UNIT 3 NORMALPREGNANCYAND

MANAGEMENT
Structure
Objectives
Introduction
NormalPregnancy
MaternalPhysiologyDuringPregnancy
SignsandSymptomsofPregnancy
DiagnosisofPregnancy
MinorDisordersinPregnancy
EmotionalAspectsRelatingtoPregnancy
AntenatalCare
AntenatalExaminationandTest
AntenatalAdvices
NutritioninPregnancy
AntenatalExercises,RestandWork
PersonalHygiene
SpecialTeaching
PsychologicalCareinPregnancy
LetusSumUp
AnswerstoCheckYourProgress

OBJECTIVES
Afterstudyingthisunit,youshouldbeableto:

· describe normal physiological changes during pregnancy and differentiate between a

primi and multigravida;
· discussthemethodoftakinghistoryfromantenatalmothers;

· identifyminordisordersduringpregnancyandexplaintheirtreatment;

· classifyvariousroutinetestsduringpregnancyandexplaintheirimportance;

· describetherelationshipoffoetustouterusofmother;

· identifythedietarymodificationsrequiredduringpregnancy;

· advisethemotherandfoetalwellbeingduringpregnancy;and

· explain the advices to be given to antenatal mothers regarding the maternal and foetal
well being.

INTRODUCTION
You have already studied midwifery during your GNM training, and registered as a nurse
and midwife.These units written on maternity nursing is based on the presumption that you
will further read in detail if necessary to clarify your doubts.

This unit on normal pregnancy described the normal physiological changes during
pregnancy.Safe-motherhood aim can be achieved if the mother is looked after well
throughout pregnancy, labour and puerperium.To understand the physiological changesthe
midwife needs to know the anatomical features of the female reproductive system and the
process of reproduction.

Inthisunityouwillstudyonthevariouschangesthattakeplaceinthebodydueto 57
MaternalHealthandNursingIn
tervention pregnancy, the signs, symptoms and diagnosis of pregnancy by the midwife, the common
complaints that the mother may have and how to deal with them.The midwife’s role is to
help the mother keep well and give birth to a alive, healthy newborn.

NORMALPREGNANCY
Letusstartwithwhatisnormalpregnancy.
Pregnancyisdescribedasaconditionorastatefromthetimeofconceptionuptothetime of delivery.
A hormone indicating pregnancy can be detected in the blood of pregnantwomen as early as
three days following fertilization and in the urine within one week of the first missed
menstrual period. This hormone known as human chorionic gonadotropin(HCG) is produced
by the placenta.
Therearecertainchangesinawomanwhichcanbeidentifiedbyboththewomanaswell as a
midwife.Certain changes during pregnancy also indicate whether the woman has conceived
earlier or not.It is the midwife who notices the pregnancy changes with the helpof her
knowledge about normal anatomy and physiology.
Physiological changes in mother’s body during pregnancy are due to the effects of specific
hormones. These changes enable her to help in the development of fertilized ovum; to
prepare the foetus, prepare her body for labour and lactation.A detailed knowledge about
these changes help a midwife to identify not only the changes but also detect
deviationsfrom normal for an early appropriate intervention.
The following are a list of those physiological changes which will be a great help to you in
rendering antenatal care to antenatal mothers.

MaternalPhysiologyDuringPregnancy
ReproductiveSystem
a) Vulva becomes vascular and hypertrophied, pigmented and varicose veins appear in
some.
b) Vagina becomes vascular and hypertrophied, looks bluish, is felt soft. Vaginal
secretion, increases in amount and is acidic due to the production of lactic acid.
c) Cervix remains 2.5 cm long throughout pregnancy, but the hygroscopic properties of
oestrogen cause it to increase in width. Oestrogen increases cervical vascularity and if
viewedthroughaspeculumthecervixlookspurple.Inlatepregnancy,softeningof the cervix
occurs in response to increasing painless contractions occurring throughout pregnancy.
The cervix acts as an effective barrier against infection, and also helps to continue
pregnancy.
Cervical mucosa undergo hypertrophy and hyperplasia and occupies inner half of
cervix. A mucus plug called “operculum” is formed between the maternal and
external os (Fig. 3.1).

Internalos

Vascularity
increases

Cervix
MucusPlug

Hypertrophyof
Endocervix

Externalos

58 Fig3.1:Cervicalchangesinpregnancy
d) Uterus: Gravid uterus gradually enlarges from 50 gm muscular organ to 900 gm atterm NormalPregnancyand
pregnancy. Length becomes 30 cm; breadth 22.5 cm and thickness 20 Management
cm.Uterinewallformsasaccontainingamnioticfluidandfoetus.Theperimetriumis the
outermost layer of the uterus. It does not totally cover the uterus. Themyometrium or
muscle coat surrounds the cornua, lower uterine segment and cervix during labour. The
muscle layer is involved in the contraction necessary to expel the foetus at the end of
the pregnancy. The outer longitudinal layer of muscle fibres contract and retract during
labour causing upper segment to thicken. The thickened upper segment acts as a piston
to force the foetus into the receptive, passive lower segment. During pregnancy, the
muscle layer becomes more differentiated and organised which take part in expelling
the foetus at term. Oestrogen is responsible for thegrowthoftheuterinemuscle.The
endometriumlinesthebodyoftheuterusand is rich in blood supply. It is known as the
decidua when the fertilised ovum gets embedded in it (Fig. 3.2).

Loweruterine
Isthmus segment
16weeks
Internalos
Cervix 12 weeks
8weeks
Externalos

Fig3.2:GrowthofIsthmusanditsincorporationintobodyofuterusduringpregnancy

Isthmus, which is the lower 0.5 cm portion of corpus above internal os of cervix
muscles less than the corpus also undergoes changes upto 12 weeks to pregnancy as it
elongates.Thereafter it’s cavity unfolds from above downwards to be included in the
cavity of uterus.It forms the thinner lower uterine segment after 12th week.Lower
uterinesegmentdevelopsbestduringthelasttrimesterashemisphericalsegment (Fig. 3.3).

59
FMyometriuminthreelayers
MaternalHealthandNursingIn
tervention Changes in Uterine Shape: The uterus changes its shape from early pregnancy to
anticipate foetal growth and to accommodate increasing amounts of liquor and placenta
tissue. This causes pressure on other pelvic organs. At 12th week of pregnancy, the
uterus is no longer ante-verted and ante-flexed.

36weeks
40weeks
28weeks

24-26weeks

20-22weeks

16weeks

12weeks

Fig.3.4:Fundusofuterusatdifferentperiodsofgestation

12th Week: The fundus of the uterus may be palpated abdominally above the
symphysis pubis.

16th Week: The uterus reaches half way between the symphysis pubis and the
umbilicus and the shape is ovoid.

20thWeek:Theuterusistwofingersbelowumbilicus.

24thWeek:Fundusisatthelevelofumbilicusoronefingerlowerlevelofumbilicus.

30th Week: The lower uterine segment can be identified. It is still not complete but
can be defined as that portion lying below the reflection. The fundus lies between the
umbilicus and xiphisternum.

36th Week: The uterus now reaches its highest level at the xiphisternum (near
subcostal arch).

38th Week: The fundus sinks down to the subcostal arch below ensiform cartilage,
the level of 34th week pregnancy. This is called ‘lightening’ .

40thWeek: The lower uterine segment gets relaxed and stretched whereas the cervixis
shortened and soft. The uterus is now ready for labour.

e) Ovaries: Ovulation ceases throughout pregnancy. Corpus luteum of usual menstrual

cycle persists and enlarges to 2.5 cm till 8th week due to the changes in the fertilized
ovum (trophoblast) and helps in producing hormones.

f) Breasts: under the stimulation of estrogen and progesterone the breasts increase insize,
nodularity and sensitivity throughout pregnancy with increased vascularitis. The
nipples enlarge, become dark, erect and the gland of Montogomery enlarges. Total
weight becomes 0.4 kg volume. Enlargement is due to alveolar proliferation and
deposition of fat. A clear sticky fluid can be squeezed from 16th week onwards.
Production of colostrums occurs in late pregnancy. Areola becomes dark pigmented,
which is primary areola, and a second zone of pigmentation appears around theprimary
areola in second trimester, which is secondary areola. The breast ductalsystem has
intense growth during the 1st three months of pregnancy.As pregnancy progresses, the
alveolar cell becomes secretory.

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ChangesinOtherSystemsoftheBody NormalPregnancyand
Management
1) CardiovascularSystem

a) Heart works more during pregnancy: There is increase in the cardiac volume by
10% but there is no change in E.C.G. except slight left axis deviation. Cardiac
output increases by 15-30%. Cardiac output increases due to increased heart rate
and increase stroke volume. Pulse rate near term increases by 10 per minute.
Platelet count shows slight decrease due to increased concentration and ESR
increase to 40-45 mm due to fibrinogen content.

b) Blood Pressure and Blood volume: Blood pressure remains within normal limits
with mid pregnancy drop in blood pressure in some women. Venous pressure–
Femoral venous pressure rises from 10 cm water to 30 cm water. This is due to
pressureofgraviduterusonpelvicveins.Bloodvolumeincreasesfrom3rd
monthandreachesapeakof25%riseat32weeks.Theredcellvolume increases by 200
ml, plasma volume increases to 1000 ml.On the whole the blood flow increases to
many parts of the body such as uterus, pulmonary, renal, skin and mucosal.

2) RespiratorySystem

Mucous of upper respiratory tract shows hyperaemia and congestion. There is increased
inspiration so the increased oxygen intake results in improved oxygen supply to the foetus.
Due to increased expiration, more carbondioxide is expelled, there is low maternal
carbondioxide leading to easy transfer of CO2from foetus to mother’s blood.

In the later weeks of pregnancy, due to the pressing of the gravid uterus on diaphragm
(around 36 weeks) there is a complaint of breathing difficulty which is relieved after
lightening.

3) DigestiveSystem

The muscle tone of the gastrointestinal system is reduced due to progesterone effect.
Relaxation of cardiac sphincter leads to regurgitation of stomach juice and heart burn.
With diminished gastric mortality slow emptying of stomach results which continues in
labour.Gums become spongy and vascular and may bleed during brushing in many
women. The intestines show reduced motility, there is better absorption of food and
constipation.There is a tendency to gall stone formation due to high serum cholesterol.

4) NervousSystem

Slumpliness is common and mood changes occur in many.Pregnancy is one of the periodsin
a woman’s life when there seems to be lowering of the ability to cope with emotional
experiences in life.Even the cases where the coming of the baby is welcome a mild degreeof
depression or irritability may be evident during the early months, longings for certainsour
food, spiced food, coal, clay ash may be due to nausea rather than to nervousinstability. It is
also called “Pica” and neuritis is common in pregnancy.

5) UrinaryTract

Frequency of micturition is common in early pregnancy and late pregnancy.Stress

incontinence may also occur.Due to dilatation of uterus and renal pelvis during early
pregnancy which continues till mid-pregnancy there is a tendency for urinary stasis and
these favours infection. Renal function is augmented during pregnancy.

6) LocomotorSystem

Due to lordosis of pregnancy and relaxation of joints under the influences of relaxin
hormone backache is common. Leg cramps occur due to pressure on sacral and lumbar
plexus. Gait becomes waddling.

7) EndocrineSystem

Gonadotrophine: FST, LH are inhibited by placental steroids. Prolactin rises throughout

pregnancy. Protein hormones, HCG appears in blood and urine from 8th day of fertilisation,
andreachesapeakat9th-10thweek,thereafterdropsrapidlyandremainsataplateaufor the rest of
pregnancy. HCG values are increased in presence of multiple pregnancies.
Oestrogenandprogesteronelevelsincreaseandcontinuetobesecretedfromtheplacenta
61
MaternalHealthandNursingIn
tervention during the last 6 months of pregnancy. Progesterone is produced by all steroid-forming
glands including ovaries, testes and adrenal. It acts as an immediate or precursor for other
hormones. During pregnancy, progesterone is secreted by corpus luteum up to eight weeks
of pregnancy. Thereafter, the placenta takes over the function of progesterone productionup
to term.

Prolactin: During pregnancy, prolactin values rise to about 100 mg/ml due to maternal
pituitary activity. The decidual lining of the uterus contributes to amniotic fluid content of
prolactin.

Oestrol: Oestrol levels reach 25-30 mg/day. Extremely low Oestrol denotes foetal death or
anencephaly. High circulating oestrol values are associated with multiple pregnancies or Rh
isoimmunisation. A normal oestrol level signifies foetal well being.

HPL (Human Placental Lactogen): HPL levels vary directly according to placental mass.
Therefore HPL levels are higher in multiple pregnancy.

• Thyroidactivityisincreased
• Increaseinestrollevels(anindicatoroffoetalwellbeing)
• Secretionofoxytocin(stimulatesuterinecontraction)
• Dropinprogesteronelevelneartermbringsaboutlabour

8) WeightGain

Average weight gain during pregnancy is about 10 kilogram in the pregnant Indian womanof
average built and can be accounted for the weight of foetus, placenta, amniotic fluid,
increase in weight of breasts and uterus, increase in blood value, extra cellular fluid and fat.
Usually the mother gains about 3 kilogram during first half and 7 kilogram during
secondhalf of pregnancy. Poor weight gain is due to nausea, vomiting, indigestion,
underweight woman.Inadequate food, overwork, maternal illness, intra-uterine growth
retardation of foetal death are other factors. Excessive weight gain is due to overeating,
excess waterintake, oedema, large foetus, multiple pregnancy and overweight of woman.

9) GeneralMetabolism

The basal metabolic rate increases during the later half of pregnancy in response to the
demandsofthegrowthfetusandmaternaltissuesandsoenergyrequirementishigher. Total daily
energy requirement increases by 300 K Cal. Glucosuria occurs in 10 per cent of woman
probably due to lowering of the renal threshold for glucose.Extracellular water
retentionisthere.About40%ofwomendevelopphysiologicalankleoedemaduringthe last 12
weeks of pregnancy which disappears with rest and is rarely present in the morning.
However, oedema in pregnancy should never be considered physiological until all
pathological causes have been ruled out.

10) SkinChanges

Pigmentation becomes visible at various places of the body, i.e. breasts, face, skin,
abdominal wall and external genitalia. Pigmentation of face is called chloasma, others are
striae gravidarum and linea nigra.

CheckYourProgress1

1) Fillintheblanks:
a) Weightofthegraviduterusincreasesfrom50gmto...................atterm.
b) Threelayersofgraviduterusare...........,.............and........................
c) At36thweek,uterusreachesthelevelof........................................

2) Explainthechangesthattakeplaceinbreastsduringpregnancy.
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62
 SignsandSymptomsofPregnancy NormalPregnancyand
Management
A healthy married woman who has been menstruating regularly misses a period. In 98% of
cases this is due to pregnancy.In these days the advanced diagnostic tests such as
ultrasonography, immunological tests for pregnancy has reduced or eliminated the needs to
rely on the more inaccurate presumption of probable signs of pregnancy.

In this sub-section we will acquint you about signs and symptoms of pregnancy. From signs
and symptoms, you will come to know the woman is pregnant or not. Positive signs showthat
a woman is pregnant.

Signsofpregnancyareclassifiedas:

a) Presumptivesignsandsymptoms
b) Probablesigns
c) Positivesigns

a) Presumptive signs and symptoms: Mostly subjective, may be indicative of other

illnesses.

• Amenorrhoea
• Morningsickness
• Fatigue
• Nauseaandvomiting
• Breastchanges
• Bladderirritability
• Darkeningorpigmentationofface,breast
• Quickening – feeling of movement about 16 to 20 weeks. Recording the date of
quickening is a useful way to calculate the expected date of confinement when
the mothers are unsure of her dates.

b) Probablesigns:Objectivebutstillnotdefiniteconfirmationofpregnancy.

• Enlargement of abdomen and assessment of the number of weeks of pregnancy

by palpation of abdomen.
• Pregnancy Tests: The urine of pregnant women contains HCG(Hormone
Chorionic Gonatotrophin), one of the placental hormones, in fairly large
concentration by the fifteenth day of pregnancy. More recently immunological
pregnancy tests, dependent upon antigen-antiserum reaction, have replaced the
biological tests. These tests are based on the reaction of human urinary
gonadotrophin (HCG) to antiserum. The tests are easy to use clinically and are
highly reliable, Also the test material is readily available commercially.
• Other signs are changes in the uterus, softening of the cervix uterine souffle,
abdominal enlargement, Braxton Hicks contraction site.

c) Positivesigns:Confirmspregnancy.

