NORMAL

PREGNANCY, LABOR
AND DELIVERY
Definition of Terms :
• Acme – highest intensity of uterine
contraction.
• Amniocentesis – is a diagnostic
procedure in which a small amount of
amniotic sac, a membrane surrounding
the fetus in uterus . To detect fetal defects
such as Down‘s syndrome and other sex –
linked disorders.
• Amnion - smooth, tough, inner membrane
containing the ammiotic fluid.
• Asynclitism – an oblique presentation of
fetal head in labour.
• Attitude ( habitus ) - relation of the fetal
limbs and head to its trunk usually one of
flexion .
• Ballottment – rebound of the fetus to its
original position with the tap felt by the
examining hand.
• Bandl’s Ring – marked ridge between the
upper and lower uterine wall segment
noted in the obstructed labor.
• Bartholomew‘s rule – estimation of the duration
of pregnancy by noting the fundic height in
relation to the three anatomical landmarks.
• Blastocyst - the fertilized ovum ready for
implantation about 10 days after fertilization.
• Brandt-Andrew’s Maneuver – method of
placental delivery where the hand is placed over
the lower abdomen and made to push the uterus
upwards to displace the placenta from the lower
segment to the vagina with simultaneously
traction of the cord.
• Braxton – Hicks Contraction – palpable but
ordinarily painless uterine contraction at irregular
intervals.
• Calkins Sign – change in the size and
consistency of the uterus from a flattened
discoid body to a firm globular mass. This is the
earliest sign of placental separation.
• Cardinal Movement of Labour – process of
adaptation and accommodation of the head to
the various segment of the pelvis. This positional
change in the presenting part constitutes the
mechanism of labor.
The seven cardinal movements
in order are ;
• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• External Rotation
• Expulsion
• Caul - portion of intact membranes
covering the head of the newborn.
• Chadwicks ‘s Sign – violet color of the
vaginal mucosa due to increased
vascularity.
• Chloasma – or melasma, extra
pigmentation on cheeks and across the
nose dut to the increased production of
melanocytes by the pituitary gland.
• Conception / Fertilization – fusion of the
ovum and spermatozoa.
• Crowning – encirclement of the largest
diameter of the fetal head by the vulvar
ring.
• Decrement – stage of diminishing
intensity of a contraction.
• Denominator – part of the presentation
that determines. The denominator in
vertex presentation is the occiput , in
breech the sacrum, in face the mentum, in
shoulder or transverse the acromion
process or scapula.
• Duncan Mechanism – method of placental extrusion in
which separation of the placenta occurs first at the
periphery and blood may escape into the vagina even
before the placenta is out.
• Effacement – shortening ( obliteration or taking up )
of the cervical canal from structure about 2cm in length
to one in which the canal is replaced by a mere circular
orifice. The degree of effacement in terms of the length
of the cervical canal compared to the uneffaced cervix is.
Cervical Canal ¾ of original length -25%
Cervical Canal ½ of original length – 50%
Cervical Canal ¼ of original length – 75%
No Canal – 100%
• Embryo – the product of conception from
the 3rd to the 7th week.

• Engagement – when the greatest

transverse diameter of the fetal head
biparietal passes through the pelvic inlet.
• Episiotomy – incision of the perineum to
substitute a straight neat surgical incision of a
ragged laceration.
• Foramen Ovale – the opening between the
two aortas of the fetal heart that hunt the
blood from the right to the left auricle.
• Gravida – a woman who is or has been
pregnant irrespective of the pregnancy
outcome.
• Goodel’s sign – softening of the cervix
similar to the lips to the mouth in primigravida
by 6-8 weeks of gestation.
• Gynecology – deals with physiology and
the pathology of the female reproductive
organs in the non-pregnant state.
• Haase Rule – rough estimate of the fetal
length in centimeters from crown to heel.
• Hegar’s sign – softening of the isthmus of
the uterus about 6-8 weeks from the LMP.
• Polyhydramnios – excessive quantity of
amniotic fluid of more than 2000 ml.
• Implantation – embedding of the fertilized
ovum into myometrium.
• Involution – process by which the
reproductive organs return to their non-
pregnant state.
• Leopolds Maneuver – a systematic
abdominal palpation and recognition of
presentation and position.
• Lie – relationship of the long axis of the uterus
to the long axis of the fetus, and is whether
longitudinal or transverse.
• Lightening – descent of the fetal head through
the pelvis with subsequent decrease fundic
height. This occurs two weeks before the onset
of labour.
• Linea Nigra – brown line running from
umbilicus to symphysis pubis.
• Lochia – variable amount of uterine
discharge in the puerperium.
• Macrosoma – excessively large infant
weighing 4500 grams.
• Mittleschmerz – pain in either the right or
left lower quadrant felt by a woman during
ovulation.
• Multigravida – a woman who has had two
or more pregnancies.
• Multipara - a woman who has completed
two or more pregnancies to the age of
viability.
• Naegel’s Rule – time honored to estimate
EDC.
• Nuchal cord – cord loops around the fetal
neck.
• Nulligravida – a woman who is not now or
never have been pregnant.
• Nullipara – a woman who has never
completed pregnancy beyond an abortion.
• Obstetrics – branch of medicine that
deals with parturition, its antecedents, and
its sequel.
• Oligohydramnios – deficient quantity of
amniotic fluid less than 500 cc.
• Oxytocin – a drug that stimulates uterine
contractions.
• Ovulation – rupture of a mature graffian
follicle and release of a mature ovum. Two
weeks before menstruation.
• Para – number of deliveries that have
reach the age of viability.
• Parturition – an act of giving birth.
• Parturient – a woman in labor.
• Position – relation of an arbitrary chosen
portion of the presenting part of the fetus
through cervix on vaginal examination.
• Post-term infant – infant born at 42
weeks gestation age or more.
• Prenatal Care = or antenatal care refers
to the health care given to a woman and
her family during pregnancy.
• Presentation –portion of the fetus that lies
in the pelvic brim.
• Presenting Part – portion of the fetus felt
through the cervix on vaginal examination.
• Pre-term or Premature infant – infant
born before 37 completed weeks.
• Primipara – a woman who has completed
one pregnancy to viability.
• Primigravida – a woman pregnant for the first
time.
• Puerpera – a woman who has just given birth.
• Puerperium – complete return of the
degenerative organ to normal non-pregnant
state covering a period of 6-8weeks.
• Quickening – perception of the slight fluttering
movements in the abdomen which gradually
increases in intensity between 16-20 weeks after
onset of LMP.
• Ritgen’s Maneuver – controlled delivery of the
fetal head by maintaining flexion and promoting
birth of the head by gradual extension.
• Schultz Mechanism – placental
separation started at the center,, fetal
surface appears first and blood is
concealed behind the placenta and
membranes.

• Spinnbarkeitt – a sign of ovulation where

the cervical mucous can be drawn into
long threads with considerable elastic coil.
• Station – degree of descent of the presenting
part through the birth canal.
Level of the pelvic inlet = (-) 3 station
1/3 the distance from the inlet to ischial spine
and pelvic outlet = (-) 2 station
2/3 the distance from the inlet to ischial spine
and pelvic outlet = (-) 1 station
Level of the ischial spine = 0
 1/3 the distance between the ischial spine
and pelvic outlet = (+) 1 station
2/3 the distance between the ischial spine and
pelvic outlet = (+) 2 station
Level of the perineum = (+) 3 station
• Striae Gravidarum – increased uterine
size results in rupture and atrophy of the
connective tissue layers, seen as pink or
reddish streaks.
• Term infant – an infant born between 38 and 41
weeks gestation.
• Ultrasonography – technology developed to
• Improve pregnancy outcome by interpreting high
frequency sound wave. Uses are:
– Placental localization
– Presence of intrauterine pregnancy
– Identification of H-mole
– Identification of tumor and multiple fetuses
– Detection of fetal abnormalities and foreign bodies
(e.g. IUD)
• Zygote – fertilized ovum.
PART I: Human Anatomy and
Reproduction
• THE VULVA – the external female genital
organs consisting of the following structures.
• Mons Veneris or Mons Pubis (mount of
Venus) – is a pad of fat lying over the symphysis
pubis, covered with pubic hair from the time of
puberty.
• Labia Majora (greater lips) – are two folds of
fats and areolar tissue covered with skin and
pubic hair on the outer surface. They arise in the
mons veneris and merge into the perineum
behind.
• Labia Minora (lesser lips) – are two folds of
the skin between the labia majora. Anteriorly
they divide to enclose the clitoris; posteriorly
they fuse, forming the fourchette.
• Clitoris – is a small rudimentary organ
corresponding to the male penis. It is
extremely sensitive highly vascular and plays
a part in the orgasm of sexual intercourse.
• Vestibule – area enclose by the labia minora
in which are situated in the opening of the
urethra and the vagina.
• Urethral Orifice – this orifice lays 2.5 cm posterior to the
clitoris. On either side lie the openings of Skene’s ducts,
to small blind – ended tubules 0.5 cm long running within
the urethral wall.
• Vaginal Orifice – also known as the introitus of the
vagina and occupies the posterior 2/3 of the vestibule. It
is partially closed by the hymen, a thin membrane that
tears during sexual intercourse or during the birth of the
first child. The remaining tags of the hymen are known
as the carunculae myrtiforms because they resemble
myrtle berries.
• Bartholin’s Glands – are the two small glands which
open on either side of the vaginal orifice and lie on the
posterior part of the labia majora. They secrete mucus
which lubricates the vaginal opening.
• Skene’s ducts – two small blind-ended tubules 0.5 cm
long running within the urethral wall.
THE VAGINA
Functions:
• A passage that allows the escape of the menstrual
flow
• Receives the penis and the ejected sperm during
sexual intercourse.
• And provides an exit for the fetus during delivery.
Structure:
• The upper end of the vagina is known as a vault
• The vaginal walls are pink in appearance and
thrown into small folds called the rugae. These allow
the vaginal walls to stretch during intercourse and
delivery.
THE UTERUS
Functions:
• The uterus exists to shelter the fetus during
pregnancy. It prepares for this possibility each
month and following pregnancy it expels the uterine
contents.
Structure:
• The non-pregnant uterus is a hallow, muscular, pear-
shaped organ situated in the true pelvis. It is 7.5 cm
long, 5cm wide and 2.5 cm in each direction. Weighing
50-60 grams in a non-pregnant woman held in place by
broad ligaments (from sides of the uterus to pelvic walls;
also hold fallopian tubes and ovaries in place) and round
ligaments (from sides of uterus to mons pubis).
• Part of the Uterus
• Body or corpus – makes up the upper 2/3 of the
uterus and is the greater part.
• Fundus – is the domed upper wall between the
insertions of the uterine tubes.
• Cornua – are upper outer angles of the uterus where
the uterine tubes join.
• Cavity – is a potential space between the anterior and
posterior walls. It is a triangular in shape, the base of
the triangle being uppermost.
• Isthmus – is a narrow area between the cavity and
the cervix, which is 7mm long. It enlarges during
pregnancy to form the lower uterine segment.
• Cervix or neck – protrudes into the vagina. The
upper half, being above the vagina, is known as
supravaginal portion while the lower half is the
infravaginal portion.
• Internal os – is the narrow opening between the
isthmus and the cervix.
• External os – is a small round opening at the
lower end of the cervix. After childbirth it
becomes a transverse slit.
• Cervical canal – lies between these two ora and
is a continuation of the uterine cavity. This canal
shaped like a spindle, narrow at each end and
wider in the middle.
Layers of the Uterus
• Endometrium – forms a lining of ciliated
epithelium ( mucuous membrane ) on a base of
connective or stroma.
• Myometrium or muscle coat – is thick in the
upper part of the uterus and is sparser in the
isthmus and cervix.
• Perimetrium – is a double serous membrane ,
an extension of the peritoneum, which is draped
over the uterus , covering all but a marrow strip
on either side or the anterior wall of the
supravaginal cervix from where it is reflected up
over the bladder .
UTERINE TUBES
Function :

