Unit 11- Mother and Child Health with such natural law are morally correct.
Those
A. PROCREATIVE HEALTH DEFINITION AND
THEORIES RELATED TO PROCREATION
Procreative Health – is the moral
obligation of the parents to
have the healthiest children
thru all natural and artificial
means available.
DISTINCTION BETWEEN PROCREATION AND
REPRODUCTION
Reproduction - defined as the action
of making a copy of something, or the
production offspring by sexual intimacy. In
contrast, procreation roots sexuality and
childbearing deeply within with two
relations:
That of the man and woman, and that
between the couple and GOD (2006).
THEORIES RELATED TO PROCREATION
1. Theories of conception have to do with
far more than the physical process of
human coming into being. In all times
and places, people have had ideas
about the process, and these ideas are
interrelated with ideas about gender,
kinship, property, and religion.
2. Natural Law Theory: with this theory
actions in conformity and support of
natural laws are morally correct. A
simple summary would be: What is
Consistent with the Natural Law Is
Right and What is not in keeping with
the Natural Law is Wrong.
Note: This is NOT what is natural is morally
correct and what is unnatural is morally wrong.
The focus is on the natural Laws and not simply
natural acts. Natural Law Theory support doing
unnatural deeds such as surgery for the sake of
realizing a restoration of health and the
prolongation of human life which are each
consistent with the natural drives of organisms:
survival
Two Types of Natural Law Theory:
Natural Law Theory - can be held and
applied to human conduct by both theists and
atheists. The atheist uses reason to discover the
laws governing natural events and applies them to
thinking about human action. Actions in accord
that go against such natural laws are morally
wrong.
For the theists there is still the belief that
humans have reasoning ability and with it the laws
of nature are discernible. For atheists who accept
this approach to act in keeping with the laws of
nature is the morally correct thing to do.
Parent Development Theory: Understanding
Parents, Parenting Perceptions and Parenting
Behaviors
- for the importance of parenting, with the
long-term implications for children, families,
and society, there is precious little
psychological theory specifically on parents
and parent development. And, while there
are many parent education programs
available and certainly substantial research
on parents (e.g., Baurmind, 1975, 1991),
none are based on an overall theoretical
model regarding who parents are and how
they develop in relation to the parenting role.
This article provides as theoretical
framework, the Parent Development Theory
(PDT) to assist professionals in organizing
their thinking, practice, and research
regarding parenting. Originally called the
Parent Role Development Theory (PRDT).
Theory for Child Oriented Professionals
Theoretical Perspectives on Siblings
Relationships
Theories of Motivation
Evolutionary Theory of Motivation - according to
evolutionary psychology, individuals are
motivated to engage in behaviors that maximize
their genetic fitness.
Process of Human Reproduction
Reproductive development begins at the moment
of conception and continues through life.
Intrauterine development gonad-is a body organ
that produces the cells necessary for reproduction
(the ovary in females, the testis in
males) oocytes- cells that will develop
into eggs throughout the woman’s
mature years)
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Pubertal development
- is the stage of life at which secondary sex
changes begin. These changes in girls are
stimulated when the hypothalamus
synthesizes and releases
gonadotropinreleasing hormone (GnRH),
which then triggers the anterior pituitary
to release follicle-stimulating hormones
(FSH) and luteinizing hormone (LH). FSH
and LH are termed gonadotropin (gonad =
“ovary”; tropin = “growth”) hormones not
only because they begin the production of
androgen and estrogen, which in turn
initiate secondary sex characteristics, but
also because they continue to cause the
production of eggs and influence
menstrual cycles throughout women’s
lives. Hypothalamus- serves as gonadostat
or regulation mechanism to “turn
on”gonad functioning
The Role of Androgens
- Androgenic hormones are the hormones
responsible for muscular development,
physical growth, and the increase in
sebaceous gland secretions that cause typical
acne in both boys and girls during
adolescence. In males, androgenic hormones
are produced by the adrenal cortex and the
testes, and, in females, by the adrenal cortex
and the ovaries.
- The level of the primary androgenic
hormone, testosterone, is low in males until
puberty (between ages 12 and 14 years)
when it rises to influence pubertal changes in
the testes, scrotum, penis, prostate, and
seminal vesicles; the appearance of male
pubic, axillary and facial hair; laryngeal
enlargement with its accompanying voice
change; maturation of spermatozoa; and
closure of growth plates in long bones
(termed adrenarche). In girls, testosterone
influences enlargement of the labia majora
and clitoris and formation of axillary and
pubic hair.
The Role of Estrogen
- when triggered at puberty by FSH, ovarian
follicles in females begin to excrete a high
level of the hormone estrogen. This increase
influences the development of the uterus;
fallopian tubes, and vagina; typical female fat
distribution; hair patterns; and breast
development. It also closes the epiphysis of
long bones in girls the same way
testosterone closes the growth plate in boys.
The beginning of breast development is
termed thelarche, which usually starts 1 to 2
years before menstruation.
Secondary Sex Characteristics
Adolescent sexual development has been
categorized into stages (Tanner 1990). There is
wide variation in the time required for adolescents
to move through these developmental stages;
however, the sequential order is fairly constant. In
girls, pubertal changes typically occur as:
•Growth spurt
•Increase in the transverse diameter of the pelvis
•Breast development
•Growth of pubic hair
•Onset of menstruation
•Growth of axillary hair
•Vaginal secretions
The average age at which the menarche (the first
menstrual period) occurs is 12, 4 years of age
(Ledger, 2012). It may occur as early as age 9 years
as late as age 17 years, however, and still be within
a normal age range. Irregular menstrual periods
are the rule rather than the exception for the first
year or two, menstrual periods do not become
regular until ovulation occurs consistently and this
does not to happen until 1 to 2 years after
menarche. In boys, production of spermatozoa
does not begin in intrauterine life as does the
production of ova in girls nor are spermatozoa
produced in a cyclic pattern as are ova; rather,
they are produced in a continuous process. The
production of ova stops at menopause. In
contrast, sperm production continues from
puberty throughout the male’s life.
Secondary sex characteristics of boys usually occur
in the order of:
*Increase in weight
*Growth of testes
*Growth of face, axillary, and pubic hair
*Voice changes
*Penile growth
*Increase in height
*Spermatogenesis (production of sperm)
2
Factors that may lead to genetic abnormalities:
- They may be due to several problems, or a
combined effect of genes and the
environment. It is difficult to predict
inheritance of abnormalities caused by
multiple factors. Examples include heart
defects, cleft lip or cleft palate, and neural
tube defects (defects in the spine or brain).
Genetic Disorders:
- Many human diseases have a genetic
component. Some of these conditions are
under investigation by researchers at or
associated with the National Human Genome
Research Institute (NHGRI).
A genetic disorder is a disease caused in whole or
in part by a change in the DNA sequence away
from the normal sequence.
- Most genetic diseases are the direct result of
a mutation in one gene. However, one of the
most difficult problems ahead is to further
elucidate how genes contribute to diseases
that have a complex pattern of inheritance,
such as in the cases of diabetes, asthma,
cancer, and mental illness.
- A genetic disease is any disease caused by an
abnormality in the genetic make-up of an
individual. The genetic abnormality can range
from miniscule to major-from a discrete
mutation in a single base in the DNA of a
single gene to a gross chromosome
abnormality involving the addition or
subtraction of an entire chromosome or set
of chromosomes. Some people inherit
genetic disorders from the parents, while
acquired changes or mutations in a
preexisting gene or group of genes cause
other genetic diseases. Mutations can occur
either randomly or due to some
environmental exposure.-
a. Multifactorial inheritance is also called complex
or polygenic inheritance.
- are disorders caused by a combination of
environmental factors and mutations in
multiple genes. For example, different genes
that influence breast cancer susceptibility
have been found on chromosomes 6, 11, 13,
14, 15, 17 and 22. Some common chronic
diseases are multifactorial disorders.
Examples of multifactorial inheritance include:
heart disease; high blood pressure, Alzheimer’s
disease, arthritis, diabetes, cancer, and obesity.
Multifactorial inheritance also is associated with
heritable traits such as fingerprint patterns,
height, eye color, and skin color.
b. Chromosome abnormalities
- Chromosomes, distinct structures made up of
DNA and protein, are located in the nucleus of
each cell. Because chromosomes are the carriers
of the genetic material, abnormalities in
chromosome number or structure can result in
disease. Abnormalities in chromosomes typically
occur due to a problem with cell division.
For example, Down syndrome (sometimes
referred to as Down’s syndrome) or trisomy 21 is
a common genetic disorder that occurs when a
person has three copies of chromosome 21. There
are many other chromosome abnormalities
including:
a. Turner syndrome (45, XO)
b. Klinefelter syndrome (47, XXY)
c. Cri du chat syndrome - or the “cry of the cat
"syndrome (46. XX or XY, 5p-) Diseases may also
occur because of chromosomal translocation in
which portions of two chromosomes are
exchanged.
c. Mitochondrial Genetic Inheritance
- This type of genetic disorder is caused by
mutations in the nonnuclear DNA of mitochondria.
Mitochondria are small round or rod-like
organelles that are involved in cellular respiration
and are found in the cytoplasm of plant and animal
cells. Each mitochondrion may contain 5 to 10
circular pieces of DNA. Since egg cells, but not
sperm cells, keep their mitochondria during
fertilization, mitochondrial DNA is always
inherited from the female parent.
Examples of mitochondrial disease include:
a. Leber’s hereditary optic atrophy (LHON), an eye
disease;
b. Myoclonic epilepsy with ragged red fibers
(MERRF); and
c. Mitochondrial encephalopathy, lactic acidosis,
and stroke-like episodes (MELAS) , a rare form of
dementia
3
B. Antepartum/ Pregnancy
MALE REPRODUCTIVE SYSTEM
The Female Reproductive System
Female External Structures- are termed the vulva-
from the Latin word for “covering”.
FEMALE INTERNAL GENITALIA
Cervix - lowest portion of the uterus
Fallopian tubes - long channels that
transport the ovum from the ovary to the uterus
Fundus - portion of the uterus between the
points of attachment of the fallopian tubes
Ovary - almond-shaped glandular
structure on either side of the uterus that
produces, matures, and discharges ova
Uterus - hollow, pear-shaped muscular
organ in the lower pelvis that provides a
place for fertilized ovum to implant and
houses growing fetus.
Vagina - vascularized muscular
membranous tube that extends from the
external genitals to the uterus and is the
organ of intercourse
Fallopian tubes divided into 4 parts
1. Interstitial portion- most proximal
division,lies within the uterine wall.
2. Isthmus- portion of the tube that is cut
or sealed in a tubal ligation.
3. Ampulla- third and the longest portion
of the tube.Fertilization of an ovum usually
occurs.
4. Infundibular portion- most distal
segment of the tube. Covered by fimbria
(small hairs) that help to guide the ovum
into the fallopian tube.
Three Parts of the Uterus:
1. Body or corpus – uppermost portion;
bulk of uterus; expands to accommodate
fetus. The portion of the uterus between
the points of attachment of the fallopian
tubes is termed the fundus.
2. Isthmus – Short segment between
corpus and cervix. It is the portion where
the incision is made when a fetus is born by
caesarean birth.
3. Cervix – Lowest part; 1/3 of total size
Uterine Layers:
a. Endometrium – inner mucous
membrane layer of the uterus that sheds during
menstruation
b. Myometrium – three interwoven layers
of smooth muscle that give the uterus its strength
c. Perimetrium – outer layer that covers
the body of the uterus and part of the cervix
Types of Uterine Deviations
1. Bicornuate uterus-oddly shape
“horns” at the junction of the fallopian tubes.
(heart shape)
2. Septum- Dividing Uterus
3. Double Uterus
Deviations in Uterine Position That Are Commonly
Seen:
1. Anteversion-the entire uterus tips far forward.
2. Retroversion-the entire uterus tips far back
3. Anteflexion-body of uterus bends sharply
forward at the junction with the cervix
4. Retroflexion-body of uterus bends sharply
backward just above the cervix.
Types of Pelvis
• Gynecoid - round shaped
– Transversely rounded and slightly ovoid
• Android – wedge-shaped / heartshaped
– Angulated, resembles male pelvis;
• Anthropoid - inlet oval-shaped
– Oval, wider anteroposterior diameter
• Platypelloid -oval shaped transversely
– Flat anteroposterior diameter; wide
transversely
FEMALE REPRODUCTIVE CYCLE
Purpose is to mature ovum and renew the uterine
tissue bed
Menarche usually occurs between ages 9 and 17
Average length of menstrual cycle is 28 days
Average length of menses is 2 to 9 days
Initiated by the release of LHRH, also known as
GnRH, from the hypothalamus
Under the influence of LHRH, the anterior lobe of
the pituitary produces two hormones (FSH and LH)
that act on the ovaries to further influence the
menstrual cycle
4
The MENSTRUAL CYCLE B. Luteal Phase
– Periodic uterine bleeding in response to Days 15 to 22
cyclical hormonal changes Corpus luteum develops from a ruptured
– Begins at puberty, ends at menopause – follicle
Structures involved: Corpus luteum produces large quantities
• Hypothalamus of progesterone
• Pituitary gland *If conception occurs, ovum proceeds down the
• Ovaries fallopian tube and plants on the endometrium of
• Uterus the uterus.
1. Uterine Phase *If conception does not occur the unfertilized
A. Menstrual Phase ovum atrophies after4-5 days.
Days 1 to 5 *The corpus luteum remains only 8-10 days and
Endometrial lining is shed gradually regresses and turns into corpus albican
LH, Estrogen, & Progesterone at their or white body.
lowest level •The first day of menstrual flow is used to mark
FSH increases --Graafian follicle begins the beginning days of a new menstrual cycle.
maturing •Menstrual cycle begins with the first day of
B. Proliferative Phase bleeding which is counted as day 1, the cycle ends
Days 5 to 14 just before the next menstrual period.
Uterine lining grows due to increased •For example if your period starts on Oct 6th, that
Estrogen; thickens by 8 to 10-folds is day 1,if your next period starts on the nov 3, the
Glands and vascularization are developed 2nd of nov was the 28th day of your last cycle and
3 to 4 days before ovulation the 3rd day of Nov is the first day of the next
C. Ovulation menstrual cycle.
Days 12 to 16
Estrogen is high & Progesterone is low Menstrual Cycle
LH stimulates the release of mature, non- Purpose:
fertilized ovum 1. To bring ovum to maturity
Spinnbarkeit – stretchable cervical mucus 2. Renew a uterine tissue bed that will be
D. Secretory or Luteal Phase responsible for ova’s growth should it be fertilized.
Days 15 to 26 * Interval: Ave: 28 days, 23-35 days not unusual
Uterus prepared for implantation *Duration: Ave:4-6 days, may be 1-9 days
Estrogen level drops, Progesterone level is *Amt. Of menstrual flow: ave: 30-80 ml
high (produced by corpus luteum) *Color- Dark red, made up of blood, mucus and
Increased uterine vascularity; Tissue endometrial cells
glycogen levels increase Determination of Ovulation
E. Ischemic Phase Mittelschmerz
Days 27 to 28 Spinnbarkeit
Estrogen & Progesterone levels declines Basal Body Temperature
Arterial vessels constrict Ferning
Endometrium prepares to shed Glycogen content of vagina and the
Blood vessels rupture Menstruation cervical cells
begins To compute for the exact date of ovulation,
count back 14 days from the first day of
2. Ovarian Response menstruation.
A. Follicular Phase Spinnbarkeit
Days 1 to 14 First half of the cycle- cervical mucus is
Follicle matures due to FSH thick and scant
Ovulation occurs due to LH surge

5
 At the time of ovulation, when the
estrogen level is high- cervical mucus become thin
and copious
During the second half of the cycle, the
cervical mucus again becomes thick and
sperm survival is poor.
Fern Test- mucus can be examined at mid cycle to
detect ferning
Cervical mucous forms “fernlike “ patterns
when it smeared and dried on a glass slide.
The pattern are due to crystallization of
sodium chloride on mucus fibers.
If increased progesterone fern pattern is
no longer discernible.
Basal Body Temperature
The basal temp. drops before the day of
ovulation and rises on the day after ovulation
The temperature remains at this level until
approximately day 24 of the menstrual cycle when
the level of the progesterone drops.
Process of Conception
(Chapter 9)
Fertilization
Proper timing is essential for fertilization to
occur. The ovum will only be receptive to
fertilization for 24 hours whereas the
sperm remains viable only for 24-72 hours.
During ovulation, the fimbriae of the
fallopian tubes pick up the released ovum
and the ovum moves down the tubes by
ciliary action. It usually takes about 3 days
for this whole process to be completed.
Of the 200-400 million sperm released into
the vagina during intercourse, only about
one hundred reach the distal end of the
uterine tube to reach the ovum and
fertilize it. The sperm that do reach the
ovum shall surround the latter and secrete
hyaluronidase which will break down the
cells surrounding the ovum. This process
will allow the sperm to penetrate the ovum
and fertilize it.
Upon penetration of the sperm, the zona
pellucida will undergo several changes
which shall prevent fertilization of the
ovum by another sperm. Fertilization
culminates with the combining of the 23
unpaired chromosomes for each of the
gametes and initiate further cell division.
Cell division commences even as the
fertilized ovum is propelled proximally
down the uterine tube. It is called the
morula when it is at the 16-50 cell stage.
The outermost cells of the morula then
secrete fluid which forms a sac within
which an inner mass of cells is located. The
latter then becomes a two layered group of
cells called the embryonic disc which will
later on form the embryo and amnion. The
outermost cells, also known as
trophoblast, will become the placenta and
the chorion.
The fertilized ovum has 46
chromosome
Spermatozoon and ovum each
carried 23 chromosomes
(22 autosomes and 1 sex
chromosomes)
If TWO X chromosomes (XX)
female
If X and Y (XY) male
Growth and development of the
fetus begins with fertilization
After fertilization, fetal
development occurs in 3 stages
1st (preembryonic stage) - 1st 14 days after
conception
2nd (embryonic stage) - 3rd wk after
conception until the embryo reaches 3 cm
(1.2 in.) in length (8 wks); referred to as
fetus
3rd (fetal stage) - 8 to 10 wks after
conception until the end of pregnancy
FETAL DEVELOPMENT
Zygote
–Cell that results from fertilization of the ovum by
the sperm cell
Blastomere
–results from mitotic division of the zygote
Morula
–solid ball of cells formed by 16 or more
blastomeres
Blastocyst
–morula that has reached the uterus (7 days after
fertilization)
FETAL DEVELOPMENT
6
Embryo blood travels to the non-functioning lungs.
–organism that contains the 3 germ layers (7 days While the remaining blood is shunted
to 8th week); All organ systems present through the ductus arteriosus into the aorta
Fetus to supply the rest of the body.
-organ systems develop and grow, from the 8th wk - One umbilical vein carries oxygen and
until term nourishment from the placenta to the fetus
11 wks 16 wks 20 wks 24 wks - Two umbilical arteries carry deoxygenated
blood from the fetus to the placenta.
- Blood flow through the cord is about 400
ml/min.

Milestone of Fetal Development

Week 1 – Ovum becomes fertilized. Divides and
implant into the uterus
The Primary Germ Cells
Week 2 – Ectoderm, mesoderm, endoderm are
Germ Layer Structure Formation formed
• Ectoderm Skin Week 3 – The first body segment appears which
Nervous system will eventually form the spine, brain and spinal
Nasal passages cord
Eyes Week 4 – Heart, blood circulation, and digestive
Pharynx tract take shape
Mammary Week 5 – Heart starts to pump blood
Lens of the gland Week 6 – Eyes begin to take shape
Salivary gland Week 7 – Face is complete with nose, eyes, lips
Mesoderm Muscles and tongue
Circulatory system Week 8 – Heart beating at about 40 to 80/min
Bones Week 9 – Genitals are well defined. Embryo
Reproductive system becomes a fetus
Connective system Week 10 – Fetus assumes a more human shape.
Kidneys, ureters First movements begin.
Week 11 – Pancreas produces insulin. The kidneys
Formation Structure urine
• Endoderm Week 12 – Swallowing reflexes mastered as the
Alimentary tract fetus sucks its tongue
Respiratory tract Week 14 – Musculoskeletal system matured
Bladder Week 15 – Kicks restlessly against the amniotic sac
Pancreas Week 18 – Fine hairs covers the body and keeps
Liver the oil on the skin
Week 19 – Eyebrows, eyelashes & hair developed
Fetal circulation Week 20 – Has a regular schedule of sleeping,
- The umbilical vein carries oxygen rich blood turning, sucking and kicking
from the placenta to the liver and the ductus Week 22 – Skeleton develops
venosus. From there it is carried to the Week 23 – Eyelids begin to open and close
inferior vena cava to the atrium of the heart. Week 26 – Baby can breathe, swallow, & regulates
Some of the blood is shunted through the its body temperature
foramen ovale to the left side of the heart Week 27 – Surfactant forms in the lungs
where it is routed to the brain and upper Week 29 – Fat deposits builds up beneath the skin
extremities. The rest of the blood travels Week 30 – Digestive tract & lungs nearly fully
down to the right ventricle and through the matured.
pulmonary artery. A small portion of the

7
Week 30 to 34 – 280 to 320 mm in length and
weighs 700 to 2,500 g. Vigorous fetal movement
occurs
Week 35 to 37 – 330 to 360 mm in length; weight
2,700 to 3,400 g.
Week 38 to full term – 360 mm in length and
weighs 3,400 to 3,600 g. Skin is smooth, chest is
prominent, bones of skull are ossified. Testes are
in scrotum
Determination of Age of Gestation
Last Menstrual Period (LMP)
–Calculating time from the first day of the last
menstrual period up to the present
–Can be used to compute the EDD (expected date
of delivery) using the
Naegele’s Rule
Add 7 days to the first day of LMP, count
back 3 months, and add 1 year if applicable.
Quickening
– noted at 20 weeks in Primi & 16 wks in
multigravidas
Using Nagele's, what would be the
estimated date of delivery for a woman
whose first day of her last menses was
March 17, 2016?
Months
Measured as nine months on the calendar
-- starting one week after your LMP.
Trimesters
Three periods of three months each.
Months 1 - 3 are the first trimester
Months 4 - 6 are the second trimester
Months 7 - 9 are the third trimester
Lunar Months
Prenatal development is often measured in lunar
months.
Each lunar month consists of 28 days,
organized into four weeks of seven days each.
That means a pregnancy is 10 lunar months
long.
Weeks
40 weeks from the start of your LMP.
Gestation is 38 weeks from conception to birth.
Days
280 days from your LMP. No matter what
method is used to determine EDD.
Determination of Age of Gestation
Assessment of Fundic Height
– McDonald’s Rule
Fundic height (cm) x 2/7 = AOG in lunar
months
Fundic Height (cm) x 8/7 = AOG in wks –
Bartholomew’s Rule
Estimates AOG by the position of the
uterus in the abdominal cavity
»12 wks – symphysis pubis
»16 wks – halfway between umbilicus & symphysis
pubis
»20 wks – level of umbilicus
»24 wks – 2 FB above umbilicus
»30 wks – half way bet umbilicus & xiphoid
process
»36 wks – level of xiphoid process
»40 wks – just below xiphoid process
36 weeks 40 weeks
5th lunar months
3rd lunar months
Measuring Fundal Height
1. Explain the procedure to the client
2. Have the woman void
3. Help the woman into a supine position and
drape her, expose her abdomen
4. Measure the FH using a tape measure from the
symphysis pubis over the abdomen to the top of
the fundus
Typically, between the 20th and 32nd weeks of
gestation, the FH in centimeters corresponds to
the week of gestation
Determination of Age of Gestation
Johnson’s Rule
Estimates the weight of fetus in grams relative to
height of the fundus
Fetal weight = fundic ht (cm) – N x K
K – 155 (constant)
N – 12 if engaged, 11 if not yet engaged
Hasse’s Rule
To determine the length of fetus in cm.
1st half of pregnancy (1 to 5 lunar months)–
square the no. of mos
8
 2nd half of pregnancy (6 to 10 lunar months) Health History
multiply the no. of months by 5 • Data: Age, Marital Status, Family Setting, source
Mc Donald's rule of income, cultural values and practices relative to
FH = 34 cm 34cm multiply by 8 divided by 7 bearing and child rearing, education, employment
Ans. = 38 to 39 weeks background
34cm multiply by 2 divided by 7 Ans.= 9 to 10 Initial Prenatal History:
lunar months A.Family History of Health Problems
B.Patient’s medical history
Johnson's rule (grams) C.Gynecologic History
Fh= 21 cm, not engaged D.Obstetrical History
FH (cm) – n multiply by K (155) 21 – 11 =10 multiply A.Relevant data of previous pregnancies
by 155 = ?? Ans. = 1550 grams B.History of present pregnancy:
Hasse's rule LMP, EDC
7 months= 7 multiply by 5 = 35 cm length *Estimating Fetal Growth by:
Information to obtain from prenatal clients-- •Naegele’s Rule
Obstetrical history •McDonald’s Rule
Gravida, Parity (20 weeks AOG) 1. Measurement of fundal height
T-infant born @ 37 wks or after, weight is Bartholomew’s Rule- position of uterus in the
5 -8 lbs (2,500 – 4000 grams) abdomen
P-infant born before 37 wks , ended after 20 wks •12 wks, above symphysis pubis
A-(spontaneous/induced)-delivered before the •20 wks, umbilicus
end of 20wks (5 month) •36 wks xyphoid process
L-living children •Baseline height / weight and vital sign
M-multiple pregnancies-- para 1 –Medical and measurement
Surgical History, -sudden increased of BP and weight gain –
–Family History,Current problems gestational hypertension
Gravida- indicates the number of times the -sudden increased in pulse or respiration-
mother has been pregnant, regardless of whether undetected bleeding
these pregnancies were carried to term. A current Weight Gain during Pregnancy
pregnancy, if any, is included in this count •Roughly 20 to 30 lbs / 30 to 35 lbs
Para- indicates the number of viable (>20 wks) •First Trimester
births. Pregnancies consisting of multiples, such as •2 to 4 lbs; 1 lb per month
twins or triplets, count as ONE birth •Second
Trimester
Prenatal Assessment during
Antepartum/Antepartal •11 to 14 lbs; 0.9 lb per week
Purposes of prenatal care: Period •Third Trimester
1. Establish a baseline of present health. •8 to 11 lbs; 0.5 to 1 lb per week
2. Determine the gestational age of the fetus. •Note: Pattern of weight gain is more important
3. Monitor fetal development and maternal well than amount of weight gain.
being Physical Examination
4. Identify women at risk for complications 1. General Appearance and Mental Status
5. Minimize the risk of possible complications by •-hygiene, sad facial expression,the way they
anticipating and preventing problems before they speak,check for sign of partner abuse ( marks from
occur. battering and ecchymotic spots)
6. Provide time for education about pregnancy, 2. Head and Scalp
lactation and newborn care.
9
-examine women’s head for symmetry,normal
contour,and tenderness .
-presence of hair (distribution,thickness,dryness/
oiliness
•dryness or sparseness of hair suggests poor
nutrition 3. Eyes
-edema of the eyelids combined with a swollen
optic disk suggests gestational hypertension
-Report spots before their eyes or diplopia
suggests gestational hypertension
4. Nose
-increased level of estrogen cause nasal
congestion or the appearance of swollen nasal
membrane
Physical Examination
5.Ears
- nasal stuffiness may lead to blocked eustachian
tubes
( fullness in the ears or dampening of sound )
6.Sinuses
- should feel nontender headache suggests a
danger sign until ruled otherwise.
7.Mouth, teeth and throat
-gingival (gum) hypertropy result from increased
estrogen
-cracked corners of the mouth suggests Vit.A
deficiency
-pinpoint lesion with erythematous base on the
lips –suggests herpes infection.
- encourage good dental hygiene or yearly dental
exam
8.Neck
-slight thyroid hypertropy may occur due to
increased metabolic rate
-encourage a serving of seafoods at least once
weekly to supply enough iodine for the increased
thyroxine production -Use iodized salt
Physical Examination
9.Lymph nodes
-no palpable lymph nodes should be present
10.Breast
-Areolae darken
-Secondary areola develop
-Montgomery tubercles in the areola become
prominent
-Overall breast size increase
-Breast consistency firms
-Veins become prominent
• Colostrum as early the16th week of pregnancy
Physical Examination
10.Heart
-ranges from 70 to 80 beats / min in pregnant
woman - no accessory sounds or murmurs should
be present.
-teach woman to rest or sleep on their side ( left
side)-to keep their uterus from compressing their
vena cava(a cause of supine hypotension
syndrome as well as heart palpitations).
11.Lungs
-diaghragmatic excursion (diaphragm movement )
is lessened because the diaphragm cannot
descend fully as usual because of the distended
uterus.
12.Back
-lumbar curve is accentuated and standing so that
they can maintain body posture in the face of
increasing abdominal size( Lordosis –the pride of
pregnancy )
13.Rectum
-hemorrhoidal tissue commonly occurs from
uterine pressure on pelvic veins.
14.Extremities and skin
-palmar erythema or itching early in pregnancy
due to high estrogen level
-subclinical jaundice (jaundice that is not yet
apparent by a color change) from reabsorbed
bilirubin because of slowed intestinal peristalsis
-assess for varicosities (filling time of toenails
should be under 5 seconds) and edema caused by
impaired venous return from the lower
extremities
•Edema more than ankle swelling may be a danger
sign of pregnancy.
- waddling gait late in pregnancy may cause pain if
the cartilage at the joint becomes so unstable that
it moves from walking.
-
Measurement of fundal height and fetal heart
sound
Bartholomew’s Rule- position of uterus in the
abdomen
12 wks, above symphysis pubis
20 wks, umbilicus
36 wks xyphoid process
10
•-lightening- uterus returns 4cm below the
xiphoid at 40 weeks
Fetal heart sound
-120 to 160 beats / min heard at
*10 to 12 weeks using a doppler technique
*18 to 20 weeks using a regular stethoscope
Internal Pelvic Measurement
-Give actual diameters of the inlet and outlet in
which the fetus must pass
-Lithotomy position (on her back with her thighs
flexed and her feet resting in the examining table
stirrups) – used for pelvic exam
Internal Pelvic Measurement page 263
1. Fingers are introduced vaginally and pressed
inward and upward until the middle finger
touches the sacral prominence. With the other
hand, the part of the examining hand where it
touch the symphysis pubis is marked. After
withdrawing the hand , the distance between the
tip of the middle finger and the mark point on the
glove is measured.
3. Ischial tuberosity diameter- the narrowest
diameter
-most apt to cause a misfit
-a pelvimeter / ruler - is used to measure the
medial or lowermost aspect of the ischial
tuberosity at the level of the anus. 11 cm is
considered adequate
Pelvis: Internal Measurements
•Diagonal conjugate
–Distance between anterior surface of sacral
prominence & posterior surface of inferior margin
of symphysis pubis
–Should be 10.5 cm-11cm to be adequate
•True conjugate/ Conjugate vera
–Distance between anterior surface of sacral
prominence & posterior surface of inferior margin
of the SP
–[ 1.5 – 2 cm(usual depth of sp) is subtracted from
DC ] = 10.5-11.0 cm
•Transverse Diameter
–Distance bet. Ischial tuberosities or the
transverse diameter of the outlet
–Adequate measurement: 11 cm ( fetal head
9cm)
Prenatal Care
PRENATAL CARE VISITS
First visit
- As soon as the woman missed her menstrual
period and pregnancy is suspected
Follow up visits
- Once a month – first 28 weeks; Twice a month
– 28 to 36 weeks; Every week – 37 to 40
weeks
Leopold’s Maneuver
- A systematic method of observation and
palpation to determine fetal presentation
and position.
First Maneuver (Fundal Grip) - To determine
presenting part at the fundus
Second Maneuver - To determine fetal back
Third Maneuver - To determine position and
mobility of the presenting part
Fourth Maneuver ( Pelvic Grip) - To determine
fetal descent and attitude
Psychological Task of
Pregnancy
First Trimester: Acceptance of the pregnancy
Second trimester: Acceptance of the baby
Third trimester: Preparation for parenthood
- If more than 12.5 cm, the pelvis is rated as
adequate for child birth. (the diameter of fetal
head that must pass that point averages 9cm in
diameter)
True conjugate or conjugate vera
- The usual depth of the symphysis pubis (1.5 -
2cm) is subtracted to the diagonal conjugate
measurement.
Ave is 10.5-11 cm.
Psychosocial changes that occur with Pregnancy
- Accepting the Pregnancy
- Woman and partner both spend time recovering
from shock of learning they are pregnant and
concentrate of what it feels like to be pregnant.
Common reaction is ambivalence
- Accepting the Baby
- Woman and partner move through emotions
such as narcissism and introversion as they
concentrate on what it feel like to be a parent.
11
Role playing and increased dreaming are more
common.
- Preparing for the baby and the end of pregnancy
- Woman and partner prepare for clothing and
sleeping arrangements for the baby but also grow
impatient with pregnancy as they ready
themselves for birth.
Emotional Responses to Pregnancy
Ambivalence - normal response; discomforts of
pregnancy caused mixed feelings. She may make
comments such as: “I thought I wanted a baby, but
now I'm not so sure.”
Grief - commonly occurs as a result of changes in
the woman's role
Narcissism - woman focuses on self and changing
body
-Signifies an effort by the woman to protect her
body and the fetus
Introversion or Extroversion - woman focuses on
self or become more out going
Stress reaction - pregnancy interferes with ability
to perform daily tasks such as caring for other
family members; support systems can alleviate
some stress and aid adaptation to pregnancy
Emotional lability-mood changes; influenced by
hormones; avoiding fatigue and reducing stress
can help
Couvade Syndrome - partner may experience
discomforts such as nausea, vomiting, fatigue,
similar to or possibly more intense than those that
the pregnant woman experiences
Maternal Physiology Changes During Pregnancy
Uterus
-length increases from approximately 6.5 to 32cm
-depth increases from 2.5 to 22 cm
-width expands from 4 to 24 cm
-weight increases from 50 to 1000g
-early in pregnancy uterine wall thickens about 1
cm to 2 cm towards the end of pregnancy only
about 0.5 cm thick
-the volume of the uterus increases from about
2ml to more than 1000ml
-the uterus can hold a 7 lb(3175) fetus plus 1000ml
amniotic fluid for a total of 4000g at term
-before pregnancy uterine blood flow is 15 to 20
ml/min, by the end of pregnancy as much as 500
to 750 ml/ min which 75 % goes to the placenta.
- uterus feels more ante-flexed, larger and softer
to the touch
-Hegar’s sign- softening of the lower uterine
segment
-lightening - the uterus returns to the height it was
at 36 weeks, it seems to lighten the woman’s load.
Ballottement-16th to 20th weeks of pregnancy
-if the lower uterine segment is tapped sharply by
the lower hand, the fetus can be felt to bounce or
rise in the amniotic fluid up against the top
examining hand.
Braxton Hicks Contractions -“practice”
contractions
-felt by a woman as waves of hardness or
tightening across her abdomen
Ovaries
-Ovulation stops with pregnancy because of the
active feedback mechanism of estrogen &
progesterone produced by the corpus luteum
early in pregnancy and by the placenta later in
pregnancy. this feedback causes the pituitary
gland to halt production of FSH & LH ,thereby
ovulation will not occur.
-Amenorrhea (absence of menstruation) occurs
with pregnancy because the suppression of FSH by
rising estrogen levels
Cervical changes
-The cervix of the uterus becomes more vascular
and edematous, it darkens from a pale pink to a
violet hue
-endocervix undergo both hypertrophy and
hyperplasia
-operculum- mucous plug in the cervix
Goodell’s sign – softening of the cervix
nonpregnant cervix- nose
pregnant cervix- earlobe
just before labor- soft as butter ,said to be ripe for
birth
Vaginal changes
-Chadwick’s sign–increase in circulation changes
the color of the vaginal walls from the normal light
pink to deep violet
12
-Vaginal secretions during pregnancy fall from a
pH of greater than 7 ( alkaline pH)
-pH 4 or 5 (an acid pH) owing to increased
production of lactic acid from glycogen in the
vaginal epithelium by lactobacillus acidophilus.
-vaginal epithelium and underlying tissue become
hypertrophic and enriched with glycogen which
results in a white vaginal discharge throughout
pregnancy
Changes in the breast
-feeling of fullness, tingling or tenderness in her
breast because of high estrogen level
-areola of the nipple darkens and its diameter
increases from about 3.5cm to 5 or 7.5 cm.
-darkening of the skin surrounding the areola in
some women, forming a secondary areola.
-Montgomery’s tubercules enlarge and become
protuberant.
-by 16th week, colostrum can be expelled from the
breasts
Systemic changes
Integumentary system
-Striae gravidarum often develop- pink or reddish,
slightly depressed streaks in the skin of abdomen,
breast, and thighs. (Become glistening silvery lines
after pregnancy.)
-Diastasis-rectus muscles separate to
accommodate the growing fetus.(after pregnancy
it appear as a bluish groove at the site of
separation)
-umbilicus appear as if it has turned inside out,
protruding as a round bump at the center of the
abdominal wall.
Linea nigra – a narrow brown line may form
running from the umbilicus to the symphysis pubis
and separating the abdomen into right and left
hemisphere
Melasma / Chloasma
“the mask of pregnancy”- darkened areas may
appear on the face (cheek and across
the nose)
-vascular spider or telangiectases (small, fiery red
branching spots) on the thigh,result from
increased level of estrogen
-increased activity of sweat glands- increase in
respiration
Palmar erythema-(redness and itching) occurs on
hands due to increased estrogen level.
-scalp hair growth is increased due to increased
metabolism
Respiratory system (RR 18 to 20 breaths/min)
-marked congestion or stuffiness of the
nasopharynx due to increased estrogen
-crowding of the chest cavity causes shortness of
breath late in pregnancy, until lightening relieves
the pressure
-tidal volume (volume of air inspired) is increased
up to 40% as a woman draws in extra volume to
increased the effectiveness of air exchange.
-total oxygen consumption increases by as much
as 20%
-increased mild hyperventilation to blow off
excess CO2 shifted to her by the fetus to prevent
the mother’s ph level becoming acidic
-to exhale more than the usual CO2 the woman
may develop respiratory alkalosis, to compensate
kidney excrete plasma bicarbonate in urine.This
result in polyuria .
Temperature
-body temp increases slightly because of
progesterone as the placenta takes over the
function of the corpus luteum at about 16 weeks,
the temp usually decreases to normal.
Cardiovascular system
*Blood volume
-Increased total circulatory blood volume by at
least 30% or 50%
-Blood loss NSVD – 300 to 400 ml
-Blood loss CS – 800 to 1000 ml
Pseudoanemia - a condition where the plasma
volume increases faster than RBC production,
thereby hemoglobin and erythrocytes
concentration declines on the first trimester
-increased need of iron about 800 mg
Decreased gastric acidity during pregnancy
impaired iron absorption
-increased need of folic acid
13
Megalohemoglobinemia (large nonfunctioning
RBC)
Neural tube disorders in fetus
-encourage woman to eat (spinach, asparagus,
legumes)
Heart
-heart rate increases by 10 beats/ min
-diaphragm is pushed upward by the growing
uterus late in pregnancy, the heart is shifted to a
more transverse position in the chest cavity.
-palpitation of the heart in the early months of
pregnancy are probably caused by sympathetic
nervous system stimulation, in later months result
from increased thoracic pressure caused by the
pressure of the uterus against the diaphragm.
Peripheral blood flow
-blood flow to the lower extremities is impaired by
the pressure of the expanding uterus on veins and
arteries leads to edema and varicosities of the
vulva, rectum and legs
Supine hypotension syndrome
-when a pregnant woman lies supine ,the weight
of the growing uterus presses the vena cava
against the vertebrae, obstructing blood flow from
the lower extremities.
-woman experiences hypotension, as
lightheadedness, faintness, and palpitations. -may
cause fetal hypoxia
- can be corrected by having a woman turn on her
side (left side)
Gastrointestinal system
-nausea and vomiting /morning sickness-due to
increased HCG and progesterone
-as the uterus increases in size, it pushes the
stomach and intestines toward the back and sides
of the abdomen, this pressure slow intestinal
peristalsis and the emptying time of the stomach
leading to heartburn, constipation and flatulence
-relaxin / progesterone may contribute to
decreased gastric motility
-decreased emptying of bile from the gallbladder
can lead to reabsorption of bilirubin into the
maternal bloodstream which lead to generalized
itching -increased tendency to stone formation
due to increased plasma cholesterol level and
cholesterol incorporated in bile
-hypertrophy of the gums and bleeding of gingival
tissue
Hyperptyalism -increased saliva formation due to
increased estrogen level
Skeletal syatem
The increasing mobility of sacroiliac,
sacrococygeal, and pelvic joints during pregnancy
is the result of hormonal (progesterone) changes.
- This mobility contributes to alteration of
maternal posture and to back pain.
- Lordosis- the pride of pregnancy
Endocrine system
-placenta produces estrogen, progesterone, HCG,
human placental lactogen, relaxin, prostaglandin
Pituitary gland-a major change in the PT is the halt
in production of FSH and LH because of high
estrogen and progesterone levels produced by
placenta.
-increased production of growth hormone and
melanocyte-stimulating hormone, late in
pregnancy oxytocin and prolactin.
Thyroid and Parathyroid
-levels of protein- bound iodine,
butanolextractable iodine, and thyroxine are all
elevated
-emotional lability, tachycardia, palpitation, and
increased perspiration may lead to a mistaken
diagnosis of hyperthyroidism.
-parathyroid gland necessary for metabolism of
calcium also increased
Adrenal gland
-increased level aid in suppressing an
inflammatory reaction or help reduce the
possibility of a woman’s body rejecting the foreign
protein of the fetus.
-help regulate glucose metabolism
-Aid in promoting sodium reabsorption and
maintaining osmolality in the amount of fluid
retained
14

Pancreas
-secretes an increased level of insulin, it appears
to be not effective
-to ensure against hypoglycemia ,diet high in
calories and should never go longer than
12 hrs between meals
-Immune system
-Decreased immunoglobulin to prevent a
woman’s body from rejecting the fetus.
Immunoglobulin G(IgG) is decreased which make
a woman prone to infection.
SIGNS & SYMPTOMS OF PREGNANCY
Subjective (Presumptive) Changes – symptoms
are experienced by a woman
 Amenorrhea (80% of patients) or slight,
painless spotting of unknown cause in
early gestation (20% of patients)
 Nausea and vomiting
 Urinary frequency and urgency
 Breast enlargement and tenderness,
fatigue
 Intensified skin pigmentation [melasma,
linea nigra, striae gravidarum]
 Quickening (mother's perception of fetal
movement)
 Thinning and softening of fingernails
Probable - signs are perceived by the examiner
 Uterine enlargement
 Goodell's sign (softening of the cervix)
 Chadwick's sign (bluish mucous
membranes of the vagina, cervix and vulva
 Hegar's sign (softening of the lower uterine
segment
 SIGNS & SYMPTOMS OF PREGNANCY
 Probable (continued)
 Braxton Hicks contractions (painless
uterine contractions that recur throughout
pregnancy)
 Ballottment (passive fetal movement and
response to tapping of the lower portion of
the uterus or cervix)
 Laboratory test results indicating
pregnancy (positive HCG pregnancy test)
 Uterine souffle (soft blowing sound heard
when auscultating the abdomen, caused
by blood pulsating through the placenta
 Palpable fetal outline during examination
 Ultra-sonographic evidence of a
gestational sac (visible as early as 4 to 6
weeks gestation)
SIGNS & SYMPTOMS OF PREGNANCY
Diagnostic (Positive) Changes
Signs are completely objective and caused only by
pregnancy
Fetal heartbeat audible at 10 to 12 weeks
gestation by Doppler ultrasound and at 16 to 20
weeks gestation with a fetoscope
Ultrasonography results as early as 6 weeks
gestation
Fetal movements felt by the examiner after 16
weeks gestation
Visualization of the fetus and fetal outline by
sonogram
COMMON DISCOMFORTS DURING THE FIRST
TRIMESTER
1. Nausea and vomiting (morning sickness)
Cause: Hormonal changes, fatigue, emotional
factors, changes in carbohydrate metabolism
Patient teaching – avoid greasy, highly seasoned
foods; eat small, frequent meals; eat dry toast or
crackers before getting out of bed
2. Nasal stuffiness, discharge or obstruction
Cause: Edema of the nasal mucosa from elevated
estrogen levels
Patient teaching – use a cool moist humidifier; use
normal saline nose drops or nasal spray; apply cool
compresses to nasal area
3. Breast enlargement and tenderness
Cause: Increased estrogen and progesterone
levels
Patient teaching: wear a well-fitting bra with wide
shoulder straps; maintain good posture; wash
breast and nipple area with water only
4. Urinary frequency and urgency
15
Cause: Pressure of the enlarging uterus on the
bladder; around the 12th week the uterus rises
into the abdominal cavity causing symptoms to
disappear; symptoms recur in the 3rd trimester as
the uterus again presses on the bladder
Patient teaching: decrease fluid intake in the
evening to minimize nocturia; limit intake of
caffeinated beverages; promptly response to the
urge to void to prevent bladder distention and
urine stasis; perform Kegel's exercises; teach signs
and symptoms of UTI and instruct to report
promptly
5. Increased leukorrhea
Cause: Hyperplasia of vaginal mucosa; increased
mucus production by the endocervical glands
Patient teaching: daily bath and avoid using soap
on the vulvar area; reinforce the need to wipe
from front to back; wear loose, absorbent cotton
underwear and to avoid tight pants and
pantyhose; avoid douching; notify health care
provider if the discharge changes in color or odor
6. Increased fatigue
Cause: The increased effort of the body to
manufacture the placenta; the need to adjust to
the many physical and emotional demands of
pregnancy
Patient teaching – have frequent rest periods;
obtain rest during the day; eat a balance diet and
take iron supplement; suggest use of warm milk or
warm shower before going to bed at night to aid
in relaxation; engage in moderate regular exercise
THE 2ND AND 3RD TRIMESTER
1. Heartburn
Cause: decreased GI motility; increased
production of progesterone; gastric displacement
Patient teaching: Eat small, frequent meals; avoid
fatty and fried foods and caffeine products;
remain upright for one hour after meals
2. Constipation
Cause: Oral iron supplement; displacement of the
intestines by the fetus; bowel sluggishness caused
by increased progesterone
Patient teaching: engage in moderate daily
exercise; drink plenty of fluids; increase daily
intake of fiber; maintain regular elimination
patterns; avoid use of mineral oil which can
deplete her level of fat soluble vitamins
3. Hemorrhoids
Cause: Pressure on the pelvic veins by the
enlarging uterus, which interferes with venous
circulation; increased pressure secondary to
constipation
Patient teaching: Avoid constipation; avoid
prolonged standing and wearing constrictive
clothing; lie on left side with feet slightly elevated;
use topical ointment or anesthetic if allowed; use
of witch hazel compresses, sits bath or apply warm
soaps
4. Backache
Cause: Postural adjustment of pregnancy
secondary to curvature of the lumbosacral
vertebrae that increases with uterine enlargement
Patient teaching: Use proper body mechanics;
maintain good posture; wear low-to-mid heeled
shoes; walk with pelvis tilted forward; use a board
under the current mattress to add firmness;
perform pelvic rocking or tilting exercises; apply
local heat to the back, if necessary
5. Leg Cramps
Cause: Pressure from the enlarging uterus; poor
circulation; fatigue; balance in the calcium-
phosphorus ratio
Patient teaching: Rest with legs slightly elevated;
wear warm clothing; assist woman with measures
to alter calcium and phosphorus intake; teach her
what to do during a leg cramp (pull the toes up
toward the legs while pressing down on the knee)
6. Shortness of breath
Cause: Pressure of the uterus on the diaphragm
Patient teaching: maintain proper posture; use
semifowler's position when sleeping; encourage a
balance of activity and rest
7. Ankle edema
Cause: Poor venous return from the lower
extremities aggravated by prolonged sitting or
standing and by warm weather; fluid retention
Patient teaching: Lie on the left side in bed to
enhance glomerular filtration rate of the kidneys;
avoid wearing tight, constrictive clothing; elevate
legs during rest periods; dorsiflex the feet when
16
standing or sitting for prolonged period; get up
and move about every 1 to 2 hours when sitting
for long periods
8. Varicose Veins
May affect the lower extremities, vulva, and
pelvis.
1. Cause:
a.Heredity
b.Pressure of gravid uterus on the great veins of
the pelvis.
c.Prolonged standing
d.Constrictive clothing2. Treatment:
a.Avoid restrictive clothing
b.Elevate legs and hips on pillows above the level
of the heart.
c.Wear elastic stockings or bandages.
d.Take frequent rest periods.
SEXUAL DESIRE BY TRIMESTER
First Trimester -may decrease due to discomfort
and fatigue
Second Trimester – may increase when
discomforts wane. The woman may have greater
sexual
satisfaction than before pregnancy because of
vascular congestion of the pelvis
Third Trimester – may decrease due to increasing
fatigue and abdominal size. Changes in position
and use of water soluble lubricant may be
necessary
Sexual behavior is usually unrestricted in
complication-free pregnancies
PATIENT COUNSELING
Danger signs to report immediately:
Severe vomiting
Frequent, severe headaches
Epigastric pain
Fluid discharge from vagina
Fetal movement changes or cessation after
quickening
Swelling of the fingers or face
Vision disturbances
Signs of vaginal or UTI
Unusual or severe abdominal pain
Seizure or muscular irritability
Preterm signs of labor such as, rhythmic
contractions
Self – care Needs
Bathing
-sweating tends to increased during pregnancy
-daily bath tubs or showers are now
recommended
-woman should not soak for long periods in
extremely hot water or hot tubs may lead to
hyperthermia in the fetus
-as pregnancy advances, she should change to
showering or sponge bathing for her own safety
-if membranes ruptured, cervix begin to dilate or
vaginal bleeding present, tub baths are
contraindicated because of danger of
contamination of uterine content
Breast care
Proper breast support promotes comfort,retains
breast shape,and prevent back strain
Washing the breast with clear water and no soap
daily
Gauze or breast pads may be needed if the
woman's secretion of colostrum is significant
Dental Care
– dental check up early in pregnancy and routine
examinations and cleaning are encourage
-Nausea, vomiting, heartburn may lead to poor
oral hygiene and dental caries
- The fetus receives calcium and phosphorus from
the pregnant patient's diet not from her teeth, the
belief that a patient looses a tooth for every
pregnancy is a fallacy
-Nutritional snacks (fresh fruits and vegetables)
are recommended to avoid excessive contact of
sugar with the teeth
Perineal hygiene
-the woman may desire to have a vaginal douche
due to an increased vaginal discharges during
pregnancy
-Douching is contraindicated during pregnancy
17
 -the force of the irrigating fluid could cause to
enter the cervix and lead to infection
-douching alters the ph of the vagina, leading to
an increased risk of bacterial growth
Clothing – Comfort is the key
-recommend loose-fitting,comfortable garments
- Non restrictive and low-to-mid heeled shoes to
prevent backache and poor balance
- Avoid tight-fitting such as garters,girdles with
panty legs, and knee –high stockings
Sexual activity
• sexual relation during pregnancy are
contraindicated:
• woman with a history of spontaneous
miscarriage
• woman whose membranes have ruptured or
have vaginal spotting to avoid infection
• advise caution about male –oral female genital
contact, because accidental air embolism has been
reported
• Side by side position or woman in a superior
position may be more comfortable
Exercise
• extreme exercises has been associated with
lower birth weight
• moderate exercise is healthy
• walking is the best exercise during pregnancy
• jogging can cause pelvic pain
• high –impact aerobics contraindicated
• swimming is not contraindicated as long as the
membranes are intact
• diving or long distance swimming should be
avoided
• Hot tubs/ saunas after workouts longer than 15
mins is contraindicated
Sleep
• Pregnant woman need rest period during the
afternoon as well as a full night sleep
• Modified sim’s position- with the top leg forward
• Avoid resting on her back to prevent supine
hypotension syndrome
Employment
Check the work site for potential environmental
hazards(pesticides, anesthetic gas, heavy metals
as lead and mercury
-If it involves lifting heavy object ,excessive
physical strains, long periods of standing or sitting
pregnant ,interference with adequate rest and
nutrition, the pregnnat woman should not
continue working.
Travel
• When riding in a car, wear seat belts low, under
the abdomen
• On a long trip, get out of the car every hour ,but
at least every 2 hrs to walk around
• Travel by air in airplanes with well-pressurized
cabins. Some airlines have restrictions for woman
more than 7 months pregnant
Perineal and Abdominal Exercises
1. Tailor sitting- stretches abdominal muscles -It
also improves your posture, keeps your pelvic
joints flexible and increases blood flow to your
lower body.
2. Squatting- stretches perineal muscle and can be
a useful position during the 2nd stage of labor
3. Pelvic floor contractions or kegel exercises- a
perineal muscle strengthening exercise, helpful in
the post partum period to reduce pain and
promote perineal healing.
4. Abdominal muscle contractions- help
strengthen abdominal muscle during pregnancy
therefore may help prevent constipation as well as
restore abdominal tone after pregnancy
5. Pelvic rocking- helps relieve backache during
pregnancy and early labor by making lumbar spine
more flexible.
Nutrition during pregnancy
– Calories-requirement exceeds pre-pregnancy
needs by 300calories/day(from 2,200 kcal/day to
2,500 kcal/day)
– Protein-from 46g/day to 71 g/day
– Fats-20% to 35% of woman's daily calorie intake
*Linoleic acid( found in veg oils ,such as corn,
olive),
Vitamins-Intake of all vit. should be increased
Fat –soluble vitamins
– Vit A- 750 ug /day
– Vit D-5 ug /day
– Vit E- 15 mg/day Water – soluble vitamins
– Vit C -80mg/day
– Folic acid -600ug/day
– Niacin -18 mg/day
18
– Thiamine B1- 1.4 mg/day
– Vit B12 -2.8ug/day
– Vit B6 – 1.9 mg/day
Nutrition during pregnancy Minerals
-Calcium 1300mg/day
-Fluoride 3 mg/day
-Iodine 220 ug/day
-Iron 220 ug/day
-Magnesium 400 mg/day
-Phosphorous 400 mg/day
-Zinc 12 mg/day
Fluid needs
-6 to 8 glasses daily
Fiber needs
-encourage women to eat plenty of fruits and
vegetables
Foods to avoid or limit in pregnancy
1.alcoholic beverages-teratogenic effect
2.food additives
3.excess seafood
-2 to 3 meals of seafood or shellfish / week
-For their omega -3 and iodine content
-6 ounces(1 meal) per week of fish
- sharks, swordfish,king mackerel or tilefish are
high in mercury contamination
4. Foods with caffeine
-a central nervous system stimulant capable of
increasing heart rate,urine production in the
kidney,and secretion of acid in the stomach
-2 to 3 cups of coffee has not been associated with
low birth weight infant
- drinking over 3 cups is associated with early
miscarriage
-chocolate, cocoa bean,softdrinks and tea contain
caffeine
Artificial sweeteners -used to improve the taste
and to limit the caloric content of foods -pregnant
woman need carbohydrates from sugar rather
than artificial substances -sweetener aspartame-
safe for pregnancy -saccharine not recommended
during pregnancy because it is eliminated slowly
from the fetal bloodstream
Danger Signs of Pregnancy
-Signs Indicating Complications of Pregnancy
1. Vaginal Bleeding – spotting
2. Persistent Vomiting - vomiting continues after
12th weeks (hyperemesis gravidarum)
3. Chills and Fever - benign gastroenteritis -
intrauterine infection
4. Sudden Escape of Fluid from the Vagina -
threatened abortion ,umbilical cord prolapse,
5. Abdominal or Chest Pain - ectopic
pregnancy,separation of the placenta, - preterm
labor, appendicitis, ulcer - chest pain (pulmonary
embolus that can fallow thrombophlebitis)
6. Pregnancy Induced Hypertension several
symptoms
• severe and even fatal elevation of blood
pressure that occurs during pregnancy.
1. Rapid wt. Gain( over 2 lb per week in the 2nd
trimester, 1 lb per week in the third trimester)
2. Swelling of the face or fingers
3. flashes of light or dots before the eyes
4. dimness or blurring of vision
5. severe continous headache
6. decreased urine output
7. Increase or Decrease in Fetal movement -
unusual increase or decrease in movement
suggests that a fetus is responding to a need of
oxygen
Laboratory assessment
urine pregnancy test -determine pregnancy
through the detection of the hormone Human
Chorionic Gonadotropin (hCG) in a woman’s urine.
- Human Chorionic Gonadotropin (hCG) is a
hormone which is produced early in pregnancy by
the placenta in great volume (hormone released
by developing embryos).
-test is done 10 to 14 days after the missed
menstrual period.
Main Causes for False Positive Pregnancy Test
• Soap or detergents -don’t use soap or any
detergents before making your pregnancy test.
• Some medications may cause a false positive on
a pregnancy test. These include anti-Convulsants,
medications to treat Parkinson’s disease, certain
tranquilizers,oral contraceptives and certain
diuretics
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• Do not drink fluids from 8pm to concentrate the
urine
• Collect first- voided urine in the morning
serum pregnancy test
• In pregnant woman trace amount of HCG appear
in the serum as early as 24 to 48 hrs after
implantation
• About 50 milli IU / ml after 7 to 9 days after
conception
• Levels peak at about 100 m IU / ml between the
60th and 80th day of gestation,after that point,
the concentration of HCG declines again so that ,
at term ,it is barely detectable in serum or urine
Blood studies
1.Complete blood count
• Hemoglobin , hematocrit and red cells index- to
determine anemia
• White blood cell- to determine infection
• Platelet count- to estimate clotting ability
2. Genetic screen
• For common ethnically inherited disease
3.Serologic test for syphilis ( VDRL or rapid plasma
reagin)
4.Blood typing (including Rh factor )
5. Maternal serum for alfa-fetoprotein(MSAFP)
• done at 16 to 18 weeks of pregnancy
• elevated for neural tube or abdominal defect is
present in the fetus
• decreased for chromosomal anomaly
• 2.5 MOM ( multiple of the mean) normal value
6. Indirect Coombs test
• Determination if Rh antibodies are present in an
Rh negative woman
• Test is repeated at 28 weeks of pregnancy
• if the titers are not elevated, an Rh negative
woman will receive RhoGAM at 28 weeks and after
any procedure that might cause placental bleeding
• It may be administered within 72 hours after
birth of a positive Rh baby whose cord blood
showed no antibodies ,a negative reaction, or
after an ectopic pregnancy.
7.Antibody titers for rubella and hepatitis B
• determine whether a woman is protected
against rubella and whether a newborn well have
the chance of developing hepatitis B
8.HIV screening
• Screening cannot be mandatory in prenatal
setting
• Done by enzyme-linked immunosorbent assay
(ELISA) if positive , the finding is confirmed by
Western blot.
9. to rule out gestational diabetes
• history of unexplained fetal death ,fetal loss
,family history of diabetes, LGA babies ,obese, has
glycosuria
• 50 g oral 1 hour glucose loading or tolerance test
towards the end of the first trimester to rule out
gestational diabetes
• Done routinely at 24th to 28th week to evaluate
insulin-antagonistic effects of placental hormones
• Plasma glucose level should not exceed 140
mg/dl at 1 hour
10. Urinalysis
• to test for proteinuria , glycosuria, and pyuria (
pus in urine )
Tuberculosis screening
• purified protein derivative (PPD) tuberculin test
• if positive reaction- a chest radiograph is
indicated further diagnosis
Monitoring Fetal Status
Ultrasonography- non-invasive use of sound
waves to determine fetal presence, size, position
and presentation and to detect abnormalities.
Provides information about the fetus during each
trimester:
First trimester: Assessment of gestational
age,evaluation for congenital anomalies;
Diagnostic evaluation of vaginal bleeding;
Confirmation of suspected multiple
gestation,evaluation of fetal growth, adjunct to
prenatal testing such as amniocentesis or
CVS(chorionic villus sampling)
Second trimester: Assessment of placental
location, diagnosis of multiple gestation
Evaluation for congenital anomalies Guidance of
procedure such as amniocentesis and fetoscopy
Third trimester: Determination of fetal position,
estimation of fetal size A full bladder may
improve ultrasonic resolution before 20 weeks'
gestation Client may be instructed to drink a
quart or more of fluids 1 to 2 hours before the
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procedure (abdominal UTZ), for transvaginal UTZ
usually performed during first trimester, a full
bladder is unnecessary

Preparation of labor
1.Lightening or descent -Settling of the fetal head
into the inlet of the true pelvis
-in primiparas approximately 2 weeks(10 to 14
days) before labor -in multiparas on the day of
labor or after labor has begun.
-experience frequency in urination(frm pressure
on bladder),sciatic pain (pain across a buttocks
radiating down her legs) from the lowered fetal
position,increased amts of vaginal discharge.
2.Show -as the cervix softens and ripens, the
mucus plug that filled the cervical canal during
pregnancy is expelled.
-the release of the cervical plug (operculum) -it
consist of a mucus, often blood
–streaked vaginal discharge -indicates the
beginning of cervical dilatation
Rupture of membranes -a sudden gush of clear
fluid (amniotic fluid ) from the vagina indicates
rupture of the membranes
-after rupture of membranes there is danger of
cord prolapse and infection
-early rupture of the membrane can be
advantageous as it can cause the fetal head to
settle snugly into the pelvis,aiding cervical dilation
and shortening labor.
Excess energy -extremely energetic is a sign of
labor -part of body‘s physiologic preparation of
labor
Uterine contractions -labor begins with
contractions
-true labor contractions usually start in the back
and sweep forward across the abdomen
-gradually increase in frequency and intensity

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