Zygote Fertilization to Implantation.

Table: Fertilization
TOPIC OUTLINE Implantation to 5-8 weeks. FERTILIZATION
I. Terms To Describe A. Cardiovascular System Pronuclei (Zygote)
Fetal Growth X. Fetal Circulation
 2-5 weeks of gestation during 🡣
II. Fertilization
Embryo which time various organs are Undergo Mitosis (Cell division)
XI. Terms
A. Characteristics Of XII. Diagnosis of Pregnancy developed & a definite form is 🡣
Sperm for Fertilization XIII. Specific Teratogens assumed. 2, 4, 8, 16
B. Zygote XIV. Different Body System Fetus 5-8 weeks until term. 🡣
III. Implantation Are Develop Developing embryo & placental structures Morula (16th cell stage, approximately on the 3rd day)
A. Zygote XV. Milestones of Fetal Conceptus 🡣
throughout pregnancy.
B. Embryo Growth & Dev Blastocyst
C. Two Layers of XVI. Physiologic Changes Age of Viability 24 weeks or weigh > 500 – 600g.
Blastocyst During Pregnancy
IV. Embryonic Structure A. Local Changes
V. Pregnancy B. Systemic Changes Table: Ovum & Sperm During Fertilization
A. Decidua C. Psychological Changes OVUM SPERM
VI. Fetal Membrane XVII. Signs Of Pregnancy  Capable of fertilization for  Functional life of
A. Amniotic Fluid XVIII. Prenatal Care only 24 (48 hrs.) spermatozoon 5 day
VII. Placenta A. Leopold's Maneuver
A. Functions Of the
 Very mature ⭢ T  3 days – 72 hrs.
XIX. Minor Discomforts of
estrogen  Ejaculation of semen –
Placenta Pregnancy and Their Relief
B. Mechanism By Which 2.5 mL of fluid containing
Measures
Nutrients Cross the
20 – 200 million
A. Employment/Travel
Placenta B. Marital Relations
 Zona Pellucida – ring of  X – long life & slow
C. Endocrine Function XX. Danger Signs of
mucopolysaccharide moving
VIII. Umbilical Cord  Corona Radiata – circles  Y – short life & fast
Pregnancy
IX. Origin And XXI. Schedule Of Clinic Visits
of cells moving
Development of Organ
System

A. CHARACTERISTICS OF SPERM FOR

I. TERMS TO DESCRIBE FETAL GROWTH FERTILIZATION

1. Capacitation – the capacity to penetrate the ovum which

Figure: Ovulation, Fertilization, & Implantation involves the removal of the protective layer of corona cells by the
TRIMESTER MONTHS WEEKS enzyme Hyaluronidase (proteolytic enzyme) a protein layer
1 1–3 1–4 II. FERTILIZATION that coats the head of the spermatozoon
5–8 - Union of ovum & spermatozoan. 2. Acrosome reaction – release of another trypsin like enzyme
9 – 13 - Also known as conception, impregnation or fecundation.
Acrosin dissolving layers surrounding the ovum zona pellucida
2 3–6 14 – 17 - Ampulla: fertilization occur in the outer third of the fallopian
18 – 22 tube.  Sperm tails is left once penetrated
- Once the sperm cell has entered, the ovum and the nucleus of 2
23 – 27
sex cells has fused, fertilization is achieved. - Zona reaction – formation of new barriers around the egg cell
3 6–9 28 – 31 - The second meiotic cell division of the ovum is completed after after it has been fertilized to prevent the entry of the sperm
32 – 35 fertilization & it is the secondary oocyte that is fertilized.
36 – 40 - 3 – 4 days – stay in the fallopian tube
- 3 – 4 days – float in the uterine cavity Accessory Structures Needed for Support During
Table: Period of Prenatal Development
- 6 – 8 days – implantation (upper portion) Intrauterine Life
NAME TIME PERIOD
 Placenta Previa: placenta develops on/ near the cervix 1. Placenta
- 7 days – average implantation
Ovum Ovulation to Fertilization.

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2. Fetal Membrane
b. Secrete HCG necessary to prolong the life of corpus  Supporting structure: Musculoskeletal
3. Amniotic Fluid
luteum o Connective tissue
4. Umbilical Cord
- Fluid fills the spaces found within the cells o Bones
o Cartilage
B. ZYGOTE
B. TWO LAYERS OF BLASTOCYST o Muscle
- 1st cell of the human body formed fertilization of sperm & ovum.
1. Trophoblast (Outer Layer/ Trophoderm) – gives rise to o Ligaments
- It contains 46 chromosomes: 44 are autosomes & the
the placenta, fetal membranes, umbilical cord & amniotic o Tendons
remaining are either XX chromosome (female) and XY
fluid. MESODERM  Upper urinary tract
chromosome (male).
 “Feeding” layer; principal functions are to o Kidney
- The zygote our journeys from the fallopian tube for a period of 3
secure food for the embryo o Uterus
-4 days aided by muscular contractions of fallopian tube.
- At around the 3rd week of gestation, the trophoblast cells  Reproductive System
- About 24 hours after fertilization, it undergoes 1st cell division.
surrounding the blastocyst differentiate in 2 distinct layers:  Cardio
The daughter cells formed from this cell division are called
blastomeres.  Lymph
A. Cytotrophoblast: 1st layer that develops also called the  Circulatory
- Subsequent cell divisions occur after every 22 hrs.
Langhan’s Layer  Blood cells
- When there are 16 or more blastomeres, the zygote is termed a
morula. It is in this form that the zygote travels from fallopian  Langhan’s layer: protection against syphilis ⭢ 2nd trimester  Lining of pericardial, pleura, peritoneal
tube to the uterus. - Protects the fetus against syphilis until 2nd cavities
trimester only because after 3 months of  Lining of:
III. IMPLANTATION pregnancy, it become less numerous o GI
- 8 – 10 days B. Syncytiotrophoblast (Syncytium): outer layer which ENDODERM o Respiratory
- The trophoblast cells release enzymes (proteolytic) that digest originates from cytotrophoblast. o Tonsils
endometrial cells causing rupture of several capillaries resulting - Produces the various hormones of pregnancy: o Parathyroid
in bleeding at the implantation site. This may cause vaginal  Estrogen o Thyroid
bleeding called implantation bleeding.  Progesterone o Thymus glands
- The ideal site of implantation is the fundal portion  HCG
posterior surface of the upper uterine segment.  HPL - Germ layer is helpful to know because coexisting
- Placenta Previa: result of implantation in the lower portion.  Secrete HCG (Human Chorionic congenital disorder found in newborns usually arise
Gonadotropin) to prolong life of the corpus from the same germ layer
A. ZYGOTE luteum - Rubella: one reason it is so serious because this virus is
- Upon reaching the uterine cavity, the remaining zona 2. Endoblast/ Embryoblast (Inner Layer) – develops into capable of infecting all three-germ layer
pellucida disintegrates & the morula is transformed into fetus/ baby. Gives rise to the three primary germ.
blastocyst - Blastocoele or Embryonic Disc IV. EMBRYONIC STRUCTURE
- The zygote period: fertilization to implantation  1 month ⭢1.3m ⭢ Organogenesis ⭢ Sensitive
st - As early as 12 days after fertilization the trophoblast cells
rapidly multiply & mature to form tiny projections around the
B. EMBRYO  Table: Origin of Body Tissue
zygote called villi.
- Blastocyst: is a ball like structure composed of inner cell GERM  Villi: attachment on/ to natural blood vessels
mass called embryonic disc or blastocoele. BODY PORTION FORMED - These villi are classified as:
LAYER
A. Trophoblast/ Trophoderm: occupying one of its poles &  CNS
an outer layer of rapidly developing cells  Chorion Frondosum: these are in contact with
 PNS
 Trophoblast ⭢ Chorionic Villi (back part) ⭢ Chorion  Skin, hair, nails & tooth enamel
decidua basalis and later from the fetal side of the
 Gives rise to placenta, fetal membrane, umbilical placenta.
 Sense Organ
cord & amniotic fluid. - Responsible for absorbing nutrient &
ECTODERM  Mucous membrane of the:
 The important function of the trophoblast is to: O2 from maternal blood stream &
o Anus
a. Absorb nutrients from the endometrium disposing fetal waste products.
o Mouth
 Chorion Laeve (Bald Chorion): not involve in
o Nose
implantation; gradually degenerates eventually
 Mammary Glands forming the chorionic membrane.

