The Growing Fetus

Fetal growth
Ovum – ovulation to fertilization
Zygote – Fertilization to implantation
Embryo – implantation to 5-8 weeks
Fetus – 5-8 weeks to until term
Conceptus Developing of the embryo

A. Fertilization
-Union of a matured egg and a sperm & the product is called a conceptus or zygote.
-Occurs at the distal 3rd of the fallopian tube – the ampulla

two changes that take place in the sperm as it reaches the ovum
1. Capacitation – removal of the protective coating (zona pellucida & corona radiata) of the sperm
2. Acrosome reaction = perforation of the head and release of enzymes (Hyaluronidase)

B. Implantation / Nidation:
- the blastocyst remains free floating in the uterine cavity for 3-5 days & implants in the endometrium 6-
7 days after fertilization.
- as it attaches itself to the wall of the uterus, its trophoblast (layer of blastocyst) cells release enzymes
allowing it to burrow deep into the endometrium resulting in rupture of vessels & bleeding at the
implantation site. “Implantation bleeding”.

STAGES OF FETAL DEVELOPMENT

Ovum
• It is the female sex cell or gamete.
• Following ovulation, as the ovum is extruded from the graafian follicle, it is surrounded by a ring
of fluid “zona pellucida”, & a circle of cells called “Corona radiata”
Sperm cell
• Can live for 48-72 hours
• Reproductive cells, during gametogenesis divide by meiosis (haploid number of daughter cells)
• Only males have Y chromosome
• Androsperm – x carrying sperm
• Gynosperm – y carrying sperm
Zygote
• Is the first cell formed
• Contains 46 chromosomes: 44 autosomes
• Journeys from the fallopian tube to the uterus for 3-5 day
• Blastomere - 16 hours after fertilization, it undergoes its first cell division.
• Morula - 16 or more blastomeres
• Blastocyst – when it reaches the Uterus
• Blastocyst compost of
• Blastocele (embryonic disc)
 • Trophoblast (outer layer) – nutrients for embryo
• inner cell
• Trophoblasts - secretes a hormone called “human chorionic gonadotropin” (HGC) necessary in
prolonging the life of the corpus luteum (yellow body=progesterone)
• Blastocele has 3 germ layers
• Ectoderm – Outer layer (skin, nail, nose, mucus, nervous sys)
• Mesoderm - Middle layer (Connective tissue)
• Endoderm – Inner layer (Organs)

EMBRYONIC AND FETAL STRUCTURES

>Decidua
• after implantation, the endometrium(uterus) is now referred to as the decidua.
• Decidua layers:
1. Decidua basalis –layer where implantation takes place. It will later on form the maternal side of
the placenta.
2. Decidua capsularis – layer which encloses, envelopes the blastocyst & becomes the bag of
water.
3. Decidua vera – no function ** decidua parietalis – located under the decidua basalis.
• Decidua membranes:
1. Chorion – outer fetal membrane maternal side of placenta.
2. Amnion – smooth & translucent membrane directly enclosing the fetus & the amniotic
fluid. (Amniocentesis – get AF test for fetal infection)

>Chorionic villi
• As early as 12 days after fertilization, tiny projections around the zygote, called villi, can be seen.
• They receive rich blood supply. It will later on form the fetal side of the placenta.
• Chronic villi: Trophoblasts two distinct layers:
1. Cytotrophoblast or Langhan’s layer: - inner layer that protects the fetus against syphilis until the
2nd trimester.
2. Syncytiotrophoblast or syncytial layer: - outer layer that produces hormones HCG, HPL. Estrogen
& progesterone.

