PHYSICAL EXAMINATIONPHYSICAL EXAMINATION• I. VITAL SIGNSI. VITAL SIGNS

• A. Blood Pressure A. Blood Pressure • - The Bp is the most important vital sign that - The Bp is the most important vital sign that

should be monitored every clinic visit. There is should be monitored every clinic visit. There is usually no significant change in Bp during usually no significant change in Bp during gestation. However, expect a slight drop in the 2gestation. However, expect a slight drop in the 2ndnd trimester that returns to normal on the 3trimester that returns to normal on the 3rdrd trimester.trimester.

• B. Pulse RateB. Pulse Rate• Pulse rate increases by about 10 bts/min. due to Pulse rate increases by about 10 bts/min. due to

increased cardiac workload. increased cardiac workload.

• - Arrhythmias or palpitation are normal during - Arrhythmias or palpitation are normal during pregnancy as long as it is not accompanied by pregnancy as long as it is not accompanied by dizziness and syncope.dizziness and syncope.

• C. Respiratory RateC. Respiratory Rate• - Increases in depth, no significant change in - Increases in depth, no significant change in

rate.rate.• - Shortness of breath and dyspnea late in - Shortness of breath and dyspnea late in

pregnancy is common.pregnancy is common.

• D. TemperatureD. Temperature• - There is a slight elevation in temperature - There is a slight elevation in temperature

early in pregnancy due to the thermogenic effect early in pregnancy due to the thermogenic effect of progesterone. It drops to normal after 16 of progesterone. It drops to normal after 16 weeks.weeks.

• II. Physical AssessmentII. Physical Assessment

• A. Head and ScalpA. Head and Scalp• - Hair tends to grow faster during pregnancy. - Hair tends to grow faster during pregnancy.

Oily hair is also not uncommon. Excess hair Oily hair is also not uncommon. Excess hair dryness indicates poor nutrition.dryness indicates poor nutrition.

• B. EyesB. Eyes• - Pale conjunctiva indicates anemia. Edema - Pale conjunctiva indicates anemia. Edema

of the eyelids accompanied by visual of the eyelids accompanied by visual disturbances is sign of PIH.disturbances is sign of PIH.

• C. NoseC. Nose• - Normal nasal congestion occurs as a result - Normal nasal congestion occurs as a result

of estrogen stimulation.of estrogen stimulation.

• D. EarsD. Ears• - Nasal stiffness results in blockage of the - Nasal stiffness results in blockage of the

eustachian tube which may affect pregnant eustachian tube which may affect pregnant woman’s hearing.woman’s hearing.

• E. Mouth and TeethE. Mouth and Teeth• - It is normal to find swollen gums (epulis) due - It is normal to find swollen gums (epulis) due

to estrogen stimulation. Cracked corners of the to estrogen stimulation. Cracked corners of the mouth may be caused by vitamin deficiency mouth may be caused by vitamin deficiency which pregnant women are prone to develop. which pregnant women are prone to develop. Dental carries should be treated during Dental carries should be treated during pregnancy as they may become site of infection. pregnancy as they may become site of infection. Major dental operations such as tooth extraction Major dental operations such as tooth extraction should be postponed until the postpartum period.should be postponed until the postpartum period.

• F. NeckF. Neck• - Slight thyroid enlargement is brought about - Slight thyroid enlargement is brought about

by increased basal metabolic rate.by increased basal metabolic rate.

• G. BreastG. Breast• - Normal findings include enlargement of the - Normal findings include enlargement of the

breast with wider and darker areola, prominent breast with wider and darker areola, prominent veins. Breast masses, nodules, dimpling of the veins. Breast masses, nodules, dimpling of the skin and bloody nipple discharge are abnormal skin and bloody nipple discharge are abnormal findings and should be reported to the physician findings and should be reported to the physician right away. Colostrum, a thin watery fluid, can be right away. Colostrum, a thin watery fluid, can be expressed from the nipple.expressed from the nipple.

• H. SkinH. Skin• - Linea negra, mask pf pregnancy - Linea negra, mask pf pregnancy

(melasma/chloasma), spider nevi, palmar (melasma/chloasma), spider nevi, palmar erythema are common findings. Pallor, jaundice, erythema are common findings. Pallor, jaundice, rashes and skin lesions are abnormal findings.rashes and skin lesions are abnormal findings.

• I. BackI. Back• - Exaggerated lumbar curve late in pregnancy - Exaggerated lumbar curve late in pregnancy

occurs as a result of the shifting of the pregnant occurs as a result of the shifting of the pregnant woman’s center of gravity.woman’s center of gravity.

• J. RectumJ. Rectum• - Hemorrhoids may be present especially in - Hemorrhoids may be present especially in

the last months of pregnancy.the last months of pregnancy.

• K. ExtremitiesK. Extremities• - Ankle swelling is a normal finding in the 2- Ankle swelling is a normal finding in the 2ndnd

half of pregnancy. Leg edema especially in the half of pregnancy. Leg edema especially in the late afternoon is common to pregnant women. late afternoon is common to pregnant women. Waddling gait is due to relaxation of pelvic joint. Waddling gait is due to relaxation of pelvic joint. Edema of upper extremities, face and hands are Edema of upper extremities, face and hands are danger signs.danger signs.

• III. Abdominal Palpation: Leopold’s ManeuverIII. Abdominal Palpation: Leopold’s Maneuver

• - Abdominal palpation of pregnant women or - Abdominal palpation of pregnant women or Leopold’s Maneuver is preferably performed after Leopold’s Maneuver is preferably performed after 24 weeks gestation when fetal outline can 24 weeks gestation when fetal outline can already be palpated.already be palpated.

• Preparations for Leopold’s Maneuver:Preparations for Leopold’s Maneuver:

• 1. Cardinal Rule: Instruct woman to empty her 1. Cardinal Rule: Instruct woman to empty her bladder.bladder.

• 2. Place woman in a dorsal recumbent position to 2. Place woman in a dorsal recumbent position to relax abdominal muscles. Place a small pillow relax abdominal muscles. Place a small pillow under the head for comfort.under the head for comfort.

• 3. Drape properly to maintain privacy.3. Drape properly to maintain privacy.• 4. Explain procedure to gain patient’s 4. Explain procedure to gain patient’s

cooperation.cooperation.• 5. Warm hands first by rubbing them together 5. Warm hands first by rubbing them together

before placing them over the woman’s abdomen. before placing them over the woman’s abdomen. Cold hands may stimulate uterine contraction.Cold hands may stimulate uterine contraction.

• 6. Use palm for palpation not fingers.6. Use palm for palpation not fingers.

