1 NORMAL PREGNANCY and ANC

By :Hunduma Dina(Masters in CLMW)

APFS 03/22/2024
 Normal Pregnancy

1. Physiological changes during

pregnancy
 There are physiological, biochemical and anatomical
changes that occur during pregnancy.
 These changes may be systemic or local.
Physiological changes during
pregnancy..
 Most of the systemic changes return to pre-
pregnancy status 6 weeks after delivery.
 These changes occur during pregnancy to
maintain a healthy environment for the fetus
with out compromising the mother’s health.
Physiological changes during pregnancy..

 And prepare for the process of delivery and care of

the newborn.
 Understanding of the normal changes helps to
understand coincidental disease processes.
A. Changes in Endocrine System
 Secretion of HCG hormone by placenta at 12
weeks.
 Estrogen and progesterone are produced in larger

amount
Thyroid gland
 The size and the acidity is influenced because of

circulating estrogens.
B. Changes in the Reproductive Organs

1. Uterus
 Grows and increase in weight from 60g to about
600-1000 gram at term
 Size increase from 7.5x 5x2.5 cm to 30x30x20cm
volume 10ml to 5 liter
 The cervix becomes softer and the glands secrete
thick mucus.
2. Vagina
Because of estrogen and increased blood supply to it:
 The vaginal tissue soften and more elastic which

allows easier dilatation in labor .There is increase

of normal white vaginal discharge called
Leucorrhoea
 Appear reddish purple
3. Ovaries
 Ripening of the ovum stops ,function taken by the
placenta.
 Ovulation ceases during pregnancy and the
maturation of new follicles is suspended.
4. Breasts
 Estrogen develops the ducts system
 Progesterone the glandular system
 The breast enlarge due to increase tissue growth
blood supply and fat deposition.
 Breast increases in size with enlargement of the
nipple and increased vascularity and pigmentation
of areola.
C. Change in Cardiovascular System

 There is an increase in blood volume

amounting to an extra 1.5-2 liters (45-50%)by
the 34th week of pregnancy
 RBC increase by 33%
 Iron need increases because of increases in
RBC
Change in Cardiovascular System...
 An increase in plasma is greater than blood cells
due to this the Hg level falls and the pregnant
women may become anemic.
 There is little change in SBP but DBP decrease by
5-10mmHg from 12 -26 weeks then increases to
none pregnant level by term.
Change in Cardiovascular System cont’d

 Cardiac out put

 Increase by 49% during pregnancy at 20-24 weeks
of gestation the constant until term.
 Heart slightly shift in position.
 Venous pressure
 No change in the upper body
 venous return to the heart increases pressure and
results in edema.
D. Changes in Respiratory System
 At the end of pregnancy oxygen requirement will
increase by 20%
 In late pregnancy the large uterus presses the lower
lobes of the lung and causes difficult breathing.
E. Change in the Renal System
The enlarged uterus compress on the bladder and
causes frequency of micturition;
 Early in pregnancy (6-12 weeks) and
 At the end of the pregnancy when the head

engaged
Because of progesterone urethra become dilated and
kinked, slow emptying may cause tendency for UTI
and stone formation
 F. Changes in the GIT

 Gums hypertrophy and hyperemic, easily bleed.

 Gastrointestinal mobility may be reduced due to
increased progesterone hence gastric emptying is
slowed and similarly in other part of GIT constipation.
 Oral cavity feels salivation
Changes in the GIT cont’d
 Stomach production of gastrin increase, increase
gastric volume and decrease PH.
 Mucus production increased so PUD usually
improve or disappear.
 But enlarging uterus causes heart burn which is
common due to reflux and relaxation of cardiac
sphincter.
Changes in the GIT cont’d
 Pica (craving for unnatural substance) women
often experiences changes in their sense of test and
leading to dietary changes and food craving
 Nausea and vomiting is usually between 4-14
week (occur in the mornings)
G. Changes in the skin

Abdominal wall
 The skin of abdomen is stretched and small tears

of the deeper layers occur, this is called striae

gravidarum "stretch marks” and produce line
in the abdomen may occur on breasts and
thighs.
 The sebaceous and sweat glands become more

active (women often feels hot )

