REFRESHER: OBSTETRICS

LECTURER: PROFESSOR KENNETH ARZADON

ANATOMY AND PHYSIOLOGY ● Ends during ovulation

SECOND PHASE: LUTEAL / PROGESTATIONAL /

OVARY –– produces estrogen and progesterone in
SECRETORY PHASE
NON-pregnant women
● If there will be pregnancy, the cycle will stop.
- Releases ovum during ovulation.
● If there is no pregnancy, the level of progesterone
decreases.
GRAAFIAN FOLLICLES –– contains the ovum, follicular fluid
- Once it ruptures, it will result in ovulation.
THIRD PHASE: ISCHEMIC
- Once all of the graafian follicles are consumed, it will
● Decreased progesterone and estrogen
result in menopause.
○ Shedding or sloughing of the endometrium

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→ menstrual bleeding
AMPULLA –– site of fertilization.
○ Estrogen will send a signal again to the
hypothalamus → another cycle.
UTERINE ENDOMETRIUM –– site of implantation.
FOURTH PHASE: MENSTRUAL BLEEDING
MENSTRUAL CYCLE ● First day of menstrual bleeding marks the first day of
the menstrual cycle.
● Onset of menarche: 9-17 years old ● Happens after 14 days (constant)
● Interval of menses: 23-35 days
● Duration of bleeding: 2-9 days DATE OF LAST MENSTRUAL BLEEDING
●

●
Amount for the whole duration: 30-80 mL (⅓ of A
cup)
Odor: Marigold

PHYSIOLOGY
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Decrease levels of estrogen will stimulate the hypothalamus
-
1.

2.
Example: July 10 – July 16 (32 day cycle)
First day of the next menstrual cycle: August 11
a. Always start the first day on the last day of
the last menstrual period = July 10 to August
10.
Day of ovulation: 18th day of the cycle
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and it will signal the APG to produce the: a. 32 – 14 = 18th day of the cycle
● FSH → 3. Date of ovulation: July 27
○ Increases the level of estrogen, which 4. Fertile period: July 23 to 31
thickens the lining of endometrium in a. 3 to 4 days before and after ovulation.
preparation of pregnancy.
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○ Increases production of follicular fluid, which - Example: October 5 – October 9 (34 day cycle)
prompts rupture of graafian follicle, starting 1. First day of the next menstrual cycle: November 8
ovulation. 2. Day of ovulation: 34 – 14 = 20th day
○ Production of FSH stops, when there is 3. Date of ovulation: October 24
ovulation 4. Fertile period: October 20 to 28
A

● LH (LH peaks a day before ovulation) →

○ Causes the ripening of graafian follicle
○ Formation of corpus luteum, which produces
progesterone––hormone for pregnancy, that
maintains the thickness of the endometrium.
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IF YOU ARE HAVING MENSTRUAL BLEED
EVERY MONTH, DOES IT MEAN YOU ARE
REGULAR?

If there is no fertilization, there will be no pregnancy, ovum will No, because your cycle may vary. You are only considered
be atrophied, and corpus luteum will remain for 10 days. regular if you have a constant cycle (E.g. 28-day cycle every
month).
If there is fertilization, there will be pregnancy, and corpus
luteum will remain for 16 weeks. - Example (irregular): keep a diary of 6 previous cycle
● After 16 weeks, the placenta will takeover in the ○ Jan - Feb = 28 days
production of progesterone ○ Feb - Mar = 35 days (longest)
○ Mar - Apr = 29 days
PHASES OF MENSTRUAL CYCLE ○ Apr - May = 28 days
FIRST PHASE: FOLLICULAR / ESTROGENIC / ○ May - Jun = 27 days (shortest)
PROLIFERATIVE PHASE ○ Jun - Jul = 33 days
● Proliferation of endometrial tissues
● Determines the length of the cycle 1. First day of the next menstrual cycle: August 8
 REFRESHER: OBSTETRICS
LECTURER: PROFESSOR KENNETH ARZADON

