UNIT II: PREGNANCY
Definitions:
- Braxton hicks contraction---irregular, mild uterine contractions
that occur throughout pregnancy; they become stronger in the
last trimester.
- Chadwick’s sign---bluish discoloration of the cervix, vagina
and labia during pregnancy as a result of increased vascular
congestion.
- Choasma---brownish
pigmentation
of
the
face
during
pregnancy; also called “mask of pregnancy”
- Decidua---endometrium.
- Erythema ---is reddening of the palms.
- Goodell`s sign---softening of the cervix, uterus, and vagina
during pregnancy.
- Hagar’s sign---is a bimanual examination for assessing the
softening and compressibility of the isthmus between the 6 th
and 12th weeks of pregnancy.
- Hyperplasia---increase number of cells due to division.
- Hypertrophy---increase in size of cells.
- Lordosis---increase the curvature of the back.
- Osiander`s sign---is an increased pulsation of blood in the
uterine arteries, felt with the fingers in the lateral vaginal
fornices.
- Ptyalism---increase of saliva.
- Vascular spiders--- is minute red elevations on the skin of the
face, neck, arms and chest.
- Quickening---the first fluttering movements of the fetus felt by
the mother. A primigravida woman feels it at 18-20weeks, and
a multigravida woman at 16-18weeks.
- Steria gravidarum---irregular pinkish streaks resulting from
tears in connective tissue; during pregnancy these streaks
generally appear on the woman’s
- abdomen, breasts, or thighs.
- Uterine souffle---Gush of blood in the uterine arteries. Heard
by fetal stethoscope.
- Umbilical souffle------Gush of blood in the umbilical cord.
Heard by fetal stethoscope.
Introduction:
Physiological adaptation to pregnancy is dramatic and often
underestimated. The timing and intensity of the changes vary between
systems, but all are designed to enable the woman to nurture the fetus and
prepare her body for labor and lactation. The appreciation of the normal
physiological changes of pregnancy will enable to identify pregnancy
induced alterations, detect abnormalities, especially when affected by
preexisting illnesses, and provide appropriate care to all women.
DIAGNOSIS OF PREGNANCY
The diagnostic confirmation of pregnancy is based on a combination
of the presumptive, probable, and positive changes/signs of pregnancy.
This information is obtained through history, physical and pelvic
examinations, and laboratory and diagnostic studies.
a. Presumptive Signs of Pregnancy
The presumptive signs of pregnancy include all subjective signs of
pregnancy (i.e., physiological changes perceived by the woman herself ):and
these signs lead a woman to believe that she is pregnant.
■ Amenorrhea: Absence of menstruation
■ Nausea and vomiting: Common from week 2 to 12
■ Breast changes: Changes begin to appear at 2 to 3 weeks
■ Enlargement, tenderness, and tingling of breast
■ Increased vascularity of breast
■ Fatigue: Common during the first trimester
■ Urination frequency: Related to pressure of enlarging uterus on
bladder; decreases as uterus moves upward and out of pelvis
■ Quickening: A woman’s first awareness of fetal movement;
occurs around 16 to 20 weeks’ gestation
All of these changes could have causes outside of pregnancy and are
not considered diagnostic.
b. Probable Signs of Pregnancy:
The probable signs of pregnancy are objective signs of pregnancy
and include all physiological and anatomical changes that can be
perceived by the health care provider.
■ Chadwick’s sign: Bluish-purple coloration of the vaginal
mucosa, cervix, and vulva seen at 6 to 8 weeks
■ Goodell’s sign: Softening of the cervix and vagina with
increased leukorrheal discharge; palpated at 8 weeks
■ Hegar’s sign: Softening of the lower uterine segment; palpated
at 6 to 8 weeks
■ Uterine growth and abdominal growth
■ Skin hyperpigmentation
_ Melasma (chloasma), also referred to as the mask of pregnancy:
Brownish pigmentation over the forehead, temples, cheek, and/or
upper lip
_ Linea nigra: Dark line that runs from the umbilicus to the pubes
_ Nipples and areola: Become darker; more evident in primigravidas
and dark-haired women
■ Ballottement: A light tap of the examining finger on the cervix
causes fetus to rise in the amniotic fluid and then rebound to its
original position; occurs at 16 to 18 weeks. Usually it is disappear with
walking or exercise.
■ Positive pregnancy test results
_ Laboratory tests are based on detection of the presence of human
chorionic gonadotropin (hCG) in maternal urine or blood.
_ The tests are extremely accurate, but not 100%. There can be both
false-positive and false-negative results. Because of this, a positive
pregnancy test is considered a probable rather than a positive
sign of pregnancy.
_ A urine pregnancy test is best performed using a first morning
urine specimen, which has the highest concentration of hCG, and
becomes positive about 4 weeks after conception.
■ A maternal blood pregnancy test can detect hCG levels before a
missed period.
Home pregnancy tests are also accurate (but not 100%) and
are simple to perform. These urine tests use enzymes and rely on
a color change when agglutination occurs, indicating a pregnancy.
The home tests can be performed at the time of a missed menstrual
period. If a negative result occurs, the instructions suggest
that the test be repeated in one week if a menstrual period has
not begun.
All of these changes could also have causes other than pregnancy and
are not considered diagnostic. The presumptive and probable signs of
pregnancy are important components of assessment in confirming a
pregnancy. Early in gestation, before any positive signs of pregnancy,
a combination of presumptive and probable signs is used to make a
practical diagnosis of pregnancy.
c. Positive Signs of Pregnancy
The positive signs of pregnancy are the objective signs of pregnancy
that can only be attributed to the fetus:
■ Auscultation of the fetal heart, by 10 to 12 weeks
■ Observation and palpation of fetal movement by the examiner after
about 20 weeks' gestation
■ Sonographic visualization of the fetus: Cardiac movement noted
at 4 to 8 weeks.
Physiological Changes during Pregnancy
PHYSIOLOGICAL CHANGES
A. Respiratory system
-Hormones of pregnancy stimulate the
respiratory center and act on lung tissue to
increase and enhance respiratory
function
-Increase of oxygen consumption by 15%–
20%
CLINICAL SIGNS AND SYMPTOMS
-Increase in tidal volume by 30%–40%, Due
to Expansion of the rib cage
-Slight increase in respiratory rate by 2b\min
-Increase in inspiratory capacity due to
Increase in tidal volume
-Decrease in expiratory or residual volume
-Estrogen, progesterone, and prostaglandins -up to 70% of pregnant women experience
cause vascular engorgement and smooth
Slight hyperventilation, can be uncomfortable
muscle relaxation
and may lead to dyspnoea and dizziness.