AMNIOTIC FLUID: FORMED BY THE SECRETION OF: (normal is 500-1000ml)

• Amniotic cells
• Fetal lung, skin and urine
• should be clear, colorless to straw colored with tiny specks of vernix caseosa (covering of baby)
• Hydramnios – too much amniotic fluid. More than 2000ml
• Oligohydramnios – less than 300ml
• Amniotomy – paputukin yung panubigan
 • Abnormal amniotic colors:
1. Green tinges or meconium stained – signifies fetal distress
2. Gold or yellow – signifies hemolytic disease such as rh or abo incompatibility
3. Gray – indicates infection
4. Pink – signifies bleeding

>Placenta
• Has 20 cotyledons
• Formed from the chorionic villi and decidua basalis.
• Functional at the end of the 2nd month & it reaches maturity at 12 weeks gestation
• Continue to function until the 40 to 41st week.
• Degenerate after the 42nd week making it dangerous
• 2 sides of placenta:
1. Maternal side which is irregular and is divided into subdivisions called cotyledons
2. Fetal side covered by amnion, so it is smooth and shiny
1. Functions of the placenta
1. Respiratory system = exchange of gases
2. Renal system = waste products
3. Gastrointestinal system = nutrients
4. Circulatory system = fetus placental circulation
5. Protective barrier = provides IGG that gives fetus passive immunity
6. Endocrine system = produces hormones HCG, HPL, estrogen, progesterone, relaxin
2. Estrogen - stimulates development of uterine and breast tissues in the mother -
increases vascularity and vasodilation in the villous capillaries
3. Progesterone - after 11 weeks of pregnancy, placenta takes over the production of
progesterone from the corpus luteum

4. UMBILICAL CORD / FUNIS

5. 50-55 cm long
6. 2 arteries & 1 vein. 2 arteries carry deoxygenated blood from the fetus to the placenta
7. Carry 02 and nutrients
8. Wharton’s jelly – gelatinous substance covers the umbilical cord to prevent kinking &
trauma to the cord.

9. Cord insertion:
a. Central insertion – normally, cord is inserted at the center of the fetal surface of
the placenta.
b. Lateral insertion – cord is inserted away from the center of the placenta but not
at its edges.
c. Velamentous insertion – cord is inserted in the membranes about 5 to 10 cm
away from the edge of the placenta.
d. Battledore insertion – cord is inserted at the edge of the placenta
STAGES OF FETAL GROWTH AND DEVELOPMENT
A. Pre-embryonic = first 2 weeks beginning with fertilization
B. Embryonic = weeks 3-8, considered the most critical in fetal stage because of organogenesis.
C. Fetal = weeks 8 to birth
1st Trimester – 12 weeks
2nd Trimester – 13-27 weeks
3rd Trimester - 28-40 weeks

NORMAL FETAL DEVELOPMENT

First trimester
• (4 weeks)
1. Form of embryonic disc
2. Spinal cord is formed; rudiment
3. Anterior surface, arms & legs
• (8 weeks)
1. Organogenesis is complete
2. Heart beats rhythmically
3. Facial features
4. External genitalia present but not distinguishable
5. Sonogram shows
6. Gestational sac (diagnostic of pregnancy)
• (12 weeks)
1. Bone ossification begins
2. Sex distinguishable by outward appearance
3. Heartbeat audible by a doppler

Second trimester
• (16 weeks)
1. Fetal heart sounds audible via fetoscope
2. Lanugo is well formed, liver & pancreas functioning
3. Swallowing reflex,
4. Sex can be determined by ultrasound
5. Quickening felt by a multigravida
• (20 WEEKS)
1. Quickening felt by a primagravida
2. Antibody production is possible
3. Hair forms
4. Meconium present in upper intestine
5. Brown fat
6. Fetal heart audible via stethoscope
7. Vernix caseosa begins to form
• (24 weeks)
1. Passive antibody transfer
2. Active production of lung surfactant begins
 3. Eyelids now open
4. Pupils reactive to light
5. Hears in response to sudden sound.

