NORMAL

PREGNANCY
DEFINITION
PREGNANCY

It is the development of one or more offspring known as an

embryo or fetus in a women uterus. It is the common name for
gestations in humans.
OR
The progression of stage from conception to birth is called
pregnancy.
The reproductive period women begins at menarche, 12-18. End in menopause,
45-55.

DURATION OF PREGNANCY-

The duration of pregnancy has traditionally been calculated by the clinicians in

term of 10 lunar months as 9 calender months 7 days, 280 days or 40 weeks,
calculated from the Ist day of the last menstrual period. This is called
menstrual or gestational age.

Fertilization usually occurs, 14 days prior to the extended missed period & in a
previously 28 days of cycle.
Terminology

 Para- number of births after 28 weeks gestation regardless of whether

the infants were born alive or dead,twins are considered a single para
 Primagravida- woman pregnant for the first time
 Mulrigravida- woman who is in Conceive second or more pregnancy
 Gravida- No of Conception
 Nulligravida- a woman who has never been pregnant
 Multipara-woman who has given birth two or more times at more than
28 weeks gestation/
Trimesters & length of pregnancy
Old Added
◦ Newly Added  Average Pregnancy lasts 280 days-40
– 1st trimester 0-3months(1-14WK) weeks and is divided into trimesters
– 2ndTrimester 3-6 months(14-28/29WK) – 1st trimester 0-3months(1-12/13WK)
– 3rdTrimester-6-9 months(29-39WK) – 2ndTrimester 3-6 months(14-27WK)
– 10 lunar months – 3rdTrimester-6-9 months(28-39WK)
– 9 calendar months – 10 lunar months
– 9 calendar months
Profile of previous obstetric history

 GTPALM
 G=gravida
 T=term
 P=premature births
 A=abortions
 L= number of living children
 M= multiple births
Obstetrical Score GTPAL/ GTPALM

 A lady who is pregnant has 3 children and a history of 1

miscarriage (abortion).

 This would be written as follows

–G T P A l M
– 5-3-0-1-3-0
 Other institutions use only 2 letters
– P & G to indicate PARA and Gravida
– A woman pregnant for the first time would be
P0, G1
A woman is pregnant has 4 children and has a history of 2
abortions
 P4, G 7
DETERMINATION OF DATE OF BIRTH

 Nagele’s rule
 1st day LMP - 9 months + seven days
 LMP Oct 10th2023
 +9mts
 +7 days
 EDD= July 17th 2024
Pre-natal care
 Improved pre-natal care has dramatically reduced infant and
maternal mortality
 Detecting potential problems early leads to prompt assessment
and treatment
 Preventative measures such as adequate nutrition, proper
exercise, assessment of pregnancy and a planned regimen of
care are essential
 A pregnant woman should seek health care as soon as she
suspects she is pregnant
Physiological changes during pregnancy
During pregnancy there is progressive anatomical and physiological changes in all system of today
especially to the genital organs.

Changes in the reproductive system:-

The changes in pregnancy that take place in the reproductive system are a temporary adoption to meet
the needs & demands of the fetus.

Uterus
Consists 3 layer
An extended serous epithelial layer or perimetrium.

The middle muscle layer or myometrium.

The internal layer endometrium (decidua)

 Perimetrium
 Thin and outer most layer of peritoneum that protects the uterus.
 Myometrium
 The myometrium is made up of highly muscular smooth muscle fibers, middle layer held together by
connective tissue.
 This is expand during pregnancy and contracts to push your baby out.
 Muscle fibers grow up to 15 to 20 times their non pregnant length.
 Decidua/Endometrium
 Decidua' in pregnancy endometrium is called decidua.
 The inner layer or lining of your uterus (uterine lining).
 Estrogens & progesterone produced by the corpus luteum, causes the decidua to become thicker, richer
& more vascular the fundus & in the upper body of the uterus, which is the visual site of implantation .
The decidua provides a glycogen rich environment for the blastocyst until the
placenta is formed.

Blood Supply:
The uterine blood vessel increased in the diameter and new vessels develop under the

influence of estrogen.
The blood supply to the uterus through the uterine & ovarian arteries increases to

about 750ml per minutes at term, and with its growth & also meet the needs of the
functioning placenta.
 Changes in uterine size
 The size of the uterus increases-
 Length- 6.5 to 32,35cm
 Width- 4 to 24cm
 Depth- 2.5 to 22cm
 Weight on pre pregnant stage- 50 to 80gm
 Weight increases during pregnancy- 50 to 1000gm
 Shape- Pyriform shape
 At 12 week- globular
 At 16 weeks- dome shape
 At 28 weeks- ovoid
 At 36 weeks and beyond- spherical
 Changes in uterine shape/growth of the uterus-
Weeks Measurement of fundal height
8 weeks •Uterus cannot be palpated abdominally.
•Bimanual examination its found to be about the size of a
“tennis ball”
12weeks •Uterus fills the pelvic cavity & the fundus reaches just
palpable above the symphysis pubis.
•It is globular in shape like a small grape fruit.

