NCM 107 – Care of Mother, Child and Adolescent d. Indigestion.
SIGNS OF PREGNANCY
Presumptive Signs and Symptoms of Pregnancy
1. Amenorrhea (Cessation or menstruation).
2. Nausea and Vomiting (Morning sickness).
3. Frequent urination
4. Breast changes
5. Vaginal changes :
a. Chadwick’s sign
b. Leukorrhea
6. Quickening (Feeling of life).
7. Skin changes : Stretch marks, Linea
nigra, Chloasma
8. Fatigue
9. Positive home test
Amenorrhea (Cessation or menstruation)
1. Amenorrhea is once of the earliest clues of
pregnancy.
2. 2. Other causes for amenorrhea must be ruled
out, such as:
• (a) Menopause
• (b) Stress (severe emotional shock, tension,
fear, or a strong sign of pregnancy).
• (c) Chronic illness (tuberculosis, endocrine
disorders, or central nervous system
Abnormality).
• (d) Anemia
• (e) Excessive exercises.
Nausea and Vomiting (Morning sickness)
1. Usually occurs in early morning during the first week
of pregnancy.
2. Usually spontaneous and subsides in 6 to 8 weeks or
by the twelfth or sixteenth week of pregnancy.
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 upset fluid
and electrolyte balance of the patient
Nausea and vomiting are unreliable signs of pregnancy
since they may result from
other conditions such as:
a. Gastromtestinal disorders (hiatal hernias, ulcers, and
appendicitis).
b. Infection (influenza and encephalitis).
c. Emotional stress, upset (anxiety and anorexia
nervosa).
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 week of pregnancy
as the head of the fetus presses against the bladder.
4. Frequent urination is not a definite sign since other
factor can be apparent (such as tension, diabetes, urinary
track infections, or tumors).
Breast changes
• Darkening of the areola- the brown part of the
nipple.
• Enlargement of Montgomery glands- the tiny
nodules or sebaceous glands within the areola.
• Increased firmness or tenderness of the breast.
• More prominent and visible veins due to
increased blood supply.
• Presence of colostrums (thin yellowish fluid that
is the precursor of the breast milk). This can be
expressed during the first trimester and may
ever leak out in the latter part of the pregnancy.
Vaginal changes
1.Chadwick’s sign. The vaginal walls have taken on a
deeper color caused by the increased vascularity
because of the increased hormones. It is noted at the
sixth week when associated with pregnancy. It may also
be noted with a rapidly growing uterine tumor or any
cause of pelvic congestion.
2. Leukorrhea. This is an increase in the white or slightly
gray mucous discharge that has a faint musty odor. It is
due to hyperplasia of vaginal epithelial cells or the cervix
because of increased hormone level from the pregnancy.
Leukorrhea is also present in vaginal infection
Quickening (Feeling of life)
1. This is the first perception of fetal movement within
the uterus. It usually occurs toward the end of the fifth
month because of the spasmodic flutter.
(a) A multigravida can feel quickening as early as
sixteen weeks.
(b) A primigravida usually cannot feel quickening until
after 18 weeks.
2. Once quickening has been establish, 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.
Skin changes
• Striae gravidarum (stretch marks). These are
marks noted on the abdomen and/or buttocks.
• (a) These marks are caused by increased
production or sensitivity to adrenocortical
hormones during pregnancy not just weight
gain.
• (b) These marks maybe seen on patients with
Cushing’s disease or a patient with sudden
weight gain.
LINEA NIGRA
• (a) This is a black line in the midline of the
abdomen that may run from the sternum or
umbilicus to the symphysis pubis.
• (b) This appears on the primigravida by the third
month and keeps pace with the raising height of
the fundus.
• (c) The entire line may appear on the
multigravida before the third month.
• (d) These may be a probable sign if the patient
is never been pregnant.
CLOASMA
This is called mask of pregnancy is bronze type of facial
coloration seen more on dark haired women it is seen
after 16th weeks of pregnancy.
Finger nail
Some patient note mark thinning softening by the sixth
week.
Fatigue
This is a common complaint by most patients during the
first trimester. Fatigue may also be a result of anemia,
infection, emotional stress, or malignant disease.
Positive home test
This test may note always be accurate however they are
very effective today if they are performed properly.
Probable Signs and Symptoms of Pregnancy
• Probable signs and symptoms of pregnancy are
those signs commonly noted by the physician
upon examination of the patient.
• These are symptoms that, most of the time, do
indicate pregnancy -- but, in certain cases, might
be false or caused by another condition.
Uterine changes
• Position. By the twelfth week, the uterus arises
above the symphisis pubis and it should reach
the xiphoid process by the 36th week of
pregnancy. These guidelines are fairly accurate
only as long as pregnancy is normal and there are
no twins, tumors, or excessive2. Amniotic fluid.
• Size. The urine increases in width and length
approximately five times its normal size. Its
weight increases from 50 grams to 1000 grams.
• Hegar’s sign. This is softening of the lower
uterine segment just above the cervix. When the
uterine is compressed between examining
fingers, the wall feels tissue paper thin. The
Hegar’s sign is noted by the six to eighth weeks
of pregnancy.
• Ballottement. This is demonstrated during the
bimanual exam during the 16th to 20th week.
Ballottement is when the lower uterine segment
or the cervix is tapped by the examiner’s finger
and left there, the fetus floats upward, then sinks
back and a gentle tap is felt on the finger.
Abdominal changes
These correspond to changes that occur in the uterus, as
the uterus grows the abdomen gets larger
Cervical changes
1. Goodell’s sign. The cervix is normally firm like the
cartilage at the end of the nose. The Goodle’s sign is
when there is marked softening of the cervix. This is
present at the 6 weeks of pregnancy.
2. Formation of the mucous plug. This is due to
hyperplasia of the cervical glands as a rest of increased
hormones. It serves to seal the cervix of the pregnant
uterus and to protect it from contamination by bacteria
in the vagina. The mucous is expelled at the end of
pregnancy near or at the onset of the labor.
3. Braxton-Hick’s sign. This includes painless uterine
contractions occurring throughout pregnancy. It usually
brings about the 12th week of pregnancy and becomes
progressive stronger.
Basal body temperature
This is a good indication if the patient has been recording
for several cycles previously. A persistent temperature
elevation spanning over 3 weeks.
Palpation of fetal movement
This is done by a trained examiner. It is easily elicited
after 24 weeks of pregnancy
X-ray
An X-ray will identify the entire fetal skeleton by the 12th
week. In utero, the fetus receives total body radiation
that may lead to generic or gonadal alterations. An x-ray
is not a recommended test for identifying pregnancy.