• The uterine tube propels the ovum

towards the uterus, receives the
spermatozoa as they travel upwards and
provides a site for fertilization . It supplies
the fertilized ovum with the nutrition during
its journey to the uterus.
Structure:
• Each tube is 10cm long. The lumen of the tube
provides an open pathway from the outside to the
peritoneal cavity. the uterine tube has four portions:
– the interstitial portion – is 1.25 cm long and lies
within the wall of the uterus. Its lumen is 1mm wide.
– the isthmus – is another narrow part which extends
from 2.5cm from the uterus.
– the ampulla – is the wider portion where fertilization
usually occurs.
– the infudibulum – this is the funnel –shaped fringed
end that is composed of many processes known as
fimbrae. One fimbria is elongated to form the overian
fimbria, which is attached to the ovary.
• OVARIES
Functions:
• Oogenesis – for development and maturation of ovum
• Ovulation – release of ovum from the ovary
• Hormone production – it produce estrogen and
progesterone.
Structure:
• Almond shaped, dull white sex glands near the
fimbriae, kept in place by ligaments.
• The ovary is composed of medulla and cortex,
covered with germinal epithelium.
• Cortex - this is the functioning part of the
ovary which is filled with the ovarian and
graafian follicles. The immature
(primordial) follicles mature into ova and
produce large amount of estrogen and
progesterone.

• Medulla - this is the supporting

framework, which is made up of fibrous
tissue; the ovarian blood vessels,
lymphatics and nerves travel through it.
• Breast - the mammary glands or breasts are accessory
organs of reproduction meant to provide the infant with
the most ideal nourishment after birth. They remain in
halted stage of development until a rise in estrogen at
puberty produces a marked increase in their size. The
size increase consists mainly of connective tissue plus
deposition of fat. The glandular tissue of the breast,
necessary for successful breast-feeding, remains
undeveloped until a first pregnancy begins. Milk glands
of the breasts are divided by the connective tissue
partitions into approximately 20 lobes. Each lobe is
divided into lobules that consist of alveoli and ducts. The
alveoli contain acini cells which produce milk stimulated
by the hormone, prolactin. And deliver it to the nipple via
a lactiferous duct. The nipple has approximately 20 small
openings through which milk is secreted.
• An ampulla (lactiferous sinus) portion of the duct, located
just posterior to the nipple, serves as a reservoir for milk
before breast-feeding. A nipple is composed of smooth
muscle that is capable of erection on manual or sucking
stimulation. On stimulation, it transmits sensations to the
posterior pituitary gland to release oxytocin. Oxytocin
acts to constrict milk gland cells and push milk forward
into the ducts that lead to the nipple (Let-down reflex).
The nipple is surrounded by a darkly pigmented area of
epithelium approximately 4cm in diameter, termed the
areola which appears rough on the surface because it
contains many sebaceous glands, called Montgomery’s
tubercles.
FEMALE PELVIS
• Pelvis– it is a funnel shaped structure. It is one of the
strongest joint comprising of 6 bones taking the weight
of spinal column.
• Female Pelvic Cavity – is broader because of child
birth. It protects abdominal organs like bladder, uterus,
etc. It contains two (2) innominate bones which are
joined by rigid sacroiliac joints to the sacrum . It is
curved forward to join at pubis symphysis. Each
innominate bone consists of three (3) fused bones :
ilium, ischium and pubis . In women the pelvis is
generally shallow and broad and a pubis symphysis
joint is less rigid than men.
There are four ( 4) pelvic bones:
• Two (2) innominate (nameless) or big bones.
• One (1) sacrum
• One (1) coccyx
1. Innominate bones – composed of
three (3) parts
– The Ilium – is the large flared out part . When the hand is placed
on the pig it reston the iliac crest which is the upper border.
– The Ischium – is the thick lower part . It has a large prominence
as the ischial tuberrosity, on which the body rest when sitting
– The Pubic Bone – this bone forms the anterior part . It has a
body and two oar like projections, the superior ramus and the
inferior ramus . The two pubic bones meet at the symphysis
pubis and the two inferior rami form the pubic arch.
• The Sacrum - is a wedge –shaped bone
consisting of five (5) fused vertebrae .
The upper border of the of the first sacral
vertebra joints forward and is known as
the sacral promontory.
• The Coccyx – is a vestigial tail. It consists
of four ( 4 ) fused vertebrae, forming of a
small triangular bone.
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.
• 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.
• True Pelvis - inferior half formed by the
pubes in front, the ilia and the ischia,
sacrum and coccyx. A bony canal through
which the fetus must pass during birth . It
has a brim , a cavity & an outlet.
THE FOUR TYPES OF PELVIS
1. The Gynaecoid Pelvis – is the ideal
pelvis for childbearing.
2. The Android Pelvis – this is so called
because it resembles the nail pelvis.
3.The Anthropoid Pelvis – this has a
long,oval brim in which the anteroposterior
diameter is longer than the transverse.

4. The Platypelloid Pelvis – this flat pelvis

has kidney shaped brim in which the
anteroposterior diameter is reduced and
transverse increased.
FEATURES OF THE FOUR TYPES
OF PELVIS
Features Gynecoid Android Anthropoid Platypelloid
Brim Rounded Heart Long oval Kidney
shaped shaped

Forepelvis Generous Narrow Narrowed Wide

Side walls Straight Convergent Divergent Divergent

Ischial spines Blunt Prominent Blunt Blunt

Sciatic notch Rounded Narrow Wide Wide

Sub-pubic 90degrees <90 degrees >90 degrees >90 degrees

angle

Incidence 50% 20% 25% 5%

Internal Measurement
1. Diagonal Conjugate – distance between sacral
promontory and inferior margin of the symphysis
pubis.
• Average = 12.5 cm
2. True Conjugate – distance between the anterior
surface of the sacral promontory and the superior
margin of the symphysis pubis. Very important
measurement because it is the diameter of the pelvic
inlet.
• Average = 10.5 – 11 cm
3. Bi-ischial diameter – transverse diameter of the
pelvic outlet. Is measured at the level of the anus.
• Average = 11 cm
Diagonal conjugate
• THE PELVIC FLOOR
Supports the weights of the
abdominal and pelvic organs. Its muscles
are responsible for the voluntary control of
micturition and defecation and play an
important part in sexual intercourse.
During childbirth it influences the passive
movements of the fetus through the birth
canal and relaxes to allow its exit from the
pelvis.
Muscle Layers
The superficial layer composed of five (5)
muscles:
• The external anal sphincter – encircles the anus and is attached
behind by a few fibers to the coccyx.
• The transverse perineal muscles – pass from the ischial
tuberosities to the perineum.
• The bulbocavernous muscles – pass from the perineum forwards
around the vagina to the corpora cavernosa of the clitoris just under
the pubic arch.
• The ischiocavernosus muscles – pass from the ischial
tuberosities along the pubic arch to the corpora cavernosa.
• The membranous sphincter of the urethra – is composed of
muscle fibers passing above and below the urethra and attached to
the pubic bones. It is not a true sphincter since its not circular, but it
acts to close the urethra
The Perineal body – is a pyramid of muscle
and fibrous tissue situated between the
vagina and the rectum.

