ANTEPARTUM

Topic 1: EMBRYONIC AND FETAL STRUCTURES

The corpus luteum in the ovary continues to function rather than atrophying under the influence of Human Chorionic
Gonadotropin or HCG.
Human Chorionic Gonadotropin (HCG)
- secreted by trophoblast cells
- causes uterine endometrium to continue to grow in thickness and vascularity instead of sloughing off in a usual
menstrual cycle.

Endometrium
- typically called as Decidua or uterine lining

3 Separate Areas:
a. Decidua Basalis - where the implantation takes place
b. Decidua Capsularis - lies like a capsule around the chorion.
c. Decidua Vera - exclusive area occupied by the implanted ovum and chorion.

Chorionic Villi
- are miniature villi resembling the fingers.
2 Covering Layers
a. Syncytiotrophoblast or Syncytial layer
On the 11th or 12th day, the chorionic villi reach out the trophoblast
cells into the uterine endometrium to begin the formation of the placenta.
b. Cytotrophoblast or Langhan's layer
- this protects the growing embryo and fetus to certain infectious
organisms.
- it disappears between the 20th and 24th week of pregnancy.
Placenta
- the Latin word for pancake
- it has:
a. Circulation
- begins on the 12th day of pregnancy where maternal blood begins to collect in
the intervillous spaces of the uterine endometrium surrounding the chorionic villi.
By the third week, the oxygen and other nutrients such as glucose, amino acids,
fatty acids, minerals, vitamins, and water osmose from maternal blood through the
cell layers of the chorionic villi into the capillaries.
b. Endocrine
- includes:
• HCG - first placental hormone produced and can be found in the blood or urine
as early as first missed menstrual period. It becomes negative 1-2 weeks after
birth. When it becomes negative, it is the proof that placental tissue is no longer
present.
• Estrogen - it produced a second of essential cells. It contributes to a woman's
mammary gland development in preparation for lactation. It stimulates uterine
growth to accommodate the growing fetus.
• Progesterone - necessary to maintain the endometrial lining of the uterus during
the hormone of
pregnancy.
women
Estrogen -

the hormone of mothers

progesterone
• Human Placental Lactogen - Human Chorionic Somatopropin or the Growth
-

Promoting Lactogenic properties produced by the placenta as early as the 6th

week of pregnancy. It promotes mammary gland in preparation for the lactation in
mothers.

SBSR
 Different Membranes:
Chorionic Membrane - the outermost fetal membrane
Amniotic Membrane - forms beneath the chorion..

Umbilical Cord
- formed from fetal membranes (amnion and chorion)
- provides circulatory pathways that connects the embryo to the chorionic
villi of the placenta.
- also transports oxygen and nutrients to the fetus from the placenta
- 53cm in length and 2cm thick.
- its bulk is gelatinous mucopolysaccharide (Wharton's jelly)

Contents:
1) veins - carrying blood from the placental villi to the fetus
2) arteries - carrying blood from the fetus back to the placental villi.

Amniotic Fluid
- constantly being formed and absorbed by direct contact with fetal surface of
the placenta
- around 800-1200ml
- its purpose is to shield the fetus against pressure or mother's abdomen.
- protects fetus in changes in temperature and aids in muscular development.

Two common problems:

1) Hydramnios - is when there is an excessive amniotic fluid move than 2000ml
2) Oligohydramnios - when there is reduction in the amount of amniotic fluid
which is less than 300ml.

Topic 2: ORIGIN AND development of organ systems

3 types of Stem cells
a. Totipotent stem cells - which cycle cells for first four days of life.
These are undifferentiated.
b. Pluripotent stem cells - it becomes an embryo. It shows
differentiation and slated to become specific body cells such as
nerve, skin, and cells.
c. Multipotent stem cells - specific and grows into a particular body
organ such as spleen, liver or brain.

