1

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A. Stages of Intrauterine life
1. Zygote ( fertilized ovum )- 1st 2 weeks
a. Stages
1. Blastomere
2. Morula

3. Blastocyst
a. Parts
1. Trophoblast
a. Cytotrophoblast
b. Syncitiotrophoblast
a. Langhan’s layer
b. Syncitial layer
1. Amnion-thinner membrane
a. Amniotic fluid-

c. Funis or Umbilical cord

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 2. Chorion-thicker membrane
a. Placenta
=Parts:
1. Maternal

2. Fetal

2. Embryoblast
a. Germ layers
1. Ectoderm
2. Mesoderm
3. Entoderm or Endoderm

2. Embryo- 2nd to 8th weeks

3. Fetal stage- 8th weeks till birth
a. Fetal Growth and development
2 weeks- heart beats
4 weeks- heart fully developed, rudimentary arms and legs
bud appear
8 weeks-brain developed, neuromuscular movement; external
genitalia appears
12 weeks- placenta matures; sex apparent; begins to swallow;
kidneys secrete urine; FHT detectable thru Doppler
ultrasound
16 weeks- external genitalia obvious; GIT developed;
secretes meconium; quickening by multigravida; fetal
skeleton- X-ray ( safe now )
20 weeks- quickening stronger felt by primigravida; FHT-
audible; lanugo and vernix in the skin
24 weeks- hearing established; more human appearance
28 weeks- surfactant appears- legal age of viability; skin red
and wrinkled; iron stores in the liver
32 weeks- with fat deposition; skin pink and smooth; more
iron stored; Calcium stored in the bones
36 weeks- lungs mature; L S ratio 2:1; more reflexes; 45 cm
approx length
40 weeks- mature; age at EDC; with less lanugo and more
vernix; 50 cm ave length

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UNIT IV: Signs of Pregnancy
1. Presumptive Signs ( Subjective )
a. Morning sickness
b.Urinary frequency
c. Fatigue
d. Quickening
e. Breast changes- tingling sensation, enlargement, darkening of nipple, colostrum
f. Skin changes-
1. Melasma or chloasma
2. Linea nigra
3. Striae gravidarum
g. Chadwick sign
2. Probable Signs ( Objective )
a. Positive pregnancy test
b. Abdominal enlargement
c. Braxton Hicks contractions

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 d. Ballotement
e. Uterine changes
1. Hegar’s sign
2. Ladin’s sign
3. Mc Donald’s sign
4. Piscacek’s sign
5. Braun von fernwald sign
6. Goodel’s sign
7. Chadwick’s sign
3. Positive signs
a. FHT
b. Fetal outline
c. Fetal skeleton
d. Fetal parts on palpation

UNIT V: Physiologic changes of pregnancy

1. Cardiovascular/ Circulatory
= increase cardiac volume by 30-50% peak 6th month ( inc. in plasma )
= Hgb decreases but not < 11 gms/ L- PHYSIOLOGIC ANEMIA manifested by
 easy fatigability / short breath
 slight cardiomegaly
 systolic murmurs- due to decrease blood viscosity
 nosebleeds due to congestion of nasopharynx
= palpitation due to sympathetic stimulation and increase pressure of uterus against
the diaphragm
= increase in WBC to 11,500 /mm3 PHYSIOLOGIC LEUCOCYTOSIS during
pregnancy; higher during labor and after delivery to 21,500/mm3
=later in pregnancy due to pressure by the gravid uterus on the bld.vessels of the
lower extremities, the woman may experience discomforts- leg cramps, pedal edema,
varicosities ( legs, thigh, vulva )
 For Pedal edema, nursing measures include
* raise legs above hip level
* Avoid using constricting clothings ( garterized stockings )
*Avoid prolong standing, sitting and cross-legging
 For Varicosities
* Wear/ use support hose stockings
* Elastic bandage- apply from distal to proximal
 In case of vulvar hemorrhage- side lying with hips elevated or
Modified knee-chest position
= increase level of circulating fibrinogen predispose the pregnant woman to blood clots
Note: No massage
= pressure maybe applied in the IVC- Supine hypotensive or Vena cava syndrome
 Left lateral position

2. Gastrointestinal changes

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= Morning sickness related to increase hormone HCG, psychological or emotional factors
maybe relieved by
 dry CHO diet- ( plain crackers and toast ) 30 mins. Before arising
from bed
 small but frequent meals
 avoid fatty and spicy foods
Note: If vomiting persists beyond first trimester condition
Hyperemesis Gravidarum
Management include:
 Hospitalization
 CBR
 IV replacement with D10 NSS 1L in 8 hours for 24 hours
Complications:
 Dehydration
 Acidosis
 Starvation
= Pyrosis or heartburn
= due to increase hormone Progesterone causing relaxation of the cardiac sphincter
resulting to reflux of gastric contents can be managed by
 Avoid fried fatty foods
 Sips of milk
 May have antacid
 Avoid Na HCO3- promotes water retention
 Small frequent meals
 Bend at the knees not waist
= Constipation/ Flatulence
= due to increase Progesterone causing relaxation of stomach and intestinal muscles
managed by;
 Increase fluid and roughage
 Establish regular pattern of BM
 Moderation of exercise
 Avoid enema, and use of harsh laxatives,instead stool softeners (
ex. Colace-dioctyl Na ) more advisable
 Avoid mineral oil- interferes with Fat sol vitamins absorption
= Hemorrhoids- due to pressure by gravid uterus in the anus managed by application of
cold compress with witch hazel or Epsom salts

3. Respiratory
= shortness of breath

4. Musculoskeletal
= As the pregnant woman attempts to stand taller and straight and because of enlarged
abdomen the woman becomes LORDOTIC- pride of pregnancy
= Due to hormone Relaxin- pelvic bones become more supple and movable
= Prone to accident and falls due to wobbly gait

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Note: Low heeled shoes after first trimester

= Leg cramps maybe due to hypocalcemia , pressure by gravid uterus in the LE causing
muscle tenseness and fatigue . Managed by:
 Increase Ca and PO4 intake- ( dairy products, green leafy veg.,
tablets )
 Press affected knee with foot dorsiflexion
 No massage
 Feet elevation
5.Urinary
= urinary frequency ( 1st and 3rd trimesters ). Nursing management include:
 Increase fluid intake ( H2O and fruit juices)
 Report any abnormal finding like burning, pain, and difficulty
 Advise to void after coitus
 Advise to use perineal pad to absorb leaks

6. Endocrine
= Placenta –an added endocrine organ; secretes hormones Progesterone, Estrogen, HPL,
and HCG
=Thyroid gland enlarge due to hyperplasia of glandular tissues and increase vascularity
=Increase Parathyroid gland size due to increase need of Ca by the fetus
=Adrenal Cortex hypertrophies
=Gradual increase in insulin production

7. Temperature- elevated due to increase production of Progesterone

8. Weight gain-25-35 lbs.
Note: The pattern of weight gain is more important than the amount of weight gain
= Pattern of weight gain as follows:
First trimester- 0.9- 1.0 lb/ mo; a total of 3 lbs
Second and Third trimesters- 1 lb/ wk.; a total of 10-12 lbs
Distribution of weight gain include
* Fetus- 7 lbs
* Placenta- 1 lb
* Amniotic fluid- 1- 11/2 lbs
*Uteruss- 2 lbs
*Blood volume- 1 lb
* Breasts- 11/2- 3 lbs.
* Additional fluid- 2 lbs
* Fat and fluid acc 4-6 lbs

9. Emotional Responses
= First trimester
 Fetus unidentified concept
 Ambivalence
 Denial as to the result of pregnancy test
 Disbelief, Rejection

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= Second trimester
 Fetus perceived as separate entity
 Acceptance
 Fantasize/ daydream on the appearance of the baby
 Evaluates relationship with the husband, in-laws,etc
= Third trimester
 Has personal ID with a real baby about to be born
 Best time to talk about layettes, infant feeding methods, and
family planning
 Fear of unknown, death of fetus and self, defects, complications
and etc.
B. Local changes
1. Uterus measures:
 weighs- 1000 gms

 width- 20-25 cm
= pear to ovoid
= softening due to increase progesterone
= Mucous plug ( operculum) forms to seal out bacteria

2. Vagina= increase vascularity from pink to blue or violet ( Chadwick’s or

Jacquiemer’s )
= increase activity of epithelial cells, increase amount of vaginal discharges (Leukorrhea)
= ph becomes alkaline ( increase estrogen )- predisposes the woman to Infection
Common causes off vaginal infections include
Trichomonas Vaginalis Candida Albicans
*frorthy vaginal discharge * white patchy cheese like
*foul odor * irritatingly itchy w/ foul odor
*vulvar edema & hyperemia
Tx.- Flagyl Nystatin-2x x15 days
Vagisec Gentian violet swab

3. Abdominal wall
= Striae gravidarum ( due to rupture & atrophy of connective tissue layers )
Mgt. Rub oil to prevent Diastasis recti
= Melasma or Chloasma- “ Mask of pregnancy “ = extra pigmentation on cheeks & nose
( due to increase melanocytes by the pituitary gland )
= Increase activity of sweat glands

4. Breasts
= Increase in size- due to hyperplasia of mammary alveoli & fat deposits
Mgt. Proper breast support with well fitting brassiere to prevent sagging
= Feeling of fullness & tingling ( first sign )
= Nipples more erect ( in prep x BF- nipple rolling or rub with towel to toughen )

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 = Montgomery glands- bigger & protuberant
= Areola- darker & increase in diameter
= secretes colostrum- 4th month