16weeks •At lower one- third of the distance between the symphysis
pubis and umbilicus or 7.5cm.
•The fundus becomes doom shaped between 12 to 16 weeks.
20weeks •At two- third of the distance the fundus is below between the
level of umbilicus or 15cm above the symphysis pubis.
•In avoid shape.
24weeks At the level of the umbilicus (about 20cm).
28weeks At lower one- third of the distance between the
umbilicus and xiphsternum.
30weeks Rise ultimately reaching near the subcostal arch.
32weeks At one- third of the distance between the umbilicus and
xiphsternum.

36weeks At the level of xiphisternum

38 to 40 weeks •At the 38weeks, the fundus sinks down to about the level
of 32 weeks of pregnancy known as lightening .
• Descent of the fetal head into the pelvic brim (engagement
) leads to slight lowering of the fundus known as lightening
which causes a changes in shape of the abdomen.
The fallopian tube
 The fallopian tubes on either side are more stretched out in pregnancy and
is much more vascular.
 Total length is increased
 Tube become congested
 Muscle undergo hypertrophy
 The uterine and of the tube is usually ilosed and the fimbriated end remains

open.
Cervix
 The cervix remains tightly closed during pregnancy providing protection to
the fetus and resistance to pressure from above when the women is in
standing position.
 Softening of the cervix (Goodell’s Sign).
 Vascularity is increased.
 Squamous cells also become hyperactive.
 Secretion is copious and tenacious- physiological leucorrhoea of pregnancy
 Becomes bulky.
Isthmus
 During the first trimester isthmus hypertrophies and elongates to about 3
times its originals length.
 Becomes softer.
Vagina
 It becomes vascular and hypertrophied, looks bluish, felt soft
 Increased blood supply of the venous plexus surrounding the wall gives the bluish.
 Vaginal secretion, increases in amount and is acidic (3.5-6) due to the production of
lactic acid.
 Its acidic because of the presence of bacillus bacteria.
 It can covert glycogen in to lactic acid and makes vagina acidic.
 It prevent the growth of micro organisms and ascending infection.
 CHANGES IN OTHER
SYSTEM OF THE BODY
CARDIOVASCULAR SYSTEM
 Size of heart- increases about 12%.
 Cardiac capacity- increases 70-80ml.
 Cardiac output- increase by 30-40% till 30 weeks there after continue to

increase up to 15% till term.

 Clotting time- from 12 minutes to 8 minutes.
 Blood pressure
 Systolic- slight changes or same.
 Diastolic-reduce 5-10 mmHg at about 12-26 weeks and by 36 weeks

comes to pre pregnancy level.

 There is no changes in ECG,.
 Cardiac output increases by 15-30% due to increased heart rate and

increase stroke volume.

 Pulse rate near term increase by 10 per minute.
 Platelet count shows slight decrease due to increased concentration.
 Blood pressure and blood volume
 Blood pressure remains with in normal limits.
 Due to pressure of gravid uterus on pelvic veins.
 Venous pressure- femoral venous pressure rises from 10cm water to 30 cm

water.
 Blood volume increases from 3rd month and reaches a peak of 25% rise at

32 weeks.
 The red cells volume increases by 200ml, plasma volume increases to

100ml.
 Capillaries- increased permeability.
RESPIRATORY SYSTEM
 The shape of the chest changes and circumference increase in pregnancy
by 6cm.
 As the uterus enlarge the diaphragm is elevated as much as 4cm and the rib

cage is displaced upwards.

 The lower ribs flare out and may not always fully recover their original

position after pregnancy.

 Increase the oxygen consumption cause by the increased metabolic needs

of the mother and fetus.

 Normal oxygen consumption is 250ml/min at rest and increase by 20% in

pregnancy in order to meet the 15%.

 The mucosa of the respiratory tract becomes hypermic and edementous
with hyper secretion of mucus which can lead to staffiness and epitaxis
 Edementous is swelling caused by excess fluid in body tissue.
 As a women suffer from chronic cold during pregnancy.
 Long term use of nasal decongestant sprays should be avoid because of

their effect on mucosa.

 During later weeks of pregnancy there is an uphold displacement of

diaphragm which decrease the capacity of lungs causes breathlessness

before 36 weeks of pregnancy.
URINARY SYSTEM
 Kidney- increase in length by 1-1.5cm.
 Ureters- (a) Elongate, widen and are curved, (b) Result in increased

urinary statsis. (infection)

 Bladder- (a) vascularity increase, (b) muscle tone decreases, (c) bladder

mucosa edematous, (d) Increased frequency of urination

 GFR- increases by 50%
 Renal blood flow (plasma flow rate)- increase by 25-50%.
 The urine of pregnant women is more alkaline due to the alkalemia of
pregnancy. Due to increase ph its acidic.
 The muscle of the bladder is relaxed & raised level of progesterone.
 Towards the end of pregnancy as the head engages the entire bladder may

be displaced upwards.
 Urinary output is diminished because of an enhanced tubular reabsorption

of water.
GASTROINTESTINAL SYSTEM
 Oral cavity: increase salivation
 Saliva become acidic- causes tooth decay
 Gums may swell and bleed easily, due to increased vascularity
 Changes in sense of taste.
 Increase craving for bizarre substances, example: Mud, pencil, etc.
 Stomach and esophagus: due to increase hormonal level (progesterone

and relaxin)-- muscle of digestive tract become relaxed causing frequent

gastric reflux.
 Gastrointestinal motility: increase progesterone –- decrease GI motility –-