Positive pregnancy test by the physician Diagnostic Tests

This may be increased by doing it too early or too late. Blood. Radioimmunoassays (RIA) can detect HCG in the
Even if the test is positive, it could be a result of ectopic blood 2 days after implantation or 5 days before the first
pregnancy or a hydatidiform mole (an abnormal growth menstrual period is missed.
of a fertilized ovum).

Fetal palpation
This is a probable sign in early pregnancy. The physician
can palpate the abdomen and may be palpated and
mistakenly identified as an infant.

Positive Signs of Pregnancy

• Positive signs of pregnancy are those signs that
are definitely confirmed as a pregnancy.
• Are those which cannot be mistaken for any
other condition -- they are considered absolute
evidence that you are, in fact, pregnant. They
rely on the senses: sound, sight and touch, as
interpreted by your caregiver

Fetal heart sounds

• The fetal heart begins beating by 24th day
following conception. It is audile with a Doppler
by 10 weeks of pregnancy and with a fetoscope
after the 16th week. It is not to be confused with
uterine soufflé or swishlike tone from pulsating
uterine arteries. The normal fetal heart rate is
120 to 160 beats.

Ultrasound scanning of the fetus

The gestation sac can be used and photographed. An
embryo as early as 4th week after conception can be
identified. The fetal parts begin to appear by the 10th
week of gestation