5. Ovaries- no activity
= produce relaxin ( 3rd trimester )- makes bones supple and relax

UNIT VI. Danger Signs of Pregnancy

1. Vaginal bleeding
First trimester-
Third trimester
2. Fever and chills
3. Escape of fluid from vagina
4. Abdominal pain
 Early pregnancy-crampy with bleeding-Abortion
 Unilateral low quadrant pain radiating to shoulder-Ectopic
pregnancy
 Hard, boardlike painful abdomen
 Sudden sharp abdominal pain with signs of shock
5. Severe, persistent headache and dizziness
6. Swelling of hands and face
7. Severe vomiting
8. Dimness, blurring and doubling of vision
9. Dysuria with burning sensation on urination
10. Marked change in intensity and frequency of fetal movement or absence of
movement after quickening

UNIT VII: Pre-natal Care

Maternal and infant morbidity and mortality rates have decreased and
will continue with increase provision of prenatal care. The patient’s understanding
and participation of the modalities of care maybe considered as among the reasons.
A. The duration of pregnancy is 266-294 days with average of 280 days or 38- 42
weeks. A pregnacy terminated at 20 weeks or before 38 weeks is Pre-maturity and if
after 42 weeks- Post-maturity or postdate.
A. Pregnancy tests:
1. Urine pregnancy tests is based on the presence of the hormone HCG believed to
be produced by the trophoblast in early pregnancy and later the placenta. Highly
elevated between 2-3 mos.or bet the 60-90 days after fertilization, and believed to
decrease after reaching the lowest level on the 5th mo.
= Preparation for the test include:
a. No water after 8 pm the night before urine collection
b. First morning urine ,midstream should be collected in a clean, dry
container
c. Refrigerate the specimen if >1 hour would lapse. (HCG is unstable in
room temp.)
= Types of tests

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 1. Biological exams- presence of HCG will produce bleeding changes in the
ovaries or testes of the animal when the urine of the pregnant woman is
injected into it.
2. Immunodiagnostic tests- baassed on the principle of antigen- antibody
reaction. Example:
a. LAI (Latex agglutination inhibition ) easy to do and yield results in 2
mins., are accurate from 4-10 days after missed menses.
b. HAI (Hemagglutination inhibition )

3. Progesterone Withdrawal tests

= a contraceptive pill once or 3x/day for 3 days is/are taken. If woman is not
pregnant, bleeding occurs in 10-15 days. If pregnant , no bleeding occurs.

4. Serum Pregnancy test

a. Radioreceptor assay is a 1-hr. serum test requiring the use of highly
sophisticated equipment to measure the ability of the blood sample to
inhibit the binding of radiolabeled HCG to receptors. Usually accurate
at the time of missed menses ( 14 days after conception ).
b. Radioimmunoassay pregnancy test- requires the test be done in the
laboratory. This test takes 1-5 hours. Is the most sensitive pregnancy
test available today. Can confirm pregnancy 8 days after ovulation or 6
days before missed menses.
c. ELISA ( Enzyme linked immunosorbent assay )- most popular
method of testing pregnancy. Serves as the basis of over the counter
home pregnancy test.
B. Components of Pre-natal Visit
1. History-taking
a. Personal data- patient’s age, CS, address, and family hx
b. Obstetrical data
 Gravida- number of pregnancies a woman has had
= Primi
= Multi
= Nulli
 Para- number of viable pregnancies regardless of number of
fetus, whether alive or dead, and outcome of the TPALM
T- ERM
P- RETERM
A- BORTION
L - IVE
M- ULTIPLE PREGNANCIES
Past pregnancies
1. Method of delivery
 NSVD
 VDAC/ VBAC
 CS

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 2.Where
3. Risks involved
Present pregnancies
1. Chief concern
2. Danger Signals
2.Vital Statistics
a.Weight- to be taken every pre-natal visit
b.Height- to be taken initial visit
3.Vital Signs
a.Temperature
b.Pulse rate
c.Respiratory rate
d.Blood pressure
4. Physical Assessment ( Head to toe assessment )
( Presumptive, Probable, Positive )

5. Important Estimates
a. Estimates on gestational age ( AOG )
1. Nagele’s Rule- to calculate the EDC or EDD
1. Estimated Date of Confinement (EDC)
March 20, 1995
Minus-3 months +7 days +1 year
December 27, 1996

2. Mc Donald’s Rule- determines AOG in mos and weeks using the fundic
height

McDonalds Formula (age of gestation)

Fundic ht in cm x 2 divided by 7 = AOG in months
21 cm x2 7 = 24 weeks

3. Bartholomew’s rule- estimates AOG by the relative position of the uterus

in the abdominal cavity

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 4. Haase’s Rule- estimates the fetal length using the AOG in months
. Fetal Length (Haase’s Rule)
1 – 5 months - =months (squared)
6 - 10 months = months x 5

11. Abdominal wall

= Striae gravidarum ( due to rupture & atrophy of connective tissue layers )
Mgt. Rub oil to prevent Diastasis recti
= Melasma or Chloasma- “ Mask of pregnancy “ = extra pigmentation on cheeks & nose
( due to increase melanocytes by the pituitary gland )
= Increase activity of sweat glands

12. Breasts
= Increase in size- due to hyperplasia of mammary alveoli & fat deposits
Mgt. Proper breast support with well fitting brassiere to prevent sagging
= Feeling of fullness & tingling ( first sign )
= Nipples more erect ( in prep x BF- nipple rolling or rub with towel to toughen )
= Montgomery glands- bigger & protuberant
= Areola- darker & increase in diameter
= secretes colostrum- 4th month

13. Ovaries- no activity

= produce relaxin ( 3rd trimester )- makes bones supple and relax

UNIT VI. Danger Signs of Pregnancy

5. Vaginal bleeding

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 First trimester-
Third trimester
6. Fever and chills
7. Escape of fluid from vagina
8. Abdominal pain
 Early pregnancy-crampy with bleeding-Abortion
 Unilateral low quadrant pain radiating to shoulder-Ectopic
pregnancy
 Hard, boardlike painful abdomen
 Sudden sharp abdominal pain with signs of shock
5. Severe, persistent headache and dizziness
14. Swelling of hands and face
15. Severe vomiting
16. Dimness, blurring and doubling of vision
17. Dysuria with burning sensation on urination
18. Marked change in intensity and frequency of fetal movement or absence of
movement after quickening

UNIT VII: Pre-natal Care

Maternal and infant morbidity and mortality rates have decreased and
will continue with increase provision of prenatal care. The patient’s understanding
and participation of the modalities of care maybe considered as among the reasons.
A. The duration of pregnancy is 266-294 days with average of 280 days or 38- 42
weeks. A pregnacy terminated at 20 weeks or before 38 weeks is Pre-maturity and if
after 42 weeks- Post-maturity or postdate.
A. Pregnancy tests:
2. Urine pregnancy tests is based on the presence of the hormone HCG believed to
be produced by the trophoblast in early pregnancy and later the placenta. Highly
elevated between 2-3 mos.or bet the 60-90 days after fertilization, and believed to
decrease after reaching the lowest level on the 5th mo.
= Preparation for the test include:
a. No water after 8 pm the night before urine collection
b. First morning urine ,midstream should be collected in a clean, dry
container
c. Refrigerate the specimen if >1 hour would lapse. (HCG is unstable in
room temp.)
= Types of tests
5. Biological exams- presence of HCG will produce bleeding changes in the
ovaries or testes of the animal when the urine of the pregnant woman is
injected into it.
6. Immunodiagnostic tests- baassed on the principle of antigen- antibody
reaction. Example:
a. LAI (Latex agglutination inhibition ) easy to do and yield results in 2
mins., are accurate from 4-10 days after missed menses.
b. HAI (Hemagglutination inhibition )

15
 7. Progesterone Withdrawal tests

= a contraceptive pill once or 3x/day for 3 days is/are taken. If woman is not
pregnant, bleeding occurs in 10-15 days. If pregnant , no bleeding occurs.

8. Serum Pregnancy test

a. Radioreceptor assay is a 1-hr. serum test requiring the use of highly
sophisticated equipment to measure the ability of the blood sample to
inhibit the binding of radiolabeled HCG to receptors. Usually accurate
at the time of missed menses ( 14 days after conception ).
b. Radioimmunoassay pregnancy test- requires the test be done in the
laboratory. This test takes 1-5 hours. Is the most sensitive pregnancy
test available today. Can confirm pregnancy 8 days after ovulation or 6
days before missed menses.
c. ELISA ( Enzyme linked immunosorbent assay )- most popular
method of testing pregnancy. Serves as the basis of over the counter
home pregnancy test.
B. Components of Pre-natal Visit
2. History-taking
a. Personal data- patient’s age , age, CS, address, and family hx
b. Obstetrical data
 Gravida- number of pregnancies a woman has had
= Primi
= Multi
= Nulli
 Para- number of viable pregnancies regardless of number of
fetus, wether alive or dead, and outcome of the TPALM
T- ERM
P- RETERM
A- BORTION
L - IVE
M- ULTIPLE PREGNANCIES
Past pregnancies
1. Method of delivery
 NSVD
 VDAC/ VBAC
 CS
2.Where
3. Risks involved
Present pregnancies
1. Chief concern
2. Danger Signals
2.Vital Statistics
a.Weight- to be taken every pre-natal visit
b.Height- to be taken initial visit
3.Vital Signs

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a.Temperature
b.Pulse rate
c.Respiratory rate
d.Blood pressure
4. Physical Assessment ( Head to toe assessment )
( Presumptive, Probable, Positive )

5. Important Estimates
a. Estimates on gestational age ( AOG )
5. Nagele’s Rule- to calculate the EDC or EDD
1. Estimated Date of Confinement (EDC)
March 20, 1995
Minus-3 months +7 days +1 year
December 27, 1996

6. Mc Donald’s Rule- determines AOG in mos and weeks using the fundic
height

McDonalds Formula (age of gestation)

