PHYSIOLOGIC CHANGES IN  Hypertrophic and enriched with glycogen

PREGNANCY  Loosen connective tissues in preparation

for distention at birth

 Leukorrhea – increased white vaginal

discharge
1. UTERUS
 pH – from 7 to 4 or 5 
Increase growth  Manifestations – itching, burning,
creamcheese like discharge
 Length – 6.5 to 32 cm  Management - Nystatin
 Depth – 2.5 to 22 cm

 Width – 4 to 24 cm 4. OVARY
 Weight – 50 to 1000g  Ovulation stops (estrogen &
progesterone)
 Formation of uterine muscles fibers
 Amenorrhea
 Stretching of existing muscle fibers

 Growth – steady, constant

5. BREAST
and predictable
 Increased breast stimulation due to estrogen
-12th week- above symphysis pubis
 Fullness, tingling, or tenderness
-16th week- midway between umbilicus and symphysis  Hyperplasia of mammary alveoli and fat
pubis deposits
 Breast size increases
-20-22nd week – level of umbilicus
 Areola – darkens; increases in diameter (2-3
-36th week – xiphoid process inches)
 Blue veins become prominent over the surface
 Colostrum – expelled by 16th week
2. CERVIX

 Cervix becomes vascular and edematous 5. INTEGUMENTARY SYSTEM

(estrogen)
 Increased fluids between cells leads to  Activation of melanocyte -
Goodell’s sign stimulating hormone by the pituitary
 Increased vascularity gland
 Increased mucus production- this prevents  Striae gravidarum – pink or
infection in fetus and membrane reddish streaks on abdominal wall
 Linea nigra – narrow brown line
running from umbilicus to the
symphysis pubis

3. VAGINA
  Melasma /Chloasma – “mask Pressure of the uterus:
of pregnancy”; darkened areas on the
cheeks and across the nose  Slow peristalsis
 Vascular spiders at thighs (estrogen) - small,  Heartburn
fiery-red branching spots  Constipation
 Palmar erythema – redness and itchiness  Flatulence
(estrogen)  Hemorrhoids
 Increased perspiration by the -There is weight gain
increased activity of sweat glands
 Increased scalp hair growth

11. URINARY SYSTEM

7. RESPIRATORY SYSTEM  Compression of the bladder and ureters

 Increased total body water
 Congestion or stuffiness of nasopharynx
 Increased urine output 60 to 80%
 Shortness of breath – late pregnancy due
 Frequency of urination
to displacement of the lungs by 4 cm
 Diameter of ureter increased by 25%
upward
 Mild hyperventilation – progesterone
decreased levels of PCO2 at 27-32mmHg
12. SKELETAL SYSTEM

 Walks with difficulty

8. TEMPERATURE  Lordosis (“pride of pregnancy”)
-to change center of gravity
 Increases slightly due to progesterone (CL)
-makes ambulation easier
then decreases back to normal after 16 weeks
-may also lead to backache

9. CARDIOVASCULAR SYSTEM

 Blood volume is increases

13. ENDOCRINE SYSTEM
 Plasma volume : 3,600ml
 Pseudo anemia  Human growth hormone increases
 Decreased Iron  Pituitary gland
 Anemia – hgb is is less than  Increased growth hormone
11.5g/100ml; hct is less than 30%  Prolactin late in pregnancy
 Increased need for folic acid  Enlargement of thyroid gland
 Blood pressure:  Thyroid hormone production increases
1st trimester – no change
2nd trimester – slight decrease
3rd trimester – return to pre-pregnancy level 14. IMMUNE SYSTEM
 Supine hypotension syndrome
 Decreased immunologic competency
 Increase your risk of having certain
10. GASTROINTESTINAL SYSTEM
infections
 No to live vaccines to increase immunity

AGE OF GESTATION AND

EXPECTED DATE OF
CONFIRMENT (EDC)

IMPORTANCE OF DETERMINATION OF
GESTATIONAL AGE

 Gestational age is a common term used during

pregnancy to describe how far along the
pregnancy is. It is measured in weeks, from
the first day of the woman’s last menstrual
cycle to the current date. A normal pregnancy
can range from 38 to 42 weeks.
 Accurate determination of the Expected Due
Date (EDD) is one of the most important
factors in early pregnancy assessment.
  It is vital for the timing of appropriate
antenatal care, scheduling and interpretation
of tests, determining appropriate fetal growth,
and intervention purposes.

