LESSON: 4 PREGNANCY AND PRENATAL CARE

 Immediately after fertilization, the fertilized ovum

FERTILIZATION or zygote stays in the fallophian tube for 3 days,
 The union of the sperm cell and the mature ovum in during which rapid cell division (mitosis) is taking
the outer third or half of the fallophian tube place. The developing cells are now blastomer and
when there are already about 16 blastomers, it is
now a morula. In this morula form, it will start to
GENERAL CONSIDERATIONS travel (by ciliary action and peristaltic contractions
 Normal amount of semen per ejaculation : 3-5 cc = of the fallophian tube) to the uterus where it will
I teaspoon. stay for another 3-4 days.
 Number of sperms in an ejaculate : 120-150  When there is already a cavity formed in the
million/cc. morula, it is now called a blastocyst. Fingerlike
 Mature ovum is capable of being fertilized for 12- projections, called trophoblasts, form around the
24 hours after ovulation. Sperms are capable of blastocyst and these trophoblasts are the ones which
fertilizing even for 3-4 days after ejaculation will implant high on the anterior or posterior
 Normal life of sperms : 7 days. surface of the uterus. Thus, implantation, also
 Sperms, once deposited in the vagina, will called nidation, takes place.
generally reach the cervix with 90 seconds after
deposition.  Once implantation takes place, the uterine
 Reproductive cells after gametogenesis, divide by endothelium is now term decidua.
meiosis (haploid number of daughter cells)  Occasionally, a small amount of vaginal spotting
therefore, they contain only 23 chromosones (the (implantation bleeding appears with implantation
rest of the body contains 46 chromosones). Sperm because capillaries are ruptured by the implanting
have 22 autosomes and one X chromosome and one trophoblast.
X chromosome or one Y chromosome. The union  Implication : it should not be mistaken for the last
of an X-carrying sperm and mature ovum results in menstrual period. (LMP)
a baby girl (XX); the union of a Y-carrying sperm
and a mature ovum results in a baby boy (XY).
Important : Only fathers, therefore, determine the OUTLINE OF TROPHOBLAST
sex of their child. DIFFERENTIATION
 Fertilization and the initial stages of development
 Fertilization occurs in the fallopian tube within 24
IMPLANTATION
to 48 hours of ovulation. The initial stages of
 In humans, implantation is the stage development, from fertilized ovum (zygote) to a
of pregnancy at which the embryo adheres to the mass of cells (morula), occur as the embryo passes
wall of the uterus. ... In humans, implantation of through the fallopian tube encased within a
a fertilized ovum is most likely to occur around nonadhesive protective coating known as the zona
nine days after ovulation; however, this can range pellucida. The morula enters the uterine cavity
between six and 12 days. approximately 2 to 3 days after fertilization.
 The early stages of human development from
fertilization to blastocyst formation. Fertilization
occurs in the fallopian tube within 24 to 48 hours of
ovulation. The initial stages of development, from
fertilized ovum (zygote) to a solid mass of cells
(morula), occur as the embryo passes through the
fallopian tube encased within a nonadhesive
protective shell (the zona pellucida). The morula
enters the uterine cavity approximately two to three
days after fertilization.
 The appearance of a fluid-filled inner cavity marks
the transition from morula to blastocyst and is
accompanied by cellular differentiation: the surface
cells become the trophoblast (and give rise to
extraembryonic structures, including the placenta)
and the inner cell mass gives rise to the embryo.

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

 Within 72 hours of entering the uterine cavity, the CHORION

embryo hatches from the zona, thereby exposing its
outer covering of trophectoderm. Figure kindly – together with the desidua basalis, gives rise to the
provided by S.S. Gambhir and J. Strommer, placenta, which starts to form at 8th week gestation. It
Stanford University (Stanford, California, USA). develops into 15-20 subdivisions called cotyledons.
THE PLACENTA SERVES THE FOLLOWING
TABLE ON OUTLINE OF TROPHOBLAST PURPOSES :
DIFFERENTIATION
RESPIRATORY SYSTEM
 Cytotrophoblast – the inner layer
 Syncytotrophoblast – the outer layer containing a) – exchange of gases takes place in the placenta, not
fingerlike projections called chorionic villi, which in the fetal lings.
differentiate into. RENAL SYSTEM
A. Langhan’s layer – believed to protect the fetus
against Treponema Pallidum (etiologic agent of b) – waste products are excreted through the placenta
syphilis). Present only during the second trimester of (note : it is the mother’s liver which detoxifies fetal
pregnancy. waste products).
B. Syncytial layer – gives rise to the fetal membranes. GASTROINTESTINAL SYSTEM
1. Amnion – inner membrane which gives rise to
a. Umbilical cord/funis – contains two arteries and one c) – nutrients pass to the fetus via the placenta by
vein, which are supported by Wharton’s jelly. diffusion through the placental tissues.

AMNIOTIC FLUID CIRCULATORY SYSTEM

 Clear, albuminous fluid in which the baby floats d) – feto-placental circulation is established in
 Begins to form at 11-15 weeks gestation selective osmosis.
 Approximates water in specific gravity (1.007- ENDOCRINE SYSTEM
1.025). Note: the higher the pH, the more alkaline,
the lower the pH the more acidic e)– it produces the following important hormones
 Near term is clear, colorless, containing little white (before 8 weeks gestation, the corpus luteum is the
speaks of vernix caseosa and other solid particles. one producing theses hormones):
 Produced at a rate of 500 ml. in 24 hours and fetus  Human Chorionic gonadotrophin (HCG). “Orders”
swallows it at an equally rapid rate. By the 4th the corpus luteum to keep on producing estrogen
lunar month, urine is added to the amount of and progesterone, that is why menstruation does not
amniotic fluid. Amniotic fluid, therefore, is derived take place during pregnancy.
chiefly from maternal serum and fetal urine.  Human placental lactogen (HPL) or human
 Implication ; a case of polyhydramnios (=more chorionic somatomammotrophin. Promotes growth
than 1500 ml. of amniotic fluid stems from the of mammary glands necessary for lactation. It has
inability of the fetus to swallow the amniotic fluid also growth-stimulating properties.
rapidly, as in tracheosophgeal fistula; while
 While oligohydramnios (=amniotic fluid less than PROTECTIVE BARRIER
500 ml.) is due to the kidneys to add urine to the
amniotic fluid, as in congenital renal anomaly. f) – inhibits the passage of some bacteria and large
 Also known as bag of water (BOW). It serves the molecules.
following purposes:
 Protection . Shields the fetus against or pressures on STAGES OF FETAL DEVELOPMENT
the mother’s abdomen; against sudden changes in
the temperature because liquid changes temperature 1. ZYGOTE – first 12-14 days
more slowly than air; and from infections. 2. EMBRYO – day 15 to 8th week
 Diagnosis . As in amniocentesis: meconium-stained 3. FETUS - Week 8 to delivery
amniotic fluid means fetal distress.
 Fetal delivery. Aids in the descent of the fetus
during active labor.

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

FETAL DEVELOPMENT FOURTH LUNAR MONTH

 Lanugo hair appears
 Buds of permanent teeth form
FIRST LUNAR MONTH  Heart beats may audible with a fetoscope
1. – Germ layers differentiate by the 2nd week.(In cases
of multiple congenital anomalies, the structures that will
be affected are those that arise from the same germ FIFTH LUNAR MONTH
layer)  Vernis caseosa appears
 Endoderm – develops into the lining of the GIT.  Lanugo hair covers the entire body
The respiratory tract, tonsils, thyroid (for basal  Quickening (fetal movements) are felt
metabolism, parathyroid (for calcium metabolism)  Fetal heart beats are very audible
thymus gland (for development of immunity)
bladder and urethra. SIXTH LUNAR MONTH
 Mesoderm – forms into the supporting structures of  Skin is markedly wrinkled
the body (connective tissues, cartilage, muscles and  Proportions of a full-term baby is attained
tendons); heart, circulatory system, blood cells,
reproductive system, kidneys and ureters.
 Ectoderm – responsible for the formation of the SEVENTH LUNAR MONTH
nervous system, skin, hair and nails, and the  Alveoli begin to form (28th weeks of gestation is
mucous membrane of the anus and mouth. said to be the lower limit of prematurity because if
baby is delivered at this time, he/she will cry and
 Fetal membranes (amnion and chorion) appear by breathe but usually dies).
the 2nd week
 The nervous system very rapidly develops by the EIGHT LUNAR MONTH
3rd week. (dizziness is said to be the earliest sign of  Fetus is viable
pregnancy because as the fetal brain rapidly  Lanugo hair begins to disappear
develops, the glucose stores of the mother are  Nails extends to the ends of fingers
depleted, thus causing hypoglycemia in the latter).  Subcutaneous fat deposition begins
 The fetal heart begins to form as early as the 16th
day of life. (To the question, “When does the fetal NINTH LUNAR MONTH
heart begins to beat?” the answer is first lunar  Lanugo and vernix disappears
month. But to the question, “When can fetal heart  Amniotic fluid volume somewhat decreases.
tones be first heard?” the answer is 5th month).
 The digestive and respiratory tracts exist as a single TENTH LUNAR MONTH
tube until the 3rd week of life when they start to  All characteristics of the normal newborn
separate.
SECOND LUNAR MONTH FOCUS OF FETAL DEVELOPMENT
 All vital organs are formed by the 8th week;
placenta develops fully. FIRST TRIMESTER
 Sex organs (ovaries and testes) are formed by the  – period of organogenesis.
8th week. (To the question, “When is sex
determined?” the answer is “At the time of SECOND TRIMESTER
conception”).  – period of continued fetal growth and
development, rapid increase in fetal length.
THIRD LUNAR MONTH
 Kidneys are able to function. Urine is formed by the THIRD TRIMESTER
12th week.  – period of most rapid growth and development
 Buds of milk teeth formed. because of rapid deposition of subcutaneous fat.
 Bone ossification begins.
 Fetus swallows amniotic fluid. LABOR AND DELIVERY
 Feto-placental circulation is established by selective
osmosis. There is no direct exchange between fetal Labor is the series of events by which the products of
and maternal blood. conception are expelled from the woman’s body. The
terms childbirth, encouchement, confinement,
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

parturition, and travail are all synonyms for labor. Labor LAMBOID SUTURE LINE
is an apt term because a great deal of work is involved in
the process of birth. For the woman and the fetus alike it 2. – the membranous interspace which joins the
is a time of change, both a time of ending and a time for occiput and parietals.
beginning.

THE FETAL SKULL

 Importance: From an obstetrical point of view the
fetal skull is the most important part of the fetus
because it is the :
 Largest part of the body
 Most frequent presenting part
 Least compressible of all parts
 Once the head has been born, the birth of the rest of
the body is rarely delayed.
THREE MAJOR PARTS OF THE FETAL FONTANELS:
SKULL : membrane covered spaces at the junction of the
main suture lines.
 The face
 The base of the skull (cranium) ANTERIOR FONTANEL
 Vault of the cranium (roof)
1. the larger, diamond- shaped fontanel which
CRANIAL BONES: closes between 12-18 months in an infant.
the first 3 are not important because they lie at the base POSTERIOR FONTANEL
of the cranium and, therefore, are never the presenting
2. the smaller, triangular shaped fontanel which
parts.
closes between 2-3 months in the infant.
1. sphenoid - 1 4. frontal - 2
2. ethmoid - 1 5. occipital - 1 MEASUREMENTS
3. temporal - 2 6. parietal - 2
the shape of the fetal skull causes it to be wider in its
anteroposterior (AP) diameter than in its transverse
These bones are not fused, allowing this portion of the
diameter.
head to adjust in shape as the presenting parts passes
through the narrow portions of the pelvis. The cranial TRANSVERSE DIAMETERS
bones overlap under pressure of the powers of labor and
1. of the fetal skull
the demands of the underlying pelvis. The overlapping is
-biparietal = 9.25 cm.
called molding.
-bitemporal = 8 cm.
-bimastoid =7cm
MEMBRANE SPACES
ANTEROPOSTERIOR DIAMETERS
Suture lines are important because they allow the bones
- SUBOCCIPITOBREGMATIC (A) – from below
to move and overlap, changing the shape of the fetal
the occiput to the anterior fontanel = 9.5 cm. (the
head in order to fit through the birth canal, a process
narrowest AP diameter)
called molding.
- OCCIPITOFRONTAL (B) – from the occiput to the
SAGITTAL SUTURE LINE mid-frontal bone = 12 cm.
- OCCIPITOMENTAL © - from the occiput to the
1. – the membranous interspace which joins the
chin = 13.5 (the widest AP diameter.)
parietal bones.
2.
THEORIES OF LABOR ONSET
CORONAL SUTURE LINE
 Labor normally begins when the fetus is sufficiently
– the membranous interspace which joins the frontal
mature to cope with extra-uterine life yet not to large to
bone and the parietal bones.
cause mechanical difficulties in delivery. However, the
trigger that converts the random painless contractions
into strong, coordinated, productive labor contractions

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

is unknown. A number of theories have been proposed 4. – the woman’s psyche is preserved so afterwards
to explain why labor begins. These includes: labor can be viewed as a positive experience.
PRELIMINARY/PRODROMAL/
UTERINE STRETCH THEORY PREMONITORY SIGNS OF LABOR
– any hollow body organ when stretched to capacity will
necessary contract and empty. LIGHTENING
1. – the settling of the fetal head into the pelvic brim. In
OXYTOCIN THEORY
primis, it occurs 2 weeks before EDC; in multis, on or
– labor, being considered a stressful event, stimulates before labor onset. Lightening should not be confused
the hypophysis to produce oxytocin from to posterior with engagement. Engagement occurs when the
pituitary gland. Oxytocin causes transaction of the presenting part has descended into the pelvic inlet.
smooth muscles of the body. E.g., uterine muscles.
LIGHTENING RESULTS IN:
PROGESTERONE DEPRIVATION THEORY
- Increase in urinary frequency
– progesterone, being the hormone designed to promote - Relief of abdominal tightness and diaphragmatic
pregnancy, is believed to inhibit uterine motility. Thus, pressure.
if its amount decreases, labor pains occur. - Shooting pains down the legs because of pressure on
the sciatic nerve.
PROSTAGLANDIN THEORY
- Increase in the amount of vaginal discharges.
– initiation of labor is said to result from the release of - Increases lordosis as the fetus enters the pelvis and
Arachidonic acid produced by steroid action on lipid falls further forward
precursors. Arachidonic acid is said to increase - increased varicosities
prostaglandin synthesis which , in turn causes uterine
contractions. INCREASED IN ACTIVITY LEVEL
2. – due to increased epinephrine secreted to prepare the
THEORY OF AGING PLACENTA
body for the coming “work” ahead. Advise the pregnant
– because of the decrease in blood supply, the uterus woman not to use this increased energy for doing
contracts. household chores.

COMPONENTS OF LABOR
A successful labor depends on these integrated LOSS OF WEIGHT
concepts: 3. – about 2-3 lbs. 1- 2 days before labor onset,
probably due to decrease in progesterone production,
PASSAGEWAY
leading to decrease in fluid retention.
1. – this refers to the route the fetus must travel from the
uterus through the cervix and vagina to the perineum; BRAXTON-HICKS CONTRACTIONS
because these organs are contained inside the pelvis, the 4. – painless, irregular practice contractions.
fetus must also pass between the pelvic ring.
What is Braxton Hicks?
PASSENGER
 Before experiencing true contractions, many
2. – Several aspects of the fetus body and position are women have what’s known as Braxton Hicks
critical to the outcome of labor. Primary among these contractions, also referred to as practice
are the size and the orientation of the fetal head. The contractions or false labor. They are described by
fetus is of appropriate size and in advantageous position the American Congress of Obstetricians
and presentation. and Gynecologists as “irregular and they do not
come closer together.” Therefore, the key to
POWER
recognizing actual labor is understanding the
3. – this is supplied by the fundus of the uterus and pattern of the contractions.
implemented by uterine contractions, a process that  These false labor contractions can begin in the
causes cervical dilatation and the expulsion of the fetus second or third trimester and have been said to be
from the uterus. the uterus practicing or toning up for real labor.
They can range from a completely painless
PSYCHE
tightening to a jolt that can take your breath away.

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

They can sometimes increase in frequency as the  If you’re bleeding

big day approaches.  If you have painful contractions of six or more in an
hour — before 37 weeks of pregnancy
FALSE VS. TRUE LABOR RIPENING OF THE CERVIX
 The timing of the contractions is a big component 5. – from Goodell’s sign, the cervix becomes the “
for recognizing the differences between true and butter-soft”.
false labor. Other differences you might notice
include the contractions changing when you change
positions, like stopping with movement or rest. The SIGNS OF TRUE LABOR
strength of contractions is also different, and the
pain is felt in different places. UTERINE CONTRACTIONS
– the surest sign that labor has begun is the initiation of
effective, productive, involuntary, uterine contractions.
IT’S FALSE LABOR IF… Pain in uterine contractions result from:
 Contractions don’t come regularly and they don’t - Contraction of uterine muscles when in an ischemic
get closer together state.
 They stop with walking or resting or with changes - Pressure on nerve ganglia in the cervix and lower
in position uterine segment.
 They are usually weak and don’t get stronger, or - Stretching of ligaments adjacent to the uterus and in
start strong and get weaker the pelvic joints.
 Usually the pain is only felt in the front - Stretching and in displacement of the tissues of the
vulva and perineum.
IT’S TRUE LABOR IF…
 Contractions come and get closer together over PHASES OF UTERINE CONTRACTIONS:
time, lasting about 30-70 seconds each - INCREMENT – first phases during which the
 They continue regardless of movement or resting intensity of contraction increases; also known as
 They progressively get stronger crescendo.
 Usually they start in the back and move to the front - ACME – the height of the uterine contraction; also
known as apex.
OTHER WAYS TO RECOGNIZE LABOR: - DECREMENT – last phase during which intensity of
 The 5-1-1 Rule: The contractions come every 5 contraction decreases; also known as decrescendo.
minutes, lasting 1 minute each, for at least 1 hour
 Fluids and other signs: CHARACTERISTICS OF CONTRACTIONS
 You might notice amniotic fluid from the sac that - FREQUENCY – this is the time from the beginning
holds the baby. This doesn’t always mean you’re in of one contraction to the beginning of the next.
labor, but could mean it’s coming - DURATION – this is the time from the moment the
 A bloody show or a “mucus plug” could mean a uterus begins to tighten until it relaxes again.
cervical change, which means labor is close - INTENSITY – it may be mild, moderate or strong at
 Nausea and/or vomiting might happen due to the its acme.
contractions becoming very intense and the change a. MILD – the uterine muscle becomes somewhat tense,
in hormones in the bod but can be indented with gentle pressure.
 Sometimes vaginal tears can indicate the discomfort b. MODERATE – the uterus becomes moderately firm
is more intense and things are progressing and a firmer pressure is needed to indent it.
c. STRONG – the uterus becomes so firm that it has the
fee of the wood like hardness, and at the height of the
ONE DEFINITE SIGN: contraction, the uterus cannot be indented when
The only way to know for sure if you’re in true labor is pressure is applied by the examiner’s finger.
to be evaluated by a professional, as true labor is when
contractions cause cervical change.
UTERINE CHANGES
 As labor contraction progresses, the uterus is
WHEN TO CALL YOUR PROVIDER gradually differentiated into two distinct portions.
 If you’re leaking fluid or think you might be These are distinguished by a ridge formed in the
 If you notice decreased fetal movement inner uterine surface, the physiologic ring.
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

DILATATION OCCURS FOR TWO

REASONS :
1. Uterine contractions gradually increase the diameter
Stage of Labor Primi Multi of the cervical canal lumen by pulling the cervix up over
the presenting part of the fetus.
First stage 12 ½ hours 7 hours and 20 2. The fluid-filled membranes press against the cervix.
minutes
Second stage Minutes 30 minutes SHOW
- due to pressure of the descending presenting part of the
Third stage 10 minutes 10 minutes
fetus which causes rupture of minute capillaries in the
mucus membrane of the cervix. Blood mixes with
Total 14 hours 8 hours
mucus when the operculum is released. Show, therefore,
is only a pinkish vaginal discharge.
PHYSIOLOGICAL RETRACTION RING
 is formed at the boundary of the upper and lower
uterine segments. In difficult labor when the fetus is
larger than the birth canal, the round ligaments of RUPTURE OF THE MEMBRANES
the uterus becomes tense during dilatation and 6. – this is the sudden gush or a scanty slow seeping of
expulsion, causing an abdominal indentation called amniotic fluid from the vagina. It is important to
 BANDL’S PATHOLOGICAL remember that once membranes (BOW) have ruptured:
RETRACTION RING, a danger sign of labor  Labor is inevitable. It will occur within 24 hours.
signifying impending rupture of the uterus if the  The integrity of the uterus has been destroyed.
obstruction is not relieved. Infection, therefore, can easily set in. That is why
once membranes have ruptured:
- Aseptic techniques should be observed in all
TWO DISTINCT PORTION OF THE procedures.
UTERUS:
a. UPPER UTERINE SEGMENT – this portion - Doctors do less obstetric manipulation (e.g., IE).
becomes thicker and active, preparing it to exert the - Enema is no longer ordered.
strength necessary to expel the fetus during the - Temperature should be taken regularly so that fever, a
expulsion phase. sign of infection, can be detected.
b. LOWER UTERINE SEGMENT – this portion Umbilical cord compression and/or cord prolapsed can
becomes thin walled, supple, and passive so that the occur (especially in breech presentation.) nursing action
fetus can pushed out of the uterus easily. depends on the specific situation.
- A woman in labor seeking admission to the hospital
CONTOUR OF THE UTERUS CHANGES and saying that her BOW has ruptured should be put to
 – from a round ovoid to a structure markedly bed immediately, and the fetal heart tones taken
elongated in a vertical diameter than horizontally. consequently.
This serves to straighten the body of the fetus and - If a woman in the Labor Room says that her
place it in better alignment to the cervix and pelvis. membranes have ruptured, the initial nursing action is to
take the fetal heart tones.
CERVICAL CHANGES - If a woman in labor says that’s he feels a loop of the
a. EFFACEMENT – shortening and thinning of the cord coming out of the vagina (umbilical cord prolapse),
cervical canal to paper-thin edges as distinct from the the first nursing action is to put her on Trendelenburg
uterus. In primiparas, effacement is accomplished before position (lower the head of the client) in order to reduce
dilatation begins while with multiparas, dilatation may pressure on the cord. (Remember: only 5 minutes of
proceed before effacement is completes. It is expressed cord compression can already lead to irreversible brain
in percentage. damage or even death.) In addition, apply a warm saline
b. DILATATION – enlargement of the external saturated OS on the prolapsed cord to prevent drying of
cervical is up to 10 cm primarily as a result of uterine the cord.
contractions and secondarily as a result of pressure of
the presenting part and the BOW.  The color of the amniotic fluid should always be
noted.

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

 At term, this is clear, almost colorless and contains  Station 0: at the level of the ischial spines;
specks of vernix caseosa. synonymous to engagement
 Green staining means it has been contaminated with  Station -1: presenting part above the level of the
meconium, a sign of fetal distress ischial spines
 Yellow staining may mean blood incompatibility.  Station +1: presenting part below the level of the
 Pink staining may indicate bleeding ischial spines.
 If labor does not occur spontaneously at the end of  Station +3 or +4: synonymous to crowning
24 hrs after membrane ruptures, labor will be (encircling of the largest diameter of the fetal head
induced, provided the woman is estimated to be by the vulvar ring.)
term.
PRESENTATION
STAGES OF LABOR – relationship of the long axis of the mother to the long
FIRST STAGE (STAGE OF DILATATION ) – axis of the fetus; also known as lie. Presenting part is the
begins with true labor pains and ends with complete fetal part which enters the pelvis first and covers the
dilatation of the cervix. internal cervical os.
PHASES:
VERTICAL
LATENT
1. – early time in labor A. CEPHALIC
 Cervical dilatation is minimal because effacement  Vertex: head is sharply flexed, making the parietal
is occurring. bones the presenting parts.
 Cervix dilates only 3-4 cm. In poor flexion:
 Contractions are of short duration and occur  Face
regularly 5-10 minutes apart (the best time for the  Brow
pregnant woman to seek admission to the hospital.)  Chin
 Mother is excited but has some degree of
apprehension and still has the ability to
communicate. B. BREECH
Breech: buttocks are the presenting parts
ACTIVE/ACCELERATED - complete: thighs is flexed on the abdomen and legs are
 Cervical dilatation reaches 4-8 cm. on the thighs.
 Rapid increase in duration, frequency and intensity - Frank: thighs are flexed and legs are extended, resting
of contractions. on the anterior surface of the body.
 Mother fears of losing control of herself.
C. FOOTING
NURSING CARE - Single: one leg unflexed and extended;one foot
1. HOSPITAL ADMISSION – provide privacy and presenting
reassurance from the very start. - Double: legs unflexed and extended; both feet are
2. PERSONAL DATA – name, age, address, civil presenting
status
3. OBSTETRICAL DATA – determine the EDC; HORIZONTAL
obstetrical score (gravida, para, TPAL); amount a. Transverse lie
and character of show; and whether or not b. Shoulder presentation
membrane have ruptured.
4. GENERAL PHYSICAL EXAMINATION, IMPORTANT CONSIDERATIONS:
internal exam and Leopold’s maneuvers are done to a. in vertex and breech presentations, fetal heart sounds
determine: Effacement and dilatation (FHS) are best heard at the area of the fetal back; in face
presentations FHS are at the area of the fetal chest.
b. in vertex presentations, FHS are usually located in
STATION either the left or right lower quadrant (LLQ or RLQ); in
- relationship of the fetal presenting part to the level of breech presentation, at or above the level of the
the ischial spines. umbilicus, either left or right upper quadrant (LUQ or
RUQ).
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

C. FACE
Hazards of breech deliver:
- cord compression - LMA (left mentoanterior)
- Abruption placenta - LMP (left mentoposterior)
- Erb-duchenne paralysis - LMT (left metrotransverse)
- RMA (right mentoanterior)
Erb'spalsy or Erb–Duchennepalsy is a paralysis of the - RMP (right monteposterior)
arm caused by injury to the upper trunk C5–C6 nerves. - RMT (right mentotransverse)
They form part of the brachial plexus, comprising the D. SHOULDER
ventral rami of spinal nerves C5–C8 and
thoracic nerve T1. These injuries arise most commonly - LADA (left acromiodorsoanterior)
from shoulder dystocia during a difficult birth. - LADP (left acromiodorsoposterior)
- RADA (right acromiodorsoanterior)
Horizontal lie is very rare (1%) and maybe due to a - RADP (right acromiodorsoposterior)
relaxed abdominal wall because of multiparity, pelvic
contraction or placenta previa. MONITORING AND EVALUATING
POSITION IMPORTANT ASPECTS
– relationship of the fetal presenting part to a specific In assessing uterine contractions, fingers should be
quadrant I the mother’s pelvis. spared lightly over the fundus
 Posterior positions result in more backaches 1. Duration – from the beginning of one contraction to
because of pressure of the fetal presenting part on the end of the same contraction (A an B)
the maternal sacrum  Duration during early labor : 20-30 seconds
 Duration late in labor : 60 to 70 seconds (should
1. THE PELVIS IS DIVIDED INTO FOUR never be longer)
QUADRANTS: 2. INTERVAL – from the end of one contraction to the
a. Right anterior beginning of the next contraction ( B to C).
b. Left anterior Interval early in labor : 40 – 45 minutes
c. Right posterior Interval late in labor : 2- 3 minutes
d. Left posterior 3. FREQUENCY – from the beginning of one
contraction to the beginning of the next contraction (A
2. POINTS OF DIRECTION IN THE FETUS: to C). Observe 3-4 contractions to have a good picture of
a. occiput – in vertex presentation the frequency of contractions.
b. chin (mentum) – in face presentations 4. INTENSITY – the strength of a contraction; maybe
c. sacrum – in breech presentations mild, moderate or strong. Intensity is measured by the
d. scapula (acromio) – in horizontal presentations. consistency of the fundus at the acme of the contraction.
When estimating the intensity, check fundus at the end
3. POSSIBLE FETAL POSITIONS of contraction to determine whether it relaxes.
______________ ______________
A. VERTEX A B C D
- LOA (left occipitoanterior (most common and
favorable position at birth) BLOOD PRESSURE – should not be taken during a
- LOP (left occipitoposterior) contraction as it tends to increase. Because no blood
- LOT (left occipitotransverse) supply goes to the placenta during a contraction, all of
- ROA (right occipitoanterior) the blood is in the periphery that is why there is
- ROP (right occipitoposterior increased BP during uterine contractions.
- ROT (right occipitotransverse) 1. BP reading should be taken at least every half hour
during active labor.
B. BREECH 2. When a woman in labor complains of a headache, the
- LSA (left sacroanterior) first nursing action is to take the BP. If it is normal, it is
- LSP (left sacroposterior) only stress headache; if the BP is increased, refer
- LST (left sactrotransverse) immediately to the doctor (it could be a sign of toxemia)
- RSA (right sacroanterior)
- RSP (right sacroposterior) FETAL HEART RATE (FHR) – should not be
- RST (right sacrotransverse) mistaken
for uterine soufflé (synchronizes with maternal

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

pulse rate) - clamp rectal tube during a contraction

1. Normally 120 to 160 per minute. - important nursing action : check FHR after enema
2. Should not be taken during uterine contraction administration to determine after fetal distress.
because it tends to decrease the FHB.
Compression of the fetal head when the uterus contracts Contraindications to enema in labor
stimulates the vagal reflex which in turn, causes - Vaginal bleeding
bradycardia. - Premature labor
3. Should be taken every hour during the latent phase of - Abnormal fetal presentation or position
labor, every half hour during the active phase and every - Ruptured membranes
15 minutes during the transition period. - Crowning
4. For any abnormality in FHR, the initial nursing
action is to change the mother’s position. Encourage the mother to void every 2-3 hours by
5. Signs of fetal distress: offering the bedpan because
- Bradycardia (FHR less than 100/minute) or tachycardia - A full bladder retards fetal descent
(FHR more than 180/minute) - Urinary stasis can lead to urinary tract infection
- Meconium- stained amniotic fluid in non-breech - A full bladder can be traumatized during the delivery
presentation
- fetal thrashing (hyperactivity of the fetus as it struggles Perineal prep – done aseptically.
for more oxygen) - Use “no.7” method, always from front to back
.
Emotional support is provided for the woman in labor by Perineal shave – not a routine procedure;
keeping her constantly informed of the progress of labor. - maybe done to provide a clean area for delivery.
- muscles at the symphysis pubis area should be kept
HEALTH TEACHINGS taut and razor moved along the direction of hair growth.
 Bath – advisable if contractions are tolerable or not
too close to one another. Will make the mother feel
more comfortable. ENCOURAGE SIM’S POSITION BECAUSE IT:
 Ambulation – during the latent phase of labor - Favors anterior rotation of the fetal head
helps shorten the first stage of labor. But definitely - Promotes relaxation between contractions
not allowed anymore if membranes have ruptured. - Prevents continual pressure of the gravid uterus on the
 Solid or liquid foods are to be avoided because inferior vena cava (the blood vessel which
digestion is delayed during labor. A full stomach brings unoxygenated blood back to the heart.
interferes with proper bearing down. May vomit - Pressure results in supine hypotensive syndrome, also
and cause aspiration. called vena cava syndrome. Hypotension is due to the
 Enema – not a routine procedure reduced venous return resulting in decreased cardiac
output and therefore, a fall in arterial BP.
PURPOSES:
- A full bowel hinders the progress of labor. Woman in labor should not be allowed to
- effectiveness of enema in labor can be determined by - push or bear down unnecessarily during contractions of
evaluating change in uterine tone and the amount of the first stage because.
show. - It leads to unnecessary exhaustion.
- Expulsion of feces during second stage of labor - Repeated strong pounding of the fetus against the
predisposes mother and baby to infection pelvic floor will lead to cervical edema, thus interfering
- Full bowel predisposes to postpartum discomfort with dilatation and prolonging length of labor.

Procedure of enema administration Abdominal breathing is advised for contractions

- enema solution may either be soap suds or Fleet enema during the first stage in order to reduce tension and
(contraindicated in patients with toxemia because of its prevent hyperventilation.
sodium content.)
- optimum temperature of the solution – 105 degrees Administer analgesics as ordered. The dosage is based
Fahrenheit to 115 degrees Fahrenheit (40.5 degrees on the patient’s weight, status of labor and age of
Celsius – 46.1 degrees Celsius) gestation.
- patient on side- lying position - Narcotics are the most commonly used,
- when there is resistance while inserting rectal catheter, specifically, Demerol.
withdraw the tube slightly while letting a small amount
of solution enter
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

- Pharmacologic effect: depresses the sensory - Post spinal headaches may be due to leakage of
portion of the cerebral cortex. It is not only a potent anesthetic into the CSF or injection of air at time of
analgesics, it is also a sedative and an antispasmodic. needle insertion. Management: flat on bed for 12 hours
- It is not given early in labor because it can and increase fluid intake.
retard progress (is an antispasmodic), but cannot also be
given if deliver is only one hour away because it is not
given early in labor because it can retard progress (is an COMMON SIDE EFFECTS:
antispasmodic), but cannot also be given if deliver is Hypotension – because Xylocaine is a vasodilator.
only one hour away because it causes respiratory Management:
depression in the new born (that is why it can be given  turning side; prompt elevation of leg;
only if cervical dilatation is 6-8 cm.) administration of vasopressor and oxygen, as
- Given 25-100 mg., depending on body weight. ordered.)
- Takes effect in 20 minutes – patient - Fetal bradycardia
experiences a sense of well – being and euphoria. - Decreased maternal respirations
- Narcotic antagonists (e.g., Narcan, Nalline) are given
to counteract any toxic effects of Demerol. A sure sign that the baby is about to be born is the
- Assist in administration of regional anesthesia bulging of the perineum. In general, Primigravidas
– preferred over any other form of anesthesia because : are transported from the labor Room to the Delivery
 it does not enter maternal circulation and so does Room when the cervix is fully dilated or when there is
not affect the fetus. bulging of the perineum.
 Patient is completely awake and aware of what is Multiparas, on the other hand, are transported when
happening. Does not depress uterine tone, thus cervical dilatations are 7-9 cm.
optimal uterine contraction is achieved.
Transition Period – when the mood of the woman
- Xylocaine is the anesthetic of choice suddenly changes and the nature of the contractions
- Patient on NPO with IV to prevent dehydration, intensify.
exhaustion and aspiration because glucose aids in proper
functioning of the fetus. CHARACTERISTICS
 If membranes are still intact, this period is marked
by a sudden gush of amniotic fluid as fetus is
TYPES OF ANESTHESIA pushed into the birth canal. If spontaneous rupture
a. Paracervical – transvaginal injection into either side does not occur, amniotomy (snipping of BOW with
of the cervix. Patient on lithotomy position. Coupled a sterile pointed instrument, e.g, Kelly or Allis
with a local anesthetic results in “painless childbirth” forceps or amniohook to allow amniotic fluid to
(uterine contractions are not felt by mother.) drain) is done to prevent fetus from aspirating the
b. Pudendal – through the sacrospinous ligament into amniotic fluid as it makes its different fetal position
the posterior areolar tissues to reduce perception of pain changes.
during second stage and make patient comfortable.  Amniotomy, however, cannot be done if station is
Patient on lithotomy. Side effect: an ecchymotic still “minus” , as this can lead to cord compression.
(purplish discoloration of the skin due to blood in  There is an uncontrollable urge to push with
subcutaneous tissues) area of hematoma in the perineum contractions, a sign of impending second stage of
may be an aftermath. No special treatment is needed: ice labor. Profuse perspiration and distention of neck
bag applied to the area on the first day may reduce the veins are seen.
swelling.  Nausea and vomiting is a reflex reaction due to a
c. Low spinal decreased gastric motility and absorption.
- Epidural – injection of local anesthetic at the lumbar  In primis, baby is delivered within 20 contractions
level outside the dura mater. (40 minutes); in multis, after 10 contractions (20
- Saddle block – injection into the 5th lumbar space, minutes)
causing anesthesia in the parts of the body that come in
contact with a saddle (perineum, upper thighs and lower
pelvis.) blocks nerves that transmit pain of first stage of NURSING ACTIONS ARE PRIMARILY
labor. In sitting or side- lying position, with back flexed. COMFORT MEASURES:
 Sacral pressure (applying pressure with the heel of
- Forceps are generally needed in delivery of patient the hand on the sacrum) – relieves discomfort from
under anesthesia because of loss of coordination in contractions.
second –stage pushing.
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

 Proper bearing down techniques m- push with

contractions.
 Controlled chest (costal) breathing during TYPES OF EPISIOTOMY:
contractions. a. Median – from middle portion of the lower vaginal
 Emotional support border directed towards the anus.
b. Mediolateral – begun in the midline but directed
3. SECOND STAGE (STAGE EXPULSION ) – laterally away from the anus. Often done because it
begins with complete dilatation of the cervix and ends prevents 4th degree laceration should it occur despite
with the delivery of the baby. episiotomy. Natural anesthesia is used in episiotomy,
a. POWERS/FORCES: involuntary uterine i.e.; no anesthetic is injected because pressure of fetal
contractions and contractions of the diaphragmatic and presenting part against the perenium is so intense that
abdominal muscles nerve endings for pain are momentarily deadened.
MECHANISM OF LABOR/FETAL D. APPLY THE MODIFIED RITGEN’S
POSITION CHANGES (D FIRE ERE) MANEUVER.
 Descent – may be preceded by engagement. 1. Cover the anus with a sterile towel and exert upward
 Flexion – as decent occurs, pressure from the and forward pressure on the fetal chin, while exerting
pelvic floor causes chin to bend forward onto gentle pressure with two fingers on the head to control
the chest. emerging head. This will not only support the perineum,
 Internal Rotation – from AP to transverse, then thus preventing lacerations, but will also favor flexion so
AP to AP. that the smallest suboccipitobregmatic diameter of the
 Extension – as the head comes out, the back of fetal head is presented.
the neck stops beneath the public arch. The 2. Ease the head out and immediately wipe the nose and
head extends and the forehead, nose, mouth mouth of secretions to establish a patent airway
and chin appear. (remember: the first and most important principle in the
 External Rotation (also called restitution) – care of the newborn is established and maintains a patent
Anterior shoulder rotates externally to the AP airway.) The head should be delivered in between
position. contractions.
 Expulsion – delivery of the rest of the body. 3. Insert 2 fingers into the vagina so as to feel for the
presence of a cord looped around the neck (nuchal cord).
C. NURSING CARE: If so, but loose, slip it down the shoulders or up over the
 When positioning legs on lithotomy, put them up at head; but if tight, clamp the cord twice, an inch apart,
the same time to prevent injury to the uterine and then cut I between.
ligaments. 4. As the head rotates, deliver the anterior shoulder by
 As soon as the fetal head crowns, instruct the exerting a gentle downward push and the slowly give an
mother not to push, but to pant (rapid and shallow upward lift to deliver the posterior shoulder.
breathing to prevent rapid expulsion of the baby). If 5. While supporting the head and the neck, deliver the
panting is deep and rapid, called hyperventilation, rest of the body. Take note of the time of the delivery of
the patient will experience lightheadedness and the baby.
tingling sensation of the fingers leading to 6. Immediately after the delivery, the newborn should be
carpopedal spasms because of respiratory alkalosis. held below the level of the mother’s vulva for a few
 Management: let the patient breathe into a brown minutes to encourage flow of the blood from the
paper bag to recover lost carbon dioxide; a cupped placenta to the baby.
hand over the mouth and nose will serve the same 7. The infant is held with his head in a dependent
purpose. position (head lower than the rest of the body) to allow
 Assist in episiotomy (incision made in the perineum for drainage of secretions. (Remember: Never stimulate
primarily to prevent lacerations) a baby to cry unless you have drained him out of his
secretions.)
8. Wrap the baby in a sterile towel to keep him warm.
OTHER PURPOSES: (Remember: Chilling increases the body’s need for
 a. prevent prolonged and severe stretching of oxygen.)
muscles supporting the bladder or rectum. 9. Put the baby on the mother’s abdomen. The weight of
 b. reduce duration of second stage when there the baby will help contract the uterus.
is hypertension or fetal distress. 10. Cutting of the cord is postponed until the pulsations
 c. enlarge outlet, as in breech presentation or have stopped because it is believed that 50-100 ml of
forceps delivery. blood is flowing from the placenta to the baby at this
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

time. After cord pulsations have stopped, clamp it twice, contractions, thus prevent hemorrhage. Note: oxytocins
an inch apart and then cut in between. are not given before placental delivery.
11. Show the baby to the mother, inform her of the sex 8. Inspect the perineum for lacerations. Any time the
and time of the delivery then give the baby to the uterus is firm following placental delivery, yet bright
circulating nurse. red vaginal bleeding is gushing forth from the vaginal
opening, suspect lacerations (tend to heal more slowly
4. Third stage (placental stage) – begins with the because of ragged edges)
delivery of the baby and ends with the delivery of the
placenta.
a. Signs of Placental separation: CATEGORIES OF LACERATIONS:
 Uterus becoming round and firming again, 1. First degree – involves the vaginal mucous
rising high to the level of the umbilicus membranes and perineal skin.
(Calkin’s sign) – in the earliest sign of 2. Second degree – involves not only the muscles,
placental separation vaginal mucous membranes and skin, but also the
 Sudden gush of blood from the vagina muscles.
 Lengthening of the cord 3. Third degree – involves not only the vaginal mucous
membranes and skin, but also the external sphincter of
B. TYPES OF PLACENTAL DELIVERY: the rectum.
Schultz – if placenta separates first at its center and then 4. Fourth Degree – involves not only the external
at its edges, it tends to fold on itself like an umbrella and sphincter of the rectum, the muscles, vaginal mucous
presents the fetal surface which is shiny (“Shiny” for membranes and skin, but also the mucous membranes of
Schultz); 80% of placentas separate in this manner. the rectum.
Duncan – if placenta separates firsts at its edges, it a. Assist the doctor in doing episiorrhaphy (repair of
slides along the uterine surface and presents with the episiotomy or lacerations). In vaginal episiorrhaphy,
maternal surface which is raw, red, beefy, irregular and packing is done to maintain pressure on the suture line,
“dirty” (“Dirty” for Duncan). Only about 20% of thus prevent further bleeding. Note: vaginal packs have
placentas separate this way. to be removed after 24-48 hours.
b. Make mother comfortable by perineal care and
applying clean sanitary napkin snugly to prevent its
[Link] CARE moving forward from the anus to the vaginal opening.
1. Do not hurry the expulsion of the placenta by Soiled napkins should be removed from front to back.
forcefully pulling out the cord or doing vigorous fundal c. Position the newly-delivered mother flat on bed
push as this can cause uterine inversion. Just watch for without pillows to prevent dizziness due to decrease in
the signs of placental separation. intra-abdominal pressure.
2. Tract the cord slowly, winding it around the clamp d. The newly-delivered mother may suddenly complain
until the placenta spontaneously comes out, slowly of chills due to decreased blood pressure, fatigue or cold
rotating it so that no membranes are left inside the temperature in the delivery room.
uterus, a method called Brandt-Andrews maneuver. Management:
3. Take note of the time of placental delivery. It should a. Provide additional blankets to keep her warm.
be delivered within 20 minutes after the delivery of the b. May give initial nourishment, e.g., milk, coffee, or
baby. Otherwise, refer immediately to the doctor as this tea.
can cause severe bleeding in the mother. c. Allow patient to sleep in order to regain lost energy.
4. Take note of the time of placental delivery. It should
be delivered within 20 minutes after the delivery of the 5. Fourth Stage (Stage of Recovery) – first 1-2 hours
baby. Otherwise, refer immediately to the doctor as this after delivery which is said to be the most critical stage
can cause severe bleeding in the mother. for the mother because of unstable vital signs.
5. Inspect for completeness of cotyledons; any placental
fragment retained can also cause severe bleeding and A. ASSESSMENT
possible death.  Fundus – should be checked every 15 minutes for
6. Palpate the uterus to determine degree of contraction. 1 hour then every 30 minutes for the next 4 hours.
If relaxed boggy or non-contracted, first nursing action Fundus should be firm, in the midline, and during
is to massage gently and properly. An ice cap over the the first 12 hours postpartum, is a little above the
abdomen will also help contract the uterus since cold umbilicus. First nursing action for a non-contracted
causes vasoconstriction. uterus: massage.
7. Inject oxytocin (Methergin = 0.2mg/ml or  Bladder – a full bladder is evidenced by a fundus
Syntocinon = 100/ml) IM to maintain uterine which is to the right of the midline and dark-red
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

bleeding with some clots. Will prevent adequate delivered patient for the first time, the nurse should
uterine contraction. hold on to the patient’s arm.
 Perineum – is normally tender, discolored and
edematous. It should be clean, with intact sutures.
 Blood pressure and pulse rate may be slightly RECOMMENDED EXERCISES:
increased from excitement and effort of delivery,  Kegel and abdominal breathing on post-partum day
but normalize within one hour. one (PPD 1)
 Chin-to-chest on PPD2 to tighten and form up
b. Lactation – suppressing the agents – estrogen – abdominal muscles.
androgen preparations given within the first hours  Knee-to-abdomen when perineum has healed, to
postpartum to prevent breast milk production in mothers strengthen abdominal and gluteal muscles.
who will not (or cannot) breastfeed, e.g.,
diethylstilbestrol, TACE#, Parlodel or deladumone. c. Massage is contraindicated
These drugs tend to increase uterine bleeding and retard All blood values are back to prenatal levels by the 3rd
menstrual return. or 4th week postpartum.

c. Rooming-in concept – mother and baby are together

while in the hospital. The concept of a family, therefore, [Link] CHANGES
is felt from the very beginning because parents have the  Uterine involution is assessed by measuring the
baby with them, thus providing opportunities for fundus by fingerbreadth (= 1 cm.)on PPD1, fundus
developing a positive relationship between parents and is 1 fingerbreadth below the umbilicus; on PPD2, 2
newborn (maternal-infant bonding). Eye-to- eye contact fingerbreadths below and so forth until on PPD10,
is immediately established, releasing the maternal it can no longer be palpated because it is already
caretaking responses behind the symphysis pubis. Subinvoluted uterus is
a uterus larger than normal and vaginal bleeding
with clots. Since blood clots are good media for
PUERPERIUM bacteria; it is, therefore, a sign of puerperal sepsis.
A. DEFINITION OF TERMS  To encourage the return of the uterus to its usual
Puerperium/Post-partum – refers to the six-week anteflexed position, the prone and knee chest
period after delivery of the baby. positions are advised.
Involution – return of the reproductive organs to their  Afterpains/ afterbirth pains – strong uterine
prepregnant state. contractions felt more particularly by multis, those
who delivered large babies or twins and those who
breastfeed. It is normal and rarely lasts for more
B. PRINCIPLES OF POST-PARTUM CARE than 3 days.
Promote healing and return to normal (involution) of the
different parts of the body. MANAGEMENT:
1. Vascular Changes  Never apply heat on the abdomen.
 The 30%-50% increase in total cardiac volume  Give analgesics as ordered.
during pregnancy will be absorbed into the general
circulation within 5-10 minutes after placental Lochia – uterine discharge consisting of blood, decidua,
delivery. Implication: the first 5-10 minutes after WBC, mucus and some bacteria.
placental delivery is crucial to gravidocardiacs 1. Pattern: R-S-A (rubra-serosa-alba)
because the weak heart may not be able to handle  Rubra – first 3 days postpartum; red and moderate
such workload. in amount.
 Serosa –next 4-9 days; pink or brownish and
a. White blood cell (WBC) count increases to 20,000- decreased in amount
30,000/mm3. Implication: the WBC count, therefore,  Alba – from 10th day up to 3-6 weeks postpartum;
cannot be used as an indication or sign of postpartum colorless and minimal in amount
infection.
b. There is extensive activation of the clotting factors, 2. CHARACTERISTICS:
which encourages thromboembolization.  Pattern should not reverse.
 It should approximate menstrual flow. However, it
This is the reason why: increases with activity and decreases with
1. Ambulation is done early 4-8 hours after normal breastfeeding.
vaginal delivery. When ambulating, the newly-
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

 It should not have any offensive odor. It has the  If these measures fail, catheterization, done gently
same fleshy odor as menstrual blood. If it is foul- and aseptically, is the last resort on doctor’s order.
smelling, it may mean either poor hygiene or (if there is resistance to the catheter when it reaches
infection. the internal sphincter, ask patient to breathe through
 It should not contain large clots. the mouth while rotating the catheter before moving
 It should not be absent, regardless of method of it inward again.)
delivery. Lochia has the same pattern and amount,
whether CS or normal vaginal delivery.
 Pain in perineal region may be relieved by: Sim’s GASTROINTESTINAL CHANGES
position – minimizes strain on the suture line. – delayed bowel evacuation postpartally may be due to:
 Perineal o heat lamp or warm Sitz baths twice a day  Decreased muscle tone
– vasodilation increases blood supply and,  Lack of food + enema during labor
therefore, promote healing.  Dehydration
 Application of topical analgesics or administration  Fear of pain from perineal tenderness due to
of mild oral analgesics as ordered episiotomy, lacerations or hemorrhoids.
 Sexual activity – ideally sexual activity resumes at
6 weeks postpartum but it may be resumed by the 5. Vital signs
3rd or 4th week postpartum if bleeding has stopped  Temperature may increase because of the
and episiorrhaphy has healed. Decreased dehydrating effects of labor. Implication: any
physiologic reactions to sexual stimulation are increase in body temperature during the first 24
expected for the first 3 months postpartum because hours postpartum is not necessarily sign of
of hormonal changes and emotional factors postpartum infection.
 Menstruation – if not breastfeeding, return of  Bradycardia (heart rate of 50-70 per minute) is
menstrual flow is expected within 8 weeks after common for 6-8 days postpartum.
delivery. If breastfeeding, menstrual return is  There is no change in the respiratory rate.
expected after 3-4 months; in some women, no
menstruation occurs during the entire lactation 6. Weight – there is an immediate weight loss o 10-20
period.(Important: Amenorrhea during lactation is pounds representing the weights of the fetus, placenta,
no guarantee that the woman will not become amniotic fluid and blood. Further weight loss will occur
pregnant. She may be ovulating; the absence of during the next days due to diaphoresis.
menstruation may be her body’s way of conserving Provide emotional support – the psychological phases
fluids for lactation. Implication: she should be during the postpartum period are:
protected against a subsequent pregnancy by a. Taking-in phase
observing a method of contraception, except the - First 1-2 days postpartum when mother is passive and
pill.) relieves on others to care for her and her newborn.
 Postpartum Check-Up – should be done after the - She keeps on verbalizing her feelings regarding the
6th week postpartum to assess involution recent delivery for her to be able to integrate the
experience into herself.
3. URINARY CHANGES b. Taking-hold Phase
There is marked diuresis within 12 hours postpartum to - begins to initiate action and make decisions.
eliminate excess tissue fluid accumulation during - Postpartum blues (an overwhelming feeling of sadness
pregnancy. that cannot be accounted for) may be observed. Blues
Some newly-delivered mothers may complain of could be due to hormonal changes, fatigue or feelings of
frequent urination in small amounts; explain that this is inadequacy in taking care of a new baby.
due to urinary retention with overflow. Others, on the
MANAGEMENT
other hand, may have difficulty voiding because of
decreased abdominal pressure or trauma to the trigone of explain that it is normal. Crying is a therapeutic, in fact.
the bladder. c. Letting-Go Phase
 The mother redefines her new role.
Voiding may be initiated by:  Gives up the fantasized image of her child and
 Pouring warm and cold water alternately over the accepts the real one.
vulva; Prevent postpartum complications:
 Encouraging the client to go to the comfort room; - Hemorrhage
or - Infection
 Let her listen to the sound of running water.  Establish successful lactation.

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

7. Implications of the physiology of breastmilk  Effectiveness is ensured when the:

production.  baby’s mouth parts “hike will up” into the
 Regardless of the mother’s physical condition, areola
method of delivery, or breast size/condition, milk  mother feels afterpains as the baby sucks
will be produced.  other nipple flows with milk while baby is
 Lactation does not occur during pregnancy because feeding on other breasts.
estrogen and progesterone are present and therefore - To prevent nipple from becoming sore and cracked,
inhibit prolactin production. infant should be introduced to the breast gradually. The
 Lactation-suppressing agents are to be given baby should be fed for only 5 minutes at each breast
immediately after placental delivery to be effective. during each feeding on the first day, increasing the time
 Oral contraceptives are contraindicated in lactating at each breast by 1 minute per day until the infant is
mothers decreasing milk supply. nursing for 10 minutes at each breast, making a total
 Afterpains are felt more by breastfeeding women feeding time of twenty minutes per feeding.
because oxytocin production; they also have less - For continuous milk production, at each feeding, the
lochia and experience more rapid involution. infant should be placed first on the breasts he fed on last
during the previous feeding. This ensures that each
breast will be completely emptied at every other feeding.
IN AN EMERGENCY DELIVERY: If breasts are completely emptied, they will only half-
 Determine the EDC, whether the woman in labor is refill and after some time, they will become insufficient.
a primi or a multi, as well as the stage of labor she - To break away from the closed suction at the breast
is in. after feeding, insert a clean little finger in the corner of
 If no sterile equipment is available to cut the cord, the infant’s mouth to release the suction, then pull the
wrap the baby and placenta together; never cut the chin down. This also helps prevent sore nipples
cord unless sterile equipment is/are available. - Feed as often as the bay is hungry, especially during
 If the uterus fails to contract after delivery, put the the first few days, because he is receiving colostrum
oxytocin which causes uterine contraction which is not very fulfilling; however, it contains gamma
globulin (antibodies), the only group of substances that
Advantages of breastfeeding for the mother: can never be replicated by any artificial formula.
 economical in terms of time, money and effort - Advise the mother to learn how to relax during
 more rapid involution feedings because tension prevents good let-down.
 lower incidence of cancer of the breasts, according
to some studies. ASSOCIATED PROBLEMS
Advantages of breastfeeding for the baby: a. Engorgement
- closer mother-infant relationship  Feeling of tension in the breasts during the third
- contains antibodies that protect against common postpartum day sometimes accompanied by an
illnesses increase in temperature (milk fever)
- less incidence of gastrointestinal diseases.  The breasts become full, feel tense and hot, with
- always available at the right temperature throbbing pain.
 It lasts for about 24 hours and is due to increased
HEALTH TEACHINGS lymphatic and nervous circulation.
1. Hygiene
- Wash breasts daily at bath or shower time MANAGEMENT:
- Soap or alcohol should never be used on the breasts as  Advise the use of firm-fitting brassiere for good
they tend to dry and crack nipples and cause sore support. It will not only decrease the discomfort
nipples. Wash hands before and after every feeding. from the breast engorgement but will also prevent
- Insert clean OS squares or piece of cloth in the contamination of the nipples and areolae.
brassiere top absorb moisture when there is considerable  Cold compress is applied if the mother does not
breast discharge. intend to breastfeed; warm compress is applied if
2. Method she will breastfeed.
- Side-lying position with a pillow under the mother’s  Breast pump should not be used and breast massage
head while holding the bulk of breasts tissues away from should not be done if the mother is not going to
the infant’s nose. breastfeed, since either will stimulate milk
- Stimulate the baby to open his mouth to grasp the production.
nipples by means of the rooting reflex.
- Infant should grasp not only the nipple but also the b. Sore nipples - not contraindications to breastfeeding.
areola for effective sucking motion. Management:
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES
 LESSON: 4 PREGNANCY AND PRENATAL CARE

 Expose nipples to air by leaving bra unsnapped for TYPES:

10-15 minutes after feeding.
 When normal air drying is not effective, exposure Combined – estrogen and progesterone ion the same
to a 20-watt bulb placed 12-18 inches away will dosage each day for 20 days, starting on the 5th day of
cause vasodilation and therefore promote healing. the menstrual cycle, after which it is discontinued and
 Do not use plastic liners that are found in some then resumed on the 5th day of the next menstrual cycle.
nursing bras because they prevent air from Sequential - estrogen alone for 15 days, then estrogen
circulating around the breasts. and progesterone for the next 5 days.
 Use a nipple shield. Mini- pill – taken continuously.
SIDE EFFECTS
c. Mastitis – inflammation of the breasts; Symptoms
include: :same complaints of pregnant women because of
 Localized pain; swelling and redness in breasts estrogen and progesterone
tissues  Nausea and vomiting
 Lumps in the breasts  Headache and weight gain – due to fluid retention
 Milk becomes scanty because of progesterone.
 Breasts tenderness
 Dizziness
MANAGEMENT:  Breakthrough bleeding/spotting between periods.
 Antibiotics as ordered  Chloasma
 Ice compress  Contraindications:
 Proper breast support  Breastfeeding
 Discontinue breastfeeding in affected breast.
CONTRAINDICATIONS:
4. Nutrition – lactating mothers should take 3000
calories daily and should have larger amounts of  Breastfeeding
proteins (96 Gms per day), calcium, iron, Vitamins A, B  Certain diseases
and C. non-breastfeeding women can have the same  Thromboembolism –because there is increased
requirements as in pregnant tendency towards clotting in the presence of
estrogen
 Diabetes mellitus and liver disease because
CONTRAINDICATIONS estrogen tends to interfere with carbohydrate
 Drugs – oral contraceptives, atropine, metabolism
anticoagulants, antimetabolites, cathartics,  Migraine, epilepsy; varicosities
tetracyclines. (Insulin, epinephrine, most  Cancer; renal disease; recent hepatitis
antibiotics, antidiarrheals and antihistamines are  Women who smoke more than 2 packs of cigarettes
generally not contraindicated. Therefore, diabetics per day
and those with asthma can breastfeed.)  Strong family history of heart attack
 Certain disease conditions specifically tuberculosis,  Should the woman forget to take the pill on the
because of the close contact between mother and scheduled time, she should take one as soon as she
baby during feeding. (However, mothers may use remembers and take the next pill on its regular
masks to prevent droplet spread.) TB germs, taking time. If she still fails to do so, withdrawal
however, are not transmitted thru breast milk. bleeding will occur because of the sudden decrease
in hormonal levels.
6. Motivate the use of family planning program depends
to a large extent on the motivation of both husband and B. MECHANICAL METHODS
wife.
Intrauterine device (IUD)
ARTIFICIAL METHODS  Specific action: prevents implantation by setting up
a non-specific cell inflammatory reaction to the
PHYSIOLOGIC METHOD: device.
 Oral Contraceptive pill  Inserted during menstruation to ensure that the
Action: Suppresses the pituitary gland, thus inhibiting woman is not pregnant; septic abortion can result if
ovulation. she is pregnant.
 Side effects:
1. Increased menstrual flow

BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES

 LESSON: 4 PREGNANCY AND PRENATAL CARE

2. Spotting or uterine cramps during the first 2 weeks  Specific action: the couple abstains on days that the
after insertion. woman is fertile.
3. Increased risk of infection
4. When pregnancy occurs with the IUD in place, it PROCEDURE:
needs not be removed since it stays outside the - The woman charts her menstrual cycles for 12
membranes and, therefore, will not in any way harm the continuous months in order to determine the shortest and
fetus. the longest cycles.
- The first fertile day is determine by subtracting “ 18”
from the shortest menstrual cycle, and “11” from the
DIAPHRAGM longest menstrual cycle, e.g., if a woman’s shortest
 Specific action: A circular rubber disc that fits over menstrual cycle is 26 days and her longest is 32 days,
the cervix and forms a barrier against the entrance her fertile period would be the 8th to the 21st day of her
of sperms. cycle.
 Initially inserted by the doctor who determines the
depth of the vagina
 May be coated with spermicide jelly or cream for RHYTHM/CALENDAR/OGINO-KNAUSE
double protection –A woman can discern her fertile and infertile days
 May be washed with soap and water after use; is based on her sensory and visual observations of the
reusable cervical mucus (when it becomes thin and watery –
 Sperms remain viable in the vagina for 6 hours, so spinnbarkheit). Intercourse is avoided 4 days prior to
the device should be kept in place during such time, and 3 days after the spinnbarkheit.
but should not stay for more than 24 hours because
stasis of semen can lead to infection. BILLINGS METHOD/CERVICAL MUCUS
when cervical discharges are thin and watery, couple
CONDOM resumes sexual intercourse 3-4 days after.
 Specific action: sperms are deposited at the tip of Therefore, she should not have sexual intercourse during
the rubber sheath, which has been placed on an these days.
erect penis prior to coitus. Has the added potential 26 32
of lessening the chance of contracting sexually- - 18 - 11
transmitted diseases (STDs, esp. AIDS) 8 21
 Most common complaint of users: it interrupts the
sexual act to apply.
SYMPTOTHERMAL METHOD/BASAL BODY
TEMPERATURE (BBT)
CHEMICAL METHODS:
– involves daily observation of the temperature of the
spermicidals (kill sperms) in the form of jellies, creams, woman at rest, free from any factor that may cause it to
foaming tablet and suppositories. fluctuate (immediately upon waking up, before brushing
teeth, drinking, etc.) only 3-4 days after the temperature
SURGICAL METHODS:
drops slightly and then increases (which means
 Tubal ligation – the fallopian tubes are ligated in ovulation has taken place), can sexual intercourse be
order to prevent passage of sperms. Menstruation resumed. Fertile and infertile days are determined after
and ovulation continue. having established an accurate record of the six
 Vasectomy – small incision made into each side of immediately preceding menstrual cycles then watching
the scrotum and the vas deferens is cut and tied, out for BBT fluctuations.
blocking the passage of sperms. Sperm production
continues, only passage into the exterior is
prevented. (Sperms in the vas deferens at the time SOCIAL METHODS
of surgery remain viable for a long as 6 months. - Abstinence
Implication: couple should still observe a form of - Withdrawal/coitus interruptus
contraception during this time to ensure protection
against subsequent pregnancy).

NATURAL
Biological method: Rhythm/Calendar/Ogino-Knause
Formula
BY: LURIZ, RAIZA R. |BSN- 2D| MATERNAL LECTURE TRANSES