MANEUVERMANEUVER PROCEDUREPROCEDURE FINDINGSFINDINGS

I.I. Fundic GripFundic Grip

a.a. To determine fetal To determine fetal part lying in the part lying in the fundusfundus

b. To determine b. To determine presentationpresentation

Place both hands in the Place both hands in the upper quadrants of the upper quadrants of the patient’s abdomenpatient’s abdomen

Using both hands, feel for Using both hands, feel for the fetal part lying in the the fetal part lying in the fundus.fundus.

If the nurse-midwife feels If the nurse-midwife feels the head which is round, the head which is round, smooth with transverse smooth with transverse groove of the neck, the groove of the neck, the fetus is in breech fetus is in breech presentation.presentation.

If the nurse-midwife feels If the nurse-midwife feels the buttocks which is soft the buttocks which is soft and angular, it means the and angular, it means the fetus is in vertex fetus is in vertex presentation.presentation.

II.II. Umbilical GripUmbilical Grip

a.a. To identify location To identify location of fetal backof fetal back

b.b. To determine the To determine the positionposition

Place both hands in the Place both hands in the paraumbilical regions.paraumbilical regions.

One hand is used to One hand is used to steady the uterus on one steady the uterus on one side of the abdomen while side of the abdomen while the other hand on the the other hand on the other side. Moves from other side. Moves from top to the lower segment top to the lower segment of the uterus to feel for of the uterus to feel for the fetal back and small the fetal back and small fetal parts. Use gentle but fetal parts. Use gentle but deep pressure.deep pressure.

Small fetal parts feel Small fetal parts feel nodular with numerous nodular with numerous angular nodulations.angular nodulations.

Fetal back feels smooth, Fetal back feels smooth, hard, like resistant plane.hard, like resistant plane.

III.III. Pawlik’s GripPawlik’s Grip

a.a. To determine To determine engagement of engagement of presenting parts presenting parts and to estimate and to estimate fetal station.fetal station.

b.b. To determine To determine presentation.presentation.

The 3The 3rdrd maneuver is maneuver is suprapubic palpation with suprapubic palpation with a single dominant hand.a single dominant hand.

Using the thumb and Using the thumb and finger, grasp the lower finger, grasp the lower portion of the abdomen portion of the abdomen above symphisis pubis, above symphisis pubis, press in slightly and make press in slightly and make gentle movements from gentle movements from the side.the side.

The presenting part is The presenting part is engage if it is not engage if it is not movable.movable.

It is not yet engage if it is It is not yet engage if it is still movable.still movable.

IV.IV. Pelvic GripPelvic Grip

a.a. To determine To determine degree of flexion degree of flexion of fetal head.of fetal head.

b.b. To determine To determine attitude or habitusattitude or habitus

The 4The 4thth maneuver involves maneuver involves palpation of the lower palpation of the lower quadrants using both quadrants using both hands.hands.

Facing foot part of the Facing foot part of the woman, palpate fetal woman, palpate fetal head pressing downward head pressing downward about 2 inches above the about 2 inches above the inguinal ligament.inguinal ligament.

If descended deeply, only If descended deeply, only a small portion of the fetal a small portion of the fetal head will be palpated.head will be palpated.

If cephalic prominence or If cephalic prominence or brow of the baby is on the brow of the baby is on the same side of the small same side of the small fetal parts, the head is fetal parts, the head is flexed.flexed.

If cephalic prominence is If cephalic prominence is on the same side of the on the same side of the fetal back, the head is fetal back, the head is extended.extended.

• IV. Internal Examination or Vaginal ExaminationIV. Internal Examination or Vaginal Examination

• Purpose:Purpose:

• A. During the 1A. During the 1stst clinic visit, IE is used to confirm clinic visit, IE is used to confirm pregnancy and gestation.pregnancy and gestation.

• B. After 34 wks., IE is performed to assess B. After 34 wks., IE is performed to assess consistency of cervix, length and dilation, fetal consistency of cervix, length and dilation, fetal presenting part, bony architecture of the pelvis, presenting part, bony architecture of the pelvis, anomalies of the vagina and perinium, including anomalies of the vagina and perinium, including rectocele, cystocele and lesions.rectocele, cystocele and lesions.

• Preparation for IE:Preparation for IE:

• 1. Provide explanation1. Provide explanation• 2. Let woman empty her bladder2. Let woman empty her bladder• 3. Provide good lighting3. Provide good lighting• 4. Place woman in lithotomy position with 4. Place woman in lithotomy position with

buttocks extended slightly beyond examining buttocks extended slightly beyond examining table.table.

• 5. Drape properly.5. Drape properly.• 6. Let support person stay at the head of the bed.6. Let support person stay at the head of the bed.• 7. Instruct woman not to:7. Instruct woman not to:• - hold or squeeze your hand or that of her - hold or squeeze your hand or that of her

husbandhusband• - hold her breath- hold her breath

• - close eyes tightly- close eyes tightly• - clench fist- clench fist• - contract perineal muscles- contract perineal muscles• 8. Explain the procedure. It may be slightly 8. Explain the procedure. It may be slightly

uncomfortable.uncomfortable.• 9. After the procedure, provide tissue to wipe 9. After the procedure, provide tissue to wipe

perineum of lubricant.perineum of lubricant.

• V. Speculum Examination and Papanicolau SmearV. Speculum Examination and Papanicolau Smear

• The purpose of the speculum examination is to The purpose of the speculum examination is to examine the internal genital tract and to obtain examine the internal genital tract and to obtain specimen for cytological examination known as specimen for cytological examination known as Papanicolau Smear or Pap smear.Papanicolau Smear or Pap smear.

• Pap Smear Pap Smear • A pap smear test is done to screen for cancerous A pap smear test is done to screen for cancerous

and precancerous cells of the cervix.and precancerous cells of the cervix.

• Specimen Collected:Specimen Collected:• - Endocervix Specimen- Endocervix Specimen• - Ectocervical specimen – common site for - Ectocervical specimen – common site for

malignancymalignancy• - Vaginal pool specimen – specimen for posterior - Vaginal pool specimen – specimen for posterior

fornix.fornix.

• Findings:Findings:• - Class I – normal findings- Class I – normal findings• - Class II - Normal with atypical cells present. - Class II - Normal with atypical cells present.

Atypical cells are often caused by inflammatory Atypical cells are often caused by inflammatory conditions such as infection.conditions such as infection.

• - Class III - Suggestive of malignancy with - Class III - Suggestive of malignancy with benign and pssibly malignant cells.benign and pssibly malignant cells.

• - Class IV - Probably malignant, with signs of - Class IV - Probably malignant, with signs of malignancy present.malignancy present.

