labia majora and labia minora

Week 1: Reproductive System/ Responsible - sometimes cut during vaginal birth (episiotomy)
Parenthood
• SKENE’S GLANDS (PARAURETHRAL GLANDS)
Female Reproductive System - are located lateral to the urinary meatus on either
side
- help lubricate the ext genitalia during intercourse
• BARTHOLIN’S GLANDS (VULVOVAGINAL GLANDS)
- Secrete mucus along with Skene’s glands during
sexual
stimulation
- alkaline ph of Skene’s and Bartholin’s help improve
sperm
survival in the vagina
F. PERINEAL. BODY / PERINEAL MUSCLE /
PERINEUM
- Post. to the fourchette
- Easily stretched during childbirth to allow
enlargement of the vagina
G. URETHRAL MEATUS
- Located 1-2.5cm below the clitoris

EXTERNAL GENITALIA:
A. MONS PUBIS
- Provides an adipose cushion over the anterior
symphysis pubis
- Protects the pelvic bones
B. LABIA MAJORA
- Positioned lateral top of the labia minor
- Covered by pubic hair
C. LABIA MINOR
- Consists of connective tissue, elastic fibers, veins and
sebaceous glands
- Protect the ext. genitalia and the distal urethra and
vagina
- Unite to form the fourchette, the vaginal vestibule
D. CLITORIS
INTERNAL GENITALIA:
- 1-2 cm in size
A. UTERUS
- Located in the anterior position of the vulva
Functions:
- Covered by a fold of skin called the prepuce
- To receive the ovum from the Fallopian tube
- Make up of erectile tissue, nerves and blood vessels
- To provide a place for the ovum to implant
E. VAGINAL VESTIBULE
- To offer nourishment and protection to the growing
- Flattened smooth surface inside the labia
fetus
- Openings to the bladder (urethra) and the uterus
- To expel the fetus when mature
(vagina), both arise
4 Parts:
from the vestibule
1. Body/corpus - uppermost portion
- Consists of the vaginal orifice, the hymen, the
2. Fundus - between points of attachment of the
fourchette, Skene’s and
fallopian tubes
Bartholin’s glands
3. Isthmus - short segment between corpus and cervix
• HYMEN
- cut during cesarean birth
- Is a thin but tough, vascularization mucous membrane
4. Cervix - lowest part
- located at the vaginal orifice
- the junction of the canal at the isthmus is the internal
• FOURCHETTE
cervical os
- Is the ridge of tissue formed by the post. joining of the
- the distal opening into the vagina is the external
two

1
cervical os ligation
Ampulla - 3rd and longest portion of the tube; 5cm
- fertilization of an ovum takes place
B. UTERINE LAYERS Infundibular - 4th most distal of the tube
1. ENDOMETRIUM - 2 cm long and funnel shaped
- Inner mucous membrane layer that’s shed during - the rim of the funnel is covered by fimbriae (small
menstruation hairs) that help guide the ova into the tube

2. MYOMETRIUM
- 3 interwoven layers of smooth muscle, which are
arranged in longitudinal, transverse, & oblique
directions - offers extreme strength to the uterus

3. PERIMETRIUM
- Outer layer that covers the body of the uterus and
part of the cervix
- Adds strength and support

C. UTERINE NERVE SUPPLY

- Both afferent (sensory) & efferent (motor) nerves
H. OVARIES
- 2 almond shaped glandular structures on either side
D. UTERINE BLOOD SUPPLY of the uterus, below and behind the Fallopian tubes
- Uterine arteries - Produce mature and discharge ova
- The uterus also receives blood from the ovarian
arteries

E. UTERINE SUPPORT
BROAD LIGAMENTS - 2 fold of peritoneum that cover
the front and back of the uterus and extend to the
pelvic sides
ROUND LIGAMENTS - 2 fibrous muscular cords that
pass from the body of the uterus near the attachments
of the Fallopian tubes
F. VAGINA
- Vascularized musculomembranous tube that extends
from the external genitalia to the uterus
- Functions as the organ of intercourse, channeling
sperm to the cervix
- Expands with pregnancy to function as birth canal
- Act as uterine excretory duct for menses and other
secretions RELATED STRUCTURES:
FEMALE ACCESSORY GLANDS:
G. FALLOPIAN TUBES
- Each is about 10cm /12 cm long
4 layers: 1. BREASTS /Mammary glands
Peritoneal - Divided by connective tissue into approx. 20 lobes
Subserous - All the glands in each lobe produce milk by ACINI cells
Muscular , produces peristaltic motions that conduct and deliver it to the nipple by lactiferous duct
the ova the length of the tube - Nipple is surrounded by a darkly pigmented area of
Mucosal - act as lubricant to aid ova travel and also act epithelium approx. 4 cm - areola
as nourishment for the fertilized egg; contains CHON, - The areola appears rough due to many sebaceous
H2O, and salt glands called
4 Portions: MONTGOMERY’S tubercles
Interstitial - proximal portion; 1 cm in length - Provide nourishment to the infant and transfer
Isthmus - next distal portion; 2 cm maternal antibodies during breastfeeding
- is the portion of the tube that is cut or sealed in tubal - Enhance sexual pleasure

2
- Blood supply: thoracic branches of axillary, internal
mammary and intercostal arteries

4 TYPES OF FEMALE PELVIS

1. GYNECOID
2. ANDROID
3. PLATYPELLOID
4. ANTHROPOID

Responsible Parenthood

-Also termed as MENSE / PERIOD

2. FEMALE PELVIS
- Supports and protects the reproductive organs
- Bones which compose the body pelvis: ILIUM,
ISCHIUM, PUBIS, SACRUM, COCCYX
- Average length of menstrual flow is 2 - 7 days
although some may have periods as short as 1 day or as
long as 9 - 10 days
MENARCHE
- 1st menstruation period in girls
- May occur as early as 9 years and as late as age 17
and still be within normal limits

DIFFERENT MENSTRUAL CONCERNS

Amenorrhea
Dysmenorrhea
Metrorrhagia
Menorrhagia
Menopause

MENSTRUAL CYCLE
FALSE PELVIS
- Also termed FEMALE REPRODUCTIVE CYCLE
- Supports the uterus during the late months of
- Periodic uterine bleeding in response to cyclic
pregnancy
hormonal changes
- Directs the fetus into the true pelvis
- Purpose is to bring an ovum to maturity and renew a
uterine tissue bed that will be responsive to its growth
TRUE PELVIS should it be fertilized
Inlet - entrance to the true pelvis; upper ring of the
PHYSIOLOGY OF MENSTRUATION
bone
Pelvic Cavity - space between the inlet and outlet
Outlet - inferior portion of the pelvis 4 STRUCTURES INVOLVED IN THE MENSTRUAL CYCLE:

For the fetus to be delivered vaginally, it must be able 1. HYPOTHALAMUS

to pass through the ring of the pelvic bone and the - Releases LHRH / GnRH which initiates menstrual cycle
opening must be sufficient, otherwise the fetus may - Presence of estrogen represses the hormone
have to be delivered via CS

2. PITUITARY GLAND
- Under the influence of LHRH, the anterior lobe of the

3
pituitary gland (adenohypophysis) produces 2
hormones that act on the ovaries to further influence
the menstrual cycle:
FSH - Responsible for maturation of the ovum
LH - becomes most active at the midpoint of the cycle
and is responsible for ovulation
3. OVARIES
- Maturation of locates (4 million at present)
- Ovulation; every month, one of the follicles is
activated by FSH.
At maturity, it is visible on the surface of the ovary as a
clear water blister approximately 1/4 - 1/2 termed
GRAAFIAN FOLLICLE
- The ovum is set free from the surface of the ovary, a
process termed OVULATION; ovulation occurs on
approximately 14th day before the onset of the next
cycle (subtract 14 days from the
length of the menstrual cycle)
- The LH causes the ovary to produce LUTEINIZING, a
bright yellow fluid, instead of follicular fluid. This yellow
fluid fills the empty follicle, which is then termed
CORPUS LUTEUM (yellow body)
- FSH stimulates Graafian follicle
- FSH production decreases before ovulation (around
day 14)
2ND PHASE: SECRETORY / LUTEAL / PROGESTATIONAL
/
PREMENSTRUAL
- Day 14 - 25
- The corpus luteum forms under the influence of LH
- Estrogen and progesterone production increase
- The endometrium is prepared for implantation of
fertilized ovum
- Increase vascular supply (capillaries)
3rd PHASE: ISCHEMIC PHASE
- Approximately 24 /25 day of the cycle
- Days 26 through 28
- Corpus luteum degenerates if conception doesn’t
occur
- Estrogen and progesterone levels decline if
conception doesn’t occur
- Arteries and capillaries constrict and endometrium
become anemiccapillaries rupture with minute
hemorrhages, and the endometrium sloughs off
4TH PHASE: MENSTRUATED PHASE / MENSE
- The end of menstrual cycle
- Comprise the 1st 5 days of the cycle
- The 1st day is used to mark the beginning of a new
menstrual cycle
- 30-80ml of blood / 50-150ml
- Estrogen and progesterone level decrease
- FSH levels rise, and steady levels of LH influence the
ovary to secret estrogen
- Usually lasts about 4-5 days, but 1-10 days maybe
normal for some women

SIGNS OF OVULATION:
• Mittleschmerz - slight discomfort in right / left iliac
region
• Spinnbarkeit - stretchable, clear vaginal / cervical
secretions
• Change in body temperature 1 degree Fahrenheit the
day following ovulation due to the concentration of
HORMONES INVOLVED:
progesterone.
1. GnRH (APG) - initiates the menstrual cycle
4. UTERUS • FSH
IST PHASE: PROLIFERATIVE / FOLLICULAR / - stimulate development of primordial follicles into
ESTROGENIC / Graafian follicles
POSTMENSTRUAL • LH
- Day 5-14 / 6-13 - responsible for ovulation
- Estrogen increases, leasing to proliferation of 2. ESTROGEN
endometrium and myometrium in preparation of - secondary sex characteristics
possible implantation of a fertilized ovum - Fertile cervical mucus
- Follicle secretes estradiol - Maintains the endometrium

