COURSE OUTLINE

most metabolic functions accelerate

METABOLIC during pregnancy to support the
CHANGES additional demands of the growing
fetus and its support system.
SIGNS AND
Presumptive, Probable & Positive
SYMPTOMS OF
Signs of Pregnancy
PREGNANCY
TYPES OF
Clinical and Over-the-counter
PREGNANCY
Pregnancy Tests
TEST
EMOTIONAL
RESPONSE
PRENATAL
CARE
 0
1
METABOLIC
CHANGES
METABOLIC CHANGES
WEIGHT GAIN
● Causes
- Growth of the uterus and its content.
- Growth of the breasts
- Increased Intravascular Fluids
- Maternal Reserves - Storage of extra fat, water and
proteins.
● Recommended Weight Gain
- 11.5 - 16 kg
- 6.8 - 11.5 kg
- 11.5 - 16 kg plus required weight to reach IBW
● Average Increase in weight per trimester
- 1.6 - 2.3 kg
- 5.5 - 6.8 kg
 METABOLIC CHANGES
● Water Metabolism - Increased water retention is a
basic chemical alteration of pregnancy.
● Nutrient Metabolism
- Increased protein retention early in pregnancy
- Fats are more completely absorbed during
pregnancy.
- The woman’s body switches from glucose
metabolism to lipid metabolism once glucose from
food intake has been used up.
 METABOLIC CHANGES
● Nutrient Metabolism
- FBS (Fasting Blood Sugar) levels fall slightly returning to
more normal by the 6th postpartal month
- Plasma levels of insulin increases
- Demand for iron is increased
- Approximately 30 grams of calcium is retained in
maternal bone for fetal deposition late in pregnancy
- Little metabolism of most vitamins and minerals other
than retention of amounts needed for fetal growth
 02
SIGNS &
SYMPTOMS
OF
PRESUMPTIVE SIGNS
- are largely subjective and maybe appreciated or experienced by the
woman but cannot be documented by the examiner.
1. Amenorrhea – is the earliest symptom of pregnancy. Not more than 10
days after missed period strongly suggests pregnancy.
2. Nausea and Vomiting – due to the increased HCG and changed
carbohydrate metabolism
3. Excessive Fatigue – is noted within a few weeks after LMP and may
persist.
Cause: Rapid fetal growth

4. Urinary Frequency – appears during the first trimester; decreases during

the second trimester and reappears in the third trimester.
Causes:
a. Pressure on the bladder.
b. Increased vascularization
PRESUMPTIVE SIGNS
5. Breast Changes – are noted early in pregnancy or prior to
LMP.
a. Engorgement – hormone induced.
b. Tenderness – due to congestion
c. Areolar pigmentation and nipple engorgement
d. Skin Changes – striae gravidarum, linea nigra,
chloasma, areolar pigmentation.
6. Quickening- is the mother’s perception of fetal movement. It
occurs at 18-20 weeks after LMP in primi and as early as 16
weeks in multi.
7. Chadwick’s Sign – bluish or purplish discoloration of the
vaginal walls
 PROBABLE SIGNS
- more diagnostic than subjective symptoms,
however, it does not offer a definite diagnosis of
pregnancy.

1. Changes in Pelvic Organs

a. Goodell’s Sign
b. Hegar’s Sign
c. Ladin’s Sign
d. Mc Donald’s Sign
 PROBABLE SIGNS
e. Braun Von Fernwald’s Sign – occurs about the
5th week; is the irregular softening and enlargement
of the site of the uterine implantation.
f. Piskacek’s Sign – is the occasional tumor-like,
asymmetric enlargement of the uterus. Fundus rises
upwards as pregnancy continues.
Fundal Landmarks:
● 10-20 weeks – below the umbilicus
● 20-22 weeks – level of the umbilicus
● 36 weeks – level of the xyphoid process
 PROBABLE SIGNS
2. Enlargement of the abdomen – size of the
abdomen corresponds to the gradual increase in the
size of the uterus. It is generally more pronounced in a
woman whose abdominal muscles lost its tone due to
previous childbirth.
3. Braxton Hicks Contractions – are irregular,
painless uterine contractions throughout the pregnancy.
Purposes:
a. It promotes blood circulation in the placenta.
 PROBABLE SIGNS
b. It plays a role in the formation of the lower
uterine segment the last week of pregnancy.
c. It increases the size of the uterus to
accommodate the growing fetus.
4. Uterine Souffle – is a soft blowing sound
synchronous to the maternal pulse.
5. Funic Souffle – is a soft whistling sound of
blood pulsating thru the umbilical arteries. It is
synchronous to the FHT.
 PROBABLE SIGNS