• - Class V - Definitely malignant cells are - Class V - Definitely malignant cells are present.present.

• VI. Blood TestsVI. Blood Tests

• A. Hematocrit (hct) and Hemoglobin (hb)A. Hematocrit (hct) and Hemoglobin (hb)• - done at initial clinic visit and repeated at 28-- done at initial clinic visit and repeated at 28-

32 wks. To detect anemia. During pregnancy 32 wks. To detect anemia. During pregnancy blood volume increases by 30-50%. Since plasma blood volume increases by 30-50%. Since plasma volume increases more than red cell volume, Hb volume increases more than red cell volume, Hb and Hct levels fall, resulting in pseudoanemia.and Hct levels fall, resulting in pseudoanemia.

• . Anemia during pregnancy is usually of iron-. Anemia during pregnancy is usually of iron-deficiency type. A folic acid deficiency state may deficiency type. A folic acid deficiency state may co-exist with iron deficiency.co-exist with iron deficiency.

• - Normal Hb is between 12 – 16 mg/dl.- Normal Hb is between 12 – 16 mg/dl.• - Normal hct is between 37 – 47%- Normal hct is between 37 – 47%

• - Mild Anemia is Hb less than 11 gm/dl (hct 27 - Mild Anemia is Hb less than 11 gm/dl (hct 27 – 33%)– 33%)

• - Severe Anemia is Hb less than 9 gm/dl. - Severe Anemia is Hb less than 9 gm/dl. (hctless than 27%)(hctless than 27%)

• B. Leukocyte CountB. Leukocyte Count• - done to screen and rule out leukemia and - done to screen and rule out leukemia and

possible infection. Nonpregnat value are 5,000 – possible infection. Nonpregnat value are 5,000 – 10,000 but may reach 16,000 in pregnancy10,000 but may reach 16,000 in pregnancy

• C. Differential smearC. Differential smear• - done primarily to identify the types of - done primarily to identify the types of

leukocytes, erythrocytes, abnormalities and leukocytes, erythrocytes, abnormalities and adequacy of platelets.adequacy of platelets.

• D. VDRLD. VDRL• - screen for maternal syphilis. Untreated - screen for maternal syphilis. Untreated

syphilis in the 2syphilis in the 2ndnd trimester can infect the fetus trimester can infect the fetus and result to congenital abnormalities. If woman and result to congenital abnormalities. If woman is (+) for an STD, recommend testing and is (+) for an STD, recommend testing and treatment of partner.treatment of partner.

• E. HIV screenE. HIV screen• - if the woman belongs to the high risk group, - if the woman belongs to the high risk group,

HIV screening may be done by enzyme linked HIV screening may be done by enzyme linked immunosorbent assay (ELISA) testing.immunosorbent assay (ELISA) testing.

• If the result is (+), the diagnosis is confirmed If the result is (+), the diagnosis is confirmed usually by Western blot test. Women with HIV usually by Western blot test. Women with HIV are treated with Zidovudine (AZT) during are treated with Zidovudine (AZT) during pregnancy to decrease the risk of the fetus pregnancy to decrease the risk of the fetus acquiring the infection. HIV screening is acquiring the infection. HIV screening is recommended to women:recommended to women:

• - who are IV users- who are IV users• - with multiple sexual partners- with multiple sexual partners• - with sexual partners (+) for HIV or who - with sexual partners (+) for HIV or who

belong to the high risk group (homosexual, IV belong to the high risk group (homosexual, IV drug users, hemophiliacs)drug users, hemophiliacs)

• - who received blood transfusion between - who received blood transfusion between 1977 to 1985 when HIV testing for blood products 1977 to 1985 when HIV testing for blood products is not yet routinely conducted.is not yet routinely conducted.

• F. Antibody screenF. Antibody screen• - conducted for the purpose of screening the - conducted for the purpose of screening the

pregnant woman’s serum for antibodies formed pregnant woman’s serum for antibodies formed from exposure to major or minor blood group from exposure to major or minor blood group antigens.antigens.

• G. Rubella antibody titerG. Rubella antibody titer• - determines a woman’s degree pf protection - determines a woman’s degree pf protection

against German measles. A test result of 1:8 or against German measles. A test result of 1:8 or less indicates that the mother is at risk or less indicates that the mother is at risk or susceptible of acquiring the infection during susceptible of acquiring the infection during pregnancy. Since Rubella vaccine cannot be pregnancy. Since Rubella vaccine cannot be given during pregnancy, the pregnant woman given during pregnancy, the pregnant woman must avoid exposure to the infection.must avoid exposure to the infection.

• H. DM Universal screeningH. DM Universal screening• - conducted to screen women who have high - conducted to screen women who have high

probability of developing gestational DM. A 50 gm probability of developing gestational DM. A 50 gm oral glucose tolerance test is conducted at 24 – 28 oral glucose tolerance test is conducted at 24 – 28 wks. gestation irregardless of the time of the day wks. gestation irregardless of the time of the day and meals taken, ideally for all pregnant women. and meals taken, ideally for all pregnant women. If test results shows a plasma value that is more If test results shows a plasma value that is more than 140 mg/dl after one hour, 100 gms three than 140 mg/dl after one hour, 100 gms three hours oral glucose tolerance test (OGTT) is hours oral glucose tolerance test (OGTT) is performed to confirm the result. The following performed to confirm the result. The following risk factors can be used to select patients for DM risk factors can be used to select patients for DM screening:screening:

• - age more than 25 yrs. Old- age more than 25 yrs. Old• - family history- family history• - glycosuria- glycosuria• - history of unexplained pregnancy losses- history of unexplained pregnancy losses• - Previous fetal or neonatal death- Previous fetal or neonatal death

• I. Maternal Serum AlphafetoproteinI. Maternal Serum Alphafetoprotein• involves drawing a small amount of blood from involves drawing a small amount of blood from

the mother to check for the level of alpha-the mother to check for the level of alpha-fetoprotein. - previous infants with congenital fetoprotein. - previous infants with congenital anomaliesanomalies

• - large infants more than 4,000 gms.- large infants more than 4,000 gms.• - polyhydramnois- polyhydramnois

• Alpha-fetoprotein is produced by the fetal liver Alpha-fetoprotein is produced by the fetal liver and is excreted through the placenta into the and is excreted through the placenta into the mother’s blood. This test is best conducted mother’s blood. This test is best conducted between 15 – 17 wks. A high amount could between 15 – 17 wks. A high amount could indicate that the baby has a neural tube defect indicate that the baby has a neural tube defect such as spina bifida (open spine) or anencephaly such as spina bifida (open spine) or anencephaly (absence of the brain). If the value is low, it could (absence of the brain). If the value is low, it could be indicative of Trisomy 21 or Down’s syndrome.be indicative of Trisomy 21 or Down’s syndrome.

