CHAPTER IV. NORMAL PREGNANCY AND PRENATAL CARE.

Birth Rate
 It is the number of individuals born in a population in a given
amount of time. Birth rate is stated as the number of individuals
born per year per 1,000 in the population.

Perinatal Mortality Rate

 It is the "number of stillbirths and deaths in the first week of life
per 1,000 total births, the perinatal period commences at 22
completed weeks (154 days) of gestation, and ends seven
completed days after birth.

Fetal Death Rate

 Fetal death (also called a stillbirth) is the death of a fetus that is
at least 20 weeks gestation but dies before it is born.

Neonatal Death Rate

 Number of deaths during the first 28 completed days of life per
1,000 live births in a given year or period.

Infant Mortality Rate

 Infant mortality is the death of an infant before his or her first
birthday. The infant mortality rate is the number of infant deaths
for every 1,000 live births.

Maternal Mortality Rate

 It is the number of maternal deaths during a given time period per
100,000 live births during the same time period.
 Number of deaths that occurs due to complications of pregnancy,
labor and puerperium.

PREGNANCY

 Pregnancy is the term used to describe the period in which a fetus

develops inside a woman's womb or uterus. Pregnancy usually lasts
about 40 weeks, or just over 9 months, as measured from the last
menstrual period to delivery. It occurs when a sperm fertilizes an egg
after it's released from the ovary during ovulation.

FERTILIZATION

 The union of sperm and mature ovum in the outer third or outer
half of the fallopian tube. When the sperm cell reach the uterus,
its head undergoes structural changes called capacitation, the
 outer covering at the head of the sperm cell disappears and tiny
holes appear in it. When it meets the ovum in the fallopian tube it
secretes the enzymes hyalurunidase through the holes in its head
which dissolves the outermost covering of the egg cell which is the
corona radiata. Once corona radiata has disintegrated the sperm
cell will secrete another enzyme called acrosin which will dissolve
the portion of the zona pellucida where it gets into contact with
while entering the ovum. The entire zona pellucida does not
disintegrate during fertilization. Once the sperm cell has entered
the ovum and then nucleus has fused as one, fertilization is
completed. Both the tail and the head of the sperm cell enter the
ovum but the tail degenerates right after. After the sperm cell
has entered the ovum, the plasma membrane of the latter will
undergo certain structural changes to prevent polyspermy or other
sperm cells from entering the ovum. The second meiotic cell
division of the ovum is completed after fertilization and it is the
secondary oocyte that is fertilized.

 The hereditary traits and characteristics of a person are found

inside the cell’s nucleus in the form of chromosomes. Each strand
of chromosomes is made up of thousands of genes that are
composed of protein substance called deoxyribonucleic acid (DNA)
and ribonucleic acid (RNA).

GENERAL CONSIDERATIONS:

1. Normal amount of semen per ejaculation is 3 to 5 cc. or equivalent to

1 tsp.
2. Number of sperms/cc. is 120 to 150 million.
3. Mature ovum is capable of being fertilized for 24 – 36 hours after
ovulation.
Sperm is viable within in 48 – 72 hours in 2 – 3 days.
4. Sperms once deposited in the vagina will generally reach the cervix within
90 seconds and after 5 minutes to the fallopian tubes
5. Reproductive cells during gametogenesis which divide meiosis which is
the number of daughter cells and which contain only half the number of
chromosomes because the rest of the body cells contain chromosomes.
Reproductive cells only have 23 chromosomes. Sperm have 22
autosomes and 1X and 1Y sex chromosomes. The union of an X carrying
sperm and a mature ovum results in a baby girl (XX) and the union of a Y
carrying sperm and a mature ovum results in a baby boy (XY).

IMPORTANT: Only the father who determine the sex of their children.
THE FERTILIZATION PROCESS
FETAL DEVELOPMENT
 Immediately after fertilization the fertilized zygote stays in the
fallopian tube for 3 to 4 days during which time rapid cell division
which is mitosis resulting daughter cells contain double the
number of chromosomes which is called diploid division is taking
place. The developing cells are now called blastomere and when
there are already 16 blastomeres it is now termed as morula. In
this morula form, it will start to travel by ciliary action and
peristaltic contractions of the fallopian tube to the uterus where it
will stay for another 3 to 4 days. When there is already a cavity
formed in the morula, it is now termed a blastocyst. It is a finger –
like projections which is called as trophoblast which form around
the blastocyst and these trophoblasts are the one will implant high
on the anterior or posterior surface of the uterus. Implantation
also called nidation, therefore takes place about a week or 6 to 8
days after fertilization.

 The outermost layer of the fertilized ovum or zygote is termed the

chorion. It serves for nutritional and protection of the embryo
and consists of an inner mesodermal layer and an outer
ectodermal layer, the trophoblast. Initially the trophoblast is a
poorly defined syncytium but it soon develops into 2 tissue type;

 The langhan’s striae which is the inner distinctly cellular

cytotrophoblast
 The syntrophoblast which is the outer confluent but
differentiated plasmotrophoblast

 The trophoblast produces enzymes capable of rapid destruction of

endometrium and myometrium. They enable the embryo to erode
deeply and without delay into the functionalis layer of the
endometrium but usually not beyond the compacta. Deeper
invasion is prevented by formation of nitabuch’s striae, it is a
layer of hyalinized fibrin just beyond the advancing trophoblasts.

 Normally, the blastocyst implants in the decidua and lining

the anterior or posterior wall of the fundus. The site of
implantation heals over. Three decidual areas may now be
recognized:

Decidua Capsularis or Reflexa

 that portion of the uterine mucosa immediately
overlying the embryo.
 Part of endometrium that encapsulates the fetus.
Decidua Basalis
  that portion of the uterine mucosa beneath the
embryo.
 Part of the endometrium which is located directly
under the fetus where placenta is developed.
Decidua Parietalis or Vera
 that portion of the uterine mucosa which is the
remainder of the uterine lining.

- The decidua capsularis disappears as the embryo increases

in
size to fill the uterine cavity. The deciduas basalis is the site
of
future development of the placenta.

General considerations:
1. Once implantation has taken place, the uterine endothelium is now
termed
decidua.
2. Occasionally a small amount of vaginal spotting appears with
implantation because
capillaries are ruptured by the implanting trophoblasts. If there is
implantation
bleeding, this should not to be mistaken as the first day of the Last
Menstrual
Period (LMP) when estimating for the Expected Date of Confinement
(EDC).

2 Layers of Trophoblast:

1. Cytotrophoblast
 Which is the outer layer which protects fetus against syphilis and
capable of living until 24 weeks or 6 months.

