MANIFESTATIONS OF PREGNANCY

 Presumptive
o More of a symptom rather than a sign
 Possible
 Positive

PRESUMPTIVE SIGNS

1. Amenorrhea
 Ten (10) day allowance if you have regular menstruation period
 Ten days after expected period (+) pregnancy due to increased HCG; but this is
not absolute

2. Breast Changes
 Tenderness and tingling sensation
 This is not absolute

3. Changes in Urination
 Urinary frequency
o Present in First and Third Trimester
o No Urgency
 Second Trimester
o This disappears
o Uterus starting to enlarge in First Trimester
o Uterus becomes abdominal organ in the second trimester
o This releases pressure on the bladder
 Third Trimester
o Uterus enlarges and presses again against the bladder in the Third
Trimester

4. Nausea and Vomiting

 Human Chorionic Gonadotropin
o Primigravida
 Mostly manifests this
 Peaks at FIRST TRIMESTER
o At two (2) to three (3) months of pregnancy
o At eight (8) to twelve (12) weeks of pregnancy
 Nursing Responsibility
o Provide:
 Dry unsalted crackers
 Ice chips
 Small, frequent feedings
 Six (6) times a day
 This is the best among all the options
  Split food into two halves and give meals after every two (2) hours
 Less fatty foods in diet
 Do not lie supine after eating
 Encourage ambulation

Important Concept!
 Progesterone decreases gastric emptying!

 If nausea and vomiting is severe

o Consider
o Hydration
o Vomiting
o Hypokalemia, presenting as generalized weakness
o Electrolyte Balance
 Therefore, client needs to be admitted

5. Fatigue
 Diaphragm does not descend upon inspiration

6. Skin Changes
 Brought about by hormonal changes - ESTROGEN
o Cloasma
 Mask of pregnancy
 Visible at the cheek
o Melasma
 Darkening of the neck
o Linea Negra
 From the symphysis pubis to the umbilicus
o Striae Gravidarum
 Silvery in color
 Due to distention of the collagen of the abdomen as the uterus
enlarges

PROBABLE SIGNS
 More of the signs

1. Abdominal Enlargement
 Symmetrical and globular
 High risk
 Less than eighteen (18) weeks
 See different Landmarks:
 If uterus is at the level of the symphysis pubis
o Age of Gestation = 12 weeks
 If uterus is midway between umbilicus and symphysis pubis
o Age of Gestation = 16 weeks
 If uterus is at the level of the umbilicus
 o Age of Gestation = 20 weeks
 Then, increase of one centimeter (1 cm) in FUNDIC HEIGHT = Additional Four
(4) weeks in Age of Gestation
o 1 cm above the umbilicus = 24 wks
o 2 cm above the umbilicus = 28 wks
o 3 cm above the umbilicus = 32 wks
o 4 cm above the umbilicus = 36 wks
 At the LEVEL OF THE XIPHOID PROCESS, Age of Gestation is 36 weeks
 If one centimeter (1cm) below the xiphoid process, Age of Gestation is 40 weeks
due to LIGHTENING (presenting part enters the true pelvis) or DESCENT

Important Concept!
 Lightening or Descent occurs
o In Primigravida
 Two weeks earlier
o In Multigravida
 Occurs during the time of labor

2. BALLOTTEMENT
 When you tap the uterus, there is a sensation that something
is sinking and floating
 Sinking and floating of fetus in the uterus
 Appreciated at sixteen (16) to twenty-four (24) weeks only
 After twenty-four weeks (> 24 weeks), NO BALLOTEMENT
OCCURS
 This is because the size of the baby is greater in respect to the amniotic fluid

3. BRAXTON HICKS
 False labor
 Palpable uterine contraction
 Starts at approximately twenty-eight (28) weeks and above
  This is okay unless it does not give progressive cervical dilatation

4. CHADWICK’S SIGN
 Bluish-purple coloration of the vagina due to increase in vagina’s vascularity
 Vagina becomes swollen due to estrogen and progesterone
 Increase in acidity of vaginal pH due to lactobacillus acidophilus
 Lactobacillus acidophilus protects the vagina from ascending infection but favors
increased growth of candidiasis
 Candidiasis
o This problem increases in pregnancy

5. GOODEL’S SIGN
 Softening of the cervix to ready cervix for dilatation and effacement
 Increased vascularity (red and bluish cervix)
 Hyperplasia and hypertrophy of cervical glands (uterus hypertrophy only)
 Increased cervical glands
 Increased cervical secretions
 Leukorrhea or white secretions
 Cervical secretions coagulation or clumping resulting into MUCOUS PLUG or
OPERCULUM
 Operculum
o Protects the baby and the placenta from ascending infection

6. HEGAR’S SIGN
 Softening of the lower uterine segment

7. POSITIVE PREGNANCY TEST

 HCG levels determine this
 Ten (10) days after missed period, this can be detected
 Peak of level of HCG is ten (10) weeks Age of Gestation or 2½ months
 Then it goes down
 Therefore, yield of positivity of pregnancy tests to go down after ten (10) weeks
POSITIVE MANIFESTATIONS

1. FETAL HEART TONE

 1.1) Ultrasound
o Cardiac pulsation as early as six (6) to eight (8) weeks

 1.2) Doppler
o Fetal heart tone at ten (10) to twelve (12) weeks
 1.3) Fetoscope / Stethoscope
o Fetal heart tone at eighteen (18) to twenty (20) weeks
 1.4) External Electronic Fetal Monitor
o Fetal heart tone at twenty-four (24) weeks Age of Gestation

2. QUICKENING
 Quickening felt by the examiner is a positive sign of pregnancy
 Quickening felt by the mother is a presumptive sign
 In Primigravida
o This occurs later than twenty (20) weeks
 In Multigravida
o This occurs earlier than sixteen (16) weeks

3. X-RAY / FETAL SKELETON APPRECIATED

 X-ray on pregnant mother is okay as long as there is ABDOMINAL SHIELD
 This is done on the SECOND (2 nd) or THIRD (3rd) TRIMESTER but NEVER
DURING THE FIRST (1st) TRIMESTER

4. PULSATION OF HEART OF BABY THROUGH ULTRASOUND

LABOR

STAGE 1
TRUE UTERINE CONTRACTION TO FULL CERVICAL DILATATION (10 cm)

For Primigravida (in normal circumstances)

 First Stage lasts for eight (8) to twelve (12) hours
For Multigravida (in normal circumstances)
 First Stage lasts for six (6) to eight (8) hours
In Precipitate Labor
 Entire labor is through within three (3) hours
PHASE 1
LATENT PHASE OF FIRST STAGE OF LABOR
 Cervical Dilatation
o Zero centimeters (0 cm) to three (3 cm)
 Uterine Contraction
o Duration
 Twenty (20) to Forty (40) seconds
o Interval
 Five (5) to ten (10) minutes
o Intensity
 Mild Intensity

PHASE 2
ACTIVE PHASE OF FIRST STAGE OF LABOR
 Cervical Dilatation
o Four centimeters (4 cm) to Seven (7 cm)
 Uterine Contraction
o Duration
 Thirty (30) to Fifty (50) seconds
o Interval
 Two (2) to Five (5) minutes
o Intensity
 Moderate Intensity
PHASE 3
TRANSITIONAL PHASE OF FIRST STAGE OF LABOR
 Cervical Dilatation
o Eight centimeters (8 cm) to ten (10 cm)
 Uterine Contraction
o Duration
 Up to sixty (60) seconds
o Interval
 Two (2) to three (3) minutes
o Intensity
 Strong Intensity

GENERAL NURSING MANAGEMENT IN THE FIRST STAGE OF LABOR

Internal Examination identified
Therefore, 1st Stage

1. Establish rapport with client

 Gain trust
 Decrease anxiety to decrease pain perception
2. Establish baseline information
Assess the following:
 Gravidity
o (if 5 or 6, risk for uterine atony)
 Parity

