MRS. MIRASOL R.

REYES, RN, LPT,

MPA
1.1. Assessment:
 Ideally, assessment for pregnancy
begins before the pregnancy.
During preconception assessment,
it is important to evaluate the
woman's health status, nutritional
intake and lifestyle; identify any
potential health problems; and
identify the woman's understanding
and expectations of conception,
pregnancy and parenthood.
 Anxiety r/t unexpected pregnancy
 Altered breathing pattern r/t
respiratory system changes of
pregnancy
 Disturbed body image r/t weight
gain with pregnancy
 Deficient knowledge r/t normal
changes of pregnancy
 Imbalanced nutrition, less than body
requirements r/t morning sickness
 Nursing care in connection with the
physiologic and psychological
changes in pregnancy.
The changes in pregnancy may
appear insignificant if taken one by
one.
In nine months, a woman gains 25
to 30 lbs. and her figure changes so
drastically that none of her pre-
pregnancy clothes any longer fit.
There is appearance of stretch
marks on her abdomen.
 At beginning of her pregnancy, she
feels constantly nauseated.
Endocrine changes can make her
feel moody and quickly to cry.
 Provide knowledge about health
before and during pregnancy.
 Prenatal check up schedule.
 Provide suggestion on exercise,
nutrition to prepare and to follow
during pregnancy.
Evaluation should determine
whether the woman has really
“heard” your teaching despite
the stress of her pregnancy,
because people who are in
stress do not comprehend well.
So it is not unusual for a woman
to pocket away information.
 Evaluation should reveal the quality of
learning with criteria including:
client states she is able to continue her
usual lifestyle throughout pregnancy.
Family members describe ways they
have adjusted their lifestyles to
accommodate the mother's fatigue.
Couple states they accept the
physiologic changes of pregnancy as
normal.
1.1 (B) History-taking
Personal data – patient’s
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?)
1.1 (B) Obstetrical data
Gravida = number of pregnancies
a woman has had
Para = number of viable
deliveries, regardless of number
and outcome
TPAL score = number of full-term
babies, abortions; living children
 Past pregnancies
 Method of delivery – normal,
spontaneous vaginal, caesarean
section; indication for past CS.
 Where – at home? In the hospital?
 Risks involved – Prematurity?
Toxemia?
 Present pregnancy
 Chief concern – is there nausea and
vomiting?
1.1 (C) Psychological Changes of
Pregnancy
 Pregnancy is such a huge change in a woman's
life that it brings about more psychological
changes than any other life event (besides
puberty).
 A woman’s attitudes towards pregnancy depend a
great deal on psychological aspects such as the
environment in which she was raised, the
messages about pregnancy her family
communicate to her as a child, the society and
culture in which she lives as an adult and whether
the pregnancy has come at a good time in her life.
1. Social Influences
• Before, pregnancy conveyed the idea of 9-
month-long illness, but today our society has
come to view pregnancy as a time of health.
 Nurses have played the important role in
helping to convince other health providers that
certain long-standing protocols that separated
women from their families are no longer
appropriate.
 As a result, instead of coming alone for prenatal
care, women now bring their families and urge
to participate actively in the experience.
2. Cultural Influences
• A woman's cultural background
may strongly influence how
active a role she wants to take
in her pregnancy, because
certain beliefs and taboos may
place restrictions on her
behavior and activities.
• Ask at prenatal visit if there is
anything they believe should or should
not be done to make pregnancy
successful and keep the baby healthy.
 Example 1: beliefs that lifting your
arms over your head during pregnancy
will cause the cord to twist.
 Example 2: watching a lunar eclipse
will cause birth deformities.
3. Family Influences
 The family in which a woman was raised
can be influential to her beliefs about
pregnancy.
If she & her siblings were loved & seen as the
pleasant outcome of a happy marriage, she is
more likely to have a positive attitude toward
her pregnancy. But if her mother constantly
reminded her “if you hadn't come along, I could
have gone to college” or “I could have had a
career,” the daughter may view pregnancy as a
disaster.
4. Individual Influences
•A woman's ability to cope with or
adapt to stress plays a major role
in how she will resolve conflict and
adapt to the new life contingencies
that are coming. (ready to
mothering, love her child as well as her
husband)
•Extent to which a woman feels secure
in her relationship with the people
around her , especially the father of
her child, is also important to her
acceptance of pregnancy. Father
gives emotional support.
 Theseare real feelings that must be taken
seriously in counseling a pregnant women:
She thinks of brides as young but a mother as
old, may believe pregnancy will rob her of her
youth.
She thinks children are sticky–fingered and
time-consuming and views pregnancy as taking
away her freedom.
She heard pregnancy will permanently stretch
her abdomen and breast and lose her looks,
rob her financially, and ruin her chances of job
promotion.
I. First Trimester
 Task: Accepting the Pregnancy
Woman and partner spend time recovering
from shock of learning the FORMER is
pregnant & concentrate on what it feels like
to be pregnant. A common reaction is
ambivalence.
Most cultures structure their celebrations
around important life events.
This is a stage of denial until result of
pregnancy kit. A partner should try to give
the woman emotional support while she is
learning to accept the reality of pregnancy.
Psychosocial change Description