• Hearingoffoetalheartsound
• Active movements of the foetus felt by the examiner at about 22nd week of
pregnancy.
• Ultrasoundevidenceofpregnancy.

DiagnosisofPregnancy
Diagnosisofpregnancyisbasedonanyoneofthefollowing:

1) Presumptive/Subjectivesymptoms/Positivesignsofpregnancy.
2) Clinicalexaminationfindings.
3) Investigations.
63
MaternalHealthandNursingIn
tervention 1) PresumptiveSymptomsorSubjectiveSymptoms

These are cessation of menses, breast changes, and nausea which is present in about 70% of
womenduring early hours or the day and may accompany vomiting. Other symptoms are
frequent micturition, fatigue etc.

2) ClinicalExaminationFindings

Through examination, the clinician can elicit signs, which strongly endorse the suspicion of
pregnancy.Theenlarginggraviduterusisgenerallywellpalpableabovethepubic symphysis only
after 17 weeks and reaches the level of the umbilicus by around 20 weeks.

Changes in the Uterus: During early pregnancy, the pyriform shape of the uterus becomes
globular. It is about the size of an egg at 6 weeks, a cricket ball at 8 weeks and about
thesize of the foetal head at 12 weeks. The cervix and uterus feel softer because of
thesoftening of the isthmus ( Goodell’s sign). The cervix and bulky uterus feel separated
between the 6th and 10th weeks of gestation on bimanual examination (Hegar’s sign). On
speculum inspection of the cervix and vagina they appear to have a bluish or purplish
discoloration(Jacquemier’s signs).

a) PregnancyDiagnosisinSecondTrimester

Signs

• Amenorrhoeacontinues
• Breastchangescontinue
• Quickening— at the 16 week women are able to appreciate the feeling of foetal
movements.

Investigations

a) X-raysareabletodetectthefoetalskeletalshadowatabout16weeks(notadvised).
b) By Sonography, you can detect not only foetal skeleton and foetal organs, but it also
reveals the location of the placenta, amount of amniotic fluid present, condition of the
internal os.

b) PregnancyDiagnosisinThirdTrimester

It is easy for you to diagnose pregnancy at third trimester. Enlargement of abdomen is

progressive in later part of pregnancy, lightening also takes place and frequency of
micturition may be there.

Signs

• Uterineshapebecomesmoreglobular.
• Fundalheightcontinuestogrow.
• Braxton-Hickscontractionaremoreevident.
• Foetalmovementareeasilypalpableandalsocanbenoticedoninspection.
• Foetalpartscanbepalpable.
• Auscultationrevealsaregularfoetalheartrhythm.

Investigations

SonographyandX-rays

3) Investigation

ImmunologicalTests

Modern sensitive immunological tests for early diagnosis of pregnancy is based on the
detection of bile subunit of HCG in the maternal serum or urine. HCG reaches urine
approximately 8 days after a missed period. HCG in the urine is 1.5-3.510/ml.

64
Gravidatest NormalPregnancyand
Management
It is based on the latex agglutination inhibition (LAI) technique. It is an accurate and
inexpensive test requiring 2 minutes time for its performance. Absence of agglutination
indicates presence of pregnancy.

Ultrasonography

This is a very reliable test. As early as the 5th week of intrauterine life, the gestational sac
can be identified. The foetal node can be observed after 6th week and foetal cardiac
pulsation by the 8th week.

CheckYourProgress2

1) Listthepresumptivesignsorsymptomsofpregnancy.
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

2) Fillintheblanks:

a) Probablesignsarenot..................................confirmationofpregnancy.
b) Hearingfoetalheartsoundisa....................................signofpregnancy.
c) Throughultrasonographythefoetalsaccanbeidentifiedasearlyas......................... week
of pregnancy.
d) X-raysare...............................forthegrowingfoetus.
e) Aregularfoetalheartrythmcanberevealedby.............................

MinorDisordersinPregnancy
In this section, we shall focus on common complications of pregnancy. Though these
ailments do not necessarily endanger life, they could be of such intensity as to make the
woman feel miserable and may even distress her more than some serious disorders of
pregnancy. However, as a midwife, you should be alert of this symptoms so that there may
not be any complication from these problems.
MorningSickness
This is one of the earliest symptoms of pregnancy. The patient feels nauseated on rising in
the morning; she may actually vomit or have nausea with excessive salivation. At times,
these symptoms persist throughout the day and may impair the woman’s appetite.
Advisethe woman to avoid the diet, which tends to nauseate her and to take easily digestible
food, eat food rich in vitamin and mineral salts. She should take adequate amount of fluid.
Abland diet is better than fried food. She should be advised to take rest after meal and suck
some peppermint, eat little food at frequent intervals and to avoid over distension of the
stomach or the eating of greasy, indigestible food.
Constipation
Constipation is a common complaint in pregnancy because of the relaxing effect of
progesterone on the plain muscles of the intestinal wall. Adequate intake of fluid, fruits and
vegetablesshouldpreventit.Advisewomentotakeroughage,sometimesdrugslikemilk
ofmagnesia(30mleverynight)canbegiven.Regularwalking,exercisealsohelp alongwith good
diet and fluid intake.
VaricoseVeinsandHaemorrhoids
These are engorged superficial veins on the legs, the vulva and the anus. The anal ones are
known as haemorrhoids. At times, they are harmless though unsightly. If they are painful,
oedematous and tend to ulcerate. Medical advice must be sought immediately. The risk of
venous thrombosis is increased with varicosity. The midwife should, therefore, suspect
thrombosis if a woman with varicose veins complains of a dull aching pain in her legs. The
varicose vein of the vulva can be very painful. The woman should be advised for treatment.
Haemorrhoidsarevaricoseveinsintheanalcanal.Theymaycausebleedingand sometimes they
prolapse and become external. Severe cases of haemorrhoids should be referred to a doctor.
65
MaternalHealthandNursingIn
tervention FaintingandGiddiness

Fainting and giddiness could occur as a result of anaemia, cardiac impairment, sudden
change in posture, e.g., from lying to sitting position, or standing for long periods in the
sun. Crowded and stuffy rooms could also predispose to fainting.