.
The Pelvic Joints
There are four (4) pelvic joints:
• One Symphysis Pubis – is formed at the
junction of the two pubic bones which are united
by and pad of cartilage
• Two Sarcoiliac Joints – these are the strongest
joints in the body. They join the sacrum to the
ilium and thus connect the spine to the pelvis
• The Sacrococcygeal joint – this joint is formed
where the base of the coccyx articulates with the
tip of the sacrum.
The Male Reproductive Organ
SCROTUM
Functions:
• The Scrotum forms a pouch in which the
testes are suspended outside the body. It
lies below the symphysis pubis and
between the upper parts of the thighs
behind the penis.
Structure:
• It is formed of pigmented skin and has two
compartments one of each testes.
SCROTUM
TESTES
Functions:
• The testes are the male gonads and produce
spermatozoa and the hormone testosterone.
Testosterone is responsible for the development of
secondary sex characteristics. Together with follicle –
stimulating hormone (FSH). It also promotes production
of sperm.
Position:
• The testes are situated in the scrotum. In order to
achieve their proper function they must be kept below
body temperature, and this is why they are situated
outside the body.
Structure:
• Each testes is 4.5cm long, 2.5cm wide and 3cm thick
TESTES
There are three (3) layers to the testes:
• Tunica Vasculosa – this is an inner layer of
connective tissue containing a fine network
capillaries
• Tunica Albuginea – is a fibrous covering, ingrowths
of which divide the testis into 200 – 300 lobules.
• Tunica Vaginalis – the outer layer, which is made
of peritoneum brought down with the descending
testis when it migrated from the lumbar region in
fetal life.
The Seminiferous (seed-carrying) – are where
spermatogenesis of production of sperm, takes
place.
• The Epididymis – is a comma-shaped,
coiled tube that lies on the superior
surface and travels down the posterior
aspect to the lower pole of the testis,
where it leads into the deferent duct or vas
deferens.
SPERMATIC CORD
Function:
• Transmit the deferent duct up into the body,
along with other structures. Deferent duct
carry the sperm to the ejaculatory duct.
Structure:
• The spermatic cord consists of the deferent
duct, the testicular blood vessels, lymph
vessels and nerves.
• Nerve Supply – from the 10th and 11th
thoracic nerves.
SPERMATIC CORD
• SEMINAL VESICLE
Function:
• Production of a viscous secretion to keep
the sperm alive and motile.
Structure:
• Seminal vesicles are 5cm long and
pyramid shape. Composed of columnar
epithelium, muscle tissue and fibrous
tissue.
SEMINAL VESICLE
• PROSTATE GLAND
Function:
• Produces a thin lubricating fluid that enters
the urethra through ducts.
Structure:
• It is 4cm transversely, 3cm in its vertical
diameter and 2cm deep. Composed of
columnar epithelium, a muscle layer and
an outer fibrous layer.
PROSTATE GLAND
PENIS
Function:
• Carries the urethra, which is passage for both
urine and semen.
Structure:
Columns of erectile tissue:
• Corpura cavernosa – two lateral columns form
the corpora cavernosa; there is one on either
side in the front of the urethra.
• Corpus spongiosum – is a posterior column
that contains the urethra. The tip is expanded to
form the glands penis.
MALE HORMONE
• The control of the male gonads is similar to that in
the female, but it is not cyclical. The hypothalamus
produces gonadotrophin releasing factor. These
stimulate the anterior pituitary gland to produce FSH
and luteinising hormone LH. FSH acts on the
seminiferous tubules to bring about the production
of sperm, whereas LH acts on the interstitial cell that
produce testosterone.
• Testosterone – is responsible for the secondary
sex characteristics namely deepening of voice,
growth of the genitalia and growth of the hair on the
chest, pubis, axilla and face.
HORMONAL CYCLES
• PUBERTY – period of life in which the
reproductive organs undergo a surge in
development and reach maturity. The first
signs are breast development and the
appearance of the pubic hair. The body
grows considerably and takes on the female
shape. Puberty culminates in the onset of
menstruation (menarche). The first few cycles
are usually not accompanied by ovulation so
that conception is unlikely before a girl has
menstruating for a year or two.
• Is the time during which physical growth and sexual
maturation occurs. Begins before 9-12 years. The
initiation of puberty is under the control of hypothalamus.
Under the stimulation of hypothalamus, the pituitary
glands release gonadotropin hormones that stimulate the
gonads (testes and ovaries) and adrenals to release
hormones that stimulate and regulate both the growth
and function of the sex organs. The first sign of
pubescence in females is usually breast bud formation
(normal age of onset has a range of 8-14 years) or
thelarche. Puberty ends with menarche which occurs
approximately two years after thelarche and is usually
result of fluctuating estrogen associated with follicle
development without ovulation. The first ovulation often
occurs six months after the first episode of bleeding with
regular ovulation occurring two years after the first
menses.
Pubertal Changes (Female) ♀:
• ✍ Growth spurt
– Increase in the transverse diameter of the
pelvis
– Breast development
– Growth of pubic hair
– Onset of menstruation
– Growth of axillary hair
– Vaginal secretions
• The first sign of pubescence in males’
usually testicular enlargement (normal age
of onset is 11.5 years with a range of 9-14
years).
• Pubertal Changes (Male) ♂:
– Increase in weight
– Growth of testes
– Growth of face, axillary, and pubic hair
– Voice changes
– Penile growth
– Increase in height
– Spermatogenesis (production of sperm)
Definition of terms:
• Menarche – first menstruation
• Thelarche – breast development
• Adrenarche – the increase secretion of
androgens by the adrenal gland that
stimulate the development of pubic and
axillary hair.
• Gonadarche – the initiation of hormone
production by the gonads. The ovaries
produce estrogen and progesterone and
the testes secrete testosterone.
• MENOPAUSE – the end of woman’s
reproductive life is characterized by the
gradual cessation, the first becoming
irregular and then ceasing altogether.
Signs are as follows:
• Mood swings
• Increased tendency for obesity
• Sexual drive maybe diminished
• Hot flushes - characterized by sensation of
heat that begins in the face progressing to the
chest followed by reddening of the face, neck
and chest (hot flush) and profuse perspiration.
 Menopause is the cessation of
menstrual cycles. The age range at which
menopause occurs is wide, between
approximately 45 and 55 years. Both the
age of menarche and menopause tend to
be familial. The earlier the age of
menarche, the earlier the menopause
tends to occur.
THE MENSTRUAL CYCLE / UTERINE
CYCLE
General Considerations:
• 2 million immature oocytes per ovary are present at
birth (were formed during the first 5 months of
intrauterine life). Between 5 and 7 million of these are
formed in utero, many however, degenerate and
atrophy (process called atresia). By age 7 yrs, only
approximately 500, 000 are present in each ovary,
400, 000 at puberty; by 22 years, there are
approximately 300, 000; and by menopause, none
are left ( all have either matured or atrophied). About
300 -400 mature during the entire reproductive cycle
of the woman.
• Ushered in by the menarche (first menstruation
in girls) and ends with menopause (the point at
which no functioning oocyte remain in the
ovaries).
• Menarche may occur as early as 8 or 9 or as
late as 17 and still within the normal limits.
(Average age at onset, 11-13 years; average
range, 9-17 years)
• Normal period (days when there is
menstrual flow) lasts for 4-6 days,
although woman may have periods as
short as 2 days or as long as 7 days.
• A menstrual flow contains only approximately
30 – 80ml, with an average of 50 ml.
Saturating pad or tampon in less than an hour
is heavy bleeding.
• Menstrual cycle (from first day of menstrual
period to first day of next menstrual period)
maybe anywhere from 23 – 35 days but
accepted average length is 28 days.
• Color of menstrual bleeding is dark red; a
combination of blood, mucus, and endometrial
cells.
• Odor similar to that marigold
Associated Terms:
• Gonad – a body organ that produces sex
cells (ovary in female and testes in males).
• Oocyte – cells that will develop into eggs
throughout the woman’s mature years.
Body structures involved:*