2. Day of ovulation: unknown EMBRYO–– Period of organogenesis; 5 – 8 weeks

3. Date of ovulation: unknown
4. Fertile period: July 15 to 30
a. For fertile period, constantly subtract:
i. Shortest: 18 → 27 – 18 = 9th day
ii. Longest: 11 → 35 – 11 = 24th day
OVULATION
- 14 days before the next bleeding
- Fertile period: 3-4 days before ad after ovulation
- Estrogen: hormone for ovulation
● Focus on educating the client regarding proper
nutrition because of the need to increase the intake of
folic acid to prevent neural tube defects
○ High in folic acid:
■ Squash
■ Spinach
■ Green leafy vegetables
FETUS –– 8 week to term (37 weeks)
● Lecithin-sphingomyelin –– lung surfactant, is

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appropriate
SIGN AND SYMPTOMS OF OVULATION ○ Normal LS ratio is 2:1
● Increased body temperature –– caused by increased ■ Indicates fetal lung maturity
progesterone.
○ Initially, on the day of ovulation, the EMBRYONIC FETAL STRUCTURES
temperature will decrease but will increase Placenta –– where nutrients exchange happens,
after 24 hours for about 0.07 to 0.08 degree - Serves as fetal lungs, kidneys, and GIT
Celsius that will last for three days. ○ Lungs = oxygen
○ Kidneys = wastes
● Mittelschmerz (AKA mid cycle pain)– caused by ○ GIT = nutrients

●
○ Unilateral lower abdominal discomfort,
depending on which ovary will ovulate.IL
peritoneal irritation due to graafian follicle rupture

(+) Spinnbarkeit –– elasticity of the cervical mucus.

-

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● (+) Ferning –– palm leaf
microscope (cervical mucus).
-
There is no direct blood exchange in both fetus and
mother.
Endocrine function:
○ Estrogen and progesterone
○ Human chorionic gonadotropin –– causes
nausea and vomiting
pattern under the ■ PEAK production: 60th – 70th or
3rd month of pregnancy

● Cervical mucus –– comparable to egg whites; Umbilical Cord –– 2 arteries, 1 vein

caused by the increased level of estrogen. - 21 inches
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○ Characteristic of fertile cervical mucus:
CWETS Amniotic fluid –– protects the fetus from temperature and
■ Clear pressure changes
■ Watery - Aids in muscular development as it allows the fetus to
■ Elastic move.
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■ Thin - Ensured adequate oxygenation for the fetus

■ Slipper ○ Prevents cord compression
- Components:
STAGES OF FETAL DEVELOPMENT ○ Fetal urine
■ Fetal kidneys start forming and
excreting urine during the 12th
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OVUM → fertilization within 24 hours → once fertilized →

week of pregnancy –– earliest for
ZYGOTE → mitosis → BLASTOCYST → implantation within 1
amniocentesis
week → DECIDUA (endometrium)
- Amount:
● Decidua basalis –– base of the implanted ovum; in
○ Normal: 800 -1200 mL
contact with maternal blood vessels
○ Oligohydramnios: < 800 mL
● Decidua capsularis –– encapsulates the blastocyst
■ Fetal renal problem (fetal agenesis
● Decidua vera –– remaining portion of endometrium
→ incomplete formation of kidneys
→ no urine and low amniotic fluid)
PREGNANCY TEST: HCG ○ Polyhydramnios: > 1200mL
■ Fetal GI problem (esophageal
○ Blood specimen: 1 week atresia –– narrowing of esophagus)
○ Urine specimen: 10 days
 REFRESHER: OBSTETRICS
LECTURER: PROFESSOR KENNETH ARZADON

■ Gestational DM –– maternal
hyperglycemia; glucose attracts
water → maternal polyuria
● Glucose can pass through
placenta → fetal
hyperglycemia → fetal
polyuria → increase urine
output and amniotic fluid.
GRAVITY AND PARITY
boys at 38 weeks, and the third resulted in the live
birth of a daughter at 34 weeks
a. G4 T2 P1 A1 L3 M1
OBSTETRICAL FORMULA AND COMPUTATIONS
NAEGELE’S RULE
⇒ To estimate: estimated date of confinement
- Prerequisite: last menstrual period (always get
the first day of LMP)

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Gravity –– number of pregnancies regardless of outcome of
duration.
Month Day Year
Parity –– number of deliveries that reach the age of viability
Jan-Mar + 9 + 7
subsequently delivered; dead or alive
- Age of viability: 20 weeks Apr - Dec –3 + 7 + 1

