MAKILALA INSTITUTE OF SCIENCE AND TECHNOLOGY

Concepcion , Makilala Cotabato

BACHELOR OF SCIENCE IN MIDWIFERY

Course Number : CP 101 – A

Course Title : Clinical Practicum
Credit Units 3 units
Module No: 1 and 2
Instructor : Lolita A. Inot RM, BSM
Email Address : mistlolitainot@gmail.com

Duration : 2 weeks February 15 - 28

Mobile No. 09171260262
_________________________________________________
_ I. LEARNING OUTCOME:

At the end of this module the students are expected to:

1. define the terms related to Pregnancy.

2. identify the Physiologic changes to Pregnancy.
3. recognize and enumerate the Signs and Symptoms of pregnancy.
4. recognize the early detection of abnormalities.
5. discuss the basic intervention / health teaching.

II. TOPIC / SUBJECT MATTER

 Pregnancy
 Physiological Changes in the Female Reproductive System during Pregnancy 
Clinical Sign and symptom of Pregnancy

III. REFERENCES:
 Myles textbook , Williams OB , Pilliteri

IV. COURSE CONTENT:

 Management of Normal Pregnancy A. DEFINITION
OF TERMS:
TERMS DEFINITION
GRAVIDA a woman who is pregnant.
 GRAVITY pregnancy.
PARA Number of deliveries a woman has had.
Deliveries made after 20 weeks is considered
part of parity.
A delivery before the 20 weeks is medically
known as an abortion.
PARITY The number of pregnancies in which the fetus or
fetuses have reached viability, not the number of
fetuses (ex- twins) born. Whether the fetus is born
alive or is stillborn (fetus who shows no signs of life
at birth) after viability is reached does not affect
parity.
NULLIGRAVIDA A woman who has never been pregnant.
PRIMIGRAVIDA First pregnancy.
NULLIPARA A woman who has not completed a pregnancy with a
fetus or fetuses who have reached the stage of fetal
viability.

PRIMIPARA A woman who has completed 1 pregnancy with a

fetus or fetuses who have reached the stage of fetal
viability.
MULTIPLE A woman who has completed two or more
PREGNANCY pregancies to the stage of fetal viability.
CHILDBIRTH Occurs around 40 weeks from the last menstrual
period (LMP). This is just over nine months.
PRETERM an infant who is born after 20 weeks of gestation
but before completion of 37 weeks gestation.
POSTTERM birth of an infant after 42 weeks of gestation.
BIRTH
TERM BIRTH a birth that occurs between the 38 and 42 weeks
of gestation
CONFIRMATION is usually made based on the result of the patient
OF PREGNANCY physical examination sign and symptom ,pregnancy
test for HCG and ultrasonography.
TRIMESTER one of the three equal 13 weeks parts of a full
term pregnancy.
VIABILITY Capacity to live outside the uterus; approximately
22-24 weeks since last menstrual period, or
greater than 500g.
I.PREGNANCY

 cessation of menses ( amenorrhea ) , enlargement of the uterus and positive

result of pregnancy test.
  Period between conception through complete birth of the products of
conception.
 The usual duration of pregnancy is 280 days or 9 calendar months.

A. PHYSIOLOGICAL CHANGES DURING PREGNANCY

During pregnancy estrogen promotes maternal blood flow within the uterus
and the placenta.

1. FEMALE REPRODUCTIVE SYSTEM

UTERUS
After conception the uterus provides a nutritive and protective environment
in which the fetus will grow and develop.
It increases from the size of a small pear in its non-pregnant state to
accommodate a full-term baby at 40 weeks of gestation.
Original pear shaped uterus changes to globular form and spherical at
third month then to oval shape.
Contractility
 The uterus undergo irregular contraction starting on the
first trimester.
 Late pregnancy these contraction known as Braxton Hicks
Contraction.
INDICATOR PRE – TERM
PREGNANCY PREGNANCY
Weight 50gm 1000gm
Thickness 2cm 0.5cm
Length 6.5cm 32cm
Depth 2.5cm 20cm
Width 4cm 24cm
Capacity 10ml 5000ml

A. Hypertrophy and Hyperplasia of uterine muscle fibers

 (5 times to 10 times) due to the action of estrogen and progesterone in first 3
months then in later months distention is mainly mechanical due to expanding
products of conception.
B. Growth of Fundic Height
At 12 weeks’ gestation (near the end of the first trimester, three-month
period), the fundus (upper margin of the body of the uterus) may be palpated
( firm globular mass ) through the abdomen above the pubic bone (symphysis
pubis).
The size of the uterus usually reaches its peak at about 36 weeks’ gestation
DIFFERENT STAGES OF GESTATION AS FOLLOWS

Age of Fundic Height

Gestation
12 weeks Fundus at the level of symphysis pubis
16 weeks Fundus half way between symphysis pubis
and umbilicus
20weeks Fundus at the level of the umbilicus
24 weeks Fundus two finger above umbilicus
28-30 Fundus midway between umbilicus and
weeks xiphoid process Figure 1
32-34 Fundus two fingers below xiphoid process
weeks
36 weeks Fundus at the level of xiphoid process
40 weeks Fundus two fingers below umbilicus
drops at 34 weeks due to lightening

The uterus may drop slightly as the fetal head

settles

into the pelvis, preparing for delivery.