4
 - Stimulates uterine contraction
3. PROGESTERONE
- Prepares the endometrium
- Relaxes the myometrium
- Increases basal body temperature
- Infertile mucus
- Maintains pregnancy
Family Planning
Contraception can be used to prevent pregnancy and
some types will also protect you from sexually
transmissible infections (STIs).
The Condom
The condom is the only form of contraception that
protects against most STIs as well as preventing
pregnancy. This method of contraception can be used
on demand, is hormone free and can easily be carried
with you. And it comes in male and female varieties.
Male condoms are rolled onto an erect penis and act as
a physical barrier, preventing sexual fluids from passing
between people during sex. The female condom is
placed into the vagina right before sex. Based on typical
use, the female condom is not quite as effective as the
male latex condom and it may take a little practice to
get used to.
Pros include: It’s the best protection against STIs; can
be used on demand; hormone free.
Cons include: It can tear or come off during sex if not
used properly; some people are allergic to latex
condoms.
Facts about the female condom
 If used correctly, female condoms are 95% effective.
 They protect against pregnancy and sexually
transmitted infections (STIs).
 A female condom needs to be placed inside the vagina
before there's any contact with the penis.
 Always buy condoms that have the CE mark or the BSI
Kitemark on the packet. This means they have been
tested to high safety standards.
 A female condom can get pushed inside the vagina
during sex, but it's easy to remove them yourself if this
happens.
 Female condoms may not be suitable for women who
are not comfortable touching their genital area.
 Female condoms should not be reused. Open a new
one each time you have sex.
 Condoms have a use-by date on the packaging. Do not
use out-of-date condoms.
The Oral Contraceptive Pill
It’s the little tablet taken once a day. There are a few
different types of pill to choose from, so it’s about
finding the one that’s right for you. The combined pill
contains estrogen and progestin and mini pill contains
only one hormone, a progestin. The pill can have many
benefits, however remembering to take it on time is a
must.
Pros of taking the pill include: Highly effective when
used correctly; permits sexual spontaneity and doesn’t
interrupt sex; some pills may even reduce heavy and
painful periods and/or may have a positive effect on
acne.
Cons include: Forgetting to take your pill means it
won’t be as effective; it can only be used by women; is
not suitable for women who can't take oestrogen-
containing contraception; it does not protect against
STIs.
Contraceptive patch
The contraceptive patch is a small sticky patch that
releases hormones into your body through your skin to
prevent pregnancy. In the UK, the patch's brand name
is Evra.
Facts about the patch
 When used correctly, the patch is more than 99%
effective at preventing pregnancy.
 Each patch lasts for 1 week. You change the patch
every week for 3 weeks, then have a week off without a
patch.
 You don't need to think about it every day, and it's still
effective if you're sick (vomit) or have diarrhea.
 You can wear it in the bath when swimming and while
playing sports.
5
 If you have heavy or painful periods, the patch can
help.
 The patch can raise your blood pressure, and some
women get temporary side effects, such as headaches.
 Rarely, some women develop a blood clot when using
the patch.
 The patch may protect against ovarian, womb and
bowel cancer.
 It may not be suitable for women who smoke and who
are 35 or over, or who weigh 90kg (14 stone) or more.
 The patch does not protect against sexually transmitted
infections (STIs), so you may need to use condoms as
well.
How it works
The patch releases a daily dose of hormones through
the skin into the bloodstream to prevent pregnancy.
It contains the same hormones as the combined pill –
estrogen and progestogen – and works in the same way
by preventing the release of an egg each month
(ovulation).
It also thickens cervical mucus, which makes it more
difficult for sperm to move through the cervix and thins
the womb lining so a fertilized egg is less likely to be
able to implant itself.
How to use the patch
Apply your first patch and wear it for 7 days. On day 8,
change the patch to a new one. Change it like this every
week for 3 weeks, and then have a patch-free week.
During your patch-free week you'll get a withdrawal
bleed, like a period, although this may not always
happen.
After 7 patch-free days, apply a new patch and start the
4-week cycle again. Start your new cycle even if you're
still bleeding.
Where to put the patch
Stick the patch directly onto your skin. You can put it
onto most areas of your body, as long as the skin is
clean, dry and not very hairy. You shouldn't stick the
patch onto:
 sore or irritated skin
 an area where it may get rubbed off by tight clothing
 your breasts
It's a good idea to change the position of each new
patch to help reduce the chance of skin irritation.
When the patch starts to work
If you start using the patch on the first day of your
period, and up to and including the fifth day of your
period, you'll be protected from pregnancy straight
away.
If you start using it on any other day, you need to use
an additional form of contraception, such as condoms,
for the first 7 days.
If you have a short menstrual cycle with your period
coming every 23 days or less, starting the patch on the
fifth day of your period or later means you may not be
protected against pregnancy and will also need
additional contraception for the first 7 days.
You can talk to a GP or nurse about when the patch will
start to work, and whether you need to use additional
contraception in the meantime.
What to do if a patch falls off
The contraceptive patch is very sticky and should stay
on. It shouldn't come off after a shower, bath, hot tub,
sauna, or swim.
If the patch does fall off, what you need to do depends
on how long it has been off.
If it's been off for less than 48 hours:
 put a new patch on (don't try to hold the old patch in
place with a plaster or bandage)
 change it on your normal change day
 you're protected against pregnancy if you've used your
patch correctly for the past 7 days (and the 7 days
before your patch-free week, if you're in week 1)
If it's been off for 48 hours or more, or you're not sure
how long:
 put on a new patch
 change it on your normal change day, if you're in week
1 or 2 of your patch cycle
 if you're in week 3, you need to start a new patch cycle
(this is now day 1 of your new cycle) and miss your
usual patch-free week
 whatever week you're in, use additional contraception,
such as condoms, until you've had a patch on for 7 days
in a row
 you may need emergency contraception if you had sex
during the patch-free break, or in week 1, and the
patch fell off during week 1. Or, you had sex during
week 2 or 3 when a patch had not been on properly for
the previous 7 days. In these situations, ask a GP or
nurse for advice
What to do if you forget to take a patch off
If you forget to take a patch off, what you should do
depends on how many extra hours it has been left on.
6
 If you remove it before going over 48 hours (it's been
on for 8 or 9 days in total):
 take off the old patch and put on a new one
 change it on your normal change day
 you're protected against pregnancy if you've used the
patch correctly up until the time you forgot to take it
off
If a patch has been on for an extra 48 hours or longer
(it's been on for 10 days or more):
 put on a new patch as soon as possible
 change it on your normal change day
 use additional contraception, such as condoms, until
you've had the patch on for 7 days in a row
 see a GP or nurse for advice if you've had sex in the
previous few days as you may need emergency
contraception
If you forget to take the patch off after week 3, take it
off as soon as possible. Start your patch-free break and
start a new patch on your usual start day, even if you're
bleeding. This means you won't have a full week of
patch-free days.
You'll be protected against pregnancy and won't need
to use any additional contraception. You may or may
not bleed on the patch-free days.
What to do if you forget to put a patch on after the
patch-free week
Put on a new patch as soon as you remember. This is
the beginning of your new patch cycle. You'll now have
a new day of the week as your start day and change
day.
If you're more than 24 hours late sticking on the patch
(the interval has been 8 days or more), you may not be
protected against pregnancy and will need to use
additional contraception, such as condoms, for 7 days.
See a GP or nurse for advice if you've had unprotected
sex in the patch-free interval, as you may
need emergency contraception.
Bleeding in the patch-free week
Some women don't always have a bleed in their patch-
free week. This is nothing to worry about if you've used
the patch properly and have not taken any medicine
that could affect it.
See a GP or nurse for advice if you're worried, or do
a pregnancy test to check if you're pregnant.
If you miss more than 2 bleeds, get medical advice.
Who can use the patch
The contraceptive patch isn't suitable for everyone, so
if you're thinking of using it, a GP or nurse will need to
ask about you and your family's medical history. Tell
them about any illnesses or operations you've had, or
medicines you're taking.
You may not be able to use the patch if:
 you're pregnant or think you may be pregnant
 you're breastfeeding a baby less than 6 weeks old
 you smoke and are 35 or over
 you're 35 or over and stopped smoking less than a year
ago
 you're very overweight
 you're taking certain medicines, such as St John's Wort,
or medicines used to treat epilepsy, tuberculosis
(TB) or HIV
You may also not be able to use the patch if you have
or have had:
 blood clots in a vein or artery (or an immediate family
member had a blood clot before they were 45)
 a heart problem
 high blood pressure
 some blood conditions that increase your chance of
getting a blood clot, such as lupus (systemic lupus
erythematosus)
 breast cancer
 migraine with aura (warning signs)
 disease of the liver or gallbladder
Advantages and disadvantages of the patch
Advantages:
 it's very easy to use and doesn't interrupt sex
 unlike the combined oral contraceptive pill, you don't
have to think about it every day – you only have to
remember to change it once a week
 the hormones from the patch aren't absorbed by the
stomach, so it still works if you're sick (vomit) or have
diarrhoea
 it can make your periods more regular, lighter and less
painful
 it can help with premenstrual symptoms
 it may reduce the risk of ovarian, womb and bowel
cancer
Disadvantages:
 it may be visible
 it can cause skin irritation, itching and soreness
 it doesn't protect you against STIs, so you may need to
use condoms as well
 some women get mild temporary side effects when
they first start using the patch, such as headaches,
7
 sickness (nausea), breast tenderness and mood
changes – this usually settles down after a few months
 bleeding between periods (breakthrough bleeding) and
spotting (very light, irregular bleeding) is common in
the first few cycles of using the patch – this is nothing
to worry about if you're using it properly and you'll still
be protected against pregnancy
 some medicines can make the patch less effective – see
a GP, nurse, or pharmacist for advice
 you need to remember to change it every week, so if it
would be easier to use a method that you don't have to
think about you may want to consider
the implant or intrauterine device (IUD)
Blood clots
A very small number of people using the patch may
develop a blood clot in a vein or an artery. Don't use
the patch if you've had a blood clot before.
Your risk is higher if:
 it's your first year of using the patch
 you smoke
 you're very overweight
 you're unable to move (immobile) or use a wheelchair
 you have migraines with aura (warning signs)
 a close family member has had a heart attack, stroke or
blood clot before they were 45
Cancer
Research suggests that people who use the
contraceptive patch have a small increased risk of being
diagnosed with breast cancer compared with those
who don't. But this reduces with time after stopping
the patch.
Research also suggests there's a small increase in the
risk of developing cervical cancer with long-term use of
oestrogen and progestogen hormonal contraception.
Intrauterine Device (IUD)
This small, T-shaped device is made from made of
material containing progesterone hormone or plastic
and copper and is fitted inside a woman’s uterus by a
trained healthcare provider. It's a long-acting and
reversible method of contraception, which can stay in
place for three to 10 years, depending on the type.
Some IUDs contain hormones that are gradually
released to prevent pregnancy. The IUD can also be an
effective emergency contraception if fitted by a
healthcare professional within five days (120 hours) of
having unprotected sex.
IUDs containing coppers are 99% effective and the ones
containing hormones are 99.8% effective, so you’re
about as protected as you possibly can be by a
contraceptive method.
Cons include: Irregular bleeding and spotting occurs in
the first six months of use; requires a trained
healthcare provider for insertion and removal; does not
protect against STIs.
The Contraceptive Implant
In this method, a small, flexible rod is placed under the
skin in a woman’s upper arm, releasing a form of the
hormone progesterone. The hormone stops the ovary
releasing the egg and thickens the cervical mucus
making it difficult for sperm to enter the womb. The
implant requires a small procedure using local
anesthetic to fit and remove the rod and needs to be
replaced after three years. Women can choose to use
the implant as a long-term contraceptive method.
Pros of the implant include: Highly effective; doesn’t
interrupt sex; is a long-lasting, reversible contraceptive
option.
Cons include: Requires a trained healthcare provider
for insertion and removal; sometimes there can be
irregular bleeding initially; does not protect against
STIs.
The Contraceptive Injection
The injection contains a synthetic version of the
hormone progestogen. It is given into a woman’s
buttock or the upper arm, and over the next 12 weeks
the hormone is slowly released into your
bloodstream. The contraceptive injection uses
progestogen to prevent pregnancy.
Pros: The injection lasts for up to three months; is very
effective; permits sexual spontaneity and doesn’t
interrupt sex.
Cons: The injection may cause disrupted periods or
irregular bleeding; it requires keeping track of the
number of months used; it does not protect against
STIs.
Emergency Contraception Pill (The ‘Morning After Pill)
The Emergency Contraception Pill can be used to
prevent pregnancy after sex if contraception wasn’t
used, a condom has broken during sex, or a woman has
been sexually assaulted.
While it is sometimes call the ‘Morning After’ pill, it can
actually be effective for up to five days after having
unprotected sex. The sooner it is taken, the more
effective it is; when taken in the first three days after
sex, it prevents about 85% of expected pregnancies.
8
This pill contains special doses of female hormones.
Any woman can take the emergency contraception pill,
even those who cannot take other oral contraceptive
pills. It can be bought over the counter at a pharmacy
or chemist without a prescription.
The common side effects of the emergency
contraceptive include nausea, vomiting and the next
period may be early or delayed. Emergency
contraception does not protect against STIs.
Emergency contraception can be used after having sex
to prevent pregnancy.
Contraceptive Ring
This method consists of a flexible plastic ring constantly
releasing hormones that is placed in the vagina by the
woman. It stays in place for three weeks, and then you
remove it, take a week off then pop another one in.
The ring releases the hormones oestrogen and
progestogen. These are the same hormones used in the
combined oral contraceptive pill, but at a lower dose.
The contraceptive ring releases a lower dose of
hormones to control a woman's ability to conceive than
other contraceptive methods like the pill.
Pros include: You can insert and remove a vaginal ring
yourself; this contraceptive method has few side
effects, allows control of your periods and allows your
fertility to return quickly when the ring is removed.
Cons include: It is not suitable for women who can't
take oestrogen-containing contraception; you need to
remember to replace it at the right time; does not
protect against STIs.
Diaphragm
A diaphragm is a small, soft silicon dome is placed
inside the vagina to stop sperm from entering the
uterus. It forms a physical barrier between the man's
sperm and the woman's egg, like a condom.
The diaphragm needs to stay in place for at least six
hours after sex. After six - but no longer than 24 hours
after sex - it needs to be taken out and cleaned.
Some of the pros: You can use the same diaphragm
more than once, and it can last up to two years if you
look after it.
Some of the cons: Using a diaphragm can take practice
and requires keeping track of the hours inserted. The
diaphragm works fairly well if used correctly, but not as
well as the pill, a contraceptive implant or an IUD.
Sterilization
Sterilization is the process of completely taking away
the body’s ability to reproduce through open or
minimal invasion surgery. It is a permanent method of
contraception, suitable for people who are sure they
never want children or do not want any more children.
Sterilization is available for both women and men and
is performed in a hospital with general anesthesia.
Depending on the method used, you would either have
a general anaesthetic, where you're asleep during
surgery, or local anaesthetic, where you'd be awake but
not feel any pain.
Because sterilisation can be permanent, it's only
suitable for people who definitely do not want to have
any children, or any further children, in the future.
If you are thinking about sterilisation, issues to talk with
your doctor about include your reasons for wanting to
be sterilised, whether other methods of contraception
might be more suitable and any side effects, risks and
complications of the procedure.
Facts about female sterilization
 Female sterilisation is more than 99% effective at
preventing pregnancy.
 You do not have to think about protecting yourself
against pregnancy every time you have sex, so it does
not interrupt your sex life.
 It does not affect your hormone levels and you'll still
have periods.
 You'll need to use contraception up until you have the
operation, and until your next period or for 3 months
after the operation (depending on the type of
sterilisation).
 As with any surgery, there's a small risk of
complications, such as internal bleeding, infection or
damage to other organs.
 There's a small risk that the operation will not work.
Blocked tubes can rejoin immediately or years later.
 If the operation fails, this may increase the risk of a
fertilised egg implanting outside the womb (ectopic
pregnancy).
 Sterilisation is very difficult to reverse, so you need to
be sure it's right for you.
 Sterilisation does not protect against sexually
transmitted infections (STIs), so you may need to use
condoms as well.
How female sterilization is carried out
The surgeon will block your fallopian tubes (tubal
occlusion) by either:
 applying clips – plastic or titanium clamps are closed
over the fallopian tubes
 applying rings – a small loop of the fallopian tube is
pulled through a silicone ring, then clamped shut
 tying, cutting and removing a small piece of the
fallopian tube
9
 This is a fairly minor operation and many women return
home the same day.
Depending on your general health and job, you can
normally return to work 5 days after tubal occlusion,
but avoid heavy lifting for about a week.
You may have some slight vaginal bleeding. Use a
sanitary towel, rather than a tampon, until this has
stopped.
You may also feel some pain, like period pain. You can
take painkillers for this.
Having sex
Your sex drive and sex life should not be affected. You
can have sex as soon as it's comfortable to do so after
the operation.
If you had tubal occlusion, use additional contraception
until your first period to protect yourself from
pregnancy.
Sterilisation does not protect against sexually
transmitted infections (STIs), so you may need to use
condoms.
Advantages and disadvantages of female sterilisation
Advantages:
 more than 99% effective at preventing pregnancy
 blocking the fallopian tubes and removal of the tubes
should be effective immediately – but use
contraception until your next period
 it will not affect your sex drive or interfere with sex
 it will not affect your hormone levels
Disadvantages:
 it does not protect against STIs, so you may need to use
condoms
 it cannot be easily reversed, and reversal operations
are rarely funded by the NHS
 it can fail – the fallopian tubes can rejoin and make you
fertile again, although this is rare
 there's a very small risk of complications, including
internal bleeding, infection or damage to other organs
 if you get pregnant after the operation, there's an
increased risk it'll be an ectopic pregnancy
Vasectomy (male sterilization)
facts about vasectomy
 A vasectomy is more than 99% effective.
 It's considered permanent, so once it's done you don't
have to think about contraception again.
 It doesn't affect your sex drive or ability to enjoy sex.
You'll still have erections and ejaculate, but your semen
won't contain sperm.
 You'll need to use contraception for at least 8 to 12
weeks after the operation, because sperm will still be in
the tubes leading to the penis.
 Up to 2 semen tests are done after the operation to
make sure that all the sperm have gone.
 Your ball sack (scrotum) may become bruised, swollen
or painful – some men have ongoing pain in their
testicles.
 As with any surgery, there's a small risk of infection.
 It's very difficult to reverse, so be sure it's right for you.
 A vasectomy doesn't protect against sexually
transmitted infections (STIs), so you may need to use
condoms as well.
There are 2 types of vasectomy:
 a conventional vasectomy using a scalpel (surgical
knife)
 a no-scalpel vasectomy
·         No-scalpel vasectomy
 The doctor first numbs your scrotum with local
anaesthetic. They then make a tiny puncture
hole in the skin of your scrotum to reach the
tubes. This means they don't need to cut the
skin with a scalpel.
 The tubes are then closed in the same way as
a conventional vasectomy, either by being tied
or sealed.
 There's little bleeding and no stitches with this
procedure. It's thought to be less painful and
less likely to cause complications than a
conventional vasectomy.
Natural family planning (fertility awareness)
Natural family planning (or "fertility awareness") is a
method of contraception where a woman monitors and
records different fertility signals during her menstrual
cycle to work out when she's likely to get pregnant.
Facts about natural family planning
 If natural family planning is followed consistently and
correctly, it can be up to 99% effective (1 to 9 women
in 100 who use natural family planning will get
pregnant in 1 year).
 It is less effective if the instructions are not carefully
followed.
 There are no physical side effects, and you can use it to
plan when you get pregnant.
10
 You have to keep a daily record of your fertility signals,
such as your temperature and the fluids coming from
your cervix – it takes 3 to 6 menstrual (monthly) cycles
to learn the method.
 Your fertility signals can be affected by illness, stress
and travel.
 If you want to have sex during the time when you
might get pregnant, you'll need to use contraception,
such as a condom, diaphragm or cap.
 By using condoms as well as natural family planning,
you'll help to protect yourself against sexually
transmitted infections (STIs).
How natural family planning works
Natural family planning involves identifying the signs
and symptoms of fertility during your menstrual cycle
so you can plan or avoid pregnancy.
There are 3 different fertility signals you can monitor
and record for natural family planning. These are:
 the length of your menstrual cycle
 daily readings of your body temperature
 changes to your cervical secretions (cervical mucus)
It's best to record these measures together to give you
a more accurate picture of when you're likely to be
most fertile.
You can use fertility charts to record and track your
measurements over the course of each menstrual
cycle. You can download fertility charts from the
Fertility Education and Training site, with information
on how to use them.
You can also download smartphone apps to track this
information.
Your menstrual cycle and ovulation (Calendar
Method)
Your menstrual cycle lasts from the first day of your
period until the day before your next period starts. This
is 28 days on average but longer or shorter cycles, from
21 to 40 days, are normal.
During your cycle, an egg is released from one of your
ovaries (ovulation) and travels down the fallopian tube.
It is usually released 10-16 days before your next
period. Occasionally, a second egg is released, within
24 hours of the first egg.
The egg only lives for a maximum of 24 hours after
ovulation, and a sperm must meet the egg within that
period for pregnancy to happen.
You can get pregnant up to 2 days after you ovulate.
But if you've had sex in the 7 days before ovulation, it's
possible to get pregnant because sperm can live inside
a woman's body for up to 7 days and fertilise the egg
when it's released.
By tracking your cycle, you can calculate when you're
most likely to be fertile (able to conceive). But you
need to allow for uncertainty over exactly when you
ovulate.
The length of a menstrual cycle can vary over time, so
to make sure your calculations are as precise as
possible, measure your menstrual cycle over the course
of 12 months.
The temperature method (Basal Body Temperature)
The temperature method is used because there's a
small rise in body temperature after ovulation.
You'll need to use either a digital thermometer or a
thermometer specifically designed for natural family
planning. Ear or forehead thermometers are not
accurate enough for this.
The temperature method involves taking your
temperature every morning before you get out of bed.
This should be done before eating, drinking and
smoking, and ideally at the same time every morning.
Look out for 3 days in a row when your temperature is
higher than all of the previous 6 days. The increase in
temperature is very small, usually around 0.2C (0.4F).
It's likely that you're no longer fertile at this time.
Cervical secretion monitoring method
There's a change in the amount and texture of your
cervical secretions (cervical mucus) during different
times in your menstrual cycle.
You can check this by gently placing your middle finger
into your vagina and pushing it up to around your
middle knuckle. For the first few days after your period,
you'll probably find your vagina is dry and you cannot
feel any mucus.
As your hormone levels rise to prepare your body for
ovulation, you'll probably find that you start to produce
mucus that is moist, sticky, white and creamy. This is
the start of the fertile period of your menstrual cycle.
Immediately before ovulation the mucus will get
wetter, clearer and slippery – a bit like raw egg white.
This is when you're at your most fertile.
The mucus should then soon return to being thicker
and sticky, and after 3 days you should no longer be
fertile.
How effective is natural family planning?
If natural family planning instructions are carefully
followed, this method can be up to 99% effective. This
means that 1 to 9 women in 100 who use natural family
planning correctly will get pregnant.
11
 But if natural family planning methods are not quite
followed correctly, more women will get pregnant. It
takes commitment and practice to use natural family
planning effectively.
Who can use natural family planning
Most women can use natural family planning.
However, certain situations can affect fertility signs and
you might want to consider a different method if:
 there could be a health risk to the baby if you got
pregnant
 you're having irregular periods
 you have a short or long-term condition affecting your
fertility signs, such as a sexually transmitted infection
(STI) or pelvic inflammatory disease
 you're taking a medication that disrupts production of
cervical mucus (ask your GP or a pharmacist if you're
not sure)
 you've recently stopped taking hormonal contraception
 you've recently had a miscarriage or abortion
 you've recently given birth and are breastfeeding
 you regularly travel through different time zones
 you have a vaginal infection such as thrush or an STI, or
you're at increased risk of getting an STI
 you're not able to take your temperature in the
recommended way
 you're a heavy drinker
Advantages:
 It does not cause any side effects.
 Natural family planning is acceptable to all faiths and
cultures.
 Most women can use natural family planning, as long
as they're properly trained by a fertility awareness
teacher.
 Once you've learned the techniques, there should be
no further need for input from health professionals.
 Natural family planning can be used either to avoid
pregnancy or to become pregnant.
 It does not involve chemicals or physical products.
 It can help you recognise normal and abnormal vaginal
secretions, so you can be aware of possible infection.
 It involves your partner in the process, which can help
increase feelings of closeness and trust.
Disadvantages:
 Natural family planning does not protect against STIs
such as chlamydia or HIV.
 You'll need to avoid sex, or use contraception such as
condoms, during the time you might get pregnant,
which some couples can find difficult.
 If you decide to abstain, there can sometimes be up to
16 days during which you cannot have sex, depending
on your cycle.
 It can be much less effective than other methods of
contraception if the methods are not followed
accurately.
 It will not work without continued commitment and
practice.
 It can take several menstrual cycles before you become
confident in identifying your fertile time. During this
time, you'll have to use barrier contraception, such as
condoms.
 You'll need to keep a daily record of your fertility signs.
 It's not suitable for every woman.
 Stress, illness, travel, lifestyle and hormonal treatments
can disrupt your fertility signs.
 If you use the emergency contraceptive pill, you'll need
to wait for 2 complete cycles before relying on natural
family planning again.
Lactational amenorrhoea method (LAM)
You're unlikely to have any periods if you breastfeed
exclusively (give your baby breast milk only) and your
baby is under 6 months old. Because of this, some
women use breastfeeding as a form of natural
contraception. This is known as the lactational
amenorrhoea method (LAM).
When used correctly and consistently, less than 2 in
100 women who use LAM will get pregnant in the first
6 months. However, take care to use the method
correctly. Do not feed your baby other foods because
this may reduce your lactation.
LAM becomes unreliable when:
 gaps between feeds are longer than 4 hours during the
day or longer than 6 hours at night
 other foods or liquids are substituted for breast milk
 your baby reaches 6 months old
 you have a period
After having a baby, it is possible to get pregnant
before your periods start again. This is because you
ovulate around 2 weeks before your period.
Male Reproductive Organ
12

EXTERNAL MALE GENITALIA
1. PENIS
- Has 3 layers of erectile tissue
2 corpora cavernousa
1 corpus spongiosum
- Gland is at the distal end of the penis
A retractable casing of skin or prepuce
protects the glans at birth
- Deposits spermatozoon in the female
reproductive tract
- Contains sensory nerve endings that provide
sexual pleasure
- Serves as an outlet for the urinary tract
- Penile artery supplies blood to the penis
2. SCROTUM
- Pouch-like structure made up of skin, fasciae
connective tissue, and smooth-muscle fibers
- House the testes, epididymis, and the lower
portion of the spermatic cord
- Protects the testes and spermatozoa from
high body temperature
TESTES
- Are 2 oval-shaped glandular organs inside the scrotum
- Seminiferous tubules produces spermatozoa
- Leydig’s cells produce testosterone, the primary male
sex hormone
- Sperm can’t survive at body temperature; the testes
are suspended outside the body where the
temperature is approximately 1oF lower than body
temperature.
FOLLICLE-STIMULATING HORMONE - Stimulates
production of sperm in the seminiferous tubules
LUTEINIZING HORMONE - Stimulates production of
testosterone in the interstitial cells
FSH & Testosterone - stimulates spermatogenesis
INTERNAL GENITALIA
1. EPIDIDYMIS
- Tightly curled, the length totals 6m
- Responsible for conducting sperm from the testis to
the vas deferens or storing it
- Sperm are immobile as they pass through or stored
here
- Takes at least 12-20 days for the sperm to travel the
length of the epididymis and a total of 64 days for them
to reach maturity
2. VAS DEFERENS
- Also called DUCTUS DEFERENS
- Carries sperm from the epididymis through
the inguinal canal into the abdominal cavity
where it ends at the seminar vesicles into the
ejaculatory ducts
- Blood vessels and the vas deferens together
are referred as SPERMATIC CORD
3. EJACULATORY DUCTS
- Located between the seminal vesicles and
urethra
13

4. URETHRA
- Extends from the bladder through the penis to the
external urethral opening
- Serves as excretory duct for urine and semen
2.
3.
4.
2. SEMINAL VESICLES
- Secrete a viscous portion of the semen that
aids in spermatozoa motility and metabolism
because the fluid is alkaline and sperm are
more motile in an alkaline fluid
6. PROSTATE GLAND
- Located just below the bladder
- Homologous to Skene’s glands in females
- Secretes an alkaline fluid that enhances
spermatozoa motility and lubricates the
urethra during sexual activity
7. BULBOURETHRAL / COWPER’S GLANDS
- 2 pea sized glands that lie beside the
prostate and empty into the urethra
- Secrete an alkaline fluid that neutralized
acidic secretions in the female reproductive
tract, thus prolonging spermatozoa survival
- The alkaline fluid and sperm combination is a
thick, whitish secretion termed SEMEN
Week 2: Antepartum Care
Continue
Sex and Fertilization
- clitoris increase in size
- Lubrication
- Vagina widens
- Breast nipples become erect
- Increase BP, HR, RR
Physiological changes in men:
- Erection
- Scrotal thickening
- Elevation of the testes
- Increase BP, HR, RR
PLATEAU PHASE
- Reached first before orgasm
- Women: formation of orgasmic platform, increased
nipple engorgement
- Men: full distention of the penis
ORGASM PHASE
- Discharge of accumulated sexual tension
- Shortest stage
RESOLUTION STAGE
- External and internal organs return to their uncrossed
state
Generally takes 30 min
FERTILIZATION
CONCEPTION / IMPREGNATION / FECUNDATION
- Union of ovum and spermatozoon
- Fertilized egg is called ZYGOTE
OVUM - from ovulation to fertilization
ZYGOTE - from fertilization to implantation
EMBRYO - from implantation to 5-8 weeks
FETUS - From 5-8 weeks until term
CONCEPTUS - developing embryo / fetus and placental
structures throughout pregnancy

SEX
Act of copulation / “coitus

SEXUAL RESPONSE CYCLE

4 Stages of Sexual Response:
1. EXCITEMENT PHASE
- Physical and psychological stimulus
- Arterial dilatation and venous constriction in the
genital area  
Physiological changes in woman:     The functional life of a spermatozoa is about 48h,
possibly as long as 72h

14
     - Ova about 24h possibly if 48h
    - The ovum is surrounded by a ring of
mucopolysaccharide fluid (zona pellucida) and a circle
of cells (corona radiata) - serve as protection from
injury
1.
2.
3.
Fertilization usually occurs in the outer 3rd of the
Fallopian tube, the ampullae portion
- Normally, an ejaculation of semen averages 2.5 ml of
fluid containing 50M - 200 million spermatozoa per
milliliter or an average of 400 million / ejaculation
- Spermatozoa deposited in the vagina during
intercourse generally reach the cervix within 90 sec and
the other end of the Fallopian tube within 5 min after
deposition
CAPACITATION
- Final process that sperm must undergo to be ready for
fertilization
- The sperm move toward the ovum
 Changes in the plasma membrane of the sperm head,
reveals the sperm - binding receptor sites
HYALURONIDASE
- Proteolytic enzyme
 Released by the spermatozoa and acts to dissolve the
layer of cells protecting the ovum
Normally, only one spermatozoon is able to penetrate
the cell membrane of the ovum. Once it penetrates the
zona pellucida, the cell membrane becomes impervious
to other spermatozoa.
After the spermatozoon penetrates the ovum, its
nucleus is released into the ovum, its tail degenerates
and its head enlarge and fuses with the nucleus of the
ovum. This fusion provides the fertilized ovum, called a
zygote, with 46 chromosomes. The spermatozoon and
ovum each carried 23 chromosomes (22 autosomal and
1 sex chromosome)
3 SEPARATE FACTORS FOR FERTILIZATION TO OCCUR
Maturation of both sperm and ovum
Ability of sperm to reach the ovum
Ability of the sperm to penetrate the zona pellucida
and cell membrane and achieve fertilization
IMPLANTATION
- Occurs when the cellular wall of growing structure /
zygote implants itself in the endometrium of the
anterior or posterior fundal region, 8-9 days after
fertilization after the corona and zona pellucida
degenerates
- After fertilization. It takes 3-4 days for the zygote to
reach to the body of the uterus (free floating). During
this time, mitosis cell division, or cleavage begins.
- Day 2 - 1st cell division
- Day 3 - morula; bumpy appearance; consists of 16-50
cells; body of the uterus; floats free in the uterine
cavity for 3-4 days
Day 4
- Blastocyst; large cells collect at the periphery of the
ball, leaving a fluid space surrounding an inner cell
mass
- this structure attaches to the uterine endometrium
- the cells in the outer ring are known as trophoblasts
which will form into placenta and membranes
the inner cell mass (enclosed within the trophoblast
will form the embryo)
15
 patient, which impel her to make an appointment with
a physician.
These signs and symptoms are not proof of pregnancy,
but they will make the physician and woman suspicious
of pregnancy.