• A genetic condition in which there is an extra A genetic condition in which there is an extra chromosomes #21 and carries many physical chromosomes #21 and carries many physical defects as well as varying degrees of mental defects as well as varying degrees of mental retardation. To confirm diagnosis, chromosomal retardation. To confirm diagnosis, chromosomal study of fetal cells taken by amniocentesis may be study of fetal cells taken by amniocentesis may be performed.performed.

• Caused of elevated AFTCaused of elevated AFT• - underestimated gestational age- underestimated gestational age• - open NTDs- open NTDs• - fetal nephrosis and cystic hygroma- fetal nephrosis and cystic hygroma• - GI obstruction, omphalocele, gastroschisis- GI obstruction, omphalocele, gastroschisis• - Prematurity, low birth weight, IUGR- Prematurity, low birth weight, IUGR• - abdominal pregnancy- abdominal pregnancy• - multiple fetuses- multiple fetuses• - fetal demise- fetal demise•

• Cause of low AFPCause of low AFP• - overestimated gestational age- overestimated gestational age• - missed abortions- missed abortions• - molar pregnacies- molar pregnacies• - chromosomal abnormalities (including Down - chromosomal abnormalities (including Down

syndrome)syndrome)

• VI. UrinalysisVI. Urinalysis

• 1. Collect urinary specimen by midstream or 1. Collect urinary specimen by midstream or clean catch technique.clean catch technique.

• 2. A complete urinalysis should be conducted on 2. A complete urinalysis should be conducted on the 1the 1stst clinic visit and repeated at 28 – 30 wks. clinic visit and repeated at 28 – 30 wks.

• - Benedict’s test – detect glycosuria- Benedict’s test – detect glycosuria• - Acetic Acid test – detect proteinuria.- Acetic Acid test – detect proteinuria.• 3. Microscopy3. Microscopy• - can identify bacteria, leukocytes, and - can identify bacteria, leukocytes, and

erythrocytes, which may indicate infection. Casts erythrocytes, which may indicate infection. Casts and/or RBC may indicate chronic pyelonephritis. and/or RBC may indicate chronic pyelonephritis. Asymptomatic bacteruria can lead to abortion Asymptomatic bacteruria can lead to abortion early in pregnancy and can cause premature labor early in pregnancy and can cause premature labor late in pregnancy.late in pregnancy.

• 4. Glucose4. Glucose• - Glycosuria may occur in pregnancy because - Glycosuria may occur in pregnancy because

of increased glomerular filtration rate. However, it of increased glomerular filtration rate. However, it may also indicates carbohydrate intolerance. If may also indicates carbohydrate intolerance. If urine isurine is

• Positive for glucose further testing is necessary to Positive for glucose further testing is necessary to confirm diagnosis.confirm diagnosis.

• 5. Protein5. Protein• - A value of 1+ is abnormal. The cause - A value of 1+ is abnormal. The cause

should be identified with further testing (UTI, PIH, should be identified with further testing (UTI, PIH, renal disease)renal disease)

• 6. Leukocyte6. Leukocyte• - is helpful in identifying patient with - is helpful in identifying patient with

significant leukocyturia. Current opinion is that significant leukocyturia. Current opinion is that the test strip could reduce screening costs by the test strip could reduce screening costs by replacing microscopy.replacing microscopy.

FETAL ASSESSMENTFETAL ASSESSMENT• I. Fetal Heart RateI. Fetal Heart Rate• - fetal heart rate can be 1- fetal heart rate can be 1stst heard between 16 heard between 16

– 19 wks. Gestation– 19 wks. Gestation• - FHT is audible at about 16 wks or 4 months - FHT is audible at about 16 wks or 4 months

in multiparas and 2o wks or 5 months in in multiparas and 2o wks or 5 months in primiparas.primiparas.

• - 80% of pregnant women, FHT is audible at - 80% of pregnant women, FHT is audible at 20 wks, 95% at 21 wks. And at 22 wks; FHT can 20 wks, 95% at 21 wks. And at 22 wks; FHT can be heard in all pregnant women.be heard in all pregnant women.

• - After it has been initially auscultated, it - After it has been initially auscultated, it should be auscultated every clinic visit primarily should be auscultated every clinic visit primarily to determine if the fetus is alive.to determine if the fetus is alive.

• II. AmniocentesisII. Amniocentesis

• - Amniocentesis is the removal of fluid from the - Amniocentesis is the removal of fluid from the amniotic cavity by needle puncture. An ultrasound amniotic cavity by needle puncture. An ultrasound is performed first to determine the safe site where is performed first to determine the safe site where the needle can be inserted.the needle can be inserted.

• - A long, 2o to 22 gauge spiral needle is - A long, 2o to 22 gauge spiral needle is inserted into the mother’s uterus and into the inserted into the mother’s uterus and into the amniotic sac to aspirate 5 to 20 ml. of amniotic amniotic sac to aspirate 5 to 20 ml. of amniotic fluid.fluid.

• - During the procedure, the fetus is - During the procedure, the fetus is continuously monitored by ultrasound to ensure continuously monitored by ultrasound to ensure the well-being.the well-being.

• - The mother may experience minor side - The mother may experience minor side effects, including cramping, leakage of fluid and effects, including cramping, leakage of fluid and minor irritation around the entry site. minor irritation around the entry site. Amniocentesis carries a slight risk of miscarriage, Amniocentesis carries a slight risk of miscarriage, ranging from 1 in 400 to 1 in 200. Other risk ranging from 1 in 400 to 1 in 200. Other risk include trauma to fetus or the placenta and include trauma to fetus or the placenta and bleeding into the maternal circulation.bleeding into the maternal circulation.

• A. Amniotic Fluid AnalysisA. Amniotic Fluid Analysis

1. Karyotyping and detection of fetal abnormalities 1. Karyotyping and detection of fetal abnormalities early in pregnancy.early in pregnancy.

2. To determine fetal lung maturity.2. To determine fetal lung maturity.

• A. L/S ratioA. L/S ratio• - L/S ratio result of 2:1 is generally accepted as a - L/S ratio result of 2:1 is generally accepted as a

sign of pulmonary maturity that would enable the sign of pulmonary maturity that would enable the fetus to survive extrauterine life.fetus to survive extrauterine life.

• B. Lung ProfileB. Lung Profile• - is the study of all surfactants not only the - is the study of all surfactants not only the

lecithin and sphingomyelin. These other surfactants lecithin and sphingomyelin. These other surfactants are equally important indicators of fetal lung are equally important indicators of fetal lung maturity.maturity.