Principle in identifying parity:

1. Multiple pregnancy – COUNTED as one Example:
2. Abortion – < 20 weeks; DO NOT count
3. Stillbirth – COUNTED

Examples
IL
1. Patient A is pregnant for the first time and carries a
twin = G1P0
2. Patient B delivered to an alive monozygotic twin =
1. July 11, 2023

ANSWER:
07

–3

4
11

+7

18
2023

+1

2024
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G1P1
3. Patient C is now pregnant. Her pregnancy 3 years 2. LMP ended October 17 lasted for 7 days
ago ended in abortion = G2P0 a. October 11 (count backwards starting
4. Patient D has delivered an alive baby girl. Her from Oct 17)
pregnancy 3 years ago ended in abortion = G2P1
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5. Patent E pregnancy 3 years ago ended in abortion. BARTHOLOMEW’S METHOD (SUX)
She aborts for the second time = G2P0
⇒ Measures the fundal height.
● Symphysis pubis: 12 weeks
GTPALM SCORING
● Umbilicus: 20 weeks
● Gravity
A

● Xiphoid process: 36 weeks

● Term –– 37 weeks and above
● Preterm –– 36 weeks and below
● Abortion –– less than 20 weeks AGE OF GESTATION
● Living
● Multiple Pregnancy From the 20th to 36th week, the fundal height in cm is
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equal to AOG in weeks.

PRETERM, TERM, AND ABORTION

SIGNS AND SYMPTOMS OF PREGNANCY

Count the number of twins as TWO for infants born, whether
preterm or term. Same goes with triplets, quadruplets or etc.
However, abortion is counted as ONE for twins or etc. PRESUMPTIVE
⇒ highly SUBJECTIVE
Example: - Can be caused by other conditions.
1. Patient X is experiencing her fourth pregnancy. Her
first pregnancy ended in a spontaneous abortion at 8 ● Amenorrhea
weeks, the second resulted in the live birth of twin ○ Conditions:
■ PCOS
 REFRESHER: OBSTETRICS
LECTURER: PROFESSOR KENNETH ARZADON

■ Hypothyroidism HEARTBURN (PYROSIS)

● Nausea and vomiting ● Manifestation: substernal chest pain
● Urinary frequency ● Elevate head of bed 3 hours after meals
● Milk in between meals
○ Conditions:
● Safe to administer antacids: NEEDS MD ORDER
■ DM
○ Tums (calcium carbonate) –– most
● Breast changes recommended because it provides additional
● Uterine enlargement calcium for the mother needed for fetal bone
● Quickening –– first movement of the baby and relieves heartburn.
○ Ranitidine
Skin discoloration ○ Omeprazole

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● Melasma / chloasma (face)
● Linea nigra (xiphoid process to symphysis pubis) CONSTIPATION
● Increase oral fluid intake
● Striae gravidarum (lower abdomen)
● High fiber diets
● Safe to give stool softeners: NEEDS MD ORDER
PROBABLE
○ Docusate sodium (colace)
⇒ OBJECTIVE signs ○ Metamucil
- Can be documented. ○ Milk of magnesia
○ Bisacodyl (dulcolax)
● Chadwick’s sign (VV)–– affects the vagina;

●
purplish-bluish discoloration

softening of cervix
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Goodell’s sign (C) –– affects the cervix;

Hegar’s sign (|_|) –– affects the uterus;

softening of lower uterus
BACKACHE
● Pelvic rocking or tilt exercises (OTSO-OTSO)
● Sleep in a flat, firm surface

LORDOSIS
● Pride of pregnancy
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● Braxton Hicks contractions –– painless
contraction relieved by walking WADDLING GAIT
● Ballottement –– rebounding of the fetus ● Duck walk
● Positive HCG (pregnancy test) ● Relaxation of pelvic joints
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POSITIVE CAUSE: INCREASE IN THE LEVEL OF ESTROGEN
⇒ CONFIRMATORY - Increase in estrogen → increases varicosities,
● Fetal heart rate–– through doppler secretion
● Fetal outline –– through UTZ - Responsible for breast enlargement
● Fetal movement –– through MD or RN
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BREAST TENDERNESS
● Wearing a supportive bra
COMMON DISCOMFORTS DURING PREGNANCY
● Avoid using soap to prevent drying