Fundic ht in cm x 2 divided by 7 = AOG in months
21 cm x2 7 = 24 weeks

7. Bartholomew’s rule- estimates AOG by the relative position of the uterus

in the abdominal cavity

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 8. Haase’s Rule- estimates the fetal length using the AOG in months
. Fetal Length (Haase’s Rule)
1 – 5 months - =months (squared)
6 - 10 months = months x 5

9. Johnson’s rule- estimates the fetal weight using the fundic height

10. Laboratory tests:

a. Urine tests:
1. Routine urinalysis- detects presence of infection, PIH, and
Diabetes
a. Albuminuria- ideally negative. The presence of albumin in
the urine should be reported immediately because it is
possible sign of PIH.
b. Pyuria- indicates UTI w/c can lead to premature delivery

c. Glycosuria- specimen should be taken before breakfast to

avoid false positive results. Should not be more than +1 sugar
b. Blood tests:
1. Complete blood count
2. Serological tests for Syphilis ( VDRL or Kahn and
Wassermann)- done during the first and third trimesters
3. Blood typing, including Rh factor determination
4. Hemagglutination-inhibition assay test for Rubella- to determine
how much antibodies the pregnant woman has against German
measles. If titer is less than 1 : 8, is considered at risk for
congenital rubella syndrome; if the titer is more than 1 : 16 has
enough protection against GM
c. Pelvic Examinations/ Internal Exam or Vaginal tests
= Purposes

Figure 1 Ultrasound

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 Figure 2 amniocentesis

X-RAY Can be used late in pregnancy (after ossification of fetal bones) to

confirm position and presentation; not used in early pregnancy to
avoid possibility of causing damage to fetus and mother.

ALPHA-FETOPROTEIN Maternal serum screens for open neural tube defects. It is a

SCREENING glucoprote in produced by fetal yolk sac, GI tract and liver. Test done
between 16 and 18 weeks gestation.
Alpha Fetoprotein:
 PRINCIPAL SCREENING TEST DOR THE DETECTION OF
NEURAL TUBE DEFECTS (spina bifida, hydrocephalus-can be
reduced through increase folic acid-0.4 mg/day in the 1st trimester)
> Maternal blood sampling between 16-20 weeks.
LOW: chromosomal defects (Downs syndrome)
HIGH: (greater than 10 mg/dl) Neural tube defects, anencephaly &
the absence of ventral abdominal wall, premature delivery, toxemia &
fetal distress & Rh immunization.
L/S RATIO Uses amniotic fluid to ascertain fetal lung maturity through
measurement of presence and amounts of the lung surfactants lecithin
and sphingomyelin. At 35-36 weeks; ratio is 2:1 indicative of mature
levels.
PHOSPHATIDYL GLCEROL Found in amniotic fluid after 35 weeks. In conjunction with the L/S
ratio; it contributes to increased reliability of fetal lung maturity

19
 testing. Maybe done in laboratory.

Phosphatidyl Glycerol (PG): when present in the amniotic fluid, it can

be predicted that respiratory distresss will not occur, or RDS will
not occur.

CREATININE LEVEL Estimates fetal renal maturity and function, uses amniotic fluid.

BILIRUBIN Level-high early in pregnancy; drops after 36 weeks gestation; uses

FETAL MOVEMENT COUNT
PERCUTANEOUS UMBILICAL
BLOOD SAMPLING
BIOPHYSICAL PROFILE
amniotic fluid.
The yellow color is the result of fetal anemia and bilirubin.
Teach mother to count 2-3 times daily, 30-60 minutes each time,
should feel 5-6 movements per counting time; mother should notify
care giver immediately of abrupt change or no movement.
Uses ultrasound to locate umbilical cord. Cord blood aspirated and
tested. Used in second and third trimesters.
A collection of data on fetal breathing movements, body movements,
muscle tone, reactive heart rate and amniotic fluid volume.

ELECTRONIC MONITORING

A. Non-Stress Test – accelerations in heart rate accompany normal fetal movement; non-invasive
Tocodynamometer records fetal movements and Doppler ultrasound measures

- Observation of fetal heart rate related to fetal movement. Fetal well-being.

Indicated for: assess placental function & oxygenation, fetal well being, evaluates fetal heart rate
in response to fetal movement especially for: Maternal Problems such as chronic hypertension,
diabetes and Pre-eclampsia, given after the 32nd week.

PREPARATION:
Patient should eat snacks.

Position: Semi-Fowlers or left lateral positions the mother may ask tom press the button every
time she feels fetal movements; the monitor records a mark at each point of fetal
movement.

RESULTS:
1. Reactive (normal): indicates a fetal fetus
 Greater than 15 beats per minute- occur with fetal movement in a 10 or 20 minute
period. FAVORABLE RESULTS:
- 2 or more FHR accelerations of 15 seconds over a 20 minutes interval and return of FHR to
normal baseline.
2. Non-Reactive (Abnormal): No fetal movement occurs or there is short-term fetal heart
rate variability (less than 6 beats per minute). The doctor will order an Oxytocin Test
AFTER the patient has non-reactive test.

NOTE: COMMONLY PERFORMED ON DIABETIC PATIENTS BECAUSE OF THE INCREASE

RISK FOR STILL BIRTH.

B. Contraction Stress Test (CST) – based on the principle that healthy fetus can withstand
decreased oxygen during contraction but compromised fetus cannot. Response of the fetus to
induced uterine contractions as an INDICATOR OF UTEROPLACENTAL & FETAL
PHYSIOLOGICAL INTEGRITY.

20
 PREPARATION:
 Woman in semi-Fowler’s or side-lying position.
 Monitor for post-test labor onset.
TYPES:
a. Mammary stimulation Test or Breast Stimulation Exam or
Nipple Stimulated CST – non-invasive
b. Oxytocin Challenge test

Indications: ALL PREGNANCIES AFTER 28 WEEKS WITH HIGH RISK CLIENTS.

Contraindicated for history of PRE-TERM LABOR.

Interpretations:

POSITIVE RESULT: Late decelerations with at least 50% of contractions. Potential risks to the fetus,
which may necessitate to C-section.
Abnormal and known as “Positive window”. Abnormal: “Positive Window”: (+) LATE
DECELERATIONS OF FHR with three contractions a 10 minute interval. Indicates
Uteroplacental Insufficiency.

NEGATIVE RESULTS: No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in
10 minutes period. Normal: “Negative Window”: (-) LATE DECELERATIONS OF FHR with
three contractions a 10m minute interval
Normal and known as “Negative window

Laboratory Studies

1. Estriol excretion: measures placental functioning through urine test.

 Collect a 24-hour urine specimen or serum blood levels.
 High Estriol: Good placental function
 Low Estriol: Fetal hypoxia
Estriol: estrogenic hormone, synthesized by the placenta & adrenal gland of the fetus which
secreted by the ovaries

 Rh Incompatibility Test:
Purpose: a. to discover presence of antibodies present in Rh-negative mother’s blood.
> Test will confirm the diagnosis for Hemolytic Disease in the Newborn.

Types:
1. Indirect Coomb’s Test: women who have Rh negative have this
test done to determine if they have antibodies to the factor present.
Repeated 28 weeks pregnancy. Mothers reveal antibodies as a result of
previous transfusion or pregnancy.
2. Direct Coomb’s test: tests for newborns cord blood- determines
presence of maternal antibodies attached to the baby’s cell.

 Rh (D) & D negative who hasn’t formed antibodies should receive

Rhogam at 28 weeks gestation or after 72 hours after delivery.

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 The Betke-Kleihauer test is a test that determines if a greater than usual fetal – maternal blood
mix occurred. It is also used in Rh incompatibility cases to determine if another dose of
Rhogam is needed

 Fern Test: determine the presence of Amniotic Fluid leakage. Using a sterile technique, a specimen is
obtained from the external os of the cervix & vaginal pool.
Position: Dorsal Lithotomy, Instruct the client to cough to cause the fluid to leak from the uterus if
the membranes are ruptured.
 Nitrazine Test: use of nitrazin strip to detect the presence of amniotic fluid.
Vaginal Secretions: PH: 4.5- 5.5
Amniotic fluid: PH: 7.2 – 7.5 (turns the yellow Nitrazine blue gray, blue green – Ruptured
Membranes)
 Kicks count: fetal movement counting mother sits quietly on the LEFT SIDE for 1 hour after meals
& count fetal kicks for 30 minutes. Notify the physician or health care provider if FEWER THAN
3 KICKS.
 Biophysical Profile : surveillance of fetal well being base on 5 categories:
1. Fetal breath mov’t
2. Fetal tone
3. Amniotic fluid
4. Fetal heart reactivity
5. Placental Grade
Interpretation:
Fetal score of 8 – 10: normal fetal well-being
Fetal score of 4 – 6: fetal distress

VII. Other Gynecological Procedures

a. Schiller Test: indicated for cancer, candidates are women of 20 years old & above & sexually
active women.
> Cervix is tainted with tincture of iodine; color change in the cervix is noted.
 Result:
Negative: mahogany brown stain
Positive: no staining
b. Papanicolau Test

b. Papanicolau Test: cytologic test for cancer

> Detect precancerous lesions &, detect the recurrence of Cancer.

c. Hysterosalphingogram : COMPLETE EVALUATION OF ALL PELVIC ORGANS IN FEMALES

> EVALUATES TUBAL PATENCY & PROBLEMS IN FERTILITY.
> If the tubes are patent, the dye can be visualized passing out the fimbtriated end & of the fallopian
tubes.

d. Rubins Test- determines tubal patency of the fallopian tubes. CO2 is passed through the cervix to
the uterus.
> If patent, gas will pass through the fimbriated end of the fallopian tubes, will give a sensation of
fullness & spasmodic pains due to irritation from the gas.
> A test to detect infertility caused by a defect in the tube, which is usually related to Past Infection.

e. Sims Huhner Test (Post Coital Test): within 1 –2 days, a specimen of seminal fluid from the
posterior fornix & cervical canal is aspirated 2 –4 hours after coitus.

22
 Purpose: test for incompatibility of sperms with cervical mucus.
1-2 days is the best time to evaluate fertility because there is increase estrogen.
- ABUNDANT CERVICAL MUCUS- increases sperm survival.

11. Health teachings

A. Nutrition: most important aspect
1. Women who need special attention
a. Pregnant adolescents
b. Low prepregnant weight, obese
c. Low income
d. Successive pregnancies
e. Vegetarians- although with high vitamins and mineral intake, are
low in proteins because there are many essential amino acids that
are found only in animal sources
Note: Nutritional assessment is based on taking a diet hx first: food
preferences, eating habits; cultural/ religious influences; educational/
occupational level
NUTRIENTS NON-PREGNANT PREGNANT
Calories (kcal) 2000 +300-400
Proteins (gm) 46 +30
Calcium (mg) 800 +400
Phosphorous (mg) 800 +400
Iron (mg) 18 +18
Folic acid ( mg) 400 +400
Vitamin C (mg) 45 +15
Vitamin A (I.U.) 4000 +1000
Vitamin D (I.U.) 400 +0
Vitamin E (I.U.) 12 +3

Note: Malnutrition during pregnancy results in:

1. Prematurity
2. Preeclampsia
3. Abortion
4. Stillbirth
5. LBW
6. Congenital defects

b. Avoidance of intake or use of the following substances which include:

1. Alcohol- may cause LBW, fetal brain maldevelopment, and other congenital
anomalies

23
 2. Drugs- dangerous specially during period of organogenesis as this may cause
congenital anomalies, brain damage, IUGR. Examples include
a. Thalidomide- causes Amelia or Phocomelia
b. Steroids- causse Cleft lip and palate, Abortion
c. Iodides-( maybe contained in antitussives)-cause enlargement of the fetal
thyroid gland leading to tracheal decompression and dyspnea at birth
d. Vit. K- causes hemolysis and hyperbilirubinemia
e. Aspirin/ Phenobarbital- causes bleeding disorders
f. Streptomycin/Quinine- causes damage to the 8th cranial nerve ( deafness )
g. Tetracycline- causes staining of tooth enamel and inhibits growth of long
bones
3. Exercises: To strengthen the muscles used in labor and delivery
= Should be done in moderation
= Should be individualized
=Exercises recommended for pregnant women
1. Squatting
2. Pelvic rock
3. Modified knee-chest
4. Shoulder circling
5. Walking
6. Kegel’s

4. Sexual activity-as desired. Libido decreases on the first and third trimesters and
improves on the second trimester. Sexual intercourse is contraindicated in the
following conditions:
a. Ruptured bag of water
b. Spotting or bleeding
c. Incompetent cervical os
d. Deeply engaged presenting part

5. Travelling- no restrictions , but trips maybe postpone on the last trimester.On long
rides, 15-20 mins rest period every 2-3 hours to walk or empty bladder is
advisable.
6. Employment
7. Rest and Sleep
8. Frequency of Prenatal visits
 First trimester- once every month on the first 7 mos
 On the 8th month- twice
 On the 9th month- every week

UNIT VIII: Prepared Childbirth / Childbirth Education

= aims to prepare the pregnant couple for childbearing
= operates basically on the “ Gate Control theory” of pain. Pain is controlled in the spinal
cord . To ease pain in one body part, the “gate” to this pain should be “closed”.

24
=Discomfort during labor can be minimized if the laboring woman comes into labor
informed about what is happening and prepared with breathing exercises to use during
labor.
= Major Approaches include teaching the couple on Anatomy and Physiology, Labor and
Delivery, relaxation techniques, breathing exercises, hygiene, diet, and comfort measures
( Effleurage and sacral pressure )
1. Lamaze – Psychoprophylaxis- is based on stimulus response conditioning
2. Grantly- Dick Read- Fear leads to tension and tension to pain
3. Bradley-“ Husband coached “ approach
4. Leboyer- the birth of the baby is a shocking experience to him, to make it less
traumatic, environmental modifications are considered like dimming the light,
room is made warm,and minimal noise.
UNIT IX: Common Obstetrical Tests
1. Ultrasound
2. Amniocentesis- determination of AFP and L: S ratio
3. Non- stress Test
4. Stress Test
5. Estriol determination

ANTEPARTAL COMPLICATIONS

A. Abortion
-termination of pregnancy before the fetus is viable (20 weeks or a weight of 500 g)

ABORTION

Therapeutic Spontaneous

Inevitable Threatened

Complete Incomplete Missed Habitual

Fig. 4.4 T y p e s o f A b o r t i o n

25
B. Ectopic Pregnancy

C. Hydatidiform mole / Trophoblastic Disease / Molar Disease

26
. Incompetent cervix
- Painless premature dilatation of the cervix (usually in the 16th to 20th week)

INCOMPETENT CERVIX

Figure 19

F. CARDIAC DISEASE

CLASSIFICATION EFFECTS MANAGEMENT

Class I Asymptomatic Retarded growth Goal is to reduce
Class II Asymptomatic at rest; Fetal distress workload of heart
symptomatic with heavy physical To relieve fetal distress Promote rest
activity let the patient lie on her Promote a healthy
Class III Asymptomatic at rest; side diet
symptomatic with ordinary activity Educate regarding
Class IV Symptomatic with all Premature labor medication
activity; symptomatic at rest You don’t have to notify Educate regarding
the physician if the avoidance of infection
a. Class I: no limitation of activities. No patient complains of a Promote reduction of
symptoms of cardiac insufficiency. “fluttering” sensation in physiologic stress
b. Class II: slight limitation of activity, her chest because of
Asymptomatic at rest. Ordinary taking terbutaline
activities causes fatigue, palpitations (Brethine) SQ for
and dyspnea premature contractions
c. Class II: marked limitation of because it is a common
activities, comfortable at rest, less side effect unless vital
than ordinary activities causes signs indicate stress
discomforts
d. Class IV: unable to perform any
physical activity without discomfort.
May have the symptoms during rest.

. BLEEDING DISORDERS AFFECTING THE PLACENTA

Placenta Previa (low implantation) Abruptio Placenta (Premature separation)

Assessment: Assessment:

. Painless . Severely painful

. Heavy bleeding . Heavy bleeding w/c maybe
. Soft, non tender, relaxed uterus w/ normal tone partially\completely hidden

27
 . Shock in proportion to observed blood loss . Rigid (board like), tender uterus possible w/
. Signs of fetal distress usually not present contractions
. Shock seeming to be out of proportion
. Signs of fetal distress
Predisposing Factors: Predisposing Factors:

* Multiparity* Advancing maternal age, * * Chronic Hypertensive disease* history of a

Multiple gestation* Alteration in the uterine short cord * Multigravida * trauma
structures
Nursing Considerations: Nursing Considerations:

. Client is hospitalized and put on bed rest
. Continually monitor fetal well- being
. Caesarean delivery indicate
. Measure blood loss through perineal pad counts
. NO vaginal exams
. Provide emotional support
. Bed rest in wedge position too prevent supine
hypotension
.
. Continually monitor fetal well- being
. Treat signs of shock and hemorrhage
. Provide emotional support
. Prepare for delivery

PLACENTA PREVIA

Figure 20 a

PLACENTA PREVIA
Definition > Improperly implanted placenta in the lower uterine segment near or over the
internal cervical os
> Total: the internal os is entirely covered by the placenta when cervix is fully
dilated
> Marginal: only an edge of the placenta extends to the internal os

> Low-lying placenta: implanted in the lower uterine

segment but does not reach the os (Saunders page
299)

28
Predisposing Factor > Maternal age
> Parity (no. Of pregnancy)
> Previous uterine surgery

Cardinal Manifestation > Painless bleeding as early as 7 months (mild to hemorrhage)

> Soft uterus
> Abdominal fetal position of breech or transverse lie
> Uterine contractions
> Anemic
Complication > anemia, #1hemorrhage, #2shock, renal failure, #3 disseminated
intravascular coagulation, cerebral ischemia, maternal and fetal death
(Nursing Alert p.418)
Therapeutic Interventions > Ultrasonography to confirm the pressure of placenta previa.
> Depends on location of placenta, amount of bleeding and status of the
fetus.
> Home monitoring with repeated ultrasounds may be possible with type I-
low lying
> Control bleeding
> Replace blood loss if excessive
> Cesarean birth if necessary
> Betamethasone is indicated to increase fetal lung maturity. (Mosby,
Comprehensive p. 203)
Nursing Diagnosis with #1 NURSING DIAGNOSIS: Potential fluid volume deficit
Nursing Intervention > Maintain bed rest
> #1 Assessment - Monitor maternal vital signs, FHR, and fetal activity
> Assess bleeding (amount and quality)
> Monitor and treat signs of shock
> Avoid vaginal examination if bleeding is occurring
> Prepare for premature birth or cesarean section
> Administer IV fluids as ordered
> Administer iron supplements or blood transfusion as ordered (maintain
hematocrit level)
> Prepare to administer Rh immune globulin

BESTPOSITION The patient with placenta previa should be maintained on bed rest,
preferably in a side-lying position. Additional pressure from an upright
position may cause further tearing of the placenta from the uterine lining.
Ambulating would therefore be indicated for this patient. Performing a
vaginal examination and applying internal scalp electrode could also cause
the placenta to be further torn from the uterine lining.

Confirmatory Test > Ultrasound for placenta localization

NOTE:
Manual pelvic examinations are contraindicated when vaginal bleeding is
apparent in the third trimester unit a diagnosis is made and placenta
previa is ruled out. Digital examination of the cervix can lead to maternal
and fetal hemorrhage. A diagnosis of placenta previa is made by
ultrasound. The hemoglobin and hematocrit levels are monitored and
external electronic fetal heart rate monitoring is initiated. Electronic fetal
monitoring (external) is crucial in evaluating the status of the fetus who is
at risk for severe hypoxia. (Saunders Comprehensive 2002 Edition, p. 304)

29
UNIT X: LABOR and DELIVERY

LABOR- the process by which the products of conception are expelled.

1. Theories of labor
 Uterine Stretch or Myometrial irritability theory
 Theory of Aging Placenta
 Prostaglandin Theory
 Progesterone Deprivation Theory
 Estrogen Theory
 Oxytocin Theory
 Fetal hormone Theory
2. Premonitory signs of labor
 Lightening- descent of the presenting part in the pelvis
 Increase braxton-hicks contraction
 Increase in maternal activity
 Rupture of BOW- occasional
 Show
 Nesting
 Decrease in maternal weight by 2-3 lbs
4. Factors that affect Labor ( 5 P’s )
a. Power-
 Voluntary –Bearing down

 Involuntary- Uterine contractions

30
 = Monitor DIF and intensity, and strength
D- uration ( start to end )
I- interval ( end to start )
F- requency ( start to start )
= Assess for abnormalities in Power which include
1. Primary Uterine inertia

2. Secondary Uterine inertia

b. Passsenger
1. Fetus- assess the following
= Size, number ( singleton or multiple )
= Presentation
= Lie
= Position
= Presence of congenital defects

31
32
2. Placenta

c. Passageway ( PUV )
= P- elvis
1. Types of Pelvis
 Gynecoid
 Anthropoid
 Android
 Platypelloid

2. Pelvic Measurements
 Inlet
= Diagonal Conjugate
= True Conjugate
= Obstetrical Conjugate
 Midpelvis
= Bi ischial diameter
 Outlet
 = Intertuberosities

33
OUTLET
Widest diameter: Anterior posterior diameter (requires the internal Relationship of fetal head for entry)
Narrowest diameter: Transverse Intertuberous Diameter (facilitates delivery in Occipital Anterior
Posterior)

= U- terus assess for

 Cervical Effacement
 Cervical Dilatation
 Physiologic retraction/ Bandl’s ring

34
 3. Pelvic Measurements
 Inlet
= Diagonal Conjugate
= True Conjugate
= Obstetrical Conjugate
 Midpelvis
= Bi ischial diameter
 Outlet
 = Intertuberosities

OUTLET
Widest diameter: Anterior posterior diameter (requires the internal Relationship of fetal head for entry)
Narrowest diameter: Transverse Intertuberous Diameter (facilitates delivery in Occipital Anterior
Posterior)

= U- terus assess for

 Cervical Effacement

35
  Cervical Dilatation
 Physiologic retraction/ Bandl’s ring

= V- agina- assess for Infections especially Herpes Simplex

d. Psyche

e. Position

5. Differences between true and false labor

True False
* Uterine contraction
* Location of pain
* Intensity related to walking
* Appearance of Show
* Cervical Dilatation

6. Stages of Labor

STAGE PHASE ASSESSMENT NURSING CONSIDERATION

1 Latent Onset of labor until cervical dilatation  Monitor frequency, intensity,
of 4 cm. and patterns of uterine contractions
 Monitor fetal status during
labor by monitoring fetal heart rate
 Assess bloody show (pink or
blood streaked mucus), perineal
bulging, membrane status
 Periodic vaginal exams
 Monitor vital signs
 Assess client’s ability to cope
with contractions
 Provide emotional support

36
2 From dilation to delivery of the fetus  Prep client for delivery
 Immediate assessment of the
newborn
Nursing care for the client during the
second stage of labor should include
assisting the mother with pushing,
helping position her legs for maximum
pushing effectiveness, and monitoring
the fetal heart rate

3 From delivery of the fetus to delivery  Assess umbilical cord for 3

of the placenta, usual within 5-20 vessels (2 arteries, 1 vein)
mins. Of delivery  Assess placenta for intactness
 The fundus should be midline
at or two cm. Below the umbilicus

By the 2nd postpartum day, the fundus

should be firm and two fingerbreadths
below the umbilicus. The fundus should
be at the level of the umbilicus on the
day of delivery and falls below the
umbilicus by approximately one
fingerbreadth (1 cm) per day, until it
has contracted into the pelvis by the 9th
or 10th day. The fundus should be firm,
not soft. A soft or boggy fundus
indicates that the uterus isn't
contracting properly. The fundus
should be palpated in the midline of the
abdomen; if the woman has a full
bladder, however, the fundus may be
deviated to the right or left.

 The fundus should descend

4 The period of immediate recovery and
observation after delivery of the
placenta. Approximately 2 hours
approximately 1-2 cm every 24
hours
 NOTE: The fundus should
not be massaged unless it is
relaxed. Constant massaging
would tire the uterine muscle,
contributing to hemorrhage
 Promote parent-infant bonding
 Assess maternal vital signs,
fundal height, lochia and bladder
distention

One hour after birth expect the fundal

height at midway between the umbilicus
and the symphysis pubis.

37
 Generally, the fundal height descends
into the pelvis one finger’s-breadth per
day.

 Assist breastfeeding efforts if

indicated

In teaching the client about postpartum

weight loss in relation to breastfeeding
the factors that should be considered is
the caloric needs of a nursing mother
and dieting should be avoided, in order
to maintain adequate milk supply.

* First stage: Stage of Dilatation

= Latent

= Active

= Transition
* Second stage: Stage of Expulsion
= Characteristics:
CARDINAL MOVEMENTS OF THE FETUS

Descent Flexion Internal Rotation Extension External Rotation

Expulsion

* Third stage: Placental Expulsion ( 15-20 minutes )

38
The first 1-2 hours postpartum. Priority nursing actions include:
A.Assessment of:
1. Fundus- should be checked every 15 mins. For one hour then every 30 mins. for
the next 4 hours.
 should be firm, in the midline, and during the first 12 hours
slightly above umbilicus. Note: if non-contracted- massage;
apply ice cap over the abdomen; administer oxytocin as
prescribed.
 Involution of the uterus ( the return of the uterus to its non
pregnant condition ) occurs between 4-6 weeks effected by the
contraction of the uterus with the decrease in size of individual
myometrial cells and partly by autolytic processes in which some
of the protein material of the uterine wall is broken down into
simpler components which then are absorbed.
 By the 9th or the 10th day it can be compared with a grapefruit not
only in size but also in consistency.
 Immediately after delivery, the weight of the uterus is 1000gm;
after a week- 500 gm; after 2 weeks- 100 gm, and after 4 weeks-
4weeks- 60 gm.
 Fundic ht immediately after birth- above umbilicus; within 24
hrs- umbilical level; then, 1 cm below umbilicus/ day; by the 7th
day at the symphysis pubis and on the 10th day no longer
palpable.

39
 2. Lochia – is moderate in amount. Right after delivery, a perineal pad is completely
saturated within 30 minutes. Composed of blood with a small amount of mucus,
decidual particles, cells from the placental site, WBC, bacteria ( from the vagina ).
Types:
a. Lochia rubra- first three days after delivery, consist almost of entirely of
blood with only decidual particles and mucus, red in color
b. Lochia serosa- about the fourth day, leucocytes begin to invade the area as
they do any healing surface, the flow becomes pink or brownish in color
c. Lochia alba- on the 9th day, the amount of flow decreases and becomes
colorless or white.

3. Perineum- is tender, discolored and edematous.Should be clean with intact

stitches. Check for laceration manifested by trickling of blood with the uterus firm
and contracted.
Types of laceration:
a. First degree- involve the vaginal mucous membrane,and perineal skin to
the fourchette.
b. Second degree- involve the vaginal mucous membrane, perineal skin, and
perineal muscles
c. Third degree- involve the entire perineum, perineal skin and muscles, and
external sphincter of the rectum.
d. Fourth degree- involve the vaginal mucous membrane, perineal skin and
muscles, rectal sphincter and rectal mucusa.
Management: Episiorraphy under local anesthesia ( (Xylocaine )

4. Bladder- should be emptied every 2 hours. A full bladder is evidenced by a

fundus in the right side of the midline, dark red bleeding with some clots. This
condition may delay uterine contraction. The bladder mucosa following delivery
shows varying degrees of edema and hyperemia with decrease muscle tone thus
most women do not have the sensation of having to void resulting to urinary stasis
and infection (( Cystitis )
5. VS especially the BP and PR- maybe slightly increased from excitement and
effort of delivery, but stabilizes in an hour
a. Temperature- may have a slight increase on the first 24 hours due to
dehydration ( fluid and blood). Any increase after the first day with boggy
uterus and abnormal discharge may mean Puerperal sepsis.
b. Pulse- slightly lower than normal due to increased amount of blood that
returns to the circulatory system following delivery of the placenta.
Usually the PR is 60-70 /min
c. Blood Pressure- Increased in the blood volume during the postpartal
period raises the BP. The slowing of the heart beat is a compensatory
mechanism to decrease the pressure in the circulatory system. A reading
above 140/ 90 mmHg needs further evaluation.

B. Lactation/Breastfeeding- first 30 mins or immediately following the delivery of the

40
Baby. Benefits:
1. Bonding
2. Facilitates release of colostrums
3. Stimulates the pituitary to produce Prolactin and Oxytocin
4. For the newborn- Prevents physiologic jaundice due to stimulation of gastrocolic
reflex which causes more expulsion of meconium
Note: If no intention to breaastfeed, a lactation suppressant meds can be used on the first
hours postpartum. Estrogen-androgen preparations include- Deladumone, TACE, and
DES.