Third Trimester
• (28 weeks)
1. Lung alveoli begins to mature
2. Surfactant present in amniotic fluid
3. Blood vessels of the retina extremely susceptible to damage from high o2 concentrations
• (32 weeks)
1. Subcutaneous fat begins to be deposited (the former “stringy” old man appearance is lost)
2. Fetus is aware of sounds outside the mother’s body
3. Active moro reflex present
4. Birth position (vertex or breech) may be assumed
5. Iron stores
• (36 weeks)
1. Additional amounts of subcataneous fats are deposited
2. Lanugo begins to diminish
3. most babies turn into a vertex or head-down presentation during this month
• (40 weeks)
1. Fetus kicks actively causing discomfort to the mother
2. vernix caseosa is fully formed
3. in primiparas, the fetus lightening in last two weeks

ASSESSMENT OF FETAL GROWTH

Estimating fetal growth

• McDonald’s Rule – determining during mid- pregnancy, that the fetus is growing in utero by
measuring the fundal (uterine) height
12 - symphysis pubis 28
16 – between 32 – midway navel and xiphoid
20-22- umbilicus 36 - xiphoid process
24 – 2 fingers above umbilicus 40 – 2 finger below umbilicus

Fetal movement (Quickening)

• Begins at approximately 18 – 20 weeks of pregnancy; peaks at 28-38 weeks
• Primigravid- quickening:20 weeks
• Multigravida- 16 weeks
• A healthy fetus moves at least 10x a day.
• Sandovsky method - mother is in a left lateral recumbent position; fetus normally moves a minimum
of twice every 10 minutes or an average of 10 - 12x an hour
• Cardiff method – Count to ten - records the time it takes for her to feel 10 fetal movements; usually
within 60 minutes
Fetal heart rate
• FHR should be 120-160 beats per minute
• Can be heard with a Doppler: 10 – 12th week of pregnancy
• Fetoscope: 16-20 week

Ultrasound
• Transabdominal UTZ
• full bladder
• client lies on her back
• Transvaginal UTZ
• probe is inserted in the vagina
• lithotomy position
• empty bladder

Nonstress Test
• Measures the response of fetal heart rate to fetal movement
• Tocodynamometer - measure the contraction, tracing for 20 minutes
• Reactive nonstress test normal/negative (2, f heartrate, 15 bpm for 15 sec)
• Nonreactive nonstress test: abnormal
• Unsatisfactory

Contraction Stress Test

• Assesses placental oxygenation and function
• The uterus is stimulated to contract by a dose of oxytocin or nipple stimulation
• NEGATIVE CST/ NORMAL – 3 contraction in 40 seconds for 10 min
• POSITIVE CST/ ABNORMAL - late or variable decelerations of FHR with 50% or more of the
contractions in the absence of hyperstimulation of the uterus.
• EQUIVOCAL – with decelerations but with less than 50% of the contractions
• UNSATISFACTORY

Chorionic villus sampling (CVS)

• transcervical aspiration of chorionic vill for diagnosing of genetic disorders comparable to
amniocentesis
Estriol levels
• urine samples
Percutaneous umbilical blood sampling (PUBS)
• aspirate cord blood (location identified by ultrasound) to test for genetic conditions,
chromosomal abnormalities, fetal infections, hemolytic or hematological disorders
Lecithin/ Sphingomyelin ratio (2:1)
• lowers surface tension of the lungs that facilitates extrauterine expiration
Biophysical profile (BPS)
• Assesses 4 to 6 parameters
• BPS 8 – 10: fetus is doing well
 • BPS 4 – 6: fetus is in jeopardy