Zygote Growth
• The development proceeds from cephalocaudal direction or from head to toe.
• Development continues after birth as shown by the way infants are able to lift up their heads.
Primary Germ Layers
includes:
• Ectoderm - forms the exoskeleton
• Mesoderm - develops into organs
• Endoderm - forms the inner lining of inner organs.
Cardiovascular System
- is the first body system to become functional.
From a single heart tube that forms on the 16th day of life and beats
as early as the 24th day.
It is heard through Doppler as early as 10-12 weeks of life.
The normal fetal heartbeat is 120-160 beats per minute.
Respiratory System
• The surfactant is secreted by the alveolar cells of the lungs by the
24th week of pregnancy.

The surfactant has 2 components:

• Lecithin
• Sphingomyelin

Nervous System
• the parts of the nervous system develops in the uterus and
continues to grow until 5-6 years old.
• the brain waves are detected on the 8th week.
• ear is capable to hear sounds by the 24th week.
Digestive System
• the meconium is sticky in consistency and appears black or dark green that
accumulates in the intestines by 16th week.
• the gastrointestinal tract is sterile before birth.
• vitamin K is necessary for blood clotting and is synthesized by action of bacteria
in the intestines which is non-existent in the newborn.
• after birth, it is routinary to administer vitamin K.
Musculoskeletal System
• the movement of the fetus is noticed in the 11th week through the ultrasound
• fetal movement or quickening is felt by the mother during the 20th week.
Reproductive System
• gender can be attained through chromosomal analysis by 8th week.

Urinary System
• the urine is formed during the 12th week and is excreted in the amniotic fluid by the
16th week.
• fetal urine excreted at term is 500ml per day
• oligohydramnios suggest that fetal kidneys are not functioning

Integumentary System
• the fetus is covered by a fine hair called lanugo which serves an insulation to preserve warmth in the uterus.
• a creamcheese-like substance or the vernix caseosa is important for lubrication and for keeping skin from
macerating in the uterus.
• both are present at birth.
Immune System
• the immunoglobulin G maternal antibodies cross the placenta into the fetus as early as 20th week where to give
temporary passive immunity against disease for which the mother has antibodies.
 Topic 3: ESTIMATING EDC

Estimating Expected Date of Confinement or Delivery EDC - Expected Date of Confinement

EDD - Expected Date of Delivery
1. Naegele's Rule EDB - Expected Date of Birth
- if a woman's LMP is between April to December, subtract 3 calendar LMP - Last Menstrual Period (first day)
months, add 7 days and add 1 year because the woman is expected to AOG - Age of Gestation
give birth the following year.
- or if a woman's LMP is between January to March, add 9 calendar
months, add 7 days and no need to add 1 year since the woman is
expected to give birth within the same year.
Example

Situation 1: Elena is a 26-year old primigravida who visited the Barangay Health
Center for her pre-natal check-up. Her LMP is May 10-13, 2020.

a. When is Elena's EDC? a. 5.10.20 b. M 21 >

"
iiiir c.
416T¢
I
b. What is Elena's AOG in weeks if she visits the health center today September 31-7 +
J 16 Weeks
-

30 4 months
2.17.21 J and 4 days
3, 2020?
31

A 31
c. What is Elena's AOG in months?
I
2. Mcdonald's Rule
116 days

- fundal height measurement

- the distance between the uterine fundus to the symphisis pubis
- measured in cm using a tape measure while the woman lies supine
- the measurement in cm is equal to the week of gestation between the 20th and 31st weeks of pregnancy.
- measured from the notch of the symphisis pubis to over the top of the uterine fundus.

3. Bartholomew's Rule
- this method estimates the age of gestation relative to the height of the fundus of the uterus above the symphisis pubis.
• 12 weeks - symphysis pubis
• 16 weeks - in between the symphysis pubis and the umbilicus
• 20 weeks - umbilicus
• 36 weeks - xiphoid process
• 40 weeks - 2cm below the xiphoid process