Changes in the skin cont’d

Hyperpigmentation over some part of the body

Irregular brownish patches of varying size appear on
the face and neck, giving rise to chloasma or
melasma gravidarum, also-called mark of pregnancy.
 A dark line, Linea nigra is often seen extending

from the symphysis pubis to the umbilicus

 Increased activity of stimulating melanin hormone

cause darkening of the areola

H. Changes in general metabolism

 The activity of all body function increase to

meet the growing demands of the fetus and
maternal tissue
 Weight increase due to increase in

 Fetus---------------3-4 Kg
 Fat------------------3-5Kg
 Placenta-----------0.6 Kg
 Breast--------------0.5 Kg
 Amniotic fluid-----0.6Kg
 Uterus--------------1Kg
 Blood volume-----1.5 liter
 At full term the weight should not exceed 9 -12 kilos totally
Changes in the Musculoskeletal System

 Slight movement of the pelvic joints may cause

backache.
 Poor posture puts the additional strain on the
muscle and ligaments of the back and backache
may follow.
 J. Emotional changes
 The changes need to be understood by not only the
health workers but also by the woman and her
families.
 The news of the pregnancy may be received in
many ways depending on the circumstances of the
woman and the family.
Emotional changes cont’d
 There may be some emotional instability during
early months .At moment the woman may be happy
and the next moment in tears.
 A usually calm woman may become irritable and
an anxious. The husband may become confused
 Physical and emotional support during last months
needed.
 Emotional changes cont’d
 Whatever the reaction, the woman needs support,
love and reassurance particularly from her husband
and family.
 She also needs to build up confidence in the
medical staff who cares for her.
 Minor Disorders of Pregnancy
 Minor disorders are only disorders that occur
during pregnancy and are not life threatening.
 1. Nausea and vomiting

 This presents between 4 and 12 weeks gestation.

Hormonal influences are listed as the most likely
causes. It usually occurs in the morning but can
occur any time during the day, aggravated by
smelling of food.
 Nausea and vomiting cont’d

Management
 Reassure the mother
 Small frequent meals(dry meals)
 Reduce fatty and fried contain foods
 Rest
 2. Heartburn

 It is a burring sensation in the mid chest region.

Progesterone relaxes the cardiac sphincter of the
stomach and allows reflex of gastric contents into
esophagus.
 Heartburn is most trouble at 30 -40 weeks gestation
because at this stage is under pressure from the
growing uterus.
 Heartburn cont’d

Management
 small and frequent meals ,sleeping with extra

pillows than usual

 for persistence/sever case /prescribe antacids.
3. Pica
 This is the term when mother craves certain foods
of unnatural substance such as coal soil etc. the
cause is unknown but hormones and changes in the
metabolism are blamed
Management
 Seek medical advice if the substance craved is

potentially harmful to the unborn baby

4. Constipation
 Progesterone causes relaxation and decreases
peristalsis of the gut which is also displaced by the
growing fetus
Management
 Increase the intake of water, fresh fruits, vegetables

and roughages in the diet

 Exercise is helpful especially walking
5. Backache
 The hormones sometimes soften the ligaments
to such a degree that some support is needed
Management
 Advice the mother to sleep on firm bed

 Advice support mechanism of the back

6. Fainting
 In early pregnancy fainting may be due to the
vasodilatation occurring under the influence of
progesterone; before there has been a compensatory
increase in blood volume .the weight of the uterine
content presses on the inferior venacava and slows
the return of the blood to the heart
Fainting cont’d
Management
 Avoid long period of standing

 Sit or lie down when she feels slight dizziness

 She would be wise not to lie on her back except

during abdominal examination

7. Varicosities
 Progesterone relaxes the smooth muscles of the vein
and result in sluggish circulation. The valves of the
dilated veins become inefficient and varicosities
result. it occurs in leg, anus(hemorrhoids) and vulva
Varicosities cont’d
Management
 Exercising the calf muscle by rising on the toes

 Elevate the leg and rest

 Support the thigh and legs

 Avoid constipation and advise adequate fluid in

take
 Sanitary pad give support for vulva varicosities
Conclusion…

 Most minor disorder can be advanced to a more

serious complication of pregnancy. The disorders
that require the immediate actions are as follows
(Danger signs of pregnancy)
Danger signs of pregnancy
 Vaginal bleeding
 Reduced fetal movement
 Frontal or recurrent headaches
 Sudden swelling
 Rupture of the membrane
 Premature onset of contractions
 Maternal anxiety for whatever reason.
Diagnosis of pregnancy
 Pregnancy is mainly diagnosed on the symptoms
reported by the woman and signs elicited by a
health care provider.
Signs and symptoms are divided into 3
 Presumptive sign

 Probable sign

 Positive sign
1. Presumptive (Possible) sign
a) Amenorrhea sudden stopping of menstruation is
correct in 98% of cases but it can happen in change
of environment, distress, serious illness, severe
anemia
 In women with irregular cycles, amenorrhea is not a
reliable sign.
Presumptive Sign cont’d
b) Breast change 3-4th weeks: prickling sensation
 6th week enlargement and sometimes tender, visible
surface veins
 12th weeks primary areola becomes darker and
larger.
 16th week colostrum appears in breast (can be
expressed).
Presumptive Sign cont’d
c) Morning sickness 50% of the mother experience
this but other condition can raise to vomiting
 Is most marked at 2–12 weeks' gestation
c) Frequency of micturition without burning
sensation or pain occurs before the 12th week
Presumptive Sign cont’d
e) Skin change there is chloasma, linea nigra, striae
graviderium are due to stretching of the skin.
f) Quickening; the first fetal movement felt by the
mother ,and it occurs around the 16th -20th week
Note: slight tingling can be experienced by non-
pregnant women and chloasma can be present in
ovarian cyst or fibroid
2. Probable signs
1. Hegar’s sign:
 Is widening of the softened area of the isthmus,
resulting in compressibility of the isthmus on
bimanual examination.
 This occurs by 6–8(12) weeks;
 Is one of the early sign and detected by an
examination carried out by the Professionals.
Probable signs cont’d
2. Abdominal enlargement
 There is progressive abdominal enlargement from 7–
28 weeks. At 16–22 weeks, growth may appear more
rapid as the uterus rises out of the pelvis and into the
abdomen.
 No other condition makes the uterus enlarge so quickly
and progressively.
 Can also due to fat, flatus, full bladder, fluid or fibroid
Probable signs cont’d
3. Changes in the uterus
 From 8th week onwards the uterus enlarge;
 The consistency is soft, the shape globular
Probable signs cont’d
4. Braxton Hicks
 Painless intermittent contraction of the uterus,
during pregnancy felt on palpation from the 16 th
week onwards (28).
 The contraction help in the circulation of blood to
the placenta site and in the formation of the lower
uterine segment.
Probable signs cont’d
5. Uterine souffle
 From 12 - 16th week, soft sound heard on
auscultation.
 It is the same rate as maternal pulse also heard in
fibroid due to increased blood flow to uterus.
Probable signs cont’d
6. Internal ballottement: The sensation of an object
rebounding after being pushed by an examining
hand.
 May be felt by the 16th week on examination
carried out by the professional.
Probable signs cont’d
7. Softening of the cervix
 The cervix undergoes increased softening as
pregnancy advances.
 Felt from the 10th week (normally the cervix feels
like cartilage)
 As pregnancy progresses, the cervical canal may
become sufficiently patulous to admit the fingertip.
Probable signs cont’d

8. Chadwick's Sign(Blue discoloration)

 Congestion of the pelvic vasculature causes
bluish or purplish discoloration of the vagina
and cervix starting from 8th week onward.
Probable signs cont’d
9. Leukorrhea
 An increase in vaginal discharge consisting of
epithelial cells and cervical mucus is due to
hormone stimulation.
3. Positive signs

