FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY

I.

THE EXTERNAL REPRODUCTIVE ORGANS

A. Mons pubis or mons veneris pad of fat which lies over the symphysis pubis covered by skin and at
puberty by short hairs; protects the surrounding delicate tissues from trauma.
B. Labia majora two folds of skin with fat underneath; contain Bartholins glands which are believed to
secrete a yellowish mucus which acts as a lubricant during sexual intercourse. The openings of the
Bartholin;s glands are located posteriorly on either side of the vaginal orifice.
C. Labia minora two thin folds of delicate tissues; form an upper fold encircling the clitoris )called the
prepuce) and unite posteriorly (called the fourchette) which is highly sensitive to manipulation and
trauma that is why it is often torn during a womans delivery.
D. Glans clitoris - small erectile structure at the anterior junction of the labia minora, which is comparable
to the penis in its being extremely sensitive.
E. Vestibule narrow speace seen when the labia minora are separated.
F. Urethral meatus external opening of the urethra: slightly behind and to the side are the openings of the
Skenes glands (which are often involved in infections of the external genitalia).
G. Vaginal orifice or Introitus external opening of the vagina covered by a thin membrance (called
hymen) in virgins.
H. Perinuem area from the lower border of the vaginal orifice to the anus; contains the muscles (e.g.,
pubococcoygeal and levator ani muscles) which support the pelvic organs, the arteries that supply blood
to the external genitalia and the pudendal nerves which are important during delivery under anesthesia.

II.

THE INTERNAL RERODUCTIVE ORGANS

A. Vagina a 3-4 inch long dilatable canal located between the bladder and the rectum; contains rugae
(which permit considerable stretching without tearing); organ of copulation; passageway for menstrual
discharges and fetus.
B. Uterus
1. Hollow pear-shaped fibromuscular organ 3 inches lone, 2 inches wide, 1 inch thick and weighing
50-60 gms. In a non-pregnant woman
2. Held in place by broad ligaments (from sides of uterus to pelvic walls; also hold Fallopian tubes
and ovaries in place) and round ligaments (from sides of the uterus to the mons pubis)
3. Abundant blood supply from uterine and ovarian arteries
4. Composed of 3 muscle layers: perimetrium, myometrium and endometrium
5. Consists of three parts
5.1 Corpus (body)- upper portion with a triangular part called fundus
5.2 Isthmus area between corpus and cervix which forms part of the lower uterine segment
5.3 Cervix lower cylindrical portion.
6. Organ of menstruation; site of implantation, retainment and nourishment of the products of
conception.
C. Fallopian Tubes 4 inches long from each side of the fundus; widest part (called ampulla) spreadsinto
fingerlike projections (called fimbriae). Responsible for transport of mature ovum from ovary to uterus;
fertilization takes place in its outer third or outer half.
D. Ovaries almond-shaped, dull white sex glands near the fimbriae, kept in plact by ligaments. Produce,
mature and expel ova and manufacture estrogen and progesterone.

III. THE PELVIS although not a part of the female reproductive system but of the skeletal system, it is a very
important body part of pregnant women.
A. Structure
1. Two os coxae/innominate bones made up of:
1.1 Ilium upper extended part; curved upper border is the iliac crest.
1.2 Ischium under part; when sitting, the body rests on the ischial tuberosities; ischial
spines are important landmarks.
1.3 Pubes front part; join to form an articulation of the pelvis called the symphysis pubis.
2. Sacrum wedge-shaped, forms the back part of the pelvis. Consists of 5 fused vertebrae,
the first having a prominent upper margin called the sacral promontory.
3. Coccyx lowest part of the spine; degree of movement between sacrum and coccyx made
possible by the third articulation of the pelvis called sacroccygeal joint which allows room
for delivery of the fetal head.
B. Divisions set apart by the linea terminalis, an imaginary line from the sacral promontory to the ilia
on both sides to the superior portion of the symphysis pubis.
1. False pelvis superior half formed by the ilia. Offers landmarks for pelvic measurements;
supports the growing uterus during pregnancy; and directs the fetus into the true pelvis near
the end of gestation.
2. True pelvis inferior half formed by the pubes in front, the iliac and the ischia on the sides
and the sacrum and coccyx behind. Made up of three parts:

2.1 Inlet entranceway to the true pelvis. Its transverse diameter is wider than its
anterosposteior diameter. Thus:
2.1.1 Transverse diameter = 13.5 cm.
2.1.2 Anteroposterior diameter (AP) = 11 cm.
2.1.3 Right and left oblique diameter = 12.75 cm.
2.2 Cavity space between the inlet and the outlet. Contains the bladder and the rectum,
with the uterus between them in an anteflexed position towards the bladder.
2.3 Outlet inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by
the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the
pubic arch. Its AP diameter is wider than its transverse diameter.
C. Types/Variations
1. Gynecoid normal female pelvis. Inlet is well rounded forward and back. Most ideal for
childbirth.
2. Anthropoid transverse diameter is narrow, AP diameter is lager than normal.
3. Platypelloid inlet is oval, AP diameter is shallow
4. Android male pelvis. Intel has a narrow, shallow posterior portion and pointed anterior
portion.
D. Measurements
1. External suggestive only of pelvic size:
1.1 Intercristal diameter distance between the middle points of the iliac crests.
Average = 28 cm.
1.2 Interspinous diameter distance between the anterosuperior iliac spines.
Average = 25 cm.
1.3 Intertrochanteric diameter distance between the trochanters of the femur.
Average = 31 cm.
1.4 External conjugate/Baudelocques diameter distance between the anterior aspect of the
symphysis pubis and depression below L5. Average = 18-20 cm.
2. Internal give the actual diameters of the inlet and outlet
2.1 Diagonal conjugate distance between the sacral promontory and inferior margin of the
symphysis pubis. Average = 12.5 cm.
2.2 Important measurement because it is the diameter of the pelvic inlet. Average = 10.5
11 cm.
2.3 Bi-ischial diameter/tuberischii transverse diameter of the pelvic outlet. Is measured at
the level of the anus. Average = 11 cm.
The Pelvis
FEEDBACK MECHANISM OF MENSTRUATION
A. General Considerations
1. 300, 000 400, 000 immature oocytes per ovary are present at birth (were formed during the
first 5 months of intrauterine life, a process called oogenesis); many of these oocytes,
however, degenerate and atrophy (a process called atresia). Only about 300-400 mature
during the entire reproductive cycle of women.
2.
Ushered in by the menarche (very first menstruation in girls) and ends with menopause
(permanent cessation of menstruation, i.e., there are no more functioning oocytes in the
ovaries); age of onset and termination vary widely depending on heredity, racial background,
nutrition and even climate.
3. Normal period (days when there is menstrual flow) lasts for 3-6 days; menstrual cycle (from
first day of menstrual period up to the first day of next menstruation period) may be
anywhere from 25-35 days, but accepted average length is 28 days.
4. Anovulatory states after menarche are not unusual because of immaturity of feedback
mechanism. Anovulatory states also occur in pregnancy, lactation and related disease
conditions.
5. Associated terms
5.1 Amenorrhea temporary cessation of menstrual flow.
5.2 Oligomenorrhea markedly diminished menstrual flow, nearing amenorrhea
5.3 Menorrhagia excessive bleeding during regular menstruation.
5.4 Metrorhagia bleeding at completely irregular intervals.
5.5 Polymenorrhea frequent menstruation occurring at intervals of less than 3 weeks.
5.6 Oligomenorrhea markedly diminished menstrual flow.
6. Body structures involved
6.1 Hypothalamus
6.2 Anterior pituitary gland
6.3 Ovary
6.4 Uterus
7. Hormones which regulate cyclic activities

7.1 Follicle-stimulating hormone (FSH)

7.2 Luteinizing hormone (LH)
8. Effects of estrogen in the body
8.1 Inhibits production of FSH
8.2 Causes hypertrophy of the myometrium
8.3 Stimulates growth of the ductile structures of the breasts.
8.4 Increases quantity and pH of cervical mucus, causing it to become thin and watery and
can be stretched to a distance of 10-13 cm. (Spinnbarkheit test of ovulation).
9. Effects of progesterone in the body
9.1 Inhibits production of LH
9.2 Increases endomentrial tortuosity
9.3 Increases endometrial secretions
9.4 Inhibits uterine motility
9.5 Decreases muscle tone of gastrointestinal and urinary tracts
9.6 Increases musculoskeletal motility
9.7 Facilitates transport of the fertilized ovum through the Fallopian tubes
9.8 Decreases renal threshold of lactose and dextrose
9.9 Increases fibrinogen levels; decreases hemoglobin and hematocrit
9.10 Increases body temperature after ovulation. Just before ovulation basal body
temperature decreases slightly (because of low progesterone level in the blood) and then
increases slightly a day after ovulation (because of the presence of progesterone)
B. Sequential steps of the menstrual cycle
1. On the third day of the menstrual cycle, serum estrogen level is at its lowest. This low
estrogen level serves as the stimulus for the hypothalamus to produce the FollicleStimulating Hormone Releasing Factor (FSHRF).
2. FSHRF is the one responsible for stimulating the Anterior Pituitary Gland (APG) to
produce the first of two hormones which regulate cyclic activities, the Follicle-Stimulating
Hormone (FSH).
3. FSH, in turn, will stimulate the growth of an immature oocytes inside a primordial follicle by
stimulating production of estrogen by the ovary. Once estrogen is produced, the primordial
follicle is now termed as Graafian follicle (The Graafian follicle, therefore, is the structure
which contains high amounts of estrogen).
4. Estrogen in the Graafian follicle will cause the cells in the uterine endothelium to
proliferate (grow very rapidly), thereby increasing its thickness to about eightfold. This
particular phase in the uterine cycle, therefore, is called proliferative phase. In view of the
change from primordial to Graafian follicle, it is also called follicular phase. Because of the
predominance of estrogen, it is also called the estrogenic phase. And since it comes right
after the menstrual period, it is also called postmenstrual phase. And it is also called the
pre-ovulatory phase.
5. On the 13th day of the menstrual cycle, there is now a very low level of progesterone in the
blood. This low serum progesterone level is the stimulus for the Hypothalamus to produce
the Luteinzing Hormone Releasing Factor (LHRF).
6. LHRF is responsible for stimulating the APG to produce the second hormone which
regulates cyclic activity, the Luteininzing Hormone (LH).
7. The LH, in turn, is responsible for stimulating the ovary to produce the second hormone
produced by the ovaries, progesterone.
8. The increased amounts of both estrogen and progesterone push the new mature ovum to the
surface of the ovary until, on the following day (the 14th day of the menstrual cycle), the
Graafian follicle ruptures and releases the mature ovum, a process called ovulation.
9. Once ovulation has taken place, the Graafian follicle, because it now contains increasing
amounts of progesterone, giving it its yellowish appearance, is termed Corpus Luteum.
(Therefore, the structure which contains high amounts of progesterone is the Corpus
Luteum).
10. Progesterone causes the glands of the uterine endothelium to become corkscrew or twisted in
appearance because of the increasing amount of capillaries. Progesterone, therefore, is said
to be the hormone designed to promote pregnancy because it makes the uterus nutritionally
abundant with blood in order for the fertilized zygote to survive should conception take
place, that is why this phase in the uterine cycle, that is why this phase in the uterine cycle is
what we call progestational phase. This phase in the uterine cycle is also called secretory
phase because it secretes the most important hormone in pregnancy. In view of the change
from Graafian follicle to corpus Luteum, it is called luteal phase. Because it occurs just
after ovulation, it is also called the post-ovulatory phase. And, it is also called the premenstrual phase.
11. Up until the 24th day of the menstrual cycle, if the mature ovum is not fertilized by a sperm,
the amounts of hormones in the corpus Luteum will start to decrease. The corpus Luteum
turning white is now called the corpus albicans and in 3-4 days, the thickened lining of the

uterus produced by estrogen starts to degenerate and slough off and capillaries rupture. And
thus begins another menstrual period.
C. Additional Information
1. When the ovary releases the mature ovum on the day of ovulation, sometimes a certain
degree of pain in either the right or left lower quadrants is felt by the woman. This sensation
is normal and termed mittelschmerz.
2. The first 14 days of the menstrual cycle is a very variable period. The last 14 days of the
menstrual cycle is a fixed period exactly 2 weeks after ovulation, menstruation will occur
(unless a pregnancy has taken place) because the corpus Luteum has a life span of only 2
weeks. Implications: when given options regarding the exact date of ovulation, choose two
weeks before menstruation.
3. In a 28-day cycle, ovulation takes place on the 14th day. In a 32-day cycle, ovulation takes
place on the 18th day. In a 26-day cycle, ovulation takes place on the 12 th day (Subtract 14
days from the cycle).
4. Menstruation does not occur during pregnancy because progesterone does not decrease in
amount. Corpus Luteum continues to produce progesterone until the placenta takes over
production of hormones by the 8th week of pregnancy.
5. Menstruation can occur even without ovulation (as in women taking oral contraceptives).
Ovulation can likewise occur even without menstruation (as in lactating mothers).

HUMAN SEXUALITY
I. DEFINITION OF TERMS
A. Puberty encompasses the physiologic changes leading to the development of adult reproductive
capacity; the process includes maturation of the hypothalamus, pituitary gland and gonads. The
role of the anterior pituitary gland. The pituitary secretion of gonadotropin initiates growth and
maturation. It occurs initially during sleep and later in puberty throughout wakefulness.
B.
Adolescence encompasses the physiologic, social, and cognitive changes leading to
the development of adult identity. The process includes individual, achievement of personal
independence and maturation of cognitive reasoning skills.
C.
Thelarche budding of the breasts
D.
Adrenarche development of axillary and pubic hair
II. SEXUAL DEVELOPMENT (Table 1)
Criteria
1. Start of growth spurt

Males
Around 13 years old

2. Growth rate

Rapid early growth

3. Growth cessation

Early cessation

4.
Order
maturation

of

sexual 6 months later than females

Completed in 5 years
4.1
Darkening
and
thinning of scrotum and
enlargement of testes and
scrotum first visible sign
4.2 Appearance of body
hair
4.2.1 Pubic area
4.2.2 Axilla
4.2.3 Upper lip
4.2.4 Face
4.3 Penis grows, enlarges
4.4 Nocturnal emissions
(wet dreams) - male
counterpart of menstruation
4.5 Spermatogenesis

Females
After onset of menses,
around 10-12 years old
Sharp decrease after menses
occur
1-2 years after onset of
menses
6 months earlier than males
Completed in 3 years
4.1 Breast budding - first
visible sign
4.2 Increased size of pelvis
4.3 Appearance of body hair
4.3.1 Pubic area
4.3.2 Axilla
4.4 Menstruation
4.5 Ovulation

Table 1. Sexual Development

III. TANNER STAGING (Table 2 and Table 3)
A. A rating system for pubertal development

B. It is the biologic marker of maturity

C. It is based on the orderly progressive development of:
1. Breasts and pubic hair in females
2. Genitalia and pubic hair in males
Stages
I
II
III

IV

Males
Childhood size of penis, testes, scrotum
Enlargement of testes and scrotum
Lengthening of the penis
Further enlargement of testes and
scrotum
Deepening pigmentation of scrotal skin
Widening and further lengthening of
penis
Further enlargement of testes and
scrotum
Deepening pigmentation of scrotal skin
Adult configuration and size of genitalia

Females
Prepubertal, no breast tissue
Appearance of breast bud
Enlargement of the breasts and
areola
Areola and nipple form a mound
atop underlying breast tissues

Adult configuration and size of

genitalia
Areola and breasts have smooth
contour

Table 2. Tanner Stages of Pubertal Development: Thelarche & Genitalia

Stages
I
II
III
IV
V

Males
Prepubertal, no pubic hair
Sparse, downy hair at the base of the
phallus
Darkening, coarsening, curling of hair
which extend upward and laterally
Hair of adult consistency limited to the
mons pubis
Hair spreads to the medial aspect of the
thighs

Females
- same At the medial aspect of the labia
majora
- same - same - same -

Table 3. Tanner Stages of Pubertal Development: Adrenarche

IV. HUMAN SEXUAL CYCLE
A. Excitement
1. Vaginal lubrication and vasocongestion of the genitalia.
2. Penile erection due to vasocongestion
B. Plateau
1. Formation of orgasmic platform due to prominent vasocongestion.
2. Generalized muscle tension, hyperventilation, increased BP, tachycardia in the late plateau
phase.
3. Pre-ejaculatory phase with live spermatozoa
C. Orgasmic
1. Strong rhythmic contractions of vagina and uterus.
2. In males, vas deferens, seminal vesicle, ejaculatory duct and prostate contract 3-4 times over
a few seconds causing pooling of seminal fluid in the prostatic urethra. Rhythmic
contractions in males occur at 0.8 seconds interval that assist in the propulsion process
D. Resolution rapid decline in pelvic vasocongestion. All organs return to previous position
E. Refractory phase only in males; the period during which no amount of stimulation can cause
another erection. Not manifested in females because females are multi-orgasmic. This phase
lengthens with age.