GESTATIONAL AGE CAN BE DETERMINED

BY:

 Clinical history
 Physical examination
 Ultrasound scan

LAST MENSTRUAL PERIOD

 It estimates a woman due date and gestational

age based on the woman’s last menstrual
period (LMP).
 It bases its calculation that the woman has a
28 days menstrual cycle and that the whole
gestational period will be 280 days (40
weeks).

ESTIMATED DUE DATE (EDD)

 is the date that spontaneous onset of labor is

expected to occur. The due date may be
estimated by adding 280 days (9 months and 7
days) to the first day of the last menstrual
period (LMP). This is the method used by
"pregnancy wheels".

HOW TO COMPUTE AGE OF GESTATION

(AOG)?

HOW TO COMPUTE EDD?

  Computation of EDC/EDD

 LMP ( Naegle’s Rule)

 Formula:

         Jan- March = +9   +7

         April – Dec = -3 +7 +1

LEOPOLD’S MANEUVER

WHAT IS LEOPOLD'S MANEUVER?

-are a common and systematic ways to determine the

position of a fetus inside the woman's uterus through
observation and palpation to determine fetal
presentations and positions.

Purposes:

These maneuvers help identify the ff:

• Number of fetuses

• Presenting part, fetal lie and fetal attitude

• Degree of the presenting part’s descent into

the pelvis

TAKE NOTE:
  Maneuvers are the primary assessment in
determining whether the fetal lie is correctly
ascertained but the maneuvers are not truly
diagnostic.
 Actual position can only be determined by
ultrasound performed by a competent
technician or professional.

1ST MANEUVER OR FUNDAL GRIP

THINGS TO REMEMBER BEFORE DOING  Upper pole
THE PROCEDURE:  This maneuver determines whether
1. Patient should empty her bladder fetal head or breech is in the
fundus
2. Examiner’s hand should be warm  To determine what part of the baby lies in the
upper part of the uterus.
3. Explain the procedure to the patient
 Palpating, with both hands, the
4. Provide privacy
uterine fundus to determine
5. Position patient in dorsal recumbent. PRESENTATION ("the presenting part"):
that portion of the fetus in closest proximity
6. Gentle yet firm touch to the birth canal (cephalic, breech, shoulder
presentations)

3 Questions to be asked:
There are 4 distinct Leopold Maneuvers.
1. Relative consistency- the head is harder than
the breech.

2. Shape- head is firm, round, and

hard. Breech is softer and feels more
angular.

3. Mobility- head will move independently of

the trunk but the breech only with the trunk.

Nurse Alert:

-If it is hard, round and movable, it is likely the head

(indicating a breech presentation) and if it is softer,
more triangular and not movable, it is probably the
buttock (indicating a cephalic presentation)

2ND MANEUVER OR UMBILICAL GRIP

 Sides of maternal abdomen

 To determine in which side of the uterus of
the baby’s back is located.
  Palpating, with both hands simultaneously,  Should only be done if fetus is in cephalic
the sides of the uterus to locate the fetal back presentation
and determine  To determine the degree of flexion of fetal
 POSITION: the relationship of a given head.
landmark on the fetus to the mother's right
and left. Nurse Caution:
-Cephalic landmarks: occiput (vertex);  Leopold's maneuvers are intended to be
sinciput (brow); mentum (face). performed by health care professionals, as
-Breech landmark: sacrum they have received training and instruction in
-Shoulder landmark: acromion process of the how to perform them.
scapula  It is important to note that all findings are not
 LIE: the relationship of the long axis of the truly diagnostic, and as such ultrasound is
baby to the long axis of the mother, i.e., required to conclusively determine fetal lie.
longitudinal, transverse, and oblique.

Nurse Alert: If you feel a smooth, curved resistant

plane in one side, you have located the back. If you
feel smaller lumps, irregular parts, those are the
knees and elbows of the fetus.

3RD MANEUVER OR PAWLIK'S GRIP

 Lower pole
 This maneuver determines the part of the fetus
at the inlet and its mobility.
 To determine what occupies
the lower uterine
 segment and to determine whether it is
engaged or not.
 ENGAGEMENT: when
the biparietal diameter of the fetal head
reaches or passes the plane of the pelvic inlet.