1. Hypothalamus - initiates the menstrual cycle by

releasing GnRH (also called luteinizing hormone
releasing hormone or LHRH).
2. Pituitary Gland - under the influence of GnRH, the
anterior lobe of the pituitary gland (adenohypophysis)
produces two hormones that act on the ovaries to further
influence the menstrual cycle: FSH (Follicle Stimulating
Hormone) *and LH *(Luteinizing Hormone).
3. Ovary - The gonadotropic hormones, follicle-stimulating
hormone (FSH) and luteinizing hormone (LH) cause
growth (trophy) to the gonad (ovaries).
• FSH – a hormone that is active early in the cycle and is
responsible for maturation of the ovum.
• LH – a hormone that becomes most active at the
midpoint of the cycle and is responsible for ovulation or
release of mature egg cell from the ovary and growth of
the uterine lining during the second half of the menstrual
cycle.
• Ovulation occurs on approximately 14 days before the
onset of menstruation.
• Uterus - The organ from which menstrual discharge is
formed. The changes that occur in the uterine
endometrium are due to the influence of the ovarian
hormones; estrogen and progesterone. Stimulation from
the hormones produced by the ovaries causes specific
monthly effects on the uterus.
Effects of Estrogen in the body
• Stimulates deposition of fat in subcutaneous tissues that
gives a female shape and development of secondary
sexual characteristics in female (breast enlargement, fat
deposition that gives a woman’s body a female shape).
• Development of the uterus, fallopian tubes, and vagina
and the thickening of the endometrium.
• Stimulates growth of the ductile structures of the breasts
(thelarche).
• 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 (spinnbarkeit test of ovulation).
• Menarche and menstruation
Effects of progesterone in the body
• Converts the endometrium to its secretory
stage to prepare the uterus for
implantation.
• Relaxes uterine muscle (Inhibits uterine
motility)
• Promotes growth of the acini cells of the
breast.
• Causes fluid retention that result in weight
gain.
• If pregnancy does not occur, progesterone
levels will decrease, leading to
menstruation.
• 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 in the body.
• Causes tingling sensation and feeling of
fullness in the breast before menstruation.
SEQUENTIAL
STEPS IN THE
MENSTRUAL
CYCLE
First Phase of Menstrual
Cycle (Proliferative)
• Immediately after menstrual flow (which occurs during
the first 4 or 5 days of a cycle), the uterus is very thin.
The serum estrogen is at its lowest. The hypothalamus
initiates the menstrual cycle by releasing GnRH (also
called luteinizing hormone- releasing factor.
• Gonadotropin-releasing hormone (GnRH) triggers the
anterior pituitary gland (adenohypophysis) to produce
two hormones follicle-stimulating hormone (FSH) and
luteinizing hormone (LH).
• FSH, in turn, will stimulate the growth of an immature
oocyte inside a primordial follicle by stimulating
production of estrogen by the ovary. Once estrogen is
produced. The primordial follicle is now termed Graafian
follicle. (The Graafian follicle therefore is the structure
which contains high amounts of estrogen).
• Estrogen in the Graafian follicle will cause the cells in the
uterine endothelium to proliferate (grow very rapidly), thereby
increasing its thickness to about eight fold. This particular
phase in the uterine cycle, therefore, is called Proliferative
Phase.
• LH in turn, is responsible for stimulating the ovary to produce
the second hormone produced by the ovaries, progesterone.
LH promotes ovulation.
• On the 14th day of the menstrual cycle), the Graafian follicle
ruptures and releases the mature ovum, a process called
Ovulation.
• Once ovulation has taken place, the Graafian follicle, because
it now contains increasing amount of progesterone, giving it
its yellowish appearance, is termed Corpus Luteum.
(Therefore, the structure which contains high amounts of
progesterone is the Corpus Luteum.
Second Phase of Menstrual
Cycle (Secretory Phase)
Menstrual phase for
implantation
• After ovulation, the formation of progesterone in the
corpus luteum (under the direction of the LH) causes the
glands of the uterine endometrium to become corkscrew
or twisted in appearance and dilated with quantities of
glycogen (an elementary sugar) and a mucin (a protein).
• The capillaries of the endometrium increase in amount
until the lining takes on the appearance of rich, spongy
velvet.
• 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.
This phase in the uterine cycle is called the Secretory
Phase because it secretes the most important hormone
in pregnancy.
Third Phase of Menstrual
Cycle (Ischemic Phase)
• If fertilization does not occur, the corpus luteum in the ovary
begins to regress after 8 to 10 days, as a result the production
of the progesterone and estrogen decreases. And because of
the withdrawal of progesterone, the endometrium of the
uterus begins to degenerate (at approximately day 24 or day
25 of the cycle) thus, the capillaries rupture, with minute
hemorrhages and the endometrium sloughs off.
• Progesterone withdrawal results in formation and release of
prostaglandins which cause contraction of myometrium that
may cause some degree of discomfort in some women,
commonly known as menstrual cramps or dysmenorrhea
when severe.
• The Corpus Luteum, turning white is now called, the Corpus
Albicans and after 3-4 days, the thickened lining of the uterus
produced by estrogen starts to degenerate and slough off and
the capillaries rupture. And thus begins another menstrual
period.
Menses: The Final Phase of a
Menstrual Cycle
 The following products are discharged
from the uterus as the menstrual flow or
menses:
• Blood from the ruptured capillaries
• Mucin from the glands
• Fragments of the endometrial tissue
• The microscopic, atrophied, and unfertilized
Ovum
• Iron loss in a typical menstrual flow is
approximately 11mg
Associated terms:
• Amenorrhea – temporary cessation of menstrual
flow.
• Oligomenorrhea – markedly diminished menstrual
flow nearing amenorrhea.
• Menorrhagia – excessive bleeding during regular
menstruation.
• Metrorrhagia – bleeding between menstrual
periods. Frequently caused by an underlying
disease process.
• Polymenorrhea – frequent menstruation occurring
at intervals of less than three weeks. Frequently due
to a disease process.
THE FETUS
• DEVELOPMENT OF THE FERTILIZED OVUM:
Fertilization – the union of the sperm and the mature
ovum in the outer third or outer half of the fallopian tube.
General Consideration:
• Normally, an ejaculation of semen averages 2-
5ml of fluid contains 50 to 200 million
spermatozoa per ml, or an average of 400
million sperm per ejaculation.*
• Sperm transport: generally reach the cervix
within 80secs and the outer end of a fallopian
tube within 5 minutes after deposition.*
• Mature ovum is capable of being fertilized for 24
hours after ovulation(48 hours at the most).
*Sperms are capable of fertilizing ovum for 2-3
days after ejaculation.
• Hyaluronidase (a proteolytic enzyme) is released by the
spermatozoa and acts to dissolve the layer of cells protecting the
ovum*, the zona pellucida (a ring of mucopolysaccharide fluid)
and a circle of cells, the corona radiata.
• Only one spermatozoon is able to penetrate the cell membrane
of the ovum. Once it penetrates the cell, the cell membrane
changes its composition to become impervious to other
spermatozoa.
• Immediately after penetration of the ovum, the chromosomal
material of the ovum and spermatozoon fuse. The resulting
structure is called a zygote.
• Each spermatozoon and ovum carried 23 chromosomes (22
autosomes and 1 sex chromosome), the fertilized ovum has 46
chromosomes. If an X-carrying spermatozoon entered the ovum,
the resulting child will have two X chromosomes and will be
female (XX). If a Y-carrying spermatozoon fertilized the ovum,
the resulting child will have an X and a Y chromosome and will
be male (XY). Important: only fathers determine the sex of their
children.
Implantation
• Immediately after fertilization, the fertilized ovum or zygote stays
in the fallopian tube for 3 days, during which time rapid cell division
(mitosis) is taking place*. The developing cells are now called
blastomere and when there are already 16 blastomeres. It is now
termed a morula. In this morula form it will start to travel (by ciliary
action and peristaltic contractions of the fallopian tube) to the uterus
where it will stay for another 3-4 days. When there is already a
cavity formed in the morula, it is now called a blastocyst.
• Fingerlike projections, called trophoblasts form around the
blastocyst and these trophoblast are the ones which will implant
high on the anterior or posterior surface of the uterus. Thus
implantation, also called nidation, takes place about a week after
fertilization.
Occasionally, a small amount of vaginal spotting appears with
implantation because capillaries are ruptured by the implanting
trophoblasts (implantation bleeding). This should not be mistaken for
the Last Menstrual Period (LMP).
• Decidua – After fertilization, the corpus luteum in
the ovary continues to function rather than
atrophying, because of the influence of human
chorionic gonadotropin (hCG), a hormone
secreted by the trophoblast cells. The
endometrium, instead of sloughing off as in a
normal menstrual cycle, continues to grow in
thickness and vascularity. The endometrium is
now termed the decidua.
Three separated areas of Decidua:

1. Decidua Basalis – the part

of the endometrium that lies
directly under the embryo (or
portion where the trophoblast
cells are establishing
communication with maternal
blood vessels). It will later
form the maternal side of the
placenta.
2. Decidua Capsularis – the
portion of the endometrium
that stretches or
encapsulates the surface
of the trophoblast
3. Decidua Vera – the
remaining portion of the
uterine lining.
 Chorionic Villi
 As early as the 11th or 12th day after fertilization, tiny
projection or miniature villi (probing “fingers”) around
the zygote can be seen.
 Has a central core of loose connective tissue
surrounded by a double layer of trophoblast cells.
 The central core of connective tissue contains fetal
capillaries.
 The chorionic villi in contact with decidua basalis
proliferate rapidly because they receive rich blood
supply from the uterus.
 These villi are responsible of absorbing nutrients and
oxygen from maternal blood stream and disposing of
fetal waste product including carbon dioxide.
Chorionic Villi
• The inner layer, known
as the cytotrophoblast
or Langhans layer, is
present as early as 12
days gestation and
disappears on 20th and
24th week. It appears to
function early in
pregnancy to protect the
growing embryo and
fetus from certain
infectious organisms
such as Treponema
Pallidum or Syphilis.
• The outer of the two
covering layers is
termed
syncytiotrophoblast
or the syncytial layer
This layer of cells is
instrumental in the
production of hCG,
somatomammotropin
(human placental
lactogen (hPL),
estrogen, and
progesterone).
Human Chorionic Gonadotrophin (HCG)
 The first hormone produced, hCG can be
found in maternal blood and urine as early
as the first missed menstrual period
(shortly after implantation has occurred)
through about 100th day of pregnancy.
 HCG forms the basis of many pregnancy
test.
 The purpose of hCG is to act as a fail-safe
measure to ensure that the corpus luteum
of the ovary continues to produce
progesterone and estrogen.
Human Placental Lactogen (hPL)
• A hormone with both growth-promoting
and lactogenic (milk producing) properties.
• It promotes mammary gland (breast)
growth in preparation for lactation in the
mother.
• It also serves the important role of
regulating maternal glucose, protein and
fat levels so that adequate amounts of
these nutrients are always available to the
fetus.
Estrogen
• “Hormone of women”
• Contributes to the mother’s mammary
gland development in preparation for
lactation and stimulates uterine growth to
accommodate the developing fetus.
Progesterone
• “Hormone of mothers”
• Necessary in pregnancy to maintain the
endometrial lining of the uterus.
• This hormone also appears to reduce the
contractility of the uterine musculature
during pregnancy which prevents
premature labor.
 While the trophoblast is developing into the placenta,
which will nourish the fetus, inner cell mass (embryonic
disc) is forming the fetus itself.
Trophoblast = Placenta + Chorion
Inner Cell Mass = Fetus + Amnion + Umbilical cord
• Gives rise to the three primary germ layers which will
form particular parts of the fetus:
1. Ectoderm
• Gives rise to the skin, hair, nails, sense organs,
nervous systems, mucous membrane of the mouth
and anus,pituitary, mammary and sweat glands
2. Mesoderm
• Gives rise to the kidney, musculoskeletal
system (bones and muscles), reproductive
system and cardiovascular system (heart and
blood vessels).

