MCN  Eyelids can now open.

 Pupils react to light.

Milestones of Fetal Growth and Development  The fetus has reached the age of viability, wherein
they could survive externally if cared for in a modern
4th Week of Gestation intensive facility.
 Responds to sudden sounds.
 Spinal cord is formed and fused at the midpoint.
 Head folds forward and is prominent. 28th Week of Gestation
 The back is bent, which makes the head almost touch
the tail.  Surfactant is demonstrated in the amniotic fluid.
 A prominent bulge appears which would later form as  Alveoli are starting to mature.
the heart.  Testes descend into the scrotal sac.
 Lateral wings, the body, folds forward and fuse at  Retinal blood vessels start to form but are highly
midline. susceptible to damage.
 Arms and legs are budlike structures.
 Eyes, ears, and nose are barely recognizable. 32nd Week of Gestation

8th Week of Gestation  Subcutaneous fat is deposited.

 Fetus responds to sounds outside the mother’s body
 Organogenesis is achieved and complete. through movements.
 The heart already developed a septum and valves  Active Moro reflex is present.
and is beating rhythmically.  Iron stores are starting to develop.
 Arms and legs have developed.  Fingernails are starting to grow.
 Facial features are noticeable.
 The genital starts to form but is not yet recognizable. 36th Week of Gestation
 Fetal intestine is rapidly growing.
 Results of an ultrasound would show a gestational  Depositions of iron, carbohydrate, calcium, and
sac which confirms pregnancy. glycogen stores are in the body.
 Additional subcutaneous fats are deposited.
12th Week of Gestation (First Trimester)  One or two creases are present at the sole of the foot.
 Lanugo starts to diminish.
 The toes and fingers already have nail beds.  Some babies turn and assume a vertex presentation.
 Faint fetal movements are starting.
 Early reflexes are present. 40th Week of Gestation (Third Trimester)
 Tooth buds are forming.
 Formation of bone ossification centers initiate.  Fetus now kicks very actively and hard enough to
 The genital is already recognizable through its cause discomfort.
appearance.  The fetal hemoglobin is being converted to adult
 Urine secretion begins but is not yet evident. hemoglobin.
 Heartbeat could be detected by Doppler.  Vernix caseosa is fully formed.
 Fingernails extend to the fingertips.
16th Week of Gestation  The soles of the feet have creases that cover at least
two-thirds of the surface.
 An ordinary stethoscope could detect the fetus’ heart
beat. Obstetric History
 Lanugo has started to form.
 The pancreas and liver are forming.  Previous Obstetric History
 Urine is present in the amniotic fluid.
 Fetus starts to swallow the amniotic fluid. A good starting point is to ask about number of children the
 Ultrasound could determine the sex of the fetus. patient has given birth to. Next, sensitively ask about
miscarriages, stillbirths, ectopics and terminations.
20th Week of Gestation
Term Pregnancies
 Mother could sense spontaneous fetal movements.
 There is hair formation on the head until the For each previous pregnancy carried beyond 24 weeks, inquire
eyebrows. about the following:
 The upper intestine contains meconium.
 Brown fat starts to form behind the kidneys, sternum,  Gestation – previous preterm labour is a risk factor
and posterior neck. for subsequent preterm labour.
 Vernix caseosa also starts to form and covers the  Mode of delivery – spontaneous vaginal, assisted
skin. vaginal or Caesarean.
 Passive antibody transfer begins.  Gender
 The sleep and activity patterns of the fetus are  Birth weight – a previous small for gestational age
evident. (SGA) baby increases the risk of a subsequent one.
 Complications – e.g. pre-eclampsia, gestational
24th Week of Gestation (Second Trimester) hypertension, gestational diabetes, obstetric anal
sphincter injury (3rd, 4th degree tears), post-partum
 Lung surfactant begins to develop. haemorrhage.
 Meconium is present at the rectum.  Assisted reproductive therapies (ART) – e.g.
 Eyebrows and eyelashes are distinguishable. ovulation induction with clomiphene, IVF.
