MATERNAL/OB NOTES

I. Human Sexuality
A. Concepts
1. A persons sexuality encompasses the complex behaviors, attitudes, emotions and preferences that are related
to sexual self and eroticism.
2. Sex is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Defnitions related to sexuality:
Gender identity sense of femininity or masculinity
2 ! years " # years gender identity develops.
$ole identity attitudes, behaviors and attributes that di%erentiate roles.
Sex biologic male or female status. Sometimes referred to a speci&c sexual behavior such as
sexual intercourse.
Sexuality behavior of being boy or girl, male or female' man or (oman.
)t is an entity sub*ect to a life long dynamic change.
developed at the moment of conception.
II. Sexual Anatomy and Pysiolo!y
A. "emale #eproducti$e System

1. External vulva or pudendum
a. %ons pu&is'$eneris a pad of fatty tissues that lies over the symphysis pubis covered by s+in and at puberty
covered by short pubic hair that serves as cushion or protection to the symphysis pubis and surrounding
delicate tissues from trauma.
Tannerscale tool used to determine sexual maturity rating.
Sta!es o( Pu&ic Hair De$elopment
Sta!e 1 ,readolescence -o pubic hair except for &ne body hair only
Sta!e 2 .ccurs bet(een ages // and /2 sparse, long, slightly pigmented 0 curly
hair along the labia .
Sta!e 3 occurs bet(een ages /2 and /# hair becomes dar+er 0 curly hair that
develops along symphysis pubis.
Sta!e ) occurs bet(een ages /# and /!. 1air assumes the normal appearance of
an adult but is not so thic+ and does no appear to the inner aspect of the
upper thigh.
Sta!e * sexual maturity normal adult appear to the inner aspect of thigh.
&. +a&ia %a,ora means 2large lips3 a longitudinal fold, that extends from the symphysis pubis to the
perineum' 4(o folds of s+in (ith fat underneath' contain 5artholenes glands
c. +a&ia %inora means 2nymphae3 a soft and thin longitudinal fold that is located in bet(een the labia
ma*ora' t(o thin folds of delicate tissues' form an upper fold encircling the clitoris called the prepuce and
unite posteriorly called the fourchette .
2 sensiti$e structures o( la&ia minora:
c.1. clitoris means 2+ey3 anterior, pea shaped erectile tissue composed of so many nerve endings
(hich is the sight of sexual arousal in female. 6Gree++ey7
c.2. (ourcette ,osterior, tapers posteriorly of the labia minora
very sensitive to manipulation, oftenly torn during vaginal delivery.
common site episiotomy.
d. -esti&ule an almond shaped, narro( space area seen (hen the labia minora are separated,
that contains the hymen, vaginal ori&ce and bartholenes glands.
i. Urinary Meatus small opening of urethra that serves for urination' external opening of the urethra'
slightly behind and to the side are the openings of the S+enes Glands.
ii. Skenes Glands/or Paraurethral Gland t(o small mucous secreting substances that serve for
lubrication' often involved in infections of the external genitalia.
iii. Hymen a membranous tissue that covers vaginal ori&ce, membranous tissue
8 9arumculae mystiforms healing of a torn hymen
1
i$. Vaginal ri!ce external opening of vagina
$. "artholene#s Glands/or Para$aginal Gland or Vul$o Gland 2 small mucus secreting substance that
secrets alkaline substances responsible for the acidity of the vagina.
6 5elieved to secrete a yello(ish mucous (hich acts as a lubricant during sexual intercourse. 4he
openings are located posteriorly on either side of the vaginal ori&ce7
%lkaline neutrali:es acidity of vagina
Ph o& $agina acidic
'oderleins (acillus responsible for acidity of vagina
e. Perineum . a muscular structure that is located in bet(een the lo(er vagina 0 anus' contains muscles (hich
support the pelvic organs, the arteries that supply blood and the pudendal nerves (hich are important during
delivery under anesthesia.
). *nternal+

A. -a!ina female organ of copulation' passage(ay of menstruation 0 fetus
it is # ! inches or ; /< cm long of dilated canal located bet(een the bladder and
the rectum. 9ontains8 ,ugae permits considerable amount of stretching (ithout tearing
B. /terus 0 .rgan of menstruation, site of implantation and retainment and nourishment of
the products of conception. )t is a hollo(, thic+ (alled muscular organ. )t varies
in si:e, shape and (eights.
Si:e / inch thic+' 2 inches (ide' # inches long
Shape= non pregnant > pear shaped or inverted avocado
,regnant > ovoid
?eight = -on pregnant= @< A< grams
,regnant= /<<< grams
!
th
stage of labor /<<< grams
2 (ee+s after delivery @<< grams
# (ee+s after delivery #<< grams
-ormal State @ A (ee+s after delivery @< A< grams
Entire Process is -*n$olution o& Uterus.
1ree parts o( te uterus
1. (undus upper cylindrical layer
2. corpus'&ody upper triangular layer
3. cer$ix lo(er cylindrical layer
8 *sthmus +no(n at the lo(er uterine segment during pregnancy
8 /ornua *unction bet(een fundus 0 interstitial
%uscular compositions: there are tree main muscle layers (hich ma+e expansion possible in
every direction.
1. 2ndometrium inside uterus, in lines the nonpregnant uterus. Buscle layer for menstruation. Sloughs o%
during menstruation.
0 'ecidua thic+ layer' .nce implantation has ta+en place, the uterine endothelium is termed decidua.
.ccasionally, a small amount of vaginal spotting appears (ith implantation because
capillaries are ruptured by the implanting trophoblasts > implantation bleeding . . .
Implication: this should not be mista+en for the CB,6Cast Benstrual ,eriod7
0Endometriosis 2ectopic endometrium3 abnormal proliferation of endometrial
lining outside uterus.
9ommon site= ovary.
Signs"symptoms= persistent dysmennorhea and lo( bac+ pain.
Diagnostic test= biopsy, laparoscopy
Drug of choice= /. Dana3ole 4Danocrene5
Action= a. to stop menstruation
b. inhibit ovulation
2. +upreulide 4+upron5
Action= a. inhibit DS1"C1 production
2. %yometrium largest part of the uterus
it is the muscle layer responsible for delivery process
it is a smooth muscles considered to be the li$ing ligature of the body.
po(er of labor, responsible for the contraction of the uterus
3. Perimetrium muscle layer that protects entire uterus
C. 6$aries Almond shape, dull (hite sex glands near the &mbrae, +ept in place by ligaments.
) &emale sex glands that ser$es &or t1o &unctions+
1. ovulation
2. ,roduction of t(o hormones
D. "allopian tu&es 2 # inches long that serves as a passage(ay of the sperm from the uterus to the ampulla of the
passage(ay of the mature ovum of fertili:ed ovum from the ampulla to the uterus. ?idest part
2
6ampulla7 spreads into &ngerli+e pro*ections called 6&mbrae7 responsible for the transport of
mature ovum from ovary to uterus' fertili:ation ta+es place in its outer tird or outer al(.
) si!nifcant se!ments
1. )nfundibulum most distal part of Dallopian 4ube, trumpet or funnel shaped, s(ollen
at ovulation
2. Ampulla outer #
rd
or 2
nd
half, site of fertili:ation
3. )sthmus site of sterili:ation bilateral tubal ligation
). )nterstitial most dangerous site of ectopic pregnancy
8 9ortex of the ovary releases the matured ovum
B. %ale #eproducti$e System
1. 2xternal
Penis the male organ of copulation and urination. )t contains of a body of a shaft consisting of
# cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to
that of the clitoris in the female the glands penis.
3 Cylindrical +ayers
2 corpora cavernosa
1 corpus spongiosum
Scrotum a pouch hanging belo( the pendulous penis, (ith a medial septum dividing into
t(o sacs, each of (hich contains a testes. )t is the cooling mechanism of testes
E 2 degrees 9 than body temperature
2eydigs cell release testosterone
8 pure sperm plus secreting substance eFuals SGBG-8
2. Internal
1e Process o( Spermato!enesis . maturation of sperm
Epididymis 6 meters coiled
tubules site for maturation of sperm
Vas Deferens conduit for
spermatozoa or pathway of sperm
Entry of pure sperm
Seminal vesicle secretes:
1.) Fructose form glucose that has
nutritional alue.
2.) !rostaglandin causes reerse
contraction of uterus
"ypothalamus
will release
#n$"
#onadotropin
releasing hormone
%nterior !ituitary #land
release
F&"
Follicle &timulating
"ormone
'F
'uteinizing
"ormone
Function:
&perm
(aturation
Function:
"ormones for
)estosterone
!roduction
Testes *++ coiled ,- inch long
at age 1. onwards)
,&eminiferous tubules)
Ejaculatry duct conduit of semen
!rstate "land / release al0aline substance
#$pers "land / release al0aline substance
%ret&ra
Final lin0 from anterior to posterior
.
%ale and "emale omolo!ues
%ale "emale
,enile glans 9litoral glans
,enile shaft 9litoral shaft
4estes .varies
,rostate S+enes gands
9o(pers Glands 5artholeneHs glands
Scrotum Cabia Ba*ora
III. Basic 7no8led!e on 9enetics and 6&stetrics
'( D-A carries genetic code
)( 9hromosomes threadli+e strands composed of hereditary material +no(n as D-A
*( -ormal amount of e*aculated sperm # @ cc., / tsp
+( .vum is capable of being fertili:ed (ith in 2! #A hrs after ovulation
,( Sperm is viable (ithin !; I2 hours or 2 # days
-( $eproductive cells divides by the process of meiosis 6haploid7
Spermatogenesis maturation of sperm
.ogenesis process maturation of ovum
Gametogenesis process of formation of 2 haploid into diploid 2# J 2# > !A or diploid
.( Age of $eproductivity /@ !! years old
/( Benstruation
Benstrual 9ycle beginning of menstruation to the beginning of the next menstruation
Average Benstrual 9ycle 2; days
Average Benstrual ,eriod # @ days
-ormal 5lood loss @< cc or K cup (ith &brinolysin to prevent clot formation
$elated terminologies=
%enarce the beginning or the /
st
menstruation
Dysmenorrea painful menstruation
%etrorra!ia bleeding at completely irregular intervals of menstruation
Polymenorrea frequent menstruation occurring at intervals of less than three (ee+s
%enora!ia excessive bleeding during regular menstruation
Amenorrea absence of menstruation
6li!omenorrea marked diminished menstrual Lo(, nearing amenorrhea
%enopause cessation of menstruation " average = @/ years old
:. Dunctions of Gstrogen and ,rogestin
; 2stro!en 21ormone of the ?oman3
Primary function: responsible for the development of secondary sexual characteristic of female.
enlargement of the breast
pelvic
axillary
pubic hair
Others:
1. inhibit production of DS1 6 maturation of ovum7
2. responsible for the hypertrophy of myometrium
3. responsible for Spinnbar+eit 0 Derning 6 billings method" cervical7
). responsible for the development of ductile structure of the breast
*. responsible for the increase osteoblast activities of long bones causing increase
in height in female
<. responsible for the early closure of epiphysis of long bones
=. responsible for sodium retention
>. responsible for the increase sexual desire
8 Progestin 2 1ormone of the Bother3
Primary function: prepares endometrium for implantation of fertili:ed ovum ma+ing it thic+ 0
tortous 6t(isted7
econdary !unction: )t decreases contractility of the uterus 6favors pregnancy7
Others:
1. )t inhibit the production of C1 6hormone for ovulation7
2. )t decreases 9I1 motility
M
decreases Peristalsis
M
increase ?ater #ea&sorption
M
C6@S1IPA1I6@
3. responsible for the development of mammary gland
). responsible for the increase permeability of +idney to lactose 0 dextrose causing 6J7 sugar
*. responsible for mood s(ings in (oman
1
<. responsible for the increase 5asal 5ody 4emperature
1A. %enstrual Cycle: a$era!e . 2> days
3 4hases o& Menstrual /ycle
1.1. ,roliferative
1.2. Secretory
1.3. )schemic
1.). Benses
Parts o& (ody res4onsi(le &or menstruation+
1. hypothalamus
2. anterior pituitary gland mastercloc+ of the body
3. ovaries
). uterus
I. Initial pase of menstruation, the estrogen level is B , this level stimulates the hypothalamus to release
Gn$16gonadotrophin releasing hormone7 or DS1$D6Dollicle Stimulating 1ormone $eleasing Dactor7
#
rd
day Decreased estrogen
/#
th
day ,ea+ estrogen, Decrease progesterone
/!
th
day )ncrease estrogen, )ncrease progesterone
/@
th
day Decrease estrogen, )ncrease progesterone
II. 9n#H4!onadotropin releasin! ormone5 or "SH#"4"ollicle Stimulatin! Hormone #eleasin! "actor5
stimulates the anterior pituitary gland to release DS1 6Dollicle Stimulating 1ormone7
"unctions o( "SH=
A. Stimulate ovaries to release estrogen
B. Dacilitate gro(th primary follicle to become graNan follicle
6structures that secrets large amount of estrogen 0 contains mature ovum.7
III. Proli(erati$e Pase contains mature ovum 6ovulation7
proliferation of tissue O follicular phase O post menstrual phase O ,reovularoty ,hase
"ollicular Pase causing irregularities or variations of menstruation' /!
th
days
Postmenstrual Pase occurs after menstruation day
Preo$ulatory Pase happens before menstruation day
2 all phases increase EST,GE53
I-. /#
th
day of menstruation, estrogen level is pea+ (hile the progesterone level is do(n , these stimulates the
hypothalamus to release Gn$1 or C1$D 6Cuteini:ing 1ormone $eleasing Dactor7
-. Gn$1"C1$D stimulates the anterior pituitary gland to release C16Cuteini:ing 1ormone7
"unctions o( +H=
1. C1 stimulates ovaries to release progesterone
2. hormone for ovulation
-I. /!
th
day estrogen level is increased (hile the progesterone level is increased causing rupture
of graNan follicle on process of o$ulation.
Si!ns and symptoms:
1.5 Bittelschmer: slight abdominal pain on Ceft or $ight lo(er Puadrant of abdomen, mar+s ovulation
day.
2.5 9hange in 5asal 5ody 4emperature
3.5 Bood S(ing
).5 9onstipation
-II. /@
th
day, after ovulation day, graa&an follicle starts on degenerate becoming yello(ish +no(n as cor4us luteum
6secretes large amount of progesterone7
-III. Secretory phase
Cutheal ,hase
,ostovulatory )ncreased progesterone
,remenstrual
Secretory Pase secretes the most important hormone in pregnancy (hich is the
4rogesterone because it ma+es the uterus nutritionally abundant (ith blood in order for the fertili:ed
:ygote to survive should conception ta+e place. )t is also called 4rogestational 4hase.
