NCM 107j - Maternal

Review of Anatomy & Physiology of Human Reproductive System

Anatomy and Physiology of the Reproductive System

Study of the female reproductive organs is called

GYNECOLOGY
Study of the male reproductive organs is called
ANDROLOGY
Male Reproductive System
Gonads
Primary sex organs
Testes (males)
Ovaries (females)
Body organs that produces sex cells (gametes)
Sperm – male gametes
Ova (eggs) – female gametes
Secrete hormone

External Structures (Male)

Testes
Penis

TESTES
2 ovoid glands
2-3cm wide
scrotum (rugated, skin-covered, muscular pouch)
Supports testes and help regulate temp. of sperm

PENIS
Tubular organ that surrounds the latter part of the urethra
Purposes:
Outlet of urine
Delivers sperm into the female reproductive system

Regions of the Penis:

Shaft
Glans penis (enlarged tip)
Prepuce (foreskin)
Folded cuff of skin around proximal end
Often removed by circumcision

3 cylindrical masses of erectile tissue in the shaft:

2 corpus cavernosa
Corpus spongiosum
Normally not filled with much blood
Sexual excitement
Sexual Excitement
 Nitric oxide released from blood vessels
Dilatation of blood vessels and in blood flow to the arteries of the penis (engorgement)
Penis becomes longer, wider and rigid (erection)

Male Internal Structures

Epididymis
Vas deferens (ductus deferens)
Seminal vesicles
Ejaculatory ducts
Prostate gland
Urethra
Bulbourethral glands

EPIDIDYMIS
Coiled tube approx. 20 ft. long
Found on the superior part of the testis and along the posterior lateral side
Functions to store and mature sperm cells
10 – 20 days to travel epididymis
64 days to reach maturity

EPIDIDYMIS
Expels sperm with the contraction of muscles in the epididymis walls to the vas deferens

DUCTUS (VAS) DEFERENS

Hollow tube surrounded by arteries and veins and protected by thick fibrous coating
Carries sperm from the epididymis into the abdominal cavity seminal vesicles and ejaculatory
ducts (thru peristalsis)

DUCTUS (VAS) DEFERENS

Sperm mature as they pass thru the vas deferens
Spermatic cord – blood vessels and vas deferens together
Ends in the ejaculatory duct w/c unites with the urethra

Vasectomy – cutting of vas deferens @ the level of the testes to prevent transport of sperm; male birth
control

URETHRA
Extends from the base of the urinary bladder to the tip of the penis
Carries both urine and sperm
Approx. 8 inches (18 – 20 cm)

SEMINAL VESICLES
2 convoluted pouches along the base of the bladder
SEMINAL VESICLES
Secrete 60% semen that is viscous (thick), yellowish
Basic sugar (fructose)
Protein
Prostaglandins
Other substances that nourish and activate sperm

PROSTATE GLAND
Chestnut – sized gland
Encircles the upper part of the urethra
Secretes a thin, alkaline fluid
When added to the secretion from seminal vesicles and sperm – protects sperm from being immobilized

BULBOURETHRAL GLANDS
Cowper’s glands
Lie beside the prostate gland and empty by short ducts into the urethra

BULBOURETHRAL GLANDS
Secretes thick, clear, alkaline fluid
Cleanses urethra of acidic urine
Ensure safe passage of sperm
Serves as lubricant during sexual intercourse

Semen
Milky mixture of sperm and accessory gland secretions
Alkaline – pH 7.2 – 7.6 – helps neutralize acidic environment of the vagina (pH 3.5 – 4)
Contains seminal plasmin – inhibits bacterial multiplication
Relaxin and enzymes – enhance sperm motility
2 – 5 mL semen propelled out
50 – 130 million sperm/mL

Female Reproductive System

External Genitalia
Vulva (Latin – covering)
Mons veneris, labia minora, labia majora
Vestibule, clitoris, Skene’s glands, fourchette, hymen

Mons pubis
Pad of adipose tissue located over the symphysis pubis
Covered by pubic hair
Protect the junction of pubic bone from trauma

Labia Minora
Hairless folds of connective tissue

Majora
Pubic hair
Protect external genitalia and distal urethra and vagina
Other external organs
Vestibule
Flattened smooth surface inside the labia
Urethra and Vagina both arise here

Clitoris
1 – 2 cm, rounded organ of erectile tissue
Covered by a fold of skin (prepuce)
Sensitive to touch and temp; center of sexual arousal and orgasm in female

Skene’s glands
Paraurethral glands
Located lateral to the urinary meatus, one on each side
Bartholin’s glands (vulvovaginal)
Lateral to vaginal opening on both sides
Secretions from both help lubricate external genitalia during coitus
Alkaline pH improve sperm survival in the vagina

Fourchette
Ridge of tissue formed by the posterior joining of the labia minora and majora
Structure that is sometimes cut during childbirth to enlarge vaginal opening (episiotomy)

Hymen
Tough but elastic semi-circle of tissue that covers the opening to the vagina in childhood
Often torn during the time of 1st intercourse
Use of tampons
Active sports

Internal Structures
Ovaries
Fallopian tubes
Uterus
Vagina

OVARIES
4cm long, 2cm diameter, 1.5cm thick (size and shape of almonds)
Grayish-white and appears pitted (w/ indentations on the surface)
Composed of ovarian follicles (sac-like structures)
structures: oocyte (immature ova), follicular cells
Ovarian Follicle stages:
Primary follicle – contains an immature oocyte
Graafian (vesicular) follicle – growing follicle with a maturing oocyte
Ovulation – when the egg is mature follicle ruptures
Occurs about every 28 days
Ruptured follicle is transformed into a corpus luteum

Functions of the 2 ovaries:

To produce, mature, and to discharge ova (egg cells)
In the process, produces estrogen and progesterone – initiate and regulate menstrual cycles

NO ESTROGEN:
breasts prevented from maturing @ puberty
Menopause – uterus, breast, ovaries will atrophy

Ovarian fxn necessary for maturation and maintenance of 2ndary sex characteristics
Ovaries
Suspended @ the end of the fallopian tubes by 3 strong supporting ligaments attached to the uterus or
pelvic wall
Suspensory ligaments – secure ovaries to lateral walls of the pelvis
Ovarian ligaments – attach to uterus
Broad ligament – a fold of the peritoneum, encloses suspensory ligament

FALLOPIAN TUBES
Smooth, hollow tunnel
Approx. 10 cm in length (Adult)

Fxn:
To convey the ovum from the ovaries to the uterus
Provide a place for fertilization of the ovum by the sperm

4 separate portions:
Interstitial portion – lies w/in the uterus; 1 cm long; lumen is 1 mm in diameter
Isthmus – 2 cm long; portion that is cut or sealed in tubal ligation;
Ampulla – longest – 5 cm long; portion where fertilization occurs
Infundibulum – most distal segment; 2 cm long; funnel-shaped; rim is covered by fimbriae (small
hairs)

Cilia inside the uterine tube slowly move the oocyte towards the uterus (takes 3 – 4 days)

UTERUS
Hollow, muscular, pear-shaped organ
Located between urinary bladder and rectum

Functions of the Uterus:

Receive the ovum from the fallopian tube
Provide a place for implantation and nourishment during fetal growth
Furnish protection to a growing fetus
At maturity of the fetus, expel it from a woman’s body
Regions of the Uterus:
Body (corpus) – main portion; expands to contain growing fetus

Fundus – can be palpated abdominally to determine:

the amt. of uterine growth occurring during pregnancy
to measure the force of uterine contractions during labor
To assess that the uterus is returning to its nonpregnant state after childbirth

Isthmus – enlarges during pregnancy to accommodate growing fetus; portion commonly cut during
C/S

Cervix – lowest portion; 1/3 of the total uterus size; narrow outlet that protrudes into the vagina
Opening – internal cervical os
Distal opening to the vagina – external os
Level of external os - @ the level of the ischial spines (impt. rel. in estimating the level of the fetus in the
birth canal)

Uterine coats/walls:
Endometrium
inner layer
Important for menstrual function
allows for implantation of fertilized egg
Sloughs off if no pregnancy occurs (menstruation)

Uterine coats/walls:
Myometrium
Middle layer of smooth muscle
Constricts tubal junctions preventing regurgitation of menstrual blood into the tubes
Holds internal cervical os closed during pregnancy to prevent preterm birth
Portion where myomas and benign uterine tumors arise

Perimetrium
Outermost layer
Adds strength and support to the uterus

Uterine Deviations
A number of uterine deviations – shape and position – may interfere with fertility or pregnancy
Bicornuate uterus – oddly shaped “horns” @ the junction of the fallopian tubes
Septum Dividing uterus
Double uterus
May decrease ability to conceive and carry fetus to term
Less placenta implantation space

Positional Deviations of the Uterus

Normally uterus is tipped slightly forward
Anteversion – fundus tipped forward
Retroversion – fundus tipped back
Anteflexion – body of uterus bent sharply forward
Retroflexion – body bent sharply back just above cervix
VAGINA
Hollow, musculomembranous canal
Located behind (posterior) the bladder and in front (anterior)of rectum
Extends from the cervix of the uterus to the external vulva

Functions of the vagina:

Acts as an organ of intercourse
Conveys sperm to the cervix so sperm can meet w/ the ovum in the fallopian tube
Serves as birth canal

PELVIS
Serves to support and protect the reproductive and other pelvic organs
Bony ring formed by 4 united bones:
Innominate bones (flaring hip)
Coccyx
Sacrum

3 divisions of the innominate bones:

Ilium – forms the upper and lateral portion
Ischium – inferior portion
2 projections:
Ischial tuberosities – portion on w/c a person sits
Ischial spines – small projections that extend from the lateral aspects into the pelvic cavity; midpt. of pelvis

3 divisions of the innominate bones:

Pubis – anterior portion of the innominate bone
Symphysis pubis – is the junction of the innominate bones at the front of the pelvis

PELVIS
Sacrum – upper portion of the pelvic ring
Coccyx – below the sacrum; composed of 5 very small bones fused together
Stiff, w/ a degree of movement – permits coccyx to be pressed backward, allowing more room for the
fetal head to pass during childbirth

Obstetric division of Pelvis:

False pelvis – superior half
Supports the uterus during late months of pregnancy
Aids in directing fetus into the true pelvis for birth

True pelvis – inferior half

Pelvic inlet – entrance to the true pelvis or upper ring of bone thru w/c fetus must pass to be born
vaginally; heart-shaped
Pelvic outlet – portion bounded in the back by the coccyx, side by the ischial tuberosities, front by the
inferior aspect of the symphysis pubis

Pelvic cavity – space bet. the inlet and the outlet; curved passage
The curve slows and controls the speed of birth – reducing sudden pressure changes in the fetal head
Compresses chest of fetus – helping expel lung fluid and mucus to prepare lungs for good aeration at birth

For a baby to be delivered vaginally – pass thru the inlet, cavity, and the outlet
 NCM 107j
Human Sexuality

SEXUALITY
A multidimensional phenomenon that includes feelings, attitudes, and actions
Sexuality has always been a part of human life
Feelings and attitudes about SEX vary widely
Has both biologic and cultural components
It encompasses and gives direction to a person’s physical, emotional, social, and intellectual responses
throughout life
Each person is born a sexual being

Gender
Biologic gender – term used to denote a person’s chromosomal sex
Male – XY
Female – XX

Gender (sexual) identity – inner sense a person has of being male or female (may be the same as or different
from biologic gender)

Gender role – male or female behavior a person exhibits

Sexual Response Cycle

Sexual experience is unique to each individual
But sexual physiology (how the body responds to sexual arousal) has common features:

Sexual Response Cycle (Masters and Johnson)

EXCITEMENT
PLATEAU
ORGASM
RESOLUTION

EXCITEMENT
Physical and psychological stimulation (sight, sound, emotion, or thought)
Causing parasympathetic nerve stimulation
Leads to arterial dilatation and venous constriction in the genital area
blood supply to genital area vasocongestion and ing muscular tension
WOMEN:
Clitoris in size
Mucoid fluid appear on vaginal walls as lubrication
Vagina widens in diameter, es in length
Nipples become erect
MEN:
Penile erection
Scrotal thickening and elevation of testes
Both: ed heart and respiratory rates
PLATEAU
Reached just before orgasm
WOMEN:
Clitoris drawn forward, retracts under the clitoral prepuce
Lower part of vagina becomes extremely congested (formation of orgasmic platform)
ed nipple elevation

MEN:
Vasocongestion = full distention of penis
Heart rate es to 100 – 175 beats/min
RR: 40 breaths/min

ORGASM
Occurs when stimulation proceeds thru the plateau stage to a point @ w/c the body suddenly discharges
accumulated sexual tension
Vigorous contraction of muscles in the pelvic area expels or dissipates blood and fluid from the area of
congestion
WOMEN:
18 – 15 contractions @ intervals of one every 0.8 seconds
MEN:
Muscle contractions surrounding seminal vessels and prostate project semen into the
proximal urethra
Followed immediately by 3 – 7 propulsive ejaculatory contractions, same time interval as in
the woman, forcing semen from penis
Shortest stage in he sexual response cycle
Experienced as intense pleasure affecting the whole body (not just pelvic area)
Highly personal experience:
Descriptions of orgasm vary greatly from person to person

RESOLUTION
Period during w/c the external and internal genital organs return to an unaroused state
Women don’t go thru refractory period – possible for women who are interested and properly stimulated –
have additional orgasms after the first
Usually takes 30 minutes for both men and women

Freud identified 2 types of female orgasms:

Clitoral – originating from masturbation or other noncoital acts; sexual immaturity
Vaginal – said to be authentic; mature form of sexual behavior in women

Controversies about Female Orgasm

Freud: women are neurotic if they did not achieve orgasm thru intercourse
Masters (1998):no physiological difference bet. orgasm thru intercourse or thru clitoral stimulation
Most women – adequate time for foreplay is essential for them to be orgasmic
Existence or Not of the “G spot”
1st described by German physician Gräfenberg (1950)
Presumably located on the inner portion of the vaginal wall, halfway between the pubic bone and the cervix
Promoted as an area of heightened erotic sensitivity
Several studies carried out in the past 10 years – have not been able to verify existence of “G spot”
Altho’ some women do claim to possess such an erotic trigger

Influence of the Menstrual Cycle on Sexual Response

nd
During 2 half of the menstrual cycle – Luteal Phase – there is ed fluid retention and vasoconstriction in
the woman’s lower pelvis
Because some vasocongestion is already present at the beginning of the excitement stage – women appear to
reach the plateau stage more quickly and achieve orgasm more readily during this time
Women seem to be more interested in initiating sexual relations during this time

Influence of Pregnancy on Sexual Response

Pregnancy = also w/ vasocongestion of the lower pelvis – due to the rapidly growing fetus
Some women – 1st orgasm during their 1st pregnancy – growing fetus
After a pregnancy – many women – experience ed sexual interest – because the new growth of blood
vessels during pregnancy lasts for some time and continues to facilitate pelvic congestion
Women need to be free of myths and misconceptions – notion that orgasm will cause spontaneous
miscarriage
Some women – w/ ed breast engorgement that accompanies pregnancy = extreme breast sensitivity during
coitus
Foreplay that includes sucking or massaging of the breasts may cause release of oxytocin
Tho’ not contraindicated unless the woman has a hx of premature labor

SEXUAL ORIENTATION
Sexual gratification is experienced in a number of ways
What is considered normal varies greatly among cultures

General components of accepted sexual activity include:

Privacy
Consent
Lack of force
Most of our value systems are closely aligned to the cultural norm

TYPES of SEXUAL ORIENTATION

HETEROSEXUALITY
Heterosexual – one who finds fulfillment with a member of the opposite gender

HOMOSEXUALITY
Homosexual – a person who finds sexual fulfillment with a member of his or her own sex
“Gay”
Lesbian – homosexual woman
 They say it’s genetically determined or develops because of the effect of an abnormal level of estrogen or
testosterone in utero is ing
Homophobia – refusal to associate w/ homosexual; fear of homosexuals

BISEXUALITY
Achieve sexual satisfaction from both homosexual and heterosexual relationships

TRANSSEXUALITY
Transsexual or transgender
An individual who although of one biologic gender, feels as if he or she should be of the opposite gender
Some may have sex change operations – to appear cosmetically as the sex they envision themelves to be

TYPES of SEXUAL EXPRESSION

CELIBACY
Abstinence from sexual activity
Avowed state of certain religious orders
Way of life for many adults
Theoretical advantage: ability to concentrate on means of giving and receiving love other than thru sexual
expression

MASTURBATION
Self-stimulation for erotic pleasure
Can be mutually enjoyable activity for sexual partners
Offers sexual release – may be interpreted by the person as overall tension or anxiety relief
Masters (1998) – reported that women may find masturbation to orgasm the most satisfying sexual
expression = use it more commonly than men
Children 2 – 6 years – discover it as an enjoyable activity – explore their bodies

EROTIC STIMULATION
Use of visual materials such as magazines or photographs for sexual arousal
Thought to be mostly a male phenomenon - ing interest in women

FETISHISM
Sexual arousal resulting from the use of certain objects or situations
Leather, rubber, shoes, feet, underwear – perceived to have erotic qualities
Object of stimulation does not enhance the experience – rather, it becomes a focus of arousal
Person may come to require the object for stimulation

TRANSVESTISM
Transvestite – individual who dresses to take the role of the opposite sex
Can be heterosexual, homosexual or bisexual; married hetero
Keeps it a secret from friends, neighbors
VOYEURISM
Obtaining sexual arousal by looking at another person’s body
Sexually provocative movies – media
Reflects great insecurity or the inability to feel confident enough to relate to others on more personal levels

SADOMASOCHISM
Involves inflicting pain (sadism) or receiving pain (masochism) to achieve sexual satisfaction
Considered normal as long as pain involved is minimal and the experience satisfying to both sexual partners
Autoerotic asphyxia – extreme practice of causing oxygen deficiency (usually by hanging) during
masturbation – goal is to produce a feeling of extreme sexual excitement – may be fatal
Victims usually adolescents

Other Types of Sexual Expression

Exhibitionism – revealing one’s genitals in public
Pedophiles – individuals interested in sexual encounters w/ children; sex offenders
Bestiality – sexual intercourse with animals
Obscene phone calling

Sexual Harassment
Unwanted, repeated sexual advances, remarks, or behavior toward another that:
Is offensive to the recipient
Interferes w/ job performance
Can involve actions like a job superior demanding sexual favors or giving or sending sexist jokes to a
person he or she supervises
Rules apply to same – gender as well as opposite – gender harassment

Disorders of Sexual Functioning

Can be lifelong (primary) or acquired (secondary)
Can have psychogenic origin (produced by psychic rather than organic factors), biogenic (produced by
biologic processes), or both
Disorders of Sexual Functioning

Erectile dysfunction (ED)

Formerly impotence, is the inability of a man to produce or maintain an erection long enough for vaginal
penetration or partner satisfaction
Causes:
Physical: aging, atherosclerosis, or diabetes
OTHER Causes:
Side effect of certain drugs
Debilitating disease – DM
Psychological: stress, depression, anxiety
Premature Ejaculation
Ejaculation before penile-vaginal contact
Often used to mean ejaculation before the sexual partner’s satisfaction
can be unsatisfactory and frustrating for both partners

Psychological – masturbation, doubt about masculinity, fear of impregnating the woman

Pain Disorders
Reproductive system has a sensitive nerve supply
When pain occurs in response to sexual activities = can be acute and severe and impair a person’s ability to
enjoy the sexual contact

Vaginismus
Involuntary contraction of the muscles @ the outlet of the vagina when coitus is attempted
Prohibiting penile penetration
May occur to rape victims
Can be a result of early learning patterns in w/c sexual relations were viewed as bad or sinful

Dyspareunia/Vestibulitis
Pain during coitus
Vestibulitis – inflammation of the vestibule
Can occur due to:
endometriosis (abnormal placement of endometrial tissue)
vaginal infection,
hormonal changes – menopause causing vaginal drying
psychological
 1
Menstruation
MENSTRUAL CYCLE – also termed as female reproductive cycle; defined as episodic uterine bleeding in
response to cyclic hormonal changes
The process that allows for conception and implantation of a new life
PURPOSE OF MENSTRUAL CYCLE: to bring an ovum to maturity and renew a uterine tissue bed that will
be responsible for its growth should it be fertilized

MENARCHE – 1st menstrual period in girls; may occur as early as age 8 or 9, or as late as age 17 and still be
within normal limits

