Medical Colleges of Northern Philippines

Alimannao Hills, Peñablanca Cagayan

“Family Centered Care in the Childbearing Process”

In Partial Fulfillment of the Requirement in

Maternal and Child Nursing Presented to: Faculty of the College of Nursing

Presented by: SARRAH JANE A. DE GUZMAN BSN – IV APPROVAL SHEET

This book entitled “Maternal and Child Health Nursing” authored by SARRAH JANE A. DE GUZMAN in partial fulfillment of the requirements for the degree of Bachelor of Science in Nursing is hereby presented to the faculty of College of Nursing. Approved By: ___________________________ MARCELYN ALMAZAN, RN, MSN Level II Coordinator ___________________________ LIEZEL CANAPI, RN, MSN Level IV Coordinator

___________________________ CHERYLL JM GUMABAY, RN, RM, MSN Dean, College of Nursing ACKNOWLEDGEMENT

A journey is easier when you travel together. Interdependence is certainly more valuable than independence. This thesis is the result of few months’ work whereby I have been accompanied and supported by many people. It is a pleasant aspect that I have now the opportunity to acknowledge and extend my heartfelt gratitude for all of them.

First and foremost I offer my sincerest gratitude to my Clinical Instructors who supported me throughout this book with their patience, knowledge, encouragement and useful suggestions. Without them this book would not have been completed or written successfully.

In my daily activities I have been blessed with a friendly and cheerful group of fellow students. I am grateful for their helpful comments, useful arguments and suggestions and moral support.

I am as ever, especially indebted to my parents for their love and support for they taught the things that matter most in life. To my siblings for rendering me the sense and value of a family. Moreover my sincere thanks to my friends who shared their love and experiences with me.

And to the Human Creator who made all things possible. My deepest and sincere gratitude for inspiring and guiding me all throughout. To God be the glory.

DEDICATION

This book is dedicated to my greatest parents who have raised me to be the person I am today. You have been with me every step of the way, through good times and bad. Thank you for all the unconditional love, guidance and support you are continuously giving me, helping me to succeed and instilling in me the proper values I need to guide me through my battle of conquering wisdom which would bring me to success. Thank you for everything. I love you.

I am also grateful to the participants of this Maternal Book. Those people who welcomed me into their home, who answered my questions and book. took part in the activities required to complete this

To our professors and Clinical Instructors who opened the door of nursing world. Their teachings and guidance that made us what we are now.

To my fellow students who made comments and endure efforts to learn the process of being nurse. Thank you very much! PREFACE

Maternal- newborn nursing are expanding areas of nursing as a result of the broadening scope of practice within the nursing profession and the recognized need for better preventive and restorative care in these areas.

The care of the childbearing and childrearing family is a major focus of nursing practice. To have healthy children, it is important to promote the health of the childbearing woman, her family from the time before the children is born to the time until they reach childhood. Prenatal care and guidance are essential to the health of the woman, fetus, and of the family’s emotional preparation for childbearing.

As you scan this book, you can see the different interviews and assessment to the clients done by the author and the appropriate interventions to any existing problems encountered during

childbearing and childbirth as well. Also, the author discussed the nursing process, the systemic changes that normally occur during pregnancy, the immediate care given to the newborn, the menstrual cycle, and the overview of both the female and male reproductive systems.

This maternal and child book views maternal and child health care not as two separate disciplines but as a continuum of knowledge.

TABLE OF CONTENT Approval Sheet Acknowledgement Dedication Preface

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

CHILBEARING AND CHILDREARING

Childbirth, a life-cycle event, has occurred since time immemorial. It is a constant that affects all of us, the world over. It repeats itself as surely as the sun rises and sets. It is a reassurance that life continues and infinitum, and it reaffirms that new life will always be with us. Perhaps procreation falls into a mosaic affecting men, women and children. The close blood-kin relationship is a binding one in which members of a family interact, share and become a functioning unit. As the child grows from infancy to childhood, puberty, and young adulthood in the security and love given by his parents, he is

made ready for the same life-cycle event of childbearing. The child builds values on what he perceives and experiences within the family. As he witnesses new life in his own family, the imprints remain and affects his future as a parent. Thus, people bring to parenthood a variety of well-defined set of beliefs; they know what they want from childbearing experience. Most couple come with a philosophy that childbirth is a combined effort of a man and a woman and that both has something to give and take from this event. They believe that through their combined efforts, the experience will turn out to be rich and rewarding one where growth and maturation occur. Accompanying this philosophy is a sense of

responsibility. As a man and woman love, respect, and grow in responsibility, they will be better prepared to parent a child. Perhaps one of the greatest changes that occurs in childbearing is the emphasis on the quality of life rather than quantity. Certainly, the responsibility that lies among the young people is that new life they procreate should have the right to enjoy the essentials of a healthy beginning. Couples must give serious thought to when, how, where they would have children and how many children they would have. The whole emphasis is on planned and responsible parenthood rather than haphazard, unplanned pregnancy. Childbirth for the future will make even greater strides. Family living and sex education are now integral parts of school curriculum. Young people are learning a great deal about the life-cycle. In the future, childbirth will take on greater dimensions as families share and participate in childbirth, making it a fruitful family experience.

NURSING PROCESS

The term NURSING PROCESS was first used/mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 steps: observation, administration of care and validation. Since then, nursing process continue to evolve: it used to be a 3step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process (ADPIE) ASSESSMENT, DIAGNOSIS, PLANNING, IMPLEMENTATION and EVALUATION.

is a systematic, organized method of planning, and providing quality and individualized nursing care. it is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result. it is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.