+uteal Pase . change from Graa&an follicle to 9orpus Cuteum6yello(ish appearance7
Posto$ulatory Pase . occurs *ust after ovulation
Premenstrual Pase . occurs after menstruation
IC. 2!
th
day no fertili:ation, corpus luteum degenerate turning (hite 6 1hitish 6 cor4us al(icans7
C. 2;
th
day no sperm in ovum endometrium begins to slough o% to have the next menstrual period
/
st
I days menstrual phase
I /!
th
days proliferative phase
/! 2; days secretory phase
11 . Sta!es o( Sexual #esponses 6G,.$7
Initial responses:
"asocongestion congestion of blood vessels
#yotonia increase muscle tension
2
1. Gxcitement Phase 6moderate vital signs = sign present in both sexes, moderate increase in
1$, $$,5,, sex Lush, nipple erection7 during this phase= erotic
stimuli increase sexual tension that may lasts from minutes to hours.
2. ,lateau Phase 6accelerated Qital Signs7 increasing 0 sustained tension nearing orgasm.
Bay lasts #< seconds # minutes.
3. .rgasm 6involuntary spasm throughout the body, pea+ vital signs7. 4his is the
involuntary release of sexual tension accompanied by physiologic and
psychologic release +no(n as 2immeasura(le 4eak o& sexual ex4erience3.
Bay last from 2 /< sec most a%ected are is pelvic area$
). $esolution 6vital sign return to normal, genitals return to preexcitement phase7
#e(ractory Period the only period present in males, (herein he cannot be restimulated for about
/< /@ minutes
I-. ?onders o( "ertili3ation
Dornix (here sperm is deposited
Sperm small head, long tail, pearly (hite
,honones vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and :ona pellocida.
9apacitation ability of sperm to release proteolytic en:yme to penetrate corona radiata and
:ona pellocida.
A( "ertili3ation . union of the sperm and the mature ovum in the outer third or outer half of the
Dallopian 4ube.
General 9onsideration=
1. -ormal amount of semen per e*aculation # @ cc > / teaspoon
2. -umber of sperms in an e*aculate > /2< /@< million"cc
3. Bature ovum is capable of being fertili:ed for 2! #A hours after ovulation.
). Sperms are capable of fertili:ing even for # ! days after e*aculation
*. Sperm is viable (ithin !; I2 hours or 2 # days
<. -ormal lifespan of sperm > I days
=. Sperms, once deposited in the vagina, (ill generally reach the cervix (ithin R< seconds after deposition.
>. $eproductive cells, during gametogenesis, divide by meiosis 6haploid number of daughter cells7' therefore, they contain
only 2# chromosomes 6 the rest of the body cells have !A chromosomes 7. Sperms have 22 autosomes and / S sex
chromosomes or / T sex chromosome' .vum contain 22 autosomes and / S sex chromosome. 4he union of an S
carrying sperm and a mature ovum results in a baby girl 6SS7' the union of a Tcarrying sperm and mature ovum results
in a baby boy 6ST7.
Important: .nly 2&athers. determine the sex of their children
B( Sta!es o( "etal 9ro8t and De$elopment
# ! days travel of :ygote D during the travel D mitotic cell division begins
8Pre0em&ryonic Sta!e
a. 7ygote % fertili:ed ovum. Cifespan of :ygote from fertili:ation to 2 months
fetus 2 months to birth
(. Morula mulberryli+e ball (ith /A @< cells, start to travel by ciliary action and
peristaltic contractions of fallopian tube to the uterus (here it (ill stay for ! days
free Loating 0 multiplication
c. "lastocyst enlarging cells that forms a cavity in the morulla, that later becomes the embryo.
1ropo&last &ngerli+e pro*ections covering around the blastocyst that later becomes placenta and
membrane.
d. *m4lantation other term 5idation occurs after fertili:ation I /< days.
Placenta previa implantation at the lo(er side of the uterus
Si!ns o( implantation=
/. slight pain
2. slight vaginal spotting
if (ith fertili:ation corpus luteum continues to function 0 become source of estrogen
0 progesterone (hile placenta is not developed.
8 3 processes o( Implantation
1. Apposition blastocysts begin to brush the endothelial lining
2. Adhesion blastocysts begin to attached the endothelial lining
3. )nvasion blastocysts begin to settle do(n
-Proteolytic en8yme. 6 for dissolving endothelial lining allo(ing implantation
8 2m&ryonic Sta!e
C. Decidua thic+ened endometrium 6Gree+ (ord falling o%7' implantation has ta+en place
7inds o( decidua=
; Basalis 4&ase5 part of endometrium located directly beneath or under the implanted ovum"fetus
(here placenta is developed.
; Capsularies encapsulate or co the fetus
; -era remaining portion of endometrium.
D. Corionic -illi 0 /< //
th
day of pregnancy' &ngerli+e pro*ections
9 $essels > t(o arteries, one vein
A unoxygenated blood
- .2 blood
A unoxygenated blood
:harton#s ;elly protects cord
6
Corionic -illi Samplin! 4C-S5 removal of tissue sample from the fetal portion of the developing placenta for genetic
screening. Done early in pregnancy.
&ommon dangerous side e'ects: fetal limb defect such as missing digits"toes.
Advance #aternal Age ( candidate for amniocentesis
2. Cytotropo&last inner layer or langhans layer of the trophoblast that gives rise to the outer surface and
villi of the chorion.
protects fetus against syphilis, ho(ever it can be capable of living for 2! (ee+s"A months
life span of langhans layer increase.
8 5efore 2! (ee+s critical, might get infected syphilis
". Syncytiotropo&last syncytial layer or outer layer . )t erodes the uterine (all during implantation and give rise to the villi
of the placenta. )t is responsible production of hormones. )t is also called 4lasmidotro4ho(last<
syncytial tro4ho(last= syntro4ho(last
T1o structures de$elo4ed=
1. Amnion innermost layer. )t is a membrane, continuous (ith and covering the fetal side of
the placenta that forms the outer surface of the umbilical cord.
2 structures pro!ress:
a. Um(ilical /ord other term chorda um(ilicalis= &uniculus um(ilicans= &unis, a Lexible structure
connecting the umbilicus (ith the placenta in the gravid uterus and giving passage to the umbilical
arteries and vein' (hitish grey, 2/@ @@ cm, 2< 2/3.
8*m4ortance o& determining the length o& the cord+
Short cord= abruptio placenta or inverted uterus.
Cong cord= cord coil or cord prolapse
)e*born: 2 feet long and U inch in diameter' /
st
formed during the @
th
(ee+ of pregnancy' it contains the yol+
sac and the body stal+ (ith enclosed allatois.
&. %mniotic >luid , also +no(n as ?":@ (ag o& 1ater= clear, odor mousy"musty, (ith crystalli:ed forming
pattern, slightly al+aline.
;"unction o( Amniotic "luid:
1. cushions fetus against sudden blo(s or trauma
2. facilitates musculo s+eletal development and symmetrical gro(th
3. maintains temperature
). prevent cord compression
*. help in delivery process
normal amount of amniotic Luid @<< to /<<<cc
polyhydramnios, hydramnios G)4 malformation 64GA7 4racheoesophageeal Atresia "64GD7
4racheoesophageal Distula, increased amount of Luid
oligohydramnios decrease amount of Luid +idney disease' 2inom O absorbed O ihi3
Dia!nostic 1ests (or Amniotic "luid
A. Amniocentesis . aspiration of amniotic Luid
0 empty bladder before performing the procedure.
Pur4ose obtain a sample of amniotic Luid by inserting a needle through the abdomen
into the amniotic sac.
>luid is tested &or+
'( Genetic screening " abnormality maternal serum alpha fetoprotein test 6BSAD,7
/
st
trimester
)( Determination of fetal lung maturity primarily by evaluating factors indicative of
lung maturity #
rd
trimester
2./ 4esting time #A (ee+s
decreased BSAD,6maternal serum alpha feto%protein test+ > do(n syndrome
increase BSAD,6maternal serum alpha feto%protein test+ > spina bi&da or open neural tube defect
9ommon infections amniocenthesis infection
Dangerous complications spontaneous abortion " bleeding
#
rd
trimester pre term labor' indication of diabetic mother
)mportant factor to consider for amniocentesis needle insertion site
Aspiration of yello(ish amniotic Luid *aundice baby " hyperbilirubin
Greenish mecomium
A. Amnioscopy direct examination thru an intact fetal membrane.
B. "ern 1est determine if amniotic Luid has ruptured or not
6blue paper turns green"grey J ruptured amniotic Luid7
C. @itra3ine Paper 1est di% amniotic Luid 0 urine.
,aper turns yello( urine. ,aper turns blue green"gray 6J7 rupture of amniotic Luid.
2. Corion (here placenta is developed outermost membrane
Cecithin Sphingomyelin C"S
$atio 2=/ signi&es fetal lung maturity not capable for
$DS6$espiratory Distress Syndrome7
1est (or "etal +un! %aturity:
hake test amniotic J saline 0 sha+e
!oam test amniotic J saline 0 sha+e
Phosphatiglycerol: ,GJ de&nitive test to determine fetal lung maturity
a. Placenta 6Secundines7 Gree+ panca+e, combination of chorionic villi J deciduas basalis.
Si:e= @<<g or U +g
/@ 2; cotyledons
/ inch thic+ 0 ;3 diameter
"unctions o( Placenta:
3
1. $espiratory System beginning of lung function after birth of baby. Simple di%usion
2 1igher 9oncentration to Co(er 9oncentration3
2. G)4 transport center, glucose transport is facilitated di%usion more rapid from higher to lo(er. )f
mom hypoglycemic, fetus hypoglycemic
21igher to Co(er 9oncentration but $A,)D3
3. Gxcretory System artery carries (aste products. Civer detoxi&es (aste products of the fetus.
). 9irculating system achieved by selective osmosis
*. Gndocrine System produces hormones
1uman 9horionic Gonadrophin maintains corpus luteum alive' basis of pregnancy test
1uman placental Cactogen or sommamommamotropin 1ormone for mammary gland
development. 1as a diabetogenic e%ect serves as insulin antagonist
$elaxin 1ormone causes softening *oints 0 bones
estrogen
progestin
<. )t serves as a protective barrier against some microorganisms 1)Q,15Q
Gntire pregnancy days 2AA 2;< days #I !2 (ee+s
2;< divided by 2; > /< lunar months
2;< divided by #/ days > R.I days 6calendar months7
/
st
(ee+ counted 2:ero3
"etal Sta!e E "etal 9ro8t and De$elopmentF
"irst trimester: period of organogenesis, most critical period
Dirst Bonth 5rain 0 heart development
G)4 0 respiratory 4ract remains as single tube
1. Detal heart tone begins heart is the oldest part of the body
2. 9-S develops di::iness of mother due to hypoglycemic e%ect
Dood of brain glucose
complex 91. pregnant (omans food 6potato7
DiGerentiation o( Primary 9erm layers
; 2ndoderm
/
st
(ee+ endoderm primary germ layer
4hyroid for basal metabolism' respiratory
,arathyroid for calcium metabolism
4hymus development of immunity
Civer
Cining of upper $espiratory 4ract 0 Gastro )ntestinal 4ract
; %esoderm development of heart, musculos+eletal system, +idneys and
reproductive organ
; 2ctoderm development of brain 9-S, s+in and @ senses, hair, nails,
mucous membrane of anus 0 mouth
Second Bonth
1. All vital organs formed, placenta developed
2. 9orpus luteum source of estrogen 0 progesterone of infant life span end of 2
nd
month
3. Sex organ formed
). Beconium is formed
4hird Bonth
1. Vidneys functional
2. Detus begin to s(allo( amniotic Luid
3. 5uds of mil+ teeth appear
). Detal heart tone heard Doppler /< /2 (ee+s
*. Sex is distinguishable
Second 1rimester: D.9WS length of fetus
Dourth Bonth
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, /; 2< (ee+s
3. buds of permanent teeth appear
Difth Bonth
1. lanugo covers body
2. actively s(allo(s amniotic Luid
3. /R 2@ cm fetus,
). Puic+ening /
st
fetal movement. /; 2< (ee+s primi, /A /; (ee+s multi
*. fetal heart tone heard (ith or (ithout instrument
Sixth Bonth
1. eyelids open
2. (rin+led s+in
3. vernix caseosa present
1ird trimester: ,eriod of most rapid gro(th. D.9WS= (eight of fetus
4
Seventh Bonth
development of surfactant lecithin
Gighth Bonth
1. lanugo begin to disappear
2. subcutaneous fats deposit
3. -ails extend to &ngers
-inth Bonth
1. lanugo 0 vernix caseosa completely disappear
2. Amniotic Luid decreases
4enth Bonth
bone ossi&cation of fetal s+ull
1erato!ens0 any drug, virus or irradiation, the exposure to such may cause damage to the fetus
A. Drugs=
Streptomycin anti 45 0 or Puinine 6anti malaria7 damage to ;
th
cranial nerve poor
hearing 0 deafness
4etracycline staining tooth enamel, inhibit gro(th of long bone
Qitamin V lead to hemolysis 6destruction of $597' hyperbilirubenia or *aundice
)odides enlargement of thyroid or goiter
4halidomides Amelia totally no extremities
,ocomelia absence of distal part of extremities
Steroids cleft lip or cleft palate or even abortion
Cithium congenital malformation
B. Alcohol lo( birth (eight 6vasoconstriction on mother7, fetal alcohol (ithdra(al syndrome charteri:ed by
microcephaly
C. Smo+ing lo( birth (eight
D. 9a%eine lo( birth (eight abruption placenta
2. 9ocaine lo( birth (eight

16#CH 41errato!enic5 In(ections viruses
91A$A94G$)S4)9S= group of infections caused by organisms that can cross the placenta or ascend through birth canal and
adversely e%ect fetal gro(th and development. 4hese infections are often characteri:ed by vague, inLuen:a li+e &ndings,
rashes and lesions, enlarged lymph nodes, and *aundice 6hepatic involvement7. )n some cases the infection may go
unnoticed in the pregnant (oman yet have devastating e%ects on the fetus. 16#CH: 4oxoplasmosis, .ther, $ubella,
9ytomegalo virus, 1erpes simples virus.