PREGNANCY AND PRENATAL CARE

I. FERTILIZATION
A.
Definition: the union of the sperm and the mature ovum in the outer third or outer
half of the Fallopian tube.
B.
General considerations
1. Normal amount of semen per ejaculation = 3-5 cc. = 1 teaspoon.
2. Number of sperms in an ejaculate = 120-150 million/cc
3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation. Sperms are capable
of fertilizing even for 3-4 days after ejaculation.

4. Normal life span of sperms = 7 days

5. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after
deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis (haploid umber of daughter cells);
therefore, they contain only 23 chromosomes (the rest of the body cells contain 46
chromosomes). Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex chromosome.
The union of an X-carrying sperm and mature ovum results in a baby girl (XX); the union of a
Y-carrying sperm and a mature ovum results in a baby boy (XY). Important: Only fathers,
I. Cytotrophoblast the inner layer.
therefore, determine the sex of their children.
II. Syncytiotrophoblast the outer layer containing fingerlike projections
called chorionic villi, which differentiate into:
II. IMPLANTATION
A. Langhans layer believed to protect the fetus against Treponema
A. Implementation after fertilization, the fertilization ovum or zygote stays in the Fallopian tube for 3
Pallidum (etiologic agent of syphilis). Present only during the second
days, during which time rapid cell division (mitosis) is taking place. The developing cells are now
trimester of pregnancy.
called blastomere and when there are already about 16 blastomeres, it is now termed a morula. In
B. Syncytial layer gives rise to the fetal membranes:
this morula for, it will start to ravel (by ciliary action and peristaltic contractions of the Fallopian
1. Amnion inner membrane which gives rise to
tube) to the uterus where it will stay for another 3-4 days. When there is already a cavity formed in
1.1 Umbilical cord/funis contains two arteries and one vein,
the morula, it is now called a blastocyst. Fingerlike projections, called trophoblasts (Table 4), form
which are supported by the Whartons jelly.
around the blastocyst and these trophoblasts are the ones which will implant high on the anterior or
1.2 Amniotic fluid
posterior surface of the uterus. Thus, implantation, also called nidation, takes place about a week
after fertilization. Clear, albuminous fluid in which the baby floats.
Begins to form at 11-15 weeks gestation.
B. General Considerations
has
Approximates
water
in specific
gravityis(1.007-1.025)
1. Once implantation
taken place, the
uterine
endothelium
now termed decidua.
and
is
neutral
to
slightly
alkaline
= implantation
7.0-7.25). because capillaries
2. Occasionally, a small amount of vaginal spotting appears(pH
with
Note: the trophoblasts
higher the pH,
the more bleeding.
alkaline; the
are ruptured by the implanting
= implantation
Implication: this should
lower
the
pH,
the
more
acidic
not be mistaken for the Last Menstrual Period (LMP)
Near term is clear, colorless, containing little white
specksDEVELOPMENT
of vernix caseosa and other solid particles.
III. STAGES OF HUMAN PRENATAL
Produced at a rate of 500 ml in 24 hours and fetus
A. First 12-14 days = zygote
it at an equally rapid rate. By the 4 th lunar
B. From 15th day up to the 8thswallows
week = embryo
th
month,
urine=isfetus
added to the amount of amniotic fluid.
C. From 8 week up to the time
of birth
Amniotic fluid, therefore, is derived chiefly from
maternal serum and fetal urine. Implication: a case of
polyhydramnios )=more than 1500 ml of amniotic
fluid) stems from the inability of the fetus to swallow
amniotic rapidly, as in tracheoesophageal fistula;
while oligohydramnios )=amniotic fluid less than 500
ml) is due to the inability of the kidneys to add urine
to the amniotic fluid, as in congenital renal anomaly.
Also known as bag of water (BOW), it serves the
following purposes:
Protestion shields the fetus against blows or
pressures on the mothers abdomen; against
sudden changes in temperature because liquid
changes temperature more slowly than air; and
from infections
Diagnosis as in amniocentesis; meconiumstained amniotic fluid means fetal distress
Aids in descent of the fetus during active labor
2. Chorion together with the deciduas basalis, gives rise to the placenta, which
starts to form at 8th week gestation. Develops into 15-20 subdivisions call
cotyledons. Placenta serves the following purposes:
2.1 Respiratory system exchange of gases takes place in the placenta, not in
the fetal lungs
2.2 Renal system waste products are being excreted through the placenta
(Note: it is the mother;s liver which detoxifies the fetal waste products).
2.3 Gastrointestinal system nutrients pass to the fetus via the placenta by
diffusion through the placental tissues
2.4 Circulatory system feto-placental circulation is established by selective
osmosis
2.5 Endocrine system it produces the following important hormones (before
8 weeks gestation, the corpus luteum is the one producing these
hormones):
Human chorionic gonadotropin (HCG) orders the corpus luteum to
keep on producing estrogen and progesterone, that is why menstruation
does not take place during pregnancy.
Human placental lactogen (HPL) or human chorionic
somatomammotropin promotes growth of mammary glands
necessary for lactation. Also has growth-stimulating properties.

 Estrogen and Progesterone

2.6 Protective barrier inhibits the passage of same bacteria and large
molecules
Table 4. Outline of Trophoblast Differentiation
IV.

FETAL DEVELOPMENT
A. First Lunar Month
1. Germ layers differentiat by the 2nd week: (in cases of multiple congenital anomalies, the structures that
will be affected are those that arise out of the same germ layer).
1.1 Entoderm develops into the lining of the GIT, the respiratory tract, tonsils, thyroid (for basal
metabolism), parathyroid (for calcium metabolism), thymus gland (for development of immunity),
bladder and urethra
1.2 Mesoderm forms into the supporting structures of the body (connective tissues, cartilagem
muscles and tendons); heart, circulatory system, blood cells, reproductive system, kidneys and
ureters
1.3 Ectoderm responsible for the formation of the nervous system, the skin, hair and nails, and the
mucous membrane of the anus and mouth.
2. Fetal membranes (amnion and chorion) appear by the second week.
3. Nervous system very rapidly develops by the 3rd week. (Dizziness is said to be the earliest sign of
pregnancy because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus
causing hypoglycemia in the latter).
4. Fetal heart begins to form as early as the 16th day of life. (To the question, When does the fetal heart
begin to beat?, the answer is first lunar month. But to the question, When can fetal heart tones to first
heard? the answer is fifth month.)
5. The digestive and respiratory tracts exist as a single tube until the 3rd week of life when they start to
separate.
B. Second Lunar Month
1. All vital organs are formed by the 8th week; placenta develops fully
2. Sex organs (ovaries and testes) are formed by the 8th week. (To the question, When is sex determined?
the answer is At the time f conception).
3. Meconium (first stools) are formed in the instestines by the 5th 8th week.
C.
1.
2.
3.
4.
5.

Third Lunar Month

Kidneys are able to function urine is formed by the 12th week.
Buds of milk teeth form
Beginning bone ossification
fetus swallows amniotic fluid
Feto-placental circulation is established by selective osmosis; no direct exchange between fetal and
maternal blood.

D.
1.
2.
3.

Fourth Lunar Month

Lanugo appears
Buds of permanent teeth form
Heart beats maybe audible with fetoscope

E.
1.
2.
3.
4.

Fifth Lunar Month

Vernix caseosa appears
Lanugo covers entire body
Quickening (fetal movements) felt
Fetal heart beats very audible

F. Sixth Lunar Month

1. Skin markedly wrinkled
2. Attains proportions of fullterm baby
G. Seventh Lunar Month alveoli begin to form (28th weeks of gestation is said to be the lower limit of
prematurity because if baby is delivered at this time, will cry and breathe but usually dies)
H.
1.
2.
3.
4.

Eighth Lunar Month

Fetus is viable
Lanugo begins to disappear
Nails extend to ends of fingers
Subcutaneous fat deposition begins

I. Ninth Lunar Month

1. Lanugo and vernix disappear

2. Amniotic fluid volume somewhat decreases
J. Tenth Lunar Month all characteristics of the normal newborn.
V.

FOCUS OF FETAL DEVELOPMENT

A. First trimester period of organogenesis
B. Second trimester period of continued fetal growth and development; rapid increase in fetal length
C. Third trimester period of most rapid growth and development because of rapid deposition of
subcutaneous fat

VI.

NORMAL ADAPTATIONS IN PREGNANCY

A. Systemic Changes
1. Circulatory/Cardiovascular
1.1 Beginning the end of the first trimester there is a gradual increase of about 30% - 50% in the total
cardiac volume, reaching its peak during the 6th month. This causes a drop in hemoglobin and
hematocrit values since the increase is only in the plasma volume = physiologic anemia of
pregnancy. Consequences of increased total cardiac volume are:
1.1.1 Easily fatigability and shortness of breath because of increased workload of the heart
1.1.2 Slight hypertrophy of the heart, causing it to be displaced to the left, resulting in
torsion on the great vessels (the aorta and pulmonary artery).
1.1.3 Systolic murmurs are common due to lowered blood viscosity
1.1.4 Nosebleeds may occur because of marked congestion of the nasopharynx as
pregnancy progresses.
1.2 Palpitations are due to:
1.2.1 Sympathetic nervous system stimulation during the first half of pregnancy
1.2.2 Increased pressure of uterus against the diaphragm during second hald of pregnancy
1.3 Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the
lower extremities:
1.3.1. Edema of the lower extremities occurs. Management legs above hip level. Important: Edema
of the lower extremities is normal during pregnancy; it is not a sign of toxemia
1.3.2. Varicosities of the lower extremities can also occur. Management:
Use/wear support hose or elastic stockings to promote venous flow, thus preventing stasis
in lower extremities
Apply elastic bandage start at the distal end of the extremity and work toward the trunk to
avoid congestion and impaired circulation in the distal part; do not wrap toes so as to be
able to determine adequacy of circulation (Principle behind bandaging: blod flow through
tissues is decreased by applying excessive pressure on blood vessels)
Avoid use of constricting garters, e.g., knee-high socks
1.4 Because of poor circulation in the blood vessels of the genitalia due to the pressure of the gravid
uterus, varicosities of the vulva and rectum can occur. Management: side-lying position with
hips elevated on pillow and modified knee-chest position.
1.5 There is increased level of circulating fibrogen, that is why pregnant women are normally
safeguarded against undue bleeding. However, this also predisposes them to formation of blood
clots (thrombi). The implication is that pregnant women should not be massaged since blood clots
can be released and cause thromboembolism.
2. Gastrointestinal changes
2.1 Morning sickness nausea and vomiting during the first trimester is due to increased human
chorionic gonadotropin (HCG). It may also be due to increased acidity or even to emotional
factors. Management: Eat dry toast or crackers 30 minutes before arising in the morning (or dry,
high carbohydrate, low fat and low spices in the diet).
2.2 Hyperemesis gravidarum = excessive nausea and vomiting which persists beyond 3 months;
results in dehydration, starvation and acidosis. Management: D10NSS 300 ml in 24 hours is the
priority treatment; complete bed rest is also important.
2.3 Constipation and flatulence are due to displacement of the stomach and intestines, thus slowing
peristalsis and gastric emptying time. May also be due to increased progesterone during
pregnancy. Management:
2.3.1 Increase fluids and roughage in the diet
2.3.2 Establish regular elimination time
2.3.3 Increse exercise
2.3.4 Avoid enemas

2.3.5
2.3.6

Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are better
Mineral oil should not be taken because it interferes with absorption of fat-soluble
vitamins.

2.4 Hemorrhoids are due to pressure of enlarged uterus. Management: cold compress with witch
hazel or Epsom salts.
2.5 Heartburn, especially during the last trimester, is due to increased progesterone which decreases
gastric motility, thereby causing reverse peristaltic waves which lead to regurgitation of stomach
contents through the cardiac sphincter into the esophagus, causing irritation. Management:
2.5.1 Pats or butter before meals
2.5.2 Avoid fried, fatty foods
2.5.3 Sips of milk at frequent intervals
2.5.4 Small, frequent meals taken slowly
2.5.5 Bend at the knees, not at the waist
2.5.6 Take antacids (e.g. milk of Magnesia) but never sodium bicarbonate (e.g. Alka
Seltzer or baking soda) because it promotes fluid retention.
3. Respiratory changes shortness of breath
3.1 Causes
3.1.1 Increased oxygen consumption and production of carbon dioxide during the first
trimester.
3.1.2 Increased uterine size causes diaphragm to be pushed or displaced, thus crowding the
chest cavity.
3.2 Management: Lateral expansion of the chest to compensate for shortness of breath increases
oxygen supply and vital lung capacity.
4. Urinary changes
4.1 Urinary frequency, the only sign in pregnancy seen during the first trimester disappears during the
second and reappears during the third trimester. Early in pregnancy is due to increased blood
supply to the kidneys and to the uterus rising out of the pelvic cavity; in the last trimester is due
to pressure of enlarged uterus on the bladder, especially with lightning (descent of the fetus into
the pelvic brim).
4.2 Decreased renal threshold for sugar due to increased production of glucocorticoids which cause
lactose and dextrose to spill into the urine; also an effect of the increased progesterone.
(implication: it would be difficult to diagnose diabetes in pregnancy based on the urine sample
alone because a pregnant women have sugar in their urine.)
5. Muscoloskeletal changes
5.1 Because of the pregnant womans attempt to change her center of gravity, she makes ambulation
easier by standing more straight and taller, resulting in a lordotic position (pride of pregnancy)
5.2 Due to increased production of the hormone relaxin, pelvic bones become more supple and
movable, increasing the incidence of accidental falls due to the wobbly gait. Implication: Advise
use of low-heeled shoes after the first trimester
5.3 Leg cramps
5.3.1 Causes
Increased pressure of gravid uterus on lower extremities
Fatigue
Chills
Muscle tenseness
Low calcium, high phosphorus intake
5.3.2 Management
Frequent rest periods with feet elevated
Wear warm, more confortable clothing
Increase calcium intake (calcium tablets and diet)
Do not massage blood clots can cause embolism.
Most effective treatment: Press knee of the affected leg and dorsiflex the foot.
6. Temperature slight increase in basal temperature due to increased progesterone, but the body adapts
after the 4th month
7. Endocrine changes
7.1 Addition of the placenta as an endocrine organ, producing large amounts of HCG, HPL, estrogen
and progesterone.
7.2 Moderate enlargement of the thyroid gland due to hyperplasia of the glandular tissues and
increased vascularity. Could also be due to increased basal metabolic rate to as much as +25%
because of the metabolic activity of the products of conception.
7.3 Increased size of the parathyroid, probably to satisfy the increased need of the fetus for calcium.