● If the complaint is normal, provide proper LEG VARICOSITIES AND PEDAL EDEMA
education on how to manage symptoms. No ● Elevate the legs.
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need to refer to a physician. ● Anti-embolic stockings compresses the nerves and

push the
CAUSE: INCREASE IN HCG “RELAXING EFFECT” ● Avoid prolonged sitting and standing.
● Avoid crossing the legs.
NAUSEA AND VOMITING
● Dry crackers / carbohydrates
HEMORRHOIDS
● Small frequent feedings
● Knee Chest position.
● Avoid fried, fatty, and spicy foods
● Modified sim’s position (side-lying with pillow under
● Fluid in between meals
buttocks)
● Let the nausea pass before eating
● Cold/Ice Compress for severe pain or bleeding
● Acupressure –– apply pressure on the Neiguan point;
● Warm sitz bath to promote comfort
3 inches below the wrist.
○ Hot is contraindicated as it causes massive
vasodilation → decreased blood supply to
 REFRESHER: OBSTETRICS
LECTURER: PROFESSOR KENNETH ARZADON

placenta → decreased placental perfusion → PHYSIOLOGIC CHANGES DURING PREGNANCY

decreased fetal oxygen → uteroplacental
insufficiency
⇒ Normal changes
○ The temperature of the water should not be
more than 40 degrees Celsius.
To support the growing fetus:
○ Should not be done for > 20 minutes.
● ↑ Blood volume
LEUKORRHEA ○ Increased BV → increased plasma →
● Whitish non-foul vaginal discharge. Pseudo-anemia
● Use cotton underpants / perineal pads ● ↑ Cardiac output
● Contraindicated: ● ↑Heart rate

○ Tub bath because contaminated water may
go inside the vagina causing infection
○ Vaginal douching
○ Tampons
LEG CRAMPS
● Due to decrease Ca = increase pH
● Increase Ca in the diet.
○ RDA: 1,200 mg/day = 4 glasses of milk/day
● Dorsiflexion of the foot to stretch the muscle.
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To prevent bleeding and infection:
● ↑ Platelets and WBC
Sources of energy:
● ↑ Lipids and serum cholesterol
The pregnant woman’s kidney eliminates the fetal waste:
● ↑ GFR and creatinine clearance
● ↑ Urine output

URINARY FREQUENCY
● Common only in 1st and 3rd trimester. IL
○ Uterus is still low during 1st trimester
Compression of the bladder.
○ Uncommon: uterus elevates and becomes
● ↓ BUN and plasma creatinine (Measurement of waste
product in the blood)

To prevent infection:
● ↓ Vaginal pH to maintain acidity (3.8 to 4.5)
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part of abdominal cavity relieving the To prevent fetal rejection:
compression of the bladder → less urinary ● ↓ IgG
frequency ○ Only antibody that could pass through the
■ If there is still urinary frequency, placenta
SUSPECT GDM. ○ Pregnant women are considered
immunocompromised.
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● Increase fluid intake.
● Wipe perineum front to back.
To increase O2:
SUPINE HYPOTENSIVE SYNDROME ● Mild hyperventilation
● Cause: vena cava compression.
● Inferior vena cava is located on the right side of the NUTRITION IN PREGNANCY
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body.
● Manifestation: ● ↓ Fats: Difficult to ingest.
○ Dizziness while lying supine because of ● ↑ Proteins: For fetal and placental development.
decreased O2 going to the brain ● ↑ Carbohydrate (1st trimester) –– glucose is needed
○ Decreased BP
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for fetal brain development.

○ Increased PR ● ↓ Carbohydrate (2nd and 3rd trimester) –– increased
● Management: Left side lying position to relieve human placental lactogen → ↓ insulin to prevent
compression. hyperglycemia

ROUND LIGAMENT PAIN

NORMAL WEIGHT GAIN IN PREGNANCY
● Stabbing or jabbing pain in the lower abdomen
aggravated by movement because of the stretching of ⇒ Weight is the best index of health.
round ligament - Normal BMI: 18.5 to 24.9 (+ 1 if pregnant)
● Management:
○ Flex the hips 1st trimester 1lb/month = 3lbs.
○ Let the patient sit
○ Use warm compress 2nd trimester 1lb/week = 12lbs.
 REFRESHER: OBSTETRICS
LECTURER: PROFESSOR KENNETH ARZADON

○ Naming the baby.