1 toxoplasmosis mom ta+es care of cats. Deces of cat go to ra( vegetables or meat
6 others. 1epa A or infectious heap oral" fecal 6hand (ashing7
1epa 5, 1)Q blood 0 body Luids
Syphilis
# rubella German measles congenital heart disease 6/
st
month7 normal rubella titer /=/<
E /=/< less immunity to rubella, after delivery, mom (ill be given rubella vaccine. Avoid
pregnancy for # months because Qaccine is terratogenic' -otify the doctor
C cytomegalo virus 69BQ7
H herpes simplex virus
-. Pysiolo!ical Adaptation o( te %oter to Pre!nancy
A. Systemic Can!es
1. /ardio$ascular System beginning the end of the /
st
trimester, there is a gradual increase
blood volume of mom 6 plasma blood 7 #< @<X > /@<< cc
of blood
easy fatigability, increase heart (or+load, slight hypertrophy
of ventricles,
epistaxis due to hyperemia of nasal membrane
palpitation due to stimulation of parasymphathetic nervous system
Pysiolo!ic Anemia pseudo anemia of pregnant (omen
@ormal -alues
1ct #2 !2X
1gb /<.@ /!g"dC
Criteria
/
st
and #
rd
trimester. pathologic anemia if lo(er
1ct should not fall belo( ##X
1gb should not fall belo( //g"dC
2
nd
trimester 1ct should not fall belo( #2X
1gb should not fall belo( /<.@X
pathologic anemia if lo(er
Pato!enic Anemia
/ iron de&ciency anemia is the most common hematological disorder. )t a%ects toughly 2<X of pregnant
(omen.
Assessment re$eals:
,allor, constipation
*
Slo(ed capillary re&ll
9oncave &ngernails 6late sign of progressive anemia7 due to chronic physiologic hypoxia
@ursin! Care:
-utritional instruction +ang+ong, liver due to ferridin content, green leafy vegetablealugbati, saluyot,
malunggay, horseradish, ampalaya
,arenteral )ron 6 )mferon7 severe anemia, give )B, Y tract if improperly administered, hematoma.
.ral )ron supplements 6ferrous sulfate <.# g. # times a day7 empty stomach / hr before meals or 2 hours
after, blac+ stool, constipation
Bonitor for hemorrhage
Alert:
)ron from red meats is better absorbed iron form other sources
)ron is better absorbed (hen ta+en (ith foods high in Qitamin 9 such as orange *uice
1igher iron inta+e is recommended since circulating blood volume is increased and hemoglobin is reFuired
from production of $59s
2dema occurs because of poor circulation resulting from pressure of the gravid uterus on
the blood vessels of the lo(er extremities due venous return is constricted due to
large belly.
Management+ elevate " raise legs above hip level.
-aricosities pressure of uterus
Management+ use support stoc+ings, avoid (earing +nee high soc+s
use elastic bandage lo(er to upper
-ul&ar $aricosities painful, pressure on gravid uterus,
Management+ to relieve position side lying (ith pillo( under hips or
modi&ed +nee chest position
1rom&ople&itis presence of thrombus at inLamed blood vessel
pregnant mom hyper&brinogenemia
increase &brinogen
increase clotting factor
thrombus formation candidate
outstanding sign 6J7 1omanHs sign pain on cu% during dorsiLexion
mil+ leg s+inny (hite legs due to stretching of s+in caused by inLammation or
phlagmasia albadolens
Management+
1.5 9omplete 5ed rest
2.5 -ever massage
3.5 Assess J 1oman sign once only might dislodge thrombus
).5 Give anticoagulant to prevent additional clotting 6thrombolytics (ill dilute7
*.5 Bonitor A,44 1eparin toxicity = protamine sulfate6antidote for heparin7
<.5 Avoid aspirinZ Bight aggravate bleeding.
). ,es4iratory system common problem Shortness .f 5reathing due to enlarged uterus 0
increase .2 demand
Management+ ,osition= lateral expansion of lungs or side lying position.
9. Gastrointestinal /
st
trimester change
; %ornin! SicHness nausea 0 vomiting due to increase 19G.
Management:
Gat dry crac+ers or dry 91. diet #< minutes before arising bed.
-ausea afternoon small freFuent feeding.
o -omitin! in pre!nancy emesisgravida.
o 2xcessi$e -omitin! hyperemesisgravidarum
Betabolic al+alosis, Dluids 0Glectrolytes imbalance
primary medical management $eplace Dluids.
Bonitor )nput 0 .utput
; Constipation progesterone responsible for constipation.
Management:
8 )ncrease Luid inta+e
8 )ncrease &ber diet =
fruits papaya, pineapple, mango, (atermelon, cantaloupe,
apple (ith s+in, suha, except guava has pectin for constipating
vegetables petchay, malunggay, s(amp cabbage 6+ang+ong7
8 Gxercise
8 Bineral .il excretion of fat soluble vitamins
; "latulence avoid gas forming food such as cabbage, camote
8 Heart&urn or - 4yrosis. reLux of stomach content to esophagus
Management+
/ small freFuent feeding, avoid # full meals, avoid fatty 0 spicy food,
sips of mil+ at freFuent interval, proper body mechanical
increase salivation ptyalsim management: mouth(ash
8 Hemorroids pressure of gravid enlarged uterus.
Management+
hot sit: bath for comfort
1+
cold compression (ith (itch ha:el or G,S.B salts
). /rinary System
freFuency of urination during /
st
0 #
rd
trimester
management for nocturia = lateral expansion of lungs or side lying position
-octuria urination during night time
1eat Acetic Acid test is a test to determine the presence of albumin and protein
in urine
5enedicts test test used to determine sugar in urine
*. Musculoskeletal
22ordosis. 6Gree+= lordos bent for(ard' osis condition7 also +no(n as the 2pride of pregnancy3
/ an abnormal anterior concavity of the lumbar part of the bac+' in(ard curvature of the spine
2:addling Gait. characteri:ed by exaggerated lateral trun+ movements and hip elevation (hich can be
observed in a pregnant patient.
a(+(ard (al+ing of a pregnant mother, candidate for accidental fall due to relaxation and the
hormone responsible for this gait is #elaxin responsible for softening of *oints 0 bones' ,rone to accidental falls
Management (ear Lat " no heels shoes
,regnant mothers can develop 22eg /ram4s. causes= prolonged standing, over fatigue, 9a 0 phosphorous
imbalance 6 [/ cause (hile pregnant 7, chills, oversex, pressure of gravid uterus 6 labor cramps 7 at lumbo sacral nerve plexus
5ote+
+e! cramps during labor is due to pressure of gravid uterus
+e! cramps during pregnancy is due to decrease calcium and increase phosphorus
Management+ Dood 4hat Are $ich in 9alcium=
1. )ncrease 9a diet mil+ 6 )ncrease 9a 0 )ncrease phosphorus 7
/ pint"day or # ! servings"day.
5ote+ theres still a tendency that a mother (ill experience leg cramps due to high level of
phosphorus
2. 9heese, yogurt, and dairy products
3. head of &sh, Dilis, sardines (ith bones, broccoli, seafood such as tahong 6mussels7, lobster, crab.
). Qegetable broccoli

Management+ ,lace the foot a%ected then dorsiLexion
5ote+ Qitamin D for increased 9a absorption
B. +ocal Can!es
1. -a!ina 9had(ic+s sign 6color change of the vagina from pin+ to violet7
blue violet discoloration of vagina
Cer$ix GoodellHs sign 6softening of the cervix7
change of consistency of cervix
/terus 1egarHs sign 6softening of the lo(er uterine segment7
change of consistency of isthmus 6lo(er uterine segment7
+2/76##H2A (hitish gray, mousy odor discharge
2S1#692@ hormone, responsible for leu+orrhea 6remember the second letter of Ceu+orrhea7
6P2#C/+/% mucus plug to seal out bacteria.
P#692S12#6@2 hormone responsible for operculum
6 remember the second letter of .4erculum 7
Pro&lems #elated to te Can!e o( -a!inal 2n$ironment:
a. -a!initits caused by Trichomonas Vaginalis= a Aagellated 4roto8oa= local infection
of the vagina, due to al+aline environment of vagina of pregnant mom acidic
to al+aline change to protect bacterial gro(th 6vaginitis7
2!lagellated proto-oa ( *ants alkaline3
Si!ns ISymptoms=
Greenish cream colored and frothy discharge, irritatingly itchy (ith foul smelling
odor accompanied by vaginal edema
%ana!ement Dru! o( Coice :
"+A9J+ 6Betronida:ole antiproto:oa7.
5ote+ not to be given to pregnant mothers on her /
st
trimester due to
/arcinogenic eBects.
1. on the 2
nd
and #
rd
trimester Lagyl can be given
). treat dad also to prevent reinfection
9. avoid alcohol, antabuse drus has antibuse e%ect
-A9I@A+ D6/CH2 ) Fuart of (ater and / tbsp (hite vinegar
&. %oniliasis or Candidiasis caused by &andida Albicans also called &andidiasis,
fungal infestation.
Si!ns I Symptoms=
/olor (hite cheeseli+e patches adheres to the (alls of vagina, extreme pruritus
Management :
anti&ungal -istatin, gentian violet, cotrimaxole, canesten
9onorrea 4hic+ purulent discharge
11
-a!inal 8arts condifoma acuminata due to papilloma virus
Management+ cauteri:ation
). %(dominal /hanges
8 striae !ra$idarium 6stretch mar+s7 due to enlarging uterus brought
by destruction of subcutaneous tissue.
5ursing /are: )nstruct to avoid scratching and application of oil
8 um&ilicus is protruding
*( Skin /hanges
8 9hloasma" Belasma (hite or light bro(n pigmentation in the nose, chin, chee+s
due to increased melanocytes.
8 Cinea -igra bro(n pin+ish line running from symphisis pubis to umbilicus
+( "reast /hanges all breast changes are related to change and increase in hormones
si:e and color of areola 0 nipple change
pre colostrums present by A (ee+s, colostrums at #
rd
trimester
BS2 4Breast sel( exam5 one (ee+ or I days after menstruation
Position: supine (ith pillo( at bac+
Fuadrant 5 upper outer common site of cancer
1est to determine &reast cancer:
%ammo!rapy #@ to !R years old should submit to mammography once every 2 years
@< years old and above once a year
*. 6$aries rested during pregnancy' no signi&cant changes
<. Si!ns I symptoms o( Pre!nancy
A$ Presumpti$e signs and symptoms felt and observed by the mother but does not con&rm positive
diagnosis of pregnancy = ub.ective
/$ Pro&a&le signs observed by the members of health team= Ob.ective
&$ Positi$e Si!ns undeniable signs con&rmed by the use of instrument.
Ballotement si!n o( myoma
8 J 19G sign of 1 mole
trans vaginal ultrasound. Gmpty balder
C ultrasound 6 &ull (ladder
placental !radin! rating"grade
< immature
/ slightly mature
2 moderately mature
# placental maturity
?hat is deposited in placenta (hich signify maturity there is calcium
Presumpti$e Pro&a&le Positi$e
1
st
1rimester
5reast changes
Wrinary freFuency
Datigue
Amenorrhea
Borning sic+ness
Gnlarged uterus
2
nd
1rimester
9loasma
Cinea negra
)ncreased s+in pigmentation
Striae gravidarium
Puic+ening
GoodelHs change of consistency of cervix
9had(ic+s blue violet discoloration of vagina
1egarHs change of consistency of isthmus
Glevated 554 due to increased progesterone
,ositive 19G or 6J7pregnnacy test
5allottement bouncing of fetus (hen lo(er uterine is tapped sharply,
sign of myoma
Gnlarged abdomen
5raxton 1ic+s contractions painless irregular contractions
Wltrasound evidence
6sonogram7 full bladder
4ransvaginal empty
bladder
Detal heart tone
Detal movement
Detal outline on xray
Detal parts palpable
-I. Psycolo!ical Adaptation to Pre!nancy 6Gmotional response of mom $eva $ubin theory7
>irst Trimester+
-o tanginal signs 0 symptoms, surprise, ambivalence, denial
Sign of mal adaptation to pregnancy
'e$elo4mental task+ is to accept biological parts of pregnancy
Health Teaching+ bodily changes of pregnancy,
>ocus+ nutrition and on gro(th and development
Second Trimester
12
tangible Signs 0 Symptoms= mother identi&es fetus as a separate entity due to presence of Fuic+ening,
fantasy.
'e$elo4mental task+ to accept gro(ing fetus as baby to be nurtured.
>ocus+ gro(th 0 development of fetus.
Third Trimester+ mother has personal identi&cation on appearance of baby
'e$elo4ment task+ prepare of birth 0 parenting of child.
Health Teaching+ responsible parenthood
5est for 0baby1s 2ayette3 best time to do shopping.
Bost common fear about moms fetus let mother listen to Detal 1eart 4one to allay fear
Cama:e classes
-II. Pre0@atal -isit:
Basic Considerations:
1. "reKuency o( -isit: /
st
I months once a month
; R months t(ice a month
/< once a (ee+ 6(ee+ly7
post term t(ice a (ee+
2. Personal data=
@ame: for identi&cation
A!e: to determine if the mother is in high ris+ 6high ris+ E /; 0 \#@ yrs old7
4HB%#5 Home Base %oterLs #ecord tool used to determine high ris+ pregnancy
Sex: PE45O&6EI false pregnancy common to male
&O4"A5E 6)57O#E psychosomatic reaction (herein the father experiences the
mother goes through' the father is the one to vomits,etc 6lihi7
#eli!ion: for their culture 0 beliefs (ith respect, non *udgmental
6ccupation: &nancial condition or occupational ha:ards
2ducation BacH!round: to determine level +no(ledge
AddressM ci$il status
3. Dia!nosis o( Pre!nancy
1.5 urine exam to determine 19G A (ee+s after Cast Benstrual ,eriod , !< /<<
th
day but pea+ A< I< day best
to get urine exam.
2.5 Glisa test test to detect beta subunit of 19G as early as I /< days
3.5 1ome pregnancy +it do it yourself
). Baseline Data:
Qital Signs especially 5lood ,ressure
Bonitor (eight 6increase (eightt /
st
sign preeclampsia7, pattern of (eight gain"loss is important
?ei!t %onitorin!
Dirst 4rimester= -ormal ?eight gain /.@ # lbs 6 .@ / lb"month 7
Second trimester=-ormal ?eight gain /< /2 lbs 6! lbs"month7 6/ lb"(+7
4hird trimester= -ormal ?eight gain /< /2 lbs 6! lbs" month7 6 /lb"(+7
Average (eight gain 2< 2@ lbs
.ptimal (eight gain 2@ #@ lbs
*. 6&stetrical Data=
nullipara no pregnancy
a. 9ra$ida number of pregnancies, 2 children G2
&. Para number of viable pregnancies, 2 viable ,2
"iability the ability of the fetus to live outside the uterus at the earliest possible gestational age.
%ge o& Via(ility 2< 2! (ee+s
Term #I !2 (ee+s
Preterm 2< #I (ee+s
%(ortion E 2< (ee+s
Sample 9ases=
a. / abortion G24<,<A/C<
/ 2
nd
month pregnant G2,<

b. / !<
th
A.G GA4/,2 A 2C!