B. Rooming-in =the neonate is brought out from the nursery in order to be with parents.
Benefits include : promotion of bonding, participation of mother as well as the father
in caring for the newborn that may foster a positive relationship among the family
members.

IV. POSTPARTUM DISCOMFORTS

A. Perineal discomfort

Apply ice packs to the perineum during the first 24 hours to reduce swelling after the first 24 hours,
apply warmth by sitz baths

B. Episiotomy

1. Instruct the client to administer perineal care after each voiding

2. Encourage the use of an analgesic spray as prescribed
3. Administer analgesics as prescribed if comfort measures are unsuccessful

C. Breast discomfort

PREVENTION:
The BEST PREVENTION TECHNIQUE IS TO EMPTY THE BREST REGULARLY AND FREQUENTLY
WITH FEEDINGS. The 2nd is EXPRESSING A LITTLE MILK BEFORE NURSING, MASSAGING THE
BREASTS GENTLY OR TAKING A WARM SHOWER BEFORE FEEDING MAY HELP TO IMPROVE
MILK FLOW. Placing as much of the areola as possible into the neonate’s mouth is one method. Other
methods include changing position with each nursing so that different areas of the nipples receive the
greatest stress from nursing and avoiding breast engorgement, which make I difficult for the neonate to
grasp. In addition, nursing more frequently, so that a ravenous neonate is not sucking vigorously at the
beginning of the feedings, AND FEEDING ON DEMAND to prevent over hunger is helpful. AIRDRYING
THE NIPPLES AND EXPOSING THEM TO THE LIGHT HAVE ALSO BEEN RECOMMENDED. Warm
Tea bags, which contain tannic acid also, will sooth soreness. WEARING A SUPPORTIVE BRASSIERE
DOES NOT PREVENT BREAST ENGORGEMENT. APPLYING ICE and LANOLIN DOES NOT RELIEVE
BREAST ENGORGEMENT. (Page 178 -179 lippincot)

INTERVENTION:
Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a
few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the
nipples air dry after feedings, and avoiding the use of soap on the nipples.

41
NOTE: Specific nursing care for breast Engorgement
1. Breastfeed frequently
2. Apply warm packs before feeding
3. Apply ice packs between feedings

NOTE: Specific Nursing Care for Cracked nipples

1. Expose nipples to air for 10 to 20 minutes after feeding
2. Rotate the position of the baby for each feeding
3. Be sure that the baby is latched on to the areola, not just the nipple

NOTE: Do not use soap on the breasts, as it tends to remove natural oils, which increases the chance of
cracked nipples

NOTE: Inverted Nipples

Push the areola tissues away from the nipples, and then grasp the nipples to tease them out of the tissue. Using a
Woolrich breast shield, which pushes the nipples through openings in the shield, also can help overcome inverted
nipples

. The LATERAL HEEL (HEEL STICK) is the best site because it prevents damage to the posterior tibial
nerve and artery and plantar artery.

POSTPARTUM DISCHARGE TEACHINGS

A. General Principles/Considerations

A. Breast Feeding
The American Academy of Pediatrics recommends beginning breast feeding as soon as possible
after delivery or during the first period of reactivity. A neonate that will be breast fed should not be given
formula by bottle at this time. Many institutions provide sterile water for the initial feeding to assess for
esophageal atresia. Because colustrum is not irritating if aspirated and is readily absorbed by the
neonate’s respiratory system, breast feeding can be done immediately after birth. Colustrum contains
antibodies that the neonate lacks, such as Immunoglobulin A. Breast feeding stimulates the oxytocin
secretion, which causes the uterine muscles to contract.

NOTE: Oral contraceptives containing estrogen are not recommended for breastfeeding
mothers; progestin-only birth control pills are less likely to interfere with the milk supply
14. Baby will develop his or her own feeding schedule. Hormonal contraceptives may cause
a decrease in the milk supply and are best avoided during the first 6 weeks after birth.

NOTE: The condom is the only safe, non prescription contraceptive to use while a woman
lactating and before there is normal uterine involution at this time.

NOTE: LET DOWN REFLEX OF THE BREAST

Oxytoxin is the #1 factor that stimulates the let down reflex while Prolactin is the one that
stimulates the acini cells to produce milk.

A. First Breast Feeding

42
 The mother should be encouraged to nurse frequently during the first few days after delivery.
BREAST FEEDING FOR AT LEAST 7-10 MINUTES PER SIDE FOR THE LET DOWN REFLEX TO
BEGIN.

2nd breast Feeding

AFTER THE FIRST BREAST FEEDING, the mother should breast feed her infant 2-3 hours until
her milk supply is established.

Breast milk contents versus cow’s milk

BREAST MILK is higher in fat content than cow’s milk; 35% - 55% of the calories in breast milk are from
fat. Cow’s milk is higher in iron, sodium calcium & phosphorus.

COWS MILK
According to the American Academy of Pediatrics (AAP) recommends that infants be given breast milk of
formula UNTIL 1 YEAR OF AGE. The AAP Committee decreed that cow’s milk could be substituted in the
SECOND 6 MONTHS OF LIFE, BUT ONLY IF THE AMOUNT OF MILK CALORIES DOES NOT
EXCEDD 65% of total calories and iron is replaced by solid foods. The protein content o cow’s milk is too
high, and therefore is poorly digested, and may cause gastrointestinal tract bleeding

SUPPLEMENTING BREAST FEEDING WITH BOTTLED FEEDING

Bottle supplements tend to cause a decrease in the breast milk supply and demand for breast feeding, AND
SHOULD BE AVOIDED

NOTE: Breast milk Storage

Never store it in clean glass containers because immunoglobulins tend to stick to glass bottles
and the containers should BE STERILE. The client should use STERILE PLASTIC
CONTAINERS labeled with time, date and amount. Store breast milk at the refrigerator for 48
hours or in a freezer for 2 months. Frozen breast milk should be thawed in the refrigerator for
a few hours, placed under warm tap water, then shake it.

NOTE: START OF SOLID FOOD is usually 4 months.

B. BURPING & FEEDING

BURPING
Another word is bubbling the neonate should be done after 5 minutes of feeding, in the middle of the
feeding, and at the end o the feeding.The neonate should be held in an upright position and patted on the
back.

POSITION FOR FEEDING

The neonate should be placed on the right side, placing the patient on prone position has been associated
with SIDS (Sudden Infant Death Syndrome)

NOTE:
If the bottle nipple is kept full of formula, the infant will suck less air, the infant is less likely to spit up and
less likely to swallow air. Swallowing air can lead to colic. A bottle should never be propped because of
the chance of aspiration. Burping should occur after each 2 oz. Burping frequently decreased the
chance of spitting up. The nipple should be all the way in the infant’s mouth so the infant can create a
good suck.

NOTE: Bottle-fed infants are usually fed within the first few hours after birth. The nurse must
determine if the newborn is ready for this feeding. Signs are indicative of readiness for feeding include

43
presence of rooting and sucking reflexes, active bowel sounds, absence of abdominal dissension, and
absence of signs of respiratory distress.

NOTE: How to stimulate the Infant’s lips to take the nipple?

Lightly brushing the neonates lips with nipple causes the neonate to open the mouth the begin sucking.
Such techniques as pulling down on the chin, squeezing the cheek, or placing the nipple directly in the
mouth force the mouth open or force the neonates to take the nipple.

C. Psychological Adaptation

Taking-in Phase Postpartum blues: overwhelming sadness

Taking-hold Phase Postpartum depression
Letting-Go Postpartum Psychoses

Rubin's Postpartum Phases of Regeneration (POSTPARTUM PSYCHOSOCIAL ADAPTATION)

“TAKING IN” PHASE (DEPENDENT) First 3 Days

.During this time, food and sleep are a major focus for the client. In addition, she works through the birth
experience to sort out reality from fantasy and to clarify any misunderstandings. This phase lasts 1 to 3
days after birth. The primary concern is to meet her own needs.
• Takes place 1-2 days postpartum
• Mother is passive and dependent; concerned with own needs.
• Verbalizes about the delivery experience.
• Sleep/food important.
• Mother focuses on her own primary needs, such as sleep and food
 Important for the nurse to listen and to help the mother interpret the events of delivery to
make them more meaningful
 Not an optimum time to teach the mother about baby care

“TAKING HOLD” PHASE

(DEPENDENT/INDEPENDENT)
The client is concerned regarding her need to resume control of all facets of her life in a competent manner.
At this time, she is ready to learn self-care and infant care skills.

• 3-10 days postpartum

• Mother strives for independence and begins to reassert herself.
• Mood swings occur. May cry for no reason.
• Maximal stage of learning readiness.
• Mother requires reassurance that she can perform tasks of motherhood.
• Begins to assume the tasks of mothering
• An optimum time to teach the mother about baby care.

