Module

Course Outline:
A.
B.
C.
D.
E.
F.
G.
H.
I.

Identification of Risk Pregnancy

Leading Causes of Maternal Mortality
Dangers Signs during intrapartum and post-partum
Recommendations for Postpartum Care
Common Discomforts in Pregnancy
Prenatal care
Tetanus Toxoid Immunization
Recommended Weight Gain per Trimester
Exercise during Pregnancy

A. Identification of High Risk Pregnancy:

Maternal Age: <18 years old or nullipara >35 years old

Maternal Height: 60 inches or less (153 cm or less)
Weight: Obesity: more than 20% of standard weight for height
Social factors: single, unwed, working mothers, low socioeconomic status, diet,
smoking, drugs, alcohol
Obstetrical History:
o Multiparity
o PROM, IUGR
o Premature labor
o Macrosomia
o Multiple pregnancy
o UTI, Diabetes, HPN
o Thyroid disease
o Uterine/Ovarian disease
o Abnormal presentations
o Placental abnormalities

C. Danger Signs in Pregnancy

Intrapartum:

Severe abdominal pain

T
Persistent/severe nausea & vomiting
Severe headache
B. Top
Leading
Causes
Vaginal bleeding, passage
of 5
blood
clots/meaty
tissue of Maternal Mortality in the Philippines (1991-2009
Complications related to pregnancy occurring in the course of labor, deliver
Fever
Hypertension complicating pregnancy, childbirth and puerperium
Increased blood pressure
Postpartum
hemorrhage
Epigastric pain or RUQ
pain
Pregnancy with abortive outcomes
Sudden edema ( hands,face)
Hemorrhage in early pregnancy
Seizure
*www.doh.gov.ph
Dyspnea
Visual disturbance
Altered mental status
Weakness/malaise
Rapid weight gain
Reduced fetal movement
Lower back discomfort or midline pelvic cramping
Abnormal vaginal discharge
Foul smelling vaginal discharge
Dysuria
Regular contractions prior to 37 weeks AOG
Premature rupture of membranes

Post-partum:

Fever
Chills
Lower abdominal pain
Foul smelling lochia
Bleeding that soaks a pad every hour

Uterus getting larger

Calf pain
Dyspnea
Wound infection
Severe breast pain
Inflammed/sore nipple or breast

Danger symptoms during pregnancy

Symptoms the mother experiences
(terms in italics are the most important)

She may have this medical condition

Conception to 20 weeks of pregnancy

Persistent vomiting, weight loss

Hyperemesis gravidarum
Characterised by persistent vomiting, weight
loss of 5 kg and above, urine analysis shows
ketones 2+ or more

Vaginal bleeding (fresh), may include passage of clots and

fleshy material, with crampy lower abdominal pain

Abortion (acute)
All types of spontaneous abortions except
missed abortion are acute sudden events

Pregnancy symptoms disappear, abdomen is not growing or is

even decreasing in size, there may be minimal dark vaginal
bleeding

Missed abortion
When the fetus or fetal tissue is entirely in the
uterus, but it has no signs of life and the
cervix is completely closed

Vaginal bleeding (menstrual-like), lower abdominal pain,

missed or irregular period

Ectopic pregnancy

Vaginal bleeding (fresh), passage of tissues which look like an

ice spoiled with blood (grape-like tissues), fast abdominal
growth

Molar pregnancy

20 weeks to full term pregnancy

Headache, burning epigastric pain (Figure 15.4), blurred

vision, generalised body swelling (involving the back,
abdominal wall, hands and face), decreased urine output

Hypertensive disorders of pregnancy

(pre-eclampsia and eclampsia)

Late abortion (20-27 weeks) or antepartum

Vaginal bleeding in late pregnancy, even a minimal amount

haemorrhage (28 weeks +)

Leakage of watery fluid from the vagina that wets her

underwear significantly and may be extensive

Premature rupture of membranes (PROM)

Progressively increasing pushing down pain in the lower

abdomen before 9 months of gestation

Preterm labour

No change in abdominal growth, fetal kick felt less than 10

times in 12 hours. (Any number of fetal kicks felt in one
minute is counted as one kick)

Absent fetal kick for more than 6 hours

Intrauterine fetal growth restriction

(IUGR)

Intrauterine fetal death (IUFD)

At any time during pregnancy

Fever, headache, chills, rigor, sweating, feels thirsty,

generalised aching pain, lost appetite

Urination becomes painful, frequent, urgent and may be

bloody or look like pus

Malaria, typhoid fever, typhus fever or

relapsing fever

Urinary tract infections (UTIs, cystitis or

urethritis)

Pain in the sides (flanks), fever, vomiting, bloody urine,

urgency and frequency in urination

Acute pyelonephritis

Thirsty, drinks excessive amounts of water, urinates a lot,

feels hungry, weight loss

Diabetes mellitus

Persistent cough

Lung and heart disease

D. Post-partum
WHO Recommendations on postnatal care
RECOMMENDATION 1: Timing of discharge from a health facility after birth
After an uncomplicated vaginal birth in a health facility, healthy mothers and
newborns should receive care in the facility for at least 24 hours after birth.
RECOMMENDATION 2: Number and timing of postnatal contacts
If birth is in a health facility, mothers and newborns should receive postnatal care in
the facility for at least 24 hours after birth.

If birth is at home, the first postnatal contact should be as early as possible within
24 hours of birth.
At least three additional postnatal contacts are recommended for all mothers and
newborns, on day 3 (4872 hours), between days 714 after birth, and six weeks
after birth.
RECOMMENDATION 3: Home visits for postnatal care
Home visits in the first week after birth are recommended for care of the mother
and newborn.
Advise on danger signs
Advise to go to a hospital or health centre immediately, day or night, WITHOUT WAITING, if any of
the following signs:
o
o
o
o
o
o

vaginal bleeding: more than 2 or 3 pads soaked in 20-30 minutes after delivery OR
bleeding increases rather than decreases after delivery.
convulsions.
fast or difficult breathing.
fever and too weak to get out of bed.
severe abdominal pain.

Go to health centre as soon as possible if any of the following signs:

o fever
o abdominal pain
o feels ill
o breasts swollen, red or tender breasts, or sore nipple
o urine dribbling or pain on micturition
o pain in the perineum or draining pus
o foul-smelling lochia

E. Common Discomforts in Pregnancy

1. Nausea and Vomiting
o begin as early as 4th week of pregnancy and continue on until about the 12th week.
o Eating small frequent meals is recommended. Medications are generally not required because of
possible effects to the fetus.
o excessive nausea and vomiting warrants consultation with a doctor to correct possible fluid and
electrolyte imbalance.
2. Backpain
o due to postural changes associated with increased weight of the abdomen that stresses the
o low back area
o backache frequently responds to analgesics, warm compress and rest.
3. Varicosities
o Treatment of this condition consists of rest with elevation of the feet and the use of elastic support
stockings.
4. Pica
o This is the bizarre craving of bizarre food that are considered not edible. The cause is still
unknown.
5. Fatigue and Headache

disappears spontaneously by the fourth month

F. Prenatal Care

WHO recommends a minimum of four antenatal visits, comprising interventions such as tetanus toxoid
vaccination, screening and treatment for infections, and identification of warning signs during pregnancy.

Age of
gestation
0-28 weeks
AOG
28-36 weeks
AOG
>36 weeks
AOG

# of visits

Once a month or every 4

weeks
Twice a month or every 2
weeks
Once a week or weekly

G. Tetanus Toxoid Immunization

TT
1
TT
2
TT
3
TT
4
TT
5

First contact or as early as possible

At least 4 weeks after TT1

At least 6 months after TT2

At least 1 year after TT3 or during

subsequent pregnancy
At least 1 year after TT4 or during
subsequent pregnancy

H. Weight gain during Pregnancy

Recommended Ranges of Weight Gain during Singleton Gestations Stratified by Prepregnancy Body Mass
Indexa

Weight-for-Height Category

Recommended Total Weight Gain

Category

BMI

kg

lb

Low

< 19.8

12.518

2840

Weight-for-Height Category

Recommended Total Weight Gain

Category

BMI

kg

lb

Normal

19.826

11.516

2535

High

2629

711.5

1525

Obese

> 29

<7

<15

Recommended Dietary Allowances

1. Protein - best sources of protein are meats, milk and eggs
2. Carbohydrates - main source of energy during pregnancy; sources of carbohydrates
are rice, bread and rootcrops.
3. Fats
4. Dietary Fiber - it is recommended for pregnant women to take liberal amounts of
fruits, vegetables and whole grain cereals.
5. Minerals

Iron For the duration of pregnancy, 41 mg/day of iron is required which is higher
than what can be provided in the diet. Therefore iron supplementation is recommended.
Iron is needed to allow for expansion of the red cell mass and to provide for the needs
of the fetus and placenta. Iron supplementation is needed to prevent iron deficiency
anemia and withholding iron during the first trimester also adds to aggravating nausea
and vomiting.

Iodine the use of iodized salt is recommended to prevent iodine deficiency and other
disorders such as goiter.
6. Vitamins

Folate Deficiency of this vitamin leads to magaloblastic anemia during pregnancy.

Sources are deep-green colored leafy vegetable such as mustard and kangkong and
animal liver.

Vitamin A Excessive consumption of this vitamin proved to have negative effects on

the developing fetus. For the Filipino pregnant woman, 475 retinol equivalent/day is
recommended. Dietary sources are liver, milk, egg yolk, fatty fish, dark green leaves,
deep yellow and orange fruits and vegetables. Vitamin A is required for vision and
growth and for improving the integrity of the immune system.

Vitamin B

Vitamin C During pregnancy, Vit C content of maternal blood decreases. It is

therefore recommended to increase the intake of this vitamin. Dietary sources are green
leafy vegetables and fresh fruits.

Vitamin D and E

H.

Exercise

during
be

Absolute and Relative Contraindications to Aerobic

Exercise during Pregnancy
Absolute Contraindications

joint

level
with
No
able
all

kinds
be
o
o

Hemodynamically significant heart disease

Restrictive lung disease

Incompetent cervix/cerclage

Multifetal gestation at risk for preterm labor

Persistent second- or third-trimester bleeding

Placenta previa after 26 weeks

Preterm labor during the current pregnancy

Ruptured membranes

Preeclampsia/pregnancy-induced
hypertension

Relative Contraindications

Severe anemia

Unevaluated maternal cardiac arrhythmia

Exercise programs
pregnancy should
directed toward
muscle
strengthening to
minimize the risk of
and ligament
injuries. The goal of
exercise is to
maintain the highest
of fitness consistent
maximum safety.
single exercise
program will be
to meet the needs of
pregnant women.
There are four
of exercise that can
useful during
pregnancy:
Aerobics
Calisthenics
specifically
designed for
pregnancy
Relaxation
techniques
Toning (Kegel)
exercises