NCM 107 LEC – MIDTERM COVERAGE ⚫ Description: woman and partner move

through emotions such as narcissism and

Healthy Adaptation to Pregnancy
introversion as they concentrate on what
Assessment for pregnancy begins before the they will feel like to be a parent. Role-
pregnancy. playing and increased dreaming are
common.
⚫ Evaluate the woman’s health status
⚫ THIRD TRIMESTER: Preparing for the baby
⚫ Nutritional intake(sufficient intake of folic and end of pregnancy. Preparing for
acid) Parenthood
⚫ Lifestyle(drinking and smoking habits) ⚫ Description: woman and partner grow
impatient with pregnancy as they ready
⚫ Identify any potential problems
themselves to birth.
⚫ Identify the woman’s understanding and
Events that could Contribute to Difficulty Accepting
expectations of conception, pregnancy, and
Pregnancy
parenthood
1. Learning that the pregnancy is a multiple
Nursing Diagnosis:
pregnancy.
1. Anxiety related to unexpected pregnancy
2. Learning that the fetus has a development
2. Altered breathing pattern related to abnormality.
respiratory system changes of pregnancy.
3. Pregnancy less than 1 year after a previous
3. Disturbed body image related to weight one.
gain with pregnancy.
4. Relocation during pregnancy.
4. Deficient knowledge related to normal
5. Moving away from the family or back to the
changes of pregnancy.
family for economic reasons.
5. Imbalanced nutrition less than body
6. Job loss
requirements, related to morning sickness.
7. Marital infidelity
PSYCHOLOGICAL CHANGES OF PREGNANCY
8. Illness in self, husband or relative.
⚫ SOCIAL INFLUENCES
9. Loss of significant others.
⚫ CULTURAL INFLUENCES
10. Complications of pregnancy.
⚫ FAMILY INFLUENCES
11. Having friend or relatives who have had children
⚫ INDIVIDUAL INFLUENCES
born with health disorders.
PSYCHOLOGICAL TASKS OF PREGNANCY
12. A series of devaluing experiences.
⚫ FIRST TRIMESTER: Accepting the Pregnancy
13. History of previous miscarriage., fertility,
Description : woman and partner both spend time problems, traumatic births.
recovering from shock of learning they are pregnant
14. Previous fetal loss, neonatal loss.
and concentrate on what it feels like to be pregnant.
A common reaction is ambivalence, or feeling both Emotional Responses to Pregnancy
pleased and not pleased about the pregnancy.
⚫ Ambivalence (conflict feeling)
⚫ SECOND TRIMESTER: Accepting the Baby
⚫ Grief
 ⚫ Narcissism (self-centeredness)
⚫ Introversion versus extroversion Oval
⚫ Body Image and Boundary
⚫ Stress
⚫ Couvade Syndrome – men experience same
physical symptoms of pregnancy.
⚫ Emotional Lability (unstable)
⚫ Changes in Sexual Desire
⚫ Changes in the Expectant Family
Fetal development
Antenatal nursing
⚫ Starts from conception and fetal
development to the beginning of labor
⚫ Encompasses all aspects of health care
delivery of the childbearing individual Fetal Development
⚫ FERTILIZATION : the union of the sperm and
the mature ovum in the outer third or outer
half of the fallopian tube.
⚫ General Considerations:
1. Normal amount of semen per ejaculation =
3-5 cc, which is = to 1 teaspoon
2. Number of sperms/cc = 120-150 million
3. Mature ovum is capable of being fertilized
for 12-24 hours after ovulation. Sperms are
capable of fertilizing even for 3-4 days after
ejaculation
4. Normal life span of sperm = 72 hours
5. Sperms once deposited in the vagina, will
generally reach the cervix within 90 seconds
6. Reproductive cells, during gametogenesis, divide
by meiosis; that is why they contain only half the
number of chromosomes, reproductive cells only 23
Fetal Circulation
chromosomes). Sperm have 22 autosomes; ova
contain 22 autosomes and 1 X sex chromosomes. A. LEFT UMBILICAL VEIN
The union of an X-carrying sperm and a mature
ovum results in a baby girl(XX); the union of a Y-
carrying sperm and a mature ovum results in a baby
boy (XY).
Fertilization
makes for 24- 48 hours
- zona pellucida
- corona radiata- cell cover the ova
Fetus- 6- 7 m
at birth- 7m
puberty- 300,000
reproductive lifetime- 300- 400
⚫ Pre-embryonic period
⚫ Embryonic period
⚫ Fetal period
⚫ Immediately after fertilization, the fertilized
zygote stays in the fallopian tube for 3-4
days, during which time rapid cell division is
taking place. The developing cells are now
called blastomere and when there are
already about 16-50 blastomeres ,it is now
termed as morula. In this morula form, it
will start to travel ( ciliary action and
peristaltic contractions of the Fallopian
tube) to the uterus where it will stay for
another 3-4 days. When there is already a
cavity formed in the morula, it is now
termed blastocyst. Finger like projections,
called trophoblasts, around the blastocyst
and these trophoblast are the ones which
will implant high on the anterior or
posterior surface of the uterus.
Implantation, also called nidation.
Therefore, take place about a week (6-
days) after fertilization.
⚫ Receives oxygenated blood from placenta
and shunts most of it to ductus venosus;
small amount goes to the liver to nourish it.
 ⚫ Closes with cord clamping at birth and later 1. Once implantation has taken place, the
becomes LIGAMENTUM TERES uterine endotelium is now termed decidua.

B. R & L UMBILICAL ARTERIES 2. Occasionally, a small amount of vaginal

spotting appears with implantation because
⚫ Receive unoxygenated blood from
capillaries re ruptured by the implanting
HYPOGASTRIC ARTERIES and course it to
trophoblasts implantation bleeding.
placenta for oxygenation
Implications: this is not menstrual period
⚫ Functionally closes at birth with m(LMP) when estimating for the EDC.
establishment of respiration

⚫ Permanently closes in several months to

Throphoblast Differentiation
become LIGAMENTUM ARTERIOSUM;
failure to close results to patent ductus I. Cytotrophoblast – inner layer
arteriosus
II. Syntiotrophoblast – the outer layer
E. FORAMEN OVALE containing fingerlike projections called
chorionic villi, which differentiate into
⚫ Shunts blood from the right to the left
auricle `A. Langhan’s layer - believed to protect the fetus
against Treponema Pallidum . Present only during
⚫ Functionally closes at birth with
the 2nd trimester of pregnancy.
establishment of respiration
B. Syncytial layer – gives rise to the fetal membrane
⚫ Permanently closes in few months (2-3
months or 1 year) 1. Amnion – inner membrane which gives
rise to
F. HYPOGASTRIC ARTERIES : two vessels that branch
off from the INTERNAL ILIAC ARTERIES and become a. umbilical cord
umbilical arteries when they enter the umbilical cord
b. amniotic fluid
Fetal Circulation
Auxillary structures
⚫ Oxygenated blood enters the umbilical vein
⚫ Fetal membranes
from the placenta ---- enters ductus
venosus--- passes through inferior vena ⚫ Placenta
cava ---- enters the right atrium --- enters
the foramen ovale --- goes to the left atrium ⚫ Umbilical cord
--- passes through left venttricle --- flows to
Umbilical cord
ascending aorta to supply nourishment to
the brain and upper extremities--- enters ⚫ Contains two arteries, one vein
superior vena cava --- goes to the right
atrium --- enters right ventricle --- enters ⚫ Wharton’s jelly – prevents kinking of the
pulmonary artery with some blood going to cord
the lungs to supply oxygen and ⚫ Formed by the amnion and chorion
nourishment --- flows to ductus arteriosus
--- enters descending aorta (some blood ⚫ Transports oxygen and nutrients
going to the lower extremities) --- enters
⚫ Has approximately same length as that of
hypogastric arteries--- goes back to the
the baby
placenta.
⚫ Blood vessels
A. General Considerations
 - 2 arteries which carry the most
unoxygenated blood to the placenta.
- 1 vein which carries the most
oxygenated blood to the fetus.
⚫ Length:
- 50-55 cm long and 2 cm in diameter
- appears dull white, moist and covered by
amnion.
Origin :
- originate from the yolk sac and umbilical
vesicles.
Wharton’s jelly
- a gelatinous substance found inside the
cord.
⚫ Cord insertion:
- central insertion – normal, the cord is
inserted at the center of the fetal surface of the
placenta.
- lateral insertion – when the cord is
inserted away from the center of the placenta but
not at its edges.
- velamentous insertion -
AMNIOTIC FLUID
⚫ Volume
- 500 to 1200 ml, average is 1000ml
- the volue of amniotic fluid increase from
the first trimester until 38th week, diminished slightly
until term.
⚫ Composition
- 99% water and 1 % solid particles, contains
albumin, urea, uric acid, creatinine, lecithin,
sphingomyelin, bilirubin and vernix caseosa.
- early in pregnancy it is chiefly composed of
maternal serum. When the fetus begins to urinate
after the 10th week of pregnancy, fetal urine
contribute to the volume of AF.
⚫ Functions :
1. protects the fetus from trauma, blows
and pressure
2. allows freedom of movement thereby
permitting symmetrical growth and development of
musculoskeletal system.
3. acts as an excretion and secretion system
4. maintain a constant temperature
5. source of oral fluid for the fetus who
swallows it.
⚫ Appearance:
- it should be clear and colorless to sraw
colored
- green tinged or meconium stained
amniotic Fluid in breech presentation signifies fetal
distress.
- golden colored amniotic fluid signifies
hemolytic disease such as Rh or ABO incompatibility
- gray colored AF indicates infection.
pH – 7.0 to 7.2 , reaction is neutral to alkaline
⚫ Aids in diagnosis of maternal and fetal
complications
⚫ Aids fetal descent during labor by providing
lubrication in the birth canal
⚫ During labor, as long as the membranes are
intact, the amniotic fluid protects the fetus
from uterine contractions
⚫ It also aids in effacement and dilatation of
the cervix
⚫ Prevents pressure on the cord
⚫ Diagnostic functions of amniotic fluid
a. amniocentesis – removal of amniotic
fluid to diagnose chromosomal abnormalities
b. meconium –stained amniotic fluid in non-
breech presentation is a sign of fetal distress.
2. Chorion – together with the decidua basalis. Gives
rise to the placenta, which starts to form at 8 weeks
gestation age. Before this time, it is the corpus
luteum which produces the hormones necessary to
maintain the pregnancy. Develops into 15-20
cotyledons.
⚫ Placenta serves the ff purposes:
1. Respiratory system – exchange of oxygen
and carbon dioxide takes place in the
placenta, not in the fetal lungs.
2. Gastrointestinal system – nutrients pass to
the fetus via the placenta by means of
diffusion through the placental tissues.
3. Circulatory system – feto-placental
circulation take s place by selective osmosis
via the umbilical arteries and umbilical vein.
4. Renal system – waste products are excreted
through the placenta (note: it is the mother’s
liver which detoxifies the waste products of the
fetus).
5. Endocrine system – it produces the following
hormones:
a. Human Chorionic gonadotropin (HCG)-
“orders” the corpus luteum to keep on producing
estrogen and progesterone, that is why there is
amenorrhea during pregnancy. It is basis for
pregnancy test.
b. Human Placental lactogen – (HPL) or
human chorionic somatotropin- promotes growth of
the mammary glands necessary for lactation. Also
has growth-stimulating properties.
c. estrogen
d. progesterone
6. Protective – inhibits the passage of bacteria and
large molecules to the fetus.
Sequential Stages of Fetal Development
1. First Lunar Month ( 4 weeks)
Germ Layers differentiate by the 2nd week
Embryonic Germ Layers
A. ECTODERM – outer layer; develops inot
- hair, nails, skin (epidermis)
- Nervous system
- salivary glands, mouth cavity
B. MESODERM – middle layer; develops into:
- cardiovascular system, blood
- Reproductive system
- Connective tissue, musculoskeletal system
- urinary system (except the bladder)
C. ENDODERM: inner layer; develop into:
- Bladder, Thyroid, Thymus
- Respiratory tract
- Linings of GIT, liver, pancreas
Fetal Membrane (amnion and chorion) appear by
the second week
Nervous system appears by the 3rd week. (dizziness
is said to be the earliest sign of pregnancy because
of the depletion of the mother’s glucose stores
which the embryo needs for proper brain
development.
Fetal heart begins to form as early as the 16th day
of life.
Second Lunar month (8 weeks)
a. all vital organs are formed by the 8 th
week.
b. placenta develops
c. sex organs (ovaries/testes) are formed
d. meconium is formed in the intestines by
th th
the 5 -8 week.
Third Lunar month (12 weeks)
a. kidneys are able to function – urine is
formed by the 12th week of pregnancy.
b. buds of milk teeth form
c. beginning bone ossification
 d. feto-placental circulation is established
by selective osmosis; no direct exchange between
fetal and maternal blood.
Fourth lunar month (16th weeks)
a. lanugo hair appears
b. buds of permanent teeth form
c. heart beats maybe audible with
fetoscope
Fifth lunar month (20 weeks)
a. vernix caseosa
b. lanugo covers entire the body
c. quickening felt
d. fetal heart beats very audible
Sixth lunar month (24 weeks)
a. skin markedly wrinkled
b. attains proportion of fullterm baby
Seventh lunar month (28 weeks)
a. alveoli begin to form (that is why 28 th
week AOG has a lower limit of prematurity, baby
usually dies.
Eight lunar month (32 weeks)
a. fetus is viable
b. lanugo begins to disappear
c. nails extend to ends of fingers
d. subcutaneous fat deposition begns
Ninth lunar month (36 weeks)
a. lanugo and vernix diasppear
b. amniotic fluid volume decreases
Tenth lunar month (40 weeks)
a. has all the characteristics of a normal
newborn
Normal Adaptations in Pregnancy
Systemic Changes
1. Circulatory /cardiovascular
a. gradual increase of 30-50% in the total
cardiac volume, reaching its peak during the 6 th
month of pregnancy. This causes a drop in
hemoglobin and hematocrit values since the
increase is its plasma volume- physiologic anemia of
pregnancy.
Consequences of increased total cardiac volume are:
a. easy fatigability and shortness of breath
because of increased workload of the heart
b. systolic murmurs are common due to the
lowered blood viscosity
c. nosebleeds may occur because of marked
congestion of the nasopharynx as pregnancy
progresses
-Palpitations are due to :
* sympathetic nervous system stimulation
during the first half of pregnancy.
* increased pressure of the uterus against
the diaphragm during second half of pregnancy.
-Because of poor circulation resulting from pressure
of the gravid uterus on the blood vessels of the
lower extremities
* edema of the lower extremities occurs.
Management : raise legs above hip level.
* varicosities of the lower extremities
Management:
* use/wear support hose or elastic stockings
to promote venous flow, thus preventing stasis in
lower extremities.
* apply elastic bandage – start at the distal
end of the extremity and work toward the trunk to
avoid congestion and impaired circulation in the
distal part; do not wrap the toes to determine
adequacy of circulation.
 * avoid constricting garters
-Varicosities of the vulva and rectum appear.
Management: side-lying position with hips elevated
on pillows or do modified knee-chest position.
- There is an increased level of circulating fibrinogen ,
that is why pregnant women are normally
safeguarded against undue bleeding and predispose
to blood clot formation. Implication: pregnant
women should no be massaged since blood may be
dislodged, leading to thromboembolism and possible
death.
- Gastrointestinal
a. morning sickness (nausea and vomiting) during
the 1st three months of pregnancy) due to increased
HCG and due to increased production of gastric acids
or to emotional factors.
Management: eat dry toast or crackers 30 minutes
before arising in the morning (or dry , high
carbohydrates, low fat and low spices in the diet).
b. Constipation and flatulence are due to
displacement of the stomach and intestines, thus
slowing peristalsis and gastric emptying time and
due to increased progesterone which inhibits gastric
motility.
Management:
* increase fluids and fibers in the diet
* establish regular elimination time
* avoid enemas
* avoid laxative
c. Hemorrhoids due to pressure of enlarged uterus
on the intestines.
Management: cold compress with Epsom salts
d. Heartburn , during the last trimester due to
increased progesterone which decreases gastric
motility and thereby causing reverse peristaltic
waves which leads to regurgitation of acidic stomach
contents through the cardiac sphincter into the
esophagus, causing irritation.
Management:
* pats of butter before meals
* avoid fried , fatty foods
* sips of milk at frequent intervals
* small, frequent meals taken slowly
* bend at the knees, not the waist
* take antacids ( milk of magnesia)
Heartburn is known as pyrosis
3. Urinary
a. urinary frequency during first trimester
due to increase blood supply to the kidney and third
trimester is due to pressure of enlarged uterus on
the bladder (lightening = descent of the fetus into
the pelvic brim).
b. decreased renal threshold for sugar
because the increased production of glucocorticoids
cause lactose and dextrose to spill into the urine of
pregnant women, and effect of increased
progesterone.
c. increased susceptibility to urinary tract
infection because of increased diameter during
pregnancy and decreased peristalsis of the ureters
4. Respiratory – shortness of breath
a. increased oxygen consumption and
production of carbon dioxide by the products of
conception during the first trimester.
b. increase uterine size causes diaphragm to
pushed or displaced, thus crowding the chest cavity.
Management : Lateral expansion of the chest to
compensate for shortness of breath increases
oxygen supply and vital lung capacity.
- Musculoskeletal
- A. Because of the pregnant woman’s
attempt to change her center of gravity, she
makes ambulation easier by standing more
straight and taller, resulting in a lordotic
position (pride of pregnancy)
b. Due to increased production of the hormone
relaxin, pelvic bones become more supple and
movable, increasing the possibilty of acidental falls
due to the wobbly gait. Note: advise use of low-
heeled shoes.
c. Leg cramps are caused by:
* increased pressure of gravid uterus on the
lower extremities
* fatigue and muscle tenseness; chills
* low calcium, high phosphorous serum
level
Management of Leg cramps :
* frequent rest periods with feet elevated
e. Gradual increase in insulin production but the
body’s sensitivity to insulin is decreased during
pregnancy.
- Weight
a. during the first trimester, weight gain of
1-3 lbs, 2nd and 3rd trimester, weight gain of 10-11 lbs
per trimester is recommended.
b. Total allowable weight gain during entire period of
pregnancy is 20-25 lbs or 10-12 kilograms.
c. Pattern of weight gain is more important than the
amount of weight gain.

* comfortable, warm clothing d. Distribution of weight gain:

* increase calcium intake fetus 7lbs.

* do not massage – blood clots may be placenta 1 lb.

dislodged and cause embolism.
amniotic fluid 1 ½ lbs.
* most effective treatment : press the knee
increased uterine weight 2 lbs.
of the affected leg and dorsiflex the foot
increased blood volume 1 lb.

increased weight of breasts 1 ½- 3lbs.

-Temperature – slight increase in the basal
temperature due to an increased progesterone, but weight of additional fluid 2 lbs.
the body adapts after 4th month of pregnancy.
fat and fluid accumulation 4-6 lbs.
-Endocrine
20-25 lbs.
a. addition of the placenta as an endocrine organ,
Emotional Responses:
producing large amounts of HCG, HPL, estrogen and
progesterone. a. First trimesters : the fetus is an unidentified
concept with great future implications but without
b. moderate enlargement of the thyroid gland due to
tangible evidence of reality. Some degrees of
hyperplasia of the glandular tissues
rejection, disbelief, denial and repression.
and increased vascularity. Could also be due to an
increased basal metabolic rate to as much as +25%
because of the metabolic activity of the products of b. Second trimester: Fetus is perceived as a separate
conception. entity. Fantasizes appearance of the baby.
c. Increased size of the parathyroids, probably to c. Third Trimester: Has personal identification with a
satisfy the increased need of the fetus for calcium. real baby about to be born and realistic plans for
future child care responsibilities. Best time to talk
d. Adrenal cortex hypertrophies and its activity
about layette, infant feeing methods and family
increases, increasing the amounts of circulating
planning. Fear of death, thought, is prominent.
cortisol, aldosterone and ADH,
Local Changes:
all of which affect carbohydrates and lipid
metabolism. 1. Uterus
a. weight increases to about 1000 gms at full term * White , patchy, cheese-like particles that adhere to
vaginal walls.
b. change in shape from pear-like to ovoid
*Irritatingly itchy and foul-smelling vaginal
c. enormous change in size and shape of the uterus
discharges.
is due to the increase amount of fibrous and elastic
tissues. Treatment: mycostatin vaginal suppositories

d. change in consistency of lower uterine segment
causes extreme softening- Hegar’s sign, seen at 6th
week gestation
e. Mucus plugs in the cervix, operculum, are
produced to seal out bacteria.
f. Cervix becomes more vascular and edematous,
resembling the consistency of an earlobe, Goodell’s
sign
2. Vagina
a. increased vacularity causes change in color from
light pink to deep purple or violet, Chadwick’s sign
Moniliasis is seen as oral thrush in newborn acquired
during delivery.
3. Abdominal Wall
a. Striae gravidarum – increased uterine size results
in rupture and atrophy of connective tissue layers,
pink or reddish streaks.
b. melasma or chloasma /”mask of pregnancy” =
extra pigmentation on cheeks and across the nose
due to increased production of melanocytes by the
pituitary gland
c. sweat glands activated.

b. due to increased estrogen, activity of the 4. Breasts – all changes due to increased estrogen.
epithelial cells increases, thus increasing the amount
a. increase in size due to hyperplasia of the
of vaginal discharges, leukorrhea.
mammary alveoli and fat deposits. Proper breast
c. the pH of the vagina changes from normally acidic support with well-fitting brassiere to prevent sagging
(because of the presence of the Doderlein bacilli) to of breasts.
alkaline (because of increased estrogen). An alkaline
b. feeling of fullness and tingling sensations
vaginal environment is said to protect against
bacteria, it favors the growth of: c. nipples more erect.
1.Trichomonas , a protozoa or flagellate. d. montgomery gland become bigger and
Trichomonas vaginalis/ trichomonas vaginitis protruberant
Symptoms: e. areola become darker and diameter increase
• Frothy , greenish, irritatingly itchy and foul- Minor Discomforts of Pregnancy
smelling discharges.
⚫ Nausea and Vomiting
• Vulvar edema and hyperemia secondary to
irritation from discharges. Management :

• Treatment : vaginal suppositories of
Trichomonilial compounds. Acidic vaginal
douche
2. Candida albicans, a fungus. Moniliasis or
Candidiasis. The fungus loves to thrive in
environment rich in carbohydrates
Symptoms:
1. eat dry toast or crackers before rising from bed
2. eat small frequent meals rather than 3 large ones
⚫ Frequent urination
1. limit fluid intake before bedtime
2. kegels exercise to improve to of muscles
that controls urination
Signs and Symptoms of Pregnancy * Second trimester

⚫ Presumptive Signs ⚫ Positive Signs

1. Amenorrhea – 1. Fetal Heart tone can be detected by

doopler at 12 weeks, fetoscope at 16 weeks
2. Breast changes-
, stethoscope at 20 weeks
3. Urinary frequency-
2. Funic suffle – a swishing sound synchronous
4. *Quickening with fetal heart beat caused by blood
rushing through the umbilical arteries.
5. Easy fatigability-
3. Fetal movement felt by examiner from 20
6. Leukorrhea weeks onward
7. Nausea and vomiting 4. X-ray visualization of fetal skeleton as early
as 14 weeks
8. *Skin changes
5. *Ultrasonographic evidence of pregnancy.

⚫ Abdominal pulse echo sonography can

* Second trimester
detect intrauterine pregnancy at 4 to 5
⚫ Probable Signs weeks

1. Hegar’s sign ⚫ Small white gestational ring can be detected

after 6 weeks
2. Uterine growth
⚫ Fetal brain and heart action is
3. *Ballotement – refers to the rebound that demonstrated by eight weeks using Doopler
occurs when the examiner’s fingers tap the or real time sonography
floating fetus within the uterus and caused
by the fetus floating away and returning ⚫ Fetal heart and thorax can be identified by
back to its previous position. ( begins at 6-8 14th week.
weeks)
* First trimester
4. Uterine suffle – a muffled swishing sound
PRENATAL VISIT
heard over the abdomen in union with the
mother’s heart beat. ⚫ Primary factor in the improvement of
maternal and infant mortality and morbidity
5. Goodell’s sign – softening of the cervix
rates.
6. *Braxton- Hicks contraction – painless palpable
⚫ To ensure the success of prenatal care
uterine contraction
programs
7. Fetal outline – palpable at 24 weeks
⚫ 266-280 days
8. Positive pregnancy test- time that can be
⚫ 38-42 weeks (average is 40 weeks)
detected:
⚫ 9 calendar months
- 8 days after fertilization (2-3 days)
Components of a Prenatal Visit
- 23 days after LMP
⚫ History Taking
- 5 days before the expected menstrual
period a. Personal data- name, age, civil status
 b. Obstetrical data ⚫ History of pregnancies- labor,
delivery, abortion, complications
* gravida
⚫ History of exposure to medications
*parity
(DES)
* past pregnancies
⚫ History of chronic illness- epilepsy,
** method of delivery DM, HPN, IDA, endocrine disorders

** where? ⚫ Genetic disorder-

** risks involved ⚫ Urinary and Bowel problems- UTI,

hemorrhoids, constipation
* present pregnancy
⚫ Sexual history/Gynecologic history
** chief concern
⚫ History of STD
** danger signals
⚫ Surgical history including female
- vaginal bleeding genitalia mutilation or
circumcision, blood transfusion
- swelling of face or fingers
⚫ History of dysmenorrhea or
- severe, continuous headache
dyspareunia
- flashes of light or dots before the
⚫ History of sexual function
eyes
⚫ Contraceptive use
- pain in the abdomen
Other Components of Prenatal Care
- persistent vomiting
1. History Taking
- chills and fever
2. Physical Examination
- sudden escape of fluid from the
vagina ⚫ Weight
- absence of FHS ⚫ Height
⚫ Medical data – history of : ⚫ Blood Pressure
* kidney disease ⚫ Examinations of face and conjunctiva and
palms for pallor
* heart disease
⚫ Abdominal exam, fundic height, fetal
* liver disease
position, presentation, FHT
* hypertension
⚫ Examination of breast
* STDs
3. Treatment of diseases
* tuberculosis
4. TT immunization
Assessment
⚫ TT1 anytime during pregnancy
⚫ Health history
⚫ TT2 one month afterTT1
⚫ Menstrual history- length, amount,
⚫ TT3 six months after TT2
regularity, pain, bleeding
 ⚫ TT4 one year after TT3 or next pregnancy
⚫ TT5 one year after TT4 or next pregnancy
5. Iron supplementation
6. Health Education
7. Laboratory Examination
8. Oral Dental Examination
9. Referral when necessary
History of Present Pregnancy
⚫ Expected Date of Delivery
⚫ Naegeles Rule – add 7 days to the first day
of LMP, count back 3 months and add one
year.
Example :
LMP 6 - 3 - 11
-3 + 7 + 1
EDC 3 - 10 - 12
Note: start on April to Dec., for Jan to March – add 9
months and add 7 days
⚫ If the woman cannot remember her LMP,
ask her when she first felt the fetus move
To get EDC for primigravida, add 22 weeks to the
date of quickening
To get EDC for multigravida, add 24 weeks to the
date of quickening
⚫ Assessment of Fundic height – is measured
to estimate AOG, EDC and fetal growth rate.
Measure fundic height from top of
symphysis pubis to the top of the fundus
with the bladder empty.
MC DONALD’S RULE is used to calculate AOG
Fundic height (cm) X2/7 = AOG in lunar months
Fundc height (cm) X 8/7 = AOG in weeks
⚫ BARTOLOMEW’S RULE is used to calculate
AOG
⚫ Height of fundus is used to determine AOG,
fundic heigh is determined by palpatio and
by relating to the different landmarks in the
abdomen; umbilicus, symphysis pubis
xiphoid process.
⚫ 12 weeks – level of symphysispubis
⚫ 16 weeks – halfway between umbilicus and
symphysis pubis
⚫ 20 weeks – level of umbilicus
⚫ 24 weeks – 2 fingers above umbilicus
⚫ 30 weeks – halfway between umbilicus and
xiphoid process
⚫ 34 weeks – just below xiphoid process
⚫ 36 weeks – level of xiphoid process
⚫ 40 weeks – at 34 weeks level due lightening
⚫ JOHNSON’S RULE is used to calculate fetal
weight in grams.
Fundic height (cm) – N X K = fetal weight
K = 155 (constant)
N = 12 if engaged
N = 11 if not engaged
⚫ HAASE’S RULE is used to determine length
of fetus
a. During the first half of pregnancy, square
the number of months
b. During the second half of pregnancy,
multiply the number of months by five.
Leopolds Manuever
⚫ First Manuever: Fundal Grip
Purpose:
1. To determine fetal part lying in the fundus
2. To determine presentation
Procedure: using both hands, feel for the fetal part
lying in the fundus.
Findings : if the nurse-midwife feels the head which
round, smooth with transverse groove of the neck,
the fetus is in breech presentation.
Preparation
⚫ Cardinal Rule – instruct woman to empty
her bladder first.
⚫ Place woman in dorsal recumbent position,
supine with knees flexed to relax abdominal
muscle. Place a small under the head for
comfort.
⚫ Drape properly to maintain privacy.
⚫ Explain procedures to gain cooperation.
⚫ Warm hands . Colds stimulate uterine
contractions.
⚫ Use palm for palpation not fingers.
If the nurse-midwife feels the buttocks which is soft
and angular, it means the fetus is in vertex
presentation.
Second Manuever: Umbilical Grip
Purpose:
1. To identify location of fetal back
2. To determine position
Procedure : one hand is used to steady the uterus on
one side of the abdomen while the other hand
moves slightly on a circular motion from top to the
lower segment of the uterus to feel for the fetal back
and small fetal parts. Use gentle but deep pressure.
Findings:
Small fetal parts feel nodular with numerous angular
nodulations.
Fetal back feels smooth hard, like a resistant plane.
⚫ Third Manuever: Pawlick’s Grip
Purpose:
To determine engagement of presenting part.
Procedure:
Using thumb and finger, grasp the lower portion of
the abdomen above symphysis pubis, press in
slightly and make gentle movements from side to
side.
Findings:
1. The presenting part is engaged if it is not
movable.
2. It is not yet engaged if it is still movable.
⚫ Fourth Manuever: Pelvic Grip
Purpose:
1. To determine degree of flexion of fetal
head.
2. To determine attitudes or habitus
Procedure: facing foot part of the woman, palpate
fetal head pressing downward about 2 inches above
the inguinal ligament. Use both hands.
Findings:
1. If descended deeply, only a small portion of
the fetal head will be palpated.
2. If cephalic prominence or brow of the baby
is on the same side of the small fetal parts,
the head is flexed.
3. If cephalic prominence is on the side of the
fetal back, the head is extended.
Laboratory Test
⚫ Urinalysis –
Benedict test to detect glycosuria
Acetic acid test to detect proteinuria
Urinalysis to detect present of bacteria
⚫ Blood test
HCT – 37 to 47 %
Hgb – 12 to 16 mg/dl
⚫ Determination of blood type and Rh factor
⚫ Rubella antibody titer degree of protection
against German measles.
Health Teaching ⚫ Advantages:

⚫ SCHEDULE OF CLINIC VISIT – 1. Strengthen the muscle to promote their

From first visit to 32 weeks – every 4 weeks
From 32 weeks to 36 weeks – every 2 weeks
2.
From 36 weeks until delivery – every week
quick return to normal condition after
childbirth
Promote circulation, prevent and relieve
problems like varicosities & hemorrhoids

Steps to Follow in Prenatal Care 3. Relieve tension and anxiety

15) Encourage the woman to come back for return 4. improve posture and appetite
visits.
5. Improves metabolic efficiency
At least 4 routine antenatal visits
Bed rest is recommended for women with:
st
1 visit: before 4 months
⚫ Pregnancy Induced Hypertension
nd
2 visit: 6 months
⚫ Pregnant with 2 or more fetuses
rd
3 visit: 8 months
⚫ Women with growth retarded fetus
th
4 visit: 9 months – return if
⚫ Women with several heart disease
undelivered within 2 weeks after the EDC.
General Considerations:
Pregnant women who do not come for prenatal
care should be visited at home. ⚫ The pregnant woman should not start a
new exercise regimen during pregnancy.
Health Teaching
⚫ Exercise should be individualized and
⚫ Normal signs and symptoms of pregnancy
adjusted to the stage of pregnancy
⚫ Minor discomforts, preventions and
⚫ No activities or sports that involves of
management
bodily harm such as contact
⚫ Danger signs and symptoms
⚫ Exercises should be performed in
⚫ Nutrition and diet moderation, should not cause fatigue.

⚫ Rest, exercise and relaxation ⚫ No holding of breath while exercising, no

pointing of toes, no hyperextension of the
⚫ Avoidance of drugs, alcohol, cigarettes and back.
too much caffeine
Recommended Exercises
⚫ Clothing
⚫ Pelvic Rocking – relieve low backache
⚫ Sexual relations
-Strengthen the muscle of the lower
⚫ Employment back
⚫ Travel ⚫ Squatting and Tailor sitting – stretch and
strengthen perineal muscles, improves
⚫ Preparation for baby’s birth, labor, delivery
circulation in the perineum
and puerperium
⚫ Rib cage lifting - relieve shortness of breath
⚫ Exercise -to strengthen the muscle used for
labor and delivery. Proper exercise during ⚫ Calf stretching – relieve leg cramps
pregnancy.
 ⚫ Shoulder circling – relieve upper backache - wash with water only, no soaps and
and numbness of arms alcohol

⚫ Abdominal muscle contraction – strengthen

abdominal muscles in preparation for labor
⚫ Employment
pushing
- continue working as long as their job is not
⚫ Modified knee chest – relieve hemorrhoids,
involve lifting heavy objects, standing and sitting for
vulvar varicosities and low backache
long periods and emotional strain and exposure to
⚫ Leg elevation – relieve swelling, fatigue, toxic substances
varicosities of lower extremities
- avoid : exhaustion, discomfort, strenuous
⚫ Leg raising – strengthen abdominal muscles exercise, extreme temperature, smoking areas,
ladder climbing, straining, running, overtime.
⚫ Kegel exercise – strengthen perineal
muscles

⚫ Dental Care

1. Dental check up early in pregnancy ⚫ Travel

2. Dental caries should be treated during - no travel restrictions during pregnancy,

pregnancy
3. Alkaline mouthwash is used to counteract
the acidic saliva during pregnancy
⚫ Clothing
a. light weight, non-constrictive and loose
fitting, absorbent and washable
b. void constricting garters around the leg,
abdomen, and breast
c. flat heeled shoes
⚫ Bathing-
- daily bath to keep fresh and clean
- tube bath is discouraged
- can go swimming but not diving
- contraindicated when there is vaginal
bleeding, ruptured membrane
avoid long trips on the third trimester. The best time
to travel is on the second trimester.
- when traveling: 15-to 20 minutes rest
period every 2 hours on long rides
⚫ Sexual Relations
1. Sexual desires continue during pregnancy
but sexual drive and responsiveness vary
among women at different stages of
pregnancy.
- first trimester – decrease sexual desire
- second trimester – increase sexual desire
- third trimester –decrease sexual desire
because of the fear of hurting the fetus and
discomfort.
Contraindications sexual intercourse:
- deeply presenting part

⚫ Breast Care - rupture bag of water

- well-fitting and larger size of brassiere, - vaginal spotting or bleeding

with wide strap and deep cups
- incompetent cervical os
- nipple rolling between thumb and
Last 6 weeks of pregnancy, coitus is discouraged.
forefinger
⚫ Alcohol – refrain from drinking any
alcoholic beverages

⚫ Smoking – avoided to prevent small

gestational age baby.

⚫ Caffeine – avoided 4 cups of caffeine

containing foods and beverages

⚫ Drugs – should not take any drug not

prescribed by a physician