Antenatal care

Introduction
Every year there are an estimated 200 million
pregnancies in the world. Each of these
pregnancies is at risk for an adverse outcome for
the woman and her infant. While risk can not be
totally eliminated, they can be reduced through
effective, affordable, and acceptable maternity
care. To be most effective, health care should
begin early in pregnancy and continue at regular
intervals.

Outlines
Goals of antenatal care.
Signs of pregnancy.
Physical changes during pregnancy.
Assessment and physical examination.
history.
Physical assessment.
Laboratory data.
Ultrasound.

 Managing the minor disorders of pregnancy.

Health teaching during pregnancy.

Goals of antenatal care

To reduce maternal and perinatal mortality and
morbidity rates.
To improve the physical and mental health of
women and children.
To prepare the woman for labor, lactation, and
care of her infant.
To detect early and treat properly complicated
conditions that could endanger the life or impair
the health of the mother or the fetus.

Signs of pregnancy
Presumptive (subjective )signs of pregnancy:
These signs are least indicative of pregnancy; they could easily indicate
other conditions. signs lead a woman to believe that she is pregnant
Amenorrhea.
Breast changes and tangling sensation.
Chlosma and linea nigra.
Abdominal enlargement & striae gravidarum.
Nausea & vomiting.
Frequent urination.
Fatigue
quickening :sensations of fetal movement in the abdomen. Firstly
felt by the patient at approximately 16 to 20 weeks.
.

Probable signs( objective) of pregnancy:

They are more reliable than the presumptive signs, but
they still are not positive or true diagnostic findings.
Hegars sign (softening of the lower uterine segment).

6-8 weeks

Goodells sign (softening of the cervix ,uterus, and

vagina during pregnancy.). 4-6 weeks
Ballottement. dropping and rebounding of the fetus
in its surrounding amniotic fluid in response to a
sudden tap on the uterus
Positive pregnancy test.
Braxton hicks contractions. more frequently felt

after 28 weeks. They usually disappear with

walking or exercise.

 The uterus changes from a pear

shape to a globe shape.
Enlargement and softening of the
uterus

 Chadwicks sign---bluish discoloration of

the cervix, vagina and labia during
pregnancy as a result of increased vascular
congestion.
-Osiander`s sign (pulsation of fornices)

Positive signs of pregnancy:

Fetal heart tones can be detected
as early as 9 to 10 weeks from
the last menstrual period (LMP)
by Doppler technology
Fetal movement felt by the
examiner. after about 20 weeks'
gestation
Visualization of the fetus by the
ultrasound.

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Definitions
It is a planned examination and observation
for the woman from conception till the birth .
Or
Antenatal care refers to the care that is given
to an expected mother from time conception
is confirmed until the beginning of labor

Goals and Objectives of Antenatal Care

Goals:
*To reduce maternal mortality and morbidity
rates.
* To improve the physical and mental health of
women and children.
* antenatal care aims to prevent and identify
maternal and fetal abnormality that can
adversely affect pregnancy outcome.

Objectives
Antenatal care support and encourage a
familys healthy psychological adjustment to
childbearing
FACTORS AFFECTING MOTHERS
UTILIZATION OF ANTENATAL CARE
Demographic and Biological Factors
Socioeconomic Factors
Psychosocial Factors
Health Services Factors
Environmental Factors

Assessment and physical

examination

Component of antenatal care

Assessment:

1. The initial assessment interview can

establish the trusting relationship between
the nurse and the pregnant woman.
2. establishing rapport
3. getting information about the womans
physical and psychological health,
4. obtaining a basis for anticipatory guidance
for pregnancy .

 During the first visit, assessment and

physical examination must be completed.
Including:

history.
Physical examination.
Laboratory data.
Psychological assessment.
Nutritional assessment.

History
Welcome the woman, and ensure a quite place
where she can express concerns and anxiety
without being overheard by other people.
Personal and social history:
This include: womans name, age, occupation,
address, and phone number. marital status,
duration of marriage, Religion , Nationality
and language, Housing and finance

Menstrual history:
A compete menstrual history is important to establish the
estimated date of delivery. It includes:
-

Last menstrual period (LMP).

Age of menarche.
Regularity and frequency of menstrual cycle.
Contraception method.

- Any previous treatment of menstrual complains

- Expected date of delivery (EDD) is calculated as
followed:
1st day of LMP 3 months +7 days, and change the year.
Example: calculate EDD if LMP was august 30, 2007.
= June 6, 2008.

Current problems with pregnancy :

Ask the patient if she has any current problem, such as:
- Nausea & vomiting.
- Abdominal pain.
- Headache.
- Urinary complaints.
- Vaginal bleeding.
- Edema.
- Backache.
- Heartburn.
- Constipation.

 Obstetrical history:
This provides essential information about the previous
pregnancies that may alert the care provider to
possible problems in the present pregnancy. Which
includes:
Gravida, para, abortion, and living children.
Weight of infant at birth & length of gestation.
Labor experience, type of delivery, location of birth,
and type of anesthesia.
Maternal or infant complications.

 Medical and surgical history:

Chronic condition such as diabetes mellitus,
hypertension, and renal disease can affect the
outcome of the pregnancy and must be
investigated.
Prior operation, allergies, and medications
should be documented.
Previous operations such as cesarean section,
genital repair, and cervical cerclagc.
Accidents involving injury of the bony pelvis

 Family history:
Family history provides valuable information about
the general health of the family, and it may reveal
information about patters of genetic or congenital
anomalies.
Including:
- D.M.
- Hypertension.
- Heart disease.
- Cancer.
- Anemia.

Physical examination
Physical examination is important to:
detect previously undiagnosed physical
problems that may affect the pregnancy
outcome.
and to establish baseline levels that will
guide the treatment of the expectant mother
and fetus throughout pregnancy.

General Examination
It should be started from the moment the pregnant
woman walks into the examination room.
Examine general appearance:
Observe the woman for stature or body build and
gait
The face is observed for skin color as pallor and
pigmentation as chloasma.
Observe the eyes for edema of the eyelids and
color of conjunctiva. Healthy eyes are bright and
clear.

Vital signs:
Blood pressure:
1. It is taken to ascertain normality and provide a
baseline reading for a comparison throughout the
pregnancy.
2. In late pregnancy, raised systolic pressure of 30 mm
Hg or raised diastolic pressure of 15 mm Hg above
the baseline values on at least two occasions of 6 or
more hours apart indicates toxemia.
Pulse:
The normal pulse rate = 60-90 BPM.
Tachycardia is associated with anxiety, hyperthyrodism,
or infection.

 Respiratory rate:
The normal is 16-24 BPM.
Tachypnea may indicate respiratory infection,
or cardiac disease.
Temperature:
normal temperature during pregnancy is
36.2C to 37.6C.
Increased temperature suggests infection.

Cardiovascular system:
Venous congestion:
Which can develop into
varicosities, venous congestion
most commonly noted in the
legs, vulva, and rectum.

Edema:
Edema of the extremities or face
necessitates further assessment
for signs of pregnancy-induced
hypertension.

Musculoskeletal system
Posture and gait:
Body mechanics and changes
in posture and gait should be
addressed. Body mechanics
during pregnancy may
produce strain on the
muscles of the lower back
and legs.

 Height & weight:

An initial weight is needed to establish a baseline for
weight gain throughout pregnancy.
Preconception:
Wt. lower than 45kg, or Ht. under 150 cm is associated
with preterm labor, and low birth weight infant.
Wt. higher than 90 kg is associated with increased
incidence of gestational diabetes, pregnancy induced
hypertension, cesarean birth, and postpartum infection.
Recommendation for weight gain during pregnancy are
often made based on the womans body mass index.

 Pelvic measurement:
The bony pelvis is evaluated early in the
pregnancy to determine whether the
diameters are adequate to permit vaginal
delivery.

 Observe the neck for enlarged thyroid gland and

scars of previous operations.
* Observe complexion for presence of blotches.
* Ensure that the general manner of the woman indicates
vigor and vitality.
* An anemic, depressed, tired or ill woman is lethargic,
not interested in her appearance, and unenthusiastic
about the interview.
* Lack of energy is a temporary state in early pregnancy, a
woman often feels exhausted and debilitated.
* Discuss the woman's sleeping patterns and minor
disorders and give advice as necessary.
* Report any signs of ill health.

Abdomen:
The size of the abdomen
is inspected for:
- the height of the fundus,
which determines the
period of the gestation.
- multiple pregnancy.

The shape of the abdomen is inspected for:

- fetal lie & position.
- the abdomen is longer if the fetal
lie is longitudinal as occurs in
99.5% of cases.
- the abdomen is lower & broad if
the lie is transverse.

- fetal movement is inspected as

evidence of fetal life and position.
- fetal heart beat can be heard by
stethoscope after the 20th week, or
Doppler after 8th week. Normal
fetal heart rate is 120-160
beats/min.

1-Inspection:
The nurse should look at the following:
Skin changes such as linea nigra, striae
gravidarum and scars of previous
operations.
The size of the abdomen is inspected
for:
* Height of the fundus, which determines
the period of gestation.
* Multiple pregnancy and polyhydramnios
will enlarge both the length and breadth of
the uterus.
* A large fetus increases only the length of
the uterus.

 Contour of the abdominal wall is observed

for pendulous abdomen, lightening
protrusion of umbilicus and full bladder
2-Palpation
The uterus will be palpable per abdomen after the
12th week of gestation
Abdominal palpation includes
Estimation of the period of gestation. This is done by
determination of fundal height.

The uterus may be higher than expected :

1. large fetus, multiple pregnancy
2. polyhydrammnios
3. mistaken date of last menstrual period

The uterus may be lower than expected :

1. small fetus, intrauterine growth restriction
2. oligohydramnios
3. mistaken date of last menstrual period.

 Fundal palpation is performed to determine

whether it contains the breech or the head.
This will help to diagnose the fetal lie and
presentation.

 Calculations:

Calculation of gestation using fundal

height
McDonalds method: Measure from symphasis
pubis to top of fundus in cm.
Gestation is measurement + or 2 weeks

12 weeks :the uterus fills the

pelvis so that the fundus of the
uterus is palpable at the
symphysis pubis .

16 weeks, the uterus is

midway between the
symphysis pubis and the
umbilicus.

20 weeks, it reaches the

umbilicus

Methods for Determining Fetal

Presentation
Leopold's maneuvers

 First maneuver :to determine fetal presentation

(longitudinal axis) or the part of the fetus (fetal
head or breech) that is in the upper uterine fundus.
Second maneuver :to determine the fetal position
or identify the relationship of the fetal back and
the small parts to the front, back, or sides of the
maternal pelvis.
*Determine what fetal body part lies on the side of
the abdomen. Reverse the hands and repeat the
maneuver. If firm, smooth, and a hard continuous
structure, it is likely to be the fetal back; if smaller,
knobby, irregular, protruding, and moving, it is
likely to be the small body parts (extremities).

 Third maneuver :to determine the portion of

the fetus that is presenting.
The head will feel firm and globular. If not
engaged into the pelvis, the presenting part
is movable. If immobile, engagement has
occurred. This maneuver is also known as
Pallach's maneuver or grip

 Fourth maneuver :to determine fetal attitude

or the greatest prominence of the fetal head
over the pelvic brim
If the cephalic prominence is felt on the
same side as the small parts, it is usually the
sinciput (fetus' forehead), and the fetus will
be in vertex or flexed position. If the
cephalic prominence is felt on the same side
as the back, it is the occiput (or crown), and
the fetus will be vertex or slightly extended
position.

 If the cephalic prominence is felt equally on both

sides, the fetus' head may be in a military position
(common in posterior position). Then move the
hands toward the pelvic brim. If the hands converge
(come together) around the presenting part, it is
floating. If the hands diverge (stay/move apart), the
presenting part is either dipping or engaged in the
pelvis.

Neurological system
Deep tendon reflexes should be evaluated
because hyperreflexia is associated with
complications of pregnancy.

Skin
Pallor of the skin my indicate anemia.
Jaundice may indicate hepatic disease.
Chloasma and linea nigra related to
pregnancy.
Striae graviderum should be noted.
Nail beds should be pink with instant
capillary return.

Legs:
* Legs should be noted for edema.
* They should be observed for varicose veins
* The calf must be observed for reddened areas which
may be caused by phlebitis and white areas which
could be caused by deep vein thrombosis.
* Ask the woman to report tenderness during
examination.
* The legs should be observed for unequal length or
muscle wasting which may be an indication of
pelvic abnormalities.

Breast
Assess breast size, symmetry, condition of
nipple, and the presence of colostrum.

Gastrointestinal systems
Mouth:
The gum may be red, tender, edematous as a result
of the effects of increased estrogen. Observe the
mouth for:
Dryness or cyanosis of the lips.
Gingivitis of the gums.