1. Amenorrhea (Cessation of Menstruation).

After implantation, the endometrium is called the
DECIDUA
Once implanted, the zygote is called an EMBRYO
(1) Amenorrhea is one of the earliest clues of
pregnancy. The majority of patients have no periodic
bleeding after the onset of pregnancy. However, at
least 20 percent of women have some slight, painless
spotting during early gestation for no apparent reason
and a large majority of these continue to term and have
normal infants.
(2) Other causes for amenorrhea must be ruled out,
such as:
(a) Menopause.
(b) Stress (severe emotional shock, tension, fear, or a
strong desire for a pregnancy).
(c) Chronic illness (tuberculosis, endocrine disorders, or
central nervous system abnormality).
(d) Anemia.
(e) Excessive exercise.

1. Nausea and Vomiting (Morning Sickness).

(1) Usually occurs in early morning during the first
weeks of pregnancy.
(2) Usually spontaneous and subsides in 6 to 8 weeks or
by the twelfth to sixteenth week of pregnancy.
Antepartum Care (3) Hyperemesis gravidarum. This is referred to as
nausea and vomiting that is severe and lasts beyond
the fourth month of pregnancy. It causes weight loss
and upsets fluid and electrolyte balance of the patient.
(4) Nausea and vomiting are unreliable signs of
pregnancy since they may result from other conditions
such as:
(a) Gastrointestinal disorders (hiatal hernias, ulcers,
and appendicitis).
(b) Infection (influenza and encephalitis).
(c) Emotional stress, upset (anxiety and anorexia
nervosa).
(d) Indigestion.
MGT: Dry toast / crackers before rising in the morning;
avoid greasy / fatty foods; avoid highly seasoned foods;
eat small, frequent meals

1.
DIAGNOSIS OF PREGNANCY
SIGNS AND SYMPTOMS OF PREGNANCY
PRESUMPTIVE
Presumptive means speculation or unconfirmed.
Presumptive signs and symptoms of pregnancy are
those signs and symptoms that are usually noted by the
Frequent Urination.
(1) Frequent urination is caused by pressure of the
expanding uterus on the bladder.
(2) It subsides as pregnancy progresses and the uterus
rises out of the pelvic cavity.
(3) The uterus returns during the last weeks of
pregnancy as the head of the fetus presses against the
bladder.
(4) Frequent urination is not a definite sign since other
factors can be apparent (such as tension, diabetes,
urinary tract infection, or tumors).
MGT: Decrease fluid intake in the evening
Avoid caffeine and tea

16
 Void as soon as the urge is felt
Teach how to perform Kegel’s exercise 1. Skin Changes.
Report signs of UTI at once (1) Striae gravidarum (stretch marks). These are marks
noted on the abdomen and/or buttocks.
1. Breast Changes. (a) These marks are caused by increased production or
sensitivity to adrenocortical hormones during
pregnancy, not just weight gain.
(b) These marks may be seen on a patient with
Cushing’s disease or a patient with sudden weight gain.
(2) Linea nigra.
(a) This is a black line in the midline of the abdomen
that may run from the sternum or umbilicus to the
(1) In early pregnancy, changes start with a slight,
symphysis pubis.
temporary enlargement of the breasts, causing a
sensation of weight, fullness, and mild tingling.
Breast Changes during Pregnancy
(2) As pregnancy continues the patient may notice:
(a) Darkening of the areola–the brown part around the
nipple.
(b) Enlargement of Montgomery glands–the tiny
nodules or sebaceous glands within the areola.
(c) Increased firmness or tenderness of the breasts.
(d) More prominent and visible veins due to the
increased blood supply.
(e) Presence of colostrum (thin yellowish fluid that is
the precursor of breast milk). This can be expressed
during the second trimester and may even leak out in
the latter part of the pregnancy. This patient has both striae gravidarum (stretch marks)
(3) These breast changes can be more positive if the and the midline Linea nigra
patient has not recently delivered and is not presently (b) This appears on the primigravida by the third month
breastfeeding. and keeps pace with the rising height of the fundus.
(c) The entire line may appear on the multigravida
1. Vaginal Changes. before the third month.
(1) Chadwick’s sign. The vaginal walls have taken on a (d) This may be a probable sign if the patient has never
deeper color caused by the increased vascularity been pregnant.
because of increased hormones. It is noted at the sixth (3) Chloasma. This is called the “Mask of Pregnancy.” It
week when associated with pregnancy. It may also be is a bronze type of facial coloration seen more on dark-
noted with a rapidly growing uterine tumor or any haired women. It is seen after the sixteenth week of
cause of pelvic congestion. pregnancy.
(2) Leukorrhea. This is an increase in the white or (4) Fingernails. Some patients note marked thinning
slightly gray mucoid discharge that has a faint musty and softening by the sixth week.
odor. It is due to hyperplasia of vaginal epithelial cells
of the cervix because of increased hormone level from 1. Fatigue.
the pregnancy. Leukorrhea is also present in vaginal This is a common complaint by most patients during
infections. the first trimester. Fatigue may also be a result of
anemia, infection, emotional stress, or malignant
1. Quickening (Feeling of Life). disease.
(1) This is the first perception of fetal movement within
the uterus. It usually occurs toward the end of the fifth 1. Positive Home Test.
month because of spasmodic flutter. These tests may not always be accurate; however, they
(a) A multigravida can feel quickening as early as 16 are very effective today if they are performed properly.
weeks.
(b) A primigravida usually cannot feel quickening until
after 18 weeks.
(2) Once quickening has been established, the patient
should be instructed to report any instance in which
fetal movement is absent for a 24-hour period.
(3) Fetal movement early in pregnancy is frequently
thought to be gas.

17
 - Maybe detected as early as the 6th week of gestation,
although usually done at 16 - 18 weeks
1. ROENTGENOGRAPHY
- X-ray of fetal skeleton; usually done at 14th - 20th
week

PHYSIOLOGIC CHANGES OF PREGNANCY

1. REPRODUCTIVE SYSTEM
- Uterine changes
- “Practice contractions” - Braxton Hick’s contractions
- Amenorrhea
- Cervical changes
- Vaginal changes
- Ovarian changes
- Changes in the breasts

1. INTEGUMENTARY SYSTEM
- Hyperactive sweat and sebaceous glands
- Hyperpigmentation
- Palmar erythema & increase angiomas
- Increase hair & nails growth
 
1. RESPIRATORY SYSTEM
- Increase vascularization of the respiratory tract
caused by increased estrogen levels
- Shortening of diaphragm caused by the enlarging
uterus
- Increase tidal volume causing slight hyperventilation
- Slight increase (2 bpm) in respiratory rate

1. METABOLIC
- Increase water retention caused by higher levels of
steroids sex hormones
- Decrease serum CHON levels
- Increase intra-capillary pressure and permeability
- Increase levels of serum lipids, lipoproteins, and
cholesterol
- Increase iron requirements
- Increase CHO needs
- Increase body temperature
Weight gain 25 - 30 lb (11.3 - 13.6 kg)
Allowable weight gain in pregnancy
1st trimester - 2-4 lb
2nd trimester - 11 - 13 lb
3rd trimester - 11 - 13 lb

1. CARDIOVASCULAR
Heart
POSITIVE - Increase cardiac workload > increase cardiac output >
- Absolute evidence left ventricular hypertrophy > palpitations, increase
1. FHR heart rate
Funic soufflé - Stroke vol >increase 10 - 30%
Uterine soufflé - Heart displaced up and the left, PMI shifts about 1.5
1. FETAL MOVEMENT cm to the left
- When felt by the examiner, after the 16th week but Blood
usually about 5 months - Increase iron demand
1. ULTRASONOGRAPHY - Increase water retention
- Decrease blood viscosity and increase blood flow

18
 ->pulmonic and apical systolic murmurs
- Increase progesterone > increase fibrinogen >
increase clotting factor XII, IX, and X at term
Blood Volume
- Circulating blood volume increase by 30-50% by water
and Na retention approximately 1,500 cc Blood
Pressure
- Brachial artery pressure highest when sitting; lowest
when at lateral recumbent position
- 2nd & 3rd trimester - increase relaxin > vasodilation,
muscle relaxation and decrease muscle tone > decrease
peripheral resistance > decrease BP
- Venous compression > increase venous stasis >
proximity to thrombosis
- BP is lowest on the 2nd trimester because of pseudo
anemia
- Compression of iliac veins leads to.
- Supine hypotensive syndrome
- increase hydrostatic pressure in leg veins > varicose
veins and dependent edema
1. GASTROINTESTINAL
- Stomach displaced upward > increase reflux of acids
in the lower esophagus > heartburn (pyrosis) and
flatulence - related to increase HCG, progesterone
- Increase progesterone > decrease GI motility and
emptying > tendency for N&V
EPULIS OF PREGNANCY due to estrogen
PTYALISM due to increased level of estrogen
Ptyalism gravidarum (PG) also known as
hypersalivation or sialorrhea is a condition of
hypersalivation that affects pregnant women early in
gestation. Symptoms include massive saliva volumes
(up to 2 liters per day), swollen salivary glands, sleep
deprivation, significant emotional distress, and social
difficulties.
Management:
 Chewing on ice
 Using minty mouthwash
 Brushing your teeth often with a minty toothpaste —
it's also good for dental care, which is extra important
during pregnancy
 Chewing sugarless gum
 Eating or drinking something sour, like sucking on
lemon slices
 Always carry paper towels and a tissue with you, so you
can blot any saliva that escapes from your mouth
 

 
1. URINARY SYSTEM
A pregnancy epulis is a benign (harmless) tumor and
- Diuresis > pressure of enlarging uterus to bladder in
does not have the potential to become cancerous.
1st trimester
Some women may have the epulis removed during
- Relieved when uterus rises out of the pelvis in 3-4
pregnancy for cosmetic reasons, or because the
months but returns with LIGHTENING (2 weeks before
diagnosis is uncertain. However, if left alone, the epulis
onset of labor)
will usually become smaller or disappear after
childbirth.
1. SKELETAL SYSTEM
Postural Changes
Hemangiomas of gingival capillaries (epulis of
- Lumbosacral curve increases accompanied by a
pregnancy) are treated with proper dental hygiene and
compensatory curvature in the cervicodorsal region
avoidance of trauma. Surgical excision, cryotherapy,
- Characteristic posture in pregnancy: Backward tilt of
and electrodesiccation can cause unnecessary blood
torso to balance the weight of the enlarging abdomen >
loss or permanent disfigurement and should be
strain on back and thigh muscles and ligaments > back
avoided. The lesion usually resolves spontaneously
pains and cramps later in pregnancy
after delivery.
- Thicker bile secretion due to progesterone

19
 - Waddling-Gait of Pregnancy - duck-like movement of
pelvis when walking due to pelvic instability caused by
the enlarging abdomen and relaxation of sacro-iliac
joint and symphysis pubis
- Enlarging uterus > anterior abdominal wall stretching
> umbilical stretched > DIATASIS RECTI
I.ENDOCRINE SYSTEM
- The major endocrine gland during pregnancy is the
PLACENTA
- Increase BMR (up to 25% at term)
- Increase iodine metabolism from slight hyperplasia of
the thyroid gland
- Slight parathyroidism
- Production of PROLACTIN
- ESTROGEN & PROGESTERONE > GnRH suppression >
decreases gonadotrophic hormones > no ovulation
- Increase HCG > (+) pregnancy test > prolongs life of
corpus luteum > continued production of estrogen and
progesterone > continued vascularity of endometrium
> support life of embedded embryo / fetus
- Increase HPL detectable as early as 3 weeks and found
in the maternal blood by 6th week > decrease ability of
the mother to use insulin (anti-insulin effect) > increase
maternal serum glucose supply to support the fetus &
placenta > may cause GESTATIONAL DIABETES
- Increase maternal cortisol / steroids > also has anti-
insulin effect > increase maternal serum glucose supply
to support the fetus and placenta > may contribute to
development of Gestational DM
- Increase OXYTOCIN (later part of pregnancy) >
stimulates the milk let-down reflex for the release of
milk after delivery of the baby and stimulates labor
contractions to occur at term
1. IMMUNOLOGIC SYSTEM
- Only maternal IgG cross placental barrier to provide
the baby with antibodies in the early neonatal period
- IgA is secreted in the colostrum providing baby with
additional gastrointestinal protection during
breastfeeding
- Fetal immune system develops as early as the 7th
week and antigen recognition by 12th week
- Fetus develops all types of immunoglobulins by 12th
week, except IgA with highest amount at term before
delivery
PSYCHOLOGICAL / EMOTIONAL RESPONSES TO
PREGNANCY
1. AMBIVALENCE
- Refers to the interwoven feelings of wanting and not
wanting that always exist at high levels
- Normal response in both the woman and her partner
- Lack of knowledge of or preparation for parenthood
and children may also contribute to ambivalence
2. GRIEF
- Commonly occurs as a result of changes in the
woman’s role
3. NARCISSISM
- Self-centeredness / egocentrism
- Generally, an early reaction to pregnancy
- Occurs as the woman becomes focused on herself and
the changes occurring in her body
4. INTROVERSION / EXTROVERSION
- Some pregnant women become introverted during
pregnancy, focusing entirely on their bodies and
themselves
- Other women become extroverted - may increase
their participation in activities and appear more
outgoing, they may view their expanding abdomen
with a sense of fulfillment
5. STRESS REACTION
- For some women pregnancy can be a time of stress
- The woman and her partner may view the pregnancy
as interfering with his or her ability to accomplish daily
tasks
- Adequate support systems can help alleviate some of
this stress and aid in adapting to pregnancy
6. EMOTIONAL LABILITY
- Mood changes occur frequently
- May be the result of the woman’s introversion and
narcissism
- Additionally, hormonal changes, specifically increase
estrogen and progesterone contribute to this lability
- Feelings are easily hurt by remarks that would have
been laughed off before
7. COUVADE SYNDROME
- Partner may experience discomforts such as nausea &
vomiting, fatigue, or weight gain, like or possibly more
intense than those that the pregnant woman
experiences
- The more he is involved or attuned to the changes of
his partner’s pregnancy, the more symptoms he may
experience
- These discomforts are normal and temporary and
become problematic only if the partner becomes
delusional or emotionally disruptive
8. CHANGES IN SEXUAL DESIRE
- During the 1st trimester, most women report a
decrease in libido because of the nausea, fatigue, and
breast tenderness
- During the 2nd trimester, as blood flow to the pelvic
area increases to supply the placenta, libido and sexual
enjoyment rise markedly
- During the 3rd trimester, it may remain high or
decrease because of the awkwardness of finding a
comfortable position and increasing abdominal size
9. BODY IMAGE & BOUNDARY
- The way your body appears to yourself
- A zone of separation you perceive between yourself
and objects or other people
20
 - Maybe INTERNAL or EXTERNAL and strain related
bowel movement may cause bleeding
DEVELOPMENTAL / PSYCHOLOGICAL TASKS OF - Pressure on the pelvic veins by the enlarging uterus,
PREGNANCY which interferes with venous circulation
FIRST TRIMESTER - Acceptance of the Pregnancy
- “I am pregnant”
- Pregnancy confirmation may leave some couples with MGT:
disbelief, shock, or amazement - Avoid constipation
- The woman & her partner must learn to accept the - Avoid prolonged standing
reality of the pregnancy - Avoid constrictive clothing
- Some couples experience some degree of - Topical ointments / anesthetic
ambivalence - Sitz baths or apply warm soaks
- Feeling the fetus move or seeing the fetus on an - Lie on her side with feet slightly elevated
ultrasound can help the couple achieve acceptance - Re-insert external hemorrhoids, by placing patient
inside lying / knee-chest position, using a lubricant and
SECOND TRIMESTER - Acceptance of the Baby using only gentle pressure
- “I’m Going to Have a Baby” 4. Backache
- The woman and her partner work to accept the baby 5. Leg Cramps
- Acceptance of the baby refers to acknowledgment 6. Ankle Edema
that the fetus is a distinct individual, separate from the 7. Shortness of breath
mother 8. Fainting spells / Hypotension
- Feeling the fetus move or hearing its heartbeat 9. Varicose veins
demonstrates that the fetus is an active being 10. Braxton Hick’s contractions
- The woman and her partner begin active preparations - are normal throughout the entire pregnancy, maybe
for the baby more pronounced in the latter part of pregnancy
- A good way to measure the level of a woman’s 11. Headache
acceptance of the coming baby is to measure how well 12.
she follows prenatal instructions DANGER SIGNS OF PREGNANCY
1. Severe, persistent vomiting
THIRD TRIMESTER - Preparation for Parenthood 2. Vaginal bleeding
- “I’m going to be a mother” 3. Sudden escape of fluid from the vagina
- The couple work on preparing to become parents 4. Chills and fever
- The couple begin to demonstrate “nesting” behaviors 5. Epigastric / Abdominal or Chest pain
such as preparing the baby’s room, shopping for 6. Swelling of finger / face
necessary baby items, and discussing names 7. Vision disturbances
- The couple may attend childbirth education classes 8. Seizures / muscular irritability
- The couple may review relationships with their own 9. Frequent, severe headaches
parents and engage in role-playing and fantasizing 10. Decrease urine output
about being a parent 11. Rapid weight gain
12. Increase or decrease fetal movements
MATERNAL DISCOMFORTS ASSOCIATED WITH
PREGNANCY Estimated Date of Delivery / EDC - Expected Date of
Confinement
FIRST TRIMESTER Pregnancy Timeline
1. Nausea & Vomiting
2. Breast enlargement and tenderness
3. Urinary frequency and urgency
4. Nasal stuffiness, discharge, or obstruction
5. Leukorrhea
6. Fatigue  
Terms:
SECOND TRIMESTER Gravidity is defined as the number of times that a
1. Heartburn / pyrosis woman has been pregnant, regardless the
2. Constipation outcome. Either twins or multiples count as ONE.
3. Hemorrhoids Parity is defined as the number of times that she has
- commonly known as PILES given birth to a fetus with a gestational age of 24 weeks
- Over dilation of veins under the mucous membrane in or more, regardless of whether the child was born alive
the rectal / anal area or both related to the weakness or was stillborn.
in the walls of the rectum

21
Nullipara a woman (or female animal) that has never gestation and a 5-year-old who was born at 40 weeks
given birth. gestation. She had no history of miscarriage or
Primigravida a woman who is pregnant for the first abortion. What is her GTPAL? *
time.       G=3, T=2, P=0, A=0, L=3
Nulligravida a woman who has never been pregnant Estimated Date of Delivery / EDC - Expected Date of
Multigravida a woman who has been pregnant more Confinement
than once     NAGELE’s Rule
Grand multipara is a woman who has already delivered     - Count back 3 calendar months from the 1st day of
five or more infants who have achieved a gestational LMP then add 7 days.
age of 24 weeks or more, and such women are     - e.g., Oct 5, ---> 10-3, 5+7
traditionally considered to be at higher risk than the                                =. 7.     12
average in subsequent pregnancies.                                    July 12
      DATE OF QUICKENING
Grand multigravida has been pregnant five times or     Primigravida:
more.     - Date of quickening + 4 months and 20 days = EDC
  Multigravida:
Great grand multipara has delivered seven or more     - Date of quickening + 5 months and 4 days = EDC
infants beyond 24 weeks of gestation.     First three months = +9 +7
A 28-year-old female gives birth to twins at 38 weeks
gestation. This is her first pregnancy. best describes the AGE OF GESTATION
patient’s gravidity and parity 1. MC DONALD’S rule
  - uses fundal height to determine duration of
Gravida 1, para 1 pregnancy
  - Measurement is made from the notch of the woman’s
Gravida 1, para 1… Gravida is the number of times the symphysis pubis to over the top of the
woman has been pregnant, regardless the outcome. uterine fundus as the woman lies supine
The patient has been pregnant just once (twins or - Typically, the distance from the fundus to symphysis
multiples count as ONE). Parity is the number of births pubis in centimeters is equal to the week of gestation
(hence completed pregnancies) that occurred at between 20th - 31st week
greater than 20 weeks gestation. The patient’s parity is Mc Donald’s rule becomes inaccurate during the 3rd
1 (twins or multiples count as ONE). trimester of pregnancy
 
A more elaborate coding system used elsewhere,
including America, is GTPAL (G = gravidity, T = term
deliveries, P = preterm deliveries, A = abortions or
miscarriages, L = live births).
A full-term pregnancy lasts between 39 weeks, 0 days
and 40 weeks, 6 days. This is 1 week before your due
date to 1 week after your due date.
     At 37 weeks, your pregnancy is considered full-term.
The average baby weighs around 3-4kg by now. Your
baby is ready to be born. Your baby's lungs, liver, and
brain go through a crucial period of growth between 37
weeks and 39 weeks of pregnancy. Waiting until 39
weeks, now called "full term," gives your baby the best
possible chance for a healthy start in life. 2. Bartholomew’s Rule of Fours
Preterm birth is when a baby is born too early, before - Measures age of gestation by determining the
37 weeks of pregnancy have been completed. position of the fundus in the abdominal cavity
Abortion termination of a human pregnancy during the Normal length of pregnancy:
first 28 weeks of pregnancy.
A 30-year-old female is 25 weeks pregnant with twins.
She has 5 living children. Four of the 5 children were
born at 39 weeks gestation and one child was born at
27 weeks gestation. Two years ago, she had a
miscarriage at 10 weeks gestation. What is her GTPAL?
*
     G=7, T=4, P=1, A=1, L=5
A 27-year-old female is currently 16 weeks pregnant.
She has 2-year-old twins that were born at 39 weeks

22
 Days - 267 - 280 will feel like a hard ball. You can feel the top by curving
Weeks - 40 - 41 weeks your fingers gently into the abdomen.
Lunar months - 10
Calendar months - 9
Trimesters – 3

FUNDAL HEIGHT

What to Know About Measuring Fundal Height

Measuring fundal height is one way to keep track of
your baby’s development while you’re pregnant.
1. Move the tape measure vertically from the top
What Is Fundal Height?
of the pubic bone to the top of the
It’s the distance from your pubic bone to the top of
uterus.  This is the patient’s fundal height
your uterus.
measurement.
Measuring your fundal height is one test your doctor
may do at your pregnancy check-ups. Other ways they
How to measure fundal height using the finger
may check on your baby’s health include checking your
method
physical health, running labs on your body, listening to
If the top of the uterus is below the bellybutton,
your baby’s heartbeat, checking how often your baby
measure how many fingers below the bellybutton it is.
moves, and looking at your baby with an ultrasound.
If the top of the uterus is above the bellybutton,
Doctors combine all these factors to give you the most
measure how many fingers above the bellybutton it is.
accurate understanding of how well your baby is
With the woman lying on her back, begin by finding the
developing.
top of the uterus with your fingers. Then see how many
months pregnant the woman is by comparing the
What Does Fundal Height Talk About the Baby?
number of fingers (each line is about the width of two
Doctors use fundal height measurement to test how
fingers).
well the baby is growing.‌
It’s one of many tests’ doctors use to measure a baby’s
growth. Fundal height is compared to the mother’s
estimated pregnancy date to suggest whether the baby
is growing on track.
If the fundal height isn’t what you expect it to be, it
doesn’t automatically mean that there’s something
wrong with the baby. But if the fundal height is on
track, the baby is growing the way the doctors are
expecting it to.