Constipation.
MUSCULOSKELETAL SYSTEM
 Gravid uterus—alteration in body posture—lordosis (effects on lumbar
spine called swayback).
 Increase estrogen and progestrone– relaxes/ softens pelvic joints and

ligaments.
METABAOLIC CHANGES
 Increase total lipids, triglycerides, cholesterol and phospholipids.
 Increased (15%) caloric requirements.
 Increased (50%) protein requirements.
 Increased requirements for folate, calcium, phosphorus, magnesium, iron,

vitamin A and C, zinc and iodine.

Weight gain
 A pregnant woman gains weight around 12kg of weight.
Reproductive weight gain –
 Weight of fetus- 3.3kg
 Weight of placenta- 0.6kg
 Weight of liquor- 0.8kg
 Weight of uterus- 0.9kg
 Weight of breasts- 0.4kg

Net maternal weight gain-

 Increase in blood volume- 1.3kg
 Increase in extracellular fluid- 1.2kg
 Accumulation of fat and protein – 3.5kg
Skin changes
 Linea Nigra-dark hairy line that runs from umbilicus to symphysis pubis
become dark.
 Chloasma: Brownish hyperpigmentation of skin over face and forehead

also called mask of pregnancy.

 Striae gravidarum- stretch marks on abdomen, thighs and breasts/ breast.
 Vascular spiders- minutes red elevations on face, neck arms and chest.
Breast changes
 Breast become more vascular.
 Weight increase (0.4kg)
 Secretion of colostrum.
 Pigmentation of areola.
 Development of montgomery’s tubercles( oil sebaceous) darker.
 Development of secondary areola(2nd trimester)
HEMATOLOGICAL CHANGES
 Increased blood volume (30-40%), red blood cells (20-30%), plasma
volume (40-50%) and viscosity of blood is decreased.
 Hb increase but Hb concentration/hematocrit is decreased.
 Increased blood fibrinogen. 5g/l
 Fibrinolytic activity depressed.
 Increased level of all coagulation factors except factor XI and factor XII

factors.
 Increased erythrocyte sedimentation rate (ESR) (about 4 times).
 Decreased haematocrit
 Neutrophilic leucocytosis occur.(WBC, fight infection,heal injuries.
ENDOCRINE SYSTEM
 Syncytiotrophoblast secretes beta hCG
 Placenta secretes human placcental lactogen.
 Pituitary gland enlarges and compresses optic nerve that causes headache.
 Follicle –stimulaitng hormone (FSH) and luteinizing hormone (LH)

inhibited during pregnancy.

 Thyroid gland enlarges, basal metabolic rate increases.
 Increase ACTH and cortisol level.
 Hyperinsulisim occurs if mother is dabetic.
a) Placental hormones
 The high levels of estrogen and progesteron responsible for breast changes,
skin pigmentation an a uterine enlargement in the first trimester.
 Chronic gonadotropin is the basis for the immunologic pregnancy tests.
 Human placental lactogen stimulates the growth of the breast.
B) Pituitary hormones
 Follicle stimulating hormones and lutenizing hormones secretion is greatly
inhibited by placental progestrone and estrogen
 Prolactin causes the breasts to grow and make milk during pregnancy and

after birth.
 The posterior pituitary gland releases oxytocin in low frequency pulses

throughout pregnancy for arising uterine contraction.

C) Thyroid function
 There is normally an increased uptake of iodine during pregnancy which
may be to compensate for renal clearance of iodine leading to reduced level
of plasma iodine.
 Pregnancy can give the impression of hyperthyroidism thyroid function is

basically normal.
D)Adrenal gland
 Adrenal gland is stimulated by estrogen to produce increasing levels of
total and free plamsa cortisol and other corticosteroids include- ACTH
from 12 weeks to term.
 Free cortisol have an antagonistic action to insulin more glucose in made

available to the fetus by raising the level of glucose in the blood mobilizing
maternal fatty acids and aminoacid for production of glycogen and
decrease the uptake of glucose by muscle.
PSYCHOLOGICAL CHNAGES
 Pregnancy is an experience full of growth changes, environment and
challenge.
 Fears and expectation about becoming parents.
 Emotions in both mother and father.
 Mood swings
 Depression
 Anxiety
 Psychological fatigue
NERVOUS SYSTEM
 The nervous system is a more excitable condition in pregnant women
tempramental changes are frequently noticed mood changes: like excited,
sad, laughing , anxious etc. and sometimes symptoms of psychosis may
develop in those with in a family history.
 TOPIC-2

DISCOMFORT OF PREGNANCY
Nausea and vomiting:
Nausea and vomiting upon getting up in the morning are experienced by some women,
especially primigravidae in the first trimester. Normally the problem subsides
automatically after first trimester.

Treatment:
 Avoid fatty food and fluid in empty stomach.

 Take dry toast or biscuit before rising out of bed.

 Antiemetic drugs can be taken with plenty of glucose drink

Constipation:
 This is common problem in pregnancy due to the effect of progesterone on the

intestines and diminished physical activity, gravid uterus reduces the GI motility.

Treatment :
 Regular bowel habits

 Take plenty of fluids/vegetables/ ilk and milk products.

 Mild laxative if required

Heart Burn:
 It is due to the effect of progesterone, which relaxes the cardiac sphincter during

pregnancy. The stomach is compressed and pushed up by the gravid uterus. As result,
digestion is impaired in the stomach and takes longer to empty the food.

Treatment:
 Avoid taking heavy meals.

 Eat small, frequent meals.

 Avoid spicy/fatty foods.

 Avoid eating before sleeping.

 Take pillow during sleep.

 Avoid drinking lot of liquids with meals.

Bleeding from gums:
 It is due to increased blood supply to the gums and higher blood level of

progesterone. Soft brushes should be used to prevent bleeding from gums.

Flatulence:
 Increase gas in bowels, caused swallowing air in order to relieve nausea.

Pica:
 it is a craving for certain foods or unnatural substances, such a mud,

or pencil, etc.
Backache:
This sort of problem is experienced in the last trimester by some women. Relaxation of
pelvic joints, faulty posture, shift of center of gravity, muscle spasm and urinary
infection are some of the common causes for backache.

Treatment:
 Advice rest in hard bed.

 Massaging back.

 Analgesics.

 Wearing well-fitted pelvic girdle belt during walking.

Leg cramps
 Leg cramps often occur due to deficiency of serum calcium, elevation of serum

phosphorus and pressure of gravid uterus on pelvic nerves.

Treatments :
 Instruct the patient to elevate her legs periodically.

 Avoid lying with toes pointed.

 Take calcium and vitamin B complex substances.

 Take warm bath at bed time.

 Wear elastic stockings.

 Regular exercise.
Dizziness and fainting:
 Dizziness and fainting occur mainly because of fall in B.P as progesterone relaxes

the muscles of blood vessels or gravid uterus puts pressure on the inferior vena cava
and diminishes blood return to the heart.

Treatment:
 Advice mother to lie in left lateral position.

 Avoid long periods of standing.

 Vericosa vein:
 Varicosa vein in the legs, vulva or rectum appear in the later month of pregnancy
due to effect of progesterone that relaxes the smooth muscles of veins which result
in diminished circulation. Gravid uterus also compresses the pelvic nerves.


 Treatment:
 elevation of legs while resting.

 Wear elastic crepe bandage during walking.

 Perform circulatory exercises for toes and ankles.

 For hemorrhoids mild laxatives, regular bowel

habits and hydrocortisone ointment can be used.

Ankle edema:
 Ankle edema occurs due to retention of fluid during pregnancy, hot weather and

because of long standing period.

Treatment :
 Not to sit with feet hanging down.

 Elevation of longs while resting.

 Not sit near the edge of chair.

Polyuria and Dysuria:
Two main cause:
 Gravid uterus put pressure on the bladder.

 Kidneys function efficiency and the urine production increases.

Treatment :
 Take more fluids during day time.

 Avoid holding the urine.

 Early treatment of urinary tract infection.

Leucorrhea:
 During pregnancy, there is increased white, non-irritant vaginal discharge, due to

changes in vaginal pH and flora.

Treatment:
 Instruct woman for local cleanliness of genitals.

 Presence of any vaginal infection treated with medication such as metronidazole or

miconazole.
 Avoid tight/synthetic underwear.
Itching/Pruritus:
 The skin of abdomen stretches during 3rd trimester and becomes dry and itchy. There

are stretch marks on breasts, abdomen and thighs.

Treatment:
 Drink plenty of fluids.

 Apply any moisturizing lotion.

Depigmentation of skin:
 The three main areas of the darkening of the skin are: around the nipples, around

navel and between external genitalia and anus. It is believed to be due to higher level
of estrogen in pregnancy.



Carpal Tunnel Syndrome:
 Retention of fluids during pregnancy, causes edema and pressure on the median

nerve. Women feel numbness, “pins and needles” in the fingers and hands.

Treatment:
 Restrict salt intake in the diet. Rest the hands on pillow while sleeping wear splint at

night. Perform circulatory exercise such as flexing and extending of fingers and
wrist.
Insomnia:
 It is due to uncomfortable posture during pregnancy, frequency of micturition, fetal

movements, etc.


Treatments:
 Lie in left lateral position.

 Provide comfortable environment.

 Wear loose/cotton cloth at night.

 Pass urine before going to bed. Do not drink fluids before sleeping.
 TOPIC-3
DIAGNOSIS OF PREGNANCY
SIGN OF PREGNANCY
Pregnancy Trimester
Diagnosing of normal pregnancy can be divided according to the pregnancy trimester.
 First trimester (early pregnancy) first-12 -14weeks.

 Second trimester (mid pregnancy) 13-14-28 weeks.

 Third trimester (late pregnancy) 29-40 weeks.

 Signs and symptoms of pregnancy
1. Presumptive sign
2. Probable sign
3. Positive sign
1. Presumptive sign/ Subjective sign
 Amenorrhea (Cessation of menstruation) 4 weeks.
 Nausea and vomiting from 4th to 14 weeks.
 Tingling, tenseness and enlargement of breasts from 3rd to 4th week.
 Frequency of micturition (6-12 weeks) increases.
 Fatigue.
 Quickening- the fetal movement of fetus felt by the mother around 18-20th week.
 Breasts changes include darkening of nipples, primary and secondary areolar
changes and appearance of montgomery tubercles.
 Presence of colostrums in the nipples.
 Excessive salivation.
 Skin pigmentation and condition such as chloasoma, breasts and abdominal striae,
linea nigra and palmer erythema.

2. Probable sign/objective sign
 These are maternal physiological changes other than presumptive signs which are
detected upon examination and documented by the examiner.
 Enlargement of the uterus.
 Presence of hCG in blood from 6-12 weeks.
 Vaginal discharge- copious non irritating mucoid discharge which appears at 6th
week.
 Hegar’s sign- (6th to 8th weeks) this is softening of the lower uterine segment just
above the cervix. When the uterine is compressed between examining fingers, the
uterine wall fees like paper thin. The physician will use bimanual maneuver
stimultaneously (abdominal and vaginal) and will cause the uterus to tilt forward.
 Jacquemier’s sign/chadwick’s sign- (8th week)-Violet blue discoloration of the
vaginal membrane due to increased vascularity by about 8th week.
 Osiander’s sign- (8th week) -Increased pulsation felt in the lateral fornices from 8 th
week onwards.
 Palmer’s sign- (4-8th week)-Regular and rhythmic uterine contraction resembling
systole and diastole of heart that can be elicited during bimanual examination as
early as 48 weeks.
 Goodell’s sign – softening of the cervix from a non pregnant state of frimness
similar to the tip of nose to the softness of lips of mouth in the pregnant state by 6th
week.
 Globular enlargement of uterus with soft consistency. (10th
week)
 Palpation of Braxton Hick’s Concentration.(20th week)
 Ballottement of fetus from 16th to 28th weeks.
 Uterine souffle 16th weeks.
 Piskaceks sign- (5-8th weeks)- Irregular softening and

enlargement of the uterine fundus during early pregnancy . It

occurs at 5-8 weeks gestation, the sign is named after karl von
braun –fernwald.
3. Positive Signs
 Visualization of fetus by ultrasound from 6th week onwards.
 Visualization of fetal skeleton by 16th week.

Fetal Heart
 It can be heard with stethoscope or fetoscope after 18 weeks of pregnancy. These sound are heard

at a rate of about 140 to 160 beats/min and fetal heart tone with doppler ultrasound as early as the
10th weeks.

Fetal part
 Fetal parts can be felt about the 22nd and 24th weeks.

Fetal Movement
 Fetal movement can be palpable and visible about the 22 nd week of pregnancy.
 Ultrasound Evidence
 It is available as early as 6 weeks amenorrhoea.

 Radiological Evidence
 Radiological demonstration of fetal skeleton can be made the 16th weeks of
pregnancy.
 TOPIC-3
DIFFERENTIAL DIAGNOSIS
OF PREGNANCY
 While the clinical diagnosis of pregnancy at times becomes easy but there are
occasions where the diagnose poses a problem. The enlargement of uterus caused by
pregnancy may have to be differentiated from abdominal pelvic swellings, such as
uterine fibroid, cystic ovarian tumor, encysted tubercular peritonitis, hematometra or
even distended urinary bladder.
Condition correlating with pregnancy
 Pseudocyesis (false pregnancy)- it is a psychological disorder where the women has
the false but firm belief that she is pregnant although no pregnancy exists. The
women often is infertile who has an intense desire to have a baby. The conspicuous
feature is cessation of menstruation. Other confusing manifestations are gradual
enlargement of the abdomen because of deposition of fat, secretion from breasts and
intestinal movements, imagining it to be fetal movement. Obstetric and clinical test
reveals absence of positive signs of pregnancy.
 Fibroid- In case of fibroid, women may become confused with pregnancy because
of enlargement of abdomen.

 Clinical manifestation includes-

 Tumor is slow growing, often takes years.
 Amenorrhea is absent.
 The feel is firm, more towards hard but may be cystic degeneration.
 Positive signs of pregnancy are absent.
 Ultrasonography or immunological test for pregnancy gives negative result.
 Cystic ovarian tumor- The diagnostic points are-

 The swelling is slow glowing, usually takes months to grow.

 Amenorrhea is usually absent.
 It feels cystic or tense cystic.
 Absence of braxton-hicks contraction.
 Encysted Peritonitis-
 History of koch infection.
 Amenorrhea of longer duration may be present.
 Swelling ill defined.
 Absence of positive signs of pregnancy.
 Internal examination reveals normal uterus separated from the swelling.
 Ultrasonography- absence of fetus.
 Distended urinary bladder-
 In chronic retention of urine due to retroverted gravid uterus, the distended bladder
may be mistaken as ovarian cyst or acute hydramnios. Catheterization of the bladder
solves the problem.
Confirmatory Test
 Immunologic test- This test is based on the production of chorionic gonadotropin
(hCG) by the syncytiotrophoblastic cells during early pregnancy.hCG is secreted into
maternal bloodstream and then excreted in mother’s urine.
Specific antisera are mixed with urine from the women suspected of being
pregnant. If the urine contains hCG, it will neutralize the antibodies in the antiserum
and inhibit agglutination indicating a positive pregnancy test. If the urine does not
contain hCG, agglution will occur indicating negative pregnancy test.
 Radioimmunoassay test- Blood is tested to detect the beta hCG subunit. These are
extremly senitive tests, able to detect hCG at far lower levels than other tests. The
test known as beta-preg can be used as early as one week after conception, if
laboratory facilites are available.
 Ultrasonography- Ultrasonography of abdomen can diagnose the pregnancy as follows-

 At 5th Week- spherical gestation sac is visible.

 At 6th Week- fetal pole can be seen.
 At 7th Week- one can see crown- rump length.
 At 10th Week- fetal heart sound heard by ultrasound doppler.
 At 12th Week- biparietal diameter (2.1) is seen.

Transvaginal ultrasonography- can diagnose earlier than abdominal sonography

 At 4th Week- visualization of gestational sac.

 At 5th Week- yolk sac and fetal cardiac motion.

 TOPIC-3
ANTENATAL ASSESSMENT
 Antenatal care refers to the care given to an expectant mother the time of the conception
until the beginning of labor.


 Objectives –
 Promote, protect and maintain the health of the mother during pregnancy.
 Detect high risk pregnancies and give special attention.
 Foresce complications and take preventive measures.
 Remove anxiety and fear associated with pregnancy and outcome.
 Reduce maternal and infant morbidity and mortality.
 Teach the mother elements of nutrition, personal hygiene and newborn care.
 Sensitize the mother to the need of family planning.
 Prepare the mother for motherhood.
 The importance of regular visits to the prenatal clinic must be emphasized to help the
mother, have an optimum outcome of pregnancy that is “healthy mother with healthy
baby.

Assessment –
 History taking – Ideally the mother should visit the antenatal clinic once a month

during the first seven months (28 weeks) twice a month during the eight month (up
to 32 weeks) and thereafter once a week if everything is normal. The first visit
irrespective of when it occurs should include the client’s health history, obstetric
history, physical and pelvic examinations and laboratory examinations.
Antenatal History Collection
I. Patient profile
 Full name :
 Age (in years) :
 Hospital No. :
 I.P. No. :
 Material status : Married/Ummarried/divorced/separated
 Occupation :
 Husband’s name :
 Age (in years) :
 Education status :
 Occupation :
 Type of family :
 Per capita income :
 Date of booking :
 Date of last antenatal visit :
 Date of admission :
 Obstetric score :

Gravida :
Para :
Abortion :
MTP :
Living :
II. Reasons for hospitalization/chief complaints
 Onset

 Duration

 Severity

 Relieving factors

 Aggravating factors

III. Menstrual history

 Age at menarche

 Duration of cycles

 Regularity

 Flow- heavy/ moderate scanty

Clots
Number of days
 Any dysmenorrhea
 Relief measures

 Last menstrual period

 Period menstrual period

IV. Obstetric history:

Pregnant obstetric history
• Is pregnancy confirmed : yes/no

• When, where and how it was confirmed

• What test was done for confirmation

• Quickening

• Immunization

Other complaints like: vomiting, hemorrhoids, heart burn, backache, bleeding, vericose vein,
constipation, leg cramps, fever, leucorrhoea, anorexia, insomnia.
S.No Date of Place of Duration Method of Course of Labor Puerperium baby
delivery birth of delivery pregnancy
pregnancy
sex weight
V. Family history:
• Congenital diseases

• Any hereditary diseases

• Multiple pregnancy

• Diabetes

• Heart disease

• Any mental retardation

• Hypertension or PPH (in mother/sisters)

• Twin pregnancy

• If yes, in whom? Mother/Father

VI. Medical-surgical history
• Childhood disease

• Chronic disease, like asthma, disease, diabetes, epilepsy

• Previous surgery

• Injuries, especially of back and pelvis

• Hepatitis, STD, HIV

• History of anemia

• Any medication taken at present or past

• Reason for use, date stopped

• Blood transfusion, allergic reaction

VII. Nutrition:
• General nutrition- veg/non-veg

• Appetite – decreased/increased

• Any eating disorders 24 hours recall

VIII. Partner’s health history:

• Genetic abnormalities

• Chronic disease

• Infections

• Use of drugs such as cocaine, alcohol

• Smoking habits: tobacco, cigrette

• Sexually transmitted disease- HIV/AIDS

• Blood type
IX. Psycho-Social history:
• Emotional changes experienced

• Women’s and family’s reactions to present pregnancy family support system- family

members and friends

• Coping strategies

• Lifestyle changes

• Social relationships with the neighbours

• Financial support
Physical examination
 General appearance:
A complete screening physical examination is done during the initial antenatal
examination in order to ascertain if the women has any medical disease or
abnormalities. General observation includes appearance, emotional state, posture and
apparent state of health.
The components of physical examination are as follows-
• Built: obese/average/poor

• Nutrition: Good/average/poor

• Height: short or long stature ( below 5 feet) short stature is likely to be associated

with a small pelvis.

• Weight: weight checking at each visit by weighing machine.
 Pallor: sites noted are conjunctiva, dorsum of tongue and nail beds.
 Jaundice: Sites noted are conjunctiva, under surface of tongue, hard palate and skin.
 Teeth , tongue, gums and tonsils: Evidence of malnutrition is evident from glossitis
and stomatitis.
 Neck: Neck veins, thyroid gland or lymph nodes are observed for any abnormality.
 Edema of legs: Site noted are medial malleolus and anterior surface of the lower one-
third of the tibia.
 Check the pulse and blood pressure, respiration and temperature of the women.
 Review of systems, Heart, lungs, liver spleen: assess both anatomically and
physiologically.
 Breast: note the skin condition of areola.
 Nipples cracked/depressed (inverted).
ANTENATAL EXAMINATION
It includes:
 Abdominal examination

 Vaginal examination

 Breast examination
Abdominal Examination
 It is the process in which a pregnant women is examined to identify the position of
the fetus in uterus and its relationship to the maternal pelvis, normalcy of fetal
growth in relation to the gestational age.
purposes
 To measure the abdominal girth and fundal height.
 To assess the abdominal muscle tone.
 To note the fetal lie, position, presentation, variety (anterior and posterior),

engagement and attitude.

 To identify the exact location of the heart sound (FHS)
 To detect any deviation from normal.
Articles
 Fetoscope/stethoscope
 Measuring tape/pelvimeter
Procedure
NURSING ACTION RATIONALE
Explain the procedure to the women To promote relaxation, and reduces anxiety
during the procedure
Allow the women to empty her bladder To avoid discomfort during palpation
Draw curtains around the bed To maintain privacy of the patient
INSPECTION
Position the women for examination (knees To promote relaxation of the abdominal muscles
flexed)
 place a pillow under her head and shoulders
Have her arms by her sides To visualize of the whole abdomen
Expose her abdomen from below the breasts
to the symphysis pubis.
Inspect abdomen for any scars, linea nigra,
striae gravidarum, diastasis recti, hernia,
contour of the abdomen, state of umbilicus and
skin condition
Determine the fundal height using the To estimate whether fetal growth
ulnar side of the palm corresponds to the gestational
• 12 weeks – at the level of symphysis
period
pubis
•16 weeks – midway between symphysis
pubis and umbilicus
•20 weeks – 1-2 finger breadth below
umbilicus
•24 weeks – at the level of umbilicus
•32 weeks – halfway between umbilicus
and xiphoid process
•36 weeks – at level of xiphoid process
•40 weeks – 2-3 finger breadth below the
xiphoid process if lightening occurs
Measure fundal height using any one of the
following methods:
Using measuring tape: Place zero line of the
tape measure on the upper border of the
symphysis pubis and stretch the tape across the
contour of the abdomen to the top of the fundus
along the midline.
Caliper method (Pelvimeter): Place one tip
of the caliper on the upper border of the
symphysis pubis and the other tip at the top of
the fundus. Both placements are in the midline. The number of centimeters measured should
Read the measurement on the centimeter be approximately equal to the weeks of
scale located on the arc, close to the joint. The
gestation after about 22-24 weeks .
number of centimeters should be equal
This method is more accurate.
approximately to the weeks of gestation after
about 22-24 weeks.
Measure the abdominal girth by Normally the measurement is 2
encircling the women’s abdomen inches (5cm) less than the weeks of
with a tape measure at the level of gestation.
the umbilicus. ( it is measured in For example, 32 inches at 34 weeks
inches) gestation.
Measurement more than 100cm
(39.5 inches) is abnormal at any
week of gestation.
 ABDOMINAL – PALPATION OR LEOPOLD MANEUVERS
Instruct the women to relax her abdominal These steps of reduce the stretching and
muscles by bending her knees slightly and tension of abdominal muscles.
doing deep breathing.
Be sure your hands are warm before Cold hands may cause muscle contraction
beginning to palpate, rest your hand on the and discomfort. Resting hands on mother’s
mother’s abdomen lightly while giving abdomen would help her to become
explanation about the procedure. accustomed to your touch and dissipate
muscle tightening.
For the technique of palpation: These measures would aid in gathering
Use the flat palmer surface of finger’s greatest amount of information with least
and not finger tips. Keep finger’s of hands discomfort to the women.
together and apply smooth’ deep pressure
as firm as necessary to obtain accurate
findings.
Palpate the other side of the Indicative of the fetal small
abdomen with the examining parts. Small parts all over the
finger from the midline to the abdomen are indicative of a
lateral side and from the fundus posterior position.
using smooth pressure and
rotatory movements.
Repeat the procedure for
examination of opposite side of
the abdomen.
Perform the first maneuver (Fundal Round, hard, readily, movable part, ballotable
Palpation) between the fingers of both hands is indicative
Face the women’s head of head non- engagement.
Place your hands on the sides of the fundus Irregular, bulkier, less firm and not well-
and curve the fingers around the top of the defined or movable part is indicative of breech.
uterus Neither of the above is indicative if transverse
Palpate for size, shape, consistency and lie.
mobility of the fetal part in the uterus.
Do the second maneuver (lateral palpation) A firm convex, continuously smooth and
Continue to face the women’s head resistant mass extending from breech to neck is
Place your hands on the both sides of the indicative of fetal back. Small knobby,
uterus about midway between the symphysis irregular mass, which move when, pressed or
pubis and the fundus. may kick or hit your examining hand is limbs
Apply pressure with one hand against the of the fetus.
side of the uterus pushing the fetus to the other
side and stabilizing it there.
Third maneuver (pawlik’s grip) Avoids discomfort
•Continue to face the women’s head make sure the
women has her knees flexed/bent.
•Grasp the portion of the lower abdomen immediately If the fetal head is above the brim, it will be readily
above the symphysis pubis, if is indicative of an movable and ballotable. If not readily movable, it is
engaged head. It is done with one hand only. indicative of an engaged head.