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Trophoblast (Chorion, Future Placenta) is responsible for
 Bilirubin
embedding the ovum.
- The most ideal site for implantation because of its rich blood  Mineral
🡣
supply that ensure maximum placental growth & development - Suspend materials such as:
Chorionic Villi develops from trophoblastic layer and extend to blood
- It provides easy access to the birth of the baby at the end of  Desquamated epithelial cells
filled spaces (mother). It contains blood vessels connected to fetus
gestation as it is continuous with the birth canal  Vernix caseosa
🡣 - It may prevent infections coming from the vaginal & cervix 5. It is clear & colorless to straw colored
Prod. HCG after implanting which maintains progesterone - It produces the following hormones:  Green tinged or meconium stained in non-
production which in turn stimulates & support endometrial growth for
 Prolactin breech presentation: fetal distress
the conceptus
 Relaxin  Golden colored: hemolytic disease such as
 Corticotropin Releasing Hormone (CRH) RH or ABO group incompatibility
V. PREGNANCY  Oxytocin  Gray Colored: infection
- After implantation, the endometrium is referred to as decidua,
 Endothelin  Blood AF at the time of rupture: vasa previa
the specialized endometrium of pregnancy. It is composed of 3
layers:  Brownish, coffee or tear colored: fetal death
VI. FETAL MEMBRANE 6. PH: 7.0 – 7.25 reaction is neutral to alkaline (litmus test:
1. Chorion – from the chorionic villi that envelops the embryo. blue gray to deep blue – nitrazine)
1. Decidua Basalis – portion that is pushed out by embedded &
The outermost membrane of the growing zygote which serves as 7. Specific gravity: 1,005 – 1.025
growing ovum. It will later form the maternal side of the placenta.
protective and nutritive covering. 8. Production & removal is achieved through the following
 Endometrium “pregnant” - It provides support to the amniotic membrane mechanism:
2. Decidua Capsularis – portion that is pushed out by embedded 2. Amnion – most internal of the fetal membranes, contains cells A. The mother contributed to the AF by
& growing ovum. that produce water (amniotic fluid) surrounding the fetus in the transudation from maternal circulation.
3. Decidua Vera – remaining portion which is not in immediate utero. Maternal serum composes most of the fluid in
contact with ovum - Also secrete phospholipid that plays an important role in early pregnancy
prostaglandin synthesis, a hormone that simulates uterine B. The fetus contributes to AF by:
- 4th month – d. capsularis lies in intimate contact with d. vera. contraction & can initiate labor  Active secretion from the
epithelium of the amniotic
A. DECIDUA A. AMNIOTIC FLUID membrane
 Cells of amnion & urine of fetus forms the amniotic fluid  Transudation from fetal circulation
 Fetal urination as primary source of
 24 hrs. ⭢ AF released during labor & infection ⭢
AF in late pregnancy
Chorioamnionitis
C. Removal to uptake of AF is by:
 Premature ⭢ Maternal Sinuses ⭢ Maternal Hemorrhage  Absorption through the amnion to
⭢ Early Separation of Placenta ⭢ Solid Particles ⭢ the maternal circulation
Embolus ⭢ Amniotic Fluid Embolism  Fetal swallowing is the chief
mechanism which controls the
1. Medium which the fetus & cord float inside the amniotic volume of fluid
membrane 9. Functions
2. It is not static but is in a continuous turn over 350 – 500  Keeps fetus at even temperature
mL of it is produced & replaced each hour  Cushion fetus against possible injury
3. Normal amniotic fluid volume ranges from 500 – 1200
 Provides medium which fetus can move easily
mL, averaging at 1000 mL
 Acts as hydrostatic wedge easing the pathway of
4. It is composed of 99% water & 1% solid particles it
fetus during delivery
contains:
 Prevents adhesion between the sac & the
 Albumin
embryo
 Urea
 Can be a basis to determine fetal maturity &
 Uric acid fetal genetic make-up
Figure: Decidua  Creatinine  Fetus drinks the fluid, source of oral fluid
 Lecithin 10. Deviations from Normal:
 Sphingomyelin
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A. Oligohydramnios: scanty amniotic fluid
b. Nutrients, drug, antibodies & viruses CAN
<500 mL cause:
pass through Progesterone
 Fetal renal anomalies resulting to
anuria - Hormone of pregnancy
B. MECHANISM BY WHICH NUTRIENTS CROSS THE - Early as 14th week: present in a pregnant patient’s serum
 Premature rupture of membranes PLACENTA result of the continuation of the corpus luteum
 Exposure to angiotensin
1. Diffusion: when there is a greater concentration of a - Reduce the contractility of the uterus during pregnancy ⭢
converting enzymes inhibitors
substance on one side of a semipermeable membrane than to prevent premature labor
B. Polyhydramnios: excessive amniotic fluid
on the other, substance of correct molecular weight crosses
>2000 mL cause:
the membrane from the area of higher concentration to the Estrogen
 Fetal abnormalities like
area of lower concentration. - Second product of the syncytial cells
anencephaly & esophageal
 Oxygen - Contributes to the mammary gland development
atresia
 Carbon dioxide preparation
 Multiple pregnancy
 Sodium - Simulates uterine growth to accommodate the
 Diabetes mellitus
 Chloride can cross the placenta by this development of the fetus
method
VII. PLACENTA 2. Facilitated diffusion
- Formed at 3rd month
Human Placental Lactogen (Human Chorionic
 Glucose Somatomammotropin)
- A fleshy dislike organ which measures 20 cm in diameter & 2
3. Active transport - Hormone with growth-promoting and lactogenic properties
cm thickness late in pregnancy
 Acids and water-soluble vitamins (C, B) - 16th weeks of pregnancy begins, T to a peak level at term
- Formed by union of chorionic villi & decidua basalis
4. Pinocytosis: this is absorption by the cellular - Promote breast growth
- At term, it weighs 500 g. Approximately 1/3 of baby’s
membrane of microdroplets of plasma & dissolved - Important role of regulating parenteral glucose, protein, and fat
weight
substance
- Fetal side is smooth & glistening & covered by amnion
 Gamma globulin, lipoproteins & Placental Proteins
 Smooth ⭢ Schultz (Fetal Side) phospholipids: all have molecular structures - Placenta produces numbers of plasma protein
- Maternal side is red & flesh like divided into number of too larger for diffusion so cross in this manner. - ⭣ the immunological impact of the growing placenta
segments or cotyledons Unfortunately, viruses that then infect the fetus - Help prevent HTP of pregnancy
 Dirty ⭢ Duncan (Maternal Side) can also cross in this manner
 Slightly pat feet/ buttocks to stimulate crying
VIII. UMBILICAL CORD
 SGA ⭢ Small Gestation Age C. ENDOCRINE FUNCTION
- Connects the placenta with the umbilicus of the fetus
- Alcohol makes the brain of the baby small (mental - Syncytial (outer) layer of the chorionic villi: develop into
- Made up of 2 arteries and 1 vein (AVA)
