Fertilization: The beginning of pregnancy

Fertilization
-is the union of an ovum and a
spermatozoon.
-It is also called conception, impregnation
or fecundation and usually occurs in the
outer third of the fallopian tube, the
ampullar portion.
 Important facts about fertilization
-An ovum is capable of fertilization for 24 to 48
hours( 1-2 days). After this time, the ovum
atrophies and becomes nonfunctional.

-The functional life of a spermatozoon is about

48-72 hours.(2-3 days)

-The normal amount of semen in an ejaculation is

about 3-5 cc (average: 2.5 ml).
The number of sperms in an ejaculate is 50-
200 million per milliliter or an average of 400
million sperm per ejaculation.
Spermatozoon reaches the cervix within 80
seconds(1minute and 20 seconds) and the
outer end of the fallopian tube within 5
minutes after deposition
As ovum is extruded from a graafian follicle
-ovum becomes surrounded by a ring of
mucopolysaccharide fluid( ZONA PELLUCIDA)
and a circle of cells(CORONA RADIATA)
-the surrounding cells of the ovum(zona pellucida &
corona radiata) increase the bulk of the ovum and
serve as buffers agianst injury.
Fimbriae
- Fine hairlike structures that line the openings of the
fallopian tubes.
Capacitation
-final process that sperm must undergo to be ready for
fertilization.
-happens as the sperm move toward the ovum consist
of changes in plasma membrane of the sperm head
which reveal the sperm-binding receptor sites.

Getting to the right site:
Helping the sperm:
At ovulation, the cervical mucus increases in amount
and becomes less thick, allowing easier sperm transport.
Passage of the sperm through the uterus and oviduct
occurs mainly due to muscular contractions of uterus &
oviducts.
Oocyte:
The ends of the oviducts come into close contact with the
ovary during ovulation.
Fimbriae of oviduct ends “sweep” the ovulated ovum into
the oviduct.
Peristaltic waves of oviduct musculature bring the
ovum into the ampulla of the oviduct.
•A sperm enters an ovum, and the nuclei
combine to form one with 46
chromosomes and the resulting structure is called
ZYGGOTE.

•-under ordinary circumstances, only one spermatozoon

is able to penetrate the cell membrane of the ovum, an
exception to this is the formation of hydatidiform mole in
which multiple sperm enter, this lead to abnormal
growth.
Words to know…
Fuse- to physically join together
Ovum – egg cell (female gamete)
Cleavage – process of cell division during
development
Differentiation – the process of forming different
kinds of cells from similar cells of the early embryo.
Morula – solid ball of cells formed from cleavage
Blastula – hollow ball of cells formed from cleavage
Gastrula – a hollow ball of cells with an “in
pushing” and 3 layers (germ layers)
Decidualization, the transformation of secretory
endometrium to decidua,( dependent on the action of
estrogen and progesterone and factors secreted by the
implanting blastocyst during trophoblast invasion.)

Ovum(ovulation to fertilization)
Zygote(fertilization to implantation)
Embryo(From implantation to 5-8 weeks)
Fetus(from 5-8 weeks until term)
Conceptus(developing embryo or fetus & placental
structure throughout pregnancy)
midterm
Fertilization: Four Major Steps
1. Sperm contacts the egg
2. Sperm or its nucleus enters the egg
3. Egg becomes activated and developmental
changes begin
4. Sperm and egg nuclei fuse
Fertilization
 FACTORS AFFECTING FERTILIZATION
1.Equal maturation of both ovum and
sperm
2.Ability of the sperm to reach the
ovum
3.Ability of sperm to penetrate the
zona pellucida and cell membrane
 Stage 1 of fertilization:
Acrosome
-a structure at the end of the sperm cell that releases
enzymes to digest the cell membrane of an egg.
The acrosome reaction must be completed before
the sperm can fuse with the secondary oocyte(The
acrosome reaction is associated with the release of
acrosome enzymes that facilitate fertilization)
 Occurs when sperms come into contact with the corona
radiata of the oocyte
 Perforations develop in the acrosome
 Point fusions of the sperm plasma membrane and the
external acrosomal membrane occur
Passage of sperm through the corona radiata
depends on enzyme action:
hyaluronidase (proteolytic enzyme) released from sperm
acrosome
Tubal mucosal enzymes
Flagella action also aids corona radiata penetration
An ovum is surrounded by a
ring of polysaccharide
called the zona pellucida
and a circle of cells called
corona radiata as it is
forced out of the graafian
follicle of the ovary during
ovulation. These
surrounding cells serve as a
protective buffer of the
ovum against injury.
The Nuclei Fuse Together
Capacitation: readying the sperm
Sperms cannot fertilize oocytes when they are newly
ejaculated.
The process of capacitation takes 5-7 hours.
Capacitated sperms are more active.
Location: capacitation occurs in the uterus and oviducts
and is facilitated by substances of the female genital
tract.
The acrosomal reaction cannot occur until capacitation
has occurred.
Right after penetration, the chromosomal material of
the ovum and sperm combine. The resulting
structure is termed zygote (fertilized ovum).
Implantation
The embryo implants in the wall of the uterus on about
the 7th day of development
Implantation is the penetration of the growing
structure to the uterine endothelium.
  It occurs approximately 8 to 10 days after
fertilization.
 Immediately after fertilization, the fertilized ovum
or zygote stays in the fallopian tube for 3 days.
During this time a rapid cell division (mitosis) or
cleavage is taking place.
 The first cleavage occurs at about 24 hours and it
continues to rapidly divide at a rate of one in every
22 hours.
Stages
Ovum
Zygote
Morula
Blastocyst
Embryo
Fetus
 Ovum becomes zygote after
Fertilization(day 1)
THEN
Travel towards the body of the
uterus 3-4 days with the help of
muscular contractions of the
Ftube.Moving towards the uterus
mitotic cell division or cleavage
begins.
First Cleavage occurs at about 24
hours & the division is via mitosis
and it forms the 2 cell stage(day 2)
The developing cells
are now termed as
BLASTOMERES.
They split again to form the 4 cell
stage
And again to form the 8 cell stage…
then blastomeres (developing cells)
is now consist of 16 to 50 cells
and this tend to create a bumpy
appearance and it is now called
MORULA. (day 3)
Morula comes from a Latin word
“morus” meaning mulberry.
Morula
Then morula continues to multiply as it floates
free in the uterine cavity for 3-4 more days

Large cells tend to accumulate at the side of the

structure. Because of this peripheral
accumulation, a fluid space surrounding the
inner cell mass is created or the so called
cavity.

When a cavity is formed in the morula the

structure is now called a BLASTOCYST.
Blastocyst(structure attaches to
uterine endometrium)
Cells in the outer ring of the blastocyst is called
trophoblast cells.

Trophoblast cells
-enable the blastocyst to invade the endometrium
-These cells will later form the placenta and
membranes.

The inner cell mass is called EMBRYOBLAST CELLS,

the portion of the structure that will form the
embryo.
By 8-10 days after fertilization the implantation or
contact between the growing structure and the
uterine endometrium occurs.

At the time of implantation the blastocyst is already

differentiated into germ layer(ectoderm, mesoderm,
endoderm)

Touching or implantation point is usually high in the

uterus(posterior surface) so as the growing placenta
may not occlude the cervix(placenta previa)
 The brushing of the blastocyst to the uterine
endometrium is a process called APPOSITION.
 The attachment of the blastocyst to the uterine
endometrium is termed as ADHESION.
 The settling down of the blastocyst down into its
soft folds is a process called INVASION. Invasion is
made possible because as the growing structure
touches the endometrial wall a proteolytic
enzyme is produced that dissolve the tissues that
they come in contact with.
 The blastocyst burrows deep into the endometrial
wall to receive nourishment from the endometrial
glands.
 Continued invasion establishes an effective
communication network with the maternal
circulation.
 Once implanted the zygote is now termed
embryo and the uterine endometrium is now
termed decidua.
 Implantation bleeding is characterized by a
small amount of vaginal spotting that appears
with implantation as capillaries are ruptured by
the penetrating trophoblast cells. (This should
not be mistaken for the woman’s last menstrual
period or LMP.)
Embryonic and Fetal Structures
1.Decidua

2.Chorionic Villi

3.Placenta

4.Umbilical Cord

5.Membranes and Amniotic Fluid

 1.The Decidua (Endometrium)

After fertilization corpus luteum in the ovary

continues to function rather than atrophying
because of hCG(human chorionic gonadotropin)
release by trophoblast cells.
The uterine endometrium instead of sloughing off
as in normal menstrual cycle, continues to grow in
thickness and vascularity hence the endometrium
is now called DECIDUA. (latin word for falling off
because it will be discarded after birth of the
child.
 3 separate areas of decidua
1.Decidua basalis –part of the endometrium
lying directly under the embryo or the portion
where the trophoblst cells are establishing
communication with maternal blood vessels.
2.Decidua capsularis – stretches or encapsulates
the surface of the trophoblast
3.Decidua vera – remaining portion of the
uterine lining
NOTE: As the embryo continue to grow, it pushes the
decidua capsularis eventually enlargement brings the
structure into contact with the opposite uterine wall.

Decidua capsularis fuses with the endometrium of

the opposite uterine wall hence at birth the entire
inner surface of the uterus is stripped away, leaving
the organ highly susceptible to hemorrhage and
infection.
 2. Chorionic Villi

-Form as early as 11th – 12th day

-it is also called as Miniature villi or probing fingers
Term: 200 villi will form
Division of chorionic villi
1. Central core of loose connective tissue
Contains fetal capillaries
2. syncytiotrophoblast/ syncytial layer
Outer layer
Responsible for the production of various placental
hormones;
- Human chorionic gonadotrophin
- Somatomammotropin (human placental lactogen)
- Estrogen
- Progesterone
3. cytotrophoblast/ langhan’s layer
Present as early as 12 days gestation
Inner layer
It appears to function early in pregnancy to protect
the growing embryo & fetus from certain infectious
organism such as spirochete of syphilis.
Disappear between 20th -24th week.(therefore syphilis
is considered to have potential for fetal damage late in
pregnancy.
 3. The Placenta
-Latin for pancake
Arises out of trophoblast tissue
Serve as fetal lungs, kidneys & gastrointestinal tract.
15-20cm in diameter
2-3cm depth at term
weighs about 500~600 g. or 1lb. (term) 1/6 the
weight of the baby
Contains 30 cotyledons
For each cotyledon, a 1:1:1 ratio of artery to vein to
cotyledon
Function
Exchange of metabolic & gaseous products
between maternal & fetal bloodstreams
Exchange of gases –
Exchange of nutrients & electrolytes –
Transmission of maternal antibodies –

Production of hormones
As early as 12th day of pregnancy, maternal blood
begins to collect in the intervillous spaces of the
uterine endometrium sorrounding the chorionic
villi.
The intervillous spaces of a mature placenta
contain approximately 150 ml of blood, which is
replenished about 3 or 4 times per minute.
 by the 3rd week oxygen & other nutrients such as
glucose, amino acids, fatty acids, minerals, vitamins
and water diffuse from maternal blood through the
cell layer of the chorionic villi, to the villi capillaries.
From there, nutrients are transported back to the
embryo.
The exchange is carried only by selective osmosis
through the chorionic villi, no direct exchange of
blood between the embryo and the mother during
pregnancy.
 However , because the chorionic villi layer is only
one celled thick, minute breaks do allow occasional
fetal cells to cross, as well as enzymes such as alpha-
fetoprotein from the fetall iver(highlevel in maternal
serum alpha feto protein means fetus has open spinal
or abdominal defect.)

Placental osmosis is so effective

-all but few substances are able to cross from the mother
into the fetus.
-almost all drugs are able to cross into fetal
circulation(nonessential drugs including alcohol &
nicotene
 specific mechanisms that allow nutrients to cross the
placenta(all these pocesses are affected by maternal
blood pressure and the pH of the fetal &maternal
plasma)
1.Diffusion
-when there is a greater concentration of a substance on
one side of a semipermiable membrane than on the
other, substances of correct molecular weight cross
the membrane from the area of higher concentration
to the area of lower concentration.
-Oxygen, CO2, Na, Chloride
-molecules spread out randomly from areas of
higher concentration to areas of lower
concentration until they are distributed evenly
in a state of dynamic equilibrium.
2.Facilitated diffusion
-provides a means(carrier) for certain needed
substances to pass through the membrane
because its to large or lipid insoluble
Example of carrier: protein carrier, this carry glucose
3.Active transport
-this process requires energy and action of an enzymes
to facilitate transport.
-needs energy because they cross the placenta against
the pressure gradient(lower molecular concentration
to the higher
Note: amino acid concentration in the fetal plasma are
twice what they are in the mother( to provide
building substances for active fetal growth)
-essential amino acids & water soluble vitamins
4. Pinocytosis
-absorption by the cellular membrane of microdroplets
of plasma and sissolved substances
Pinocytosis
-this is helpful if molecular structure are too large for
diffusion and cannot participate in active transport
cross
-EX: -gamma globulin, lipoproteins, phospholipids
-viruses can that can affect fetus

-Number of chorionic villi increases with pregnancy

hence villi form an increasingly complex
communication network with maternal blood.
-intervillous spaces grow larger & larger becoming
separated by a series of partitions(SEPTA)
Matured Placenta
-consist of 30 separate segments or compartments called
COTYLEDONS.
-this compartments makes the maternal side of the
placenta at term look rough and uneven.

