MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peñablanca, Cagayan

INSTRUCTIONAL
LEARNING GUIDE

COURSE AUDIT IN MATERNAL

AND CHILD NURSING
INTERSESSION CLASS F.Y. 2020-2021

MIDTERM PERIOD
 CHAPTER 1

This chapter adds information about how to educate women and their partners about sexuality and
pregnancy to better prepare them for childbearing and childrearing.

Duration: 3 hours

MAJOR TOPICS SUBTOPICS

1. Concept of Procreation Process of Human Reproduction
Assessment and Diagnostic Exams for
Genetic Abnormalities and Fetal Growth
2. Pregnancy / Antepartum Overview of the Anatomy and Physiology of
Reproductive System
Menstrual Cycle
Process of Conception
Fetal Growth and Development
Assessment of Pregnancy
Prenatal Health Teachings
Childbirth Preparation

Specific Activities:
1. Labeling diagrams
2. Multiple Choice Questions with Rationalization of answers
3. Critical Thinking Exercises

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain the following
Intended Learning Outcomes:
1. Define procreation and identify the process of reproduction
2. Describe the anatomy and physiology pertinent to reproductive and sexual health
3. Identify the structures and functions of the male and female reproductive systems
4. Describe the phases of menstrual cycle and the common abnormalities related to it.
5. Explain the process of conception.
6. Identify and decide appropriate nursing intervention to related to abnormalities during the
process of conception
7. Describe the growth and development of a fetus by gestation month
8. Assess fetal growth and development through maternal and pregnancy landmarks
9. Describe common physiologic and psychological changes that occur with pregnancy and the
relationship of the changes to pregnancy diagnosis
10. Describe common preparations for childbirth and parenting
 Prepare your books and notebooks. Highlight concepts that need to be reinforced. Jot down
supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of this chapter is also
provided along with other resources to facilitate better understanding of the topics.

Let’s Begin!

KEY TERMS
 Reproduction
 Sexuality
 Fertilization
 Ovulation
 Implantation
 Conception
 Menstrual cycle
 Antepartum
 Childbirth preparations

1) CONCEPT OF PROCREATION
1.1 PROCESS OF HUMAN REPRODUCTION

 Terminologies:
 Sexuality: includes feelings, attitudes and actions; encompasses and gives direction to a
person’s physical, emotional, social and intellectual responses
 Biologic Gender: used to denote a person’s chromosomal sex
 Gender Identity/ Sexual Identity: inner sense a person has of being male or female
 Gender Role: male or female behavior a person exhibits

 Human Sexual Response (EPOR)

 Excitement: occurs with physical or psychological stimulation (PNS activation)
: arterial dilation and venous constriction (muscular tension)
: erection of muscular structures (penis, clitoris, Nipple); VS ↑
 Plateau: vasocongestion leads to distention of penis, clitoris retracts, sustained ↑ VS
 Orgasm: body discharges accumulated sexual tension; ejaculation occurs in men
 Resolution: genitalia remains at unaroused state for 30 mins
*refractory state (male): further orgasm is impossible

1.2. ASSESSMENT AND DIAGNOSTIC EXAM FOR GENETIC ABNORMALITIES

 History Taking: assess history of genetic disorders
: ethnic background
: ask for history of miscarriage

 Physical Assessment
 Diagnostic Testing

Table 1.1
DIAGNOSTIC EXAM DESCRIPTION/ FINDINGS
Karyotyping Specimen: peripheral venous blood or scraped
cells (buccal area)
*cells are allowed to grow until it reach
metaphase
*cells will be stained and examined under the
microscope
Maternal Serum screening -assesses alpha-fetoprotein (AFP)
(AFP : produced by the fetal liver; peaks in
maternal serum bet. 13th -32nd wk AOG)
↓ : spina bifida
↑: Down Syndrome
Done @: 15th week AOG
Chorionic Villi Sampling Specimen: chorionic villi (placenta) for DNA
analysis
Done as early as 5 weeks AOG
Common: 8th - 10th week AOG

WOF: vaginal bleeding, chills and signs of

infection
Rh negative: give RhoGam to prevent
isoimmunization
amniocentesis -withdrawal of amniotic fluid
Done @ 14th -16th week AOG
Needle is guided thru utz

