Normal Pregnancy

Normal pregnancy
Adem Gemechu, B.Sc, M.Sc fellow
06/23/2023 1
Learning objectives
By the end of this chapter, you will be able to:
 Describe the physiology of pregnancy

 Discuss about minor disorders of pregnancy
 Discuss about sign of pregnancy
 Discuss about ANC,FANC
06/23/2023 2
Introduction
 Pregnancy rates at 1 year approach 90 percent for sexually
active fertile women who do not use contraception
 Because ovulation often precedes menstruation, young women
should be advised to use contraception whenever they begin
sexual activity
06/23/2023 3
Physiological changes during pregnancy
 There are physiological, biochemical and

anatomical changes that occur during
pregnancy.
 These changes may be systemic or local.
 Most of the systemic changes return to pre

pregnancy status 6 weeks after delivery.
06/23/2023 4
Physiological changes …cont’d
Purpose of the change

 To maintain a healthy environment for the fetus with out
compromising the mother’ s health.
 To prepare for the process of delivery and care of the
newborn.
• Understanding of the normal changes helps to understand
co incidental disease processes
06/23/2023 5
Changes in estrogen and progesterone
 A woman will produce more estrogen during one pregnancy than
throughout her entire life when not pregnant .
 During pregnancy, estrogen promotes maternal blood flow with
in the uterus and the placenta .
How does estrogen play an important role in the development of
the fetus?
By promoting maternal blood flow to the uterus and placenta;
 it ensures that the fetus is supplied with nutrients and oxygen for
its development, and
 waste products from the fetus are removed in the mother ’ s blood.
06/23/2023 6
Physiological changes …cont’ d
Changes in estrogen… cont’ d

 A pregnant woman’ s progesterone levels are also very high.
 Among other effects, high levels of progesterone cause
 some internal structures to increase in size, including the

uterus, enabling it to accommodate a full term baby.
 It has other effects on the blood vessels and joints such as
relaxing effect of smooth muscle
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Change in integumentary System
Hyperpigmentation: Estrogen and progesterone stimulate increased

melanin deposition of light brown to dark brown pigmentation.
Linea nigra: Darkened line in midline of abdomen
 Melasma (chloasma), also referred to as mask of pregnancy, is brownish

pigmentation of the skin over the cheeks, nose, and forehead.
Striae (stretch marks):Stretching of skin due to growth of breast, hips,

abdomen, and buttock plus the effects of estrogen, relaxin, and
adrenocorticoids may result in tearing of subcutaneous connective
tissue/collagen
06/23/2023 8
 Striae gravidarum
 Linea nigra
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Changes in the uterus, cervix and vagina

Uterus
 At 12 weeks’ gestation ,the fundus may be palpated through the abdomen
above the pubic bone (symphysis pubis).
 By mid-pregnancy, the uterine fundus reaches the level of the umbilicus
abdominally
 The size of the uterus usually reaches its peak at about 36 weeks’ gestation
 Upper part fundus and body change in to upper uterine segment
06/23/2023 10
Cervix
 Lower part cervix and isthmus change in to lower uterine
segment
 The cervix remains 2. 5 cm long throughout pregnancy.
 In late pregnancy, softening of the cervix occurs in

response to increasing painless contractions of its
muscular walls
06/23/2023 11
Vagina
 An increase of vascularity due to the expanded circulatory needs
 An increase of vaginal discharge (leukorrhea)which is in response
to the estrogen-induced hypertrophy of the vaginal glands
 Relaxation of the vaginal wall and perineal body which allows
stretching of tissues to accommodate the birthing process.
 Acid pH of the vagina which inhibits growth of bacteria, but
allows over growth of Candida albicans.
 This places the pregnant woman at risk for candidiasis (yeast
infection).
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Change in Cardiovascular System

