Physical Examination For Ob

PHYSICAL EXAMINATION • I. VITAL SIGNS • A. Blood Pressure • - The Bp is the most important vital sign that should be monitored every clinic visit. There is usually no significant change in Bp during gestation. However, expect a slight drop in the 2nd trimester that returns to normal on the 3rd trimester. • B. Pulse Rate Pulse rate increases by about 10 bts/min. due to • increased cardiac workload.

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- Arrhythmias or palpitation are normal during pregnancy as long as it is not accompanied by dizziness and syncope.

• C. Respiratory Rate • - Increases in depth, no significant change in rate. - Shortness of breath and dyspnea late in • pregnancy is common. • D. Temperature • - There is a slight elevation in temperature early in pregnancy due to the thermogenic effect of progesterone. It drops to normal after 16 weeks.

• II. Physical Assessment • A. Head and Scalp - Hair tends to grow faster during pregnancy. • Oily hair is also not uncommon. Excess hair dryness indicates poor nutrition. • B. Eyes • - Pale conjunctiva indicates anemia. Edema of the eyelids accompanied by visual disturbances is sign of PIH. • C. Nose • - Normal nasal congestion occurs as a result of estrogen stimulation.

• D. Ears - Nasal stiffness results in blockage of the • eustachian tube which may affect pregnant woman’s hearing. • E. Mouth and Teeth - It is normal to find swollen gums (epulis) due to • estrogen stimulation. Cracked corners of the mouth may be caused by vitamin deficiency which pregnant women are prone to develop. Dental carries should be treated during pregnancy as they may become site of infection. Major dental operations such as tooth extraction should be postponed until the postpartum period.

• F. Neck - Slight thyroid enlargement is brought about by • increased basal metabolic rate. • G. Breast - Normal findings include enlargement of the • breast with wider and darker areola, prominent veins. Breast masses, nodules, dimpling of the skin and bloody nipple discharge are abnormal findings and should be reported to the physician right away. Colostrum, a thin watery fluid, can be expressed from the nipple.

• H. Skin Linea negra, mask pf pregnancy • (melasma/chloasma), spider nevi, palmar erythema are common findings. Pallor, jaundice, rashes and skin lesions are abnormal findings. • I. Back - Exaggerated lumbar curve late in pregnancy • occurs as a result of the shifting of the pregnant woman’s center of gravity. • J. Rectum • - Hemorrhoids may be present especially in the last months of pregnancy.

• K. Extremities - Ankle swelling is a normal finding in the 2nd half • of pregnancy. Leg edema especially in the late afternoon is common to pregnant women. Waddling gait is due to relaxation of pelvic joint. Edema of upper extremities, face and hands are danger signs. • III. Abdominal Palpation: Leopold’s Maneuver •

- Abdominal palpation of pregnant women or Leopold’s Maneuver is preferably performed after 24 weeks gestation when fetal outline can already be palpated.

• Preparations for Leopold’s Maneuver: • 1. Cardinal Rule: Instruct woman to empty her bladder. • 2. Place woman in a dorsal recumbent position to relax abdominal muscles. Place a small pillow under the head for comfort. • 3. Drape properly to maintain privacy. • 4. Explain procedure to gain patient’s cooperation. • 5. Warm hands first by rubbing them together before placing them over the woman’s abdomen. Cold hands may stimulate uterine contraction. • 6. Use palm for palpation not fingers.

MANEUVER I. c.

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PROCEDURE

FINDINGS

Fundic Grip

Place both hands in the If the nurse-midwife feels upper quadrants of the the head which is round, smooth with transverse To determine fetal patient’s abdomen groove of the neck, the part lying in the is in breech fundus Using both hands, feel for fetus the fetal part lying in the presentation. To determine fundus. If the nurse-midwife feels presentation the buttocks which is soft and angular, it means the fetus is in vertex presentation. Umbilical Grip

Place both hands in the Small fetal parts feel paraumbilical regions. nodular with numerous angular nodulations. To identify location of fetal back One hand is used to steady the uterus on one side of Fetal back feels smooth, To determine the the abdomen while the other hard, like resistant plane. hand on the other side. position Moves from top to the lower segment of the uterus to feel for the fetal back and small fetal parts. Use gentle but deep pressure.

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Pawlik’s Grip

The 3rd maneuver is The presenting part is suprapubic palpation with a engage if it is not movable. To determine single dominant hand. engagement of It is not yet engage if it is presenting parts and Using the thumb and finger, still movable. to estimate fetal grasp the lower portion of station. the abdomen above symphisis pubis, press in To determine slightly and make gentle movements from the side. presentation. Pelvic Grip

The 4th maneuver involves If descended deeply, only a palpation of the lower small portion of the fetal To determine quadrants using both hands. head will be palpated. degree of flexion of fetal head. Facing foot part of the If cephalic prominence or woman, palpate fetal head brow of the baby is on the To determine pressing downward about 2 same side of the small fetal inches above the inguinal parts, the head is flexed. attitude or habitus ligament. If cephalic prominence is on the same side of the fetal back, the head is extended.

• IV. Internal Examination or Vaginal Examination • Purpose: • A. During the 1st clinic visit, IE is used to confirm pregnancy and gestation. After 34 wks., IE is performed to assess • B. consistency of cervix, length and dilation, fetal presenting part, bony architecture of the pelvis, anomalies of the vagina and perinium, including rectocele, cystocele and lesions.

• Preparation for IE: • • • • • • • • •

1. Provide explanation 2. Let woman empty her bladder 3. Provide good lighting 4. Place woman in lithotomy position with buttocks extended slightly beyond examining table. 5. Drape properly. 6. Let support person stay at the head of the bed. 7. Instruct woman not to: - hold or squeeze your hand or that of her husband - hold her breath

- close eyes tightly • - clench fist • • - contract perineal muscles • 8. Explain the procedure. It may be slightly uncomfortable. • 9. After the procedure, provide tissue to wipe perineum of lubricant. • V. Speculum Examination and Papanicolau Smear •

The purpose of the speculum examination is to examine the internal genital tract and to obtain specimen for cytological examination known as Papanicolau Smear or Pap smear.

• Pap Smear A pap smear test is done to screen for cancerous and • precancerous cells of the cervix. • Specimen Collected: • - Endocervix Specimen - Ectocervical specimen – common site for malignancy • - Vaginal pool specimen – specimen for posterior fornix. • • Findings: - Class I – normal findings • - Class II - Normal with atypical cells present. • Atypical cells are often caused by inflammatory conditions such as infection.

- Class III - Suggestive of malignancy with benign and pssibly malignant cells. - Class IV - Probably malignant, with signs of • malignancy present. • - Class V - Definitely malignant cells are present. •

• VI. Blood Tests • A. Hematocrit (hct) and Hemoglobin (hb) • - done at initial clinic visit and repeated at 28-32 wks. To detect anemia. During pregnancy blood volume increases by 30-50%. Since plasma volume increases more than red cell volume, Hb and Hct levels fall, resulting in pseudoanemia.

• . Anemia during pregnancy is usually of irondeficiency type. A folic acid deficiency state may coexist with iron deficiency. - Normal Hb is between 12 – 16 mg/dl. • - Normal hct is between 37 – 47% • - Mild Anemia is Hb less than 11 gm/dl (hct 27 – 33%) - Severe Anemia is Hb less than 9 gm/dl. (hctless • than 27%) •

• B. Leukocyte Count • - done to screen and rule out leukemia and possible infection. Nonpregnat value are 5,000 – 10,000 but may reach 16,000 in pregnancy

• C. Differential smear - done primarily to identify the types of • leukocytes, erythrocytes, abnormalities and adequacy of platelets. • D. VDRL • - screen for maternal syphilis. Untreated syphilis in the 2nd trimester can infect the fetus and result to congenital abnormalities. If woman is (+) for an STD, recommend testing and treatment of partner. • E. HIV screen • - if the woman belongs to the high risk group, HIV screening may be done by enzyme linked immunosorbent assay (ELISA) testing.

• If the result is (+), the diagnosis is confirmed usually by Western blot test. Women with HIV are treated with Zidovudine (AZT) during pregnancy to decrease the risk of the fetus acquiring the infection. HIV screening is recommended to women: - who are IV users • • - with multiple sexual partners • - with sexual partners (+) for HIV or who belong to the high risk group (homosexual, IV drug users, hemophiliacs) - who received blood transfusion between 1977 to • 1985 when HIV testing for blood products is not yet routinely conducted.

• F. Antibody screen - conducted for the purpose of screening the • pregnant woman’s serum for antibodies formed from exposure to major or minor blood group antigens. • G. Rubella antibody titer - determines a woman’s degree pf protection • against German measles. A test result of 1:8 or less indicates that the mother is at risk or susceptible of acquiring the infection during pregnancy. Since Rubella vaccine cannot be given during pregnancy, the pregnant woman must avoid exposure to the infection.

• H. DM Universal screening - conducted to screen women who have high • probability of developing gestational DM. A 50 gm oral glucose tolerance test is conducted at 24 – 28 wks. gestation irregardless of the time of the day and meals taken, ideally for all pregnant women. If test results shows a plasma value that is more than 140 mg/dl after one hour, 100 gms three hours oral glucose tolerance test (OGTT) is performed to confirm the result. The following risk factors can be used to select patients for DM screening: • - age more than 25 yrs. Old • - family history • - glycosuria - history of unexplained pregnancy losses • - Previous fetal or neonatal death •

• I. Maternal Serum Alphafetoprotein involves drawing a small amount of blood from the • mother to check for the level of alpha-fetoprotein. previous infants with congenital anomalies - large infants more than 4,000 gms. • - polyhydramnois • • Alpha-fetoprotein is produced by the fetal liver and is excreted through the placenta into the mother’s blood. This test is best conducted between 15 – 17 wks. A high amount could indicate that the baby has a neural tube defect such as spina bifida (open spine) or anencephaly (absence of the brain). If the value is low, it could be indicative of Trisomy 21 or Down’s syndrome.

• A genetic condition in which there is an extra chromosomes #21 and carries many physical defects as well as varying degrees of mental retardation. To confirm diagnosis, chromosomal study of fetal cells taken by amniocentesis may be performed. • Caused of elevated AFT - underestimated gestational age • - open NTDs • - fetal nephrosis and cystic hygroma • - GI obstruction, omphalocele, gastroschisis • - Prematurity, low birth weight, IUGR • - abdominal pregnancy • - multiple fetuses • - fetal demise • •

• Cause of low AFP - overestimated gestational age • • - missed abortions • - molar pregnacies - chromosomal abnormalities (including Down • syndrome) • VI. Urinalysis • 1. Collect urinary specimen by midstream or clean catch technique. • 2. A complete urinalysis should be conducted on the 1st clinic visit and repeated at 28 – 30 wks.

- Benedict’s test – detect glycosuria • - Acetic Acid test – detect proteinuria. • • 3. Microscopy • can identify bacteria, leukocytes, and erythrocytes, which may indicate infection. Casts and/or RBC may indicate chronic pyelonephritis. Asymptomatic bacteruria can lead to abortion early in pregnancy and can cause premature labor late in pregnancy. • 4. Glucose - Glycosuria may occur in pregnancy because of • increased glomerular filtration rate. However, it may also indicates carbohydrate intolerance. If urine is

• Positive for glucose further testing is necessary to confirm diagnosis. • 5. Protein • - A value of 1+ is abnormal. The cause should be identified with further testing (UTI, PIH, renal disease) • 6. Leukocyte - is helpful in identifying patient with significant • leukocyturia. Current opinion is that the test strip could reduce screening costs by replacing microscopy.

FETAL ASSESSMENT • I. Fetal Heart Rate • - fetal heart rate can be 1st heard between 16 – 19 wks. Gestation • - FHT is audible at about 16 wks or 4 months in multiparas and 2o wks or 5 months in primiparas. • - 80% of pregnant women, FHT is audible at 20 wks, 95% at 21 wks. And at 22 wks; FHT can be heard in all pregnant women. - After it has been initially auscultated, it should • be auscultated every clinic visit primarily to determine if the fetus is alive.

• II. Amniocentesis •

- Amniocentesis is the removal of fluid from the amniotic cavity by needle puncture. An ultrasound is performed first to determine the safe site where the needle can be inserted.

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- A long, 2o to 22 gauge spiral needle is inserted into the mother’s uterus and into the amniotic sac to aspirate 5 to 20 ml. of amniotic fluid.

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- During the procedure, the fetus is continuously monitored by ultrasound to ensure the well-being.

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- The mother may experience minor side effects, including cramping, leakage of fluid and minor irritation around the entry site. Amniocentesis carries a slight risk of miscarriage, ranging from 1 in 400 to 1 in 200. Other risk include trauma to fetus or the placenta and bleeding into the maternal circulation.

• A. Amniotic Fluid Analysis 1. Karyotyping and detection of fetal abnormalities early in pregnancy. 2. To determine fetal lung maturity.

• A. L/S ratio - L/S ratio result of 2:1 is generally accepted as a • sign of pulmonary maturity that would enable the fetus to survive extrauterine life. • B. Lung Profile - is the study of all surfactants not only the lecithin • and sphingomyelin. These other surfactants are equally important indicators of fetal lung maturity. • 3. Amniotic Fluid Bilirubin - is usually analyzed with a spectrophotometer that • measures the optical density of the amniotic fluid specimen against the characteristic absorption peak at 450 mm.

• To protect the amniotic fluid specimen, it is important to use amber glass container or if these are not available, nurse can cover a clear glass container with occlusive tape. • A. Rh Incompatibility - amniotic fluid can be assessed for bilirubin • levels repeatedly in RH incompatibility during pregnancy to monitor the progression of the disease and the fetal condition. • B. Fetal Maturity - it is expected that during the 2nd half of • pregnancy the concentration of amniotic fluid bilirubin decreases until it virtually disappears during

• the last month of gestation. • 4. For detection of certain infection. • Nsg. Care during amniocentesis: • 1. Assist client to empty her bladder before the procedure • 2. Place in supine position and drape properly. • 3. Put rolled towel under right hip to tip body to the left and remove pressure of uterus on vena cava. • 4. Instruct not to take a deep breath and hold it while needle is being inserted as it will shift the uterus and needle may hit placenta or fetus.

• 5. Inform client that it is not painful because anesthesia will be applied at the insertion site. She may experience pressure sensation during the insertion of the needle. • 6. Monitor FHT before, during and in 30 min. after the test. • 7. Administer Rh immunoglobulin if the patient is Rh negative. If the father is also Rh negative, this may not be necessary. • 8. Instruct patient to observe for: - infection • - uterine cramping • - vaginal bleeding •

• III. Obstetric Ultrasound • • • • • • • • •

Purpose 1. Diagnosis and confirmation of early pregnancy 2. Vaginal bleeding in early pregnancy 3. Determination of gestational age and assessment of fetal size 4. Diagnosis of fetal malformation and other chromosomal abnormalities. 5. Placental location 6. Multiple pregnancies 7. Hydramnios and oligohydramnios 8. Other areas

- confirmation of intrauterine death - confirmation of fetal presentation - evaluation of fetal tone, movement and breathing • - detection of uterine and pelvic abnormalities during pregnancy such as fibromyomata and ovarian cyst. • • •

• IV. Fetoscopy procedure in which an endoscope is inserted • transabdominally into the amniotic cavity to directly visualize the fetus. This procedure is performed around 18 wks. gestation.

• V. Amnioscopy - is direct visualization of amniotic fluid through • the fetal membranes with cone-shaped hollow, inserted through the cervix • VI. Radiography - confirm pregnancy with identification of fetal • skeletal parts at 16 wks. During the 2nd half of pregnancy, multiple pregnancies can be diagnosed and in the 3rd trimester, anencephaly and hydrocephaly can be seen.

• VII. Nonstress Test (NST) •

- This test relies on Fetal heart rate reactivity. A NST assesses fetal well-being based on the relationship between the baby’s heart rate and the baby’s reactivity. The FHR pattern is assessed by external monitoring without any stress or stimuli to the fetus. The baby’s heart rate should accelerate, by fifteen beats for at least 15 seconds, twice in a twenty minute period. This is called a reactive NST and is a good sign that the fetus is healthy. A reactive NST indicates intrauterine survival for one week

• VIII. Contraction Stress Test or Oxytocin Challenge Test (CST) •

used to measure uteroplacental function or the feto-placental respiratory reserve by observing the response of fetal heart rate to uterine contractions induced by oxytocin administration or nipple stimulation.

HEALTH TEACHING • I. Schedule of Visit • - 1st visit to 32 weeks – every 4 weeks • - 32 weeks to 36 weeks - every 2 weeks • - 36 weeks until delivery - every week • II. Exercise the primary purpose of the exercise is to • strengthen the muscles to be used for labor and delivery.

• Contraindicated: • - PIH • - PROM - PTL • - incompetent cervix • - vaginal bleeding • • - IUGR

Exercise Pelvic Rocking

Benefit Relieve low backache Strengthen the muscles of the lower back. - The woman must get on all fours by hollowing the back and then arching it upward to form a mound. This may also be done by lying on her back standing up. - Thrust back outward with buttocks tucked under. Hold for a least 3 seconds and release. Repeat 5 times.

Tailor Sitting

Stretch and strengthen perineal muscles. Improve circulation in the perineum. - Sit flat on the floor with legs outstretched; knees are gently pushed to the floor until the perineal muscles begin to stretch. - Hold this position for increased amounts of time each time performed.

Abdominal Muscle Contraction

Strengthen abdominal muscles in preparation for labor pushing. - Contract and relax the muscles of the abdomen - Repeat as often as desired and gradually increase the time held.

Squatting

The exercise stretches the perineal muscles and increase blood flow to the perineum. - The woman must squat and keep her feet flat on the floor. - should be done 15 minutes per day.

Kegel Exercise

Strengthen perineal muscles - The patient should alternate between tightening and relaxing the perineal muscles. - This can be done at any time and should be repeated 75 to 100 times/day.

Calf Stretching

Relieve leg cramps

Shoulder Circling

Relieve upper backache and numbness of arms and finger.

Modified knee chest

Relieve hemorrhoids, vulvar varicosities and low backache

Leg Elevation

Relieve swelling, fatigue, varicosities of lower extremities.

Leg Raising

Strengthen abdominal muscles

Incidence where recommended:

reduced

physical

activity

- PROM - CHF - Hemoglobinopathies - Marfan’s Syndrome - DM with multiple end-organ involvement

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- 2 previous pregnancies - incompetent cervix - fetal loss secondary to uterine anomalies - PIH - Multiple gestation - IUGR - severe heart disease - preterm labor

• III. Employment - pregnant women can continue working as long as • their job does not involve lifting heavy object, standing and sitting for long periods of time, excessive physical and emotional strain and expose to toxic substances.

• IV. Dental Care - The pregnant woman should have a dental check• up early in pregnancy to give plenty of time for repairs and treatment of infected teeth and for instructions on proper dental care. - dental x-ray is allowed as long as the woman • wears lead apron over her abdomen to protect the fetus from the damaging effects of radiation. • V. Maternity clothes - Lightweight, non-constrictive and loose fitting • - absorbent and washable because of increase • perspiration - Reasonably priced because they will only be used • during pregnancy.

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- flat heeled shoes that provide good support are recommended during pregnancy because of the altered balance of the woman especially when the abdomen has grown large enough.

• VI. Bathing • - The woman perspires more heavily because she needs to excrete the waste products of her body and that of the fetus. Due to increased perspiration, the pregnant woman is encouraged to have a daily bath to keep fresh and clean. - Bathing is contraindicated when there is vaginal • bleeding and after the membranes have ruptured.

• VII. Breast Care - Well fitting and large size brassiere is • recommended for the increased breast mass and pendulous breast. Bras should provide adequate support, with wide straps and deep cups to prevent loss of breast tone. - If woman plans to breastfeed, nipple rolling • between thumb and forefinger and drying of nipples with rough towel is encourage to toughen the nipple. • VIII. Immunization - Immunization with vaccines containing live • viruses is contraindicated during pregnancy because of the danger of the virus crossing the placenta and infecting the fetus.

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- The immunization recommended to all pregnant women in the Philippines is Tetanus Toxoid vaccine given in the following schedule:

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TT1 TT2 TT3 TT4 TT5

anytime during pregnancy 1 month after TT1 (3 yrs. Protection) 6 month after TT2 (5 yrs. Protection) 1 year after TT3 ( give 10 yrs. Protection) 1 year after TT4 (gives lifetime protection)

• IX. Travel • - There are usually no travel restrictions during pregnancy but it is advised that pregnant women avoid long trips on the 3rd trimester. The best time to travel is on the 2nd trimester because the woman is

• Most comfortable at this time and there is minimum danger of abortion and preterm labor. - When traveling: • - 15 to 20 mins. Rest period on long rides to • move about and empty bladder. • X. Sexual Relation - 1st tri – decrease sexual desire due to • discomforts of pregnancy - 2nd tri - increase sexual desire because woman • has already adjusted to pregnancy and this is the period when she is most comfortable. - 3rd tri - decrease sexual desire because of the • fear of hurting the fetus and the discomfort caused by enlarged abdomen and deep penile penetration.

• XI. Alcohol - refrain from drinking alcohol because it may • cause fetal anomalies. - Alcohol increases the risk of: • - midtrimester abortion • - mental retardation • • - behavior and learning disorder • - Fetal alcohol syndrome (SGA) • XII. Smoking - nicotine causes vasoconstriction resulting in • decreased blood flow to the placenta which in turn diminished oxygen supply to the fetus. Fetal hypoxia leads to low birth weight.

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- Smoking increases the risk for: - poor lung development - asthma, and respiratory infection - increased risk of SIDS - physical growth deficiency - intellectual development deficiency - behavioral problems

• XIII. Medications - Classification of medication with regards to • adverse fetal effects (FDA) •

- Category A - safe for fetus in human studies (Vitamins)

- Category B - adverse effect not demonstrated in animal studies with no human studies; or adverse effects shown in animal studies have not been reproduced in human studies (penicillin). - Category C - no adequate animal or human • studies are available; or animal studies show adverse fetal effects with no human data. • Category D - Evidence of fetal risk but benefits believed to outweight the risk (carbamazepine) • - Category X - drugs with proved fetal risks that outweight any benefits. •

• Pregnancy medications that show no adverse effect at the usual dose: - antihistamines • - decongestants (pseudoepinephrine) • - some antibiotics ( penicillin, ampicillin, • cephalosporins, erythromycin ) - non-quinine antimalarial • - gen. anesthetics • • - acetaminophen • - Tuberculostatics ( INH, PAS, and Rif-ampin) • - Metronidalose ( avoid in first tri if possible) • - Steroids - Accidental use of clomiphene, bromocriptine, • birth control pills, vaginal spermicides)

DRUGS

TERATOGENIC EFFECTS

Androgen, estrogen, progesterone

Masculinization of female infants

Thalidomide

Phocomelia, cardiac and lung defect

Anticonvulsant (Dilantin)

Cleftlip, palate, congenital heart defects

Lithium

Congenital heart defect

Tetracycline

Yellow staining of teeth, inhibits bone growth

Vit. K

Hyperbilirubinemia

Salicylates (aspirin)

Neonatal bleeding, decreased intrauterine growth

Sodium Bicarbonate

Fetal metabolic alkalosis

Streptomycin

Nerve Deafness

Vit. A

Central venous system defects

DANGER SIGNS OF PREGNANCY • • • • • • • • •

1. 2. 3. 4. 5. 6. 7. 8. 9.

Vaginal bleeding of any amount Persistent vomiting Chills and fever Sudden escape of fluid from the vagina Swelling of the face and finger Visual disturbance Painful urination or dysuria Abdominal pain Severe or continuous headache

MINOR DISCOMFORTS OF PREGNANCY • 1. Nausea and vomiting • • •

Management: A. Eat dry toast or crackers before rising from bed B. Eat small frequent meals rather than 3 large ones

• 2. Frequent urination • Management: • A. Limit fluid intake before bedtime

• B. Kegel exercise to improve tone of muscles that controls urination. • 3. Fatigue • Management: • A. Take at least 8 hours of sleep at night and frequent rest periods during the day. • B. Avoid standing for long periods, work while seated as much as possible • C. Eat a well balanced diet to provide enough energy • 4. Breast tenderness and nipple irritation

• Management: • A. Wash breast with water only, no soaps and alcohol to prevent drying and irritation • B. Wear supportive maternity brassiere • 5. Leukorrhea • Management: • A. Proper perineal hygiene, flush perineu with water after each voiding, no douching is necessary • B. Use sanitary pad for excessive vaginal discharge • 6. Nasal stiffness

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Management: A. Avoid allergen and smoked filled room B. Normal saline nose drops (1/4 salt in 1 cup water) C. Breathe steam from pot of boiling water

• 7. Heartburn or pyrosis • • •

Management: A. Take small meals rather that three large ones B. Bend at knees not at waist when picking objects from the floor, avoid lying flat

• 8. Varicose Veins • Management: • 1. Leg varicosities a. Periodic rest with elevation of the legs, lie with • feet against the wall b. Avoid prolonged sitting or standing, • constricting garters, knee high socks c. Wear support hose • • d. Apply elastic bandage before getting up in the morning starting at the distal ends but don’t wrap toes

• 2. Vulvar Varicosities a. Rest with pillow under hips • • b. Modified knee chest position • 3. Anal Varicosities or Hemorrhoids a. Sim’s position several times a day • b. Avoid constipation • • c. Hot sitz bath 15 to 20 minutes • d. Avoid bearing down e. Observe good bowel habit • f. Use a topically applied anesthetics, use stool • softeners and warm soaks

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9. Backache Management: A. Pelvic rocking exercise to relieve low backache 2. Frequent rest and avoidance of fatigue

• 10. Leg cramps • Management: • A. For immediate relief, push toe upward while applying pressure on the knee to straighten the leg • B. One quart of milk a day to meet calcium needs or oral calcium supplements as prescribed by physician

• C. Exercise regularly but avoid pointing of toes • 11. Headache • headache is normal during the 1st trimester. Some cases lead to sinusitis or ocular strain caused by refractive errors. • 2nd tri – less headache because the pregnant woman is already adjusted • 3rd tri - especially if frontal and accompanied by visual disturbances should be investigated as this maybe caused by pregnancy induced hypertension (PIH)