2. Syncytiotrophoblast
 Which is the inner layer which is responsible for production of
hormones.

2 Layers:
1. Langhan’s layer
 believed to protect the fetus against treponema pallidum
which the etiologic agent of syphilis. Present only during
the second trimester of pregnancy.
2. Syncytial layer
 it gives rise to two fetal membranes or parts;
a.) Amnion
b.) Chorion
 A. AMNION
 The amnion gives rise to two inner membrane or part of
the fetus, they are:

a.) Umbilical cord or funis

 It is about 20 inches in length and about 3 quarters of an inch in
diameter.
 Contains 2 arteries and 1 vein which are kept in place by wharton’s
jelly.
 Whitish gray in color which joins fetus to placenta.

b.) Amniotic fluid

 clear albuminous fluid in which the baby floats. Begin to form at 11 to
15 weeks gestation
 Approximates water in specific gravity is 1.007 to 1.025.
 Neutral to slight alkaline
 Near term, it is clear, colorless, containing little white specks of vernix
caseosa and other solid particles.
 Also known as) bag of water (BOW)
 Produced at a rate of 500 ml. in 24 hours and the fetus swallows it in
an equally rapid rate of 500 ml./24 hours. By the 4th month, urine of
the fetus is added to the amount of amniotic fluid. Amniotic fluid,
therefore is derived from maternal serum and fetal urine.

IMPLICATION: A case of polyhydramnios.

 More than 500 cc. of amniotic fluid was swallowed by the

fetus
because tracheo-esophageal fistula.
 May indicate GIT problems like congenital defect of the
esophagus.

A case of oligohydramnios.

 The fetus swallows amniotic fluid less than 500 cc due to

the fetal kidneys that are not functioning normally
because of congenital renal anomaly or kidney anomaly.

PROTECTIVE FUNCTIONS OF BOW:

 Shields the fetus against blows or pressure on the mother’s abdomen.

 Protects the fetus against sudden changes in temperature.
 Protects the fetus from infection.
 Facilitate musculoskeletal development and symmetrical growth.
 Prevents cord compression.
 Helps in delivery process.

DIAGNOSTIC FUNCTION OF BOW:

1. AMNIOCENTESIS

 Getting a sample of amniotic fluid to determine fetal lung maturity and

genetic abnormalities.

2. MECONIUM – STAINED

 A meconium- stained amniotic fluid in non – breech presentation is a

sign of fetal distress
 Aids in the descent of the fetus during active labor.

B. CHORION

 Together with the decidua basalis, the chorion gives rise to the
placenta which starts to form at 8 weeks gestational age (GA).
Before this time, it is the corpus luteum which produces the hormones
necessary to maintain the pregnancy.
 Outermost membrane of the fetus, it is where placenta is developed.

IMPORTANCE OF PLACENTA:

RESPIRATORY SYSTEM

 The exchange of oxygen and carbon dioxide takes place in the

placenta not in the lungs of the fetus.

GASTROINTESTINAL SYSTEM

 The nutrients are pass to the fetus via the placenta by means of
diffusion through the placental tissue.
 It is the active transport for amino acids.

CIRCULATORY SYSTEM

 The feto-placental circulation takes place in the placenta by selective

osmosis via the umbilical arteries and umbilical veins.
RENAL SYSTEM

 Waste products are excreted through the placenta.

NOTE: It is the mother’s liver which detoxifies the waste products of

the fetus.

ENDOCRINE SYSTEM

 HUMAN CHORIONIC GONADOTROPIN (HCG)

Orders the corpus luteum to keep on producing estrogen and

progesterone that is why there is amenorrhea during pregnancy
and it is also the basis for pregnancy test.
  HUMAN PLACENTAL LACTOGEN

Also known as Human Chorionic Somatotropin (HCS)

Promotes growth of the mammary gland necessary for lactation
and it has also a growth stimulating properties.

NOTE: The estrogen and progesterone is produced by the corpus

luteum before the development of the placenta.

PROTECTIVE FUNCTIONS OF THE PLACENTA:

 Inhibits passage of bacteria and large molecules to the fetus.

STAGES OF HUMAN PRENATAL DEVELOPMENT:

1. Fertilization to 14 days.
 It is called zygote or ovum, including the fetal sac.

2. From 14 days up to 8th weeks

 It is called embryo

3. From the 8th weeks up to the time of birth

 It is called fetus

4. After birth
 It is called baby

SEQUENTIAL STAGES OF FETAL DEVELOPMENT:

1. 2 WEEKS

 Fetal membranes like the amnion and chorion appears.

 Germ layers are differentiated

3 Germ Layers

ENDODERM

 develops the lining of the gastro intestinal tract (GIT) respiratory

tract, tonsil, thyroids for basal metabolism, parathyroids for
calcium metabolism, thymus gland for development of immunity,
bladder and urethra.

MESODERM

 Forms into the supporting structures of the body like the

connective tissues, cartilage, bones, muscles and tendons. It
also includes the heart,
circulatory system, reproductive system, kidneys and ureters.

ECTODERM

 Responsible for the formation of the nervous system, the skin,

nails and hair, mucous membrane of the mouth and anus.

NOTE: In cases of multiple congenital anomaly, the structures

involved arises
out of the same germ layer.

SUMMARY OF GERM LAYERS

ENDODERM MESODERM ECTODERM
 Thyroid  Heart  CNS
 Parathyroid  Musculoskeletal  5 Senses
 Liver System  Skin
 Linings of the  Reproductive  Hair
upper respiratory Organs  Nails
tract and GIT  Kidneys  Mucous
 Thymus membranes of
anus and mouth
WEEK 2

 Fetal hearts begins to form as early as the 16 th day of life and begins to
beat by 25th day but the fetal heart tone can be first heard by the 5 th
month.

WEEK 3

 The ovum is the size of a grape, covered with fine shaggy-looking

chorionic villi.
 No human features can be recognized
 Nervous system appears by the 3rd week (brain is earliest to develop)
 Dizziness is said to be the earliest sign of pregnancy because of the
depletion of the mother’s glucose stores which the embryo needs for
proper brain development. Hypoglycemia therefore is the cause of
dizziness.
WEEK 4

 Sac is about the size of a pigeon’s egg. The embryo is about 1 cm. and
weighs 1 gram.
 The embryo's cells will develop into organs and body parts.
 Also developing in this week are the fluid-filled amnion, which protects
baby, and the yolk sac, which provides nourishment early on.

WEEK 5

 The embryo begins to take on its distinct shape.

 Developing parts in this week include the neural tube (which will
become the spinal cord and brain) and heart and blood vessels.
WEEK 6

 Fetal heart is beating

 Small buds that will become the arms and legs are appearing.
 Also forming in this week are the digestive and respiratory systems.

WEEK 7

 Fetal’s facial features are taking shape.

 The mouth, nose, ears, and eyes will become more defined.
 Tiny arm bud now has a hand on the end of it, which looks like a
paddle.
WEEK 8

 Sac is the size of a hen’s egg. The chorionic villi disappear except in
the area where they are deeply embedded. The embedded villi grow
fast and are known as the chorion frondosum which will ultimately
form the placenta.
 Embryo weighs about 4 grams.
 All vital organs are formed, including the sex organs (ovaries/testes).
 Meconium is formed in the intestines.
 Toe buds and finger buds take shape

WEEK 9
  Measures about an inch long.
 Fetus may make some first movements as muscles develop, but it
cannot be felt until after several more weeks.