7.4 Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortiso,,
aldosterone and ADH, all of which affect carbohydrate and fat metabolism, causing
hyperglycemia.
7.5 Gradual increase in insulin production but the bodys sensitivity to insulin is decreased during
pregnancy.
8. Weight (Table 5)
8.1 During the first trimester, weight gain of 1.5-3 lbs is normal
8.2 On 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is recommended.
8.3 Total allowable weight gain during entire period of pregnancy, therefore, is 20-25 pounds (10-12
kgs).
8.4 Pattern of weight gain is more important than the amount of weight gained.
Fetus
Placenta
Amniotic fluid
Increased weight of uterus
Increased weight of the breasts
Weight of additional fluid
Fat and fluid accumulation
Characteristics of pregnancy

7lbs.
1 lb.
1 lbs.
2 lbs.
1/1 3 lbs.
2 lbs.
4-6 lbs.
Total

20-25 lbs.

Table 5. Distribution of Weight Gain During Pregnancy

9. Emotional responses
9.1 First trimester. The fetus is an unidentified concept with great future implications but without
tangible evidence of reality. Some degree of rejection, disbelief, even depression. (Implication:
when giving health teachings, emphasize the bodily changes in pregnancy).
9.2 Second trimester: fetus is perceived as a separate entity. Fantasizes appearance of the baby.
9.3 Third trimester: has personal identification with a real baby about to be born and realistic plans for
future childcare responsibilities. Best time to talk about layette and infant feeding method. Fear
of death, though is prominent (To allay fears, let pregnant woman listen to the fetal heart sounds.)
B. Local Changes (Table 6)
1. Uterus
1.1 Weight increases to about 1000 grams at full tern; due to increase in the amount of fibrous and
elastic tissues.
1.2 Change in shape from pear-like to ovoid; enormous change in consistency of lower uterine
segment causes extreme softening, known as Hegars sign, seen at about the 6th week
1.3 Mucous plugs in the cervix, called operculum, are produced to seal out bacteria.
1.4 Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known
as Goodells sign.
2. Vagina
2.1 Increased vascularity causes change in color from light pink to deep purple or violet known as
Chadwicks sign.
2.1.1 To prevent confusion as to pregnancy signs, arrange the body parts from out to in and
the different signs alphabetically. Thus:
Vagina Chadwicks sign
Cervix Goodells sign
Uterus Hegars sign
2.1.2 Due to increased estrogen, activity of the epithelial cell increases, thus increasing
amount of vaginal discharges called leucorrhea. 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.
2.2 The pH of the vagina changes from normally acidic (because of the presence of Dederlein
bacillie) to alkaline (because of increased estrogen). Alkaline vaginal environment is supposed to
protect against bacterial infection; however, there are two microorganisms which thrive in an
alkaline environment.
2.2.1 Trichomonas, a protozoa or flagellate. The condition is called trichomonas vaginalis or
trichomonas vaginitis or trichomoniasis.
Signs and symptoms of Trichomoniasis
Frothy, cream-colored, irritatingly itchy, foul-smelling discharges
Vulvar edema and hyperemia due to irritation from the discharges

 Management
Flagyl for 10 days p.o. or vaginal suppositories of trichomonicidal compounds.
(e.g., Tricofuron, Vagisec or Devegan).
o Is carcinogenic during the first trimester
o Treat male partner also with Flagyl.
o Avoid alcoholic drinks when taking Flagyl can cause Antabuse like
reactions: vomiting, flushed face and abdominal cramps.
o Dark brown urine a minor side effect no need to discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar in 1 quart of water or 15 ml. white
vinegar in 1000 ml. of water) to counteract alkaline preferred environment of
the protozoa.
Avoid intercourse to prevent reinfection
2.2.2

Candida albicans, a fungus or yeast. The condition is called Moniliasis or Candidiasis.

Fungus also thrives in an environment rich in carbohydrates (that is why it is common
among poorly-controlled diabetics) and in those on steroid or antibiotic therapy when
acidic environment is altered. Moniliasis is seen as oral thrush in the newborn when
transmitted during delivery through the birth canal of the infected mother.
Symptoms
White, patchy, cheese-like particles that adhere to vaginal walls
Irritatingly itchy and foul-smelling vaginal discharges
Management
Mycostatin/Nystatin p.o. or vaginal suppositories/peccaries (100,000 U) twice a
day for 15 days
Gentian violet swab to vagina (use panty shields to prevent staining of clothes
or underwear)
Correct diabetes
Avoid intercourse
Acidic vaginal douche

3. Abdominal Wall
3.1 Striae gravidarum increase uterine size results in rupture and atrophy of connective tissue layers,
seen as pink or reddish streaks (gently rubbing oil on the skin helps prevent diastasis)
3.2 Umbilicus pushed out
4. Skin
4.1 Linea nigra brown line running from umbilicus to symphais pubis
4.2 Melasma or chloasma extra pigmentation on cheeks and across the nose due to increased
production of melanocytes by the pituitary gland
4.3 Sweat glands unduly activated
5. Breasts all changes due to increased estrogen
5.1 Increase in size due to hyperplasia of mammary alveoli and fat deposits. Proper breast support
with well-fitting brassiere necessary to prevent sagging
5.2 Feeling of fullness and tingling sensation in the breasts
5.3 Nipples more erect. For mothers who intend to breastfeed, advise:
5.3.1 Nipple rolling
5.3.2 Drying nipples with rough towel to help toughen the nipples.
5.3.3 Not to use soap or alcohol as this can cause drying which could lead to sore nipples.
5.4 Montgomery glands become bigger and more protruberant
5.5 Areola becomes darker and diameter increases
5.6 Skin surrounding areolae turns dark
5.7 By the fourth month, a thin, watery, high protein fluid, called colostrums, is formed. It is the
precursor of breast milk.
6. Ovaries no activity whatsoever since ovulation does not take place during pregnancy. Progesterone
and estrogen are being produced by the placenta.
Stage
First Trimester

Second Trimester

Presumptive
Amenorrhea
Morning sickness
Breast changes
Urinary frequency
Enlarging uterus
Quickening
Skin pigmentation

Probable
Chadwicks sign
Goodells sign
Hegars sign
Positive HCG
Elevation of BBT
Enlarged abdomen
Braxton Hicks

Positive
Ultrasound evidence

Fetal heart tones

Fetal movements

(chloasma and linea

nigra)
Striae gravidarum

Ballotement

felt by examiner
Fetal outline on xray

Signs of Pregnancy
VII. THE PRENATAL VISIT
A. The provision of prenatal care is the primary factor in the improvement of maternal and infant morbidity
and mortality statistics. To ensure the success of the prenatal care programs, it should be remembered
that the patients understanding of the modalities of care is basic to cooperative action.
B. The duration of a normal pregnancy is 266-280 days, or 38-42 weeks (average is 40 weeks), or 9
calendar months or 10 lunar months. Any baby, therefore, who is born before the 38th week of gestation
is called pre-term and a baby born after the 42nd week of gestation is said to be post-term.
C. Diagnosis of Pregnancy. Urine examination human chorionic gonadotropin (HCG) in the urine is the
basis for pregnancy tests. It is present from the 40th day through the 100th day, reaching a peak level on
the 60th day. HCG, therefore, is most correct 6 weeks after the last menstrual period (LMP). If more
than 1 hour would lapse before being tested, refrigerate specimen because HCG is unstable under room
temperature. Biological tests (e.g., frog tests) are no longer done. Immunodiagnostic tests (antigenantibody reaction) are widely used at present because results are obtained faster and do not involve the
sacrifice of an animal. E.g., Gravindex, Pregnex, Prognosticon.
D. Components of a Prenatal Visit
1. History-taking
1.1 Personal data patients name, age, address, civil status, (an unwed pregnancy is a risk
pregnancy) and family history (With whom does she live? Are there familial diseases that
could possibly affect the pregnancy?)
1.2 Obstetrical data
1.2.1 Gravida number of pregnancies a woman has had.
1.2.2 Para number of viable pregnancies, regardless of number and outcome
1.2.3 TPAL score (_ _ _ _) number of full term babies (T, premature (P) babies, abortion (A),
living children (L)
1.2.4 Past pregnancies
Method of delivery normal spontaneous vaginal? Caesarion section (CS)?
Indication for past CS?
Where At home? In the hospital?
Risks involved Prematurity? Toxemia?
1.2.5 Present pregnancy
Chief concern is there nausea and vomiting?
Danger signals
Vaginal bleeding, no matter how slight
Swelling of face and fingers
Severe, continuous headache
Dimness or blurring vision
Flashes of light or dots before eyes
Pain in the abdomen
Persistent vomiting
Chills and fever
Sudden escape of fluids from the vagina
Absence of fetal heart sounds after they have been initially auscultated n the 4th
or 5th month
1.3 Medical data is there a history of kidney, cardiac or liver disease; hypertension; tuberculosis;
sexually-transmitted diseases (STDs)?
2. Assessment
2.1 Physical examination review of systems is indicated, including inspection of the teeth
because they are common foci of infection.
2.2 Pelvic examination (Cardinal rule: Empty the bladder first)
2.2.1 Internal exam (IE) to determine Hegars, Chadwicks, and Goodells
2.2.2 Ballotement fetus will bounce when lower uterine segment is tapped sharply (on 5th
month of pregnancy)
2.2.3 Papanicolau (Pap smear) cytological examination to diagnose cervical carcinoma.
Classification of findings
Class 1 absence of a typical or abnormal cells (normal)
Class 2 atypical/abnormal cytology but no evidence of malignancy
Class 3 cytology suggestive of malignancy
Class 4 cytology strongly suggestive of malignancy

 Class 5 conclusive for malignancy

Clinical stages that reflect localization or spread of malignant cervical changes.
Stage 1 CA confined to the cervix
Stage 2 CA extends beyond the cervix into the vagina, but not into the pelvic
wall or lower 1/3 of the vagina
Stage 3 Metastasis to the pelvic wall
Stage 4 Metastasis beyond pelvic wall into the bladder and rectum
Pelvic measurements are preferably done after the 6th lunar month. X-ray pelvimetry
(several flat plate X-ray pictures of the pelvis taken from different angles) is the most
effective method of diagnosing cephalopelvic disproportion (CPD). But since X-rays
are teratogenic, the procedure can be done only 2 weeks before EDC.
2.2.5 Leopolds maneuvers
Purposes
To determine presentation, position, and gratitude
Estimate fetal size
Locate fetal parts
Preparatory steps
Palpate with warm hands; cold hands cause abdominal muscles to contract
Use palms, not fingertips
Position patient on supine with knees flexed slightly (dorsal recumbent position)
so as to relax abdominal muscles.
Apply gentle but firm motions
Procedure
First manever: Facing head part of pregnant woman, palpate for fetal part found
in the fundus to determine presentation (a hard, smooth, ballotable mass at the
fundus means the fetus is in breech presentation
Second maneuver: Palpate sides of the uterus to determine the location of fetal
back (best place to hear fetal heart tones) and small fetal parts
Third maneuver: Grasp lower portion off abdomen just above the symphysis
pubis to find out degree of engagement.
Fourth maneuver: Facing the feet part of the patient, press fingers downward on
both sides of the uterus above the inguinal ligaments to determine attitude
(degree of flexion of fetal head)
2.2.4

2.5

2.3 Vital signs temperature, pulse and respiratory rates are important especially during the initial
prenatal visit. More important, however, are the weight and blood pressure as baseline data to
determine any significant increases.
2.4 Blood studies
2.4.1 Blood Typing
2.4.2 Complete blood count, including Hgb and Hct, to determine anemia
2.4.3 Serological tests (VDRL and Kahn Wasserman) to diagnose for syphilis
Urine examinations
2.5.1 Heat and acetic acid test to determine albuminuria. Any sign of albumin in the urine
should be reported immediately because it is a sign of toxemia
2.5.2 Benedicts test for glycosuria, a sign of possible gestational diabetes. Urine should be
collected before breakfast to avoid false positive results. Should not be more than +1
sugar.
2.5.3 Determination of pyura. Urinary tract infection has been found to be a common cause of
premature delivery.

3. Important Estimates
3.1 Age of Gestation (AOG)
3.1.1 Nageles Rule calculation of expected date of confinement (EDC). Count back three
months from the first day of the last menstrual period (LMP) then add 7 days. Substitute
number for month for easy computation. E.g., LMP is September 6
September is the 9th month of the year 3 = 6 (June)
Add 7 days to 6 = 13
EDC June 13
3.1.2 McDonalds Method determine age of gestation by measuring from the fundus to the
symphysis pubis (in cm.) then divide by 4 = AOG in months. E.G., fundic height of 16
cm. divided by 4 = 4 months AOG = 16 weeks AOG.
3.1.3 Bartholomews Rule estimate AOG by the relative position of the uterus in the
abdominal cavity (Figure 4).
By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis

 On the 5th lunar month, the fundus is at the level of the umbilicus
On the 9th lunar month, the fundus is below the xiphoid process
Bartholomews Rule
3.2 Haases Rule determines the length of the fetus in centimeters.
3.2.1 During the first half of pregnancy, square the number of the month (E.g., first lunar
month: 1 x 1 = 1 cm.)
3.2.2 During the second half of pregnancy, multiply the month by 5 (E.g., 6th lunar month: 6 x
5 = 30 cm)
3.3 Johnsonss Rule estimates the weight of the fetus in grams. Formula: fundic height in cm. n x
k
k is a constant, it is always 155
n is = 12 (if fetus is engaged)
= 11 (if fetus is not yet engaged)
4. Health Teachings
4.1 Nutrition most important aspect (Table 7 and 8)
4.1.1 Women who need special attention
Pregnant teenagers
Extremes in weighing scale low prepregnant weight and the obese
Low income women
Successive pregnancies
Vegetarians although with high vitamin intake, are low in proteins and minerals
because there are many essential amino acids that can be found only in animal
sources
4.1.2

Nutritional assessment is based on taking a diet history first

Food preferences/eating habits
Cultural/religious influences
Educational/occupational level

4.1.3

Computation of caloric equivalents

Carbohydrates x 4
Proteins x 4
Fats x 9

4.1.4

Food sources
Protein-rich foods meat, fish, eggs, milk, poultry, cheese, beans, mongo
Vitamin A eggs, carrots, squash, all green and leafy vegetables
Vitamin D fish, liver, eggs, milk, (Caution: excess Vit. D during pregnancy can lead
to fetal cardiac problems)
Vitamin E green leafy vegetables, fish
Vitamin C tomatoes, guava, papaya
Folic acid especially needed to prevent megaloblastic anemia, abruption placenta
and prematurity because, together with iron, folic acid is needed for hemoglobin
formation. E.g., asparagus
Vitamin B food rich in protein
Calcium/phosphorus milk, cheese
Iron
Especially important during the last trimester when the pregnant woman is going
to transfer her iron stores from herself to her fetus so that the baby has enough
iron stores during the first three months of life when all he takes is milk (which is
deficient in iron).
Iron has very low absorpotion rate; only 10% of iron intake can be absorbed by
the body. Thus, for optimum absorpotion, give Vitamin C.
Iron should be given after meals because it is irritating to the gastric mucosa.
Foods rich in iron: liver and other internal organs, camote tops, kangkong, egg
yolk, amplaya, amlunggay.

4.1.5

Malnutrition during pregnancy can result in prematurity; preeclampsia, absorption, low

birth weight babies, congenital defects or even stillbirths.

