proper timing is essential for fertilization to occur.
The ovum will only be receptive to fertilization for
24 hours whereas the sperm remains viable only
for 24-72 hours.
During ovulation, the fimbriae of the fallopian
tubes pick up the released ovum and the ovum
moves down the tubes by ciliary action. It usually
takes about 3 days for this whole process to be
completed.
Of the 200-400 million sperm released into
the vagina during intercourse, only about
one hundred reach the distal end of the
uterine tube to reach the ovum and fertilize
it. The sperm that do reach the ovum shall
surround the latter and secrete
hyaluronidase which will break down the
cells surrounding the ovum. This process
will allow the sperm to penetrate the ovum
and fertilize it.
Upon penetration of the sperm, the
zona pellucida will undergo several
changes which shall prevent
fertilization of the ovum by another
sperm. Fertilization culminates with
the combining of the 23 unpaired
chromosomes for each of the
gametes and initiate further cell
division.
Cell division commences even as the
fertilized ovum is propelled proximally
down the uterine tube. It is called the
morula when it is at the 16-50 cell stage.
The outermost cells of the morula then
secrete fluid which forms a sac within
which an inner mass of cells is located.
The latter then becomes a two layered
group of cells called the embryonic disc
which will later on form the embryo and
amnion. The outermost cells, also known
as trophoblast, will become the placenta
and the chorion.
• The fertilized ovum has 46 chromosome
• Spermatozoon and ovum each carried 23
chromosomes
• (22 autosomes and 1 sex chromosomes)
• If TWO X chromosomes
( XX ) female
• If X and Y
( XY ) male
• Growth and development of the fetus
begins with fertilization
• After fertilization, fetal development
occurs in 3 stages
– 1st (preembryonic stage) 1st 14 days after
conception
– 2nd (embryonic stage) 3rd wk after
conception until the embryo reaches 3 cm
(1.2 in.) in length (8 wks); referred to as
fetus
– 3rd (fetal stage) 8 to 10 wks after conception
until the end of pregnancy
FETAL DEVELOPMENT
• Zygote
– Cell that results from fertilization of the ovum
by the sperm cell
• Blastomere
– results from mitotic division of the zygote
• Morula
– solid ball of cells formed by 16 or more
blastomeres
• Blastocyst
– morula that has reached the uterus (7 days
after fertilization)
FETAL DEVELOPMENT
• Embryo
– organism that contains the 3 germ
layers (7 days to 8th week)
– All organ systems present
• Fetus
– organ systems develop and grow, from
the 8th wk until term
11 wks 16 wks 20 wks 24
wks
N,
Body Structures Developing From
the Primary Germ Cells
Germ Layer Structure Formation
• Ectoderm Skin
Nervous system
Nasal passages
Eyes
Pharynx
Mammary
Lens of the gland
Salivary gland
Germ Layer Structure Formation
• Mesoderm Muscles
Circulatory system
Bones
Reproductive system
Connective system
Kidneys, ureters
Germ Layer Structure

Formation
• Endoderm Alimentary tract
Respiratory tract
Bladder
Pancreas
Liver
• Fetal circulation
The umbilical vein carries oxygen rich blood from
the placenta to the liver and the ductus venosus.
From there it is carried to the inferior vena cava to
the atrium of the heart. Some of the blood is
shunted through the foramen ovale to the left side
of the heart where it is routed to the brain and
upper extremities. The rest of the blood travels
down to the right ventricle and through the
pulmonary artery. A small portion of the blood
travels to the non-functioning lungs. While the
remaining blood is shunted through the ductus
arteriosus into the aorta to supply the rest of the
body.
• One umbilical vein carries oxygen and
nourishment from the placenta to the fetus
• Two umbilical arteries carry deoxygenated

blood from the fetus to the placenta.
• Blood flow through the cord is about 400

ml/min.
Milestone of Fetal Development
• Week 1 – Ovum becomes fertilized. Divides and
implant into the uterus
• Week 2 – Ectoderm, mesoderm, endoderm are
formed
• Week 3 – The first body segment appears which will
eventually form the spine, brain and spinal cord
• Week 4 – Heart, blood circulation, and digestive
tract take shape
• Week 5 – Heart starts to pump blood
• Week 6 – Eyes begin to take shape
• Week 7 – Face is complete with nose, eyes, lips
and tongue
• Week 8 – Heart beating at about 40 to 80/min
• Week 9 – Genitals are well defined. Embryo
becomes a fetus
• Week 10 – Fetus assumes a more human shape.
First movements begin.
• Week 11 – Pancreas produces insulin. The kidneys
urine
• Week 12 – Swallowing reflexes mastered as the
fetus sucks its tongue
• Week 14 – Musculoskeletal system matured
• Week 15 – Kicks restlessly against the amniotic sac
• Week 18 – Fine hairs covers the body and

keeps the oil on the skin
• Week 19 – Eyebrows, eyelashes & hair
developed
• Week 20 – Has a regular schedule of
sleeping, turning, sucking and kicking
• Week 22 – Skeleton develops
• Week 23 – Eyelids begin to open and close
• Week 26 – Baby can breath, swallow, &
regulates its body temperature
• Week 27 – Surfactant forms in the lungs
• Week 29 – Fat deposits builds up beneath the skin
• Week 30 – Digestive tract & lungs nearly fully
matured.
• Week 30 to 34 – 280 to 320 mm in length and
weighs 700 to 2,500 g. Vigorous fetal movement
occurs
• Week 35 to 37 – 330 to 360 mm in length; weight
2,700 to 3,400 g.
• Week 38 to full term – 360 mm in length and weighs
3,400 to 3,600 g. Skin is smooth, chest is
prominent, bones of skull are ossified. Testes are in
scrotum
The Newborn
Determination of Age of Gestation
• Last Menstrual Period (LMP)

– Calculating time from the first day of the
last menstrual period up to the present
– Can be used to compute the EDD
(expected date of delivery) using the
*Naegele’s Rule
• Add 7 days to the first day of LMP,
count back 3 months, and add 1 year if
applicable.
• Quickening
– noted at 20 weeks in Primi &
16 wks in multigravidas
• Using Nagele's,what would be the
estimated date of delivery for a woman
whose first day of her last menses was
March 17,2016?
a.June 24 b.August 10
c. Jan 31 d.Dec 24
Note: add 12 to the numerical value for the first 3 months

March 3 + 12 = 15 17
- 3 +7 2016
______________
? ?
Client's last menstrual period began july
5,2016.
Her EDD should be which of the following?
A. Jan 2,2017
B. March 12,2017
C. April 12,2017
D. October 12,2016
July 7 5 2016
• -3 +7 +1
• _______________
• MARCH 28, 2016 3 +12 =15
• 15 28 2016
• -3 +7 +1
• ______________________
• 12 35 2017
• -31 days
_________________________
1 4 2017
• LMP Feb 28,2016
• Prenatal-June 24
• Feb - 0
• March-31
• April- 30
• May- 31
• June- 24
• ______________
• 116 / 7
• AOG = 16 5 weeks
• 7
• Months
Measured as nine months on the calendar -- starting one week after your
LMP.
• Trimesters
Three periods of three months each.
• Months 1 - 3 are the first trimester
• months 4 - 6 are the second trimester
• months 7 - 9 are the third trimester
• Lunar Months
Prenatal development is often measured in lunar months.
• Each lunar month consists of 28 days, organized into four weeks of seven
days each.
• That means a pregnancy is 10 lunar months long!
• Weeks
40 weeks from the start of your LMP. Gestation is 38 weeks from conception
to birth.
• Days
280 days from your LMP. No matter what method is used to determine EDD.
• No matter how you measure your pregnancy, even the best estimated due
date can be inaccurate. Your baby will be born when he or she is ready!
• Assessment of Fundic Height
– McDonald’s Rule
• Fundic height (cm) x 2/7 = AOG in lunar months
• Fundic Height (cm) x 8/7 = AOG in wks
– Bartholomew’s Rule
• Estimates AOG by the position of the uterus in the
abdominal cavity
»12 wks – symphysis pubis
»16 wks – halfway bet. Umbilicus & SP
»20 wks – level of umbilicus
»24 wks – 2 FB above umbilicus
»30 wks – half way bet umbilicus & xiphoid
process
»36 wks – level of xiphoid process
»40 wks – just below xiphoid process
page 229
36 weeks
40 weeks
• 5th lunar months
•
•
•
•
• 3rd lunar months
page 229
36 weeks
40 weeks
• 5th lunar months
•
•
•
•
• 3rd lunar months
• Measuring Fundal Height
1. Explain the procedure to the client
2. Have the woman void
3. Help the woman into a supine position
and drape her, expose her abdomen
4. Measure the FH using a tape measure
from the symphysis pubis over the
abdomen to the top of the fundus
Typically,between the 20th and 32nd weeks of
gestation ,the FH in centimeters
corresponds to the week of gestation
Johnson’s Rule
• Estimates the weight of fetus in grams relative to
height of the fundus
• Fetal weight = fundic ht (cm) – N x K
• K – 155 (constant)
• N – 12 if engaged, 11 if not yet engaged
Hasse’s Rule
• To determine the length of fetus in cm.
• 1st half of pregnancy (1 to 5 lunar months )–
square the no. of mos
• 2nd half of pregnancy (6 to 10 lunar months)-
multiply the no. of months by 5
• Mc Donald's rule
FH = 34 cm 34cm multiply by 8 divided by 7
Ans. = 38 to 39 weeks
34cm multiply by 2 divided by 7
Ans.= 9 to 10 lunar months
• Johnson's rule (grams)

Fh= 21 cm, not engaged
FH (cm) – n multiply by K (155)