Good to include health teaching information on menstruation to both girls and their parents as early as
4th grade as part of routine care
Length of menstrual cycles differs from woman to woman – accepted average length is 28 days (from the
beginning of one menstrual flow to the beginning of the next)
Not unusual for cycles to be as short as 23 days or as long as 35 days
Length of the average menstrual flow (menses): 4 – 6 days; short – 2 days; long – 7 days
Amount of menstrual flow: difficult to estimate; average 30 – 80 mL per menstrual period; saturating
pad or tampon in less than an hour is heavy bleeding
Color: dark red; a combination of blood, mucus, and endometrial cells

PHYSIOLOGY OF MENSTRUATION
4 body structures involved in the physiology of the menstrual cycle:
1. HYPOTHALAMUS
2. PITUITARY GLAND ALL 4 STRUCTURES MUST CONTRIBUTE THEIR PART FOR A MENSTRUAL CYCLE TO BE
3. OVARIES COMPLETE; inactivity of any part results in an incomplete or ineffective cycle
4. UTERUS

HYPOTHALAMUS
There are 5 hormones released from the hypothalamus that have an effect on the menstrual cycle:
1. Gonadotrophin Releasing Hormone (GnRH) also called luteinizing hormone – releasing
hormone)
2. Thyrotropin Releasing Hormone (TRH)
3. Somatotropin Release – Inhibitory Factor (SRIF)
4. Corticotrophin Releasing Hormone (CRF)
5. Prolactin Release – Inhibiting Hormone (PIF)

GNRH – release by the hypothalamus initiates the menstrual cycle

transmitted from the hypothalamus to the anterior pituitary gland = signals the gland to begin
producing the gonadotropic hormones follicle stimulating hormone (FSH) and leuteinizing
hormone (LH)
ed level of estrogen (produced by the ovaries) = repressed release of GnRH
GnRH production is cyclic = menstrual periods also cycle
Diseases of the hypothalamus = deficiency of GnRH = delayed puberty
Diseases causing early activation of GnRH = abnormally early sexual development or precocious
puberty
 2
PITUITARY GLAND
Under the influence of the GnRH, the anterior lobe of the pituitary gland produces 2 hormones
that act on the ovaries to further influence the menstrual cycle:
1. FSH – active early in the cycle; responsible for maturation of the ovum
2. LH – becomes most active @ the midpoint of the cycle; responsible for ovulation (release of
mature egg from the ovary), and growth of the uterine lining during 2nd half of the menstrual
cycle
FSH and LH are called gonadotropic hormones because they cause growth (trophy) in the gonads
(ovaries)

OVARY
Every month during the fertile period of a woman’s life (menarche – menopause), one of the
ovary’s primordial follicles is activated by FSH to begin to grow and mature
As it grows, its cells produce a clear fluid (follicular fluid) – contains high content of estrogen
(mainly estradiol) and some progesterone
At full maturity – it visible on the surface of the ovary as a clear water blister; approximately
0.25 – 0.5 inches across
Ovum – barely visible to the naked eye; approximately the size of a printed period; surrounded
by follicle membrane and fluid = graafian follicle
With the upsurge of LH – prostaglandins are released and the graafian follicle ruptures
Release of ovum (ovulation) swept into the open end of the fallopian tube
Ovulation – occurs on approximately the 14th day before the onset of the next cycle; midpoint of
a 28-day cycle
20-day cycle = ovulation is day 6
21-day cycle = ovulation is day 7
35-day cycle = day 21
After ovum and follicular fluid have been released cells of the follicle remain in the form of a
hollow, empty pit FSH has done its work and now es in amount LH continues to rise and
acts on the follicle cells of the ovaries LH causes follicle cells to begin to produce lutein, a
bright-yellow fluid (instead of follicular fluid) – high in progesterone w/ some estrogen fills the
empty follicle – corpus luteum (yellow body)
Progesterone – thermogenic; responsible for increase in body temp. by 1°F on the day after
ovulation
If conception (fertilization by a spermatozoon) occurs – fertilized ovum implants on the
endometrium; corpus luteum remains throughout the major portion of the pregnancy (approx.
16 – 20 weeks)
NO CONCEPTION – unfertilized ovum atrophies after 4 – 5 days; corpus luteum (“false” corpus
luteum) remains only for 8 – 10 days
As corpus luteum regresses – gradually replaced by white fibrous tissue = corpus albicans (white
body)
 3
UTERUS
Stimulation from the hormones produced by the ovaries causes specific monthly effects on the
uterus

FIRST PHASE OF MENSTRUAL CYCLE (PROLIFERATIVE)

estrogen and progesterone

Follicle Stimulating Hormone releasing hormone (FSHRh)

Follicle Stimulating Hormone (FSH)

Follicle to mature (primordial – Graafian)

Estogen (follicular fluid)

Endometrium proliferates – increase thickness (eightfold)

Increase (thickness) – continues for the 1st half of the menstrual cycle (from approximately day 5 –
day 14)
Also termed – proliferative, estrogenic, follicular, or postmenstrual phase

SECOND PHASE OF MENSTRUAL CYCLE (SECRETORY)

estrogen

Leuteinizing Hormone Releasing hormone (LHRh)

Leuteinizing Hormone

Ovulation

Corpus leuteum

Progesterone - blood supply to endometrium

15th – day 21
After ovulation, the formation of progesterone in the corpus luteum (under the direction of
the LH) causes the glands of the uterine endometrium to become “corkscrew” or twisted in
appearance
Endometrium also becomes dilated w/ quantities of glycogen (elementary sugar) and mucin
(protein)
Capillaries of the endometrium increase in amount until lining takes on the appearance of
rich, spongy velvet – ready for implantation
Also termed – progestational, luteal, premenstrual, or secretory phase

THIRD PHASE OF MENSTRUAL CYCLE (ISCHEMIC)

If fertilization does not occur, corpus luteum in the ovary begins to regress after 8 – 10 days
Progesterone and estrogen decreases = endometrium begins to degenerate at approximately
day 24 or day 25 of the cycle
 4
Corpus luteum degenerates

estrogen and progesterone

Capillaries rupture, minute hemorrhages

Endometrium slough/ shed off

MENSES: THE FINAL PHASE OF THE MENSTRUAL CYCLE

The following products are discharged from the uterus as the menstrual flow or menses:
Blood from the ruptured capillaries
Mucin from glands
Fragments of endometrial tissue
Microscopic, atrophied, and unfertilized ovum
1st day of menstrual flow – is used to mark the beginning day of a new menstrual cycle
Approximately 30 – 80 mL of blood – seems like more because of accompanying mucus and
endometrial sheds
o > 80 mL = hypermenorrhea
o < 30 mL = hypomenorrhea
o Bleeding in between cycle = metrorrhagia
o Painful menstruation = dysmenorrhea
Iron loss: approximately 11 mg – may leave some women with iron deficiency; need iron
supplement to prevent iron depletion
 Fetal Circulation (The Growing Fetus)
Chapter 9
Page 189 - 215

Stages of Fetal Development

38 weeks = fertilized egg (ovum) fully developed fetus

Fetal Growth and Development typically divided into 3 periods:

1. Pre-embryonic – 1st 2 weeks beginning w/ fertilization
2. Embryonic - Weeks 3 - 8
3. Fetal – weeks 8 through birth

Fertilization, Conception, Impregnation, Fecundation*

Usually occurs at the outer third of fallopian tube = ampulla
usually only 1 ovum reaches maturity each month

Fxnal life of spermatozoon

42 hrs (possibly up to 72 hrs)
Critical time span for (sexual relations must occur) successful fertilization?
72 hours (48hrs b4 ovulation + 24hrs after)

EMBRYONIC AND FETAL STRUCTURES

The Decidua
After fertilization, the corpus luteum in the ovary continues to function rather than
atrophying *
The uterine endometrium, instead of sloughing off as in a normal menstrual cycle,
continues to grow in thickness and vascularity = DECIDUA
Latin word for “falling off”

Decidua has 3 separate areas:

Decidua basalis
part of the endometrium that lies directly under the embryo
or the portion where the trophoblast cells are establishing communication w/
maternal blood vessels
Decidua capsularis
encapsulates the surface of the trophoblast
Decidua vera
the remaining portion of the uterine lining

Chorionic Villi
After implantation trophoblast cell matures

11th or 12th day – miniature villi (probing “fingers”)

Chorionic villi

At term almost 200 villi have formed

Chorionic villi have a central core surrounded by a double layer of trophoblast cells
Outer of the 2 covering layers is termed the syncytiotrophoblast, or the syncytial layer
Inner /Middle layer – cytotrophoblast or Langhan’s layer
Outer of the 2 covering layers is termed the syncytiotrophoblast, or the syncytial layer –
instrumental in the production various placental hormones:
hCG (Human chorionic gonadotrophin)
Somatomammotropin (human placental lactogen [hPL])
Estrogen
Progesterone

Inner layer – cytotrophoblast or Langhan’s layer

Appears to function early in pregnancy to protect the growing embryo and fetus from
certain infectious organisms such as the spirochete of syphilis
Disappears bet. 20th and 24th week = syphilis not a threat before this time
Offers little protection viral invasion @ any point
The Placenta
Fetal in origin
15 – 20 cm in diameter, 2 – 3 cm in depth
Serves as fetal lungs, kidneys, and GI tract, and as a separate endocrine organ
throughout pregnancy

Placental Circulation
3rd week
oxygen
glucose osmose from the maternal
amino acids blood thru the cell layers of
fatty acids the chorionic villi to the villi
minerals capillaries
vitamins
water

Placental Circulation
For practical purposes, there is no direct exchange of blood between the embryo and the
mother during pregnancy*
outer chorionic villi layer – only one cell thick
Only a few substances are able to cross from the mother into the fetus
Almost all drugs are able to cross into fetal circulation
woman should take no non-essential drugs (including alcohol and nicotine) during
pregnancy
All of the specific mechanisms or processes that allow nutrients to cross the placenta are
affected by:
Maternal blood pressure and
pH of the fetal and maternal plasma

As the # of chorionic villi increases w/ pregnancy

Villi form an increasingly complex communication network w/ the maternal blood

Intervillous spaces grow larger and larger

Becoming separated by a series of partitions or septa

Matured placenta – 30 separate segments or

cotyledons

These compartments make maternal side of the placenta @ term look rough and uneven

Placental Formation
100 maternal uterine arteries supply the mature placenta*
1
No additional maternal arteries appear after the 1st 3 mos. of pregnancy
2
mother’s heart rate, total cardiac output, and blood volume to supply the placenta

Placental Circulation
In the intervillous spaces – maternal blood jets from the coiled or spiral arteries in streams or
spurts

Maternal blood is then propelled from compartment to compartment by the currents initiated

As blood circulates around the villi and nutrients osmose from maternal blood into the villi

Maternal blood gradually loses its momentum and settles to the floor of the cotyledons

Blood enters the orifices of maternal veins located in the cotyledons

Blood is returned to maternal circulation

The Placenta
Braxton Hicks contractions
present from about 12th weeks of pregnancy
aid in maintaining pressure in the intervillous spaces by closing off uterine veins
momentarily w/ each contraction
When mother lies on her LEFT SIDE
lifts the uterus away from the inferior vena cava1
When mother lies on her BACK
weight of the uterus compresses the vena cava
placental circulation can be sharply reduced =
SUPINE HYPOTENSION *
At term: placenta weighs 400 – 600 gms (1lb.) or 1/6 the weight of the baby
Diabetic woman - fetus may develop a larger than usual placenta

Endocrine Function
Syncytial (outer) layer of chorionic villi – serves as source of oxygen and nutrients, and develops
into a separate, important HORMONE – PRODUCING system

WHAT HORMONES ARE PRODUCED BY THE SYNCYTIAL LAYER?

1. Human Chorionic Gonadotrophin (hCG)
1st hormone produced
Can be found in maternal blood and urine as early as the 1st missed menstrual period
(shortly after implantation has occurred) through about 100th day (14 th week) of
pregnancy
Negative hCG in mother’s serum – w/in 1 – 2 weeks after birth
Testing for hCG can be used as proof that all of the placental tissue has been delivered
Human Chorionic Gonadotropin (hCG)*
Purpose: to act as a fall-safe measure to ensure that the corpus luteum of the ovary
continues to produce progesterone and estrogen1
May also play a role in suppressing the maternal immunologic response^
8th week of pregnancy: outer layer of cells of the developing placenta begins to produce
progesterone – production of hCG begins to decrease at this point

2. Estrogen
Primarily estriol
“hormone of women”
Contributes to the mother’s mammary gland development in preparation for lactation
Stimulates uterine growth to accommodate the developing fetus

3. Progesterone
“hormone of mothers”
Appears to reduce contractility of the uterine muscles during pregnancy preventing
premature labor=
probably produced by a change in electrolytes (potassium and calcium), w/c es
contraction potential of the uterus

4. Human Placental Lactogen ( hPL, Human Chorionic Somatomammotropin)

w/ both growth-promoting and lactogenic (milk-producing) properties
produced by the placenta beginning the 6th week of pregnancy – increasing to a peak
level @ term
promotes mammary gland growth in preparation for lactation in the mother*
serves the important role of regulating maternal glucose, protein, and fat levels**

Placental Proteins
Placenta also produces several plasma proteins*
may contribute to decreasing the immunologic impact of the growing placenta
The Amniotic Membranes
The chorionic villi on the medial surface of the trophoblast*
begins to gradually thin, leaving the medial surface of the structure smooth
chorion leave, or smooth chorion
Smooth chorion eventually becomes the chorionic membrane -

Once it becomes smooth, it offers support to the sac that contains the amniotic fluid

2nd membrane lining the chorionic membrane = the amniotic membrane or amnion forms
beneath the chorion
the amniotic membranes not only offers support to amniotic fluid but also actually produces
the fluid* = Phospholipid

The Amniotic Fluid

constantly being newly formed and reabsorbed by the amniotic membrane *
reabsorbed @ the rate of 500 mL/24 hours
some of it is probably absorbed by direct contact w/ the fetal surface of the placenta
major method of absorption occurs because fetus continually swallows the fluid
Amount @ term? - 800 – 1200 mL

Method of absorption:
Fetus swallows amniotic fluid

From the fetal intestine, it will be absorbed into the fetal bloodstream

Goes to the umbilical arteries

To the placenta

And it is exchanged across the placenta

If fetus is unable to swallow (esophageal atresia or anencephaly) =

Hydramnios – >2,000 mL*
When fetal kidneys become active = urine adds to the quantity of the amniotic fluid**
Oligohydramnios (<300 mL)

FUNCTIONS of AMNIOTIC FLUID

1. Shields fetus against pressure or a blow to the mother’s abdomen
2. Protects fetus from changes in temperature
a. because liquid changes temperature more slowly than air
3. Aids in fetal muscular development
a. allows fetus the freedom to move
4. Protects umbilical cord from pressure, protecting the fetal O2 supply

Amniotic fluid is slightly alkaline = pH 7.2

Urine is acidic = pH 5.0 – 5.5

The Umbilical Cord

formed from the fetal membranes (amnion and chorion)
provides a circulatory pathway that connects the embryo to the chorionic villi of the
placenta
Functions:
to transport oxygen and nutrients to the fetus from the placenta and
to return waste products from the fetus to the placenta
53 cm (21 inches) in length (@ term)
2 cm (3/4 inch) thick
What is the bulk of the cord called?*
A gelatinous mucopolysaccharide
Wharton’s jelly
outer surface – covered w/ amniotic membrane
the remnant of the yolk sac may be found in the fetal end of the cord – as a white
fibrous streak @ term
 Contains how many veins and arteries?
1 vein*
2 arteries*
# of veins and arteries in the cord is always assessed and recorded @ birth:
1% - 5% of all infants are born w/ a cord that contains a single vein and artery

Rate of blood flow thru an umbilical cord is rapid 350 mL/min @ term*
Percutaneous umbilical blood sampling (PUBS)
blood is withdrawn from the umbilical vein or transfused into the vein during intrauterine
life for fetal assessment or treatment
Nuchal cord
loose loop of cord around fetal neck;
20% of all births
oxygen supply is not impaired

The Umbilical Cord

Walls of the umbilical cord arteries are lined w/ smooth muscle
Constriction of these muscles after birth contributes to hemostasis and helps prevent
hemorrhage of the newborn thru the cord
Contains NO nerve supply – can be cut @ birth w/o discomfort to either mother or child

Origin and Development of Organ Systems

Chapter 9
pages 197 – 215

From the moment of fertilization, the zygote and later the embryo and fetus is composed of active,
growing cells.

Stem Cells
1st 4 days of life – zygote cells = totipotent stem cells, or cells that are so undifferentiated that
they have the potential to form a complete human being

After another 4 days, as structure implants and becomes an embryo – cells begin to show
differentiation and are no longer capable of becoming just any body cell

Become specific body cells such as nerve, brain, or skin cells = pluripotent stem cells

Another few days, cells grow so specific = multipotent stem cells – evident what body organ
they will create

If nucleus is removed from an oocyte, and adult nucleus is transferred into the oocyte = embryo has
the potential to grow into an infant that is identical to the adult donor = reproductive cloning

If pluripotent stem cells are removed and allowed to grow in the laboratory = has the potential to be
able to supply any type of body cell needed by the adult donor = therapeutic cloning

Zygote Growth
o Development proceeds in a cephalocaudal (head-to-tail) direction
o head development occurs first, followed by the development of the middle and, finally, the
lower body parts
o As a fetus grows, body organ systems develop from specific tissue layer called germ layers

Primary Germ Layers

o @time of implantation blastocyst already has differentiated (distinguishable) to
a pt. @ w/c
o
o 2 separate cavities appear in the inner structure:
Amniotic cavity
Yolk sac
Amniotic cavity
o Large one
o Lined w/ a distinctive layer of cells =ECTODERM
 Yolk sac
o Smaller cavity
o Lined w/ ENTODERM
o Supply nourishment only until implantation
o After, it provides a source of RBC until the embryo’s hematopoetic system is
mature enough to perform this fxn – about 12th week of intrauterine life
o It then atrophies and remains only as a thin white streak discernible in the cord @
birth

ECTODERM – lines the amniotic cavity

ENTODERM – lines the yolk sac
MESODERM – found bet. Amniotic cavity and yolk sac

Where these 3 layers meet, embryo starts to develop = EMBRYONIC SHIELD

o Each of these germ layers of primary tissue develops into specific body systems
o Co-existing congenital defects Fistula bet. Trachea and esophagus Both arise from the
entoderm
o Heart and kidney defects Both arise from mesoderm = commonly seen together
o Malformation of heart (mesoderm) and lower urinary tract (bladder and urethra –
entoderm) Rare

Rubella infection = so serious in pregnancy

o Virus is capable of infecting all three germ layers
o Causing congenital anomalies in numerous body systems

Organogenesis
all organ systems are complete, @ least in a rudimentary form - @ 8 weeks’ gestation
(end of embryonic period)
Organogenesis – organ formation
growing structure is most vulnerable to invasion by teratogens
Teach women to minimize exposure to teratogens

CARDIOVASCULAR SYSTEM
One of the 1st systems to become functional in intrauterine life
Simple blood cells joined to the walls of the yolk sac progress to become a network of
blood vessels and a single heart tube – w/c forms as early as the 16th day of life
beats as early as the 24th day
Septum that divides the heart into chambers – develops during the 6th or 7th week
Heart valves begin to develop in the 7th week
Heartbeat may be heard w/ a Doppler instrument – 10th – 12th week of pregnancy
Electrocardiogram (ECG) may be recorded on a fetus – as early as 11th week
more accurate about the 20th week of pregnancy (conduction is more regulated)
Heart rate of fetus is affected by:
o Fetal oxygen level
o Body activity
o Circulating blood volume

Fetal Circulation
3rd week of intrauterine life – fetal blood begins to exchange nutrients w/ the maternal
circulation across the chorionic villi
Fetal circulation differs from extrauterine circulation in several aspects:
1. Fetus derives oxygen and excretes carbon dioxide not from oxygen exchange in
the lungs but from the placenta
2. Blood does enter the blood vessels of the lungs while the child is in-utero, but this
blood flow is to supply the cells of the lungs themselves, not for oxygen
exchange.
3. Specialized structures present in the fetus shunt blood flow to supply the most
important organs of the body: the brain, liver, heart, and kidneys.
Fetal Circulation
Blood arriving @ the fetus from the placenta is highly oxygenated Enters through the umbilical
vein (called a vein tho’ it carries oxygenated blood – because direction of the blood is toward the
fetal heart)