-Upward displacement of diaphragm by
enlarging uterus
-Slight respiratory alkalosis
-Dyspnea
-Nasal and sinus congestion& Epistaxis,
because edema and vascular congested which
cause by increase estrogen level.
-Shift from abdominal to thoracic breathing
-Estrogen causes a relaxation of the
ligaments and joints of rib
-Chest and thorax expand to accommodate
thoracic breathing and upward displacement
of diaphragm
- Lung capacity slight decrease or may remain
unchanged .
-Shortness of breath because enlarge uterus
cause elevated the diaphragm on the lung
 Hyperventilation of pregnancy
causes a 15-20% decrease in
maternal arterial CO2.
Hyperventilation facilitates
the transfer of CO2 from fetus
to the mother and to be
washed out of the lungs.
INTEGUMENTARY SYSTEM
-Linea nigra
-Estrogen and progesterone levels stimulate
increased melanin deposition, causing light
brown to dark brown pigmentation.
-Melasma (chloasma)
-Increased blood flow, increased basal
metabolic rate, progesterone-induced
increase in body temperature, and
vasomotor instability
-Increased action of adrenocorticosteroids
leads to cutaneous elastic tissues becoming
fragile
-Darken of nipples, areola, vulva, scars, and
moles
-Hot flashes, facial flushing, alternating
sensation of hot and cold
-Striae gravidarum (stretch marks) on
abdomen, thighs, breast, and buttocks
-Angiomas (spider nevi)
-Increased estrogen levels lead to color and
vascular changes.
-Increased androgens lead to increase in
sebaceous gland secretions
-Palmar erythema: Pinkish-red mottling over
palms of hands
-Increased oiliness of skin and increase of acne
-Mild hirsutism is common during pregnancy,
particularly on the face
-Itching of the skin in pregnancy (not
common), can be distressing. The evidence
suggests that, in the absence of a rash, aspirin is
effective but if there is a rash, chlorphenamine
may be more effective
Changes in the urinary system
-urinary frequency occur during in the first
-Increased progesterone levels, which cause and third trimester due to pressure of the
large uterus on the bladder.
a relaxation of smooth muscles
-Dilatation of the kidney, ureter and urethra .
-Pressure of enlarging uterus on renal
structures
- Urinary stasis and urinary tract infection due
-Alterations in cardiovascular system
pressure of the uterus on ureter and urethra .
(increased cardiac output and increased
blood and plasma volume) lead to increased
renal blood flow of 50%–80% in first
trimester and then decreases
-Decreased renal flow in third trimester
Increased vascularity
-Glycosuria due to re-absorption of glucose
by renal tubules may be evident because of the
increase in glomerular filtration,.
- Increase renal clearness of urea and
creatinine.
-. Kidneys increase in weight and lengthen by
1cm
-Bladder pressure increases and may result in
reduced bladder capacity. The muscles of the
internal urethral sphincter relax, with pressure
from the pregnant uterus on the bladder,
causes some women experience some degree
of stress incontinence
GASTROINTESTINAL SYSTEM
-Nausea and vomiting during early pregnancy
-Increase levels of hCG and altered
carbohydrate metabolism
-Constipation
-Increased progesterone levels lead to
decreased muscle tone and slowing of
digestive processes
-Delayed stomach emptying leads to heartburn
Increased risk of gallstone formation and
cholestasis
-Increased progesterone levels lead to
decreased muscle tone of
gallbladder, resulting in prolonged
emptying time.
-Increase or decrease in appetite
Nausea
-Changes in senses of taste and smell
-Displacement of intestines by uterus
-Increased levels of estrogen lead to
increased vascular congestion
of mucosa.
-Pica: Abnormal; craving for and ingestion of
nonfood substances such as clay or starch
-Flatulence, abdominal distension, abdominal
cramping, and pelvic heaviness
-Gingivitis, bleeding gums, increase risk of
periodontal disease
-Secreation of saliva may increase.
-Heartburn (pyrosis) is common caused by
reflux of acid secretions in the lower
esophagus, and relaxation of the stomach
muscle ( delay stomach emptying time).
-Hemorrhoids are common because of
elevated pressure in veins below the level of
the large uterus and constipation
MUSCULOSKELETAL SYSTEM
-Increased progesterone and relaxin levels
lead to softening of joints and increased
joint mobility, resulting in widening and
increased mobility of the sacroiliac and
symphysis pubis.
-Distension of abdomen related to
expanding uterus, reduced
abdominal tone, and increased breast size
-Increased estrogen and relaxin levels lead
to increased elasticity and relaxation of
ligaments
-Abdominal muscles stretch due to
enlarging uterus
ENDOCRINE SYSTEM
Decreased follicle-stimulating hormone
Increased progesterone
Increased estrogen
Increased prolactin
Increased oxytocin
Increased human chorionic gonadotropin
(hCG)
Human placental lactogen/human chorionic
somatomammotropin
Hyperplasia and increased vascularity of
thyroid
Increased BMR related to fetal metabolic
activity
-Altered gait: “Waddle” gait
-Facilitates birthing process Pelvic tilts
forward, leading to shifting of center of
gravity that results in change in posture and
walking style, increasing lordosis
-Increased risk of falls due to shift in center of
gravity and change in gait and posture
-Round ligament spasm
-Increase risk of joint pain and injury
Diastasis recti
-Late in pregnancy aching, numbness, and
weakness in the upper extremities may occur
because of lordosis, and pressure on the unlar
nerve.
Amenorrhea
Maintains pregnancy by relaxation of smooth
muscles, leading
to decreased uterine activity, which results in
decreased
risk of spontaneous abortions
Decreases gastrointestinal motility
Facilitates uterine and breast development
Facilitates increases in vascularity
Facilitates hyperpigmentation
Alters metabolic processes and fluid and
electrolyte balance
Facilitates lactation
Stimulates uterine contractions
Increased need for glucose due to
developing fetus
Increase in cortisol
Stimulates the milk let-down or ejection reflex
in response
to breastfeeding
Maintenance of corpus luteum until placenta
becomes fully
functional
Facilitates breast development
Alters carbohydrate, protein, and fat
metabolism
Facilitates fetal growth by altering maternal
metabolism;
acts as an insulin antagonist
Enlargement of thyroid
Heat intolerance and fatigue
Depletion of maternal glucose stores leads to
increased risk
of maternal hypoglycemia.
Increased production of insulin
Increase in maternal resistance to insulin leads
to increased
risk of hyperglycemia.
H. Metabolic Changes
 Average weight gain during pregnancy is 11.5 to 16 kg.
 I. Neurological System changes:
 - Usually no system changes
 - Mild frontal headaches are common in the first and second trimester
 - Dizziness due to postural hypotension
 - Tingling sensations in the hands
Cardiovascular system changes.
1.the heart is displaced upward, to the left, and forward.
2. edema and varicosities of the legs because pressure of
the uterus on the blood vessels and blood stasis .
3. supine position during the 2nd trimester, due to pressure
of the uterus on the inferior vena cava so decrease blood return to the heart
then circulation.
4.By mid-pregnancy more than 90% of women develop an systolic murmur,
which lasts until the first week postpartum. 20% develop a transient diastolic
murmur and 10% develop continous murmurs, heard over the base of the
heart, owing to increased mammary blood flow.
5. heart rate increase by 10 to 15 beats\mint
6. blood volume increase 30% to 50%
7.cardiac output increase by 25% to 50%.
-The increased cardiac output allows blood flow to the kidneys, brain and
coronary arteries to remain unchanged, while the distribution to other organs
varies as pregnancy advances
*The increased cardiac
output is due to increases in
both stroke volume and heart rate.
8.Blood pressure: decrease blood pressure beginning in the first trimester and
becoming maximal in the second trimester . then returns to pre-pregnancy
levels in the third trimester.
 the systolic blood pressure falls an average of 5-10 mmhg below baseline
levels and the diastolic pressure falls 10-15 mmhg by 24 weeks` gestation.
 The expansion in plasma volume is greater than the expansion of red cell
mass, causing the physiological anemia .
 -The increase in plasma volume reduces the viscosity of the blood and
improves capillary flow.
 Red cell mass, increases during pregnancy in response to the extra oxygen
requirements of maternal and placental tissue.
 The total white cells count rises in pregnancy and reaches a peak at 30
weeks.
 . increase in the fibrinogen level, and decrease hematocrit ( MCV)
Immunity---HCG and prolactin are known to suppress the immune response
of pregnant women. Lymphocyte function is depressed
Changes in the Reproductive Tract:
A. Uterus:
 - Enlargement and thickening of the uterine wall are most marked in the
fundus.
 - Braxton Hicks contractions irregular painless contractions can be felt by
women by fourth months .
 - uterian circulation increase so increase the
 Size and number of the blood vessel and lymphatic
 As the uterus rises out of the pelvis, it rotates somewhat to the right because
of the presence of the recto sigmoid colon on the left side of the pelvis.
. Cervix:
- softening(goodle sign) and cyanosis` ”due to increased vascularity, edema,
hypertrophy, and hyperplasia of the cervical glands.
 Endocervical glands secrete thick mucus that forms a cervical plug and
obstructs cervical canal. This plug prevents bacteria and other substances
from entering and ascending into uterus.
 Chadwick's sign, bluish, purplish coloring of cervix due to increased
vascularity caused by increased estrogen levels.
c. ovaries:


- amenorrhea ( absent of the menses )
-corpus luteum functions during early pregnancy (first 10 to 12 weeks),
producing mainly progesterone.
Antenatal Care
Introduction
Every year there are an estimated 200 million pregnancies in the world. 50
million each year, experience pregnancy-related health problems during or
after childbirth. Fifteen percent of these women suffer serious or long-term
complications (WHO, 1999; SMH, 2002). a pregnant woman’s risk for
optimal health of the mother and her fetus. In Egypt, according to the last
statistics from Ministry of Health and Population, maternal mortality rate is
about 84/100000/year women die from complications of pregnancy and
childbirth (Ministry of Health and Population, 2000).
While risks in pregnancy cannot be totally eliminated, they can be
reduced through effective, affordable, accessible and acceptable maternity
care. Therefore, it is recommended that all mothers see a trained provider at
least four times during pregnancy. The EIDHS-98 found that during the
five-year period before the survey, only 33 % of women reported that they
had received four or more antenatal visits. So The nurse plays an important
role to improve the quality of antenatal care,
Definitions
• It is a planed examination and observation for the woman from
conception till the birth .
Or
• Antenatal care refers to the care that is given to an expected mother from
time of conception is confirmed until the beginning of labor
Goals and Objectives of Antenatal Care
Goals
* To reduce maternal mortality and morbidity rates.
* To improve the physical and mental health of women and children.
* antenatal care aims to prevent, identify, and ameliorate maternal and fetal
abnormality that can adversely affect pregnancy outcome.
*to decrease financial recourses for care of mothers.
Objectives
• Antenatal care support and encourage a family’s healthy psychological
adjustment to childbearing
FACTORS AFFECTING MOTHERS UTILIZATION OF
ANTENATAL CARE
Demographic and Biological Factors
Socioeconomic Factors
Psychosocial Factors
Health Services Factors
Environmental Factors
Preparation of Antenatal Rooms
•
Furniture: Ensure that the furniture is arranged
conveniently for the work of all staff and comfortable for the clients.
• Stationery: Ensure that the desk is supplied with cards, pencils, etc.
•
Trays:
check the preparation of the following trays :
*
•
Medication tray.
*
Immunization kit .
*
Temperature tray.
*
Treatment and dressing tray.
Visual displays : Ensure that the visual displays and posters are arranged.
•
Waiting area : Ensure that the waiting area is comfortable for the
clients and educational materials are available.
•
Examination instruments and equipment:
* Make sure that all instruments and equipment are available and in
working order.
* Check and balance the scales at the beginning of the clinic, then repeat
as needed during the session.
 Component of antenatal care:
Assessment:
The assessment process begins at the initial prenatal visit and is continued
throughout pregnancy. The initial assessment interview can establish the
trusting relationship between the nurse and the
pregnant woman. It is a planned purposeful communication that focuses on
specific content. The purposes of the initial interview include establishing
rapport, getting information about the woman’s physical and psychological
health, and obtaining a basis for anticipatory guidance for pregnancy .
1- Physical Examinations and Assessments
Initial Visit and Examination
- Welcome the woman .
- Greet her to establish a good relationship .
• keep Privacy or Discuss in suitable place .
- Discuss any problems.
- follow the principals of good communication .
Component of antenatal care .
1-History taking:
The nurse begins to take complete history from the pregnant woman, which
includes personal, obstetric, medical, surgical, family, and psychological
elements.
• Personal and social history
- The woman's name and address should be filled out clearly, so that the
individual woman can be traced by a home visit if she fails to keep her next
appointment.
- Other personal data such as age, education, marital status, duration of
marriage, and occupation of both partners.
- Housing and finance should be considered as evidence that prenatal
mortality and morbidity are higher in families who live in poor conditions.
- Religion may give an indication of particular attitudes, beliefs or practices
associated with childbirth and lifestyle such as dietary taboos.
- Nationality and language should also be recorded.
• Medical and surgical history:
as evidence studies showed that Certain diseases may have an adverse effect
on pregnancy, so a note is made about details regarding:
- Childhood illnesses and any serious, chronic, or infectious diseases such
as: diabetes mellitus, hypertension, urinary tract troubles, heart diseases, and
viral infections.
- Allergies, radiation exposure, blood transfusions, and current medications.
- Previous operations such as cesarean section, genital repair, and cervical
cerclagc.
- Recent surgery, particularly on the genital tract.
- Accidents involving injury of the bony pelvis.
• Obstetrical history:
Details of previous pregnancies such as:
•
Length, outcome, and problems of each pregnancy.
•
Date of last abortion.
Details of previous labors such as:
•
Sex and weight of each infant.
• Whether live or stillborn.
• Whether breast or artificially fed.
•
Prematurity and neonatal death,
•
Complications of previous labors.
•
Date of last delivery.
Details of previous postpartum such as:
• Contraceptive history.
• Complications such as postpartum hemorrhage.
Menstrual history:
* Age of menarche.
* Regularity and frequency of menstrual cycle.
* Duration and nature of menstrual flow.
* Any previous treatment of menstrual! problems or infertility.
* Date and character of last menstrual period (LMP).
*
Expected date of delivery (EDD) is calculated as follows:
• 1st day of LMP + 7 days - 3 months + 1 year.
• 1st day of LMP + 7 days + 9 months. Family history:
Family history:
* Some families have genetic pre-dispositions to certain diseases
especially if the parents are close relatives.
* Prevalence of any of the following within the families of both parents
should be noted; diabetes mellitus, essential hypertension, cardiac disease,
mental illness, multiple pregnancy, congenital abnormalities, and allergic
conditions such as asthma, eczema and high fever.
* Sickle cell anemia and thalassemia are common in particular races.
* Poor living conditions may increase the chance of tuberculosis and/or
vitamin deficiency that may cause spina bifida.
• History of present pregnancy:
* Symptoms of pregnancy.
* Minor complaints of pregnancy.
* Symptoms of complications as pre-eclampsia.
* Fetal movement.
2-Physical Examinations
General Examination
• It should be started from the moment the pregnant woman walks
into the examination room. A general examination should be done
systematically. Start by looking at the woman's face, then progress
downwards to finish with an inspection of her legs and feet,
• Examine general appearance:
Observe the woman for stature or body build and gait.
Check the hair of woman to assess her health. The hair of a healthy woman
is shim and glossy.
• Look at the woman's face to assess her health. The face is observed for
skin color as pallor and pigmentation as chloasma.
* Observe the eyes for edema of the eyelids and color of conjunctiva.
Healthy eyes are bright and clear.
* Observe the mouth for:
•
Dryness or cyanosis of the lips.
•
Gingivitis of the gums.
•
Septic focus or caries of the teeth.
* Observe the neck for enlarged thyroid gland and scars of previous
operations.
* Observe complexion for presence of blotches.
* Ensure that the general manner of the woman indicates vigor and vitality.
* An anemic, depressed, tired or ill woman is lethargic, not interested in her
appearance, and unenthusiastic about the interview.
* Lack of energy is a temporary state in early pregnancy, a woman often
feels exhausted and debilitated.
* Discuss the woman's sleeping patterns and minor disorders and give
advice as necessary.
* Report any signs of ill health.
• Examine height :
* Height of over 150 cm and shoe size above 3 give an indication of an
average-sized pelvis.
•Weight :
* The approximate weight gain during pregnancy is 12 kg-i 2kg in the first
20 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term)
as evidance.
* Little or no maternal weight gain leads to fetal jeopardy.
* Obesity (more than 20 kg above the weight-height formula) leads to an
increased risk of gestational, diabetes
pregnancy-induced hypertension and thrombo embolic disorders.
* Underweight (less than 20 kg below the weight-height formula) also puts
the pregnant woman at great risk.
• Blood pressure:
* It is taken to ascertain normality and provide a baseline reading for a
comparison throughout the pregnancy.
* If the blood pressure is elevated because the woman is nervous and
anxious, take it again when the woman is more relaxed.
* In late pregnancy, raised systolic pressure of 30 mm Hg or raised diastolic
pressure of 15 mm Hg above the baseline values on at least two occasions of
6 or more hours apart indicates toxemia.
• Breast examination:
* The breast should be gently palpated to feel any lump.
* The nipple should be drawn forward to see if it is protractile.
* The breast should be observed for pregnancy changes.
• Medical examination:
* The doctor should examine the heart and lungs to exclude diseases.
• Elimination:
* Ask the woman about her bowel habits.
* Carry out routine urine analysis.
* Check the presence of dysuria and frequency of micturition.
• Vaginal discharge:
* Ask the woman about any increase or change of vaginal discharge.
* Report to the obstetrician any mucoid loss before the 37th week of
pregnancy.
• Vaginal bleeding:
* Vaginal bleeding at any time during pregnancy should be reported to the
obstetrician to investigate its origin.
• Legs:
* Legs should be noted for edema.
* They should be observed for varicose veins which predispose to deep vein
thrombosis.
* The calf must be observed for reddened areas which may be caused by
phlebitis and white areas which could be caused by deep vein thrombosis.
* Ask the woman to report tenderness during examination.
* The legs should be observed for unequal length or muscle wasting which
may be an indication of pelvic abnormalities.
• Local Abdominal Examination
1-Inspection
The nurse should look at the following:
• Skin changes such as linea nigra, striae gravidarum and scars of previous
operations.
• The size of the abdomen is inspected for:
* Height of the fundus, which determines the period of gestation.
* Multiple pregnancy and polyhydramnios will enlarge both the length and
breadth of the uterus.
* A large fetus increases only the length of the uterus.
• The shape of the abdomen is inspected for:
* Fetal lie and position.
* The abdomen is longer if the fetal lie is longitudinal as occurs in 99.5% of
cases.
* The abdomen is lower and broad if the lie is transverse.
* Contour of the abdominal wall is observed for pendulous abdomen,
lightening protrusion of umbilicus and full bladder.
* Fetal movements are inspected as evidence of fetal life and position.
* The abdomen is also inspected for edema and varicose veins.
2-Palpation
• The uterus will be palpable per abdomen after the 12th week of gestation
• Abdominal palpation includes:
* Estimation of the period of gestation. This is done by determination of
fundal height.
-The uterus may be higher than expected due to large fetus, multiple
pregnancy, polyhydrammnios or mistaken date of last menstrual period.
-The uterus may be lower than expected due to small fetus, intrauterine
growth retardation, oligohydramnios or mistaken date of last menstrual
period.
• Fundal palpation is performed to determine whether it contains the
breech or the head. This will help to diagnose the fetal lie and presentation.
Pelvic examination is done to determine:
* Fetal position and presentation.
* Engagement of fetal head.
* Disproportion between head and pelvis.
• Pawlik's maneuver is sometimes used to:
* Locate the round, hard head.
* Judge the size flexion and mobility of the head.
3-Auscultation
• Fetal heart sound is heard by sonicaid as early as 10 th week of
pregnancy.
• Fetal heart sound is heard by Pinard's fetal stethoscope after the 20 th
week of pregnancy.
• The normal fetal heart rate is 120-160 beats/minute.
• Fetal heart sound has been described as the ticking of a watch under a
pillow.
Investigations:
• Urine is tested for protein, glucose, and ketones. Traces of protein and
sugar, and low specific gravity of urine(less than 1.102) may be found
due to physiological changes of pregnancy.
• Stool analysis for ova and parasites.
• Complete blood picture:
* Hemodilution of blood during pregnancy results in lowered hemoglobin
level (11-12 g/dl), hematocrit, and red blood cell count (normal range is
3.600.000-4.700.000/mm3).
* White blood cells are increased especially neutrophils (more than 70%),
which enhances the blood phagocytotic and bactericidal properties.
* Coagulation time changes from 12 to 8 minutes. This increased capacity
for clotting results in higher risk of thrombosis and embolism.
* Screening for sickle cell anemia, thalassemia and hepatitis may be
necessary for some women.
* Testing for rubella antibodies if the pregnant woman comes in contact
with the disease is required.
* ABO blood group and Rhesus factor (Rh).
* Random blood glucose (80-120 mg/looml).
* Venereal disease tests should be performed (VDRL). Toxoplasmosis.
* Ultrasound scanning is used to assess the fetal
* Urine should be tested for sugar, ketones, and protein.
* Hemoglobin will be repeated:
- At 36 weeks of gestation.
- Every 4 weeks if Hb is<9g/dl.
- If there is any other clinical reason.
• Fetal kick count:
* The pregnant woman reports at least 10 movements in 12 hours.
* Absence of fetal movements precedes intrauterine fetal death by 48
hours.
Schedual of antenatal care:
the nurse provides the pregnant women information about the
recommended schedule for antenatal care visits during normal pregnancy.
It entails that she should have a medical check up every four weeks up to
28 weeks gestation, then every 2 weeks until 36 weeks of gestation
followed by a visit each week until delivery (Littleton and
Engebreston,2002).
More frequent visits may be required if there are abnormalities or
complications or if danger signs arise during pregnanc the WHO
technical working group has recommended a minimum of 4 antenatal
visits for a woman with normal pregnancy. However, some women will
require more than 4 visits especially those who develop complications
(WHO, 2002).
 Services at subsequent visits:
-There is continuity & follow up of the all types of services provide at
first visit.
-At the subsequent prenatal visits, the nurse inquires about physical
changes that are related directly to the pregnancy, such as the woman’s
perception of fetal movement, any exposure to contagious illness,
medical treatment and therapy prescribed for non-pregnancy problems
since the last visit, and any prescribed medications that were not
prescribed as a part of the women’s prenatal care. By evaluation, the
woman is able to verbalize her knowledge, fells comfortable in her ability
to care with her situation, and has resources to call on. The woman will
accept minor discomfort of her pregnancy (Lond, 2000).
 Items of health education:
 Follow up:
Advice the mother to follow up according to the schedule of antenatal
care that mentioned before, advise the mother to follow up immediately if
any danger sings appears, describe the important of follow up to the
mother.
 Danger signs of pregnancy:
Every pregnant woman should be thought as a part of her antenatal
care about the following warning sings:
- Vaginal bleeding including spotting.
- Persistent abdominal pain.
- Sever & persistent vomiting.
- Sudden gush of fluid from vagina.
- Absence or decrease fetal movement.
- Sever headache.
- Edema of hands, face, legs & feet.
- Fever above 100 F( greater than 37.7C).
- Dizziness, blurred vision, double vision & spots before eyes.
- Painful urination.
Any woman developing any of the following warning sings should report
the nearest clinic with out delay.
 Hygiene:
-the pregnant woman should bath daily to remove increased perspiration
and become comfort.
- Avoid hot bath because of fainting.
- avoid vaginal douche because of changing the vaginal PH & cause
infection.
- Daily complete bath is very necessary.
- pregnant woman can have a routine dental care.
- It is advisable to have cavities filled and infected teeth treated.
-The nurse can encourage the woman to use a soft toothbrush to lessen
bleeding from the gums, which increases due to the increased vascularity
during pregnancy (Pillitteri, 2003)..
 Breast examination & care:
-Careful examination of the nipples to be sure that it is not retracted or
inverted,
- advise the mother to be mentally prepared for breast feeding,
- the breast should be supported with a well fitting brassiere for prevent
or alleviating upper back ache & gives comfortable,
-advise the pregnant woman to expresses colostrums during the last
trimester of pregnancy to prevent congestion.
-She should put emphasis on the importance of cleanliness especially as
the client begins produce colostrum (Wheat, 2001).
 Diet:
-Daily requirement in pregnancy about 2500 calories.
- Women should be advised to eat more vegetables, fruits, proteins, and
vitamins and to minimize their intake of fats.
Purpose:
1. *Growing fetus.
2. *Maintain mother health.
3. *Physical strength & vitality in labor.
4. *Successful lactation.
 Activity:
Avoid heavy work, house work continued but with exercises & rest.
Rest and Sleep:
the nurse informs the pregnant women about adequate rest during
pregnancy. At least sleep for 8 hours per day and 1-2 hours during
afternoon are important for both physical and emotional health. Sleeping
becomes more difficult during the third trimester because of the enlarged
abdomen so the nurse should encourage the client to try a
left
lateral position, which reduces uterine pressure on the other organs. Also
the nurse should teach the client the appropriate relaxation technique to
prepare her for sleep (Lees et al, 2000).
 Exercises:
Prenatal exercises are very important in pregnancy:
- Purpose:
1. To develop a good posture.
2. To reduce constipation & insomnia.
3. To alleviate discomvortable, postural back ache& fatigue.
4. To ensure good muscles tone& strength pelvic supports.
5 To develop good breathing habits, ensure good oxygen supply to the
fetus.
6- to prevent circulatory stasis in lower extremities, promote circulation,
lessen the possibility of venous thrombosis
Guide lines for exercises during pregnancy:
-Maintain adequate fluid intake.
-Warm up slowly, use stretching exercises but avoid over stretching to
prevent injury to ligaments.
-Avoid jerking or bouncing exercises.
- Be careful of loose throw rugs that could slip& cause injury.
Exercises on regular basis (three times per week).
- After first trimester, avoid exercises that require supine position.
 Contraindications:
1. -Vaginal bleeding.
2. -Sever anemia.
3. -History of preterm labor,
4. -Extreme over or under weight.
5. -Hypertension, heart, lung, thyroid diseases.
 Coitus:
Sexual relations continue throughout normal pregnancy.
 Contraindications:

Rupture of membranes.

Preterm labor.

Incompetent cervix.

Spotting or bleeding.
 Clothes:
-It must be comfortable, washable, loose, mood fitting,
-avoid restrictive clothing because they can impede venous circulation
-adjustable & comfortable shoes
-Shoes should fit properly, feel comfortable, and have a flat or low wedge
heel.
- The nurse should instruct the pregnant woman to avoid high-heeled
shoes because they increase spinal curvature and aggravate backache
(Pillitteri, 2003).
Employment: unless jobs involve exposure to toxic substances, lifting
heavy objects or other kinds of excessive physical strain, long period of
standing, or having to maintain body balance, employment is not
forbidden during pregnancy (Frazier et al, 2001).
 Traveling:
It must be comfortable, train is safer than traveling by car for car
traveling long journey break must taken every two hours air traveling is
contraindication after 34 weeks of gestation.
 Hazards:
Occupational hazards: lead, mercury, X ray s& ethylene oxide.
1. Infection: rubella, toxoplasmosis, syphilis.......................
2. Smoking & alcohol: increase risk for pregnancy, prematurity,
fetal death, mental retardation & congenital anomalies.
3. Drugs: as sedative & analysis, anticoagulant, antithyrodism,
hormones& antibiotics.
Immunization:
the nurse instructs the woman to receive immunization against -tetanus
to prevent the risk for her and her fetus.
Also, it is important that every pregnant mother should receive a tetanus
vaccination card with her first tetanus dose and keep it to record
subsequent doses (WHO, 1999).
 Preparation for labor:
Many women expecting a child have a profound desire to learn about
pregnancy & birth & want to be as well prepared as possible for this
events, many prenatal & child birth program are offer to meet this need
in a variety of setting prenatal clinic & hospital. While program length&
organization may differ among the various classes offered, all have
certain content in common:
1. Pain management & relaxation& breathing techniques that can be
used during labor& delivery.
2. Role of support person during labor& delivery.
3. Possibility of high risk birth including CS.
4. Preparation for parenting.
Family planning:
the role of the nurse involves counseling about family planning
methods and modern contraceptive or emergency type of contraceptives.
The nurse should use a wide variety of audio-visual methods or teaching
strategies as overhead transparencies, posters, films, and lectures with
group discussion (Leonard and Perry, 2004).
 Mental preparation:
Fear from unknown acts through the cortex& hypothalamus on
sympathetic system, tension is produced neither mother nor her uterus
can property relax & exhaustion fallows.
Fear of labor is universal the most effective antidote is a doctor -client
relationship which allows the mother to repose an absolute trust &
confidence in her attendants, close personal involvement of the doctor is
not always possible in the circumstance of present day obstetric practice,
but antenatal instruction has been systematized.
Minor Disorders of Pregnancy "First Trimester".
 Digestive System
 Morning sickness:
Nausea and vomiting occur between 4-6 weeks gestation in about 50-70
percent of expectant mothers. It is not confined to early morning but can
occur at any time during the day.
 Causes:
 The most likely cause is hormonal influences such as human
chorionic gondotrophin, estrogen and progesterone.
 Emotional factors such as tension

Management:
 Understanding the cause helps in coping.
 Adequate rest and relaxation will often help to reduce
tension and prevent nausea.
 Eating six small meals a day rather than three large ones is
advisable in an attempt to keep some food in the stomach at
all times.
 Solid food may be tolerated better than liquid food, e.g.
eating two or three crackers or a piece of dry toast with
nothing to drink, immediately on awakening, then lying
quietly in bed for 20-30 minutes and thereafter arising and
eating a light breakfast.
 Carbohydrate snacks at bedtime and before rising can
prevent hypoglycemia, which cause nausea and vomiting.
 Food should not have a strong odor, should not be either
very hot or very cold, and fried or greasy foods should be
avoided.
 Excessive salivation (ptyalism)
It occurs from 8 weeks gestation and may accompany heartburn.
 Causes: is a pregnancy hormone.
 Management: Explanation and attentive listening are helpful.
 Heart burn:
It is a burning sensation in the stomach that rises into the throat.
 Causes:
•Progesterone hormone relaxes the cardiac sphincter of the stomach and
allows reflux or bubbling back of gastric contents into the esophagus.
 Management
•Avoiding bending over and lying flat can prevent the reflux.
•Sleeping with more pillows and lying on the right side can sometimes
help.
•Small frequent meals take up less room in the reduced stomach space
and are digested more easily.
•Resting in a semi-reclining position for about half an hour after meals is
helpful.
•For persistent heartburn, the doctor may prescribe antacids.
 Taking baking soda in a glass of water is contraindicated
because of the possibility of retention of sodium and
subsequent edema.
 Distress:
A vague and ill-defined form of discomfort that occurs after eating. It
resembles heartburn and makes the woman very uncomfortable. It is
more likely to occur in a person who eats rapidly, or does not chew food
thoroughly, or eats more at one time than the stomach can comfortably
hold. Small amounts of food taken slowly and masticated thoroughly may
prevent distress.
 Pica (Cravings):
It is the term used when a mother craves certain foods or unnatural
substances such as coal.
 Cause: is unknown, but may be due to pregnancy hormones and
changes in metabolism.
The nurse should be aware of this condition and seek medical advice if
the substance craved is harmful to the fetus, e.g. lead.
 Flatulence:
It may or may not be associated with heartburn; it is fairly common and
rather uncomfortable.
 Causes:
 Bacterial action in the intestines, which result in the
formation of gas.
 Hypochlorhydria during pregnancy and decreased motility of
the entire gastrointestinal tract retard normal peristalsis and
gas sometimes accumulates to a very uncomfortable extent.
 Management:
•The diet should contain adequate amounts of fresh fruits, coarse
vegetables, whole-grain breads and cereals and abundant fluids.
•A regular time for defecation should be established and action upon the
desire for defecation should be prompt.
•When trying to have bowel movement, the woman should sit
comfortably back on the commode seat with her feet flat on the floor or
supported on a low step.
•A glass of warm water in the morning before tea or breakfast may
activate the gut and help regular bowel movement.
•Exercise, especially walking, is also beneficial.
•Laxatives and cathartics should be taken only if prescribed by the
physician.
 Irritant cathartics and enemas are to be avoided during
pregnancy unless all other treatment has been ineffective.
 Mineral oil is contraindicated as it is ineffective and inhibits
the absorption offal-soluble vitamins.
 Musculoskeletal System
•Many women experience marked fatigue and lassitude early in
pregnancy.
• This feeling usually disappears by the end of the third month of
pregnancy.
• Women require many more hours of sleep during this time than they
usually do.
 Genitourinary System
• Changes in frequency of micturition.
•In the early weeks of pregnancy, it occurs due to the pressure of the
growing uterus on the bladder.
•The pregnant woman should be reassured that the problem is resolved
when the uterus rises into the abdomen after the 12th week.
 Circulatory System
 Fainting:
In early pregnancy it may be due to the vasodilatation effect of
progesterone.
 Management:
 The reason should be explained to the pregnant woman.
 The pregnant woman should avoid long periods of standing.
Minor Discomforts of Pregnancy - Third Trimester
 Respiratory System
 Dyspnea:
 Causes:
•Upward pressure of the uterus.
•Increased sensitivity of the respiratory center to the carbon dioxide
content of the blood.
•It is aggravated by the mother lying down.
 Management:
•Dyspnea is relieved by sitting up preferably in a straight chair, or being
well propped up on pillows while lying down.
•Lying on the back with the arms extended above the head and resting on
the bed for a few minutes and before sleep at night.
•Intercostal breathing may also give some relief.
 Digestive System
 Heart bum:
 Causes:
The pressure of the growing uterus on the stomach from about 30-40
weeks gestation.
 Management: Same as first trimester.
 Distress: Same as first trimester.
 Flatulence: Same as first trimester.
 Constipation:
 Causes:
•The gut is displaced by the growing fetus.
•Constipation is sometimes associated with the taking of oral iron.
 Management: Same as first trimester
 Musculoskeletal System
 Backache:
 Causes:
•Backache may be due to muscular fatigue and strain that accompany
poor body balance.
•It may be due to increased lordosis during pregnancy in an effort to
balance the body.
•The pregnancy hormones sometimes soften the ligaments to such a
degree that some support is needed.
 Management:
•The pregnant woman is reassured that once birth has occurred, the
ligaments will return to their pre-pregnant strength.
•Exercises: improvement of posture and abdominal support aid in the
prevention of backache.
 Round ligament pain:
As the uterus grows, the round ligaments are stretched and cause
abdominal pain and tenderness.
 Management:
•Other causes of abdominal pain should be ruled out.
•Rest and change of position usually will provide relief.
•Cramps in the leg, numbness or tingling may be the result of
overstretching of muscles and fascia.
•They may be caused by circulatory impairment in the muscles owing to
pressure of the large, heavy uterus on the pelvic veins.
•A muscular tetany, resulting in leg cramps is sometimes caused by
depression of available serum calcium, due to excess phosphorus in the
blood.
 Management to relieve sudden cramps in the calf muscle:
•In the sitting position, the woman may be advised to hold the knee
straight and stretch the calf muscle by pulling the foot upwards
(dorsiflexion).
•She stands firmly on the affected leg and strides forward with the other
leg.
•She raises the foot of the bed about 25 cm.
•Application of a hot water bottle or gentle leg movement whilst in a
warm bath enhances circulation and removes waste products from the
muscle.
The doctor may prescribe vitamin B complex and calcium.
 Fatigue:
Tiredness is likely to reappear during the last trimester.
 Management is the same as first trimester.
 Genitourinary System
 Frequency of micturition:
In the later weeks, it occurs because the fetal head usually enters the
pelvis and reduces the space required by the bladder.
The pregnant woman should be reassured that the problem is resolved
after delivery.
It is increased white, non-irritating vaginal discharge during the latter
months of pregnancy.
 Management:
•Douching should be avoided during pregnancy except when specifically
ordered by the physician.
•In addition to regular bathing, the vulva may be rinsed with warm water
after each voiding.
•Wearing cotton underwear and thin sanitary napkins usually gives a
feeling of cleanliness and comfort.
•If the discharge is abnormally profuse, irritating or foul smelling, and
distressing by persistent itching and burning, medical investigation is
needed for possible pathologic causes.
Circulatory System
 Supine hypotensive syndrome:
 It may cause dizziness and a faint feeling during the latter
part of pregnancy.