“LETTING GO” PHASE (INTERDEPENCE)

• 10 to 6 weeks postpartum
• Realistic regarding role transition.
• Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit.
Accepts baby as separate person

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 • 10 to 6 weeks postpartum
• Realistic regarding role transition.
• Shows pattern of life-style that includes the new baby but still focuses on entire family as a unit.
• Accepts baby as separate person.
 Mother may feel deep loss over separation of the baby from part of the body and may
grieve over the loss
 Mother may be caught in a dependent/independent role, wanting to feel safe and secure
yet wanting to make decisions
 Teenage mothers need special consideration because of the conflict taking place within
them as part of adolescence

POSTPARTUM WARNING S/S TO REPORT TO THE PHYSICIAN

Increased bleeding, clots or passage of tissue.
Bright red vaginal bleeding anytime after birth.
Pain greater than expected.
Temperature elevation to 100.4º F.
Feeling of full bladder accompanied by inability to void.
Enlarging hematoma.
Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness; and visual disturbance.
Pain, redness, and warmth accompanied by a firm area in the calf.
Difficulty breathing, rapid heart rate, chest pain, cough, feeling of apprehension, pale, cold, or blue skin
color

COMPLICATIONS OF LABOR
1. DYSTOCIA – broad term for abnormal or difficult labor and delivery
a. Uterine Inertia- sluggishness of contraction
Causes:
 Inappropriate use of analgesic
 Pelvic bone contraction
 Poor fetalposition
 Overdistention- due to multiparity, multiple gestation,
polyhydramnios or macrosomia
Types:
1. Primary ( hypertonic ) uterine dysfunction- relaxation are inadequate and mild,
therefore, ineffective. Since uterine muscle is in a state of greater than normal
tension, latent phase is prolonged. Treatment: Sedation with Diazepam, provision
of comfort measures like bedbath and restful environment
2. Secondary ( hypotonic ) uterine dysfunction- contractions have been good but
gradually became infrequent and poor of quality and dilatation ceases.
Treatment:Oxytocin administration or amniotomy to augment
Ambulation and Enema if BOW is intact
3. Precipitate delivery- labor and delivery in less than 2-3 hours after the onset of
true labor pains. Common in multiparity or following administration or
amniotomy. Possible complications include: Hemorrhage due to sudden release of
pressure, extensive laceration, or abruptio placenta.

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3.Prolonged labor

4.Uterine rupture- occurs when the uterus undergoes more strain than it is capable of
sustaining.
Causes:
1. Scar from a previous classic CS
2. Unwise use of Oxytocin
3. Faulty presentation
4. Prolonged labor
5. Overdistention
Signs and symptoms:
1. Sudden,severe pain
2. Hemorrhage
3. Change in abdominal contour with two abdominal swelling; the retracted uterus
and the extrauterine fetus
Treatment: Hysterectomy

5.Uterine Inversion- turning inside out of the uterus

Causses:
1. Insertion of placenta at the fundus, so that as as fetus is rapidly expelled the
fundus is pulled down
2. Strong fundal push when mother fails to bear down effectively
3. Attempts to deliver the placenta before placental separation occurs.
Treatment: Hysterectomy

6. Amniotic fluid embolism- occurs when amniotic fluid enters the maternal circulation
causing cardiopulmonary failure
Signs and symptoms: dramatic
= woman in labor suddenly sits up and grasps her chest because of sharp pain and
inability to breathe
=Turns pale and becomes bluish-gray color associated with pulmonary embolism
=Death may occur in few minutes
Treatment:
1. Emergency C PR measures; IV; O2 inhalation
2. Inform family and provide emotional support

Figure 23

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 PROLAPSE UMBILICAL CORD
Definition  The umbilical cord is displaced, either between the presenting post
and the amnion or protruding through the cervix.
Synonyms  Cord Prolapse

Predisposing Factors 

Fetal Position other than cephalic presentations

 Prematurity:
NOTE: Small fetus allows more space around presenting part.
 Polyhydramnios
 Multiple fetal gestation
 FetoPelvic disproportion
 Abnormally long umbilical cord.
 Placenta Previa
 Intrauterine tumors that prevent the presenting part from engaging
> Breech presentation, Transverse lie, Unengaged presenting part,
Twin gestation, Hydramnios
 Small fetus
Initial Sign  Cord Prolapse:
NOTE: first discovered when there is variable decelerated pattern
FHR pattern variable: Decelerations with contractions or between
contraction or fetal bradycardia present
 Persistent non reassuring fetal heart rate – fetal distress
 Atrophy of the umbilical cord & cord protruding from vagina
Cord may be palpated in cervix/vagina
 Reflex constriction when cord is exposed to air
Late Sign  Cool, moist skin
 Dystocia
Cardinal Sign  Rupture of Membrane spontaneously
 The cord may then present/visible @ the vulva.
Note: Do not attempt to push the cord into the uterus.
Confirmatory Test  Amniotomy: Rupture of Membranes
Best Major Surgery  Cesarian Section if the cervix incompletely dilated.
 Fast vaginal delivery with forceps
Disease Complication  #1 Maternal & Fetal Infection - Causing compression of the cord
and compromising fetal circulation
OTHERS: Prematurity, Hypoxia, Meconium aspiration,Fetal death if
delayed or undiagnosed
Best Position  Trendelenberg’s position or Knee Chest position -which causes
the presenting part to fall back from the cord.
 Turn side to side -Helps may be elevated to shift to fetal presenting
toward diaphragm.

Bedside equipment  Eternal Electronic Fetal Heart Rate monitoring

 Oxygen with face-mask.
 Sterile hand glove
Best Drug  Heparin IV
Nature of the drug  To control intravascular coagulation in the pulmonary circulation
History of the Disease  Fetal nutrients supply
 Compression of the umbilical cord
Nursing Diagnosis  Fluid volume deficit related to active hemorrhage

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  Altered tissue perfusion related to maternal vital organ and fetal
related to hypovolemia
 Risk for infection related traumatize tissue

Nursing Intervention NOTE: The nurse’s #1 priority action to a prolapse cord is to assess
the fetal heart rate. A prolapsed cord interrupts the oxygen and
nutrient flow to the fetus. If the fetus doesn’t receive adequate oxygen,
hypoxia develops, which can lead to central nervous system damage in
the fetus.

The primary goal with a prolapsed of the umbilical cord is to remove

the pressure from the cord. Changing the maternal position is the first
intervention. Acceptable positions include knee-chest, side-lying and
elevation of the hips. The nurse may also perform a vaginal
examination and attempt to push the presenting part off the cord.
Administering the oxygen benefits the fetus only if circulation through
the cord has been reestablished.

 Start or maintain an IV as prescribed. Use of large-gauge catheter

when starting the IV for blood and large quantities of fluid intake.
 Administer oxygen by face –mask to provide high oxygen
concentration at 8 –10L/min.
 Instruct patient to cleanse from the front to the back.
 Explain the importance of hand washing before and after perineal
care.
 OTHER MANAGEMENT:
Reposition client to trendelenburg or knee- chest position
Oxygen
Push presenting part upward
Apply moistened sterile towels
Delivery as soon as possible

Trial labor- if a woman has borderline ( just adequate) pelvic measurements, but fetal
positions and presentations are good, labor maybe continued as long as with progressive
fetal descent and cervical dilatation.
Treatment:
1. Monitor FHT and uterine contraction
2. Keep bladder empty to allow all available space for descent
3. Emotional support

8. Premature labor and delivery- if uterine contractions occur before 38 weeks gestation
= If no bleeding and cervical dilatation – premature contractions can be stopped by drugs:
1. Ethyl alcohol ( Ethanol- IV )-blocks the release of Oxytocin
Side effects: N&V, mental confusion
2. Vasodilan, Isoxelan, Duvadilan
3. Ritodrine orally- muscle relaxant
4. Bricanyl
= If with bleeding and progressive cervical dilatation occurs premature delivery is
inevitable. Treatment may include:
1. administration of Steroid to the mother to help in the maturation of surfactant .

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 2. Pain medications are kept to a minimum because analgesics are known to cause
respiratory depression.
IV. POST PARTUM COMPLICATIONS
A. HEMORRHAGE

CAUSES SIGNS OF HEMORRHAGE MANAGEMENT

The #1 cause of POSTPARTUM
HEMORRHAGE IS RETAINED
PLACENTAL FRAGMENTS.
Uterine atony and vaginal &
cervical tears are associated with
early postpartum hemorrhage
The #2 cause is OVER-
DISTENTION OF THE UTERUS
from more than (10) pounds,
OTHERS ARE: 4000 gms,
neonate, excessive oxytocin use,
Polyhydramnios and Placental
Disorders.
You should assess for uterine
atony after a c-section delivery.
This is more common after a c-
section than after a vaginal
delivery.
Boggy uterus (does not
respond to massage)
A boggy uterus would be
palpable above the umbilicus and
would be soft and poorly
contracted.
Abnormal clots unusual
pelvic discomfort or headache
Excessive or bright-red
bleeding
Signs of shock
Early Hemorrhage starts on the
first 24 hours, or more than 500
ml of blood on the first 24 hrs in
a Normal spontaneous delivery..
Fluid replacement
Emergency lay
Oxygen
Vital signs
Perineal pad count
Psychological support
Massaging the lower abdomen
after delivery is done to maintain
a firm uterus, which will aid in
the clumping down of blood
vessels in the uterus, thereby
preventing any further bleeding.
“BOGGY UTERUS
Uterine atony means that the
uterus is not firm or it is not
contracting. The nurse should
gently massage the uterus which
will contract the uterus and make
it firm. Clients who are
predisposed are usually
MULTIPLE GESTATION,
POLYHYDRAMNIOS,
PROLONGED LABOR and LGA
(LARGE GESTATIONAL AGE
fetus.

B. THROMBOPLEBITIS
- Inflammation of the vein caused by a clot
The positive Homan’s sign indicate is possibility of thrombophlebitis or a deep venous thrombosis that is
present in the lower extremities.

When assessing for Homan’s sign ask the patient to stretch her kegs out with the knee slightly flexed
while dorsiflex the foot. A positive sign is present when pain is felt at the back of the knee or calf.
It is normal for a patient on magnesium sulfate to feel tired because it acts as a central nervous
depressant and often makes the patient drowsy.

MANIFESTATION MANAGEMENT CURATIVE

Edematous extremities Preventive Immobilize extremity
Fever with chills Analgesics
Pain and redness in affected Anticoagulant
area Thrombolytics
Positive Homan’s sign

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 C. INFECTION

PREDISPOSING FACTORS MANIFESTATION MANAGEMENT

Rupture of membranes over Fever
24 hours before delivery Chills
Retained placental Poor appetite
fragments General body malaise
Internal fetal monitoring Abdominal pain
Vaginal infection Foul-smelling lochia
Puerperial infection is an
infection of the genital tract.
Early signs and symptoms of
puerperial infection include
chills, fever, and flu-like
symptoms. It can occur up to one
month after delivery.
Antibiotics
Oxytocin
Analgesics
Maintain hygiene
Semi-fowlers positions
Vital signs
Early ambulations
Assess lochia
Bright red blood is a normal
lochial finding in the first 24
hours after delivery. Lochia
should never contain large clots,
tissue fragments, or membranes.
A foul odor may signal infection,
as may absence of lochia.

D. MASTITIS

ASSESSMENT:
Elevated temperature, chills, general aching, malaise and localized pain
Engorgement, hardness and reddening of the breasts
Nipple soreness and fissures
Inflammation of the breast as a result of infection
Primarily seen in breastfeeding mothers 2 to 3 weeks after delivery but may occur at any time
during lactation
NURSING IMPEMENTATION:
Instruct the mother in good hand washing and breast hygiene techniques
Apply heat or cold to site as prescribed
Maintain lactation in breastfeeding mothers
Encourage manual expression of breast milk or use of breast pump every 4 hours
Encourage mother to support, breasts by wearing a supportive bra
Administer analgesics & antibiotics as prescribed

E. Postpartum Mood Disorders

MOOD DISORDERS ASSESSMENT

Postpartum blues Onset: 1-10 days postpartum lasting 2 weeks or less
 Fatigue
 Weeping anxiety
 Mood instability
Postpartum depression Onset: 3-5 days lasting more than 2 weeks
 Confusion
Normal processes during  Fatigue
postpartum include the  Agitation
withdrawal of progesterone and  Feeling of hopelessness and shame “let down feeling”
estrogen and lead to the  Alterations in mood “roller coaster emotions”
psychological response known as

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"the blues." Postpartum
depression is a psychiatric
problem that occurs later in
postpartum and is characterized
by more severe symptoms of
inadequacy. Because the client's
behavior is normal, notifying her
physician and conducting a home
assessment aren't necessary.
Postpartum psychosis
 Appetite and sleep disturbance
According to Rubin, dependence and passivity are typical during the
taking-in period, which may last up to 3 days after delivery. A client
experiencing postpartum depression demonstrates anxiety, confusion,
or other signs and symptoms consistently. Maternal role attainment
occurs over 3 to 10 months. Attachment also is an ongoing process
that occurs gradually.
Onset: 3-5 days postpartum
 Symptoms of depression plus delusions
 Auditory hallucinations
 Hyperactivity

The female bony pelvis is divided into:

 False pelvis: above the pelvic brim and has no obstetric importance.
 True pelvis: below the pelvic brim and related to the child -birth.

THE TRUE PELVIS

It is composed of inlet, cavity, and outlet.

The Pelvic Inlet (Brim)

Boundaries

 Sacral promontory,
 alae of the sacrum,
 sacroiliac joints,
 iliopectineal lines,
 iliopectineal eminencies,
 upper border of the superior pubic rami,
 pubic tubercles,
 pubic crests and
 upper border of symphysis pubis.

Diameters

 Antero -posterior diameters:

o Anatomical antero-posterior diameter (true conjugate) = 11cm
 from the tip of the sacral promontory to the upper border of the symphysis pubis.
o Obstetric conjugate = 10.5 cm
 from the tip of the sacral promontory to the most bulging point on the back of
symphysis pubis which is about 1 cm below its upper border. It is the shortest
antero-posterior diameter.
o Diagonal conjugate = 12.5 cm
 i.e. 1.5 cm longer than the true conjugate. From the tip of sacral promontory to
the lower border of symphysis pubis.

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 o External conjugate = 20 cm
 from the depression below the last lumbar spine to the upper anterior margin of
the symphysis pubis measured from outside by the pelvimeter . It has not a true
obstetric importance.
 Transverse diameters:
o Anatomical transverse diameter =13cm
  between the farthest two points on the iliopectineal lines.
  It lies 4 cm anterior to the promontory and 7 cm behind the symphysis.
  It is the largest diameter in the pelvis.
o Obstetric transverse diameter:
 It bisects the true conjugate and is slightly shorter than the anatomical transverse
diameter.
 (C) Oblique diameters:
o  Right oblique diameter =12 cm
 from the right sacroiliac joint to the left iliopectineal eminence.
o  Left oblique diameter = 12 cm
 from the left sacroiliac joint to the right iliopectineal eminence.
o  Sacro-cotyloid diameters = 9-9.5 cm
 from the promontory of the sacrum to the right and left iliopectineal eminence, so
the right diameter ends at the right eminence and vice versa.

The Pelvic Cavity

It is a segment, the boundaries of which are:

 the roof is the plane of pelvic brim,

  the floor is the plane of least pelvic dimension,
  anteriorly the shorter symphysis pubis,
  posteriorly the longer sacrum.

The Pelvic Outlet

Anatomical outlet

It is lozenge-shaped bounded by;

  the lower border of symphysis pubis,   

  pubic arch,
  ischial tuberosities,
  sacrotuberous and sacrospinous ligaments and,     
  tip of the coccyx.

Obstetric outlet

It is a segment, the boundaries of which are:

  the roof is the plane of least pelvic dimension,

  the floor is the anatomical outlet,
  anteriorly the lower border of symphysis pubis,
  posteriorly the coccyx.
  laterally the ischial spines.

Diameters of pelvic outlet

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  Antero - posterior diameters:
o Anatomical antero-posterior diameter =11cm
 from the tip of the coccyx to the lower border of symphysis pubis.
o Obstetric antero-posterior diameter = 13 cm
 from the tip of the sacrum to the lower border of symphysis pubis as the coccyx
moves backwards during the second stage of labour.
 Transverse diameters:
o Bituberous diameter = 11 cm
 between the inner aspects of the ischial tuberosities.
o Bispinous diameter = 10.5 cm
 between the tips of ischial spines.

Pelvic Planes

These are imaginary planes lie as follow:

Plane of pelvic inlet:

passing with the boundaries of pelvic brim and making an angle of 55o with the horizon (angle of pelvic
inclination).

Plane of mid cavity (plane of greatest pelvic dimensions)

 pass between the middle of the posterior surface of the symphysis pubis and the junction between
2nd and 3rd sacral vertebrae. Laterally, it passes to the centre of the acetabulum and the upper
part of the greater sciatic notch.
 It is a round plane with diameter of 12.5 cm.
 Internal rotation of the head occurs when the biparietal diameter occupies this wide pelvic plane
while the occiput is on the pelvic floor i.e. at the plane of the least pelvic dimensions.

Plane of obstetric outlet (plane of least pelvic dimensions):

passes from the lower border of the symphysis pubis anteriorly, to the ischial spines laterally, to the tip of the
sacrum posteriorly.

Plane of anatomical outlet:

passes with the boundaries of anatomical outlet and consists of 2 triangular planes with one base which is
the bituberous diameter.

 Anterior sagittal plane: its apex at the lower border of the symphysis pubis.
  Posterior sagittal plane: its apex at the tip of the coccyx.
 Anterior sagittal diameter: 6-7 cm
o from the lower border of the symphysis pubis to the centre of the bituberous diameter.
 Posterior sagittal diameter: 7.5-10 cm
o from the tip of the sacrum to the centre of the bituberous diameter.

Pelvic Axes

Anatomical axis (curve of Carus)

 It is an imaginary line joining the centre points of the planes of the inlet, cavity and outlet.
  It is C shaped with the concavity directed forwards.
  It has no obstetric importance.

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Obstetric axis

  It is an imaginary line represents the way passed by the head during labour.
  It is J shaped passes downwards and backwards along the axis of the inlet till the ischial spines
where it passes downwards and forwards along the axis of the pelvic outlet.

Caldwell- Moloy Classification of Pelvic Types (1933)

Four types of female pelves were described. Actually, the majority of pelves are of mixed types:

 Gynaecoid pelvis(50%):
o It is the normal female type.
o Inlet is slightly transverse oval.
o Sacrum is wide with average concavity and inclination.
o Side walls are straight with blunt ischial spines.
o Sacro-sciatic notch is wide.
o Subpubic angle is 90-100o.
 Anthropoid pelvis (25%):
o It is ape-like type.
o All anteroposterior diameters are long.
o All transverse diameters are short.
o Sacrum is long and narrow.
o Sacro-sciatic notch is wide.
o Subpubic angle is narrow.
 Android pelvis (20%):
o It is a male type.
o Inlet is triangular or heart-shaped with anterior narrow apex.
o Side walls are converging (funnel pelvis) with projecting ischial spines.
o Sacro-sciatic notch is narrow.
o Subpubic angle is narrow <90o.
 Platypelloid pelvis (5%):
o It is a flat female type.
o All anteroposterior diameters are short.
o All transverse diameters are long.
o Sacro-sciatic notch is narrow.
o Subpubic angle is wide.

N.B. At the Level of Ischial Spines:

 The plane of obstetric outlet (plane of the least pelvic dimensions) is at this level.
 The levator ani muscles are situated at this level and its ischio-coccygeous part is attached to the
ischial spines.
 The obstetric axis of the pelvis changes its direction.
 The head is considered engaged when the vault is felt vaginally at or below this level.
 Internal rotation of the head occurs when the occiput is at this level.
 Forceps is applied only when the head at this level (mid forceps) or below it (low and outlet
forceps).
 Pudendal nerve block is carried out at this level.
 The external os of the cervix is located normally.
 The vaginal vault is located nearly.
 The ring pessary should be applied above this level for treatment of prolapse.

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