Blood is carried into the inferior vena cava thru an accessory structure – ductus venosus,
allowing oxygenated blood to be supplied directly to the fetal liver

Oxygenated blood empties into the inferior vena cava, then, carried to the right side of the heart

Because there is no need for the bulk of the blood to pass thru the lungs, it is shunted as it
enters the right atrium (extrauterine circulation: pass thru rt. ventricle – lungs)
Fetal Circulation
Into the left atrium thru an opening in the atrial septum, called the foramen ovale

Follows the course of normal circulation into the left ventricle and into the aorta
Small amount – returns to the via vena cava does leave the rt. Atrium by the adult circulatory
route
Larger portion of this blood is shunted away from the lungs thru an additional structure – ductus
arteriosus directly into the descending aorta

Transported by the umbilical arteries (transporting deoxygenated blood – away from the fetal
heart) back thru the umbilical cord

placental villi maternal circulation – where new oxygen exchange takes place

Fetal blood O2 saturation level: 80% of a newborn’s saturation level

Rapid fetal heart rate during pregnancy = 120 – 160 beats/min; is necessary to supply O2 to
cells, because RBCs are never fully saturated

Fetal Hemoglobin
Differs from adult hemoglobin in several ways:
Fetal hemoglobin has a different composition:
Fetus: 2 alpha and 2 gamma chains
Adult: 2 alpha and 2 beta chains
It is more concentrated and has greater oxygen affinity – 2 features that increase its
efficiency
Newborn’s hemoglobin level :17.1 g/100 mL
o Adult’s normal level :11 g/ 100 mL
Newborn’s hematocrit :53%
o Adult’s normal level :45%

Respiratory System
3rd week of intrauterine life – respiratory and digestive tracts exist as a single tube*
End of 4th week – a septum begins to divide the esophagus from the trachea;
lung buds also appear on the trachea : 7th week of life*
If diaphragm fails to close completely the stomach, spleen, liver, or intestines may be
pulled up into the thoracic cavity
Child will be born w/ Diaphragmatic hernia or w/ intestine still present in the chest*

Important respiratory devtl. milestones:

Alveoli and capillaries begin to form bet. 24th and 28th weeks*
Spontaneous respiratory practice movements begin as early as 3 months’ gestation and
continue throughout pregnancy
Important respiratory devtl. milestones:
Specific lung fluid w/ a low surface tension and low viscosity forms in alveoli
24th week (6 months) of pregnancy, alveolar cells secrete = Surfactant*
o es alveolar surface tension on expiration, preventing alveolar collapse and
o improving the infant’s ability to maintain respirations in the outside environment
Components of surfactant:
o Lecithin (L)
o Sphingomyelin (S)*
o L/S Ratio: 2:1
 Analysis of L/S ratio thru amniocentesis = fetal maturity
Respiratory distress syndrome* - ing steroid levels in the fetus*

Nervous System*
3rd to 4th weeks of life – active formation of the nervous system and sense organs
Requires vast quantity of glucose during this time – embryo takes glucose – leaving mother
w/ mild hypoglycemia = dizziness, vomiting
A neural plate (thickened portion of the ectoderm) is apparent by the 3rd week of gestation
Its top portion differentiates into the neural tube – will form the central nervous system
(brain and spinal cord),
And the neural crest – will develop into the peripheral nervous system
All parts of the brain (cerebrum, cerebellum, pons, and medulla oblongata) form in utero*
Eye and inner ear develop as projections of the original neural tube
By 24 weeks – ears is capable of responding to sound
eyes exhibit papillary reaction, indicating sight is present
8th week – brain waves can be detected on an electroencephalogram (EEG)
Prone to insult during early weeks of embryonic period
Spinal cord disorders
Meningocele (herniation of meninges) –
Due to lack of folic acid*
All other – during pregnancy and birth – vulnerable to damage from ANOXIA

Endocrine System
Fetal adrenal glands supply a precursor/basis for estrogen synthesis by the placenta
Fetal pancreas produces the insulin needed by the fetus*
Thyroid and parathyroid glands play vital roles in metabolic fxn and calcium balance

Digestive System
4th week – digestive tract separates from the respiratory tract*
Atresia or stenosis
Proliferated cells shed in the 2nd re-canalization – w/c forms the basis for meconium
6th week – abdomen becomes too small to contain the intestine and portion of it guided
by the viteline membrane (a part of the yolk sac) intestine is pushed into the base of the
umbilical cord where it remains until about the 10th week*
Digestive System
As intestine returns to the abdominal cavity – it must rotate 180 degrees
Failure to rotate = inadequate mesentery attachments = volvulus (twisting of the bowel) of
the intestine in the newborn
*Omphalocele – congenital anomaly
Gastroschisis*
Meckel’s Diverticulum – a pouch of intestinal tissue
Meconium – forms in the intestines as early as 16th week
o collection of cellular wastes, bile, fats, mucoproteins, mucopolysaccharides, and
portions of the vernix caseosa*
o sticky in consistency and
o appears black or dark green
o White meconium – sign of biliary obstruction
GI tract is sterile before birth
Vit. K levels are low in newborns*
32 weeks’ gestation: fetus weighs 1,500g; sucking and swallowing reflexes are matured
enough
36 weeks – GI tract is able to secrete enzymes essential to carbohydrate and protein
digestion
Amylase– enzyme found in saliva, necessary for digestion of complex starches
Lipase – necessary for fat digestion
Liver is active throughout gestation
functions as a filter bet. incoming blood and the fetal circulation, and
as a deposit site for fetal stores such as iron and glycogen
Still immature @ birth
possibly leading to hypoglycemia and hyperbilirubinemia – 2 serious problems in the 1st 24
hours after birth
Musculoskeletal System
1st 2 weeks of fetal life – cartilage prototypes provide position and support
12th week – ossification of bone tissue begins and continues until adulthood
Carpals, tarsals, and sternal bones generally do not ossify (harden) until birth is imminent
11th week – Fetal movements visible on ultrasound
Almost 20 weeks of gestation (5th month) – mother feels the fetal movements (quickening)

Reproductive System
Child’s sex is determined @ the moment of conception*
6th week of life – gonads (ovaries or testes) form
If testes form = testosterone is secreted, influencing the sexually neutral genital duct to form
other male organs (maturity of the wolffian, or mesonephric ducts)
Absence of testosterone secretion = female organs will form (maturation of müllerian, or
paramesonephric duct)*
Androgen*
Female and male ducts could develop =Pseudo-hermaphrodism or intersex
Testes 1st form in the abdominal cavity and do not descend into the scrotal sac until the
34th – 38th week
Male preterm infants – born w/ undescended testes*
Surgery – necessary as undescended testes are associated with poor sperm production and
testicular cancer

Urinary System
End of 4th week – rudimentary kidneys already present;
do not appear essential for life before birth – placenta clears the fetus of waste products
12th week – urine is formed and excreted thru the amniotic fluid by the 16th week of
gestation*
@ term, fetal urine is excreted @ the rate of 500 mL/day*
Patent urachus – discovered @ birth; persistent drainage of a clear, acid-pH fluid (urine)
from the umbilicus

Integumentary System
Skin of a fetus appears thin and almost translucent until subcutaneous fat begins to be
deposited @ about 36 weeks
Lanugo – soft downy hairs covering fetal skin*
Vernix caseosa – cream cheese-like substance, important for lubrication and for keeping the
skin from macerating in utero

Immune System
Immunoglobulin G (IgG) - maternal antibodies
cross the placenta into the fetus as early as the 20th week of pregnancy
gives fetus temporary passive immunity against diseases for w/c mother has antibodies
These often include:
poliomyelitis
rubella (German measles)
rubeola (regular measles)
diphtheria
tetanus
infectious parotitis (mumps)
hepatitis B
pertussis (whooping cough)

Level of these acquired passive IgG peaks @ birth and then es over the next 8 mos.
While infant begins to build up his or her own stores of IgG, as well as IgA and IgM
Immunization against diphtheria, tetanus, pertussis, poliomyelitis, rotovirus, h. influenzae,
and pneumococcus– is typically started (by about 2 mos)
Passive antibodies to measles – seen to last for more than 1 year = measles immunization is
not given until 12mos. of age
It has been shown that fetus is capable of active antibody production late in pregnancy
Tho’ not necessary – antibodies are manufactured only after stimulation by invading antigen
Infants w/ mother who have had infetion (rubella) during pregnancy – typically have active
IgM antibodies to rubella in their bld. serum @ birth**
little or no immunity to herpes virus (cold sores, genital herpes)
average newborn is potentially susceptible to these diseases
IgA and IgM – cannot cross the placenta
If present in a newborn = proof that fetus has been exposed to a disease

Determination of EBD
Traditionally: EDC
Expected Date of Confinement
Because women are no longer “confined” after childbirth =
EDB or EDD used today
Nagele’s Rule
Count backward 3 calendar mos from the 1st day of woman’s LMP and
Add 7 days
-3 +7
LMP: July 23 EDD:?
Estimating Gestational Age
McDonald’s Rule
Symphysis-fundal height measurement
From notch of the symphysis pubis to over the top of the uterine fundus as the woman is
lying supine
Inaccurate during 3rd trimester
Fetus is growing more in weight than in height
Gestational age in lunar mos.
FH (in cm) x 2 7
FH: 31.5cm Age in lunar mos.?
9 mos.
Gestational age in weeks
FH (in cm) x 2 7
FH: 36cm Age in weeks?
41 – 42 weeks
 CHAPTER 10

Psychological and Physiologic Changes of Pregnancy

Pregnancy brings both psychological and physiological changes to a woman and her partner

Clients are more interested in learning more about the changes pregnancy brings – because
these changes verify the reality and mark the progress of a pregnancy

Physiologic Changes in pregnancy

occur gradually but eventually affect all organ systems of a woman’s body.
Changes are necessary:
to allow a woman to be able to provide O2 and nutrients for her growing fetus, as well
as extra nutrients for her own ed metabolism during the pregnancy
prepare her body for labor and birth and for lactation once baby is born

Psychological changes

occur in response not only to the physiologic alterations that are occurring but also to the
increased responsibility associated with welcoming a new and completely dependent person to
the family.
WELLNESS, not illness
Because of this, the major responsibility of a nurse caring for a pregnant woman and family is:
To help the family maintain a state of wellness throughout the pregnancy and into early
parenthood
PREGNANCY brings about more psychological changes than any other life event besides puberty.
A woman’s attitude toward a pregnancy depends a great deal on the following factors:
Social Influence
Cultural Influences
Family Influences
Individual Influences

Social Influence
Before: pregnancy was viewed as a 9-month long illness
Pregnant woman went alone for prenatal
Today: society view pregnancy as a time of health
cultural background, personal experiences, and the experiences of friends and
relatives, as well as the current public philosophy of childbirth – affect partner’s
view about pregnancy
“demedicalize” childbirth – enjoy pregnancy

Cultural Influences
Cultural background strongly influence pregnant woman’s role in her pregnancy
certain beliefs and taboos may place restrictions on her behavior and activities

Family Influences
The family in w/c a woman was raised can be as influential to her beliefs about
pregnancy as her cultural environment
“People love as they have been loved”
Woman who views mothering as a positive way is more likely to be pleased when
she becomes pregnant than one who devalues mothering
Individual Influences
Woman’s ability to cope w/ or adapt to stress plays a major role in how she will
resolve conflict and adapt to the new life contingencies that are coming
The ability to adapt depends, in part, on her:
Basic temperament
Whether she adapts to new situations quickly or slowly
Whether she faces them w/ intensity or maintains a low-key approach
Whether she has had experiences coping w/ change and stress
Security in the pregnant woman’s relationship
Brides – young, mothers – old = may believe pregnancy will rob her of her youth
Children are sticky-fingered and time - consuming = may view pregnancy as
taking away her freedom
Pregnancy will permanently stretch her abdomen and breasts = concern that
she will lose her looks
Pregnancy will rob her financially and ruin her chances of job promotion
Woman needs an opportunity to express these feelings and become aware of
their intensity to resolve them.

The Psychological Tasks of Pregnancy

Initial reactions of a woman and her partner to pregnancy:

surprise
at finding out the woman is pregnant (or wishing she were not)
pleasure and acceptance
of the fact as they begin to identify w/ the coming child
worry and fear
for themselves and the child
near the end of pregnancy – impatience and boredom
9-month period of pregnancy
Physiologic standpoint
gives fetus time to mature and be prepared for life
Psychological standpoint
gives family time to prepare emotionally
“guaranteeing safe passage” for the fetus
How well a woman adjusts to potential stress of pregnancy can affect her rel. w/ the
child and even influence whether she can carry pregnancy to term
Tasks of Pregnancy
First Trimester: Accepting the Pregnancy
The Woman
Task of women during the 1st trimester is to accept the reality of the pregnancy
Receiving confirmation of pregnancy makes woman feel more pregnant
Initial reaction – ambivalence, or feeling both pleased and not pleased about
the pregnancy
Most women are able to change their attitude toward the pregnancy by the
time they feel the child move inside them
The Partner
As a woman adapts to pregnancy, her partner may go through some of the same
psychological changes
Accepting the pregnancy means not only accepting the certainty of the
pregnancy and the reality of the child to come but also accepting the woman
in her changed state
Partner should try to give the woman emotional support while she is learning to
accept the reality of pregnancy
Woman should also reciprocate when the partner begins to go through the
process
Second Trimester: Accepting the Baby
 Quickening – 2nd turning point in pregnancy
woman is able to give the child an identity – as a separate entity
begins to imagine how she will feel @ the birth
imagine herself as a mother = anticipatory role-playing
an important task for a pregnant woman – makes her realize that not only is she
pregnant but also there is a child inside her
Woman’s Acceptance of the baby may occur when:
she announces the news to her parents and hears them express their joy
she sees a look of pride on her partner’s face
moment of quickening
shopping for baby clothes for the first time
setting up the crib
seeing a blurry outline on a sonogram screen
a good way to measure the level of a woman’s acceptance of the coming baby is to
measure how well she follows prenatal instructions
The Partner
partner may feel left out, waiting to be asked to take part in the event
Misinformation about sexuality, pregnancy and women’s health:
Breast-feeding will make his wife’s breasts no longer attractive
Childbirth will stretch his wife’s vagina – sexual relations will no longer
be enjoyable
Needs education to correct misinformation

Third Trimester: Preparing for Parenthood

couples usually begin “nest-building” activities
all are evidence that woman is completing the 3rd trimester task of pregnancy
or preparing for parenthood
Couples at this point are interested in attending prenatal classes or preparation for
childbirth classes
It is helpful to ask a couple what specifically they are doing to get ready for birth in
order to document how prepared they will be for the baby’s arrival

Other Specific Tasks couple must complete to be ready to be Parents:

Reworking Developmental Tasks
Working through previous life experiences:
Woman’s relationship w/ parents, particularly w/ mother
Fear of “separation” from family or dying
“Am I ever going to make it thru this?” – distress
Means: simply tired or needs reassurance that she will survive
this event
Woman needs to have confidence in those who provide health care for her
during pregnancy – so she can express some of these disturbing thoughts and
work thru them
As a rule: a woman who is comfortable seeking information, experiences less
anxiety than one who is unable to do this.
Pregnant woman’s partner needs to do the same reworking of old values and
forgotten developmental tasks

Role-Playing and Fantasizing

2nd step in preparing for parenthood is role-playing or fantasizing – about what
it will be like to be a parent:
Pregnant woman begins to spend time w/ other pregnant women or
mothers w/ young children – to learn how to be a mother
Finds that her own mother becomes more important
 Women’s dreams tend to focus on the pregnancy and concerns
about keeping themselves and their coming child safe
Father-to-be also has role-playing to do

Emotional Responses to Pregnancy

It is important to caution pregnant woman and her partner about common
changes they may expect so as not to misinterpret them as loss of interest in
their relationship.
Ambivalence
A separate individual is growing inside the woman, changing how she
looks and feels
She may want to be pregnant, and yet she may not be enjoying it =
leading to some degree of ambivalence
Refers to the interwoven feelings of wanting and not wanting that can
exist @ high levels = normal
Partners – also experience ambivalence – afraid to voice their
concerns, not well-prepared for parenthood or have had little
experience w/ children
Grief
Before a mother can take on a mothering role, she has to give up or
alter her present roles
She must incorporate her new role as a mother into her roles as a
daughter, wife, or friend (same w/ partner)
Narcissism
self – centeredness – an early reaction to pregnancy
Previously – barely conscious of her body; suddenly begins to
concentrate on these aspects
a woman may manifest her narcissism by a change in her activity
level
stop playing tennis
criticize husband’s driving
does these things to unconsciously protect her body and her baby
this need to protect her body has implications for nursing care
may regard unnecessary nudity as a threat to her body
be sure to drape properly for pelvic and abdominal examinations
may resent casual remarks such as, “You’ve gained weight!” –
threat to her appearance
“You don’t like milk?” – threat to her judgment

Introversion vs Extroversion
INTROVERSION
turning inward to concentrate on oneself and one’s body – common
finding during pregnancy
Some women react in an entirely opposite fashion and become
more EXTROVERTED
Become more active
Appear healthier than ever before
More outgoing

Body Image and Boundary

Body image – the way your body appears to yourself
part of the basis for narcissism and introversion
Body boundary – a zone of separation you perceive between yourself
and objects or other people
perceived as extremely vulnerable, as if body were delicate and
easily harmed

Stress
Pregnancy can be a time of extreme stress for a woman
 can make it difficult for the woman to make decisions, be as aware of
her surroundings as usual, or maintain time management w/ her usual
degree of skill
may cause people who were dependent on her before pregnancy to feel
neglected – she seems to have strength only for herself
Woman w/ few support people – have more difficulty adjusting to and
accepting a pregnancy and a new child
Stress may lead to acute loneliness, depression, and a further inability
to function

Couvade Syndrome
Many men experience physical symptoms such as nausea, vomiting, and
backache to the same degree or even more intensely than their
partners do during a pregnancy
couvade syndrome
These symptoms result from stress, anxiety, and empathy for the
pregnant woman
The more the partner is involved in or attuned to the changes of the
pregnancy, the more symptoms he may experience:

Emotional Lability
mood changes/mood swings occur frequently in a pregnant woman
as a manifestation of narcissism (feelings are easily hurt by
remarks)
and partly because of hormonal changes (sustained in estrogen
and progesterone)
what she finds acceptable one week she may find intolerable the
next

Changes in Sexual Desire

Worried about becoming pregnant – might truly enjoy sex for the first
time during pregnancy
Others feel a loss of desire due to the estrogen increase
Or might unconsciously view sexual relations as a threat to the fetus
they must protect
Worry that having sex could bring on early labor
1st trimester – most women report a decrease in libido because of the
nausea, fatigue, and breast tenderness that accompany early
pregnancy
2nd trimester – increase blood flow to pelvic area to supply placenta =
libido and sexual enjoyment rise markedly
3rd trimester – sexual desire remain high, or may decrease because of
difficulty finding a comfortable position and increasing abdominal size

Changes in the Expectant Family

Older children need preparation when a new baby is on the way
Both preschool and school – age children may need to be reassured
periodically during pregnancy
that a new baby will be an addition to the family and will not
replace them in their parents’ affection

The Diagnosis of Pregnancy

Presumptive Signs of Pregnancy
Probable Signs of Pregnancy
Positive Signs of Pregnancy
Presumptive Signs of Pregnancy
Least indicative of pregnancy
Largely subjective
experienced by the woman but cannot be documented by an examiner
Strong possibility
Presumptive Signs of Pregnancy
Breast changes
after the 2nd month – feeling of tenderness, fullness, or tingling
sensation; enlargement and darkening of areola
Nausea and vomiting
“morning sickness”; appears about 2 weeks after the 1st missed period
subsides spontaneously 6 or 8 weeks later;
also present in other conditions such as indigestion
Amenorrhea
absence of menstruation
altho’ cessation of menstruation is the earliest and one of the most
important symptoms of pregnancy, it shd be noted that pregnancy may
occur w/o prior menstruation and occasionally menstruation may continue
after conception
may result from a number of other conditions
Frequent urination
sense of having to void frequently
attributed to the fact that the growing fetus or uterus stretches the base
of the bladder
same sensation felt when bladder wall is stretched w/ urine
Fatigue
general feeling of tiredness; lassitude and drowsiness
Uterine enlargement
uterus can be palpated over symphisis pubis
Quickening
fetal movement first felt by woman
Linea nigra
brown line running on the abdomen, from the umbilicus to the symphysis
pubis
Melasma (chloasma)
“mask of pregnancy”
dark pigment on face particularly on the cheeks and across the nose
Striae gravidarum
red streaks on abdomen, breast and thighs