 A positive diagnosis must be made on objective

findings.
a) Hearing the fetal heart beat/Fetal Heart
Tones (FHTs)
 It is possible to detect FHT by hand held Doppler
as early as 10 weeks' gestation.
 The normal fetal heart rate is 120–160 beats per
minute. It may be detected by fetoscope by 18–20
weeks' gestation, although this device is rarely
used at present.
 Positive signs cont’d

b) Feeling fatal parts like hand or limbs on

Palpation
 After 22 weeks, the fetal outline can be palpated
through the maternal abdominal wall.
 Fetal movements may be palpated after 18 weeks.
This may be more easily accomplished by a vaginal
examination.
Positive signs cont’d
c) Seeing Fetal Movement on Inspection
d) Seeing Fetal Parts on x-ray
e) Ultrasound Examination of Fetus
 Sonography is one of the most useful technical aids
in diagnosing and monitoring pregnancy.
 Cardiac activity is discernible at 5–6 weeks,
 Limb buds at 7–8 weeks, and finger and limb
movements at 9–10 weeks.
 At the end of the embryonic period (10 weeks by
LMP), the embryo has a human appearance.
Positive signs cont’d
f) Pregnancy Tests
 Sensitive, early pregnancy tests measure changes in
levels of hCG.
 Presence of human chorionic gonadotrophic (hCG)
in blood from 9 -10 and in urine starting from 14
days.
Positive signs cont’d
 hCG is produced by the syncytiotrophoblast 8
days after fertilization and may be detected in
the maternal serum after implantation occurs, 8–
11 days after conception.
 hCG levels peak at approximately 10–12 weeks
of gestation.
Positive signs cont’d
Urine Pregnancy Test
 This is the most common method used to confirm

pregnancy. Is qualitative- +ve or –ve.

 Using antibodies, the test identifies the subunit of

hCG, minimizing cross-reaction with similarly

structured hormones.
 Affordable, reliable and fast (1–5 minutes to obtain

results) tool to diagnose pregnancy in the office

Positive signs cont’d
Serum Pregnancy Tests
 hCG can be detected in the serum as early as a

week after conception.

 The serum pregnancy test is a reliable method to

diagnose an early pregnancy.

 NEW 2016
Antenatal Care
DEF: ANTENATAL CARE IS THE
CARE GIVEN TO A PREGNANT
WOMAN TO ACHIEVE SAFE
PREGNANCY AND DELIVER
Definitions of Important terms
1. Pregnancy (gestation) is the maternal condition
of having a developing fetus in the body.
2. Embryo is the human conceptus from
fertilization through the eighth week of
pregnancy.
3. Fetus is from the eighth week until delivery.
Definitions of terms cont’d
4. Gravid: means pregnant
5. Gravidity: is the total number of pregnancies
(normal or abnormal).
6. Parity is the state of having given birth to an
infant or infants weighing 500 g or more, alive or
dead. Refers to delivery
Definitions of terms cont’d
7. Primigravida: is a woman pregnant for the first
time.
8. Multi gravida: is a woman who has had two or
more pregnancy.
9. Nulli para: is a woman who has not given birth
to child.
10. Multi para: is a woman who has given birth to
two or more child.
 Definitions of terms cont’d

 Grand multi Para: is a woman who has given birth

five times or more.
 Gestational age: the estimated age of the fetus is
calculated from the first day of the last (normal)
menstrual period (LMP), assuming a 28-day cycle.
Definitions of terms cont’d
 Developmental age (fetal age): is the age of the
offspring calculated from the time of implantation.
 Effecement: is thinning and shortening of the
cervix that occurs just prior to dilatation.
 Quickening: is Perception of the first fetal
movement by the mother
Definitions of terms cont’d
 Lie is the relationship of long axis of the fetus to
the long axis of the mother’s uterus and normal
lie is longitudinal. Abnormal are transverse,
oblique and variable.
 Attitude is the relationship of the fetal parts to
one another (head and limbs to its trunk) and the
normal attitude is flexion. Abnormal are
extension(face) and deflection(brow).
Definitions of terms cont’d
 Presenting part: the part of the fetus felt at the
lower pole of the uterus and the normal
presentation is vertex. Abnormal are breech, face,
brow and shoulder.
 Denominator: the part of the fetus which
determines the position (vertex, occiput, breach-
sacrum face–mentum)
Definitions of terms cont’d
 Position is the relationship between the
denominator of the presentation to the six points
on the pelvic brim and the normal position is
occipitoanterior or occipitolateral. abnormal
(Mal-position) is occipitoposterior position.
Definitions of terms cont’d
 Crowned when the biparietal diameter pass the
ischial spines and the head no longer recedes
between contractions;
 Engaged when the biparietal diameter of the fetal
head passes through the pelvic brim
Definitions of terms cont’d
 Stationis a measure of descent of the bony
presenting part of the fetus through the birth
canal. The current standard classification (-5 to
+5) is based on a quantitative measure in
centimeters of the distance of the leading bony
edge from the ischial spines.
 ANC and its role in reducing maternal
mortality
New 2016 ANC
 that “Every Pregnancy is at risk”