Notice the position at 40 weeks of gestation,
which is shown as a dotted line in Figure 1 This
dropping is referred to as ‘lightening’.
It is more noticeable in a primigravida (pregnant
for the first time) than in a multigravida (a woman
who
has been pregnant previously, regardless of
outcome).

CERVIX
• Cervix becomes vascular and edematous in response to increased level of
circulating estrogen from the placenta.
 • Increased fluid between the cells causes the cervix to soften (Goodell’s sign) and
increased vascularity causes it to darken from pale pink to a violet or pinkish
to purplish during pregnancy due to increased blood supply.

a.LEUKORRHEA
 Placental estrogen increases the activity of cervical glands , resulting in
increases cervical mucus production.
b.GOODELL’S SIGN
 An indication of pregnancy.
 It is a significant softening of the vaginal portion of the cervix from
increased
Vascularization(hypertrophy and engorgement of the vessels below
growing fetus and this sign occurs at approximately four weeks'
gestation.

c.MUCOUS PLUG
 This thick mucus accumulates in the cervical canal forming barrier
against ascending infection.
 A tenacious coating of mucus fills the cervical canal called operculum
which seals out bacteria during pregnancy.
 During labor the mucous plug mixes the blood from the ruptured
capillaries in the cervix and dislodged when the cervix dilates.
 The blood stained mucous is called SHOW - is an important sign of
labor

d.CONSISTENCY OF THE CERVIX

 During pregnancy : it is as soft as the earlobe.
 During labor : it is soft as the butter.
 Cervical softening indicates that the cervix is “RIPE” for labor and ready for
dilatation and effacement.

VAGINA
 Vaginal epithelium become hypertrophic and enriched with glycogen which
results in white vaginal discharge throughout pregnancy.
 becomes more elastic towards the end of pregnancy.
 dilate during the second stage of labor, as the baby passes down the birth
canal.
 Softening of the vagina and cervix is important to allow the easier distention
during labor.
 Vaginal secretions becomes acidic to prevent infections. (Doderlien Baccili)
 a.SECRETIONS:
 changes from pH over 7(alkaline) to pH 4 to 5(acidic) due to Lactobacillus
acidophilus, a bacteria that grows freely in glycogen environment.
 increases the lactic acid content of the secretions.
 A lower vaginal pH favors of candida albicans , moniliasis or candiasis.

b.CHADWICK’S SIGN
 vaginal wall changes color from light pink to deep violet color due to
increased circulation.
 bluish discoloration of the cervix, vagina, and labia resulting from increased
blood flow.
 It can be observed as early as 6 to 8 weeks after conception, and its
presence in early sign of pregnancy.
 Increased sensitivity and heightened sexual responsiveness.

OVARIES:

 Ovulation stops due to the active feedback mechanism of estrogen and

progesterone.
 Production and release of follicles from ovaries ceases with pregnancy.
 The corpus luteum is formed within the ovary & secretes progesterone
peaks at 8 days (necessary for maintenance of pregnancy).
 At 6-7 wks the placenta begins manufacturing progesterone and involution
of the corpus luteum begins.
 Corpus luteum increases in size until week 16 and then the placenta has
taken over as provider of progesterone and estrogen.

BREASTS:
 Changes are due to increased production of estrogen & progesterone.
 Become full & tender early in pregnancy.
 The number of mammary alveoli increases and the
breasts become larger (in preparation of
breastfeeding).
 The pre pregnant size of the breasts has no effect on
the ability to breastfeed.
 Breast changes experience by the woman  as early
as 5 -6 weeks are:
a. Darkening of the skin around the areola.
b. Nipples become more erectile.
 c. Montgomery’s tubercles
- sebaceous glands of the areola enlarge and become protuberant.
-It’s secretions keep the nipple supple and help prevent cracking and
drying during lactation.

a.COLOSTRUM
 A clear fluid can be expressed from the nipple as early as 4th month 
contains the mother’s antibodies to diseases and is secreted for the first 2
to 3 days after birth in the breastfeeding woman.
 This “premilk” is high in protein, fat-soluble vitamins, and minerals, but it
is low in calories, fat, and sugar.”

CARDIOVASCULAR

 The cardiovascular system consists of the heart, the blood vessels (veins
and arteries), and the blood that circulates around the body.
 It is the transport system that supplies oxygen and nutritive substances
absorbed from the gastrointestinal tract to all the cells, tissues and
organs of the body, enabling them to generate the energy they need to
perform their functions.
 It also returns carbon dioxide, the waste product of respiration, to the
lungs, where it is breathed out.
 The chemical processes that go on in the body generate many waste
products, which the blood transports to the kidneys and liver, where they
are removed.
 Other functions of the cardiovascular system include the regulation of
body temperature, and the circulation and delivery of hormones and
other agents that regulate body functions.
 There are several significant changes in this complex system during
pregnancy.
V. Activity /Exercises:

Activity 1

Name: Section:
Date

Instructions:
1. write your complete name clearly
2. Read the question carefully
3. Send your answer to my E mail address NOT to my messenger.

I. Identification

Instructions :
Read the question carefully and write your answer on the SPACE provided before
each number.

___________1. The human milk that can be expressed from the breast as early
as four months is called?
___________ 2. The mucus that accumulate in the cervical canal that protect
against the ascending infection is called?
___________3.What gestation age that the fetus can live outside the uterus?
__________ 4. A woman who has never been pregnant is refers to?
__________ 5.How many calendar days the duration of pregnancy?

II.ESSAY:

Instructions:
Read the question and discuss your own idea on the SPACE provided.

1. How many weeks of pregnancy can the fundus be palpated at the height of the
woman’s umbilicus (Belly-Button), according To Figure 7.1?(10points )
Slight cardiac hypertrophy- increase due to blood volume & cardiac output:
Changes in cardiac output during pregnancy
WOMAN’S CONDITION CARDIAC OUTPUT
(LITRES PER MINUTE)
non-pregnant, resting 2.5
end of 1st trimester 5
end of 2nd trimester 6
full-term 7

BLOOD CONSTITUENTS

• RBC increases as much as 33 %

• Hemoglobin fall from 14mg/dl to 11.5-12mg/dl due to
hemodilution( physiologic anemia )

a. PHYSIOLOGIC ANEMIA OR PSEUDOANEMIA

 the higher proportion of the liquid component of the blood result in lowered
hematocrit and hemoglobin
 Increased supply of blood to several areas of the body such as the skin , uterus
and kidney
 Decreased blood flow the lower extremities caused by varicosities and foot
edema common in late pregnancy

b.IRON
 is present in all cells and has several important functions, including oxygen
transport and storage in the human body.
 It is the critical component of the oxygen-carrying substance haemoglobin, found
in all red blood cells.
 that makes these cells appear red.
 If the diet is too low in iron, the person cannot make enough red blood cells.
  involved in the storage and release of oxygen in the muscles.

c. LEUKOCYTES
 Increases from 7000/mm to 10,500/mm during pregnancy and up to
1600/mm during labor to protect the woman against infection that can
threatened fetal and maternal wellbeing
 Immune response against bacterial infection
=is enhance during pregnancy but suppressed of T cell activity
causes increased susceptibility to viral infection , such as
hepatitis , rubella , herpes and papilloma virus.
d.BLOOD LIPIDS AND CHOLESTEROL LEVELS:

blood lipids increases by 35% *Provides available supply of energy for

Blood cholesterol increases by the fetus. almost 100% due to the effect
*Serum levels fall rapidly after delivery

of HPL but cholesterol and triglyceride may remain elevated even up to 6 to 7

weeks
post-partum

Decline in serum protein level due to the increase of protein requirement

of the fetus and hemodilution.
Reduction in protein level lower lower down osmotic pressure within
intravascular space which cause fluid interstitial space.
Contributes to the normal ankle and foot edema of pregnancy.

E.INCREASED LEVEL of CLOTTING FACTORS

 Fibrinogen increases by as much as 50% due to the effect of elevated

estrogen level.
 Clotting factor 7,8,9& 10 increases during pregnancy to protect the woman
from any major bleeding.
 Pregnancy is hypercoagulable state which means that pregnant woman is
prone to thrombosis or clot formation due to the ff:
 Venostasis due to venous dilatation.
 Pressure on the venous return due to the gravid uterus.
 Elevated clotting factors.
 Decline in fibrinolytic activity and anti-coagulants
f. BLOOD VOLUME, CARDIAC OUTPUT CARDIAC WORKLOAD
 2. Increased Blood volume
Total blood volume 45% to 50%
increase Maternal vital signs may
The increase of blood volume reaches its not show changes for
peak at 24 to 28 weeks
blood loss of 1500cc or
Plasma 75%
less
plasma volume blood loss 500ml
during normal vaginal
delivery
Cesarian birth 1000ml
RBC 25%
INCREASED CARDIAC WORKLOAD

 Second trimester
 Monitoring of vital signs is recommended during labor and postpartum period

During Labor :
 Cardiac output will increase to 15 %
First and second stage
 50%
** due to the ff:
• Pain
• Uterine contraction
• Expulsive effort of the mother which pushes blood into the general circulation
and which turn increase the blood going to the heart and being pumped
out of it

INCREASED CARDIAC OUTPUT

 Increased to 25-50%
 Increased when the preg. women is in left lateral position because the gravid
uterus does not rest on the vena cava and is not impending the flow of blood
from the lower part of the body to the heart.
 After delivery there is immediate rise in cardiac output due to the ff :

