THE REPRODUCTIVE SYSTEM

MALE REPRODUCTIVE SYSTEM Anatomy:

A. External Genitalia Descriptions and Functions

1. Penis - Composed of erectile tissue.

- Designed to deliver semen or sperms into the vaginal canal of a woman.
- Also serves as exit of urine.
- Main organ for copulation/intercourse.

 Corpora - Tissue surrounding the urethra

spongiosum  - Two layers of erectile tissues that fill with blood during erection
Corpora cavernosa  - Covers the 2 c. cavernosum
Tunica albuginea - Enlarged tip of the penis
 Glans penis - Skin-covered length of the penis
 Shaft - Skin in the proximal end of the gland which is removed during circumcision.
 Prepuce or foreskin
- ―pouch‖, divided sac of skin that holds the testes
2. Scrotal sac or scrotum - keeps the testes cooler than the rest of the body

B. Internal Genitalia Descriptions and Functions

1. Testes - 2 olive-shaped organs approximately 4 cm long and 2.5 cm wide.

- contains 900 coiled seminiferous tubules
- Primary reproductive/sex organs of males (male gonads).

 Tunica - ―white coat‖, fibrous connective capsule that surrounds each testis
albuginea  Septa - Extensions of tunica albuginea that divide the each testis into lobules.
 Interstitial cells/ - site for testosterone production
Leydig cells
 Seminiferous tubules - ―rete testis‖, set of tubules, site of sperm production

- Collection of ducts or channels which transport the sperms from the body.
2. Duct System
- First part of the duct system that serves as temporary site for immature sperms.
 Epididymis
 Ductus or Vas - Connects the epididymis to the ejaculatory duct. Propels the sperms from
their storage site to the urethra. Cut during vasectomy.
deferens
 Spermatic Cord - Connective tissue sheath that covers the vas deferens, blood vessels
and nerves.
 Ejaculatory Duct - A connection between the vas deferens , seminal vesicle and urethra through
the prostate
 Urethra - Carries both urine and semen/sperm to the body exterior.
 Prostatic - Urethral duct surrounded by the prostate
 Membranous - Spans between prostatic urethra to the
penis  Spongy / Penile - Urethral duct in the penis

3. Accessory glands - Glands that produces the bulk of the semen.

 Seminal Vesicles - Found at the base of the bladder. Produces thick yellowish secretion rich
in sugar, Vitamin C and prostaglandins that compose 60 % of semen.
 Prostate gland - Chestnut like gland below the bladder that produces milky fluid that activates
the sperm.
 Bulbourethral or - Pea-sized glands inferior to the prostate that produces thick, clear mucus.
Cowper’s glands This mucus serves as lubricant during intercourse.

4. Semen - Milky white, sticky mixture of sperm and accessory gland secretions. Transport,
nourishes and protects the sperms. Contains seminalplasmin (antibiotic),
relaxin and other chemicals to enhance sperm motility.
- Each ejaculation expels 2 - 5 ml of semen with 50 - 130 Million sperms/ml.

C. Gamete Descriptions and Functions

Sperm - Male gamete responsible for fertilization of female gamete (ova or egg)

 Head - Nucleus of the sperm and contains the DNA

 Acrosome - A membrane that covers the head. Like a lysosome, when the sperm comes
into contact with the egg, it breaks down and release enzymes to help the
sperm
 Midpiece penetrate into the egg.
 Tail - middle part that contains the centrioles
- the end part of the sperm composed of filaments and mitochodria

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MALE REPRODUCTIVE SYSTEM Physiology:

A. Spermatogenesis - Exocrine function of testes. Sperm production begins at puberty and continues
through out life. Occurs in the Seminiferous Tubules inside the testes under
the influence of Follicle Stimulating Hormone (FSH). It is followed by
spermiogenesis where excess cytoplasms of sperms are stripped off and the
tails are formed resulting to mature sperms.

Puberty

Anterior pituitary gland secretes Follicle Stimulating Hormone

Spermatogonia or stem cells multiply rapidly through mitosis

Type A daughter cell (46) Type B daughter cell (46)

Remains in the periphery of s.tubules Goes to tubule lumen

to maintain stem cell population and becomes Primary Spermatocyte

Primary Spermatocyte (46) undergo meiosis

Meiosis I

2 Secondary Spermatocytes (23 chromosomes each)

Meiosis II

4 Early Spermatids (nonfunctional)

Spermiogenesis

Excess cytoplasms are stripped off and tails form

Mature sperms

*** Sperms can survive for 24 - 72 hours in body temperature after ejaculation
***Men do not loose the ability to reproduce even with aging.

B. Testosterone Production - Endocrine function of the testes. Starts at puberty and occurs in the
interstitial cells in the testes. It happens under the influence of Luteinizing
Hormone (LH) or Interstitial cell – Stimulating Hormone (ICSH).
Testosterone is responsible for the development of secondary sex
characteristics:

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FEMALE REPRODUCTIVE SYSTEM Anatomy:
A. External Genitalia (Vulva) Descriptions and Functions
1. Mons pubis - ―mountain on the pubis‖, fatty rounded area in pubic symphysis. It is
covered with hair at puberty.
2. Labia majora - 2 elongated hair-covered skin folds
3. Labia minora - 2 delicate, hair-free folds enclosed in the labia majora
4. Clitoris - ―hill‖, small protruding erectile structure that corresponds to the penis
5. Vestibule - A region enclosed in the labia minora that holds the external urethral
meatus, vagina and Bartholin’s glands.
6. Skene’s glands - Mucus producing glands found on the sides of the urethral meatus
7. Greater Vestibular glands - Pair of mucus-producing glands in the vestibule, one on each side of
or Bartholin’s glands the vagina. Their secretion lubricates the vagina during intercourse

8. Vaginal opening - Site for entry for the penis during intercourse.

9. Fourchette - Portion below the vaginal opening. Cut during episiotomy

B . Internal Genitalia Descriptions and Functions

1. Ovaries - 2 almond-sized and shaped organs. Primary reproductive/sex organs

of females (female gonads).

 Ovarian follicles - Sac-like structures inside the ovaries that holds and immature egg
 Oocyte - Immature egg inside the ovarian follicle
 Vesicular or - Mature form of ovarian follicle that holds more developed egg
Graafian Follicle
 Corpus luteum - ―yellow body‖, ruptured follicle left behind after the release of an egg

2. Duct System
 Uterine or Fallopian - First part of the duct system which receives the ovulated egg from the
Tubes ovaries and provide a site for fertilization. Each tube is 10 cm long and
extends from the ovaries to the uterus. It has 3 parts:
. Infundibulum – has fimbriae that partially surrounds the ovaries
. Ampulla – most common site for fertilization
. Isthmus– proximal to the uterus, site for ligation
. Interstitial - most dangerous site of implantation
 Uterus
- ―Womb‖, hollow, pear-sized organ that receives, retains, nourishes a
fertilized egg. It is suspended in the pelvic cavity by broad ligament and
anchored by round (anteriorly) and uterosacral (posteriorly) ligaments.
3 regions:
. Fundus – superior round portion
. Body or corpus – major middle portion
. Cervix – narrow outlet connected to the vaginal canal
3 layers:
. Endometrium – inner mucosal layer, site for implantation
. Myometrium – bulky middle layer of smooth muscles
. Perimetrium or visceral peritoneum – outermost serous layer
 Vaginal Canal
- Thin walled tube 8 – 10 cm long. Receives the penis, provides a
passageway for delivery of infant and menstrual flow. Main organ for
copulation/intercourse.
3. Menses
- Collection of blood and dead uterine endometrial tissues that is released
once a moth if fertilization did not take place.

C. Gamete Descriptions and Functions

Egg / Ovum - Female gamete that undergoes fertilization once penetration by a sperm.
Lives for 24 hours after release from ovaries.
 Corona radiata - Follicle cell capsule
 Zona pellucida

D. Other Organ: Descriptions and Functions

Mammary glands - ― Breasts‖, present in both sexes but more functional in females.
 Alveolar glands - Modified sweat glands that functions to produce milk that nourishes a
 Lactiferous ducts newborn baby. Lac. ducts transport milk from alv. glands to the nipple.
 Areola – sudoriferous - Pigmented area surrounding the nipples
glands
 Nipple - Protruding structure where major lactiferous ducts are located.
 Prolactin - Hormone from anterior pituitary gland, responsible for milk production
 Nipple

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FEMALE REPRODUCTIVE SYSTEM Physiology:

A. Oogenesis – Exocrine function of the ovaries. Occurs during fetal development so the total supply of
eggs is already determined at the time of birth. The release of eggs (ovulation) begins at
puberty up to a woman’s fifties (menopause).

Female Fetal Development

Oogoniumor stem cell multiply rapidly

Primary oocytes are produced and forms the primary follicles

At birth

Oogonia are lost and about 2 Million of primary oocytes/follicles are formed

Childhood

Primary oocytes remain inactive

Puberty

Anterior pituitary gland releases Follicle-stimulating Hormone

A small number of primary oocytes grow and mature each month

Anterior pituitary gland releases Luteinizing Hormone

Ovarian Cycle: Ovulation

***Ovum can be fertilized within 24 - 36 hours after ovulation

***The average reproductive age of women is 15 - 44 y/o.

B. Estrogen and Progesterone Production – Endocrine function of the ovaries. Occurs under the
influence of anterior pituitary gonadotropic hormones (FSH
and LH)

1. Estrogen - ―Hormone of the Woman‖

Primary Function: Development of secondary sexual characteristics in
female. Others:
1. Inhibit production of FSH ( maturation of ovum)
2. Responsible for hypertrophy of myometrium
3. Spinnbarkeit & Ferning ( billings method/ cervical)
4. Development ductile structure of breast
5. Increase osteoblastic activity of long bones
6. Increase in height in female
7. Causes early closure of epiphysis of long bones
8. Causes sodium retention
9. Increase sexual
10. vaginal lubrication

2. Progestin - ― Hormone of the Mother‖

Primary Function: Prepares endometrium for implantation, make it thick & tortous (twisted)
Secondary Fx.: Inhibits uterine contractility (favors pregnancy)
Others:
1. Inhibit production of LH ------ LH: hormone for ovulation
GIT 2. Decreased GIT motility
3. Mammary gland development
4. Increase permeability of kidney to lactose & dextrose causing (+) sugar
5. Causes mood swings in moms
H2O 6. Elevated BBT

Constipation

C. Menstrual Cycle

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FEMALE REPRODUCTIVE SYSTEM ANATOMY: (Continuation)
UTERINE LIGAMENTS
1. Broad ligament – supports the sides of the uterus & assists in holding the uterus in anteversion
2. Cardinal ligament – lower portion of the broad ligament. It is the main support of the uterus.damage to
this ligament will result to uterine prolapse.
3. Round ligament – connects the uterus to the labia majora. Gives stability to the uterus.
4. Uterosacral ligament – connects uterus to the sacrum
5. Anterior ligament – provides support to the uterus in connection with the bladder. Overstretching of
this ligament will lead to herniation of the bladder to the vagina (cystocele).
6. Posterior ligament – forms the cul-de-sac of douglas. Damage to this ligament will lead to herniation
of rectum to the vagina (rectocele).

THE BREASTS
Functions:
1. Lactation
2. Milk secretion/ ejection

Structures:
1. Lobes = consists of 15-20 lobes which are subdivided into lobules or acinar cells ( responsible for
milk production)
2. Lactiferous ducts = milk reservoir – which open to the nipple.
3. Areola = dark pigmented part around the nipple
4. Montgomery tubercle = secretes fatty substance to lubricate nipples
5. Nipple = elevated part of the breasts containing 15-20 openings from the lactiferous ducts
6. Cooper’s ligament = provides support to the mammary gland while it permits mobility on the chest wall

Physiology of milk production

1. The production of breast milk is not achieved during pregnancy because of the predominance of
estrogen & progesterone.
2. Immediately after the delivery of the placenta, there is marked decrease of both estrogen &
progesterone w/c serves as a stimulus for the APG to produce prolactin.
3. Prolactin acts on the acini cells to stimulate production of milk & stored in the lactiferous ducts.
4. As the infant sucks, the PPG is stimulated to release the hormone oxytocin causing the collecting
sinuses of the mammary glands to contract, forcing milk forward through the nipples called ― let down
reflex‖ or ―milk ejection reflex‖ .
5. Pregnanediol – drug that suppresses milk formation.

SUMMARY

ORGAN MALE FEMALE

1. Primary sex/reproductive organs: gonads Testes Ovaries
2. Sex cells: Gamete Sperm egg or ovum
3. Organ for Copulation Penis Vagina
4. Organ for arousal glans penis Clitoris
5. Main hormone testosterone Estrogen
6. Gamete Production spermatogenesis Oogenesis
7. Gamete Release ejaculation Ovulation

-semen by seminal -mucus by skene’s and

bartholin’s glands
8. Other substance produced vesicles, prostate and
bulbourethral glands -menses forn dead
endometrial tissue if uterus
9. Age of reproduction Puberty to lifetime 15 – 44 y/o

PUBERTAL DEVELOPMENT
Puberty
- The stage of life at which the secondary sex changes and reproductive organs become functional.

Girls - age 9 to12 years, must reach a critical weight of approx. 95lbs (43kgs)

Boys- age 12 to 14 years

The role of Androgen – hormones (“Testosterone - 1° androgenic hormone”) responsible for :

1. Muscular development
2. Physical growth
3. Increase sebaceous gland secretion (acne)

In girls, testosterone influences the development of labia majora, clitoris, and axillary & pubic hair latter termed
as (adrenarche)

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 SECONDARY SEX CHARACTERISTICS
Female Male
1. in height in weight
2. in pelvis diameter Growth of testes
3. Breast enlargement Growth of face, axillary & pubic hair
4. Pubic hair growth Voice changes
5. Growth of axillary hair Penile growth
6. Onset of menstruation - menarche in height
7. Vaginal secretions Spermatogenesis

MENSTRUAL CYCLE
 Episodic uterine bleeding in response to hormonal changes
 Periodic series of changes that recur in the uterus and associated organs beginning at puberty
and ending at menopause
 Taken from the first day of menstruation to the first day of the next menstruation

Menstruation:
 Periodic, sloughing off of the endometrium which occurs every 28 days but could be anywhere from
21 to 35 days & lasts for 3-5 days.