4. Johnson's Rule fundic height is 28cm

Example
-

- used to estimate the weight of the fetus in grams fetus is not engaged
-

- the standard formula is: fundic height in fundic height in Cm n ✗ K

( Iss)
-

Cm K-
constant
n x
-

L if fetus is engaged (1/2) 28 -

11 ✗ 155
if fetus is not ( Il) 155
17 ×

=
2,635g
 Topic 4: Health assessment during the first pre-natal visit
For Initial Interview:
• good interviewing technique
• establish rapport
• private, quiet setting
• caution that a first visit may be lengthy
• ask what name a woman wants you to use
• make certain she knows your name and understands your role correctly
Components of a Health History
1. Demographic Data
• you need to ask for the mother's name, age, address, telephone number, email address, religion and health insurance
information.
2. Chief Concern
• what is the main reason why the woman came to the health care setting?
3. History of Past Illness
• this past condition can become active during or immediately following pregnancy
4. History of Family Illness
• this can help identify potential problems in a woman during pregnancy or in her infant at birth.
5. Day History/Social Profile
• ask for the information about a woman's current nutrition, elimination, sleep, recreation and interpersonal interactions that
can be elicited by asking a woman to describe a typical day in her life.
6. Gynecologic History
• obtain information about her age of menarche, usual menstrual cycle, their past reproductive surgery, or if using
reproductive planning methods.
7. Obstetric History
- is done by determining the ff terms:
PARA
- number of pregnancies that have reached viability, regardless of whether the infants were born alive.
GRAVIDA
- woman who is or has been pregnant
PRIMIGRAVIDA
- woman who is pregnant for the first time
PRIMIPARA
- woman who has given birth to one child past the age of viability
MULTIGRAVIDA
- woman who has been pregnant previously
NULLIGRAVIDA
- woman who has never been and is not currently pregnant

Classifying Pregnancy Status

GRAVIDA - the number of pregnancies

TERM - the number of full-term infants born (born 37 weeks or after
PRETERM - the number of pre-term infants born (born before 37 weeks of gestation)
ABORTION - a number of spontaneous miscarriages or therapeutic abortion
LIVEBIRTHS - number of living children
MULTIPLE PREGNANCIES - if mother has twins, triplets or etc.

Example: A woman who had two previous pregnancies, has given birth to two term children and is again pregnant.

G P (T P A L M)
§ live births
 TOPIC 5: normal changes during pregnancy

Signs and Symptoms of Pregnancy

Presumptive Signs
- signs and symptoms or sensations that while possibly indicating pregnancy could also be a cause by any number of conditions.
Examples; amenorrhea, nausea and vomiting, frequent urination, breast tenderness, quickening, skin changes, fatigue

Probable Signs
- most all of the time, this indicates pregnancy but in certain cases, they might be false or caused by another condition.
Examples: abdominal enlargement, hegar's sign, goodelle's sign, chadwick's sign, braxton hicks contractions, positive pregnancy
test, and ballotement.

Positive Signs
- indicate that the woman is already pregnant
Includes: fetal heartbeat and the visualization of the fetus

Reproductive Changes

a) Uterine Changes
• increase in the size of the uterus
• fundal height changes
• hegar's sign - softening of the cervix
• balottement - a technique in palpating to check for pregnancy
• Braxton hicks contractions - false labor contractions
• amenorrhea - absence of menstruation

b) Cervical Changes
• operculum - it feels and seals the cervical canal during pregnancy. formed by a small amount of cervical mucus.
• goodell's sign - significant softening of the vaginal portion of the cervix

c) Vaginal Changes
• Chadwick's sign - bluish discoloration of the cervix, vagina and labia (observed as early as 6-8 weeks after conception)

d) Changes in the breasts

- feeling of fullness, tingling or tenderness
- most likely at 16th week of pregnancy, colostrum may already be excreted from the breast

Systemic Changes

Integumentary System
• striae gravidarum - stretch marks
• diastasis - the partial or complete separation of the rectus abdominus to accommodate the growing fetus
• linea nigra - a line that extends from the symphysis pubis to the umbilicus
• melasma - mast of pregnancy. a brownish hyperpigmentation of the skin over the cheeks, nose and forehead
• vascular spiders - pinkish red diffuse mottling on the palms of hands
• palmar erythema