 Changes are seen in the hemodynamic, anatomical, and
hematological areas.
Hemodynamic changes include:
 Blood volume increases by 1,500 mL or by 40% to 50% this
is referred to as hypervolemia of pregnancy
 Blood volume increases to support utero placental demands
and maintenance of pregnancy.
 Plasma and red blood cell(RBC)volume increase in response
to increased utero placental and renal perfusion needs.
06/23/2023 13
Change in Cardiovascular…
Hemodynamic changes…cont’ d
 Cardiac output increases 30% to 50% with an increase in
heart rate of 15 to 20 beats per minute (bpm); 20% increase
 Enlarging uterus can compress the inferior vena cava (cause
Supine Hypotensive Syndrome/Fainting in pregnancy).
 The hemodynamic changes are also a protective mechanism
for the inevitable intra partum blood loss
 Increase in the resting heart rate ; the heart rate is about 15
beats per minute higher in the pregnant woman
06/23/2023 14
Hematological changes include:
 The RBC count increases 30% and RBC volume
increases 17% to 33% in response to increased oxygen
requirements of pregnancy.
 Blood volume expansion leads to physiological anemia
of pregnancy.
 Physiological anemia of pregnancy, also referred to as
pseudo anemia of pregnancy, is due to hemodilution.
 The increase in plasma volume is relatively larger than
the increase in RBCs and results in decreased
hemoglobin and hematocrit values.
06/23/2023 15
Hematological change… cont’ d

 Iron-deficiency anemia, defined as hemoglobin of less
than 11 .0 g/dL and hematocrit less than 33%.
 Maternal iron stores are insufficient to meet the
demands for iron in fetal development.
 The white blood cell(WBC)count increases, with
values up to 15,000 mm3 in the absence of infection
 The increase is hormonally induced and similar to
elevations seen in physiological stress such as exercise.
06/23/2023 16
Hematological change… cont’ d

 Hypercoagulation occurs during pregnancy to
decrease the risk of postpartum hemorrhage.
 These changes place the woman at increased risk for
thrombosis and coagulopathies.
—This is b/c
o Plasma fibrin increase by 40%
o Fibrinogen increase by 50%
o Coagulation inhibiting factors decrease
06/23/2023 17
CRITICAL COMPONENT
Supine Hypotensive Syndrome
 Supine hypotensive syndrome is a hypotensive condition
resulting from a woman lying on her back in mid to late
pregnancy.
 In a supine position, the enlarged uterus compresses the
inferior vena cava, leading to a significant drop in cardiac
output and blood pressure, and resulting in the woman feeling
dizzy and faint.
 Pregnant women should be advised to lie on their side and rise
slowly when in a supine position to decrease the risk of a
hypotensive event.
06/23/2023 18
Change in Cardiovascular…
Anatomical changes include:

 The heart enlarges slightly as a result of
hypervolemia and increased cardiac output.
 The heart shifts upward and laterally as the
growing uterus displaces the diaphragm.
06/23/2023 19
Change in Gastro intestinal system

 During pregnancy, the muscles in the walls of the
gastro intestinal system relax slightly, and the rate at
which food is squeezed out of the stomach and along
the intestines is slowed down.
What do you think the advantage and disadvantage of
this change?
 Nutritional requirements including for vitamin and
minerals are increased so usually mother's appetite
increase
06/23/2023 20
Change in Gastro … cont’ d

 Oral cavity:- feels salivation (ptyalism)
 Gums- hypertrophic and hyperemic, easily bleed
(secondary to increased systemic estrogen)
 Stomach production of gastrin increase; increased garstric
volume and decreases pH ,mucous production increased
—PUD usually improve or disappear because of these
changes during pregnancy
—However, during pregnancy because of the enlarging
uterus, heart burn is common due to gastric reflex
06/23/2023 21
Change in Gastro … cont’ d

 Enlarging uterus slower emptying time, increase intra
gastric pressure; increase acidity and increased gasric
reflex
 The anatomical position of small and large intestine as
well as appendix will shift because of the enlarging
uterus
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Gallbladder
 Progesterone decreased motility → decreased empty time of bile
→stasis →stone formation and infection.
Liver
 No morphological changes but functional changes
 Decreased plasma protein (albumen)and globline (synthesized
by liver)increases serum alkaline phosphates activity.
Bladder
 Is displaced upward and anteriorly by enlarged uterus as a result
it increases pressure leading to urinary urgency and frequency
06/23/2023 23
Change in urinary systems

Physiological changes include:
 Renal plasma flow increases.
 Glomerular filtration rate (GFR) increases.
 Urine volume dose not increase although GFR increase because of
reabsorption
 Renal tubular reabsorption increases.
 Proteinuria and glucosuria can normally occur in small amounts
related to tubal reabsorption threshold of protein and glucose being
exceeded due to increased volume.
 Even though a small amount can be normal, it is important to assess
and monitor for pathology.
06/23/2023 24
Change in urinary … cont’ d