Nurse Alert: The examiner stands to the mother's

side and faces the mother's feet, then grasps the
lower abdomen just above the symphysis pubis,
between the thumb and fingers of the hand as
Pawlik’s grip. If the presenting part is not engaged, it
will be movable.

4TH MANEUVER OR PELVIC GRIP

 Presenting part evaluation

Parity  The number of pregnancy
that have reached the age
of viability, regardless
whether the infant is born
alive or not

NULLIPARA PRIMIPARA MULTIPARA

(0) (1) (2+)

 Zero  One  2 or
pregnanc pregna more
ies ncy pregnanc
beyond that has ies that
viability reached have
(20 viabilit reached
weeks) y (20 viability
weeks) (20
weeks)

OBSTETRIC SCORING (OB

SCORING)

WHAT IS GTPAL?

-GTPAL is an acronym to remember essential

information for a complete obstetric history. Each
letter represents one aspect of the obstetric history
that should be assessed when examining an individual
for the first time, including gravidity, term, preterm,
abortion, and living.  GTPAL

Gravida/  The number of pregnancy

Gravidity G  The number of pregnancies
(Gravida)
 Includes the present
NULLIGRA PRIMIGRAVIDA MULTIGRAV pregnancies
VIDA IDA  Includes miscarriages /
abortions
 Never  Pregnant for  A  Twins/ Triplets count as one
been the first time woman
pregn who T (Term  The number born at term
ant had 2 Births)
or  37th week of gestation
more  Includes alive or stillborn
pregna
ncies.  Twins/ Triplets count as one

P (Pre-  The number of pregnancies

term Births) delivered beginning with the
20th – 36 6/7th weeks of
gestation

 Includes alive or stillborn

 Twins/ Triplets count as one

A  The number of pregnancies

(Abortions/ delivered before 20 weeks
Miscarriage gestation
s)
WHY IS GTPAL IMPORTANT?  Counts with gravidity

-GTPAL is very important at the initial assessment to  Twins/ Triplets count as one
ensure the healthcare professional has asked for all
the crucial information about an individual’s L (Living  The number of current living
reproductive history.  Children) children

 Twin/triplets count
individually
EXAMPLE 1: P–1
A–1
-A pregnant woman comes to the clinic for a visit. L–5
This is her third pregnancy. She had a miscarriage
at 12 weeks and gave birth to a son, now 3 years
old, at 32 weeks. Using GTPAL system, the nurse PRACTICE:
would document this women’s obstetric history as: -A 27-year-old female is currently 16 weeks
ANSWER: pregnant. She has 2-year-old twins that were born
at 39 weeks’ gestation and a 5-year-old who was
G–3 born at 40 weeks’ gestation. She had no history of
T–0 miscarriage or abortion. What is her GTPAL?
P–1 ANSWER:
A–1
L–1 G–3
T–2
P–0
EXAMPLE 2: A–0
L–3
-A nurse is collecting dictate during an admission
assessment of a client who is pregnant with twins.
the client has a healthy 5-year-old child who has
delivered at 38 weeks and tells the nurse that she
does not have a history of any type of abortion or
fetal demise. the nurse would document the
GTPAL for this client as:

ANSWER:

G–2
T–0
P–1
A–0
L–1

PRACTICE:
-A 30-year-old female is 25 weeks pregnant with
twins. She has 5 living children. Four of the 5
children were born at 39 weeks’ gestation and one
child was born at 27 weeks’ gestation. Two years
ago, she had a miscarriage at 10 weeks’ gestation.
What is her GTPAL?

ANSWER:

G–7
T–4
 Fetal growth & development increases the BMR by
5% during 1st trimester and 12% during 2nd & 3rd
trimester. This increases the total energy
requirement.

2. Gastrointestinal changes:

There is an alteration in GI functions which causes

nausea, constipation

& vomiting. In later trimester of pregnancy

absorption of nutrients like vitamin B 12 , iron and
calcium increases in order to meet the increased
needs of the mother & fetus.

3. Changes in body fluid

Mother’s blood volume increases so as to carry the

appropriate amount

of nutrients to the fetus and metabolic waste away

from the fetus. With increase in the blood volume the
concentrations of plasma proteins, hemoglobin and
other blood constituents is lowered.

IMPORTANCE OF GOOD NUTRITION

DURING PREGNANCY

 A well nourished woman prior to conception

NUTRITION IN PREGNANCY enters pregnancy with reserve of several
nutrients that meets the needs of the growing
AND LACTATION fetus without affecting her own health.
 A well nourished woman suffers fewer
complications during pregnancy & there are
“Nutrition requirements increases tremendously few chances of premature births.
during pregnancy and lactation as the expectant or  A well nourished mother will give birth to a
nursing mother not only has to nourish herself but healthy child.
also growing fetus and the infant who is being breast  Maternal diet during pregnancy has a direct
fed”. influence on fetal growth, size & health of the
newborn.
 Poor diet during pregnancy affects mother’s
WHY THE BODY OF THE WOMEN NEEDS health, a malnourished mother provides
NUTRIENTS DURING PREGNANCY? nutrients to the fetus at the expense of her
own tissues.
1. ↑Basal metabolic rate (BMR)
  Poor nutrition during pregnancy increases the FATS
risk of complications such as prolonged
labour and even death.  Omega-3 fatty acid
 Inadequate diet during pregnancy affects the  like DHA (Docosahexaenoic acid)
health of the baby during early infancy. If the  Essential for brain development and prevents
infants survive they develop nutritional preterm births.
diseases like anemia, rickets etc. or suffer  It is required for fetal visual development
from infectious diseases due to lack of good  It reduces the incidence of heart diseases &
immunity. heart disease related deaths in infants.

ENERGY REQUIREMENT DURING

PREGNANCY

 During pregnancy additional energy is

CALCIUM REQUIREMENTS DURING
required to support the:
PREGNANCY
 Growth of fetus.
 Development of placenta & maternal  Growth and development of bones as well as
tissues. teeth of the fetus.
 To meet the needs for increased basal  Decreases risk of hypertension,
metabolic rate. To deposit fat which will  pre-eclampsia in mothers and low birth
be used during lactation. weights and chronic hypertension in
newborns.
 Maintaining bone strength
 Proper muscle contraction
 Blood clotting

-If calcium intake is inadequate during pregnancy

then calcium is mobilized from maternal bones to
meet the fetal calcium needs and this
demineralization of maternal bones leading to easy
PROTEIN & FAT REQUIREMENTS DURING fractures.
PREGNANCY
 Recommended daily allowance ( RDA) for
PROTEINS calcium during pregnancy is 1g.

 Growth of fetus Development of placenta

Enlargement of maternal Increased maternal
IRON REQUIREMENTS DURING
blood volume
PREGNANCY
 Formation of amniotic fluid Protein reserves
prepares the mother for labour,  Fetal growth
delivery and lactation  Expansion of maternal tissues including
the red blood cell Maintaining
-Additional 15g of protein is required 2nd & 3rd
additional iron content of placenta
trimester of pregnancy.
 Building the iron stores in fetal liver
 Compensate blood loss during delivery
 -Vitamin B12 supplementation during pregnancy
helps in brain & nervous system development of the
MINERALS REQUIREMENTS DURING fetus.
PREGNANCY

Folic acid (RDA- 400 µg/d)

Vit C (60mg/d)
 During pregnancy maternal blood formation
increases thus folic acid requirement also -It increase iron absorption and also helps in fetal
increases. growth. Deficiency of vitamin C increases the
 Folic acid supplementation during pregnancy chances of preterm delivery.
prevents fetal neural tube defects and
Vit B6 (2.5mg/d)
improves birth weights of the fetus.
-It is required for normal fetal development &
Zinc (RDA-12mg/d) :
positive pregnancy outcomes.
 It is required for synthesis of nucleic acids
Vit B1 (+0.2mg/d), B2 (+0.2 mg/d), B3(+2mg/d)
DNA & RNA and it is having important role
in reproduction. -As total energy requirement increases during
 Zinc deficiency during pregnancy can pregnancy so B vitamin requirement also increases.
cause poor pregnancy outcomes and abnormal
deliveries including congenital
malformations. THINGS TO KEEP IN MIND DURING
Iodine PREGNANCY:

Caffeine: Coffee should be avoided during

 Lack of iodine causes still birth, birth defects
pregnancy as it can cross the placenta & enter fetal
 Decreased fetal brain development
circulation and increases the risk of miscarriages,
premature deliveries and small for date infants.