/ #A
th
A.G GA ,#
2 miscarriage
/ t(ins #@
th
A.G
/ !
th
month pregnant
c. / #R
th
(ee+
/ miscarriage
/ stillbirth ## A.G 6considered as para7 G!,2
/ pregnant #
rd
(+ G!4/,/A/C/
d. / ##
rd
,
/ !/
st
C
/ abortion A
/ stillbirth #R
th
GA42,2A/C@
1.
/ triplet #2
nd
GA,!
/ !
th
month pregnant
e. / #R
th
A.G
/ miscarriage G!,/
/ stillbirth ##
rd
A.G G!4/,/A/C/
/ #
rd
month pregnant
(. / !<
th
A.G
/ Abortion G!,2
/ t(in #I
th
A.G G!4/,/A/C#
/ !
th
month pregnant
!. / #;
th
A.G / 4riplets #<
th
A.G
/ #I
th
A.G / #2
nd
A.G GA,@
/ Abortion / Stillbirth !2
nd
A.G GA4#,2A/CA
c. Important 2stimates:
1. @a!eleLs #ule used of determine expected date of delivery
]anuary, Debruary and Barch JRJI *hile
April to December #JIJ/
Get Cast Benstrual ,eriod #J I J/ AprDec CB, ]an Deb Bar
B D T JR JI no year
Gxample= a. CB, ]anuary <#, 2<<@
</ <# <@
J <R <I^^^
/</<<@> Gxpected Date of 9on&nement .ctober /<, 2<<@

b. CB, August <!, 2<<@
<; <! <@
<#J<IJ</
<@//<A> GD9 Bay //, 2<<A
2. %cDonaldLs #ule used to determine age of gestation )- ?GGVS
9et te len!t in cm x ='> N A69 in 8eeHs
!4)5I& 89 : ;<=>AO? in *eeks
Dundic 1t S I > A.G in (ee+s
;
Drom symphysis pubis to fundus 2! S I >2/ (+s
;
3. Bartolome8Ls #ule used to determine age of gestation of the fetus
by proper location of fundus at abdominal cavity.
# months above symphysis pubis
@ months level of umbilicus
R months belo( xiphoid
/< months level of ; months due to lightening
). Haases rule . used to determine length of the fetus in cm.
Dormula= /
st
U of preg , sFuare _ month
2
nd
U of preg, x _ month by @
#mos x # > Rcm
! mos x ! > /A cm /< x @ > @< cm /
st
U of preg
@ x @ > 2@ cm
A x @ > #< cm
I x @ > #@ cm 2
nd
U of preg
; x @ > !< cm
R x @ > !@ cm
d. 1etanus Immuni3ations prevents tetanus neonatum
mother (ith complete # doses D,4 young age considered as 44/ 0 2. 5egin 44#
44/ any time during pregnancy
442 ! (ee+s after 44/ # yrs protection
44# A months after 442 @ yrs protection
44! / year after 44# /< yrs protection
11
44@ year after 44! lifetime protection
)ote: if the mother received # doses of D,4 during childhood, she (ill be given 44#.
*. Pysical 2xamination: &ephalocaudal including the teeth
8 Gxamine teeth= sign of infection
Dan!er si!ns o( Pre!nancy:
9 chills" fever infection
9erebral disturbances 6 headache preeclampsia7
A abdominal pain 6 epigastric pain7 aura"alert of impending convulsions
5 boardli+e abdomen sign of abruption placenta
)ncrease 5, 1,-6hypertension7
5lurred vision pre eclampsia
5leeding =
/
st
trimester abortion, ectopic pregnancy
2
nd
trimester 1 mole, incompetent cervix
#
rd
trimester any placental anomalies such as abruption placenta,
placenta previa
S sudden gush of Luid ,$.B 6premature rupture of membrane7 prone to infection.
s(elling"edema of upper extremities 6pre eclampsia7
<. Pel$ic 2xamination = )nternal Gxamination
Preparation: @$ empty bladder
A$ universal precaution
.n the &rst visit the mother (ill examined internally in order to determine the presence of probable signs
such as 9had(ic+, Goodels and 1egars sign.
Pap Smear cytological examination to determine the presence of cancer cells
2xternal 6S o( cer$ix site for getting specimen ' composed of sFuamous
columnar tissue' Site for cervical cancer
Vaginal S4eculum (ill be needed, to avoid contact from other organ
#esult:
9lass ) normal
9lass ))A suggestive of inLammation
5 acytology but no evidence of malignancy
9lass ))) cytology suggestive of malignancy
9lass )Q cytology strongly suggestive of malignancy
9lass Q cytology conclusive of malignancy
Sta!es o( Cer$ical Cancer
Stage < carcinoma insitu
/ cancer con&ned to cervix
2 cancer extends to vagina
# pelvis metastasis
! a%ectation to bladder 0 rectum
=. +eopoldLs %aneu$er
,urpose= is done to determine the attitude, fetal presentation lie, presenting part, degree
of descent, an estimate of the si:e, and number of fetuses, position, fetal bac+ 0
fetal heart tone' use palmZ ?arm palm.
,reparation for mothers=
/. Gmpty bladder
2. ,osition of momsupine (ith +nee Lex
6dorsal recumbent to relax abdominal muscles7
Procedure:
1
st
maneu$er= ,lace patient in supine position (ith +nees slightly Lexed' ,ut to(el under head
and right hip' ?ith both hands palpate upper abdomen and fundus. Assess si:e, shape,
movement and &rmness of the part. )n dorsal recumbent position to relax the abdominal
muscles. 4o determine presentation parts.
2
nd
%aneu$er: (ith both hands moving do(n, identify the bac+ of the fetus 6to hear fetal heart
sound7 (here the ball of the stethoscope is placed to determine Detal 1eart 4one. Get Qital
Signs 6before 2
nd
maneuver7 ,ulse $ate to di%erentiate fundic sou`a 6Detal 1eart $ate7 0
uterine sou`a 6Baternal 1eart $ate7. 4o determine fetal bac+.
3
rd
%aneu$er= using the right hand, grasp the symphysis pubis part using thumb and &ngers.
12
4o determine degree of engagement. 6Assess (hether the presenting part is engaged in the
pelvis 7 Alert = if the head is engaged it (ill not be movable.
)
t
%aneu$er: the Gxaminer changes the position by facing the patients feet. ?ith t(o hands,
assess the descent of the presenting part by locating the cephalic prominence or bro(.
?hen the bro( is on the same side as the bac+, the head is extended. ?hen the bro( is on the
same side as the small parts, the head (ill be Lexed and vertex presenting. 4o determine
attitude relationship of fetus to / another.
%ttitude refers to the relationship of fetus to each part into one another 6 degree of Lexion 7
>ull Aexion (hen the chin touches the chest
>. Assessment o( "etal ?ell0Bein!0
A. Daily "etal %o$ement Countin! 4D"%C5 . begin 2I (ee+s
Bother begin after meal brea+fast
a. CardiG count to 1A metod one method currently available
415 5egin at the same time each day 6usually in the morning, after brea+fast7 and count
each fetal movement, noting ho( long it ta+es to count /< fetal movements 6DBs7
425 Gxpected &ndings /< movements in / hour or less
435 ?arning signs
a.5 more than / hour to reach /< movements
&.5 less than /< movements in /2 hours 6nonreactive fetal distress7
c.5 longer time to reach /< 6DBs7 fetal movements than on previous days
d.5 movement are becoming (ea+er, less vigorous
8 Bovement alarm signals B C !#s in @A hours
4).5 ?arning signs should be reported to healthcare provider immediately' often reFuire
further testing. Gxamples= non stress test 6-S47, biophysical pro&le 65,,7
&. @onstress test to determine the response of the fetal heart rate to activity
*ndication pregnancies at ris+ for placental insuNciency
Postmaturity
a.5 ,regnancy )nduced 1ypertension 6,)17, diabetes
&.5 ?arning signs noted during DDB9
c.5 Baternal history of smo+ing, inadeFuate nutrition
Procedure:
Done (ithin #< minutes (herein the mother is in semifo(lers position 6(" fetal
monitor7'external monitor is applied to document fetal activity' mother activates the
2mar+ button3 on the electronic monitor (hen she feels fetal movement.
Attac external nonin$asi$e (etal monitors
1. 1ocotransducer over fundus to detect uterine contractions and fetal movements 6DBs7
2. /ltrasound 1ransducer over abdominal site (here most distinct fetal heart sounds are detected
3. Bonitor until at least 2 DBs are detected in 2< minutes
if no DB after !< minutes provide (oman (ith a light snac+ or gently stimulate fetus through
abdomen
if no DB after / hour further testing may be indicated, such as a 9S4

#esult:
-oncreative
-onstress
-ot Good
#eactive
#esponsive is
#eal Good
Interpretation o( results
i. #eacti$e #esult
1. 5aseline D1$ bet(een /2< and /A< beats per minute
2. At least t(o accelerations of the D1$ of at least /@ beats per minute, lasting at
least /@ seconds in a /< to 2< minutes period as a result of Detal Bovement
3. Good variability normal irregularity of cardiac rhythm representing a balanced
interaction bet(een the parasympathetic 6decreases D1$7 and sympathetic 6increase D1$7
nervous system' noted as an uneven line on the rhythm strip.
). result indicates a healthy fetus (ith an intact nervous system
ii. @onreacti$e #esult
1. Stated criteria for a reactive result are not met
2. 9ould be indicative of a compromised fetus.
$eFuires further evaluation (ith another nonstress test -S4, biophysical pro&le,
65,,7 or 9ontraction Stress 4est 69S47
:. Healt 1eacin!s : do nutritional assessment
a. @utrition daily food inta+e
16
Hi! risH moters:
'( ,regnant teenagers very long compliance to health regimen.
)( Gxtreme (eight
4nder*eight: malnourished li+e elite model
Over *eight : candidate for 1,-, DB
*( Bothers (ith lo( socio economic status refer to DS?D
+( Qegetarian mothers decrease 91.- needs Qitamin 5/2"folic acid cyanocobalamin formation of
folic acid needed for cell D-A 0 $59 formation. 6Decrease folic acid spina bi&da"open neural tube
defect, meningocele umphalocele7
1ypes o( -e!etarian:
1. Strict Qegetarian vegetables only 6 (ith rigid personality7
2. Cactovegetarian vegetables"mil+
3. Cactoovovegetarian vegetables"mil+"egg
Ho8 many calorie = 91. x !, 91.- x !, DA4S x R
Daily Calorie IntaHe : -on ,regnant 2,2<<
Add #<<
,regnant 2,@<<
During Cactation Add @<<
-III. #ecommended @utrient #eKuirement tat increases Durin! Pre!nancy
@utrients #eKuirements "ood Source
Calories
Gssential to supply energy for
/ increased metabolic rate
/ utili:ation of nutrients
/ protein sparing so it can be used
for
/ Gro(th of fetus
/ Development of structures
reFuired for pregnancy including
placenta, amniotic Luid, and
tissue gro(th.
#<< calories"day above the pre
pregnancy daily reFuirement to maintain
ideal body (eight and meet energy
reFuirement to activity level
/ 5egin increase in second trimester
/ Wse (eight gain pattern as an
indication of adeFuacy of calorie
inta+e.
/ Dailure to meet caloric reFuirements
can lead to +etosis as fat and
protein are used for energy' +etosis
has been associated (ith fetal
damage.
9aloric increase should reLect
/ Doods of high nutrient value such as protein,
complex carbohydrates 6(hole grains,
vegetables, fruits7
/ Qariety of foods representing foods sources
for the nutrients reFuiring during pregnancy
/ -o more than #<X fat
Protein
Gssential for=
/ Detal tissue gro(th
/ Baternal tissue gro(th including
uterus and breasts
/ Development of essential
pregnancy structures
/ Dormation of red blood cells and
plasma proteins
8 )nadeFuate protein inta+e has been
associated (ith onset of pregnancy
induces hypertension 6,)17
A< mg"day or an increase of /<X above
daily reFuirements for age group
Adolescents have a higher protein
reFuirement then mature (omen since
adolescents must supply protein for
their o(n gro(th as (ell as protein t
meet the pregnancy reFuirement
,rotein increase should reLect
/ Cean meat, poultry, &sh
/ Gggs, cheese, mil+
/ Dried beans, lentils, nuts
/ ?hole grins
8 vegetarians must ta+e note of the amino acid
content of 91.- foods consumed to ensure
ingestion of suNcient Fuantities of all amino
acids
Calcium0Posporous
Gssential for
/ Gro(th and development of
fetal s+eleton and tooth buds
/ Baintenance of
minerali:ation of maternal
bones and teeth
/ 9urrent research is =
Demonstrating an association
bet(een adeFuate calcium inta+e and
the prevention of pregnancy induce
hypertension
9alcium increases of
/ /2<< mg"day representing an
increase of @<X above pre
pregnancy daily reFuirement.
/ /A<< mg"day is recommended for
the adolescent. /< mcg"day of
vitamin D is reFuired since it
enhances absorption of both
calcium and phosphorous
9alcium increases should reLect=
/ dairy products = mil+, yogurt, ice cream,
cheese, egg yol+
/ (hole grains, tofu
/ green leafy vegetables
/ canned salmon 0 sardines (" bones
/ 9a forti&ed foods such as orange *uice
/ Qitamin D sources= forti&ed mil+, margarine,
egg yol+, butter, liver, seafood
Iron #< mg"day representing a doubling of
13
Gssential for
/ Gxpansion of blood volume and
red blood cells formation
/ Gstablishment of fetal iron stores
for &rst fe( months of life
the pregnant daily reFuirement
/ 5egin supplementation at #<
mg"day in second trimester, since
diet alone is unable to meet
pregnancy reFuirement
/ A< /2< mg"day along (ith copper
and :inc supplementation for
(omen (ho have lo( hemoglobin
values prior to pregnancy or (ho
have iron de&ciency anemia.
/ I< mg"day of vitamin 9 (hich
enhances iron absorption
/ inadeFuate iron inta+e results in
maternal e%ects anemia depletion
of iron stores, decreased energy
and appetite, cardiac stress
especially labor and birth
/ fetal e%ects decreased availability
of oxygen thereby a%ecting fetal
gro(th
8 iron de&ciency anemia is the most
common nutritional disorder of
pregnancy.
)ron increases should reLect
/ liver, red meat, &sh, poultry, eggs
/ enriched, (hole grain cereals and
breads
/ dar+ green leafy vegetables, legumes
/ nuts, dried fruits
/ vitamin 9 sources= citrus fruits 0 *uices,
stra(berries, cantaloupe, broccoli or
cabbage, potatoes
/ iron from food sources is more readily
absorbed (hen served (ith foods high
in Qitamin 9
Oinc
Gssential for
8 the formation of en:ymes
8 may be important in the prevention
of congenital malformation of the
fetus.