Nutrients

Non-Pregnant

Pregnant

Women
Calories (kcal)
Proteins (Gm)
Vitamin A (IU)
Vitamin D (IU)
Vitamin E (IU)
Ascorbic acid/Vitamin C (mg)
Folic acid (mg)
Niacin (mg)
Riboflavin (mg)
Thiamine (mg)
Vitamin B12 (ug)
Vitamin B6 (mg)
Calcium (mg)
Phosphorus (mg)
Iodine (ug)
Iron (mg)
Magnesium (mg)

Food
Meat
Vegetables specially dark
green and deep yellow
Fruits: Citrus and others
Breads
Milk
Additional fluid

2000
46
4000
400
12
45
400
13
1.2
1.0
3.0
2.0
800
800
100
18
300

Active Non-Pregnant
Women
2 servings of meat, fowl or
fish/day; 3-5 eggs/week
1 serving/day (at least
3/week)
2 or more servings/day
1 serving/day
4 or more servings/day
1 pint (6-8 oz. glasses /day)

+300-400
+30
+1000
+0
+3
+15
+400
+2
+0.3
+0.3
+1.0
+0.5
+400
+400
+25
+18
+150

Pregnant Women
2-3 servings of meat, fowl
or fish/day; 1 egg/day
1 serving/day
2-3 servings/day
1 servings/day
4 servings/day
1 quart (2-6 glasses/day)

4.2 Smoking causes vasoconstriction, leading to low birth weight babies and, therefore, is
contraindicated during pregnancy
4.3 Drinking in moderation is not contraindicated but when excessive can cause transient respiratory
depression in the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty
calories.
4.4 Drugs dangerous to fetus especially during the first trimester when the placental barrier is still
incomplete and the different body organs are developing. Are teratogenic (can cause congenital
defects) and, therefore contraindicated unless prescribed by the doctor.
4.4.1 Thalidomide auses Amelia or phocomelia (short or no extremeties)
4.4.2 Steroids can cause cleft palate and even abortion
4.4.3 Iodine contained in many over-the-counter cough suppressants, cause enlargement of
the fetal thyroid gland, leading to tracheal compression and dyspnea at birth
4.4.4 Vitamin K causes hemolysis and hyperbilirubinemia
4.4.5 Aspirin and Phenobarbital cause bleeding disorder
4.4.6 Streptomycin and quinine cause damage to the 8th cranial nerve (nerve deafness)
4.4.7 Tetracycline causes staining of tooth enamel and inhibits growth of long bones (not
given also to children below 8 years for the same reasons)
4.5 Sexual activity
4.5.1 Sexual desires continue throughout pregnancy, but levels change
During the first trimester, there is a decreased in sexual desire because the woman is
more preoccupied with the changes in her body
During the second trimester, there is another decrease in sexual desire because the
woman is afraid of hurting the fetus
4.5.2
4.5.3
4.5.4

Sex in moderation is permitted during pregnancy but not during the last 6 weeks since
there is increased incidence of postpartum infection in women who engage in sex during
the last 6 weeks.
Counsel the couple to look for more comfortable positions. Definitely, the missionary
(man-on-top) position is not advisable
Sex is contraindicated in the following situations
Spotting or bleeding
Ruptured BOW
Incompetent cervical os

 Deeply-engaged presenting part

4.6 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. Advise
pregnant women to walk about every few hours of her work day long periods of standing or sitting
to promote circulation.
4.7 Traveling no travel restrictions but postpone a trip during the last trimester. On long rides, 1520 minute rest periods every 2-3 hours to walk about or empty the bladder is advisable.
4.8 Exercises
4.8.1 Chief aim: To strengthen the muscles used in labor and delivery
4.8.2 Should be done in moderation
4.8.3 Should be individualized: according to age, physical condition, customary amount of
exercises (swimming or tennis not contraindicated unless done for the first time) and the
stage of pregnancy)
4.8.4 Recommended exercises
Squatting (Figure 5) and Tailor Sitting (Figure 6) to stretch and strengthen perineal
muscles; increase circulation in the perineum; make pelvic joints more pliable. When
standing from squatting position, raise buttocks first before raising the head to
prevent postural hypotension.
Pelvic rock maintains good posture; relieved pressure abdominal pressure and low
backache; strengthens abdominal muscles following delivery
Modified knee-chest position - relieves pelvic pressure and cramps in the thighs or
buttocks; relieves discomfort from hemorrhoids
Shoulder-circling strengthens muscles of the chest
Walking said to be the best exercises
Kegel relieves congestion and discomfort in pelvic region; tones up pelvic floor
muscles
4.9 Prepared Childbirth/Childbirth Education preparing the pregnant couple for childbearing
4.9.1 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.
4.9.2 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 womans abdomen is relaxed and
the uterus is allowed to rise freely against the abdominal wall during contractions.
4.9.3

Major approaches to prepared childbirth pregnant couples are taught about anatomy,
pregnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene, diet
comfort measures
Grantly Dick Read Method fear leads to tension and tension leads to pain.
Lamaze psychoprohylactic method; based on stimulus-response conditioning. To
be effective, full concentration on breathing exercises during labor should be
observed (Implication: Nurse should not interrupt the couple doing breathing
exercises.)

4.10 Tetanus immunization given 0.5 ml IM (deltoid region of the upper arm) to all pregnant women anytime
during pregnancy. It shall be given in two doses at least 4 weeks apart, with the second dose at least 3
weeks before delivery. Booster doses shall be given during succeeding pregnancies regardless of the
interval. Three booster doses will confer lifelong immunity.
4.11 Clinic appointments
4.11.1 First 7 lunar month every month
4.11.2 On 8th and 9th lunar month every other week or twice a month
4.11.3 On 10th lunar month every week until labor pains set in

LABOR AND DELIVERY

I.

THE FETAL SKULL (Figure 10)

A. Importance: From an obstetrical point of view the fetal skull is the most important part of the fetus
because it is the:
1. largest part of the body
2. most frequent presenting part
3. least compressible of all parts

B. Cranial bones - the first 3 are not important part of the fetus because it is the:
1.
2.
3.
4.
5.
6.

Sphenoid
Ethmoid
Temporal
Frontal
Occipital
parietal

C. Membrane space suture lines are important because they allow the bones to move and overlap,
changing the shape of the fetal head in order to fit through the birth canal, a process called
molding.
1. Sagittal suture line the membranous interspace which joins the parietal bones
2. Coronal suture line the membranous interspace which joins the frontal bone and the parietal
bones
3. Lambdoid suture line the membranous interspace which joins the occiput and the parietals.
D. Fontanels membrance covered spaces at the junction of the main suture lines
1. Anterior fontanel the larger, diamond-shaped fontanel which closes beween 12-18 months
in an infant
2. Posterior fontanel the smaller, triangular shaped fontanel which closes between 2-3 months
in the infant
E. Measurements the shape of the fetal skull causes it to be wider in its anteroposterior (AP)
diameter than in its transverse diameter
1. Transverse diameters of the fetal skull
1.1 Biparietal = 9.25 cm.
1.2 Bitemporal = 8 cm.
1.3 Bimastoid = 7 cm.
2. Anteroposterior diameters (Figure 11)
2.1 Suboccipitobregmatic (A) from below the occiput to the anterior fontanel = 9.5 cm.
(the narrowest AP diameter)
2.2 Occipitofrontal (B) from the occiput to the mid-frontal boe = 12 cm.
2.3 Occipitomental - from the occiput to the chin = 13.5 cm (the widest AP diameter)
Anteroposterior Diameters of the Fetal Skull
Which one of these diameters is presented at the birth canal depends on the degree of flexion (known as
attitude) the fetal head assumes prior to delivery. In full flexion (very good attitude when the chin is flexed on
the chest), the smalles suboccipitobregmatic diameter (A) is the one presented at the birth canal. If in poor
flexion, the widest occipitomental diameter (D) will be the one presented and will give mother and the baby
more problems.
II.
THEORIES OF LABOR ONSET
A. Uterine Stretch Theory any hallow body organ when stretched to capacity will necessarily contract
and empty.
B. Oxytocin theory labor, being considered a stressful event, stimulates the hypophysis to produce
oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the smooth muscles of the
body, e.g., uterine muscles.
C. Progesterone Deprivation theory progesterone, being the hormone designed to promote pregnancy, is
believed to inhibit uterine motility. Thus, if its amount decreases, labor pains occur.
D. Prostaglandin theory initiation of labor is said to result from the release of arachidonic acid produced
by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which,
in turn, causes uterine contractions.
E. Theory of Aging Placenta because of the decrease in blood supply, the uterus contracts.
III.
PRELIMINARY/PRODROMAL SIGNS OF LABOR
A. Lightening the settling of the fetal head into the pelvic brim. In primis, it occurs 2 weeks before EDC;
in multis, on or before labor onset. Lightening should not be confused with engagement; engagement
occurs when the presenting part had descended into the pelvic inlet. Lightening results in:
1. increase in urinary frequency
2. relief of abdominal tightness and diaphragmatic pressure
3. shooting pains down the legs because of pressure on the sciatic nerve
4. increace in the amount of vaginal discharges

B. Increased activity evel due to increased epinephrine secreted to prepare the body for the coming
work ahead. Advise the preganant woman no to use this increased energy for doing household chores.
C. Loss of weight about 2-3 lbs. 1 to 2 days before labor onset; probably due to decrease in progesterone
production leading to decrease in fluid retention.
D. Braxton Hicks contractions painless, irregular practice contractions.
E. Ripening of the cervix from Goodells sign, the cervix becomes butter-soft
F. Rupture of the membranes it is important to remember that one membranes (BOW) have ruptures:
1. Labor is inevitable. It will occur within 24 hours.
2. The integrity of the uterus has been destroyed. Infection, therefore, can easily set in. That is
why once membranes have rupture:
2.1 Aseptic techniques should be observed in all procedures
2.2 Doctors do less obstetric manipulations (e.g. IE)
2.3 Enema is no longer ordered
2.4 Temperature should be taken regularly so that fever, a sign of infection, can be
detected.
3. Umbilical cord compression and/or cord prolapsed can occur (especially in breech
presentation). Nursing action depends on the specific situation:
3.1 A woman in labor seeking admission to the hospital and saying that her BOW
has rupture should be put to bed immediately, and the fetal heart tones taken
consequently
3.2 If a women in Labor Room says that her membranes have rupture, the initial
nursing action is to take the fetal heart tones.
3.3 she feels a loop of the cord coming out of the vagina (cord prolapse), the first
nursing

FALSE LABOR PAINS

1. Remain irregular
2. Generally confined to the abdomen
3. No increase in duration, frequency
and intensity
4. Often disappears if the women
ambulates
5. Absent cervical changes

TRUE LABOR PAINS

3. May be slightly irregular at first but
become regular and predictable in a
matter of hours.
4. First felt in the lower back and
sweep aroung to the abdomen in a
girdle-like fashion.
5. Increase in duration, frequency and
intensity.
6. Continue no matter what the
woman;s level of activity is.
7. Accompanied by cervical effacement
and dilatation (the most important
differenc)

Differences Between False and True Labor Pains

G. Effacement shortening and thinning of the cervical canal as distinct from the uterus. It is expressed in
percentage.
H. Dilatation enlargement of the external cervical os up to 10 cm primarily as a result of uterine
contractions and secondarily as a result of pressure of the presenting part and the BOW.
I. Uterine Changes
1. The uterus is gradually differentiated into two distinct portions
4.1.
Upper uterine segment becomes thick and active to expel out fetus
4.2.
Lower uterine segment become thin-walled, supple and passive so that fetus can be pushed
out easily.
5. Physiological retraction ring is formed at the boundary of the upper and lower uterine segments. In
difficult labor when the fetus is larger than the birth canal, the round ligaments of the uterus become
tense during dilatation and expulsion, causing an abdominal indentation called Bandls pathological
retraction ring, a danger sign of labor signifying impending rupture of the uterus if the obstruction is not
relieved.
6. Nursing Care
III.1 Hospital admission provide privacy and reassurance from the very start
III.1.1 Personal data name, age, address, civil status
III.1.2 Obstetrical data determine EDC; obstetrical score (gravida, para, TPAL); amount and
character of show; and whether or not membranes have ruptured.

III.2 General physical examination, internal exam and Leopolds maneuvers are done to determine:
III.2.1 Effacement and dilatation
III.2.2 Station relationship of the fetal presenting part to the level of the ischial spine (Figure 14)
Station 0 at the level of the ischial spines; synonymous to engagement
Station -1 presenting part above the level of the ischial spines
Station +1 presenting part below the level of the ischial spines
Station +3 or +4 synonymous to crowning (encircling of the largest diameter of the fetal head
by the vulvar ring)
III.2.3 Presentation relationship of the long axis of the mother to the long axis of the fetus; also
known as lie. Presenting part if the fetal part which enters the pelvis first and covers the
internal cervical os
I.
VERTICAL
A. Cephalic head is the presenting part
1. Vertex head sharply flexed, making the parietal bones the presenting parts
2. If in poor flexion
2.1 Face
2.2 Brow
2.3 Chin
B. Breech buttocks are the presenting parts
1. Complete thighs flexed on the abdomen and legs are on the thighs
2. Frank thighs are flexed and legs are extended, resting on the anterior surface of the body
C. Footling
1. Single one leg unflexed and extended; one foot presenting
2. Double legs unflexed and extended; feet are presenting
II. HORIZONTAL = Transverse lie = Shoulder presentation
In vertex presentation, FHS are usually located in either the left or right lower quadrant
(LLQ or RLQ); in breech presentation, at or above the level of the umbilicus, either left or
right upper quadrant (LUQ or RUQ)
Hazards of breech delivery
Cord compression
Abruptio placenta
Erb Duchenne paralysis
Horizontal lie is very rare (1%) and maybe due to a relazed abdominal wall because of
multiparity, pelvic contraction or placenta previa
3.2.4. Position relationship of the fetal presenting part to a specific quadrant in the mothers pelvis
The pelvis is divided into four quadrants
Right anterior
Left anterior
Right posterior
Left posterior
o Posterior positions result in more backaches because of pressure of the fetal
presenting part on the maternal sacrum
Points of direction in the fetus
Occiput in vertex presentations
Chin (mentum) in face presentations
Sacrum in breech presentations
Scapula (acromio) in horizontal presentations
Possible fetal positions
Vertex
o LOA left occipitoanterior (most common and favorable position at birth)
o LOP left occipitoposterior
o LOT left occipitotransverse
o ROA right occipitoanterior
o ROP right occipitoposterior
o ROT right occipitotransverse
Breech
o LSA left sacroanterior
o LSP left sacroposterior
o LST left sacrotransverse

o RSA right sacroanterior

o RSP right sacroposterior
o RST right sacrotransverse
Face
o LMA left mentoanterior
o LMP left mentoposterior
o LMT left mentotransverse
o RMA right mentoanterior
o RMP right mentoposterior
o RMT right mentotransverse
Shoulder
o LADA left acromiodorsoanterior
o LADP left acromiodorsoposterior
o RADA right acromiodorsoanterior
o RADP right acromiodorsoposterior
3.3 Monitoring and evaluating important aspects
3.3.1 Uterine contractions fingers should be spread lightly over the fundus.
(Figure 15)
Duration from the beginning of one contraction to the end of the same contraction (A to B)
Interval from the end of one contraction to the beginning of the next contraction (B to C)
Interval early in labor 40 45 minutes
Interval late in labor 2 3 minutes
Frequency from the beginning of one contraction to the beginning of the next contraction
(A to C). Observe 3 4 contractions to have a good picture of the frequency of contractions
Intensity the strength of contraction; maybe mild, moderate or strong. Intensity is
measured by the consistency of the fundus at the acme of the contraction. When estimating
intensity, check fundus at the end of contraction to determine whether it relaxes.
___________
A

__________
B
C

___________
D

Figure 15. Aspects of Contraction

3.3.2

3.3.3

Blood Pressure should not be taken during a contraction as it tends to increase. Because no
blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is
why there is increased BP during uterine contractions.
BP readings should be taken at least every half hour during active labor
When a woman in labor complains of a headache, the first nursing action is to take BP. If it
is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it
could be a sign of toxemia)
Fetal heart rate (FHR) should not be mistaken for uterine souffl (synchronizes with maternal
pulse rate)
Normally 120 to 160 per minute
Should not be taken during a uterine contraction because it tends to decrease. Compression
of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, causes
bradycardia
Should be taken every hour during the latent phase of labor, every half hour during the active
phase and every 15 minutes during the transition period
For any abnormality in FHR, the initial nursing action is to change the mothers position
Signs of fetal distress
Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute)
Meconium stained amniotic fluid in non breech presentation
Fetal thrahing hyperactivity of the fetus as it struggles for more oxygen