* removal of the inferior vena caval obstruction *

contraction of the uterus that displaces blood
to systemic circulation
*Return of fluid from the extra vascular
space to intra vascular system.
HEART
 is elevated upward & rotated forward to the left due to diaphragm
displacement by enlarging uterus.
 Increased heart rate by 10 beats per minute as a compensatory
mechanism to pheripheral vasodilation and as an effort to handle the
increase in blood volume.
 Systolic murmur = 90%
 Diastolic murmur = 20%
 Increased cardiac work load can cause of slight cardiac enlargement.
 Palpitation and benign arrhythmias that last a few second to minute
when sudden positional changes during exertion is attribute to :

*sympathetic nervous system stimulation during the first trimester from the
increased of cathecolamine levels.
*pressure of the gravid uterus against the diaphragm on the month of pregnancy

a. Increased Heart rate

 Decrease the amount of blood going to the heart to compensate for this
the stroke volume increases by 10 beats /min.
 Increase the blood volume to 40% to maintain adequate blood supply to
the uterus.
 Increased the blood volume in the second trimester makes the heart rate
increased.

b. Heart Displacement

Enlargement of the uterus pushes the diaphragm upward.

The apex of the heart to the left and upward so that the 4 th intercostal
space will lie outside the midclavicular area.

c.Blood Pressure

Progesterone causes the ligaments and joints to loosen during pregnancy.

Acts with some other natural chemicals in the body that cause the
muscular walls of the blood vessels to relax slightly.
less resistance to the flow of blood around the body due to the same volume of blood
that circulates slightly wider in the blood vessels.
Pressure in the lower extremities increases accompanied by pedal edema

 Normally, the patient’s blood pressure will not rise.

 1st trimester no change
 2nd trimester a decrease in both systolic & diastolic pressure of 5-10 mmHg,  3rd
trimester BP should return to pre pregnant level.
d.Supine Hypotensive syndrome
 When a pregnant woman is lying flat on her back, the weight of her uterus and
its contents compresses the large blood vessel (vena cava) leading from her lower
body to the heart.
 When this blood vessel is squashed, the blood flow back to the heart is reduced,
which in turn leads to a reduction in the blood flow out of the heart to the rest of
the body.
 common after 24 weeks of pregnancy to twin pregnancies
 increase the volume of amniotic fluid (waters surrounding the fetus).

 The decrease amount going to back to the heart result in decreased cardiac
output that leads to:
• Decreased blood pressure
• Decreased blood supply to the brain causing dizziness , faintness and
lightheadedness
V. Activity /Exercises:
Activity 2:

Name: Section:

Date:

Instructions:
1. write your complete name clearly.
2. Read the question carefully.
3. Send your answer to my E mail address NOT to my messenger.

Instructions:

Read the question carefully and write TRUE if the answer is true and write FALSE if
the answer is false on the SPACE provided before each number
______ 1. 2nd trimester a decrease in both systolic & diastolic pressure of 5-10
mmHg.

_______ 2. Maternal vital signs may not show changes for blood loss of 1500cc or
less.
_______ 3. The blood lipids and cholesterol levels contributes to the ankle
and foot edema of pregnancy.

_______4. Decrease the amount of blood going to the heart to compensate for this
the stroke volume increases by 10 beats /min.

_______ 5. After delivery there is immediate rise in cardiac output due to the
removal of the inferior vena cava obstruction.

II.ESSAY ( 10POINTS )

Instructions :
Read the question carefully and write your answer on the space provided

1. Why do you think the workload of the heart has to increase?

Intervention:

The patient’s blood pressure should be checked carefully and often since a
significant increase is one of the indicators of toxemia of pregnancy.
When monitoring the blood pressure, be sure it is done under the same
circumstances (that is, patient sitting and left arm).
RESPIRATORY SYSTEM

 During pregnancy, the amount of air moved in and out of the lungs increases by
nearly 50% due to two factors:
• each breath contains a larger volume of air
• the rate of breathing (breaths per minute) increases slightly.
 Decreased residual volume ( amount of air left in the lungs after
expiration  Dyspnea or shortness of breath that relieved after lightening.

Intervention
Check for signs of sickness, heart problems, anemia or poor diet.
Get medical advice if you think she may have any of these
problems.

a.OXYGEN
 Increased oxygen requirement as the mother supply not only for herself but for
the baby.
 Total body consumption of oxygen increase by 15 -20%.
 Tidal volume (amount of air inspired ) increase in early pregnancy and continues
to rise to 30 - 40 % above the pre – pregnancy ( returns to normal at 6-8 weeks
postpartum ).
 Inspiratory capacity increases%.
by 5

Normal Findings During Pregnancy

INCREASED DECREASED
plasma PH 7.44 PCO2 30%
Plasma PO2 >100 Residual vol. 20%

Tidal vol 30-40% Expiratory 20%

reserve
Respiratory 1-2/min
rate / min
 HYPERVENTILATION
The pregnant woman experience hyperventilation with ventilation capacity increasing by
40% (effort to blow off the extra carbon dioxide coming from the fetus to prevent acidosis)

URINARY SYSTEM

Responsible for maintaining electrolyte & acid-base balance, regulating

extracellular fluid volume excreting waste products, & conserving essential nutrients
Changes of the urinary system results from:
*Effects of estrogen and progesterone activity
*Compression of the bladder and ureters by the growing uterus

Trimester Description
First trimester: The uterus exerts pressure
on the bladder as it rise out
of the pelvic cavity
Third trimester: Pressure of the presenting
part on the bladder after
lightening
Increased blood flow to the kidney increase
globular filtration rate and urinary output
Normal Urinary changes during pregnancy

Total body water increases to 7.5 Liters.

