II.

BRIEF DESCRIPTION OR BACKGROUND OF PRESENT’S ILLNESS

Definition of Terms
PREGNANCY – occurs when a sperm fertilizes an egg after it’s released from the ovary during ovulation. The
fertilized egg then travels down into the uterus, where implantation occurs. A successful implantation results in
pregnancy. On average, a full-term pregnancy lasts 40 weeks.
LABOR – Childbirth, the process of delivering a baby and the placenta, membranes, and umbilical cord from the
uterus to the vagina to the outside world.
FIRST TRIMESTER – begins on the first day of your last period and lasts until the end of week 12.
SECOND TRIMESTER – includes weeks 13 through 27 of a pregnancy.
THIRD TRIMESTER – begins in week 28 of pregnancy and lasts until you give birth, which may be around week 40
of pregnancy. In other words, your third trimester lasts from month 7 through month 9 of pregnancy. 
MENSTRUATION – menstruation is also known by the terms menses, menstrual period, cycle or period. The
menstrual blood which is partly blood and partly tissue from the inside of the uterus flows from the uterus through the
cervix and out of the body through the vagina.
FERTILIZATION – a complicated multistep molecular process where two highly methylated and specified haploid
gametes, spermatozoon and oocyte, are coming together forming a male and a female pronucleus, respectively, and
culminating in the fusion of the two pronuclei giving rise to the formation of the zygote.
ZYGOTE – the union of the sperm cell and the egg cell. The zygote begins as a single cell but divides rapidly in the
days following fertilization. The zygote's single cell contains all of the 46 necessary chromosomes. It gets 23 from the
sperm and 23 from the egg.
IMPLANTATION – a process that occurs after an embryo (fertilized egg) travels down the fallopian tube and burrows
deep into the lining of the uterus, where it will remain until delivery. Once the embryo is implanted, it starts releasing
hormones that prepare your body for baby, turning off your period, building up the placenta and possibly making you
feel cramps and tired.
NONSTRESS TEST OR NST – a third trimester check of your baby's well-being. It is a test that measures your
baby’s heart rate and response to movement. Designed to make sure she’s doing well and getting enough oxygen.
NITRAZINE TEST – involves putting a drop of fluid obtained from the vagina onto paper strips
containing Nitrazine dye. The strips change color depending on the pH of the fluid. The strips will turn blue if the pH
is greater than 6.0. A blue strip means it's more likely the membranes have ruptured.
AMNIOCENTESIS – involves taking a small sample of the amniotic fluid that surrounds the fetus. It is used to
diagnose chromosomal disorders and open neural tube defects, such as spina bifida. Testing is available for other
genetic defects and disorders depending on your family history and the availability of lab testing at the time of the
procedure.
VITAL SIGNS – measurements of the body's most basic functions. The four main vital signs routinely monitored by
medical professionals and health care providers includes Body Temperature, Pulse Rate, Respiration Rate, Blood
Pressure.
FETAL MONITORING – fetal heart rate monitoring is a method of checking the rate and rhythm of the fetal
heartbeat.

Fetal development: First trimester

Fetal development begins soon after conception. A baby grows and develops during first trimester.

1st and 2nd week Conception typically occurs about two weeks after your last period begins. To calculate
your estimated due date, your health care provider will count ahead 40 weeks from the
 start of your last period. This means your period is counted as part of your pregnancy.
Even though you weren't pregnant at the time.
3rd week The sperm and egg unite in one of your fallopian tubes to form a one-celled entity called a
zygote. If more than one egg is released and fertilized or if the fertilized egg splits into two,
you might have multiple zygotes. These chromosomes help determine your baby's sex and
physical traits. Soon after fertilization, the zygote travels down the fallopian tube toward the
uterus. At the same time, it will begin dividing to form a cluster of cells resembling a tiny
raspberry, a morula.
4th week The rapidly dividing ball of cells, now known as a blastocyst has begun to burrow into the
uterine lining (endometrium). Implantation occurs. Within the blastocyst, the inner group of
cells will become the embryo. The outer layer will give rise to part of the placenta, which
will nourish your baby throughout the pregnancy.
5th week On the third week after conception, the levels of HCG hormone produced by the blastocyst
quickly increase. This signals your ovaries to stop releasing eggs and produce more
estrogen and progesterone. Increased levels of these hormones stop your menstrual
period, often the first sign of pregnancy, and fuel the growth of the placenta. The embryo is
now made of three layers. The top layer, the ectoderm will give rise to your baby's
outermost layer of skin, central and peripheral nervous systems, eyes, and inner ears.
Your baby's heart and a primitive circulatory system will form in the middle layer of cells,
the mesoderm. This layer of cells will also serve as the foundation for your baby's bones,
ligaments, kidneys and much of the reproductive system. The inner layer of cells, the
endoderm is where your baby's lungs and intestines will develop.
6th week Growth is rapid this week. Just four weeks after conception, the neural tube along your
baby's back is closing. The baby's brain and spinal cord will develop from the neural tube.
The heart and other organs also are starting to form and the heart begins to beat.
Structures necessary to the formation of the eyes and ears develop. Small buds appear
that will soon become arms. Your baby's body begins to take on a C-shaped curvature.

7th week Baby's brain and face are growing. Depressions that will give rise to nostrils become
visible, and the beginnings of the retinas form. Lower limb buds that will become legs
appear and the arm buds that sprouted last week now take on the shape of paddles.