Goal-oriented – nurse make her objective based on client’s health needs. Remember: Goals and plan of care should be base according to client’s problems/needs NOT according to your own problem as the nurse. Organized/Systematic – the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.

Humanistic care

plan

to

care

is

developed

and

implemented

taking

into

consideration the unique needs of the individual client.

plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)

in providing care, it involves respect of human dignity

Efficient – plan of case is relevant/related to the needs of the client thereby promoting client satisfaction and progress. Effective – in planning care, utilized resources wisely (staff, time, money/cost) Aside from GOSH, other characteristic of Nursing Process Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status. Involves skill in Decision-making – nurse makes important

decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available. Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking. PURPOSE OF NURSING PROCESS 1. To identify a client’s health status; his Actual/Present and potential/possible health problems or needs. 2. To establish a plan of care to meet identified needs.

3. To provide nursing interventions to meet those needs. 4. To provide an individualized, holistic, effective and efficient nursing care. STEPS/PHASES OF THE NURSING PROCESS
1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

- First Step in the Nursing Process

it is systematic and continuous collection, validation and communication standard/norm. of client data as compared to what is

it includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.

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

nursing health history physical assessment

• • •

the physician’s history & physical examination results of laboratory & diagnostic tests material from other health personnel

4 Types of Assessment: a. Initial assessment – assessment performed within a specified time on admission Ex: nursing admission assessment b. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment Ex: problem on urination-assess on fluid intake & urine output hourly c. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest. d. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

Activities:
1. Collection of data

2. Validation of data 3. Organization of data 4. Analyzing of data 5. Recording/documentation of data Assessment = Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record I. Collection of data •

gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status

includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)

current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)

Types of Data: a. Subjective data

also referred to as Symptom/Covert data

information from the client’s point of view or are described by the person experiencing it.

information supplied by family members, significant others, other health professionals are considered subjective data.

Example: pain, dizziness, ringing of ears/Tinnitus b.
• •

Objective data also referred to as Sign/Overt data those that can be detected, observed or measured/tested using accepted standard or norm.

Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin Methods of Data Collection: a. Interview

a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.

it is used while taking the nursing history of a client Observation – use to gather data by using the 5 senses and

b.

instruments.

c.

Examination systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA),

interpretation of laboratory results.

should be conducted systematically:

c.1. Cephalocaudal approach – head-to-toe assessment c.2. Body System approach – examine all the body system c.3. Review of System approach – examine only particular area affected Source of data:
a. Primary source – data directly gathered from the client using

interview and physical examination.
b. Secondary

source – data gathered from

client’s

family

members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals. In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to collect specific data and to obtain a detailed health record of a client. Components of a Nursing Health History

Biographic data – name, address, age, sex, martial status, occupation, religion.

Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization.

History of present Illness – includes: usual health status, chronological story, family history, disability assessment.

Past Health History – includes all previous immunizations, experiences with illness.

Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).

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

Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies.

Social

data

include

family

relationships, status,

ethnic home

and and

educational

background,

economic

neighborhood conditions.

Psychological data – information about the client’s emotional state.

Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors.

II. Validation of Data – the act of “double-checking” or verifying data to confirm that it is accurate and complete.

Purposes of data validation: a. ensure that data collection is complete b. ensure that objective and subjective data agree c. obtain additional data that may have been overlooked d. avoid jumping to conclusion e. differentiate cues and inferences Cues – subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure. Inferences – the nurse interpretation or conclusion based on the cues. Example: red, swollen wound = infected wound

Dry skin = dehydrated III. Organization of Data – uses a written or computerized format that organizes assessment data systematically. - Maslow’s basic needs - Body System Model

MATERNAL DATA BASE ASSESSMENT GUIDE Personal Data Name of Patient : R.T.B Age Address Nationality : 19 y/o : Ipil, Echague, Isabela : Filipino

Occupation : Plain Housewife Birthplace Religion Civil Status : Ipil, Echague, Isabela : Roman Catholic : Married

Educational Attainment: College Undergraduate

Menstrual History Menarche occurred at the age of 15, 4 days of moderate flow with unrecalled pads for the whole duration of menstruation. The color is deep red and with an interval of 28-29 days. Sometimes, the patient experienced dysmenorrhea or menstrual cramps during her

menstruation, but not all the times. Maternal History Obstetrical Score G1P1 G1- 1001- F- NSD- Cephalic- TBA-Alive History of Present Pregnancy LMP- May 23, 2009 EDD- January 30, 2010 AOG- 40 weeks Past Health History a. Family History

Her father is hypertensive. Both parents are not diabetic, doesn’t have asthma and non-TB carriers. b. Personal and Social History The patient is non- smoker and non-alcoholic drinker.

Health Perception-Health Management Pattern Before Pregnancy: • Mrs. R stated that being healthy is free from sickness and the absence of disease. She perceived that her child is healthy in his own way. She uses Biogesic, Paracetamol, Alaxan and other OTC drugs which she knows their actions whenever she is not feeling well. They refer to medical institution, whenever one of the family members gets sick. She is aware and conscious of personal hygiene, safety and comfort. She takes a bath twice to thrice a day. She showed independence and autonomy in performing activities of daily living. The patient doesn’t have any vices.

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

uneasy because of her baby. She doesn’t take any OTC drugs because she is aware of the effects of these drugs to her baby. She takes a bath twice a day. She calls for assistance when doing heavy ADL’s.

