Medical Colleges of Northern Philippines

Alimannao Hills, Peñablanca Cagayan

“Family Centered Care in the Childbearing Process”

In Partial Fulfillment of the Requirement in

Maternal and Child Nursing

Presented to:

Faculty of the College of Nursing

Presented by:

SARRAH JANE A. DE GUZMAN

BSN – IV

APPROVAL SHEET
 This book entitled “Maternal and Child Health Nursing” authored

by SARRAH JANE A. DE GUZMAN in partial fulfillment of the

requirements for the degree of Bachelor of Science in Nursing is

hereby presented to the faculty of College of Nursing.

Approved By:

___________________________

MARCELYN ALMAZAN, RN, MSN

Level II Coordinator

___________________________

LIEZEL CANAPI, RN, MSN

Level IV Coordinator

___________________________

CHERYLL JM GUMABAY, RN, RM, MSN

Dean, College of Nursing

ACKNOWLEDGEMENT
 A journey is easier when you travel together. Interdependence is

certainly more valuable than independence. This thesis is the result of

few months’ work whereby I have been accompanied and supported by

many people. It is a pleasant aspect that I have now the opportunity to

acknowledge and extend my heartfelt gratitude for all of them.

First and foremost I offer my sincerest gratitude to my Clinical

Instructors who supported me throughout this book with their patience,

knowledge, encouragement and useful suggestions. Without them this

book would not have been completed or written successfully.

In my daily activities I have been blessed with a friendly and

cheerful group of fellow students. I am grateful for their helpful

comments, useful arguments and suggestions and moral support.

I am as ever, especially indebted to my parents for their love and

support for they taught the things that matter most in life. To my

siblings for rendering me the sense and value of a family. Moreover my

sincere thanks to my friends who shared their love and experiences

with me.
 And to the Human Creator who made all things possible. My

deepest and sincere gratitude for inspiring and guiding me all

throughout. To God be the glory.

DEDICATION
 This book is dedicated to my greatest parents who have raised

me to be the person I am today. You have been with me every step of

the way, through good times and bad. Thank you for all the

unconditional love, guidance and support you are continuously giving

me, helping me to succeed and instilling in me the proper values I

need to guide me through my battle of conquering wisdom which

would bring me to success. Thank you for everything. I love you.

I am also grateful to the participants of this Maternal Book. Those

people who welcomed me into their home, who answered my

questions and took part in the activities required to complete this

book.

To our professors and Clinical Instructors who opened the door of

nursing world. Their teachings and guidance that made us what we are

now.

To my fellow students who made comments and endure efforts

to learn the process of being nurse. Thank you very much!

PREFACE
 Maternal- newborn nursing are expanding areas of nursing as a

result of the broadening scope of practice within the nursing profession

and the recognized need for better preventive and restorative care in

these areas.

The care of the childbearing and childrearing family is a major

focus of nursing practice. To have healthy children, it is important to

promote the health of the childbearing woman, her family from the

time before the children is born to the time until they reach childhood.

Prenatal care and guidance are essential to the health of the woman,

fetus, and of the family’s emotional preparation for childbearing.

As you scan this book, you can see the different interviews and

assessment to the clients done by the author and the appropriate

interventions to any existing problems encountered during

childbearing and childbirth as well. Also, the author discussed the

nursing process, the systemic changes that normally occur during

pregnancy, the immediate care given to the newborn, the menstrual

cycle, and the overview of both the female and male reproductive

systems.
 This maternal and child book views maternal and child health

care not as two separate disciplines but as a continuum of knowledge.

TABLE OF CONTENT

Approval Sheet
Acknowledgement
Dedication
Preface
Introduction
A. Nursing Process
● Assessment
● Nursing Diagnosis
● Planning
● Intervention
● Evaluation
B. Maternal Data Base Assessment
● Patient Personal Data
● Nursing History (Menstrual History)
● Maternal History
● Family History
● Past Medical History
● Gordon’s Eleven Functional Health Pattern
● Physical Assessment
C. Nursing Care Plan
D. General Health Teaching
● Discomforts of Pregnancy
● Anatomy and Physiology of Female Reproductive
● Anatomy and Physiology of Male Reproductive System
● Menstruation
● Menstrual Cycle
● Reproductive Hormones
● Sexual Responses
● Growth and Development of Fetus
● Care for Pregnant Women
● Physiology of Breast Feeding
● Breastfeeding
● Labor and Delivery
● Comparison between True and False Labor
● Stages of Labor
● FHT and other Abdominal Sounds
● Mechanism of Labor and Delivery (ed, fire, ere)
● Maternal Physiology Response to Labor and Birth
● Leopold’s Maneuvers
E. Documentation

INTRODUCTION

CHILBEARING AND CHILDREARING

 Childbirth, a life-cycle event, has occurred since time

immemorial. It is a constant that affects all of us, the world over. It

repeats itself as surely as the sun rises and sets. It is a reassurance

that life continues and infinitum, and it reaffirms that new life will

always be with us. Perhaps procreation falls into a mosaic affecting

men, women and children. The close blood-kin relationship is a binding

one in which members of a family interact, share and become a

functioning unit.

As the child grows from infancy to childhood, puberty, and young

adulthood in the security and love given by his parents, he is

made ready for the same life-cycle event of childbearing. The child

builds values on what he perceives and experiences within the family.

As he witnesses new life in his own family, the imprints remain and

affects his future as a parent.

Thus, people bring to parenthood a variety of well-defined set of

beliefs; they know what they want from childbearing experience. Most

couple come with a philosophy that childbirth is a combined effort of a

man and a woman and that both has something to give and take from

this event. They believe that through their combined efforts, the

experience will turn out to be rich and rewarding one where growth

and maturation occur. Accompanying this philosophy is a sense of

responsibility. As a man and woman love, respect, and grow in

responsibility, they will be better prepared to parent a child.

Perhaps one of the greatest changes that occurs in childbearing

is the emphasis on the quality of life rather than quantity. Certainly,

the responsibility that lies among the young people is that new life

they procreate should have the right to enjoy the essentials of a

healthy beginning. Couples must give serious thought to when, how,

where they would have children and how many children they would

have. The whole emphasis is on planned and responsible parenthood

rather than haphazard, unplanned pregnancy.

Childbirth for the future will make even greater strides. Family

living and sex education are now integral parts of school curriculum.

Young people are learning a great deal about the life-cycle. In the

future, childbirth will take on greater dimensions as families share and

participate in childbirth, making it a fruitful family experience.

NURSING PROCESS
 The term NURSING PROCESS was first used/mentioned by Lydia

Hall, a nursing theorist, in 1955 wherein she introduced 3 steps:

observation, administration of care and validation.

Since then, nursing process continue to evolve: it used to be a 3-

step process, then a 4-step process (APIE), then a 5-step (ADPIE), now

a 6-step process (ADPIE) ASSESSMENT, DIAGNOSIS, PLANNING,

IMPLEMENTATION and EVALUATION.

is a systematic, organized method of planning, and

providing quality and individualized nursing care.

it is synonymous with the PROBLEM SOLVING APPROACH

that directs the nurse and the client to determine the need for

nursing care, to plan and implement the care and evaluate

the result.

it is a G O S H approach (goal-oriented, organized,

systematic and humanistic care) for efficient and effective

provision of nursing care.

Goal-oriented – nurse make her objective based on client’s health

needs.

Remember: Goals and plan of care should be base according to

client’s problems/needs NOT according to your own problem

as the nurse.

Organized/Systematic – the nursing process is composed of 6

sequential and interrelated steps and these 6 phases follow a logical

sequence.

Humanistic care

• plan to care is developed and implemented taking into

consideration the unique needs of the individual client.

• plan of care therefore is individualized (no 2 person has the

same health needs even with same health condition/illness)

• in providing care, it involves respect of human dignity

Efficient – plan of case is relevant/related to the needs of the client

thereby promoting client satisfaction and progress.

Effective – in planning care, utilized resources wisely (staff, time,

money/cost)

Aside from GOSH, other characteristic of Nursing Process

Cyclic and Dynamic in nature – data from each phase provides the

input into the next phase so that is becomes a sequence of events

(cycle) that are constantly changing (dynamic) base on client’s health

status.

Involves skill in Decision-making – nurse makes important

decisions related to client care, she choose the best action/steps to

meet a desired goal or to solve a problem. She must make decisions

whenever several choices or options are available.

Uses Critical Thinking skills – the nurse may encounter new ideas

or less-than-routine or non-ordinary situations where decisions must be

made using critical thinking.

PURPOSE OF NURSING PROCESS

1. To identify a client’s health status; his Actual/Present and

potential/possible health problems or needs.

2. To establish a plan of care to meet identified needs.

 3. To provide nursing interventions to meet those needs.

4. To provide an individualized, holistic, effective and efficient

nursing care.

STEPS/PHASES OF THE NURSING PROCESS

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

- First Step in the Nursing Process

• it is systematic and continuous collection, validation and

communication of client data as compared to what is

standard/norm.

• it includes the client’s perceived needs, health problems, related

experiences, health practices, values and lifestyles.

Purpose: To establish a data base (all the information about the

client):

• nursing health history

• physical assessment
 • the physician’s history & physical examination

• results of laboratory & diagnostic tests

• material from other health personnel

4 Types of Assessment:

a. Initial assessment – assessment performed within a specified time

on admission

Ex: nursing admission assessment

b. Problem-focused assessment – use to determine status of a

specific problem identified in an earlier assessment

Ex: problem on urination-assess on fluid intake & urine output hourly

c. Emergency assessment – rapid assessment done during any

physiologic/physiologic crisis of the client to identify life threatening

problems.

Ex: assessment of a client’s airway, breathing status & circulation after

a cardiac arrest.

d. Time-lapsed assessment – reassessment of client’s functional

health pattern done several months after initial assessment to

compare the clients current status to baseline data previously

obtained.
Activities:

1. Collection of data

2. Validation of data

3. Organization of data

4. Analyzing of data

5. Recording/documentation of data

Assessment = Observation of the patient + Interview of patient,

family & SO + examination of the patient + Review of medical record

I. Collection of data

• gathering of information about the client

• includes physical, psychological, emotion, socio-cultural, spiritual

factors that may affect client’s health status

• includes past health history of client (allergies, past surgeries,

chronic diseases, use of folk healing methods)

• current/present problems of client (pain, nausea, sleep pattern,

religious practices, meds or treatment the client is taking now)

Types of Data:

a. Subjective data

• also referred to as Symptom/Covert data

 • information from the client’s point of view or are described by

the person experiencing it.

• information supplied by family members, significant others, other

health professionals are considered subjective data.

Example: pain, dizziness, ringing of ears/Tinnitus

b. Objective data

• also referred to as Sign/Overt data

• those that can be detected, observed or measured/tested using

accepted standard or norm.

Example: pallor, diaphoresis, BP=150/100, yellow discoloration of

skin

Methods of Data Collection:

a. Interview

• a planned, purposeful conversation/communication with the

client to get information, identify problems, evaluate change, to

teach, or to provide support or counseling.

• it is used while taking the nursing history of a client

b. Observation – use to gather data by using the 5 senses and

instruments.
 c. Examination

• systematic data collection to detect health problems using unit

of measurements, physical examination techniques (IPPA),

interpretation of laboratory results.

• should be conducted systematically:

c.1. Cephalocaudal approach – head-to-toe assessment

c.2. Body System approach – examine all the body system

c.3. Review of System approach – examine only particular area

affected

Source of data:

a. Primary source – data directly gathered from the client using

interview and physical examination.

b. Secondary source – data gathered from client’s family

members, significant others, client’s medical records/chart, other

members of health team, and related care literature/journals.

In the Assessment Phase, obtain a Nursing Health History - a

structured interview designed to collect specific data and to obtain a

detailed health record of a client.

Components of a Nursing Health History

 • Biographic data – name, address, age, sex, martial status,

occupation, religion.

• Reason for visit/Chief complaint – primary reason why client

seek consultation or hospitalization.

• History of present Illness – includes: usual health status,

chronological story, family history, disability assessment.

• Past Health History – includes all previous immunizations,

experiences with illness.

• Family History – reveals risk factors for certain disease

diseases (Diabetes, hypertension, cancer, mental illness).

• Review of systems – review of all health problems by body

systems

• Lifestyle – include personal habits, diets, sleep or rest patterns,

activities of daily living, recreation or hobbies.

• Social data – include family relationships, ethnic and

educational background, economic status, home and

neighborhood conditions.

• Psychological data – information about the client’s emotional

state.

• Pattern of health care – includes all health care resources:

hospitals, clinics, health centers, family doctors.