6. Changes in the appearance of

abdominal striae and skin
pigmentation.
a. nipple pigmentation
b. chloasma
c. linea nigra
d. striae gravidarum
 PROBABLE SIGNS
8. Fetal Outline – identified thru Leopold’s Maneuver
at 6 months AOG. It is easily distinguishable as term
approaches.
9. Ballotment – is the passive fetal movement elicited by
pushing up against the cervix with two fingers.
10. Pregnancy Tests – are based on analysis of maternal
blood or urine for the detection of HCG.
NOTE: These tests are NOT considered POSITIVE
SIGNS of pregnancy because of the SIMILARITIES OF
HCG AND THE PITUITARY SECRETED HORMONE (LH)
occasionally to CROSS-REACTION.
PREGNANCY
TESTS
 CLINICAL PREGNANCY TEST
1. Urine Specimen
a. Hemagglutination –inhibition Test (Pregnosticon
R) – is based on the fact that clumping of cells occurs
when the urine of a pregnant woman is added to the HCG-
sensitized RBC of sheep.
b. Latex Agglutination Test ( Gravidex and
Pregnosticon Slide Test) – is an immunoassay; is based
on the fact that latex particle agglutination is inhibited in
the presence of urine.
 CLINICAL PREGNANCY TEST
2. Maternal Serum Specimen
a. β-Sub Unit Radio Immunoassay (RIA) – uses an
antiserum with specificity for the β sub unit of HCG in blood
plasma. This is a VERY ACCURATE pregnancy test that becomes
positive a few days after presumed implantation, thereby
permitting earlier diagnosis of pregnancy. This test is also used
to diagnose ectopic pregnancy or trophoblastic disease.
 CLINICAL PREGNANCY TEST
B. Immunoradiometric Assay ( IRMA)- uses a
radioactive antibody to identify the presence of HCG in the
serum.
C. Enzyme-linked Immunosorbent Assay ( ELISA) –
does not use radioisotopes but a substance that results in a
color change after binding. It is sensitive and quick. It can
detect HCG levels as early as 7-9 days after ovulation and
conception.
D. Flouroimmunoassay (FIA) – uses an antibody tagged
with a fluorescent label to detect serum HCG. It is
extremely sensitive. It is used primarily to identify and
follow HCG concentrations. It takes 2-3 hours to perform.
 OVER-THE-COUNTER PTs
Are quite sensitive and detect even low levels
of HCG in the urine. The best results are
obtained with the specimen obtained in the
first morning urine, “midstream catch”.
 POSITIVE SIGNS

– are completely objective.

● Demonstration of a fetal heart separate

from the mother’s
● Fetal movements felt by an examiner
● Visualization of the fetus by ultrasound
POSITIVE SIGNS
1. FHT – is detected with a fetoscope
approximately at 17-20 weeks. With the
Doppler monitor, it can be detected as early as
10-12 weeks.
Sounds Mistaken as FHT:
a. Placental Souffle – soft blowing sound
synchronous with the maternal pulse heard over the lower
abdomen. It is produced by the large blood vessels of the
abdomen.
 POSITIVE SIGNS
b. Funic / Fetal / Umbilical Souffle – is a sharp
whistling sound synchronous with the FHT. It is heard in 5% of
cases. It is due to the rush of blood thru the umbilical arteries
under circumstances in which they are subject to tension or
pressure.
c. Maternal Pulse – loud pulsations of the aorta.
d. Borborygmus/Borborygmi – gurgling sound of gas
in the abdomen.
NOTE: determine the fetal position before locating the
FHT.
 POSITIVE SIGNS
2. Fetal movements felt by a skilled examiner and
on sonogram – movements are felt usually at 20 weeks.
They vary from faint flutter in early months to more
vigorous in late pregnancy.
3. Fetal Outline by UTZ – visualization of the fetus by
ultrasound confirms pregnancy. Gestational sac is seen
at 4-5 weeks AOG. Fetal parts can be seen as early as 8
weeks.
NOTE: Trans-vaginal ultrasound can detect
gestational sac 10 days after implantation.
 03
EMOTIONAL
RESPONSES
TO
EMOTIONAL RESPONSES TO
PREGNANCY
GRIEF- Can be positive or negative reason
NARCISSISSM- conscious of her body
BODY IMAGE AND BOUNDARY
STRESS
COUVADE SYNDROME- Men are
experiencing the symptoms of pregnancy
Emotional Lability- mood swings
Changes in sexual Desire
 04
PRENATAL
CARE
 RELATED TERMS
1. Antepartum –time between conception and
onset of labor and usually describe the period during
the pregnancy of a woman.
2. Intrapartum –from onset of labor until the birth
of the placenta.
3. Postpartum - from birth until the woman’s
body returns to its pre-pregnant state.
4. Gestation – is the number of weeks since the
first day of the LMP.
5. Abortion – is the birth that occurs before 20
weeks gestation or birth of a fetus-neonate who weighs
less than 500 grams.
 RELATED TERMS
6. Term – the normal duration of pregnancy:
 280 days
 38-42 weeks
 9-10 lunar months
7. Preterm Labor– is labor that occurs after 20 weeks
but before the completion of 37 weeks.
8. Post term Labor – is labor that occurs after 42
weeks.
9. Gravida– is any pregnancy regardless of duration,
including present pregnancy.
10. Nulligravida – is a woman who has NEVER been
pregnant.
 RELATED TERMS
11. Primigravida – is a woman who is pregnant for
the first time.

12. Multigravida – is a woman who is in her second or

any subsequent pregnancy.

13. Para/Parity – pregnancy reached viability; birth

after 20 weeks AOG regardless of whether the infant is
born dead or alive.
 RELATED TERMS
14. Nullipara – is a woman who has not given birth at
more than 20 weeks.

15. Primipara – is a woman who has had one birth at

more than 20 weeks AOG, regardless of whether the
infant is born dead or alive.

16. Multipara – is a woman who has had two or more

births at more than 20 weeks.
 IMPORTANT CONSIDERATION

1. The term Gravida and Para refer to the

PREGNANCIES, NOT THE FETUS

2. Twins, triplets ,etc is counted as ONE

PREGNANCY AND ONE BIRTH.
 STEPS IN PRENATAL CARE
1. Frequency of Visit to the health care provider

 Every month for the first and second trimester.

 Every 2 weeks for the 7th -8th month.
 Every week for term / 9th-10th month.
 STEPS IN PRENATAL CARE
2. History-Taking
Purpose: To assess risk factors of pregnancy
 Age – pregnant adolescents have a higher incidence
of:
● Prematurity Pregnant women over 35
● PIH are at risk for:
● CPD ● Chromosomal disorders
● Poor nutrition ● PIH
● Inadequate prenatal care ● CS
 STEPS IN PRENATAL CARE
 Parity ( TPAL), LMP and Gravida
T- number of term babies
P– number of premature births
A- number of abortion.
L- number of live children delivered
 Past Health History
a. DM e. Anemia
b. Heart diseases f. Thyroid disorders
c. Renal conditions g. Physical and drug
d. Essential HPN abuse
 STEPS IN PRENATAL CARE
 Past Obstetrical History
a. Lack of prenatal care h. Previous fetal loss
b. Abortions i. PIH
c. Ectopic pregnancy j. DM
d. Preterm labor and delivery k. Vaginal bleeding in
e. IUGR pregnancy
f. Congenital malformations l. Multiple gestation
g. Caesarean births m. LGA babies
 STEPS IN PRENATAL CARE
 Current Obstetrical History
a. PIH
b. Infections
 STD
 TORCH – Toxoplasmosis, Other infections, Rubella,
Cytomegalovirus, Herpes
 Other viral diseases
 Bacterial infections
c. Hemorrhage
 STEPS IN PRENATAL CARE
 Current Obstetrical History
d. Intake of Teratogenic Drugs
B – Barbiturates
S - Salicylates
A – Antimalarial
A – Anesthetics
e. Multiple gestation
f. Chronic health problems
g. Abnormal prenatal results
h. Low socio-economic status
i. Malnutrition
j. Drug or alcohol addiction and smoking
 STEPS IN PRENATAL CARE
3. Physical Assessment

a.Leopold’s Maneuver – is a systematic method of

observation and palpation to determine the
presenting part, fetal position, presentation and
engagement.
b.Weight Monitoring – check normal weight gain
c. Vital Signs – especially BP
d.Inspection of teeth and gums – for the presence
of gingivitis
 STEPS IN PRENATAL CARE
3. Physical Assessment

e.Estimation of pelvic measurements

( Pelvimetry) – to assess the woman’s pelvis to
accommodate passage of fetus.
f. Vaginal Exams ( IE) – to rule out abnormalities of
birth canal.
g.Fundic Height Measurement – estimate AOG
TYPES OF PELVIC SHAPE
 STEPS IN PRENATAL CARE
4. Laboratory Tests
 Fetal Maturity and Placental Functions
a.Fetal movement
b.NST
c. Oxytocin Challenge Test
d.Nipple Stimulation Test
e.Ultrasound
f. Chorionic Villi Sampling
g.Biophysical Profile
h.Amniocentesis
 STEPS IN PRENATAL CARE
i. Laboratory Studies
 Estriol excretion
 Alpha Fetoprotein
 Serum Placental Lactogen
 L/S Ratio
 Phosphatidyl Glycerol
 Creatinine level
 STEPS IN PRENATAL CARE
 Gynecological Procedures
a. Schiller’s Test
b. Papanicolau Test ( Pap Smear)
c. Cervical Biopsy and Cauterization
d. Culdoscopy
e. Laparoscopy
l. CBC
f. Hystero-salphingogram
m. VDRL Test
g. Rubin’s Test
n. Blood Typing
i. Sim’s Huhner’s Test
o. indirect COOMB’s Test
j. Semen Analysis
p. HIV Screening
k. Computerized Tomography
 STEPS IN PRENATAL CARE
5. Estimating Expected Date of Confinement
( EDC), Fundic Height, AOG, Fetal Length and
Fetal Weight
 EDC Estimation
Naegele’s Rule – is the standard method in estimating
or predicting the length of fetal maturity.
 Fundic Height ( Bartholomew’s Rule) – noting the
fundic height at various weeks of pregnancy.
 AOG ( Mc Donald’s Method) – fundic height
computation
 STEPS IN PRENATAL CARE
6. Health Education
 Nutrition in Pregnancy
a. Quality rather than quantity is the main
consideration.
b. Consider the patient’s activity in relation to her
diet.
c. Appetite is decreased during the first and increased
during the second and third trimesters.
d. Restriction of excessive salt intake.
e. Advise client to drink a quart of milk daily or other
milk products.
 STEPS IN PRENATAL CARE
6. Health Education
 Nutrition in Pregnancy
g. Fruits and vegetables are necessary.
h. Fluids should be taken freely.
i. Vitamins should be included in the diet.
j. Mineral elements should be included.
 General Hygiene and ADL
a. Care of the skin
b. Care of the breast
c. Care of the teeth
d. Bowel habits
 STEPS IN PRENATAL CARE
6. Health Education
 General Hygiene and ADL
e. Vaginal douche
f. Relaxation, rest and sleep
g. Exercise ( Tailor Sitting, Squatting, Kegel’s Exercise)
h. Employment
i. Travelling
j. Clothing
k. Marital relations
 STEPS IN PRENATAL CARE
6. Health Education
 Minor Discomforts of Pregnancy
a. Frequent urination
b. Nausea and vomiting
c. Heartburn
d. Flatulence
e. Backache
f. Dyspnea
g. Varicosities
h. Hemorrhoids
i. Leg cramps
 STEPS IN PRENATAL CARE
6. Health Education
 Minor Discomforts of Pregnancy
j. Edema of legs and feet
k. Vaginal discharges
l. Fatigue s. Supine Hypotension
m. Palmar erythema Syndrome
n. Breast tenderness
o. Decreased gastric motility
p. Constipation
q. Insomnia
r. pain in the thighs and perineum
INTERVENTIONS
INTERVENTIONS