retardation) a separate and important hormone producing system
- 50 – 55 cm (20 in.) L & 2 cm diameter
- Smoking makes interfere with blood flow thus small baby o A short cord may lead to:
with complication Human Chorionic Gonadotropin
- First placental hormone  Turtle Sign
- 6 months of life (3rd trimester) – span when mother still
- Found in maternal blood and urine  Intrapartum hemorrhage due to
gives protection to the baby through transfer of
- 1 – 2 weeks after birth: pregnancy person’s blood serum premature separation of the placenta
immunoglobulins IgG (passive immunity)
will be completely negative for hCG after birth  Delayed descent of fetus during labor
- Proof that placental tissue is no longer present  Inversion of the uterus
A. FUNCTIONS OF THE PLACENTA o Long cord may lead to:
1. Transfer of gases (acts as fetal lungs) - Similar to LH: If the fetus is male, it exerts effect on the fetal
testes to begin testosterone production and maturation of  Cord presentation & cord prolapse
2. Transport of nutrient (source of nutrition)  Coiling of cord around the neck
3. Excretion of waste (acts as kidney reproductive system
- Purpose:  True knots of the cord
4. Transfer of heat (acts as skin) - Wharton’s jelly: encased in a mass of gelatinous tissue, no
5. Hormone production (acts as endocrine organ through o Fail-safe measure to ensure the corpus luteum of the
ovary continues to produce estro & prog so that the nerve ending
production of various proteins & hormones) o It may prolapse; if outside the vagina – revealed, if
6. Provider of antibodies (passive natural immunity, IgG) endometrium is maintained.
o Suppressing the maternal immunologic response so inside the vagina – concealed
7. Protective barrier – filter microorganism - Knots of the cord:
a. Large particles such as bacteria CAN’T placental tissue is not detected and rejected as a
foreign substance.
pass through
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o True Knots – fetus passes through a loop of
11th – 20th week Early ECG are not accurate to injury. Syphilis and toxoplasmosis can cause abnormalities
cord in organs that are originally formed normally.
o False Knots – Wharton’s jelly containing a loop 3. Affinity to specific tissue - ex. Lead attacks & disabled nervous
of umbilical vessels X. FETAL CIRCULATION
tissue; Thalidomide causes limb defects; Tetracycline causes
- Loops of the cord: cord coil around the fetal body & neck. - Difference between adult & fetal circulation: tooth enamel deficiencies & possibly long bone deformities; rubella
When the cord coil is around the neck also called nuchal cord 1. Presence of certain structure in the fetus: AVA virus affects many organs like eyes, ears, heart & brain.
a. Umbilical arteries (2): carry unoxygenated blood
 Cord prolapsed: Nursing Intervention ⭢ Trendelenburg
from fetus to the placenta (later; filled with clotted XIII. SPECIFIC TERATOGENS
Position or Knee-Chest Position A. Maternal Infections
blood)
b. Umbilical vein (1): carry oxygenated blood from 1. Rubella (German Measles), effects to baby include deafness,
IX. ORIGIN AND DEVELOPMENT OF ORGAN the placenta to the fetus (later; becomes round cataracts, mental & motor retardation, cleft lip & palate,
SYSTEM abortion, cardiac effects (patent ductus arteriosus & pulmonary
ligament)
stenosis, SGA)
- Zygote ⭢ embryo ⭢ fetus
- Zygote formation: !!! development proceeds in a XXII. TERMS 80% - 1st - 12 weeks titer >1:8 -immunity
cephalocaudal direction!!!! A. Gravidity 54% -13 - 14 weeks titer<1:8 - Susceptible
- Primary germ layers: (EME) all organ system is complete at 1. Gravida - refers to a pregnant woman 25% - after this 30% spontaneous abortion or
8-week gestation. ⭢ the end of the embryonic period 2. Gravidity - refers to number of pregnancies stillbirth If occurred on the 1st
3. Nulligravida - a woman who has never been pregnant trimester
Table: Stem Cells 4. Primigravida - a woman who is pregnant for the first time
DAYS TERMS 5. Multigravida - a woman in at least her second pregnancy 2. Sexually transmitted diseases
4th day Zygote cell ⭢ totipotent stem cells a. Syphilis - congenital syphilis (damage occurs 16-18
B. Parity weeks), untreated beyond 18 weeks results to deafness,
Another 4th day Termed pluripotent stem cells: become
1. Parity - is the number of births (not the number of fetuses) cognitive impairment, fetal death.
specific body cell: nerve, brain, or skin cells carried past 20 weeks gestation, whether or not the fetus was born - Newborn with congenital syphilis has extreme rhinitis
Another few Multipotent: cannot be deterred from growing alive. Or term for previous pregnancies that terminated after the syphilimezt.google.com is sharing your screen Infection usually leads
days into a particular organ: spleen, liver, or brain infant was viable whether alive or dead. to spontaneous abortion
2. Nullipara- a woman who has not had a birth at more than 20 b. Gonorrhea
weeks gestation - Fetus is contaminated at the time of delivery
A. CARDIOVASCULAR SYSTEM
3. Primipara - a woman who has had one birth that occurred after - Maternal infection may result in postpartum
- First system to become functional the 20th week of gestation infection of the neonate
- Simple blood cells joined to the wall of yolk sac progress to 4. Multipara - a woman who has had two or more pregnancies - Risk to the neonate include ophthalma
become a network of blood vessel and a single heart tube resulting in viable offspring neonatorum, pneumonal and sepsis
- HR of a fetus is affected by: 3. Toxoplasmosis – contact with cat’s stool or litter. Cause
 Oxygen level XII. DIAGNOSIS OF PREGNANCY CNS damage, hydrocephalus, microcephaly intracerebral
A. Growth and Development of the Fetus calcification & retinal deformities
 Activity
Three Germ Layer: 4. AIDS – repeated exposure to virus during pregnancy through
 Circulating blood volume unsafe sex practice or IV drug use can increase the risk of
1. Ectoderm - gives rise to the skin, hair, nails, sense organs, nervous
system, mucous membrane of the mouth and anus, the first germ transmission to the fetus
Table: Development of Cardiovascular System layer to develop - Perinatal administration of zidovudine (ZDV) maybe
DEVELOPMENT OF CARDIOVASCULAR SYSTEM 2. Mesoderm – gives rise to the kidney, muscoskeletal system (bones recommended to decrease the transmission of HIV virus
16th day Form and muscle) reproductive system, and cardiovascular system (heart from mother to fetus
24th day Beats and blood vessels), last germ layer to develop
16th – 17th week Septum that divides the heart into chamber 3. Entoderm – gives rise to the bladder, lining of gastrointestinal
tract, tonsils, thyroid gland, and respiratory system
17th week Heart valves develop
28th week When the sympathetic nervous system
matures the HR stabilizes and a consistent HR of Teratogens - any factor, chemical or physical that adversely affect the fetal
110 – 160 beats per min. is assessed. development.