II. Validation of Data – the act of “double-checking” or verifying

data to confirm that it is accurate and complete.

Purposes of data validation:

a. ensure that data collection is complete

b. ensure that objective and subjective data agree

c. obtain additional data that may have been overlooked

d. avoid jumping to conclusion

e. differentiate cues and inferences

Cues – subjective or objective data observed by the nurse; it is what

the client says, or what the nurse can see, hear, feel, smell or

measure.

Inferences – the nurse interpretation or conclusion based on the cues.

Example: red, swollen wound = infected wound

Dry skin = dehydrated

III. Organization of Data – uses a written or computerized format

that organizes assessment data systematically.

- Maslow’s basic needs

- Body System Model

 MATERNAL DATA BASE ASSESSMENT GUIDE

Personal Data

Name of Patient : R.T.B

Age : 19 y/o

Address : Ipil, Echague, Isabela

Nationality : Filipino

Occupation : Plain Housewife

Birthplace : Ipil, Echague, Isabela

Religion : Roman Catholic

Civil Status : Married

Educational Attainment: College Undergraduate

Menstrual History

Menarche occurred at the age of 15, 4 days of moderate flow

with unrecalled pads for the whole duration of menstruation. The color

is deep red and with an interval of 28-29 days. Sometimes, the patient

experienced dysmenorrhea or menstrual cramps during her

menstruation, but not all the times.

Maternal History

Obstetrical Score G1P1

G1- 1001- F- NSD- Cephalic- TBA-Alive

History of Present Pregnancy

LMP- May 23, 2009

EDD- January 30, 2010

AOG- 40 weeks

Past Health History

a. Family History
 Her father is hypertensive. Both parents are not diabetic,

doesn’t have asthma and non-TB carriers.

b. Personal and Social History

The patient is non- smoker and non-alcoholic drinker.

Health Perception-Health Management Pattern

Before Pregnancy:

• Mrs. R stated that being healthy is free from sickness and the

absence of disease. She perceived that her child is healthy in his

own way. She uses Biogesic, Paracetamol, Alaxan and other OTC

drugs which she knows their actions whenever she is not feeling

well. They refer to medical institution, whenever one of the

family members gets sick. She is aware and conscious of

personal hygiene, safety and comfort. She takes a bath twice to

thrice a day. She showed independence and autonomy in

performing activities of daily living. The patient doesn’t have any

vices.
 During Pregnacy:

• The patient stated that her health is “okay” but sometimes

uneasy because of her baby. She doesn’t take any OTC drugs

because she is aware of the effects of these drugs to her

baby. She takes a bath twice a day. She calls for assistance

when doing heavy ADL’s.

Nutrition-Metabolic Pattern

Before Pregnancy:

• The patient prefers to eat vegetables than meat. She eats

thrice a day with adequate amount of food. She has no

allergies on all foods. She stated that she has a good appetite.

Drinks 6-8 glasses of water a day. She drinks coffee with milk

early in the morning, take snacks in between meals. She has

no difficulty in swallowing or ingesting foods.

During Pregnancy:

• The patient stated that she prefers to eat meat other than

vegetables not just like before. “My appetite has changed” as

she stated. She eats thrice a day with adequate amount of

food, take snacks in between meals. She has no allergies on

 all foods. She drinks 6-8 glasses of water a day. She has no

difficulty in swallowing or ingesting foods.

• Elimination Pattern

Before Pregnancy:

• She urinates 4-5 times a day with the amount of at least 700 ml

a day and has a yellow amber color of urine. She has no difficulty

in urinating. She usually defecates early in the morning with a

consistency of brownish in color and semi-solid. But this depends

on the food eaten by her. She has no difficulty in defecating. She

does not use any laxatives and other stool softeners.

During Pregnancy:

• She urinates 3-4 times a day with the amount of at least 650-

700ml and has a yellow amber color of urine. There were no

problems in bowel elimination. Regular bowel habits are

observed by the patient with a consistency of brownish in color.

She doesn’t use any stool softeners.

Activity-Exercise Pattern

Before Pregnancy:
 • She wakes up as early as 5:00 in the morning. This is her usual

time. She prepares their breakfast and did all the household

chores. Her ADL’s serves as her exercise and takes care of her

child and her husband.

During Pregnancy:

• She wakes up 5:30 in the morning. She did her usual activities.

Sleep-Rest Pattern

Before Pregnancy:

• She sleeps 7-8 hours a day. Watching television helps her to get

her sleep. She is not using sleeping pills. She is used to have 2

pillows when sleeping. She usually takes a nap in the afternoon

for at least 45 minutes. She doesn’t have any sleeping difficulty.

During Pregnancy:

• She has a good sleeping habit. She sleeps as usual hours of her

sleep.

Cognitive-Perceptual Pattern

Before Pregnancy:
 • She is a high school graduate at Western Isabela Academy. She

speaks Ilokano, Tagalog, and English. She is fully oriented to

time, place and persons around her. She is able to answer

questions immediately. She can hear soft whisper, identify

things/objects, smell and taste foods and able to respond to

stimuli.

During Pregnancy:

• There’s no change on her cognitive-perceptual pattern. She is

fully oriented to time, place and person. Her senses are intact.

Self-Perception-Self- Concept Pattern

Before Pregnancy:

• Mrs. R. views herself as a patient and as a loving mother to her

siblings and a sweet housewife to her husband. She fears of

losing someone. “Aalagaan ko ang mga anak ko hanggang sila’y

tumanda” as she said.

During Pregnancy:

• The patient stated that she will take good care of her new baby

when it will bear. She will be a loving mother as she stated.

Role Relationship Pattern

 Before Pregnancy:

• She is a loving housewife and a mother. She loves to mingle with

different kind of people. When conflict arises, she wants to

resolve it immediately. They have a nuclear family. She has two

daughters.

During Pregnancy:

• She prepares herself with the additional role for the delivery of

her new baby.

Sexuality-Reproductive Pattern

Before Pregnancy:

• There’s no history of reproductive problems in the patient’s

family. Her menarche begun when she was 14 years old. She has

a regular menstrual period.

During Pregnancy:

• There were changes in the reproductive system as the

pregnancy go through.

Coping Stress Pattern

Before Pregnancy:
 • She is in stressed whenever problems arise. In times of

problems, she talks about it with her mother and finds ways and

means to solve it. When she is stressed, she just turns on their

television to watch her favorite telenovels as her way of coping.

During Pregnancy:

• Whenever she is stressed, she just sits down and takes some

rest, and at the same time drinks water to ease her stress.

Sometimes, just like she usually did, she watches television with

her daughters.

Value-Belief Pattern

Before Pregnancy:

• She is a devoted Roman Catholic. She and her family

attended mass every Sunday. She also believes on

superstitions like not sweeping at night and many more. She

strongly believes in miracles and power of God. She prays

always and thank God for the blessings He is doing. The Lord

is their source of strength.

During Pregnancy:

• She continues her religious beliefs.

Date Assessed: October 16, 2009

Time Assessed: 10:00 AM

Vital Signs:

Temperature: 36.50C

Pulse Rate: 75 bpm

Respiratory Rate: 18 cpm

Blood Pressure: 110/70 mmHg

General Appearance:

• The patient is awake and coherent, fully oriented to time,

place and person.

• The patient can follow instructions and commands easily.

• Patient is well groomed and dressed appropriately.

AREA TECHNIQU NORMAL ACTUAL ANALYSI

ASSESSED ES USED FINDINGS FINDINGS S

SKIN

Color Inspection Tan Tan Normal

Texture Palpation Smooth, soft Smooth, soft Normal
Turgor Palpation Skin snaps Skin snaps Normal

back back

immediately immediately

when pinched when pinched

Hair Inspection Evenly Evenly Normal

Distribution distributed distributed

Temperature Palpation Warm to Warm to Normal

touch touch
Moisture Palpation Dry, skin Dry, skin Normal

folds are folds are

normally normally

moist moist
NAILS

Color of Inspection Pink and Pink and Normal

nailbed Clean Clean

Texture Palpation Smooth Smooth Normal
Shape Inspection Convex Convex Normal

curvature curvature
Nail Base Inspection Firm Firm Normal
Capillary Blanch 2-3 seconds 2-3 seconds Normal

Refill time Test

HAIR

Color Inspection Black (varies) Black Normal

Distribution Inspection Evenly Evenly Normal
 distributed distributed
Moisture Inspection Neither Neither Normal

excessively excessively

dry nor oily dry nor oily

Texture Inspection Silky, resilient Silky, resilient Normal
HEAD

Scalp Inspection Symmetrical Symmetrical Normal

Symmetry
Skull Size Inspection Normocephali Normocephali Normal

c c
Shape Inspection Round Round Normal

and

Palpation
Nodules/ Palpation Absence of Absence of Normal

Masses nodules and nodules and

masses masses
FACE

Symmetry Inspection Symmetrical Symmetrical Normal

Facial Inspection Symmetrical Symmetrical Normal

Movement
Skin color Inspection Tan Tan Normal
EYES

Eyebrows Inspection Symmetrically Symmetrically Normal

aligned, equal aligned, equal

movement movement
Eyelashes Inspection Slightly Slightly Normal

curved curved
 upward upward

Eyelids Inspection Smooth, tan, Smooth, tan, Normal

do not cover do not cover

pupil as pupil as

sclera, close sclera, close

symmetrically symmetrically

Ability to Inspection Blinks Blinks Normal

blink voluntarily voluntarily

and bilaterally and bilaterally

Frequency of Inspection 20 blinks per 20 blinks per Normal

blinking minute minute

Ocular Inspection Eye moves Eye moves Normal

movement freely freely

Position Inspection Drawn from Drawn from Normal

lateral angle lateral angle

Size Inspection Medium Medium Normal
Texture Palpation Mobile, firm Mobile, firm Normal

and non and non

tender tender
Conjunctiva

Color Inspection Transparent Transparent Normal

with light with light

color color
Texture Inspection Shiny and Shiny and Normal
 smooth smooth
Presence of Inspection No lesions No lesions Normal

lesions
Lacrimal

Apparatus

Cornea

Clarity
Inspection Clear Clear Normal
Texture Inspection Shiny, Shiny, Normal

smooth, smooth,

transparent transparent
Pupils

Color Inspection Black Black Normal

Reaction to Inspection Pupils Equally Pupils Equally Normal

light Round and Round and

React to Light React to Light

Accommodati Accommodati

on (PERRLA) on (PERRLA)
Size Inspection Equal Equal Normal
Shape Inspection Round and Round and Normal

constrict constrict

briskly briskly
Symmetry Inspection Equal in size Equal in size Normal
Visual Acuity Inspection Able to real Able to read Normal

news print newsprint

Visual Fields Inspection When looking When looking Normal

straight straight
 ahead, client ahead, client

can see can see

objects in objects in

periphery periphery
Ocular Inspection Eyes move Eyes moves Normal

freely freely
NOSE

Symmetry, Inspection Symmetrical, Symmetrical, Normal

shape, size smooth and smooth and

and color tan tan

Mucosa color Inspection Reddish to Reddish to Normal

Pinkish Pinkish
Nasal

Septum

Nares
Inspection Oval, Oval, Normal

symmetrical symmetrical
Nasal Inspection No discharge No discharge Normal

discharge
Sinuses Inspection Not tender Not tender Normal
MOUTH

Lips

Color Inspection Pinkish to Pinkish to Normal

 slightly brown slightly brown
Symmetry Inspection Symmetrical Symmetrical Normal
Texture Palpation Soft, moist, Soft, moist, Normal

smooth smooth
Moisture Palpation Soft and moist Soft and Normal

moist
Gums

Color Inspection Pinkish Pinkish Normal

Moisture Palpation moist moist Normal
Buccal

Mucosa

Color
Inspection Glistening Glistening Normal

pink pink
Texture Palpation Soft Soft Normal
Moisture Palpation moist moist Normal
Tongue

Color Inspection Pinkish Pinkish Normal

Size Inspection Medium Medium Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Mobility Inspection Moves freely Moves freely Normal

Uvula

Location Inspection At the midline At the midline Normal

Symmetry Inspection Symmetrical Symmetrical Normal
Tonsils

Color Inspection Pinkish Pinkish Normal

Discharges Inspection No discharges No discharges Normal
Teeth

Color Inspection Ivory/yellowis Yellowish Normal

h
NECK

Position Inspection Head- Head- Normal

Centered Centered
Movement Inspection Moves freely Moves freely Normal
Range of Inspection Full range Full range Normal