FUNCTIONS OF MENSTRUAL CYCLE

1. Preparation for ovulation
2. Preparation for fertilization
3. Preparation for implantation

BODY STUCTURES INVOLVED IN MENSTRUATION

1. Hypothalamus
2. Anterior pituitary gland
 Follicle stimulating hormone ( fsh)
 Luteinizing hormone ( lh )
3. Ovary
 Estrogen
 Progesterone
4. Uterus (endometrium)

3 GENERAL CYCLES OF MENSTRUATION

1. Hormonal Cycle

2. Ovarian Cycle

3. Uterine Cycle

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3 GENERAL CYCLES OF MENSTRUATION

I. THE UTERINE CYCLE 3 PHASES:

1. Menstrual phase
. Day 1 - 5
. First day of bleeding is the first day of cycle
. Stratum functionale (compactum and spongiosum) is shed
. Around 60 ml average!
. The functional layer of the uterus, endometrium is sloughing off and passes through the vagina
as detached tissues with blood. This is known as menses. The average blood loss is 50 – 150 ml. By
day 5, the ovaries begin to produce more estrogen.

2. Proliferative Phase
. Day 6 - 14
. Epithelial cells of functionale multiply and form glands
. Due to the influence of estrogen
. The endometrium thickens and becomes well vascularized again in response to rising estrogen
level. At the end of this phase, LH level reaches its peak leading to rise in progesterone. This is the
time for ovulation.

3. Secretory Phase
. Day 15 - 28
. Endometrium becomes thicker and glands secrete nutrients
. Uterus is prepared for implantation
. Due to progesterone
. If no fertilization constriction vessels menstruation
. The endometrium thickens more and receives further increased blood supply. Endometrial glands
grow and secrete nutrients as preparation for possible pregnancy. This is the time for
implantation. If fertilization dos not occur, LH level declines so the corpus luteum degenerates
leading to decline in estrogen and progesterone. As a result, blood vessels in the endometrium go
into spasms and kink depriving the endometrium of oxygen and nutrients. Endometrial cells begin
to die and pass out as menses at day 28 signifying the start of another cycle.

II. HORMONAL CYCLE 4 PHASES:

1. Menstrual phase
. Decreased Estrogen, decreased progesterone, decreased FSH and decreased LH
2. Proliferative/ Pre-ovulatory phase
. Increased FSH and Estrogen in small amounts
3. Ovulatory phase
. Increased FSH, Increased LH (surge) Increased Estrogen
4. Post ovulatory/Luteal Phase
. Increased Estrogen, increased progesterone, decreased FSH and LH

III. OVARIAN CYCLE 3 PHASES:

1. Pre-ovulatory /Follicular phase
. Variable in length: day 6- day 13
. Dominant follicle matures and becomes graafian follicle with primary oocyte
. FSH increases initially then decreases because of estrogen increase
2. Ovulatory phase
. Day 14
. Rupture of the Graafian follicle releasing the secondary oocyte
. Due to the LH surge
. MITTELSCHMERZ- pain during rupture of follicle
3. Post-ovulatory / Luteal phase
. Day 15- day 28
. MOST CONSTANT 14 days after ovulation
. Corpus luteum secretes Progesterone
. If no fertilization, corpus luteum will become corpus albicans then degenerate
. Decreased estrogen and progesterone

SIGNS OF OVULATION
1. Mittelschmerz
= a certain degree of pain felt at the lower left or right iliac
2. Cervical mucus method or Billing’s method
= changes in cervical mucus secretions to clear, elastic & watery (most reliable
sign). 3. Spinnbarkheit test
= test for elasticity of cervical mucus
4. Thermogenic Effect
= Increase in basal body temperature due to rising levels of progesterone
5. Mood changes
6. Breast changes and enlargement
7. Increased libido

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PREMENSTRUAL SYNDROME

- Emotional and physical manifestation that occur cyclically before menstruation and regress thereafter
- Peak 30-40 y/o
- No specific hormone, treatment or markers
- Mood and behavioral changes inherent to menstrual cycle

Etiology and Risk Factors

1. Caffeine
2. Smoking
3. Lack of exercise
4. Improper diet
5. Inadequate sleep
6. Stress

Management: Supportive

ABNORMALITIES OF MENSTRUATION
1. Amenorrhea = temporary absence of menstrual flow
2. Dysmenorrhea = painful menstruation
3. Oligomenorrhea = markedly diminished menstruation
4. Polymenorrhea = too frequent menstruation occurring at intervals of less than three weeks
5. Menorrhagia = excessive menstrual bleeding
6. Metrorrhagia = bleeding between periods, intercyclic bleeding
7. Hypomenorrhea = abnormally short menstruation
8. Hypermenorrhea = abnormally long menstruation

MENOPAUSE
= Permanent cessation of menstrual cycles that occurs between 45 & 55 y/o; ave:
50y/o = The point at which no functioning oocytes remain in the ovaries

S/s of menopause:
1. Hot flashes - sensation of heat that begins in the face to the chest & profuse perspiration.
2. Smaller stature - loss of breast mass & firmness, atrophy of reproductive organs.
3. Dyspareunia (painful intercourse) - due to decreased vaginal lubrication.
4. Osteoporosis - estrogen promotes calcium deposition in the body. A fall in estrogen levels will
liberate calcium from the bones making them brittle

Management:
1. Estrogen replacement therapy ( hrt; ert)
2. CALCIUM (1g/day at bedtime) & Vitamin D supplementation
3. Liberal fluid intake to dilute urine as more calcium is liberated from the bones & could cause
renal calculi/stones.
4. Weight bearing exercises
5. Dress in layered look, remove outer clothing during attacks.
6. Avoid hot environment
6. Avoid emotional stress
7. Avoid foods that could trigger hot flashes: spicy foods, coffee, tea, alcohol
8. Use cooling techniques: fans, showers, ice cubes.
9. Encourage woman to engage in regular exercise program to maintain muscle tone
10. Instruct on proper use of water soluble vaginal lubricant for painful intercourse.
11. Instruct to avoid smoking & alcohol
12. Regular physical examination.

SEXUAL RESPONSE CYCLE

1. Excitement phase = occurs with physical, psychological (sight, sound, emotion or thought) stimulation
that causes parasympathetic nerve stimulation. Vaginal lubrication occurs, arterial
dilation & venous constriction in the genital area, overall muscle tension increases. In
men, erection increases, PR,RR,BP increases
2. Plateau phase = nipples become further engorged. In men, vasocongestion leads to full distention of the
penis, flushing occurs, breathing becomes deeper, PR,RR & BP increase markedly
3. Orgasmic phase = shortest stage in the sexual response cycle, strong muscular contractions both voluntary
& involuntary in many parts of the body, RR,PR doubles and BP increasing as much as
1/3 above normal
4. Resolution phase = generally takes approximately 30 minutes for both men & women , general
muscle relaxation occurs, external & internal organs to unaroused state.

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 THE BEGINNING OF LIFE

FERTILIZATION
(CONCEPTION, FECUNDATION, IMPREGNATION)
= It is the union of a matured egg and a sperm and the product is called a conceptus or
rd
zygote. =It occurs at the distal 3 of the fallopian tube – the ampulla

OVUM:
1. It is the female sex cell or gamete.
2. Only one ovum reaches maturity every month
3. 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‖

** Ovum can stay viable & is capable of being fertilized for 12-24 hours after ovulation but can live up to 3-4
days.

SPERM CELL:
1. Spermatozoa deposited in the vagina reaches the waiting egg in the fallopian tube in about 5 minutes
2. The functional life of spermatozoa is 48-72 hrs (3days) but can stay alive in the vagina for 5 -7 days.
3. Only one spermatozoon is able to penetrate the cell membrane of the ovum after which cell
membrane becomes impervious to other spermatozoa.
4. Reproductive cells, during gametogenesis divide by meiosis ( haploid number of daughter cells)
5. The rest of the body cells have 46 chromosomes
6. Sperms therefore contain only 23 chromosomes = 22 pairs of autosomes & 1 X sex chromosome or 1
Y sex chromosome.
7. The union of an x carrying sperm (gynosperm)& a mature ovum results in a baby girl (xx)
8. The union of a y carrying sperm(androsperm) & a mature ovum results in a baby boy (xy)
9. Only fathers can determine the sex of their children.
10. Sex of a child is determined at the time of fertilization

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

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 cells release enzymes allowing it to burrow
deep into the endometrium resulting in rupture of vessels & bleeding at the implantation site.
- “Implantation bleeding ”.
- Ideal site of implantation is the fundal portion.

STAGES OF FETAL GROWTH AND DEVELOPMENT

1. Pre-embryonic = first 2 weeks beginning with fertilization

2. Embryonic = weeks 3-8, considered the most critical in fetal stage because of organogenesis.

3. Fetal = weeks 8 to birth

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 STAGES OF FETAL GROWTH AND DEVELOPMENT
I. PRE-EMBYONIC STAGE

ZYGOTE
- Is the first cell formed from the fertilization of sperm & ovum.
- It contains 46 chromosomes: 44 autosomes & either xx chromosomes if the offspring is a female, or
xy chromosome, if the offspring is a male.
- It journeys from the fallopian tube to the uterus for 3-5 days
- 16 hours after fertilization, it undergoes its first cell division , ”blastomere”
- When there are already 16 or more blastomeres, the zygote is termed “morula”(morus – mulberry)
- When it reaches the uterus it is transformed into a “blastocyst” – a ball like structure composed of
an inner cell mass, called embryonic disc or blastocele & an outer layer of rapidly developing cells
called trophoblasts or trophoderm.
- The trophoblasts secretes a hormone called ― Human chorionic gonadotropin‖ necessary in prolonging
the life of the corpus luteum.
- The blastocele or embryonic disc gives rise to the three primary germ layers: ectoderm,
mesoderm, endoderm.

PRIMARY GERM LAYERS

Tissue Layer Body Portions Formed
Ectoderm (Outer Layer) Nervous system, skin, hair, nails, sense organs, mucus membranes
of nose & mouth

Mesoderm (Middle Layer) Connective tissue, bones, cartilage, muscles, tendons, kidneys, ureters,
reproductive system, heart, circulatory system, blood cells

Endoderm / Entoderm Lining of the GI tract, respiratory tract, tonsils, parathyroid, thyroid,
(Inner Layer) thymus glands, bladder, urethra

II - III. EMBRYONIC AND FETAL STRUCTURES

1. Decidua
2. Chorionic villi
3. Placenta and umbilical cord

DECIDUA:
- After implantation, the endometrium is now referred to as the decidua.

Layers:
1. Decidua basalis –layer where implantation takes place, later on forms the maternal side of the placenta.
2. Decidua capsularis – layer which encloses, envelopes the blastocyst & becomes the bag of water.
3. Decidua vera – remaining portion of the uterine lining

Membranes:
1. Chorion = outer fetal membrane; together with the decidua basalis becomes the maternal side of placenta.
2. Amnion = smooth, thin, tough & translucent membrane directly enclosing the fetus & the amniotic fluid. It
is continuous with the umbilical cord & covers the fetal surface of the placenta & umbilical cord.

CHORIONIC VILLI:
- As early as 12 days after fertilization, tiny projections around the zygote, called villi, can be seen.
- The chorionic villi in contact with the decidua basalis proliferate very rapidly because they receive
rich blood supply. It will later on form the fetal side of the placenta.
- Chorionic villi: trophoblasts: at about 3 weeks, the trophoblast cells differentiate into two distinct layers:
1. Cytotrophoblast or Langhan’s layer
nd
= inner layer that protects the fetus against syphilis until the 2 trimester.
2. Syncytiotrophoblast or Syncytial layer
= outer layer that produces hormones HCG, HPL, Estrogen & Progesterone.
- Amniotic Fluid:
 800 ml to 1200 ml at term; average 1000 ml; replaced approx. Every 3 hours
 99% water & 1% solid particles containing albumin, urea, uric acid, creatinine, lecithin,
sphingomyelin, bilirubin & vernix caseosa.
 Should be clear, colorless to straw colored with tiny specks of vernix caseosa.

Functions of Amniotic Fluid:

1. Protects the fetus from trauma
2. Allows freedom of movement which permits symmetrical growth & development
3. Source of oral fluid intrauterine.
4. It protects the umbilical cord from pressure, protecting fetal oxygenation
5. Aids in fetal descent during labor by providing lubrication in the birth canal.

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 Amniotic Fluid Amount Abnormalities:
1. Hydramios- excessive amniotic fluid; more than 2000ml; mostly seen in diabetic mothers
2. Oligohydramios- reduction in amniotic fluid less than 300ml; mostly seen in those having disturbance
in kidney function

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
- A membranous vascular organ connecting the fetus to the mother, supplies the fetus with oxygen and
food and transports waste product out of fetal system
- The placenta is formed from the chorionic villi and decidua basalis.
- development is stimulated by progesterone secreted by corpus luteum
rd
(3 wk after fertilization)
th
fully functional by the 12 week
nd
- It becomes functional at the end of the 2 month & it reaches maturity at 12 weeks gestation and
st nd
continues to function effectively until the 40 to 41 week. It begins to degenerate after the 42 week
making it dangerous for the fetus to remain in utero beyond 42 weeks gestation.