GlossitisandGingivitis

Glossitis and gingivitis are fairly common amongst pregnant women of low income class.
They occur as a result of inadequate vitamin (especially vitamin B) and calcium intake as
well as poor oral hygiene. The patients find it difficult to eat and they tolerate hot spicy
food poorly. Glossitis can be cured by routine administration of vitamin B complex.
Glossitis is relieved by improvement of oral hygiene. Advise the mother to take green leafy
vegetables, yeast, eggs, cheese etc.

Itching

Itching of the body could be caused by striae gravidarum, poor personal hygiene, heat, rash
and minor skin diseases. Regular daily baths and generous application of calamine lotion or
talcum powder could be soothing to the skin. Itching of the vulva or pruritus vulva could be
present during pregnancy.The midwife should inspect the vulva for abnormal vaginal
discharge. Advise the mother for vulval hygiene.

BackacheandJointPains

Backache and joint pains are more common in tired multiparous women with bad posture.
The midwife must, however, remember that backache could be associated with
pyelonephritis, retroverted gravid uterus and may be an early sign of labour. In such cases,
other signs and symptoms should be looked for and the patient may be referred to a
doctorif necessary.

FrequencyofMicturition

During the first 12 weeks of pregnancy, before the uterus rises out of the pelvis, there is
slightly an increased pressure on the bladder. The same applies in late pregnancy when the
foetal head sinks into the pelvis.

Cramp

Cramp usually in the legs, is quite common. It has been attributed to deficiency in vitamin
B, calcium and chlorides. Extra amounts of these substances are sometimes prescribed.

Insomnia

Insomnia may occur anytime but it is more usual in late pregnancy. Simple measures like a
warm bath at night before going to bed, a drink of a warm beverage, and sleeping in a cool,
airy room should help.

CheckYourProgress3

1) Listthecommonproblemsinpregnancy.
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..........................................................................................................................................

2) Whatarethecommoncausesofconstipationduringpregnancy?
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..........................................................................................................................................

3) Whatarethecommoncausesofbackacheduringpregnancy?
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 NormalPregnancyand
EMOTIONALASPECTSRELATINGTO Management
PREGNANCY
Whenyouaresurethatawomanispregnantthenasamidwifeyouhavetoencourageher to continue
the pregnancy. There may be anxiety or distress due to unfavourable socio- economic
factors. As a midwife, you explain to the woman that if she is psychologically or emotionally
disturbed then general outlook to life can affect her mental reaction to pregnancy. Some of
the causes of adverse emotional reaction to pregnancy include:

• Poorsocio-economicstatus,i.e.lackoffinancialsupport.
• Poorrelationshipwiththehusband
• Unmarriedpregnantmother.
• Anxietyovernormalcyofthebaby.
• Poorenvironmentalorlivingcondition.
• Fearoftheunknown,basedonsuperstitions.

As a nurse midwife, you must observe for irritability, insomnia and anxiety states. The
irritable woman is usually quarrelsome and exhibit temper tantrums.

The woman should be advised to keep herself happy, cheerful and pleasant.Listening tosoft
music, reading light story books, talking to friends, taking care of herself helps a lot to
maintain a good mental health.She can also seek for professional advise if necessary.

ANTENATALCARE
Inthissectionyouwilllearnaboutantenatalexaminationandroutinetest.Itisveryimportant to do
routine blood and urine test during pregnancy. After going through this section you will also
learn about all types of test and its abnormality to fetus and mother.

AntenatalExaminationandTest
RoutineTestsduringPregnancy

CBC

A complete blood count gives information regarding leucocyte and erythrocyte levels and
plasma volume ratio. If leukocyte are high, infection may be present and thus can be treated
early.Iftheerythrocytecountisloworhaemoglobinandhemotocritlevelsarelow, anaemia may be
a problem.

BloodTypeandRh

Blood type of Rh is important for prevention or treatment of erythroblastosis in the foetus.If

the mother is Rh –ve and unsensitized, preventive Rh immune globulin should be givenat
28th week.

AntibodyScreen

Screening should be done regardless of the Rh type because other haemolytic

incompatibilities may be present.

RubellaScreen

A Rubella screen gives information about immunity against the disease rubella (rubella
antibody time).This test is not done as a routine in India.

VDRLandELISA(AIDS)

A serology test to screen for syphilis should be done on all mothers because this has
implications for the treatment of the mother and for potential congenital syphilis in the
foetus caused by maternal infection. AIDS test is compulsory for all the mothers.

BloodSugar

Bloodsugarmustbeevaluatedifthefamilyhistoryisstronglypositivefordiabetesorifthe 67
MaternalHealthandNursingIn
tervention woman is over 35 years age. Both fasting and post-prandial blood sugar must be estimated.
One hour past glucose blood sugar estimation for patients at high risk for diabetes at 28th
week of gestation, as indicated by:

• Familyhistoryofdiabetes
• Maternalage>35yrs.

UrineAnalysis

Routine examination of urine for presence of sugar, albumin must be done during each visit
of the mother to the antenatal clinic.

Urine analysis and culture and sensitivity of the urine can offer information about renal
function and urinary tract infection. If renal function is the question, further evaluation for
creatinine, protein, and uric acid may be done of the urine and serum.

PapanicolauSmear

A pap smear should be done on all pregnant women at the time of their first prenatal visit if
one has not been done in the previous year. In presence of cervical cancer, pregnancy might
need to be terminated for the treatment of the mother.

HistoryTakinginPregnancy

The purpose of taking history is not merely for recording facts and statistics.It is a vital
means of assessing the health of the woman and bringing to light any defect/deficit which
would adversely affect child bearing.History taking also should lead to taking remedial
action as far as possible.

The midwife need to develop great patience and fact in taking history of a new patient
especially a primigravida to whom pregnancy may seem to be an ordeal.As far as possible
non-technicaltermsshouldbeused,andquestionsshouldbeaskedinsuchawayasto avoid waiting
tension or fear in the mother. Midwife need to be kind and reassuring in her approach to
convey the impression that she is there to look after her, to give support and guidance as
needed.

FamilyHistory

This should be enquired into since some families have a genetic predisposition to certain
diseases such as psyclia disorders, diabetes, essential hypertension, twins etc.

MedicalHistory

Sinceformerillnessesmaydamagecertainorgans,structureswhichmayeffect
pregnancy,labour.Soitisessentialtoenquireaboutherprevioushealth.Diseaseslike
diabetes,hypertension,tuberculosisofspineandhip,epilepsyandpsychiatricdisorder
shouldbeenquiredinto.Historyabouttakingbloodtransfusion.Majormedical
complicationssuchasdiabetesandcardiacconditionsrequiretheinvolvementand
supportofthemedicalteam.

SurgicalHistory

By taking surgical history, you will come to know about any surgery that has been done on
her like heart surgery, kidney surgery or gallbladder surgery or caesarean section.

MenstrualHistory

Menarche and duration of menstrual flow, cycle regular/irregular.When was the first day of
the last normal menstrual period (LMP). Expected date of delivery (EDD) is calculated by
adding 9 calendar months and 7 days to first day of last normal menstrual period.

ObstetricalHistory

After taking history, you will come to know whether the mother is primigravida or
primipara and how many living children she is having, their health status, age and sex.

Pastobstetricalhistoryisveryimportant,asyouwillcometoknowaboutanybadobstetrical history
like:
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• Stillbirthorneonataldeath NormalPregnancyand
Management
• Babysmallorlargeforgestationalage

• Congenitalabnormality

• Rhesusimmunisation

• Pregnancy-inducedhypertension

• Twoormoreterminationofpregnancy

• Spontaneousabortiontwiceormore

• Prematurelabour

• Previouscaesareansection

• Antepartum or postpartum haemorrhage

You will come to know the following:

• Expecteddateofdelivery(EDD)
• Contraceptivehistory
• Anyhighriskpregnancy,hospital/home
• Alive/deadchildren
• Causesofdeath

Other tests such as mantoux, G6PD deficiency, HIV screening, thalasemmia etc. is done in
selected cases when indicated.

CheckYourProgress4

1) Listalltypesofbloodtesttobedoneduringpregnancy.
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

2) Whyisitimportanttodopapsmearforallpregnantwomen?
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

GeneralExamination

General examination is done for assessment of risk.This may be done in an organized and
standardized form,where the nurse/midwife will do assessment and write all the findings.
Head to toe examination is done.Weight and blood pressure should be taken in every
general examination and the nurse should be looking at the woman’s face then progress
downwards to finish with an inspection of her legs and feet.Minor disorder of pregnancy
can be detected during examination.Examine breast alsofor cracked and inverted nipple.
Blood pressure is taken in order to ascertain normalcy while doing general examination.
Midwife should ask women about normal bowel habit.Dietary advice may be necessary
during the visit.

Midwife’sExamination

As a nurse/midwife, you should examine women to find out about the progress of
pregnancy, diagnosis, any risk factors so that proper steps can be taken to reduce the risk.

AbdominalExamination

You will study how to do abdominal examination of a pregnant woman from your practical
section.However,hereyouwillcometoknowonlytheorypartmainlythefindingsofabdominal
examination. 69
MaternalHealthandNursingIn
tervention AimsofAbdominalExamination

Abdominalexaminationshouldbedoneto:

• observesignsofpregnancy;
• assessfoetalsizeandgrowth;
• assessfoetalhealth;and
• diagnose the location of the foetal parts.

The steps of abdominal examination consist of:

a) Inspection

By inspection, you will come to know the size of the abdomen and stretch marks or striae,
and linea nigra and any surgery scar.

b) Palpation

Uterine fundus is palpated at each check up to corroborate normal foetal growth as

14th week–2.5 cm above symphysis pubis

18thweek–4cmbelowumbilicus
24thweek–Atlevelofmaternalumbilicus
28thweek–At lower 1/3rd distance between umbilicus and ensiform cartilage 32nd
week–At lower 2/3rd distance between umbilicus and ensiform cartilage 36thweek–
reaches below sub costal arch.
40thweek–comeslowerbelow36thweekbutliesabove32ndweek.

You will come to know how to palpatle in your practical but in theory you will know the
steps of abdominal palpation.

FirstStep—Fundalpalpation—Palpationofheightoffundusbyoutstretchedleftpalm.

Second Step — Fundal grip — Midwife faces the woman’s face. Uterine fundus is
palpated by both palms to determine soft pole of foetus or hand foetal head is felt

Third Step — Lateral grip — Uterus is felt to determine foetal back on one side and
irregular limbs on the other in vertex and breech presentation.

Fig.3.5:Lateralgrip

Pelvic grip: Foetal pole at lower part of uterus is palpable by both palms. Hard foetal
headis felt in vertex, soft breech in breech presentation.
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 NormalPregnancyand
Management

Fig.3.6:Pelvicpalpation
Pawlik’s grip: Foetal head– In vertex presentation. Foetal head is gripped at lower part of
pregnant uterus. This palpation confirms palpation by pelvic grip.

Fig.3.7:Pawlik’sgrip
HearingofFoetalHeartSoundorAuscultation:Foetalheartsoundisheardbystethoscope at the
site of foetal back on the spino-umbilical line or on the flanks in vertex presentation. Foetal
heart rate heard at 120-140/min ensures foetal well-being.

Fig.3.8:Auscultationoffetalheart
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MaternalHealthandNursingIntervention CheckYourProgress5

Fillintheblanks:

1) Thefindingsofabdominalinspectionare.............................and.............................
2) Uterusreachestheumbilicusat....................................week.
3) Byfundalpalpation,youwillcometoknowthe.........................................ofthefundus.
4) Foetalbackispalpatedby....................................grip.
5) Foetalheartsoundisheardthrough..............................
ANTENATALADVICES
Asamidwife,youwillexamine,advise,superviseandattendapregnantwoman:

a) To help her maintain good health and where applicable, early detection and treatment
of abnormalities.
b) Undergo a pleasant child-bearing experience and adequate preparation for labour and
lactation.
c) Givebirthtoanalive,healthybabyattheendofpregnancy.

Antenatalcareshouldcommenceoncepregnancyisdiagnosedandshouldcontinueuntil the safe

delivery of the patient. In India, women, sometimes do not attend the clinic. So as a
nurse/midwife you have to make women, their husbands and relatives understand the
necessity and value of early antenatal care. Women should be encouraged to attend the
antenatal clinic early at least 4 times throughout pregnancy. 1st visit is registration and 2nd
visit at 16-20 weeks of pregnancy and 3rd visit in 32 weeks of pregnancy and 4th visit at 36
weeks of pregnancy.

NutritioninPregnancy
Malnutrition, which is common in our country, may become worse in pregnancy when the
needs of the growing foetus further deplete the maternal stores of nutrients. The midwife
should always advise that daily intake of protein, vitamins and mineral salts is necessary to
provide for the needs of the growing foetus and prevent anaemia in the mother. A pregnant
woman needs an ample amount of protein daily. About 80-90g of protein has been
recommended as the minimum daily requirement of a pregnant woman. Advise the
mothertotake1stclassproteinsuchasliver,meat,eggs,fish,chicken,cheeseendmilk.Those
whocannotbuy1stclassproteintheycanbuysecondclassprotein,whichisgoodand fairly cheap.
These include bean, ground nut, pulses. Carbohydrate and fat should be included in the
daily diet.

Vitamins and Mineral Salts: The most important vitamins during pregnancy are vitamins
A,B,C and D. So as a nurse/midwife you must advise pregnant woman to take these
vitamins. She should take eggs, meat, liver, green vegetables and wheat as vitamin B
complexis essential for carbohydrates metabolism and prevention of anaemia.

Vitamin D: is necessary for normal formation of bones. It is found in egg yolk, fatty fish,
cheese and milk. The richest source of Vitamin D in the tropics is sunshine. Vitamins are
mainly found in fresh fruits and vegetables. Therefore, a woman should take fresh fruitsand
vegetables. A pregnant woman should take more fluid.

Folic Acid: The daily requirement is about 0.5-1.0 mg. It can be easily provided in the diet
by consumption of green leafy vegetables, cereals and pulses.

Calcium:Therecommendedcalciumrequirementis1000-1200mg/day.

Iron: Anaemia is very common during pregnancy. It may be due to repeated pregnancy or
irondeficiency.Manywomenembarkonapregnancywithdepletedironstoresdueto heavy earlier
menstrual losses, or rapid successive pregnancies. The demand of the growing maternal
tissues and the foetus further contribute to the deficiency state.

In present day practice, it is accepted that all pregnant women should be advised
supplemental oral iron daily containing 30-60 mg. While giving iron, the women must be
72 advised that it should be given in between meal and should not be given in tea for
properabsorption.
 AntenatalExercises,RestandWork NormalPregnancyand
Management
Adequate rest and sleep are very important for the maintenance of good health. Pregnant
women should sleep for 8 hours at night in an airy room. If there is anxiety or any pain,
women should sleep for more hours. The women should take rest in the afternoon or relax
quietly in a comfortable position for about one to two hours. She can do light work but
notto lift heavy things.

ExerciseandRecreation

Exerciseandrecreationisveryimportantduringpregnancy.Mothershouldnotbeupset. She may

have fear of labour or any complication of pregnancy. It is also unsafe for apregnant woman
to undertake long strenuous journeys towards the end of her pregnancy. Moderate exercise,
particularly in the open air is beneficial. Healthy women may undertake exercise to which
they are accustomed. Ordinary housework should be done but not liftingor pulling any
heavy articles. Breathing exercises are performed during the last eight weeksof pregnancy.
Slow, continuous, deep breathing is done with a relaxed abdominal wall.

PersonalHygiene
Pregnant women have to take bath daily because the skin is more active during pregnancy.
She should clean her teeth daily so as to keep them in good condition. The midwife should
teach the patient how to take proper bath and she should design clothing for the pregnant
women. The clothing should be loose and of cotton material. A midwife should advise the
patient to take everyday bath and change clothes everyday.

A daily bath or shower is necessary because the sweat and sebaceous glands are moreactive.
Tub bath should be avoided particularly in the last two months. While taking bath,she
should take care of her breast, as care of breast promotes successful breast-feeding.
Particular attention to the nipple is to be encouraged. The areola should be thoroughly
washed with the soft cloth and soap. Each nipple should be pulled out and rolled
betweenthefingersaboutthreetimesdailytomakeitmoreprojectile.Inthelasttrimester, colostrum
should be expressed from the breast in order to keep the duct clear. The brassier should be
adjustable so that it fits the patient throughout the duration of pregnancy. Bowels must be
moved daily. Dental caries and septic foci must be treated during pregnancy. High heeled
shoes should not be used because they make the patient lean forward. They alsocause lower
abdominal discomfort and fatigue. Sexual intercourse is not harmful but it should be
avoided during first and last trimester.

SpecialTeaching
Feelingsofanxietyarecommontoallpregnantwomenandcommonproblemsin pregnancy leads
to anxiety. Health teaching is to be given for various reasons because if pregnancy is
increased irritability, explosions of tears and anger, or feeling of great joy and cheerfulness
alternate with little or no provocation. Mother should sleep for 8-10 hours and take proper
rest and diet. Teaching is to be given about sexual relationship. Sexualexpression during
pregnancy is affected by physical, emotional and interactional factors.
Explain the pregnant women about birth process and labour pain. In each case any
complication like antepartum haemorrhage, placenta praevia or early rupture of membranes
then inform doctor/midwife immediately. Womenshould be instructed to reportimmediately
if any of the following symptoms is experienced:

• Vaginalbleeding
• Puffinessoffaceortightnessofrings
• Severeorcontinuousheadache
• Blurringordimnessofvision,doublevisionorspotsbeforetheeyes
• Dizzinessorfaintingspells
• Acutepersistentabdominalpain
• Persistentvomiting
• Chillorfever
• Dysuria
73
MaternalHealthandNursingIn
tervention • Teach the mother about diet.How it effects on her health and growth of the foetus,
advise the mother to take more vitamins, iron and calcium at least 0.4 mg of folic
acid. Anaemic woman require 60 mg of ferrous iron.
• Maintainpersonalhygieneandbreasthygieneandregularemptingofbowel.
• Advise for regular check up to detect high risk or any abnormality and routine blood
test and take tetanus injection.
• Exercise is important. Most activities may be continued during pregnancy. Morning
and evening exercises to be practised at home before breakfast and dinner.
• Restrictionofalcoholandnicotineintake.
• Teach mother for delivery and lactation.If mother want to have confinement, teach
the mother accordingly.
• Advisehertocheckfoetalmovement,anyvaginalbleedingetc.

Travelling is allowed in the second trimester but as a whole travelling should be avoided.
With a history of recurrent abortions orpre-term deliveries, travelling should be avoided at
the gestational age. Sometimes morning sickness is further complicated by motion sickness
during travel. Air travel poses the risk of hypoxia due to high altitude. Air travel should not
be undertaken after 32 completed weeks of pregnancy for fear of onset of labour during
travel.

PsychologicalCareinPregnancy
The addition of a new baby to the family affects not only the mother but also the father. So
both the parents should be encouraged to learn about their baby. The husband is the best
person to support the woman during pregnancy and labour. The midwife must take every
opportunity to teach individual. She should give advice, encourage questions and allow
expectant mother to discuss their problems. The change in body size and shape
raisescertain anxieties. Some women feel their self image is affected by society’s standards
of beauty.Women may be concerned that she is no longer attractive to her partner,
weightgain and increase in size are not the only issues in the sense of decreased
attractiveness.
Otherbodychangesmayalsocontributetothesenseoflossofphysicalappearance.

LET US SUMUP
In this unit, you have learnt about the Normal Pregnancy and its management.As a nurse,
you know normal functioning of a woman is disturbed when an woman is pregnant.But
effective management of pregnancy leads to healthy puerperium and can reducecomplication
of pregnancy. After learning about normal pregnancy and management, you
willtakepropercareofmotheranddoallnecessaryinvestigationsfordetectionofhigh risk.As you
know, high risk pregnancy is a major cause of maternal mortality in India.Soas a nurse you
should take proper care after reading this unit.Nurse can be a supportive to pregnant woman
and help her take care of herself.Psychological care has a very important role to play during
pregnancy.As you know from this unit that teaching is to be given toboth the parents.

ANSWERSTOCHECKYOURPROGRESS
CheckYourProgress1

1) a) 900gm
b) perimetrium,myometriumandendometrium
c) xiphisternum
2) Refersub-section3.2.1

CheckYourProgress2

1) —amenorrhoea
— morningsickness
— fatigue,nauseaandvomiting
74
 — breastchanges,bladderirritability NormalPregnancyand
Management
— pigmentationofbreasts,skin,face
— quickening

2) a) definite
b) positive
c) 5th
d) harmful
e) auscultation

CheckYourProgress3

1) Morning sickness, constipation, varicose veins, haemorrhoids, fainting, giddiness,

glossitis, gingivitis, itching, backache and joint pains, frequency of micturition,
cramp, insomnia.
2) Duetorelaxingeffectsofprogesteroneontheplainmusclesoftheintestinalwall.
3) In multipaarous women with bad posture. May be associated with pyelonephritis or
retroverted gravid uterus.

CheckYourProgress4

1) Completebloodcount,bloodtype,Rhtype,bloodsugar.
2) Todetectcervicalcancer.

CheckYourProgress5

1) sizeoftheabdomen,foetalmovements

2) 24th

3) height

4) lateral

5) stethoscopeorfoetoscope

75