• 3. Amniotic Fluid Bilirubin3. Amniotic Fluid Bilirubin• - is usually analyzed with a spectrophotometer - is usually analyzed with a spectrophotometer

that measures the optical density of the amniotic that measures the optical density of the amniotic fluid specimen against the characteristic absorption fluid specimen against the characteristic absorption peak at 450 mm.peak at 450 mm.

• To protect the amniotic fluid specimen, it is To protect the amniotic fluid specimen, it is important to use amber glass container or if these important to use amber glass container or if these are not available, nurse can cover a clear glass are not available, nurse can cover a clear glass container with occlusive tape.container with occlusive tape.

• A. Rh IncompatibilityA. Rh Incompatibility• - amniotic fluid can be assessed for bilirubin - amniotic fluid can be assessed for bilirubin

levels repeatedly in RH incompatibility during levels repeatedly in RH incompatibility during pregnancy to monitor the progression of the pregnancy to monitor the progression of the disease and the fetal condition.disease and the fetal condition.

• B. Fetal MaturityB. Fetal Maturity• - it is expected that during the 2- it is expected that during the 2ndnd half of half of

pregnancy the concentration of amniotic fluid pregnancy the concentration of amniotic fluid bilirubin decreases until it virtually disappears bilirubin decreases until it virtually disappears duringduring

• the last month of gestation.the last month of gestation.

• 4. For detection of certain infection.4. For detection of certain infection.

• Nsg. Care during amniocentesis:Nsg. Care during amniocentesis:

• 1. Assist client to empty her bladder before the 1. Assist client to empty her bladder before the procedureprocedure

• 2. Place in supine position and drape properly.2. Place in supine position and drape properly.• 3. Put rolled towel under right hip to tip body to 3. Put rolled towel under right hip to tip body to

the left and remove pressure of uterus on vena the left and remove pressure of uterus on vena cava.cava.

• 4. Instruct not to take a deep breath and hold it 4. Instruct not to take a deep breath and hold it while needle is being inserted as it will shift the while needle is being inserted as it will shift the uterus and needle may hit placenta or fetus.uterus and needle may hit placenta or fetus.

• 5. Inform client that it is not painful because 5. Inform client that it is not painful because anesthesia will be applied at the insertion site. anesthesia will be applied at the insertion site. She may experience pressure sensation during She may experience pressure sensation during the insertion of the needle.the insertion of the needle.

• 6. Monitor FHT before, during and in 30 min. 6. Monitor FHT before, during and in 30 min. after the test.after the test.

• 7. Administer Rh immunoglobulin if the patient is 7. Administer Rh immunoglobulin if the patient is Rh negative. If the father is also Rh negative, this Rh negative. If the father is also Rh negative, this may not be necessary.may not be necessary.

• 8. Instruct patient to observe for:8. Instruct patient to observe for:• - infection- infection• - uterine cramping- uterine cramping• - vaginal bleeding- vaginal bleeding

• III. Obstetric UltrasoundIII. Obstetric Ultrasound

• PurposePurpose• 1. Diagnosis and confirmation of early pregnancy1. Diagnosis and confirmation of early pregnancy• 2. Vaginal bleeding in early pregnancy2. Vaginal bleeding in early pregnancy• 3. Determination of gestational age and 3. Determination of gestational age and

assessment of fetal sizeassessment of fetal size• 4. Diagnosis of fetal malformation and other 4. Diagnosis of fetal malformation and other

chromosomal abnormalities.chromosomal abnormalities.• 5. Placental location5. Placental location• 6. Multiple pregnancies6. Multiple pregnancies• 7. Hydramnios and oligohydramnios7. Hydramnios and oligohydramnios• 8. Other areas8. Other areas

• - confirmation of intrauterine death- confirmation of intrauterine death• - confirmation of fetal presentation- confirmation of fetal presentation• - evaluation of fetal tone, movement and - evaluation of fetal tone, movement and

breathingbreathing• - detection of uterine and pelvic abnormalities - detection of uterine and pelvic abnormalities

during pregnancy such as fibromyomata and during pregnancy such as fibromyomata and ovarian cyst.ovarian cyst.

• IV. FetoscopyIV. Fetoscopy• procedure in which an endoscope is inserted procedure in which an endoscope is inserted

transabdominally into the amniotic cavity to transabdominally into the amniotic cavity to directly visualize the fetus. This procedure is directly visualize the fetus. This procedure is performed around 18 wks. gestation.performed around 18 wks. gestation.

• V. AmnioscopyV. Amnioscopy• - is direct visualization of amniotic fluid - is direct visualization of amniotic fluid

through the fetal membranes with cone-shaped through the fetal membranes with cone-shaped hollow, inserted through the cervixhollow, inserted through the cervix

• VI. RadiographyVI. Radiography• - confirm pregnancy with identification of fetal - confirm pregnancy with identification of fetal

skeletal parts at 16 wks. During the 2skeletal parts at 16 wks. During the 2ndnd half of half of pregnancy, multiple pregnancies can be pregnancy, multiple pregnancies can be diagnosed and in the 3diagnosed and in the 3rdrd trimester, anencephaly trimester, anencephaly and hydrocephaly can be seen.and hydrocephaly can be seen.

• VII. Nonstress Test (NST)VII. Nonstress Test (NST)

• - This test relies on Fetal heart rate reactivity. - This test relies on Fetal heart rate reactivity. A NST assesses fetal well-being based on the A NST assesses fetal well-being based on the relationship between the baby’s heart rate and relationship between the baby’s heart rate and the baby’s reactivity. The FHR pattern is the baby’s reactivity. The FHR pattern is assessed by external monitoring without any assessed by external monitoring without any stress or stimuli to the fetus. The baby’s heart stress or stimuli to the fetus. The baby’s heart rate should accelerate, by fifteen beats for at rate should accelerate, by fifteen beats for at least 15 seconds, twice in a twenty minute least 15 seconds, twice in a twenty minute period. This is called a reactive NST and is a period. This is called a reactive NST and is a good sign that the fetus is healthy. A reactive good sign that the fetus is healthy. A reactive NST indicates intrauterine survival for one weekNST indicates intrauterine survival for one week

• VIII. Contraction Stress Test or Oxytocin VIII. Contraction Stress Test or Oxytocin Challenge Test (CST)Challenge Test (CST)

• used to measure uteroplacental function or used to measure uteroplacental function or the feto-placental respiratory reserve by the feto-placental respiratory reserve by observing the response of fetal heart rate to observing the response of fetal heart rate to uterine contractions induced by oxytocin uterine contractions induced by oxytocin administration or nipple stimulation.administration or nipple stimulation.