 ANC to detect and treat existing problems

 Services are available to respond to Obstetric emergencies

when they occur

 Prepare women and their families for the eventuality of

an emergency
Detection of complications
Pregnant women and family must
 Know what to expect during pregnancy

 Plan the appropriate location for the delivery

 Choose a skilled provider

 Have the needed supplies to conduct a clean and safe

delivery
 Make a plan for the skilled attendant to reach the home

or for the women reaching the skilled attendant at onset

of labor
 Plan appropriate care for the postpartum mother and

newborn
2016 WHO ANC model
Detection of complications
 Identify support people to help
 Be able to identify the signs of an obstetric
emergency
 Know the importance of seeking care without delay
when complications occur
 Have a plan to be able to respond immediately in
the event of an emergency to avoid delays
Detection of complications
 Know the location of the nearest health facility
where emergency obstetric care (EMOC) is
available
 Have a means of traveling to this facility
 Set aside funds for medical care in advance so that
the woman can reach appropriate medical facilities
as quickly as possible.
Birth preparedness
 A plan of where to have the delivery
 A skilled birth attendant
 Supplies needed for a clean delivery
 Supplies needed for a clean postpartum
 Being aware of the signs of an emergency and the
need to act immediately
 Complication readiness
 Designated decision maker
 A way communicated with a source of help (skilled
attendant, facility, transportation)
 Emergency funds
 Emergency transportation
 Blood donors
 Complication readiness
 The name and location of the nearest hospital that 24-
hours functioning emergency obstetric care services.
 The interval from onset to death for antepartum
hemorrhage (APH) can be approximately 12 hours.
 The interval from onset to death for postpartum
hemorrhage(PPH) can be two hours.
 Key danger signs
 Key danger signs during pregnancy
 Sever vaginal bleeding
 Swollen hands and face
 Blurred vision
 Key danger signs during labour& delivery
 Sever vaginal bleeding
 Prolonged labour >12 hours
 Retained placenta
 Key danger signs

 Key danger signs during Postpartum

 Sever vaginal bleeding
 Foul smelling Vaginal discharge
 High fever
 Key danger signs in the new born
 Convulsion/ spasm/ Rigidity
 Difficult/fast/breathing
 Very Small baby
 Lethargy/unconsciousness
Key behavioral change messages

 Obstetric emergencies cannot be predicted, so we must

be prepared in case they occur
 Delays in seeking and reaching care for obstetric
emergencies can kill mother and child
 Know the signs of and obstetric emergency during
pregnancy, delivery or postpartum/post abortion,
newborn
 Any bleeding in pregnancy and heavy bleeding during
and following delivery convulsions/loss of consciousness
Key behavioural messages
 High fever with or without abdominal pain
 Labor lasting longer that 12 hours
 Placenta does not come out within 30 minutes of the
birth;
 Take the woman without delay to the nearest hospital
if she has signs of and emergency
 Be prepared in case of an emergency: set aside funds,
arrange transport, and identify a blood delivery.
Key advocacy messages
 Provide 24-hour emergency obstetric care 7 days a
week
 Allocate funds for emergency transportation and
medical treatment at the community level
 Ensure skilled providers for maternity and newborn
care
Techniques of
ANC
a) History Taking

 History taking is a means of assessing the health of

the woman to find out any condition which may
affect child bearing.
 1. Social history
 Name, age, address (distance from the health
institution), occupation.
i) Age
 The best age to get children is between 22-28 (20-30)

 Primigravida less than 16 years has

 Neither developed physically nor psychologically.

