PINES CITY COLLEGES

COLLEGE OF NURSING

BSN II
Care of Mother and Child
First Semester, AY 2023-2024

HUMAN SEXUALITY

I. Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes
emotions and preferences that are related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on

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human sexuality.

B. Definitions related to sexuality:

Gender identity – sense of femininity or masculinity 2-4 yrs/3 yrs gender identity
develops.
Role identity – attitudes, behaviors and attributes that differentiate roles

Sex – biologic male or female status. Sometimes referred to a specific sexual

behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life
long dynamic change.
- developed at the moment of conception.

I. DEFINITION OF TERMS

NCM 107
LECTURE 1
 A. Puberty – encompasses the physiologic changes leading to the
development of adult reproductive capacity; the process includes maturation
of the hypothalamus, pituitary gland and gonads. The role of the anterior
pituitary gland. The pituitary secretion of gonadotropin initiates growth and
maturation. It occurs initially during sleep and later in puberty throughout
wakefulness.
B. Adolescence – encompasses the physiologic, social, and cognitive
changes leading to the development of adult identity. The process includes
individual, achievement of personal independence and maturation of
cognitive reasoning skills.
C. Thelarche – budding of the breasts
D. Adrenarche – development of axillary and pubic hair

II. SEXUAL DEVELOPMENT (Table 1)

Criteria Males Females

1. Start of growth Around 13 years old After onset of menses,
spurt around 10-12 years old
2. Growth rate Rapid early growth Sharp decrease after
menses occur
3. Growth cessation Early cessation 1-2 years after onset of
menses

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4. Order of sexual  6 months later than  6 months earlier
maturation females Completed in 5 than males
years  Completed in 3
 Darkening and thinning of years
scrotum and enlargement of  Breast budding -
testes and scrotum – first first visible sign
visible sign  Increased size of
 Appearance of body hair pelvis
 Pubic area  Appearance of
 Axilla body hair
 Upper lip  Pubic area
 Face  Axilla
 Penis grows, enlarges  Menstruation
 Nocturnal emissions (wet  Ovulation
dreams) - male counterpart of
menstruation
 Spermatogenesis

III. TANNER STAGING (Table 2 and Table 3)

A. A rating system for pubertal development
B. It is the biologic marker of maturity
C. It is based on the orderly progressive development of:
1. Breasts and pubic hair – in females
2. Genitalia and pubic hair – in males
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LECTURE 2
 Stages Males Females
I Childhood size of penis, testes, Prepubertal, no breast tissue
scrotum
II Enlargement of testes and scrotum Appearance of breast bud
III Lengthening of the penis Enlargement of the breasts and
Further enlargement of testes and areola
scrotum
Deepening pigmentation of scrotal
skin
IV Widening and further lengthening of Areola and nipple form a mound
penis atop underlying breast tissues
Further enlargement of testes and
scrotum
Deepening pigmentation of scrotal
skin
V Adult configuration and size of Adult configuration and size of
genitalia genitalia
Areola and breasts have smooth
contour

Table 2. Tanner Stages of Pubertal Development: Thelarche & Genitalia

Stages
I
II
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Males
Prepubertal, no pubic hair
Sparse, downy hair at the base of
Females
- same -
At the medial aspect of the labia
the phallus majora
III Darkening, coarsening, curling of - same -
hair which extend upward and
laterally
IV Hair of adult consistency limited to - same -
the mons pubis
V Hair spreads to the medial aspect of - same -
the thighs
Table 3. Tanner Stages of Pubertal Development: Adrenarche

IV. HUMAN SEXUAL CYCLE

A. Excitement
1. Vaginal lubrication and vasocongestion of the genitalia.
2. Penile erection due to vasocongestion
 Initial response (sign present in both sexes, moderate increase in HR, RR,BP,
sex flush, nipple erection) – erotic stimuli cause increase sexual tension, lasts
minutes to hours.

NCM 107
LECTURE 3
 B. Plateau
1. Formation of orgasmic platform due to prominent vasocongestion.
2. Generalized muscle tension, hyperventilation, increased BP,
tachycardia in the late plateau phase.
3. Pre-ejaculatory phase with live spermatozoa
 Initial response (accelerated V/S) – increasing & sustained tension nearing
orgasm. Lasts 30 seconds – 3 minutes

C. Orgasmic
1. Strong rhythmic contractions of vagina and uterus.
2. In males, vas deferens, seminal vesicle, ejaculatory duct and prostate
contract 3-4 times over a few seconds causing pooling of seminal fluid
in the prostatic urethra. Rhythmic contractions in males occur at 0.8
seconds interval that assist in the propulsion process
 Initial response (involuntary spasm throughout body, peak v/s)
involuntary release of sexual tension with physiologic or psychologic
release, immeasurable peak of sexual experience. May last 2 – 10
sec- most affected are is pelvic area

D. Resolution – rapid decline in pelvic vasocongestion. All organs return to

previous position
 Initial response (v/s return to normal, genitals return to pre-excitement

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phase)

E. Refractory phase – only in males; the period during which no amount of

stimulation can cause another erection. Not manifested in females because
females are multi-orgasmic. This phase lengthens with age.

FEMALE PELVIS AND MEASUREMENTS

A. True pelvis
1. Lies below the pelvic brim
2. Consists of the pelvic inlet, midpelvis, and pelvic outlet
B. False pelvis
1. The shallow portion above the pelvic brim
2. Supports the abdominal viscera

C. Types of pelvis
The gynecoid pelvis is most
1. Gynecoid favorable for successful labor and birth. If
a. Normal female pelvis cephalopelvic disproportion (CPD) exists, the
normal labor process will be delayed and
most likely result in a cesarean delivery.
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LECTURE 4
 b. Transversely rounded or blunt

2. Anthropoid
a. Oval shape
b. Adequate outlet, with a narrow pubic arch

3. Android
a. Heart-shaped or angulated
b. Resembles a male pelvis
c. Not favorable for labor and vaginal birth
d. Narrow pelvic planes can cause slow descent and midpelvic
arrest.

4. Platypelloid
a. Flat with an oval inlet
b. Wide transverse diameter, but short anteroposterior diameter,
making labor and vaginal birth difficult

D.Pelvic inlet diameters

1. Anteroposterior diameters

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a. Diagonal conjugate: Distance from the lower margin of the symphysis
pubis to the sacral promontory
b. True conjugate or conjugate vera: Distance from the upper margin of the
symphysis
pubis to the sacral promontory
c. Obstetric conjugate: Extends from the sacral promontory to the top of
the symphysis pubis. It is the smallest front-to-back distance through which the
fetal head must pass in moving through the pelvic inlet.
2. Transverse diameter: The largest of the pelvic inlet diameters; located
at right angles to the true conjugate

3. Oblique (diagonal) diameter: Not clinically measurable

4. Posterior sagittal diameter: Distance from the point where the

anteroposterior and transverse diameters cross each other to the
middle of the sacral promontory

E. Pelvic midplane diameters

1. Transverse (interspinous diameter)
2. Midplane normally is the largest plane and has the longest diameter.

F. Pelvic outlet diameters

1. Transverse (intertuberous diameter)
2. Outlet presents the smallest plane of the pelvic canal.

NCM 107
LECTURE 5
 V.ANTEPARTAL CARE
Antepartum Care. A comprehensive antepartum
 care program involves a coordinated approach to medical care and psychosocial
support that optimally begins before conception and extends throughout
the antepartum period.

Pregnancy- is the term used to describe the period in which a fetus develops inside a woman's
womb or uterus.
Pregnancy usually lasts about 40 weeks, or just over 9 months, as measured from the last
menstrual period to delivery. Health care providers refer to three segments of pregnancy, called
trimesters.

1. FERTILIZATION

A. Definition: the union of the sperm and the mature ovum in the outer third or outer
half of the Fallopian tube.

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 When fertilized, the membrane of the ovum undergoes changes that prevent
entry of other sperm.

B. General considerations
1. Normal amount of semen per ejaculation = 3-5 cc. = 1 teaspoon.
2. Number of sperms in an ejaculate = 120-150 million/cc
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 sperms = 7 days
5. Sperms, once deposited in the vagina, will generally reach the cervix within 90
seconds after deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis (haploid umber of
daughter cells); therefore, they contain only 23 chromosomes (the rest of the
body cells contain 46 chromosomes). Sperms have 22 autosomes and 1 X sex
chromosome or 1 Y sex chromosome. The union of an X-carrying sperm and
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). Important: Only fathers, therefore,
determine the sex of their children.

2. IMPLANTATION

A. Implementation after fertilization, the fertilization ovum or zygote stays in the

Fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking
NCM 107
LECTURE 6
 place. The developing cells are now called blastomere and when there are already
about 16 blastomeres, it is now termed a morula. In this morula for, it will start to
ravel (by 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 called a blastocyst. Fingerlike projections, called
trophoblasts (Table 4), form around the blastocyst and these trophoblasts are the
ones which will implant high on the anterior or posterior surface of the uterus. Thus,
implantation, also called nidation, takes place about a week after fertilization.
B. General Considerations
1. Once implantation has taken place, the uterine endothelium is now termed
decidua.
2. Occasionally, a small amount of vaginal spotting appears with implantation
because capillaries are ruptured by the implanting trophoblasts = implantation
bleeding. Implication: this should not be mistaken for the Last Menstrual Period
(LMP)

3. STAGES OF HUMAN PRENATAL DEVELOPMENT

A. First 12-14 days = zygote
B. From 15th day up to the 8th week = embryo
C. From 8th week up to the time of birth = fetus

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Outline of Trophoblast Differentiation
I. Cytotrophoblast – the inner layer.
II. Syncytiotrophoblast – the outer layer containing fingerlike projections called
chorionic villi, which differentiate into:
A. Langhan’s layer – believed to protect the fetus against
Treponema Pallidum (etiologic agent of syphilis). Present only
during the second trimester of pregnancy.
B. Syncytial layer – gives rise to the fetal membranes:

1. Amnion – inner membrane which gives rise to

1.1 Umbilical cord/funis – contains two arteries and one vein, which are supported by the
Wharton’s jelly.
1.2 Amniotic fluid
 Clear, albuminous fluid in which the baby floats.
 Begins to form at 11-15 weeks gestation.
 Approximates water in specific gravity (1.007-1.025) and is neutral to slightly
alkaline (pH = 7.0-7.25). Note: the higher the pH, the more alkaline; the
lower the pH, the more acidic
 Near term is clear, colorless, containing little white specks of vernix caseosa and
other solid particles.
 Produced at a rate of 500 ml in 24 hours and fetus swallows it at an equally rapid
rate. By the 4th lunar month, urine is added to the amount of amniotic fluid.
Amniotic fluid, therefore, is derived chiefly from maternal serum and fetal urine.
NCM 107
LECTURE 7
 Implication: a case of polyhydramnios )=more than 1500 ml of amniotic fluid)
stems from the inability of the fetus to swallow amniotic rapidly, as in
tracheoesophageal fistula; while oligohydramnios )=amniotic fluid less than 500
ml) is due to the inability of the kidneys to add urine to the amniotic fluid, as in
congenital renal anomaly.
 Also known as bag of water (BOW), it serves the following purposes:
 Protestion – shields the fetus against blows or pressures on the mother’s
abdomen; against sudden changes in temperature because liquid
changes temperature more slowly than air; and from infections
 Diagnosis – as in amniocentesis; meconium-stained amniotic fluid
means fetal distress
 Aids in descent of the fetus during active labor
Diagnostic Tests for Amniotic Fluid
A. Amniocentesis empty bladder before performing the procedure.
Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the
amniotic sac; fluid is tested for:
1. Genetic screening- maternal serum alpha feto-protein test (MSAFP) – 1st trimester
2. Determination of fetal maturity primarily by evaluating factors indicative of lung
maturity – 3rd trimester

2. Chorion – together with the deciduas basalis, gives rise to the placenta, which starts to

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form at 8th week gestation. Develops into 15-20 subdivisions call cotyledons. Placenta
serves the following purposes:
2.1 Respiratory system – exchange of gases takes place in the placenta, not in the
fetal lungs
2.2 Renal system – waste products are being excreted through the placenta
(Note: it is the mother’s liver which detoxifies the fetal waste products).
2.3 Gastrointestinal system – nutrients pass to the fetus via the placenta by diffusion
through the placental tissues
2.4 Circulatory system – feto-placental circulation is established by selective osmosis
2.5 Endocrine system – it produces the following important hormones (before 8 weeks
gestation, the corpus luteum is the one producing these hormones):
 Human chorionic gonadotropin (HCG) “orders” the corpus luteum to keep on
producing estrogen and progesterone, that is why menstruation does not take
place during pregnancy.
 Human placental lactogen (HPL) or human chorionic somatomammotropin –
promotes growth of mammary glands necessary for lactation. Also has growth-
stimulating properties.
 Estrogen and Progesterone
2.6 Protective barrier – inhibits the passage of same bacteria and large
molecules

NCM 107
LECTURE 8
 VI. Fetal Circulation
A. Umbilical cord
1. It contains 2 arteries and 1 vein.
2. The arteries carry deoxygenated blood and waste products from the fetus.
3. The vein carries oxygenated blood and provides oxygen and nutrients to the fetus.

B. Fetal heart rate (FHR)

1. FHR depends on gestational age; FHR is 160 to 170 beats/minute in the first
trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term.
2. FHR is about twice the maternal heart rate.

C. Fetal circulation bypass (Fig. 24-1)

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 Fetal circulation. Three shunts (ductus venosus, ductus arteriosus, and foramen ovale)
allow most blood from the placenta to bypass the fetal lungs and liver
1. Fetal circulation bypass is present because of nonfunctioning lungs.

NCM 107
LECTURE 9
2. Bypasses must close after birth to allow blood to flow through the lungs and the liver.
3. The ductus arteriosus connects the pulmonary artery to the aorta, bypassing the lungs.
4. The ductus venosus connects the umbilical vein and the inferior vena cava, bypassing the
liver.
5. The foramen ovale is the opening between the right and left atria of the heart, bypassing the
lungs.

IV. FETAL DEVELOPMENT

A. First Lunar Month

1. Germ layers differentiat by the 2nd week: (in cases of multiple congenital anomalies, the
structures that will be affected are those that arise out of the same germ layer).
1.1 Entoderm – develops into the lining of the GIT, the respiratory tract, tonsils, thyroid
(for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for
development of immunity), bladder and urethra
1.2 Mesoderm – forms into the supporting structures of the body (connective tissues,
cartilagem muscles and tendons); heart, circulatory system, blood cells,
reproductive system, kidneys and ureters
1.3 Ectoderm – responsible for the formation of the nervous system, the skin, hair and

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nails, and the mucous membrane of the anus and mouth.
2. Fetal membranes (amnion and chorion) appear by the second week.
3. Nervous system very rapidly develops by the 3rd week. (Dizziness is said to be the
earliest sign of pregnancy because as the fetal brain rapidly develops, glucose stores of
the mother are depleted, thus causing hypoglycemia in the latter).
4. Fetal heart begins to form as early as the 16th day of life. (To the question, “When does
the fetal heart begin to beat?”, the answer is first lunar month. But to the question,
“When can fetal heart tones to first heard?” the answer is fifth month.)
5. The digestive and respiratory tracts exist as a single tube until the 3rd week of life when
thwhen they start to separate.
1st month - Brain & heart development
GIT& resp Tract – remains as single tube
1. Fetal heart tone begins – heart is the oldest part of the body
2. CNS develops – dizziness of mom due to hypoglycemic effect
Food of brain – glucose complex CHO – pregnant womans food (potato)

B. Second Lunar Month

1. All vital organs are formed by the 8th week; placenta develops fully
2. Sex organs (ovaries and testes) are formed by the 8th week. (To the question, “When
is sex determined?” the answer is “At the time f conception”).
3. Meconium (first stools) are formed in the instestines by the 5th – 8th week.

NCM 107
LECTURE 10
 4. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd
month

C. Third Lunar Month

1. Kidneys are able to function – urine is formed by the 12th week.
2. Buds of milk teeth form
3. Beginning bone ossification
4. fetus swallows amniotic fluid
5. Feto-placental circulation is established by selective osmosis; no direct exchange
between fetal and maternal blood.
6. Fetal heart tone heard – Doppler – 10 – 12 weeks
7. Sex is distinguishable

Second Trimester: FOCUS – length of fetus

D. Fourth Lunar Month

1. Lanugo appears
2. Buds of permanent teeth form
3. Heart beats maybe audible with fetoscope-18 – 20 weeks

E. Fifth Lunar Month

1. Vernix caseosa appears

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2. Lanugo covers entire body
3. Quickening (fetal movements) felt-1st fetal movement. 18- 20 weeks primi, 16- 18 wks –
multi
4. Fetal heart beats very audible
5. actively swallows amniotic fluid
6. 19 – 25 cm fetus,

F. Sixth Lunar Month

1. Skin markedly wrinkled
2. Attains proportions of fullterm baby
3. eyelids open
4. vernix caseosa present

Third trimester: Period of most rapid growth. FOCUS: weight of fetus

G. Seventh Lunar Month – alveoli begin to form (28th weeks of gestation is said to be the
lower limit of prematurity because if baby is delivered at this time, will cry and breathe
but usually dies)
– development of surfactant – lecithin

H. Eighth Lunar Month

NCM 107
LECTURE 11
 1. Fetus is viable
2. Lanugo begins to disappear
3. Nails extend to ends of fingers
4. Subcutaneous fat deposition begins

I. Ninth Lunar Month

1. Lanugo and vernix disappear
2. Amniotic fluid volume somewhat decreases

J. Tenth Lunar Month – all characteristics of the normal newborn.

- bone ossification of fetal skull

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Fetal Development
In WEEKS
Preembryonic Period Week 1
 First 2 weeks after conception  Blastocyst is free-floating.
Embryonic Period Weeks 2 to 3
 Beginning day 15 through  Embryo is 1.5 to 2 mm in length.
approximately week 8 after  Lung buds appear.
conception  Blood circulation begins.
Fetal Period  Heart is tubular and begins to beat.
 Week 9 after conception to birth
NCM 107
LECTURE 12
  Neural plate becomes brain and
spinal cord.
Week 5
 Embryo is 0.4 to 0.5 cm in length.
 Embryo is 0.4 g.
 Double heart chambers are visible.
 Heart is beating.
 Limb buds form.
Week 8
 Embryo is 3 cm in length.
 Embryo is 2 g.
 Eyelids begin to fuse.
 Circulatory system through umbilical
cord is well established.
 Every organ system is present.
Week 12
 Fetus is 6 to 9 cm in length.
 Fetus is 19 g.
 Face is well formed.
 Limbs are long and slender.
 Kidneys begin to form urine.
 Spontaneous movements occur.
 Heartbeat is detected by Doppler
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transducer between 10 and 12
weeks.
 Sex of fetus is visually recognizable.
Week 16
 Fetus is 11.5 to 13.5 cm in length.
 Fetus is 100 g.
 Active movements are present.
 Fetal skin is transparent.
 Lanugo hair begins to develop.
 Skeletal ossification occurs.
Week 20
 Fetus is 16 to 18.5 cm in length.
 Fetus is 300 g.
 Lanugo covers the entire body.
 Fetus has nails.
 Muscles are developed.
 Enamel and dentin are depositing.
 Heartbeat is detected by regular
(nonelectronic) fetoscope.
Week 24
 Fetus is 23 cm in length.
 Fetus is 600 g.
 Hair on head is well formed.
 Skin is reddish and wrinkled.
 Reflex hand grasp functions are
present.
 Vernix caseosa covers entire body.
 Fetus has ability to hear.
Week 28
 Fetus is 27 cm in length.
 Fetus is 1100 g.
 Limbs are well flexed.
 Brain is developing rapidly.
 Eyelids open and close.
 Lungs are developed sufficiently to
provide gas exchange (lecithin
forming).
 If born, neonate can breathe at this
time.
Week 32
 Fetus is 31 cm in length.
 Fetus is 1800 to 2100 g.
 Bones are fully developed.
 Subcutaneous fat has collected.
 Lecithin-to-sphingomyelin (L/ S) ratio
is 1.2:1.
Week 36
 Fetus is 35 cm in length.
 Fetus is 2200 to 2900 g.
 Skin is pink and body is rounded.
 Skin is less wrinkled.
 Lanugo is disappearing.
 L/ S ratio is greater than 2:1.

NCM 107
LECTURE 13
  Lanugo is present on upper arms and shoulders.
 Vernix caseosa decreases.

Week 40
 Fetus is 40 cm in length.
 Fetus is more than 3200 g.
 Skin is pinkish and smooth.
 Fingernails extend beyond fingertips.
 Sole (plantar) creases run down to the heel.
 Testes are in the scrotum.
 Labia majora are well developed.

V. FOCUS OF FETAL DEVELOPMENT

A. First trimester – period of organogenesis

B. Second trimester – period of continued fetal growth and development; rapid increase in fetal
length
C. Third trimester – period of most rapid growth and development because of rapid deposition of
subcutaneous fat

Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A.Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing &
deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter

VICENCIOUS
Thalidomides – Amelia or pocomelia, absence of extremities

Steroids – cleft lip or palate

Lithium – congenital malformation
B.Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by
microcephaly
C.Smoking – low birth rate
D.Caffeine – low birth rate
E.Cocaine – low birth rate, abruption placenta

TORCH (Terratogenic) Infections – viruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend
through birth canal and adversely affect fetal growth and development. These infections are often
characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice
(hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have
devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes
simples virus.

T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat
O – others. Hepa A or infectious heap – oral/ fecal (hand washing)
Hepa B, HIV – blood & body fluids
Syphilis
R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10
<1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get
pregnant for 3 months. Vaccine is terratogenic
C – cytomegalo virus
H – herpes simplex virus

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LECTURE 14
VI. NORMAL ADAPTATIONS IN PREGNANCY
A. Systemic Changes
1. Circulatory/Cardiovascular
A. Beginning the end of the first trimester there is a gradual increase of about 30% - 50% in
the total cardiac volume, reaching its peak during the 6th month. This causes a drop in
hemoglobin and hematocrit values since the increase is only in the plasma volume =
physiologic anemia of pregnancy. Consequences of increased total cardiac volume are:
 Easily fatigability and shortness of breath because of increased workload of the
heart
 Slight hypertrophy of the heart, causing it to be displaced to the left, resulting in
torsion on the great vessels (the aorta and pulmonary artery).
 Systolic murmurs are common due to lowered blood viscosity
 Nosebleeds may occur because of marked congestion of the nasopharynx as
pregnancy progresses.
 Physiologic Anemia – pseudo anemia of pregnant women
 Normal Values
o Hct 32 – 42%
o Hgb 10.5 – 14g/dL
 Criteria
o 1st and 3rd trimester.- pathologic anemia if lower
o HCT should not be 33%, Hgb should not be < 11g/dL

o 2nd trimester – Hct should not <32%

Hgb Shdn't < 10.5% pathologic anemia if lower
 Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It affects
toughly 20% of pregnant women.
- Assessment reveals:
•
•
•
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Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to chronic physio
hypoxia
 Nursing Care:
•Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable-
alugbati,saluyot, malunggay, horseradish, ampalaya
•Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered,
hematoma.
•Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before
meals or 2 hrs after, black stool, constipation
•Monitor for hemorrhage
 Alert:
•Iron from red meats is better absorbed iron form other sources
•Iron is better absorbed when taken with foods high in Vit C such as orange juice
•Higher iron intake is recommended since circulating blood volume is increased and
heme is required from production of RBCs

B. Palpitations are due to:

 Sympathetic nervous system stimulation during the first half of pregnancy
 Increased pressure of uterus against the diaphragm during second hald of
pregnancy
C. 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 due venous return is constricted due to large
belly, elevate legs above hip level..
 Management legs above hip level. Important: Edema of the lower extremities is
normal during pregnancy; it is not a sign of toxemia
 Varicosities of the lower extremities can also occur. Management:

NCM 107
LECTURE 15
  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 toes
so as to be able to determine adequacy of circulation (Principle behind bandaging:
blod flow through tissues is decreased by applying excessive pressure on blood
vessels)
 Avoid use of constricting garters, e.g., knee-high socks
 Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position – side lying with
pillow under hips or modified knee chest position
 Thrombophlebitis – presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate
> outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion
milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia
albadolens

Mgt:
a. Bed rest
b. Never massage
c. Assess + Homan sign once only might dislodge thrombus
d. Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
e. Monitor APTT antidote for Heparin toxicity, protamine sulfate
f. Avoid aspirin! Might aggravate bleeding.

2.Respiratory system – common problem SOB due to enlarged uterus & increase O2 demand
Position- lateral expansion of lungs or side lying position

VICENCIOUS
A. Because of poor circulation in the blood vessels of the genitalia due to the pressure of the gravid
uterus, varicosities of the vulva and rectum can occur. Management: side-lying position with hips
elevated on pillow and modified knee-chest position.
B. There is increased level of circulating fibrogen, that is why pregnant women are normally
safeguarded against undue bleeding. However, this also predisposes them to formation of blood
clots (thrombi). The implication is that pregnant women should not be massaged since blood
clots can be released and cause thromboembolism.

2. Gastrointestinal changes
A. Morning sickness – nausea and vomiting during the first trimester is due to increased human
chorionic gonadotropin (HCG). It may also be due to increased acidity or even to emotional
factors. Management: Eat dry toast or crackers 30 minutes before arising in the morning (or
dry, high carbohydrate, low fat and low spices in the diet).
 Nausea afternoon - small freq feeding. Vomiting in preg – emesisgravida.
 Metabolic alkalosis, F&E imbalance – primary med mgt – replace fluids.
 Monitor I&O
B. Hyperemesis gravidarum = excessive nausea and vomiting which persists beyond 3 months;
results in dehydration, starvation and acidosis.
 Management: D10NSS 300 ml in 24 hours is the priority treatment; complete bed rest is
also important.
C. Constipation and flatulence are due to displacement of the stomach and intestines, thus slowing
peristalsis and gastric emptying time. May also be due to increased progesterone during
pregnancy. Management:
 Increase fluids and roughage in the diet
 Establish regular elimination time
 Increase exercise
 Avoid enemas
 Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are better
 Mineral oil should not be taken because it interferes with absorption of fat-
soluble vitamins.
NCM 107
LECTURE 16
  - fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin,
suha.
Except guava – has pectin that’s constipating – veg – petchy, malungay.
- exercise
 -mineral oil – excretion of fat soluble vitamins

D. Hemorrhoids are due to pressure of enlarged uterus. Management: cold compress with witch
hazel or Epsom salts. >hot sitz bath for comfort
E. Heartburn or pyrosis, especially during the last trimester, is due to increased progesterone
which decreases gastric motility, thereby causing reverse peristaltic waves which lead to
regurgitation of stomach contents through the cardiac sphincter into the esophagus, causing
irritation. Management:
 Pats or butter before meals
 Avoid fried, fatty foods
 Sips of milk at frequent intervals
 Small, frequent meals taken slowly
 Bend at the knees, not at the waist
 Take antacids (e.g. milk of Magnesia) but never sodium bicarbonate (e.g. Alka
Seltzer or baking soda) because it promotes fluid retention.

3. Respiratory changes – shortness of breath

a. Causes
 Increased oxygen consumption and production of carbon dioxide during the first
trimester.
 Increased uterine size causes diaphragm to be pushed or displaced, thus
crowding the chest cavity.
b. Management: Lateral expansion of the chest to compensate for shortness of breath
increases oxygen supply and vital lung capacity.
4. Urinary changes

VICENCIOUS
A. Urinary frequency, the only sign in pregnancy seen during the first trimester disappears
during the second and reappears during the third trimester. Early in pregnancy is due to
increased blood supply to the kidneys and to the uterus rising out of the pelvic cavity; in
the last trimester is due to pressure of enlarged uterus on the bladder, especially with
lightning (descent of the fetus into the pelvic brim).
B. Decreased renal threshold for sugar due to increased production of glucocorticoids which
cause lactose and dextrose to spill into the urine; also an effect of the increased
progesterone. (implication: it would be difficult to diagnose diabetes in pregnancy based on
the urine sample alone because a pregnant women have sugar in their urine.)
C. Acetyace test – albumin in urine
D. Benedicts test – sugar in urine
5. Muscoloskeletal changes
 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”)
 Due to increased production of the hormone relaxin, pelvic bones become more supple and
movable, increasing the incidence of accidental falls due to the wobbly gait. Implication:
Advise use of low-heeled shoes after the first trimester
 Leg cramps (pressure of gravid uterus )
 Causes
 Increased pressure of gravid uterus on lower extremities
 Fatigue
 Chills
 Muscle tenseness
 Low calcium, high phosphorus intake
 Management
 : Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4
servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones,
brocolli, seafood-tahong (mussels), lobster, crab.
 Vit D for increased Ca absorption
NCM 107
LECTURE 17
  Frequent rest periods with feet elevated
 Wear warm, more confortable clothing
 Increase calcium intake (calcium tablets and diet)
 Do not massage – blood clots can cause embolism.
 Most effective treatment: Press knee of the affected leg and dorsiflex the
foot.

 Waddling Gait – awkward walking due to relaxation – causes softening of joints & bones
 Prone to accidental falls – wear low heeled shoes
6. Temperature – slight increase in basal temperature due to increased progesterone, but the body
adapts after the 4th month
7. Endocrine changes
A. Addition of the placenta as an endocrine organ, producing large amounts of HCG, HPL,
estrogen and progesterone.
B. Moderate enlargement of the thyroid gland due to hyperplasia of the glandular tissues and
increased vascularity. Could also be due to increased basal metabolic rate to as much as
+25% because of the metabolic activity of the products of conception.
C. Increased size of the parathyroid, probably to satisfy the increased need of the fetus for
calcium.
D. Increased size and activity of the adrenal cortex, thus increasing the amount of circulating
cortiso,, aldosterone and ADH, all of which affect carbohydrate and fat metabolism,
causing hyperglycemia.
E. Gradual increase in insulin production but the body’s sensitivity to insulin is decreased
during pregnancy.
8. Weight (Table 5)
 During the first trimester, weight gain of 1.5-3 lbs is normal
 On 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is recommended.
 Total allowable weight gain during entire period of pregnancy, therefore, is 20-25 pounds (10-12
kgs).

VICENCIOUS
 Pattern of weight gain is more important than the amount of weight gained.

Distribution of Weight Gain During Pregnancy

Fetus 7lbs.
Placenta 1 lb.
Amniotic fluid 1 ½ lbs.
Increased weight of uterus 2 lbs.
Increased weight of the breasts 1/1 – 3 lbs.
Weight of additional fluid
9. Emotional responses 2 lbs.
Fat and fluid
A. First trimester. Theaccumulation 4-6great
fetus is an unidentified concept with lbs. future implications but
without tangible
Ch evidence
i i fof reality. Some degree of rejection, disbelief, even depression.
(Implication: when giving health teachings, emphasize the bodily changes in pregnancy).
B. Second trimester: fetus is perceived as a separate entity. Fantasizes appearance of the
baby.
C. Third trimester: has personal identification with a real baby about to be born and realistic
plans for future childcare responsibilities. Best time to talk about layette and infant feeding
method. Fear of death, though is prominent (To allay fears, let pregnant woman listen to
the fetal heart sounds.)

B. Local Changes (Table 6)

1. Uterus
A. Weight increases to about 1000 grams at full tern; due to increase in the amount of fibrous
and elastic tissues.
B. Change in shape from pear-like to ovoid; enormous change in consistency of lower uterine
segment causes extreme softening, known as Hegar’s sign, seen at about the 6th week
C. Mucous plugs in the cervix, called operculum, are produced to seal out bacteria.
D. Cervix becomes more vascular and edematous, resembling the consistency of an earlobe,
known as Goodell’s sign.

NCM 107
LECTURE 18
2. Vagina
A. Increased vascularity causes change in color from light pink to deep purple or violet known
as Chadwick’s sign.
 To prevent confusion as to pregnancy signs, arrange the body parts from “out to in” and
the different signs alphabetically. Thus:
 Vagina – Chadwick’s sign- blue violet discoloration of vagina
 Cervix – Goodell’s sign- change of consistency of cervix
 Uterus – Hegar’s sign- change of consistency of isthmus (lower uterine segment)
 Due to increased estrogen, activity of the epithelial cell increases, thus increasing
amount of vaginal discharges called leucorrhea. As long as the discharges are not
excessive, green/yellow in color, foul-smelling or irritatingly itchy, it is normal.
Management: maintain or increase cleanliness by taking twice daily shower baths using
cool water.
 The pH of the vagina changes from normally acidic (because of the presence of
Dederlein bacillie) to alkaline (because of increased estrogen). Alkaline vaginal
environment is supposed to protect against bacterial infection; however, there are two
microorganisms which thrive in an alkaline environment.
 VAGINITIS- Trichomonas, a protozoa or flagellate. The condition is called trichomonas
vaginalis or trichomonas vaginitis or trichomoniasis.
 Signs and symptoms of Trichomoniasis
 Frothy, cream-colored, irritatingly itchy, foul-smelling discharges
 Vulvar edema and hyperemia due to irritation from the discharges
 Management
 Flagyl for 10 days p.o. or vaginal suppositories of trichomonicidal
compounds. (e.g., Tricofuron, Vagisec or Devegan).
o Is carcinogenic during the first trimester
o Treat male partner also with Flagyl.
o Avoid alcoholic drinks when taking Flagyl – can cause Antabuse –
like reactions: vomiting, flushed face and abdominal cramps.

VICENCIOUS
o Dark brown urine a minor side effect – no need to discontinue the
drug.
 Acidic vaginal douche (1 tbsp. white vinegar in 1 quart of water or 15 ml.
white vinegar in 1000 ml. of water) to counteract alkaline – preferred
environment of the protozoa.
 Avoid intercourse to prevent reinfection

 Candida albicans, a fungus or yeast. The condition is called Moniliasis or Candidiasis.

Fungus also thrives in an environment rich in carbohydrates (that is why it is common
among poorly-controlled diabetics) and in those on steroid or antibiotic therapy when
acidic environment is altered. Moniliasis is seen as oral thrush in the newborn when
transmitted during delivery through the birth canal of the infected mother.
 Symptoms
 White, patchy, cheese-like particles that adhere to vaginal walls
 Irritatingly itchy and foul-smelling vaginal discharges
 Management
 Mycostatin/Nystatin p.o. or vaginal suppositories/peccaries (100,000 U)
twice a day for 15 days
 Gentian violet swab to vagina (use panty shields to prevent staining of
clothes or underwear)
 Correct diabetes
 Avoid intercourse
 Acidic vaginal douche

3. Abdominal Wall
 Striae gravidarum – increase uterine size results in rupture and atrophy of connective
tissue layers, seen as pink or reddish streaks (gently rubbing oil on the skin helps prevent
diastasis)
 Umbilicus pushed out

NCM 107
LECTURE 19
 4. Skin
 Linea nigra – brown line running from umbilicus to symphais pubis
 Melasma or chloasma – extra pigmentation on cheeks and across the nose due to
increased production of melanocytes by the pituitary gland
 Sweat glands unduly activated

5. Breasts – all changes due to increased estrogen

 Increase in size due to hyperplasia of mammary alveoli and fat deposits. Proper breast
support with well-fitting brassiere necessary to prevent sagging
 Feeling of fullness and tingling sensation in the breasts
 Nipples more erect. For mothers who intend to breastfeed, advise:
 Nipple rolling
 Drying nipples with rough towel to help toughen the nipples.
 Not to use soap or alcohol as this can cause drying which could lead to sore nipples.
 Montgomery glands become bigger and more protruberant
 Areola becomes darker and diameter increases
 Skin surrounding areolae turns dark
 By the fourth month, a thin, watery, high protein fluid, called colostrums, is formed. It is the
precursor of breast milk.

6. Ovaries – no activity whatsoever since ovulation does not take place during pregnancy.
Progesterone and estrogen are being produced by the placenta.

Signs & symptoms of Pregnancy

A. Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of
pregnancy . Subjective

VICENCIOUS
B. Probable – signs observed by the members of health team. Objective

C.Positive Signs – undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma
* + HCG – sign of H mole
- trans vaginal ultrasound. Empty bladder
- ultrasound – full bladder

Stage Presumptive Probable Positive

First Amenorrhea Goodel's- change of consistency of Ultrasound evidence
Trimester Morning sickness cervix
Breast changes Chadwick’s- blue violet discoloration
Urinary frequency of vagina
Enlarging uterus Hegar's- change of consistency of
Fatigue isthmus
Elevated BBT – due to increased
progesterone
Positive HCG or (+)preg test
Second  Quickening Enlarged abdomen Fetal heart tones
Trimester  Skin Braxton Hicks– painless irregular Fetal movements
pigmentation contractions felt by examiner
(chloasma and Ballotement– bouncing of fetus when Fetal outline on x-
linea nigra) lower uterine is tapped sharply ray
 Striae
gravidarum

C. Psychological Adaptation to Pregnancy

(Emotional response of mom –Reva Rubin theory)
NCM 107
LECTURE 20
First Trimester: No tanginal signs & sx, surprise, ambivalence, denial – sign of maladaptation to
pregnancy.
 Developmental task is to accept biological facts of pregnancy
 Focus: bodily changes of pregnancy, nutrition

Second Trimester – tangible S&Sx. mom identifies fetus as a separate entity – due to presence of
quickening, fantasy. Developmental task – accept growing fetus as baby to be nurtured.
 Health teaching: growth & development of fetus.

Third Trimester: - mom has personal identification on appearance of baby

 Development task: prepare of birth & parenting of child. HT: responsible parenthood
‘baby’s Layette” – best time to do shopping.
 Most common fear – let mom listen to FHT to allay fear
 Lamaze classes

Sources:
Saunders Comprehensive Review, 7th Edition, 2017
https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo#:~:text=Pregnancy%20is%20the%20ter
m%20used,segments%20of%20pregnancy%2C%20called%20trimesters.
Internet sources

VICENCIOUS

NCM 107
LECTURE 21