 OTHER TESTS
1. UTZ
2. NON-STRESS TEST
: Done to assess FHT vs. fetal activity
: Heart beat of the fetus should accelerate by 15 beats for 15 seconds, twice in a
20 minute period(reactive).
:if the result is Non-reactive, the doctor orders for CST/OCT.
 3.
CONTRACTION STRESS TEST/OXYTOCIN CHALLENGE TEST
:it evaluates the reaction of the fetal heart rate induced by oxytocin induction or
nipple stimulation
:POSITIVE- there is persisent late deceleration
:NEGATIVE-there is no pesistent late deceleration
:SUSPICIOUS- inconstant late deceleration pattern.
REMEMBER:
Variable deceleration = Cord Compression
Early deceleration = Head Compression
V-E-L-C-H-U
Late Deceleration = Uteroplacental Insufficiency

4. Fetal Movement
Quickening: 16th for multipara and 20th week for primipara
*fetus moves at least 10 times in a day
*Sandovsky Method
- in a left recumbent position, mother counts fetal movement after
a meal; RESULT: moves TWICE q 10 mins (10-12x per hour)
*CARDIFF METHOD
- “Count-to-ten”
- woman records the time interval it takes for her to feel the
movements
2) PREGNANCY / ANTEPARTUM
1.1 Overview of the Anatomy and Physiology

 Female Reproductive System (External and Internal Genitalia)

 External Genitalia

Structures:
1. MONS PUBIS - a pad of adipose tissues over the symphysis pubis; mons veneris
2. LABIA MAJORA - two thick folds of adipose tissue from the mons pubis to perineum
3. LABIA MINORA - two thin folds of connective tissue; forms the prepuce and fourchette
4. CLITORIS - highly sensitive; erectile tissue; landmark for catheterization
5. FOSSA NAVICULARIS - space between the fourchette and the vaginal opening
6. VESTIBULE - triangular space between the labia minora
7. BARTHOLIN’S GLANDS - located on each side of the vagina
8. SKENE’S GLANDS - situated at each inner side of the urethral meatus
9. VAGINAL ORIFICE - vaginal opening
10. HYMEN - covers the vaginal opening (Abn: imperforate, rigid or caruncle mytirforms)
11. URETHRAL MEATUS - external opening of the female urethra
12. PERINEUM - space between the anus and vagina; cut during episiotomy
*The external genitalia receives its blood supply from the pudendal and inferior rectus arteries; nerve
supply comes from the ilioinguinal and genitofemoral nerve for the anterior portion and pudendal
nerve for the posterior portion

 Internal Genitalia
1. VAGINA
-organ of copulation
-discharges menstrual flow
-birth canal
*rugae: transverse folds of skin
*pH: 4-5 d/t doderleins bacilli
*blood supply- from the vaginal artery
-Upper portion- cervicovaginal branch of uterine artery
-Middle portion- inferior vesical arteries
-Lower portion- rectal and pudendal arteries
 *nerve supply- uterovaginal plexus or Lee Franken hauser plexus and S1 to S3 nerves

2. UTERUS
-organ of reproduction
-organ of menstruation
-contractile organ
Parts:
A. Fundus: uppermost portion
B. Cornua: adjacent to the fallopian tube/ junction
C. Corpus: body
D. Isthmus: lower uterine segment

*cervix- neck of the uterus; 2.5 cm long; diameter of 2.5 cm

PARTS OF THE CERVIX
a. Internal Os
b. Cervical Canal
c. External Os

Diagram 1.2 Female Reproductive System

LAYERS OF THE UTERUS

1. Perimetrium- outer, serosal layer
2. Myometrium- middle; muscular; contracts during labor
3. Endometrium- the innermost ciliated mucosal layer containing numerous uterine glands.
a. Glandular Layer
b. Basal Layer

BLOOD SUPPLY OF THE UTERUS

a. Uterine Artery
b. Ovarian Artery

3. FALLOPIAN TUBES / oviducts

-transport ovum from ovary to the uterus
-the site of fertilization
-provides nourishment to the ovum during its journey

PARTS OF THE FALLOPIAN TUBE

1. Interstitial/ Intramural
2. Isthmus- narrowest
3. Ampulla-site of fertilization
4. Infundibulum-distal; has fimbriae

4. OVARIES
-oogenesis
-ovulation
-hormone production

LAYERS OF THE OVARY

 Tunica Albuginea - outer; protective cover
 Cortex- functional layer; contains ovum
 Medulla- contains blood vessels

ANALOGOUS STRUCTURES IN THE MALE AND FEMALE REPRODUCTIVE SYSTEM

MALE FEMALE
spermatozoa ovum
glans penis glands clitoris
scrotum labia majora  CHECKPOINT
penis vagina QUESTION
testes ovaries When does gender
vas deferens fallopian tubes differentiation occurs?
prostate glands skene’s glands _______
cowper’s glands bartholin’s glands

 THE MAMMARY GLANDS

External structures
1. Nipple or Papillae - located on the surface of each breast
2. Areola - surrounds the nipple; pigmented
3. Montgomery Tubercles - glands that secrete oily substance to lubricate areola and nipples

Internal structures
1. Lobes: 15 to 20 lobes/breast
2. Lobules: composed of acini cells
3. Acini cells: secretes milk d/t prolactin
4. Lactiferous Ducts: stimulates development of the ductile structures of the breast
5. Lactiferous Sinus: reservoir of milk.

Know your HORMONES!

EStrogen - responsible for Secondary Sex characteristics; telarche
Progesterone - develops acinar structures during Pregnancy
HPL: breast enlargement during pregnancy
Oxytocin: “Oozing”; Milk let-down reflex
Prolactin: Production of milk

Video Link: https://www.patreon.com/medsimplified , https://youtu.be/ZZEsPUQ1gG4

 MALE REPRODUCTIVE SYSTEM

 External organs
1. Penis: consists of two corposa cavernosa and one corposa spongiosum
- organ of copulation
- urination
PARTS:

2. Scrotum: hanging sac-like structure; contains testes

 Internal organs
1. Testes : descends in the scrotum after 28 weeks AOG
- produces testosterone (spermatogenesis)
PARTS:
A. Seminiferous tubules: site of spermatogenesis (176 sperm/day)
B. Leydig/Interstitial cells: produce testosterone
C. Sertoli Cells: supports sperm transport

Common Disorders:
*Cryptorchidism: undescended testes; remains in the abdominal cavity
- non-palpable testes in the scrotum
- Mgt: Surgery > orchiopexy - physician stitches the testes into the scrotum
- Post - op mgt:
2. Epididyms: passageway of sperm
 3. Vas deferens: propels sperm during ejaculation
4. Ejaculatory Duct- it connects the seminal vesicles to the urethra.

Diagram 1.2. Male Reproductive System

ACCESSORY ORGANS
 Seminal Vesicle
 Prostate Gland secretes alkaline fluid
 Cowper’s/Boulburethral Gland

*Seminal Fluid or Semen-mixture of secretions from the seminal vesicles, prostate gland,Cowper’s
gland, ejaculatory duct and sperm cells.

Did you know?

1 ejaculation is equivalent to 3-5 ml
of semen with 20-50 million of sperm

Diagram 1.3 The Sperm Cell

Video Link: https://youtu.be/k1aFBOy6dDI

Important Note:
Be sure to familiarize the structures and its functions. No peeking! :)

2.2. THE MENSTRUAL CYCLE

Structures involved:
 Hypothalamus
 Anterior Pituitary Gland
 Ovaries
 Uterus

Table 1.2. Hormones and its Functions

 HORMONES FUNCTION/ PURPOSE
GnRh Signals pituitary to release FSH and LH
(Hypothalamus)
FSH For follicle maturation
(A. Pituitary Gland) Triggered by a decrease in estrogen
↓Estrogen = ↑FSH ; ↑Estrogen = ↓FSH
LH Stimulates ovulation
(APG) Suppressed by Progesterone
Develops the corpus luteum
Estrogen Secreted by Graafian follicles
Takes over proliferative phase
Thickens the endometrium
Responsible for secondary sex characteristics
Hormone of women
Progesterone Corpus Luteum hormone
Prepares uterus for implantation
Hormone of pregnancy
Most important hormone during the secretory
phase

PHASES OF THE MENSTRUAL CYCLE (28-day cycle)

1. MENSTRUAL PHASE
-day 1-5
-shedding of endometrium (2/3)
-uterus lining is in its thinnest
-total blood loss:30-80 ml (Average: 50 ml)
- iron loss: 12 to 29mg

2. PROLIFERATIVE PHASE (follicular, postmenstrual and estrogenic phase)

-day 6-13 (Lasts 8-10 days)
-stimulated by ↓ estrogen = APG releases FSH
-maturation occurs: from Primordial follicle to Graafian follicle
-↑ FSH = thickening of endometrium

3. SECRETORY PHASE
-day 13-25
-↑ estrogen, ↓FSH
-↓ progesterone = hypothalamus releases LHRF to stimulate APG to release LH
-↑ LH = ovulation (ovum can only lasts for 24-48 hrs)
-Graafian follicle becomes the corpus luteum
-after ovulation, Graafian follicle is now the Corpus Luteum (life span: 10-12 days)
-endometrium appears spongy

4. ISCHEMIC PHASE
-release of prostaglandins =arteriolar spasm →necrosis→rupture of blood vessels
-uterine cramping occurs
-beginning of another cycle If my regular cycle is 35 days,
when is my estimated
OVULATION ovulation day? ________
-14th day of a 28-day cycle
-estimate day of ovulation by subtracting 14 from your regular cycle If my regular cycle is 28
days, and my first day of
menstruation is June 5,when
Signs of Ovulation is my estimated ovulation
 Mittelschmerz: unilateral pain felt on either side of the abdomen day? ________
 Spinnbarkeit: stretchy, thin, transparent and watery mucus secretion
 Sudden increase in body temp: 1 F

COMMON MENSTRUAL PROBLEMS

 Dysmenorrhea: painful menstruation

a. Primary dysmenorrhea: no known cause
 *management: give analgesics as prescribed
: offer warm compress
: provide emotional support
B. Secondary dysmenorrhea: coomon causes are PID,
WHEN TO SEE YOUR DOCTOR? 3
endometriosis, uterine prolapse, polyps “yes” answers in 3 months
*management: treat the cause 1. Before/during/after
 Amenorrhea: absence of menses menstrual pain?
 Oligomenorrhea: infrequent menstrual flow 2. Pain during coitus
 Hypomenorrhea: scanty menstrual flow 3. Irregular cycle?
 Menorrhagia / hypermenorrhea: heavy and prolonged menses 4. Constipation during or
after period?
 Metrorrhagia: bleeding in between menses
5. Does the pain in the
 Polymenorrhea: bleeding at frequent intervals
abdomen shoot into the legs?
 Menopause: Climacterium
- cessation of menses
*Perimenopause: hormones become imbalanced (34-36 years old)
*Menopause: end of reproductive age
*Post-menopause: year after; loss of estrogen
- s/sx: hot flushes, sweating even when envt is cold, insomnia, forgetfulness, atrophy
of reproductive organ, dyspareunia, loss of breast mass
- mngt: Estrogen Replacement Therapy
Engage in regular exercise
Calcium supplementation
Avoid smoking and alcohol

Video Link: https://youtu.be/tOluxtc3Cpw

2.3 PROCESS OF CONCEPTION

 Ovum
-female sex cell
-covering: corona radiata (outer) and zona pellucida (inner)
-life span is 48 hours
 Sperm cell
-three parts: head, neck, tail
-life span: 72 hours
-Types: Gynosperm: x-carrier; lesser in number; better in acidic envt
Androsperm: y-carrier; better in alkaline envt

1. FERTILIZATION - union of matured ovum and sperm; occurs in the ampulla

1.1. ZYGOTE
-fertilized ovum
-journeys from the fallopian tube and to the uterus in 3-4 days
-24 hrs after fertilization, it undergoes the first cell division(blastomere: 2 cells then to
morula:group of cells)
-sex of the baby is already determined (XX - Female; XY: Male)

1.2. BLASTOCYST - at the uterus

-called embryonic disc/blastocele: has cavity
-2 parts: *Myoblast : Fetus
*Trophoblast: outer layer
: will give rise to amniotic membrane (Amnion) and placenta (chorion)
: syncitiotrophoblast: releases human chorionic gonadotropin (HCG)
:Cytotrophobast/langhan’s layer: ptotection from syphillis (up to 2 nd tri)

-three primary germ layers

a. Ectoderm-gives rise to the skin, hair, nails, sense organs, nervous system, mucous
membrane of the mouth and the anus
b. Mesoderm- gives rise to the kidney, musculoskeletal system, reproductive system
nand the cardiovascular system
c. Entoderm-gives rise to he bladder, lining of the GIT, tonsils, thyroid gland and
respiratory system.
Video link: https://youtu.be/EwTZ1fypivg

COMMON ABNORMALITIES:

 Hydatidiform Mole (H-mole) / Gestational Trophoblastic Disease / Molar pregnanc

- degeneration of chorion and death of the embryo
2 types of H. Mole:
A. Complete: (+) placental parts, (-) embryo
B. Partial: incomplete products of conception
Risk Factors:
1. Age (<18; >4o y/o)
2. Low socioeconomic status
3. Molar history
S/sx:
- excessive n/v
- spotting (brownish)
-grape-like discharge (4th month)
-abnormally large abdomen vs AOG
-signs of pre-eclampsia
-(-) FHT and movement
-snowflake pattern vesicles on utz
-*HCG level is high (up to 100 days)
Management:
1. D&C
2. Hysterectom
3. DOC: Methotrexate (anti-neoplastic agent) to prevent “choriocarcinoma” as complication
**Management of all trophoblastic tumors is HYSTERECTOMY
Nursing mngt:
-monitor HCG for 1 year
-no pregnancy for 1 year
-contraception: take progesterone-only pills (X estrogen)

2. IMPLANTATION
-progesterone makes the uterus ready for implantation
-site: Fundus, posterior

COMMON ABNORMALITIES:
 ECTOPIC PREGNANCY
Causes:
1. Mechanical Factors – “delay passage of ovum”
2. Functional Factors
3. Assisted Reproduction
4. Failed contraception
Types:
-Tubal (95%); ampulla
-ovarian
-abdominal
-cervical
S/Sx:
-amenorrhea
-unilateral lower abdominal pain (Arias-Stella Reaction)
-bleeding
Ruptured:
-sudden, knife-like pain radiating to neck and shoulder
-cervical pain
-dark brown bleeding
-Cullen’s sign (bluish discoloration of umbilicus)
-hard, board-like abdomen
-signs of shock
Diagnostics:
-transvaginal utz
 -laparoscopy
Mangement:
-Therapeutic abortion (unruptured)
-Give Methotrexate: prevent cellular multiplication
-ruptured: surgery (LAPAROSCOPIC)
Nursing Interventions:
1. Prevent and treat hemorrhage
2. Assist in positioning the patient
3. Post – op interventions:
- monitor v/s
- assistance with positioning & ambulation
- monitor IV fluids therapy
- If patient is Rh-negative, RhoGAM is given within 72 hours and before discharge
- provide contraceptive counseling
4. Provide emotional support
 PLACENTA PREVIA - low-lying placenta
Causes:
-scarring of uterus
-multiple gestation
-tumors
-multiparity
-advanced age
Types:
-Complete/Total PP – covers the internal os
- Partial PP – partially covers the internal os
-Marginal PP – edge at the margin of the internal os
Complications:
-Hemorrhage
-Infection
-Prematurity
-DIC
-Anemia
-More lacerations
**Ultrasonography: best way to differentiate Abruptio Placenta from PP; earliest and safest
S/Sx:
-painless vaginal bleeding
-bright red bleeding
-no fetal engagement
-Decreased urinary output
Management:
-IE by MD only under double set up (done in the OR – patient is prepped and draped)
**Double Setup is Indicated When:
A. Utz is not available
B. Utz is inconclusive
C. ongoing vaginal bleeding
D. + marginal previa
-monitor blood loss, VS, urine flow
-monitor FHT and activity
-monitor uterine contractions
-CBR c BRP if without bleeding
-Keep woman on NPO
-shock: start IVT and BT
-active labor: Give TOCOLYTICS
-Betamethasone (Celestone) for fetal lung maturity (12mg IM q 12 hrs for 2 doses)
-no heavy workload
-no sexual activity

CHORIONIC VILLI
-release enzyme to tap for maternal vessels
DECIDUA (endometrium)
a. Decidua parietalis
b. Decidua basalis
 c. Decidua capsularis- encloses the blastocyst after implantation
THE MEMBRANES
a. Chorionic membrane- thick,opaque and friable
b. Amniotic membrane-smooth, thin, tough, translucent membrane; encloses fetus
AMNIOTIC FLUID
- vol: 500 to 1200ml (Ave: 1 L)
-composition: 99% water and 1% solid particles
-clear and colorless to straw colored
-green tinged: meconium stained
-golden: hemolysis, ABO, Rh incompatibility
-gray: IUFD
-red: hemorrhage/ Abruptio placenta
- pH- 7.0-7.25
-specific gravity-1.005 to 1.025
FUNCTIONs:
-protection
-allows movement
-secretion and excretion system of the fetus
-maintain temperature
-aids in diagnosis of maternal and fetal complications
-aids in fetal descent during labor
-prevents pressure on the cord
Common Abnormalities:
1. Oligohydramnios: less than 400 ml
: decrease urine production
: d/t kidney agenesis
2. Polyhydramnios: >2000 ml
:failure to swallow fluid d/t Tracheoesophageal Fistula and Atresia (TEFA)
:d/t GDM and multiple gestation
UMBILICAL CORD/FUNIS
-main function is to carry oxygen and nutrients from the placenta
-contains 2 arteries and 1 vein
-length: 50-55 cm long, 2 cm in diameter
-Wharton’s Jelly found inside the cord

Common Abnormalities:
1. Long cord: Nuchal cord
2. Too short: Abruptio Placenta
3. Cord Prolapse and Compression
- Mngt: POSITION: Trendelenberg or Knee-chest position to relieve pressure
-monitor FHT
-if cord is EXPOSED: COVER with gauze soaked in WARM NSS! DO NOT PUSH BACK THE
CORD!

PLACENTA
- functional @ 12 weeks AOG
-wt: 500 g
-MATERNAL SIDE: 15-20 cotyledons
-FETAL SIDE: the amnion covers it
Functions:
-nutrition
-release of hormones (HCG and HPL - causes insulin resistance)
-excretory
-protective barrier-blocks teratogens
-immunologic: IgG (Passive natural immunity)

COMMON ABNORMALITIES OF THE PLACENTA

 Placenta Bipartita-placenta not divided in two lobes
 Placenta Duplex-placenta is separated completely into two parts
 Placenta Succenturiata- has an accesory lobe with blood vessels connected to it.
 Ring-shaped placenta- associated with fetal growth retardation,postpartum and antepartum
bleeding
 Fenestrated Placenta- the central portion of the maternal side of the placenta is missing.
 Placenta Circumvallata-cental depresion sorrounded by a thickened white-grayish ring .
 Circummarginate placenta-when the white-grayish ring is located at the margin of the placenta
 Placenta accreta- deeply implanted placenta
 Large placenta- encountered in syphilis and erythroblastosis fetalis

 ABRUPTIO PLACENTA
Causes:
-PIH
-advanced age (>35)
-trauma/injury to uterus
-grand multiparity
-short cord
-behavioral (smoking, alcoholism)
Types:
A. Classification According to Placental Separation
1. Covert/Central AP – “concealed bleeding”
2. Overt/Marginal AP – “bleeding is external”
B. Classification According to Signs and Symptoms
1. Grade 0 – no symptoms
2. Grade 1 – slight external bleeding, uterine tetany, (-)fetal distress
3. Grade 2 – grade 2 + fetal distress
4. Grade 3 – profuse bleeding, tetany, shock, fetal death
**Complication: DIC
S/Sx:
-Dark red bleeding (Covert); central separation/fetal side: SHINY SHULTZ
-Bright red bleeding (overt); marginal separation/ maternal: DIRTY DUNCAN
-Abdominal pain (sudden, sharp)
-Uterine irritability and low back pain (2/3 of patient)
-Board like abdomen (COUVELAIR UTERUS)
-Signs of shock and fetal distress if bleeding are severe
Management:
-ADMIT patient
-If PRE-TERM
a. manage @ prolonging pregnancy with the hope of improving fetal maturity if:
- bleeding is not life threatening
- FHT are normal
- mother is not in active labor
b. manage bleeding episode
- place in bedrest (sidelying position)
- IFC to accurately record I&O (at least 30cc/hr)
- NPO status
- O2 therapy (NC @ 4 – 6 lpm)
- monitor bleeding q 30 mins
-monitor VS, FHT
-start IVT and prepare for BT
-bethametasone for lung maturity
-tocolytics (MgSo4, Ritodrine, Terbutaline)

2.4 FETAL GROWTH AND DEVELOPMENT

 FETAL CIRCULATION
Shunts: Ductus Venosus: between umbilical vein and vena cava, bypasses liver
Ductus Arteriosus: between pulmonary artery and aorta
Foramen Ovale: between two atria
**PLACENTA works as RESPIRATORY SYSTEM
**shunts are closed during the first breath/cry**
Ductus Venosus = Ligamentum Venosum
Ductus Arteriosus = Ligamentum Arteriosum
Foramen Ovale = Fossa Ovale

Diagram 1.4. The Fetal Circulation

Video Link: https://youtu.be/zTXmaVgobNw

 FETAL MILESTONES

Table 1.3. Fetal Growth and Development

MONTH SIGNIFICANT DEVELOPMENT
1 -Arms are formed, webbed toes form
2 -eyes develop; fingers and toes are formed, genitalia begins to differentiate
3 -sucking reflex appears, genitals are formed; growth in size and weight; FHT can be heard
by Doppler
4 -FHT is more pronounced (fetoscope), cartilage stiffens. Major organs begin to form,
lanugo and vernix starts to appear
5 -quickening occurs; FHT can be heard by steth
6 -eyelids open, lung circulation develops
7 -fat deposition under skin; lung maturity
8 -fat deposit increases, most senses are developed; LS Ratio 2:1
9 -fully developed

COMMON TERATOGENS (ToRCH)

 Toxoplasmosis: protozoan infection; spread through uncooked meat or contaminated soil or
cat litter
S/sx: malaise, lymphadenopathy
: can cause CNS damage to infant
Mngt: SULFONAMIDES (Pyrimethamine)
 Rubella: most dangerous; can cause microcephaly, glaucoma, cataract and mental retardation
: advice mother to get vaccinated but NO PREGNANCY within 3 months
 Cytomegalovirus: herpes virus; causes CNS damage
 Herpes Simplex Virus: can cause severe congenital anomalies or abortion
 Chickenpox: HIGH IMMUNITY in the first 7 months; can have vaccine after delivery

2.5 ASSESSMENT OF PREGNANCY / PHYSIOLOGIC CHANGES IN PREGNANCY

 PRENATAL CARE
COMPONENTS:
o History taking
o Physical examination
o TT Immunization
o Iron Supplementation
o Health Education
o Laboratory examination
o Oral-dental examination
o Referral when necessary
 Nutrition
 *Recommended weight gain: 25-35 lbs (ave 12kg)
1st tri: 1 lb per month
2nd and third tri: 1 lb per week
*Iron, Folic and Calcium supplementation
 OBSTETRIC HISTORY
Gravida: # of pregnancies
Parity: # of pregnancies that have reached the age of viability (25 weeks)
Term: infants born @ 37 weeks AOG
Pre-term: infants born <37 weeks AOG
Abortion: miscarriage/ termination of pregnancy before 25 weeks
Living: number of alive children
Multiple gestation: # of pregnancies carrying twins or the like
-Blood flow: increases from 20ml before pregnancy to 700-900 ml at the end of pregnancy
 Determination of Age of Gestation
Menstrual age/Gestation Age-measures from LMP
 BARTHOLOMEW’S RULE (measures the location of fundus to determine AOG)
-12 wks: at the level of the symphisis pubis
-16 wks-halfway between symphisis pubis and umbilicus
-20 wks-at the level of the umbilicus
-24 wks-two fingers above umbilicus
-30 wks- midway between umbilicus and xyphoid process
-36 wks-at the level of xyphoid process
-40 wks-two fingers below umbilicus, drops at 34 wks.level because of lightening.
 Mc Donald’s Rule (AOG)
- Fundic height (cm) X 2/7=AOG in lunar months
- Fundic height (cm) X 8/7= AOG in weeks
 Johnson’s Rule-use to calculate fetal weight in grams
FH(cm) - N X K= fetal weight
K= 155(constant)
N= 12 if engaged
N= 11 if not yet engaged
 Haase’s Rule to determine the length of the fetus
a. during the first half of pregnancy, square the number of months
b. during the second half of pregnancy, multiply the number of months by 5.
*Greater fundic height indicates:
- multiple pregnancy
-miscalculated due date
-polyhydramnios
-Hydatidiform mole
*Lesser Fundic height indicates
-fetal growth retardation
-fetal death
-error in estimating AOG
-oligohydramnios
 Expected Date of delivery
Naegele’s Rule
ex. April 3 2020
-3 +7 +1
EDC=January 10,2021

Note: BE SURE TO REMEMBER ALL FORMULAs

 LEOPOLD’S MANEUVER

Table 1.4 Mnemonic on Leopold’s Maneuver

MANEUVER DESCRIPTION ASSESSMENT FOR BETTER RETENTION :)
1ST (FUNDAL GRIP) -facing head of the -assess fetal part in the
mother fundus
-place both hands over *soft and round:
the fundus buttocks (CEPHALIC
position)
*hard and round: head L1e
 (BREECH position)
*nodular: extremities
(TRANSVERSE
position)
2nd (UMBILICAL) -face head part of the - determines fetal back
mother to assess FHT
-place one hand on Normal: 120-160 bpm
either side of the
abdomen to stabilize it
-use the other hand to
palpate
B2ck
3rd (PAWLIK’S GRIP) Use one hand to grasp Engaged: NON-
the presenting part Movable
over the symphysis Engaged: MOVABLE 3ngag3m3nt
pubis
4th (PELVIC GRIP) -face FOOT part of Tilt lightly
mother -Flexion
-move the presenting -Extension
part with both hands
4ttitude
 PSYCHOLOGIC/EMOTIONAL ADAPTATIONS OF PREGNANCY
1. Acceptance of Pregnancy (1st tri)
2. Acceptance of the Fetus (2nd tri)
3. Acceptance of motherhood (3rd tri)