3.4 Emotional support is provided for the woman in labor by keeping her constantly informed of the
progress labor
3.5 -------------------------------------------3.5.3 Solid or liquid foods are to be avoided because
Digestion is delayed during labor
A full stomach interferes with proper bearing down
May vomit and cause aspiration
3.5.4 Enema not a routine procedure
Purposes

A full bowel hinders the progress of labor effectiveness of enema in labor can be
determined by evaluating change in uterine tone and the amount of show
Expulsion of feces during second stage of labor predisposes mother and baby to infection
Full bowel predisposes to postpartum discomfort
Procedure of enema administration
Enema solution may either be soap suds or Fleet enema (contraindicated in patients with
toxemia because of its sodium content)
Optimum temperature of the solution 105F to 115F (40.5 C 46.1C)
Patient on side lying position
When there is resistance while inserting rectal catheter, withdraw the tube slightly while
letting a small amount of solution enter
Clamp rectal tube during a contraction
Important nursing action: Check FHR after enema administration to determine fetal
distress
Contraindications to enema in labor
Vaginal Bleeding
Premature labor
Abnormal fetal presentation or position
Ruptured membranes
Crowning
3.5.5 Encourage the mother to void every 2 3 hours by offering the bedpan because
A full bladder retards fetal descent
Urinary stasis can lead to urinary tract infection
A full bladder can be traumatized during delivery
3.5.6 Perineal prep done aseptically. Use No. 7 method, always from front to back
3.5.7 Perineal shave not a routine procedure; maybe done to provide a clean area for delivery.
Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair
growth
3.5.8 Encourage Sims position because it:
Favors anterior rotation of the fetal head
Promotes relaxation between contractions
Prevents continual pressure of the gravid uterus on the inferior vena cava (the blood vessel
which brings unoxygenated blood back to the heart); pressure results in Supine Hypotensive
Syndrome, also called Vena Cava Syndrome (Figure 16). Hypotension is due to the
reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial
BP.
3.5.9 Woman in labor should not be allowed to push or bear down unnecessarily during contractions
of the first stage because
It leads to unnecessary exhaustion
Repeated strong pounding of the fetus against the pelvic floor will lead to ce4rvical edema,
thus interfering with dilatation and prolonging length of labor.
3.5.10 Abdominal breathing advised for contractions during the first stage in order to reduce
tension and prevent hyperventilation

16. Supine Hypotensive Syndrome

3.6 Administer analgesics as ordered. The dosage is based on the patients weight, status of labor and age of
gestation.
3.6.1 Narcotics are the most commonly used, specifically Demerol.
Pharmacologic effect: depresses the sensory portion of the cerebral cortex. It is not only a
potent analgesic, it is also a sedative and an antispasmodic.
It is not given early in labor because it can retard, progress (is an antispasmodic), but cannot
also be given if delivery is only one hour away because it causes respiratory depression in
the newborn (that is why it can be given only if cervical dilatation is 6 8 cm.)
Given 25 100 mg., depending on body weight
Takes effect in 20 minutes patient experiences a sense of well being and euphoria
Narcotic antagonist (e.g. Narcan, Nalline) are given to counteract any toxic effects of
Demerol
3.7 Assist in administration of regional anesthesia preferred over any other form of anesthesia because it
does not enter maternal circulation and so does not affect the fetus. Patient is completely awake and aware
of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved.
3.7.1 Xylocaine is the anesthetic of choice
3.7.2 Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucose
aids in proper functioning of the fetus

3.7.3 Types of Anesthesia

(purplish discoloration of the skin due to blood in subcutaneous tissues) area or hematoma in the
perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the
first day may reduce the swelling
3.7.4 Forceps are generally needed in delivery of patient under anesthesia because of loss of
coordination in second stage pushing.
3.7.5 Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time
of needle insertion. Management: Flat on bed for 12 hours and increase fluid intake
3.7.6 Common side effects
Hypotension because Xylocaine is vasodilator. Management turn to side; prompt elevation
of legs; administration of vasopressor and oxygen, as ordered.
Fetal bradycardia
Decreased maternal respirations
3.8 A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are
transported from the Labor Room to the Delivery Room when the cervix is fully dilated or when there is
bulging of the perineum. Mutiparas, on the other hand, are transported when cervical dilataton iis 7 8
cm.
B Transition Period when the mood of the woman suddenly changes and the nature of contractions intensify
1. Characteristics
1.1 If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is
pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW
with a sterile pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow amniotic fluid to
drain) is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal
position changes. Amniotomy, however, can not be done if station is still minus, as this can lead to
cord compression
1.2 Show becomes more prominent.
1.3 There is an uncontrollable urge to push with contractions, a sign of impending second stage of
labor. Profuse perspiration and distention of neck veins are seen.
1.4 Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption.
1.5 In primis, baby is delivered with 20 contractions (40 minutes); in multis, after 10 contractions (20
minutes).
2. Nursing actions are primarily comfort measures
2.1 Sacral pressure (applying pressure with the heel of the hand on the sacrum) relieves discomfort from
contractions
2.2 Proper bearing down techniques: push with contractions
2.3 Controlled chest (costal) breathing during contractions
2.4 Emotional support
C Second Stage (Stage of expulsion) begins with complete dilatation of the cervix and ends with the
delivery of the baby.
1. Powers/forces: involuntary uterine contractions and contractions of the diaphragmatic and abdominal
muscles
2. Mechanisms of labor/Fetal Position Changes (D FIRE ERE)
3.1 Descent may be preceded by engagement.
3.2 Flexion- as descent occurs, pressure from the pelvic floor causes the chin to bend forward onto the
chest.
3.3 Internal Rotation from AP to transverse, the AP to AP
3.4 Extension as head comes out, the back of the neck stops beneath the pubic arch. The head extends
and the forehead, nose, mouth and chin upper.
3.5 External Rotation (also called restitution) anterior shoulder rotates externally to the AP position.
3.6 Expulsion delivery of the rest of the body.
3. Nursing Care
3.1 When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine
ligaments
3.2 As soon as the fetal head crowns, instruct mother not to push, but to pant (rapid and shallow
breathing to prevent rapid expulsion of the baby). If panting is deep and rapid, called
hyperventilation, the patient will experience lightheadedness and tingling sensation of the fingers
leading to carpopedal spasms because of respiratory alkalosis. Management: let the patient breathe
into a brown paper bag to recover lost carbon dioxide; a cupped hand over the mouth and nose will
serve the same purpose.
3.3 Assist in episiotomy (incision made in the perineum primarily to prevent lacerations).
3.3.1 Other purposes
Prevent prolonged severe stretching of muscles supporting the bladder or rectum
Reduce duration of second stage when there is hypertension or fetal distress
Enlarge outlet, as in breech presentation or forceps delivery
3.3.2 Types of episiotomy

 Median from middle portion of the lower vaginal border directed towards the anus
Mediolateral begun in the midline but directed laterally away from the anus. Often done
because it prevents 4th degree laceration should it occur despite episiotomy.
3.3.3 Natural Anesthesia jis used in episiotomy, i.e., no anesthetic is injected because pressure of
fetal presenting part against the perineum is so intense that nerve endings for pain are
momentarily deadened
3.4 Apply the Modified Ritgens Maneuver
3.4.1 Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin,
while exerting gentle pressure with two fingers on the head to control emerging head. This will
not only support the perineum, thus preventing lacerations, but will also favor flexion so that the
smallest suboccipitobregmatic diameter of the fetal head is presented.
3.4.2 Ease the head out and immediately wipe the nose and mouth of secretions to establish a patent
airway (remember: the first and most important principle in the care of the newborn is establish
and maintain a patent airway). The head should be delivered in between contractions.
3.4.3 Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck
(nuichal cord). If so, but loose, slip it down the shoulders or up over the head; but if tight, clamp
the cord twice, an inch apart, and then cut it in between.
3.4.4 As the head rotates, deliver the anterior shoulder by exerting a gentle
3.5 Immediately after delivery, the newborn should be held below the level of the mothers vulva for a
few minutes to encourage flow of blood from the placenta to the baby
3.6 The infant is held with is head in a dependent position (head lower thatn the rest of the body) to
allow for drainage of secretions. Remember: never stimulate a baby to cry unless you have drained
him out of his secretions.
3.7 Wrap the baby in a sterile towel to keep him warm. Remember: Chilling increase the bodys need
for oxygen
3.8 Put the baby on the mothers abdomen. The weight of the baby will help contract the uterus.
3.9 Cutting the cord is postponed until the pulsations have stopped because it is believe that 50 100 ml.
of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped,
clamp it twice, an inch apart and then cut in between.
3.10 Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the
circulating nurse.
D Third Stage (Placental Stage) begins with the delivery of the baby and ends with delivery of placenta.
1. Signs of placental separation
1.1 Uterus becoming round and firm again, rising high to the level of the umbilicus (Calkins sign) the
earliest sign of placental separation
1.2 Sudden gush of blood from the vagina
1.3 Lengthening of the cord
2. Types of placental delivery
2.1 Schultz if placenta separates first at its center and last at its edges, it tends to fold on itself like an
umbrella and presents the fetal surface which is shiny (Shiny for Schultz); 80% of placentas
separate in this manner.
2.2 Duncan if placenta separates first at its edges, it slides along the uterine surface and presents with
the maternal surface which is raw, red, beefy, and irregular and dirty (Dirty for Duncan). Only
about 20% of placentas separate this way.
3. Nursing Care
3.1 Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous
fundal push as this can cause uterine inversion. Just watch for the signs of placental separation.
3.2 Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out,
slowly rotating it so that no membranes are left inside the uterus, a method called Brandt
Andrews maneuver.
3.3 Take note of the time of placental delivery. It should be delivered within 20 minutes after the
delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in
the mother.
3.4 Inspect for completeness of cotyledons; any placental fragment retained can also cause severe
bleeding and possible death.
3.5 Palpate the uterus to determine degree of contraction. If relaxed boggy or non - contracted, first
nursing action is to massage gently and properly. An ice cap over the abdomen will also help
contract the uterus since cold causes vasoconstriction.
3.6 Inject oxytocin (Methergin = 0.2 mg./ml. or Syntocinon = 10U/ml) IM to maintain uterine
contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery.
3.7 Inspect the perineum for lacerations. Any time the uterus is firm following placental delivery, yet
bright red vaginal bleeding is gushing forth from the vaginal opening, suspect lacerations (tend to
heal more slowly because of ragged edges)
3.7.1 Categories of lacerations
First degree involves the vaginal mucous membranes and perineal skin

 Second degree involves not only the muscles, vaginal mucous membranes and skin, but
also the muscles.
Third degree involves not only the vaginal mucous membranes and skin, but also the
external sphincter of the rectum
Fourth degree involves not only the external sphincter of the rectum, the muscles, vaginal
mucous membranes and skin, but also the m mucous membranes of the rectum.
3.7.2 Assist the doctor in doing episiorrhaphy 9repair of episiotomy or lacerations). In vaginal
episiorrhaphy, packing is done to maintain pressure on the suture line, thus prevent further
bleeding. Note: Vaginal packs have to be removed after 24 48 hours
3.H Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its
moving forward from the anus to the vaginal opening. Soiled napkins should be removed from front
to back.
3.I Position the newly delivered mother flat on bed without pillows to prevent dizziness due to
decrease in intraabdominal pressure.
3.J The newly delivered mother may suddenly complain of chills due to decreased blood pressure,
fatique or cold temperature in the delivery room. Management: provide additional blankets to
keep her warm.
3.KMay give initial nourishment; e.g., milk, coffee or tea
3.L Allow patient to sleep in order to regain lost of energy.
E Fourth Stage first 1 2 hours after delivery which is said to be the most critical stage for the mother
because of unstable vital signs.
1. Assessment
1.1 Fundus should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4
hours. Fundus should be firm, in the midline, and during the first 12 hours postpartum, is a little
above the umbilicus. First nursing action for a non- contracted uterus: massage.
1.2 Lochia shuld be moderate in amount. Immediately after delivery, a perineal pad can be
completely saturated after 30 minutes. If saturated in 15 minutes or earlier, may mean
hemorrhage.
1.3 Bladder a full bladder is evidenced by a fundus which is to the right of the midline and dark
red bleeding with some clots. Will prevent adequate uterine contraction.
1.4 Perineum is normally tender, discolored and edematous. It should be clean, with intact sutures.
1.5 Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery,
but normalize within one hour.
2. Lactation suppressing agents estrogen androgen preparations given within the first hours
postpartum to prevent breast milk production in mothers who will not (or cannot) breastfeed. E.g.,
diethylstilbestrol, TACE, Parlodel and deladumone. These drugs tend to increase uterine bleeding and
retard menstrual return
3. Rooming in concept mother and baby are together while in the hospital. The concept of a family,
therefore, is felt from the very beginning because parents have the baby with them, thus providing
opportunities for developing a positive relationship between parents and newborn (maternal infant
bonding). Eye to eye contact is immediately established, releasing the maternal caretaking responses.

PUERPERUM
I.

DEFINITION OF TERMS
A. Puerperium/Postpartum refers to the six week period after delivery of the baby
B. Involution - return of the reproductive organs to their prepregnant state

II.

PRINCIPLS OF POSTPARTUM CARE

A. Promoting and return to normal (involution) of different parts of the body.
1. Vascular changes
1.1 The 30% - 50% increase in total cardiac volume during pregnancy will be reabsorbed into the
general circulation with 5 10 minutes after placental delivery. Implication: the first 5 10
minutes after placental delivery is crucial to gravidocardiacs because the weak heart may not be
able to handle such workload.
1.2 While blood cell (WBC) count increases to 20,000 30,000/mm 3. implication: the WBC count,
therefore, cannot be used as a indicationor sign of postpartum infection
1.3 Thre is extensive activation of the clothing factors, which encourages thromboembolization. This
is the reason why:
1.3.1 Ambulationis done early 4 8 hours after normal vaginal delivery. When ambulating
the newly delivered patient for the first time, the nurse should hold on to the patients
arm.
1.3.2 Recommended exercises
2.1 Kegal and abdominal breathing on postpartum day one (PPD1).
2.2 Chin to chest on PPD2 to tighten and firm up abdominal muscles
2.3 Knee to abdomen when perineum has healed, to strengthen abdominal and gluteal muscles.
1.3.3 Massage is contraindicated
1.4 All blood values are back to prenatal levels by the 3rd or 4th week postpartum
2. Genital Changes
2.1 Uterine involution is assessed by measuring the fundus by fingerbreadth (=1 cm.). on PPD1,
fundus is 1 finger breadth below the umbilicus; on PPD2, 2 fingerbreaths below and so forth
until on PPD10, it can no longer be palpated because it is already behind the symphysis pubis.
Subinvoluted uterus is aa uterus larger than normal and vaginal bleeding with clots since blood
cltos are good media for bacteria, it is , therefore, a sign of puerperal sepsis.
2.2 To encourage the return of the uterus to its usual anteflexed position, prone and knee chest
positions are advised.
2.3 Afterpains/afterbirth pains strong uterine contractions felt more particularly by multis, those
who delivered large babies or twins and those who breastfeed. It is normal and rarely lasts for
more than 3 days.
Management:
2.3.1 Never apply heat on the abdomen
2.3.2 Give analgesics as ordered
2.4 Lochia uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria.
2.4.1 Pattern
Rubra first 3 days postpartum; red and moderate in amount
Serosa net 4 9 days; pink or brownish and decreased in amount
Alba from 10th day up to 3 6 weeks postpartum; colorless and minimal in amount
2.4.2 Characteristics
Pattern should not reverse
It should approximate menstrual flow. However, it increases with activity and
decreases with breastfeeding.
It should not have any offensive odor. It has the same fleshy odor as menstrual blood.
If fol smelling, may mean either poor hygiene or infection
It should not contain large clots.
It should never be absent, regardless of method of delivery. Lochia has the same
pattern and amount, whether CS or normal vaginal delivery
2.5 Pain in perineal region may be relieved by:
2.5.1 Sims Position minimizes strain on the suture line