HEALTH TEACHINGHEALTH TEACHING

• I. Schedule of VisitI. Schedule of Visit• - 1- 1stst visit to 32 weeks – every 4 weeks visit to 32 weeks – every 4 weeks• - 32 weeks to 36 weeks - every 2 weeks- 32 weeks to 36 weeks - every 2 weeks• - 36 weeks until delivery - every week- 36 weeks until delivery - every week

• II. ExerciseII. Exercise• the primary purpose of the exercise is to the primary purpose of the exercise is to

strengthen the muscles to be used for labor and strengthen the muscles to be used for labor and delivery.delivery.

• Contraindicated:Contraindicated:• - PIH- PIH• - PROM- PROM• - PTL- PTL• - incompetent cervix- incompetent cervix• - vaginal bleeding- vaginal bleeding• - IUGR- IUGR

ExerciseExercise BenefitBenefit

Pelvic RockingPelvic Rocking Relieve low backacheRelieve low backache

Strengthen the muscles of the Strengthen the muscles of the lower back.lower back.

- The woman must get on all - The woman must get on all fours by hollowing the back and fours by hollowing the back and then arching it upward to form a then arching it upward to form a mound. This may also be done mound. This may also be done by lying on her back standing up.by lying on her back standing up.

- Thrust back outward with - Thrust back outward with buttocks tucked under. Hold for a buttocks tucked under. Hold for a least 3 seconds and release. least 3 seconds and release. Repeat 5 times.Repeat 5 times.

Tailor SittingTailor Sitting Stretch and strengthen perineal Stretch and strengthen perineal muscles.muscles.

Improve circulation in the Improve circulation in the perineum.perineum.

- Sit flat on the floor with legs - Sit flat on the floor with legs outstretched; knees are gently outstretched; knees are gently pushed to the floor until the pushed to the floor until the perineal muscles begin to stretch.perineal muscles begin to stretch.

- Hold this position for - Hold this position for increased amounts of time each increased amounts of time each time performed.time performed.

Abdominal Muscle ContractionAbdominal Muscle Contraction Strengthen abdominal muscles in Strengthen abdominal muscles in preparation for labor pushing.preparation for labor pushing.

- Contract and relax the muscles - Contract and relax the muscles of the abdomenof the abdomen

- Repeat as often as desired and - Repeat as often as desired and gradually increase the time held.gradually increase the time held.

SquattingSquatting The exercise stretches the perineal The exercise stretches the perineal muscles and increase blood flow to muscles and increase blood flow to the perineum.the perineum.

- The woman must squat and keep - The woman must squat and keep her feet flat on the floor.her feet flat on the floor.

- should be done 15 minutes per - should be done 15 minutes per day.day.

Kegel ExerciseKegel Exercise Strengthen perineal musclesStrengthen perineal muscles

- The patient should alternate - The patient should alternate between tightening and relaxing the between tightening and relaxing the perineal muscles.perineal muscles.

- This can be done at any time and - This can be done at any time and should be repeated 75 to 100 should be repeated 75 to 100 times/day.times/day.

Calf StretchingCalf Stretching Relieve leg crampsRelieve leg cramps

Shoulder CirclingShoulder Circling Relieve upper backache and Relieve upper backache and numbness of arms and finger.numbness of arms and finger.

Modified knee chestModified knee chest Relieve hemorrhoids, vulvar Relieve hemorrhoids, vulvar varicosities and low backachevaricosities and low backache

Leg ElevationLeg Elevation Relieve swelling, fatigue, varicosities Relieve swelling, fatigue, varicosities of lower extremities.of lower extremities.

Leg RaisingLeg Raising Strengthen abdominal musclesStrengthen abdominal muscles

Incidence where reduced physical activity is recommended:

- PROM - CHF - Hemoglobinopathies - Marfan’s Syndrome - DM with multiple end-organ involvement

• - 2 previous pregnancies- 2 previous pregnancies• - incompetent cervix- incompetent cervix• - fetal loss secondary to uterine anomalies- fetal loss secondary to uterine anomalies• - PIH- PIH• - Multiple gestation- Multiple gestation• - IUGR- IUGR• - severe heart disease- severe heart disease• - preterm labor- preterm labor

• III. EmploymentIII. Employment• - pregnant women can continue working as - pregnant women can continue working as

long as their job does not involve lifting heavy long as their job does not involve lifting heavy object, standing and sitting for long periods of object, standing and sitting for long periods of time, excessive physical and emotional strain and time, excessive physical and emotional strain and expose to toxic substances.expose to toxic substances.

• IV. Dental CareIV. Dental Care• - The pregnant woman should have a dental - The pregnant woman should have a dental

check-up early in pregnancy to give plenty of check-up early in pregnancy to give plenty of time for repairs and treatment of infected teeth time for repairs and treatment of infected teeth and for instructions on proper dental care.and for instructions on proper dental care.

• - dental x-ray is allowed as long as the woman - dental x-ray is allowed as long as the woman wears lead apron over her abdomen to protect wears lead apron over her abdomen to protect the fetus from the damaging effects of radiation.the fetus from the damaging effects of radiation.

• V. Maternity clothesV. Maternity clothes• - Lightweight, non-constrictive and loose - Lightweight, non-constrictive and loose

fittingfitting• - absorbent and washable because of increase - absorbent and washable because of increase

perspirationperspiration• - Reasonably priced because they will only be - Reasonably priced because they will only be

used during pregnancy.used during pregnancy.

• - flat heeled shoes that provide good support - flat heeled shoes that provide good support are recommended during pregnancy because of are recommended during pregnancy because of the altered balance of the woman especially the altered balance of the woman especially when the abdomen has grown large enough.when the abdomen has grown large enough.

• VI. BathingVI. Bathing• - The woman perspires more heavily because - The woman perspires more heavily because

she needs to excrete the waste products of her she needs to excrete the waste products of her body and that of the fetus. Due to increased body and that of the fetus. Due to increased perspiration, the pregnant woman is encouraged perspiration, the pregnant woman is encouraged to have a daily bath to keep fresh and clean.to have a daily bath to keep fresh and clean.

• - Bathing is contraindicated when there is - Bathing is contraindicated when there is vaginal bleeding and after the membranes have vaginal bleeding and after the membranes have ruptured.ruptured.

• VII. Breast CareVII. Breast Care• - Well fitting and large size brassiere is - Well fitting and large size brassiere is

recommended for the increased breast mass and recommended for the increased breast mass and pendulous breast. Bras should provide adequate pendulous breast. Bras should provide adequate support, with wide straps and deep cups to support, with wide straps and deep cups to prevent loss of breast tone.prevent loss of breast tone.