 SIGNS AND SYMPTOMS OF PREGNANCY

Table 1.5. Signs and Symptoms of Pregnancy

PRESUMPTIVE SIGNS PROBABLE SIGNS POSI+IVE SIGNS DANGER SIGNS
(QUELNACS) (PUGO HUB) (FUX F2) -refer
-subjective -objective
Quickening Positive FHT -vaginal bleeding of
Urinary pregnancy test UTZ any amount
frequency Uterine growth X-ray -persistent vomiting
Easy fatigabilty Goodel’s sign -chills and fever
Leukorrhea Outline of the Funic Souffle -sudden escape of fluid
Nausea and fetus Fetal movement felt by from the vagina
Vomiting the examiner -swelling of face and
Amenorrhea Hegar’s sign fingers
Chadwick’s Sign Uterine souffle -visual disturbances
Skin changes Ballotement -painful urination or
dysuria
-abdominal pain
-severe or continuous
headache

 LABORATORY TEST
1.Urinalysis
2.Blood Tests (Hgb and Hct, Rh determination, Rubella titer, etc)

2.6 PRENATAL HEALTH TEACHINGS

1. Schedule of Clinic Visit
1st Tri: at least 1
2nd tri: at least 1
3rd tri: every week starting 36 wks
2. Exercise
ADVANTAGES OF EXERCISE
-pelvic rocking
DURING PREGNANCY
-squatting and tailor sitting -strengthen muscles
-Rib Cage Lifting - promote circulation
-calf stretching -relieves tension and anxiety
-improves posture and appetite
-improves metabolic efficiency
 -kegel’s exercise
-shoulder circling
-abdominal muscle contractions
-modified knee chest

3. Dental Care (gargle with alkaline mouthwash)

4. Clothing : lightweight and non-constrictive
5. Bathing: NO TUB bath
6. Breast Care: wash breast with water only
7. No Alcohol and limit caffeine
8. Drugs: take meds prescribed by ONLY by physicians

 COMMON DISCOMFORTS

Table 1.6. Physical Discomforts of Pregnancy and its Management

S/SX CAUSE MANAGEMENT
FIRST TRIMESTER
N&V Hcg -offer dry crackers or toast
-no oily, greasy food
-drink fluids between meals
Urinary frequency Pressure of fundus Empty bladder as needed
Breast tenderness ↑ E and P Wear a well-fitting bra
Leukorrhea ↑ mucus production Keep it dry
Refer if infection is suspected
Ptyalism Offer hard candy
SOB Rise slowly; assume Semi-
Fowler’s position
SECOND TRIMESTER
Pyrosis D/t esophageal reflux -assume SF position
-refrain from lying down after
meals
-offer sips of warm water
-AVOID ANTACIDS
Ankle Edema D/t venous stasis Elevate legs
Left side lying position
Varicosities Weakening of faulty valves Elevate feet
Use support hose
Hemorrhoids/ D/t constipation Eat high fiber diet
↑ OFI
Stool Softeners as prescribed
(Colace)
Backache Lumbosacral pressure Pelvic tilting
Leg cramps Losing Calcium Tailor sitting; dorsiflexion of foot

2.7. CHILDBIRTH PREPARATIONS

Table 1.7. Childbirth Preparations

METHOD DESCRIPTION
Bradley (Partner-coached) -husband plays an important role
-reduce labor pain by abdominal breathing
-woman does muscle-toning exercises
Psychosexual Method -developed by Sheila Kitzinger
-includes a program of conscious relaxation and
levels of progressive breathing
Dick-Read Method -fear leads to tension which in turn leads to pain
-prevent fear thru prenatal classes (aabdominal
breathing)
Lamaze “psychoprophylactic”
-conscious relaxation -preventing pain in labor by using the “mind”
-cleansing breath -uses imagery to block incoming sensations
-controlled breathing
-effleurage
-Focusing/Imagery
TEACHER’S INSIGHT

Improving the well being of mothers, children and their families is an integral function of a health
care provider. It is important to equip student nurses about topics related to MCN for them to
address a wide range of conditions and health-related behaviors.

Pregnancy can provide an opportunity to identify existing health risks in women which can be used
as a medium to prevent future health problems for them and their families as well.

As nurses both in the clinical and community setting, we should be able to facilitate a rewarding
experience for expectant parents.

You have reached the end of Chapter I. Please turn to the next page and proceed with the exam. Good
luck!

Reminders when taking the exam:

Before you proceed:

1. If you think you have not fully understood the topics, you may re-read the chapter and supplement
it with the links provided in the cover page.

2. Take the exam as if you are in the actual classroom setting

3. Do not go over your lecture notes while taking the exam. CHEATING is extremely discouraged.
Honesty on the other hand is highly appreciated.