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• I. VITAL SIGNS
• A. Blood Pressure
• - The Bp is the most important vital sign that
should be monitored every clinic visit. There is
usually no significant change in Bp during gestation.
However, expect a slight drop in the 2nd trimester
that returns to normal on the 3rd trimester.
• B. Pulse Rate
• Pulse rate increases by about 10 bts/min. due to
increased cardiac workload.
• - Arrhythmias or palpitation are normal during
pregnancy as long as it is not accompanied by
dizziness and syncope.
• C. Respiratory Rate
• - Increases in depth, no significant change in
rate.
• - Shortness of breath and dyspnea late in
pregnancy is common.
• D. Temperature
• - There is a slight elevation in temperature early
in pregnancy due to the thermogenic effect of
progesterone. It drops to normal after 16 weeks.
• II. Physical Assessment
• B. Eyes
• - Pale conjunctiva indicates anemia. Edema of the
eyelids accompanied by visual disturbances is sign of
PIH.
• C. Nose
• - Normal nasal congestion occurs as a result of
estrogen stimulation.
• D. Ears
• - Nasal stiffness results in blockage of the
eustachian tube which may affect pregnant woman’s
hearing.
• G. Breast
• - Normal findings include enlargement of the
breast with wider and darker areola, prominent veins.
Breast masses, nodules, dimpling of the skin and
bloody nipple discharge are abnormal findings and
should be reported to the physician right away.
Colostrum, a thin watery fluid, can be expressed from
the nipple.
• H. Skin
• - Linea negra, mask pf pregnancy
(melasma/chloasma), spider nevi, palmar erythema are
common findings. Pallor, jaundice, rashes and skin
lesions are abnormal findings.
• I. Back
• - Exaggerated lumbar curve late in pregnancy
occurs as a result of the shifting of the pregnant
woman’s center of gravity.
• J. Rectum
• - Hemorrhoids may be present especially in the
last months of pregnancy.
• K. Extremities
• - Ankle swelling is a normal finding in the 2nd half
of pregnancy. Leg edema especially in the late
afternoon is common to pregnant women. Waddling
gait is due to relaxation of pelvic joint. Edema of
upper extremities, face and hands are danger signs.
• Purpose:
• 1. Provide explanation
• 2. Let woman empty her bladder
• 3. Provide good lighting
• 4. Place woman in lithotomy position with buttocks
extended slightly beyond examining table.
• 5. Drape properly.
• 6. Let support person stay at the head of the bed.
• 7. Instruct woman not to:
• - hold or squeeze your hand or that of her
husband
• - hold her breath
• - close eyes tightly
• - clench fist
• - contract perineal muscles
• 8. Explain the procedure. It may be slightly
uncomfortable.
• 9. After the procedure, provide tissue to wipe
perineum of lubricant.
• Specimen Collected:
• - Endocervix Specimen
• - Ectocervical specimen – common site for malignancy
• - Vaginal pool specimen – specimen for posterior fornix.
• Findings:
• - Class I – normal findings
• - Class II - Normal with atypical cells present.
Atypical cells are often caused by inflammatory conditions
such as infection.
• - Class III - Suggestive of malignancy with
benign and pssibly malignant cells.
• - Class IV - Probably malignant, with signs of
malignancy present.
• - Class V - Definitely malignant cells are present.
• B. Leukocyte Count
• - done to screen and rule out leukemia and
possible infection. Nonpregnat value are 5,000 –
10,000 but may reach 16,000 in pregnancy
• C. Differential smear
• - done primarily to identify the types of
leukocytes, erythrocytes, abnormalities and adequacy
of platelets.
• D. VDRL
• - screen for maternal syphilis. Untreated syphilis
in the 2nd trimester can infect the fetus and result to
congenital abnormalities. If woman is (+) for an STD,
recommend testing and treatment of partner.
• E. HIV screen
• - if the woman belongs to the high risk group,
HIV screening may be done by enzyme linked
immunosorbent assay (ELISA) testing.
• If the result is (+), the diagnosis is confirmed usually
by Western blot test. Women with HIV are treated
with Zidovudine (AZT) during pregnancy to decrease
the risk of the fetus acquiring the infection. HIV
screening is recommended to women:
• - who are IV users
• - with multiple sexual partners
• - with sexual partners (+) for HIV or who belong
to the high risk group (homosexual, IV drug users,
hemophiliacs)
• - who received blood transfusion between 1977 to
1985 when HIV testing for blood products is not yet
routinely conducted.
• F. Antibody screen
• - conducted for the purpose of screening the
pregnant woman’s serum for antibodies formed from
exposure to major or minor blood group antigens.
• VI. Urinalysis
• 4. Glucose
• - Glycosuria may occur in pregnancy because of
increased glomerular filtration rate. However, it may
also indicates carbohydrate intolerance. If urine is
• Positive for glucose further testing is necessary to
confirm diagnosis.
• 5. Protein
• - A value of 1+ is abnormal. The cause should be
identified with further testing (UTI, PIH, renal
disease)
• 6. Leukocyte
• - is helpful in identifying patient with significant
leukocyturia. Current opinion is that the test strip
could reduce screening costs by replacing microscopy.
FETAL ASSESSMENT
• I. Fetal Heart Rate
• - fetal heart rate can be 1st heard between 16 –
19 wks. Gestation
• - FHT is audible at about 16 wks or 4 months in
multiparas and 2o wks or 5 months in primiparas.
• - 80% of pregnant women, FHT is audible at 20
wks, 95% at 21 wks. And at 22 wks; FHT can be heard
in all pregnant women.
• - After it has been initially auscultated, it should
be auscultated every clinic visit primarily to
determine if the fetus is alive.
• II. Amniocentesis
• B. Lung Profile
• - is the study of all surfactants not only the lecithin
and sphingomyelin. These other surfactants are equally
important indicators of fetal lung maturity.
• A. Rh Incompatibility
• - amniotic fluid can be assessed for bilirubin
levels repeatedly in RH incompatibility during
pregnancy to monitor the progression of the disease
and the fetal condition.
• B. Fetal Maturity
• - it is expected that during the 2nd half of
pregnancy the concentration of amniotic fluid
bilirubin decreases until it virtually disappears during
• the last month of gestation.
• Purpose
• 1. Diagnosis and confirmation of early pregnancy
• 2. Vaginal bleeding in early pregnancy
• 3. Determination of gestational age and assessment
of fetal size
• 4. Diagnosis of fetal malformation and other
chromosomal abnormalities.
• 5. Placental location
• 6. Multiple pregnancies
• 7. Hydramnios and oligohydramnios
• 8. Other areas
• - confirmation of intrauterine death
• - confirmation of fetal presentation
• - evaluation of fetal tone, movement and
breathing
• - detection of uterine and pelvic abnormalities
during pregnancy such as fibromyomata and ovarian
cyst.
• IV. Fetoscopy
• procedure in which an endoscope is inserted
transabdominally into the amniotic cavity to directly
visualize the fetus. This procedure is performed
around 18 wks. gestation.
• V. Amnioscopy
• - is direct visualization of amniotic fluid through
the fetal membranes with cone-shaped hollow,
inserted through the cervix
• VI. Radiography
• - confirm pregnancy with identification of fetal
skeletal parts at 16 wks. During the 2nd half of
pregnancy, multiple pregnancies can be diagnosed and
in the 3rd trimester, anencephaly and hydrocephaly
can be seen.
• VII. Nonstress Test (NST)
• II. Exercise
• the primary purpose of the exercise is to
strengthen the muscles to be used for labor and
delivery.
• Contraindicated:
• - PIH
• - PROM
• - PTL
• - incompetent cervix
• - vaginal bleeding
• - IUGR
Exercise Benefit
- PROM
- CHF
- Hemoglobinopathies
- Marfan’s Syndrome
- DM with multiple end-organ involvement
• - 2 previous pregnancies
• - incompetent cervix
• - fetal loss secondary to uterine anomalies
• - PIH
• - Multiple gestation
• - IUGR
• - severe heart disease
• - preterm labor
• III. Employment
• - pregnant women can continue working as long as
their job does not involve lifting heavy object,
standing and sitting for long periods of time,
excessive physical and emotional strain and expose to
toxic substances.
• IV. Dental Care
• - The pregnant woman should have a dental check-
up early in pregnancy to give plenty of time for
repairs and treatment of infected teeth and for
instructions on proper dental care.
• - dental x-ray is allowed as long as the woman
wears lead apron over her abdomen to protect the
fetus from the damaging effects of radiation.
• V. Maternity clothes
• - Lightweight, non-constrictive and loose fitting
• - absorbent and washable because of increase
perspiration
• - Reasonably priced because they will only be used
during pregnancy.
• - flat heeled shoes that provide good support are
recommended during pregnancy because of the
altered balance of the woman especially when the
abdomen has grown large enough.
