pregnancy

SIGNS OF PREGNANCY
PRESUMPTIVE
Subjective
Can be felt by the patient
PROBABLE
Objective
Can be seen, feel and
observe by the patient

FIRST TRIMESTER
PRESUMPTIVE

PROBABLE

AMENORRHEA
MORNING
SICKNESS
BREAST CHANGES
FATIGUE
URINARY
FREQUENCY
ENLARGING
UTERUS

CHADWICKS
GOODELLS
HEGARS
POSITIVE HCG
ELEVATION OF
BASAL BODY
TEMPERATURE

POSITIVE
ULTRASOUND
EVIDENCE

SECOND TRIMESTER
PRESUMPTIVE

PROBABLE

QUICKENING
INCREASES SKIN

ENLARGED

PIGMENTATION
CHLOASMA /
LINEA NIGRA

ABDOMEN
BRAXTON HICKS
BALLOTEMENT

POSITIVE
FETAL HEART TONE
FETAL MOVEMENTS
FETAL OUTLINE ON
X-RAY

PRENATAL VISIT
IMPROVEMENT OF MATERNAL
MORBIDITY AND MORTALITY STATISTICS
DURATION OF NORMAL PREGNANCY
266-280 DAYS
38-42 WEEKS (AVERAGE 40 WEEKS)
9 CALENDAR MONTHS
10 LLUNAR MONTTHS

PRETERM
Baby born before 38th
weeks of gestation
POSTTERM
Baby born after 42nd week
of gestation

PRETERM

POST TERM

A. DIAGNOSIS OF PREGNANCY
1. URINE EXAMINATION
HCG IN THE URINE IS THE
BASIS OF PREGNANCY TEST
PRESENT IN THE 40TH TO 100TH
DAY, REACHING THE PEAK
LEVEL ON THE 60TH DAY.
MOST CORRECT TIME: 6
WEEKS AFTER LMP

TYPES OF URINE EXAM

a. BIOLOGIC TEST

Presence of HCG will

produce hemorrhagic
changes in the
ovaries/testes of the animal
(male frog) when the urine
of a pregnant woman is
injected. Considered
obsolete.

b. IMMUNODIAGNOSTIC
TEST
ANTIGEN-ANTIBODY
REACTION
WIDELY USED
BECAUSE RESULT
ARE OBTAINED
FASTER

PREGNANCY TESTING

2. PROGESTERONE WITHDRAWAL
TEST
A contraceptive pill is taken by the
woman 3x a day for 3 days or a
test pill taken once.
If menstruation occurs within 10-15
days after, the woman is not
pregnant.
If pregnant, there will be no
menstruation because the corpus
luteum produces enough hormone
to neutralize the effect of with
drawn synthetic progesterone.

B. COMPONENTS OF PRENATAL
VISIT
1. HISTORY TAKING
A. PERSONAL DATA
Patients Name
Age
Address
Civil status unwed is risk
Family history any familial
disease that may affect

B. OBSTETRICAL DATA
Gravida number of pregnancies a
woman had
Para (parity) number of viable
deliveries, regardless of number
and outcome
TPAL score ( _ _ _ _ ) number of
fullterm babies; premature babies;
abortions; living children
i.e. 3104

 Immunization history
status of tetanus toxoid immunization
Tetanus toxoid (TT1) 1st visit
(TT2)
one month after the TT1
(TT3) next pregnancy/ 6 mos. after TT2
(TT4) 1 yr after TT3 or on 3rd pregnancy
(TT5) 1 yr after TT4 or on 4th pregnancy
fully immunized mother.

Past pregnancies
Method of delivery
Where at home? In the
hospital?
Risk involved
Prematurity,
toxemia

Present pregnancy
Chief concern nausea & vomiting
Danger signs:
Vaginal bleeding, no matter how slight
Swelling of the face and fingers
Severe continuous headache
Dimness or blurring of visions
Flashes of light or dots before the eyes

Pain in the abdomen

Persisting vomiting
Chills and fever
Sudden escape of fluids from the
vagina
Absence of fetal heart sounds after
they have been initially auscultated
on the 4th or 5th month

C. MEDICAL DATA
Any history of the following:
History of kidney, cardiac or
liver disease
Hypertension
Tuberculosis
Sexually-transmitted disease

2. ASSESSMENT
A. PHYSICAL ASSESSMENT
A review of the system is
indicated, including
inspection if the teeth
because they are common
foci of infection.