Nutrition-Metabolic Pattern Before Pregnancy: • The patient prefers to eat vegetables than meat. She eats

thrice a day with adequate amount of food. She has no allergies on all foods. She stated that she has a good appetite. Drinks 6-8 glasses of water a day. She drinks coffee with milk early in the morning, take snacks in between meals. She has no difficulty in swallowing or ingesting foods. During Pregnancy:

The patient stated that she prefers to eat meat other than

vegetables not just like before. “My appetite has changed” as she stated. She eats thrice a day with adequate amount of food, take snacks in between meals. She has no allergies on

all foods. She drinks 6-8 glasses of water a day. She has no difficulty in swallowing or ingesting foods. • Elimination Pattern

Before Pregnancy: • She urinates 4-5 times a day with the amount of at least 700 ml a day and has a yellow amber color of urine. She has no difficulty in urinating. She usually defecates early in the morning with a consistency of brownish in color and semi-solid. But this depends on the food eaten by her. She has no difficulty in defecating. She does not use any laxatives and other stool softeners. During Pregnancy: • She urinates 3-4 times a day with the amount of at least 650700ml and has a yellow amber color of urine. There were no problems in bowel elimination. Regular bowel habits are

observed by the patient with a consistency of brownish in color. She doesn’t use any stool softeners.

Activity-Exercise Pattern Before Pregnancy:

She wakes up as early as 5:00 in the morning. This is her usual time. She prepares their breakfast and did all the household chores. Her ADL’s serves as her exercise and takes care of her child and her husband. During Pregnancy:

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

Sleep-Rest Pattern Before Pregnancy: • She sleeps 7-8 hours a day. Watching television helps her to get her sleep. She is not using sleeping pills. She is used to have 2 pillows when sleeping. She usually takes a nap in the afternoon for at least 45 minutes. She doesn’t have any sleeping difficulty. During Pregnancy: • She has a good sleeping habit. She sleeps as usual hours of her sleep. Cognitive-Perceptual Pattern Before Pregnancy:

She is a high school graduate at Western Isabela Academy. She speaks Ilokano, Tagalog, and English. She is fully oriented to time, place and persons around her. She is able to answer questions immediately. She can hear soft whisper, identify things/objects, smell and taste foods and able to respond to stimuli. During Pregnancy:

There’s no change on her cognitive-perceptual pattern. She is fully oriented to time, place and person. Her senses are intact.

Self-Perception-Self- Concept Pattern Before Pregnancy: • Mrs. R. views herself as a patient and as a loving mother to her siblings and a sweet housewife to her husband. She fears of losing someone. “Aalagaan ko ang mga anak ko hanggang sila’y tumanda” as she said. During Pregnancy: • The patient stated that she will take good care of her new baby when it will bear. She will be a loving mother as she stated. Role Relationship Pattern

Before Pregnancy: • She is a loving housewife and a mother. She loves to mingle with different kind of people. When conflict arises, she wants to resolve it immediately. They have a nuclear family. She has two daughters. During Pregnancy: • She prepares herself with the additional role for the delivery of her new baby. Sexuality-Reproductive Pattern Before Pregnancy: • There’s no history of reproductive problems in the patient’s family. Her menarche begun when she was 14 years old. She has a regular menstrual period. During Pregnancy: • There were changes in the reproductive system as the

pregnancy go through. Coping Stress Pattern Before Pregnancy:

She is in stressed whenever problems arise. In times of problems, she talks about it with her mother and finds ways and means to solve it. When she is stressed, she just turns on their television to watch her favorite telenovels as her way of coping. During Pregnancy:

Whenever she is stressed, she just sits down and takes some rest, and at the same time drinks water to ease her stress. Sometimes, just like she usually did, she watches television with her daughters.

Value-Belief Pattern Before Pregnancy: • She is a devoted Roman Catholic. She and her family mass every Sunday. She also believes on

attended

superstitions like not sweeping at night and many more. She strongly believes in miracles and power of God. She prays always and thank God for the blessings He is doing. The Lord is their source of strength. During Pregnancy: • She continues her religious beliefs.

Date Assessed: October 16, 2009 Time Assessed: 10:00 AM Vital Signs: Temperature: 36.50C Pulse Rate: 75 bpm Respiratory Rate: 18 cpm Blood Pressure: 110/70 mmHg General Appearance: • The patient is awake and coherent, fully oriented to time,

place and person. • • The patient can follow instructions and commands easily. Patient is well groomed and dressed appropriately. TECHNIQU ES USED NORMAL FINDINGS ACTUAL FINDINGS ANALYSI S

AREA ASSESSED

SKIN Color Texture Turgor Inspection Palpation Palpation Tan Smooth, soft Skin snaps back immediately Hair Distribution Temperature Moisture Inspection Palpation Palpation when pinched Evenly distributed Warm to touch Dry, skin folds are normally moist NAILS Color of nailbed Texture Shape Nail Base Capillary Refill time HAIR Color Distribution Inspection Palpation Inspection Inspection Blanch Test Pink and Clean Smooth Convex curvature Firm 2-3 seconds Pink and Clean Smooth Convex curvature Firm 2-3 seconds Normal Normal Normal Normal Normal Tan Smooth, soft Skin snaps back immediately when pinched Evenly distributed Warm to touch Dry, skin folds are normally moist Normal Normal Normal Normal Normal Normal