 Age
o (if > 35, high risk)
 Contraction
o When did it start?
o Time of uterine contraction
o How frequent is the contraction?
 Membranes
o Is there watery vaginal discharge?
o If the client identifies that there is watery discharge
 Color of Amniotic Fluid
o Water-like, clear with some white specks
o Cheesy – vernix
 If greenish
o Meconium
 Hypoxia is effect
o Meconium aspiration syndrome
o Plugs airway leading to hypoxia
o Also leads to secondary infection
o Meconium is produced in GUT at ten (10) weeks AOG
o It is passed out if the fetus is out of the uterus (extrautero) or if there is
ASPHYXIA or DISTRESS

3. Previous MEDICAL HISTORY OBSTETRIC COMPLICATION

4. TIME OF LAST MEAL / DRINK

 For Caesarian Section
o It should be NPO
 For aspiration if CS or NSD
o It limits use of anesthesia if patient had a meal
 Normal Spontaneous Delivery (NSD)
o Normal anesthesia:
 General Anesthesia via I.V. or sedation (not given with a full
stomach)
o If client had a meal and has a full stomach, client will gag and aspirate
o Therefore, use REGIONAL or LOCAL ANESTHESIA
 Medications:
o Alcoholic mothers
 Sedation takes a longer time to take effect
5. ESTABLISH MATERNAL VITAL SIGNS

First Stage - LATENT PHASE

 The following are taken every FOUR (4) HOURS:
o Temperature
o Respiratory Rate
o Pulse Rate
 This is taken EVERY HOUR:
o Blood Pressure

First Stage - ACTIVE PHASE

 The following are taken EVERY HOUR:
o Temperature (if ROM has occurred, this is done to check for infection)
o Respiratory Rate
o Pulse Rate
 Blood Pressure
o This is taken EVERY THIRTY (30) MINUTES

First Stage - TRANSITIONAL PHASE (UP UNTIL BIRTH OF BABY OCCURS)

 The following are taken EVERY HOUR:
o Temperature
o Respiratory Rate
o Pulse Rate
 Blood Pressure
o This is taken EVERY FIFTEEN (15) MINUTES

Important Concept!
 Do not take blood pressure if there is contraction
 There is false high blood pressure if there is contraction due to pain
 Remember, PAIN INCREASED BLOOD PRESSURE

6. CHECK FETAL HEART TONE

 First Stage – LATENT PHASE
o Taken EVERY HOUR
 First Stage – ACTIVE PHASE
o Taken EVERY AFTER EACH UTERINE CONTRACTION (UP UNTIL
BIRTH OF BABY TAKES PLACE)

7. ASSESS FOR CERVICAL DILATATION AND EFFACEMENT BEFORE INTERNAL

EXAMINATION
 Take Fetal Heart Tone first before doing the speculum examination

SECOND STAGE OF LABOR

FROM FULL CERVICAL DILATATION UP TO DELIVERY OF THE FETUS

 In Primigravida
o One (1) to four (4) hours long
 In Multigravida
o Twenty (20) to forty-five (45) minutes only

THIRD STAGE OF LABOR

DELIVERY OF BABY TO DELIVERY OF PLACENTA

 Lasts for five (5) to ten (10) minutes

 Maximum waiting time is thirty (30) minutes
 Beyond thirty (30) minutes is ALREADY ABNORMAL

SIGNS OF PLACENTAL EXPULSION

 1. Calkins’s Sign
o Uterus becomes firm and globular
 2. Lengthening of the Cord
 3. Sudden Gush of Blood
 4. Rising of the Uterus into the Abdomen
o Up to the level of the umbilicus or one centimeter (1 cm) after umbilicus
after the delivery of the placenta

FOURTH STAGE OF LABOR

FIRST ONE (1) TO TWO (2) HOURS AFTER DELIVERY OF THE PLACENTA

 Crucial Problem or Main Problem at this stage

o BLEEDING
 All the retained water retained previously will be reabsorbed into the circulation
o Increase in Cardiac Output
o Increase in Oxygen Consumption