MATERNITY NURSING

LECTURE
( Arellano University)

JOANNE MARIE S. GARCIA R.N. MAN

 FETAL DEVELOPMENT
OVUM:
1. IT IS THE FEMALE SEX CELL OR FEMALE GAMETE.
2. REGULARLY RELEASED BY THE OVARY BY
OVULATION
3. ONLY ONE OVUM REACHES MATURITY EVERY
MONTH
4. OVUM HAS 2 LAYERS OF PROTECTIVE COVERING ;
A RING OF FLUID CALLED“ ZONA PELLUCIDA”, &
A CIRCLE OF CELLS CALLED “ CORONA RADIATA”
= these structures increase the bulk of the ovum,
facilitating its migration to the uterus.
** OVUM CAN STAY VIABLE & IS CAPABLE OF
BEING FERTILIZED FOR 12-24 HOURS AFTER
OVULATION BUT CAN LIVE UP TO 3-4 DAYS.
** ONLY ONE SPERMATOZOON IS ABLE TO
PENETRATE THE CELL MEMBRANE OF THE OVUM
AFTERWHICH THE OVUM BECOMES IMPERVIOUS
TO OTHER SPEMATOZOA.
2 KINDS OF SPERM CELL:
1. GYNOSPERM – X CARRYING SPERM CELL. It has a
large oval head, lesser in number than
androsperms & thrive better in acidic environment.
2. ADROSPERM – Y CARRYING CELL. It has a small
head & thrive better in alkaline environment
SPERM CELL:

** HAS 3 PARTS : HEAD THAT CONTAIN

CHROMATIN MATERIALS; NECK OR MID PIECE
THAT PROVIDE ENERGY & TAIL THAT IS
RESPONSIBLE FOR ITS MOTILITY.

**SPERMATOZOA DEPOSITED IN THE VAGINA

.
REACHES THE WAITING EGG IN THE FALLOPIAN
TUBE IN ABOUT 5 MINUTES

** THE FUNCTIONAL LIFE OF SPERMATOZOA IS

48-72 HRS (OR 3 TO 4 DAYS AFTER EJACULATION)
BUT CAN STAY ALIVE IN THE VAGINA FOR 5 -7
DAYS.
 Insemination
 Deposition of the sperm in the female internal
organs which occur during sexual intercourse
 Although millions of sperms are deposited in
the vagina, only a few reach the uterus because
many of them are immobilized by the acidic
vaginal environment
A.FERTILIZATION ( CONCEPTION,
FECUNDATION, IMPREGNATION)
= IT IS THE UNION OF A MATURED EGG AND A
SPERM & THE PRODUCT IS CALLED A
CONCEPTUS OR ZYGOTE.
=IT OCCURS AT THE DISTAL 3RD OF THE
FALLOPIAN TUBE – THE AMPULLA

Before fertilization can happen, two things must

occur:
1. Ovulation
2. Insemination
** When the sperm cell reaches the uterus, it
removes its protective covering, a process called “
CAPACITATION”, the outer covering at the head of
the sperm cell disappears & tiny holes appear on it.
** when it meets the ovum in the fallopian tube it
secretes the enzymes HYALURONIDASE through the
holes in its head which dissolves the outermost
covering of the egg cell, the corona radiata (a
process called “ ACROSOME REACTION”.)
** when radiata is dissolved, the sperm will again
secrete another enzyme called ACROSIN to dissolve a
portion of the zona pellucida & will enter the ovum.
** once the sperm cell has entered the ovum & their
nucleus has fused together, fertilization is completed.
** the plasma membrane of the ovum will undergo
structural changes to prevent POLYSPERMY ( or
other sperms cells entering the ovum)
** the hereditary traits & characteristics of a person
are found in the cell’s nucleus in the form of
chromosomes. Each strand of chromosome is made
up of thousands of genes that are composed of
protein substances called deoxyribose nucleic acid
(DNA) & ribonucleic acid (RNA)
** REPRODUCTIVE CELLS, DURING
GAMETOGENESIS DIVIDE BY MEIOSIS
( HAPLOID NUMBER OF DAUGHTER CELLS)
THEREFORE THEY CONTAIN ONLY 23
CHROMOSOMES).
= 22 pairs of autosomes
= 1 pair of sex chromosomes
** ( BODY CELLS OR SOMATIC CELLS HAVE 46
CHROMOSOMES BEC THEY DIVIDE VIA MITOSIS)
** SPERMS HAVE 23 CHROMOSOMES = 22
AUTOSOMES & 1 X SEX CHROMOSOME OR 1 Y SEX
CHROMOSOME.
** THE UNION OF AN X CARRYING SPERM
(GYNOSPERM) & A MATURE OVUM RESULTS IN A
BABY GIRL (XX)
** THE UNION OF A Y CARRYING
SPERM(ANDROSPERM) & A MATURE OVUM
RESULTS IN A BABY BOY (XY)
** ONLY FATHERS CAN DETERMINE THE SEX
OF THEIR CHILDREN
** SEX OF A CHILD IS DETERMINED AT THE
TIME OF FERTILIZATION.
 Genes – basic units of heredity that detrmine
both the physical and cognititve characteristics
of people
 Phenotype – refers to his or her outward
appearance or the expression of the genes
 Genotype – refers to his or her actual gene
composition
 Genome – complete set of genes present
 46XX or 46XY (chromosomes)
 Ex:
 46XX5p- = female with 46 chromosomes but
with the short arm of chromosome 5 missing
( cru de chat syndrome)
 47XX21 or 47 XY21 – person has an extra
chromosome21 ( Trisomy 21 or Down’s
syndrome)
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. FLUID
FILLS THE SPACES FOUND
WITHIN THE CELLS.
-
 The trophoderm layer gives rise to the placenta,
fetal membranes, umbilical cord and amniotic
fluid
 The important functions of the trophoblasts are
to:
 1) absorb nutrients from the endometrium
 2.) secrete a hormone called “ Human Chorionic
Gonadotropin” necessary in prolonging the life of
the corpus luteum.
TROPHOBLASTS OR THE OUTER CELLS:
AT ABOUT 3 WEEKS, THE TROPHOBLAST CELLS
DIFFERENTIATE INTO TWO DISTINCT LAYERS:
1.CYTOTROPHOBLAST OR LANGHAN’S LAYER:
- INNER LAYER THAT PROTECTS THE FETUS
AGAINST SYPHILIS UNTIL THE 2ND TRIMESTER.
2. SYNCYTIOTROPHOBLAST OR SYNCYTIAL
LAYER:
- OUTER LAYER THAT PRODUCES THE HORMONES 1.
HUMAN CHORIONIC GONADOTROPIN (HCG), 2.HUMAN
PLACENTAL LACTOGEN (HPL). 3.ESTROGEN &
4.PROGESTERONE.
1.HCG: HUMAN CHORIONIC GONADOTROPIN
- FIRST HORMONE TO APPEAR IN PREGNANCY WHICH
SERVES AS THE BASIS FOR PREGNANCY TESTING
- SECRETED BY TROPHOBLASTS DURING EARLY
PREGNANCY
- PREVENTS INVOLUTION OF THE CORPUS LUTEUM,
STIMULATES IT TO CONTINUE PRODUCING
PROGESTERONE AND ESTROGEN FOR 11-12 WEEKS
- 8 – 10 DAYS AFTER FERTILZATION, HCG IS PRESENT
IN THE MATERNAL BLOOD
- FEW DAYS AFTER MISSED MENSES (+) IN THE URINE
2. Human placental lactogen
- makes sufficient amount of protein,
glucose, and minerals
- an insulin antagonist (maternal
metabolism of glucose)
- ensures that the mother’s body is prepared
for lactation

24
3.Estrogen
- stimulates development of uterine and
breast tissues in the mother
- increases vascularity and vasodilation in
the villous capillaries

25
4. Progesterone
- after 11 weeks of pregnancy, placenta takes over
the production of progesterone from the corpus
luteum

- it is a smooth muscle relaxant, prevents uterine

contraction by decreasing its contractility
- also maintains the endometrium

26
 - 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 NERVOUS SYSTEM, SKIN, HAIR
( OUTER LAYER) NAILS, SENSE ORGANS, MUCUS
MEMBRANES OF NOSE & MOUTH

MESODERM CONNECTIVE TISSUE, BONES,

( MIDDLE LAYER) CARTILAGE, MUSCLES,
TENDONS, KIDNEYS, URETERS,
REPRODUCTIVE SYSTEM, HEART,
CIRCULATORY SYSTEM, BLOOD
CELLS
 ENDODERM / ENTODERM LINING OF THE GI TRACT,
( INNER LAYER)
RESPIRATORY TRACT,
TONSILS, PARATHYROID,
THYROID, THYMUS GLANDS,
BLADDER, URETHRA
FETAL MEMBRANES: -
= this enclose the fetus & the amniotic fluid. They
also protect the fetus against ascending bacterial
infection. Once the integrity of the membranes are
destroyed, the woman is prone to develop
infection.
1.CHORIONIC MEMBRANE – ( OUTER MEMBRANE)
= TOGETHER WITH THE DECIDUA BASALIS
GIVES RISE TO THE PLACENTA . IT CONTAINS
15-20 COTYLEDONS .
2. AMNIOTIC MEMBRANE –( INNER FETAL
MEMBRANE)
= IT IS A SMOOTH, THIN, TOUGH &
TRANSLUCENT MEMBRANE DIRECTLY ENCLOSING
THE FETUS & THE AMNIOTIC FLUID. IT IS
CONTINUOUS WITH THE UMBILICAL CORD &
COVER THE FETAL SURFACE OF THE PLACENTA &
UMBILICAL CORD.
= AMNION & CHORION DOES NOT CONTAIN
NERVE ENDINGS
IMPLANTA
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”.
DECIDUA:
- AFTER IMPLANTATION, THE ENDOMETRIUM
IS NOW REFERRED TO AS THE DECIDUA.
LAYERS:
1.DECIDUA BASALIS –LAYER WHERE
IMPLANTATION TAKES PLACE. IT WILL LATER
ON FORM THE MATERNAL SIDE OF THE
PLACENTA.
2.DECIDUA CAPSULARIS – LAYER WHICH
ENCLOSES, ENVELOPES THE BLASTOCYST &
BECOMES THE BAG OF WATER.
3. . DECIDUA VERA – REMAINING LAYER
AMNIOTIC FLUID:
- 500 ML TO 1200 ML AT TERM; AVERAGE 1000
ML; replaced approximately 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.
- AMNIOTIC FLUID VOLUME INCREASES DURING
PREGNANCY & PEAKS APPROXIMATELY 2 WEEKS
BEFORE EDC
 AMNIOTIC FLUID

 fetus contributes to the fluid through

urine excretion and absorbs from it by
swallowing
 Hydramnios or polydydaramnios (>
2000 ml)-
 Oligohydramnios (< 500) ml indicates
disturbance in kidney function
ABNORMAL AMNIOTIC COLORS:
1. GREEN TINGES OR MECONIUM STAINED IN A
NON BREECH PRESENTATION – SIGNIFIES
FETAL DISTRESS
2. GOLD OR YELLOW – SIGNIFIES HEMOLYTIC
DISEASE SUCH AS Rh OR ABO
INCOMPATIBILITY
3. GRAY – INDICATES INFECTION
4. PINK – SIGNIFIES BLEEDING
 FUNCTIONS OF AMNIOTIC FLUID:
1. PROTECTS THE FETUS FROM TRAUMA, BLOWS &
PRESSURE
2. ALLOWS FREEDOM OF MOVEMENT WHICH
PERMITS SYMMETRICAL GROWTH &
DEVELOPMENT
3.MAINTAINS A CONSTANT TEMPERATURE.
4. SOURCE OF ORAL FLUID INTRAUTERINE.
5. AIDS IN DIAGNOSIS OF MATERNAL & FETAL
COMPLICATIONS.
6. AIDS IN FETAL DESCENT DURING LABOR BY
PROVIDING LUBRICATION IN THE BIRTH CANAL.
 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 CARDIAC 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
** UMBILICAL CORD ORIGINATES FROM THE
YOLK SAC & UMBILICAL VESICLES.
** WHARTON’S JELLY – GELATINOUS
SUBSTANCE THAT COVERS THE UMBILICAL
CORD TO PREVENT 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.

NO MAJOR CONSEQUENCE IN UTERO, BUT COULD LEAD TO A GREATER CHANCE FOR CORD
TRAUMA
* 4. Battledore insertion
 The cord is inserted
marginally rather than
centrally
 The cord is inserted at
the edge of the placenta
 Cord Abnormalities
 Knots of the Cord – fetal movements may
cause knots in the cord which could lead to
perinatal loss. Its incidence is high in
monoamniotic twinning. Normal false knots
results from kinking to accommodate cord
length.
 Loops of the Cord- the cord may coil around
the fetal body and neck. When cord coil is in
the neck, it is called nuchal cord.
Umbilical knot
 PLACENTA

* THE PLACENTA IS FORMED FROM THE

CHORIONIC VILLI AND DECIDUA BASALIS.
* IT REACHES MATURITY AT 8 WEEKS AND
BECOMES FUNCTIONAL AT 12 WEEKS
GESTATION ( 3 MONTHS) AND CONTINUE
TO FUNCTION EFFECTIVELY UNTIL THE 40
TO 41ST WEEK.. IT BEGINS TO DEGENERATE
AFTER THE 42ND WEEK MAKING IT
DANGEROUS FOR THE FETUS TO REMAIN
IN UTERO BEYOND 42 WEEKS GESTATION.
Placenta - membranous vascular organ
connecting the fetus to the mother, supplies
the fetus with oxygen and food and transports
waste product out of fetal system
- development is stimulated by progesterone
secreted by corpus luteum
( 3rd wk after fertilization)
- fully functional by the 12th week

54
2 sides of placenta:

1.maternal side which is irregular and is

divided into subdivisions called
cotyledons
2. fetal side covered by amnion, so it is
smooth and shiny

55
 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
NOTE: 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
AFTER BIRTH.
6. ENDOCRINE SYSTEM = PRODUCES
HORMONES HCG, HPL ( HUMAN PLACENTAL
LACTOGEN “ CHORIONIC
SOMATOMAMMOTROPIN”, ESTROGEN ,
PROGESTERONE, RELAXIN
 Anomalies of the placenta and cord
 Placenta
 Weighs approximately 500 g and is 15 – 20 cm in
diameter, 1.5 – 3 cm thick
 Weight is 1/6 of the fetus
 Maternal and fetal sides

 Umbilical cord
 length:55 cm at term
 1 vein (carries oxygenated blood to the fetus)
 2 arteries (carry deoxygenated blood from fetus to
placenta)
 Wharton’s jelly, gelatinous substance
 Cord extends from the fetal surface of the placenta to the
fetal umbilicus
Placenta succenturiata
 Placenta has 1 or
more accessory
lobes connected to
the main placenta
by blood vessels
Placenta circumvallata
 Ordinarily, chorion
membrane begins at the
edge of the placenta; no
chorion covers the fetal
side of the placenta
 This kind- the fetal side
of the placenta is covered
with chorion
 Abnormal Placental
Implantation
 Placenta Acreta – invasion of the placenta
deep into the endometrium
 Placeta increta- invasion of the placenta into
the myometrium
 Placenta percreta – penetration of the
placenta through the myometrium to the serosa
 Vasa previa – placental vessels crossing the
cervical os
The Growing Fetus
 STAGES OF FETAL GROWTH AND
DEVELOPMENT

A.PRE-EMBRYONIC or GERMINAL STAGE =

FIRST 2 WEEKS BEGINNING WITH
FERTILIZATION ( ZYGOTE)
B. EMBRYONIC = WEEKS 2-8, CONSIDERED
THE MOST CRITICAL IN FETAL STAGE
BECAUSE OF ORGANOGENESIS.
( EMBRYO)
C. FETAL = WEEKS 8 TO BIRTH ( FETUS)
 NORMAL FETAL DEVELOPMENT
FIRST TRIMESTER
4 WEEKS FORM OF EMBRYONIC DISC,
NOT CLEARLY DEFINED FEATURES,
SPINAL CORD IS FORMED; RUDIMEN
TARY HEART APPEARS AS A
PROMINENT BULGE ON THE
ANTERIOR SURFACE, ARMS & LEGS
BUD LIKE STRUCTURES,
RUDIMENTARY EYES, EARS, & NOSE
ARE DISCERNABLE
8 WEEKS ORGANOGENESIS IS COMPLETE, HEART
BEATS RHYTHMICALLY, , FACIAL FEATURES
ARE DISCERNABLE,EXTREMITIES HAVE
DEVELOPED,, EXTERNAL GENITALIA
PRESENT BUT NOT DISTINGUISHABLE
PRIMITIVE TAIL IS REGRESSING, ABDOMEN
APPEARS LARGE AS FETAL INTESTINES
GROWS RAPIDLY,EYES MOVE FROM FACE TO
FRONT SONOGRAM SHOWS
GESTATIONAL SAC ( DIAGNOSTIC OF
PREGNACY)
12 WEEKS NAIL BEDS FORMING ON FINGERS & TOES,
BONE OSSIFICATION BEGINS, TOOTH BUDS
PRESENT, SEX DISTINGUISHABLE BY
OUTWARD APPEARANCE, KIDNEYS
SECRETE, HEARTBEAT AUDIBLE BY A
DOPPLER

16 WEEKS FETAL HEART SOUNDS AUDIBLE VIA

FETOSCOPE, LANUGO IS WELL FORMED,
LIVER & PANCREAS FUNCTIONING, FETUS
SWALLOWS AMNIOTIC FLUID SHOWING AN
INTACT BUT UNCOORDINATED
SWALLOWING REFLEX, SEX CAN BE
DETERMINED BY ULTRASOUND;QUICKENING FELT BY
A MULTIGRAVIDA
20 WEEKS QUICKENING FELT BY A PRIMAGRAVIDA,
ANTIBODY PRODUCTION IS POSSIBLE,
HAIR FORMS INCLUDING EYEBROWS & HAIR ON
HEAD, MECONIUM PRESENT IN UPPER INTESTINE,
BROWN FAT ( AIDS IN TEMPERATURE REGULATION AT
BIRTH) BEGINS TO BE FORMED BEHIND THE
KIDNEYS, STERNUM, & POSTERIOR NECK,
FETAL HEART AUDIBLE VIA
STETHOSCOPE, VERNIX CASEOSA BEGINS TO FORM,
24 WEEKS PASSIVE ANTIBODY TRANSFER FROM
MOTHER TO FETUS BEGINS .INFANTS BORN
BEFORE ANTIBODY . TRANSFER HAS TAKEN
PLACE HAVE NO NATURAL IMMUNITY & NEED MORE
THAN THE USUAL PROTECTION AGAINST
INFECTIOUS DISEASE IN THE NEWBORN UNTIL THE
INFANT’S OWN STORE OF IG’S CAN BUILD UP;
MECONIUM IS PRESENT IN THE RECTUM; ACTIVE
PRODUCTION OF LUNG SURFACTANT BEGINS;
EYEBROWS & EYELASHES WELL DEFINED; EYELIDS NOW
OPEN; PUPILS REACTIVE TO LIGHT; HEARS
IN RESPONSE TO SUDDEN SOUND.
28 WEEKS LUNG ALVEOLI BEGINS TO MATURE;
SURFACTANT PRESENT IN AMNIOTIC FLUID;
TESTES BEGIN TO DESCEND;

32 WEEKS
SUBCUTANEOUS FAT BEGINS TO BE
DEPOSITED ( THE FORMER “ STRINGY” OLD MAN
APPEARANCE IS LOST); FETUS IS AWARE OF SOUNDS
32 weeks
OUTSIDE THE MOTHERS BODY; ACTIVE MORO
REFLEX PRESENT, BIRTH POSITION( VERTEX OR
BREECH) MAY BE ASSUMED; IRON STORES
THAT PROVIDE IRON FOR THE TIME THAT THE
NEONATE WILL INGEST ONLY MILK AFTER BIRTH ARE
BEGINNING TO BE DEVELOPED; FINGERNAILS GROW
TO REACH END OF FINGERTIPS.
36 WEEKS ADDITIONAL AMOUNTS OF SUBCATANEOUS
FATS ARE DEPOSITED; SOLE OF THE FOOT HAS
ONLY ONE OR TWO CRISSCROSS CREASES;
LANUGO BEGINS TO DIMINISH; MOST BABIES TURN
INTO A VERTEX OR HEAD-DOWN PRESENTATION
DURING THIS MONTH

40 WEEKS FETUS KICKS ACTIVELY CAUSING

DISCOMFORT TO THE MOTHER; VERNIX CASEOSA
IS FULLY FORMED;
** IN PRIMIPARAS, THE FETUS OFTEN SINKS INTO THE BIRTH
CANAL DURING THE LAST TWO WEEKS ( UP TO 4 WEEKS), GIVING
THE MOTHER A FEELING THAT HER LOAD IS BEING LIGHTENED.
THIS IS TERMED LIGHTENING. IT IS A FETAL ANNOUNCEMENT THAT
THE THIRD TRIMESTER OF PREGNANCY HAS ENDED AND BIRTH IS
AT HAND.**
 ** THE DURATION OF A NORMAL
PREGNANCY IS 266 – 280 DAYS OR 38-42
WEEKS ( AVERAGE IS 40 WEEKS) ; OR 9
CALENDAR MONTHS OR 10 LUNAR MONTHS.
** BOTH OVULATION & GESTATIONAL AGE
ARE ALSO SOMETIMES MEASURED IN LUNAR
MONTHS ( 4 WEEK PERIODS) OR IN
TRIMESTERS ( 3 MONTH PERIOD) RATHER
THAN IN WEEKS. IN LUNAR MONTHS, A
PREGNANCY IS 10 MONTHS ( 40 WEEKS OR
280 DAYS) LONG; A FETUS GROWS IN UTERO
9.5 LUNAR MONTHS OR THREE FULL
TRIMESTERS ( 38 WEEKS OR 266 DAYS)
 SIGNS & SYMPTOMS OF PREGNANCY:
PRESUMPTIVE SIGNS: ( SUBJECTIVE SIGNS)
1. AMENORRHEA of more than 10 days
2. MORNING SICKNESS ( NAUSEA & VOMITING)
3. EASY FATIGABILITY
4. URINARY FREQUENCY
5. STRIAE GRAVIDARUM
6. CHLOASMA, MELASMA OR “ MASK OF
PREGNANCY” 8. QUICKENING
7. LINEA NIGRA 9. LEUKORRHEA
 SKIN
 Pink or reddish abdominal streaks (striae gravidarum)
which is caused by stretching of the skin
 Chloasma or “mask of pregnancy -Increased
pigmentation can occur on the face as blotchy brown
areas on the forehead an cheeks
 linea nigra – on the abdomen as dark line from the
symphysis pubis
 Minute vascular spiders may occur
 The umbilicus is pushed outward, and by about the
seventh month its depression disappears and becomes a
darkened area on the abdominal wall
 Sweat and sebaceous glands are more active
CHLOASMA
STRIAE GRAVIDARUM
STRIAE ALBICANTES/
ATROPICANTES
PROBABLE SIGNS: ( OBJECTIVE SIGNS)
1.CHADWICK’S SIGN – PURPLISH
DISCOLORATION OF THE VAGINA DUE TO HIGH
VASCULARITY IN THE AREA.
2. GOODEL’S SIGN – SOFTENING OF THE CERVIX
3. HEGAR’S SIGN – SOFTENING OF THE LOWER
UTERINE SEGMENT.
4. BALLOTEMENT – BOUNCING OF THE BABY WHEN TAPPED
BY AN EXAMINING FINGER.
5. BRAXTON HICK’S – PAINLESS UTERINE CONTRACTIONS
6. (+) POSITIVE PREGNANCY TEST
7. Uterine enlargement
 POSITIVE SIGNS OF PREGNANCY:

1. PRESENCE OF FETAL HEART TONE

2. FETAL OUTLINE BY XRAY / ULTRASOUND

3. FETAL MOVEMENT FELT BY EXAMINER

 SYSTEMIC CHANGES:
CIRCULATORY / CARDIOVASCULAR:
** BEGINNING THE END OF THE FIRST
TRIMESTER, THERE IS A GRADUAL INCREASE
OF ABOUT 30%-50% IN TOTAL CARDIAC
VOLUME. THIS CAUSES A DROP IN HgB & HcT
VALUES SINCE THE INCREASE IS ONLY IN
PLASMA.” PHYSIOLOGIC ANEMIA OF
PREGNANCY”
Mx : iron supplement
CONSENQUENCES OF INCREASED CARDIAC
VOLUME:
** EASY FATIGABILITY & SOB DUE TO
INCREASED WORKLOAD OF THE HEART
MX: REST
** SLIGHT HYPERTHOPHY OF THE HEART
CAUSING IT TO BE DISPLACED TO THE LEFT
** SYSTOLIC MURMURS DUE TO LOWERED
BLOOD VISCOSITY
** NOSEBLEEDS MAY OCCUR DUE TO
MARKED CONGESTION OF THE NASOPHARYNX
 ** PALPITATIONS DUE TO INCREASED
PRESSURE ON THE DIAGPHRAGM
** EDEMA OF LOWER EXTERMITIES OCCURS
DUE TO POOR CIRCULATION RESULTING FROM
PRESSURE OF THE GRAVID UTERUS ON THE
BLOOD VESSELS
MX; > RAISE LEGS ABOVE HIP LEVEL
> AVOID PROLONGED STANDING & SITTING
NOTE: EDEMA OF THE LE IS NOT A SIGN OF
TOXEMIA.
** VARICOSITIES COULD OCCUR DUE TO
PRESSURE OF THE GRAVID UTERUS ON THE
BLOOD VESSELS OF THE LE
MX: > DO NOT CROSS LEGS WHEN SITTING
> WEAR SUPPORT HOSE TO PROMOTE
VENOUS FLOW THUS PREVENTING STASIS IN
THE LOWER EXTREMITIES
> APPLY ELASTIC BANDAGE – START AT
THE DISTAL END TOWARDS THE TRUNK TO
AVOID CONGESTION & IMPAIRED CIRCULATION
IN THE DISTAL PART
> AVOID USE OF KNEE HIGH SOCKS
 ** VARICOSITIES OF THE VULVA & RECTUM
MX: > SIDE LYING POSITION WITH HIPS
ELEVATED ON PILLOWS
> MODIFIED KNEE CHEST POSITION
** THERE IS INCREASED CIRCULATING
FIBRINOGEN ( CLOTTING FACTOR) THAT IS
WHY PREGNANT WOMEN ARE NORMALLY
SAFEGUARDED AGAINST UNDUE BLEEDING.
HOWEVER THIS ALSO PREDISPOSES THEM TO
CLOT FORMATION ( THROMBI)
IMPLICATION: PREGNANT WOMEN SHOULD
NOT BE MASSAGED SINCE BLOOD CLOTS
CAN BE RELEASED & CAUSE
THROMBOEMBOLISM.

** DURING DELIVERY, THE ALLOWABLE

BLOOD LOSS IS 250-450 ML (MAXIMUM 500 ML)
FOR A SINGLE FETUS, 1000 ML FOR VAGINAL
DELIVERY OF TWINS OR CESARIAN SECTION.
 ** SUPINE HYPOTENSION SYNDROME OR
VENA CAVA SYNDROME = THE WEIGHT OF
THE GRAVID UTERUS PRESSES ON THE VENA
CAVA OBSTRUCTING BLOOD FLOW. THE
WOMAN EXPERIENCES LIGHTHEADEDNESS,
FAINTNESS & HEART PALPITATIONS.
MX: LEFT SIDE LYING OR LEFT LATERAL SO
AS NOT TO COMPRESS THE VENA CAVA. NO
SUPINE POSITION AFTER 20 WEEKS AOG
RESPIRATORY SYSTEM:
** SLIGHT DYSPNEA MAY OCCUR UNTIL
LIGHTENING CAUSED BY INCREASED O2
CONSUMPTION & PRODUCTION OF CO2
GASTROINTESTINAL SYSTEM:
** MORNING SICKNESS
MX: EAT DRY CRACKERS 30 MINUTES BEFORE
ARISING IN THE MORNING. AVOID SPICY,
FATTY FOODS
HYPEREMESIS GRAVIDARUM = EXCESSIVE
NAUSEA & VOMITING WHICH PERSISTS
BEYOND 3 MONTHS THAT COULD RESULT TO
DEHYDRATION, STARVATION, MALNUTRITION
AND F & E IMBALANCE
MX: D10NSS 3000 ML IN 24 HOURS IS THE
PRIORITY OF TREATMENT
> REST
> ANTI- EMETICS (EX. PLASIL)
CONSTIPATION = DUE TO DISPLACEMENT OF
THE STOMACH & INTESTINES AND DUE TO
INCREASED PROGESTERONE DURING
PREGNANCY ( DECREASED PERISTALSIS)
MX:
> INCREASE FLUID INTAKE
> HI - FIBER DIET
ESTABLISH REGULAR ELIMINATION PATTERN
EXERCISE
> MINERAL OIL SHOULD NOT BE USED
BECAUSE IT INTERFERES WITH ABSORPTION
OF FAT SOLUBLE VITAMINS ( ADEK)
HEARTBURN = REFLUX OF STOMACH
CONTENT INTO THE ESOPHAGUS DUE TO
INCREASED PROGESTERONE WHICH
DECREASES GASTRIC MOTILITY
MX: > PATS OF BUTTER BEFORE MEALS
> AVOID FRIED, FATTY FOODS
> BEND AT THE KNEES NOT AT THE WAIST
> TAKE ANTACIDS EX. MILK OF MAGNESIA
BUT NEVER SODIUM NHCO3 ( ALKA SELTZER
OR BAKING SODA) BECAUSE IT PROMOTES
FLUID RETENTION.
PICA = **ABNORMAL CRAVING FOR NON
NUTRITIOUS SUBSTANCES. THE MOST
COMMON IS CRAVING FOR ICE CUBES. THERE
COULD ALSO BE CRAVING FOR PAPER, ETC.,
**OFTEN ACCOMPANIES IRON DEFICIENCY
ANEMIA
**ENCOURAGE TO TAKE IRON SUPPLEMENTS
MUSCULOSKELETAL SYSTEM
GRADUAL SOFTENING OF PELVIC LIGAMENTS AND
JOINTS TO FACILITATE PASSAGE OF THE BABY.
LORDOSIS= FORWARD CURVATURE OF THE
LUMBER SPINE . “THE PRIDE OF PREGNANCY”
LEG CRAMPS – ALSO KNOWN AS “CHARLEY
HORSE” MAY OCCUR FROM AN IMBALANCE OF
CALCIUM PHOSPHORUS RATIO IN THE BODY AND
FROM PRESSURE OF THE UTERUS ON LOWER
EXTREMITIES; FATIGUE; CHILLS
BACK PAINS – RELIEVED BY WEARING LOW
HEELED SHOES
MANAGEMENT:
**FREQUENT REST PERIODS WITH FEET
ELEVATED **WEAR WARM, COMFORTABLE
CLOTHING **INCREASE CALCIUM INTAKE
(CALCIUM TABLETS AND DIET)
**DO NOT MASSAGE= BLOOD CLOTS CAN
CAUSE EMBOLISM
**pelvic rocking
 c. THE PSYCHOLOGICAL TASKS OF
PREGNANCY
 First trimester –ACCEPTING THE
PREGNANCY”I am pregnant”
 maternal ambivalence, even in planned
pregnancy, is usual; there may be some
anticipation and concern related to fears and
fantasies about the pregnancy
 The fetus is an unidentified concept with
great future implications but without tangible
evidence of reality.
 Implication: when giving health teachings,
be sure to emphasize the bodily changes in
pregnancy.
 Second trimester
 ACCEPTING THE BABY as a separate
individual
 “ I am going to have a baby”
 quickening by 20 weeks can help a woman
realize that the fetus inside her womb is a real
& separate individual to care for. She begins to
fantasize about the child’s sex & appearance
 Third trimester
 PREPARING FOR DELIVERY AND PARENTHOOD
“ I am going to be a mother”
 possible new fears related to labor and delivery and
fantasies about the appearance of the baby;
 Woman begins to plan about the birth of the baby.
She selects a baby layatte, choose names for her baby,
make plans on how the baby will be fed, where the
baby will sleep at home etc.
 PATERNAL REACTIONS TO PREGNANCY:
A. FIRST TRIMESTER = AMBIVALENCE &
ANXIETY ABOUT ROLE CHANGE; CONCERN
FOR IDENTIFICATION WITH MOTHER’S
DISCOMFORTS ( COUVADE SYNDROME)
B. SECOND TRIMESTER = INCREASED
CONFIDENCE & INTEREST IN MOTHER’S CARE;
DIFFICULTY RELATING TO FETUS; “JEALOUSY”
 PRENATAL CARE ( ANTEPARTUM CARE)
- Refers to the health care given to a woman &
her family during pregnancy. The primary goal
is to provide maximum health to expectant
mothers & their babies.
3 PHASES:
1. PRE-CONSULTATION = HISTORY TAKING,
FAMILY, MEDICAL, OB HISTORY)
2. CONSULTATION = PHYSICAL ASSESSMENT
3. POST CONSULTATION = HEALTH TEACHINGS
COMPONENTS OF PRE NATAL VISIT
1.PRE- CONSULTATION PHASE: History Taking
PERSONAL DATA: AGE, SEX, CIVIL STATUS,
WEIGHT, HEIGHT
1. AGE : UNDER 17 OR ABOVE 35 (GREATER
RISK IF OVER 40)
** PREGNANT ADOLESCENTS HAVE A
HIGHER INCIDENCE OF PREMATURITY, PIH,
CEPHALOPELVIC DISPROPORTION, POOR
NUTRITION & INADEQUATE ANTEPARTAL
CARE. ** WOMEN OVER 35 YEARS OLD ARE AT
RISK FOR CHROMOSOMAL DISORDERS IN
INFANTS, PIH & CESARIAN DELIVERY.
OBSTETRICAL DATA:
MENSTRUAL HISTORY: INCLUDES MENARCHE,
LENGTH & REGULARITY OF MENSES, INTERVAL
BETWEEN PERIODS, AMOUNT OF FLOW,
DYSMENORRHEA
TERMINOLOGIES:
GRAVIDA = THE NUMBER OF PREGNANCIES
REGARDLESS OF DURATION OR OUTCOME
PARA = PAST PREGNANCIES RESULTING IN
VIABLE FETUS ( 20 WEEKS) WHETHER BORN
DEAD OR ALIVE. ( TWINS, TRIPLETS ETC.
CONSIDERED AS ONE).
T= NUMBER OF FULL TERM BIRTHS
P= NUMBER OF PREMATURE BIRTHS
A= NUMBER OF ABORTIONS
L= NUMBER OF LIVING CHILDREN
PRIMIGRAVIDA = A WOMAN WHO IS PREGNANT
FOR THE FIRST TIME
PRIMIPARA = A WOMAN WHO HAS DELIVERED
A VIABLE LIVE OR DEAD CHILD
MULTIGRAVIDA = A WOMAN WHO HAS HAD 2
OR MORE PREGNANCIES
NULLIGRAVIDA = A WOMAN WHO HAS NEVER
BEEN & IS NOT CURRENTLY PREGNANT
NULLIPARA – A WOMAN WHO HAS NEVER
DELIVERED A FETUS THAT REACHED THE AGE OF
VIABILITY. SUCH WOMAN MAY OR MAY NOT HAVE
BEEN PREGNANT BEFORE.

MULTIPARA – A WOMAN WHO HAS COMPLETED

TWO OR MORE PREGNANCIES TO THE AGE OF
VIABILITY.
 DEFINITION OF TERMS
 Term infant – an infant born between 38 and 42
weeks of gestation
 Preterm – an infant born before 38 weeks
 Post term – an infant born after 42 weeks
 Abortion – pregnancy that terminates before the
period of viability (20 wks)
 Live birth – a live birth is recorded when an infant
born shows sign of life
 DEFINITION OF TERMS
 Stillbirth – infant born without signs of life
 Early neonatal Death – death of newborn within 7 days
after birth
 Late neonatal Death – death of newborn between 7 to 29
days after birth
 Low birth weight – < 2500 grams
 Normal Birth weight – 2500 – 4000 grams
 Large birth weight - > 4000 grams
 Parturient – a woman in labor
 Puerpera – a woman who just delivered (within six weeks
after delivery)
 STATISTICS
 Birth rate – number of birth per 1000
population
 Fetal death rate – number of fetal deaths per
1000 population
 Perinatal mortality rate – number of deaths
occurring after 28 weeks of pregnancy until 6
days after birth
 Neonatal mortality rate – number of infant
death during the first 28 days of life over 100
live births
MATERNAL MORTALITY RATE – NUMBER OF DEATHS
THAT OCCURRED DUE TO COMPLICATIONS OF
PREGNANCY, LABOR & PUERPERIUM PER 10,000 LIVE
BIRTHS. THE THREE MAJOR CAUSES OF MATERNAL
MORTALITY ARE:
1. HEMORRHAGE
2. INFECTION
3. PREGNANCY INDUCED HYPERTENSION
INFANT MORTALITY RATE – NUMBER OF INFANT
DEATHS DURING THE FIRST 12 MONTHS OF LIFE PER
1000 LIVE BIRTHS
FERTILITY RATE – NUMBER OF LIVE BIRTHS PER 1000
FEMALE POPULATION AGED 15 TO 44 YEARS
2. CONSULTATION PHASE: Physical
assessment
1. Initial visit – complete physical exam

Determine Goodel’s, Hegars and Chadwick signs

121
 Laboratory screening
 Initially and at routine visits, urine dipstick for
glucose, protein (pregnancy induced hypertension
and UTI), CBC, rubella IgG antibody
 Maternal serum alpha-fetoprotein (AFP) at 16-18 wk
to identify risk of neural tube defect in fetus
 Glucose screening between 24-28 wk to detect
gestational diabetes
 Repeat CBC at 24 –28 wk
 Rh antibody titers for Rh(-) woman at 24, 28, 32, and
40 wks
 ultrasound

122
 Laboratory Tests
 Urinalysis
 1.Collect urinary specimen by midstream or clean catch
technique
 2. Benedict’s test to detect glycosuria
 3. Heat & acetic acid to detect proteinuria
 4. Urinalysis in the first trimester is also performed to
detect asymptomatic bacteuria. Bacteuria can lead to
abortion early in pregnancy & can cause premature
labor late in pregnancy.
 Blood Tests
 Hematocrit & Hemoglobin – count at initial
clinic visit & repeated at 28-32 weeks to detect
anemia.
 Normal Hemoglobin level is between 12-16 mg/dl
 Normal Hematocrit count is between 37-47%
 VDRL and Kahn & Wassaerman test to detect
Syphilis
 Gonorrhea Culture
 Rubella Antibody Titer – to detect degree of
protection against german measles. A test result of 1:8
or less indicates that the mother is at risk of acquiring
the infection during pregnancy. A titer more than 1:8
means that the mother has immunity against german
measles
 Assessment of Fetal Growth
Assessing fetal well-being

 Fetal movement
 Maternal serum alpha-
fetoprotein
 Fetal heart rate
 Triple screening (AFP,
 Ultrasound estriol and hCG)
 Nonstress Test  Chorionic villi sampling
 Amniocentesis
 Percutaneous umbilical
blood sampling
 Biophysical profile

126
 Fetal movement
 Fetal movement that can be felt by the mother :
QUICKENING begins at approximately 18 – 20
weeks of pregnancy; peaks at 28-38 weeks
 Primigravid- quickening:20 weeks ( 5 months)
 Multigravid- 16 weeks ( 4 months)
 Ask the mother to observe fetal movement.
 A healthy fetus moves at least 10x a day.

127
 Fetal heart rate
 FHR should be 120-160
beats per minute

 Can be heard with a Doppler

: 10 – 12th week of pregnancy
( 3 months)

 Fetoscope: 18-20 weeks

( 4 months)
 Stethoscope: 20 weeks
( 5 months)

128
LOCATING FETAL HEART SOUNDS BY FETAL POSITION
FHT – heard best at the FETAL BACK
 Ultrasound
 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
( UZ is Best performed bet 8-
18 weeks)
130
 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
 Predict maturity by measurement of the
biparietal diameter (BPD)
 discover complications of pregnancy / fetal
anomalies
131
 Pre-procedure:
 Drink 1 glass of water every 15 minutes for 90
minutes
 Bi parietal Diameter
 Ultrasound is used to predict fetal maturity by
measuring the biparietal diameter ( side to side
or transverse diameter) of the fetal head.
 8.5 cm or greater = infant weighs more than
2500g ( 5.5lbs)
 8.5 cm bi parietal diameter indicates fetal age
of 40 weeks ( term)
 Nonstress Test ( NST)

 Measures the response of

fetal heart rate to fetal
movement
 Determines fetal well-
being
 Performed to assess
placental function and
oxygenation

134
 An external ultrasound transducer and the
tocodynamometer are applied to the mother and
a tracing of at least 20 minutes’ duration is
obtained so that the FHR and the uterine activity
can be observed.
 Obtain baseline blood pressure and monitor
blood pressure frequently.
 Position mother in semi-fowler’s or side- lying
position or left lateral position to avoid vena cava
compression.
 The mother may be asked to press a button every
time she feels fetal movement; the monitor
records a mark at each point of fetal movement,
which is used as a reference point to assess FHR
response. 135
RESULTS OF NST:
 REACTIVE NONSTRESS TEST:Normal/Negative

- indicates a healthy fetus

- requires 2 or more FHR accelerations of at least 15 beats per
minute, lasting at least 15 seconds from the beginning of the
acceleration to the end, in association with fetal movement,
during a 20-minute period.

 NONREACTIVE NONSTRESS TEST: Abnormal

-No accelerations or accelerations of less than 15 bpm or lasting
less than 15 seconds in duration occur in a 40 minute observation.

 UNSATISFACTORY – The result cannot be interpreted because

of the poor quality of the FHR tracing.

136
 Contraction Stress Test (CST)or
Oxytocin Challenge Test ( OCT)
 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.

137
 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.
138
RESULTS OF CST:
 NEGATIVE CST/ NORMAL
- no late or variable decelerations of FHR

 POSITIVE CST/ ABNORMAL

- late or variable decelerations of FHR with 50% or more of
the contractions in the absence of hyperstimulation of the
uterus.

 EQUIVOCAL – with decelerations but with less than 50% of

the contractions, or the uterine activity shows a
hyperstimulated uterus.

 UNSATISFACTORY – adequate uterine contractions cannot

be achieved, or the FHR tracing is not of sufficient quality for
adequate interpretation.

139
Fetal Heart Rate Patterns Indicative of… Intervention
Tachycardia (>160 bpm) Maternal or fetal infection Depends on the cause
Fetal hypoxia (ominous sign)

Bradycardia (<120 bpm) Fetal hypoxia or stress Place client on her left side
Maternal hypotension after epidural Increase fluids to counteract
initiation hypotension
Stop oxytocin (Pitocin) if in use

Early deceleration Head compression :not ominous None required

(deceleration begins and ends with Vagal stimulation
uterine contraction)

Late deceleration Fetalstress and hypoxia Change maternal position

(HR decreases after peak of contraction Deficient placental perfusion Correct hypotension
and recovers after contraction ends) Supine position Increase IV fluid rate as ordered
Maternal hypotension Discontinue oxytocin
Uterine hyperstimulation Administer oxygen as ordered

Variable deceleration Cordcompression Change maternal position

(transient decrease in HR anytime Hypoxia or hypercarbia Administer Oxygen
during contraction

Decreased variability Fetalsleep cycle Depends on the cause

Depressant drugs
Hypoxia
CNS anomalies
 Presumptive Probable Positive
S/sx felt and Signs Undeniable signs
observed by the observed by confirmed by the
mother but does not the members use of instrument
confirm the of the health
diagnosis of care team
pregnancy
First Breast changes Goodel’s sign Ultrasound
trimester Urinary changes Chadwick’s Evidence
Fatigue sign
Amenorrhea Hegar’s sign
Morning sickness Elevated BBT
Enlarge uterus Positive HCG

Second Chloasma Ballotement

Trimeste Linea Nigra Enlarge Fetal Heart Tone
r Increase Skin Abdomen Fetal movement
Pigmentation Braxton Hicks Fetal outline
Striae gravidarum Contraction Fetal parts
 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); 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
 An ultrasound is performed to determine a safe site for the
needle to enter.
 Watch out for cramping, leakage o fluid, minor irritation
around entry site & slight risk for miscarriage.
143
 Prior to the procedure, the patient’s bladder
should be emptied if AOG is more than 20 weeks

 Post procedure, monitor for signs and symptoms

of hemorrhage, labor, premature separation of
placenta, fetal distress, amniotic fluid embolism,
infection, inadvertent injury to maternal
intestines/bladder or fetus; RhoGam is indicated
for Rh(-) mothers

144
 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 because no
amniotic fluid is retrieved during the
procedure )
Pre-procedure: there should be full bladder;
ultrasound is used as in amniocentesis;
Post procedure: precautions as for amniocentesis
145
 Estriol levels

– serial 24-h maternal urine samples or

serum specimens to determine
fetoplacental status; falling levels usually
indicate deterioration

146
 Percutaneous umbilical blood sampling
(PUBS)Cordocentesis/Funicentesis

– 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

147
 Lecithin/ Sphingomyelin ratio (2:1)

– important components of surfactant, a

phosphoprotein that lowers surface
tension of the lungs that facilitates
extrauterine expiration
- Prevents lung collapse

148
 Biophysical profile (BPS)
 Assesses 4 to 6 parameters (fetal breathing
movement, fetal body movement, fetal tone, amniotic
fluid volume, placental grading, and 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 6: fetus is in jeopardy; worrisome
 BPS 4 or less is Ominous. The doctor may decide to
deliver the baby if the score is 6 or below
149
 Criteria in BPS:
 1. Fetal Breathing Movements ( FBM)
 Normal: At least one episode of FBM of at least 30
sec duration in 30 mins of observation
 Abnormal: Absent FBM o no episode of more than
30 sec in 30 mins
 2. Gross Body Movement
 Normal: at least 3 discrete body/limb movements in
30 mins w/ episodes of activity
 Abnormal: 2 or fewer episodes of body/limb
movements in 30 mins
 3. Fetal Tone
 Normal: the fetus must extend and then flex the
extremities or spine at least once in 30 minutes
 4. Amniotic fluid volume
 Normal: a pocket of amniotic fluid
measuring more than 1 cm in vertical
diameter must be present
 5. Placental grade
 Normal: grade 3 ( grading is based on structure
and amount of calcium present)
 Placental Grading
 Determines the amount of calcium deposits on
the base of the placenta
 0 = 12 to 24 weeks
 1 = 30 to 32 weeks
 2 = 36 weeks
 3 = 38 weeks ( mature)
Amniotic Fluid Volume Assessment
 Maternal Serum
Alphafetoprotein
 Involves drawing a small amount of BLOOD from
the mother to check for the level of
alphafetoprotein
 AFP is produced by the fetal liver & is excreted
thru placenta into the mother’s blood ( usually
tested at 15 & 17 wks)
 High amount: Neural Tube defect ( NTD) such as
spina bifida (open spine)or anencephaly ( absence
of brain)
 Low amount: Indicative of Trisomy 21
 Best results are obtained if taken between 16-18
wks
 TESTS DONE:
 Between 16-18 weeks
 Maternal serum Alphafetoprotein
 Between 26-28 weeks
 Diabetic screening for all pregnant women
 Repeat Hgb & Hct
 Repeat Antibody for unsensitized Rh negative women
 Between 32-36 weeks
 Ultrasound
 Testing for STD
BASELINE VITAL SIGNS = TEMPERATURE, PULSE
AND RESPIRATORY RATES ARE IMPORTANT
ESPECIALLY DURING THE INITIAL PHASE OF THE
PRENATAL VISIT . BUT CERTAINLY MORE
IMPORTANT ARE THE WEIGHT & BLOOD
PRESSURE AS BASELINE DATA TO DETERMINE
ANY SIGNIFICANT INCREASE.
WEIGHT
*DURING THE FIRST TRIMESTER, WEIGHT GAIN
OF 1.5-3LBS.( 1lb per month)
*ON THE 2ND AND 3RD TRIMESTERS, WEIGHT GAIN
OF 10-11 POUNDS PER TRIMESTER IS
RECOMMENDED.( 1 lb per week)
*TOTAL ALLOWABLE WEIGHT GAIN DURING THE
ENTIRE PERIOD OF PREGNANCY IS 20-25 LBS.
( 10-12 KGS.). MORE THAN 30 LBS OF WEIGHT
GAIN IS A DANGER SIGN = POSSIBLE
PREECLAMPSIA.
DISTRIBUTION OF WEIGHT GAIN DURING
PREGNANCY:
FETUS 7 LBS
PLACENTA 1 LB
AMNIOTIC FLUID 11/2 LBS
INCREASED WT. OF UTERUS 2 LBS
INCREASED BLOOD VOLUME 1 LB
INCREASED WT. OF THE BREASTS11/2-3 LBS
WT. OF ADDITIONAL FLUID 2 LBS
FAT & FLUID ACCUMULATION 4-6 LBS.
TOTAL 25 LBS
 3.POST – CONSULTATION PHASE = HEALTH
TEACHINGS
 Schedule of clinic visits
 Exercises
 Dental hygiene
 Clothing
 Traveling
 Bathing
 Employment
 Sexual relation
 Immunization
A.PRENATAL CARE:
SCHEDULE OF PRENATAL VISIT:
A. ONCE EVERY 4 WEEKS , UP TO 32 WEEKS
B. EVERY 2 WEEKS FROM 32 – 37 WEEKS
( MORE FREQUENTLY IF PROBLEM
EXISTS)
C. EVERY WEEK FROM 37 – 40 WEEKS
*** To monitor VS, Weight, FHT, Fundal height and
Outline
BATHING:

DUE TO INCREASED PERSPIRATION , THE PREGNANT

WOMAN IS ENCOURAGED TO HAVE A DAILY BATH
TO KEEP HER FRESH & CLEAN.

2. TUB BATH IS DISCOURAGED BECAUSE ALTERATION

IN THE WOMAN’S BALANCE MAKES GETTING IN &
OUT OF THE BATH TUB DIFFICULT, SHE MIGHT
SLIP & FALL & HURT HERSELF.

3. SWIMMING IS OK BUT NO DIVING.

4. DOUCHING IS CONTRAINDICATED DURING
PREGNACY – CAN INTRODUCE INFECTION
BREAST CARE:

1. WELL FITTING & LARGER SIZED BRASSIERE

( WIDE STRAPS & DEEP CUPS TO PREVENT LOSS
OF BREAST TONE.)
2. WASH BREAST WITH WATER ONLY. NO SOAPS
OR ALCOHOL SHOULD BE USED AS THESE
CAUSES DRYING & CRACKING. DRY NIPPLES
THOROUGHLY
**SMOKING= CAUSES VASOCONSTRICTION
LEADING TO DECREASED BLOOD FLOW TO THE
PLACENTA WHICH IN TURN DIMINISHES O2
SUPPLY TO THE FETUS. FETAL HYPOXIA LEADS
TO LOW BIRTH WEIGHT BABIES AND THEREFORE
IS CONTRAINDICATED DURING PREGNANCY.
** EMPLOYMENT = AS LONG AS THE JOB DOES
NOT ENTAIL HANDLING TOXIC SUBSTANCES
OR LIFTING HEAVY OBJECTS , OR EXCESSIVE
EMOTIONAL STRAIN, THERE IS NO
CONTRAINDICATION TO WORKING. ADVISE
PREGNANT WOMEN TO WALK ABOUT EVERY
FEW HOURS OF HER WORKDAY DURING LONG
PERIODS OF STANDING OR SITTING TO
PROMOTE CIRCULATION THEREBY MINIMIZING
VARICOSE VEINS.
** TRAVELLING = NO TRAVEL RESTRICTIONS
BUT POSTPONE A TRIP DURING THE LAST
TRIMESTER. ON LONG RIDES , 15-20 MINUTE
REST PERIODS EVERY 2-3 HOURS TO WALK
ABOUT OR EMPTY THE BLADDER IS
ADVISABLE.
** EXERCISE = SHOULD BE DONE IN
MODERATION; SHOULD BE INDIVIDUALIZED:
ACCORDING TO AGE, PHYSICAL CONDITION,
CUSTOMARY AMOUNT OF EXERCISE
( SWIMMING OR TENNIS) NOT
CONTRAINDICATED UNLESS DONE FORE THE
FIRST TIME ; & STAGE OF PREGNANCY
**DRINKING= IN MODERATION IS NOT
CONTRAINDICATED BUT WHEN EXCESSIVE, CAN
CAUSE TRANSIENT RESPIRATORY DEPRESSION IN
THE NEWBORN AND FETAL WITHDRAWAL
SYNDROME: BESIDES, ALCOHOL SUPPLIES ONLY
EMPTY CALORIES.

**DRUGS= DANGEROUS TO FETUS ESPECIALLY

DURING THE FIRST TRIMESTER WHEN THE
PLACENTAL BARRIER IS STILL INCOMPLETE AND
THE DIFFERENT BODY ORGANS ARE DEVELOPING.
ARE TERATOGENIC (CAN CAUSE CONGENITAL
DEFECTS)(AND THEREFORE, CONTRAINDICATED
UNLESS PRESCRIBED BY THE DOCTOR)
 Drugs Teratogenic Effects
Androgen, Estrogen - Musculinization of female infants
Progesterone
Thalidomide - Phocomelia, cardiac & lung defect
Anticonvulsant - cleft lip & palate; CHD
Lithium - CHD
Tetracycline - yellow staining of teeth, inhibit bone growth
Vitamin K - Hyperbilirubinemia
Salicylates ( aspirin) - neonatal bleeding,decreased IUG
Streptomycin - Nerve defects
Vitamin A - CNS defects
Barbiturates - Bleeding disorders
SEXUAL RELATIONS: CHANGES IN SEXUAL
DESIRE:

A.FIRST TRIMESTER = SEXUAL DESIRE IS

DECREASED AS CAUSED BY NAUSEA, FATIGUE &
SLEEPINESS.

B. SECOND TRIMESTER = SEXUAL DESIRE IS

INCREASED DUE TO PELVIC CONGESTION &
SENSE OF WELL BEING.

C. THIRD TRIMESTER = SEXUAL DESIRE IS

DECREASED DUE TO FATIGUE & PHYSICAL
BULKINESS
** SEXUAL INTERCOURSE IS ALLOWED UNTIL THE
LAST 6 WEEKS OF PREGNANCY ( BECAUSE IT HAS
BEEN FOUND OUT THAT THERE IS INCREASED
INCIDENCE OF POSTPARTUM INFECTION IN
WOMEN WHO ENGAGE IN SEX DURING THE LAST
6 WEEKS) AS LONG AS THERE ARE NO
CONTRAINDICATIONS LIKE THE FOLLOWING:
1. BLEEDING
2. INCOMPETENT CERVICAL OS
3. DEEPLY ENGAGED PRESENTING PART
4. RUPTURED BOW
** SEXUAL INTERCOURSE SHOULD BE DONE
WITH THE WOMAN IN A COMFORTABLE
POSITION:
1. SIDE LYING
2. WOMAN SUPERIOR – WOMAN ON TOP
TT IMMUNIZATION:
> TT1 GIVEN ANYTIME DURING
PREGNANCY
> TT2 ONE MONTH AFTER TT1 ( 3 YEARS
PROTECTION)
> TT3 SIX MONTHS AFTER TT2 ( 5 YEARS
PROTECTION)
> TT4 ONE YEAR AFTER TT3 ( 10 YRS)
> TT5 ONE YEAR AFTER TT4 OR NEXT
PREGNANCY ( LIFETIME PROTECTION)
NUTRITION = MOST IMPORTANT ASPECT OF
POST CONSULTATION

FOOD SOURCES:
** PROTEIN RICH FOODS = MEAT, FISH, EGGS,
MILK, POULTRY, CHEESE, BEANS, MONGO
** VIT. A = EGGS, CARROTS, SQUASH, CHEESE,
BEANS, VEGETABLES
** VIT. D = FISH, LIVER, EGGS, MILK ( EXCESS
VIT.D DURING PREGNANCY CAN LEAD TO FETAL
CARDIAC PROBLEMS)
**VITAMIN E = GREEN LEAFY VEGETABLES, FISH
**VITAMIN C= TOMATOES, GUAVA, PAPAYA
**VITAMIN B= PROTEIN RICH FOODS
**CALCIUM/PHOSPHORUS=MILK, CHEESE
**IRON= ESPECIALLY IMPORTANT DURING THE
LAST TRIMESTER WHEN THE PREGNANT WOMAN
IS GOING TO TRANSFER HER IRON STORES FROM
HERSELF TO HER FETUS SO THAT THE BABY HAS
ENOUGH IRON STORES DURING THE 1ST 3
MONTHS OF LIFE WHEN ALL HE TAKES IS
MILK(WHICH IS DEFICIENT IN IRON). IRON HAS A
VERY LOW ABSORPTION RATE: ONLY 10% OF THE
IRON INTAKE CAN BE ABSORBED BY THE BODY.
THUS, FOR OPTIMUM ABSORPTION, GIVE VITAMIN
C.
IRON SHOULD BE GIVEN AFTER MEALS BECAUSE
IT IS IRRITATING TO THE GASTRIC MUCOSA.

SOURCES: LIVER AND OTHER INTERNAL

ORGANS, CAMOTE TOPS, KANGKONG, EGG YOLK,
AMPALAYA, MALUNGGAY, SALUYOT.
**MALNUTRITION DURING PREGNANCY CAN
RESULT IN PREMATURITY, PREECLAMPSIA,
ABORTION, LOW BIRTH WEIGHT BABIES,
CONGENITAL DEFECTS OR EVEN STILL
BIRTHS.
** FOLIC ACID – TO PREVENT NEURAL TUBE
DEFECTS ( SPINA BIFIDA, MENINGOCOELE )
SOURCES:
** GREEN LEAFY VEGETABLES
** FRUITS ( oranges)
** liver, legumes, nuts
** RDA FOR SALT IN A PREGNANT WOMAN IS
3g/DAY BECAUSE OF INC IN BLOOD VOLUME TO
MAINTAIN F & E BALANCE.
 NUTRITIONAL
REQUIREMENTS
 Calories – 300 kcal/d; may need adjustment for
prepregnant under/overweight
 There should be no attempt at weight reduction
during pregnancy
 Carbohydrates – needed to prevent unsuitable
use of fats/proteins for added energy needs;
important to avoid “empty” calorie sources
e. Iron – to a total of 30 mg/d of elemental iron; usually requires
supplement

f. Calcium to 1,200mg; best obtained from dairy products; if

milk is disliked or poorly tolerated, calcium supplement may be
necessary

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

excess should be discouraged

g. Phosphorus – for the dev’t of fetal bones & teeth. 1200mg

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

woman
 ** THE PROVISION OF PRENATAL CARE IS
THE PRIMARY FACTOR IN THE IMPROVEMENT
OF MATERNAL MORBIDITY & MORTALITY
STATISTICS. “”
 IMPORTANT ESTIMATES
1. NAEGELE’S RULE = CALCULATION OF
EXPECTED DATE OF CONFINEMENT ( EDC )
FORMULA: COUNT BACK 3 MONTHS FROM
THE LAST DAY OF THE MENSTRUAL PERIOD
(LMP) THEN ADD 7 DAYS PLUS 1 YEAR.
EXAMPLE: LMP APRIL 22, 1995
-3 +7 +1
JAN 29, 1996
 EDC
LAST MENSTRUAL PERIOD ( LMP ) – counted from first
day of the last menses
 AOG
COMPUTATION OF AGE OF GESTATION
Example: LMP: January 1, 2007
Date of consult: August 31, 2007

AOG: Total # of days from LMP up to date of consult

7

January 31 days
February 28 Total = 243 days
March 31 AOG = 243
April 30 7
May 31 34 to 35 weeks
June 30
July 31
August 31
2. MC DONALD’S RULE = ( ESTIMATION OF
AOG IN MONTHS & WEEKS BY FUNDIC HEIGHT
MEASUREMENT)=
FORMULA :
FUNDIC HEIGHT IN CMS X 2/7 OR 8/7
EXAMPLE:
FUNDIC HEIGHT IS 21 CMS
21 CMS X 2 =42
42/ 7 = 6 ( AOG IN MONTHS)
6 MONTHS X 4 = 24 ( AOG IN WEEKS)
 Fundic Height
McDonald’s Rule – determines during midpregnancy,
that the fetus is growing in utero by measuring the
fundal (uterine) height

Typically, the distance from the fundus to the

symphysis in centimeters is equal to the week of
gestation between the 20th and 31st weeks of
pregnancy.
Measuring Fundic
Height
 Measure from the notch of the symphysis
pubis to over the top of the uterine fundus as
the woman lies supine.
 Place the zero line of the tape measure on the
anterior border of the symphysis pubis and
stretch tape over midline of abdomen to top of
fundus.
 The tape should be brought over the curve of
the fundus.
 The height of the fundus in centimeters equals
the number of weeks gestation plus or minus 2.
(inaccurate in the 3rd trimester esp after 32
wks)
Typical measurements
 Over the symphysis pubis: 12 wks
 At the umbilicus: 20 wks
 At the xiphoid process: 36 wks

Rises about 1cm per week; after which it

varies
 BARTHOLOMEW’S RULE = ESTIMATION OF
AOG BY THE RELATIVE POSITION OF THE
UTERUS (FUNDUS) IN THE ABDOMINAL
CAVITY.
12 weeks  at the level of the symphysis pubis
16 weeks  halfway between symphysis pubis and
umbilicus
20weeks  at the level of the umbilicus
24 weeks  two fingers above umbilicus
30 weeks  midway between umbilicus and xiphoid
process
36 weeks  at the level of xiphoid process
40 weeks  two fingers below xiphoid process,
drops at 34 weeks level because of lightening
Fundic Height
LEOPOLD’S MANEUVER
 LEOPOLD’S MANEUVER
= A SYSTEMATIC METHOD OF OBSERVATION &
PALPATION TO DETERMINE THE
PRESENTATION, FETAL POSITION, ATTITUDE,
FETAL LIE & DEGREE OF ENGAGEMENT. THE
WOMAN SHOULD BE IN SUPINE POSITION
WITH HER KNEES FLEXED SLIGHTLY SO AS
TO RELAX THE ABDOMINAL MUSCLES.
PREPARATORY STEPS:
** INSTRUCT THE CLIENT TO VOID
** PALPATE WITH WARM HANDS. COLD HANDS
CAUSE ABDOMINAL MUSCLES TO CONTRACT.
 ** USE GENTLE BUT FIRM MOTIONS.
PROCEDURE:
1. FIRST MANEUVER = ( DETERMINES THE
FETAL PRESENTATION)= “ FUNDIC GRIP”
** FACING THE HEAD PART OF THE CLIENT,
PALPATE THE SUPERIOR SURFACE OF THE
FUNDUS.DETERMINE CONSISTENCY,
SHAPE & MOBILITY. A HARD BALLOTABLE
MASS AT THE FUNDUS MEANS THE FETUS
IS IN BREECH PRESENTATION.
 First Maneuver
Palpation of the Uterine Fundus

MARY LOURDES NACEL G. CELESTE, RN, MD 191

2. SECOND MANEUVER = ( DETERMINES THE
FETAL BACK)= “UMBILICAL GRIP”
**PALPATE THE SIDES OF THE UTERUS TO
DETERMINE WHERE THE FETAL BACK IS
FACING. THE LEFT HAND IS LEFT STATIONARY
ON THE LEFT SIDE OF THE UTERUS WHILE THE
RIGHT HAND PALPATES OPPOSITE SIDE OF
THE UTERUS FROM TOP TO BOTTOM. DO ON
THE OPPOSITE SIDE.
 Second Maneuver
Determines small parts and back of fetus along the
sides of maternal abdomen

MARY LOURDES NACEL G. CELESTE, RN, MD 193

3.THIRD MANEUVER =( DETERMINES DEGREE
OF ENGAGEMENT)- “ PAWLICK’S GRIP”
> PALPATE TO DISCOVER THE PART OF THE
FETUS AT THE INLET & ITS MOBILITY. GRASP
THE LOWER PORTION OF THE ABDOMEN JUST
ABOVE THE SYMPHYSIS PUBIS BETWEEN THE
THUMB & INDEX FINGER . DETERMINE ANY
MOVEMENT & WHETHER THE PART IS FIRM OR
SOFT. IF THE PRESENTING PART MOVES
UPWARD,SO AN EXAMINING FINGERS CAN BE
PRESSED TOGETHER, THE PRESENTING PART
IS NOT ENGAGED ( NOT FIRMLY SETTLED INTO
THE PELVIS). IF THE PART IS FIRM , IT IS THE
HEAD; IF SOFT THEN IT IS IN BREECH
POSITION.
 Third Maneuver
(Lower uterine segment or uterine pole)

MARY LOURDES NACEL G. CELESTE, RN, MD 195

 Fourth Maneuver
(pelvic palpation of the uterus
- assess the presenting part)

MARY LOURDES NACEL G. CELESTE, RN, MD 196

4. FOURTH MANEUVER = ( DETERMINES FETAL
ATTITUDE & DEGREE OF FLEXION OR
EXTENSION).NOTE: THIS SHOULD ONLY BE
DONE IF THE FETUS IS IN CEPHALIC
PRESENTATION. = “PELVIC GRIP”
** FACING THE FEET PART OF THE PATIENT,
PLACE FINGERS ON BOTH SIDES OF THE
UTERUS APPROXIMATELY 2 INCHES ABOVE
THE INGUINAL CANAL PRESSING DOWNWARD
& INWARD IN THE DIRECTION OF THE BIRTH
CANAL. ALLOW FINGERS TO BE CARRIED
DOWNWARD. IF THE FINGERS OF ONE HAND
WILL SLIDE ALONG THE UTERINE CONTOUR &
MEET NO
OBSTRUCTION, IT INDICATES NECK OF THE
FETAL BACK. THE OTHER HAND WILL MEET AN
OBSTRUCTION AN INCH OR SO ABOVE THE
LIGAMENT – THIS IS THE FETAL BROW. THE
POSITION OF THE FETAL BROW SHOULD
CORRESPOND TO THE SIDE OF THE UTERUS
THAT CONTAINED THE ELBOWS & KNEES OF
THE FETUS. IF THE FETUS IS IN A POOR
ATTITUDE, THE EXAMINING FINGER WILL MEET
AN OBSTRUCTION ON THE SAME SIDE AS THE
FETAL BACK, THAT IS, THE FINGERS WILL
TOUCH THE HYPEREXTENDED HEAD.
 DANGER SIGNS OF PREGNANCY
1. VAGINAL BLEEDING = VAGINAL BLEEDING
SHOULD BE REPORTED IMMEDIATELY FOR
FURTHER EVALUATION
2. PERSISTENT VOMITING ( HYPEREMESIS
GRAVIDARUM) = NAUSEA & VOMITING THAT
CONTINUES PAST THE 12 WEEK OF
PREGNANCY IS EXTENDED VOMITING. IT
DEPLETES THE NUTRITIONAL SUPPLY
AVAILABLE TO THE FETUS.
3. CHILLS & FEVER = MAY BE EVIDENCE OF
INTRAUTERINE INFECTION WHICH IS A
SERIOUS COMPLICATION FOR BOTH THE
WOMAN & THE BABY.
4. SUDDEN ESCAPE OF FLUID FROM THE
VAGINA = MEANS THAT THE MEMBRANES
HAVE RUPTURED. BOTH THE MOTHER & THE
FETUS ARE THREATENED BECAUSE UTERINE
CAVITY IS NO LONGER SEALED AGAINST
INFECTION.
** IF FETUS IS SMALL & HIS HEAD DOES NOT
FIT INTO THE CERVIX, THE UMBILICAL CORD
MAY PROLAPSE WITH THE RUPTURED
MEMBRANE , THE HEAD MAY BE
COMPRESSED AGAINST THE CORD. ANOTHER
DANGEROUS COMPLICATION IS ASCENDING
INFECTION.
5. ABDOMINAL OR CHEST PAINS = ABDOMINAL
PAINS MAY MEAN TUBAL PREGNANCY THAT
HAVE RUPTURED, SEPARATION OF THE
PLACENTA, PRETERM LABOR WHILE CHEST
PAINS MAY INDICATE PULMONARY EMBOLUS
THAT FOLLOWS THROMBOPHLEBITIS.
6. ABSENCE OF FETAL HEART SOUNDS AFTER
THEY HAVE INITIALLY BEEN AUSCULTATED ON
THE 4TH & 5TH MONTH ( MAY INDICATE
INTRAUTERINE FETAL DEATH - IUFD)
7. SWELLING OF THE FACE & FINGERS =
EDEMA
8. FLASHES OF LIGHTS OR DOTS ( SCOTOMA)
9. BLURRING OF VISION
10. SEVERE HEADACHE & DIZZINESS
** MAY MEAN SIGNS OF PREGNANCY
INDUCED HYPERTENSION
 Teratogenic Maternal Infections
 Teratogen – any factor, chemical or physical that
adversely affects the fertilized ovum, embryo or
fetus
 Can involve either sexually transmitted or
systemic infections
T – Toxoplasmosis
O – other infections ( syphilis, HepaB, HIV)
R – Rubella
C – Cytomegalovirus ( CMV)
H – Herpes Simplex virus
 Rubella ( German Measles)
 Damage on the fetus includes deafness, mental
and motor challenges, cataracts, cardiac defects
( PDA and pulmonary stenosis) retarded
intrauterine growth ( SGA) dental and facial
clefts ( cleft lip & palate)
 Rubella titer greater than 1:8 suggests immunity
to rubella
 Rubella titer less than 1:8 suggests that the woman
is susceptible to the virus
 Titer that is greatly increased over a previous
reading or initially high suggests that a recent
infection has occurred.
 Cytomegalovirus ( CMV)

 CA – herpes virus
 Droplet transmission from person to person
 Effects on the infant includes:
 Neurological challenge ( hydrocephalus,
microcephalus, spasticity, ) with eye damage
( optic atrophy, deafness, liver disease
 No tx
 Herpes Simplex Virus
( Genital Herpes Infection)
 Systemic involvement ( Viremia) and crosses
the placenta to the fetus.
 1st tri- severe congenital anomalies or
spontaneous miscarriage
 2nd tri & 3rd tri- premature birth, IUG
retardation and continuing infection of the
newborn at birth
 Tx; IV or oral Acyclovir (Zovirax) during
pregnancy
 Terminologies
 High risk pregnancy – is one in which a
concurrent disorder, pregnancy related
complication, or external factor jeopardizes the
health of the mother, the fetus or both.
 Isoimmunization – the production of
antibodies against Rh(+) blood by the
immunologic system
 Tocolytic – a drug that halts labor ( stops
uterine contractions by relaxing smooth
muscles)
 Risk Factors Associated with
Pregnancy

BLEEDING COMPLICATIONS IN PREGNANCY

First Trimester Abortion

( 1-3 months) Ectopic Pregnancy
Second Trimester Hydatidiform Mole
( 4-6 mos) Incompetent Cervix
Third Trimester Abruptio/Ablatio Placenta
( 7-9 mos) Placenta Previa
Preterm Labor
 HYPERTENSIVE DISORDERS IN
PREGNANCY
Gestational Hypertension
Chronic Hypertension
 Pregnancy Induced Hypertension
 Pre-eclampsia
 Eclampsia
 HeLLP Syndrome
 METABOLIC DISORDER IN PREGNANCY
 Gestational Diabetes Mellitus
 MEDICAL CONDITIONS COMPLICATING
PREGNANCY
 Heart Disease

 Risk Factors associated with
Pregnancy
 Advanced age of 35 yrs and above is a high risk
pregnancy
 Teenage pregnancy of 16 years and below is
considered a high risk pregnancy

 Parity
 First pregnancy – is the period of highest risk
 Second / Third and Fourth pregnancy – the risk of
death for the mother is at its lowest
 Fifth pregnancy – marked increase especially when
the pregnant mother is over 40 years of age.
 COMPLICATIONS OF PREGNANCY
A.FIRST TRIMESTER BLEEDING:
1. ABORTION
- THE EXPULSION OF THE
PRODUCTS OF CONCEPTION BEFORE
THE AGE OF VIABILITY ( FETUS CAN
SURVIVE EXTRAUTERINE LIFE)
- FETUS IS LESS THAN 20 WEEKS ( 24
weeks in the US) OR LESS THAN 500
GRAMS
CAUSES OF ABORTION:
1. ABNORMALITY IN THE GERM PLASMA
2.ABNORMALITY IN THE IMPLANTATION PROCESS
3. TRAUMA – PSYCHOLOGICAL,
PHYSICAL
4. HORMONAL IMBALANCE ( LOW
PROGESTERONE)
5. INTAKE OF DRUGS – QUININE, ASPIRIN
6. INFECTIOUS DISEASES – GERMAN
MEASLES, PTB, HERPES
7. PRESENCE OF VENEREAL DISEASES
8. ABNORMALITY IN THE REPRODUCTIVE
SYSTEM
8. SEVERE MALNUTRITION
EARLY ABORTION – HAPPENS BEFORE 16 WEEKS
LATE ABORTION – HAPPENS BETWEEN 16 – 20 WEEKS
Types of Abortion:
• SPONTANEOUS = UNINTENDED
TERMINATION OF PREGNANCY AT ANY
TIME BEFORE THE FETUS HAS
ATTAINED VIABILITY.
THREATENED – POSSIBLE LOSS OF THE
PRODUCTS OF CONCEPTION
S/SX: SLIGHT BLEEDING; MILD UTERINE
CRAMPING BUT NO CERVICAL
DILATATION ON VAGINAL
EXAMINATION;NO PASSAGE OF TISSUE
INEVITABLE OR IMMINENT
ABORTION - is a loss of pregnancy
that cannot be prevented.
Clinical Manifestations:
 Moderate to profuse Bleeding
 Moderate to severe uterine cramping
 Cervix dilated
 Membranes rupture
TYPES OF INEVITABLE ABORTION:

1) Complete – all products of conception are

expelled.
Sxs of complete abortion:
 Moderate bleeding
 Mild uterine cramping
 Passage of tissue
2) Incomplete – not all products of conception are
expelled from the uterus.
Signs and Sxs:
 Profuse vaginal bleeding

 Severe uterine cramping

 Open cervix

 Passage of tissue

 Other products are retained

 Missed miscarriage
 Retention of all products of conception after
the death of the fetus in the uterus
S/Sx:
- No FHT
- Signs of pregnancy disappear
Management:
D&C
 Septic Abortion
 Abortion complicated by infection

S/Sx:
- Foul smelling vaginal dischrage

- Uterine cramping

- Fever

Management:
- Treat abortion

- Antibiotics
 HABITUAL OR RECURRENT PREGNANCY
LOSS –SPONTANEOUS ABORTION IN
THREE OR MORE SUCCESSIVE
PREGNANCIES USUALLY DUE TO
INCOMPETENT CERVIX.
B. Induced Abortion – is an intentional loss of
pregnancy through direct stimulation either
by chemical or mechanical means.
Types of induced abortion:
1) Therapeutic abortion – to preserve the life
of the mother
2) Elective abortion
2. ECTOPIC PREGNANCY
- ANY PREGNANCY THAT OCCURS
OUTSIDE THE UTERINE CAVITY.
---SECOND LEADING CAUSE OF
BLEEDING IN EARLY PREGNANCY.
TYPES:
1.AMPULAR 4. CERVICAL
2. INTESTINAL 5. ABDOMINAL
3. OVARIAN
Predisposing causes:
 Salpingitis or PID
 Previous ectopic pregnancy
 Tumors that distort the tubes

 External migration of the ovum

 Intrauterine device (IUD)

 Adhesion of the fallopian tube from a

previous infection
 Scars from tubal surgery
s/sx of ectopic pregnancy:
 Vaginal spotting or bleeding
 Cul de sac mass

Signs of tubal rupture:

Severe sharp knife like pain ( stabbing) in the

lower quadrant of the abdomen
Abdominal rigidity
Sharp localized pain in the cervix on internal
examination
 Signs of hemorrhage:
 - Cullen’s sign – bluish discoloration of the
umbilicus due to the presence of blood in the
peritoneal cavity
-Hard or rigid board-like abdomen
- signs of shock
 Diagnostic Aids
 Culdocentesis – aspiration of bloody fluid
from Cul de sac of Douglas
 Ultrasound reveals presence of the
gestational sac outside of the uterine cavity
 Prevent and treat hemorrhage which is the main
danger of ectopic pregnancy.
 Blood transfusion
 Place patient flat in bed with legs elevated

 Monitor Vital signs, I & O, & amount of blood

loss

Prevent infection as the woman who lost so much

blood is susceptible to infection

Contraception must be started upon discharge from

hospital. Ovulation begins as early as 19 days or 3
weeks after resection of ectopic pregnancy.
B. SECOND TRIMESTER BLEEDING
1. GESTATIONAL TROPHOBLASTIC
DISEASE (HYDATIDIFORM MOLE OR H-
MOLE))
- is a mass of abnormal rapidly growing
trophoblastic tissue in which avascular
vesicles hang in grapelike clusters THAT
PRODUCE LARGE AMOUNTS OF HCG.
Gestational trophoblastic disease
(hydatidiform mole)
Predisposing factors:
cause is unknown
 17 years old below and 35 yrs. Above

 Low protein intake

 Previous mole

 Higher incidence in Asian women

TYPES:
1.COMPLETE MOLE – LACKS AN EMBRYO
OR FETUS ( NO FETAL BLOOD)
2. PARTIAL MOLE – INVOLVES A
CHROMOSOMALLY ABNORMAL
EMBRYO OR FETUS.( WITH FETAL
BLOOD)
- 69 XXX or 69 XXY
CAUSES:
1. SPERM + OVUM + DUPLICATION =46 (COMPLETE
( 23) ( 0) MOLE)
2. SPERM + OVUM =69 (PARTIAL
(46) (23) MOLE)
3. SPERM
( 23) OVUM
+ + ( 23) =69 (PARTIAL
SPERM MOLE)
( 23)
Signs and Sxs:
 Rapid increase in uterine size greater than
gestational age of the fetus
 Marked increase HCG titer; NV:400,00 iu
 Excessive nausea and vomiting due to elevated
HCG
 Brownish vaginal discharge around 4th month
containing grapelike vesicles
 No FHT is detected after 10 to 12 weeks, no
fetal movement after 18-20 weeks
 No fetal parts
 Bleeding which may vary from spotting to
profuse hemorrhage and is usually brownish but
may be bright red
 No fetal skeleton
 Hypertension & other sx of preeclampsia
 Symptoms of PIH before 24th week
gestation

**difference bet.H-mole & pre-eclampsia

- before 20 weeks =H mole
- after 20 weeks up to 2 weeks post
partum = preeclampsia
DX:
 Ultrasound will identify the characteristic
vesicles.
Treatment and management:
 D and C or D & E to remove the mole. ( If the
woman is more than 40 yrs old, hysterectomy is
done since she has a higher chance of
developing CHORIOCARCINOMA
 Monitor HCG for 1 year ( HCG shld be
negative 2-6 weeks after removal of H-mole.)
 Chest X ray every 3 mos for 6 mos. The lungs
are the most common site of metastasis of
choriocarcinoma
 Chemotherapy ( Methotrexate) if:
-HCG titers are increased for 3 consecutive
weeks or double at anytime
-HCG titers remain elevated 3-4 mos. after
delivery
 The woman is advised not to get pregnant for 1
year, contraceptive method should NOT be the
pills. Pills contain estrogen which promote
regrowth of the chorionic villi.
 Use mechanical equipments against pregnancy
Ex. Condom
 Hysterectomy is the method of tx for women
above 40 yrs old because of the higher incidence
of malignancies & to clients who have completed
childbearing & require sterilization.
*** Management of all trophoblastic tumors is
HYSTERECTOMY ****
2. INCOMPETENT CERVIX OR
PREMATURE CERVICAL DILATATION:
- PAINLESS CERVICAL EFFACEMENT &
DILATATION IN EARLY MIDTRIMESTER
RESULTING IN EXPULSION OF
PRODUCTS OF CONCEPTION.
- MOST COMMON CAUSE OF HABITUAL
ABORTION
CAUSES:
1.INCREASED MATERNAL AGE
2. CONGENITAL MALDEVELOPMENT OF
THE CERVIX – short cervix
3. TRAUMA TO THE CERVIX ( HISTORY OF
REPEATED D & C’S; CERVICAL
LACERATIONS WITH PREVIOUS
PREGNANCIES )
Signs and Sxs:
 Presence of uterine contractions in
midtrimester
 Rupture of the bag of waters
 Expulsion of the conceptus

 Presence of painless cervical dilatation

 Relaxed cervical os on pelvic
examination
MX:
1. CERVICAL CERCLAGE – MEDICAL
MANAGEMENT WHEREIN THE PHYSICIAN
SUTURES A CERTAIN PART OF THE
CERVIX BETWEEN 14 AND 16 WEEKS
GESTATION TO PREVENT CERVICAL
DILATATION.
a.MCDONALD’S – NYLON SUTURES ARE
PLACED HORIZONTALLY & VERTICALLY
ACROSS THE CERVIX & PULLED TIGHT
TO REDUCE THE CERVICAL CANAL TO
A FEW MILLIMETERS IN DIAMETER.
b. SHIRODKAR – STERILE TAPE IS
THREADED IN A PURSE-STRING
MANNER UNDER THE SUBMUCUS
LAYER OF THE CERVIX & SUTURED IN
PLACE TO ACHIEVE A CLOSED CERVIX.
 Prerequisites of Cervical
Cerclage
 Cervix not dilated
 Intact membranes
 No vaginal bleeding & uterine cramping
C. THIRD TRIMESTER BLEEDING
1.PLACENTA PREVIA
- LOW IMPLANTATION OF THE
PLACENTA
TYPES:
1. LOW-LYING – IMPLANTATION OF THE
PLACENTA IN THE LOWER RATHER
THAN IN THE UPPER PORTION OF THE
UTERUS
2. MARGINAL – PLACENTA EDGE
APPROACHES THAT OF THE CERVICAL
OS
3.PARTIAL – IMPLANTATION THAT
OCCLUDES A PORTION OF THE
CERVICAL OS
4. COMPLETE ( TOTALIS) – PLACENTA
THAT TOTALLY OBSTRUCTS THE
CERVICAL OS
Predisposing factors:
 Multiparity

 Advanced maternal age – over 35 yo

 Multiple pregnancy

 Uterine tumor
 Scarring from previous previous CS
 Decreased vascularity of upper uterine
segment
Past uterine D&C
Signs and Sxs:
 Painless, bright red vaginal bleeding
during the 3rd trimester
 Abdomen soft, non tender
 Ultrasound reveals placenta previa
NURSING MANAGEMENT:
1. MONITOR VITAL SIGNS & BLEEDING
( WEIGH UNUSED PERINEAL PAD, THEN
WEIGH PERINEAL PAD SOAKED IN
BLOOD, THEN SUBTRACT. THE
DIFFERENCE IS THE WEIGHT OF THE
BLOOD LOSS.)
2.PROVIDE STRICT BED REST TO MINIMIZE THE
RISK TO FETUS.( CBR without BRP’s )
3.OBSERVE FOR FURTHER BLEEDING
EPISODES.( PREPARE FOR BT) ( Hgb & Hct)
4. AVOID VAGINAL EXAMINATIONS ( NO IE). IF
IE IS INDICATED, IT SHOULD BE DONE IN A
DOUBLE SET-UP ENVIRONMENT. ( MEANING:
the DR is prepared for vaginal exam and for
cesarean birth in case the examination
precipitates profuse bleeding) WHEREIN THE
PATIENT HAS ALREADY SIGNED A CONSENT
FORM, PRE-OP
MEDS HAVE BEEN GIVEN, ABDOMINAL
PREP HAS BEEN DONE SO THAT IF THE
PLACENTA IS ACCIDENTALLY DETACHED
BECAUSE OF MANIPULATIONS, CS CAN
BE DONE IMMEDIATELY.
5. ASSESS FETAL LUNG MATURITY
6. OBSRVE STRICT ASEPTIC TECHNIQUE
7. OBSERVE PP HEMORRHAGE
8. PROVIDE EMOTIONAL SUPPORT
DURING THE GRIEVING PROCESS.
**** CLASSICAL CESARIAN SECTION
(UTERUS IS INCISED IN THE VERTICAL
SEGMENT) IS DONE IN CASE OF SEVERE
BLEEDING.**

Complications of placenta previa:

 Hemorrhage
 Infection
 Prematurity
 ** BLEEDING WITH PLACENTA PREVIA
OCCURS WHEN THE LOWER UTERINE
SEGMENT BEGINS TO DIFFERENTIATE
FROM THE UPPER SEGMENT LATE IN
PREGNANCY ( APPROXIMATELY WEEK 30
because of uterine contractions ) & THE
CERVIX BEGINS TO DILATE. THE
BLEEDING PLACES THE MOTHER AT RISK
FOR HEMORRHAGE. BECAUSE THE
PLACENTA IS LOOSENED, THE FETAL
OXYGEN MAY BE COMPROMISED”
IMMEDIATE CARE MEASURES:
** TO ENSURE AN ADEQUATE BLOOD
SUPPLY TO THE MOTHER & FETUS,
PLACE THE WOMAN ON BED REST IN A
LEFT SIDE LYING POSITION.( LLP)**
2. ABRUPTIO PLACENTA
- ABRUPT SEPARATION OF AN
OTHERWISE NORMALLY IMPLANTED
PLACENTA AFTER 20 WEEKS AOG.
TYPES:
1.MARGINAL ( OVERT)
SEPARATION BEGINS AT THE EDGES
OF THE PLACENTA ALLOWING BLOOD
TO ESCAPE FROM THE UTERUS.
BLEEDING IS EXTERNAL.
2. CENTRAL ( COVERT)
PLACENTA SEPARATES AT THE CENTER
RESULTING IN BLOOD BEING TRAPPED
BEHIND THE PLACENTA. BLEEDING
THEN IS INTERNAL AND NOT OBVIOUS.
CAUSES:
1.MATERNAL HYPERTENSION ( CHRONIC
OR PREGNACY INDUCED)
2. ADVANCED MATERNAL AGE
3. GRAND MULTIPARITY – MORE THAN 5
PREGNANCIES
4. TRAUMA TO THE UTERUS
S/SX:
1. SHARP PAIN IN THE FUNDAL AREA AS
THE PLACENTA SEPARATES
2.PAINFUL DARK RED VAGINAL BLEEDING
IN COVERT TYPE
3.PAINFUL BRIGHT RED VAGINAL
BLEEDING IN OVERT TYPE
4.HARD, RIGID, FIRM,BOARD-LIKE
ABDOMEN CAUSED BY ACCUMULATION
OF BLOOD BEHIND THE PLACENTA WITH
FETAL PARTS HARD TO PALPATE.
5. ABNORMAL TENDERNESS DUE TO
DISTENTION OF THE UTERUS WITH
BLOOD.
6. SIGNS OF SHOCK & FETAL DISTRESS
AS THE PLACENTA SEPARATES.
MX:
1. WHEN PLACENTA ABRUPTIO IS
SUSPECTED OR DIAGNOSED,
HOSPITALIZATION IS A MUST.
2. BEDREST OR SIDE LYING POSITION
FOR OPTIMUM PLACENTAL PERFUSION.
3. MONITOR VITAL SIGNS, FHT, AMOUNT
OF BLOOD LOSS – GIVE MASK O2 IF
FETAL DISTRESS IS PRESENT.
4. DELIVERY:
** VAGINAL DELIVERY – IF THERE IS NO
SIGN OF FETAL DISTRESS, BLEEDING IS
MINIMAL & VITAL SIGNS ARE STABLE.
** CESARIAN DELIVERY – IF BLEEDING
IS SEVERE, FETAL DISTRESS IS PRESENT
& FETUS CANNOT BE DELIVERED
IMMEDIATELY WITH VAGINAL METHOD.
COMPLICATIONS:
1.COUVELAIRE UTERUS OR UTERINE
APOPLEXY – INFILTRATION OF BLOOD
INTO THE UTERINE MUSCULATURE
RESULTING IN THE UTERUS
BECOMING HARD & COPPER
COLORED.
2. HEMORRHAGE & SHOCK – TREATED
BY BLOOD TRANSFUSION
3. DIC – MANAGED BY FIBRINOGEN &
CRYOPRECIPITATE
 Disseminated Intravascular Coagulation (DIC)
 Disorder of blood clotting = fibrinogen levels fall below
effective limits ( hypofibrinogenemia)
 This problem begins with the excessive triggering of
coagulation mechanisms, most commonly encountered
in abruptio placenta, PIH, amniotic fluid embolism. This
overstimulation of the coagulation system leads to rapid
formation of massive numbers of clots. In turn, the
fibrinolytic system is overactivated & clots are broken
down. As a result, clotting factors are used up &
generalized hemorrhage occurs leading to shock &
death.
 Symptoms
 Bruising or bleeding
 massive hemorrhage initiates coagulation process causing
massive numbers of clots in peripheral vessels (may result
in tissue damage from multiple thrombi), which in turn
stimulate fibrinolytic activity, resulting in decreased
platelet and fibrinogen levels
 signs and symptoms of local generalized bleeding
(increased vaginal blood flow, oozing IV site, ecchymosis,
hematuria, etc)
 monitor PT, PTT, and Hct, protect from injury; no IM
injections

 Tx:Replacement of clotting factors _ Cryoprecipitate

or fresh frozen plasma or platelet transfusion
HYPERTENSIVE DISORDERS IN
PREGNANCY:
GESTATIONAL HYPERTENSION:
- HYPERTENSION THAT DEVELOPS
DURING PREGNANCY OR DURING THE
FIRST 24 HOURS AFTER DELIVERY
WHICH IS NOT ACCOMPANIED BY
EDEMA, PROTEINURIA & CONVULSIONS
& DISAPPEARS WITHIN 10 DAYS AFTER
DELIVERY.
CHRONIC HYPERTENSION:
- THE PRESENCE OF HYPERTENSION BEFORE
PREGNANCY OR HYPERTENSION THAT DEVELOP
BEFORE 20 WEEKS GESTATION IN THE ABSENCE
OF H-MOLE & PERSIST BEYOND THE POSTPARTUM
PERIOD.
PREGNANCY INDUCED HYPERTENSION
(TOXEMIA):
- HYPERTENSION THAT DEVELOPS AFTER THE
20TH WEEK OF GESTATION TO A PREVIOUSLY
NORMOTENSIVE WOMAN.
RISK FACTORS:
1. SAID TO BE A DISEASE OF PRIMIPARAS – HIGHER
INCIDENCE IN PRIMIPARAS BELOW 17 & ABOVE 35
YEARS.
2. LOW SOCIO ECONOMIC STATUS ( LOW PROTEIN INTAKE
)
3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER,
H-MOLE, DIABETES MELLITUS,MULTIPLE PREGNANCY,
POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE
4. HEREDITARY – hx of preeclampsia in mothers or sisters
5. H-mole
6. Previous hx of preeclampsia
CAUSES:
1. UNKNOWN
2. PROTEIN DEFICIENCY THEORY
3. UTERINE ISCHEMIA
4. ARTERIAL VASOSPASM
TRIAD SX:
I HYPERTENSION
2. EDEMA ( INCRESE IN WEIGHT)
3. PROTEINURIA
= 2nd leading cause of maternal death
= chief causes of maternal death due to PIH:
- cerebral hemorrhage
- cardiac failure with pulmonary edema
- renal, hepatic or resp. failure
- obstetric hemorrhage assoc. with abruptio placenta
 VASOSPASM – due to damage to the endothelium
VASCULAR EFFECTS KIDNEY EFFECTS INTERSTITIAL EFFECTS

VASOCONSTRICTION DECREASED DIFFUSION OF FLUID

GLOMERULI FILTRATION FROM BLOOD
STREAM
RATE & INCREASED INTO INTERSTITIAL
PERMEABILITY OF TISSUE
GLOMERULI MEMBRANES

POOR ORGAN Inc BLOOD EDEMA

PERFUSION UREA NITROGEN, URIC
ACID, CREATININE
INCREASED BP DECREASED URINE OUTPUT
& PROTEINURIA
Warning Signs:
– Rapid weight gain, 4-5 lbs in a single week
– Sudden swelling
– Swelling of face & hands
– Swelling of ankles or feet that does not go
away after 12 hours rest
– A rise in BP
– Protein in the urine
– Severe headaches
– Blurry vision
– Seeing spots in the eyes
– Severe pain over the stomach, under the ribs
– Decrease in the amount of urine
S & SX MILD PREECLAMPSIA SEVERE PREECLAMPSIA

BLOOD PRESSURE 140/90; Systolic 160/110

elevation of 30 mm/Hg
Diastolic elevation of 15
mm/Hg

Proteinuria +1 to +2 +3 to +4 in clean catch

300 mg/ L24 hour urine urine or 5 g/24 hour
collection urine collection
Edema Digital edema ( +1 +2) Pitting edema (+3 +4)
Dependent edema Generalized edema

Weight Gain 3 lb/week More rapid weight gain

Urinary Output Not less than 500 Less than 500 ml/24
ml/24 hours hours; oliguria
Headache Occasional headache Severe headache
Reflexes Normal to +1 +2 Hyperreflexia,+3 +4
Visual Disturbances Absent Photophobia, blurring
spots before the eyes
Epigastric Pain (liver Absent Right upper quadrant
involvement) pain (aura to
convulsion)
EDEMA:
(+1) – PHYSIOLOGIC TYPE IN PREGNANCY, THERE
IS SLIGHT EDEMA IN THE LOWER EXTREMITIES
( DUE TO PRESSURE & POSTURE)
(+2) – MARKED EDEMA OF LOWER EXREMITIES
(PATHOLOGIC)
(+3) – EDEMA FOUND ON THE FACE & FINGERS.
(+4) – GENERALIZED EDEMA ( ANASARCA)
SEIZURE PRECAUTIONS:
1. SIDE RAILS UP
2.PAD THE SIDE RAILS
3. PUT BED AT LOWEST POSITION.
4. ROOM SHOULD BE DIM, QUIET,& AWAY FROM
AREAS OF ACTIVITY. ( AVOID BRIGHT LIGHTS
SUCH AS FLASHLIGHTS)
5. RESTRICT VISITORS TO ALLOW PATIENT TO
REST.
6. HAVE EMERGENCY EQUIPMENT AVAILBLE:
- SUCTION APPARATUS, MAGNESIUM SULFATE,
CALCIUM GLUCONATE, O2
MEDICATIONS:
1.HYDRALAZINE – ( APRESOLINE )
- ANTIHYPERTENSIVE ( PERIPHERAL
VASODILATOR) USED TO DECREASE Hpn
Dosage – 5-10 mg/IV - administer slowly to avoid
sudden fall in BP
- Maintain diastolic pressure at 90 mm/Hg to
ensure adequate placental filling
2. MAGNESIUM SULFATE ( MgSO4)
- DRUG OF CHOICE TO TREAT & PREVENT
CONVULSIONS, also a muscle relaxant
- Loading dose is 4-6g. Maintenance dose is 1-
2g/h IV
- Infuse loading dose slowly over 15-30 min.
- Always administer as a piggyback infusion
- Serum Mg level should remain below 7.5 mEq/L
ACTIONS OF MgSO4:
a. PREVENT CONVULSION
b. REDUCE BLOOD PRESSURE
CHECK THE FOLLOWING FIRST BEFORE
ADMINISTERING MgSO4:
1. DEEP TENDON REFLEX PRESENT - +2 ( NORMAL)
2. RR SHOULD BE AT LEAST 12 BPM
3. URINE OUTPUT SHOULD BE AT LEAST 30 ML/HR
** IF MgSO4 TOXICITY DEVELOPS AS SHOWN BY
RR DEPRESSION TO LESS THAN 12 BPM &
DISAPPEARANCE OF THE DTR, GIVE THE ANTIDOTE
CALCIUM GLUCONATE & NOTIFY PHYSICIAN.
- 1g/IV ( 10 ml of a 10% sol)
- have prepared at bedside when administering
MgSO4
** IF MgSO4 IS GIVEN POSTPARTUM, MONITOR
FOR UTERINE ATONY AS IT CAN CAUSE UTERINE
RELAXATION.
Repeat doses should not be given &
physician should be notified if any of the
following signs of Mg toxicity exist:
 Patellar knee jerk absent ( test brachial
reflexes if epidural anesthesia is present)
 Respirations less than 12/min
 Urine output less than 30 ml/hr
 Signs of fetal distress
 Elevated serum Mg levels ( more than 8
mg/dl)
 Diazepam ( Valium)
– Halt seizures
– 5-10 mg/IV
– Administer slowly
– Dose may be repeated every 5-10 mins ( up
to 30 mg/hr)
– Observe for respiratory depression or
hypotension in mother & respiratory
depression & hypotonia in infant at birth.
MANAGEMENT:
A. AMBULATORY MX
1. HOME MANAGEMENT IS ALLOWED ONLY IF:
a. BP IS 140/90 O BELOW
b. THERE IS NO PROTEINURIA
c. THERE IS NO FETAL GROWTH
RETARDATION
d. THE PATIENT IS NOT A YOUNG
PRIMIPARA.
2. BED REST – THE WOMAN SHOULD BE IN BED
REST FOR MOST PART OF THE DAY & FREE
FROM PHYSICAL & EMOTIONAL STRESS.
3. THE WOMAN SHOULD CONSULT THE CLINIC AS
OFTEN AS NECESSARY.
4. DIET SHOULD BE HIGH IN PROTEIN &
CARBOHYDRATES WITH MODERATE SODIUM
RESTRICTION.
5. HOSPITALIZATION IS NECESSARY IF CONDITION
WORSENS.
6. PROVIDE DETAILED INSTRUCTIONS ABOUT
WARNING SIGNS:
a. EPIGASTRIC PAIN –AURA TO CONVULSION
b. VISUAL DISTURBANCES
c. SEVERE CONTINUOUS HEADACHE
 d. NAUSEA & VOMITING
B. HOSPITAL MANAGEMENT:
1. BP GOES ABOVE 140/90 mm Hg
2. BED REST IS ONE OF THE MOST IMPORTANT
PRINCIPLES OF CARE.
a. REST IN LEFT LATERAL POSITION TO
PROMOTE BLOOD SUPPLY TO THE PLACENTA &
THE FETUS.
 STAGES OF CONVULSION:
1. STAGE OF INVASION – FACIAL TWITCHING,
ROLLING OF THE EYES TO ONE SIDE, STARING
FIXEDLY IN SPACE.
2. TONIC PHASE – BODY BECOMES RIGID, AS ALL
MUSCLES GO INTO VIOLENT SPASMS OR
CONTRACTIONS, EYES PROTRUDE, HANDS ARE
CLENCHED, WOMAN STOPS BREATHING FOR 15-
20 SECONDS.
3. CLONIC PHASE – JAWS & EYELIDS CLOSE & OPEN
VIOLENTLY, FOAMING OF THE MOUTH, FACE
BECOMES CONGESTED & PURPLE,MUSCLES OF
THE BODY CONTRACT & RELAX ALTERNATELY.
THE CONTRACTIONS ARE SO VIOLENT THAT THE
WOMAN MAY THROW HERSELF OUT OF BED.
LASTS FOR ABOUT A FEW MINUTES.
4. POST ICTAL PHASE –WOMAN IS
SEMICOMATOSE, NO MORE VIOLENT MUSCULAR
CONTRACTIONS. THE PATIENT WILL NOT
REMEMBER THE CONVULSION & THE EVENTS
IMMEDIATELY BEFORE & AFTER.
 RESPONSIBILITIES DURING A CONVULSION
1. ALWAYS MONITOR PATIENT FOR IMPENDING
SIGNS OF CONVULSION: EPIGASTRIC PAIN, SEVERE
HEADACHE, NAUSEA & VOMITING.
2 THE MAIN RESPONSIBILITIES OF A NURSE
DURING A CONVULSION ARE: MAINTENANCE PF
PATENT AIRWAY & PROTECTION OF PATIENT FROM
INJURY.
3. TURN PATIENT TO HER SIDE TO ALLOW
DRAINAGE OF SALIVA & PREVENT ASPIRATION.
4. NEVER LEAVE AN ECLAMPTIC PATIENT ALONE
5. DO NOT RESTRICT MOVEMENT DURING A
CONVULSION AS THIS COULD RESULT IN
FRACTURES.
6. WATCH FOR SIGNS OF ABRUPTIO PLACENTA:
VAGINAL BLEEDING, ABDOMINAL PAIN,
DECREASED FETAL ACTIVITY.
7. TAKE VITAL SIGNS & FHT AFTER A CONVULSION.
8. DO NOT GIVE ANYTHING BY MOUTH UNLESS
THE WOMAN IS FULLY AWAKE AFTER A
CONVULSION
** THE ONLY KNOWN CURE OF PIH IS DELIVERY
OF THE BABY.
** AS SOON AS THE BABY IS STABLE, THE BABY
IS DELIVERED.
** THE PREFERRED METHOD OF DELIVERY IS
VAGINAL .
** IF LABOR INDUCTION IS UNSUCCESSFUL &
FETAL DISTRESS IS SO SEVERE THAT THE FETUS
NEED TO BE DELIVERED, CESARIAN SECTION IS
PERFORMED.
POSTPARTUM CARE:
1. THE DANGER OF CONVULSION EXISTS UNTIL 24
HOURS AFTER DELIVERY. MgSO4 THERAPY IS
CONTINUED UNTIL THE IMMEDIATE 24 HOUR
POSTPARTUM.
2. ERGOT PRODUCTS ARE CONTRAINDICATED
BECAUSE THEY ARE HYPERTENSIVES.
3. TWO YEARS SHOULD ELAPSE BEFORE ANOTHER
PREGNANCY IS ATTEMPTED TO DECREASE THE
LIKELIHOOD THAT PIH WILL RECUR ON THE
SUBSEQUENT PREGNANCY.
 HELLP Syndrome
 H – hemolysis
 EL – elevated liver enzymes
 LP – low platelets
 Severe case of PIH
 Cause is unknown
 Occurs in both primis and multis
 S/S: nausea, epigastric pain, general
malaise, right upper quadrant tenderness
 Laboratory results: hemolysis of RBC
( fragmented on a peripheral blood
smear), thrombocytopenia ( platelet count
below 100,000/mm3) & elevated liver
enzymes ( ALT) alanine amino transferase
( AST) serum aspartate aminotransferase
– liver enzymes are elevated from
hemorrhage and liver necrosis.
 Mx: Transfusion of fresh frozen plasma
 Cx: liver hematoma, hyponatremia, renal
failure, hypoglycemia.
 Method of delivery preferred: vaginal or
CS
 ** Maternal bleeding may occur at birth
because of poor clotting ability. Epidural
anesthesia may not be possible because
of the low platelet count and the high
possibility of bleeding at the epidural site
 Premature Labor:
 Is labor that occurs between 20 weeks to
37 weeks gestation characterized by
regular uterine contraction ( four every 20
minutes) that lasts more than 30 seconds
& result in cervical dilatation & effacement.
It is the greatest cause of neonatal
mortality & morbidity.
Causes:
 PROM – most often associated with infection
 Retained IUD
 Fetal death
 History of premature labor & abortion
 Overdistention of the uterus – caused by
multiple pregnancy, hydramnios
 Incompetent cervix
 Dehydration
 UTI
 Chorioamnionitis – infection of the fetal
membranes and fluid
SSx:
 Persistent, dull, ;low backache,
 Dx is made when there is regular uterine
contractions occuring 5-8 minutes apart
accompanied by:
 Progressive cervical changes
 Cervical dilatation of more than 2 cm
 Cervical effacement of 80% or more
 Duration of at least 30 secs
 10 mins apart
 Menstrual like cramping
 Watery or bloody vaginal discharge
 Low back pain
MX:
1. Prevention – regular prenatal check up
2. If fetus is less than 32-34 weeks, and still premature to be
delivered, labor must be arrested:
1. Bedrest on LLP to promote blood flow to the placenta
2. Hydration – IV fluids
3. Tocolytics – medications to stop uterine contractions
( relaxes smooth muscles)
1. Ritodrine Hcl
2. Terbutaline –( check pulse rate because it can
cause tachycardia)
Drugs to hasten fetal lung maturity:
- GLUCOCORTICOID therapy if labor can be
delayed for 48 hours – administration of
BETAMETHASONE accelerate fetal lung maturity &
prevents respiratory distress & hyaline membrane
disease ( most common problem of the premature
neonate).
-
 Betamethasone
 Is a corticosteroid that acts as anti-inflammatory
& immunosuppressive agent. It is given to
pregnant women 12 to 24 hrs before birth to
hasten fetal lung maturity if the fetus is less than
34 weeks gestation & help prevent RDS in the
newborn
 Dosage: 12-12.5 mg IM initially; maybe repeated
in 24 hrs & again in 1 to 2 weeks
 Adverse effects: burning, itching, irritation at the
injection site, swelling, tachycardia, headache,
 Multiple Pregnancy
When 2 ( twin), 3 ( triplets), 4
( quadruplets) or even 5(quintuplets)
fetuses develop in the uterus at the same
time. A multifetal pregnancy is associated
with more risks than a singleton pregnancy
 Twins – 2 fetuses
 Triplets – 3 fetuses
 Quadruplets – 4 fetuses
 Quintuplets – 5 fetuses
TYPES:
MONOZYGOTIC or IDENTICAL TWIN
 Develop from one ovum & one sperm cell that
undergo rapid cell division after fertilization
that resulted in two or more individuals. Since
they come from only one sperm and one
ovum, these individuals possess the same
genetic traits and are always of the same sex.
If twinning occurred within 72 hours after
fertilization, there will be:
 2 amnions ( diamnionic)
 2 chorions ( dichorionic)
 2 embryos
If twinning occurred between the 4th & 8th day
after fertilization, there will be :
 2 amnions
 1 chorion ( monochorionic)
 2 embryos
If twinning occurred after 8 days, there will
be :
 1 amnion ( monoamnionic)
 1 chorion
 2 embryos
If twinning occurred after the embryonic
disc is formed, CONJOINED TWINS will
develop. Conjoined twins are classified
according to the part of the body where
they are attached.
 Anterior – Thoracopagus
 Posterior – pyopagus
 Cephalic – craniopagus
 Caudal – Ischiopagus
DIZYGOTIC TWINS or FRATERNAL
TWINS
 Develop from 2 or more ova and sperm cells
that were fertilized at the same time. They
have different genetic traits, may or may not be
of the same sex and always have 2 chorions &
2 amnions.
** More females than males because female
zygote has a higher tendency to divide into
twins
** Female zygotes have higher rate of survival
than male zygotes
Predisposing factors of Dizygotic Twinning
 Race – highest in black women
 Heredity – more common in women with familial history
of twinning
 Age & parity – increased incidence in high parity &
advanced maternal age
 Higher incidence in women taking fertility drugs that
promote ovulation & release of several ova at the same
time
 Higher incidence within the first months after stopping
oral contraceptives because of the sudden & greater
amount of pituitary gonadotropin released at this time
 In vitro fertilization – stimulation of formation of
numerous follicles, harvesting them in the ovary &
fertilizing them in vitro. All zygotes that were fertilized
are returned to the uterus to grow & develop
Complications of Multiple Fetuses:
 Abortion
 Death of one fetus
 Perinatal mortality
 Preterm labor – as the number of fetuses increases,
the duration of pregnancy decreases
 Low birth weight
 Congenital malformations
 Hydramnios
 Maternal hypertension
 Placenta previa & Abruptio placenta
 Intrauterine growth retardation
 Cord entanglement, prolapse & compression
 Maternal anemia
S/Sx
 1. Uterus large for gestational age
 2. Auscultation of two or more fetal heart tone
 3. Hx of twins in the family
 4. Palpation of three or more large fetal parts
 5.Ultrasound reveals two or more gestational
sac
 Management:
Clinic Visit:
First Trimester – every month
Second Trimester – every 2 weeks
Third Trimester – every week
Nutrition – additional 300 kcal to the
normal pregnancy requirement
6 small meals rather than 3 large meals to
decrease discomfort of a large uterus
compressing a full stomach
Labor and Delivery:
The cord is cut right after delivery of the first
infant
Presentation of second infant is ascertained
after birth of first twin either by ultrasound or
Leopold’s or both
The normal interval of delivery of the first twin
and second twin is (30 minutes)
If the second twin cannot be delivered vaginally
because of abnormal position, CS is done.
Cesarean delivery – delivery of choice if
the twins or one of them cannot be
delivered normally or if complications arise
that necessitate immediate delivery.
Post partum period – watch out for
Hemorrhage due to overdistention of the
uterus.
 HEART DISEASE
CLASSIFICATION:
1. CLASS I = NO LIMITATION,UNCOMPROMISED
= ASYMPTOMATIC, NO DISCOMFORT
WITH ORDINARY PHYSICAL
ACTIVITY.
2. CLASS II =SLIGHT LIMITATION, SLIGHTLY
COMPROMISED, ORDINARY
ACTIVITY CAUSES DYSPNEA,
FATIGUE, CHEST PAIN &
PALPITATIONS.
3. CLASS III = MARKED LIMITATION LESS THAN
ORDINARY ACTIVITY CAUSE
EXCESSIVE FATIGUE;
PALPITATIONS, CHEST PAIN & DYSPNEA.
4. CLASS IV =SEVERE LIMITATION; PATIENT
EXPERIENCES SYMPTOMS EVEN
AT REST; UNABLE TO PERFORM ANY
PHYSICAL ACTIVITY WITHOUT
DISCOMFORT.
NURSE ALERT:
** REMEMBER A PREGNANT WOMAN WITH
HEART DISEASE SHOULD AVOID INFECTION,
EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA
BECAUSE THESE CONDITIONS INCREASE THE
WORKLOAD OF THE HEART.
MX:
A.PRENATAL CARE:
1. PROMOTION OF REST ( CLASS I & CLASS II)
* 8 HOURS OF SLEEP DURING THE NIGHT &
HAVE FREQUENT REST PERIODS DURING THE
DAY.
* LIGHT WORK IS ALLOWED BUT NO HEAVY
WORK, NO STAIR CLIMBING, NO EXHAUSTION.
2. DIET
* HIGH IN IRON, PROTEIN,MINERALS &
VITAMINS
3. AVOID HIGH ALTITUDES, SMOKING AREAS,
UNPRESSURIZED PLANES & OVERCROWDED AREAS.
CIGARETTE SMOKING & ALCOHOLIC BEVERAGES
ARE STRICTLY PROHIBITED.
4.PREVENTION OF INFECTION
* AVOID PERSONS WITH ACTIVE INFECTIONS
(COLDS, COUGH).
* EARLY TREATMENT OF INFECTIONS
5. PROVIDE INSTRUCTIONS ON DANGER SIGNS OF
HEART FAILURE:
* COUGH WITH CRACKLES IS USUALLY THE
FIRST SIGN OF AN IMPENDING HEART FAILURE.
 * INCREASING DYSPNEA, TACHYCARDIA, RALES,
EDEMA

MEDICATIONS:
>IRON SUPPLEMENTATION TO PREVENT ANEMIA
>DIGITALIS TO STRENGTHEN MYOCARDIAL
CONTRACTION AND SLOW DOWN HEART RATE
>NITROGLYCERINE TO RELIEVE CHEST PAIN
>ANTIBIOTICS TO PREVENT AND TREAT
INFECTION
>DIURETICS MAY BE PRESCRIBED IN CASE OF
HEART FAILURE
INTRAPARTAL CARE
1.EARLY HOSPITALIZATION- WOMAN IS HOSPITALIZED
BEFORE LABOR BEGINS TO PROMOTE REST, FOR
CLOSER SUPERVISION AND PREVENT INFECTION
2.WOMAN LABOR’S IN SEMI-FOWLER’S POSITION OR
LEFT LATERAL RECUMBENT POSITION. NO LITHOMY
POSITION.
3.VITAL SIGNS- VITAL SIGNS ARE MONITORED
CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY
RATE MORE THAN 24 ARE SIGNS OF IMPENDING
CARDIAC DECOMPENSATION. DURING THE FIRST
STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES
AND MORE FREQUENTLY DURING THE SECOND STAGE
4.EPIDURAL ANESTHESIA- IS INSTITUTED FOR
PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS
USED TO SHORTEN THE SECOND STAGE. PUSHING IS
CONTRAINDICATED
5. WOMEN WITH HEART DISEASE ARE POOR
CANDIDATE FOR CS DUE TO INCREASED RISK FOR
HEMORRHAGE, *INFECTION AND
THROMBOEMBOLISM
POSTPARTUM CARE
1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE
POSTPARTUM BECAUSE OF THE SUDDEN INCREASE
IN CIRCULATORY BLOOD VOLUME.
2. MONITOR VITAL SIGNS.
3. PROMOTE REST- RESTRICT VISITORS TO ALLOW
PATIENT TO REST, THE WOMAN STAYS IN THE
HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS
STABILIZED.
4. EARLY BUT GRADUAL AMBULATION TO PREVENT
THROMBOPHLEBITIS.
5. MEDICATIONS
*ANTIBIOTICS
*STOOL SOFTENERS TO PREVENT STRAINING AT
STOOL CAUSED BY CONSTIPATION. SEDATIVES MAY BE
ORDERED TO PROMOTE REST.
6. BREASTFEEDING IS ALLOWED IF THERE ARE NO
SIGNS OF CARDIAC DECOMPENSATION DURING
PREGNANCY, LABOR AND PUEPERIUM.
Hemolytic Disease:
ISOIMMUNIZATION / RH INCOMPATIBILITY
- OCCURS WHEN AN RH-NEGATIVE MOTHER IS
CARRYING AN RH-POSITIVE FETUS.
- FOR SUCH A SITUATION TO OCCUR, THE
FATHER OF THE CHILD MUST EITHER BE A
HOMOZYGOUS ( DD) OR HETEROZYGOUS ( Dd) RH
POSITIVE.
- IF THE FATHER OF THE CHILD IS
HOMOZYGOUS (DD), 100% OF THE COUPLE’S
CHILDREN WILL BE RH (+).
 -PEOPLE WHO HAVE RH (+) BLOOD HAVE A
PROTEIN FACTOR ( D ANTIGEN) THAT RH (-)
PEOPLE DO NOT.
- WHEN AN RH(+) FETUS BEGINS TO GROW
INSIDE AN RH (-) MOTHER, IT IS THOUGH HER
BODY IS BEING INVADED BY FOREIGN AGENT, OR
ANTIGEN.
- THEORETICALLY, THERE IS NO CONNECTION
BETWEEN FETAL BLOOD & MATERNAL BLOOD
DURING PREGNANCY BUT
BUT SOMETIMES ACCIDENTAL BREAKS IN THE
PLACENTAL VILLI RESULTS IN FETAL BLOOD
ENTERING THE MATERNAL BLOODSTREAM. (ex:
AMNIOCENTESIS , PUBS, ABORTION).
- ONLY A FEW ANTIBODIES ARE FORMED THIS
WAY SO THAT IT DOES NOT AFFECT THE FIRST
INFANT.
- DURING PLACENTAL SEPARATION AND
DELIVERY, A GREAT AMOUNT OF MATERNAL &
FETAL BLOOD ARE MIXED, CAUSING THE MOTHER
TO PRODUCE LARGE AMOUNTS OF ANTIBODIES
DURING THE FIRST 72 HOURS AFTER PLACENTAL
DELIVERY.
 - IF THE FETUS IN SUBSEQUENT PREGNANCIES
IS RH (+), THE ANTIBODIES ALREADY PRESENT IN
THE BLOODSTREAM WILL CROSS THE PLACENTA,
ATTACK & DESTROY THE FETAL RED BLOOD CELLS
( HEMOLYSIS). THE FETUS BECOMES SO
DEFICIENT IN RBC’S THAT SUFFICIENT O2
TRANSPORT TO BODY CELLS CANNOT BE
MAINTAINED. THIS CONDITION IS TERMED “
HEMOLYTIC DISEASE OF THE NEWBORN” OR
ERYTHROBLASTOSIS FETALIS.
DX:
1. INDIRECT COOMB’S TEST – TEST TO CHECK
FOR THE PRESENCE OF ANTIBODIES IN
MATERNAL SERUM.
2. DIRECT COOMB’S TEST –TEST TO CHECK THE
PRESENCE OF ANTIBODIES IN FETAL CORD
BLOOD.
 Prevention:
 Administration of Rh ( anti D) globulin (Rhogam)
at 28 weeks gestation and within the first 72 hours
after delivery to a woman who:
 Have delivered Rh positive fetus
 Have had untypeable pregnancies such as ectopic
pregnancies, stillbirth & abortion
 Have received ABO compatible Rh positive blood
 Have had invasive diagnostic procedure such as
amniocentesis, PUBS ( cordocentesis)
ABO INCOMPATIBILITY
 The problem occurs when the maternal blood enters fetal
circulation.
 Most common: mother is Type O and the fetus is either
Type A, B, or AB
 The mother’s plasma naturally contains anti-A and anti B
antibodies
 With weaker hemolytic effect than Rh antibodies and
only affect mature RBC’s
 Number of antibodies is limited to the amount of
maternal blood that entered circulation
 May affect fetus of the 1st pregnancy
 Affected newborn will become jaundiced in the first 3
days of life
 Possible combinations for
ABO INCOMPATIBILITY

MOTHER FETUS
A B
B A
O A, B, AB
MX of HEMOLYTIC DISEASE:
1. SUSPENSION OF BREASTFEEDING DURING THE
FIRST 24 HOURS TO PREVENT PREGNANEDIOL
(BREAKDOWN PRODUCT OF PROGESTERONE
EXCRETED IN BREASTMILK) FROM INTERFERING
WITH THE CONJUGATION OF INDIRECT
BILIRUBIN TO DIRECT BILIRUBIN.
2. PHOTOTHERAPY – DESTRUCTION OF RBC’S
RESULTS IN THE FORMATION OF INDIRECT
BILIRUBIN. INDIRECT BILIRUBIN MUST FIRST BE
CONVERTED TO DIRECT BILIRUBIN BY THE LIVER
CELLS BEFORE IT CAN BE EXCRETED IN THE
BODY. THE LIVER IS IMMATURE AT BIRTH SO IT
CANNOT CONVERT LARGE AMOUNTS OF
BILIRUBIN FORMED DURING HEMOLYSIS OF RBC.
a. USES BILI OR FLUORESCENT LIGHTS
POSITIONED 18 – 20 INCHES ( 12-30) ABOVE
THE INFANT.
NURSING CARE DURING PHOTOTHERAPY:
1. COVER EYES WITH DRESSING
2. COVER GENITALS TO PREVENT PRIAPISM.
3. EXPECT THE STOOL TO BE LOOSE & BRIGHT
GREEN FROM EXCESSIVE BILIRUBIN EXCRETION
& THE SKIN TO BE DARK BROWN ( BRONZE
BABY SYNDROME).
4. PROVIDE GOOD SKIN CARE BECAUSE STOOL
CAN BE IRRITATING TO THE SKIN.
5. EXPECT THE URINE TO BE DARK COLORED
BECAUSE OF UROBILINOGEN FORMATION.
6. ASSESS FOR DEHYDRATION ( I & O ; SKIN
TURGOR). FLUID LOSS THROUGH INSENSIBLE
WATER LOSS MAY OCCUR BECAUSE OF THE HEAT
FROM THE FLUORESCENT LIGHT ABOVE THE
INFANT.
7. OFFER GLUCOSE WATER EVERY 3 HOURS TO
PREVENT DEHYDRATION.
8. MAINTAIN BODY TEMP BETWEEN 36C & 37C.
EXCHANGE TRANSFUSION:
1. INTRAUTERINE TRANSFUSION:
- DONE BY INJECTING RBC’S DIRECTLY INTO A
VESSEL IN THE FETAL CORD OR DEPOSITING
THEM IN THE FETAL ABDOMEN USING
AMNIOCENTESIS TECHNIQUE.
- BLOOD USED FOR TRANSFUSION IS EITHER
THE FETUS’ OWN TYPE OR GROUP O NEGATVE
IF THE FETAL BLOOD TYPE IS UNKNOWN.
-FROM 75 TO 150 ML OF WASHED RBC’S WILL
BE USED, DEPENDING ON THE AGE OF THE
FETUS.
NOTE:
ADMINISTER RhoGAM TO ALL Rh (-) MOTHERS
DURING PREGNANCY ( AT 28 WEEKS GESTATION)
AND WITHIN 72 HOURS OF DELIVERY OR
ABORTION OF AN Rh (+) FETUS **
 - AFTER BIRTH, THE INFANT MAY REQUIRE AN
EXCHANGE TRANSFUSION TO REMOVE
HEMOLYZED BLOOD CELLS & REPLACE THEM
WITH HEALTHY ONES.
Notify your healthcare provider if your baby has
any of the following s/s after returning home:
> Fever
> Jaundice
> Poor appetite or poor weight gain
> Excessive crying that does not stop when the
baby is held.
Signs in the newborn:
 Paleness
 Jaundice that begins within 24 hours after
delivery ( pathologic jaundice)
 Unexplained bruising or blood spots under the
skin
 Tissue swelling ( edema)
 Seizures
 Lack of normal movement
 Poor reflex response
 Gestational Diabetes Mellitus
-is a hereditary endocrine disorder due to
inadequate or lack of insulin production that
results in impaired glucose absorption &
metabolism.
- all women appear to develop an insulin
resistance as pregnancy progresses ( insulin does
not seem normally effective during pregnancy) a
phenomenon that is probably caused by the
presence of the hormone Human Placental
Lactogen (HPL)
SSx:
1. Hyperglycemia – pancreas does not produce
enough insulin , thus glucose is unable to enter
the cells & accumulates in the bloodstream
resulting in hyperglycemia
2. Glycosuria –when blood glucose levels goes
beyond the renal threshold for sugar, glucose spills on
the urine.
3. Polyuria – glucose attracts water so that when it is
excreted in the kidney, it brings along with it large
amounts of water resulting in the woman excreting
large amounts of urine, a condition called, POLYURIA.
4. Polydipsia – the excretion of large amounts of fluid
from the body leads to dehydration. Excessive thirst or
polydipsia is an important symptom of dehydration.
Effects of Diabetes:
Mother:
1. Increased tendency to pre-eclampsia &
eclampsia, UTI, & candidiasis
2. Increased risk for postpartum hemorrhage d/t
overdistention of the uterus.
3. Maternal mortality
4. Preterm delivery
Infant:
1. Macrosomia
2. Hydramnios
3. Prematurity
4. Hypoglycemia ( lowered serum glucose levels)
5. Predisposition to diabetes mellitus later in life as
the disease is hereditary
Complications:
1. Macrosomia – Infants of women with poorly
controlled diabetes tend to be large ( more than
10 lbs) because glucose can cross the placental
barrier, it acts acts as a growth stimulant. The
increased glucose adds subcutaneous fat
deposits. All the nutrients that the fetus receives
comes directly from the mother’s blood.
2. Birth Injury – may occur due to the baby’s large
size and difficulty being born.( may cause CPD
which may necessitate being born by CS)
3. HYPOGLYCEMIA – refers to low blood sugar in
the baby immediately after delivery. This
problem occurs if the mother’s blood sugar
levels have been consistently high, causing the
fetus to have a high level of insulin in its
circulation. After delivery, the baby continues to
have a high insulin level, but no longer has the
high level of sugar from its mother, resulting in
the newborn’s blood sugar level becoming very
low. The baby’s blood sugar level is checked
after birth, and if the level is too low, it may be
necessary to give the baby glucose
intravenously
4. Respiratory distress (difficulty breathing) –
too much insulin or too much glucose in a
baby’s system may delay lung maturation
and cause respiratory difficulties in babies.
This is more likely if they are born before
37 weeks of pregnancy.
Prenatal Management:
1. Diagnosis; Suspect DM in a woman
a. With family history of DM
b. With history of unexplained repeated
abortions and stillbirth
c. With glycosuria
d. Who are obese
e. Who have history of giving birth to large
infants, over 10 lbs. and infants with
congenital anomaly
2. Screening tests
a. Universal screening- 50 gram oral glucose
tolerance test ( OGTT) between 24-28
weeks gestation irregardless of the time of
the day and meals taken for all pregnant
women. If the plasma value is more than
140 mg/dl after one hour, 100 gram three
hour oral glucose tolerance test is performed
to confirm if the woman is having
hypergycemia.
Criteria of 100 gram Oral Glucose Tolerance Test-
(Instruct not to eat after midnight)
Time of Test Venous Level Plasma Level
Fasting 90mg/dl 105mg/dl

1-hour 165mg/dl 190mg/dl

2-hour 145mg/dl 165mg/dl

3-hour 125mg/dl 145mg/dl

3. Diet
a. Caloric intake should be enough to meet needs of
pregnancy, fetus and mother (1,800 to 2,400
cal/day) but not too much to promote excessive
weigh gain. 20% of caloric intake should come from
protein foods, 50% from carbohydrates, 30% from
fats.
b. Weight gain should be about 24 lbs. Too much
weight gain can lead to large infants and
cephalopevic disproportion.
c. Teach and instruct to:
 Reduce saturated fat
 Reduce cholesterol
 Increase dietary fiber
 Avoid fasting and feasting
d. Have the woman become familiar with food
exchange list and caloric values of foods
she usually eats to enable her to plan her
diet properly and estimate her caloric intake
accurately.
e. The goal is to maintain a fasting blood sugar
level of 80 mg/dl and postprandial blood
sugar level of 110mg/dl
4. Exercise
 A liberal cardiovascular-conditioning
exercise and diet therapy is the
management for Gestational Diabetes
Mellitus
 Exercise lowers blood glucose levels and
decreases the need for insulin.
 The exercise regimen should be
individualized, performed regularly and
under supervision.
 Advise woman to eat complex
carbohydrates before exercising to prevent
hypoglycemia.
Remember that hypoglycemia could occur in
persons undergoing insulin therapy during
peak action hour of insulin:
 Short acting or regular insulin – after 2-3
hours of injection
 Intermediate or Lente insulin – after 6-8 hours
of injection
 Long-acting or ultralente – after 16 – 18 hours
of injection
 The sign of hypoglycemia are: dizziness,
diaphoresis, weakness, blurring of vision
 Give a hypoglycemic person a glass of
orange juice.
5. Insulin therapy
 Insulin requirements increase during pregnancy
 Oral hypoglycemics such as Tolbutamide and
Diamicron are contraindicated during pregnancy
because they are teratogenic for they can cross the
placenta and may cause fetal and new born
hypoglycemia.
 Combined fast acting and intermediate insulin made
up of human derivative/humulin. Humulin is the
insulin of choice during pregnancy because it is the
least allergenic
 2/3 in the morning, 1/3 at dinner administered
subcutaneously ½ hour before meals.
 Insulin requirement is decreased on the first
trimester due to nausea & vomiting and highest
during the third trimester.
Delivery:
1. Delivery is effected when the fetus is mature
enough after 38 weeks gestation, but not too large
so as to cause cephalopelvic disproportion. Thus,
early hospitalization and labor induction is
performed to deliver the baby before it becomes too
large to pass the birth canal
2. If cervix is not yet ripe, baby is macrosomic and
fetal distress occurs, CS is performed
3. Regular insulin is given on the day of delivery not
long acting insulin because insulin requirement drop
immediately after delivery. The woman may not
require insulin during the first 24 hours postpartum
and her insulin requirements usually fluctuates
during the next few days.
4. Contraception:
a. IUD and combined oral contraceptives are
contraindicated
*Progesterone interferes with insulin activity
therefore increases blood glucose levels.
*Estrogen increases lipid & cholesterol
levels & risk for increased blood coagulation
b. Norplant (subcutaneous progestin implant
system) or Depo -provera may be good
choices & safely used by diabetic women
 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
P’S IN LABOR & DELIVERY
1. PASSENGER = THE FETUS
2. PASSAGEWAY = THE BIRTH CANAL
3. POWERS OF LABOR= FORCE OF UTERINE
CONTRACTIONS
4. PLACENTAL IMPLANTATION
5. PSYCHE of the mother
1. THE PASSENGER ( FETUS) =
THE FETAL SKULL = FROM AN
OBSTETRICAL POINT OF VIEW, THE FETAL
SKULL IS THE MOST IMPORTANT PART OF
THE FETUS BECAUSE:
A. IT IS THE LARGEST PART OF THE BODY
B. IT IS THE MOST FREQUENT PRESENTING
PART
C. IT IS THE LEAST COMPRESSIBLE OF ALL
PARTS
A. CRANIAL BONES
1. FRONTAL
2. TEMPORAL
3. PARIETAL
4. OCCIPITAL
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 = THE
MEMBRANOUS INTERSPACE WHICH JOINS
THE 2 PARIETAL BONES.
2. CORONAL SUTURE LINE = THE
MEMBRANOUS INTERSPACE WHICH JOINS
THE FRONTAL BONE AND THE PARIETAL
BONES.
 3. LAMBDOIDAL SUTURE LINE
C. FONTANELLES = MEMBRANE –
COVERED SPACES AT THE JUNCTION OF
THE MAIN SUTURE LINES:
1. ANTERIOR FONTANEL = THE
LARGER, DIAMOND SHAPED FONTANEL
WHICH CLOSES BETWEEN 12 TO 18
MONTHS IN AN INFANT
 2. POSTERIOR FONTANEL = THE
SMALLER TRIANGULAR SHAPED
FONTANEL WHICH CLOSES BETWEEN 2-
3 MONTHS IN THE INFANT. THE SPACE
BETWEEN THE TWO FONTANELLES IS
REFERRED TO AS THE VERTEX.
D. MEASUREMENTS – THE SHAPE OF
THE FETAL SKULL CAUSES IT TO BE
WIDER IN ITS ANTEROPOSTERIOR
(AP) DIAMETER THAN IN ITS
TRANSVERSE DIAMETER.
ANTERIOR & POSTERIOR FONTANEL
1. TRANSVERSE DIAMETER OF THE FETAL
SKULL:
I. BIPARIETAL = 9.25CM TO 9.5
II. BITEMPORAL = 8 CM.
III. BIMASTOID = 7 CM.
2. ANTEROPOSTERIOR DIAMETERS
I. SUBOCCIPITOBREGMATIC = FROM
BELOW THE OCCIPUT TO THE ANTERIOR
FONTANELLE = 9.5 CM ( THE NARROWEST AP
DIAMETER)
 II. OCCIPITOFRONTAL = FROM THE
OCCIPITAL PROMINENCE TO THE
BRIDGE OF THE NOSE = 12 CM.
III. OCCIPITOMENTAL = FROM THE
POSTERIOR FONTANELLE TO THE CHIN
= 13.5 CM (THE WIDEST AP DIAMETER)
 ** WHICH ONE OF THESE DIAMETERS
IS PRESENTED AT THE BIRTH CANAL
DEPENDS ON THE DEGREE OF FLEXION
(ATTITUDE) THE FETAL HEAD ASSUMES
PRIOR TO DELIVERY. IN FULL FLEXION,
( CHIN IS FLEXED ON THE CHEST), THE
SMALLEST SUBOCCIPITOBREGMATIC
DIAMETER IS THE ONE PRESENTED AT
THE BIRTH CANAL. IF IN POOR FLEXION,
THE WIDEST OCCIPITOMENTAL
DIAMETER WILL BE THE ONE
PRESENTED & WILL GIVE MOTHER &
BABY MORE PROBLEMS.
ENGAGEMENT = REFERS TO THE
SETTLING OF THE FETAL PRESENTING
PART FAR ENOUGH INTO THE PELVIS TO
BE AT THE LEVEL OF THE ISCHIAL SPINES
( A MIDPOINT OF THE PELVIS)

The level of the ischial spines marks the midpoint of

the pelvis. This marker is used to assess the level to
which the fetus has descended into the birth canal
during labor
 IN A PRIMIPARA, NONENGAGEMENT OF
THE HEAD AT THE BEGINNING OF LABOR
INDICATES A POSSIBLE COMPLICATION
SUCH AS ABNORMAL PRESENTATION OR
POSITION, ABNORMALITY OF THE FETAL
HEAD, OR CEPHALOPELVIC
DISPROPORTION (CPD).
IN PRIMIPARAS, ENGAGEMENT MAY OR
MAY NOT BE PRESENT AT THE
BEGINNING OF LABOR. A PRESENTING
PART THAT IS NOT ENGAGED IS SAID TO
BE “ FLOATING”. ONE THAT IS
DESCENDING BUT HAS NOT YET
REACHED THE ISCHIAL SPINES CAN BE
SAID TO BE “ DIPPING”. THE DEGREE OF
ENGAGEMENT IS ASSESSED BY
VAGINAL & CERVICAL EXAMINATION.
 FETAL STATION: The relationship of the
presenting part to an imaginary line drawn
between the ischial spine (the narrowest diameter
through which the fetus must pass to be born
vaginally) and the maternal pelvis.
 .
 **STATION 0 = PRESENTING PART IS AT
THE LEVEL OF THE ISCHIAL SPINES
(SYNONYMOUS TO ENGAGEMENT)
** STATION -1 = PRESENTING PART IS
1CM ABOVE THE ISCHIAL SPINES
** STATION +1 = PESENTING PART IS
1CM BELOW THE ISCHIAL SPINES
 ** STATION +3 OR +4 = THE
PRESENTING PART IS AT THE PERINEUM
& CAN BE SEEN IF THE VULVA IS
SEPARATED; SYNONYMOUS TO
“CROWNING”. ( ENCIRCLING OF THE
LARGEST DIAMETER OF THE FETAL
HEAD BY THE VULVAR RING).
FETAL LIE = IS THE RELATIONSHIP
BETWEEN THE LONG AXIS OF THE
MOTHER TO THE LONG AXIS OF THE
FETUS.
2 KINDS OF LIE
1. LONGITUDINAL LIE = LONG AXIS OF
THE FETUS IS PARALLEL TO THE LONG
AXIS OF THE MOTHER.
2. TRANSVERSE LIE = LONG AXIS OF
THE FETUS IS PERPENDICULAR
( RIGHT ANGLE)TO THE LONG AXIS OF
THE MOTHER.
 FETAL PRESENTATION: is determined by the fetal
lie and the body part of the fetus that enters the
pelvic passage first. The portion of the fetus is
referred to as the presenting part.
 
 TYPES OF FETAL PRESENTATION
A.LONGITUDINAL OR VERTICAL LIE:
1. CEPHALIC PRESENTATION (96%)=
MEANS THAT THE HEAD IS THE BODY
PART THAT FIRST CONTACTS THE
CERVIX.
a. VERTEX OR OCCIPUT ( MOST
COMMON) = THE HEAD IS FULLY
FLEXED ON THE CHEST MAKING THE
PARIETAL BONES OR THE SPACE
BETWEEN THE FONTANELLES, THE
“ VERTEX” THE PRESENTING PART,
(ALLOWS THE SUBOCCIPITOBREGMATIC
DIAMETER TO PRESENT TO THE CERVIX).
b. SINCIPUT = ( MILITARY POSITION) =
HEAD IS MODERATELY FLEXED, THE
SINCIPUT BECOMES THE PRESENTING
PART.
 4. FACE = THE HEAD IS EXTENDED &
THE FACE IS THE PRESENTING PART.
( FROM THIS POSITION, EXTREME EDEMA
& DISTORTION OF THE FACE MAY OCCUR.
 4. MENTUM ( CHIN) = HEAD IS
HYPEREXTENDED TO PRESENT THE CHIN. THE
WIDEST DIAMETER ( OCCIPITOMENTAL IS
PRESENTING). AS A RULE, THE FETUS
CANNOT ENTER THE PELVIS IN THIS
PRESENTATION.THE PRESENTING DIAMETER,
THE OCCIPITOMENTAL IS SO WIDE BIRTH
MAY BE IMPOSSIBLE
2. Pelvic or Breech Presentation:
3% = MEANS THAT EITHER THE
BUTTOCKS OR FEET ARE THE FIRST
BODY PARTS TO CONTACT THE CERVIX.
 a. COMPLETE BREECH =
= FETUS HAS THIGHS TIGHTLY
FLEXED ON THE ABDOMEN; BOTH THE
BUTTOCKS & THE TIGHTLY FLEXED
FEET PRESENT TO THE CERVIX.
b. FRANK BREECH =
= HIPS ARE FLEXED BUT THE KNEES
ARE EXTENDED TO REST ON THE
CHEST. THE BUTTOCKS ALONE
PRESENT TO THE CERVIX.
Complete breech Frank breech Single footling
 c. FOOTLING
= FOOT PRESENT AT THE INTROITUS.
NEITHER THE THIGHS NOR LOWER LEGS
ARE FLEXED.
** SINGLE FOOTLING – ONE LEG IS
EXTENDED AT THE HIP & KNEE & THE
OTHER LEG PRESENTS IN THE
INTROITUS.
** DOUBLE FOOTLING – BOTH LEGS
ARE UNFLEXED & BOTH FEET ARE THE
PRESENTING PART.
3. TRANSVERSE LIE/ HORIZONTAL LIE =
PRESENTING PART IS ONE OF THE
SHOULDERS ( ACROMIUM PROCESS), A
HAND, AN ELBOW, OR AN ILIAC CREST.
POSITION = REFERS TO THE RELATIONSHIP
OF THE PRESENTING PART TO A SPECIFIC
QUADRANT OF THE WOMAN’S PELVIS.
 QUADRANTS OF THE MATERNAL
PELVIS:
A. RIGHT ANTERIOR
B. LEFT ANTERIOR
C. RIGHT POSTERIOR
D. LEFT POSTERIOR
E. TRANSVERSE
4 PARTS OF THE FETUS CHOSEN AS
LANDMARKS:
1.OCCIPUT “O”- VERTEX PRESENTATION
2. MENTUM “M”(CHIN) –FACE
PRESENTATION
3. SACRUM “ Sa”– IN BREECH
PRESENTATION
4. SCAPULA “Sc”– IN SHOULDER
PRESENTATION
Left Occiput Anterior (LOA)
Right Occiput Anterior (ROA)
Left Occiput Transverse (LOT)
Right Occiput Transverse (ROT)
Occiput Posterior (OP)
Occiput Anterior (OA)
Left Occiput Posterior (LOP)
Right Occiput Posterior (ROP)
POSITION IS IMPORTANT BECAUSE IT
INFLUENCES THE PROCESS &
EFFICIENCY OF LABOR. TYPICALLY, A
FETUS DELIVERS FASTEST FROM AN
LOA – LEFT OCCIPITO ANTERIOR ( MOST
COMMON) & ROA – RIGHT OCCIPITO
ANTERIOR ( 2ND MOST COMMON).
POSTERIOR POSITIONS MAY BE MORE
PAINFUL FOR THE MOTHER BECAUSE
THE ROTATION OF THE FETAL HEAD
PUTS PRESSURE ON THE SACRAL
NERVES, CAUSING SHARP BACK PAINS.
(“ BACK LABOR”)
II THE PASSAGEWAY (THE BIRTH
CANAL)
A.THE PELVIS
 OUTLET
PELVIS
 Gynecoid Normal female pelvis
Transversely rounded or blunt
Most favorable for successful labor & birth

 Anthropoid Oval shaped

Adequate outlet

 Android Wedge shaped or angulated

Seen in males
Not favorable for labor

 Platypelloid Flat with oval inlet

 Narrow oval shape,
resembles
Ape pelvis

Wide but flat;

May still allow vaginal
delivery
 Pelvic types:
 a. Gynecoid – classic female pelvis inlet, well
rounded (oval); ideal for delivery
 - most ideal for childbirth (50% of women)
 b. Android – resembling a male pelvis, narrow and
heart-shaped; usually requires cesarean section or
difficult forceps delivery (20% of women)
 c. Platypelloid – flat, broad pelvis;rarest type of
pelvis; usually not adequate for vaginal delivery (5%
of women)
 d. Anthropoid – similar to pelvis of anthropoid ape;
long & deep. Narrow transverse & wide AP does not
conform to the head of the baby;(25% of women)
411
DIVISIONS OF THE PELVIS:
1.FALSE PELVIS = “ SUPERIOR HALF”;
SUPPORTS THE UTERUS DURING THE
LATE MONTHS OF PREGNANCY & AIDS
IN DIRECTING THE FETUS INTO THE
TRUE PELVIS FOR BIRTH.
2.TRUE PELVIS = : INFERIOR HALF”;
FORMED BY THE PUBES IN FRONT, THE
ILIA & THE ISCHIA ON THE SIDES & THE
SACRUM & COCCYX BEHIND.
** THE 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. **
** Internal pelvic measurements give the actual diameters of
the inlet and outlet through which the fetus must pass.
The True Pelvis consists of the following
parts:
1.Pelvic Inlet or Pelvic brim – entrance to the
true pelvis: AP Diameters:
a. DIAGONAL CONJUGATE = DISTANCE BETWEEN
THE MIDPOINT OF THE SACRAL PROMONTORY TO THE
LOWER MARGIN OF THE SYMPHYSIS PUBIS.
( MEASURED BY INTERNAL EXAMINATION)
ADEQUATE = 12.5 TO 13 CMS
** THE DIAMETER OF THE FETAL HEAD THAT MUST
PASS THAT POINT AVERAGES 9CM DIAMETER
** DC – suggests the AP diameter of the pelvic inlet (
the narrower diameter of at that level, or the one
that is most apt to cause a misfit with the fetal
head)
- To measure, 2 fingers are introduced vaginally and
pressed inward and upward until the middle
finger touches the sacral prominence.
B. TRUE CONJUGATE/ CONJUGATA VERA = THE
DISTANCE BETWEEN THE MIDPOINT OF THE SACRAL
PROMONTORY TO THE INFERIOR MARGIN OF THE
SYMPHYSIS PUBIS.
= Average 10.5 TO 11 cm
= ASCERTAINED BY SUBTRACTING 1 TO 1.5 CM
FROM THE DIAGONAL CONJUGATE..

= ACTUAL DIAMETER
OF THE PELVIC INLET
THROUGH WHICH THE FETAL HEAD MUST PASS
b. MIDPELVIS/ PELVIC CAVITY/ PELVIC
CANAL = THE SPACE BETWEEN THE INLET &
THE OUTLET. THIS IS NOT A STRAIGHT LINE
BUT A CURVED PASSAGE.THE CURVATURE IS
SO DESIGNED BY NATURE TO CONTROL THE
SPEED OF DESCENT OF THE FETAL HEAD.
RAPID FETAL DESCENT CAN RESULT TO
RUPTURE OF CEREBRAL ARTERIES DUE TO
THE SUDDEN CHANGE OF PRESSURE.
Interspinous ( smallest diameter of the pelvis ) 10
cm
AP diameter at level of ischial spines = 11.5 cm
Posterior saggital diameter – 4.5 cm
3. PELVIC OUTLET = THE INFERIOR
PORTION OF THE PELVIS. THE MOST
IMPORTANT DIAMETER OF THE OUTLET
IS ITS TRANSVERSE OR BI-ISCHIAL
DIAMETER( DISTANCE BET THE TWO
ISCHIAL TUBEROSITIES) WHICH IS
ABOUT 11.5 CM
> AP DIAMETER 9.5 TO 11.5 CM
 C. ISCHIAL TUBEROSITY DIAMETER
 Distance between the ischial tuberosities or the
transverse diameter of the outlet ( the narrowest
diameter at that level) or the one apt to cause misfit.
A pelvimeter is generally used but a ruler can be
used or clenched fist measurement.
 Adequate: 11 cm ( because it will allow the widest
diameter of the fetal head or 9 cm to pass freely.
 Obstetric conjugate
 Shortest anteroposterior diameter between the
sacral promontory and the symphysis pubis
 Can only be measured radiographically
 Normal > 10 cm

423
** CONTRACTED PELVIS – A PELVIS WITH A
MEASUREMENT OF LESS THAN 1.5 TO 2 CM IN ANY
OF ITS IMPORTANT DIAMETERS THUS MAKING
VAGINAL DELIVERY OF THE FETUS NOT POSSIBLE “

**PELVIC MEASUREMENTS ( XRAY PELVIMETRY)

ARE PREFERABLY DONE AFTER THE 6TH LUNAR
MONTH. IT IS THE MOST EFFECTIVE METHOD OF
DIAGNOSING CEPHALOPELVIC DISPROPORTION
(CPD). BUT SINCE X-RAYS ARE TERATOGENIC, THE
PROCEDURE CAN ONLY BE DONE 2 WEEKS BEFORE
DELIVERY.
PRELIMINARY/ PRODROMAL SIGNS OF
LABOR
A. LIGHTENING (“ the baby dropped”) =
THE SETTLING OF THE FETAL HEAD INTO
THE PELVIC BRIM. IN PRIMIS, IT OCCURS
2 WEEKS BEFORE EDC ( 10-14 DAYS). IN
MULTIS, ON OR BEFORE LABOR ONSET.
 RESULTS OF LIGHTENING:
1.INCREASE IN URINARY FREQUENCY
2. RELIEF OF ABDOMINAL TIGHTNESS &
DIAPRAGMATIC PRESSURE
3. SHOOTING PAINS DOWN THE LEGS
DUE TO PRESSURE ON THE SCIATIC
NERVE.
4. INCREASE IN THE AMOUNT OF
VAGINAL DISCHARGES
6. LOSS OF WEIGHT OF ABOUT 2-3 LBS
ONE TO TWO DAYS BEFORE LABOR
ONSET = DECREASE IN
PROGESTERONE THUS DECREASE IN
FLUID RETENTION
7. RIPENING OF THE CERVIX = FROM
GOODEL’S SIGN THE CERVIX BECOMES
“BUTTER SOFT”
 SIGNS OF LABOR
1.UTERINE CONTRACTIONS – THE
SUREST SIGN THAT LABOR HAS BEGUN
IS THE INITIATION OF EFFECTIVE
PRODUCTIVE UTERINE
CONTRACTIONS.
2. IF RUPTURE OF MEMBRANES ( ROM) IS
SUSPECTED, CONFIRMATION CAN BE
DONE BY TESTING THE VAGINAL
DISCHARGE WITH A NITRAZINE PAPER.
** PAPER TURNS BLUE SINCE AMNIOTIC
FLUID IS ALKALINE.
** PAPER TURNS YELLOW IF FLUID IS
URINE SINCE URINE IS ACIDIC.
ONCE MEMBRANES ( BOW) HAVE
RUPTURED:
1.LABOR IS INEVITABLE. IT WILL OCCUR
WITHIN 24 HOURS.
2. THE INTEGRITY OF THE UTERUS HAS
BEEN DESTROYED . INFECTION,
THEREFORE CAN EASILY SET IN.
3.ASEPTIC TECHNIQUE SHOULD BE
OBSERVED IN ALL PROCEDURES.
DOCTORS DO LESS MANIPULATIONS
( EX. IE)
4. ENEMA IS NO LONGER REQUIRED.
5. UMBILICAL CORD COMPRESSION &
OR CORD PROLAPSE CAN OCCUR
ESPECIALLY IN BREECH
PRESENTATIONS
** A WOMAN IN LABOR SEEKING
ADMISSION TO THE HOSPITAL & SAYING
THAT HER BOW HAS RUPTURED
SHOULD BE PUT TO BED IMMEDIATELY
& THE FETAL HEART TONES TAKEN
CONSEQUENTLY.
 ** IF A WOMAN IN LABOR SAYS SHE
FEELS A LOOP OF THE CORD IS COMING
OUT OF THE VAGINA ( CORD PROLAPSE),
THE FIRST NURSING ACTION IS TO PUT
HER IN KNEE CHEST POSITION OR
TRENDELENBURG POSITION ( IN ORDER
TO REDUCE PRESSURE ON THE CORD.
REMEMBER: ONLY 5 MINUTES OF CORD
COMPRESSION CAN ALREADY LEAD TO
IRREVERSIBLE BRAIN DAMAGE OR EVEN
FETAL DEATH.
IN ADDITION, APPLY A WARM SALINE
SATURATED OS ON THE PROLAPSED
CORD TO PREVENT DRYING OF THE
CORD.
III POWERS
a. INVOLUNTARY UTERINE
CONTRACTIONS
b. VOLUNTARY UTERINE
CONTRACTIONS
PHASES OF UTERINE CONTRACTIONS:
1.INCREMENT = WHEN THE INTENSITY
OF THE CONTRACTIONS INCREASES
2. ACME = WHEN THE CONTRACTIONS
ARE AT ITS STRONGEST
3. DECREMENT = WHEN THE INTENSITY
DECREASES
CHARACTERISTICS OF UTERINE
CONTRACTIONS:
1. DURATION = REFERS TO THE LENGTH
OF CONTRACTIONS STARTING FROM
THE BEGINNING OF ONE CONTRACTION
TO THE END OF SAME CONTRACTION.
2. FREQUENCY = STARTS FROM THE
BEGINNING OF ONE CONTRACTION TO
THE BEGINNING OF THE NEXT
CONTRACTION.
3. INTERVAL = REFERS TO THE
REGULARITY OF CONTRACTIONS. IT
STARTS FROM THE END OF ONE
CONTRACTION TO THE BEGINNING OF
THE NEXT CONTRACTION.
4. INTENSITY = REFERS TO THE
STRENGTH OF UTERINE
CONTRACTIONS.
a. MILD – IF THE FUNDUS IS SLIGHTLY
TENSE & EASY TO INDENT WITH
FINGERTIPS
b. MODERATE – IF THE FUNDUS IS
FIRM & IS DIFFICULT TO INDENT WITH
FINGERTIPS
c. STRONG – IF THE FUNDUS IS HARD &
RIGID & ALMOST IMPOSSIBLE TO
INDENT.
** AS LABOR CONTRACTIONS
PROGRESS & BECOME REGULAR &
STRONG, THE UTERUS GRADUALLY
DIFFERENTIATES ITSELF INTO TWO
DISTINCT FUNCTIONING AREAS. THE
UPPER PORTION BECOMES THICKER &
ACTIVE, PREPARING TO EXERT ITS
STRENGTH NECESSARY TO EXPEL THE
FETUS. THE LOWER PORTION BECOME
THIN WALLED, SUPPLE & PASSIVE, SO
THE FETUS CAN BE EXPELLED OUT
EASILY.THE BOUNDARY BETWEEN THE
TWO PORTIONS BECOMES MARKED BY A
RIDGE CALLED “ PHYSIOLOGIC
RETRACTION RING”
IN A DIFFICULT LABOR , THE RING MAY
BECOME PROMINENT & OBSERVABLE AS
AN ABDOMINAL INDENTATION. THIS IS
TERMED AS “PATHOLOGIC RETRACTION
RING” OR “BANDL’S RING” A DANGER
SIGN THAT SIGNIFIES IMPENDING
RUPTURE OF THE LOWER UTERINE
SEGMENT.
 CERVICAL CHANGES:
- EVEN MORE MARKED THAN THE
CHANGES IN THE BODY OF THE UTERUS
ARE TWO CHANGES THAT OCCUR IN
THE CERVIX:
1.EFFACEMENT = SHORTENING &
THINNING OF THE CERVICAL CANAL.
NORMALLY THE CANAL IS 1-2 CM LONG.
WITH EFFACEMENT, THIS CANAL
VIRTUALLY DISAPPEARS.THIS IS
EXPRESSED IN PERCENTAGE ( % )
Cervical effacement
2. DILATATION – REFERS TO THE
ENLARGEMENT OF THE CERVICAL CANAL
FROM AN OPENING A FEW MMLLIMETERS
WIDE TO ONE LARGE ENOUGH
( APPROXIMATELY 10 CM) TO PERMIT
PASSAGE OF THE FETUS.
CERVICAL DILATATION
CERVICAL DILATATION
 SHOW – the pressure exerted by the
presenting part result in the rupture of
several blood vessels in the cervix. BLOOD
released from these ruptured capillaries mixes
with OPERCULUM ( MUCUS PLUG) giving it
a pinkish coloration. When the cervix
dilates, this blood tinged mucus, called
SHOW is released.
IV PLACENTAL IMPLANTATION
a. IF THE PLACENTA HAS IMPLANTED
NORMALLY IN THE FUNDAL PORTION OF
THE UTERUS ( ANTERIOR OR
POSTERIOR), IT RARELY CAUSE
TROUBLE DURING LABOR & DELIVERY.
b. WHEN MALIMPLANTATION OF THE
PLACENTA OCCURS IN THE LOWER
UTERINE SEGMENT, IT NECESSITATES
MEDICAL OR SURGICAL INTERVENTION.
DIFFERENCES BETWEEN TRUE LABOR &
FALSE LABOR:
FALSE LABOR TRUE LABOR
1.CONTRACTIONS 1. MAY BE
SLIGHTLY
REMAIN IRREGULAR IRREGULAR AT
FIRST BUT BECOME
REGULAR IN A
MATTER OF HRS.
2. GENERALLY 2. FIRST FELT IN THE
CONFINED TO LOWER BACK & SWEEP
THE ABDOMEN AROUND TO THE
ABDOMEN IN A GIRDLE
LIKE FASHION.
3. NO INCREASE IN 3. INCREASE IN
DURATION, INTENSITY
INTENSITY DURATION
& FREQUENCY & FREQUENCY
4. OFTEN 4. CONTINUE NO
DISAPPEARS MATTER WHAT
IF THE WOMAN THE WOMAN’S
AMBULATES LEVEL OF ACTIVITY
WALKING
INTENSIFIES
CONTRACTIONS.
5. ABSENT 5. ACCOMPANIED BY
CERVICAL CERVICAL
CHANGES. EFFACEMENT &
DILATATION ( MOST
IMPORTANT
DIFFERENCE)
6. NO BLOOD 6. BLOOD SHOW &
SHOW PROGRESSIVE
FETAL DESCENT
 THEORIES OF LABOR ONSET:

1.OXYTOCIN STIMULATION THEORY – AS

PREGNANCY NEARS TERM, OXYTOCIN
PRODUCTION BY THE PPG INCREASE & AS
A RESULT , THE UTERUS BECOME
INCREASINGLY SENSITIVE TO OXYTOCIN.
OXYTOCIN STIMULATES UTERINE
CONTRACTIONS.
2. UTERINE STRETCH THEORY =
ANY HOLLOW MUSCULAR ORGAN WHEN
STRETCHED TO CAPACITY WILL
CONTRACT & EMPTY.
3. PROGESTERONE DEPRIVATION
THEORY
- PROGESTERONE MAINTAINS
PREGNANCY BY ITS RELAXANT EFFECT
ON THE SMOOTH MUSCLES OF THE
UTERUS.AS PREGNANCY NEARS TERM,
PROGESTERONE PRODUCTION
DECREASE. WHEN PROGESTERONE LEVEL
DROPS, UTERINE CONTRACTION OCCURS.
4. THEORY OF THE AGING PLACENTA
- AS THE PLACENTA AGES, IT BECOMES
LESS EFFICIENT & AS A RESULT , IT PRODUCES
LESS & LESS AMOUNT OF PROGESTERONE &
ALLOWS CONCENTRATION OF
PROSTAGLANDIN & ESTROGEN TO RISE
STEADILY WHICH RESULTS TO RHYTHMIC
REGULAR AND STRONG UTERINE
CONTRACTIONS
 LENGTH OF LABOR:
STAGE PRIMIS MULTIS
1ST STAGE 10-12 HRS 6-8 HRS
2ND STAGE 30MIN-2 HRS 20 - 90 MIN
AVE. 50 MIN AVE. 20 MIN
3RD STAGE 5 TO 20 MIN 5 TO 20 MIN
4TH STAGE 2 TO 4 HRS 2 TO 4 HRS
 Stages of Labor
Stage 1 = Stage of Cervical Dilatation
Stage 2 = Stage of Fetal Expulsion
Stage 3 = Stage of Placental Expulsion
Stage 4 = Stage of Puerperium or
Vigilance
 STAGES OF LABOR

A.FIRST STAGE OF LABOR ( STAGE OF

CERVICAL DILATATION) – FROM THE
ONSET OF TRUE LABOR PAINS & ENDS
WITH COMPLETE DILATATION OF THE
CERVIX. (10 CM).
 Care of the Parturient
PHASES OF THE FIRST STAGE OF LABOR:
1. LATENT PHASE:
DILATATION: 0-3 CMS
INTENSITY: MILD & SHORT
CONTRACTIONS
DURATION:20-30 SECONDS
INTERVAL: 15 – 20 MINS
BREATHING: SLOW, DEEP CHEST BREATHING
** MOTHER IS EXCITED WITH SOME
DEGREE OF APPREHENSION BUT STILL
WITH ABILITY TO COMMUNICATE.
** TAKES UP 8 OF THE 12 HOUR FIRST
STAGE.
** BEST TIME TO TEACH BREATHING
TECHNIQUES BECAUSE THE WOMAN IS
STILL COMFORTABLE, COOPERATIVE &
CAN STILL CONCENTRATE ON A
CONVERSATION WELL.
2. ACTIVE PHASE –
DILATATION: 4 – 7 CMS.
INTENSITY: MODERATE
DURATION: 30 – 50 SECONDS
INTERVAL: 3 -5 MINUTES
** THIS PHASE LASTS APPROXIMATELY 3
HOURS IN A NULLIPARA & 2 HOURS IN A
MULTIPARA.
** ANESTHESIA IS GIVEN DURING THIS
PHASE AT 5-6 CM DILATATION.
 Timing of administration
1. Before 5 cm (latent phase)
– may retard or stop labor
2. From 5 to 7 cm (early active
phase) – may aid relaxation
3. After 8 cm (transition phase) –
may result in respiratory
depression requiring
resuscitative measures in
sedated neonate
 TYPES OF ANESTHESIA
a.PARACERVICAL – TRANSVAGINAL
INJECTION INTO EITHER SIDE OF THE
CERVIX. PATIENT ON LITHOTOMY
POSITION. COUPLED WITH A LOCAL
ANESTHETIC, RESULTS IN A PAINLESS
CHILDBIRTH ( UTERINE
CONTRACTIONS ARE NOT FELT BY
THE MOTHER)
b. PUDENDAL – INJECTION THROUGH
THE SACROSPINOUS LIGAMENT INTO
POSTERIOR AREOLAR TISSUES TO
REDUCE PERCEPTION OF PAIN DURING
SECOND STAGE & MAKE MOTHER
COMFORTABLE. PATIENT IS ON
LITHOTOMY POSITION.
SIDE EFFECT: ECCHYMOSIS =
PURPLISH DISCOLORATION OF THE SKIN
DUE TO BLOOD IN THE SUBCUTANEOUS
TISSUES
NURSING CARE: APPLY ICE BAG TO THE
AREA ON THE FIRST DAY WHICH COULD
REDUCE SWELLING.
1. Lumbar epidural block –affects the entire pelvis
by blocking impulses at level of T12 through S5;
may be administered continuously through
tubing left in place; incidence of maternal
hypotension may be minimized if 500-1000 ml of
IV fluids is infused at a rapid rate prior to
administration and mother is maintained in
side-lying position
A. There must be vigilant monitoring of
maternal BP and FHR every 1-2 min x 15 min
and every 10-15 min thereafter
2. Caudal – administered during
second stage just before delivery;
not commonly used
3. Subarachnoid block/ “saddle block”
(nerves from S1 to S4) –
anesthetizes perineum, lower pelvis,
and upper thighs; diminishes
pushing efforts; high incidence of
maternal hypotension and potential
for fetal hypoxia
4. Spinal block – now used primarily
just prior to cesarean delivery
B. Management of maternal hypotension
includes:
 Mild/Moderate – place mother in left lateral
position, increase the rate of IV fluid;
administer oxygen by mask
 Severe/prolonged – place mother in
Trendelenburg position for 2-3 min
Common analgesic and anesthetic in
labor and delivery
A. Miperidine hydrochloride (Demerol)
Hypotension
side effect: Respiratory depression
Gastric irritability
Constipation
Bradycardia
Constricted pupil
 nursing consideration: Increases pain tolerance
Do not administer within 2
h of expected delivery
B. Secobarbitol sodium (Seconal)
side effects: Drowsiness,
Lethargy, Respiratory depression,
nursing consideration:
Sedates, Anxiety relief
C. Naloxone hydrochloride (Narcan)
side effect: Tachycardia
HypertensionTremors
nursing consideration:
IV into umbilicus vein for neonates (0.01 mg/kg)
Reverses narcotic depression
D. Thiopental sodium (Sodium pentothal)
side effect: Respiratory depression
nursing consideration:
Induction anesthesia for
cesarean secretion.
E.Tetraccaine hydrochloride (Pontocaine;
lidocaine)
Side effect: Confusion Tremors Restlessness,
Hypotension Dysrhythmias Tinnitus Blurred
vision
Nursing consideration:
If subarachnoid space used, keep
patient flat for 6-8 h Regional
nerve block ,Relieves uterine or perineal
pain
3. TRANSITION PHASE – ** WHEN THE
MOOD OF THE WOMAN SUDDENLY
CHANGES & THE NATURE OF THE
CONTRACTIONS INTENSIFY **
DILATATION: 8 – 10 CM
INTENSITY: STRONG
DURATION: 60 – 90 SECONDS
INTERVAL: 2-3 MINUTES
STATION: +1 +2
Breathing Techniques During transition phase:
Take a deep breath and exhale slowly and
completely. At the beginning of a contraction,
take a fairly deep breath. Then engage in
shallow breathing. If there is an urge to push,
puff out every 3rd, 4th, or 5th breath. Take
deep breath at the end of contraction.

MLNG CELESTE, RN, MD 47

6
 Attitude of woman in labor: As intensity of
contractions become stronger & start to cause
pain & much discomfort, the woman prefers to
stay in bed. She withdraws from her environment
as her attention is focused on herself & the
sensations on her body.

Nursing Responsibility:
Coach woman on breathing & relaxation
techniques. Abdominal breathing is recommended
during the latent phase & active phase
 Breathing Techniques during Labor
.
Begin the Breathing Technique:
  This technique is done only during contractions. Rest and
sleep between contractions is important. Instruct the
laboring woman to do the following:
 Assume a comfortable position.
 Try to maintain a relaxed state throughout the contraction.
 Close her eyes or
 Concentrate on a focal point while doing the breathing (e.g.,
a pretty picture, a button on some­one's shirt).

MLNG CELESTE, RN, MD 47

8
 Breathing Techniques during labor
Cleansing Breath:
Begin and end each breathing technique with a cleansing
breath. This is simply a deep quick breath, like a big sigh.
Inhalation is through the nose; exhalation is through
slightly pursed lips.
 Slow-Paced Breathing:
This technique can be used in early labor and for as long
as the mother is comfortable with it. For some women, this
may last throughout the entire first stage of labor.
1. Take a cleansing breath as soon the contraction begins.
2. Breathe slowly and deeply in through the nose and out
through slightly pursed lips or the nose over the duration
of the contraction.
3. Maintain a steady rate of approximately 6 to 9 breaths
during a 60-second contraction (the cleansing breaths do
not count).
MLNG CELESTE, RN, MD 47
9
 *** A SURE SIGN THAT THE BABY IS
ABOUT TO BE BORN IS THE BULGING OF
THE PERINEUM. IN GENERAL,
PRIMIGRAVIDAS ARE TRANSPORTED
FROM LR TO DR WHEN THERE IS
BULGING OF THE PERINEUM ( 10 CM);
MULTIPARAS ARE TRANSPORTED AT 7-8
CM CERVICAL DILATATION OR AT +1+2***
CHARACTERISTICS:
IF SPONTANEOUS RUPTURE DOES NOT
OCCUR AT THIS TIME, AMNIOTOMY
( SNIPPING OF BOW WITH A STERILE
POINTED INSTRUMENT TO ALLOW
AMNIOTIC FLUID TO DRAIN) IS DONE
TO PREVENT FETUS FROM
ASPIRATING THE AMNIOTIC FLUID AS IT
MAKES ITS VARIOUS FETAL POSITION
CHANGES
AMNIOTOMY HOWEVER CANNOT BE
DONE IF STATION IS STILL AT “ MINUS” AS
THIS CAN LEAD TO CORD COMPRESSION.
3. THERE IS AN UNCONTROLLABLE URGE
TO PUSH WITH CONTRACTIONS, A SIGN
OF AN IMPENDING SECOND STAGE OF
LABOR.
 NOTE: CHECKING THE BLOOD
PRESSURE SHOULD BE DONE MIDWAY
BETWEEN CONTRACTIONS BECAUSE IT
NORMALLY INCREASES DURING A
CONTRACTION.
FHR SHOULD NOT BE TAKEN DURING
UTERINE CONTRACTIONS SINCE IT
TENDS TO SLOW DOWN AS INDUCED BY
THE COMPRESSION OF THE FETAL HEAD
DURING UTERINE CONTRACTIONS
NURSING ALERT:ANY CHANGE IN THE
FHR, THE FIRST NURSING ACTION IS TO
CHANGE THE POSITION OF THE MOTHER”
( LLP)
NURSING ACTIONS:
** PRIMARILY COMFORT MEASURES**
a. SACRAL PRESSURE ( APPLYING
PRESSURE WITH THE HEEL OF THE
HAND ON THE SACRUM) RELIEVES
DISCOMFORT FROM CONTRACTIONS.
b. PROPER BEARING DOWN
TECHNIQUE.
c. CONTROLLED CHEST ( COSTAL)
BREATHING DURING CONTRACTIONS.
D. EMOTIONAL SUPPORT
B. SECOND STAGE OF LABOR ( STAGE
OF FETAL EXPULSION)
= BEGINS WITH COMPLETE DILATATION
( 10 CM) & ENDS WITH THE DELIVERY OF
THE BABY.
= MOST CRITICAL STAGE ON THE PART
OF THE FETUS
7 CARDINAL MOVEMENTS/ MECHANISM
OF LABOR / FETAL POSITION CHANGES:
1.ENGAGEMENT = SYNONYMOUS TO
STATION 0
2. DESCENT = DOWNWARD MOVEMENT
OF THE BIPARIETAL DIAMETER OF THE
FETAL HEAD TO WITHIN THE PELVIC
INLET.( occurs due to the pressure on the
fetus by the uterine fundus) THE PRESSURE
OF THE FETUS ON THE SACRAL NERVES
CAUSES THE MOTHER TO EXPERIENCE A
PUSHING SENSATION.
3. FLEXION = AS FETAL HEAD REACHES PELVIC
FLOOR, PRESSURE FROM THE PELVIC FLOOR
CAUSES THE FETAL HEAD TO BEND FORWARD
ONTO THE CHEST. THIS PERMITS THE SMALLEST
AP DIAMETER (SUBOCCIPITOBREGMATIC
DIAMETER) TO PRESENT IN THE OUTLET.
4. INTERNAL ROTATION – THE HEAD FLEXES &
THE OCCIPUT ROTATES UNTIL IT IS SUPERIOR,
OR JUST BELOW THE SYMPHYSIS PUBIS
BRINGING THE HEAD TO THE BEST
RELATIONSHIP TO THE OUTLET OF THE PELVIS. (
SMALLEST DIAMETER IS PRESENTED TO THE
PELVIC OUTLET).
5. EXTENSION = AS THE HEAD COMES OUT, THE
BACK OF THE NECK STOPS AT THE PUBIC ARCH
& ACTS AS A PIVOT FOR THE REST OF THE
HEAD. THE HEAD EXTENDS & THE FOREHEAD,
NOSE, MOUTH & FINALLY THE CHIN APPEAR.
6. EXTERNAL ROTATION =( RESTITUTION)
- AS THE HEAD IS BORN IT ROTATES BRIEFLY
BACK TO DIAGONAL OR TRANSVERSE
POSITION OF THE EARLY PART OF LABOR, (THE
POSITION IT OCCUPIED WHEN IT WAS
ENGAGED) BRINGING THE SHOULDER TO AN A-
P POSITION.
** WHEN THE BIPARIETAL DIAMETER OF THE
FETAL HEAD HAS PASSED THE PELVIC INLET,
THE PALPABLE PORTION OF THE FETAL HEAD IS
APPROXIMATELY AT STATION +2). ONE
SHOULDER, IS ANTERIOR TO THE SYMPHYSIS
PUBIS & THE OTHER IS POSTERIOR TO THE
PELVIC FLOOR.)
7.EXPULSION = WITH THE DELIVERY OF THE
SHOULDERS, THE REST OF THE BABY IS BORN
EASILY & SMOOTHLY BECAUSE OF ITS
SMALLER SIZE & BIRTH IS COMPLETED.( END
OF PELVIC DIVISION OF LABOR).
NURSING CARE:
a.WHEN POSITIONING LEGS IN
LITHOTOMY POSITION, PUT THEM UP
AT THE SAME TIME TO PREVENT
INJURY TO THE UTERINE LIGAMENTS.
b. AS SOON AS THE FETAL HEAD
CROWNS, INSTRUCT THE MOTHER NOT
TO PUSH BUT TO PANT INSTEAD
( RAPID & SHALLOW BREATHING), TO
PREVENT RAPID EXPULSION OF THE
BABY.
c. IF PANTING IS DEEP & RAPID, CALLED
HYPERVENTILATION,THE PATIENT WILL
EXPERIENCE LIGHTHEADEDNESS &
TINGLING SENSATION OF THE FINGERS
LEADING TO CARPOPEDAL SPASMS
BECAUSE OF RESPIRATORY ALKALOSIS.
MX:
- LET THE PATIENT BREATHE INTO A
PAPER BAG TO RECOVER LOST CARBON
DIOXIDE.( A CUPPED HAND WILL SERVE
THE SAME PURPOSE)
d. ASSIST IN EPISIOTOMY – INCISION
MADE IN THE PERINEUM PRIMARILY TO:
1. PREVENT LACERATIONS
2. PREVENT PROLONGED & SEVERE
STRETCHING OF MUSCLES SUPPORTING
BLADDER OR RECTUM
3. REDUCE DURATION OF SECOND
STAGE OF LABOR WHEN THERE IS
HYPERTENSION & FETAL DISTRESS
4. ENLARGE OUTLET, AS IN BREECH
PRESENTATION OR FORCEPS DELIVERY
 TYPES OF EPISIOTOMY
1. MEDIAN - FROM MIDDLE PORTION
OF THE LOWER VAGINAL BORDER
DIRECTED TOWARDS THE ANUS.

2. MEDIOLATERAL – BEGINS IN THE

MIDLINE BUT DIRECTED LATERALLY
AWAY FROM THE ANUS.
e. APPLY THE MODIFIED RITGEN’S
MANEUVER
** COVER THE ANUS WITH STERILE
TOWEL & EXERT UPWARD & FORWARD
PRESSURE ON THE FETAL CHIN. WHILE
EXERTING GENTLE PRESSURE WITH
TWO FINGERS ON THE HEAD TO
CONTROL THE EMERGING HEAD.
RITGEN’S MANEUVER
THIS WILL NOT ONLY SUPPORT THE
PERINEUM THUS PREVENTING
LACERATIONS BUT WILL ALSO FAVOR
FLEXION SO THAT THE SMALLEST
SUBOCCIPITOBREGMATIC DIAMETER OF
THE FETAL HEAD IS PRESENTED.
** EASE THE HEAD OUT IN-BETWEEN
CONTRACTIONS & IMMEDIATELY WIPE
THE NOSE & MOUTH OF SECRETIONS TO
ESTABLISH A PATENT AIRWAY.
REMEMBER:
** THE FIRST PRINCIPLE IN THE CARE
OF THE NEWBORN IS TO ESTABLISH &
MAINTAIN A PATENT AIRWAY.**
- THE HEAD SHOULD BE DELIVERED
IN BETWEEN CONTRACTIONS.
** INSERT TWO FINGERS INTO THE
VAGINA SO AS TO FEEL FOR THE
PRESENCE OF A CORD LOOPED
AROUND THE NECK ( NUCHAL CORD ).
IF SO, BUT LOOSE, SLIP IT DOWN THE
SHOULDERS OR UP OVER THE HEAD;
BUT IF TIGHT, CLAMP CORD TWICE AN
INCH APART, AND THEN CUT IN-
BETWEEN.
** AS THE HEAD ROTATES, DELIVER
THE ANTERIOR SHOULDER BY EXERTING
A GENTLE DOWNWARD PUSH & THEN
SLOWLY GIVE AN UPWARD LIFT TO
DELIVER THE POSTERIOR SHOULDER.
Clamp the umbilical cord
Cut between the clamps
 CESARIAN BIRTH
- DELIVERY OF THE BABY THROUGH AN
ABDOMINAL & UTERINE INCISION.
INDICATIONS:
1.CEPHALOPELVIC
DISPROPORTION(CPD)
2. FETAL DISTRESS
3.BREECH PRESENTATION
4. DYSTOCIA
5. PRIOR CESARIAN SURGERY
6. CORD PROLAPSE
7. ABRUPTIO PLACENTA
8. PLACENTA PREVIA
COMPLICATIONS:
1.INFECTIONS
2. HEMORRHAGE
3. BLOOD CLOTS
4. SURGICAL INJURY TO THE BLADDER
OR INTESTINES
5. SURGICAL INJURY TO THE FETUS.
TYPES:

1.LOW SEGMENT / LOW TRANSVERSE /

LOW CERVICAL ( LTCS)
- INCISION IS MADE TRANSVERSELY
ON THE LOWER SEGMENT OF THE
UTERUS.( PFANNENSTIEL INCISION)
ADVANTAGES:
1. INVOLVES LESS BLOOD LOSS
2. LESS POSSIBILITY OF RUPTURE OF CS SCAR
DURING SUBSEQUENT PREGNACY
3. LESS INCIDENCE OF POSTOPERATIVE
COMPLICATIONS: INFECTION, ADHESION OF
BOWEL TO THE INCISIONAL LINE, INTESTINAL
OBSTRUCTION.
4. ALLOWS A VAGINAL DELIVERY AFTER A
PREVIOUS CESARIAN SECTION.(VBAC)
DISADVANTAGES:
1.DIFFICULT & LONGER TO PERFORM
THAN THE CLASSICAL TYPE.
2. NOT RECOMMENDED WITH ANTERIOR
PLACENTA PREVIA
2. CLASSICAL TYPE
- A VERTICAL INCISION IS MADE
DIRECTLY INTO THE WALLS OF THE
CORPUS, WHICH IS THE MOST
CONTRACTILE PORTION.
ADVANTAGES:
1.EASIEST & QUICKEST INCISION TO
PERFORM
2. RAPID EXTRACTION OF FETUS CAN BE
DONE.
DISADVANTAGES:
1. INVOLVES MORE BLOOD LOSS BECAUSE
INCISION IS MADE ON THE THICK VASCULAR
PORTION OF THE UTERUS
2. HIGHER INCIDENCE OF POST-OP
COMPLICATIONS
3. RUPTURE OF CS SCAR ON SUBSEQUENT
PREGNANCY IS MORE LIKELY.
4.INVOLVES MORE HEALING DISCOMFORT & A
WIDER CS SCAR.
C. THIRD STAGE OF LABOR = STAGE OF
PLACENTAL EXPULSION
- BEGINS WITH THE DELIVERY OF THE
INFANT TO THE DELIVERY OF THE
PLACENTA.
SIGNS OF PLACENTAL SEPARATION
1. CALKIN’S SIGN – UTERUS BECOMING
ROUND & FIRM & GLOBULAR AGAIN,
RISING HIGH TO THE LEVEL OF THE
UMBILICUS.
2. SUDDEN GUSH OF BLOOD FROM THE
VAGINA
3. LENGTHENING OF THE CORD FROM
THE VAGINA
TYPES OF PLACENTAL SEPARATION:
1. SCHULTZ – IF THE PLACENTA
SEPARATES FIRST AT ITS CENTER & LAST
AT ITS EDGES, IT TENDS TO FOLD ON
ITSELF LIKE AN UMBRELLA & PRESENTS
THE FETAL SURFACE WHICH IS SHINY.
80% OF PLACENTAS SEPARATE THIS WAY.
“ SHINY FOR SCHULTZ”
2. DUNCAN – IF THE PLACENTA
SEPARATES FIRST AT ITS EDGES, IT
SLIDES ALONG THE UTERINE SURFACE &
PRESENTS AT THE VAGINA WITH THE
MATERNAL SURFACE WHICH IS RAW,
RED, & IRREGULAR WITH THE RIDGES
OR COTYLEDONS THAT SEPARATE
BLOOD COLLECTION SPACES SHOWING.
ONLY ABOUT 20% OF PLACENTAS
SEPARATE THIS WAY. “ DIRTY FOR
DUNCAN”
Placenta
NURSING CARE:
1. DO NOT HURRY THE EXPULSION OF
THE PLACENTA BY FORCEFULLY PULLING
OUT THE CORD OR DOING VIGOROUS
FUNDAL PUSH AS THIS CAN CAUSE
UTERINE INVERSION.
2. TRACT THE CORD SLOWLY, WINDING IT
AROUND THE CLAMP UNTIL THE
PLACENTA SPONTANEOUSLY COMES OUT
,ROTATING IT SLOWLY SO THAT NO
MEMBRANES ARE LEFT INSIDE THE UTERUS. A
METHOD CALLED “ BRANDT ANDREW’S
MANEUVER”
3. TAKE NOTE OF THE TIME OF PLACENTAL
DELIVERY. IT SHOULD BE DELIVERED WITHIN 5 TO
20 MINUTES AFTER THE DELIVERY OF THE BABY,
OTHERWISE REFER IMMEDIATELY TO THE
PHYSICIAN AS THIS CAN CAUSE SEVERE
BLEEDING IN THE MOTHER.
** IF BLEEDING OCCURS & THE PLACENTA
CANNOT BE DELIVERED, MANUAL EXTRACTION
OF THE PLACENTA IS INDICATED **
4. INSPECT FOR COMPLETENESS OF
COTYLEDONS; ANY PLACENTAL
FRAGMENT RETAINED CAN ALSO CAUSE
SEVERE BLEEDING & POSSIBLE DEATH. (
FIRST NURSING ACTION IN THE 3RD
STAGE OF LABOR).
Inspect the placenta for
completeness.
5. PALPATE THE UTERUS TO DETERMINE
DEGREE OF CONTRACTION. IF RELAXED,
BOGGY OR NON CONTRACTED; THE
FIRST NURSING ACTION IS TO MASSAGE
GENTLY & PROPERLY. AN ICE CAP OVER
THE ABDOMEN WILL ALSO HELP
CONTRACT THE UTERUS SINCE COLD
CAUSES VASOCONSTRICTION.
6. INJECT OXYTOXICS, METHERGIN OR
SYNTOCINON (IM) TO MAINTAIN UTERINE
CONTRACTIONS, THUS PREVENTING
HEMORRHAGE.
NOTE: OXYTOXICS ARE NOT GIVEN
BEFORE PLACENTAL DELIVERY
BECAUSE PLACENTAL ENTRAPMENT
COULD OCCUR. DO NOT GIVE
METHERGIN IF BP IS 130/100 OR ABOVE.
7. INSPECT THE PERINEUM FOR
LACERATIONS. ANYTIME THE UTERUS IS
FIRM FOLLOWING PLACENTAL DELIVERY,
YET BRIGHT RED VAGINAL BLEEDING IS
GUSHING FORTH FROM THE VAGINAL
OPENING, SUSPECT LACERATIONS.
 CATEGORIES OF LACERATIONS
1.FIRST DEGREE – INVOLVES THE
FOURCHETTE, PERINEAL SKIN VAGINAL
MUCUS MEMBRANES
2. SECOND DEGREE – INCLUDES THE
MUSCLES OF THE PERINEAL BODY.
3. THIRD DEGREE – EXTENDS TO THE
ANAL SPHINCTER
4. FOURTH DEGREE – EXTENDS TO THE
MUCOSA OR LUMEN OF THE RECTUM.
D. FOURTH STAGE OF LABOR – STAGE
OF PUERPERIUM / STAGE OF VIGILANCE

-SAID TO BE THE MOST CRITICAL FOR

THE MOTHER BECAUSE OF UNSTABLE
VITAL SIGNS.
= STARTS IMMEDIATELY AFTER THE
DELIVERY OF THE FETUS UP TO 4
HOURS & IS COMPLETED WHEN THE
REPRODUCTIVE TRACT HAS RETURNED
TO ITS NON PREGNANT CONDITION
 COMPLICATIONS OF LABOR
1. DYSTOCIA – PROLONGED & DIFFICULT
LABOR ( LABOR THAT LASTS MORE THAN 24
HOURS).
CAUSES:
A. ABNORMALITIES OF THE POWER / UTERINE
DYSFUNCTION
a. HYPOTONIC UTERINE CONTRACTION –
WEAK & INFREQUENT CONTRACTIONS WHICH
ARE INSUFFICIENT TO DILATE THE CERVIX.
USUALLY OCCURS DURING THE ACTIVE PHASE
CAUSES:
1. OVERDISTENTION OF THE UTERUS
2. PELVIC BONE CONTRACTION
3. UNRIPE OR RIGID CERVIX
4. CONGENITAL ANOMALIES OF THE UTERUS.
MX:
1. REEVALUATE PELVIC SIZE TO RULE OUT
FETOPELVIC DISPROPORTION
2. AMNIOTOMY IF MEMBRANES ARE NOT YET
RUPTURED
3. AUGMENT LABOR BY OXYTOCIN
ADMINISTRATION
4. IF CONTRACTED PELVIS IS THE CAUSE, CS IS
PERFORMED.
b. HYPERTONIC UTERINE CONTRACTIONS
- CONTRACTIONS THAT ARE TOO FREQUENT BUT
UNCOORDINATED, THE UTERUS DOES NOT
RELAX COMPLETELY IN BETWEEN
CONTRACTIONS & CONTRACTIONS ARE MORE
PAINFUL BUT INEFFECTIVE.
MX: SIDE LYING POSITION TO MAXIMIZE BLOOD
FLOW TO THE FETUS & THE PLACENTA.
2. PRECIPITATE LABOR /
PRECIPITATE BIRTH:
-labor lasting < 3 hrs from the onset of
contractions to the birth of infant
MATERNAL COMPLICATIONS:
1.increase risk of uterine rupture
2. laceration of cervix, vagina and perineum
3. postpartum hemorrhage
FETAL COMPLICATION:
1.hypoxia
 Bandl’s ring
 Or Pathologic retraction ring
 seen as a horizontal indentation running
across the abdomen
 Inversion of the Uterus
 Uterus is completely turned inside out
Causes:
 Pulling of the umbilical cord

 Applying pressure on uncontracted uterus

 Placenta accreta
 MX:
 Morphine SO4 to relax the uterus
 CS section for immediate delivery of the fetus
& prevent uterine rupture if Morphine SO4 is
ineffective
 If Bandl’s ring develop during the placental
stage, woman is placed under anesthesia & the
placenta is removed manually.
1. Prevention:
1. Never apply pressure on an uncontracted uterus
2. Never pull the cord to hasten placental delivery
2. Lower uterine segment is inserted first manually &
fundus last.
3. BT & IVF to combat shock
4. Do not attempt to remove the placenta if it is still
attached to the uterus as this will only enlarge the
bleeding area
5. Give oxytocin only after the uterus is properly
replaced
6. If the placenta is still attached to the uterus,
remove it when the uterus is replaced &
contracted
PUERPERIUM / POSTPARTUM = REFERS
TO THE SIX TO EIGHT WEEK PERIOD
AFTER THE DELIVERY OF THE BABY.
INVOLUTION = THE RETURN OF THE
REPRODUCTIVE ORGANS TO THEIR PRE-
PREGNANT STATE.( 6 WEEKS)
ASSESSMENT:
1.FUNDUS - FUNDUS SHOULD BE FIRM,
IN THE MIDLINE, & DURING THE FIRST
12 HOURS POST PARTUM, IS A LITTLE
ABOVE THE UMBILICUS.
2. LOCHIA – UTERINE DISCHARGE
CONSISTING OF BLOOD, DECIDUAS,
WBC & MUCUS. SHOULD BE MODERATE
IN AMOUNT.
 PATTERN OF LOCHIA:
1.RUBRA = 0-3 DAYS , DARK RED &
MODERATE IN AMOUNT, SMALL CLOTS,
FLESHY STALE ODOR.
2. SEROSA = 4 -7 DAYS ; PINK OR
BROWNISH IN COLOR, NO CLOTS, NO
ODOR ( UNLESS POOR HYGIENE)
3. ALBA = 1 – 3 WEEKS; CREAM TO
YELLOWISH IN COLOR; MINIMAL IN
AMOUNT; NO ODOR; NO CLOTS
NOTES ON LOCHIA:
a.PATTERN SHOULD NOT REVERSE
b. IT SHOULD APPROXIMATE
MENSTRUAL FLOW
c. IT HAS THE SAME FLESHY ODOR AS
MENSTRUAL BLOOD.
d. IT SHOULD NEVER BE ABSENT,
REGARDLESS OF THE METHOD OF
DELIVERY. ( NSD OR CS)
3. BLADDER = A FULL BLADDER IS
EVIDENCED BY A FUNDUS WHICH IS
RIGHT TO THE MIDLINE
4.PERINEUM – IS NORMALLY TENDER ,
DISCOLORED ( ECCHYMOTIC) &
EDEMATOUS. ( APPLY ICE BAG TO THE
PERINEUM IMMEDIATELY). IT SHOULD BE
CLEAN WITH INTACT SUTURES.
5. ROOMING – IN CONCEPT – ( PRIMARILY
TO PROMOTE BONDING).
5. GENITAL CHANGES – UTERINE
INVOLUTION IS ASSESSED BY
MEASURING THE FUNDIC HEIGHT BY
FINGERBREADTHS (=1 CM). ON
POSTPARTUM DAY 1 ( PPD 1) = FUNDUS
IS ONE FINGERBREADTH BELOW THE
UMBILICUS; ON PPD 2, 2
FINGERBREADTHS BELOW THE
UMBILICUS & SO FORTH UNTIL ON DAY
10, IT CAN NO LONGER BE PALPATED
BECAUSE IT IS ALREADY BEHIND THE
SYMPHYSIS PUBIS.
6. AFTERPAINS / AFTERBIRTH PAINS =
STRONG UTERINE CONTRACTIONS FELT
MORE PARTICULARLY BY MULTIS,THOSE
WHO DELIVERED LARGE BABIES, &
THOSE WHO BREASTFEED BECAUSE OF
OXYTOCIN PRODUCTION. IT WILL BE
RELIEVED IN 3 -4 DAYS.

may be relieved by lying on abdomen with small

pillow, heat, ambulation, mild analgesic (if breast
feeding, 1 h before nursing)
 ELIMINATION
 GI – bowel sluggishness, decreased abdominal
muscle tone, perineal discomfort may lead to
constipation;
 managed by:
 early ambulation, increased dietary fiber and
hydration, stool softeners
 PERINEUM
 possible discomfort – swelling and/or
ecchymosis
 Managed with analgesics and/or topical
anesthetics, ice packs for first 12-24 h and then
20 min sitz baths 3-4 times/d, tightening
buttocks before sitting
 Monitor episiotomy/laceration – teach
techniques to prevent infection, e.g., change pads
on regular basis, peri care (cleaning from front to
back using peri-bottle or surgigator after each
voiding and bowel movement), and sitz baths
 SEXUAL ACTIVITIES
 abstain from intercourse until episiotomy is healed and lochia
has ceased (usually 3-4 wk)
 may be affected by fatigue, fear of discomfort, leakage of
breast milk, concern about another pregnancy
 assess and discuss couple’s desire for and understanding about
contraceptive methods
 breastfeeding does not give adequate protection
 oral contraceptives should not be used during breastfeeding
(CONDOM only)
Complications of the Postpartum
Period
1. Postpartum Hemorrhage – is the leading
cause of maternal mortality.
 Blood loss of more than 500 ml is considered
hemorrhage.
 The most dangerous time at which hemorrhage
is likely to occur is during the first hour
postpartum
Types of postpartum hemorrhage
 Early postpartum hemorrhage – occurs during
the first 24 hrs after delivery
 Causes:
 . Uterine atony
 Laceration of the birth canal
 Inversion of the uterus
 Late postpartum hemorrhage – occurs from 24
hrs after birth until 4 weeks postpartum
 Uterine Atony
 Most common cause of EARLY postpartum
hemorrhage. When the uterus fails to contract,
open blood vessels in the placental site
continue to bleed resulting in hemorrhage.
 Causes of Uterine Atony:
 Overdistention of the uterus – hydramnios,
multiple pregnancy
 Complication of labor – precipitate, prolonged
labor
 High parity & advanced maternal age
 Presence of fibroid tumors
 Overmassage of the uterus
 Retained placental fragments
 Management
 First action taken when uterus is relaxed & boggy is to
MASSAGE IT GENTLY.
 Keep bladder empty since a full bladder interferes with
effective uterine contractions
 Monitor vital signs & amount of blood loss during the early
postpartal period
 Administer oxytocin if uterus is not contracted
 BT & IVF to replace blood loss
 If retained placental fragments is the cause, curettage is
performed
 If bleeding cannot be controlled by the above measures,
HYSTERECTOMY is performed as the last resort.
 Lacerations
 When bright red blood continue to gush from
the vagina & the uterus is firmly contracted,
lacerations of the birth canal are usually the
cause of bleeding. Lacerations can occur
anywhere in the cervix, vagina, & perineum.
 Causes of laceration
 Operative delivery – forceps delivery
 Precipitate delivery
 Large infant – over 9 lbs
 Multiple pregnancy
 Primigravidas
 Abnormal fetal presentation & position
 Management
 Return woman to delivery room for inspection &
repair, if laceration is suspected.
 Vaginal packing to maintain pressure on suture line.
Be sure to remove packing after 24 to 48 hrs
 3rd & 4th degree lacerations – no enema or rectal
suppository. Constipation should be avoided & temp
should not be taken rectally.
 Retained Placental Fragments
 Uterus will not be able to contract effectively if
placental fragments are retained resulting in
uterine atony & hemorrhage.
 Most common cause of LATE postpartum
hemorrhage.
 Causes of retained placenta
 Partial separation of a normal placenta
 Manual removal of the placenta
 Entrapment of placenta in the uterus
 Abnormal adherent placenta – acreta, increta,
percreta
 Management
 D & C to remove adherent placenta
 Hysterectomy – for severe cases
 Subinvolution of the Uterus
 Occurs when there is a delay in the return of
the uterus to its prepregnant size, shape &
function
Causes:
 Retained placental fragments

 Infection – Endometritis

 Uterine tumors
SSx:
 Enlarged & boggy uterus
 Prolonged lochial discharge – persistent lochia rubra
 Backache

Management:
 Methergin to stimulate uterine contractions .2 mg
4x/day for 3 days
 Antibiotics to prevent or treat infection
 D & C if there are retained fragments
 Instruct woman to report the following signs – fever,
vaginal bleeding, passage of tissue
 Hematomas
 This is due to injury to blood vessels during
delivery or during repair of episiotomy
resulting in blood escaping to the connective
tissue under the skin.
Causes:
1. Vulvar varicosities
2. Precipitate labor
3. Forceps delivery
4. Inadequate suturing of episiotomy or
lacerations
Signs and Symptoms:
 Perineal pain

 Swelling
 Discoloration of skin over the swollen
area
 Feeling of pressure over the vagina
 Management:

 Application of ice packs wrapped with

towel to stop bleeding by vasoconstriction
 Large hematomas are potentially
dangerous because they may rupture &
cause severe bleeding & infection. The
woman is brought back to the DR for
incision & ligation of bleeding vessels.
 Analgesics for pain
 Broad spectrum antibiotics to prevent or treat
infection
 Blood transfusion to combat hypovolemia
 Mastitis
 Infection of the breast tissue commonly
occurring in breastfeeding mothers.
 Usually appears during the 2nd & 3rd week
postpartum when milk supply is already
established
 Staphylococcus aureus – most common
causative agent found in the oral nasal cavity
of the infant ( acquired from health care
personnel in the nursery or from cracks &
fissures in the nipples)
 Engorgement or swelling of affected breast &
chills are usually the first signs
 Fever, tachycardia,body malaise
 Hard & reddened breast
 Reduced milk supply as edema &
engorgement obstruct milk flow
 Management
1. Prevention:
 Prevent nipple cracks & fissures by correct
placement of infant’s mouth on the nipple ( latch-
in) not feeding the baby too long, using correct
technique when releasing the baby from the nipple
after feeding , proper breast care .
 Express excess milk after feeding the baby to
prevent milk stasis which is a good medium for
bacterial growth
 Isolation of infants with cord or skin infections
 Persons with known or suspected
staphylococci infections should not be allowed
to care for newborn in the nursery
 Proper handwashing technique in between
handling of newborns. Observance of strict
aseptic technique.
 Wash hands before and after changing perineal
pads, good personal hygiene on the part of the
mother
2. Comfort Measures:
 Instruct mother to wear supportive brassiere
 Application of heat to the breast to promote
comfort & relieve engorgement
 Discontinue breastfeeding from the affected breast.
Express milk every 4 hours to maintain lactation
 3. Antibiotic therapy to fight infection
 4. If abscess develops, the affected area is
incised & drained.
 Thrombophlebitis / Deep Vein
Thrombosis
 Inflammation in the lining of the blood vessels
with formation of blood clots or thrombi.
Causes:
 Stasis of circulation
 Increased fibrinogen during pregnancy
Types:
1. Femoral Thrombophlebitis: infection of the
veins of the legs ( femoral, saphenous,
popliteal veins)
SSx:
 Homan’s sign- calf pain when the foot is
dorsiflexed
 Milk leg or Phlegmasia alba dolens – leg is
shiny white
 Swelling of affected leg, pain & stiffness
 Fever
 Management:
1. Prevention:
> Early ambulation after delivery
> Use of support stocking in women with
varicosities to promote circulation & prevent
stasis – put on stocking before rising from bed
in the morning
2. Bedrest until signs & symptoms disappear
3. Anticoagulant medications to prevent
further clot formation.
 Heparin – not passed to breastmilk
 Protamine Sulfate – antidote of heparin
 Dicumerol – passed to breastmilk so
mother must stop breastfeeding
4. Do not give Aspirin or ASA if patient is
receiving anticoagulant drugs because
aspirin increases coagulation time.
Watch for signs of bleeding: bleeding
gums, ecchymotic skin, increased
lochial discharge.
5. Antibiotic therapy to combat infection,
analgesics for pain.
6. Gradual ambulation after symptoms
disappear
7. Never massage the affected leg
8. Warm wet compress dressings to
promote circulation & for comfort
POSTPARTUM PSYCHOLOGICAL
ADAPTATION:
1. TAKING- IN PHASE = 1 – 3 DAYS
POSTPARTUM WHEN MOTHER RELIES ON
OTHERS TO CARE FOR HER & HER
NEWBORN.PREOCCUPIED WITH SELF &
OWN NEEDS ( FOOD & SLEEP), CLIENT
MAY VERBALIZE HER FEELINGS
REGARDING RECENT DELIVERY.
HESITANT ABOUT MAKING DECISIONS.
2. TAKING – HOLD PHASE = 4 – 7 DAYS
POSTPARTUM WHEN MOTHER BEGINS TO
INITIATE ACTIONS & DECISIONS;
DEPENDENCY /INDEPENDENCY; READY FOR
MOTHERING ROLE; POST-PARTUM BLUES –
(AN OVERWHELMING FEELING OF SADNESS
THAT CANNOT BE ACCOUNTED FOR) MAY
BE OBSERVED. COULD BE DUE TO
HORMONAL CHANGES, FATIGUE OR
FEELINGS OF INADEQUACY IN TAKING CARE
OF A NEW BABY.
MX:
- EXPLAIN THAT IT IS NORMAL & THAT
CRYING COULD BE THERAPEUTIC. BUT IF
POSTPARTUM BLUES EXTEND BEYOND TWO
WEEKS, IT COULD LEAD TO POSTPARTUM
DEPRESSION & POSTPARTUM PSYCHOSIS
;THEREFORE CONSTANT MONITORING SHOULD
BE DONE TO THE MOTHER.
IMPLICATION: PROVIDE PSYCHOLOGICAL
SUPPORT .
1. LETTING –GO PHASE = 10 DAYS
- WOMAN ATTAINS COMPLETE
INDEPENDENCE; ASSUMING NEW ROLES
AND RESPONSIBILITIES

may Experience grief for relinquished roles;

adjustment to accommodate for infant in family
B – breasts
U – terus
B – owel
B – ladder
L – ochia
E – pisiotomy
S – ex / skin
H – oman’s sign
E – motional status of the mother