• - If woman plans to breastfeed, nipple rolling - If woman plans to breastfeed, nipple rolling between thumb and forefinger and drying of between thumb and forefinger and drying of nipples with rough towel is encourage to toughen nipples with rough towel is encourage to toughen the nipple.the nipple.

• VIII. ImmunizationVIII. Immunization• - Immunization with vaccines containing live - Immunization with vaccines containing live

viruses is contraindicated during pregnancy viruses is contraindicated during pregnancy because of the danger of the virus crossing the because of the danger of the virus crossing the placenta and infecting the fetus.placenta and infecting the fetus.

• - The immunization recommended to all - The immunization recommended to all pregnant women in the Philippines is Tetanus pregnant women in the Philippines is Tetanus Toxoid vaccine given in the following schedule:Toxoid vaccine given in the following schedule:

• TT1 anytime during pregnancyTT1 anytime during pregnancy• TT2 1 month after TT1 (3 yrs. Protection)TT2 1 month after TT1 (3 yrs. Protection)• TT3 6 month after TT2 (5 yrs. Protection)TT3 6 month after TT2 (5 yrs. Protection)• TT4 1 year after TT3 ( give 10 yrs. Protection)TT4 1 year after TT3 ( give 10 yrs. Protection)• TT5 1 year after TT4 (gives lifetime protection)TT5 1 year after TT4 (gives lifetime protection)

• IX. TravelIX. Travel• - There are usually no travel restrictions during - There are usually no travel restrictions during

pregnancy but it is advised that pregnant women pregnancy but it is advised that pregnant women avoid long trips on the 3avoid long trips on the 3rdrd trimester. The best time trimester. The best time to travel is on the 2to travel is on the 2ndnd trimester because the woman trimester because the woman isis

• Most comfortable at this time and there is Most comfortable at this time and there is minimum danger of abortion and preterm labor.minimum danger of abortion and preterm labor.

• - When traveling:- When traveling:• - 15 to 20 mins. Rest period on long rides - 15 to 20 mins. Rest period on long rides

to move about and empty bladder.to move about and empty bladder.

• X. Sexual RelationX. Sexual Relation• - 1- 1stst tri – decrease sexual desire due to tri – decrease sexual desire due to

discomforts of pregnancydiscomforts of pregnancy• - 2- 2ndnd tri - increase sexual desire because tri - increase sexual desire because

woman has already adjusted to pregnancy and woman has already adjusted to pregnancy and this is the period when she is most comfortable.this is the period when she is most comfortable.

• - 3- 3rdrd tri - decrease sexual desire because of tri - decrease sexual desire because of the fear of hurting the fetus and the discomfort the fear of hurting the fetus and the discomfort caused by enlarged abdomen and deep penile caused by enlarged abdomen and deep penile penetration.penetration.

• XI. AlcoholXI. Alcohol• - refrain from drinking alcohol because it may - refrain from drinking alcohol because it may

cause fetal anomalies.cause fetal anomalies.• - Alcohol increases the risk of:- Alcohol increases the risk of:• - midtrimester abortion- midtrimester abortion• - mental retardation- mental retardation• - behavior and learning disorder- behavior and learning disorder• - Fetal alcohol syndrome (SGA)- Fetal alcohol syndrome (SGA)

• XII. SmokingXII. Smoking• - nicotine causes vasoconstriction resulting in - nicotine causes vasoconstriction resulting in

decreased blood flow to the placenta which in decreased blood flow to the placenta which in turn diminished oxygen supply to the fetus. Fetal turn diminished oxygen supply to the fetus. Fetal hypoxia leads to low birth weight.hypoxia leads to low birth weight.

• - Smoking increases the risk for:- Smoking increases the risk for:• - poor lung development- poor lung development• - asthma, and respiratory infection- asthma, and respiratory infection• - increased risk of SIDS- increased risk of SIDS• - physical growth deficiency- physical growth deficiency• - intellectual development deficiency- intellectual development deficiency• - behavioral problems- behavioral problems

• XIII. MedicationsXIII. Medications• - Classification of medication with regards to - Classification of medication with regards to

adverse fetal effects (FDA)adverse fetal effects (FDA)

• - Category A - safe for fetus in human - Category A - safe for fetus in human studies (Vitamins)studies (Vitamins)

• - Category B - adverse effect not - Category B - adverse effect not demonstrated in animal studies with no human demonstrated in animal studies with no human studies; or adverse effects shown in animal studies; or adverse effects shown in animal studies have not been reproduced in human studies have not been reproduced in human studies (penicillin).studies (penicillin).

• - Category C - no adequate animal or human - Category C - no adequate animal or human studies are available; or animal studies show studies are available; or animal studies show adverse fetal effects with no human data.adverse fetal effects with no human data.

• - Category D - Evidence of fetal risk but - Category D - Evidence of fetal risk but benefits believed to outweight the risk benefits believed to outweight the risk (carbamazepine)(carbamazepine)

• - Category X - drugs with proved fetal risks - Category X - drugs with proved fetal risks that outweight any benefits.that outweight any benefits.

• Pregnancy medications that show no adverse Pregnancy medications that show no adverse effect at the usual dose:effect at the usual dose:

• - antihistamines- antihistamines• - decongestants (pseudoepinephrine)- decongestants (pseudoepinephrine)• - some antibiotics ( penicillin, ampicillin, - some antibiotics ( penicillin, ampicillin,

cephalosporins, erythromycin )cephalosporins, erythromycin )• - non-quinine antimalarial- non-quinine antimalarial• - gen. anesthetics- gen. anesthetics• - acetaminophen- acetaminophen• - Tuberculostatics ( INH, PAS, and Rif-ampin)- Tuberculostatics ( INH, PAS, and Rif-ampin)• - Metronidalose ( avoid in first tri if possible)- Metronidalose ( avoid in first tri if possible)• - Steroids- Steroids• - Accidental use of clomiphene, - Accidental use of clomiphene,

bromocriptine, birth control pills, vaginal bromocriptine, birth control pills, vaginal spermicides)spermicides)

DRUGSDRUGS TERATOGENIC EFFECTSTERATOGENIC EFFECTS

Androgen, estrogen, progesteroneAndrogen, estrogen, progesterone Masculinization of female infantsMasculinization of female infants

ThalidomideThalidomide Phocomelia, cardiac and lung Phocomelia, cardiac and lung defectdefect

Anticonvulsant (Dilantin)Anticonvulsant (Dilantin) Cleftlip, palate, congenital heart Cleftlip, palate, congenital heart defectsdefects