2.5.2 Perineal heat lamp or warm Sitz baths twice a day vasodilatation increases blood supply
and, therefore, promotes healing
2.5.3 Application of topical analgesics or administration of mild oral analgesics as ordered
2.6 Sexual activity maybe resumed by the 3 rd or 4th week postpartum if bleeding has stopped and
episiorrhappy has healed. Decreased physiologic reactions to sexual stimulation are expected for
the first 3 months postpartum because of hormonal changes and emotional factors.
2.7 Menstruation if not breastfeeding, return of menstrual flow is expected within 8 weeks after
delivery. If breastfeeding, menstrual return is expected in 3-4 months; in some women, no
menstruation occurs during the entire lactation period. (important: amenorrhea during lactation
is no guarantee that the woman will not become pregnant. She may be ovulating the absence of
menstruation may her bodys way of conserving fluids for lactation. Implication: she should be
protected against a subsequent pregnancy by observing a method of contraception, except the
pill).
2.8 Postpartum check up should be done after the 6th week postpartum to assess involution.
3. Urinary Changes
3.1 There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid
accumulation during pregnancy.
3.2 Some newly delivered mothers may complain of frequent urinatin in small amounts; explain that
this is due to urinary retention with overflow. Other, on the other hand, may have difficulty
voiding because of decreased abdominal pressure or trauma to the trigone of the bladder.
Voiding may be initiated by:
3.2.1 Pouring warm and cold water alternately over the vulva
3.2.2 Encouraging the client to go the comfort room
3.2.3 Let her listen to the sound of running water
3.2.4 If these measures fail, catheterization, done gently and aseptically, is the last resort on
doctors order. (if there is resistance to the catheter when it reaches the internal
sphincter, ask patient to breathe through the mouth while rotating the catheter before
moving it inward again).
4. Gastrointestinal changes delayed bowel evacuation postpartally may be due to:
4.1 Decreased muscle tone
4.2 Lack of food + enema during labor
4.3 Dehydration
4.4 Fear of pain from perineal tenderness due to episotomy, lacerations or hemorroids
5. Vital Signs
5.1 Temperature may increase because of the dehydrating effects of labor. Implication: any increase
in body temperature during the first 24 hours postpartum is not necessarily a sign of postpartum
infection.
5.2 Bradycardia (heart rate of 50 70 per minute) is common for 6 8 days
B. Provide emotional support the psychological phases during the postpartum period are:
1. Taking in phase first 1 2 days postpartum when mother is passive and relies on others to care
for her and her newborn. She keeps on verbalizing her feelings regarding the recent delivery for her
to be able ot integrate the experience into herself.
2. Taking hold phase begins to initiate action and make decisions. Postpartum blues (an
overwhelming feeling of sadness that cannot be accounted for) may be observed. Could be due to
hormonal changes, fatigue or feeling of inadequacy in taking care of a new baby. Management:
explain that it is normal; crying is therapeutic, in fact.
C. Prevent postpartum complications
1. Hemorrhage (see page 68-69)
2. Infection
D. Establish successful lactation (Table 12)0
Estrogen and progesterone levels after placental delivery
Stimulates anterior pituitary gland to produce proclatin
acts on
Acinar cells to produce foremilk
stored in collecting tubules.
When infant sucks
posterior pituitary gland is stimulated to
Produced oxytocin
causes contraction of smooth muscles of
Collecting tubules
milk ejected forward let down or milk ejection
Reflex
hindmilk is produced

Table 12. Physiology of Breastmilk Production

1. Implications of physiology of Breastmilk production
1.1 Regardless of the mothers physical condition, method of delivery, or breast size/condition, milk
will be produced.

1.2 Lactation does not occur during pregnancy because estrogen and progesterone are present and
therefore inhibit prolactin production.
1.3 Lactation suppressing agents are to be given immediately after placental delivery to be
effective.
1.4 Oral contraceptives are contraindicated in lactating mother because they contain estrogen and
progesterone, thereby decreasing milk supply.
1.5 Afterpains are felt more by breastfeeding women because of oxytocin production; they also have
less lochia and experience more rapid involution.
1.6 In an emergency delivery;
1.6.1 Determine the EDC, whether the woman in labor is a primi or a multi, and the stage of
labor.
1.6.2 If no sterile equipment is available to cut the cord, wrap the baby and placenta together;
never cut the cord unless sterile equipment is are available.
1.6.3 If the uterus fails to contract after delivery, put the infant to the breast; the sucking of the
infant produces oxytocin which causes uterine contraction
2. Advantages of Breastfeeding
2.1 For mother
2.1.1 Economical in terms of time, money and effort
2.1.2 More rapid involution
2.1.3 Less incidence of cancer of the breast, according to some studies
2.2 For the baby
2.2.1 Closer mother infant relationship
2.2.2 Contains antibodies that protect against common illnesses
2.2.3 Less incidence of gastrointestinal diseases
2.2.4 Always available at the right temperature
3. Health Teachings
3.1 Hygiene
3.1.1
3.1.2

Wash breasts daily at bath or shower time.

Soap or alcohol should never be used on the breasts as they tend to dry and crack the nipples and
cause sore nipples.
3.1.3 Wash hands before and after every feeding.
3.1.4 Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is
considerable breast discharge.
3.2 Method as suggested by the La Leche League
3.2.1 Side-lying position with a pillow under the mothers head while holding the bulk of breast tissues
away from the infants nose.
3.2.2 Stimulate the baby to open his mouth to grasp the nipples by mans of the rooting reflex.
3.2.3 Infant should grasp not only the nipple but also the areola for effective sucking motion.
Effectiveness is ensured when the:
babys mouth parts hike well up into areola
mother feels after pains as the baby sucks
other nipple flows with milk while baby is feeding on other breast
3.2.4 To prevent nipples from becoming sore and cracked, infant should be introduced to the breast
gradually. The baby should be fed for only 5 minutes at each breast during each feeding on the
first day, increasing the time at each breast by 1 minute per day until the infant is nursing for 10
minutes at each breast, making a total feeding time of twenty minutes per feeding.
3.2.5 For continuous milk production, at each feeding, the infant should be placed first on the breast he
fed last in the previous feeding. This ensures that each breast will be completely emptied at every
other feeding. If breasts are completely emptied, they completely refill; if only half-emptied will
also half-refill and after some time, will become insufficient.
3.2.6 To break away from the closed suction at the breast after feeding, insert a clean little finger in the
corner of the infants mouth to release the suction, then pull the chin down. This also helps
prevent sore nipples.
3.2.7 Feed as often as the baby is hungry, especially during the first few days, because he is receiving
colostrums which is not very filling; however, it contains gamma globulin (antibodies), the only
group of substances that can never be replicated by any artificial formula.
3.2.8 Advise the mother to learn how to relax during feedings because tension prevents good let-down.
3.3 Associated problems
3.3.1 Engorgement feeling of tension in the breasts during the third postpartum day sometimes
accompanied by an increase in temperature (milk fever). The breasts become full, feel tense and
hot, with throbbing pain. It lasts for about 24 hours and is due to increased lymphatic and venous
circulation. Management:
Advise use of firm-fitting brassiere for good support. It will not only decrease the discomfort
from breast engorgement but will also prevent contamination of the nipples and areolae.
Cold compress is applied if the mother does not intend to breastfeed; warm compress is
applied if she will breastfeed.
Breast pump should not be used and breast massage should not done if the mother is not
going to breastfeed, since either will stimulate milk production.
3.3.2 Sore nipples not contraindications to breastfeeding. Management:

 Do not use plastic liners that are found in some nursing bras because they prevent air from
circulating around the breasts.
Use nipple shield.
3.3.3 Mastitis inflammation of the breasts
Symptoms
Localized pain, swelling and redness in breast tissues
Lumps in the breasts
Milk becomes scantly
Management
Antibiotics as ordered
Ice compress
Proper breast support
Discontinue breastfeeding in affected breast
3.4 Nutrition lactating mothers should take 3000 calories daily and should have larger amounts of proteins
(96 Gms per day), calcium, iron Vitamins A, B and C. Non-breastfeeding women can have the same
requirements as in pregnancy.
3.5 Contraindications
3.5.1 Drugs oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines.
(Insulin, epinephrine, most antibiotics, antidiarrheals and histamines are generally not
contraindicated. Therefore, diabetics and those with asthma can breastfeed.)
3.5.2 Certain disease conditions, specifically tuberculosis, because of the close contact between mother
and baby during feeding. (However, mothers may use masks to prevent droplet spread) TB
germs, however, are not transmitted thru breast milk.
E. Motivate use of family planning methods the success of the family planning program depends to a large extent
on the motivation of both husband and wife.
1. Artificial Methods
1.1 Physiological method oral contraceptive.
1.1.1 Action: Suppresses the pituitary gland, thus inhibiting ovulation.
1.1.2 Types
Combined estrogen and progesterone in the same dosage each day for 20 days,
starting on the 5th day of the menstrual cycle, after which it is discontinued and
then resumed on the 5th day of the next menstrual cycle.
Sequential estrogen alone for 15 days, then estrogen and progesterone for the
next 5 days.
Mini-pill taken continuously.
1.1.3 Side effects same complaints of pregnant women because of estrogen and progesterone
Nausea and vomiting
Headache and weight gain - due to fluid retention because of progesterone
Breast tenderness
Dizziness
Breakthrough bleeding/spotting between periods
Chloasma
1.1.4 Contraindications
Breastfeeding
Certain diseases
Thromboembolism because there is increased tendency towards
clotting in the presence of estrogen
Diabetes mellitus and liver disease because estrogen tends to interfere
with carbohydrate metabolism
Migraine; epilepsy; varicosities
Cancer; renal disease; recent hepatitis
Women who smoke more than 2 packs of cigarettes per day
Strong family history of heart attack
1.1.5 Should the woman forget to take the pill on the scheduled time, she should take one as
soon as she remembers and take the next ill on its regular taking time. If she still fails to
do so, withdrawal bleeding will occur because of the sudden decrease in hormonal levels.
1.2 Mechanical methods
1.2.1 Intrauterine device (IUD)
Specific action: Prevent implantation by setting up a non-specific cell
inflammatory reaction to the device
Inserted during menstruation to ensure that the woman is not pregnant; septic
abortion can result if she is pregnant
Side effects
Increased menstrual flow
Spotting or uterine cramps during the first 2 weeks after insertion
Increased risk of infection
When pregnancy occurs with the IUD in place, it need not be removed since it
stays outside the membranes and, therefore, will not in any harm the fetus.
1.2.2 Diaphragm

1.3
1.4

2.
2.1

Specific action: A circular rubber disc that fits over the cervix and forms a barrier
against the entrance of sperms
Is initially inserted by the doctor who determines the depth of the vagina
May be coated with spermicide jelly or cream for double protection
Maybe washed with soap and water after use; us reusable
Sperms remain viable in vagina for 6 hours, so the device should be kept in place
during such time, but should not stay for more than 24 hours because stasis of semen
can lead to infection
1.2.3 Condom
Specific action: Sperms are deposited at the tip of the rubber sheath, which has been
placed on an erect penis prior to coitus. Has the added potential of lessening the
chance of contracting sexually-transmitted diseases (STDs, esp. AIDS)
Most common complaint of users: it interrupts the sexual act to apply.
Chemical methods are spermicidals (kill sperms) E.g., jellies, creams, foaming tablet, and
suppositories.
Surgical method
1.4.1 Tubal ligation the Fallopian tubes are ligated in order to prevent passage of sperms.
Menstruation and ovulation continue
1.4.2 Vasectomy small incision made into each side of the scrotum and the vas deferens is
cut and tied, blocking the passage of sperms. Sperm production continues, only passage
into the exterior is prevented. (Sperms in the vas deferens at the time of surgery remain
viable for as long as 6 months. Implication: Couple should still observe a form of
contraception during this time to ensure protection against subsequent pregnancy.)
Natural
Biological method Rhythm/Calendar/Ogino-Knause Formula
2.1.1 Specific action: the couple abstains on days that the woman is fertile
2.1.2 Procedure
The woman charts her menstrual cycles for 12 continuous months in order to
determine the shortest and the longest cycles
26
18
8

32
11
21

2.1.3

Rhythm/Calendar/Ogino-Knause a woman can discern her fertile and infertile days

based on her sensory and visual observations of the cervical mucus (when it becomes thin
and watery spinnbarkheit). Intercourse is avoided 4 days prior to and 3 days after the
spinnbarkheit.
2.1.4 Billings method/cervical mucus when cervical discharges are thin and watery, couple
resumes sexual intercourse 3-4 days after
2.1.5 Symptothermal method/Basal Body Temperature (BBT) involves daily observation of
the temperature of the woman at rest, free from any factor that may cause it to fluctuate
(immediately upon waking up, before brushing teeth, drinking, etc.). Only 3-4 days after
the temperature drops slightly and then increases (which means ovulation has taken
place), can sexual intercourse be resumed. Fertile and infertile days are determined after
having established an accurate record of the six immediately preceding menstrual cycles
then watching out for BBT fluctuations
2.2 Social methods
2.2.1 Abstinence
2.2.2 Withdrawal/Coitus Interruptus

RISK CONDITIONS
I.

INFECTIONS
A. Syphilis
1. Cause: Treponema pallidum a spirochete which enters the body during coitus or through cuts and
breaks in the skin or mucous membrane
2. Treatment: 2.4-4.8 million units of Penicillin (if allergic, 30-40 gms. erythrocin) will usually prevent
congenital syphilis in the newborn because penicillin readily crosses the placenta. If untreated,
syphilis can cause midtrimester abortion, CNS lesions in the newborn or even death.
3. The newborn with congenital syphilis
3.1 Signs and symptoms
3.1.1 Jaundice at 2 weeks of life first sign of the disease
3.1.2 Anemia and hepatosplenomegaly
3.1.3 Snuffles (persistent rhinorrhea); coppery rashes on palms and soles; mucous
patches; condylomas; pseudoparalysis due to bone inflammation
3.1.4 If untreated, can progress on to deformed bones, teeth, nose, joints and CNS
syphilis
3.2 Management: Penicillin IM for 10 days or one long-acting Penicillin (Penadur LA)
B. Rubella/German Measles
1. Incidence

1.1 Mother the earlier the mother contracted the disease, the greater the likelihood that the
baby will be affected. The rubella virus slows down division of infected cells during
organogenesis, thus causing congenital defects
1.2 Newborn can carry and transmit the virus for as long as 12-24 months after birth
2. Signs and symptoms of Congenital Rubella Syndrome
2.1 Low birth weight; jaundice; petechiae; anemia; thrombocytopenia; hepatosplenomegaly
2.2 Classic seequelae
2.2.1 Eyes: chorioretinitis, cataract, glaucoma
2.2.2 Heart: Patent Ductus Arteriousus, stenosis, coarctations
2.2.3 Ear: Nerve deafness
2.2.4 Dental and facial clefts
C. Postpartum Infection
1. Sources
1.1 Endogenous (primary) sources bacteria in the normal flora become virulent when tissues
are traumatized and general resistance is lowered.
1.2 Exogenous sources pathogens introduced from external sources. (Most common is
anaerobic streptococci). Common exogenous sources:
1.2.1 Hospital personnel
1.2.2 Excessive obstetric manipulations
1.2.3 Breaks in aseptic techniques faulty handwashing, unsterile equipments and
supplies
1.2.4 Coitus in late pregnancy
1.2.5 Premature rupture of the membranes
2. General symptoms: malaise anorexia, fever, chills and headache
3. General management
3.1 Complete bed rest (CBR)
3.2 Proper nutrition
3.3 Increased fluid intake
3.4 Analgesics
3.5 Antipyretics and antibiotics, as ordered
4. Types of infection
4.1 Infection of the perineum
4.1.1 Specific symptoms
Pain, heat and feeling of pressure in the perineum
Inflammation of the suture line, with 1 or 2 stitches sloughed off
With or without elevated temperature
4.1.2 Specific management
Doctor removes sutures to drain area and resutures
Hot sitz bath or warm compress
4.2 Endometritis
4.2.1 Specific symptoms
Abdominal tenderness
Uterus not contracted and painful to touch
Dark brown, foul-smelling lochia
4.2.2 Specific management
Oxytocin administration
Fowlers position to drain out lochia and prevent pooling of infected
discharge
4.3 Thrombophlebitis infection of the lining of a blood vessel with formation of clots; usually
an extension of endometritis
4.3.1 Specific symptoms
Pain, stiffness and redness in the affected part of the leg
Leg begins to swell below the lesion because venous circulation has been
blocked
Skin is stretched to a point of shiny whiteness, called milk leg or phlegmasia
alba dolens
Positive Homans sign pain in the calf when the foot is dorsiflexed
4.3.2 Specific management
Bed rest with affected leg elevated
Anticoagulants, e.g., Dicumarol or Heparin, to prevent further clot formation
or extension of a thrombus
o Analgesics are given but never Aspirin because it inhibits
prothrombin formation therefore causes hemorrhage
4.4 Mastitis inflammation of breast tissues
4.4.1 Pathophysiology local inflammatory response to bacterial invasion; suppuration
may occur; organism can be recovered from breast milk.
4.4.2 Etiology most common: Staphylococcus aureus
4.4.3 Assessment
Signs of infection (may occur several weeks postpartum).
Fever
Chills
Tachycardia

4.4.4

Malaise
Abdominal pain
Breast
Reddened areas
Localized/generalized swelling
Heat, tenderness, palpable mass.
Nursing care goal: prevent infection. Health teaching in early postpartum
Handwashing
Breast care
Wash with warm water only (no soap)
Let breast milk dry on nipples to prevent drying of tissue.
Clean bra (with no plastic pads or liners) to support breasts, reduce
friction, minimize exposure to microorganisms.
Good breastfeeding techniques

II. BLEEDING/HEMORRHAGE
A. Bleeding in pregnancy (Table 13)
I. First Trimester Bleeding
A. Abortion
1. Spontaneous
1.1 Threatened
1.2 Imminent
1.2.1 Complete
1.2.2 Incomplete
2. Induced
3. Missed
B. Ectopic pregnancy
1. Tubal most common
2. Cervical
3. Ovarian
II. Second Trimester Bleeding
A. Hydatidiform Mole
B. Incompetent Cervical Os
III. Third Trimester Bleeding
A. Placenta Previa
B. Abruptio Placenta
Table 13. Bleeding in Pregnancy
1. Abortion any interruption in pregnancy before the age of viability
1.1 Spontaneous
1.1.1 Natural causes
Blighted ovum/germ plasma defect = most common cause. It is natures way
of eliminating the birth of a congenitally defective baby
Implantation or hormonal abnormality
Following trauma, infection (e.g., rubella, influenza) or emotional problems
1.1.2 Types
Threatened
Symptom: bright red vaginal bleeding which is moderate in amount
Management
o Complete bed rest for 24-48 hours; if bleeding will stop it
usually stops within this time
o Coitus is restricted for 2 weeks after bleeding has stopped in
order to prevent further bleeding or infection
o Endocrine/hormonal therapy
o Advise patient to save all pads, clots and expelled tissues
Imminent/inevitable
Symptom: Bright red vaginal bleeding which is moderate in amount
and accompanied by uterine contractions and cervical dilatation.
Loss of the products of conception is inevitable.
Management depends on whether it is:
o Complete abortion all products of conception are expelled;
bleeding is minimal and self-limiting. No intervention is
therefore needed.
o Incomplete abortion part of the conceptus (usually the
fetus) is expelled, but membranes or placental fragments are
retained. D & C is indicated as management.
1.2 Induced abortion is never allowed in the Philippines
1.2.1 Therapeutic performed by a doctor in a controlled hospital or clinic setting for a
medical or a legal reason. Also known as medical, planned or legal abortion.

2.

3.

4.

5.

1.3 Missed abortion fetus dies in utero but is not expelled. Usually discovered at a prenatal
visit when fundal height is measured and no increase is demonstrated or when previously
heard fetal heart tones are no longer present. In two weeks time, signs of abortion should
occur; otherwise, labor will have to be induced to prevent hypofibrinoginemia or sepsis.
Ecotopic Pregnancy any gestation located outside the uterine cavity.
2.1 Signs and symptoms since the wall of the Fallopian tube is not sufficiently elastic, it
ruptures within the first 12 weeks of gestation as it can no longer give way for growing fetus
2.1.1 Severe, sharp, knife-like stabbing pain either the right or left lower quadrant (in
bleeding wherein there is no exit or egress of blood from the body, pain is the
outstanding symptom; this pain differentiates Ectopic pregnancy from abortion)
2.1.2 Rigid abdomen
2.1.3 (+) Cullens sign bluish umbilicus
2.1.4 Excruciating pain when cervix is moved on IE
2.1.5 Signs of shock: falling BP, PR more than 100/minute, rapid RR, lightheadedness
2.2 Management ruptured Ectopic pregnancy is an emergency situation.
2.2.1 Salpingosomy if Fallopian tube can still be replaced and preserved,
Hydatidiform Mole developmental anomaly of the placenta resulting in proliferation and
degeneration of the chorionic villi
3.1 Incidence: Is the most common lesion anteceding choriocarcinoma. It occurs most often in
women:
3.1.1 From low socioeconomic backgrounds with low protein intake
3.1.2 Over 35 years and under 18 years of age.
3.2 Signs and symptoms Because of rapid proliferation of the placental tissues and, therefore,
high levels of HCG
3.2.1 Highly positive urine test for pregnancy (that is why a positive pregnancy test
cannot be considered a positive sign of pregnancy)
3.2.2 Nausea and vomiting is usually marked
3.2.3 Rapid increase in fundic height. Rapid increase in weight
3.2.4 Toxemia signs and symptoms appear before the 24th week of gestation
3.2.5 No fetal heart tones
3.2.6 Vaginal bleeding seen as clear, fluid-filled, grape-sized vesicles
3.3 Management
3.3.1 D & C to evacuate the mole
3.3.2 Prophylactic course of Methotrexate, the drug of choice for choriocarcinoma
3.3.3 Urine testing for one year to find out if new villi are developing. Contraceptives
(but not the pills) have to be used so as not to confuse the results
Incompetent Cervical Os one that dilates prematurely. It is the chief cause of habitual abortion (3
or more consecutive abortions).
4.1 Causes
4.1.1 Congenital developmental factors
4.1.2 Endocrine factors
4.1.3 Trauma to the cervix
4.2 Signs and symptoms
4.2.1 Presence of show and uterine contractions
4.2.2 Rupture of membranes
4.2.3 Painless cervical dilatation
4.3 Management: McDonald/Shirodkar-Barter procedure a cerclage procedure wherein purse
string sutures are placed around the cervix on the 14 th - 18th week of gestation. These are
removed during vaginal delivery (if McDonalds method, since sutures are temporary) or the
patient delivers by cesarean section (if Shirodkar method, since sutures are permanent).
Placenta Previa low implantation of the placenta so that it is in the way of the presenting part.
5.1 Predisposing factors
5.1.1 Increasing parity
5.1.2 Advanced maternal age
5.1.3 Rapid succession of pregnancies
5.2 Types
5.2.1 Low lying
5.2.2 Partial
5.2.3 Complete
5.3 Diagnosis made by means of symptoms and ultrasound (also known as Ultrasonic Echo
Sounding or Sonar. Uses intermittent waves of very high frequency/above audible range in
order to picture the fetus. Sound waves are projected towards the mothers abdomen, are
reflected back and converted into electrical impulses and recorded on a permanent graph
paper).
5.3.1 Preparation for ultra sound
Explain the procedure to the patient, informing her that it is painless and
there are no known ill effects
Empty the bladder but ask the patient to take 6 glasses of water afterwards in
order to dilate the bladder. A full bladder displaces a gas filled bowel and,
therefore, permits better visualization of the pelvis and its contents.
5.3.2 Clinical uses of ultra sound
Diagnose pregnancy as early as 5-6 weeks gestational age

 Can establish that the fetus is increasing in size and, therefore, can predict
EDC
Can determine gestational age by measuring the biparietal diameter of the
fetal skull (if it is more than 8.5 cm., it is more than 2500 gms); therefore,
can diagnose intrauterine growth retardation, hydrocephaly, microcephaly
and anencephaly
Can demonstrate size and growth rate of the amniotic sac; therefore; can
identify poly- or oligo-hydramios
Can confirm presence, size and location of the placenta; therefore, is valuable
before amniocentesis
Can diagnose multiple pregnancy
Can visualize ascites, polycystic kidneys, ovarian cysts, etc.
Can determine babys sec (during third trimester and if in cephalic
presentation)
5.4 Signs and Symptoms first and most constant: painless, bright red vaginal bleeding due to
tearing of placental attachment as a consequence of dilatation of the internal cervical os
5.5 Management
5.5.1 Complete bed rest
5.5.2 Monitor vital signs of the mother and the fetal heart rate
5.5.3 Prepare oxygen and blood
5.5.4 Internal examination (IE) is not done. If ever it is to be done, it has to be a
double set-up (done in the operating room wherein the patient has already signed
the consent form, preop medication have been given, abdominal prep has been
done, etc., so that if ever placenta is accidentally detached CS, can be done
immediately.
5.6 Complications
5.6.1 Hemorrhage
5.6.2 Infection
5.6.3 Prematurity
6. Abruptio Placenta premature separation of the placenta
6.1 Predisposing factors
6.1.1 Maternal hypertension or toxemia
6.1.2 Increasing parity and maternal age
6.1.3 Sudden release of amniotic fluid
6.1.4 Short umbilical cord
6.1.5 Direct trauma
6.1.6 Hypofibrinoginemia
6.2 Signs and symptoms
6.2.1 Severe, sharp, knife-like, stabbing pain high in the fundus
6.2.2 Hard, boardlike uterus; rigid abdomen
6.2.3 Signs of shock
6.2.4 Concealed bleeding, if extensive, causes uterus to lose its ability to contract. It
becomes ecchymotic and copper-colored, called Couvelaire uterus, causing
severe bleeding. Since the uterus no longer has the ability to contract,
hysterectomy will have to be done.
B. Postpartum Hemorrhage
2.1.1 Uterine Atony uterus is not contracted, relaxed or boggy; most frequent cause
Predisposing factors
Overdistention of the uterus e.g., multiple pregnancy, multiparity,
excessively large baby, polyhydramnios
Caesarian section
Placental accidents (previa or abruptio)
Prolonged and difficult labor
Management
Massage first nursing action
Ice compress
Oxytocin administration
Empty the bladder
Bimanual compression to explore retained placental fragments
Hysterectomy last resort
2.1.2 Lacerations
2.1.3 Hypofibrinoginemia a clothing defect, Management: blood transfusion
2.2 Late postpartum hemorrhage
2.2.1 Retained placental fragments management: dilatation and curettage (D & C)
2.2.2 Hematoma due to injury to blood vessels in the perineum during delivery
Incidence: Commonly seen in precipitate delivery and those with perineal
varicosities
Treatment
Ice compress during first 24 hours
Oral analgesics, as ordered
Site is incised and bleeding vessel is ligated

III. TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) - a vascular disease of unknown cause which

occurs anytime after the 24th week of gestation up to two weeks postpartum.
A. Triad of symptoms
1. Hypertension
2. Edema
3. Proteinuria (specifically albumiuria).
B. Predisposing factors
1. Age primis under 20 and over 30 years
2. Gravida 5 or more pregnancies
3. Low socioeconomic status (SES)
4. Multiple pregnancy
5. With underlying medical conditions, e.g., heart disease, hypertension or diabetes
C. Classification (Table 14)
D. Pathogenesis: (Figure 17)
E. Diagnosis: roll-over test assesses the probability of developing toxemia when performed between the
28th and 32nd week of pregnancy.
1. Procedure
1.1 Patient lies in lateral recumbent position for 15 minutes until BP has stabilized
1.2 Then rolls over to supine position
1.3 BP is taken at 1 minute and 5 minutes after having rolled over.
2. Interpretation: if diastolic increases 20 mm Hg or more, patient is prone to toxemia.
I. Acute toxemia symptoms appear after the 24th
week of gestation
A. Preeclampsia
1. Mile
2. Severe
B. Eclampsia
II. Chronic hypertension with pregnancy
III. Unclassified
HYPERTENSION
Table 14. Classification of Toxemia

Blood supply & oxygen

perfusion to vital

KIDNEYS

LIVER
PLACENTA
PERIPHERAL ARTERIOLAR
VASOCONSTRICTION

Glomerular degeneration

Glomerular Filtiration Tissue ischemia

Glomerular permebility

Tubular reabsorption Vascular stasis

of sodium

Albumin& globulin cross

into the urine

PROTEINURIA

Water retention

EDEMA

Tissue
ischemia

release
thromboplastin
like substances

Epigastric pain

OLIGURIA

Premature placental
deterioration

Fluid diffuses from

circulatory system to
extracellular spaces

Fetal
nutrient

Abruptio
placenta

Generalized
water retention
LUNGS

BRAIN
Fetal Distress

Pulmonary
edema
CHF

cyanosis

Cerebral
edema

hypoxia

Cerebral
irritability
CONVULSIONS

Premature Labor
and Delivery

1.1.2

Generalized vasoconstriction and associated microangiopathy disease of

capillaries
1.1.3 Abnormal retention of sodium and water by body tissues
1.2
Medical complications
1.2.1 Cerebrovascular hemorrhage
1.2.2 Acute pulmonary edema
1.2.3 Acute renal failure
1.3
Types
1.3.1 Mild preeclampsia signs and symptoms
Sudden, excessive weight gain of 1-5 lbs. per week (earliest sign of
preeclampsia) due to edema which is persistent and found in the upper
half of the body (e.g. inability to wear the wedding ring)
Systolic BP of 140, or an increase of 30mm. Hg. or more and a diastolic
of 90, or a rise of 15 mm. Hg. or more, taken twice 6 hours apart.
Proteinuria of 0.5 gms/liter or more
1.3.2 Severe preeclampsia signs and symptoms
BP of 160/110 mm Hg.
Proteinuria of 5 gm/liter or more in 24 hours
Oliguria of 400 ml. or less in 24 hours (normal urine output/day = 1500
ml).
Cerebral or visual disturbances
Pulmonary edema and cyanosis
Epigastric pain (considered an aura to the development of convulsions)
2. Eclampsia the main difference between preeclampsia and Eclampsia is the presence of convulsion in
eclampsia. Signs and symptoms as in preeclampsia plus:
2.1 increased BUN
2.2 increased uric acid
2.3 decreased CO2 combining power

F. Management
1. Complete bed rest sodium tends to be excreted at a more rapid rate if the patient is at rest. Energy
conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered
oxygen tension in toxemia is the result of vasoconstriction and decreased blood flow that diminishes
the amount of nutrients and oxygen in cells. In any condition wherein there is a possibility of
convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling.
2. Diet
2.1 For mild preeclampsia high protein, high carbohydrate, moderate salt restriction (no added
table salt, including bagoong, patis, tuyo, canned goods, bottled drinks, preserved
foods and cold cuts)
2.2 For severe preeclampsia high protein, high calorie and salt-poor (3 gms of salt per day)

3. Medications
3.1 Diuretics e.g., chlorthiazide/Diuril. Hourly urine output should be at least 20-30
ml. (normally 50-60 ml. per hour)
3.1.1 Pharmacologic effect: decreased reabsorption of sodium and chloride at
the proximal tubules, thereby increasing renal excretion of sodium,
chloride and water, including potassium.
3.1.2 Side effects: fatigue and muscle weakness due to fluid and electrolyte
imbalance
3.1.3 Nursing care: closely monitor intake and output
3.2 Digitalis if with heart failure.
3.2.1 Pharmacologic action: Increase the force of contraction of heart, thereby
decreasing heart rate.
3.2.2 Important: Should not be given, therefore, if heart rate is below
60/minute.
3.2.3 Implication: take the heart rate before giving the drug.
3.3 Potassium supplements patients receiving diuretics are prone to hypokalemia; if
digitalis is given at the same time, hypokalemia increases the sensitivity of the heart
to the effects of digitalis. Potassium supplements (e.g., banana) must be given tot
prevent cardiac arrhythmias.

3.4 Barbiturates sedation by means of CNS depression

3.5 Analgesics; antihypertensives; antibiotics; anticonvulsants; sedatives
3.6 Magnesium sulfate the drug of choice
3.6.1 Actions
CNS depressant lessen the possibility of convulsions
Vasodilator decreases the BP
Cathartic causes a shift of fluid from the extracellular spaces into the
intestines from where the fluid can be excreted.
3.6.2 Dosage: 10 gms. initially, either by slow IV push over 5-10 minutes, or
deep IM, 5 gms/buttock, then IV drip of 1 gm. per hour (1 gm/100 ml.
D10W) IF:
Deep tendon reflexes are present
Respiratory rate is at least 12 per minute
Urine output is at least 100 ml. in 6 hours
3.6.3 Antidote for magnesium sulfate toxicity: Calcium gluconate, 10% IV, to
maintain cardiac and vascular tone.
3.6.4 Earliest sign of magnetism sulfate toxicity: disappearance of the knee
jerk/patellar reflex.
4. Method of delivery preferably vaginal, but if not possible, CS will have to be done.
G. Prognosis: the danger of convulsions is present until 48 hours postpartum.
IV.

DIABETES MELLITUS chronic hereditary disease which is characterized by hyperglycemia due to relative
insufficient or lack of insulin from the pancreas which, in turn, leads to abnormalities in the metabolism of
carbohydrates, proteins and fats.
A. Diabetogenic effects of pregnancy many women who have had no evidence of diabetes in the past
develop abnormalities in glucose tolerance
1. Decrease renal threshold for sugar because of increased estrogen; that is why it is common to find
dextrose and lactose in the urine of pregnant women
2. increased production of adenocorticoids, anterior pituitary hormones and thyroxin, which affect
carbohydrate concentration in blood (hyperglycemia)
3. rate of insulin secretion is increased but sensitivity of the pregnant body to insulin is decreased, i.e.,
insulin does not seem to be normally effective during pregnancy
B. Attendant risks
1. Toxemia
2. Infection
3. Hemorrhage
4. Polyhydramnios
5. Spontaneous abortion because of vascular complications which affect placental circulation
6. Acidosis because of nausea and vomiting. It is the chief threat to the fetus in utero
7. Dystocia due to excessively large baby
C. Diagnosis made on the basis of the glucose Tolerance Test (GTT)
1. Procedure
1.1 NPO after midnight
2.3 If more than 120 mg% - overt gestational diabetes
D. Categories to predict the outcome of pregnancy
1. Class A GTT is only slightly abnormal; minimal dietary restriction; insulin not need; fetal survival
is high
2. Classes C to E have 25% perinatal mortality
3. Class F therapeutic abortion (in other countries may be justified, not in the Philippines)
E. Management
1. Diet highly individualized. Adequate glucose intake (1800-2200 calories) to prevent intraurine
growth retardation.
2. Insulin requirements are likewise highly individualized, requiring close observation throughout
pregnancy. Since the effects of the hormones are more pronounced during the 2 nd and 3rd trimesters
there is increased need for insulin.
2.1 Insulin is regulated to keep urine +1 for sugar (minimal glycosuria is necessary to prevent
acidosis) but negative for acetone.
2.2 Long-acting insulin (Ultralente) will have to be changed to regular insulin (Lente) during
the last few weeks of pregnancy.
3. Often delivered by CS
3.1 Baby is typically larger or maybe in distress because of placental insufficiency.
3.2 Severe metabolic imbalances in vaginal delivery can occur because of depletion of
glycogen reserve in the liver and skeletal muscles by strenuous muscular exertion during
labor.
4. Maximum difficulty in controlling diabetes is during the early postpartum period because of the
drastic changes in hormonal levels.
F. Infant of the Diabetic Mother (IDM)
1. Is typically longer and weighs more because of:
1.1 excessive supply of glucose from the mother
1.2 increased production of growth hormones from the maternal pituitary gland
1.3 increased secretion of insulin from the fetal pancreas

2.
3.
4.
5.
6.

V.

VI.

1.4 increased action of adrenocortical hormones that favor passage of glucose from mother to
fetus
Congenital anomalies are often seen
Cushingoid appearance (puffy, but limp and lethargic)
More often born premature, so respiratory distress syndrome is common
Lose a greater proportion of weight than normal newborns because of loss of extra fluid
Are prone to the following complications
6.1 Hypoglycemia blood sugar level less than 30 mg%. It is the most common complication
to watch for
6.1.1 Cause: while inside the uterus, the fetus tends to be hyperglycemic because of
maternal hyperglycemia. The fetal pancreas thus responded to the high glucose
level by producing matching high levels of insulin. Following delivery, the
glucose level begins to fall because the baby has been severed from the mother.
Since there has been previous production of high levels of insulin, hypoglycemia
develops.
6.1.2 Clinical signs of hypoglycemia
Shrill, high-pitched cry
Listlessness/jitteriness/tremors
Lethargy; poor suck
Apnea; cyanosis
convulsions
6.1.3 Consequences: hypoglycemia, if not treated, can lead to brain damage and even
death
6.1.4 Management: feed with glucose water earlier than usual, or administer IV of
glucose.
6.2 Hypocalcemia serum calcium level of less than 7 mg%.
6.2.1 Signs: same as hypoglycemia
6.2.2 Sequela: Same as that of hypoglycemia
6.2.3 Management: Calcium gluconate to prevent bypocalcemic tetany

HEART DISEASE
A. Classification
1. Class I no limitation physical activity
2. Class II slight limitation of physical activity; ordinary activity causes fatigue; palpitation, dyspnea
or angina
3. Class III moderate to marked limitation of physical activity; less than ordinary activity causes
fatigue, etc.
4. Class IV unable to carry on any activity without experiencing discomfort
B. Prognosis
1. Classes I and II normal pregnancy and delivery
2. Classes III and IV poor candidates
C. Signs and symptoms
1. Because of increased total cardiac volume during pregnancy, heart murmurs are observed
2. Cardiac output may become so decreased that vital organs are not perfused adequately; oxygen and
nutritional requirements, therefore, are not met.
3. Since the left side of the heart is not able to empty the pulmonary vessels adequately, the latter
become engorged, causing pulmonary edema and hypertension. Moist cough in gravidocardiacs,
therefore, is a danger sign.
4. Liver and other organs become congested because blood returning to the heart may not be handled
adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged
capillaries and cause edema or ascites.
5. Congestive heart failure is a high probability also because of the increased cardiac pain on exertion,
and cyanosis of nailbeds are obvious.
D. Management consider the functional capacity of the heart
1. Bed rest especially after the 30 th week of gestation to ensure that pregnancy is carried to term or at
least 36 weeks gestation
2. Diet should gain enough, but not too much as it would add to the workload of the heart
3. Medications
3.1 Digitalis
3.2 Iron preparations, e.g., Fer-in-sol or Feosol anemia should be prevented because the body
compensates by increasing cardiac output, thus further increasing cardiac workload.
4. Classes III and IV are not placed in lithotomy position during delivery to avoid increasing venous
return. The semi-sitting position is preferred to facilitate easy respirations.
5. Anesthetic of choice is caudal anesthesia for effortless, pushless and painless delivery. Remember:
Gravidocardiacs are not allowed to push with contractions (to prevent Valsalva maneuver which
increases venous return to an already weak, damaged heart). Low forceps, therefore, is the best
method of delivery.
6. ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral contraceptives are
contraindicated because they cause fluid retention and promote thromboembolization.
7. Most critical period the period immediately following delivery because the 30% - 500
MULTIPLE PREGNANCY (Twin Pregnancy)
A. Classification

1. Monozygotic/Identical twins begin with a single ovum and sperm, but in the process of fusion or in
one of the first cell divisions, the zygote divides into two identical but separate individuals.
1.1 Characteristics
1.1.1 Always of the same sex
1.1.2 With 2 amnions, 1 chorion, 2 umbilical cords and 2 placentas fused as one.
1.2 Incidence a chance occurrence
1.2.1 More frequent among non-whites
1.2.2 More frequent among young primis and old multis
2. Dizygotic/Fraternal two separate ova are fertilized by 2 separate sperms. They are actually sibling
growing at the same time in utero.
2.1 Characteristics
2.1.1 May or may not be of the same sex
2.1.2 With 2 amnions, 2 chorions, 2 placentas and 2 umbilical cords
2.2 Incidence familial maternal pattern of inheritence
B. Suspect multiple pregnancy if:
1. faster rate of increase in uterine size
2. on quickening, there are several flurries of action in different abdominal positions
3. on auscultation, 2 sets of fetal heart tones are heard
4. there is marked weight gain, not due to toxemia or obesity
C. complications
1. Toxemia
4. Abruptio placenta
2. Polyhydramnios
5. Prematurity
3. Anemia
6. Postpartum hemorrhage
VII. BLOOD INCOMPABILITY an antigen-antibody reaction which causes excessive destruction of fetal red
blood cells
A. Mother is Rh negative and the fetus is Rh positive (because the father is either a homozygous or a
heterozygous Rh positive)
B. Mother is Type O and the fetus is either Type A or Type B (because the father is either Type A or Type
B)
VIII. DYSTOCIA broad term for abnormal or difficult labor and delivery
A. Uterine Inertia sluggishness of contractions
1. Causes
1.1 Inappropriate use of analgesics
1.2 Pelvic bone contraction
1.3 Poor fetal position
1.4 Overdistention due to multiparity, multiple pregnancy, polyhydramnios or excessively
large baby
2. Types
2.1 Primary (hypertonic) Uterine Dysfunction relaxation are inadequate and mild, thus are
ineffective. Since uterine muscles are in a state of greater than normal tension, latent phase
of the first stage of labor is prolonged. Treatment: sedate patient.
2.2 Secondary (hypertonic) Uterine Dysfunction contractions have been good but gradually
become infrequent and of poor quality and cervical dilatation stops. Treatment: stimulation
of labor either by Oxytocin administration or amniotomy.
B. Precipitate Delivery labor and delivery that is completed in less than 3 hours after the onset of true labor
pains. Probably due to multiparity or following Oxytocin administration or amniotomy. Can lead to:
1. extensive lacerations
2. abruptio placenta
3. hemorrhage due to sudden release of pressure, leading to shock.
C. Prolonged Labor in primis, labor lasting more than 18 hours and in multis, more than 12 hours. Can
lead to:
1. maternal exhaustion
2. uterine atony
3. caput succedaneum
D. Uterine Rupture occurs when the uterus undergoes more straining than it is capable of sustaining.
1. Causes
1.1 Scar from a previous classic Cesarean section (CS)
1.2 Unwise use of oxytocins
1.3 Overdistention
1.4 Faulty presentation
1.5 Prolonged labor
2. Signs and symptoms
2.1 Sudden, severe pain
2.2 Hemorrhage and clinical signs of shock (restlessness, pallor, decreasing BP, increasing
respiratory and pulse rates)
2.3 Change in abdominal contour, with two swellings on the abdomen: the retracted uterus and
the extrauterine fetus
3. management: hysterectomy
E. Uterine Inversion fundus is forced through the cervix so that the uterus is turned inside out.
1. Causes
1.1 Insertion of placenta at the fundus, so that as fetus is rapidly delivered, especially if
unsupported, the fundus is pulled down

1.2 Strong fundal push when mother fails to bear down properly during 2nd stage of labor
1.3 Attempts to deliver the placenta before signs of placental separation appear
2. Management: hysterectomy
F. Amniotic Fluid Embolism occurs when amniotic fluid is forced into an open maternal uterine blood
sinus through some defect in the membranes or after partial premature separation of the placenta. Solid
particles in the amniotic fluid enter maternal circulation and reach the lungs as emboli.
1. Signs and symptoms are dramatic
1.1 Woman in labor suddenly sits up and grasps her chest because of inability to breathe and
sharp chest pain
1.2 Turns pale and then the typical bluish-gray color associated with pulmonary embolism
1.3 Death may occur in a few minutes
2. Management
2.1 Emergency measures to maintain life: IV, oxygen, CPR
2.2 Provide intensive care in the ICU
2.3 Keep family informed
2.4 Provide emotional support
G. Trial Labor if a woman has borderline (just adequate) pelvic measurements but fetal position and
presentation are good. Maybe continued for as long as there is progressive fetal descent of the presenting
part and the cervix continues to dilate actively. Management:
1. Monitor FHRs and uterine contractions
2. Keep bladder empty to allow all available space to be used by the fetus
3. Emotional support
1.1 Ethyl alcohol (Ethanol) IV blocks the release of Oxytocin. Side effects: nausea and
vomiting, mental confusion, etc. (same side effects when alcohol is taken orally in excessive
amounts)
1.2 Vasodilan IV a vasodilator. Side effects: hypotension and tachycardia
1.3 Ritodrine a muscle relaxant given orally
1.4 Bricanyl a known bronchodilator
2. If premature uterine contractions are accompanied by progressive fetal descent and cervical
dilatation, premature delivery is inevitable.
2.1 May not necessarily be shorter than full term labor
2.2 Pain medications are kept to a minimum because analgesics are known to cause respiratory
depression. As it is, premature babies already have enough difficulty breathing on their own;
giving analgesics, therefore, would add up to the problem. Implication: give emotional
support to the mother such that she focuses her attention not on her own needs but those of
her baby.
2.3 Steroids (glucocorticoids) are given to the mother to help in the maturation of the fetal lungs
by hastening production of surfactants
2.4 Caudal, spinal or infiltration anesthesia is preferred because it does not compromise fetal
respiration.
2.5 Episiotomy is not necessary smaller than in full term deliveries; may even be larger so that
the preemie can be delivered at the shortest possible time, since excessive pressure on the
fragile preemies head can cause subarachnoid hemorrhage that could be fatal
2.6 Forceps may be applied gently
2.7 Cord is cut immediately, rather than waiting for pulsations to stop, because preemies have
difficult time excreting large amounts of bilirubin that will be formed from the extra amount
of blood.
IX.

INDUCED LABOR to bring about labor either by amniotomy or drugs (Oxytocin, prostaglandins) before the
time when it would have occurred spontaneously or because it does not occur spontaneously.
A. Indications
1. Maternal
1.1 Toxemia
1.2 Placental accidents
1.3 Premature rupture of the BOW
2. Fetal
2.1 Diabetes terminated about 37 weeks AOG if indicated
2.2 Blood incompatibility with rising titer
2.3 Excessive size
2.4 Postmaturity
B. Prerequisites
1. No CPD
2. Fetus is viable survival is decreased if below 32 weeks AOG
3. Single fetus in longitudinal lie and is engaged
4. Ripe cervix fully or partially effaced; dilated at least 1-2 cm.
C. Procedure
1. Oxytocin administration
1.1 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8 gtts/minute given initially. If no fetal
distress is observed in 30 minutes, infusion rate is increased 16-20 drops/minute
1.2 Amniotomy will be done when cervical dilatation reaches 4 cm. Check FHR and quality of
fluid after amniotomy
1.3 Nurisng Care

1.3.1
1.3.2
1.3.3

Primary concern: monitor intensity of uterine contractions. If uterine

contractions are unduly sustained, uterine rupture can occur.
Monitor flow rate regularly
Turn off IV drip if with abnormalities in FHR or uterine contractions.