8th week Baby's lower limb buds take on the shape of paddles. Fingers have begun to form. Small
swellings outlining the future shell-shaped parts of your baby's ears develop and the eyes
become obvious. The upper lip and nose have formed. The trunk and neck begin to
straighten. By the end of this week, your baby might be about 1/2 inch (11 to 14
millimeters) long from crown to rump, about half the diameter of a U.S. quarter.

9th week Baby's arms grow and elbows appear. Toes are visible and eyelids form. Your baby's head
is large but still has a poorly formed chin. By the end of this week, your baby might be a
little less than 3/4 inch (16 to 18 millimeters) long from crown to rump, the diameter of a
U.S. penny.

10th week Baby's head has become more round. Your baby can now bend his or her elbows. Toes
and fingers lose their webbing and become longer. The eyelids and external ears continue
to develop. The umbilical cord is clearly visible.

11th week Baby's head still makes up about half of its length. However, your baby's body is about to
catch up. Your baby is now officially described as a fetus. This week your baby's face is
broad, the eyes widely separated, the eyelids fused and the ears low set. Buds for future
teeth appear. Red blood cells are beginning to form in your baby's liver. By the end of this
week, your baby's external genitalia will start developing into a penis or a clitoris and labia
majora. By now. your baby might measure about 2 inches (50 millimeters) long from crown
to rump, the length of the short side of a credit card, and weigh almost 1/3 ounce (8
grams).

12th week Baby is sprouting fingernails. Your baby's face now has taken on a more developed profile.
His or her intestines are in the abdomen. By now your baby might be about 2 1/2 inches
(61 millimeters) long from crown to rump, the length of the short side of a U.S. bill, and
weigh about 1/2 ounce (14 grams).
Fetal development: Second trimester
Fetal development takes on new meaning in the second trimester. Highlights might include finding out your baby's
sex and feeling your baby move.

13th week baby is beginning to make urine and release it into the surrounding amniotic fluid. Your
baby also swallows some amniotic fluid. Bones are beginning to harden in your baby's
skeleton, especially in the skull and long bones. Your baby's skin is still thin and
transparent, but it will start to thicken soon.

14th week baby's neck has become more defined. Red blood cells are forming in your baby's spleen.
Your baby's sex will become apparent this week or in the coming weeks. By now your
baby might be almost 3 1/2 inches (87 millimeters) long from crown to rump and weigh
about 1 1/2 ounces (45 grams).

15th week Baby is growing rapidly. Bone development continues and will soon become visible on
ultrasound images. Your baby's scalp hair pattern also is forming.
16th week Baby's head is erect. His or her eyes can slowly move. The ears are close to reaching their
final position. Baby's skin is getting thicker. Baby's limb movements are becoming
coordinated and can be detected during ultrasound exams. However, these movements
are still too slight to be felt by you. By now your baby might be more than 4 1/2 inches (120
millimeters) long from crown to rump and weigh close to 4 ounces (110 grams).

17th week Toenails begin developing. Baby is becoming more active in the amniotic sac, rolling and
flipping. His or her heart is pumping about 100 pints of blood each day.

18th week Baby's ears begin to stand out on the sides of his or her head. Your baby might begin to
hear sounds. The eyes are beginning to face forward. Your baby's digestive system has
started working. By now your baby might be 5 1/2 inches (140 millimeters) long from crown
to rump and weigh 7 ounces (200 grams).

19th week Growth slows. A greasy, cheese like coating called vernix caseosa begins to cover your
baby.

20th week You might be able to feel your baby's movements (quickening). Your baby is regularly
sleeping and waking. He or she might be awakened by noises or your movements. By now
your baby might be about 6 1/3 inches (160 millimeters) long from crown to rump and
weigh more than 11 ounces (320 grams).

21 week Baby is completely covered with a fine, downy hair called lanugo. The lanugo helps hold
the vernix caseosa on the skin. The sucking reflex also is developing, enabling your baby
to suck his or her thumb.

22 week Baby's eyebrows and hair are visible. Brown fat also is forming, the site of heat production.
For boys, the testes have begun to descend. By now your baby might be 7 1/2 inches (190
millimeters) long from crown to rump and weigh about 1 pound (460 grams).

23 week Baby begins to have rapid eye movements. Ridges also form in the palms of the hands
and soles of the feet that will later create the foundation for fingerprints and footprints. Your
baby might begin hiccupping, causing jerking movements.

24 week Baby's skin is wrinkled, translucent and pink to red because of visible blood in the
capillaries. By now your baby might be about 8 inches (210 millimeters) long from crown to
rump and weigh more than 1 1/3 pounds (630 grams).

25 week Baby might be able to respond to familiar sounds, such as your voice, with movement.
Your baby is spending most of his or her sleep time in rapid eye movement (REM), when
the eyes move rapidly even though the eyelids are closed.

26 week Baby's lungs are beginning to produce surfactant, the substance that allows the air sacs in
the lungs to inflate and keeps them from collapsing and sticking together when they
deflate. By now your baby might be 9 inches (230 millimeters) long from crown to rump
 and weigh nearly 2 pounds (820 grams).

27 week Baby's nervous system is continuing to mature. Your baby is also gaining fat, which will
help his or her skin look smoother.

Fetal development: Third trimester

Fetal development continues during the third trimester. Your baby will open his or her eyes, gain more weight, and
prepare for delivery.