 The pelvis might be small
 Young girl tend to give premature baby.
1.Age cont’d
 Woman over 38 years are at increasing risk of
giving abnormal baby
 Primigravida greater than 35 years - Muscles and

soft parts of the birth canal are not as elastic as

younger woman and do not stretch easily
2. Family history
 Family history is to know the genetic

predisposition to certain disease.

3. Past Medical history
 Former illness may damage certain structure or
organs which could give rise to complication
during pregnancy and labour.
e.g. Tuberculosis, Venereal disease
like syphilis, gonorrhea,
 Heart disease/hypertension
 Renal disease
 Diabetes
4. Surgical history

 Operation on the genital tract

 Any abnormal operations,
 Surgery of abdominal organs
5. The obstetric history
5.1. Past Obstetric History
a) How many times have you been pregnant (gravida)
the number of total pregnancy
 Grand multi Parity (more than five babies have

greater occurrence of
- Postpartum hemorrhage
- Poor contraction during delivery
- Risk for mal-presentation
- Risk for uterus rupture
Past Obstetric History cont’d
b) Did you have any abortion?
If yes
 Do you know what causes it?

 At how many months?

 Did you attend antenatal care during previous

pregnancy.
Past Obstetric History cont’d
c) To how many children did you give birth?
 Were all babies alive at birth?
 Was any child born before full term?
 Did the labor last long time >24 hours?
 Where did you give birth?
 Who helped you?
- Relative, friend
- Midwife /nurse/doctor
Past Obstetric History cont’d
 Note previous history is very important because
many conditions in pregnancy are likely to recur.
 The risk of mother to die is higher from the first
pregnancy than from the second and third. After the
fifth the risk increases with every pregnancy.
Past Obstetric History cont’d
The reasons for this are:
 Anemia

 Fibrous tissue increase in the uterus (risk for uterus

rupture)
 Pelvic floor muscles loose their elasticity may lead

to uterus prolepses
 Mal-presentation
 5.2. History of present pregnancy

Ask the normal menstrual period (when was your last

normal menstrual period (LNMP)) and then calculate:

The gestational age of the pregnancy

 Calculating the days and dividing by 7
History of present pregnancy cont’d

Expected date of delivery (EDD)

For Ethiopian calendar
 Add 10 days and 9 months if pagume is not

included (crossed)
 5 days and 9 months if pagume is included

(crossed)
Expected date of delivery (EDD) cont’d

 E.g 1. LNMP Meskerem 1, 2004 (pagume or leap

not passed)
 EDD= 1 1 2004
+10 9_______
 = 11 10 2004
 E.G.2. LMP Megabit 20 2003(crosses leap)
 EDD = 20 7 2003
 +5 9______
 = 25 4 2004
Expected date of delivery (EDD)
cont’d
For European calendar
 Add 7 days and 9 months

 E.g. LNMP September 24, 2011

 EDD 24 9 2011
 +7 9______
 = 01 7 2012
Examination of pregnant woman

A. General appearance

 As she walks observe

 Any deformity, stunted growth, limbs etc….
 Does she look well or pale and tired?
 Examination of pregnant woman ..

B. Clinical observation
 Height: 150 cm or less needs special care (might

have small pelvis)

 Weight the average weight gain during pregnancy is

9-12(14).
- The woman should gain 0.4 kg per month in the
first trimester and
- In the second and third trimester she should gain
0.4 kg per week.
Physical examination
1. Appearance
 The hair of the healthy woman is shining and
glossy
 Her eyes bright and clear
2. Face
 Edema sign of anemia -pale or jaundiced

3. Neck
 Swollen glands
Examination of pregnant woman ..

C. Blood pressure
 Check and record at each visit
 Having the knowledge of BP range is better.
 Relative rise of 30 mmHg systolic or 15 mmHg
diastolic is one of the early signs of pre-eclampsia
 Examination of pregnant woman ..

D. Breast examination
 Asses the size, any lamp in the breast

 Nipples are inverted or flat ,if the nipple are flat tell

the mother to roll several times a day

 Teach the mother breast self examination.
Examination of pregnant woman ..