3rd trimester 1lb/week = 12lbs.
○ Preparing the room of the baby.
○ Buying stuffs for the baby.
Total: 27 lbs during pregnancy.
Normal weight gain: 25 to 35lbs.
OBSTETRICAL PROCEDURES

LEOPOLD’S MANEUVER
- Client instruction: Empty the bladder.
- Client Position: Supine position/dorsal recumbent.
- Nursing Considerations: Use the PALMS (Rub and

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Warm)
- Position of the nurse:
○ Left-handed (Nurse): Left side of the woman.
○ Right-handed (Nurse): Right side of the
woman.

First Maneuver: Fundal Grip

● Hard, Round and Smooth (fetal head) – Breech
presentation
● Soft and Glandular (fetal buttocks) – Cephalic

ALCOHOL AND SMOKING

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There is no known amount of alcohol use during pregnancy
presentation

Second Maneuver: Umbilical Grip

● Hard and Smooth (fetal back)
○ The location of the fetal back is also the
location where you will monitor the FHR.
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● Irregular and Bony (fetal extremities)
or while trying to get pregnant. All types of alcohol are
equally harmful including all wines and beer → Fetal Third Maneuver: Pawlik’s Grip
Alcoholic Syndrome ● Movable (not engaged)
● Not movable (engaged)
Pregnancy and Smoking: Cigarette contains nicotine →
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vasoconstriction → decreased nutrient exchange → Small Fourth Maneuver: Pelvic Grip
for gestational age (Low birth weight) ● Degree of Flexion
● Fetal neck – Fetal attitude (Good: Acutely flex)
PSYCHOLOGICAL CHANGES IN PREGNANCY
FETAL MOVEMENT COUNT
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- Best done starting on the 28th week of pregnancy

FIRST TRIMESTER: ACCEPTING THE PREGNANCY
- NORMAL fetal movement count:
- Anxiety ○ SANDOVSKY Method: 10-12 movement per
- Ambivalence –– 2 opposing feelings hour.
- Couvade syndrome –– husband experience signs ○ CARDIFF Method: 10 movements in 12
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and symptoms hours.

- Cause: anxiety, hormonal, attachment to baby.
SANDOVSKY METHOD
SECOND TRIMESTER: ACCEPTING THE BABY - Performed early in the morning because the woman is
- Narcissism/Introversion (Woman) well-rested.
- Extroversion (Husband) - After meals due to high levels of glucose = high
○ Work overtime energy
- Quickening –– first movement of the baby. - Position: Left side lying to prevent vena cava
○ Primigravida: 20th week compression
○ Multigravida: 16th week. - Same time each day.
- Maximum 2 attempts if the result is <10.
THIRD TRIMESTER: PREPARE FOR DELIVERY
- NEST building
 REFRESHER: OBSTETRICS
LECTURER: PROFESSOR KENNETH ARZADON

FETAL HEART TONE MONITORING

- Principles/Equipment used:
○ Doppler: Earliest time to monitor FHR is 8th
week of pregnancy
○ Fetoscope: Used during 12th week.
○ Stethoscope: Used during 16th week.
- Promote bonding: Let the parents listen to the fetal
heartbeat.
- Normal fetal heart rate: 120 to 160 bpm.
○ Any conditions where heart rate is
● Intervention: Reposition on knee chest or modified
sim’s position.
AMNIOCENTESIS
- Earliest time: At 12th week.
- Client position: Supine position with pillow under the
right hip
○ To prevent supine hypotensive syndrome
- Site: between the umbilicus and symphysis pubis.
- Client instruction

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above/below normal → NOTIFY the
physician = Sign of fetal distress.
NON-STRESS TEST
- Fetal heart rate in response to fetal movement.
○ Reactive: ↑ FHR of 15 bpm in 15 seconds (2
episodes in 20 minutes)
○ Non-Reactive: NO ↑ FHR / less than 15 bpm.
■ The doctor will order a contraction
○ Before: Empty the bladder.
○ After: Avoid sexual intercourse and
strenuous activities for 24 hours.
- Important Assessment:
○ Mother: Assess temperature (possible
infection)
○ Fetal: Assess FHR (Priority; possible fetal
distress)
PREGNANCY AND VACCINATION

