DEDICATION

With deepest admiration, this book entitled “Maternal and Child Nursing: A
Family Centered Approach” is dedicated to my significant others that includes, my
mother, my sisters and to my friends who have stood by me over the years who
provided inspirations to achieve this accomplishment this book is made for them to
know more about maternal and child and for them to apply this knowledge and skills....

And to Almighty God for His unending and immeasurable love, forgiveness and
blessings that have showered upon us…
 ACKNOWLEDGMENTS

Grateful acknowledgement is made to my parents for their unending support and

wholeheartedly given their love and concern in many ways.
The author is greatly indebted to my client who shared her understanding and
some classified information necessary for this book. Likewise my deepest appreciation
and gratitude for her cooperation most especially during the documentation, without her
this book would not have been completed.
Special acknowledgment to Ms. who both assisted me during the prenatal and in
documenting during the delivery and in the newborn care.
My sincerest thanks to my Clinical Instructor, who imparted her knowledge, skills
and assistance throughout the duration of this book.

And above all, to Almighty God, for the strength, love and grace in writing this book.
 INTRODUCTION

Someone once said, “pregnancy begins at that unfelt, unknown moment of time
when a single, wiggling sperm penetrates a mature ovum. Even though this momentous
event of fertilization occurs without notice, the changes, which take place within the
mothers’ body in the next nine months, are undeniable and amazing. Yeah, our coming
to earth is really magical and we should thank our mothers for they sacrificed their lives
just to give us our precious gift… our LIFE.
Childbirth is a good metaphor for life. It begins at time of conception, when long
gestation by hard labor to bring forth a new creation. Mixed passion and discomfort
strike before fulfillment.

For every person going through the process of birth, there is a possibility of
transformation at the individual and the family level. That’s why everyone views birth as
the most critical time, a hopeful time.

In many ways, birth has become crucible in which modern woman is around and
burned; it is our testing place. But there’s value in this work. True-births have often been
difficult and painful, but pain can be essential part of growth.

Maternal and child care is a philosophy based on the consideration of a mother

and child in relation to each other and consideration of a whole family with each
meaningful relationship as well as its cultural and socio-economic environment of the
client. The overall trust of maternity care is to assist each mother throughout the stage
of pregnancy, labor and delivery and the puerperium in such a way that minimal
discomfort will be experienced and to ensure optimal health and well being for the
mother and her newborn. Sure care must also meet the psychological needs of the
mother and her partner and their contribution to satisfactory infant- maternal bonding
following delivery.

Obstetrics
 Branch of medicine concerned with the treatment of women during pregnancy,
labor, childbirth and the time after childbirth. Obstetricians work to ensure that
pregnancy culminates in the delivery of a healthy baby, without impairing the health of
the mother. The mother's medical history and health status are initially evaluated.
Physical examination discloses the mother's uterine size and estimates the length of her
pregnancy. If the obstetrician detects abnormalities, prenatal testing may need to be
done on the fetus. An important modern development has been ultrasonography, which
allows the obstetrician to non-invasively diagnose intra-uterine conditions. Delivery of
the baby is helped by the use of a Friedman's chart, which shows the patterns of
cervical dilation. The care of women during childbirth was originally in the hands of
women but in the 16th cent. physicians grew interested in the field. Of special
importance were the invention of the delivery forceps by Peter Chamberlen in the 17th
cent. and the introduction of anesthesia in the 19th cent. The adoption of antiseptic
methods according to the theories of Joseph Lister and Ignaz Semmelweis reduced the
incidence of infection in childbirth and made possible successful cesarean section.
Obstetrics is often combined with gynecology as a medical specialty

Gynecology

Branch of medicine specializing in the disorders of the female reproductive

system. Modern gynecology deals with menstrual disorders, menopause, infectious
disease and maldevelopment of the reproductive organs, disturbances of the sex
hormones, benign and malignant tumor formation, and the prescription of contraceptive
devices. A branch of gynecology, reproductive medicine, deals with infertility and utilizes
artificial insemination and in-vitro fertilizations, where a human egg is harvested,
fertilized in a test tube, then implanted into the womb. Some gynecologists also practice
obstetrics. Surgical gynecology began to make progress in the 19th cent., when the
introduction of anesthesia and antisepsis (see antiseptic) paved the way for many
advances. The American physician J. M. Sims was largely responsible for gaining
acceptance of gynecology as a medical and surgical specialty. Until then there had
been opposition to it on moral grounds from midwives, the clergy and the medical
profession. In recent years, because of controversies over abortion and birth control,
government has become involved in gynecological practice.

Pregnancy

Period of time between fertilization of the ovum (conception) and birth, during
which mammals carry their developing young in the uterus (see embryo). The duration
of pregnancy in humans is about 280 days, equal to 9 calendar months. After the
fertilized ovum is implanted in the uterus, rapid changes occur in the reproductive
organs of the mother. The uterus becomes larger and more flexible, enlargement of the
breasts begins, and alteration of renal function, blood volume, and blood cell count
occur. Movement of the fetus and fetal heartbeat can be detected early in pregnancy.
One test that has been used to determine pregnancy uses blood or urine
samples to detect a hormone known as BhCG, found exclusively in pregnant women.
Later, prenatal diagnostic tests such as alpha fetoprotein, amniocentesis, and chorionic
villus sampling may be performed as screening measures for congenital defects.
Ultrasound, a sonar device using high-frequency wavelengths, is used to detect defects,
measure fetal heartbeat, and monitor growth of a fetus. Complications of pregnancy
include eclampsia, premature birth, and erythroblastosis fetalis (Rh incompatibility).
Ectopic pregnancy, in which the fetus begins to develop outside the uterus, often in a
fallopian tube, is another complication. It is often the result of scarring from a sexually
transmitted disease. Smoking has been linked to low—birth weight infants; alcohol
consumption during pregnancy has been linked to a group of defects called fetal alcohol
syndrome.
The technology relating to pregnancy has made great advances and has created
a number of ethical issues. Many women in their 40s are now able to sustain successful
pregnancies, due to technological devices that carefully monitor the progress of the
fetus. In vitro fertilization and other infertility treatments have allowed even
postmenopausal women to give birth. The use of fertility drugs has led to a marked
increase in multiple births. Abortion, in which pregnancy is terminated prior to birth, has
long been a subject of heated debate, and surrogate motherhood (see surrogate
mother) has also raised ethical issues in recent years
Reproduction is the process by which organisms produce more organisms like
themselves. All living things, including humans, reproduce: it's one of the things that set
us apart from nonliving matter. And because all living things eventually die, new
creatures of the same kind must constantly be born to perpetuate a particular species.
Interestingly, although the reproductive system is essential to keeping a species alive,
unlike other body systems, it is not essential to keeping an individual being alive.

Early Signs of Pregnancy

The signs of pregnancy can vary from person to person. You may have none, some,
or all of the following signs of pregnancy:

• A missed period, spotting, or a period with less bleeding than normal

• Nausea or vomiting
• Tender, swollen, or tingling breasts
• Fatigue
• Changes in appetite or digestion
• Frequent urination and urgency

Although some of these signs may be due to factors other than pregnancy, you
should take care of yourself and your body if you think you are pregnant. In addition,
you should make an appointment to see a health care provider.

Anatomy and Physiology

Ovary, in anatomy, organ of female animals, including humans, that produces
reproductive cells called eggs, or ova. In humans they are oblong, flattened, ductless
glands, about 3.8 cm (about 1.5 in) long, on either side of the uterus, to which they are
connected by the Fallopian tubes. Each ovary is composed of two portions: an external,
or cortical, portion, and a deep, medullary portion. The cortical portion in the adult
contains an enormous number of follicles, or sacs, varying in size. called Graafian
follicles, they contain the ova, the female reproductive cells. The interior of the ovary is
distinctly divided into an outer cortex, where the germ cells develop, and a central
medulla occupied by the major arteries and veins. Each egg cell develops in its own
fluid-filled follicle and is released by ovulation. The ovary is supplied with an ovarian
artery, ovarian veins, and ovarian nerves, which travel through the suspensory ligament.

Left Ovary Right Ovary

The ovary is held in place by the ovarian, suspensory, and broad ligaments as
well as a peritoneal fold called the mesovarium. The ovary secretes hormones that,
together with secretions from the pituitary gland, contribute to secondary female sexual
characteristics and also regulate menstruation. The union of the male sperm cell with
the ovum results in fertilization. The ovary may be the site of several disease conditions.
It can be the site of acute and chronic inflammation; this may arise from injuries during
labor, operations in the pelvic area, or gonorrheal infection spreading from the vagina.
The ovary also may be the site of neoplasms (tumors) of several varieties. Some are
fluidic enlargements of one or more Graafian follicles and may attain an enormous size;
these are known as ovarian cysts. Other growths, of a solid nature, are known as
dermoid cysts. These enlargements, usually benign, occasionally prove to be
cancerous.

Ovary and Fallopian Tube Uterine Tube and Ovary with

Ligaments

Most species have male and female organisms. Each sex has its own unique
reproductive system. They are different in shape and structure, but both are specifically
designed to produce, nourish, and transport either the egg or sperm. Unlike its male
counterpart, the female reproductive system is almost entirely hidden within the pelvis. It
consists of organs that enable a woman to produce eggs (ova), to have sexual
intercourse, to nourish and house the fertilized egg (ovum) until it is fully developed, and
to give birth.

`Females
also have external
organs collectively
called the vulva
(which means "covering"). Located between the legs, the outer parts of the vulva cover
the opening to a narrow canal called the vagina. The fleshy area located just above the
top of the vaginal opening is called the mons pubis. A thin sheet of tissue called the
hymen partially covers the opening of the vagina. Two pairs of skin flaps, the labia
(which means "lips") surround the vaginal opening. The clitoris, which is located toward
the front of the vulva where the folds of the labia join, is a small cylindrical structure
similar to the male penis; it also contains erectile tissue. Inside the labia are openings to
the urethra (the canal that carries urine from the bladder to the exterior of the body) and
vagina. The outer labia and the mons pubis are covered by pubic hair in the sexually
mature female.

The female internal organs are the vagina, uterus, fallopian tubes, and ovaries.
The vagina is a 3- to 6-inch-long tubular structure that extends from the vaginal opening
to the uterus. It has muscular walls lined with mucous membrane, and it serves as the
female organ of copulation (sexual intercourse) as well as the birth canal. It connects
with the uterus, or womb, which houses the fetus during pregnancy. About 3 inches
long and 2 inches wide and shaped like an inverted pear, the uterus is a muscular,
expandable organ with thick walls At the lower part of the uterus is the cervix, which
opens into the vagina. At the upper part, the fallopian tubes connect the uterus with
the ovaries, two oval-shaped organs that lie to the right and left of the uterus. They
produce, store, and release eggs through the fallopian tubes into the uterus. The
ovaries also produce the hormones estrogen and progesterone. Also part of the
reproductive system are the breasts. Mammary glands inside the breasts secrete milk
after childbirth.

Normal Physiology

The organs of sexual reproduction are the gonads, which are the ovaries in
females and the testes in males. Females produce female gametes, or eggs; males
produce male gametes, or sperm. Sexual reproduction is the fertilization of a female
gamete by a male gamete. When a female is born, each of her ovaries has hundreds of
thousands of eggs, but they remain dormant until her first menstrual cycle, which occurs
during puberty. At this time, during adolescence, the pituitary gland secretes hormones
that stimulate the ovaries to produce female sex hormones, including estrogen, which
helps the female develop into a sexually mature woman. Also at this time, females
begin releasing eggs as part of a monthly period called the menstrual cycle.
Approximately once a month, during ovulation, an ovary discharges a tiny egg that
reaches the uterus through one of the fallopian tubes. Unless fertilized by a sperm while
in the fallopian tube, the egg dries up and is expelled about 2 weeks later from the
uterus during menstruation. Blood and tissues from the inner lining of the uterus
combine to form the menstrual flow, which usually lasts from 3 to 5 days.

If a female and male have sexual intercourse within several days of ovulation,
fertilization can occur. When the male ejaculates, about one tenth of an ounce of semen
is deposited into the vagina. Between 200 and 300 million sperm are in this small
amount of semen, and they "swim" up from the vagina through the cervix and uterus to
meet the egg in the fallopian tube. It takes only one sperm to fertilize the egg. About a
week after the sperm fertilizes the egg, the fertilized egg has become a multicelled
blastocyst, a pinhead-sized hollow ball with fluid inside, now housed in the uterus. The
blastocyst burrows itself into the lining of the uterus, called the endometrium. Estrogen
causes the endometrium to thicken and become rich with blood, and progesterone,
another hormone released by the ovaries, maintains the thickness of the endometrium
so that the blastocyst can attach to the uterus and absorb nutrients from it. This process
is called implantation.

As cells from the blastocyst take in nourishment, the embryonic stage of

development begins. The inner cells form a flattened circular shape called the
embryonic disk, which will develop into a baby. The outer cells become thin membranes
that form around the baby. The embryonic cells multiply thousands of times, move to
new positions, and eventually become the embryo. After approximately 8 weeks, the
embryo is about the size of an adult's thumb, but all of its parts - the brain and nerves,
the heart and blood, the stomach and intestines, and the muscles and skin - have
formed. During the fetal stage, which lasts from 9 weeks after fertilization to birth,
development continues as cells multiply, move, and differentiate. The fetus floats in
amniotic fluid inside the amniotic sac. Its oxygen and nourishment come from the
mother's blood via the placenta, a disk-like structure that adheres to the inner lining of
the uterus and is connected to the umbilical cord. The umbilical cord attaches the
embryo at its navel to the mother's uterus. The umbilical arteries in the cord carry blood
from the fetus to the placenta, and an umbilical vein returns blood from the placenta to
the fetus. The amniotic fluid and membrane cushion the fetus against bumps and jolts to
the mother's body.
 Pregnancy lasts an average of 266 days. When the baby is ready for birth, its
head presses on the cervix, which begins to relax and widen to get ready for the baby to
pass into and through the vagina, which has enlarged to become the birth canal. The
mucus that has formed a plug in the cervix loosens, and with amniotic fluid, comes out
through the vagina when the mother's "water" breaks. When contractions begin, the
uterine walls contract as they are stimulated by the pituitary hormone oxytocin. The
contractions cause the cervix to widen and begin to open. After several hours of this
widening, the cervix is dilated (opened) enough for the baby to come through. The baby
is pushed out of the uterus, through the cervix, and along the birth canal. The baby's
head usually comes first; the umbilical cord comes out with the baby and is cut after the
baby is delivered.

The last stage of the birth process involves the delivery of the placenta, which is now
called the afterbirth. It has separated from the inner lining of the uterus, and through further
contractions of the uterus it is expelled with its membranes and fluids.

Menstruation

A menstrual cycle (also termed a female reproductive cycle) can be defined as

episodic uterine bleeding in response to a cyclic hormonal changes. It is the process
that allows for conception and implantation of a new life. The purpose of a menstrual
cycle is to bring an ovum to maturity and renew a uterine tissue bed that will be
responsible for its growth should it be fertilized. Menarche, the first menstrual period in
girls, may occur as early as age 8- 9 or as late as 17 and still be within normal limits.
Because menarche may occur as early as age 9 years, it is good to include health
teaching information on menstruation to both girls and their parents as early as 4th
grade as part of routine care. It is a poor introduction to sexuality and womanhood for
a girl to begin menstruation unwarned and unprepared for the important internal
function it represents.

The length of menstrual cycle differs from woman to woman, but the accepted
average length is 28 days (from the beginning of one menstrual flow to the beginning
of the next). However, it is not unusual for cycles to be as short as 23 days or as long as
35 days. The length of the average menstrual flow is (termed memses) is 2 to 7 days
although women may have periods as short as 1 day or as long as 9 days.

Because there is such variation in length, frequency, and amount of menstrual

flow and such variation in he onset of menarche, many women have questions about
what is considered normal. Contact with health care personnel during the yearly health
examination or pre- natal visit is often the first opportunity some women have to ask
question they have had for sometime.

PHASES OF MENSTRUAL CYCLE

1. Proliferative Phase
 Immediately after a menstrual flow (occurring the first 4 or 5 days of a cycle), the
endometrium, or lining of the uterus, is very thin, only approximately one cell layer in
depth. As the ovary begins to produce estrogen (in follicular fluid,under the direction of
the pituitary FSH), the endometrium begins to proliferate. This growth is very rapid and
increase the thickness of the endometrium approximately eightfold. This increase
continues for the first half of the menstrual cycle (from approximately day 5 to 14). This
half of menstrual cycle is termed interchangeably the proliferative, estrogenic,
follicular or post menstrual phase.

2. Secretory Phase
After ovulation, the formation of progesterone in the corpus luteum (under the
direction of the LH) causes the glands of the uterine endometrium to become corkscrew
or twisted in appearance and dilated with quantities of glycogen and mucin, an
elementary sugar and protein. The capillaries of the endometrium increase in amount
until the lining takes on the appearance of rich, spongy velvet. This second phase of
menstrual cycle is termed the progestational, luteal, premenstrual, or secretary
phase.

3. Ischemic Phase
If fertilization does not occur. The corpus luteum in the ovary begins to regrets
after 8 to 10 days. As it regresses, the production of progesterone and estrogen
decreases. With the withdrawal of progesterone stimulation, the endometrium of the
uterus begins to degenerate (approximately day 24 or 25 of the cycle). The capillaries
rupture, with minute hemorrhages, and the endometrium sloughs off.

4. Menses: Final Phase of Menstrual Cycle

The following products are discharged from the uterus as the menstrual flow or
menses: blood from ruptured capillaries; mucin from the glands, fragments of
edometrial tissues, microscopic, atrophied and unfertilized ovum.
Menses is actually the end of an arbitrarily defined menstrual cycle. Because it is the
only external marker of the cycle, however, the first day of menstrual flow is used to
mark the beginning day of a new menstrual cycle. Contrary to common belief, menstrual
flow contains only approximately 30 to 80 ml of bloods, it may seem more because of
the accompanying mucus and endometrial shreds. The iron loss during menstrual flow
is approximately 11 mg, this is enough that many woman need to take daily iron
supplement to prevent iron depletion during their menstruating years.
In women who are going through menopauses, menses may typically be a few days of
spotting before a heavy flow or heavy flow followed by a few days of spotting, because
progesterone withdrawal is more sluggish or tends to “staircase” rather than withdraw.

TEACHING ABOUT MENSTRUAL HEALTH

Exercise
It’s good to continue moderate exercise during menses because it increases abdominal
tone. Sustained excessive exercise, such as professional athletes maintain, can cause
amenorrhea.

Sexual Relations
Not contraindicated during menses (the male should wear a condom to prevent
exposure to body fluid). Heightened or decrease sexual arousal may be noticed during
menses. Orgasm may increase menstrual flow.

Activities of Daily Living

Nothing is contraindicated (many people believed incorrectly that things like washing
hair are harmful).

Pain Relief
Any mild analgesic is helpful. Prostaglandin inhibitors such as ibuprofen (Motrin) are
specific for menstrual pain. Applying local heat may also be helpful

Rest
More rest may be helpful if dysmenorrhea interferes with sleep at night.

Nutrition.
Many women may need iron supplementation to replace iron lost in menses. Eating
pickles or cold food does not cause dysmenorrhea.

Stages of Fetal Development

In just 38 weeks, a fertilized egg matures from a single cell carrying all the
necessary genetic material to a fully developed fetus ready to born. Fetal growth and
development is typically divided into three periods. Pre- embryonic (First 2 weeks
beginning with fertilization); embryonic (from 3 weeks through 8), and fetal (from week
8 through birth).

Ovum From ovulation to fertilization

Zygote From fertilization to implantation
Embryo From implantation to 5 – 8 weeks
Fetus From 5 – 8 weeks until term
Conceptus Developing embryo or fetus and placental
structures throughout pregnancy

Milestones of Fetal Growth and Development

The life of the fetus is generally measured from the time of ovulation or
fertilization (ovulation age), but the length of pregnancy is generally measured from the
first day of the last menstrual period (gestational age). Because ovulation and
fertilization take place about 2 weeks after the last menstrual period, the ovulation age
of the fetus is always 2 weeks less than the length of the pregnancy or the gestational
age.

Both ovulation and gestational age are also sometimes measured in lunar months

(4 - week periods) or in trimesters (3- month. Period) rather than in weeks. In lunar
months, a pregnancy is 10 months (40 weeks or 280 days) long; a fetus
grows in utero 9.5 lunar months or three full trimesters (38 weeks or 266
days)

End of 4 Gestation Weeks

At the end of the 4th week gestation, the human embryo is rapidly growing formation of
cells but does not resemble a human being yet.
• Length: 0.75 to 1 cm.
• Weight: 400 mg.
• The spinal cord is formed and fused at the midpoint.
• Lateral wings that will form the body are folded forward to fuse at the midline.
• Head folds forwards, becoming prominent, comprising about one third of the
entire structure.
• The back is bend so the head almost touches the tip of the tail.
• The rudimentary heart appears as a prominent budge on the anterior surface.
• Arms and legs are bud like structures.
• Rudimentary eyes, ears and nose are discernible.
End of 8 Gestation Weeks
• Length: 2.5 cm (1cm).
• Weight: 20 g.
• Organogenesis is complete.
• The heart, with a septum and values, is beating rhythmically.
• Facial features are definitely discernible.
• Extremities have developed.
• External genitalia are present, but sex is not distinguished by simple observation.
• Primitive tail regressing.
• Abdomen appears large as the fetal intestine is growing rapidly.
• Sonogram shows gestational sac, diagnostic of pregnancy.

End of 12 Gestation Weeks (First Trimester)

• Length: 7 to 8 cm.
• Weight: 45 g.
• Nail beds are forming on fingers toes.
• Spontaneous movements are possible, although usually too faint to be felt by the
mother.
• Some reflexes, such as Babinski reflex are present.
• Bone ossification centers are forming.
• Tooth buds are present.
 • Sex is distinguishable by outward appearance.
• Kidney secretion has begun, although urine may not be evident in amniotic fluid.
• Heart beat is available by a Doppler

End of 16 Gestation Weeks

• Length: 10 to 17 cm.
• Weight: 55 to 120 g.
• Fetal heart sounds are audible with an ordinary stethoscope.
• Lanugo (fine, downy hair on the back and arms of newborns, apparently serving
as a source of insulation for body heart) is well formed.
• Liver and pancreas are functioning.
• Fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated
swallowing reflex, urine is present in amniotic fluid.
• Sex can be determined by ultrasound.

End of 20 Gestation weeks

• Length: 25 cm.
• Weight: 223 g.
• The mother can sense spontaneous fetal movements.
• Antibody production is possible.
• Hair forms, extending to include eyebrows and hair on the head.
• Meconium is present in the upper intestine.
• Brown fat, a special fat that will aid in temperature regulation at birth, begins to
be formed behind the kidneys, sternum and posterior neck.
• Fetal heart beat is strong – enough to be audible
• Vernix caseosa, a cream cheese -like substance produced by the sebaceous
gland that serves as a protective skin covering intrauterine life, begins to form.
• Definite sleeping and activity patterns are distinguishable (the fetus has
developed biorhythms that will guide sleep /wake patterns throughout life).

End of 24 Gestation Weeks (Second Trimester)

• Length: 28- 36 cm.
• Weight: 550 g.
• Passive antibody transfer from mother to fetus probably begins as early as 20th
week of gestation, certainly by the 24th week of gestation. Infants born before
antibody transfer has taken place have natural immunity and need more than the
usual protection against infectious disease in the newborn period until the infant’s
own store pf immunoglobulins can build up.
• Meconium is present as far as the rectum.
• Active production of lung surfactant begins.
• Eyebrows and eyelashes are well defined.
• Eyelids, previously fused since the 12th week, are now open.
• Pupils are capable of reacting to light.
• When fetuses reach 24 weeks or 601 g, they have achieved a practical low- end
age of viability if they are cared for after birth in a modern intensive care facility.
• Hearing can be demonstrated by response to sudden sound.
End of 28 Gestation Weeks
• Length: 35 to 38 cm.
• Weight: 1,200 g.
• Lung alveoli begin to mature, and surfactant can be demonstrated in amniotic
fluid.
• Testes begin to descend into the scrotal sac from the lower abdominal cavity.
• The blood vessels of the retina are extremely susceptible to damage from high
oxygen concentrations (an important consideration when caring for preterm
infants who need oxygen).
• The eyes open.

End of 32 Gestations Weeks

• Length: 38-43 cm.
• Weight: 1,600 g.
• Subcutaneous fat begins to be deposited (the former is stringy “ Little old man”
appearance is lost).
• Fetus is aware of sounds outsides the mothers body.
• Active Moro reflex is present.
• Birth position (vertex or breech) may be assumed.
• Iron stores that provide iron for the time during which the neonate will ingest only
milk after the birth are beginning to be developed.
• Finger nails grow to reach the end of the fingertips.

End of 36 Gestation weeks

• Length: 42 to 49 cm.
• Weight: 1,900 to 2,700 g (5 – 6 lbs).
• Body stores of glycogen, iron, carbohydrate and calcium are augmented.
• Additional amounts of subcutaneous fat are deposited.
• Sole of the foot has only one or two crisscross crisscross creases compared with
the full crisscross pattern that will be evident at term.
• Amount of lanugo begins to diminish.
• Most babies turn into vertex or head – down presentation during this month.

End of 40 gestation Weeks (Third Trimester)

• Length: 48 to 52 cm (crown to rump, 35 to 37 cm).
• Weight: 3,000g (7 – 7.5 lbs).
• Fetus kicks actively, hard enough to cause the mother considerable discomfort.
• Fetal hemoglobin begins its conversion to adult hemoglobin. The conversion is
so rapid that, at birth about 20% hemoglobin will be adult in character.
• Vernix caseosa is fully formed.
• Fingernails extend over the fingertips.
• Creases on the soles of the feet cover at least two thirds of the surface.

In primiparas (women having their first baby), the fetus often sinks into the birth
canal during these last 2 weeks, giving the mother a feeling that her load is being
 lightened. This event is termed lightening. It is the fetal announcement that the third
trimester of pregnancy has ended and birth is at hand.

CONCEPT OF FAMILY

Family

A basic unit of social structure, the exact definition of which can vary greatly from
time to time and from culture to culture. How a society defines family as a primary
group, and the functions it asks families to perform, are by no means constant. There
has been much recent discussion of the nuclear family, which consists only of parents
and children, but the nuclear family is by no means universal. In the United States, the
percentage of households consisting of a nuclear family declined from 45% in 1960 to
23.5% in 2000. In pre-industrial societies, the ties of kinship bind the individual both to
the family of orientation, into which one is born, and to the family of procreation, which
one founds at marriage and which often includes one's spouse's relatives. The nuclear
family also may be extended through the acquisition of more than one spouse
(polygamy and polygyny), or through the common residence of two or more married
couples and their children or of several generations connected in the male or female
line. This is called the extended family; it is widespread in many parts of the world, by
no means exclusively in pastoral and agricultural economies. The primary functions of
the family are reproductive, economic, social, and educational; it is through kin–itself
variously defined–that the child first absorbs the culture of his group.

Evolution of the Western Family

The patriarchal family, which prevailed among the ancient Hebrews, Greeks, and
Romans, is often associated with polygamy. In Rome, the paterfamilias was the only
person recognized as an independent individual under the law. He possessed all
religious rights as priest of the family ancestor cult, all economic rights as sole owner of
the family property, and power of life and death over the members of the family. At his
death, his name, property, and authority descended to his male heirs. The Roman
system was transferred in many of its details into both the canon and secular law of
Western Europe.

In the 19th century, when the Western nations began to grant women equal
rights with men with respect to the ownership of property, the control of children,
divorce, and the like, basic changes took place in the structure of the family, and the
rights and protections associated with it. The state has also intervened to modify the
authority of parents over their children. At the same time, education has shifted
increasingly from the household to the school. The effect has been to loosen traditional
family ties. In Western Europe, where legislation provides equal financial benefits and
legal standing to all children, families have increasingly come to consist of one or two
unwed parents and children, especially in Scandinavia and other part of N Europe.
Another factor affecting the modern Euro-American family was the Industrial Revolution,
which removed from the home to the factory many economic tasks, such as baking,
spinning, and weaving. Economic and social conditions have discouraged the presence
of the husband and father in the home; in industrial communities the wife and mother
also is often employed outside the home, leaving the children to be cared for by others.
Sociologists and psychologists find in these changed relations of the members of the
family to each other and of the family to the community at large the source of many
problems such as divorce, mental illness, and juvenile delinquency.

RESPONSIBLE PARENTHOOD

Responsible Parenthood

We affirm the principle of responsible parenthood. The family, in its varying

forms, constitutes the primary focus of love, acceptance, and nurture, bringing fulfillment
to parents and child. Healthful and whole personhood develops as one is loved,
responds to love, and in that relationship comes to wholeness as a child of God.

Each couple has the right and the duty prayerfully and responsibly to control
conception according to their circumstances. They are, in our view, free to use those
means of birth control considered medically safe. As developing technologies have
moved conception and reproduction more and more out of the category of a chance
happening and more closely to the realm of responsible choice, the decision whether or
not to give birth to children must include acceptance of the responsibility to provide for
their mental, physical, and spiritual growth, as well as consideration of the possible
effect on quality of life for family and society. To support the sacred dimensions of
personhood, all possible efforts should be made by parents and the community to
ensure that each child enters the world with a healthy body and is born into an
environment conducive to the realization of his or her full potential.

When through contraceptive or human failure an unacceptable pregnancy

occurs, we believe that a profound regard for unborn human life must be weighed
alongside an equally profound regard for fully developed personhood, particularly when
the physical, mental, and emotional health of the pregnant woman and her family show
reason to be seriously threatened by the new life just forming. We reject the simplistic
answers to the problem of abortion that, on the one hand, regard all abortions as
murders, or, on the other hand, regard abortions as medical procedures without moral
significance.

When an unacceptable pregnancy occurs, a family—and most of all, the

pregnant woman is confronted with the need to make a difficult decision. We believe
that continuance of a pregnancy that endangers the life or health of the mother, or
poses other serious problems concerning the life, health, or mental capability of the
child to be, is not a moral necessity. In such cases, we believe the path of mature
Christian judgment may indicate the advisability of abortion. We support the legal right
to abortion as established by the 1973 Supreme Court decision. We encourage women
in counsel with husbands, doctors, and pastors to make their own responsible decisions
concerning the personal and moral questions surrounding the issue of abortion .

We therefore encourage our churches and common society to:

 provide to all education on human sexuality and family life in its varying forms,
including means of marriage enrichment, rights of children, responsible and joyful
expression of sexuality, and changing attitudes toward male and female roles in
the home and the marketplace;
 provide counseling opportunities for married couples and those approaching
marriage on the principles of responsible parenthood;
 build understanding of the problems posed to society by the rapidly growing
population of the world, and of the need to place personal decisions concerning
childbearing in a context of the well-being of the community;
 provide to each pregnant woman accessibility to comprehensive health care and
nutrition adequate to ensure healthy children;
 make information and materials available so all can exercise responsible choice
in the area of conception controls. We support the free flow of information about
reputable, efficient, and safe nonprescription contraceptive techniques through
educational programs and through periodicals, radio, television, and other
advertising media. We support adequate public funding and increased
participation in family planning services by public and private agencies, including
church-related institutions, with the goal of making such services accessible to
all, regardless of economic status or geographic location;
 make provision in law and in practice for voluntary sterilization as an appropriate
means, for some, for conception control and family planning;
 safeguard the legal option of abortion under standards of sound medical
practice;
 make abortions available to women without regard to economic standards of
sound medical practice, and make abortions available to women without regard
to economic status;
 monitor carefully the growing genetic and biomedical research, and be prepared
to offer sound ethical counsel to those facing birth-planning decisions affected by
such research;
 assist the states to make provisions in law and in practice for treating as adults
minors who have, or think they have, venereal diseases, or female minors who
are, or think they are, pregnant, thereby eliminating the legal necessity for
notifying parents or guardians prior to care and treatment. Parental support is
crucially important and most desirable on such occasions, but needed treatment
ought not be contingent on such support;
 understand the family as encompassing a wider range of options than that of the
two-generational unit of parents and children (the nuclear family); and promote
the development of all socially responsible and life-enhancing expressions of the
extended family, including families with adopted children, single parents, those
with no children, and those who choose to be single;
 view parenthood in the widest possible framework, recognizing that many
children of the world today desperately need functioning parental figures, and
also understanding that adults can realize the choice and fulfillment of
parenthood through adoption or foster care;
  encourage men and women to actively demonstrate their responsibility by
creating a family context of nurture and growth in which the children will have the
opportunity to share in the mutual love and concern of their parents;
 be aware of the fears of many in poor and minority groups and in developing
nations about imposed birth-planning, oppose any coercive use of such policies
and services, and strive to see that family-planning programs respect the dignity
of each individual person as well as the cultural diversities of groups.

NURSING PROCESS

A process is a series of planned actions or operations directed toward a

particular result or goal. He nursing process is a systemic, rational method of planning
and providing individualized nursing care. Is purpose is o identify a client’s health status,
actual or potential health care problems or needs; to establish plans to meet identified
needs; and to deliver specific nursing interventions o meet hose needs. The nursing
process is cyclical; that is, the components of the nursing process follow a logical
sequence, but more than one component may se involved at any one time.

Assessment- is the process of gathering, verifying and communicating data about a

client. The purpose of the assessment is to establish a data base about the client’s level
of wellness, health practices, past illness and related experiences and health care
goals. The information contained in the data base is the basis for an individualized plan
of nursing care developed throughout the nursing process.

Nursing Diagnosis- is a statement that describes a patient’s actual or potential

health problem, which are potentially responsive to nursing therapy.

Plan- involves a series of steps in which the nurse and the client set priorities and
goals or expected outcomes to resolve or minimize the identified problems of the client.
In collaboration with the client, the nurse develops specific interventions for each
nursing diagnosis. The product of planning phase is a written care plan used to
coordinate the care provided by all the health members.

Intervention- is putting the nursing care plan into action. During the implementation
phase, the nurse carries out the prescribed nursing activities or delegates the care to an
appropriate person, and validates the nursing care plan. This phase ends when the
nurse records the care given and the client’s responses to care in the client record.

Evaluation- it measures the client’s response to nursing actions and the client’s
progress toward achieving goals. Evaluation is the ongoing and occurs when the nurse
has contact with a client. The emphasis is on client outcomes. The nurse evaluates
whether the client’s behavior or responses reflect a reversal or improvement in a
nursing diagnosis or maintenance of a healthy state.

Maternal Data Base Assessment Guide

Personal Data

Name of client : F. A.
Age : 25 y/o
Address : Atulayan Tuguegarao City
Nationality : Filipino
Occupation : Plain Housewife
Birthplace : Tuguegarao City
Religion : Roman Catholic
Civil Status : Married
Attended by : Midwife

Menstrual History

Menarche occurred at the age of 14, using IUD, 5 days of moderate flow with
unrecalled pads for the whole duration of menstruation. The color is deep red and with a
–n interval of 28-29 days. The patient never experienced dysmenorrhea or menstrual
cramps during menstruation.

Maternal History

1. Obstetrical Score G2P1(2-0-01)

G1- 2007- M- NSD- Cephalic- TBA-Alive

G2- 2009- M- NSD- Cephalic- TBA-Alive

2. History of Present Pregnancy

1. LMP- February. 11, 2009

2. EDD- October 18, 2009: date of delivery: october 09,2009
3. AOG- 36 1/7 week

3. Physiological and Psychological Changes of Pregnancy

a. First Trimester
o Patient did suffer from UTI during her 1st month of pregnancy. She never had
episodes of dizziness or vomiting. There were no visible changes in the body that
was noted. She only went to the RHU once during her pre-natal check up. She
was only given 1 dose of Tetanus toxoid immunization. She was never given any
vitamins(ferrous sulfate) for her supplement. She is thin and anemic.
b. Second Trimester
o She had difficulties during this stage of her pregnancy. She was confined at the
People’s Emergency Hospital for 5 days because of severe nausea and
vomiting. She also suffered from headache but was no breast tenderness noted.
According to her, it was in the 5th month were she felt movement of her baby.
c. Trimester
o There was increased in frequency of urination and episodes of leg cramps. She
usually wakes up at the middle of the night due to abdominal comforts especially
few days prior to her delivery.

4. Past Health History

a. Family History
Her mother is hypertensive and her father has arthritis. 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.

5. Prenatal check up: (/ ) yes ( ) no when : every week

where: barangay health center
by whom: midwife
frequency: every week

6. Reactions /feelings regarding the present pregnancy:

A. Her pregnancy was planned, and she never went to hilot again instead
She always visit a midwife on the BHC. Because she never want to
happen again what happen to her first baby. Who died because
of hilot Due to dehydration and no prenatal check up.

7. Reactions/ feelings regarding the newly born baby

A. they were so very happy because another member of the family was
Added to them and they thank god because it is a healthy baby boy.

8. Reactions /feelings about breastfeeding?

 A. this is her 3rd baby and the mother planned to breastfeed her baby, t
he Mother has already aware about breastfeed because she always
attend
The meeting/seminar every Monday at the BHC which was attended By
midwife.

9. Medications taken during pregnancy.

( ) Iron preparation ( ) Multivitamins
( x ) None

Gordon’ s Functional Health Pattern in Reproductive System

1. Health Perception- Health Management

o She stated that he has not suffered form any illness except for toothache. She
said that she takes in one Ponstan, relief of pain was observed but there was
recurrent pain. There was no minor infections with signs and symptoms of
cough, fever and headache. 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.
2. Nutritional- Metabolic Pattern
o The patient eats green leafy vegetables. Due to financial constraints, foods high
in protein, high in calories and CHO was not eaten that much. She drinks
adequate amount of water(6-8 g/day)
3. Elimination Pattern
o There were no problem in bowel elimination. Regular bowel habits are observed
by the patient. At present, the patient urinate 3x/day, no significant changes in
bowel elimination.
4. Activity-Exercise Pattern
o She use to perform her daily and takes care of her child and her husband.
5. Sleep-Rest
o She has a good sleeping habit during the entire pregnancy except for interrupted
sleep prior to the delivery of her baby. She usually wakes up at night due to
impending delivery. The patient had no night sweats.
6. Cognitive-Perceptual
o When the patient used to have her menstrual period, she experienced minor
headache, irritability, bloating and breast tenderness. Not all signs exist at he
same time before and during the menstruation period. Sometimes experience
tolerable cramping before and during her menstrual period. She took pain
reliever during her menstrual cramps. She didn’t have pain in her genital area.
No vaginal itching, pain or dryness.
7. Self-perception- Self-Concept
o As a woman, patient’s problem with her reproductive system makes her anxious.
She want also to undergo BTL because she is at risk for pregnancy especially
 with her condition of having Polio. This was acquired when she was still a baby
when she was rushed to the hospital due to convulsion. According to her, due to
over dosage of medication that was administered to her, thus resulting the said
condition.
8. Role-Relationship
o The patient had monthly sexual intercourse with her husband. She does not like
to have another baby. She plans to under BTL. But with her decision, she has a
good relationship with her husband and her family. With that, she still perform her
responsibilities like taking care of her child and the needs within the family.
9. Sexuality-Reproductive
o There’s no history of reproductive problems in the patient’s family. Her menarche
begun when she was 14 years old.
10. Coping-Stress
o She states that whenever she is angry due to the stubbornness of her children,
she just sit down and take a rest, and at the same time drinks water to ease the
tension she felt.
11. Value-Belief
o She was born Catholic and her cultural background influenced her sexual
activities and her feelings about herself as a woman. She believes that she can
still perform a lot of task and continually express various human emotions to
other people despite of her condition.

Physical Assessment

General Appearance

Patient is 31 year old, ambulatory, thin built, ambulatory morena in complexion,

hair is unkept and the client was not dressed properly. There is also presence of slight
body odor, too. She does her usual activities of daily living. Patient is conscious,
coherent and oriented into spheres of time, place, and person, she is not also in cardio-
respiratory distress.

V/S: 110/80 mmHg RR: 18 cpm

T: 36.7 c PR: 85bpm

Head to toe assessment

Body Parts Technique Used Findings Analysis
Head Palpation, size, The skull is round,
Skull shape, contour, any appropriate to body Normal
lumps and size. There is no
deformities. bulginess and
Scalp/Hair tenderness.
Inspection, The hair is evenly Normal
appearance, color, distributed, there’s no
distribution, texture, manifestation of
 Face presence of lice, nits. baldness. No lice and
Inspection, note nits present. Normal
symmetry, shape, The face is oval,
expressions, there’s balance of
Eyes appearance and eyebrows, nasolabial Normal
movements. folds and sides of the
mouth.
Inspection
There is a slight
Eyelids and eyebags, eyebrows are
Eyelashes present bilaterally. It Normal
moves proportionally.
Eyeballs Lid margins, No swelling or lesions
Conjunctivae secretions, position, Eyelids are intact. The Normal
and sclera distribution. eyelashes is evenly
distributed along the lid
margins and curved Pale
outward. conjunctiva is
Note any protrusions There is no due to poor
Note the color and protrusions. nutrition
appearance. no swelling or lesions.
Sclera is white with
visible veins. Pale
conjunctiva
Ear Inspection, symmetry, Ears are proportional Normal
size, color, with no protuberance,
discharges. has no lumps or
Palpation, firmness swelling.
and tenderness
The pinna is firm and
there is no pain when it
is touched. The color is
same as the other body
parts and has no
discharges.
Nose Inspection, Symmetric, in midline Normal
placement, and proportion to other
discharges and facial features. No
patency deformity, inflammation
or skin lesions. Patent.

Mouth Inspection, color, slight halitosis Presence of

shape, moisture, dental carries
symmetry,
Lips appearance The lips are dark , dry Due to poor
and there are cracks water intake.
Teeth and Gums but no lesions.
Color, appearance, Teeth are yellow and
well aligned, free presence of dental
from carries carries at upper teeth,
 gums are dark red in
Tongue color.
Size, color, shape, White to yellow in
symmetry, moisture , color, it is moist and
movement moves freely.
Neck Inspection, symmetry, The neck is center, no
position enlargement present Normal
Palpation, lumps and when it moves. No
masses lumps, bums, scar,
swelling or masses.
Thorax Inspection, symmetry, There is uniformity of
color, deformities the thorax. Skin color is
Palpation, lumps, the same with the rest Normal
masses of the body. There are
no lesions, lumps and
masses.
Breast/Abdomen Inspection, color, Breast is symmetrical n
symmetry, contour shape, no cracks and
Palpation, tender, discharges, no lumps
lumps, masses, and tenderness, brown
distention nipples.
Percussion Abdomen is
proportional bilaterally,
there’s 5 ‘ of incision Normal
/tenderness at the RLQ
due to her operation.
The umbilicus is in the
center. No
discoloration and
inflammation.
Normal bowel sounds
heard.
Upper Inspection, symmetry,
extremities size, deformities, Shoulders are Normal
Shoulders lesions, swelling proportional, no
redness malformation
or protruding present. Normal
Elbow There is o
malformation, swelling Normal
Elbow or redness.
There is no bulging,
Wrist and Hand redness, deformities,
swelling and nodules Does not cut
Nails present. his finger
The nails are dirty and toe nails.
Lower Inspection No discharges on the
extremities penis, swelling or
tenderness. Normal
Genitalia Legs equal in length,
no scaling, no lesions,
 there are calluses in
both foot, no swelling
or any masses.

Leopold's Maneuvers

First Maneuver (Upper uterine segment or the uterine fundus)

Nurse faces woman's head

Palpate uterine fundus
Determine the height the uterine fundus
Determine what fetal part is in the uterine fundus
Palpation of the Uterine Fundus

Will usually indicate the fetal part situated in the fundus; usually a fetal head;
infrequently a fetal breech. Place hands on either side of the fundal area so that the
fingers of both hands almost tough each other (face the woman's head). A somewhat
hard and roundish shape, which when moved back and forth between the finger pads,
also moves the entire fetus usually indicates a fetal breech. Press gently and firmly with
finger pads. A very hard round well defined shape which can be moved back and forth
(balloted) usually indicates a fetal head.

Second Maneuver

(Determines small parts and back of fetus along the sides of maternal abdomen)

Examiner faces woman's head Palpate with one hand on each side of abdomen
Palpate fetus between two hands Assess on which side is the fetal back or spine and
which side has small parts or extremities

Third Maneuver (Lower uterine segment or uterine pole)

Face the woman's head and spread your hands widely apart Grasp the uterine
contents just above the symphysis pubis (firmly but gently) Hold presenting part
between index finger and thumb Assess for cephalic versus Breech Presentation Move
the fetal presenting part gently back and forth in your hand Fetal head will shift more
easily back and forth Fetal breech will move the whole body

Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part)

Provides information about the presenting part: breech or head, attitude (flexion
or extension), and station (level of descent of the presenting part). Examiner faces
woman's feet Place hands on either side of the lower abdomen with finger pads at the
lower uterine pole (bikini line) and thumbs directed toward the umbilicus. Carefully
move fingers of each hand towards each other in a downward and inward manner using
gentle pressure. The nurse's thumbs should point towards the woman's umbilicus. If
there is a head palpated in the pelvis, the fetal presentation is referred to as a cephalic
or vertex presentation.

Assess if a prominence on one side of the abdomen can be palpated higher than
a prominence on the other side. The first prominence felt indicates the occiput
(forehead) of the infant and is on the same side as the fetal small parts. Therefore, the
occiput is on the side opposite the fetal back. The prominence felt further down the
pelvis is the fetal occiput back of the head) and is on the same side as the fetal back.
This maneuver provides information related to fetal descent into the pelvis. How much
of the fetal head can be palpated above the pelvic brim? Is the head fixed into pelvis?
Can the head be easily moved from side to side? When moved from side to side does
the presenting part move by itself back and forth (balloted)? Does the whole fetal body
move when palpating the presenting part side to side?

Findings from Leopold's Maneuver

• Movement of the fetal part in the fundus moves the entire fetus. This part is firm
and roundish (the 1st Leopold's maneuver).
• There is a long firm smooth area which covers most of one side of the maternal
far right abdomen. The flat smooth surface is felt deep on the right lateral side
(the 2nd Leopold's maneuver).
• "Walking the fingers" across the uterus finds many large and small dips and
contours on the maternal left lateral margin.
• The lower uterine pole contains a round small, hard object. This object can be
moved slightly from side to side (the 3rd Leopold's maneuver).
• In the pelvis, the prominence which is higher is found on the maternal left side
(the 4th Leopold's maneuver)

Estimate Fetal Growth

Nagele’s Rule

To calculate the date of birth by this rule, count backward 3 calendar months from the
first day of the last menstrual period and add seven days.
Eq: 02 - 11 - 09
-03 +7 + 0
10 - 18- 09

Mc Donald’s Rule:
Measurement of the height of the fundus using a tape measure. The distance from the
symphisis pubis to the level xyphoid process. Used to calculate the AOG.

Eq: Fundic height (cm) x 2/7 = AOG in lunar months

Fundic height (cm) x 8/7 = AOG in weeks.
Bartolomew’s Rule:

Height of fundus is used to determine the AOG. Fundic height is used to determined by
palpation and by relating it to the different landmark in the abdomen: umbilicus:
symphisis pubis and xiphoid process.
 12 wks - level of syphisis pubis
16 wks - halfway between umbilicus and symphisis pubis
20 wks - level of umbilicus
24 wks - 2 finger breaths above umbilicus
30 wks - midway between umbilicus and xiphoid process
34 wks - just below xiphoid process
36 wks - at the level of xiphoid process
40 wks - at 34 wks level due to lightening
Johnson’s Rule:
Used to calculate the fetal weight in grams.
Fundic height in (cm) - N x K = weight of the fetus
K= 155 (constant) N- 12 (engaged) 11 (not engaged)
Eq: 30 - 12 x 155 = 18 x 155 = 2790 gms.

Haase’s Rule:

Is used to determine length of fetus

A. During the first half of pregnancy, square the number of months
B. During the second half of pregnancy, multiply the number of months by five.

Beliefs and Practices

Belief and Practices Rationale Clinical Significance

Prenatal

So that the mother will No scientific basis

Do not eat twin banana not give birth to a twin
baby
The baby’s skin will have No scientific basis
Do not eat dark foods dark complexion
So that the baby will No scientific basis
Avoid hiding of foods came out naturally
Always have a garlic on Protection from No scientific basis
your pocket “aswang”
Do not see a dying The baby will come out No scientific basis but
person grasping from breath may affect the mother
and may die emotionally.
Intrapartal
For easy delivery Doorsteps or stairs has
Nobody should stay on no connection with the
the door or near the stair. progress of labor.
‘Atang’ are the ones they Has nothing to do with
Member of the family offer to the spirits to help the progress of labor
should give ‘atang’ to the the people who are kind
anitos to help the woman to them
in labor
Let the mother eat soft To make the mother’s No scientific basis
boiled egg and drink lard birth canal slippery thus because the birth canal
 facilitate easy delivery of will surely give wayto the
the baby baby to be delivered
Kick every corner of the To facilitate easy delivery No scientific basis
house during labor

Post Partal
To prevent post partal Taking a bath is very
Mother should not take a complications important to promote
bath for 9 days after good hygiene
delivery
So that mother will not Mother should have
Mother should wear thick get sick exercise and can work as
clothes and confine long as she can for early
to bed after delivery wound healing and
peristalsis
To make the baby No Scientific basis
Keep the baby’s first cut intelligent
hair and finger nails

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

What is new born care?

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.
Some basics of newborn care include:

• Infants need breast milk or formula only.

Breastfeeding offers many advantages to both infants and their mothers, and
breastmilk is the best source of food for your baby's health and development.
However, a major brand of formula is sufficient if the mother chooses not to
breastfeed. Newborn babies do not need any other food.

• Infants need to be warm and comfortable.

Babies should be dressed appropriately for the weather. If parents are wearing
shorts, then baby can wear shorts too. Babies should not be overdressed, since this
can cause irritability and elevated body temperature.

• Diapers should be changed as soon as they are wet or soiled.

Failure to change diapers when wet or soiled can lead to discomfort and skin
irritation. Cloth diapers are better than plastic ones, and diapers should be free of
chemicals and fragrances. Should a rash occur, exposing the affected skin to air is
excellent treatment.

• Infants need to be clean.

Babies should be sponge-bathed until the umbilical cord falls off (about 10-14
days). After that occurs, babies can be tub bathed with mild nondetergent baby
soap. They don't need to be bathed more than once every other day. Washing too
often can lead to dry skin. Water should be warm, never hot. After bathing, oils and
powders are not necessary. If dry skin develops, a cream or lotion (like Eucerin) can
be used. If baby develops "cradle cap," or yellow scales on the scalp, treatment
includes a once or twice weekly shampoo with a product like Sebulex.

• The umbilical cord should be cleaned every 4-6 hours with

rubbing alcohol and cotton.
 • Infants need sleep.

Babies sleep many hours throughout the day, and sleep patterns differ from one
baby to the next. During the first few weeks, babies should sleep in the parents'
room. Babies should be placed on their backs. Sleeping on the abdomen has been
related to SIDS (sudden infant death syndrome).

• Infants need stimulation.

Appropriate stimulation includes talking to, singing to, and holding the baby.

• Infants cry.

Crying is how babies "talk" to their parents, and babies often cry up to several
hours each day. Babies cry when they are hungry, sick, angry, in pain, or have a wet
diaper. Whenever a baby cries, the caretaker should consider these reasons first.
Sometime, babies also cry for no apparent reason, except that they may be irritable.
Babies who cry during most of their waking hours are called "colicky." Colic usually
disappears after a few months. If this occurs, you can try:

o Holding the baby closely

o Holding the baby more often during periods when s/he is not crying
o Gently rubbing the abdomen
o Burping the baby more often during feedings
o Changing the diet (avoiding cow milk formula)
o Gently rocking or swinging the baby

Infants need regular preventive medical visits.

A good time to find a pediatrician is before the baby is born. During "well-baby visits"
with a health care provider, infant growth and development will be monitored. In
addition, providers will screen for common childhood conditions and provide
immunizations

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.
 0 1 2 Score
Sign
Absent Slow <100 >100 2
Heart Rate
Respirator Absent Slow, Good strong 2
y Effort irregular, cry
weak cry

Muscle Flaccid Some flexion Well flexed 2

Tone of extremities
Reflex No Response Grimace Cry and 2
Irritability withdrawal of
foot
Blue pale Body pink, Completely 2
Color
extremities pink
blue
10

Implication: The baby had a total score of 10. She was in good condition.

PUERPERIUM

Postnatal Care and Puerperium

Introduction:

Throughout pregnancy, you were center stage: your partner, your family, your
doctor and you yourself were concentrating on various aspects of your health and care
in pregnancy and labour. The foetus growing inside you was a secondary patient. Now
that you have delivered, the focus of everybody’s attention, including your own seems to
have shifted suddenly from you to the little bundle of joys (well, most of the time joy,
sometimes trouble!) next to you. This is but natural, and we are sure you will take it in
your stride. However, there are many things about your body that are still going to
change. This post delivery period is extremely important, and to recover to your pre-
pregnancy health (if not better) you need to pay attention to yourself too.
Phases of Puerperium:

• Taking - In Phase
The taking -in phase, the first phase experienced, is a time of reflection for a woman.
During this period, the woman is largely passive. She prefers having a nurse minister to
her to get her a bath towel or a clean night gown, and make decisions for her rather
than doing these things herself. This dependence is due partly to her physical
discomfort from possible perineal stitches, afterpains, or hemorrhoids; partly to her
uncertainty in caring for newborn; and partly from the extreme exhaustion that follows
childbirth.
• Taking - Hold Phase
After the time of passive dependence, a woman begins to initiate action. She prefers to
get her own washcloth and to make her own decisions. Women who give birth without
anesthesia may reach this second phase in a mater of hours after birth. During the
taking - in period, a woman may have expressed little interest in caring for her child.
Now, she begins to take a strong interest, as a rule therefore, it is always best to give
the woman brief demonstration of baby care and then allow her to care for the child
herself with watchful guidance. Although a woman’s action suggest strong
independence during this time, she often stills feels insecure about her ability to care for
her new child. She needs praise for the things she does well to give her confidence. Do
not rush a woman through the phase of taking - in or prevent her from taking hold when
she reaches that point. For many young mothers, learning to make decisions about their
child’s welfare is one of the most difficult phases of motherhood. It helps if the woman
has practice in making such decisions in a sheltered setting rather than first taking on
that level of responsibility when she is on her own.
• Letting - Go Phase
In this 3rd phase, called letting go, the woman finally refines her new role. She gives up
fantasize image of her child and accept that real one; she gives up her old role of being
childless or the mother of only one or two. This process requires some grief work and
adjustment of relationships similar to what occurred during pregnancy. It is extended,
and continues during the child’s growing years. A woman who has reached this phase is
well into her new role.

Immediate Puerperium:

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.

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 ovulation. 8 – 10 weeks 17 weeks (variable)

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 120/80 mmHg
Cardiac Rate 70 bpm
Respiratory Rate 20 cpm
Temperature 37. 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
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.
 NURSING CARE PLAN

ANTEPARTAL

Assessment
Subjective:
“Ita siyam nga bulan toy tyan kon marigatan nak nga aganges” as verbalized by the
patient.
Objective:
Shallow breathing
Weak
Limited movement

Nursing Diagnosis
Ineffective Breathing Pattern: Dyspnea r/t increase pressure due to enlarging uterus
secondary to pregnancy.

Planning
The patient will be able to attain good breathing pattern after 24 hours as evidence by
patient verbalization of having an improvement in her breathing pattern.

Intervention
1. Advised to increase the number of pillows by 2-3 when lying down in prone position.
This is done to slightly elevate the head part thus decreasing the pushing up of the
diaphragm by the enlarging uterus promoting easy respiration.
2.Demonstrated deep breathing.
Demonstrating such intervention will help alleviate the discomfort.
3.Advised to take a rest away after 2 hours when working.
Resting every 2 hours will prevent tiredness which may induce shortness of breath.
4.Advised the client to lie in a side lying position particularly on left side lying position.
Pressure on the inferior vena cava will be lessen does facilitate venous return and so
there will be easy respiration.
Side lying position facilitates easy breathing pattern because pressure exerted by the
enlarged uterus over the diaphragm.
5. Advised the client to avoid strenuous activity.
Strenuous activities will lead to tiredness and fatigability thus affecting breathing
pattern, so avoid strenuous activities to be able to attain easy respiration.
 Evaluation
The client attained good breathing pattern after a day when practiced and applied all the
intervention.

Assessment
Subjective:
“kanayun nga agsakit ti likod ko” as verbalized by the patient.
Objective:
• Lordotic
• Poor body mechanics
• Grimaced face
• Weak

Nursing Diagnosis
Alteration in comfort: Back pain r/t to increased curvature of the back brought about by
enlarging uterus.

Planning
The patient will be able to lessen the pain brought by the increase curvature of the back
after 1 hour as evidence by patient verbalization of “saanen nga kanayun nga agsakit ti
likod ko” .

Intervention

1. Back massage offered.

• Back massage promote circulation, helps relax the back thereby relieving pain.
2. Advised to exercised regularly
• Exercise will relieve discomfort and decrease body tension thereby pain will be
lessen.
3. Advised to have proper body mechanics.
• Good posture minimized hollow curvature of the lower back which causes strain.

Evaluation
The patient had been alleviated from pain after 2 days.

Assessment
Subjective:
“Idi kalman pay nga saanak makatakki, nu dad-duma natangken ti takkik” as verbalized
by the patient.
Objective:
• Facial grimaced
• Hard stool
Nursing Diagnosis
Alteration in Bowel Elimination: constipation r/t increasing size of the uterus which will
decrease the mobility of the intestine secondary to pregnancy.

Planning
After 2 hours the patient will be able to defacates easily.

Intervention
1. Advised to do relaxation exercise regularly.
Exercise will decrease stress and emotional upset which may promote elimination.
2. Encouraged to increase fluid intake.
Fluids especially water tends to soften the stools for easy passage in the intestine for
bowel elimination.\
3. Advised her to increase fiber intake by eating fiber raw, unpeeled vegetables or dry
fruits except bananas.
Fibers will bulk the stool making it soft and easy to pass through the large intestines
and anus.
4. Advised her to chew foods thoroughly.
Chewing food thoroughly will facilitates digestion.
5. Advised her to establish regular bowel habits.
This promotes normal bowel elimination.

Evaluation
The patient has been verbalized to defacates easily.

INTRAPARTAL

Assessment
Subjective:
“Aray nagsakit” as verbalized by the patient.
Objective:
• Facial grimace
• Excessive respiration

Nursing Diagnosis
Alteration in Comfort: Pain r/t rapid uterine contraction during the latest phase.
Planning
The patient will be able to feel a lesser degree of pain after 1 hour.
Intervention
1. Advised the patient to do breathing exercise.
Breathing exercises will help the client to relax thus reduce the perception of pain.
2. Provided comfort measures like back rub.
Providing comfort measures will help the client psychologically. It promotes relaxation
and physical comforts.
3. Encourage patient to void.
This will keep the bladder free of distension which can result to discomfort, result in
possible trauma, interfere with the fetus to descend and prolong labor.
4. Encourage diversional activity.
This will help the will help divert away the attention of the client from labor making
time pass more quickly. This will help also to decrease perception of pain.

Evaluation
The client was able to feel lesser degree of pain and discomfort, maintain breathing and
relaxing in between contraction after 1 hour as evidenced by expression of pain
reduction.

Assessment

Subjective:
“ Nasakit! Madikun!” as verbalized by the patient.

Objective:
• Excessive perspiration
• Facial grimace
• Restlessness

Nursing Diagnosis
Alteration in Comfort: Pain r/t dilation of the cervix, stretching of the lower uterine
segment during transitional phase and birth.

Planning
The patient will be able to feel lesser degree of pain after 24 hours.
Intervention
1. Provided comfort measure like back rubbing, touching the face or hand of the
client.
• Helps the client psychologically. Promotes relaxation and physical comfort
which help reduce perception of pain.
2. Encouraged diversional activities like listening to a solemn music.
• Helps divert away the attention of the client from labor and delivery and
helps decrease the perception of pain.
3. Advised the client to do breathing exercise.
 • It promotes relaxation, will help reduce perception of pain.

Evaluation
After an hour, the client was able to feel lesser degree of pain and discomforts as
evidenced by the expression of pain reduction, relax between contraction, maintain
breathing, felt a lesser degree of pain and discomfort.

Assessment
Subjective:
“Aray nagskit” as verbalized by the patient.
Objectives:
• Diaphoresis
• Increase muscle tone
• Body weakness
• Guarded movement
• Facial grimace

Nursing Diagnosis
Alteration in Comfort: Acute pain r/t second stage of labor and strong uterine contraction.
Planning
The client will be able to experience reduce pain as a result of uterine after 1 hour.
Intervention
1. Advised client to push only during uterine contraction.
• Unnecessary movement will add up to mothers agony’
2. Gave her back massage
• Massaging the back contributes to pain reduction.
3. Tried to distract attention
• The pain becomes more tolerable when client becomes less aware of it.
4. Kept her constantly informed by her progress of labor.
• The will help relieved anxiety.
5. Position in side lying or fowlers position.
• Proper positioning promotes comfort and reduces irritation.

Evaluation
To client verbalized reduced discomforts and pain after 1 hour.

Assessment
Subjective:
“Saan ku kaya ti sakit nan” as verbalized by the patient.
Objective:
• Diaphoresis
• Unwilling to be left alone
• Body malaise

Nursing Diagnosis
Ineffective individual copping r/t inappropriate relaxation and breathing pattern, length
and discomfort of labor progress, fatigability, and energy.

Planning
The patient will be able to verbalized increase of ineffective individual copping in 1 hour
as evidenced by willingness to be left alone and verbalization of the patient that she can
managed it.

Intervention
1. Encouraged client to do or use breathing pattern technique.
• This will help her to cope with her labor and lessen her fatigability.
2. Encouraged active participation of support system.
• Client stays in control with support system around and for client self – esteem.
3. Reassured client and provided information to SO regarding labor process.
• This will help client comfort and also for her cooperation.
4. Tough proper technique and bearing down.
• To lessen unnecessary loss of energy and agony
.
Evaluation
The client verbalized reduce discomfort and pain after an hour.

POSTPARTUM

Assessment
Subjective:
“Nasakit paylang toy matris ko” as verbalized by the patient.
Objective:
• Facial grimace
• Self focusing

Nursing Diagnosis
Alteration in Comfort: After pain r/t uterine involution.
Planning
After 3 hours to 4 days, there would be decrease discomfort of pain felt by the patient.
Intervention
1. Gently massage the fundus.
• Will stimulate the uterus to contract which will lead to uterine involution and
prevent excessive bleeding.
2. Ice pack apply over the abdomen.
• Cold compress promotes vasoconstriction will lead to involution of the uterus. It
also provides local anesthesia.
3. Encouraged Kegel’s exercise.
• Aids in healing and recovery of pubococcygeal muscle tone and prevent urinary
stasis.
4. Advised early activity and ambulation as early as possible.
• It enhances circulation, facilitates bowel and bladder function thereby promoting
healing.
5. Explained reason why discomfort occur.
• For the understanding of the mother that it is the normal occurrence it would ease
discomfort and anxiety.

Evaluation
The client after three days would feel comfortable because of uterine pain as evidenced
by relaxed appearance and verbalization of “ di na masyadong masakit”.

Assessment
Subjective:
“Nasakit toy susok” as verbalized by the patient.
Objective:
• Breast fullness
• Shiny skin
• Redness of skin

Nursing Diagnosis
Alteration in Comfort: Breast engorgement r/t venous and lymphatic filling of the alveolar cells
with milk.
Planning
After 3 days, the patient will experience lesser degree of pain as evidenced by letdown
reflex, and client verbalization of being relieved from pain.

Intervention
1. Advised the client to apply cold compress.
• To numb the nerve endings.
2.Let the baby suck the breast of the mother.
• To lessen the volume of milk in the alveolar duct which will lessen the breast
engorgement.
3. Advised the mother to avoid putting pressure on the breast.
• Pressure will just add to the degree of pain felt.
4. Encouraged the client to use fitting brassiere.
• For support of breast.

Evaluation
The client was relieved from the pain she felt after three days of implementing the nursing
intervention as evidenced by patient verbalization of being relieved from pain.

Assessment
Subjective:
“Nabayag pay” as verbalized by the patient.
Objective
• Diaphoresis
• Restlessness
• Irritability
• Nervousness

Nursing Diagnosis
Anxiety r/t birthing process, fear from self and infant urgency in micturation, increase
muscle tension.

Planning
The patient will be able to reduced the level of anxiety in 3 hours.

Intervention
1. Explain the physiology of labor and delivery.
• Increase awareness of birthing process contribute to her comfort.
2. Give emotional support such as touch and smoothing words.
• For the clients emotional equilibrium.
3. Facilitate a quite environment like asking friends to talk outside the house.
• To provide time for self and that noise contributes to irritability and restlessness

Evaluation

Client anxiety level was lessened after 3 hours as manifested by clients feeling little
okay.
 CONTENTS
Acknowledgement
Dedication
Introduction
The Female Reproductive System
Menstruation
• Phases of Menstrual Cycle
• Teaching About Menstrual Health

Stages of Fetal Development

• Milestones of Fetal Growth and Development

Nursing Assessment Form

Maternal Data- based Assessment Guide

Leopold’s Manuever

Fetal Estimates
• Nagele’s Rule
• Mc Donald’s Rule
• Haase’s Rule
• Johnson’s Rule
• Bartholomew’s Rule

Risk Indication Form

Laboratory Examination

Beliefs and Practices

General Physical Assessment Tool
Stages of Labor
Mechanisms of Labor
The Placenta
Immediate Care for the Newborn
APGAR Scoring
Puerperium
Postpartal Assesstment

Breastfeeding
• Beginning of Breastfeeding
• How to Feed

Health Teachings
• Nutrition during Pregnancy
• Rest, Sleep and Exercise
• Sexual Activity
• Care of the Teeth
• Care of the Nipples
• Dressing
• Work/ employment
• Travel
• Bathing
• Immunization
• Perineal Hygiene Exercises During Pregnancy

Postpartal Exercises

Nursing Care Plan

Documentation
 Medical Colleges of
Northern Philippines
Alimannao Hills, Penablanca, Cagayan

Is Hereby Presented To The

Faculty of College of Nursing

Submitted by:
LIONEL RICHIE C. BELISARIO
 THE AUTHOR

Being a nursing student is one of the greatest courses in the entire

universe. It offer you sacrifices and hardship in order to pass.

Being one in the college of nursing is an honor to me as a student nurse like me.
As they always say many are called but few are chosen.

I’m LIONEL RICHIE C. BELISARIO student. Simple and industrious

and luck enough to reach at this level. May the almighty God may guide me
along may journey being a student nurses to become a registered nurse in the
near future.
 APPROVAL SHEET

This book entitled “Maternal and child Nursing approach” a family centered and
child bearing family Authored by LIONEL RICHIE C. BELISARIO is presented to the
college of Nursing in partial Fulfillment of the requirement in Maternal and Child Nursing.

Presented to:

Mr.Christopher Gunacao RN
ADVISER

Ms.Karen Castillo RN
LEVEL III Clinical Coordinator

Ms. Liezel Canapi RN,MSN

LEVEL IV Clinical Coordinator

Approved by:

Ms.Cheryll JM Gumabay RM,RN,MSN

Dean of Colleges of Nursing