B. PELVIC EXAMINATION:
Cardinal Rule: Empty the bladder first
INTERNAL EXAM
(IE)
To determine
Hegars
Chadwicks
Goodells
signs.

BALLOTEMENT
Fetus will bounce when
lower uterine segment is
tapped sharply on the 5th
month of pregnancy.
A palpatory technique for
feeling a floating object in
the body (especially for
determining the position
of a fetus by feeling the
rebound of the fetus after
a quick digital tap on the
wall of the uterus).

PAPANICOLAUS
SMEAR (Pap smear)
Cytological
examination to
diagnose cervical
carcinoma

Classification of Findings:
Class 1 absence of atypical or abnormal
cells.
Class 2 atypical 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 changes:
Stage 1 CA confined to the cervix
Stage 2 CA extends beyond 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.

CERVICAL CANCER

PELVIC MEASUREMENTS
Preferably done after 6th lunar month
X-ray pelvimetry
Most effective method of diagnosing
cephalopelvic disproportion

LEOPOLDS MANEUVER
To determine presentation, position and
attitude, estimate fetal size and locate
fetal parts.
Palpatory steps:
Palpate with warm hands
Use palm and not fingertips
Position patient in supine with knees
flexed slightly Dorsal recumbent
position.
Use gentle but firm motion

FIRST MANEUVER
Facing head part of
pregnant, palpate for
the fetal part in the
fundus to determine
presentation ( a hard,
smooth, round,
ballotable mass at the
fundus means fetus
in breech
presentation.

SECOND
MANEUVER
Palpate sides of
the uterus to
determine the
location of the fetal
back and the small
parts.

THIRD
MANEUVER
Grasp the lower
portion of the
abdomen just
above the
symphysis pubis to
find the 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 the
fetal head

C. VITAL SIGNS
Temperature, pulse and
respiratory rate are important
during the initial prenatal visit.
Most important:
Weight
Blood pressure
Baseline data to determine
any significant increase

D. BLOOD STUDIES
Blood typing
Complete blood count,
hemoglobin & hematocrit
determine anemia
Serological test VDRL to
diagnose syphilis

E. URINE EXAMINATION
Heat and Acetic Acid
Used to determine albuminuria
Sign of toxemia
Benedicts Test
Used to determine glycosuria
Sign of possible gestational
diabetes
Before breakfast not >+1

 Determination of Pyuria
Indicates urinary tract
infection
Common cause of
premature dleivery

3. IMPORTANT ESTIMATES
A.ESTIMATES OF AGE OF
GESTATION
NAGELES RULE
Calculation of expected date of
confinement (EDC)

Count back 3
months from the
1st day of the last
menstrual period
(LMP) then add 7
days

i.e.
LMP
April 2,
2010
4 2 2010
-3 +7
+1
1 /9 / 2011
(EDC)

 MC DONALDS METHOD
Determines age of
gestation by
measuring from the
fundus to the
symphysis pubis (in
cm.) then divide by 4
= AOG in months

i.e.
Fundic ht
16cm.
4
4 months = AOG

McDonalds Methods
HT FUNDUS/4 ( AOG WEEKS)
1. LUNAR MOS. FUNDAL HT(CM)X 2/7
2. WEEKS OF PREGNANCY: Fundal ht.(cm)x 8/7
ex. Fundal ht 14cms
Lunar mos. 14cmsx2=28/7=4mos.
Weeks pregnant 14cmsx8=112/7=16wks AOG

Importance
A shorter measure can happen for one of the following
reasons:
Fetus descent into the pelvis, seen normally two to four
weeks before delivery
Error in estimated date of pregnancy based on first day
of last menstrual period
Fetus is healthy but physically small
Oligohydramnios
Fetus positioned sideways
Small for gestational age

A longer measure can be caused by:

Twins, or other types of multiple birth
Error in estimated date of conception
Fetus is healthy but physically large
Polyhydramnios
Large for gestational age
Hydatidiform Mole
Breech birth
As a pregnancy approaches its end, the fundal height will
become less accurate.
Most caregivers will record their patient's fundal height on
every prenatal visit. Measuring the fundal height can be an
indicator of proper fetal growth and amniotic fluid
development.
Illustration of fundal height at various points during pregnancy

 BARTHOLOMEWS RULE
Estimates AOG by the relative position of
the uterus in the abdominal cavity.
3rd lunar month = fundus is slightly
palpable above the symphysis pubis
5th lunar month = fundus is at the level of
umbilicus.
9th lunar month = fundus is below the
xiphoid process

B. HAASES RULE
Determines the length of the
fetus in centimeters.
During the first half of pregnancy;
square the number of month
2 months x 2 = 4 cms.
During the second half of
pregnancy
Multiply the month by 5
6 months x 5 = 30 cms.

C. JOHNSONS RULE
Estimates the weight of the
fetus in grams
fundic ht. in cm. - n x k
k is constant, always 155
n is 12; if fetus is engaged
11; if fetus is not yet
engaged

JONHSONS RULE
EXAMPLE:
Fundic ht. 28cm, and fetus is not engaged
28-11 x 155 = 17 x 155
= 2635 gram

4. HEALTH TEACHINGS
A. NUTRITION
Women who need special attention:
Pregnant teenagers
Extreme in weight scale low
prepregnant weight and obese
Low income women
Successive pregnancies
vegetarians

Nutritional Assessment
based on taking a diet history first
Food preferences/eating habits
Cultural/religious influences
Educational/occupational level

Computation of caloric equivalent

Carbohydrates x 4
Proteins x 4
Fats x 9

RECOMMENDED DAILY ALLOWANCE

NUTRIENTS
CALORIES kcal
PROTEINS gm
VITAMIN A IU
VITAMIN D IU
VITAMIN E IU
ASCORBIC
(VIT C) mg
FOLIC ACID mg

NON PREGNANT

PRE PREGNANT

2000
46
4000
400
12
45

+300-400
+30
+1000
+0
+3
+15

400

+400

NUTRIENTS

NON PREGNANT

PRE PREGNANT

NIACIN mg
RIBOFLAVIN mg
THIAMINE mg
VITAMIN B12 ug
VITAMIN B6 mg
CALCIUM mg
PHOSPHORUS
IODINEug
IRRON mg
MAGNESIUM mg

13
1.2
1.0
3.0
2.0
800
800
100
18
300

+2
+0.3
+0.3
+1.0
+0.5
+400
+400
+25
+18
+150

FOOD SOURCES:
PROTEIN RICH
FOODS
Meat, fish, eggs,
milk, poultry,
cheese, beans,
mongo

VITAMIN A
Eggs, carrots,
squash, all green
leafy vegetables

 VITAMIN D

VITAMIN E

Fish, liver, eggs,

milk,

Green leafy
vegetables, fish

Excess of Vit. D
during pregnancy
can lead to fetal
cardiac problems

VITAMIN C
Tomatoes, guava,
papaya

 VITAMIN B
Food rich in
proteins
CALIUM /
PHOSPHORUS
Milk, cheese

IRON
For better
absorption, take
Vit. C.
Sources: liver and
other internal
organs, camote
tops, kangkong,
egg yolk, ampalaya

MALNUTRITION
During pregnancy, it can result in:

Prematurity
Preeclampsia
Abortion
Low birth weight babies
Congenital defects
Stillbirths

B. SMOKING
Causes:
Vasoconstriction
Leading to low birth
weight babies

C. DRINKING
In moderate no cause
In excess can cause:
Transient respiratory
depression in newborn
Fetal withdrawal syndrome

C. DRUGS
dangerous to fetus especially the
first trimester.

Teratogenic
Can cause congenital
defects

CONTRAINDICATED unless prescribed by

the doctor:

THALIDOMIDE
Causes amelia
or phocomelia

STEROIDS
Causes cleft
palate and even
abortion

IODIDES
Contained in
many over-thecounter cough
supressants
Cause
enlargement of
the fetal thyroid
gland and
dyspnea at birth

VITAMIN K
Causes
hemolysis and
hyperbilirubinemi
a

ASPIRIN /
PHENOBARBIT
ALS
Causes bleeding
disorders

STREPTOMYCIN/
QUININE
Causes damage
to the 8th crainial
nerve (nerve
deafness)

TETRACYCLINE
Causing staining
of the tooth
enamel and
inhibit growth of
long bones

E. SEXUAL ACTIVITY
1ST trimester decrease in women
due to changes in her body
2nd trimester improvement of sexual
desire due to adaptation to the
growing fetus
3rd trimester decrease because
woman is afraid of hurting the fetus

CONTRAINDICATED:

Should be no
sex 6 months
Spotting or bleeding
prior to delivery

Incompetent
to prevent post
cervical
os
partum infection
Ruptured BOW
Deeply-engaged
presenting part

F. EMPLOYMENT
Not contraindicated, as long as the
job does not entail handling toxic
substances, or lifting heavy objects,
or excessive physical or emotional
strain.
Advise walk every hour during long
periods of sitting or standing to
promote circulation

G. TRAVELLING
No restriction as long as there is
no frequent contractions, and
bleeding.
Long rides, 15-20 minutes rest
period, 2-3 hours to walk, or
empty bladder is advisable

H. EXERCISE

To strengthen the muscle used in labor

and delivery
Should be done in moderation
Should be individualized according to: age,
physical condition, customary amount of
exercise and stage of pregnancy

RECOMMENDED EXERCISES:

Squatting and tailor sitting

Half stretch and strengthen perineal
muscles; increase circulation in the
perineum; make pelvic joint more pliable.
When standing from squatting, raise
buttocks first before head to prevent
postural hypertension

Squatting

Tailor sitting

Pelvic rock
Maintains good
posture, relieves
abdominal
pressure and low
backaches;
strengthen
abdominal
muscles
following delivery

Modified knee-chest position

Relieves pelvic
pressure and
cramps in the
thigh or buttocks;
relieves
discomfort from
hemorrhoids

Shoulder-circling exercise

Strengthens
muscle of the
chest

Kegels exercise

Relieves
congestion and
discomfort in
pelvic region;
tones up pelvic
floor muscles

I. PREPARED CHILDBIRTH/CHILDBIRTH
EDUCATION

Operates in the Gate Control

Theory of pain.
Pain is controlled in the spinal
cord
To ease the pain, the gate
should be closed.

Discomfort during labor can be

minimized:
Breathing exercise
Womens abdomen should
be relaxed and allow uterus
to rise freely against the
abdominal wall with
contraction

Major approaches are being taught to

prepare childbirth pregnant couple:

Anatomy
Pregnancy
Labor and delivery
Relaxation techniques
Breathing exercises
Hygiene diet
Comfort measures

COMFORT MEASURES:
Grantly-Dick Read
Method
Fear leads to
tension and
tension leads to
pain
Use abdominal
breathing during
contraction

 Psychoprophylacti
c method; based
on the stimulus
response
conditioning.
To be effective, full
concentration on
breathing exercise
during labor should
be observed

Lamaze Method

LEBOYER METHOD OF DELIVERY

BIRTH OF THE BABY

IS A SHOCKING
EXPERIENCE TO THE
MOTHER

J. TETANUZ IMMUNIZATION
0.5 ml IM deltoid region of the upper
arm
2 doses at least 4 weeks apart
2nd dose at least 3 weeks before
delivery
Booster dose: given during
succeeding pregnancies
regardless
of the interval
3 Booster doses: confer lifelong
immunity

CLINIC APPOINTMENTS:
1st seven lunar months =
every month
8th to 9th lunar month = every
other week / twice a
month
10th lunar month = every
week until labor pains
set in

Health education
Family planning must be incorporate in the HE
NFP
SDM- Standard days method
Women with 26- 32 days cycle of menstruation only
1-7 days safe period
8- 19th days unsafe period
20th menstrual days safe period
Sympto thermal method- combination of cervical mucus
methods and basal body temperature method (BBT)
BBT- use of thermometer through getting body temp. every
morning rise in temp. means past the ovulation.

NFP
Lactation amenorrhea method (LAM)
< six mos past partum
< mother should be full time BF
< mother must be amenorrhea

Artificial method
Hormonal
Pills
a. progestine only
progesterone
DMPA- injectable
Condom
IUD

b. estrogen &