VITAMIN REQUIREMENTS DURING Smoking: During pregnancy smoking results in

PREGNANCY placental abnormalities & fetal damage, including
prematurely & low birth weights. Smoking impairs
Vitamins A (600 µg/d retinol) oxygen & nutrient transport through the placenta due
-It is needed in small amounts to protect the fetus to reduced blood flow
from immune system problems, blindness, infections Alcohol: During pregnancy alcohol consumption
and death. causes low birth weight infants & growth retardation,
Vitamin D (5µg/d) fetal impaired central & nervous system performance
including growth retardation.
-It is required for formation of fetal bones.
Drugs: During pregnancy drugs consumption lead to
Vitamin K poor prenatal weight gain, very short or prolonged
labour, operative delivery and other perinatal
-Vitamin K is required for normal coagulation of problems.
blood & prevents new born infants hemorrhages.
Diet & feeding pattern :
Vit B12 (1.2 µg/d)
 To meet the increased nutrients need during
pregnancy mother should increase her
 feeding. Pregnant woman should consume 5-  Lactating mother requires larger quantities of
6 meals a day and snacks in between the main body building and protective foods &
meals. additional energy yielding foods to facilitate
 To meet the increased protein demand good the formation & secretion of breast milk.
quality protein rich foods like milk, meat,  Fluid intake should be increased as fluids are
eggs, fish should be included. essential for adequate quantity of milk
 Nutrient rich foods specially iron, calcium, production.
folic acid , calcium & DHA rich foods should  No food should be restricted except highly
be included in the diet during pregnancy. spiced & strongly flavored food, as they
impart flavor to milk which may be repulsive
to the baby.
IMPORTANCE OF GOOD NUTRITION  Nutrient needs of lactating mother are greatly
DURING LACTATION enhanced during lactation hence she should
have snacks in between the meals. Lactating
 Mother needs extra nutrition as she has to mother should have 5-6 meals in a day.
nourish a fully developed & rapidly growing
infant. Any inadequacy in mothers diet
influence both the quality & quantity of
mother’s milk secreted.
 Nutrient deficiency can lead to lower levels
of nutrients in the mother’s milk.

NUTRITIONAL REQUIREMENTS DURING

LACTATION:

 Energy
-During first 6 months of lactation –
additional 550 kcal/d energy is required
During 6-12 months of lactation- additional
400 kcal/d energy is required
QUIZ 1
 Protein
-During first 6 months of lactation- 75g of
protein is required everyday During 6-12 A client arrives at the prenatal clinic for the first
months of lactation – 68g of protein is prenatal assessment. The client tells the nurse that the
required everyday first day of her last menstrual period was September
19, 2007. the nurse determines the estimated date of
 OTHERS: confinement as:
-Calcium, Iron, Folic Acid, Vitamin A & C,
a. July 26, 2008
Vitamin B6 & B12
b. June 12, 2008
c. June 26, 2008
d. July 12, 2008
DIET AND FEEDING PATTERNS FOR
LACTATING WOMEN:
During a prenatal visit a patient tells you her last In Naegel’s Rule, when to use the formula of (-3 +7
menstrual period was August 15, 2016, when is the +1)?
estimated due date of her baby. a. January-March
b. April-September
a. May 24, 2016 c. April- December
b. April 4, 2017 d. January- April
c. May 4, 2017
d. May 22, 2017 It is termed as the “mask of pregnancy”.
a. Linea nigra
During a prenatal visit a patient tells you her last b. Striae gravidarum
menstrual period was March 14, 2022. Based on the c. Melasma
Naegele's Rule, when is the estimated due date of her d. Cholasma
baby?
a. July 4, 2017
b. June 4, 2017 A woman who is 39 weeks pregnant expresses fear
c. July 7, 2018 about her impending labor and how she will manage.
d. June 7, 2018 What is the nurse's best response?
a. "Don't worry about it. You'll do fine."
During a prenatal visit a patient tells you her last b. "It's normal to be anxious about labor.
menstrual period was August 28, 2016. Based on the Let's discuss what makes you afraid."
Naegele's Rule, when is the estimated due date of her c. "Labor is scary to think about, but the actual
baby? experience isn't."
a. December 20, 2022 d. "You may have an epidural. You won't feel
b. December 21, 2022 anything.
c. January 1, 2023 The primary health care provider (PHP) advised the
d. January 2, 2023 nurse to assess the maternal temperature and vaginal
discharge of a pregnant patient every 2 hours. What is
the reason behind this advice?
a. To evaluate fetal status
During a prenatal visit a patient tells you her last b. To know the onset of labor
menstrual period was January 30, 2022. Based on the c. To assess for potential risk for infection
Naegele's Rule, when is the estimated due date of her d. To prevent fetal hypertension
baby?
a. October 6, 2022 d. Cholasma
b. October 7, 2022
c. November 6, 2022
d. November 7, 2022

