LOCAL

CHANGES

2
 1. Uterus
• wt increase to about 1000 grams at
full term due to increase in fibrous
and elastic tissues
a. Becomes ovoid in shape
b. Softening of lower uterine segment:
Hegar’s sign seen at 6th week
c. Operculum – mucus plug to seal out
bacteria
d. Goodell’s sign – cervix becomes
3
vascular and edematous giving it
 2. Vagina
• – increased vascularity occurs
a. Chadwick’s sign – purplish
discoloration of the vagina
b. Leukorrhea – increased amount of
vaginal discharges due to increased
activity of estrogen and of the
epithelial cells.
c. Must not be itchy, foul smelling,
excessive, nor green/yellow in color.
d. Management: good hygiene
4
e. Under the influence of estrogen,
vaginal epithelium & underlying
tissues hypertrophic & enriched with
glycogen
f. pH of vaginal secretions during
pregnancy fall

5
 3. Ovaries
• Inactive since ovulation does not
take place during pregnancy.
• Placenta produces Progesterone and
Estrogen during pregnancy

6
 4. Abdominal Wall

a. Striae Gravidarum – due to rupture

and atrophy of connective tissue
layers on the growing abdomen
b. Umbilicus is pushed out

7
 5. Skin

a. Linea Negra – Brown line running

from umbilicus to symphisis pubis
b. Melasma or Chloasma – increased
pigmentation due increased
production of melanocytes by the
pitutitary
c. Unduly activated sweat glands

8
 6. Breast

a. All changes due to increased

estrogen
b. Increase in size due to
hyperplasia of mammary alveoli
and fat deposits: Proper breast
support with well fitting brassiere
necessary to prevent sagging.
c. Nipples more erect

9
Appropriate
Relief
Measures

10
• Nausea and vomiting
– Avoid odors, eat dry crackers in the
morning
– Avoid greasy foods and drink fluids
between meals
• Heartburn
– Eat small, frequent meals
– Avoid overeating and lying down after a
meal
• Flatulence: Chew food completely
and avoid gas forming foods 11
FIGURE 11–2 Acupressure wristbands are sometimes used to help relieve nausea during early pregnancy.

12
Appropriate Relief Measures
• Constipation
– Increase fluid and fiber in diet
– Develop regular bowel habits
• Faintness
– Change positions slowly
– Avoid standing for long periods
• Backache
– Use good body mechanics
– Practice pelvic tilt exercises
• Leg cramps: Apply heat to affected muscles and
dorsiflex feet

13
FIGURE 11–4 When picking up objects from floor level or lifting objects, the pregnant woman must use
proper body mechanics.

14
FIGURE 11–4 (continued) When picking up objects from floor level or lifting objects, the pregnant
woman must use proper body mechanics.

15
Appropriate Relief Measures
• Ankle edema
– Elevate legs while sitting or standing
– Dorsiflex feet frequently
• Varicose veins
– Elevate legs as much as possible
– Wear support hose
• Hemorrhoids
– Avoid constipation
– Use ice packs or sitz baths as necessary
16
FIGURE 11–3 Swelling and discomfort from varicosities can be decreased by lying down with the legs and
one hip elevated (to avoid compression of the vena cava).

17
FIGURE 11–8 Position for relaxation and rest as pregnancy progresses.

18
 Breast Care
• Recommend: Wear bra with good
support and fit
– If breastfeeding, avoid soap on breasts
– Nipple preparation: Go braless to
toughen nipples
– Roll nipples or oral stimulation by
partner to prepare for breastfeeding
– Should be avoided in women who have
had previous preterm labor
19
Appropriate Relief Measures
• Increased vaginal discharge: Bathe
daily and wear cotton underwear
• Nasal stuffiness and epistaxis: Use
cool mist vaporizer
• Carpal tunnel syndrome: Avoid
repetitive hand movement and
elevate arm as needed

20
 Common
Obstetric
Terminology

21
 Common Obstetric
Terminology
• Gravida: Any pregnancy, regardless
of duration, includes the current
pregnancy
• Parity: Birth after 20 weeks’
gestation; infant may be born alive
or dead

22
 Common Obstetric
Terminology (cont’d)
• TPAL
– T: Number of term infants born
– P: Number of preterm infants
– A: Number of pregnancies ending
in either spontaneous or
therapeutic abortion
– L: Number of currently living
children
23
FIGURE 10–1 The TPAL approach provides detailed information about the
woman’s pregnancy history.

24
 Common Obstetric
Terminology (cont’d)
• Gestation: Number of weeks since
the first day of the last menstrual
period
• Abortion: Birth occurring before the
end of 20 weeks’ gestation
• Term: Normal duration of pregnancy
(38 to 42 weeks’ gestation)
• Antepartum: Time between
conception and the onset of labor
• Intrapartum: Period from the onset of
true labor until the birth of the infant
25
 Common Obstetric
Terminology (cont’d)
• Postpartum: Time from birth until the
woman’s body returns to
prepregnant condition
• Preterm or premature labor: Labor
that occurs after 20 weeks’ but
before completion of 37 weeks’
gestation
• Nulligravida: Woman who has never
been pregnant
• Primigravida: Woman pregnant for 26
Prenatal
History
27
 Prenatal History
• Details of current pregnancy
– First day of last normal menstrual period
(LMP)
– Presence of complications
– Attitude toward pregnancy
– Results of pregnancy tests, if completed
– Presence of discomforts since LMP
– Number of pregnancies and number of
living children
– Number of abortions, spontaneous or 28
 Prenatal History
• History of previous pregnancies
– Length of pregnancy
– Length of labor and birth
– Type of birth
– Type of anesthesia used (if any)
– Woman’s perception of the
experience
– Complications associated with
childbirth
29
– Neonatal complications
 Prenatal History
• Gynecologic history
– Date of last Pap smear - any history of
abnormal Pap smear
– Previous infections: Vaginal, cervical,
tubal, or sexually transmitted
– Previous surgery
– Age at menarche and sexual history
– Regularity, frequency, and duration of
menstrual flow
– History of dysmenorrhea and
30
 Prenatal History
• Current medical history
– General health: Weight, nutrition, and
regular exercise program
– Blood type and Rh factor, if known
– General health: Nutrition and regular
exercise program
– Medications and use of herbal
medication use during pregnancy
– Previous or present use of alcohol,
tobacco, or caffeine
– Illicit drug use and drug allergies and
other allergies 31
 Prenatal History
• Current medical history
– Potential teratogenic insults to
this pregnancy
– Presence of disease conditions
such as diabetes
– Immunizations (especially
rubella)
– Presence of any abnormal
symptoms 32
 Prenatal History
• Past medical history
– Childhood diseases
– Past treatment for any disease
condition
– Surgical procedures
– Presence of bleeding disorders or
tendencies (Has she received blood
transfusions?)

33
 Prenatal History
• Family medical history
– Presence of chronic or acute systemic
diseases
– Complications associated with
childbirth: Preeclampsia
– Occurrence of multiple births
– History of congenital diseases or
deformities
– Occurrence of cesarean births and
cause, if known
34
 Prenatal History
• Religious preference and religious
beliefs related to health care and
birth:
– Prohibition against receiving blood
products
– Dietary considerations or
circumcision rites
• Practices that are important to
maintain her spiritual well-being
• Practices in her culture or that of her 35
 Prenatal History
• Occupational history: Physical
demands of present job
• Partner’s history: Genetic conditions
and blood type
• Woman’s demographic information
– Age, educational level
– Ethnic background
– Socioeconomic status
36
 Subsequent Prenatal
Assessment
• Prenatal visits
– Every 4 weeks for the first 28
weeks’ gestation
– Every 2 weeks until 36 weeks’
gestation
– After week 36, every week until
childbirth

37
 Subsequent Prenatal
Assessment
• Assessments during prenatal visits
– Vital signs and weight
– Edema
– Uterine size and fetal heartbeat
– Urinalysis
– Blood tests for AFP, glucose
– Vaginal swab for group B strep
– Expected psychological stage of
pregnancy
38
IMPORTANT
ESTIMATES

39
 Age of Gestation
Nagele’s Rule: -3 calendar months and
+7 days
Ex. LMP= May 15, 2006 or 5-15-06
LMP: 5 15
Formula: - 3 + 7
EDC: 2 22 or February 22, 2007

40
McDonald’s Rule:

Ht fundus/4 (AOG wks)

Measure in cms the length from the
symphysis to the level of fundus
• Lunar months: Fundal Height (cms) x
2/7
• Weeks of pregnancy: Fundal height
(cms) x 8/7 41
Ex. Fundal Height =
14 cms

• Lunar Month:
14cms x 2 = 28 /
7 = 4 months
• Weeks Pregnant:
14 cms x 8 = 112
/ 7 = 16 weeks
AOG 42
FIGURE 10–3 A cross-sectional view of fetal position when McDonald’s method is used to assess fundal
height.

43
Bartholomew’s
Rule: based on
position of
fundus in
abdominal
cavity
• 3rd month =
above
symphysis
• 5th month = 44
b. Fetal Length:
Haase’s Rule: 1st half of
pregnancy – square
number of months
• Example : 2 months =
2x2 = 4 cm
• 2nd half of pregnancy
– number of months
multiplied by 5
• Example: 7 months x 5
45
c. Fetal Weight:
Johnson’s Rule: Fundic Ht – n x k
( k=155; n = 11 not engaged/12
engaged)
• Example for a not engaged fetus
• Fundic Height given = 35 cms
• n = 11 (standard for not engaged
fetus)
• k= 155 gms. (standard) 46
FIGURE 10–2 The EDB wheel can be used to calculate the due date. To use it, place the “last menses
began” arrow on the date of the woman’s LMP. Then read the EDB at the arrow labeled 40. In this case the
LMP is September 8, and the EDB is June 17.

47
DANGER SIGNS
OF
PREGNANCY

48
Signs of Infection or Cancer
• Elevation in vital signs
• Urine with elevated white blood cells
• High white blood cell count in the
blood
• Lesions in the genital area
• Excessive malodorous vaginal
discharge
• Positive tests for sexually
transmitted infections 49
Signs of Infection or Cancer
• Tender, hard fixed nodes in the
neck
• Abnormal lung sounds
• Breast lumps
• Nipple discharge
• Redness and tenderness of
breast tissue
50
 Signs of Anemia or
Cardiopulmonary Problems
• Pale mucous membranes
• Skin pallor
• Signs of nutrition deficiency
• Low hemoglobin and hematocrit
levels
• Elevations in blood pressure
• Edema
• More than expected weight gain 51
 Signs of Cardiopulmonary
Problems
• Abnormal lung sounds
• Increased respiratory
rate
• Abnormal heart rhythm
• Extra heart sounds
52
 Other Danger Signs
• Less than expected weight gain
• Petechiae or bruises
• Inflamed gingival tissue
• Enlarged thyroid
• Abdominal tenderness or mass
• Lack of peripheral pulses

53
 Other Danger Signs
• Failure to detect fetal heart
rate
• Abnormal spinal curves
• Hyperactive reflexes
• Below normal pelvic
measurements
• Hemorrhoids
54
Danger Signs in Pregnancy

55
Danger Signs in Pregnancy

56
Informatio
n About
Other
Factors
57
Information About Other
Factors
• Clothing: Non-constricting
• Shoes: Low heeled
• Bathing: Be aware of cultural
norms and avoid falls
• Employment
– No complications, work until labor
– Assess for fetotoxic hazards
• Travel: Complicated pregnancy,
avoid travel
• Dental Care: Maintain regular
dental checkups
58
• Immunizations: Avoid live virus
vaccines
• Tetanus Toxois (TT) = 0.5 ml IM for
all pregnant women shall be given in
2 doses- 4 wks interval with 2nd dose
at least 3 wks before delivery
• booster doses given during
succeeding pregnancies regardless
of interval.
• 3 booster doses is equal to lifetime59
 Information About Other
Factors
• Activity and Rest
– Regular exercise in uncomplicated
pregnancy
– Rest periods
• Exercises to prepare for childbirth:
Pelvic tilt
• Perineal exercises: Kegel
• Inner thigh exercises

60
FIGURE 11–9 A, Starting position when the pelvic tilt is done on hands and knees. The back is flat and
parallel to the floor, the hands are below the head, and the knees are directly below the buttocks.

61
FIGURE 11–9 (continued) B, A prenatal yoga instructor offers pointers for proper positioning for the first
part of the tilt: head up, neck long and separated from the shoulders, buttocks up, and pelvis thrust back,
allowing the back to drop and release on an inhaled breath.

62
FIGURE 11–9 (continued) C, The instructor helps the woman assume the correct position for the next part
of the tilt. It is done on a long exhalation, allowing the pregnant woman to arch her back, drop her head
loosely, push away from her hands, and draw in the muscles of her abdomen to strengthen them. In this
position the pelvis and buttocks are tucked under, and the buttock muscles are tightened.

63
FIGURE 11–9 (continued) D, Proper posture. The knees are slightly bent but not locked, and the pelvis
and buttocks are tucked under, thereby lengthening the spine and helping support the weighty abdomen. With
her chin tucked in, this woman’s neck, shoulders, hips, knees, and feet are all in a straight line perpendicular to
the floor. Her feet are parallel. This is also the starting position for doing the pelvic tilt while standing.

64
FIGURE 11–10 Kegel exercises. The woman learns to tighten the pubococcygeus muscle, which improves
support to the pelvic organs.

65
FIGURE 11–10 (continued) Kegel exercises. The woman learns to tighten the pubococcygeus muscle,
which improves support to the pelvic organs.

66
 Concerns and
Information About
Sexual Activity

67
 Information About Other
Factors
• Sexual activity: Consider alternative
positions for intercourse
• Avoid: Medications not prescribed,
alcohol, tobacco, and illicit drugs
• Risks and benefits of homeopathic
remedies and herbs

68
 Concerns and Information
About Sexual Activity
• Concerns
– Possible injury to the baby or the woman during
intercourse
– Changes in the desire each partner feels for the
other
– Communication of desire and need
• Information
– Partners need to communicate feelings and needs
– Healthy pregnancy: No reason to limit sexual
activity

69
Accurate Information About
Sex During Pregnancy
• Information
– Complicated pregnancy
– Limit sexual activity
• Contraindicated for sexual activity
– Multiple pregnancy
– Threatened abortion

70
Accurate Information About
Sex During Pregnancy
• Contraindicated for sexual activity
– Incompetent cervix
– Sexually transmitted infection
– Miscarriage following orgasm
– Rupture of membranes
– Preterm labor

71
 Medical Risks
• Fetal death risk is increased for all
women older than 35
• Mother is more likely to have
chronic medical conditions
• Chronic medical conditions could
pose a risk to the fetus
• Increased risk for Cesarian section
• Increased risk for Down syndrome
• Increased risk for autosomal
dominant inherited disorders 72
 Special Concerns
• Parents’ ability to meet needs of
child
• Not doing same things as peers
• Social isolation may occur
• Concern that “biological clock”
continues to tick
• Fear of own mortality

73
 Teratogenic Substances
Teratogens – substances that adversely
affect the normal growth and
development of fetus
• Drugs – may be teratogenic hence
contraindicated unless prescribed by
Doctor
• Drinking – can cause respiratory
depression in the NB and fetal
withdrawal syndrome if excessive;
alcohol has empty calories 74
Fetal alcohol Syndrome

75
Low Birth Weight

76
Premature Babies

77
 PREPARATION FOR LABOR
AND DELIVERY
• Based on Gate Control Theory: pain
is controlled in the spinal cord and
there is a gate that can be closed to
ease pain felt.
• Information and breathing
techniques help minimize discomfort
of labor experience
• Discomfort can be lessened if
abdomen is relaxed and allows
uterus to rise freely against it during
78
Major Approaches To Prepared
Childbirth
Teaching about anatomy,
pregnancy, labor and delivery,
relaxation techniques, breathing
exercises, hygiene, diet and
comfort measures
• Grant-Dick Read Method: Fear
leads to tension and tension
leads to pain
• Lamaze Method:
Psychoprophylactic method ; 79
Lamaze Method

80
FIGURE 11–11 For many older couples, the decision to have a child may be very rewarding.

81