II. Second Trimester

Task: Accepting the Baby
Woman and partner move through emotions such as
narcissism and introversion as they concentrate on what
it will feel like to be a parent. Role playing and increased
dreaming are common.
Woman accepts that she is having a baby.
Best way: measure how well she follows prenatal
instructions.
Some men may have difficulty enjoying the pregnancy
if they have been misinformed about sexuality,
pregnancy and women's health. (e.g. breast-feeding will
make his wife's breasts no longer attractive and believe
that childbirth will stretch his wife's vagina that sexual
relationship are no longer enjoyable and so will advocate
cesarean birth)
Psychosocial change Description

III. Third Trimester

 Task : Preparing for Birth
woman and partner grow impatient with for
the baby and pregnancy as they ready
themselves for birth end of pregnancy
Allay anxiety, difficulties in accepting
pregnancy.
Couples usually begin “ nest-building “
activities, such as planning of infant sleeping
arrangements, buying clothes, choosing
names for the infant, and ensuring safe
passage”. By learning about birth. (Couples at
this point are interested in attending prenatal
classes of preparation for childbirth classes.
1. Reworking Developmental
Tasks
 One task of pregnancy is working through
previous life experiences.
 Fear of being separated from family or dying
is a common childhood fear that can be
revived during pregnancy.
 A clue that might signal a woman's distress
over this could be: “Am I ever going to make
it through this?” This expression might simply
mean that she is tired of her backaches, but
it also might be a plea for reassurance that
she will survive this event in her life.
2.

2. Role-playing and Fantasizing

 Role-playing or fantasizing about what it
will be like to be a parent.
 Although role-playing may be difficult for
a pregnant teen who has not yet made
the transition to adulthood, it is
important in helping her become a
mother.
 The father-to-be also has role-playing to
do during pregnancy. He has to imagine
himself as the father of a boy or a girl.
 Learning that the pregnancy is multiple
pregnancy
 Learning that the fetus has a developmental
abnormality.
 Pregnancy less than 1 year after a previous
one
 Relocation during pregnancy (involves a
need to find new support people)
 Moving away from family or back to the
family for economic reasons
 Role reversal (a previously supporting
person who becomes dependent or vice
versa)
 Job Loss
 Marital infidelity
 Illness in self, husband or a relative
 Loss of significant others
 Complications of pregnancy
 Having children or relatives who
have children born with health
disorders
 A series of devaluing experiences
(e.g. failure in school or work)
 History of previous miscarriages,
fertility problems, traumatic births
 Previous fetal or neonatal loss
 Emotional response to pregnancy
can vary greatly, but common
reaction includes ambivalence,
grief, narcissism, introversion or
extroversion, body image and
boundary concerns, couvade
syndrome, stress mood swings,
and changes in sexual desire.
1. Ambivalence
It refers to the interwoven
feelings of wanting and not
wanting that can exist at high
levels.
She may want to be pregnant
but yet she may not enjoying
it. This leads to some degree of
ambivalence.
 2.Grief
Before a woman can take a
mothering role she has to give up
or alter her present roles. (e.g. She
will never be a daughter in exactly
the same way again.) She must
incorporate her new role as a
mother into her other roles as a
daughter, wife or friend.
Her partner must incorporate a
new role as a father into other
roles of a son, husband or friend.
 3. Narcissism
Self-centeredness is generally an early
reaction to pregnancy
A woman who previously was barely
conscious of her body, who dressed in
the morning with little thought about
what to wear, who was unconcerned
with her posture and weight, suddenly
begins to concentrate on these aspects
of her life. She dresses so her
pregnancy will or will not show, and
dressing becomes a time-consuming.
 4.
Introversion versus
Extroversion
Introversion, or turning inward to
concentrate on oneself and one's body,
is a common finding during pregnancy.
Some women, however, react in an
entirely opposite fashion and become
more extroverted. They become
active, appear healthier than ever
before, and more outgoing.
 5. Body Image and Boundary
▪ body image (the way your body appears to
yourself)
▪ body boundary (a zone of separation you perceive
between yourself and objects other people)
 Woman begins to envision herself as a mother in
addition to being a daughter or wife and begins to
see herself becoming “bigger” in many different
ways.
 boundary perception is so startling that pregnant
women may walk far away from an object (such as
a table) in order to avoid bumping against it.
 6. Stress
Because pregnancy brings with it such
a major role change, it can be a
time of extreme stress for a woman.
This stress of pregnancy, like any
stress, can make it difficult for the
woman to make decisions, be as aware
of her surroundings as usual, or
maintain time management with her
usual degree of skill. (e.g. Backaches,
acute loneliness, depression)
 7. Couvade Syndrome
 Many men physical symptoms such as nausea,
vomiting and backache to the same degree or
even intensely than their partners do during a
pregnancy. These symptoms apparently result
from stress , anxiety and empathy for the
pregnant woman.
 As the woman's abdomen begins to grow, the
father may perceive himself as growing larger,
too as if he were the one who was pregnant or
has changing boundaries the same as his partner.
 For the most part , these are healthy happenings
and required psychological attention only if the
man becomes emotionally stressed or delusional.
 8. Emotional Lability
Mood changes occur frequently in a
pregnant woman, partly as a manifestation
of narcissism (her feelings are easily hurt by
remarks that would have been laughed off
before) as partly because of hormonal
changes, particularly the sustained increase
in estrogen and progesterone.
Mood swings may be so common that they
make a woman's reaction to her family and
to health care routines unpredictable.
 9. Changes in Sexual Desire
Most women report that their sexual
desire changes, at least to some degree,
during pregnancy
Others might feel a loss of desire due to
the estrogen increase, or they might
unconsciously view sexual relations as a
threat to the fetus they must protect.
Some may worry that having sex could
bring on early labor.
1. BREAST TENDERNESS
 often the first symptoms noticed in
early pregnancy
 MANAGEMENT:
a. Encourage the woman to wear a
bra with a wide shoulder strap for
support
b. Dress warmly – to avoid cold
drafts if cold increases symptoms
2. PALMAR ERYTHEMA/PRURITUS
 may be caused by increased estrogen
levels and will just disappear as soon as the
baby will adjust to the increase of estrogen.
 constant redness or itching of the palms
may make the woman think that she has
allergy
 MANAGEMENT:
a. Explain that this is normal
b. Apply calamine lotion , changes soap and
lotions
3. CONSTIPATION FLATULENCE
 MANAGEMENT:
a. Regular elimination pattern
b. Increase intake of high
fiber/roughage food (increase
bulk of the stool stimulates
peristalsis)
c. Increase water intake = at least
8 oz. glasses daily
d. Avoid gas forming foods such
as: cabbage, beans, root crops
e. Avoid laxatives such as:
 Mineral oil = it interferes the
absorption of fat-soluble
vitamins (ADEK) which is
essential for good fetal
growth and maternal health
 Enemas = it may initiate
labor
4. NAUSEA ,
VOMITING
is due to:
a. increase HCG
b. increased acidity
c. emotional factors
 MANAGEMENT:
a. Eat dry toast or crackers 30
minutes before arising in the
morning or dry high
carbohydrate
b. Eat small meals several times/
small frequent feedings
c. Avoid spicy, greasy, fried foods
d. Avoid foods with strong odors
5. HYPEREMESIS
GRAVIDARUM:
Management: D10NSS
3L/24 HOURS
6. HEARTBURN/ PYROSIS
Management:
a. small meals
b. sit upright
c. avoid coffee, smoking
7. FATIGUE
 is extremely common due to
increased metabolic requirements
 Management:
a. increasing amount of rest and
sleep
b. A good resting position = modified
Sim’s position with top leg forward
8. MUSCLE CRAMPS
 it may be due to imbalanced of calcium
phosphorous levels and possibly
interference with circulation
 MANAGEMENT:
a. Lying on her back momentarily and
extending the involved leg while keeping
her knee straight and pressing the knee
and dorsiflexing the foot until the pain is
gone
b. Elevating the lower extremities
frequently during the day to improve
circulation
c. Avoid full leg extension such as
stretching with the toes pointed
9. HYPOTENSION (postural – sitting or
lying)
 supine hypotension occurs when a
woman lies on her back and the uterus
presses on the vena cava thus impairing
blood return to the heart.
 due to pooling of blood in the pelvic area
or lower extremities
 the woman experiences and irregular
heart rate and feeling of apprehension
 MANAGEMENT:
a. Turn to her side/ assume side lying
position (to removed pressure from the
vena cava and blood flow return)
b. Avoid rising suddenly from sitting or
lying position
c. Avoid standing for an extended time in
a warm or crowded area (she may faint)
d. If woman feel faint = assume
sitting with head lowered to relieved
fainting
10. VARICOSITIES
 due to the weight of the distended
uterus puts pressure on the veins
returning blood from the lower
extremities.
 This causes pooling of blood in the
vessels
 the veins become engorged,
inflamed and painful
VULVA:
woman with family history
of varicose veins with large
fetus and multiple
pregnancy
 MANAGEMENT:
a. Resting in Sim’s position
b. Lie with legs raised/ elevated for 15 –
20 minutes twice a day
c. Avoid crossing legs at the knees while
sitting
d. Avoid constrictive clothing / knee-high
hose stocking/ garters
e. Use elastic support stocking
f. Exercise encourage
g. Encourage intake of Vitamin C
11. HEMORRHOIDS
 due to the pressure on the veins from
the bulk of the growing fetus
 MANAGEMENT:
a. PREVENTIVE Measures in early
pregnancy is effective
b. Daily/routine bowel evacuation
c. Resting in modified SIM’s position daily
d. Assume knee chest position 10-15
minutes at the end of the day
NOTE: To prevent
lightheadedness with the
position instruct woman to
remain in this position for only
a few minutes at first , and
then gradually increase the
time until she can maintain the
position for 15minutes.
 WOMAN WITH HEMORRHOIDS:
 Stool softeners
 Apply cod compress (may help
relieve pain)
 Replacing hemorrhoids with
gentle finger pressure can be
helpful (prolapsed)
 Hot sitz bath
12. HEART PALPATATIONS
(bounding palpitation on the heart)
 on sudden movement such as
turning over in bed
 probably due to the circulatory
adjustments necessary to
accommodate her increased
 blood supply during pregnancy
 MANAGEMENT:
a. Gradual , slow movements will
help
b. Explain woman that
palpitations is normal and to be
expected in occasion and only
temporary (note if with pain or
continues need to refer)
13. FREQUENT URINATION
 occurs in early pregnancy due to the
pressure on the growing uterus on the
anterior bladder
 the sensation will last for about 3 months
 disappears at midpregnancy when the
uterus rises above the bladder
 returns in the late pregnancy as the fetal
head presses against the bladder
 no intervention / encourage to do Kegel’s
exercise
14. LEUKORRHEA
 Increased whitish, viscous vaginal
discharge/ or increase in the amount
of normal vaginal secretions
 occurs in response to the high
estrogen levels and the increased
blood supply to the vaginal
epithelium and cervix in pregnancy.
 MANAGEMENT:
a. Daily bath / shower – to wash
away accumulated secretions and
prevent vulvar excoriations
b. Caution woman not to douche
(contraindicated throughout
pregnancy)
c. Perineal pads should change
frequently
d. Wearing cotton undergarments and
sleeping at night without underwear
(prevent moisture)
e. Avoiding tight underpants and
pantyhose
f. Advise woman to refer to
physician/nurse/midwife = if there is a
change in color, odor, character of the
discharge which might suggest
infection.
15. BACKACHE
Lower backaches may be a
symptom that occurs early
in pregnancy; however, it
is common to experience a
dull backache throughout
an entire pregnancy.
 MANAGEMENT: (suggestions)
a. Practice good posture. Tuck your
buttocks under and stand straight
and tall.
b. Always be careful when lifting
objects. Bend your knees instead of
bending over at the waist. Lift with
your legs instead of your back.
c. Wear supportive shoes with low
heels.
d. Avoid standing for long periods of
time
e. Assume tailor sitting position
f. Shoulder circling /pelvic rocking
exercise
g. Squat rather than bend when
lifting object
h. Encourage to walk with her pelvis
tilted forward
i. Provide a firmer mattress
j. Applying local heat
k. Caution not to use medicines
without prescription to relieve
pain
l. Refer if severe – (it may be a
sign of bladder or kidney
infection)
16. HEADACHE
apparently it may due to the
expanding blood volume,
which puts pressure on
cerebral arteries
MANAGEMENT: Try to reduce
any causative situations such
as: eye strain and tension
17. DYSPNEA
As the expanding fetus puts
pressure on the diaphragm,
causing some lung expansion,
shortness of breath may occur
notice this: during night time
when her body is flat and on
exertion
 MANAGEMENT:
a. Encourage to sit upright – allowing
the weight of the uterus to fall away
from the diaphragm helps relieve the
problem
b. Use two or more pillows to sleep on
at night
c. Elevate head of the bed
d. Caution to limit activities during the
day before she becomes short of breath
18. ANKLE EDEMA
 swelling of the ankles and feet – especially
at the end of the day
 probably caused by reduced blood
circulation to the lower extremities due to
uterine pressure and general fluid retention
 woman will notice when they removed their
shoes and cannot be put it on again
 Normal as long as woman is (-) proteinuria
 MANAGEMENT:
a. In resting left side-lying
position
b. Sitting half and an hour in the
afternoon and evening with
legs elevated
c. Avoid wearing constricting
clothing such as: panty girdles
and knee high stocking
 The duration of 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 born
before the 38th week of gestation is
called preterm and a baby born
after the 42nd week of gestation is
said to be post term.
• 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
LMP.
-trace amounts of HCG appear in the
serum as