 Urinary stasis
 Progesterone reduces the tone of renal structures,
allowing for pooling of urine.
 Stasis promotes bacterial growth and increases the
woman’ s risk for urinary tract infections and
pyelonephritis.
 Most women experience urinary symptoms of frequency,
urgency, and nocturia beginning early in pregnancy and
continuing to varying degrees throughout the pregnancy.
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Change in urinary … cont’ d

—These symptoms are primarily a result of the systemic
hormonal changes of pregnancy, and
—May also be attributed to anatomical changes in the

renal system and other body system changes during
pregnancy, but are not generally indicative of infection
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Change in respiratory system

 Pulmonary function is not compromised in a normal pregnancy.
 Physiological changes that occur to accommodate the additional
requirements for oxygen delivery and carbon dioxide removal in
mother and fetus during pregnancy are: Physiological changes
include:
 Tidal volume increase
 Slight respiratory alkalosis
 Decrease in PCO2 leads to an increase in pH(more alkaline)and
decrease in bicarbonate
■This change promotes transport of carbon dioxide away from the
fetus.
06/23/2023 27
Change in respiratory … cont’ d

 Increases in estrogen, progesterone, and
prostaglandins cause vascular engorgement and
smooth muscle relaxation resulting in edema and
tissue congestion, which can lead to:
 Nasal and sinus congestion
 Epistaxis (nose bleeding)
Anatomical changes include:
 Diaphragm is displaced upward.
06/23/2023 28
Changes in the Breast

 Breast increases in size with enlargement of
the nipple
 Increased vascularity and
 Pigmentation of areola
06/23/2023 29
Immune system
 HCG reduces immune response of the mother and decreased plasma protein
such as albumen production by the liver also contribute for this
 Serum Ig’G, Ig’M and IgA decrease from tenth week to thirtieth week then they
will remain at the same level
Weight gain
 On average 12.5 kg (10-14 kg) is gained during pregnancy
 The average distribution is as follow :
 Fetus 3300gm
 Breast 400gm -Placenta 600 gm
 Blood 1200ml -Amniotic fluid 800ml
 Uterus 900-1000gm -Extracellular fluid 2600ml
-Deposition of fat 2500gm
06/23/2023 30
Minor Disorders of Pregnancy
• Minor disorders are only disorders that occur

during pregnancy and are not life threatening
06/23/2023 31
1. Nausea and vomiting
• This presents between 4 and 12 weeks gestation
• Hormonal influences are listed as the most likely

causes
• It is usually occurs in the morning but can occur
any time during the day, aggravated by smelling
of food
06/23/2023 32
Management
• Reassure the mother
• Small frequent meals (dry meals)
• Reduce fatty and fried containing foods.
• Rest
• Ginger and
• vitamin B6
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2. Heart burn
• is a burning sensation in the mid chest region
• Progesterone relaxes the cardiac sphincter of the stomach
and allows reflex of gastric contents into esophagus
• Heart burn is most troublesome at 30-40 weeks gestation
because at this stage is under pressure from the growing
uterus
06/23/2023 34
Management
• Advice on diet and lifestyle (avoidance of large,

fatty meals and alcohol, cessation of smoking,
and raising the head of the bed to sleep)
• Antacid preparations can be used depending on
the women’s symptoms.
• sleeping with more pillows than usual
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3. Pica
• This is the term used when mother craves

certain foods of unnatural substances such as
coal, soil...etc
• The cause is unknown but hormones and
changes in metabolism are blamed
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Management
• Seek medical advice if the substance craved is

potentially harmful to the unborn baby
06/23/2023 37
4. Constipation
• Progesterone causes relaxation and decreased

peristaltic activity of the gut, which is also
displaced by the growing uterus
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Management
• Dietary modification
• High fiber diet
• Regular bowel habit and

• Adequate fluid intake.
06/23/2023 39
5. Backache
• The hormones sometime soften the segments

to such a degree that some support is needed.
Management
• Advice the mother to sleep on firm bed.
• Advice support mechanisms of the back
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6. Fainting
• In early pregnancy fainting may be due to the
vasodilation occurring under the influence of
progesterone before there has been a compensatory
increase in blood volume
• The weight of the uterine contents presses on the
inferior venacava and slows the return of blood to the
heart
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Management
• Avoid long period of standing
• Sit or lie down when she feels slight dizziness
• She would be wise not to lie on her back

except during abdominal examination
06/23/2023 42
7. Varicositis
• Progesterone relaxes the smooth muscles of the

veins and result in sluggish circulation
• The valves of the dilated veins become
insufficient and varicosities result
• It occurs in legs, anus (hemorrhoids) and vulva
06/23/2023 43
Management
• Exercising the calf muscles by rising on the toes
• Elevate the leg and rest on the table

• Support thighs and legs
• Avoid constipation and advise adequate fluid intake.
• Sanitary pad give support for vulva varicositis
06/23/2023 44
8. Leg cramps
• It is believed to be the result of phosphorous

deficiency
Management
• Magnesium, calcium or non-pharmacological
treatment options can be used for the relief of
leg cramps in pregnancy
06/23/2023 45
Danger signals of pregnancy
• Vaginal bleeding
• Reduced fetal movements
• Frontal or recurring headaches
• Sudden swelling
• Rupture of the membrane
• Premature onset of contractions
• Maternal anxiety for whatever reason
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Diagnosis of pregnancy
 The diagnostic confirmation of pregnancy is based on a
combination of the presumptive, probable, and positive
changes/signs of pregnancy
 This information is obtained through history, physical and
pelvic examinations, and laboratory and diagnostic studies
Presumptive Signs of Pregnancy (possible Sign)
The presumptive signs of pregnancy include all subjective
signs of pregnancy (i.e. physiological changes perceived by
the woman herself ):
 Amenorrhea
 Nausea and vomiting
 Breast changes By Adem Gemechu 47
Signs of pregnancy … cont’ d
Presumptive Signs of Pregnancy… cont’ d
 Enlargement, tenderness, and tingling of breast
 Increased vascularity of breast
 Fatigue: Common during the first trimester
 Urination frequency: Related to pressure of enlarging uterus
on bladder; decreases as uterus moves upward and out of pelvis
 Quickening: A woman’ s first awareness of fetal movement;
A primigravida women feels it at 18-20 weeks the
Multigravida at 16-18 weeks
 All of these changes could have causes outside of pregnancy
and are not considered diagnostic
By Adem Gemechu 48
Probable Signs of Pregnancy

 The probable signs of pregnancy are objective signs of
pregnancy
 Include all physiological and anatomical changes that
can be perceived by the health care provider
 Chadwick’ s sign: Bluish-purple coloration of the
vaginal mucosa, cervix, and vulva seen at 6 to 8 weeks
 Goodell’ s sign: Softening of the cervix and vagina with
increased leukorrheal discharge; palpated at 8 weeks
 Osiander’ s sign: pulsation of fornixes of the vagina
By Adem Gemechu 49
Probable Signs… cont’ d

 Hegar’ s sign: Softening of the lower uterine segment; palpated at 6 weeks
 Uterine growth and abdominal growth
 Skin hyperpigmentation
Melasma (chloasma), also referred to as the mask of pregnancy: Brownish
pigmentation over the forehead, temples, cheek, and/or upper lip
 Linea nigra:is darkening midline of the abdomen from the umbilicus to the
symphysis pubis due to increased MSH
Nipples and areola: Become darker; more evident in primigravida’s and
dark-haired women
By Adem Gemechu 50
Probable Signs… cont’ d

 Ballottement: dropping and rebounding of the
fetus in its surrounding amniotic fluid in
response to a sudden tap on the uterus
 Positive pregnancy test results
 Presence of HCG in blood and urine
By Adem Gemechu 51
Positive sign of pregnancy

 Visualization of fetus by
 Ultrasound 6 weeks of gestation
 X -ray after 12 weeks of gestation (less practical/not recommended)
 Fetal heart beat heard by fetoscope (20weeks) or Doppler (10-12 week) or
ultrasound
 FHR = 120 to160 beat per minute
 Fetal movement perceived by the health personnel (by palpation and inspection)
Fetal palpation
Fundal height: Above symphysis pubis @ 12weeks, @umbilicus 20 weeks, @
xiphoid 38 week
By Adem Gemechu 52
Antenatal care
By Adem Gemechu, B.Sc,

M.Sc fellow
06/23/2023 53
Terminologies
• Gravidity: Pregnancy
Primigravida = a woman pregnant for the first time
Multigravida = a woman who has had two or more pregnancies
• Parity- refers to delivery
Nullipara = a woman who has not given birth to a child birth)
Multipara a woman who has given birth to more than one child
Grandmultipara woman who has given birth to 5 or more
children
06/23/2023 54
Terminologies cont. …
• Lie: is the relationship of the long axis (spine) of the fetus
to the long axis of the mother’s uterus, and the normal lie is
longitudinal Abnormal are transverse, oblique and variable.
• Attitude: is the relationship of the fetal parts to one another
 the normal attitude is flexion
 Abnormal attitude is extension and deflection
06/23/2023 55
• Presenting part: is the part of the fetus felt at the

lower pole of the uterus and felt on abdominal
examination and on vaginal examination
• Presentation: is the part of the fetus in the lower pole
of the uterus and the normal presentation is vertex,
abnormal are breech, face, brow and shoulder.
06/23/2023 56
• Position: is the relationship of the denominator to the
six areas of the mother’s pelvis, normal position is
anterior or lateral abnormal is Malposition is Occipital
posterior position
• Crowned: When the Bi-parietals pass the ischial spines
and the head no longer recedes between contractions
06/23/2023 57
• Denominator: The part of the fetus which

determines the position. (Vertex- occipute,
breach -sacrum. Face- mentum).
• Engaged: when the Bi-parietal diameters of the
fetal head passes through the pelvic brim
06/23/2023 58
ANC
• ANC is defined as the complex of

interventions that a pregnant woman and
adolescent girl receive from skilled health care
professionals in order to ensure the best health
conditions for both mother and baby during
pregnancy
06/23/2023 59
Purpose
• ANC reduces maternal and perinatal morbidity and mortality
through:
 Screening, diagnosis and management of the risk factors and
pregnancy-related complications
 Identification of women and girls at increased risk of developing
complications
 Provides an important opportunity to prevent and manage
concurrent diseases through integrated service delivery
 Ensuring referral to an appropriate level of care

06/23/2023 60
Components of ANC
• Health promotion and disease prevention
• Screening, diagnosis and management or

referral for disease
• Birth planning and complication readiness.
06/23/2023 61
Cont. …
• During each ANC contact, gather and interpret

information (History, P/E, Investigations),
classify the type of care (basic versus
specialized), develop care plan, implement
care plan (take action) and evaluate care plan
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ANC classification diagramme
06/23/2023 63
ANC information gathering and classifying form
06/23/2023 email: kenayeroket2022@gmail.com 64

Contact schedule, risk identification, list of interventions at each contact

The first antenatal contact
• Confirmation of pregnancy and gestational age

 Confirmation of pregnancy, complete
assessment of gestational age (LNMP, EDD
and Gestational age) are made at the first
antenatal visit
06/23/2023 68
The first antenatal contact cont. …
• Last menstrual period is valid if the woman is sure of her

dates and reliable (three consecutive menses and no use
of hormonal contraceptives)
• Ultrasound scan for gestational age estimation for

women who are unsure of dates with SFH measurement
less than 24 weeks
06/23/2023 69
nursing assessment
• To come up with a clear understanding of a

patient’s problem, detailed history and
physical examination is important
06/23/2023 70
History
• Identification
 Name
 Age
 Marital status
 Address
 Religion
 Occupation
 Date and time of admission
 Ward and bed number
 MRN
06/23/2023 71
History cont. …
• Chief complaints
 Patients may have come for routine ANC
follow up or may come with one or more
specific complaints
 Note the duration of each complaints
06/23/2023 72
History cont. …
• History of present pregnancy
 Get information on the following points:
 Gravidity
 Parity
 Abortion
 LNMP
 Calculate EDD
06/23/2023 73
History cont. …
• EDD is calculated by using:

 Naegele’s rule by using GC
 Ethiopian calendar
06/23/2023 74
History cont. …
• Naegele’s rule
 EDD= LNMP+9months +7days
 EDD=LNMP-3months+7days
• Ethiopian calendar
 EDD=LNMP+9months +10days if pagume is not
passed(from 1/1-25/3/--)
 EDD=LNMP+9months +5days if pagume passed( from
26/3-5/13/---)
 EDD=LNMP+9months +4days (lip year=if pagume
passed by 6)
06/23/2023 75
History cont. …
• Calculate GA by completed weeks
• GA=Arrival date minus LNMP
7
• Quickening: the first time the mother felt fetal
movement
o In primigravida=18-20wks
o In multigravida=16-18wks
06/23/2023 76
History cont. …
• Presence of ANC else where, place and number of
visits, what was done and laboratory results
• Elaboration of c/c
• Dangers symptoms of pregnancy
• Common complaints of pregnancy
• Ask if pregnancy is wanted, planned and supported
• Ask positive of negative statement according to
patient complaints
06/23/2023 77
History cont. …
• Past obstetric history
• Ask the following for all previous pregnancies in
chronological orders:
 Date, month and year of gestation
 Length of gestation: abortion(<28wks). Preterm(<37wks),
term(37-42wks) and post term(>42wks)
 Significant antenatal medical problems like HDP, APH
and DM
 Onset of labor: spontaneous vs induced
 Fetal presentation
06/23/2023 78
Past obstetric history
cont. …
 Duration of labor
 Mode of delivery: SVD, IVD. C/S and DVD
 Fetal outcome: alive or dead, sex of newborn,
wt., malformation and current conditions
 Postpartum complications: PPH
 Breast feeding
06/23/2023 79
History cont. …
• Gynecologic history
FP methods: user, type, duration and side effect
Sexual history: STI and HIV/AIDS
Gynecologic operations: FGC/FGM, laparotomy, D and C, E and

C, MVA
Menstrual history: age of menarche, interval of period(21-
36days).amount of flow(10-80ml), duration of flow(1-8days),
normally, dark red and non clotted
06/23/2023 80
History cont. …
• Past medical and surgical history

History of DM, HTN, hypo/hyperthyroidism,
blood transfusion
Drugs
Maternal infection- TORCH syndrome
06/23/2023 81
History cont. …
• Personal, family and social history
Childhood development
Educational status
Habits like alcohol, smoking elicit drugs

Occupation: exposure to radiation, anesthesia, chemicals and
factory
Income: LSES associated with PE and preterm
Family history of DM, HTN, multiple pregnancy and genetic

disorders
06/23/2023 82
P/E
• GA: well looking or sick looking
• V/S:
 B/P
 PR: increases 10-15 bpm
 RR :increases 1-4 breaths/min
T
 WT.: more than 1kg/week is abnormal
 HT.
06/23/2023 83
P/E cont. …
• HEENT
 Head: hair distribution. Head injury scalp and
laceration
 Ear : for ear discharge
 Eyes: conjunctiva and sclera
 Nose : nasal stiffness, nasal discharge and
nasal septum
 Throat: buccal mucosa, mouth, tongue
06/23/2023 84
P/E cont. …
• LGS: thyroid gland for
hypothyroidism/hyperthyroidism
• Breast: nipple retraction, pigmentation, lumps ,
discharges and color change
• Respiratory and CVS
 Same steps of examination as non pregnant patient
 Normal finding:
 Decreased diagrammatic exertion, PMI deviated to left
 S3 gallop sound functional systolic murmur
06/23/2023 85
P/E cont. …
Abdomen
• Steps of abdominal examination:
 Inspection
 Palpation and
 auscultation
06/23/2023 86
P/E cont. …
• Inspection
 5s : size, shape, symmetry, skin, strae and scar
 Palpation
 Superficial palpation: to check rigidity, tenderness,
superficial mass and abdominal wall defect
 Deep palpation: to check for mass, organometallic and
characterize mass
06/23/2023 87
Obstetric palpation/ Leopold's maneuver
• The first Leopold's maneuver(fundal palpation)
• The second Leopold's maneuver(lateral palpation )

• The third Leopold's maneuver(pelvic palpation)
• The fourth Leopold's maneuver(pawlik grip)
06/23/2023 88
The first Leopold's maneuver(fundal palpation)
• Purpose- To know lie and presentation

• Method: - Use 2 hands using palms of hands
palpate on either side of the fundus. Fingers
held close together, palpate the upper pole of
then uterus and feel that as it is hard or soft or
irregular
06/23/2023 89
Figure:Fundal palpation
06/23/2023 90
Lateral Palpation: (2nd Leopled maneuver)
• Purpose-To know lie and position

• Method: - always facing the mother, fix the
hand on the center of the abdomen, fix the right
hand and palpate with left hand and vise versa
• Note the regularity; the regular side is the back
06/23/2023 91
Figure ; Lateral palpation
06/23/2023 92
Deep pelvic Palpation: (3rd Leopoled
Maneuver)
• Purpose -To Know Presentation & Attitude
• Method: - Feel presenting part, is it hard or

soft while palpating for the presenting part feel
for eminences on back side.
06/23/2023 93
Figure : Deep pelvic palpation
06/23/2023 94
Pawlick's Grip: (4th Leopard Maneuver)
• The lower pole of the uterus is grasped with

the right hand the midwife facing the women's
head, feel the occiput and sinciput, note which
is lower
06/23/2023 95
Figure . Pawlick’s grip
06/23/2023 96
P/E cont. …
• Percussion
 Shifting and flank dullness
 Fluid thrill
• Auscultation
 FHB is heard in the back side at 16-18whs in multigravida and 18-

20wks in primigravida
 In complete breech FHB is heard above umbilicus
 In cephalic presentation FHB is heard below umbilicus
 OP position FHB is heard in the flank
06/23/2023 97
P/E cont. …
• GUS
 Cost vertebral and suprapubic tenderness
 P/E: done two times if no complications
1. In the first trimester: to diagnosis pregnancy

2. Late in pregnancy greater than 37 wks:
 To diagnosis contracted pelvis
 To assess Bishop score
 To assess cervical dilation and effacement
06/23/2023 98
P/E cont. …
• IGS
 Hyperpigmentation on breast, lower and
midline abdomen
 Genitals are normally seen
 Vascular changes: spider angiomata and
palmar erythema
06/23/2023 99
P/E cont. …
• Extremities
 Check for edema, dilated vessels and calf
tenderness
 Dependent edema(peri tibial. Ankle and pedal
ema0 are seen in 80% of normal pregnancies
 Pathological edema(non dependent ) involves
the face, fingers or the whole-body
06/23/2023 100
P/E cont. …
CNS
Consciousness
Alertness
Orientation to:
Time place and
person
06/23/2023 101
Investigations
• Determine the essential screening investigations (Hemoglobin,
HIV test, urine analysis, blood group, VDRL, HBsAg)
• Ultrasound scan before 24 weeks of gestation
• Indirect coomb’s test for Rh negative women.
• Urine test
 Urine strip test and microscopy (albumin, sugar, ketone, WBC
etc.)
 Urine midstream gram stain to diagnose asymptomatic
bacteriuria (ASB)
06/23/2023 102
Advice and counseling
• Danger signs and symptoms of pregnancy: Severe

headache, blurring of vision, abdominal pain (not
discomfort), leakage of liquor from the vagina,
vaginal bleeding and decreased fetal movements.
A woman that experiences any of these symptoms
should come to health facility immediately
06/23/2023 103
Advice and counseling cont. …
• Self-care in pregnancy: Diet and exercise,

personal hygiene and breast care, avoid
unnecessary use of medications, limit use of
caffeine, avoid substance use (alcohol, tobacco
and recreational drugs)
06/23/2023 104
• Birth preparedness and complication readiness (delivery plan):

At the end of her ANC contact, all pregnant women should be
given a provisional delivery plan: The expected date of delivery,
the expected place of delivery, the expected mode of delivery, a
transport plan for emergency or delivery (including important
contact numbers) and the practice of home delivery should be
discouraged
06/23/2023 105
• Institutional delivery: Advice the patient about the importance of

institutional delivery
• Maternity waiting home: If mothers are leaving far from the

delivery centre, they will be admitted to maternity waiting home
which is located near or within health centers in their final weeks
of pregnancy to bridge the geographical gap in obstetric care.
06/23/2023 106
• Newborn/infant care: Plans for infant feeding

and techniques, details of follow up care,
immunization and where this can be obtained.
• Family planning: Counsel on future
pregnancies and use of postpartum
contraception
06/23/2023 107
Assessment and planning
• The final assessment includes:

 Risk factor identified
 The best estimate of gestational age
 A plan for management or appropriate referral
for any problems
06/23/2023 108
Content of subsequent antenatal visits
• Ask about general well-being, fetal movements, danger
symptoms and any problems.
• Check the blood pressure, heart rate, weight and color of the
mucous membranes and conjunctivae.
• Measure the symphysis-fundal height (SFH) and compare
with previous measurements.
• Palpate the presenting part after 34 weeks of gestation

06/23/2023 109
Content of subsequent antenatal visits cont.
…
• One step screening using 75 gm glucose at 24 to 28 wks, if the woman
is high risk for diabetes. If test result is abnormal refer for further
evaluation and management.
• Repeat investigations
 Repeat HIV counseling and testing during third trimester preferably
between28 to 36 weeks for those tested negative at the initial visit
 Repeat blood tests: Hgb at 32 and 38 weeks.
 Repeat urine test at 26 to 34 weeks

06/23/2023 110
Content of subsequent antenatal visits cont.
…
• Repeat information for danger signs pregnancy, and

review delivery and transport plans, as well as feeding
and contraception choices.
• Document the detail contact schedule, risk

identification, list of intervention at each contact
06/23/2023 111
Medications and vaccines
• Td vaccination - two doses, on the first visit and four weeks
after the initial dose (regardless of the gestational age of her
first contact)
• Iron and folic acid supplements: daily oral iron and folic
acid supplementation with 30 mg to 60 mg of elemental iron
and 400 μg (0.4 mg) of folic acid
• Daily calcium supplementation: 1.5–2.0 g oral elemental
calcium starting from 14 weeks of gestation

06/23/2023 112
Medications and vaccines cont. …
• If there is asymptomatic bacteriuria give amoxicillin 500 mg PO
TID for seven days.
• Preventive antihelminthic treatment- Preventive chemotherapy
(deworming), using single-dose albendazole (400 mg) or
mebendazole (500 mg) is recommended after the first trimester
• If indirect coomb’s test is negative, administer anti-D
immunoglobulin at 28 weeks and immediately after delivery
after cord blood check-up.

06/23/2023 113
S ?
ON
T I
ES
QU
N Y
A
06/23/2023 114

Normal Pregnancy

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Normal pregnancy

Adem Gemechu, B.Sc, M.Sc fellow

By the end of this chapter, you will be able to:

 Describe the physiology of pregnancy

 There are physiological, biochemical and

 Most of the systemic changes return to pre

Purpose of the change

Changes in estrogen… cont’ d

 Among other effects, high levels of progesterone cause

 some internal structures to increase in size, including the

Change in integumentary System

Hyperpigmentation: Estrogen and progesterone stimulate increased

Linea nigra: Darkened line in midline of abdomen

 Melasma (chloasma), also referred to as mask of pregnancy, is brownish

Striae (stretch marks):Stretching of skin due to growth of breast, hips,

Changes in the uterus, cervix and vagina

 Upper part fundus and body change in to upper uterine segment

 In late pregnancy, softening of the cervix occurs in

Change in Cardiovascular System

Hematological change… cont’ d

Hematological change… cont’ d

Anatomical changes include:

Change in Gastro intestinal system

Change in Gastro … cont’ d

Change in Gastro … cont’ d

Change in urinary systems

Change in urinary … cont’ d

Change in urinary … cont’ d

—May also be attributed to anatomical changes in the

Change in respiratory system

Change in respiratory … cont’ d

Changes in the Breast

• Minor disorders are only disorders that occur

• This presents between 4 and 12 weeks gestation

• Hormonal influences are listed as the most likely

• Reassure the mother

• Small frequent meals (dry meals)

• Reduce fatty and fried containing foods.

• Advice on diet and lifestyle (avoidance of large,

• This is the term used when mother craves

• Seek medical advice if the substance craved is

• Progesterone causes relaxation and decreased

• High fiber diet

• Regular bowel habit and

• The hormones sometime soften the segments

• Avoid long period of standing

• Sit or lie down when she feels slight dizziness

• She would be wise not to lie on her back

• Progesterone relaxes the smooth muscles of the

• Exercising the calf muscles by rising on the toes

• Elevate the leg and rest on the table

• Avoid constipation and advise adequate fluid intake.

• Sanitary pad give support for vulva varicositis

• It is believed to be the result of phosphorous

Probable Signs of Pregnancy

Probable Signs… cont’ d

Probable Signs… cont’ d

Positive sign of pregnancy

By Adem Gemechu, B.Sc,

Primigravida = a woman pregnant for the first time