• VI. Bathing
• - The woman perspires more heavily because she
needs to excrete the waste products of her body and
that of the fetus. Due to increased perspiration, the
pregnant woman is encouraged to have a daily bath to
keep fresh and clean.
• - Bathing is contraindicated when there is vaginal
bleeding and after the membranes have ruptured.
• VII. Breast Care
• - Well fitting and large size brassiere is
recommended for the increased breast mass and
pendulous breast. Bras should provide adequate
support, with wide straps and deep cups to prevent
loss of breast tone.
• - If woman plans to breastfeed, nipple rolling
between thumb and forefinger and drying of nipples
with rough towel is encourage to toughen the nipple.
• VIII. Immunization
• - Immunization with vaccines containing live
viruses is contraindicated during pregnancy because
of the danger of the virus crossing the placenta and
infecting the fetus.
• - The immunization recommended to all pregnant
women in the Philippines is Tetanus Toxoid vaccine
given in the following schedule:
• IX. Travel
• - There are usually no travel restrictions during
pregnancy but it is advised that pregnant women avoid
long trips on the 3rd trimester. The best time to
travel is on the 2nd trimester because the woman is
• Most comfortable at this time and there is minimum
danger of abortion and preterm labor.
• - When traveling:
• - 15 to 20 mins. Rest period on long rides to
move about and empty bladder.
• X. Sexual Relation
• - 1st tri – decrease sexual desire due to
discomforts of pregnancy
• - 2nd tri - increase sexual desire because woman
has already adjusted to pregnancy and this is the
period when she is most comfortable.
• - 3rd tri - decrease sexual desire because of the
fear of hurting the fetus and the discomfort caused
by enlarged abdomen and deep penile penetration.
• XI. Alcohol
• - refrain from drinking alcohol because it may
cause fetal anomalies.
• - Alcohol increases the risk of:
• - midtrimester abortion
• - mental retardation
• - behavior and learning disorder
• - Fetal alcohol syndrome (SGA)
• XII. Smoking
• - nicotine causes vasoconstriction resulting in
decreased blood flow to the placenta which in turn
diminished oxygen supply to the fetus. Fetal hypoxia
leads to low birth weight.
• - Smoking increases the risk for:
• - poor lung development
• - asthma, and respiratory infection
• - increased risk of SIDS
• - physical growth deficiency
• - intellectual development deficiency
• - behavioral problems
• XIII. Medications
• - Classification of medication with regards to
adverse fetal effects (FDA)
Vit. K Hyperbilirubinemia
Salicylates (aspirin) Neonatal bleeding, decreased
intrauterine growth
• Management:
• A. Eat dry toast or crackers before rising from bed
• B. Eat small frequent meals rather than 3 large ones
• 2. Frequent urination
• Management:
• A. Limit fluid intake before bedtime
• B. Kegel exercise to improve tone of muscles that
controls urination.
• 3. Fatigue
• Management:
• A. Take at least 8 hours of sleep at night and
frequent rest periods during the day.
• B. Avoid standing for long periods, work while seated
as much as possible
• C. Eat a well balanced diet to provide enough energy
• 5. Leukorrhea
• Management:
• A. Proper perineal hygiene, flush perineu with water
after each voiding, no douching is necessary
• B. Use sanitary pad for excessive vaginal discharge
• 6. Nasal stiffness
• Management:
• A. Avoid allergen and smoked filled room
• B. Normal saline nose drops (1/4 salt in 1 cup water)
• C. Breathe steam from pot of boiling water
• 7. Heartburn or pyrosis
• Management:
• A. Take small meals rather that three large ones
• B. Bend at knees not at waist when picking objects
from the floor, avoid lying flat
• 8. Varicose Veins
• Management:
• 1. Leg varicosities
• a. Periodic rest with elevation of the legs, lie with
feet against the wall
• b. Avoid prolonged sitting or standing,
constricting garters, knee high socks
• c. Wear support hose
• d. Apply elastic bandage before getting up in the
morning starting at the distal ends but don’t wrap
toes
• 2. Vulvar Varicosities
• a. Rest with pillow under hips
• b. Modified knee chest position
• Management:
• A. For immediate relief, push toe upward while
applying pressure on the knee to straighten the leg
• B. One quart of milk a day to meet calcium needs or
oral calcium supplements as prescribed by physician
• C. Exercise regularly but avoid pointing of toes
• 11. Headache
• headache is normal during the 1st trimester. Some
cases lead to sinusitis or ocular strain caused by
refractive errors.