Table: Development of Cardiovascular System Factors influencing the amount of damage a teratogen can cause: ►
INSTRUMENTS 1. Strength - rays of sun in small amount is all right but frequent
exposure maybe bad. Increase dose/amt., increase teratogenic effect
10th – 12th week Heartbeat may be heard with a Doppler
2. Timing - if teratogen is introduced before implantation, either
zygote is destroyed or unaffected. 2nd - 8th week vulnerability
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XIV. DIFFERENT BODY SYSTEM ARE DEVELOP
- Heart begins to form as early as
16th day of life.
- Fetal circulation differs from
CIRCULATORY extrauterine Circulation.
SYSTEM - Oxygen exchange and excretion of
carbon dioxide takes place through 2
umbilical arteries and 1 vein of
the placenta and not to the lungs.

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- 28th weeks of gestation is believed to possible to distinguish a boy from a - Extremities have developed
RESPIRATORY be the practical lower limit of girl until birth. - Penis begins to appear in boys.
prematurity or the earliest gestation - But with the advances in technology a - Abdomen appears large as fetal intestine
SYSTEM age at which a fetus can survive baby's sex may be known even before grows rapidly
outside a woman's womb.
it presents itself - Baby is moving, although the mother
- Morning sickness may be interpreted
to the world cannot yet feel movement
as a sign of pregnancy because this
symptom is brought about by a - Kidneys are non-functional before
depletion in maternal blood glucose birth even if they are already present
NERVOUS levels. in rudimentary form as early as 4th
- This results from the embryo's intake week of fetal life.
SYSTEM URINARY SYSTEM
of glucose from the mother which is - Urine is only formed by the 12th
necessary for the rapid development week.
of the nerve tissues - At 9th months fetal urine is
during the 3rd and 4th week of life. excreted at the rate of 500 ml./day
- 3rd week of life, the respiratory and
digestive tracts exist as a single tube. XV. MILESTONES OF FETAL GROWTH & DEV
- Digestive tract separates from the At the - Length: 0.75 to 1 cm Weight: 400 mg
respiratory tract at about the 4th end of - Baby is 1/4 inch long.
week of life. four - Heart, digestive system, backbone and spinal cord
- It grows very fast so that by 5th-8th begin to form.
weeks: At the - Baby is 2-1/2 to 3 inches long (7-8 cm)
week, meconium is already formed in - Placenta (sometimes called "afterbirth") begins
to develop. end of - Weight is about 1/2 to 1 ounce (45 g)
DIGESTIVE the intestines.
- Arms & legs are budlike structures 12 - Baby develops recognizable form.
SYSTEM - Meconium - colored black or dark
- Rudimentary eyes, ears & nose are discernible - Nails start to develop, and earlobes are
green and sticky in texture, the end weeks:
- The single fertilized egg is now 10,000 times formed.
-product of fetal metabolism made up
larger than it was at conception - Bone ossification centers are forming
of bile, mucoproteins, fats, cellular
- Sex is distinguishable by outward appearance
waste, mucopolysaccharides and some
- Arms, hands, fingers, legs, feet and toes are
vernix caseosa.
fully formed.
- Eyes are almost fully developed.
- Baby has developed most organs and tissues.
- A fetus cannot be visualized by X-
- Baby's heart rate can be heard at 10 weeks
ray until a degree of Ossification has
with a special instrument called a Doppler.
taken place.
- Ossification of bone tissue in the
SKELETAL 3rd month and continue all
SYSTEM throughout fetal life.
- Fetal X-ray is teratogenic factor
which can cause damage to the
developing fetus early in
pregnancy
- The sex of the baby is determined at
the moment of conception by a
spermatozoon carrying an X Y sex
At the - Baby is 1-1/8 inches long.
GENITAL SYSTEM chromosome.
end of 8 - L-2.5 cm Wt. - 20 g
- 8th weeks of gestation when the
weeks: - Organogenesis is complete
gonads (ovaries or testes) would
- Heart is functioning.
have been formed, it still not
- Eyes, nose, lips, tongue, ears and teeth
are forming.
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At the - Baby is 6-1/2 to 7 inches long. (10 to 17 cm)