28 week Baby's eyelids can partially open and eyelashes have formed. The central nervous system
can direct rhythmic breathing movements and control body temperature. By now your baby
might be nearly 10 inches (250 millimeters) long from crown to rump and weigh nearly 2
1/4 pounds (1,000 grams).

29 week Baby can kick, stretch and make grasping movements.

30 week Baby's eyes can open wide. Your baby might have a good head of hair by this week. Red
blood cells are forming in your baby's bone marrow. By now your baby might be more than
10 1/2 inches (270 millimeters) long from crown to rump and weigh nearly 3 pounds (1,300
grams).

31 week Baby has finished most of his or her major development. Now it's time to gain weight
quickly.
32 week Baby's toenails are visible. The layer of soft, downy hair that has covered your baby's skin
for the past few months (lanugo) starts to fall off this week. By now your baby might be 11
inches (280 millimeters) long from crown to rump and weigh 3 3/4 pounds (1,700 grams)

33 week Baby's pupils can change size in response to a stimulus caused by light. His or her bones
are hardening. However, the skull remains soft and flexible.
34 week Baby's fingernails have reached his or her fingertips. By now your baby might be nearly 12
inches (300 millimeters) long from crown to rump and weigh more than 4 1/2 pounds
(2,100 grams).

35 week Baby's skin is becoming smooth. His or her limbs have a chubby appearance.
36 week The crowded conditions inside your uterus might make it harder for your baby to give you a
punch. However, you'll probably still feel lots of stretches, rolls and wiggles.
37 week Baby has a firm grasp. To prepare for birth, your baby's head might start descending into
your pelvis. If your baby isn't head down, your health care provider will talk to you about
ways to deal with this issue.

38 week The circumference of your baby's head and abdomen are about the same. Your baby's
toenails have reached the tips of his or her toes. Your baby has mostly shed all of his or
her lanugo. By now your baby might weigh about 6 1/2 pounds (2,900 grams).

39 week Baby's chest is becoming more prominent. For boys, the testes continue to descend into
the scrotum. Fat is being added all over your baby's body to keep him or her warm after
birth.

40 week Your baby might have a crown-to-rump length of around 14 inches (360 millimeters) and
weigh 7 1/2 pounds (3,400 grams). Remember, however, that healthy babies come in
different sizes. Don't be alarmed if your due date comes and goes with no signs of labor
starting. Your due date is simply a calculated estimate of when your pregnancy will be 40
weeks. It does not estimate when your baby will arrive. It's normal to give birth before or
after your due date.

SYMPTOMS OF PREGNANCY
The most common early signs and symptoms of pregnancy might include:

Missed Period If you're in your childbearing years and a week or more has passed without the start of
 an expected menstrual cycle, you might be pregnant. However, this symptom can be
misleading if you have an irregular menstrual cycle.
Tender, swollen breast Early in pregnancy hormonal changes might make your breasts sensitive and sore.
The discomfort will likely decrease after a few weeks as your body adjusts to hormonal
changes.
Nausea with or without Morning sickness, which can strike at any time of the day or night, often begins one
vomiting month after you become pregnant. However, some women feel nausea earlier and
some never experience it. While the cause of nausea during pregnancy isn't clear,
pregnancy hormones likely play a role.
Increased urination You might find yourself urinating more often than usual. The amount of blood in your
body increases during pregnancy, causing your kidneys to process extra fluid that ends
up in your bladder.
Fatigue Fatigue also ranks high among early symptoms of pregnancy. During early pregnancy,
levels of the hormone progesterone soar which might make you feel sleepy.

Other pregnancy signs and symptoms

Other less obvious signs and symptoms of pregnancy that you might experience during the first trimester include:

Moodiness The flood of hormones in your body in early pregnancy can make you unusually
emotional and weepy. Mood swings also are common.
Bloating Hormonal changes during early pregnancy can cause you to feel bloated, similar to
how you might feel at the start of a menstrual period.
Light spotting Sometimes a small amount of light spotting is one of the first signs of pregnancy.
Known as implantation bleeding, it happens when the fertilized egg attaches to the
lining of the uterus about 10 to 14 days after conception. Implantation bleeding occurs
around the time of a menstrual period. However, not all women have it.
Cramping Some women experience mild uterine cramping early in pregnancy.
Constipation Hormonal changes cause your digestive system to slow down, which can lead to
constipation.
Food aversions When you're pregnant, you might become more sensitive to certain odors and your
sense of taste might change. Like most other symptoms of pregnancy, these food
preferences can be chalked up to hormonal changes.
Nasal congestion Increasing hormone levels and blood production can cause the mucous membranes in
your nose to swell, dry out and bleed easily. This might cause you to have a stuffy or
runny nose.