Septic focus or caries of the teeth

Intestine:
Assess for the bowel sound.
Assess for constipation or diarrhea.

 Vaginal discharge:
* Ask the woman about any increase or
change of vaginal discharge.
Report to the obstetrician any mucoid loss
before the 37th week of pregnancy.
Vaginal bleeding:
* Vaginal bleeding at any time during
pregnancy should be reported to the
obstetrician to investigate its origin.

Laboratory data
Test

Purpose

Blood group

To determine blood type.

Hgb & Hct

To detect anemia.

(RPR) rapid plasma reagin

To screen for syphilis

Rubella

To determine immunity

Urine analysis

To detect infection or renal disease.

protein, glucose, and ketones

Papanicolaou (pap) test

To screen for cervical cancer

Chlamydia

To detect sexual transmitted disease.

Glucose

To screen for gestational diabetes.

Test

purpose

Stool analysis

for ova and parasites

* Venereal disease tests should be performed

To screen for syphilis

(VDRL)

Hepatitis Baserface
antigen

To detect carrier status or

active disease

*
-

Hemoglobin will be repeated:

At 36 weeks of gestation.
Every 4 weeks if Hb is<9g/dl.
If there is any other clinical reason.

Ultrasound
Is performed to:
estimate the gestational age.
Check amniotic fluid volume.
Check the position of the placenta.
Detect the multifetal pregnancy.
The position of the baby.

 Fetal kick count:

The pregnant woman reports at least 10
movements in 12 hours.
* Absence of fetal movements precedes
intrauterine fetal death by 48 hours.

Schedual of antenatal care:

a medical check up every four weeks up
to 28 weeks gestation,
every 2 weeks until 36 weeks of gestation
visit each week until delivery
More frequent visits may be required if
there are abnormalities or complications
or if danger signs arise during pregnancy

Frequency of antenatal appointments

Nulliparous with an uncomplicated pregnancy, a

schedule of 10 appointments.
Parous with an uncomplicated pregnancy, a
schedule of 7 appointments.

 Services at subsequent visits:

the nurse inquires about physical changes that are
related directly to the pregnancy, such as the
womans perception of fetal movement, any
exposure to contagious illness, medical treatment
and therapy prescribed for non-pregnancy
problems since the last visit,
prescribed medications that were not prescribed as
a part of the womens prenatal care.

health education:
Follow up:
Advice the mother to follow up according
to the schedule of antenatal care that
mentioned before, advise the mother to
follow up immediately if any danger sings
appears, describe the important of follow up
to the mother.

Health teaching during

pregnancy

Health promotion during pregnancy begins with

reviewing health hare.

Hygiene:
Daily all over wash is necessary because it is
stimulating, refreshing, and relaxing.
Warm shower or sponge baths is better than tub bath.
Hot bath should be avoided because they may cause
fatigue. &fainting
Regular washing for genital area, axilla, and breast
due to increased discharge and sweating.
Vaginal douches should avoided except in case of
excessive secretion or infection.

Danger signs of pregnancy

Vaginal bleeding including spotting.
Persistent abdominal pain.
Sever & persistent vomiting.
Sudden gush of fluid from vagina.
Absence or decrease fetal movement.
Sever headache.
Edema of hands, face, legs & feet.
Fever above 100 F( greater than 37.7C).
Dizziness, blurred vision, double vision & spots before
eyes.
Painful urination.

Breast care:
Wear firm, supportive bra with wide straps to spread
weight across the shoulder.
Wash breasts with clean tap water (no soap, because
that could be drying). Daily to remove the colostrum &
reduce the risk of infection.
It is not recommended to massage the breast, this may
stimulate oxytocin hormone secretion and possibly lead
to contraction.
advise the mother to be mentally prepared for breast
feeding

advise the pregnant woman to expresses

colostrums during the last trimester of
pregnancy to prevent congestion.

Dental care:
The teeth should be brushed carefully in the
morning and after every meal.
Encourage the woman the to see her dentist
regularly for routine examination &
cleaning.
Encourage the woman to snack on nutritious
foods, such as fresh fruit & vegetables to
avoid sugar coming in contact with the teeth.
A tooth can be extracted during pregnancy,
but local anesthesia is recommended.

Dressing:
Woman should avoid wearing tight cloths
such as belt or constricting bans on the legs,
because these could impede lower extremity
circulation.
Suggest wearing shoes with a moderate to
low heel to minimize pelvic tilt & possible
backache.
Loose, and light clothes are the most
comfortable.

Travel:
Many women have questions about travel
during pregnancy.
Early in normal pregnancy, there are no
restrictions.
Late in pregnancy, travel plans should take
into consideration the possibility of early
labor.

Sexual activity:
Sexual intercourse is allowed with
moderation, is absolutely safe and normal
unless specific problem exist such as:
vaginal bleeding or ruptured membrane.
If a woman has a history of abortion, she
should avoid sexual intercourse in the early
months of pregnancy.

Exercises:
Exercise should be simple. Walking is ideal,
but long period of walking should be
avoided.
The pregnant woman should avoid lifting
heavy weights such as: mattresses furniture,
as it may lead to abortion.
She should avoid long period of standing
because it predisposes her to varicose vein.
She should avoid setting with legs crossed
because it will impede circulation.

Purpose:
1. To develop a good posture.
2. To reduce constipation & insomnia.
3. To alleviate discomvortable, postural back
ache& fatigue.
4. To ensure good muscles tone& strength
pelvic supports.
5 To develop good breathing habits, ensure
good oxygen supply to the fetus.
6- to prevent circulatory stasis in lower
extremities, promote circulation, lessen the
possibility of venous thrombosis

 Guide lines for exercises during pregnancy:

-Maintain adequate fluid intake.
-Warm up slowly, use stretching exercises but
avoid over stretching to prevent injury to
ligaments.
-Avoid jerking or bouncing exercises.
Be careful of loose throw rugs that could slip&
cause injury.
Exercises on regular basis (three times per week).
After first trimester, avoid exercises that require
supine position.

 Contraindications:
-Vaginal bleeding.
-Sever anemia.
-History of preterm labor,
-Extreme over or under weight.
-Hypertension, heart, lung, thyroid diseases

Sleep:
The pregnant woman should lie down to relax
or sleep for 1 or 2 hours during the afternoon.
At least 8 hours sleep should be obtained every
night & increased towards term, because the
highest level of growth hormone secretion
occurs at sleep.
Advise woman to use natural sedatives such as:
warm bath & glass of worm milk.

