CREDITS TO THE OWNER

1. • Components of the prenatal visit:
1. pre-consultation phase
2. Consultation phase
3. Post consultation phase

2. Pre-consultation phase
• Initial interview
 demographic profile
 health history (present, past, family, medical,
surgical, gynecological and obstetrical)
• Verify pregnancy
• Get the estimates ( AOG, fetal length, weight
• Review of systems

3. Consultation phase
• Conduct physical exam
• Conduct pelvic exam
 IE
PAPANICOLAU SMEAR – is a diagnostic
cytological test for early detection of cervical
cancer.
• INDICATIONS:
1. All married women
2. single but sexually active
3. post partum women from 6 wks – 6 mos.
4. single not sexually active but more than 40

4. Consultation phase
• Vital signs monitoring including weight and
height.
allowable weight gain : 20 – 25 lbs
wt. distribution :
1st tri – 1 lb/mon
2nd & 3rd – 1 lb/wk
pattern of wt. gain : a.3, 5,12
b.5, 5,12
c.3,12,12
d.5,12,12

5. Consultation phase
• Laboratory and diagnostic test
 CBC
 Blood Typing
 Gram Staining
 Urinalysis

6. Consultation phase
 Ultrasonography:
1. AOG
2. Sex of baby
3. amount of amniotic fluid
4. locates the placenta
5. Ectopic pregnancy, H-mole
6. Gyne: tumors, cyst, myomas
7. limited congenital anomalies

7. Consultation phase
• Assessment of the fetal growth
 AOG, FHT, Length, weight
 Fetal movement
 Leopolds maneuver

8. Post- consultation phase
• Health teachings:
1. Schedule of clinic visits
2. Exercises
3. Dental hygiene
4. Clothing
5. Traveling
6. Bathing
7. Employment
8. Sexual relation
9. Immunization

9. 9
Routine visits
A. Every month - 1 to 8 months or
from the time pregnancy is detected
– 32 wks.
B. Twice a month / every 2 weeks – 32
to37 wks
C. Weekly - 37weeks – birth or
EDB
D. 2X A Week - for all Post term or >
42 wks

10. 10
NUTRITION = MOST IMPORTANT ASPECT
Food sources:
** Protein rich foods = meat, fish, eggs, milk,
poultry, cheese, beans, mongo
** Vit. A = eggs, carrots, squash, cheese, beans,
vegetables
** Vit. D = fish, liver, eggs, milk ( excess vit.D
during pregnancy can lead to fetal cardiac
problems)
**Vitamin E = green leafy vegetables, fish

11. 11
**Vitamin c= tomatoes, guava, papaya
**Vitamin B = protein rich foods
**Calcium/phosphorus = milk, cheese
**Iron = especially important during the last
trimester when the pregnant woman is going to
transfer her iron stores from herself to her fetus
so that the baby has enough iron stores during
the 1st 3 months of life when all he takes is
milk(which is deficient iron). Iron has a very low
absorption rate: only 10% of the iron intake can
be absorbed by the body. Thus, for optimum
absorption, give vitamin c.

12. 12
Iron should be given after meals because it
is irritating to the gastric mucosa.
Sources: liver and other internal organs,
camote tops, kangkong, egg yolk,
ampalaya, malunggay, saluyot.
**Malnutrition during pregnancy can
result in prematurity, preeclampsia,
abortion, low birth weight babies,
congenital defects or even still births.

13. 13
** Folic acid – to prevent neural tube defects (
spina bifida, meningocoele )
Sources:
** Green leafy vegetables
** Fruits
** RDA FOR SALT IN A PREGNANT WOMAN IS
3g/DAY BECAUSE OF INC IN BLOOD VOLUME TO
MAINTAIN F & E BALANCE.

14. 14
TT IMMUNIZATION:
• TT1 given anytime during pregnancy
• TT2 one month after tt1 ( 3 years protection)
• TT3 six months after tt2 ( 5 years protection)
• TT4 one year after tt3 ( 10 yrs)
• TT5 one year after tt4 or next pregnancy
( lifetime protection)

15. 15
Perinatal Exercises

16. 16
PRE-EXERCISE POINTERS
1. Always let breath flow freely. Let abdomen
and ribcage expand and compress naturally
as you inhale and exhale.
2. Warm up with gentle stretching before
exercise program - increase blood flow to
muscles and loosen them up.
3. When you finish, take time to relax fully; lie
in comfortable position on floor for 10
minutes with eyes closed; let breathing slow
down.
4. As strength improves, add one repetition of
each exercise until you’re up to 10; also, try
holding positions from 3 to 5 counts.

17. 17
PRE-EXERCISE POINTERS
5. Do each exercise slowly and thoroughly. Allow rest
between each exercise.
6. Avoid extreme motions like deep lunges or twisting
movements.
7. Avoid lying flat on your back for prolonged periods; it
may become uncomfortable and the position allows less
blood flow to the uterus. Lying on your side increases
blood flow.
8. Think of opportunities for exercises during day; Kegel’s
while standing in line at grocery store, squatting while
peeling potatoes, talking on the phone, watching
television, etc.
9. If there is a prenatal exercise class in your area, join it. It
is fun to get into shape with other pregnant women.

18. 18
A. Tailor Sitting
1. It strengthens the thigh and
stretches the perineal
muscles
2. Done at least 15 min/day
• Sit on floor with thighs apart,
knees bent, legs parallel to
each other, one ankle should
NOT be on top of the other,
push knees gently towards
the floor until you feel the
perineum stretch. Use this
when watching TV, reading or
entertaining friends. Do this
for 15 minutes daily.

19. 19
B. Squatting
1. Helps to stretch muscle
of the pelvic floor.
2. Done at least
15min/day
• When lifting something
from the floor, bend
knees rather than the
back; do not squat on
tiptoes but keep feet
flat on the floor;
incorporate this into
daily activities; practice
for 15 minutes daily

20. 20
C. Pelvic Floor Contractions
(Kegel’s Exercise)
• It is designed to strengthen pubococcygeus
muscle.
• It may lead to increased sexual enjoyment.
• Each is a separate exercise and should be done 3x
a day.
1. Squeeze the muscle surrounding the vagina as if
stopping the flow of urine, hold for 3 seconds then
relax. (10x)
2. Contract and relax the muscles surrounding the
vagina as rapidly as possible 10 – 25x
3. Imagine that you are sitting in the bath tub of
water and squeeze muscles as if sucking water into
the vagina. Hold for 3 seconds then relax. 10x

21. 21
D. Abdominal Muscle Contractions
1. strengthen the abdominal muscles
2. help prevent constipation
3. may be done as often as she wishes
• Tighten abdominal muscles, then relax and
repeat as often as you can; can be done on
lying or standing position along with pelvic
floor contractions.

22. 22
E. Pelvic Rocking
1. Helps to relieve backache during pregnancy
and early labor
2. Makes the lumbar spine more flexible
3. Can be done on a variety of positions
The woman arches her back, trying to
lengthen or stretch her spine. She holds the
position for 1 minute, and then hollows her
back.
- do this at the end of the day (5x)

23. 23
F. Pelvic Tilt
1. PELVIC TILT – SUPINE
Do daily and after delivery.
Position: Backlying, knees bent.
Exercise: Press small of back against floor by
tightening abdominal muscles and buttocks
muscles.

24. 24
F. Pelvic Tilt
2. PELVIC TILT – STANDING
Position: Stand with back to
wall, feet about three inches
from base of wall.
Exercise: Tighten stomach and
buttocks and press low back
against the wall so that your
back is touching the wall.
Your knees must be relaxed or
slightly bent to do this.

25. 25
F. Pelvic Tilt
3. PELVIC TILT - ALL FOURS
Position: On hands and
knees.
Exercise:Tighten stomach
muscles and arch back
toward the ceiling. Hold.
Tighten buttocks, pelvic
floor and back muscles
and arch
back to produce hollow.
Hold.

26. 26
G. Sit ups
1. SIT-UPS - Modified
Purpose: Strengthen abdominal
muscles. Good muscle tone is
important for maintaining good
posture, for effective pushing,
and for early return of figure
postpartum.
Position: Backlying, knees bent,
low back flat (pelvic tilt).
Exercise: Lift head and shoulders off floor, reaching hands toward
knees (lift trunk to about 45° angle). Slowly return to starting
position; do not drop back.

27. 27
G. Sit ups
2. OBLIQUE (DIAGONAL)
SIT-UPS - Modified
Purpose: Strengthen
oblique abdominal
muscles.
Position: Backlying, knees
bent, low back flat.
Exercise: As above, but
reach up and across to
the outside of the
opposite knee.

28. 28
H. GLUTEAL / PELVIC FLOOR
SETTING
Position: Backlying, legs straight, ankles crossed,
arms at sides.
Exercise: Pinch buttocks, squeeze pelvic floor
muscles, squeeze thighs together, raise head
off floor.

29. 29
SPECIFIC ACTIVITIES
To the pregnant Client
1. Jogging:
 Wear good shoes; supportive bra. Keep pelvic floor
muscles strong with Kegel exercises. Jog at a slower
pace, shorter distances, less frequently.
 Remember: Increased weight and laxity of ligaments
means more strain on lower body (lower spine, hip
joints, knees, ankles and feet). Do not overexert
yourself.
2. Bicycling and Swimming:
 Excellent activities with reasonable limitations. Don’t
push yourself!

30. 3. Tennis, Basketball, other “sudden stop and start”
Activities.
More awkward as bulk increases; listen to your body and
slow down when necessary.
4. Skating, Horseback Riding:
Danger of falling! Advise against. Consult your obstetrician
as needed.
5. Walking:
Most highly recommended for the pregnant woman; ideal
alternative to more strenuous exercise. Walk uphill,
downhill, and at different speeds.

31. Marital relations/sexual activity
• Sexual desires continue throughout
pregnancy, but levels change
– During the first trimesters, there is a decrease in
sexual desire because the woman is more
preoccupied with the changes in her body.
– During the second trimester, there iv an
improvement in sexual desire becauve the woman
has adapted to the growing fetus.
– During the third trimester, there is another
decrease in sexual desire because the woman is
afraide of hurting the fetus.

32. Marital relations/sexual activity
• Sex in moderation is permitted during
pregnancy but no during the last 6 weeks
since there is increased incidence of
postpartum infection in women who engage
in sex during the last 6 weeks.
• Counsel the couple to look for more
comfortable positions. Missionary position is
not advisable. Suggested positions are: side-
lying and woman-on-top position.

33. Marital relations/sexual activity
• Sex is contraindicated with the following
situations:
–Spotting /bleeding
–Ruptured BOW
–Incompetent cervical os
–Deeply-engaged presenting part

34. Sleep and rest
• Average number of hours of sleep is 8 hours;
may need 1-2 hours of afternoon nap
• Avoid supine position on 2nd trimester

35. Traveling
• No restrictions but postpone a trip during last
trimester
• On long rides, 15-20 mins rest periods every 2-
3 hours ride
• Walk and empty bladder

36. Bath
• Daily bath preferred
• Avoid soaps on nipples
• Douching is not advisable
• Tub bath is not advisable to prevent injuries
and accidents.

37. Clothing
• Loose, comfortable clothes and cotton
material is best
• Avoid constricting clothes
• Wear flat-healed shoes

38. Employment
• As long as the job does not entail handling of
toxic substances, or lifting heavy objects, or
excessive physical or emotional strain, there is
no contraindication to working.
• Advise to walk about every few hours at swork
during long periods of standing or sitting to
promote circulation

39. Traveling
• No restrictions but postpone a trip during last
trimester
• On long rides, 15-20 mins rest periods every 2-
3 hours ride
• Walk and empty bladder

40. S – A – D habits of pregnancy
• Smoking
– Causes vasoconstriction, leading to SGA infants
• Alcohol
– Likely to cause fetal abnormalities
– Known leading teratogen
– Effects of chronic alcoholism: retardation, craniofacial
defects; cardiovascular defects; limb defects; impaired
fine and gross motor functions.
• Drugs
– No medication is taken during pregnancy unless
absolutely necessary and prescribed.
– Illicit drugs taken during 1st trimester can cause mot
adverse fetal malformations

41. 41
Patient Teaching:
 Consult obstetrician early in pregnancy.
 In general, can continue pre-pregnant
routine of exercising.
 Stop when something hurts, or when
fatigued. Know the limits, and avoid
exercising to the point of exhaustion.

42.  It is generally advised that do not begin any
new sport or activity during pregnancy.
 may taper off sports participation during the
last few months, but may still continue to
exercise gently.
 Avoid exercising in very hot or humid
weather, or at high altitudes if not used to it.

43. 43
** The provision of prenatal
care is the primary factor in the
improvement of maternal morbidity
& mortality statistics.

44. 44
ANTENATAL FETAL TESTING

45. 45
Ultrasound
• Response of sound waves
against objects
• Allows visualization of the
uterine content
• Transabdominal UTZ
- full bladder
- client lies on her back
• Transvaginal UTZ
- probe is inserted in the
vagina
- lithotomy position
- empty bladder

46. 46
• Diagnose pregnancy as early as 6 weeks
• Confirm the presence, size and location of the
placenta and amniotic fluid
• Establish that the fetus is growing and has no
gross defects (eg, hydrocephalus, anencephaly,
spinal cord, heart, kidney and bladder defects)
• Establish the presentation and position of the
fetus (sex can be diagnosed)
• Predict maturity by measurement of the biparietal
diameter (BPD)
• discover complications of pregnancy / fetal
anomalies

47. 47
Estimation of Fetal Age
• Gestational sac – 5 – 6 weeks
• Crown rump length – 7 – 14 weeks
• Femoral length – 12 – 22 weeks
• Biparietal Diameter 17 -26 weeks

48. 48
Biophysical profile (BPS)
• Assesses 4 to 6 parameters (fetal breathing
movement, fetal movement, fetal tone, amniotic
fluid volume, placental grading, and fetal heart
reactivity/ reactive NST)
• Each item has a potential for scoring a 2; 12 highest
possible score
• BPS 8 – 10: fetus is doing well
• BPS 4 – 6: fetus is in jeopardy

49. 49
Nonstress Test
• Measures the response of
fetal heart rate to fetal
movement
• Determines fetal well-
being
• Performed to assess
placental function and
oxygenation

50. 50
• An external ultrasound transducer and the
tocodynamometer are applied to the mother and a
tracing of at least 20 minutes’ duration is obtained
so that the FHR and the uterine activity can be
observed.
• Obtain baseline blood pressure and monitor blood
pressure frequently.
• Position mother in semi-fowler’s or side- lying
position or left lateral position to avoid vena cava
compression.
• The mother may be asked to press a button every
time she feels fetal movement; the monitor records
a mark at each point of fetal movement, which is
used as a reference point to assess FHR response.

51. 51
RESULTS OF NST:
• REACTIVE NONSTRESS TEST:Normal/Negative
- indicates a healthy fetus
- requires 2 or more FHR accelerations of at least 15 beats per
minute, lasting at least 15 seconds from the beginning of the
acceleration to the end, in association with fetal movement,
during a 20-minute period.
• NONREACTIVE NONSTRESS TEST: Abnormal
-No accelerations or accelerations of less than 15 bpm or lasting
than 15 seconds in duration occur in a 40 minute observation.
• UNSATISFACTORY – The result cannot be interpreted because of
the poor quality of the FHR tracing.

52. 52

53. 53
Contraction Stress Test
• Assesses placental oxygenation and
function
• Determines fetal ability to tolerate
labor and determines fetal well-being
• Fetus is exposed to the stressor of
contractions to assess the adequacy of
placental perfusion under simulated
labor conditions.

54. 54
• External fetal monitor is applied to the
mother, and a 20 to 30 minute baseline
strip is recorded.
• The uterus is stimulated to contract by the
administration of a dilute dose of oxytocin
or by having the mother use nipple
stimulation until 3 palpable contractions
with a duration of 40 seconds or more in a
10 minute period have been achieved.
• Frequent maternal BP readings are done,
and the mother is monitored closely while
increasing doses of oxytocin are given.

55. 55
RESULTS OF CST:
• NEGATIVE CST/ NORMAL
- no late or variable decelerations of FHR
• POSITIVE CST/ ABNORMAL
- late or variable decelerations of FHR with 50% or more
of the contractions in the absence of hyperstimulation
of the uterus.
• EQUIVOCAL – with decelerations but with less than 50%
of the contractions, or the uterine activity shows a
hyperstimulated uterus.
• UNSATISFACTORY – adequate uterine contractions
cannot be achieved, or the FHR tracing is not of
sufficient quality for adequate interpretation.

56. 56
Amniocentesis
- Withdrawal of amniotic fluid from the
abdominal wall for analysis

57. 57
Amniocentesis
• Indicated early in pregnancy (14-17 wk) to detect
inborn errors of metabolism, chromosomal
abnormalities, open NTD (neural tube defect);
determine sex of fetus and sex-linked disorders
after 28 wk
• Used to diagnose potential genetic problems in the
fetus (Down Syndrome), to estimate fetal lung
maturity or to diagnose fetal hemolytic disease
• Indicated for pregnant women 35 years and older;
couples who already have had a child with a genetic
disorder; one or both parents affected with a genetic
disorder; mothers who are carriers for X-linked
disorders

58. 58
• Prior to the procedure, the patient’s bladder
should be emptied; ultrasonography (x-ray
only if necessary) is used to avoid trauma
from the needle
• Post procedure, monitor for signs and
symptoms of hemorrhage, labor, premature
separation of placenta, fetal distress,
amniotic fluid embolism, infection,
inadvertent injury to maternal
intestines/bladder or fetus; RhoGam is
indicated for Rh- mothers

59. 59
Chorionic villi sampling
-transcervical (or transabdominal) aspiration of
chorionic villi

60. 60
• Retrieval and analysis of chorionic villi for
chromosome analysis
• Transcervical or transabdominal; may be done as
early as 5 weeks, but more commonly done at 8-12
weeks of pregnancy
• Risks: bleeding/ loss of pregnancy; limb reduction
syndrome; infection
• Diagnosis of Sickle cell disease, thalassemia
• diagnosing of genetic disorders comparable to
amniocentesis (except for NTD); preprocedure: there
should be full bladder; ultrasound is used as in
amniocentesis; post procedure: precautions as for
amniocentesis
Chorionic villus sampling (CVS)

61. 61
Percutaneous umbilical blood sampling (PUBS)
– second- and third-trimester method to
aspirate umbilical cord blood (location
identified by ultrasound) to test for genetic
conditions, chromosomal abnormalities, fetal
infections, hemolytic or hematological
disorders

62. 62
Percutaneous
umbilical blood sampling

63. 63
Estriol levels
– serial 24-h maternal urine samples or serum
specimens to determine fetoplacental status;
falling levels usually indicate deterioration

64. 64
Lecithin/ Sphingomyelin ratio (2:1)
– important components of surfactant, a
phosphoprotein that lowers surface tension of
the lungs that facilitates extrauterine
expiration