Palpation of the entire fetus

Palpation must include the fetus head, back, and upper
and lower body parts. This is positive sign after the 24th
week of pregnancy if the woman is not obese
MATERNAL CHANGES DURING PREGNANCY
Psychological Changes
Psychological tasks
➢ Emotional responses
➢ Ambivalence
➢ Grief
➢ Narcissism
➢ Introversion vs extroversion
➢ Body image and boundary
➢ Stress
➢ Couvade syndrome
➢ Emotional lability
➢ Changes in sexual desire
➢ Changes in the expectant family
Physiologic Changes (Local and Systemic)
that occurs during pregnancy
Uterus
Changes in the uterus are phenomenal. By the rime the
pregnancy has reached term, the uterus will have
increased five times its normal size:
• In length from 6.5 to 32cm.
• In depth from 2.5 to 22cm.
• In width from 4 to 24cm.
• In weight from 50 to 1000grams.
• In thickness of the walls from 1 to 0.5cm.
The capacity of the uterus must expand to normally
accommodate a seven (7) pound fetus and the placenta,
the umbilical cord, 500ml to 1000ml of amniotic fluids,
and the fetal membranes.
The abdominal contents are displaced to the sides as the
uterus grows in size, which allows for ample space for the
uterus within the abdominal cavity.
• Growth of the uterus occurs at a steady,
predictable space.
• Measurement of the fundal height.
• Growth that occurs too fast or too slow
could be an indication of problems.
• The size of the uterus usually reaches its
peak at 38 weeks gestation.
Cervix
• The cervix undergoes a marked softening which
is referred to as the Goodell’s sign.
• A mucus plug, which is known as “operculum” is
performed in the cervical canal.
• Additional changes and softening of the cervix
occur prior to the beginning of labor.
Vagina
Increased circulation to the vaginal early in pregnancy
changes the color from normal light pink to a purple hue
is known as the “Chadwick’s Sign”.
Ovaries
The follicle-stimulating hormone (FSH) increases its
activity due to the increased levels of estrogen and
secreted by the ovaries and corpus luteum. The FSH
prevents ovulation and menstruation.
The corpus luteum enlarges during early pregnancy and
may even form a cyst on the ovary. The corpus luteum
produces progesterone to help maintain the lining of the
endometrium in early pregnancy.
Changes of the Circulatory System during Pregancy
Blood volume
Blood volume increases gradually by 30 to 50 percent
(1500ml to 3units). This results in decrease
concentration of red blood cells and hemoglobin.
By the time pregnancy reaches term, the body has
usually compensated for the decrease resulting in an
essentially normal blood count.
Blood count is interpreted as anemia by the physician if
the hemoglobin falls below 10.5grams per100ml and the
hematocrit drops below 30 percent.
Increased blood volume compensates for hypertrophied
vascular system of enlarged uterus. It improves the
placental performance. Blood lost during delivery, less
than 500cc is normal (300 to 400cc is average)
Cardiac output
• Cardiac output increases about 30 percent
during the first and second trimester to
accommodate for hypervolemia.
• Change in output is reflected in the heart rate. It
usually increases by 10 beats per minute.
• Nursing implication. Patients with a diseased
heart need to be advised to get plenty of rest and
to report any shortness of breath or unusual
symptoms of their physician.
Blood pressure
• Normally, the patient’s blood pressure will not
arise.
• Nursing implications:
• The patient’s blood pressure should be checked
carefully and often since a significant increase is
one of the indicators of toxemia of pregnancy.
• When monitoring the blood pressure, be sure it
is done under the same circumstances (that is,
patient sitting and left arm).
Venous return
• The lower extremities are often hampered in the
last months of pregnancy due to the expanding
uterus restricting physical movement and
interfering with the return of blood flow. This
result in swelling of the feet and legs.
Nursing Implications:
• Advise the patient to rest frequently. This will
improve venous return and decrease edema.
• Have the patient to elevate her feet and legs
while sitting.
• Remind the patient not to lie in a supine position
since this inhibits return blood flood flow as the
heavy uterus presses on the vessels. This leads to
the vena cava syndrome or supine hypotension.
The patient may complain of feeling dizzy,
nauseated, or weak.
Changes of the Respiratory System during Pregnancy
• The respiratory rate rises to 18 to 20 to
compensate for increased maternal oxygen
consumption, which is needed for demands of
the uterus, the placenta, and the fetus.
• Women may feel out of breath and may need to
sit a moment to catch their breath.
Changes of the Breasts
• In the early pregnancy, the breast may feel full
or tingle, and increase in size as pregnancy
progresses. The areola of the nipples darkens
and the diameter increases. The Montgomery‘s
glands (the subcutaneous glands of the areola)
enlarge and tend to protrude. The surface
vessels of the breast may become visible due to
increased circulation and turns to a bluish tint to
the breasts.
• By the 16th week 92nd trimester) the breasts
begin to produce colostrums. This is the
precursor of breast milk. It is a thin, watery,
yellowish secretion that thickens as pregnancy
progresses. It is extremely high in protein.
• Nursing implication: Inform the pregnant patient
to wear a good, supporting bra
Changes of the Body Temperature during Pregnancy
A slightly increase in body temperature in early
pregnancy is noted
Changes of the Urinary System during Pregnancy
• There is an increase in urinary output and a
decrease in specific gravity.
• The patient may develop urine stasis and
pyelonephritis in the right kidney. This is done to
pressure on the right ureter resulting from
displacement of the uterus slightly to the right by
the sigmoid colon.
• Frequent urination.
Changes of the Skeletal System during Pregnancy
• The patient walks with head and shoulders
thrust backward and chest protruding outward
to compensate. This gives the patients a
“wadding” gait.
• There is a slight relaxation and increased
mobility of the pelvic joints, which allows
stretching at the time of delivery of the infant.
There is a realignment of the spinal curvatures during
pregnancy to maintain balance. It is due to the increase
in size of the uterus and pressure on the abdominal wall
Changes of the Gastrointestinal System during
Pregnancy
• Displacement the stomach, intestines and other
adjacent organs.
• Peristalsis is slowed because of the production of
the hormone progesterone, which decreases
tone and mobility of smooth muscles.
• Slow emptying may increase nausea and
heartburn (pyrosis). Relaxation of the cardiac
sphincter may increases regurgitation and
chance of heartburn. Movement through the
large intestines is also due to an increase in