/@ mcg"day representing an increase of
# mg"day over prepregnant daily
reFuirements.
Yinc increases should reLect
/ liver, meats
/ shell &sh
/ eggs, mil+, cheese
/ (hole grains, legumes, nuts
"olic AcidP "olacinP "olate
Gssential for
/ formation of red blood cells
and prevention of anemia
/ D-A synthesis and cell
formation' may play a role in
the prevention of neutral
tube defects
6spina bi&da7, abortion,
abruption placenta
!<< mcg"day representing an increase
of more then 2 times the daily pre
pregnant reFuirement. #<<mcg"day
supplement for (omen (ith lo( folate
levels or dietary de&ciency
! servings of grains"day
)ncreases should reLect
/ liver, +idney, lean beef, veal
/ dar+ green leafy vegetables, broccoli,
legumes.
/ ?hole grains, peanuts
Additional #eKuirements
%inerals
/ iodine
/ Bagnesium
/ Selenium
/I@ mcg"day
#2< mg"day
A@ mcg"day
)ncreased reFuirements of pregnancy can easily
be met (ith a balanced diet that meets the
reFuirement for calories and includes food
sources high in the other nutrients needed
during pregnancy.
-itamins
G
4hiamine
$iboLavin
,yridoxine 6 5A7
5/2
-iacin
/< mg"day
/.@ mg"day
/.A mg"day
2.2 mg"day
2.2 mg day
/I mg"day
Qitamin stored in body. 4a+ing it not needed fat
soluble vitamins. 1ard to excrete.
Vitamin %='=E=D % % % )o need to take it daily D !A9 O24/2E +
2. Sexual Acti$ity
a.5 should be done in moderation
&.5 should be done in private place
c.5 that the mother should be placed in comfortable position' sidelying or mother on top
d.5 it must be avoided A (ee+s prior to Gxpected Date of Delivery
e.5 avoid blo(ing or air during cunnilingus to prevent air embolism
(.5 changes in sexual desire of mom during pregnancy
a.5 /
st
trimester decrease desire due to bodily changes
&.5 2
nd
trimester increased desire due to increase estrogen that enhances lubrication
c.5 #
rd
trimester decreased desire due to bodily changes
Contraindication in sex:
1. vaginal spotting
/
st trimester
threatened abortion
2
nd
trimester placenta previa
2. incompetent cervix
3. preterm labor
). premature rupture of membrane prone to infection
14
3. 2xercise . to strengthen muscles that (ill be used during delivery process
it must be done in moderation principles of exercise
it must be individuali:ed case to case basis
8 Ealking best exercise
8 SFuatting strengthen muscles of perineum and increase circulation to perineum. Done
feet Lat on Loor
8 4ailor Sitting same (ith sFuatting done by placing one leg in front of other leg 6 )ndian seat7
$aise buttoc+s /
st
before head to prevent postural hypotension di::iness (hen
changing position
8 Shoulder 9ircling Gxercise to strengthen chest muscles
8 ,elvic $oc+ing",elvic 4ilt Gxercise to relieve lo( bac+ pain 0 maintain good posture
can be used to Cordosis
8 Arch 5ac+ standing or +neeling. Dour extremities on Loor
8 Vegel Gxercise to strengthen pubococcygeal muscles
as if hold urine, release /<x or muscle contraction
8 Abdominal Gxercise to strengthen the muscles of the abdomen
done as if blo(ing candle
). Cild&irt Preparation:
$erall goal+ to prepare parents physically and psychologically (hile promoting (ellness behavior
that can be used by parents and family thus, helping them achieved a satisfying and
en*oying childbirth experience.
a. Psycopysical
1. Bradley %etod discovered by 'r. ,o(ert "radley , advocated active participation of
husband during delivery process to serve as a coach. 5ased on imitation
of nature.
!eatures:
1.5 dar+ened room
2.5 Fuiet environment
3.5 relaxation tech
).5 closed eye 0 appearance of sleep
2. 9rantly DicH #ead %etod that fear leads to tension (hile tension leads to pain
to remove fear by relaxation techniFue and abdominal
exercises
&. Psycosexual
1. 7it3in!er %etod discovered by 'r. Shiela Dit8inger , that pregnancy, labor, birth 0 the
care of the ne(born is an important turning point in a (omans life
cycle
for a mother to achieve the satisfying childbirth experiences, Lo( (ith
contraction rather than struggling (ith contraction
c. Psycopropylaxis prevention of pain
1. +ama3e . discovered by 'r. >erdinand 2ama8e
0 prevention of pain in the brain
!eatures: discipline, conditioning 0 concentration (ith the help of the 1usband
1. 9onscious relaxation
2. 9leansing breathe inhaling through the nose and exhaling through the mouth
3. G`eurage gentle circular massage over abdomen to relieve pain
). )maging sensate focus
*. DiGerent %etods o( deli$ery:
1.5 /irthing &hair bed convertible to chair 2semifo(lers3 position
2.5 /irthing /ed 2dorsal recumbent3 position
3.5 quatting Position position that facilitates descent and relieves lo( bac+ pain during labor pain
).5 2eboyers #ethod features: (arm, Fuiet, dar+ened room, calm and comfortable environment,
room temperature, soft music.
After delivery, baby gets (arm bath.
*.5 /irth 4nder Eater (arm (ater in a bathtub labor 0 delivery (arm (ater, soft music.
/ After delivery the baby should be +ept (armth, prepare for bathing
IC. Intrapartal @otes inside Gmergency $oom
A. Admitting the laboring Bother=
8 ,ersonal Data= name, age, address, etc
8 5aseline Data= v"s especially 5,, (eight
8 .bstetrical Data= gravida [ pregnancy, para viable pregnancy 22 2! (ee+s
8 ,hysical Gxamination
8 ,elvic Gxamination
B. 5asic +no(ledge in )ntrapartum.
1*
&. 1 1eories o( te 6nset o( +a&or
1.5 Wterine Stretch 4heory any hollo( organ once stretched to its maximum potential
(ill al(ays contract 0 expel its content
contraction action
2.5 .xytocin 4heory posterior pituitary gland releases oxytocin that produce by
hypothalamus.
3.5 ,rostaglandin 4heory stimulation of Arachidonic Acid (hich causes contraction to the
onset of labor.
prostaglandin 2male3
).5 ,rogesterone 4heory before labor, decrease progesterone (ill stimulate contractions
and labor
*.5 4heory of Aging ,lacenta lifespan of placenta is !2 (ee+s. 5y #A (ee+s the placenta
is beginning to degenerate hence causes the uterus to
contract to the onset of labor.
&.2. 1e ) PLs o( +a&or
1. Passen!er 0 !E94
a. "etal ead is the largest and common presenting part comprises of K of its length.
Bones . E &etal (ones 6 in all > > &ones 7
S sphenoid
" frontal sinciput
2 ethmoid
6 occuputal occiput
1 temporal
P parietal 2 x
Important %easurement (etal ead:
'( 4ransverse Diameter
5iparietal largest transverse R.2@cm
5itemporal ; cm
5imastoid Icm smallest transverse
2. Anterior ,osterior Diameter 6A, 7
Suboccipitobregmatic from occiput to bregmatic 6 smallest A, diameter7
complete Lexion
.ccipito Drontal /2 cm partial Lexion
.ccipito Bental /#.@ cm hyperLexion 6 largest A, 7
Su(mento(regmatic 6 face presentation 7
Sutures . intermembranous spaces that allo( molding.
a0 Sagittal Suture connects 2 parietal bones 6 sagitna 7
10 9oronal Suture connect parietal 0 frontal bone 6 cro(n 7
c0 Cambdoidal Suture connects occipital 0 parietal bone
%oldin!s: the overlapping of the sutures of the s+ull to permit passage of the
head to the pelvis
"ontanels:
'(0 Anterior fontanel 2bregma3, diamond sha4e, # x ! cm,6 \ @ cm
hydrocephalus7, 9loses @A ( @= months after birth
)(0 ,osterior fontanel 2lambda3 triangular sha4e, / x / cm. 9loses 2 #
months.
2. Passa!e8ay . "agina < Pelvis
&andidate for &< > /.7 5elo( !R3 tall
2.7 5elo( /; years old pelvic not yet achieve fully
#.7 Wnder(ent cephalo pelvic dislocation
a. Pel$is
) main pel$ic types
1. 9ynecoid round, (ide, deeper most suitable 6normal female pelvis7 for pregnancy
2. Android heart shape 2male pelvis3 anterior part pointed, posterior part shallo(
3. Antropoid oval, ape li+e pelvis, oval shape, A, diameter (ider transverse narro(
). Platypelloid Lat A, diameter narro(, transverse (ider
&. Bones o( Pel$is
) hi4 (ones 6 2 innominate bones
2+
3 Parts o( 2 Innominate Bones
Ileum lateral side of hips
F iliac crest Laring superior border forming prominence of hips
Iscium inferior portion
Fischial tuberosity areas (here (e sit , the basis in getting external
measurement of pelvis
Pu&es in the anterior portion
Fsymphysis pubis *unction bet(een 2 pubis
1 sacrum posterior portion
Fsacral prominence basis for internal measurement of pelvis
1 coccyx composed of @ small bones compresses during vaginal delivery
Important %easurements:
1. Dia!onal Con,u!ate measure bet(een sacral promontory and inferior margin of
the symphysis pubis.
#easurement: 11.* cm 0 12.* cm basis in getting true con*ugate.
6D9 //.@ cm > true con*ugate7
2. 1rue con,u!ate'con,u!ate $era measure bet(een the anterior surface of the sacral
promontory and superior margin of the symphysis
pubis.
#easurement: 11.A cm
3. 6&stetrical con,u!ate smallest A, diameter.
,elvis measuring at /< cm or more.
). 1u&eroisci Diameter transverse diameter of the pelvic outlet.
FIschial tuberosity approximated (ith use of &st
; cm 0 above.

3. Po8er . the force acting to expel the fetus and placenta
myometrium po(ers of labor
a. )nvoluntary 9ontractions
&. Qoluntary bearing do(n e%orts
c. 9haracteristics= (ave li+e
d. 4iming= freFuency, duration, intensity
e. Support System
). Psyce'Person . 6mother7 psychological stress exist (hen the mother is &ghting the
labor experience 6 e%ective pushing 7
a. 9ultural )nterpretation
&. ,reparation
c. ,ast Gxperience
d. Support System
&.3 Pre0eminent Si!ns o( +a&or
1. Cightening settling of presenting part into pelvic ring
2 (ee+s prior to GDD
igns Gymptoms:
shooting pain radiating to the legs
urinary freFuency 6plexus"bladder7
pressure at the lumbo sacral nerve
8 Gngagement settling of presenting part of the fetus far enough into the pelvis to be at the
level of ischial spine, a midpoint of the pelvis.
2. 5raxton 1ic+s 9ontractions painless irregular contractions
3. )ncrease Activity of the Bother 2nesting instinct3 6due to epinephrine7.
Cet the mother reserve the energy, (ill be used for delivery.
). $ipening of the 9ervix comparable to butter softness
*. decreased body (eight /.@ # lbs
<. 5loody Sho( pin+ish vaginal discharge 6 combinatiuon of blood 0 leu+orrhea 7
=. $upture of Bembranes rupture of (ater bag. 9hec+ Detal 1eart 4one
P#6B+2%S:
Premature #upture o( %em&rane 4 P#6%5 0 do )nternal Gxamination to chec+ for cord prolapse
8 9ontraction drop in intensity even though very painful
8 9ontraction drop in freFuently
8 Wterus tense and"or contracting bet(een contractions
8 Abdominal palpations
@ursin! Care:
8 Administer Analgesics 6Borphine7
8 Attempt manual rotation for $., or C., most common mal position
8 5ear do(n (ith contractions
8 AdeFuate hydration prepare for 9esarean Section
8 Sedation as ordered
8 9esarean delivery may be reFuired, especially if fetal distress is noted
@612: 5o internal examination *hen the umbilical cord falls or is *ashed through the
21
cervix into the vagina
Cord Prolapse a complication (hen the umbilical cord falls or is (ashed through the cervix
into the vagina.
Dan!er si!ns:
8 ,$.B
8 ,resenting part has not yet engaged
8 Detal distress
8 ,rotruding cord form vagina
@ursin! care:
'( Slip cord a(ay from presenting part
)( 9ount pulsation of cord for Detal 1eart 4one
*( ,ositioning trendelenberg or +nee chest position
+( .bserve for fetal distress
,( provide emotional support
-( ,repare mother for 9esarean Section
9over cord (ith sterile gau:e (ith saline solution to prevent drying of cord so
cord (ill remain slippery.
8 -.4G= &ve minutes cord compression can lead to irreversible brain damage such
as cerebral palsy.
&.). DiGerence Bet8een 1rue +a&or and "alse +a&or
"alse +a&or 1rue +a&or
8 )rregular contractions
8 -o increase in intensity
8 ,ain con&ned on abdomen
8 ,ain relived by (al+ing
8 -o cervical changes
8 9ontractions are regular
8 )ncreased intensity
8 ,ain begins lo(er bac+ radiates to abdomen
8 ,ain intensi&ed by (al+ing
8 9ervical e%acement 0 dilatation
ma*or symptom of true labor.
2Gacement softening 0 thinning of cervix. Wse X in unit of measurement
Dilatation (idening of cervix. Wnit used is cm.
&.* Duration o( +a&or
Primipara /! hours not more than 2< hours
%ultipara ; hours not more than /! hours
&.< @ursin! Inter$entions in 2ac Sta!e o( +a&or
) segments o& the uterus
1. upper uterine fundus
2. lo(er uterine isthmus
1. "irst Sta!e: onset of true contractions to full dilation and e%acement of cervix.
+atent Pase: 6 4he mother is excited but apprehensive and can communicate7
Assessment: Dilatations= < # cm
DreFuency= every @ /< min
)ntensity = mild
@ursin! Care:
1. Gncourage (al+ing to shorten the /
st
stage of labor
2. Gncourage to void every 2 # hours full bladder inhibit uterine contractions
3. 5reathing chest breathing
Acti$e Pase: 4 Bother feels losing control of herself 7
Assessment: Dilatations= ! ; cm
)ntensity= moderate
DreFuency = every # @ minutes lasting for #< A< seconds
@ursin! Care:
% medications have medicines ready
A assessment include= vital signs, cervical dilatation and e%acement, fetal monitoring, etc.
D dry lips oral care 6ointment7
dry linens, change the (et linen
B abdominal breathing
1ransitional Pase: 6 the mood of the mother suddenly change accompanied by
hyperesthesia hypersensitivity to touch 7
Assessment: Dilatations= ; /< cm
DreFuency = every 2 # minutes contractions
Durations = !@ R< seconds
)ntensity= Strong
8yperesthesia ( increase sensitivity to touch, pain all over
22

@ursin! Care:
1 tires
I inform of progress best (ay to give emotional support to the mother
# restless, support her to do breathing techniFue 6chest breathing7
2 encourage and praise
D discomfort due to sacral pressure
Healt 1eacin! :
8 teach the father about sacral pressure techniFue on lo(er bac+ to inhibit transmission
of pain
8 +eep informed of progress
8 controlled chest breathing
Contractions:
Increment' Crescendo beginning of contraction until it increases
Acme' Apex height of contraction
Decrement' Decresendo from height of contraction until it decreases
; Pel$ic 2xams
EBacement+ softening 0 thinning of cervix.
'ilatation+ (idening of cervix.
a. Station . relationship of the presenting part to the ischial spine
landmark used: ischial spine
>loating negative station
0 1 station > presenting part /cm above ischial spine if 67 Loating
0 2 station > presenting part 2 cm above ischial spine if 67 Loating
0 A station > level at ischial spine engagement
Q 1 station > belo( / cm ischial spine
Q3 PQ)P Q* > cro(ning occurs at 2
nd
stage of labor
&. Presentation'lie the relationship of the long axis 6spine7 of the fetus to the
long axis of the mother spine of mom and spine of fetus
18o types:
&.1. +on!itudinal +ie 4 Parallel5
&ephalic % "ertex (hen the fetus is completely Lex
Dace
5ro( Poor "lexion
9hin

/reech 9omplete 5reech thigh rest on abdomen, (hile leg rest on thigh
)ncomplete 5reech
Dran+ thigh rest on abdomen (hile leg rest on the head
Dootling presenting part foot = single, double
Vneeling presenting part +nees
&.2. 1rans$erse +ie 4Perpendicular5 or Perpendicular lie.
Shoulder presentation is very rare / X
c. Position . relationship of the fatal presenting part to speci&c Fuadrant of the
mothers pelvis.
Qariety=
.ccipito" .cciput
C.A left occipito anterior 6most common and favorable position7
side of maternal pelvis
C., left occipito posterior
C., most common mal position, most painful
$., sFuatting pos on mom
$.4
$.A
A . Anterior
+ . +e(t . side o( maternal pel$is
6 . 6ccipito . denominator
$.,' C., = most painful position' best sFuatting position
C.A most favorable position
"AC2 . Bentum CBA, CB4, CB,, $BA, $B4, $B,
Shoulder Acromio Dorso CADA, CAD4, CAD,, $ADA, $AD4, $AD,
5reech SA9$. CSA left sacro anterior CS4, CS,, $SA, $S4, $S,
Soulder'acromniodorso: CADA, CAD4, CAD,, $AD,
Cin ' %ento: +%AP +%1P +%PP #%PP #%AP #%1P #%P
*n cases o& (reech 4resentation 6place the stethoscope above the umbilicus
Si!n o( (etal distress:
E /2< or \ /A< bpm
meconium stain
2.
fetal trushing hyperactivity of fetus due to lac+ of oxygen
%onitorin! te Contractions and "etal eart 1one
Spread &ngers lightly over fundus to monitor contractions
Parts o( contractions=
)ncrement or crescendo beginning of contractions until in increases
Acme or apex height of contraction
Decrement or decrescendo from height of contractions until it decreases
Duration beginning of contractions to end of same contraction
)nterval from the end of / contraction to beginning of next contraction
DreFuency beginning of / contraction to beginning of next contraction
)ntensity the strength of contraction
.nce contraction occur, the blood vessel (ill constrict vasoconstriction decrease the oxygen"circulation
hence, maternal 5, increases Increase /P (hile Detal 1eart 4one decreases.
Ehat *ill happen to the fetusH > 4he fetus has placental reserve for A< seconds
5est time to get 5, of the mother > *ust after the contraction
5est time to get D14 > mid*ay of contraction
,lacental reserve > A< seconds for fetus during contractions
Duration of contractions shouldnt \ A< sec
-otify BD
Healt 1eacin!s:
Bom has Headace chec+ 5,, if same 5,, let mom rest.
)f 5, increases, notify BD preeclampsia
Hun!ry mother @P6 no meals G) is not functioning thus to prevent aspiration
Bate mother can bathe after the delivery
2nema optimum rectal tube /2 /; inches
a.5 4o cleanse bo(el
&.5 ,revent infection
c.5 Sims position"side lying
Constipated moter . slo(ly pulling the rectal tube
8 During insertion of rectal tube contraction clamp after insertion
chec+ the D14 after administration of enema
-ormal D14 > /2</A< bpm
8 ,erineal ,reparation method 6 I method 7
Position : +e(t lateral position . to prevent supine hypotension or the supine vena
caval syndrome.
Pain during labor can give %eperidine HC+ 4 Demerol 5 narcotic antispasmodic
6 during active phase A ; cm 7
Toxic EBect+ respiratory depression
%ntidote + -arcan 6 -aloxone 7
5ote+
Amniotomy arti&cial rupture of the membrane
#espiratory AlHalosis signs and symptoms 6 increase $$, 4ingling sensation,
light headedness,
2. Second Sta!e= fetal stage, complete dilation and e%acement to birth.
1e moter 8ill &e trans(erre to te deli$ery room 8en=
= . > cm for the multi bring to delivery room
> . 1A cm for the primi 6fully dilated7 bring to delivery room
Position: Cithotomy by placing the mothers legs at the same time up
Bul!in! o( perineum sure to come out
Breatin! panting 6 teach mother7
Assist the doctor in doing episiotomy to prevent laceration
/ (iden vaginal canal
/ shorten 2
nd
stage of labor.
2pisiotomy median less bleeding, less pain easy to repair, fast to heal, possible to
reach rectum 6 urethroanal &stula7
Bediolateral more bleeding 0 pain, hard to repair, slo( to heal
use local or pudendal anesthesia.
)roning the perineum to prevent laceration
Bodi&ed $itgens maneuver place to(el at perineum
1.5 4o prevent laceration
2.5 ?ill facilitate complete Lexion 0 extension. 6Support head 0 remove
secretion, chec+ cord if coiled. ,ull shoulder do(n 0 up.
9hec+ time, identi&cation of baby.
%ecanisms o( la&or
1. Gngagement
2. Descent
3. Dlexion
21
). )nternal $otation
*. Gxtension
<. Gxternal rotation
=. Gxpulsion
1ree parts o( Pel$is
1. Inlet A, diameter narro(, transverse diameter (ider
2. &avity area of inlet and outlet
3. Outlet A, (ider, transverse narro(
18o %a,or Di$isions o( Pel$is
1. 9rue pelvis belo( the pelvic inlet
2. !alse pelvis above the pelvic inlet' supports uterus during pregnancy
; +inea 1erminales diagonal imaginary line from the sacrum to the symphysis pubis that
divides the false and true pelvis.
8 2pisiotomy is a surgical incision of the perineum in order to prevent laceration' to (iden
the vaginal canal' to shorten the second stage of labor.
18o 1ypes o( episiotomy:
1. %idline . incise the midline of the perineum
%d$antage+ Gasy to repair, fast healing, less blood loss, less postpartum discomfort
'isad$antage+ incision may extend to anus that leads to urethroanal &stula
6 use sometimes 7
2. %ediolateral . incision is made beginning to the midline but directed laterally a(ay from the
rectum.
%d$antage+ less danger of complication from rectal mucosal tear
'isad$antage+ more bleeding 6more blood vessels hit7, hard to repair, slo( healing,
more discomfort
5ote+
.nce the head is cro(ning ironing the perineum 6to prevent laceration7
Bodi&ed $itgens Baneuver support the perineum 6prevent laceration7
.nce the head is out support the head and remove secretions, chec+ the cord by
inserting 2 &ngers.
@ursin! Care:
-ote the time of delivery
,lacing the baby belo( the vulva
,lace un dependent part
,lace in the abdomen of the mother for bonding and the (eight of the baby facilitates the
contraction of the uterus
9lamp the babys cord (ait for pulsation to stop before clamping the cord since A< /<< cc of blood
(ill be going to baby.
,roper identi&cation, footprinting
)f in case the baby is dead, sho( the baby to the mother for acceptance of the &nality of dead.
4o prevent puerperal sepsis E !; hours only vaginal pac+
)ote: 5olus of Ptocin can lead to hypotension.
3. 1ird Sta!e: &irt to expulsion o( Placenta 0 placental stage
1e Placenta sould &e expelled 301A minutes a(ter te deli$ery o( te &a&y
Si!ns o( placental separation
/. Dundus rises becomes &rm 0 globular 2 9al+ins sign3 if not Wterine Atony
2. Cengthening of the cord 5randt Andre(s maneuver slo(ly pulling of the cord
#. Sudden gush of blood
1ypes o( placental deli$ery
Sult3 2shiny3 begins to separate from center to edges presenting the
fetal side shiny
DunHan 2dirty3 begins to separate form edges to center presenting
maternal side beefy red or dirty
)ote: Slo(ly pull cord and (ind to clamp 5$A-D4 A-D$G?S BA-GWQG$
1urrying of placental delivery (ill lead to inversion of uterus.
@ursin! care (or placenta:
9hec+ completeness of placenta. placenta has /@ 2; cotyledons
9hec+ fundus 6if relaxed, massage uterus if not &rm7
9hec+ blood pressure Administer Bethergine )B 6Bethylergonovine Baleate7 as ordered. )t should be
given )B, chec+ the 5, before administration. 2Grgotrate derivatives.
Bonitor hypertension 6or give oxytocin )Q7
9hec+ perineum for lacerations
Assist BD in doing episiorapy , vaginal pac+ should be used for !; hours to prevent puerperal sepsis.
)n recovery room, should be Dlat on bed
)f chilling occurs due to dehydration *ust give additional 5lan+et
22
Give clear liFuid 6 tea, ginger ale, clear gelatin, Gatorade7 once regulated, can be given full liFuid
such as mil+, ice cream, soup then soft diet to regular diet.
Cet mother sleep to regain energy.
). "ourt Sta!e: te frst 1 0 2 ours a(ter deli$ery o( placenta reco$ery sta!e.
a. %aternal 6&ser$ations body system stabili:es
9hec+ the vital signs F /@ for / hour. 2
nd
hour F #< minutes.
&. Placement o( te "undus *ust above the umbilicus or level of umbilicus. )f palpated on the
right side it means full bladder therefore empty the bladder.
)f fundus above umbilicus, deviation of fundus
/.7 Gmpty bladder to prevent uterine atony
2.7 9hec+ lochia
c. +ocia vaginal discharges after the delivery process
,u(ra red , / # days moderate
Serosa pin+ to bro(n, ! R days , decrease in amount, (ith musty odor
%l(a creamy (hite , /< days # (ee+s
d. Perineum chec+ the perineum for =
$ redness
G edema
G ecchymosis
D discharges
A approximation of blood loss.
8 9ount pad 0 saturation
8 Dully soa+ed pad = #< !< cc (eigh pad. / gram > /cc
e. Bondin! interaction bet(een mother and ne(born
1ypes o( roomin!:
/.7 Strict rooming= 2! hours baby stays (ith mother.
2.7 ,artial rooming in= baby stays (ith mother in the morning
and stays in the nursery at night .
Complications o( +a&or
Dystocia diNcult labor related to mechanical factor
due to uterine inertia (hich means sluggishness of contraction
2 1ypes o( uterine inertia:
/.7 hypertonic or primary uterine inertia intense excessive contractions
resulting to ine%ective pushing
Management+ sedation BD administer sedative
-alium'Dia3epam muscle relaxant
2.7 hypotonic secondary uterine inertia, slo( irregular contraction
resulting to ine%ective pushing.
Management+ Administer 6xytocin
Prolon!ed la&or . resulting to=
Maternal EBect+ exhaustion 6 overpushing 7
>etal EBect+ fetal distress, cephalohematoma or caput succedaneum
2A hours ,rimi
1) hours Bulti
; normal length of labor in primi /! 2< hours ' Bulti /< /! hours
Management+ 9hec+ and monitor 9ontraction and Detal 1eart 4one
Precipitate +a&or labor of E # hours. extensive lacerations to mother that leads to profuse
bleeding O hypovolemic shoc+ O hypotension, 4achypnea, 4achycardia, cold clammy s+in
5ote+ Garliest sign= tachycardia 0 restlessness
Cate sign= hypotension
.utstanding -ursing diagnosis= Luid volume de&cit
,osition of mother= Bodi&ed 4rendelenberg
)Q fast drip due Luid volume de&cit
Si!ns o( Hypo$olemic SocH:
1ypotension
4achycardia
4achypnea
9old clammy s+in
In$ersion o( te /terus uterus is turned inside out due to the follo(ing factors=
a. hurrying pull out of the placenta
&. ine%ective fundal pressure
c. short cord
Management+ BD (ill push uterus bac+ inside or not hysterectomy.
/terine #upture Possi(le causes+
1.5 ,revious classical 9esarean Section
2.5 Carge baby
3.5 )mproper use of oxytocin 6)Q drip7
Sym4toms+
a.5 sudden pain
26
&.5 profuse bleeding
c.5 hypovolemic shoc+
d.5 4A15S.
5ote+ ,hysiologic $etraction boundary bet(een upper and lo(er uterine segment
Suprapubic Depression sign of impending rupture of the uterus
5andls ,athologic $ing bleeding that leads to hypovolemic to 4A515S.
Amniotic "luid 2m&olism a situation of amniotic Luid or fragments of placenta
enters natural circulation resulting to embolism.
I( @SD . Si!ns and Symptoms:
a. dyspnea
&. chest pain
c. frothy sputum
Pre4are+ suctioning
end stage: D)9 disseminated intravascular coagopathy
; intra$ascular coago4athy bleeding to all portions of the body such as
eyes, nose, etc.
1rial +a&or . (hen the head measurement and pelvis measurement falls on
the borderline.
Management+ Give the mother A hours of labor allo(ance= Bulti= ; /!' primi = /! 2<
Bonitor Detal 1eart 4one and 9ontraction
Pre 1erm +a&or . labor after 2) 8eeHs &e(ore te 3=
t
8eeH
1riad o( Preterm Symptoms:
1. ,remature contractions every /< minutes
2. G%acement of A< ;< X
3. Dilatation of 2 # cm
Home %ana!ement:
/. complete bed rest
2. avoid sex
#. empty bladder
!. drin+ # ! glasses of (ater full bladder inhibits contractions
@. consult BD if symptoms persist
Hospital %ana!ement:
/. )f cervix is closed 62 # cm7, dilation saved by administer
1ocolytic a!ents to halts the preterm contractions of the uterus.