- Weight is about 6 to 7 ounces. (55 to 120 g)
- Baby is developing reflexes, such as sucking and
swallowing, and may begin sucking thumb.
- Tooth buds are developing.
- Sweat glands are forming on palms and soles.
- Fingers and toes are well defined.
- Gender is identifiable by UTZ
- Skin is bright pink, transparent and covered

At the - Baby is 11 to 14 inches long. (28-36 cm)

end
end of 6 - Weight is about 1-3/4 to 2 pounds. (550 g)
months: - Eyelids begin to part, and eyes open
sometimes for short periods of time.
- Skin is covered with protective coating called
At the - Baby is 16-1/2 to 18 inches long.
vernix.
end of 8 - Weight is about 4 to 6 pounds.
- Baby is able to hiccup.
months: - Overall growth is rapid this month.
- Tremendous brain growth occurs at this time.
- Most body organs are now developed, except
of 4 - for the lungs.
- Movements or “kicks" are strong enough to be
months:
visible from the outside.
with soft, downy hair. (lanugo)
- Kidneys are mature.
- Although recognizably human in appearance,
- Skin is less wrinkled.
the baby would not be able to survive outside
- Fingernails now extend beyond fingertips
the mother's body.

At the - Baby is 14 to 16 inches long.

end of 7 - Weight is about 2-1/2 to 3-1/2 pounds.
months: - Taste buds have developed.
- Fat layers are forming.
- Organs are maturing.
- Skin is still wrinkled and red.
- If born at this time, the baby will be considered
premature and require special care
At the - Baby is 19 to 20 inches long.
end of 9 - Weight is about 7 to 7-1/2 pounds.
months: - The lungs are mature.
- Baby is now fully developed and can survive
outside the mother's body.
- Skin is pink and smooth.

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- The baby settles down lower in the abdomen to B. Cervix  T glandular activity - sweat glands
prepare for birth and may seem less - Operculum - mucous plug are produced which serve to seal  sebaceous gland - oil secretion
out bacteria during pregnancy and thus prevent infection in
the fetus and the membrane. G. Breast Changes - bigger because of estrogen & HCS
- Cervix becomes more vascular and edematous resemble the - Increase breast size due to alveolar tissue growth, fat
consistency of an earlobe when it is used to be like a nose deposition and increase in vascularity.
during nonpregnant State. - Increase estrogen level pregnant women experienced
fullness or tingling sensation of breast.
NOT PREGNANT soft as tip of the nose - Areola gets darker and increase in diameter.
PREGNANT soft as earlobe - Montgomery gland (sebaceous gland) enlarge and become
NEAR DELIVERY soft as butter prominent.
- A clear fluid, called Colostrum, can be expressed from it as
- Goodell’s sign - Softening of the cervix. early as the 4th month.

C. Vagina Table: Breast Changes

- Chadwick's sign - When vagina change in color from light 4th month precursor of breast milk maybe expressed
pink to deep violet due to increase blood supply. (colostrum)
XVI. PHYSIOLOGIC CHANGES DURING
- White Vaginal discharge is often observed during pregnancy due 3-4 wks prickling & tingling sensation 6 wks. - becomes
PREGNANCY
to the increase in the activity of the epithelia cells. enlarge & tense
A. LOCAL CHANGES - Change in PH (4/5 - acidic) of Vaginal secretions during 8 wks surface veins are visible, Montgomery’s tubercles
pregnancy to protects it from bacterial invasion. more protuberant
A. Uterus - But it is favorable for the growth of a yeast-like fungus 12 wks. darkening of the areola
- Increase in sized in order to accommodate the growing fetus. (Candida) which can be transmitted and manifests as 16 wks. colostrum can be expressed
UTERINE PRE- TERM PREGNANCY thrush in the infant's mouth.
PREGNANCY B. SYSTEMIC CHANGES
Weight 50 gm. 1000 gm. D. Ovaries A. Respiratory system
Thickness 2 cm 0.5 cm - Ovulation and menstruation stop with pregnancy because of lack - Shortness of breath - common complaint of pregnant
Length 6.5 cm 32 cm of activity of the follicle stimulating hormone and the production mothers.
of human chorionic gonadotropin hormone. - Due to the increase uterine size causes the diaphragm to be
Depth 2.5 cm 22 cm
pushed or displaced crowding the chest cavity.
Width 4 cm 24 cm
E. Abdominal Wall - Nose bleeding - normal Occurrence due to marked
Capacity 10 cm 5000 ml
- Striae gravidarum - pink or reddish Streaks on the abdominal congestion of the nasopharynx as pregnancy progresses.
wall and on the thighs due to the stretching of the abdominal  T 102 consumption-slight hyperventilation T RR
- Is proven by the fact that at term it can hold a 2 lbs. baby + walls due to increase uterine size, results to rupture and atrophy  ⭣ vertical diameter of thoracic cavity; T horizontal/
1000 ml. amniotic fluid, or a total 4000 gm. more or less. of the connective layer of the skin. transverse diameter
- Hegar's sign - uterine segment becomes so soft that during - Woman's umbilicus is affected by stretch, making it appear  nasal mucous membrane T blood supply - Vasocongestion
bimanual examination the wall of the uterus can't be felt or feels smooth and obliterated or even protruding. (due to estrogen) resulting to nose bleeding or difficulty of
like tissue paper.
breathing (nasal stuffiness)
 Is evident at about 6th week of pregnancy. F. Integumentary Changes
- Linea Negra - a brown line running from the umbilicus to B. Temperature Changes
FUNDUS the symphysis pubis, dividing the abdomen into left and right - Slight increase in temperature until about the 4th month
- 1-3 MONTHS - not palpable (still in pelvic cavity hemisphere. when function of the corpus luteum, which is rich in
- 3-4 MONTHS -above symphysis pubis - Chloasma or melasma - "mask of pregnancy" progesterone.
- 5-6 MONTHS - umbilicus  Extra pigmentation observed on the cheeks and
- 8 MONTH - at the xiphoid process (below the breast) across the nose. C. Circulatory System
- 2 weeks before labor - few inches below xiphoid process in  Disappears after pregnancy when the melanocyte - Blood volume increases to 30-50 % to provide for an adequate
preparation for delivery stimulating hormone is no longer produced by pituitary amount of exchange of nutrients in the placenta.
gland.