Maternal uterine arteries supply the mature placenta

-100 maternal uterine arteries

Uteroplacental blood flow in pregnancy

-increases from 50ml/min at 10 weeks to 500 – 600ml/min
at term(to provide enough blood for exchange
-no additional maternal arteries appear after the first 3
months of pregnancy instead there is increase in size to
accommodate the increase blood flow.
-systematically, the mother’s heart rate, total cardiac
output, and blood volume increase to supply the
placenta.

-in intervillous spaces, maternal blood jets from the coiled

or spiral arteries in streams or sputrs and propelled from
compartment to compartment
-as the blood circulates around the villi and nutrients
osmose from maternal blood to villi, maternal blood
gradually loses its momentum and settles to the floor of
the cotyledons.
-from floor of the cotyledons it enters the orifices of the
maternal veins located in the cotyledons and is returned
to the maternal circulation.

BRAXTON HICKS CONTRACTIONS

-barely noticeable uterine contractions that are present
from about the 12th week of pregnancy
-aid in maintaining pressure in the intervillous spaces by
closing off the uterine veins momentarily with
contraction.
uterine perfusion and placental circulation
-most efficient when mother lies on her left side

Left side position/left side lying position

-lifts the uterus AWAY from the INFERIOR VENA CAVA
(preventing blood from being trapped in the lower
extremeties )

If mother lies on her back(supine/dorsal)

-weight of the uterus compresses the vena cava hence
placental circulation can be so sharply reduced that
supine hypotension occurs(low maternal blood pressure)
The fetus of a woman with DM may develop a larger than
usual placenta(due to excess fluid collected between
cells)

*Aside from serving as the source of oxygen and nutrients

for the fetus, the outer layer of the chorionic villi
(syncytial) develops into a separate important
hormone-producing system.

1.Human Chorionic Gonadotropin(hCG)

-first hormone produced
-can be found in maternal blood and urine as early as the
first missed menstrual period(shortly after implantation
occurred) through about the 100th day of pregnancy.
Within 1-2 weeks after birth
-Mother’s serum will be completely negative for HCG

Purpose for Testing hCG after birth

-to proof that all of the placental tissue has been delivered

Purpose of hCG
-act as a fail-safe measure to ensure that the corpus luteum
of the ovary continues to produce progesterone and
estrogen.
-suppresing the maternal immunologic response so that
placental tissue is not rejected.
If corpus luteum should fail and the level of progesterone
fall, this cause endometrial sloughing, with loss of
pregnancy followed by a rise of pituitary gonadotropins
to induce a new menstrual cycle.

HCG
-has a similar structure to that of luteinizing hormone of
pituitary gland ,if the fetus is male, it exerts an effect on
the fetal testes to begin testosterone production.(cuases
maturation of the reproductive tract.)
8th week pregnancy
-the outer layer of the cells of the developing placenta
begins to produce progesterone, hence corpus luteum is
no longer needed.

2.Estrogen
-primarily ESTRIOl is produced as a second product of the
syncytial cells of the placenta
-contributes to the mother’s mammary gland development
in preparation for lactation and stimulates uterine
growth to accommodate the fetus development.
-hormone of women
3. Progesterone
-hormone of mothers
-necessary in pregnancy to maintain the endometrial lining
of the uterus.
-present in serum as early as the 4 th week of pregnancy as a
result of the continuation of the corpus luteum.
-apears to reduce the contractility of the uterine
musculator during pregnancy which prevents premature
labor.
Note:
-reduced contractility is probably produced by a change in
electrolytes(Na & Ca) which decreases the contraction
potential of the uterus.
-after placental synthesis begins(12 th week) the level of
progesterone RISES progressively during the remainder of
the pregnancy.

4. Human Placental Lactogen(Human chorionic

somatomammotropin)hPL
-hormone with growth promoting and
lactogenic(milkproducing) properties.
-produced by the placenta beginning as early as the 6 th
week of pregnancy increasing to a peak at term.
-can be assayed in both maternal serum and urine
-promotes mammary gland(breast) growth in preparation
for lactation in the mother.
-serve as important role of regulating maternal glucose,
protein and fat levels so that adequate amount of these
nutrients are always available to the fetus.
 4. The Umbilical Cord

Formed from fetal membranes( amnion & chorion)

Provides a circulatory pathway connecting the embryo
to the chorionic villi of the placenta.
Function: to transport oxygen and nutrients to
the fetus from the placenta and to return waste
products from the fetus to the placenta.
53cm (21 inches) in length
2cm (3/4inches) in thick
1 vein 2 arteries
Rate of blood flow 350ml/min.(at term)
Umbilical cord contains:
1.Vein(1)- carry blood from the placental villi to the
fetus.
2.Arteries(2)- carry blood from the fetus back to the
placental villi.
If one artery and one vein only, there is congenital
anomaly either in kidney or heart.

The walls of the umbilical cord arteries are lined with

smooth muscle. Constriction of these muscles after
birth contributes to hemostasis and helps prevent
hemorrhage of the newborn through the cord.
The bulk of the cord is a gelatinous
mucopolysaccharide which gives the cord body &
prevent pressure on the vein & arteries.(Wharton’s
jelly)
-the outer surface is covered with amniotic
membrane.The remnant of the yolk sac may be found
in the fetal end of the cord as a white fibrous streak at
term.

Why is it that the cord can be cut at birth without

discomfort to both mother and child?
-because umbilical cord contains NO nerve supply.
-blood can be drawn from the umbilical vein or
transfused into the vein during intrauterine life for
fetal assessment or treatment.(PUBS-percutaneous
umbilical blood sampling)

The rate of blood flow through an umbilical cord is rapid

-350ml/min at term

Because the rate of blood flow through the cord is so

rapid, it is unlikely that a cord will twist or knot(can
interfere with fetal oxygen supply)

NUCHAL CORD
-loose loop of cord found around the fetal neck
5.Amniotic Membrane
Chorionic villi on the medial surface of the
trophoplast(those that are not involved in
implantation because they do not touch the
endometrium) gradually thin, living the medial
surface of the structure smooth(chorion laeve or
smooth chorion) The smooth chorion
eventually becomes the chorionic membrane.

Chorionic membrane
( outermost fetal membrane)
-support the amniotic fluid
A second membrane lining the chorionic membrane ,is the
Amniotic membrane/amnion- (forms beneath the chorion.)

Amniotic membrane/Amnion
-forms beneath the chorion
-at birth they covers the fetal surface of the placenta & gives
its typical shiny appearance.
-also offer support to amniotic fluid but actually produces
amniotic fluid
-Produce phospholipid that initiates the formation of
prostagalndins that causes uterine contraction
No nerve supply(hence mother & child will not
experience pain when it raptures spontaneously or
artificial rapture is done.
6. The Amniotic fluid
Constantly being newly formed by the amniotic
membrane(so never become stagnant)
 Fetus continually swallows the fluid
If unable to swallow: there is congenital
anomaly(esophageal atresia or anencephaly)
In the fetal intestine: it is absorbed into the fetal
bloodstream go to umbilical arteries, to the placenta
and it is exchanged across the placenta.
Ranges 800-1,200ml( term)
Slightly alkaline pH 7.2(to differentiate it from urine,
check the pH)
Early in fetal life(as soon as fetal kidneys become
active): fetal urine adds to the quantity of amniotic
fluid.
Function:
Protective mechanism for the fetus
It shields against pressure or blow to the mothers
abdomen
It protects the fetus from changes in temperature
Aids in muscular development( because it allows
freedom to move
Protects the umbilical cord from pressure, protecting
fetal oxygenation
6.The Amniotic fluid
Oligohydramnios- reduction in the amount of
amniotic fluid (less than 300ml in total or no pocket
on ultrasound larger than 1cm)
-this is caused by disturbance of kidney function
Hydramnios/polyhydramios- excessive AF 2000ml or
pockets of fluid larger than 8cm on ultrasound.
-this may occur due to the fetus who is unable to
swallow fluid(esophageal atresia)
-tends to occur in women with DM because
hyperglycemia causes excessive fluid shift into the
amniotic space.
 END,
CONT. BELOW
 Fetal circulation
Gas exchange occurs in the placenta
Ventricles work in parallel and not on series
Preferential flow of blood
Presence of shunts:
1.Ductus Venosus
2. Foramen ovale
3. ductus arteriosus
Fetal circulation
1. Oxygenated blood enters the umbilical vein from
the placenta
2. Enters ductus venosus
3. Passes through inferior venacava
4. Enters the right atrium
5. Enters the foramen ovale
6. Goes to the left atrium
7. Passes through left ventricle
8. Flows to ascending aorta to supply nourishment to
the brain and upper extremeties
9. Enters superior vena cava
10. Goes to right atrium
11. Enters the right ventricle
12. Enters pulmonary artery with some blood going to
the lungs to supply oxygen and nourishment
13. Flows to ductus arteriosus
14. Enters descending aorta ( some blood going to the
lower extremeties)
15. Enters hypogastric arteries
16. Goes back to the placenta
Cardiovascular System

First system to become functional in intrauterine life.

Beats as early as 24th day
FHR 120-160/Min
Septums that divide the heart into chambers develop
as early as 6th- 7th week.
10th -12th week of pregnancy heart beat can be heard
using Doppler.
HR is affected by fetal oxygen level, body activity &
circulating blood volume.
Respiratory system
3rd week of intrauterine life respiratory & digestive
tract exist as a single tube.
By the end of 4th week septums begin to divide the
esophagus from the trachea.
7th week of life, diaphragm does not completely divide
the thoracic cavity from the abdomen.
Alveoli & capillaries begin to form between 24th – 28th
weeks.
Spontaneous respiratory movement begin as early as
3 months of pregnancy, continuing throughout
pregnancy.
Specific lung fluid with a low surface tension & low
viscosity forms in alveoli to aid in expansion of alveoli
at birth; it is rapidly absorbed after birth.
Surfactant a phospholipid surface is formed &
excreted by the alveolar cells at about 24th weeks of
pregnancy.
- 2 components;
- lecithin
- sphingomyelin
- Sphingomyelin is the chief component of surfactant in
the early life.
At 35th weeks surge in the production of lecithin &
becomes the chief component with a ratio of 2:1
Lack of surfactant is associated with the development
of RDS.
Nervous system
3rd & 4th weeks of life
Neural plate is apparent by the 3rd week of gestation.
Its top portion differentiates into the neural tube,
which will form CNS (brain & spinal cord)
The neural crest will develop into the peripheral NS
8th week brain waves can be detected by
electroencephalogram.
All parts of the brain (cerebrum, cerebellum, pons &
medulla oblongata) form in utero.
24th week ear is capable of responding to sound; eyes
exhibit pupillary reaction.
Endocrine system
The fetal adrenal glands supply a precursor for
estrogen synthesis by the placenta.
Fetal pancreas produces the insulin needed by the
fetus.
The thyroid & parathyroid glands play vital roles in
metabolic fxn. & calcium balance.
Digestive system
16th week meconium forms in the intestine
- Cellular waste
- Bile fats
- Mucoproteins
- Mucopolysaccharide
- Vernix caseosa
Meconium is black or dark green & sticky.
GIT is sterile before birth.
- beacause vit. K is synthesized by the action of
bacteria in the intestine.
Swallowing begins at 10-12weeks
Coincident with intestine peristalsis and glucose
transport
Sucking & swallowing reflexes are not mature
until fetus is about 32 weeks/ fetus weighs 1,
500grams.
What stimulates swallowing -> not clear
The fetal neural analog of thirst
Gastric emptying
Change in the amnionic fluid composition
Fetal taste buds
Late in pregnancy, the volume of amnionic fluid -
> regulated by fetal swallowing
Term fetus : 200-760mL per day
The swallowed amnionic fluid
Contributes little to the caloric requirements
Contributes essential nutrients
Late in pregnancy, about 0.8g of soluble protein,
approximately half albumin, each day
GIT ability to secrete enzymes essential to CHO,
CHON digestion mature at 36th weeks
14weeks : amylase in amnionic fluid
16weeks : Most pancreatic enzymes are present
 Trypsin, Chymotrypsin, Phospholipase A, lipase
Musculoskeletal system
As early as 11th week fetus can be seen to move on
UTZ.
12th weeks of pregnancy ossification of bone tissue
begins.
Reproductive system
As early as 8th weeks child sex can be determined at
the moment of conception by a spermatozoon
carrying an X or a Y chromosome.
6th weeks gonads form.
Urinary system
2weeks : pronephros
5weeks : mesonephros -> producing urine
11-12weeks : mesonephros -> degeneration
9-12weeks : ureteric bud and nephrogenic
blastema -> metanephros
14weeks : loop of Henle -> functional &
reabsorption occurs
Until 36weeks : new nephrons
Urinary system (2)
The kidney receive 2-4% of the cardiac output
Renal vascular resistance is high
The glomerular filtration fraction is low
The filtration rate increases with gestational age
12weeks : less than 0.1mL/min
20weeks : 0.3mL/min
Urine production start at 12weeks
18weeks : 7-14mL/day
At term : 27mL/hr, 650mL/day
Integumentary system
skin appears thin & almost translucent until
subcutaneous fat begin to be deposited at about 36th
weeks.
Lanugo – soft downy hair
Vernix caseosa- cream cheese like substance.
Immune system
IgG maternal antibodies cross the placenta into the
fetus primarily during the 3rd trimester of pregnancy,
giving temporary PASSIVE IMMUNITY.
STAGES OF DEVELOPMENT
1 Month
 First Trimester
At the end of four weeks:
 Baby is .75-1cm in length
 Weight:400mg
 Heart, digestive system,
backbone and spinal cord begin
to form
 Placenta (sometimes called
"afterbirth") begins to develop
 The single fertilized egg is now
10,000 times larger than size at
conception
Mother
You may have gained a few pounds by now.
If you have been nauseated and not eating
well, you may have lost weight.
You will notice some body changes and your
clothes are getting a little tighter around the
waist.
You may be gaining weight in your legs or
beasts.
You may experience heartburn (pyrosis), food
cravings and constipation
Month 2
 First Trimester
At the end of 8 weeks:
 Length: 2.5 cm (1 in).
 Weight: 20 g.
 Organogenesis is complete.
 The heart, with a septum and valves,
is beating rhythmically.
 Facial features are definitely
discernible.
 Extremities have developed.
 External genitalia are present, but
sex is not distinguishable by simple
observation.
 The primitive tail is regressing.
 Abdomen appears large as the fetal
intestine is growing rapidly.
 Sonogram shows a gestational sac,
diagnostic of pregnancy.
Mother
You may feel cramping or even pain in your
lower abdomen or your sides.
Many women experience an occasional
excruciating pain in their buttocks and down
the back or side of their legs as pregnancy
progresses. This is called sciatic-nerve pain, it
is caused by pressure on the nerve from
growing, expanding uterus.
Month 3
 First Trimester
At the end of 12 weeks:
 Length: 7 to 8 cm.
 Weight: 45 g.
 Nail beds are forming on fingers and
toes.
 Spontaneous movements are
possible, although usually too faint
to be felt by the mother.
 Some reflexes, such as Babinski
reflex, are present.
 Bone ossification centers are
forming.
 Tooth buds are present.
 Sex is distinguishable by outward
appearance.
 Kidney secretion has begun,
although urine may not yet be
evident in amniotic fluid.
 Heartbeat is audible by a Doppler.
Mother
 By the end of 12 weeks, your uterus is too large to remain
completely in your pelvis. You may feel it above your pubic bone
(pubic symphysis).
 The uterus has a remarkable ability to grow while you’re
pregnant. During pregnancy, it grows upward to fill the pelvis
and abdomen, and returns to its usual size within a few weeks
after delivery.
 Before pregnancy, your uterus is almost solid. It holds about 0.3
ounce (10ml) or less. The uterus changes during pregnancy into
a comparatively thin-walled, muscular container big enough to
hold the fetus, placenta and amniotic fluid. The uterus increases
its capacity 500 to 1000 times during pregnancy.
The weight of the uterus also changes. When
your baby is born, your uterus weighs almost
40 ounces (1100g) compared to 2.5 ounces
(70g) before pregnancy.
The uterine wall grows during the first few
months of pregnancy due to hormonal
stimulation by estrogen and progesterone.
Later in your pregnancy, the growth of the
baby and the placenta stretch and thin the
uterine wall.
Month 4
 Second Trimester
At the end of 4 months:
 Length: 10 to 17 cm.
 Weight: 55 to 120 g.
 Fetal heart sounds are audible with
an ordinary stethoscope.
 Lanugo (the fine, downy hair on the
back and arms of newborns,
apparently serving as a source of
insulation for body heat) is well
formed.
 Liver and pancreas are functioning.
 Fetus actively swallows amniotic
fluid, demonstrating an intact but
uncoordinated swallowing reflex;
urine is present in amniotic fluid.
 Sex can be determines by
ultrasound.
Mother
As your baby grows, your uterus and placenta
are also growing.
Six weeks ago, your uterus weighed about 5
ounces (140g).
Today, it weighs about 8.75 ounces (250g). The
amount of amniotic fluid around the baby is
also increasing. There is now about 3 inches
(7.6cm) below your bellybutton.
Month 5
 Second Trimester
At the end of 5 months:
 Length: 25 cm.
 Weight: 223 g.
 Spontaneous fetal movements can be
sensed by the mother.
 Antibody production is possible.
 Hair forms, extending to include
eyebrows and hair on the head.
 Meconium is present in the upper
intestine.
 Brown fat, a special fat that will aid
in temperature regulation at birth,
begins to be formed behind the
kidneys, sternum, and posterior
neck.
 Fetal heartbeat is strong enough to
be audible through the abdomen
with an ordinary stethoscope.
 Vernix caseosa, a cream
cheese-like substance
produced by the sebaceous
glands that serves as a
protective skin covering
during intrauterine life,
begins to form.
 Definite sleeping and activity
patterns are distinguishable
(the fetus has developed
biorhythms that will guide
sleep/wake patters
throughout life).
Month 6
 Second Trimester
At the end of 6 months:
 Length: 28 to 36 cm.
 Weight: 550 g.
 Passive antibody transfer from
mother to fetus probably begins
as early as the 20th week of
gestation, certainly by the 24th
week gestation. Infants born
before antibody transfer has
taken place have no natural
immunity and need more than
the usual protection against
infectious disease in the
newborn period until the
infant’s own store of
immunoglobulins can build up.
 Meconium is present as far as the
rectum.
 Active production of lung
surfactant begins.
 Eyebrows and eyelashes are well
defined.
 Eyelids, previously fused since
the 12th week, are now open.
 Pupils are capable of reacting to
light.
 When fetuses reach 24 weeks, or
601 g, they have achieved a
practical low-end age of viability
if they are cared for after birth in
a modern intensive care facility.
 Hearing can be demonstrated by
response to sudden sound.
Mother
Your uterus is now about 1.5 to 2 inches (3.8 to
5.1cm) above the bellybutton. It measures almost
10 inches (24cm) above the pubic symphysis.
Month 7
 Third Trimester
At the end of 7 months:
 Length: 35 to 38 cm.
 Weight: 1,200 g.
 Lung alveoli begin to mature,
and surfactant can be
demonstrated in amniotic fluid.
 Testes begin to descend into the
scrotal sac from the lower
abdominal cavity.
 The blood vessels of the retina
are extremely susceptible to
damage from high oxygen
concentrations (an important
consideration when caring for
preterm infants who need
oxygen).
 The eyes open.
Mother
Your uterus is now well above your
umbilicus. Sometimes this growth seems
gradual. At other times, it may seem as
though changes happen rapidly, as if
overnight.
Your uterus is about 3.2 inches (8cm) above
your bellybutton. If you measure from the
pubic symphysis, it is about 11 inches (28cm)
to the top of the uterus. Your weight gain by
this time should be between 17 and 24 pounds
(7.7 and 10.8 kg).
Month 8
 Third Trimester
At the end of 8 months:
 Length: 38 to 43 cm.
 Weight: 1,600 g.
 Subcutaneous fat begins to be
deposited (the former stringy, “little
old man” appearance is lost).
 Fetus is aware of sounds outside the
mother’s body.
 Active Moro reflex is present.
 Birth position (vertex or breech) may
be assumed.
 Iron stores that provide iron for the
time during which the neonate will
ingest only milk after birth are
beginning to be developed.
 Fingernails grow to reach the end of
fingertips.
Mother
Measurement to the top of the uterus from the
pubic symphysis is about 12.8 inches (32cm).
Measuring from your bellybutton, the top of the
uterus now measures almost 5 inches (12cm).
Month 9
Third Trimester
At the end of 9 months:
 Length: 42 to 48 cm.
 Weight: 1,800 to 2,700 g (5 to 6 lb).
 Body stores of glycogen, iron,
carbohydrate, and calcium are
augmented.
 Additional amounts of subcutaneous
fat are deposited.
 Sole of the foot has only one or two
crisscross creases compared with the
full crisscross pattern that will be
evident at term.
 Amount of lanugo begins to
diminish.
 Most babies turn into a vertex or
head-down presentation during this
month.
Mother
Measuring from the pubic symphysis, it’s
about 14.5 inches (36cm) to the top of your
uterus. If you measure from your bellybutton,
it’s more than 5.5 inches (14cm) to the top of
your uterus.
You may feel as though you’ve run out of
room! Your uterus has grown bigger in the past
few weeks as the baby has grown inside of it.
Now the uterus is probably up under your ribs.
40 weeks
 Length: 48 to 52 cm (crown to
rump, 35 to 37 cm).
 Weight: 3,000 g (7 to 7.5 lb).
 Fetus kicks actively, hard enough
to cause the mother considerable
discomfort.
 Fetal hemoglobin begins its
conversion to adult hemoglobin.
The conversion is so rapid that,
at birth, about 20% of
hemoglobin will be adult in
character.
 Vernix caseosa is fully formed.
 Fingernails extend over the
fingertips.
 Creases on the soles of the feet
cover at least two thirds of the
surface.
Mother:
From the pubic symphysis to the top of the
uterus, you probably measure 14.4 to 16 inches
(36 to 40cm). From your bellybutton to the
top of your uterus is 6.4 to 8 inches (16 to
20cm).
By this time, you probably don’t care an awful
lot about how much you measure. You feel
you’re as big as you could ever be, and you’re
ready to have your baby.
VIABILITY
Capability of fetus to
survive outside uterus at
the earliest gestational
age - 22-24 weeks
Survival depends on:
Maturity of fetal central
nervous system
Maturity of lungs
START
Psychological changes that occur with pregnancy
Psychological Change
1.First Trimester
Task: Accepting the pregnancy

Description:
-woman & partner both spend time recovering from
shock of learning they are pregnant and concentrate
on what it feels like to be pregnant. A common
reaction is ambivalence, or feeling both pleased and
not pleased about the pregnancy.
2.Second Trimester
Task: Accepting the baby

Description:
-woman & partner move through emotions such as
narcissism and introversion as they concentrate on
what it will feel like to be a parent. Role playing and
increased dreaming are common
Psychological changes that occur with pregnancy
-accepting that there is a baby is more stronger on the
first moment a woman feels fetal movement.
(quickening)
-anticipatory role playing is an important task for a
pregnant woman, this leads to a larger concept of her
condition and helps her realize that not only she is
pregnant but also there is a child inside her
*beginning to imagine how she will feel at the birth
when the physician announces”it’s a boy or girl”
*begin to imagine as mother teaching her child the
alphabet or how to ride a bicycle
3.Third Trimester
Task: Preparing for the baby and end of pregnancy

Description:
-woman & partner grow impatient with pregnancy as
they ready themselves for birth.
-begins “nest-building activities”
*planning the infant’s sleeping arrangement
*buying clothes
*choosing names
*ensuring safe passage by learning about birth
-interested in attending prenatal class or preparation
for childbirth classes.
Emotional Responses to Pregnancy
1.Ambivalence
-the presence of two opposing emotions
at the same time.
*want that she is pregnant but not
enjoying to be pregnant because of the
physical changes she experiences
2. Grief
-intense sorrow
*in giving up or altered her present roles
*never be a daughter in exactly the same way
again
3.Narcissism
-selfcenteredness
-early reaction to pregnancy
*she dresses so her pregnancy will or will not
show and dressing becomes a time consuming
4. Intoversion versus Extroversion
Introversion
-turning inward to concentrate on oneself and one’s
body
Extroversion
-become more active
-apear healtheir than ever before
-more outgoing
5.Body image and body boundary
Body image
-the way your body appears to yourself
*change in body image is part of the basis for
narcissism and introversion.

Body boundary
-a zone of separation you perceive between yourself
and objects or other people
*the boundary is perceieved as extremely vulnerable, as
if the body were delicate and easily harmed.
6.Stress
-worry , anxiety
*because of major role changes during
pregnancy
*make it difficult for the woman to make
decisions
7.Couvade syndrome
-men exprerience physical symptoms such as
nausea, vomiting and backache to the same
degree or even more intensely than their
partners do during a pregnancy
*these symptoms apparently result from stress,
anxiety and empathy for the pregnant woman.
*the more partner is involved in or attuned to
the changes of the pregnancy the more
symptoms he may experience.
8.Emotional Lability
-mood changes
-partly as a manifestation of narcissism(her
feelings are easily hurt by remarks that would
have been laughed off before) and partly
because of hormonal changes(sustained
increased in Estrogen & progesterone
9.Changes in sexual desire
First trimester
-most women report a decrease in libido(sexual
drive) because of the nausea, fatigue and
breast tenderness that accompany early
pregnancy
Second trimester
-libido and sexual enjoyment rise markly
(because blood flow to the pelvic area increases
to supply placenta)
Third trimester
-may remain high or it may decrease because of
difficult finding a comfortable position and
increasing abdominal size.
Pregnancy

Pregnancy literally means (being with the child).

Nine calendar months or 10 lunar months/40 weeks
Forty weeks or 280 days
Divided into trimesters
 Three intervals of three months each
Known as gestational period
Presumptive signs of pregnancy
(BANF, FUQ,SML)

-are those that are LEAST indicative of

pregnancy;taken as single entities, the could
easily indicate other conditions
1.Breast changes 6.uterine enlargement
2.nausea, vomiting 7.Quickening
3.Amenorrhea 8.linea nigra
4.Frequent urination 9.melasma
5. Fatigue 10.striae gravedarum
2 weeks(from implantation)
-breast changes
*feeling of tenderness, fullness or tingling,
enlargement and darkening of areola
-nausea, vomiting
-amenorhea
3 weeks
-frequent urination
12 weeks(from implantation)(2 months &1/2)
-fatigue
*general feeling of tiredness
-uterine enlargement
*uterus can be palpated over symphysis pubis
18 weeks( 4months)/second tri
-quickening
*fetal movement felt by woman
24 weeks(from implantation)/(6 months)
-linea nigra
*line of dark pigment on the abbdomen
-melasma
*dark pigment on the face
-striae gravidarum
*red streaks on abdomen
Probable signs of pregnancy
-can be documented by the examiner, more reliable
than presumptive signs but they are still not positive
or true diagnostic findings.

Presence of hCG(serum & urine Test)

C -hadwick’s sign
H - egar’s sign
E - vidence of gestational sack through sonogram
B -allotment

B -raxton Hick’s contraction

F - fetal outline felt by examiner
1 week (from implantation)

Presence of hCG:

-Serum Laboratory tests

*Test of blood serum reveal the presence of Human
Chorionic gonadotropin hormone.(hormone created
by the chorionic villi of the placenta)

- Urine test
*for the presence of hCG hormone
Note: as early as 24 to 48 hours after implantation
6 weeks(1 month ½)/first tri
-chadwick’s sign
*color change of the vagina from pink to violet
-Hegar’s sign
*softening of the lower uterine segment
Sonographic evidence of gestational sac
- *characteristic ring is evident

16 weeks(4 months)/second tri

-Ballotment
*when lower uterine segment is tapped on a bimanual
examination, fetus can be felt to rise agaisnt abdominal
wall.
20 weeks(5 months)/second tri
-Braxton Hicks contraction
*periodic uterine tightening occurs
-Fetal outline felt by examiner
*fetal outline can be palpated through abdomen.
Positive Signs of Pregnancy
-there are only 3 positive signs of pregnancy
1. Visualization of the fetus by ultra
sound(sonographic evidence of fetal outline)
*can be seen & measured through sonogram
*8 weeks from implantation / 2 months)
2.Demonstration of fetal heart separate from the
mother’s(fetal heart audible)”120-160 beats per
minute” as early as 6th to 7th week
*doppler ultrasound( 10 – 12 weeksf rom implantation)
3. Fetal movements felt by the examiner
*can be palpated through abdomen( as early as 16 to 20
weeks or 5 months)
??????Physiological changes of
pregnancy
2 categories
1.Local changes
-confined to reproductive organs
*involves the uterus, ovaries , vagina and breast
2. Systemic
-affecting the entire body

Symptoms(subjective findings)
Signs( objective findings)
 Local changes
(Reproductive System changes- uterus, ovaries,
vagina, breast)
1.Changes in the uterus
Small, pear-shaped organ before pregnancy
Increase in size to accommodate growing fetus,
placenta, amniotic sac, and amniotic fluid during
pregnancy
Length: 6.5 to 32 cm Depth:2.5 to 22 cm
Width: 4 to 24 cm Weight: from 50 to 1000 g
Changes in the uterus
-Early in pregnancy, the uterine wall thickens from
about 1-2 cm, toward the end of pregnancy, the
wall thins to become supple(flexible and elastic) and
only about .5cm thick.
-volume: from 2ml – more than 1,000 ml
-uterus can hold 7 lb(3175 g) fetus + 1,000 ml
Amniotic fluid= 4,000g)

Uterine measuring:
-from the top of the symphysis pubis over the top
of the uterine fundus.
 ……………………………….36 weeks
40 weeks
Fetal head settles into the pelvis(lightening)
------------------------------------32 weeks
…………………………..28 weeks
……………………….24 weeks
20-22 weeks
2.Amenorrhea
-Absence of menstruation
 Menstruation stops as a result of hormonal influence during
pregnancy
 Supression of FSH by rising estrogen levels (placenta)

NOTE:
-this could also be result from tension, anxiety, fatgue, chronic
illness (severe anemia) extreme dieting, strenous exercise.
Atletes=associated with low ratio of the body fat to body
muscles which lead to excessive secretion of
prolactin(increase in prolactin causes decrease in GnRH from
hypothalamus)

Bromocriptine= can reduce high prolactin levels but

teratogenic
3. Changes in the cervix
-Due to high Estrogen level coming from the placenta the
cervix and uterus becomes more vascular and
edematous.

Increased fluid between cells = causes cervix to soften

Increased vascularity = causes the cervix and vagina to
darken.(from pale pink to violet hue)

Goodell’s Sign
 Cervix softens in consistency in preparation for childbirth
Consistency of the cervix:
Pregnant woman = resembles that of earlobes
Nonpregnant = nose

-the glands of the endocervix undergo both

hypertrophy and hyperplasia as they increase in
number and distend with mucus. A tenacious coating
of mucus fills the cervical canal.

Operculum – mucus plug, act to seal out bacteria

during pregnancy hence prevent infection in the fetus
and membranes.
4.Changes in the vagina
Chadwick’s Sign
 vagina take on a violet hue (from pale pink) hue due to
local venous congestion

Increase of glycogen in vaginal cells(under the

influence of estrogen)
 Causes increased vaginal discharge and heavy shedding of
vaginal cells
Leukorrhea
 Thick, white vaginal discharge during pregnancy
4.Changes in the vagina
Vaginal secretions during pregnancy
-fall from 7(alkalinepH) to 4-5 (acid pH)
-due to action of LACTOBACILLUS
ACIDOPHILUS(bacteria that grow freely in the
increased glycogen environment hence increased the
lactic acid content of secretions)
-changing acid content helps to make the vagina
resistant to bacterial invasion for the length of
pregnancy
-unfortunately favors the growth of CANDIDA
ALBICANS(species of yeast like fungi)
4.Changes in the vagina
Manifestation of candidal infection:
Itching, burning sensation, creamcheese-like discharge

Candidal infection
-can be transmitted to the newborn as it passes
through the birth canal at term.
Thrush or oral monilia
-Candidal infection in newnborn,(infection of the
mucous membrane of the mouth)
-characterize by white plaques on an eryythematous
base on the buccal membrane & the surface of the
togue.
-it resembles a milk curd left from a recent milk
feeding.
5. Ovarian Changes
-ovolation stops because of the active feedback
mechanism of estrogen and progesterone by corpus
luteum early in pregnancy & placenta later in
pregnancy.
6.Changes in breasts(subtle changes
-due to the production of estrogen & progesterone
Breast changes:
Feeling of fullness, tingling or tenderness of the breast.
(due to increased stimulation of the breast because of
increased estrogen level.)
Increase in size(due to hyperplasia of the mammary
alveoli and fat deposits) and shape
Nipples increase in size and become more erect
Areola become larger and more darkly pigmented its
diameter is about 3.5 cm/1.5 in or 7.5cm /2 0r 3 in
Montgomery’s tubercles or sebaceous gland of the areola
become protuberant(bulging out) , more active and secrete
substance that lubricates the nipples

Colostrum is secreted(16th week/ 4 motnhs)

 Thin, yellowish discharge from nipples throughout
pregnancy
 Forerunner to breast milk
2.Systemic changes
Cardiovascular System
prepregnancy pregnancy
Cardiac output 25% to 50%
Heart ratebpm 70-80 80-90
Plasma volume(ml) 2600 3600
Blood volume(ml) 4000 5250
RBC mass (mm3) 4,200,o00 4,650,000
Leukocytes(mm3) 7,000 20,500
Total protein(mg.dl) 7 5.5-6.0
Fibrinogen(mg/dl) 300 450
Blood pressure in 2nd tri, 3rd
tri=pre pregnancy level
-changes in the circulatory system are extremely
significant to the health of the fetus because they are
necessary for adequate placental and fetal circulation.

Blood volume increases :

-to provide for an adequate exchange of nutrients in the
placenta
-provide adequate blood to compensate for blood loss at
birth(bld volume or cardiac output-as much as 30 %-
50%)
Blood loss:
NSVD= 300 to 400 ml
CS =800 to 1000 ml
Increase in bld. Volume occurs gradually:
-beginning at the end of the first trimester.
-peaks at about the 28th to 32nd week(7 months -8
months)
-Continues at high level throughout the 3rd trimester.
Plasma volume increases faster than RBC production
hence concentration of hemoglobin and
erythrocytes may decline giving the woman a
pseudoanemia early in pregnancy

Pseudoanemia (early in pregnancy)

-the apparent anemia that occurs early in pregnancy due
to rapid expansion of blood volume.

Second trimester
-woman’s body compensates for the expansion of blood
volume by producing more red blood cells creating
near-normal levels of RBC
Considered True anemia:
((NV+ Hct=32-42%/Hgb=10.5-14g/dl
- Either hemoglobin concentration of less than
11.5g/100ml OR hematocrit value below 30%

Need for folic acid/f olacin-one of the B vit. Necessary for

normal formation of RBC in the mother as well as
preventing neural tube defects in the fetus
-fetal defects of folic acid deficiency occur in the first few
weeks of fetal development
-women expecting to become pregnant are advised to
begin a supplement of 400µg folic acid daily and eat
folacin-rich food(green leafy vegetables, oranges, dries
beans)
-during pregnancy folic acid requirement increases to
600 µg/day

Megalohemoglobinemia/megaloblastic anemia
-folic acid deficiency anemia wherein it is characterized
by large, nonfunctioning RBC.(baby:spina bifida)

Heart
-since there is increase in bld volume in the circulatory
system , woman’s cardiac out put increases
significantly by 25-50%, then heart rate increases by 10
beats per minute.
Cardiac work increase occurs during the 2nd tri with
small increase in the third trimester.
Late pregnancy:
-heart is shifted to a more transverse position in the chest
cavity(position that may appear enlarge on xray exam.)
because the diaphragm is push upward by the growing
uterus.
-audible functional heart murmur(innocent) because of
the altered heart position

Palpitation in the early months of pregnancy

-caused by sympathetic nervous system stimulation
Later months
-resulted from increased thoracic pressure caused by the
pressure of the uterus against the diaphragm.
 Blood pressure
Despite the hypervolemia of pregnancy, BP does
not normally rise because the increased heart
action takes care of the greater amount of
circulating blood.
-normally BP does not elevate during
pregnancy
-most women, BP actually decreases slightly
during the 2nd tri because the peripheral
resistance to circulation is lowered as the
placenta expands rapidly
-3rd tri,BP rises again to 1st tri level.
 Peripheral blood flow
3rd trimester
-blood flow to the lower extremities is impaired
by the pressure on veins and arteries due to the
expanding uterus.
Implication
-the decrease in blood flow in the venous system
can lead to edema & varicosities of the vulva,
rectum and legs.
 Supine hypotension Syndrome
-decreased blood pressure is experience if
woman lies supine.
Supine/ dorsal position
-weight of the growing uterus presses the inferior
vena cava and descending aorta, obstructing
blood flow from the lower extremities hence
causes decrease in blood return to the heart
and consequently decreased cardiac output
and hypotention.
Maternal hypotension is dangerous because it
can cause FETAL HYPOXIA.
-May experience hypotension during second
and third trimesters (4th – 9th month)

-When woman lying on her back May

complain of faintness, lightheadedness, and
dizziness(signs & symptoms of supine
hypotension syndrome)
-can be corrected through left side lying
position.(so that blood flow to vena cava
increase again)
 Blood Constitution
-Level of fibrinogen increases as much as 50% during
pregnancy because of increased level of estrogen.
Fibrinogen –constituent of blood that is
necessary for clotting
-other clotting factors increases(factors VII,VIII, IX and X)
- Platelet increases( to safeguard whenever placenta is
dislodge or if uterine arteries and veins be opened)
-Total WBC count rises slightly
-blood lipids increased by 1/3 & cholesterol serum level
increases by 90% - 100% (provides readily supply of
available energy to the fetus)
 Blood Constitution
-decrease total protein level of the blood(due to
others was used by the fetus)
-circulating system has a lower protein load and
hypervolemia, fluid readily leaves the blood
vessels to equalize osmotic & hydrostatic
pressure
Implication: causes the common ankle
and foot edema of pregnancy not generalized
edema because its s symptom for PIH.
Normal values in pregnancy
Hematocrit
-32-42%
Hemoglobin
-10.5 – 14 g/dl

Criteria: Hct and Hgb should not fall

1st & 3rd tri
Hct less than 33%, Hgb less than 11 g/dl

2nd tri
Hct less than 32%, Hgb less than 10.5 g/dl
Urinary System
Changes in urination
First trimester
Urinary frequency due to increasing size of
uterus, creates pressure on bladder
Second trimester
Uterus rises up out of the pelvis and pressure on
bladder is relieved
Third trimester
Frequency returns due to pressure of baby’s
head on the bladder
Particularly last two weeks of pregnancy to 10-12
times/day
Urinary System
Urinary Tract changes during pregnancy
Variable Changes
Glomerular filtration increased by 50%
Renal Plasma Flow Increased by 25%-80%
Bladder capacity increased by 1,000 ml
Diameter of ureters increased by 25%
Frequency of urination increased in 1st tri,
decreased in second
increased in 3rd tri
Bld urea nitrogen Decreased by 25%
Plasma creatinine level Decreased by 25%
Renal threshold for sugar Deceased to slow slight
spillage
Urinary System

Reasons why there is a Urinary Tract changes during

pregnancy
-effects of estrogen and progesterone level
-compression of the bladder and ureters by growing
uterus
-increased blood volume

FLUID Retention
-total body water increase(7.5 L- to provide sufficient fluid
volume for effective placental exchange
-this requires the body to increase its sodium
reabsorption in the tubules to maintain osmolarity.
Urinary System
-under influence of progesterone, there is an increased
response of the angiotensin-renin system in the kidney
which leads to an increase in aldosterone production.
Aldosterone- aids sodium reabsorption.

-Progesterone is potassium-sparing(hence even if there is

increased urine output, potassium levels remain
adequate.)

why water is retained during pregnancy?

-to aid the increase in blood volume and serve as ready
source of nutrients to the fetus.(provide physiologic
benefits to the fetus)
-excess fluid can serve to replenish the mother’s own blood
volume if hemmorrhage occur.
Urinary System
During Pregnancy
- woman’s kidney excrete not only waste products of
her body but also those of the growing fetus.
-urinary output gradually increases by 60% to 80%.
-specific gravity decreases
- In early pregnancy there is an increased needs of the
circulatory system , hence Glomerular filtration rate
& renal plasma flow begin to increase to meet the said
needs or demand demand.(increased in second tri by
30% to 50% and remain for the duration of pregnancy.

- Efficient GFR(glomerular filtration rate) levels leads

to a lower blood urea nitrogen(BUN) and low
creatinine levels in maternal plasma.
Urinary System
The value of BUN and Creatinine that is Considered
abnormal and reflect the kidney’s difficulty in
handling the increased blood load.
BUN = 15mg/100 ml or higher
serum creatinine concentration = greater than 1
mg/100ml

Ureter & Bladder

-increased level of progesterone during pregnancy leads to
increase diameter in ureters and bladder capacity(1500
ml)
-bladder tone is reduced by effects of hormones on
smooth muscles
-pressure of enlarging uterus and the effect of estrogen
on smooth muscle cause dilatation of the ureters, the
right side dilates more than the left side in most
patients.
-kidney increase in size because of increase in renal
blood flow.This reverses after the first trimester.
-lowered specific gravity due to increased urinary
output.
-glycosoria (increased excretion of sugar)is caused by
lowered renal threshold(benedict’s test)
--nocturiainterrupted sleep at night due to need to
urinate(decreased fluid intake at least 2 hours before
bedtime, sidelying position)
-protenuria(excess serum proteins in the urine)
Hence the appearance is foamy.(Heat & acetic test)
Skeletal System
Changes in posture
Waddling gait
-Manner of walking in which the feet are
wide apart and the walk resembles that of
a duck
-Due to softening of pelvic joints and
relaxing of pelvic ligaments (to facilitate
the passage of the baby through pelvis at
birth.)
-wearing of low heeled or flat shoes to
prevent falls
Skeletal System
What causes the softening of the pelvic
ligaments and joint?
-caused by the influence of both ovarian
hormone RELAXIN and PLACENTAL
PROGESTERONE.
-wide separation of the symphysis pubis is 3-4
mm by 32 weeks of pregnancy. This makes the
women walk with difficulty because of pain.
Skeletal System
--Pregnant woman’s center of gravity is
offset, to change her center of gravity
and make ambulation easier, a
pregnant woman tends to stand
straighter and taller than usual. ”pride
of pregnancy”
LORDOSIS(pride of pregnancy)
- forward curve of the spine

*shoulders back and abdomen forward

creates a lordosis which may lead to
back achea.
Skeletal System
-calcium & phosphorus needs are increased
during pregnancy because the fetal skeleton
must be built.
Leg cramps
-may occur from imbalance of
calcium(hypocalcemia) in the body and from
pressure of the gravid uterus on nerves
supplying the lower extremities
Skeletal System
Management of leg cramps
-milk should be limited to 1 pint or 4 cups/day
or 3-4 servings.
-include in the diet the following:calcium –rich
food like sardines specially the head of the
fish, sea foods, cheese, yogurts, broccoli, dairy
products
-put the affected leg in a flat surface and then
dorsiflexion
Integumentary System
Changes in the skin
Possible increased feeling of warmth and sweating
 Due to increased activity of the sweat glands
Possible problems with facial blemishes
 Due to increased activity of sebaceous glands
Chloasma/melasma
 Hyperpigmentation (brown patches) seen on forehead,
cheeks, and bridge of nose
 Known as the “mask of pregnancy”
 Increased in pigmentation are caused by melannocyte
stimulating hormone(MSH) secreated by pituitary.
 After pregnancy these areas are lighten & disappear because
of the decrease in the level of hormone(MSH)
Changes in the skin
Linea Nigra
 Darkened vertical midline between the fundus and the
symphysis pubis on the abdomen
 Extra pigmentation of the abdominal wall

Areola
 Becomes darker as pregnancy progresses
Stria Gravidarum
 Stretch marks on the abdomen, thighs, and breasts that occur
during pregnancy
 Caused by stretching of the abdominal wall because of
increasing size of the uterus, stretching can cause rupture
and atrophy of small segments of the connective layer of
the skin hence lead to pink or reddish streaks or the so called
striae gravidarum.
 Do not scratch instead apply oil or lotion
Palmar erythema(redness and itching)
-may occur from increased estrogen level.

Diaphoresis
-excretion of waste through the skin

Diastasis
-the difficulty of stretching the abdominal wall that causes the rectus
muscles to actually separate
-if this happens, it will appear a bluish groove at the site of separation
after pregnancy.
Gastrointestinal System
As uterus increases , it tends to push the stomach and
intestines toward the back and sides of the abdomen
-the pressure is sufficient in midpoint of pregnancy
that leads to slowing intestinal peristalsis and
emptying of the stomach leading to
heartburn,constipation and flatulence.

Heartburn”pyrosis” –reflux of stomach content to the

esophagus.
Prevented: eating small frequent meals, avoid fatty and
spicy foods, body mechanics, taking sips of milk.
Morning sickness
-characterized by early morning n/v due to increased
hCG and reduction in hydrochloric acid secretion
that interfers with gastric motility.

First trimester morning sicknes

Prevented: getting out of bed slowly after eating a few
crackers, eating frequent, small meals after nausea
and avoiding spicy or greasy foods.

Hyperemesis graviidarum
-excessive vomiting during ppregnancy, may result to
metabolic alkalosis
Alkalosis
-occurs from vomiting or hyperventilation
Acidosis
-occurs from fecal losses

-Decreased emptying time of gallbladder(may lead to

development of gallstone)
-food craving
Pica-food craving of unusual sunstances(clay, starch,
dirt)
Ptyalism
-increased salivation caused b elevated estrogen
levels( nursing care:offer mouthwash)
Hyperemia and softening of gums with accompanying
hyperacidity of oral secretions
-result in nonspecific gingivities
-nursing care: increased vit. C & regular oral hygienne

Flatulence(due to increased progesterone)

-presence of excessive amount of gas in the stomach and
intestines
-avoid intake of gas-forming foods(rootcrops, beans)

Constipation
-condition in which bowel movements are infrequent or
incomplete
-due to hypoperistalsis, lack of fluids, poor dietary
habits, pressure of the enlarge uterus on internal
organs, effects of progesterone on muscles and
hemorroids
Prevented:
-increased fluid intake
-eating fiber rich food(oatmeal, papaya, pineapple,
grapes, apple, water melon)-regular exercise.

Hemorrhoid(due to gravid uterus)

-a varicose condition of the external hemorrhoidal
veins causing painful swellings at the anus
Management
-warm sitz bath
-sit on soft pillow
-high fiber diet & increased fluid intake

Changes in weight
Recommended weight gain during pregnancy
 Ranges from 25 to 30 pounds

Pattern of weight gain is important

 1st– 3rd month = 3 - 4 pounds total
 4th – 9th month = 1 pound per week

Critical to monitor weight gain for unexpected increases

 Fluidretention
 Pregnancy-induced hypertension
Respiratory System
Marked nasal congestion or stuffiness of the nasopharynx
-due to increased estrogen level.

There is pressure on Diaphragm and ultimately on the lungs

-diaphragm is displaced as much as 4cm upward.
-crowding of the chest cavity causes an acute sensation of
shortness of breath late in pregnancy until lightening.
Hyperventilation
-occurs due to the mother’s need to blow-off increased CO2
transferred to her from the fetus
Temperature

Early in pregnancy, body temp increases slightly

-due to secretion of progesterone from corpus luteum(temp.
which increased at ovulation remains elevated)
-16 weeks ,the temp. decreases to normal because the
placenta takes over the function of the corpus luteum.
Endocrine System
The most striking change in the endocrine system during
pregnancy is the addition of placenta as an endocrine
organ.
Placenta produces large amount of :
1.Estrogen
2. Progesterone
3.hCG
4.Human placental lactogen(hPL)/Human Chorionic
somatomammatropin
5.Relaxin
6.prostaglandins.
Endocrine System
Estrogen
-causes breast & uterine enlargement
-palmar erythema(early pregnancy)

Progesterone
-maintains the endometrium
-inhibiting uterine contractility
-aids in development of the breast for lactation

Relaxin
-secreted primarily by corpus luteum
-inhibits uterine activity
-softens the cervix & collagen in joints.
Endocrine System
Softening of the cervix
-allows dilatation at delivery
Softening of the collagen
-allows laxiness in the lower spine and helps enlarge the
birth canal.

hCG(secreted by trophoblast cells of the placenta early in

pregnancy)
-stimulates progesterone and estrogen synthesis in the
ovaries until the placenta can assume this role.
Endocrine System
Human Placental lactogen (hPL)/Human Chorionic
somatomammatropin(hCS)
-serve as an antogonist to insulin, making insulin less
effective, which allows more glucose to become available
for fetal growth.
-decrease utilization of protein for energy
-increasing protein available for fetal growth

Prostaglandin
-increases(high concentrations in female reproductive tract
and the decidua during pregnancy)
-affect smooth muscle contractility to such an extent they
may be trigger that initiates labor at term
Pituitary Gland
-halt in the production of gonadotropin hormons( FSH and
LH )due to high estrogen and progesterone levels of the
placenta
Implication: Anovulation
-increased of growth hormome & melanocyte-stimulating
hormone
Implication: causes skin pigment changes or increased skin
pigmentation)

Late in pregnancy
-begin to produce oxytocin(posterior pituiatry) which will be
needed to aid labor
-prolactin is increased to prepare the breast for lactation.
Thyroid gland
-slight enlargement early in pregnancy (effect: increased
basal metabolism rate)
-Increased thyroid hormone in blood serum: protein-bound
iodine, butanol-extractable iodine, thyroxine(effect:
increased oxygen consumption)

Parathyroid gland
-slight enlargement
-increased parathyroid hormone production
-Effect: better utilization of calcium and vit. D.
Adrenal glands
-adrenal glands activity increases in pregnancy hence
production of corticosteroids and aldosterone increases.
-increased levels supress an inflammatory reaction or help
reduce the possibility of the woman’s body rejecting the
foreign protein of the fetus.
-help regulate glucose metabolism in woman

Increased aldosterone level

-aids in promoting sodium reabsorption and maintaining
osmolarity in the amount of fluid retained, hence
indirectly helps safeguard the blood volume and to
provide adequate perfusion pressure across the placenta.
Pancreases
-Increase production of insulin in response to higher levels
of glucocorticoid produced by adrenal glands.
-insulin is less effective than normal because estrogen,
prrogesterone hPL are antogonist to insulin (produced by
placenta)

Woman who is diabeetic and is taking insulin before

pregnancy will need more insulin during pregnancy.
The effect of diminishing the action of insulin is beneficial
because it ensures a ready supply of glucose for fetal
growth.

Fetal Glucose level

-30mg/100ml lower than the maternal glucose level
Pancreases
-with insulin that is less effective, fat stores of the woman
are utilized as well as available glucose.
-with insulin ineffective, glucose levels rise, serving to
safeguard the fetus from hypoglycemia.
-maternal insulin does not cross the placenta

-to ensure against hypoglycemia pregnant woman should

keep her diet high in calories and should never go longer
than 12 hours between meals.

Early pregnancy
-fasting blood glucose level is usually low(80-85 mg/100 ml)
Because the fetus uses so much glucose .
Immune System
Why is it that Immunologic competency during pregnancy
apparently decreases?
-to prevent the woman’s body from rejecting the fetus as if
were a trasnplanted organ.

Why is it that woman is more prone to infection?

-Immunoglobulin G( IgG) production is particularly
decreased

Increased WBC
-this help counteract the decrease in IgG
Antepartum Care
or Prenatal care
Estimates in Pregnancy

A good preparation for the upcoming labor and

delivery prevents life threatening   risks to the mother
and the baby. To have an idea when the estimated
date of delivery (EDD) is, nurses and the midwives
should have knowledge on the different estimates
used for pregnant women.
These techniques may or may not exactly point out
the EDD or age of gestation, but it tries to estimate
the age of pregnancy and possible date of delivery for
the mother to be prepared.
Calculation of Date of Birth
Birth date for the baby
Expected Date of Confinement (EDC)
Expected Date of Delivery (EDD)
Expected Date of Birth (EDB)
Nagele’s Rule(EDC)

Nagele’s rule is used to determine the EDD on the

basis of the first day of the last menstrual period or
LMP.
To calculate the date of birth in this rule, subtract 3
months from the first day of LMP then add 7 days and
change the year. (-3 months + 7 days)
For example the last menstrual period (LMP) began
July 15, 2011. To determine the EDD follow the
following steps:
Subtract three months from beginning of last
menstrual period (LMP)
Add seven days to date = expected date of delivery
07- 15- 2011
3 + 7+ 1
4- 22- 2012

July-15,2011 = April 22,2012

*3 – 31- 2011 3-31 -2011 38 – 31 = 7
-3 +7 -3+7
0 or 12 – 38 EDD =13- 7-12

*3-23-20011 3-23-2011
-3 +7 -3+7
0 or 12 - 30 -2011
*1 -6-2011 13-6 -2011
-3 +7 -3 +7
10-13-2011

*2-6-2011 14 – 6 - 2011
-3+7 -3 +7
11 – 13

NOTE:
-Jan to March add 12 months before subtracting to 3
or +9+7 , the year is as is,
then April to Dec ( -3+7+1)
Date of Quickening(Q) ( EDC)
Primigravida: Date of Q + 4 months and 20 days = EDC
McDonald’s Rule(AOG)
McDonald’s Rule is used to determine the age of
gestation by measuring from the fundus (obtaining
the fundal height) to the symphysis pubis.

-used during mid pregnancy but inaccurate during third

trimester because the fetus is growing more in weight
than in height.
McDonald’s Rule(AOG)
Formula:

How to measure:first take the fundic height by

measuring the distance from the NOTCH of the
symphysis pubis to the fundus

Length of fundus in cm X 8/ 7 = AOG in weeks

Length of fundus in cm X 2 / 7 = AOG in months

36 cm X8 /7 = 41 weeks or ( 41/4 = 10.25 months)

36 cm X 2 /7 = 10.28 months or ( 10.28 X 4 = 41 weeks)
Johnson’s Rule(estimated the Fetal
Weight)

Johnson’s rule is used to estimate the weight of

the fetus in grams. To determine this, a standard
formula is used.
Formula: fundic height in cm – n x k
k is constant, it is always 155
n is 12 if the fetus is engaged. It is 11 if the fetus is
not yet engaged.
Example:
A fundic height of 28 cm, and the fetus is not
engaged.
28 cm – 11 x 155 = 17 x 155 = 2635 grams
Rump to Crown Length in Utero(EFW)

Formula:
Rump to crown length in
the utero in cm x 1oo = EFW in grams
Bartholomew’s Rule of fourths ( AOG)
-determine AOG by fundic location

A. 3 months (12 weeks) – just above the symphysis pubis

B. 4 months (16 weeks)- midway between symphysis pubis
& umbilicus
C. 5 months (20 weeks)- at the level of umbilicus
D.9 months(36 weeks) – just below the xyphoid process
E. 10 months(40 weeks) – level at 8 months due to
lightening.
Bartholomew’s Rule of fourths ( AOG)

This method estimates the age of gestation

relative to the height of the fundus of the uterus
above the symphysis pubis.
By 3rd lunar month (12 weeks), the fundus is
slightly palpated above the above the symphysis
pubis.
By the 5th lunar month (20 weeks), the fundus is
palpable at the level of the umbilicus.
On the 9th lunar month, the fundus is at the level
of the xiphoid process.
Calculations by fingers!: (AOG)
As days of a year are composed of a
heterogeneous combinations of numbers ( like six
months of 31 days, one month of 29 days which is
30 days every 4 years) , introducing a simple,
straight forward formula is practically impossible.
The Obstetrics rule that gestational age should be
presented in weeks +days adds to the complexity.
The only resort is to go through the lengthy
procedure of our ancestors to use fingers or add
/divide mathematics.
The following algorithm is what we go through
unconsciously when we calculate the gestational age;
from LMP to the time of visit.
1- First we have two dates:
LMP: like 2011/13/11 and the date the woman comes to
clinic like 2012/ 1/24.
Add all the days in a month starting on the LMP.
Divided by 4 to get the weeks
Divided by 7 to get the months
LMP Nov.13, 2011
Prenatal visit: Jan.24, 2012
- Nov.17
- Dec.31 72/7=10wks.& 2 days AOG
- Jan.24
72
Nursing Dx involving the changes that occur during pregnancy

Anxiety related to unexpected pregnancy

Altered breathing pattern related to respiratory
system changes of pregnancy
Disturbed body image related weight gain with
pregnancy
Deficient knowledge related to normal changes of
pregnancy
Imbalance nutrition, less than body requirements
related to morning sickness.
Vocabulary:
Gravida- a woman who is or has been pregnant
irrespective of the pregnancy outcome.
Nulligravida- a woman who is not now & never has
been pregnant
Multigravida- woman who has been pregnant at least
twice.
Para- number of pregnancies that have reached the
period of viability.(20-24 weeks)

Nullipara- a woman who has never given birth to an

infant capable of survival.
Primipara- A woman who is pregnant for the first time.
Multipara- woman who has had two or more
pregnancies resulting in viable fetuses, whether or not
the offspring were alive at birth.

Prenatal care visit(4 visits )

-1-3 months , 4-6 months ,7-8 months , 9months

Gravidity- total number of pregnancy

Parity – total number of viable pregnancy(TPAL)
Viability – ability of the fetus to live outside the uterus
(20-24 weeks/ 5-6 months)
PRENATAL RECORD: DEFINITIONS
Parturient – a woman in labor
*Puerpera – a woman who has just given birth
*4 – digit OB SCORE
(T – P – A – L)-Term, Preterm, Abortion,Living

GTPAL(G-gravida) 5 digit OB SCORE

Term- =between 37-42 weeks/38-42
Preterm = born more than 20 weeks but
les than 37 weeks
Post term: 42 above
Gravida
-in twins, triplets etc. it is counted as 1
Para
-counted also as one in number of viable pregnancy

Still bith /IUFD(intrauterine fetal death)”FDU”(fetal death

in the utero
-counted as one viable pregnancy
*if it falls between 37-42 weeks(counted under term)
*falls less than 37 weeks but more than 20
weeks(preterm)

If delivered before the age of viability(20-24 weeks/5-6

months)= considered as ABORTION
Mrs. Yu 2 months AOG visited the rural health unit with an
Obstetrical Hx that reveals her first pregnancy resulted to
an abortion:
Give: 1 abortion, 1 2nd month
=G2P0
=GTPAl = 2,0,0,1,0
Mrs. T is again pregnant at 4 months AOG. She disclosed
that she gave birth to her first child at 40 weeks AOG, her
second baby was aborted at 16 weeks, her third was a
stillbirth at 36 weeks AOG. Determine her OB score.

1-40 wks AOG

1- abortion
1 - still birth 36 weeks
1- 4 months AOG

G4P2
GTPAL = 41111
A prenatal visit was made by Mrs. Go who’s OB hx revealed
a baby boy del. By the 39 week AOG, her second
pregnancy resulted to a miscarriage, her third pregnancy
was a twin delivered at 35 week AOG and she is pregnant
at 3rd month. What is her OB score?
G P G T P A L
1-39 weeks 11 1 1 0 0 1
1-miscarrisge 1 0 1 0 0 1 0
1 twins 35weeks 1 1 1 0 1 0 2
1-3 months 4 2 4 1 1 1 3
Antepartum or Pre-natal period
- starts when the woman’s pregnancy is diagnosed
and ends just before the baby is delivered.
- Antepartum care promotes patient education and
provides ongoing risk assessment and
development of an individualized patient
management plan.
-  The major goal of prenatal care is not only to
ensure that a healthy baby is born but also to
promote the optimum health for the mother.
The following are the goals of antepartum care:

To evaluate the health status of the mother and the

fetus
To estimate the gestational age
To identify the patient at risk for complications
To anticipate problems before they occur and prevent
them if possible.
To promote patient education and communication
Identifying Patient at Risk for
Complications

Risk Factors
Age < 16 or > 35
2 spontaneous or induced abortions
< 8th grade education
> 5 deliveries
Abnormal presentation
Active TB
Anemia (Hgb <10, Hct <30%)
Chronic pulmonary disease
Cigarette smoking
Endocrinopathy
Epilepsy
Heart disease class I or II
Infants > 4,000 gm
Isoimmunization (ABO)
Multiple pregnancy (at term)
Poor weight gain
Post-term pregnancy
Pregnancy without family support
Preterm labor (34-37 weeks)
Previous hemorrhage
Previous pre-eclampsia
Previous preterm or SGA infant
Pyelonephritis
Rh negative
Second pregnancy in 9 months
Small pelvis
Thrombophlebitis
Uterine scar or malformation
Venereal disease
PREGNANCY EXAMINATIONS
Home Pregnancy Tests
75-percent sensitivity and a high false-negative result
rate.
12.5 mIU/mL- would be required to diagnose 95% of
pregnancies at the time of missed menses
PREGNANCY EXAMINATIONS
Sonographic Recognition of Pregnancy
4 to 5 weeks-(+) gestational sac in AUTZ
35 days- normal sac should be visible
6 weeks- heart motion should be seen
4days to 12 weeks- crown-rump length is predictive of
gestational
Obstetric History
Evidence of infertility
Previous pregnancies
Time in gestation when labor occurred
Duration
Type of delivery
Complications
Weight and sex of the baby
Postpartum course of both mother and fetus
Physical Examination
Systematic: Vital signs, weight, heart,
lungs, breast, abdomen, FHT, Fundic
height, fetal lie, pelvic exam, internal
exam, extremities, etc.
1. Leopold’s Maneuver
2. Pelvic Exam
3. Rectal and Rectovaginal Exam
Leopold’s Maneuvers
Leopold’s Maneuver is preferably performed after 24
weeks gestation when fetal outline can be already
palpated.
Preparation:
Instruct woman to empty her bladder first.
Place woman in dorsal recumbent position, supine
with knees flexed to relax abdominal muscles. Place a
small pillow under the head for comfort.
Drape properly to maintain privacy.
Explain procedure to the patient.
Warms hands by rubbing together. (Cold hands can
stimulate uterine contractions).
Use the palm for palpation not the fingers.
First Maneuver:
Fundal Grip
Purpose
To determine fetal part lying in the fundus.
To determine presentation.
Procedure
Using both hands, feel for the fetal part lying in the
fundus.
Findings
Head is more firm, hard and round that moves
independently of the body.
Breech is less well defined that moves only in
conjunction with the body.
Second Maneuver:
Umbilical Grip
Purpose
To identify location of fetal back.
To determine position.
Procedure
One hand is used to steady the uterus on one side
of the abdomen while the other hand moves
slightly on a circular motion from top to the lower
segment of the uterus to feel for the fetal back and
small fetal parts.
Use gentle but deep pressure.
Findings
Fetal back is smooth, hard, and resistant surface

Knees and elbows of fetus feel with a number of

angular nodulation
Third Maneuver:
Pawlik’s Grip
Purpose
To determine engagement of presenting part.
Procedure
Using thumb and finger, grasp the lower portion of the
abdomen above symphisis pubis, press in slightly and
make gentle movements from side to side.
Findings
The presenting part is not engaged if it is not
movable.
It is not yet engaged if it is still movable.
Fourth Maneuver:
Pelvic Grip
Purpose
To determine the degree of flexion of fetal head.
To determine attitude or habitus.
Procedure
Facing foot part of the woman, palpate fetal head
pressing downward about 2 inches above the inguinal
ligament.
Use both hands.
Findings
Good attitude – if brow correspond to the side
(2nd maneuver) that contained the elbows and
knees.
Poor atitude – if examining fingers will meet an
obstruction on the same side as fetal back
(hyperextended head)
Also palpates infant’s anteroposterior position. If
brow is very easily palpated, fetus is at posterior
position (occiput pointing towards woman’s back)
Pelvic Examination
Early months- establish the diagnosis of
pregnancy or determine the presence or
absence of uterine or adnexal pathology
7th month AOG- evaluate and measure
obstetric pelvis
Pelvic tissues are more relaxed
Pelvic cavity empty (uterus become abdominal
organ)
Ischial spine and sacral promontory are more
palpable
Rectal and Rectovaginal Exam
Evaluate integrity of perineum and
competence of rectal sphincter
Detect possible presence of rectocoele or
extent if present.
Rule out pathologic conditions of rectum
Laboratory Tests
First visit:
Hemoglobin/ hematocrit
Urinalysis
Blood type and Rh factor
Antibody screen
Pap smear
Urine culture
Laboratory Tests
8 – 18 weeks : Ultrasound
Amniocentesis
Chorionic villous sampling
15 – 20 weeks: Maternal Alpha FetoProtein screening
24 – 28 weeks: Glucose tolerance test
Repeat Hemoglobin/ hematocrit
35 – 37 weeks : Repeat ultrasound
Repeat hemoglobin/ hematocrit
Rectovaginal culture (Group B strep)
Promoting Patient Education

Since the goal of antepartum care is to help achieve a

maternal and infant outcome as much as possible,
this means that psychosocial issues as well as
biological issues needs to be addressed.  One of the
major components of pre-natal care is HEALTH
TEACHING. The following are some important health
teaching during the antepartum period.
Topics for Patient Teaching
First Trimester
Developmental task: to accept the biological facts of
pregnancy: I am pregnant
Attitude toward pregnancy
Weight gain
Exercise and rest
Substance use/abuse
Traveling
Health teaching:
-bodily changes, personal hygiene, nutrition
Topics for Patient Teaching
Second Trimester
Developmental task: to accept the growing fetus as a
baby to be nurtured: I am going to have a baby
Concerns related to body changes
Fetal movement
Clothing
Care of skin and breasts
Decisions about infant feeding
Health teaching: growth & development of the fetus
Topics for Patient Teaching
Third Trimester
Developmental task: to prepare for birth and
parenting of a child: I am going to be a mother.
Exercise and rest
Traveling
Preparation for labor and birth
Decision-making about early postpartum
 Assistance
 Contraception

Health Teaching: Responsible parenthood

-best time to prepare baby’s layette, buying baby’s clothes,
lamaze classes may also be offered.
Nutrition. This is the most important aspect of
health teaching.
Nutritional Risk Factors during pregnancy:
Teenagers or adolescent (increased nutritional
needs)
Follows food fads(not adequate for pregnancy)
Underweight or overweight (indicate chronic
inadequate dietary patterns)
Low income women (not have resources to purchase
adequate food)
Short interval between pregnancies (has not had
time to replace nutritional stores depleted during
previous pregnancy)
Drug use (including cigarettes and alcohol)
Existence of a chronic illness requiring a special diet
Lactose intolerance (may not ingesting adequate
calcium for fetal growth development)
Multiple pregnancy (must supply enough nutrition
for multiple fetal development)
Anemic at conception(no iron stores for fetal growth)
Relationship of maternal
nutrition to infant health
Weight gain. The recommended average weight
gain in pregnancy is 11.2 to 15.9 kg or 25-35 lbs.
Weight gain in pregnancy occurs at
approximately 1 lb per month during the first
trimester and then 1 lb per week during the last
two trimesters.
 For a more accurate estimation of adequate
weight gain, computation of body mass index
(BMI) can be done.
To calculate for BMI, refer at the box below.
The following are the normal
prepregnancy BMI;
Underweight – under 18.5
Normal weight – 18.5 – 24.9
Overweight – 25 – 29.9
Obese – above 30
Calculating the Body Mass Index
(BMI)Example:
Mrs. White is 5’4” tall and weighs 130 lbs.
 To determine her BMI:
Convert weight into kilograms. (divide weight in
pounds by 2.2)
- 130 / 2.2 = 59 kg
Convert height into centimeters. (multiply height
in inches by 2.5)
- 5 x 12 = 60 + 4 = 64 inches (foot to inches)
- 64 inches x 2.5 = 160 cm (inches to cm)
Convert centimeters into meters. (divide result
by 100)
- 160 / 100 = 1.6 meters
Square height in meters.
- 1.6 x 1.6 = 2.56
Divide weight in kilograms by height in meters
squared.
- 59 / 2.56 = 23 BMI
- Interpretation of Result:23 BMI = Normal
Weight, thus, Mrs. White enters pregnancy at
normal weight.
?????Mrs. X is 5’2 tall & weighs 100lbs.

Convert weight into kilograms. (divide weight in

pounds by 2.2)
-100/2.2=45.45kg
Convert height into centimeters. (multiply height in
inches by 2.5)
- 5X12=60+2= 62 inches (foot to inches)
- 64x 2.5=155cm (inches to cm)
Convert centimeters into meters. (divide result by
100)
- 155/100=1.55meters
Square height in meters.
-1.55x1.55=2.40
Divide weight in kilograms by height in meters
squared.
- 45.45/2.40=18.9
- Interpretation of Result:18.9BMI = Normal Weight,
thus, Mrs. X enters pregnancy at normal weight.
5’6 tall- 160lbs.
Convert weight into kilograms. (divide weight in
pounds by 2.2)
-160/2.2=72.73kg
Convert height into centimeters. (multiply height in
inches by 2.5)
- 5X12=60+6= 66 inches (foot to inches)
- 6x 2.5=165cm (inches to cm)
Convert centimeters into meters. (divide result by
100)
- 165/100=1.65meters
Square height in meters.
-1.65x1.65=2.72
Divide weight in kilograms by height in meters
squared.
- 72.73/2.72=26.74
- Interpretation of Result:26.74 BMI = over weight
Recommended Nutrient
requirements during Pregnancy
Calorie needs. The easiest way for determining a
woman’s caloric intake is assessing the weight she is
gaining. The pattern of weight gain is as important as
the total weight gain.

Calories:
-essential to supply energy for:
*increased metabolism
*utilization of nutrients
*Protein sparing used for growth of fetus and
development of structures requires of pregnancy
including placenta, amniotic fluid, and tissue growth.
Nonpegnant= 2200
Pregnant + 300 = 2500
Lactation : + 500 = 2700

Note:
-decrease in caloric requirement can lead to KETOSIS
(overproducion of ketones) as fats and protein are used
for energy, ketosis is associated with fetal damage.
-protein and complex carbohydrates(whole grains,
vegetables and fruits)
Protein
Essential for:
*fetal tissue growth
*maternal tissue growth including uterus and breast
*development of essential pregnancy structures.
*formation of RBC and plasma proteins
*inadequate protein intake has been associated with
onset of PIH.
Protein needs. The daily recommended intake in
women is 44 to 50 mg. During pregnancy, the need
for protein increases to 60 mg daily. Foods rich in
protein are meats, fish, eggs, milk, poultry, cheese,
beans and monggo, nuts, whole grains.

Note:
-adolescents have higher protein requirements than
mature women since they must supply protein for
their own growth and to met the pregnancy
requirement.
Food Guide Pyramid
Calcium-phosporous(minerals)
Essential for:
-growth & development of fetal skeleton and tooth buds
-maintenance of mineralization of maternal bones &
teeth
-current research is demonstrating an association
between adequate calcium intake and prevention of
PIH
Requirement:Calcium 1200 mg/day with 10mcg/day of
vit.D(for absorption of both calcium &
phosporus)Phosphorus: 700 mg
Sources: dairy products, green lefy veg, canned sardines
with bones
Vit. D:egg yolk, sea food, butter, liver.
IRON(minerals)
-expansion of blood volume & RBC formation
-establishment of fetal iron stores for 1st few months of
life
Requirement: 30 mg/day in second trimester

60-120 mg along with copper & Zinc supplementation

for women who have low Hgb values prior to pregnancy
or who have iron deficiency anemia

70 mg/day of vit C for better absorption(sources of vit.C

;citrus fruits, and juices, (tomatoes, straberries, green
peppers, cabbage, potatoes)
IRON
Inadequate intake may result in:
Maternal Effects
- Iron deficeincy anemia(most common), depletion of iron
stores, decreased energy and appetite, cardiac stress
especially during labor & birth

Fetal Defects
-decreased availability of oxygen thereby affecting fetal
growth
Sources:
Liver, red meat, fish, poultry, eggs, dark green leafy veg.
nuts, dried fruits, enriched whole grain cereals and
breads.
Zinc(mineral)
-formation of enzymes
-important in the prevention of congenital
malformation of the fetus.
Requirement: 15 mg/day(prepregnant;12mg)
Sources:
-liver meats
-shell fish
-eggs, milk, cheese
-whole grains ,legumes, nuts
Folic Acid/folacin/Folate
-formation of RBC and prevention of folic acid
deficiency anemia
-DNA synthesis and cell formation; prevention of
neural tube defects, abortion and abruptio plaenta

Requirement: 600 micogram/day

Deficiency: can lead to development of spina Bifida
Sources:
-liver, kidney,dark green leafy veg.(broccoli,
asparagus,
-whole grains, peanuts
Other minerals
Iodine: 175 microgram
Magnesium: 350mg
Flouride: 3 mg

Others water soluble vit.

Ascorbic acid: 85mg Vit.B12 : 2.6 microgram
Niacin:17 mg Vit. B6: 2.0 mg
Riboflavin: 1.6 mg
Thiamine: B1: 1.4 mg
Fat Soluble Vitamins:

Vitamin A – 800 microgram

Vitamin A supplement.
Foods rich in Vitamin A are eggs, carrots, squash, and all
green and leafy vegetables.
Vitamin D – 5 microgram
Vitamin D supplement
Foods rich in Vitamin D are fish, liver, eggs, milk. Excess

Vitamin E – 15 mg
sources are green leafy vegetables and fish
Vit. K
Note: stored in the body, accumulates in the kidney,
toxic if taken daily, no need for supplement
To AVOID in pregnancy
1. Foods with caffeine
-caffeine is a CNS stimulant: capable of increasing
HR, urine production in the kidney, secretion of
acid in the stomach
8 cups of coffee/day: associated with increased still
birth
Sources: coffee, chocolate, soft drinks, tea

A cup of coffe= 120 mg caffeine

Hot chocolate= 10 mg caffeine
2. Artificial sweeteners
-the use of saccharides is not recommended during
pregnancy because it is eliminated slowly from the fetal
blood stream(need carbohydrates furnish by sugar)
3. Weight loss diets
-reducing diets and calorie restrictions are contraindicated
during pregnancy because this lead to FETAL
KETOACIDOCIS and POOR GROWTH
4. Smoking. Cigarette smoking causes vasoconstriction
which leads to low birth weight infants and has been a
risk factors for some complications during pregnancy.
Thus, it is contraindicated during pregnancy.
5. Teratogenic drugs can cause congenital defects
to the fetus, hence, they are contraindicated
unless prescribed by the physician. The following
are medications that are contraindicated during
pregnancy:
Thalidomide – can cause Amelia or Phocomelia
(underdevelopment of arm or leg)
Steroids – can cause cleft palate and abortion
Iodides – can cause enlargement of the fetal
thyroid gland leading to tracheal decompression
and dyspnea at birth. Iodides are contained in
many OTC cough suppressants.
Vitamin K – can cause hemolysis and
hyperbilirubinemia
Aspirin and Phenobarbital – can cause bleeding
disorders and tendencies
Streptomycin and Quinine – can cause damage to the
8th cranial nerve
Tetracycline – can cause staining of tooth enamel
and inhibits growth of long bones.

Alcohol. Alcohol is a known teratogen and maternal

alcohol use is a leading cause of mental retardation.
Health Promotion During Pregnancy
1. Bathing. Daily baths protects pregnant women from
infections that may develop if bacteria normally
present on the skin are allowed to remain and
multiply.
*last trimester, balance is altered by a changing center
of gravity and she is prone to falls.
Health Promotion During Pregnancy
Hot tubs and Sauna. Caution the woman not to be
in sauna for more than 15 minutes or a hot tub for
more than 10 minutes and to keep her head and chest
out of water. Maternal hyperthermia, particularly
during the first trimester may be associated with fetal
anomalies.
Health Promotion During Pregnancy
2.Breast care. Instruct the expectant mother to avoid
using soap on her nipples because it removes the
natural lubricant that forms on the nipples. Advise her
to wear bra that fits well and supports her breasts to
prevent loss of muscle tone that can occur as the
breast becomes heavier during pregnancy.

*wear firm, supportive bra with wide straps to spread

weight across the shoulders
*at 16th week of pregnancy colostrum secretions begins,
wash breast with clear tap water to remove colostrum
and reduce the risk for infection.
-if colostrum is profuse, place a gauze squares or
breast pads inside her bra, changing them frequently
to maintain dryness.

Note: constant moisture next to the breast nipple can

cause nipple excoriation, pain, and fissuring.
Health Promotion During Pregnancy
3.Dental Care
-gingival tissue tend to hypertrophy during pregnancy
-encourage to see dentist regularly for routine exam &
cleaning.
-tooth decay occurs from action of bacteria on sugar.This
lowers the pH of the mouth, creating an acid medium
that leads to etching or destruction of enamel teeth.
-encourage to snack on nutritious foods and vegetables to
avoid sugar coming in contact with the teeth.
-if had trouble avoiding sweet snacks, only those that
dissolve easily only like chocolate bar not chewy candy.
Health Promotion During Pregnancy
4.Perineal Hygiene
-Douching. Despite increased vaginal discharge,
douching is unnecessary before, during or after
pregnancy. (because the force of the irrigating fluid
could cause it to enter the cervix and lead to infection)
-douching alters pH of the vagina leading to an
increased risk of bacterial growth.(alkaline)
Health Promotion During Pregnancy
5.Dressing
-avoid garters, extremely firm girdles with panty legs
and knee high stocking
Reason:
-impede lower extremity circulation

Shoes
-moderate to low heel
Reason:
-minimize pelvic tilt and possible backache
6. Sexual Activity.
During the first trimester, there is a decrease in
sexual desire as the woman is more preoccupied
with the changes in her body and because of
increased estrogen level in her body.
 However, during the second trimester, there is
an improvement in the sexual desire as the
woman has already adapted to the growing fetus.
 During the third trimester, a decrease in sexual
desire is noted as the woman is afraid of hurting
the fetus.
 Sex in moderation is permitted during pregnancy.
 During the last 6 weeks of pregnancy, sexual activity
is not advised as it has been noted that there is
increased evidence of postpartum infection on
women who engage in sex during the last 6 weeks.
 Sex is contraindicated in the following situations:
 Hx of spontaneous miscarriage
 Spotting or bleeding
 Incompetent cervical os
 Ruptured BOW
 Deeply engaged presenting part

Sexual Position:sidelying, wot(woman on top)

7. Employment. As long as the job does not entail
handling toxic substances or lifting heavy objects or
excessive physical and emotional strain, there is no
contraindication to working. It is important for the
nurse to advise the pregnant woman to walk about
every few hours of working long periods of standing
or sitting to promote circulation.
8.Traveling. There are no travel restrictions during
pregnancy. However, trips should be postponed on
the last trimester of pregnancy. On long trips, it
is advisable to allot about 15-20 minute of rest
period
every 2-3 hours to walk about or empty the bladder.
Reason:
-relieve stiffness and muscle ache and improve lower
extremity circulation
-helps prevent varicosities, hemorrhoid, and
thrombophlebitis.
9.Tetanus Immunization. Tetanus Immunization
should be given to pregnant women.
Schedule
TT1
- interval: at first contact with woman 15-49 yrs.or at
first antenatal care visit
- Duration of protection: No protection
TT2
Atleast 4 weeks after TT1
Infants born to the mother will be protected from
neonatal tetanus
3 years of protection for the mother
TT3
At least 6 months after tt2
Infants protected from neonatal tetanus
5 years of protection for the mother
TT4
At least 1 year after TT3
10 years of protection for the mother
TT5
Atleast 1 year after TT4
Lifetime protection for the mother
Schedule of AP visit
At least 4 routine antenatal visits
1st visit: before 4 months
2nd :6 months
3rd :8 months
4th :9 months –return if undelivered within 2 weeks
after the EDC
1-7 month= once a month
8-9 month = twice
10 months = every week
Post term = twice a week
10. Exercise
Goal of Performing Prenatal Exercises: To strengthen
the muscle that will be used in labor and delivery.
Exercise during pregnancy is important to prevent
circulatory stasis.
Extreme exercise is associated with lower birth rate
-swimming is good activity for pregnant woman
provided that membranes are still intact(relieve back
ache)”moderation”
30 consecutive minutes everyday
-5 minutes=warm up
-20 minutes= stimulus or active phase
-5 minutes cool-down exercises.
10. Exercise
Walking
-best exercise during pregnancy
-promote circulation
Guidelines in Performing Exercises during
pregnancy:
Exercise should be done in moderation. Recommend
that moderate exercise should be done 30 or more
minutes daily.
The pregnant woman should avoid strenuous
activity or intensifying training.
Exercises where there is a risk of falling or
abdominal trauma should be avoided.
Pre-natal exercises should NOT be done during a
hot or humid weather.
All exercises in supine position after the first trimester of
pregnancy should not be done by the pregnant woman as
this position increases the risk of supine hypotensive
syndrome.
Should be individualized. Meaning the exercises
recommended for each pregnant woman should be
according to ones age, physical condition, customary
amount of exercise and the stage of pregnancy.
Adequate fluid intake before and after exercise should be
practiced by the pregnant woman.
Exercises that cause fatigue should be stopped.
It is important to follow the health care provider’s
advice about taking the pulse rate during the
exercise and keeping it within a certain range.
The pregnant woman should stop the exercise and
seek medical advice if she experiences the following:
Chest pain
Dizziness
Headache
Decreased fetal movement
Signs of labor
Pelvic Rock
Maintains good posture
Relieves abdominal pressure and low backaches
Strengthen abdominal muscles following delivery
Squatting
 Modified knee-chest position

Relieves pelvic pressure and cramps in

thighs or buttocks
Relieves discomfort from hemorrhoids
Shoulder
circling
Strengthens
muscles of
the chest
Kegel exercise(pelvic floor excercise)
-strengthen pelvic floor muscles ,which support the
uterus, bladder ,small intestine and rectum.
-Squeeze the muscle surrounding the vagina as if
stopping the flow of urine.Hold for 3 seconds
Relax.Repeat the sequence 10 times.

-Relieves congestion and discomfort in pelvic region

-Tones up pelvic floor muscles

Postpartum:((also helpful)
-reduce pain and promote perineal healing
11.Sleep
During sleep
-growth hormone secretion is at highest level
-There is an Increased metabolic demand of
pregnancy hence increased amount of sleep is
needed.
Trouble falling sleep
-drink a glass of warm water
Good resting or sleeping position
-modified sim’s position, with the top leg forward(this
puts the weights of the fetus on the bed, this allows
circulation in the lower extremities.
PRENATAL SURVEILLANCE
Maternal
1. Blood pressure—current and extent of change
2. Weight—current and amount of change
3. Symptoms—including headache, altered vision,
abdominal pain, nausea and vomiting, bleeding,
vaginal fluid leakage, and dysuria
4. Height in centimeters of uterine fundus from
symphysis
5. Vaginal examination late in pregnancy
1) Confirmation of the presenting part and its station.
2) Clinical estimation of pelvic capacity and its general
configuration
3) Consistency, effacement, and dilatation of the cervix.
Prenatal Instructions
1. Inform possible problems and discuss
management
2. Begin antepartum educational program by
means of personal interviews, reading
materials and hospital classes.
3. Explain future visits
4. Discuss the economic aspect of pregnancy
5. Give instructions about diet, relaxation and
sleep, bowel habits, exercise, bathing,
recreation, sexual intercourse, smoking,
drug and alcohol ingestion
6. Emphasize danger signals: vaginal bleeding,
persistent vomiting, fever and chills, sudden
escape of fluid from vagina, abdominal pain,
swelling of face, blurring of vision,
continuous headache
Common prescription in prenatal Visits
A. Iron with folic acid Supplementation
Low dose Vit. A Supplementation
TT Schedule
Iodized Capsule(goiter endemic areas)
Chloroquine Phosphate (for malaria endemic areas)
Method for nonpharmacologic Pain reduction during labor
1.Lamaze method/psychoprophylactic method
-Ferdinand Lamaze
-based on the gating control theory of pain relief
-based on the theory that through stimulus-response
conditioning, women can learn to use controlled
breathing to reduce pain during labor
-it focuses on preventing pain in labor by use of mind
Six major concepts are stressed in Lamaze
1.Labor should begin on its own not artificially induces
2.Women should be able to move about freely
throughout labor, not be confined to bed
3.Women should receive continuous support during
labor
4.No routine interventions such as intravenous fluid are
needed
5.Women should be allowed to assume a non-supine
(upright or sidelying) position for birth
6.Mother and baby should be housed together
following birth with unlimited opportunity for breast-
feeding.
3 main premises are taught in the prenatal period related to the
gaiting control method of pain relief
1.Pain occurs to lesser extent if a woman is relaxed.
-teach the process of labor and delivery, anatomy..etc
2.Sensations such as uterine contractions can be
blocked from reaching the brain cortex and
registering as pain through active interventions.
-woman is taught to concentrate on breathing patterns
and to use imagery or focusing on specific object to
block incoming pain sensations.
3 main premises are taught in the prenatal period related to the
gaiting control method of pain relief
3.Conditioned reflexes can also be used to displace
pain during labor.
-teach learning conditioning reflexes.(teaching the
woman to relax automatically on hearing a
command”contraction beginning, or feel of
cpontraction beginning)
2. Dick-Read Method
-Grantly Dick-read
-based on the premise that fear leads to tension which
leads to pain
-must break the chain between fear and tension.
-woman achieves relaxation and reduced pain by
focusing on abdominal breathing during contraction.
3.Bradley(partner-Coached) method)
-Robert Bradley
-based on the premise that childbirth is a joyful natural
process and stresses the important role of woman’s
partner during pregnancy, labor and the early
newborn period.
Danger Signs During Pregnancy
ABC’s of Danger signs of pregnancy
Abdominal pain(epigastric pain is an aura of an empending
convulsion)
Bleeding ( 1st tri-abortion, ectopic 2nd tri- Hmole, incompetent
cervix , 3rd tri-placental anomalies),board like
abdomen(abruptio placenta),blurred vision(preeclampsia),Bp
increased(hypertension)
Chills and fever(signs of infection)/ cerebral disturbance(head
ache-sign of preeclampsia)
Dysuria( painful urination -sign of infection)
Edema or swelling of the upper extremeties(preeclampsia)
Fetal movements change
Gush of fluid from vagina(PROM-predispose both mother and
fetus to infection.
Danger Signs in Pregnancy
Visual Disturbances
Blurred
Blurred Vision
Vision
Blurred
Blurred Vision
Vision

Double Vision
Double Vision
Blind Spots
Halos
Danger Signs in Pregnancy
Swelling or Edema
generalized
face
fingers
pretibial
sacrum
Danger Signs in Pregnancy
Headaches
severe
continuous
unrelieved
Danger Signs in Pregnancy
Muscular irritability
Seizures
Danger Signs in Pregnancy
Epigastric pain
Danger Signs in Pregnancy
Check BP
Check reflexes
Check clonus
Order baseline PIH labs
Proteinuria
Platelets
Serum creatnine, LDH, AST, ALT
Danger Signs in Pregnancy
Fluid discharge from
vagina
bleeding
amniotic fluid
Danger Signs in Pregnancy
Bleeding
Threatened, missed, spontaneous abortion
 βHcg
 U/S

 Bedrest/Pelvic rest/expectant management

Placenta previa
Abruptio placenta
Determine last sexual intercourse
Danger Signs in Pregnancy
Amniotic fluid
Nitrazine
Ferning

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 Test
 Nitrazine test
 Fluid from vaginal exam
placed on strip of nitrazine
paper
 Paper turns blue in presence
of alkaline (pH > 7.1) amniotic
fluid

 Fern test
 Fluid from vaginal exam
placed on slide and allowed to
dry
 Amniotic fluid narrow fern vs.
cervical mucus broad fern
Danger Signs in Pregnancy
Persistent vomiting
Danger Signs in Pregnancy
Urinalysis for ketones
Check skin turgor
Check mucous membranes
Check weight
Danger Signs in Pregnancy
Signs of infection
fever
chills
dysuria
Danger Signs in Pregnancy
Viral?
URI?
UTI?
Danger Signs in Pregnancy
Abdominal pain
severe
unusual
Danger Signs in Pregnancy
Round ligament pain
Abruption
Preeclampsia
Danger Signs in Pregnancy
Change in fetal
movements
absence
pattern
count
Danger Signs in Pregnancy
Check for FHTs
NST
Danger Signs in Pregnancy
 C = Chills and fever
Cerebral disturbances
 A = Abdominal pain
 B = Blurred vision
Blood pressure
Bleeding
 S = Swelling
Sudden escape of fluid
Pregnancy brings both psychological and
physical changes to a woman. Although
occurring gradually, the physiologic changes of
pregnancies affect all organ systems of a woman’s
body.
These changes are necessary for both the woman
and the growing fetus. Through these changes
the fetus is provided with oxygen and nutrients
and the woman’s increased metabolism during
pregnancy is met.
1.Nausea and vomiting
70-90% of all pregnant women have nausea…until 12
weeks
Relief
 Dry crackers/toast
 Avoid odors/causative factors

 Small, frequent, dry meals

 Pyridoxine

 Emetrol: 1-2 tbs q 15’

2.Urinary Frequency
Void frequently
 fluids in the evening
3.Fatigue
Plan naps and rest
Seek assistance
Avoid caffeine
Warm milk
4.Breast tenderness
Wear well-fitting, supportive bra
5. Leukorrhea(whitish, viscous
vaginal discharge)
Hygiene
Avoid douching
Avoid pantyhose
Cotton underwear

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6.Ptyalism(sialorrhea)
- Excessive production of saliva

Astringent mouthwashes
Chew gum or suck hard candy
Good oral hygiene

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 7.Pyrosis(heartburn)
-uncomfortable burning sensations in the lower chest

Small, frequent meals

Low-sodium antacids/Tums
Avoid overeating, fatty and fried foods
Tagamet 200 mg
Zantac 75 mg
8.Varicose Veins(development of
tortous leg veins or may extend into the vulva
- Comon in pregnancy because the weight of the distended uterus
puts pressure on the veins returning the blood from lower
extremities. This causes the pooling of blood and destension of the
vessels.
- Veins becomes engorged, inflamed and painful

- Elevate legs frequently

Support hose
Avoid standing for prolonged periods
Avoid crossing legs
Avoid excessive weight gain
8.Varicose Veins(development of
tortous leg veins or may extend into the vulva
Sim’s position or on the back with the legs raised against the
wall or elevated footstool for 15-20 minutes twice a day

Some women developed varicosities during previous

pregnancy : need an elastic support stocking(TEDS) to
relieve of varicocities.(don before arises in the morning)

Vit c is helpful in reducing the size of varicosities because it

is necessary for the formation of vessel collagen and
endometrium.
9.Constipation
- Occurs because the weight of the growing uterus
presses against the bowel and peristalsis slows hence
constipation occur.

fluids( 8 oz glasses/day), fiber and exercise

Regular bowel habits
Stool softeners

-not to use mineral oil to relieve constipation

Because it can absorb fat soluble Vit(ADEK)
And flush them out of the body
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9.Constipation
Avoid Enemas
-their action can initiate labor

Stool softener
-docusate sodium (colace)
Evacuation suppositories
-glycerin

Flatulence acoompanying constipation

-avoid gas forming foods(cabbage, beans, rootcrops)

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10.Hemorrhoids(varicosities of
the rectal veins)
-because of pressure on rectal veins by growing fetus

Avoid constipation
Ice packs, topical ointments, tucks pads
Warm soaks or cool sitz baths
Kegels
High fiber diet
Stool softeners
Applying witch hazel or cold compress(pain relief)
11.Flatulence
Limit gas forming foods
Carbonated beverages, beans, cheese, bananas, peanuts
Avoid mint
12.Abdominal discomfort/Round
ligament pain
Avoid stretching/twisting
Flex knee and hip on affected side
Heat
Avoid excessive exercise
13.Leg cramps
Dorsiflex feet to stretch
Heat
Wear low heeled shoes

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 14. Faintness
Avoid sudden changes in position
Avoid prolonged standing
Wear compression stockings
Ankle Edema(Dependent Edema)

Foot exercises
Maternity support hose
Elevate feet and legs
avoid prolonged standing
Drink 6-8 glasses of water daily
Resting in side lying position:
-increases kidney’s glomerular filtration rate & allows
good venous return
Avoid wearing constricting clothes(panty girdles)
Backache
-Proper body mechanics
Pelvic tilt exercises/pelvic rock
Comfortable, low-heeled shoes
Back rubs
Dyspnea

Evaluate for severity

Avoid restrictive clothing
Posture
Avoid warm environments www.reliefmart.com

Pillows for sleeping

Headache
- Because of expanding blood volume which put
pressure on cerebral arteries.

-resting with cold waters on the forehead and

acetaminophen
Braxton Hicks Contraction
-beginning as early as 8th to 12th week of pregnancy,
uterus periodically contracts and then relaxes again.
Thank you!!