INTRODUCTION TO OBSTETRICS

Obstetrics- is the branch of medicine that

deals with the management of pregnancy,
parturition( labor and delivery) and
puerperium ( the sixth weeks following
childbirth)
SIGNIFICANT DEVELOPMENT IN OBSTETRICS

PRIMITIVE PERIOD
 WOMAN IN LABOR GIVES BIRTH IN SQUATTING POSITION OR
SIT IN SPECIAL BIRTH STOOL
 KILLING OF BABY IS PRACTICED
 CHILD IS NOT CONSIDERED A PERSON WITH SOUL UNTIL HE
RECIEVES A NAME AND PRESENTED TO SPIRIT
ANCIENT TIME( ANCIENT EGYPT)
 EGYPTIANS ARE CONSIDERED TO BE THE FOUNDERS OF
MEDICINE
 CHILDREN WERE VALUED HIGHLY AND INFANTICIDE WAS
NOTALLOWED BY THE LAW DURING THIS TIME
 PRACTICE OF MEDICINE WAS MORE SOPHISTICATED – FORCEP,
CS,PODALIC VERSION WAS ALREADY PRACTICED DURING THIS
PERIOD.
ANCIENT INDIA
 HIPPOCRATES WAS CONSIDERED THE “
FATHER OF MEDICINE”
 SORANUS OF EPHESUS WAS
CONSIDERD THE ‘FATHER OF
OBSTETRICS”
MIDDLE AGE
LYING- IN HOSPITAL ARE ALREADY AVAILABLE
MIDWIVES ARE CONSIDERED ATTENDANTS OF
NORMAL DELIVERY
DOCTORS ATTEND COMPLICATED DELIVERIES
WET NURSING OR BREAST FEEDING WAS
PRACTICED
PRESENT TRENDS
 PRENATAL CARE ARE PRACTICE
 HUSBAND AND WIFE ARE ENCOURAGED TO SHARE INCHILD-
BEARING EXPERIENCES
 ROOMING-IN AND MOTHER-BABY FRIENDLY HOSPITAL
STARTS
 Unang Akap or First Embrace practice.
 KMC or Kangaroo mother care
 Breast feeding practice intensified.
MATERNAL ADAPTATION TO PREGNANCY
 BIOCHEMICAL, PHYSIOLOGICAL AND ANATOMIC CHANGES

A. ORGANIC CHANGES
UTERUS- HYPERTROPHY AND DILATATION
1. NON- PREGNANT UTERUS- ALMOST SOLID WITH 10ML
CAVITY
PREGNANT UTERUS- BECOMES THIN- WALLED AND ENLARGED
TO ACCOMMODATE FETUS,PLACENTA, AMNIOTIC FLUID
2. TOTAL
VOLUME OF UTERINE CONTENTS AT TERM
AVERAGES ABOUT 5 LITERS TO AS MUCH AS 10 LITERS
OR MORE WHICH IS 500-1000 TIMES ITS NON-
PREGNANT CAPACITY
3. NON- PREGNANT UTERUS WEIGHTS ABOUT 70
GRAMS
TERM PREGNANCY -1100 GRAM
4.PREGNANCY- HYPERTROPHY/ENLARGEMENT OF
MUSCLE FIBERS AND TO A LIMITED DEGREE AND DUE
TO ESTROGEN AND PROGESTERONE.
5.UTERINE WALLS BECOME THICKER DURING FEW
MONTHS THEN BECOME THIN AS 1.5 CM AT TERM THIS
ALLOWS MOVEMENT OF THE FETAL EXTREMITIES AND
FACILITATE PALPATION OF FETAL PARTS ABDOMINALLY
BY LEOPOLD’S MANUEVER.
UTERINE SIZE,SHAPE,AND POSITION
SIZE
1. BY THE END OF THE 12TH WEEK GESTATION, THE
UTERUS HAS GROWN TOO LARGE TO REMAIN IN
THE PELVIS, SO IT RISES UP TO THE ABDOMINE
CAVITY.

SHAPE- PEAR SHAPE-GLOBULAR to OVOID FROM 1

WEEKS UNTIL TERM
NOTE: INCREASEOF FUNDIC HEIGHT IS AN IMPORTANT
SIGN OF FETAL GROWTH AND WELL BEING.
12 WEEKS - FUNDUS CAN ALREADY BE PALPATED AS IT
RISES OUT OF THE PELVIC CAVITY.
 AT THE LEVEL OF SYMPHISIS PUBIS.

1 WEEKS - HALFWAY BETWEEN SYMPHISIS PUBIS AND UMBILICUS.

2OWEEKS - AT THE LEVEL OF UMBILICUS.

2 WEEKS - TWO FINGERS ABOVE UMBILICUS.

2-3 WEEKS - MIDWAY BETWEEN UMBILICUS AND XYPHOID PROCESS.

32-3 WEEKS - TWO FINGER BELOW THE XIPHOID PROCESS.

WEEKS- TWO FINGERS BELOW UMBILICUS, DROPS AT 3 WEEKS

LEVEL
WEEKS- TWO FINGERS BELOW UMBILICUS, DROPS AT 3 WEEKS
LEVEL BECAUSE OF LIGHTENING.
ISTHMUS – NARROW PORTION OF THE UTERUS THAT JOINS THE
CONNECTIVE TISSUE OF THE CERVIX TO THE MUSCLE FIBERS OF
THE BODY OF THE UTERUS.
HEGAR’S SIGN – REFERS TO THE SOFTENING OF THE LOWER
UTERINE SEGMENT THE BEGINS AS EARLY AS 5 WEEKS
GESTATION.
CERVIX COLOR
MATERNAL ADAPTATION TO PREGNANCY
A.CARDIOVASCULAR SYSTEM
1. AT 3RD MONTHS, THERE IS AN INCREASE IN BLOOD VOLUME OF
30-50% ( AROUND 1500 ML) WHICH CONTRIBUTES TO
INCREASED CARDIAC WORKLOAD. BLOOD VOLUME IS
INCREASED TO MEET THE DEVELOPMENT NEEDS OF THE FETUS.
THIS INCREASE FURTHER WITH MULTIPLE PREGNANCIES.
2. MOTHER FEELS FATIGUE ( LASSITUDE)
3. SLIGHTLY HYPERTROPHY OF VENTRICLES
4. HEART RATE INCREASES 10-15 BEATS PER MINUTE IN THE LETTER
HALF OF PREGNANCY
5. PALPITATION IS ALSO COMMON DUE TO STIMULATION OF THE
SYMPATHETIC NERVOUS SYSTEM
6. BLOOD PRESSURE MAY DROP SLIGHTLY IN SECOND TRIMESTER
7. SUPINE HYPOTENSION SYNDROME: IN SUPINE POSITION
WEIGHT OF ENLARGED UTERUS OBSTRUCTS VENA CAVA,
WHICH DECREASES BLOOD RETURN TO HEART THERFORE
DECREASING CARDIAC OUTPUT RESULTING TO HYPOTENSION,
LIGHTHEADEDNESS,FAINTNESS AND PALPITATIONS.
8. WHITE BLOOD CELLS, FIBRINOGEN AND OTHER
CLOTTINGFACTORS INCREASES.
9. PHYSIOLOGIC ANEMIA
a. occurs as a result of hemodilution of the blood.
b. There is 45-50% increase in blood volume expansion, of
which about 75% is plasma and 25% is RBC.
c.Normal values in pregnancy
 Hct. 32-42 %
 Hgb. : 10.5-14 g/L
11. PATHOLOGIC ANEMIA
a. IRON DEFICIENCY ANEMIA-MOST COMMON
HEMATOLOGIC DISORDER AFFECTS ROUGHLY 20% OF
PREGNANT WOMEN
b. ASSEESSMENT REVEALS: PALLOR, SLOWED CAPILLARY REFIL,
CONCAVE FINGERNAILS( LATE SIGN OF PROGRESSIVE
ANEMIA) CAUSED BY CHRONIC TISSUE HYPOXIA AND
CONSTIPATION
NURSING CARE
 Nutritional INSTRUCTION- INCREASED IRON IN THE DIET
 PARENTERAL IRON THRU Z- TRACT METHOD.IF NOT GIVEN
PROPERLY HEMATOMA FORMATION MAY OCCUR
 ORAL IRON SUPPLEMENTS ( FERROUS SULFATE 0.3G,3X A DAY)
BEST GIVEN 1 HOUR BEFORE MEALS OR WITH EMPTY STOMACH
FOR BETTER ABSORPTION, HOWEVER CAN LEAD TO GIT
IRRITATION, HENCE, GIVEN ON FULL STOMACH BUT WITH
VITAMIN C TO ENHANCE ABSORPTION.
SIDE EFFECT: CONSTIPATION AND BLACK TARRY STOOL.
 MONITOR FOR HEMORRHAGE
 IRON FROM REDIS BETTER ABSORBED THAN IRON FROM OTHER
SOURCES
 IRON IS BETTER ABSORBED WHEN TAKEN WITH FOODS RICH IN
VITAMIN C SUCH AS ORANGE JUICE
 HIGHER IRON INTAKE IS RECOMMENDED SINCE CIRCULATING
BLOOD VOLUME IS INCREASED AND IS REQUIRED FROM
PRODUCTION OF RBC’S.
BEST SOURCES OF IRON : LIVER,LEAN OR RED MEAT,
LEGUMES SUCH AS MONGGO AND GREEN LEAFY
VEGETABLES SUCH AS KANGKONG, AMPALAYA,
SPINACH AND MALUNGAY
11. EDEMA OF THE LOWER EXTREMITIES IS NORMAL
BUT EDEMA IN THE UPPER EXTREMITIES IS A SIGN OF
PRE-ECLAMPSIA
12.VARICOSITIES- CAN BE PREVENTED THRU WEARING OF
PANTYHOSE OR SUPPORT STOCKINGS
13. THROMBOPHLEBITIS OR DEEP VEIN THROMBOSIS
( DVT) – VENOUS INFLAMMATION WITH THROMBUS
FORMATION.
SIGNS AND SYMPTOMS:
 (+) HOMAN’S SIGN –PAIN ON CALF UPON DORSIFLEXION
 MILK LEG OR “PHLAGMASIA ALBA DOLENS”-SHINY
WHITE LEG BROUGHT ABOUT BY STREGHING AND
INFLAMMATION OF SKIN.
NURSING INTERVENTIONS:
 COMPLETE BED REST
 NEVER MASSAGE THE AFFECTED LEG TO PREVENT
THROMBOEMBOLISM.
 ASSESS THE PATIENT FOR HOMAN’S SIGN ONCE ONLY.
 ANTICOAGULANT PREVENTS ADDITIONAL THROBUS
 AVOID GIVING ASPIRIN BECAUSE IT MAY AGGREVATE BLEEDING
PROBLEM( ANTIDOTE: PROTAMINE SULFATE)
ENDOCRINE SYSTEM
1. ELEVATED HCG LEVELS WHICH REACHES PEAK AT THE THIRD
MONTHS THEN DROPS
2. ESTROGEN AND PROGESTERON INCREASE AND CONTINUE TO
BE SECRETED FROM THE PLACENTA DURING THE LAST 6
MONTHS OF PREGNANCY
3. THYROID ACTIVITY IS INCREASED; NORMAL PREGNANCY MAY
EMULATE A MILD HYPERTHYROID STATE.
RESPIRATORY SYSTEM
1. THE MOTHER EXPERIENCES SHORTNESS OF BREATH BECAUSE OF
ENLARGING UTERUS AND THERE IS ALSO AN INCREASED OXYGEN
DEMAND; POSITION THE MOTHER ON LEFT SIDE LYING TO PROMOTE
LATERAL EXPANSION OF THE LUNGS
2. HYPERVENTILATION OCCURS DUE TO THE MOTHER’S NEED TO
BLOW-OFF INCREASED CARBON DIOXIDE TRANSFERRED TO HER
FROM THE FETUS.
3. NASAL CONGESTION OCCURS AS A RESPONSE TO INCREASED
ESTROGEN LEVELS
GASTROINTESTINAL SYSTEM
1. MORNING SICKNESS-CHARACTERIZED BY EARLY MORNING
NAUSEA AND VOMITING DUE TO INCREASED HCG AND
REDUCTION IN HYDROCHLORIC ACID SECRETION THAT
INTERFERE WITH GASTRIC MOTILITY.
NURSING MANAGEMENT:
 GETTING OUT OF BED SLOWLY AFTER EATING CRACKERS
 SMALL FREQUENT MEALS
 AVOID SPICY OR GREASY FOODS
2. HYPEREMESIS GRAVIDARUM- EXCESSIVE VOMITING DURING
PREGNANCY . MAY RESULT TO METABOLIC ALKALOSIS
 ACID: ALKALOSIS- OCCURS WITH LOSSES FROM VOMITING OR
HYPERVENTILATION
 BASE: ACIDOSIS- OCCURS FROM FECAL LOSSES ( DIARRHEA)
4. HEARTBURN OR PYROSIS- REFLUX OF STOMACH CONTENT TO THE
ESOPHAGUS.CAN BE PREVENTED BY EATING SMALL FREQUENT
MEALS, AVOIDING FATTY AND SPICY FOODS, PROPER BODY
MECHANICS AND TAKING SIPS OF MILK.
5. DECREASED EMPTYING OF GALLBLADDER MAY PRECIPITATE
DEVELOPMENT OF GALLSTONES.
6. FOOD CRAVINGS MAY OCCUR UNSUAL CRAVED (PICA) FOR
EXAMPLE:
CLAY,DIRT,STARCH
7. PTYALISM- INCREASED SALIVATION CAUSED BY ELEVATED
ESTROGEN LEVELS.
NURSING CARE: OFFER MOUTH WASH
8.SOFTENING OF THE GUMS WITH ACCOMPANYING
HYPERACIDITY OF ORAL SECRETIONS RESULT IN NON
SPECIFIC GINGIVITIS.
NURSING CARE: :INCREASE VITAMIN C INTAKE AND REGULAR
ORAL HYGIENE
9. FLATULENCE- PRESENCE OF EXCESSIVE AMOUNT OF GAS IN
THE SOMACH AND INTESTINES DUE TO INCREASED
PROGESTERONE. IT CAN BE LESSENED BY AVOIDING
INTAKE OF GAS- FORMING FOODS LIKE ROOT CROPS, BEANS
10. CONSTIPATION-A CONDITION IN WHICH BOWEL MOVEMENT
ARE INFREQUENT OR INCOMPLETE CAUSED BY HYPOPERISTALSIS,
LACK OF FLUIDS,POOR DIETARY HABITS, PRESSURE OF THE
ENLARGED UTERUS ON INTERNAL ORGANS, EFFECTS OF
PROGESTERONE ON MUSCLE AND HEMORRHOIDS.
Management:
 Increase oral fluid intake
 Eat high fiber diet-oatmeal,papaya,pinya
 Regular exercise
11. Hemorrhoids -a varicose condition of the external
hemorrhoidal veins causing painful swelling at
the anus. This is due to the gravid uterus
Nursing intervention:
 Warm sitz bath
 Sit on soft pillows
 High fiber diet
 RENAL SYSTEM
1. PROXIMITY OF THE UTERUS AND BLADDER IN EARLY AND LATE
PREGNANCY CAUSES URINARY FREQUENCY
a. 1ST TRIMESTER- FREQUENT URINATION
b. 2nd TRIMESTER- NORMAL AS BLADDER IS ALREADY ADJUSTED.
c. 3rd TRIMESTER – INCREASE IN FREQUENCY OF URINATION DUE TO
PRESSURE OF THE GRAVID UTERUS ON URINARY BLADDER.
2. BLADDER TONE IS REDUCED BY EFFECTS OF THE HORMONES ON
SMOOTH MUSCLES.
3. PRESSURE OF ENLARGING UTERUS AND THE PROGESTERONE EFFECT
ON SMOOTH MUSCLES CAUSES DILATATION OF THE URETERS. THE
RIGHT SIDE DILATES MORE THAN THE LEFT IN MOST PATIENTS.
4. THE KIDNEYS INCREASE IN SIZE BECAUSE OF THE
INCREASE IN RENAL BLOOD FLOW. THIS REVERSES
AFTER THE FIRST TRIMESTER.
5. INCREASED URINARY OUTPUT RESULTS IN LOWERED
SPECIFIC GRAVITY.
6. GYCOSURIA- INCREASED EXCRETION OF SUGAR
CAUSED BY LOWERED RENAL THRESHOLD;
DETERMINED BY BENEDICT’S TEST
7. NOCTURIA- IS THE NEED TO GET UP DURING THE NIGHT IN ORDER
TO URINATE, THUS INTERRUPTING SLEEP, MANAGED BY:
A .Decreased oral fluid intake at least two hours before bedtime
B .Side lying or lateral position
8. PROTEINURIA-EXCESS SERUM PROTEIN IN THE URINE GIVING ITS
FOAMY APPEARANCE; DETERMINED BY HEAT AND ACETIC ACID
TEST
 MUSCULOSKELETAL SYSTEM
1. LORDOSIS- “ PRIDE OF PREGNANCY”
2. SOFTENING OF ALL LIGAMENTS AND JOINTS, especially symphysis and
sacroiliac joints, caused by increased hormonal action of estrogens and
relaxin.
 WADDLING GAIT- awkward walking due to relaxin hence, the mother is
candidate for accidental falls.
3. LEG CRAMPS may occur from an imbalance of calcium ( hypocalcemia) in
the body and from pressure of the gravid uterus on the nerves supplying the
lower extremities.
 INTEGUMENTARY SYSTEM
1. STRIAE GRAVIDARUM OR STREACH MARKS- caused by enlarging uterus
which causes destruction of connective tissue resulting from separation
of underlying collagen which appears as irregular scars. Do not scratch
instead apply oil or lotion.
2. PROTRUDING UMBILICUS
3. LINEA NIGRA- used to be the linea alba but changes to brownish-pinkish
line running from symphysis pubis to the umbilicus due to increased
melanin.
CHLOASMA-melanoderma or MELASMA characterized by
the occurrence of extensive brown patches of irregular
shape and size on the skin of the face and elsewhere; the
pigmented facial patches.it is also called “ MASK OF
PREGNANCY” and are associated most commonly with
pregnancy and use of oral contraceptive.
5. Excretion of wastes through the skin causes diaphoresis
REPRODUCTIVE CHANGES
1. AMENORRHEA- occurs because the corpus luteum persists and
ovulation is inhibited by high level of circulating estrogen and
progesterone.
2. Changes in the uterus are circulatory , hormonal and related to
fetal growth
a. CHADWICK’S SIGN –purplish discoloration of the cervix and
vaginal mucosa.
 LEUKORRHEA –whitish gray, moderate in amount vaginal
discharge
b. GOODELL’S SIGN – softening of the cervix.
 OPERCULUM- mucus plug to seal off bacteria, hormone responsible
is progesterone
c. HEGAR’S SIGN- softening of the lower uterine segment
d. Uterus enlarges in size
e. Changes in position of the uterus
 First trimester: uterus in pelvic cavity
 Second and third trimester: uterus is in abdominal cavity before
lightening occurs.
3. OVARIES –pregnancy is the rest period for the ovaries.
4. BREAST CHANGES such as fullness, tingling, soreness, and darkening of
the areola and nipples occur along with an increase in hormonal
levels.
Disc omfort during p reg. Trimester most Re lief measures
p rominent
N ausea and vomiting 1st  E at five or six small frequent meals,crackers,
av o id foods high in carbohydrates,fried and
gre asy, or with strong o dor
F requency o f urination 1 s t and 3rd We ar p erineal pads if t here is leakage
nd
he artburn 2 and 3rd Av oid fatty fatty, fried and highly spiced foods,small
fre quent feedings,use antacids
Abdominal distress 1st ,2nd,3rd E at slowly, chew foods thoroughly, take smaller
amo unt o f foods
nd
flat ulence 2 and 3rd Maintain daily bowel movement, avoid gas –forming
fo o ds. Take antacids flatulence as doctors
nd
c onstipation 2 and 3rd Drink sufficient fluids, eat fruit and foods high in
ro ughage
E xe rcise moderately
Take stools softener if p rescribed by doctor
he morrhoids 3rd Ap ply o intment s suppositories ,warm compresses,
av o id constipation and get adequate rest
insomia 3rd E xe rcise moderately to p romote relaxation and
fat ique
Change position while sleeping, if severe c onsult a
do ctor
backache 3rd Re st and improve posture, use a firm matters
U se a good abdominal support, wear comfortable
shoes
Do e xercises such as squatting, sitting and pelvic
ro ck
Varicosities o f legs and 3rd Av oid long periods of standing or sitting with legs
v ulva wit h legs crossed, sit or lie with feet and hips
e le vated, move about while standing t o improve
circulation
We ar support hose, avoid t ight garters
E de ma o f legs and 3rd E levated feet while sitting or lying do wn
le g cramps E xt end cramped legs and flex ankles pushing foot
up ward with toes pointed toward knees, increase cal.
 SIGN AND SYMPTOMS OF PREGNANCY

PRESUMPTIVE SIGN
- SIGNS ANS SYMPTOMS ARE FELT AND OBSERVED BY THE MOTHER BUT
DOES NOT CONFIRM THE DIAGNOSIS OF PREGNANCY.
 B- breast changes f 1st trimester
 U- urinary frequency i
 F-fatigue r
 A- amenorrhea s
 M- morning sickness t
 E- enlarged uterus
2ND TRIMESTER SIGNS AND SYMPTOMS OF PREGNANCY

PRESUMPTIVE

C-chloasma
L- linea nigra
I- increased pigmentation
S- striae gravidarum
Q- quickening
PROBABLE
Signs and symptoms observed by the mother and the members of the
health care team
FIRST TRIMESTER
 G- Goodell’s sign
 C- Chadwick’s sign
 H-Hegar’s sign
 P-Positive HCG
2ND TRIMESTER PROBABLE S/S
 B- Ballotment – floating or bounching back of the fetus
when the uterine segment is tapped sharply; it may also
be a sign of uterine myoma
 E – enlargemed abdomen
 B- Braxton – hicks contraction- painless and irregular
contraction
POSITIVE SIGNS AND SYMPTOMS
Undeniable signs confirmed by the use of instruments.
FIRST TRIMESTER
 Ultrasound-in general full bladder
 Transabdominal- supine and full bladder
 Transvaginal- lithotomy and empty bladder
POSITIVE S/S 2ND TRIMESTER
 F-FETAL HEART TONE AUDIBLE
 F- FETAL MOVEMENT
 F- FETAL OUTLINE
 F- FETAL PARTS PALPABLE
POSITIVE EVIDENCE OF PREGNANCY
1. hearing or pulsations assures diagnosis:
a. by stethoscope by the 17th weeks of pregnancy on the average and
almost all pregnancies by the 19th week AOG ranging from 120 to
160 bpm which is distinct from the mother’s pulse.
b. A doppler can detect fetal heartbeat almost always by the 10th to
12th weeks AOG.
2. Echocardiography can detect fetal heart always by the 10 th to the 12th
weeks AOG.
3. Ultrasonography can detect fetal heartbeat as early as 5 weeks post LMP.
4. In the later months of pregnancy, other sounds can be heard over the
abdomen such as:
a. Funic or umbilical souffle
b. Uterine souffle
c. Maternal pulse
d. Sounds resulting from fetal movements
e. Gurgling sounds of gas in the intestine
II. PSYCHOLOGICAL ADAPTATION DURING PREGNANCY

A. 1ST TRIMESTER
ESTABLISH AN ACCEPTANCE OF PREGNANCY
1.No tangible signs and symptoms
2. Feeling of surprise, ambivalence ( existence of two opposing
feelings), emotional , money worries, body image changes
3. denial: a sign of maladaptation to pregnancy
DEVELOPMENTAL TASK:
To accept the biological facts of pregnancy” I Am pregnant”

HEALTH TEACHING:
 Bodily changes, personal hygiene and nutrition
B. 2ND TRIMESTER: CONTINUATION OF PREGNANCY

1. WITH TANGIBLE SIGNS AND SYMPTOMS

2. ROLE IDENTIFICATION AND HEIGHTENED SENSE OF TIME
3. MOTHER IDENTIFIES AS A SEPARATE ENTITY DUE TO
QUECKENING
4. MOTHER BEGINS TO FANTASIZE THE APPEARANCE OF THE
BABY
5. CHANGE IN SEXUAL INTEREST; FATHER EXAMINES HIS OWN
ABILITY TO PARENT.
DEVELOPMENTAL TASK:
TO ACCEPT THE GROWING FETUS AS A BABY TO BE NURTURED “ I
AM GOING TO HAVE A BABY”.

HEALTH TEACHING:
 GROWTH AND DEVELOPMENT OF THE FETUS.
C. 3RD TRIMESTER:PREPARATION FOR SEPARATION OF
THE BABY
1. Mother has a personal identification of the appearance of the
baby
2. Mother has fears due to enlarged abdomen. Allow her to hear the
FHT
3. Labor and delivery are on the mother’s mind; safe passage for
herself and the newborn
4. Nesting behaviors: busy days and restless nights
5. Father prepares for birth and his involvement.
DEVELOPMENTAL TASK:

 To prepare for birth and parenting of the child. “ I AM GOING TO

BE A MOTHER”

HEALTH TEACHING;

Responsible parenting; best time to prepare for baby’s layette,

shopping and buying baby’s clothes, Lamaze classes may also be
offered
 DEFINITION OF TERMS:

1. Labor – a low risk throughout, spontaneous in onset

with the fetus presenting by vertex culminating in the
mother and infant in good condition following birth
(WHO, 1977).
 A process by the products of conception is expected
through the birth canal after the 28th weeks of
frequency (Cunningham).
Precipitate labor – labor which lasts for three hours or less.
2. First stage of labor – the period from the onset of true labor contraction until full
cervical dilatation and effacement is achieved.
3. Uterine contraction – hardening of the uterus caused by the contraction of the uterine
muscle.
4. Latent phase of labor – or preparatory phase begins at the onset of regularly perceive
uterine contraction and ends when rapid cervical dilatation begins.
5. Active phase of labor – cervical dilatation occurs more rapidly going from 4cm to
7cm and a period of maximum stage cervical dilatation proceed at its most rapid
phase.
6. Transitional phase – maximum dilatation of 8cm to 10cm occurs contraction reach
their peak of intensity occurring every 2cm to 3cm duration
7. Cervical dilatation – is the process of enlargement of the os uteri from
a tightly closed aperture to opening large enough to permit passage of
the fetal head.
8. Cervical effacement – refers to the inclusion of the cervical canal into
the lower uterine segment.
9. Multiple os – terms used a parous woman effacement and dilatation
that may occur simultaneously and small canal may be felt in early
labor.
10.Cephalic presentation – the head is the body part that first contacts the
cervix
11.Floating – is when the head is still movable above the pelvic inlet on palpation.
12.Fixation – is the descent of the fetal head to the inlet to a level that it can no longer be
moved.
13.Moulding – is the changes in shape of the fetal skull produced by the forces of
uterus contraction pressing the vertex against the not yet dilated cervix.
14.Descent – refers to the downward movement of the fetus in the birth canal brought
about the forces of uterine contractions.
15.Rupture of membrane or bag of water – is signified by gush or steady tickle of clear fluid
from the vagina.
16.Retraction ring or bandl’s ring – an indention across the women’s abdomen where the
upper and lower segment of the uterus join.
CHANGES DURING THE LAST WEEK OF PREGNANCY

1. Mood swing is common and surge of energy may be experienced.

2. Two to three weeks before the onset of labor the lower uterine segment
extends and allows the fetal head to sink lower and it may engage in
the pelvis.
3. Walking may become more difficult for some women at the end of
pregnancy because the symphsis pubis is more mobile and relaxation
of the sacroiliac joints may give rise to backache.
CARE AND MANAGEMENT OF ANTENATAL
WOMAN
Ante natal period- refers to the nursing care given to the mother from
fertilization to the beginning of true contractions.
A. Personal data
1. Name ,age, address
2. Sex
a. Pseudocyesis or false pregnancy-father of mother can experience
presumptive or probable signs of pregnancy however there is no FHT.
b. Couvade syndrome- psychosomatic reaction wherein the father
experiences what the mother goes through during pregnancy.

3. Civil status
a. unwed mothers are considered high risk patients.
b. home based mother’s record(HBMR) to determine high risk
pregnancy.
4. Religion- to determine cultural diversity
5. Occupation-to determine occupational hazards
6. education-to determine level of knowledge
B. DIAGNOSIS OF PREGNANCY
1. Amenorrhea
2. Urine pregnancy test-may be positive within days of the first
missed menstrual period.
a. Human Chorionic gonadotropin (HCG)
present at 41-100th day of pregnancy
b. HCG peaks at 60-70th day
c. 6th week after LMP best time to do the test
3. Fetal
heart tones can be detected as early as 8 weeks from the last
menstrual period ( LMP) by Doppler.
Normal Fetal heart rate is 120- 160 beats per minute and it is irregular.
4. Fetal movements ( quickening ) are first felt by primiparous mother at
18-20 weeks.
5. ultrasound-will visualize a gestational sac at 5-6 weeks and a fetal
pole with movement and cardiac activity by 7-8 weeks. Ultrasound
can estimate fetal age accurately if completed before 24 weeks.
6. Estimated date of delivery. The mean duration of pregnancy is 40
weeks from LMP.EDD can be calculated by Nagele’s rule: add 7 days
to the first day of the LMP, then subtract 3 months.
BASELINE DATA
1. ROLL – OVER TEST – IS PERFORMED TO DIAGNOSE PRE- ECLAMPSIA USING THE
BLOOD PRESSURE
A. THE MOTHER IS PLACED ON SIDE LYING POSITION FOR ABOUT 10-15 MINUTES
THEN PLACED IN SUPINE.
B. NEXT, THE BP IS TAKEN.
C. IF THE SYSTOLIC PRESSURE IS GREATER THAN 30 MMHG AND THE DIASTOLIC
PRESSURE IS ABOVE 15 MMHG ,A SIGN TO SUPPORT DIAGNOSIS OF PRE-
ECLAMPSIA
INCREASE IN WEIGHT
IS THE FIRST SIGN OF PRE- ECLAMPSIA BUT PATTERN OF WEIGHT GAIN IS MORE IMPORTANT.
MINIMUM WEIGHT GAIN: 20-25 LBS.
OPTIMUM WEIGHT GAIN : 25-35 LBS.

IDEAL WEIGHT GAIN

PER TRIMESTER PER MONTH
First: 1.5 – 3 lbs. 1 lb/ mos.
Second:10-12 lbs. 4 lbs./mos.
Third : 10-12 lbs. 4 lbs./ mos.
total gain: 20- 25 lbs
Multifetal pregnancy: 35-40 for twins, 50 for triplets.
GYNECOLOGIC AND OBSTETRIC HISTORY

1. GRAVIDITY- is the total number of pregnancies.

2. PARITY- is the total number of viable pregnancies; expressed as the
number of Term pregnancies, Preterm pregnancies, Abortion and
Live birth(TPAL)
3. VIABILITY- the ability of the fetus to live outside the uterus at the
earliest possible gestational age; 20-24 th weeks or 5-6 months
4. GTPAL SCORE
a. GRAVIDA : number of pregnancy
b. Term: born between 37-42 weeks
c. Preterm: born more than 20 weeks but less than 37 weeks.
d. Abortion: number of pregnancy ending in therapeutic or
spontaneous abortion.
e. Live: living children.
GENERAL RULE IN GETTING GTPAL
=Multiple gestations(twins,triplets,etc.)is counted as one in the number of
pregnancy(Gravida) and is counted as one in the number of viable
pregnancy(Para)
=Stillbirth/Intrauterine Fetal Death(IUFD)/Fetal Demise is counted as one
viable pregnancy
-If it falls between 37 to 42 weeks it is counted under term pregnancy
-If it falls less than 37 weeks but more than 20 weeks it is counted in
preterm pregnancy.
=If the product of conception was delivered before the age of viability(20-24
weeks) it is considered under abortion
Mrs. Palaypay is pregnant again at 3 months AOG .She told the nurse that she gave
birth to her 1st child at 38 weeks AOG her second baby was aborted at 15 weeks,
her 3rd was still birth delivered at 35 weeks AOG. Determine her OB score.
Gravida-pregnancy more than 20 weeks AOG G-4
Term-38weeks and above T-1
Preterm-less than 37 weeks P-1
Abortion-less than 20 weeks A- 1
Living- alive L- 1
4-1-1-1-1
A prenatal visit was made by Mrs. Duterte who’s OB history revealed a
baby boy delivered by 39 weeks AOG, her second pregnancy
resulted to a miscarriage, her 3rd pregnancy was a twin delivered
at 35th weeks AOG and she is pregnant at 3rd month. What is her
OB score?

G4 P2 GTPAL = 4-1-1-1-3
5. The character and length of previous labors.
6. Type of delivery, complications, infant status, and birth
weight are recorded.
7. Assess prior cesarean sections and determine type of C-
section(low transverse or classical), and determine
reason it was performed.
F. Medical
and surgical history and prior hospitalizations are
documented.
G. Medications and allergies are recorded
H. Family history of medical illnesses, hereditary illness, or
multiple gestation is sought.
I. Social history. Cigarettes, alcohol, or illicit drug use.
J. Review of systems. Abdominal pain, constipation, headaches,
vaginal bleeding, dysuria or urinary frequency, or hemorrhoids.
ESTIMATION OF GESTATIONAL AGE
NAEGELE’S RULE- USED TO DETERMINE THE EXPECTED DATE OF DELIVERY
BY DETERMINING THE LMP OF THE MOTHER.

2. MC DONALD’S RULE – USED TO DETERMINE THE AGE OF GESTATION.

Formula:
a. Length of fundus in cm x 8/7 = AOG in weeks or
b. Length of fundus in cm x 2/7 = AOG in months
 3. BARTHOLOMEW’S RULE
TO DETERMINE AGE OF GESTATION BY FUNDIC LOCATION.
a. 3 MONTHS – JUST ABOVE THE THE SYMPHYSIS PUBIS.
b. 4 MONTHS – MIDWAY BETWEEN SYMPHYSIS PUBIS AND UMBILICUS
c. 5 MONTHS – AT THE LEVEL OF THE UMBILICUS
d. 9 MONTHS – JUST BELOW THE XYPHOID PROCESS
e. 10 MONTHS – LEVEL AT 8 MONTHS DUE TO LIGHTENING.
 HAASE’S RULE
 To determine the length of the fetus in centimeter.
a. First half of pregnancy ( 1-5 months ): Month2
b. Second half of pregnancy ( 6-10 months): Month x 5
 After 20 weeks, there is a correlation between the number of weeks of
gestation and the number of centimeter from the pubic symphysis to the top
of the fundus.
 Uterine size that exceeds the gestational dating by 3 or more weeks suggests
multiple gestation , molar pregnancy , or ( most commonly ) an inaccurate
date for LMP . Ultrasonography will confirm inaccurate dating or
intrauterine growth failure.
LEOPOLD’S MANEUVERS
 Done to determine the attitude, fetal presentation, lie,
presenting part, degree of descent, estimate of fetal size, fetal
back, FHT, number of fetuses and position.
 Difficult to perform on obese women and women who have
hydramnios.
 Help determine the position and presentation of the fetus,
which in conjunction with correct assessment of the shape of
the maternal pelvis can indicate whether or not the delivery is
going to be complicated , or whether or not a cesarean section
is necessary.
FIRST MANEUVER
 While facing the woman, palpate the woman’s upper abdomen
with both hands. Assess size, shape, movement and firmness of the
part.
 Determine presentation
 BREECH: softer, symmetric, has bony prominences and moves with
the trunk ( buttocks part).
 CEPHALIC hard, firm and round and moves independently of the
trunks.
SECOND MANEUVER
With both hands moving down , identify the fetal back where the ball
of the stethoscope is placed to determine Fetal Heart tone(FHT)
Assess pulse rate:
 Uterine soufflé: corresponds with maternal heart rate
 Funic souffle: corresponds with fetal heart rate
THIRD MANEAUVER
Using the dominant hand , grasp the symphysis pubis with thumb and
fingers.
Assess whether the presenting part is engaged in the pelvis
 Floating/ movable presenting part: unengaged
 Immovable presenting part: engaged
FOURTH MANEUVER
The examiner changes the position by facing the patient’s feet with two
hands, assess the descent of the presenting part by locating cephalic
prominence or brow. the side where there is the resistance to the descent
of the fingers toward the pubis is greatest is where the brow is located.

Assess fetal attitude (relationship of the fetus to one another:

 if the head of the fetus is well flexed, it should be on the opposite side
from the fetal back.
 If the fetal head is extended though, the occiput is instead is felt and is
located on the same side as the back.
IV. HEALTH TEACHINGS ABOUT PREGNANCY

A. FREQUENCY OF PRE-NATAL VISITS

MONTH FREQUENCY
1-7 ONCE A MONTH
8-9 TWICE A MONTH
10 EVERY WEEK
POST-TERM TWICE A WEEK
DANGER SIGNS OF PREGNANCY
1. SWELLING OR EDEMA OF THE UPPER EXTREMITIES-
PREECLAMPSIA
2. CHILLS AND FEVER –SIGNS OF INFECTION
CEREBRAL DISTURBANCES “ HEADACHE” SIGN OF PREECLAMPSIA
3. ABDOMINAL PAIN- “EPIGASTRIC PAIN” IS AN AURA OF AN
IMPENDING CONVULSION.
4. Board like abdomen – abruptio placenta

Blurred vision – preeclampsia

Bp increase- hypertension
Bleeding

a. First trimester- abortion, ectopic pregnancy

b. Second trimester- hydatidiform mole, incompetent cervix
c. Third trimester- abruptio placenta, placenta previa
5. Sudden gush of fluid- premature rupture of membranes ( PROM)
predispose the mother and fetus to infection