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- Heart rates increase its output to be able to handle the
- Frequency of urination is common complaint due to:  HCG secreted by trophoblast cells stimulates estrogen &
additional volume.
 First trimester - uterus exerts pressure on the bladder as it rises progesterone synthesis until placenta assumes the role
- Edema of the lower extremities and varicosities of the vulva,
out of the pelvic cavity.  HPL serves as antagonist to insulin, freeing fatty acids for
rectum and legs are caused by decreased blood flow in these
 2nd trimester - pressures of the presenting part on the energy so glucose becomes available for fetal growth
areas resulting to pressure of the uterus on vein and arteries of the
bladder after lightening.
dependent parts.
- Palpitation - due to sympathetic nervous system stimulation  Increase blood flow to the kidney which increases H. Weight
glomerular filtration rate and urinary output. - Increase of about 20-25 lbs.
in the early months of pregnancy, and increased pressure of
the uterus against the diaphragm.  Lactosuria - presence of sugar or lactose in the urine is Fetus 7 lb.
- Increase in the level of circulating fibrinogen safeguards the considered normal. Placenta 1 lb.
pregnant woman against undue bleeding.  Lactose is secreted by the mammary glands, but it is not yet Amniotic fluid 1–1.5 lbs.
 heart moves higher toward left (upward & leftward used during pregnancy it normally spills in the urine. Increased weight of fetus 2 lbs
displacement) - T frequency of urination - pressure of uterus on urinary Increased blood volume 1 lb
 T blood volume (appxtly. 70 cc of blood/51); 30% – bladder Increased weight of breast 1-1.5 lbs
- glycosuria 2o ⭣ renal threshold (⭣ capability of kidney to
50% T Weight additional fluid 2 lbs
absorb sugar if not the blood) Fat and fluid accumulation 4-6 lbs
 BP remains slightly ⭣ bec. Muscles relax (effect of
- urinary stasis may cause dilatation of the ureter & kidney
progesterone) vasodilation Total of 20 – 25 lbs up to 30 lbs.
usually on the right side.
 Hemodilution - bld..conc.⭣. ⭣RBC - anemia
(physiologic) normal anemia due to blood dilution - Weight gain faster by midpoint of pregnancy rather than
F. Skeletal System
 T CR, T CO - possibility for cardiac failure early in pregnancy.
- center of gravity changes begin in the 2nd trimester are
 edema of lower extremities & varicosities of the caused by the hormone’s relaxin & progesterone
vulva, rectum & legs rapid growth of the
 “Pride of pregnancy” – pregnant woman Change her
 due to ⭣ blood flow to these areas as a result of 1-3 lbs first trimester different body
center of gravity to make ambulation easier forces her to
pressure of uterus on veins & arteries of the dependent organ.
stand more Straight and taller than usual.
parts. increase in fetal
 Leg Cramps - caused by pressure of gravid uterus on the 10-11 lbs 2nd trimester
 T ESR - T fibrinogen level (bld. clotting) - prevent length
nerve and imbalance of calcium in the body.
undue bleeding rapid growth in fetal
- Relaxation of pelvic articulation – "waddling gait" 10-11 lbs. 3rd trimester
 T CO – 4.5 – 6 L/min. weight.
- Lumbosacral & spinal curve are accentuated - lordosis/
 Hemodilution 2o T plasma level - (iron intake is "pride of pregnancy"
needed) NOT MORE THAN.9 – 1 LB PER WEEK
 T WBC - moderate leukocytes -prevent infection G. Endocrine Changes
 T PR- 05/min C. PSYCHOLOGICAL CHANGES
- Thyroid gland - Slight enlarge due to increase metabolism.
- Production of large amount of estrogen and progesterone 1. First trimester
D. Gastrointestinal System leading to suppression of FSH and LH during pregnancy because a) ambivalence
- Heartburn, constipation and flatulence are caused by of the presence of placenta. b) acceptance
increasing uterus displacing the stomach and intestines - Parathyroid gland - enlarged to meet the increased needs for c) introversion & egocentricity - self centered
toward the back and sides of the stomach. calcium to be utilized from the development of fetal bones and d) fetus is perceived as merely a part of self
- Relaxin - hormone is produce by ovaries which contributes to teeth.
decrease motility. 2. Second trimester
 Placenta produce large amount of estrogen,
 hyperemia of the gums ( T bld. in gums - reddish gums), T a) fetus is perceived as a separate human being
progesterone, hcg, hpl, relaxin, prostaglandin
absorption in mouth b) changed body image - protective container
 Estrogen causes breast & uterine enlargement.
 T nausea & vomiting 2o T HCG c) fantasy about the child
Palmar erythema during early pregnancy is in
 T salivation - ptyalism response to high circulating estrogen levels
3. Third trimester
 heartburn, constipation, flatulence - displaced stomach &  Progesterone maintains endometrium, inhibit uterine
intestines bec. Of enlarged uterus. Ovaries produced relaxin a) eagerness for labor to occur-anxious
contractility & aid in dev't. of breast for lactation
b) nest building - preparing
contributing to ⭣ gastric motility  Relaxin inhibit uterine activity, soften cervix & the
c) role playing
collagen joints
E. Renal System

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d) identification of the fetus – “my baby”

XVII. SIGNS OF PREGNANCY

1. Presumptive signs - those that suggest but do not positively
indicate pregnancy
- Cessation of menses/amenorrhea
- Frequent urination
- Breast - tenderness (4th week), increased sensitivity,
darkening of nipples and areola enlargement on the 10th week
- Fatigue – 1st trimester
- Morning sickness (nausea and vomiting)
- Quickening – 1st fetal movement, between 14th-17th weeks
- pigmentation changes - abdomen (Linea nigra)
 face (chloasma) XVIII. PRENATAL CARE
 Striae gravidarum - Components of the Initial: pre-natal visit:
 Increased perspiration 1. History
a. Obstetric HX
- gravida, para, abortion & living children
- weight of infants at birth, length of gestation
- labor experience, type of deliver
- type of anesthesia, difficulties with anesthesia
during childbirth or previous surgeries
- maternal complication e.g. HPN, diabetes
- Braxton-Hicks contraction — painless palpable - complication with the infant
contractions occurs at irregular interval and felt by the - method of infant feeding planned
mother as sensation of tightness over her abdomen at - special concerns
around 3rd month. b. Menstrual HX
- Positive pregnancy Test — presence of HCG in woman's - Computation of expected date of confinement/ delivery
blood and urine that gives a positive result to PT. based on:
2. Probable Signs - 3 Common Test for pregnancy:
- Enlargement of abdomen 1. Frog Test 1. Naegele’s Rule – subtract 3 months, add 7 days to the 1st day
- Changes in the Reproductive organs 2. Progesterone Withdrawal Test & correct the year if appropriate
a. Goodell's - softening of a normally firm cervix 3. Ultrasound
b. Hegar's sign - softening of uterus  If LMP occurred between January and March Example:
c. Chadwick - change in vaginal/cervical color 3. Positive Signs LMP 1 4 2007
- Detection of fetal heart tones
+9 7
- Ballottement - rebound occurs when the examiner's finger taps  Doppler – 12th weeks EDC 10 11 2007
the floating fetus within the uterus and caused by the fetus  Fetoscope – 16th week
floating.  Stethoscope - 20th weeks  If LMP occurred between April and December
- Uterine souffle - a muffled swishing sound heard over the LMP 5 28 07
abdomen in union with the mother's heartbeat. - Palpation of fetal movement
-3 +7 +1
 Felt from 20th weeks onward
EDC 2 35 08
- Ultrasonic evidence of a fetus (after 16 weeks) EDC 3 7 08
- X-ray visualization of Fetal skeleton as early as 14 weeks.
2. Quickening – first discernible fetal movement. It usually
occurs at the 16th -18th week for primigravida.

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- To estimate the EDD for primigravida, 22 weeks (5.5 mos.)
- Amount of caffeine & alcohol consumed per C. The area above the symphysis pubis is palpated to locate the
are for practical purposes, it is suggested to add 6 mos. To
day fetal presenting part and thus determine how far the Fetus has
the date of quickening
- Tobacco use descended and whether the fetus is engaged.
Primigravida 2019-1st fetal - Prescription of other drugs D. One hand applies pressure on the fundus while the index Finger
Example: July 31 movement - Complementary or alternative therapies and thumb of the other hand palpate the presenting Part to
6 months - General nutrition, hx of eating disorders confirm presentation and engagement
EDC January 2020 - Contact with pets
- Allergies and drug sensitivities
Multigravida: 2019- - Occupation & related risks
Example July 31 quickening e. Family health Hx
+6 mos. - Valuable information about the general
January 2020 health of the family including chronic
diseases such as DM, heart disease, TB,
3. Bartholomew’s rule – is used to calculate AOG hepatitis, use of drugs, alcohol, smoking,
blood type.
f. Psychosocial Hx
g. Physical examination
1) Vital signs with emphasis on BP and weight
taking
2) Cardiovascular system
- Observe venous congestion exp. On legs,
vulva or rectum
- Edema of the leg may benign: edema of the
hands & face maybe a sign of preeclampsia XIX. MINOR DISCOMFORTS OF PREGNANCY AND
3) Musculoskeletal system
THEIR RELIEF MEASURES
- Posture & gait
1. Nausea & Vomiting
- 8 weeks – just above the symphysis pubis - Height & weight to establish baseline for
- eat dry crackers or toast before arising in am then get
- 12 weeks – midway weight gain throughout pregnancy
out of bed slowly seat small amounts of carbohydrate
- 16 weeks – two finger below the umbilicus - Pelvic management
foods frequently during the day and 5
- 20 weeks – level of umbilicus - Abdomen where its contour, size, muscle tone,
— 6 small meals
- 24 weeks – 2 finger about umbilicus fundic height are assessing including FHR
- drink fluids separately from meals
- 28 weeks – midway between umbilicus and xiphoid 4) Neurologic assessment is not necessary if free
- avoid fried, greasy or spicy foods or those with
process of signs & symptoms
strong odors
- 34 weeks – just below xiphoid process 5) Integumentary system – skin color, pallor,
- if emotionally triggered, emotional support is in
- 36 weeks – just below the xiphoid process jaundice, lesion, hyperpigmentation related to
order
- 40 weeks – two finger below the xiphoid pregnancy
- if symptom worsens, report to the physician
c. Contraceptive HX 6) Endocrine system- hyperthyroidism or gross
2. Pyrosis or Heartburn
d. Medical & surgical HX enlargement of the thyroid gland shd be
- eat several small meals daily & avoid fatty or spicy
- Age, race, ethnic background (for genetic observed
foods
problems like sickle class) disease - curtail smoking & coffee drinking which stimulates acid
- Childhood disease & immunizations A. LEOPOLD'S MANUVER
formation in the stomach
- Chronic illnesses e.g. asthma, heart disease A. The uterine fundus is palpated to determine which fetal Part
- Sit upright for at least 1 hour after meals to reduce
- Previous illness, surgical procedures, occupies the fundus.
reflux & relieve symptoms
injuries B. Each side of the maternal abdomen is palpated to
- do not eat or drink just before bedtime & sleep with
- Previous infection: hepatitis, std, tb determine which side is fetal spine and which is the
extra pillow
- Hx of anemia extremities.
- sip water to help relieve burning sensation
- Changes in bowel & bladder function 3. Backache
- maintain correct posture: head up, shoulders back
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- avoid high heeled shoes to improve posture
8. Palpitation - Signals of Toxemia - such as swelling of face or fingers,
- to pick up objects, squat rather than bend at the waist
- result of circulatory adjustments necessary to dots before the eyes, blurring of vision & severe or continuous
- when sitting, use foot supports, arm rests and pillows
accommodate increased blood supply during headache
behind the back
pregnancy
- exercises using tailor sitting, shoulder circling Abd
pelvic rocking
- advise the mother to refrain from making sudden, XXI. SCHEDULE OF CLINIC VISITS
rapid movements at anytime - First 7 months - once a month
4. Varicosities
9. Leukorrhea - 7th to 8th month - every other week
- avoid constricting clothing & crossing the legs at the knees
- daily bath is usually enough to control this problem of - 9th month - every week
which impedes blood return from the legs
whitish, viscous vaginal discharge because of the increase
- rest frequently with the legs elevated above the level of
in the amount of normal vaginal secretions during XXII. NUTRITION DURING PREGNANCY
the hips
pregnancy a. To say that a good diet makes an important contribution to good
- wear support or elastic stockings that reach above the
10. Urinary frequency pregnancy is an understatement. For it is in fact crucial in
varicosities. Apply them before getting out of bed each
- performing kegel exercise helps maintain bladder control determining the health of the pregnant mother, her offspring and
morning
'explain that it cannot be helped since the growing their offspring
- if working in one position for prolonged periods of time,
fetus presses on the bladder b. Specific Nutrients needs are:
walk around for a few minutes at least every 2 hours
11. Pruritus 1. Calories: average recommended allowance (RDA) of calories
5. Muscle or Leg cramps
- must be referred to a physician because of the for women of childbearing age is 2,200. Additional 300 calories
- to prevent cramps, elevate the legs often during the day
possibility of infection or a total caloric intake of 2,500 calories is recommended
to improve circulation
- to relieve cramps, extend the affected leg, keeping the knee 2. Protein: RDA for women is 34-46 g. During pregnancy, the
straight. Bend the foot toward the body or ask someone to
A. EMPLOYMENT/TRAVEL need for protein increases to 71 g daily. Meat, poultry, fish,
assist. If alone, stand and apply pressure on the affected leg yogurt, eggs, milk are the best sources containing 9 essential
- Unless the job involves handling toxic substances, lifting amino acids (complete protein)
- Avoid excessive food high in phosphorous. Additional
heavy objects or other excessive physical strain, the pregnant 3. Fat needs: omega-3-fatty acids, particularly Linoleic acid, are
calcium or magnesium maybe helpful but should be taken
woman may continue to be employed fats that are essential for new cell growth but cannot be
only with the advice of the health care provider
- No restrictions to travel early in pregnancy, unless manufactured by the body. Good sources are: vegetable oils like
6. Hemorrhoids
otherwise advised by the physician safflower, corn, peanut and olive oils; fatty fish; omega infused
- to prevent, establish a regular pattern of bowel elimination
that does not require straining. Drink plenty of water, eat - If travelling in long distances, advise to have scheduled eggs and spreads, Pregnant women should ingest 200 and 300
foods rich in fiber and exercise regularly stops in between and have a short walk or ambulation mg of omega-fatty-acids daily
- to relieve existing hemorrhoids, take frequent tepid baths. 4. Vitamins: a supplement is necessary during pregnancy because
Apply cool with hazel compresses or anesthetic ointments B. MARITAL RELATIONS of Increase requirements of fat- and water-soluble vitamins to
- gently push the hemorrhoids back into the rectum. To do support the growth of fetal cells. Example: Vitamin D ( fortified,
so, put on a glove and lubricate the index finger. Maintain - Unless there has been previous problem of abortion, cheese, milk, egg, salmon) for calcium absorption & immune
pressure for 1-2 minutes. premature birth, or bleeding during pregnancy, there system functioning. Vitamin A, Vitamin C, Folic Acid are
- if pain persists or bleeding occurs, call your health care should be no reason for avoiding intercourse during important as well.
provider pregnancy 5. Mineral needs: Calcium and phosphorous (for calcification of
7. Constipation - As pregnancy advances and the woman's abdomen increase fetal bones), lron (RDA is 27 mg. = to build elevated
- drink at least 8 glasses of water each day. Avoid in size, new positions maybe mutually agreed upon hemoglobin & Increase level of oxygen), Iodine (essential for
coffee, tea or carbonated drinks because of their thyroid gland to produce thyroxine necessary for overall body
diuretic effect. XX. DANGER SIGNS OF PREGNANCY metabolism), fluoride (formation of strong teeth), sodium (acts
- eat foods high in fiber to body fluid), zinc (synthesis of RNA & DNA fetal growth
- restrict cheese consumption which cause constipation - Vaginal Bleeding - may mean abortion
- curtail intake of sweets which increase bacterial - Persistent Vomiting (hyperemesis gravidarum) - may XXIII. BASIC PREGNANCY EXERCISES
growth in the intestines and can lead to flatulence lead to severe dehydration & fetal distress 1. Basic breathing exercise
- a brisk walk of at least 1 mile per day stimulates - Chills & Fever - may signal infection 2. Perineal and abdominal exercises
peristalsis and improves muscle tone - Sudden Escape of Fluid in the Vagina -evidence of 3. Tailor sitting: This exercise makes your thigh, pelvic, and hip
rupture of membranes, thus a threat to infection or muscles more flexible.
prolapsed cord
- Pain in the Abdomen - may mean ectopic pregnancy,
separation of placenta, appendicitis, ulcer, pancreatitis
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a. Sit on the floor with the soles of your feet together.
Your back should be straight.
b. Gently lean forward until you feel a mild stretch in your hip
and thigh muscles. Your back should remain straight. Don't
push down on your legs with your hands.
c. Hold and count to 5, then relax.

Figure: Pelvic Rocking

Figure: Tailor Sitting Exercise

 Squatting Pregnancy-safe squat exercises
1. Stand with feet shoulder-width apart.
2. Hold your arms straight out in front of your body for balance if
you don't have weights or a bar.
3. Lower yourself into a squat position....
4. Return to starting position, squeezing your glutes on the way
up.
5. Perform 3 sets of 10 to 15 repetitions

Figure: Squatting
 Pelvic floor contraction (Kegel exercise)
o Squeeze your pelvic floor muscles and hold for several
seconds. Then relax for a few seconds and repeat. Initially,
you may only be able to hold for one or two seconds, but
over a few weeks, you'll gradually be able to increase the
hold time by a second or two until you can hold for 10
seconds.
 Pelvic rocking
o This exercise strengthens your back, hip, and abdomen
muscles. Positioned on your hands and knees, place your
hands directly under your shoulders and your knees under
your hips. Breathe in deeply. Tuck your head downward and
round your back up, making a curve with your back in the
shape of the letter

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