WEEK 10

 All of baby's vital organs have been formed and are starting to work
together.
 Birth defects are unlikely to develop after this week.

WEEK 11

 Fetus looks like a miniature genius. The giant head takes up about half of
the body length.
WEEK 12
 Sac is the size of a goose’s egg and the placenta by now is well formed,
weighs more than the fetus.
 Fetus is 3 ½ inches long and weighs 2 ounces.
 Tiny fingernails and toenails start to form this week, which is the end of
the first trimester.
 Kidneys are able to function. Urine is formed by the 12 th week of
pregnancy.
 Buds of milk teeth or temporary teeth is formed.
 Feto – placental circulation is established by selective osmosis, no direct
exchange of fetal and maternal blood.
WEEK 13
 This week marks the beginning of the second trimester.
 Even though the mother do not feel it yet, fetus is moving and kicking
often. In fact, the fetus may be able to put a thumb in the mouth.

WEEK 14

 This week genitals are fully formed, so at the next ultrasound

appointment the doctor might be able to tell the fetal sex.

WEEK 15

 This week, the fetus eyebrows are growing and hair starts to appear on
the head.
WEEK 16

 Fetus now measures 6 inches and weighs 6 ounces. There is a good

heartbeat but it cannot be heard oftentimes during abdominal
auscultation.
 Buds of permanent teeth formed.
 Heart beat may be audible with stethoscope.
 Some fine hairs, called lanugo, have developed on the fetal face. This
soft, colorless hair protects the skin and will eventually cover most of
your baby's body until it is shed before delivery.
WEEK 17

 Fetus is still very tiny, about 5 inches in length and weighing about 5
ounces.
 It is able to swallow amniotic fluid, and may get hiccups as a result!

WEEK 18

 This week, the fetal bones begin to harden, or ossify.

WEEK 19
 A cheese-like substance called vernix caseosa is covering the body of the
fetus to help protect delicate skin from being chapped, scratched and
dry.

WEEK 20

 Fetus is 8 inches long and weighs 10 ounces.

 By now quickening is felt by the mother.
 Fetal heart beats are very audible.
 It is almost halfway of the pregnancy
WEEK 21

 Fetal ears have moved into their final position on the side of the head. It
probably starting to hear sounds

WEEK 22

 Taste buds are forming as well as sense of touch is developing.

WEEK 23
 More forceful movements can be felt in this week. Fetus’ daily workout
routine now includes moving the muscles in the fingers, toes, arms, and
legs.

WEEK 24

 Fetus measures 14 inches and weighs about 1 ½ pounds.

 Meconium is present in the intestines.
 Skin markedly wrinkled.
 Attains proportions of a full term.
WEEK 25

 Fetal hearing continues to develop. Fetus can able to hear mother’s

voice, music, and the voices of others close by.

WEEK 26

 This is the last week of the second trimester.

 Fetus gain fats.

WEEK 27
 This is the first week of the third trimester.
 Fetal lungs, liver, and immune system still need to fully mature, but if
born now, it would have a very good chance of survival.
 Alveoli begins to form

WEEK 28

 Fetus measures 14 inches and weighs 2 ½ pounds

 The eyes that have been sealed for so long are just beginning to open,
and fetus will get the first glimpse of the womb and the surrounding.

WEEK 29
 Fetus is starting to gain weight at a quicker pace.
 What used to be flutters of movement now may be hard jabs and kicks
that can be felt by the mother.

WEEK 30

 Fetus continues to make breathing movements, getting ready for the

birth process.
 Mothers will feel regular twitches in the uterus from time to time, it is due
to hiccups.

WEEK 31
 Fetus’ pees several cups of urine a day into the amniotic fluid. This fluid
helps keep the womb cushiony so that fetus is protected.

WEEK 32

 Fetus measures 16 inches and weighs 3 ½ pounds.

 Skin is red and wrinkled.
 Lanugo is less plentiful because it begins to disappear.
 Fetus is viable.
 Nails extend to ends of fingers.
 Subcutaneous fat deposition begins.
WEEK 33

 Your baby sleeps most of the day and night, and even has REM (rapid eye
movement) sleep, during which dreams happen.

WEEK 34

 The bones that make up the fetal skull can move while inside the pelvis.
This is called "molding" and helps the fetus pass through the birth canal.

WEEK 35

 Your growing fetus is now cramped inside the uterus.

 Movements may decrease, but will feel stronger and more forceful.
WEEK 36

 Fetus is 18 inches long and weighs 5 ½ pounds.

 Little subcutaneous fat appears.
 Nails reach the fingertips and cartilage of the ear is soft.
 Lanugo and vernix caseosa disappear.
 Amniotic fluid volume decreases.

WEEK 37
 Fetus’ eyesight is already developed that if a bright light shines on
mother’s belly, fetus may see it and turn toward it.
 Can also determine the presenting part during delivery

WEEK 38

 Fetus has likely "dropped" into the pelvis in preparation for birth. This
means that the bladder is squished, making the mother to pee more
often.

WEEK 39

 Fetus is considered full-term this week.

WEEK 40

 Fetus measures 20 inches in length and weighs 7 pounds.

 Body is well covered by subcutaneous fat and skin is red, not wrinkled.
 It has all the characteristics of a normal newborn.

FOCUS OF DEVELOPMENT

1. FIRST TRIMESTER
  Organogenesis
2. SECOND TRIMESTER
 Period of continued fetal growth and development and rapid increase
in fetal length.
3. THIRD TRIMESTER
 Period of most rapid growth and development because of rapid
deposition of subcutaneous fat.

TERMINOLOGY

Gravida
 Number of pregnancies regardless of outcome (including current
pregnancy)
 Each pregnancy counts as 1, regardless of the number of fetuses

Nulligravida
 No prior pregnancies

Primigravida
 Currently in first pregnancy

Multigravida
 Two or more pregnancies (including current pregnancy)
Parity (or Para, Parous Events)
 Number of births after 20 weeks gestation
 Multiple Gestation (e.g. twin, triplet) births count as one

Nullipara (or Nulliparous)

 No prior births after 20 weeks gestation

Primipara (or Primiparous)

 One prior birth >20 weeks gestation

Multipara (or Multiparous)

 Two or more births after 20 weeks gestation

Grand Multipara (Grand Multiparity)

 Five or more births after 20 weeks gestation

 A woman pregnant for the first time is a primigravida and is described

as Gravida 1, Para 0
 A woman who delivered 1 fetus to the period of viability and who is
pregnant again is described as Gravida 2, Para 1
 A woman with 2 abortions and no viable children is Gravida 2, Para 0.
  In some obstetrical services, a woman’s past obstetrical history is
summarized by a series of 5 digits or G.T.P.A.L.
 The first digit or the G refers to total number of pregnancies
(Gravida)
 The second digit or the T refers to the number of FULL TERM
deliveries (37-40+ weeks gestation).
 The third digit or the P refers to the number of PRETERM deliveries
(20-36 weeks gestation).
 The fourth digit or the A refers to the number of ABORTIONS
and Miscarriages before 20 weeks gestation.
 The fifth digit or the L refers to the number of LIVING Children (this
reflects Multiple Gestation births),

 There are several conditions that maybe mistaken for pregnancy.