 The inferior vena cava may be compressed by pressure of
the heavy pregnant uterus when the mother lies on her back
causing decreased venous return to the hart.
 Management:
•An immediate change of position to the left side is important for the
mother's comfort.
•A folded towel placed under the right hip will usually displace the uterus
enough to prevent or relieve symptoms.
 Varicosities:
 Although varicose veins are confined to the legs, they may
occur in the vulva. Varicose veins in the vulva are very rare
and painful.
 Aching of the legs is a common symptom, even when the
veins are not visible.
 Causes:
•Progesterone relaxes the smooth muscles of the veins and results in
sluggish circulation. The valves of the dilated veins become inefficient
and varicose veins result.
•Varicose veins are most likely to develop in pregnant women with a
family history or when they must stand for long periods of time or sit
with legs dependent.
 Management:
•One preventive measure is to sit down with the feet elevated.
•If it is necessary to stand up, moving the legs about is better than
standing still.
 Lying flat on the bed with the legs elevated 45 degrees,
resting them on a footstool for 5-10 minutes three to four
times a day will help reduce varicose veins and aching of the
legs.
 Exercising the calf muscle by rising on to the toes or making
circling movements with the ankles will help venous return
 Elastic stockings or spiral elastic bandages will give relief
and help to prevent the veins from growing larger. They
should be put on before getting up in the morning or after
resting for few minutes with the leg elevated.
 Tight bands that interfere with return circulation should be
avoided.
 Engorged veins in the vulva may be relieved by:
1. Lying flat and elevating the hips, or by adopting the elevated Sim's
position for a few moments several times a day
2. Applying pressure to the vulva by means of a folded up hand towel,
several sanitary pads or a panty girdle.
 Hemorrhoids:
 They are varicose veins that protrude from the rectum.
 They are extremely painful and may itch and bleed.
 Straining incident to constipation and pressure made by the
enlarging uterus may cause them.
 Management:
•Exacerbation of hemorrhoids will be reduced by avoidance of
constipation.
•Push them back gently into the rectum after lubricating the fingers with
petroleum jelly or cold cream.
 Lying down with the hips elevated on a pillow and
application of an ice bag or cold compresses to the anus
usually give relief.
 The physician may prescribe medicated ointments, lotions or
suppositories in case of sever condition.
 Operation is rarely resorted to during pregnancy because
there is marked improvement after delivery.
 Edema:
 Swelling of the feet is very common during pregnancy and
sometimes there is also swelling of the hands.
 Edema may be confined to the back of the ankles or may
extend up to the legs and thighs and may even include the
vulva.
 It is physiological and results from mechanical interference
with venous return and other circulatory modifications of
pregnancy.
 Management:
 Lying down in a lateral position favors venous return from
the lower extremities and decreases fluid retention.
 Sitting with the feet resting on a chair or footstool also will
give some relief.
 For employed woman, elevation of the feet for 10-15
minutes, several times a day may increase her comfort.
 Dietary salt restriction is not indicated since sodium
retention is not an etiologic factor.
 Sodium intake is necessary to maintain normal maternal and
fetal electrolyte balance.
 The nurse must be keenly aware of the fact that although
edema may be of mechanical origin, it is also a sign of
toxemia and any swelling should prompt further
investigation.
 Nervous System
 Carpal tunnel syndrome:
 It is a feeling of numbness and pins and needles in the
fingers and hands in the morning or at any time of the day.
 It is caused by fluid retention, which creates edema and
pressure on the median nerve.
 Management:
 Explain to the pregnant woman that this syndrome usually
resolves spontaneously following delivery.
 Wearing a splint at night with the hand resting high on two
or three pillows sometimes gives relief.
 The doctor may prescribe diuretics.
 Insomnia:
1. Physical reasons include:
 Difficulty in finding a comfortable position in bed because
of a large and cumbersome body.
 Fetal activity is often vigorous and disturbing.
 Nocturnal frequency of micturation.
2. Psychological reasons include:
 The excitement and anticipation of birth may make it hard to
relax and "turn off the mind for sleeping.
 Dreams about labor and the infant may be more frequent and
sometimes frightening.
 Management:
 A warm drink or warm bath at bedtime or reading
some light material in bed.
A back rub with a soothing lotion promotes relaxation.
Relaxation techniques learned in parenting classes are
beneficial now.
 Lying on the side and using small pillows or rolled
towels to support the heavy abdomen and upper leg
will usually permit greater muscle relaxation.
 It is helpful to concentrate on having every part of the
body limp and then to make a conscious effort to have
each inspiration and expiration exactly the same
length and depth.
 Periods of rest and sleep during the day are important
in order to compensate for loss of sleep during the
night.
 Going to bed earlier may give the infant an active
period and allow the pregnant woman to sleep at her
usual time.
 Talking through common fears of pregnancy will
relieve anxieties.
 Sensitive listening, explanation and reassurance can
be helpful.
 A lie-in in the morning or a rest in the afternoon will
help to prevent tiredness and depression that can occur
in the last trimester of pregnancy.
 Sharing the pregnant woman's feeling can result in a
sense of normality and lightness.
 Encouraging the pregnant woman to think about
positive aspects of the infant and having a family may
relieve depression due to hormonal changes towards
the end of pregnancy.
 Skin:
 Itching:
The breasts, abdomen and palms of the hands are commonly affected
areas, although itching may be generalized to the entire body.
 Causes:
 The increased excretory function of the skin may result in the
elimination of irritating substances by the skin glands.
 Stretching of the skin owing to weight gain, the growing uterus,
and the fluid that is held in the skin.
 Generalized itching over the abdomen results from liver
response to pregnancy hormones and raised bilurubin levels
 Management:
 Explain to the pregnant woman that itching will be reduced after
childbirth.
 Bathing in tepid rather than hot, water and adding sodium
bicarbonate (baking soda) to the bath water are soothing measures.
 Dabbing, rather than rubbing, to dry the skin with a towel will
reduce stimulation of the skin and is less likely to produce itching.
 Lotions and oils are often helpful and rubbing them on the
uncomfortable area is a constructive alternative to scratching.
 Sometimes, changing soaps or reducing the use of soap to a
minimum will provide relief.
 Loose, nonrestrictive clothing is comfortable and not so apt to
induce itching.
 Antihistamines that are prescribed by the doctor will provide
limited comfort.
Investigation
health education first trimester (1-3