OBSTETRIC

NURSING

MERIAM DELOS REYES FLORES R.N.

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•In sharing what we know, we
are definitely helping others
and more so ourselves and for
whatever good we give
out………..the goodness will
complete the circle and the
rewards will undoubtedly
come back to us.
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 Anatomy and Physiology

FEMALE REPRODUCTIVE ORGAN

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 External Genitalia/Pudenda
/Vulva
• Mons Pubis
• Labia Majora
• Labia Minora
• Vestibule
• Clitoris
• Breasts
• (Mammary
• Glands)

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• Mons Pubis
• Labia Majora
• Labia Minora
• Vestibule
• Clitoris
• Breasts
• (Mammary
• Glands)

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 Stages of Pubic Hair
Development
• Tanner scale tool - used to determine sexual maturity
rating.
• Stage 1 – Pre-adolescence. No pubic hair. Fine body
hair only
• Stage 2 – Occurs between ages 11 and 12 – sparse,
long, slightly pigmented & curly hair at pubis
symphysis
• Stage 3 occurs between ages 12 and 13 – darker &
curlier at labia
• Stage 4 – occurs between ages 13 and 14, hair
assumes the normal appearance of an adult but is not
so thick and does no appear to the inner aspect of the
upper thigh.
• Stage 5 sexual maturity- normal adult- appear inner
aspect of upper thigh .
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Internal Genitalia
• Vagina
• Uterus
• Fallopian
tubes
• Ovary

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External parts
of the breast
Nipple - Sinuses
merge into openings
on nipple
- muscles and
- nerves
- glands
- milk pores
Areola
- Montgomery
- tubercles
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 Male Reproductive System
External
Genitalia
• Penis
• Glans Penis
• Frenulum
• Scrotum

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 Internal
Genitalia
• Testis
• Epididymis
• Vas Deferens
• Prostate Gland
• Seminal Vesicles
• Bulbourethral
Glands/Cowper’s
Gland
• Urethra

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MALE REPRODUCTIVE SYSTEM:
SEMEN:
• Is a thick whitish fluid ejaculated by the male during orgasm,
contains spermatozoa and fructose-rich nutrients.
• During ejaculation, semen receives contributions of fluid from
Prostate gland (60%)
Seminal vesicle (30%)
Epididymis ( 5%)
Bulbourethral gland (5%)

• Average pH = 7.5
• The average amount of semen released during ejaculation is
2.5 -5 ml. It can live with in the female genital tract
for about 24 to 72 hours.
• (50-200 million/ml of ejaculation ave. of 400 million/
ejaculation )
• 90 seconds- cervix
• 5 mins.- end of fallopian tube

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MALE REPRODUCTIVE SYSTEM:
SPERMATOZOA are produced by:
Hypothalamus Control by
GnRH (+/-) feedback
Anterior Pituitary gland
FSH / LH
Testes

FSH - release of Androgen Binding Protein (ABP) which

promote SPERMATOGENESIS

LH - release of Testosterone.

“Spermatozoa does not survive at body

temperature. They usually survive 1°F lower
than body temperature”.

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Seminal Fluid Circulation
Testes

Epididymis

Vas Deferens -

Seminal Vesicle

Ejaculatory Duct -

Prostate/Cowper’s Gland Urethra

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• Menarche – first menstruation
• Puberty – transitional stage between
childhood and sexual maturity. At
around age 13.
- age at which reproductive
organs become functionally active

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• Menopause – the cessation of
menstrual cycle
• Post menopausal period – it is the
time of life ff. menopause
• Perimenopausal – period during
which menopausal change are
occurring between 44 – 50 years old

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 – Amenorrhea = temporary cessation of menstrual
flow
– Oligomenorrhea = markedly diminished
menstrual flow, nearing amenorrhea
– Menorrhagia = excessive bleeding during regular
menstruation
– Metrorrhagia = bleeding at completely irregular
intervalsor in between menstruatio n
– Polymenorrhea = frequent menstruation
occurring at intervals of less than three weeks

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 MENSTRUAL
CYCLE
• Periodic recurring
changes in hormonal
status that prepares
the body for pregnancy
• To bring the ovum to
maturity and renew a
uterine tissue bed that
wilt be responsible to
its growth and should
be fertilized.

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• a woman’s menstrual cycle begins on the first
day of her menstruation and ends on the day
before her next menstruation.
• this cycle begin at puberty and continue until
woman reaches menopause.
• on average, cycles can range from 23 to 35
days (median length is 28 days). Some women
have short cycle some women have long cycle.
• Cycle can vary among women or at times may
even vary in individual women.

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 Menstruation
• The periodic uterine bleeding that
begins approximately 14 days after
ovulation
• It usually occur at monthly interval
through the reproductive period except
during pregnancy and lactation
• Average flow is 2 -7 days

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 Organs involve in Menstrual
cycle
• Hypothalamus
• Pituitary gland
• Ovary
• Uterus

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 Phases of
Menstrual Cycle
• Hypothalamic-
Pituitary Cycle
• Ovarian Cycle
• Endometrial Cycle

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 HYPOTHALAMIC
-PITUITARY
CYCLE

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 Menstruation Hypothalamus Secretes FSH
FSHRH APG
Carried by
Stimulates blood stream
Secretes triggers

Ovary causing
Low level of estrogen &
Follicular Devt. of young cells
Progesterone in blood
Phase (graafian follicles
to mature)
APG to Stop
producing LH Produces estrogen
Carried by

Hypothalamus
MENSTRUAL CYCLE blood stream

to Stop
producing LHRH Proliferative Uterus lining
High level of estrogen & Progesterone Phase Becomes thick
in blood sends feedback

Uterus causing further thickening of uterus High level of

(more vascular tortous & field with mucin Estrogen in
The blood

Ovulation (Luteal Phase)

Progesterone carried
by blood stream Sends feedback to
Causing matured follicle LH is carried APG stops producing Hypothalamus to stop
to ruptured follicle by the FSH instead released FSHRH instead
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called corpus luteum blood stream produces LH produces LHRH31
Produces progesterone
HYPO-PIT

OVARIAN

ENDOMETRIAL

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 Ovarian and Uterine Cycles

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Figure 16.12c, d
 OVARIAN CYCLE

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 OVARIAN CYCLE

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 Endometrial Cycle

• Menstrual Phase
• Proliferative Phase
• Secretory Phase
• Ischemic Phase

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• When a woman is fertile the mucus helps
the pregnancy to occur in 3 ways.
• Functions of the Mucus:
• - nourishes the sperm
• - forms channels to help the sperm swim
to the egg
• - filters out abnormal sperm so they do
not reach the egg

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 OTHER CYCLE

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 Sexual Stimulation

1. Physical Stimulation - involves touch

and/or pressure to parts of the body and may
be applied by one's self, by another's body
contact or by inanimate objects. E.g. kissing,
hugging, stroking etc.
• a. Foreplay - pre-coital activity to arouse
sexual desires. It. includes kissing, hugging,
stroking, fondling and manipulation of all
parts of the body including genitalia and
breasts.

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• b. Orgasm - climax of sexual excitement or as
prelude to sexual intercourse.
• c. Masturbation - manual self stimulation.
• 1. Most common in pre-school and often
associated with comfort and pleasure.
• 2. Men usually begin to experience masturbating
often before 20's.

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 Phases of Physiological Responses to
Sexual Stimulation:
• 1. Excitement Phase: lasts for
several minutes to hours.
• Heart rate and Blood pressure
increases
• Nipples become erect
• Myotonia begins

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 Changes in Female and
Male
– clitoris increases - Erection of the
in diameter and penis – increases in
swells length and
- external genitals diameter
become congested - Scrotal skin
and darkened becomes
- vaginal lubrication congested and
with 2/3 of vagina thickens
lengthens and - Testes begin to
extend. increase in size
- cervix and uterus and elevate
pull upward
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• 2. Plateau Phase: the period during which
sexual tension increases to levels nearing
orgasm, may last from 30 seconds to 3 minutes.
Formation of orgasmic platform in the vagina.
• Heart rate and BP continue to increase
• Respirations increases
• Myotonia becomes pronounced
• Grimacing occurs

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 Female-Male

Clitoral head retracts Head of penis may

under the clitoral enlarge slightly
hood. Scrotum continues to
Lower one third of grow tense and thicken
vagina becomes Testes continue to
engorged. elevate and enlarge
Skin color changes Preorgasmic emission of
occur-red flush may 2 or 3 drops of fluid
be observed across appears on the head of
breasts, abdomen or the penis
other surfaces
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• 3. Orgasmic Phase: is the
involuntary climax of sexual tension,
accompanied by physiologic and
psychologic release.
• "This is considered the measurable
peak of sexual intercourse.”
• It is short lasting 3 to 10 seconds.
Strong rhythmic contractions of vagina
and uterus.
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• Heart rate, blood pressure and
respirations increases to maximum
levels
• Involuntary muscle spasms occur
• External rectal sphincter contracts

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 Female - Male

- Strong rhythmic - Testes elevate at

contractions are maximum level
felt in the clitoris, - Point of inevitability
vagina and uterus occurs just before
- Sensations of ejaculation and
warmth spread awareness of fluid in the
through the pelvic urethra.
area - Rhythmic contractions
occur in the penis.
- Ejaculation of semen
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occurs 50
• 4. Resolution Phase - the period of return to
the unaroused state, may last 10 to 15 minutes
after orgasm, longer if there is no orgasm. Cervix
dips into seminal pool in vagina; all organs
returns to previous condition
• Heart rate, BP and respirations return to normal.
• Nipple erection subsides
• Myotonia subsides

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 Female
Engorgement in 50% of erection is
external genitalia lost immediately
and vagina with ejaculation
resolves Penis gradually
Uterus descends returns to normal
to normal position size
Cervix dips into Testes and scrotum
seminal fluid return to normal size
Breast size
decreases
Skin flush
disappears
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• Refractory –
– only in males, the period during
which no amount of stimulation
can cause another erection.
– Not manifested in females
because females are multi
orgasmic.
– This phases lengthens with age
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 Male Sexual Dysfunction

• 1.Erectile failure - inability of a man

to attain or maintain an erection to
such an extent that he can't have
satisfactory intercourse.
• 2. Premature ejaculation - ejaculation
or orgasm before or very soon after
entering the vagina.
• 3. Retarted ejaculation (ejaculatory
impotence) - inability to ejaculate into
the vagina or to suffer with delayed
intravaginal ejaculation.
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 Female Sexual Dysfunction
• 1. Frigid- inhibition in sexual arousal
that leads to absent or minimal
vaginal lubrication.
• 2. Orgasmic dysfunction - persistent
inability of a woman to reach
orgasm.
• 3. Dyspareunia - painful intercourse.
• 4. Vaginismus - condition in which
the vaginal opening closes tightly
and prevents penile penetration.
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 FETAL DEVELOPMENT

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 Fetal Development
• Fertilization: the union of the ovum
& sperm.
• - The start of Mitotic cell division &
fetal sex determination
• Other name: Conception,
Impregnation and Fecundation

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 Process of
Fertilization/Implantation
After ovulation ovum will be expelled from the Graafian
follicles
Ovum will be surrounded by Zona Pellucida
(mucopolysaccharide fluid) & a circle of cells
(Corona Radiata) which increases the bulk of the Ovum

Ovum expelled from the Fallopian Tube by the Fimbriae (infundibulum).

Sperms move by flagella &

Penetrate the & dissolve the
cell wall of the ovum by
releasing a proteolytic
enzyme (Hyaluronidase)
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 After penetration Fusion
will result to Zygote

Zygote migrate for 4 days in

the body of the uterus
(Cell division will take place
- Cleavage formation will
begin)

After 16-50 cell

formation from cell
division, a mulberry
& Bumpy appearance
will follow morula

After 3-4 days,

the structure will
be ball like in
Implantation appearance which
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Blastocyst.
 Implantation occurs at the end of the 1st
week after fertilization,
when the blastocyst attaches to the
endometrium

2nd week (14 days after implantation),

implantation progresses and two germ
layers, cavities, and cell layers develop

3rd week of development (21 days after

implantation), the embryonic disk evolves
into three layers, and three new structures —
the primitive streak, notochord, and allantois
— form

Early during the 4th week (28 days

10/16/09 after implantation), cellular 61
differentiation and organization occur.
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Development from Ovulation to
Implantation

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Figure 16.15
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 Fertilization

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 First cell Division
DAY 1 (Zygote) – Day 2

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 Morula Blastocyst
Day 3 Day 4

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 Fetal Development
Fertilization/Preembryonic

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Early Development: Implantation

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 Development After
Implantation

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Figure 16.16
 Uterine Changes
• Conversion of the endometrium to decidua:
• Decidua basalis – part of the endometrium where the
embryo lies or where the throphoblast cells are
establishing communication with the maternal blood
vessels
• Decidua capsularis – portion of the endometrium that
stretches or encapsulates the surface of the trophoblast
• Decidua vera – remaining portion of the uterine lining

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 Developmental Stages
• Ovum: From ovulation to fertilization
• Zygote: From fertilization to
implantation
• Embryo: From implantation to 5 - 8
weeks.
• Fetus: From 8 weeks until term
The ovum is said to be viable for 24-
36 hours.
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 Preembryonic stage: stage of the
ovum
– fertilization to the first 3 weeks
– fertilize ovum growth and
differentiates
– formation of the three primary germ
layers endoderm, ectoderm and
mesoderm
– implantation in the endometrial
tissue

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 Embryonic stage
– fourth week to the eight week of
development
– period of organogenesis –
differentiation of cells, organs and
organ systems
– highly vulnerable, time for
congenital anomalies to occur
– at the end of this period of
development, embryo has features
of the human body
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 Fetal stage
– eight weeks to the time of birth
– characterized by growth and
development of organs and organ
systems

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 ORIGIN OF BODY TISSUE

• Tissue Layer
• - Ectoderm
• - Endoderm
• - Mesoderm

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 Ectoderm/Outer
• – Skin
- Hair
- Nails
- Tooth enamel
- Nervous system
- Sense organs
- Mucous membrane of the anus and
mouth.

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 Mesoderm/Middle Layer
- Muscle
- Connective Tissue
- Circulatory/Heart
- Blood cells
- - Reproductive
- Bones
- Cartilage
- Kidneys
- Ureters

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 Endoderm/Inner
• - GI (Hepatobiliary/Pancreas)
- Respiratory
- Endocrine
- Tonsils
- Thyroid (for basal metabolism)
- Parathyroid (for calcium metabolism)
- Thymus glands (for development of immunity)
- Bladder and urethra

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 Fetal Blood Supply

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 Fetal Circulation

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 1 Lunar Month
st

• Germ layers differentiate by the

2nd week
• Entoderm
• Mesoderm
• Ectoderm

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• Fetal membranes (amnion and chorion)
appear by the second week
• Nervous system very rapidly develops by the
3rd week (Dizziness is said to be the earliest
sign of pregnancy because as the fetal brain
rapidly develops, glucose stores of the
mother are depleted, thus causing
hypoglycemia in the latter)

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 1 Lunar Month
st

• Fetal heart begins to form as early as the

16th day of life (To the question, “When
does the fetal heart begin to heat?”, the
answer is the first lunar month. But to the
question, “When can fetal heart tones be
first heard?” the answer is fifth month).
• The digestive and respiratory tracts exist
as a single tube until the 3rd week of life
when they start to separate.

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 Second Lunar Month
• All vital organs are formed by the end of
the 8th week.
• Placenta develops fully.
• Sex organs (ovaries and testes) are
formed by the 8th week (To the
question, “When is sex determined?” ,
the answer is at the time of conception).
• Meconium first stools) are formed in the
intestines by the 5th-8th week.

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 Third Lunar Month
Kidneys are able to function –
urine formed by the 12th
week
Buds of milk teeth form
Beginning bone ossification
Fetus swallows amniotic fluid
Feto-placenta circulation is
established by selective
osmosis; no direct
exchange between fetal
and maternal blood.

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 Fourth
Lunar Fifth Lunar
Month
Month
Lanugo appears
Vernix caseosa
Buds of permanent teeth
form appears
Heart beat audible with Lanugo covers entire
fetoscope body
Quickening (fetal
movements) felt
Fetal heart beats
very audible

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 Fifth Lunar Month
• Vernix caseosa appears
• Lanugo covers entire body
• Quickening (fetal movements) felt
• Fetal heart beats very audible

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Seventh Lunar Month
Skin markedly wrinkled
Attains proportions of
fullterm baby
Surfactant begins to
produce

Sixth Lunar Month

Alveoli begin to form
(28th weeks gestation is
said to be the lower limit
of prematurity; if born,
cries, breathes, but
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usually dies) 93
 Eigth Lunar Ninth Lunar
Month Month
Fetus is viable Lanugo and vernix
Lanugo begins to disappear
disappear
Amniotic fluid volume
Nails extend to
somewhat
ends of fingers
decreases
Subcutaneous fat
deposition begins

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 Tenth Lunar Month

• all
characteristic
s of the
normal
newborn

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• First trimester – organogenesis
• Second trimester- period of continued fetal
growth and development; rapid increase in
fetal length
• Third trimester – period of most rapid
growth and development because of rapid
deposition of subcutaneous fat

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 Special Structures of
Pregnancy
• Fetal Membranes:
• - arise from the
zygote
• - inner (amnion) and
outer (chorion)
• - holds the
developing fetus as
well as the amniotic
fluid

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Fetal Membranes:
membranes that surround
the fetus, & give the
placenta the shiny
appearance.
Inner (amnion) - shiny
membrane on the 2nd week
of Embryonic Development
& encloses the Amniotic
Cavity
and holds the amniotic fluid
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Chorion: Outer
membrane that supports
the sac of the amniotic
fluid.
Chorionic Villi: finger like
projections from the
chorion. This is the
place where gases,
nutrients and waste
products between the99
maternal & fetal blood
• Syncytiotrophoblast or synytial layer – outer
covering or layer of the chorionic villi.
• Secretes the ff hormones:
• - HCG
• - Estrogen
• - Progesterone
• - HPL (somatotrophin)
• Cytotrophoblast or langhan’s layer – inner layer.
• Function:
• - protects the growing embryo and fetus from
infectious organisms

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 Amniotic Fluid
• clear, yellow fluid surrounding the developing fetus
and surrounds the embryo, contains fetal urine,
lanugo from fetal skin & epithelial cells.
• Functions:
• protects the fetus/shields
• allows free movement
• maintains temperature
• provides oral fluid

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• Ph is 7. 2.
• Specific Gravity: 1.005 – 1.025
 Normal Amount: 500 – 1500 ml.
 Oligohydramnios - less than 500 ml.
 Polyhydramnios - more than 2000 ml. observe
for congenital defects
• can be aspirated and tested for various diseases
and abnormality during pregnancy (genetic)
• alkaline ph: can be testes when membrane ruptures

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 Amniotic Fluid Colors
• a. pale straw color – normal
• b. yellow stained/ dark amber
• = fetal hypoxia that occurred 36 hours or
more before the rupture of membranes
• = fetal hemolytic disease (Rh or ABO
incompatability, intrauterine infection)
• = Ominous sign of presence of Bilirubin,
hemolytic disease
• Character – thick secretions with unpleasant
odor = infection

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• c. Greenish: Meconium Stained / FETAL
DISTRESS, Also if ph is less than 7.2
• greenish brown (meconium – sustained)
• = fetus had a hypoxic episode ---- relaxation of
the anal sphincter ---- passage of meconium from
the bowel
• = normal in breech presentation
  If with odor: deliver within 24 hours, may
indicate infection.
• d. Port Wine Color – admixture of amniotic
fluid and blood - indication abruptio placenta

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 Test for rupture of
membranes
• Voiding by an incontinent woman and
leukorrhea should be differentiated from
amniotic fluid.
• Spread a drop of the fluid on a clean slide.
Dried amniotic fluid will show a fern like
crystalline pattern when viewed under the
microscope (positive fern test).

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 • Determine the pH of the vagina fluid.
Amniotic fluid is slightly alkaline;
urine or pus is acidic.
• With sterile speculum, us sterile
cotton swabs to take samples of
vaginal secretions at cervical os
• Test with pH paper (Nitrazine)

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 Interpretation
• Yellow/Olive Yellow/Olive Green = pH5 to 6
(membrane probably intact)
• Blue green/blue gray/deep blue = pH 6.5 to 7.5
(ruptured membrane)
• Fetal lanugo or fetal squamous cell may be seen on
the microscope
• Sudan III and Nile blue tests for detection of fetal
fat particles and desquamated fetal aft cells

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 Umbilical Cord
• 21 inches in length & 2 cm in thickness, circulatory
communication of the fetus to the mother.
• there are no pain receptors in the umbilical cord
• connecting link between fetus and placenta
• contains 2 arteries and 1 vein supported by mucoid
material/ mucopolysaccharide called (Wharton’s jelly)
to prevent kinking and knotting

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 Placenta
• transient organ allowing passage of nutrients and
waste materials between mother and fetus
• contains 20 cotyledons, weighs 400-600 grams.
• fully develops on the 3rd month.
• form from Chorionic villi & deciduas basalis.
Deciduas (meaning endometrial changes & growth)
• acts as an endocrine organ (hormones) and as a
protective barrier against some drugs or infectious
agents

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 Functions
• Respiration – O2 , CO2
• Excretion
• Nutrition
• Storage - CHO, CHON, calcium and iron
• Protects the growing embryo and fetus from
infectious organisms
• Mother also transmit immunoglobulin G (IgG) to
fetus through placenta, providing limited passive
immunity

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 Hormones Associated with
Pregnancy
HCG – indicator Estrogen – initially
of pregnancy secreted by the
- secreted by the copus luteum
chorionic villi and – enhances fat
later by the deposition
placenta promotes sodium and
- lengthens the water retention
lifespan of corpus - mediates vascular
luteum changes
- produces
enlargement of
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genitals
Progesterone
– initially secreted
by the corpus
luteum and later
by the placenta
- produces
relaxation of
smooth muscle
maintains decidua

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•Human chorionic
somatomammotropin/human
placental lactogen (HCS/HPL):
similar to growth hormone;
•- affects maternal insulin Relaxin
production (diabetogenic inhibits uterine
hormone for the mother to activity and
diminish insulin efficiency) relax pelvic
•- prepares breast for joint
lactation, detectable in
trophoblast as early as third
week after ovulation.
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Prolactin –
released from the
anterior pituitary
gland
- Suppressed
during pregnancy
- milk production Oxytocin – released
from the PPG
-produces smooth
muscle contraction
- milk ejection
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 DIAGNOSIS OF
PREGNANCY

MERIAM DELOS REYES FLORES R.N.

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 Obstetrical Terms
• Gravida – woman who is pregnant
• Gravidity – pregnancy
• Parity – number of pregnancies whose fetus
have reached the age of viability
• Multigravida - woman who has 2 or more
pregnancies
• Multipara – woman who has completed 2 or
more pregnancies

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• Nulligravida – woman who has never pregnant
• Nullipara - woman who has not completed pregnancy with
a fetus who have reached the stage of viability
• Primigravida – woman who is pregnant for the first time
• Primipara – woman who has completed one pregnancy
with a fetus who have reached the stage of viability
• Viability – capacity to live outside the uterus which about
>20 weeks or > 500 grams

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• Term – 38 – 42 weeks
• Post date – Postterm - > 42 weeks
• Preterm – 21 to 37 weeks
• Immature – 21 to 27 weeks (----)
• Abortion - < 20 weeks or < 500
grams

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 Obstetrical Score

• T – P – A - L (F P A L)
a. Term birth or Full term
b. Preterm
c. Abortion
d. Living children

N.B. Some use G T P A L / G T P A L M

10/16/09 119
 PREGNANCY
• gestational process, comprising the growth
and development within a woman of a new
individual from conception through the
embryonic and fetal periods to birth
• Other name: gestation, fecundation,
impregnation, conception
• Gestation – period from the fertilization of
the ovum until birth

10/16/09 120
• Diagnosis of pregnancy can be done by
physical assessment and simple laboratory
procedures:
• by simple ultrasound
• by urine testing or blood test – determining
the HCG or Human chorionic gonadotrophin
hormone
• - produced by the chorionic villi of the
placenta that can be tested on the urine
and serum (RIA)
10/16/09 121
 HCG
• - in serum you can test after 24 – 48
hours after implantation
• in the urine 1st morning void and can
be detected 26 days after conception
• Peak level between 60 – 70 days. But
will last until 100 – 130 days then it
will go down.
• In post partum women it will become
negative in serum testing after 1 – 2
weeks after delivery.
10/16/09 122
 Diagnosis of Pregnancy
• Presumptive – subjective – sign that
suggest that do not confirm pregnancy
and could be due to other condition
• Probable – objective – strong indication
of pregnancy not likely but still
possibly due to other condition.
• Positive – signs definitively confirming
pregnancy

10/16/09 123
 PRESUMPTIVE PROBABLE POSITIVE
Subjective Objective
Amenorrhea Positive HCG Ultrasound evidence
Morning sickness Chadwick’s Fetal heart tones
Breast changes Goodell’s Fetal movements
Fatigue Hegar’s Fetal outline on
Urinary Frequency Ballotment X-ray
Enlarging Uterus Braxton Hicks
Quickening contraction
Leucorrhea
Weight Changes
Increased skin pigmentation:
- Chloasma
- Linea nigra
- Striae gravidarum

10/16/09 124
 Psychosocial Changes
• There are several psychosocial
changes that occurs in pregnancy to
the family.
• It may affects the father, mother and
of course the siblings

10/16/09 125
 CHANGES OF THE EXPECTANT
FAMILY
• Pregnancy is considered a normal
maturational crisis and
developmental stage for the
expectant couple.
• Pregnancy is physiologic

10/16/09 126
 Changes in the Father
First trimester
• 1. May feel left out of pregnancy.
• 2. Confused by partner's mood swings.
• 3. Couvade syndrome cause by stress,
anxiety and empathy for the pregnant
women and the father will also experience
physical symptoms of nausea, vomiting and
backache or similar symptoms of
discomfort along with his partner.

10/16/09 127
 Second trimester
• 1. Promote his involvement by his watching and
feeling fetal movement.
• 2. Needs to confront and resolve his own conflicts
about the fathering he received as a child.
• 3. Will decide on what he does and does not want
to imitate from his father role figure.
• 4. May react differently to partner's physical body
changes.

10/16/09 128
 Third trimester
• 1. Concerns and fears resurface.

10/16/09 129
 Maternal Adaptation to
Pregnancy
• Psychologic
• Anatomical and Physiologic
– systemic
- local

10/16/09 130
 Psychological Adaptation to
Pregnancy/Emotional Responses

– First trimester
– Second trimester
- Third trimester

10/16/09 131
 Psychological responses

– Ambivalence
– Acceptance
– Introversion
– Mood swings
– Body images changes

10/16/09 132
 Ambivalence
• First Trimester: AMBIVALENCE-
about pregnancy: pregnant woman
focus only to self.
• the fetus is an unidentified concept
with great future implications but
without tangible evidence of reality.
Some degree of rejection, denial and
disbelief, even repression.

10/16/09 133
• Implication: when giving health
teachings, be sure to emphasize the
bodily changes in pregnancy.
• I am pregnant. …Accept the
biological fact of pregnancy

10/16/09 134
• Conflicting feelings about pregnancy
• If women feels comfortable in
addressing ambivalent feelings, the
focus is usually on changed life style
or the career -motherhood dilemma.

10/16/09 135
• Indirect evidence of ambivalence:
• a. Complaints of depression or
physical discomfort.
• b. Complaints of feeling ugly or
unattractive.
• 3. Some women may consider the
possibility of abortion, if pregnancy is
unwanted.
10/16/09 136
 Acceptance
• Second Trimester: ACCEPTANCE---of
the identification of motherhood &
awareness & interest in the fetus.
• - fetus is perceived as a separate
entity. Fantasizes appearance of the
baby.
• I am going to have a baby… Accept
the growing fetus as distinct from self
& as person to care for
10/16/09 137
• With an unplanned pregnancy, there
is greater evidence of fear and
conflict along with more physical
discomfort and depression.
• If pregnancy is well accepted, women
experiences less discomfort and
more tolerance to physical
discomforts during the last trimester.

10/16/09 138
 Introversion
• 1. This "turning in on oneself' focus is
normal.
• 2. Helps the mother plan, adjust,
adapt, build, and draw strength in
preparation for childbirth.

10/16/09 139
 Mood swings/Emotional
lability
• Can cause difficulty in the
relationship if couple doesn't realize
what is occurring.
• Husband may feel exasperated with
her tears and withdraw and ignore
problem when she really needs him
to be affectionate and supportive.

10/16/09 140
• Third Trimester: EMOTIONAL LABILITY-
assuming already the mother, fears &
fantasies & dreams about labor
• has personal identification with a real
baby about to the born and realistic plans
for future child care responsibilities.
• Best time to talk about preparation of
layette and infant feeding method.
•

10/16/09 141
• Fear of death, though, is prominent
to allay fears, let pregnant woman
listen to the fetal heart tones.
• I am going to be a mother…Prepare
realistically for birth & parenting

10/16/09 142
 Body images changes
• Woman may feel negative toward
body, especially during 3rd trimester.

10/16/09 143
 Psychological tasks of the
mother
• Ensuring safe passage through
pregnancy, labor, and birth.
• Seeking acceptance of this child by
others.
• Seeking of commitment and
acceptance of self as mother to the
infant (binding-in).
• Learning to give of oneself on behalf on
one's child.
10/16/09 144
 Emotional Responses
• First trimester: the fetus is an
unidentified concept with great future
implications but without tangible
evidence of reality. Some degree of
rejection, denial and disbelief, even
repression.
• Implication: when giving health
teachings, be sure to emphasize the
bodily changes in pregnancy.
10/16/09 145
• Second trimester: fetus is perceived
as a separate entity. Fantasizes
appearance of the baby.

10/16/09 146
• Third trimester: has personal
identification with a real baby about
to the born and realistic plans for
future child care responsibilities.
• Best time to talk about preparation
of layette and infant feeding method.
• Fear of death, though, is prominent
to allay fears, let pregnant woman
listen to the fetal heart tones.
10/16/09 147
 Systemic Changes
• 1. Circulatory/Cardiovascular
• 2. Gastrointestinal changes
• 3. Respiratory Changes
• 4. Urinary changes

10/16/09 148
• 5. Musculoskeletal changes
• 6. Endocrine changes
• 7. Temperature
• 8. Metabolism
• 9. Reproductive system

10/16/09 149
 Local Changes
• 1. Cervix - Goodell’s sign
• 2. Uterus - Hegar’s sign
• 3. Vagina - Chadwick’s sign
• 4. Abdominal Wall
- Striae gravidarum

10/16/09 150
• 5. Skin
- Chloasma gravidarum
- Linea nigra
• 6. Breasts
• 7. Ovaries

10/16/09 151
 Cardiovascular
• Increase metabolic demand of new
tissue growth
• Expansion of the vascular channel
especially the genital tract
• Increased in the steroid hormones which
exerts a positive effect on sodium and
water balance

10/16/09 152
• Blood volume:
• a. Increases progressively throughout
pregnancy, beginning in the first trimester and
peaking in the middle of the third trimester at
about 45% above prepregnant levels.
• b. Normal blood pressure maintained by
peripheral vasodilatation.
• c. Extra volume of blood acts as a reserve for
blood loss during delivery.

10/16/09 153
 Heart
• a. Increase in heart rate; ten beats
per minute by the end of the first
trimester.
• Blood pressure falls during the
second trimester; rises slightly (no
more than 15 mm in either systolic
or diastolic) during the last trimester.
• b. Increase in cardiac output.
10/16/09 154
• c. Palpitations of the heart usually
due to sympathetic nervous system
disturbance; later in pregnancy due
to the intraabdominal pressure of the
growing uterus.
• d. Cardiac enlargement and systolic
murmurs.

10/16/09 155
 Red blood cells (RBC)
• a. Stimulation of the bone marrow
leads to a 20-30% increase in total
RBC volume.
• b. The plasma volume increase is
greater than the RBC increase which
leads to a hemodilution, typically
referred to as physiologic anemia of
pregnancy (pseudoanemia).

10/16/09 156
- Pregnancy induced hypervolemia has
several important functions:
• To meet the demands of the
enlarged uterus with it greatly
hypertrophied vascular system

10/16/09 157
• To protect the mother and in turn
the fetus, against deleterious
effects of impaired venous return
in the supine and erect position
• To safeguard the mother against
the adverse effects of blood loss
associated with partutrition

10/16/09 158
 Total Iron requirements
• 1 gram or 6 -7 mg/day
• - 300 mgs used by the fetus and
placenta
• - 200 mgs are excreted
• - 500 mgs are used in erythrocyte
production

10/16/09 159
 White blood cells (WBC):
• White blood cells (WBC): 10 to
11,000 per cu mm; may increase up
to 25,000 per cu mm during labor
and postpartum.

10/16/09 160
• Total plasma proteins: decrease due
to fall in serum albumin level.
• Sedimentation rate: increases due to
the
decrease in plasma proteins.
• Fibrin level increases as much as
40% at term with the plasma
fibrinogen level increasing as much
as 50%.
10/16/09 161
 Respiratory Changes
• Oxygen consumption increased by 15-20%
between the sixteenth and fortieth weeks.
• Diaphragm is elevated; change from
abdominal to thoracic breathing around the
twenty-fourth week.
• Tidal volume increases steadily throughout
pregnancy.
• Tidal volume - amount of air moving in and
out of the lungs in one normal breath.

10/16/09 162
• Vital capacity increases slightly,
while pulmonary compliance and
diffusion remain constant.
• Vital capacity-amount of air inhaled
and forcibly exhaled in one breath.
• Common complaints of nasal
stuffiness and epistaxis due to
estrogen influence on nasal mucosa.
10/16/09 163
 Urinary changes
• Ureter and renal pelvis dilate (especially on
the right side) as a result of the growing
uterus.
• Frequency of urination (first and last
trimester).
• Decreased bladder tone (due to effect of
progesterone); bladder capacity increases:
1,300 to 1,500 cc.

10/16/09 164
• Reduced renal threshold for sugar;
leads to glycosuria.
• Due to an increased glomerular
filtration rate (GFR), as much as 50%,
there is a decreased serum BUN,
creatinine, and uric acid.

10/16/09 165
 GIT
• Pregnancy gingivitis-gums reddened,
swollen, and bleed easily.
• Increased saliva (ptyalism); decreased
gastric acidity .
• Nausea and vomiting due to elevated
human chorionic gonadotropin (HCG).
• Decreased tone and motility of smooth
muscles
• Decreased emptying time of stomach;

10/16/09 166
• Slowed peristalsis due to increased
progesterone lead to complaints of bloating,
heartburn, and constipation.
• Pressure of expanding uterus leads to
hemorrhoidal varicosities and contributes to
continuing constipation.

10/16/09 167
• Hyperemesis Gravidarum – it is a
syndrome of excessive nausea and
vomiting due to excessive hormonal
changes of pregnancy especially HCG.
• - characterized by the pernicious
vomiting during pregnancy.
• It occurs in every one thousand
pregnancies, the cause is debatable but
seems to be related to HCG and
psychological factors.
10/16/09 168
 Clinical Manifestations
• Severe persistent vomiting which leads to
dehydration or nutritional deficiency;
progresses to fluid and electrolyte
imbalance and alkalosis from loss of Hcl
– if untreated, ketoacidosis (from loss
intestinal juices), hypovolemia,
hypokalemia, jaundiced and hemorrhage
– hypothrombinemia and decreased urine
output.

10/16/09 169
 Treatment
• a. antivomiting – Bendectin (Doxylamine
succinate plus pyridoxine).
• b. Dietary – NPO for first 48 hours, after
condition improves, then six small feedings
alternated with liquid nourishment in small
amounts every one to two hours,
• - if vomiting reoccurs, NPO and IVFluids
started

10/16/09 170
• c. Effective psychological support can be
offered in the form of reassurance to the
pregnant woman that these symptoms will
disappear by the fourth month
• d. prompt correction of fluid and
electrolytes imbalances.
• Stress and emotional factors have been
found to play a major role in hyperemesis
gravidarum, psychotherapy is
recommended
10/16/09 171
 Musculoskeletal System
• Increase in the normal lumbosacral curve
leads to backward tilt of the torso.
• Center of gravity is changed which often leads
to leg and back strain and predisposition to
falling.
• Pelvis relaxes due to the effects of the
hormone relaxin; leads to the characteristic
"duck waddling" gait.

10/16/09 172
 Endocrine changes
Placenta.
• a. Functions include transport of nutrients
and removal of waste products from the
fetus.
• b. Produces human chorionic gonadotropin
(HCG) and human placental lactogen (HPL).
• c. Produces estrogen and progesterone after
two months of gestation.

10/16/09 173
• Thyroid gland.
• a. May increase in size and activity.
• b. Increase in basal metabolic rate.
Parathyroid glands-increase in activity
• (especially the last half of the
pregnancy) due to increased
requirements for calcium and vitamin

10/16/09 174
• Pituitary gland.
• a. Enlargement greatest during the
last month of gestation.
• b. Production of anterior pituitary
hormones: FSH, LH, thyrotropin,
adrenotropin, and prolactin.
• Production of posterior pituitary
hormones: oxytocin which promotes
uterine contractility and stimulation of
milk let-down reflex.
10/16/09 175
• 4. Adrenal glands.
• a. Hypertrophy of the adrenal cortex.
• b. Increase in aldosterone, which retains
• sodium, results in a decreased ability of
the kidneys to handle salt during
pregnancy; consequently, improper
control of dietary sodium can lead to
fluid retention and edema.

10/16/09 176
 Metabolism
• Weight gain.
• a. Normal weight gain: 25 to 35 lb b.
Pattern of weight gain.
• (1) First trimester- 3 to 4 lb
• (2) Second trimester- 12 to 14 lb.
• (3) Third trimester-8 to 10 lb.

10/16/09 177
• c. Total weight gain is accounted for as follows:
• (1) Fetus: 7.5 lb.
• (2) Placenta and membranes: 1.5 lb.
• (3) Amniotic fluid: 2 lb.
• (4) Uterus: 2.5 lb.
• (5) Breasts: 3 lb.
• (6) Increased blood volume: 2-4 lb.
• (7) Remaining 4-9 lb. is extravascular fluid
and fat reserves.

10/16/09 178
 Local Changes
• 1. Uterus - Hegar’s sign
• 2 . Cervix - Goodell’s sign
• 3. Vagina - Chadwick’s sign
• 4. Abdominal Wall
- Striae gravidarum
• 5. Skin
- Chloasma gravidarum
- Linea nigra
• 6. Breasts
• 7. Ovaries
10/16/09 179
 Uterus
• Increase in size due to hypertrophy of the
myometrial cells (increase seventeen to forty
times their prepregnant state) as a result of the
stimulating influence of estrogen and the
distention caused by the growing fetus.
• Weight increases from 50 to 1,000 grams.
• Increase in fibrous and connective tissues which
strengthen the elasticity of the uterine muscle
wall.

10/16/09 180
• Hegar's sign - Softening of the lowe
uterine segment (Hegar's sign).
• Irregular, painless uterine contractions
(Braxton-Hicks) begin in the early weeks
of pregnancy; contraction and relaxation
assist in accommodating the growing
fetus.
• Multigravidas tend to report a greater
incidence of Braxton-Hicks than
primigravida
10/16/09 181
 Cervical changes
• Softening of the cervix due to
increased vascularity, edema, and
hyperplasia of cervical glands
(Goodell's sign).
• Formation of the mucous plug to
prevent
bacterial contamination from the
vagina.
10/16/09 182
 Vagina
• Influence of estrogen leads to
hypertrophy and hyperplasia of the
lining along with an increase in vaginal
secretions.
• (Chadwick's sign) - a blue purple hue
of the vaginal walls is seen very early.
• Vaginal secretions: acidic (pH is 3.5 to
6.0) and thickish white.

10/16/09 183
 Breasts
• Increase in breast size accompanied by
feelings of fullness, tingling, and heaviness.
• Superficial veins prominent; nipples erect;
darkening and increase in diameter of the
areola.
• Thin, watery secretion, precursor to
colostrum, can be expressed from the nipples
by the end of the tenth week.

10/16/09 184
 Skin
• Increased skin pigmentation in various areas
of the body.
• a. Facial: mask of pregnancy (chloasma).
• b. Abdomen: striae (red purple stretch marks)
and linea nigra (darkened vertical line from
umbilicus to symphysis pubis).
• Appearance of vascular spider nevi,
especially on the neck, arms and legs.
• Acne vulgaris, dermatitis, and psoriasis
usually improve during pregnancy.

10/16/09 185
 PRENATAL CARE
• Major Goals:
• - to define the health status of the
mother and fetus
• - to determine the gestational age of
the fetus
• - to initiate plan for continuing
maternal care

10/16/09 186
10/16/09 187
• Assessment
• A. Initial visit.
• 1. Complete history and physical.
• 2. Obstetric history .
• a. Past pregnancies (date, course of
pregnancy, labor and postpartum;
information about infant and neonatal
course).
• b. Present pregnancy.
10/16/09 188
 Prenatal Surveillance
• Fetal –
• a. heart rate (s)
• b. size – actual and fate change
• c. amount of amniotic fluid
• d. presenting part and station in late
pregnancy
• e. activity

10/16/09 189
 Maternal
• A. blood pressure – actual and extent change
• B. weight – actual and extent change
• C. symptoms including headache, altered
vision, abdominal pain, nausea and vomiting,
bleeding, fluid from vagina and dysuria
• D. height in cm. of uterine fundus from
sumphysis

10/16/09 190
• E. vaginal examination in late pregnancy
often provides valuable information:
• - confirmation of presenting part
• - station of the presenting part
• - clinical estimation of pelvic capacity and
its general configuration
• - consistency, effacement and dilatation of
the cervix
• - position of presenting part

10/16/09 191
• B. Schedule of return prenatal visits.
• 1. Frequency of return visits.
• a.. Monthly for first thirty-two weeks.
• b. Every two weeks to the thirty-sixth
week.
• c. After the thirty-sixth week, weekly
until
• delivery.
10/16/09 192
• 2. Subsequent assessment data follow-up.
• a. Vital signs.
• b. Urinalysis-check for protein and sugar.
• c. Monitor weight.
• d. Measurement of height of uterine fundus
• e. Auscultation of fetal heart rate (FHR).

10/16/09 193
 Physical Assessment
• Vital signs
• Cephalocaudal assessment
• Abdomino/Pelvic exam:
• - Leopold’s maneuver
• - Speculum
• -IE
• - Pelvic measurement

10/16/09 194
 Leopolds Manuever
• - determine the orientation of the fetus
through abdominal palpation
• Purpose:
• - to determine presentation, position and

atttiude
- estimate fetal size
- locate fetal parts/FHB or FHT

10/16/09 195
 Preparatory
Steps
• Palpate with warm hands, cold
hands cause abdominal muscle
to contract
• Use palms not fingers –
educate them
• Position patient on supine with
knee flex slightly (dorsal
recumbent) so as to relax
abdominal muscles
• Apply gently but firm motions
• Abdominal examination should
be conducted systematically
employing the 4 maneuver’s.
• The mother should be in with
her abdomen bared.

10/16/09 196
10/16/09 197
 L 1-Palpation of the fundus
• The fundus is gently
palpated between the
palms of two hands
• The upper pole (in this
case the breech) is
identified
• Characteristically the
breech is softer than the
head, there is no angle
formed by the neck and
the surface continues
smoothly with the back

10/16/09 198
 L 2 - Palpation of the body
• The palpation
continues down the
body of the uterus
• The smooth back is
palpated and
identified
• The irregular surface
created by the limbs,
hands and feet is
identified

10/16/09 199
 L 3 - Palpation of the vertex
• The head is
identified (in the
case in the lower
pole)
• The head feels
hard and rounded

10/16/09 200
L 4 - Assessing engagement
• Facing the woman’s
feet
• The vertex is palpated
using both hands
• An assessment is made
of how much of the
head can be palpated
and whether the head
is engaged, fixed or
mobile

10/16/09 © Dr Paul Bradley, Clinical Skills 201

Resource Centre, University of
Liverpool, UK
 Fundic Height

10/16/09 202
 Symphysis-fundal height
• More accurate
assessment of
fundal height
involves direct
measurement in
centimetres of the
distance from the
symphysis pubis to
the top of the
fundus
10/16/09 203
 Technique
Measuring tape • The woman lies supine
• The pubic symphysis is
identified
Tape zero held • The zero end of the tape
Gentle measure is held against it
against pubic
pressure • Tape is stretched over
symphysis
applied the abdomen
• A hand on top of the tape
applies gentle pressure to
palpate the top of the
fundus
• An estimate of fundal size
Uterus can thus be made
Abdo wall
10/16/09 204
 Diagnostic
- CBC, Blood typing
- Urinalysis
- Hep. B Profile
- HIV
- Vaginal Smear – GbS/Paps smear
- UTZ
- Rubella titer
- OGTT (DM)
10/16/09 205
 Estimations
• Naegele’s Rule
• McDonald’s Method
• Bartholomew’s Rule
• Haase’s Rule
• Johnson’s Rule
• Ultrasound - BPD

10/16/09 206
• Naegele’s Rule (EDC) - estimation of
AOG by LMP
• McDonald’s Method (Age of gestation)
- – determines age of gestation by
measuring from the fundus to the
symphysis pubis (in cm.) then divide
by 4 = AOG in months.

10/16/09 207
 General Assessment of
the Obstetric Patient
• Physical Examination
– Asses fundal height to determine gestation.

10/16/09 208
 Bartholomew’s
Rule (Age of
gestation )
• Estimates AOG by the
relative position of the uterus
in the abdominal cavity.
• By the 3rd lunar month, the
fundus is palpable slightly
above the symphysis pubis
• On the 5th lunar month, the
fundus is at the level of the
umbilicus
• On the 9th lunar month, the
fundus is below the xiphoid
process

10/16/09 209
 Assessing fundal height
• Uterine fundal height can indicate pregnancy duration
• It is a crude method depending on body build, examiner
technique, foetal growth, accurate dates, etc
• It is better to measure the height of the fundus to the
pubic bone and compare to a standard chart
34 • Even better estimation of gestation and foetal
development is obtained by ultrasonography
28 • 34 weeks just below xiphisternum
• 28 weeks midway between umbilicus and xiphisternum
20 • 20 weeks at the umbilicus
16 • 16 weeks midway between pubic bone and umbilicus
• 12 weeks just above pubic bone
12

10/16/09 210
Haase’s Rule (Fetal Length)
• Determines the length of the fetus in
centimeters.
• During the first half of pregnancy,
square the number of the month (E.g.,
first lunar month: 1 x 1 = 1 cm.)
• During the second half of pregnancy,
multiply the month by 5 (E.g., 6th lunar
month: 6 x 5 = 30 cm.

10/16/09 211
 Johnson’s Rule
• Estimate the weight of the fetus in
grams.
• Formula: fundic height in cm. – n x k
• “k” is a constant, it is always 155
• “n” is = 12 ( if fetus is engaged)
• = 11 (if fetus is not yet
engaged)

10/16/09 212
 Thank you!!!

10/16/09 213