WONDERS OFWONDERS OF
FERTILIZATIOFERTILIZATIO
NN
STAGES OF FETALSTAGES OF FETAL
GROWTH ANDGROWTH AND
DEVELOPMENTDEVELOPMENT
FERTILIZATIONFERTILIZATION
 Other terms: CONCEPTION,Other terms: CONCEPTION,
IMPREGNATION, ORIMPREGNATION, OR
FECUNDATION...
 After ovulation the ovum is releasedAfter ovulation the ovum is released
from the graafian folliclefrom the graafian fol...
 Only one ovum reaches maturityOnly one ovum reaches maturity
each montheach month
 Once released fertilization mustOnce...
 At the time of ovulation there isAt the time of ovulation there is
a reduction of cervical mucusa reduction of cervical ...
 Phonus – vibration of the head ofPhonus – vibration of the head of
the sperm and determines thethe sperm and determines ...
 Once it penetrates the zonaOnce it penetrates the zona
pelucida, the cell membranepelucida, the cell membrane
becomes im...
 Fertilization depends on 3Fertilization depends on 3
factorsfactors::
 Maturation of both sperm andMaturation of both s...
IMPLANTATIONIMPLANTATION
 It takes 3 or 4 days for the zygote to reach theIt takes 3 or 4 days for the zygote to reach th...
 Morula continues to multiply as itMorula continues to multiply as it
floats free in the uterine cavity forfloats free in...
Implantation/ NidationImplantation/ Nidation
 Occurs 8 to 10 days after fertilizationOccurs 8 to 10 days after fertilizat...
 The trophoblast cell outside theThe trophoblast cell outside the
blastocyst structure touch theblastocyst structure touc...
Embryonic and FetalEmbryonic and Fetal
StructureStructure
 DECIDUADECIDUA
 After fertilization, corpus luteum in the ova...
3 separate area of3 separate area of
Decidua:Decidua:
 Decidua BasalisDecidua Basalis – the part of the– the part of the
...
CHORIONIC VILLICHORIONIC VILLI
 As early as 11As early as 11thth
or 12or 12thth
day miniature villi,day miniature villi,
...
Chorionic VilliChorionic Villi
SamplingSampling Removal of tissue sample from the fetalRemoval of tissue sample from the ...
 Complication rate is slightly higher thanComplication rate is slightly higher than
for amniocentesis primarily related t...
 Position depends on approach –Position depends on approach –
transabdominal (supine) or transcervicaltransabdominal (sup...
Outline of TrophoblastOutline of Trophoblast
DifferentiationDifferentiation
 CYTOTHROPOBLAST or Langhan’sCYTOTHROPOBLAST ...
SYNCTIOTROPHOBLASSYNCTIOTROPHOBLAS
T or Syncytial layerT or Syncytial layer
 The outer layer containing fingerlikeThe out...
 AMNIOTIC FLUIDAMNIOTIC FLUID
 Clear albuminous fluid in which the babyClear albuminous fluid in which the baby
floatsfl...
 Amniotic fluid therefore, is derived chieflyAmniotic fluid therefore, is derived chiefly
from maternal serum and fetal u...
 Also known as Bag of WaterAlso known as Bag of Water
(BOW), it serves the following(BOW), it serves the following
purpos...
 Diagnostic test for Amniotic FluidDiagnostic test for Amniotic Fluid
 AMNIOCENTESISAMNIOCENTESIS
 Purpose: obtain a sa...
2. Determination of fetal maturity primarily2. Determination of fetal maturity primarily
by evaluating factors indicative ...
 Indications:Indications:
 Family HistoryFamily History
 Women of advance age, >35 years of ageWomen of advance age, >3...
a.a. Ultrasound – identify placental and fetalUltrasound – identify placental and fetal
location to avoid damage and pinpo...
 Greenish Amniotic Fluid – ExperienceGreenish Amniotic Fluid – Experience
Hypoxia, common in post term babyHypoxia, commo...
2. CHORION2. CHORION
 Together with the decidua basalis, givesTogether with the decidua basalis, gives
rise to the placen...
 Gastrointestinal System – Nutrients passGastrointestinal System – Nutrients pass
to the fetus via the placenta by diffus...
 At term, the placental circulatory network is soAt term, the placental circulatory network is so
extensive that a placen...
 ESTROGEN – (Estriol) contributes to theESTROGEN – (Estriol) contributes to the
mother’s mammary gland development inmoth...
 HUMAN PLACENTALHUMAN PLACENTAL
LACTOGEN(HUMAN CHORIONICLACTOGEN(HUMAN CHORIONIC
SOMATOMAMMOTROPIN) – promotesSOMATOMAMMO...
Origin andOrigin and
Development of OrganDevelopment of Organ
SystemSystem
 PRIMARY Germ layer – at the time ofPRIMARY Ge...
 A smaller cavity, the yolk sac,A smaller cavity, the yolk sac,
which is lined withwhich is lined with
ENTODERM cellsENTO...
ECTODERMECTODERM
 Central Nervous SystemCentral Nervous System
 Peripheral Nervous systemPeripheral Nervous system
 Ski...
MESODERMMESODERM
 Connective tissues,Connective tissues,
bones, cartilage, muscle,bones, cartilage, muscle,
ligaments and...
ENTODERMENTODERM
 Lining of pericardial,Lining of pericardial,
pleura, and peritonealpleura, and peritoneal
cavitiescavit...
 All organ systems are complete, atleastAll organ systems are complete, atleast
in a rudimentary form, at 8 weeksin a rud...
TERATOGENSTERATOGENS
 Any drug, virus or irradiation, the exposure toAny drug, virus or irradiation, the exposure to
whic...
 AlcoholAlcohol
 Low birth weightLow birth weight
 Fetal alcohol withdrawal symptomsFetal alcohol withdrawal symptoms
...
TORCH (teratogenic)TORCH (teratogenic)
InfectionsInfections
 Group of infections caused by organismsGroup of infections c...
 T – TOXOPLASMOSIS – a protozoanT – TOXOPLASMOSIS – a protozoan
infection transmitted by handling rawinfection transmitte...
 Hepatitis B (serum hepatitis) – a viralHepatitis B (serum hepatitis) – a viral
infection transmitted by contactinfection...
 HUMAN IMMUNODEFICIENCY VIRUS – aHUMAN IMMUNODEFICIENCY VIRUS – a
retrovirus transmitted by contact withretrovirus transm...
 RUBELLA (GERMAN or 3 DAYRUBELLA (GERMAN or 3 DAY
Measles)- Viral infection transmitted byMeasles)- Viral infection trans...
 H - HERPES – SIMPLEX VIRUS – aH - HERPES – SIMPLEX VIRUS – a
sexually transmitted viral infection thatsexually transmitt...
CARDIOVASCULCARDIOVASCUL
AR SYSTEMAR SYSTEM
 First systems to becomeFirst systems to become
functional in intrauterine li...
FETAL CIRCULATIONFETAL CIRCULATION
 PLACENTA ---- OXYGENATED BLOODPLACENTA ---- OXYGENATED BLOOD
IS CARRIED BY THE VEIN -...
 The remaining 30 % ---- tricuspid valveThe remaining 30 % ---- tricuspid valve
---- right ventricle ---- pulmonary arter...
FetalFetal
HemoglobinHemoglobin
 Fetal hemoglobin has greaterFetal hemoglobin has greater
oxygen affinity, which increase...
RESPIRATORYRESPIRATORY
SYSTEMSYSTEM
 77thth
week of life DIAPHRAGMweek of life DIAPHRAGM
completely divide the thoracic c...
 Analysis of the Lecithin/sphingomyelinAnalysis of the Lecithin/sphingomyelin
(LS) ratio by an amniocentesis technique(LS...
NERVOUS SYSTEMNERVOUS SYSTEM
 Active formation of the nervous system andActive formation of the nervous system and
sense ...
DIGESTIVEDIGESTIVE
SYSTEMSYSTEM
 MECONIUM forms in theMECONIUM forms in the
intestines as early as the 16intestines as ea...
 Gastrointestinal tract is sterile beforeGastrointestinal tract is sterile before
birth.birth.
 Vit K, essential for blo...
 Many newborn have not yet developMany newborn have not yet develop
lipase, an enzyme needed for fatlipase, an enzyme nee...
MUSCULOSKELETMUSCULOSKELET
AL SYSTEMAL SYSTEM
 Fetus can be seen to move onFetus can be seen to move on
ultrasound as ear...
REPRODUCTIVEREPRODUCTIVE
SYSTEMSYSTEM Child sex is determined at the moment ofChild sex is determined at the moment of
co...
URINARY SYSTEMURINARY SYSTEM
 Rudimentary kidneys are present as early asRudimentary kidneys are present as early as
the ...
INTEGUMENTARYINTEGUMENTARY
SYSTEMSYSTEM
 The skin of the fetus appears thin andThe skin of the fetus appears thin and
alm...
IMMUNE SYSTEMIMMUNE SYSTEM
 IgG maternal antibodies cross theIgG maternal antibodies cross the
placenta into the fetus du...
MILESTONES OF FETALMILESTONES OF FETAL
GROWTH ANDGROWTH AND
DEVELOPMENTDEVELOPMENT
End of 4 GestationEnd of 4 Gestation
WeeksWeeks
 Length: .75 to 1 cmLength: .75 to 1 cm
 Weight: 400 mgWeight: 400 mg
 ...
End of 8End of 8thth
GestationGestation
weeksweeks
 Length: 2.5 cm (1in)Length: 2.5 cm (1in)
 Weight: 20 gWeight: 20 g
...
End of 12End of 12thth
Gestation weekGestation week Length: 7 to 8 cmLength: 7 to 8 cm
 Weight: 45 gWeight: 45 g
 Nail ...
End of 16End of 16thth
GestationGestation
weekweek Length: 10 – 17 cmLength: 10 – 17 cm
 Weight:4Weight:4
 55 – 120 g55...
End of 20 gestationEnd of 20 gestation
WeeksWeeks
 Length: 25 cmLength: 25 cm
 Weight: 223cmWeight: 223cm
 Spontaneous ...
 Brown fat begins to be formed behind theBrown fat begins to be formed behind the
kidneys, sternum and posterior neck.kid...
End of 24 GestationEnd of 24 Gestation
WeeksWeeks
 Length: 28 to 36 cmLength: 28 to 36 cm
 Weight: 550 gWeight: 550 g
 ...
End of 28End of 28thth
GestationGestation
weeksweeks Length: 35 to 38 cmLength: 35 to 38 cm
 Weight: 1,200gWeight: 1,200...
End of 32 GestationEnd of 32 Gestation
WeeksWeeks Length: 38Length: 38thth
to 43 cmto 43 cm
 Weight: 1600gWeight: 1600g
...
End of 36 GestationEnd of 36 Gestation
WeeksWeeks
 Length: 42 – 48 cmLength: 42 – 48 cm
 Weight: 1800 – 2700 gWeight: 18...
End of 40 GestationEnd of 40 Gestation
WeeksWeeks
 Length: 48 – 52 cmLength: 48 – 52 cm
 Weight: 3000 gWeight: 3000 g
 ...
Determination of EstimatedDetermination of Estimated
Birth DateBirth Date
 NAGELE’S RULENAGELE’S RULE
 To calculate the ...
Estimating Fetal GrowthEstimating Fetal Growth
 McDONALD’S RULEMcDONALD’S RULE
 Is a method of determining, during midIs...
PHYSIOLOGICALPHYSIOLOGICAL
ADAPTATION OF THEADAPTATION OF THE
MOTHER TO PREGNANCYMOTHER TO PREGNANCY
SYSTEMIC CHANGESSYSTEMIC CHANGES
 CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM
 Normal increase in blood volume by 30 – 50...
 Because of poor circulation resultingBecause of poor circulation resulting
from pressure of the gravid uterus on thefrom...
 Physiologic Anemia (Pseudo anemia ofPhysiologic Anemia (Pseudo anemia of
pregnancy) Normal value: Hct (32-42%),pregnancy...
 Nursing care:Nursing care:
 Nutritional instructions: swamp cabbage,Nutritional instructions: swamp cabbage,
kangkong, ...
GASTROINTESTINALGASTROINTESTINAL
SYSTEMSYSTEM
 At midpoint of pregnancy, the pressureAt midpoint of pregnancy, the pressu...
 Management for morning sickness – EatManagement for morning sickness – Eat
dry toast or crackers 30 minutes beforedry to...
 Decrease emptying of bile fromDecrease emptying of bile from
Gallbladder due to gradual slowing ofGallbladder due to gra...
 Flatulence and constipation is common due toFlatulence and constipation is common due to
increase progesterone and displ...
RESPIRATORY SYSTEMRESPIRATORY SYSTEM
 Shortness of breathShortness of breath
 Diaphragm may be displaced by as much as 4...
URINARY SYSTEMURINARY SYSTEM
 Urinary frequency, the only sign inUrinary frequency, the only sign in
pregnancy seen durin...
 Decreased renal threshold for sugar dueDecreased renal threshold for sugar due
to increased production ofto increased pr...
MUSCULOSKELETALMUSCULOSKELETAL
CHANGESCHANGES
 Because of the pregnant woman’s attempt toBecause of the pregnant woman’s ...
 Leg crampsLeg cramps
 Causes:Causes:
 Increased pressure of gravid uterus on lowerIncreased pressure of gravid uterus ...
TEMPERATURETEMPERATURE
 Slight increase in basal bodySlight increase in basal body
temperature due to increasedtemperatur...
INTEGUMENTARYINTEGUMENTARY
SYSTEMSYSTEM
 Striae gravidarum – pink or reddishStriae gravidarum – pink or reddish
streaks a...
 Diastasis - separation of the rectusDiastasis - separation of the rectus
musclesmuscles
 The umbilicus is stretched by ...
 MELASMA (CHLOASMA) or the mask ofMELASMA (CHLOASMA) or the mask of
pregnancy – darkened areas on the face,pregnancy – da...
ENDOCRINE CHANGESENDOCRINE CHANGES
 Addition of the placenta as an endocrineAddition of the placenta as an endocrine
orga...
 Increased size and activity of the adrenalIncreased size and activity of the adrenal
cortex, thus increasing the amount ...
LOCAL CHANGESLOCAL CHANGES
 UTERUSUTERUS
 Weight increases to about 1000g at full termWeight increases to about 1000g at...
 BALLOTMENT – 16BALLOTMENT – 16thth
to 20to 20thth
week ofweek of
pregnancy (‘from the french wordpregnancy (‘from the fr...
AmenorrheaAmenorrhea
 Absence of menstruation because of theAbsence of menstruation because of the
suppression of follicl...
CERVICAL CHANGESCERVICAL CHANGES
 Cervix becomes more vascular andCervix becomes more vascular and
edematous due to incre...
 GOODELL’S SIGN – softening of theGOODELL’S SIGN – softening of the
pelvispelvis
 the consistency of a nonpregnant cervi...
VAGINAL CHANGESVAGINAL CHANGES
 Vaginal epithelium and underlying tissueVaginal epithelium and underlying tissue
become h...
 This changing acid content makes theThis changing acid content makes the
vagina resistant to bacterial invasion forvagin...
OVARIAN CHANGESOVARIAN CHANGES
 Ovulation stops with pregnancy.Ovulation stops with pregnancy.
Progesterone and estrogen ...
ABDOMINAL WALLABDOMINAL WALL
CHANGESCHANGES
 STRIAE GRAVIDARUM – increase inSTRIAE GRAVIDARUM – increase in
uterine size ...
SKINSKIN
 LINEA NIGRA – brown line running fromLINEA NIGRA – brown line running from
umbilicus to symphysis pubisumbilicu...
BREASTBREAST
 All changes due to increase in estrogenAll changes due to increase in estrogen
 Increase in size due to hy...
 For mothers who intend to breast feed,For mothers who intend to breast feed,
advise:advise:
 Nipple rollingNipple rolli...
 Areola becomes darker and diameterAreola becomes darker and diameter
increasesincreases
 Skin surrounding areola turns ...
SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS
OF PREGNANCYOF PREGNANCY
 PRESUMPTIVE – s/s felt and observePRESUMPTIVE – s/s felt a...
FIRSTFIRST
TRIMESTERTRIMESTER
 PRESUMPTIVE:PRESUMPTIVE:
 B – reast changesB – reast changes
 U – rinary frequencyU – ri...
PROBABLEPROBABLE
 G – OODLES SIGNG – OODLES SIGN
 C –HADWICK SIGNC –HADWICK SIGN
 H – EGARSH – EGARS
 E – LEVATED BODY...
POSITIVEPOSITIVE
 ULTRASOUNDULTRASOUND
SECOND TRIMESTERSECOND TRIMESTER
 PRESUMPTIVEPRESUMPTIVE
 C – LOASMAC – LOASMA
 L – INEA NIGRAL – INEA NIGRA
 I – NCRE...
PROBABLEPROBABLE
 B – ALLOTMENTB – ALLOTMENT
 E – NLARGE ABDOMENE – NLARGE ABDOMEN
 B – RAXTON HICKS CONTRACTIONB – RAX...
POSITIVEPOSITIVE
 F – ETAL HEART TONEF – ETAL HEART TONE
 F – ETAL MOVEMENTF – ETAL MOVEMENT
 F – ETAL OUTLINEF – ETAL ...
PSYCHOLOGICALPSYCHOLOGICAL
ADAPTATION TOADAPTATION TO
PREGNANCYPREGNANCY
 FIRST TRIMESTERFIRST TRIMESTER
 NO TANGIBLE SI...
SECOND TRIMESTERSECOND TRIMESTER
 TANGIBLE SIGN AND SYMPTOMS OFTANGIBLE SIGN AND SYMPTOMS OF
PREGNANCYPREGNANCY
 MOTHER ...
THIRD TRIMESTERTHIRD TRIMESTER
 Mother has personal identification with theMother has personal identification with the
ap...
Emotional Response toEmotional Response to
PregnancyPregnancy
 Ambivalence – interwoven feelings ofAmbivalence – interwov...
 Introversion vs. Extroversion –Introversion vs. Extroversion –
introversion or turning inward tointroversion or turning ...
 Emotional Lability – mood changes dueEmotional Lability – mood changes due
to Hormonal changes, particularly theto Hormo...
The Pre-Natal VisitThe Pre-Natal Visit
 Basic considerationsBasic considerations
 Frequency of visit:Frequency of visit:...
 It should be remembered that patientsIt should be remembered that patients
understanding of the modalities of care isund...
DIAGNOSIS OFDIAGNOSIS OF
PREGNANCYPREGNANCY
 URINE EXAMINATION – HCG in theURINE EXAMINATION – HCG in the
urine is the ba...
Components of PrenatalComponents of Prenatal
visitvisit
 HISTORY TAKINGHISTORY TAKING
 PERSONAL DATA – patients name, ag...
OBSTETRICALOBSTETRICAL
ASSESSMENTASSESSMENT
 GESTATIONGESTATION
 Time until the estimated date of confinement orTime unt...
Gravidity and ParityGravidity and Parity
 GravidityGravidity
 GravidaGravida refers to a pregnant womanrefers to a pregn...
PARITYPARITY
 Is the number of births (not the number ofIs the number of births (not the number of
fetuses, e.g., twins) ...
Use of GTPALUse of GTPAL
 G is gravidity, the number of pregnanciesG is gravidity, the number of pregnancies
 T is term ...
 Example: A woman is pregnant for the fourthExample: A woman is pregnant for the fourth
time. She had one elective aborti...
BASELINE DATABASELINE DATA
 Vital signVital sign
 Rollover test – mother will be place onRollover test – mother will be ...
Weight MonitoringWeight Monitoring
 First Trimester: Normal Weight Gain 1.5First Trimester: Normal Weight Gain 1.5
– 3 lb...
Important EstimatesImportant Estimates
 Mc Donald’s Rule – to determine age ofMc Donald’s Rule – to determine age of
gest...
Physical ExaminationPhysical Examination
 Danger signs of pregnancy:Danger signs of pregnancy:
 C – hills and fever, cer...
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W O N D E R S O F F E R T I L I Z A T I O N

  1. 1. WONDERS OFWONDERS OF FERTILIZATIOFERTILIZATIO NN STAGES OF FETALSTAGES OF FETAL GROWTH ANDGROWTH AND DEVELOPMENTDEVELOPMENT
  2. 2. FERTILIZATIONFERTILIZATION  Other terms: CONCEPTION,Other terms: CONCEPTION, IMPREGNATION, ORIMPREGNATION, OR FECUNDATION.FECUNDATION.  THE UNION OF SPERM CELL ORTHE UNION OF SPERM CELL OR SPERMATOZOON AND EGG CELLSPERMATOZOON AND EGG CELL OR OVUMOR OVUM  Occurs in the outer third of theOccurs in the outer third of the fallopian tubefallopian tube  Fertilization may occur in about 72Fertilization may occur in about 72 hourshours
  3. 3.  After ovulation the ovum is releasedAfter ovulation the ovum is released from the graafian folliclefrom the graafian follicle  The ovum is surrounded by ZONAThe ovum is surrounded by ZONA PELLUCIDA a ring ofPELLUCIDA a ring of mucopolysaccharide fluid and a circlemucopolysaccharide fluid and a circle of cells the CORONA RADIATA.of cells the CORONA RADIATA.  These increase the bulk of the ovumThese increase the bulk of the ovum thus facilitates the migration to thethus facilitates the migration to the uterusuterus  Peristaltic action of the tube andPeristaltic action of the tube and movement of the tube cilia helpmovement of the tube cilia help propel the ovum along the length ofpropel the ovum along the length of the tube.the tube.
  4. 4.  Only one ovum reaches maturityOnly one ovum reaches maturity each montheach month  Once released fertilization mustOnce released fertilization must occur quickly because an ovum isoccur quickly because an ovum is capable of fertilization for only 24capable of fertilization for only 24 hours (48 hours the most)hours (48 hours the most)  If not fertilized it atrophies andIf not fertilized it atrophies and becomes non functionalbecomes non functional  Normally an ejaculation of semenNormally an ejaculation of semen averages 2.5 ml of fluid containingaverages 2.5 ml of fluid containing 50 – 200 million spermatozoa per50 – 200 million spermatozoa per milliliter, or an average of 400 millionmilliliter, or an average of 400 million per ejaculationsper ejaculations  3 -5 cc or 1 teaspoon – normal3 -5 cc or 1 teaspoon – normal amount of spermamount of sperm
  5. 5.  At the time of ovulation there isAt the time of ovulation there is a reduction of cervical mucusa reduction of cervical mucus viscosity, making it as an easyviscosity, making it as an easy access for spermatozoonaccess for spermatozoon penetrationpenetration  Spermatozoa deposited in theSpermatozoa deposited in the vagina during intercoursevagina during intercourse generally reach the cervixgenerally reach the cervix within 80 seconds and thewithin 80 seconds and the outer end of fallopian tubeouter end of fallopian tube within 5 minutes.within 5 minutes.  Sperm: pearly white, smallSperm: pearly white, small head, long tail or flagellahead, long tail or flagella
  6. 6.  Phonus – vibration of the head ofPhonus – vibration of the head of the sperm and determines thethe sperm and determines the location of the ovumlocation of the ovum  CAPACITATION – ability of theCAPACITATION – ability of the sperm to release proteolyticsperm to release proteolytic enzymes and penetrates coronaenzymes and penetrates corona radiataradiata  This process, which happens as theThis process, which happens as the sperm move toward the ovum,sperm move toward the ovum, consist of plasma changes in theconsist of plasma changes in the sperm head which reveals thesperm head which reveals the sperm binding receptor sitessperm binding receptor sites  Only one spermatozoon is able toOnly one spermatozoon is able to penetrate the cell membrane of thepenetrate the cell membrane of the ovumovum
  7. 7.  Once it penetrates the zonaOnce it penetrates the zona pelucida, the cell membranepelucida, the cell membrane becomes impervious to otherbecomes impervious to other spermatozoa.spermatozoa.  After penetration of the ovum theAfter penetration of the ovum the chromosomal material of thechromosomal material of the ovum and spermatozoon fuse.ovum and spermatozoon fuse. They are now called the ZYGOTEThey are now called the ZYGOTE  A fertilized ovum has 46A fertilized ovum has 46 chromosomeschromosomes  Spermatozoon and ovum eachSpermatozoon and ovum each carried 23 chromosomes (22carried 23 chromosomes (22 autosomes and 1 sexautosomes and 1 sex chromosomes)chromosomes)
  8. 8.  Fertilization depends on 3Fertilization depends on 3 factorsfactors::  Maturation of both sperm andMaturation of both sperm and ovumovum  The ability of the sperm toThe ability of the sperm to reach the ovumreach the ovum  The ability of the sperm toThe ability of the sperm to penetrate the zona pellucidapenetrate the zona pellucida and the cell membrane andand the cell membrane and achieve fertilizationachieve fertilization
  9. 9. IMPLANTATIONIMPLANTATION  It takes 3 or 4 days for the zygote to reach theIt takes 3 or 4 days for the zygote to reach the body of the uterusbody of the uterus  During this time, mitotic cell division orDuring this time, mitotic cell division or cleavage, begins.cleavage, begins.  The first cleavage occurs at about 24 hoursThe first cleavage occurs at about 24 hours  PRE EMBRYONIC STAGE: By the time thePRE EMBRYONIC STAGE: By the time the fertilized cell reaches the body of the uterus, itfertilized cell reaches the body of the uterus, it consist of 16 to 50 cells.consist of 16 to 50 cells.  Because of its bumpy outward appearance it isBecause of its bumpy outward appearance it is termed a morula (mullberry)termed a morula (mullberry)
  10. 10.  Morula continues to multiply as itMorula continues to multiply as it floats free in the uterine cavity forfloats free in the uterine cavity for 3 or 4 more days3 or 4 more days  Blastocyst – enlarging cellBlastocyst – enlarging cell forming a cavity that becomes anforming a cavity that becomes an embryo. These structuresembryo. These structures attaches to the uterineattaches to the uterine endometrium.endometrium.  Thropoblast – covering ofThropoblast – covering of blastocyst that become placentablastocyst that become placenta and membranesand membranes  The inner cell mass (embryoblastThe inner cell mass (embryoblast cells) is the portion that will latercells) is the portion that will later form the embryo.form the embryo.
  11. 11. Implantation/ NidationImplantation/ Nidation  Occurs 8 to 10 days after fertilizationOccurs 8 to 10 days after fertilization  3 Process of implantation3 Process of implantation  Apposition – Blastocyst begin to brushApposition – Blastocyst begin to brush endometriumendometrium  Adhesion – Blastocyst begin to attach toAdhesion – Blastocyst begin to attach to endometriumendometrium  Invasion – Blastocyst begins to settle down intoInvasion – Blastocyst begins to settle down into the soft folds of endometrium.the soft folds of endometrium.
  12. 12.  The trophoblast cell outside theThe trophoblast cell outside the blastocyst structure touch theblastocyst structure touch the endometrium, they produceendometrium, they produce proteolytic enzyme that dissolve theproteolytic enzyme that dissolve the tissue they touch.tissue they touch.  This action allows the blastocyst toThis action allows the blastocyst to burrow deeply into the endometriumburrow deeply into the endometrium and receive some basicand receive some basic nourishment of glycogen andnourishment of glycogen and mucoprotein from the endometrialmucoprotein from the endometrial glandgland  Effective communication networkEffective communication network with the blood system of thewith the blood system of the endometrium is establishedendometrium is established
  13. 13. Embryonic and FetalEmbryonic and Fetal StructureStructure  DECIDUADECIDUA  After fertilization, corpus luteum in the ovaryAfter fertilization, corpus luteum in the ovary continues to function rather than to atrophycontinues to function rather than to atrophy because of HCG secreted by trophoblastbecause of HCG secreted by trophoblast cellscells  Thus the endometrium continues to grow inThus the endometrium continues to grow in thickness and vascularitythickness and vascularity  The endometrium is now termed DECIDUAThe endometrium is now termed DECIDUA
  14. 14. 3 separate area of3 separate area of Decidua:Decidua:  Decidua BasalisDecidua Basalis – the part of the– the part of the endometrium lying directly under the embryoendometrium lying directly under the embryo ( the portion where the trophoblast cells are( the portion where the trophoblast cells are establishing communication with maternalestablishing communication with maternal blood vessels)blood vessels)  Decidua CapsularisDecidua Capsularis – The portion of the– The portion of the endometrium that stretches or encapsulatesendometrium that stretches or encapsulates the surface of the trophoblastthe surface of the trophoblast  Decidua VeraDecidua Vera – Remaining portion of the– Remaining portion of the endometriumendometrium
  15. 15. CHORIONIC VILLICHORIONIC VILLI  As early as 11As early as 11thth or 12or 12thth day miniature villi,day miniature villi, or probing “fingers” termed chorionic villi,or probing “fingers” termed chorionic villi, reach out from the single layer of cellsreach out from the single layer of cells into the uterine endometrium.into the uterine endometrium.  At term, nearly 200 such villi will haveAt term, nearly 200 such villi will have formedformed
  16. 16. Chorionic VilliChorionic Villi SamplingSampling Removal of tissue sample from the fetalRemoval of tissue sample from the fetal portion of the developing placentaportion of the developing placenta  Purpose – to determine the presence ofPurpose – to determine the presence of genetic abnormalities; a transabdominal orgenetic abnormalities; a transabdominal or transcervical approach may be used.transcervical approach may be used. Genetic screening.Genetic screening.  Indications – as for amniocentesis but CVSIndications – as for amniocentesis but CVS can be performed earlier (9 to 12 weekscan be performed earlier (9 to 12 weeks gestation) and results obtained sooner (1 togestation) and results obtained sooner (1 to 2 weeks)2 weeks)
  17. 17.  Complication rate is slightly higher thanComplication rate is slightly higher than for amniocentesis primarily related tofor amniocentesis primarily related to bleeding spontaneous abortion, rupturebleeding spontaneous abortion, rupture of membranes, infection, preterm birthof membranes, infection, preterm birth fetal limb defects such as missing fingersfetal limb defects such as missing fingers of toes.of toes.  Protocol: Invasive procedure: neededProtocol: Invasive procedure: needed consent and full bladderconsent and full bladder  Ultrasound – used throughout to guide theUltrasound – used throughout to guide the procedureprocedure  Client preparation – similar to that of anClient preparation – similar to that of an amniocentesis except full bladder may beamniocentesis except full bladder may be needed to position the uterus for easierneeded to position the uterus for easier catheter insertioncatheter insertion
  18. 18.  Position depends on approach –Position depends on approach – transabdominal (supine) or transcervicaltransabdominal (supine) or transcervical (lithotomy)(lithotomy)  Vital signs are monitoredVital signs are monitored  Care after the procdure and dischargeCare after the procdure and discharge instructions are similar to those for aninstructions are similar to those for an amniocentesisamniocentesis
  19. 19. Outline of TrophoblastOutline of Trophoblast DifferentiationDifferentiation  CYTOTHROPOBLAST or Langhan’sCYTOTHROPOBLAST or Langhan’s layer – present as early as 12 dayslayer – present as early as 12 days gestation.gestation.  Protects the growing embryo and fetus fromProtects the growing embryo and fetus from certain infectious organisms such as thecertain infectious organisms such as the spirochete of syphilis.spirochete of syphilis.  This layer disappears between the 20This layer disappears between the 20thth andand 2424thth week.week.
  20. 20. SYNCTIOTROPHOBLASSYNCTIOTROPHOBLAS T or Syncytial layerT or Syncytial layer  The outer layer containing fingerlikeThe outer layer containing fingerlike projections called chorionic villiprojections called chorionic villi  Gives rise to the fetal membranes:Gives rise to the fetal membranes: 1.AMNION – inner membrane which gives1.AMNION – inner membrane which gives rise torise to  UMBILICAL CORD/FUNIS – contains 2UMBILICAL CORD/FUNIS – contains 2 Arteries and 1 Vein, which is supported byArteries and 1 Vein, which is supported by Wharton’s JellyWharton’s Jelly
  21. 21.  AMNIOTIC FLUIDAMNIOTIC FLUID  Clear albuminous fluid in which the babyClear albuminous fluid in which the baby floatsfloats  Begins to form at 11 – 15 weeks gestationBegins to form at 11 – 15 weeks gestation  Approximates water in specific gravity (1.007Approximates water in specific gravity (1.007 – 1.025) and is neutral to slightly alkaline– 1.025) and is neutral to slightly alkaline  Near term is clear, colorless, containing littleNear term is clear, colorless, containing little white specks of vernix caseosa and otherwhite specks of vernix caseosa and other solid particlessolid particles  Produced at a rate of 500 ml in 24 hours andProduced at a rate of 500 ml in 24 hours and fetus swallows it at an equally rapid rate. Byfetus swallows it at an equally rapid rate. By the 4the 4thth lunar month urine is added to thelunar month urine is added to the amount of amniotic fluid.amount of amniotic fluid.
  22. 22.  Amniotic fluid therefore, is derived chieflyAmniotic fluid therefore, is derived chiefly from maternal serum and fetal urinefrom maternal serum and fetal urine  Implications: a case ofImplications: a case of POLYHYDRAMNIOS (>1500ml ofPOLYHYDRAMNIOS (>1500ml of amniotic fluid) stems from inability of theamniotic fluid) stems from inability of the fetus to swallow amniotic fluid rapidly asfetus to swallow amniotic fluid rapidly as in tracheoesophageal fistula.in tracheoesophageal fistula.  OLIGOHYDRAMNIOS (<500 ml ofOLIGOHYDRAMNIOS (<500 ml of amniotic fluid, is due to inability of theamniotic fluid, is due to inability of the kidneys to add urine to the amniotic fluid,kidneys to add urine to the amniotic fluid, as in Congenital renal Anomalyas in Congenital renal Anomaly
  23. 23.  Also known as Bag of WaterAlso known as Bag of Water (BOW), it serves the following(BOW), it serves the following purpose:purpose:  Protection – shields the fetusProtection – shields the fetus against blows or pressures on theagainst blows or pressures on the mothers abdomen, againstmothers abdomen, against sudden changes in temperaturesudden changes in temperature and from infectionsand from infections  Diagnosis – as in amniocentesis;Diagnosis – as in amniocentesis; meconium stained amniotic fluidmeconium stained amniotic fluid means fetal distressmeans fetal distress  Aids in the descent of fetus duringAids in the descent of fetus during active laboractive labor
  24. 24.  Diagnostic test for Amniotic FluidDiagnostic test for Amniotic Fluid  AMNIOCENTESISAMNIOCENTESIS  Purpose: obtain a sample of amniotic fluidPurpose: obtain a sample of amniotic fluid by inserting a needle through the abdomenby inserting a needle through the abdomen into the amniotic sac; fluid is tested forinto the amniotic sac; fluid is tested for 1.1. Genetic screeningGenetic screening Early testing time – 9 – 12 weeks with resultsEarly testing time – 9 – 12 weeks with results available in 10 to 14 daysavailable in 10 to 14 days Traditional Testing time – 14Traditional Testing time – 14thth to 16to 16thth week withweek with results availableresults available Performed to determine presence of such problemPerformed to determine presence of such problem as Down syndrome, Neural Tube Defect,as Down syndrome, Neural Tube Defect, Inborn errors of metabolismInborn errors of metabolism
  25. 25. 2. Determination of fetal maturity primarily2. Determination of fetal maturity primarily by evaluating factors indicative of lungby evaluating factors indicative of lung maturitymaturity Testing time – During 3Testing time – During 3rdrd trimester aroundtrimester around 3636thth when lung maturation have occurredwhen lung maturation have occurred Factors – both should be present @Factors – both should be present @ approximately 36 wks AOGapproximately 36 wks AOG 1. L/S ratio (lecithin/ sphingomyelin)1. L/S ratio (lecithin/ sphingomyelin) greater than 2;1greater than 2;1 2. Presence of phosphatidyglycerol (PG)2. Presence of phosphatidyglycerol (PG) termed PG+ (definite test for fetal lungtermed PG+ (definite test for fetal lung maturity)maturity)
  26. 26.  Indications:Indications:  Family HistoryFamily History  Women of advance age, >35 years of ageWomen of advance age, >35 years of age  Assurance of lung maturity prior to inducingAssurance of lung maturity prior to inducing labor or performing an elective cesareanlabor or performing an elective cesarean sectionsection Overall complication rate is 1 %:Overall complication rate is 1 %: Most common complication: Infection,Most common complication: Infection, Spontaneous abortion, Preterm laborSpontaneous abortion, Preterm labor Position: Transvaginal = LithotomyPosition: Transvaginal = Lithotomy Trans abdominal = SupineTrans abdominal = Supine Protocol: empty the bladderProtocol: empty the bladder
  27. 27. a.a. Ultrasound – identify placental and fetalUltrasound – identify placental and fetal location to avoid damage and pinpointlocation to avoid damage and pinpoint amniotic fluid pocketsamniotic fluid pockets b.b. PreparationPreparation a.a. Provide emotional support and assistanceProvide emotional support and assistance with relaxation techniques since womanwith relaxation techniques since woman may be restless and frightenedmay be restless and frightened b.b. Verify informed consent forms areVerify informed consent forms are completecomplete c.c. Assist woman to empty bladderAssist woman to empty bladder d.d. Position: supine, be alert for supinePosition: supine, be alert for supine hypotensive syndrome during and after thehypotensive syndrome during and after the test.test.
  28. 28.  Greenish Amniotic Fluid – ExperienceGreenish Amniotic Fluid – Experience Hypoxia, common in post term babyHypoxia, common in post term baby  Yellowish Amniotic Fluid – Jaundice orYellowish Amniotic Fluid – Jaundice or hyperbilirubinemiahyperbilirubinemia  Cloudy Amniotic fluid – InfectionCloudy Amniotic fluid – Infection  Shake test or Foam test:Shake test or Foam test:  Stable Bubbles – 2:1 L/S ratioStable Bubbles – 2:1 L/S ratio  Bubbles evaporates – 1:2 L/S ratio/Bubbles evaporates – 1:2 L/S ratio/ Respiratory Distress SyndromeRespiratory Distress Syndrome
  29. 29. 2. CHORION2. CHORION  Together with the decidua basalis, givesTogether with the decidua basalis, gives rise to the placenta, which starts to formrise to the placenta, which starts to form at 8at 8thth week gestation. Develop into 15 –week gestation. Develop into 15 – 20 subdivisions called COTYLEDONS.20 subdivisions called COTYLEDONS.  Placenta serves the following purpose:Placenta serves the following purpose:  Respiratory System – exchange of gasesRespiratory System – exchange of gases takes place in the placenta not in the fetaltakes place in the placenta not in the fetal lungslungs  Renal System – waste products are beingRenal System – waste products are being excreted through the placenta( Note: it is theexcreted through the placenta( Note: it is the mothers liver that detoxifies fetal wastemothers liver that detoxifies fetal waste products)products)
  30. 30.  Gastrointestinal System – Nutrients passGastrointestinal System – Nutrients pass to the fetus via the placenta by diffusionto the fetus via the placenta by diffusion through the placental tissuesthrough the placental tissues  Circulatory System – feto-placentalCirculatory System – feto-placental circulation is established by selectivecirculation is established by selective osmosis through the chorionic villi. Aboutosmosis through the chorionic villi. About 100 maternal uterine artery supply the100 maternal uterine artery supply the mature placenta.mature placenta.  To provide enough blood for exchange, theTo provide enough blood for exchange, the rate of uteroplacental blood flow torate of uteroplacental blood flow to pregnancy increases from about 50ml/min atpregnancy increases from about 50ml/min at 10 weeks to 500 – 600 ml/min at term10 weeks to 500 – 600 ml/min at term
  31. 31.  At term, the placental circulatory network is soAt term, the placental circulatory network is so extensive that a placenta weighs 400 – 600extensive that a placenta weighs 400 – 600 grams and is 1 sixth the weight of the baby.grams and is 1 sixth the weight of the baby.  Endocrine system – it produces the followingEndocrine system – it produces the following important hormonesimportant hormones  Human Chorionic Gonadotrophin – orders theHuman Chorionic Gonadotrophin – orders the corpus luteum to keep on producing estrogen andcorpus luteum to keep on producing estrogen and progesterone, that is why menstruation does notprogesterone, that is why menstruation does not occur during pregnancy.occur during pregnancy.  At about 8 weeks of pregnancy, the outerAt about 8 weeks of pregnancy, the outer layer of cell of developing placenta beginslayer of cell of developing placenta begins to produce progesterone.to produce progesterone.
  32. 32.  ESTROGEN – (Estriol) contributes to theESTROGEN – (Estriol) contributes to the mother’s mammary gland development inmother’s mammary gland development in preparation for lactation and stimulatespreparation for lactation and stimulates uterine growth to accommodate theuterine growth to accommodate the developing fetusdeveloping fetus  PROGESTERONE – maintain thePROGESTERONE – maintain the endometrial lining of the uterus duringendometrial lining of the uterus during pregnancy. Reduce the contractility ofpregnancy. Reduce the contractility of the uterine musculature duringthe uterine musculature during pregnancy, which prevents prematurepregnancy, which prevents premature laborlabor
  33. 33.  HUMAN PLACENTALHUMAN PLACENTAL LACTOGEN(HUMAN CHORIONICLACTOGEN(HUMAN CHORIONIC SOMATOMAMMOTROPIN) – promotesSOMATOMAMMOTROPIN) – promotes growth of mammary glands necessary forgrowth of mammary glands necessary for lactation. Also has growth stimulatinglactation. Also has growth stimulating propertiesproperties
  34. 34. Origin andOrigin and Development of OrganDevelopment of Organ SystemSystem  PRIMARY Germ layer – at the time ofPRIMARY Germ layer – at the time of implantation, the blastocyst alreadt hasimplantation, the blastocyst alreadt has differentiated to a point at which twodifferentiated to a point at which two separate cavities appear in the innerseparate cavities appear in the inner structure:structure:  A large one the amniotic cavity, which isA large one the amniotic cavity, which is lined with ECTODERMlined with ECTODERM
  35. 35.  A smaller cavity, the yolk sac,A smaller cavity, the yolk sac, which is lined withwhich is lined with ENTODERM cellsENTODERM cells  Between the amniotic cavityBetween the amniotic cavity and the yolk sac, a third layerand the yolk sac, a third layer of primary cells, theof primary cells, the MESODERM forms.MESODERM forms.  The embryo will begin toThe embryo will begin to develop at the point wheredevelop at the point where the three cell layers meetthe three cell layers meet
  36. 36. ECTODERMECTODERM  Central Nervous SystemCentral Nervous System  Peripheral Nervous systemPeripheral Nervous system  Skin, hair and nailsSkin, hair and nails  Sebaceous glandsSebaceous glands  Sense organsSense organs  Mucous membranes of the anus,Mucous membranes of the anus, mouth and nosemouth and nose  Tooth enamel and MammaryTooth enamel and Mammary glandsglands
  37. 37. MESODERMMESODERM  Connective tissues,Connective tissues, bones, cartilage, muscle,bones, cartilage, muscle, ligaments and tendonsligaments and tendons  Dentin of teethDentin of teeth  Kidneys and uretersKidneys and ureters  Reproductive systemReproductive system  HeartHeart  Circulatory SystemCirculatory System  Blood cells and LymphBlood cells and Lymph vesselsvessels
  38. 38. ENTODERMENTODERM  Lining of pericardial,Lining of pericardial, pleura, and peritonealpleura, and peritoneal cavitiescavities  Lining of theLining of the Gastrointestinal tractGastrointestinal tract  Respiratory tract, tonsils,Respiratory tract, tonsils, parathyroid, thyroid,parathyroid, thyroid, thymus glandsthymus glands  Bladder and UrethraBladder and Urethra
  39. 39.  All organ systems are complete, atleastAll organ systems are complete, atleast in a rudimentary form, at 8 weeksin a rudimentary form, at 8 weeks gestation. During this early time ofgestation. During this early time of ORGANOGENESIS, the growingORGANOGENESIS, the growing structure is vulnerable to invasion bystructure is vulnerable to invasion by teratogens.teratogens.
  40. 40. TERATOGENSTERATOGENS  Any drug, virus or irradiation, the exposure toAny drug, virus or irradiation, the exposure to which may cause damage to the fetuswhich may cause damage to the fetus  A. DRUGSA. DRUGS  Streptomycin – ototoxic (poor hearing), CN 8Streptomycin – ototoxic (poor hearing), CN 8 affectedaffected  Tetracycline – Staining of tooth enamel, InhibitsTetracycline – Staining of tooth enamel, Inhibits growth of long bonesgrowth of long bones  Iodides – Enlargement of thyroid or GoiterIodides – Enlargement of thyroid or Goiter  Thalidomides – Phocomelia or ameliaThalidomides – Phocomelia or amelia  Steroids – Cleft lip, cleft palate, abortionSteroids – Cleft lip, cleft palate, abortion  Lithium – congenital malformationLithium – congenital malformation
  41. 41.  AlcoholAlcohol  Low birth weightLow birth weight  Fetal alcohol withdrawal symptomsFetal alcohol withdrawal symptoms  VasoconstrictionsVasoconstrictions SMOKINGSMOKING CAFFEINECAFFEINE Low birth weightLow birth weight
  42. 42. TORCH (teratogenic)TORCH (teratogenic) InfectionsInfections  Group of infections caused by organismsGroup of infections caused by organisms that can cross the placenta or ascendthat can cross the placenta or ascend through birth canal and adversely affectthrough birth canal and adversely affect fetal growth and development.fetal growth and development.  Often characterized by vague, influenzaOften characterized by vague, influenza like findings, rashes and lesions,like findings, rashes and lesions, enlarged lymph nodes, and jaundiceenlarged lymph nodes, and jaundice  Devastating effect on the babyDevastating effect on the baby
  43. 43.  T – TOXOPLASMOSIS – a protozoanT – TOXOPLASMOSIS – a protozoan infection transmitted by handling rawinfection transmitted by handling raw meat, cat litter or soil contaminated withmeat, cat litter or soil contaminated with cat feces, eating raw or inadequatelycat feces, eating raw or inadequately prepared meat animal products andprepared meat animal products and inadequately washed vegetables.inadequately washed vegetables.  O – OthersO – Others  HEPATITIS A – a viral infection transmittedHEPATITIS A – a viral infection transmitted by droplets, hands contaminated by oralby droplets, hands contaminated by oral fecal material while eating and eating foodfecal material while eating and eating food handled by persons with contaminatedhandled by persons with contaminated hands.hands.
  44. 44.  Hepatitis B (serum hepatitis) – a viralHepatitis B (serum hepatitis) – a viral infection transmitted by contactinfection transmitted by contact substances containing blood. Use of orsubstances containing blood. Use of or injury by contaminated needles orinjury by contaminated needles or syringes, sexual intercourse, handling ofsyringes, sexual intercourse, handling of materials containing blood includingmaterials containing blood including transfusions, dressings, drainage ortransfusions, dressings, drainage or exposure during a splash or spray ofexposure during a splash or spray of blood as may occur during birth, surgery.blood as may occur during birth, surgery.
  45. 45.  HUMAN IMMUNODEFICIENCY VIRUS – aHUMAN IMMUNODEFICIENCY VIRUS – a retrovirus transmitted by contact withretrovirus transmitted by contact with contaminated body fluids including blood andcontaminated body fluids including blood and semen; infected pregnant women can infectsemen; infected pregnant women can infect fetus – newborn transplacentally, contact withfetus – newborn transplacentally, contact with maternal blood, body fluids during labor andmaternal blood, body fluids during labor and birth, ingestion of breast milkbirth, ingestion of breast milk  SYPHILLIS (TREPONEMA PALLIDUM) –SYPHILLIS (TREPONEMA PALLIDUM) – sexually transmitted disease caused by thesexually transmitted disease caused by the spirochete, treponema pallidum.spirochete, treponema pallidum. Transplacental transmission is possible afterTransplacental transmission is possible after the 16the 16thth to 18to 18thth week of pregnancy resulting inweek of pregnancy resulting in stillbirth or congenital syphillis.stillbirth or congenital syphillis.
  46. 46.  RUBELLA (GERMAN or 3 DAYRUBELLA (GERMAN or 3 DAY Measles)- Viral infection transmitted byMeasles)- Viral infection transmitted by dropletsdroplets  CYTOMEGALOVIRUS – Viral infectionCYTOMEGALOVIRUS – Viral infection transmitted by contact with contaminatedtransmitted by contact with contaminated saliva respiratory secretions, urine,saliva respiratory secretions, urine, semen, breastmilk, blood cervical-vaginalsemen, breastmilk, blood cervical-vaginal secretions. Most often asymptomatic insecretions. Most often asymptomatic in the mother but produces several fetalthe mother but produces several fetal and neonatal effects including hemolyticand neonatal effects including hemolytic anemia, jaundice, hydrocephaly-anemia, jaundice, hydrocephaly- microcephaly, pneumonitis, mentalmicrocephaly, pneumonitis, mental retardationretardation
  47. 47.  H - HERPES – SIMPLEX VIRUS – aH - HERPES – SIMPLEX VIRUS – a sexually transmitted viral infection thatsexually transmitted viral infection that occurs when contact is made withoccurs when contact is made with contaminated genital secretions. Infectedcontaminated genital secretions. Infected women can infect fetus transplacentallywomen can infect fetus transplacentally especially during a primary infectionespecially during a primary infection when systemic findings occur and arewhen systemic findings occur and are most severe and through contact withmost severe and through contact with other lesions and contaminatedother lesions and contaminated secretions during passage through thesecretions during passage through the birth canal.birth canal.