How to Measure Fundal Height?

Understand that even trained doctors can have a hard
time measuring it accurately. So, before you try
measuring the fundal height at home, have your doctor
show you where your pubic bone is and how to locate If the baby is growing normally, by how many finger-
the top of your uterus. widths should the uterus rise in the second
Here are the basic steps to follow. trimester (3-6 months of pregnancy, or 15-27
1. Empty the bladder first.  A full bladder can completed weeks of gestation)?
change fundal height measurements by
several centimeters.
2. Next, lay down the patient on her back with
your legs out in front. Using a tape measure
that measures centimeters, place the zero
marker at the top of the uterus. 
To feel the uterus, have the mother lie on her back with
some support under her head and knees. Explain to her
what you are going to do (and why) before you begin
touching her abdomen. Your touch should be firm but
gentle. Walk your fingers up the side of her abdomen
until you feel the top of her abdomen under the skin. It

23

  Fundal height at 7 months’ gestation.
 
What Should the Fundal Height Be?
Starting at 24 weeks, the fundal height should be about
the same number of centimeters as the number of
weeks you’ve been pregnant.‌
Your fundal height may be off by up to 2 centimeters in
either direction and still be considered normal.
So, for example, if you’re 30 weeks pregnant, a fundal
height of 28 to 32 centimeters is considered to be a
normal range.
What Can Impact Fundal Height?
There are a number of things that can affect it. Not all
of these factors have to do with your baby. For
example, your fundal height measurement may not be
accurate if:
 You have a BMI of 30 or more.
 You have a history of uterine fibroids.
 Your bladder is full.
 You’re not lying on your back when you take
the measurement.‌
There are other reasons your fundal height may be
bigger or smaller than expected. If your fundal height is
larger than expected, it may be because:
 You have too much amniotic fluid.
 You’re having more than one baby.
 Your baby is larger than expected.
If your fundal height is smaller than expected, it may be
because:
 Your baby is smaller than expected.
 You don’t have enough amniotic fluid.
 Your baby’s growth is being restricted.
Your fundal height measurement may also be off if your
pregnancy is further along, or less far along, than you
thought. Your due date is an estimate based on the last
day of your last period, so it can sometimes be
inaccurate.‌
Doctors usually use the assumption that you have a
standard 28-day period when making their due date
predictions. Since periods and ovulation windows can
vary, your doctor may have been off by a couple of
weeks when first predicting your due date.
What Should You Do if You’re Concerned About Your
Fundal Height?
If your fundal height isn’t measuring as expected, your
doctor will need to do some follow-up tests to
determine the root cause. These tests could include an
ultrasound to get a better look at your baby or labs to
test the health of your body.‌
An unusual fundal height measurement on its own is an
indication that there’s something happening with your
baby.
Once your doctor has figured out why your fundal
height measurement is off, they can help you figure out
what steps need to be taken next, if any, to help your
baby grow at a healthy rate.
THE FETUS
STAGES OF FETAL DEVELOPMENT:
1. 1. Pre-embryonic Period
- Begins with fertilization and lasts about 3 weeks
- As the zygote passes through the Fallopian tube, it
undergoes a series of mitosis divisions, or cleavage
- Once formed, the zygote develops into morula and
then blastocysts eventually becoming attached to the
endometrium.
2. 2. Embryonic Period
- Begins with the 4th week of gestation and ends with
the 7th week (2wk - 8 wks.)
- Germ layers develop, giving rise to organ systems
- The embryo is highly vulnerable to injury from
maternal drug use, certain maternal infections, and
other factors
3. Fetal Period
- Begins with the 8th week of gestation and continues
until birth (9 weeks/2months-birth)
- During this period, the embryo, now called a FETUS
matures, enlarges, and grows heavier
-The head is disproportionately larger when compared
to its body - lacks subcutaneous fat
EMBRYONIC AND FETAL STRUCTURES
1.
2. DECIDUA
24
 -refers to the endometrial lining during pregnancy
3 Separate layers:
DECIDUA BASALIS - lies directly under the embryo; it’s
where trophoblasts connect to the maternal blood
vessels
DECIDUA CAPSULARIS - Stretches over or forms a
capsule over the trophoblast; enlarges as the embryo
grows; eventually coming into contact & fusing at the
opposite side of the uterine wall
DECIDUA VERA/PARIETAL - remaining area of the
endometrial lining
ENDOCRINE FUNCTIONS OF THE DECIDUA
- Secretes PROLACTIN to promote lactation
- Secretes RELAXIN, which relaxes the connective tissue
of the symphysis pubis and pelvic ligaments; also
promotes cervical dilation MECHANISMS OF PLACENTA
- Secretes PROSTAGLANDIN, important for mediating 1. SCHULTZ’ mechanism
several physiologic functions - fetal side goes out first
- Most common; 80% of deliveries
1. CHORIONIC VILLI 1. DUNCAN’s mechanism
- Develops on the 11th / 12th day - 20%
- Miniature villi or probing fingers that reach out from
the single layer of cells into the uterine endometrium FUNCTIONS OF THE PLACENTA
2 layers: 1. 1. Respiration, 2. circulation
SYNCYTIOTROPHOBLAST / SYNCYTIAL LAYER  - 1 Umbilical vein - carries oxygenated blood
- Produces HCG, somatomammotropin (HPL), estrogen - 2 Umbilical arteries - carry deoxygenated blood
and progesterone - Foramen ovale - septal opening between the atria of
- Outer layer the fetal heart
CYTOTROPHOBLAST / LANGHAN’S LAYER - Ductus arteriosus - connects the pulmonary artery to
- Inner layer the aorta, allowing blood to shunt around the fetal
- Develops after fertilization - 12 days gestation lungs
- Functions in early pregnancy by protecting the - Ductus venous - carries oxygenated blood from the
growing embryo and fetus from certain infectious umbilical vein to the inferior vena cava bypassing the
organisms liver

1. PLACENTA 2. 3. Nutrition
- Latin for pancake - supplies the fetus with CHO, H2O, fats, CHON,
- is formed by the union of chorionic villi and decidua minerals, and inorganic salts
basalis 3. Protection
- Contains 15 - 29/30 subdivisions called COTYLEDONS - transfers passive immunity via maternal antibodies
- Maturity: 12 weeks/3 months; functions most (IgG)
effectively through 40 - 41 weeks 4. Excretion
- Weighs 400-600 gm; 1/6 of the weight of the baby; - it carries end products of fetal metabolism to the
measures from 15-20cm in diameter and 2-3cm in maternal circulation for excretion
depth at term 5. Endocrine function
2 parts: - produces hormones
Maternal side - has a rough surface  HCG - first hormone produces
Fetal side - shiny and gray  Estrogen - hormone of women
- primarily Estriol
- contributes to the mother’s mammary gland
development
- stimulates uterine growth to accommodate the
developing fetus
 Progesterone - hormone of mothers
- necessary to maintain the endometrial lining of the
uterus during pregnancy
- reduce the contractility of the uterine musculature
during pregnancy, which prevents premature labor

25
 HPL / Human Chorionic Somatomammotropin
- Growth promoting and lactogenic properties
- Regulates maternal glucose, CHON, and fat levels
UMBILICAL CORD
- Originates from the amnion and chorion
- Serves as the lifeline from the embryo to the placenta;
provides circulatory pathway
- About 53 - 55 cm (21 inch) in length at term
3 Parts:
1 vein
2 arteries
Wharton’s jelly - gelatinous substance that helps
prevent kinking of the cord in uterus (cord coiling /
nuchal cord); gives the cord body and prevents
pressure on the veins and arteries
FETAL MEMBRANES & AMNIOTIC FLUID
- The chorionic villi on the medial surface of the
trophoblast gradually thins and leave the medial
surface of the structure smooth
- The smooth chorion eventually becomes the chorionic
membrane, the outermost fetal membrane
 Chorion - outer wall of blastocyst
- covering of the fetus
- holds the sac of amniotic fluid
Amniotic / amniotic membrane - holds / lines amniotic
fluid
- inner fetal membrane
- forms beneath the chorion
- also produces fluid (amniotic fluid)
Amniotic fluid - source is the fetal urine and amnion
secretions
Characteristics:
- clear / yellowish
- 800 - 1200 cc
- 7.2 pH
Amniotic fluid is responsible for:
 Protecting the fetus: The fluid cushions the baby from
outside pressures, acting as a shock absorber.
 Temperature control: The fluid insulates the baby,
keeping it warm and maintaining a regular
temperature.
 Infection control: The amniotic fluid contains
antibodies.
 Lung and digestive system development: By breathing
and swallowing the amniotic fluid, the baby practices
using the muscles of these systems as they grow.
 Muscle and bone development: As the baby floats
inside the amniotic sac, it has the freedom to move
about, giving muscles and bones the opportunity to
develop properly.
 Lubrication Amniotic fluid prevents parts of the body
such as the fingers and toes from growing
together; webbing can occur if amniotic fluid levels are
low.
 Umbilical cord support: Fluid in the uterus
prevents the umbilical cord from being
compressed. This cord transports food and
oxygen from the placenta to the growing fetus.
Normally, the level of amniotic fluid is at its highest
around 36 weeks of pregnancy, measuring around 1
quart. This level decreases as birth nears.
When the waters break, the amniotic sac tears. The
amniotic fluid contained within the sac then begins to
leak out via the cervix and vagina.
The water usually breaks toward the end of the first
stage of labor. When this happens, it is time to contact
the health provider as delivery may be imminent.
Problems of Amniotic Fluid:
Oligohydramnios - lesser amount of amniotic fluid
(300cc)
Polyhydramnios- excessive amount of fluid (3000-
5000cc)
Embryonic Germ Layers:
26
 3. 3. Nervous System
- Develops during 3rd and 4th week of life
- Neural plate (thickened portion of ectoderm) is
apparent by 3rd week of gestation
- Brain waves can be detected on EEG by the 8th week
- By the 24th week, the ear is capable of responding to
sound; the eye exhibits a pupillary reaction, indicating
sight is present

4. 4. Endocrine System
- They mature in intrauterine life
The endoderm is the innermost of the three germ
5. 5. Digestive System
layers. Cells derived from the endoderm eventually
- Separated from the respiratory tract at about 4th
form many of the internal linings of the body, including
week
the lining of most of the gastrointestinal tract,
- MECONIUM forms in the intestines as early as the
the lungs, the liver, the pancreas and other glands that
16th week. It consists of cellular wastes, bile, fats,
open into the gastrointestinal tract, and certain other
mucoproteins, mucopolysaccharides, and portions of
organs, such as the upper urogenital tract and
the vernix caseosa
female vagina. Endoderm cells give rise to certain
- Meconium is black or dark green (obtaining its color
organs, among them the colon, the stomach, the
from bile pigment and sticky
intestines, the lungs, the liver, and the pancreas.
- Sucking and swallowing reflexes are not mature until
the fetus is about 32 weeks or the fetus weighs 1500
The ectoderm, on the other hand, eventually forms
gm
certain “outer linings” of the body, including
the epidermis (outermost skin layer) and hair.
6. 6. Musculoskeletal System
The mesoderm also is the precursor to mammary
- Quickening - 1st fetal movements perceived by the
glands and the central and peripheral nervous systems.
mother
16th week - multiparous
EMBRYONIC AND FETAL STRUCTURES
20th week - primipara
- Fetus can be seen to move on ultrasound as early
1. Cardiovascular System
as 11th week
- One of the 1st systems to become functional in
intrauterine life
7. 7. Reproductive System
- Single heart tube forming as early as the 16th day of
- Child’s sex is determined at the moment of
life, beating as early as the 24th day
conception
- Heart beat may be heard with a Doppler as early as
- Can be determined as early as 8 weeks by
the 10th - 12th week of pregnancy; 16th - 20th week
chromosomal analysis
with a stethoscope
- Gonads form at about 6th week
https://www.youtube.com/watch?v=-IRkisEtzsk&t=6s
- Testes first form into the scrotal sac late in
intrauterine life at the 34th - 38th week
2. Respiratory System
- 3rd week, respiratory and digestive tracts exist as a
8. 8. Urinary System
single tube
- Rudimentary kidneys are present as early as the end
- End of 4th week, a septum begins to divide the
of the 4th week
esophagus from the trachea. At the same time, lung
- Urine is formed by the 12th week and is excreted into
buds appear on the trachea
the amniotic fluid by the 16th week of gestation
- Spontaneous respiratory movements begin as early as
- At term, fetal urine is being excreted at the rate
3 months
of 500 ml/ day
- SURFACTANT, a phospholipid substance is formed and
excreted by the alveolar cells at about 24th week. This
9. 9. Immune System
decreases alveolar surface tension on expiration,
- IgG maternal antibodies cross the placenta into the
preventing alveolar collapse
fetus primarily during the 3rd trimester of pregnancy,
Surfactant has 2 components:
giving a fetus temporarily passive immunity against
- 35th week - lecithin and sphingomyelin
diseases for which the mother has antibodies
- Ratio: 2:1
- The level of passive IgG immunoglobulins peaks at
- With fetal lung movements, surfactant mixes with
birth and then decreases over the next 9 months
amniotic fluid
10. Integumentary System

27
 Skin covered by soft downy hairs (lanugo), and a cream
cheese like substances Vernix Caseosa - secreted by
sebaceous glands, important for lubrication, provide
warmth, and keeping skin from
macerating.    rate that occur over the 20-minute time period
FETAL WELL-BEING
ASSESSMENT of FETAL WELL-BEING
1. FETAL MOVEMENT
- Also called quickening; described as light fluttering
- Typically follows a consistent pattern, usually on the
average of at least 10x / day
- Sandovsky method, to assess the fetal movement, ask
the woman to lie in a recumbent position after a meal
and record the number of fetal movements within an
hour. In every 10 minutes, the fetus normally moves at
least twice or 10 to 12 times in an hour.
- CARDIFF method – A way to assess intrauterine well-
being in which the expectant woman records fetal
movement during her usual activities. There should be
at least 10 movements within a 12-hour period; if
fewer than 10 movements are perceived, further
medical evaluation is needed.
2. FETAL HEART SOUNDS / RATE
- Heart rate should be 120 - 160 beats/min throughout
pregnancy
1. RHYTHM STRIP TESTING
- Assessment of the FHR in terms of baseline and long
and short variability
- BASELINE - refers to the average rate of the fetal
heartbeat per minute
- SHORT-TERM VARIABILITY / BEAT-TO-BEAT
VARIABILITY small changes in rate that occur from
second to second
- LONG-TERM VARIABILITY - the differences in heart
- Rhythm strip requires the mother to remain in a fixed
position for 20 minutes
2. NON-STRESS TEST (NST)
- Measures the response of the FHR to fetal movement
- The woman pushes a button attached to the monitor
whenever she feels the fetus move
- Fetal movement typically results in an increase in FHR
of about 15 beats/min
- This increase should be sustained for about 15
seconds and turn to baseline or average when fetus
quiets down
- Absence of an increase in FHR with movement is
highly suggestive of fetal hypoperfusion / fetal hypoxia
- Non-stress test is usually done for 10-20 minutes (20-
40)
- The test is REACTIVE if two accelerations of FHR (15
beats or more) lasting for 15 seconds occur after
movement within the chosen time period.
NON-REACTIVE if no accelerations occur with the fetal
movements
3. STRESS TEST / CONTRACTION STRESS TEST /
OXYTOCIN CHALLENGE TEST
(OCT)
- Method of evaluating fetal ability to withstand
decrease O2 supply and the physiologic stress of
oxytocin
- induced contractions before true labor begins
- IV oxytocin is administered, usually starting at
0.5mU/min at 15-20 min intervals until three high
quality uterine contractions are obtained within 10
minutes
- Can be used at 32 - 34-week gestation
4. NIPPLE STIMULATION STRESS TEST (breast
self-stimulation)
- Carries the risk of hyper stimulation or
embarrassment because it can’t be controlled if there’s
hyper stimulation
- May require nipple rolling or application of warm
washcloths to one nipple
- Induces contractions by activating sensory receptors
in the areola, triggering the release of oxytocin by the
posterior pituitary gland
- Exhibits the same reactive pattern as the reactive NST
result and the same pattern as the abnormal OCT result
28
3. BIOPHYSICAL PROFILE
- Assesses several variables
Fetal breathing movements
Fetal body movements
Fetal muscle tone
Fetal amniotic fluid volume
Fetal heart rate reactivity

PLACENTAL GRADE
- Each variable is scored as 0 - 2, with 0 indicating
abnormal finding and 2 indicating a normal finding;
some institutions use a scoring system of 0, 1 and 2;
total score is then calculated
- This profile is commonly referred to as the FETAL
APGAR SCORE because scoring is similar to that of the
Neonatal APGAR Score
- Can detect CNS depression
4. ULTRASOUND
- Provides immediate results without potential harm to
the fetus or the mother
- Non-invasive and painless
- Provides info about fetal presence, size, position, and
presentation, placental location, amniotic fluid, and
gestational maturity via biparietal measurements
- Evidence of normal fetal growth or possible defects or
malformations, fetal death, malpresentations, placental
abnormalities, multiple gestation and hydra nips or
oligohydramnios
- It is helpful if the mother has a full bladder at the time
of the procedure
- May also be done by an intravaginal technique
5. BIPARIETAL DIAMETER
- The widest transverse diameter of the fetal head; a
side-to-side measurement obtained using ultrasound
- Measurements can be made by 12-13 weeks of
gestation
- Typically, if the biparietal diameter is 8.5 cm or more,
the fetus will weigh more than 5.5 lb. (2,500g)
6. DOPPLER UMBILICAL VELOCIMETRY
- Measures the velocity at which RBC in the uterine and
fetal vessels are traveling
7. PLACENTAL GRADING
- Placentas can be graded by ultrasound as 0 (a
placenta 12-24 weeks), 1 (30-32 weeks), 2 (36 weeks), 3
(38 weeks)
 Because fetal lungs are apt to be mature at 38 weeks; a
grade 3 placenta suggests that the fetus is mature
Video: placental grade
https://www.youtube.com/watch?v=OCL9R4Lg8ow
8. AMNIOTIC FLUID VOLUME ASSESSMENT
- Amount of amniotic fluid present is an important fetal
assessment measure because a portion of the fluid is
formed by fetal kidney output
9. ELECTROCARDIOGRAPHY
- May be recorded as early as the 11th week of
pregnancy
10. MRI
- Has the potential to replace or complement
ultrasound as a fetal assessment technique
- It may be most helpful in diagnosing complications
such as ectopic pregnancy / trophoblasts disease
11. MATERNAL SERUM ALPHA-FETOPROTEIN
- Requires a blood sample obtained via venipuncture to
evaluate the level of alpha fetoprotein in the mother’s
serum
- Fetal liver produces alpha fetoprotein
- This CHON crosses the placenta and appears in the
mother’s serum
- Alpha-fetoprotein begins to rise at 11 weeks
gestation, then steadily increases until term
- Elevated maternal serum AFP (MSAFP) level suggests
a neural tube defect or other neural tube anomaly
(open spinal/abdominal defect) - open body defects
- Decrease MSAFP levels are associated with Down
Syndrome
- Definitive diagnosis requires ultrasound and
amniocentesis
12. TRIPLE SCREENING
- Involves a blood sample that tests 3 parameters:
Maternal serum for alpha fetoprotein, unconjugated
estriol, HCG

13. CHORIONIC VILLI SAMPLING (CVS)

- Involves removal and analysis of a small tissue
specimen from the fetal portion of the placenta to
determine the genetic make-up of the fetus
- Done at 10-12 weeks of pregnancy