Motion
Consistency Inspection No No Normal

Enlargement Enlargement

HEART
Heart sounds Auscultatio Clear, without Clear, without Normal

n crackles crackles
Lung Field Auscultatio Resonant Resonant Normal

n
THORAX

AND LUNGS

Posterior

Thorax

Symmetry

Inspection Symmetrical Symmetrical Normal

Respiratory Inspection Normally 12- 18 cpm Normal

rate 20 cpm
Spinal Inspection Spine Sligthly curve Due to
alignment vertically backward(lord pregnanc

aligned osis) y
Anterior

Thorax

Breathing
Auscultatio Breathing is Breathing is Normal
pattern
n automatic and automatic and

effortless, effortless,

regular and regular and

even and even

produces no

noise.
Lung/ breath Auscultatio Broncho- Broncho- Normal

sounds n vesicular
vesicular
ABDOMEN

Contour Inspection Flat Flat Normal

Texture Palpation Smooth Smooth Normal
Frequency Auscultatio Audible; soft Audible; soft Normal

and character n gurgling gurgling

sound occur sound occur

irregularly and irregularly

ranges from and ranges

5-30 minutes from 5-30

minutes
UPPER
EXTREMITY

Skin color
Inspection Tan Tan Normal
Size (arms) Inspection Equal Equal Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Hair Inspection Evenly Evenly Normal

distribution distributed distributed

LOWER

EXTREMITY

Skin color
Inspection Tan Tan Normal
Size (legs) Inspection Equal Equal Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Hair Inspection Evenly Evenly Normal

distribution distributed distributed

NEUROLOGI

Level of
Interview Can follow Can follow Normal
consciousnes
instructions instructions
s
and and

commands commands
Behavior and Interview Makes eye Makes eye Normal

appearance contact with contact with

the examiner the examiner

Mood Interview Expresses Expresses Normal

feelings which feelings which

correspond to correspond to
 situation situation
Mannerisms

and actions

Language

Voice

inflection Interview Clear and Clear and Normal

strong strong
Tone Interview Fluent and Fluent and Normal

articulated articulated
Manner and Interview Can give Can give Normal

speech appropriate appropriate

answers to answers to

questions questions

Mental

Status
Interview Oriented with Oriented with Normal

Orientation time, place time, place

and person and person

Time

Recall recent Interview Recall events Recall events Normal

and remote readily, readily,

memory immediate immediate

recall of recall of

remote remote

information information

Judgments Interview Can make Can make Normal

and thoughts logical logical

decisions decisions
Assessmen Nursing Planning Nursing Rationale Evaluation

t
Diagnosis Interventions

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 Pregnancy is a time of both physical and

emotional changes. Aside from the

obvious changes in your body shape and

the size of your uterus, shifts in

hormonal levels and metabolism can

contribute to various physical and

emotional discomforts.

Although the pregnancy

discomforts mentioned below are common, they are not experienced

by all pregnant women and may not be a part of your pregnancy. It is

important to remember:

• You may need to try more than one remedy before you find one that

works for you.

• Good nutrition is especially important for a comfortable and healthy

pregnancy. Eating well can minimize discomforts and help your body

cope with the stress of daily life.

• If you have a physical discomfort that is severe or does not go away,

contact your health care provider.

• If you have a chronic health condition, such as diabetes or asthma, it

is very important that you see your health care provider throughout

your pregnancy.

DISCOMFORT SOLUTION
Ankle Edema Rest with your feet elevated. Avoid

standing for long periods. Avoid

restrictive garments on the lower half

of your body.
Backache Apply local heat. Avoid long periods

of standing. Stoop to pick up objects.

Tylenol in usual adult dose may help.

Wear low-heeled shoes.

Breast Tenderness Wear a supportive bra. Decrease the

amount of caffeine and carbonated

beverages ingested.
Constipation Increase fiber in your diet. Drink

additional fluids. Have a regular time

for bowel movements.

Difficulty Sleeping Drink a warm, caffeine-free drink

before bed and practice relaxation

techniques.
Fatigue Schedule a rest period daily. Have a

regular bedtime routine. Use extra

pillows for comfort.

Faintness Move slowly. Avoid crowds. Remain in

a cool environment. Lie on your left

side when at rest.

Headache Avoid eye strain. Visit your eye
 doctor. Rest with a cool cloth on your

forehead. Take Tylenol in regular

adult dose, as needed. Report

frequent or persistent headaches to

your primary care provider.

Heartburn Eat small, frequent meals each day.

Avoid overeating, as well as spicy,

fatty, and fried foods.

Hemorrhoids Avoid constipation and straining with

a bowel movement. Take a sitz bath.

Apply a witch hazel compress.

Leg cramps Avoid pointing your toes. Straighten

your leg and dorsiflex your ankle.

Nausea Eat six small meals per day rather

than three. Eat a piece of dry toast or

some crackers before getting out of

bed. Avoid foods or situations that

worsen the nausea. If it persists,

report this problem to your primary

care provider.
Nasal stuffiness Use cool air vaporizer or humidifier,

increase fluid intake, place moist

towel on the sinuses, and massage

the sinuses.
Ptyalism Use mouthwash as needed. Chew

gum or suck on hard candy.

Round ligament pain Avoid twisting motions. Rise to
 standing position slowly and use your

hands to support the abdomen. Bend

forward to relieve discomfort.

Shortness of breath Use proper posture. Use pillows

behind head and shoulders at night.

Urinary frequency Void as necessary, at least every 2

hours. Increase fluid intake. Avoid

caffeine. Practice Kegel exercise.

Vaginal discharge Wear cotton underwear. Bathe daily.

Avoid tight pantyhose.

1. Mons Veneris/Pubis - Pad of fat which lies over the symphysis

pubis where dark and curly hair grow in triangular shape that

begins 1-2 years before the onset of menstruation. It protects the

surrounding delicate tissues from trauma.

2. Labia Majora - Two (2) lengthwise fatty folds of skin extending

from mons veneris to the perineum that protect the labia minora,

urinary meatus and vaginal orifice.

3. Labia Minora - 2 thinner, lenghtwise folds of hairless skin

extending from clitoris to fourchette.

o Glands in the labia minora lubricates the vulva

o Very sensitive because of rich nerve supply

o Space between the labia is called the Vestibule

4. Clitoris - small, erectile structure at the anterior junction of the

labia minora that contains more nerve endings. It is very

sensitive to temperature and touch, and secretes a fatty

substance called Smegma. It is comparable to the penis in it’s

being extremely sensitive.

5. Vestibule - the flattened smooth surface inside the labia. It

encloses the openings of the urethra and vagina.

6. Skene’s Glands/Paraurethral Glands - located just lateral to

the urinary meatus on both sides. Secretion helps lubricate the

external genital during coitus.

7. Bartholin’s Gland/Vulvovaginal Glands - located lateral to

the vaginal opening on both sides. It lubricates the external

vulva during coitus and the alkaline pH of their secretion helps to

improve sperm survival in the vagina.

8. Fourchette - thin fold of tissue formed by the merging of the

labia majora and labia minora below the vaginal orifice.

9. Perineum - muscular, skin-covered space between the vaginal

opening and the anus. It is easily stretched during childbirth to

 allow enlargement of vagina and passage of the fetal head. It

contains the muscles (pubococcygeal and levator ani) which

support the pelvic organs, the arteries that supply blood and the

pudendal nerves which are important during delivery under

anesthesia.

10. Urethral meatus - external opening of the urethra. It contains

the openings of the Skene’s glands which are often involved in

the infections of the external genitalia.

11. Vaginal Orifice/Introitus - external opening of the vagina,

covered by a thin membrane called Hymen.

1. Fallopian tube/Oviduct - 4 inches long from each side of the

uterus (fundus). It transports the mature ova form the ovaries to

the uterus and provide a place for fertilization of the ova by the

sperm in it’s outer 3rd or outer half.

Parts:

o Interstitial - lies within the uterine wall

o Isthmus - portion that is cut or sealed in a tubal ligation.

 o Ampulla - widest, longest portion that spreads into

fingerlike projections/fimbriae and it is where fertilization

usually occurs.

o Infundibulum - rim of the funnel covered by fimbriated

cells (hair covered fingerlike projections) that help to guide

the ova into the fallopian tube.

2. Ovaries - Oval, almond sized, dull white sex glands on either

side of

the

uterus

that

measures 4 by 2 cm in diameter and 1.5 cm thick. It is

responsible for the production, maturation and discharge of ova

and secretion of estrogen and progesterone.

 3. Uterus - hollow, pear-shaped muscular organ, 3 inches long, 2

inches wide, weighing 50-60 grams held in place by broad and

round ligaments, and abundant blood supply from the uterine

and ovarian arteries. It is located in the lower pelvis, posterior to

the bladder and anterior to the rectum. Organ of menstruation,

site of implantation and provide nourishment to the products of

conception.

Layers:

1. Perimetrium - outermost layer of the uterus comprised of

connective tissue, it offers added strenght and support to the

structure.

2. Myometrium - middle layer, comprised of smooth muscles

running in 3 directions; expels fetus during birth process then

contracts around blood vessels to prevent hemorrhage.

3. Endometrium - Inner layer which is visibly vascular and is shed

during menstruation and following delivery.

Divisions of the Uterus:

1. Fundus - upper rounded, dome-shaped portion that can be

palpated to determine uterine growth during pregnancy and the

 force of contractions and for the assessment that the uterus is

returning to it’s non-pregnant state following child birth.

2. Corpus - body of the uterus.

3. Isthmus - area between corpus and cervix which forms part of

the lower uterine segment. It enlarges greatly to aid in

accommodating the fetus. The portion that is cut when a fetus is

delivered by a caesarian section.

4. Cervix - lower cylindrical portion that represents 1/3 of the total

uterus. Half of it lies above the vagina; half of it extends to the

vagina. The cavity is termed the cervical canal. It has 2

openings/Os: internal os that open to the uterine cavity and the

external os that opens to the vagina.

5. Vagina - a 3-4 inch long dilatable canal located between the

bladder and the rectum, it contains rugnae which permit

considerable stretching without tearing. It acts as a organ of

intercourse/copulation and passageway for menstrual discharges

and fetus. Doderlein’s bacillus is the normal flora of the vagina

which makes the pH of vagina acidic, detrimental to the growth

of pathologic bacteria.
Organ Functions

1. Vagina a. Passageway of menstrual flow

b. Female organ for coitus; receives male penis

c. Passageway for the fetus during birth

2. Uterus a. Houses and nourishes fetus until sufficiently mature

to function outside the mother’s body

b. Uterine muscles propels fetus outside.

3. Fallopian a. Provides passageway for ovum as it travels from

Tube ovary to uterus.

b. Site of Fertilization.
4. Ovaries a. Endocrine glands that secrete estrogen and

progesterone.

b. Contain ova within follicles for maturation during the

woman’s reproductive life.

Ovary Releasing an Ovum

The ovary is the female organ that produces the reproductive cells called eggs, or ova.
This false-color electron micrograph shows the release of a mature ovum at ovulation. The
ovum (red) is surrounded by cells and liquid from the ruptured ovarian follicle.
 Ovum

The ovum is the

female sex cell.

• It is regularly

released by the

ovary through

the process of

ovulation.

• It has two layers of protective covering, the outer layer is the

corona radiata and the inner layer is the zona pellucida.

• The egg cell has a lifespan of 24 hours, thus, it can only be

fertilized within this period. After 24 hours, it regresses and is

resorbed.

• Sperm cell is present in the fallopian tube only in 3 out of 5

ovulations of married women.

 Sperm Cell

The sperm cell has three parts: a head that contain the chromatin

materials, a neck or mid-piece that provides energy for movement, and

a tail that is responsible for it’s mobility. The sperm cell has a lifespan

of 48 to 72 hours or 3 to 4 days after ejaculation. The sperm must be in

the genital tract 4-6 hours before they are able to fertilize an ovum to

give time for the enzyme hyaluronidase to be activated. There are two

kinds of sperm cell:

1. Gynosperm - This is the X carrying sperm cell. It has a large

oval head, are lesser in number than androsperms and thrive

better in acidic environment.

2. Androsperm - the sperm cell which carries the Y chromosome,

with a small head, and thrive better in alkaline environment.

Fertilization
 • Per ejaculation the average 2.5ml of seminal fluid contains 50 to

200 million spermatozoa per ml or 400 million per ejaculation.

• Fertilization occurs in the outer third (ampullar portion) of a

fallopian tube.

• Hyaluronidase released by the spermatozoa dissolves the layer

of cells protecting the ovum, facilitating the penetration of the

spermatozoon.

• Upon fertilization, the resulting structure is called zygote.

• Only the father can determine the gender of the child - X -

carrying spermatozoon leads to XX combination for a female

offspring; Y-carrying spermatozoon leads to XY combination

for a male offspring. The ovum carries only X chromosome.

Segmentation:
Within a few hours after fertilization, after the nucleus of the sperm

has united with the nucleus of the egg, the result of their union, the

zygote, begins a process of internal division. First, it divides into two

cells, then four, eight, sixteen, and so on, doubling the number with

each new division. This process

of cell division or cleavage in

the zygote is called

segmentation. It transforms the

zygote into a cluster of cells called

morula which, seen through a

microscope, resembles a

mulberry. The morula slowly moves down the Fallopian tubes toward

the uterus, where it arrives after about three days. By this time, it has

developed into a hollow ball of cells called blastocyst.

• It takes 3 to 4 days for the zygote to journey to the uterus

(where implantation will take place), and during such journey

mitotic cell division happens. Floating freely in the uterus for the

next 3 to 4 days, the morula (16 to 50 cell bumpy appearance

resulting from mitotic cell division) grows to become a blastocyst

with tropoblast cells cells (forming placenta and membrane in

 later development). Therefore, it takes 7 to 8 days from

fertilization to implantation.

• Implantation occurs at high and posterior portion of the uterus.

• On implantation, the structure is called embryo until 5-8 weeks

when it begin to be referred to as fetus.

• Implantation bleeding (mistaken as menstrual period) results

from capillary rupture on implantation.

• Endometrium (the inner lining of the uterus) is termed decidua

on conception.

Day 1 - conception takes place

7 days - tiny human implants in mother’s uterus

10 days - mother’s menses stop

18 days - heart begins to beat

21 days - pumps own blood through separate close circulatory system

with own blood type

28 days - eye, ear, and respiratory system begin to form

42 days - brain waves recorded skeleton complete, reflexes present

7 weeks - capable of thumb sucking

8 weeks - all body systems present

9 weeks - squints, swallows, moves tongue, makes fist

11 weeks - spontaneous breathing movements, has fingernails, all

body systems working

12 weeks - weighs one ounce

16 weeks - genital organs clearly differentiated, grasps with hands,

swims, kicks, turns, somersaults, ( still not felt by the mother)

18 weeks - vocal cords work

20 weeks - has hair on head, weighs one pound, 12 inches long

23 weeks - 15% chance of viability outside of womb if birth premature

24 weeks - 56% of babies survive premature birth

25 weeks - 79% of babies survive premature birth

Menstruation - is the periodic discharge of blood, mucus and

epithelial cells from the uterus.

Menstrual Cycle - periodic uterine bleeding in response to cyclic

hormonal changes. A process that allows for conception and

implantation of new life.

It is usually determined by counting as day 1 the 1st day of a

menstrual period until the last day before the next menstrual period.

Purpose:

• To bring an ovum to maturity

• To renew a uterine tissue bed that will be responsive to fetal

growth

• To prepare the uterus for pregnancy

Characteristics of Normal Menstrual Cycles

TERM DESCRIPTION
Beginning (Menarche) average age of onset: 12 or 13

years;

average range of age: 9-17 years

Interval between cycles average 28 days; cycles of 23 to 35

days not usual

Duration of Menstrual flow average flow: 2-7 days; ranges 1-9

days not normal

Amount of menstrual flow difficult to estimate; average 30 to

80 ml. per menstrual period;

saturating a pad in less than an

hour is considered heavy bleeding.

Color of menstrual flow dark red; a combination of blood,

mucus, and endometrial cells

Odor of menstrual flow marigold

Discomforts of Menstruation

1. Breast tenderness and feeling of fullness

2. Tendency towards fatigue

3. Temperament and mood changes - because of hormonal

influence and decreased levels of estrogen and progesterone

4. Discomfort in pelvic area, lower back and legs

5. Retained fluids and weight gain

Abnormalities of Menstruation

1. Amenorrhea - absence of menstrual flow

2. Dysmenorrhea - painful menstruation

3. Oligomenorrhea - scanty menstruation

4. Polymenorrhea - too frequent menstruation

5. Menorrhagia -excessive menstrual bleeding

6. Metrorrhagia - bleeding between periods of less than 2 weeks

7. Hypomenorrhea - abnormally short menstruation

 8. Hypermenorrhea - abnormally long menstruation

Four body structure involved in the physiology of the

menstrual cycle:

1. Hypothalamus

2. Pituitary gland

3. Ovaries

4. Uterus

Reproductive Hormones:

1. Gonodotropin-Releasing

Hormone (GnRH)

o Stimulates release of FSH and LH initiating puberty and

sustaining menstrual cycle.

2. Follicle-stimulating Hormone (FSH)

o secreted by anterior pituitary gland during the 1st half of

menstrual cycle

o stimulate growth and maturation of graafian follicle before

ovulation

o thins the endometrium

3. Luteinizing Hormone (LH)

o secreted by the anterior pituitary gland

 o stimulates final maturation of graafian follicle

o surge of LH about 14 days before next menstrual period

causes ovulation

o stimulates transformation of graafian follicle into corpus

luteum

o thickens the endometrium

4. Estrogen

o secreted primarily by the ovaries, corpus luteum, adrenal

cortex and placenta in pregnancy

o considered the Hormone of Women

o stimulates thickening of the endometrium; causes

suppression of FSH secretion

o responsible for the development of secondary sex

characteristics

o stimulates uterine contractions

o increases water content of uterus

o high estrogen concentration inhibits secretion of FSH and

Prolactin but stimulates secretion of LH7.

o low estrogen concentration after pregnancy stimulates

secretion of Prolactin

5. Progesterone

o secreted by the ovary, corpus luteum and placenta during

pregnancy
 o inhibits secretion of LH

o has thermogenic effect (increases body temperature)

o relaxes smooth muscles thereby decreases contractions of

uterus

o causes cervical secretion of thick mucus

o maintain thickness of endometrium

o allows pregnancy to be maintained = Hormone of

Pregnancy

o prepares breasts for lactation

6. Prolactin

o secreted by the anterior pituitary gland

o stimulates secretion of milk

7. Oxytocin

o secreted by the posterior pituitary gland

o stimulates uterine contractions during birth and compress

uterine blood vessels and control bleeding

o stimulates let-down or milk-ejection reflex during

breastfeeding

8. Prostaglandins

o fatty acids’ categorized as hormones

o produced by many organs of the body, including the

endometrium
 LABOR AND DELIVERY

Childbirth Process: Phases of Labor

The first phase during delivery is initiated when contractions

begin. If this is your first child, you will begin dilatation after the cervix

becomes effaced or thins out. Contractions are present every 20 to 30

minutes and last 15 to 20 seconds each. This process takes about 6 to

8 hours. In first time moms the whole delivery process may last 8 to 12

hours. If a woman has already had a baby the delivery process is

shorter; Approximately 4 to 6 hours.

Once the cervix has effaced, contractions will intensify in order

to allow the uterus to reach an "opening" of 10 cm. This process is

called "dilation". Dilation is broken into two phases:

 First: Cervix dilates from 0 to 8 centimeters.

 Second: Cervix reaches it's goal of 10 centimeters.

At the beginning of the first phase, you will feel soft contractions

every 10 to 15 minutes. Each one will last about 20 seconds. At this

moment, the opening of your cervix should be around 2 centimeters.

Progressively, contractions are going to increase in frequency as well

as duration. When you feel your contractions every 5 minutes and they
last 30 to 40 seconds, your cervix will estimate 4 to 5 centimeters

dilation. As time goes on, contractions get stronger every 3 or 4

minutes and last close to 45 seconds each. At this moment your cervix

is 6 centimeters dilated. When you feel your contractions every 2 or 3

minutes lasting approximately 50 seconds, your cervix should be 8

centimeters dilated.

Transition is the phase in which contractions occur every 1 to 2

minutes and last one minute; You are about to reach 10 centimeters of

dilation. At this moment you will have a short time to recover between

one contraction and the other. You will also feel swelling around your

vagina and the urge to push. However, it is important not to respond to

this urge until the doctor approves. Once you have reached 10 cm.

dilation, expulsion period begins. You will feel that contractions are

less frequent, every 2 to 3 minutes. This is the moment the doctor will

request that you push. During this period, the baby's head penetrates

the delivery canal and goes down to the perineo making an internal

rotation. The doctor waits until he/she sees 3 or 4 centimeters of the

baby's head. The next contraction will occur and the decision will be

made if an episiotomy must be done in order to facilitate the exit of

your child.

Once the head is shown (complete coronation) the doctor will tell you

to push to help the baby during the final process. First the head exits
and in another push the doctor will help the baby remove a shoulder,

then the other, and finally the remainder of the infant.

Pre-Labor

A very normal experience for women getting ready to labor is to

have rhythmic contractions for a few hours or a few days that come

and go without actually begining labor. Doctors used to refer to these

contractions as "False Labor." They can also be called Braxton-Hicks

contractions. The best term for these contractions is Pre-Labor.

Using the term Pre-Labor gives recognition to the fact that these

contractions are a normal part of labor and they are getting work done.

The more work you get done during pre-labor, the less work you have

to do in actual labor. During these pre-labor contractions your cervix

may be softening and effacing, it may also be dilating a centimeter or

two. Your body is being washed in relaxin, a hormone that allows your

pelvis to stretch to let the baby fit through. You body may also be

adjusting the levels of hormones so that labor can start. Some women

lose their mucus plug during pre-labor, and some women have bloody

show at this time as well. These are both normal occurrences as your

body begins to open the cervix. Contractions at this point are

generally 10 minutes apart or more. However, it is possible to have

them closer together and still be in pre-labor. The key to distinguishing

between labor and pre-labor is time. Over a few hours, have your

contractions gotten closer together, lasting longer and feeling more

intense. If not, it is not the actual labor. The biggest difficulties for

women experiencing a long pre-labor are the emotional and physical

fatigue that accompanies it. To avoid this, it is important that you

follow your normal routine as long as possible. Sleep if you are tired,

eat if you are hungry and go about your normal day until contractions

demand your attention.

Early Labor

After a few hours, days or weeks of pre-labor contractions, your

body will begin to have rhythmic contractions that seem "different" to

you. After a few hours you may realize that the contractions are

becoming longer and stronger, and they are happening closer

together. These are all signs that you have moved from pre-labor into

early labor. In early labor, most women feel excited. The wonder "could

this be it?" At the same time, their behavior displays this nervous

excitement. Some women find that they feel restless, a little hungry

and want to talk to someone. Many women find that this is when they

experience Bloody Show and Lose their Mucus Plug. You may also

experience a runny nose and an increased need to urinate. Your body

will empty itself through several bowel movements that seem like a
mild diarrhea. At this point contractions are generally less than 10

minutes apart and last 45-60 seconds long. Contractions will get

stronger, closer together and longer with time. These contractions may

be moderate to strong, and might feel like pressure in the pelvis,

menstrual cramping or a dull backache. At this point, most women are

more comfortable moving through their contractions.

Active Labor

Eventually, the contractions that you have been experiencing will

become stronger and more intense. You will also find that as time

progresses the contractions are getting closer together and lasting

longer. When this happens, you will have moved into active labor. For

most women, active labor is the longest part of their labor. During this

time, your body is opening the cervix so the baby can move into the

birth canal (vagina). At this point your body is also preparing for your

baby to be born by stretching the pelvis, preparing the colostrum and

stimulating the baby's nervous and respiratory systems. You will find

that as active labor progresses, you will become more serious or

"focused" during your contractions. You may find yourself slowly

moving from not talking during the peak of a contraction - to not

talking during a contraction - to barely talking even between

contractions. You may also find that your movements become slower
and more deliberate as you progress through active labor. Eventually

you may even be at the point that moving between contractions is

uncomfortable and difficult to manage.

These are normal physical reactions to labor. As your body works

harder to contract the uterus, you will naturally spend less energy on

"non-labor" activities such as moving and talking. You will also find that

your hunger naturally disappears so your body will not waste energy

trying to digest food. For most women, the increased focus it takes to

labor also prevents them from being concerned with societal norms

leading to a decrease in modesty and the pleasantries of conversation.

During active labor, mothers find that changing their activity and

position as desired helps them to remain comfortable. This may be due

to two factors. First, it prevents overstressing one or two muscle

groups by varying the way you hold your body. Secondly, it allows you

to respond to changes in the way your body feels, which may be

caused by the movement of the baby through the pelvis. Although the

desire for food disappears during labor, it is important to stay well

hydrated. Dehydration will decrease the amount of work your muscles

are able to do with each contraction, and it will decrease your ability to

handle the stress and contractions. During active labor, some women

find that making noise, called vocalization, with contractions helps to

keep them relaxed during the contractions. Many women also find that
tuning out the world around them, sometimes called "going inside

yourself," helps them to stay relaxed and handle contractions more

effectively. Most women will develop some form of pattern or ritual

during active labor. This means that she will repeat the same

responses to contractions for several contractions in a row. An

example of a ritual may be walking in a circle between contractions; as

the contraction begins she takes a deep breath and begins to moan;

she leans over on her support person until the contraction is done;

then she walks in a circle again until the next contraction begins. There

appears to be some comfort afforded a woman by repeating what

worked from the previous contraction. As you see these behaviors

build (vocalization, tuning out and using rituals), you will know that

labor is progressing. By keeping track of the behaviors the physical

signs (loss of hunger, loss of modesty and deliberate movement), and

the emotional signs (focusing, decreasing talkativeness, decreasing

humor) you can get a pretty good estimate of "how far" into labor the

mother is. It is important to note though, that not every mother will

respond in the same way or with the same behaviors and signs. Some

mothers do continue to talk throughout labor, some mothers do not

make noise, some mothers focus on contractions very early in labor. As

you use these markers of progress you must look at the total picture of

the laboring mother, not simply one marker or behavior.

Transition

As the body adjusts to accommodate the last few centimeters of

dilation, just before you begin pushing, the hormone levels are so high

that you will see undeniable physical signs. Observation of these signs

alert you to the fact that you are in transition. Transition is generally

the shortest part of labor, lasting 15 minutes to half an hour on

average. However, this is also the most intense part of labor for many

women. Some women find that being reminded that they are in

transition increases their ability to handle the intensity. The major

emotional marker for this stage is giving up. It is in this part of labor

that most women ask for medication. This is unfortunate since the

shortness of this stage of labor may cause the mother to be pushing

before she has received any medical pain relief. When physical signs

indicate transition, it may be best to hold out, handling the

contractions as best as possible. Physical signs of transition include

shaking or trembling which may resemble shivering or could be

stronger. Nausea and vomiting are also common signs. In addition to

these, some women will feel hot and cold flashes or have cold sweats.

Other women may begin burping or hiccupping as the body prepares.

Another physical sign is the inability to relax or be comfortable. A

woman who was handling labor well may suddenly find that she has no

idea what to do and nothing is comfortable any more. At this point, it is

the job of her coach or labor partner to assist her into various positions
in an attempt to find the one that will keep her most comfortable.

During transition, contractions will be long and close. They may be 90

seconds long and two minutes apart, which gives you a 30 second rest

time between contractions. The contractions may double peak, or they

may seem to be one right after the other without any break. Transition

is the time when the mother is the most emotionally needy as well.

Some women need constant reassurance that they are ok and the

baby is fine. This may be due to the overall "giving up" and feeling that

she is out of control. Most women will respond well to positive

encouragements and some require no special consideration other than

giving them the physical and emotional space to labor. The "giving

up" or feeling out of control may be recognized by comments the

mother makes. It is not uncommon for a mother to say, "I can't do

this," or "I need something." Recognize that this is not the mother

asking for medication, but for help. She can no longer handle the labor

the way she has been, and she needs to do something different.

Pushing

One of the most common questions among first time mothers is,

"When will I know it's time to push?" The most common answer among

experienced mothers is, "You'll just know!" The body is designed to

begin pushing when pushing will provide assistance at getting the

baby out. When you need to push has very little to do with your
dilation, although the general medical practice is to prevent pushing

until the cervix is dilated to 10 and begin pushing immediately when

10 is reached. This came into practice in an attempt to prevent the

cervix from swelling, however it is now known that the cervix is more

likely to swell from pushing without an urge than it is from pushing

before reaching a specified dilation. As the baby descends into the

birth canal (vagina), the head or other presenting part puts pressure

on the rectum. This pressure stimulates the nerves of the rectum

which send a signal to bear down and empty the bowels. It feels

exactly like having to go to the bathroom. Sometimes the pressure is

overwhelming, and the mother's body pushes involuntarily. You may

recognize this by her bearing down, grunting, bracing herself against a

sturdy object or by her exclaiming "I have to push!" Other times the

urge to push begins mildly, with urges to push only at the peak of the

contractions. If the urge is only at the peak, changing position will

either take the urge away, or will allow the baby to slip further into the

birth canal and begin strong urges to push. Some women find that

simply leaning forward is enough to remove the pressure from gentle

urges to push. If the urge to push is not strong, it may be better to

change position or lean into the contraction until the pushing urge is

strong. This helps to prevent fatigue and allows the strongest pushing

to be done when it will be the most effective.

 When left alone to push as necessary, most women will do

between 3 and 5 pushes that last approximately 6 seconds in one

contraction. The variation in length, duration and number of urges in a

contraction is due to the position of the baby. Sometimes the baby

moves enough with a push that for the next contraction the uterus

needs to contract to get tight against the baby again to push on the

baby and put pressure on the rectum. Every contraction will have a

different pushing pattern. Some mothers find that they have no urge to

push, the baby is simply pushed out by the contractions of the uterus.

Most women find that some form of breath holding and contracting of

the abdominal muscles similar to a bowel movement feels the most

comfortable. Pushing is done when the baby is outside of the mother.

This can take anywhere from 20 minutes to over three hours. After the

baby is out, the third stage of labor begins. This is the expulsion of the

placenta. It is generally less than 20 minutes and is no more

uncomfortable than giving a moderate push when the pelvis feels full.

Third Stage of Birth: Delivery of Placenta

 In this, the shortest stage of labor, lasting no more than 5 to 20

minutes, placental separation and expulsion take place, following

delivery of the baby. The placenta will separate from the wall of the

uterus and be expelled from the body, along with the umbilical cord

and other membranes . The placenta is examined to check if it is intact

and if not, the rest of the placenta is removed from the uterus. For the

mother the main risks in this stage of birth are hemorrhage during or

after separation of the placenta, as well as retention of the placenta.

Postpartum hemorrhage is one of the main causes of maternal

mortality; the large majority of these cases occurring in developing

countries. The incidence of postpartum hemorrhage and retention of

the placenta is increased if predisposing factors are present, such as

multiple pregnancy or polyhydramnios , and complicated labor .

Therefore the mother is often given an oxytocin to decrease estimated

postpartum blood loss.

Description of Station

What does it look like?

Fetal station is the position of the fetal presenting part and its descent

into the pelvis...how far has the fetus descended...the ischial spines of

the maternal pelvis are used to describe 0 station.

 Fetal Lie

The fetal lie is described by the relationship of the long axis of the

fetus to the long axis of the mother. This is a vertical lie. It is the

most common fetal lie.

This picture shows the transverse lie of the This is a picture

of an oblique lie of the

fetus. This is a problem with a term baby and fetus and is a

problem in a term pregnancy.

labor approaching.

CARE OF NEWBORN

W h a t i s n e w b o r n c a r e ?

Caring for a brand new baby can be overwhelming and tiring. It

includes adjusting to round-the-clock diaper changes and feedings.

Ideally, new mothers should receive significant support from partners,

other family members, and friends. The new mother's partner can and

should participate in most aspects of newborn care. Even during

breastfeeding, partners can help to ensure that the mother is

comfortable and receiving adequate nourishment.

S o m e b a s i c s o f n e w b o r n

c a r e i n c l u d e :

• I n f a n t s n e e d b r e a s t

m i l k o r f o r m u l a o n l y .

B r e a s t f e e d i n g o f f e r s

m a n y a d v a n t a g e s t o b o t h

i n f a n t s a n d t h e i r
m o t h e r s , a n d b r e a s t m i l k

i s t h e b e s t s o u r c e o f

f o o d f o r y o u r b a b y ' s

h e a l t h a n d d e v e l o p m e n t .

H o w e v e r , a m a j o r b r a n d o f

f o r m u l a i s s u f f i c i e n t i f

t h e m o t h e r c h o o s e s n o t t o

b r e a s t f e e d . N e w b o r n

b a b i e s d o n o t n e e d a n y

o t h e r f o o d .

• I n f a n t s n e e d t o b e

w a r m a n d c o m f o r t a b l e .

B a b i e s s h o u l d b e

d r e s s e d a p p r o p r i a t e l y f o r

t h e w e a t h e r . I f p a r e n t s

a r e w e a r i n g s h o r t s , t h e n

b a b y c a n w e a r s h o r t s t o o .

B a b i e s s h o u l d n o t b e

o v e r d r e s s e d , s i n c e t h i s

c a n c a u s e i r r i t a b i l i t y a n d

e l e v a t e d b o d y

t e m p e r a t u r e .
• D i a p e r s s h o u l d b e

c h a n g e d a s s o o n a s

t h e y a r e w e t o r s o i l e d .

F a i l u r e t o c h a n g e

d i a p e r s w h e n w e t o r

s o i l e d c a n l e a d t o

d i s c o m f o r t a n d s k i n

i r r i t a t i o n . C l o t h d i a p e r s

a r e b e t t e r t h a n p l a s t i c

o n e s , a n d d i a p e r s s h o u l d

b e f r e e o f c h e m i c a l s a n d

f r a g r a n c e s . S h o u l d a r a s h

o c c u r , e x p o s i n g t h e

a f f e c t e d s k i n t o a i r i s

e x c e l l e n t t r e a t m e n t .

• I n f a n t s n e e d t o b e

c l e a n .

B a b i e s s h o u l d b e

s p o n g e - b a t h e d u n t i l t h e

u m b i l i c a l c o r d f a l l s o f f

( a b o u t 1 0 - 1 4 d a y s ) . A f t e r

t h a t o c c u r s , b a b i e s c a n
b e t u b b a t h e d w i t h m i l d

n o n d e t e r g e n t b a b y s o a p .

T h e y d o n ' t n e e d t o b e

b a t h e d m o r e t h a n o n c e

e v e r y o t h e r d a y . W a s h i n g

t o o o f t e n c a n l e a d t o d r y

s k i n . W a t e r s h o u l d b e

w a r m , n e v e r h o t . A f t e r

b a t h i n g , o i l s a n d p o w d e r s

a r e n o t n e c e s s a r y . I f d r y

s k i n d e v e l o p s , a c r e a m o r

l o t i o n ( l i k e E u c e r i n ) c a n

b e u s e d . I f b a b y d e v e l o p s

" c r a d l e c a p , " o r y e l l o w

s c a l e s o n t h e s c a l p ,

t r e a t m e n t i n c l u d e s a o n c e

o r t w i c e w e e k l y s h a m p o o

w i t h a p r o d u c t l i k e

S e b u l e x .

• T h e u m b i l i c a l c o r d

s h o u l d b e c l e a n e d

e v e r y 4 - 6 h o u r s w i t h
 r u b b i n g a l c o h o l a n d

c o t t o n .

• I n f a n t s n e e d s l e e p .

B a b i e s s l e e p m a n y h o u r s

t h r o u g h o u t t h e d a y , a n d

s l e e p p a t t e r n s d i f f e r

f r o m o n e b a b y t o t h e

n e x t . D u r i n g t h e f i r s t f e w

w e e k s , b a b i e s s h o u l d

s l e e p i n t h e p a r e n t s '

r o o m . B a b i e s s h o u l d b e

p l a c e d o n t h e i r b a c k s .

S l e e p i n g o n t h e a b d o m e n

h a s b e e n r e l a t e d t o S I D S

( s u d d e n i n f a n t d e a t h

s y n d r o m e ) .

• I n f a n t s n e e d

s t i m u l a t i o n .

A p p r o p r i a t e s t i m u l a t i o n

i n c l u d e s t a l k i n g t o ,
s i n g i n g t o , a n d h o l d i n g

t h e b a b y .

• I n f a n t s c r y .

C r y i n g i s h o w b a b i e s

" t a l k " t o t h e i r p a r e n t s ,

a n d b a b i e s o f t e n c r y u p

t o s e v e r a l h o u r s e a c h

d a y . B a b i e s c r y w h e n t h e y

a r e h u n g r y , s i c k , a n g r y ,

i n p a i n , o r h a v e a w e t

d i a p e r . W h e n e v e r a b a b y

c r i e s , t h e c a r e t a k e r

s h o u l d c o n s i d e r t h e s e

r e a s o n s f i r s t . S o m e t i m e ,

b a b i e s a l s o c r y f o r n o

a p p a r e n t r e a s o n , e x c e p t

t h a t t h e y m a y b e

i r r i t a b l e . B a b i e s w h o c r y

d u r i n g m o s t o f t h e i r

w a k i n g h o u r s a r e c a l l e d

" c o l i c k y . " C o l i c u s u a l l y

d i s a p p e a r s a f t e r a f e w
 m o n t h s . I f t h i s o c c u r s ,

y o u c a n t r y :

o H o l d i n g t h e b a b y

c l o s e l y

o H o l d i n g t h e b a b y m o r e

o f t e n d u r i n g p e r i o d s

w h e n s / h e i s n o t

c r y i n g

o G e n t l y r u b b i n g t h e

a b d o m e n

o B u r p i n g t h e b a b y m o r e

o f t e n d u r i n g f e e d i n g s

o C h a n g i n g t h e d i e t

( a v o i d i n g c o w m i l k

f o r m u l a )

o G e n t l y r o c k i n g o r

s w i n g i n g t h e b a b y

I n f a n t s n e e d r e g u l a r

p r e v e n t i v e m e d i c a l

v i s i t s .
A g o o d t i m e t o f i n d a

p e d i a t r i c i a n i s b e f o r e t h e

b a b y i s b o r n . D u r i n g

" w e l l - b a b y v i s i t s " w i t h a

h e a l t h c a r e p r o v i d e r ,

i n f a n t g r o w t h a n d

d e v e l o p m e n t w i l l b e

m o n i t o r e d . I n a d d i t i o n ,

p r o v i d e r s w i l l s c r e e n f o r

c o m m o n c h i l d h o o d

c o n d i t i o n s a n d p r o v i d e

i m m u n i z a t i o n s

APGAR

The APGAR scoring provides a valuable index for assessing the

newborn’s condition at birth. The APGAR Score standardizes infant

evaluation and serves as a baseline for future evaluations. Using the

APGAR system, the infant is assessed at one minute and 5 minutes

after birth. An infant whose total score is under 4 is in serious danger

and needs resuscitation. A score of 4 to 6 means that the condition is

guarded and the baby may need clearing of the airway and
supplementary oxygen. A score of 7 to 10 is considered good. The

highest score is 10.

Immediate Puerperium:
Sign 0 1 2 Score
Heart Absent Slow <100 >100 2

Rate
Respirato Absent Slow, Good strong 2

ry Effort irregular, cry

weak cry
Muscle Flaccid Some Well flexed 2

Tone flexion of

extremities
Reflex No Grimace Cry and 2

Irritability Response withdrawal

of foot
Color Blue pale Body pink, Completely 2

extremities pink

blue
10

The first 24 hours after birth, or the immediate puerperium, is a

critical stage. This is the time when your uterus has to contract well, in

order to stop the bleeding from the site of placental attachment. It is

also the initiation of breastfeeding and bonding. Occasionally, this is

the time that most life threatening complications of delivery manifest.

 These include postpartum excessive bleeding, collapse of the

circulation, cardiac failure, etc. These are not common, but even with

normal vaginal birth there is a risk of death of about 1 in 10,000

women. This risk may be more in women with pre-existing medical

conditions like anaemia, hypertension or heart diseases. It is also more

with operative deliveries. Hence you will be advised to stay in hospital

for at least 24 hours following childbirth.

Early Puerperium:

This refers to the 2<sup>nd to 7<sup>th day post delivery

where major changes start in your genital tract. This is probably also

the time of maximum adjustment when you come to terms with your

new role as ‘mother’. You will also be going home with your baby in

this period. There are many relatively minor, yet significant bodily

changes you should be aware of. These include:

Lochia / Vaginal discharge:

This term refers to the discharge from the vagina, coming mainly

from shedding of the inner lining of the uterus. For the first 4 days,

there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You

may need to use 2 pads at a time, changing 3 – 4 times a day.

However, if you find it very heavy, or large clots keep coming out, you

must inform your doctor. Usually by the 5<sup>th day the flow
becomes much less, and may now be more of a blood stained

yellowish-brown discharge. You may still require sanitary protection,

about 2 – 3 pads a day. This discharge called ‘lochia serosa’ usually

stops by the end of the second week after which it becomes a plain

white discharge. Good hygiene and care of episiotomy will prevent

infection. Any foul smell in the discharge should be reported to your

doctor.

Urination:

The first day you must pass urine at least 2 – 3 hourly, despite pain in

the stitches. This is because the bladder may become overfull without

you realize it, which can cause problems, especially infections later.

During the first week, you may notice that you seem to be passing a

lot of urine. This is because your body is removing some of the excess

water and salt that was retained in pregnancy.

Stools:

You may not have a good bowel motion for the first 2 days following

delivery, for various reasons. One is that you have not eaten much

during labor, you are exhausted and sleepy. Secondly you may be

having pain in the stitches of the episiotomy It is important to take a

high fiber diet and plenty of liquids to prevent hard stools. You may

need a mild laxative for a few days.

Breast:

The first day you will have only a watery, yellowish discharge, not

looking like ‘real’ milk coming from the breasts. This is called

colostrum and it is rich in many nutritive factors that are needed by

your baby. You must feed your baby at this time. By the third day, the

milk flow increases a lot, due to hormonal changes in your body.

Regular feeding is important to prevent engorgement. Link to

engorged breast in Breastfeeding.

After – Pains:

The delivery is over. You have borne with labor pains. So now you may

be worried that you are still getting a cramping lower abdominal pain

off and on. Don’t worry, there is nothing left inside! This is a normal

phenomenon, which occurs due to the uterus contracting in response

to oxytocin, a natural body hormone. This is more marked when you

are breastfeeding. Link to letdown reflex in Breastfeeding. It is nature’s

way of getting your uterus back to the normal size. If the pain is
severe, or you are having other symptoms like fever or excess

bleeding, you need to inform your doctor.

Early Puerperium:

This refers to the 2<sup>nd to 7<sup>th day post delivery

where major changes start in your genital tract. This is probably also

the time of maximum adjustment when you come to terms with your

new role as ‘mother’. You will also be going home with your baby in

this period. There are many relatively minor, yet significant bodily

changes you should be aware of. These include:

Lochia / Vaginal discharge:

This term refers to the discharge from the vagina, coming mainly

from shedding of the inner lining of the uterus. For the first 4 days,

there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You

may need to use 2 pads at a time, changing 3 – 4 times a day.

However, if you find it very heavy, or large clots keep coming out, you

must inform your doctor. Usually by the 5<sup>th day the flow

becomes much less, and may now be more of a blood stained

yellowish-brown discharge. You may still require sanitary protection,

about 2 – 3 pads a day. This discharge called ‘lochia serosa’ usually

stops by the end of the second week after which it becomes a plain

white discharge. Good hygiene and care of episiotomy will prevent

infection. Any foul smell in the discharge should be reported to your

doctor.

Urination:

The first day you must pass urine at least 2 – 3 hourly, despite pain in

the stitches. This is because the bladder may become overfull without

you realize it, which can cause problems, especially infections later.

During the first week, you may notice that you seem to be passing a

lot of urine. This is because your body is removing some of the excess

water and salt that was retained in pregnancy.

Stools:

You may not have a good bowel motion for the first 2 days following

delivery, for various reasons. One is that you have not eaten much

during labor, you are exhausted and sleepy. Secondly you may be

having pain in the stitches of the episiotomy It is important to take a

high fiber diet and plenty of liquids to prevent hard stools. You may

need a mild laxative for a few days.

Breast:
The first day you will have only a watery, yellowish discharge, not

looking like ‘real’ milk coming from the breasts. This is called

colostrum and it is rich in many nutritive factors that are needed by

your baby. You must feed your baby at this time. By the third day, the

milk flow increases a lot, due to hormonal changes in your body.

Regular feeding is important to prevent engorgement. Link to

engorged breast in Breastfeeding.

After – Pains:

The delivery is over. You have borne with labor pains. So now you may

be worried that you are still getting a cramping lower abdominal pain

off and on. Don’t worry, there is nothing left inside! This is a normal

phenomenon, which occurs due to the uterus contracting in response

to oxytocin, a natural body hormone. This is more marked when you

are breastfeeding. Link to letdown reflex in Breastfeeding. It is nature’s

way of getting your uterus back to the normal size. If the pain is

severe, or you are having other symptoms like fever or excess

bleeding, you need to inform your doctor.

Care of Episiotomy:
If you have had stitches on your perineum there are a few

things you need to do, particularly in the first week, to make

yourself comfortable and keep healthy.

• Cleaning the area at least twice a day, with local dilute antiseptic

solution like Savlon or Dettol. E – com. This is a must after passing

stools, and washing with water should be done after passing urine.

Remember, always wash from front to back, never the other way,

to prevent infection.

• Local application of antiseptic creams such as Soframycin,

Metrogyl gel, Betadine E – com may be useful to prevent infection.

This is usually done twice daily, after bath and before going to

sleep at night.

• Pain relieving methods such as hot seitz baths, hot water washes

or hot water bag may be useful. For a seitz bath you need a round

tub large enough for your bottom to fit in, in which hot water with

dilute antiseptic solution is kept. These measures make you feel

better, usually.

• Another way of getting pain relief is local application of ointment

such as 2% xylocaine, E – com, which acts as a local pain-reliever.

• Infrared lamp to apply day heat to the area of stitches may be

given to you in hospital.

• Oral medications such as antibiotics to prevent infection, or pain

killer tablets (paracetamol, ibuprofen, etc. E – com) should only be

 taken as advised by your doctor.

• Most doctor use stitches, which dissolve on their own and / or fall

off after a few days. Ask your doctor if you need to come back to

show the stitches.

Post Partum Blues:

There are many changes, which have happened to you in the

past 9 months, and even more are happening now. You may be feeling

a little left out or dissociated from your surroundings. Link to

introduction of puerperium The swings in your hormone levels are

maximum in the first week. Your baby may be keeping you awake all

the time, your breasts feel sore, and your stitches are hurting …….

Many things add up to make you feel down. Many women feel low or

depressed soon after delivery – in fact, it is so common that there is a

medical team for it, called ‘fifth day blues’! Talk to your partner, your

friends, an older relative or your health care persons. Ask for help with

the baby if you are tired. Have a good cry. Take a break, sleep for a

while and you will feel better. If this feeling of depression does not

settle in a few days, then perhaps you should see your doctor for help,

Sometimes an underlying hormonal problem like low thyroid function

may be causing these feelings.Remember that these feelings are not

uncommon. You are not the only mother who is not feeling ‘100%

maternal love’ all the time, particularly soon after delivery. Be good to

yourself, pamper yourself also, and talk about what you feel. Soon, you

too will feel on ‘top of the world’!

Resuming Activities:

As discussed earlier, it takes up to 6 weeks for your body to

recover from the changes of pregnancy. So, be patient with yourself.

Listen to your body and do as much as you feel up to, Different women

have different abilities to deal with their health changes. However, in

most cases, after a normal vaginal delivery, you will be able to resume

your daily personal care activities within a day, and your household

routine within a week, Don’t overexert yourself – This is the time you

need to devote to yourself and your baby. Take help, involve your

partner, Link to Father’s role, and others available to make your life

easier. After a complicated childbirth, or after a caesarean delivery

your recovery may take twice as much time, so be patient.

Postnatal Exercises:

Sexual Activity is best avoided in the early post delivery period.

This is because your stitches may be raw or painful, and your genital

tract is prone to infection, particularly in the 1<sup>st week. Complete

restoration of the lining of the uterus, including the placental site, is

not complete. Hence traditionally some advise abstinence till 6 weeks

following delivery.However, if you have had an uncomplicated birth,

and are not having any problems, you could resume your sexual life

earlier. You and your partner may have been deprived of each other,

particularly in the last month of pregnancy. Hence, it is not unusual to

feel the need to renew your sex – life. Until you feel comfortable for

actual penetrative sexual intercourse, other displays of caring and

affection can suffice. Hugging, kissing, petting or touching is not

forbidden at anytime during pregnancy or post-delivery.

Lactational Amenorrhoea:

Link to Lactation amenorrhoea in Preventing Pregnancy. While you

are exclusively breastfeeding, Link to exclusive breastfeeding in

Breastfeeding, the hormonal changes is your body act on the genital

tract to suppress ovulation and menstruation. Link to female

reproductive, tract, ovulation, and menstruation. You may not get your

periods for a few months. Some women do not start menstruating for

up to a year, depending on the pattern and frequency of

breastfeeding.

Timing No lactation If lactation established

Menstruation 6 – 12 weeks 36 weeks (average)
Earliest ovulation 4 weeks 12 weeks
Average time for 8 – 10 weeks 17 weeks (variable)
ovulation.

Does this mean you cannot get pregnant? The answer is NO. About 5%

of women get pregnant before they start menstruating, post-delivery.

Lactational amenorrhoea (absence of periods) does protect you from

pregnancy to some extent. However, you can rely completely on

Lactational amenorrhoea as a method of preventing pregnancy ONLY

IF ALL 3 preconditions listed below are satisfied:

Contraception:

If you are relying on lactational amenorrhoea. If not, that brings

us to the important question: Are you ready for another pregnancy?

You need to give your body time to recover, your baby time to grow up

and yourself time to adjust to the new role of ‘mother’. Of course, it is

a question of personal choice but a minimum gap of 2 years is

recommended between successive pregnancies . So, how can you

prevent pregnancy during the post-delivery period?

There are many methods available. During the post partum period,

however, certain factors need to be kept in mind:

Whether breastfeeding or not.

Frequency of sexual intercourse.
For how long pregnancy prevention is required.
The final choice is also influenced by your personal needs and

experience.

Others:
Condoms

Condoms are a good, locally acting method, which are reliable if

used correctly and consistently. They have no side effects and are

useful for couples with less frequent sexual intercourse.

IUCDs or ‘loops’:

These are a very reliable method, requiring one visit to the doctor for

insertion, which can be done easily without anaesthesia. They are

effective for average 3 – 5 years (depends on the device) and are

independent of the sexual act, unlike condoms. This is a very popular

method for women with one or more children. Infact, can be used as an

option to permanent procedure. The IUCD can be inserted at the first

postnatal visit. Link (6 weeks from childbirth) or later, even if you do

not have periods, provided your internal checking is normal.

Oral Contraception pills:

These are a type of hormonal contraception. During the period of

exclusive breastfeeding the combined Oral Contraception pills

(containing Estrogen + Progesterone) may reduce the breast milk flow.

Hence are not popularly recommended. Once weaning is begun, there

can be used safely.

Sterilisation:
 This is a permanent method, which can be opted for after you

have completed your family. This is a procedure which can be done

easily immediately post-delivery (puerperial sterilization) or at the time

of caesarean section. For both these options, you need to discuss the

pros and cons with your doctor and spouse before delivery, ideally in

one early antenatal period. Some prefer to wait until the youngest

child is older, preferably above 1 year old, before doing this permanent

procedure. As an interval procedure, 6 weeks or more after delivery, it

is usually done by laparoscopy.

First Postnatal Visit:

You and your baby have been through a lot. After you go home,

and you recover from childbirth, your doctor will need to see you at

least once to confirm that your recovery is complete. The first check up

is usually 6 weeks from delivery. It may be earlier, about 3 weeks, if

you have needed special care or had any problem in delivery. At the

first visit, your doctor will check

Your weight.
Blood pressure.
Signs of anaemia.
Your breasts.
Your episiotomy scar (should be dissolved by now).
Your uterus (to see if it is shrinling back to normal size).
You may need to do some tests. You need to discuss the

following issues with your doctor

Restoration of your complete health.

Postnatal exercises
Diet and nutrition.
Your baby’s health.
Immunization schedule.
Continuing exclusive breastfeeding
Contraception.

ESTABLISH SUCCESSFUL LACTATION

In most of the hospital they require the mothers who delivered

there to breast reed as soon as possible because the baby will receive

colostrums that contains gamma globulins. Advantages of breath

feeding to the mother are: It is economical in terms of money and

effort, more rapid involution, loss incidence of cancer of the breast. For

the baby: closer mother infant relationship, contains antibodies that

protect against common illness, less incidence of gastrointestinal

diseases and always available at the right temperatures.

Postpartum Assessment

BP 130/90 mmHg

Cardiac Rate 80 bpm

Respiratory Rate 24 cpm

 Temperature 37.5 c

1. Condition of the Uterus

I checked the fundus with my clients back flat an bed with her feet

together and knees apart. I asked her to empty her bladder and she

was able to do it. With one supporting the lower fundus just above the

symphisis pubis, I cupped my hands around the fundus and rotated it

gently. I noted that the fundus is getting firmer and slowly getting

smaller.

2. Lochia

According to my client the lochias smell is fleshy with no foul

smelling odor. The first discharge was bright red bloody and this

lasted for 3 dys. After 3 days a pint discharge was noted. On the 7th

day I was able to notice pink brown, serous with no foul smelling

discharges. On the 10th day, my client to continue monitoring her

Jochia discharges and note its characteristics. There should not be a

foul smelling order and this will only lasts for 6 weeks.
3. Perineum

It is in good condition. No lacerations and no hematomas found.

4. Urinary System

She was able to void 5 hours after delivery.

5. Intestinal Elimination

No hemorrhoids, able to defacate the next day after delivery.

6. Breast

Absence of any cracks, nipples protruded and erect. Breastfeed was

done 1 hours after delivery.

7. Nutrition

I encouraged her to eat green leafy vegetables, foods rich in iron like

liver. I also asked her to eat egg, meat, plenty of soup. Verbalized she

has increased in appetite and loves to eat most especially after

breastfeeding.

Breastfeeding
 Breast milk is preferred method of feeding a newborn because it

provides nukerous health benefits to both the mother and the infant. it

remains the ideal nutritional source for infants through the first year of

life.

Nurses can play a major role in teaching women about the benefits of

breastfeeding and providing anticipatory guidance for problems that

may occur by implementing steps such as:

• Educating all pregnant woman about the benefits and management

of breastfeeding.

• Helping women initiate breastfeeding within half an hour of birth.

• Assisting mothers to breast-feed and maintain lactation even if they

should be separated

from their infant.

• Not giving newborns food or drink other than breast milk unless

medically indicated.

• Not giving pacifies to breastfeeding infant.

• Practicing rooming- in (allow mothers and infants to remain together)

24 hours a day.
• Encouraging breastfeeding on demand.

• Fostering the establishment of breastfeeding support groups and

referring mothers to them on discharge from the birthing center or

hospital.

The mother gains several physiologic benefits from breast feedings,

such as: breastfeeding may serve as a protective function in

preventing breast cancer, the released of oxytocin from the posterior

pituitary aids uterine involution and successful breastfeeding can have

an empowering effect because it is a skill only woman can master.

Breastfeeding also reduces the cost of feeding and preparation time.

Many women feel that breastfeeding enhances the formation of a true

symbiotic bond with their child.

Breastfeeding has major physiologic advantages for the baby. Breast

milk contains secretary immunoglobulin A, which binds large molecules

of foreign proteins, including viruses and bacteria and keeps them

from being absences to the GIT into the infant.

Prolactin
An anterior pituitary hormone, acts on the acinar cells of the mammary

gland to stimulate the production of milk. In addition, when infants

sucks at the breast, nerve impulses travel from the nipple to the

hypothalamus to stimulate the production of prolactin releasing factor.

Colustrum

A thin watery, yellow fluid composed of protein, sugar, fat, water,

minerals, vitamins, and maternal antibodies, is secreted by the acinar

breast cells starting in the 4th month of preganancy.

Lactoferin

Is an iron binding protein in breast milk that interferes with growth of

pathogenic bacteria.

Lysozyme

In breast milk apparently actively destroys bacteria by lying their cell

membranes, possibly increasing the effectiveness of antibodies.

Leukocytes

In breast milk provide protection against common respiratory

infections invaders.

L bifidus
Interferes with the colonization of pathogenic bacteria, in GIT. the

incidence of diarrhea. Breast milk also contains ideal electrolyte and

mineral composition for human infant growth.

Advantage of breastfeeding

Little controversy exist about breastfeeding as the best nutrition

for human infants, but the decisions to breastfeed depends on what

would please the woman the most and make and make her most

comfortable. If she is comfortable and pleased with what she is doing,

her infant will be comfortable and pleased, will enjoy being fed, and

will thrive.

Breastfeeding is contraindicated in only a few circumstances,

such as:

• An infant with galactosemia (such infant cannot digest the

lactose in milk

• Herpes lesions on the mothers nipples

• Mother is on restricted nutrient diet that prevents quality milk

production
• Mother is receiving medications that are inappropriate for

breastfeeding, such as lithum or methotrexate.

• Maternal exposure to radioactive compounds, as could happen

during thyroid testing

• Breast cancer

Advantage for the mother

A woman gains several physiologic benefits from breastfeeding,

including:

Breastfeeding may serve a protective function in preventing breast

cancer

The release of oxytocin from the posterior pituitary gland aids in

uterine involution

Successful breastfeeding can have an empowering effect because it is

a skill only woman can master.

Breastfeeding, also reduces the cost of feeding and preparation

time. Many women feel that breastfeeding provides the best

opportunity to enhance the formation of a true symbiotic bond with

their child. Although this does occur readily with breastfeeding, a

woman who holds her baby to bottle- feed can form this bond equally

well. some woman believe that breastfeeding is a fool proof

contraceptive technique. Some feel breastfeeding will help them lose

their weight gained during pregnancy. This also is not true, and women

who are breastfeeding need to concentrate on eating a well balance

diet to ensure that her milk is rich in nutrients. Some woman are

reluctant to breastfeed because they fear that having to be available

to feed the baby every 3 or 4 hours will tie them down.

 Advantage for the Baby

Breastfeeding has many physiologic advantages for the baby.

Breast milk contains contains immunoglobulin A (IgA), which binds

large molecules of foreign proteins, including bacteria and viruses.

Thus keeping them from being absorbed through the gastrointestinal

tract into the infant. Lactoferin is an iron binding protein in breast

milk that interferes with growth of pathogenic bacteria. Lysozyme in

breast milk apparently actively destroys bacteria by lying their cell

membranes, possibly increasing the effectiveness of antibodies.

Leukocytes in breast milk provide protection against common

respiratory infections invaders. L bifidus interferes with the

colonization of pathogenic bacteria, in GIT. the incidence of diarrhea.

Breast milk also contains ideal electrolyte and mineral composition for

human infant growth.

Breast milk contains more linoleic acid, an essential amino acid

for skin integrity, and less sodium, potassium, calcium and

phosphorous than do many formulas. Breast milk also has a better

balance of trace elements, such as zinc, than formulas do. These levels

of nutrients are enough to supply the infants needs, yet they spare the

infant’s kidneys from having to process a high renal solute load of

unused nutrients.
One disadvantage of breast milk is that it may carry microorganisms

such as hepatitis B and cytomegalovirus, although the risk to infant is

small. HIV is carried at a high enough level in breast milk that women

who are HIV positive are advised not to breast feed.

Preparing for Breastfeeding

Ask all women during pregnancy whether they plan to breast-

feed or formula feed their newborn. Thinking about feeding in advance

allows couples to make informed choices. Some fathers experience

jealousy at the thought of breastfeed ing.

Physical preparation such as nipple rolling, advised in the past as a

way of making the nipple more protuberant is no longer advised. This

is unnecessary because few women have inverted or non protuberant

nipples, plus oxytocin, released by this maneuver, could lead to pre-

term labor (nipple rolling is used to create uterine contractions for

stress test). Practicing breast massage to move the milk forward in the

milk ducts (manual expression of milks) maybe helpful.

This can help a woman who feels hesitant about handling her

breast to grow accustomed to doing so, allowing her to assist with milk

production in the first few days after birth. Manual expressions consists

of supporting the breast firmly, then placing the thumbs and forefinger
on the opposite sides of the breast just behind the areolar margin, first

pushing backward toward the chest wall and then downward until

secretion begins to flow.

Teach woman not to used soap on their breasts during pregnancy

because soap tends to dry and crack nipples. The occasional woman

who has inverted nipples may need to wear a nipple cup (a plastic

shell) to help the nipples become more protuberant.

BEGINNING BREASTFEEDING

Breastfeeding should begin as soon as possible, ideally while the

woman is still in the delivery or birthing room and while the infant is in

the first reactivity period. This practice has several advantages infant

suckling stimulates release of oxytocin which in turns stimulates

uterine contracts to prevent hemorrhage, promotes closer maternal

and infant relationship, prevents breast engorgement:

If it is not possible to start breastfeeding right after delivery,

initiate breastfeeding, then, after 4 to 8 hours when the mother has

already rested on her condition and stable.

 HOW TO FEED

1. Instruct mother to relax first before feeding, anxiety and fatigue

interferes

with the let down reflex

2. Wash hands and assume a comfortable position. The mother can

breastfeed lying down or sitting, which ever is comfortable for her and

her baby.

3. If the baby is asleep or sleepy talking or rubbing baby’s soles will

gently wake him or wake up breastfeeding is more effective if the

baby is awake.

4. Guide baby to the breast by stimulating rooting reflex, touch the

cheek nearest the

breast. The baby will respond by turning his head and opening his

mouth.

5. Press the breast away from the nose with a finger if the baby’s nose

is blocked by

the breast.

6. Let the baby’s mouth grasp both the nipple and areola.
7. Feed the baby for only 2 to 3 minutes during the first time, then,

increase feeding time by one minute each day until the infant is fad for

ten minutes on each breast

8. When removing the baby from the breasts, pull the chin down or

place a finger in the corner of the mouth to break the suction. Pulling

the baby from the breasts is painful and can cause sore nipple.

9. On the next feeding, place infant on the breast where she or he last

fed during the previous feeding.

10. Instruct mother to burp infant after feeding by placing baby on her

lap on a prone position or positioning him or her in sitting upright.

11. Signs of proper feeding:

• The baby’s mouth group both nipple and areola.

• The other breast flows with milk. Infant sucking stimulates

release of oxytocin which in form

stimulates milk let down reflex.

• The mother feels after pains or uterine cramping while

breastfeeding, this is due to release of oxytocin.

12. It is not unusual to haves scanty milk supply during the first few

days after delivery. There is no need to offer milk formula to the

infant. Placing infant regularly on the breasts will stimulate milk

production. Maintenance of successful lactation requires that breasts

are completely emptied at each feeding so that they will completely

fill again. The more the baby suckles, the more milk is produced.

13. Instruct the mother to avoid:

• Smoking

• Oral contraceptives because they decrease milk supply

• Drugs passed to infant via breast milk.

Problems of breastfeeding:

1. Breast Engorgement

Breast engorgement usually occurs during the 3rd to 4th day after

delivery. The mother complains of pain and tenderness, the breast are

reddish, tense, shiny, hot to touch and feels firm and nodular. Breast

engorgement is not cause by milk or infection but by lymphatic and

venous congestion. When the breast are engorged, the infant will not

be able to grasp the nipple effectively and pain can cause the mother

to avoid or refused breastfeeding.

Management:

• Give analgesics before feeding to provide pain relief

• Give breast more often to empty breast with milk and prevent further

engorgement

• Initiate breastfeeding as soon as possible after delivery to prevent

engorgement.

• Let warm water run over the breast or apply warm compress to

improve circulation

and promote comfort if the mother plans breastfeed. If the mother

does not plan to

breastfeed, apply ice packs.

• Reassure mother that engorgement is temporary and it will subside

after 24 hours.

2. Sore and Crack Nipples

Causes:

• Forceful pulling of the infant after feeding

• Improper sucking - infant grasping only the nipple during feeding

• Breastfeeding too long

• Nipple remaining moist for a long time due to leakage of milk

Management:

• Expose to air after feeding to let nipples dry

• Use of loose fitting clothing and leaving bra unsnapped to let air

circulate in the breast for a few minutes

• Limit amount of time of feeding to allow nipple to healed

• Use of nipple shield

• Exprese milk usually or by breast pump if breastfeeding causes too

much pain

to maintain milk supply

• Sore nipples are not contraindication to breastfeeding unless the

mother cannot

tolerate the discomfort caused by infant suckling. She can express

milk from her breasts

and give it to infant using feeding bottle.

 GENERAL HEALTH TEACHING

1. Pre-natal care Visits

 Blood pressure will be monitored each month. While low blood

pressure is rarely a reason for concern, an abnormal increase

may be sign of problems that can affect you and your baby.

 Weight is normal for your body to gain weight or experience a

little ankle swelling due to water retention during pregnancy.

Your doctor will advice you about how much weight gain is good

for you.

 Urinalysis, bodily functions will be determined through this test.

It will also detect diabetes, kidney and bladder infections, and

early signs of many problems in pregnancy.

 Blood test, samples will be taken to determine blood type and Rh

factor to check for anemia and other blood diseases, and to

screen for potential birth defects.

 Ultrasound or sonograms, will be done to check for twins, baby’s

position, and due date accuracy. Breast exam, may be done on

your first pre-natal visit. Advice will be given on breastfeeding as

well as nipple and breast preparation.

  Abdominal exam, the doctor will measure the size of your uterus,

which shows the growth of you baby, as well as check the baby’s

position.

 Pelvic exam, on your first prenatal visit, your doctor will perform

a vaginal exam to evaluate the size of your birth canal. Unless

absolutely necessary, this exam will not be repeated until just

before the baby is due, when changes such as dilation and

effacement of the cervix will be measured.

 1st visit: 32 weeks: visit must be every 4 weeks

 2nd visit: 32-36 weeks: visit must be every 2 weeks

 3rd visit: 36-40 weeks: visit must be once every week

2. Work

 you can go to work, but take care not to strain yourself or subject

yourself to stress.

 Avoid prolonged standing or sitting.

 Provide deep breathing, foot circling and relaxation.

3. Sleep

 get plenty of bed rest. In the last months of your term, you may

have some difficulty sleeping. Try to nap when you have the

chance.
4. Exercise

 moderate exercise, such as relaxed swimming, is allowed. Take

care not to overheat.

 Kegel’s exercise is recommended to strengthen the muscles

around the reproductive organs and improve muscle tone.

5. Travel

 routine travel, such as daily commute, is allowable. Airplane

flights are possible usually until the last trimester of your

pregnancy.

 Proper use of seatbelt and headrest and lap belts must be done.

 Avoid long trips especially on the 1st and 3rd trimester but can

travel in 2nd trimester.

 Periods of activity and rest must be done fro 15 mins. every 2

hours for emptying of bladder.

 In high altitudes regions, lowered O2 mav cause hypoxia or fetal

brain damage , It may be pressurized.

6. Nutrition

 quality of your diet is essential. Your doctor may give you advice

on a particular set of foods you can eat, given your condition. He

 may also prescribe vitamin and mineral supplements. Avoid

salty, too-sweet, and fatty foods.

 Drink 8-12 glasses of liquid a day, juices may be included to

lower the pH of urinary tract.

 Increase caloric intake to prevent maternal underweight.

 Eat variety of foods and maintain small, frequent feeding.

7. Hygiene

 keep yourself clean always. Bathe regularly to keep your body

cool. Do not use feminine washes or douches unless advised by

your doctor.

 Do not use bath tub, can alter balance

 Do not bath if there is vaginal bleeding and rupture of

membranes.

 Warm showers can be therapeutic, relax tensed tired muscles,

helps counter insomnia, makes us feel fresh.

 Can swim but no diving to prevent traumatic injury.

8. Sexual activity

 contrary to what some people say, sexual intercourse is not

harmful to the baby. However, take care not to put too much

weight on the abdomen. Try other position instead. If you have

 been exposed to any sexually transmitted disease, report it to

your doctor immediately.

 Provide a safe, open, non-judgmental atmosphere,

 Provide comfortable environment, offer alternatives and show

illustrations.

 Avoid sexual intercourse during the 1st and 3rd trimester.

9. Smoking

 Stop! Smoking depletes much- needed oxygen and may cause

birth defects.

10. Drinking

 alcohol can harm your baby and should not be ingested during

pregnancy.

 Avoid alcoholic beverages to prevent growth retardation and

musculoskeletal deformities.

11. Caffeine

 limit your intake or cut it altogether, it hinders the body

absorption of certain nutrients like iron.

12. Medications/Drugs

 self-treatment must be discouraged.

  All drugs, including aspirin should be limited and careful record

of therapeutic agents used should be used.

 Consult your physician who undergone medications to reduce the

cause of possible teratogenecity or fetal drug toxicity.

13. Immunizations

 Tetanus toxoid must be given to pregnant woman.

 Do not give medications such as measles, mumps and polio

vaccine due to potential teratogenecity.

14. Dental care

 Adequate calcium and phosphorus in the teeth must be included

on the diet.

 Dental tooth extraction is prohibited during pregnancy.

EXERCISES DURING PREGNANCY

 KEGEL EXERCISES

Are exercises designed to strengthen the pubococcygeal muscles.

They should be done about 3 times a day. Exercises are as follows:

1. Squeeze the muscles surrounding the vagina as if stopping the

flow of urine. Hold for 3 secs. Relax repeat 10 times.

2. Contract and relax the muscles surrounding the vagina as

rapidly as possible 10 to 25 times.

3. Imagine that you are sitting in a bath tub of water and squeeze

muscles as if sucking water into the vagina. Hold for 3 secs.

Relax Repeat 10 times.

4. Push out with the vagina as if expelling something from it. Hold

for 3 secs. Relax Repeat 10 times.

It may take as long as 6 weeks of exercise before,

pubococcygeal muscles are strengthened. In addition to

strengthening urinary control and preventing stress

incontinence, exercises can lead to increased sexual enjoyment

because of the tightened vaginal muscles.

PERINEAL AND ABDOMINAL EXERCISES

1. Tailor sitting - strengthens the things and stretches perineal

muscles to make them more supple. A woman could use this

position for TV watching, telephone conversations, or playing with

an older child. It is good to plan on sitting in this position for at

least 15 minutes. Should also practice this position for 15 mins a

day.

2. Squatting – stretches the perineal muscles. Should also

practice this position for 15 mins a day. For the pelvic muscles to

stretch, the woman most keep her feet flat on the floor.

3. Pelvic Floor Contractions – done during the course of daily

activities as well. Perineal muscle – strengthening exercise will be

helpful in the postpartum period as well as to promote perineal

healing, to increase sexual responsiveness, and to help to prevent

stress incontinence.

4. Abdominal muscles contractions – help strengthen abdominal

muscles during pregnancy. Strong abdominal muscles can also

contribute to effective second – stage pushing during labor and

help to prevent constipation. Abdominal contractions can be done in

standing or lying position along the pelvic floor contractions. The

 woman merely tightens here abdominal muscles, then relaxes, she

can repeat the exercise as often as she wished during the day.

Another way to do the same thing is to practice blowing out

a candle”. The women takes a fairly deep inspiration, then

exhales normally. Holding her finger about 6 inches infront of

herself, as if were a candle, she than exhales forcibly, pushing out

residual air from her lungs.

5. Pelvic Rocking – helps relieve backache during pregnancy

and early labor by making the lumbar spine more flexible. It can be

done in a variety of positions. On hand on knees, lying down, sitting

or standing. The woman arches her back, trying lengthening or

stretching her spine. She holds the position for I minutes, then

hallows her back. A woman can do this at the end of the day a bout

five times to relieve back pain and make herself more comfortable

for the night.

POST PARTAL EXERCISES

MUSCLE STRENGTHENING EXERCISE

1. Abdominal Breathing – abdominal breathing maybe started

on the first day postpartum, because it is a relatively easy

 exercise. Lying flat on her back on sitting, a woman should

breath slowly and deeply in and out 5 minds, using her

abdominal muscles.

2. Chin – to chest – chin to chest exercise is excellent for the

second day. Lying on chin forward on her chest without moving

any other part of her body while exhaling. She should start this

gradually, repeating it no more than 5 times the first time and

then increasing it to 10-15 times in succeeding. The exercises

can be done 3 to 4 times a day. She will feel the abdominal

muscles pull and tighten if she is doing it correctly.

3. Perineal Contraction – If a woman is not already if she is doing

it correctly. Of alleviating perineal discomfort, it is a good one

to add on the third day. She would tighten and relax her perineal

muscles 10-15 times in succession as if the trying to stop

voiding. She will feel her perineal muscles working if she is

doing it correctly.

4. Arm Raising - Arm raising helps both the breasts and the

abdomen return to good time is a good exercise to add on the

fourth day. Lying an back, arms at her sides, a woman moves

arms out from her sides until they are perpendicular to her body.

She time raises them over her body until they are perpendicular

to her body. She then raises them over her body until her hands
 touch and lowers them slowly to her sides. She should rest a

moment, then repeat the exercise 5 times.

5. Abdominal Crunches - It s advisable to wait until to 10th and

12th day after delivery before attempting abdominal crunches.

Lying flat an her back with knees bent a woman folds her arms

across her chest and raises herself to a sitting position. This

exercise expenses a great deal foe effort and tires a postpartum

woman easily. She should be cautioned to begin it very gradually

and work up slowly to doing it 10 times in a row.

 Choosing to be in the college of nursing entails a lot of hard work

and perseverance to achieve the degree you’ve been aiming for. You

need to give your best shot in every situation the school is putting you,

we are like animals we lash out in order to survive.

I, Sarrah Jane A. De Guzman, a now graduating student is now

ready to meet and face the world’s demands. I’ve grown up and

achieved the confidence needed to reach success yet as humble as

can be. My parent’s, together with the institution aided in my quest for
wisdom and proper values which I’ll be needing as my weapons as I

come to reach the top of the mountain. I once used to be naïve but as I

mature and reach this stage, I’ve come to know that you can never

reach your destination if you’re unwilling to move your feet. And now

I’m coming out from my shell to meet the wonderful future I have of

becoming a Registered Nurse.