Special Structures:
Foramen Ovale
▪Connects the left and right atrium
▪Bypassing fetal lungs
▪Obliterated after birth to become fossa ovalis
Umbilical Vein
▪Brings oxygenated blood coming from the placenta to the fetus
▪Becomes ligamentum teres
Umbilical arteries
▪Carry unoxygenated blood from the fetus to placenta
▪Become umbilical ligaments after birth
Ductus venosus
▪Carry oxygenated blood from umbilical vein to IVC
▪Bypassing fetal liver
▪Becomes ligamentum venosum after birth
Ductus arteriosus
▪Carry oxygenated blood from pulmonary artery to aorta
▪Bypassing fetal lungs
▪Becomes ligamentum arteriosum; closes after birth
1. Nulligravida – a woman who has never been pregnant
2. Primigravida – a woman who is pregnant for the first time
3. Multigravida – a woman who has two or more pregnancy
4. Para – number of past pregnancies
5. Nullipara – a woman who has never delivered a fetus that reached the age of viability
6. Primipara – a woman who has completed one pregnancy to viability
7. Multipara – a woman who has completed two or more pregnancy to the age of viability
8. Term infant – an infant born between 38 and 42 weeks of gestation
9. Preterm – an infant born before 38 weeks
10. Post term – an infant born after 42 weeks
11. Live birth – a live birth is recorded when an infant born shows sign of life
12. Parturient – a woman in labor
13. Puerpera – a woman who just delivered (within six weeks after delivery)
14. Low birth weight – < 2500 grams
15. Normal Birth weight – 2500 – 4000 grams
16. Large birth weight - > 4000 grams

SIGNS OF LABOR
1.Uterine contractions – the surest sign that labor has begun is the initiation of effective productive
uterine contractions.
2. If rupture of membranes (rom) is suspected, confirmation can be done by testing the vaginal discharge
with a nitrazine paper. Yellow = acidic. Blue= Alkaline.
3. Show – this is due to pressure of the descending presenting part of the fetus which causes rupture of
minute capillaries in the mucus membrane of the cervix. Blood mixes with mucus when operculum
(mucus plug) is released.

DIFFERENCES BETWEEN TRUE LABOR & FALSE LABOR:

False labor
1.contractions remain irregular
2. Generally confined to the abdomen
3. No increase duration, intensity & frequency 3. Increase duration, intensity & frequency
4. Often disappears if the woman ambulates
(walk)
5. Absent cervical changes
6. No blood show
True labor
1. May be slightly irregular at first but become
regular in a matter of hrs.
2. First felt in the lower back & sweep around to
the abdomen in a girdle like fashion.
4. Continue no matter what level of activity
5. Accompanied by cervical effacement &
dilatation (most important difference
6. Blood show
7.progressive fetal descent

Theories of labor
1. oxytocin stimulation theory
- stimulates the uterine contraction
- oxytocin= contractions and milk ejection
2. uterine strech theory
- hollow muscular organ when strech will contract and empty
3. progesterone deprivation theory
-not enough progesterone (maintains pregnancy)
4. theopry of againg placenta
- BPS biophysical scoring
- prostagalndin- pain and contraction
-prostaglandin can also come from semen

Stages of Labor
First stage- (STAGE OF DILATATION)
➢Latent phase (3cm, short contraction for 20-40 sec, 15-20 intervals)
➢Active phase (4-7cm, moderate, 40-60 sec, 3-5 min) 3Hrs in primipara & 2Hrs in multipara. Give
anesthesia
➢Transition phase (8-10cm, strong, 60-90 sec, 2-3 min)
Second stage (STAGE OF EXPULSION) effaced - (thinning of cervix)
➢Period from full dilatation and cervical effacement to birth of the infant
Third stage (STAGE OF PLACENTAL EXPULSION)
➢Placental separation
➢Placental expulsion
Fourth Stage (STAGE OF PUERPERIUM / STAGE OF VIGILANCE) 3-6 hours for delivery
➢ Stage of recovery
LENGTH OF LABOR
STAGE. PRIMIS MULTIS
1 ST STAGE 10-12 HRS 6-8 HRS
2 ND STAGE 2 HRS 50 MIN AVE. 20 TO 90 MIN AVE.
3 RD STAGE 5 TO 20 MIN 5 TO 20 MIN
4 TH STAGE 2 TO 4 HRS 2 TO 4 HRS

Electronic fetal monitoring:

1.external or indirect monitoring
1. Applied when membranes are still intact such as tocodynamometer and uterine transducer.
2. Internal or direct monitoring
1. Applied when membranes have ruptured & cervix has dilated 2-3 cm.

TYPES OF ANESTHESIA
A. Paracervical – transvaginal injection into either side of the cervix. Patient on lithotomy position.
Coupled with a local anesthetic, results in a painless childbirth
B. Pudendal – injection through the sacrospinous ligament into posterior areolar tissues to reduce
perception of pain during second stage & make mother comfortable. Patient is on lithotomy position.
Side effect:
ecchymosis = purplish discoloration of the skin due to blood in the subcutaneous tissues
C. Epidural – injection of local anesthetic at the lumbar level outside the dura mater. Can’t feel from
below abdomen. No pillows for 8-12hrs to avoid headache

REASONS FOR ADMINISTRATION OF ENEMA:

A. To prevent infection to both the mother & the fetus.
B. It helps to increase uterine contractions.
C. Prevents postpartum discomfort
D. To facilitate the descent of the fetus to the birth canal

CONTRAINDICATIONS OF ENEMA:
A. Malpresentation & position
B. Vaginal bleeding
C. Ruptured bag of waters
D. Crowning
E. Placenta previa

CARDINAL MOVEMENTS/ MECHANISM OF LABOR / FETAL POSITION CHANGES:

1. Descent
- downward movement
2. Flexion
- fetal head to bend forward onto the chest.
3. Internal rotation
– occiput rotates until it is superior, or just below the symphysis pubis
4. Extension
- as the head comes out, the back of the neck stops at the pubic arch & acts as a pivot for the rest of the
head. The head extends & the forehead, nose, mouth & finally the chin appear.
5. External rotation =( restitution)
- as the head is born it rotates briefly from the position it occupied when it was engaged.
6.expulsion
- with the delivery of the shoulders, the rest of the baby is born

TYPES OF EPISIOTOMY = for clean incision

1. Median - from middle portion of the lower vaginal border directed towards the anus.
2. Mediolateral – begins in the midline but directed laterally away from the anus

RITGEN’S MANEUVER
• Cover the anus with sterile towel & exert upward & forward pressure on the fetal chin. While
exerting gentle pressure with two fingers on the head to control emerging head. This will not
only support the perineum thus preventing lacerations but will also favor flexion so that the
smallest suboccipitobregmatic diameter of the fetal head is presented.

FORCEP DELIVERY
• Obstetrical forceps are double bladed instruments designed to grasp the fetal head
• The use of forceps requires a fully dilated cervix (10 cm)
TYPES:
1. Outlet forcep - used when the head is visible in the perineum. This is advocated for delivery of
preterm infants.
2. Mid forcep – used when the fetal head is above the ischial spines (rarely used)

SIGNS OF PLACENTAL SEPARATION

1. Calkin’s sign – uterus becoming round & firm & globular again, rising high to the level of the umbilicus.
(earliest sign of placental separation)
2. Sudden gush of blood from the vagina
3. Lengthening of the cord from the vagina

TYPES OF PLACENTAL SEPARATION:

1. Schultz – if the placenta separates first at its center & last at its edges, it tends to fold on itself like an
umbrella & presents the fetal surface which is shiny. 80% of placentas separate this way. “shiny for
schultz”
2. Duncan – if the placenta separates first at its edges, it slides along the uterine surface & presents at
the vagina with the maternal surface which is raw, red, & irregular with the ridges or cotyledons that
separate blood collection spaces showing. Only about 20% of placentas separate this way. “dirty for
duncan”

BRANDT ANDREW’S MANEUVER

• Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out,
rotating it slowly so that no membranes are left inside the uterus
OXYTOXICS are not given before placental delivery because placental entrapment could occur. Do not
give METHERGIN if bp is 130/100 or above.

CATEGORIES OF LACERATIONS(tahi)
1.First degree – involves the vaginal mucus membranes & skin of the perineum & the fourchette.
2. Second degree – involves not only the vaginal mucus membranes & skin but also the muscles.
3. Third degree – involves not only the rectal sphincter of the rectum, muscles, vaginal mucus
membranes & skin but also the mucus membranes of the rectum

PUERPERIUM / POSTPARTUM
• refers to the six-to-eight-week period after the delivery of the baby.
INVOLUTION
• the return of the reproductive organs to their prepregnant state. (6 weeks

LOCHIA
• Uterine discharge consisting of blood, deciduas, wbc & mucus. Should be moderate in amount

PATTERN OF LOCHIA
1. Rubra = 0-3 days , dark red & moderate in amount, small clots, fleshy stale odor.
2. Serosa = 4 -7 days ; pink or brownish in color, no clots, no odor ( unless poor hygiene)
3. Alba = 1 – 3 weeks; cream to yellowish in color; minimal in amount; no odor; no clots

Maternal and Fetal Responses to Labor

Danger signs of labor – fetal Danger signs of labor – maternal
➢Heart rate ➢Blood pressure
➢Meconium staining ➢Abnormal pulse
➢Hyperactivity ➢Inadequate or prolonged contractions
➢Fetal acidosis ➢Pathologic retraction ring
➢Abnormal lower abdominal contour
➢Apprehension

LABOR AND DELIVERY

Labor = physical & mechanical process in which the baby, the placenta & fetal membranes are propelled
through the pelvis & are expelled from the birth canal.
Delivery = actual event of birth

5 p’s in labor & delivery

1. Passenger = the fetus
2. Passageway = the birth canal
3. Powers of labor= force of uterine contractions
4. Placental implantation
5. Psychological state or feelings that women bring to labor
A. CRANIAL BONES
1. Sphenoidal
2. Frontal
3. Ethmoidal
4. Temporal
5. Parietal
6. Occipital

B. MEMBRANE SPACES
• Suture lines are important because they allow the bones to move and overlap, a process called
molding.
1. Sagittal suture line = the membranous interspace which joins the 2 parietal bones.
2. Coronal suture line = the membranous interspace which joins the frontal bone and the
parietal bones.
3. Lambdoidal suture line

C. FONTANELLES MEMBRANE
• Covered spaces at the junction of the main suture lines:
1. Anterior fontanel = the larger, diamond shaped fontanel which closes between 12 to 18
months in an infant
2. Posterior fontanel = the smaller triangular shaped fontanel which closes between 2-3 months
in the infant. The space between the two fontanelles is referred to as the vertex.

D. MEASUREMENTS
• The shape of the fetal skull causes it to be wider in its anteroposterior (ap) diameter than in its
transverse diameter.

1. TRANSVERSE DIAMETER OF THE FETAL SKULL:

I. Biparietal = 9.25cm to 9.5
II. Bitemporal = 8 cm.
III. Bimastoid = 7 cm.
2. ANTEROPOSTERIOR DIAMETERS
I. SUBOCCIPITO-BREGMATIC = from below the occiput to the anterior fontanelle = 9.5 cm (the narrowest
ap diameter)
II. OCCIPITOFRONTAL = from the occipital prominence to the bridge of the nose = 12 cm.
III. OCCIPITOMENTAL = from the posterior fontanelle to the chin = 13.5 cm (the widest ap diameter)

STATION
• Refers to the relationship of the presenting part of the fetus to the level of the ischial spines.
• Station 0 = presenting part is at the level of the ischial spines (synonymous to engagement)
• Station -1 = presenting part is 1cm above the ischial spines
• Station +1 = presenting part is 1cm below the ischial spines
• Station +3 or +4 = the presenting part is at the perineum & can be seen if the vulva is separated;
synonymous to “crowning”.
FETAL LIE/ PRESENTATION
• Is the relationship between the long axis of the fetus to the long axis of the mother
Presenting part
• refers to the fetal part that first enters the maternal pelvis & cover the internal os.

2 kinds of lie
1. Longitudinal lie = long axis of the fetus is parallel to the long axis of the mother.
2. Transverse lie = long axis of the fetus is perpendicular to the long axis of the mother
• causes of transverse lie: 1. multiparity 2. Contracted pelvis 3. Placenta previa

TYPES OF FETAL PRESENTATION

• Vertical/ longitudinal lie:
1. Cephalic presentation (96%) -means that the head is the body part that first contacts the cervix.
Vertex/ occiput (most common)
• the head is fully flexed on the chest making the parietal bones or the space between the
fontanelles, the “vertex” the presenting part
Sinciput = moderate flexion (military position)
• Head is moderately flexed, the brow or sinciput becomes the presenting part.
Face
• the head is extended & the face is the presenting part.( from this position, extreme edema &
distortion of the face may occur.
Mentum (chin)
• head is hyperextended to present the chin. The widest diameter (occipitomental is presenting).
As a rule, the fetus cannot enter the pelvis in this presentation. The presenting diameter, the
occipitomental is so wide birth may be impossible.

2. Pelvic or breech presentation: 3% - means that either the buttocks or feet are the first body parts to
contact the cervix
Complete breech = (good full flexion)
• Fetus has thighs tightly flexed on the abdomen; both the buttocks & the knees tightly flexed feet
present to the cervix.
Frank breech = (moderate flexion)
• Hips are flexed but the knees are extended to rest on the chest. The buttocks alone present to
the cervix.
Footling (poor flexion)
• Foot present at the introitus. Neither the thighs nor lower legs are flexed.
• Single footling – one leg is extended at the hip & knee & the other leg presents in the introitus.
• Double footling – both legs are unflexed & both feet are the presenting part.

3. TRANSVERSE LIE/ HORIZONTAL LIE

• Presenting part is one of the shoulders (acromium process), heart shape sya sa loob
4 QUADRANTS OF THE MATERNAL PELVIS:
A. Right anterior
B. Left anterior
C. Right posterior
D. Left posterior
E. Transverse

4 PARTS OF THE FETUS CHOSEN AS LANDMARKS:

1.Occiput “o”- vertex presentation
2. Mentum “m” (chin) –face presentation
3. Sacrum “Sa”– in breech presentation
4. Scapula “Sc”– in shoulder presentation

THE PASSAGEWAY/ THE BIRTH CANAL

A.THE PELVIS
TYPES OF PELVIS
1. Gynecoid
• Normal female pelvis; the inlet is well rounded forward & backward; the pubic arch is wide; this
pelvis is ideal for childbirth
2. Android
• “Male pelvis”; the pubic arch in this pelvis type forms an acute angle making the lower
dimensions of the pelvis narrow. A fetus may have difficulty exiting from this type of pelvis. (least
favorable)
3. Anthropoid pelvis
• “Ape-like pelvis”; the transverse diameter is narrow & the ap diameter of the inlet is larger than
normal.
4. Platypelloid
• “Flattened pelvis” the inlet is an oval smoothly curved, but the ap diameter is shallow. A fetal
head might not able to rotate to match the curves of the pelvic cavity

DIVISIONS:
1. False pelvis
• “Superior half”; supports the uterus during the late months of pregnancy & aids in directing the
fetus into the true pelvis for birth.
2. True pelvis
• Inferior half”; formed by the pubes in front, the ilia & the ischia on the sides & the sacrum &
coccyx behind.

LINEA TERMINALIS CONSIST OF:

A. Pelvic inlet
• Entrance to the true pelvis, or the upper ring of bone through which the fetus must first pass to
be born vaginally. Its transverse diameter is wider than its ap diameter. Thus: ** transverse
diameter = 13.5 cm ** ap diameter = 11 cm
B. MidPelvis/ pelvic cavity
• The space between the inlet & the outlet. This is not a straight but a curved passage.
C. Pelvic outlet
• The inferior portion of the pelvis. The most important diameter of the outlet is its transverse or
bi-ischial diameter (distance bet the two ischial tuberosities) which is about 11.5 cm > ap
diameter 9.5 to 11.5 cm
PHASES OF UTERINE CONTRACTIONS:
1.increment = when the intensity of the contractions increases
2. acme = when the contractions are at its strongest
3. Decrement = when the intensity decreases

