Physiological Task of Pregnancy
happens around the 6-8th week of
First Trimester:
- Accepting the pregnancy
Second Trimester:
- Accepting the baby (as soon as fetal
movements can be felt, the physiological
reaction for both partners will change).
Third Trimester:
- Preparing for parenthood
Emotional Responses:
❖ Grief
❖ Narcissism
❖ Stress
❖ Depression
❖ Couvade syndrome
❖ Changes in sexual desire
❖ Changes in the expectant family
Confirmation of Pregnancy:
❖ Presumptive Symptoms
- Period Absent (amenorrhea)
- Really Tired (fatigued)
- Enlarged Breast
- Sore Breast
- Urination Increased
- Movement of the fetus in the uterus.
(woman perceives a fluttering sensation in
her lower abdomen, and this is referred to
as QUICKENING. This occurs at 16 weeks
for 2nd time moms and around 20 weeks for
1st time moms.
- Emesis and nausea
❖ Probable Signs
- Positive pregnancy test
- Return of the fetus (ex: bouncing back of
the fetus) against the fingers when the
uterus is pushed during palpation. This is
referred to as “external ballottement”.
- Outline of fetus can be palpated
- Braxton Hicks Contractions - false labor
contractions that are not regular and won’t
result in cervical dilation
- A softening of the cervix “Goodell’s Sign” -
gestation.
- Bluish color “Chadwick's Sign”, to the
vulva, cervix, and vagina due to increased
blood flow. This happens around 4 weeks
gestation.
- Lower uterine segment (LUS) becomes
soft “Hegar’s Sign” - happens around 6-12
week of gestation.
CONFIRMATION OF PREGNANCY:
- Fetal movements felt by doctor or nurse
- Electronic device detects fetal heart sounds
(Doopler)
- The delivery of the baby
- Ultrasounds detects the fetus
- See visible movement of the baby by the
doctor or nurse
Purposes of Prenatal Care:
- Establish a baseline of present health
- Determine the gestational age of the fetus
- Monitor fetal development and material
well-being
- Identify women at risk for complications
- Minimize the risk of possible complications
by anticipating and preventing problems
before they occur
- Provide time for education about pregnancy
lactation and newborn care
PRECONCEPTUAL VISIT
- To obtain reliable information on
reproductive life planning, to provide fertility
confirmation and to identify any issues that
might need to be addressed through a
detailed history.
Procedure during the First Visit:
❖ Initial Interview
- establish rapport, gaining information
about physical and psychosocial health
❖ Patient’s Profile
❖ Chief Concern
❖ Family Profile
❖ Detailed health history (past medical history,
family illness history)
Health Assessment during First Prenatal Visit
❖ Present OB History
- current pregnancy (EDD, AOG, Gravidty
and Parity)
- Previous Pregnancies and Outcomes
(GTPAL Score) - provides greater detail on
a woman’s pregnancy history.
Gravidity - no. of total pregnancies
Term Births - Term delivers (full) births (37 weeks or
more)
Preterm Births - Preterm deliveries (born before 37
weeks)
Abortion/Miscarriages - abortions (both surgical and
miscarriages)
Living Children - living children
Terms related to Pregnancy:
❖ Para - no. of pregnancies that have reached
viability.
❖ Gravida - a woman who is or who has been
pregnant
❖ Primigravida - woman who is pregnant for
the first time
❖ Multigravida - woman who has been
pregnant previously
❖ Grand Multipara - a woman who has carried
five or more pregnancies to viability.
❖ Multipara - woman who has carried two or
more pregnancies to viability
❖ Nulligravida - woman who has never been
and is not currently pregnant
Physical Examination
❖ Ask the woman to void before the
examination.
❖ Get baseline height / weight and vital signs
❖ Assessment of body systems
❖ Measurement of fundal height and fetal
heart sounds.
Pelvic Examination
- Provides details about the health of both
internal and external reproductive organs
(lithotomy position)
- External genitalia signs of inflammation,
irritation or infection such as redness,
ulceration or vaginal discharge are noted.
Internal Genitalia
- to see the cervix, the vagina must be
opened with a speculum
- Do not apply any lubricant other than warm
water to the speculum blades.
- In a nulligravida, the cervical os is round
and small. In woman who has had a
previous pregnancy with a vaginal birth, the
os has much more of a slit-like appearance
Papanicolaou Smear
- A Pap Smear is used for early detection and
treatment of precancerous and cancerous
disorders of the uterine cervix, vulva or
vagina.
Vaginal Inspection
- Sides of the vagina may be inspected when
the speculum is removed. For non-pregnant
women, the vaginal walls are light pink,
pregnancy turns the dark blue to purple. All
areas of inflammation, ulceration, discharge
should be noted.
Bi-manual (two-handed) Examination
- to determine the shape, contour,
consistency and tenderness of the pelvic
organs
Rectovaginal Examination
- to determine the strength and irregularity of
the posterior vaginal wall by palpating the
tissue
Pelvis
- A bony structure formed by 4 single bones.
- 2 innominate bones forming the anterior and
lateral parts of the body.
- Coccyx and sacrum - posterior parts
For OB purposes:
- False pelvis - upper half
- Protects the uterus during the late months
of pregnancy and helps to carry the fetus to
the true pelvis for conception
- Only separated from the real pelvis by an
imaginary line - linea terminalis
- True Pelvis - lower half
PELVIC INLET ❖ First Trimester
Anteriorly: Symphysis pubis. - Breast tenderness
Posteriorly: Promontory of sacrum, ala of sacrum. - Palmar erythema or pruritus
Laterally: Iliopectineal (arcuate) lines. - Constipation
- Nausea, vomiting
PELVIC OUTLET - Fatigue
Anteriorly: Symphysis pubis - Muscle cramps
Posteriorly: Соссух, - Varicosities
Anterolaterally: ischiopubic ramus - Hemorrhoids
Posterolaterally: Sacrotuberous ligament. - Palpitations
- Frequent urination
Laboratory Assessment - Leukorrhea
❖ Urinalysis
❖ Blood Tests ❖ Second / Third Trimester
❖ Tuberculosis Test (Mantoux test) - Lumbar lordosis
❖ Ultrasonography. - Headache
- Dyspnea
Signs Indicating Possible Complications of - Ankle edema
Pregnancy: - Braxton Hicks contractions
❖ Vaginal Bleeding
❖ Persistent Vomiting Teratogens
❖ Chills and fever or pain in urination
❖ Sudden escape of clear fluid from the Several factors influence the amount of damage:
vagina 1. The strength of teratogen
❖ Abdominal or chest pain 2. Timing of the teratogenic insult
❖ Gestational Hypertension/Pregnancy 3. Teratogens affinity for specific tissue.
Induced Hypertension
- Rapid weight gain Teratogenic Maternal Infections
- Swelling of face or fingers - Malaria Rubella
- Blurring of vision - Herpes simplex Virus (genital herpes)
- Severe, continuous headache - Syphilis
- Measles
Health Promotion - Mumps
❖ Self-care needs - Polio
- Bathing - Influenza
- Breast care
- Dental care Intrapartal Care
- Perineal hygiene
- Clothing Preliminary Signs of Labor
❖ Sexual activity ❖ Lightening - drop of the fetus in the pelvis
❖ Exercise begins approximately 10 to 14 days before
❖ Sleep the start of labor.
❖ Employment ❖ Increase in energy - may wake up in the
❖ Travel morning full of energy
❖ Backache - when labor contractions begin in
the back, an occasional back pain that is
worse than normal can be the first symptom
a woman experience.
 ❖ Braxton Hicks Contraction - Ripening of the
cervix
Signs of True Labor
❖ Uterine Contraction
- True labor contractions typically begin in
the back, spreading forward across the
abdomen
- Slowly increase in frequency and strength
over a period of hours
- Typical time of contractions - 5 minutes
apart
❖ Show
- Bloody show - the release of the cervical
plug (operculum) that was formed during
pregnancy.
❖ Rupture of Membranes
- May begin with the ROM.
Theories of Labor Begins
➢ Labor usually starts when the fetus is
mature enough to cope with extrauterine life
but not too large to cause complications at
birth.
➢ Factors that shows the initiation of labor
- Depletion of progesterone
- Rise in prostaglandins and other complex
biochemical markers
➢ The uterine muscle stretches from the
increasing size of the fetus. It results in the
production of prostaglandins.
➢ The fetus presses the cervix
➢ Oxytocin stimulation
➢ Placental age - triggers contraction
➢ Fetal membrane production of
prostaglandins - stimulates contractions
The Forces/ 5 P's of Labor
I. Passage
II. Passenger
III. Powers
IV. Psychological state of the woman
V. Position (maternal)
Fetal variables that can affect labor:
➔ Fetal size
➔ Fetal Lie - longitudinal, transverse or
oblique
➔ Fetal presentation - vertex, breech,
shoulder, compound (vertex and hand), and
funic (umbilical cord).
➔ Attitude - degree of flexion or extension of
the fetal head
➔ Position
➔ Station - degree of descent of the
presenting part of the fetus, measured in
centimeters from the ischial spines
➔ Number of fetuses
➔ Presence of fetal anomalies -
hydrocephalus, sacrococcygeal teratoma
1st P: Passage (Birth Canal)
➢ Consists of the bony pelvis and soft tissues
of the birth canal (cervix, pelvIc floor
musculature)
➢ Small pelvic outlet can result in
cephalo-pelvic disproportion
2nd P: Passenger
➢ Fetus and the products of conception.
➢ Fetal head= largest diameter of a fetus.
Structure of the Fetal Skull
❖ Cranium = has 8 bones
- (4 superior bones) frontal bones, two
parietal bones, occipital bone, sphenoid
bone, ethmoid bone, two temporal bones
Important Landmarks:
➔ Sinciput= area over the frontal bone.
➔ Occiput= area over the occiput bone
➔ Mentum= fetal chin
➔ Facial= fetal face
❖ Fetus Sutures
- Frontal
- Sagittal
- Coronal
- Lambdoidal
MOLDING - adaptation of fetal head to the pelvic
cavity during birth.
- change in the shape of the fetal skull
produced by the force of uterine
contractions pressing the vertex against the
not-yet-dilated cervix.
 - not a permanent condition, lasts 1-2 days.
Fetal Attitude
- is the relation of the fetal body parts to one
another
- The fetus assumes a characteristic posture
(attitude) in utero partly because of the
mode of fetal growth and partly because of
the way the fetus conforms to the shape of
the uterine cavity.
- Lie is the relation of the long axis (spine) of
the fetus to the long axis (spine) of the
mother.
- The two primary lies are longitudinal, or
vertical, in which the long axis of the fetus is
parallel with the long axis of the mother and
transverse, horizontal, or oblique, in which
the long axis of the fetus is at a right angle
diagonal to the long axis of the
mother.
Fetal Presentation and Position
➔ Presentation refers to the part of the fetus
that enters the pelvic inlet first and leads
through the birth canal during labor at term.
➔ It is measured by the combination of fetal
lies and the degree of fetal flexion (attitude)
- Cephalic Presentation
- Breech Presentation
- Shoulder Presentation
Cephalic - most common presentation (95%)
- Vertex: occiput
- Brow: sinciput
- Face: face o
- Mentum: chin
Note: Caput succedaneum
Breech - either the buttocks/feet are the first body
parts that will contact the cervix (3%).
- Complete breech
- Frank breech
- Footling breech
Shoulder - seen in transverse lie, acromion
process, iliac crest, a hand or elbow.
D. Position
- relationship of the landmark of the fetal presenting
part to the maternal pelvis.
❖ Maternal pelvis (Right anterior, left anterior,
right posterior, left posterior)
❖ Fetal landmarks
- Occiput in vertex
- Mentum/chin in face presentation
- Sacrum in breech presentation
- acromion of the scapula in shoulder
presentation
❖ Expressed as three letter abbreviation like
LOA (most common), LSaA, LMA, LAA
Station:
➢ The relationship of presenting part of the
fetus to the level of the ischial spines.
➢ Ischial spines of pelvis (0 station)
➢ Measured cm above (+) or below ischial
spines (-)
➢ Some use +3 to -3; some use +5 to -5 In
normal pelvis, narrowest diameter thru
which fetus passes
➢ Floating is above the spines.
➢ Engaged is the level of the spines.
➢ Crowning: the presenting part is at the
perineum and can be seen if the vulva is
separated
Station - degree of descent of the presenting part
of the fetus, measured in centimeters from the
ischial spines
Methods to detect Fetal Position/ Presentation
1. Combined abdominal inspection and
palpation (Leopold's maneuver
2. Vaginal examination
3. Auscultation of fetal heart tone
4. Sonography
3rd P: Powers
Forc0-s of labor, acting in concert, to expel the
fetus.
* Involuntary contraction of the uterine muscle
- Assess for frequency, duration and intensity of
uterine contractions
- Assess for uterine resting tone o In hypertonic
uterine activity, resting tone is elevated, reducing
blood flow and decreasing oxygen supply to the
fetus
- Abdominal contraction while mother bears down
during the second stage of labor. "bearing down"

Uterine Contractions
* Origins. Pacemaker point at the myometrium near
the uterotubal junction. Begins at a certain point
then sweeps downward as a wave.
* May not be working in a synchronous manner
may lead to failure to progress and fetal distress.
* Phases. Increment Acme Decrement
* Relaxation= 10 mins to 2-3 mins
* Duration= 20-30 secs to 60-90 secs
- Allay fear, apprene and anxiety -> decreases
perception of pain
- Support system helps mother cope up easily
5th P: Position (maternal)
- Dorsal recumbent and Side-lying or upright
(standing, walking, squatting, semi-sitting)
- Conventional: Lithotomy position: Elevate both
feet at the same time to prevent strand on the back
and lower abdominal muscles.

Characteristics of Contractions
• Contraction-exhibits a wavelike pattern that
begins slowly climbing (increment) to a peak, and
decreases (decrement)
* Duration- from beginning of one contraction to the
end of the same contraction
* Frequency- from beginning of one contraction to
the beginning of another contraction
* Interval -7 dung time between contractions for
placental perfusion
* Contour changes. Upper portion becomes thicker
and active, the lower segment becomes
thin-walled, supple and passive.
* "Physiologic retraction ring"= boundary bet. the
two portions, a ridge on the inner uterine surface.

the Physiological Retraction Ring

• As a result of the lower segment thinning and
concomitant upper segment thickening, a boundary
between the two is marked by a ridge on the inner
uterine surface--the physiological retraction ring.

Cervical Changes
Effacement. Shortening and thinning of the cervical
canal. (1-2 cm long)
- Primipara= effacement before dilation
- Multipara= dilatation may proceed before
effacement is complete.

* Dilatation. Enlargement or widening of the cervical

canal from an opening a few mm wide to one large
enough. (10 cm)
- Reasons: contractions lead to full cervical
dilatation.
- > Fluid filled membranes press against the cervix.

4th P: Psychological state of the