2 sides of placenta:
1. Maternal side = irregular and is divided into subdivisions called cotyledons
2. Fetal side = covered by amnion, so it is smooth and shiny

Functions of the placenta

1. Respiratory system = exchange of gases takes place in the placenta, not in the fetal lung.
2. Renal system = waste products are being excreted through the placenta
** it is the mother’s liver which detoxifies the fetal waste products
3. Gastrointestinal system = nutrients pass to the fetus via the placenta by diffusion through the
placental tissues.
4. Circulatory system = feto placental circulation is established by selective osmosis
5. Protective barrier = inhibits passage of certain bacteria & large molecules
** provides maternal immunoglobulin g (Ig G) that gives fetus passive immunity
to certain diseases for the first few months afterbirth.
6. Endocrine system = produces the following hormones:
A. HCG / Human Chorionic Gonadotropin = secreted by trophoblast, during early pregnancy
- Prevents involution of corpus luteum, stimulates it to continue producing progesterone
and estrogen for 11- 12 weeks
- 8 to 10 days after fertilization, HCG is present in maternal blood
- few days from missed menses, (+) in urine
B. HPL / Human Placental Lactogen
- An insulin antagonist (maternal metabolism of glucose)
- Ensures that the mother’s body is prepared for lactation
C. Estrogen = stimulates development of uterine and breast tissues in the mother
- Increases vascularity and vasodilation in the villous capillaries

D. Progesterone = after 11 weeks of pregnancy, placenta takes over the production from the
corpus luteum
- it is a smooth muscle relaxant, prevents uterine contraction by decreasing its contractility
- also maintains the endometrium
E. Relaxin = causes changes in collagen

UMBILICAL CORD / FUNIS

- Structure that connects the fetus to the placenta. Main function is to carry o2 & nutrients from the
placenta to the fetus & return the unoxygenated blood & fetal waste products to the placenta.
- 50 -55 cms long. Appears dull white, moist & covered by amnion.
- Composed of 2 arteries & 1 vein ( AVA)
- If only two blood vessels, suspect renal and heart anomalies.
- 2 arteries carry deoxygenated blood from the fetus to the placenta
- 1 vein carries oxygenated blood to the fetus, along with nutrients, hormones etc
- Wharton’s jelly – gelatinous substance that covers the umbilical cord to prevent kinking, and trauma to
the cord.

Cord insertion:
1. Central insertion – normally, the cord is inserted at the center of the fetal surface of the placenta.
2. Lateral insertion – when the cord is inserted away from the center of the placenta but not at its edges.
3. Velamentous insertion – when the cord is inserted in the membranes about 5 to 10 cm away from the
edge of the placenta.
4. Battledore insertion – when the cord is inserted at the edge of the placenta

11
 STAGES OF FETAL GROWTH AND DEVELOPMENT

First trimester: Period of Organogenesis/ Development of Organs

- Most Critical Period
st
1 - 4 weeks / 1 Month: Brain & Heart development

1. Length / Weight - 1 cm , 400 mg

2. FHT begins -heart is the oldest part of the body
3. CNS develops -gives dizziness to mom d/t hypoglycemic effect
4. GIT& URT - remains as single tube
nd
5. Differentiation of Primary Germ layers---by end of 2 week
* Endoderm -Thyroid – for basal metabolism
-Parathyroid - for calcium
-Thymus – development of immunity
-Liver & lining of upper RT & GIT

* Mesoderm -Heart, musculoskeletal system

-Kidneys, Reproductive organs
* Ectoderm -Brain, CNS, skin, 5 senses
-mucus membrane of hair, nails, anus & mouth
nd
5 - 8 weeks / 2 Month: All vital organs are formed

1. Length / Weight -2 cm/ 1 inch, 20 grams

2. Placenta developed
3. Blood circulation well established
4. Sex organ formed -not yet distinguishable
5. GI tract enlarges
6. Corpus luteum - source of estrogen & progesterone of infant
nd
-lifespan & functions until the end of 2 month
rd
9 - 12 weeks / 3 Month: Placenta is Complete

1. Length / Weight -7 to8 cm , 45 grams

2. Kidneys functional -little urine
3. Buds of milk teeth appear
4. Fetal heart tone heard -Doppler (10 – 12 weeks)
5. Sex is distinguishable

Second Trimester: Period of Continuous Growth &

Focus ----length of fetus
th
13 - 16 weeks / 4 Month:

1 Length / Weight - 10 to 17 cm , 55 – 120

. Lanugo begins to appear
2. FHT heard grams
3. Buds of teeth appear
4. Urine is present in amniotic fluid, fetus actively swallows
5. Sex can be correctly identified in UTZ
6.
Month:
th
17 - 20 weeks/ 5
Length / Weight - 25 cm , 223 grams
st
1 Quickening - 1 fetal movement (Primi: 18- 20 wks) (Multi: 16- 18 wks)
. FHT heard -Stethoscope (18 – 20 weeks)
2. Langhan’s Layer disappears - Risk for infection
3. Lanugo covers body
4. Vernix caseosa forms
5. Meconium is present -Up to upper intestines
6. Fetus develops sleep/wake patterns
7.
8.
th
21 - 24 weeks / 6 Month:

1. Length / Weight - 28 to 36 cm, 550 grams

2. Transfer of antibody from mother to fetus
3. Skin red & wrinkled with lots of vernix
4. Eyelids open, pupil reactive to light
5. Exhibits hearing, startle reflex
6. Sucking
7. Meconium present up to rectum

12
Third trimester: Period of Most Rapid Growth
- Focus : Weight of fetus
th
25 - 28 weeks / 7 Month:
1. Length / Weight - 36 to 38 cm, 550 grams
2. Lungs produce surfactant - (+) Lecithin
3. Male : testes begin to descend into scrotal sac
4. Female : clitoris is prominent & labia majora are small & do not cover labia minora
th
28 - 32 weeks / 8 Month:
1. Length / Weight - 38 to 43 cm, 1,600 grams
2. Lungs mature - Lecithin to Spingomyelin ratio = 1.2:1
3. Lanugo begin to disappear
4. Subcutaneous fat deposits, steady weight gain occurs
5. Iron stores develop
6. Nails extend to fingers
7. Active Moro reflex is present
8. Assumes birth position
th
33 - 36 weeks / 9 Month:
1. Length / Weight - 43 to 48 cm, 1,800 – 2,700 grams
2. Lung surfactant are well balanced - Lecithin to Spingomyelin ratio = 2:1
3. Lanugo & vernix caseosa begins to thin
4. Sole of foot has few creases
5. Amniotic fluid decreases
6. Fats, Iron, carbohydrates, glycogen and calcium are abundant
7. Birth position is permanent
th
37 - 40 weeks / 10 Month:
1. Length / Weight - 48 to 52 cm, 3,000 grams
2. Lungs are fully developed
3. Bone ossification of fetal skull - *Moulding no longer occurs for post-term babies
4. Vernix caseosa is evident in body folds
5. Soles of feet covered by creases , 2/3
6. Long fingernails
7. Fetal kicks hard
8. Fetal hemoglobin converts to adult hemoglobin

POINTS TO CONSIDER:

1. Teratogens - any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A. Drugs:
Streptomycin – anti TB & or Quinine ( anti malaria)
th
– damage to 8 cranial nerve : Ototoxicity & deafness
Tetracycline – staining of tooth enamel, inhibits growth of long bone
Vitamin K – Hemolysis, hyperbilirubenimia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia (absence of extremities) or
– Pocomelia (Absence of distal parts of extremeties)
Steroids – cleft lip or palate or abortion
Lithium – anti-manic may cause congenital malformation

B. Alcohol – LBW (vasoconstriction – mother/ FAS or fetal alcohol syndrome ---microcephaly)

C. – LBW
Smoking D. – LBW
Caffeine E. – LBW w/c causes vasoconstriction leads to abruptio placenta
Cocaine

2. TORCH (Teratogenic) Infections – viruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or
ascend through birth canal and adversely affect fetal growth and development. These infections
are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph
nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the
pregnant woman yet have devastating effects on the fetus.

T – toxoplasmosis – handling of cat litter or raw vegetables or meat

O – others. Hep. A or Hep. B, HIV – blood & body fluids, Syphilis
st
R – rubella – German measles – congenital heart disease (1 month) normal rubella titer 1:10
< 1 : 1 0 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’ t get
pregnant for 3 months. Vaccine is teratogenic
C –cytomegalo virus
H – herpes simplex virus

13
 FETAL BLOOD CIRCULATION

PRINCIPLE:
Most vital organs receive the maximum concentration of oxygenated blood.
Fetal brain requires the highest concentration of oxygenated blood.
Lungs are essentially non-functional: Lungs are collapsed creating pulmonary vascular resistance
that allows blood to bypass the lungs and pressure on right side of the heart to increase.
The liver and GIT is only partially functional, therefore, lesser blood is needed.

SPECIAL STRUCTURES:
A. Umbilical Vein
. Brings oxygenated blood coming from the placenta to the fetus
. Becomes ligamentum teres

B. Umbilical arteries
. Carry unoxygenated blood from the fetus to placenta
. Become umbilical ligaments after birth

C. Ductus venosus
. Carry oxygenated blood from umbilical vein to IVC
. Bypassing fetal liver
. Becomes ligamentum venosum after birth

D. Ductus arteriosus
. Carry oxygenated blood from pulmonary artery to aorta
. Bypassing fetal lungs
. Becomes ligamentumarteriosum; closes after birth

E. Foramen Ovale
. Connects the left and right atrium
. Bypassing fetal lungs
. Obliterated after birth to become fossa ovalis

PROCESS:

Oxygen and nutrients-rich blood form the placenta enters the fetus via UMBILICAL VEIN

Liver: Blood goes to PORTAL/HEPATIC CIRCULATION and remaining blood goes to DUCTUS VENOSUS connecting to
the INFERIOR VENA CAVA

Higher pressure in RA pushes blood to the LA through the FORAMEN OVALE (R - SHUNT)

Oxygenated blood in LA is pumped to the LV through the MITRAL VALVE then to the ASCENDING AORTA to be delivered to
the head and upper extremities.

Unoxygenated blood from head and upper extremities goes back the RA through the SUPERIOR VENA CAVA then to the
RV through the TRICUSPID VALVE

Unoxygenated blood in the RV is pumped to the PULMONARY ARTERY, where the major portion is shunted to the
DESCENDING AORTA via the DUCTUS ARTERIOSUS. Small amount flows to and from the non-functional fetal
lung.

The blood in the descending aorta is returned to the PLACENTA through the 2 UMBILICAL ARTERIES to be reoxygenated.

14
 POSTNATAL CIRCULATION
PRINCIPLE:

Transition from fetal to postnatal circulation involves the functional closure of the fetal shunts;
1. Foramen ovale
2. Ductus arteriosus
3. Ductus venous

The factors responsible for ductal closure are:

1. Increased oxygen concentration in the blood – most important factor
2. Fall in endogenous prostaglandins, pH (acidosis).

FO closes functionally at or soon after birth,

th
DA is closed functionally by the 4 day in well neonates but may be delayed in ill or preterm infants.
Because of reversible flow of blood through DA during the early neonatal period, a functional murmur can
be occasionally heard.
DA becomes Ligamentumarteriosus,
DV become Ligamentum teres.

PROCESS:
STIMULI [like thermal (primary) or the sudden chilling of the newborn because of exposure to a cooler environment,
chemical (secondary) or low oxygen, high carbon dioxide and low pH of the blood, and tactile], INITIATE
REPIRATION.

Inspired air DILATES the lungs/pulmonary vessels

DECREASE in pulmonary resistance and INCREASE in pulmonary blood flow

Pressure in RA, RV and PA DECREASES

Cord Clamping Pressure in systemic vascular resistance and the blood volume INCREASES

INCREASE Pressure in Left Side of the Heart, circulation in of blood through fetal shunts is REVERSED.
(L-R SHUNT)

Eventually, fetal ducts will close and the newborn’s circulation fully resembles that of the adult circulation.

ADULT CIRCULATION:

Oxygenated blood from the lungs enters the 4 PULMONARY VEINS, empties to the LA, MITRAL VALVE then LV.

From LV, the blood will be pumped to the SYSTEMIC CIRCULATION through the AORTA.

The Oxygenated blood divides to two: ASCENDING AORTA to be delivered to the head and upper extremities,
DESCENDING AORTA to be delivered to thorax, abdominal organs and lower extremities.

Oxygen in the blood will b used up by the cells and Carbon Dioxide will form. This unoxygenated blood will
cross the CAPILLARIES and enter the major VEINS

Unoxygenated blood from head and upper extremities goes back to the heart via the SUPERIOR VENA CAVA
while the unoxygenated blood from the rest of the body enters the INFERIOR VENA CAVA

Unoxygenated blood empties to the RA, TRICUSPID VALVE then RV

From RV, the blood will be pumped to the LUNGS through the PULMONARY ARTERY for reoxygenation.

15
 ANTEPARTUM: THE PREGNANT WOMAN
TERMS:

1. Gravidity pregnancy regardless of duration

2. Gravida pregnant woman
3. Nulligravida a woman who has never been pregnant
4. Multigravida a woman with two or more pregnancies
5. Primigravida a woman who is pregnant for the first time
6. Parity pregnancies that reached the age of viability (20 weeks)
7. Nullipara a woman whose pregnancy reached 2 0 weeks but did not last up to term ( 3 8 - 4 0 weeks)
8. Multipara a woman who has completed 2 or more pregnancies up to term
9. Primipara a woman who reached the term of pregnancy and will give birth for the first time
10. Age of Gestation duration of pregnancy measured in weeks since the last menstrual period
11. Preterm 20 to 37 weeks
12. Term 38 to 40 weeks
13. Post term/postdate 42 weeks and beyond
1 4 . Viability capacity to live outside the uterus, 20/24 weeks or 500 grams

SIGNS & SYMPTOMS OF PREGNANCY:

1. Presumptive S/S felt & observed by the mother but does not confirm pregnancy =Subjective
2. Probable Signs observed by the members of health team =Objective
3. Positive Signs Undeniable signs confirmed by the use of instrument

Age of Presumptive sign Probable sign Positive sign

Gestation

First trimester Breast Changes Goodell’s sign Fetal outline in

1 – 12 weeks Amenorrhea Chadwick’s sign ultrasound Fetal heart
Nausea and vomiting Hegar’s sign tone in
Urinary frequency Positive Pregnancy test ultrasound
Fatigue

Second Quickening Braxton Hicks Fetal outline in other

trimester contractions Ballottement exams Fetal heart tone in
13 – 24 weeks Doppler Fetal heart tone in
Steth.
Fetal movements
palpated by examiner

Third trimester --- --- Visible fetal movements

25 – 40
weeks

PHYSIOLOGIC CHANGES DURING PREGNANCY:

A. Cardiovascular System
- Normal increase blood volume of mother----- 1,500 cc (+500 for multiple pregnancy)
- Plasma volume increase only
- Increase cardio workload-------easy fatigability
- Slight hypertrophy of ventricles
- Epistaxis d/t hyperemia of nasal membrane
- Palpitation d/t stimulation of CNS

1. Physiologic Anemia = Normal (pseudo anemia of pregnant women), no management needed

Normal Values
Hematocrit 32 – 42%
Hemoglobin 10.5 – 14g/dL
Criteria
st rd
1 and 3 trimester: Hct. >33% & Hgb >11g/dL = Pathologic anemia if lower
nd
2 trimester – Hct >32% & Hgb >10.5 g/dl = Pathologic anemia if lower

2. Pathogenic Anemia
Iron deficiency anemia = most common hematological disorder. It affects 20% of pregnant women.
Criteria: Pallor, constipation, Slow capillary refill >3 seconds, Concave fingernails (late sign)
Management: Iron and Vitamin C

3. Edema of lower extremities = Normal due to poor venous return, large belly
Management: Elevate legs above hip level

16
PHYSIOLOGIC CHANGES DURING PREGNANCY:

A. Cardiovascular System

4. Leg Varicosities - due to increasing pressure of uterus

Management: Use support stockings/elastic bandage, avoid wearing knee high sock, elevate legs

5. Vulvar varicosities -painful, pressure on gravid uterus

Management: Side lying w/ pillow under hips or modified knee chest position

6. Thrombophlebitis or “Deep Vein Thrombosis” – presence of thrombus at inflamed blood vessel

- Pregnant body: Altered hyperfibrinogenemia
- Increase fibrinogen to prevent hemorrhage & increase clotting factor
- Thrombus formation candidate
- Outstanding sign : (+) Homan's sign (pain on calf during dorsiflexion)
- ―Milk leg‖ or Phlagmasia Alba Dolens: the shiny white legs d/t stretching of skin caused
by inflammation
Management:
1.) Complete bed rest
2.) Never massage
3.) Check dorsalis pedis pulse (distal)
4.) Assess for (+) Homan sign only once to prevent dislodge of thrombus
5.) Avoid aspirin! Might aggravate bleeding.
6.) Give anticoagulant to prevent additional clotting
Ex. Heparin (it does not cross placental membrane)
Antidote: Protamine Sulfate (no aspirin)
Monitor APTT (best) then PTT
7.) Thrombolytics----example streptokinase, to dissolve clots

B. Respiratory System = Shortness of Breath d/t enlarged uterus & increase O2 demand
Management: Position in a side lying position to allow expansion of lungs

C. Gastrointestinal System
st
1. Morning Sickness/ Emesis Gravidarum = 1 trimester change is normal , d/t increase HCG
Management: Eat dry crackers or CHO diet 30 minutes before arising from bed,
Small frequent meals, monitor for excessive vomiting: Hyperemesis gravidarum
nd
2. Constipation = 2 trimester changes, due to progesterone, and decrease motility
Management: Increase fluid intake & increase fiber diet and exercise

3. Flatulence = due to increase progesterone

Management: Avoid gas forming food – cabbage

4. Heartburn or Pyrosis = Reflux of stomach content to esophagus

Management: Small frequent feeding, avoid 3 full meals
Diet: avoid fatty & spicy food, sips of milk
Proper body mechanics----avoid downward positioning

5. Ptyalism = increase salivation

Management: mouthwash

6. Hemorrhoids = Caused by pressure of gravid uterus

Management: Hot sitz bath for comfort, avoid hot & spicy foods
st rd
D. Urinary System = Frequency of urination: 1 & 3 trimester only
Management: Lateral expansion of lungs or side lying position prevents Nocturia

E. Musculoskeletal

1. Lordosis =―Pride of pregnancy‖

Management: Proper posture

2. Waddling Gait = awkward walking due to Relaxin – causes softening of joints & bones
Management: Prone to accidental falls – wear low heeled shoes

3. Leg Cramps = due to #1 cause during pregnancy: Ca & phosphorous imbalance

Other causes: prolonged standing, over fatigue,chills, oversex, labor compression of
lumbo sacral nerve plexus by the gravid uterus
Management: Immediate dorsiflexion of foot, Increase Ca & phosphorus, 3-4 glassess of
milk/day, cheese, yogurt, head of fish, dilis, sardines with bones, brocolli,
seafood- tahong (mussels), lobster, crab, Vitamin D for increased Ca absorption

17
LOCAL PHYSIOLOGIC CHANGES:

A. Female Reproductive Tract

VAGINA Chadwick’s -Bluish Violet Discoloration Of Vagina &Cervix
Sign CERVIX Goodell's -Change In Consistency Of Cervix
Sign -Change In Consistency Of Isthmus (Lower Uterine
UTERUS Hegar's Sign Segment) -Mucus Plug In Cervix To Seal Out Bacteria D/T
OPERCULUM Progestin
LEUKORRHEA -whitish gray, moderate amount, musky odor discharge---d/t Estrogen

1. Vaginitis = Trichomonas vaginalis, a Flagellated protozoan – likes alkaline environment

S/S: Greenish, cream-colored frothy discharge, irritatingly itchy, foul odor, vaginal edema
Mgt:
1. Anti-protozoan ----FLAGYL (Metronidazole).
st
-Teratogenic drug especially at 1 trimester (do not give too early)
-Treat also the partner to prevent reinfection
-No alcohol-----antaabuse effect
2. VAGINAL DOUCHE – 1 quart H2O : 1 tbsp white vinegar

2. Moniliasis or Candidiasis = Candida Albecans ( a fungal infection)

S/S: White cheese-like patches that adheres walls of vagina, Baby with oral thrust if delivered vaginally
Mgt:
1. Antifungal------Nystatin, Mycostatin, Gentian violet, Cotrimaxole

3. Gonorrhea = Thick purulent discharge

Mgt: Antibiotics after pregnancy

4. Vaginal Warts = Condylomata Acuminata, Papilloma virus

Mgt: Cauterization

B. Skin Changes

1. Melasma/Chloasma -white/ light brown pigmentation on nose chin, cheeks d/t increased melanocytes.
2. Linea Nigra -Brown to pinkish line from symphisis pubis to umbilicus
3. Striae Gravidarium -stretch marks due to enlarging uterus-destruction of sub Q tissues
4. Diastasis -bluish shadow that reflects stretching of rectus abdominal muscles
Management: Avoid scratching, use coconut oil

C. Breast Changes
- All changes r/t increase hormones
- Color & size of areola & nipple
rd
- Pre-colostrum is present by 6 wks. & Colostrums at 3 trimester

E. Ovaries – rested during pregnancy

PSYCHOLOGICAL ADAPTATION TO PREGNANCY:

By: Reva Rubin: Theory of Maternal Role Attainment (MRA): The emotional response of the mother to
pregnancy

1st Trimester: ACCEPTING THE PREGNANCY

. No tangible S/S
. Feeling of Surprise, Ambivalence & Denial – sign of maladaptation to pregnancy
. Developmental Task: Accept the biological facts of pregnancy
. Focus: Bodily changes of pregnancy & nutrition

2nd Trimester: ACCEPTING THE BABY

. Tangible S/S
. Mother identifies fetus as a separate entity d/t presence of quickening
. Fantasy
. Developmental Task: Accept growing fetus as baby to be nurtured
. Focus: Growth & Development of fetus.

3rd Trimester: PREPARING FOR PARENTHOOD

. Mother has personal identification w/ the appearance of the baby
. Allay fear of mother-----let mom listen to FHT
. Development Task: Prepare for birth & Parenting of child
. Focus: Responsible parenthood ---best time to prepare ―baby’s Layette‖ Lamaze
class, shopping.

18
 ASSESSING THE PREGNANT WOMAN DURING PRENATAL VISIT

FREQUENCY OF VISITS:
st
1 7 months - 1x a month
th th
8 - 9 months - 2 x a month
th
10 month - once a week
Post-term - 2 x a week

COMPONENTS OF VISITS:

1. Personal Data: Home Base Mother’s Record

a. Name
b. Age
c. Civil Status
d. Address
e. Educational level
f. Occupation
g. Religion, culture, beliefs

2. Diagnosis of Pregnancy
1. Home Pregnancy Kit - do it yourself, 1 bar (-), 2 bar (+)
th
2. Urine Exam - to test for HCG, present on 4 0 - 1 0 0 day of pregnancy
th th
*Peak of HCG: 60 -70 day
*Perform Urine test: 6 weeks after LMP

3. Elisa Test - test for early pregnancy to detect beta subunit of HCG as early as 7 - 10days

3. Initial Physical Assessment

a. V/S especially BP
*Roll-Over Test - to determine pre-eclampsia
- Side-lying position 10- 15 mins then supine, get BP, if > 30/15mmHg (+)

b. Monitor patterns of weight gain

st
1 Trimester: Normal Weight Gain (.5 - 1lb/month)
nd 1.5 - 3 lbs
2 Trimester: Normal Weight Gain 10 - 12 lbs (4 lbs/month) or lb/wk)
rd
3 Trimester: Normal Weight 10 - 12 lbs (1 (4 lbs/month) lb/wk)
Gain or (1
st
*Increase wt - 1 sign preeclampsia
*Minimum Wt Gain: 20 - 25 lbs (9 - 11 kg)
*Optimal Wt Gain: 25 - 35 lbs (11 - 15 kg)

4. Obstetrical Data
a. Date of Last Menstrual Period / LMP - get the FIRST day
b. GP - Gravida, Para
c. GTPAL: - Gravida, Term, Preterm, Abortion, Living
*Twins: considered as 1 pregnancy

5. Important Estimates:
a. Nagele’s Rule : Determines expected date of delivery (EDD or EDC) based on LMP
Formula:
If LMP: January - March = + 9 months + 7 days

April - December = - 3 months + 7 days + 1 year

b. McDonald’s Rule : Determines age of gestation (AOG) in WEEKS, if LMP is NOT available
Formula:
Fundic Height (measure from symphysis pubis to fundus) in cm x 7 / 8 = AOG in weeks

c. Bartholomew’s Rule: Determines AOG by proper location of fundus at abdominal cavity.

Formula:

3 Months: Just above symphysis pubis

5 Months: Level of umbilicus
9 Months: Below xiphoid process
10 Months: Level of 8 months d/t lightening (32 wks.)

19
5. Important Estimates:

d. Haase’s Rule: Use to determine length of the fetus in cm.

Formula:
2
First half of pregnancy = month
Second half of pregnancy = month x 5

3mos x 3 = 9cm 6 x 5 = 30 cm
st ND
4 mos x 4 = 16 cm 1 ½ of pregnancy 7 x 5 = 35 cm 2 ½ of pregnancy
5 x 5 = 25 cm 8 x 5 = 40 cm
9 x 5 = 45 cm
10 x 5 = 50 cm

6. Physical Examination:

a. Head to Toe / Cephalocaudal

- Systemic and Local Changes
- Examine teeth: if staining occurs-----sign of infection

b. Danger Signs of Pregnancy “CABBBBSSS”

- Chills & Fever = infection, cerebral problems, pre eclampsia
- Abdominal pain = epigastric pain: aura of impending convulsions
- Board-like abdomen = abruptio placenta
- BP elevation = HPN
- Blurred vision = preeclampsia
st
- Bleeding = 1 trimester: -------Abortion, Ectopic Pregnancy
nd
2 trimester: H Mole & Incompetent
rd
Cervix 3 trimester: Placental Anomalies
- Sudden gush of fluid = premature Rupture of Membranes/ PROM prone to----- infection
- Swelling = edema to upper extremities ----preeclampsia
- Scotoma- = spots on eye------------------------preeclampsia

c. Leopold’s Maneuver
- Done 5 months beyond, to determine the attitude, fetal presentation, lie, presenting part, degree
of descent, an estimate of the size & # of fetuses, position, fetal back ( best site for FHT) & FHT.
- Empty bladder
- Position mother: Dorsal Recumbent : supine w/ knee flex to relax abdominal muscles)
- Use palm! Warm palm by rubbing briskly w/ each other
- Terms
*Attitude – relationship of fetus to its part – or degree of flexion
*Full flexion – when the chin touches the chest

- Procedure:
st
1 maneuver: To determine presentation:
Place patient in supine position with knees slightly flexed; put towel under, head & right hip; w/
both hands palpate upper abdomen & fundus. Assess size, shape, movement & firmness of
the part Determine Presenting Parts: immovable, round, ballotable

nd
2 Maneuver: To determine the fetal back for site of FHT
W/ both hands moving down, identify the back of the fetus (to hear FHT) where the ball of
nd
the stethoscope is placed to determine FHT. *Take Pulse before 2 maneuver to differentiate
between Fundic soufflé (FHR) & uterine soufflé (MHR)

rd
3 Maneuver: To determine degree of engagement.
Using the right hand, grasp the symphysis pubis part using thumb & fingers. Assess whether
the presenting part is engaged in the pelvis ) . Alert : if the head is engaged it will not be movable).

th
4 Maneuver: To determine attitude – relationship of fetus
Examiner changes the position by facing the patient’s feet. With 2 hands, assess the descent of
the presenting part by locating the cephalic prominence or brow.
When the brow is on the same side as the back, the head is extended.
When the brow is on same side as the small parts, head will be flexed & vertex presenting.

20
7. Diagnostic and Laboratory Examination:

a. Pelvic Examination or Internal Examination (IE)

st
. Done in 1 Trim to check for presence of (+) signs – Goodel’s sign
nd
. Done on 2 Trim to determine premature cervical effacement and dilatation or preterm labor
rd
. Done on 3 Trim to check for progress of labor
- Empty bladder
- Position in lithotomy, lift 2 legs at the same time
- Don’t attempt IE if (+) bleeding
- Universal precaution, wear gloves
- Estimate the degree of effacement and dilatation

b. Pap Smear ( Papanicolau Test)

- Cytological exam to determine presence of cancer cells/ Cervical Cancer
- External OS of cervix – site for getting the specimen
- Common site for cervical cancer-----External OS of Cervix
- Cancer cells ----composed of squamous columnar tissue
- Result:
Class I – Normal
Class IIA – Maybe abnormal but no evidence of malignancy
Class IIB – Suggestive of inflammation
Class III – Cytology suggestive of malignancy
Class IV – Cytology strongly suggestive of malignancy
Class V – Cytology conclusive of malignancy

- Stages of Cervical Cancer:

0 – Carcinoma in situ
1 – Cancer confined to cervix
2 –Cancer from cervix extends to vagina (upper 2/3 of vagina)
3 – Pelvis metastasis (pelvic wall)
4 – Affection to bladder & rectum

ASSESSING THE FETUS DURING PRENATAL VISIT

1. ULTRASOUND / UTZ

2. FETAL HEART RATE

3. FETAL MOVEMENT TEST

4. NONSTRESS TEST

5. CONTRACTION STRESS TEST

6. AMNIOCENTESIS

7. CHORIONIC VILLUS SAMPLING (CVS)

8. ESTRIOL LEVELS - MOTHER

9. PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS)

10. LECITHIN/ SPHINGOMYELIN RATIO (2:1)

11. BIOPHYSICAL PROFILE (BPS)

12. AMNIOTIC FLUID EVALUATION

21
 ASSESSING THE FETUS DURING PRENATAL VISIT

1. ULTRASOUND / UTZ
- Response of sound waves against objects
- Allows visualization of the uterine content
- TRANSABDOMINAL UTZ= full bladder, client lies on her back
- TRANSVAGINAL UTZ = probe is inserted in the vagina, lithotomy position, empty bladder
- Diagnose pregnancy as early as 6 weeks
- Confirm the presence, size and location of the placenta and amniotic fluid
- Establish that the fetus is growing and has no gross defects (eg, hydrocephalus, anencephaly, spinal cord,
heart, kidney and bladder defects)
- Establish the presentation and position of the fetus (sex can be diagnosed)
- Predict maturity by measurement of the biparietal diameter (BPD)
- discover complications of pregnancy / fetal anomalies

2. FETAL HEART RATE

- FHR should be 120-160 beats per minute
th
- Can be heard with a Doppler : 10 – 11 week of pregnancy
- Fetoscope: 18-20 weeks

3. FETAL MOVEMENT TEST

- Begin > 27 wks of pregnancy
- Components:
1. Fetal Sleep-Wake Pattern
2. Maternal Food intake
3. Drug use, nicotine use
4. Environment stimuli
- 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
- Begin at the same time each day (usually in the morning, after breakfast)
- Done after a meal or breakfast when mother is full & count each fetal movement
- Note how long it takes to count 10 fetal movements (FMs)
- Expected Findings: Normal: 10-12 movements / hour
- WARNING SIGNS:
1. More than 1 hour to reach 10 movements
2. Less then 10 movements in 12 hours (non-reactive- fetal distress)
3. Longer time to reach 10 FMs than on previous days
4. Movement are becoming weaker, less vigorous
5. *Movement Alarm Signals: < 3 FMs in 12 hours
6. Warning signs should be reported to healthcare provider immediately; often require further
testing. Examples: nonstress test (NST), biographical profile (BPP)

4. NONSTRESS TEST:
- To determine the response of the fetal heart rate to activity
- Indication – pregnancies at risk for placental insufficiency
1. PIH, DM
2. Warning signs noted during DFMC
3. Maternal history of smoking, inadequate nutrition
4. Post maturity
- Procedure:
1. Donew/n 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor)
2. External monitor is applied to document fetal activity
3. Mother activates the ―mark button‖ on the electronic monitor when she feels fetal movement.
4. Monitor until at least 2 FMs are detected in 20 minutes
 If no FM after 40 minutes provide woman with a light snack or gently stimulate
fetus through abdomen
 If no FM after 1 hour, further testing may be indicated, such as a
CST - Interpretation of Results
1. REACTIVE RESULT
a. Baseline FHR between 120 & 160 beats per minute
b. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least
15 seconds in a 10 to 20 minute period as a result of FM
c. Good variability – normal irregularity of cardiac rhythm representing a balanced
interaction between the parasympathetic (decreases FHR) & sympathetic (increase FHR)
nervous
system; noted as an uneven line on the rhythm strip.
d. Result indicates a healthy fetus with an intact nervous system

2. NONREACTIVE RESULT
a. Stated criteria for a reactive result are not met
b. Could be indicative of a compromised fetus.

22
 c. Requires further evaluation with another NST, biophysical profile, (BPP), Or
contraction stress test (CS

3. UNSATISFACTORY - The result cannot be interpreted because of the poor quality of the
FHR tracing.

5. CONTRACTION STRESS TEST

- Assesses placental oxygenation and function
- Determines fetal ability to tolerate labor and determines fetal well-being
- Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under
simulated labor conditions.
- External fetal monitor is applied to the mother, and a 20 to 30 minute baseline strip is recorded.
- The uterus is stimulated to contract by the administration of a dilute dose of oxytocin or by having the mother
use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in a 10 minute period
have been achieved.
- Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of
oxytocin are given.
- RESULTS OF CST:
1. NEGATIVE CST/ NORMAL = no late or variable decelerations of FHR
2. POSITIVE CST/ ABNORMAL = late or variable decelerations of FHR with 50% or more of
the contractions in the absence of hyperstimulation of the uterus.
3. EQUIVOCAL - with decelerations but with less than 50% of the contractions, or the uterine
activity shows a hyperstimulated uterus.
4. UNSATISFACTORY - adequate uterine contractions cannot be achieved, or the FHR tracing is
not of sufficient quality for adequate interpretation.

6. AMNIOCENTESIS
- Amniotic fluid is aspirated by a needle inserted through the abdominal and uterine walls; indicated early
in pregnancy (14-17 wk) to detect inborn errors of metabolism, chromosomal abnormalities, open NTD (neural
tube defect); determine sex of fetus and sex-linked disorders after 28 wk; determine lung maturity.
- Indicated for pregnant women 35 years and older; couples who already have had a child with a genetic
disorder; one or both parents affected with a genetic disorder; mothers who are carriers for X-linked disorders

7. CHORIONIC VILLUS SAMPLING (CVS)

- Transcervical aspiration of chorionic villi that allows for first trimester (8-12 wk) diagnosing of genetic
disorders comparable to amniocentesis (except for NTD); preprocedure: there should be full bladder; ultrasound
is used as in amniocentesis; post procedure: precautions as for amniocentesis

8. ESTRIOL LEVELS
- Serial 24-h maternal urine samples or serum specimens to determine fetoplacental status; falling levels
usually indicate deterioration

9. PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS)

- Second- and third-trimester method to aspirate cord blood (location identified by ultrasound) to test for
genetic conditions, chromosomal abnormalities, fetal infections, hemolytic or hematological disorders

10. LECITHIN/ SPHINGOMYELIN RATIO (2:1)

- Important components of surfactant, a phosphoprotein that lowers surface tension of the lungs that
facilitates extrauterine expiration

11. BIOPHYSICAL PROFILE (BPS)

- Assesses 4 to 6 parameters
1. fetal breathing movement
2. fetal movement
3. fetal tone
4. amniotic fluid volume
5. placental grading
6. fetal heart reactivity/ reactive NST
- Each item has a potential for scoring a 2; 12 highest possible score
- BPS 8 - 10: fetus is doing well
- BPS 4 - 6: fetus is in jeopardy

12. AMNIOTIC FLUID EVALUATION

- Color:
1. Yellowish - Jaundice/ Hyperbilibirubinemia
2. Greenish - Meconium stained
3. Cloudy - infection

- Amnioscopy: direct visualization or exam to an intact fetal membrane.

- Fern Test: determine if bag of water has ruptured or not. Done for laboring mother
- Nitrazine Paper Test: used to differentiate amniotic fluid & urine.
1. Paper turns yellow - urine only, membranes intact.
2. Paper turns blue green/gray-(+) rupture of amniotic fluid.

23
 ADDRESSING THE NEEDS OF PREGNANT CLIENT

A. NUTRITION
- High Risk Mothers For Nutrition:
1. Pregnant Teenagers: poor compliance to heath regimen.
2. <18 y/o & >35 y/o
3. Extremes in weight: underweight----malnourished, Overweight-----candidate for HPN, DM
4. Low socio – economic status
5. Vegetarian mothers---decrease CHON
= CHON is important for Vit. B12 – cyanocobalamin, folic
acid, and DNA & RBC formation

*Decrease folic acid----leads to Spina Bifida/Open Neural Tube Defect

- Assessment:
1. Ask the daily food intake
2. Needed calories of the mother
st
1 Trimester----no change
nd rd
2 & 3 Trimester---additional 300kc/day (total of 2,500)
Lactating mother----- + 500 (total of 2,700)
Non-pregnant---------2,200 only
3. How many Kcal: 1 CHO X 4, CHON x 4, FATS x 9 = Total recommended Calories
4. Sodium: 3g/day (eat in moderation)

- Assessment of WEIGHT GAIN during

pregnancy: Fetus 7 Lbs
Placenta 1 Lb
Amniotic Fluid 1.5 Lbs
Increased weight of uterus 2 Lbs
Increased Blood Volume 1 Lb
Increased weight of breasts 1.5-3 Lbs
Weight of Additional Fluid 2 Lbs
Fat & Fluid Accumulation 4-6 Lbs.
20 – 25 lbs

Recommended Nutrient Requirement That Increases During Pregnancy

Nutrients Requirements Food Source

Calories:
Essential to supply energy for
- Increased metabolic rate
- Utilization of nutrients
- Protein sparing so it can be
used for
- Growth of fetus
- Development of structures
required for pregnancy including
placenta,
amniotic fluid & tissue growth.
Protein
Essential for:
- Fetal tissue growth
- Maternal tissue growth
including uterus & breasts
- Development of
essential pregnancy
structures
- Formation of RBC &
plasma proteins
* Inadequate protein intake has been
associated with onset of PIH
Calcium-Phosphorous
Essential for
- Growth & dev’tof
fetal skeleton & tooth
buds
- Maintenance of
mineralization of maternal
bones and teeth
- Demonstrating an
association between
adequate calcium
intake & the prevention of PIH
300 calories/day above the
pre-pregnancy daily requirement to
maintain ideal body weight & meet
energy requirement to activity level
- Begin increase in second trimester
- Use weight – gain pattern as an
indication of adequacy of
calorie intake.
- Failure to meet caloric req. lead to
ketosis as fat & protein are used for
energy; ketosis associated with
fetal damage.
60 mg/day or an increase of 10% above daily requirements forage group
Adolescents have a higher protein
requirement than mature women since
adolescents must supply protein for their
own growth as well as protein to meet
the pregnancy requirement
Ca increases of
- 1200 mg/day representing an increase
of 50% above pre-pregnancy/ day
requirement.
- 1600 mg/day is recommended for
the adolescent. 10 mcg/day of Vit. D
is
require, it enhances absorption of
both calcium & phosphorous
Caloric increase should reflect
- Foods of high nutrient
value such as protein,
complex
carbohydrates (whole
grains, vegetables, fruits)
- Variety of foods
representing foods sources
for the nutrients requiring
during pregnancy
- No more than 30% fat
Protein increase should reflect
- Lean meat, poultry, fish
- Eggs, cheese, milk
- Dried beans, lentils, nuts
- Whole grains
*Vegetarians must take note
of the amino acid content of
CHON foods consumed to
ensure ingestion of sufficient
quantities of all amino acids
Calcium increases should
reflect:
- Dairy products : milk,
yogurt, ice cream,
cheese, egg yolk
- Whole grains, tofu,Green
leafy vegetables
- Salmon & sardines
w/ bones
- Ca fortified foods such
as orange juice
- Vitamin D : fortified
milk, margarine, egg
yolk,
butter, liver, seafood

24
 Nutrients Requirements Food Source

Iron 30 mg/day representing a doubling of Iron increases should reflect:

Essential for the pregnant daily requirement
- Expansion of blood volume & - Liver, red meat,
RBC formation - Begin supplementation at 30- fish, poultry, eggs
- Establishment of fetal iron mg/day in 2nd trimester, since diet - Enriched, whole
stores for first few months of life alone is grain cereals &
unable to meet pregnancy requirement breads
PICA - 60 - 120 mg/day along with copper - Dark green leafy
PSEUDOCYESIS & zinc supplementation for women vegetables, legumes
COUVADE SYNDROME who have low hemoglobin values - Nuts, dried fruits
prior to pregnancy or who have IDA - Vit. C sources: citrus
IRON INTAKE DOUBLES DURING - 70 mg/day of Vit. C which fruits & juices,
PREGNANCY enhances iron absorption strawberries,
*Not given in the 1st half of - Inadequate iron intake results in cantaloupe, broccoli or
pregnancy-----aggravate maternal effects - anemia depletion of cabbage, potatoes
discomfort in the 1st half (nausea & iron stores, decreased energy & - Iron from food sources
vomiting) appetite, cardiac stress esp. labor is more readily absorbed
-----GIT irritation---iron & birth when served with
cause constipation----- - Fetal effects decreased availability foods high in Vit. C
blakish of oxygen, affecting fetal growth
discoloration of stool * Iron deficiency anemia is the most
*Last 4 wks. ----greatest need— common nutritional disorder of pregnancy.
fetus acquires iron reserves
Zinc
Essential for 15mcg/day representing an increase of 3 Zinc increases should reflect
* The formation of enzymes mg/day over pre-pregnant daily - liver, meats
* Maybe important in the prevention requirements. - shellfish
of congenital malformation of the - eggs, milk, cheese
fetus. - whole grains, legumes,
nuts
Folic Acid, Folacin, Folate
Essential for 400 mcg/day representing an increase of Increases should reflect
- Formation of RBC & prevention more then 2 times the daily prepregnant - liver, kidney, lean beef, veal
of anemia requirement. 300mcg/day supplement for - dark green leafy
- DNA synthesis & cell formation; women with low folate levels or dietary vegetables, broccoli,
may play a role in the prevention deficiency legumes.
of neutral tube defects (spina *4 servings of grains/day - Whole grains, peanuts
bifida), abortion, abruption
placenta
Additional Requirements
Minerals Increased requirements
1. Iodine 175 mcg/day of pregnancy can easily be
2. Magnesium 320 mg/day met with a balanced diet that
3. Selenium 65 mcg/day meets the requirement for
calories & includes food
sources high in the other
nutrients needed during
pregnancy.
Vitamins
1. E 10 mg/day Vit. stored in body
2. Thiamine 1.5 -Fat soluble Vits.---ADEK
3. Riborlavin mg/day 1.6 -Not taken daily, can lead
4. Pyridoxine ( B6) mg/day 2.2 to toxicity. Hard to excrete.
5. B12 mg/day 2.2
6. Niacin mg day
17 mg/day

B. IMMUNIZATION:
- Tetanus Immunizations
- Best way to prevent tetanus neonatorum
- Given 5 times
- Mother w/ complete 3 doses DPT in childhood considered as TT1 & 2. Begin TT3

TT1 - any time during pregnancy - None

TT2 - 4 wks after TT1 or 1 month - 3 yrs protection
TT3 - 6 months after TT2 - 5 yrs protection
TT4 - 1 yr after TT3 - 10 yrs protection
TT5 - yr after TT4 - lifetime protection

25
C. SEXUAL ACTIVITY
- Principles
1. Allowed until the last 6 weeks of pregnancy as long as there are no
contraindications a. Bleeding / Vaginal Spotting
b. Incompetent Cervical Os
c. Deeply Engaged Presenting Part
d. Ruptured Bow and preterm labor
2. Should be done in moderation
3. Should be done in private place
4. Mother placed in comfortable position: side-lying or mom on top
5. Avoided 6 weeks prior to EDD
6. Avoid blowing of air during cunnilingus to prevent air embolism

- Changes in Sexual Desire During pregnancy:

st
1 . 1 Trimester – decrease desire – d / t bodily changes, nausea, fatigue & sllepiness.
nd
2. 2 trimester – increased desired/t increase estrogen that enhances lubrication
rd
3. 3 trimester – decreased desire due to fatigue & physical bulkiness

D. EXERCISE
- Done during pregnancy to strengthen muscles that will be used during delivery process
- Principles
1. Done in moderation
2. Must be individualized
- Examples

1. Walking - Best form of exercise

2. Squatting - Strengthen muscles of perineum & increase circulation to

perineum -Squat – feet flat on floor
-Watch out for postural hypotension----raise buttocks before head

3. Tailor Sitting -same with squatting, 1 leg in front of other leg ( Indian seat)

4. Kegel Exercise - strengthen pulococcygeal muscles (done 15 minutes/3x/day)

- As if holding urine, release 10x or muscle contraction

5. Shoulder Circling Exercise - strengthen chest muscles

6. Pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture
* Arch back – standing or kneeling. Four extremities on floor

7. Abdominal Exercise – strengthens muscles of abdomen– done as if blowing candle

E. NEEDS OF THE FATHER/ PATERNAL REACTIONS TO PREGNANCY:

1. First trimester = ambivalence & anxiety about role change; concern for identification
with mother’s discomforts ( Couvade syndrome)
2. Second trimester = increased confidence & interest in mother’s care; difficulty relating to
fetus; ―jealousy‖
3. Third trimester = changing self concept; concern about body changes , active involvement
in common fears about delivery, mutilation or death of partner or fetus

F. SIBLING REACTIONS TO PREGNANCY:

1. Normal rivalry dependent on developmental stage
2. May need increased affection & attention
3. Regression in behavior ( may appear in bedwetting & thumb sucking); rejection

G. CHILDBIRTH PREPARATION:
- Overall goal: To prepare parents physically & psychologically while promoting wellness behavior
that can be used by parents & family thus, helping them achieved a satisfying & enjoying
childbirth experience.
- PSYCHOPHYSICAL
1. Bradley Method : By Dr. Robert Bradley
- Advocated active participation of husband as a coach at delivery process.
- Based on imitation of nature.
- Features:
a. Darkened room
b. Quiet environment
c. Relaxation technique
d. Closed eye & appearance of sleep

*Environmentt of Womb: warm,darkened,fluid-filled,quiet

26
 - PSYCHOPHYSICAL

2. Grantly Dick Reed Method

- Based on concept that fear leads to tension while tension leads to pain
- To decrease pain is to relieve fear
- Abdominal health exercise & relaxation technique

- PSYCHOSEXUAL
1. Kitzinger Method : By Dr. Shela Kitzinge
- ―Pregnancy, labor, birth & care of newborn is an important turning point in the
woman’s life cycle‖
- Flow with contraction than struggle with contraction

- PSYCHOPROPHYLAXIS: PREVENTION OF PAIN

1. Lamaze: By Dr. Ferdinand Lamaze
- Prevention of pain thru the mind requiring discipline, conditioning & concentration
w/ the help of the husband to serve as a coach
- Features:
a. Conscious Relaxation-relaxing the body part by part
b. Cleansing Breathe - inhale thru nose, exhale thru mouth
c. Effleurage – gentle circular massage over abdomen to relieve
pain d. imaging – sensate focus, imagining favorite person

- DIFFERENT METHODS OF DELIVERY:

1. Birthing chair – bed convertible to chair – semi-fowler’s position
2. Birthing bed – Dorsal recumbent pos
3. Squatting Position – relieves low back pain during labor
4. Leboyer’s Method – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.
5. Birth underwater – bathtub – labor & delivery – warm water, soft music.

PRENATAL CARE (ANTEPARTUM CARE)

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

27
 INTRAPARTUM: THE WOMAN IN 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

THEORIES OF THE ONSET OF LABOR:

1. Uterine Stretch Theory
- Any hallow organ stretched, will always contract & expel its content

2. Oxytocin Stimulation Theory

- Posterior Pituitary Gland releases oxytocin---stimulates contraction.

3. Progesterone Deprivation Theory

- Progesterone maintains pregnancy by its relaxant effect on the smooth muscles of the uterus
as pregnancy nears term, progesterone production

4. Prostaglandin Theory
- Stimulation of Arachidonic Acid – prostaglandin- contraction. (Fetal-Adrenal Response Theory)

5. Theory of Aging Placenta

- Life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).

FOUR P’s OF LABOR:

1. Passenger - Baby
2. Passageway - Pelvis, Cervix and Vagina
3. Power - Force of Muscular Contractions
4. Placental Factor - Placental Position / Implantation
5. Psyche - Mother’s Perception

I. PASSENGER (Baby):

Fetal head – the most common, largest and least compressible presenting part:
Common presenting part – ¼ of its length.

A. Bones
1. Sphenoidal
2. Frontal
3. Ethmoidal
4. Temporal
5. Parietal

B. Membrane spaces - suture lines are important because they allow the bones to move and
overlap, changing the shape of the fetal head in order to fit through the birth
canal, a process called molding.
1. Sagittal suture line - joins the 2 parietal bones.
2. Coronal suture line - joins the frontal bone and the parietal bones.
3. Lambdoidal suture line

C. Fontanels - membrane – covered spaces at the junction of the main suture lines:
1. Anterior fontanel - larger, diamond shaped fontanel , closes between 12 to 18 months
2. Posterior fontanel - smaller triangular shaped fontanel, closes between 2-3 months
3. Vertex - space between the two fontanels

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 2. Antero-Posterior Diameter

. Biparietal : 9.25 cm (largest TD) - Suboccipitobregmatic: 9.5 cm (smallest
AP)
. Bitemporal: 8 cm - Occipitofrontal : 12 cm
. Bimastoid : 7cm (smallest TD) - Occipitomental : 12. 5– 13. 5 cm(widest
AP)
- Submentobregmatic: face presentation

28
 2. AnteroPosterior Diameter
. Suboccipitobregmatic – From below the Occiput to the anterior fontanel
- 9.5 cm (complete flexion, smallest AP)
. Occipitofrontal – From Occipital prominence to the bridge of the nose
- 12 cm partial flexion
. Occipitomental – From the posterior fontanelle to the chin
- 13.5 cm 13.5 cm hyper extension (widest)
. Submentobregmatic – Face presentation

Presentation / Lie / Attitude

- Presentation refers to the body part of the fetus that is in the mother’s pelvis
- Lie is the relationship of long axis (spine) of the fetus to the long axis / spine of the mother
- Attitude refers to the degree of flexion or extension of the presenting part.
Two Types of Lie and Presentation:
A. Longitudinal Lie ( Parallel) or ―Vertical‖
1. Cephalic
. Vertex/Occiput – Complete flexion
. Sinciput/Forehead – Moderate Flexion
. Face
. Brow Poor Flexion
. Chin and Complete Extension

2. Breech
. Complete Breech - Thigh breast on abdomen, breast lie on thigh , good flexion
. Incomplete Breech - Thigh rest on abdominal
. Frank - Legs extend to head, partial flexion
. Footling - Single, double
. Kneeling
*** if breech, put stethoscope above umbilicus to get the FHT

B. Transverse Lie (Perpendicular) or ―Horizontal‖ = Shoulder presentation, hand, elbow or iliac

crest. *Causes of transverse lie:
1. Multiparity
2. Contracted pelvis
3. Placenta previa

*Possible injuries in breech presentation:

1. Cord prolapse/cord compression
2. Intracranial hemorrhage caused by unmolding
3. Erb’s paralysis
4. Hip dislocation
5. Fracture of the clavicle
6. Premature separation of the placenta

Position – relationship of the fetal presenting part to specific quadrant of the mother’s pelvis.
4 Quadrants of the maternal pelvis:
1. Right anterior
2. Left anterior
3. Right posterior
4. Left posterior
5. Transverse

4 Parts of Fetus as Landmarks:

1. Occiput ―o‖ – vertex presentation 5. A - Anterior
2. Mentum ―m‖(chin) –face presentation 6. P - Posterior
3. Sacrum ― sa‖ – in breech presentation 7. T - Transverse
4. Scapula ―sc‖ – in shoulder presentation

Types of Fetal Position:

A. Occipito:
1. LOA – Left Occipito Anterior, most common & favorable position
2. ROA – Right Occipito Anterior second most common position
3. LOP – Left Occipito Posterior, most common malposition, most painful
4. ROP – Right Occipito Posterior, squatting position for mother

B. Breech- Use sacrum (Sacro)

1. LSA – Left Sacro Anterior
2. LSP
3. RSA
4. RSP

29
 Types of Fetal Position:

C. Shoulder / Acromniodorso D. Chin / Mento

1. LADA 1. LMA
2. LADT 2. LMT
3. LADP 3. LMP
4. RADA 4. RMA
5. RADT 5. RMT
6. RMP

Station – refers to the relationship of the presenting part of the fetus to the level of the ischial spines.
1. Station 0 = presenting part is at the level of the ischial spines ( synonymous to engagement)
2. Station - 1 = presenting part is 1cm above the ischial spines
3. Station +1 = presenting part is 1cm below the ischial spines
4. Station +3 or +4 = presenting part is at the perineum & can be seen if the vulva is
separated; Synonymous to ―crowning‖ . (Encircling of the largest
diameter of the fetal head by the vulvar ring).

II. PASSAGEWAY
Components: Problems in Passageway:
1. Pelvis 1. Mother < 4’9‖ tall
2. Cervix 2. < 18 years old
3. Vagina 3. Pelvis type
4. Underwent pelvic dislocation, or accident (cephalopelvic disproportion)
5. Scars, Tumors, Inflammatory and infectious conditions
mother’s genitourinary tract

4 Main Pelvic Types:

1. Gynecoid Normal female pelvis. Round, wide, deeper most suitable for
2. Android pregnancy Male pelvis. Heart shape- anterior part pointed, posterior
3. Anthropoid part shallow
4. Platypelloid Ape like pelvis. Oval shape, AP diameter wider, transverse narrow
Flat pelvis. AP diameter – narrow, transverse – wider
*Gynecoid & Anthropoid- can deliver vaginally

Bones of Pelvis-----4 bones:

1. 2 Hip Bones
2. 2 Innominate bones: 3 Parts

a. Ileum Lateral side of hips

*Iliac Crest – flaring superior border forming prominence of hips
b. Ischium Lnferior portion
*Ischial tuberosity where we sit: landmark to get external measurement of pelvis
c. Pubes Anterior portion
*Symphysis pubis- junction between 2 pubis
d. 1 sacrum Posterior portion
*Sacral prominence – landmark to get internal measurement of pelvis
e. 1 coccyx 5 small bones that compresses during vaginal delivery

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.
False pelvis is divided from the true pelvis only by an imaginary line: the
linea terminalis drawn from the sacral prominence at the back to the superior
aspect of the symphysis pubis at the front of the pelvis. **

2. True pelvis – ―Inferior half‖; formed by the pubes in front, the ilia & the ischia on the sides &
the sacrum & coccyx behind.
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

-Space between the inlet & the outlet. This is not a straight but a curved passage.

c. Pelvic outlet
-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) .
Transverse diameter = 11.5 cm **AP diameter 9.5 to 11.5 cm

30
 Important Measurements:
1. True conjugate/ conjugata vera - Distance between the midpoint of the sacral promontory to the
upper margin of the symphysis pubis. Very important measurement because it
is the
diameter of the pelvic inlet.
Average = 11 - 11.5 cm.

2. Diagonal conjugate - Distance between the midpoint of the sacral promontory to the lower margin
of the symphysis pubis. (measured by internal examination)
Average = 11.5 to 13 cms

3. Obstetric conjugate – Smallest diameter. Distance between the mid point of sacral promontory to
the midline of the symphysis pubis which is ascertained by subtracting 1 to
1.5 cm from the diagonal conjugate.
Average = 10 - 11 cm

4. Tuberoischi Diameter – transverse diameter of the pelvic outlet.

Ischial tuberosity – approximated with use of fist during lithotomy: 8 cm & above.

***Trial Labor—if passageway & fetus head exactly the same size

Cervical Changes (IE):

1. Effacement – shortening & thinning of the cervical canal. Normally the canal is 1-2 cm long.
- with effacement, this canal virtually disappears.
- expressed in percentage (%) = fully effaced is 100 %

2. Dilatation – enlargement of the cervical canal from an opening a few millimeters wide to
one large enough to permit passage of the fetus.
- expressed in centimetres (cm) = 1 to 10 cm, fully dilated is 10 cm

Vaginal Changes:
1. Thinning of vaginal wall – bleeding and hematoma
2. Swelling or vulvar edema – difficult labor
3. Possible infections – transfer to baby

III. POWER - the forces acting to expel the fetus & placenta *Myometrium – smooth muscle contraction
Components:
1. Involuntary Contractions
2. Voluntary bearing down efforts

Elements / Characteristics of Contraction:

1. Duration - from beginning to end of one contraction
2. Frequency - from beginning of one contraction to the beginning of next contraction
3. Interval - from end of one contraction to the beginning of next contraction
4. Intensity - strength of uterine contractions
a. Mild - fundus is slightly tensed, indentable with fingers
b. Moderate - fundus is firm, difficult to indent
c. Strong - fundus is hard and rigid, cannot be indented

Phases of Contractions:
1. Increment - when intensity of contractions increase
2. Acme - peak or strongest point of contraction
3. Decrement - when the intensity of contractions decrease

Uterine Changes during contractions:

1. Upper segment - thicker, active
2. Lower segment - thin walled, supple, passive
3. Middle segment - ridge, ―Physiologic Retraction Ring‖
- becomes ―Pathologic Retraction Ring or Bandl’s Ring‖ in difficult
labor, seen as abdominal indentation

IV. PLACENTAL IMPLANTATION

1. Implanted normally in the fundal portion of the uterus (anterior or posterior), it rarely cause
trouble during labor & delivery.
2. When malimplanted the lower uterine segment, it necessitates medical or surgical intervention (CS).

V. PSYCHE/PERSON - psychological stress when the mother is fighting the labor experience
1. Cultural Interpretation
2. Preparation
3. Past Experience
4. Support System

31
 ASSESSMENT AND CARE DURING LABOR
PRELIMINARY SIGNS OF LABOR

1. Lightening - Settling of presenting part into pelvic brim.

- Primi: 2 weeks prior to EDD, Multipara- hours before labor
2. Engagement - setting of presenting part into pelvic inlet
Effects of Lightening & Engagement:
a. Increase in urinary frequency
b. Relief of abdominal tightness & diaphragmatic pressure
c. Shooting pains down the legs due to pressure on the sciatic
nerve. d. Increase in the amount of vaginal discharges
e. Loss of weight of about 2-3 lbs one to two days before labor onset = decrease in
progesterone thus decrease in fluid retention
f. Ripening of the cervix = from Goodel’s sign the cervix becomes ―butter soft‖
3. Braxton Hicks Contractions - painless irregular contractions
4. Increase Activity of the Mother - ―Nesting instinct‖ d/t sudden rush of epinephrine
- Mgt: Conserve energy, will be used for delivery.
- Fatigue may affect the type of anesthesia used
5. Bloody Show / Pink Show - Pinkish vaginal discharge (Blood + Leucorrhea + Operculum)
6. Rupture of Membranes - Means that delivery will take place within 24 hours

Complications of Premature Rupture of Membranes / PROM:

a. Cord Prolapse – a complication when u. cord falls/ is washed thru the cervix into the vagina.
Cord compression of 5 minutes leads to irreversible brain damage--cerebral palsy
b. Fetal Distress
c. Infection

Nursing Care:
a. Bring mother immediately to bed and check the FHT
b. Place mother in Knee – Chest or Trendelenburg Position
c. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery
& prevent cord compression
d. Slip cord away from presenting part using gloved hand
e. Count pulsation of cord for FHT
f. Protect from infection, no to enema, limit invasive vaginal examinations (IE)
g. Prepare for CS
h. Provide emotional support

SPECIFIC SIGN OF LABOR

The surest sign that labor has begun is the initiation of effective productive uterine contractions.

Difference between True Labor & False Labor

False Labor True Labor

Irregular contractions
No increase in intensity
Pain – confined to
abdomen Pain – relieved
by walking
No cervical changes
Contractions are regular
Increased intensity
Pain – begins lower back radiates to abdomen
Pain – intensified by walking
Cervical effacement & dilatation--Major Sx of true labor.

Immediate Care of Woman In Labor:

1. Admitting the laboring Mother – privacy and comfort
2. Personal Data – name, age, address, etc
3. Baseline Data – v/s especially BP, weight
4. Obstetrical Data – gravida # preg, para- viable preg, – 22 – 24 wks
5. Pelvic Exam / IE – empty bladder
6. Physical Exam – FHT, other s/s

DURATION / LENGTH OF LABOR:

Stage Primipara Multipara
st
1. 1 Stage 10 - 12 hrs 6 - 8 hrs
nd
2. 2 Stage 30 min -2 20min – 1.5 hrs
hrs Ave. 50 Ave. 20 min
3.
rd
3 Stage min
th
5 - 20 min
4. 4 Stage 5 - 20 min 2 - 4 hrs
2 - 4 hrs

32
 ASSESSMENT AND CARE DURING STAGES OF LABOR
STAGES OF LABOR:

A. First Stage - Onset of true contractions to full dilation & effacement of cervix.

1. Latent Phase:
Dilations: 0 – 3 cm
Frequency: every 5 – 10 min
Duration: Less than 30 seconds
Intensity: Mild
Mother: Excited, apprehensive, can communicate

Care:
st
. Encourage walking - shorten 1 stage of labor
. Encourage to void q 2 – 3 hrs : Full bladder inhibit contractions
. Breathing : Chest breathing

2. Active Phase:
Dilations: 4 - 7 cm
Frequency: every 3-5 min
Duration: 30 – 60
Intensity: seconds
Mother: Moderate
Fears losing control of self

Care:
. M – edications – have meds ready
. A – ssessment include: V/S, cervical dilation & effacement, fetal monitor, etc.
. D – dry lips – oral care (ointment), provide dry linens
. B – abdominal breathing, don’t push yet, pant

3. Transitional Phase:
Dilations: 8 – 10 cm
Frequency: every 2-3 min contractions
Durations: 45 – 90 seconds
Intensity: Strong
Mother: Mood suddenly changes accompanied by hyperesthesia
(Increase sensitivity to touch, pain all over)

Care:
. T – ires, go with the flow of contraction, don’t resist
. I – nform of progress
. R – estless support her breathing technique
. E – ncourage & praise
. D – iscomfort highest, let husband massage lower back / sacrum

Other Care on First Stage of Labor:

1. Ok to shower: bath as necessary, shave woman’s perineal hair
2. Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD – preeclampsia
3. NPO – GIT stops function during labor if with food---vomiting & aspiration---chemical pneumonitis
4. Enema administer during labor – unless is PROM
. a.)To cleanse bowel
. b.)Prevent infection
5. Monitor for signs of Fetal Distress: Done in between contractions NOT during
. <120 & >160
. Meconium stain amnion fluid
. Fetal Thrashing: hyperactive fetus due to lack O2
. Position mother to Left Side Lying

B. Second Stage: Complete dilation & effacement to birth. “Fetal Stage”

Mechanisms of labor – ED FIRE ERE

1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion

;;
B. Second Stage: Complete dilation & effacement to birth. “Fetal Stage”
nd
Care on 2 Stage:
1. Check IE - bring to DR if 7 – 8 cm Multipara or 10 cm primipara
2. Lithotomy position - put legs same time up
3. Observe bulging of perineum – sure sign that the baby is about to be delivered
4. Teach Breathing - pant & blow breathing, push w/ open
glottis a. Check signs of Respiratory Alkalosis
. Tachypnea, lightheadedness
. Tingling sensation, circumoral numbness, carpopedal spasm
. Offer paper bag to rebreathe CO2
5. Perform Modified Ritgen’s maneuver – place towel at perineum
. To prevent laceration
. Will facilitate complete flexion & extension.
6. Support head & remove secretions, establish clear airway
7. Pull shoulder down & up
8. Check cord, if tight - cut & clamp
9. Note time of delivery
10. Maintain temperature
11. Put on abdomen of mother to facilitate contraction/bonding
12. Clamp, do not milk. Wait for pulsation to stop then cut cord---allows 60- 100cc of blood
13. Proper identification-----ID band in ankle
14. Let mother see condition of baby even if dead to accept finality of death
15. Remove placenta carefully by twisting it around the clamp and apply gentle traction / pull
– BRANDT ANDREW’S MANEUVER

nd
Other Concerns on 2 Stage:
1. Bolus of Oxytocin / Pitocin - given to strengthen contraction, can lead to hypotension, monitor BP
2. Amniotomy - artificial rupture of the bag of water to facilitate delivery
3. Episiotomy - cutting of perineal tissue to widen exit for baby, shortens labor and prevents laceration
. Use local anesthesia or natural anesthesia or pudendal block
. Iron the perineum – to prevent laceration

2 Types of Episiotomy:
Median Mediolateral
Less Bleeding More Bleeding
Less Pain More pain
Easy Repair Hard to repair
Fast Healing Slow to heal
May lead to urethrouanal fistula No major disadvantage

C. Third Stage: Birth to Expulsion of Placenta. “Placental Stage”

Placenta delivered from 3-20 minutes from birth of the baby.

3 Signs of Placental Separation:

st
1. Fundus rises – becomes firm & globular : ― Calkins Sign‖---- 1 sign
2. Lengthening of the cord
3. Sudden gush of blood

Types of Placental Delivery:

1. Shultz: ―Shiny‖ – begins to separate from center to edges presenting the fetal side.
2. Duncan : ―Dirty‖ – separate from edges to center presenting maternal side – beefy red or dirty
rd
Care for the 3 Stage:
1. Check completeness of placenta - 15 – 28 cotyledons
2. Check firmness of fundus - if relaxed, massage uterus
3. Administer medications - Methergine IM (Methylergonovine Maleate)―Ergotrate
derivatives S/E : HPN-----if HPN----give Oxytocin IV
4. Check BP - Monitor HPN (or give oxytocin IV), monitor Hypotension (blood loss)
5. Check perineum for lacerations
6. Assist MD for episiorraphy
7. Vaginal pack -placed to prevent bleeding, used for < 48 hours only – may lead to puerperal infection
8. Saline & Betadine cleansing
9. Changed Clothes
10. Chills - due to dehydration, give blanket
11. Flat on bed - let Mother sleep to regain energy
12. Recovery - Give clear liquid like tea, ginger ale, clear gelatin --full liquid---soft diet---regular diet

34
D. Fourth Stage: The First 1-2 hours after delivery of placenta. “Recovery Stage”
th
Care for the 4 Stage:
1. Maternal Observations – body system stabilizes
nd
. Monitor V/S every 15 minutes for 1hour, every 30 minutes for the 2 hr

2. Check placement of Fundus at level of umbilicus.

. After delivery, fundus bet. umbilicus
. 2 hrs. after delivery---at the level of umbilicus
. If fundus above umbilicus, deviation of fundus
. Check for empty bladder to prevent uterine atony-----hemorrhage

3. Check Lochia – RSA

. Rubra – red 1 – 3 days
. Serosa – pink / brown 4 – 9 days
. Alba – white 10 days – 3 weeks after delivery

4. Perineum – Check for ―REEDA‖

. R – edness
. E – dema
. E – cchymosis
. D – ischarges
. A – pproximation of closure of sutures or approximation of blood loss.
Count pad & saturation = Fully soaked pad : 30 – 40 cc weigh pad. (1 gram=1cc)

5. Bonding – interaction between mother & newborn/ Rooming-in types

. Straight Rooming-in baby: 24hrs with mom.
. Partial Rooming-in: baby in morning , at night nursery

COMPLICATIONS OF LABOR:

1. Dystocia - Difficult labor r/t mechanical factor

. Uterine Inertia – main cause of dystocia. Sluggishness of contraction

2. Prolonged Labor - Labor of more than 20 hrs. for primi. and 14 hrs. for multipara
. Ineffective pushing

3. Precipitate Labor - Labor of < 3 hrs. with extensive lacerations--profuse bleeding---hypovolemic shock

4. Inversion Of the Uterus - Uterus is turned inside out

. Short cord
. Hurrying of placental delivery
. Ineffective fundal pressure

5. Uterine Rupture - Rupture of the uterus

. Previous Classical CS----once classical, always classical
. Large baby
. Improper use of oxytocin (IV drip)
. Bandl’s Ring

6. Amniotic Fluid Embolism or Placental Embolism

- Amniotic fluid /fragments of placenta entered maternal circulation resulting to embolism

7. Trial Labor - Measurement of head and pelvis falls on borderline. Mom given 6 hrs of labor
- Multipara: 8 – 14 hrs. and Primipara 14 – 20 hrs.

8. Preterm Labor - Labor after 20 weeks or before 37 wks.)

. Premature baby

35
 POSTPARTUM: THE MOTHER AND HER NEWBORN

th
POSTPARTAL PERIOD: “5 Stage of Labor‖

PUERPERIUM:
st
- Covers 1 6 wks. Post-delivery
Encourage early ambulation to prevent Hyperfibrinogenia ----prone to thrombus formation

INVOLUTION:
- Return of reproductive organ to its non -pregnant state.

PUERPERIAL INFECTION:
- Any type of infection that occurs to the mother during the postpartal period, related to birth.

PRINCIPLES UNDERLYING PUERPERIUM

1. To return to normal state and facilitate healing
2. To prevent complication
3. Provision of emotional support

I. TO RETURN TO NORMAL STATE & FACILITATE HEALING

A. Cardiovascular System
- The first few minutes after delivery is the most critical period in mothers because the increased
in plasma volume return to its normal state & thus adding to the workload of the heart. This is
critical especially to gravidocardiac mothers.

- After 24 hr: Normal increase WBC up to 30,000 cubic

mm (Normal WBC: 10,000 - 15,000 mm)

- Monitor:
1. Increase plasma volume to 1,500 cc
2. Sudden decrease in BP
2. Elevated WBC up to 30,000 um
st
3. Increase temperature = w/n the 1 24 hr. post-partum is normal
= After 24 hrs.----a sign of infection
4. Foul-smelling lochia = a sign of infection
5. V/S every 15 minutes, every 30 minutes 2 hrs. after
6. Hyperfibrinogenemia
7. Orthostatic hypotension

B. Genital Tract
1. Cervix - Check cervical opening, Vaginal & Pelvic Floor
2. Uterus
- Return to normal 6 – 8 wks (INVOLUTION)
th
- Fundus goes down 1 finger breath/day until 10 day
th
- 10 day– no longer palpable already behind symphysis pubis

*Subinvolution of the uterus:

- 3 days after post partum, delayed healing of uterus w/ big clots of blood - infection
- Management: Dilatation and Curettage (D&C)

*After birth pains are normal----for multipara especially when breastfeeding

- Mgt:
a. Position prone
b. Cold compress – to prevent bleeding
c. Mefenamic acid
*Lochia
- Components of WBC: blood, WBC, deciduas, bacteria, microorganism.
st
a. Rubra: Red - 1 3 days present, musty/mousy odor, moderate amount
th
b. Serosa: Pink/brown - 4 to 9 day, limited amount
- 4, 5, 6 – pink & 7, 8, 9---brown
c. Alba: Créme white - 10 to 21 days or 3 wks. Very decreased amt

C. Urinary Tract

1. Bladder: Frequency in urination after delivery d/t urinary retention with overflow
2. Dysuria Post-Partum---cause by damage to the trigone muscles of the
bladder *Mgt:
- Urine collection, alternate warm & cold compress, stimulate bladder

36
 D. Colon/ Perineum
1. Constipation - d/t NPO, fear of bearing down of tearing laceration
2. Painful Perineal Area:
- Lateral Sims position for painful perineum
- For episiotomy site: Cold compress if (+) pain post-delivery followed by
warm compress
- After 24 hrs. recommend hot sitz bath, not compress
- Sex- when perineum has healed

II. PREVENT COMPLICATIONS

Hemorrhage
- Bleeding of > 500cc
- Most common complications
- NSD normal loss of 500 cc blood
- CS lost of blood 600 - 800 cc normal

Types:
1. Early Postpartum Hemorrhage
a. Uterine atony
b. Lacerations
c. Disseminated Intravacular Coagulopathy (DIC)
d. Hematoma

2. Late Postpartum Hemorrhage

a. Retained Placental Fragments
b. Infections

III. PREVENT COMPLICATIONS

st
A. Early Postpartum Hemorrhage: Bleeding w/n 1 24 hrs post-partum

1. Uterine Atony 3. Disseminated Intravascular Coagulopathy

S/Sx: (DIC)
- Baggy or relaxed uterus - Consumption of pregnancy or
- Profuse bleeding Hypofibrinogenemia - failure to coagulate
- Complications = - Bleeding to any part of body (eyes, ears)
Hypovolemic shock - Results to stillbirth or abruptio
**Mgt: placenta **Mgt:
. Massage uterus only if w/ . Blood Transfusion- cryoprecipitate or
uterine atony until contracted fresh frozen plasma
. Cold compress . Hysterectomy
. Modified Trendelenburg
. IV fast drip/ oxytocin IV drip
. Breastfeeding for sucking--- 4. Hematoma
PPG will release oxytocin - Bluish or purple discoloration of
so uterus will contract. SQ tissue of vagina or perineum.
- Candidate if there is too
2. Lacerations much manipulation
Types: - Delivery of very large baby
st
- 1 degree - affects vaginal - Pudendal
skin, mucus membrane, & anesthesia **Mgt:
fourchette. . Cold compress q 10-20 minutes
nd st
- 2 degree - 1 degree with rest period of 30 minutes for 24
+ muscles of vagina hrs
rd nd
- 3 degree - 2 degree + . Shave
external sphincter of rectum . Incision on site, scraping & suturing
th rd
- 4 degree - 3 degree +
mucus membrane of rectum
S/Sx:
- Well-contracted uterus
- Profuse bleeding
- Assess perineum for laceration
- Degree of
laceration **Mgt =
Episiorrhaphy

B. Late Postpartum Hemorrhage: Bleeding after 24 hrs

37
 B. Late Postpartum Hemorrhage: Bleeding after 24 hrs

1. Retained Placental Fragments

S/Sx:
- Bleeding, uterine
atony ** Mgt:
. D&C or manual extraction of fragments & massaging of uterus.
. D&C except in 3 cases = HYSTERECTOMY
a. Placenta Acreta – attached placenta to myometrium
b. Placenta Increta – deeper attachment of placenta to myometrium -
Grandmultiparous b. Placenta Percreta – invasion of placenta to perimetrium -Post
CS

2. Infection
Sources of infection:
a. Endogenous – from within body
b. Exogenous – from outside
Causes:
a. Anaerobic streptococci – most common - from members HT
b. Unhealthy sexual practices
General Signs of Infection:
a. Inflammation : Calor (heat), Rubor (red), Dolor (pain)
Tumor(swelling) b. Purulent discharges
c. Fever
d. Loss of function
General Mgt:
a. Supportive care: CBR, hydration, TSB, cold compress, analgesic, Vit. C
b. Culture & sensitivity – for antibiotic—should be taken on time prolonged use of
antibiotic lead to superinfection Ex. fungal infection

Specific Types of Infection:

a. Perineal Infection
S/Sx: = 2-3 stitches dislodge w/ purulent discharge
**Mgt: = Removal of sutures & drainage, saline

b. Endometriosis/endomitritis
S/Sx: = Inflammation of endometrial lining & abdominal pain
**Mgt: = Fowler’s Position to facilitate drainage & localize
infection = Oxytocin & antibiotic

c. Thrombophelibitis
S/Sx: = inflammation, infection in veins of the legs
**Mgt: = Rest, Antiembolic stockings, Anticoagulatants (Heparin)

III. PROVIDE EMOTIONAL SUPPORT (REVA RUBIN THEORY = Postpartum Psychological Adaptation)

A. Taking In Phase: “ Dependent Phase”

st
- (1 three days)
- Mother : Passive, self – centered, cannot make decisions
- Tells child birth experiences
- Focus HT: Proper Hygiene

B. Taking Hold Phase: “ Dependent to Independent Phase”

- 4 to 7 days
- Mother: Active, ready for mothering role, can make decisions
- Focus HT: Care of newborn & Family Planning Method

*Post-Partum Blues/ Baby Blues

. Present 4 – 5 days (50-80% incidence rate)
. Overwhelming feeling of depression characterized by crying, despondence
& Inability to sleep & lack of appetite.

. D/t sudden hormonal changes---– let mom cry – therapeutic.

. More than 2 weeks= May lead to Post-Partum Psychosis

*Management: Explain that this is normal (less than 2 weeks), crying can be helpful, support mother.

C. Letting Go Phase: “Interdependent Phase”

- 7 days & above (10 days)
- Mother redefines new roles as parents may extend until child grows.

38
 FAMILY PLANNING
Motivate the Use of Family Planning/ Principles:
st
1. Determine one’sown beliefs 1
2. Never advice a permanent method of planning
3. Method of choice is an individual choice.
4. Informed Consent

Methods:
1. Natural Method
2. Social Method
3. Physiologic Method
4. Barriers
5. Surgical Method

I. NATURAL METHOD – the only method accepted by the Catholic Church

Method PROCEDURE Education

1. Billings / . Test for Spinnbarkeit & Ferning Pattern Perform the test before
Cervical Mucus (Estrogen) arising from bed
th
. Peak 13 day: clear, watery,
stretchable, elastic (10- 15 cm) long
spinnbarkeit
th
2. Basal Body . 13 day temperature goes down No sex
Temperature before ovulation & upon 14 th & 15 th Get before arising in bed
day
. Progesterone responsible for temp. changes
3. LAM . A woman who breastfeeds her baby Disadvantage of LAM
(Lactation EXCLUSIVELY will be protected – might get pregnant
Amenorrheal from pregnancy
Method) . Prolactin : Hormone that inhibits
(BIOLOGIC ovulation especially in:
METHOD) - Breast feeding = menstruation will
come out 4 – 6 months
- Bottle feeding = 2 – 3 months

4. Symptothermal . Combination of BBT & cervical mucus Most effective natural

method

II. SOCIAL METHOD

Method PROCEDURE Education

1. Coitus . Male partner withdraws the penis just Least effective method
Interruptus / before ejaculation
Withdrawal

2. Coitus . Sex without ejaculation

Reservatus
3. Coitus . No actual penetration to the vagina but
Interfemora in between thighs

4. Calendar . Get the cycles from January to December

Method / . Shortest cycle minus 18
Origoknause . Longest cycle minus 11
st
Formula . Count from the 1 day of
menstruation (unsafe days)
. Example:
Shortest = 23 days – 18 = 5
Longest = 30 days – 11 = 19
From day 5 to 19 = UNSAFE
Mense: May 5, 2012
May 10 to May 24 = UNSAFE

39
III. PHYSIOLOGIC METHOD:

Method PROCEDURE Education

1. Pills . Combined Waiting time to become pregnant - 3 months.

oral contraceptives
prevent ovulation by
inhibiting the anterior
pituitary gland
production of FSH &
LH w/c are essential for
the maturation & rupture
of a follicle.
. 99.9 %effective
th
- 21 day pill- start 5 day of menses
st
- 28day pill- start 1 day of menses
- Missed 1 pill – take 2 next day
- Missed 2 pills – use other methods
- Consult OB every 6 mos
Adverse Effects
- Breakthrough Bleeding
Contraindications:
1. Chain Smoking
2. HPN
3. DM
4. Heart Disease
5. Extreme obesity
6. Thrombophlebitis
7. Problems in clotting factors

Stop if:
A – abdominal pain
C – chest pain
H – headache
E – eye problems
S – severe leg cramps

2. DMPA /
Depomedroxy . Inhibits ovulation: has IM q 3 months:
Progesterone progesterone inhibits LH - Never massage injected site, may
Acetate lessen the duration of effect.
(Depo-
proveda)
. Composed of 6 match sticks
3. Norplant – like capsules Disadvantage = poor effect with keloid skin
implanted subdermally/ As soon as removed = can become
SC pregnant Good for 5 yrs
. Contains progesterone.

IV. PHYSICAL MECHANISM & CHEMICAL BARRIERS

Method PROCEDURE Education

Alerts:
1. Intrauterine . Prevents implantation by - Right time to insert is after delivery
Device / IUD altering the motility of or during menstruation
sperm & ovum - Primary indication for use of IUD
. 99.7 % effective : Parity or # of children, if 1 kid
only DON’T use IUD
- Does not give protection
against Syphilis
- Check for string daily
- Monthly checkup
- Regular pap smear
Most common complication
- Excessive Menstrual Flow &
Expulsion of the device
Other Side Effects:
- Uterine inflammation
- Uterine perforation
- Ectopic pregnancy
Monitor for:
P - eriod late (pregnancy
suspected) A - bnormal spotting or
bleeding
A - bdominal pain or pain with
intercourse I - nfection (abnormal
vaginal discharge)
N - ot feeling well, fever, chills
S - trings lost, shorter or longer

40
 Method PROCEDURE Education

2. Condom . Made of Latex inserted to Advantage:

erected penis or - It gives higher protection in
lubricated vagina the prevention of STDs
. Prevents the sperm to - Highest protection against
enter the uterus STDs---- Female condom

Disadvantage:
- It lessen sexual satisfaction

3. Diaphragm . Rubberized dome- Alerts:

shaped material inserted - Reusable
to cervix preventing - Keep in place 6-8 hrs.
sperm to get to the after intercourse
uterus. - Contraindication: UTI

Monitor:
- Proper hygiene
- Check for holes before use
- Must stay in place 6 - 8 hrs after sex
- Must be refitted especially if
w/ weight change of 15 lbs

4. Cervical Cap . Same with diaphragm No need to reapply spermicide

. More durable Could stay for more than 24 hrs.
than diaphragm Contraindication: Abnormal Pap Smear
. Has spermicide
- kills sperms

5. Foams/ . Contains Spermicide Monitor:

Jellies/ (Non- oxynol-9) - Proper hygiene
Creams . Foams (most - Adverse Effect: Toxic
effective spermicide) Shock Syndrome

V. SURGICAL METHOD

Method PROCEDURE Education

1. Bilateral Tubal . Female Sterilization - Can be reversed 20% chance

Ligation (BTL) . Cutting and suturing depending on type of operation
separate ends of the - Can take effect immediately
isthmus of Fallopian tube - Avoid lifting heavy objects

2. Vasectomy . Male Sterilization - Wait for >30 ejaculations before

. Cut at the vas deferens. safe sex
- O / zero sperm count for at least 2
(-) results to be considered effective

41