A pregnant women came at the clinic and as the

nurse, you want to know how long she is in her
pregnancy. She said during the interview that her
LMP is April 20,2022 and her last clinical visit is
September 30, 2022. What is her AOG?
a. 20 2/7 weeks
b. 21 2/7 weeks
c. 22 2/7 weeks
d. 23 2/7 weeks
QUIZ 2

Quiz #2- Leopold Maneuver, OB Scoring, &

Nutrition in Pregnancy and Lactation

During the first step of Leopold's maneuver, you felt

something soft, broad mass which moves together
with the rest. This finding's accurate assessment is:
a. The mass palpated at the fundal part is the head
part
b. The presentation is breech
c. The mass palpated is the back
d. The mass palpated is the buttocks

What does GTPAL stand for?

a. G - gravida, T - term births, P - preterm births,
A - abortions, L - living children
b. G - gravida, T - total pregnancies, P - premature
infants, A - abortions, L - living children
c. G - gravida, T - total pregnancies, P - pelvic
infections, A - accidental pregnancies, L - living
children
d. G - gravida, T - term births, P - premature infants,
A - abortions, L - living children

What do you call “the relationship of the long axis of

the fetal head to the long axis of the fetal trunk”
a. Axis
b. Fetal lie
c. Attitude
d. Vertex
 d. G=4, T=2, P=1, A=0, L=5
A pregnant woman comes to the clinic for a visit.
This is her third pregnancy. She had a miscarriage at A 29-year-old female is currently 9 weeks pregnant.
12 weeks and gave birth to a son, now 3 years old, at She has no living children. Two years ago, she had 2
32 weeks. Using GTPAL system, the nurse would miscarriages at 10- and 12-weeks’ gestation. What is
document this women’s obstetric history as: her GTPAL?
a.    G3T1P0A2L1
b.    G3T0P1A1L1 a. G=3, T=0, P=0, A=2, L=0
c.    G2T1P2A1L2 b. G=2, T=1, P=0, A=0, L=1
d.    G2T0P1A1L1 c. G=2, T=1, P=2, A=0, L=1
A 27-year-old female is currently 16 weeks pregnant. d. G=3, T=0, P=1, A=2, L=2
She has 2-year-old twins that were born at 39 weeks’
gestation and a 5-year-old who was born at 40 weeks’ During first 6 months of lactation or breastfeeding,
gestation. She had no history of miscarriage or how many grams of protein is required to take by the
abortion. What is her GTPAL? mother everyday?
a.    G3T2P0A0L1 a. 70 grams
b.    G3T2P0A0L3 b. 72 grams
c.    G1T1P1A0L1 c. 74 grams
d.    G2T0P0A0L1 d. 75 grams

A nurse is collecting data during an admission

assessment of a client who is pregnant with twins. the
client also has a 5-year-old child. the nurse would
document which gravida and para status on the
client?
a.    Gravida III, para II
b.    Gravida II, para II
c.    Gravida I, para I
d.    Gravida II, para I

A 35-year-old female is currently pregnant with

twins. She has 10-year-old triplets who were born at
32 weeks gestation, and a 16-year-old who was born
at 41-week gestation. Twelve years ago, she had a
miscarriage at 19 weeks gestation. What is her
GTPAL?

a. G=4, T=1, P=2, A=1, L=1 

b. G=3, T=1, P=1, A=0, L=4
c. G=4, T=1, P=1, A=1, L=4
d. G=4, T=1, P=1, A=1, L=1

A 39-year-old female is currently 18 weeks pregnant.

She has two sets of twin daughters that were born at
38- and 39-weeks’ gestation and an 11-year-old son
who was born at 32 weeks gestation. She has no
history of miscarriage or abortion. What is her
GTPAL?
a. G=4, T=2, P=2, A=1, L=5
b. G=4, T=1, P=1, A=0, L=4
c. G=4, T=1, P=2, A=1, L=4