E. Abdominal Examination
Steps for abdominal examination
I. Inspection
II. Palpation
III. Auscultation
 The woman should emptied her bladder and should

lie on her back with arms at her side

Abdominal Examination cont’d

I. Inspection (5s)
a) Shape
- Is it round? Oval? Irregular or pendulous?
- Longitudinal ovoid in primigravida
- Round in multi gravid (a big round uterus may be due
to multiple pregnancy, transverse lie, hydraminious or
obesity
- Broad in transverse lie
 Inspection (5s) cont’d

b) Size: should correspond with the estimated period

of gestation
c) Skin: the dark line which is linea nigra is seen, any
rash?
d) striae gravidarium
e) Scar: any operation scar (c/s)
 II. Palpation
1. Fundal height and fundal palpation (1st Leopold
Maneuver)
1. 1. Fundal height

 Place the ulnar side of the left hand on the fundus and
compare the height with the size expected for the
period of gestational age.
Fundal height cont’d

 Normally the fundus will be about two fingers breadth

higher each month of pregnancy
 At about 12-14wks fundus reaches just above the
symphysis pubis as a firm globular shape
 16 weeks mid way between the symphysis pubis and
umbilicus
 20 week about two finger bellow the umbilicus
Fundal height cont’d

 24 week at the upper boarder of the umbilicus

 30 week mid way between umbilicus and
xyphisternum.
 36 week at the level of xyphisternum.
 40 week the fundus falls again as the baby go
descends into the pelvis and is ready to go into labor.
It might be palpated at the same level as 32-36 weeks
Symphysis to fundus measurement

 By measuring the length from the upper edge of the

symphysis bone to the top of the uterus it is possible
to get a picture of a length of the fetus
 A tape measure which is soft but not getting longer by
pulling should be used
 The SF measurement will increase by 0.8-1cm per
week
 Measurement done by the same examiner might have
a variation of +0.5-1cm and done by other person
may be even more
 Reasons for too high SF measurement

 Wrong dates
 Big fetus
 Twins
 Hydro amnions
 Malformations
 Any tumor outside the uterus
Reasons for too low SF measurement

 Wrong date
 Growth retardation
 Oligoamnions
 Intrauterine Fetal death
 Malformation
 The most common sources of error

 Measuring the uterus longitudinal but the fetus is

in different lie
 Not finding the top of the uterus
 Fetus is deeply engaged
 Corpulent (fat pregnant woman)
 Not measuring longitudinal direction of the uterus
Palpation cont’d
a) The lie and presentation of the fetus
 Presentation is found from the lie of the fetus
 It is done by deep pelvic palpation and pawlik’s
palpation
 Find out if the fetal head is in the pelvis
 Palpation cont’d
b) The head feels
 Round and hard if not engaged, it is easily moved side ways
c) The buttocks feels
 Soft and round mass and it is not easy to move
 The lower limbs may be palpated around it
 If you cannot find head in the pelvis try in the fundus
 If the presentation is breech after 32 weeks refer the woman to
hospital where external version (turning form breech to vertex)
can be done
Engagement
 Engagement of the fetal head in primigravida
occurs usually by the 38th week
 In multigravida engagement may not take place
before labor has started
Fundal palpation
 Purpose
 to know lie and presentation of the fetus
 Method
 Use 2 hands using palms of hands on either side of
the fundus.
 Fingers held close together palpate the upper pole
of the uterus and feels as it is hard or soft or
irregular
Lateral palpation (2nd Leopold
maneuver)

 Purpose
 To know lie and position
 Method
 Always facing the mother, fix the hand on the
center of the abdomen fix the right hand and
palpate with left hand and vise versa
 Note the regularity :the regular side is the back.
Deep pelvic palpation (3rd Leopold
maneuver)

Purpose
 To know presentation & attitude

Method
 Feel presenting part, it is hard or soft while palpating

Deep Pawlik`s Grip (4thLeopold maneuver)