Probable Signs of Pregnancy

can be documented by the examiner
more reliable than presumptive signs, but still not positive or true
diagnostic findings
Laboratory tests
commonly used lab tests for pregnancy are based on detecting the
presence of human chorionic gonadotropin (hCG), hormone created by the
chorionic villi of the placenta, in the urine or blood serum
95% - 98% accurate
Serum: Radioimmunoassay (RIA), enzyme-linked immunosorbent assay
(ELISA), or radioreceptor assay (RRA) techniques – measurement of hCG
(international units)
Trace amounts of hCG appear in serum as early as 24 – 48 hours after
implantation
Reach measurable level 7 – 9 days after conception – about 50
mIU/mL
Levels peak bet. 60th and 80th day of gestation – 100 mIU
Urine: now used rarely because blood serum tests give earlier results
 Home Pregnancy Tests
available OTC
have a high degree of accuracy (about 97%)
Convenient
can detect as little as 35 mIU/mL of hCG
Women taking psychotropic drugs (antianxiety agents), oral contraceptives, w/
proteinuria, postmenopausal, or hyperthyroid dse. – may have false-positive
results
Chadwick’s sign
color change of the vagina from pink to violet
Goodell’s sign
softening of the cervix; from tip of nose to the one resembling an
earlobe
Hegar’s sign
softening of the lower uterine segment
Sonographic evidence of gestational sac
characteristic ring is evident
Ballottement
when lower uterine segment is tapped in a bimanual examination, the
fetus can be felt to rise against abdominal wall
Braxton Hicks Contractions
“painless contractions”
periodic uterine tightening or hardening felt across the abdomen; also
called Hicks sign
Fetal outline felt by examiner
about 5 – 6 months of pregnancy, uterus has become thinned to such
degree that a fetal outline w/in the uterus may be palpated through
the abdomen and identified by a skilled examiner

Positive Signs of Pregnancy

There are only 3 positive signs of pregnancy:
Demonstration of a Fetal Heart Separate from the Mother
Fetal Movements Felt by the examiner
Visualization of Fetus by Ultrasound

Demonstration of a Fetal Heart Separate from the Mother

Transabdominal UTZ
growing embryo inside a gestational sac as early as 5th or 6th week
beyond the last menstrual period
Visualization of fetal heart and show it beating as early as 6th or 7th
week of pregnancy
Doppler technique
ultrasonic monitoring systems that convert ultrasonic frequencies to
audible frequencies
detect fetal heart sounds as early as the 10th – 12th week of gestation
Echocardiography
as early as 5 weeks
Auscultation of the abdomen thru ordinary stethoscope – 18 – 24 weeks of
pregnancy (tho’ heart has been beating since the 24th day after
conception)
Fetal heart sounds:
difficult to hear if abdomen has a great deal of subcutaneous fat or in
hydramnios
best heard when position of fetus is determined by palpation
(Leopold’s maneuver) and stethoscope is placed over the area of the
fetus’ back
Fetal heart rate: 120 – 160 beats/minute
 Fetal Movements Felt by the examiner
Fetal movements 1st felt by the woman as early as 16 – 20 weeks of
pregnancy (presumptive sign)
Those felt by an objective examiner are much more reliable (positive
sign)
felt 20th – 24th week of pregnancy, unless woman is extremely obese

Visualization of Fetus by Ultrasound

Characteristic ring, indicating the gestational sac will be revealed on the
oscilloscope screen as early as 4th – 6th week of pregnancy
8th week – fetal outline can be seen so clearly w/in the sac
crown-to-rump length can be measured to establish gestational age of
the pregnancy

Physiologic Changes of Pregnancy

pp. 230 - 242

Physiologic Changes of Pregnancy

Can be categorized as LOCAL (confined to the reproductive organs) or SYSTEMIC (affecting the
entire body)
Both symptoms (subjective findings) and signs (objective findings) of the physiologic changes
are used to diagnose and mark the progress of pregnancy

Local Changes: Reproductive System Changes

Uterine Changes
Uterus increases in size to make room for the growing fetus
Length grows from approx. 6.5 – 32 cm
Depth increases from 2.5 – 22 cm
Width expands from 4 – 24 cm
Weight increases from 50 – 1000 g
Uterine wall thickens (early in pregnancy) from 1 – about 2 cm; toward the end of
pregnancy, thins to become supple and only about 0.5 cm thick
Volume increases from 2 mL to more than 1000 mL; can hold a 7lb (3.175 g) fetus plus
1000 mL of amniotic fluid (total of about 4000 g)

o Great uterine growth is due partly to formation of a few muscle fibers in the uterine
myometrium but principally due to the stretching of existing muscle fibers
o End of 12th week of pregnancy – large enough to be palpated as a firm globe under
the abdominal wall, just above the symphysis pubis
o Uterine growth is constant, steady and predictable
20th – 22nd week = level of the umbilicus
36th week = touch the xiphoid process
o 2 weeks before term (38th week) – primigravida, woman in her 1st pregnancy
fetal head settles into pelvis to prepare for birth, uterus returns to the height it
was @ 36 weeks = termed
LIGHTENING, because woman’s breathing is so much easier it seems, lighten the
woman’s load
o Uterine height is measured from the top of the symphysis pubis over the top of the
uterine fundus
o Uterine blood flow increases during pregnancy as placenta grows and requires more
and more blood for perfusion

Fundic Height
 o Doppler ultrasonography uterine blood flow – from 15 – 20 mL/min (before pregnancy)
to 500 – 750 mL (end of pregnancy)
75% of that volume goes to the placenta
Toward end of pregnancy – 1/6 of the total body blood supply is circulating
through the uterus
Uterine bleeding is always potentially dangerous – vaginal blood loss (suggesting
uterine bleeding), shd. be reported to health care practitioners
o Bimanual examination
one finger of the examiner is placed in the vagina, the other hand on the
abdomen
shows that uterus is more anteflexed (bent forward), larger and softer to the
touch than usual
Hegar’s sign
16th – 20th week fetus is small in relation to the amount of amniotic fluid =
ballottement (French word balloter, meaning to toss about)
Braxton Hicks contractions
12th week
“practice” contractions – serve as warm-up exercises for labor and also increase
placental perfusion
become so strong and noticeable in the last month – may be mistaken from
labor contractions (false labor) – no cervical dilatation
Amenorrhea
Occurs with pregnancy due to suppression of follicle stimulating hormone (FSH)
by rising estrogen levels
Healthy woman – amenorrhea strongly suggests impregnation has occurred
May also indicate onset of menopause, uterine infection, worry over becoming
pregnant, chronic illness (severe anemia, stress)
athletes who train strenuously - %age of body fat drops below critical point –
making amenorrhea only a presumptive sign

Cervical changes
Cervix of the uterus becomes more vascular and edematous – response to the increased level
of circulating estrogen from the placenta during pregnancy
Goodell’s sign) - Softening of the cervix – due to increased fluid between cells
Nonpregnant cervix – tip of nose
Pregnant cervix - earlobe
Just before labor – consistency is like butter or is said to be “ripe” for birth
Darkening of the cervix from a pale pink to violet – due to increased vascularity
Gland of the endocervix undergo both hypertrophy and hyperplasia and distend w/ mucus
Tenacious coating of mucus fills cervical canal
mucus plug, called
operculum – acts to seal out bacteria and helps prevent infection in the fetus and
membranes

Vaginal changes
Vaginal epithelium and underlying tissue become hypertrophic and enriched w/ glycogen
due to influence of estrogen
Structures loosen from connective tissue attachments – in preparation for great distention @
birth
resulting in a white vaginal discharge throughout pregnancy
Chadwick’s sign -Change in the color of the vagina from normal light pink to a deep violet
due to increase in the vascularity of the vagina, increase in circulation
Vaginal secretions fall from a pH of greater than 7 (alkaline) to 4 or 5 (acid pH) – due to the
action of
Lactobacillus acidophilus, bacteria that grow freely in the glycogen enriched environment,
increasing lactic acid content of secretions
Helps make vagina resistant to bacterial invasion for the length of pregnancy
 Change in pH favors growth of Candida albicans – a specie of yeast-like fungi
candidal infection is manifested by itching, burning sensation, cream cheese-like
discharge
Candidal infection in the newborn – thrush or oral monilia

Ovarian changes
Ovulation stops w/ pregnancy – due to the active feedback mechanism of estrogen and
progesterone produced by the corpus luteum (early in pregnancy) and placenta (later)
Feedback causes the pituitary gland to halt production of FSH and LH

Breast changes
One of the 1st physiologic changes in pregnancy (@ about 6 weeks)
feeling of fullness, tingling, or tenderness in her breast – due to increased stimulation of
breast tissue by the high estrogen level
Breast size increases as pregnancy progresses – due to hyperplasia of the mammary alveoli and
fat deposits
Areola of the nipple darkens, diameter s from about 3.5 cm (1.5 in) to 5 or 7 cm (2 – 3 in)
Darkening of skin surrounding the areola in some women – forming secondary areola
Blue veins may become prominent over surface of the breasts – due to increased vascularity of
the breasts
Montgomery’s tubercles – sebaceous glands of the areola – enlarge and become protruberant
Secretions from these glands keep the nipple from cracking and drying during lactation
16th week – the thin, watery, high-protein fluid that is the precursor of breastmilk – can be
expelled from the nipples - colostrum

Systemic Changes

INTEGUMENTARY SYSTEM
As uterus increases in size, abdominal wall must stretch to accommodate it
Stretching (plus possibly adrenal cortex activity) – can cause rupture and atrophy of
small segments of connective layer of the skin
pink or reddish streaks
striae gravidarum appearing on the sides of the abdominal wall and sometimes on
thighs and breasts
Weeks after birth lighten to silvery – white color - striae albicantes or
atrophicae
tho’ permanent, become barely noticeable
Occasionally, abdominal wall has difficulty stretching enough to accommodate growing
fetus causing rectus muscles to actually separate - known as diastasis
Umbilicus is stretched – by 28th week depression becomes obliterated and smooth
because it has been pushed so far outward
Most women – may appear as if it has turned inside out, protruding as a round bump @
the center of the abdominal wall
Linea nigra, melasma – caused by melanocyte-stimulating hormone (secreted by the pituitary)
Vascular spiders – small, fiery-red branching spots, sometimes seen on the skin of pregnant
woman, particularly on the thighs = increased level of estrogen; may fade out but not
completely disappear after childbirth
Increased activity of sweat glands – increase in perspiration
Palmar erythema – redness and itching on the hands; increased estrogen level

Respiratory system
Marked congestion, or “stuffiness” of the nasopharynx response to increased estrogen levels
Pressure from growing uterus diaphragm may be displaced
Crowding of chest cavity causes SOB late in pregnancy until lightening relieves the
pressure
To keep mother’s pH level from becoming acid due to the load of carbon dioxide being shifted
to her by the fetus increased ventilation (mild hyperventilation) to blow off excess CO2 begins
early in pregnancy
Temperature
Early in pregnancy – body temperature increases slightly = due to secretion of progesterone
from the corpus luteum
As the placenta takes over the fxn of the corpus luteum @ about 16 weeks – temperature
usually decreases to normal

Cardiovascular system
Changes in the circulatory system are extremely significant to the health of the fetus
necessary for adequate placental and fetal circulation

Blood Volume
Total circulatory blood volume increases by @ least 30% (as much as 50%) – to provide for
adequate exchange of nutrients in the placenta and to provide adequate blood to compensate
for blood loss @ birth
Blood loss @ normal vaginal birth: 300 – 400 mL
From C/S: 800 – 1000 mL
Increase in blood volume occurs gradually beginning end of 1st trimester
Peaks about the 28th to the 32nd week then continues @ high level throughout 3rd
trimester
Because plasma volume increases faster than RBC production does – concentration of
hemoglobin and erythrocytes decline = giving the woman a pseudoanemia early in pregnancy
Woman’s body compensates by producing more RBC, creating near-normal levels by the
2nd trimester

Iron Needs
Fetus requires a total of about 350 – 400 mg of iron to grow
Increases in the mother’s circulatory RBC mass require an additional 400 mg of iron
Total increased need of about 800 mg
Average woman’s store of iron is less – only about 500 mg
Additional iron is often prescribed to prevent true anemia – because iron absorption is
impaired during pregnancy as a result of decreased gastric acidity (iron is absorbed best
from an acid medium)
Need for folic acid increases more during pregnancy
Not enough intake of folic acid =
megalohemoglobinemia (large, non-functioning RBC)
Inadequate folic acid levels have also been linked to an increased risk for neural tube
disorders in fetus
Eat foods high in folic acid (spinach, asparagus, legumes) during pre-pregnancy and
pregnancy period
Folic acid is also routinely prescribed as a prenatal vitamins

Heart
to handle the increase in blood volume in the circulatory system, a woman’s cardiac output es
significantly, by 25% - 50% - heart has more blood to pump through the aorta
HR es by 10 beats/minute (80 – 90 beats/min)
Because the diaphragm is pushed upward by growing uterus late in pregnancy – heart is shifted
to a more transverse position in the chest cavity (making it appear enlarged on x-ray
examination
Palpitation are not uncommon particularly on quick motion
In early months – due to sympathetic nervous system stimulation
In later months – due to increased thoracic pressure caused by pressure of the uterus
against the diaphragm
Caution women not to feel frightened

Blood Pressure
BP does not normally rise – because the increased heart action takes care of the greater amount
of circulating blood
Most women, BP es slightly during the 2nd trimester – because peripheral resistance to
circulation is lowered as the placenta expands rapidly
3rd trimester – BP rises again to 1st trimester levels
 Peripheral Blood Flow
3rd trimester – blood flow to lower extremities is impaired by the pressure of the expanding
uterus on veins and arteries
in blood flow in the venous system can lead to edema and varicosities of the vulva, rectum
and legs
Supine Hypotension Syndrome
When lying supine, the weight of the growing uterus presses the vena cava against the
vertebrae, obstructing blood flow from the lower extremities
Causes a in blood return to the heart and, consequently ed cardiac output and
hypotension
This maternal hypotension is potentially dangerous because it can cause fetal hypoxia
Feeling of lightheadedness, faintness, and palpitations
Supine Hypotension Syndrome
Can easily be corrected by having the woman turn unto her side (preferably the left side) so that
blood flow through the vena cava es again.
Blood Constitution
Level of circulating fibrinogen, a constituent of the blood necessary for clotting - es as much as
50% during pregnancy
Other clotting factors (factors VII, VIII, IX, and X) and platelet count also es
These es are a safeguard against major bleeding should the placenta be dislodged and the
uterine arteries or veins be opened

Gastrointestinal system
Stomach and intestines are pushed toward the back and sides of the abdomen – due to growing
uterus
Midpoint of pregnancy – intestinal peristalsis and emptying time of stomach is slowed
heartburn (burning sensation in the substernal area due to reflux of acid contents of the
stomach into the esophagus), constipation, and flatulence
Stomach and intestines are pushed toward the back and sides of the abdomen – due to growing
uterus
Midpoint of pregnancy – intestinal peristalsis and emptying time of stomach is slowed
heartburn (burning sensation in the substernal area due to reflux of acid contents of the
stomach into the esophagus), constipation, and flatulence
Relaxin – hormone produced by the ovary – may contribute to decreased gastric motility
At least 50% of women experience some nausea and vomiting early in pregnancy
Most apparent in early morning, on rising, or if woman becomes fatigued during the
day; more frequent in women who smoke cigarettes
Usually subsides after the 1st 3 months, after w/c woman may have a voracious
appetite
Some women notice hypertrophy @ their gum line and bleeding of gingival area when they
brush their teeth
ed saliva formation
hyperptyalism – probably as a local response to increased levels of estrogen
Lower than normal pH of saliva ed tooth decay if tooth brushing is not done
conscientiously

Urinary system
Changes in the urinary system result from the following:
Effects of high estrogen and progesterone levels
Compression of the bladder and ureters by the growing uterus
Increased blood volume
Postural influences
Fluid Retention
to provide sufficient fluid volume for effective placental exchange, total body water es
to 7.5L – requires the body to increase its sodium reabsorption in the tubules to
maintain osmolarity
influence of progesterone ed response of the angiotensin-renin system in the
kidney in aldosterone production
Aldosterone aids in sodium reabsorption
 Water is retained during pregnancy:
to aid the increase in blood volume and
to serve as a ready source of nutrients to the fetus

Renal Function
Woman’s kidneys must excrete not only waste products of her body but also those of
the fetus
Her kidneys must be able to excrete additional fluid and manage the demands of
increased renal blood flow
Kidneys may in size – changing their structure and affecting their function
Urinary output gradually es (by about 60% - 80%)
Specific gravity es
GFR and renal plasma flow begin to increase in early pregnancy to meet the increased
needs of the circulatory system
Renal threshold for glucose decreases and glucose and lactose is frequently seen in the
urine
Traces of albumin may be present in urine – due to congestion in renal capillaries
Ureter and Bladder Function
Increased urinary frequency during 1st trimester (10 – 12 times/day) – until uterus rises
out of the pelvis and relieves pressure on the bladder
May return @ the end of pregnancy – fetal head exerts pressure on bladder
Because of high progesterone levels = ureters in diameter and bladder capacity es
to about 1,500 mL
Pressure of the uterus on the right ureter may lead to urinary stasis and pyelonephritis if
not relieved
Pressure on the urethra = may lead to poor bladder emptying and bladder infection –
dangerous coz it:
may ascend and become kidney infections and
dangerous to fetus coz UTI are associated w/ preterm labor

Skeletal system
Calcium and phosphorus needs are increased – fetal skeleton must be built
As pregnancy advances – gradual softening of the woman’s pelvic ligaments and joints – to
create pliability and to facilitate passage of baby through the pelvis @ birth
Softening is caused by influence of both the ovarian hormone relaxin and placental
progesterone
Excessive mobility of the joints can cause discomfort
Wide separation of the symphysis pubis – as much as 3 – 4 mm by 32 weeks of pregnancy =
makes women walk w/ difficulty because of pain
To change her center of gravity and make ambulation easier – pregnant woman tends to stand
straighter and taller than usual = stance is referred to as the “pride of pregnancy”
Standing this way – shoulders back and abdomen forward = lordosis (forward curve of the
lumbar spine) – may lead to backache

Endocrine system
Most striking change is the addition of placenta as an endocrine organ
Endocrine Gland Changes and Effects During Pregnancy (page 241)

Immune system
Immunologic competency during pregnancy decreases – probably to prevent the woman’s body
from rejecting fetus as if it were transplanted organ
Immunoglobulin (IgG) production is particularly decreased = making woman more prone to
infection during pregnancy
Increase in WBC – may help counteract the decrease in IgG response

Weight
20 – 25 lbs – desirable total weight gain for pregnant woman
Fetus: 7 lbs.
Placenta: 1lb.
Amniotic Fluid : 1 ½ lbs.
Uterus : 2 lbs.
Blood volume : 1 lb.
Weight of breast: 1 ½ lbs.
Weight of additional fluid : 2 lbs
 Chapter 11
Assessing Fetal and Maternal Health

