FAR EASTERN UNIVERSITY

Institute of Nursing
Handouts on Antepartum Pregnancy

FEMALE REPRODUCTIVE OGANS

Internal Organs of Reproduction
 Uterine Length = 6-8cms
 Uterine weight = 50-60 grams
- 4th stage = 1000 grams
- 1 week after = 500 grams
- 2 weeks after = 300 grams
- 6 weeks after = 50 – 60 grams
 Endometrium
- Basal layer
- Glandular layer
 Compact
 Spongy
 Basal

 Myometrium
- Longitudinal
- Transverse
- Oblique
 Endocervix = 700 cc mucus / day

Uterine Attachments
1. Broad ligaments are reflections of peritoneum and extend from the uterus and pelvic organs to the
lateral pelvic walls
2. Round ligaments are reflections of the same peritoneum that arises from cornu of the uterus and
inserted in the upper border of the labia minora. They are capable of contraction at time of labor
and serves to hold the uterus in anteflexion position
3. Cardinal ligaments of Mckenrodt (Transverse Cervical Ligament) are a condensation of subserous
fascia extending from the uterus to the lateral pelvic wall. If overstretched or damaged can result to
prolapse of the uterus.
4. Uterosacral ligaments are condensation of subserous fascia that extend from sacrum around the
rectum of to the cervix. Helps the uterus from sagging downwards and maintaining anteflexion
position.
Positions
a. Anteverted –the uterus is tipped FORWARD in more than 50% of women
b. Retroverted – the uterus is tipped BACKWARD in approximately 25% of women
c. Midposition – the uterus is in the midposition in the remainder of women

Main Blood supply – Internal Iliac Artery

- 500 ml at term
FUNCTIONS of the UTERUS
1. Facilitates sperm transport from the cervix to the oviduct
2. Provides a rich vascular environment for nourishment of the developing embryo
3. Provides a safe location for the growing fetus throughout pregnancy
4. Expels the mature fetus by means of myometrial contractions to outside the body

Functions of fallopian tube

1. Facilitates sperm migration from the uterus to the ampulla for fertilization of the ovum
2. Transport the fertilized ovum toward the uterus

The OVARY
 Intrauterine Oocytes
- 2 months = 600,000
- 5 months = 6 – 8 M
- At birth = 2M
 At Puberty = 200,000 – 400,000
 Actually ovulated = 400 – 500
Main Function of the Ovary
1. Ovulation
2. Endocrine Function
a. Estrogen
b. Progesterone
c. Relaxin

Common terms in Menstruation

Menstruation- is the periodic discharge of blood, mucus and epithelial cells from the uterus
Menarche- first menstrual period that occurs typically at age 12 but may also occur as early as 9 and as
late as 17.
Puberty – age in which the regenerative organ becomes functionally active
Menopause- is the cessation of menstrual cycles that occurs between 40 and 55 years of age

1. Four Body Structures involved in Menstruation

1. Hypothalamus 2. Pituitary Gland
3. Uterus 4. Ovaries
2. Purpose of Menstrual Cycle
 1. To bring an ovum to maturity
2. To renew a uterine tissue bed that will be responsible to its growth if ovum is fertilized.
3. Length = 28 days cycle
Shortest = 20 days Longest = 45 days
4. Average menstrual flow = 4 – 6 days
Shortest = 1 day Longest = 9 days

Phases of Menstrual cycle

1. Menstrual Phase- day 1 to 5

 Corpus luteum degenerates
 There is cessation of progesterone and estrogen produced by the corpus luteum and blood
level drops
 drop in blood levels of estrogen and progesterone stimulate the production of FSH
and new cycle begins
2. Proliferative Phase –day 6 to 14
 Follicle stimulating hormone (FSH) released by the anterior pituitary stimulates the
development of the graafian follicle
 As graafian follicle develops, it produces increasing amounts of follicular fluid containing a
hormone called estrogen
 Estrogen stimulates thickening of the endometrium.
 As estrogen increases in the blood stream, it suppresses secretion of FSH and favors
secretion of the lutienizing hormone (LH)
3. Secretory Phase- day 15-21
 Follows ovulation which is the release of mature ovum from the graafian follicle
 Cavity of the graafian follicle is replaced by the corpus luteum ( secretes progesterone and
some estrogen
 Progesterone acts upon the endometrium to bring about secretory changes that prepare it
for pregnancy. It also maintains the endometrium during the early phase of pregnancy,
should a fertilized ovum be implanted
4. Pre-menstrual – day 22 to 28
 If fertilization does not occur the corpus luteum in the ovary begin to regress
 Production of estrogen and progesterone decreases
 Endometrium of uterus begins to degenerate and sloughs off
 If fertilization occurs, the corpus luteum will stimulate the production of progesterone