PHYSIOLOGIC SIGNS OF PREGNANCY

Pregnancy might leave you feeling delighted, anxious, exhilarated and exhausted, sometimes all at once.
Even if you're thrilled about being pregnant, a new baby adds emotional stress to your life. It's natural to worry about
your baby's health, your adjustment to parenthood and the financial demands of raising a child. If you're working, you
might worry about how to balance the demands of family and career. You might also experience mood swings. What
you're feeling is normal.
There are several other physical changes in your body by the coming weeks, including:

Tender, swollen breast Soon after conception, hormonal changes might make your breasts sensitive or sore.
The discomfort will likely decrease after a few weeks as your body adjusts to hormonal
changes.
Nausea with or without Morning sickness, which can strike at any time of the day or night, often begins one
vomiting month after you become pregnant. This might be due to rising hormone levels. To help
relieve nausea, avoid having an empty stomach.
Increased urination You might find yourself urinating more often than usual. The amount of blood in your
body increases during pregnancy, causing your kidneys to process extra fluid that ends
up in your bladder.
Food cravings and When you're pregnant, you might become more sensitive to certain odors and your
aversions sense of taste might change. Like most other symptoms of pregnancy, food
preferences can be chalked up to hormonal changes.
Heartburn Pregnancy hormones relaxing the valve between your stomach and esophagus can
allow stomach acid to leak into your esophagus, causing heartburn.
Constipation High levels of the hormone progesterone can slow the movement of food through your
digestive system, causing constipation. Iron supplements can add to the problem.

MANAGING SYMPTOMS OF PREGNANCY

What to do When to call

Nausea and vomiting Try eating small, frequent meals to help
manage nausea and vomiting. Choose
foods that are low in fat. Avoid foods or
smells that make your nausea worse and d
rink plenty of fluids. Other remedies that
work for some women include eating ginger,
drinking chamomile tea or wearing an anti-
nausea wristband.
Fatigue Take naps if possible, and make adequate
sleep a top priority. Try to get eight hours of
sleep each night. While it may become
more challenging later in your pregnancy,
most women have little trouble finding
comfortable sleep positions in the first
trimester. It may also help to wind down with
relaxing activities before bed. For example,
drinking chamomile tea or reading may help
calm you for a good night of rest. Usually by
the second trimester, energy levels perk up
again.
If you don’t see improvement, you can
ask your doctor or midwife about safe
anti-nausea medications. If your
symptoms are bad enough that you can’t
eat or drink for 24 hours, go to the
nearest emergency department
immediately.
Contact your doctor or midwife if no
matter how much you sleep, you never
feel like you have enough energy to get
through the day. Your provider may
decide to check your thyroid levels to
determine if there is an underlying cause
of your fatigue.

Round ligament pain Yoga, stretching, or working with a If you’re experiencing round ligament
chiropractor who specializes in Webster pain, discuss it with your doctor or
technique can help manage round ligament midwife at your next visit.
pain. While these options may work for
some women, be sure to get clearance from
your doctor or midwife before trying any
new activity.

Heartburn Don’t lie down immediately after eating.
Allow at least 60 minutes for your food to
digest. Also, avoid acidic foods, and eat
smaller meals more often throughout the
day. For additional relief, you may also
consider asking your doctor or midwife
about trying papaya enzymes or over-the-
counter medications that are safe to take
during pregnancy.
if you have nausea and vomiting,
headache that doesn’t go away with
Tylenol of caffeine, sport before your
eyes, Right upper belly pain that feels like
heartburn in conjunction with the
symptoms listed above could be a sign of
preeclampsia.

Breast changes Wear a supportive bra. Try different styles if you notice one of these symptoms:
and sizes. They may be more comfortable Lump or firm feeling in your breast or
than bras you currently wear. under your arm. 

Frequent Urination Try to reduce your fluid intake before going
to bed but only just before going to bed.
Also, avoid drinks with caffeine, which can
increase the frequency of urination in
addition to increasing your blood pressure
and heart rate.
Hemorrhoids Eat a high-fiber diet with whole grains, raw
fruit, and vegetables; drink plenty of water;
if you're urinating more frequently than
usual and if: There's no apparent cause,
such as drinking more total fluids, alcohol
or caffeine.
 if yours bleed or hurt a lot
 exercise regularly. Creams are available to
soothe the burning and itching.
Back Pain When bending, keep your back straight and if your back pain is accompanied by:
bend your knees. Do not stay in the same Numbness or weakness: Severe pain,
position for too long—move around. Avoid numbness or weakness in the legs may
heavy lifting. Try to develop good posture be a sign of a condition called sciatica.
and do not wear heels. Try back exercises
for pregnant women. Supportive garments
that support your back and abdomen may
also be helpful.
Insomnia Try to unwind before going to bed with a  last longer than four weeks or interfere
warm bath, relaxing music, stress-relieving with your daytime activities and
exercises, and comfortable bed clothing. ability to function. You are concerned
about waking up many times during the
night gasping for breath and are
concerned about possible sleep apnea or
other medical problems that can
disrupt sleep.
Bleeding Gums Practice good oral hygiene. Brush your If you notice a nodule on your gums that
teeth several times per day, especially after bleeds when you brush.
eating, and use dental floss. Make sure you
visit the dentist during your pregnancy.
Constipation Maximize your hydration by drinking at least If you’re experiencing constipation,
2 liters of water each day. You may discuss it with your doctor or midwife at
consider adding herbs or fruit or drinking your next visit.
sparkling water to make it more appealing.
Some foods, such as cucumber and
watermelon, carry high water content,
making them good options to help increase
hydration as well. Increasing fiber in your
diet can also help prevent or manage
constipation. Good sources of fiber include
bananas, oranges, apples, mangos, kale,
spinach, beans, legumes and whole grain
bread.