Health Promotion during pregnancy

Purposes of prenatal care:
Establish a baseline of present health
Determine gestational age of the fetus
Monitor fetal devt and maternal wellbeing
Identify women @ risk for complications
Minimize the risk of possible complications by anticipating and preventing probs before
they occur
Provide time for education about pregnancy, lactation and newborn care
Prenatal Management
1st prenatal visit
As soon as mother missed a menstrual period when pregnancy is suspected
Major causes of death for pregnancy:
Ectopic pregnancy, HPN, hemorrhage, embolism, anesthesia-relate complications
(intrapartum cardiac arrest)
Schedule of prenatal visits
Once a month: up to 1st 32 weeks
2 x a month (q 2 weeks): 32 – 36 weeks
4 x a month (q week): 36 – 40 weeks
Presence of danger signals of pregnancy – mother shd be instructed to report promptly for
evaluation
Conduct of initial visit
Baseline data collection
Basis for comparison
To screen for high-risk factors
OB history
Menstrual hx – menarche (onset, regularity, duration, frequency, character)
LMP, sexual hx, methods of contraception
PMP – menstrual period before the LMP
Conduct of Initial visit
Medical and surgical hx
Past illnesses and surgical procedures, current drugs used
Family hx
To detect illnesses or conditions that are transmittable
Current problems
ADL, discomforts, danger signs
Initial and subsequent visits
Vital signs
Temperature
rate: plus 10 – 15 bpm
RR: tend to be rapid and deep (16/min)
BP: tends to be hypotensive w/ supine position
Elevated BP = PIH
Do roll-over test in 1st trimester – for early detection of developing PIH by 20 – 24
weeks
Roll-Over Test
Procedure:
Place mother on LLR
Check BP until stable, may take 10 – 15 mins
Roll to supine
Check BP right away
Wait for 5 mins
Check BP again. Compare w/ 2nd diastolic reading
Interpretation:
Positive: in diastolic pressure greater than 20 mmHG; woman @ risk
Negative: in diastolic pressure less than 20 mmHG

1
Initial and subsequent visits
Weight
Checked in q visit
1st trimester: 1 lb/ mo (3 – 4 lb total)
2nd trimester: 0.9 – 1 lb/week to about 10 – 12 lb
3rd trimester: 0.5 – 1 lb/week 8 – 11 lb*
Weight is a measue of health of a mother
Urine testing for albumin and sugar
Sugar – ideally not more than 1+
Albumin – negative; nephritis
Fetal growth and devt assessment
Fundal height
FHT/FHR
Abdominal palpation
Quickening – 1st plus subsequent movements
Initial and subsequent visits
OB history
4-Point system: past pregnancies and perinatal outcomes (FPAL)
5-Point System: GFPAL
Estimates in Pregnancy
EDC/EDD
Naegele’s Rule
Mittendorf’s Rule
Date of Quickening
Fundic Height
AOG
McDonald’s Rule (2nd and 3rd trimester)
Bartholomew’s Rule of Fours
Estimated fetal weight (EFW)
Johnson’s Rule
Estimated fetal height in cm (EFL)
Haase’s Rule
Complete physical Examination
Includes internal gynecologic and bimanual examinations
Internal examination (IE)
Detects early signs of pregnancy
Chadwick’s, Goodell’s, and Hegar’s signs
Preparations for IE
Explanation
Void before
Proper positioning:
Draping
Instructions:
DON’Ts:
Complete physical Examination
Impt. Concerns of PE:
Breasts: look for changes, adequacy of breasts for breastfeeding, abnormal signs
Abdomen: Fundic height; Leopold’s
Pelvic measurements: done in the 3rd trimester to determine CPD (cephalo-pelvic
disproportions)
Extremities:
Discomforts: leg cramps, varicosities, pedal edema
Danger signs: + Homan’s sign = thrombophlebitis
Laboratory Tests
Blood studies
Complete blood count (CBC)
Hgb: 12 – 16g/dL
Hct: 37 – 47%
Leucocytosis – elevated WBC; normal
– Pregnancy: 5,500 – 11,500/mm3
– Labor: 20,000/mm3
– Postpartum: 25,000/mm3

2
 Blood typing and Rh determination
Accdg to institution protocol, Serology for:
Syphylis (VDRL)
Rubella antibody titer
HIV
Alpha-fetoprotein (AFP) screening @ 16 – 18 weeks’ gestation to rule out neural
defects
Urine Test
Tested for sugar
Bacteria – asymptomatic bareriuria w/c can result in abortion in early pregnancy, and
premature labor, late in pregnancy
Laboratory Tests
Pelvic Lab tests
Collection of pelvic cultures
Pap test, culture for gonorrhea and Chlamydia
Bimanual examination
Usually last part of the initial PE
To identify cervical and uterine changes
Detect uterine size
Assess for deviation in expected shape and size
In all the necessary, prepare the client thru the ff steps:
Providing an explanation of the procedure
Physical prep specific to procedure
Provision of support to client and spouse; encouraging verbalization of concerns
Monitoring of client and fetus after procedure
Documentation prn
Assignment:
Rules in the different estimates in Pregnancy
Discomforts in pregnancy and management/relief measures for each discomfort (Tabulated)
Nutritional considerations:
Nutritional profile: pre-pregnant and current nutritional status
What is Pica?
What are some physical findings indicative of poor nutritional status? (@ least 5)
Factors/ conditions requiring special attention (@ least 5)
Nutrient needs:
Calories
Protein
Carbohydrates
Fiber
Fats
Essential minerals: Iron, calcium, sodium, folic acid, vitamins
Daily food needs/servings (Tabulated)
Food:
Number of servings each

Chapter 12
Promoting Fetal and Maternal Health

Health promotion during pregnancy begins with reviewing self-care

Self-Care Needs
Because pregnancy is not an illness, few special care measures other than common sense about self-
care are required

Average woman needs some help separating fact from fiction so that she can enjoy her pregnancy
unhampered by unnecessary restrictions

Be alert to the common misunderstandings, misconceptions, or inappropriate information of

pregnancy

Bathing

3
 Chapter 12
Promoting Fetal and Maternal Health

Health promotion during pregnancy begins with reviewing self-care

Self-Care Needs
Because pregnancy is not an illness, few special care measures other than common sense
about self-care are required
Average woman needs some help separating fact from fiction so that she can enjoy her
pregnancy unhampered by unnecessary restrictions
Be alert to the common misunderstandings, misconceptions, or inappropriate information of
pregnancy

Bathing

Misconceptions:

Tub baths restricted @ one time – water would enter the vagina and cervix and
contaminate the uterine contents
Hot water touching the abdomen might initiate labor

Truths:
Normally vagina is in a closed position – danger of tub bath entering the cervix is
minimal
Water temperature has no documented effect on initiating labor

During pregnancy, sweating tends to because woman excretes waste products for
herself and the fetus
Vaginal discharge ed

Daily tub baths and showers are now recommended

As pregnancy advances – woman may have difficulty maintaining her balance when
getting in and out of a bath tub
change to showering or sponge bathing for her own safety
If membranes rupture or vaginal bleeding present
tub baths contraindicated because of danger of contamination of uterine contents
During last month of pregnancy, when uterine cervix may begin to dilate
some health care providers restrict tub bathing

Breast Care
Woman shd wear a firm, supportive bra w/ wide straps to spread weight across the
shoulders
May need to buy a larger bra halfway through pregnancy – to accommodate ed breast
size
If plans to breastfeed – choose bras suitable for breast-feeding so she can continue to use
them after baby’s birth

16th week of pregnancy – colostrum secretion begins in the breast

Sensation of a fluid discharge can be frightening unless woman is warned that this is a
possibility
Instruct to wash her breasts w/ clear tap water daily (no soap coz it could be drying) –
to remove colostrum and reduce risk of infection
Dry her nipples well by patting them
If colostrum secretion is profuse
need to place gauze or breast pads inside her bra, change frequently – to
maintain dryness
constant moisture next to nipple can cause excoriation, pain, and fissuring
Dental Care
Gingival tissue hypertrophy during pregnancy
Unless woman brushes well, pockets of plaque form readily bet. enlarged gumline and
teeth
Encourage to see dentist regularly for routine examination and cleaning – 9 months is a
fairly long time to be w/o preventive dental care
Woman should question the need for x-rays during pregnancy – if necessary, abdomen
should be shielded w/ a lead apron
Tooth decay occurs from the action of bacteria on sugar = lowers pH of the mouth, creating
an acid medium etching or destruction of the enamel of teeth
Encourage to snack on nutritious foods – fresh fruits and vegetables (apples, carrots) to
avoid sugar coming in contact w/ teeth
If w/ trouble avoiding sweet snacks – suggest those that dissolve easily (chocolate bar)
to minimize the level of sugar in the mouth

Perineal Hygiene
Douching is contraindicated
force of irrigating fluid could enter cervix and lead to infection
Douching alters pH of the vagina = ed risk of bacterial growth

Dressing
Garters
extremely firm girdles w/ panty legs May impede lower extremity circulation
knee-high stockings

Suggest: shoes w/ moderate to low heel – to minimize pelvic tilt and backache

Sexual Activity
Many need information to refute some myths about sexual relations in pregnancy that still
exists, such as:
Coitus on expected date of period will initiate labor
Orgasm will initiate labor; sexual relations w/o orgasm will not cause labor
Coitus during fertile days of a cycle will cause a 2nd pregnancy or twins
Coitus might cause rupture of membranes
Asking a woman @ a prenatal if she has any questions about sexual activity – allows her to
voice concerns; nurse can help dispel myths
Coitus is contraindicated in the ff. conditions:
Hx of spontaneous miscarriage
Ruptured membranes
Vaginal spotting
Deeply engaged presenting part
Advise caution about male oral – female genital contact = accidental air embolism has been
reported from this act during pregnancy
Couple shd be advised to find a comfortable position for intercourse
w/ non-monogamous sexual partner – partner needs to use a condom to prevent STIs
during pregnancy
women may use female condom throughout pregnancy
Sex in moderation is permitted but not during the last 6 weeks of pregnancy – increase
incidence of postpartum infection in women who engage in sex during the last 6 weeks

Exercises
Important during pregnancy to prevent circulatory stasis in the lower extremities
to strengthen the muscles used in labor and delivery
it also offers a general feeling of well-being
Should be done in moderation
Exercise Programs:
Exercises that target large muscle groups rhythmically – e.g. walking, are best
Intensity of exercise program depends on the woman’s cardiopulmonary fitness
Before any exercise program – woman must consult her physician or nurse-midwife
 If any complication of pregnancy occurs – e.g. bleeding or PIH – discontinue until she
rechecks w/ primary health care provider about continuing
Exercise shd be individualized – accdng to age; physical condition; customary amount of
exercise (e.g. swimming, tennis), not C/I unless done the first time; stage of pregnancy
Swimming may help relieve backache
Membranes shd be intact
Walking – best exercise
Shd be encouraged to take daily walks unless bad weather, many levels of stairs or
unsafe neighborhood will not permit

Sleep
The optimal condition for body growth occurs when growth hormone secretion is @ its
highest level – that is, during sleep
This, plus overall increased metabolic demand of pregnancy – appears to be the physiologic
reason pregnant women need an ed amount of sleep or @ least rest to build new body
cells during pregnancy
Pregnant women rarely have difficulty falling asleep @ night
Trouble falling asleep – drink a glass of warm milk may help
Relaxation techniques – lying quietly, systematically relaxing neck muscles, shoulder
muscles, arm muscles, and so on = may also be effective
Late in pregnancy – awakening @ short, frequent intervals by the activity of the fetus
Leads to loss of REM sleep
On rising, may feel anxious or not well-rested
May also awaken w/ pyrosis or dyspnea, if she has been lying flat – sleeping on 2 pillows or
on a couch w/ an armrest may be helpful
Rest period during the afternoon and full night of sleep – needed to obtain enough sleep
and rest during pregnancy
Modified Sim’s position w/ top leg forward
good resting or sleeping position
Puts weight of the fetus on the bed, not on the woman, and allows good circulation in
the lower extremities

Avoid resting in a supine position

prevent supine hypotension syndrome
Avoid resting w/ knees sharply bent either when sitting or lying down
minimize risk of venous stasis below the knee

Employment
Not contraindicated unless it entails:
exposure to toxic substances
lifting heavy objects
other kinds of physical strains
long periods of standing
or having to maintain body balance
Advise to walk about every few hours to break long periods of standing or sitting to
promote circulation

Travel
Early in a normal pregnancy – no travel restriction
Susceptible to motion sickness – shd not take any medication unless specifically
prescribed or approved by physician or nurse-midwife
Late in pregnancy – travel plans shd take into consideration the possibility of early labor,
requiring birth @ a strange setting where woman’s health history will be unknown
 Advise a woman taking long trip by automobile:
Plan for frequent rest or stretch periods q hour
Q 2h, shd get out of the car and walk short distance – relieve stiffness and muscle ache;
improve lower extremity circulation = preventing varicosities, hemorrhoids and
thrombophlebitis
Traveling by plane – not C/I; as long as plane has a well-pressurized cabin
Some airline do not permit women who are more than 7 months pregnant
Others require written permission from woman’s primary care provider
Advise to inquire about these restrictions by calling airline
Advise additional immunizations (cholera vaccines) if traveling internationally
All live virus vaccines (measles, mumps, rubella, yellow fever) – C/I during pregnancy,
and shd not be administered unless risk of disease outweighs risk to the pregnancy

DISCOMFORTS OF PREGNANCY

Discomforts of Early Pregnancy: The First Trimester

Breast Tenderness - one of the first symptom
*Encourage woman to wear a bra with a wide shoulder strap for support and dress
warmly to avoid cold drafts.
Palmar Erythema- palmar pruritus; occurs early in pregnancy caused by ed estrogen
levels.
*Use Calamine lotion
Constipation – As the weight of the growing uterus presses against the bowel and peristalsis
slows.
Nausea, Vomiting and Pyrosis
Fatigue - due to increased metabolic requirements.
Muscle Cramps -Decreased serum calcium levels, ed serum phosporus levels & possibly,
interference with circulation.
*Best relieved if woman lies on her back and extends her involved leg while keeping her
knee straight & dorsiflexing the foot.
Hypotension –
Varicosities -or the development of tortous leg veins – bec. of the weight of the distended
uterus – causes pooling of blood & distention of the vessels.
Hemorrhoids – varicosities of the rectal vein; pressure from the bulk of the growing uterus.
Heart Palpitations - due to the circulatory adjustments necessary to accomodate her ed
blood supply during pregnancy.
Frequent Urination – last for 3 months; disappear in midpregnancy when the uterus rises
above the bladder.
Abdominal Discomforts – experienced a pulling – when standing up quickly – sometimes
sharp & frightening pain in the right or left lower abdomen from tension on a round
ligament.
Leukorrhea - a whitish, viscous vaginal discharge or an ed in the amount of normal vaginal
secretions - estrogen levels & ed blood supply.

Discomforts of Middle to Late Pregnancy

Backache –as pregnancy advances, a lumbar lordosis occurs and postural changes necessary
to maintain balance –may lead to backache.
Headache –
Dyspnea –
Ankle Edema
Braxton Hicks Contractions

DANGER SIGNS OF PREGNANCY

Vaginal Bleeding
Persistent Vomiting
Chills and Fever
Sudden escape of clear fluid from the vagina
Abdominal or chest pain
Pregnancy-induced hypertension
Increased or decrease in fetal movement
 Preparing for Labor

Lightening - is the settling of the fetal head into the inlet of the true pelvis.
- occurs approx. 2 weeks before labor in primiparas but unpredictable times
in multiparas.
Show - is the common term used to describe the release of the cervical plug
(operculum) that formed during pregnancy. It consists of mucous, often blood-streaked
vaginal discharge & indicates the beginning of cervical dilatation.
Rupture of the membranes – a sudden gush of clear fluid (amniotic fluid) from the
vagina indicates rupture of the menbranes.
Excess Energy – feeling extremely energetic – is a sign of labor impt. for women to
recognize.
- occurs as part of the body’s physiologic preparation for labor.
Uterine Contractions – true labor contractions usually start in the back and sweep
forward across the abdomen like the tightening of band.
- gradually increase in frequency and intensity.
 1
CHAPTER 14
PREPARATION FOR CHILDBIRTH AND PARENTING

CHILDBIRTH EDUCATION
Began initially to encourage women to come for prenatal care
Goal: to prepare expectant parents emotionally and physically for childbirth while promoting
wellness behaviors that can be used by parents and families for life

CHILDBIRTH EDUCATORS
Healthcare providers w/ professional degree in the helping professions; w/ certificate from a
course specifically on childbirth education
Teach expectant parents – physical and emotional aspects of pregnancy, childbirth, early
parenthood, coping skills and labor support techniques
Nurses play a major role in designing and teaching
Methods of teaching:
Group format
Video tapes, slides
Lecture
Demonstration (relaxation and breathing techniques)
Group interaction

EFFICACY OF CHILDBIRTH EDUCATION COURSES

satisfaction, reduce amount of reported pain, feelings of control
Can proportion of new mothers who breastfeed

Preconception Classes
For couples who:
Are planning to get pregnant usually w/in the next year
Want to know more about what they can expect a pregnancy to be like, and
what are birth setting/procedure choices available
stress that pregnancy brings w/ it psychological as well as physical changes
recommended dietary modifications – folic acid intake

Expectant Parenting Classes

for couples already pregnant
focus on family health during pregnancy
covers topics such as:
psychological and physiological changes of pregnancy
pregnancy nutrition
newborn care
lasts 4 – 8 hrs over a 4- to 8-week period
both women and support people are invited
curriculum – individualized

Sibling Education Classes

organized to acquaint older brothers and sisters w/ what happens during birth and what they can
expect a newborn to look like and act like
review how babies grow and things children can do to help their mother during a pregnancy
age-appropriate information and activities must be provided for classes to be successful

Breast-Feeding Classes
designed to help women learn more about breast-feeding
so they not only choose breast-feeding over bottle-feeding but also continue w/ breast-feeding for
@ least 6 months following child’s birth
covers physiology of breast-feeding, psychological aspects
 2
PREPARATION FOR CHILDBIRTH CLASSES
preparation for childbirth classes focus on:
explaining the birth process (rather than pregnancy) and
ways to prevent or reduce the pain of childbirth
Common goals are to:
Prepare expectant mother and her support person for the childbirth experience
Create clients who are knowledgeable consumers of obstetric care
Help clients reduce and manage pain w/ both pharmacologic and non-pharmacologic
methods
Help the couple’s overall enjoyment of and satisfaction w/ the childbirth experience
Includes teaching about normal labor, exercises to prepare body for labor, methods of pain
prevention or relief in labor

PERINEAL AND ABDOMINAL EXERCISES

Encourage women to maintain an overall active exercise program during pregnancy – may help
prevent the need for cesarean birth

In childhood preparation classes – women learn specific exercises to strengthen their pelvic and
abdominal muscles and make these both stronger and more supple
Allow for ready stretching during birth
Reduce discomfort, and
Help muscles revert more quickly to their normal condition and function more efficiently
after childbirth

Women shd not participate in a formal exercise program w/o physician’s or nurse-midwife’s
approval of
Shd not attempt to exercise if any of the danger signs of pregnancy appear; not to the point of
fatigue
Incorporate into daily activities
Initially – do each exercise only a few times gradually ing the # each session

TAILOR SITTING
Shd be done in a way that stretches the perineal muscles w/o occluding blood supply to the lower
legs
shd not put one ankle on top of the other – but PLACE ONE LEG IN FRONT OF THE OTHER
gently push on her knees toward the floor until she feels her perineum stretch
while watching TV, reading, talking on the phone
done @ least 15 minutes everyday

SQUATTING
stretches perineal muscles; useful for 2nd stage of labor
15 minutes/day
Woman must keep her feet flat on the floor
Incorporate into daily activities – picking up toys, etc

PELVIC FLOOR CONTRACTIONS (KEGEL EXERCISES)

Can be done while sitting, working around the house
Done by tightening the muscles of the perineum
Helpful in the postpartum period to reduce pain and promote perineal healing
Long-term effects of increasing sexual responsiveness and helping prevent stress incontinence
 3
ABDOMINAL MUSCLE CONTRACTION
Help strengthen abdominal muscles during pregnancy
May prevent constipation
Help restore abdominal tone after pregnancy
Strong abdominal muscles = effective 2nd stage pushing during labor
Done while standing or lying along w/ pelvic floor contractions
Woman tightens her abdominal muscles, then relaxes them
Repeat as often as she wishes during the day

“Blowing out a candle”

Deep inspiration, exhale normally
Finger 6” in front of herself (like a candle), exhale forcibly, out residual air from lungs –
feeling abdominal muscles contract as she reaches end of forcible exhalation

PELVIC ROCKING
Helps relieve backache during pregnancy and early labor by making lumbar spine more flexible
Can be done in a variety of positions:
On hands and knees
Lying down
Sitting or standing
Woman arches her back – trying to lengthen or stretch her spine
Holds the position for 1 minute, then hollows her backpack
Can be done 5x/day – to relieve back pain and make her comfortable for the night

METHODS FOR PAIN MANAGEMENT

Beginning late 1950s – many specific methods for non-pharmacologic pain reduction during labor
were developed
Lamaze, Dick-Read, Bradley methods
Childbirth education – moving away from strict method approaches to more eclectic/diverse ones
Much research are being done – to verify the effectiveness of each of these many techniques
Most of the methods advocated are based on 3 premises:

1. Discomfort during labor can be minimized if a woman comes into labor informed about what is
happening and prepared w/ breathing exercises to use during contractions.
Learns about her body’s response in labor
Mechanisms involved in childbirth
Breathing exercises
2. Discomfort can be minimized if the woman’s abdomen is relaxed and the uterus is allowed to rise
freely against the abdominal wall w/ contractions.
3. Pain perception can be altered by distraction techniques or by the gating control theory of
pain perception
Similar to closing a gate
Gate control mechanisms – halting an impulse @ the level of the spinal cord so it is never
perceived @ the brain level as pain

THE BRADLEY (PARTNER – COACHED) METHOD

Originated by Robert Bradley
Childbirth is a joyful, natural process and stresses the important role of a woman’s partner during
pregnancy, labor, and the early newborn period
During pregnancy:
Woman performs muscle-toning exercises, and
Limits or omits foods that contain preservatives, animal fat, or a high salt content
 4
During labor:
Pain is reduced by abdominal breathing
Woman is encouraged to walk, and
Use an internal focus point as a disassociation technique

THE PSYCHOSEXUAL METHOD

Sheila Kitzinger; England; during the 1950s
Stresses that pregnancy, labor, and birth, and the early newborn period are important points in a
woman’s life cycle

program of conscious relaxation Encourages woman to

“flow with” rather than
levels of progressive breathing struggle w/ contractions

THE DICK – READ METHOD

proposed by Grantly Dick-Read, English physician
fear leads to tension, w/c leads to pain
if one can prevent this chain of events from occurring or break the chain between fear
and tension or tension and pain, then one can reduce the pain of contractions
relaxation and reduced pain is achieved by focusing on abdominal breathing during
contractions

THE LAMAZE METHOD

based on the gating control theory of pain relief
through stimulus – response conditioning, women can learn to use controlled breathing to reduce
pain during labor
originally – psychoprophylactic method
focuses on preventing pain in labor (prophylaxis), and
use of the mind (psyche)
popularized by Ferdinand Lamaze, French physician; but developed in Russia

6 Major concepts:
1. Labor should begin on its own, not artificially induced
2. Women should be able to move about freely throughout labor, not confined to bed
3. Women should receive continuous support during labor
4. No routine interventions (IVF) are needed
5. Women should be allowed to assume a non-supine (upright or side-lying) position for birth
6. Mother and baby should be housed together following birth, w/ unlimited opportunity for
breast-feeding

3 main premises taught in the prenatal period related to gating control method of
pain relief:

1. Pain occurs to a lesser extent if a woman is relaxed.

Familiarity w/ what will happen in labor and the nature of contractions – couple can
enter labor w/ ed tension
2. Sensations such as uterine contractions can be blocked from reaching the brain cortex and
registering as pain through active interventions.
Concentrate on breathing
patterns To block
Use imagery or focusing
incoming pain
(concentrating) on a specified
object sensations
 5
3. Conditioned reflexes can also be used to displace pain during labor.
Conditioned reflexes – automatically occur in response to a stimulus
woman is conditioned to relax automatically on hearing a command – “Contraction
beginning”; or on the feel of a contraction beginning
responses to contractions must be recently conditioned to be effective – may fade if
not reinforced
women shd attend class in the last trimester

advise a woman to bring a support person w/ her to class to practice breathing exercises w/ her

Common features taught in Lamaze classes:

CONSCIOUS RELAXATION
Learning to relax body portions deliberately so that, unknowingly a woman does not remain tense
and cause unnecessary muscle strain and fatigue during labor
practices during pregnancy by deliberately relaxing one set of muscles, then another .
. . until body completely relaxes
support person – concentrates on noticing symptoms of tension:
wrinkled brow
Placing hand on tensed body area
clenched fists
telling woman to relax that area
stiffly held arm

CLEANSING BREATH
To begin all breathing exercises: Woman breathes in deeply and then exhales deeply =
cleansing breath
• Repeated to end each exercise
This limits the possibility of hyperventilation – happens w/ rapid breathing patterns = helps
ensure an adequate fetal O2 supply
if woman becomes light-headed during labor from hyperventilation (respiratory alkalosis) =
breathe into a paper bag (re-breathing of exhaled CO2)

CONSCIOUSLY CONTROLLED BREATHING

set breathing patterns @ specific rates
• provides distraction
• as well as prevents the diaphragm from descending fully and putting pressure on the
expanding uterus
To practice:
woman inhales comfortably but fully, then exhales (exhalation a little stronger than
inhalation) – to help prevent hypoventilation
@ a controlled pace, depending on the intensity of contractions
Woman who can perform breathing @ various levels and maintaining relaxation – is prepared to
handle all labor contractions up to the 2nd stage of labor

EFFLEURAGE
to encourage relaxation and displace pain in the Lamaze method
Effleurage – French; light abdominal massage, done with just
enough pressure to avoid tickling
Woman traces a pattern on her abdomen w/ her
fingertips
Rate of effleurage shd remain constant even though
breathing rates change
 6
Serves as a distraction technique and es sensory stimuli transmission from the abdominal wall
– helping limit local discomfort

FOCUSING OR IMAGERY
Focusing intently on an object – “sensate focus”
Another method of keeping sensory input from reaching the cortex of the brain
woman brings into labor photograph, graphic design, or just something that appeals to her
concentrates on it during contractions
use of imagery – imagining they are in a calm place

SECOND – STAGE BREATHING

holding breath for a prolonged time impairs blood return from the vena cava (Valsalva
maneuver)= now discouraged
teach women to breathe out while pushing may be helpful = physiologic pushing
women shd not practice pushing – possibility membranes will rupture
practice assuming a good position for pushing (squatting, sitting upright, leaning on partner)

THE BIRTH SETTING

setting for birth that a couple chooses depends on the:

woman’s health and that of her fetus
couple’s preferences on how much supervision they desire @ birth

CHOOSING THE APPROPRIATE SETTING

Women having uncomplicated pregnancies – may choose hospitals, birthing centers, or their
homes as settings for birth
Women w/ high-risk pregnancies – less choice; advised to give birth @ hospitals, where
immediate emergency care is available

CHOOSING A BIRTH ATTENDANT AND SUPPORT PERSON

US – supervised by an obstetrician
Family medicine practitioners
Nurse – midwives

Support person:
Past years: offered by experienced women in the community
1960s: father of the baby
Today: both men and women; doula (person specially prepared to assist w/ birth)

HOSPITAL BIRTH
Major advantage: supplies and expert personnel are readily available if mother or newborn should
have a complication
Evaluating studies: Women who gave birth in hospitals invariably have more complications than
those who gave birth in other settings

Birthing room
Labor-delivery-recovery rooms (LDRs)
Labor-delivery-recovery-postpartum rooms (LDRPs)
Decorated in a home-like way
Couples can bring favorite music or reading materials – to use during labor
Bed can be used as labor bed until birth – converts into a birthing bed or lithotomy position
bed
Minimum analgesia and anesthesia
Support person and other family members can stay w/ woman throughout labor and birth –
more control over their birth experience
 7
Supine recumbent position (on her back w/ knees flexed) – reduces tension on the perineum
= fewer perineal tears than lithotomy position

Birthing chairs
Comfortable reclining chairs w/ a slide-away seat
Allows a woman to assume a comfortable position during labor
Furnishes perineal exposure so a birth attendant can assist w/ the birth
Maintains the woman in a semi-Fowler’s position – acts w/ gravity and so may speed 2nd stage
of labor

POSTPARTUM CARE
Encourage mothers to breast-feed immediately
Urge couples to keep infant w/ them – ample time to become acquainted
Women who gave birth in:
LDRPs – remain in the room w/ their families for the rest of the hospital stay
Birthing rooms – transferred to postpartum unit
Both LDRPs and postpartum unit – serve as “rooming – in” units in w/c the infant
remains in the mother’s room for most of the day

Rule: Breast-feeding on demand for infants

no restrictions on visiting for primary support persons
siblings of the newborn should be allowed to visit @ least once

ALTERNATIVE BIRTHING CENTERS (ABCS)

wellness – oriented childbirth facilities
designed to remove childbirth from the acute care hospital setting while still providing enough
medical resources for emergency care shd a complication of labor and birth arise
located w/in or near a hospital, or @ least w/in easy distance
w/ LRDPs; birth attendants are nurse-midwives
encourage a woman to express her own needs and wishes during the labor process:
minimum of analgesia or anesthesia is provided – recovers quickly after birth and ready to be
discharged early
woman can choose a birth position
can bring her own music, or distraction objects
partner can cut the umbilical cord if he/she chooses
remain from 4 – 24 hours after birth

HOME BIRTH
usual mode of birth in developing countries
under supervision of nurse – midwives (more likely choice)
physician may also supervise
Main advantage – allows for family integrity:
Woman and her family are not separated
baby can be immediately integrated in to the family

Disadvantages:
Puts responsibility on a woman to prepare her home for the birth (difficult if she is
exhausted towards the end of pregnancy), and
To take care of the infant after birth
Interference w/ the “taking-in phase” (1st postpartum phase) because woman must
“take hold”
Woman must independently monitor her postpartal status
 8
Candidate for home birth:
Woman must be in good health
Able to adjust to changing circumstances
Must have adequate support people who will sustain her during labor and assist her for
the 1st few days after birth

ALTERNATIVE METHODS OF BIRTH

Leboyer Method
Frederick Leboyer – French obstetrician
Postulated that moving from a warm, fluid-filled intrauterine environment to a noisy, air-filled,
brightly lit birth room creates major shock for a newborn
Birthing room is darkened – no sudden contrast of light
Kept pleasantly warm, not chilled
Soft music played, or harsh noises are kept to a minimum
Infant handled gently
Cord is cut late – can lead to excess blood viscosity in the newborn
Infant placed immediately after birth into a warm-water bath – could reduce spontaneous
respirations and allow high level of acidosis to occur

Hydrotherapy and Water Birth

reclining or sitting in warm water during labor can be soothing

feeling of weightlessness
that occurs underwater Contribute to
relaxation from the
warm water
reducing
allow women to labor in warm showers or discomfort in labor
give birth in spa tubs of warm water

baby is born under water then immediately brought to the surface for a first breath

Potential difficulties:
Contamination of bath water w/ feces expelled w/ pushing efforts during 2 nd stage of
labor = uterine infection in the mother
Aspiration of bath water by the fetus = pneumonia
Maternal chilling when she leaves the water

Advise women choosing this method that research on safety and wisdom of the method is
ongoing
 Chapter 15
Caring for a Woman During Vaginal Birth

Theories of Labor Onset

LABOR – series of processes by w/c the mature, or almost mature, products of conception are expelled from the
mother’s body

The trigger that converts the random, painless Braxton Hicks contractions into strong, coordinated, productive
labor contractions is unknown

Although a number of theories have been proposed to explain why labor begins, it is believed that labor is
influenced by a combination of factors originating from the mother and the fetus

These factors include the following:

Uterine muscle stretching, w/c results in release of prostaglandins (Uterine Stretch Theory)
Pressure on the cervix – w/c stimulates the release of oxytocin from the posterior pituitary (Oxytocin
Theory)
Oxytocin stimulation – w/c works together w/ prostaglandins to initiate contractions
Change in the ratio of estrogen (stimulating effect) to progesterone (relaxing effect)– stimulates uterine
contraction
Placental age – w/c triggers contractions @ a set point (Placental Degeneration Theory)
At the end of 8th month, thrombosis formed on the venous sinus of the placenta – will impair
circulation to the placenta = causing it to age or senile = causing it to be incapable in providing
hormone and nutrient to the fetus = termination of pregnancy
Rising fetal cortisol levels w/c reduce progesterone formation and prostaglandin formation
(Progesterone Deprivation Theory)
Fetal membrane production of prostaglandin – w/c stimulates contractions

Signs of Labor

Preliminary Signs of Labor

Before labor, a woman often experiences subtle signs that signal onset of labor
All pregnant women should be taught these signs so that they can recognize when labor is beginning

1. Lightening
Primiparas: lightening or descent of the fetal presenting part in to the pelvis – occurs approximately 10 –
14 days before labor begins
Changes a woman’s abdominal contour – uterus becomes lower and more anterior
Gives woman relief from the diaphragmatic pressure and SOB that she has been experiencing
Multiparas: not as dramatic as in primiparas – usually on the day of labor or even after labor has begun
As fetus sinks lower into the pelvis, mother may experience:
shooting leg pains – from the ed pressure on sciatic nerve
increased amounts of vaginal discharge, and
urinary frequency from pressure on the bladder

2. Increase in Level of Activity

woman may awaken on the morning of labor full of energy – in contrast to her feelings of chronic
fatigue
related to in epinephrine release initiated by a in progesterone produced by the placenta
additional epinephrine prepares a woman’s body for the work of labor ahead

3. Braxton Hicks Contractions

Last week or days before labor begins – extremely strong Braxton Hicks contractions, w/c she may
interpret as true labor contractions
Primiparas may have difficulty distinguishing the 2 forms of contractions
DIFFERENCE BETWEEN TRUE AND FALSE LABOR CONTRACTIONS (TABLE 18.1, P. 490)

FALSE CONTRACTIONS TRUE CONTRACTIONS

Begin and remain irregular
Felt 1st abdominally and remain confined to the
abdomen and groin
Often disappear w/ ambulation and sleep
Do not increase in duration, frequency, or intensity
Begin irregularly but become regular and predictable
Felt 1st in lower back and sweep around to the
abdomen in a wave
Continue no matter what the woman’s level of
activity
Increase in duration, frequency, and intensity
 Do not achieve cervical dilatation Achieve cervical dilatation
4. Ripening of the Cervix
An internal sign seen only on pelvic examination
Throughout pregnancy – “Goodell’s sign”
At term – “butter – soft,” and tips forward
Ripening is an internal announcement that labor is very close @ hand

Signs of True Labor

Involve uterine and cervical changes
Knowledge about true labor signs may be helpful to:
o Prevent preterm birth, and
o Feel secure knowing what is happening during labor

1. Uterine Contractions
Productive uterine contractions – surest sign that labor has begun
Contractions are involuntary and come w/o warning –their intensity can be frightening in early labor
Breathing exercises offers her a sense of control to the discomfort due to contractions

2. Show
As cervix softens and ripens, mucus plug that filled the cervical canal during pregnancy (operculum) is
expelled
Exposed cervical capillaries seep blood as a result of pressure exerted by the fetus
Blood mixed w/ mucus, takes on a pink tinge = “show” or “bloody show”

3. Rupture of the Membranes

Experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina
amniotic fluid continues to be produced until delivery of the membranes after the birth of the fetus – no
labor is ever “dry”
early rupture may be advantageous if it causes the fetal head to settle snugly into the pelvis – this can
actually shorten labor
2 Risks w/ ruptured membranes:
Intrauterine infection
Prolapse of the umbilical cord – can cut off the O2 supply to the fetus
If labor has not spontaneously occurred by 24 hours after membrane rupture and pregnancy is @ term –
labor is induced to help these risks

Components of Labor
A successful labor depends on 4 integrated concepts (4 P’s):

1. The woman’s pelvis is of adequate size & contour (THE PASSAGE)

2. The fetus of appropriate size and in an advantageous position and presentation (THE PASSENGER)
3. Uterine factors are adequate (THE POWERS OF LABOR)
4. A woman’s PSYCHE is preserved, so that afterward labor can be viewed as a positive experience

PASSAGE
Refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum
Since the cervix and vagina are contained inside the pelvis, a fetus must also pass through the bony pelvic ring
For a fetus to pass thru the pelvis – pelvis must be of adequate size
2 pelvic measurements that are important to determine adequacy of the pelvic size:
Diagonal conjugate (anterior – posterior diameter of the inlet) – the narrowest diameter @ the
pelvic inlet
Transverse diameter of the outlet – the narrowest @ the outlet

PASSENGER
The passenger is 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
thru the pelvic ring
Whether a fetal skull can pass or not depends on both its structure (bones, fontanelles, and suture lines) and its
alignment w/ the pelvis

Structure of the Fetal Skull

Cranium – uppermost portion of the skull; comprises 8 bones:
4 superior bones: frontal (actually 2 fused bones), 2 parietal, the occipital – bones important in
childbirth
Other 4 bones of the skull: sphenoid, ethmoid, and 2 temporal bones – lie @ the base of the
cranium; they are of little significance in childbirth; never presenting parts
Chin – referred to by its Latin name mentum – can be a presenting part
 Bones of the skull meet @ the suture lines:
Sagittal suture – joins the 2 parietal bones of the skull
Coronal suture – line of juncture of the frontal bones and the 2 parietal bones
Lambdoid suture – line of juncture of the occipital bone and the 2 parietal bones
Suture lines are important in birth because as membranous interspaces, they allow the cranial bones to move
and overlap, molding or diminishing the size of the skull so that it can pass thru the birth canal more readily

Fontanelles – membrane-covered spaces found @ the junction of the main suture lines
Anterior fontanelle (bregma) – lies @ the junction of the coronal and sagittal sutures; diamond-
shaped – 4 bones are involved @ this junction (frontal and 2 parietal bones); anteroposterior
diameter measures approximately 3 – 4 cm; transverse diameter, 2 – 3 cm
Posterior fontanelle – lies @ the junction of the lambdoidal and sagittal sutures; triangular shape – 2
parietal bones and occipital bone are involved @ this junction; smaller than the anterior fontanelle,
measuring approximately 2 cm across its widest part
Fontanelle spaces compress during birth to aid in molding of the fetal head
Their presence can be assessed manually thru the cervix after it has dilatated during labor
This helps to establish the position of the fetal head and whether it is in a favorable position for birth
The space between the 2 fontanelles is referred to as vertex
The area over the frontal bone is referred to as the sinciput
The area over the occipital bone – occiput

Diameters of the Fetal Skull

The shape of the fetal skull causes it to be wider in its anteroposterior diameter than in its transverse
diameter
To fit thru the birth canal best, fetus must present the smaller diameter (transverse diameter) to the smaller
diameter of the maternal pelvis – otherwise progress can be halted and birth may not be accomplished
The diameter of the anteroposterior fetal skull depends on where the measurement is taken:
Narrowest diameter (approximately 9.5 cm) – is from the inferior aspect of the occiput to the center
of the anterior fontanelle = suboccipitobregmatic diameter
Occipitofrontal diameter – measured from the bridge of the nose to the occipital prominence;
approximately 12 cm
Occipitomental diameter – widest anteroposterior diameter; approximately 13.5 cm; measured from
the chin to the posterior fontanelle

The anteroposterior diameter that will be presented to the birth canal is determined by the degree of flexion
of the fetal head:
• Full flexion – fetal head flexes so sharply the chin rests on the thorax, and the smallest anteroposterior
diameter, the suboccipitobregmatic, is presented to the birth canal
• Moderate flexion – occipitofrontal diameter is presented
• Poor flexion – head hyperextended; largest diameter (occipitomental) will present
Molding
The change in shape of the fetal skull produced by the force of uterine contractions pressing the vertex of the
head against the not-yet-dilatated cervix
Pressure causes bones of the fetal skull to overlap (not yet completely ossified) and cause the head to become
narrower and longer – a shape that facilitates passage through the rigid pelvis
Only lasts a day or two and is not permanent
Little molding – brow as presenting part because frontal bones are fused
No skull molding – breech presentation, because the buttocks, not the head are presented 1 st

Fetal Presentation and Position

Attitude – describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to
each other
• Good attitude – is in complete flexion; spinal column is bowed forward, the head is flexed forward so
much that the chin touches the sternum, arms are flexed and folded on the chest, thighs flexed onto
the abdomen, and calve pressed against posterior aspect of the thighs
This normal “fetal position” – advantageous for birth – helps a fetus present the smallest
anteroposterior diameter of the skull to the pelvis, and puts the whole body into an ovoid
shape, occupying the smallest space possible
• Moderate flexion – chin is not touching the chest but is in an alert or “military position”
Occipitofrontal diameter (2nd widest anteroposterior diameter) as presenting
Does not usually interfere w/ labor – later mechanisms of labor (descent and flexion), fetus is
forced to flex the head fully
 • Poor flexion – back is arched, neck is extended; fetus is in complete extension = occipitomental
diameter to the birth canal (face presentation)
Less than normal amount of amniotic fluid present (oligohydramnios) – does not allow a
fetus adequate movement
May reflect a neurologic abnormality causing spasticity
• Partial extension – presents the “brow” of the head to the birth canal
Engagement – refers to the settling of the presenting part of a fetus far enough into the pelvis to be @ the
level of the ischial spines, a midpoint of the pelvis
• Primipara – nonengagement of the head @ the beginning of labor indicates possible
complication,
such as abnormal presentation or position, abnormality of the fetal head, or cephalo-pelvic
disproportion
• Multipara – engagement may or may not be present @ the beginning of labor
• Degree of engagement is assessed by vaginal and cervical examination
• Presenting part that is not engaged = “floating”
• Presenting part that is descending but has not yet reached the ischial spine = “dipping”
Station – refers to the relationship of the presenting part of a fetus to the level of the ischial spines
• Presenting part @ the level of the ischial spines = 0 station (synonymous w/ engagement)
• Above the ischial spines = distance is measured and described as minus stations, w/c range from -1 to –
4 cm
- 4 station = head is floating
• Below the ischial spines = stated as plus stations (+1 to +4 cm)
• @ a +3 or +4 station= presenting part is @ the perineum and can be seen if vulva is separated (i.e., it
is crowning)

Fetal Lie – relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal)
axis of a woman’s body; whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal)
position
• 99% of fetuses assume a longitudinal lie (their long axis is parallel to the long axis of the woman)
• Longitudinal lie further classified as:
Cephalic – head will be the 1st part to contact the cervix
Breech – breech or buttocks as the 1st to contact the cervix

Types of Fetal Presentation

Fetal presentation denotes the body part that will first contact the cervix or be born 1 st
This is determined by a combination of fetal lie and the degree of fetal flexion (attitude)

Cephalic Presentation
Most frequent type of presentation – occurring as often as 95% of the time
Fetal head is the body part that will 1st contact the cervix
4 Types of Cephalic Presentation:

TYPE LIE ATTITUDE DESCRIPTION

Vertex Longitudinal Good (Full flexion) The head is sharply flexed, making parietal
bones or the space bet. fontanelles (vertex)
the presenting part
Most common presentation and allows the
suboccipitobregmatic diameter to present to
the cervix
Brow Longitudinal Moderate (military) Because head is only moderately flexed, the
brow or sinciput becomes the presenting part
Face Longitudinal Poor Head of fetus is extended = face is the
presenting part
From this position, extreme edema and
distortion of the face may occur
Presenting diameter (occipitomental) is so
wide that birth may be impossible
Mentum Longitudinal Very Poor Head hyperextended – chin presentation
Widest diameter (occipitomental) is
presenting
As a rule, the fetus cannot enter the pelvis in
 this presentation

During labor, the area of the fetal skull that contacts the cervix often becomes edematous from the
continued pressure against it = caput succedanum

Breech Presentation
Either the buttocks or the feet are the 1st body parts that will contact the cervix
Occur in approx. 3% of birth and are affected by fetal attitude
Good attitude – brings fetal knees up against the umbilicus
Poor attitude – means that knees are extended
Can be difficult births – w/ the presenting point influencing the degree of difficulty
3 Types of Breech Presentation:
1. Complete – fetus has thighs tightly flexed on the abdomen; both buttocks and the tightly flexed
feet present to the cervix
2. Frank – Attitude is moderate because hips are flexed but knees are extended to rest on the chest;
buttocks alone present to the cervix
3. Footling – neither thighs nor lower legs are flexed; if 1 foot presents = single footling; both legs
= double footling breech

Shoulder Presentation
In a transverse lie - fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to
that of the mother
Presenting part – usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow
Fewer than 1% of fetuses lie transversely
May be caused by:
Relaxed abdominal walls from grand multiparity – w/c allow the unsupported uterus to fall
forward
Pelvic contraction – w/c the horizontal space is greater than the vertical space
Placenta previa (placenta located low in the uterus, obscuring some of the vertical space) –
may limit a fetus’ ability to turn, resulting

Types of Fetal Position

Position – the relationship of the presenting part to a specific quadrant of a woman’s pelvis

4 Pelvic Quadrants accdng. to mother’s right and left:

1. right anterior 3. right posterior
2. left anterior 4. left posterior

4 parts of a fetus have been chosen as landmarks to describe the relationship of the presenting part to one of
the pelvic quadrants:
Vertex presentation – occiput (O) is the chosen point
Face presentation – chin (mentum) (M)
Breech presentation – sacrum (Sa)
Shoulder presentation – scapula or the acromion process (A)

Position is indicated by an abbreviation of 3 letters:

First letter – defines whether the landmark is pointing to the mother’s right (R) or left (L)
Middle letter – denotes fetal landmark (O for occiput, M – mentum, Sa – sacrum, and A – acromion
process)
Last letter – defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T)

LOA – most common fetal position Fetus born fastest in

ROA – 2nd most frequent these 2 positions

ROP / LOP – labor is considerably extended; posterior positions may also be more painful for the mother –
rotation of fetal head puts pressure on the sacral nerves, causing sharp back pain
 1
Chapter 15
Caring for a Woman during Vaginal Birth

Mechanisms (Cardinal Movements) of Labor

Passage of a fetus thru the birth canal involves a number of different position changes (termed as cardinal
movements of labor) to keep the smallest diameter of the fetal head (in cephalic presentations) always
presenting to the smallest diameter of the birth canal
Usually accomplished during the 2nd stage of labor

Cardinal Movements of Labor

DESCENT
is the downward movement of the biparietal diameter of the fetal head to w/in the pelvic inlet
Full Descent – occurs when the fetal head extrudes beyond the dilated cervix and touches the
posterior vaginal floor
occurs because of pressure on the fetus by uterine fundus
pressure of fetal head on sacral nerves @ the pelvic floor causes mother to experience a pushing
sensation
aided by abdominal muscle contraction as the woman pushes

FLEXION
head bends forward onto the chest, making the smallest anteroposterior head diameter
(suboccipitobregmatic diameter) the presenting part to the birth canal
aided by abdominal muscle contraction during pushing

INTERNAL ROTATION
During descent, the head enters the pelvis w/ the fetal anteroposterior head diameter
(suboccipitobregmatic, suboccipitomental, or occipitofrontal, depending on the amount of flexion)
in a diagonal or transverse position
Head flexes s it touches the pelvic floor, and the occiput rotates until it is superior, or just below the
symphysis pubis – bringing the head into the best relationship to the outlet of the pelvis

EXTENSION
Begins @ the level of the maternal vulva
As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the
rest of the head
Head extends, and the foremost parts of the head, the face and chin, are born

EXTERNAL ROTATION (RESTITUTION)

After delivery of the head of the infant, the head rotates back to the diagonal or transverse position
of the early part of labor
Fetus resumes its normal face-forward position
Its face begins to “look @ one of mother’s leg”
The anterior shoulder is born first, assisted perhaps by downward flexion of the infant’s head
Put pressure on the perineum to prevent lacerations

EXPULSION
Once shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size
End of the 2nd stage of labor

Importance of determining Fetal Presentation and Position

Presentation of a body part other than the vertex could put a fetus @ risk:
Implies a proportional difference bet. the fetus and maternal pelvis = pelvis too narrow to allow fetus to
pass thru C/S birth
Membranes more apt to rupture early = ing possibility of infection
Fetal anoxia and meconium staining – complications that lead to respiratory distress @ birth
Labor is longer due to ineffective descent of the fetus, ineffective dilatation of cervix, or irregular and weak
uterine contractions

4 Methods used to determine fetal position, presentation, and lie:

Combined abdominal inspection and palpation (Leopold’s Maneuvers)
Vaginal Examination
Auscultation of fetal heart tones
Sonography
 2
Powers of Labor (3rd P)
Supplied by the fundus of the uterus
Implemented by uterine contractions – process causes cervical dilatation and then expulsion of the fetus from the
uterus
After full dilatation of the cervix – primary power is supplemented by use of abdominal muscles
Advise woman not to bear down w/ their abdominal muscles until cervix is fully dilated – may impede primary
force and could cause fetal and cervical damage

Uterine Contractions
The mark of effective uterine contractions is rhythmicity and progressive lengthening, and intensity.
ORIGINS:
Begin @ a “pacemaker” point located in the myometrium near one of the anterotubal junctions then
sweeps down over the uterus as a wave w/ rest periods in between contractions
In early labor: contractions are not synchronized (sometimes strong/weak and irregular) but
improves after a few hours
Some women: contractions originate in the lower uterine segment rather than the fundus = reverse
ineffective contractions; may actually cause tightening rather than dilatation of cervix
PHASES:
1. Increment – intensity of contraction increases
2. Acme – contraction is @ its strongest; peak
3. Decrement – intensity decreases

CONTOUR CHANGES:
As labor progresses, the uterus gradually differentiates itself into two distinct functioning areas:
1. Upper portion becomes thicker and active – preparing it to be able to exert strength necessary to
expel fetus
2. Lower portion becomes thin-walled, supple, and passive – to accommodate fetal head and fetus
can be pushed out of the uterus easily

Physiologic Retraction Ring – boundary bet. the 2 portions becomes marked by a ridge on the inner
uterine surface; normal in labor
The elongation of the uterus exerts pressure against the diaphragm and causes the often-expressed
sensation that a uterus is “taking control” of a woman’s body
In a difficult labor (if fetus is larger than the birth canal), round ligaments of the uterus become tense
and may be palpable on the abdomen
Pathological Retraction Ring (Bandl’s Ring) – common in obstructed labor; retraction ring is indented
deeply and palpable as a mass in the middle of the abdomen
Danger sign – signifies impending rupture of the lower uterine segment if the obstruction is
not relieved

Cervical Changes
Effacement – shortening and thinning of cervical canal
Nly: 1 – 2 cms long
w/ effacement – canal virtually disappears
Primiparas: effacement before dilatation
Multiparas: both come simultaneously or dilatation comes ahead (before effacement) - before fetus
can be safely pushed thru cervical canal – otherwise, cervical tearing could result
Dilatation – refers to the enlargement or widening of the cervical canal from an opening a few mm wide to
one large enough (approx. 10 cm) to permit passage of a fetus
Occurs for 2 reasons:
1. uterine contractions gradually increase the diameter of the cervical canal lumen by pulling the
cervix up over the presenting part of the fetus
2. Fluid-filled membranes press against the cervix
If membranes are intact – they push ahead of fetus and serve as an opening wedge
If ruptured – presenting part serves this same function
As dilatation begins – increase amount of vaginal secretions (show) because last of the operculum in
the cervix is dislodged and minute capillaries in the cervix rupture

PSYCHE (4th P)
Refers to the psychological state or feelings that a woman brings into labor
Woman must have a strong sense of self-esteem and a meaningful support with them
Encourage pregnant women during prenatal visits to ask questions
and to attend preparation for childbirth classes – to prepare them for labor
 3

STAGES OF LABOR

In nursing literature, labor is traditionally divided into 3 stages:

1. Stage of Dilatation – begins w/ initiation of true labor contractions and ends when the cervix is fully dilated
2. Stage of Expulsion – period from complete dilatation of the cervix to the birth of the baby
3. Placental Stage – period from birth of the baby thru the birth of the placenta
4. 4th Stage – first 1 – 4 hours after birth of the placenta – to emphasize importance of the close observation
needed @ this time
1st hour post partum – most dangerous – because V/S are still unstable

Friedman – physician who studied the process of labor extensively, used data to identify 2 phases of labor: latent
and active phases

First Stage of Labor

A. Latent (Preparatory) Phase
begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation
begins
contractions are mild & short lasting 20 – 40 seconds
cervical effacement occurs, cervix dilates from 0 – 3 cm.
Primi: Lasts for 6 hours; Multipara: 4.5 hours

B. Active Phase
cervical dilatation occurs more rapidly, increasing from 4 – 7 cm
contractions grow stronger, lasting 40 – 60 seconds, and occur every 3 – 5 minutes
Primi: lasts for 3 Hrs; Multi: 2 hrs.
Show and perhaps rupture of membranes may occur during this time
May be a difficult time – contractions grow strong, last longer, and begin to cause true discomfort

C. Transition Phase
contractions reach their peak of intensity, occurring every 2 – 3 minutes with a duration of 60 – 90
seconds and causing maximum dilatation of 8 – 10 cm
if membranes have not previously ruptured or been ruptured by amniotomy – will rupture @ this phase,
as a rule @ full dilatation (10 cm)
by the end of this phase, both full dilatation and complete cervical effacement have occurred
intense discomfort – accompanied by nausea and vomiting; feeling of loss of control (labor has taken
charge of her), anxiety, panic, or irritability

Nursing Care during 1st Stage of Labor

1. Admission
provide privacy and reassurance from the start
fill chart in a short time – mother usually tense, irritable and in pain
Initial interview – use skill and tact so that you will not leave an impression that you are more
interested in the info than in the mother
EDC/EDD
Character of show and whether or not membranes have ruptured
Last time she ate – may help if general anesthesia will be used
Known allergies to drugs
Record TPR, and FHT
BP – should not be taken before the contraction as it tends to increase
BP readings should be taken at least every half hour during active labor
When a woman is in labor, complains of headache, nursing action is to take BP, if it
is normal = stress headache; if BP is increased, refer immediately to the obstetrician
(it could be a sign of toxemia)
General physical examination, internal exam and Leopold's maneuvers are done to determine
effacement (expressed in percentage) and dilatation (cm); Station; Lie; Presentation;
Position; Attitude
Monitoring and evaluating important aspect – Uterine contraction
increment (crescendo); Acme (apex); Decrement (Decrescendo)

Duration – timed from the moment uterus tenses until it has relaxed
20 to 30 seconds during early labor
60 to 90 seconds late in labor (should never be longer)
Relaxation/interval – from the end of one contraction to the beginning of another
contraction
40 – 45 minutes early in labor
2- 3 minutes late in labor
Frequency – timed from the beginning of one contraction to the beginning of the next
 4
Intensity – strength of the contraction
Mild, moderate, strong
measured by the consistency of the fundus at the acme of the contraction
When estimating intensity, check the fundus at the end of contraction to determine
whether it relaxes.
2. Advise not to bear down
3. Health teachings
Bath
Ambulation (not allowed if membranes have ruptured) helps shorten the first stage of labor
Solid or liquid foods are to be avoided - Digestion is delayed during labor
Full stomach interferes with proper bearing down, may vomit
Expulsion of feces during second stage of labor, predisposes mother and baby to infection
Full bowel predisposes to postpartum discomfort
enema not a routine procedure
Urge patient to void @ least every 2 – 4 hours; full bladder can:
Retard fetal descent
Urinary stasis can lead to UTI
Can be traumatized during delivery
4. Watch for signs of 2nd stage of labor – mother restless and apprehensive
5. May assist in analgesia
6. Prepare perineum:
Shaving and douching – to cleanse and disinfect the area surrounding vagina preventing
contamination and infection of birth canal, and to be able to see crowning of the vulva
7. Once labor is established – never leave woman alone in DR – danger of falling
8. Husband may be w/ woman – support and help in abdominal and relaxing exercises
9. Give comfort measures:
Positioning
Minimize sacral pressure – pass hand over sacrum to relieve pain and pressure
Prevent leg cramps
Give ice chips or cotton balls wet w/ water – relieve thirst

Second Stage of Labor

Period from full dilatation and cervical effacement to birth of the infant
Uncomplicated birth: takes about 1 hour
contractions change from the crescendo – decrescendo pattern to an overwhelming, uncontrollable urge to
push or bear down with each contraction as if to move her bowels
she pushes with such force causing her to perspire and blood vessels in neck are distended
perineum bulges and appears tense – as the fetus pushes toward the perineum
anus may become everted, stool may be expelled
fetal scalp appears @ the opening to the vagina
@ 1st, opening is slit-like, then becomes oval, then circular – circle enlarges = CROWNING
Mechanisms or Cardinal signs of labor
Nursing Care During 2nd Stage of Labor:
1. Support
From support persons, experienced health care providers
Serve as coach for patient to bear down
2. Assess FHT @ the beginning of 2nd stage – to be certain that the start of baby’s passage in birth canal is
not occluding the cord and interfering w/ fetal circulation
3. Preparing the place for birth
4. Positioning for birth – variety of positions can be used:
Lithotomy – no longer position of choice in birthing rooms
Alternative birth positions: lateral or Sim’s position, dorsal recumbent (on the back w/ knees
flexed), semi-sitting, and squatting
5. Promoting effective 2nd – stage pushing
Woman must push w/ contractions (effective pushing) and rest between them
Can use short pushes or long, sustained ones – whichever are more comfortable
Usually best done from a semi-Fowler’s, squatting, or “all-fours” position – to allow gravity to
aid the effort
Avoid holding breath during contraction – could cause Valsalva maneuver or temporarily
impede blood return to the heart (due to ed intrathoracic pressure)
To prevent – urge to breathe out during pushing effort
Multipara – to keep 2nd stage from moving too fast – may be necessary to prevent woman from
pushing
Ask her to pant w/ contractions (“panting like a puppy”) – this limits pushing
Take deep cleansing breaths between contractions – to prevent hyperventilating
6. Perineal cleaning
Clean perineum w/ a warmed antiseptic (cold solution causes cramping) then rinse w/ a
designated solution before birth according to policy
Clean from vagina outward – microorganisms are moved away from vagina
 5
Place sterile drapes around perineum
If fecal material is expelled w/ pushing – sponge this away to prevent contamination of the birth
canal
7. Episiotomy – surgical incision of the perineum
Done during contraction and cervix is 10 cm dilated – aeg wont feel the pain because of the
pressure of presenting part on the nerve ending of perineum
Made w/ blunt-tipped scissors in:
1. Midline - midline of the perineum; easily contaminated; wound heals faster; less discomfort
during postpartum; less blood loss
2. Mediolateral incision – begun in the midline but directed laterally away from rectum;
advantageous – if tearing occurs beyond incision, it will be away from rectum; creating less
danger of complication from rectal mucosal tears; less contamination
Advantages:
Substitutes a clean cut for a ragged tear
Minimizes pressure on fetal head
May shorten the last portion of the 2nd stage of labor
8. Birth
To avoid laceration:
Ritgen’s Maneuver – as soon as head of fetus is prominently visible, physician or nurse-midwife
may place a sterile towel over rectum and press forward on the chin of fetus while pressing the
other hand downward on the fetal occiput
Helps fetus achieved extension – so that head is born w/ the smallest diameter
presenting and controls the rate @ w/c head is born
Pressure shd never be applied over fundus of uterus to effect birth = uterine rupture
Woman is asked to continue pushing until occiput of the head is firmly @ the pubic arch
Woman asked to pant deliberately – so she does not push during a contraction
Immediately after birth of baby’s head – physician or nurse-midwife suctions out the infant’s
mouth w/ a bulb syringe and then passes his/her fingers along the occiput to the newborn’s neck
– to determine whether a loop of umbilical cord is encircling the neck
Note time the whole body is born and record this as the time of birth – this is a nursing
responsibility

9. Cutting and Clamping the Cord

While infant is held w/ his or her head in a slightly dependent position – to allow secretions to
drain from the nose and mouth – mouth may be gently aspirated by a bulb syringe to remove
additional secretions
Infant is laid on abdominal drape of mother while cord is cut
Cord continues to pulsate for a few minutes after birth
As soon as pulsation stops – cord is clamped 8 – 10 “ from infant’s umbilicus by 2 Kelly hemostat
and cut between them; then umbilical cord clamp or tie is applied
Vessels in the cord is counted – to ensure three are present
Delaying cutting until pulsation ceases and maintaining the infant @ uterine level – allows as
much as 100 mL of blood to pass from placenta into the fetus; helps ensure adequate RBC count
in the newborn
Late clamping of cord – could cause over infusion w/ placental blood and possibility of
polycythemia and hyperbilirubinemia (particular concern in preterm infants)
Cutting cord – part of the stimulus that initiates a 1st birth – establishment of independent
respirations – transition to outside world
10. Introducing Infant
Wrap infant in a sterile blanket – hold firmly, because newborns are covered w/ slippery
amniotic fluid and vernix
Take infant to visit new parents
Allow parents to touch and hold newborn – assures them baby is well and an important step in
establishing parent-child relationship
Breastfeeding may be started – stimulates release of endogenous oxytocin, encouraging uterine
contraction and involution (return of uterus to pre-pregnant state)

Third Stage of Labor

Placental stage
begins w/ the birth of the infant and ends w/ the delivery of the placenta
After birth, uterus can be palpated as a firm, round mass just inferior to the level of the umbilicus
After a few minutes of rest, uterine contractions begin again, and the organ assumes a discoid shape.
It retains this new shape until the placenta has separated – approx. 5 minutes after the birth of the infant

2 Phases:
1. PLACENTAL SEPARATION
As uterus contracts on an empty interior, active bleeding on the maternal surface of the placenta
begins with separation
this bleeding helps to separate the placenta still further by pushing it away from its attachment site
 6
As separation is completed, placenta sinks to the lower uterine segment or the upper vagina

Signs that placenta has loosened and is ready to deliver:

Lengthening of the umbilical cord
Sudden gush of vaginal blood
Change in the shape of the uterus
Firm contraction of the uterus
Appearance of the placenta@ the vaginal opening

SHULTZE PLACENTA
Placenta separates 1st at its center and lastly at its edges, it tends to fold like an umbrella &
presents at the vaginal opening with fetal surface evident
It is shiny and glistening from the fetal membranes

DUNCAN PLACENTA
Placenta separates 1st @ its edges, slides along the uterine surface and presents @ the vagina
w/ the maternal surface evident
Looks raw, red, and irregular, w/ the ridges or cotyledons that separate blood collection
spaces showing

Normal blood loss: 300 – 500 mL

2. PLACENTAL EXPULSION
Placenta is delivered either by the natural bearing-down effort of the mother or
By gentle pressure on the contracted uterine fundus by the physician/nurse/midwife = Crede’s
maneuver
Pressure must never be applied to a non-contracted postpartal uterus – may cause uterus to evert
and hemorrhage
If placenta does not deliver spontaneously – remove manually
With delivery of placenta, 3rd stage of labor is over
May be used for stem cell research (blood), or as temporary coverings for burns (membranes)

Care of the Woman During the 3rd and 4th Stages of Labor
1. Oxytocin
Once placenta is delivered – oxytocin is usually ordered to be administered IM or IV to the mother
(nursing responsibility)
es uterine contractions – thereby minimizing uterine bleeding
Causes hypertension (HPN) by vasoconstriction – obtain baseline BP before administering medication

2. Placenta Delivery
if placenta does not deliver spontaneously – physician or nurse-midwife will need to remove it
manually
after delivery, placenta is inspected to be certain that it is intact and normal in appearance and
weight
Normally: 1/6 of the weight of the fetus

3. Perineal Repair
Any necessary perineal stitching is performed after delivery of placenta = episiorrhaphy

4. Immediate Postpartum Assessment and Nursing Care

Once episiotomy repair is complete – drapes are removed and woman’s legs are simultaneously and
carefully lowered from the stirrups (if used) – to prevent back injury
Obtain V/S every 15 minutes for the first hour, then according to agency policy or as ordered by
physician
PR and RR usually fairly rapid – 80 – 90 bpm and 20 – 24 respirations/minute
BP slightly elevated –due to excitement of the moment and oxytocin administration
Palpate woman’s fundus – size, consistency, and position
Observe amount and characteristics of lochia (normal postpartum discharge)
Perform perineal care and apply perineal pad

5. Aftercare
Because uterus may be exhausted from labor that it cannot maintain contraction – high risk for
hemorrhage
Woman may be unable to assess her own condition or report any changes
 Nursing Care of a Woman and Family (Puerperium)
Chapter 22

Postpartal Period
•Also puerperium (Latin)
Puer – “child”
Parere – “to bring forth”
•Refers to the 6-week period after childbirth
•“4th trimester of pregnancy”
2 Maternal changes involved:
•Retrogressive changes
Involution of the uterus, vagina
•Progressive changes
Production of milk for lactation
Restoration of normal menstrual cycle
Beginning of a parenting role (psychological changes)

•Protecting a woman’s health as these changes occur is important

For preserving her future childbearing function and
For ensuring she is physically well enough to incorporate her new child into her family

Phases of the Puerperium

Taking – in
1st phase experienced; Time of reflection; 2- to 3-day period;
Woman is largely passive - Depends entirely on a nurse or other individuals for her
needs, even decision-making
•Due partly to:
Physical discomfort - due to perineal stitches, after pains, hemorrhoids
Uncertainty in caring for her newborn
Extreme exhaustion that follows childbirth
•Woman would usually want to talk about her pregnancy, esp. about her labor and delivery
•Holds her new child w/ a sense of wonder
•She rests to regain her physical strength and to calm and contain her swirling thoughts
•Encouraging her to talk about the birth helps her integrate it into her new life experiences
Taking-Hold Phase
•Woman begins to initiate actions
•Begins to do things for herself gradually
•Takes interest in caring for the baby
•Best to give woman brief demonstrations of baby care and then allow her for her child herself
– w/ watchful guidance
•Still feels insecure about her ability to care for her new child
•Needs positive reinforcement
Praise for things she does well – to give her confidence
•Do not rush the woman thru the phase
Letting Go Phase
•Woman finally defines her new role; she gives up the fantasized image of her child and
accepts the real one; gives up her old role of being childless or mother of 1 or 2
•Requires some grief work and readjustment; extended and continues during the child’s
growing years

1
Dev’t of Parental Love and Positive Family Relationship
•During pregnancy – almost q woman worries about her ability to be a “good” mother
Does not evaporate as soon as baby is born
Many may not experience maternal feelings for their infants until days or even weeks
after giving birth
Until as late as 3 mos. after birth – child begins to smile, coo, interact more directly

•“Claiming” or bonding
Feeling motherly or fatherly love toward the new child
Holds child more, express more warmth, touching child w/ palms of hand (rather than
fingertips)
Become a mother tending to her child

•En face position, engrossment – looking directly @ newborn’s face, w/ direct eye contact; sign mother or
father is beginning effective interaction or is relating well w/ child

Rooming – In
•Infant stays w/ mother in the room rather than in a central nursery
•She can become better acquainted w/ her child and begin to feel more confident in her ability to care for
her/him after discharge

2 Types of Rooming – In
•Complete – Mother and child together 24 hours/day
•Partial – Infant remains in woman’s room for most of the time, then taken to a small nursery (near woman’s
room) or returned to a central nursery for the night

Postpartal Maternal Concerns

•Breast soreness
•Regaining her figure
•Regulating demands of housework, partner, and children
•Coping w/ emotional tension and sibling jealousy
•fatigue
Postpartal Maternal Feelings
•Abandonment – feeling less important after giving birth; feeling of jealousy; help woman
move past these feelings by verbalizing the problem
•Disappointment – child does not meet their expectations; expecting different sex, size or look
of child
Handle child warmly – to show infant is satisfactory or even special
Comment on child’s good points – long fingers, lovely eyes . . .

Postpartum Blues
50% of women experience feelings of overwhelming sadness
Burst into tears easily, feel let down, or irritable
Temporary feeling known as “baby blues”
Hormonal changes - estrogen and progesterone that occurs after delivery of
placenta
•May be a response to dependence and low self-esteem caused by
exhaustion, being away from home, physical discomfort, tension in assuming a new role, not receiving
enough support from partner
• evidenced by
Tearfulness, feelings of inadequacy, mood lability, anorexia, sleep disturbance

Nursing Mgt. on Postpartum Blues

•Reassure sudden crying episodes are normal
•Anticipatory guidance and individualized support – to help parents understand that this is
normal

2
 •Allow to verbalize feelings
•Allow to make as many decisions as possible – give her sense of control over her life
Postpartum Depression
•30% of women; more serious level of sadness after birth
•Require formal counseling or psychiatric care (12%)
•Complication of puerperium = psychosis
Reproductive System Changes
•Involution
Process whereby the reproductive organs return to their non-pregnant state
Woman is in danger of hemorrhage from the denuded surface of the uterus until
involution is complete

Physiologic Changes of the Postpartal Period

Uterus
•Involution of uterus involves 2 main processes
Area where placenta was implanted is sealed off = preventing bleeding
Uterus is reduced to its approximate progestational size

Mechanism
(Sealing of placenta site)
Accomplished by rapid contraction immediately after delivery of placenta

Pinches blood vessels in the area left denuded by placenta

Stopping bleeding

Thrombi form w/in uterine sinuses to permanently seal the area

Endometrial tissue undermines site and obliterates organized thrombi

Covering and sealing area completely

Leaving no scar tissue w/in the uterus and does not compromise future implantation sites

Mechanism
(Reduction of bulk of uterus)
Devoid of the placenta and membranes – walls of uterus thicken and contract

Gradually reducing uterine size

•Main mechanism – CONTRACTION

Similar w/ a rubber band that’s been stretched for many months and now regaining its
normal contour – not destroyed but shape is altered

Uterus weight
•Immediately after delivery – uterus weighs 1000g
•End of 1st week – 500g
•Time Involution is complete (6 weeks) – 50g (pre-pregnant weight)
Fundus
•Immediately post delivery – halfway bet. umbilicus and symphysis pubis
•1H after to the next 24H – level of umbilicus
•Decreases 1 fingerbreadth/day (about 1 cm)
•Ave. woman – by 9th or 10th day – uterus have w/drawn into the pelvis an no longer detected by abdominal
palpation
•Uterine involution
•Uterus es in size @ a predictable rate during postpartal period
•After 10 days – recedes under pubic bone, no longer palpable
3
•Breastfeeding mother
•Uterus contract more quickly and forcefully
•Release of oxytocin
•Stimulating uterine contraction
•Not enough to protect against postpartum hemorrhage
Delayed uterine involution
1. Birth of multiple fetuses
2. Hydramnios
3. Exhaustion from prolonged labor or difficult birth
4. Grand multiparity
5. Physiological effects of excessive analgesia
6. Retained placenta or membranes – contraction may be difficult

•1stH after birth – potentially the most dangerous

•Relaxed uterus = Uterine atony – lose blood very rapidly because no thrombi have yet formed @ the
placental site

•After–pains = contractions of uterus after birth causes intermittent cramping (similar to menstruation)
•Noticed most by multiparas, women given birth to large babies, over-distended uterus
•so uterus must contract more forcefully to regain pre-pregnancy size and difficulty maintaining steady
contracted state
•Ice compress over uterus
Lochia
• Uterine flow consisting of blood, fragments of decidua, white blood cells, mucus, and some bacteria
• Normal discharge postpartum
• Uterus where placenta was not attached is fully cleansed by this sloughing process – will be in a
reproductive state in about 3 weeks

•Types of Lochia
1. Lochia Rubra
• 1 – 3 days
• Consists entirely of blood, fragments of decidua, and mucus
• Red in color
• Moderate in amount

2. Lochia serosa
• About 4th – 10th day
• Discharge becomes pink or brownish
• Blood, mucus, and invading leukocytes
• Small in amount compared to rubra

3. Lochia alba
• 10th – 14th day
• may last 3rd – 6th week
• Amount decreases
• Becomes white – colorless
• Largely mucus, leukocyte count high

Evaluating Lochia Flow

Evaluate the Amount

•Shd approximate to a menstrual flow
•Breast-feeding mothers – less lochia
•Oxytocin – strengthens uterine contractions
•Conservation of fluid for labor
4
• es on strenuous exercise/activity
•Abnormal: if perineal pad becomes saturated in less than an hour
Check the Consistency
•Shd contain no large clots
• May indicate a portion of placenta has been retained – preventing closure of maternal uterine blood sinuses
• Denote poor uterine contraction
Observe the pattern
•Pattern should not reverse
•Red flow after a pink or white
•retained placental fragments, or
• ing uterine contraction and new bleeding is beginning
Assess the Odor
•Odor same as menstrual flow
•Shd not have an offensive odor
•Indicates uterine infection
•Immediate intervention is needed to halt postpartal infection
Watch for Absence of Lochia
•Shd never be absent
•Scant in amount in cesarean section – but never absent
Cervix
•Immediately ff. delivery, it is soft and malleable
•Both internal and external os are open
•By end of 7 days – external os has narrowed to size of pencil opening
•Cervix feels non-gravid again
•External os remains slightly open and appears slit-like or stellate (star-shaped) – previously round
Vagina
• Soft, w/ few rugae, and diameter is considerably greater than normal
• Hymen permanently torn and heals w/ small, separate tags of tissue
• Takes 6 weeks (entire postpartal period) to involute until gradually returns to pre-pregnant state
•Thickening of walls – depend on renewed estrogen stimulation from ovaries
•Breast-feeding – delayed ovulation
•Thin-walled or fragile vaginal cells – slight bleeding on intercourse until 6 week’s time
•Outlet remains slightly more distended than before
•Kegel exercises – strength and tone of vagina will increase more rapidly
•May be important for sexual enjoyment of couples
Perineum
• Edema and generalized tenderness – pressure during birth
• Ecchymosis on the surface – from ruptured capillaries
• Majora and minora – typically remain atrophic and softened, never returning to pre-pregnant state
To alleviate discomfort:
• Hot sitz bath
• Analgesia
• Heat lamps or infrared lamps
• Nursing Care – focus on perineal area
Douching – prevent infection due to proximity to anal canal; for faster healing also
Advice early ambulation – prevent complication

5
Systemic Changes
•Pregnancy hormones begin to decrease as soon as placenta is no longer present
•hCG and hPL levels – almost negligible by 24H
•Week 1 – progestin, estrone, estradiol are @ pre-prenancy levels
•FSH remains low for about 12 days then begins to rise as a new menstrual cycle is initiated
Urinary System
• Extensive diuresis takes place almost immediately – to rid body of excess fluid accumulated during pregnancy
• urinary output to as much as 3000mL (1500mL, normal) during 2nd – 5th day after birth
• During vaginal birth – fetal head exerts pressure on bladder and urethra
bladder w/ transient loss of tone , together w/ edema surrounding urethra = es woman’s ability to
sense when she has to void
Assess for over distention of bladder

Urinary System
•Hydronephrosis or ed size of ureters – remains present for about 4 weeks after delivery
In conjunction w/ reduced bladder sensitivity = es possibility of urinary stasis and UTI postpartum
•Diaphoresis - excessive perspiration
Another way of body to rid itself of excess fluid
Prevent chills; change clothing; daily bath

Circulatory system
•Diuresis + blood loss @ birth – act to reduce added blood volume accumulated during pregnancy
Reduction occurs rapidly – blood volume to normal pre-pregnant state by 1st – 2nd week after delivery
•High level of plasma fibrinogen continues during 1st postpartal week
Protective measure against hemorrhage
es risk of thrombus formation

• ed WBC – 30,000 cells/mm3 – particularly in prolonged and difficult labor

Part of body’s defense against infection and aid in healing
•Varicosities – recede but rarely return to completely pre-pregnant state
•Vascular blemishes – spider angiomas – fade slightly but may not disappear completely
Gastrointestinal System
•Digestion and absorption begin to be active again soon after birth
•Woman feels hungry and thirsty
Due to long period of restricted fluid during labor and beginning diaphoresis
•Hemorrhoids (distended rectal veins) – often present due to the effort pelvic-stage pushing
•Bowel sounds active but passage of stool may be slow due to still-present effect of relaxin
•Bowel evacuation may be difficult – due to pain of episiotomy sutures or hemorrhoids
Integumentary System
•Stretch marks (striae gravidarum) – still appear reddened and may even be more prominent than during
pregnancy
•Excessive pigment on face and neck (chloasma) and linea nigra – barely detectable in 6 week’s time
Effects of Retrogressive Changes

Exhaustion
•As soon as birth is completed – woman experiences total exhaustion
Last several months of pregnancy – experienced difficulty in sleeping
Near end of pregnancy – unable to find comfortable position in bed and fetus’ activity, back or leg pain
“sleep hunger” – difficult for her to cope w/ new experiences and stressful situations

Weight Loss
• Rapid diuresis and diaphoresis (2nd – 5th day after birth) – result in weight loss of 5 lb (2 – 4 kg) in addition to
aprox. 12 lbs (5.8 kg) loss @ birth

6
• Lochia flow causes additional 2- to 3-lb (1 kg) loss
• Total weight loss: 19 lbs
•Influenced by nutrition, exercise, breastfeeding
•Weight woman reaches @ 6 weeks after birth – baseline postpartal weight
Vital Sign Changes
• Vital sign changes in the postpartum period reflect the internal adjustments that occur as the woman’s body
returns to its pre-pregnant state

Temperature
•Always taken orally or tympanically (never rectally) during puerperium
•Danger of vaginal contamination and discomfort involved in rectal intrusion
•Slight during 1st 24H – due to DHN that occurred during labor
Adequate fluid 1st 24H – temp returns to normal
Not a problem since most women are thirsty immediately after births
•If oral temp. rises above 38C after 1st 24H period = postpartal infection
•3rd or 4th postpartum day – woman may have ed temp
•Woman’s breasts fill w/ milk
•Due to vascularity of breast tissues
•If lasts longer than a few hours – infection
Pulse
•Usually slightly slower than normal
ed stroke volume reduces PR to bet. 60 – 70 bpm
•End of 1 week – PR returned to normal
st

•Rapid, thready pulse during postpartal period = sign of hemorrhage

Blood Pressure
•Shd be monitored carefully postpartum
can indicate bleeding
Elevation above 140 mmHg (systolic) or 90 mmHg (diastolic) – indicate devt of postpartal PIH – unusual
but serious complication of the puerperium
•Compare woman’s pre-pregnancy BP level w/ postpartal level
•Oxytocin - es BP
Check BP prior to administration
Withhold if BP is > 140/90 mmHg and notify AP – to prevent HPN and possibly, cerebrovascular accident
(stroke)
•Orthostatic hypotension
Occurs on standing due to lack of adequate blood volume to maintain nourishment of brain cells
Advise to always sit up slowly and “dangle” feet on the side of her bed before attempting to ambulate
Caution not to walk carrying baby

Progressive Changes
• 2 physiologic changes that occur during puerperium involve progressive changes, or the building of new tissue
• Building new tissue requires good nutrition
• Caution women against strict dieting that would limit cell-building ability during the 1st 6 weeks after childbirth
Lactation
•Begins in a postpartal woman whether or not she plans to breast-feed
•Continues to excrete colostrum the 1st 2 postpartum days
•3rd day – breasts become full and feel tense of tender as milk forms w/in breast ducts
• Breast milk forms in response to in estrogen and progesterone levels that follows delivery of placenta
Stimulating prolactin production, and
Milk production
•Nipple secretion changes from clear colostrum to bluish white – typical color of breast milk
7
•Many women experience feeling of heat or throbbing pain
•Breast tissue may appear reddened – stimulating acute inflammatory or infectious process
•Distention not limited to milk ducts but also occurs in surrounding tissue
Blood and lymph enter area to contribute fluid to the formation of milk
• Feeling of tension in breasts on the 3rd or 4th day after delivery is termed as primary engorgement
Fades as infant begins effective sucking
•Milk production depends on sucking of the infant or the use of breast pump
Release oxytocin contract milk ducts and push milk forward to cause a =
let-down reflex
•To treat breast engorgement:
1. Breast feeding
2. Breast pump
3. Alternate heat and cold
4. Analgesic – severe cases

Return of Menstrual Flow

•Woman not breast-feeding – menstrual flow return in 6 – 10 weeks after birth
•Breast-feeding – flow may not return for 3 – 4 mos (lactational amenorrhea)
Some women – flow may not return the entire lactation period
•Absence of menstrual flow – not a guarantee woman will not conceive during this time
She may ovulate well before menstruation returns

Early Ambulation
•Advantages:
Prevents circulatory complication like thrombophlebitis
Assess for thrombophlebitis – dorsiflex woman’s ankle and ask if she feels pain in her calf on that
motion (Homan’s sign)
Assess for redness in calf area
Fewer bowel and bladder complications
Prevent abdominal distentions

Preparation for Discharge

• Greatest need of a postpartal woman before discharge from a health care agency is EDUCATION to prepare
her to care for herself and her newborn @ home
She must be aware of danger signs to look for and to know whom to call for if she notices any
Must understand safe baby care

•As she enters taking-hold period

She grows increasingly receptive to advice and looks to the nurse for information she needs
Best time to impart health teachings
• Before discharge, woman will be given instructions by health care provider concerning her care @ home
•Make sure woman is aware that
she has to return for an examination 4 – 6 weeks after birth
She shd make an appointment to take baby to primary care provider @ 2 – 4 weeks of age
•Discharge instructions are given verbally and in writing
Review instructions to parents to be sure they understand them

•Read Postpartal Discharge Instructions (Table 22.3, page 649)