  Care providers – was the patient’s care completely  Family History
with a midwife or was there previous obstetric input, if
so, why Although not usually regarded as a substantial part of the
 ART pregnancies are often conceived after a long obstetric history, there is increasing evidence that certain
period of time and after much psychological distress; conditions are associated with adverse pregnancy outcomes.
it is important to be aware of this. In addition, use of
ARTs can increase the risk of pre-eclampsia during
pregnancy. Conditions such as cystic fibrosis and sickle-cell disease
are heritable – the patient should be counselled as to the risk
Other Pregnancies of her baby developing these conditions (based on the parental
genotypes).
For pregnancies not carried beyond 24 weeks, inquire about:
A family history of type 2 diabetes in a first degree relative is
 Gestation – miscarriages can be classified into early considered a risk factor for developing gestational diabetes.
pregnancy (12 weeks or less) or second trimester (13-
24 weeks).
 Social History
 Miscarriages – outcome (spontaneous, medical
management, surgical management – evacuation of
retained products of conception). Pregnancy can be a time of great elation, intense anxiety – and
 Terminations – method of management: medical or quite possible a mixture of anything and everything between.
surgical. Ask the patient about her thoughts of the pregnancy; be
 Identified causes of miscarriage / stillbirth – e.g. sensitive if the pregnancy is unplanned.
abnormal parental karyotype, fetal anomaly.
 Ask about current / previous occupation, and plans for
For ectopic pregnancies, ask about: returning to work (or otherwise).
 Inquire about home circumstances: e.g. who does the
 Site of the ectopic patient live with – partner / spouse? Children in the
 Management: expectant (monitoring of serum hCG home? Ask also about support networks, e.g. parents
levels), medical (methotrexate injection), surgical / in-laws, neighbors, friends.
(laparoscopy or laparotomy; salpingectomy (removal  Inquire about financial circumstances – the cost of
of tube) or -otomy (cutting of tube and suctioning of caring for a child in addition to being out of work can
trophoblastic tissue)) potentially have an adverse impact on the patient’s
ability to cope financially. Is the patient eligible for
 Past Medical History social security / child benefit payments?
 Ask about smoking – how many per day; what drug
Ask the usual questions about past medical history, abdominal (tobacco, cannabis, others); duration of smoking.
or pelvic surgery and mental health conditions. Remember that Would the patient like to quit, and would they like help
the medical co-morbidities that are most likely to affect women with this? Reiterate the association between smoking
of childbearing age include: and small-for-gestational-age babies, and offer her
help to quit.
 Asthma
 Cystic fibrosis It is also important to remember that at least once during the
 Epilepsy course of the pregnancy, women should be asked whether
 Hypertension (older women) they are victim to domestic abuse.
 Congenital heart disease
 Diabetes – check if type 1 or type 2 Techniques for Fetal Movement Counts
 Systemic autoimmune disease e.g. systemic lupus
erythematosus (SLE), rheumatoid arthritis Cardiff Technique
 Haemoglobinopathies: sickle-cell disease,
thalassaemias
 Blood-borne viruses: HIV, hepatitis B, hepatitis C o The woman lies or sits and concentrates on fetal
movements until she records 10 movements. She
 Drug History must record the length of time during which the 10
movements occurred. She is instructed to notify her
In addition to asking about drug allergies and intolerances, be health care provider if she doesn’t feel at least 10
aware that the embryonic (first 12 weeks) period of pregnancy movements within 1 hour. Further follow-up testing is
is thought to be the time of most sensitivity for drugs to cause indicated.
fetal structural defects (teratogenicity). Thus, inquire about
drugs taken around conception and during the first 12 weeks. Sadovsky Technique

Inquire about drugs currently being taken (include

o The woman lies down on her left side for 1 hour after
herbal/complementary therapies). Ask about illicit drugs and
meals and concentrates on fetal movement. Four
alcohol – recommend the patient to stop these drugs, and to
movements should be felt within 1 hour. If four
offer referral to help-to-quit services too.
movements have not been felt within 1 hour, then the
Recommend that the patient takes 400μg folic acid per day for woman should monitor movement for a second hour.
the first 12 weeks, to reduce the chance of the baby If after 2 hours four movements haven’t been felt, the
client should contact her health care provider.
developing a neural tube defect.
CDC Guidelines for Vaccine Administration During
Pregnancy

Vaccines That Should be Considered If Otherwise Indicated

• Hepatitis B, Influenza (inactivated), Tetanus/diphtheria,

Meningococcal, Rabies

Vaccines Contraindicated During Pregnancy

• Influenza (live, attenuated vaccine), Measles, Mumps,

Rubella, Varicella o Ripening of the cervix- is an internal sign seen only on
pelvic examination. Throughout pregnancy, the cervix
Signs of Labor feels softer than normal to palpation, similar to the
consistency of an earlobe (Goodell’s sign). At term,
Preliminary Signs of Labor the cervix becomes still softer (described as “butter-
soft”), and it tips forward. Cervical ripening this way is
an internal announcement that labor is very close at
o Lightening: In primiparas, lightening, or descent of the hand.
fetal presenting part into the pelvis, occurs
approximately 10 to 14 days before labor begins. This Signs of True Labor:
fetal descent changes a woman’s abdominal contour, involves uterine and cervical changes
because it positions the uterus lower and more
anterior in the abdomen. Lightening gives a woman o Uterine Contractions- The surest sign that labor has
relief from the diaphragmatic pressure and shortness begun is productive uterine contractions. Because
of breath that she has been experiencing and in this contractions are involuntary and come without
way “lightens” her load. Lightening probably occurs warning, their intensity can be frightening in early
early in primiparas because of tight abdominal labor. Helping a woman appreciate that she can
muscles. In multiparas, it is not as dramatic and predict when her next one will occur and therefore
usually occurs on the day of labor or even after labor can control the degree of discomfort she feels by
has begun. As the fetus sinks lower into the pelvis, a using breathing exercises offers her a sense of well-
woman may experience shooting leg pains from the being.
increased pressure on her sciatic nerve, increased o Show- As the cervix softens and ripens, the mucus
amounts of vaginal discharge, and urinary frequency plug that filled the cervical canal during pregnancy
from pressure on her bladder. (operculum) is expelled. The exposed cervical
o Increase in Level of Activity: a woman may awaken capillaries seep blood as a result of pressure exerted
on the morning of labor full of energy, in contrast to by the fetus. This blood, mixed with mucus, takes on
the feeling of chronic fatigue she felt during the a pink tinge and is referred to as “show” or “bloody
previous month. This increase in activity is related to show.” Women need to be aware of this event so that
an increase in epinephrine release initiated by a they do not think they are bleeding abnormally.
decrease in progesterone produced by the placenta. o Rupture of the Membranes- Labor may begin with
This additional epinephrine prepares a woman’s body rupture of the membranes, experienced either as a
for the work of labor ahead. sudden gush or as scanty, slow seeping of clear fluid
o Slight Loss of Weight- As progesterone level falls, from the vagina. Some women may worry if their labor
body fluid is more easily excreted from the body. This begins with rupture of the membranes, because they
increase in urine production can lead to a weight loss have heard that labor will then be “dry” and that this
between 1 and 3 pounds. will cause it to be difficult and long. Actually, amniotic
o Braxton Hicks Contractions- In the last week or days fluid continues to be produced until delivery of the
before labor begins, a woman usually notices membranes after the birth of a fetus, so no labor is
extremely strong Braxton Hicks contractions. Women ever “dry.” Early rupture of the membranes can be
having their first child may have great difficulty advantageous as it can cause the fetal head to settle
distinguishing between these and true contractions. snugly into the pelvis, actually shortening labor. Two
risks associated with ruptured membranes are
intrauterine infection and prolapse of the umbilical
cord, which could cut off the oxygen supply to the. In
most instances, if labor has not spontaneously
occurred by 24 hours after membrane rupture and the
pregnancy is at term, labor will be induced to help
reduce these risks.

Components of Labor

A successful labor depends on four integrated concepts:

  A woman’s pelvis (the passage) is of adequate size
and contour. Gravidity and Parity
 The passenger (the fetus) is of appropriate size and in  Gravida-it is used to describe a woman who is
an advantageous position and presentation. pregnant and is also a medical term for the total
 The powers of labor (uterine factors) are adequate. number of confirmed pregnancies a woman has had,
(The powers of labor are strongly influenced by the regardless of the outcome of the pregnancy.
woman’s position during labor.)  Para- refers to the total number of pregnancies that a
 A woman’s psychological outlook is preserved, so that woman has carried past 20 weeks of pregnancy. This
afterward labor can be viewed as a positive number includes both live births and pregnancy
experience. losses after 20 weeks, such as stillbirths.
 Primigravida- which means first pregnancy
Mechanisms (Cardinal Movements) of Labor  Multigravida- has been pregnant more than once.
 Grand multipara- is a woman who has already
delivered five or more infants who have achieved a
Passage of a fetus through the birth canal involves several gestational age of 24 weeks or more, and such
different position changes to keep the smallest diameter of the women are traditionally considered to be at higher risk
fetal head (in cephalic presentations) always presenting to the than the average in subsequent pregnancies
smallest diameter of the pelvis. These position changes are  Primipara- may be used to describe a woman who
termed the cardinal movements of labor: descent, flexion, has had one delivery after 20 weeks
internal rotation, extension, external rotation, and expulsion  Multipara- is used for a woman who has had two or
(Fig. 15.8). more births.
 Nulliparous- is the term that describes a woman who
 Descent. is the downward movement of the biparietal has never given birth after 20 weeks of pregnancy.
diameter of the fetal head to within the pelvic inlet.
Full descent occurs when the fetal head extrudes PRINCIPLES IN IDENTIFYING PARITY
beyond the dilated cervix and touches the posterior
vaginal floor. Descent occurs because of pressure on
the fetus by the uterine fundus. The pressure of the A. The number of pregnancies is counted and not the
fetal head on the sacral nerves at the pelvic floor number of fetuses. Multiple pregnancies do not
causes the mother to experience a pushing sensation. increase parity.
Full descent may be aided by abdominal muscle B. Abortion is not included in parity count because in
contraction as the woman pushes. abortion the fetus is delivered before the age of
 Flexion. As descent occurs and the fetal head viability (before 20 weeks).
reaches the pelvic floor, the head bends forward onto C. Live birth or stillbirth is counted in parity count.
the chest, making the smallest anteroposterior
diameter (the suboccipitobregmatic diameter) present OBSTETRICAL SCORING: CODING RESULTS OF
to the birth canal. Flexion is also aided by abdominal PREVIOUS PREGNANCIES
muscle contraction during pushing.
 Internal Rotation. During descent, the head enters
 T- Term (37-41weeks)
the pelvis with the fetal anteroposterior head diameter
 P- Preterm (20-36weeks)
(suboccipitobregmatic, occipitomental, or
 A- Abortion (before 20 weeks)
occipitofrontal, depending on the amount of flexion) in
a diagonal or transverse position. The head flexes as  L- Living
it touches the pelvic floor, and the occiput rotates to
bring the head into the best relationship to the outlet GTPAL or TPAL
of the pelvis (the anteroposterior diameter is now in
the anteroposterior plane of the pelvis). This G = gravida, T = term births, P = preterm births, A = abortions,
movement brings the shoulders, coming next, into the L = living children
optimal position to enter the inlet, putting the widest
diameter of the shoulders (a transverse one) in line
with the wide transverse diameter of the inlet.  G—the current pregnancy
 Extension. As the occiput is born, the back of the  T—the number of pregnancies ending >37 weeks’
neck stops beneath the pubic arch and acts as a pivot gestation, at term
for the rest of the head. The head extends, and the  P—the number of preterm pregnancies ending >20
foremost parts of the head, the face and chin, are weeks or viability but before completion of 37 weeks
born.  A—the number of pregnancies ending before 20
 External Rotation. In external rotation, almost weeks or viability
immediately after the head of the infant is born, the  L—the number of children currently living
head rotates (from the anteroposterior position it
assumed to enter the outlet) back to the diagonal or Consider this example: Mary Johnson is pregnant for the fourth
transverse position of the early part of labor. This time. She had one abortion at 8 weeks’ gestation. She has a
brings the aftercoming shoulders into an daughter who was born at 40 weeks’ gestation and a son born
anteroposterior position, which is best for entering the at 34 weeks. Mary’s obstetric history would be documented as
outlet. The anterior shoulder is born first, assisted follows: Using the gravida/para method: gravida 4, para 2
perhaps by downward flexion of the infant’s head. Using the TPAL method: 1112 (T = 1 [daughter born at 40
Expulsion. Once the shoulders are born, the rest of weeks]; P = 1 [son born at 34 weeks], A = 1 [abortion at 8
the baby is born easily and smoothly because of its weeks]; L = 2 [two living children])
smaller size. This movement, called expulsion, is the
end of the pelvic division of labor.
Essential 3c

Clamping of the Umbilical Cord: Early cord clamping is

generally carried out in the first 60 seconds after birth, whereas
later cord clamping is carried out more than one minute after
the birth or when cord pulsation has ceased.

Delaying cord clamping allows blood flow between the

placenta and neonate to continue, which may improve iron
status in the infant for up to six months after birth.

Cutting the Umbilical Cord: