MATERNAL/OB NOTES

I. Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes, emotions and
preferences that are related to sexual self and eroticism.
2. Sex – is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Definitions related to sexuality:
Gender identity – sense of femininity or masculinity
2 - 4 years / 3 years gender identity develops.
Role identity – attitudes, behaviors and attributes that differentiate roles.
Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as
sexual intercourse.
Sexuality - behavior of being boy or girl, male or female; man or woman.
- It is an entity subject to a life long dynamic change.
- developed at the moment of conception.
II. Sexual Anatomy and Physiology
A. Female Reproductive System
1. External - vulva or pudendum
a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by
skin and at puberty covered by short pubic hair that serves as cushion or protection to the
symphysis pubis and surrounding delicate tissues from trauma.
Tannerscale - tool used to determine sexual maturity rating.
Stages of Pubic Hair Development
Stage 1 – Pre-adolescence - No pubic hair except for fine body hair only
Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly
hair along the labia .
Stage 3 - occurs between ages 12 and 13 – hair becomes darker & curly hair that
develops along symphysis pubis.
Stage 4 – occurs between ages 13 and 14. Hair assumes the normal appearance of
an adult but is not so thick and does no appear to the inner aspect of the
upper thigh.
Stage 5 - sexual maturity - normal adult - appear to the inner aspect of thigh.
b. Labia Majora – means “large lips” - a longitudinal fold, that extends from the symphysis
pubis to the perineum; Two folds of skin with fat underneath; contain Bartholene’s glands
c. Labia Minora – means “nymphae” – a soft and thin longitudinal fold that is located in
between the labia majora; two thin folds of delicate tissues; form an upper fold encircling
the clitoris called the prepuce and unite posteriorly called the fourchette.

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 2 sensitive structures of labia minora:
c.1. clitoris – means “key”- anterior, pea shaped erectile tissue composed of so many
nerve endings which is the sight of sexual arousal in female. (Greek-key)
c.2. fourchette - Posterior, tapers posteriorly of the labia minora
- very sensitive to manipulation, oftenly torn during vaginal delivery.
- common site – episiotomy.
d. Vestibule – an almond shaped, narrow space area seen when the labia minora are separated,
that contains the hymen, vaginal orifice and bartholene’s glands.
i. Urinary Meatus – small opening of urethra that serves for urination; external opening of
the urethra; slightly behind and to the side are the openings of the Skene’s Glands.
ii. Skenes Glands/or Paraurethral Gland – two small mucous secreting substances that
serve for lubrication; often involved in infections of the external genitalia.
iii. Hymen – a membranous tissue that covers vaginal orifice, membranous tissue
* Carumculae mystiforms - healing of a torn hymen
iv. Vaginal Orifice – external opening of vagina
v. Bartholene’s Glands/or Paravaginal Gland or Vulvo Gland - 2 small mucus secreting
substance that secrets alkaline substances- responsible for the acidity of the vagina.
( Believed to secrete a yellowish mucous which acts as a lubricant during sexual
intercourse. The openings are located posteriorly on either side of the vaginal orifice)
Alkaline – neutralizes acidity of vagina
Ph of vagina - acidic
Doderleins bacillus – responsible for acidity of vagina
e. Perineum – a muscular structure that is located in between the lower vagina & anus;
contains muscles which support the pelvic organs, the arteries that supply blood and the
pudendal nerves which are important during delivery under anesthesia.
2. Internal:
A. Vagina – female organ of copulation; passageway of menstruation & fetus
- it is 3 – 4 inches or 8 – 10 cm long of dilated canal located between the bladder and
the rectum. Contains* Rugae – permits considerable amount of stretching without tearing
B. Uterus - Organ of menstruation, site of implantation and retainment and nourishment of
the products of conception. It is a hollow, thick walled muscular organ. It varies
in size, shape and weights.
Size - 1 inch thick; 2 inches wide; 3 inches long
Shape: non pregnant = pear shaped or inverted avocado
Pregnant = ovoid
Weight : Non pregnant: – 50 - 60 grams
Pregnant: - 1000 grams
4th stage of labor - 1000 grams
2 weeks after delivery - 500 grams
3 weeks after delivery - 300 grams
Normal State - 5 - 6 weeks after delivery - 50 – 60 grams
Entire Process is “Involution of Uterus”

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 Three parts of the uterus
1. fundus - upper cylindrical layer
2. corpus/body - upper triangular layer
3. cervix - lower cylindrical layer
* Isthmus – known at the lower uterine segment during pregnancy
* Cornua - junction between fundus & interstitial
Muscular compositions: there are three main muscle layers which make expansion possible in
every direction.
1. Endometrium - inside uterus, in lines the nonpregnant uterus. Muscle layer for
menstruation. Sloughs off during menstruation.
* Decidua - thick layer; Once implantation has taken place, the uterine endothelium is
termed decidua. Occasionally, a small amount of vaginal spotting appears
with implantation because capillaries are ruptured by the implanting
trophoblasts = implantation bleeding . . .
Implication: this should not be mistaken for the LMP(Last Menstrual Period)
*Endometriosis – “ectopic endometrium” abnormal proliferation of endometrial
lining outside uterus.
Common site: ovary.
Signs/symptoms: persistent dysmennorhea and low back pain.
Diagnostic test: biopsy, laparoscopy
Drug of choice: 1. Danazole (Danocrene)
Action: a. to stop menstruation
b. inhibit ovulation
2. Lupreulide (Lupron)
Action: a. inhibit FSH/LH production
2. Myometrium – largest part of the uterus
- it is the muscle layer responsible for delivery process
- it is a smooth muscles considered to be the living ligature of the body.
- power of labor, responsible for the contraction of the uterus
3. Perimetrium – muscle layer that protects entire uterus
C. Ovaries – Almond shape, dull white sex glands near the fimbrae, kept in place by ligaments.
2 female sex glands that serves for two functions:
1. ovulation
2. Production of two hormones
D. Fallopian tubes – 2 - 3 inches long that serves as a passageway of the sperm from the uterus to
the ampulla of the passageway of the mature ovum of fertilized ovum from the
ampulla to the uterus. Widest part (ampulla) spreads into fingerlike projections
called (fimbrae) responsible for the transport of mature ovum from ovary to
uterus; fertilization takes place in its outer third or outer half.
4 significant segments
1. Infundibulum – most distal part of Fallopian Tube, trumpet or funnel shaped, swollen
at ovulation
2. Ampulla – outer 3rd or 2nd half, site of fertilization
3. Isthmus – site of sterilization – bilateral tubal ligation
4. Interstitial – most dangerous site of ectopic pregnancy
* Cortex of the ovary – releases the matured ovum

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 B. Male Reproductive System
1. External
Penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of
3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to
that of the clitoris in the female – the glands penis.
3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum
Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into
two sacs, each of which contains a testes. It is the cooling mechanism of testes
- < 2 degrees C than body temperature
Leydigs cell – release testosterone
* pure sperm plus secreting substance equals SEMEN*
2. Internal
The Process of Spermatogenesis – maturation of sperm

Testes – 900 coiled (½ inch long

at age 13 onwards)
(Seminiferous tubules)

Hypothalamus
will release Epididymis – 6 meters coiled
tubules site for maturation of sperm

GnRH
Gonadotropin
releasing hormone Vas Deferens – conduit for
spermatozoa or pathway of sperm
Entry of pure sperm

Anterior Pituitary Gland

release Seminal vesicle – secretes:
1.) Fructose – form glucose that has
nutritional value.
2.) Prostaglandin – causes reverse
FSH LF contraction of uterus
Follicle Stimulating Luteinizing
Hormone Hormone
Ejaculatory duct – conduit of semen

Function: Function: Prostate gland - release alkaline substance

Hormones for
Sperm Testosterone
Maturation Production Cowpers gland - release alkaline substance

Urethra
Final link from anterior to posterior

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 Male and Female homologues
Male Female
Penile glans Clitoral glans
Penile shaft Clitoral shaft
Testes Ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholene's glands
Scrotum Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

1. DNA – carries genetic code
2. Chromosomes – threadlike strands composed of hereditary material known as DNA
3. Normal amount of ejaculated sperm - 3 – 5 cc., 1 tsp
4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation
5. Sperm is viable within 48 – 72 hours or 2 - 3 days
6. Reproductive cells divides by the process of meiosis (haploid)
Spermatogenesis – maturation of sperm
Oogenesis – process - maturation of ovum
Gametogenesis – process of formation of 2 haploid into diploid 23 + 23 = 46 or diploid
7. Age of Reproductivity – 15 – 44 years old
8. Menstruation -
Menstrual Cycle – beginning of menstruation to the beginning of the next menstruation
Average Menstrual Cycle – 28 days
Average Menstrual Period - 3 – 5 days
Normal Blood loss – 50 cc or ¼ cup with fibrinolysin to prevent clot formation
Related terminologies:
Menarche – the beginning or the 1st menstruation
Dysmenorrhea – painful menstruation
Metrorrhagia – bleeding at completely irregular intervals of menstruation
Polymenorrhea – frequent menstruation occurring at intervals of less than three weeks
Menorhagia – excessive bleeding during regular menstruation
Amenorrhea – absence of menstruation
Oligomenorrhea – marked diminished menstrual flow, nearing amenorrhea
Menopause – cessation of menstruation / average : 51 years old
9. Functions of Estrogen and Progestin
* Estrogen “Hormone of the Woman”
Primary function: responsible for the development of secondary sexual characteristic of female.
• enlargement of the breast
• pelvic
• axillary
• pubic hair
Others:
1. inhibit production of FSH ( maturation of ovum)
2. responsible for the hypertrophy of myometrium
3. responsible for Spinnbarkeit & Ferning ( billings method/ cervical)
4. responsible for the development of ductile structure of the breast
5. responsible for the increase osteoblast activities of long bones causing increase
in height in female
6. responsible for the early closure of epiphysis of long bones
7. responsible for sodium retention

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 8. responsible for the increase sexual desire
* Progestin “ Hormone of the Mother”
Primary function: prepares endometrium for implantation of fertilized ovum making it thick &
tortous (twisted)
Secondary Function: It decreases contractility of the uterus (favors pregnancy)
Others:
1. It inhibit the production of LH (hormone for ovulation)
2. It decreases GIT motility
↓
decreases Peristalsis
↓
increase Water Reabsorption
↓
CONSTIPATION
3. responsible for the development of mammary gland
4. responsible for the increase permeability of kidney to lactose & dextrose causing (+) sugar
5. responsible for mood swings in woman
6. responsible for the increase Basal Body Temperature
10. Menstrual Cycle: average – 28 days
4 phases of Menstrual Cycle
1.1. Proliferative
1.2. Secretory
1.3. Ischemic
1.4. Menses
Parts of body responsible for menstruation:
1. hypothalamus
2. anterior pituitary gland – masterclock of the body
3. ovaries
4. uterus
I. Initial phase – of menstruation, the estrogen level is ↓ , this level stimulates the hypothalamus to release
GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing Factor)
3rd day – Decreased estrogen
13th day – Peak estrogen, Decrease progesterone
14th day – Increase estrogen, Increase progesterone
15th day – Decrease estrogen, Increase progesterone
II. GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing
Factor) – stimulates the anterior pituitary gland to release FSH (Follicle Stimulating Hormone)
Functions of FSH:
A. Stimulate ovaries to release estrogen
B. Facilitate growth primary follicle to become graffian follicle
(structures that secrets large amount of estrogen & contains mature ovum.)
III. Proliferative Phase – contains mature ovum (ovulation)
proliferation of tissue → follicular phase → post menstrual phase → Preovularoty Phase
Follicular Phase – causing irregularities or variations of menstruation; 14th days
Postmenstrual Phase – occurs after menstruation day
Preovulatory Phase – happens before menstruation day
“ all phases – increase ESTROGEN”

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IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these
stimulates the hypothalamus to release GnRH or LHRF (Luteinizing Hormone Releasing Factor)
V. GnRH/LHRF stimulates the anterior pituitary gland to release LH(Luteinizing Hormone)
Functions of LH:
1. LH stimulates ovaries to release progesterone
2. hormone for ovulation
VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture
of graffian follicle on process of ovulation.
Signs and symptoms:
Mittelschmerz – slight abdominal pain on Left or Right lower Quadrant of abdomen, marks ovulation day.
2.) Change in Basal Body Temperature
3.) Mood Swing
4.) Constipation
VII. 15th day, after ovulation day, graafian follicle starts on degenerate becoming yellowish known as
corpus luteum (secretes large amount of progesterone)
VIII. Secretory phase
Lutheal Phase
Postovulatory Increased progesterone
Premenstrual
• Secretory Phase – secretes the most important hormone in pregnancy which is the
progesterone because it makes the uterus nutritionally abundant with blood in order for the
fertilized zygote to survive should conception take place. It is also called progestational
phase.
• Luteal Phase – change from Graafian follicle to Corpus Luteum(yellowish appearance)
• Postovulatory Phase – occurs just after ovulation
• Premenstrual Phase – occurs after menstruation
IX. 24th day - no fertilization, corpus luteum degenerate turning white ( whitish – corpus albicans)
X. 28th day – no sperm in ovum – endometrium begins to slough off to have the next menstrual period
1st 7 days – menstrual phase
7 – 14th days – proliferative phase
14 – 28 days – secretory phase
11. Stages of Sexual Responses (EPOR)
Initial responses:
Vasocongestion – congestion of blood vessels
Myotonia – increase muscle tension
1. Excitement Phase – (moderate vital signs : sign present in both sexes, moderate increase in
HR, RR,BP, sex flush, nipple erection) – during this phase: erotic
stimuli increase sexual tension that may lasts from minutes to hours.
2. Plateau Phase – (accelerated Vital Signs) – increasing & sustained tension nearing orgasm.
May lasts 30 seconds – 3 minutes.
3. Orgasm – (involuntary spasm throughout the body, peak vital signs). This is the
involuntary release of sexual tension accompanied by physiologic and
psychologic release known as “immeasurable peak of sexual experience”.
May last from 2 – 10 sec- most affected are is pelvic area.
4. Resolution – (vital sign return to normal, genitals return to pre-excitement phase)
Refractory Period – the only period present in males, wherein he cannot be restimulated for about

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 10 - 15 minutes
IV. Wonders of Fertilization
Fornix - where sperm is deposited
Sperm - small head, long tail, pearly white
Phonones -vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and zona pellocida.
Capacitation - ability of sperm to release proteolytic enzyme to penetrate corona radiata and
zona pellocida.
Fertilization – union of the sperm and the mature ovum in the outer third or outer half of the
Fallopian Tube.
General Consideration:
1. Normal amount of semen per ejaculation - 3 – 5 cc = 1 teaspoon
2. Number of sperms in an ejaculate = 120 – 150 million/cc
3. Mature ovum is capable of being fertilized for 24 – 36 hours after ovulation.
4. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation
5. Sperm is viable within 48 – 72 hours or 2 – 3 days
6. Normal lifespan of sperm = 7 days
7. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after
deposition.
8. Reproductive cells, during gametogenesis, divide by meiosis (haploid number of daughter cells);
therefore, they contain only 23 chromosomes ( the rest of the body cells have 46 chromosomes ).
Sperms have 22 autosomes and 1 X sex chromosomes or 1 Y sex chromosome; Ovum contain 22
autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results
in a baby girl (XX); the union of a Y-carrying sperm and mature ovum results in a baby boy (XY).
Important: Only “fathers” determine the sex of their children
Stages of Fetal Growth and Development
3 - 4 days travel of zygote → during the travel → mitotic cell division begins
*Pre-embryonic Stage
a. Zygote - fertilized ovum. Lifespan of zygote – from fertilization to 2 months
fetus - 2 months to birth
b. Morula – mulberry-like ball with 16 – 50 cells, start to travel by ciliary action and
peristaltic contractions of fallopian tube to the uterus where it will stay for 4 days
free floating & multiplication
c. Blastocyst – enlarging cells that forms a cavity in the morulla, that later becomes the embryo.
Trophoblast – fingerlike projections covering around the blastocyst that later becomes
placenta and membrane.
d. Implantation other term Nidation - occurs after fertilization 7 – 10 days.
Placenta previa – implantation at the lower side of the uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization – corpus luteum continues to function & become source of estrogen
& progesterone while placenta is not developed.
* 3 processes of Implantation
1. Apposition – blastocysts begin to brush the endothelial lining
2. Adhesion – blastocysts begin to attached the endothelial lining
3. Invasion – blastocysts begin to settle down
“Proteolytic enzyme” – for dissolving endothelial lining allowing implantation
* Embryonic Stage

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C. Decidua – thickened endometrium (Greek word – falling off); implantation has taken place
Kinds of decidua:
* Basalis (base) part of endometrium located directly beneath or under the implanted ovum/fetus
where placenta is developed.
* Capsularies – encapsulate or co the fetus
* Vera – remaining portion of endometrium.
D. Chorionic Villi - 10 – 11th day of pregnancy; fingerlike projections
3 vessels = two arteries, one vein
A – unoxygenated blood
V – O2 blood
A – unoxygenated blood
Wharton’s jelly – protects cord
Chorionic Villi Sampling (CVS) – removal of tissue sample from the fetal portion of the developing
placenta for genetic screening. Done early in pregnancy.
Common dangerous side effects: fetal limb defect such as missing digits/toes.
Advance Maternal Age – candidate for amniocentesis
E. Cytotrophoblast – inner layer or langhans layer of the trophoblast that gives rise to the outer
surface and villi of the chorion.
- protects fetus against syphilis, however it can be capable of living
for 24 weeks/6 months
- life span of langhans layer increase.
* Before 24 weeks critical, might get infected syphilis
F. Syncytiotrophoblast – syncytial layer or outer layer . It erodes the uterine wall during implantation and
give rise to the villi of the placenta. It is responsible production of hormones. It is
also called plasmidotrophoblast; syncytial trophoblast, syntrophoblast
Two structures developed:
1. Amnion – innermost layer. It is a membrane, continuous with and covering the fetal side of
the placenta that forms the outer surface of the umbilical cord.
2 structures progress:
a. Umbilical Cord other term chorda umbilicalis, funiculus umbilicans, funis, a flexible
structure connecting the umbilicus with the placenta in the gravid uterus and giving
passage to the umbilical arteries and vein; whitish grey, “15 – 55 cm, 20 – 21”.
*Importance of determining the length of the cord:
Short cord: abruptio placenta or inverted uterus.
Long cord: cord coil or cord prolapse
Newborn: 2 feet long and ½ inch in diameter; 1st formed during the 5th week of
pregnancy; it contains the yolk sac and the body stalk with enclosed allatois.
b. Amniotic Fluid , also known as (BOW) bag of water, clear, odor mousy/musty, with crystallized
forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo - skeletal development and symmetrical growth
3. maintains temperature
4. prevent cord compression
5. help in delivery process
normal amount of amniotic fluid – 500 to 1000cc
polyhydramnios, hydramnios - GIT malformation (TEA) Tracheoesophageeal Atresia /
(TEF) Tracheoesophageal Fistula, increased amount of fluid
oligohydramnios- decrease amount of fluid – kidney disease; “inom → absorbed → ihi”

Diagnostic Tests for Amniotic Fluid

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 A. Amniocentesis – aspiration of amniotic fluid
- empty bladder before performing the procedure.
Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen
into the amniotic sac.
Fluid is tested for:
1. Genetic screening / abnormality - maternal serum alpha feto-protein test (MSAFP)
– 1st trimester
2. Determination of fetal lung maturity primarily by evaluating factors indicative of
lung maturity – 3rd trimester
2.1 Testing time – 36 weeks
decreased MSAFP(maternal serum alpha feto-protein test) = down syndrome
increase MSAFP(maternal serum alpha feto-protein test) = spina bifida or open neural
tube defect
Common infections amniocenthesis – infection
Dangerous complications – spontaneous abortion / bleeding
3rd trimester- pre term labor; indication of diabetic mother
Important factor to consider for amniocentesis - needle insertion site
Aspiration of yellowish amniotic fluid – jaundice baby / hyperbilirubin
Greenish – mecomium
A. Amnioscopy – direct examination thru an intact fetal membrane.
B. Fern Test - determine if amniotic fluid has ruptured or not
(blue paper turns green/grey - + ruptured amniotic fluid)
C. Nitrazine Paper Test – diff amniotic fluid & urine.
Paper turns yellow- urine. Paper turns blue green/gray -(+) rupture of amniotic fluid.
2. Chorion – where placenta is developed – outermost membrane
Lecithin Sphingomyelin L/S
Ratio - 2:1 signifies fetal lung maturity not capable for
RDS(Respiratory Distress Syndrome)
Test for Fetal Lung Maturity:
Shake test – amniotic + saline & shake
Foam test – amniotic + saline & shake
Phosphatiglycerol: PG+ definitive test to determine fetal lung maturity
a. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis.
- Size: 500g or ½ kg
- 15 – 28 cotyledons
-1 inch thick & 8” diameter
Functions of Placenta:
1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion
“ Higher Concentration to Lower Concentration”
2. GIT – transport center, glucose transport is facilitated diffusion more rapid from
higher to lower. If mom hypoglycemic, fetus hypoglycemic
“Higher to Lower Concentration but RAPID”
3. Excretory System- artery - carries waste products. Liver detoxifies waste products of
the fetus.
4. Circulating system – achieved by selective osmosis

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 5. Endocrine System – produces hormones
• Human Chorionic Gonadrophin – maintains corpus luteum alive; basis of
pregnancy test
• Human placental Lactogen or sommamommamotropin Hormone – for
mammary gland development. Has a diabetogenic effect – serves as insulin
antagonist
• Relaxin Hormone- causes softening joints & bones
• estrogen
• progestin
6. It serves as a protective barrier against some microorganisms – HIV,HBV
Entire pregnancy days – 266 – 280 days 37 – 42 weeks
280 divided by 28 = 10 lunar months
280 divided by 31 days = 9.7 days (calendar months)
1st week counted “zero”
Fetal Stage “ Fetal Growth and Development”
First trimester: period of organogenesis; most critical period
First Month - Brain & heart development
GIT & respiratory Tract – remains as single tube
1. Fetal heart tone begins – heart is the oldest part of the body
2. CNS develops – dizziness of mother due to hypoglycemic effect
Food of brain – glucose complex CHO – pregnant woman’s food (potato)
Differentiation of Primary Germ layers
* Endoderm
1st week endoderm – primary germ layer
Thyroid – for basal metabolism; respiratory
Parathyroid - for calcium metabolism
Thymus – development of immunity
Liver
Lining of upper Respiratory Tract & Gastro Intestinal Tract
* Mesoderm – development of heart, musculoskeletal system, kidneys and
reproductive organ
* Ectoderm – development of brain CNS, skin and 5 senses, hair, nails,
mucous membrane of anus & mouth
Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month
3. Sex organ formed
4. Meconium is formed
Third Month
1. Kidneys functional
2. Fetus begin to swallow amniotic fluid
3. Buds of milk teeth appear
4. Fetal heart tone heard – Doppler – 10 – 12 weeks
5. Sex is distinguishable

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 Second Trimester: FOCUS – length of fetus
Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 – 20 weeks
3. buds of permanent teeth appear
Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16 - 18 weeks – multi
5. fetal heart tone heard with or without instrument
Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
Third trimester: Period of most rapid growth. FOCUS: weight of fetus
Seventh Month
– development of surfactant – lecithin
Eighth Month
1. lanugo begin to disappear
2. subcutaneous fats deposit
3. Nails extend to fingers
Ninth Month
1. lanugo & vernix caseosa completely disappear
2. Amniotic fluid decreases
Tenth Month
– bone ossification of fetal skull
Teratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus
A. Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor
hearing & deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – lead to hemolysis (destruction of RBC); hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia – totally no extremities
Pocomelia - absence of distal part of extremities
Steroids – cleft lip or cleft palate or even abortion
Lithium – congenital malformation
B. Alcohol – low birth weight (vasoconstriction on mother), fetal alcohol withdrawal syndrome charterized by
microcephaly
C. Smoking – low birth weight
D. Caffeine – low birth weight abruption placenta
E. Cocaine – low birth weight

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 TORCH (Terratogenic) Infections – viruses
CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend
through birth canal and adversely effect fetal growth and development. These infections are often
characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice
(hepatic involvement). In some cases the infection may go unnoticed in the pregnant woman yet have
devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes
simples virus.
T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat
O – others. Hepa A or infectious heap – oral/ fecal (hand washing)
Hepa B, HIV – blood & body fluids
Syphilis
R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10
< 1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Avoid
pregnancy for 3 months because Vaccine is terratogenic; Notify the doctor
C – cytomegalo virus (CMV)
H – herpes simplex virus
Physiological Adaptation of the Mother to Pregnancy
A. Systemic Changes
1. Cardiovascular System – beginning the end of the 1st trimester, there is a gradual increase
blood volume of mom ( plasma blood ) 30 – 50% = 1500 cc
of blood
- easy fatigability, increase heart workload, slight hypertrophy
of ventricles,
- epistaxis due to hyperemia of nasal membrane
- palpitation due to stimulation of parasymphathetic nervous system
Physiologic Anemia – pseudo anemia of pregnant women
Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL
Criteria
1st and 3rd trimester.- pathologic anemia if lower
Hct should not fall below 33%
Hgb should not fall below 11g/dL
2nd trimester – Hct should not fall below 32%
Hgb should not fall below 10.5%
pathologic anemia if lower
Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It affects toughly 20%
of pregnant women.
Assessment reveals:
• Pallor, constipation
• Slowed capillary refill
• Concave fingernails (late sign of progressive anemia) due to chronic physiologic
hypoxia

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 Nursing Care:
• Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable-
alugbati, saluyot, malunggay, horseradish, ampalaya
• Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered,
hematoma.
• Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before
meals or 2 hours after, black stool, constipation
• Monitor for hemorrhage
Alert:
• Iron from red meats is better absorbed iron form other sources
• Iron is better absorbed when taken with foods high in Vitamin C such as orange juice
• Higher iron intake is recommended since circulating blood volume is increased and
hemoglobin is required from production of RBCs
Edema – occurs because of poor circulation resulting from pressure of the gravid uterus on
the blood vessels of the lower extremities due venous return is constricted due to
large belly.
Management: elevate / raise legs above hip level.
Varicosities – pressure of uterus
Management: - use support stockings, avoid wearing knee high socks
- use elastic bandage – lower to upper
Vulbar varicosities - painful, pressure on gravid uterus,
Management: to relieve- position – side lying with pillow under hips or
modified knee chest position
Thrombophlebitis – presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate
outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion
milk leg – skinny white legs due to stretching of skin caused by inflammation or
phlagmasia albadolens
Management:
1.) Complete Bed rest
2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
5.) Monitor APTT - Heparin toxicity : protamine sulfate(antidote for heparin)
6.) Avoid aspirin! Might aggravate bleeding.
2. Respiratory system – common problem Shortness Of Breathing due to enlarged uterus &
increase O2 demand
Management: Position: lateral expansion of lungs or side lying position.
3. Gastrointestinal – 1st trimester change
* Morning Sickness – nausea & vomiting due to increase HCG.
Management:
• Eat dry crackers or dry CHO diet 30 minutes before arising bed.
• Nausea afternoon - small frequent feeding.

14
 o Vomiting in pregnancy – emesisgravida.
o Excessive Vomiting - hyperemesisgravidarum
Metabolic alkalosis, Fluids &Electrolytes imbalance
primary medical management – Replace Fluids.
- Monitor Input & Output
* Constipation – progesterone responsible for constipation.
Management:
* Increase fluid intake
* Increase fiber diet :
fruits – papaya, pineapple, mango, watermelon, cantaloupe,
apple with skin, suha, except guava – has pectin for constipating
vegetables – petchay, malunggay, swamp cabbage (kangkong)
* Exercise
* Mineral Oil – excretion of fat soluble vitamins
* Flatulence – avoid gas forming food such as cabbage, camote
* Heartburn or “ pyrosis” – reflux of stomach content to esophagus
Management:
- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food,
sips of milk at frequent interval, proper body mechanical
- increase salivation – ptyalsim – management: mouthwash
* Hemorrhoids – pressure of gravid enlarged uterus.
Management:
• hot sitz bath for comfort
• cold compression with witch hazel or EPSOM salts
. Urinary System
frequency of urination - during 1st & 3rd trimester
management for nocturia: lateral expansion of lungs or side lying position
Nocturia – urination during night time
Heat Acetic Acid test – is a test to determine the presence of albumin and protein
in urine
Benedict’s test – test used to determine sugar in urine
. Musculoskeletal
“Lordosis” – (Greek: lordos - bent forward; osis - condition) also known as the
“pride of pregnancy”
- an abnormal anterior concavity of the lumbar part of the back; inward
curvature of the spine
“Waddling Gait” – characterized by exaggerated lateral trunk movements and hip elevation
which can be observed in a pregnant patient.
- awkward walking of a pregnant mother, candidate for accidental fall due
to relaxation and the hormone responsible for this gait is Relaxin –
responsible for softening of joints & bones; Prone to accidental falls
Management – wear flat / no heels shoes
Pregnant mothers can develop “Leg Cramps” – causes: prolonged standing, over fatigue, Ca &
phosphorous imbalance ( #1 cause while pregnant ), chills, oversex, pressure of gravid uterus
( labor cramps ) at lumbo sacral nerve plexus
Note:
Leg cramps during labor is due to pressure of gravid uterus
Leg cramps during pregnancy is due to decrease calcium and increase phosphorus

15
 Management: Food That Are Rich in Calcium:
1. Increase Ca diet - milk ( Increase Ca & Increase phosphorus )
-1 pint/day or 3 - 4 servings/day.
Note: there’s still a tendency that a mother will experience leg cramps
due to high level of phosphorus
2. Cheese, yogurt, and dairy products
3. head of fish, Dilis, sardines with bones, broccoli, seafood such as tahong (mussels),
lobster, crab.
4. Vegetable – broccoli
Management:
Place the foot affected then dorsiflexion
Note: Vitamin D for increased Ca absorption
B. Local Changes
1. Vagina – Chadwick’s sign (color change of the vagina from pink to violet)
– blue violet discoloration of vagina
Cervix – Goodell's sign (softening of the cervix)
– change of consistency of cervix
Uterus – Hegar's sign (softening of the lower uterine segment)
– change of consistency of isthmus (lower uterine segment)
LEUKORRHEA – whitish gray, mousy odor discharge
ESTROGEN – hormone, responsible for leukorrhea (remember the second letter of Leukorrhea)
OPERCULUM – mucus plug to seal out bacteria.
PROGESTERONE – hormone responsible for operculum
( remember the second letter of Operculum )
Problems Related to the Change of Vaginal Environment:
a. Vaginitits – caused by Trichomonas Vaginalis, a flagellated protozoa, local infection
of the vagina, due to alkaline environment of vagina of pregnant mom – acidic
to alkaline change to protect bacterial growth (vaginitis)
“Flagellated protozoa – wants alkaline”
Signs &Symptoms:
Greenish cream colored and frothy discharge, irritatingly itchy with foul smelling
odor accompanied by vaginal edema
Management Drug of Choice :
FLAGYL – (Metronidazole – antiprotozoa).
Note: not to be given to pregnant mothers on her 1st trimester due to
Carcinogenic effects.
1. on the 2nd and 3rd trimester – flagyl can be given
2. treat dad also to prevent reinfection
3. avoid alcohol, antabuse drus – has antibuse effect
VAGINAL DOUCHE – I quart of water and 1 tbsp white vinegar

16
 b. Moniliasis or Candidiasis – caused by Candida Albicans also called Candidiasis,
fungal infestation.
Signs & Symptoms:
Color – white cheeselike patches adheres to the walls of vagina, extreme pruritus
Management :
antifungal – Nistatin, gentian violet, cotrimaxole, canesten
Gonorrhea - Thick purulent discharge
Vaginal warts - condifoma acuminata due to papilloma virus
Management: cauterization
2. Abdominal Changes
* striae gravidarium (stretch marks) due to enlarging uterus brought
by destruction of subcutaneous tissue.
Nursing Care: Instruct to avoid scratching and application of oil
* umbilicus is protruding
3. Skin Changes
* Chloasma/ Melasma – white or light brown pigmentation in the nose, chin, cheeks
due to increased melanocytes.
* Linea Nigra – brown pinkish line running from symphisis pubis to umbilicus
4. Breast Changes – all breast changes are related to change and increase in hormones
- size and color of areola & nipple change
pre colostrums present by 6 weeks, colostrums at 3rd trimester
BSE (Breast self exam) - one week or 7 days after menstruation
Position: supine with pillow at back
quadrant B – upper outer – common site of cancer
Test to determine breast cancer:
Mammography – 35 to 49 years old should submit to mammography once every 2 years
50 years old and above – once a year
5. Ovaries – rested during pregnancy; no significant changes
6. Signs & symptoms of Pregnancy
A. Presumptive – signs and symptoms felt and observed by the mother but does not confirm
positive diagnosis of pregnancy : Subjective
B. Probable – signs observed by the members of health team: Objective
C. Positive Signs – undeniable signs confirmed by the use of instrument.
Ballotement sign of myoma
* + HCG – sign of H mole
- trans vaginal ultrasound. Empty balder
- ultrasound – full bladder
placental grading – rating/grade
0 – immature
1 – slightly mature
2 – moderately mature
3 – placental maturity

17
 What is deposited in placenta which signify maturity - there is calcium

Presumptive Probable Positive

st
1 Trimester
Breast changes Goodel's- change of consistency of cervix Ultrasound evidence
Urinary frequency Chadwick’s- blue violet discoloration of vagina (sonogram) full
bladder
Transvaginal – empty
bladder
Fatigue
Amenorrhea Hegar's- change of consistency of isthmus
Morning sickness Elevated BBT – due to increased progesterone
Enlarged uterus Positive HCG or (+)pregnnacy test
2nd Trimester
Cloasma Ballottement – bouncing of fetus when lower uterine is Fetal heart tone
Linea negra tapped sharply, sign of myoma Fetal movement
Increased skin Enlarged abdomen Fetal outline on x-ray
pigmentation Braxton Hicks contractions – painless irregular Fetal parts palpable
Striae gravidarium contractions
Quickening

VI. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)
First Trimester:
• No tanginal signs & symptoms, surprise, ambivalence, denial
• Sign of mal adaptation to pregnancy
Developmental task: is to accept biological parts of pregnancy
Health Teaching: bodily changes of pregnancy,
Focus: nutrition and on growth and development
Second Trimester
• tangible Signs & Symptoms: mother identifies fetus as a separate entity due to presence
of quickening, fantasy.
Developmental task: to accept growing fetus as baby to be nurtured.
Focus: growth & development of fetus.

Third Trimester: - mother has personal identification on appearance of baby

Development task: prepare of birth & parenting of child.
Health Teaching: responsible parenthood
Best for ‘baby’s Layette” – best time to do shopping.
Most common fear about moms fetus – let mother listen to Fetal Heart Tone to allay fear
- Lamaze classes
VII. Pre-Natal Visit:
Basic Considerations:
1. Frequency of Visit: 1st 7 months – once a month
8 – 9 months – twice a month
10 – once a week (weekly)
post term - twice a week

18
2. Personal data:
Name: for identification
Age: to determine if the mother is in high risk (high risk < 18 & >35 yrs old)
(HBMR) Home Base Mother’s Record – tool used to determine high risk pregnancy
Sex: PSEUDOCYESIS – false pregnancy common to male
COUVADE SYNDROME – psychosomatic reaction wherein the father experiences the
mother goes through; the father is the one to vomits,etc – (lihi)
Religion: for their culture & beliefs with respect, non judgmental
Occupation: financial condition or occupational hazards
Education Background: to determine level knowledge
Address; civil status
3. Diagnosis of Pregnancy
1.) urine exam to determine HCG - 6 weeks after Last Menstrual Period , 40 – 100th day but
peak 60 – 70 day best to get urine exam.
2.) Elisa test – test to detect beta subunit of HCG as early as 7 – 10 days
3.) Home pregnancy kit – do it yourself
4. Baseline Data:
Vital Signs especially Blood Pressure
Monitor weight (increase weightt – 1st sign preeclampsia), pattern of weight gain/loss is
important
Weight Monitoring
First Trimester: Normal Weight gain 1.5 – 3 lbs ( .5 – 1 lb/month )
Second trimester: Normal Weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: Normal Weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk)
Average weight gain – 20 – 25 lbs
Optimal weight gain – 25 – 35 lbs
5. Obstetrical Data:
nullipara – no pregnancy
a. Gravida - number of pregnancies, 2 children G2
b. Para - number of viable pregnancies, 2 viable P2
Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.
Age of Viability - 20 – 24 weeks
Term - 37 – 42 weeks
Preterm - 20 – 37 weeks
Abortion < 20 weeks