  48. 48. CARDIOVASCULCARDIOVASCUL AR SYSTEMAR SYSTEM  First systems to becomeFirst systems to become functional in intrauterine lifefunctional in intrauterine life  Forms as early as 16Forms as early as 16thth day of life,day of life, beating as early as the 24beating as early as the 24thth dayday  The heartbeat maybe heard withThe heartbeat maybe heard with a Doppler as early as the 10a Doppler as early as the 10thth toto 11th week of pregnancy11th week of pregnancy  After the 28After the 28thth week of pregnancy,week of pregnancy, the heart rate begins to show athe heart rate begins to show a baseline variability of about 5baseline variability of about 5 beats per minutebeats per minute
  49. 49. FETAL CIRCULATIONFETAL CIRCULATION  PLACENTA ---- OXYGENATED BLOODPLACENTA ---- OXYGENATED BLOOD IS CARRIED BY THE VEIN ---- LIVERIS CARRIED BY THE VEIN ---- LIVER ---- DUCTUS VENOSUS ---- INFERIOR---- DUCTUS VENOSUS ---- INFERIOR VENACAVA ---- RIGHT ATRIUM ---- 70VENACAVA ---- RIGHT ATRIUM ---- 70 % SHUNTED TO FORAMEN OVALE ----% SHUNTED TO FORAMEN OVALE ---- LEFT ATRIUM ---- MITRAL VALVE ----LEFT ATRIUM ---- MITRAL VALVE ---- LEFT VENTRICLE ---- AORTA ----LEFT VENTRICLE ---- AORTA ---- LOWER EXTREMITIESLOWER EXTREMITIES
  50. 50.  The remaining 30 % ---- tricuspid valveThe remaining 30 % ---- tricuspid valve ---- right ventricle ---- pulmonary artery---- right ventricle ---- pulmonary artery ---- lungs ---- vasoconstriction of lungs---- lungs ---- vasoconstriction of lungs pushes the blood to Ductus arteriosuspushes the blood to Ductus arteriosus ---- aorta ---- to supply the upper---- aorta ---- to supply the upper extremities.extremities.
  51. 51. FetalFetal HemoglobinHemoglobin  Fetal hemoglobin has greaterFetal hemoglobin has greater oxygen affinity, which increasesoxygen affinity, which increases its efficiency, and is moreits efficiency, and is more concentratedconcentrated  Hemoglobin level at birth isHemoglobin level at birth is about 17.1 g/100ml (Adultabout 17.1 g/100ml (Adult 11g/100ml)11g/100ml)  Hematocrit is about 53 % (adultHematocrit is about 53 % (adult 45 %)45 %)
  52. 52. RESPIRATORYRESPIRATORY SYSTEMSYSTEM  77thth week of life DIAPHRAGMweek of life DIAPHRAGM completely divide the thoracic cavitycompletely divide the thoracic cavity from abdominal cavityfrom abdominal cavity  Alveoli and Capillaries begin to formAlveoli and Capillaries begin to form between 24between 24thth and 28and 28thth weeks.weeks.  Continues respiratory movementsContinues respiratory movements begins as early as 3 months ofbegins as early as 3 months of pregnancypregnancy  Surfactant is formed and excretedSurfactant is formed and excreted by the alveolar cells at about the 24by the alveolar cells at about the 24thth weekweek
  53. 53.  Analysis of the Lecithin/sphingomyelinAnalysis of the Lecithin/sphingomyelin (LS) ratio by an amniocentesis technique(LS) ratio by an amniocentesis technique is one of the primary tests for fetalis one of the primary tests for fetal maturitymaturity  L/S ratio is 2:1, at about 35 weeks, thereL/S ratio is 2:1, at about 35 weeks, there is a surge in the production of lecithin.is a surge in the production of lecithin.
  54. 54. NERVOUS SYSTEMNERVOUS SYSTEM  Active formation of the nervous system andActive formation of the nervous system and sense organs has already begun during the 3sense organs has already begun during the 3rdrd and 4and 4thth week of life.week of life.  Brain waves can be detected on anBrain waves can be detected on an electroencephalogram (EEG) by the 8electroencephalogram (EEG) by the 8thth weekweek  By 24 weeks, the ear is capable of respondingBy 24 weeks, the ear is capable of responding to sound; the eyes exhibit a pupillary reaction,to sound; the eyes exhibit a pupillary reaction, indicating sight is presentindicating sight is present  Brain growth continue to occur rapidly during 1Brain growth continue to occur rapidly during 1stst year and continues at high levels until 5 or 6year and continues at high levels until 5 or 6 years of age.years of age.
  55. 55. DIGESTIVEDIGESTIVE SYSTEMSYSTEM  MECONIUM forms in theMECONIUM forms in the intestines as early as the 16intestines as early as the 16thth weekweek  Meconium is black or dark greenMeconium is black or dark green ( obtaining its color( obtaining its color from bile pigment) and stickyfrom bile pigment) and sticky  It consist of cellular wastes, bile,It consist of cellular wastes, bile, fats, mucoprotein,fats, mucoprotein, mucopolysaccharides, andmucopolysaccharides, and vernix caseosa, lubricatingvernix caseosa, lubricating sustance that forms the fetal skinsustance that forms the fetal skin
  56. 56.  Gastrointestinal tract is sterile beforeGastrointestinal tract is sterile before birth.birth.  Vit K, essential for blood clotting, isVit K, essential for blood clotting, is synthesized by the action of bacteriasynthesized by the action of bacteria in the intestines, this can causein the intestines, this can cause vitamin K levels to be low in thevitamin K levels to be low in the newborn.newborn.  Sucking and swallowing reflexesSucking and swallowing reflexes matures at 32 weeks or until fetusmatures at 32 weeks or until fetus weighs 1500 g.weighs 1500 g.  GIT secretes enzymes essential forGIT secretes enzymes essential for digestion of CHO and CHON at 36digestion of CHO and CHON at 36 weeksweeks
  57. 57.  Many newborn have not yet developMany newborn have not yet develop lipase, an enzyme needed for fatlipase, an enzyme needed for fat digestion.digestion.  Amylase is not mature until 3 monthsAmylase is not mature until 3 months after birthafter birth  Liver is active throughout gestation,Liver is active throughout gestation, function as filter between incoming bloodfunction as filter between incoming blood and fetal circulation and as a deposit forand fetal circulation and as a deposit for fetal stores such as iron and glycogen.fetal stores such as iron and glycogen.  Hypoglycemia and hyperbilirubinemiaHypoglycemia and hyperbilirubinemia two serious problems in the first 24 hourstwo serious problems in the first 24 hours after birth.after birth.
  58. 58. MUSCULOSKELETMUSCULOSKELET AL SYSTEMAL SYSTEM  Fetus can be seen to move onFetus can be seen to move on ultrasound as early as the 11ultrasound as early as the 11thth week, although the mother usuallyweek, although the mother usually does not feel this movementdoes not feel this movement (QUICKENING) until nearly 20(QUICKENING) until nearly 20 weeks.weeks.  Ossification of bone tissue beginsOssification of bone tissue begins about 12about 12thth week.week.
  59. 59. REPRODUCTIVEREPRODUCTIVE SYSTEMSYSTEM Child sex is determined at the moment ofChild sex is determined at the moment of conception by a spermatozoon carryingconception by a spermatozoon carrying an X or a Y chromosomes.an X or a Y chromosomes.  Can be determined as early as 8 weeksCan be determined as early as 8 weeks by chromosomal analysisby chromosomal analysis  The GONADS form at about 6The GONADS form at about 6thth weeks ofweeks of lifelife  Testes descend from pelvic cavity at 34Testes descend from pelvic cavity at 34thth – 38– 38thth weekweek
  60. 60. URINARY SYSTEMURINARY SYSTEM  Rudimentary kidneys are present as early asRudimentary kidneys are present as early as the end of the 4the end of the 4thth weekweek  Urine is formed by the 4Urine is formed by the 4thth week and excreted inweek and excreted in the amniotic fluid by 16the amniotic fluid by 16thth weekweek  At term fetal urine is being excreted at the rateAt term fetal urine is being excreted at the rate of 500ml/dayof 500ml/day  OLIGOHYDRAMNIOS an amount of amnioticOLIGOHYDRAMNIOS an amount of amniotic fluid that is < normal suggest that fetal kidneysfluid that is < normal suggest that fetal kidneys are not secreting adequate urineare not secreting adequate urine
  61. 61. INTEGUMENTARYINTEGUMENTARY SYSTEMSYSTEM  The skin of the fetus appears thin andThe skin of the fetus appears thin and almost translucentalmost translucent  Subcutaneous fat begins to be depositedSubcutaneous fat begins to be deposited at about 36 weeksat about 36 weeks  Skin is covered by soft downy hairsSkin is covered by soft downy hairs (LANUGO) and a cream cheese-like(LANUGO) and a cream cheese-like substance, vernix caseosa, which issubstance, vernix caseosa, which is important for lubrication and keeping theimportant for lubrication and keeping the skin from maceratingskin from macerating
  62. 62. IMMUNE SYSTEMIMMUNE SYSTEM  IgG maternal antibodies cross theIgG maternal antibodies cross the placenta into the fetus during the 3placenta into the fetus during the 3rdrd trimester of pregnancy (Giving fetustrimester of pregnancy (Giving fetus temporary passive immunity)temporary passive immunity)  Little or no immunity to Herpes virusLittle or no immunity to Herpes virus  Level of passive IgG immunoglobulinsLevel of passive IgG immunoglobulins peaks at birth, then decreases by thepeaks at birth, then decreases by the next 8 monthsnext 8 months
  63. 63. MILESTONES OF FETALMILESTONES OF FETAL GROWTH ANDGROWTH AND DEVELOPMENTDEVELOPMENT
  64. 64. End of 4 GestationEnd of 4 Gestation WeeksWeeks  Length: .75 to 1 cmLength: .75 to 1 cm  Weight: 400 mgWeight: 400 mg  Spinal cord is formed and fused at theSpinal cord is formed and fused at the midpointmidpoint  Lateral wing that form the body are foldedLateral wing that form the body are folded forward to fuse at the midlineforward to fuse at the midline  Head folds forward, becoming prominent,Head folds forward, becoming prominent, representing about 1/3 of the entirerepresenting about 1/3 of the entire structurestructure  The back is bent so the head almostThe back is bent so the head almost touches the tip of the tailtouches the tip of the tail  Arms and legs are budlike structuresArms and legs are budlike structures  Rudimentary eyes, ears and nose areRudimentary eyes, ears and nose are discerniblediscernible
  65. 65. End of 8End of 8thth GestationGestation weeksweeks  Length: 2.5 cm (1in)Length: 2.5 cm (1in)  Weight: 20 gWeight: 20 g  Organogenesis is completeOrganogenesis is complete  The heart with septum and valves, isThe heart with septum and valves, is beating rhythmicallybeating rhythmically  Facial features are definitely discernibleFacial features are definitely discernible  Extremities have developedExtremities have developed  External genitalia are present, but sex is notExternal genitalia are present, but sex is not distinguishabledistinguishable  Primitive tail is regressingPrimitive tail is regressing  Abdomen appears large as the fetal intestine isAbdomen appears large as the fetal intestine is growing rapidlygrowing rapidly
  66. 66. End of 12End of 12thth Gestation weekGestation week Length: 7 to 8 cmLength: 7 to 8 cm  Weight: 45 gWeight: 45 g  Nail beds are forming on fingersNail beds are forming on fingers and toesand toes  Spontaneous movement areSpontaneous movement are possiblepossible  Babinski reflex are presentBabinski reflex are present  Bone ossification centers areBone ossification centers are presentpresent  Sex is distinguishable by outwardSex is distinguishable by outward appearanceappearance  Kidney secretion has begunKidney secretion has begun  Heartbeat is audible by a dopplerHeartbeat is audible by a doppler
  67. 67. End of 16End of 16thth GestationGestation weekweek Length: 10 – 17 cmLength: 10 – 17 cm  Weight:4Weight:4  55 – 120 g55 – 120 g  Fetal heart sounds are audible with anFetal heart sounds are audible with an ordinary stethoscopeordinary stethoscope  Lanugo (fine downy hair on the back andLanugo (fine downy hair on the back and arms of newborns, servin as a source ofarms of newborns, servin as a source of insulation for body heat) is well formedinsulation for body heat) is well formed  Liver and pancreas are functioningLiver and pancreas are functioning  Sex can be determined by ultrasoundSex can be determined by ultrasound  Fetus actively swallows amniotic fluidFetus actively swallows amniotic fluid  Urine is present in amniotic fluidUrine is present in amniotic fluid
  68. 68. End of 20 gestationEnd of 20 gestation WeeksWeeks  Length: 25 cmLength: 25 cm  Weight: 223cmWeight: 223cm  Spontaneous fetal movements can beSpontaneous fetal movements can be sensed by the mothersensed by the mother  Antibody production is possibleAntibody production is possible  Hair forms (eyebrows and hair on theHair forms (eyebrows and hair on the head)head)  Meconium is present in the upperMeconium is present in the upper intestineintestine
  69. 69.  Brown fat begins to be formed behind theBrown fat begins to be formed behind the kidneys, sternum and posterior neck.kidneys, sternum and posterior neck.  Fetal heartbeat is strong enough to beFetal heartbeat is strong enough to be audible through the abdomen with anaudible through the abdomen with an ordinary stethoscopeordinary stethoscope  Vernix caseosa, a cream cheese-likeVernix caseosa, a cream cheese-like substance produced by thesubstance produced by the sebaceous glands that serves as asebaceous glands that serves as a protective skin covering duringprotective skin covering during intrauterine life begins to formintrauterine life begins to form  Definite sleping and activity patterns areDefinite sleping and activity patterns are distinguishabledistinguishable
  70. 70. End of 24 GestationEnd of 24 Gestation WeeksWeeks  Length: 28 to 36 cmLength: 28 to 36 cm  Weight: 550 gWeight: 550 g  Meconium is present as far as the rectumMeconium is present as far as the rectum  Active production of lung surfactantActive production of lung surfactant beginsbegins  Eyebrows and eyelashes are wellEyebrows and eyelashes are well defineddefined  Eyelids are now openEyelids are now open  Pupils are capable of reacting to lightPupils are capable of reacting to light  Hearing can be demonstrated byHearing can be demonstrated by
  71. 71. End of 28End of 28thth GestationGestation weeksweeks Length: 35 to 38 cmLength: 35 to 38 cm  Weight: 1,200gWeight: 1,200g  Lung alveoli begin to mature;Lung alveoli begin to mature; surfactant can be demonstrated insurfactant can be demonstrated in amniotic fluidamniotic fluid  Testes begin to descend into the scrotalTestes begin to descend into the scrotal sac from the lower abdominal cavitysac from the lower abdominal cavity  The blood vessels of the retina areThe blood vessels of the retina are extremely susceptible to damage fromextremely susceptible to damage from high O2 concentrationshigh O2 concentrations  The eyes openThe eyes open
  72. 72. End of 32 GestationEnd of 32 Gestation WeeksWeeks Length: 38Length: 38thth to 43 cmto 43 cm  Weight: 1600gWeight: 1600g  Subcutaneous fat begins to be depositedSubcutaneous fat begins to be deposited  Fetus is aware of sounds outside theFetus is aware of sounds outside the mother’s bodymother’s body  Active Moro reflex is presentActive Moro reflex is present  Birth position may be assumedBirth position may be assumed  Iron stores are beginning to beIron stores are beginning to be developeddeveloped  Fingernails grow to reach the end ofFingernails grow to reach the end of fingertipsfingertips
  73. 73. End of 36 GestationEnd of 36 Gestation WeeksWeeks  Length: 42 – 48 cmLength: 42 – 48 cm  Weight: 1800 – 2700 gWeight: 1800 – 2700 g  Body source of calcium glycogen, ironBody source of calcium glycogen, iron and carbohydrates are augmentedand carbohydrates are augmented  Additional amount of subcutaneous fatAdditional amount of subcutaneous fat are depositedare deposited  Amount of lanugo begins to diminishAmount of lanugo begins to diminish  Sole of the foot has only one or twoSole of the foot has only one or two crisscross creasescrisscross creases
  74. 74. End of 40 GestationEnd of 40 Gestation WeeksWeeks  Length: 48 – 52 cmLength: 48 – 52 cm  Weight: 3000 gWeight: 3000 g  Fetus kicks actively strong enough toFetus kicks actively strong enough to cause considerable discomfortcause considerable discomfort  Vernix caseosa is fully formedVernix caseosa is fully formed  Fingernails extend over the fingertipsFingernails extend over the fingertips  Creases on the sole of the feet coverCreases on the sole of the feet cover atleast 2/3 of the surfaceatleast 2/3 of the surface  Fetal Hgb begin its conversion to adultFetal Hgb begin its conversion to adult HgbHgb
  75. 75. Determination of EstimatedDetermination of Estimated Birth DateBirth Date  NAGELE’S RULENAGELE’S RULE  To calculate the date of birth by this ruleTo calculate the date of birth by this rule count backward 3 calendar months from thecount backward 3 calendar months from the first day of the last menstrual period and addfirst day of the last menstrual period and add 7 days.7 days.
  76. 76. Estimating Fetal GrowthEstimating Fetal Growth  McDONALD’S RULEMcDONALD’S RULE  Is a method of determining, during midIs a method of determining, during mid pregnancy that the fetus is growing inpregnancy that the fetus is growing in utero by measuring fundal (uterine)utero by measuring fundal (uterine) height.height.  The measurement is made from theThe measurement is made from the notch of symphysis pubis to over the topnotch of symphysis pubis to over the top of the uterine fundus as the woman liesof the uterine fundus as the woman lies supinesupine
  77. 77. PHYSIOLOGICALPHYSIOLOGICAL ADAPTATION OF THEADAPTATION OF THE MOTHER TO PREGNANCYMOTHER TO PREGNANCY
  78. 78. SYSTEMIC CHANGESSYSTEMIC CHANGES  CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM  Normal increase in blood volume by 30 – 50 % - forNormal increase in blood volume by 30 – 50 % - for an adequate exchange of nutrients in the placentaan adequate exchange of nutrients in the placenta and to provide adequate blood to compensate forand to provide adequate blood to compensate for blood loss at birthblood loss at birth  Increase in plasma volumeIncrease in plasma volume  Increase in cardiac workload: causes lassitude orIncrease in cardiac workload: causes lassitude or easy fatigueability and hypertrophy of the hearteasy fatigueability and hypertrophy of the heart  PalpitationsPalpitations  Epistaxis d/t hyperemia of mucous membraneEpistaxis d/t hyperemia of mucous membrane  Supine Hypotension SyndromeSupine Hypotension Syndrome  BP does not normally riseBP does not normally rise
  79. 79.  Because of poor circulation resultingBecause of poor circulation resulting from pressure of the gravid uterus on thefrom pressure of the gravid uterus on the blood vessels of the lower extremities;blood vessels of the lower extremities;  Edema of the LE occurs: Mgt: raise the legsEdema of the LE occurs: Mgt: raise the legs above hip levelabove hip level  Varicosities of the lower extremities can alsoVaricosities of the lower extremities can also occur. Management:occur. Management:  Wear support hose or elastic stockings toWear support hose or elastic stockings to promote venous flowpromote venous flow  Apply elastic bandageApply elastic bandage  Avoid use of constricting garter (knee highAvoid use of constricting garter (knee high stockings)stockings)
  80. 80.  Physiologic Anemia (Pseudo anemia ofPhysiologic Anemia (Pseudo anemia of pregnancy) Normal value: Hct (32-42%),pregnancy) Normal value: Hct (32-42%), Hgb (10.5-14 g/dl)Hgb (10.5-14 g/dl)  Criteria: 1Criteria: 1stst and 3and 3rdrd Trimester – HgbTrimester – Hgb >11g/dl, Hct > 33%, 2>11g/dl, Hct > 33%, 2ndnd Trimester – HgbTrimester – Hgb <10.5 g/dl / Hct < 32%<10.5 g/dl / Hct < 32%  Pathologic Anemia – Iron DeficiencyPathologic Anemia – Iron Deficiency Anemia – is the most commonAnemia – is the most common hematologic disorder. It affects roughlyhematologic disorder. It affects roughly 20 % of pregnant women20 % of pregnant women  Assessment: pallor, slowed capillary refill,Assessment: pallor, slowed capillary refill, concave finger nail, constipationconcave finger nail, constipation
  81. 81.  Nursing care:Nursing care:  Nutritional instructions: swamp cabbage,Nutritional instructions: swamp cabbage, kangkong, liver and red meatkangkong, liver and red meat  Parenteral Iron (Imferon): Z-tract techniqueParenteral Iron (Imferon): Z-tract technique  Oral iron supplements (ferrous sulfate 0.3 g,Oral iron supplements (ferrous sulfate 0.3 g, 3 times a day)3 times a day)  Monitor for hemorrhageMonitor for hemorrhage  Nursing alerts: iron is better absorbed whenNursing alerts: iron is better absorbed when taken with foods high in Vitamin C such astaken with foods high in Vitamin C such as orange juiceorange juice  Higher iron intake is recommended sinceHigher iron intake is recommended since circulating blood volume is increased andcirculating blood volume is increased and Heme is required from production of RBCsHeme is required from production of RBCs
  82. 82. GASTROINTESTINALGASTROINTESTINAL SYSTEMSYSTEM  At midpoint of pregnancy, the pressureAt midpoint of pregnancy, the pressure may be sufficient to slow intestinalmay be sufficient to slow intestinal peristalsis and the emptying time of theperistalsis and the emptying time of the stomach, leading to heartburn,stomach, leading to heartburn, constipation and flatulenceconstipation and flatulence  Morning sickness, nausea and vomitingMorning sickness, nausea and vomiting bein to be noticed at the time that levelsbein to be noticed at the time that levels of Hcg and progesterone begin to riseof Hcg and progesterone begin to rise
  83. 83.  Management for morning sickness – EatManagement for morning sickness – Eat dry toast or crackers 30 minutes beforedry toast or crackers 30 minutes before arising in the morning or dry high CHO,arising in the morning or dry high CHO, low fat or low spices in the diet.low fat or low spices in the diet.  Hyperemesis Gravidarum – excessiveHyperemesis Gravidarum – excessive nausea and vomiting which persistnausea and vomiting which persist beyond 3 months; results in dehydration,beyond 3 months; results in dehydration, starvation and acidosis.starvation and acidosis.  Management: D10 NSS 3000ml is theManagement: D10 NSS 3000ml is the priority treatment; complete bed rest ispriority treatment; complete bed rest is also importantalso important
  84. 84.  Decrease emptying of bile fromDecrease emptying of bile from Gallbladder due to gradual slowing ofGallbladder due to gradual slowing of gastrointestinal tractgastrointestinal tract  Reabsorption of bilirubin to maternalReabsorption of bilirubin to maternal bloodstream, giving rise to symptom ofbloodstream, giving rise to symptom of generalized itching (subclinical jaundice)generalized itching (subclinical jaundice)  Hypertrophy of gumlines and bleeding ofHypertrophy of gumlines and bleeding of gingival tissue when they brush theirgingival tissue when they brush their teethteeth  Hyperptyalism – increased salivaHyperptyalism – increased saliva formation as local response to increaseformation as local response to increase levels of estrogenlevels of estrogen
  85. 85.  Flatulence and constipation is common due toFlatulence and constipation is common due to increase progesterone and displacement ofincrease progesterone and displacement of stomach and intestines, thus slowing gastricstomach and intestines, thus slowing gastric emptying time.emptying time.  Hemorrhoids due to gravid uterusHemorrhoids due to gravid uterus  Heartburn due to pyrosis or reflux of stomachHeartburn due to pyrosis or reflux of stomach content to the esophaguscontent to the esophagus  Improve condition of peptic ulcer duringImprove condition of peptic ulcer during pregnancy because the acidity of the stomachpregnancy because the acidity of the stomach is decreaseis decrease  Relaxin may contribute to decreased gastricRelaxin may contribute to decreased gastric motilitymotility
  86. 86. RESPIRATORY SYSTEMRESPIRATORY SYSTEM  Shortness of breathShortness of breath  Diaphragm may be displaced by as much as 4Diaphragm may be displaced by as much as 4 cm upwardcm upward  Total oxygen consumption increases by asTotal oxygen consumption increases by as much as 20%much as 20%  The fetal CO2 level is higher than that in theThe fetal CO2 level is higher than that in the mother, allowing CO2 to cross readily from themother, allowing CO2 to cross readily from the fetus to the motherfetus to the mother  Mild hyperventilationMild hyperventilation  Congestion and stuffiness of the nasopharynx,Congestion and stuffiness of the nasopharynx, a response to increase estrogen levela response to increase estrogen level
  87. 87. URINARY SYSTEMURINARY SYSTEM  Urinary frequency, the only sign inUrinary frequency, the only sign in pregnancy seen during the 1pregnancy seen during the 1stst trimester,trimester, disappear during the 2disappear during the 2ndnd trimester andtrimester and reappears during the 3reappears during the 3rdrd trimestertrimester  Early in pregnancy is due to increasedEarly in pregnancy is due to increased blood supply to the kidneys and to theblood supply to the kidneys and to the uterus rising out of the pelvic cavity.uterus rising out of the pelvic cavity.  In the last trimester is due to pressure ofIn the last trimester is due to pressure of enlarged uterus on the bladder,enlarged uterus on the bladder, especially with lighteningespecially with lightening
  88. 88.  Decreased renal threshold for sugar dueDecreased renal threshold for sugar due to increased production ofto increased production of glucocorticoids which cause lactose andglucocorticoids which cause lactose and dextrose to spill into the urine; also andextrose to spill into the urine; also an effect of the increased progesteroneeffect of the increased progesterone
  89. 89. MUSCULOSKELETALMUSCULOSKELETAL CHANGESCHANGES  Because of the pregnant woman’s attempt toBecause of the pregnant woman’s attempt to change her center of gravity; she makeschange her center of gravity; she makes ambulation easier by standing more straightambulation easier by standing more straight and taller, resulting in aand taller, resulting in a lordotic positionlordotic position “pride of pregnancy”“pride of pregnancy”  Increased production of the hormoneIncreased production of the hormone RELAXIN, pelvic bones become more suppleRELAXIN, pelvic bones become more supple and movable, increasing the incidence ofand movable, increasing the incidence of accidental falls due to the wobbly gait.accidental falls due to the wobbly gait.  Advise use of low heeled shoes after the firstAdvise use of low heeled shoes after the first trimestertrimester
  90. 90.  Leg crampsLeg cramps  Causes:Causes:  Increased pressure of gravid uterus on lowerIncreased pressure of gravid uterus on lower extremitiesextremities  FatigueFatigue  ChillsChills  Muscle tensenessMuscle tenseness  Low calcium, high phosphorus intakeLow calcium, high phosphorus intake  Management: press knee of the affected legManagement: press knee of the affected leg and dorsiflex the footand dorsiflex the foot  Do not massage and wear warm, moreDo not massage and wear warm, more comfortable clothingcomfortable clothing
  91. 91. TEMPERATURETEMPERATURE  Slight increase in basal bodySlight increase in basal body temperature due to increasedtemperature due to increased progesterone, but the body adapts afterprogesterone, but the body adapts after the 4the 4thth monthmonth  As the placenta takes over the function ofAs the placenta takes over the function of the corpus luteum at about 16 weeks, thethe corpus luteum at about 16 weeks, the temperature generally decreases totemperature generally decreases to normalnormal
  92. 92. INTEGUMENTARYINTEGUMENTARY SYSTEMSYSTEM  Striae gravidarum – pink or reddishStriae gravidarum – pink or reddish streaks appearing on the sides of thestreaks appearing on the sides of the abdominal wall and sometimes on theabdominal wall and sometimes on the thigh.thigh.  In the weeks after birth, striaeIn the weeks after birth, striae gravidarum lighten to a silvery – whitegravidarum lighten to a silvery – white color (striae albicantes or atrophicae)color (striae albicantes or atrophicae) and although permanent, become barelyand although permanent, become barely noticeablenoticeable
  93. 93.  Diastasis - separation of the rectusDiastasis - separation of the rectus musclesmuscles  The umbilicus is stretched by pregnancyThe umbilicus is stretched by pregnancy to such an extent that by the 28to such an extent that by the 28thth week,week, its depression becomes obliterated andits depression becomes obliterated and smooth because it has been pushed sosmooth because it has been pushed so far outwardfar outward  Extra pigmentation, a brown line (lineaExtra pigmentation, a brown line (linea nigra) may be present, running from thenigra) may be present, running from the umbilicus to the symphysis pubis andumbilicus to the symphysis pubis and separating the abdomen into a right andseparating the abdomen into a right and left hemisphereleft hemisphere
  94. 94.  MELASMA (CHLOASMA) or the mask ofMELASMA (CHLOASMA) or the mask of pregnancy – darkened areas on the face,pregnancy – darkened areas on the face, cheeks and across the nosecheeks and across the nose  Palmar erythema (redness and itching)Palmar erythema (redness and itching)  Increase sweat gland activityIncrease sweat gland activity  Vascular spiders (small fiery red-Vascular spiders (small fiery red- branching spots)branching spots)
  95. 95. ENDOCRINE CHANGESENDOCRINE CHANGES  Addition of the placenta as an endocrineAddition of the placenta as an endocrine organ, producing large amounts of HCG,organ, producing large amounts of HCG, estrogen and progesteroneestrogen and progesterone  Moderate enlargement of the thyroidModerate enlargement of the thyroid gland due to hyperplasia of glandulargland due to hyperplasia of glandular tissues and increased vascularity.tissues and increased vascularity.  Increased size of the parathyroidIncreased size of the parathyroid probably to satisfy the increase need ofprobably to satisfy the increase need of the fetus for calciumthe fetus for calcium
  96. 96.  Increased size and activity of the adrenalIncreased size and activity of the adrenal cortex, thus increasing the amount ofcortex, thus increasing the amount of circulating cortisol, aldosterone and ADHcirculating cortisol, aldosterone and ADH all of which affect CHO and fatall of which affect CHO and fat metabolism, causing hyperglycemiametabolism, causing hyperglycemia  Gradual increase in insulin productionGradual increase in insulin production but the body’s sensitivity to insulin isbut the body’s sensitivity to insulin is decreased during pregnancydecreased during pregnancy
  97. 97. LOCAL CHANGESLOCAL CHANGES  UTERUSUTERUS  Weight increases to about 1000g at full termWeight increases to about 1000g at full term  Change in shape from pear-like to ovoidChange in shape from pear-like to ovoid  HEGAR sign – change in consistency ofHEGAR sign – change in consistency of lower uterine segment, seen at about 6lower uterine segment, seen at about 6thth weeksweeks  Operculum – mucus plug in the cervix, whichOperculum – mucus plug in the cervix, which is produce to seal out bacteriais produce to seal out bacteria  Goodles sign – cervix becomes moreGoodles sign – cervix becomes more vascular and edematous resembling thevascular and edematous resembling the consistency of an earlobeconsistency of an earlobe
  98. 98.  BALLOTMENT – 16BALLOTMENT – 16thth to 20to 20thth week ofweek of pregnancy (‘from the french wordpregnancy (‘from the french word balloter, meaning to toss about’)balloter, meaning to toss about’)  BRAXTON HICKS CONTRACTIONs -BRAXTON HICKS CONTRACTIONs - uterine contraction beginning early inuterine contraction beginning early in pregnancy, at least by 12 th week andpregnancy, at least by 12 th week and are present throughout the rest ofare present throughout the rest of pregnancy.pregnancy.  A waves of tightness or hardness acrossA waves of tightness or hardness across her abdomenher abdomen
  99. 99. AmenorrheaAmenorrhea  Absence of menstruation because of theAbsence of menstruation because of the suppression of follicle stimulatingsuppression of follicle stimulating hormonehormone  A presumptive sign of pregnancyA presumptive sign of pregnancy
  100. 100. CERVICAL CHANGESCERVICAL CHANGES  Cervix becomes more vascular andCervix becomes more vascular and edematous due to increasing level ofedematous due to increasing level of circulating estrogencirculating estrogen  Presence of tenacious coating of mucousPresence of tenacious coating of mucous plug which act to seal out bacteria duringplug which act to seal out bacteria during pregnancy and so help prevent infectionpregnancy and so help prevent infection in the fetus and membranesin the fetus and membranes (OPERCULUM)(OPERCULUM)
  101. 101.  GOODELL’S SIGN – softening of theGOODELL’S SIGN – softening of the pelvispelvis  the consistency of a nonpregnant cervixthe consistency of a nonpregnant cervix may be compared with that of the nose,may be compared with that of the nose, whereas the consistency of a pregnantwhereas the consistency of a pregnant cervix more closely resembles that of ancervix more closely resembles that of an earlobeearlobe  Just before labor, the cervix becomes soJust before labor, the cervix becomes so soft that it takes on the consistency ofsoft that it takes on the consistency of butter and is said to be ripe for birthbutter and is said to be ripe for birth
  102. 102. VAGINAL CHANGESVAGINAL CHANGES  Vaginal epithelium and underlying tissueVaginal epithelium and underlying tissue become hypertrophic and enriched withbecome hypertrophic and enriched with glycogenglycogen  CHADWICK’S SIGN – the resulting increase inCHADWICK’S SIGN – the resulting increase in circulation to the vagina changes the color ofcirculation to the vagina changes the color of the vaginal walls from the normal light pink to athe vaginal walls from the normal light pink to a deep violetdeep violet  Vaginal secretions during pregnancy fall from aVaginal secretions during pregnancy fall from a pH of over 7 (an alkaline pH0 to 4 or 5 (an acidpH of over 7 (an alkaline pH0 to 4 or 5 (an acid pH) due to Lactobacillus acidophilus bacteria.pH) due to Lactobacillus acidophilus bacteria.
  103. 103.  This changing acid content makes theThis changing acid content makes the vagina resistant to bacterial invasion forvagina resistant to bacterial invasion for the length of pregnancythe length of pregnancy  Unfortunately, favors the growth ofUnfortunately, favors the growth of Candida Albicans, a species of yeastlikeCandida Albicans, a species of yeastlike fungi.fungi.  Manifested by an ithching, burningManifested by an ithching, burning sensation in addition to a cream cheesesensation in addition to a cream cheese like discharge.like discharge.
  104. 104. OVARIAN CHANGESOVARIAN CHANGES  Ovulation stops with pregnancy.Ovulation stops with pregnancy. Progesterone and estrogen are beingProgesterone and estrogen are being produced by the placentaproduced by the placenta
  105. 105. ABDOMINAL WALLABDOMINAL WALL CHANGESCHANGES  STRIAE GRAVIDARUM – increase inSTRIAE GRAVIDARUM – increase in uterine size results in rupture anduterine size results in rupture and atrophy of connective tissue layers, seenatrophy of connective tissue layers, seen as pink or reddish streaksas pink or reddish streaks  Umbilicus is pushed outUmbilicus is pushed out
  106. 106. SKINSKIN  LINEA NIGRA – brown line running fromLINEA NIGRA – brown line running from umbilicus to symphysis pubisumbilicus to symphysis pubis  MELASMA OR CHLOASMA – extraMELASMA OR CHLOASMA – extra pigmentation on cheeks and across thepigmentation on cheeks and across the nose due to increased production ofnose due to increased production of melanocytes by the pituitary glandmelanocytes by the pituitary gland  Sweat glands unduly activatedSweat glands unduly activated
  107. 107. BREASTBREAST  All changes due to increase in estrogenAll changes due to increase in estrogen  Increase in size due to hyperplasia ofIncrease in size due to hyperplasia of mammary alveoli and fat deposits.mammary alveoli and fat deposits. Proper breast support with well fittingProper breast support with well fitting brassiere necessary to prevent saggingbrassiere necessary to prevent sagging  Feeling of fullness and tingling sensationFeeling of fullness and tingling sensation in the breastin the breast  Nipples more erectNipples more erect
  108. 108.  For mothers who intend to breast feed,For mothers who intend to breast feed, advise:advise:  Nipple rollingNipple rolling  Drying nipples with rough towel to helpDrying nipples with rough towel to help toughen the nipplestoughen the nipples  Not to use soap or alcohol as this canNot to use soap or alcohol as this can cause drying which could lead to sorecause drying which could lead to sore nipplesnipples  Montgomery glands become bigger andMontgomery glands become bigger and more protuberant. This keeps the nipplesmore protuberant. This keeps the nipples supple and prevent cracking and drying.supple and prevent cracking and drying.
  109. 109.  Areola becomes darker and diameterAreola becomes darker and diameter increasesincreases  Skin surrounding areola turns darkSkin surrounding areola turns dark  By the fourth montha, a thin, watery, highBy the fourth montha, a thin, watery, high protein fluid called colostrum, is formed.protein fluid called colostrum, is formed. It is the precursor of breastmilkIt is the precursor of breastmilk
  110. 110. SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS OF PREGNANCYOF PREGNANCY  PRESUMPTIVE – s/s felt and observePRESUMPTIVE – s/s felt and observe by the mother but does not confirmby the mother but does not confirm positive diagnosis of pregnancypositive diagnosis of pregnancy  PROBABLE – Signs observe by thePROBABLE – Signs observe by the members of health team but does notmembers of health team but does not confirm a positive diagnosis of pregnancyconfirm a positive diagnosis of pregnancy  POSITIVE SIGN – undeniable signsPOSITIVE SIGN – undeniable signs confirmed by the use of instrumentsconfirmed by the use of instruments
  111. 111. FIRSTFIRST TRIMESTERTRIMESTER  PRESUMPTIVE:PRESUMPTIVE:  B – reast changesB – reast changes  U – rinary frequencyU – rinary frequency  F – atigueF – atigue  A – menorrheaA – menorrhea  M – orning sicknessM – orning sickness  E – nlarge uterusE – nlarge uterus
  112. 112. PROBABLEPROBABLE  G – OODLES SIGNG – OODLES SIGN  C –HADWICK SIGNC –HADWICK SIGN  H – EGARSH – EGARS  E – LEVATED BODY TEMPERATUREE – LEVATED BODY TEMPERATURE  P – OSITIVE HCGP – OSITIVE HCG
  113. 113. POSITIVEPOSITIVE  ULTRASOUNDULTRASOUND
  114. 114. SECOND TRIMESTERSECOND TRIMESTER  PRESUMPTIVEPRESUMPTIVE  C – LOASMAC – LOASMA  L – INEA NIGRAL – INEA NIGRA  I – NCREASED SKIN PIGMENTATIONI – NCREASED SKIN PIGMENTATION  S – TRIAE GRAVIDARUMS – TRIAE GRAVIDARUM  Q - UICKENINGQ - UICKENING
  115. 115. PROBABLEPROBABLE  B – ALLOTMENTB – ALLOTMENT  E – NLARGE ABDOMENE – NLARGE ABDOMEN  B – RAXTON HICKS CONTRACTIONB – RAXTON HICKS CONTRACTION
  116. 116. POSITIVEPOSITIVE  F – ETAL HEART TONEF – ETAL HEART TONE  F – ETAL MOVEMENTF – ETAL MOVEMENT  F – ETAL OUTLINEF – ETAL OUTLINE  F – ETAL PARTS PALPABLEF – ETAL PARTS PALPABLE
  117. 117. PSYCHOLOGICALPSYCHOLOGICAL ADAPTATION TOADAPTATION TO PREGNANCYPREGNANCY  FIRST TRIMESTERFIRST TRIMESTER  NO TANGIBLE SIGN AND SYMPTOMSNO TANGIBLE SIGN AND SYMPTOMS  FEELING OF SURPRISEFEELING OF SURPRISE  MALADAPTATION: DENIAL OFMALADAPTATION: DENIAL OF PREGNANCYPREGNANCY  DEVELOPMENTAL TASK: TO ACCEPTDEVELOPMENTAL TASK: TO ACCEPT BIOLOGICAL FACTS OF PREGNANCYBIOLOGICAL FACTS OF PREGNANCY  FOCUS OF TEACHING: BODILYFOCUS OF TEACHING: BODILY CHANGES OF PREGNANCYCHANGES OF PREGNANCY
  118. 118. SECOND TRIMESTERSECOND TRIMESTER  TANGIBLE SIGN AND SYMPTOMS OFTANGIBLE SIGN AND SYMPTOMS OF PREGNANCYPREGNANCY  MOTHER IDENTIFIES fetus as aMOTHER IDENTIFIES fetus as a separate identityseparate identity  FantasyFantasy  Developmental task: accept the growingDevelopmental task: accept the growing fetus as a baby to be nurturedfetus as a baby to be nurtured  Focus of health teaching: Growth andFocus of health teaching: Growth and development of fetusdevelopment of fetus
  119. 119. THIRD TRIMESTERTHIRD TRIMESTER  Mother has personal identification with theMother has personal identification with the appearance of the babyappearance of the baby  Mother has fearsMother has fears  Let mother listen to FHT to ally fear of theLet mother listen to FHT to ally fear of the  Developmental task: prepare for birth andDevelopmental task: prepare for birth and parenting of the childparenting of the child  Focus of health teaching: ResponsibleFocus of health teaching: Responsible perenthood. Best time to prepare baby’sperenthood. Best time to prepare baby’s layette, lamaze classeslayette, lamaze classes
  120. 120. Emotional Response toEmotional Response to PregnancyPregnancy  Ambivalence – interwoven feelings ofAmbivalence – interwoven feelings of wanting and not wanting pregnancywanting and not wanting pregnancy  Grief – contributed by giving up orGrief – contributed by giving up or altering present roles to take on aaltering present roles to take on a mothering rolemothering role  Narcissism – self centeredness isNarcissism – self centeredness is generally an early reaction to pregnancygenerally an early reaction to pregnancy
  121. 121.  Introversion vs. Extroversion –Introversion vs. Extroversion – introversion or turning inward tointroversion or turning inward to concentrate on oneself and one’s body,concentrate on oneself and one’s body, is a common finding during pregnancyis a common finding during pregnancy  StressStress  Couvade syndrome – psychosomaticCouvade syndrome – psychosomatic reaction wherein father experiences whatreaction wherein father experiences what mother goes through. Men experiencesmother goes through. Men experiences physical symptoms such as nauseaphysical symptoms such as nausea vomiting and back ache.vomiting and back ache.
  122. 122.  Emotional Lability – mood changes dueEmotional Lability – mood changes due to Hormonal changes, particularly theto Hormonal changes, particularly the sustained increase in Estrogen andsustained increase in Estrogen and ProgesteroneProgesterone  Changes in sexual desire –Changes in sexual desire –  First tri there is a decrease in libido becauseFirst tri there is a decrease in libido because of the nausea, fatigue, and breastof the nausea, fatigue, and breast tendernesstenderness  During second trimester as blood flow to theDuring second trimester as blood flow to the pelvic area increases to supply the placenta,pelvic area increases to supply the placenta, libido and sexual enjoyment rise markedlylibido and sexual enjoyment rise markedly  Third trimester it may remain high orThird trimester it may remain high or decrease because of difficulty finding adecrease because of difficulty finding a comfortable position and increasingcomfortable position and increasing abdominal sign.abdominal sign.
  123. 123. The Pre-Natal VisitThe Pre-Natal Visit  Basic considerationsBasic considerations  Frequency of visit:Frequency of visit:  1 to 7 month: once a month1 to 7 month: once a month  8 to 9 months: Twice a month8 to 9 months: Twice a month  10 months: every week10 months: every week  The provision of prenat care is the primaryThe provision of prenat care is the primary factor in the improvement of maternal andfactor in the improvement of maternal and infant morbidity and mortality statistics.infant morbidity and mortality statistics.
  124. 124.  It should be remembered that patientsIt should be remembered that patients understanding of the modalities of care isunderstanding of the modalities of care is basic to cooperative actionbasic to cooperative action  The duration of a normal pregnancy isThe duration of a normal pregnancy is 266 – 280 days, or 38 – 42 weeks266 – 280 days, or 38 – 42 weeks (average is 40 weeks), or 9 calendar(average is 40 weeks), or 9 calendar months or 10 lunar months.months or 10 lunar months.  Any baby born before the 39Any baby born before the 39thth week ofweek of gestation is called pre-term and a babygestation is called pre-term and a baby born after the 42born after the 42ndnd week of gestation isweek of gestation is said to be post termsaid to be post term
  125. 125. DIAGNOSIS OFDIAGNOSIS OF PREGNANCYPREGNANCY  URINE EXAMINATION – HCG in theURINE EXAMINATION – HCG in the urine is the basis for pregnancy tests.urine is the basis for pregnancy tests.  Present from the 40Present from the 40thth day through theday through the 100100thth day reaching a peak level on the 60day reaching a peak level on the 60thth dayday  HCG therefore is most correct 6 weeksHCG therefore is most correct 6 weeks after the last menstrual periodafter the last menstrual period
  126. 126. Components of PrenatalComponents of Prenatal visitvisit  HISTORY TAKINGHISTORY TAKING  PERSONAL DATA – patients name, agePERSONAL DATA – patients name, age address, civil status, family history,address, civil status, family history, religion, occupation,educationalreligion, occupation,educational backgroundbackground  With whom does she lives? Are thereWith whom does she lives? Are there familial disease that could affectfamilial disease that could affect pregnancypregnancy
  127. 127. OBSTETRICALOBSTETRICAL ASSESSMENTASSESSMENT  GESTATIONGESTATION  Time until the estimated date of confinement orTime until the estimated date of confinement or estimated date of deliveryestimated date of delivery  About 280 daysAbout 280 days  Nagele’s rule for estimating the date ofNagele’s rule for estimating the date of confinement. This requires that the womanconfinement. This requires that the woman have a regular 28have a regular 28thth day menstrual cycleday menstrual cycle  Add 7 days to the 1Add 7 days to the 1stst menstrual period, subtractmenstrual period, subtract 3 months, and then add 1 year to the date3 months, and then add 1 year to the date
  128. 128. Gravidity and ParityGravidity and Parity  GravidityGravidity  GravidaGravida refers to a pregnant womanrefers to a pregnant woman  GravidityGravidity refers to the number of pregnancyrefers to the number of pregnancy  NulligravidaNulligravida is a woman who has neveris a woman who has never been pregnantbeen pregnant  PrimigravidaPrimigravida is a woman who is pregnant foris a woman who is pregnant for the first timethe first time  MultigravidaMultigravida is a woman in at least heris a woman in at least her second pregnancysecond pregnancy
  129. 129. PARITYPARITY  Is the number of births (not the number ofIs the number of births (not the number of fetuses, e.g., twins) past 20 weeks of gestation,fetuses, e.g., twins) past 20 weeks of gestation, whether the fetus was born alive or notwhether the fetus was born alive or not  NulliparaNullipara is a woman who has not had a birthis a woman who has not had a birth at more than 20 weeks of gestationat more than 20 weeks of gestation  PrimiparaPrimipara is a woman who has had one birthis a woman who has had one birth that occurs after the 20that occurs after the 20thth week of gestationweek of gestation  MultiparaMultipara is a woman who has had two oris a woman who has had two or more pregnancies resulting in viable offspringmore pregnancies resulting in viable offspring
  130. 130. Use of GTPALUse of GTPAL  G is gravidity, the number of pregnanciesG is gravidity, the number of pregnancies  T is term births, the number born atT is term births, the number born at births(40 weeks)births(40 weeks)  P is preterm births, the number bornP is preterm births, the number born before 40 weeks’ gestationbefore 40 weeks’ gestation  A is abortions/miscarriages, the numberA is abortions/miscarriages, the number of abortions and miscarriagesof abortions and miscarriages  L is live births, the number of live birthsL is live births, the number of live births or living childrenor living children
  131. 131.  Example: A woman is pregnant for the fourthExample: A woman is pregnant for the fourth time. She had one elective abortion in the firsttime. She had one elective abortion in the first trimester, a daughter who was born at 40trimester, a daughter who was born at 40 weeks gestation, and a son who was born atweeks gestation, and a son who was born at 36 weeks gestation.36 weeks gestation.  What is the GTPAL?What is the GTPAL?  Viability – the ability of the fetus to live outsideViability – the ability of the fetus to live outside the uterus at the earliest possible gestationalthe uterus at the earliest possible gestational age.age.  Age of viability: 20 – 24 weeks (5 – 6 months)Age of viability: 20 – 24 weeks (5 – 6 months)
  132. 132. BASELINE DATABASELINE DATA  Vital signVital sign  Rollover test – mother will be place onRollover test – mother will be place on sidelying position for 10 – 15 minutes,sidelying position for 10 – 15 minutes, until BP is stable. Then mother is place inuntil BP is stable. Then mother is place in supine, then take BP immediately,supine, then take BP immediately, systolic >30mmHg, Diastolic > 15mmHgsystolic >30mmHg, Diastolic > 15mmHg
  133. 133. Weight MonitoringWeight Monitoring  First Trimester: Normal Weight Gain 1.5First Trimester: Normal Weight Gain 1.5 – 3 lbs (1 lbs/month)– 3 lbs (1 lbs/month)  Second Trimester: Normal Weight GainSecond Trimester: Normal Weight Gain 10 – 12 lbs (4lbs/month)10 – 12 lbs (4lbs/month)  Third Trimester: Normal Weight Gain 10Third Trimester: Normal Weight Gain 10 – 12lbs (4lbs/month)– 12lbs (4lbs/month)
  134. 134. Important EstimatesImportant Estimates  Mc Donald’s Rule – to determine age ofMc Donald’s Rule – to determine age of gestationgestation  From symphysis pubis to fundusFrom symphysis pubis to fundus  Fundic height in cm multiply to 7/8 =Fundic height in cm multiply to 7/8 = AOGAOG  Bartholomew’s Rule – to determine ageBartholomew’s Rule – to determine age of gestationof gestation  Haases Rule – to determine length ofHaases Rule – to determine length of fetus in cm ( 1fetus in cm ( 1stst half of pregnancy: monthhalf of pregnancy: month times 2, 2times 2, 2ndnd half: month times 5)half: month times 5)
  135. 135. Physical ExaminationPhysical Examination  Danger signs of pregnancy:Danger signs of pregnancy:  C – hills and fever, cerebral disturbancesC – hills and fever, cerebral disturbances  A – bdominal pain: epigastric painA – bdominal pain: epigastric pain (impending convulsion)(impending convulsion)  B – oard like abdomen (Abruptio placenta)B – oard like abdomen (Abruptio placenta)  B – P elevatedB – P elevated  B – lurred visionB – lurred vision  S – welling, scotoma, sudden gush of fluidsS – welling, scotoma, sudden gush of fluids

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