D649OPA7 % 6utopar 8cl+ /@< mg incorporated @<< cc Dextrose piggybac+.
%onitor: D14 \ /;< bpm
Baternal 5, E R<"A<
9rac+les notify BD
,ulmonary edema administer oral yutopar #< minutes before d"c )Q
Pre1erm: Magnesium Sul&ate
5efore delivery mother (ill be given =
DGSABG41AS.-G to facilitate surfactant maturation.
4ocolytic 6,hil7
4erbuthaline 65ricanyl or 5rethine7 sustained tachycardia
Antidote propranolol or inderal betabloc+er
5ote + 8 )f cervix is open BD steroid dexamethsone 6betametha:one7 to
facilitate surfactant maturation preventing $espiratory Distress Syndrome
8 ,retermcut cord ASA, to prevent *aundice or hyperbilirubenia.
8 4erm suction at once
C. Postpartal Period @
th
stage of labor
a(ter 2)ours: -ormal increase ?59 up to #<,<<< mm
#
Puerperium covers /
st
A (+s post partum
In$olution return of reproductive organ to its non pregnant or normal state.
Hyperf&rino!enia
prone to thrombus formation
early ambulation
Principles /nderlyin! Puerperium
I. 1o return to @ormal and "acilitate Healin!
A. Pysiolo!ic Can!es
a.1. Systemic Can!es
1. Cardio$ascular System
4he &rst &e1 minutes after delivery is the most critical period in mothers because the increased in plasma
volume return to its normal state and thus adding to the (or+load of the heart. 4his is critical especially to
gra$idocardiac mothers.6 /
st
one hour after delivery monitor the vital signs every /@ minutes 7 )ncrease
of temperature on the /
st
2! hours is normal. )ncrease in ?59 6#<,<<<mm
#
7 immediately after delivery
results to 8yperIbrogenemia. 4o prevent 9hromboplebitis encourage early ambulation, sometimes, may
experience Postural 8ypotension gradually position the patient from semi to high fo(lers
a.2. 9enital 1ract
a. 9ervix cervical opening
&. Qaginal and ,elvic Dloor
23
c. Wterus return to normal A ; (ee+s.
Dundus goes do(n / &nger breath"day until /<
th
day no longer palpable
due behind symphysis pubis
# days after post partum= subinvolution uterus delayed healing uterus containing big,
Fuarters or deep clots of blood a medium for bacterial gro(th 6puerperal sepsis7
Management+ 'ilatation F /urettage
After (irth 4ain +
1. position prone
2. cold compress to prevent bleeding
3. mefenamic acid
d. +ocia bld, (bc, deciduas, microorganism. -SD 0 9"S (ith lochia.
/. $uba red /
st
# days present, musty"mousy, moderate amount
2. Serosa pin+ to bro(n ! R
th
day, limited amount
#. Alba creamy (hite /< 2/ days very decreased amount
a.3. /rinary tract: Bladder
"reKuency in urination a(ter deli$ery 4postpartum5
urinary retention (ith overLo(
'ysuria ( trigone of bladder
5ursing %ction+
urine collection
alternate (arm 0 cold compress
stimulate bladder
Colon: Constipation due to -,., fear of bearing do(n' episiotomy
Perineal area= painful episiotomy site
Position+ Sims position
9old compress for immediate pain after 2! hours,
1ot sit: bath, 1ot compress for immediate pain after 2! hours
Sex %ct (hen perineum has healed
II. Pro$ide 2motional Support $eva $ubia
1. Psycolo!ical #esponses:
a. 4a+ing in phase dependent phase 6/
st
three days7 mother passive, cannot ma+e
decisions, activity is to tell childbirth experiences.
)ursing &are: proper hygiene
b. 4a+ing hold phase dependent to independent phase 6! to I days7. Bother is active,
can ma+e decisions
!ocus= /$ 9are of ne(born
2. )nsert family planting method
5ote+ common post partum blues" baby blues present ! @ days @< ;< X
moms over(helming feeling of depression characteri:ed by crying,
despondence
inability to sleep 0 lac+ of appetite.
let mom cry, it is therapeutic.
c. Cetting go interdependent phase I days 0 above.
Bother rede&nes ne( roles may extend until child gro(s.
III. Pre$ent complications
1. Hemorra!e bleeding of R *AAcc
9S <AA . >AA cc normal
-SD *AA cc
I. 2arly postpartum emorra!e bleeding (ithin /
st
2! hours.
a. Wterine Atony 5oggy or relaxed uterus 0 profuse bleeding
&omplications: hypovolemic shoc+.
Position: Bodi&ed 4rendelenberg
#anagement:
/.7 massage uterus until contracted
2.7 cold compress
#.7 modi&ed trendelenberg
!.7 )Q fast drip" oxytocin )Q drip as ordered
-ote= 8 )f no e%ect after massage O cold compress O position O then let the ne(born suc+ the
mothers breast in order to stimulate the pituitary to release oxytocin for the contraction of the
uterus.
8 5reast feeding posterior pituitary gland (ill release oxytocin so uterus
(ill contract.
8 ?ell contracted uterus J bleeding > laceration
&. Caceration 9ontracted uterus but (ith profuse bleeding
)ursing Action: assess episiotomy
assess perineum for laceration
degree of laceration
#anagement= Gpisiorapy
/
st
degree laceration a%ects vaginal s+in 0 mucus membrane.
24
2
nd
degree /
st
degree J muscles of vagina
#
rd
degree 2
nd
degree J external sphincter of rectum
!
th
degree #
rd
degree J mucus membrane of rectum
c. 1ematoma bluish " purplish discoloration of subcutaneous vagina or ,erineum. Bay be
due to = too much manipulationlarge baby pudendal anesthesia
#anagement: F 9old compress every #< minutes (ith rest period of #< minutes
repeat for 2! hours
8 Shave
8 )ncision on site, scraping 0 suturing
DIC . Disseminated Intra$ascular Coa!ulopaty. Hypof&rino!en
failure to coagulate bleeding to any part of body
)ote: hysterectomy if (ith abruption placenta
#anagement: 5lood 4ransfusion , cryoprecipitate or fresh fro:en plasma
II. +ate Postpartum emorra!e bleeding after 2! hours
1. #etained Placental "ra!ments
#anagement: Dilatation 0 9urettage or manual extraction of fragments
0 massaging of uterus =
Exce4t+ 0 Placenta Accreta unusual attachment to myometrium
0 Placenta Increta deeper attachment of placenta to
myometrium
8 Placenta Percreta invasion of placenta to perimetrium
2. In(ection0 sources o( in(ection
1.5 endogenous from (ithin body
2.5 exogenous from outside
9eneral si!ns:
/. )nLammation calor 6heat7, rubor 6red7, dolor 6pain7 tumor6s(elling7 and loss
of function.
anaerobic streptococci most common= /. from members health team
2. brea+ in the chain of infection
#. unhealthy sexual practice
!. purulent discharges
@. fever
9eneral %ana!ement:
Su44orti$e /are+ 9omplete 5ed $est , hydration" Luid inta+e, 4S5, cold
compress, paracetamol, Q)49,
culture 0 sensitivity before ta+ing antibiotic
8 prolonged use of antibiotic lead to fungal infection
*n&ection o& Perineum + 2 to # stitches dislodged (ith purulent discharge
coming out
%ana!ement: $emoval of sutures 0 drainage
Endometritis inLammation of endometrial lining
Signs of infection plus abdominal tenderness
Position : Do(lers to facilitate drainage
Administration of oxytocin as ordered
Antibiotic if not treated lead to thrombophlebitis
I-. %oti$ate te use o( "amily Plannin!
1.5 determine ones o(n /
S4
beliefs
2.5 never advice a permanent method of family planning
3.5 method of choice is an individuals choice" o(n decision.
).5 )nformed consent
@atural %etod the only method accepted by the 9atholic 9hurch
Billin!s ' Cer$ical mucus test s4inn(arkeit ?estrogen@ clear, (atery,
stretchable, elastic long spinnbar+eit
&erning microscopic fern pattern
Basal Body 1emperature . due to progesterone
/#
th
day temp goes do(n before ovulation no sex
/ get before arising in bed
+A% Cactation Amenorrhea Bethod related to breast feeding
,rolactin hormone that inhibits menstruation"ovulation
5ottle Deeding the mother (ill menstruate after 2 # months
5reastfeeding the mother (ill menstruate after ! A months
5isadvantage = might get pregnant
Symptotermal . combination of 554 0 cervical. 5est method
2*
Social %etod:
o coitus interuptus" (ithdra(al least e%ective method
o coitus reservatus sex (ithout e*aculation ' common to callboy"callgirl
o coitus interfemora 2ipit3
o calendar method 2; days cycle 6 $GGWCA$ 7
6-/+A1I6@ count minus /! days before next menstruation 6/! days before
next menstruation7
6ri!oHnause (ormula )$$GGWCA$ BG-S4$WA4).- get the longest and shortest cycle
Sortest minus 1> an lon!est minus 11 unsafe period
#29/+A# %2@S1#/A1I6@ 2; days minus /! days plus # ! days before and after
menstruation
monitor cycle for / year
get short test 0 longest cycle from ]anuary December
shortest /;
longest //
]une 2A Dec ##
/; //
; 22 unsafe days
2/ day pill start @
th
day of menstruation
2; day pill start /
st
day of menstruation
missed / pill ta+e 2 next day
Pysiolo!ic %etod
Pills combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production
of DS1 and C1 (hich are essential for the maturation and rupture of a follicle. RR.RX e%ective.
?aiting time to become pregnant # months.
9onsult .5 A months.
Alerts on 6ral Contracepti$e:
)n case a mother (ho is ta+ing an oral contraceptive for almost long time plans to have a baby,
mother (ould (ait for at least # months before attempting to conceive to provide time for the
estrogen and progesterone levels to return to normal.
)f a ne( oral contraceptive is prescribed the mother should continue ta+ing the previously prescribed
contraceptive and begin ta+ing the ne( one on the &rst day of the next menses.
Discontinue oral contraceptive if there is signs of severe headache as this is an indication of
hypertension associated (ith increase incidence of 9QA and subarachnoid hemorrhage.
Immediate Discontinuation
A abdominal pain
9 chest pain
1 headache
G eye problems
S severe leg cramps
A91GS signs of hypertension hence if the 5lood ,ressure of the mother is
increased stop the pills S4A4Z
if forgotten for one day, immediately ta+e the forgotten tablet plus the tablet scheduled that day. )f
forgotten for t(o consecutive days, or more days, use another method for the rest of the cycle and the
start again.
Adversed E'ect: brea+through bleeding
Contraindicated=
chain smo+er
extreme obesity
1ypertension
Diabetes Bellitus
4hrombophlebitis or problems in clotting factors
D%PA Depot ,rovera Bedroxy ,rogesteron Acetate depoproveda has progesterone inhibits C1
inhibits ovulation
Depomedroxy progesterone acetate has progesterone inhibits C1 inhibits ovulation
)B every month
never massage in*ected site, it (ill shorten duration
6 it can easily absorbed 7
-orplant has A matchstic+s li+e capsule"rod dermally implanted containing
progesterone.
)ote : @ years disadvantage if +eloid s+in
as soon as removed can become pregnant
%ecanical and Cemical Barriers
Intrauterine De$ice 4I/D5
%ction+ prevents implantation a%ects motility of sperm 0 ovum
right time to insert is after delivery or during menstruation
.+
4rimary indication &or the use & *U'= parity or [ of children BWC4)A$)4T
if / child only dont use )WD
Healt 1eacin!:
a. 9hec+ for string daily
&. Bonthly chec+up
c. $egular pap smear
Alerts:
prevents implantation
inserted during menstruation and after delivery because the cervix is open
most common complications= excessive menstrual Lo(
most common problem= expulsion of the device
others complications uterine infection uterine perforation and ectopic pregnancy
Period late 6pregnancy suspected7 Abnormal spotting or bleeding
Abdominal pain or pain (ith intercourse
Infection 6abnormal vaginal discharge7
@ot feeling (ell, fever, chills
Strings lost, shorter or longer
Condom made up of latex inserted to erected penis or lubricated vagina
/ it lessen sexual satisfaction
/ it gives higher protection in the prevention of S4Ds
Alert = female condom give the most and highest protection against S4D
Diapra!m made up of rubberi:ed dome shaped material inserted to the cervix
preventing sperm to get to the uterus. $GQG$SA5CG
Alert=
/.7 proper hygiene should be observed since it is reusable
2.7 chec+ for holes before using it
#.7 must be +ept in place for about A ; hrs after sex
!.7 must be re&tted especially if (eight change, bor M by /@ lbs
@.7 spermicide chemical 5arrier
example= Doam 6most e%ective7, *ellies, creams
Side e%ect= 4oxic shoc+ syndrome
Cer$ical Cap most durable than diaphragm
/ no need to apply spermicide
/ should be +ept 2! hours, no need to reapply spermicides
&ontraindication= abnormal pap smear
"oamsP SelliesP CreamsP Spermicidal a!ents to +ill spermicides
"oam . most e%ective
Spermicidal a!ents . toxic e%ect 4oxic Shoc+ Syndrome
Sur!ical %etod
B1+ 4 Bilateral 1u&al +i!ation 7 (omen 6 tie, cut, cautery 7
0 immediate sterili:ation cut
can be reversed 2<X chance. 6 2< #< reanastamosis 7
/ istmus 0 is the site for sterili:ation
1ealth 4eaching = Avoid lifting heavy ob*ect
-asectomy 6 men 7 cut vas deferense.
/ not immediate sterili:ation
/ need to e*aculate #< S for < sperm before considering a safe sex
1ealth 4eaching = \ #< e*aculations before safe sex
. :ero sperm count, safe
CI. Hi! #isH Pre!nancy
1. Hemorra!ic Disorders
4o determine the integrity of sac
,repare the mother for ultrasound
Save discharges for histopathology
Assess for complications li+e hypovolemic shoc+
9eneral %ana!ement
/.7 9omplete 5ed $est
2.7 Avoid sex
#.7 Assess for bleeding
Dully saturated pad 6per pad #< !< cc7 6(eight / gm >/ cc7
!.7 Wltrasound to determine integrity of sac
@.7 Signs of 1ypovolemic shoc+
A.7 Save discharges for histopathology to determine if product of conception has been expelled or not
"irst 1rimester Bleedin! abortion or eptopic
.1
A. A&ortions termination of pregnancy before age of viability 6before 2< (ee+s7
Age of viability . 2A 0 2) 8eeHs
Intrauterine death or tillbirth after the age of viability
1. Spontaneous A&ortion . also +no(n as miscarriage
&auses: 1.5 chromosomal alterations
2.5 blighted ovum
3.5 plasma germ defect
&lassiIcations:
a. 4hreatened pregnancy is *eopardi:ed by bleeding and cramping but the cervix is
closed' can give progesterone
b. )nevitable moderate bleeding, cramping, tissue protrudes form the cervix
69ervical dilation7 cervix is open
1ypes:
b./. 9omplete all products of conception are expelled.
