* NLE * NCLEX * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY * MED TECH *RESPI

NORMAL OB
HANDOUTS
Prepared by: Ms. Lorelie Pomentil

OBSTETRIC NURSING I: (OB NORMAL)

I. The MENSTRUAL CYCLE

- Episodic uterine bleeding in response to cyclic hormonal changes episodic uterine bleeding in response to cyclical
- Purpose: 1. Prepares the body for pregnancy to bring an ovum into maturity hormonal changes
2. to renew the endometrial lining
• Menarche – first menstrual bleed or period that usually occurs between the ages 12-14 years but can occur anytime between 9-15.; can happen as early as
9 years old
• Average length of menstrual cycle: 28 days (ranges: 33-35 days)
• Average length of menstrual flow: 4-9 days; can happen for as long as 9 days; shortest 2 days
• Color of menstrual flow: dark red ( blood mucus, endo lining)
• Odor: semigold to marigolds

“The Menstrual Cycle”

The 4 body structures involved in menstrual cycle and their hormones

1. Hypothalamus hormones produce: Gonadotropin (GnRH) - baba kay putitary gland which will release FHA and LH)
2. Pituitary gland anterior pituitary gland: follicle stimulating hormone (FSH) & posterior pituitary gland: oxytocin and anti diuretic hormone
Luteinizing hormone (LH)
4 PHASES OF MENSTRUAL CYCLE
3. Ovaries - releases progesterone and estrogen 1. PROLEFERATIVE
2. SECONDARY - menstrual cycle stops here if
4. Uterus fertilization and pregnancy occurs.
3. ISCHEMIC
4. menstruation

▪ Ovulation – ovum is set free from the ovaries; most fertile period __________
3-4 days before and after ovulation

* age of liability of sperm cell can take up to 5

➢ S & Sx: days (maximum)
1. Inc. In Basal Body temp. – 0.5 C, occurs 1 day post ovulation; occurs due
to hormone progesterone *a woman is most fertile at 24-48 hours after
menstruation
2. Mittelschmerz – cramps
3. Spinbarkeit – refers to elasticity of the cervical mucus; the mucus is clear; mucus can extend within 1 inch wiouth breaking
4. Fern test – done in lab, mucus cervical secretion will be collected and observed in microscope; may makikita na fern or palm leaf like pattern. this is
an indicative that a woman is ovulating
5. Cervical mucus – clear, thin, stretchy, watery and white egg like due to estrogen *increasing estrogen level causes ovulation

II. STAGES OF FETAL DEVELOPMENT

Ovum - from ovulation until fertilization.
Zygote - once it is fertilized it will be called a zygote. from fertilization to implantation. Ranges from 8 days; can happen as fast/ early as 5 days.
Embryo - from implantation to 5-8 weeks AOG; 8 weeks kung san nakukumpletpo ang organogenesis (the formation of vital organs in the fetus's
body)
Fetus - once the vital organs are developed, it will be called a fetus. from 8 weeks to term.
how do we know if the fetus has reached its term?
LA's ratio -
2:1 - this is an indication that the kungs is mature, and the fetus can
survived outside the uterus.
▪ Embryonic and Fetal Structure Conceptus - developments of the structures inside the uterus; fetus,
umbilical cord,
1. Decidua – endometrium is called decidua after implantation
2. Placenta – served as the fetal lung, kidneys, and GI tract. it also has an endocrine function; releases hormones, continues the release of estrogen and progesterone. PROGESTERONE - the
hormone of pregnancy,1. mainly because it is the one that maintains the uterine lining of the uterus. 2. it reduces contractivity which prevents premature bleeding.

➢ Endocrine Fx of placenta:
a. Estrogen
b. Progesterone prominent hormone during the 2nd phase of menstrual cycle.
hormone of pregnancy

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 -
-
c. Human Placental Lactogen (HPL) Prolactin: is the hormone responsible for
- lactation: promotes growth of mammary gland in breast. Main purpose of HPL is lactation. lactation, certain breast tissue development,
and milk production.
- growth- promoting: regulates maternal glucose.
HPL: one of its property is; it is insulin antagonist (kalaban)

3. Amniotic membranes – compose of 2 layers that support the amn. Fluid:

*chorionic and amniotic membrane can fused.
- Chorionic membrane: outermost layer
- Amniotic membrane: innermost layer; it is the one that produces the amniotic fluid.
4. Amniotic Fluid
- serves as a shield for the fetus agianst pressure or blow. ( ex. nabunggo is mother, nabangga, or nasuntok hinfi maapektuhan yung fetus directly(most important purpose of
amniotic fluid)
- shields fetus from the temperature outside
atresia - complete blockage
- aids in muscular development; because the fetus can move freely from inside the mother's womb
- protects the umbilical cord from pressure
-
*normal amount of amniotic fluid - 800-1200
• ml.
another term polyhydramnios; refers to amniotic fluid exceeding 2000ml. can be caused by:
hydramnios – 1. The fetus is unable to swallow(amniotic fluid should be swallowed by the fetus)
• oligohydramnios
2. Gestational Diabetes Mellitus; too much glucose can attract water through osmotic pressure.
– less than normal level of amniotic fluid. cause of oligohydramnios
fetus has renal problem

✓ Nitrazine test – fluid from the mother in tested with nitrazine paper, if the test strip appears: clear liquid ay
lumalabas kay mother
o Yellow – if the paper turns yellow; it is urine because the urine is acetic pero hindi alam if ihi
or amniotic fluid.
o Blue – if it turns blue, it is amniotic fluid, it turns blue because amniotic fluid
is alkaline
Purpose:
1. Transports oxygen and nutrients from placenta
5. Umbilical Cord – umbilical cord contains: 2 arteries and 1 vein to fetus.
- provides circulatory pathway between fetus and placenta 2. returns waste products from fetus

- mother and fetus does not have a blood exchange; the blood exchange happens in placenta
- it provides the circulatory pathway between the fetus and the placenta.

III. Physiologic Changes of Pregnancy

Common Discomforts Nursing Intervention

1.Nause & Vomiting - eat: complex carbs --> crackers (skyflakes)

Common during the first trimester due to the
hormone HCG. - avoid: GI irritants --> fried, fatty, spicy foods, coffee, carbonated drinks
HCG --> pinakamataas sa 1st 100 days of
pregnancy. Highest level is usually sa morning - SFF; fluid in between promote small frequent feedings; fluid in between para hindi mabigla ang tiyan.
kay nagooccur ang N&V (morning sickness). - Instruction to mother: wait for the nausea to pass before eating breakfast
2. Pyrosis (Heart urn) - SFF small frequent feeding
caused by regurgitation of food from - avoid: lying down 2 hours post meal
stomach to esophagus.
- avoid: GI irritants

3. Constipation - inc. OFI & high fluid intake because it promotes gastric
- starts first with independent nursing - stool softeners:
intervention not all laxatives are safe for pregnant
*safe laxatives: 1.DUCOSATE SODIUM (COLACE)
- woman.
2. MILK OF MAGNESIUM - NOT USED FOR LONG TERM; CAN ONLY BE USED FOR AS LONG AS 7
DAYS
3.METAMOSIL
4.BISACODYL (DULCOLAX)
happens due to
4. Breast tenderness hormone - wear: WEAR A SUPPORTIVE BRA (MALAPAD ANG SHOULDER
estrogen SUPPORT)
happens due to
5.Palmar erythema increase in
estrogen
- use: INSTRUCT THE MOTHER TO USE CALAMINE LOTION
- INSTRUCT THE MOTEHR TO INCREASE THE AMOUNT OF SLEEP AND REST
6.Fatigue
- INSTRUCT THE MOTHER TO: DO NOT MASSAGE BECAUSE IT CAN CAUSE PULMONARY
- caused by decrease EMBOLISM.
7. Leg cramps calcium in the body. - NI:
1. Extend the leg and dorsiflex the foot (initial management).
2. increased calcium intake (if calciu is not available, the mother can drink 4 glasses of milk daily.
8. Leg varicosities and Ankle - elevate the legs
edema(Pagmamanas) - avoid crossing legs while sitting
- use elastic support stocking (medical support hose)
- take ____________
a walk break at least twice a day --> promotes good circulation

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 - left side lying position - when lying down, instruct the mother to be in a left side lying position.

9. Hemorrhoids - adequate OFI & fiber in diet

- constipation - position: modified sims - knee chest for about 10-15 minutes
- for pain: mother can do cold compress

10. Lordosis and backache - low to moderate heels

- walk pelvis tilting forward
- for pain:heating pad on back
- _________
SQUAT rather bending over
- lift object _______________
CLOSE TO BODY because it is the center of gravity and to also prevent fall.
- sleep on flat /firm
______
surface/ mattress

-_________________
PELVIC ROCKING – best exercise to relieve back pain

11. Leukorrhea - daily bath or shower to wash away secretions

- common in pregnancy due to - wear: a cotton underwear
increase estrogen production.
- NO: do not wear underwear at night to reduce moisture --> increase moisture can cause/ lead to UTI
- may wear perineal pad NO TAMPONS
- normal urinary bladder capacity: 500-800
12. Urinary Frequency - ___________ in pregnancy ml - pregnant mother cannot hold the capacity which results to urinary frequency.
- this can cause or lead to dehydration and UTI.
- due to pressure of growing fetus in NOT TO
the bladder - emphasize to: CONSTRICT DEHYDRATION - can lead to preterm labor because ADH is released from posterior pituitary gland
ORAL FLUID thus also releasing oxytocin which will stimulate the contraction of the uterus.
INTAKE
13. Supine hypotension - Position: Left side lying position

- if can’t sleep in side-lying; insert/put pillow under the right hip.

✓ Major Contraindications in Pregnancy:

1. TUB BATH: might cause organism to enter the woman's reproductive tract and cause infection.
2. USAGE OF TAMPONS
3. VAGINAL DOUCHE: - must be totally avoided
Ex. pag-gamit ng bidet

IV. The Psychological Tasks of Pregnancy

➢ 1st Trimester: ACCEPTING THE PREGNANCY
AMBIVALENCE:
• Two opposing feelings; wanting & not wanting the pregnancy:
COVADE SYNDROME:
• Husband experiencing s & sx of pregnancy; results from stress, anxiety & empathy:

➢ 2nd Trimester:
> QUICKENING: the first time the mother felt fetal movement which
- accepting the baby usually happens at _____________
QUICKENING can make the mother have a feeling of acceptance.
*Primi: happens at 20 weeks
*Multi: happens at 16 weeks
- the woman’s acceptance of her coming baby can be well measured by her ________________________________
COMPLIANCE OF PRENATAL INSTRUCTION
- partner becomes overly absorbed in work to compensate feelings of helplessness
➢ 3rd Trimester: 1. PREPARING FOR PARENTING

• Evidence that the couple is completing the 3 tri task: _________________

rd 2. EVIDENCE THAT THE COUPLE IS COMPLETING THE 3RD TRI TASK IS THROUGH
NEST BUILDING
- choosing name for the infant, buying stuff, planning sleeping arrangement
NEST BUILDING:

V. Confirmation of Pregnancy
✓ Presumptive ____________
SUBJECTIVE symptoms – can indicate other conditions
- reported by the mother

- Breast changes
- N&V
- Amenorrhea
- Fatigue
- Urinary frequency
- Uterine enlargement
- Quickening
- All skin discoloration:
melasma/chloasma - MASK OF PREGNANCY

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 linea nigra – IS THE LINE OF DARK PIGMENTATION STARTING FROM XIPHOID PROCESS TO SYMPHYSIS PUBIS
striae gravidarum – STRETCH MARKS

✓ Probable ___________
OBJECTIVE Signs
- Chadwick’s sign: BLUISH/ PURPLISH DISCOLORATION; CHECK FOR LETTER W
- ANATOMIC STRUCTURE INVOLVED IS VAGINA
- Goodell’s sign:THERE IS SOFTENING OF CERVIX; - ANATOMIC STRUCTURE INVOLVED
IS CERVIX
- Hegar’s sign:SOFTENING OF THE UTERUS; - ANATOMIC STRUCTURE INVOLVED IS UTERUS
- Ballottement: BOUNCING OF THE BABY IN THE AMNIOTIC FLUID

- Braxton-hicks contractions:PRACTICE CONTRACTIONS; FALSE CONTRACTIONS

- Sonographic evidence of GESTATIONAL SAC
- Fetal _________
OUTLINE felt by examiner
- Positive Pregnancy test - probable because (+) pregnancy test can be also caused by H.mole and Ectopic pegnancy.

✓ Positive __________
CONFIRMATORY of Pregnancy

Fetal heart rate – OBTAINED BY A DOPPLER

Fetal movement – FELT BY THE EXAMINER * FETAL MOVEMENT FELT BY MOTHER IS PRESUMPTIVE BECAUSE ITS DATA IS SUBJECTIVE
(QUICKENING)
Fetal outline –BY ULTRASOUND; CONFIRMATORY

VI. Obstetrical Formula & Computation

▪ Naegele’s Rule – standard method to predict length of pregnancy
Pre-requisite: 1ST DAY OF LMP EXAMPLES:
1. LMP: FEB 14, 2021 2. LMP: NOV. 20, 2022
✓ Jan – Mar: +9 +7
2 14 21 11 20 22
✓ Apr – Dec: -3 +7 +1 + 9+7 - 3+7+1
_______________ _____________
11 21 21 (NOV. 21, 2021) 8 27 23 (SEP. 27, 2023)

▪ Bartholomew’s Method – through palpation of Fundal height

From 20th week to 31st week:
* STARTS MEASURING FROM SYMPHYSIS
Fundic height in cm = ___________
AOG IN WEEKS PUBIS TO XIPHOID PROCESS
• Rapid growth may indicate
- MULTIPLE PREGNANCIES
- POLYHYDRAMNIOS
- H.MOLE
• Lesser than expected
- GROWTH RESTRICTION DUE TO CIGARETTE SMOKING, ALCOHOL INTAKE, AND
DRUGS
- OLIGOHYDRAMNIOS
- FETAL DEATH
VII. OBSTETRIC HISTORY
• Gravida – no. of pregnancies REGARDLESS of __________________
OUTCOME

• Para – no. of pregnancies that reached the age of viability: dead or alive. Para is broken down as follows:
o Term: 37 WEEKS AND ABOVE
( 20 WEEKS) *H.MOLE AND ECTOPIC PREGNANCY ARE COUNTED IN
o Pre-term: 20-36 WEEKS GRAVIDA AND ABORTION

o Abortion: LESS THAN 20 WEEKS; LOSS OF PREGNANCY LESS THAN 20 WEEKS

o Living: NO. OF LIVING CHILDREN

❖ Leopold’s Manuever
• Purpose: TO DETERMINE FETAL PRESENTATION AND POSITION
• Instruction:INSTRUCT MOTHER TO EMPTY BLADDER BEFORE THE PROCEDURE
• Position: SUPINE POSITION; KNEE ARE SLIGHTLY FLEXED (DORSAL RECUMBENT)

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 ❖ Weight changes

1st tri: 1.5 lbs/ month = 4.5 lbs

2nd tri:1 lbs/ month = 12 lbs
s3rd tri:1 lbs/ week__________
= 12 lbs
28.5 lbs

Total allowance wg gain: 27 - 28.5 lbs

*Pattern of weight gain is more important than the amount of weight gain
Sudden increase: suggest fluid retention & polyhydramnios
1st manuever: Fundal grip 3rd manuever: Pawlick’s grip
Purpose: To determine what is in the fundus of the mother Pupose: to determine fetal engagement to mother's pelvic inlet
• Hard & round – FETAL HEAD; CEPHALIC PRESENTATION Movable – not engaged
• Soft & moves dependent – FETAL BUTTOCKS; BREACH Not movable: engaged
PRESENTATION

2nd manuever: Umbilical grip 4th manuever: Pelvic grip

Purpose: to determine what is lying in the side of the mother Purpose: determine fetal attitude/ degree of flexion
• Hard & smooth – FETAL BACK Good attitude: COMPLETE
FLEXION
• Irregular & feels bumpy – FETAL EXTREMITIES FETAL ATTITUDE: pertains to baby's head

- DONE ONLY IF THE BABY IS IN CEPHALIC PRESENTATION.

- NOT DONE IF THE BABY IS IN BREACH PRESENTATION.

Loss of weight:

VIII. Fetal assessments

1. Fetal movement count

• Daily Fetal Movement (Kick Counts)
Normal =10 kicks/ hr
➢ Instructions:
• Position: Left side lying position post meal; the glucose aids in fetal movement
• Count fetal movement until ______ 10 kicks
• Record the time - starts the timer immediately when the mother lie down.
- No 10 fetal movement in the first hr; walk around a little and repeat counting
- No 10 fetal movement in the second period: contact health care provider

2. Fetal Heart tone monitoring

➢ Principles & Equipment D.F.S
• Doppler – equipment used in earliest period; can be used at 10-12 weeks of pregnancy (8 weeks pwede din)
• Fetoscope – 12 - 14 weeks
• Stethoscope - 14 - 20 weeks

*note: if a woman is obese –REGARDLESS OF AOG, DOPPLER IS ALWAYS USE BECAUSE ABDOMINAL TISSUE IS THICK PARTICULARLY THE
SUBCUTANEOUS TISSUE.
*Promote bonding: ALWAYS KET THE PARENTS TO HEAR THE FHT
*Normal FHR:110-160 BPM
- any situation where FHR is above or below normal: immediately inform the physician

❖ Nonstress Test
- FETAL MOVEMENT
FHR in response to _________________ - USUALLY DONE AT 28 WEEKS AOG
- First step: OBTAIN FIRST THE BASELINE FHR

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 - Reactive – GOOD reaction; FHR should inc. in response to movement
- Inc. should be 15
______
BPM for ______
15 SEC for _____________
2 CONSECUTIVE readings;
“FHR ACCELERATION”
• Nonreactive – No inc in FHR in response to movement or less than 15 bpm
➢ If the result of Nonstress test is Nonreactive; perform: CONTRACTION TEST

❖ Contraction Stress Test

- FHR in response to ________________
CONTRACTION - THIS TEST IS PERFORMED WHEN NONSTRESS TEST RESULTS AS
NON-REACTIVE.
- Simulates labor contractions by administering ___________
OXYTOCIN

- Purpose: to det. if baby can tolerate the drop in blood and oxygen during labor contractions

N
ormal - there should be no deceleration
egative during contraction.
o acceleration
o decrease in fetal heart rate
➢ Findings and Interpretations
• Early Decelerations – NORMAL; begins and ends with the contraction - Once the contractions starts, may increse din FHR ni baby
- Cause: Head compression which is expected
- Ang FHR at contraction ay hindi nagsasabay; nauna contraction; mauuna din titigil ang
- Intervention: 1. continue monitoring contraction; then pag nag stop ang contraction, mag sstop din ang deceleration.
• Late Decelerations – Begins after the onset of a contraction
- Cause:uteroplacental insufficiency (most risky)
- Intervention: 1. initial NI: stop the oxytocin; to stop the contraction
2. Repositioning: left lateral position
3. Oxygenate the mother
4. Notify the physician IF IT IS EMPHASIZED THAT THE CAUSE IS
CORD PROLAPSE:
• Variable Decelerations – occurs at unpredictable times in relation to contractions - if the cause is cord prolapse; cord prolapse makikita na
- Cause: cord compression sa vaginal opening yung cord.

- Intervention: reposition the mother to left lateral position Positioning: Knee Chest
EARLY: HEAD COMPRESSION
LATE: UTEROPLACENTAL INSUFFICIENCY
IX. PREPARATION FOR CHILDBIRTH & LABOR VARIABLE: CORD COMPRESSION

▪ Exercises during pregnancy

Walking – "BEST SOURCE"
Squatting – TO STRETCH THE PERINEAL MUSCLE
REPITION: 15-30/ DAY
Tailor sitting – TO STRETCH THE PERINEAL MUSCLE
PURPOSE:
Kegel Exercise – TO CONTRACT THE PERINEAL MUSCLE; CONTRACT FOR 15 SECS AND THEN RELAX FOR 10 SECS. - TO STRENGTHENED THE PERINEAL
MUSCLE; TO PREVENT TEARING OF
Pelvic Rocking – TO HELP RELIEVE BACKACHE PERINIUM DURING CHILDBIRTH
( LACERATION).

▪ Signs of Labor
• Preliminary Signs of Labor

1. Lightening (engagement) – relief of diaphragmatic pressure - Happens at engagement of the fetus

Primipara: happens as early as 1-2 weeks before labor
Multipara: happens on the day of labor
2. Ripening of Cervix – cervix is as soft as butter
3. Increase in energy – due to release of epinephrine, this is the way of the body to prepare for labor.
4. Increased Braxton Hicks contractions – irregular contractions that is confined in the abdomen
- disappears thru ambulation/ sleeping
- do not achieve cervical dilatation
• True Signs of Labor
1. Show – pink-tinged spot
2. Uterine Contractions - regular and predictable; girdle-like; persists regardless of activity; achieve cervical dilatation.
3. Rupture of membranes – sudden gushed of clear fluid from the vagina.

X. LABOR & BIRTH

▪ Stages of Labor
1. 1st Stage of Labor: Stage of ___________–
DILATATION from the onset of true labor contractions to full
cervical dilatation; divided into 3 phases
Phase Cervical Dilatation Duration of Interval
Contraction

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 1.Latent 0-3 CM
20-40 SECS 10 MINS

2. Active 4-7 CM 40-60 SECS 5 MINS

3.Transition 8-10 CM 60-90 SECS 3 MINS

➢ Nursing Considerations for each Phase:

Latent – INSTRUCT THE MOTHER TO WALK ( TO FURTHER CERVCAL CILATATION) DILATATION - pagluwang/ pagkapal ng
Active – SHOWING (SHOW) cervix.
EFFACEMENT - shortening of cervix
Transition – PREPARE FOR DELIVERY
By the end of the 1st stage : FULL DILATATION(10 CM) AND COMPLETE EFFACEMENT (100%) OCCYRS.

2. 2nd Stage of Labor: Stage of __________

EXPULSION
- from ________________
FULL DILATION &COMPLETE
___________________
EFFACEMENT to _____________________
THE BIRTH OF THE INFANT.
*_________________
CROWNING – the fetal scalp appears at the opening of the vagina

3. 3rd Stage of Labor: _______________

PLACENTAL STAGE
– from infant birth to the delivery of the placenta; divided into 2 phases
▪ Placental separation (1 MIN - 30 MINS)
➢ Signs of placental separation
1. CALKIN'S SIGN - UTERINE FIRM & GLOBULAR --> BECAUSE OF CONTRACTION
2. LENGTHENING OF THE CORD
3. SUDDEN GUSH OF BLOOD
4. PLACENTA IS ALREADY VISIBLE TO THE OPENING OF THE VAGINA.

Presentation of the placenta:

o Schultz – SHINY; FETAL SIDE
o Duncan – DIRTY; MATERNAL SIDE

▪ Placental Expulsion
- placenta deliver by
1. Natural bearing down effort of the mother
2. Crede maneuver – GENTLE PRESSURE ON A CONTRACTED UTERUS
- NEVER APPLY TO NON-CONTRACTED UTERUS BECAUSE UTERINE INVERSION CAN OCCUR
✓ Nursing action: 1. Inspect if placenta is "complete"
- retained placental fragment will not contract the uterus and results to bleeding ( POST PARTUM HEMORRHAGE)

XI. PUERPERIUM
- the postpartal period: 6 WEEKS PERIOD POST CHILD BIRTH
- characterized by: INVOLUTION PROCESS --> returned of the uterus to pre-pregnancy state ( closely monitord the uterus)
- Uterine involution – accomplished by CONTRACTION
“Normal Location” - immediately post birth, the uterus is in between the umbilicus and the symphysis pubis for the 1st hour.
- in the first 24 hours, the uterus should be at the level of the umbilicus.
- then from the umbilicus, everyday ang uterus ay bababa for 1cm or 1 finger depth.
- Ex. 3 days post-partum--. the uterus should be 3 finger depth under/ below the umbilicus.
• Afterpains – considered as NORMAL Scenario:
Ang uterus ay nagc-contract pero hindi
- this is how intermittent cramping caused by uterine contractions. bumababa.
NI:immediately empty the bladder
❖ Postpartal Psychological Adaptation: 3 phases by Reva Rubin
hindi bumababa ang uterus dahil puno and
- The mother is still internalizing the delivery. bladder
1.Taking In – -- takes place 1-3 days after labor. * IF the uterus is contracting, instruct the mother to massage
mother is self-centered, demanding, and dependent the fundus.
2. Taking Hold - taking hold of RESPONSIBILITY; the mother starts to take hold the responsibility of MOTHERHOOD.
- occurs 3-9 days post partum
3. Letting Go – the mother is letting go of her previous role.

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