Fourth maneuver (Pelvic palpation) Avoids pain with the maneuver.

•Turn and face towards woman’s feet (make sure that
women’s knees are flexed).
•Place your both hands on the sides of the uterus, with
the palm of hands just below the level of umbilicus and
fingers directed towards the symphysis pubis
•Press deeply with your fingertips into the lower
abdomen and move them towards the pelvic inlet . Cephalic prominence on the same side as the fetal
•Around the presenting part small parts indicates vertex presentation with well-
•If the presenting part is engaged or dipping. The hands flexed head cephalic prominence on the same side as
will diverge away from the presenting part and there the fetal back may be occiput in a face presentation
will be no mobility. with extended head prominence are felt on both sides
(brow- presentation).
 AUSCULTATION
•Place fetoscope or stethoscope and over the convex Fetal heart sounds are heard over fetal back (scapula
portion of the fetus closet to the anterior uterine wall. region) in vertex and breech presentation. Over chest in
Count fetal heart rate for 1 minute. face presentation.
•Inform the mother about your finding. Make her
comfortable.
• Replace articles and wash hands
•Record in the patient’s chart the time, finding and
remarks if any
 Presentation and location of FHR

Presentation Location of FHR

Cephalic / vertex Midway between umbilicus and level of anterior super

iliac spine.

Breech Level with or above umbilicus

Anterior Close to the abdominal midline

Occiput transverse In lateral abdominal area

Occiput posterior In flank area

Vaginal Examination
The vaginal examination is an intimate procedure that should be performed
in the antenatal clinic when the patient attends the clinic for the first time
before 12 weeks.
Purpose
 To diagnose the pregnancy
 To corroborate the size of the uterus with the period of amenorrhea
 To exclude any pelvic pathology

Contraindication –
 Previous history of miscarriage
 Vaginal bleeding in present pregnancy (Ultrasound examination preferred

in this case)
Preliminaries
 Empty the bladder of the patient
 Draw curtains around the bed
 Provide dorsal position with thigh flexed along the buttock placed on the

foot end of the table

 Wash hand with soap and water
 Wear sterile gloves (usually right hand)
Steps of vaginal examination
1. Inspection: By separating the labia-using the left two fingers ( thumb and index),
the character of the vaginal discharge, if any, is noted. Presence of cystocele or
uterine prolapse or rectocele is to be elicited.

2. Sepculum examination: This should be done prior to bimanual examination,

especially when the smear for exfoliative cytology or vaginal swab is to taken. A
bivalve speculum is used. The cervix and the vault of the vagina are inspected with
the help of good light source placed behind. Cervical smear for exfoliate cytology
or a vaginal swab from the upper vagina, in presence of discharge, may be taken.
3. Bimanual: Two fingers (index and middle) of the right hand are introduce deep into
the vagina while separating the labia by left hand. The left hand is now placed
suprapubically. Gentle and systematic examinations are to be done to note:
 Cervix: Consistency, direction and any pathology

 Uterus: Size, shape, position and consistency

 Adnexa: Any mass felt through the fornix

 If the introitus is narrow, one finger may be introduced for examination “ No attempt

should be made to assess pelvis at this stage.

Breast Examination
 It is a technique by which a through inspection and palpation of the breasts
is made to collect data about the breasts condition of mother.
 The patient should be understand to the waist and seated/ lying supine with

arms by side.
Inspection
 Breasts size, symmetry, shape of breasts, skin color and superficial veins.
 Nipples

 Flat (Nipple does not protrude with stimulation)

 Retracted (Nipple pulls back slightly)
 Inverted (Nipples pull inward when compressed
 Everted (Nipple that protrude outward)
Palpation
Nodule
 Location (by quadrant or clock)
 Size in cm
 Shape
 Consistency
 Tenderness
 Mobility
 Nipple Discharge
 Milky (hypothyroidism, prolactinoma, drugs)
 Bloody (Papilloma, paget’s disease)