PRENATAL CARE (ANTEPARTUM CARE) 3 PHASES

1. Pre-consultation = history taking, family, medical, OB history)
2. Consultation = physical assessment
3. Post consultation = health teachings

A. PRENATAL CARE: SCHEDULE OF PRENATAL VISIT:

A. Once every 4 weeks, up to 32 weeks
B. Every 2 weeks from 32 – 36 weeks (more frequently if problem exists)
C. Every week from 36 – 40 weeks

RULES
1.NAEGELE’S RULE
• Calculation of expected date of confinement (edc)
• - 3 +7 +1
2. MC DONALD’S RULE
• Estimation of aog in months & weeks by fundic height measurement
• Weeks and days
• 34 weeks & 7 days (36w 7/7)
3. HAASE’S RULE
• ESTIMATION OF FETAL LENGTH
• FIRST HALF OF PREG, SQUARE THE NUMBER OF THE MONTH
• SECOND HALF OF PREG, MULTIPLY THE MONTH BY 5
• 8 months x 5 = 40 CMS length
4. JOHNSON’S RULE
• Estimation of weight in grams
• Fundic height in cm – N X K
• “K” is constant, it is always 155
• “N” is minus 11 if part is not yet engaged(22 below), minus 12 if part is already engaged(23-27)
• 21 – 11 = 10 X 155 = 1,550 GMS
5. BARTHOLOMEW’S RULE
• Estimation of AOG by the relative position of the uterus in the abdominal cavity.
• By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis
• On the 5th lunar month, the fundus is at the level of the umbilicus
• On the 9th lunar month, the fundus is below the level of the xiphoid process
Maternal Diet and Infant Health
Components of healthy nutrition
• Fluid needs
• Fiber needs
• Foods to avoid
1. Alcohol
2. Caffeine
3. Artificial sweeteners
4. Weight loss diets

Nutritional status
1. Weight gain should be within expected parameters
2. increased nutrient requirements
a. Calories – 300 kcal/d; may need adjustment for prepregnant under/overweight

b. There should be no attempt at weight reduction during pregnancy

c. Carbohydrates – needed to prevent unsuitable use of fats/proteins for added energy needs; important
to avoid “empty” calorie sources

d. Proteins to 60 g/d; additional increase for adolescent/multiple pregnancies; efficient use of requires
complete protein (contains all essential amino acids; animal sources) or complemented with other
protein sources, e.g., legumes, grains, nuts

e. Iron – to a total of 30 mg/d of elemental iron; usually requires supplement

f. Calcium to 1,200/d; best obtained from dairy products; if milk is disliked or poorly tolerated, calcium
supplement may be necessary

g. Sodium – should not be restricted without serious indication; excess should be discouraged

3. 24-h recall/diet diaries may be used to evaluate high-risk woman

POST-CONSULTATION PHASE = HEALTH TEACHINGS

NUTRITION = MOST IMPORTANT ASPECT
FOOD SOURCES:
• Protein rich foods = meat, fish, eggs, milk, poultry, cheese, beans, mongo
• Vit. A = eggs, carrots, squash, cheese, beans, vegetables
• Vit. D = fish, liver, eggs, milk
• Vitamin e = green leafy vegetables, fish
• Vitamin c= tomatoes, guava, papaya
• Vitamin b= protein rich foods
• Calcium/phosphorus=milk, cheese
• Iron= especially important during the last trimester. Iron has a very low absorption rate: only
10% of the iron intake can be absorbed by the body. Thus, for the optimum absorption, give
vitamin c. Sources: liver and other internal organs, camote tops, kangkong, egg yolk, ampalaya.
• Malnutrition during pregnancy can result in prematurity, preeclampsia, abortion, low birth
weight babies, congenital defects or even still births.
• Smoking= causes vasoconstriction, leading to low-birth-weight babies and therefore is
contraindicated during pregnancy.
• Folic acid – to prevent neural tube defects (spina bifida, meningocoele) sources:
• Green leafy vegetable