Respiratory Changes
- most likely the mother will experience toughness of the nasopharynx or shortness of breath.
 Cardiovascular Changes
• blood loss for normal vaginal birth is around 300-400ml
• cs or caesarean birth would be around 800-1000ml
• the fetus requires a total amount of 350-400 milligrams of iron to grow
• encourage women to eat foods that are high in folic acid

Gastrointestinal Changes
• the first sensation a woman may experience during pregnancy is the nausea or vomiting

Urinary Changes
• increased urinary frequency during the first 3 months of pregnancy and at the end of pregnancy is expected

Skeletal Changes
• lordosis - pride of pregnancy
• there is gradual softening of a woman's pelvic ligaments and joints to create pliability and to facilitate passage
of the baby throughout the pelvis

Endocrine Changes
• the placenta is an additional endocrine hormone during pregnancy

Weight Gain
• it is expected that the mother will gain around 2-4 pounds during the first trimester
•. 11-12 pounds during the second and third trimester
• a total of 25-35 pounds during the span of pregnancy
• a double in weight gain every month could indicate that the mother is having multiple pregnancy or other conditions

TOPIC 6: Discomforts of pregnancy

Discomforts of Early Pregnancy

a) Breast Tenderness - the first symptom noticed in early pregnancy

b) Palmar Erythema- caused by increased estrogen levels. this disappears after adjustments to levels of estrogen
c) Constipation - slowed peristalsis due to growing fetus that pressess against the bowel
d) Nausea and vomiting
e) Fatigue - due to the increased metabolic requirements
f) Muscle cramps - relieved when woman lies on her back momentarily and extends involved leg while keeping the knee
straight and dorsiflexes foot until pain disappears or elevating lower extremities frequently during the day to improve
circulation
g) Supine Hypotension - a symptom that occurs when a woman is on her back, and the uterus presses on the vena cava
impairing blood.
Signs and Symptoms: irregular heartbeat and feeling of apprehension
h) Varicosities - common in pregnancy becausethe weight of the distended uterus puts pressure on the veins returning blood
from the lower extremities
i) Hemorrhoids - happens because of pressure on the veins from the bulk of growing fetus
j) Heart Palpitations - a bounding palpitation of the heart and sudden movement
k) Frequent urination - occurs in early pregnancy because of the pressure of the growing uterus on the anterior bladder
l) Abdominal Discomfort - standing with crossed arms above the abdomen relieves the discomfort
m) Leukorrhea - whitish vaginal discharge or an increase in the amount of normal vaginal secretions in response to increased
estrogen levels.
Discomforts of Middle to Late Pregnancy

a) Backache - lumbar lordosis develops and postural changes necessary to maintain balance leads to backache.
b) Headache - due to expanding blood volume.
* a continuous sharp headache may be a dangerous sign of high blood pressure.
c) Dyspnea - difficulty of breathing is brought about by expanding uterus which places pressure on the diaphragm
d) Ankle Edema - swelling of the ankles and feet caused by general fluid retention and reduced blood circulation in the
lower extremities because of the uterine pressure.
e) Braxton Hicks Contractions - the uterus periodically contracts and relaxes at around 8-12 weeks.

TOPIC 7: PERINeal and abdominal exercises

1) Tailor Sitting
- it stretches perineal muscles without occluding blood supply to the lower legs
- can be done within 15 mins

2) Squatting
- it can be a useful position for second stage of labor
- can strengthen the body and prepare it for labor and birth
- can be done 15 mins everyday

3) Pelvic Floor Contractions

- commonly known as Kegel's exercise
- can tighten muscles of perineum
- can be helpful during postpartum period to reduce pain and promote perineal
healing

4) Abdominal Muscle Contractions

- this can help strengthen abdominal muscles during pregnancy
- help prevent constipation and help restore abdominal tone after pregnancy
- can be done in standing or lying position along with pelvic floor contractions
• a woman merely tightens her abdominal muscles then relaxes them

5) Pelvic Rocking
- helps relieve backache during pregnancy and early labor by making the lumbar spine
more flexible
 INTRAPARTUM

Theories of Labor Onset Psychological Responses of a Woman to Labor

1) Uterine Stretching 1) Fatigue
2) Pressure on the Cervix 2) Fear
3) Oxytocin Stimulation 3) Cultural influences
4) Change in the ratio of estrogen to progesterone
5) Placental age
6) Rising fetal cortisol levels Psychologic Effects of Labor to a Fetus
7) Fetal membranes production of prostaglandin 1) Neurologic System
2) Cardiovascular system
3) Integumentary system
Signs of Labor 4) Musculoskeletal system
5) Respiratory system
Preliminary Signs of Labor
1) Lightening
2) Increase in level of activity Physiologic Effects of Labor on a Woman
3) Slight loss of weight 1) Cardiovascular System
4) Braxton Hicks Contractions 2) Hemopoietic System
5) Ripening of the Cervix 3) Respiratory system
4) Temperature regulation
Signs of True Labor 5) Fluid balance
1) Uterine Contractions 6) Urinary system
2) Show 7) Musculoskeletal system
3) Rupture of the Membranes 8) Gastrointestinal system
9) Neurologic and Sensory response

Components of Labor

A successful labor depends on 4 integrated concepts.

1) Passage or the woman's pelvis is at adequate size

2) Passenger or the fetus is of appropriate size and in advantageous position and presentation
3) Powers of Labor or the Uterine Factors are adequate.
- the powers of labor are strongly influenced by the woman's position during labor
4) A woman's psychological outlook is preserved so that afterwards, labor can be viewed as a positive experience.
PASSAGE
- refers to the route a fetus must travel from the uterus to
the cervix and vagina to the external perineum.

Two important pelvic measurements:

- to determine the adequacy of the pelvic size
1) Diagonal Conjugate or the Anterior Posterior diameter of
the inlet
2) Transverse Diameter of the outlet

Subdivisions of true pelvis:

a) inlet
b) midpelvis
c) outlet

Different types of pelvis

a) gynecoid
- female pelvis
- has an inlet that is well rounded forward and backward and
a wide pubic arc
- this type is ideal for childbirth
b) android
- male pelvis
- the pubic arc forms an acute angle making the lower
dimensions of the pelvis extremely narrow
- a fetus may have difficulty exiting from this type of pelvis
c) platypelloid
- flattened pelvis
- as a smoothly curved oval inlet, but the anterior posterior
diameter is shallow
- a fetal head might not be able to rotate to match the
curves of the pelvic cavity in this tyoe of pelvis
d) anthropoid
-the transverse diameter is narrow and the anterioposterior
diameter of the inlet is larger than normal
- this structure does not accommodate a fetal head as well as
gynecoid pelvis.
PASSENGER
- the fetus
• the body part of the fetus that has the widest diameter is the head. This is the part least likely to be able to
pass through the pelvic ring.
• whether a fetal skull can pass depends on both its structure and its alignment with the pelvis

Structure of the Fetal Skull: Fontanelles

1) Anterior Fontanelle
- sometimes referred to as the bregma
- lies at the junction of the coronal and sagittal sutures
- diamond in shape, and closes when the infant is 12-15 months of age
2) Posterior Fontanelle
- lies at the junction of lambdoidal and sagittal sutures
- triangular in shape, and closes when an infant is about 2 months of age

Molding
- a change in the shape of the fetal skull produced by the force of uterine
contractions pressing the vertex of the head against the not yet dilated cervix
- commonly seen in infants just after birth
- only last a day or two and is not a permanent condition
• no skull molding occurs when a fetus is breech

Other factors play a part in whether a fetus is lined up in the best position to
be born

Fetal Presentation and Position

1. Attitude
- describes the degree of flexion a fetus assumes during labor or the relation
of the fetal parts to each other.
• a fetus in good attitude is in complete flexion.
- the spinal column is bowed forward, the head is flexed forward, so much
that the chin touches the sternum. the arms are flexed and folded on the
chest, the thighs are flexed unto their abdomen and the calves are pressed
against the posterior aspect of the thighs. this normal fetal presentation is
advantageous for birth because it helps a fetus present the smallest
anteroposterior diameter of the skull to the pelvis.
• moderate flexion - if the chin is not touching the chest but it is in alert or
military position
• partial or poor extension - it presents the brow of the head of the birth
canal.
• if the fetus is in complete extension, the back is arc, and the neck is
extended presenting the occipitomental diameter of the head to the birth canal
or face presentation.
2. Engagement
- the settling of the presenting part of the fetus far enough into the
pelvis to be at the level of the ischial spine (a midpoint of the pelvis). the
degree of engagement is assessed by vaginal and cervical examination. a
presenting part that is not engaged is said to be floating. one that is
descending but has not yet reached the ischial spine is said to be
deeping.
3. Station
- the relationship of the presenting part of a fetus to the level of ischial
spines. when the presenting fetal part is at the level of the ischial spine,
it is at a zero station or synonymous with engagement.

4. Fetal Lie
- the relationship between the long cephalocaudal axis of the fetal body and the long
cephalocaudal axis of a woman's body. in others words, whether the fetus is lying in a
horizontal or transverse, or a vertical or longitudinal position. approximately, 99% of
the fetuses assume a longitudinal lie.

Longitudinal lie - are further classified as cephalic which means the head will be the
first part to contact the cervix.
Breech - with the buttocks as the first position to contact the cervix.

Types of Fetal Presentation

Fetal Presentation - denotes a body part that will first contact the cervix or be born
first. this is determined by combination of fetal lie and the degree of fetal flexion or
the attitude.

1. Cephalic - most frequent type of presentation occurring as often as 95% of the

time. the fetal head is the body part that will first contact the cervix.
4 types of cephalic presentation:
• vertex - ideal presenting part
• brow
• face
• mentum

2. Breech - means that either the buttocks or the feet are the first body parts that
will contact the cervix. it can be difficult birth with the presenting point influencing
the degree of difficulty.
3 types of breech presentation:
• complete
• frank
• footling

3. Shoulder - in a transverse lie, a fetus lies horizontally in the pelvis so that the
longest fetal access is perpendicular to that of the mother. the presenting part is
usually one of the shoulders or the acromion process, an iliac crest, a hand, or an
elbow.
 Types of Fetal Position

Position - the relationship of the presenting part to a specific quadrant of a woman's pelvis.
For convenience, the maternal pelvis is divided into 4 quadrants according to the mother's right
and left:
1) Right anterior
2) Left anterior
3) Right posterior
4) Left posterior

4 parts of the fetus have been chosen as landmarks to describe the relationship of the
presenting part to one of the pelvic quadrants:
1) Vertex position: Occiput
2) Face presentation: Chin or mentum
3) Breech presentation: sacrum
4) Shoulder presentation: scapula or acromion process

Positions indicated by abbreviations of three letters

a) First letter - defines whether the landmark is pointing to thr mother's left or right
b) Middle letter - denotes the fetal landmark
c) Last letter - defines whether the landmark points anteriorly or posteriorly
Mechanisms of Labor (Cardinal Movements)
1) Descent
2) Flexion
3) Internal Rotation
4) Extension
5) External Rotation
6) Expulsion
POWERS OF LABOR
- force supplied by the fundus of the uterus implemented by uterine contractions and
natural process that causes cervical dilatation and then expulsion of fetus from the uterus.
after full dilatation of the cervix, the primary power is supplemented by the use of the
abdominal muscles.

1. Uterine Contractions
- the mark of effective uterine contractions is rhythmicity and progressive lengthening and
intensity.
2. Cervical Changes
- even more mark than the changes in the body of the uterus are two changes that occur
in the cervix:
a) Effacement - shortening and thinning of the cervical canal. normally, the canal is
approximately 1-2cm long. the canal virtually disappears. this occurs because of longitudinal
contractions from the contracting uterine fundus.
b) Dilatation- the enlargement or widening of the cervical canal from an opening a few
millimeters wide to one large enough approximately 10cm to permit the passage of a fetus.

PSYCHE
- the psychological state or feelings that a woman brings to labor. For many women, this is a feeling of apprehension
or fright. for almost everyone, it includes a sense of excitement or awe. women who manage best in labor are typically
those strong sense of self-esteem and a meaningful support person within.