PHYSIOLOGICAL CHANGES IN THE FEMALE REPRODUCTIVE SYSTEM DURING PREGNANCY

Changes in oestrogen and A woman will produce more oestrogen during one pregnancy than throughout
progesterone her entire life when not pregnant. During pregnancy, oestrogen promotes
maternal blood flow within the uterus and the placenta. A pregnant woman’s
progesterone levels are also very high. Among other effects, high levels of
progesterone cause some internal structures to increase in size, including the
uterus, enabling it to accommodate a full-term baby.
Changes in the uterus, cervix, After conception, the uterus provides a nutritive and protective environment in
and vagina which the fetus will grow and develop. It increases from the size of a small pear
in its non-pregnant state to accommodate a full-term baby at 40 weeks of
gestation. The tissues from which the uterus is made continue to grow for the
first 20 weeks, and it increases in weight from about 50 to 1,000 gm (grams).
After this time, it doesn’t get any heavier, but it stretches to accommodate the
growing baby, placenta and amniotic fluid. 
Pregnancy-related changes in A pregnant woman’s entire posture changes as the baby gets bigger. Her
posture and joints abdomen transforms from flat or concave (dished) to very convex (bulging
outwards), increasing the curvature of her back. The weight of the fetus, the
enlarged uterus, the placenta and the amniotic fluid (the bag of waters
surrounding the baby), together with the increasing curvature of her back, puts a
large strain on the woman’s bones and muscles. As a result, many pregnant
women get back pain. Too much standing in one place or leaning forward can
cause back pain, and so can hard physical work. Most kinds of back pain are
 normal in pregnancy, but it can also be a warning sign of a kidney infection. 
Changes in body weight Continuing weight increase in pregnancy is considered to be one favourable
indication of maternal adaptation and fetal growth. However, routine weighing of
the mother during pregnancy is not now thought to be necessary, because it
does not correlate well with pregnancy outcomes. For example, there can be a
slight loss of weight during early pregnancy if the woman experiences much
nausea and vomiting
Changes in the cardiovascular The heart may increase in size during pregnancy due to an increase in its
system workload. The heart rate is about 15 beats per minute higher in the pregnant
woman, which increase the resting heart rate. The volume of blood pumped out
of the heart in a single heartbeat. It is about 7 milliliters (ml) larger per heart beat
in the pregnant woman which increase the stroke volume. During the second
trimester of pregnancy, the mother’s heart at rest is working 40% harder than in
her non-pregnant state. Most of this increase results from a more efficiently
performing heart, which ejects more blood at each beat.
Respiratory changes The amount of air moved in and out of the lungs increases by nearly 50% due to
each breath contains a larger volume of air and the rate of breathing (breaths per
minute) increases slightly. Many women find they get short of breath (cannot
breathe as deeply as usual). This is because the growing baby crowds the
mother’s lungs and she has less room to breathe. But if a woman is also weak
and tired, or if she is short of breath all of the time, she should be checked for
signs of sickness, heart problems, anemia or poor diet. Get medical advice if you
think she may have any of these problems.
Changes in the gastrointestinal The muscles in the walls of the gastrointestinal system relax slightly, and the rate
system at which food is squeezed out of the stomach and along the intestines is slowed
down. Undesirable effects also result from slow emptying of the stomach, and
slow movement of food through the gut. Many women also have nausea in the
first months of pregnancy. A burning feeling, or pain in the stomach or between
the breasts, is called indigestion (or ‘heartburn’, although the heart is not
involved). It happens because as the pregnancy progresses, the growing baby
crowds the mother’s stomach and pushes it higher than usual. The acids in the
mother’s stomach that help digest food are pushed up into her chest, where they
cause a burning feeling. This is not dangerous and usually goes away after the
birth.
Changes in the urinary system Needing to urinate (pee) often is normal, especially in the first and last months of
pregnancy. This happens because the growing uterus presses against the
bladder. In late pregnancy, a woman often has to get up during the night to
urinate, because fluid retained in the legs and feet during the day (oedema) is
absorbed into the blood circulation when her legs are raised in bed. The kidneys
extract the excess fluid and turn it into urine, so the bladder fills more quickly at
night.
Skin changes Changes in the woman’s hormones, and mechanical stretching of her growing
abdomen and breasts, are responsible for several changes in the skin during
pregnancy. This dark line may appear between the umbilicus (belly-button) and
the symphysis pubis (pubic bone); in some pregnant women it may extend as
high as the sternum (the bone between the breasts). It is a hormone-induced
excess production of brown material (pigment) in the skin cells in this area. After
delivery, the line begins to fade, though it may never completely disappear.
Some women produce a brownish pigmentation of the skin over the face and
forehead, known as the ‘mask of pregnancy’ (or chloasma). It gives a bronze
look. It begins about the 16th week of pregnancy and gradually increases, but it
usually fades after delivery. 
Changes in the breasts The breasts may feel full or tingle, and they increase in size as pregnancy
progresses. The areola around the nipples (the circle of pigmented skin) darkens
and the diameter increases. The Montgomery’s glands (the tiny bumps in the
areola) enlarge and tend to protrude (stick out more). The surface blood vessels
of the breast may become visible due to increased circulation, and this may give
a bluish tint to the breasts.
LABOR - Labor is the process of childbirth, starting with contractions of the uterus and ending with the delivery of the baby.
SIGNS OF LABOR
Preliminary Labor: One hour to a full month or more before labor

Baby “drops” Your baby will start to drop, or descend into your pelvis, a few weeks before labor
begins. In subsequent births, this “lightening” doesn't often happen until you’re truly in
labor. Your baby is getting into position to make his exit, ideally with the head down
and low. You might feel like you’re waddling even more than you have been up until
this point and you may still be taking frequent bathroom breaks like you’ve probably
been doing in the third trimester because baby’s head is now pushing down on your
bladder.
Cervix dilates Your cervix, too, is starting to prepare for birth: It starts to dilate (open) and
efface (thin out) in the days or weeks before you deliver. At your weekly check-
ups in the home stretch of your pregnancy, your provider may measure and track
dilation and effacement via an internal exam.
Feel more cramps and Especially if this is not your first pregnancy, you may feel some crampiness and pain
increased back pain in your lower back and groin as labor nears. Your muscles and joints are stretching
and shifting in preparation for birth.
Joints feel looser The joints all over your body feel a bit less tight and more relaxed. It’s just nature’s
way of opening up your pelvis for your little passenger to make his way into the world.
Diarrhea Just as the muscles in your uterus are relaxing in preparation for birth, so too are
other muscles in your body — including those in the rectum. And that can lead to
diarrhea, that pesky labor symptom you may well have experienced at other times
during pregnancy. Just be sure to stay hydrated and it’s a good sign.
Stop gaining weight or lose This is normal and won’t affect your baby’s birth weight. He’s still gaining, but you’re
pounds dropping due to lower levels of amniotic fluid, more bathroom breaks and maybe
even increased activity.
Feel extra tired That super-size belly, along with your compressed bladder and other organs, can
make it tricky to get a good night’s sleep during the last days and weeks of
pregnancy. So pile up those pillows and take naps when you can, if at all possible.

Early Labor: the days and hours before labor starts

Lose your mucus plug and In the last days before labor, you'll likely see increased and/or thickened vaginal
your vaginal discharge discharge. This thickened, pinkish discharge is called bloody show and is a good
changes color and consistency indication that labor is imminent. But without contractions or dilation of 3 to 4
centimeters, labor could still be a few days away.

Feel stronger. More frequent You can experience Braxton Hicks contractions (or "practice contractions") for
contractions weeks and even months before delivery. You’ll feel their pinch as the muscles in
your uterus tighten in preparation for their big moment: pushing that baby out.
Water breaks Your water breaking is actually one of the final signs of labor most women experience
and it happens in only around 15 percent of births or fewer.

FALSE VS. TRUE LABOR

TRUE LABOR FALSE LABOR

Contractions come and get closer together over time,
lasting about 30-70 seconds each
They continue regardless of movement or resting
They progressively get stronger
Usually they start in the back and move to the front
Contractions don’t come regularly and they don’t get
closer together
They stop with walking or resting or with changes in
position
They are usually weak and don’t get stronger, or start
strong and get weaker
Usually the pain is only felt in the front

STAGES OF LABOR
The progress of cervical effacement, cervical dilatation, and descent of fetal presenting part dictate stages of labor.
Here are the stages of labor and significant events that mark their beginning and end:

Stages of Labor Start End Nullipara Multipara

Frist stage True labor contractions Full cervical dilatation 10-12 hr 6-8 hrs but
bur 6-20 hrs 2-12 hrs is
is the the normal
normal limit unit
Latent Phase Onset of regularly 3 cm cervical dilatation 6 hrs 4.5 hrs
perceived uterine
contractions (mild
contractions lasting 20-40
sec)
Acrive Phase Stronger uterine 10 cm cervical dilatation 3 hrs 1.5-2 hrs
contractions lasting 40-
60secs
Second stage Full cervical dilatation Infant birth <2 hrs 0.5-1hrs
3 hrs with 2 hrs with
epidurals epidurals
Third Stage Infant birth Placental delivery Maximum of 30 mins

COMPONENTS OF LABOR

Passage Route the fetus must travel from the uterus through the cervix and vagina to the external
perineum
Passenger The fetus
Powers of Labor Supplied by the fundus of the uterus. Are implemented by uterine contraction, a process
that causes cervical dilatation and then expulsion of the fetus from the uterus
Psyche Psychological state or feelings that women bring into labor with them

Test Done During Pregnancy

Ultrasound An ultrasound scan is a diagnostic technique that uses high-frequency sound waves
to create an image of the internal organs. A screening ultrasound is sometimes
done during the course of your pregnancy to check normal fetal growth and verify
the due date.

Ultrasounds may be done at various times throughout pregnancy for several

reasons:
First Trimester
 To establish the due date (this is the most accurate way of determining the
due date)
 To determine the number of fetuses and identify placental structures
 To diagnose an ectopic pregnancy or miscarriage
 To examine the uterus and other pelvic anatomy
 To detect fetal abnormalities (in some cases)
Midtrimester
 To confirm the due date (a due date set in the first trimester is rarely
changed)
 To determine the number of fetuses and examine the placental structures
 To assist in prenatal tests, such as an amniocentesis
 To examine the fetal anatomy for abnormalities
 To check the amount of amniotic fluid
 To examine blood flow patterns
 To observe fetal behavior and activity
 To measure the length of the cervix
 To monitor fetal growth
Third Trimester
  To monitor fetal growth
 To check the amount of amniotic fluid
 To conduct the biophysical profile test
 To determine the position of the fetus
 To assess the placenta

Two types of ultrasounds can be performed during pregnancy:

Abdominal Ultrasound – In an abdominal ultrasound, gel is applied to your
abdomen. The ultrasound transducer glides over the gel on the abdomen to create
the image.
Transvaginal Ultrasound – In a transvaginal ultrasound, a smaller ultrasound
transducer is inserted into your vagina and rests against the back of the vagina to
create an image. A transvaginal ultrasound produces a sharper image than an
abdominal ultrasound and is often used in early pregnancy.

Nonstress Test (NST) used to evaluate a baby's health before birth. The goal of a nonstress test is to
provide useful information about your baby's oxygen supply by checking his or her
heart rate and how it responds to your baby's movement. The test might indicate the
need for further monitoring, testing or delivery.

Nonstress test is recommended if you have:

 A multiple pregnancy with certain complications
 An underlying medical condition, such as type 1 diabetes, heart disease or
high blood pressure during pregnancy
 A pregnancy that has extended two weeks past your due date (post-term
pregnancy)
 A history of complications in a previous pregnancy
 A baby who has decreased fetal movements or possible fetal growth
problems
 Rh (rhesus) sensitization: a potentially serious condition that can occur,
typically during a second or subsequent pregnancy, when your red cell
antigen blood group is Rh negative and your baby's blood group is Rh
positive.
 Low amniotic fluid (oligohydramnios)

First Trimester Prenatal Screening Test

First trimester screening This test includes a blood test and an ultrasound exam. It helps to determine
whether the fetus is at risk for a chromosomal abnormality (such as Down
syndrome) or birth defects (such as heart problems).

Ultrasound This safe and painless test uses sound waves to make images that show the baby's
shape and position. It can be done early in the first trimester to date the pregnancy
or during weeks 11–14 as part of the first trimester screening. Women with high-risk
pregnancies might have multiple ultrasounds during their first trimester.

Chorionic villus sampling This test checks cells from the placenta to see if they have a chromosomal
(CVS) abnormality (such as Down syndrome). It can be done from weeks 10 to 13, and
can tell for sure if a baby will be born with a specific chromosomal disorder.

Cell-free DNA testing
This blood test checks for fetal DNA in the mother's blood. It's done to see whether
the fetus is at risk for a chromosomal disorder, and can be done from 10 weeks on.
It is not a diagnostic test. If the results are abnormal, another test must confirm or
rule out the diagnosis. It's usually offered to pregnant women at higher risk because
they're older or have had a baby with a chromosomal abnormality.

Second Trimester Prenatal Screening Test

 AFP screening This blood test measures the level of AFP in your blood during pregnancy. AFP is a
protein normally produced by the fetal liver that is present in the fluid surrounding
the fetus (amniotic fluid). It crosses the placenta and enters your blood. 

Estriol This is a hormone produced by the placenta. It can be measured in maternal blood
or urine to be used to determine fetal health.

Inhibin This is a hormone produced by the placenta.

Human chorionic This is also a hormone produced by the placenta.

gonadotropin.

Ultrasound A diagnostic technique that uses high-frequency sound waves to create an image of
the internal organs. A screening ultrasound is sometimes done during the course of
your pregnancy to check normal fetal growth and verify the due date.

Third Trimester Prenatal Screening Test

Genetic Screening Many genetic abnormalities can be diagnosed before birth. Your doctor or midwife
may recommend genetic testing during pregnancy if you or your partner has a
family history of genetic disorders. You may also choose to have genetic screening
if you have had a fetus or baby with a genetic abnormality.
Amniocentesis An amniocentesis involves taking a small sample of the amniotic fluid that
surrounds the fetus. It is used to diagnose chromosomal disorders and open neural
tube defects, such as spina bifida. Testing is available for other genetic defects and
disorders depending on your family history and the availability of lab testing at the
time of the procedure.

Chorionic Villus Sampling a prenatal test that involves taking a sample of some of the placental tissue. This
(CVS) tissue contains the same genetic material as the fetus and can be tested for
chromosomal abnormalities and some other genetic problems. Testing is available
for other genetic defects and disorders, depending on your family history and the
availability of lab testing at the time of the procedure. Unlike amniocentesis, CVS
does not provide information on open neural tube defects. Therefore, women who
undergo CVS also need a follow-up blood test between 16 and 18 weeks of
pregnancy to screen for these defects.

Fetal Monitoring Fetal heart rate monitoring is a method of checking the rate and rhythm of the fetal
heartbeat. The average fetal heart rate is between 120 and 160 beats per minute.
This rate may change as the fetus responds to conditions in the uterus. An
abnormal fetal heart rate or pattern may mean that the fetus is not getting enough
oxygen or indicate other problems. An abnormal pattern also may mean that an
emergency cesarean delivery is needed.
Glucose Testing used to measure the level of sugar in your blood. A glucose challenge test is usually
conducted between 24 and 28 weeks of pregnancy. Abnormal glucose levels may
indicate gestational diabetes.
Nitrazine Test involves putting a drop of fluid obtained from the vagina onto paper strips
containing Nitrazine dye. The strips change color depending on the pH of the fluid.
The strips will turn blue if the pH is greater than 6.0. A blue strip means it's more
likely the membranes have ruptured.
Group B Strep Culture a type of bacteria found in the lower genital tract of about 20 percent of all women. 

Contraction stress Test This test stimulates the uterus with pitocin, a synthetic form of oxytocin (a hormone
secreted during childbirth), to determine the effect of contractions on fetal heart rate.
It may be recommended when an earlier test indicated a problem and can see
whether the baby's heart rate is stable during contractions.

DIAGNOSTIC PROCEDURE
MEDICAL MANAGEMENT

NURSING INTERVENTION DURING LABOR AND DELIVERY

First stage of Labor
Divided into three sub-phases, namely: latent, active, and transitional phases
Latent Phase – starts from the onset of true labor contractions to 3 cm cervical dilatation. Here are nursing
responsibilities during this phase:

1. Assess patient’s psychological readiness. Provide continuous maternal support (compared to usual care)
2. Measure duration of latent phase. For nulliparas, it should not be more than 6 hours. On the other hand,
for multiparas, it should be within 4.5 hours. Determine if patient received anesthesia because it can
prolong latent phase. One of the most common cause of prolonged latent phase is cephalopelvic
disproportion (CPD) and it requires cesarean birth.
3. Allow patient to be continually active. Upright maternal positions are recommended for women on the first
stage of labor. Patients without pregnancy complications can still walk around and make necessary birth
preparations.
4. Conduct interviews and filling in of forms (e.g. birth certificate) at this phase while the patient experiences
minimal discomfort and has control over contraction pains.
5. Conduct health teaching on breastfeeding, newborn care, and effective bearing down because during this
time, patient’s anxiety is controlled and she is able to focus on nurse’s instructions.
6. Educate patient on different relaxation techniques. As early as this phase, encourage patient to begin
alternative therapy of pain relief.
7. Ensure that the total number of internal examinations the woman receives in the entire course of labor is
limited to 5 only.
8. Ensure that birthing companion of choice is present all throughout the course of labor.

Active Phase –  starts from 4 cm cervical dilatation to 7 cm cervical dilatation. During this phase, contraction
intensity is stronger, interval shortens, and duration lengthens. This is where true discomfort is first felt by the patient
so she is dependent and her focus is on herself. Here are nursing responsibilities in this phase:

1. Inform patient on the progress of her labor to lessen her anxiety and obtain her trust and cooperation.
2. Start monitoring progress of labor with the use of WHO partograph, 2-hour action line.
3. Encourage patient to be continually active to maximize the effect of uterine contractions. Upright maternal
positions are recommended if tolerated.
4. Assist patient in assuming her position of comfort. For those who can’t stay upright, left-side lying is
recommended to avoid disruption in fetal oxygenation.
5. Monitor maternal vital signs and fetal heart rate every 2 hours, or depending on the doctor’s order.
6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping bed clean and dry, providing ice
chips or lip balm) to promote comfort.
7. Determine when patient last voided because a full bladder can hinder fast labor progress.
8. Institute non-pharmacological pain measures (e.g. breathing exercises, distraction method, imagery,
music therapy, etc.)

Transition Phase – starts from 8 cm cervical dilatation to 10 cm (full) cervical dilatation and full cervical effacement.
During this time, patient may be exhausted and withdrawn or aggressive and restless. Patient’s urge to push is
noticeable. Here are nursing responsibilities in this phase:

1. Inform patient on progress of her labor.

2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate every 30 minutes -1 hour, or depending on the doctor’s
order. Contraction monitoring is also continued.
4. When perineal bulging is noticeable, prepare for delivery. Check room temperature (25-280C and free of
air drafts). The nurse should also notify staff and prepare necessary supplies and equipment, including
 resuscitation machine. Lastly, perform handwashing and double gloving.

Second Stage of Labor

Starts when cervical dilatation reaches 10 cm and ends when the baby is delivered. At this stage, the patient feels an
uncontrollable urge to push. The patient may also experience temporary nausea together with increased
restlessness and shaking of extremities. The nurse at this stage must coach quality pushing and support delivery.
Nursing care for this stage are:

1. Instruct patient on quality pushing. The abdominal muscles must aid the involuntary uterine contractions
to deliver the baby out.
2. Provide a quiet environment for the patient to concentrate on bearing down.
3. Provide positive feedback as the patient pushes.
4. Repeat doctor’s instructions. At this phase, the patient barely hears the conversation around the room
because all her energy and thoughts are being directed toward giving birth.
5. Take note of the time of delivery and proceed to initiate essential newborn care. Delayed cord clamping is
recommended.
6. Assist in restrictive episiotomy for patients who had vaginal births.

Third Stage of Labor

Also known as the placental stage starts from birth of infant to delivery of placenta. It is divided into two separate
phases: placental separation and placental expulsion. Five minutes after delivery of baby, the uterus begins to
contract again, and placenta starts to separate from the contracting wall. Blood loss of 300-500 mL occurs as a
normal consequence of placental separation. Placenta sinks to the lower uterine segment or upper vagina. The
placenta is then expelled using gentle traction on the cord.

1. Coach in relaxation for delivery of placenta.

2. Congratulate on delivery of baby.
3. Encourage skin-to-skin contact to facilitate bonding and early breastfeeding.
4. Ask patient whether placenta is important to them before it is destroyed. For those who want to take it
home, ensure that they understand and follow standard infection precautions and hospital policy.
5. Administer prophylactic oxytocin as ordered.
6. Utilize controlled cord traction technique for placental expulsion.
7. Utilize absorbable synthetic suture materials (over chromic catgut) for primary repair of episiotomy or
perineal lacerations.