When collecting urine for

pregnancy testing:
 early as 24 to 48 hours after
implantation. They reach a
measurable level (about 50
mlU/mL) 7 to 9 days after
conception. Levels peak at about
100mlU/mL between the 60th and
80th day of gestation.
 Urine test still form the basis of home
pregnancy test. Blood serum test gives
earlier results.
 A woman who had urine test but has
negative results is advised to repeat one
week later, if she is still experiencing
amenorrhea. If she is not pregnant, she
might have condition such as an ovarian
tumor causing the amenorrhea and
needs appropriate diagnosis for this
condition.
• No water taken after 8 PM the night
before urine collection in order to
have concentrate urine.
• First morning urine, midstream,
should be collected in a clean, dry
jar.
• If more than 1 hour would lapse
before being tested, refrigerate
specimen because HCG is unstable
under room temperature.
• Biological tests – presence of HCG will
produce hemorrhagic changes in the
ovaries/testes of the animal when the
urine of a pregnant woman is injected.
 Immunodiagnostic tests – antigen-
antibody reaction. Widely used at
present because results are obtained
faster and do not involved the sacrifice
of an animal. (E.g. Gravindex; Pregnex;
Prognosticon)
Signs of Pregnancy
STAGE PRESUMPTIVE PROBABLE POSITIVE
First Trimester Amenorrhea Serum lab. test Ultrasound
Morning Sickness Chadwick’s evidence: 5-
6wk
Breast changes Goodell’s
Fatigue Hegar’s
Urinary frequency Positive HCG
Enlarging uterus Elevation of
basal body temp.