Reproductive Hormones
1. Follicle Stimulating Hormone-
- secreted by the anterior pituitary gland during the first half of menstrual cycle
- stimulates development of graafian follicle
- thins the endometrium
2. Lutienizing Hormone
- secretes by pituitary gland
- stimulates ovulation and development of corpus luteum
- thickens the endometrium
3. Estrogen – true ovarian hormone

ESTROGEN: HORMONE OF WOMEN

 secreted primarily by the ovaries by the adrenal cortex and by placenta in pregnancy
 stimulates thickening of the endometrium ; causes suppression of FSH secretion
 assists in maturation of ovarian follicles
 responsible for the development of secondary sex characteristics
 stimulates uterine contractions
 mildly accelerates sodium and water reabsorption by kidney tubules; increase water content of
uterus
 accelerate protein metabolism
 increases sexual desire
 increases vaginal secretions – spinnbarkeit (ability to thread and spinn 10-12 cms)
 increase vaginal pH – alkaline to keep the sperm alive

4. PROGESTERONE – HORMONE OF MOTHERS

-Secreted by corpus luteum and placenta during pregnancy
- inhibits secretion of LH
- has thermogenic effect ( increases temperature)
- relaxes smooth muscles; decrease GIT motility
- thickens cervical mucus - operculum
- maintain thickness of endometrium
- increases vascularization of the uterus
- allows pregnancy to be maintained
- stimulates alveoli of the breast during the 2nd half of Pregnancy

5. Prostaglandin
-fatty acids categorized as hormone - produced by many organs of the body
- affects menstrual cycle
- influences the onset and maintenance of labor

THE CHILD BEARING CYCLE

Conception
The penetration of one ovum (female gamete) by one sperm (male gamete) resulting in
a fertilized ovum (zygote). Each gamete has haploid number (23). Zygote has a diploid number(46) with
one of each pair from each parent.
Sex of child is determined at moment of conception by male gamete.
If X-bearing male gamete unites with ovum, result is a female child (X + X).
If Y- bearing male gamete unites with ovum, result is a male child (X + Y).

Fertilization is the union of the ovum and a spermatozoa

Terms: conception, impregnation, fecundation
Egg life -24 hrs.
Sperm life -72 hrs.-5ml with 400 million per ejaculation
Zona pellucida - ring of mucopolysaccharide
and Corona radiata – circle of cells
The ovum and surrounding cells are propelled FIMBRIAE –part of the fallopian tube – the fine hairlike
structures and peristaltic movement of the tube.
Capacitation –is the final process that sperm must undergo to be ready for fertilization

Fetal Growth
 Ovum – from ovulation to fertilization
 Zygote – from fertilization to implantation
 Embryo – from implantation to 5-8 weeks
 Fetus – from 5- 8 weeks until term
 Conceptus – developing embryo or fetus and placental structures throughout pregnancy

Embryonic and Fetal Structures

 Morula – 16 – 50 cells
 Blastocyst – fluid space mass in the uterus
 Trophoblast – cells in the outer ring will become placenta and membranes
 Embryoblast – inner cells will form the embryo
 Decidua – endometrium; has 3 separate areas:
 Decidua basalis – part under the embryo, communicates with maternal blood vessels
 Decidua capsularis – encapsulates the surface of the trophoblast
 Decidua Vera – remaining portion

Chorionic villi
Embryonic and Fetal Structures
Implantation- 6 to 9 days after fertilization
It takes 3 to 4 days for the zygote to reach the body of the uterus
MORULA
Blastocyst attaches to the decidua
TROPHOBLAST- cells in the outer ring- which will become the placenta and membranes
inner cell mass –later form the embryo
Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are
ruptured by the implanting trophoblast – IMPLANTATION BLEEDING

Primary Germ Layers

 At implantation, blastocyst differentiates into:
a. amniotic cavity – larger, ectoderm
b. yolk sac – lined with entoderm, nourishment for embryo

First lunar month

 Ectoderm
Ectoderm forms tissues associated with outer layers: skin, hair, sweat glands, epithelium. The brain and
nervous system also develop from the ectoderm.
 Mesoderm
The mesoderm forms structures associated with movement and support: body muscles, cartilage, bone,
blood, and all other connective tissues. Reproductive system organs and kidneys form from mesoderm.
 Endoderm
The endoderm forms tissues and organs associated with the digestive and respiratory systems. Many
endocrine structures, such as the thyroid and parathyroid glands, are formed by the endoderm. The
liver, pancreas, and gall bladder arise from endoderm.
Cardiovascular System
 Simple blood cells → network of blood vessels → single heart tube
 As early as the 16th day of life
 Heart beats as early as the 24th week
 Septum develops on the 6th and 7th week
 Heart valves develop on the 7th week

Respiratory System
 Alveoli and capillaries begin to form between the 24th to 28th weeks
 Spontaneous respiratory movements begin as early as 3 months
 Surfactant
- Phospholipid substance
- Excreted by the alveolar cells at about 24th week
- Decreases alveolar surface tension on expiration
- Prevents alveolar collapse, improves the infant’s ability to maintain respiration in the outside
environment

Nervous System
a. Neural plate is apparent on the 3rd week of gestation
b. Brain waves can be detected by EEG on the 8th week
c. All parts of the brain form in utero although not completely mature at birth
d. Eye and inner ear develop as projections of the origin neural tube
e. By 24 weeks, the ear is capable of responding to sound, the eyes exhibit a pupillary reaction

Endocrine System
a. Fetal adrenal glands supply a precursor for estrogen synthesis by the placenta
b. Fetal pancreas produces the insulin needed by the fetus
c. Thyroid and parathyroid glands play vital roles in metabolic function and calcium balance

Digestive System
a. Digestive tract is separated from the respiratory tract at about 4th week of gestation
b. Meconium forms in the intestines as early as the 16th week
c. Sucking and swallowing reflexes are not mature until about 32 weeks
d. Ability to secrete enzymes mature at 36 weeks
e. Amylase is not mature until 3 months after birth
f. Liver is active throughout gestation

Musculoskeletal System
a. Fetus can be seen to move on ultrasound as early as the 11th week
b. Quickening – felt by mother at about 20 weeks
c. First 2 weeks – cartilage prototypes provide support and position
d. Ossification begins at 12th week

Reproductive System
a. Child’s sex is determined at the moment of conception by a spermatozoon carrying an X or Y
chromosome
b. Can be determined as early as 8 weeks by chromosomal analysis
c. Gonads form at 6th week
 If testes form, testosterone is secreted influencing the sexually neutral duct to form other male
organs
 In the absence of testosterone, female organs will develop
d. Testes descend from the pelvic cavity at the 34th – 38th week

Urinary System
a. Rudimentary kidneys are present at the end of 4th week
b. Urine is formed by the 12th week
c. Urine is excreted into the amniotic fluid by the 16th week
d. At term, fetal urine is being excreted at a rate of 500 ml/ day

Integumentary System
a. Skin appears thin and translucent until subcutaneous fat begins to be deposited at about 36 weeks
b. Lanugo – soft downy hair
c. Vernix caseosa – cream-cheese like substance important for lubrication and keeps skin from
macerating

Immune System
a. Level of passive IgG immunoglobulins peaks at birth and then decreases over the next 9 months
b. Fetus is capable of active antibody production late in pregnancy

Definition of terms
1. Gravida – number of times a woman has been pregnant
2. Nulligravida – a woman of childbearing age who has never been pregnant
3. Primigravida – a woman who has been pregnant once
4. Multigravida – a woman who has been pregnant for 5 times or more
5. Parity – number of times a woman has given birth
6. Primipara – a woman who has given birth once
7. Multipara – a woman who has given birth for 5 times or more

 4 consecutive digits
- F-P-A-L
- Full term – preterm – abortion – living
 2 consecutive digits
- G, P
- Gravidity - Parity
 6 consecutive digits
- G–P–F–P–A–L
- Gravidity – parity – full term – preterm – abortion - living

Measurements of length of pregnancy:

Computation of AOG
 Example:
- Date today: October 19, 2010
- LMP: April 5, 2010
- Computation:
- April = 25 days
- May = 31 days
- June = 30 days
- July = 31 days
- August = 31 day
- September = 30 days
 - October = 20 days
- Answer: 198 days = 28 weeks and 2 days

Estimating Fetal Growth

 McDonald’s Rule
 Method of determining the growth of fetus in utero by measuring fundal height
- (Distance in cm) X 8 / 7 = Total Weeks of Gestation
- (Distance in cm) X 2 / 7 = Total Months of Gestation
- 20th to 31st weeks – fundic height is equivalent to the gestational weeks

 Haase’s Rule
- Method of determining fetal length
- 1st half of pregnancy = multiply month by itself (2 months X 2 = 4 cms.)
- 2nd half of pregnancy X 5
(6 months X5 = 30 cms)

 Bartholomew’s Rule of Fourths

- Fundic Height in Months
 9 months – just below the xiphoid process
 8 months – ¾ from umbilicus to xiphoid
 7 months – ½ from umbilicus to xiphoid
 6 months – ¼ from umbilicus to xiphoid
 5 months – level of umbilicus
 4 months – ¾ from umbilicus to symphysis pubis
 3 months – ½ from umbilicus to symphysis pubis
 2 months – ¼ from umbilicus to symphysis pubis
 1 month – level of symphysis
 Johnson’s Rule
Determining Fetal Weight
 Fundic Height – n X k = Fetal weight
 n = 12 if fetal head is below the level of the ischial spines ( engaged)
 n = 11 if presenting fetal part is above the level of the ischial spines
 1 is added to n for patients over 200 pounds
 K = 155 gms

Common Teratogens and Its Effects

[Link]

Placenta
Pancake – weighs 1 lb. or 1/6 of baby’s weight
Function:
• Fetal lungs
• Kidneys
• Gastrointestinal
• Endocrine
• Barrier
• ENDOCRINE
 Human Chorionic Gonadotropin (HCG)
- orders the corpus luteum to keep on producing estrogen and progesterone,
a. That is why there is amenorrhea during pregnancy.
b. It is also the basis for pregnancy tests.
 Human Placental Lactogen
-promotes the growth of the mammary glands necessary for lactation.
 Estrogen and Progesterone
 3 subtypes of Estrogen:
• Estrone(E1)- post menopausal women
• Estradiol(E2)- non-pregnant
• Estriol(E3)- pregnancy
Umbilical Cord
A circulatory pathway connecting the embryo to the chorionic villi . Length 55 cm or 21 inches
Function :
• Transport oxygen and nutrients to the fetus from the placenta and to return waste products
from the fetus to the placenta
Parts- maternal and fetal side
1 vein carries oxygenated blood
2 arteries carry deoxygenated blood
Wharton’s jelly- gelatinous mucopolysacharides

AMNIOTIC FLUID
 It is also known as the bag of water, it serves the ff purpose:
o protects the fetus against blows or pressure on the mothers abdomen
o protects the fetus against the sudden changes in to since liquid changes to more slowly than air.
o protects the fetus from infection
o provides free movement for the fetus
o Acts as fluid wedge
Terms
Polyhydramnios- excessive amount of amniotic fluid greater than 1000 ml. to 1500 ml.
Oligohydramnios- amount less than 300-500 ml.
Abnormal colors:
• green-tinged in a non-breech presentation –fetal distress
• Golden- color – hemolytic disease

Signs of Pregnancy
1. Presumptive signs
a. Amenorrhea - absence of menstruation, ovulation inhibited by increased progesterone and
estrogen level
b. Nausea and vomiting
c. Increased breast sensitivity and breast changes
d. Integumentary changes – increased pigmentation in localized area
e. Constipation
f. Frequent urination due to increased renal blood and plasma flow ; increased GFR
g. Quickening
h. Abdominal enlargement

2. Probable sign
a. Uterine enlargement
b. Hegar’s sign- softening of the lower uterine segment
c. Goodel’s sign – softening of the cervix due to increased blood supply
d. Chadwick’s –purplish discoloration of the vaginal mucosa
e. Ballotment- when fetus rebounds against examiners finger’s during palpation
f. Braxton’s Hicks contraction
g. Positive pregnancy test

3. POSITIVE SIGN
a. Fetal heart tone can be heard
b. X-ray or ultrasound of fetus
c. Palpable fetal movements

PRENATAL CARE
 Schedule of first visit is as soon as the woman missed her menstrual period and pregnancy is
suspected .
 The objective of prenatal care is to reach all pregnant women, to give sufficient care to ensure a
healthy pregnancy and the birth of a full term healthy baby
Follow-up visit:
Once a month – first to 28 weeks
Twice a month- 28- 36 weeks
Every week-36-40 weeks

Maternal Health Program

 Task is to reduce the maternal mortality ratio (MMR) by three-quarters by 2015 – from 112/100,000
live births in 2010 and 80/100,000 live births in 2015
 Essential Health Services Packages Available in the Health Care Facilities
Maternal Health Program
 A. Antenatal Registration

Maternal Health Program

Tetanus Toxoid Immunization – 2 doses of Tetanus toxoid vaccination given one month before delivery
to protect the baby from neonatal tetanus
Micronutrient Supplementation

Birth registration
Newborn screening within 48 hours up to 2 weeks after birth
Schedule when to return for consultation for postpartum visits
Recommended Schedule:
1st Visit - 1st week postpartum preferably
3 – 5 days
nd
2 Visit - 6 weeks postpartum
Reproductive Health
10 Elements
1. Family Planning
2. Maternal and Child Health and Nutrition
3. Prevention and management of Reproductive Tract Infections Including Sexually Transmitted
Infections (STI’s) and HIV/AIDS
4. Adolescent Reproductive Health (ARH)
5. Prevention and Management of Abortion and Its Complications
6. Prevention and Management of Breast and Reproductive tract Cancers and other gynecological
conditions
7. Education and Counseling on Sexuality and Sexual Health
8. Men’s Reproductive Health (MRH) and Involvement
9. Violence Against Women and Children
10. Prevention and Management of Infertility and Sexual Dysfunction

Philippine Reproductive Health

 DOH has focused in addressing the health concerns on the first 4 priority elements of reproductive
health:
1. Family Planning
2. Maternal and Child Health and Nutrition
3. Prevention and management of reproductive Tract infections including Sexually Transmitted
Infections (STI’s) and HIV/AIDS
4. Adolescent Reproductive Health (ARH)
 Other six elements are at different stages of development from policy/framework formulation to
pilot implementation in selected facilities and areas

Components of pre-natal check up

 Initial Interview
 Comprehensive Health History
 Demographic data
 Chief concern
 Current Pregnancy
 Obstetrical and Gynecologic History
o Menarche
o Menstrual History
o STD
o Sexual History
 Past medical history
 Family history
 Social, Experiential and Occupational History
 Nutritional History
 Day history

MATERNAL RISK FACTORS

 Age of 18 and below or more than 35 years
 Height is less than 4”10” (145 cm)
 5th or more pregnancy
 Any of the following conditions
- Asthma
- Heart Disease
- Goiter
- Diabetes Mellitus
 - Hypertension
- Pulmonary Tuberculosis
 Previous CS / Miscarriage
 3 consecutive Miscarriage or stillbirth
 Postpartum Bleeding History

Physical examination
 Baseline height and weight
 Vital signs measurement
 Assessment of system
 Measurement of fundic height and fetal heart tones

Pelvic examination
 External genitalia
o Inspection of the VULVA – Lesions, Venerial warts, Cystocele and rectocele
o Vaginal Discharges
 Candida – itching, irritation; yeast like odor or none, thick curd like white in appearance
 Bacterial Vaginosis – fishy odor noticed after sexual intercourse; thin grayish or yellow
secretions
 Trichomonas – irritation, malodorous; frothy, copious yellow green discharge
 Internal genitalia
o Speculum examination (not lubricated when doing Pap Smear)
 Cervix – assess for abnormal growth like benign cysts; nabothian cyst (bluish or white cyst),
polyp (dark red that protrude thru the OS; carcinoma (cauliflower like growth that easily
bleeds when touched.
 Paps Smear
 Advised not to douche before the exam; perform when not menstruating
 Rotate spatula at the OS
 Cervical brush inserted about 2 cm and rotated 180 L in the OS
 Spread on the glass slide & sprayed
 Thin prep pap smear – immersed in solution rather than spread on a slide to allow
papilloma virus (HPV) testing
o Bimanual Examination
 Cervical palpation as to consistency, mobility, size and position – If hard, immobile
indicates presence of neoplasm
 Pain on gentle movement of the cervix is called as CHANDELIER sign or (+) cervical
motion tenderness (+CMT)
o Uterine palpation (Bimanual exam) to assess uterine size, mobility & contour.
 Fixation of the uterus in the pelvis is a sign of endometriosis or malignancy
 Adnexal palpation to evaluate tubes and ovaries
 Rectovaginal examination
 Laboratory assessment
 Blood studies
 Urinalysis
COMMON LABORATORY PROCEDURES
CBC, Hgb, Urinalysis, urine test for protein, random blood sugar, typing
Others:
 Maternal Serum Alpha fetoprotein (MSAFP)
 Triple Screen ( MSAFP, hCG, unconjugated estriol)
 Glucose Challenge
 1 hour glucose tolerance
 3 hour glucose tolerance
Urine Tests
Acetic Acid Test
Albumin determination test
Result:
+ 1 – trace
+ 2 – cloudy
+ 3 – whitish ring
+ 4 – pure whitish solution
Benedicts Test
To determine sugar or glucose
Result :
(-) – no change in color
+1 – bluish
+2 – greenish yellow
+3 – yellow orange
+4 – brick red

 Diagnostic Examinations
o Cytologic test for cancer ( Papanicolaou smear)
 Acetic acid test
 leukoplakia – white plaque before applying acetic acid – acetowhite tissue after applying
acetic acid
 punctuation – dilated capillaries in dotted or stripped pattern
 Mosaicism – a tile like pattern
 Atypical vascular pattern
o Colposcopy & Cervical Biopsy – a portable microscope that allows to visualize the cervix and
obtain sample of abnormal tissue for analysis
 Endocervical Curettage – If shows pre malignant cells (CIN – cervical intraepithelial
neoplasm) needs Cryotherapy – freezing with nitrous oxide; Laser therapy;
 Cone Biopsy – LEEP Procedure ( Loop electrosurgical excision which uses a laser beam.
o Laparoscopy- Pelvic Peritoneoscopy – visualization of the pelvic structures
Insufflation – injection of CO2intraperitoneally to separate the intestines from the pelvic organs.
o Endometrial (Aspiration) Biopsy
o Hysteroscopy – ( transcervical intrauterine endoscopy)
 performed about 5 days after menstruation; in the estrogenic phase
 Paracervical anesthetic block or lidocaine spray is used
  A hyteroscope is passed into the cervical canal and advance 1-2 cm under direct vision.
 Uterine distending fluid (NSS or D5W) is infused to thru the instrument to dilate the uterine
cavity and enhance visualization.
 Contraindicated to patients with cervical or endometrial carcinoma
o Hysterosalpingography – an X-ray examination of the uterus and fallopian tubes after contrast
dye is injected through the cervix.
 Scheduled within the first 10 days after mentruations to precede ovulation and decrease the
possibility of disturbing an unknown pregnancy.
 Laxative or enema so gas shadows do not distort x –ray findings
 Analgesics or antibiotics prior to the procedure may be ordered
o Ultrasonography
 assess fetal general size, structural disorders of the internal organs, spine, limbs
 response of sound waves against objects
 diagnose pregnancy as early as 6 weeks of gestation
a. Confirm presence, size, location of the placenta and amniotic fluid
b. Establish the fetus is growing and has no gross defects- hydrocephalus, anencephaly or
spinal cord, heart, kidney & bladder defects
c. Establish presentation & position of the fetus; sex can be identified
d. Predict maturity by biparietal diameter – If 8.5 cm or more, weighs 2500 gms. or 5.5
lbs., head circumference and femoral length
 advised to drink a full glass of water every 15 minutes; begin an hour and half before the
procedure (6 glasses)
o Amniocentesis
 withdrawal of amniotic fluid thru the abdominal wall for analysis
 done during the 14th to 16th week of pregnancy – 5cc.
 Ask client to void to reduce bladder size prior to the procedure
 Fetal monitor applied and BP taken
 Needle used 3-4 inches at 20-22 gauge
 Advised NOT to do DEEP BREATHING to prevent lowering of diaphragm
 Rest for 30 minutes after and assess for FHT and uterine contraction
 If Rh (-) give RhoGam
 Information are as follows:
1. Color – water, slight yellow during late pregnancy; strong yellow indicated blood
incompatibility; green color indicates fetal distress
2. Lecithin / Sphingomyelin Ratio = 2:1 indicates lung maturity present 22nd to 24th week
3. Phosphatidyl Glycerol and Desaturated Phosphatidylcholine at 35th to 36th week predicts
respiratory distress syndrome will not occur.
4. Bilirubin determination for blood incompatibility
5. Chromosome analysis – Karyotyping
6. Fetal Fibronectin – if present in woman’s vagina indicates preterm labor. Increases
secretion early 20th week then during labor
7. Inborn Errors of Metabolism – Enzyme defect
8. Alpha fetoprotein – Increase amount indicates fetus has an open body defect like
anencephaly, myelomeningocele, omphalocele and decrease amount in Down
syndrome

Assessing Fetal well-being

a. Fetal movement – quickening; at least 10 times/hour; Sandovsky Method
b. Fetal heart rate – 120 – 160 bpm; Doppler 10 -12 weeks; Stethoscope (20 weeks)
c. Non-stress testing – reactive (with 2 accelerations of FHR by 15 beats or more lasting for 15 secs
occur after movement)
d. Contraction stress testing – with IV oxytocin administration or nipple stimulation; normal if no FHR
decelerations are present with contraction
e. Ultrasound – used to diagnose pregnancy as early as 6 weeks

COMMON PRESCRIPTIONS
Iron supplementation shall be given from the 5th mos. of pregnancy up to 2 months post-partum. (100-
200 mg. orally per day daily per orem for 210 days)
- Low –dose Vit.A supplementation ( 10,000 IU in 2 weeks
- In endemic areas , 1 iodized capsule to all pregnant women
- In areas with Malaria , 2 tablets of Chloroquine ( 150 mg/ 2 tablets every week for the duration of
pregnancy
Health Teaching
1. Nutrition
2. Personal Hygiene
3. Prevention of UTI
4. Preparation for breastfeeding
5. Dental Care
6. Physical Activity and Exercise
7. Posture and Body Mechanics
8. Rest and Relaxation
9. Employment
10. Safety
11. Clothing
12. Travel
13. Immunizations
14. Intake of Alcohol, Caffeine, Cigarette Smoking and Drug abuse
Thalidomide – amelia & phocomelia
Steroids – cleft palate & abortion
Iodides – enlargement of fetal thyroid
glands
Vitamin K – Hemolysis &
Hyperbilirubinemia
Streptomycin / Quinine – damage of the 8th cranial nerve (deafness)
Tetracycline – stains tooth enamel

PHYSIOLOGICAL CHANGES DURING PREGNANCY

Reproductive System
1. Uterus- enlarges; painless contractions occur
2. Ovaries- ovulation stops due to high levels of placental estrogen and progesterone
3. Vagina- becomes softer; mucosa thickens ,vascularity increases, vaginal discharge increases and
becomes more acidic
4 Breast – increase in size and and become full and tender, areola darkens ; colostrum is excreted
5. Cervix- soften’s ( Goodel’s sign) becomes congested with blood (Chadwicks sign) proliferating glands
form mucus plug.

Cardiovascular System
1. Heart muscle enlarges
2. Heart rotates upward and to the left
3. Stroke volume increases
4. Cardiac output increases primarily as a result of expanded vascular volume
5. Pulse rate increases by about 10-15 beats per minute
6. Peripheral vascular resistance falls under the influence of progesterone and prostaglandins
7. Cardiovascular System
8. Femoral venous pressure increases
9. Blood pressure remains essentially the same , despite increase blood volume
10. Blood volume increases to 1200-1500 ml. above pre-pregnancy values
11. Total red cell mass increases , however , the increase in plasma volume is even more pronounced
12. White blood cell count increases to to an average of 10,000 /mm3
13. Clotting factors increase, offering protection against but increasing

Respiratory System
1. Oxygen consumption increases by about 20 percent
2. Dyspnea is common
3. Nosebleeds and nasal stuffiness are common
4. Rib cage widen
5. Respiratory depth increases

Gastrointestinal System
1. Gums appear red and swollen and bleed easier, caused by elevated levels of estrogen
2. Reduced tone of esophageal sphincter allows reflux of acidic stomach contents , producing heart burn
3. Decreased motility in large intestine allows more water to be absorbed ; may cause constipation and
hemorrhoids
4. Increased thirst and appetite

Urinary System
1. Increased urinary frequency on the first and third trimester because of pressure on the bladder
2. Glomerular filtration rate increased 50%
3. Glycosuria – because of increase secretion of sugar by lowered renal threshold
4. Lower specific gravity as a result of increase urinary output

Endocrine System
1. Thyroid activity is increased
2. HCG reaches a peak in the third month
3. Secretion of oxytocin which stimulates uterine contractions coupled with the drop of progesterone
brings about labor
4. Uterine contractions increase in frequency and intensity culminating in fetal expulsion

Skeletal System
1. Gradual softening of pelvic ligaments
2. and joints to facilitate passage of the fetus
3. Lordosis ( forward curvature of the spine in order to change the center of gravity) Pride of
Pregnancy
4. Leg cramps may occur from an imbalance of calcium phosphorus ratio in the body and from
pressure of the uterus

DISCOMFORTS OF PREGNANCY

Ankle Edema
1. occurs during the second and third trimesters.
2. caused by reduced blood circulation in the lower extremities
3. it becomes pathologic if accompanied by the following:
a. Proteinuria
b. Edema of nondependent parts.
c. Sudden increase in weight.
d. Hypertension.
Nursing intervention consists of advising the patient to:
a. Maintain good posture.
b. Avoid prolonged standing or sitting.
c. Wear support stockings.
d. Avoid constrictive clothing (garters, knee-high hose).
e. Drink at least eight glasses of fluid for "natural" diuretic effect.
f. Get adequate rest and exercise; include rest periods to elevate legs.
Treatment of ankle edema.
g. Elevate the feet as often as possible.
h. Apply support stockings before getting up.
i. Diuretics are contraindicated.

Backache
1. caused by relaxation of the sacroiliac joint which is due to increased hormones (steroid sex hormone
and relaxing)
2. exaggerated lumbar and cervico thoracic curves caused by changes in the center of gravity from the
enlarging abdomen and breasts.
a. practice good posture and good body mechanics (use the pelvic tilt and bend at the knees).
b. wear appropriate, well-fitting shoes.
c. sleep on a firm mattress or backboard.
Backaches may indicate a kidney or bladder infection.

Constipation
1. caused by:
 a. an increase of progesterone during pregnancy
b. intake iron supplements
2. Interventions to prevent and ease constipation.
a. Daily bowel elimination
b. Eat foods that are high in fiber such as fruits, vegetables, cereals and whole grain breads.
- Eat small and frequent meals throughout the day.
- Drink six to eight glasses of water every day. Sometimes, apple or prune juice can help.
- Exercise: Yoga, walking, swimming or simple stretches

Muscle Cramps
1. caused by:
a. Compression of nerves supplying the lower extremities due to the enlarging uterus.
b. Reduced level of diffusible serum calcium or elevation of serum phosphorus in the bloodstream.
c. Fatigue, chilling, or tense body posture.
2. Nursing interventions :
a. Avoid fatigue and cold legs.
b. Eat a diet with adequate calcium or prescribed calcium.
c. Avoid drinking more than one (1) quart of milk - will create too much phosphorus in the system.
d. Take the prescribed vitamins B and D per doctor's instructions.

3. Treatment during muscle cramps.

e. The patient should lie on her back and extend the affected limb. A second individual should
apply pressure on the patient's knee with one hand and sharply flex the foot with the other
hand. The affected muscle may also be kneaded with the heel or palm of the hand.

Dyspnea
1. Nursing interventions consist of advising the patient to:
a. Sleep on additional pillows.
b. Maintain good posture.
c. Avoid overeating.
d. Stop or decrease smoking.
e. Limit activity

Urinary Frequency
1. caused by:
a. the vascular engorgement and altered bladder function.
b. an increase in hormones
c. reduction of bladder capacity due to the enlarging uterus and fetal presenting part.
2. Nursing interventions consist of advising the patient:
a. That this is normal.
b. To limit fluid intake before bedtime
c. To wear perineal pads.
d. Notify the physician if pain or burning is noted.

Varicose Veins
1. caused by
 2. the relaxation of smooth muscle walls of veins - due to (progesterone).
3. aggravated by gravity and bearing down for bowel movements
4. a hereditary disposition.
5. involves the veins of the lower extremities, the external genitalia (vulva or labia), the pelvis, and
the perineal area (hemorrhoids).

Varicose Veins
Nursing intervention consists of advising the patient to:
a. Avoid obesity.
b. Avoid lengthy standing or sitting.
c. Avoid constrictive clothing.
d. Avoid constipation and bearing down.
e. Elevate legs when sitting. Get adequate rest.
f. Perform moderate exercise.
g. Rest with legs and hips elevated.
Treatment for Varicose Veins
a. Wear support stockings before rising (getting up) if varicose veins are severe.
b. If in the vulva, may be relieved by placing a pillow under the buttocks to elevate the hips,
assuming the Sim's position for a few minutes several times a day, avoid standing as much as
possible, or laying down instead of sitting when practical.
c. To relieve pain and swelling, take hot sitz baths or local application of warm compresses .

Vaginal Discharges: Leukorrhea

1. a white or yellowish mucous discharge from the cervical canal or the vagina.
2. caused by the hormonal stimulation of the cervix, which becomes hypertrophic and hyperactive
producing an abundant amount of mucous.
3. Leukorrhea may lead to pruritis (severe itching), burning on urination, foul odor from the discharge,
or edema of the vulva.
4. Treatment/nursing intervention consists of:
a. reassuring the patient that this is normal.
b. use perineal pads and to change them frequently
c. cleanse the vulva at least once a day with soap and water and to dry thoroughly
d. Advising the patient to maintain good hygiene.

Supine Hypotension
1. Caused by pressure of the gravid uterus on the descending vena cava when the woman is supine
which decreases the return of the blood.
2. Symptoms include nausea, cold and clammy, feels faint, and hypotensive (decreased blood
pressure).
3. Nursing interventions consist of advising the patient to:
a. Get up slowly.
b. Use the side-lying position, preferably on the left side.

DANGER SIGNALS OF
PREGNANCY
1. Vaginal bleeding
2. Persistent vomiting
3. Chills and Fever
4. Sudden escape of fluid from the vagina
5. Abdominal or chest pain
6. Danger signs of pregnancy induced hypertension
a. swelling of the face and fingers
b. flashes of lights or dots before the eyes
c. dimness or blurring of vision
d. severe or continuous headache
7. Vaginal bleeding
8. Severe vomiting

DEVELOPMENTAL TASKS OF PREGNANCY

Validation – observed during the first trimester
1. Ambivalence, shock or denial may be experienced at the time of knowing occurrence of
pregnancy.
2. Introvert manifestation is usual with weight gain and other outward signs of pregnancy.

Fetal Embodiment; Second trimester.

1. Fetus is viewed as part of self
2. Role adjustments- time of emotional maturity
3. Gains inner strength with the condition
4. Fetal distinction -5th lunar month
5. Fetus is viewed as separate to self
6. Quickening encourages this feeling
7. Woman daydreaming on her role as mother and future of the baby

Role Transition – Third trimester

1. Woman becomes irritable and wanted to end the pregnancy
2. With concrete plans about herself and the baby

Family Task
1. Physical maintenance - Being certain that family has ample resources
2. Allocation of resources - Prioritizing family need, especially the need of children
3. Socialization of Family Members
Involves preparation of the children to live in the community and interact outside the family
4. Maintenance of Order
Opening an effective means of communication between family members, establishing values and rules
5. Division of Labor
Giving roles to the family members
6. Reproduction, Recruitment and Release of the Family Member
Accepting new family member by pregnancy or adoption
7. Placement of members into a larger society
8. Maintenance of motivation and morale