-ursing Banagement= no need for D 0 9, *ust emotional supportZ
b.2 )ncomplete ,lacenta and membranes retained.
Banagement= for D0 9
b.# 1abitual # or more consecutive pregnancies result in abortion usually
related to incompetent cervix. ,resent 2
nd
trimester
Incompetent cer$ix . a&ortion
Surgery= a. BcDonalds procedure temporary circlage on cervix
8 During delivery, circlage is removed. -SD
Side G%ects= infection.
b. Shirod+ar permanent surgery on cervix. 9S
b.! Bissed fetus dies' product of conception remain in uterus ! (ee+s or
longer' signs of pregnancy cease. 67 pregnancy test, scanty, dar+
bro(n bleeding
Banagement= induced labor (ith oxytocin or vacuum extraction
c. )nduced Abortion therapeutic abortion to save life of mother based on the
principles of t(ofolds e%ect choose bet(een lesser evil.
B. 2ctopic Pre!nancy occurs (hen gestation is located outside the uterine cavity.
Common site = tubal or ampular
Dan!erous site : interstitial
Wnruptured 4ubal rupture
o missed period
o abdominal pain (ithin # @ (ee+s of missed period
6maybe generali:ed or one sided7
o scant, dar+ bro(n, vaginal bleeding
o vague discomfort

o sudden , sharp, severe pain.
Wnilateral radiating to shoulder.
o shoulder pain 6indicative of intraperitoneal bleeding that
extends to diaphragm and phrenic nerve7
o J 9ullens Sign bluish tinged umbilicus signi&es intra
peritoneal bleeding
o syncope 6fainting7
@ursin! Care: Sur!ery:
Qital Signs 8 Dallopian Salphingectomy
Administer )Q Luids 8 Abdominal Gxploratory Caparotomy
Bonitor for vaginal bleeding 8 Wterus 1ysterectomy
Bonitor ) and .
Second trimester &leedin! . small and incompetent cervix
C. Hydatidi(orm %ole 2bunch or grapes3 or gestational trophoblastic disease. (ith fertili:ation.
/ ,rogressive degeneration of chorionic villi. $ecurs.
/ Gestational anomaly of the placenta consisting of a bunch of clear vesicles.
/ 4his neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertili:ed egg.
/ 4he nucleus of the sperm duplicates, producing a diploid number !A SS
/ )t gro(s 0 enlarges the uterus vary rapidly. 6 progressive degeneration of corion ic villi 7
.2
Wse= methotrexate to prevent choriocarcinoma
Assessment:
Early signs vesicles passed thru the vagina
1yperemesis gravidarium due to increase 19G
Dundal height
Qaginal bleeding 6 scant or profuse7
2arly in pre!nancy 0 1igh levels of 19G
/ ,re eclampsia at about /2 (ee+s
+ate si!ns= hypertension before 2<
th
(ee+
Qesicles loo+ li+e a 2 sno(storm3 on sonogram
Anemia
Abdominal cramping
Serious +ate complications = hyperthyroidism
,ulmonary embolus
@ursin! care:
,repare for D 0 9
Do not give oxytoxic drugs may cause embolism
1eacin!s:
a. $eturn for pelvic exams as scheduled for one year to monitoring 19G
and assess for enlarged uterus and rising titer could indicative of
choriocarcinoma
&. Avoid pregnancy for at least one year . 9an have sex provided the partner
(ill use condom for protection
1ird 1rimester Bleedin! EPlacenta AnomaliesF
D. Placenta Pre$ia . it occurs (hen the placenta is improperly implanted in the lo(er uterine
segment,
sometimes covering the cervical os.
Abnormal lo(er implantation of placenta.
8 candidate for 9S
4otal complete cover of the cervical os
,artial @X
Co(
Assessment:
.utstanding signs and symptoms=
D$A-V5$)G14 $GD ,CGGD)-G, ,A)-CGSS 5CGGD)-G
Gngagement 6usually has not occurred7
Detal distress
,resentation 6 usually abnormal 7
Complications:
)nternal examination
Sudden fetal blood loss
Dia!nostic 2xamination:
Wltrasound
@ote: Avoid= sex, )G, enema may lead to sudden fetal blood loss
Double set up= delivery room may be converted to .$
@ursin! Care:
-,.
5ed rest
,repare to induce labor if cervix is ripe
Administer )Q
@ote Alert : Surgeon in charge of sign consent, $- as (itness
BD explain to patient
2. A&ruptio Placenta 0 it is the premature separation of the placenta form the implantation site.
/ )t usually occurs after the t(entieth (ee+ of pregnancy.
6due to use of cocaine 7 ,)1
Assessment:
dar+ red, painful bleeding
board li+e or rigid uterus"abdomen
9oncealed bleeding"hemorrhage 6retroplacental7
9ouvelaire uterus 6caused by bleeding into the myometrium7inability of uterus to contract due to
hemorrhage.
Severe abdominal pain
Dropping coagulation factor 6a potential for D)97
Complications:
Sudden fetal blood loss
..
placenta previa 0 vasa previa
9eneral @ursin! Care:
)nfuse )Q, prepare to administer blood
4ype and crossmatch
Bonitor D1$
)nsert Doley
Beasure blood loss' count pads
$eport signs and symptoms of D)9
Bonitor v"s for shoc+
Strict ) 0 .
". Placenta succenturiata / or 2 more lobes connected to the placenta by a blood vessel
(hich may lead to retained placental fragments if vessel is cut.
9. Placenta Circum$alata fetal side of placenta covered by chorion
H. Placenta %ar!inata fold side of chorion reaches *ust to the edge of placenta
I. Battledore Placenta cord inserted marginally rather then centrally
S. Placenta Bipartita placenta divides into 2 lobes
7. Placenta 1ripartita placenta divides into # lobes
+. -ilamentous Insertion o( cord cord divides into small vessels before it enters the placenta
%. -asa Pre$ia velamentous insertion of cord has implanted in cervical .S
2. Hypertensi$e Disorders
I. Pre!nancy Induced Hypertension 4PIH7
1ypertension after 2! (+s of pregnancy, solved A (ee+s post partum.
'(0 ?estational hypertension 1,- (ithout edema 0 protenuria 1 (ithout G,
)(0 Pre%eclampsia 1,- (ith edema 0 protenuria or albuminuria 1G,"A
/ idiopathic
*(0 8E22P syndrome hemolysis (ith elevated liver en:ymes 0 lo( platelet count
/ common in primi because of increase exposure to chronic villi
/ multiple pregnancy
/ Bother lo( socioeconomic status
/ )ncrease sensitivity to Angiotensin ))

II. 1ransissional Hypertension . 1,- bet(een 2< 2! (ee+s
III. Cronic or pre0existin! Hypertension 1,- before 2< (ee+s not solved A (ee+s post partum.
1ree types o( pre0eclampsia
1.5 %ild preeclampsia earliest sign of preeclampsia
a.5 increase (t due to edema
&.5 5, /!<"R<
c.5 protenuria J/ J2
2.5 Se$ere preeclampsia
Signs present= cerebral and visual disturbances, epigastric pain due to liver edema
and oliguria usually indicates an impending convulsion. 5, /A<"//<, protenuria
J# J!
3.5 2clampsia (ith sei:ureZ )ncrease 5W- glomerular damage. ,rovide safety.
Cause o( pre eclampsia
1.5 idiopathic or un+no(n common in primi due to /
st
exposure to chorionic villi
2.5 common in multiple pre 6t(ins7 increase exposure to chorionic villi
3.5 common to mom (ith lo( socioeconomic status due to decrease inta+e of 91.-
@ursin! care:
, promote bed rest to decrease .2 demand, facilitate, sodium excretion,
(ater immersion (ill cause to urinate.
, prevent convulsions by nursing measures or sei:ure precaution
/.7 maintain dimly lit room
2.7 Fuiet calm environment
2.7 minimal handling planning procedure
#.7 avoid *arring bed
8 $ight ,lace of the patient= across the nursing station
, prepare the follo(ing at bedside
tongue depressor
side rail up before the sei:ure
.1
turning to side done AD4G$ sei:ure
6to facilitate drainage of secretion7
prepare suction machine
.bserve onlyZ for safely.
G ensure high protein inta+e 6 /g"+g"day7
-a in moderation 6replace the protein loss7
A antihypertensive drug 1ydrala:ine 6 Apresoline7
9 convulsion, prevention by =
Bg S<! 9-S depressant or anti convulsant 6absence of sei:ure7
G valuate physical parameters for Bagnesium sulfate
%a!nesium S6) 1oxicity:
/. 5, decrease
2. Wrine output decrease
#. $esp E /2
1. ,atella reLex absent /
st
sigh Bg S.! toxicity.
Antidote : 9a gluconate
3.Dia&etes %ellitus 0 absence of insuNcient insulin 6)slet of Cangerhans of pancreas7
"unction o( insulin:
/ facilitates transport of glucose to cell
glucose energi:er of cell
insulin +ey for glucose
Dia!nostic 1est: / hour @< grams 6glucose tolerance test 7 G44
@ormal !lucose ;< /2< mg"dl 6 euglycemia7
E ;< hypoclycemic
\ /2< hyperglycemia
3 ours 911 of \ /#< mg"dC
%aternal 2Gect Dia&etes %ellitus
1.5 1ypo or hyperglycemia /
st
trimester hypo, 2
nd
#
rd
trim hyperglycemic
; pl serves as insulin antagonist
2.5 DreFuent infection moniliasis"candidiasis
3.5 ,olyhydramnios
).5 Dystocia diNcult birth due to abnormalities in fetus or mother is big
*.5 )nsulin reFuirement, decrease in insulin by ## X in /
st
tri' @< X increase
insulin at 2
nd
#
rd
trimester.
,ost partum decrease 2@X due placenta out.
@o more ormone 4pl5 given by shots, not oral because it is teratogenic
"etal eGect
1.5 yper 0 ypoglycemia
2.5 macrosomia large for gestational age
baby delivered \ !<<< g or ! +g
largest ;<<< g
3.5 preterm &irt to prevent stillbirth
).5 I/9# 6)ntrauterine Gro(th $etardation7
@e8&orn 2Gect : Diabetes Bellitus
1.5 hyperinsulinism
2.5 hypoglycemia
normal glucose in ne(born !@ @@ mg"dC
borderline !< mg"dC
hypoglycemic E !< mg"Dl
8 !lucose food for the brain
%ana!ement:
1eel stic+ test get blood at heel
/ administer dextrose
/ monitor
Si!ns and Symptoms=
/ 1ypoglycemia
/ high pitch shrill cry
/ tremors
*(0 hypocalcemia E I mgX
Si!ns and Symptoms:
9alcemic tetany
4rousseau sign
%ana!ement : Give calcium gluconate if decrease calcium
#ecommendation
4herapeutic abortion
)f push through (ith pregnancy
1.5 antibiotic therapy to prevent sub acute bacterial endocarditis
2.5 anticoagulant heparin doesnt cross placenta
Class I I II good prognosis for vaginal delivery
Class III I I- poor prognosis, for vaginal delivery, not 9SZ
/ general anesthesia
.2
/ anti coagulant therapy 21eparin3 if pregnant only
/ Antibiotic to prevent subacute endocarditis
-.4 lithotomyZ
1igh semifo(lers or sidelying position during delivery 6best position7
-o valsalva maneuver
$egional anesthesiaZ 9audal 6anesthesia of choice7
Co( forcep delivery due to inability to push. )t (ill shorten 2
nd
stage of labor.
Heart disease
Bothers (ith $1D at childhood
Class I no limitation of physical activity
Class II slight limitation of physical activity.
.rdinary activity causes fatigue 0 discomfort.
$ecommendation of class ) 0 ))
1.5 sleep /< hours a day
2.5 rest #< minutes 0 after meal
Class III moderate limitation of physical activity.
.rdinary activity causes discomfort and fatigue
$ecommendation=
1.5 early hospitali:ation by I months
Class I-. mar+ed limitation of physical activity for even at rest there is fatigue 0 discomfort.
$ecommendation= 4herapeutic abortion
CII. Intrapartal complications
/. Cesarean Deli$ery )ndications=
a. Bultiple gestation
&. Diabetes
c. Active herpes ))
d. Severe toxemia
e. ,lacenta previa
(. Abruptio placenta
!. ,rolapse of the cord
. 9,D primary indication
i. 5reech presentation
,. 4ransverse lie
Procedure:
a. Classical vertical insertion. .nce classical al(ays classical
&. +o8 se!ment bi+ini line type 2aesthetic use3 transverse
-BAC vaginal birth after 9S lo( segment
I@"2#1I+I1J inability to achieve pregnancy. ?ithin a year of attempting it
Banageable
S12#I+I1J
irreversible
*m4otency inability to have an erection
2 types o( in(ertility
/.7 ,rimary no pregnancy at all
2.7 Secondary /
st
pregnancy, no more next pregnancy
1est %ale 1
st

o more practical 0 less complicated
o need= sperm only
o sterile bottle container 6 not plastic has chem.7
o Sims 1uhner test or post coital test.
Procedure: sex 2 hours before test
mother remains supine /@ minutes after e*aculation
-ormal= cervical mucus must be stretchable ; /< cm (ith /@ 2< sperm.
)f \ /@ lo( sperm count
5est criteria sperm motility for impotency
Dactors= lo( sperm count
/.7 .ccupation truc+ driver
2.7 chain smo+er
Administer: clomid 4 comepine citrate5 to induce spermatogenesis
B if not e'ective
%ana!ement= 9I"1 > 2Gamete )ntra Dallopian 4ransfer3 for lo( sperm count
)mplant sperm in ampula
1.5 Bom= ano$ulation no ovulation. Due to increase prolactin
hyperprolactinemia 6 inhibit ovulation 7
Administer: parlodel 6 5romocryptice Besylate7
Action: antihyper prolactineuria 6antipar+insonian7
Give mom clomid: action: to induce oogenesis or ovulation
Side 2Gects: multiple pregnancy
2.5 1u&al 6cclusion tubal bloc+age
.6
o 1istory of ,)D that has scarred tubes
o Wse of )WD 6peritonitis7
o Appendicitis 6burst7 0 scarring
Dia!nostic 1est: hysterosalphingography used to determine tubal patency (ith use of
radiopaFue material
%ana!ement: )QD invitrofertili:ation 6test tube baby7
England /
st
test tube baby
1o sorten 2
nd
sta!e o( la&or:
1.5 fundal pressure
2.5 episiotomy
3.5 forcep delivery
.3