Second Quickening Enlarged Fetal heart

Trimester Increased Skin abdomen tones audible 10-
Pigmentation 12wk
- Braxton Hicks Fetal movements
- Chloasma Ballotement felt by
- Linea nigra
examiner
- Striae gravidarum Fetal
outline (X– ray) - Melasma fetal
outline felt by
examiner
Sonographic evidence
of gestational
sac
1. Assessment
 a. Physical examination – a review of
systems is indicated, including inspection of
the teeth because they are common foci of
infection.
 b. Pelvic examination – (Cardinal rule:
Empty the bladder first )
• Internal Exam – to determine Hegar’s,
Chadwick, and Goodell’s
• Ballotement – fetus will bounce when lower
uterine segment is tapped sharply (on 5th
month)
• Papanicolau smear (Pap smear ) – cytological
examination to diagnose cervical carcinoma.
Classification of Findings:
 Class 1 = absence of atypical or
abnormal cells (normal )
 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 one third of the vagina.
 Stage 3 = metastasis to the pelvic wall
 Stage 4 = metastasis beyond the
pelvic wall into the bladder and rectum
• Pelvic measurements are preferably
done after 6th lunar month.
• X-ray pelvimetry (several flat plate
X-ray pictures of the pelvis are taken
from different angles), however, is
the most effective method of
diagnosing cephalopelvic
disproportion. But since X-rays are
teratogenic, the procedure can be
done only 2 weeks before EDC.
• Leopold’s Maneuver – to determine
presentation, position, and attitude;
estimate fetal size and 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.
• Use gentle but firm motion.
 c.Vital signs – temperature and
pulse and respiratory rates are
important especially during the
initial prenatal visit. But certainly
more important are the weight
and blood pressure as baseline
data to determine any significant
increases.
 d. Blood studies
• Blood typing
• Complete blood count
• Hematocrit (to determine
anemia)
• Serological tests (VDRL and
Kahn and Wasserman) to
diagnose for syphilis
e. Urine Examinations
•Heat and acetic acid test to determine
albuminuria. Any sign of albumin in the
urine should be reported immediately
because it is a serious sign of toxemia.
•Benedict’s test for glycosuria, a sign of
possible gestational diabetes. Specimen
should be taken before breakfast to
avoid false positive results. Should not
be more than +1 sugar.
•Determination of pyuria. Urinary tract
infection has been found to be a
common cause of premature delivery.
2. Important Estimates
 Estimates of age of gestation (AOG )
• Naegele’s Rule – calculation of EDC.
Count back 3 months from the first day
of the LMP, then add 7 days. Substitute
number for month for easy computation.
• McDonald’s Method – determines AOG
by measuring from the fundus to the
symphysis pubis (cm.) then divide by 4
= AOG in months.
 Bartholomew’s Rule – estimates
AOG by relative position of the uterus
in the abdominal cavity.
 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.
 Haase’s Rule – determines the
length of the fetus in cm.
 During the first half of pregnancy,
square the number of the month
(e.g. first lunar month 1x1 = 1 cm)
 During the second half of
pregnancy, multiply the month by 5
(e.g. 6th lunar month: 6x5 = 30 cm.)
• Johnson’s Rule – estimates the
weight of the fetus in grams.
 Formula: fundic height in cm. = n x k
 “ k “ is constant, it is always 155
 “ n “ is = 12 ( if fetus is engaged )
 = 11 ( if fetus is not yet engaged )
3. Danger Signals
 Vaginal bleeding, no matter how slight
 Swelling of face or fingers
 Severe continuous headache
 Dimness or blurring of vision
 Flashes of light or dots before the
eyes
 Pain in the abdomen
Persistent vomiting
 Chillsand 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
 Medical data – Is there a history of
kidney, cardiac or liver diseases;
hypertension; tuberculosis; sexually
transmitted diseases.
4. Weight
 a. 1st trimester: weight gain of 1.5–3 lbs.
 b. 2nd and 3rd trimesters: weight gain of
10–11 lbs. per trimester is recommended.
 c. Total allowable weight gain during the
entire period of pregnancy: 20-25 lbs. or
10-12 kgs.
 d. Pattern of weight gain is more
important than the amount of weight
gained.
 e.Distribution of weight gain during
pregnancy:
 Fetus = 7 lbs.
 Placenta = 1 lb.
 Amniotic fluid = 1.5 lbs.
 Increased weight of uterus = 2 lbs.
 Increased blood volume = 11 lb.
 Increased weight of the breasts = 1.5 to 3
lbs.
 Weight of the additional fluid = 2 lbs.
 Fat & fluid accumulation characteristics of
pregnancy = 4-6 lbs.
 Beginning the end of first trimester,
there is gradual increase of about 30-
50% in 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:

 Easyfatigability and shortness of

breath
increased workload of the heart

 Slighthypertrophy of the heart,

causing it to be displaced to the left
resulting in torsion on the great vessels
(the aorta and pulmonary artery)
Systolic murmurs are common
due to lowered blood viscosity.

Nosebleeds may occur because

of marked congestion of the
nasopharynx as pregnancy
progresses.
Palpitations may occur due to:
 Sympathetic nervous system
stimulation during the first
half of pregnancy.
 Increased pressure of uterus
against the diaphragm during
the second half of pregnancy
Edema of the lower extremities - Due
to poor circulation resulting from
pressure of the gravid uterus on the
blood vessels of the lower
extremities
 Management:
a. Raise legs above hip level.

(Important: Edema of the lower

extremities is NOT a sign of toxemia.
Varicosities of the lower
extremities
Management:
▪ Avoid use of constricting garters.
(e.g. knee-high socks)
▪ Use or wear hose or elastic
stockings to promote venous
flow, thus preventing stasis in the
lower extremities
▪ 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 the adequacy of
circulation.
▪ Principle behind bandaging: Blood
flow through tissues is decreased
by applying excessive pressure on
blood vessels.
Varicosities (Vulva and Rectum)
 Due to poor circulation in the
blood vessels of the genitalia
 Pressure of the gravid uterus
 Management:
 Side-lying position with hips
elevated on pillows.
 Advise modified knee-chest
position
There is increased level of
circulating fibrinogen
• Pregnant women are normally
safeguarded against undue bleeding.
• However this also predisposes them
to formation of blood clots (thrombi).
• Important: “SHOULD NOT
MASSAGE” since blood clots can be
released and cause
thromboembolism.
A)There is shortness of breath
 Causes:
1. Increased oxygen consumption
and production of carbon dioxide
during the first trimester.
2. Increased uterine size causes the
diaphragm to be pushed or
displaced, thus crowding chest
cavity.
 Management:
1. Lateral expansion of the
chest to compensate for
shortness of breath
increases oxygen supply and
vital lung capacity.
B) Temperature
Slight increase of body
temperature due to
increased progesterone,
but the body adapts after
the 4th month.
C) Morning sickness
 Nausea and vomiting during
the first trimester due to
1. increased HCG
2. 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-spice diet.
D) Hyperemesis gravidarum
excessive nausea and vomiting which
persists beyond 3 month; will result in
dehydration, starvation and acidosis.
Management:
1. D10 NSS 3000 ml. in 24hrs. is the
priority of treatment.
2. Complete bed rest is also an
important aspect of
treatment.
E) Constipation and flatulence
 Due to the displacement of the
stomach and intestines, thus slowing
peristalsis and gastric emptying time
 Increased progesterone during
pregnancy.
 Management:
1. Increase fluids and roughage in the
diet.
2. Establish regular elimination time.
3. Increase exercise.
4. Avoid enemas.
5. Avoid harsh laxatives; stool softeners.
6. Mineral oil should not be taken
because it interferes with the
absorption of fat- soluble vitamins.
F. Hemorrhoids
 Due to pressure of
enlarged uterus.
 Management:
1. Cold compress
G) Heartburn
 During the last trimester
 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:
1. Pats of butter before meals.
2. Avoid fried, fatty foods.
3. Sips of milk at frequent intervals.
4. Small, frequent meals taken slowly.
5. Bend at the knees not at the waist.
6. Take antacids (e. g. Milk of
Magnesia) but never Sodium
bicarbonate (e.g. Alka Seltzer or
baking soda) because it promotes
fluid retention.
A) Urinary frequency, the only sign in
pregnancy seen during the first
trimester, disappears during the
second trimester and reappears
during the third trimester.
 Early in pregnancy is due to increased
blood supply in the kidneys and to the
uterus rising out of the pelvic cavity
 On the last trimester, is due to
pressure of enlarged uterus on the
bladder, especially with lightening.
B) Decreased renal threshold for
sugar
 Due to increased production of
glucocorticoids which causes lactose
and dextose to spill into the urine
 Effect of the increase in progesterone

(Implication: It would be difficult to

diagnose diabetes in pregnancy based on
the urine sample alone because all
pregnant women have sugar in the
urine).
A) Addition of the placenta as
an endocrine organ,
producing large amounts of
estrogen, progesterone,
HCG, and HPL
B) Moderate enlargement of the
thyroid gland
 due to hyperplasia of the glandular
tissues and increased vascularity
 due to increased basal metabolic
rate to as much as +25 % because
of the metabolic activity of the
products of conception.
C) Increased size of the parathyroids
- probably to satisfy the increased
need of the fetus for calcium.