 A good sleeping position is sims position,

with the top leg forward. This puts the
weight of the fetus on the bed, not on the
woman, and allows good circulation in the
lower extremities.
avoid resting in supine position, as supine
hypotension syndrome can develop.

 Hazards
Occupational hazards: lead, mercury, X ray
s& ethylene oxide.
Infection: rubella, toxoplasmosis,
syphilis.......................
Smoking & alcohol: increase risk for
pregnancy, prematurity, fetal death, mental
retardation & congenital anomalies.
Drugs: as sedative & analysis,
anticoagulant, antithyrodism, hormones&
antibiotics.

Immunization:
the nurse instructs the woman to receive
immunization against -tetanus to prevent the
risk for her and her fetus.
Also, it is important that every pregnant
mother should receive a tetanus vaccination
card with her first tetanus dose and keep it to
record subsequent doses

 Diet:
-Daily requirement in pregnancy about
2500 calories.
- Women should be advised to eat more
vegetables, fruits, proteins, and vitamins
and to minimize their intake of fats.
Purpose:

*Growing fetus.
*Maintain mother health.
*Physical strength & vitality in labor.
*Successful lactation.

Managing the minor

disorders of pregnancy

Nausea and vomiting

-occur between 4-6 weeks gestation
Causes:
- hormonal influences: hcg, progesterone, estrogen.
- emotional factors like tension.
Management:
- adequate rest and relaxation.
- eating small six meals a day rather than three large meals.
- solid food tolerated better than liquid food like: crackers or
piece of dry toast.
- carbohydrate snacks at bedtime can prevent hypoglycemia
which cause nausea & vomiting.
- Food should not have a strong odor, should not be either very
hot or very cold, and fried or greasy foods should be
avoided.

Heartburn

Causes:
- progesterone hormone relaxes the cardiac sphincter of the
stomach and allows reflex or bubbling back of gastric contents
into the esophagus.
- the pressure of the growing uterus on the stomach from about
30-40 weeks.

Management:
- avoid

lying flat.
- sleeping with more pillows and lying on the right side.
- small frequent meals.
- take antacids.
- taking baking soda in a glass of water is contraindicated because
of the possibility of retention of sodium and subsequent edema
Avoid fried ,spicy, and fatty food
Avoid citrus juices

Backache
Cause:
Backache may be due to muscular fatigue
and strain that accompany poor body
balance.
It may be due to increased lordosis during
pregnancy in an effort to balance the
body.
The pregnancy hormones sometimes
soften the ligaments to such a degree that
some support is needed.

Management:
- exercise.
- sit with knee slightly higher than the hips.
-The pregnant woman is reassured that once
birth has occurred, the ligaments will
return to their pre-pregnant strength.

Urinary frequency
Cause:
Occur due to the pressure of the growing
uterus on the bladder.
Management:
The problem will resolved when the uterus
rises into the abdomen after the 12th week.
Kegel exercises are some times recommended
to help maintain the bladder.

Varicosities
Causes:
- progesterone relaxes the smooth muscles of the veins
and result in sluggish circulation. The valves of the
dilated veins become inefficient & varicose veins
result.
- weight of the uterus partially compressed the veins
returning blood from the legs.
Management:
- lying flat on the bed with the feet elevated.
- moving the legs about is better than standing still.

Constipation
Causes:
- intestinal motility decreased during pregnancy as a
result of progesterone.
- iron supplementation.
Management:
- the food should have amount of fruit & green
vegetables which contain fibers.
- drinking a lot of water.
- exercise & walking.
- laxatives could prescribed by physician.

Major Disorders

Asthma
Cystic fibrosis
Hypertension/PIH/PET
Arrthymias
Valvular disease
Cardiomyopathy
Cyanotic heart disease
Pulmonary hypertension
Epilepsy
Multiple sclerosis
Intracranial hypertension
Benign cranial tumours.eg.
adenomas
Obstetric Cholestasis

Acute Fatty Liver of Pregnancy

IBS
Crohns/Ulceative colitis
Thrombophilias
Antiphospholipid syndrome
SLE
Rheumatoid arthritis
Sickle cell disease/thalassaemias
Anaemia
Diabetes
Hypo/hyperthyroidism
Adrenal disease
Cancer

DIABETES
Important issue in pregnancy
Major impacts on maternal and fetal health

Requires multidisciplinary care in combined

clinic
Pre-existing Type 1
Pre-existing Type 2 (increasing)
Gestational Diabetes (increasing)

 Effects of diabetes on
pregnancy
Miscarriage
Fetal malformations
Cardiac
Neural tube
Caudal regressions
syndrome (200x)

IUGR
Macrosomia
Unexplained IUD
PET

Effects of pregnancy on
diabetes
Poorer control
Deterioration of renal
function
Deterioration of opthalmic
disease
Gestational DM

Effects of Diabetes - fetus

Maternal diabetes
hyperglycaemia
Fetal hyperinsulinaemia
Increased fetal growth
Fetal
macrosomia

Polyuria
Increased oxygen demands
Polyhydramnios
Polycythaemia

Risk of preterm labour

/ malpresentation/
cord prolapse

Risk of birth injury/

shoulder dystocia

Neonatal
hypoglycaemia

Risk of
cerebral palsy

Risk of unexplained
term stillbirth

Fetal effects
Macrosomia
Increased risks of birth injury/ shoulder
dystocia***
Major cause of obstetric litigation
LSCS recommended in DM where
macrosomia and EFW >4000g

Polyhdramnios
Fetal malpresentations and possible increased
risk preterm labour

Hyperinsulinaemia
Severe hypoglycaemia (risk of CP)

Polycythaemia
Thrombotic effects
Jaundice

Hypocalcaemia

Thyroid and Pregnancy

hCG has thyrotrophic function
May suppress TSH during first trimester
Thyrotoxicosis may be a feature of hydatidiform pregnancy where
levels of hCG are extremely elevated

Thyroid function remains essentially normal in pregnancy

Marked increase in thyroid binding globulin (? Effect of oestrogen?)
Increase in bound thyroxin (T4) t3 (more active)and rT3 (inactive)
Free T4 and T3 are unaltered or slightly reduced
NOTE: increased BMR, tachycardia, elevated body temperature
and increased CO are normal in pregnancy but may mimic the
effects of hyperthyoidism

Thyroid and Pregnancy

Hyperthyroid

May worsen due to HCG

Risks-hyperemesis, miscarriage
Can use carbimazole
Regular TFTs and multidisciplinary care

If well controlled, no other impact on

pregnancy care (fetal growth, delivery etc)
Inform Paeds to check fetal thyroid function,
especially if pt has thyroid Abnormalities

Pre-Eclampsia

Definition
Hypertension and proteinuria with onset 20
weeks
Oedema in the face

Diastolic 90mmHg on 2 occasions 4-6 hours

apart OR 110mmHg on one occasion
Proteinuria >300mg/24 hours

PET/Eclampsia

George Eliot Hospital, Nuneaton

95

Risk Factors:-Pre-Eclampsia
Primiparous
First pregnancy
Family history (1 in 3
risk if mother had PET)
Twins/multiples
Pregestational Diabetes

PET/Eclampsia

Essential hypertension
Renal disease
SLE
Antiphospholipid
syndrome
Age >40
Obesity

George Eliot Hospital, Nuneaton

96

What questions should you ask?

Headache (classically severe)
Effects hypertension

Visual disturbances (flashing lights)

Sign of cerebral vasospasm/impending eclampsia

Epigastric pain
Hepatic congestion/liver capsule stretching

Is baby moving normally?

Fetal wellbeing

Eclampsia
Occurrence of fits
44% postpartum
38% antenatal)
ALWAYS GRAND MAL

Due usually to cerebral vasospasm

Prevent maternal injury
Maintain oxygenation
Prevent aspiration
ABC

PET/Eclampsia

George Eliot Hospital, Nuneaton

98

Essential Hypertension
Pre-existing raised blood pressure
May be on treatment or just under
observation
May be known prior to pregnancy or
detected at booking as raised BP

Cardiovascular changes of Pregnancy

Massive changes in
cardiac output and
haemodynamics
Already occurred
largely by 12 weeks

Risks to Mum
Worsening of BP
Superimposed preeclampsia
Medical overintervention

Risks to Baby
Teratogenesis from
certain drugs (eg ACE
Inhib.)
IUGR
Pre-eclampsia
Hypoglycaemia if on
labetolol and
breastfeeding

Cardiac Disease
Pre-existing/congenital
Valvular disease
coarctation

Acquired
IHD
Aortic aneurysm
cardiomyopathy

ASTHMA
Commonest chronic medical illness to
complicate pregnancy
Up to 7% women of childbearing age
Often undiagnosed or undertreated

Effects of Pregnancy on Asthma

May improve, deteriorate or remain unchanged
Mild disease-unlikely to experience problems
Severe disease-greater risk of deterioration,
esp. in 3rd trimester
Improvement in 3rd trimester may experience
postnatal deterioration
Deterioration often due to reduction or
cessation of medications due to (unfounded)
safety fears

Effects of Asthma on Pregnancy

Most women-no adverse effects on pregnancy outcome
Severe, poorly controlled-asthmatics associated with
hypoxaemia may adversely affect fetus
Adverse effects on pregnancy rare and associated with
poor control

PIH/PET
PTL/birth
LBW
IUGR
Neonatal morbidity , hypoglycaemia, seizures, NNU
admission

EPILEPSY
About 0.5% women of
childbearing age
Most diagnosed (known)
prior to pregnancy
All seizure types may be
affected by pregnancy
Associated with risks
maternal death due to
aspiration

Effect of Pregnancy on Epilepsy

seizure frequency
Decreased % no change
If seizure free unlikely to have seizures
UNLESS stops medications
Poorly-controlled (>1/month) likely to
deteriorate in pregnancy

Any Questions?

Normal Labor and Delivery

Definition
Labor is the process by which contractions of the gravid
uterus expel the fetus.
A term pregnancy delivers between 37 and 42 weeks from the
last menstrual period (LMP).
Preterm labor is that occurring before 37 weeks of gestational
age.
Postdate pregnancy occurs after 42 weeks gestation and
requires careful monitoring.
Termination of pregnancy before 20 weeks of gestation is
defined as either spontaneous or elective abortion.

Definition
Primigravida - pregnant for first time
Multigravida - pregnant more than once
Viability - able to survive outside the womb
(24+ weeks gestation)
Nulliparous - never carried a pregnancy to
viability
Multiparous - has had two or more deliveries
that were carried to viability

The initiation of labor

Labor is influenced by combination of factors
include:
- Uterine stretching
- Progesterone withdrawal
- increased oxytocin sensitivity
- increased level of prostaglandins

Theories that explain initiation of labor:

Change in estrogen-to- progesterone ratio. Which
facilitate coordination of uterine contraction and
myometrium stretching.
Prostaglandin level increase in late pregnancy
secondary to elevated level of estrogen. It
stimulates smooth muscle contraction of the
uterus:
Leads to myometrium contraction
Reduce cervical resistance
The cervix becomes soft, thin out and dilate during
labor.

Theories that explain initiation of labor:

Increased number of oxytocin receptors late in
pregnancy, this increased the sensitivity to
oxytocin as its also increased in response to
estrogen rising.
Oxytocin also aid in stimulation of
prostaglandin synthesis in the decidua.

Oxytocin effect
The hormone oxytocin stimulates and enhances labor
contractions. As the baby moves toward the vagina (birth
canal), pressure receptors within the cervix (muscular outlet
of uterus) send messages to the brain to produce oxytocin.
Oxytocin travels to the uterus through the bloodstream,
stimulating the muscles in the uterine wall to contract stronger
(increase of ideal normal value).
The contractions intensify increase until the baby is outside
the birth canal.
When the stimulus to the pressure receptors ends, oxytocin
production stops and labor contractions cease.

Premonitory signs of labor

Cervical changes
softening and dilation with descent of the
presenting part into the pelvic. This stage occurs
one month to one hour before actual labor.
The cervix becomes shortened and thinned
segment

Premonitory signs of labor

Lightening: occurs when the fetal presenting part begins to

descend into the maternal pelvic. The uterus lowers and
moves into a more anterior position. this change will cause:
Breathing becomes easier
Increased pelvic pressure
Cramping and low backache
Lower extremities edema
Increased vaginal secretion
More frequent urination
In PG it occurs 2 weeks ore more before labor.
In MP it occurs during labor

Premonitory signs of labor

Increased energy level : many women will focus

this energy in preparation by cleaning, cooking,
preparing the nurseryit is usually occur 24-48
hours before labor.

Bloody show: the mucus plug of the cervical canal

during pregnancy is expelled as a result of cervical
softening and increased pressure of the presenting
part. The exposed cervical capillaries release a small
amount of blood that mix with the mucus, resulting
in bloody show.

Premonitory signs of labor

Braxton Hicks Contraction: these

contractions aid in moving the cervix from the
posterior position to the anterior position, they
also help in ripening and softening of the
cervix.

The contractions are irregular and diminished

by walking, voiding, eating, increasing fluid
intake, or changing position.

Premonitory signs of labor

Spontaneous rupture of membrane: one in four women
experience SROM before onset of labor. This reduces the
capacity of the uterus, thickens the uterine wall, and increases
uterine irritability. Labor usually follows.

At term, 90% will be in labor within 24 h after membrane rupture.

If labor does not begin in 24 h, the case must be considered
complicated by prolonged rupture of the membranes because
of the increased risk of ascending infection.
Risk of cord prolapses is increased if engagement of the
presenting part not occur.

True versus false labor:

Differentiating True Labor and False Labor

Factors

True labor

False labor

Contractions
timing

Regular intervals, becoming close together, usually 4-6 minutes apart,

lasting 30-60 seconds.

Irregular intervals,
not occurring close
together

Contraction
strength

Becomes stronger with time, vaginal pressure is usually felt

Frequently weak,
not getting strong
with time

Contraction
discomfort

Start in the back and radiates around toward the front of the abdomen

Usually felt in the

front of the
abdomen

Position changes

Contractions continue no matter what positional changes is made

Contraction may
stop or slow down
with walking or
changing position

Effect of analgesia

Not terminated by sedation

Frequently
abolished by
sedation

Cervical change

Progressive effacement and dilation

No change

Factors affecting the labor process:

Labor entails the interaction of the so-called
5Ps:
Passageway( birth canal)
Passenger( fetus and placenta)
Power( contractions)
Position( maternal)
Psychological response

Passageway:
It consist of maternal pelvis and soft tissue
Bony pelvis: it is divided into:
- False pelvis: consist of the upper flared parts
of the two iliac crests
- True pelvis: the bony passageway through
which the fetus must travel, it made-up of
three planes:

Pelvic shape:

Anthropoid pelvis: is common in men and occurs in 20-30%

of women. This pelvis is usually favorable for a vaginal
delivery.
Android pelvis: common in men and occurs approximately in
20% of women, it has a heart shape inlet with narrow side
walls. It is called a funnel pelvis and produces a difficult
vaginal delivery.
Gynecoid pelvis: is less common in men and is considered the
true female pelvis, although only about half of all women
have this type, vaginal birth is most favorable with this type.
Platypelloid or flat pelvis is the least common type of pelvic
structure among men and women with incidence of 5%.
Women with this pelvis require C/S.

Passenger
a. Fetal skull: is the largest presenting part and least
compressible fetal structure, making it an important factor in
relation to labor and birth.
Bones 6 bones: S sphenoid, F frontal sinciput, E
ethmoid, O occuputal occiput, T temporal, P parietal
2x
Measu rement fetal head:
1. transverse diameter 9.25cm
- biparietal largest transverse
- bitemporal 8 cm
2. bimastoid 7cm smallest transverse

Passenger
Sutures intermembranous spaces that allow molding.
1.) Sagittal suture connects 2 parietal bones
2.) Coronal suture connect parietal & frontal bone
3.) Lambdoidal suture connects occipital & parietal
bone
Moldings: the overlapping of the sutures of the skull to
permit passage of the head to the pelvis

Passenger
Fontanels:
1.) Anterior fontanel bregma, diamond shape,
3 x 4 cm, (> 5 cm hydrocephalus), 12 18
months after birth- close
2.) Posterior fontanel or lambda triangular
shape, 1 x 1 cm.
closes 2 3 months after birth

Fetal skull

Fetal attitude
Is another important consideration related to
passenger.
It refers to the posturing (flexion or extension)
of the joints and the relationship of fetal parts
to one another.

Fetal Lie
The relationship of the long axis of the fetus
to the long axis of the mother. The lie is
longitudinal with a vertex or breech
presentation or otherwise transverse or
oblique, as with a shoulder presentation

Fetal Presentation
Presentation describes that part of the fetus that
is lowest in the pelvis inlet first three main
fetal presentation:
the cephalic( head): 95% of the term new born
the breech( pelvis): 3% of term births
the shoulder( scapula): 2% of term births.

The Powers
Forces generated by uterine musculature
Frequency, amplitude, and duration of
contractions
Observation, manual palpation
Contractions cause complete dilation and
effacement of the cervix.

Uterine contraction:
Uterine contraction is involuntary and there fore
cannot be controlled by the experiencing women.ut.
Cont. is intermittent and rhythmic with a period of
relaxation. Uterine cont.has three phases:
Increment: building up of the contraction
Acme: peak or highest intensity
Decrement: descent or relaxation of the uterine
muscle fibers

Maternal position:
Changing positions and moving around during birth offer
several benefits, it facilitate fetal descend and rotation
Squatting position enlarges the pelvic outlet by approximately
25% .
The use of upright or lateral position compared with supine or
lithotomy positions may:
reduce the duration of the second stage of labor
reduce the number of assisted deliveries( vacuum and forceps)

Maternal position:

reduce episiotomies and perineal tear

contribute to fewer abnormal fetal heart
increase comfort/ reduce request for pain
medication
enhance a sense of control reported by mothers
alert the shape and size of the pelvis, which assist
descent
assist gravity to move the fetus downward
reduce the length of labor

Psychological responses:
The birth experience influence the woman's self
confidence, self esteem, and her view of life, her
relationships, and her children.
Factors influencing a positive birth experience include:

clear information on procedure

positive support, not being alone
sense of mastery, self- confidence
trust in staff caring for her
positive reaction to the pregnancy
personal control over breathing
Preparation for childbirth experience.

Physiologic responses to labor:

Maternal responses:
Increased heart rate by 10 to 18 bpm
Increased cardiac output by l 0 to 15% during the first stage
of labor and increased by 30 to 50% during the second stage
of labor
Increased blood pressure by 10 to 30 mm Hg during uterine
contractions in all labor stages
Increase in white blood cell count to 25,000 to 30,000
cells/mm3 perhaps as a result of tissue trauma
Increased respiratory rate along with greater oxygen
consumption related to the increase in metabolism

Maternal responses:

Decreased gastric motility and food absorption, which may

increase the risk of nausea and vomiting during the transition
stage of labor
Decreased gastric emptying and gastric pH , which increase
the risk of vomiting and aspiration
Slight elevation in temperature possibly as a result of an
increase in muscle activity.
Muscular aches/cramps as a result of a stressed
musculoskeletal system involved in the labor process.
Increased BMR and decreased blood glucose level because of
the stress of labor.

Fetal responses
1.
2.
3.
4.
5.

Periodic fetal heart rate accelerations and slight

decelerations related to fetal movement, fundal pressure,
and uterine contractions.
Decrease in circulation and perfusion to the fetus secondary
to uterine contractions.
Increased in arterial carbon dioxide pressure(PCO2)
Decrease in fetal breathing movements throughout labor.
Decrease in fetal oxygen pressure with a decrease in the
partial pressure of oxygen (PO2).

Stages of labor:

The first stage of labor begins with the onset of labor and
ends with complete (10 cm) dilatation of the cervix.
Duration of the first stage:

The first stage is the longest, averaging 812 h for

primigravidas or 68 h for multiparas.

However, the first stage of labor may be markedly shorter

or longer depending on the 4Ps.

Labor is a very dynamic process, and contractions should

increase steadily in regularity, intensity, and duration. This
is not always the case, and one must set limits concerning
the progress of labor.

Phases of the first stage labor:

Latent phase of labor begins with the onset of regular uterine
contractions and extends to the start of the active phase of cervical
dilatation (_0-3 cm).
Contractions may or may not be painful( mild)
Cervical effacement from 0-40%
Dilate very slowly
Can talk or laugh through contractions
May last days or longer
May be treated with sedation, hydration, ambulation, rest, or
pitocin
Nullipara lasting up to 9 hours, multipara lasting up to 5 to 6
hours.
prolonged latent phase: defined as greater than 20 hours in a
nullipara and greater than 14 hours in a parous woman

Phases of the first stage labor:

Active phase of labor: lasts from 4 to 7 cm dilation, moderate
contractions.
Regular, frequent, usually painful contractions
cervical dilation rate of 1.2 cm/hr for nulliparas and 1.5 cm/hr
for parous women
cervical effacement 40 to 80%
nullipara lasting lasting up to 6 hours, multipara lasting up to
4 hours.
Contraction frequency every 2 to 5 min.
Contraction duration 45 to 60 seconds.
Are not comfortable with talking or laughing during their
contractions

Phases of the first stage labor:

Transition phase: is from 8 to 10cm
dilation, strong uterine contraction.
Cervical effacement from 80 to 100%
Nullipara lasting up to 1 hour, multi Para
lasting up to 30 minutes.
Contraction duration 60 to 90 seconds
Contraction intensity hard by palpation.

Stages of labor
(2) The second stage of labor begins when the
cervix becomes fully dilated and ends with the
complete birth of the infant. The second stage
normally lasts up to 1 hour. While one should
be concerned when the second stage extends
longer than 1 h (based on fetal morbidity and
mortality). Safety for the fetus may be assured
by thoughtful monitoring.

The second stage of labor

Pelvic phase: period of fetal descend
Perineal phase: period of active pushing
Nullipara lasts up to 1 hour, multipara lasts up
to 30 minutes.
Contraction frequency every 2 to 3 minutes or
less
Contraction duration 60 to 90 seconds.
Strong urge to push in perineal phase.

Stages of labor
(3) The third, or placental, stage of labor is the period
from birth of the infant to 1 h after delivery of the
placenta. The rapidity of separation and means of
recovery of the placenta determine the duration of
the third stage
(4) Fourth stage of labor: is 1 to 4 hours after birth,
time of maternal physiologic adjustment.

Cardinal movements of
labour/mechanisms of normal
labour
The process of labor and delivery is marked
by characteristic changes in fetal position or
cardinal movements in relation to the maternal
pelvis. These spontaneous adjustments are
made to effect efficient passage through the
pelvis as the fetus descends.

Cardinal movement of labor:

Engagement is the descent of the largest transverse
diameter, of the fetal skull, to a level below the pelvic
inlet.
Descent of the head is a continuous process
occurring throughout labour.
Flexion decreases when the AP diameter of the fetal
head encounters the levator muscles. Later, further
flexion occurs, further reducing the diameters of the
fetal skull.

Cardinal movement of labour:

Internal rotation occurs in the midpelvis. The architecture of
the midpelvic passageway changes so that the AP diameter of
the maternal pelvis at this level is greater than the transverse
diameter. The fetus accommodates to this change by rotation
of the head from a transverse orientation to an AP alignment ,
thus accomplishing internal rotation. Further descent to the
level of the perineum occurs with the head aligned in the AP
plane.

Cardinal movement of labour:

Extension of the head allows delivery of the
head from the usual occiput anterior position
through the introitus. The face appears over
the perineal body
Occurs once fetus has descended to the level
of the introitus
Base of occiput in contact with inferior
margin of symphysis pubis

Cardinal movement of labor:

External rotation occurs after delivery of the head,
when the fetal head rotates back, or restitutes, toward
the original transverse orientation.(external rotation
or restitution)
Expulsion: The remainder of the delivery proceeds
with presentation of the anterior shoulder beneath the
symphysis pubis and the posterior shoulder across
the posterior fourchette

Care of the mother during labour

ADMISSION PROCEDURE
-One of the most critical diagnoses in obstetrics is the accurate diagnosis of
labour:
History
Physical examination:
Fundal height measurement
Uterine contraction (duration, frequency, intensity)
fetus (presentation, heart rate, size)
fetal membrane, vaginal bleeding & leakage
The fetal heart rate should be checked, especially at the end of a
contraction and immediately, thereafter, to identify pathological slowing
of the heart rate
Pain level

Laboratory studies:

CBC
Blood type and RH
UA (protein, glucose)
Syphillis, hepatitis B, HIV

Management the fist stage of labor:

Ambulation OK with intact membranes
If in bed, lie on one side or the othernot flat
on her back
Check vital signs every 4 hours (if membrane
rupture or high temperature: hourly)

Oral intake
- food should be withheld during active labour and

delivery
- in labour analgesics may be are administered
:gastric emptying time is prolonged
:not absorbed ,vomited, and aspiration
-sips of clear liquids, occasional ice chips, and lip
moisturizers are permitted
Intravenous fluids
-there is seldom any real need for such in the
normally pregnant at least until analgesia is
administered

 During early labor, for low risk patients, note

the fetal heart rate every 1-2 hours.
During active labor, evaluate the fetal heart
every 30 minutes

Urinary bladder function

-bladder distention should be avoided

: obstructed labor
subsequent bladder hypotonia and infection
-ambulation: self voiding, if not, intermittent
catheterization

Evaluation of labor progress:

Vaginal examination:

Dilatation and effacement of the cervix:

Rupture of membrane
Fetal descent and presenting part

Uterine contraction
Abdominal palpitation Maneuvers

Postpartum Physiology

Postpartum period
Is the interval between the birth of the
newborn and the return of the reproductive
organs to their normal nonpregnant state
It lasts for 6 weeks, with some variation
among women.

Postdelivery Assessment
Greatest risk for postpartum complications
is during the first 24 hours after delivery
Identification of potential problems;
immediate intervention; reassessment

 Assessment includes:

Condition of uterus
Amount of bleeding
Bladder & voiding
Vital Signs
Perineum

 Fundus = Palpated to assess firm & well

contracted
Bleeding = Assess drainage on pad
Pulse & Bp = Assess cardiovascular
function
Perineum = Assess for signs of hematoma,
lacerations, & edema

 Assessments are q 15 minutes for the first

hour post delivery
Temperature is taken at the end of first hour
Transferred to Postpartum Unit when stable

Admission to Postpartum Unit

Postpartum unit informed of transfer
Reports on both mother and baby status
handed over
Preparations made for receiving the Mother
such as:

Room Ready
IV Pole
Admission Assessment
Vital Signs Equipment

Assessment
Assessment is immediately upon arrival to
the Unit
Complete Assessment
- VS

Reassessment q Hour x 4 Hours

Uterus, Lochia, Bladder, Bp & Pulse

Vital Signs
Elevated Temperature
Normal finding for first 24 hours
Sign of Dehydration
Sign of Infection

Bradycardia
Normal Finding

 Tachycardia

Infection
Hemorrhage
Pain
Anxiety

Lowered Blood Pressure

Orthostatic Hypotension
Shock
Elevated blood pressure- PIH

Post C/S
Additional Assessment:

Incision
Fluid Intake
Bladder & Bowel
Ambulation/Orthostatic Hypotention
Thrombophlebitis

Uterus
Involution:-is the return of the uterus to a
nonpregnant state after childbirth
Involution process begins immediately after
expulsion of the placenta with contraction
of uterine smooth muscles

Cont.
At the end of third stage of labor, the uterus is
in the midline, about 2cm below the level of
the umbilicus and weighs 1000g
By 24 hours postpartum the uterus is about
the same size it was at 20 gestational weeks

Cont
-The fundus descends about 1 to 2cm every 24
hours, and by the sixth postpartum day it is
located halfway between the symphysis pubis
and the umbilicus.
-The uterus lies in the true pelvis within 2 weeks
after childbirth.

-It involutes to about 500g by 1 week after

birth, 350g by 2 weeks, and at 6 weeks it
has returned to its nonpregnant size 50-60g

Involutionoftheuterus.A,Immediatelyafterdeliveryof
theplacenta,thefundusismidlineandhalfwaybetweenthe
symphysispubisandtheumbilicus.B,About6to12hours
afterbirth,thefundusisattheleveloftheumbilicus.Itthen
descendsonefingerbreadth(approximately1cm)eachday.

Cont
Lochia
-It is the uterine discharge that occurs after birth.
Lochia is initially bright red changing later to a pinkish
red or reddish brown
-For the first 2 hours after birth the amount of lochia
should be about that of a heavy menstrual period,
after that time the lochial flow should steadily
decrease.

Cont

Lochia passes through 3 stages:1-lochia rubra:-it consists of blood, decidual and

trophoplastic debris
It lasts 3-4 days after childbirth
.
2-lochia serosa:-it consists of old blood, serum,
leukocytes, and tissue debris. the flow becomes pink or
brown.
It is expelled 3-10 days postpartum

Cont
3-lochia alba:-it consists of leukocytes, decidua,
epithelial cells, mucus, and bacteria. it is yellow to
white in color.
Lochia alba may continue to drain for up to and beyond
6 weeks after childbirth.
The amount of lochia is usually increases with
ambulation, and breastfeeding.

Cont
Persistence of lochia rubra early in the
postpartum period suggests continued
bleeding as a result of retained fragments of
the placenta or membranes.
The another common source of vaginal
bleeding is vaginal or cervical laceration.

Suggestedguidelineforassessinglochiavolume.

 A good method to remember how to check the postpartum

changes is the use of the acronym BUBBLERS:
B: Breast.
U: Uterus.
B: Bladder.
B: Bowel.
L: Lochia.
E: Episiotomy.
R: Emotional response.
S: Homans' sign.

BUBBLEHE Assessment

Breasts Soft, filling, firm, Nipples

Uterus consistency, position, height, C/S
Bladder voiding pattern
Bowels bowel sounds, hemorrhoids, BM
Lochia type, amt, clots, odor
Episiotomy laceration, bruising, swelling
Homan sign present or not
Emotional status bonding, blues

Complications
Hemorrhage Hgb < 9 requires Tx
atony- most common cause is full bladder
laceration bleeding with firm uterus
placenta fragments bleeding returns to rubra or foul odor
noted
Infection Temp above 100.4 F
urinary
mastitis
Thrombophlebitis pain and redness,
+Homan send for venous scan
pulmonary embolism sudden onset chest pain, SOB

Postpartum Depression/Psychosis
Postpartum depression- 15-25% - all ethnic groups
affected.
Cause unknown, may be related to hormones,
exhaustion, anger, chronic stress
S&S: starts first 4 wks and last several months,
fatigue, loss of self, suicide thoughts crying
TX: combination of psychotherapy, social, meds
Postpartum psychosis- rare, bipolar disorder or
major depression, frightening thoughts, delusions of
dead baby and hallucinations, need psychiatric Tx,
will not resolve itself

Nursing Care
Involution 6-7 weeks
Descent of uterus midline and descend 1cm/d
Lochia unique healing process
rubra 2-3 days - dark red with small clots
serosa 4-10 days pink to brownish
alba 1-6 weeks cream-white
Perineum if episiotomy, takes 3-6 weeks

Nursing Care - Teaching

Bladder diuresis first 24 hours
Stomach resume exercise after Dr says
Menstruations 6 weeks, delayed with lactating
mothers, STILL ovulating
Sex resume after first menstruation, after
episiotomy some loose interest for one year
Rest, Rest, Rest

summary
-Postpartum physiologic changes allow the woman

to tolerate considerable blood loss at birth

-The uterus involutes rapidly after birth returning to
true pelvis within 2 weeks
-The rapid decrease in estrogen and progesterone
levels after the expulsion of the placenta is
responsible for triggering many of anatomic and
physiologic changes in postpartum period
- Six week visit is scheduled