LithiumLithium Congenital heart defectCongenital heart defect

TetracyclineTetracycline Yellow staining of teeth, inhibits Yellow staining of teeth, inhibits bone growthbone growth

Vit. KVit. K HyperbilirubinemiaHyperbilirubinemia

Salicylates (aspirin)Salicylates (aspirin) Neonatal bleeding, decreased Neonatal bleeding, decreased intrauterine growthintrauterine growth

Sodium BicarbonateSodium Bicarbonate Fetal metabolic alkalosisFetal metabolic alkalosis

StreptomycinStreptomycin Nerve DeafnessNerve Deafness

Vit. AVit. A Central venous system defectsCentral venous system defects

DANGER SIGNS OF DANGER SIGNS OF PREGNANCYPREGNANCY

• 1. Vaginal bleeding of any amount1. Vaginal bleeding of any amount• 2. Persistent vomiting2. Persistent vomiting• 3. Chills and fever3. Chills and fever• 4. Sudden escape of fluid from the vagina4. Sudden escape of fluid from the vagina• 5. Swelling of the face and finger5. Swelling of the face and finger• 6. Visual disturbance6. Visual disturbance• 7. Painful urination or dysuria7. Painful urination or dysuria• 8. Abdominal pain8. Abdominal pain• 9. Severe or continuous headache9. Severe or continuous headache

MINOR DISCOMFORTS OF MINOR DISCOMFORTS OF PREGNANCYPREGNANCY

• 1. Nausea and vomiting1. Nausea and vomiting

• Management:Management:• A. Eat dry toast or crackers before rising from bedA. Eat dry toast or crackers before rising from bed• B. Eat small frequent meals rather than 3 large B. Eat small frequent meals rather than 3 large

onesones

• 2. Frequent urination2. Frequent urination

• Management:Management:• A. Limit fluid intake before bedtimeA. Limit fluid intake before bedtime

• B. Kegel exercise to improve tone of muscles B. Kegel exercise to improve tone of muscles that controls urination.that controls urination.

• 3. Fatigue3. Fatigue

• Management:Management:• A. Take at least 8 hours of sleep at night and A. Take at least 8 hours of sleep at night and

frequent rest periods during the day.frequent rest periods during the day.• B. Avoid standing for long periods, work while B. Avoid standing for long periods, work while

seated as much as possibleseated as much as possible• C. Eat a well balanced diet to provide enough C. Eat a well balanced diet to provide enough

energyenergy

• 4. Breast tenderness and nipple irritation4. Breast tenderness and nipple irritation

• Management:Management:• A. Wash breast with water only, no soaps and A. Wash breast with water only, no soaps and

alcohol to prevent drying and irritationalcohol to prevent drying and irritation• B. Wear supportive maternity brassiereB. Wear supportive maternity brassiere

• 5. Leukorrhea5. Leukorrhea

• Management:Management:• A. Proper perineal hygiene, flush perineu with water A. Proper perineal hygiene, flush perineu with water

after each voiding, no douching is necessaryafter each voiding, no douching is necessary• B. Use sanitary pad for excessive vaginal dischargeB. Use sanitary pad for excessive vaginal discharge

• 6. Nasal stiffness6. Nasal stiffness

• Management:Management:• A. Avoid allergen and smoked filled roomA. Avoid allergen and smoked filled room• B. Normal saline nose drops (1/4 salt in 1 cup B. Normal saline nose drops (1/4 salt in 1 cup

water)water)• C. Breathe steam from pot of boiling waterC. Breathe steam from pot of boiling water

• 7. Heartburn or pyrosis7. Heartburn or pyrosis

• Management:Management:• A. Take small meals rather that three large onesA. Take small meals rather that three large ones• B. Bend at knees not at waist when picking B. Bend at knees not at waist when picking

objects from the floor, avoid lying flatobjects from the floor, avoid lying flat

• 8. Varicose Veins8. Varicose Veins

• Management:Management:• 1. Leg varicosities1. Leg varicosities• a. Periodic rest with elevation of the legs, lie a. Periodic rest with elevation of the legs, lie

with feet against the wallwith feet against the wall• b. Avoid prolonged sitting or standing, b. Avoid prolonged sitting or standing,

constricting garters, knee high socksconstricting garters, knee high socks• c. Wear support hosec. Wear support hose• d. Apply elastic bandage before getting up in d. Apply elastic bandage before getting up in

the morning starting at the distal ends but don’t the morning starting at the distal ends but don’t wrap toeswrap toes

• 2. Vulvar Varicosities2. Vulvar Varicosities• a. Rest with pillow under hipsa. Rest with pillow under hips• b. Modified knee chest positionb. Modified knee chest position

• 3. Anal Varicosities or Hemorrhoids3. Anal Varicosities or Hemorrhoids• a. Sim’s position several times a daya. Sim’s position several times a day• b. Avoid constipationb. Avoid constipation• c. Hot sitz bath 15 to 20 minutesc. Hot sitz bath 15 to 20 minutes• d. Avoid bearing downd. Avoid bearing down• e. Observe good bowel habite. Observe good bowel habit• f. Use a topically applied anesthetics, use f. Use a topically applied anesthetics, use

stool softeners and warm soaksstool softeners and warm soaks

• 9. Backache9. Backache• • Management:Management:• A. Pelvic rocking exercise to relieve low backacheA. Pelvic rocking exercise to relieve low backache• 2. Frequent rest and avoidance of fatigue2. Frequent rest and avoidance of fatigue

• 10. Leg cramps10. Leg cramps

• Management:Management:• A. For immediate relief, push toe upward while A. For immediate relief, push toe upward while

applying pressure on the knee to straighten the legapplying pressure on the knee to straighten the leg• B. One quart of milk a day to meet calcium needs B. One quart of milk a day to meet calcium needs

or oral calcium supplements as prescribed by or oral calcium supplements as prescribed by physician physician

• C. Exercise regularly but avoid pointing of toesC. Exercise regularly but avoid pointing of toes

• 11. Headache11. Headache• headache is normal during the 1headache is normal during the 1stst trimester. trimester.

Some cases lead to sinusitis or ocular strain Some cases lead to sinusitis or ocular strain caused by refractive errors. caused by refractive errors.

• 22ndnd tri – less headache because the pregnant tri – less headache because the pregnant woman is already adjustedwoman is already adjusted

• 33rdrd tri - especially if frontal and accompanied by tri - especially if frontal and accompanied by visual disturbances should be investigated as this visual disturbances should be investigated as this maybe caused by pregnancy induced maybe caused by pregnancy induced hypertension (PIH)hypertension (PIH)