ASIA PACIFIC COLLEGE OF ADVANCED STUDIES

MATERNAL & CHILD NURISNG – PRELIMS

A.Y. 2020-2021
MR. JAYVEE DARACAY

MODULE 1: CONCEPT OF A FAMILY

• Families are important to children's growth, as no other social group has the potential to
;provide the depth of support and long ,lasting emotional ties as a person’s own family. What
people learn in their family determines how they relate to people, what moral values they
follow and the molding of their perspective on both the present and the future (Parker,
Mandleco, Olsen roper, et al.,2011)

WHAT IS FAMILY?
• The family is an intimate domestic group made up of people related to one another by
bonds of blood, sexual mating or legal ties. It is the smallest and most basic social unit,
which is also the most important primary group found in any society.
• A householder and one or more other people living in the same household who are
related by birth, marriage or adaption.
• It is the simplest and most elementary group found in a society. It is a social group
consisting of a father, mother and one or more children. It is the most immediate group a
child is exposed to. In fact, it is the most enduring group, which has tremendous influence
on the life of an individual, from birth until death. It also accounts for the most enduring
social relationship found in society. Family has been defined by different social scientists.

CHARACTERISTICS OF FAMILY:
1. Family is a Universal group
2. A family is based on marriage
3. Every family provides an individual with a name
4. Family is the group through which descent or ancestry can be traced.
5. Family is the most important group in any individual’s life.
6. Family is the most basic and important group in primary socialization of an individual.
7. A family is generally limited in size, even large, joint and extended families.
8. The family is the most important group in society; it is the nucleus of all institutions,
organizations and groups.
9. Family is based on emotions and sentiments. Mating, procreation, maternal and fraternal
devotion, love and affection are the basis of family ties.
10. The family is a unit of emotional and economic cooperation
11. 11. Each member of family shares duties and responsibilities.
12. 12. Every family is made up of husband and wife, and/or one or more children, both
natural and adopted.
13. 13. Each family is made up of different social roles, like those of husband, wife, mother,
father, children, brothers or sisters.

TYPES:
  Based on Birth:
 Based on Marriage:
 Based on Residence:
 Based on Ancestry or Descent:
 Based on Authority:
 Based on the Nature of Relations:
 Based on state or structure:

FAMILY TYPES:
 Dyad Family (Childless or Childfree Family)
Id two people living together without children
 Cohabilitation Family
Composed of couple perhaps with children. Who ,lived together but remained
unmarried
 Nuclear
This is considered to be the traditional structure. It's a family of two parents and
whatever children they have.
 Single Parent Family
The name says it all. This is a parent who is raising their child without the other
parent involved, or at least not involved too much. A single parent family is
usually a challenge, as income and household duties are cut in half. Many single
parent families may have support networks, but some do not.
 Monogamous Family:
This family consists of one husband and wife, including children and is based on
monogamous marriages.

 Polygynous Family:
 A family consisting of one husband, and more than one wife, and all the children
born to all the wives or adopted by each of them. This type of family has its basis
in the polygynous form of marriage.
 Polyandrous Family:
A family made up of one wife and more than one husband, and the children,
either born or adopted with each one of them. This family is based on poly-
androus marriage.
 Extended
This is when you have other family members living with you. For example, a
nuclear family that also has grandpa or grandma living there. Extended families
live together for financial reasons, or because one family member is older and the
family doesn't want to or can't take them to a nursing home.
 Blended Family
When a nuclear family ends up divorcing and marrying someone else, the new
family is called a blended or step family. Stepmoms, stepdads, stepbrothers, step
sisters, and other members enter the fray. Sometimes, it works out great, but other
times, the children from the original parents may clash with the step family, or
they may be new forms of discipline
 Grandparent family
This is when the grandparents raise their grandchildren because the parents are
unable to, don't want the child, or are dead. Grandparent families have many
challenges, such as the age of the grandparents and the fact that they may have to
work after retirement to raise the child.
 Non-Related Family
Also known as a family by choice. This is a group of people who aren't blood
related or married, but live together or consider themselves to be as close as a
family. They may consist of people whose blood families have abandoned them
or no longer exist.
 Stepfamily
A stepfamily is when two separate families merge into one. This can go several
different ways, like two divorced parents with one or more children blending
families, or one divorced parent with kids marrying someone who has never been
married and has no kids.
 The gay or lesbian family
LGBT parenting refers to lesbian, gay, bisexual, and transgender (LGBT) people
raising one or more children as parents or foster care parents. This includes:
children raised by same-sex couples (same-sex parenting), children raised by
single LGBT parents, and children raised by an opposite-sex couple where at least
one partner is LGBT.
STAGES OF FAMILY DEVELOPMENT:
• 1. Unattached Adult
The main issue occurring in this first stage is accepting parent-offspring
separation. Rob Smith has just turned 20. He is in college, which means he is
experiencing life on his own for the first time. The tasks that are critical for him to
accomplish in this phase include: separating from family and connecting with
peers as well as initiating a career.
 • 2. Newly Married Adults
The main in issue in this stage is commitment to the marriage. Rob is 23, and he
has just gotten married. He is learning how to no longer act for himself and now
act for the welfare of his wife and their relationship. He is accomplishing the tasks
of forming a marital system while continuing to address career demands at his job
as a copywriter.
• 3. Childbearing Adults
Rob's wife, Penny, has just given birth to their first child and named her Becky.
They are now accepting new members into the system. They need to make
adjustments in their usual schedules, finances, and duties in order to care for this
new child. They are also needing to make room for visits and interactions with
their parents in their new role as grandparents.
• 4. Preschool-age Children
Becky has just entered a preschool and is full of energy, joy, and curiosity. And,
while adored by her parents, she is also a bit draining. Now is the time for Rob
and Penny to accept the new personality of their child, adjusting to it in whatever
ways are best. It is also important that Rob and Penny make efforts to take time
out as a couple - going out on dates, for example.

MODULE 1.2: THE MATERNAL CHILD NURSING IN THE PHILIPPINES

ROLE OF A NURSE IN CARING FOR CHILBEARING FAMILIES:

• There are myriad of roles that a nurse/nurse midwife may play in caring for the
childbearing family:
1. Health care provider
2. Teacher
3. Collaborator
4. Researcher
5. Manager of care
MATERNAL AND CHILD HEALTH (MCH) NURSING
• Maternal and child health refers to the relationship of mother and child to one another
and consideration of the entire family, as well as the culture socio-economic
environment, as framework of the clients.
• Maternal and child health nursing refers to the care of the pregnant woman, child, and
family (Pillitteri, 2007)
PRINCIPLES OF MATERNAL AND CHILD HEALTH NURSING
1. The family is the basic unit of society.
2. Families represent racial, ethnic, cultural and socio-economic diversities.
 3. Children grow both individually and as part of a family.

PHASES OF HEALTH CARE IN MATERNAL AND CHILD HEALTH

1. Health promotion
2. Health maintenance
3. Health rehabilitation

GOALS OF MATERNAL AND CHILD HEALTH

1. To ensure that every expectant and nursing mother
- Maintains good health
- Learns the art of child care
- Has a normal delivery and;
- Bears healthy children
2. Maternal care consist the care of the pregnant woman, her safe delivery, postnatal care
and examination; and the care of her lactation.
3. Should begin antenatally with measures to promote the health and well-being of the
young people who are potential parents and help them to develop the right approach to
family life and the place of the family of the community.
4. That very child should live and grow in a family unit with love and security, in healthy
surroundings, receive adequate nourishment, health supervision and efficient medical
attention, and is taught the elements of healthy living.
5. It should include guidance in parenting and in problems associated with infertility and
family planning.
CURRENT TRENDS IN MATERNAL AND CHILD HEALTH

MATERNAL AND CHILD HEALTH

1. Reduction in maternal mortality by one half of the 1990 levels by 2000 and further one
half by 2015.
2. Expand the provision of maternal health services in the context of primary health care,
e.g. based on the concept of informed choices, should include education on safe
motherhood, prenatal care – International conference on population and development
ICPD.
3. Reduce the maternal mortality rate by 3 quarters by 2015 (half by 2000, half 2015)
4. Increase access to reproductive health services to 60% by 2005, 80% by 2010, and 100%
by 2015
5. NDHS data: MMR 100,000 live births.
6. Slow decrease in maternal death.

THE MATERNAL HEALTH PROGRAM

1. The strategic thrusts for 2005 – 2010 includes: BEMOC strategy or basic emergency
obstetric care in coordination with DOH that entails the establishment of facilities to
provide emergency obstetric care for every 125,000 population; improve the quality of
prenatal and postnatal care; reduce women’s exposure to health risks; and LGU’s,
NGO’s, others must advocate for health for mother and unborn
 2. Essential Health Service Packages Available in the Health Care Facilities Includes
antenatal registration to avail prenatal services; tetanus toxoid immunization , given to
mother in 2 doses on month before delivery with the 3 booster shots to complete doses
following the recommended schedule; micronutrient supplementation to prevent anemia
and other nutritional disorders; and the treatment of disease and other conditions.

FAMILY PLANNING
1. By the year 2005, provide universal access to a full range of safe and reliable family
planning methods.
2. Countries should seek to identify and remove all the major barriers to the utilization of
family planning services (ICPD).

ADOLESCENT REPRODUCTIVE HEALTH

1. Ensure that the programs and attitude of health care providers do not restrict the access of
adolescent to appropriate services and the information they need, including on sexually
transmitted disease and sexual abuse (ICPD).

REPRODUCTIVE CANCERS
1. Make accessible referral for and further diagnosis and treatment for breast cancer and
cancer of the reproductive system.
2. The Philippines has the highest rate of breast cancer in asia.

INFORMATION DESSIMINATION TO PREGNANT WOMEN

Source: Family Code of the Phils. (2008)
SEC.12. Information dissemination to pregnant women – during the prenatal,
perinatal and postnatal consultations and / or confinements of the mothers or pregnant
women in a health institutions, it shall be the obligation to health institution in the health
personnel to immediately and continuously teach, train, and support the women on
current and updated lactation management and infant care, through participator strategies
such as organization of mothers’ clubs and breastfeeding support groups and to distribute
written information materials on such matters free of charges.

ROOMING-IN AND BREASTFEEDING OF INFANTS ACT 0F 1992

• (REPUBLIC ACT OF 7600) Source: Family code of the Phils. (2008)
• SEC.4. Applicability- The provisions in this chapter shall apply to all private and
government institutions adopting rooming – in and breastfeeding.
• SEC.5. Normal Spontaneous deliveries – The following newborn infants shall be put to
the breast of a mother immediately after birth forthwith roomed – in within 30 minutes.
• SEC.6. Deliveries by Caesarian – Infants delivered by caesarian section shall be roomed
– in and breast feed within (3) to (4) hours after birth.
• SEC.7. Deliveries outside institutions – Newborns delivered outside health institutions
whose mothers have been admitted to the obstetrics department/unit and who both meet
the general conditions stated in section 5 of this act, shall be roomed in and breastfeed
immediately.
 • SEC.8. Exemptions – Infants whose conditions do not permit rooming – in and
breastfeeding as determined by the attending physician and infants whose mother are
either:
(a.) seriously ill;
(b.) taking medications contraindicated to breastfeeding;
(c.) violent psychotic; or
(d.) whose condition do not permit breastfeeding and rooming – in as determined
by attending physician shall be exempted from the provisions of sec. 5, 6, and 7:
provided, that these infants shall be fed expressed breast milk or wet – nursed as
maybe determined by attending physician.
• SEC.9. Right of the mother to breastfeed – It shall be the mother’s right to breastfeed
her child who equally has the right to her breast milk. Bottle feeding shall be allowed
only after the mother has been informed by the attending health personnel of the
advantages of breastfeeding and the proper techniques of infant formula feeding and the
mother has opted in writing to adopt infant formula feeding for her infant

STATISTICS ON MATERNAL, FETAL/INFANT AND CHILD HEALTH

• MORBIDITY: defined as an incidence of ailing health.
• FETAL DEATHS Rate: measures pregnancy wastage. Deaths of the product of
conception occurs prior to its complete expulsion, irrespective of duration of pregnancy
• INFANT MORTALITY RATE: Measures the risk of dying during the first year of life.
It is good index of the general health condition of a community since it reflects the
changes in the environment and medical condition of a community.
• MATERNAL MORTALITY: refers to the death of any woman dying of any cause
whatsoever while pregnant or within 90 days of termination of the pregnancy,
irrespective of the duration of pregnancy at the time of the termination or the method by
which it was terminated.
• LIVEBIRTHS: the category which is important in the registration of the birth in the
infant. This is whenever the infant at sometime after birth breathes spontaneously, shows
any other sign of life such as heartbeat, pulsation of the umbilical cord, or definite
movement of voluntary muscles, whether or not the umbilical cord has been cut or the
placenta is attached.
ETHICAL PERSPECTIVES ON MATERNAL AND CHILD NURSING IN THE
PHILIPPINES

• PRINCIPLES OF ETHICS

1. Beneficence: Do or promote good of others.

Maternal and child nurse must promote the health of both the mother and child as
two separate lives.
2. Nonmalifeficence: Avoid risking or causing harm to others.
Nursing care is not an experiment or a trial and error activity. To avoid risk, a
nurse must be reminded that the mother and child is not rather an object of care
but they are the lives to care for with concern.
3. Autonomy: Right to self-determination, respect, confidentiality, privacy and informed
decisions.
 Clients such as the mother and child are not for nonsense discussions during their
course of treatment. They deserve a total preservation of their integrity and
dignity.
4. Justice: Equal and fair treatment regardless of disease, social or economic status.
In as much as clients are autonomous individuals, nurses have a right to their own
beliefs and values as well. They are encouraged to acknowledge these beliefs and
standby them. Nurses are called upon however to inform their employers of their
stand prior to encountering an ethical dilemma. Moreover, the right to receiving
quality care should be respected first and foremost. Maternal and child nurse
values and morals not only as a nurse but also an individual reveal for every
circumstance she is encountering
e.g. assisting for an induced abortion.
PHILIPPINE NURSING LAWS AND BIOETHICS CONCERNING MATERNAL CHILD
NURSING “PHILIPPINE NURSING ACT OF 2002” (REPUBLIC ACT NO. 9173,
OCTOBER 2, 2002)
- It was created to repeat the “Philippine Nursing Act of 1991” also known as RA
7164.
- It is the duty of the state to safeguard and improve the nursing profession
through ensuring better education, more conducive working conditions, and
more promising career choices.
- The Board of Nursing, whose members are appointed by the President of the
Philippines, shall act as the regulating body of the nursing profession,
protected, created and held responsible by the State to perform the above duty.
BIOETHICS OF MATERNAL AND CHILD NURSING
- As a maternal-child nurses, part of the challenge is facing numerous ethical
questions. Dealing with these issues means being able to come up with the
most appropriate step for a particular situation. When one analyzes what is
morality right or wrong, ethical reasoning is said to be done.
- These numerous ethical dilemmas are multifaceted and there is no right or
wrong. Ethical dilemmas refer to instances wherein there is no single
completely acceptable solution.

There are several ethical theories proposed. There are the following:
1. Deontology theory
2. Utilitarian Theory

SOCIAL ISSUES AND PROBLEMS IN THE PHILIPPINES

• ADOLESCENT PREGNANCY IN THE PHILIPPINES
Souce: Reyala, J.P. et al. (2000) Community Health Nursing in the Phils.
Adolescence is define by WHO as the period of life between 10 and 20 years of age
while the youth refers to those who are between 15 and 24 years old. The term “young
people” refers to both age groups, meaning those aged 10 to 24 years.

• POVERTY IN THE PHILIPPINES

Sources: Garcia, M.B. (1994); Ortigas C.D. (2000); Zulueta, F.M. & Liwag, D.B. (2001)
Poverty is a condition that exists when people lack the means to satisfy their basic needs.
Extreme poverty is the main cause of malnutrition and poor health. Studies show that
 poverty is highly correlated to criminality, breakdown of morals and socially accepted
behavior, low educational attainment, low property values and poor life chances.
- Celia A. Zulueta
-
• Human beings who live inhuman lives- they are the world’s estimated 1.2 Billion poor
people. For them, each day dawns as a struggle to obtain food and basic social services, a
decent livelihood imbued with dignity, self-confidence and hope. Each day is a struggle
to get a meaningful participation in events and decisions affecting themselves, their
families, and communities. Their lot is a difficult one.
- Mary Racelis
 ABORTION IN THE PHILIPPINES
Sources: Garcia, M. Buenconsejo, (1994); Ortigas, C.D. (2000); Zuleuta, F. M. & Liaog, D.B (2001);

Abortion is defined as any interruption of pregnancy before a fetus is viable (able to

survive outside the uterus if born at that time) usually 20-24 weeks of gestation or one
that ways at least 500 grams. It is also define as the artificial termination of pregnancy
before the fetus as attained viability or becomes capable of independent life outside the
uterus. The rate of abortion in the Philippines has reached alarming proportions
particularly in the metropolis. Despite the risks involved and the penalties attached to it,
being illegal, still more and more women are resorting to it to get rid of unwanted
pregnancy. This condition can take place anytime during woman’s first trimester of
pregnancy.
• REPRODUCTIVE HEALTH (RH)

Define as the state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity in all matters relating to the reproductive system and its
functions and processes.
• Its concepts are:
o A married couple has the capability to reproduce/ procreate;
o Reproductive health is the exercise of reproductive right with responsibility; RH
means safe pregnancy and delivery;
o RH includes protection from unwanted pregnancy by having access to safe and
acceptable methods of family planning of their choice;
o RH includes sexual health for the purpose of enhancement of life and personal
relations e.g. against STD, harmful reproductive practices and violence, control
and freedom over sexual relations.

MATERNAL HEALTH CARE IN THE PHILIPPINES

PRENATAL CARE IN THE PHILIPPINES

Community Nursing for Maternal Care

 a) Objectives of prenatal care
1. To give sufficient care to all pregnant women.
2. To ensure a healthy pregnancy and the birth of a full term, healthy baby
3. Identify pregnant women who are at high risk for complications of pregnancy
delivery.
Classification if Clients

Based upon the initial evaluation and screening, pregnant women may classified as:
a) Normal Clients
Following the initial evaluation, they will be given healthy instructions and
counselling. This will include advice for prompt prenatal/care examination.
b) Clients with serious or potentially serious complications
Following the initial evaluation, this client shall be referred to the most skilled
source of medical and hospital care. As a first choice they will be referred (if at all
possible) for continuing care and consultation. 
c) Clients with mild Complications
A thorough evaluation of the needs of clients with mild complication will
determines the frequency of follow-up of this case by the rural health unit, city
health clinic or puericulture center.

Nursing Care During Pregnancy

1. All RHUs and BHS should have a master list of pregnant women in their respective
catchment areas
2. Barangay health workers (BHW), traditional birth attendants (TBAs) or hilots and other
community members concerned with maternal health or community health, should be
encourage to help identify pregnant women in the community and motivate them seek
prenatal care.
3. The homes based mother’s record (HBMR) shall be used as guide in the identification of
risk factors, dangers signs, and to be able to manage client appropriately.
4. In areas where licensed health care practitioners such as doctors, nurses and midwives are
not available, A BHW or TBA shall be trained to do regular prenatal visits using home
based mother’s record to identify risk/danger sign, and to make referrals to health
facilities

Timing of Visits
• Three (3) prenatal visits during pregnancy following the prescribe timing:
1. The first prenatal visit should be made as early as possible, during the first
trimester.
2. Second visit during second trimester
3. The third and subsequent visits during the third trimester
4. More frequents visits should be done for those who are high risks with
complications
The standard prenatal Physical examination per visit shall include the following:
1. Weight and Height
2. Blood pressure taking
 3. Examination of the eyes and palms of the hand and pallor.
4. Abdominal examination to include fundic height, fetal position, presentation, and
fetal heart tones when applicable.
5. Faced, hence and lower extremities for edema, examinations of the breast and
examination of the neck for thyroid gland enlargement (goiter)

The basic prenatal service delivery at the Hospitals, and RHU and BHS should include the
following:
 History taking
 Physical examination
 Treatment of disease
 Tetanus toxoid immunization
 Iron supplementation
 Health education
 Laboratory examinations
 Proper referral to the next higher level when applicable

PRIORITY PROGRAMS OF THE DEPARTMET OF HEALTH

• Expanded Program on Immunization against killer disease in childhood such as
measles, polio, tuberculosis, diphtheria, and tetanus. The targets of this program are areas
in the country where children have not been immunized.
• National Family Planning Program focuses on family welfare and health, through
education and choice; it aims to provide basic family planning services and information.
• Prevention and control of cardiovascular diseases and cancer is the government
response to increasing incidence of hypertension and its complication; and cancer of the
lung, breast, liver, cervix and stomach. The program aims to provide basic knowledge
and skills on the prevention and detection of this diseases.
• Environmental Health Program addresses health problems related to air, water and soil
pollution. Hospital as Centers of Wellness seek to make the hospitals a place where
programs for the prevention of diseases are also being implemented. It seeks to make
basic health services, family counseling and help education available in the hospital
setting.
• Control of Tuberculosis and Other Communicable Diseases remains to be a major
program of the government. Tuberculosis, schistosomiasis and malaria are still common
causes of sickness and death in the country. National AIDS program answers the problem
of increasing number of PWAs or persons with Acquired Immune Deficiency Syndrome
(AIDS). Tests to detect infection in high-risk groups are made available.
• Public Health Education is also undertaken
• Herbal and Philippine Traditional Medicine promotes the used of herbal medicine and
traditional healing practices. Backyard gardening, community project ad putting up of
herbal plants are among the major activities under this program. National drug policy
program seeks make essential drug available, affordable and accessible to the people.
• Nutrition Program addresses the problem of malnutrition among mother children. It
focuses on deficiencies in iron, iodine and vitamin A. Health station serve as distribution
centers where the micronutrients can be given.
 • Araw ng sangkap pinoy, the program aims to help and hidden hunger micronutrients
malnutrition problem particularly vitamin a deficiency, iron deficiency anemia and iron
deficiency disorders. Three – pronged strategy includes: micronutrient supplementation,
education on proper dietary practices and eating habits and food fortification allocation.
• Safe Water and Sanitation are major thrusts of the government because diseases due
poor environmental sanitation still bound.

VIOLENCE AGAINST WOMEN AND CHILDREN

• Violence which may be seen in beatings, choking, severe spanking, stabbing or even
killing is called “family violence “e. g. violence between husband and wife where the
wife usually the victim and is common in lower class than in middle or upper class.
• VIOLENCE AGAINTS WOMEN (VAW) – define as un any act of gender-based
violence that result in or is likely to result in physical, sexual or psychological harm or
suffering to women, including threats of such act, coercion or arbitrary deprivation of
liberty whether occurring in public or private life.
• CHILD ABUSE – defined as a deliberate attack against a child resulting in physical
injury perpetrated by any person exercising his responsibility as a caretaker ( marsden
and wrench 1997).
• ANTI-VIOLENCE AGAINTS CHILDREN (RA 7610)
• “An act providing for stronger deterrence and special protection against child abuse
exploitation and discrimination providing penalties for its violation, in for other
purposes”
• VIOLENCE AGAINTS WOMEN AND THEIR CHILDREN(VAWC) –Defined as
act or a series of acts committed by any person against a woman who is his wife, former
wife or against a woman with whom the person has or had sexual or dating relationship,
or with whom he has a common child, or against her child whether legitimate or
illegitimate, within or without the family abode, which result in or is likely to result in
physical, sexual, psychological harm or suffering, or economic abuse including threats of
such act, battery, assault, coercion, harassment or arbitrary deprivation of liberty.
• ANTI-VIOLENCE AGAINTS WOMEN AND THEIR CHILDREN (RA 9262)
∙ Protect women from all kinds of economic discrimination from sexual harassment.
∙ Counties should take full measures to eliminate all forms of exploitation, abused,
harassment and violence against women.
LEGAL ISSUES ON VIIOLENCE (Family Code of the Philippines)

RULES AND REGULATIONS IMPLEMENTING REPUBLIC ACT NO. 9262,

OTHERWISE KNOWN AS THE “ANTI-VIOLENCE AGAINST WOMEN AND THEIR
CHILDREN ACT OF 2004”
∙ Pursuant to section 46 of Republic Act. No. 9262, “AN ACT DEFINING
VIOLENCE AGAINST WOMEN AND THEIRCHILDREN, PROVIDING FOR
PROTECTIVE MEASURES FOR VICTIMS, PRESCRIBING PENALTIES
THEREFOR, AND OTHER PRPOSES” otherwise known as the “Anti-Violence
Against Women and Their Children Act of 2004”, the following rules and regulation,
having been approved by the Inter-Agency Council in Violence Against Women and
their Children the Implementing rules and regulations (IRR) Committee are hereby
promulgated:
DEFINITION OF TERMS
1. Physical violence refers to act that bodily or physical harm;
2. Sexual violence refers to an act which is sexual in nature, committed against a woman or
her child. It includes, but is not limited to:
a) Rape, sexual harassment, acts of lasciviousness, treating a woman or her child as
a sex object, making demeaning and sexually suggesting remarks, physically
attacking the sexual parts of the victims body forcing him/her to watch obscene
publication and indecent shows or forcing the woman or her child to do indecent
act and/or make films thereof, forcing the wife, a mistress/lover to live in the
conjugal home or sleep together in the same room with the abuser;
b) Acts causing or attempting to cause the victim to engage in any sexual activity by
force or other harm or threat or force, physical or other harm or coercion; and
c) Prostituting the woman or her child.
3. Psychological violence refers to acts or omission causing or likely to cause mental or
emotionally suffering to the victim such as but not limited intimidation, harassment,
stalking, damage to property public ridicule or humiliation, repeated verbal abuse, and
marital infidelity. It includes causing or allowing the victim to witness to physical, sexual
or psychological abuse of a member of the family to which the victim belongs, or witness
pornography in any form to witness abusive injury to pets or to unlawful or unwanted
deprivation of the right to custody and/or visitation of common children.
4. Economic abuse refers to acts that make a woman financially dependent which includes,
but is not limited to the following:
a) Withdrawal of financial support or preventing the victim from engaging in any
legitimate profession, occupation, business or activity, except in cases where in
the other spouse/partner object on valid, serious or oral grounds as define in
article 73 of the Family Code;
b) Deprivation or threat of deprivation of financial resources and the right to the use
and enjoyment of the conjugal, community or property owned in common;
c) Destroying household property; and
d) Controlling the victim’s own money or properties or solely controlling the
conjugal money or properties.
5. Battery – refers to an act of inflicting physical harm upon the woman or her child
resulting to physical and psychological or emotional distress.
6. Battered Woman Syndrome – refers to a scientifically defined pattern of psychological
and behavioral symptoms that have resulted from cumulative abuse found in women
living in battering relationships.
7. Stalking – refers to an intentional act committed by a person who, knowingly and
without lawful justification follows the woman or her child or places the woman or her
child under surveillance directly or indirectly or a combination thereof.
8. Dating Relationship – refer to a situation where in the partners live as husband and wife
without benefit of marriage or are romantically involved overtime and on a continuing
basis during the course of the relationship. A casual acquaintance or ordinary
socialization between two individuals in a business or social context is not a dating
relationship.
 9. Sexual Relation – refers to single sexual act which may or may not result in the bearing
of common child.
10. Safe Place or Shelter – refers to any home or institution maintained or managed by
Department of Social Welfare and Development (DSWD) or by any other agency or
voluntary organization accredited by the DSWD for the purposes of the act or any other
suitable place the resident of which is willing to temporary receive the victim.
11. Children – refers to those below eighteen (18) years of age or older but are incapable of
taking care of themselves as define under Republic Act No. 7610. As used in the act, it
includes the biological or adopted children of the victim and other children under her care
including foster children, relatives or other children who live with her.
12. Psychosocial Services – refer to the provision of help or support for the total wellbeing of
an individual who has suffered as a result of physical harm and psychological and
emotional distress that further resulted in an unpleasant or traumatic experience.
The services are provided to restore the impaired physical, social, emotional,
psychological, and spiritual aspects of the persons to ensure the victims safety and
security, and involves the process of recovery and re-integration into community life.
13. Victim survivor – refers to the women and children victims of VAWC.

RAPE
 Under the Anti-Rape Law of 1997, which amended the Revise Penal Code, rape is
committed when a man has “carnal knowledge” of a woman under any of the
following circumstances:
o Through force, threat, or intimidation;
o When the woman deprived of reason or is otherwise unconscious;
o Through fraud or grave abuse of authority;
o When the woman is “demented”; or
o When the woman is under the age of 12
 The supreme court has further declared that “minimal vaginal contact” is
sufficient to constitute carnal knowledge under the crime of rape
 Rape is also committed when any person, under any of the aforementioned
circumstances, “insert his penis in to another person’s mouth or anal orifice, or
any instrument or object, in to the genital or anal orifice of another person.
 Prior to the enactment of the Anti-Rape Law, rape was considered a crime against
chastity and its definition was limited
 “Marital Rape” is considered a crime, but the wife’s forgiveness invalidates the
criminal action or penalty; however, the marriage is void, the crime or penalty
still stands.

DOMESTIC VIOLENCE AND CHILD ABUSE

∙ The Philippines has no specific national law on domestic violence.
∙ However, the family courts Act of 1997, which establish family courts, denies domestic
violence against women as “Acts of gender base violence that result, or are likely to
result in physical, sexual or psychological harm or suffering to women; and other forms
of physical abuse such as battering or threats and coercion which violate a woman’s
personhood, integrity and freedom of movement.”
∙ When committed against children, domestic violence includes “The commission of all
forms of abuse, neglect, cruelty, exploitation, violence and discrimination and all other
conditions prejudicial to their development.”
∙ 829 exploitation is defined to include force prostitution, sexual slavery, and other forms
of sexual exploitation.
∙ 830 exploitation specifically prohibits any type of trafficking in children or the disabled
for the purpose of exploitation.
∙ Attempted involvement in child prostitution, whether as a procurer or a client, is subject
to imprisonment to 6-12 years. The act prescribes longer terms of imprisonment if the
child prostitute is under 12 years of age.
∙ Child Trafficking is specifically prohibited by the special protection of children against
Child Abuse, Exploitation and Discrimination Act.
∙ Under are republic Act No. 7658, amending for this purpose section 12, Article Vlll of
R.A. 7610, prohibits children employment below 15 years of age in public and private
undertakings.
MODULE 2: OVERVIEW OF REPRODUCTIVE ANATOMY AND PHYSIOLOGY

ANATOMY OF FEMALE REPODUCTIVE ORGAN

EXTERNAL STRUCTURES
 Mons Pubis (Mons Veneris): rounded, soft, fatty, and loose connective tissue over the
symphysis pubis. Dark, curly pubic hair growth in typical triangular shape begins here
one to two years before the onset of menstruation.
 Labia majora: lengthwise fatty folds of skin extending from the mons to the perineum
that protect the labia minora, the urinary meatus, and the vaginal introitus.
 Labia minora: thinner, lengthwise folds of hairless skin, extending from the clitoris to
the fourchette.
a. Glands in the labia minora lubricate the vulva
b. The labia minora are very sensitive because of their rich nerve supply.
c. The space between the labia minora is called the vestibule.
 Clitoris: small, erectile organ located beneath the arch of the pubis, containing more
nerve endings than the glans penis; sensitive to temperature and touch; secretes a fatty
substance called smegma.

 Vestibule: area formed by the labia minora, clitoris and fourchette, enclosing the
openings to the urethra and vagina, Skene’s and Bartholin’s glands; easily irritated by
chemicals, discharges, or friction.

 Urethra – external opening to the urinary bladder.

 Skene’s Glands (also called paraurethral glands) – secretes a small amount of mucus;
especially susceptible to infections.

 Bartholin’s Glands – located on either side of the vaginal orifice; secretes clear mucus
during sexual arousal; susceptible to infections, as well as cyst and abscess formation.

 Vaginal orifice and hymen – partial fold of tissue surrounding opening to the vagina.

 Fourchette: thin fold of tissue formed by the merging of the labia majora and labia
minora, below the vaginal orifice.

 Perineum: muscular, skin – covered area between vaginal opening and anus. Underlying
the perineum are the paired muscle groups that form the supportive “sling” for the pelvic
organs, capable of great distention during the birth process.
- An episiotomy can be made in the perineum if necessary, during the birth process.

INTERNAL STRUCTURES
• FALLOPIAN TUBES: paired tubules extending from the corner of the uterus to the
ovaries that serve as a passageway for the ova. Mucosal lining of tubes resembles that of
vagina and uterus; therefore, infection may extend from lower organs. It is also called
oviducts, and measured 8 to 14 cm (3.2 to 5.6 inches) long and quite narrow. Fallopian
 tubes are lined with folded epithelium containing cilia that beat rhythmically toward the
uterine cavity to propel the ovum through the tube.

4 DIVISIONS OF FALLOPIAN TUBES ARE:

1. Interstitial portion: runs into the uterine cavity and lies within the uterine wall. It
is 1 cm in length and only 1 mm in diameter. It is the most dangerous site of
ectopic pregnancy.
2. Isthmus: narrow part of the tube adjacent to the uterus. It is 2 cm in length. The
tubal isthmus remains contracted until 3 days after conception to allow the
fertilization ovum to develop within the tube. Isthmus is one which is clamped in
bilateral tubal ligation (BTL)
3. Ampulla: wider area of the tube lateral to the isthmus, where fertilization occurs.
It is 5 cm in length. It is the most common site of ectopic pregnancy.
4. Infundibulum: wide, funnel-shaped terminal end of the tube. Fimbrae are
fingerlike process surrounding the infundibulum. Wavelike motions of the
fimbrae ovarica (largest fimbrae), which are very near the ovary, draw the ovum
into the tubes.

 UTERUS: hollow, pear shaped muscular organs, freely movable in pelvic cavity. The
uterus houses and nourishes the fetus until birth and then contracts rhythmically during
labor to expel the fetus. Each month the uterus is prepared for a pregnancy, whether or
not conception occurs. It is measured about 7.5X 5 X 2.5 cm (3 X 2 X 1 inch) and is
larger in a woman who has borne children than in one who has not. It is suspended above
the bladder and is anterior to the rectum. Its normal position is anteverted (rotated
forward) and slightly anteflexed (flexed forward).

WALL OF UTERUS HAS THREE LAYERS:

1. Endometrium: inner layer, highly vascular: shed during menstruation and
following delivery. It is responsive to the cyclic variations of estrogen and
progesterone during the female reproductive cycle.
2. Myometrium: middle layer comprised of smooth muscle fibers running in three
directions; expels fetus during birth process, then contracts around blood process,
then contracts around blood vessels to prevent hemorrhage
3. Perimetrium (Parietal peritoneum): serous outer layer.

UTERUS HAS 3 DIVISIONS:

1. Corpus: the upper part or body of the uterus. The fundus of the uterus is the part
of the corpus above the area where the fallopian tubes enter the uterus.
2. Isthmus: a narrowed transition zone, between the corpus of the uterus and the
cervix. During the late pregnancy, the isthmus elongates and is known as the
lower uterine segment.
3. Cervix: the tubular neck of the lower uterus is about 2 to 3 cm long. The os is the
opening in the cervix that runs between the uterus and the vagina. The upper part
of the cervix is marked by the internal os (opens to the isthmus), and the lower
cervix is marked by the external os (opens to the vagina). The external os of the
 childless woman is round and smooth. After vaginal birth, the external os has an
irregular, slitlike shape and may have tags of scar tissue

 OVARIES:
oval, almond sized organs on either side of the uterus that produce ova and
hormones. Ovaries composed of cortex (most functional part, contains estrogen
and progesterone); medulla (contains nerves and lymphatics); and tunica (the
protective layer). Ovaries secrete estrogen and progesterone in varying amounts
during a woman’s reproductive cycle to prepare the uterine lining for pregnancy.
Ovarian hormone secretion gradually declines to very low levels during the
climacteric period.

At birth, the ovary contains all the immature ova about 2 million presents at birth.
Many of these degenerates until fewer than 300,000 remain puberty. Many ova
begin the maturation process during each reproductive cycle but most never reach
maturity. During the course of woman’s reproductive life, only about 400 of the
ova ever mature enough to be released and fertilized. By the time the woman has
reached climacteric, almost all her ova have regressed.

 VAGINA: muscular and membranous tissue about 8 to 10 cm long, lying between the
bladder anteriorly and the rectum posteriorly. The vagina connects the uterus above the
vestibule below. The vaginal lining has multiple folds, or rugae, and a muscular layer that
are capable of marked distention during childbirth. The vagina is lubricated by secretions
of the cervix, the lowermost part of the uterus, and by Bartholin glands.

3 MAJOR FUNCTIONS OF VAGINA ARE:

1. To allow discharge of the menstrual flow.
2. As the female organ of coitus, to receive the male penis.
3. To allow the passage of the fetus from the uterus.

SUPPORT STRUCTURES
 PELVIS
Right and left innominate bones, sacrum, and coccyx form the bony passage
through which the baby passes during birth. Relationship between pelvic
size/shape and baby may affect labor or make vaginal delivery impossible.
PELVIC MEASUREMENTS
1. True conjugate: from upper margin of symphysis pubis to sacral promontory,
should be at least 11cm; may be obtained by x-ray or ultrasound
2. Diagonal conjugate: from lower border of symphysis pubis to sacral promontory;
should be 12.5 cm to 13cm; may be obtained by vaginal examination.
3. Obstetric conjugate: from inner surface of symphysis pubis; slightly below
upper border, to sacral promontory, it is the most important pelvic measurement;
can be estimated by subtracting 1.5cm – 2cm from diagonal conjugate.
4. Intertuberous diameter; measures the outlet between the inner borders the
ischial tuberosities; should be at least 8cm.
PELVIC DIVISIONS
 a. False Pelvis: shallow upper basin of the pelvis,; supports the enlarging uterus but
not important obstetrically.
b. Linea terminalis: plane dividing upper or false pelvis from lower or true pelvis
c. True pelvis: consist of the pelvic inlet, pelvic cavity, and pelvic outlet.
Measurements of true pelvis influence the conduct and progress of labor and
delivery.

 Ligaments
Seven pairs of the ligaments maintain the internal reproductive organs, with their
nerve and blood supplies, in their proper positions within the pelvis.
A. Lateral Support: paired ligaments stabilize the uterus and ovaries laterally and
keep them in the midline of the pelvis.
a. The broad ligament is a sheet of tissue extending from each side of the uterus to
the lateral pelvic wall.
b. The round ligament and fallopian tube mark the upper border of the broad
ligament; the lower edge is bounded by the uterine blood vessels. Within the two
broad ligaments are the ovarian ligaments, blood vessels and lymphatics.
c. The right and left cardinal ligaments provide support to the lower uterus and
vagina. They extend from the lateral walls of the cervix and vagina to the side
walls of the pelvis.

ANTERIOR SUPPORT: two pairs of ligaments provide anterior support for the internal
reproductive organs.
 The two ovarian ligaments connect the ovaries to the lateral uterine walls.
 The infundibulopelvic, or suspensory ligaments connect the lateral ovary and distal
fallopian tubes to the pelvic side walls. The infundibulopelvic ligament also carries the
blood vessel and nerve supply for the ovary.
 The round ligaments connect the upper uterus to the connective tissue of the labia majora.
These ligaments maintain the uterus in its normal anteflexed position and help guide the
fetal presenting part against the cervix during labor.
 The pubocervical ligaments support the cervix anteriorly. They connect the cervix to the
interior surface of the symphysis pubis.

POSTERIOR SUPPORT: the uterosacral ligaments provide posterior support, extending

from the lower posterior uterus to the sacrum. These ligaments also contain sympathetic and
parasympathetic nerves of the autonomic nervous system.

BLOOD SUPPLY
a. The uterine blood supply is carried by the uterine arteries, which are the branches of
internal iliac artery.
b. These vessels enter the uterus at the lower border of the broad ligament, near the isthmus
of the uterus.
c. The vessels branch downward to supply the cervix and vagina and upward to supply the
uterus. The upper branch also supplies the ovaries and fallopian tubes.
d. The vessels are coiled to allow for elongation as the uterus expands during pregnancy.
 e. Blood drains into the uterine vein and from there into the internal iliac veins
f. Additional ovarian and tubal blood supply is carried by the ovarian artery, which arises
from the abdominal aorta. The ovarian blood supply drains into the two ovarian veins

NERVE SUPPLY
a. Most functions of the reproductive system are under involuntary, or unconscious, control,
b. Nerves of the autonomic nervous system from the uterovaginal plexus and inferior
hypogastric plexus control autonomic functions of the reproductive system.
c. Sensory and motor nerves that innervate the reproductive organs enter the spinal cord at
the T12 through 1.2 levels.
d. These nerves are important during childbearing for pain management.

MUSCLES
a. Paired muscles enclosed the lower pelvis and provide support for internal reproductive,
urinary, and bowel structures.
b. A fibromuscular sheet, the pelvic fascia, also supports the pelvic organs. Vaginal and
urethral opening are in the pelvic fascia.
c. The levator ani is a collection of three (3) pairs of muscle: the pubococcygeus, which is
also the pubovaginal muscles in the female; the puborectal; and the iliococcygeus.
These muscles support internal pelvic structures and resist increases in the
intraabdominal pressure. /
d. The ischiocavernosus muscle extends from the clitoris to the ischial tuberosities on each
side of the lower bon pelvis.
e. The two transverse perineal muscles extend from fibrous tissue of the perineum to the
ishial tuberosities, stabilizing the center of the perineum

THE BREASTS
a. Paired mammary glands on the anterior chest wall, between 2 nd & 6th rib comprised of
glandular tissue, fat and connective tissue.
b. Nipple and areola are darker in color than breasts.
c. Responsible for lactation after delivery.

INTERNAL BREAST STRUCTURES

1. Glandular Tissue (parenchyma is composed of acini (milk-producing) cells that cluster
in groups of 15 to 20 to form the lobes of the breast.

2. Lactiferous ducts or sinuses – form passageways from the lobes of the nipple
3. Fibrous tissue- or Cooper ligaments – provide support to the mammary glands
4. Adipose and fibrous tissues (Stoma) –provide

 THE NIPPLE: is raised, pigmented area of the breast

 THE AREOLA: pigmented skin around the nipple
 MONTGOMERY TUBERCULES: are sebaceous glands of the areola
ANATOMY OF MALE REPRODUCTIVE ORGAN

A. Testes: small oval structures suspended in the scrotum; produce sperm (exocrine
function) and male hormones (endocrine function).
B. Ductal System
a. Epididymis: first part of ductal system; soft cordlike structure that lies along the
posterolateral surface of each testes; head is attached to the top of the testes; tail is
continuous with vas deferens; stores spermatozoa while the mature
b. Spermatic cord: consist of vas deferens, arteries, veins, nerves, and lymphatic vessels.
Vas deferens joins the duct of the seminal vesicles to become the ejaculatory duct. The
epididymal lumen and the prostatic urethra connect in this area.\
A. Accessory Glands
a. Prostate: located below the bladder and in front of the rectum; approximately 4-6 cm
long enclosed in firm, fibrous capsule; connected to the urethra and ejaculatory ducts;
secretes a milk fluid that aids in the passage of spermatozoa and helps keep them liable.
b. Cowpers’ glands: lie on each side of urethra and just below the prostate; secrete a small
amount of lubricating fluid
c. Seminal vesicles: paired structures parallel to the bladder; secrete a portion of the
ejaculate and may contribute to nutrition and activation of sperm.

THE SEXUAL DEVELOPMENT

Definitions
⮚ Amenorrhea: Absence of menstruation. Primary amenorrhea is a delay of the first
menstruation. Secondary amenorrhea is a cessation of menstruation after its initiation.
⮚ Androgen: A hormone that stimulates the development of male secondary sex
characteristics and regulates the release of gonadotropin from the anterior pituitary gland.
⮚ Autosome: Any of the 22 pairs of chromosomes other than the sex chromosomes.
⮚ Celibacy: abstinence from sexual activity.
• Chromosomes: Organized into 46 paired in the nucleus of most somatic cells.
• Climacteric: Physical and emotional changes occurring at woman’s reproductive period.
Also called menopause.
• Corpora Cavernosa: one of a pair sponge-like regions of erectile tissue which contain
most of the blood in the male penis during erection.
• Corpuse Luteum: Graafian follicle cells remaining after ovulation which produces
estrogen and progesterone during pregnancy.
• Deoxyribonucleic Acid (DNA): Basic building block of genes. DNA forms a gene and
many genes form a chromosome.
• Ductus Deferens: epididymal ducts from each testis converge to form a large, thick
walled, muscular duct.
• Ejaculation: Expulsion of semen from the uterus
• Ejaculatory Ducts: two ducts, receive sperm from the ductus deferens and secretion
from the seminal vesicle; the d then empty into the urethra.
• Epididymis: comma shaped and loosely attached to the rear surface of each testis.
 • Erectile Tissue: smooth muscle and connective tissue inside the penis that contain blood
sinuses; large, irregular vascular channels.
• Fetishism: sexual arousal resulting from the use of certain objects or situations.
• Flagellum: the whip-like tail of a sperm, propels the sperm towards the egg in hopes of
achieving fertilization
• Gamete: reproductive cell – in the female (an ovum), and in the male (spermatozoon).
• Genes: A segment/part of DNA that directs the production fo a specific product needed
for bod structure or function. Humans probably composed of 30,000 to 40,000 genes.
• Genetic Sex: Sex determined at conception by union of two X chromosomes (female) or
an X or a Y chromosome (male). Also called chromosomal sex.
• Gonad: Reproductive sex gland that produces gametes and sex hormones. The female
gonads are ovaries; the male gonads are testes
• Gonadotropic Hormone: Secretions of the anterior pituitary gland that stimulate the
gonads, specifically follicle stimulating hormone and luteinizing hormone (Follicle
stimulating Hormones/ Luteinizing Hormones-FSH/LH). The placenta secretes chorionic
gonadotroping during pregnancy.
• Graafian Follicle: A small sac within the ovary that contains the maturing ovum;
becomes corpus luteum after ovulation.
• Heterosexual: one who finds sexual fulfillment with a member of the opposite sex
• Homosexual: one who finds sexual fulfillment with a member of his or her own sex.
• Lesbian: refers to the homosexual woman.
• Meiosis: reduction of cell division in gametes that halves the number of chromosomes in
each cell.
• Menarche: Onset of menstruation
• Menopause: Permanent cessation of menstruation during climacteric
• Menstrual cycle: also termed as a female reproductive cycle, can be defined as episodic
uterine bleeding in response to cyclic hormonal changes.
• Mitosis: Cell division in body cells other than the gametes.
• Nidation: Implantation of fertilized ovum (zygote) in the uterine endometrium.
• Oogenesis: Formation of gametes (ova) in the female.
• Ovulation: release of mature ovum from the ovary through Graafian follicle.
• Puberty: Period of sexual maturation accompanied by the development of secondary sex
characteristics and the capacity to reproduce. Refers to the time during which the
reproductive organs become fully functional.
• Prostate Gland: male accessory sex gland that secretes an alkaline fluid, which
neutralizes acidic vaginal secretions
• Secondary sex characteristics: Physical difference between the mature males and
females that are not directly related to reproduction.
• Somatic Sex: Gender assignment as male or female on the basis of form and structure of
the external genitalia.
• Spermatogenesis: Formation of male gametes (sperm) in the testes.
• Transvestism: an individual who dresses to take on the role of the opposite sex.
• Voyeurism: obtaining sexual arousal by looking at another person’s body.

General Information
  At conception for the first 6 weeks of prenatal life, the reproductive system of both male
and female are similar, or sexually undifferentiated.
 During the 7th week, differences between male and female appear in the internal structure.
 Until 9th week, the external genitalia look similar.
 At about 12 weeks, differentiation of the external sexual organs is completed.
 During fetal life, both ovaries/testes secrete their primary hormones – the estrogen,
progesterone and testosterone. In this period, a female fetus a million immature eggs tore
in her ovaries. Yet by the onset of puberty, the amount has dropped to 300,000 that until
during menstrual years, a woman will only release about 300 eggs.
 The fetal ovary secretes estrogen, but this hormone is not required to initiate development
of female sex structures because until during infancy, childhood to the onset of puberty,
the sex glands of both girls and boys are inactive.
 At sexual maturity (puberty), the hypothalamus of CNS stimulates the anterior pituitary
gland to produce follicle stimulating hormone and luteinizing hormones (FSH/LH) that
will stimulate sex hormones of male (testosterone) and female (estrogen/progesterone)
production by the gonads (male testes/female ovaries).

Five (5) Female Reproductive Hormones Throughout Menstruation

Gonadotropin-releasing hormone (GnRH), secreted by the hypothalamus stimulated anterior

pituitary secretion of FSH and LH.
 Follicle Stimulating Hormone (FSH), secreted by the anterior pituitary gland, acts
on an ovarian follicle responsible for maturation of the ovum.
 Luteinizing Hormone (LH), secreted by the anterior pituitary gland, acts on ovaries
to secrete estrogen and is responsible for ovulation. LH surges to midcycle to
facilitate ovulation and control the secretion of estrogen and progesterone by corpus
luteum.
 Estrogen, secreted by the ovary (follicle and then corpus luteum), causes
proliferation of the endometrium. It is also responsible in developing and maintaining
the female reproductive organs and the secondary sexual characteristics associated
with the adult female.
 Progesterone, secreted by the corpus luteum, is the most important hormone for
conditioning and maintaining the endometrium. It causes the endometrium to become
thick and secretory, allowing for implantation of a fertilized ovum.
PHYSIOLOGY OF OVULATION AND MENSTRUATION

MENSTURAL CYCLE
 is the cyclic uterine bleeding in response to cyclic hormonal changes which begins at
puberty from 9 – 17 years of age. (menarche), then end in menopause; usually on 28
day cycle. Four (4) body structures involved are: the hypothalamus, the pituitary
gland, the uterus and the ovaries.
 As the endometrium is being shed, the process of repair and regrowth starts again
preparing once more for the reception of a fertilized ovum.
 If conception does not occur, the ovum dies; tissue lining the endometrial cavity,
which has become thickened and congested, becomes hemorrhagic.
  Tissue lining the uterus, blood cells, and breakdown products slough off and are
discharged through the cervix into the vagina (menstruation).
MENARCHE – is the onset of menstruation. Early menstrual periods are often irregular and
scant.
 Early menstrual cycle is not usually fertile because ovulation occurs inconsistently.
 Fertile reproductive cycles require preparation of the uterine lining precisely time
with ovulation
 Ovulation may occur during any female reproductive cycle, however the sexual active
girl can conceive even before her first menstrual period
 After one or more years, a hypothalamic-pituitary rhythm develops, and an adequate
cyclic estrogen is produced by the ovary to mature a number of graafian follicles.
 Approximately 14 days before the beginning of the next menstrual period, pituitary
follicle-stimulating hormone (FSH) rises, surge of luteinizng hormone (LH) released
by the anterior hypophysis, and ovulation (extrusion of the ovum) occurs. Ovulatory
periods tend to be regular, monitored by progesterone.

MENSTRUAL PHASE
1. Menstrual Phase
2. Proliferative/ Follicular/ Estrogenic/ Postmenstrual/ Preovulatory Phase
3. Secretory/ Luteal/ Progestational/ Postovulatory Phase
4. Premenstrual or Ischemic Phase

MENSTRUAL PHASE
 Lasts 4 – 5 days (days 1 through 5) of the shedding of functional two thirds of
endometrial lining as initiated by vasoconstriction of spiral arterioles most marked in
the upper layers of the endometrium.
 This occurs if fertilization does not take place in where corpus luteum regresses;
luteinizing hormone, progesterone and estrogen at lowest level; endometrium
becomes ischemic, then menstrual flow begins.
 At the end of one cycle, the loss of estrogen & progesterone stimulated the
hypothalamus to secrete gonadotropin-releasing hormone (GnRH). GnRH, in turn
stimulated anterior pituitary gland to increases secretion of FSH for maturation of 6 to
20 graafian follicles to initiate another cycle.
PROLIFERATIVE/ FOLLICULAR/ ESTROGENIC/
POSTMENSTRUAL/PREOVULATORY PHASE
 Period of rapid growth that extends from about the 6 th day through 13th day to the time
ovulation starts (preovulatory). After completion of a menstrual period, the
endometrium is very thin, with only the basal layer of cells remaining. Endometrial
spiral arteries and veins elongate to accompany thickening of the functional
endometrial layer and to nourish proliferating cells.
 At first in this stage, FSH continue to increase causing the maturation of graafian
follicles that contain hormone called estrogen, thereby resulting to the increase of
estrogen level lasting about 9 days, and this causes the endometrium to grow, thicken,
and proliferate to prepare for the implantation of a fertilized ovum.
 Later, the increase of estrogen depresses FSH to further block the maturation of other
less developed graafian follicles, this to prevent multifetal pregnancy.
  2 days before ovulation, FSH rises again; estrogen level rises (estrogenic phase)
stimulating a massive release of luteinizng hormone (LH) from anterior pituitary
gland called “LH surge”, in return causing one of mature graafian follicles to release
ovum from the ovary from 14 days before the onset of next menstrual period.

SECRETORY/LUTEAL/PROGESTATIONAL/POST OVULATORY PHASE

 Extends from the day of ovulation, 14th day through 25th day, to about 3 days before
the next menstrual period.
 At ovulation, the “LH surge” causes slight fall in estrogen and a arise in progesterone
for final maturation and release of a mature ovum.
 After ovulation, corpus luteum (a yellow body fluid from the collapsed Graafian
follicle) produces large quantities of progesterone and estrogen to prepare
endometrium for a fertilized ovum. In response to this, FSH/LH decreased.
 At the end of secretory phase, the endometrium is in its thickest, becomes luxuriant
with blood and glandular secretions, a suitable protective and nutritive bed for a
fertilized ovum. Implantation occurs 7 to d10 days after ovulation.
 After fertilization, human chorionic gonadotropin (hCG) is produced, which
stimulated corpus luteum to continue producing estrogen and progesterone to prepare
uterine lining for pregnancy by thickening of endometrium. This time pregnancy test
is positive.

PREMENSTRUAL OR ISCHEMIC PHASE

 Occurs only if fertilization does not take place at 26th day through 28th day.
 Corpus luteum regresses, FSH/LH fall with the rapid fall of progesterone estrogen
which results to menstruation. The old corpus luteum becomes fibrous tissue called
corpus albicans.
 Arteries in endometrium constrict, causing uterine lining to shrink and die. The blood
supply to the functional endometrium is blocked and necrosis develops, menstrual
bleeding occurs.

MENOPAUSE
- is the stage of female life when there is physiologic cessation of the menses along
with progressive ovarian failure. Climacteric is the transition period (perimenopausal
period, premenopause, menopause, and postmenopause) during which the woman’s
reproductive function gradually diminishes and disappears. It usually occurs between
the ages 49 and 55. Hormonal changes are: FSH/LH, high; estrogen/ progesterone,
decreased; androgens,increased.

Clinical Manifestations of Menopause

1. The monthly menstrual flow becomes smaller in amount, then becomes irregular, and
finally ceases.
2. Hot or warm flashes and other vascular disturbances may be in evidence and are
endocrinologic origin or due to the decreased estrogen levels
3. Manifestations of atrophy – sagging of structures, atrophic vaginitis.
4. Evidence of stress incontinence on occasion, skin dryness, weight gain, and calcium
deficiency, which leads to osteoporosis.
 5. Psychological manifestations – dizziness, weakness, nervousness, insomnia, headache,
inability to concentrate, a feeling of being unneeded, fear of growing old, and depression.
Complications of Menopause
1. Osteoporosis: due to decreased porosity of the bone linked with lower estrogen levels.
Treatments are estrogen replacement therapy and calcium supplement.
2. Cystocele / Rectocele: sequelae of childbirth injuries: Treatment is kegel exercise, which
involves contracting or tightening vaginal muscles to help strengthen weakened muscles;
and surgical anterior and posterior colporraphy.
3. Prollapse of the uterus: result of childbirth injuries or relaxed cardinal ligaments.
Treatment is the supportive device insertion of pessary (a ring shaped material made of
rubber or plastic)

Treatment and Nursing Interventions

1. Most women respond favorably to a regiment of education and modification of lifestyle
2. Mild sedatives and tranquilizers may be required by some to relieve nervousness and
tension.
3. For persistent and severe hot flashes, it may be necessary to resort to estrogen therapy;
Diethylstilbestrol, Premarin, or Ethynil estradiol (Estinyl).
4. Close medical supervision is required. Continued use of estrogens to prevent widespread
degenerative changes continues to be controversial; however, long term use of estrogens
has been linked with cancer.
Health Education
1. Change of life is not abnormal or need it be limiting.
2. Sex life is no means terminated, but rather enhanced.
3. Avoid over fatigue and stress situations, since this exaggerate minor problems.
4. Encourage nutritious diet and keep weight under control.
5. Develop outside interests that help to absorb anxieties and lessen tension.
6. Continue to exercise and develop self-fulfilling and enriching activities.
7. Recognize that the expected life span after menopause is 30 – 35 years.
8. To alleviate vaginal dryness and pain on intercourse (due to estrogen deficiency), its safe
to use a water-based lubricant (K-Y jelly or Lubafax) than an estrogen cream.
DISTURBANCE IN MENSTRUATION
A. DYSMENORRHEA
- Painful menstruation; common in unmarried women and women who have not borne
children.

TYPES OF DYSMENORRHEA
1. Primary: due to unknown facts; thought to be intrinsic to uterus; extrinsic
pathology such as polyp and fibroids may be a factor; may also involve emotional
and psychologic factors.
2. Secondary: due to factors such as endometriosis, pelvic infection, or intrauterine
device.

Clinical Manifestations of Dysmenorrhea

1. Pain may be due to uterine spasm caused by a narrowing of the cervical canal
(exaggerated uterine contractility).
 2. Pain – colicky, cyclic, nagging, dull ache; usually in lower abdomen, may radiate
down back of legs; may require bed rest.
3. Severe dysmenorrhea may be experience with chills, headache, diarrhea, nausea,
vomiting, and syncope.
Treatment and Nursing Interventions
1. Emotional make up may accentuate discomfort.
2. Regular exercises are recommended.
3. Psychological counseling may also benefit some individuals.
4. Pharmacotherapy – Administration of prostaglandin inhibitor such as ibuprofen,
mefenamic acid, or naproxen sodium are recommended in relieving primary
dysmenorrhea.
5. If the above is unsuccessful, surgery may be necessary. Presacral and ovarian
neurectomy (cutting of nerve fibers) may be done.

B. PREMENSTRUAL SYNDROM (PMS)

 A condition related to neuroendocrine events within the hypothalamus – pituitary
axis that modulates neurotransmitter function.
 It is considered normal but when severe, medical relief is sought.
Causes
a. Estrogen excess or progesterone deficit in the luteal phase of the menstrual cycle
b. Unidentified hormones that cause symptoms at the time of menstrual changes.
c. Some theories point to B-endorphin activity, serotonin deficiency, elevated
prolactin levels, and disturbance of the hypothalamic – pituitary – ovarian axis.
Clinical Manifestations of PMS
1. Symptoms may begin 10 days or more prior to menstrual flow onset; may
diminish 1 or 2 days after menses begin.
2. Edema, breast swelling, abdominal distention – transitory because of increase in
water content in tissues.
3. Behavioral – irritability, sleep disturbance, lethargy, depression.
4. Neurologic – headache, vertigo, paresthesia of hands or feet.
5. Respiratory – colds, hoarseness, allergies (asthma) usually worse.
6. Miscellaneous – palpitation, backache, skin problems, eye complaints.

Treatment and Nursing Interventions

1. Encourage women with PMS to explore ways and means to avoid stress.
Relaxation techniques may be helpful.
2. Restrict sodium intake and limit use of caffeine, tobacco, and alcohol.
3. Try to modify hypoglycemic diet with small, frequent feelings, which often
alleviates irritability.
4. Medications prescribed – progesterone (injection, suppository), oral
contraceptives, diuretics, and monoamine oxidase inhibitors.
C. AMENORRHEA
o Absence of menstrual flow.
TYPES OF AMENORRHEA
1. Primary – when girl is 16 or 17 and has not menstruated; caused by embryo
development and immature uterus, fallopian tubes and ovaries.
 2. Secondary – menstruation has begun (initial menarche) but stops. No bleeding
for 6 months after having regular cyclic bleeding; no bleeding for 12 months after
a history of irregular bleeding.
CAUSES OF AMENORRHEA
a. Normal pregnancy and lactation
b. Psychogenic (minor emotional upsets); hypothalamic disturbances (autonomic
nervous system) may also be the cause e.g. anorexia nervosa.
c. Constitutional – any disturbance of metabolism and nutrition e.g. tuberculosis,
obesity, hypothyroidism, central nervous system lesions, and use of oral
contraceptives
d. Exercise related – rigorous involvement.
TREATMENT
1. Directed at cause – constitutional therapy, psychotherapy, and hormone therapy,
surgery
2. Teach the importance of adequate nutrition
3. Strenuous workouts or aerobic training can cause amenorrhea.
4. They also provide emotional support and explanation of proposed treatment

D. ABNORMAL UTERINE BLEEDING (AUB) INVOLVES:

a. Menorrhagia:
1. Excessive bleeding during phase of menstruation.
2. It is possibly caused by endocrine imbalance, uterine tumors, and infection.
3. Treatment is individualized by cause.
a. Metrorrhagia:
1. Bleeding from uterus between regular menstrual periods
2. It may be related to adolescence, oral contraception use, and vaginal irritation
from infection, cancer, a lower level of progesterone and endometrial sloughing
toward the end of the reproductive years, and psychogenic factors.
3. It is significant because it is usually a symptom of some disease – often cancer or
benign tumors of uterus and adnexia.
E. POLYMENORRHEA
 Frequent menstruation occurring at intervals of less than 3 weeks or shorter than
21 days.
 Causes is unclear but could be: Chlamydia or gonorrhea that became
inflammatory called pelvic inflammatory disease (PID), hyperthyroidism
 Treatment: oral contraceptives.
F. OLIGOMENORRHEA
 Markedly diminished menstrual flow nearing amenorrhea.
 Causes could be: Lack of synchronization of hypothalamus, pituitary gland and
ovaries; perimenopause; Grave disease; eating disorder like anorexia nervosa
(personality disorder manifested by aversion to food) and bulimia nervosa
(personality disorder manifested by uncontrolled ingestion of food); emotional
stress; physical illness: poor nutrition; over exercise; and frequent travel.

FAMILY PLANNING:
BASIC PRINCIPLES:

1. Family Planning – defined as the voluntary and moral management of all the
processes of family life including human reproduction.

2. The nurse should be familiar with the application, advantages and disadvantages
of the various methods of contraception available.

3. The most effective method is the one a woman selects herself and will use
consistently.

4. Women are entitled to contraceptive advice as part of good health care without
the burden of moral judgment.

5. Because family planning deals with people’s sexuality, a private setting should be
arranged whenever possible.
6. Feelings about contraception must be explored in a nonjudgmental way and the
variety of choices must be summarized to allow selection of a method that fits the
unique circumstances of the person or couple.

TYPES OF FAMILY PLANNING

NATURAL FAMILY PLANNING

Periodic Abstinence
- Abstention from sexual intercourse during fertile period of each cycle.
- This usually depends on identification of fertile period- usually about 14 days
before next menstrual period.
- Abstaining for about 7 – 18 days.
Cervical Mucus Method
- Requires a woman to examine the mucus from her cervix to determine her
fertile period.
- The consistency and amount of cervical mucus changes as hormone levels
vary during the menstrual cycle
- After 3 -4 days of the menstrual period, little or no mucus is discharged (dry
days).to avoid pregnancy, intercourse is allowed in this period (safe days)
- Just before ovulation, the cervical mucus becomes thin, watery, transparent
and copious.
- During the peak of ovulation, the cervical mucus becomes wet, slippery,
abundant, clear, stretchable like “egg white” (Spinnbarkheit), which can be
stretched to 2.5cm, and normally from 8-10cm (3 – 4 inches between thumb
and forefinger). This means “wet days” and signals “unsafe days”.
- During this ovulation, some women experience localized lower abdominal
pain called mittelschmerz which corresponds to the release of the egg cell.
- After ovulation, the mucus becomes thick, cloudy and sticky again, then
decreases or may be no mucus.
 - The consistency of cervical mucus can be affected by medications such as
antihistamines that change mucus production throughout the body, and by
spermicides, sexual intercourse, vaginal infections, or the use of the douches.
Calendar Rhythm
- In the calendar or rhythm method, a woman keeps a record of at least six
menstruation cycles and uses the record to determine which days she is most
likely to be fertilized during an average menstrual cycle.
- One difficulty with this method is that fertile periods can vary from cycle to cycle
(irregular days), meaning exact time of ovulation is hard to detect.
- According to the Ogino formula, the first unsafe days (beginning of the
fertilization period) can be determined by subtracting 18 days from the length of
the shortest cycle.
- The last unsafe days (beginning of the postovulatory safe period) can be
determined by subtracting 11 days from the length of the longest cycle.
- If the shortest cycle is 24 days and the longest is 30 days, application of the
formula is as follows:
- Shortest cycle = 24 – 18constant = 6th day
- Longest cycle 30 – 11constant = 19th day
- To avoid conception, the couple would abstain during the “fertile” period days 6
through 19.
- If the woman has very regular cycles of 28 days, the formula indicated the fertile
days to be:
- Shortest cycle 28 – 18constant = 10th day
- Longest cycle 28 – 11constant = 17th day
- To avoid pregnancy, the couple abstains from day 10 through 17 because
ovulation occurs day 14th from the first (1st) day of the last menstrual period
(LMP).

Basal Body Temperature

- The basal body temperature method measures variations in body temperature to
determine when ovulation has occurred.
- Normally, body temperature decreases slightly just before ovulation and begins to
rise for several days afterward.
- Under the influence of progesterone, 24 – 48 hours after ovulation, temperature
rises from 3 – 6 C and remains slightly elevated until next menstruation begins
- With this method, a woman takes her temperature every morning before getting
out of bed using a basal thermometer, which has an expanded scale to show slight
changes in temperature between 36 C (96 F) and 38 C (100 F).
- While this method is effective in determining the time of ovulation, the beginning
of a woman’s fertile period may occur two days before ovulation.
- Since sperm can live for up to 48 hours in a woman’s body, a woman who has
unprotected sexual intercourse just before she ovulated may become pregnant if
the sperm are still alive when the egg reaches the uterus.
- This method maybe ineffective if a woman is sick or under stress because lack of
sleep and illness can change a woman’s body temperature.
Coitus Interruptus
 - This is the withdrawal of the penis from the vagina when ejaculation is imminent;
effective when mechanical devices are unavailable.
- Contraindicated when male is not able to exert self-control.
- Ineffective when premature ejaculation occurs.
- There is a psychological ill effect for both male and female.

Coitus Reservatus: sexual intercourse without ejaculation.

Coitus Interfemora: sexual intercourse where penis is wrapped between femur.
Coitus Intermmas: sexual intercourse where penis is wrapped between mammary glands.

ARTIFICIAL FAMILY PLANNING

 Condom
- Thin stretchable rubber sheath worn over penis during intercourse; widely
available without prescription; applied ith room at tip to accommodate ejaculate;
applied to erect penis before vaginal penetration.
- Man is instructed to hold on to rim of condom as he withdraws from female to
prevent spilling semen.
 Diaphragm
- Shallow rubber dome fits over cervix, blocking passage of sperm through cervix
- Efficiency increased by use of chemical barrier as lubricant.
- Women needs to be measured for diaphragm, and refitted after childbirth or
weight gain/loss of 10lbs.
- Device needs to be left in place 6 – 244 hours after intercourse.
- Woman needs to practice insertion and removal, and to be taught how to check
for holes in diaphragm, store in cool place.
 Hormonal Control Therapy (Oral Contraceptives, Birth Control Pills)
- Ingestion of estrogen and progesterone on a specific schedule to prevent the
release of FSH and LH; thus preventing ovulation and pregnancy.
- Usually taken beginning on day 5 of the menstrual cycle though day 25, then
discontinued.
- It can cause additional tubal, endometrial, and cervical mucus changes.
- Withdrawal bleeding occurs within 2- 3 days.
- Contraindicated to patients age over 35; with history of hypertension or vascular
disorders and cigarette smoking.
- Women using oral contraceptives need to be sure to get sufficient amounts of
vitamin B as metabolism of this vitamin is affected.
- Minor side effects may include weight gain, breast changes, headache and vaginal
spotting. Report vision changes/disorders immediately
 Cervical Cap
- Cup-shaped device that is placed over cervical os and held in place by suction.
- It has 4 sizes that need to be fitted to the client.
- Women need to practice insertion and removal.
- Spermicidal increase effectiveness and may be left in place from 24 – 48 hours
 Contraceptive sponge
- Small, soft insert, with indentation on one side to fit over cervix.
 - It contains spermicide, moistened with water and inserted with indentation snugly
against cervix, which may be left in place up to 24 hours.
- No professional fitting is required; may also protect against STDs
- It should not be used by women with history of toxic shock syndrome.
- Problems include cost, difficulty in removal, and irritation.
 Intra uterine device
- Placement of plastic or noncreative device into uterine cavity during menstruation
or after devliery.
- Mode of action thought to be the creation of sterile endometrial inflammation,
discourages implantation (nidation). It does not affect ovulation or conception
- The device is inserted during or just after menstruation, while cervix is lightly
open
- It may cause cramping and heavy bleeding during menses for several months after
instertion.
- The tail of IUD hangs into vagina through cervix.
- Woman is taught to feel for it before intercourse and after each menses.
- A distinct disadvantage is the increased risk of pelvic infection (PID) with use of
IUD.
 Steroid implants
- Approved in 1990 by FDA; biodegradable rods containing suttained release, low
does progesterone.
- Inhibits LH (luteinizing hormone) release necessary for ovulation.
- Effective over 5 – year time frame.
- It needs minor surgical procedure for insertion and removal.
- Removal causes total reversibility of effect.
 Injectable Progestin
- same as steroid therapy

PERMANENT FAMILY PLANNING

 Bilateral tubal ligation in female is done by clamping or blocking the isthmus of the
fallopian tubes to prevent the passage of ova, and is done after menstruation.
 Bilateral vasectomy in the male to prevent the passage of sperm. Sperm will be absorbed
by the cells after ligation.
 Female will still menstruate but will not conceive, and male will be incapable of
fertilizing his partner after all viable sperm ejaculated from vas deferens (6 weeks or 10
ejaculations).
 There should be no effect o male capacity for erection or penetration
 Hysterectomy also causes permanent sterility in the female.

Permanent Family Planning

A. Bilateral Tubal Ligation- In female is done by clamping or blocking isthmus of the
fallopian tubes to prevent the passage of ova and is done after menstruation.
B. Bilateral Vasectomy – In male to prevent the passage of sperm.

INFERTILITY
GENERAL INFORMATION
- Inability to conceive after at least one year of unprotected sexual relations.
- Inability to deliver a live infant after three consecutive pregnancies.
- For the male inability to impregnate a female partner within the same conditions.
- May be primary (never has been pregnant/never impregnated) or secondary (pregnant
once, then unable to conceive or carry again). Affects approximately 10% - 15% of all
couples.
- While fertility implies to the ability to produce offspring and indicates the rate at which
babies are born, yet infertility is one problem being faced by some men or women.
- Factors affecting prolonged infertility are age: both men and women declines fertility at
age 35; weight: overweight or obese women have greater risks of miscarriages
malformations while undernourished or underweight women have developed
amenorrhea; toxins e.g. alcohol, caffeine and smoking can reduce chance of conceptions
medications, some medications can affect sperm count; and reproductive disorder,
blocked tubes, endometriosis and uterine problems; nutritional deficiencies: lack of key
nutrients can cause amenorrhea and infertility; egg or sperm problems which are not able
to sustain implantation (normal sperm count: 40 – 400 million); ovulation disorders: e.g.
polycystic ovary syndrome (PCOS) where woman secretes more androgen that prevents
her from ovulating, and hypothyroidism causing “anovulation” that interferes with
hypothalamus – pituitary – ovarian interaction, stress which affects the ovaries reducing
hypothalamic secretion of GnRH that lowers production of FSH and LH; and excessive
exposure to x-rays or radiations.

Tests for infertility can include:

 FOR FEMALE
 Examination of basal body temperature, cervical mucus and identification of time
of ovulation.
 Plasma progesterone level: assess corpus luteum.
 Hormone analysis: Endocrine function
 Endometrial biopsy: receptivity of endometrium.
 Pst coital test: sperm placement and cervical mucus
 Hysterosalpingography: Tubal patency/ uterine cavity.
 Rubin’s test: Tubal patency (sues carbon dioxide).
 Pelvic ultrasound: Visualization of pelvic tissues.
 Hysteroscopy and Laparoscopy: Examines uterine interior and pelvic organs with
endoscope. Identifies abnormalities (Polyps, endometrial adhesions). Visual
assessment of pelvic/abdominal organs.
 Postcoital test: Evaluates characteristics f cervical mucus and sperm function with
that mucus at time of ovulation. Ultrasonography ensures proper timing for tests.
 Ultrasonography: Evaluates structure of pelvic organs. Identifies ovarian follicle
and release of ova at ovulation. Evaluates for presence of ectopic or multifetal
pregnancy.

FOR THE MALE

 Sperm (Semen) analysis: Assess and evaluates composition, volume, motility,
agglutination and function
  Testicular biopsy: An invasive test for obtaining sample of testicular tissue;
identified pathology and obstructions.
 Endocrine tests: Evaluates function of hypothalamus, pituitary gland, and the
response of the testicles. Assays are mad to determine testosterone, estradiol,
luteinizing hormone (LH), and the follicle-stimulating hormone (FSH).
 Ultrasonography: Evaluates structure of prostate gland, seminal vesicles and
ejaculatory ducts by means of transrectal probe.
 Sperm penetration assay: Evaluates fertilizing ability of sperm; assess ability
sperm to undergo changes that allow penetration of hamster ovum from which the
zona pellucida has removed.

Medical Management
1. INFERTILITY OF FEMALE PARTNER, CAUSES AND THERAPY
a. Congenital anomalies (absence of organs, improperly formed or abnormal
organs): surgical treatment may help in some situation but cannot replace absent
structures.
b. Irregular/absent ovulation (ovum released irregularly or not at all): endocrine
therapy with clomiphene citrate (Clomid)/ menotropins (Pergonal) may induce
ovulation; risks of ovarian hyperstimulation and released of multiple ova.
c. Tubal factors (Fallopian tubes blocked or scarred from infection, surgery,
endometriosis, neoplasms): treatment may include antibiotic therapy, surgery,
hysterosalpalpingogram.
d. Uterine Conditions (endometrium unreceptive, infected): removal of an IUD,
antibiotic therapy, or surgery may be helpful.
e. Vaginal/surgical factors (hostile mucus, sperm, allergies, altered pH due to
infection) treatment with antibiotics, proper vaginal hygiene, or artificial
insemination maybe utilized.
2. INFERTILITY OF MALE PARTNER, CAUSES AND THERAPY
a. Impotence: may be helped by psychologic counseling/penile implant,
medication.
b. Low/abnormal sperm count: fewer than 40 million/ml semen, low motility, and
more than 40% abnormal forms: there is no good therapy use of hormone
replacement therapy has had little success.
c. Varicocele: (variocosity within spermatic cord): ligation maybe successful.
d. Infection in any area of the male reproductive system (may affect ability to
impregnate): appropriate antibiotic therapy is advised.
e. Social habits (use of nicotine, alcohol, other drugs; clothes that keep scrotal sac
too close to warmth of the body): changing these habits may reverse low/absent
fertility.
ALTERNATIVES FOR INFERTILE COUPLES include:

A. Artificial insemination by husband or donor: the technique of therapeutic insemination

may use either the partner’s semen or that of a donor to overcome a low sperm count.
Men who donate semen for insemination are screened to reduce the risk of transmitting
diseases or genetic defects. The artificial insemination employs two (2) methods:
 1. Artificial Insemination with husband (AIH): The wife is inseminated within her
reproductive tract with sperm from her husband.
2. Artificial Insemination with donor (AID): The woman is inseminated with sperm
of an anonymous donor. This method had become the preferred treatment when
the husband has an absence or marked decreased in the amount of sperm. (Reeder,
Martin, Konia Maternity Nursing 7th ed. 1992)
3. In vitro fertilization (IVF): involves bypassing blocked or absent fallopian tubes.
The physician removes the ova by ultrasound – guided transvaginal retrieval or
occasionally laparoscopy and mixes them with prepared sperm from woman’s
partner or a donor. Fertilized ova are returned to the uterus 1 – 2 days after
conception.
4. Surrogate parenting: Commercial surrogacy involves the hiring of a woman to
bear another couple’s child. The father’s sperm may be used to impregnate the
surrogate or in surrogate embryo transfer (SET), the surrogate is implanted with
the genetic parent’s embryo. When the fetus is born, the surrogate mother
relinquishes to the couple her rights the infant as per the terms of a contract that
has been drawn up.
B. Gamete Intrafallopian Transfer (GIFT): the woman must have at least one patent
fallopian tube twith retrieval of multiple ova and washed sperm similar to that of IVF.
Then retrieved ova are drawn into a catheter that also carries prepared sperm. Sperm and
up to 2 ova per tube are injected into each fallopian tube through laparoscope with
additional prepared sperm injected into the uterus.
C. Embryo Transfer: reinsertion of fertilized eggs into the woman’s uterus about 40 hours
after fertilization.
D. Zygote Intrafallopian Tube Transfer (ZIFT): eggs retrieval via aspiration under
ultrasonic guidance. Fertilization occurring in the laboratory. Fertilized egg transferred to
woman’s patent tube via laparoscope.
E. ACCEPTING CHILDLESSNESS, as a lifestyle may also be necessary; support group
may be helpful.

5. SELECTED MEDICATIONS for infertility therapy

1. Bromocriptine (Parolodel): corrects excess prolactin secretion by anterior pituitary
improving gonadotropin – releasing hormone secretion, normalizing follicle
stimulating hormone (FSH) and luteinizing hormone (LH) release.
2. Chorionic gonadotropin, human (hCG; Pregnyl); recombinant deoxyribonucleic
acid (DNA) origin (r-hCG; Ovidrel); used in conjunction with gonadotropin stimulate
ovulate in the female or sperm formation in the male. Stimulates progesterone
production by corpus luteum.
3. Clomiphene citrate (Clomid): induction of ovulation in women who have specific
types of ovulatory dysfunction. The drug increase frequency of GnRH secretion from
the hypothalamus, increasing FSH/LH release and maturing the ovarian follicle and
release of the ovum.
4. FSH, recombinant DNA origin (follitropin [Gonal-F]); stimulation of ovarian
follicle growth ovulation-induction gonadotropin.
5. GnRh antagonists (e.g., cetrorelix [Cetrotide], ganirelix [Antagon]; stimulates
ovulation by suppressing LH and FSH.
Nursing Interventions
1. Assist with assessment including a complete history, physical examination, laboratory,
work, and test for both partners.
2. Monitor psychological reaction to fertility.
3. Support couple through procedures and tests.
4. Identify any existing abnormalities and provide couple with information about the
conditions.
5. Help couple acknowledge and express their feelings both separately and together.
WEEK 3: NORMAL PREGNANCY

GAMETOGENESIS

 Gametogenesis is the process whereby a haploid cell (n) is formed from a diploid cell
(2n) through meiosis and cell differentiation.
 Gametogenesis in male is known as SPERMATOGENESIS and produces spermatozoa
 Gametogenesis is the female is known as OOGENESIS and result in the formation of
ova.

BEFORE PREGNANCY
 The development of ova in females and spermatozoa in males requires a special reduction
division called meiosis, in which the diploid number of chromosomes mitosis (46)
becomes halves the number of its number (haploid) (23)
 Only one of each paired chromosome (composed of strands of deoxyribonucleic acid or
DNA and protein) is directed to the gamete, 22 autosome (auto, some) and (1) sex
chromosome. The DNAs are composed of genes which are minute particles located in a
linear order on the DNA of cell nuclei.
 The maturation process of female ovum is called oogenesis and male spermatozoon is
called spermatogenesis; such is termed as gametogenesis.

OOGENESIS
- in the human female reproductive system, growth process in which the primary egg cell
(or ovum) becomes a mature ovum.

(1) Oogenesis is the process by which female gametes (ova) are produced which begins in
prenatal life.
(2) During early fetal life or before birth, the oogenia enlarges to form primary oocyte (still
with 46 chromosomes layered with follicular tissue called primary follicles).
(3) During fetal life, the first meiotic division has begun by the primary oocyte but remain
dormant (inactive) throughout childhood. Indeed, female fetus has millions of immature
eggs in her ovaries but many of these ova regress during childhood until fewer than
300,000 remain at puberty, and do complete the first meiotic division during this pubertal
period.

SPERMATOGENESIS
(1) Spermatogenesis is the formation of male gametes (sperm) in the testes, which begins in
puberty.
(2) Primitive sperm cells (speratogenia) which develop during fetal life, begin multiplying
during puberty, and matured into sperm throughout his lifetime. But male in their 50’s,
60’s and beyond, can still be father though their fertility gradually declines with age.
(3) As the spermatogenium (primary sperm cell contains 46 chromosomes [mitosis] by
replication) enters the first meiotic division, it enlarges to become a primary
spermatocyte (still with 46 chromosomes).
 (1) The first meiotic division forms 2 secondary spermatocytes which reduces the number to
23 unpaired chromosomes (22 autosomes & 1 sex chromosomes, X or 7)
(2) In the second meiotic division, each secondary spermatocyte divides again to form 2
spermatids.
(3) Half of the four (4) spermatids from 2 meiotic divisions carry an X chromosome and half
carry a Y, which these spermatids gradually mature into sperm.

CONCEPTION
- is the time when sperm travels up through the vagina, into the uterus, and fertilizes an egg
found in the fallopian tube

HOW DOES CONCEPTION HAPPEN?

- Conception occurs when a sperm cell from a fertile man swims up through the vagina and
into the uterus of a woman and joins with the woman's egg cell as it travels down one of
the fallopian tubes from the ovary to the uterus.

1. Before ovulation, numbers of oocytes begin to mature under the influence of

2. follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the woman’s
anterior pituitary gland.
3. The maturing oocytes are surrounded by a sac called graafian follicle, which collapsed
and becomes corpus luteum producing estrogen and progesterone to prepare the
endometrium for pregnancy.
4. At ovulation, such mature ovum with the timing of a motile, healthy sperm
5. after entering the vagina, can be fertilized only within 24 hours (1 day),
6. though sperm may survive at 1 – 2 days and few may remain fertile in a
7. woman’s reproductive tract for 5 days.

FERTILIZATION

 Fertilization is the process by which male and female gametes are fused together,
initiating the development of a new organism.
 The male gamete or ’sperm’, and the female gamete, ’egg’ or ’ovum’ are specialized sex
cells, which fuse together to begin the formation of a zygote during a process called
sexual reproduction.

PRE – EMBRYONIC STAGE

A. General Information
 The pre-embryonic stage period is the first 2 weeks – 3 weeks after conception,
from fertilization through implantation.
 The zygote divides into 2 cells, then 4, and 8 while in the fallopian tube for 3 days
up to 16 cell stages. The cells become smaller with each division, so they occupy
about the same amount of space as original ovum; and eventually form a solid ball
called (morula). After 3 days, the morula while dividing is delivered into the
uterus and spends about 4 days in the uterine cavity developing further into a
blastocyst.
  Blastocyst is the outer cells of the morula that secretes fluid, creating a sac of cells
that has an inner cell mass placed off the center within the sac.
 The blastocyst develops into the embryo and into a double layer called embryonic
disc from the embryo which develop with the other embryonic membrane called
amnion.
 The trophoblast attaches itself to the surface of the endometrium for further
nourishment. Between 7 and 0 days after fertilization, the zona pellucida
disappears, and the blastocyst implants itself by burrowing into the uterine lining
and penetrating down toward the maternal capillaries until it is completely
covered.

IMPLANTATION (NIDATION)

 is the stage of pregnancy at which the embryo adheres to the wall of the uterus. At this
stage of prenatal development, the conceptus is called a blastocyst. It is by this adhesion
that the embryo receives oxygen and nutrients from the mother to be able to grow.

A. General Information
1. Burrowing of developing zygote into endometrial lining of uterus may take 7 – 10 days
after fertilization at the upper two third (2/3) of the uterus, while zygote develops to
trophoblastic stage.
2. Chorionic villi appear on surface of trophoblast and secrete human chorionic
gonadotropin (HCG), which inhibits ovulation during pregnancy by stimulating
continuous production of estrogen and progesterone. This secretion of HCG forms the
basis of various tests for pregnancy.
3. Fertilized ovum from conception through first week of pregnancy, nidation complete by
the end of this period.

GERM LAYERS: Embryonic stage: 3rd to 8th week

I. EMBRYO ORGAN SYSTEMS
A. Develop from 3 primary germ layers:
1. Ectoderm – outer layer produces skin, nails, nervous system and tooth enamel.
2. Mesoderm – middle layer, produces connective tissue, muscles, blood and circulatory
system.
3. Entoderm – inner layer produces linings of gastrointestinal and respiratory tracts,
endocrine glands, and auditory canal.
B. Critical time in development: Embryo most vulnerable to teratogens (harmful substances
or conditions), which can result in congenital anomalies.

II. PLACENTA
A. Developed by the first month of pregnancy
B. Provides fetal oxygenation, nutrition and elimination.
C. Produces progesterone; estrogen; HCG; and human placental lactogen (hPL)/Human
maternal insulin production; prepares breasts for lactation.
D. Mother also transmits immunoglobulin G (IgG) to fetus through placenta, providing
limited passive immunity.
III. UMBILICAL CORD
A. Develops at same time as placenta
B. Connects fetal circulation to placenta
C. Consists of 2 arteries and 1 vein supported by mucoid material (Wharton’s Jelly) to
prevent kinking and knotting
D. Attaches at center of placenta in normal development
E. Is about 55cm long and 2cm in diameter.

IV. AMNIOTIC SAC

A. Surrounds the fetus and fetal side of placenta.
B. Is made up 2 membranes, chorion and amnion.
C. Also called bag of water (BOW)
D. Contains amniotic fluid between 500 & 100ml by end of pregnancy. Functions are:
 Protects the embryo against injury; allows fetal movement; provides a constant
temperature
 Is swallowed by fetus; promotes normal prenatal development.
 Primarily water but contains small amount of protein, glucose, fetal hair, fetal urine and
vernix caseosa.

1. OLIGOHYDRAMNIOS (less than 400 ml of amniotic fluid is associated with poor fetal
lung development and malformations that result from compression of fetal parts. This
may occur because the kidneys fail to develop, urine excretion is blocked, or placental
blood flow is inadequate.
2. POLYHYDRAMNIOS OR HYDRAMNIOS (more than 2000 ml or amniotic fluid
index greater than 97.5 percentile for the corresponding gestational age): may occur when
the fetus has severe malformation of the CNS or gastrointestinal tract that prevents
normal ingestion of amniotic fluid (e.g. esophageal atresia, a disorder of esophagus which
carries food from the mouth to the stomach).

FETAL DEVELOPMENT MILESTONE

BY 4 WEEKS
1. Embryo length about 0.4 cm; weight about 0.4gms; and appears in C shape.
2. All systems in rudimentary form; heart chambers formed and heart is beating.
3. Head becomes prominent, accounting for about one third of the entire embryo.
4. Eyes, ears, and nose appear in a rudimentary form. Nervous system begins form.
BY 8 WEEKS
1. Length about 2.5 cm, weight 2gms.
2. Some distinct features in face; head large in proportion to rest of body; some movement
3. Organ formation is complete. The developing cells are called a “fetus”
4. Head accounts for about one half of the total body mass
5. Heart is beating and has septum and valves
 6. Arms and legs are developed
7. Abdomen is large with evidence of fetal intestine
8. Facial features readily visible; eye folds are developed
9. Gestational sac visible on ultrasound; external genetalia begin to differentiate

BY 12 WEEKS
1. Length 6-8cm; weight 19-45 gms., moves body parts and swallows
2. Sex distinguishable; ossification in most bones; kidneys secrete urine
3. Eyes, ears, mouth, nose, heart and circulatory system, limbs, tail, spinal cord, bones and
nails are present.
4. Bile secreted into stomach
5. Refinement and completion of all system occurs.
6. Heartbeat can be heard using Doppler ultrasound stethoscope

BY 16 WEEKS
1. Length 11.5 cm – 17 cm, weights 100 – 200gms.
2. More human appearance; earliest movement likely to be felt by mother;
3. Meconium in bowel
4. Fetal urine present in amniotic fluid; swallows amniotic fluid
5. Fetal heart sounds are audible with fetoscope
6. Lanugo present and well formed; scalp hair
A. develops
7. Skeleton begins ossification
8. Intestines assume normal position in the abdomen

BY 20 WEEKS
1. Length 18 – 25cm; weight about 223- 450 gms.
2. Fetal hair grows, skeleton hardens, sex visible, and fetal heart audible thru fetoscope
3. Fetus able to suck and swallow
4. Mother is able to feel spontaneous movements by fetus
5. Fetus demonstrates definite sleep and awake patterns
6. Sebum is produced by sebaceous gland
7. Meconium is evident in the upper portion of the intestines
8. Lower extremities are fully formed
9. Vernix caseosa covers the skin
10. Passive antibody transfer from the mother begins as early as 20 weeks

BY 24 WEEKS
1. Length 28cm – 36 cm; weight 550 – 820 gms.
2. Body well proportioned; skin red and wrinkled
3. Eyelids are open and pupils can react to light; well-defined eyelashes and eyebrows
are visible
4. Hearing is developing with the fetus being
5. able to respond to a sudden sound
6. Lungs are producing surfactant
BY 28 WEEKS
1. Length 35 cm – 38 cm; Weight about 1100 gms – 1250 gms
2. Infant viable but immature if born at this time.
3. Eyelids open; skin red and less wrinkled; with vernix caseosa
4. Surfactant production begins
5. Some nervous system regulation begins
6. Testes descend into scrotum

BY 32 WEEKS
1. Length 38 cm – 43cm; weight 1600 – 2100 gms.
2. More subcutaneous fat beginning to deposit
3. L/S ratio in lungs now 1.2:1
4. Skin smooth and pink.
5. Fetus may assume vertex or breech position in preparation for birth
6. Iron stores are beginning to develop
7. Growth is most rapid at this period
8. Fingernails increase in length, reaching the tips of the fingers
9. Vernix caseosa becomes thick

BY 36 WEEKS
1. Length 42cm – 48 cm; weight 2200 – 2900 gms.
2. Increased fat deposits, nervous and breathing systems, and blood developed enough
to support extrauterine life
3. Lanugo decreases with vernix caseosa.
4. Soles of the feet have one or two creases
5. The fetus is storing additional glycogen, iron, carbohydrate, and calcium
6. Skin of the face and body begins to smooth
7. L/S ratio usually 2:1; definitely sleep/wake cycle

BY 40 WEEKS
1. Length 48 cm – 52cm; weight 3000- 3200gms.
2. Full term pregnancy. Baby is active, with good muscle tone; strong suck reflex; if
male, testes in scrotum; little lanugo
3. Begins to kick actively and forcefully, causing maternal discomfort
4. Vernix caseosa fully formed
5. Conversion of fetal hemoglobin to adult hemoglobal

FETAL CIRCULATION

GENERAL INFORMATION (starts from the 3rd week)

A. Placenta supplies oxygen and nutrients and removes waste; responsible for:
(i) Metabolism, fetal digestive tract
(ii) Oxygenation and waste removal, fetal lungs and kidney
(iii) Endocrine secretions, major endocrine glands
B. Umbilical cord contains two (2) arteries and one (1) vein
 Vein brings oxygen to fetus
  Arteries remove wastes from fetus

MAJOR BYPASSES IN FETAL CIRCULATION

1) FORAMENT OVALE, opening between right and left atrium of heart, bypassing lungs.
Closes functionally at birth because of increased pressure in left atrium; anatomic closure
may take several weeks to several months.
2) DUCTUS ARTERIOSUS, connects pulmonary artery to aorta, bypassing the lungs; closes
after delivery.
3) DUCTUS VENOSSU, connecting umbilical vein and ascending vena cava, bypassing liver
or portal circulation. Closes after birth.

PHYSIOLOGY
a. The Course of Fetal Circulation
 The course of fetal blood circulation is from the fetal heart, to the placenta for exchange
of oxygen and waste products, and back to the fetus for delivery to fetal tissues.
 The umbilical cord has two arteries that is high in carbon dioxide and carries other waste
products away from the fetus to the placenta, where these substances are transferred to
the mother’s circulation for elimination.
 The umbilical vein carries freshly oxygenated & nutrient rich blood from the placenta
back to the fetus.
 The umbilical arteries and vein are coiled within the cord to allow them to stretch and
prevent obstruction of blood flow through them.
 The entire cord is cushioned by a soft substance called Wharton’s jelly to prevent
obstruction caused by pressure.
FETAL CIRCULATORY CIRCUIT
 Because the fetus does not breathe air or metabolize substances in the liver, several
alterations of the post birth circulatory route are needed.
 Three shunts – the ductus venosus, the foramen ovale, and the ductus arteriosus divert
most circulating blood away from the lungs and liver.
 Oxygenated blood from the placenta enters the fetal body through the umbilical vein.

CHANGES IN BLOOD CIRCULATION Maternal adaptations to pregnancy

a. 1
st trimester: initial ambivalence about pregnancy; pregnant woman places
focus on self e.g. physical changes associated with pregnancy and emotional
reactions pregnancy.
b. 2
nd trimester: relatively tranquil period: acceptance of reality of pregnancy;

increased awareness and interest in fetus; introversion and feeling of well-

being.

c. 3
rd trimester: anticipation of labor and delivery and assuming mothering
role, viewing infant as reality vs. fantasy; fears and fantasies and dreams
about labor are common; “nesting behaviors” (e.g. preparing layette)AFTER BIRTH
 Fetal circulatory shunts are not needed after because the infant oxygenates blood in the
lunges, metabolizes substances in the liver, and stops circulating blood to the placenta.
 As the infant breathes, blood flow to the lungs increases, pressure in the right hear falls,
and foramen ovale closes.
 Pressure in the aorta rises as pressure in the pulmonary artery falls, causing the direction
of blood flow through the ductus arteriosus to reverse, from the aorta into the pulmonary
artery. The ductus arteriosus constricts as the arterial oxygen level rises.
 The ductus venosus constricts when the blood flow from the umbilical cord stops
 The foramen ovale and ductus venosus permanently close as tissue proliferates in these
structures.
 The ductus venosus and ductus arteriosus become ligaments, as do the umbilical vein and
arteries.
PSYCHOSOCIAL CHANGES/ADAPTATIONS IN PREGNANCY

Factors influencing a woman’s response to pregnancy (varies with developmental stage)

 Memories of her own childhood

 Cultural background
 Existing support system
 Socioeconomic conditions
 Perceptions of maternal role
 Impact of mass media
 Coping mechanisms

MATERNAL ADAPTATIONS TO PREGNANCY

1st trimester: initial ambivalence about pregnancy; pregnant woman places focus on self
e.g. physical changes associated with pregnancy and emotional reactions pregnancy.
2nd trimester: relatively tranquil period: acceptance of reality of pregnancy; increased
awareness and interest in fetus; introversion and feeling of well- being.mk,
3rd trimester: anticipation of labor and delivery and assuming mothering role, viewing infant as
reality vs. fantasy; fears and fantasies and dreams about labor are common; “nesting behaviors”
(e.g. preparing layette)
PSYCHOLOGICAL CHANGES/ADAPTATIONS IN PREGNANCY

Pregnancy validation/Accepting the pregnancy: first trimester

1) Often shock and denial first
2) Introversion begins and lasts 7 – 8 months; encouraged by weight gain and other outward
signs of pregnancy.
3) Ambivalent feeling (2 feelings) either to accept pregnancy or not, but finally, acceptance
came

Fetal embodiment/Accepting the baby: second trimester

1) Attempts to incorporate fetus into her body image as integral part of self.
2) Readjusts to life roles
3) Develops feelings of inner strength
4) Appears to be time of maturation.
5) Acceptance of baby.

TERMINOLOGIES OF PREGNANCY
 Gravida – number of times pregnant, regardless of duration, including the present
pregnancy.
o Nulligravida – a woman who is not now and never has been pregnant.
o Primigravida – pregnant for the first time
o Multigravida – pregnant for second or subsequent time.
 Para – number of pregnancies that lasted more than 20 weeks, regardless of outcome.
o Nullipara – a woman who has not given birth to a baby beyond 20 weeks’
gestation.
o Primipara – a woman who has given birth to one baby more than 20 weeks’
gestation.
o Multipara – a woman who has had two or more births at more than 20 weeks
gestation; twins or triplets count as 1 para.
PRESUMPTIVE SIGNS OF PREGNANCY
- more subjective signs, cannot be used to diagnose pregnancy
- Recall FANS BVOUW
 Fatigue
 Amenorrhea
 Nausea and Vomiting
 Urinary frequency
 Breast tenderness and changes
 Excessive fatigue
 Uterine enlargement
 Quickening
 Weight Changes
 Skin Changes

CHANGES/EFFECTS OF PREGNANCY ON BODILY SYSTEM

 The body needs to adapt in the physiologic changes it needs to sustain the requirements
in pregnancy.
ENDOCRINE GLANDS
A. Fatigue result of increased levels, causing sodium and water retention and smooth muscle
relaxation
B. Human Chorionic Gonadotropin (HCG) (a hormone created by chorionic villi of the
placenta, in the urine and blood serum of the pregnant woman) produced by 4th day
secreted trophoblastic tissue of conceptus (takes place 7 – 10 days after fertilization while
zygote or fertilized ovum develops), measured as part of pregnancy test.
C. Melanocyte stimulating hormone (MSH) caused increased pigmentation in localized
areas.
D. Estrogen produced by corpus luteum first 5 – 8 weeks, then by placenta, with levels
rising throughout pregnancy. Main functions are:
  Growth of uterine muscles and ability of uterine muscles to constrict.
 Aids in development of breast ducts and secretory system to prepare for
lactation
E. Progesterone: produced by corpus luteum for first 5 – 8 weeks, then by placenta. Main
functions are:
o Acting as regulatory mechanism to handle increased needs of woman and
fetus
o Causing slight increase in basal metabolic rate (BMR)
o Causing smooth muscle of uterus to relax
o Sustaining pregnancy
o Relaxing uterine muscle
o Causing endocervical glands to secrete thick mucus, impedes sperm migration
o Body temperature increases slightly.

F. Angiotensin – renin system in the kidney increases in response, under the influence of
progesterone. This leads to increased aldosterone production leading to increased
sodium-water retention that increases blood volume and serves as a ready nutrient to the
fetus.
G. Adrenal gland. Adrenal gland activity increases in pregnancy as increased levels of
corticosteroids and aldosterone are produced to suppress an inflammatory reaction or
help to reduce the possibility of woman’s body rejecting the foreign protein of the fetus,
as in the case of foreign tissue transplant.
H. Aldosterone (steroid hormone produced by the adrenal cortex causing sodium
reabsorption (+) and potassium and hydrogen (-) loss) increased to overcome the salt –
excreting/wasting effects of progesterone to maintain the necessary level of sodium in the
greatly expanded blood volume to meet the needs of fetus.
I. Insulin increases in response to higher levels of glucocorticoid produced by the adrenal
glands. But insulin is less effective due to some antagonists

Prostaglandins and relaxing hormones booth increase in levels

• Prostaglandins are found in the female reproductive tracts, and decidua during pregnancy
which they affect smooth muscle contractility. Prostaglandins prostacyclin (a potent
vasodilator) also helps maintain normal blood pressure, but with its declined level comes
the elevation of blood pressure, such in preeclampsia.
• Relaxin, on the other hand, secreted by the corpus luteum, helps prevent the uterine
activity, soften the cervix and the collagen in the joints.

Total thyroxine (t4) and thyroxin binding protein increase in the 1st trimester.
- This change causes the basal metabolic rate (BMR) increased during pregnancy causing
greater cardiac output, pulse rate, and heat intolerance.
 Parathyroid hormone production increases during pregnancy as needed for calcium.
Metabolism, being important for fetal growth, The parathyroid glands’ hypertrophy is
necessary to satisfy the increased requirement in calcium.

 Pancreatic changes lead to:

 o During the 1st trimester, the increasing glucose demand by the fetus causes a fall
in maternal blood glucose resulting to martnal hypoglycemia.
o During the 2nd trimester and throughout pregnancy, though insulin being
produced by the Islets of Langerhans increases, it appears not to be effective
because maternal tissue sensitivity to insulin begins to decline due to tohe effects
of human placenta lactogen (HPL), prolactin, progesterone, estrogen and cortisol,
which this results to hyperglycemia.

 Pituitary gland changes lead to:

o Prolactin increases from the anterior pituitary gland to prepare the breasts to
produce milk.
o The posterior pituitary secretes oxytocin, which stimulates milk ejection reflex
after childbirth. It also stimulates the contraction of the uterus, but during
pregnancy, uterine contraction is inhibited (prevented) by progesterone which
results to the relaxation of uterine smooth muscle fibers (a normal condition).
REPRODUCTIVE SYSTEM
o Amenorrhea occurs; ovulation is prevented by the increased progesterone and
estrogen levels.
o Softening of the cervix (Goodell’s sign) due to increased blood supply.
o Softening of lower segment of uterus (Hegar’s sign)
o Purplish hue to vaginal mucosa (Chadwick’s sign)
o Secretion of vaginal cells increase; leucorrhea acts as body’s first line of defense
against that rise in pH makes the pregnant more prone to yeast infections.
o Uterus enlargers.
CARDIOVASCULAR SYSTEM
Main functions:
o Deliver blood to uterine vessels at pressure adequate to fulfill requirements of
placental circulation.
o Bring about physical, chemical, and cellular changes in blood to provide adequate
oxygen exchange between mother and fetus.
Major changes include:
o Cardiac enlargement; cardiac output increased by 30% to 50% peaking in the third
trimester
o Increased cardiac rate and stroke volume
o Increased potential for varicose veins
o Pseudoanemia (false anemia without the blood sign of anemia) due to increased fluid
volume
o Displacement of the heart upward and to the left from pressure on the diaphragm.
o Supine hypotension results from obstructed blood flow from the lower extremities due to
the weight of the growing uterus pressing the vena cava against the vertebrae when
patient lies in supine position. Position patient in left side lying position.
o Pressure of the enlarged uterus on the pelvic veins and inferior vena cava results to
increased femoral venous pressure.
RESPIRATORY SYSTEM
o Increased volume of air per minute
o Increased alveolar ventilation
o Improved exchange of CO2 and O2 at cellular level
o Increased estrogen leads to nasal swelling and stuffiness
o Enlarging uterus puts pressure on diaphragm, decreasing respirator movement

URINARY SYSTEM
o Increased renal blood flow.
o Increase renal plasma flow.
o Increased glomerular filtration rate (GFR) and increasing efficiency of clearance to meet
the increase needs of circulatory system, resulting in polyuria.
o Increased susceptibility to infection from dilation of ureters and renal pelvis.
o Pressure from the uterus and loss of bladder tone, leading to urinary frequency.
GASTROINTESTINAL SYSTEM
o Increased appetite and thirst
o Increased food requirements
o Decreased gastric acids and pepsin levels
o Heartburn caused by esophageal reflux
o Increase time of content in bowel, leading to increased absorption of water and
constipation
o Delayed gastric emptying time, resulting in better absorption of nutrients, especially
glucose and iron.

MUSCULOSKELETAL CHANGES
o Lordosis is forward curvature of the spin due to the pressure of the gravid uterus.
o Calcium and phosphorous needs are increased during pregnancy, because the fetal
skeleton must be built.
o Woman’s pelvic ligaments and joints gradually softens under the influence relaxin and
progesterone to facilitate the passage of the fetus.

IMMUNE SYSTEM
o Immunologic competency is decreased, making fetus become foreign to women’s body
as if it were transported organ.
o Immunoglobulin G (IgG) production is decreased resulting to the woman’s prone of
infection during pregnancy. Increased white blood cells may help to counteract the
decrease IgG response.

ACID – BASE BALANCE

o By about 10th week of pregnancy, there is decreased of about 5mm Hg in PCO2.
o Progesterone maybe responsible for increasing the sensitivity of the respiratory center
receptors pH rises (becomes more basic).
o Alterations in acid-base balance indicate that pregnancy is a state of respiratory alkalosis
compensated by mild metabolic acidosis.
INTEGUMENTARY SYSTEM CHANGES
o Pigmentation changes occur in the areola, nipple, abdomen, thighs and vulva.
o Facial chloasma (mask of pregnancy) and vascular spider nevi may develop.
o Streae (stretch marks) commonly appear on the abdomen, breasts, and thighs.
o Activity of sebaceous and sweat glands may increase.

METABOLIC CHANGES

1) Metabolism accelerates 20% during pregnancy

2) Average weight gain during pregnancy is 24 to 30 lbs.
3) Increased water retention is a basic chemical alteration of pregnancy.
MODULE 4 : NURSING CARE DURING PREGNANCY

ANTEPARTAL VISITS
 Initial visit for pregnancy test as early in pregnancy as possible, in 1st trimester.
 Monthly visits for the first 7 months if pregnancy without problems
 During 8th month, visits usually every 2 weeks, and then weekly during last month until
delivery.
COMPONETS OF PRENATAL VISITS
Guide Summary:
 Assessment
 Diagnostic Tests During Pregnancy

ASSESSMENT
A. DATA COLLECTION of client’s health history in all pertinent areas in order to form
basis of comparison with data collected on subsequent visits and to screen for any high-
risk factors. Ask patient’s name, age, religion, economic status, and educational
attainment and the ff:
 Menstrual history: Menarche, regularity, frequency and duration of flow, last
period.
 Obstetrical history: all pregnancies, complications, outcomes, contraceptive use,
sexual history. Summarizing pregnancy information: GTPAL/GTPALM; GPAb
 GTPAL/GTPALM: (Pillitteri, Adele 2007)
 Gravida = the number of preg

GTPAL/GTPALM: (Pillitteri, Adele 2007)

 Gravida - the number of pregnancies including the present one.
 Term - total number of infants born at term 37 or more up to 42 weeks
 Preterm - total number of infants born before 37 weeks
 Abortions - total number of spontaneous or induced abortions
 Living - total number of children currently living.
 Multiple pregnancies - total of multiple pregnancies

GPAb:
 Gravida = the number of times the woman has been pregnant, including the current
pregnancies.
 Para = the number of pregnancies that reaches the age of viability – in 24 weeks
regardless of whether babies born alive or not.
Example: A woman who has been pregnant three times, had had two deliveries after
24 week, gestation, and has had one abortion; the abbreviation would be G3, P2, Ab1.

B. Medical History: include past illnesses, surgeries, current use of medications, any drug
& food sensitivity, use of oral contraceptives, use of alcohol and tobacco, blood
transfusions, endocrine disorders, infections, diabetes and heart disease.
C. Family history/ Psychosocial data: Ask for congenital disorders, hereditary diseases,
multiple pregnancies, diabetes, heart disease, hypertension, mental retardation, others.
 D. PHYSICAL EXAMINATION including internal gynecologic exam, bimanual exam,
weight, vital signs, auscultation f fetal heart rate (FHR), palpation of fetal outline
(Leopold’s Maneuver), measurement of fundal height as correlation for appropriate
progress of pregnancy, determine fetal length, calculation of fetal weight in grams and
age of gestation (AOG), and expected date of confinement EDC by (Neagle’s Rule).

LEOPOLD’S MANEUVER
- Is performed in pregnancy after the uterus becomes large enough to allow differentiation
of fetal parts by palpation

FIRST MANEUVER
Answers the question: What is in the fundus? Head or breech?
Finding: Presentation. This maneuver identifies the part of the fetus that lies over the
inlet into the pelvis. The commonest presentations are cephalic (head first) and breech
(pelvis first).

Performing First Maneuver

- Facing the patient’s head, use the tips f the fingers of both hands to palpate the
uterine fundus.
- When the fetal head is in the fundus, it will feel hard, smooth, globular, mobile
and ballotable.
- When the breech is in the fundus, it will feel soft, irregular, round and less
mobile.
- The lie of the fetus – the relationship between the long axis of the fetus and the
long axis of the mother – can also be determined during the first maneuver.
- The lie is commonly longitudinal r transverse, but occasionally be oblique.

SECOND MANEUVER
Answers the question: Where is the back?
Finding: Position. This maneuver identifies the relationship of the fetal body part to the
front, back or sides of the maternal pelvis. There are many possible fetal positions.

Performing Second Maneuver

- Remain facing the patient’s head. Place your hands on either side of the abdomen.
- Steady the uterus with your hand on one side, and palpate the opposite side to
determine the location of the fetal back.
- The back will feel firm, smooth, convex, and resistant.
- The small parts (arms and legs) will feel small, irregularly placed, and knobby
may be actively or possibly mobile

THIRD MANEUVER
Answers the question: Where is the presenting part?
Finding: Presenting part. This maneuver identifies the most dependent part of the fetus –
that is, the part that lies nearest the cervix.
 It is the part of the fetus that first contracts the finger in the vaginal examination, most
commonly the head or breech.

Performing the Third Maneuver

- Turn and face the patient’s feet.
- Place the tips of the first three fingers of each of hand on either side of the
patient’s abdomen just above the symphysis, and ask the patient to take a deep
breath and let it out.
- As she exhales, sink your fingers down slowly and deeply around the presenting
part. Note the contour, size and consistency of the part.
- The head will feel hard, smooth, and mobile if not engaged. Immobile if engaged.
The breech will feel soft and irregular.

FOURTH MANEUVER
Answers the question: Where is the cephalic prominence?
Finding: Cephalic Prominence. This maneuver identifies the greatest prominence of the
fetal head palpated over the brim of the pelvis. When the head is flexed (flexion attitude),
the forehead forms the cephalic prominence. When the head is extender (extension
attitude), the occiput becomes the cephalic prominence.

Performing the Fourth Maneuver

 Face the patient’s feet.
 Gently move your fingers down the sides of the abdomen toward the pelvis until
the fingers of one hand encounter a bony prominence. This is the cephalic
prominence.
 If the prominence is on the opposite side from the back, it is the baby’s brow, and
the head is flexed.
 If the head is extended, the cephalic prominence will be located on the same side
as the back and will be the occiput.

MCDONALD’S METHOD & RULE (MEASURING FUNDIC HEIGHT USING TAPE

MEASURE)
Uterine growth and estimated fetal growth
a) Fundus at symphysis pubis = 12 weeks’ gestation
b) Fundus between symphysis pubis and umbilicus = 16 weeks
c) Fundus at umbilicus = 20 – 22 weeks’ gestation
d) 2 fingerbreadths above umbilicus = 24 weeks
e) Fundus 28cm. from top of symphysis pubis = 28 weeks’ gestation
f) Midway between umbilicus and xiphoid process = 30 weeks
g) Just below xiphoid process = 34 weeks
h) Fundus at lower border rib cage or at the level of xiphoid process = 36 weeks gestation
i) Uterus becomes globular and drops = 40 weeks gestation

McDonald’s rule: In months: Fundic Height (cm) multiplied (X) 2/7

25 cm x 2 50
 Example: = =7 months
7 7
  In weeks: Fundic Height (cm) multiplied (X) 8/7
25 cm x 8 200
 Example: = =29 weeks
7 7

NEAGLE’S RULE
Formula in finding expected/estimated date f confinement (EDC) or estimated due date
(EDD):
 Add 7 days to the first day of the last menstrual period (LMP)
 Subtract 3 months
 Add 1 year

DIAGNOSTIC TESTS DURING PREGNANCY

a. Pregnancy test – measures HCG in urine; accurate early in pregnancy.
b. Ultrasonography – identifies fetal and maternal structures; measures the
response of sound waves against solid objects; used to discover complications of
pregnancy.

Purposes of Ultrasound:
 Diagnose pregnancy as early as 6 weeks gestation.
 To confirm the presence, size, and location of the placenta/ amniotic fluid.
 To see fetal abnormalities (congenital anomaly screening) e.g. hydrocephalus,
anencephaly, or spinal cord, heart, kidney, and bladder defects.
 To establish sex; presentation and position of fetus. Sex is seen as early as 15 weeks
through 4-dimension ultrasound (4D)

Preparation of client/ Nurse Responsibilities

 Explain test t client.
 Have client drink 6 – 8 glasses of water, without voiding before the test, so that fetal parts
are more visible.

c. Amniocentesis – determines genetic disorders, sex and fetal lung maturity

(Lecithin: sphingomyelin L:S; ratio of 2:1 is accepted as normal). It is done
through the aspiration of 15 ml amniotic fluid from the uterus between 14th and
16th weeks of pregnancy. During and 30 minutes after the procedure, observe the
FHHR to be certain that the rate remains normal and that uterine contractions are
not occurring.

Preparation of client/Nurse Responsibilities:

 Ask the woman to void, to prevent bladder puncturing.
 Since the procedure involves penetration to the amniotic sec, such is frightening to the
woman, explain the procedure and alleviate her fear.
 Place in supine position and provide privacy but exposing only her abdomen.
  Place folded towel under her right buttock to tip her body slightly t the left and move the
uterus of the vena
 cava, to prevent supine hypotension.
 Take maternal blood pressure and FHR for baseline, then attach t electronic fetal
monitoring.
 Caution the woman that she may feel a sensation of pressure as the gauge 20 – 22 spinal
needles, 3- 4 inches is introduced for aspiration.
 Caution the woman not to take a deep breath and hold it because the diaphragm lowers
uterus and shifts intrauterine contents.

Amniocentesis can provide information in some of these areas:

Color: Normal color of amniotic fluid is color water; late in pregnancy is slightly yellow
tinge; blood incompatibility is strong yellow results frora bilirubin release with hemolysis of
RBC; meconium staining is green color suggests fetal distress.

Lecithin/Sphingomyelin Ratio: Lecithin and sphingomyelin are the protein components of

the lung enzyme surfactant that the alveoli begin to form at about 22nd t 24th weeks of
pregnancy. After amniocentesis, the L/S ratio maybe determined quickly by shake test (if
bubbles appear in the amniotic fluid after shaking, the ratio is mature) r sent to laboratory for
laboratory analysis.
Phosphatidyl Glycerole and Desaturated Phosphatidylcholine: these are compounds
substances found in surfactant which are present only with mature lung function at 35 to 36
weeks. This means that fetus has no respiratory distress syndrome.
Bilirubin Determination: the blood specimen must be free from the presence of bilirubin
(yellowish pigment found in bile, a fluid produced by the liver r a yellow breakdown product
of red blood cells.)
Chromosome Analysis: used to detect chromosomal diseases through prenatal
amniocentesis.
Fetal Fibronectin: Fibronectin is a glycoprotein that plays a part in helping the placenta
attach to the uterine deciduas, found in amniotic fluid until after 20 weeks of pregnancy and
is assessed through cervical mucus. As labor approaches, it can be found in vaginal or
cervical fluid, but higher amount of these substances in the amniotic fluid would mean a
preterm labor may begin.
Inborn Errors of Metabolism: Some inherited diseases that are caused by inborn errors of
metabolism can be detected by amniocentesis.
Alpha-Fetoprotein: An increased level of alphafetoprotein in the amniotic fluid signifies
anencephaly, myellomenigoocele or omphalocele. But if level is found to be decreased, the
result is Down syndrome

d. Percutaneous Umbilical Blood Sampling (PUBS): also called cordocentesis or

funicentesis is the aspiration fo blood from the umbilical vein for analysis.

Procedures and Results:

 After the umbilical cord is located by sonography, a thin needle is inserted by
amniocentesis technique into the uterus until pierces the umbilical vein
  A sample of blood is removed for blood studies, such as complete blood cunt, direct
Coomb’s test, blood gases, and karyotyping.
 To ensure that the blood sample is from fetus, it is submitted to a Kleihauer-Betke test.
 IF a fetus if found to be anemic, blood maybe transfused using the same technique.
 The fetus is monitored by a nonstress test before and after the procedure to be certain that
there are no uterine contractions and no vaginal bleeding.

e. Contraction Stress test (CST) – based on principles that healthy fetus can withstand
decreased oxygen, but compromised fetus cannot; the FHR is analyzed in conjunction
with the contractions.

Types:
 Nipple Stimulated CST: massage or rolling of one or both nipples to stimulate uterine
activity and check effect on FHR.
 Oxytocin Challenge Test (OCT): infusion of calibrated dose of IV oxytocin thru
“piggybacked” to maintain IV line; controlled by infusion pump; amount infused
increased every 15 – 20 minutes until 3 good uterine contractions are observed within 10-
minute period.

Patient preparation:
􏰀 Explain the procedure to the patient that intravenous infusion of oxytocin were
initiated.
􏰀 Then ask the woman to roll her nipples between her fingers and thumb until
uterine contractions begin, which are recorded by a monitor.
Results:
􏰀 3 contractions with a duration of 40 seconds or longer must be present in a 10 minute window.
If the test is negative, it means normal because there is no fetal heart decelerations (fetal heart
rate deviations seen through monitor)
􏰀 If the test is positive, it is abnormal, meaning 50% or more of contractions cause late
decelerations (there is uteroplacental insufficiency resulting to the fetal hypoxia).

 Non stress test (NST): evaluates fetal heart rate in response to fetal movement, done in
10 to 20 minutes. The uterine contraction monitors are attached to the rhythm strip and
the woman pushes the button attached to the monitor whenever she feels the fetus moves.
This can be done also at home as part of home monitoring program.

Results:
> When the fetus moves, the fetal heart rate should increase about 15 beats/minute and
remain elevated for 15 seconds
? >If no increase in beats/minute on fetal movements, there is poor fetal oxygen
perfusion.
? >If a 20 minute period passes without any fetal movement, the fetus is only sleeping.
The mother should be given an oral carbohydrates snack, enough to cause fetal
movement; also may be stimulated with a loud sound.
7. Chorionic Villus Sampling (CVS): aspiration of small sample of chorionic villus tissue
at 8 – 12 weeks of gestation to detect genetic abnormalities, chromosomal or DNA
analysis.
The chorion cells are located by ultrasound. A thin catheter is inserted vaginally or
abdominally, and numbers of chorionic cells are removed for analysis.

Side Effects of CVS:

􏰀 Excessive bleeding, pregnancy loss, baby born with missing limbs, threatened
abortion.

8. Maternal serum alpha – fetoprotein: assesses quantity of fetal serum proteins

(substance produced by the fetal live), done at 15 weeks of pregnancy. If elevated, are
associated with neural tube defects. If the level is low, fetus has chromosomal defect, e.g.
Down syndrome (see previous explanations).
9. Biophysical Profile: looks at fetal hypoxia and fetal compromised by measuring 5
parameters f fetal activity – fetal heart rate, fetal breathing movements, gross fetal
movements, fetal tone and amniotic fluid volume. It can be done daily during a high risk
pregnancy.
? Results:
? A score of 6 is suspicious; 4 denotes fetal compromised; but score of 10 (highest score),
means good fetal well-being.

A. WEIGHT GAIN
o Total WEIGHT GAIN of 25 to 35lbs. (11-16kg.) for the whole pregnancy.
o 1st Trimester 3.5 – 5 lbs. (1.6 – 2.3kg) or 1.16 – 1.66 lbs/month or .29 - .42
lb/week or less than 1lb/week.
o Each of 2nd & 3rd Trimester, 12 – 15 lbs (5.5 to 6.8 kg) or 4 – 5 lbs (month or 1-
1.25 lbs/ week or 0.45 – 0.56 kg / week which consists of:
 Fetus – 7 – 7.5 lbs (3.4kg)
 Amniotic fluid – 2 lbs (0.9kg)
 Placenta and membrane – 1.5 lbs (0.6kg)
 Breasts – 1.5 – 3lbs (0.6 – 1.3kg)
 Uterus -2.5lbs (1.1kg)
 Increased blood volume – 2 – 4lbs (0.90 – 1.8kg)
 Body fat – 7 lbs (3.8kg)
 Extravascular fluid and fat – 5 – 10 lbs (2.3 – 4.5kg)

B. SPECIFIC NUTRIENTS seeds are:

1. Calories: usual addition is 300kcal/day, but there will be specific guidelines for
those beginning pregnancy either over or underweight.
2. Protein: additional 30gms / day to ensure intake of 74-76 gms/day
3. Carbohydrates: intake must be sufficient for energy needs, using fresh fruits and
vegetable as much as possible to derive additional fiber benefits.
4. Fats: high energy foods, which are needed to carry the fat soluble vitamins.
5. Iron: needed by mother as well as fetus; reserves usually sufficient for first
trimester, should be taken with Vit. C to promote absorption
 6. Calcium: 1200mg/day needed; dairy product most frequent source.
7. Sodium: contained in most foods; needed in pregnancy; should not be restricted
without serious indication.
8. Vitamins: both fat and water soluble are needed in pregnancy; essential for tissue
growth and development, as well as regulation of metabolism.
9. Folate (Folic Acid): Folate is a B vitamin which is essential for the formation of
red blood cells and must be taken before and during pregnancy. The requirement
for women for folate increases by 50% during pregnancy because this is a time of
additional blood formation and rapid tissue growth for the baby. Studies have
shown that additional folate intake during early stages of conception helps prevent
neural tube defects e.g. cleft lip & cleft palate (Guide to a Healthy Pregnancy,
Anmum Book).

TERATOGENIC FOODS, ADDITIVES, DRUGS according to US food and Drug Act

 Teratogen: An agent that can cause defect in a developing fetus/baby.
 Teach the woman to be aware of the potential hazards, because ingesting large
quantities of these substances may be harmful to her fetus.
1. Nitosamines (N-nitroso Compounds)
 These compounds are patent carcinogens in all tested species, including
amphibians, birds, fish, and mammals e.g. sodium nitrite and sodium nitrate are
added to most smoke and cured meat and fish to act as an antioxidant to ensure
preserving the foodstuff.

2. Alatoxins
 These substances are related to mcotoxins and are produced by fungal growths on
a wide range of food stuffs. For instance, the mycotoxin ergotism of rye can
induce abortion as well as gangrene and other ills of the vascular system.
3. US Certified Food Colorings
 These are the “azo” dyes, which include red #2 (amaranth), red #r, yellow #6,
(tartrazine), green (ferrous gluconate), and some others.

4. Artificial Sweeteners
 Researchers have found that mothers who had taken cyclamates during pregnancy
had children who suffered from hyperactivity and learning disabilities
5. Caffeine
 The substance is of concern because of its chemical structure, purine, one of the
constituent groups of DNA. Moreover, it crosses placenta and is known to
penetrate the preimplantation blastocytes in mammals.

6. Trace elements and Metallic and Chemical Contaminants

 Such trace elements and metallic contaminants as lead, selenium, arsenic,
cadmium, mercury and metyhylmercury occur in the ground; in fish and
crustaceans, especially when they came from contaminated waters.
7. Oral analgesics (NSAID): Aspirin; Oral hypoglycemic; Orinase; Antithroid:
Methimazole: Anticoagulant: Coumarin; Antibiotics: Sulfonamides, Tetracycline;
 ACE Inhibitors: Capotene, Vasotec; Tranquilizers: Diazepam; Vitamin A derivatives:
Isotretinoin, Etretinate; Nictine; Alcoohol: Whisky, Wine

SEXUAL ACTIVITY DURING PREGNANCY

 The result of physiologic, anatomic, and emotional changes of pregnancy makes
the couples usually ask questions and concerns about sexual activity during
pregnancy.
 Due t the possible injury to the baby, the couples are often warned to avoid sexual
intercourse during the last 6 – 8 weeks of pregnancy.
 In healthy pregnancy, there is no medical reason to limit sexual activity.
 The expectant mother may experience changes in sexual desire and response
related to various discomfortsthat occur through pregnancy.
 During the first trimester, sexual desire is decreased due to various discomforts
brought about by fatigue, nausea and vomiting, and breast tenderness.
 During the second trimester, woman may experience greater sexual desires and
satisfactions due to lessened discomforts.
 During the third trimester, interest in coitus may again decrease due to fatigue,
shortness of breath, pain in the pelvis and other discomforts.
 Solitary and mutual masturbation and oral genital intercourse maybe used by
couple as alternatives to penile-vaginal intercourse.
 The side by side position is often preferred, especially during third trimester
because it requires less energy and places less pressure on the pregnant abdomen.
 Intercourse is contraindicated for medical reasons such as:
􏰀 multiple pregnancy
􏰀 threatened abortion
􏰀 incompetent cervix
􏰀 partner with sexually transmitted disease
􏰀 maternal history of miscarriage
􏰀 membranes are ruptured
􏰀 history of preterm labor
􏰀 abdominal pain
􏰀 vaginal bleeding
􏰀 uterine contractions

 Sexual activity styles are:

1. Spoon – both bodies fit close together in this position, making it very intimate,
relaxing and optimal for slow and sensual love-making. Spooning is a great
introduction to rear-entry sex, and also is very comfortable during late pregnancy
because there is very little pressure on the woman’s stomach
2. Scissors – the woman is laying side by side so that the man is facing the woman’s
back, then sliding his body that his body is perpendicular to the woman’s body. The
end result is a little like the doggy-style position laid on its side.
 3. Penguin – a sexual position where the male partner is lying down, while the pregnant
woman partner is sitting on top of him, enough to secure the abdomen or the fetus
against harm.

IMMUNIZATIONS
- Immunity is the resistance that an individual has against disease. As a general
rule, immunizations are best avoided during pregnancy.
- Immunizations with attenuated live viruses (including mumps and rubella
vaccines) shouldn’t be given during pregnancy because of their teratogenic effect
on the developing embryo.
- Vaccinations with killed viruses (including varicella, hepatitis, influenza, tetanus,
and diphtheria vaccines) may be given during pregnancy.

Schedule of Tetanus Toxoid Immunzations for Women as per DOH (PHILS.) TT1 –
As early as possible during pregnancy; TT2 – atleast 4 weeks later
TT3 – Atleast 6 months later; TT4 – At 1 year later; TT5 – Atleast 1 year later

Benefits of Tetanus Toxoid

1. Infants: Protection from neonatal tetanus
2. Mother: Protection from tetanus for 3,5,10 years and lifetime

COMMON DISCOMFORTS IN PREGNANCY

1. First Trimester
a. Nausea and vomiting (morning sickness) due to elevated HCG levels and changes in
carbohydrate metabolism.
- Teach client to take small frequent meals with dry crackers; drink liquids between
meals; instruct patient to avoid greasy, highly seasoned food.
- Suggest intake of complex carbohydrates with the onset of nausea.

b. Fatigue
- Get plenty of rest.
c. Urinary urgency and frequency because of pressure of fundus on bladder
- Do not limit fluid intake; decreases in 2nd trimester.
d. Breast tenderness from increased levels of estrogen and progesterone
e. Increased vaginal discharge from hyperplasia of mucosa and increased mucus
production
- Take shower daily; don’t use commercial vaginal cleansing products.

f. Nasal stuffiness and epistaxis from elevated estrogen level causing edema of nasal
mucosa.
- Encourage the use of cool-moist humidifier.
- Suggest the use of normal saline nose drops or nasal spray.
- Advise patient to apply cool compresses to the nasal area.

g. Palmar erythema (Palmar pruritis): probably caused by increased estrogen level.

 - The woman may believe that she has developed an allergy.
- Tell the woman that this is normal
- Advise her to apply calamine lotion on the affected site.

h. Hypotension: symptoms that occur when a woman lies on her back and the uterus
presses on the vena cava impairing blood return to the heart.
- Turn the woman to her side to remove pressure from the vena cava, blood flow
will be restored.

2. SECOND & THIRD TRIMESTER

a. Heartburn: from esophageal reflux

- Avoid caffeine and spicy foods; sit up after meal.
b. Ankle edema: from venous stasis; normal because of the pressure of the enlarging uterus
- Elevate legs when sitting & do not cross legs.
- Avoid prolonged standing & wear support stockings.
- Recommend the woman to lie on her left side in bed to enhance glomerular
filtration rate of the kidneys.
- Encourage woman to avoid wearing tight, constrictive clothing
- Suggest her to get up and move about every 1-2 hours when sitting for long
periods.

c. Varicose veins: from weakening walls of veins or faulty valves. (Pilliteri, A. – 1st trimester
2007) Same mgt. with ankle edema
d. Hemorrhoids: from increased venous pressure or constipation. (Pilliteri, A. – 1st trimester
2007)
- Increase bulk and fluid in diet.
- Caution the woman against prolonged standing and wearing constrictive clothing
- Suggest use of topical ointment or anesthetic if allowed
- Encourage the use of witch hazel compresses.
- Teach the woman how to perm for sitz bath or apply warm soaks.
- Encourage the woman to lie on her left side with her feet slightly elevated.
e. Constipation: from sluggish bowl from progesterone and steroid metabolism, displaced
intestines, and iron supplements.
- Increase bulk and fluid in the diet; maintain regular exercise regimen.
- Caution the woman to avoid the use of mineral oil, which deplete her level of fat –
soluble vitamins

f. Backache from exaggerated lumbosacral nerve from enlarged uterus.

- Maintain good body mechanics and posture; wear lo-heeled shoes; sit in chair with
proper back support
- Advise woman to apply local heat to the back if necessary.
- Suggest sleeping on firmer mattress or using board under the current mattress to add
firmness.
- Teach the woman to do pelvic rocking or tilting exercise.
g. Leg cramps: from pressure on nerves
 - Stretch and exercise legs; maintain good posture and body mechanics.
- Encourage frequent rest periods with the legs slightly elevated.
- Encourage her to wear warm clothing
h. Faintness: a result of orthostatic changes.
- Change position slowly; sit up for several minutes before rising
i. Shortness of breath: from pressure or diaphragm
- Rest with head elevated; sleep in reclining position.
j. Braxton hicks: contractions beginning as early as the 8th to 12th weeks of pregnancy. The
uterus periodically contracts and then relaxes again. A rhythmic pattern of very light contractions
can be a beginning sign of labor.
- Advise woman to telephone or e-mail their primary caregiver.

DANGER SIGNS IN PREGNANCY

 F-ever: Indicates Infection
 R-ush of water from vagina: Indicates premature rupture of membranes (PROM
 E-pigastric pain (pain in the abdomen): Indicates preeclampsia, ischemic in the
pancreas
 S-welling of the face, hands and feet; spots before eyes: Hypertension, preeclampsia
 H-ard fall
 A-bsence of baby’s movement: Indicates fetal death
 C-ontinuous headache; convulsions: Indicates hypertension, preeclampsia, eclampsia
 P-ersisten vomiting: Indicates Hyperemesis gravidarum
 A-ny vaginal bleeding; abdominal pain: Abruptio placenta, placenta previa,
premature labor
 D-imness/blurring of vision; D-ecrease urine output (oliguria): Indicates hypertension
preeclampsia, renal impairment
 S-eizures or muscular irritability: indicates preeclampsia, eclampsia

ENVIRONMENTAL RISK FACTORS IN PREGNANCY

1. GERMAN MEASLES
(a.) Can cause major deflects in fetus between 2nd & 6th weeks after conception
(b.) Measles titer should be given before pregnancy to determine risks.

2. SEXUALLY TRANSMITTED DISEASE

(a) Chlamydial infection
- Most common sexually transmitted disease, especially in teenagers
- transmission to neonates of infected mothers during passage through birth
canal
- Must be careful with timing of treatment because doxycycline or tetracycline
used, can interfere with tooth enamel formation

(b.) Syphilis
- Passed to fetus; usually leads to spontaneous abortions
- Treated with penicillin up to last trimester; important to prevent congenital
syphilis increased incidence of mental sub normality and physical deformities.
 (c.) Herpes
- Contamination of fetus after membranes rupture or with vaginal delivery
- Generalized herpes results in 100% mortality; Cesarean Section indicated if
labor occurs during an episode.

(d) Gonorrhea
- Fetus contaminated during vaginal delivery
- Risk to neonate: Ophthalmia neonatorum, pneumonia and sepsis
- Problems avoided if treatment given before delivery.

(e.) Human immunodeficiency virus

- Risks of transmission to fetus estimated from 30% to as high as 75%
- Newborn maybe asymptomatic at birth, but signs and symptoms usually
develop during first year of life
- No effective treatment or prevention of mother HIV positive.

(f.) Group B streptococcus infection

- Most common cause of neonatal sepsis in the United States; can lead to post-
partal infection in mother
- Treatment in last semester with ampicillin can prevent transmission to neonate
during labor.

3. DRUGS ALCOHOL, TOBACCO

- Drugs cross placenta (teratogen)
- No drugs unless prescribed by physician
- No over the counter medications e.g. aspirin, herbal remedies
- No illegal drugs
- Category D drugs are those that have clear health risks for the fetus, include
alcohol, lithium and phenytoin (Dilantin)
- Category X drugs are those that have been shown to cause birth defects and
should never be taken during pregnancy.
- Alcohol during pregnancies may lead to fetal alcohol syndrome, physical
abnormalities, congenital anomalies, growth deficits or jitteriness.
- Cigarette smoking
- Leads to low birth weights and higher incidence of birth defects and stillbirth
- Research indicates that even second hand smoke is harmful.
- Nicotine cigarettes causes vasoconstriction; alters maternal and fetal heart rate.
4. RADIATION EXPOSURE
- Women should always be asked about possibility of pregnancy before radiographs
are taken.
- Increased risk of abortion and physical deformities.
5. OTHER RISK FACTORS
- Stress causes increased activity in fetus in response to increased epinephrine.
- Woman over age 35 years have greater risk of genetic abnormalities
- Girls under 15 years have greater risk of stillbirths, spontaneous abortion and
premature birth.
ADOLESCENT PREGNANCY AND PARENTHOOD
A. General Information
1. Pregnancy in a female under 17 years of age. Pregnancy is a condition of both
physical and psychologic risk. Adolescent pregnancy is considered high-risk because of
frequency of serious complications, particularly toxemia, iron deficiency anemia, preterm
birth and low birth weight infants.

2. Incidence: One million teenage pregnancies per year worldwide (World Health
Organization)
a. Earlier onset of menarche
b. Changing sexual behaviors
c. Poor family relationship
d. Poverty

3. Prognosis
a. For pregnant girls under 15 years, a high risk of stillbirths, low birth weight
infants, neonatal, mortality, and cephalopelvic disproportion (CPD).
b. Increased maternal risk of pregnancy induced hypertension, prolonged labor,
iron deficiency anemia and urinary tract infection.

B. Nursing Process
a. Assessment/ Analysis
1. Nutrition status
2. Knowledge of physiology of pregnancy
3. Emotional status
4. Support system

b. Plan, Implementation, and Evaluation

Goal: The pregnant teen will maintain good health; will eat a balance diet with
adequate protein; will prepare for birth and care of newborn; will achieve
developmental tasks of adolescence and pregnancy; fetus will develop
appropriately for gestation.
Module 5: NURSING CARE DURING LABOR

FIVE ESSENTIAL FACTORS IN LABOR (5P’S)

Guide Summary 5 P’s:
1. Passenger
2. Passageway
3. Power
4. Placenta
5. Psychological Response

LABOR:
- A series of events by which abdominal pressure and uterine contraction expels the fetus
and placenta outside the woman’s body.
- The process of fetal expulsion along with the products of conception secondary to
regular, progressive and frequently occurring uterine contractions.

PASSENGER
The size, presentation, position of the fetus, fetal attitude and fetal lie.
- Fetal head
1. Usually the largest part of the baby; it has profound effect on the birthing process.
2. Bones of skull are joined by membranous sutures, which allow for overlapping or
“molding” of cranial bones during birth process.
3. Anterior and posterior fontanels are the points of intersection for the sutures and are
important landmarks.
a. Anterior fontanel is larger; diamond shaped and closes about 18 months of age
b. Posterior fontanel is smaller, triangular, and usually closes about 3 months of age.
1. Fontanels are used as landmark for internal examinations during labor to determine the
position of the fetus.
- Fetal shoulders: maybe manipulated during delivery to allow passage of one shoulder at a
time.
- Presentation: that part of the fetus which enter in the pelvis in the birth process

Types of Presentation are:

1. CEPHALIC: head is presenting part; usually vertex (occiput), which is most favorable
and ideal for vaginal birth. Head is flexed with chin on chest.
2. BREECH: buttock or lower extremities present first. Most managed through Caesarean
birth.

Fetal Position: relationship of the fetal presenting part to a specific quadrant of a woman’s /
maternal body pelvis.
1. Maternal bony pelvis divided into four quadrants (right and left anterior, right and left
posterior). Relationship is expressed in three-letters abbreviation; first the maternal side
(R or L), next the fetal presentation, and last the maternal quadrant (A or P). Most
common positions are
 a) LOA (left occiput anterior) fetal occiput is on maternal left side and toward front, face
is down. This is a favorable delivery position.
b) ROA (right occiput anterior) fetal occiput on maternal right side toward front, face is
down. This is a favorable delivery position.

c) LOP (left occiput posterior) fetal occiput is on maternal let side and toward back face is
up. Mother experiences much back discomfort during labor, labor may be slowed;
rotation usually occurs before labor t anterior position, r health care provider may rotate
at a time of delivery. Occiput positions are managed through forceps and Caesarean
Sections.
d) ROP (right occiput posterior) fetal occiput is on maternal right side and toward back,
face is up. Presents problem similar to LOP.

e) LOT (left occiput transverse) fetal occiput is transverse the maternal left side; ROT
(right occiput transverse) fetal occiput is transverse the maternal right side.

f) LSA (left sacrum anterior) fetal sacrum is on maternal left side and toward front; RSA
(right sacrum anterior) fetal sacrum is on maternal right side and toward front
g) LSP (left sacrum posterior) fetal sacrum is on maternal left side and toward back; RSP
(right sacrum posterior) fetal sacrum is on maternal right side and toward back.

Assessment of fetal position can be made by:

a. Leopold’s maneuvers; external palpation (4 steps) of maternal abdomen to determine
fetal contours or outlines.
b. Vaginal examination location of sutures and fontanels and determination of relationship
to maternal bony pelvis
c. Rectal examination now virtually completely replaced by vaginal examination.
d. Auscultation of fetal heart tones and determination of quadrant of maternal abdomen
where best heard. Correlate with Leopold maneuvers.)
e. Fetal Attitude: The degree of flexion a fetus assumes during labor; the relationship of
fetal parts to each another. Normal or good attitudes are: spinal column is bowed
forward; moderate flexion of the head; flexion of the arms onto the chest; and the flexion
of the legs/thigh unto abdomen. Deviations in these attitudes will cause difficult,
prolonged labor
f. Fetal Lie; The relationship between the long (cephalocaudal) axis, spinal column of the
fetus and the long (cephalocaudal) axis of the mother/woman’s body. A longitudinal lie
occurs when cephalocaudal axis of the fetus is parallel to the woman’s spine. E.g. Vertex
(cephalic), breech. A transverse lie occurs when cephalocaudal axis of the fetal is at right
angles to the woman’s spine. E.g. shoulder presentation.

PASSAGEWAY
Shape and measurement of maternal pelvis and distensibility of birth canal
A. Engagement: settling of the fetal presenting part far enough into the pelvis (inlet) to be
at the level of the ishial spines. May occur two weeks before labor in primipara; usually
occurs at beginning of labor in multipara.
 B. Station: relationship of the fetal presenting part to the level of the ischial spines,
measurement of how far the presenting part has descended into the pelvis. Referent is
ischial spines, palpated through lateral vaginal wall.
1. When presenting part is at ischial spines, station is 0, meaning it is “engaged”.
2. If presenting part is above ischial spines, station expressed as a negative number
(e.g., -1, -2, -3,). -4 means presenting part is still “high” or “floating”
3. “High’ or “floating” terms used to denote “unengaged” presenting part. Soft tissue
(cervix, vagina); stretches and dilated under the force of contraction to
accommodate the passage of the fetus.
4. If presenting part is below ischial spines, station expressed as a positive number
(e.g., +1, +2). +3 and +4 means presenting part is at the perineum and can be seen
at the vulva e.g. “crowing” as the stage when fetal head has negotiated the pelvic
outlet and the largest diameter of the head is encircled by the external opening of
the vagina.

POWERS
Forces of labor, acting in concert, to expel fetus and placenta. Major forces are:
A. Uterine contractions (involuntary)
1. Frequency: timed from the beginning of one contraction to the beginning of the
next.
2. Regularity: discernible pattern; better established as pregnancy progresses.
3. Intensity: strength of contraction; a relative assessment without a use of a
monitor. May be determined by the “depress ability” of the uterus during a
contraction.
4. Duration: length of contraction. Contraction lasting more than 90 seconds
without subsequent period of uterine relaxation may have sever implication for
the fetus and should be reported.

B. Voluntary bearing-down efforts.

1. After full dilation of the cervix, the mother can use her abdominal muscle to help
expel the fetus.
2. These efforts are similar to those for defecation, but the mother is pushing out the
fetus from the birth canal
3. Contraction of levator any muscles.

PLACENTA
A. As the placenta usually forms in the fundus of the uterus, it seldom interferes with the
progress of labor.
B. A low-lying marginal partial or complete placenta previa may require medical
intervention to complete the birth process

PSYCHOLOGICAL RESPOSE

A woman who is relaxed, aware, and participating in the birth process usually has a shorter, less
intense labor. A woman who is fearful has high level of adrenaline ( epinephrine) and
norepinephrine, these area hormone catecholamines from the nerve endings, brain, and adrenal
glands which later slow uterine contraction.

THE LABOR PROCESS

CAUSES:
Actual cause unknown. Factors involved include:
A. Progressive uterine distention
B. Increase intrauterine pressure
C. Aging of the placenta
D. Changes in levels of estrogen (increased), progesterone (dropped) and prostaglandins
(increased)
E. Increasing myometrial irritability

PRELIMINARY SIGNS OF LABOR

a. Lightening: Settling or descent of the fetal presenting part into the pelvic brim 2 (two)
weeks before delivery in primigravida.
b. Increased level of activity: Increase in activity is due to an increase in epinephrine
release initiated by the decrease in progesterone by the placenta.
c. Braxton Hick’s contraction: A contraction which may be interpreted as true labor
contractions.
d. Ripening of the cervix: An integral or sure sign seen only in pelvic examination.
e. Bloody show (pinkish vaginal discharge) The mucus plug that filled the cervical canal
during pregnancy is expelled.
f. Rupture of membranes: Experience as either a sudden gush or scanty, slow seeping of
clear fluid from vagina.
g. Uterine contraction: The surest sign that labor has begun with the initiations of
effective, productive, involuntary uterine contraction.

FIVE THEORIES OF LABOR ONSET

1. Uterine Stretch Theory: Any hollow organ once stretch to its maximum potential will
always expel its contents. Stretching f uterine muscles causes prostaglandin release
2. Prostaglandin Theory: Arachidonic acid stored from amnion, chorion, and decidua's
stimulates contractions.
3. Progesterone Deprivation Theory: Sudden drop in progesterone levels will initiate
contractions.
4. The Theory of Aging Placenta: The placenta begins to degenerates at 36 weeks and the
body perceives it as a foreign object.
5. Oxytocin Stimulation Theory; The production of the posterior pituitary gland of this
substance will cause uterine contractions.

DIFFERENCE BETWEEN FALSE AND LABOR TRUE

FALSE
- Contractions – irregular, no increase in frequency and intensity
- Intervals f contraction – longer between contractions
- Pain/discomfort – lower abdomen, walking has no effect or decreases
 - No bloody show
- No dilatation and effacement
TRUE
- Contractions – regular, increase infrequency, intensity and duration
- Intervals of contraction – shorter between contractions
- Pain/discomfort – back then radiates to the abdomen, not relieved by walking
- Bloody show – present
- With effacement and dilation; fetal descent progresses
MECHANISMS OF LABOR (VERTEX PRESENTATION)
A. Engagement
1. The biparietal diameter of the head passes the pelvic inlet
2. The head is fixed in the pelvis.
B. Descent: Downward movement of the biparietal diameter of the fetal head to within the
pelvic inlet; progress of the presenting part through the pelvis.
C. Flexion: As descent occur, the head bends forward onto the chest, making the smallest
anteroposterior diameter (the suboccipito bregmatic diameter) the one presented to the
birth canal. Chin flexed more firmly onto chest by pressure on fetal head from maternal
soft tissue (cervix, vaginal walls, pelvic floor).
D. Internal rotation: During descent, the head enters the pelvis with the fetal
anteroposterior head diameter in a diagonal or transverse position.
- Fetal skull rotates along axis from transverse to anteroposterior at pelvic outlet
- Head passes the midpelvis.
E. Extension: As occiput is born, the back of the neck stops beneath the pubic arch and acts
as a pivot for the rest of the head. Fetal head passes under the symphysis pubis and is
delivered, occiput first, followed by chest and chin.
F. External rotation: Almost after the head, head rotates from anteroposterior position, it
assumes to enter the outlet back to the diagonal or transverse position of the early part of
labor. The head rotates to full alignment with back and shoulders for shoulder delivery
mechanisms. To accommodate the shoulder, the head goes back to its original position.
G. Expulsion: Once the shoulders are born, the rest of the body is born spontaneously
because of its smaller size. When entire body of the baby has emerged from mother’s
body, birth is complete. This time is recorded as the time of birth.

STAGES OF LABOR
1. First Stage/ Dilatation Stage
2. Second Stage/ Expulsion Stage
3. Third Stage/ Placental Stage
4. Fourth Stage/
Recovery
Stage
FIRST STAGE OF LABOR (1st)/ Cervical Dilatation Stage
- From onset of labor until full dilation of cervix.
Guide Summary recall LAT
1. Latent Phase
2. Active Phase
3. Transition Phase

SECOND STAGE OF LABOR (2ND )/EXPULSION STAGE

THIRD STAGE OF LABOR (3RD)/ PLACENTAL STAGE

1. Signs of placental separation
a. Calkin’s sign – earliest sign of placental separation; change in shape of uterus (discoid
uterine shape to globular)
b. Sudden gush of vaginal blood
c. Lengthening of umbilical cord
TYPES OF PLACENTAL DELIVERY:
- Shultz: Placenta separates from the center to edge.
- Duncan: Placenta separates from the edge to the center

FOURTH STAGE OF LABOR (4TH)/ RECOVERY STAGE

DANGER SIGNS OF LABOR

Fetal Danger
1. High or Low Fetal Heart Rate: FHR > 160 bpm (tachycardia) & <110 bpm
(bradycardia) – both signs of possible fetal distress as shown in the fetal
monitor with late or variable deceleration pattern.
2. Meconium Staining (green color in the amniotic fluid results in the loss of
sphincter control); fetus is experiencing hypoxia (deficient in the blood or
tissue)
3. Fetal hyperactivity, a sign of hypoxia
4. Fetal acidosis (sign of compromised fetal well being, blood pH lower than
7.23)

Maternal Danger Signs

1. Rising or falling of blood pressure
2. Abnormal pulse
3. Inadequate prolonged contractions (less frequent and shorter duration
indicates inertia)
4. Abnormal lower abdominal contour indicated full bladder
5. Increasing apprehension (sign of oxygen deprivation and internal
hemorrhage).

OPERATIVE OBSTETRICS PROOCEDURES

Operative Obstetrics refers to a number of procedures that may be used to assist the
mother in labor and delivery
Guide Summary:
1. Episiotomy 3. Caesarean birth
2. Forceps delivery 4. Vaginal birth after Caesarean
 
EPISIOTOMY: is an inclusion for the laceration during delivery to enlarge the vaginal
opening/outlet.

Types of Episiotomies:
a. Median or midline: incision is made in the middle of the perineum and directed toward
the rectum; from vaginal opening through center of perineum towards anal sphincter. It is
most frequently used; easily done; least discomfort for client. This method is believed to
heal with few complications; is more comfortable for the woman during healing.
b. Mediolateral: incision is made laterally in the perineum to avoid anal sphincter if
enlargement is needed. It begins at posterior vaginal opening but angles off to left or right
at 45-degree angle. It is done when need for additional enlargement of vaginal opening is
a possibility, but is more uncomfortable than median.

Types:
a. Low or outlet: presenting part of vaginal introitus
 b. Mild forceps: presenting part is at or below ischial spines: often a difficult procedure;
rarely done
c. High forceps: presenting part above ischial spines. This procedure has Benn replaced by
cesarean birth.

CAESARIAN BIRTH

Types
a. Classical: Vertical incisions made into both abdomen and uterus
- Used when rapid delivery is important, as in fetal distress, prolapsed cord, placenta
abruptio.
- Maternal bleeding greater with this method; client may have increased risk of uterine
rupture of scar tissue with future pregnancies; not usually a candidate of vaginal birth in
future pregnancies.
b. Low cervical/ low segment: transverse incisions made in abdomen (above pubic
hairline) and in uterus. Most common method used.
c. Procedure may take longer than classic because of need to deflect bladder, but blood loss
is lessened and adhesions are fewer.
d. Vaginal birth after this type of Caesarean birth (VBAC) is possible/

VAGINAL BIRTH AFTER CAESAREAN (VBAC)

General Information
 Women should be offered opportunity for vaginal delivery even after Caesarean Section
 Women who has low uterine incision (lower transverse) can have normal labor and
delivery.
 If no labor associated with previous sections, labor proceeds similar to that of
primigravida.
 Should be prepared to have another section if labor does not progress.

INDUCTION DURING LABOR

OVERVIEW
 According to American College of Obstetricians and Gynecologies, induction of labor
or (IOL) is defined as the stimulation of uterine contraction before the spontaneous onset
of labor, with or without ruptured fetal membrane, for the purpose of accomplishing
birth.
Guide Summary:
1. By Amniotomy 3. By Prostaglandin
2. By Oxytocin infusion 4. By Membrane Stripping

Candidates for Induction of Labor

1. Previous one or two low transverse incision
2. Pelvis evaluated for adequacy
3. No other uterine scars or previous uterine ruptures

Indications of Inductions of Labor

1. Post maturity (more than 42 weeks’ gestation), which can lead to placental insufficiency
or fetal compromise
2. Premature rupture of membranes, which increases the risk of intrauterine infection.
3. Pregnancy-induced hypertension
4. Rh is immunization, which can produce erythroblastosis fetalis
5. Maternal diabetes, which can lead to fetal death from placental insufficiency
6. Chorioamnionitis (infection of the fetal membranes and fluid)
7. Fetal death

Maternal/Fetal Contraindications
1. Previous cesarean birth with a classical incision
2. Previous hysterectomy and myomectomy
3. Previous uterine rupture
4. Placenta previa
5. Active genital herpes infection
6. Multiparity
7. Malpresentation
8. Overdistention of the uterus
9. Cancer of the cervix
10. Abnormal lie of fetus
11. Fetal distress
12. Premature or low birth weight
Positive oxytocin challenge

INDUCTION BY AMNIOTOMY
 
Description
- Involves the artificial rupturing of the membranes with a sterile instrument
- Under favorable conditions, about 80% of patients enter labor within 24 hours
Indications
- When internal fetal monitoring is desired
- When oxytocin is contraindicated
Contraindications
- Presenting part at -2 station or higher
- Placenta previa
- Abnormal presenting part
- Uncertain estimated date of delivery
Advantages
- Facilitates fetal status monitoring using an internal scalp electrode, catheter or scalp
blood sampling.
- Facilitates assessment of amniotic fluid color and composition.
Disadvantages
- Increases the risk of infections and cord prolapse.
- Increases the incidence of fetal compression.

INDUCTION BY WAY OF OXYTOCIN INFUSION

Description
 Involves the administration of I.V. oxytocin (Pitocin) 10 IU in 1000 ml of Ringer’s
Lactate augment or stimulate uterine contractions.
 Oxytocin is administered of I.V. infusion pump.

Indications
 Prolonged rupture of membranes
 Post maturity

Contraindications
 Cephalopelvic disproportion
 Fetal distress
 Previous uterine surgery
 Overdistended uterus
 Abnormal fetal presentation

Advantages
 Use a drug with a predictable action
 Doesn’t directly affect the fetus
 Stimulates contractions efficiently and effectively

Disadvantages
 Increases the risk of titanic uterine contractions.
 Increases the risk of over stimulating the uterus, which can lead to fetal distress and
uterine rupture.

INDUCTION BY WAY OF PROSTAGLANDIN

  Induction using prostaglandin (prostaglandin E2 e.g. Dinoprostone [Cervidil, Prepidil or
Prostin E2]); involves intracervical or intravaginal insertion of prostaglandin gel to soften
the cervix.
 The drug initiates the breakdown of the collagen that keeps the cervix tightly closed.
 Prostaglandin gel is applied to the interior surface of the cervix by a catheter or
suppository, to the external surface of the cervix by applying it to a diaphragm and then
placing the diaphragm against the cervix, or by vaginal insertion.
 Additional doses may be applied every 6 hours (two to three doses to cause ripening)
 The woman should remain flat in bed after application of the gel to prevent the
medication from leaking.

Indications
 Post maturity
 Long, thick cervix at the time of induction.

Contraindications
 Maternal temperature greater than 100 deg. F (37.8 deg. C)
 Asthma and cardiac disorder
 Vaginal bleeding
 Any contraindication for a vaginal delivery
 Allergy to prostaglandin

Advantages
 Decreases the likelihood of caesarean birth or failed induction
 Requires lower doses of oxytocin
 Reduces the need for analgesia or such instrument such as forceps
 Shortens labor

Disadvantages
 It increases the risk of uterine hyperstimulation.

INDUCTION BY WAY OF MEMBRANE STRIPPING OR CERVICAL RIPENING

A nonpharmacologic method of induction frequently used by physician by inserting a
gloved finger into the internal cervical os and rotates the finger at 360 degrees twice, to
separate amniotic membranes from the lower uterine segment and that are lying against
the cervix, which now releases prostaglandin PGE2 or PGF2 to further stimulate uterine
contraction.

OBSTETRIC ANALGESIA AND ANESTHESIA

MAIN PERCEPTION THEORIES

  Specificity: A specific pain system carries messages from pain receptors in the body to a
pain center in the brain.
 Pattern: Particular networks or nerve impulses are produced by sensory input at the
dorsal horn cells; pain results when the input if these cells exceeds a critical level,
 Gate Control: Local physical stimulation can balance the pain stimuli by closing down a
hypothetical gate mechanism (substancia gelatinosa) in the spinal cord that blocks pain
signals from reaching the brain.
 
SOURCES OF PAIN DURING LABOR
 Dilatation and stretching of the cervix
 Hypoxia of the uterine muscle cells during a contraction
 Lowe uterine segment stretching
 Pressure by the presenting part on adjacent structures
 Distention of the vagina and perineum
 Emotional tension
 
PAIN RELIEF MANAGEMENT DURING LABOR AND DELIVERY

A. GENERAL INFORMATION
 
 Labor and birth of a child usually produce a significant amount of discomfort and are
emotionally draining for the woman who’s experiencing them.
 Prenatal education, planning and the presence of support person during labor and
birth can alleviate the woman’s anxiety and increase her self-esteem and feelings of
control over the experience, thus reducing the discomfort she feels or, more
appropriately, increasing her ability to deal with it.
 The end result of these measure is to avoid the use of analgesia or anesthesia
necessary during the birthing process.

NONPHARMACOLOGICAL MEASURES
 RELAXATION
 FOCUSING
 IMAGENARY
 THERAPEUTIC TOUCH AND MASSAGE
 DISTRACTIONS
 EFFLEURAGE

Lamaze Breathing Techniques

Involves 3 patterns of controlled chest breathing:
Slow breathing – Inhale through the nose and exhale through the mouth or nose six to
nine times per minute.
Accelerated-decelerated – Inhale through the nose and exhale through the mouth as
contractions becomes more intense.
Pant-blow – Perform rapid, shallow breathing through the mouth only throughout
contractions, particularly during the transitional phase.
Transcutaneous electrical nerve stimulation (TENS)
 Stimulation of large diameter neural fibers through electric currents to alter pain
perception.
 TENS is effective in reducing pain caused by uterine contractions.
 TENS may be effective in reducing the extreme back pain that some woman have
during contractions.

Intracutaneous Nerve Stimulation (INS)

 A technique of counter-irritation involving the intradermal injection of sterile
water or saline along the borders of the sacrum to relieve low back during labor
(Fishburne,2000).

Hypnosis
 Involves an altered state of consciousness allowing perception and motor control
to be influenced by suggestion.
 Hypnosis can provide a satisfactory method of pain relief for the woman who
follows hypnotic suggestions.
 The woman must meet with the hypnotherapists several times during her
pregnancy for evaluation and conditioning.
 If it’s determined that she’s good candidate for this method of pain relief, she’ll
be given a posthypnotic suggestion that she’ll experience either reduced pain
during labor or no pain at all.

Acupuncture and Acupressure

- Acupuncture is the stimulation of key trigger points with needles, it’s unnecessary for
these points to be near the affected organ because their activation causes the release of
endorphins, which reduce the perception of pain.
- Acupressure is finger pressure or massage at the same trigger points.

Yoga
- Using a series of deep-breathing exercises, body stretching postures, and meditation to
promote relaxation, slow the respiratory rate, lower blood pressure, improves physical
fitness, reduce stress, and allay anxiety.
- May help reduce the pain of labor by helping the body relax and possibly releasing
endorphins.

Herbal Preparations
- Several herbal preparations have traditionally been used to reduce pain with
dysmenorrhea or labor, like raspberry leaves, fennel and life root.

Heat and Cold Application

 - Heat and cold have always been used for pain relief after injuries such as minor burns or
stained muscles.
- Hear application is used to relieve lower back pain by heating pad or a moist compress.
- Cool washcloth on the forehead is used to relieve warm form the exertion of labor.
- Ice chips being sucked is used to relieve mouth dryness.

Bathing or Hydrotherapy
- Standing under a warm shower, or soaking in a tub of warm water, jet hydrotherapy tub,
or whirlpool are other ways to apply heat to help reduce pain of labor.
- But this is not a recommended for women with ruptured membranes.

Aromatherapy and Essential Oils

- Aromatherapy is the use of aromatic essential oils to lead to emotional and physical well-
being.
- When an essential oil is inhaled, its molecules are transported via the olfactory system to
the limbic system in the brain.

Reflexology
- Reflexology is the practice of stimulating the hands, feet, and ears as a form of therapy.
- The theory behind reflexology is that each of the body’s organs and glands are linked to
corresponding areas of the hands and feet
- Application of pressure to the specific area aims to restore energy to the body and
improve the overall condition.

Biofeedback
- Biofeedback is based on the belief that people have control and can regulate internal
events such as heart rate and pain response.
- Women interested in using this pain relief in labor must attend several sessions during
pregnancy to condition themselves to regulate their pain response.

PHARMACOLOGICAL MANAGEMENT

ANESTHETICS

General Anesthesia
- Administered I.V. or by inhalation, resulting in unconsciousness.
- Used only if regional anesthesia is contraindicated or if emergency situation develops.
Suddenly inhaled anesthetics used include nitrous oxide, isoflurane (Forane), and
halothane (Flouthane).
- I.V. anesthetics (usually reserved for patients with massive blood loss) include
thiopentral (Pentothal) and Ketamine (Ketalar)
- Maternal adverse reactions include vomiting and aspiration, and increased uterine
relaxation, possibly leading to postpartum uterine atony.
- Fetal-neonatal adverse reactions include respiratory depression, fetal acidosis,
hypotonia, and lethargy.
Regional Anesthesia
- Local anesthesia is administered to block pain neuropathways that pass from the
uterus to the spinal cord by way of sympathetic nerves.
- Lumbar epidural anesthesia involves the injection of medication into the epidural
space in the lumbar region.

Advantages
- Leaves the patient awake and cooperative for delivery without adverse fetal effects
- Provide analgesia for the 1st and 2nd stages of labor and anesthesia for birth

Disadvantages
- Hypotension
- Decreased urge to push
- Post spinal headache or transient motor paralysis due to dural puncture
- Urine retention
- Marine fever due to hyperventilation and loss of heat dissipation.

Spinal Anesthesia is injection of medication into the cerebrospinal fluid in the spinal canal

Advantages
- Low incidence of adverse effects
- Useful for urgent Caesarean births because of its rapid onset

Disadvantages
- Short duration
- Possible development of post spinal headache
- Risk of transient complete motor paralysis
- Increased incidence and degree of hypotension
- Urine retention

Local Infiltration involves the injection of anesthesia into the perineal nerves.
- This method is advantageous because of its ease of administration.
- Major disadvantage is that the woman receives relief from discomfort only at
delivery, not during labor.
- Pudendal block is the blockage of the pudendal nerve.
- This method is used only for delivery, not for labor.
- Advantages: Simple, safe method that usually doesn’t depress the fetus
- Major disadvantages: Woman receives no relief from discomfort of uterine hiatus.

Advantages
- Allows patient to be awake
- Provides analgesia for the 1st and 2nd stage of labor
- Provides anesthesia for delivery

Disadvantages
- Increased incidence of hypotension
- Increased use of forceps
- Increased episodes of fetal bradycardia
- Increased risk of hematomas
- Possible risk of injecting directly into the fetus