29
- COELOCENTESIS- is an alternative method to remove
cells for fetal analysis, transvaginal aspiration of fluid
from the extra embryonic cavity
- Complications: carries the risk of spontaneous
abortion, infection, hematoma, and intrauterine death
Video:
https://www.youtube.com/watch?v=sxEf_ddmpZk
14. AMNIOCENTESIS
- Refers to a needle insertion into the uterus trans
abdominally to aspirate amniotic fluid for analysis
- Can be performed as early as 12 - 13th week of
gestation, when uterus has moved into the abdominal
cavity
- Requires only 1 ml of fluid for analysis
- Is indicated for women aged 35 and older and women
with family history of chromosomal / neural tube
defects or inborn errors of metabolism
USED FOR ASSESSMENT, DX, AND EVALUATION
- Amniotic fluid color
Normal - color water
Slightly yellow tinge - late in pregnancy
Strong yellow color - blood incompatibility
Green color - meconium staining
-Lecithin/Sphingomyelin ratio 2:1
- Phosphatidyl glycerol & desaturated phosphatidyl -
choline (present only with mature lung function)
- Bilirubin determination - analyzed if a blood
incompatibility is suspected
- Chromosome analysis - few fetal skin cells are always
present in amniotic fluid. These cells may be cultured
and stained for karyotyping
- Inborn errors of metabolism
- Alpha-fetoprotein
Video: amniocentesis vs. chorionic villi sampling
https://www.youtube.com/watch?v=bZcGpjyOXt0
https://www.youtube.com/watch?v=GB0JkmMhGnQ
15. PERCUTANEOUS UMBILICAL BLOOD
SAMPLING (PUBS)
- Also called CORDOCENTESIS / FUNICENTESIS
- Is an invasive procedure during which a needle is
inserted through the mother’s abdomen and uterine
wall into a vessel in the umbilical cord under direct
ultrasound guidance
- Provides direct access to the fetal circulation to obtain
fetal blood samples or to transfuse the fetus in utero
- Access to the fetal circulation allows for direct drug
administration
- Used when the fetus is at risk for congenital and
chromosomal abnormalities, congenital infection, or
anemia
- Also used to assess acid balance of fetuses with
intrauterine growth retardation
- Can be done any time after 16 weeks’ gestation
16. AMNIOSCOPY
- Visual inspection of the amniotic fluid through the
cervix and membranes with an amnioscopy (a small
fetoscope)
- Use to detect meconium staining
- Risk of membrane rupture
17. FETOSCOPY
- Actual visualization of the fetus by inspection through
a fetoscope
- Amniotic may occur; mother is placed on 10-day
antibiotic therapy after the procedure
DANGER SIGNS OF PREGNANCY
1. Severe, persistent vomiting
2. Vaginal bleeding
3. Sudden escape of fluid from the vagina
4. Chills and fever
5. Epigastric / Abdominal or Chest pain
6. Swelling of finger / face
7. Vision disturbances
8. Seizures / muscular irritability
9. Frequent, severe headaches
10. Decrease urine output
11. Rapid weight gain
12. Increase or decrease fetal movements
30

CHILDHOOD & PARENTHOOD EDUCATION
METHODS FOR PAIN MANAGEMENT
1. BRADLEY (HUSBAND-COACHED) METHOD
- Originated by Robert Bradley
- Focuses on muscle-toning exercises during pregnancy
combined with the limitation or elimination of foods
containing preservatives, animal fat, or large amounts
of salts
- Incorporates abdominal breathing and ambulating
during labor
2. KITZINGER METHOD / PSYCHOSEXUAL METHOD
- Encourages the woman to go with the contractions of
labor and delivery rather than right against them by
incorporating progressive relaxation and breathing
- Developed by Shiela Kitzinger
3. DICK - READ METHOD
- Developed by Grantly Dick-Read
- Emphasizes the use of abdominal breathing with
contractions to relax the body and reduce pain
4. LAMAZE METHOD / PSYCHOPROPHYLACTIC
METHOD
- Preventing pain of labor by use of the mind (psyche)
- Breathing exercises remain the focus of Lamaze class
5. DISTRACTION
- Involves diversion of attention from discomfort during
early labor
6. TENS - Transcutaneous Electrical Nerve Stimulation
- Stimulation of large diameter neural fiber through
electric currents to alter pain perception
- May be effective in reducing the extreme back pain
that some women have during contractions
7. HYPNOSIS
- Involves an altered state of consciousness allowing
perception and motor control to be influenced by
suggestion
8. ACUPUNCTURE & ACUPRESSURE
- Stimulation of key trigger points with needles, causes
the releases of endorphins of affected organs, which
reduce perception of pain
- Acupressure is finger pressure / massage at the same
trigger points
- Holding and squeezing the hand of a woman in labor
may trigger the points during labor
9. YOGA
- Uses a series of deep-breathing exercises, body
stretching postures, and meditation to promote
relaxation, slow the respiratory rate, lower BP, improve
physical fitness, reduce stress, and allay anxiety
- Releases endorphins
10. ANALGESICS
11. ANESTHETICS
- General / Regional
BIRTH SETTINGS
1. HOSPITAL BIRTH
- Has the advantage of having ready supplies and
expert personnel if the mother or fetus or newborn
should have a complication
- Birthing rooms, an important aspect is that the
support person and often other family members can
stay with the woman for the entire process
- Birthing chairs > advantage of maintaining the woman
in Semi-Fowler’s position, a position that acts with
gravity and appears to speed the secondary stage of
labor
2. BIRTHING CENTERS
- May be found in maternity facilities located in a
hospital or separate institution close to a hospital
- Provide a warm, homelike environment
- Not appropriate for high-risk deliveries
- Most care is provided by nurse-midwives
3. HOME BIRTHS
- May be considered controversial because of
inadequate medical back-up
- Usual mode of birth in developing countries
4. SIBLINGS / CHILDREN PRESENT AT BIRTH
- Fosters the integration of the newborn into the family
ALTERNATIVE BIRTHING EXPERIENCE
1. LEBOYER METHOD
- Controversial birthing method
- Focuses on a soothing, tender approach to handling
the neonate immediately after delivery
- Lights are dimmed
- Noise is diminished
- Neonate is gently placed in a warm bath after the
umbilical cord has been clamped
2. WATER BIRTH
31
 - Involves the woman sitting or reclining in a Lying Down
warm water bath during labor Sitting
Standing
- The newborn is born under water and then
-woman arches her back, trying to lengthen or stretch
immediately brought out of the water for the her spine. She holds the position for 1 min then hollows
first breath her back

Advantages:
 The water fosters a feeling of
weightlessness
 Relaxation occurs secondary to the warm
water

Disadvantages:
 Risk of fecal contamination of the water
 May lead to uterine infection and
neonatal aspiration of water during birth

PERINEAL & ABDOMINAL EXERCISES

- Prenatal exercises increase muscle strength
in preparation for delivery and promote
restoration of muscle tone after delivery
- WALKING is considered the best exercise
for the pregnant woman
- Swimming is allowed as long as
membranes haven’t ruptured

1. TAILOR SITTING
- The woman should not put one ankle on
top of the other but should place on leg in
front of the other
- At least 15 min/day
- Strengthens the thighs and stretches
perineal muscles to make them more
supple
2. PELVIC FLOOR CONTRACTIONS / KEGEL’s EXERCISE
- Tighten the muscles of the perineum
3. ABDOMINAL MUSCLE CONTRACTIONS
- help strengthen abdominal muscles during pregnancy
and therefore help restore abdominal tone after
pregnancy
- also contributes to effective 2nd stage pushing during
labor and helps to prevent constipation
4.PELVIC ROCKING
- helps relieve backache during pregnancy and early
labor by making the lumbar spine more flexible
During a normal pregnancy, return appointments are
usually scheduled:
• Every 4 weeks through the 32nd week
• Every 2 weeks through the 36th week
• Every week until birth
Purposes of Prenatal Care:
- Establish a baseline of present health
- Determine gestation age of the fetus
- Monitor fetal development
- Identify the woman at risk for complications
- Minimize the risk of possible complications by
anticipating and preventing problems before they occur
- Provide time for education about pregnancy and
possible dangers

VARIETY OF POSITIONS:
On hands and Knees

32

GRAVIDA – A woman who is pregnant has been
pregnant regardless of duration and outcome, including
the present pregnancy
PARA/PARITY – Number of pregnancies carried to
period of viability whether born dead/alive at birth
(twins are considered as one)
GTPAL / GTPALM
 T – Number of full-term infants born (at
37 weeks/after)
 P – Number of preterm infants born
(before 37 weeks)
 A – Number of spontaneous or induced
abortions
 L – Number of living children
 M – Multiple pregnancies
BATHING
- During pregnancy, sweating tends to increase because
the woman excretes waste products for herself and the
fetus. She also has increase vaginal discharges
- For these reasons, today, daily baths or showers are
recommended
- If membrane ruptures or vaginal bleeding is present,
tub baths are contraindicated because there would be
danger of contamination of uterine contents
BREAST CARE
- Proper breast support promotes comfort, retains
breast shape, and prevents back strain
- Washing the breast with clear water and no soap is
recommended
- Gauze / breast pads may be needed if the woman’s
secretions of colostrum is significant
DENTAL CARE
- Dental check-up early in pregnancy and routine
examination and cleaning are encouraged
- Nausea and vomiting, heartburn, and hypermedia of
gums may lead to poor oral hygiene and dental carries
- The fetus receives calcium and phosphorus from the
pregnant patient’s diet, not form her teeth
- Nutritious snacks, such as fresh fruits and vegetables,
are recommended to avoid excessive contact of sugar
with teeth
PERINEAL HYGIENE
- Douching is contraindicated
- The force of the irrigating fluid could possibly enter
the cervix and lead to infection
DRESSING / CLOTHING
- Clothes should be non-constrictive (impede lower
extremity circulation)
- Low to mid heeled shoes are recommended to
prevent backache and poor balance
- Comfort is the key
SEXUAL ACTIVITY
- Sexual behavior is usually unrestricted in complication
free pregnancies
- Discouraged on the 36th week, it causes premature
labor
IMMUNIZATIONS
- Immunizations with attenuated live viruses (mumps)
shouldn’t be given during pregnancy because of their
teratogenic effect on the developing embryo
- Vaccinations with killed viruses (DPT) may be given
PRECAUTIONS
- Work site should be checked for potential
environmental hazards, such as pesticides, anesthetic
gas, and heavy metals such as lead and mercury
- Work duties may have to be altered to avoid excessive
physical strain; rest periods need to be scheduled to
avoid fatigue
- When riding in a care, seat belts should be worn low,
under the abdomen
- If a long trip is planned, the woman should get out of
the car every hour to walk around
- Airplane travel is permissible in places with well-
pressurized cabins; some airlines have restrictions for
over 7 months pregnant
TERATOGENS
- Any factor, chemical or physical that adversely affects
the fertilized ovum, embryo, or fetus
- If the insult occurs when the main body systems are
being formed (2nd - 8th week), the fetus is vulnerable
to injury
- During the last trimester, the potential for harm
decreases because all the organs of the fetus are
formed and merely maturing
MATERNAL INFECTIONS
-Collectively termed TORCH
• Toxoplasmosis
- A protozoan infection
- Spread most through contact with cat stool or litter;
33
also contracted by eating undercooked meat
- Causes CNS damage, hydrocephalus, microcephalic,
intracerebral calcification and retinal deformities
- Therapy: Sulfonamides
• Rubella / German Measles
- Causes deafness, mental & motor retardation,
cataracts, cardiac defects, retarded intrauterine growth
(SGA), thrombocytopenia purpura, dental & facial clefts
- Frequency of defects is about 80% if infection occurs
in the 1st 12 weeks of pregnancy, 54% at 13-14 weeks,
25% after
- 30% chance of spontaneous abortion/ stillbirth if the
infection occurs in the 1st trimester
• Cytomegalovirus
- Causes severe brain damage, eye damage, deafness or
chronic liver disease
- Can cause infection of the NB during birth from
genital secretions or postpartum from exposure to
CMV- infected breast milk
- No treatment or vaccine
• Herpes simplex (genital herpes infection)
- If the infection takes place in the 1st trimester, severe
congenital anomalies or spontaneous abortion may
occur
- If the infection occurs during the 2nd or 3rd trimester,
there is a high incidence of premature birth,
intrauterine growth retardation, and continuing
infection of the newborn at birth
- TORCH screen still provides a quick way to assess the
potential risk of teratogenic infection in pregnant
women and newborns
Other Viral Diseases:
SYPHILIS
- Treponema Pallidum, can extensively damage the
fetus after the 16th - 18th week
- If left untreated beyond the 18th week of gestation,
deafness, cognitive impairment, osteochondritis, and
fetal death
- Benzathine Penicillin is often use safely during
pregnancy
LYME DISEASE
- Caused by a spirochete (Borrelia Burgdorgeri)
- Is spread by the bite of a deer tick
- Infection in pregnancy results in spontaneous
abortion or severe congenital anomalies
VACCINES
- Live virus vaccines, such as measles, mumps, rubella,
and polio
- May transmit virus infection to the fetus
MEDICATIONS
- The woman should not take any drug not specifically
prescribed / approved by her physician
- Prescription meds are categorized as A, B, C, D and X
- Category D drugs are those that have clear health
risks for the fetus
- Category X are those that have been shown to cause
birth defects and should never be taken during
pregnancy
- OTC meds also pose a risk to the fetus
- ASPIRIN and other drugs containing salicylate aren’t
recommended during pregnancy
- HERBAL remedies aren’t recommended because their
effects on pregnancy and the fetus are unknown
SUBTANCE ABUSE
- Increases the risk of gross structural fetal defects
- Risk is greatest in the 1st trimester, during
organogenesis
- NICOTINE causes:
Vasoconstriction
Alters maternal & fetal heart rate
- alters BP and cardiac output
- increases the incidence of low-birth weight infants
(SGA)
ALCOHOL & ILLICIT / RECREATIONAL DRUGS
- Can lead to Fetal Alcohol Syndrome, SGA,
cognitively impaired, craniofacial deformity
- Short apple real fissures, thin upper lip,
upturned nose
COCAINE
- associated with spontaneous abortion,
preterm labor, and intrauterine growth
retardation, children may experience
learning difficulties/ poor attention span
NARCOTICS
- causes intrauterine growth retardation
HYPERTHERMIA
- maternal fever early in pregnancy (4-6
weeks) may cause abnormal fetal brain
development and possibly seizure disorders,
hypotonia, and skeletal deformities
MATERNAL STRESS
- anxiety produces physiologic changes
through its effect on the sympathetic division
of the autonomic nervous system
- If anxiety is prolonged, the constriction of
uterine vessels could possibly interfere with
the blood and nutrient supply to the fetus
- If maternal stress is severe, securing
counseling for the woman during pregnancy
34
 is as important as ensuring good physical
care
NUTRITION
- Weight gain of 11.2 – 16 kg (25 – 40 lb.) is the
average weight gain during pregnancy
- QUALITY - of their intake will have to be
increased, not necessarily the quantity of
food eaten
- CALORIES
2200 – 2500 kcal/day
To support maternal fetal tissue synthesis
The easiest method for determining if the
woman’s caloric intake is adequate is
assessing weight gain
PROTEIN
- Requirement exceeds pregnancy needs by 10g/day
(from
46-50g to 60g daily)
- For expansion of blood volume
- For tissue growth
- For adequate amino acid intake for fetal development
FATS
- 20-35% of woman’s daily calorie intake
- Linoleic acid, an essential fatty acid is necessary for
new cell growth is not manufactured in the body; found
in vegetable oils, such as corn, olive, peanut, and
safflower oils
VITAMINS
- Intake of all vitamins should be increase
- Necessary for tissue synthesis & energy production
- FOLIC ACID is particularly importantly (.4 - 1mg)
Promotes fetal growth and prevents anemia
Low levels of folic acid have been associated with
premature separation of placenta, spontaneous
abortion, and neural tube defects
MINERALS
- Necessary for new cell building in the fetus
- CALCIUM & PHOSPHORUS - tooth formation
- Pregnant women need to ingest a diet high in calcium
and Vit D
- Recommended calcium for pregnancy is 1200 - 1500
mg
- Calcium supplement if the woman is unable to drink
milk or eat milk products
- Most foods high in protein also are high in
phosphorus
- IODINE - essential for the formation of thyroxine, for
the proper functioning of the thyroid gland
• Hypothyroidism may lead to cognitive impairment
• RDA for iodine is 175mcg daily during pregnancy
- IRON - high Hgb level is necessary to oxygenate the
blood during intrauterine life
• After 20 weeks of pregnancy, the fetus begins to
store iron in the liver to last through the first 3 months
of life, when intake will consist mainly of milk, typically
low in iron
• In addition, the woman needs iron to build an
increase RBC volume for herself and to replace iron lost
in blood during delivery
RDA for iron is 30 mg/day
• Iron absorption increases in an acid environment.
Thus, taking iron with orange juice is recommended
• Oral iron compounds turn stools black and tend to
cause constipation
FLOURIDE
• Aids in the formation of sound teeth
- SODIUM
• Maintain fluid balance in the body
• She should continue to season foods as usual during
pregnancy unless she is hypertensive / has heart
disease
- ZINC
• Necessary for synthesis of DNA and RNA
• Deficiency has been associated with preterm birth
• RDA for zinc is 15mg/day
- FLUID needs
• Extra amounts of water are needed during pregnant
or promote kidney function because the woman must
excrete waste produces for two
• 2 glasses of fluid daily over and above a daily quart of
milk are recommended
FIBER
- Broccoli and asparagus, are a natural way of
preventing constipation, because the bulk of the fiber
in the intestine aids evacuation
- Also has the advantage of lowering cholesterol levels
and may remove carcinogenic contaminants from the
intestines
FOODS TO AVOID DURING PREGNANCY
- Foods with caffeine > has been associated with low
birth weight
- Artificial sweeteners > use of saccharine is not
recommended during pregnancy because it is
35
eliminated slowly from the fetal bloodstream
- Weight loss diets are contraindicated during
pregnancy because they may lead to fetal keto acidosis
and neurologic defects
COMMON PROBLEMS AFFECTING NUTRITION
- Nausea & vomiting
- Cravings
- Pica
• An abnormal craving for non-food substances
• Is a symptom that often accompanies iron deficiency
- Pyrosis
- Hypercholesterolemia
• Increasing progesterone levels causes elevation of
cholesterol
• This can lead to an increased risk for gallstone
formation (cholelithiasis) and cardiovascular disease
PRELIMINARY SIGNS OF LABOR
1. LIGHTENING
- Descent of the fetal presenting part into the pelvis
- Occurs approximately 10 - 14 days before labor begins
(primipara)
- Lightening gives the woman relief from the
diaphragmatic pressure and shortness of breath she
has been experiencing, and thus “lightens” her load
- It can occur the day labor begins / after the start of
labor in multiparas
- Increases pressure on the bladder, which may cause
urinary frequency
- Uterus may cause pressure on the sciatic nerve with
resultant leg pains
2. BRAXTON-HICKS CONTRACTIONS
- Are irregular; can be diminished with increased
activity, eating, drinking, or changing position,
something that can’t be done with the contractions of
labor
- Are typically painless; if the woman feels pain from
the contractions, it’s felt only in the abdomen and groin
- never in the back
- don’t cause effacement and dilatation of the cervix
3. CERVICAL CHANGES
- Usually occur several days before initiation of labor
- Cervix soften (ripens), begins to efface, and dilates
slightly
- At term, the cervix becomes further softer and
described as “BUTTERSOFT” and tips forward
4. BURST OF ENERGY
- Due to increase in epinephrine release that is initiated
by a decrease in progesterone produced by the
placenta
- Epinephrine prepares the woman’s body for the work
of labor ahead
- Client may perform housecleaning activities called
“nesting” instinct
5. LOSS OF WEIGHT
- The pregnant woman may lose 1 - 3lb (.5 -1.4 kg) up
to 3 days before labor begins
- The levels of estrogen and progesterone are altered,
possibly resulting in an increase in voiding and
subsequent fluid loss
SIGNS OF TRUE LABOR
1. UTERINE CONTRACTIONS
 Initially irregular but soon become regular
with a predictable pattern, as labor
progresses
 Early contractions occur anywhere from 5-
30 min apart and last 30-45 sec
 The interval between the contractions
allows blood flow to resume to the
placenta thereby supplying oxygen to the
fetus and removing waste products
PAINFUL and WAVELIKE, BUILDING and RECEDING
 Begin in the lower back and move around
to the abdomen and possibly, the legs
 Stronger in the upper uterus than in the
lower uterus
36
  Unaffected by activity, eating, drinking, or S front moves to the
changing position front

3. SHOW
 Completely termed BLOODY SHOW, this
occurs as the cervix thins and begins to
dilate
 The mucus plug that has sealed the
cervical canal during pregnancy is
expelled
 The mucus from the plug mixes with the
blood from the cervical capillaries
because of the pressure of the fetus on
the canal and other changes in the cervix
 Pink-stained, blood-tinged, or brownish
secretions result

4. RUPTURE OF FETAL MEMBRANE

 May occur as a sudden gush of fluid or as LABOR INITIATION & THEORIES
a steady or intermittent, slow leakage of
fluid FACTORS INITIATING LABOR
 Rupture of the membranes may cause 1. UTERINE STRETCHING
2. CHANGES IN ESTROGEN & PROGESTERONE BALANCE
the fetal head to engage in the pelvis,
3. OXYTOCIN STIMULATION
possibly shortening labor 4. PLACENTAL AGE
 Labor begins within 24 hours for most 5. INCREASE FETAL CORTISOL LEVEL
women 6. CERVICAL PRESSURE
7. PROSTAGLANDIN PRODUCTION BY THE FETUS
TYPES OF CONTRACTIONS 8. SEASONAL AND TIME INFLUENCES
FALSE LABOR TRUE LABOR
CONTRACTION CONTRACTION THEORIES
S (BRAXTON S (BABY ON 1. OXYTOCIN STIMULATION
HICKS) THE WAY!) 2. PROGESTERONE WITHDRAWAL
TIMING OF Do not come Come at 3. FETAL-MATERNAL COMMUNICATION
CONTRACTION regularly and regular times
S do not get and get closer
closer together together over
time. Each last
about 30 to 70
seconds
CHANGE WITH Contractions Contractions
MOVEMENT may stop continue
when walking despite
or resting, or movement or
they may stop resting
with a change
of position
STRENGTH OF Usually weak Get steadily
CONTRACTION and do not get stronger
S much stronger,
or may start
COMPONENTS OF LABOR (4Ps)
strong and get
weaker 1. PASSAGE
PAIN OF Usually felt Usually starts 2. PASSENGER
CONTRACTION only in the in the back and 3. POWER

37
4. PSYCHE
- If any component is altered, the outcome of  Obstetric Conjugate
labor can be adversely affected - Shortest distance between inner surface of
symphysis pubis and sacral promontory;
PASSAGE measured by subtracting 1.5 – 2 cm
- Refers to the route that the fetus must travel (thickness of symphysis from the diagonal
when leaving the uterus, through the cervix conjugate)
and vagina to the external perineum - Usually, 11 cm
- The route includes the MATERNAL PELVIS
and SOFT TISSUES  True conjugate or conjugate Vera
- The maternal pelvis must be of adequate size - Measured from upper margin of symphysis
for the fetus to pass through pubis to sacral promontory
TYPES / SHAPES OF PELVIS - Should be at least 11 cm; obtained by x-ray
- Can also determine ability and ease with or U/Z
which the fetus can pass
GYNECOID
- Most common type of pelvis
- Occurs in about 50% of females
- Round shape with adequate diameters to
allow easy passage of fetal skull and
shoulders
ANDROID
- About 25% of females
- Oval with longer anteroposterior diameter
- May pose difficulty except when fetus is in
occipital posterior position
PLATYPELLOID
- The Pelvis is characterized by the transverse STRUCTURE OF PELVIS
diameter being greater than the  FALSE PELVIS
anteroposterior diameter, with wide - Shallow upper basin of the pelvis
sidewalls; flattened
ANTHROPOID  TRUE PELVIS
- Anteroposterior diameter being greater than - Consists of the pelvic inlet, pelvic cavity, and
the transverse diameter; oblong pelvic outlet

PASSAGEWAY
- Refers to the adequacy of the pelvis and birth
canal in allowing fetal descent
- Affected by the following factors:

Pelvic Measurement:
 Diagonal Conjugate
- From lower border of symphysis pubis to
sacral promontory
- Should be 12.5 – 13 cm; may be obtained by
vaginal exam

38
 - Describes the long axis of the fetus in relation
to the long axis of the pregnant woman
- Three ways the fetus can situate itself:
LONGITUDINAL – long axis of the fetus is parallel to the
long axis of the mother (most common)
TRANSVERSE – perpendicular
OBLIQUE – diagonal

C. FETAL PRESENTATION
- Refers to the fetal part that enters the pelvis
first
- CEPHALIC, BREECH, SHOULDER

PASSAGEWAY
- Refers to the fetus
- Affected by the following factors:
A. FETAL SKULL
- The largest and least compressible structure
- The diameter must be small enough to allow
the head to travel through the pelvis
- The shape of a fetal skull causes it to be
wider in its antero-posterior diameter than in
its transverse diameter
- To fit through the birth canal, the fetus must
present the smaller diameter (transverse) to
the smallest diameter of the maternal pelvis

Cephalic
A. Vertex
B. Brow
C. Face
D. Mentum

SUBOCCIPITOBREGMATIC 9.5 CM
OCCIPITOFRONTAL 12 CM BREECH – BUTTOCKS
OCCIPITOMENTAL 13.5 CM A. Frank
B. Complete/Incomplete
B. FETAL LIE
C. Footling

39
SHOULDER - Refers to the relations of the fetal presenting
part to the specific quadrants of maternal
pelvis
- When the position is being documented the
side of the maternal pelvis the presenting
part is facing is named first, followed by the
reference point. The last part of the
designation is used to specify whether the
presenting part is facing the anterior or the
posterior portion of the pelvis whether it is in
a transverse position

PRESENTING PART REFERENCE POINT

Vertex Occipital
D. FETAL ATTITUDE Brow Frontum (brow)
Face Mentum (chin)
- Refers to the relationship of the fetal parts to
Breech Sacrum
one another Shoulder Scapula (acromion
- The degree of flexion the fetus must assume process)
during labor and birth

Well- Vertex Smallest Diameter 9.5

flexed Presentatio cm
attitude n
No Military Occipitofrontal 11
flexion Presentatio cm
or n
extensio
n
Partial Brow Largest Diameter 13.
Extensio Presentatio 5
n n cm
Full Face Submentobregma 9.5
Extensio Presentatio tic cm
n n

F. STATION
- Refers to the relationship of the presenting
part to the ischial spines
- When the fetus is floating, he is said to be
high in the pelvis. A high station is recorded
as a negative and is read as minus (-)
number. On the other hand, if the fetus has
moved deep into the pelvis, his station is low
and is recorded as a positive (+) number
- When the presenting part has settled into the
true pelvis at the level of the ischial spines,
the fetus is at a station of zero (0) and
engaged
- As the fetus is being born, his station is a plus
E. FETAL POSITION four (+4)

40
POWERS
A. UTERINE CONTRACTIONS
- The primary force of labor comes from
involuntary muscular contractions of the
uterus
- Each involuntary uterine contraction is
composed of three phases:
INCREMENT – typical contraction rises in intensity
ACME – reaches a peak/ the highest point / peak of
contraction
DECREMENT - then lessens/ a gradual decrease
PSYCHE
Frequency – refers to how often the contractions are - Refers to the psychological state or feelings that
occurring and is measured by counting the time women bring into labor with them. When the woman
interval from the beginning of one contraction to the feels confident in her ability to cope and finds ways to
beginning of the following contraction work with the contractions, the labor process is
enhanced. However, the laboring woman becomes
fearful or has intense pain; she may become tense and
Duration - Is the interval from the beginning of a fight contraction. This situation often becomes a cycle
contraction to its end of fear, tension, and pain that interferes with the
Intensity - Refers to the strength of a contraction progress of labor.
Interval - Refers to the period from the end of a
contraction to the beginning of the following
contraction

B. CERVICAL CHANGES
- Two changes that occur in the cervix during labor
1. EFFACEMENT - is the shortening and thinning of the
cervical canal
- occurs due to the longitudinal traction from the
contracting uterine fundus
- in primipara, effacement occurs before dilatation
begins
- In multipara, dilatation may occur first before
effacement

2. DILATATION - Refers to the enlargement of the

cervical canal to permit passage of the fetus
- Dilatation occurs for two reasons:

• Uterine contractions gradually increase the diameter

of the cervical canal by pulling the cervix up
• The fluid-filled membranes press against the cervix

41
STAGES & DURATION OF LABOR
1. FIRST STAGE /FETAL STAGE
- Begins with true labor contractions and ends with full
dilatation and effacement of the cervix

RITGEN MANEUVER
- An upward pressure from the coccygeal region to
extend the head during vaginal delivery
- Usually done by a midwife in the second stage during
uterine contraction and/or during the
crowning process
DILATA DURA INTER AVERAGE TIME
TION TION VAL McROBERT’s MANEUVER
LATEN 0-3 CM 20 – 5 – 10 Nullipara > 6 hrs; - An obstetrical maneuver used to assist in childbirth
T 40 MIN Multipara > 4.5 hrs > - It is employed in case of shoulder dystopia during
SEC may feel minimal childbirth and involves hyper flexing the
discomfort mother’s legs tightly to her abdomen
ACTIV 4–7 40 – 3–5 Nullipara – 3 hr;
E cm 60 min Multipara > 2 hr
sec May begin to feel
true discomfort
May be frightening
to the woman
TRANS 8-10 60 – 2–3 May experience
ITION cm 90 min intense discomfort
sec May experience
feeling of loss of
control, anxiety,
panic, and irritability

2. SECOND STAGE / CERVICAL STAGE

- Period from full dilatation and effacement of the
cervix to birth of the infant
- Perineum starts to bulge and appear tense
- Stool may be expelled due to pressure
- The woman is encouraged to use her abdominal
muscles to bear down during contraction

42
 MATERNAL PHYSIOLOGIC ADAPTATION
THIRD STAGE / PLACENTAL STAGE - begins with the CARDIOVASCULAR SYSTEM
birth of the infant and ends with delivery of the
placenta • Cardiac Output
- Contraction greatly decreases blood flow to the
Two Phases: uterus
- Pushing increases cardiac output to as much as 40-
• PLACENTAL SEPARATION 50% above the prelabor state causing rise in systolic
- Occurs automatically as the uterus resumes pressure an average of 15 mmHg
contraction - Average blood loss with birth is 300 - 500ml and is not
- Signs of separation: detrimental to most women
Lengthening of the cord - First hour after delivery the average woman’s heart
Sudden gush of vaginal blood rate adjusts well
Change in the shape of the uterus
- Two mechanisms of placental delivery: HEMATOPOIETIC SYSTEM
Schultze - There is a sharp increase of the leukocytes average of
Duncan 25,000 - 30,000 / mm3 due to trauma

• PLACENTAL EXPULSION RESPIRATORY SYSTEM

- Pressure should never be applied to a uterus in a non- - The woman is at risk for hyperventilation and
contracted state or the uterus may invert and lead to dehydration
hemorrhage
TEMPERATURE REGULATION
https://youtu.be/Byn5YtY4PYU - Increased muscular activity may result in slight
elevation of temperature
FOURTH STAGE - Period of recovery 1-4 hours after - Diaphoresis occurs to cool and limit excessive
delivery warming
- The woman is observed frequently for signs of
hemorrhage or other complication FLUID BALANCE
- Intravenous fluid replacement is necessary if labor is
prolonged, at risk for dehydration

MUSCULOSKELETAL SYSTEM
- Increased back pain or irritating nagging pain at the
pelvis

URINARY SYSTEM
- Concentrated urine; specific gravity may rise
- Pressure from fetal presenting part may reduce the
bladder tone and ability of the bladder to sense filling
- Ask the woman to void every 2 hours > also promotes
fetal descent

GASTROINTESTINAL SYSTEM
- Inactive
- Prolonged gastric emptying time may lead to nausea
and vomiting
- May have clear liquids, unless there is a likelihood for
cesarean

NEUROLOGIC AND SENSORY RESPONSES

- Responses are related to pain

MATERNAL PSYCHOLOGICAL RESPONSES

- Labor is hard work that puts a demand on the
woman’s coping resources
MATERNAL & FETAL ADAPTATION TO LABOR
FATIGUE
FEAR

43
 presentation and position

FETAL RESPONSES TO LABOR

PROCEDURE:
CARDIOVASCULAR SYSTEM Prepare the client
- Fetal heart rate may decrease by as much as 5 bpm - Explain procedure
during a contraction - Instruct the client to empty bladder
- Amount of oxygen and nutrients are reduced during a A. Perform the FIRST maneuver
contraction - Stand at the foot of the client, facing head, and place
both hands flat on her abdomen
RESPIRATORY SYSTEM -Palpate the superior surface of the fundus
- The act of passing through the birth canal is beneficial
to the fetus in 2 ways: B. Perform the SECOND maneuver
Process of labor stimulates surfactant production - Face the client and place the palms of each hand on
Vaginal squeeze helps clear the respiratory passageway either side of the abdomen
of mucus - Palpate the sides of the uterus. Hold the left-hand
stationary on the left side of the uterus while the right
hand palpated the opposite side of the uterus from top
to bottom

C. Perform the THIRD maneuver

- Gently grasp the lower portion of the abdomen just
above the symphysis pubis between the thumb and
index finger and try to press the thrums and finger
together.

D. Perform the FOURTH maneuver

- Place fingers on both sides of the uterus
approximately 2 inches above the inguinal ligaments,
pressing downward and inward in the direction of the
IMMEDIATE ASSESSMENT OF THE WOMAN IN birth canal. Allow fingers to be carried out downward

STAGE ONE
1. For an INITIAL INTERVIEW, obtain information about
the following areas:
- EDC
- Baseline date of maternal vital signs & frequency,
duration, and intensity of contractions
- Rupture of membranes
- Time the woman last ate
- Past pregnancy history and previous pregnancy
outcomes
- Her birth plans

3. Vaginal examination
To determine the extent of cervical effacement and
dilatation and to confirm the presentation, position,
and degree of descent
- Examination during a contraction is more painful
- Palpating membrane during a contraction may cause
them to rupture
- DO NOT PERFORM VAGINAL EXAM in the presence of
FRESH BLEEDING

5. LEOPOLD’S MANEUVERS 4. SONOGRAPHY

- To determine the diameter of the fetal skull and to
- Are systematic method of observation
determine presentation, presenting part, and degree of
and palpation to determine fetal descent of the fetus

44

5. VITAL SIGNS
• Temperature - Obtain every 4 hours if membrane is
intact and every hour if membrane has ruptured
• Pulse & respiration
- Should be taken every 4 hours
- Persistent pulse rate of more than 100bpm suggests
dehydration or hemorrhage
- Observe hyperventilation
• Blood Pressure
- Should be taken every 4 hours
- Take BP between contractions
6. LAB ANALYSIS
- Blood and urine samples
7. MONITORING UTERINE CONTRACTIONS
- Labor watch
- Intensity of contractions
INITIAL FETAL ASSESSMENT
1. AUSCULTATION OF FETAL HEART SOUNDS
- Fetal heart sounds are best heard through the fetal
back
- May be intermittent or continuous
- Count FH every 30 min during beginning labor, every
15 min during active labor, and every 5 min during the
second stage
2. EXTERNAL ELECTRONIC MONITORING
- Can be used to monitor both uterine contractions and
FHR
- Watch for supine hypotension syndrome
3. FETAL HEART RATE PATTERN
• Baseline FHR
- Is measured between uterine contractions during 10-
min period
- Normally accepted baseline is between 120 - 160 bpm
- Rates between 110-120 are usually acceptable if all
other signs are reassuring
• VARIABILITY
Two types:
Short term - refers to the moment-to-moment changes
in the FHR
Long term - refers to the wider fluctuations that EFM
tracing look wavy over time
• PERIODIC CHANGES
Accelerations - are temporary normal increases in FHR
due to fetal movement or compression of the umbilical
vein during contraction
Decelerations
Early Decelerations - are periodic decreases in
FHR resulting from pressure on the fetal head during
contractions
- Is also known as Reassuring Periodic Change
- The wave of the FHR change is inverse to the
contraction waveform, with the lowest point of the
deceleration occurring with the peak of the
contraction, thus serving as the mirror image of
deceleration
Late Decelerations - are those that are delayed until 30
- 40 sec after the onset of a contraction and continue
beyond the end of the contraction
- This is an ominous pattern in labor suggesting
UTEROPLACENTAL INSUFFICIENCY
- Immediate steps to correct the situation:
If oxytocin is used, stop, or slow the administration.
Place the woman on left lateral position.  Administer
IVF and O2. Prepare for possible prompt birth of the
fetus
Variable Decelerations - occur at unpredictable times
These indicate cord compression which may also be
ominous in terms of feta well-being
45
- Cord compression may occur due to cord prolapsed
but also occur because the fetus is lying on the cord.
Tends to occur after the membrane has ruptured or
with oligohydramnios
- Exhibits a U or W shaped waves
    
- Woman should be placed on Trendelenburg position
to relieve pressure on cord
- Administer IVF and O2
- If not relieved by these measures, amnioinfusion may
be prescribed
Both late and variable decelerations are considered as
NON-REASSURING PERIOD CHANGE
NURSE’S ROLE DURING EACH STAGE OF LABOR
1. FIRST STAGE (Latent Phase)
- Assess status every hour
- Assess the woman’s psychological state. She may be
talkative and express feelings of confidence and
excitement
Preventing Fetal & Maternal Injury
- Monitor vital signs and labor progress both maternal
and fetal status every hour
- Mild tachycardia may be associated with anxiety or
the stress of labor contractions
Promoting Comfort:
- If membranes are intact and engagement has
occurred, allow the woman to ambulate
- Assist the woman with comfort measures and position
change
- Encourage left lateral position
- If medication such as narcotic is given, a woman
should remain in bed approximately 15 min after to
avoid fall
- Bladder care and voiding at least every 2 to 4 hours
Relieving Anxiety
- Encourage verbalization
- Ask for concerns
- Allow the woman to gain control of situation by
maybe allowing involvement of partner
- Be keen on non-verbal cues
Providing Patient Teaching:
- Latent phase is an excellent time to teach the woman
and partner about labor process
- Teach basic relaxation technique
- Briefly describe the frequency and purpose of nursing
assessments and interventions common to each stage
of labor
FIRST STAGE (Active phase)
- Assessment of labor progress every 30 min both
maternal and fetal status
- Note if the woman is becoming more introverted,
restless, or anxious; if she is feeling helpless or fear of
losing control
- Assess the presence and character of pain every hour
- Evaluate breathing pattern frequently
- Assess for signs of hyperventilation, which include
tachypnea, feeling of lightheaded ness or dizziness,
complaints of tingling around the mouth or in fingers,
and carpopedal spasm
Preventing Trauma during labor:
- Report any signs of fetal distress that do not respond
to position changes
- Report heavy bleeding or failure of the uterus to relax
well between contractions
- Continue bladder care, if the woman is unable to void,
prepare for a sterile in-and-out catheterization
procedure
Providing Pain Management:
- Active phase is the time when pain relief measures
are most often implemented
- Narcotics or analgesia may be administered
- Respect the woman’s preference for pain control
- Institute non-Pharmacologic pain management such
as distraction and relaxation techniques, effleurage,
46
back rubs, or application of pressure during
contractions
- Change soiled linens and gowns to minimize infection
- Provide frequent perineal care especially every after
invasive procedure involving the vagina and after
elimination
Reducing Anxiety:
- Assist the woman to implement anxiety reduction
plan agreed upon during early labor
- Continue to encourage the woman to verbalize her
concerns
- If her method of pain relief is not working, remind her
that she can change her mind about pain relief options
Promote Effective Coping Strategies:
- Allow “rituals” (routine) to help woman cope with
contractions
Promoting Effective Breathing Pattern:
- Frequently reinforce breathing techniques
- Make an eye contact and perform the breathing
patterns with the woman to help keep her focus
- If hyperventilation occurs, breathing into cupped
hands or a paper bag usually relieves the problem
Maintaining Integrity of the Oral Mucosa:
- Frequent mouth care
- Suggest brushing of teeth or gargle with normal saline
- Provide ice chips, sips os clear liquids, or hard candy if
allowed
Preventing Infection:
- Frequent vaginal examination is discouraged,
especially if membrane has ruptured
- Invasive procedure such as urinary catheterization
should be kept to a minimum
- Strict adherence to sterile technique when performing
invasive procedure is critical
FIRST STAGE (TRANSITION PHASE)
- Look for increase amount of blood show and a strong
urge to push
- The woman often express irritability, restlessness, and
will feel out of control. She may tremble, vomit, or cry
- It is important to assess for hyperventilation during
this phase
- Check labor progress every 3o min both maternal and
fetal status
- VARIABILITY SHOULD BE PRESENT BUT THERE SHOULD
BE NO LATE DECELERATIONS OR OTHER SIGNS OF
FETAL DISTRESS
Managing Pain:
- Narcotics are not given at this advanced stage a too
sleepy neonate taking the first breath
- Frequent position changes
- Continue providing comfort measures
Promoting Effective Breathing Patterns:
- Explain the importance of resisting the urge to push
until the cervix if fully dilated
- Pushing efforts before the cervix if fully dilated can
result in cervical lacerations or can cause edema of the
cervix and slow dilatation
Promoting A Sense of Control:
- Accept behavioral changes of the laboring woman
- Provide intensive psychological support
Supporting the woman through fatigue:
- Assist woman to relax to conserve energy
Preparing the room for delivery:
- Prepare the table maintaining surgical asepsis
- Make sure supply and medications for birth are
readily available
- Check infant resuscitation area
2. SECOND STAGE OF LABOR (Expulsion of the fetus)
- Monitor labor progress every 15 min maternal and
fetal status
Positioning for Birth:
- Variety of positions can be used like Lateral or Sims’
position, dorsal recumbent, semi-sitting, and squatting
Promoting Effective Second Stage Pushing:
- Encourage the woman to push with contractions
and rest between them
- Allow her to push when she feels the urge and use
the position and technique, she feels are best for her
- May use short pushes or long sustained ones
- Holding her breath during a contraction may
interfere bloody supply to the uterus
Perineal Cleaning:
- Use warmed antiseptic and rise with designated
solution after birth
- Clean from vagina outward
Episiotomy:
A surgical incision of the perineum made to prevent
tearing
47
 - Assess lochia for color and quantity
- Monitor for signs of infection
- The woman should void within 6 hours after delivery
- Assess level of comfort; cramping from uterine
contractions and perineal pain
- Mother is fatigued and ravenously hungry
- It is normal that she may demonstrate dependent
behavior

Providing Care Immediately After Delivery:

- Inspect and cleanse the perineum
- Place a blanket over a new mother
- Remove both legs from the stirrups at the same time

Promoting Parent-Newborn Attachment

- Hand the newborn the mother as soon as the
newborn is stable
- If father is present at the delivery, encourage him to
hold and interact with the newborn
- Place the newborn skin-to-skin against her body
- Initiate breastfeeding
Preparing the Delivery of the Newborn:
- Pressure should never be applied to the fundus of the
Maintaining Adequate Fluid Volume:
uterus because uterine rupture may occur
- Continue to monitor for signs of fluid volume deficit
- Suction as soon as the newborn’s head is out
- Massage fundus every 15 min
- Note the time of birth
- Offer food and fluids to the mother
Cutting, Clamping the Cord:
Promoting Urinary Elimination:
- Clamp the cord after pulsation has stopped
- Assist her to void to the bathroom
- Note the number of umbilical blood vessels
- Have her dangle her feet for several minutes before
- Introducing the infant
assisting her to a standing position
Do not massage the uterus when it is soft right after
- Straight catheterization if there is suprapubic
the birth of the newborn, or it may result to uterine
distention or discomfort from full bladder or until 6
inversion
hours have passed without voiding
3. THIRD STAGE OF LABOR (Delivery of the Placenta)
Minimizing Pain:
- Monitor for signs of placental separation, which
- May be given NSAIDs and oral narcotic analgesic
generally occur within 5 to 20 minutes of delivery
- Apply ice pack to the perineum
- Oxytocin
Obtain blood pressure before administration
Reducing Fatigue:
Inspect placenta if intact prior to the administration
- Promote rest to the new mother
Preventing Fluid Loss:
- Monitor vital signs, fundus, and lochia every 15 mins
OBSTETRIC PROCEDURES
- Monitor intravenous fluids to ensure patency and
prevent development of dehydration
1. EPISIOTOMY
- Surgical incision of the perineum used to enlarge the
Maintaining Safety and Preventing Trauma:
vaginal outlet
- Monitor for sudden change in status like shortness of
- Used to prevent the perineum from tearing, which
breath, chest pain, or tachypnea
can occur with birth
- Helps to release the pressure on the fetal head that
4. FOURTH STAGE OF LABOR
accompanies birth
- The new mother is at higher risk for hemorrhage
during the first 2-4 hours of postpartum period
- Monitor vital signs every 15 min for the first hour,
every 30 min for the second hour, and every hour for
the succeeding third and fourth hour
- Fundus should be well contracted, at the midline, and
approximately 1cm below the umbilicus after delivery

48

MIDLINE EPISIOTOMY
- Involves an incision that’s made in the middle of the
perineum
- Advantageous because it’s associated with easier
healing, decrease blood loss, and decrease postpartum
discomfort
MEDIOLATERAL EPISIOTOMY
- Involves an incision begun at the midline and then
angled to one side away from the rectum
- Advantageous because of the decreased risk of rectal
mucosa tears
Advantages:
- prevents tearing (laceration) of the perineum
- Can be repaired more easily than a tear and heals
faster
- Enlarges the vaginal outlet to facilitate manipulation
or use of forceps
Disadvantages:
- May interfere with maternal-neonatal bonding if
discomfort is severe
- Creates a potential site of infection
- May make the patient hesitant to void or have a
bowel movement
2. AMNIOTOMY
- Refers to the artificial rupture of the amniotic sac
- Performed when the membranes haven’t ruptured
spontaneously, as a means of augmenting or inducing
labor, allowing the fetal head to contact the cervix
more directly, and increasing the efficiency of the
contractions
- May be done to allow internal fetal monitoring and to
access the fetus for fetal blood sampling
- Before an AMNIOTOMY is done, the following must
be present:
The fetus must be in the vertex position with the fetal
head at +2 station or lower and a bishop score of at
least 8
(Bishop score accounts: cervical dilatation, effacement,
station)
- The cervix must be dilated at least 3 cm
- The procedure is virtually painless for the patient and
the fetus because there are no nerve endings in the
membranes
- After the woman is placed in a dorsal recumbent
position, the membranes are torn with a hemostat or
punctured with an Amniohook (a long, thin instrument
similar to a crochet hook) inserted into the vagina, and
if the tear or puncture has been performed properly,
the amniotic fluid will gush out
Advantages:
- It helps to induce or augment labor
- It provides access to the fetus
Disadvantages:
- There’s an increased risk of umbilical cord prolapse
- Patient is at risk for infection
- If the patient has hydramnios, abruptio placenta may
occur as a natural / after effect of the procedure
- As the uterus collapses due to the draining fluid, the
area of placental attachment shrinks
- The placenta no longer fits its implantation site,
resulting in a decrease in surface area where fetal
oxygenation occurs, possible adversely affecting the
fetus
3. FORCEPS DELIVERY
- Forceps are steel instruments used to assist with
delivery and to relieve fetal head compression
- Consist of 2 blades connected together; blades are
slipped into position one at a time
- Commonly used forceps: Kiellands, Elliot, Piper,
Tucker McLean, Simpson’s
Forceps delivery may either be low-forceps or mid-
forceps
- Low forceps (outlet) delivery is performed when the
fetus’ head reaches the perineum; typically, the fetal
head is at +2station or more
- Mid-forceps delivery is performed when the fetal
head is engaged but is at less than +2 station; because
of the increase risks of birth trauma, this type of
delivery is rarely done
- For a forceps delivery to be performed, the following
49
must be present: - It’s also associated with less maternal discomfort
Ruptured membranes because the cup doesn’t occupy additional space in the
Fully dilated cervix birth canal
Empty bladder - Little anesthesia is needed compared with the
Absence of cephalopelvic disproportion required for forceps delivery; subsequently, the
neonate is born with less respiratory depression

Disadvantages:
- Vacuum extraction is associated with a market
capture succedaneum of the neonate’s head, lasting if
7 days after birth
- Tentorial tears are possible from extreme pressure
- Renewed bleeding from the scalp can occur if used for
a fetus that has undergone fetal blood sampling
- Just in preterm neonate is problematic because of the
extreme softness of their skulls

Advantages:
- It shortens the 2nd stage of labor when adverse fetal
and maternal conditions exist 5. VERSION

Disadvantages:
- Increases perinatal morbidity and mortality (mid-
forceps delivery)
- Increases neonatal birth trauma and depression
- Increases incidence of perineal lacerations,
postpartum hemorrhage, and bladder injury

4. VACUUM EXTRACTION
- An alternative forceps delivery; facilitates descent of
the fetal head
- A plastic vacuum cup is applied t the fetal head,
negative pressure is exerted, and traction is applied to
Also called EXTERNAL CEPHALIC VERSION, refers to a
deliver the head
manual attempt to turn a fetus from one presentation
to another
 - Usually used to turn a fetus in the breech
presentation to a cephalic one
- After locating the breech and vertex of the fetus,
gentle pressure is applied to the abdomen to turn the
fetus
- Tocolytics agents to relax the uterus and epidural
anesthesia to relieve pain may be administered

Advantages: Advantages:
- It’s associated with a lower incidence of vaginal, - It’s a non-invasive procedure
cervical, and 3rd and Ruth degree lacerations - May decrease the number of cesarean deliveries

50
 when the placenta is anteriorly implanted
Disadvantages: - The incision is made through the abdomen, high on
- The patient may feel extreme pressure during the the uterus
manual turning - This type of incision may be used for patients with
- Rh iso-immunization is possible if minimal bleeding placenta previa because the incision can be made
occurs, thus necessitating without cutting the placenta
- The chances of vaginal birth after cesarean birth with
6. CESAREAN BIRTH this type of incision are low because of the incision’s
location in the major active contracting portion of the
uterus

Refers to the removal of the neonate from the uterus

through an abdominal incision

Indications:
- Cephalopelvic disproportion
- Uterine dysfunction
- Malposition / malpresentation
- Previous uterine surgery
- Complete or partial placenta Previn Vaginal Birth After Cesarean Birth:
- Pre-existing medical condition (DM or Cardiac disease) - A patient who has had a previous low-transverse
- Prolapsed umbilical cord cesarean delivery may attempt a vaginal birth, provided
- Fetal distress that no medical or obstetric contraindication to labor
or history of prior uterine rupture exists
2 TYPES OF CESAREAN BIRTH - The incidence of dehiscence of a firmer low-
- Scheduled transverse uterine incision dehiscence during an
- Emergency - done for reasons such as placenta previa, attempted vaginal birth after cesarean birth is less than
abruptio placenta, fetal distress, or failure to progress 1%
in labor

2 TYPES OF INCISIONS

Transverse incision
- Also known as the “bikini cut” or low segment
incision, is preferred and most common incision
- It’s associated with a decrease incidence of peritonitis
and post-op adhesions
- Blood loss is minimal
- Incision is made through the lower portion of the
uterus that’s minimally active with contractions,
making the incision less likely to rupture during future
labors
- Vaginal birth after cesarean delivery is possible with
this incision PSYCHOLOGICAL CHANGES DURING POST-PARTAL
PERIOD

PHASES OF THE PUERPERIUM

Classic /Vertical incision
- Is used when adhesions from previous cesarean • Taking-In Phase
delivery exist, when the fetus is in a transverse lie or -First 2 - 3 days
- A time of reflection for a woman

51
- The woman is largely passive & dependent
- She needs time to rest and regain her physical
strength

• Taking-Hold Phase
- The woman begins to initiate action
- She begins to take strong interest in the care of her
child
Do not rush the woman through taking-in phase but
encourage early process of taking-in to facilitate
bonding

• Letting-Go Phase The site where the placenta was attached will take 6
- The woman finally redefines her new role weeks to completely heal increasing maternal risk for
- She gives her up her old role and move into her new complications
role - Breastfeeding promotes uterine contraction and
involution
PHYSIOLOGIC ADAPTATION - The first hour postpartum is potentially the most
dangerous time for the woman. If the uterus should
1. REPRODUCTIVE SYSTEM become relaxed during this time, the woman will bleed
INVOLUTION is the process whereby the reproductive more rapidly because no permanent thrombi
organs return to their non-pregnant state yet formed at the placental site
- is complete by 6 weeks
• LOCHIA
• UTERUS Characteristics of Lochia:
- After birth, the uterus weighs about 1000g. At the end - Menstruation returns 6 - 10 weeks for non-lactating
of the first week, it weighs 500g. By the time woman; 3 - 4 months for lactating women
involution is complete, it will weigh approximately 50g,
its pre-pregnant weight
- AFTERPAINS - contractions of the uterus after birth
which causes intermittent cramping like that
accompanying a menstrual period
- They tend to be noticed most by multiparas
- These sensations are notices most intensely with
breastfeeding because the infant’s sucking causes
a release of oxytocin from the posteriorly pituitary,
increasing the strength of the contraction THE CERVIX
- After birth is soft and malleable
The FUNDUS of the uterus may be palpated halfway - Both internal and external os are open
between the umbilicus and symphysis pubis within a - By end of days, the external os is narrowed, and the
few minutes after birth cervix feels firm and non-gravid again
- One hour later, it has risen to the level of the - Permanent alteration of cervical external os shape
umbilicus, where it remains for approximately the next from a circle to a jagged slit
24 hours
- From then on, it will go down 1 finger breath (1cm) a
day
On the 1st postpartal day, the fundus of the uterus will
be palpable 1 finger breath below the umbilicus, and so
on Because a fingerbreadth is about 1cm, this can be
recorded as 1cm below the umbilicus, 2 cm below it,
and so forth

• VAGINA & PERINEUM

- After vaginal birth, the vagina is soft with few rugae
- The diameter of the introitus gradually becomes
smaller by contraction but rarely returns to its
prepregnant state

52
- Muscle tone is never fully restored to the prepregnant
state; however, Kegel’s exercises may help increase the
tone and enhance sexual enjoyment
- The woman may experience dryness especially when
breastfeeding due to suppression of ovulation
- Labia and perineum may be edematous after delivery
and may appear bruised
• BREASTS
- Colostrum is normally excreted by the breasts in the
last weeks of pregnancy and continues to be
excreted in the first few postpartum days
- Prolactin levels rise when estrogen and progesterone
levels fall
- Prolactin stimulates milk production
- Oxytocin stimulates let-down reflex
2. SYSTEMIC CHANGES
• HORMONAL SYSTEM
- HCG and HPL are almost negligible by 24 hours
- FSH remains low for about 12 days, and then begins to
rise to initiate menstrual cycle
• URINARY SYSTEM
- Pressure from labor and birth may leave the bladder
with a transient loss of tone, and edema surrounding
the urethra making voiding difficult
- Assess the woman’s abdomen frequently in the
immediate postpartal period to prevent permanent
damage to the bladder
- Full bladder sounds resonant
- Hydro nephrons is occurring during pregnancy
remains present for about 4 weeks increasing the
possibility of urinary stasis and infection
- Extensive diuresis begins to take place almost
immediately after birth
- A FULL BLADDER CAN DISPLACE THE FUNDUS AND
PREVENT IT FROM CONTRACTING CAUSING
BLEEDING
• CIRCULATORY SYSTEM
- Diuresis between 2nd and 5th days postpartum
reduces the added blood volume the woman
accumulated during pregnancy
- Blood volume returns to its pre-pregnancy level by
end of 1st or 2nd week postpartum
- Usual blood loss is 300 - 500 ml with a vaginal delivery
- 500 to 1000 ml with a cesarean birth
- 250 ml of blood loss = 4% drop in hematocrit = drop of
1 g/dl in hemoglobin
- Increased fibrinogen level persists until 1st week
postpartum increasing the risk of thrombus  formation
- WBC count may be as high as 30,000/mm3 in
response to labor, healing and prevention of infection
• GASTROINTESTINAL SYSTEM
- Digestion and absorption begin to be active soon after
birth
- The woman feels hungry almost immediately after
birth from the glucose used during labor and thirsty
from the long period of restricted fluid + diaphoresis
Bowel sounds are active, but passage of stools may be
slow due to hormone relaxin and perineal discomfort
(episiotomy, hemorrhoids)
- Bowel function returns to normal by 1st week
• INTEGUMENTARY SYSTEM
- Stretch marks still appear reddened; fades over the
next 3 to 6 months
- Excessive pigment on face, neck, and on abdomen are
barely detectable in 6 weeks’ time
- Over stretching and separation of the abdominal
muscle (diastasis recti) will appear slightly indented
• WEIGHT LOSS
- Immediately after delivery approximately 10 - 12 lb.
are lost with expulsion of the products of conception
- An additional loss of 5lb in the early postpartum
period due to fluid loss and diaphoresis
- Additional loss of 2 -3 lb. loss from lochia
- Total weight loss is about 19 lb.
- The weight the woman reaches at 6 weeks
postpartum will be her baseline postpartal weight
NURSING PROCESS FOR THE EARLY POSTPARTUM
PERIOD
Assessment
• DATA COLLECTION
- Health history
- Family profile
- Pregnancy history
- Labor and birth history
- Infant data
- Postpartal course
• LABORATORY DATA
- Hemoglobin and hematocrit level
- Blood type and Rh
• PHYSICAL ASSESSMENT
VITAL SIGNS
- Monitor vital signs q15 min during the first hour after
delivery, q30 min during the 2nd hour, q4h for the
remainder of the first postpartum day, then q8h
thereafter
- Always take oral or axillary temperature to reduce risk
of perineal contamination with rectal temperature
- Be aware that the patient’s temperature may be
elevated to 100.4oF after the 1st 24h
53
- Evaluate pulse rate based on the woman’s usual pre-
part up pulse rate
- Be aware that bradycardia (50 -70 bpm) is common
during the first 6 - 10 days after delivery because of
reductions in cardiac strain, stroke volume, and the
vascular bed
- Expect the respiratory rate to return to normal after
delivery
- Compare postpartum BP with the patient’s
pre=pregnancy
BP:
> Keep in mind that the woman’s BP is usually
normotensive within 24h of delivery
> Be alert for an increase in systolic BP greater than
140mmHg or diastolic BP greater than 90mmHg; these
could suggest development of postpartum pregnancy
induced HPN
> Check for evidence of orthostatic hypotension, which
may develop secondary to blood loss
FUNDUS
- Check the tone and location of the fundus q15min for
the 1st hour after delivery, q30min for the next 2 - 3h,
qh for the next 4h; q4h for the rest of the first
postpartum day, and then q8h until patient is
discharged
- The involution game uterus should be at midline
- The fundus should feel firm to the touch
- Keep in mind that a firm uterus helps control
postpartum hemorrhage by clamping down
on uterine blood vessels
- If the fundus feels boggy, massage it gently; if the
fetus doesn’t respond, a firmer touch
should be used
- Excessive massage can stimulate premature uterine
contractions causing undue muscle fatigue and leading
to uterine atony or inversion
- Because the uterus and its supporting ligaments are
tender after delivery, pain is the most common
complications of fundal palpation and massage
- Be prepared to administer oxytocin, ergonovine or
methylergonovine (methergine) to maintain uterine
firmness as ordered
- Be alert for uterine relaxation, which may occur if the
uterus relaxes from overstimulation because every of
massage or meds
- Evaluate any vaginal bleeding that’s considered
excessive
- Assess the patient for complaints of “AFTERPAINS”
> A multipara is more prone to AFTERPAINS from
uterine contraction
> AFTERPAINS generally last 2 - 3 days and may be
intensified by breastfeeding
- Managing AFTERPAINS:
Ibuprofen or other NSAIDs
Non-pharmacologic methods
Position for comfort
Adequate rest & nutrition & Early ambulation
LOCHIA
- Assess lochia along with the fundus q15min during the
1st hour after delivery, q30min for the next 2-3h, qh for
the next 4h, q4h for the rest of the 1st postpartum day,
and then q8h until the patient is discharged
- Note any foul odor; foul smelling lochia may indicate
an infection
- Watch for continuous seepage of bright red blood,
which may indicate a cervical or vaginal laceration,
additional evaluation is necessary
- Lochia that saturates a sanitary pad within 45min
usually indicates an abnormally heavy flow
- Weigh perineal pads to estimate the amount of blood
loss
Be sure to look under the patient’s buttocks where
blood may pool
- Lochial discharge may diminish after a cesarean
delivery
- Be alert from an increase in lochia flow on arising: a
heavier flow of lochia may occur when the patient first
rises from bed because of pooling of the lochia in the
vagina
- Evaluate amounts of clots; numerous large clots
require further evaluation because they may interfere
with involution
- Remember that breastfeeding and exertion can / may
increase lochia flow
- Know that lochia may be scant but should never be
absent; this may indicate a postpartum infection
BREASTS
- Palpate breasts to determine if soft, filling, or
engorged with milk
- Note any painful areas
- On the 1st to 2nd postpartum, the breasts should be
soft
- By the 3rd postpartum day, the breast may feel warm
and firm, indicating that the breasts are filling
By the 4th or 5th postpartum day, the breasts may feel
hard, tense, or tender and appear reddened and
large; typically, this indicates engorgement
- Check the nipples for cracking, fissures, or soreness
- Advise the patient to wear a support bra to maintain
shape and enhance comfort; urge the woman to avoid
bras with underwire
Managing Breast Pain:
- If the woman is breastfeeding have her run warm
water over her breasts in the shower; Warm compress
on the breasts
- Encourage breastfeeding
- If the engorgement prevents baby from breastfeeding
express some milk before attempting to breastfeed
- Cool compress for non-breastfeeding
- Examine nipples for cracks or fissures
- Ensure proper breastfeeding position
- Encourage the use of lanolin-based cream to keep
nipples soft and promote healing
- Mild analgesic may be helpful
54