CONTRACTION STRESS TEST

-
stress test.
○ Episodic FHR acceleration is normal →
DOCUMENT and cont

Fetal heart rate in uterine contractions

○ Normal: Negative result
IL - Safe vaccines during pregnancy: THIRD
○ Tetanus toxoid
○ Hepa B
○ Influenza (inactive form)
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○ Rabies
■ No decrease to fetal heart rate or ○ Diphtheria/Pertussis (Tdap)
deceleration in response to uterine ○ Covid-19 vaccine (Given after 1st trimester)
contraction. - Contraindicated: Live attenuated vaccines.
○ Rubella
○ AMV 1
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FINDINGS AND INTERPRETATION
○ AMV 2 (MMR)
(FHT MONITORING)
○ Varicella
Early Decelerations
● Occurs during the onset of contractions.
PREPARATION FOR CHILDBIRTH
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● Cause: Head compression – Vagal stimulation =

decreased HR ● Walking: Best source of exercise.
● Intervention: Document and continue monitoring. ● Squatting: increases blood supply to the uterus.
● Tailor sitting: tightens the perineal muscle.
Late Decelerations ● Kegel’s exercise: strengthen the perineal muscle.
● Occurs during the end of contractions.
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● Pelvic rocking: to prevent and manage back pain.

● Cause: Uteroplacental insufficiency
● Intervention: PREMONITORY / PRODROMAL SIGNS OF LABOR
○ Stop oxytocin as it promotes
vasoconstriction → decreased placental
perfusion LIGHTENING (ENGAGEMENT)
○ Reposition on left-side lying position - Relief of dyspnea, increase urinary frequency
○ Give O2 - Primipara: 1 – 2 weeks before labor.
○ Notify the physician - Multipara: a day before labor.

Variable Decelerations INCREASED BRAXTON HICKS CONTRACTION

● Occurs anytime during or in between contraction. - Painless contraction relieved by walking.
● Cause: Cord compression
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LECTURER: PROFESSOR KENNETH ARZADON

BLOODY SHOW - Station 0: Ischial spine

- Pink-tinged vaginal spot. - Station (+) 1, 2, and 3: Crowning

RIPENING OF THE CERVIX

POSITION FOR DELIVERY
- As soft as a whipped butter.

PSYCHOSOCIAL SIGN: INCREASED MATERNAL ENERGY. Best position for delivery: Squatting; Upright position.
- Due to increased adrenaline ● The gravity will aid in the descent of the baby.
- Instruct the patient to conserve energy for the ● It will widen the pelvic outlet.
delivery.

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TRUE LABOR CONTRACTIONS TIPS ON HAVING A MALE OFFSPRING

1. Have sex on the day or nearest the day of

1. Decreasing intervals (more frequent) ovulation.
2. Regular 2. Longer foreplay (Sperm lives in a alkalinic
3. Increasing intensity environment)
4. Progressive cervical effacement and dilation –– 3. Dog style
MOST IMPORTANT SIGN!!!

PAIN

PAIN CHARACTERISTIC
● Radiating from the back to the abdomen––
GIRDLE-LIKE PAIN

BACKPAIN CHARACTERISTIC
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● Normal: Intermittent, relieved by rest
● Sign of preterm labor: Persistent, unrelieved by
rest

PELVIC MEASUREMENT
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Diagonal Conjugate
- The ONLY pelvic measurement obtained thru vaginal
or internal examination.
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○ Insert two fingers until ischial tuberosity and

the location where the examining hand
touches the symphysis pubis is marked by
the other hand.
○ After withdrawing the examining hand, the
distance between the tip of the middle finger
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and the marked point is measured with a

ruler or a pelvimeter.
- Measurement: 11.5 cm
- Normal fetal head diameter: 9.5 cm

Obstetric Conjugate
- Formed due to symphysis pubis.
- The smallest and most important diameter of the
pelvic outlet which will the head traverse.
- OC = DC – 2 cm → 11.5 – 2 = 9.5

Landmarks:
- Station (-) 1, 2, and 3: Fetal head is floating