Bladder capacity – 1000ml
Frequency of urination noted
 Ureter diameter : 25%
Loss of amino acid and water soluble vitamin in the urine
Although the bladder can hold up to 1500mL of urine, the pressure of the enlarging
uterus causes increasing frequently of urination, especially in the first and third
trimesters.
Changes in the renal system may take 6 to 12 weeks after delivery to return to the
pre-pregnant state.

a.Lactosuria
 Although the bladder can hold up to 1,500mL of urine, the pressure of
the enlarging uterus causes increasing frequently of urination,
especially in the first and third trimesters.
 Lactose is secreted by the mammary gland it will spill in the urine 
Screening for Diabetes mellitus is advised

b.Glycosuria = spillage of some glucose in the urine.

c.Nocturia = accumulate water in the form of dependent edema
= fluid is mobilized and excreted via kidney ,
=Excessive urine during the night

d.Creatinine clearance
– is the most accurate test of renal function
- Normal value is 90 to 180ml / min from 24hr. urine sample

Interventions :

Consuming at least eight glasses of water each day reduces the risk for urinary
tract infection.

GASTROINTESTINAL SYSTEM

Appetite fluctuates. Intestinal secretion is reduced; Liver function is altered;

Absorption of nutrients is enhanced.
The colon is displaced laterally upward and posteriorly.
Peristaltic activity (motility) decreases, resulting in decreased bowel sounds,
constipation, nausea & vomiting.
Blood flow to the pelvis increases as does venous pressure, contributing to
hemorrhoid formation in later pregnancy.
Decreased maternal glucose levels as
glucose is being utilized for fetal brain
development
PYROSIS (HEARTBURN)
is caused by the relaxation of the cardiac sphincter of the stomach, which permits
reflux (backward flow) of the hydrochloric acid secretions into the lower esophagus.

Nausea and vomiting on the first trimester is attributed to

 Increased HCG levels
 Increased salivation (ptyalism) Effect of Estrogen
 Epulis – hyperthropy or swelling of the gums

PIKA / PICA OR CRAVING for unusual non

food stuff iron deficiency may predispose to
pica or eating soil.
Intervention
 If the mother has difficulty with nausea or indigestion, advise her to eat small,
frequent meals.
 The mother should not lie down flat for 1 to 2 hours after eating, because this may
cause these symptom.
 Avoid gastric irritants such as coffee , tea and chocolates.

INTEGUMENTARY SYSTEM

 Due to hormone changes and mechanical stretching: increases in skin

thickness & subdermal fat, hyperpigmentation (linea nigra – a pigmented line
from the symphysis pubis to the top of the fundus in the midline; darkening of
the nipples, areolae, axillae, & vulva @ approx. 16th week.
 Facial melasma – mask of pregnancy), hair & nail growth, accelerated sweat &
sebaccous gland activity, and increased circulation & vasomotor activity.
 striae gravidarum, or stretch marks – striae may appear at thigh and breast
 Cutaneous allergic reactions are common (increased itching of stretched skin).
Effect of Estrogen:
1. Palmar erythema - is characterized by increased vascularization of the palms of
the hands causing redness and itching.
2. Vascular spider nevi – is characterized prominent capillaries under the skin.
3. Increased perspiration.

ENDOCRINE SYSTEM
 Profound endocrine changes are essential for pregnancy maintenance, normal fetal
growth, and postpartum recovery.
 Elevated levels of estrogen & progesterone suppress secretion of follicle-stimulating
hormone (FSH) and luteinizing hormone (LH) by the anterior pituitary.
 Although most women experience amenorrhea, at least 20% have some slight,
painless spotting during early gestation.
 Oxytocin is produced by the posterior pituitary in increasing amounts as the fetus
matures. This hormone stimulates uterine contractions during pregnancy, but high
levels of progesterone prevent contractions until near term.
 Oxytocin also stimulates the let-down or milk-ejection reflex after birth in
response to the infant sucking at the mother’s breast.
 Prolactin –increased secretion at late pregnancy in preparation for lactation 
Thyroid gland activity & hormone production increases.
 The peak level of parathyroid hormone occurs between 15-35 weeks gestation
when the needs for growth of the fetal skeleton are greatest.
 In early pregnancy the pancreas decreases its production of insulin. Maternal
insulin does not cross the placenta to the fetus.

Role of Estrogen in Pregnancy:

 Increasing blood flow to the uterus by promoting vasodilation.

 Changing the sensitivity of the respiratory system to carbon dioxide.
 Softening of the cervix, initiating uterine activity, and maintaining labor.
 Developing the breasts in preparation for lactation and secretion of prolactin by
the pituitary gland.
 Estrogen levels increase rapidly early in pregnancy, slow between 24-32 weeks
gestation and increase again toward term.
 The production of estrogen is dependent on the interaction between the maternal
and fetal components of the placenta. Role of Progesterone in Pregnancy:

 Ready the uterus for implantation.

 Relaxes smooth muscle to prevent spontaneous abortion.
 Works to prevent a maternal immunologic response to the fetus.
 Relaxes smooth muscle
 To decrease motility & improve absorption of nutrients.
 Enlarges the ureters & bladder to increase capacity.
 Plays a role in development of the alveoli & ductal system to prepare for lactation.
THE SKELETAL SYSTEM

 Calcium and phosphorous requirement is increased during pregnancy for fetal

bones formation.
 The gradually changing body & increasing weight of the pregnant woman cause
noticeable alterations in posture and way of walking.
 Abdominal distention gives the pelvis a forward tilt, decreased abdominal muscle
tone, and increased weight bearing which require a realignment of the spinal
curvatures late in pregnancy. This shifts the woman’s center of gravity forward.
 Lordosis – this posture result in exaggerated inward curve of the spine.
 Aching, numbness, weakness of the upper extremities may result.
 Large breasts and a stoop-shouldered stance will further emphasize the lumbar
and dorsal curves.
 Walking is more difficult (develop a waddling gait).
 The ligamentous and muscular structures of the middle and lower spine may be
severely stressed. These and related changes often cause musculoskeletal
discomfort (back ache, leg aches).
 Wide separation of symphysis pubis (3mm to 4mm) at week 32
V. Activity /Exercises:

Name: Section:

Date:

Instructions:
1.Write your complete name clearly.
2. Read the question carefully.
3. Send your answer to my E mail address NOT to my messenger.

Instructions:
Define the following terms and write your answer on the space provided.

I.Definition ( 5points each )

1.Linea Nigra

2. Pyrosis (Heartburn)
3. Lactosuria

4. Prolactin

5. Oxytocin

II. ESSAY ( 20POINTS )

Instruction : Read the question Carefully and write your discussion on the space
provided.

1.What is the effect on the concentration of red blood cells and hemoglobin in the
pregnant woman’s blood, compared non-pregnant woman ?

Changes in body weight during pregnancy

 About 2.0 kg in total in the first 20 weeks.

 Then approximately 0.5 kg per week until full term at 40 weeks  A
total of 9 -12 kg during the pregnancy.
II. PSYCHOLOGICAL ADAPTATION DURING PREGNANCY

A.DEFINITION OF TERMS
DESCRIPTION
Psychological related to the mental and emotional state of a person; of or relating
to psychology.
Psychosocial it relates to one’s psychological development in the interaction with
a social environment.
Social Influences A pregnant woman and her partner feel about pregnancy and
childbirth it may affect the background, personal experiences,
experiences of friends , relatives, as well as the existing public
philosophy of childbirth.
Cultural Influences Certain beliefs (prescriptive and restrictive) and taboos may place
restrictions on her behavior and activities.
Family Influences Positive attitude and support
Negative attitude and support
Individual Influences A woman’s ability to cope with or adapt to stress plays a major role
RUBINS PSYCHOLOGIC ADAPTATION TO PREGNANCY
Psychosocial Change Description
First Trimester The couple spend time recovering from
shock of learning about the pregnancy and
focusing on concentrating on what if feels to
Task: Accepting the pregnancy be pregnant.
A common reaction is ambivalence, or
feeling both pleased and not pleased at the
pregnancy.
The Physician’s confirmation of pregnancy
often helps the woman accept the fact that
she is pregnant.
Second Trimester The couple move through emotions such as
narcissism and introversion as they
concentrate on what it will feel like to be a
Task: Accepting the baby parent.
Role-playing and increased dreaming are
common.
Quickening by 20 weeks of gestation can
be very significant in helping the woman
realize that the fetus inside the womb is not
just a part of her body but a real and
separate individual to care for.
Third Trimester The couple becomes inpatient with
pregnancy as they ready themselves for
Task: Preparing for the baby and end of
birth.
pregnancy
The woman and her partner exhibits
accomplishment of this task by exhibiting
“nest building”activities or “nesting”= a
behaviour like selecting baby’s layette
choosing names of the baby , making plans
on how the baby will sleep at home etc.
EMOTIONAL RESPONSES TO PREGNANCY

 These feelings predominate at different periods of the pregnancy , others tend to

fade in and out as pregnancy progresses
Ambivalence
Grief
Narcissism ( selfishness )
Introversion vs Extroversion
Couvades’ Syndrome
Fear and anxiety
Changes in Sexual Desire
Refers to the simultaneous negative and positive
response of pregnancy , due to doubts about the
capacity to become a good parent to her child
including doubts as to her readiness for a baby and
how the baby will affect her family and lifestyle
Experience of giving up as a childless individual and
assumes the new role as a mother
Self-centeredness is common among many pregnant
women particularly in the first month of pregnancy
She may be pre occupied with her own feeling and
thoughts
Refers to the male partner also experiencing
the physical symptoms of pregnancy that are
being experienced by the woman
The more involved the man toward the pregnancy of
his wife the more likely that he will experience
pregnancy sig and symptoms
Related to the woman’s concern about her own
health and health of her baby

Body Image and Boundary

Stress

III. MANIFESTATION OF PREGNANCY

Three Classification of Clinical Signs and Symptoms of Pregnancy

a. PRESUMPTIVE b. PROBABLE
c. POSITIVE – detected by the examiner.

CLINICAL SIGNS AND SYMPTOMS :

1. PRESUMPTIVE – subjective changes that are experience and reported by the woman.

PRESUMPTIVE
SIGNS DESCRIPTION
Suspected if more than 10 days have missede the expected
AMENORRHEA sinc menstrual period
occurs during pregnancy due to the suppression FSH by elevated
of estrogen level by the placenta ( review the
 menstrual cycle )
Changes start at 4th week of pregnancy
BREAST Enlargement of the breasts and tenderness are
CHANGES noted
Veins in breasts - become increasingly visible.
Nipples - become larger , tingling sensation and
more pigmented.
Colostrum - presence of a thin and milky fluid,
may be expressed in the second half of
pregnancy.
Montgomerys glands – areola is slightly elevated

URINARY Initially it begin 3 weeks from implantation

FREQUENCY Decreases when the uterus rises out of the pelvis (around 12 weeks)
Reappears when the fetal head engages in the pelvis at the end of
pregnancy.
Frequency of urination occurs in early pregnancy due to the pressure
of the growing uterus on the anterior bladder
PRESUMPTIVE
SIGNS DESCRIPTION IMAGES
Refers to the first fetal movementfelt by theer
QUICKENING moth approximately 18- 20 weeeks
In primipara : 20 weeks , Multipara:16 weeks
EASY Due to progesterone hormone
FATIGABILITY General feeling of tiredness due to increased
metab olic requirement
LEUKORRHEA Increased vaginal secretions
Characteristic: white mucoid due to the estrogen hormone
elevated levels.
Start at 6 wks of Age of gestation after the
NAUSEA AND LMP and persists up to 12 wks of gestation .
VOMITING this normal disturbance, the GIT(gastro
intestinal tract ) in the first trimester due to
the elevated HCG levels
CHADWICK purplish discoloration of the vagina
SIGNS (American gynecologist and medical librarian remembered for describing
the Chadwick sign of early pregnancy in 1887.)
 Striae gravidarum – silvery in color due to
distention of the
collagen of the
SKIN CHANGES abdomen as
uterus enlarges.

Linea Negra – darkening of the skin from

symphysis pubis to umbilicus

Melasma / chloasma - mask of pregnancy

Increased Perspiration

2. PROBABLE - objective findings that can be documented by the examiner primary

related to physical changes in reproductive system

PROBABLE
SIGNS DESCRIPTION IMAGES
HEGARS SIGNS Softening of the lower uterine segment which is felt at 6 to 8
wks AOG ( age of gestation ) after LMP.
The sign is usually present from 4–6 weeks until the 12th week of
pregnancy.
Hegar's sign is more difficult to recognize in multiparous women “
Alfred Hegar, was a German gynecologist famous for developing new
medical tools and techniques”
UTERINE The uterus doubles in size
GROWTH as early as 10 wks.
uterine growth is
determine by measuring
the fundal height.
 *Manual Examination of the
BALLOTTMENT uterus between 16 to 20 wks
gestation Ballottement or fetal
rebound can be elicited
* sharp upward pushing
against the uterine wall with a
finger inserted into the vagina
for diagnosing pregnancy by
feeling the return impact of the
displaced fetus

PROBABLE

SIGNS DESCRIPTION IMAGES

UTERINE A muffled swishing sound heard
SHUFFLE over the abdomen due to the union
of mothers heart beat that flow thru
the uterine vessels.
GOODEL’SIGNS Softening of the cervix can be observed at 6 t0 8 wks after LMP

BRAXTON HICKS Painless palpable contractions occur at irregular

CONTRACTION intervals tightness over her abdomen begin
as early as 8 wks of gestation. You may feel
Braxton Hicks contractions during the third
trimester or as early second trimester.

“John Braxton Hicks was a 19th-century

English doctor who specialized in obstetrics.”

POSITIVE SIGNS

SIGNS DESCRIPTION
FHT Detected by Doppler at 8 -
12 wks
Fetoscope at 16 wks and by
stethoscope at 20 wks
FUNIC SHUFFLE A swishing sound
synchronous with FHT
caused by bld rushing thru
the umbilical arteries

FETAL MOVEMENT Felt by the examiner from

20 wks on ward
X RAY Visualization of fetal
skeleton as early as 14 wks

ULTRASOUND Abdominal pulse echo

sonography can detect

IV. LABORATORY ASSESSMENT

1.Papanicolaou Smear (Pap smear)

• Pap smear is performed to detect and diagnose the presence of precancerous and
cancerous conditions of the cervix, vulva, or vagina.
• The test also reveals infectious diseases and inflammation.
• The classification of Pap smear can be seen in the Bethesda classification of Pap
smears.
• Women who have multiple sexual partners, smoke cigarettes, have a history of
HPV, and sexually active before 21 years old should have Pap smear done more
frequently.

2.Blood Studies

• Complete blood count should be taken to assess the hemoglobin, hematocrit, and
red cell index and determine the presence of anemia.
• White blood cell count and platelet count must also be obtained to assess for
infection clotting ability.
• Blood typing with Rh factor is also important because blood needs to be
available if ever the woman experiences bleeding during pregnancy.
• Maternal serum alpha fetoprotein detects birth defects such as neural tube
defects if elevated and chromosomal anomalies if decreased.
• Antibody titers for rubella and hepatitis B or HBsAG determine whether the
woman is protected against rubella and if the newborn would have a chance of
developing hepatitis B.
3.Glucose Tolerance Test

• A woman with a history of diabetes, large for gestational age babies, obese, or has
glycosuria should undergo glucose tolerance test.
• A 50-g oral toward the end of the first trimester should be performed to rule out
gestational diabetes.
• The plasma glucose level should not exceed 140mg/dl at 1 hour.

4.Urinalysis

• Urinalysis is performed to assess proteinuria, glycosuria, and pyuria.

• These can be done through test strips or microscopic examination of the urine.
• Pregnancy test used to detect pregnancy based on the presence of hormones.

5. Pregnancy Test
• Can produce 20ml of urine
• Can be perform accuretey 42 days after LMP or 2 weeks the first missed period
 The first voided urine in the morning is the best specimen to examined.
Causes of false Positive results Causes of false negative result

• Proteinuria Missed abortion

• Hematuria Ectopic pregnancy
• At time of ovulation( cross reaction Too early
with LH ) Urine stored too long in room
• HCG injection for fertility txt w/in the temperature
previous 30 days Interfering medication
• Thyrotoxicosis
• Premature menopause ( high LH and
FSH )
• Early days after delivery or abortion
 Trophoblastic dse.
• HCG secreting tumors usually of the
GIT

d. Pregnancy Test – Serum

• The serum HCG test is the most sensitive and specific pregnancy test.
• Pregnancy test becomes negative
a.2 weeks after delivery
b.2 weeks of fetal death
c. 2-4 weeks after evacuation of vesicular mole.

7.Uses of Pregnancy Test:

• Diagnosis of pregnancy
• Diagnosis of fetal death
• Diagnosis of ectopic pregnancy
 • Diagnosis and follow- up of gestational trophoblastic diseases

8.Ultrasonography:

• Ultrasound must be scheduled especially if the woman is unsure of the date

of her last menstrual period.
• Determine the growth of the fetus, but only the gestational sac would be
seen at this stage.
• is most accurate means of confirming intrauterine pregnancy and
gestational age during the early trimester.

Detection :

 Earliest structure can visualized as early as four and half wks is in gestational
sac
,
 Gestational sac of twins 5 weeks
 Gestational sac grows at a rate of 1mm per day in early gestation
 5.5 -6 wks gestation a double decidual sign can be seen w/c is the
Gestational sac surrounded by the thickened decidua.
 Yolk sac can be visualized at about 4-5 wks and is seen until approx. 10
wks gestation.
 Cardiac motion can be sometimes be identified in a 2 to 3mm embryo fetal
heart tone 100 -115 the heart will steadily increases of mean of 140 beats
min by 9 weeks of age of gestation.
VI. ASSESSMENT / EVALUATION :

Instructions:
1.Write your complete name clearly.
2. Read the question carefully.
3. Send your answer to my E mail address NOT to my messenger.

I. Multiple choices:
Directions: Select and write the letter of correct answer of the given question.

1. Increased salivation refers to?

a.Ptyalism b. Salivary gland c. Drooling of saliva d. Salivation

2. A woman who has completed two or more pregnancies to the stage of fetal
viability.
a. gravida b.multiple pregnancy c. para d.primigravida

3. The uterus becomes an abdominal organ at around

a.12 weeks b. 10 weeks c. 8 weeks d. 20 weeks

4. Pseudoanemia is normal occurrence of pregnancy that is due to:

a.increased plasma volume

b. elevated hemoglobin and hematocrit
c. rise in clotting factors and fibrinogen
d.effect of edema that normally occurs during pregnancy

5. After confirmation that she is pregnant, the client tells the midwife that she have
mixed feelings of joy and sadness , the client is experiencing abnormal emotional
reaction

A. Narcissism B. Grief C. Ambivalence D. Introversion

II. Definition

1. Couvades’ Syndrome

2. Ballottment
 3. Quickening

4. Presumptive

III. ESSAY

Directions: Read the question carefully and write your answer discussion on the space
provided.

1.A pregnant woman gained 2 kg in the first 20 weeks of pregnancy, then 0.5 kg a week
for the next 10 weeks, then 0.1 kg for the last 10 weeks.

1. What is her total weight gain at full term?

2. Give at least 3 interventions on how you manage the pregnant woman who are
complaining nauseated and episode of vomiting.