D) Increased size and activity of the

adrenal cortex, thus increasing the
amount of circulating cortisol,
aldosterone and ADH, all of which
affect the carbohydrate and fat
metabolism
E) Gradual increase in insulin
production, but the body’s
sensitivity to insulin is
decreased during
pregnancy.
Immunologic competency during
pregnancy:
 Decreases to prevent the woman’s
body from rejecting the fetus as if
were a transplanted organ.
Immunoglobulin G. (IgG) production
decreases w/c make a woman prone
to infection.
A simultaneous increase in the WBC
count may help to counteract the
decrease in IgG response.
A) First trimester:
 The fetus is an unidentified
concept with great future
implications but without tangible
evidence of reality.
 Some degree of rejection, denial
and disbelief, even repression.
 (Implication: When giving health
teachings, be sure to emphasize
the bodily changes in pregnancy).
B) Second trimester:
Fetus is perceived as a
separate entity.
Woman fantasizes
appearance of the baby.
C) Third trimester:
 Has a personal identification with a real
baby about to be born and realistic
plans for future child care
responsibilities.
 Best time to talk about preparation of
layette and infant feeding method.
 Fear of death is prominent. (To allay
fear, let pregnant woman to listen to
the fetal heat tones).
a. Weight increases to about 1000 grams
at full term, due to increase in the
amount of fibrous and elastic tissues.
b. Change in shape from pear-like to
ovoid
c. Change in consistency of the lower
uterine segment causes extreme
softening, known as Hegar’s sign,
seen at about the 6th week.
a. Mucous plugs in the cervix, called
operculum, are produced to seal out
bacteria.
b. Cervix becomes more vascular and
edematous, and increase fluid between
cells causes cervix to soften in
consistency. Increased vascularity
causes it to darken from pale pink to
violet hue resembling the consistency of
an earlobe known as the Goodel’s sign.
a.Increased in vascularity causes
change in color from light pink to
deep purple or violet, known as
Chadwick’s sign.
 To prevent confusion as to
pregnancy signs, arrange the body
parts from “out to in” and the
different signs alphabetically. Thus:
 Vagina = Chadwick’s sign
 Cervix = Goodell’s sign
 Uterus = Hegar’s sign
b. Due to increased estrogen, activity of
the epithelial cells increases, thus
increasing amount of vaginal
discharges called leukorrhea.
 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.
c. Ph of vagina changes from the
normally acidic (because of the
presence of the Doderlein bacilli) to
alkaline (because of increased
estrogen). Alkaline vaginal
environment is supposed to protect
against bacterial infection, however,
there are two microorganisms which
love to thrive in an alkaline
environment:
 Trichomonas, a protozoa or flagellate.
 The condition is called Trichomonas
vaginalis or trichomonas vaginitis or
trichomoniasis.
 Symptoms are:
Frothy, cream-colored, irritatingly
itchy, foul-smelling discharge.
Vulvar edema and hyperemia due to
irritation from the discharges.
Treatment:
Flagyl for 10 days p.o. or vaginal
suppositories of Trichomonicidal
compounds (Note: Is carcinogenic
during the first trimester)
Treat male also with Flagyl
Important: Avoid alcoholic drinks
when taking Flagyl – can cause
Antabuse like reactions: vomiting,
flushed face and abdominal cramps.
Dark brown urine a minor side
effect – no need to discontinue the
drug.
Acidic vaginal douche –to
counteract alkaline preferred
environment of the protozoa (1
tbsp. white vinegar to 1 quart
water or 15 ml. of water, white
vinegar in 1000 ml. water)
Avoid intercourse to prevent
re-infection.
 Monilia, a fungus called Candida
albicans
• The condition is called moniliasis or
Candidiasis.
• Fungus also love to thrive 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.
• Symptoms:
▪ White, patchy, cheese-like particles that
adhere to vaginal walls
▪ Irritatingly itchy and foul-smelling vaginal
discharges
Treatment:
Mycostatin/Nystatin p.o. or
vaginal suppositories twice a day
for 15 days. Gentian violet swab
to vaginal panty shield to prevent
staining of clothes or underwear.
Correct diabetes
Avoid intercourse
Acidic vaginal douche
Moniliasis is seen as oral
thrush in the newborn when
transmitted during delivery
through the birth canal of
infected mother.
Noactivity whatsoever, since
ovulation does not take place
during pregnancy and
progesterone and estrogen
are being produced by the
placenta.
a. All changes are due to
increased estrogen.
b. Increased in size due to
hyperplasia of mammary
alveoli and fat deposits. Proper
breast support with well fitting
brassiere is necessary to
prevent sagging.
c. Feeling of fullness and tingling
sensation in the breasts.
d. Nipples more erect (For mothers
who intend to breastfeed, advise
nipple rolling, drying nipples with
rough towel to help toughen the
nipples and not to use soap or
alcohol so as to prevent drying
which could lead to sore nipples.)
e. Montgomerry glands become
bigger and more protuberant
f. Areolas become darker and
diameter increases.
g. Skin surrounding areolas
become dark.
h. By the fourth month, a thin,
watery, high-protein fluid, called
colostrums is formed. It is the
precursor of breast milk.
A) Nutrition – most important
aspect
 Women who need special
attention:
 Pregnant teenagers
 Extremes in weighing scale – low
prepregnant weight and 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.