water consumption from this area. This
increases the chance for constipation.
Nursing Implications due to changes in GI system
• If the mother has difficulty with nausea and / or
heartburn, advise her to eat small frequent
meals
• The patient should eat a well – balanced diet
high in protein, iron and calcium for fetal growth;
high fiber and fluids to prevent constipation.
• The mother should not lie flat for 1 to 2 hours
after eating because this may cause heartburn
and / or regurgitation.
Changes of the Endocrine System during Pregnancy
This glands increases in size slightly. It meets the
increased requirements for calcium needed for fetal
growth.
Changes of the Endocrine System during Pregnancy
• Posterior Pituitary. Near the end of term, the
posterior pituitary will begin to secrete oxytocin
that was produced in the hypothalamus and
stored there. It will serve to initiate labor.
• Anterior Pituitary. At birth, the anterior pituitary
will begin to secrete prolactin. This stimulates
the productions of breast milk.
• Placenta. The placenta acts as a temporary
endocrine gland during pregnancy.
• It produces large amounts of estrogen and
progesterone by 10 to 12 weeks of pregnancy. It
serves to maintain the growth of the uterus,
helps to control uterine activity, and is
responsible for many of the maternal changes in
the body.
Changes in the Body Weight during Pregnancy
Normal weight gain is about 24 to 30 pounds during
pregnancy.
Weight gain in pregnancy
• There is a slight loss of pounds during early
pregnancy if the patient experiences much
nausea and vomiting.
• She then gains 2 to 4 pounds by the end of the
first trimester.
• A gain of a pound per week is expected during
the second and third trimesters.
• Monitoring of weight gain should be done in
conjunction with close monitoring of blood
pressure.
• A lack of significant weight gain may be an
indication of intrauterine growth retardation
(IUGR) of the infant.
• Patients with multiple fetuses will require a
higher caloric diet and expect a higher weight
gain that a patient with only one fetus.
• Adequate protein intake should be emphasized
to the patient for development of the healthy
fetus and proper diet reviewed at each prenatal
visit.
Prenatal Care
Personal Hygiene during Pregnancy
• Skin Care
• Hair Care
• Breast Care
• Dental Care
• Bowel Elmination
• Vaginal Douching
• Clothing
Skin Care
• The glands of the skin may be more active during
pregnancy and the patient may tend to perspire
more. Frequent baths or showers are
recommended.
• Baths can be therapeutic – relaxes tensed and
tired muscles, helps counter insomnia, and
makes the patient feel fresh and sweet smelling.
• Baths may pose a physical maneuverability
problem which increases the chance of falling
late in the pregnancy; showers are
recommended
Hair Care
• The hair tends to become oily more frequently
during pregnancy due to overactivity of oil
glands of the scalp and may require shampooing
more frequently.
Breast care
It is important to begin preparing the breast for
breastfeeding during the prenatal period.
• A well-fitting support bra should be worn at all
times. This will provide good support for the
enlarging breasts.
• Pads are worn inside the bra cups to absorb
possible colostrums leakage from the nipples.
• The breasts should be washed daily (without
soap) to remove dried colostrums and to prevent
irritation to the nipples.
Dental Care
• The patient maintains normal, daily dental care.
• Minor dental work, such as fillings and simple
extractions, may be done during pregnancy;
however, patient is advised to avoid anesthetics.
Bowel Elimination
– Patients who normally had no problems
with bowel elimination habits will
usually experience little or no change in
daily routine.
– Patients who have a tendency toward
constipation become noticeably more
irregular during pregnancy because of:
• Decreased physical exertion.
• Relaxation of bowel as a response to hormone.
• Pressure on the bowel from the gravid uterus.
Vaginal Douching
• Explain that normal vaginal secretions are
usually intensified during pregnancy due to
increased circulation and hormone.
• Vaginal douching should only be done with a
physician’s order for treatment of a specific
condition. There is potential for introduction of
infection and development of an air embolism.
• Vaginal douching should never be done after a
rupture or even suspected rupture of the
membrane.
Clothing
• The clothes should be lightweight, adjustable,
absorbent, and enhance the sense of well-being
of the patient.
Activity Modifications during Pregnancy
• Employment
• Travel
• Sexual Relations
• Alcohol Consumptions
• Smoking
• Exercise
Employment
• Whether she can or should continue to work
depends on the physical activity involved, the
industrial hazards, toxic environment (chemical
dust particles, gases, such as inhalation
anesthesia), medical or obstetrical complication
or employment regulations of the company.
Travel
• Lowered oxygen levels may cause fetal hypoxia
in high altitude regions.
• The patient should take frequent rest periods;
stop and walk around every two hours if
traveling by auto.
• Drink plenty of fluids to prevent dehydration.
These steps will help prevent fatigue, relieve
tension, and increase circulation.
• Wear seat belts at all times.
Sexual Relations
• There are no restrictions on sexual intercourse
during pregnancy except for these patients who
have a history of ruptured membranes, vaginal
spotting, or have been treated for preterm labor
during this pregnancy.
Alcohol Consumption
• Alcohol should be avoided during pregnancy to
prevent the possibility of fetal alcohol syndrome,
which includes growth retardation, mental
deficiency, and craniofacial or musculoskeletal
abnormalities.
Smoking
• Smoking, or frequent exposure to a smoke-filled
environment is harmful to the fetus. Smoking
causes vasoconstriction of the blood vessels to
include those of the placenta. It also decreases
oxygen and nutrients to the infant.
Exercise
• Moderate exercise is recommended. Activities
continued to a point of exhaustion or fatigue
compromises uterine profusion and
fetoplacental oxygenation.
Prenatal Exercises
• Prenatal exercises promote comfort and
maintain or increase muscle tone. Factors that
determine the type and amount of exercise
recommended depend on the individual need,
the patient’s general physical condition during
pregnancy, and the current stage of pregnancy.
• Specific prenatal exercise includes tailor sitting,
pelvic rocking, abdominal muscle contractions,
Kegel exercise, and squatting.
Tailor Sitting
This exercise stretches the perineal muscles and
strengthens the high muscles. The patient should:
• Sit flat on the floor with legs
outstretched; knees are gently pushed
to the door until the perineal muscle
begins to stretch.
• Holds this position for increased
amounts of time each time performed.
Pelvic Rocking
This exercise stretches the back muscles and helps to
alleviate backache. The patent should:
• Get on all fours by hallowing the back and then
arching it upward to firm a mound. This may also
be done by lying on her back or standing up.
• Thrust back outward with buttocks tucked
under. Hold for at least 3 seconds and release.
Repeat 5 times.
Abdominal Muscle Contractions
This exercise strengthens the abdominal muscles, which
assist in effective pushing during the second stage of
labor, and helps regain abdominal shape following
delivery. The patient should:
• Contract and relax the muscles of the abdomen.
• Repeat as often as desired and gradually
increase the time held
Squatting
The exercise stretches the perineal muscles. The patient
must squat and keep her feet flat on the floor. Do these
minutes per day.
Kegel exercise-pelvic floor contractions
• This exercise strengthens the muscles of the
perineal floor.
• The patient should alternate between
tightening and relaxing the perineal muscles.
• This can be done at any time and should be
repeated 75 to 100 times per day.
KEGEL’S EXERCISES
• EXERCISE NUMBER 1 : to be done 3x a day
• SQUEEZE THE MUSCLES SURROUNDING
VAGINA AS IF STOPPING THE FLOW OF
URINE. HOLD FOR THREE SECONDS.
RELAX. REPEAT THIS SEQUENCE 10
TIMES.
 • EXERCISE NUMBER 2 : to be done 3x a day
• CONTRACT AND RELAX THE MUSCLES
SURROUNDING THE VAGINA AS RAPIDLY
AS POSSIBLE 10 TO 25 TIMES.
• EXERCISE NUMBER 3 : to be done 3x a day
• IMAGINE THAT YOU ARE SIITING IN A
BATHTUB OF WATER AND SQUEEZE
MUSCLES AS IF SUCKING WATER INTO
VAGINA. HOLD FOR 3 SECONDS. RELAX.
REPEAT THIS ACTION 10 TIMES
BENEFITS OF KEGEL’S EXERCISES
a. Helps strengthen urinary control.
b. Directly strengthen’s perineal muscles for birth.
c. Decreases the possibility of stress incontinence.
d. Increased sexual enjoyment because of tightened
vaginal muscles.
*** It may take as long as 6 weeks of exercise before
pubococcygeal muscles ate strengthened.
Discomforts related to the Gastrointestinal System
Nausea and Vomiting (Morning Sickness)
One of the most common discomforts of early pregnancy
Possibly due to high levels of humanchrionic
gonadotropin (HCG) or progesterone, cultural
expectations, emotional factors, and maternal body
function, especially after a period of fasting (from night
to morning).
Nursing interventions consist of advising the mother to:
• Eat a high-protein snack at bedtime if it’s a
hypoglycemic attack.
• Eat crackers or piece of dry toast before getting up
(keep by bedside if possible).
• Eat frequently spaced, small meals of high-quality
(protein) foods.
• Sip a hot drink before arising.
Heartburn (Pyrosis)
• Heartburn is a burning sensation in the epigastric
and sternal region. It results from relaxation of
cardiac sphincter and the decreased tone and
mobility of smooth muscles which is due to
increased progesterone thereby allowing for
esophageal regurgitation, decreased emptying
time of the stomach, and reverse peristalsis.
– Eat frequent, small meals.
– Take sips of milk or hot tea.
– Eat slowly.
Constipation
• Predisposition to constipation due to oral iron
supplement (side effect of iron therapy is
constipation). Some patients respond with
diarrhea.
• Nursing intervention consists of advising the
patient to:
– Drink at least six glasses of water per
day.
– Moderate exercise every day, especially
walking.
– Maintain a regular schedule for bowel
movements.
Discomforts Related to the Musculoskeletal System
Backache
• Backache is caused by relaxation of the sacroiliac
joint which is due to increased hormones
(steroid sex hormone and relaxing) resulting in
slight joint and muscle relaxation and increased
mobility; and exaggerated lumbar and cervico
thoracic curves caused by changes in the center
of gravity from the enlarging abdomen and
breast.
• Prevention of strain, which can cause backache,
should begin early in pregnancy.
Nursing interventions consist of advising the patient:
• Those maternity girdles are no longer
recommended.
• To practice good posture and good body
mechanics (use the pelvic tilt and bend at the
knees).
• To wear appropriate, well-fitting shoes.
Muscle Cramps – dorsiflexion
• Muscle cramps are caused by:
1. Compression of nerves supplying the lower
extremities due to the enlarging uterus.
2. Reduced level of diffusible serum calcium or
elevation of serum phosphorus in the
bloodstream.
• Nursing interventions consists of advising the
patient to:
 1. Avoid fatigue and cold legs.
2. Eat a diet the adequate calcium or prescribed
calcium.
Discomforts related to the Cardiovascular System
Supine hypotension (Vena Cava Syndrome)
• Supine hypotension is caused by pressure of the
gravid uterus on the ascending vena cava when
the woman is supine which decreases the return
of the blood.
• Symptoms include nausea, cold and clammy,
feels faint, and hypotensive (decreased blood
pressure)
• Nursing interventions consist of advising the
patient.
– Get up slowly.
– Use the side-lying position, preferably
on the left side.
Varicose Veins
• Varicosity is an enlargement of lumen of a vein
due to thinning and stretching of its walls.
• Nursing intervention consists of advising the
patient to:
1. Avoid obesity.
2. Avoid lengthy standing or sitting
3. Avoid constrictive clothing
4. Avoid constipation bearing down
5. Elevate legs when sitting
Treatment once varicose veins have developed.
• Rest with legs and hips elevated.
• Wear support stockings before rising (getting up)
if varicose veins are severe.
• Lie on the bed with legs extended at a right angle
to the body.
• To relieve pain and swelling, take hot sitz baths
or local application of stringent compresses
(witch hazel pads).
Edema (Ankle Edema, Nonpitting to Lower Extremities)
• Edema is very common during pregnancy.
Edema is caused by reduced blood circulation in
the lower extremities as the gravid uterus puts
pressure on the large vessels. Edema is most
noticeable at the end of the day and it is normal
in pregnancy as long as it is not accompanied by
the following:
1. Proteinuria (the presence of an excess of serum
proteins in the urine).
2. Edema of nondependent parts.
3. Sudden increase in weight.
4. Hypertension.
Nursing Intervention consists of advising the patient to:
• Maintain good posture.
• Avoid prolonged standing or sitting
• Wear support stockings.
Treatment of ankle edema
• Elevate the feet as often as possible
• Apply support stockings before getting up.
SCHEDULE OF CHECK-UPS
• The first prenatal visit is usually the longest, as it
includes a complete health history, physical
examination (including pelvic and bimanual
exams), and blood and urine testing. A
recommended schedule for prenatal visits is:
• Once a month until 28 weeks' gestation.
• Every two weeks from week 28 to week 36.
• Every week from week 36 until delivery.
• The pregnancy is confirmed at the first prenatal
visit. A urine or blood test may be done as well
as a physical examination. A woman may have
taken a home pregnancy test after a missed
period and may already be experiencing some
nausea, vomiting, or breast tenderness.
Practitioners should assess the woman's feelings
about the pregnancy and assist in appropriate
referrals if she needs further counseling.
The complete health history should record the
following information:
• The first day of the woman's last menstrual
period.
• Previous gynecologic and obstetric history.
• Personal medical history
• Personal medical history
• Family medical history, including ethnicity.
• Information about work, lifestyle, and hobbies.
• A verbal review of body systems, from head to
toe.
• Physical exam.
• Genetic History-Taking and Genetic Counseling
Intrapartal Care
Onset of Labor Theories
The physical aging of the placenta may cause insufficient
nutrients to reach the fetus.
Uterine Stretch Theory
• when the organs are full, it will empty
• the uterus reaches a crucial point of distension, which
may cause tension on muscle fibers and stimulate their
activity.
OXYTOCIN THEORY
Nerve impulses (uterus) – Posterior pituitary gland –
OXYTOCIN – Uterus to contract initiate labor
PROGESTERONE DEPRIVATION THEORY
Progesterone = Contraction
PROSTAGLANDINS CASCADE THEORY
Adrenal gland (fetus/uterus) – Production of
prostaglandin – Initiation of labor contraction
Fetal Monitoring
DIFFERENT WAYS IN MONITORING FHT/FHR
Manual monitoring – use of stethoscope
Electronic monitoring
External electronic – can be used both uterine
contraction & FHR continuously or intermittently
Internal electronic – precise method for assessing FHR &
uterine contraction it is used if the membrane & cervix
has dilated to at least 3cm.
PRESENTATIONS AND LOCATIONS IN TAKING FHT
• In a vertex or breech presentation, fetal heart sounds
are best heard though the fetal back in a face
presentation, the back becomes concave & so the sounds
are best heard through the more convex thorax.
• In breech presentation, fetal heart sounds are heard
most clearly high in the uterus at the women umbilicus
or above.
• In cephalic presentation they are heard loudest in the
abdomen.
• In ROA position, the sounds are heard best in the right
lower quadrant.
• In LOA position, in the left lower quadrant • In posterior
positions (LOP or ROP), the heart sound are loudest at
the maternal side.
2 SOUNDS THAT CAN BE HEARD IN MONITORING THE
FHT
• FHT
• Rapid muffled sound
• sound like a thickening under a pillow.
• Uterine soufflé
* It is not a FHT sound
* swishing sound
* same rate as mother’s pulse rate
Some nurses keep their fingers on the pt’s pulse at the
same time in monitoring FHT to distinguish between the
FHT & Uterine soufflé. The normal range of FHT is
between 120- 160 beat per min. If the rate exceeds 160
or drop below 100 it should be reported immediately.
Either of these extremes indicates fetal distress.
SIGNS AND SYMPTOMS OF FETAL DISTRESS
• FHT above 160 bmp ( fetal tachycardia may due to fetal
hypoxia, Maternal fever, fetal arrhythmia, drugs,
maternal anemia or hyperthyroidism )
• FHT below 120 bmp for 10 min (fetal bradycardia )
• no signs of contraction at all
• vaginal bleeding
MONITORING CONTRACTIONS, DURATIONS,
ACCELERATIONS AND DECELERATION
MONITORING OF CONTRACTIONS – In labor, uterine
contraction are rhythmic by intermittent, between
contraction there is a period of relaxation this allows
uterine muscle to rest & provides respite for the laboring
women. It also restores uteroplacental circulation; w/c is
important to fetal oxygenation & adequate circulation in
the uterine blood vessel.
3 PHASES OF CONTRACTION
• Increment- the period during w/c the duration of the
contraction increase. (largest phase)
• Acme- a peak of the contraction.
• Decrement- letting up of the contraction.
DURATION OF CONTRACTION
 to determine the beginning of contraction with out a
monitor, rest on hand on the women’s abdomen at the
fundus of the uterus “ very gently” to sense the gradual
tensing & upward rising of the possible to palpate this
tensing approximate 5 sec before women’s is able to feel
contraction
 Contraction is palpable when the intrauterine pressure
reaches approximately 20 mmHg.
 The pain contraction is not usually felt until pressure
reaches approximately 25 mmHg.
 The duration of contraction is timed from the uterus
1st tenses until it has relaxed again.
ACCELERATION OF CONTRACTION
• In addition to observing duration of contraction,
estimate the acceleration or the strength of contraction
• Contraction are rated as:
1. mild – uterus is contracting but does not become rare
than minimally tense.
2.moderate – uterus are firm
3. strong – uterus contraction is intense the uterus feel
as hard as a wooden board at the peak of contraction.
INTERVAL OOF CONTRACTION
• The interval is timed from the beginning of one
contraction to the beginning of another contraction.
OTHER CONTRACTION
• Tetanic contraction- contraction w/c last 2 min. or
longer, this contraction should be reported immediately.
It could cause serious consequences to the mother & the
baby.
NURSING INTERVENTION DURING CONTRACTION
 respect contraction time
 promote change in position
 assess for vital signs
 Provide continue emotional support though out
contraction & provide privacy as appropriate.
 Use of control breathing & position changes help to
reduce pain of contractions & enhance feeling of control.
 Information the pt. about things that can be controlled
provide a means for focus participation
 Perform perineal care frequently, especially after
voiding & any bowel movements.
 Change bed lines & pads as soon as they become soiled
or moist.
 Perineal care & linens change help to remove any
possible drainage or secretion that may pose a risk for
infection.
 Use aseptic technique when performing of assisting w/
pelvic examination
 Administered IV fluids as ordered to maintain fluid
balance
 administered medication as ordered
NURSING INTERVENTION DURING FETAL MONITORING
• position the patient
• explain the procedure to the patient
• provide privacy
• reassure the patient & her husband about the safety of
the equipment
• provide safety measure
FACTORS THAT MAY EXTEND OR INFLUENCE THE
DURATION OF LABOR
PASSENGER (FETUS)
• Presentation of the fetus (breech, transverse)
• Position of the fetus (ROP, LOP).
• Size of the fetus.
PASSAGE (BIRTH CANAL)
• Parity of the woman, if she is has ever delivered before.
• Resistance of the soft tissues as the fetus passes
through the birth canal.
• Fetopelvic diameters.
POWERS (CONTRACTIONS)
• Site of implementation
• Whether it covers part of the cervical os
PLACENTA
• Site of implantation
• Whether it covers part of the cervical os
PSYCHOLOGICAL STATE OF THE WOMAN
• Patient extremely anxious.
• Emotional factors related to the patient. ▪ Amount of
sedation required for the patient.

KEY TERMS RELATED TO FETAL POSITIONS
“Lie” of an infant
• Lie refers to the position of the spinal column of the
fetus in relation to the spinal column of the mother.
• Two types of lie:
• Longitudinal indicates that the baby is lying
lengthwise in the uterus, with its head or buttocks
down.
• Transverse indicates that the baby is lying crosswise in
the uterus.
Presentation/Presenting Part
Presentation refers tot hat part of the fetus that is
coming through (or attempting to come through) the
pelvis first.
Types of presentation
- Vertex or cephalic, the head comes down first.
- Breech, the feet or buttocks comes down first.
- In shoulder, the arm or the shoulder comes down
first. This is usually referred to as a transverse lie.
3 Types of Breech
 Complete or full breech. This involves flexion of the
fetus legs. It looks like the fetus is sitting in a tailor
fashion. The buttocks and feet appear at the vaginal
opening almost simultaneously.
 Frank and single breech. The fetus thighs are flexed
on his abdomen. His legs are against his trunk and feet
are in his face. This is the most common and easiest
breech presentation to deliver.
 Incomplete breech. The fetus feet or knees will
appear first. His feet are labeled single or double
footing, depending on whether 1 or 2 feet appear first.
Types of Breech Presentation
• Specific presentation may be evaluated by several
ways.
1. Abdominal palpation-this is not always accurate
2. Vaginal exam-this may give a good indication but not
infallible.
3.Ultrasound- this confirms assumption made by
previous methods.
4. X-rays-this confirms the presentation, but is used only
as a least resort due to possible harm to the fetus as a
result of exposure to radiation.
Attitude – this is the degree if flexion the fetus body
parts (body, head, and extremities) to each other.
Flexion is resistance to the descent of the fetus down
the birth canal, which causes the head to flex or bend so
that the chin approaches the chest.
Attitude/Flexion
- Complete Flexion. This is normal attitude in cephalic
presentation. With cephalic, there is complete flexion at
the head when the fetus “chin is on his chest” this
allows the smallest cephalic diameter to enter the
pelvis, which gives the fewest mechanical problems
with descent and delivery
- Moderate flexion or military attitude. In cephalic
presentation, the fetus head is only partially flexed or
not flexed it gives the appearance of a military person
at attention. A larger diameter of the head would
become through the passageway.
- Poor flexion or marked extension. In reference to the
fetus head, it is extended or bent backwards. This would
be called a brow presentation. It is difficult to deliver
because the widest diameter of the head enters the
pelvis first. This type of cephalic presentation may
require a C/ section if the attitude cannot be changed.
- Hyperextended. In reference to the cephalic position
the fetus head is extended all the way back. This allows a
face or chin to present first in the pelvis. If there is
adequate room in the pelvis. The fetus may be delivered
vaginally.
Station
• This refers to the depth that the presenting part has
descending into the pelvis in relation to the ischial spines
of the mother’s pelvis measurement of the station is as
follows.
• The degree of advancement of the presenting part
through the pelvis is measured in centimeters.
• The ischial spine is the dividing line between plus and
minus stations.
• Above ischial spines is referred to as -1 to -5 the
numbers going higher as the presenting part gets higher
in the pelvis.
• The ischial spine is zero station.
• Below the ischial spines is referred to +1 to +5,
indicating the lower the presenting part advances.
Station or degree of engagement
Engagement – This refers to the entrance of the
presenting part of the fetus into the true pelvis or the
largest diameter of the presenting part into the true
pelvis. In relation to the head, the fetus is said to be
engaged when it reaches the midpelvis or at zero (0)
station. Once the fetus is engaged, it (fetus) does not go
back up. Prior to engagement occurring, the fetus is said
to be “floating” or ballottable.
Position – This is the relationship between a
predetermined point of reference or direction on the
presenting part of the fetus to the pelvis of the mother.
• The maternal pelvis is divided into quadrants.
1. Right and left side viewed as the mother would.
2. Anterior & posterior. This is a line cutting the pelvis in
the middle from side to side. The top half is anterior and
the bottom half is posterior.
Thee second letter what reference point on the fetus is
being used (occiput-O, fronto-F, mentum-M, breech S,
shoulder SC or A).
The last letter tells which half of the pelvis the
reference point is in (anterior- A, posterior- P, transverse
or in the middle-t)
B. Each presenting part has the possibility of six
position using “occiput as” as the reference point.
• Left Occiput Anterior (LOA)
• Left Occiput Posterior (LOP)
• Left Occiput Transverse (LOT)
• Right Occiput Anterior (ROA)
• Right Occiput Posterior (ROP)
• Right Occiput Transverse (ROT)
A transverse position does not use a first letter and is not
the same as a transverse lie or presentation.
• Occiput at Sacrum (O.S.) or occiput at posterior (O.P.)
• Occiput at pubis (O.P.) or occiput at anterior (O.A.)