3. Endoderm
• Gives rise to the urinary bladder, lining of the
gastrointestinal tract, tonsils, thyroid gland
and respiratory system.
Amniotic Cavity
• This cavity lies on the side of the
ectoderm.
• It is filled with fluid and gradually enlarges
and folds around the embryo to enclose it.
• The amnion forms from its lining.
Yolk sac
• Lies on the side of the endoderm and
provides nourishment for the embryo until
the trophoblast is sufficiently developed to
take over (placenta).
• Fertilized ovum/ Zygote – product of
conception from implantation to 3 weeks.
• Embryo – is the term applied to
developing offspring 3 weeks after
implantation and until 8 weeks after
conception.
• The fetus – product of conception from 8
weeks until it expelled in delivery.

• Conceptus – refers to all the products of

conception.
FETAL CIRCULATION
 Structures Enabling Fetal Circulation

The Placenta
 Arises out of trophoblast tissue. Formed from
the chorionic villi and decidua basalis.
 It reaches maturity at 12 weeks gestation and
continue to function effectively until the 40th to
41th week.
 The placenta is a discoid organ weighing
approximately 500 grams at term with a
diameter of 15-20cm and about 3cm thick.
  It serves as the fetal lungs, kidneys, and
gastrointestinal tract and as a separate
endocrine organ throughout pregnancy.
• Maternal side – It faces the mother, composed
of 20-22 cotyledons. Each cotyledon is supplied
with one artery and one vein. The lobe is a
collection of many villi and are separated by
grooves called septa.
• Fetal side – it faces the fetus. The amnion that
covers it gives it a white and shiny appearance.
Functions:
• Respiration. The fetus obtains the oxygen
and excreted carbon dioxide through the
placenta. Oxygen from mother’s
hemoglobin passes into the fetal blood by
simple diffusion and similarity the fetus
gives off the carbon dioxide into maternal
blood.
• Nutrition. The placenta selects
substances needed by the fetus and
breaks down complex nutrients into
compounds that may be used by the fetus.
• Storage. The placenta metabolizes
glucose, stores in the form of glycogen
and converts it to glucose as required. The
placenta can also store iron and fat-
soluble vitamins.
• Excretion. The main substance excreted
from the fetus is urea and uric acid are
also excreted. Waste products of fetus are
excreted through the placenta and
detoxified in the mother’s liver.
• Protection. The placenta provides limited
barrier to infection. With the exception of
the Treponema and Syphilis, few bacteria
can penetrate. Viruses however, can cross
freely.
• Towards the end of pregnancy, small
antibodies, immunoglobulin (IgG) will be
transferred to the fetus, and these will
confer immunity to the baby for the first
three months after birth. However only
those antibodies the mother herself
possesses may be transferred.
The Umbilical Cord or Funis
 Is the structure that connects the fetus to the placenta.
 Its main function is to carry oxygen and nutrients from
the placenta to the fetus and return unoxygenated blood
and fetal waste products to the placenta.
 It is composed of two arteries (which carry the most
unoxygenated blood to the placenta) and one vein
(which carries the most oxygenated blood to the fetus).
 It appears dull white, moist and covered by amnion,
enclosed and protected by Wharton’s jelly, a gelatinous
substance which give the cord body and prevents
pressure on the vein and arteries.
 Average length of the cord is 50cm considered short
when less than 40 cm, 2cm in diameter. The
disadvantage of long cord are that it may be looped
around the fetal neck or body or become knotted.
The Amniotic fluid
• 99% water and 1% solid particles, contains albumin,
urea, uric acid, creatinine, lecithin, sphingomyelin,
billirubin and vernix caseosa.
• It should be clear and colorless to straw colored.
Green tinged or meconeum stained signifies fetal
distress.
• Early in pregnancy, it is chiefly composed of maternal
serum. When the fetus begins to urinate after the 10th
week of pregnancy, fetal urine contributes to the
volume of amniotic fluid.
• The volume of amniotic fluid increases from the first
trimester until the 38th week. Then, it diminish slightly
until term.
Funtions:
a.)The fluid distends the ammiotic sac and allows for the
growth and development and free movement of the fetus.
b.) Equalizes pressure and protects the fetus from jarring and
and injury.
c.) Maintain a constant temperature for the fetus.
d.) Provides small amount of the nutrients.
e.) In labor , as long as the amniotic sac intact , the amniotic
fluid protects the placenta and umbilical cord from the
pressure of uterine contraction.
f. )Its aids in the effacement of the cervix and dilatation of the
uterine os, particularly where the presenting part is poorly
applied.
Volume:
Normal value – approximately 800ml
Oligohydraminios – less than 300cc of amniotic
fluid
Polyhydramnios – more than 1,500cc of amniotic

AMNIOTIC FLUID
Physiology
of Fetal
Circulation
Umbilical Vein – leads from the imbilical cord to the under
side of the liver and carries blood rich in oxygen and nutrients. It has
a branch which joints the portal vein and supplies the liver.
Ductus Venosus ( from vein to a vein ) connects the umbilical vein
to the inferior vena cava.
Foramen Ovale- (oval opening) – is temporary opening between
the atria entering from the inferior vena cava to pass across the left
atrium. The reason for this diversion is that blood that does not need
to pass through the lungs since it is already oxygenated.
Ductus Arteriosus – ( from an artery to an artery ) leads from
bifurcation of pulmonary artery to the descending
aorta entering it just beyond the point where the subclavian
and carotid arteries leave.
Hypogastric Arteries – branch off from the internal iliac
arteries when they enter the umbilical cord. They return blood to the
placenta.
• Oxygenated blood enters the umbilical vein
from the placenta enters ductus venosus
passes through inferior vena cava enters the
right atrium enters the foramen ovale goes to
left atrium passes through left ventricle flows
to ascending aorta to supply nourishment to the
brain and upper extremities enters superior
vena cava goes to right atrium enters right
ventricle enters pulmonary artery with some
blood going to the lungs to supply oxygen and
nourishment flows to ductus arteriosus
enters descending aorta (some blood going to
the lower extremities) enters hypogastric
arteries goes back to the placenta.
Fetal Circulation
FROM THE MOTHER (OXYGENATED
BLOOD)
SUPERIOR VENA CAVA
PLACENTA
RIGHT ATRIUM
UMBILICAL VEIN
TRICUSPID VALVE
DUCTUS VENOSUS
RIGHT VENTRICLE
INFERIOR VENA CAVA
PULMONARY ARTERY
RIGHT ATRIUM
DUCTUS ARTERIOSUS
FORAMEN OVALE
ILIAC ARTERY
LEFT ATRIUM
HYPOGASTRIC ARTERY
LEFT VENTRICLE
UMBILICAL ARTERIES
AORTA
PLACENTA

DIFFERENT ORGANS OF THE BODY

FETAL SKULL
• Contains the delicate brain which may be
subjected to great pressure as the head passes
through the birth canal,
• The head is the most delicate part to deliver
whether delivered first or last.
• An understanding of fetal skull enables the
nurse to recognize normal presentations of the
fetal position
The Fetal Skull
Bones of the vault
1. The Occipital bone – lies at the back of the head
and forms the region of the occiput . Part of it
contributes to the base of the skull as it contains the
foramen magnum, which protects the spinal cord. At
the center is the occipital protuberance.
2. The two Parietal bones – lie on either side of the
skull. The ossification center is called the parietal
eminence.
3. Two Frontal bones – from the foreheads or the
sinciput . At the center of each is frontal eminence.
The frontal bones fuse into a single bone by 8 years
of age.
Suture - Suture are cranial joints and are formed.
• There are several sutures and fontanelles in the fetal
skull :
• Lamboidal suture – separates the occipital bone from the two
parietal bones.
• Sagittal suture – lies between the two parietal bone passing from
one temple to another.
• Coronal Suture – separates three frontal bones from the parietal
passing from one temple to another.
• Frontal Suture – runs between the two halves of the frontal bone.
Fontanelles- these are form when two
bones or more sutures meet.
• Posterior Fontanelle or Lambda – is
situated at the junction of the lamboidal
and sagittal sutures. It is small, triangular
in shape and normally closes by 6 weeks
of age.
• Anterior Fontanelle or Lambda – is
found at the junction of the sagittal coronal
frontal sutures.
Region of Skull
1. Occiput – lies between the foramen magnum and the
posterior fontanelle.
2. Vertex – is bounded by the posterior fontanelle, the two
parietal and anterior fontanelles. Of the 95% of the
babies born had first, 95% present by the vertex.
3. Sinciput or brow- extends from the anterior fontanelle
and the suture to the orbital ridges
4. Face – is small in the newborn, extending from the
orbital ridges and the root of the nose to the junction of
the chin and the neck . The point between the eyebrow
is called the glabella . The chin termed the mentum and
is important landmark.
vertex

face
Attitude of the Fetal Head
It is used to describe the
degree of flexion or extension of
the head and neck. The attitude
of the head determines which
diameter will present in labor and
therefore influences the outcome.
Attitude of the Presenting Engaging Extent of the
head Diameter Diameter engaging
diameter

Vertex Estimated from

Complete Presentation Sub – below the occipital
Flexion Occipitobregmatic protuberance to the
9.3 cm mid-point of the
bregma.
Head in Military Crown Occipitofrontal From occipital
Attitude presentation 11.4 cm protuberance to
the midpoint of
the frontal suture.
Head partially Brow Presentation Mentovertical From the chin to
Extended 13.3 cm the highest point
on the vertex.