Sample Cases:
a. 1 – abortion G2T0P0A1L0
1 – 2nd month pregnant G2P0

b. 1 – 40th AOG G6T1P2 A 2L4

1 – 36th AOG G6 P3
2 – miscarriage
1 – twins 35th AOG
1 – 4th month pregnant

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 c. 1 – 39th week
1 – miscarriage
1 – stillbirth 33 AOG (considered as para) G4P2
1 – pregnant 3rd wk G4T1P1A1L1
d. 1 – 33rd P
1 - 41st L
1 – abortion A
1 – stillbirth 39th G6T2P2A1L5
1 - triplet 32nd G6P4
1 - 4th month pregnant
e. 1 – 39th AOG
1 – miscarriage G4P1
1 – stillbirth 33rd AOG G4T1P1A1L1
1 – 3rd month pregnant
f. 1 – 40th AOG
1 – Abortion G4P2
1 – twin 37th AOG G4T1P1A1L3
1 – 4th month pregnant
g. 1 – 38th AOG 1 – Triplets 30th AOG
1 – 37th AOG 1 – 32nd AOG G6P5
1 – Abortion 1 – Stillbirth 42nd AOG G6T3P2A1L6
c. Important Estimates:
1. Nagele’s Rule – used of determine expected date of delivery
January, February and March - +9+7 while
April to December - -3+7+1
Get Last Menstrual Period -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar
M D Y +9 +7 no year
Example: a. LMP January 03, 2005
01 03 05
+ 09 07___
10-10-05= Expected Date of Confinement October 10, 2005

b. LMP August 04, 2005

08 04 05
-03+07+01
05-11-06= EDC May 11, 2006
2. McDonald’s Rule – used to determine age of gestation IN WEEKS
Get the length in cm x 7/8 = AOG in weeks
FUNDIC HT X 7/8=AOG in weeks
Fundic Ht X 7 = AOG in weeks
8
From symphysis pubis to fundus 24 X 7 =21 wks
20
 8

3. Bartholomew’s Rule – used to determine age of gestation of the fetus

by proper location of fundus at abdominal cavity.
3 months – above symphysis pubis
5 months – level of umbilicus
9 months – below xiphoid
10 months – level of 8 months due to lightening
4. Haases rule – used to determine length of the fetus in cm.
Formula: 1st ½ of preg , square @ month
2nd ½ of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg
5 x 5 = 25 cm

6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
d. Tetanus Immunizations – prevents tetanus neonatum
- mother with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3
TT1 – any time during pregnancy
TT2 – 4 weeks after TT1 – 3 yrs protection
TT3 – 6 months after TT2 – 5 yrs protection
TT4 – 1 year after TT3 – 10 yrs protection
TT5 – year after TT4 – lifetime protection
Note: if the mother received 3 doses of DPT during childhood, she will be given TT3.
5. Physical Examination: Cephalocaudal including the teeth
* Examine teeth: sign of infection
Danger signs of Pregnancy:
C - chills/ fever - infection
- Cerebral disturbances ( headache – preeclampsia)
A – abdominal pain ( epigastric pain) – aura/alert of impending convulsions
B – boardlike abdomen – sign of abruption placenta
Increase BP – HPN(hypertension)
Blurred vision – pre eclampsia
Bleeding :
1st trimester - abortion, ectopic pregnancy
2nd trimester – H mole, incompetent cervix
3rd trimester – any placental anomalies such as abruption placenta,
placenta previa
S – sudden gush of fluid – PROM (premature rupture of membrane) prone to infection.
- swelling/edema of upper extremities (pre eclampsia)

21
 6. Pelvic Examination : Internal Examination
Preparation: 1. empty bladder
2. universal precaution
On the first visit the mother will examined internally in order to determine the presence of
probable signs such as Chadwick, Goodels and Hegar’s sign.
Pap Smear – cytological examination to determine the presence of cancer cells
External OS of cervix – site for getting specimen ; composed of squamous
columnar tissue; Site for cervical cancer
Vaginal Speculum will be needed, to avoid contact from other organ
Result:
Class I - normal
Class IIA – suggestive of inflammation
B - acytology but no evidence of malignancy
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy
Stages of Cervical Cancer
Stage 0 – carcinoma insitu
1 – cancer confined to cervix
2 - cancer extends to vagina
3 – pelvis metastasis
4 – affectation to bladder & rectum
7. Leopold’s Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree
of descent, an estimate of the size, and number of fetuses, position, fetal back &
fetal heart tone; use palm! Warm palm.
Preparation for mothers:
1. Empty bladder
2. Position of mom-supine with knee flex
(dorsal recumbent – to relax abdominal muscles)
Procedure:
1st maneuver: Place patient in supine position with knees slightly flexed; Put towel under head
and right hip; With both hands palpate upper abdomen and fundus. Assess size, shape,
movement and firmness of the part. In dorsal recumbent position – to relax the abdominal
muscles. To determine presentation parts.
2nd Maneuver: with both hands moving down, identify the back of the fetus (to hear fetal heart
sound) where the ball of the stethoscope is placed to determine Fetal Heart Tone. Get Vital
Signs (before 2nd maneuver) Pulse Rate to differentiate fundic soufflé (Fetal Heart Rate) &
uterine soufflé (Maternal Heart Rate). To determine fetal back.
3rd Maneuver: using the right hand, grasp the symphysis pubis part using thumb and fingers.
To determine degree of engagement. (Assess whether the presenting part is engaged in the

22
pelvis ) Alert : if the head is engaged it will not be movable.

4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands,
assess the descent of the presenting part by locating the cephalic prominence or brow.
When the brow is on the same side as the back, the head is extended. When the brow is on the
same side as the small parts, the head will be flexed and vertex presenting. To determine
attitude – relationship of fetus to 1 another.
Attitude – refers to the relationship of fetus to each part into one another ( degree of flexion )
Full flexion – when the chin touches the chest
8. Assessment of Fetal Well-Being-
A. Daily Fetal Movement Counting (DFMC) – begin 27 weeks
Mother - begin after meal – breakfast
a. Cardiff count to 10 method – one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) and count
each fetal movement, noting how long it takes to count 10 fetal movements (FMs)
(2) Expected findings – 10 movements in 1 hour or less
(3) Warning signs
a.) more than 1 hour to reach 10 movements
b.) less than 10 movements in 12 hours (non-reactive- fetal distress)
c.) longer time to reach 10 (FMs) fetal movements than on previous days
d.) movement are becoming weaker, less vigorous
* Movement alarm signals - < 3 FMs in 12 hours
(4.) Warning signs should be reported to healthcare provider immediately; often require
further testing. Examples: non stress test (NST), biophysical profile (BPP)
b. Nonstress test – to determine the response of the fetal heart rate to activity
Indication – pregnancies at risk for placental insufficiency
Postmaturity
a.) Pregnancy Induced Hypertension (PIH), diabetes
b.) Warning signs noted during DFMC
c.) Maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal
monitor);external monitor is applied to document fetal activity; mother activates the
“mark button” on the electronic monitor when she feels fetal movement.
Attach external noninvasive fetal monitors
1. Tocotransducer over fundus to detect uterine contractions and fetal movements
(FMs)
2. Ultrasound Transducer over abdominal site where most distinct fetal heart sounds
are detected
3. Monitor until at least 2 FMs are detected in 20 minutes
• if no FM after 40 minutes provide woman with a light snack or gently
stimulate fetus through abdomen
• if no FM after 1 hour further testing may be indicated, such as a CST
23
 Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
Interpretation of results
i. Reactive Result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at
least 15 seconds in a 10 to 20 minutes period as a result of Fetal Movement
3. Good variability – normal irregularity of cardiac rhythm representing a balanced
interaction between the parasympathetic (decreases FHR) and sympathetic
(increase FHR) nervous system; noted as an uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system
ii. Nonreactive Result
1. Stated criteria for a reactive result are not met
2. Could be indicative of a compromised fetus.
Requires further evaluation with another nonstress test NST, biophysical profile,
(BPP) or Contraction Stress Test (CST)
9. Health Teachings : do nutritional assessment
a. Nutrition – daily food intake
High risk mothers:
1. Pregnant teenagers – very long compliance to health regimen.
2. Extreme weight
Underweight: malnourished like elite model
Over weight : candidate for HPN, DM
3. Mothers with low socio – economic status – refer to DSWD
4. Vegetarian mothers – decrease CHON – needs Vitamin B12/folic acid –
cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation.
(Decrease folic acid – spina bifida/open neural tube defect, meningocele umphalocele)

Types of Vegetarian:
1. Strict Vegetarian – vegetables only ( with rigid personality)
2. Lactovegetarian – vegetables/milk
3. Lactoovovegetarian – vegetables/milk/egg
How many calorie : CHO x 4, CHON x 4, FATS x 9
Daily Calorie Intake : Non Pregnant – 2,200
Add - 300
Pregnant – 2,500
During Lactation Add - 500
24
 VIII. Recommended Nutrient Requirement that increases During Pregnancy
Nutrients
Calories
Essential to supply energy for
- increased metabolic rate
- utilization of nutrients
- protein sparing so it can be
used for
- Growth of fetus
- Development of structures
required for pregnancy
including placenta, amniotic
fluid, and tissue growth.
Protein
Essential for:
- Fetal tissue growth
- Maternal tissue growth
including uterus and breasts
- Development of essential
pregnancy structures
- Formation of red blood cells
and plasma proteins
* Inadequate protein intake has
been associated with onset of
pregnancy induces hypertension
(PIH)
Calcium-Phosphorous
Essential for
- Growth and development
of fetal skeleton and tooth
buds
- Maintenance of
mineralization of maternal
bones and teeth
- Current research is :
Demonstrating an association
between adequate calcium intake
Requirements Food Source
300 calories/day above the pre- Caloric increase should reflect
pregnancy daily requirement to - Foods of high nutrient value such as
maintain ideal body weight and protein, complex carbohydrates
meet energy requirement to (whole grains, vegetables, fruits)
activity level - Variety of foods representing foods
- Begin increase in second sources for the nutrients requiring
trimester during pregnancy
- Use weight – gain pattern as - No more than 30% fat
an indication of adequacy of
calorie intake.
- Failure to meet caloric
requirements can lead to
ketosis as fat and protein are
used for energy; ketosis has
been associated with fetal
damage.
60 mg/day or an increase of 10% Protein increase should reflect
above daily requirements for age - Lean meat, poultry, fish
group - Eggs, cheese, milk
- Dried beans, lentils, nuts
Adolescents have a higher protein - Whole grins
requirement then mature women * vegetarians must take note of the
since adolescents must supply amino acid content of CHON foods
protein for their own growth as consumed to ensure ingestion of
well as protein t meet the sufficient quantities of all amino acids
pregnancy requirement
Calcium increases of Calcium increases should reflect:
- 1200 mg/day representing an - dairy products : milk, yogurt, ice
increase of 50% above pre- cream, cheese, egg yolk
pregnancy daily requirement. - whole grains, tofu
- 1600 mg/day is recommended - green leafy vegetables
for the adolescent. 10 - canned salmon & sardines w/ bones
mcg/day of vitamin D is - Ca fortified foods such as orange
required since it enhances juice
absorption of both calcium - Vitamin D sources: fortified milk,
and phosphorous margarine, egg yolk, butter, liver,
seafood
25
and the prevention of pregnancy
induce hypertension
Iron
Essential for
- Expansion of blood volume
and red blood cells formation
- Establishment of fetal iron
stores for first few months of
life
Zinc
Essential for
* the formation of enzymes
* may be important in the
prevention of congenital
malformation of the fetus.
Folic Acid, Folacin, Folate
Essential for
- formation of red blood
cells and prevention of
anemia
- DNA synthesis and cell
formation; may play a
role in the prevention of
neutral tube defects
(spina bifida), abortion,
abruption placenta
Additional Requirements
Minerals
30 mg/day representing a
doubling of the pregnant daily
requirement
- Begin supplementation at 30-
mg/day in second trimester,
since diet alone is unable to
meet pregnancy requirement
- 60 – 120 mg/day along with
copper and zinc
supplementation for women
who have low hemoglobin
values prior to pregnancy or
who have iron deficiency
anemia.
- 70 mg/day of vitamin C
which enhances iron
absorption
- inadequate iron intake results
in maternal effects – anemia
depletion of iron stores,
decreased energy and
appetite, cardiac stress
especially labor and birth
- fetal effects decreased
availability of oxygen thereby
affecting fetal growth
* iron deficiency anemia is the
most common nutritional
disorder of pregnancy.
15 mcg/day representing an
increase of 3 mg/day over pre-
pregnant daily requirements.
400 mcg/day representing an
increase of more then 2 times the
daily pre-pregnant requirement.
300mcg/day supplement for
women with low folate levels or
dietary deficiency
4 servings of grains/day
Iron increases should reflect
- liver, red meat, fish, poultry,
eggs
- enriched, whole grain cereals
and breads
- dark green leafy vegetables,
legumes
- nuts, dried fruits
- vitamin C sources: citrus fruits
& juices, strawberries,
cantaloupe, broccoli or
cabbage, potatoes
- iron from food sources is more
readily absorbed when served
with foods high in Vitamin C
Zinc increases should reflect
- liver, meats
- shell fish
- eggs, milk, cheese
- whole grains, legumes, nuts
Increases should reflect
- liver, kidney, lean beef, veal
- dark green leafy vegetables,
broccoli, legumes.
- Whole grains, peanuts
Increased requirements of pregnancy
can easily be met with a balanced diet
26
 - iodine 175 mcg/day that meets the requirement for calories
- Magnesium 320 mg/day and includes food sources high in the
- Selenium 65 mcg/day other nutrients needed during
pregnancy.

Vitamins
E 10 mg/day Vitamin stored in body. Taking it not
Thiamine 1.5 mg/day needed – fat soluble vitamins. Hard to
Riboflavin 1.6 mg/day excrete.
Pyridoxine ( B6) 2.2 mg/day
B12 2.2 mg day
Niacin 17 mg/day

Vitamin A,D,E,K - - - No need to take it daily ( FAT SOLUBLE )

2. Sexual Activity
should be done in moderation
should be done in private place
that the mother should be placed in comfortable position; sidelying or mother on top
it must be avoided 6 weeks prior to Expected Date of Delivery
avoid blowing or air during cunnilingus to prevent air embolism
changes in sexual desire of mom during pregnancy
a.) 1st trimester – decrease desire – due to bodily changes
b.) 2nd trimester – increased desire due to increase estrogen that enhances
lubrication
c.) 3rd trimester – decreased desire – due to bodily changes
Contraindication in sex:
1. vaginal spotting
1st trimester – threatened abortion
2nd trimester – placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane – prone to infection
Exercise – to strengthen muscles that will be used during delivery process
- it must be done in moderation principles of exercise
- it must be individualized – case to case basis
* Walking – best exercise
* Squatting – strengthen muscles of perineum and increase circulation to perineum. Done
feet flat on floor
* Tailor Sitting – same with squatting – done by placing one leg in front of other leg ( Indian seat)
Raise buttocks 1st before head to prevent postural hypotension – dizziness when
changing position
* Shoulder Circling Exercise – to strengthen chest muscles
* Pelvic Rocking/Pelvic Tilt Exercise – to relieve low back pain & maintain good posture
- can be used to Lordosis
* Arch Back – standing or kneeling. Four extremities on floor
* Kegel Exercise – to strengthen pubococcygeal muscles
- as if hold urine, release 10x or muscle contraction
* Abdominal Exercise – to strengthen the muscles of the abdomen
27
 – done as if blowing candle

4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting wellness behavior
that can be used by parents and family thus, helping them achieved a satisfying and
enjoying childbirth experience.
a. Psychophysical
1. Bradley Method – discovered by Dr. Robert Bradley , advocated active participation of
husband during delivery process to serve as a coach. Based on imitation
of nature.
Features:
1.) darkened room
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep
2. Grantly Dick Read Method – that fear leads to tension while tension leads to pain
- to remove fear by relaxation technique and abdominal
exercises
b. Psychosexual
1. Kitzinger Method – discovered by Dr. Shiela Kitzinger , that pregnancy, labor, birth & the
care of the newborn is an important turning point in a woman’s life
cycle
- for a mother to achieve the satisfying childbirth experiences, flow with
contraction rather than struggling with contraction
c. Psychoprophylaxis – prevention of pain
1. Lamaze – discovered by Dr. Ferdinand Lamaze
- prevention of pain in the brain
Features: discipline, conditioning & concentration with the help of the Husband
1. Conscious relaxation
2. Cleansing breathe – inhaling through the nose and exhaling through the mouth
3. Effleurage – gentle circular massage over abdomen to relieve pain
4. Imaging – sensate focus
5. Different Methods of delivery:
1.) Birthing Chair – bed convertible to chair – “semifowlers” position
2.) Birthing Bed – “dorsal recumbent” position
3.) Squatting Position – position that facilitates descent and relieves low back pain during labor pain
4.) Leboyers Method – features: warm, quiet, darkened room, calm and comfortable environment,
room temperature, soft music.
- After delivery, baby gets warm bath.
5.) Birth Under Water – warm water in a bathtub – labor & delivery – warm water, soft music.
- After delivery the baby should be kept warmth, prepare for bathing
IX. Intrapartal Notes – inside Emergency Room
A. Admitting the laboring Mother:
* Personal Data: name, age, address, etc
* Baseline Data: v/s especially BP, weight
28
 * Obstetrical Data: gravida # pregnancy, para- viable pregnancy – 22 – 24 weeks
* Physical Examination
* Pelvic Examination

B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor
1.) Uterine Stretch Theory - any hollow organ once stretched to its maximum potential
will always contract & expel its content
– contraction action
2.) Oxytocin Theory – posterior pituitary gland releases oxytocin that produce by
hypothalamus.
3.) Prostaglandin Theory – stimulation of Arachidonic Acid which causes contraction to the
onset of labor.
– prostaglandin “male”
4.) Progesterone Theory – before labor, decrease progesterone will stimulate contractions
and labor
5.) Theory of Aging Placenta – lifespan of placenta is 42 weeks. By 36 weeks the placenta
is beginning to degenerate hence causes the uterus to
contract to the onset of labor.
b.2. The 4 P’s of Labor
1. Passenger - FETUS
a. Fetal head – is the largest and common presenting part comprises of ¼ of its length.
Bones – 6 fetal bones ( in all = 8 bones )
S – sphenoid
F – frontal - sinciput
E – ethmoid
O – occuputal - occiput
T – temporal
P – parietal 2 x
Important Measurement fetal head:
1. Transverse Diameter
Biparietal – largest transverse – 9.25cm
Bitemporal - 8 cm
Bimastoid - 7cm smallest transverse
2. Anterior Posterior Diameter (AP )
Suboccipitobregmatic – from occiput to bregmatic ( smallest AP diameter)
- complete flexion
Occipito Frontal – 12 cm partial flexion
Occipito Mental – 13.5 cm hyperflexion ( largest AP )
Submentobregmatic ( face presentation )
Sutures – intermembranous spaces that allow molding.
a) Sagittal Suture – connects 2 parietal bones ( sagitna )
b) Coronal Suture – connect parietal & frontal bone ( crown )
c) Lambdoidal Suture – connects occipital & parietal bone
Moldings: the overlapping of the sutures of the skull to permit passage of the
head to the pelvis
Fontanels:
1.) Anterior fontanel – “bregma”, diamond shape, 3 x 4 cm,( > 5 cm –
29
 hydrocephalus), Closes – 12 – 18 months after birth
2.) Posterior fontanel – “lambda” – triangular shape, 1 x 1 cm. Closes – 2 – 3
months.

2. Passageway – Vagina / Pelvis

Candidate for C/S = 1.) Below 4’9” tall
2.) Below 18 years old – pelvic not yet achieve fully
3.) Underwent cephalo pelvic dislocation
a. Pelvis
4 main pelvic types
1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider
b. Bones of Pelvis
2 hip bones – 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum – lateral side of hips
* iliac crest – flaring superior border forming prominence of hips
Ischium – inferior portion
*ischial tuberosity – areas where we sit , the basis in getting external
measurement of pelvis
Pubes in the anterior portion
*symphysis pubis - junction between 2 pubis
1 sacrum – posterior portion
*sacral prominence – basis for internal measurement of pelvis
1 coccyx – composed of 5 small bones compresses during vaginal delivery
Important Measurements:
1. Diagonal Conjugate – measure between sacral promontory and inferior margin of
the symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate.
(DC – 11.5 cm = true conjugate)
2. True conjugate/conjugate vera – measure between the anterior surface of the sacral
promontory and superior margin of the symphysis
pubis.
Measurement: 11.0 cm
3. Obstetrical conjugate – smallest AP diameter.
Pelvis measuring at 10 cm or more.
4. Tuberoischi Diameter – transverse diameter of the pelvic outlet.
*Ischial tuberosity – approximated with use of fist
– 8 cm & above.
3. Power – the force acting to expel the fetus and placenta
– myometrium – powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
30
 e. Support System

4. Psyche/Person – (mother) psychological stress exist when the mother is fighting the
labor experience ( effective pushing )
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System

b.3 Pre-eminent Signs of Labor

1. Lightening – settling of presenting part into pelvic ring
- 2 weeks prior to EDD
Signs &Symptoms:
- shooting pain radiating to the legs
- urinary frequency (plexus/bladder)
- pressure at the lumbo sacral nerve
* Engagement- settling of presenting part of the fetus far enough into the pelvis to be at the
level of ischial spine, a midpoint of the pelvis.
2. Braxton Hicks Contractions – painless irregular contractions
3. Increase Activity of the Mother- “nesting instinct” (due to epinephrine).
Let the mother reserve the energy, will be used for delivery.
4. Ripening of the Cervix – comparable to butter softness
5. decreased body weight – 1.5 – 3 lbs
6. Bloody Show – pinkish vaginal discharge ( combinatiuon of blood & leukorrhea )
7. Rupture of Membranes – rupture of water bag. Check Fetal Heart Tone
PROBLEMS:
Premature Rupture of Membrane ( PROM) - do Internal Examination to check for cord
prolapse
* Contraction drop in intensity even though very painful
* Contraction drop in frequently
* Uterus tense and/or contracting between contractions
* Abdominal palpations
Nursing Care:
* Administer Analgesics (Morphine)
* Attempt manual rotation for ROP or LOP – most common mal position
* Bear down with contractions
* Adequate hydration – prepare for Cesarean Section
* Sedation as ordered
* Cesarean delivery may be required, especially if fetal distress is noted
NOTE: Do internal examination when the umbilical cord falls or is washed through the
cervix into the vagina.

31
Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix
into the vagina.
Danger signs:
* PROM
* Presenting part has not yet engaged
* Fetal distress
* Protruding cord form vagina
Nursing care:
1. Slip cord away from presenting part
2. Count pulsation of cord for Fetal Heart Tone
3. Positioning – trendelenberg or knee chest position
4. Observe for fetal distress
5. provide emotional support
6. Prepare mother for Cesarean Section
• Cover cord with sterile gauze with saline solution - to prevent drying of cord so
cord will remain slippery.
* NOTE: five minutes cord compression can lead to irreversible brain damage such
as cerebral palsy.
b.4. Difference Between True Labor and False Labor
False Labor True Labor
* Irregular contractions * Contractions are regular
* No increase in intensity * Increased intensity
* Pain – confined on abdomen * Pain – begins lower back radiates to abdomen
* Pain – relived by walking * Pain – intensified by walking
* No cervical changes * Cervical effacement & dilatation
- major symptom of true labor.
Effacement – softening & thinning of cervix. Use % in unit of measurement
Dilatation – widening of cervix. Unit used is cm.
b.5 Duration of Labor
Primipara – 14 hours not more than 20 hours
Multipara – 8 hours not more than 14 hours
b.6 Nursing Interventions in Each Stage of Labor
2 segments of the uterus
1. upper uterine - fundus
2. lower uterine – isthmus
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase: ( The mother is excited but apprehensive and can communicate)
Assessment: Dilatations: 0 – 3 cm
Frequency: every 5 – 10 min
Intensity : mild
Nursing Care:
1. Encourage walking - to shorten the 1st stage of labor
32
2. Encourage to void every 2 – 3 hours – full bladder inhibit uterine contractions
3. Breathing – chest breathing

Active Phase: ( Mother feels losing control of herself )

Assessment: Dilatations: 4 - 8 cm
Intensity: moderate
Frequency : every 3 - 5 minutes lasting for 30 – 60 seconds
Nursing Care:
M – medications – have medicines ready
A – assessment include: vital signs, cervical dilatation and effacement, fetal monitoring, etc.
D – dry lips – oral care (ointment)
- dry linens, change the wet linen
B – abdominal breathing
Transitional Phase: ( the mood of the mother suddenly change accompanied by
hyperesthesia – hypersensitivity to touch )

Assessment: Dilatations: 8 – 10 cm
Frequency : every 2 - 3 minutes contractions
Durations : 45 – 90 seconds
Intensity: Strong
Hyperesthesia – increase sensitivity to touch, pain all over

Nursing Care:
T – tires
I – inform of progress- best way to give emotional support to the mother
R – restless, support her to do breathing technique (chest breathing)
E – encourage and praise
D – discomfort – due to sacral pressure
Health Teaching :
* teach the father about sacral pressure technique on lower back to inhibit transmission
of pain
* keep informed of progress
* controlled chest breathing
Contractions:
Increment/ Crescendo – beginning of contraction until it increases
Acme/ Apex – height of contraction
Decrement/ Decresendo – from height of contraction until it decreases
* Pelvic Exams
Effacement: – softening & thinning of cervix.
Dilatation: - widening of cervix.
a. Station – relationship of the presenting part to the ischial spine
landmark used: ischial spine
Floating – negative station
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
- 0 station = level at ischial spine – engagement
+ 1 station = below 1 cm ischial spine
+3 ,+4, +5 = crowning – occurs at 2nd stage of labor
33
b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the
long axis of the mother - spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
Cephalic - Vertex – when the fetus is completely flex
Face
Brow Poor Flexion
Chin

Breech - Complete Breech – thigh rest on abdomen, while leg rest on thigh
Incomplete Breech
Frank – thigh rest on abdomen while leg rest on the head
Footling – presenting part – foot : single, double
Kneeling – presenting part - knees
b.2. Transverse Lie (Perpendicular) or Perpendicular lie.
- Shoulder presentation is very rare – 1 %
c. Position – relationship of the fatal presenting part to specific quadrant of the
mother’s pelvis.
Variety:
Occipito/ Occiput
LOA left occipito anterior (most common and favorable position)
– side of maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful
ROP – squatting pos on mom
ROT
ROA
A – Anterior
L – Left – side of maternal pelvis
O – Occipito – denominator
ROP; LOP : most painful position; best – squatting position
LOA – most favorable position
FACE – Mentum LMA, LMT, LMP, RMA, RMT, RMP
Shoulder – Acromio Dorso – LADA, LADT, LADP, RADA, RADT, RADP
Breech- SACRO - LSA – left sacro anterior LST, LSP, RSA, RST, RSP
Shoulder/acromniodorso: LADA, LADT, LADP, RADP
Chin / Mento: LMA, LMT, LMP, RMP, RMA, RMT, RMP
• In cases of breech presentation –place the stethoscope above the umbilicus
Sign of fetal distress:
• < 120 or > 160 bpm
• meconium stain
• fetal trushing – hyperactivity of fetus due to lack of oxygen.

34
Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus – to monitor contractions
Parts of contractions:
Increment or crescendo – beginning of contractions until in increases
Acme or apex – height of contraction
Decrement or decrescendo – from height of contractions until it decreases
Duration – beginning of contractions to end of same contraction
Interval – from the end of 1 contraction to beginning of next contraction
Frequency – beginning of 1 contraction to beginning of next contraction
Intensity – the strength of contraction
Once contraction occur, the blood vessel will constrict – vasoconstriction – decrease the
oxygen/circulation hence, maternal BP increases - Increase BP – while Fetal Heart Tone
decreases.
What will happen to the fetus? = The fetus has placental reserve for 60 seconds
Best time to get BP of the mother = just after the contraction
Best time to get FHT = midway of contraction
Placental reserve = 60 seconds for fetus during contractions
Duration of contractions shouldn’t > 60 sec
Notify MD
Health Teachings:
• Mom has Headache – check BP, if same BP, let mom rest.
If BP increases, notify MD – preeclampsia
• Hungry mother – NPO - no meals GI is not functioning thus to prevent aspiration
• Bathe – mother can bathe after the delivery
• Enema – optimum rectal tube – 12 - 18 inches
a.) To cleanse bowel
b.) Prevent infection
c.) Sims position/side lying
Constipated mother – slowly pulling the rectal tube
* During insertion of rectal tube – contraction – clamp – after insertion –
check the FHT after administration of enema
Normal FHT = 120-160 bpm
* Perineal Preparation – method ( 7 method )
• Position : Left lateral position – to prevent supine hypotension or the supine vena
caval syndrome.
• Pain during labor – can give Meperidine HCL ( Demerol ) – narcotic antispasmodic
( during active phase 6 – 8 cm )
Toxic Effect: respiratory depression
Antidote : Narcan ( Naloxone )
35
 Note:
Amniotomy – artificial rupture of the membrane
Respiratory Alkalosis – signs and symptoms ( increase RR, Tingling sensation,
light headedness,

2. Second Stage: fetal stage, complete dilation and effacement to birth.

The mother will be transferre to the delivery room when:
7 – 8 cm for the multi – bring to delivery room
8 – 10 cm for the primi (fully dilated) – bring to delivery room
Position: Lithotomy by placing the mother’s legs at the same time up
Bulging of perineum – sure to come out
Breathing – panting ( teach mother)
Assist the doctor in doing episiotomy- to prevent laceration
- widen vaginal canal
- shorten 2nd stage of labor.
Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to
reach rectum ( urethroanal fistula)
Mediolateral – more bleeding & pain, hard to repair, slow to heal
- use local or pudendal anesthesia.
Ironing the perineum – to prevent laceration
Modified Ritgens maneuver – place towel at perineum
1.) To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head & remove
secretion, check cord if coiled. Pull shoulder down & up.
Check time, identification of baby.
Mechanisms of labor
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
Three parts of Pelvis
1. Inlet – AP diameter narrow, transverse diameter wider
2. Cavity – area of inlet and outlet
3. Outlet – AP wider, transverse narrow
Two Major Divisions of Pelvis
1. True pelvis – below the pelvic inlet
2. False pelvis – above the pelvic inlet; supports uterus during pregnancy
* Linea Terminales - diagonal imaginary line from the sacrum to the symphysis pubis that
divides the false and true pelvis.
* Episiotomy – is a surgical incision of the perineum in order to prevent laceration; to widen
the vaginal canal; to shorten the second stage of labor.
Two Types of episiotomy:

36
 1. Midline – incise the midline of the perineum
Advantage: Easy to repair, fast healing, less blood loss, less postpartum discomfort
Disadvantage: incision may extend to anus that leads to urethroanal fistula
( use sometimes )

2. Mediolateral – incision is made beginning to the midline but directed laterally

away from the rectum.
Advantage: less danger of complication from rectal mucosal tear
Disadvantage: more bleeding (more blood vessels hit), hard to repair, slow healing,
more discomfort
Note:
Once the head is crowning – ironing the perineum (to prevent laceration)
Modified Ritgens Maneuver – support the perineum (prevent laceration)
Once the head is out – support the head and remove secretions, check the cord by
inserting 2 fingers.
Nursing Care:
• Note the time of delivery
• Placing the baby below the vulva
• Place un dependent part
• Place in the abdomen of the mother – for bonding and the weight of the baby
facilitates the contraction of the uterus
• Clamp the baby’s cord – wait for pulsation to stop before clamping the cord since 60
– 100 cc of blood will be going to baby.
• Proper identification, footprinting
• If in case the baby is dead, show the baby to the mother for acceptance of the finality
of dead.
• To prevent puerperal sepsis - < 48 hours only – vaginal pack
Note: Bolus of Ptocin can lead to hypotension.
3. Third Stage: birth to expulsion of Placenta - placental stage
The Placenta should be expelled 3-10 minutes after the delivery of the baby
Signs of placental separation
1. Fundus rises – becomes firm & globular “ Calkins sign” if not – Uterine Atony
2. Lengthening of the cord – Brandt Andrew’s maneuver – slowly pulling of the cord
3. Sudden gush of blood
Types of placental delivery
• Shultz “shiny” – begins to separate from center to edges presenting the
fetal side – shiny
• Dunkan “dirty” – begins to separate form edges to center presenting
maternal side – beefy red or dirty
Note: Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER
Hurrying of placental delivery will lead to inversion of uterus.
Nursing care for placenta:
• Check completeness of placenta.- placenta has 15 – 28 cotyledons
• Check fundus (if relaxed, massage uterus – if not firm)

37
 • Check blood pressure - Administer Methergine IM (Methylergonovine Maleate) as
ordered. It should be given IM, check the BP before administration. “Ergotrate
derivatives.
• Monitor hypertension (or give oxytocin IV)
• Check perineum for lacerations
• Assist MD in doing episiorapy , vaginal pack should be used for 48 hours to prevent
puerperal sepsis.
• In recovery room, should be Flat on bed
• If chilling occurs – due to dehydration – just give additional Blanket
• Give clear liquid – ( tea, ginger ale, clear gelatin, Gatorade) – once regulated, can be
given full liquid such as milk, ice cream, soup then soft diet to regular diet.
• Let mother sleep to regain energy.
4. Fourth Stage: the first 1 - 2 hours after delivery of placenta – recovery stage.
a. Maternal Observations – body system stabilizes
Check the vital signs q 15 for 1 hour. 2nd hour q 30 minutes.
b. Placement of the Fundus – just above the umbilicus or level of umbilicus. If
palpated on the right side – it means full bladder therefore – empty the bladder.
If fundus above umbilicus, deviation of fundus
1.) Empty bladder to prevent uterine atony
2.) Check lochia
c. Lochia – vaginal discharges after the delivery process
Rubra – red, 1 - 3 days moderate
Serosa – pink to brown, 4 – 9 days , decrease in amount, with musty odor
Alba – creamy white, 10 days – 3 weeks
d. Perineum – check the perineum for :
R - redness
E- edema
E - ecchymosis
D – discharges
A – approximation of blood loss.
* Count pad & saturation
* Fully soaked pad : 30 – 40 cc weigh pad. 1 gram = 1cc
e. Bonding – interaction between mother and newborn
Types of rooming:
1.) Strict rooming: 24 hours - baby stays with mother.
2.) Partial rooming in: baby stays with mother in the morning
and stays in the nursery at night .
Complications of Labor
• Dystocia – difficult labor related to mechanical factor
– due to uterine inertia which means sluggishness of contraction
2 Types of uterine inertia:
1.) hypertonic or primary uterine inertia - intense excessive contractions
resulting to ineffective pushing
Management: sedation – MD administer sedative
Valium/Diazepam – muscle relaxant
2.) hypotonic – secondary uterine inertia, slow irregular contraction
resulting to ineffective pushing.
Management: Administer Oxytocin
• Prolonged labor – resulting to:
38
 Maternal Effect: exhaustion ( overpushing )
Fetal Effect: fetal distress, cephalohematoma or caput succedaneum
 20 hours – Primi
 14 hours – Multi
* normal length of labor in primi 14 – 20 hours ; Multi 10 - 14 hours
Management: Check and monitor Contraction and Fetal Heart Tone

• Precipitate Labor - labor of < 3 hours. extensive lacerations to mother that leads to
profuse bleeding → hypovolemic shock → hypotension, Tachypnea, Tachycardia,
cold clammy skin
Note: Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing diagnosis: fluid volume deficit
Position of mother: Modified Trendelenberg
IV – fast drip due fluid volume deficit
Signs of Hypovolemic Shock:
Hypotension
Tachycardia
Tachypnea
Cold clammy skin

• Inversion of the Uterus – uterus is turned inside out due to the following factors:
a. hurrying pull out of the placenta
b. ineffective fundal pressure
c. short cord
Management: MD will push uterus back inside or not hysterectomy.
• Uterine Rupture – Possible causes:
1.) Previous classical Cesarean Section
2.) Large baby
3.) Improper use of oxytocin (IV drip)
Symptoms:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Note: Physiologic Retraction – boundary between upper and lower uterine segment
Suprapubic Depression – sign of impending rupture of the uterus
Bandl’s Pathologic Ring – bleeding that leads to hypovolemic to TABHBSO

• Amniotic Fluid Embolism – a situation of amniotic fluid or fragments of placenta

enters natural circulation resulting to embolism.
If NSD – Signs and Symptoms:
a. dyspnea
b. chest pain
c. frothy sputum
Prepare: suctioning
end stage: DIC disseminated intravascular coagopathy
39
 * intravascular coagopathy - bleeding to all portions of the body such as
eyes, nose, etc.
• Trial Labor – when the head measurement and pelvis measurement falls on
the borderline.
Management: Give the mother 6 hours of labor allowance: Multi: 8 – 14; primi : 14 – 20
Monitor Fetal Heart Tone and Contraction

• Pre Term Labor – labor after 24 weeks before the 37th week
Triad of Preterm Symptoms:
1. Premature contractions every 10 minutes
2. Effacement of 60 – 80 %
3. Dilatation of 2 - 3 cm
Home Management:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 - 4 glasses of water – full bladder inhibits contractions
5. consult MD if symptoms persist
Hospital Management:
If cervix is closed (2 – 3 cm), dilation saved by administer
Tocolytic agents- to halts the preterm contractions of the uterus.
(YUTOPAR - Yutopar Hcl) 150 mg incorporated 500 cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - < 90/60
Crackles – notify MD
Pulmonary edema – administer oral yutopar 30 minutes before d/c IV
PreTerm: Magnesium Sulfate
• Before delivery mother will be given :
DEXAMETHASONE –to facilitate surfactant maturation.
• Tocolytic (Phil)
• Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
• Antidote – propranolol or inderal - beta-blocker
Note : * If cervix is open – MD – steroid dexamethsone (betamethazone) to
facilitate surfactant maturation preventing Respiratory Distress Syndrome
* Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.
* Term – suction at once
X. Postpartal Period 5th stage of labor
after 24hours: Normal increase WBC up to 30,000 mm3
Puerperium – covers 1st 6 wks post partum
Involution – return of reproductive organ to its non pregnant or normal state.
Hyperfibrinogenia
- prone to thrombus formation
- early ambulation

40
 Principles Underlying Puerperium
I. To return to Normal and Facilitate Healing
A. Physiologic Changes
a.1. Systemic Changes
1. Cardiovascular System
The first few minutes after delivery is the most critical period in mothers because the
increased in plasma volume return to its normal state and thus adding to the workload of
the heart. This is critical especially to gravidocardiac mothers.( 1st one hour after delivery
– monitor the vital signs every 15 minutes ) Increase of temperature on the 1st 24 hours is
normal. Increase in WBC (30,000mm3 ) immediately after delivery results to
Hyperfibrogenemia. To prevent Thromboplebitis – encourage early ambulation,
sometimes, may experience Postural Hypotension – gradually position the patient from
semi to high fowlers
a.2. Genital Tract
a. Cervix – cervical opening
b. Vaginal and Pelvic Floor
c. Uterus – return to normal 6 – 8 weeks.
Fundus goes down 1 finger breath/day until 10th day – no longer palpable
due behind symphysis pubis
3 days after post partum: subinvolution uterus – delayed healing uterus containing big,
quarters or deep clots of blood - a medium for bacterial growth - (puerperal sepsis)
Management: Dilatation & Curettage
After - birth pain :
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid
d. Lochia - bld, wbc, deciduas, microorganism. NSD & C/S with lochia.
1. Ruba – red 1st 3 days present, musty/mousy, moderate amount
2. Serosa – pink to brown 4 – 9th day, limited amount
3. Alba – creamy white 10 – 21 days very decreased amount
a.3. Urinary tract: Bladder
Frequency in urination after delivery (postpartum)
- urinary retention with overflow
Dysuria – trigone of bladder
Nursing Action:
- urine collection
- alternate warm & cold compress
- stimulate bladder
Colon: Constipation – due to NPO, fear of bearing down; episiotomy
Perineal area: – painful – episiotomy site
Position: Sim’s position
• Cold compress for immediate pain after 24 hours,
• Hot sitz bath, Hot compress for immediate pain after 24 hours
41
 Sex Act - when perineum has healed

II. Provide Emotional Support – Reva Rubia

1. Psychological Responses:
a. Taking in phase – dependent phase (1st three days) mother – passive, cannot make
decisions, activity is to tell childbirth experiences.
Nursing Care: - proper hygiene
b. Taking hold phase – dependent to independent phase (4 to 7 days). Mother is active,
can make decisions
Focus: 1. Care of newborn
2. Insert family planting method
Note: common post partum blues/ baby blues present 4 – 5 days 50 - 80 %
moms – overwhelming feeling of depression characterized by crying,
despondence
- inability to sleep & lack of appetite.
- let mom cry, it is therapeutic.
c. Letting go – interdependent phase – 7 days & above.
Mother - redefines new roles may extend until child grows.
III. Prevent complications
1. Hemorrhage – bleeding of > 500cc
CS – 600 – 800 cc normal
NSD - 500 cc
I. Early postpartum hemorrhage – bleeding within 1st 24 hours.
a. Uterine Atony - Boggy or relaxed uterus & profuse bleeding
Complications: hypovolemic shock.
Position: Modified Trendelenberg
Management:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip as ordered
Note: * If no effect after massage → cold compress → position → then let the
newborn suck the mother’s breast in order to stimulate the pituitary to release
oxytocin for the contraction of the uterus.
* Breast feeding – posterior pituitary gland will release oxytocin so uterus
will contract.
* Well contracted uterus + bleeding = laceration

b. Laceration - Contracted uterus but with profuse bleeding

Nursing Action: assess episiotomy
assess perineum for laceration
degree of laceration
Management: Episiorapy

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 1st degree laceration – affects vaginal skin & mucus membrane.
2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum

c. Hematoma - bluish / purplish discoloration of subcutaneous vagina or

Perineum. May be due to : too much manipulation
large baby
pudendal anesthesia
Management: * Cold compress every 30 minutes with rest period of 30 minutes
repeat for 24 hours
* Shave
* Incision on site, scraping & suturing
DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen
- failure to coagulate bleeding to any part of body
Note: hysterectomy if with abruption placenta
Management: Blood Transfusion , cryoprecipitate or fresh frozen plasma
II. Late Postpartum hemorrhage – bleeding after 24 hours
Retained Placental Fragments
Management: Dilatation & Curettage or manual extraction of fragments
& massaging of uterus :
Except: * Placenta Accreta - unusual attachment to myometrium
* Placenta Increta - deeper attachment of placenta to
myometrium
* Placenta Percreta – invasion of placenta to perimetrium
2. Infection- sources of infection
1.) endogenous – from within body
2.) exogenous – from outside
General signs:
1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling) and loss
of function.
anaerobic streptococci – most common: 1. from members health team
2. break in the chain of infection
3. unhealthy sexual practice
4. purulent discharges
5. fever
General Management:
Supportive Care: Complete Bed Rest , hydration/ fluid intake, TSB, cold
compress, paracetamol, VITC,
culture & sensitivity – before taking antibiotic
* prolonged use of antibiotic lead to fungal infection
Infection of Perineum : 2 to 3 stitches dislodged with purulent discharge
coming out
Management: Removal of sutures & drainage
Endometritis – inflammation of endometrial lining
Signs of infection plus abdominal tenderness
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 Position : Fowlers to facilitate drainage
Administration of oxytocin as ordered
Antibiotic – if not treated – lead to thrombophlebitis

IV. Motivate the use of Family Planning

1.) determine one’s own 1ST beliefs
2.) never advice a permanent method of family planning
3.) method of choice is an individuals choice/ own decision.
4.) Informed consent
Natural Method – the only method accepted by the Catholic Church

• Billings / Cervical mucus – test spinnbarkeit (estrogen) clear, watery,

stretchable, elastic – long spinnbarkeit
ferning – microscopic fern pattern

• Basal Body Temperature – due to progesterone

13th day temp goes down before ovulation – no sex
- get before arising in bed

• LAM - Lactation Amenorrhea Method - related to breast feeding

Prolactin – hormone that inhibits menstruation/ovulation
Bottle Feeding – the mother will menstruate after 2 – 3 months
Breastfeeding – the mother will menstruate after 4 - 6 months
Disadvantage : might get pregnant

• Symptothermal – combination of BBT & cervical. Best method

Social Method:
o coitus interuptus/ withdrawal - least effective method
o coitus reservatus – sex without ejaculation ; common to callboy/callgirl
o coitus interfemora – “ipit”
o calendar method – 28 days cycle ( REGULAR )
OVULATION – count minus 14 days before next menstruation (14 days before
next menstruation)
Origoknause formula – IRREGULAR MENSTRUATION - get the longest and shortest cycle
Shortest minus 18 an longest minus 11 – unsafe period
REGULAR MENSTRUATION – 28 days minus 14 days plus 3 – 4 days before and after
menstruation
• monitor cycle for 1 year
• get short test & longest cycle from January – December
• shortest – 18
• longest – 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days
21 day pill- start 5th day of menstruation
28 day pill- start 1st day of menstruation
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 missed 1 pill – take 2 next day
Physiologic Method
 Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary
gland production of FSH and LH which are essential for the maturation and rupture of a
follicle. 99.9% effective.
 Waiting time to become pregnant- 3 months.
 Consult OB – 6 months.
Alerts on Oral Contraceptive:
• In case a mother who is taking an oral contraceptive for almost long time
plans to have a baby, mother would wait for at least 3 months before attempting to
conceive to provide time for the estrogen and progesterone levels to return to normal.
• If a new oral contraceptive is prescribed the mother should continue
taking the previously prescribed contraceptive and begin taking the new one on the
first day of the next menses.
• Discontinue oral contraceptive if there is signs of severe headache as this
is an indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.

Immediate Discontinuation
A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – severe leg cramps
ACHES – signs of hypertension hence if the Blood Pressure of the mother is
increased – stop the pills STAT!
• if forgotten for one day, immediately take the forgotten tablet plus the
tablet scheduled that day. If forgotten for two consecutive days, or more days, use
another method for the rest of the cycle and the start again.
Adversed Effect: breakthrough bleeding
Contraindicated:
 chain smoker
 extreme obesity
 Hypertension
 Diabetes Mellitus
 Thrombophlebitis or problems in clotting factors

 DMPA – Depot Provera Medroxy Progesteron Acetate - depoproveda – has progesterone

inhibits LH – inhibits ovulation
Depomedroxy progesterone acetate – has progesterone inhibits LH – inhibits ovulation
- IM every month
- never massage injected site, it will shorten duration
( it can easily absorbed )

 Norplant – has 6 matchsticks like capsule/rod dermally implanted containing

progesterone.
Note : 5 years – disadvantage if keloid skin
as soon as removed – can become pregnant
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 Mechanical and Chemical Barriers
Intrauterine Device (IUD)
Action: prevents implantation – affects motility of sperm & ovum
- right time to insert is after delivery or during menstruation
primary indication for the use f IUD: parity or # of children MULTIARITY
if 1 child only don’t use IUD

Health Teaching:
a. Check for string daily
b. Monthly checkup
c. Regular pap smear
Alerts:
 prevents implantation
 inserted during menstruation and after delivery because the cervix is open
 most common complications: excessive menstrual flow
 most common problem: expulsion of the device
 others complications – uterine infection uterine perforation and ectopic pregnancy
Period late (pregnancy suspected) Abnormal spotting or bleeding
Abdominal pain or pain with intercourse
Infection (abnormal vaginal discharge)
Not feeling well, fever, chills
Strings lost, shorter or longer

 Condom – made up of latex inserted to erected penis or lubricated vagina

- it lessen sexual satisfaction
- it gives higher protection in the prevention of STD’s
Alert : female condom - give the most and highest protection against STD

 Diaphragm – made up of rubberized dome shaped material inserted to the cervix

preventing sperm to get to the uterus. REVERSABLE
Alert:
1.) proper hygiene should be observed since it is reusable
2.) check for holes before using it
3.) must be kept in place for about 6 – 8 hrs after sex
4.) must be refitted especially if weight change, ↑or ↓ by 15 lbs
5.) spermicide – chemical Barrier
example: Foam (most effective), jellies, creams
Side effect: Toxic shock syndrome

 Cervical Cap – most durable than diaphragm

- no need to apply spermicide
- should be kept 24 hours, no need to reapply spermicides
Contraindication: abnormal pap smear

 Foams, Jellies, Creams, Spermicidal agents – to kill spermicides

Foam – most effective
Spermicidal agents – toxic effect – Toxic Shock Syndrome

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 Surgical Method
 BTL ( Bilateral Tubal Ligation ) women ( tie, cut, cautery )
- immediate sterilization – cut
– can be reversed 20% chance. ( 20 – 30 reanastamosis )
- isthmus - is the site for sterilization
Health Teaching : Avoid lifting heavy object

 Vasectomy ( men ) - cut vas deferense.

- not immediate sterilization
- need to ejaculate 30 X for 0 sperm before considering a
safe sex
Health Teaching : > 30 ejaculations before safe sex
O – zero sperm count, safe
XI. High Risk Pregnancy
1. Hemorrhagic Disorders
• To determine the integrity of sac
• Prepare the mother for ultrasound
• Save discharges for histopathology
• Assess for complications like hypovolemic shock
General Management
1.) Complete Bed Rest
2.) Avoid sex
3.) Assess for bleeding
Fully saturated pad (per pad 30 – 40 cc) (weight – 1 gm =1 cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges – for histopathology – to determine if product of conception has been
expelled or not
First Trimester Bleeding – abortion or eptopic
Abortions – termination of pregnancy before age of viability (before 20 weeks)
Age of viability – 20 - 24 weeks
Intrauterine death or Stillbirth – after the age of viability
1. Spontaneous Abortion – also known as miscarriage
Causes: 1.) chromosomal alterations
2.) blighted ovum
3.) plasma germ defect
Classifications:
a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is
closed; can give progesterone
b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix
(Cervical dilation) cervix is open
Types:
b.1. Complete – all products of conception are expelled.
Nursing Management: no need for D & C, just emotional support!
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 b.2 Incomplete – Placenta and membranes retained.
Management: for D& C
b.3 Habitual – 3 or more consecutive pregnancies result in abortion usually
related to incompetent cervix. Present 2nd trimester

Incompetent cervix – abortion

Surgery: a. McDonalds procedure – temporary circlage on cervix
* During delivery, circlage is removed. NSD
Side Effects: infection.
b. Shirodkar – permanent surgery on cervix. CS
b.4 Missed – fetus dies; product of conception remain in uterus 4 weeks or
longer; signs of pregnancy cease. (-) pregnancy test, scanty, dark
brown bleeding
Management: induced labor with oxytocin or vacuum extraction
c. Induced Abortion – therapeutic abortion to save life of mother based on the
principles of twofolds effect - choose between lesser evil.
Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity.
Common site : tubal or ampular
Dangerous site : interstitial
Unruptured Tubal rupture

o missed period o sudden , sharp, severe pain.

o abdominal pain within 3 -5 weeks of missed
period (maybe generalized or one sided)
o scant, dark brown, vaginal bleeding
o vague discomfort
Unilateral radiating to shoulder.
o shoulder pain (indicative of intraperitoneal
bleeding that extends to diaphragm and phrenic
nerve)
o + Cullen’s Sign – bluish tinged umbilicus –
signifies intra peritoneal bleeding
o syncope (fainting)

Nursing Care: Surgery:

 Vital Signs * Fallopian - Salphingectomy
 Administer IV fluids * Abdominal - Exploratory Laparotomy
 Monitor for vaginal bleeding * Uterus - Hysterectomy
 Monitor I and O
Second trimester bleeding – small and incompetent cervix
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Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization.
- Progressive degeneration of chorionic villi. Recurs.
- Gestational anomaly of the placenta consisting of a bunch of clear vesicles.
- This neoplasm is formed form the selling of the chronic villi and lost nucleus of the
fertilized egg.
- The nucleus of the sperm duplicates, producing a diploid number 46 XX
- It grows & enlarges the uterus vary rapidly. ( progressive degeneration of corionic villi )
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs - vesicles passed thru the vagina
- Hyperemesis gravidarium due to increase HCG
- Fundal height
- Vaginal bleeding ( scant or profuse)
Early in pregnancy - High levels of HCG
- Pre eclampsia at about 12 weeks
Late signs: - hypertension before 20th week
- Vesicles look like a “ snowstorm” on sonogram
- Anemia
- Abdominal cramping
Serious Late complications : - hyperthyroidism
- Pulmonary embolus
Nursing care:
• Prepare for D & C
• Do not give oxytoxic drugs – may cause embolism
Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring HCG
and assess for enlarged uterus and rising titer could indicative of
choriocarcinoma
b. Avoid pregnancy for at least one year . Can have sex provided the partner
will use condom for protection
Third Trimester Bleeding “Placenta Anomalies”
Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment,
sometimes covering the cervical os.
- Abnormal lower implantation of placenta.
* candidate for CS
Total – complete cover of the cervical os
Partial – 5%
Low
Assessment:
Outstanding signs and symptoms:
 FRANKBRIGHT RED PLEEDING, PAINLESS BLEEDING
 Engagement (usually has not occurred)
 Fetal distress
 Presentation ( usually abnormal )
Complications:
 Internal examination
49
  Sudden fetal blood loss
Diagnostic Examination:
 Ultrasound
Note: Avoid: sex, IE, enema – may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR

Nursing Care:
 NPO
 Bed rest
 Prepare to induce labor if cervix is ripe
 Administer IV
Note Alert : Surgeon – in charge of sign consent, RN as witness
MD explain to patient
Abruptio Placenta - it is the premature separation of the placenta form the implantation site.
- It usually occurs after the twentieth week of pregnancy.
• (due to use of cocaine ) – PIH
Assessment:
 dark red, painful bleeding
 board like or rigid uterus/abdomen
 Concealed bleeding/hemorrhage (retroplacental)
 Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to
contract due to hemorrhage.
 Severe abdominal pain
 Dropping coagulation factor (a potential for DIC)
Complications:
 Sudden fetal blood loss
 placenta previa & vasa previa
General Nursing Care:
 Infuse IV, prepare to administer blood
 Type and crossmatch
 Monitor FHR
 Insert Foley
 Measure blood loss; count pads
 Report signs and symptoms of DIC
 Monitor v/s for shock
 Strict I & O
Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel
which may lead to retained placental fragments if vessel is cut.
Placenta Circumvalata – fetal side of placenta covered by chorion
Placenta Marginata – fold side of chorion reaches just to the edge of placenta
Battledore Placenta – cord inserted marginally rather then centrally
Placenta Bipartita – placenta divides into 2 lobes
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Placenta Tripartita – placenta divides into 3 lobes
Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
Vasa Previa – velamentous insertion of cord has implanted in cervical OS

2. Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)
• Hypertension after 24 wks of pregnancy, solved 6 weeks post partum.
1.) Gestational hypertension - HPN without edema & protenuria H without EP
2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HEP/A
- idiopathic
3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count
- common in primi because of increase exposure to chronic villi
- multiple pregnancy
- Mother low socio-economic status
- Increase sensitivity to Angiotensin II
↓ main effect
peripheral vascular vasospasm
↓
decrease Oxygen supply → Hypertension
( main denominator )
↓
KIDNEYS
↓

↓ ↓
↓ ↓
EYES Glomerular Degeneration Glomerular Filtration Placenta
↓ ↓ ↓ ↓
Retinal vassoconstriction increase permeability increase sodium absorption IUGR
↓ ↓ ↓ (intrauterine growth retardation)
Blurred Vision proteinuria increase water retention
↓ └ EDEMA ┘
SCOTOMA ↓
↓ ANASARCA
↓ PRE TERM LABOR
BLINDNESS ↓ ↓
BRAIN LUNGS
↓ ↓
LIVER – Tissue Ischemia Cerebral Edema Pulmonary Edema
↓ ↓
Liver Edema HEART ( CHF )
↓ ↓
Epigastric Pain CONVULSION
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 II. Transissional Hypertension – HPN between 20 – 24 weeks
III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia – earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric pain due to liver edema
and oliguria usually indicates an impending convulsion. BP 160/110, protenuria
+3 - +4
3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.
Cause of pre eclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON
Nursing care:
P – promote bed rest to decrease O2 demand, facilitate, sodium excretion,
- water immersion will cause to urinate.
P - prevent convulsions by nursing measures or seizure precaution
1.) maintain dimly lit room
2.) quiet calm environment
2.) minimal handling – planning procedure
3.) avoid jarring bed
* Right Place of the patient: across the nursing station
P- prepare the following at bedside
- tongue depressor
- side rail up before the seizure
- turning to side done AFTER seizure
(to facilitate drainage of secretion)
- prepare suction machine
- Observe only! for safely.
E – ensure high protein intake ( 1g/kg/day)
- Na – in moderation (replace the protein loss)
A – anti-hypertensive drug Hydralazine ( Apresoline)
C – convulsion, prevention by :
Mg S04 – CNS depressant or anti convulsant (absence of seizure)
E – valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
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 2. Urine output decrease
3. Resp < 12
4. Patella reflex absent – 1st sigh Mg SO4 toxicity.
Antidote : Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas)

Function of insulin:
- facilitates transport of glucose to cell
• glucose - energizer of cell
• insulin – key for glucose
Diagnostic Test: 1 hour 50 grams (glucose tolerance test ) GTT
Normal glucose – 80 – 120 mg/dl ( euglycemia)
< 80 – hypoclycemic
> 120 - hyperglycemia
3 hours GTT of > 130 mg/dL
Maternal Effect Diabetes Mellitus
1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic
* hpl – serves as insulin antagonist
2.) Frequent infection- moniliasis/candidiasis
3.) Polyhydramnios
4.) Dystocia - difficult birth due to abnormalities in fetus or mother is big
5.) Insulin requirement, decrease in insulin by 33 % in 1st tri; 50 % increase
insulin at 2nd – 3rd trimester.
Post partum decrease 25% due placenta out.
No more hormone (hpl) - given by shots, not oral because it is teratogenic
Fetal effect
1.) hyper & hypoglycemia
2.) macrosomia – large for gestational age
– baby delivered > 4000 g or 4 kg
– largest 8000 g
3.) preterm birth to prevent stillbirth
4.) IUGR (Intrauterine Growth Retardation)
Newborn Effect : Diabetes Mellitus
1.) hyperinsulinism
2.) hypoglycemia
normal glucose in newborn 45 – 55 mg/dL
borderline – 40 mg/dL
hypoglycemic < 40 mg/Dl
* glucose – food for the brain
Management:
Heel stick test – get blood at heel
- administer dextrose
- monitor
Signs and Symptoms:
- Hypoglycemia
- high pitch shrill cry
53
 - tremors
3.) hypocalcemia - < 7 mg%
Signs and Symptoms:
Calcemic tetany
Trousseau sign

Management : Give calcium gluconate if decrease calcium

Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant – heparin doesn’t cross placenta
Class I & II- good prognosis for vaginal delivery
Class III & IV- poor prognosis, for vaginal delivery, not CS!
- general anesthesia
- anti coagulant therapy – “Heparin” – if pregnant only
- Antibiotic – to prevent subacute endocarditis
NOT lithotomy!
High semi-fowlers or sidelying position during delivery (best position)
No valsalva maneuver
Regional anesthesia! Caudal (anesthesia of choice)
Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.
Heart disease
Mothers with RHD at childhood
Class I – no limitation of physical activity
Class II – slight limitation of physical activity.
- Ordinary activity causes fatigue & discomfort.
Recommendation of class I & II
1.) sleep 10 hours a day
2.) rest 30 minutes & after meal
Class III - moderate limitation of physical activity.
- Ordinary activity causes discomfort and fatigue
Recommendation:
1.) early hospitalization by 7 months
Class IV. marked limitation of physical activity for even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion
XII. Intrapartal complications
1. Cesarean Delivery Indications:
a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
h. CPD primary indication
i. Breech presentation
54
 j. Transverse lie
Procedure:
a. Classical – vertical insertion. Once classical always classical
b. Low segment – bikini line type – “aesthetic use” - transverse
VBAC – vaginal birth after CS – low segment

INFERTILITY - inability to achieve pregnancy. Within a year of attempting it

• Manageable
STERILITY
• irreversible
Impotency – inability to have an erection
2 types of infertility
1.) Primary – no pregnancy at all
2.) Secondary – 1st pregnancy, no more next pregnancy
Test Male 1st
o more practical & less complicated
o need: sperm only
o sterile bottle container ( not plastic has chem.)
o Sims Huhner test – or post coital test.
Procedure: sex 2 hours before test
mother – remains supine 15 minutes after ejaculation
Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm.
If > 15 – low sperm count
Best criteria - sperm motility for impotency
Factors: low sperm count
1.) Occupation - truck driver
2.) chain smoker
Administer: clomid ( chomephine citrate) to induce spermatogenesis
↓ if not effective
Management: GIFT = “Gamete Intra Fallopian Transfer” for low sperm count
Implant sperm in ampula
1.) Mom: anovulation – no ovulation. Due to increase prolactin
– hyperprolactinemia ( inhibit ovulation )
Administer: parlodel ( Bromocryptice Mesylate)
Action: antihyper prolactineuria (antiparkinsonian)
Give mom clomid: action: to induce oogenesis or ovulation
Side Effects: multiple pregnancy
2.) Tubal Occlusion – tubal blockage –
o History of PID that has scarred tubes
o Use of IUD (peritonitis)
o Appendicitis (burst) & scarring
Diagnostic Test: hysterosalphingography – used to determine tubal patency with use of
radiopaque material
Management: IVF – invitrofertilization (test tube baby)
England 1st test tube baby
To shorten 2nd stage of labor:
55
1.) fundal pressure
2.) episiotomy
3.) forcep delivery

56