21 – 11 =10 multiply by 155 = ??
Ans. = 1550 grams
Hasse's rule
7 months= 7 multiply by 5 = 35 cm length
• Information to obtain from Prenatal
clients-- Obstetrical history
• Gravida , Parity (20 weeks AOG)
• T-infant born @ 37 wks or after , wt is
5 -8 lbs (2,500 – 4000 grams)
• P-infant born before 37 wks , ended
after 20 wks
• A-(spontaneous/induced)-delivered
before the end of 20 wks(5 month)
• L-living children
• M-multiple pregnancies-- para 1
– Medical and Surgical History,
– Family History,Current problems
• Gravida- indicates the number of times
the mother has been pregnant, regardless
of whether these pregnancies were carried
to term. A current pregnancy, if any, is
included in this count
• Para- indicates the number of viable (>20
wks) births. Pregnancies consisting of
multiples, such as twins or triplets, count
as ONE birth
1.A pregnant woman once with twins
delivers at 35 weeks gestation and the
neonates survives. G _ P_
• T _ P_ A_ L_ M_
2.A woman who had 2 miscarriages @ 12

weeks and is again pregnant.
G_ P_ T_ P_ A_ L_
• Ans.
1. G_1__ P__1__
T__0__P__2__ A__0__ L_2_ M_1_
2. G__3__ P__0__
T__0__ P__0__ A__2__ L__0__
• Ans.
1. G_1__ P__1__
T__0__P__2__ A__0__ L_2_ M_1_
2. G__3__ P__0__
T__0__ P__0__ A__2__ L__0__
Read Chapter 11
page 243
Prenatal Assessment During Antepartal
Period
Purposes of prenatal care:
1. Establish a baseline of present health.
2. Determine the gestational age of the
fetus.
3. Monitor fetal development and maternal
well being
4. Identify women at risk for complications
5. Minimize the risk of possible
complications by anticipating and
preventing problems before they occur.
6. Provide time for education about
pregnancy, lactation and newborn care.
Health History
• Data: Age, Marital Status, Family Setting,
source of income, cultural values and
practices relative to bearing and child
rearing, education, employment
background
Initial Prenatal History:
A. Family History of Health Problems
B. Patient’s medical history
C. Gynecologic History
D. Obstetrical History
A. Relevant data of previous pregnancies
B. History of present pregnancy:
LMP, EDC
*Estimating Fetal Growth by:
• Naegele’s Rule
• McDonald’s Rule
1. Measurement of fundal height
Bartholomew’s Rule- position of uterus in
the abdomen
• 12 wks, above symphysis pubis
• 20 wks, umbilicus
• 36 wks xyphoid process
• Baseline height / weight and vital sign
measurement
-sudden increased of BP and weight
gain –gestational hypertension
-sudden increased in pulse or
respiration-undetected bleeding
Weight Gain during Pregnancy
• Roughly 20 to 30 lbs / 30 to 35 lbs
• First Trimester
• 2 to 4 lbs; 1 lb per month
• Second Trimester
• 11 to 14 lbs; 0.9 lb per week
• Third Trimester
• 8 to 11 lbs; 0.5 to 1 lb per week
• Note: Pattern of weight gain is more

important than amount of weight gain.
Physical Examination
1. General Appearance and Mental Status
• -hygiene, sad facial expression,the way they speak,check
for sign of partner abuse ( marks from battering and
ecchymotic spots)
2. Head and Scalp
- examine women’s head for symmetry,normal contour,and
tenderness .
- presence of hair (distribution,thickness,dryness/ oiliness)
• dryness or sparseness of hair suggests poor nutrition
3. Eyes
- edema of the eyelids combined with a swollen optic disk
suggests gestational hypertension
- Report spots before their eyes or diplopia suggests
gestational hypertension
4. Nose
-increased level of estrogen cause nasal congestion or the
appearance of swollen nasal membrane
5. Ears
- nasal stuffiness may lead to blocked eustachian tubes
( fullness in the ears or dampening of sound )
6. Sinuses
- should feel nontender
headache suggests a danger sign until ruled otherwise.
7. Mouth, teeth and throat
-gingival (gum) hypertropy result from increased estrogen
-cracked corners of the mouth suggests Vit.A deficiency
-pinpoint lesion with erythematous base on the lips –suggests
herpes infection.
- encourage good dental hygiene or yearly dental exam
8. Neck
-slight thyroid hypertropy may occur due to increased metabolic
rate
-encourage a serving of seafoods at least once weekly to supply
enough iodine for the increased thyroxine production
-Use iodized salt
9. Lymph nodes
-no palpable lymph nodes should be present
10.Breast
- Areolae darken
- Secondary areola develop
-Montgomery tubercles in the areola become
prominent
-Overall breast size increase
-Breast consistency firms
-Veins become prominent
• Colostrum as early the16th week of pregnancy
10. Heart
- ranges from 70 to 80 beats / min in pregnant woman
- no accessory sounds or murmurs should be present.
- teach woman to rest or sleep on their side ( left side)-to keep
their uterus from compressing their vena cava(a cause of
supine hypotension syndrome as well as heart palpitations).
11. Lungs
-diaghragmatic excursion (diaphragm movement ) is lessened
because the diaphragm cannot descend fully as usual because
of the distended uterus.
12. Back
- lumbar curve is accentuated and standing so that they can
maintain body posture in the face of increasing abdominal size(
Lordosis –the pride of pregnancy )
13. Rectum
- hemorrhoidal tissue commonly occurs from uterine pressure
on pelvic veins.
14. Extremities and skin
- palmar erythema or itching early in pregnancy
due to high estrogen level
- subclinical jaundice (jaundice that is not yet
apparent by a color change) from reabsorbed
bilirubin because of slowed intestinal peristalsis
- assess for varicosities (filling time of toenails
should be under 5 seconds) and edema caused
by impaired venous return from the lower
extremities
• Edema more than ankle swelling may be a
danger sign of pregnancy.
- waddling gait late in pregnancy may cause pain
if the cartilage at the joint becomes so unstable
that it moves from walking.
-
Measurement of fundal height and fetal heart sound
Bartholomew’s Rule- position of uterus in the abdomen
12 wks, above symphysis pubis
20 wks, umbilicus
36 wks xyphoid process
• -lightening- uterus returns 4cm below the xiphoid
at 40 weeks
Fetal heart sound
-120 to 160 beats / min heard at
* 10 to 12 weeks using a doppler technique
* 18 to 20 weeks using a regular stethoscope
Types of pelvis:
1. gynecoid
2. android
3. anthropoid
4. platypelloid
Internal Pelvic Measurement
page 259
• Give actual diameters of the inlet
and outlet in which the fetus must
pass
• Lithotomy position(on her back
with her thighs flexed and her feet
resting in the examining table
stirrups) – used for pelvic exam
•
The Pelvis
Internal Pelvic Measurement
page 263
1. Fingers are introduced vaginally and
pressed inward and upward until the
middle finger touches the sacral
prominence. With the other hand, the part
of the examining hand where it touch the
symphysis pubis is marked. After
withdrawing the hand , the distance
between the tip of the middle finger and
the mark point on the glove is measured.
3. Ischial tuberosity diameter-
- the narrowest diameter
- most apt to cause a misfit
- a pelvimeter / ruler is used to measure
the medial or lowermost aspect of the
ischial tuberosities at the level of the anus.
11 cm is considered adequate
Pelvis: Internal Measurements
• Diagonal conjugate
– Distance between anterior surface of sacral prominence &
posterior surface of inferior margin of symphysis pubis
– Should be 10.5 cm-11cm to be adequate
• True conjugate/ Conjugate vera
– Distance between anterior surface of sacral prominence &
posterior surface of inferior margin of the SP
– [ 1.5 – 2 cm(usual depth of sp) is subtracted from DC ]
= 10.5-11.0 cm
• Transverse Diameter
– Distance bet. Ischial tuberosities or the transverse diameter
of the outlet
– Adequate measurement: 11 cm ( fetal head 9cm)
Prenatal Care
• PRENATAL CARE VISITS
• First visit
• As soon as the woman missed her
menstrual period and pregnancy is
suspected
• Follow up visits
• Once a month – first 28 weeks
• Twice a month – 28 to 36 weeks
• Every week – 37 to 40 weeks
Leopold’s Maneuver
• PAGE 371 READ BOX 15.5
• A systematic method of observation and
palpation to determine fetal presentation and
position.
• First Maneuver (Fundal Grip)
• To determine presenting part at the
fundus
• Second Maneuver
• To determine fetal back
• Third Maneuver
• To determine position and mobility of
the presenting part
• Fourth Maneuver ( Pelvic Grip)
• To determine fetal descent and
attitude
Psychological task Of Pregnancy
PAGE 219
 First trimester:Acceptance of the pregnancy
 Second trimester:Acceptance of the baby
 Third trimester:Preparation for parenthood

.
• If more than 12.5 cm, the pelvis is rated as
adequate for child birth.( the diameter of fetal
head that must pass that point averages 9cm in
diameter.
2. True conjugate or conjugate vera
• The usual depth of the symphysis pubis
(1.5 - 2cm) is subtracted to the diagonal
conjugate measurement.
Ave is 10.5-11 cm.
PAGE 220
Psychosocial changes that occur with Pregnancy
• Accepting the Pregnancy
*Woman and partner both spend time recovering
from shock of learning they are pregnant and
concentrate of what it feels like to be pregnant.
Common reaction is ambivalence
• Accepting the Baby
*Woman and partner move through emotions such
as narcissism and introversion as they concentrate
on what it feel like to be a parent. Role playing and
increased dreaming are more common.
• Preparing for the baby and the end of
pregnancy
*Woman and partner prepare for clothing
and sleeping arrangements for the baby
but also grow impatient with pregnancy as
they ready themselves for birth.
Emotional Responses to Pregnancy
PAGE 223
 Ambivalence
Normal Response; Discomforts of pregnancy caused
mixed feelings. She may make comments such as: “I
thought I wanted a baby, but now I'm not so sure.”
 Grief
Commonly occurs as a result of changes in the woman's

role
 Narcissism
Woman focuses on self and changing body

Signifies an effort by the woman to protect her body
and the fetus
 Introversion or Extroversion
Woman focuses on self or become more out going

Emotional Responses to Pregnancy
Stress reaction
Pregnancy interferes with ability to perform daily tasks
such as caring for other family members; support
systems can alleviate some stress and aid adaptation to
pregnancy
 Emotional lability-mood changes;influenced by

hormones;avoiding fatigue and reducing stress can help
 Couvade Syndrome
Partner may experience discomforts such as nausea,
vomiting, fatigue, similar to or possibly more intense
than those that the pregnant woman experiences
Maternal Physiology Changes
During Pregnancy PAGE 228
Uterus
-length increases from approximately 6.5 to 32cm
-depth increases from 2.5 to 22 cm
-width expands from 4 to 24 cm
-weight increases from 50 to 1000g
-early in pregnancy uterine wall thickens about 1 cm
to 2 cm towards the end of pregnancy only about
0.5 cm thick
-the volume of the uterus increases from about 2ml
to more than 1000ml
-the uterus can hold a 7 lb(3175) fetus plus 1000ml
amniotic fluid for a total of 4000g at term
• -before pregnancy uterine blood flow is 15 to 20
ml/min,by the end of pregnancy as much as
500 to 750 ml/ min which 75 % goes to the
placenta.
• - uterus feels more anteflexed, larger and softer
to the touch
• -Hegar’s sign- softening of the lower uterine
segment
• -lightening-the uterus returns to the height it
was at 36 weeks, it seems to lighten the
woman’s load.
-Ballottement-16th to 20th weeks of pregnancy
-if the lower uterine segment is tapped sharply
by the lower hand , the fetus can be felt to
bounce or rise in the amniotic fluid up against
the top examining hand.
- Braxton hicks contractions-
- “practice” contractions
- felt by a woman as waves
of hardness or tightening across
her abdomen
Ovaries
- Ovulation stops with pregnancy because of the active feedback
mechanism of estrogen & progesterone produced by the
corpus luteum early in pregnancy and by the placenta later in
pregnancy. this feedback causes the pituitary gland to halt
production of FSH & LH ,thereby ovulation will not occur.
-Amenorrhea (absence of menstruation) occurs with pregnancy
because the suppression of FSH by rising estrogen levels
Cervical changes
- The cervix of the uterus becomes more vascular and
edematous,it darkens from a pale pink to a violet hue
-endocervix undergo both hypertrophy and hyperplasia
-operculum- mucous plug in the cervix
-Goodell’s sign – softening of the cervix
*nonpregnant cervix- nose
*pregnant cervix- earlobe
*just before labor- soft as butter ,said to be ripe for birth
Vaginal changes
-Chadwick’s –increase in circulation changes the
color of the vaginal walls from the normal light
pink to deep violet
-Vaginal secretions during pregnancy fall from a
pH of greater than 7 ( alkaline pH)
-pH 4 or 5 (an acid pH) owing to increased
production of lactic acid from glycogen in the
vaginal epithelium by lactobacillus acidophilus.
-vaginal epithelium and underlying tissue
become hypertrophic and enriched with
glycogen which results in a white vaginal
discharge throughout pregnancy
Changes in the breast
-feeling of fullness, tingling or tenderness in her
breast because of high estrogen level
-areola of the nipple darkens and its diameter
increases from about 3.5cm to 5 or 7.5 cm.
-darkening of the skin surrounding the areola in
some women, forming a secondary areola.
-Montgomery’s tubercules enlarge and become
protuberant.
-by 16th week, colostrum can be expelled from
the breasts
Systemic changes
*Integumentary system
-Striae gravidarum often develop- pink or
reddish, slightly depressed streaks in the skin
of abdomen, breast, and thighs. (Become
glistening silvery lines after pregnancy.)
-Diastasis-rectus muscles separate to
accommodate the growing fetus.(after
pregnancy it appear as a bluish groove at the
site of separation)
-umbilicus appear as if it has turned inside out,
protruding as a round bump at the center of
the abdominal wall.
-Linea nigra – a narrow brown line may form
running from the umbilicus to the symphysis
pubis and separating the abdomen into right and
left hemisphere
-Melasma / Chloasma
“the mask of pregnancy”- darkened areas may
appear on the face (cheek and across
the nose)
-vascular spider or telangiectases (small, fiery red
branching spots) on the thigh,result from
increased level of estrogen
-increased activity of sweat glands- increase in
respiration
-Palmar erythema-(redness and itching) occurs on
hands due to increased estrogen level.
-scalp hair growth is increased due to increased
metabolism
Respiratory system (RR 18 to 20 breaths/min)
-marked congestion or stuffiness of the nasopharynx
due to increased estrogen
-crowding of the chest cavity causes shortness of breath
late in pregnancy, until lightening relieves the pressure
-tidal volume (volume of air inspired) is increased up to
40% as a woman draws in extra volume to increased
the effectiveness of air exchange.
-total oxygen consumption increases by as much as
20%
-increased mild hyperventilation to blow off excess CO2
shifted to her by the fetus to prevent the mother’s ph
level becoming acidic
-to exhale more than the usual CO2 the woman may
develop respiratory alkalosis, to compensate kidney
excrete plasma bicarbonate in urine.This result in
polyuria .
Temperature
-body temp increases slightly because of
progesterone as the placenta takes over the
function of the corpus luteum at about 16
weeks, the temp usually decreases to normal.
Cardiovascular system
*Blood volume
- Increased total circulatory blood volume by at
least 30% or 50%
- Blood loss NSVD – 300 to 400 ml
- Blood loss CS – 800 to 1000 ml
• Pseudoanemia-a condition where the
plasma volume increases faster than RBC
production, thereby hemoglobin and
erythrocytes concentration declines on the
first trimester.
Pre-pregnancy Pregnancy
Cardiac output 25 – 50 %
Hear rate 70-80 80-90
Plasma volume 2,600 ml. 3,600 ml.
Blood volume 4,000 ml 5,250 ml
Red blood cells mass 4,200,000 mm3 4,650,000 mm3
Leukocytes 7,000 20,500
Total protein (gldl) 7.0 5.5 – 6.0
Blood pressure decreases in
2nd trimester
At pre-pregnancy level-3rd trim

-increased need of iron about 800 mg
*decreased gastric acidity during pregnancy
impaired iron absorption
-increased need of folic acid
* megalohemoglobinemia( large nonfunctioning
RBC)
*neural tube disorders in fetus
-encourage woman to eat (spinach, asparagus,
legumes)
Heart
-heart rate increases by 10 beats/ min
-diaghragm is pushed upward by the growing
uterus late in pregnancy,the heart is shifted to
a more transverse position in the chest cavity.
-palpitation of the heart in the early months of
pregnancy are probably caused by
sympathetic nervous system stimulation,
in later months result from increased thoracic
pressure caused by the pressure of the uterus
against the diaphragm.
Peripheral blood flow
-blood flow to the lower extremities is impaired by the
pressure of the expanding uterus on veins and
arteries leads to edema and varicosities of the vulva,
rectum and legs
Supine hypotension syndrome
-when a pregnant woman lies supine ,the weight of the
growing uterus presses the vena cava against the
vertebrae, obstructing blood flow from the lower
extremities.
-woman experiences hypotension, as lightheadedness
,faintness, and palpitations.
-may cause fetal hypoxia
- can be corrected by having a woman turn on her
side (left side)
Gastrointestinal system
-nausea and vomiting /morning sickness-due to
increased HCG and progesterone
-as the uterus increases in size, it pushes the
stomach and intestines toward the back and
sides of the abdomen, this pressure slow
intestinal peristalsis and the emptying time of the
stomach leading to heartburn, constipation and
flatulence
-relaxin / progesterone may contribute to
decreased gastric motility
-decreased emptying of bile from the
gallbladder can lead to reabsorption of
bilirubin into the maternal bloodstream
which lead to generalized itching
-increased tendency to stone formation due
to increased plasma cholesterol level and
cholesterol incorporated in bile
-hypertrophy of the gums and bleeding of
gingival tissue
-Hyperptyalism -increased saliva formation due
to increased estrogen level
Urinary sytem
Glycosuria is evident due to increase in glomerular filtration
- without increase in tubular re-absorptive capacity for filtered glucose.
Glomerular Filtration rate by 50%
Renal Plasma Flow by 25 – 80%
UN by 25%
asma creatinine level by 25%

Renal threshold for sugar To allow slight spillage
adder capacity by 1,000 ml
ameter of ureters by 25%

equency of urination 1st trimester
Last 2 wks of pregnancy
10 to 12 times/day
Skeletal syatem
-. The increasing mobility of sacroiliac,
sacrococygeal, and pelvic joints during
pregnancy is the result of hormonal
(progesterone) changes.
- This mobility contributes to alteration of
maternal posture and to back pain.
- Lordosis- the pride of pregnancy
Endocrine system
-placenta produces estrogen,
progesterone,HCG,human placental
lactogen, relaxin, prostaglandin
Pituitary gland-a major change in the PT is

the halt in production of FSH and LH
because of high estrogen and
progesterone levels produced by placenta.
-increased production of growth hormone
and melanocyte-stimulating hormone, late
in pregnancy oxytocin and prolactin.
Thyroid and Parathyroid
-levels of protein- bound iodine, butanol-
extractable iodine, and thyroxine are all
elevated
-emotional lability,tachycardia,palpitation,
and increased perspiration may lead to a
mistaken diagnosis of hyperthyroidism.
-parathyroid gland necessary for metabolism of
calcium also increased
Adrenal gland
-increased level aid in suppressing an
inflammatory reaction or help reduce the
possibility of a woman’s body rejecting the
foreign protein of the fetus.
-help regulate glucose metabolism
- Aid in promoting sodium reabsorption and
maintaining osmolality in the amount of
fluid retained
Pancreas
-secretes an increased level of insulin, it
appears to be not effective
-to ensure against hypoglycemia ,diet high in
calories and should never go longer than
12 hrs between meals
-Immune system
- Decreased immunoglobulin to prevent a
woman’s body from rejecting the fetus.
Immunoglobulin G(IgG) is decreased
which make a woman prone to infection.
SIGNS & SYMPTOMS OF PREGNANCY PAGE 226
 Subjective (Presumptive) Changes – symptoms are
experienced by a woman
 Amenorrhea (80% of patients) or slight, painless spotting of
unknown cause in early gestation (20% of patients)

 Nausea and vomiting
 Urinary frequency and urgency
 Breast enlargement and tenderness, fatigue
 Intensified skin pigmentation[melasma,linea nigra,striae
gravidarum]
 Quickening(mother's perception of fetal movement)
 Thinning and softening of fingernails
 Probable - signs are perceived by the examiner
 Uterine enlargment
 Goodell's sign (softening of the cervix)
 Chadwick's sign (bluish mucous membranes of the vagina,
cervix and vulva

 Hegar's sign (softening of the lower uterine segment
SIGNS & SYMPTOMS OF PREGNANCY
 Probable (continued)
 Braxton Hicks contractions (painless uterine
contractions that recur throughout pregnancy)

 Ballottment (passive fetal movement and response to
tapping of the lower portion of the uterus or cervix)

 Laboratory test results indicating pregnancy (positive
HCG pregnancy test)

 Uterine souffle (soft blowing sound heard when
auscultating the abdomen, caused by blood pulsating

through the placenta
 Palpable fetal outline during examination
 Ultra sonographic evidence of a gestational sac
(visible as early as 4 to 6 weeks gestation)

SIGNS & SYMPTOMS OF PREGNANCY
 Diagnostic (Positive) Changes

 Signs are completely objective and caused only by
pregnancy
 Fetal heartbeat audible at 10 to 12 weeks gestation by
Doppler ultrasound and at 16 to 20 weeks gestation

with a fetoscope
 Ultrasonography results as early as 6 weeks gestation
 Fetal movements felt by the examiner after 16 weeks
gestation
 Visualization of the fetus and fetal outline by
sonogram
COMMON DISCOMFORTS DURING
THE FIRST TRIMESTER PAGE 283
1. Nausea and vomiting (morning sickness)

 Cause: Hormonal changes, fatigue, emotional factors,
changes in carbohydrate metabolism

 Patient teaching – avoid greasy, highly seasoned foods;
eat small, frequent meals; eat dry toast or crackers before

getting out of bed
2. Nasal stuffiness, discharge or obstruction

 Cause: Edema of the nasal mucosa from elevated
estrogen levels
 Patient teaching – use a cool moist humidifier; use
normal saline nose drops or nasal spray; apply cool

compresses to nasal area
THE 1ST TRIMESTER
3. Breast enlargement and tenderness
 Cause: Increased estrogen and progesterone levels
 Patient teaching: wear a well-fitting bra with wide shoulder
straps; maintain good posture; wash breast and nipple area

with water only
4. Urinary frequency and urgency
 Cause: Pressure of the enlarging uterus on the bladder; around
the 12th week the uterus rises into the abdominal cavity
causing symptoms to disappear; symptoms recur in the 3rd
trimester as the uterus again presses on the bladder
 Patient teaching: decrease fluid intake in the evening to
minimize nocturia; limit intake of caffeinated beverages;

promptly response to the urge to void to prevent bladder
distention and urine stasis; perform Kegel's exercises; teach
signs and symptoms of UTI and instruct to report promptly
THE 1ST TRIMESTER
5. Increased leukorrhea
 Cause: Hyperplasia of vaginal mucosa; increased mucus
production by the endocervical glands

 Patient teaching: daily bath and avoid using soap on the vulvar
area; reinforce the need to wipe from front to back; wear loose,
absorbent cotton underwear and to avoid tight pants and
pantyhose; avoid douching; notify health care provider if the
discharge changes in color or odor
6. Increased fatigue
 Cause: The increased effort of the body to manufacture the
placenta; the need to adjust to the many physical and emotional

demands of pregnancy
 Patient teaching – have frequent rest periods; obtain rest during
the day; eat a balance diet and take iron supplement; suggest
use of warm milk or warm shower before going to bed at night
to aid in relaxation; engage in moderate regular exercise
THE 2ND AND 3RD TRIMESTER
1. Heartburn
 Cause: decreased GI motility; increased production of
progesterone; gastric displacement
 Patient teaching: Eat small, frequent meals; avoid fatty
and fried foods and caffeine products; remain upright for

one hour after meals
2. Constipation
 Cause: Oral iron supplement; displacement of the
intestines by the fetus; bowel sluggishness caused by
increased progesterone
 Patient teaching: engage in moderate daily exercise; drink
plenty of fluids; increase daily intake of fiber; maintain

regular elimination patterns; avoid use of mineral oil
which can deplete her level of fat soluble vitamins
3. Hemorrhoids
 Cause: Pressure on the pelvic veins by the enlarging uterus,
which interferes with venous circulation; increased pressure

secondary to constipation
 Patient teaching: Avoid constipation; avoid prolonged standing
and wearing constrictive clothing; lie on left side with feet

slightly elevated; use topical ointment or anesthetic if allowed;
use of witch hazel compresses, sitz bath or apply warm soaps
4. Backache
 Cause: Postural adjustment of pregnancy secondary to curvature
of the lumbosacral vertebrae that increases with uterine

enlargement
 Patient teaching: Use proper body mechanics; maintain good
posture; wear low-to-mid heeled shoes; walk with pelvis tilted

forward; use a board under the current mattress to add firmness;
perform pelvic rocking or tilting exercises; apply local heat to
the back, if necessary
5. Leg Cramps
 Cause: Pressure from the enlarging uterus; poor
circulation; fatigue; balance in the calcium-phosphorus

ratio
 Patient teaching: Rest with legs slightly elevated; wear
warm clothing; assist woman with measures to alter

calcium and phosphorus intake; teach her what to do
during a leg cramp (pull the toes up toward the legs while
pressing down on the knee)
6. Shortness of breath
 Cause: Pressure of the uterus on the diaphragm
 Patient teaching: maintain proper posture; use semi-
fowler's position when sleeping; encourage a balance of

activity and rest
7. Ankle edema
 Cause: Poor venous return from the lower extremities
aggravated by prolonged sitting or standing and by warm

weather; fluid retention
 Patient teaching: Lie on the left side in bed to enhance
glomerular filtration rate of the kidneys; avoid wearing

tight, constrictive clothing; elevate legs during rest
periods; dorsiflex the feet when standing or sitting for
prolonged period; get up and move about every 1 to 2
hours when sitting for long periods
8. Varicose Veins
May affect the lower extremities, vulva, and pelvis.
1. Cause:
a. Heredity
b. Pressure of gravid uterus on the great
veins of the pelvis.
c. Prolonged standing
d. Constrictive clothing
2. Treatment:
a. Avoid restrictive clothing
b. Elevate legs and hips on pillows above the level
of the heart.
c. Wear elastic stockings or bandages.
d. Take frequent rest periods.
SEXUAL DESIRE BY TRIMESTER
PAGE 225
 First Trimester -may decrease due to discomfort and
fatigue
 Second Trimester – may increase when discomforts

wane. The woman may have greater sexual
satisfaction than before pregnancy because of vascular
congestion of the pelvis
 Third Trimester – may decrease due to increasing

fatigue and abdominal size. Changes in position and
use of water soluble lubricant may be necessary
Sexual behavior is usually unrestricted in
complication-free pregnancies
PATIENT COUNSELING
Danger signs to report immediately:

 Severe vomiting
 Frequent, severe headaches
 Epigastric pain
 Fluid discharge from vagina
 Fetal movement changes or cessation after
quickening
 Swelling of the fingers or face
 Vision disturbances
 Signs of vaginal or UTI
 Unusual or severe abdominal pain
 Seizure or muscular irritability
 Preterm signs of labor such as, rhythmic contractions

Self – care needs page 276
Bathing
• sweating tends to increased during pregnancy
• daily bath tubs or showers are now
recommended
• woman should not soak for long periods in
extremely hot water or hot tubs may lead to
hyperthermia in the fetus
• as pregnancy advances ,she should change to
showering or sponge bathing for her own safety
• if membranes ruptured , cervix begin to dilate or
vaginal bleeding present, tub baths are
contraindicated because of danger of
contamination of uterine content
Breast care
 Proper breast support promotes comfort,retains
breast shape,and prevent back strain

 Washing the breast with clear water and no soap
daily
 Gauze or breast pads may be needed if the woman's
secretion of colostrum is significant

Dental Care – dental check up early in
pregnancy and routine examinations and cleaning are
encourage
 Nausea, vomiting, heartburn may lead to poor oral
hygiene and dental caries

 The fetus receives calcium and phosphorus from the
pregnant patient's diet not from her teeth, the belief

that a patient looses a tooth for every pregnancy is a
fallacy
 Nutritional snacks (fresh fruits and vegetables) are
recommended to avoid excessive contact of sugar

with the teeth
Perineal hygiene
• the woman may desire to have a vaginal
douche due to an increased vaginal discharges
during pregnancy
• Douching is contraindicated during pregnancy
• -the force of the irrigating fluid could cause to
enter the cervix and lead to infection
• -douching alters the ph of the vagina, leading to
an increased risk of bacterial growth
4. Clothing – Comfort is the key
 recommend loose-fitting,comfortable garments
- Non restrictive and low-to-mid heeled shoes to
prevent backache and poor balance

- Avoid tight-fitting such as garters,girdles with
panty legs, and knee –high stockings

Sexual activity
• sexual relation during pregnancy are
contraindicated:
• woman with a history of spontaneous
miscarriage
• woman whose membranes have ruptured
or have vaginal spotting to avoid infection
• advise caution about male –oral female genital
contact, because accidental air embolism has
been reported
• Side by side position or woman in a superior
position may be more comfortable
Exercise
• extreme exercises has been associated with lower
birth weight
• moderate exercise is healthy
• walking is the best exercise during pregnancy
• jogging can cause pelvic pain
• high –impact aerobics contraindicated
• swimming is not contraindicated as long as the
membranes are intact
• diving or long distance swimming should be avoided
• Hot tubs/ saunas after workouts longer than 15 mins is
contraindicated
Sleep
• Pregnant woman need rest period during
the afternoon as well as a full night sleep
• Modified sim’s position- with the top leg
forward
• Avoid resting on her back to prevent
supine hypotension syndrome
Supine hypotension syndrome
Employment
 Check the work site for potential
environmental hazards(pesticides, anesthetic
gas, heavy metals as lead and mercury)
 If it involves lifting heavy object ,excessive
physical strains, long periods of standing or
sitting pregnant ,interference with adequate
rest and nutrition, the pregnnat woman should
not continue working.
Travel
• When riding in a car, wear seat belts low, under
the abdomen
• On a long trip, get out of the car every hour ,but
at least every 2 hrs to walk around
• Travel by air in airplanes with well-pressurized
cabins. Some airlines have restrictions for
woman more than 7 months pregnant
Perineal and Abdominal
Exercises page 334
1. Tailor sitting- stretches abdominal muscles

-It also improves your posture, keeps your pelvic joints
flexible and increases blood flow to your lower body.
• To practice tailor sitting, sit on the floor with your
back straight. Bring the bottoms of your feet
together, pull your heels toward your groin and
gently drop your knees. You'll feel a stretch in
your inner thighs. Try tailor sitting anytime you're
able to sit on the floor.
• If it's difficult to sit in this position, use a wall to
support your back or place cushions under each
thigh. Remember to keep your back straight.
Exercises page 334
2. Squatting- stretches perineal muscle and
can be a useful position during the 2nd
stage of labor
• Stand with your feet slightly greater than
shoulder-width apart and your toes pointing
ahead. Slowly descend, bending through the
hips, knees and ankles. Keep your heels flat on
the floor. Stop when your knees reach a 90-
degree angle. If you can't bend your knees to a
90-degree angle, simply go as low as you can.
Then return to the starting position. Repeat
several times. Gradually work up to 10
repetitions.
Exercises page 334
3. Pelvic floor contractions or kegel
exercises- a perineal muscle strengthening
exercise, helpful in the post partum period
to reduce pain and promote perineal
healing.
• Start with Kegel exercises, which help tone your
pelvic floor muscles. Simply tighten your pelvic
muscles as if you're stopping your stream of
urine. Try it for five seconds at a time, four or five
times in a row. Work up to keeping the muscles
contracted for 10 seconds at a time, relaxing for
10 seconds between contractions. Aim for at
least three sets of 10 repetitions a day. You can
do Kegels while standing, sitting or lying down.
4. Abdominal muscle contractions- help
strengthen abdominal muscle during
pregnancy therefore may help prevent
constipation as well as restore abdominal
tone after pregnancy
5. Pelvic rocking- helps relieve backache
during pregnancy and early labor by
making lumbar spine more flexible.
• Nutrition during pregnancy PAGE 303
– Calories-requirement exceeds pre-pregnancy needs by
300calories/day(from 2,200 kcal/day to 2,500 kcal/day)
– Protein-from 46g/day to 71 g/day
– Fats-20% to 35% of woman's daily calorie intake
*Linoleic acid( found in veg oils ,such as corn, olive),
Vitamins-Intake of all vit. should be increased

Fat –soluble vitamins
– Vit A- 750 ug /day
– Vit D-5 ug /day
– Vit E- 15 mg/day
Water – soluble vitamins
– Vit C -80mg/day
– Folic acid -600ug/day
– Niacin -18 mg/day
– Thiamine B1- 1.4 mg/day
– Vit B12 -2.8ug/day
– Vit B6 – 1.9 mg/day
Nutrition during pregnancy
Minerals
-Calcium 1300mg/day
-Fluoride 3 mg/day
-Iodine 220 ug/day
-Iron 220 ug/day
-Magnesium 400 mg/day
-Phosphorous 400 mg/day
-Zinc 12 mg/day
Fluid needs
-6 to 8 glasses daily
Fiber needs
-encourage women to eat plenty of fruits and
vegetables
Foods to avoid or limit in pregnancy
PAGE310
1.alcoholic beverages-teratogenic effect
2.food additives
3.excess seafood
-2 to 3 meals of seafood or shellfish / week
-For their omega -3 and iodine content
-6 ounces(1 meal) per week of fish
- sharks, swordfish,king mackerel or tilefish
are high in mercury contamination
4. Foods with caffeine
-a central nervous system stimulant capable of
increasing heart rate,urine production in the
kidney,and secretion of acid in the stomach
-2 to 3 cups of coffee has not been associated with
low birth weight infant
- drinking over 3 cups is associated with early
miscarriage
-chocolate, cocoa bean,softdrinks and tea contain
caffeine
Artificial sweeteners
-used to improve the taste and to limit the
caloric content of foods
-pregnant woman need carbohydrates from
sugar rather than artificial substances
-sweetener aspartame-safe for pregnancy
-saccharine not recommended during
pregnancy because it is eliminated slowly
from the fetal bloodstream
Danger Signs of Pregnancy
page 269
• Signs Indicating Complications of Pregnancy
1. Vaginal Bleeding
- spotting
2. Persistent Vomiting
- vomiting continues after 12th weeks
(hyperemesis gravidarum)
3. Chills and Fever
- benign gastroenteritis
- intrauterine infection
4. Sudden Escape of Fluid from the Vagina
-threatened abortion ,umbilical cord prolapse,
5. Abdominal or Chest Pain
- ectopic pregnancy,separation of the placenta,
- preterm labor, appendicitis, ulcer
- chest pain (pulmonary embolus that can fallow
thrombophlebitis)
6. Pregnancy Induced Hypertension
several symptoms
• severe and even fatal elevation of blood pressure that
occurs during pregnancy.
1. Rapid wt. Gain( over 2 lb per week in the 2nd
trimester, 1 lb per week in the third trimester)
2. Swelling of the face or fingers
3. flashes of light or dots before the eyes
4. dimness or blurring of vision
5. severe continous headache
6. decreased urine output
7. Increase or Decrease in Fetal
movement
- unusual increase or decrease
in movement suggests that a
fetus is responding to a need of
oxygen
Laboratory assessment
page227 urine pregnancy test
-determine pregnancy through the detection
of the hormone Human Chorionic
Gonadotropin (hCG) in a woman’s urine.
- Human Chorionic Gonadotropin (hCG)
is a hormone which is produced early in
pregnancy by the placenta in great volume
(hormone released by developing
embryos).
-test is done 10 to 14 days after the missed
menstrual period.
Main Causes for False Positive Pregnancy Test
• Soap or detergents -don’t use soap or any

detergents before making your pregnancy test.
• Some medications may cause a false positive on a
pregnancy test. These include anti-Convulsants,
medications to treat Parkinson’s disease, certain
tranquilizers,oral contraceptives and certain -
diuretics
• Do not drink fluids from 8pm to concentrate the
urine
• Collect first- voided urine in the morning
Laboratory assessment
serum pregnancy test
• In pregnant woman trace amount of HCG
appear in the serum as early as 24 to 48 hrs
after implantation
• About 50 milli IU / ml after 7 to 9 days after
conception
• Levels peak at about 100 m IU / ml between the
60th and 80th day of gestation,after that point, the
concentration of HCG declines again so that , at
term ,it is barely detectable in serum or urine
Blood studies PAGE 268
1.Complete blood count
• Hemoglobin , hematocrit and red cells index- to
determine anemia
• White blood cell- to determine infection
• Platelet count- to estimate clotting ability
2. Genetic screen
• For common ethnically inherited disease
• Example- african american women for sickle cell
disease, caucasian women for cystic fibrosis
3.Serologic test for syphilis ( VDRL or rapid
plasma reagin)
4.Blood typing (including Rh factor )
5. Maternal serum for alfa-fetoprotein(MSAFP)
• done at 16 to 18 weeks of pregnancy
• elevated for neural tube or abdominal defect
is present in the fetus
• decreased for chromosomal anomaly
• 2.5 MOM ( multiple of the mean) normal
value
6. Indirect Coombs test
• Determination if Rh antibodies are present in an
Rh negative woman
• Test is repeated at 28 weeks of pregnancy
• if the titers are not elevated, an Rh negative
woman will receive RhoGAM at 28 weeks and
after any procedure that might cause placental
bleeding
• It may be administered within 72 hours after
birth of a positive Rh baby whose cord blood
showed no antibodies ,a negative reaction, or
after an ectopic pregnancy.
7.Antibody titers for rubella and hepatitis B
• determine whether a woman is protected
against rubella and whether a newborn
well have the chance of developing
hepatitis B
8.HIV screening
• Screening cannot be mandatory in
prenatal setting
• Done by enzyme-linked immunosorbent
assay (ELISA) if positive , the finding is
confirmed by Western blot.
9. to rule out gestational diabetes
• history of unexplained fetal death ,fetal
loss ,family history of diabetes, LGA
babies ,obese, has glycosuria
• 50 g oral 1 hour glucose loading or
tolerance test towards the end of the first
trimester to rule out gestational diabetes
• Done routinely at 24th to 28th week to
evaluate insulin-antagonistic effects of
placental hormones
• Plasma glucose level should not exceed
140 mg/dl at 1 hour
Urinalysis
• to test for proteinuria , glycosuria, and
pyuria ( pus in urine )
Tuberculosis screening
• purified protein derivative (PPD) tuberculin
test
• if positive reaction- a chest radiograph is
indicated further diagnosis
Ultrasonography- non-invasive use of sound waves to
determine fetal presence, size, position and
presentation and to detect abnormalities. Provides
information about the fetus during each trimester:
First trimester:
 Assessment of gestational age,evaluation for
congenital anomalies;
 Diagnostic evaluation of vaginal bleeding;
 Confirmation of suspected multiple
gestation,evaluation of fetal growth, adjunct to

prenatal testing such as amniocentesis or
CVS(chorionic villus sampling)
Monitoring Fetal Status
Second trimester:
 Assessment of placental location, diagnosis of
multiple gestation
 Evaluation for congenital anomalies
 Guidance of procedure such as amniocentesis and
fetoscopy
Third trimester:
 Determination of fetal position, estimation of fetal
size
 A full bladder may improve ultrasonic resolution
before 20 weeks' gestation

 Client may be instructed to drink a quart or more of
fluids 1 to 2 hours before the procedure (abdominal

UTZ), for transvaginal UTZ usually performed
during first trimester, a full bladder is unnecessary
Preparation of labor page 297
1.Lightening or descent
-Settling of the fetal head into the inlet of the
true pelvis
-in primiparas approximately 2 weeks(10 to
14 days) before labor
-in multiparas on the day of labor or after
labor has begun.
-experience frequency in urination(frm
pressure on bladder),sciatic pain (pain
across a buttocks radiating down her legs)
from the lowered fetal position,increased
amts of vaginal discharge.
2.Show
-as the cervix softens and ripens, the mucus
plug that filled the cervical canal during
pregnancy is expelled.
-the release of the cervical plug (operculum)
-it consist of a mucus, often blood –streaked
vaginal discharge
-indicates the beginning of cervical dilatation
Rupture of membranes
-a sudden gush of clear fluid (amniotic fluid )
from the vagina indicates rupture of the
membranes
-after rupture of membranes there is danger
of cord prolapse and infection
-early rupture of the membrane can be
advantageous as it can cause the fetal
head to settle snugly into the pelvis,aiding
cervical dilation and shortening labor.
Excess energy
-extremely energetic is a sign of labor
-part of body‘s physiologic preparation of
labor
Excess energy
-extremely energetic is a sign of labor
-part of body‘s physiologic preparation of
labor
Uterine contractions
-labor begins with contractions
-true labor contractions usually start in the
back and sweep forward across the
abdomen
-gradually increase in frequency and
intensity
THEORIES OF LABOR ONSET
PAGE 351
1. Uterine muscle stretching, which results in
release of prostaglandins
2. Pressure on the cervix, which stimulates the
release of oxytocin
3. Oxytocin stimulation, which works together with
prostaglandins to initiate contractions
4. Change in the ratio of estrogen to progesterone
( increasing estrogen in relation to progesterone,
which is interpreted as progesterone withdrawal)
THEORIES OF LABOR ONSET
5. Placental age, which triggers contractions
at a set point
6. Rising fetal cortisol levels , which reduces
progesterone formation and increases
prostaglandin formation
7. Fetal membrane production of
prostaglandin, which stimulates
contractions
Signs of labor PAGE 297
Preliminary signs of labor
1. lightening-occurs 10 to 14 days before labor
begins
2. Increase in level of activity –full of energy
related to increase in epinephrine release
initiated by a decrease in progesterone
produced by the placenta
3. Slight loss of weight-as progesterone level falls
body fluid is more easily excreted from the body
-weight loss between 1 to 3 pounds
Signs of labor PAGE 297
4. Braxton Hicks Contractions –false
contractions
5. Ripening of the cervix-an internal sign
only on pelvic examination described as
“butter soft” that labor is very close at hand
Comparison of true and false labor
PAGE 362
TRUE LABOR FALSE LABOR
Uterine contractions increase No increase in intensity,

in intensity, frequency & duration & frequency of
duration uterine contractions
Ambulation increases Contractions disappear with

contractions ambulation
Discomfort radiates to the Discomfort remains in the

lowerback or lumbosacral area abdomen
TRUE LABOR FALSE LABOR
Contraction persists Contraction stops when

even if woman is woman is sedated
sedated
Progressive cervical Absence of cervical

dilatation dilation
Presence of show Absence of show

General Terms PAGE 350
1. Lie- the relationship of the long axis (spinal column) of
the fetus to the long axis (Spinal column) of the mother
2. Presentation- the part of the fetus that enters the pelvic
inlet first and leads through the birth canal during labor at
term. The three main presentation are cephalic (head
first) 96%; breech (buttocks first) 3%, and shoulders, 1%.
3. Presenting Parts- refers to the leading, or most
dependent portion of the fetus, lying over the internal os
of the cervix. It is the part on which the caput
succedaneum, localized, easily identifiable edematous
area of the scalp, forms and is the part first felt by the
examining finger during the vaginal examination.
4. Attitude- relationship of the fetal body parts to each
other. Basic attitudes are flexion or extension.
PAGE 357
5.Fetal position- is the relationship of the
presenting part to a specific quadrant and
side of a woman’s pelvis.
a.Maternal pelvis is divided into 4 quadrant
according to the mother’s right and left
-right anterior
-left anterior
-right posterior
-left posterior
Fetal landmarks
• Vertex presentation-occiput - O
• Face presentation- chin(mentum)- M
• Breech presentation-sacrum- Sa
• Shoulder presentation-scapula or
acromion process- A
• Example : ROA ,LOA ,ROP,LOP
• Posterior positions may be more painful for
a woman, because the rotation of the fetal
head puts pressure on sacral
nerves,causing sharp back pain.
• Encourage to rest in a Sim’s position on
the same side as the fetal spine may
encourage rotation from an
occipitoposterior to an occipitoanterior
position before and during labor.
Components of labor
PAGE 351
• Passage-woman’s pelvis adequate
size and contour
• Passenger- (fetus) appropriate size
and in
an advantageous position and
presentation
• Power-uterine factors are adequate
• Psyche-psychological outlook is
preserved , labor can be viewed
as a positive experience
Types of Fetal Presentation
• Cephalic-head
• Breech-buttocks or feet
• Shoulder-shoulder,hand,or elbow
• Compound-two presenting parts

appear in the pelvis at the same
time
Types of Fetal Attitude page 353
• Complete flexion- fetus in good

attitude.Spinal column bowed
forward,head is flexed forward that
the chin touches the sternum,arms
are flexed and folded on the
chest,thighs are flexed unto the
abdomen.
• Moderate flexion-chin is not
touching the sternum but in “military
position”.
• Partial extension-
Types of Cephalic Presentation page 355
Vertex- longitudinal
head sharply flexed, good (full flexion)
Brow- longitudinal
head moderately flexed,moderate (military)
Face-longitudinal
head poorly flexed,poor
Mentum(chin) -longitudinal
hyperextension of head,chin present first , very
poor
Vertex- longitudinal
head sharply flexed, good (full flexion)
Brow- longitudinal
head moderately flexed, moderate (military)
Face-longitudinal
head poorly flexed, poor attitude
Mentum-longitudinal (chin)
hyperextension of head,chin present first
very poor attitude
THE FETAL HEAD PAGE 351
From the obstetrical standpoint, the fetal head is
the most important part of the fetus because
1. It is the largest part of the baby
2. It is the least compressible.
3. It is the most frequently presenting part.
Base of the Skull
1. Characteristic of Bones
a. Large
b. Ossified
c. firmly united
d. Not compressible
2. Function is to protect vital centers on the brain
stem.
Vault of the Skull (Cranium)
The cranium is thin, poorly ossified and
easily compressible and permits
overlapping known as molding. Composed
of
1. Occipital bone posteriorly
2. 2 parietal bones on the sides
3. 2 temporal bones anteriorly
4. 2 frontal bones anteriorly
Sutures of the skull
1. Aid in molding process and identifying the
position of fetal head during the labor.
2. Sagittal suture lies between the 2 parietal
bones.
3. Lambdoidal suture- lies between the
occipital and 2 parietal bones.
4. Coronal suture-extends transversely from
the anterior fontanelle; lies between the
parietal and frontal bones.
5. Frontal suture is between the 2 frontal
bones and is, an anterior continuation of
the sagittal suture.
Fontanelle
1. Membrane space where the sutures intersect.
2. Anterior fontanelle-junction of the sagittal, frontal, and
coronal sutures close by 12 to18 months of age.
• Diamond shaped ,referred as the bregma
3. Posterior fontanelle-junction of the sagittal suture meets
the lambdoidal (smaller than anterior) closes at 6-8
weeks of age.( 2 months)
• Triangular shaped
4. Mastoid Found in each side of the head; they enable
the head to compressed enough to squeeze through
the narrow birth canal (molding)
5. Sphenoid ,ethmoid,and 2 temporal bones lie at the base
of the cranium are of little significance in childbirth
• Well-flexed vertex
Well-flexed vertex
Page 352
Diameter of the fetal skull
• Suboccipitobregmatic diameter approximately
9.5cm- from the inferior aspect of the occiput
to the center of the anterior fontanelle
• Occipitofrontal diameter approximately
12cm –from the occipital prominence to the
bridge of the nose
• Occipitomental diameter approximately
13.5cm- from the posterior fontanelle to the
chin
Types of Breech Presentation
page 356
• Complete-thighs of the fetus are
tightly flexed on the abdomen
• Frank-fetal hips are flexed but the

legs are extended and resting on
the chest
• Footling-in absence of the hip or

thigh flexion,one or both feet
presents first
Types of Breech Presentation
page 356
• Complete-thighs of the fetus are
tightly flexed on the abdomen
• Frank-fetal hips are flexed but the

legs are extended and resting on
the chest
• Footling-in absence of the hip or

thigh flexion,one or both feet
presents first
,
Types of Fetal Lie
page 355
• Longitudinal-fetus lying vertically in the
uterus
• Transverse-fetus lying horizontally in

the uterus
• Oblique-rare,midway between
transverse and longitudinal
• Molding- a change in the shape of the fetal
skull produced by the force of uterine
contractions to facilitate passage through
the pelvis.
• Engagement- refers to the settling of the
presenting part of the fetus far enough into
the pelvis to be at the level of the ischial
spines, a midpoint of the pelvis.
• floating –not engaged
• Dipping-one that is descending but has not
yet reached the ischial spines
• Molding- a change in the shape of the fetal
skull produced by the force of uterine
contractions to facilitate passage through
the pelvis.
• Engagement- refers to the settling of the
presenting part of the fetus far enough into
the pelvis to be at the level of the ischial
spines, a midpoint of the pelvis.
• floating –not engaged
• Dipping-one that is descending but has not
yet reached the ischial spines
Fetal station - the relationship of the presenting
part to the ischial spines
 station 0 is at the level of the ischial spine-
“engagement”
 station +4cm at the perineum -“crowning”
-head is “at outlet”
 station -4cm head is floating
 station -1cm above the ischial spine
 station +1cm below the ischial spine
-1 to -4cm the presenting part is above the spine
+1 to +4 cm the presenting part is below the spine
Page 354
4 methods used to determine fetal
position,presentaion,and lie
1. combined abdominal inspection and
palpation ( Leopold’s maneuvers)
2. vaginal examination
3. auscultation of fetal heart tones
4. ultrasound
Uterine Contractions page 362
A. Phases
 Increment – the building up phase and longest
phase
 Acme – The peak of the contraction
 Decrement – the letting down phase
Uterine Contractions
Uterine Contractions
B. Uterine Contraction Characteristics

 Duration- beginning of increment to end of
decrement
 Frequency – beginning of one contraction to the
beginning of the next
 Intensity – measured during the acme phase
As labor progresses,the relaxation intervals decrease from 10
mins early in labor to only 2 to 3 mins. The duration of
contractions increases from 20 to 30 seconds to a range of
60 to 90 seconds.
The intensity may be described as follow:
• Mild - the uterine is somewhat tense
• Moderate- the uterine muscle is
moderately firm
• Strong- the uterine muscle is so firm that it
seems almost boardlike
• Effacement – shortening and thinning of the
cervical canal.Normally the canal is
approximately 1 to 2 cm long, with effacement
the canal virtually disappears.
• Dilatation – enlargement or widening of the
cervical canal from an opening a few millimeters
wide to one large enough (10cm) to permit
passage of a fetus.
• Primiparas-effacement is accomplished
before dilatation
• Multiparas-dilatation may proceed before
effacement is complete
• Effacement must occur before the fetus can be
pushed through the cervical canal
otherwise,cervical tearing could result.
• Effacement – shortening and thinning of the
cervical canal.Normally the canal is
approximately 1 to 2 cm long, with effacement
the canal virtually disappears.
• Dilatation – enlargement or widening of the
cervical canal from an opening a few millimeters
wide to one large enough (10cm) to permit
passage of a fetus.
• Primiparas-effacement is accomplished
before dilatation
• Multiparas-dilatation may proceed before
effacement is complete
• Effacement must occur before the fetus can be
pushed through the cervical canal
otherwise,cervical tearing could result.
Stages of Labor PAGE 364
• First Stage ( Stage of Cervical Dilatation)
– Onset of regular contraction (true labor) to full
cervical dilatation
– Duration: 10 - 12 hrs for primigravida,
6 - 8 hrs for multipara
– Frequency of contractions: every 2-4 min
lasting for 45-90 seconds
– Nursing Care:
• Monitor VS and FHR every 15 min
• Bed rest for ruptured membranes
• Empty bladder; maintain safety
• Pain relief; breathing techniques
Phases of the First stage of Labor PAGE 364
1.Latent phase - cervical dilation 0 -3cm
 Begins at the onset of regularly perceived uterine
contraction,
 mild and short contractions and last 20 – 40 sec
 Uterine contractions occur regularly every 5-10 mins
 6h for primipara ,4.5h for multipara
 provide emotional support, offer ice chips
 encourage ambulation and bladder emptying
 Prolonged latent phase indicates cephalopelvic
disproportion
 Make preparation for birth such as doing last minute
packing for her stay at the hospital
 Preparing older children for her departure and the
upcoming birth or giving instructions to person who
will take care of them while she is away
2.Active phase - cervical dilation 4-7cm
• contractions are 3 to 5 min apart and last
40-60 sec
• 3h for primipara ,2h for a multipara
• Show and spontaneous rupture of the
membranes may occur
• Contraction grow strong ,last longer
• Frightening time
• encourage proper breathing, side-lying
position
• perform perineal care
3.Transitional phase – complete effacement and
cervical dilation 8 -10cm
• contractions are 2 to 3 min apart and last 60-90 sec
• Intense discomfort, accompanied by nausea and
vomiting
• A feeling of loss of control ,panic or irritability
• If the membranes have not previously ruptured or
been ruptured by amniotomy, they will rupture as a
rule at full dilatation
• She may resist being touched and push that person
away
• stay with patient at all times, birth may be imminent
• An irrisistible urge to push occurs
Stages of Labor
• Second Stage(Stage of Expulsion)
– From full cervical dilatation to delivery of infant
– Duration: 30-60 min or 1hr (primigravida),
20 min (multipara)
– Frequency: 2-3 min lasting 60-90 sec
– Uncontrollable urge to push or bear down with each
contraction as if to move her bowels
– Strong intensity
– Perineum begins to bulge and appears tense
– Anus may become everted and stool may be
expelled
– Crowning occurs
– All of her energy, her thoughts are directed towards
giving birth
Second Stage(Stage of Expulsion)
• Nursing Care:
– Transfer to Delivery Room (8-9 cm for
multigravidas; full dilation for
primigravidas)
– Monitor VS & FHR
– Perineal prep
– Encourage pushing with contractions
– Immediate Newborn Care
Cardinal Movements/
Mechanisms of Labor PAGE 358
• E – engagement (pres.part fixed in true
pelvis)
• D - descent (pp progresses thru pelvis)
• F - flexion (chin brought down to chest)
• I - internal rotation ( pp rotates fr Left
Occiput transverse to left occiput
anterior ,90 degrees)
• E – extension ( pp reaches perineum)
• E – external rotation (shoulder rotates to
Ant.Post.)
• E - expulsion (entire infant emerges from
Stages of Labor
• Third Stage ( placental Stage)
– From delivery of infant to delivery of placenta
– After delivery of the neonate,uterus can be felt as a
round mass ,just below the level of the umbilicus .After a
few minutes of rest ,uterine contractions begin again and
the organs assume a discoid shape until the placenta
has separated approximately 5 min after the birth of the
infant.
– 5 to 30 minutes duration,
– Schultze presentation -80%
If the placenta separates first at its center and last at it
edges,it tends to fold onto itself like an umbrella and
presents at the vaginal opening with the fetal surface
evident
– shiny and glistening from the fetal membranes
Duncan presentation
-if placenta separates first at its edges,it
slides along the uterine surface and
presents at the vagina with the maternal
surface evident.
-raw, red,irregular with the ridges or
cotyledons that separate blood collection
spaces
Normal blood loss is 300 to 500 ml
Maternal side Fetal side
Signs of Placental Separation
• G - sudden Gush of blood
• U – Uterus changes from discoid to
globular
• R – Rising of the fundus
(Calkin’s sign)
• L – Lengthening of the cord
• A- appearance of the placenta at the vaginal

opening
Placental expulsion by natural bearing down or
gentle pressure on the fundus of the contracting
uterus (Crede's maneuver)
• -pressure must never be applied to a
uterus in a noncontracted state ,because
doing so may cause to evert and gross
hemorrhage.
• -ask parents whether saving the placenta
is important to them before it is destroyed.
• -asian and native american cultures
woman bury the placenta to ensure that
the child will continue to be healthy.
• -china
Placenta is cooked and eaten to ensure
the continued health of the mother
– Nursing Care:
• Assess for placental separation
• Inspection of placenta(Duncan/Schultze)
• Monitor VS
• Initiate breastfeeding
• Administer oxytocin as ordered
• Sending cord blood to laboratory if the
mother is blood type O or Rh-negative
• Allow bonding
Stages of Labor
• Fourth Stage
– time from delivery of placenta to
homeostasis
– 1 to 4 hours after birth of placenta
– Nursing Responsibilities:
• Monitor VS every 15 minutes
• Monitor fundal height, position,
and consistency
• Assess for lochia
• Check perineum
• Perform perineal care from front
to back
• Post partum care
BIRTH page 392,
• Ritgen maneuver- a sterile towel is place over the rectum
and press downward on the fetal chin while the other
hand is pressed downward on the occiput.
• Pressure should never applied to the fundus of the
uterus to effect birth ( uterine rupture)
• The woman may be asked to pant and not to push
during contraction
• Woman is asked to continue pushing until the occiput is
firmly at the pubic arch, then the head is born between
contraction
• Immediately suction the infants mouth with a bulb
syringe and check along the occiput whether a loop of
umbilical cord is encircling the neck ( nuchal cord)
• A child is considered born when the whole body is born-
this is the time that should be noted and recorded as the
time of birth – a nursing responsibility
Cutting and clamping the cord
page 393m
• The cord continues to pulsate for a few minutes after
birth and then pulsation ceases.
• Delaying the cutting until pulsation ceases and
maintaining the infant at a uterine level allows as
much as 100ml of blood to pass from the placenta into
the fetus.
• Late clamping cause over infusion,polycythemia, and
hyperbilirubinemia
Cord is clamped with 2 kelly hemostats placed 8 to 10
inches from the infant’s umbilicus and then is cut
between them.
An umbilical clamp is then applied.The vessel in the cord
are then counted to be certain that three are present
page 393m
the fetus.
hyperbilirubinemia
between them.
page 393m
the fetus.
hyperbilirubinemia
between them.
•
•
Hand baby to mom: if baby is stable
Oxytocin page 394
• Once the placenta is delivered oxytocin is
ordered to be administered IM or IV
• -increases uterine contractions and
minimizes uterine bleeding
• -oxytocin (Pitocin)- 10 to 40 U/L in IV FLUID
-10 U IM
- Side effect (hypertension)
Episiotomy page 652
• A surgical incision of the perineum used
to enlarge the vaginal outlet
Sites and benefits
- Midline, or middle of the perineum
> easier healing, decreased blood
loss, decreased postpartum discomfort
- Mediolateral, or from midline and then
angled to one side away from the
rectum
> decreased risk of rectal mucosal
tears
• Perineal cleaning
To remove vaginal or rectal secretions
To prepare the cleanest environment for the
birth of the baby
• Use warmed antiseptic (iodophor) and
rinse it with a designated solution before
birth (cold solution causes cramping)
• Always clean from the vagina outward so
that microorganism are moved away from
the vagina, not toward it.
• If fecal material expelled from the rectum,
sponge this away to prevent contamination
of the birth canal
Perineal sterile preparation page 392
• 1st sponge-begins from the mons veneris up to
the umbilicus (discard sponge)
• 2nd & 3rd- clean the area from the inner groin to
outward thigh region (midthigh)
• 4th & 5th-clean the labia (left & right) with one
downward sweep avoiding the rectum
• 6th-cleanse the vestibule with one downward
sweep from the clitoris to the vaginal OS and the
anus ( discard the sponge)
• 7th-(optional) swipe the area from the fourchette
down to the anus
Use only one stroke each time
Sterile prep is performed by circulating
nurse/midwife
Amniotomy page 652
Artificial rupture of amniotic sac to augment or
induce labor
Basic requirements:
- membranes intact
- fetus in vertex position
- fetal head at +2 station or lower
- cervical dilation of at least 3cm
Disadvantages
- increased risk of umbilical prolapse
- risk for infection
- if the patient has hydramnios, abruptio
placenta may occur
Physiologic effects of labor on a
woman PAGE 366
1. Cardiovascular system
• Cardiac output-each contraction greatly
decrease blood flow to the uterus, leading to
an increase in peripheral resistance
• -pushing during labor may increase cardiac
output by 40 % to 50 % above the prelabor
level
• -immediately after birth,with the weight and
pressure removed from the pelvis,blood
pressure decreases, then the body
compensates by sending a heavy bolus of
blood, raising the cardiac output
• -cardiac output then gradually decreases within
the first hour after birth
2. Blood pressure
-rises an average of 15 mm hg with each
contraction
-woman lies in supine position during the 2nd
stage of labor leads to hypotension
• place the woman in an upright or side lying
position
3. Hemopoietic syatem
• leukocytosis- sharp increase in WBC
• Due to stress and heavy exertion
• From 5000 to 10000 cells/mm3 to 25,000 to
30,000 cells/mm3
4. Respiratory system
• total oxygen consumption increases by
about 100% during the 2nd stage of labor
result to hyperventilation
• Appropriate breathing pattern during labor is
needed
5. Temperature regulation
• Slight elevation in temp
• Diaphoresis occurs
6. Fluid balance
• Increase in rate and depth of
respirations causes moisture to be lost
with each breath, diaphoresis, insensible
water loss during labor.
• Intravenous fluid replacement is necessary
7. Urinary system
• Decrease fluid intake during labor and increased
insensible water loss the kidneys begin to
concentrate urine to preserve both fluid and
electrolyte
• Protein traces evident in urine because of
breakdown of protein caused by increased
muscle activity
• Pressure on the bladder reduces bladder tone
• Encourage the woman to void every 2 hours
during labor
8.Musculoskeletal system
• Relaxin a hormone which soften the
cartilage between bones
• The symphysis pubis and the sacral/
coccyx joints become more relaxed and
movable which increase the pelvic ring by
as much as 2 cm.
• Woman complains of increased back pain,
or irritating, nagging pain at the pelvis as
she walks or turns in labor
9. Gastrointestinal system
• Inactive,digestive and emptying time of the
stomach become prolonged.
• Woman experience loose bowel
movement as contractions grow strong
10. Neurologic and sensory responses
• Responses related to pain (increased
pulse and respiratory rate )
Maternal Psychological
Responses to Labor
• Stage 1: anticipation, excitement or
apprehension
• Stage 2: exhaustion
• Stage 3: concern for the neonate's

condition
• Stage 4: attention focused on neonate

PAGE 370 Admission procedures for a
woman in labor
• Orientation to a birthing room
• Baseline assessment (T,PR,RR,& BP )
• Interview to obtain pregnancy history
• Brief physical examination
• Assessment of fetal heart rate
• Vaginal examination
• Urine and necessary blood samples obtained
• Explanation of fetal or uterine monitoring
equipment if this will be used and connection of
this equipment.
Intrapartum Care
• Perform admission procedures
• Lab request, perineal prep, notify AP, obtain
informed consent from client
• Provide client & family teaching throughout the
first and second stages
• Explain how activity, toileting, & hydration
needs will be met during labor
• Explain the normal process & progress of
labor
• Coach the woman regarding effective
pushing effort
• Reinforce coaching, breathing, & other relaxation
measures
• Provide physical, emotional, and pharmacologic
support as needed throughout the first and
second stages
• Promote safety
• Position to prevent cord prolapse if membranes
have ruptured
• Prevent dehydration by assessing hydration status
• Offer the client an opportunity to void every 1 to 2
hours to prevent trauma to the bladder during
pushing and birth of the newborn
• Interpret changes in the electronic fetal and
maternal monitor strip, and take appropriate action
Intrapartum Care
Prepare for the birth of the newborn

• Prepare the delivery area with equipment and
supplies
• Place the client in the birthing position
• Assist the physician with the birth
• Check all VS and FHR
Immediate postpartum assessment and nursing care
PAGE394
1. following placenta delivery ,lower both of woman’s
leg from stirrup at the same time- to prevent back
injury
2.obtain VS every 15 min for the 1st hour
-pulse & RR(80 to 90 bpm ,20 to 24 breath /min)
-BP slightly elevated
3.Palpate the fundus for size,consistency,and
position.observe for the amount of lochia
4. Perform perineal care and apply perineal pad
5.Offer a clean gown and warmed blanket
-woman may experience chills and shaking sensation
10 to 15 min after birth-due to low temp birthing
room,sudden release of presure on pelvic nerves or
of excess epinephrine production during labor.
PAGE 369 Danger signs of labor
Maternal danger signs
1. high or low blood pressure
• Systolic pressure greater than 140 mmhg
and diastolic pressure greater than
90mmhg or systolic pressure more than 30
mmhg and diastolic pressure more than
115 mmhg
• Falling BP –hemorrhage
2. Abnornal pulse
• Normal 70 to 80
• Greater than 100 bpm –hemorrhage
3. Inadequate or prolonged contractions
• Less frequent, less intense or shorter in
duration- indicate uterine exhaustion
• Longer than 70 seconds- fetal compromise
inadequate uterine filling
4. Pathologic retraction ring
• An indentation across woman’s abdomen,
a sign of extreme uterine stress and
possible impending uterine rupture
• Observe the contours of the woman’s
abdomen periodically during labor
5. Abnormal lower abdominal contour
• -full bladder during labor ,a round bulge on
her lower anterior abdomen may appear
• -bladder may be injured by the pressure of
the fetal head
• -pressure of the full bladder may not allow
the fetal head to descent
• -woman need to try to void every 2 hrs
during labor
6.Increasing apprehension
• Needs to be investigated for physical
reasons because it can be a sign of
oxygen deprivation or internal hemorrhage
PAGE 369 Fetal Danger Sign
1. High or low fetal heart rate
• FHR more than 160 bpm (fetal tachycardia)
• Less than 110 bpm (fetal bradycardia)
• Late or variable deceleration pattern on a fetal
monitor
2.Meconium staining
• A green color in the amniotic fluid
• Fetal hypoxia which stimulates the vagal reflex and
leads to increased bowel motility
• Maybe normal in breech presentation
3. Hyperactivity
• A sign of hypoxia because frantic motion is
a common reaction to the need of oxygen
• 4. Oxygen saturation
• If fetal blood was obtained by scalp
puncture the finding of acidosis (blood ph
less than 7.2 ) suggest fetal distress
• Oxygen saturation in a fetus is normally
40% to 70%
DETERMINE FETAL HEART RATE
PAGE 377
• Every 30 mins during beginning of labor
• Every 15 mins during active labor
• Every 5 mins during the second stage of labor
• BY auscultation using fetoscope,stethoscope
doppler, electronic monitoring (external
electronic monitoring or internal electronic
monitoring),telemetry
• Baseline FHR PAGE 381
NORMAL 110 -160 bpm
Fetal bradycardia –lower than 110bpm for 10mins
Moderate bradycardia-100 to 109bpm
-not serious due to compression of the
fetal head during labor
Marked bradycardia-less than 100bpm
-a sign of hypoxia and is dangerous
Fetal tachycardia-160bpm or faster for 10 min
Moderate tachycardia-161 -180bpm
Marked tachycardia-greater than 180bpm
- Cause by fetal hypoxia,maternal fever,drugs, fetal
arrhythmia,or maternal anemia or hyperthyroidism
FETAL HEART RATE PATTERN-
Periodic Changes PAGE 381
A.Early Deceleration – cause by head compression
*normally occur late in labor, when the head has
descended fairly low; they are viewed as innocent.
Intervention:
- No treatment is required.
- Rate rarely fall below 100bpm and it quickly
returns to between 110 and 160 beats at the end of
the contraction
- Continue to observe FHR
B. Late Deceleration – delayed until 30 to 40
seconds after the onset of a contraction and
continue beyond the end of a contraction. This is
an ominous pattern in labor, because it suggests
uteroplacental insufficiency or decreased blood
flow of the uterus.
*Intervention:
- Left lateral position frm supine, increase IV
flowrate
- Oxygen via face mask at least 6-10 L/min.
- D/C oxytocin infusion, notify physician
-prepare for prompt birth of the infant
FETAL HEART RATE PATTERNS
C. Variable/prolonged Deceleration –
• caused by umbilical cord compression.
Usually transient and correctable.
Intervention:
left-lateral/trendelenburg position oxygen via
face mask at 6-10 L/min,notify physician,
amnioinfusion
Non-pharmacologic way to relieve
pain during labor and delivery
PAGE 402
• Relaxation techniques
- exercises to focus attention away from pain
-bring favorite music tapes or aromatherapy
with her to enjoy in the birthing room
page 399
• Focusing-concentration on an object
• Imagery/visualization-involves mental
concentration on a person, place or thing
Prayer
• Use to relieve stress
• May bring sacred object (bible or cross)
PAGE 402
Lamaze breathing techniques-patterns of
controlled breathing:
• relax woman’s abdomen
• they are distraction techniques, because a
woman concentrate on slow paced breathing
cannot concentrate on pain
• Cleansing breath
To begin and end breathing exercises,
breathes in deeply and then exhales deeply
• inhale through the nose and exhale through
the mouth or nose
• Pant-blow pattern –useful in longest and

strongest contraction
taking three or four quick breaths (IN & OUT)
then a forceful exhalation,“Hee-hee-hee-hoo”
• Quiet, continuous, very slow panting at about

60 breaths per minute useful during strong
contractions or during 2nd stage of labor to
prevent a woman from pushing before full
dilatation
• Herbal preparation
-use to reduce pain during labor
• Little factual support for their effectiveness
• Raspberry leaves, fennel, life root
Aromatherapy and essential oils
• to complement emotional and physical
well- being
• oils penetrate cell walls and transport
nutrient or oxygen to the inside of cells
• jasmine & lavender oils for easier labor
Heat and cold application
• relieve pain of labor contraction
• application of heating pad to lower back
or moist compress for back pain
• Cool wash cloth to forehead
• Ice chips to suck for dry mouth
Bathing or hydrotherapy
• Warm shower,soaking in a tub of warm
water to apply heat to reduce labor pain
• Temp of water 35.0 to 37.8 C
• Soaking in a tub not recommended at
beginning of labor may slow contractions
and whose membrane have ruptured more
risk of infection
Therapeutic touch and massage
• Increasing the release of endorphins
• Effleurage-light abdominal massage
if with fetal monitoring is being used
effleurage may be performed on the thigh
Yoga and meditation
• Yoga-deep-breathing exercises, body-
stretching postures, and meditation to
promote relaxation
• Relax the body and release endorphins
Reflexology
• Stimulating the hands,feet and ears as a
form of therapy
• To alleviate common aliments
(headache,back pain,colds and stress)
• To restore energy to the body and improve
overall condition
Crystal or gemstone therapy
• Thought to have healing powers when
they are positioned around her body
• Woman may feel that they do not work
their healing powers in an altered position
Hypnosis
• Hypnotherapist gives posthypnotic
suggestion that she will experience
reduced pain or absence of pain during
labor
• Provide a drug free pain relief
Biofeedback
• People can control and can regulate internal
events such as heart rate and pain responses
• Must attend several sessions during pregnancy
to condition themselves to regulate their pain
response
• Biofeedback apparatus used to measure
muscle tone or ability to relax
• Transcutaneous electrical nerve stimulation
(TENS)
• Relies pain by counterirritation on nociceptors
• Electrical stimulation is applied as contraction
begins which blocks afferent fibers preventing
pain from travelling to the spinal cord synapses
from the uterus
Acupressure and acupuncture
• To correct the imbalance, needles are inserted
into the skin at designated susceptible body
points results in release of endorphins
• Application of pressure or massage
for woman in labor, Hegu point located
between the first finger and thumb on the back
of the hand
Intracutaneous nerve stimulation (INS)
• Counterirritation involving the intradermal
injection of sterile water or saline along the
borders of the sacrum to relieve lower
back pain during labor
• Aspirin interferes with blood coagulation
Obstetric Analgesia and Anesthesia
page 406
A. Opiods (meperidine,fentanyl,nalbuphine )
 Adverse reactions (mother) - respiratory depression,nausea
and vomiting, hypotension
 Adverse reaction (neonate)-respiratory depression
B. Sedatives (Barbiturates,Benzodiazepines)
Adverse reaction (mother/neonate) - respiratory depression,
decreased level of alertness
C. Anesthetics:
General anesthesia- Ketamine (Ketalar)-IV, Nitrous oxide,
isoflurane (Forane), and halothane-inhaled anesthetics
 Adverse reaction- (mother)-vomiting and aspiration,
increased uterine relaxation (postpartum uterine atony)
 Adverse reaction - (neonate)-respiratory depression, fetal
acidosis, hypotonia and lethargy

Regional anesthesia
Local anesthesia-administered to block pain neuropathways
that pass from the uterus to the spinal cord
• Lumbar epidural-injection into the epidural space in
lumbar region
- provides analgesia 1st & 2nd stages of labor
- Hypotension, postspinal headache, risk of complete
motor paralysis,urinary retention
• Spinal anesthesia-injection into the cerebrospinal fluid in
the spinal canal
• Local infiltration-injection of anesthesia into the perineal
nerves
• Pudendal block - blockage of the pudendal
Nerve used to ease pain during delivery
Spinal anesthesia
Lumbar Epidural
PUDENDAL BLOCK
Local infiltration
ANESTHETICS
Appropriate nursing diagnosis
• Pain related to labor contractions
• Powerlessness related to duration of
labor
• Risk for ineffective breathing pattern
related to breathing exercises
• Anxiety related to stress of labor
• Risk for fluid volume deficit related to
prolonged lack of oral intake and
diaphoresis from the effort of labor
Appropriate nursing diagnosis
• Pain related to labor contractions
• Powerlessness related to duration of
labor
• Risk for ineffective breathing pattern
related to breathing exercises
• Anxiety related to stress of labor
• Risk for fluid volume deficit related to
prolonged lack of oral intake and
diaphoresis from the effort of labor
• Health seeking behaviors related to
learning more about childbirth and
newborn care
• Ineffective coping related to lack of a
support person
• Anxiety related to absence of significant
other
• Decisional conflict related to lack of
information about advantages and
disadvantages of childbirth settings
• Anxiety related to role in pending birth
event and ability to welcome a sibling
• The end
Cesarean Birth
• Removal of the neonate from the uterus
through an abdominal incision
• Primary indications:
- cephalopelvic disproportion
- uterine dysfunction
- malposition or malpresentation
- previous uterine surgery
- complete or partial placenta previa
- preexisting medical
condition(diabetes/cardiac disease)
• In the case of severe obstetric
emergencies, the time from decision to
delivery is ideally within 30 minutes
• emergencies, the time from decision toIn the case of
•
•
•
Two types of incisions
• Transverse / bikini / low-segment
incision:
Incision made through lower portion of

the
uterus, allows for subsequent vaginal
birth
• Classic / vertical:
Vertical incision made through the

abdomen, limits possibility of subsequent
Classic or vertical
-vertical midline incision is made in the skin
and the body of the uterus
-indicated for fetus in transverse lie or there
are abdominal adhesions from previous
surgeries
-increased blood loss
-greater possibility of rupture of the uterine
scar
- Transverse low segment (bikini /Pfannenstiel’s
incision )
- incision is horizontal in the lower uterine

segment
- minimal blood loss,incision easy to repair
- less chance of rupture of uterine scar

Assessment
- Preoperative
- Assessing and recording FHR,maternal VS and
blood pressure
- Assisting w/ obtaining abdominal ultrasound
- Postoperative
- Monitoring for signs of infection and excessive
bleeding at the incision site
- Assessing symptoms of burning and pain on
urination
- Assessing the uterine fundus for firmness or
tenderness
- Assessing the lochia for amount and
characteristics
Nursing Intervention
- Preoperative
- Explain the procedure
- Obtaining an informed consent
- Nothing by mouth since midnight before the
procedure
- Positioning in s supine position with a rolled
towel under one hip to laterally tilt her and keep
her off of her vena cava and descending aorta.
- Inserting an indwelling urinary catheter
- Administering preoperative medication
- Preparing the surgical site
- Assuring preoperative diagnostic tests are
complete
- Providing emotional support
- Intraoperative
- Assisting in positioning on the operating table
- Continuing to monitor FHB
- Continuing to monitor vital signs,IV fluids and
urinary output
- Postoperative
- Monitoring VS
- Providing pain relief and antiemetics as
prescribed
- Encouraging turning, coughing,and deep
breathing
- Encouraging splinting of the incision w/ pillows
- Encouraging ambulation to prevent thrombus
formation

Mother and Child Health: Theories of Procreation and Human Reproduction

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Mother and Child Health: Theories of Procreation and Human Reproduction

Încărcat de

Drepturi de autor:

Formate disponibile

UUUUUUUUUUUUUUUUUUUUUUUUUUUNIT

UNIT 11 – MOTHER AND CHILD HEALTH

de111.define procreation and theories related to

Bartholin's glands-(vulvovaginal glands) bean-shaped glands on

Clitoris -erectile tissue,nerves,and blood vessels located just

Hymen - thin,vascularized mucous membrane located at

Labia majora-folds of adipose tissue that protect external

Labia minora-lubricate vulva,adding to sexual

Mons pubis-cushions anterior symphysis pubis

Skene's glands-glands located on each side of the urinary

a. Endometrium – inner mucous membrane

1. Bicornuate uterus-oddly shape

 Average length of menses is 2 to 9 days

 Initiated by the release of LHRH, also known

as GnRH, from the hypothalamus

lobe of the pituitary produces two hormones

 Endometrial lining is shed

 LH, Estrogen, & Progesterone at their lowest

 Uterine lining grows due to increased Estrogen;

 LH stimulates the release of mature, non-fertilized

 Uterus prepared for implantation

 Estrogen level drops, Progesterone level is high

(produced by corpus luteum)

 Tissue glycogen levels increase

 Estrogen & Progesterone levels declines

 Arterial vessels constrict

 Endometrium prepares to shed

 Blood vessels rupture  Menstruation begins

 Follicle matures due to FSH

 Ovulation occurs due to LH surge

 Corpus luteum develops from a ruptured

 To compute for the exact date of ovulation, count back

Germ Layer Structure

• Two umbilical arteries carry deoxygenated

• Blood flow through the cord is about 400

• Week 18 – Fine hairs covers the body and

• Last Menstrual Period (LMP)

Note: add 12 to the numerical value for the first 3 months

• 5th lunar months

• 5th lunar months

• Johnson's rule (grams)

FH (cm) – n multiply by K (155)

2.A woman who had 2 miscarriages @ 12

• Note: Pattern of weight gain is more

 Second trimester:Acceptance of the baby

 Third trimester:Preparation for parenthood

Commonly occurs as a result of changes in the woman's

Woman focuses on self and changing body

Woman focuses on self or become more out going

 Emotional lability-mood changes;influenced by

At pre-pregnancy level-3rd trim

Glomerular Filtration rate by 50%

Renal Plasma Flow by 25 – 80%

asma creatinine level by 25%

adder capacity by 1,000 ml

ameter of ureters by 25%

Pituitary gland-a major change in the PT is

unknown cause in early gestation (20% of patients)

 Urinary frequency and urgency

 Breast enlargement and tenderness, fatigue

 Intensified skin pigmentation[melasma,linea nigra,striae

 Thinning and softening of fingernails

 Probable - signs are perceived by the examiner