SPECIFIC POINTS ON THE FETUS

• Cephalic or head presentation.
1.Occiput (0). This refers to the y sutures on the top of
the head.
2.Brow or fronto (f). This refers to the diamond sutures
or anterior fontanel on the head.
3.Face or chin (m). This refers to the mentum or chin.

• Breech or butt presentation

1. Sacrum or coccyx (s). This is the point of reference.
2. Breech birth is associated with a higher perinatal
mortality.

TYPES OF BREECH PRESENTATION

• Shoulder presentation
1. This would be seen with a transverse lie.
2. Scapula (Sc) or its upper tip acromion (A) would be use
for the point of reference.

CODING AND POSITION

A. Coding simplifies explaining the various positions.

The first letter of the code tells which side of the pelvis
the fetus reference point is on (r for right, l for left).
STAGES OF LABOR
Signs of Labor  Preliminary signs of Labor
1. Lightening- descent of the fetal presenting part into
the pelvis (10-14 days)
2. Increase in Level of Activity – due to an increase in
epinephrine release initiated by a decrease in
progesterone produced by the placenta
3. Braxton Hicks Contractions – may be misinterpreted as
true labor contractions
4. Ripening of the Cervix (Goodel’s sign) – “butter-soft”
& it tips forward
Difference between True & False Labor Contractions
FALSE CONTRACTIONS
- Begin & remain irregular
- Felt first abdominally & remain confined to the
abdomen & groin
- Often disappear with ambulation & sleep
- Do not increase in duration, frequency, or intensity
- Do not achieve cervical dilatation
TRUE CONTRACTIONS
- Begin irregularly but become regular & predictable
- Felt first in lower back & sweep around to the abdomen
in a wave
- Continue no matter what the woman’s level of activity
- Increase in duration, frequency, and intensity
- Achieve cervical dilatation
Signs of True Labor
Involve uterine & cervical changes
1. Uterine contractions – effective, productive,
involuntary
2. Show
3. Rupture of the Membranes- a sudden gush or scanty,
slow seeping of clear fluid from the vagina
FIRST STAGE – The first stage of labor is divided into
three phases: the latent, the active, and the transition
phases.
Parts of Contractions
Increment or crescendo – beginning of contractions until
it increases
Acme or apex – height of contraction
Decrement or decrescendo – from height of contractions
until it decreases
Duration – beginning of contractions to end of same
contraction
Interval – end of 1 contraction to beginning of next
contraction
Frequency – beginning of 1 contraction to beginning of
next contraction
Intensity – strength of contraction
SECOND STAGE – The period from full dilatation and
cervical effacement to birth of the infant.
MOTHER’S BEHAVIOR
- The woman may experience momentary nausea or
vomiting because pressure is no longer exerted on her
stomach as the fetus descends in the pelvis. She pushes
with such force that she perspires and the blood vessels
in her neck may become distended.
- It takes a few contractions of this new type for the
woman to realize that everything is still all right, just
different, and to appreciate that it feels good, not
frightening, to push with contractions.
- The need to push becomes so intense that she cannot
stop herself. She barely hears the conversation in the
room around her. All of her energy, her thoughts, her
being are directed toward giving birth. As she pushes,
using her abdominal muscles and the involuntary uterine
contractions, the fetus is pushed out of the birth canal.
Mechanisms of Labor (Cardinal Movements)
Descent – downward movement of the biparietal
diameter of the fetal head to within the pelvic inlet
Flexion – head bends forward onto the chest, making the
smallest AP diameter present to the birth canal
Nursing care:
 Lithotomy position – put legs up at the same time
 Breathing – panting (teach mom)
 Assist doctor performing episiotomy – to prevent
laceration, widen vaginal canal, shorten 2nd stage of
labor
THIRD STAGE
❑The placental stage, begins with the birth of the infant
and ends with the delivery of the placenta.
❑Two separate phases are involved: placental
separation and placental expulsion.
PLACENTAL SEPARATION
❑ Separation occurs automatically as the uterus
resumes contractions.
❑ Active bleeding on the maternal surface of the
placenta begins with separation; bleeding helps to
separate the placenta still further by pushing it away
from its attachment site.
❑ The following signs indicate that the placenta has
loosened and is ready to deliver:
❑Lengthening of the umbilical cord
❑Sudden gush of vaginal blood
❑Change in the shape of the uterus – fundus rises,
becomes firm & globular
❑ As separation is completed, the placenta sinks to the
lower uterine segment or the upper vagina
❑If the placenta does not deliver spontaneously, it can
be removed manually. With delivery of the placenta, the
third stage of labor is over.
Nursing care:
1. Check for completeness of placenta
2. Check fundus – if relaxed, massage uterus
3. Check bp
4. Administer methergine IM
5. Monitor hpn (or give oxytocin IV)
6. Check perineum for lacerations
7. Assist MD for episioraphy
8. Flat on bed
9. Chills due to dehydration-give blanket, clear liquid
(tea, clear gelatin)
10. Let mother sleep to regain energy

❑ If placenta separates first at its center and last at its FOURTH STAGE
edges, it tends to fold on itself like an umbrella and will ❑ The first 1-2 hours after placental delivery also known
present at the vaginal opening with the fetal surface
as the “Recovery Stage”.
evident. Appearing shiny and glistening from the fetal
❑ Monitor VS q15 for 1 hr; 2nd hr q 30 mins; 3rd hr q 1hr
membranes, it is called a Schultze’s placenta.
❑ Check placement of fundus at level of umbilicus
Approximately 80% of placentas separate and present in
this way. ❑If fundus above level of umbilicus – deviation of fundus
❑Empty bladder to prevent uterine atony
❑ If, however, the placenta separates first at its edges, it ❑Check lochia
slides along the uterine surface and presents at the ❑Maternal observations – body system stabilizes
vagina with the maternal surface evident. It looks raw,
red, and irregular with the ridges or cotyledons that
separate blood collection spaces showing, and is called a
Duncan placenta.

❑Bleeding occurs as part of the normal consequence of

placental separation, before the uterus contracts
sufficiently to seal maternal sinuses. The normal blood
loss is 300-500ml.

PLACENTAL EXPULSION
❑ After separation, the placenta is delivered either by
the natural bearing down effort of the mother or by
gentle pressure on the contracted uterine fundus by the
physician or nurse-midwife (Crede’s maneuver).
❑ Pressure must never be applied to a uterus in a
noncontracted state or the uterus may evert and
hemorrhage. This is a grave complication of birth,
because the maternal blood sinuses are open and gross
hemorrhage occurs.