Inspection Inspection

Black (varies) Evenly

Black Evenly

Normal Normal

Moisture

Inspection

distributed Neither excessively

distributed Neither excessively dry nor oily Silky, resilient

Normal

Texture HEAD Scalp Symmetry Skull Size Shape

Inspection

dry nor oily Silky, resilient

Normal

Inspection Inspection Inspection and

Symmetrical Normocephali c Round

Symmetrical Normocephali c Round

Normal Normal Normal

Nodules/ Masses FACE Symmetry Facial Movement Skin color EYES Eyebrows

Palpation Palpation

Absence of nodules and masses

Absence of nodules and masses

Normal

Inspection Inspection Inspection

Symmetrical Symmetrical Tan

Symmetrical Symmetrical Tan

Normal Normal Normal

Inspection

Symmetrically aligned, equal

Symmetrically aligned, equal movement Slightly curved

Normal

Eyelashes

Inspection

movement Slightly curved

Normal

upward

upward

Eyelids

Inspection

Smooth, tan, do not cover pupil as sclera, close symmetrically

Smooth, tan, do not cover pupil as sclera, close symmetrically Blinks voluntarily and bilaterally 20 blinks per minute Eye moves freely Drawn from lateral angle Medium Mobile, firm and non tender

Normal

Ability to blink Frequency of blinking Ocular movement Position Size Texture

Inspection

Blinks voluntarily

Normal

Inspection Inspection Inspection Inspection Palpation

and bilaterally 20 blinks per minute Eye moves freely Drawn from lateral angle Medium Mobile, firm and non tender

Normal Normal Normal Normal Normal

Conjunctiva Color Inspection Transparent with light Texture Inspection color Shiny and Transparent with light color Shiny and Normal Normal

Presence of lesions Lacrimal Apparatus Cornea Clarity Texture

Inspection

smooth No lesions

smooth No lesions

Normal

Inspection Inspection

Clear Shiny, smooth, transparent

Clear Shiny, smooth, transparent

Normal Normal

Pupils Color Reaction to light Inspection Inspection Black Pupils Equally Round and React to Light Accommodati Size Shape Inspection Inspection on (PERRLA) Equal Round and constrict Symmetry Visual Acuity Visual Fields Inspection Inspection Inspection briskly Equal in size Able to real news print When looking straight Black Pupils Equally Round and React to Light Accommodati on (PERRLA) Equal Round and constrict briskly Equal in size Able to read newsprint When looking straight Normal Normal Normal Normal Normal Normal Normal

ahead, client can see objects in Ocular NOSE Symmetry, shape, size and color Mucosa color Nasal Septum Nares Inspection Nasal discharge Sinuses MOUTH Inspection Inspection Oval, symmetrical No discharge Not tender Inspection Inspection Symmetrical, smooth and tan Reddish to Pinkish Inspection periphery Eyes move freely

ahead, client can see objects in periphery Eyes moves freely Normal

Symmetrical, smooth and tan Reddish to Pinkish

Normal

Normal

Oval, symmetrical No discharge Not tender

Normal Normal Normal

Lips Color Inspection Pinkish to Pinkish to Normal

Symmetry Texture Moisture Gums Color Moisture Buccal Mucosa Color

Inspection Palpation Palpation

slightly brown Symmetrical Soft, moist, smooth Soft and moist

slightly brown Symmetrical Soft, moist, smooth Soft and moist

Normal Normal Normal

Inspection Palpation

Pinkish moist

Pinkish moist

Normal Normal

Inspection Texture Moisture Tongue Color Size Symmetry Mobility Palpation Palpation

Glistening pink Soft moist

Glistening pink Soft moist

Normal Normal Normal

Inspection Inspection Inspection Inspection

Pinkish Medium Symmetrical Moves freely

Pinkish Medium Symmetrical Moves freely

Normal Normal Normal Normal

Uvula Location Symmetry Tonsils Color Discharges Inspection Inspection At the midline Symmetrical At the midline Symmetrical Normal Normal

Inspection Inspection

Pinkish No discharges

Pinkish No discharges

Normal Normal

Teeth Color NECK Position Movement Range of Motion Consistency Inspection Inspection Inspection Inspection HeadCentered Moves freely Full range No Enlargement HEART Heart sounds Lung Field THORAX AND LUNGS Posterior Thorax Symmetry Inspection Respiratory rate Spinal Inspection Inspection Symmetrical Normally 1220 cpm Spine Symmetrical 18 cpm Sligthly curve Normal Normal Due to Auscultatio n Auscultatio n Clear, without crackles Resonant HeadCentered Moves freely Full range No Enlargement Clear, without crackles Resonant Normal Normal Normal Normal Normal Normal Inspection Ivory/yellowis h Yellowish Normal

alignment Anterior Thorax Breathing Auscultatio pattern n

vertically aligned

backward(lord osis)

pregnanc y

Breathing is

Breathing is

Normal

automatic and automatic and effortless, regular and even and produces no effortless, regular and even

Lung/ breath sounds ABDOMEN Contour Texture Frequency and character

Auscultatio n

noise. Bronchovesicular

Bronchovesicular

Normal

Inspection Palpation Auscultatio n

Flat Smooth Audible; soft gurgling sound occur irregularly and ranges from 5-30 minutes

Flat Smooth Audible; soft gurgling sound occur irregularly and ranges from 5-30 minutes

Normal Normal Normal

UPPER

EXTREMITY Skin color Size (arms) Symmetry Hair distribution LOWER EXTREMITY Skin color Size (legs) Symmetry Hair distribution NEUROLOGI C Level of Interview consciousnes instructions s and Behavior and appearance Mood Interview Interview commands Makes eye contact with the examiner Expresses feelings which correspond to and commands Makes eye contact with the examiner Expresses feelings which correspond to Normal Normal instructions Can follow Can follow Normal Inspection Inspection Inspection Inspection Tan Equal Symmetrical Evenly distributed Tan Equal Symmetrical Evenly distributed Normal Normal Normal Normal Inspection Inspection Inspection Inspection Tan Equal Symmetrical Evenly distributed Tan Equal Symmetrical Evenly distributed Normal Normal Normal Normal

situation Mannerisms and actions Language Voice inflection Tone Manner and speech Interview Interview Interview Clear and strong Fluent and articulated Can give appropriate answers to questions Mental Status Interview Orientation Oriented with time, place and person

situation

Clear and strong Fluent and articulated Can give appropriate answers to questions

Normal Normal Normal

Oriented with time, place and person

Normal

Time Recall recent and remote memory Interview Recall events readily, immediate recall of remote information Recall events readily, immediate recall of remote information Normal

Judgments and thoughts

Interview

Can make logical decisions

Can make logical decisions

Normal

Assessmen t

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Evaluation

Subjective: “hindi pa ko

Alteration in Bowel

After 30

1. Advised to

- It will decrease stress and emotional

Goal met as the patient was relieved from

minutes of do relaxation exercise

Elimination: nursing tumatae simula pa n related to ns, the nung isang increasing patient will araw” as size of the be able to verbalized uterus by the which patient. decreases be relieved the mobilityfrom of the Objective: intestine - Hard stools n and constipatio on how to learn ways

Constipatio interventio regularly.

upset which constipation may promoteand had her elimination 2. Encouraged regularly. to increase - Fluids fluid intake. soften stool for passage of stools. 3. Advised her to increase bowel elimination

secondary attain to normal fiber intake pregnancy. bowel elimination - Fiber will . 4. Advised her bulk stools to establish regular bowel habits. making it soft and for easy passage.

5. Caution her

Assessme Assessme Nursing Nursing Planning Planning Nursing Nursing Rationale Rationale Evaluation Evaluation nt nt Diagnosis Diagnosis Interventions Interventions

Subjective: Alteration After After 1-2AdvisedEncouraged help Goal met as met as Subjective: Alteration 1 1. 1. the - It will - Rest will Goal in comfort; hour days of in comfort; of patient her to have to to do client prevent evidenced by the patient “ang sakit “minsan pain leg cramps nursing breathing relax thus fatigue experienced nursing the frequent rest over decreased na” assumasakit related to interventio exercises. legs related to interventions with reducing thesensation of pain in the reduce verbalized paa ko ang rapid fatigue. the ns, , the patient elevated. perception from 5/10 to 2/10, muscle of occurrence by thelalo na pag uterine patient will able will be of pain.the lower patient of leg was patient. pagod ako” contraction report experience to 2. Provided extremities. cramps after relaxed between as - Pain scale during the decrease comfort lesser contractions2and 1 to days. verbalized 5/10 latest sensation measures. occurrence of - It maintained by the 2. Advised to phase. of pain cramps. leg promotes - Massage breathing. patient. massage the from5/10 relaxation promotes cramps Objective: to2/10. 3. Encouraged and physical relaxation muscle. client to void. comforts. and - Facial Objective: circulation; grimace it will - Irritable Numbness in the lower - Excessive extremities Perspiration , pain and stiff muscles - This will improve keep the muscle tone bladderso it will be free from relieved.

distention which can result to Increase in 3. Advised her calcium discomfort, 4. Encouraged to eat foods trauma,intake will diversional rich in calcium help in the interfere

Pregnancy is a time of both physical and emotional changes. Aside from the obvious changes in your body shape and the size of your uterus, shifts in hormonal levels and metabolism can contribute to various physical and emotional discomforts. Although the pregnancy

discomforts mentioned below are common, they are not experienced by all pregnant women and may not be a part of your pregnancy. It is important to remember: • You may need to try more than one remedy before you find one that works for you. • Good nutrition is especially important for a comfortable and healthy pregnancy. Eating well can minimize discomforts and help your body cope with the stress of daily life. • If you have a physical discomfort that is severe or does not go away, contact your health care provider. • If you have a chronic health condition, such as diabetes or asthma, it

is very important that you see your health care provider throughout your pregnancy. DISCOMFORT Ankle Edema SOLUTION Rest with your feet elevated. Avoid standing for long periods. Avoid

restrictive garments on the lower half Backache of your body. Apply local heat. Avoid long periods of standing. Stoop to pick up objects. Tylenol in usual adult dose may help. Breast Tenderness Wear low-heeled shoes. Wear a supportive bra. Decrease the amount of caffeine and carbonated Constipation beverages ingested. Increase fiber in your diet. Drink additional fluids. Have a regular time Difficulty Sleeping for bowel movements. Drink a warm, caffeine-free drink before bed and practice relaxation Fatigue techniques. Schedule a rest period daily. Have a regular bedtime routine. Use extra Faintness pillows for comfort. Move slowly. Avoid crowds. Remain in a cool environment. Lie on your left Headache side when at rest. Avoid eye strain. Visit your eye

doctor. Rest with a cool cloth on your forehead. Take Tylenol in regular adult dose, as needed. Report

frequent or persistent headaches to Heartburn your primary care provider. Eat small, frequent meals each day. Avoid overeating, as well as spicy, Hemorrhoids fatty, and fried foods. Avoid constipation and straining with a bowel movement. Take a sitz bath. Leg cramps Nausea Apply a witch hazel compress. Avoid pointing your toes. Straighten your leg and dorsiflex your ankle. Eat six small meals per day rather than three. Eat a piece of dry toast or some crackers before getting out of bed. Avoid foods or situations that worsen the nausea. If it persists, report this problem to your primary Nasal stuffiness care provider. Use cool air vaporizer or humidifier, increase fluid intake, place moist towel on the sinuses, and massage Ptyalism Round ligament pain the sinuses. Use mouthwash as needed. Chew gum or suck on hard candy. Avoid twisting motions. Rise to

standing position slowly and use your hands to support the abdomen. Bend Shortness of breath Urinary frequency forward to relieve discomfort. Use proper posture. Use pillows behind head and shoulders at night. Void as necessary, at least every 2 hours. Increase fluid intake. Avoid Vaginal discharge caffeine. Practice Kegel exercise. Wear cotton underwear. Bathe daily. Avoid tight pantyhose.

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

pubis where dark and curly hair grow in triangular shape that begins 1-2 years before the onset of menstruation. It protects the surrounding delicate tissues from trauma.
2. Labia Majora - Two (2) lengthwise fatty folds of skin extending

from mons veneris to the perineum that protect the labia minora, urinary meatus and vaginal orifice.

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

extending from clitoris to fourchette.
o o o

Glands in the labia minora lubricates the vulva Very sensitive because of rich nerve supply Space between the labia is called the Vestibule

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

labia minora that contains more nerve endings. It is very sensitive to temperature and touch, and secretes a fatty substance called Smegma. It is comparable to the penis in it’s being extremely sensitive.
5. Vestibule - the flattened smooth surface inside the labia. It

encloses the openings of the urethra and vagina.
6. Skene’s Glands/Paraurethral Glands - located just lateral to

the urinary meatus on both sides. Secretion helps lubricate the external genital during coitus.
7. Bartholin’s Gland/Vulvovaginal Glands - located lateral to

the vaginal opening on both sides. It lubricates the external vulva during coitus and the alkaline pH of their secretion helps to improve sperm survival in the vagina.
8. Fourchette - thin fold of tissue formed by the merging of the

labia majora and labia minora below the vaginal orifice.
9. Perineum - muscular, skin-covered space between the vaginal

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

allow enlargement of vagina and passage of the fetal head. It contains the muscles (pubococcygeal and levator ani) which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia.
10. Urethral meatus - external opening of the urethra. It contains

the openings of the Skene’s glands which are often involved in the infections of the external genitalia.
11. Vaginal Orifice/Introitus - external opening of the vagina,

covered by a thin membrane called Hymen.

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

uterus (fundus). It transports the mature ova form the ovaries to the uterus and provide a place for fertilization of the ova by the sperm in it’s outer 3rd or outer half. Parts: Interstitial - lies within the uterine wall Isthmus - portion that is cut or sealed in a tubal ligation.

o o

o

Ampulla - widest, longest portion that spreads into fingerlike projections/fimbriae and it is where fertilization usually occurs.

o

Infundibulum - rim of the funnel covered by fimbriated cells (hair covered fingerlike projections) that help to guide the ova into the fallopian tube.

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

side of the uterus that

measures 4 by 2 cm in diameter and 1.5 cm thick. It is responsible for the production, maturation and discharge of ova and secretion of estrogen and progesterone.

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

inches wide, weighing 50-60 grams held in place by broad and round ligaments, and abundant blood supply from the uterine and ovarian arteries. It is located in the lower pelvis, posterior to the bladder and anterior to the rectum. Organ of menstruation, site of implantation and provide nourishment to the products of conception. Layers:
1. Perimetrium - outermost layer of the uterus comprised of

connective tissue, it offers added strenght and support to the structure.
2. Myometrium - middle layer, comprised of smooth muscles

running in 3 directions; expels fetus during birth process then contracts around blood vessels to prevent hemorrhage.
3. Endometrium - Inner layer which is visibly vascular and is shed

during menstruation and following delivery.

Divisions of the Uterus:
1. Fundus - upper rounded, dome-shaped portion that can be

palpated to determine uterine growth during pregnancy and the

force of contractions and for the assessment that the uterus is returning to it’s non-pregnant state following child birth.
2. Corpus - body of the uterus. 3. Isthmus - area between corpus and cervix which forms part of

the lower uterine segment. It enlarges greatly to aid in accommodating the fetus. The portion that is cut when a fetus is delivered by a caesarian section.
4. Cervix - lower cylindrical portion that represents 1/3 of the total

uterus. Half of it lies above the vagina; half of it extends to the vagina. The cavity is termed the cervical canal. It has 2 openings/Os: internal os that open to the uterine cavity and the external os that opens to the vagina.
5. Vagina - a 3-4 inch long dilatable canal located between the

bladder and the rectum, it contains rugnae which permit considerable stretching without tearing. It acts as a organ of intercourse/copulation and passageway for menstrual discharges and fetus. Doderlein’s bacillus is the normal flora of the vagina which makes the pH of vagina acidic, detrimental to the growth of pathologic bacteria.

Organ 1. Vagina

Functions a. Passageway of menstrual flow

b. Female organ for coitus; receives male penis c. Passageway for the fetus during birth 2. Uterus a. Houses and nourishes fetus until sufficiently mature to function outside the mother’s body

b. Uterine muscles propels fetus outside. 3. Tube Fallopian a. Provides passageway for ovum as it travels from ovary b. Site of Fertilization. 4. Ovaries a. Endocrine glands that secrete estrogen and to uterus.

progesterone. b. Contain ova within follicles for maturation during the woman’s reproductive life.

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

Ovum The ovum is the female sex cell.

It

is

regularly

released by the ovary the ovulation.

through of

process

It has two layers of protective covering, the outer layer is the corona radiata and the inner layer is the zona pellucida.

The egg cell has a lifespan of 24 hours, thus, it can only be fertilized within this period. After 24 hours, it regresses and is resorbed.

Sperm cell is present in the fallopian tube only in 3 out of 5 ovulations of married women.

Sperm Cell The sperm cell has three parts: a head that contain the chromatin materials, a neck or mid-piece that provides energy for movement, and a tail that is responsible for it’s mobility. The sperm cell has a lifespan of 48 to 72 hours or 3 to 4 days after ejaculation. The sperm must be in the genital tract 4-6 hours before they are able to fertilize an ovum to give time for the enzyme hyaluronidase to be activated. There are two kinds of sperm cell:
1. Gynosperm - This is the X carrying sperm cell. It has a large

oval head, are lesser in number than androsperms and thrive better in acidic environment.
2. Androsperm - the sperm cell which carries the Y chromosome,

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

Per ejaculation the average 2.5ml of seminal fluid contains 50 to 200 million spermatozoa per ml or 400 million per ejaculation.

Fertilization occurs in the outer third (ampullar portion) of a fallopian tube.

Hyaluronidase released by the spermatozoa dissolves the layer of cells protecting the ovum, facilitating the penetration of the spermatozoon.

• •

Upon fertilization, the resulting structure is called zygote. Only the father can determine the gender of the child - X carrying spermatozoon leads to XX combination for a female offspring; Y-carrying spermatozoon leads to XY combination for a male offspring. The ovum carries only X chromosome.

Segmentation:

Within a few hours after fertilization, after the nucleus of the sperm has united with the nucleus of the egg, the result of their union, the zygote, begins a process of internal division. First, it divides into two cells, then four, eight, sixteen, and so on, doubling the number with each new division. This process of cell division or cleavage in the zygote is called

segmentation. It transforms the zygote into a cluster of cells called morula which, seen through a microscope, resembles a

mulberry. The morula slowly moves down the Fallopian tubes toward the uterus, where it arrives after about three days. By this time, it has developed into a hollow ball of cells called blastocyst.

It takes 3 to 4 days for the zygote to journey to the uterus (where implantation will take place), and during such journey mitotic cell division happens. Floating freely in the uterus for the next 3 to 4 days, the morula (16 to 50 cell bumpy appearance resulting from mitotic cell division) grows to become a blastocyst with tropoblast cells cells (forming placenta and membrane in

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

Implantation occurs at high and posterior portion of the uterus. On implantation, the structure is called embryo until 5-8 weeks when it begin to be referred to as fetus.

Implantation bleeding (mistaken as menstrual period) results from capillary rupture on implantation.

Endometrium (the inner lining of the uterus) is termed decidua on conception.

Day 1 - conception takes place 7 days - tiny human implants in mother’s uterus 10 days - mother’s menses stop 18 days - heart begins to beat

21 days - pumps own blood through separate close circulatory system with own blood type 28 days - eye, ear, and respiratory system begin to form 42 days - brain waves recorded skeleton complete, reflexes present 7 weeks - capable of thumb sucking 8 weeks - all body systems present 9 weeks - squints, swallows, moves tongue, makes fist 11 weeks - spontaneous breathing movements, has fingernails, all body systems working 12 weeks - weighs one ounce 16 weeks - genital organs clearly differentiated, grasps with hands, swims, kicks, turns, somersaults, ( still not felt by the mother) 18 weeks - vocal cords work 20 weeks - has hair on head, weighs one pound, 12 inches long 23 weeks - 15% chance of viability outside of womb if birth premature 24 weeks - 56% of babies survive premature birth 25 weeks - 79% of babies survive premature birth

Menstruation - is the periodic discharge of blood, mucus and epithelial cells from the uterus. Menstrual Cycle - periodic uterine bleeding in response to cyclic hormonal changes. A process that allows for conception and

implantation of new life. It is usually determined by counting as day 1 the 1st day of a menstrual period until the last day before the next menstrual period. Purpose:
• •

To bring an ovum to maturity To renew a uterine tissue bed that will be responsive to fetal growth

To prepare the uterus for pregnancy

Characteristics of Normal Menstrual Cycles

TERM Beginning (Menarche)

DESCRIPTION average age of onset: 12 or 13 years; average range of age: 9-17 years

Interval between cycles

average 28 days; cycles of 23 to 35 days not usual

Duration of Menstrual flow

average flow: 2-7 days; ranges 1-9 days not normal

Amount of menstrual flow

difficult to estimate; average 30 to 80 ml. per menstrual period;

saturating a pad in less than an hour is considered heavy bleeding. Color of menstrual flow dark red; a combination of blood, mucus, and endometrial cells Odor of menstrual flow marigold

Discomforts of Menstruation 1. Breast tenderness and feeling of fullness 2. Tendency towards fatigue 3. Temperament and mood changes - because of hormonal influence and decreased levels of estrogen and progesterone 4. Discomfort in pelvic area, lower back and legs 5. Retained fluids and weight gain Abnormalities of Menstruation 1. Amenorrhea - absence of menstrual flow
2. Dysmenorrhea - painful menstruation 3. Oligomenorrhea - scanty menstruation 4. Polymenorrhea - too frequent menstruation

5. Menorrhagia -excessive menstrual bleeding 6. Metrorrhagia - bleeding between periods of less than 2 weeks
7. Hypomenorrhea - abnormally short menstruation

8. Hypermenorrhea - abnormally long menstruation

Four

body

structure

involved

in

the

physiology

of

the

menstrual cycle:

1.
2.

Hypothalamus Pituitary gland Ovaries Uterus Reproductive Hormones:

3.
4.

1.

Gonodotropin-Releasing Hormone (GnRH)
o

Stimulates release of FSH and LH initiating puberty and sustaining menstrual cycle.

2. Follicle-stimulating Hormone (FSH)
o

secreted by anterior pituitary gland during the 1st half of menstrual cycle

o

stimulate growth and maturation of graafian follicle before ovulation

o

thins the endometrium

3. Luteinizing Hormone (LH)
o

secreted by the anterior pituitary gland

o o

stimulates final maturation of graafian follicle surge of LH about 14 days before next menstrual period causes ovulation

o

stimulates transformation of graafian follicle into corpus luteum

o

thickens the endometrium

4. Estrogen
o

secreted primarily by the ovaries, corpus luteum, adrenal cortex and placenta in pregnancy

o o

considered the Hormone of Women stimulates thickening of the endometrium; causes

suppression of FSH secretion
o

responsible

for

the

development

of

secondary

sex

characteristics
o o o

stimulates uterine contractions increases water content of uterus high estrogen concentration inhibits secretion of FSH and Prolactin but stimulates secretion of LH7.

o

low estrogen concentration after pregnancy stimulates secretion of Prolactin

5. Progesterone
o

secreted by the ovary, corpus luteum and placenta during pregnancy

o o o

inhibits secretion of LH has thermogenic effect (increases body temperature) relaxes smooth muscles thereby decreases contractions of uterus

o o o

causes cervical secretion of thick mucus maintain thickness of endometrium allows pregnancy to be maintained = Hormone of

Pregnancy
o

prepares breasts for lactation

6. Prolactin
o o

secreted by the anterior pituitary gland stimulates secretion of milk

7. Oxytocin
o o

secreted by the posterior pituitary gland stimulates uterine contractions during birth and compress uterine blood vessels and control bleeding

o

stimulates

let-down

or

milk-ejection

reflex

during

breastfeeding
8. Prostaglandins
o o

fatty acids’ categorized as hormones produced by many organs of the body, including the endometrium

LABOR AND DELIVERY

Childbirth Process: Phases of Labor The first phase during delivery is initiated when contractions begin. If this is your first child, you will begin dilatation after the cervix becomes effaced or thins out. Contractions are present every 20 to 30 minutes and last 15 to 20 seconds each. This process takes about 6 to 8 hours. In first time moms the whole delivery process may last 8 to 12 hours. If a woman has already had a baby the delivery process is shorter; Approximately 4 to 6 hours. Once the cervix has effaced, contractions will intensify in order to allow the uterus to reach an "opening" of 10 cm. This process is called "dilation". Dilation is broken into two phases:  First: Cervix dilates from 0 to 8 centimeters.  Second: Cervix reaches it's goal of 10 centimeters. At the beginning of the first phase, you will feel soft contractions every 10 to 15 minutes. Each one will last about 20 seconds. At this moment, the opening of your cervix should be around 2 centimeters. Progressively, contractions are going to increase in frequency as well as duration. When you feel your contractions every 5 minutes and they

last 30 to 40 seconds, your cervix will estimate 4 to 5 centimeters dilation. As time goes on, contractions get stronger every 3 or 4 minutes and last close to 45 seconds each. At this moment your cervix is 6 centimeters dilated. When you feel your contractions every 2 or 3 minutes lasting approximately 50 seconds, your cervix should be 8 centimeters dilated. Transition is the phase in which contractions occur every 1 to 2 minutes and last one minute; You are about to reach 10 centimeters of dilation. At this moment you will have a short time to recover between one contraction and the other. You will also feel swelling around your vagina and the urge to push. However, it is important not to respond to this urge until the doctor approves. Once you have reached 10 cm. dilation, expulsion period begins. You will feel that contractions are less frequent, every 2 to 3 minutes. This is the moment the doctor will request that you push. During this period, the baby's head penetrates the delivery canal and goes down to the perineo making an internal rotation. The doctor waits until he/she sees 3 or 4 centimeters of the baby's head. The next contraction will occur and the decision will be made if an episiotomy must be done in order to facilitate the exit of your child.

Once the head is shown (complete coronation) the doctor will tell you to push to help the baby during the final process. First the head exits

and in another push the doctor will help the baby remove a shoulder, then the other, and finally the remainder of the infant.

Pre-Labor A very normal experience for women getting ready to labor is to have rhythmic contractions for a few hours or a few days that come and go without actually begining labor. Doctors used to refer to these contractions as "False Labor." They can also be called Braxton-Hicks contractions. The best term for these contractions is Pre-Labor. Using the term Pre-Labor gives recognition to the fact that these contractions are a normal part of labor and they are getting work done. The more work you get done during pre-labor, the less work you have to do in actual labor. During these pre-labor contractions your cervix may be softening and effacing, it may also be dilating a centimeter or two. Your body is being washed in relaxin, a hormone that allows your pelvis to stretch to let the baby fit through. You body may also be adjusting the levels of hormones so that labor can start. Some women lose their mucus plug during pre-labor, and some women have bloody show at this time as well. These are both normal occurrences as your body begins to open the cervix. Contractions at this point are

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

them closer together and still be in pre-labor. The key to distinguishing between labor and pre-labor is time. