PHYSIOLOGIC CHANGES IN 3.

VAGINA

PREGNANCY  Hypertrophic and enriched with

glycogen

 Loosen connective tissues in

preparation for distention at birth
1. UTERUS  Leukorrhea – increased white vaginal
Increase growth discharge

 Length – 6.5 to 32 cm  pH – from 7 to 4 or 5 

 Manifestations – itching, burning,
 Depth – 2.5 to 22 cm creamcheese like discharge
 Management - Nystatin
 Width – 4 to 24 cm

 Weight – 50 to 1000g
4. OVARY
 Formation of uterine muscles fibers
 Ovulation stops (estrogen &
 Stretching of existing muscle fibers
progesterone)
 Growth – steady,  Amenorrhea
constant and predictable

-12th week- above symphysis pubis

5. BREAST
-16th week- midway between umbilicus and
 Increased breast stimulation due to
symphysis pubis
estrogen
-20-22nd week – level of umbilicus  Fullness, tingling, or tenderness
 Hyperplasia of mammary alveoli and
-36th week – xiphoid process
fat deposits
 Breast size increases
 Areola – darkens; increases in
2. CERVIX diameter (2-3 inches)
 Blue veins become prominent over
 Cervix becomes vascular and
the surface
edematous (estrogen)
 Colostrum – expelled by 16th week
 Increased fluids between cells leads
to Goodell’s sign
 Increased vascularity
 Increased mucus production- this 5. INTEGUMENTARY SYSTEM
prevents infection in fetus and
 Activation of melanocyte -
membrane
stimulating hormone by the
pituitary gland
  Striae gravidarum – pink or  Anemia – hgb is is less than
reddish streaks on 11.5g/100ml; hct is less than 30%
abdominal wall  Increased need for folic acid
 Linea nigra – narrow brown  Blood pressure:
line running from umbilicus to 1st trimester – no change
the symphysis pubis 2nd trimester – slight decrease
 Melasma /Chloasma – “mask 3rd trimester – return to pre-pregnancy
of pregnancy”; darkened areas level
on the cheeks and across the nose  Supine hypotension syndrome
 Vascular spiders at thighs (estrogen) -
small, fiery-red branching spots
10. GASTROINTESTINAL SYSTEM
 Palmar erythema – redness and
itchiness (estrogen) Pressure of the uterus:
 Increased perspiration by the
increased activity of sweat  Slow peristalsis
glands  Heartburn
 Increased scalp hair growth  Constipation
 Flatulence
 Hemorrhoids
7. RESPIRATORY SYSTEM -There is weight gain
 Congestion or stuffiness of
nasopharynx
 Shortness of breath – late 11. URINARY SYSTEM
pregnancy due to displacement
 Compression of the bladder and
of the lungs by 4 cm upward
ureters
 Mild hyperventilation –
 Increased total body water
progesterone decreased levels of
 Increased urine output 60 to 80%
PCO2 at 27-32mmHg
 Frequency of urination
 Diameter of ureter increased by 25%

8. TEMPERATURE

 Increases slightly due to progesterone 12. SKELETAL SYSTEM

(CL) then decreases back to normal
 Walks with difficulty
after 16 weeks
 Lordosis (“pride of pregnancy”)
-to change center of gravity
-makes ambulation easier
9. CARDIOVASCULAR SYSTEM -may also lead to backache
 Blood volume is increases
 Plasma volume : 3,600ml
 Pseudo anemia
 Decreased Iron
13. ENDOCRINE SYSTEM

 Human growth hormone increases

 Pituitary gland
 Increased growth hormone
 Prolactin late in pregnancy
 Enlargement of thyroid gland
 Thyroid hormone production increases

14. IMMUNE SYSTEM

 Decreased immunologic
competency
 Increase your risk of having
certain infections
 No to live vaccines to increase
immunity
AGE OF GESTATION AND and that the whole gestational period
will be 280 days (40 weeks).
EXPECTED DATE OF CONFIRMENT
(EDC)
ESTIMATED DUE DATE (EDD)

 is the date that spontaneous onset of

labor is expected to occur. The due
date may be estimated by adding
IMPORTANCE OF DETERMINATION OF 280 days (9 months and 7 days) to the
GESTATIONAL AGE first day of the last menstrual period
(LMP). This is the method used by
 Gestational age is a common term "pregnancy wheels".
used during pregnancy to describe
how far along the pregnancy is. It is
measured in weeks, from the first day
HOW TO COMPUTE AGE OF GESTATION
of the woman’s last menstrual cycle
(AOG)?
to the current date. A normal
pregnancy can range from 38 to 42
weeks.
 Accurate determination of the
Expected Due Date (EDD) is one of
the most important factors in early
pregnancy assessment.
 It is vital for the timing of appropriate
antenatal care, scheduling and
interpretation of tests, determining
appropriate fetal growth, and
intervention purposes.

GESTATIONAL AGE CAN BE DETERMINED BY:

 Clinical history
 Physical examination
 Ultrasound scan

LAST MENSTRUAL PERIOD

 It estimates a woman due date and

gestational age based on the
woman’s last menstrual period (LMP).
 It bases its calculation that the
woman has a 28 days menstrual cycle
HOW TO COMPUTE EDD?

 Computation of EDC/EDD

 LMP ( Naegle’s Rule)

 Formula:

Jan- March = +9 +7

April – Dec = -3 +7 +1
LEOPOLD’S MANEUVER 4. Provide privacy

5. Position patient in dorsal recumbent.

6. Gentle yet firm touch

WHAT IS LEOPOLD'S MANEUVER?

There are 4 distinct Leopold Maneuvers.
-are a common and systematic ways to
determine the position of a fetus inside the
woman's uterus through observation and
palpation to determine fetal presentations
and positions.

Purposes:

These maneuvers help identify the ff:

• Number of fetuses

• Presenting part, fetal lie and fetal

attitude

• Degree of the presenting part’s

descent into the pelvis

TAKE NOTE:

 Maneuvers are the primary

assessment in determining whether
the fetal lie is correctly ascertained
but the maneuvers are not truly
diagnostic.
 Actual position can only be
determined by ultrasound performed
by a competent technician or
professional.

1ST MANEUVER OR FUNDAL GRIP

THINGS TO REMEMBER BEFORE DOING THE  Upper pole

PROCEDURE:
1. Patient should empty her bladder
2. Examiner’s hand should be warm
3. Explain the procedure to the patient
 This maneuver determines
whether fetal head or breech is
in the fundus
 To determine what part of the baby
lies in the upper part of the uterus.
  Palpating, with both hands, the
uterine fundus to determine
PRESENTATION ("the presenting part"):
that portion of the fetus in closest
proximity to the birth canal (cephalic,
breech, shoulder presentations)
-Shoulder landmark: acromion process
of the scapula
 LIE: the relationship of the long axis of
the baby to the long axis of the
mother, i.e., longitudinal, transverse,
and oblique.

3 Questions to be asked: Nurse Alert: If you feel a smooth, curved

resistant plane in one side, you have
1. Relative consistency- the head is
located the back. If you feel smaller lumps,
harder than the breech.
irregular parts, those are the knees and
2. Shape- head is firm, round, elbows of the fetus.
and hard. Breech is
softer and feels more angular.
3RD MANEUVER OR PAWLIK'S GRIP
3. Mobility- head will move
independently of the trunk but the  Lower pole
breech only with the trunk.  This maneuver determines the part of
the fetus at the inlet and its mobility.
Nurse Alert:
 To determine what occupies
-If it is hard, round and movable, it is likely the lower uterine
the head (indicating a breech  segment and to determine whether it
presentation) and if it is softer, more is engaged or not.
triangular and not movable, it is probably  ENGAGEMENT: when
the buttock (indicating a cephalic the biparietal diameter of the fetal
presentation) head reaches or passes the plane of
the pelvic inlet.

Nurse Alert: The examiner stands to the

2ND MANEUVER OR UMBILICAL GRIP mother's side and faces the mother's feet,
then grasps the lower abdomen just above
 Sides of maternal abdomen
the symphysis pubis, between the thumb
 To determine in which side of the
and fingers of the hand as Pawlik’s grip. If
uterus of the baby’s back is located.
the presenting part is not engaged, it will be
 Palpating, with both hands
movable.
simultaneously, the sides of the uterus
to locate the fetal back and
determine
 POSITION: the relationship of a given 4TH MANEUVER OR PELVIC GRIP
landmark on the fetus to the mother's
 Presenting part evaluation
right and left.
 Should only be done if fetus is in
-Cephalic landmarks: occiput
cephalic presentation
(vertex); sinciput (brow); mentum
 To determine the degree of flexion of
(face).
fetal head.
-Breech landmark: sacrum
Nurse Caution:

 Leopold's maneuvers are intended to

be performed by health care
professionals, as they have received
training and instruction in how to
perform them.
 It is important to note that all findings
are not truly diagnostic, and as such
ultrasound is required to conclusively
determine fetal lie.
OBSTETRIC SCORING (OB Parity  The number of
SCORING) pregnancy that have
reached the age of
viability, regardless
whether the infant is
born alive or not

WHAT IS GTPAL? NULLIPARA PRIMIPARA MULTIPARA

-GTPAL is an acronym to remember essential (0) (1) (2+)
information for a complete obstetric history.
Each letter represents one aspect of the
obstetric history that should be assessed
when examining an individual for the first  Zero  One  2 or
time, including gravidity, term, preterm, pregna pregn more
abortion, and living. ncies ancy pregna
beyond that ncies
Gravida/G  The number of viability has that
ravidity pregnancy (20 reach have
weeks) ed reache
NULLIGRAV PRIMIGRAVIDA MULTIGRAVI viabilit d
IDA DA y (20 viability
weeks (20
) weeks)
 Neve  Pregnant  A
r for the first woma
been time n who
preg had 2 WHY IS GTPAL IMPORTANT?
nant or
-GTPAL is very important at the initial
more
assessment to ensure the healthcare
pregn
professional has asked for all the crucial
ancie
information about an individual’s
s.
reproductive history.
GTPAL individually

G  The number of
(Gravida) pregnancies

 Includes the present

EXAMPLE 1:
pregnancies
 Includes miscarriages /
-A pregnant woman comes to the clinic for
abortions
a visit. This is her third pregnancy. She had a
 Twins/ Triplets count as
miscarriage at 12 weeks and gave birth to a
one
son, now 3 years old, at 32 weeks. Using
GTPAL system, the nurse would document
T (Term  The number born at term
this women’s obstetric history as:
Births)
 37th week of gestation
ANSWER:
 Includes alive or stillborn
G–3
 Twins/ Triplets count as
T–0
one
P–1
A–1
P (Pre-  The number of L–1
term pregnancies delivered
Births) beginning with the 20th –
36 6/7th weeks of gestation
EXAMPLE 2:
 Includes alive or stillborn
-A nurse is collecting dictate during an
 Twins/ Triplets count as admission assessment of a client who is
one pregnant with twins. the client has a healthy
5-year-old child who has delivered at 38
A  The number of weeks and tells the nurse that she does not
(Abortions pregnancies delivered have a history of any type of abortion or
/Miscarria before 20 weeks gestation fetal demise. the nurse would document the
ges) GTPAL for this client as:
 Counts with gravidity
ANSWER:
 Twins/ Triplets count as
one
G–2
T–0
L (Living  The number of current
P–1
Children) living children
A–0
 Twin/triplets count L–1
PRACTICE:
-A 30-year-old female is 25 weeks pregnant
with twins. She has 5 living children. Four of
the 5 children were born at 39 weeks’
gestation and one child was born at 27
weeks’ gestation. Two years ago, she had a
miscarriage at 10 weeks’ gestation. What is
her GTPAL?

ANSWER:

G–7
T–4
P–1
A–1
L–5

PRACTICE:
-A 27-year-old female is currently 16 weeks
pregnant. She has 2-year-old twins that were
born at 39 weeks’ gestation and a 5-year-
old who was born at 40 weeks’ gestation.
She had no history of miscarriage or
abortion. What is her GTPAL?

ANSWER:

G–3
T–2
P–0
A–0
L–3
NUTRITION IN PREGNANCY AND
PREGNANCY
LACTATION
“Nutrition requirements increases
tremendously during pregnancy and
lactation as the expectant or nursing
mother not only has to nourish herself but
also growing fetus and the infant who is
being breast fed”.
WHY THE BODY OF THE WOMEN NEEDS
NUTRIENTS DURING PREGNANCY?
1. ↑Basal metabolic rate (BMR)
Fetal growth & development increases the
BMR by 5% during 1st trimester and 12%
during 2nd & 3rd trimester. This increases the
total energy requirement.
2. Gastrointestinal changes:
There is an alteration in GI functions which
causes nausea, constipation
& vomiting. In later trimester of pregnancy
absorption of nutrients like vitamin B 12 , iron
and calcium increases in order to meet the
increased needs of the mother & fetus.
3. Changes in body fluid
Mother’s blood volume increases so as to
carry the appropriate amount
of nutrients to the fetus and metabolic
waste away from the fetus. With increase in
the blood volume the concentrations of
plasma proteins, hemoglobin and other
blood constituents is lowered.
IMPORTANCE OF GOOD NUTRITION DURING
 A well nourished woman prior to
conception enters pregnancy with
reserve of several nutrients that meets
the needs of the growing fetus without
affecting her own health.
 A well nourished woman suffers fewer
complications during pregnancy &
there are few chances of premature
births.
 A well nourished mother will give birth
to a healthy child.
 Maternal diet during pregnancy has a
direct influence on fetal growth, size &
health of the newborn.
 Poor diet during pregnancy affects
mother’s health, a malnourished
mother provides nutrients to the fetus
at the expense of her own tissues.
 Poor nutrition during pregnancy
increases the risk of complications
such as prolonged labour and even
death.
 Inadequate diet during pregnancy
affects the health of the baby during
early infancy. If the infants survive
they develop nutritional diseases like
anemia, rickets etc. or suffer from
infectious diseases due to lack of
good immunity.
ENERGY REQUIREMENT DURING
PREGNANCY
 During pregnancy additional
energy is required to support the:
 Growth of fetus.
 Development of placenta &
maternal tissues.
 To meet the needs for increased
basal metabolic rate. To deposit
 fat which will be used during CALCIUM REQUIREMENTS DURING
lactation. PREGNANCY

 Growth and development of bones as

well as teeth of the fetus.
 Decreases risk of hypertension,
 pre-eclampsia in mothers and low
birth weights and chronic
hypertension in newborns.
 Maintaining bone strength
 Proper muscle contraction
PROTEIN & FAT REQUIREMENTS DURING  Blood clotting
PREGNANCY
-If calcium intake is inadequate during
PROTEINS pregnancy then calcium is mobilized from
maternal bones to meet the fetal calcium
 Growth of fetus Development of
needs and this demineralization of maternal
placenta Enlargement of maternal
bones leading to easy fractures.
Increased maternal blood
volume  Recommended daily allowance (
 Formation of amniotic fluid Protein RDA) for calcium during pregnancy is
reserves prepares the mother for 1g.
labour, delivery and lactation

-Additional 15g of protein is required 2nd &

IRON REQUIREMENTS DURING PREGNANCY
3rd trimester of pregnancy.
 Fetal growth
 Expansion of maternal tissues
FATS including the red blood cell
Maintaining additional iron content
 Omega-3 fatty acid
of placenta
 like DHA (Docosahexaenoic acid)
 Building the iron stores in fetal liver
 Essential for brain development and
 Compensate blood loss during
prevents preterm births.
delivery
 It is required for fetal visual
development
 It reduces the incidence of heart
MINERALS REQUIREMENTS DURING
diseases & heart disease related
PREGNANCY
deaths in infants.
Folic acid (RDA- 400 µg/d)

 During pregnancy maternal blood

formation increases thus folic acid
requirement also increases.
  Folic acid supplementation during Vit C (60mg/d)
pregnancy prevents fetal neural tube
-It increase iron absorption and also helps in
defects and improves birth weights
fetal growth. Deficiency of vitamin C
of the fetus.
increases the chances of preterm delivery.
Zinc (RDA-12mg/d) :
Vit B6 (2.5mg/d)
 It is required for synthesis of nucleic
-It is required for normal fetal
acids DNA & RNA and it is having
development & positive pregnancy
important role in reproduction.
outcomes.
 Zinc deficiency during pregnancy
can cause poor pregnancy outcomes Vit B1 (+0.2mg/d), B2 (+0.2 mg/d),
and abnormal deliveries including B3(+2mg/d)
congenital malformations.
-As total energy requirement increases
Iodine during pregnancy so B vitamin requirement
also increases.
 Lack of iodine causes still birth, birth
defects
 Decreased fetal brain development
THINGS TO KEEP IN MIND DURING
PREGNANCY:
VITAMIN REQUIREMENTS DURING Caffeine: Coffee should be avoided during
PREGNANCY pregnancy as it can cross the placenta &
enter fetal circulation and increases the risk
Vitamins A (600 µg/d retinol)
of miscarriages, premature deliveries and
-It is needed in small amounts to protect the small for date infants.
fetus from immune system problems,
Smoking: During pregnancy smoking results
blindness, infections and death.
in placental abnormalities & fetal damage,
Vitamin D (5µg/d) including prematurely & low birth weights.
Smoking impairs oxygen & nutrient transport
-It is required for formation of fetal bones.
through the placenta due to reduced
Vitamin K blood flow

-Vitamin K is required for normal coagulation Alcohol: During pregnancy alcohol

of blood & prevents new born infants consumption causes low birth weight infants
hemorrhages. & growth retardation, fetal impaired central
& nervous system performance including
Vit B12 (1.2 µg/d) growth retardation.
-Vitamin B12 supplementation during Drugs: During pregnancy drugs consumption
pregnancy helps in brain & nervous system lead to poor prenatal weight gain, very
development of the fetus. short or prolonged labour, operative delivery
and other perinatal problems.
Diet & feeding pattern : 6-12 months of lactation – 68g of
protein is required everyday
 To meet the increased nutrients need
during pregnancy mother should
 OTHERS:
increase her feeding. Pregnant
-Calcium, Iron, Folic Acid, Vitamin A &
woman should consume 5-6 meals a
C, Vitamin B6 & B12
day and snacks in between the main
meals.
 To meet the increased protein
DIET AND FEEDING PATTERNS FOR LACTATING
demand good quality protein rich
WOMEN:
foods like milk, meat, eggs, fish should
be included.  Lactating mother requires larger
 Nutrient rich foods specially iron, quantities of body building and
calcium, folic acid , calcium & DHA protective foods & additional energy
rich foods should be included in the yielding foods to facilitate the
diet during pregnancy. formation & secretion of breast milk.
 Fluid intake should be increased as
fluids are essential for adequate
IMPORTANCE OF GOOD NUTRITION DURING quantity of milk production.
LACTATION  No food should be restricted except
highly spiced & strongly flavored
 Mother needs extra nutrition as she
food, as they impart flavor to milk
has to nourish a fully developed &
which may be repulsive to the baby.
rapidly growing infant. Any
 Nutrient needs of lactating mother are
inadequacy in mothers diet influence
greatly enhanced during lactation
both the quality & quantity of
hence she should have snacks in
mother’s milk secreted.
between the meals. Lactating mother
 Nutrient deficiency can lead to lower
should have 5-6 meals in a day.
levels of nutrients in the mother’s milk.

NUTRITIONAL REQUIREMENTS DURING

LACTATION:

 Energy
-During first 6 months of lactation –
additional 550 kcal/d energy is
required During 6-12 months of
lactation- additional 400 kcal/d
energy is required

 Protein
-During first 6 months of lactation- 75g
of protein is required everyday During
QUIZ 1 During a prenatal visit a patient tells you her
last menstrual period was January 30, 2022.
Based on the Naegele's Rule, when is the
estimated due date of her baby?
A client arrives at the prenatal clinic for the a. October 6, 2022
first prenatal assessment. The client tells the b. October 7, 2022
nurse that the first day of her last menstrual c. November 6, 2022
d. November 7, 2022
period was September 19, 2007. the nurse
determines the estimated date of
confinement as:

a. July 26, 2008 A pregnant women came at the clinic and

b. June 12, 2008 as the nurse, you want to know how long
c. June 26, 2008 she is in her pregnancy. She said during the
d. July 12, 2008 interview that her LMP is April 20,2022 and
her last clinical visit is September 30, 2022.
During a prenatal visit a patient tells you her What is her AOG?
last menstrual period was August 15, 2016, a. 20 2/7 weeks
when is the estimated due date of her b. 21 2/7 weeks
baby. c. 22 2/7 weeks
d. 23 2/7 weeks
a. May 24, 2016
b. April 4, 2017
c. May 4, 2017 In Naegel’s Rule, when to use the formula of
d. May 22, 2017 (-3 +7 +1)?
a. January-March
During a prenatal visit a patient tells you her b. April-September
last menstrual period was March 14, 2022. c. April- December
Based on the Naegele's Rule, when is the d. January- April
estimated due date of her baby?
a. July 4, 2017 It is termed as the “mask of pregnancy”.
b. June 4, 2017 a. Linea nigra
c. July 7, 2018 b. Striae gravidarum
d. June 7, 2018 c. Melasma
d. Cholasma
During a prenatal visit a patient tells you her
last menstrual period was August 28, 2016.
Based on the Naegele's Rule, when is the A woman who is 39 weeks pregnant
estimated due date of her baby? expresses fear about her impending labor
a. December 20, 2022 and how she will manage. What is the
b. December 21, 2022 nurse's best response?
c. January 1, 2023 a. "Don't worry about it. You'll do fine."
d. January 2, 2023 b. "It's normal to be anxious about
labor. Let's discuss what makes you afraid."
c. "Labor is scary to think about, but
the actual experience isn't."
d. "You may have an epidural. You
won't feel anything.
The primary health care provider (PHP)
advised the nurse to assess the maternal
temperature and vaginal discharge of a
pregnant patient every 2 hours. What is the
reason behind this advice?
a. To evaluate fetal status
b. To know the onset of labor
c. To assess for potential risk for
infection
d. To prevent fetal hypertension

d. Cholasma
QUIZ 2
Quiz #2- Leopold Maneuver, OB Scoring, &
Nutrition in Pregnancy and Lactation
During the first step of Leopold's maneuver,
you felt something soft, broad mass which
moves together with the rest. This finding's
accurate assessment is:
a. The mass palpated at the fundal part is
the head part
b. The presentation is breech
c. The mass palpated is the back
d. The mass palpated is the buttocks
What does GTPAL stand for?
a. G - gravida, T - term births, P - preterm
births, A - abortions, L - living children
b. G - gravida, T - total pregnancies, P -
premature infants, A - abortions, L - living
children
c. G - gravida, T - total pregnancies, P -
pelvic infections, A - accidental
pregnancies, L - living children
d. G - gravida, T - term births, P - premature
infants, A - abortions, L - living children
A 27-year-old female is currently 16 weeks
pregnant. She has 2-year-old twins that were
born at 39 weeks’ gestation and a 5-year-
old who was born at 40 weeks’ gestation.
She had no history of miscarriage or
abortion. What is her GTPAL?
a. G3T2P0A0L1
b. G3T2P0A0L3
c. G1T1P1A0L1
d. G2T0P0A0L1
A nurse is collecting data during an
admission assessment of a client who is
pregnant with twins. the client also has a 5-
year-old child. the nurse would document
which gravida and para status on the
client?
a. Gravida III, para II
b. Gravida II, para II
c. Gravida I, para I
d. Gravida II, para I
A 35-year-old female is currently pregnant
with twins. She has 10-year-old triplets who
were born at 32 weeks gestation, and a 16-
year-old who was born at 41-week
gestation. Twelve years ago, she had a
miscarriage at 19 weeks gestation. What is
her GTPAL?

a. G=4, T=1, P=2, A=1, L=1

What do you call “the relationship of the
b. G=3, T=1, P=1, A=0, L=4
long axis of the fetal head to the long axis of
c. G=4, T=1, P=1, A=1, L=4
the fetal trunk”
d. G=4, T=1, P=1, A=1, L=1
a. Axis
b. Fetal lie A 39-year-old female is currently 18 weeks
c. Attitude pregnant. She has two sets of twin
d. Vertex daughters that were born at 38- and 39-
weeks’ gestation and an 11-year-old son
A pregnant woman comes to the clinic for a who was born at 32 weeks gestation. She
visit. This is her third pregnancy. She had a has no history of miscarriage or abortion.
miscarriage at 12 weeks and gave birth to a What is her GTPAL?
son, now 3 years old, at 32 weeks. Using
GTPAL system, the nurse would document a. G=4, T=2, P=2, A=1, L=5
this women’s obstetric history as: b. G=4, T=1, P=1, A=0, L=4
a. G3T1P0A2L1 c. G=4, T=1, P=2, A=1, L=4
b. G3T0P1A1L1 d. G=4, T=2, P=1, A=0, L=5
c. G2T1P2A1L2
d. G2T0P1A1L1
A 29-year-old female is currently 9 weeks
pregnant. She has no living children. Two
years ago, she had 2 miscarriages at 10-
and 12-weeks’ gestation. What is her
GTPAL?

a. G=3, T=0, P=0, A=2, L=0

b. G=2, T=1, P=0, A=0, L=1
c. G=2, T=1, P=2, A=0, L=1
d. G=3, T=0, P=1, A=2, L=2

During first 6 months of lactation or

breastfeeding, how many grams of protein is
required to take by the mother everyday?
a. 70 grams
b. 72 grams
c. 74 grams
d. 75 grams