Head fully From where the

Face Presentation Face Presentation chin joins the
Extended
neck to the
bregma.
• Moulding – is the term applied to the
change in shape of the fetal head that
takes place during the passage to the birth
canal.
o A protective mechanism and prevents the
fetal brain from being compressed as long
as it is not excessive, too rapid or in an
unfavorable direction.
o Produced by the force of uterine
contractions pressing the vertex against
the not yet dilated cervix.
LIE – refers to the relationship of the long
axis of the fetus to the long axis of the
mother. It describes the position of the
spinal column of the fetus in relation to the
spinal column of the mother. Whether the
fetus is lying in a horizontal (transverse) or
a vertical (longitudinal) position.

Three types of LIE:

 Longitudinal Lie
 Oblique Lie
 Transverse Lie
Longitudinal lie - the long axis of the fetus is
parallel to the long axis of the mother. (resulting
in either cephalic or breech presentation)

Oblique lie - the fetus assuming this lie is usually

rotates to transverse or longitudinal lie in the
course of labor. (unstable, will eventually
become either transverse or longitudinal)

Transverse lie - the long axis of the fetus is at right

angle to the long axis of the mother. (resulting
in shoulder presentation).
DENOMINATOR – is the name of the part of
the presentation which is used when
referring to fetal position. Each
presentation has a different denominator
and these are as follows:
In the vertex presentation, it is the
occiput.
In the breech presentation, it is the
sacrum.
In the face presentation, it is the mentum.
POSITION – is the relationship between the
denominator of the presentation and six
points on the pelvic brim.
• Four Methods used to determine fetal
position:

• Combined abdominal inspection and

palpation
• Vaginal examination
• Auscultation of fetal heart tones
• Sonography
Fetal Positions for Labor
and Birth
• Left Occiput Anterior (LOA)

• The Left Occiput Anterior (LOA) position is the most common in labor. It
generally represents no problems or additional pain during labor or birth.
Here the back of the baby's head is slightly off center in the pelvis with the
back of the head towards the mother's left thigh.
• Left Occiput Transverse (LOT)

• When the baby is facing out the mother's right thigh,

the baby is said to be Left Occiput Transverse (LOT).
This position is half way between a posterior and anterior
position.
Left Occiput Posterior (LOP)

• When your baby is lying in the pelvis facing forward and

slightly to the left, so that the baby would be looking out
the right thigh, it is said to be in the Left Occiput
Posterior (LOP) position. This presentation can lead to
more back pain and a slower labor.
Right Occiput Anterior (ROA)

• The Right Occiput Anterior (ROA) position is common in

labor. It generally represents no problems or additional
pain during labor or birth. Here the back of the baby's
head is slightly off center in the pelvis with the back of
the head towards the mother's right thigh.
• Right Occiput Transverse (ROT)

• When the baby is facing out the mother's

left thigh, the baby is said to be Right
Occiput Transverse (ROT).
• Right Occiput Posterior (ROP)

• When your baby is lying in the pelvis facing forward and

slightly to the right, so that the baby would be looking out
the left thigh, it is said to be in the Right Occiput
Posterior (ROP) position. This presentation can lead to
more back pain and a slower labor.
PRESENTATION – refers to the part of the
fetus which lies on the pelvic brim or in the
lower pole of the uterus.

3major possibilities:
•Cephalic – 95%
•Breech – 5%
•Shoulder – rare, 0.4% (1 in 250)
 CEPHALIC PRESENTATION
 The head is the body part that first contacts the cervix.
 The most frequent type of fetal presentations.
 Four types of cephalic presentations: (vertex, brow,
face & mentum)
– Vertex presentation occurs when the head is
completely flexed so that the chin touches the chest.
– Sinciput presentation occurs when the head is
partially flexed and the anterior fontanel is the
presenting part.
– Brow presentation occurs when the head is
extended or bent backward causing the
occipitomental diameter to be presented for delivery.
– Face presentation occur when the head is sharply
extended causing the occiput to come in contact with
the back of the fetus.
– Chin/ Mentum presentation occur when the head is
hyperextended with the chin as the presenting part.
Breech Presentations
Either the buttocks or feet are the first
body parts to contact the cervix.
Usually difficult births.

Three types of breech presentations:

(complete, frank & footling)
Complete breech

the baby's hips and knees are flexed so

that the baby is sitting crosslegged,
with feet beside the bottom.
Frank breech
• The baby's bottom comes first, and
his or her legs are flexed at the hip
and extended at the knees (with feet
near the ears). 65-70% of breech
babies are in the frank breech
position.
Footling breech
 One or both feet come first, with the
bottom at a higher position. This is rare at
term but relatively common with
premature fetuses.
 Shoulder Presentation
• The fetus is lying horizontally in the pelvis so
that its long axis is perpendicular to that of
another.
• The presenting part usually becomes one of the
shoulders, a hand or an elbow. Vaginal delivery
is not possible.
Engagement – when the greatest transverse
diameter of the fetal head biparietal passes
through the pelvic inlet.

• Refers to the settling of the presenting part of the fetus

far enough into the pelvis to be at the level of the ischial
spines.
• Non engagement of the head at the
beginning of labor indicates a possible
complication; such as abnormal
presentation or position, abnormality of the
fetal head or cephalo-pelvic disproportion.

• Floating – a presenting part that is not

engaged.
MILESTONE of Fetal
Development
0 – 4 weeks after conception
• Rapid growth
• Formation of the embryonic plate
• Primitive central nervous system arises
• Hearts develops and begins to beat
• Limb buds form

4 weeks

Length is 4-5mm
4 – 8 weeks
• Very rapid cell division
• Head and facial features develop
• All major organs laid down in primitive form
• External genitalia present but sex not distinguishable
• Early movements
• Visible on ultrasound from 6 weeks

8 weeks
8 - 12 weeks
• Eyelids fuse
• Kidneys begin to function and the fetus passes urine
from 10 weeks
• Fetal circulation functioning properly
• Sucking and swallowing begin
• Sex apparent
• Moves freely (not felt by mother)
• Some primitive reflexes present

8 – 12 weeks
• 12 – 16 weeks
• Rapid skeletal development (see on x-ray)
• Meconium present in gut
• Lanugo appears
• Nasal septum and palate fuse

12 weeks
16 – 20 weeks
• “quickening” – mother feels the fetal movements
• Fetal heart heard on auscultation
• Vernix caseosa appears
• Fingernails can be seen
• Skin cells begin to be renewed

16 weeks
20 – 24 weeks
• Most organs became capable of
functioning
• Periods of sleep and activity
• Responds to sound
• Skin red and wrinkled
• 24 – 28 weeks
• Survival maybe expected if born
• Eyelids reopen
• Respiratory movements
28 weeks
29 – 32 weeks
• Begins to store fats and iron
• Testes descend into scrotum
• Lanugo disappears from face
• Skin becomes paler and less wrinkled
32 – 36 weeks
• Increased fats makes the body more rounded
• Lanugo disappear from the body
• Head hair lengthens
• Nails reach tip of the fingers
• Ear cartilage sof1.
• Plantar creases visible
• 36 – 40 weeks after conception
(38 – 42 weeks after LMP)
• Term is reached and the birth is due
• Contours rounded
• Skull firm
 ESTIMATING
THE EDC
Expected date of confinement
1. Determine the Estimated Date of Delivery (EDD)

A. Naegele’s rule- calculates by subtracting 3 calendar

months and adding 7 days to the date of the first day of
the woman’s last menstrual period.

Example: If April 03, 2009 is the first day of Mrs. Charina’s

last menstrual period, her EDC, would be:
04 03 2009
-3 +7 +1
__________
1 10 2010 – EDC
Example: If January 26, 2009 is the first day of Mrs. Bayas
last menstrual period, her EDC, would be:
01 26 2010
-3 +7
________________
10 33 2010
+ 1 -31
----------------------------
11 02 2010
2. Determining the age of gestation (AOG) –
number of days since LMP to the present day
divided by seven.
Example: LMP- April 17, 2010
Visit- June 05, 2010

April 13
May 31
June 05
49/7=7weeks
3. Bartholomew’s Rule – the duration of pregnancy by
noting the fundic height in relation to the 3 anatomical
landmarks.

• ASSESSMENT OF FUNDIC HEIGHT - Fundic height is

measured to estimate AOG, EDC, and fetal growth rate.
Measure fundic height from top of symphysis pubis to
the top of the fundus with the bladder empty.

• Height of fundus is used to determine AOG. Fundic

height is determined by relating to the different
landmarks of the abdomen; umbilicus, symphysis pubis
and xiphoid process.
• 8 weeks- level of symphysis pubis
• 12weeks- just above the symphysis pubis
• 16 weeks- halfway between umbilicus and
symphysis pubis
• 24 weeks- 2 fingers above the umbilicus
• 30 weeks- halfway between the umbilicus and
xiphoid process
• 34 weeks- just below xiphoid process
• 36 weeks- level of xiphoid process
• 40 weeks- at 34 weeks level due to lightening
• McDonalds Rule - is used to calculate
AOG.
• Fundic height (cm) x 2/7= AOG in lunar
months
• Fundic height (cm) x 8/7= AOG in weeks
• Johnson’s Rule - is used to calculate
fetal weight in grams.
• Fundic height (cm) - N x K = fetal weight

• K= 155 (CONSTANT)
• N= 12 if engaged; do Leopold’s maneuver
• N= 11 if not engaged
Haase Rule - Rough estimation of fetal length in centimeters from
crown to heel
During the first half of pregnancy, square the number of months.
During the second half of the pregnancy multiply the number of months
in 5.f pregnancy, multiply the number of months by 5.

1-5 months 6-10 months

1 x 1 = 1 cm 6 x 5 = 30 cm
2 x 2 = 4 cm 7 x 5 = 35 cm
3 x 3 = 9 cm 8 x 5 = 40 cm
4 x 4 = 16 cm 9 x 5 = 45 cm
5 x 5 = 25 cm 10 x 5 = 50 cm
OBSTETRICS SCORING
• TPAL- is a mnemonic (an aid to memory) that is
commonly used for recording, with the use of short hand
symbols, a woman’s pregnancy history. It provides a
systemic, quick way to indicate the number of
pregnancies the woman has had as well as the outcome.
The letters indicate the following:
• T (Term) number full term infants born after 37 weeks
• P-(Premature) number of preterm infants born before 37
weeks
• A-(abortion/ miscarriage), a pregnancy that terminates
before the fetus reaches 20 weeks of gestation, or the
fetus reaches its viability.
• L-live birth. Number of living children.
 Some institution use only two letters, namely, G, and
P, to indicate Gravida and Para. A woman pregnant for
the first time would be G1, P0
G-Gravida, number of pregnancy, including the current
pregnancy
p -Para, number of births after 20 weeks of gestation

G=T+P+A
P=T+P
Example:
Juanita is pregnant and visits you at the PNC. She had
one ectopic pregnancy at 8 weeks. She has one baby
born at 39 weeks and one born at 32 weeks which is a
set of twins. What is her OB Score?
COMMON TERATOGENS AND THEIR
EFFECTS

• The word Teratogen, in Greek, means

"monster forming". Teratogens in, modern
medical vernacular, are agents that
interfere with normal development of an
embryo.
Varicella Virus (Chickenpox)
• Exposure to chickenpox virus, obviously, is very
common as it's a common airborne disease and close
proximity to an infected person can cause exposure -
exposure can also occur by coming into direct contact
with the rash of an infected person. The danger to a
developing fetus, whose mother is *newly* infected, can
be severe, including: skin scarring, a small head,
blindness, seizures, low birth weight, and mental
retardation.
Tobacco
• Exposure to tobacco is, of course, common through smoking
cigarettes or otherwise ingesting tobacco or being the
recipient of second hand smoke (10% of U.S. women
(minimum) smoke while pregnant.). The risk to a developing
fetus, whose mother is exposed to tobacco, is that the
placenta may not develop normally causing conditions like a
placenta previa that can cause severe complications,
including death, during pregnancy and/or delivery . The fetus
is also at increased risk of developing heart defects and being
born at a low birthrate. Babies that do survive are often
difficult to comfort and are sometimes described as nervous
or "jittery". Another tangential point is that babies that
continue to be exposed to tobacco (second hand smoke) after
birth have increased risk of SIDS, asthma, and other lung
related problems.
Alcohol
• When a pregnant woman drinks alcohol, so
does her unborn baby. There is no known safe
amount of alcohol to drink while pregnant and
there also does not appear to be a safe time to
drink during pregnancy either. Therefore, it is
recommended that women abstain from drinking
alcohol at any time during pregnancy. Women
who are sexually active and do not use effective
birth control should also refrain from drinking
because they could become pregnant and not
know for several weeks or more.
Accutane
• A person suffering from severe acne may be exposed to
Accutane during treatment. Accutane is a prescribed
medication that controls and prevents some of the
mechanisms in the glands that contribute to acne. A
developing fetus, whose mother is exposed to Accutane,
is extremely likely to develop either facial deformities,
heart defects, a small head, a cleft lip and palate, a
buildup of fluid in the brain, or mental retardation. This is
an extraordinarily dangerous substance for a developing
fetus.
Caffeine
• Caffeine is found in coffee, tea and colas.
Pregnant women should not take more
than 4 cups of caffeine containing foods
and beverages because it has the
following deleterious effects on the body.
– Diuretic, depletes water from the body
– Filling and satisfying without being nutritious
– Causes mood swings thus it may interfere with rest
and sleep
– Interfere with absorption of iron
– Baby may develop diabetes later in life
•
Drugs/ Medications

• Pregnant women should not use any

medication not prescribed or considered
safe by their health care provider.
 NURSING DIAGNOSES
• Much of the health history information obtained
at prenatal visits helps to determine whether a
woman has been exposed to a teratogen since
the last visit.
• Health-seeking behaviour related to mother’s
interest in avoiding exposure to substances
harmful to a fetus during pregnancy
• Risk for fetal injury related to lack of knowledge
about teratogenecity of alcohol, drugs and
cigarettes
• Risk for infection related to fetal transmission
from maternal exposure to chicken pox
 HEALTH HISTORY
• Prenatal Care/ Antenatal Care - Refers
to the health care given to a woman and
her family during pregnancy. The primary
goal of prenatal care is to provide
maximum health to expectant mothers and
their babies.
Goals of Prenatal Care
• To ensure a healthy and uncomplicated
pregnancy and the delivery of a healthy infant.
• To identify and treat high risk conditions.
• To individualize patient care.
• To assist the patient for her preparation for
labor, delivery and puerperium.
• To screen and identify risk factors or diseases
that may affect the mother or the infant’s health
and life.
• To reinforce healthy habits to the woman and
her family.
 C. Components of Pre-natal
Care:
1. History taking – begin in asking the woman of her chief
concern for coming to the health care facility.
• Personal Data – is often the first information gathered during
the interview including name, age, civil status, religion and
occupation.
Best childbearing years: 18-35 years old
Reproductive period: 15-44 years old
• Menstrual History
• Breast Health
• Contraceptive use
• Medical History - childhood diseases, drug allergies, past
surgeries, existing medical conditions, immunizations, sexual
relations, alcohol intake, cigarette smoking and use of drugs
and caffeine.
• Sexual relations – sexual desires continue during pregnancy
but sexual drive and responsiveness vary among women at
different stages of pregnancy:

1st trimester – decreased sexual desire due to discomforts

of pregnancy.
2nd trimester – increased sexual desire because the
woman has already adjusted to pregnancy and this is the
period when she is most comfortable.
3rd trimester – decreased sexual desire because of the
fear of hurting the fetus and the discomfort caused by
enlarged abdomen and deep penile penetration.
Contraindications to sexual intercourse:
• Ruptured bag of water
• Vaginal spotting or bleeding
• Incompetent cervical opening
During the last six weeks of pregnancy (36
weeks onwards), coitus is discouraged by some
physicians because it has been related to
increase incidence of postpartal infection,
preterm labor, premature rupture of membrane
and bleeding.
• Family History – significant disorder that could affect the
outcome of pregnancy include:

– Multiple gestation
– Diabetes Mellitus
– Hypertension
– Bleeding disorder
– Hereditary illnesses (e.g. cancer)
– Psychiatric disorder
2. Physical examination
– Weight
– Height
– BP
– Examination for conjunctiva and hands for pallor.
– Abdominal exam for fundic height, fetal position,
presentation and FHT.
– Examination of face, hands, lower extremities for
edema
– Examination of the breast
Examination of thyroid for enlargement and goiter

3. Treatment of disease
4. Tetanus Immunization - Adequate
immunization of women with TT prevents
tetanus in both the mother and the
newborn.
• TT1- Anytime during pregnancy
Duration of protection- infants born to mother
will be protected from neonatal tetanus.
• TT2- Give one month after TT1
Duration of protection- infants born will be
protected from neonatal tetanus and gives 3
years protection for the mother
• TT3- Given 6 months after TT2
Duration of protection- infants born will be
protected from neonatal tetanus and gives the
mother 5 years protection
• TT4-Given one year after TT3 or next pregnancy
Duration of protection- infants will be protected
from neonatal tetanus and gives the mother 10
years protection.
• TT5- Given one year after TT4 or next
pregnancy
Duration of protection- all infants born to that
mother will be protected and gives lifetime
protection for the mother.
 Tetanus Toxoid
Immunization Schedule for
Women
Vaccine Minimal Age Percent Duration of
Interval Protected Protection
As early as possible
TT1 during pregnancy 80%
At least 4 weeks later > Infants born to the
TT2 80% mother will be protected
from neonatal tetanus
> Gives 3 year protection
for the mother
At least 6 months later > Infants born to the
TT3 90% mother will be protected
from neonatal tetanus
> Gives 5 year protection
for the mother
At least 1 year later > Infants born to the mother
TT4 99% will be protected from
neonatal tetanus
> Gives 10 year protection
for the mother

At least 1 year later > Gives lifetime protection for

TT5 100% the mother
> All Infants born to the
mother will be protected from
neonatal tetanus
5. Iron supplementation
6. Health education
7. Exercise
8. Dental care
9. Clothing
- Bathing
- Breast care
 NORMAL CHANGES
DURING PREGNANCY
 SIGNS/ SYMPTOMS OF PREGNANCY:
Presumptive Signs of Pregnancy - are those that are least indicative
of pregnancy; taken as single entities, they could easily indicate
other conditions.
Four Signs:
• Amenorrhea – stoppage of normal period or flow
• Breast changes: increase in size and tenderness
• Skin pigmentation changes (appearance of chloasma, linea nigra and linea
alba)
• Perception of pregnancy by the mother
Symptoms
• Nausea with or without vomiting
• Urinary frequency
• Weight gain
• Constipation
• Fatigue
• Perception of movement
Probable Signs of Pregnancy - In contrast to presumptive signs,
probable signs of pregnancy can be documented by the examiner.
Although they are more reliable than the presumptive signs, they still
are not positive or true diagnostic findings.

Signs
– Abdominal enlargement and striae
– Vaginal mucosa discoloration (Chadwick’s sign)
– Uterine changes:
• Hegar’s sign – softening of the uterine isthmus by 6-8 weeks
gestation.
• Goodel’s sign – softening of the cervix by 6-8 weeks gestation
• Braxton Hicks contractions
• Ballotement – rebound of the fetus to its original position with the tap
felt by the examining finger.
• Outlining of the fetus
• Endocrine test positive for HCG levels
Positive evidences of Pregnancy

• Fetal heart beat heard by the examiner

• Fetal outline confirmation by sonography
• Fetal movements felt by examiner (after
20 weeks of gestation)
PHYSIOLOGIC CHANGES
OCCURING IN
PREGNANCY
1. Reproductive System
• Uterus - Uterine weight: prepregnancy – 50
grams, at term – 1000 grams. Blood flow: uterine
blood flow increases from 20ml before pregnancy to
700-900 ml at the end of pregnancy. Position: after
12 weeks gestation, the uterus loses its anteflexed
position. Contractility: Being muscular, the uterus is
highly contractile organ. Beginning on the first
trimester, the uterus undergoes irregular
contractions known as Braxton-Hicks become more
intense and frequent causing some discomfort on
the pregnant woman. It is the cause of false labor.
• Isthmus - During pregnancy, the isthmus softens and
elongates up to 25 mm. It will later form the lower uterine
segment together with the cervix.
• Hegar’s sign – softening of the lower uterine segment at
6-8 weeks gestation.
• Cervix - color of the cervix change from pinkish to
purplish due to increased blood supply. Leukorrhea:
estrogen stimulation results in increase mucus
production that leads to the formation of operculum, the
mucus plug of the cervix that protects against bacteria
and infection. The discharge of operculum at term, called
show, is an important sign of labor. Consistency:
softening of the cervix, known as Goodle’s sign, is
observable by 6-8 weeks gestation.
• Vagina -increase blood supply results in:
• Chadwick’s sign – vaginal mucosa change in
color from pinkish to purplish or dark-bluish.

• Ovaries - No Graafian follicle develops and no

ovulation occurs during pregnancy. Corpus
Luteum of pregnancy – is the chief source of
hormone progesterone during the first 12 weeks
of gestation.
• Breast - Increased breast size due to alveolar tissue growth, fat
deposition and increased vascularity occurs. Breast changes
associated with pregnancy include feeling of fullness and tingling
sensation, darkening of the skin around the areola. Montgomery
glands enlarge and become prominent, and nipples stand out. Clear
fluid, called colostrum can be expressed from it as early as the
fourth month.
• 3-4 weeks – pricking, tingling sensation due to increased blood
supply particularly around the nipple.
• 6-8 weeks – developing ducts and glands cause the breasts to be
enlarged, painful and tense, particularly in women who normally
experience premenstrual changes. Bluish surface veins are visible
• 8-12 weeks – Montgomery’s tubercles become more prominent on
the areola. These sebaceous glands secrete sebum which keeps
the nipple soft and supple. The pigmented area around the nipple
darkens and may enlarge slightly. This area is known as the primary
areola.
• 16 weeks – Colostrum may be expressed.
• Late pregnancy – colostrum may leak from the breast.
2. Cardiovascular System
• The heart is displaced to the left and upward as the
diaphragm is progressively pushed upward elevated by
enlarging uterus. Slightly cardiac enlargement by a little
more than 10%. Increased blood volume means an
increased in cardiac workload because of this, slight
hypertrophy of the heart occurs. Pregnant women
usually experience palpitations during pregnancy.
Cardiac output is increased appreciably when the
woman is in left lateral position. Pulse rate increases
about 10-15 beats per minute. Increased level of clotting
factors making woman prone to thrombus formation.
Instruct to avoid massage.
• BP remains the same as pre-pregnancy level. It
may drop slightly on the second trimester but
returns to normal levels on the third trimester.
Supine Hypotensive syndrome – when the
women lies on her back, the gravid uterus lies
on the inferior vena cava and interferes with the
blood flow from the lower extremities, resulting in
blood returning to the heart to be greatly
reduced. The decreased amount of blood going
back to the heart results in decreased cardiac
output that leads to:
• Decreased blood pressure
• Decreased blood supply to the brain causing
dizziness, faintness, and light-headedness.
3. Respiratory System
Changes in the respiratory system during pregnancy
are chiefly caused by:
• Increased oxygen requirement as the mother must
supply not only for herself but for the baby too.
• Mechanical effect of the enlarging uterus that reduces
the space in the chest.
• Hyperventilation:
• The mother experience hyperventilation in an effort to
blow off the extra carbon dioxide from the fetus.
• Displacement of the diaphragm by the enlarged uterus
up to 4cm causing shortness of breath.
• Nasal congestion occurs due to estrogen stimulation.
Advice the woman that this is normal during pregnancy.
•
4. Urinary System
Urinary frequency during pregnancy is due to:
– First trimester – uterus exerts pressure on the bladder as it
rises out of the pelvic cavity.
– Third trimester – pressures of the presenting part on the
bladder after lightening.
– Increased blood flow to the kidney which increase glomerular
filtration rate and consequently, urinary output.

• Lactosuria – presence of sugar or lactose in the urine is

considered normal. Lactose is secreted by the mammary
glands but since it is not yet used during pregnancy, it
normally spills in the urine.
5. Gastrointestinal System
• Nausea and vomiting on the first trimester is attributed to:
• Increased hCG levels
• Increased estrogen levels
• Decreased maternal glucose levels as glucose is being utilized for
fetal brain development

Effects of progesterone
• Decreased GI motility and longer emptying time which leads to
constipation.
• Pyrosis/ Heartburn – relaxation of cardiac sphincter results in reflux
of acidic gastric contents (due to hydrochloric acid into the lower
esophagus which irritates the esophageal mucosa. Instruct to avoid
gastric irritants such as coffee, tea and chocolates.
Effects of estrogen
• Ptyalism – increased salivation
• Epulis – hypertrophy or swelling of the gums, advice to
use soft toothbrush to avoid gum bleeding.
• Change in sense of taste
• Increased appetite
• Displacement of stomach and intestines
• Pica –bizarre craving for and compulsive, secret
chewing of unusual food or ingestion of non-food
substances (e.g. Ice, coal, disinfectants, clay, chalk,
starch, toothpaste, soil, ash). Reduced sensitivity of the
taste buds during pregnancy creates the desire for
markedly sweet, sour, or salty foods. Pica may prevent a
woman from ingesting foods with nutritional value.
• Maternal Weight
– 4.0 kg in the first 20weeks
– 8.5 kg in second 20 weeks
– 12.5 kg approximate total

• Factors affecting weight gain are the

following:
– Maternal edema
– Maternal metabolic rate
– Dietary intake
– Amount of the amniotic fluid
– Fetal weight
– Some disease conditions
6. Skeletal Changes
Softening of joints and ligaments especially of
symphysis and sacroiliac joints caused by relaxin and
progesterone. Posture usually alters to compensate for
the enlarging fetus posteriorly; the woman leans
backwards, causing progressive lordosis (forward curve
of the lumbar spine).
• “Pride of pregnancy” – is sometimes referred to the
stance of a pregnant woman that tends to stand
straighter and taller than usual.
• Leg cramps – caused by pressure of gravid uterus on
nerves and imbalance of calcium in the body.
7. Skin Changes
• Increased melanin production:
• During pregnancy – the anterior pituitary gland produce
more melanotropin stimulating hormone (MSH) which
stimulates the melanocytes in the skin to produce
melanin. This results in darker skin coloration in certain
parts of the body:
• Melasma/ Chloasma - deeper patchy coloring of the
face, “mask of pregnancy.”
• Linea nigra – dark line from umbilicus to symphysis
pubis.
• Hyperpigmentation of areola, perineum, neck and axilla.
• Striae Gravidarum - enlargement of the uterus results in
stretching and tearing of the elastic fibers of the
abdominal skin, that results in striae that appears pinkish
during pregnancy and turn silvery white after delivery.
Pruritus or itching of the abdominal skin is due to
stretching of the skin. Striae may also appear in the
thighs and breast.

• Effects of estrogen
– Palmar erythema- redness and itching of the skin.
– Activation of sweat and sebaceous glands result in increased
perspiration and oily skin
– Vascular spider nevi – prominent capillaries under the skin.
Minor Discomforts
Experienced by
the Mother during
Pregnancy
Discomforts related to the
Gastrointestinal System