During the early periods, pregnancy maybe simulated by enlargement
of the uterus due to interstitial myoma, sarcoma, hematometra
and other conditions due to inflammatory changes. As a rule, the
uterus in these conditions is harder and firmer than in pregnancy and
does not present the characteristic of elastic or boggy consistency.
Moreover, in such conditions except for hematometra there is no
cessation of menstruation.
 Ovarian tumors may also be mistaken for pregnancy. However, as
the tumor becomes larger and rises into the abdomen the absence of
the positive signs of pregnancy and the absence of Braxton hicks sign
will clear up the diagnosis.

SIGNS OF PREGNANCY:
STAGE PRESUMPTIV PROBABLE POSITIVE
E
st
1 Trimester - Amenorrhea - Chadwick’s - Ultrasound
- Morning sign evidence
Sickness - Goodell’s sign
- Breast - Hegar’s sign
changes - (+) HCG or
- Fatigue pregnancy
- Enlarging test
Uterus - Elevation of
- Constipation BBT
- Urinary
Frequency
nd
2 Trimester - Quickening - Enlarged - FHT
- Increase skin Abdomen - Fetal
pigmention - Braxton hicks movement
 like Contraction felt
choalasma, - Ballotment by the
linea negra examiner
and - Fetal outline
striae on
Gravidarum x-ray
- Weight gain
- Leukorrhea
- Colostrum

NORMAL ADAPTATION IN PREGNANCY

1. SYSTEMATIC CHANGES

 Circulatory/Cardiovascular
 Beginning the end of the first trimester there is a gradual increase of
30 to 50% in the total cardiac volume, reaching its peak during the 6 th
month of pregnancy. This causes a drop in hemoglobin and
hematocrit values since the increase is actually in its plasma volume
which is the physiologic anemia of pregnancy.

CONSEQUENCES OF INCREASE TOTAL CARDIAC VOLUME ARE:

 Easy fatigability and shortness of breath because of incomplete

workload of the heart. With incomplete cardiac workload the heart
pumps harder than usual causing slight hypertrophy of the heart
which results in tortion on the blood vessels.
 Systolic murmurs are common due to lowered blood viscosity.
 Epistaxis may occur because of marked congestion of the
nasopharynx as pregnancy progresses.

 Palpitations occur and they are due to :

 Sympathetic nervous stimulation during the first half of pregnancy.
 Increase pressure of the uterus against the diaphragm during the
second half of pregnancy.

 Because of poor circulation resulting from pressure of the gravid uterus

on the blood vessels of the lower extremities. Presence of :

 Edema of the lower extremities

MANAGEMENT: Raise legs above hip level.
IMPORTANT: Edema of lower extremities is NOT a sign of toxemia.
 Varicosities of the lower extremities
MANAGEMENT: - Use or wear support hose or elastic stockings to promote
venous
flow.
- Apply elastic bandage. Start at the distal end of extremities
and
work toward the trunk to avoid congestion and impaired
circulation
in distal part and do not wrap toes to determine adequacy
of
circulation.
- Avoid use of constricting garters.

 Because of poor circulation in the blood vessels of the genitalia due to

pressure of the gravid uterus;

 Varicosities of the vulva and the rectum appears

MANAGEMENT: Side lying position with hips elevated on pillows or do the
modified
knee-chest position.

 There is increased level of circulating fibrinogen that is why pregnant

women are normally safeguarded against undue bleeding, but this also
predisposes then to blood clot formation.
IMPLICATION: Pregnant woman should not be massaged since blood clots
maybe
dislodged leading to thromboembolism and possible death.

2. GASTROINTESTINAL

 Morning sickness
- Nausea and vomiting during the first three months of pregnancy due to
increased
HCG ( Human Chorionic Gonadotropin ) and also due to increase
production of
gastric acids and emotional factors.
MANAGEMENT: - Eat dry toast or crackers 30 minutes before arising in
morning.
- Eat dry, high carbohydrates, low fat and low spices in
the diet.
 Hyperemesis gravidarum
- Excessive nausea and vomiting which persists beyond 3 months resulting
in
dehydration, starvation and acidosis.
MANAGEMENT: - D10 NSS, 3000 cc. is given within 24 hours as the
priority of
 care upon admission to the hospital.
- Complete Bed Rest ( CBR ) is also important aspect of
treatment
and no visitors allowed.

 Constipation and Flatulence

- Due to displacement of the stomach and intestines thus slowing peristalsis
and gastric emptying time and also be due to increase progesterone
which inhibits gastric motility.
MANAGEMENT: - Increase fluids and roughage in the diet.
- Establish regular elimination time.
- Increase exercise.
- Avoid enema
- Avoid harsh laxative, stool softeners maybe given.
- Mineral oil should not be given because it interferes
with the
absorption of fat-soluble vitamins.

 Hemorrhoids
- Is due to pressure of enlarged uterus on the intestines.
MANAGEMENT: Cold compress with epsom salt.
Warm sitz bath
Sit on soft pillow
High fiber diet and increased fluid intake

 Heartburn
- Especially during the last trimester is due to increase progesterone which
decrease
gastric motility and thereby causing reverse peristaltic waves which lead
to
regurgitation of acidic stomach contents through the cardiac sphincter
into the
esophagus causing irritation. Also known as pyrosis.
MANAGEMENT: - Avoid fried, fatty foods
- Sips of milk at frequent intervals
- Small, frequent meals taken slowly
- Pats of butter before meals
- Take antacids

URINARY

 Urinary frequency is the only sign of pregnancy which is seen during the
first trimester, disappears during the second trimester and reappear
during the third trimester. Early in pregnancy, urinary frequency is due
to increase blood supply to the kidneys and to the uterus rising out of the
pelvic cavity and the reason on the third trimester is due to pressure of
 enlarged uterus on the bladder, especially with lightening or the
descent of the fetus into the pelvic brim.

 Decreased renal threshold for sugar because the increase production of

glucocorticoids cause lactose and dextrose to spill into the urine of
pregnant women and it is also an effect of increase progesterone.
IMPLICATION: It would be difficult to diagnose diabetes in pregnancy
based on
urine sample alone because with or without diabetes all
pregnant
women have sugar in their urine

 Increase susceptibility to urinary tract infection because of increase

diameter and decrease peristalsis of the uterus.

RESPIRATORY

 Shortness of breath during pregnancy is due to :

- Increase oxygen consumption and production of carbon dioxide by
the
products of conception during the first trimester.
- Increase in uterine size causes diaphragm to be pushed or displaced,
thus
crowding the chest cavity.
MANAGEMENT: - Increase oxygen supply and vital lung
capacity.

MUSCULOSKELETAL

 Because of the pregnant woman’s attempt to change her center of

gravity she makes ambulation easier by standing more straight and taller
resulting in a lordotic position which is the pride of pregnancy.

 Due to increase production of the hormone relaxin, pelvic bones become

more supple and movable so there could be possibility of accidental falls
due to wobbly gait.
MANAGEMENT: Advise use of low heeled shoes and not to use bath tubs
unless
accompanied or not to use non-skid materials which are
placed
on the bottom of tub and floor.

 Leg cramps are caused by:

- Increase pressure of gravid uterus on lower extremities
- Fatigue and muscle tenseness
 - Imbalance of calcium in the body and from pressure of the gravid
uterus on
nerves supplying the lower extremities.
- Low calcium, high phosphorus serum level
MANAGEMENT: - Frequent rest periods with feet elevated
- Comfortable warm clothing
- Calcium intake
- Do not massage
- The most effective treatment is: Press knee of
affected leg and dorsiflex the feet.

TEMPERATURE

 Slight increase in basal body temperature (BBT) due to increase

progesterone but the body adapts after the fourth month of pregnancy.

ENDOCRINE

 Additional of the placenta as an endocrine organ producing large

amounts of HCG, HPL, estrogen and progesterone.

 There is moderate enlargement of the thyroid gland due to hyperplasia of

the glandular tissues and increase vascularity. It is also due to increase
basal metabolic rate to as much as 25% because of the metabolic activity
of the products of conception.

 There is an increase in size of parathyroids probably to satisfy the

increase need of the fetus for calcium.

 There is adrenal cortex hypertrophies and its activity increases. There is

also an increase amounts of circulating cortisone, aldosterone and ADH,
all of which affect carbohydrate and lipoid metabolism.

 There is a gradual increase in insulin production but the body’s sensitivity

to insulin is decrease during pregnancy.

WEIGHT
 During the first trimester, weight gain of 1.5 – 3 pounds are allowed. On
the second and third trimester, weight gain of 10 – 12 pounds per
trimester is recommended.
 The total allowable weight gain during the entire period of pregnancy
therefore is 20 – 25 pounds or 10 – 12 kgs.
 Pattern of weight gain is more important than the amount of weight gain.
 Distribution of weight gain:
Fetus ---------------------------------------------- 7 lbs
Placenta ------------------------------------------- 1 lb.
 Amniotic Fluid ----------------------------------- - 1 ½ lbs.
Increased Uterine weight ----------------------- 2 lbs.
Increased blood volume ------------------------ 1 lb.
Weight of additional fluid ---------------------- 2 lbs.
Fat and Fluid Accumulation ------------------ -- 4 – 6 lbs.
TOTAL ------------------------------------- 20 – 25 lbs.

EMOTIONAL RESPONSES

1. First Trimester
o The fetus is an unidentified concept with great future
implications but without tangible evidence of reality. Some
degree of rejection, disbelief, denial and repression.
2. Second Trimester
o Fetus is perceived as a separate entity. Fantasizes the
appearance of the baby.
3. Third Trimester
o Has a personal identification with a real baby about to be born
and realistic plans for future child care responsibilities. Best time
to talk about layette, infant feeding methods and family
planning. Fear of death though is prominent, so to allay fears,
let the pregnant woman listen to the fetal heart sounds.

LOCAL CHANGES:

 UTERUS
 The weight increases to about 1,000 grams during full term.
 Enormous change in size and shape of the uterus is due to the
increase in the amount of fibrous and elastic tissues.
 The shape change to pear – like.
 Change in consistency of lower uterine segment which cause extreme
softening known as the hegar’s sign which is seen at about sixth week
gestational age.
 The mucous plugs in the cervix called operculum are produced to seal
out bacteria.
 Cervix becomes more vascular and edematous resembling the
consistency of an earlobe or the lips known as the goodell’s sign.

 VAGINA
 Increase vascularity causes change in color from light pink to deep
purple or violet known as the chadwick’s sign.
 To avoid or prevent confusion as to pregnancy signs, arrange body
parts out to in and arrange the different signs alphabetically, thus:
Vagina - Chadwick’s Sign
Cervix - Goodell’s Sign
 Uterus - Hegar’s Sign
 Due to increase estrogen, activity of the epithelial cells increases thus
there is an increase in the amount of vaginal discharges called
leukborrhea. As long as the discharges are not excessive,
green/yellow in color, foul smelling or irritatingly itchy it is normal.
MANAGEMENT: - Maintain or increase cleanliness by taking twice
daily
shower baths using cool water.
 The pH of the vagina changes from normally acidic (because of the
presence of doderlein bacilli) to alkaline (because of increase
estrogen). An alkaline environment is said to protect against bacteria
however it favors the growth of trichomona, a protozoa or flagellate.
The condition is called trichomonas vaginalis or trichomonas
vaginitis or trichomoniasis.
SYMPTOMS: - Frothy, greenish irritatingly itchy and foul
smelling
discharges.
- Vulvar edema and hyperemia secondary to
irritation
from discharges.
MANAGEMENT: - Flagyl for 10 days p.o. or vaginal suppositories.
- Acidic vaginal douches (1 tbsp. white vinegar to
1
quart of water or 15 ml. white vinegar to 1,000
ml.
water) to counteract alkaline preferred
environment
of the protozoa.
NOTE: When douching during pregnancy on doctor’s order, the
following need to be considered:
- Maybe done in bath tub while sitting then put the
solution
into the vagina under pressure.
- Gravity bag not higher than 2 feet above the level of
vagina.
- Douche tip not inserted more than 3 inches inside.
- Temperature barely warm, only slight feeling of fullness.
- Treat male partner also with flagyl.

CANDIDA ALBICAN
 This a fungus and the condition is called moniliasis or candidiasis.
Fungus loves to thrive in environment rich in carbohydrates which is
commonly found among diabetics and in those on steroids or antibiotic
therapy when acidic environment is altered.
SYMPTOMS: - White, patchy, cheese-like particles that adhere to
vaginal
 walls.
- Irritatingly itchy and foul smelling vaginal discharges.
TREATMENT: - Mycostatin or Nystatin p.o., BID for 15 days or
vaginal
suppositories.
- Gentian violet, swab to vagina. Advice patient to use
panty
shields to prevent staining of clothes or underwear.
- Correct diabetes.
- Avoid intercourse.

 Meniliasis is seen as oral thrush in the newborn, acquired during

delivery through the birth canal of infected mother.
TREATMENT: - Gentian violet

ABDOMINAL WALL

 Striae Gravidarum
- Incomplete uterine size results in rupture and atrophy of connective
tissue layers seen as pink or reddish streaks.
MANAGEMENT: - Gently rubbing oil on the abdominal skin helps
prevent
diastasis.

 Melasma or Chloasma or Mask of Pregnancy

- Extra pigmentation on cheeks and across the nose due to incomplete
production
of melanocytes by the pituitary gland.

 Sweat glands unduly activated

BREASTS

 all changes is due to incomplete estrogen.

 Incomplete in size due to hyperplasia of the mammary alveoli and fat
deposits.
MANAGEMENT: - Proper breast support with full fitting brassiere is
necessary to
prevent sagging of breasts.
 Feeling of fullness and tingling sensation.
 Nipples more erect
NOTE: - For mothers who will breastfeed, advise nipple rolling, drying
nipples
with rough towel to help toughen them.
 - Not to use soap or alcohol which can dry the breasts and cause
sore nipples.
 Areola becomes darker and diameter increases.
 Skin surrounds the areola turns dark.
 By the 4th month of pregnancy, a thin, watery, high protein fluid called
the colostrum is formed.

OVARIES

 No activity whatsoever. Evaluation does not takes place. Estrogen and

progesterone are being produced by the placenta.

PRENATAL VISIT

 The provision of prenatal care is the primary factor in the improvement

of maternal and infant mortality and morbidity rates. To ensure the
success of prenatal care programs, it should be remembered that the
patient’s understanding of the nodalities of care is basic to cooperative
action.
 The duration of a normal pregnancy is 266 – 280 days or 37 – 40 weeks
(the average is 40 weeks) or 9 months. Any baby born before the 37
weeks of gestation is said to be pre-term.

THE DIAGNOSIS OF PREGNANCY IS MADE THROUGH:

URINARY PREGNANCY TEST

 HCG in the urine or blood is basis for pregnancy tests. It is present from
the 40th day through the 100th day, reaching a peak level on the 60 th day.
HCG, therefore is most correct six weeks after the last menstrual
period(LMP).
 When collecting urine for pregnancy test, there are things to be
considered, they are as follows:
 No water taken after 8 P.M. the night before urine collection in
order to concentrate it.
 First morning urine, midstream should be collected in a clean
specimen bottle.
 If more than 1 hour would elapse before being tested, refrigerate
specimen because HCG is unstable under room temperature.

TYPES OF URINE EXAMINATION FOR PREGNANCY

Biological Test
 Presence of HCG will produce hemorrhagic changes in the ovaries or
testes of the animal when urine of a pregnant woman is injected into it.
 EXAMPLES: - Ascheim Zondek ( mice )
- Hogben ( frog )
- Friedman ( rabbit )
- Frank Berman ( rat )

Immunodiagnostic Test
 Antigen – antibody reaction. Widely used at present because results are
obtained faster and do not use animals.
EXAMPLES: - Gravindex
- Pregnes
- Prognosticon

Progesterone Withdrawal Test

 A contraceptive pill is taken by the woman who wants to find out whether
or not she is pregnant. She is to take the pill once or TID for 3 days. If
menstruation occurs within 10 -15 days, she is not pregnant. If
menstruation does not occur within 10 – 15 days, she is pregnant, the
corpus luteum produces enough hormones to neutralize the effect of
withdrawn synthetic progesterone, that is why no bleeding occurs.

COMPONENTS OF A PRENATAL VISIT:

1. History Taking

A. PERSONAL DATA:
o Patient’s name
o Age
o Civil status ( An unwed pregnancy is a risk pregnancy )
o Address
o Family History ( With whom does she live? Are there familial
diseases that could possibly affect the pregnancy? )
B. OBSTETRICAL DATA:
o Gravida - Number of pregnancies a woman has had.
o Para - Number of viable pregnancies regardless of
number and outcome.
o GTPAL - Number of full term babies, premature
deliveries,
abortions and living children.
o Past Pregnancies
 Method of delivery - Is it normal vaginal delivery
or CS
o Where - At home or in the hospital
 o Risks involved - Prematurity, toxemia, ectopic
pregnancy
o Present pregnancy - Is there nausea and vomiting?

Danger signs of pregnancy:

 Vaginal bleeding no matter how slight
 Swelling of face or fingers
 Severe, continuous headache
 Dimness or blurring of vision
 Flashness of light or dots before the eyes
 Pain in the abdomen
 Persistent vomiting
 Chills and fever
 Sudden escape of fluid from the vagina
 Absence of fetal heart sounds after they have been initially
auscultated on the 4th or 5th month of pregnancy

C. MEDICAL DATA:
o Is there a history of sexually transmitted disease (STD), kidney or
liver diseases, HPN and tuberculosis.

D. TETANUS IMMUNIZATION:
o To prevent tetanus neonatorum.
TT1 - administered anytime during pregnancy.
TT2 - 4 weeks after TT1 for 3 years protection.
TT3 - 6 months after TT2 for 5 years protection.
TT4 - 1 year after TT3 for 10 years protection
TT5 - 1 year after TT4 for lifetime protection
o If the mother has completed DPT3 during infancy, this will be
considered as TT1 and TT2.

Gestational Age

 Gestation is the period of time between conception and birth. During this
time, the baby grows and develops inside the mother's womb.
Gestational age is the common term used during pregnancy to describe
how far along the pregnancy is. It is measured in weeks, from the first
day of the woman's last menstrual cycle to the current date. A normal
pregnancy can range from 37 to 40 weeks.
 A full-term human pregnancy is considered to be 40 weeks (280 days),
though pregnancy lengths between 37 and 40 weeks are considered
normal. Infants born before 37 weeks are considered premature. Infants
born after 42 weeks are considered postmature.
ESTIMATES OF AGE OF GESTATION (AOG)

1. NAEGELE’S RULE
o Used to determine the expected date of delivery by determining
the LMP of the mother.
o Determine first day of last menstrual period (LMP), count 9
months plus 7 days.
EXAMPLE: - If the first day of LMP was June 4, 2003, the EDC will
be
March 11, 2003.
o Naegele’s rule is based on a 28 day menstrual cycle with the
expectation that ovulation occurred on the 14th day.
o In calculation of the EDC, an adjustment should be made if the
patient’s cycle is shorter or longer than 28 days.
o The discrepancies caused by 31 day months and the 29 day
variation in February of leap year are not correctible by
Naegele’s rule. Nevertheless, it provides an acceptable estimate
of the EDC.
o Only 4% of patients will deliver on the EDC after a spontaneous
labor. Most (60%) will deliver during the period extending from 5
days before through 5 days after the EDC. One should regard
term as a season or period of maturity and not as a particular
day.

2. BARTHOLOMEW’S RULE:
o Determines AOG by fundic location
o By the 3rd month, the fundus is palpable above the symphysis pubis.
o By the 4th month, it is midway between symphysis pubis and
umbilicus.
o On the 5th month, is at the level of the umbilicus.
o On the 9th month, it is just below the xyphoid process.
3. Mc DONALD’S RULE:
o Determine AOG in months by measuring from the fundus to the
symphysis pubis in centimeter then divide by 4.
EXAMPLE: - Fundic height of 16 cm. divided by 4 is equal to 4
months
AOG = 16 weeks AOG.
o Although not exact, such periodic estimates do record the progress
of pregnancy. Unexpectedly large measurements suggest either
that the date of conception is incorrect or that the patient has a
tumor, ascites, multiple pregnancy or polyhydramnios. Unusually
slow enlargement of the uterus suggests fetal abnormality or
oligohydramnios perhaps associated with placental dysmaturity.
Failure of the uterus to enlarge is associated with missed abortion
and fetal death in utero.
4. HAASE’S RULE:
o Determine the length of the fetus in centimeters.
o During the first half of pregnancy, square the number of the
months.
EXAMPLE: - First month 1x1 = 1 cm.
o During the second half of pregnancy, multiply the number by 5.
EXAMPLE: - 6th months 6x5 = 30 cm.

5. JOHNSON’S RULE:
o Estimates weight of the fetus in grams.
o A formula for estimating the weight of the fetus presenting by the
vertex has been devised by R.W. Johnson.
FORMULA: - “K” is a constant, it is always 155
“N” is = 11 if fetus is not yet engaged.
= 12 if fetus is already engaged.

ASSESSMENT

1.) PHYSICAL EXAMINATION:

o A review of system is indicated, includes inspection of teeth
because they are common foci of infection.
2.) PELVIC EXAMINATION
o Cardial rule in pelvic examination is empty bladder first before
doing the procedure.
o Internal examination (IE) to determine chadwick’s, goodell’s
and hegar signs

o BALLOTMENT - fetus will bounce when lower uterine segment

is
tapped sharply which is done on the 5th month.

o PAPANICOLAU (pap) SMEAR - Cytological study to diagnose

cervical carcinoma and cervical
carcinoma a kind of cancer (CA).
CLASSIFICATION OF FINDINGS:

Class 1 - absence of atypical or abnormal cells (normal).

Class 2A - acitology but no evidence of malignancy.
Class 2B - suggestive of inflammation.
Class 3 - cytology suggestive of malignancy.
Class 4 - cytology strongly suggestive for malignancy.
Class 5 - cytology conclusive for malignancy.

CLINICAL STAGES:

o Reflect localization or spread of malignant cervical changes.

Stage 1 - CA is confined to the cervix.
Stage 2 - CA extends beyond the cervix into the vagina, but
not
into the pelvic wall or into lower part.

THINGS TO CONSIDERED WHEN CONDUCTING PAP SMEAR:

 Not done during a menstrual period
 No douches or tub baths 48 hours before
 Get specimen from the area around the cervix
 Fix specimen before it dries up
 In case abnormal cells, not necessarily cancer (CA), maybe cervicities.
 IMPLICATION: - Refer patient for further studies like biopsy or D & C.

Pelvic measurements are done after the 6 th month and x-ray

pelvimetry (several flat plate x-ray pictures of pelvis taken from
different angles) is done preferably 2 weeks before EDC and it is the
best method to diagnose for CPD (Cephalo Pelvic Disproportion).

LEOPOLD’S MANEUVER

 Done to determine attitude, fetal presentation, lie, presenting part,

degree of descent, estimate of fetal size, fetal back, FHT, number of
fetuses and position.
 It is done in a supine position with knees flexed slightly to relax
abdominal muscles or the dorsal recumbent position.
 Use palms not fingertips
 Gentle and firm motions
 Difficult to perform on obese women and women who have
hydramnios.

4 MANEUVERS:

1. FIRST MANEUVER
 Facing head part, palpate for fetal part found in the fundus.
Head feels hard, freely movable and ballotable while breech feels
large, nodular and softer.
 Determines presentation

2. SECOND MANEUVER
 Palpate side of the uterus to determine location of fetal back and
small fetal parts.
  To assess the FHT

3. THIRD MANEUVER
 Grasp lower portion of abdomen just above symphysis pubis to
determine degree of engagement. If presenting part is movable,
engagement has not occurred, if engagement has occurred, fetal
part feels fixed in the pelvis.

4. FOURTH MANEUVER
 Facing foot part, press fingers downward on both sided of uterus
above the inguinal ligaments. Confirms findings of the 3 rd
maneuver.

VITAL SIGNS:
 Temperature, PR,RR are important especially during initial prenatal visit.
More important however, are the weight and blood pressure as baseline
data during the initial visit to determine any subsequent significant
increases. Weight and BP are taken during every clinic visit.

LABORATORY STUDIES:

1. BLOOD EXAMINATION:
o Complete Blood Count (CBC), including hemoglobin and
hematocrit
o Serological tests for syphilis like VDRL or Kahn and Wasserman
o Blood typing
o Hemaglutination- Inhibition Titer for rubella to determine how
much antibodies the pregnant woman has against german
measles. If titer is less than 1:8 it is considered at risk for
congenital rubella in the newborn because the mother does not
have enough antibodies against rubella but if titer is more than
1:16, it has enough protection against rubella.

3. URINE EXAMINATION:

o Glycosuria - Specimen should be taken before breakfast

to
avoid false positive results. Should not be
more
than +1 sugar.
o Pyuria - Urinary Tract Infection (UTI) is common
cause of
premature delivery.
o Albuminuria - Ideally negative, any sign of albumin in the
urine
 of a pregnant woman should be reported
immediately because it is a serious sign of
toxemia.

HEALTH TEACHINGS

 Nutrition is the most important aspect of the midwifes health teachings

during prenatal visit.

WOMEN WHO NEED SPECIAL ATTENTION:

 Pregnant adolescents
 Low pre pregnant weight
 Obese
 Low income
 Vegetarian - Although with high vitamin and mineral intake,
they are
low in proteins because there are many essential amino
acids that are found in animal sources.

o Nutritional assessment is based on taking a diet history

first:
 Eating habits
 Cultural and religious influences
 Occupation and educational level

RECOMMENDED DAILY ALLOWANCES

NUTRIENTS NON PREGNANT PREGNANT

- Calories 2,000 + 300 – 700
- Proteins 46 + 30
- Vitamin A 4,000 + 1,000
- Vitamin D 400 the same
- Vitamin E 12 +3
- Ascorbic Acid 45 +15
- Folic Acid 400 + 400
- Niacin 13 +2
- Riboflavin 1.2 + 0.3
- Thiamine 1.0 + 0.3
- Vitamin B12 3.0 + 1.0
- Vitamin B6 2.0 + 0.5
- Calcium 800 + 400
- Phosphorus 800 + 400
- Iodine 100 + 125
- Iron 18 + 18
- Magnesium 300 + 50
_____________________________________________________________________

MALNUTRITION IN PREGNANCY RESULTS IN:

o Pre maturity
o Low birth weight babies
o Abortion / stillbirth
o Congenital defect
o Pre eclampsia

QUANTITIES OF FOOD NECESSARY DURING PREGNANCY:

FOOD GROUP ACTIVE NON-PREGNANT
PREGNANT
- meat - 2 serving of meat, fowl or - 2-3 servings of
fish/ per day or 3-5 eggs meat, fowl or
per week. fish/day or 1
egg per day.

- vegetables: - 1 serving (at least 3/week) - 1 serving daily

Dark green or
Deep yellow

- Other vegetables - 2 or more servings - 2-3 servings

- Fruits:
Citrus fruits - 1 serving - 1 serving
Other fruits - 1 serving - 1 serving

- Bread and cereals - 4 or more servings - 4 servings

- Milk - 1 pint or 2-8 glasses - 1 quart or 4-8

glasses

- Additional fluid - at least 2

Glasses a day.

FOOD SUBSTITUTES:

- 8 OZ. GLASS WHOLE MILK - 1 cup yoghurt

- 1 glass skim milk
- 1 glass buttermilk
- ½ cup cottage cheese
 - ¼ cup non-fat or whole dry
milk
- ½ cup ice cream
- 1 ¼ oz. cheddar cheese

- 1 SERVING VEGETABLE OR FRUIT - 1 medium potato, tomato

or
Piece of fruit (used whole)
- ½ grapefruit
- 1 cup tomato juice because
it has a vitamin C content
of ½ cup orange juice.

- 2 – 3 OZ. LEAN MEAT - 2 oz. poultry or fish

- 2 eggs
- 1 oz. cheddar cheese
- 4 tablespoons peanut
butter
- 1 cup cooked dried beans,
peas, lentils or tofu
- ½ cup cottage cheese

- BREAD OR CEREALS - ½ to ¼ cup cooked or

¾
cup ready to serve cere
als
- ½ to ¾ cup cooked
macaroni, spaghetti or rice

PRENATAL VISITS:

o The patient should visit the clinic or hospital once a month from first to
seven months of pregnancy or up to 1st to 32nd week.
o Every 2 weeks on the 8th month of pregnancy or from 32 nd week to the
36th week of pregnancy.
o And weekly on the 9th month of pregnancy or from 36th week until
delivery and more often if complication arise.

 SMOKING is contraindicated during pregnancy because it causes

vasoconstriction leading to low birth weight babies.
 DRINKING in moderation is allowed during pregnancy but when
excessive can cause transcient respiratory depression and fetal
withdrawal syndrome. Alcohol supplies empty calories.
 DRUGS are dangerous to the fetus especially during the first trimester
because the placental barrier is not yet complete, so it is contraindicated
during pregnancy unless prescribed by the doctor.

DRUGS THAT ARE CONTRAINDICATED DURING

PREGNANCY:

 Thalidomide
- Causes Amelia or phocomelia

 Steroids
- Causes cleft palate or even abortion

 Iodides
- Contained in many over the counter cough suppressants.
- Causes enlargement of the fetal thyroid gland leading to tracheal
decompression
and dyspnea at birth.

 Vitamin K
- Causes hemolysis and hyperbilirubinemia

 Aspirin or Phenobarbital
- Causes bleeding disorder

 Streptomycin or Quinine
- Causes damage to the 8th cranial nerve which is deafness.

 Tetracycline
 - Causes staining of teeth/tooth enamel and inhibits growth of long
bones and not
to be given to children below 8 years for the same reason.

 Heroin
- Causes withdrawal symptoms in newborn.
-

SEXUAL ACTIVITY

 Sexual desires continue throughout pregnancy, but levels

changes:
- during the first trimester, there is a decrease in sexual desires
because the
woman is more preoccupied with the changes in her body.
- during the second trimester, there is an improvement in sexual
desires
because the woman has adapted to the growing fetus.
- during the third trimester, there is another decrease in sexual
desires
because the woman is afraid of hurting the fetus.
 Sex in moderation is permitted during pregnancy but not during the last 6
weeks because it has been found out that there is an increased incidence
of postpartum infection in women who engage in sex during the last 6
weeks.
 Sex is contraindicated in the following situations:
- ruptured bag of waters
- spotting or bleeding
- incompetent cervical os
- deeply engaged presenting part
 EMPLOYMENT
- as long as the job does not entail handling toxic substances, or lifting
heavy
objects, or excessive physical or emotional strain, there is no
contraindication
to working.
 TRAVELLING
- no travel restrictions, but postpone a trip during the last trimester.
 EXERCISES:
* CHIEF AIM: To strengthen the muscles used for labor and delivery.
* Should be done in moderation.
* Should be individualized, according to age, physical condition,
customary
amount of exercise like swimming or tennis is not contraindicated
unless
done for the first time and the stage of pregnancy.
RECOMMENDED EXERCISES DURING PREGNANCY:

1. SQUATTING
- Help stretch and strengthen perineal muscles.
- Increase circulation in the perineum
- Make pelvic joints more pliable
- When standing from the squatting position, raise buttocks first
before raising the head to prevent postural hypotension.

2. PELVIC ROCK
- Maintains good posture
- Relieves abdominal pressure and low backaches
- Strengthens abdominal muscles following delivery

3. MODIFIED KNEE-CHEST POSITION

- Relieves pelvic pressure and cramps in the thighs or buttocks.
- Relieves discomfort from hemorrhoids.

4. SHOULDER CIRCLING
- Strengthens muscles of the chest.

5. WALKING
- Said to be the best exercise.

6. KEGEL
- Relieves congestion and discomfort in pelvic region.
- Tones up pelvic floor muscles and strengthens pubococcygeal
muscles.
7. TAILOR SITTING
- Same purpose as squatting; done by placing leg in front of the other.

8. ABDOMINAL EXERCISE
- Strengthens muscles of the abdomen.

9. RIB CAGE LIFTING

- Relieves difficulty of breathing.

10. CALF MUSCLE CIRCLING

- Relieves leg cramps

PREPARING CHILDBIRTH EDUCATION:

- Preparing the couples for childbearing:

 Operates basically on the “Gate Control” theory of pain. Pain is

controlled in the
spinal cord. To ease pain in one part, the body, the gate to this pain
should be
 cleared.
 PREMISES: - Discomfort during labor can be minimized if the woman
comes
into labor informed about what is happening and
prepared with
breathing exercises to use during labor.
- Discomfort during labor can be minimized if the woman’s
abdomen is relaxed and the uterus is allowed to fuse
freely
against the abdominal wall with contraction.

Major approaches to prepared childbirth

- Pregnant couple are taught about the anatomy, pregnancy, labor and
delivery, relaxation techniques, breathing exercises, hygiene, diet
and
comfort measures.

TYPES OF RELAXATION TECHNIQUES:

1. BRADLEY METHOD
- Advocates active participation of husband during delivery and
encourages
him to serve as a coach.

2. GRANTLY-DICK READ METHOD

- Fear causes to tension and tension produces to pain.
- Advised abdominal breathing exercises and relaxation techniques.

3. LAMAZE
 - Psychoprophylactic method based on stimulus- response
conditioning. To
be effective, responses must be recently conditioned since they
easily die
out if not reinforced; that is why classes start on or after the 26 th
week up
to the end of pregnancy. Midwives must not interrupt a couple
during
breathing exercises.

DIFFERENT METHODS OF DELIVERY

1. LEBOYER METHOD OF DELIVERY

- The birth of a baby is a shocking experience to him. So to make
the
transition as gradual as possible, lights are dimmed, room is warm,
with
the minimum of noise. Skin to skin contact initiated immediately
after
delivery

2. BIRTHING CHAIR
- Semi – fowler’s position
3. BIRTHING BED:
- Dorsal recumbent or litothomy position

4. SQUATTING POSITION:
- Facilitate descent and relieves low back pain.

5. BIRTH UNDER WATER:

- Common practice in USA, Latin America, Japan and Scandinavian
Region.