Nutritional assessment is based on taking

a diet history first:
 Food preferences/eating habits
 Cultural/religious influences
 Educational/Occupational level
 Food sources:
 Protein rich foods – meat, fish, eggs,
milk, poultry, cheese, beans, monggo
 Vitamin A – eggs, carrots, squash, all
green leafy vegetables
 Vitamin D – fish , liver, eggs, milk
(excess vitamin D during pregnancy can
lead to fetal cardiac problems)
 Vitamin E – green leafy vegetables, fish
 Vitamin C – tomatoes, guava, papaya
 Vitamin B – foods rich in proteins
 Calcium/phosphorous – 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 3
months of life when all he
takes is milk (which is
deficient in iron).
Iron has a very low absorption
rate; only 10% of the iron intake
can be absorbed by the body.
Thus, for optimum absorption,
give Vitamin C.
Iron should be given after meals
because it is irritating to the
gastric mucosa.
Sources of Iron:
 liver
 internal organs
 camote tops
 kangkong
 ampalaya
 egg yolk
Malnutrition during pregnancy can
result in:
▪ Prematurity
▪ Pre-eclampsia
▪ Abortion
▪ Low birth weight babies
▪ Congenital defects
▪ Stillbirths
B) Smoking
 causes vasoconstriction,
leading to low birth weight
babies; therefore, it is
contraindicated during
pregnancy.
C) Drinking
 in moderation is not
contraindicated but when in
excess can cause transient
respiratory depression in the
newborn and fetal withdrawal
syndrome.
 Besides, alcohol supplies only
empty calories
Fetal Alcohol Syndrome
D) 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.
 Steroids – can cause cleft palate
and even abortion
 Iodides – (contained in many over-
the – counter cough
suppressants) cause enlargement
of the fetal thyroid gland leading
to tracheal decompression and
dyspnea at birth
Thalidomide – causes amelia
or phosomelia
Vitamin K – causes hemolysis
and hyperbilirubinemia
Aspirin/Phenobarbital –
causes bleeding disorders
 Sreptomycin/quinine – causes
damage to the 8th cranial
nerve (nerve deafness )
 Tetracycline – causes staining of
tooth enamel and inhibits
growth of long bones (not
given also to children below 8
years for the same reasons)
Substance Abuse and the
Newborn
E) Sexual activity
 Sexual desires continue throughout
pregnancy, but levels change:
 First trimester: There is a
decrease in sexual desire because
the woman is more preoccupied
with the changes in her body.
 Second trimester: There is an
improvement in sexual desires
because the woman has
adapted to the growing fetus.
 Third trimester: There is
another decrease in sexual
desires because the woman is
afraid of hurting the fetus.
 Sex in moderation is permitted during
pregnancy but not during the last 6 weeks of
pregnancy because it has been found out that
there is an increase incidence of postpartum
infection in women who engage in sex during
the last 6 weeks.
 Sex is contraindicated in the following
situations:
 Spotting or bleeding
 Incompetent cervical os
 Ruptured BOW
 Deeply engaged presenting part
F) Employment
 no contraindications as long as the job does
not entail
 handling toxic substances
 lifting heavy objects
 excessive physical or emotional strain

Advise pregnant women to walk about every

few hours of her work day during long
periods of standing or sitting to promote
circulation.
G) Travelling
 no travel restrictions,
but postpone a trip
during the last
trimester.
 On long rides, 15 – 20
mins. rest periods
every 2–3 hours to
walk about or empty
the bladder is
advisable.
H) Exercises
 Chief aim: To strengthen the muscles
used in labor and delivery
 Should be done in moderation
 Should be individualized: according to
age, physical condition, customary
amount of exercise (swimming, or
tennis not contraindicated unless done
for the first time ) and the stage of
pregnancy.
 Recommended exercises:
 Squatting and tailor sitting
a. help stretch and strengthen
perineal muscles
b. increase circulation in the
perineum
c. make pelvic joints more
pliable.
 When standing from the squatting
position, raise buttocks first before
raising the head to prevent postural
hypotension.
Squatting
 Opens pelvic outlet to its
maximum width (up to an extra
one-to-two centimeters)
 May require less bearing down
 May enhance the baby's
rotation and descent in a
difficult birth
 Helpful if you do not feel the
urge to push
 If you have difficulty with
squatting, try a semi-squatting
position on a stool or a stack of
pillows. Birthing beds have a
squatting bar which may be
attached to the bed so that
squatting is more comfortable.
Tailor Sitting
 stretch perineal
muscles
 make the pelvic
joints more
pliable
Pelvic Rock
 Maintains good posture
 May help relieve backache and
relieves abdominal pressure
 Strengthens abdominal muscles
 Takes pressure off hemorrhoids
Modified Knee Chest
 relieves pelvic pressure & cramps in
buttocks
 relieves discomfort from
haemorrhoids
Shoulder-circling – strengthens
muscles of the chest.
Walking – said to be the best
exercise.
Kegel – relieves congestion and
discomfort in pelvic region; tones
up pelvic floor muscles.
I) Prepared Childbirth/Childbirth
education – preparing the
pregnant couple for childbearing.
 Operates basically on the “ Gate
Control Theory” of pain: Pain is
controlled in the spinal cord.
 To ease pain in one body part, the
gate to this pain should be “closed
“.
 Premises:
 Discomfort during labor can be minimized
if the woman comes into labor informed
about what is happening and prepared with
breathing exercises to use during labor.
 Discomfort during labor can be minimized
if the woman’s abdomen is relaxed and the
uterus is allowed to rise freely against the
abdominal wall with contractions.
 Major approaches to prepared
childbirth pregnant couples are
taught about Method: Fear leads to
tension and tension leads to pain.
 Lamaze – psychoprophylactic
method; based on the stimulus-
response anatomy, pregnancy, labor
and delivery, relaxation techniques,
hygiene, diet, comfort measures
 Grantly-Dick Read conditioning
To be effective, full concentration
on breathing exercises during
labor should be observed.

 (Implication: Nurse should not

interrupt the couple doing the
breathing exercises.)
J) Tetanus Immunization: 0.5 ml
IM in deltoid muscle of the upper
arm
 TT1 – to all pregnant women any time
during pregnancy.
 TT2 – 4 weeks apart after TT1
 TT3 – 6 months after TT2
 TT4 – 1 year after TT3 or on the next
pregnancy
 TT5 – 1 year after TT4
K) Clinic appointments:
 First 7 lunar months – every
month
 On 8th and 9th lunar months –
every other week = twice a
month
 On 10th lunar month – every
week until labor pains set in