 The lower pole of the uterus is grasped with the right
hand; the nurse facing the woman's head
 feel the occiput and sinciput note which is lower
 Auscultation
 FHS are heard at their maximum at a point over the
back(first at 20-24 weeks
 If it is the last months of pregnancy and you hear the FHS
below the umbilicus the presentation is most probably the
head
 If FHB is best heard above umbilicus the presentation is
probably breech
 check for fetal heart rate and rhythm count for one minute
if regular(120-160)
 Method
 Use Pinards fetal stethoscope.
 Hands should not touch it while listening,
 Ear must be in close contact with the stethoscope.
Points to be advised on
 The advantage of antenatal check up
 The use of tetanus toxoid vaccine
 The danger of lifting heavy loads (exercise)
 The importance of exercise
 Rest at least 10 hours at night and 2 hours in the
afternoon.
 Breast care
 Diet rich in iron and protein
Routine treatment of pregnant woman

 Tetanus prevention for any child bearing age woman

 Prevention and treatment of anemia
 Advise iron rich nutrition
 Ferous sulphate tablets 1tab /day and more if Hb is less
than 10 mml/mole with folic acid
 Prevention of malaria for a woman from area of high
malaria areas prophylaxis might be given because
malaria causes
 anemia
 abortions and premature labor
Selection of mothers at risk
 Are mother who must be closely observed during
pregnancy and labor in order to avoid complication
1) Woman less then 16 years
2) Woman more than 38 years
3) Mothers with more than 4-5 children
4) History of previous PPH
5) History of previous APH
6) History of premature labour
7) Previous cesarean section
8) Previous VVF or RVF
9) History of previous uterus rupture.
10) History of previous instrumental delivery
11) One or more still birth
12) One or more neonatal death
13) Three or more repeated abortions
14) History of sever illness
 Heart disease

 Kidney disease

 Hypertension

 Pre-eclampsia
15) Malnutrition
16) Severe anemia
17) Short woman height less than 150 cm
18) Any woman with deformity of leg and pelvis
19) Certain infectious disease
 Malaria

 Syphilis

 Hepatitis
4.5. Health Education in pregnancy

H.E. is important for:

 For child welfare

 Immunization and

 Family planning
Some special topics for the discussions are:
 Nutrition

 Care of breast

 Care of the new born

 Advantage of breast feeding

 Immunization
 1. Nutrition

Very important to meet:

 Increase bulk of uterine muscle

 The formation of placenta

 Rabidly developing fetus leads to demand on all

types of nutritional intake(carbohydrate ,fat and

protein) and for formation of blood cells (Iron ,folic
acid vitamin B12 and also protein
 Energy requirement
 For this the mothers daily intake should increase by 100
calories at earlier and up to 300 ca /month later.
 Lactation
 Require additional intake of 100 calories
 Protein
 For baby building
 If 1st class protein are expensive 2nd class proteins from
vegetables, groundnuts, beans
 Protein requirement in lactation
 The child requires 3g/Kg body weight per day

 Mothers should get 20 g of additional protein/day

Vitamins and minerals

 Iron and folic acid are essential for blood formation
 2. Care of Breast

 Important particularly for primigravida

 Check for inverted nipples and show her how to
massage
 Teach if the baby is reluctant the mother should
manually express milk in to clean container.
 3. Personal Cleanliness

 Encourage good personal hygiene

 Rest and exercise
 Should get adequate rest and sleep
 Avoid carrying heavy things such as
 Water
 Firewood
 4. Walking
 Slight work in the house
 Slight work in the felid gives enough exercise which
aids circulation and prevent constipation
5. Sexual intercourse
 There is little evidence that sexual intercourse
during normal pregnancy is harmful
 A previous history of abortion is contraindication
during the first months of pregnancy
6. Drugs smoking and alcohols
 A pregnant woman should avoid all medications
except iron and folic acids
 Only drugs prescribed by physicians, nurse or
health officer should be taken if necessary
 Smoking should be discouraged
 Alcohol intake during pregnancy affects fetal
growth and development
 7. Tradition customs and beliefs

 Advise not to practice the harmful Customs and

beliefs
 Explain why they are harmful
 Give idea for safe alternative practice
 8. Immunization

 Tell her about importance of TT vaccination

 Tell her about importance of vaccinating her child
 Inform about schedules for vaccines
Childbearing age women immunization
Schedule for TT Vaccination
Dose Minimum interval Duration of
protection

TT1 First contact 0

TT2 4 weeks 3 years

TT3 6 months 5 years

TT4 1 year 10 years

TT5 1 year Life long

 The End!
THANK YOU!!!!!
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