BLADDER AND BOWEL / ELIMINATION
- Check to ensure that the patient voids within the first
6 - 8h after delivery
- The woman should be voiding adequate amount
(more than 100ml/voiding) regularly
- Check for distended bladder within the first few hours
after delivery; a distended bladder can interfere with
uterine involution
- Use prescribed pain medications before urination or
pour warm water over the perineum to eliminate the
fear of pain
- Anticipate the need for urinary catheterization if the
patient can’t void
- Check with the physician about the amount of urine
to be removed from the bladder
- If catheterization yields greater than 1000ml of urine,
expect to leave the catheter in place
- Too great a fluid loss at one time may lead to shock
- If catheter is left in place, check with the health care
provider about clamping catheter & releasing q2h
- Encourage the patient to have a bowel movement
within 2 days after delivery to avoid constipation
- Inspect abdomen and auscultate for bowel sounds
- Bowel sounds should be present in all four quadrants
- Urge increase fluid and roughage intake
- Assist with alleviating maternal anxieties regarding
pain from or damage to the episiotomy site
- If necessary, administer a laxative, a stool softener, a
suppository, or an enema as ordered
- Be aware that nothing should ever be inserted into
the rectum of a patient with a 4th degree laceration
EPISIOTOMY
- Assess the episiotomy site every shift to evaluate
healing
- Be aware that the edges of the episiotomy are usually
sealed 24h after delivery
- Note ecchymosis, hematoma, erythema, edema,
drainage or bleeding from sutures, foul odor or
infection
- Position the patient comfortably when inspecting the
episiotomy
> Position the patient with mediolateral episiotomy on
side (Sim’s) to provide better visibility and less
discomfort
> Position the patient with a midline episiotomy on the
side or the back during assessment
RECTAL AREA
- Assess the rectal area
- Note the number and appearance of hemorrhoids
MEDICATIONS
- Administer meds to relieve discomfort from the
episiotomy, uterine contractions, incision pain, or
engorged breasts as prescribed
> Analgesics
> Stool softeners and laxatives
> Oxytocic agents
- BP is monitored closely for changes
- Monitor patient for the therapeutic response &
adverse effects
POSTPARTUM PATIENT TEACHING
SELF-CARE INSTRUCTIONS TO THE MOTHER
1. Personal Hygiene
- Change perineal pads frequently, removing from front
to back
- Monitor lochia flow
> Look for flow to gradually reduce in amount and
change color
> Immediately report lochia with a foul smell, heavy
flow, or clots; also report lochia that changes to a
bright red color
> Perform perineal care with each voiding, bowel
movement and pad change
> Take a sitz bath 3 - 4x daily as directed by the health
care provider
> Take a daily shower to relieve discomfort of normal
postpartum diaphoresis
> Dispose of perineal pads in plastic bag
2. Preventing Infection
- It is important to teach the woman to wash her hands
before touching her breasts or feeding the baby
- Encourage early ambulation
- Ensure adequate nutrition and fluid intake
- Observe proper breasts care
- Change sanitary pad every 4hrs
- Encourage voiding and take steps to avoid
catheterization
3. Sexual Activity and Contraception
- Follow the health care provider’s instructions on
sexual activity and contraception
- Most couples can resume sexual activity 2 - 4 weeks
after delivery
- Cessation of vaginal bleeding and healing of the
episiotomy are necessary before sexual activity can
resume
- Sexual arousal can result in milk leakage from the
breasts
- Breastfeeding isn’t a reliable form of contraception
- Use a water-based lubricant, if needed (steroid
depletion may diminish vaginal lubrication for up to 6
months)
- Expect decrease intensity and rapidity of sexual
response (a normal response for about 3 months after
delivery
- Perform Kegel’s exercise to help strengthen the
pubococcygeal muscles
4. ACTIVITY AND EXERCISE
55
- Request assistance in getting out of bed the 1st
several times after delivery to minimize dizziness and
fainting from meds, blood loss, and decrease food
intake
- Be sure to get adequate amounts of rest
Take naps during the day
Rest when the neonate is resting
- Begin exercising when allowed by the health care
provider; start slowly and gradually increasing the
amount
> Abdominal breathing exercises can be started on the
1st postpartum day
> Chin to chest exercises are typically allowed on the
2nd postpartum day; arm- raising exercises can be
included on the 4th postpartum day
> Abdominal crunches are usually postponed for at
least 11/2 weeks after delivery
- Sit with the legs elevated for 30 min if lochia increases
or lochia rubra returns, wither of which may indicate
excessive activity; if exercise vaginal discharge persists,
notify the health care provider
- Expect abdominal muscle tone to increase 2 - 3
months after delivery
- PREVENTING INJURY FROM FALLS
> Assist woman when getting up from bed by dangling
her legs at the side of the bed for 5 minutes (she is at
risk for fainting and falling because of postural
hypotension)
> Remain with her until she returns to bed
> If she begins to black out, gently support her to the
floor
> Watch out for fainting during shower (warm water
can cause peripheral vasodilation)
- Prevent Injury from Thrombus Formation
> Assist the woman to ambulate early as much as
possible (early ambulation decreases the chance of
thrombus formation by promoting venous return)
> Liberal fluid intake (dehydration contributes to the
risk of thrombus formation)
- PROMOTING RESTFUL SLEEP
> Monitor the woman’s sleep-wake cycle
> Promote a relaxing, low stress environment before
sleep
> Medicate for pain, if needed, at bedtime
> Plan activities so that sleep is disturbed as
infrequently as possible
> Encourage the woman to rest when the baby is
sleeping
- PROMOTING PARENT-NEWBORN ATTACHMENT
> Encourage the parents to cuddle the newborn closely
> Role model attachment behavior by talking to the
newborn and calling the newborn by name
> Point out positive features of the baby
> Encourage parents to participate in the care of the
newborn
> Assist the parents to be attuned to the baby’s cues
that he is ready for interaction, that he is
overstimulated or that is he is ready for sleep
5. NUTRITION
- Increase CHON and caloric intake to restore body
tissue
- If breastfeeding, increase daily caloric intake by
200Kcal over the pregnancy requirement of 2400kcal
- Expect increase thirst because of postpartum diuresis
- If breastfeeding, drink at least ten 8-oz (237ml) glasses
of water per day
- Drink plenty of fluids, especially water and eat foods
that are high in fiber to prevent constipation
6. ELIMINATION
- Don’t ignore the urge to defecate or urinate
- Notify the health care provider of complaints of
burning or pain on urination
- Use stool softeners as prescribed
- Use Witch Hazel compresses, sitz baths, or anesthetic
sprays to help relieve discomfort of hemorrhoids
- Lie on the side (Sim’s with the upper leg flexed to help
reduce the discomfort of hemorrhoids)
7. COMFORT MEASURES
- To relieve perineal discomfort, use ice packs for the
first 8-12h to minimize edema
- Perform perineal care using peribottles, sitz baths as
ordered
- Use anesthetic sprays, creams and pads and
prescribed pain meds to help relieve pain and
discomfort
- To relieve discomfort from engorged breasts, wear a
supportive bra, apply ice packs, and take prescribed
meds
- If breastfeeding, eat frequent meals, apply warm
compresses, and express milk manually from the
breasts
8. PSYCHOLOGICAL ADJUSTMENTS
- Don’t be alarmed by mood swings and bouts of
depression, these are normal postpartum responses
- More than half of postpartum women experience
transient mood alterations called “baby blues”
- Common symptoms include sadness, crying, fatigue,
and low self-esteem
- Possible causes include hormonal changes, genetic
predisposition, and altered role and self-concept
- Know that mood swings typically occur within the 1st
3weeks after delivery and usually subside within 1-10
days
- Make a follow-up appointment for 4-6 weeks after
delivery
NEONATAL CARE INSTRUCTIONS FOR THE PARENTS
1. CORD CARE
- Wipe the umbilical cord with alcohol, especially
around the base, at every diaper change
- Report promptly any odor, discharge, or signs of skin
irritation around the cord
56
- Fold the diaper below the cord until the cord falls off
(7-10 days)
2. CIRCUMCISED PENIS CARE
- Gently clean the penis with water, and apply fresh
petroleum gauze with each diaper change
- Loosen petroleum gauze stuck to the penis by pouring
warm water over the area
- Don’t remove yellow discharge that cover the glans
about 24h after circumcision; this is part of normal
healing
- Report promptly any foul-smelling, purulent discharge
- Apply diapers loosely until the circumcision heals
(about 5 days)
3. UNCIRCUMCISED PENIS CARE
- Don’t retract the foreskin when washing the neonate
because the foreskin is adhered to the glans
4. ELIMINATION
- Become familiar with the neonate’s voiding patterns
(usually 6-8 diapers daily)
- Become familiar with the neonate’s bowel patterns
(usually 2-3 stools daily; more frequently if breastfeed)
- Become familiar with the neonate’s bowel patterns
(usually 2-3 stools daily; more frequently if breastfeed)
- The 1st stool is called MECONIUM, it’s an odorless,
dark green, thick substance containing bile, fetal
epithelial cells
- Transitional stools occur 2-3 days after ingesting of
milk; they are greenish brown and thinner than
meconium
- The stool change to a pasty, yellow, pungent stool
(bottle-fed) or to a sweet smelling loose yellow stool
(breast-fed) by the 4th day
5. THERMOMETER USE
- Refrain from using a glass mercury bulb thermometer
in the neonate’s rectum
- Obtain the neonate’s temperature under the arm
(axillary) or via the ear (tympanic membrane)
- Carefully place an axillary thermometer under the arm
and hold in place for 10 minutes
- Be aware of alternative devices for obtaining
temperature including a plastic temperature strip and
pacifiers with a built-in thermometer
6. DIAPERING
- Change diapers before and after every feeding
- Avoid diaper rash with frequent diaper changes and
thorough cleaning and drying of the skin; be sure to be
clean thoroughly between skin folds
- Expose the neonate’s buttocks to air and light several
times per day for about 20 min to treat diaper rash
Apply ointment sparingly to prevent contact of urine
and feces with skin
- Avoid the use of powders; they irritate the pores of
the skin and may cause respiratory difficulties in the
neonate
7. BATHING
- Give the neonate sponge baths until the cord falls off,
then wash him in tub containing 4” (10cm) of water
- Never leave the neonate unattended in the tub
- Place a washcloth on the bottom of the tub or sink to
regent slipping
- Use tepid bath water temperature because neonatal
thermoregulation is unstable
- Avoid using performed or deodorant soap
- Organize supplies before the bath to avoid
interruptions
- Keep room temperature between 68o and 72o F (20-
22.2o C) and avoid drafts
- Avoid using soap on the face, clean the eye from the
inner canthus to outer canthus with plain water
- Very the frequency of bathing with weather; a bathing
q other day is sufficient
8. CLOTHING
- Dress the infant appropriately according to indoor
temperature and outdoor weather conditions
- Layer clothing appropriately because infants don’t
shiver
- Provide the infant with a hat to avoid drafts and
minimize heat loss through the scalp when outdoors
9. BREASTFEEDING
- Initiate breastfeeding ASAP after delivery, and then
feed the neonate on demand
- Drink a beverage before and during or after
breastfeeding, to ensure adequate fluid intake and
maintain milk production
- Be sure to attend to personal needs and change the
neonate’s diaper before breastfeeding begins so that
feeding is uninterrupted
- Wash your hands before breastfeeding and find
comfortable position
- Try to relax during breastfeeding because relaxation
also promotes the letdown reflex
- Be aware that you may feel a tingling sensation when
it occurs and that milk may drip or spray from the
57
breasts; it may also initiated by hearing the neonate’s
cry
- Remember that uterine cramping may occur during
breastfeeding until the uterus returns to its original size
- Place thumb of free hand on top of the exposed
breast’s areola and 1st 2 fingers beneath it, forming a
“C” with the hand
- Turn the neonate so that the neonate faces the breast
- Stroke the neonate’s cheek located nearest to the
exposed breast or the neonate’s mouth with the
nipple, to stimulate the rooting reflex
- Avoid touching the neonate’s cheek because he may
turn his head toward the touch and away from the
breast
- When the neonate opens his mouth and roots for the
nipple, insert the nipple and as much of the areola as
possible into his mouth; this helps him to exert
sufficient pressure with his lips, gums, and cheek
muscles on the milk sinuses below the areola
- Check for blockage of the neonate’s nostrils by the
breast, if this happens, reposition the neonate to give
him room to breathe
- Begin nursing the neonate for 15 min on each breast
Switch to the other breast; slip a finger into the side of
the neonate’s mouth to break the seal and move him
to the other breast; never just pull it because doing so
can damage the areola
- Burp the neonate before switching to the other breast
by placing him over one shoulder and gently patting or
rubbing the back to help expel any digested air;
alternatively, hold the neonate in a sitting position on
the lap, leaning him forward against one hand and
supporting his head and neck with the index finger and
thumb of that same hand or placing the neonate in a
prone position across the lap
Perform thorough breast care to promote cleanliness
and comfort
- After each feeding, wash the nipples and areola with
plain warm water and air dry during the 1st 2-3 weeks
to prevent nipple soreness; after that, daily washing is
adequate for cleanliness
- Avoid using soap, which can dry and crack the nipples
and leave an undesirable taste for the neonate
- Apply non-alcoholic cream to the nipple and areola to
prevent drying and cracking
- Wear a well-fitted nursing bra that provides support
and contains flaps that can be loosened easily before
feeding
- Use breast pads to avoid staining clothes from
leakage, and change wet pads promptly to avoid skin
breakdown
- Begin the next feeding using the breast on which the
neonate finished during the previous feedings; place a
safety pin or as strap of the bra on the side last used as
a reminder to begin on this breast for the next feeding
- Expressed breast milk can be frozen for up to 3
months
- Follow a diet that ensures adequate nutrition for both
mother and neonate
- Drink at least four 8oz (237( glasses of fluid daily
- Increase daily caloric intake by 500kcal above the
pregnancy requirement of 2,500kcal
- Be aware that ingested substances (caffeine, alcohol,
and meds) can pass into breast milk
- Avoid foods that cause irritability, gas, or diarrhea
- Bottle-feeding and formula preparation
> If preparing formula, follow the manufacturer’s
instructions or the health care provider’s prescription
> Administer the formula at room temperature or
slightly warmer
> after properly preparing the formula and washing the
hands, invert the bottle and shake some formula onto
the wrist to test the patency of the nipple hole and the
formula’s temperature
> Always hold the bottle for a neonate; never leave a
bottle propped in the neonate’s mouth
> If left to feed himself, he may aspirate formula or
swallow air if the bottle tilts or empties
> Burp the neonate after each 1/2 to 1oz (15-30 ml)
SPECIAL ISSUES OF REPRODUCTION & WOMEN’S CARE
• HEALTH SCREENING FOR WOMEN
- Breast cancer screening
- Pelvic examination and pap smear
- Vulvar self-examination
• COMMON DISORDERS OF THE FEMALE
58
REPRODUCTIVE TRACT • Preventing pregnancy
- Menstrual disturbances - The best contraceptive method is the one that is most
> Amenorrhea comfortable and natural for the partners, and the one
> Atypical uterine bleeding that they will consistently use correctly
Menorrhagia
Metrorrhagia
> Dysmenorrhea Natural or Fertility Awareness Methods:
> post-menstruated syndrome 1. Calendar (Rhythm method)
- Endometriosis - Relies on abstinence from intercourse during fertile
- Infectious disorders periods
- Pelvic Inflammatory disease - Fertile periods are calculated by recording 12
consecutive menstrual cycles
- Subtract 18 days from the shortest cycle and 11 days
• COMMON DISORDERS OF THE UTERUS & OVARIES from the longest cycle = fertile period
- Cervical polyps - Effectivity rate is 13%
- Uterine fibroids
- Ovarian cysts
Advantages:
- Inexpensive and convenient
- Encourages communication
REPRODUCTIVE LIFE CYCLE ISSUES - No side effects
- Ethically and morally non-controversial
- Appropriate for sexual education programs

FAMILY PLANNING
- Family planning consists of two complementary
components:
> Planning pregnancy
> Preventing pregnancy
- Family planning gives the woman control over the
number of children she wishes to have and allows her
to determine when births will occur in relation to each
other and in relation to her anger and/or the age of the
father
Disadvantages:
- Requires long periods of abstinence and control
- Requires correct calculations and regular
menstruations to be effective
- Confusing irregular uterine bleeding with a menstrual
period day led to incorrect calculations
- Effectiveness is unreliable and depends on many
variables

• Planning pregnancy Natural or Fertility Awareness Methods:

- Good health and avoiding exposure to harmful 2. Cervical Mucus method
substances are significant contributing factors for a - Relies on abstinence from intercourse during fertile
successful pregnancy and a healthy baby periods
- Any woman of childbearing age should be aware of - Cervical mucus in the ovulatory period is clear and
health problems or medication regimens that may slippery and more abundant
- adversely affect pregnancy and the birth of healthy - pre-ovulatory post-ovulatory periods, cervical mucus
baby is yellowish, less abundant, thick and sticky (inhibits
- It is recommended for women to optimize their intake sperm motility)
of folic acid several months before becoming pregnant - Effectivity is about 20%
- Regular aerobic exercise conditions the body systems
- Smoking cessation is an important consideration
when planning for pregnancy Advantages:
- Alcohol intake can affect the developing child - Inexpensive
especially in the earliest weeks of pregnancy - No side effects
- A woman with chronic illness is at higher risk for poor - Ethically and morally non-controversial
pregnancy outcome

Disadvantages:
- Not as effective as other methods

59
 Disadvantages:
- Decreases spontaneity and sensation

Disadvantages:
- Should be used with vaginal jelly if condom or vagina
is dry
- Contraindicated to men and women with latex allergy

3. Symptothermal method
- Couple makes use of the combination of calendar,
basal body temperature, and cervical mucus method to
determine fertile period
- Effectivity can be as high as 13-20% among typical
users

Advantages:
- Inexpensive
- No side effects
- Encourages communication
- Provides the couple with more information
Disadvantages:
- More complex and difficult to learn 2. Intrauterine Device
- Requires regular and daily effort - Flexible device inserted in the uterine cavity during
menstruation
- This alters uterine transport of sperm so fertilization
don’t occur
4. Lactation Amenorrhea
- Side effects:
- As long as a woman is breastfeeding an infant, there is
> Dysmenorrhea
some natural suppression of ovulation
> Increased menstrual flow
- The woman may not be menstruating but may be
> Uterine infection or perforation
ovulating; the woman may still be fertile even if she has
> Ectopic pregnancy
not had a period since childbirth
- Danger signs to report
> Late or missed menstrual period
> Severe abdominal pain
Artificial Methods: Barrier Methods > Fever and chills
> Foul vaginal discharge
>Spotting, bleeding, or heavy menstrual periods
1. Male Condom >Spontaneous expulsion occur in 2-10% of users in the
- A latex or rubber sheath that fits over the erect penis first year
and prevent sperm from entering the vagina
- Effectivity is 86%

Advantages:
- No side effects
- Helps prevent conception and STDs
- Available over the counter
- Condom helps maintain erection longer
- Prevents sperm allergies
- Discretely carried by men and women

60

Advantages:
Inexpensive for long term use
- Reversible
- May be use with lactating women
- Requires no attention other than checking that it is in
place
Disadvantages:
- Available only through a health care provider
- Contraindicated if woman has an active infection of
pelvis, postpartum infection, endometrial hyperplasia
or carcinoma, uterine anomalies, women who have an
increased risk of STDs or women with multiple sexual
partners
3. Cervical cap
- Is a reusable rubber cap that fits tightly over the
cervix. The cervical cap is inserted into the vagina with
spermicide before sex to prevent pregnancy.
- For people who’ve never given birth, the cervical cap
is 86%
Advantages:
- Convenient and give you control
- Cervical caps don’t interrupt sex
- Cervical caps don’t have hormones
- Lasts a long time > only need to be replaced every
year with proper care
Disadvantages:
- Cervical caps don’t protect against sexually
transmitted infections
- You have to use it every time you have sex. Difficult /
hard to use correctly for some people to do, also,
spermicide can have side effects
- Changes in the body over time can mess up the fit of
the cervical cap. You have to get refitted for a new size
if you have a baby, miscarriage, or abortion
4. Cervical diaphragm
- Is a shallow, bendable cup that you put inside your
vagina. It’s a shallow cup like a little saucer that’s made
of soft silicone. You bend it in half and insert it inside
your vagina to cover your cervix
- Adding spermicide is used to make it more effective
- 88% effective - that means about 12 out of 100 people
who use it will get pregnant each year
Advantages:
- Convenient and give you control
- Don’t interrupt sex
- Lasts a long time up to 2 years with proper care
Disadvantages:
- You must use it correctly
- Some people have trouble inserting the diaphragm
- Spermicide may have side effects
Surgical Methods
1. Tubal Ligation
- The Fallopian tubes are surgically lighted or cauterized
either through mini laparotomy or laparoscopy
- Effectivity is 100%
Advantages:
- Highly effective
- Usually permanent
- Can be performed immediately postpartum
Disadvantages:
- Invasive procedure
61
- May be irreversible - Most reliable contraceptive method
- High risk of ectopic pregnancy after reversal - Convenient to use
- No protection against STD - Tend to decrease menstrual cramps and pain

Disadvantages:
- Contraindicated to women who are smoking
- Contraindicated to women with history of
thrombophlebitis, CVA, varicosities, DM, estrogen
dependent carcinoma, liver disease, older than 35
years of age
- Needs reassessment and re-evaluation every 6
months
- Does not offer protection against STDs

2. Vasectomy
2. Contraceptive Implants
- This procedure takes about 20 minutes
- Is a very small plastic rod about the size of a
- Small incision is made on each side of the scrotum
matchstick. A doctor inserts it into the upper arm, right
over the spermatic cord
under the skin. It releases progestin hormone into the
- Each vas deferens is lighted and cut
body to prevent pregnancy
- May experience some pain, bruising, and swelling
- Prevents pregnancy by blocking the release of eggs. It
- May apply ice pack, scrotal support, and a mild oral
also thickens cervical mucus
analgesic
- Implants must be removed after 3 years. At that time,
another implant can be inserted
1-2 days moderate activities because of scrotal
tenderness
- Sutures are removed about 4-7 days
Advantages:
- Must use another method of birth control for at least
- One of the highest levels of effectiveness of all
1 month until a negative sperm count verifies sterility
contraceptives
- The man still has the ability to achieve and maintain
- No need to worry about birth control for 3 years
erection or on the volume of ejaculate
- Fertility returns as soon as the implant is removed
- Appropriate for women who can’t use birth control
that contains estrogen
Pharmacologic Methods
1. Oral Contraceptives
- Used to prevent conception by inhibiting ovulation
- Causes atrophied changes of the endometrium to
prevent implantation Disadvantages:
- Causes thickening of cervical mucus to inhibit sperm - No protection against STIs
travel - High up-front cost
- Regulates menstrual cycle - Insertion requires a doctor’s visit
- Combined estrogen and progesterone in table form - Must be removed after 3 years
- Effectivity is about 97-100% if properly used

Side effects:
- breakthrough bleeding
- Nausea and vomiting
- Susceptibility to vaginal infections
- Thrombus formation

Edema and weight gain

- Irritability
- Missed periods

Advantages:

62
63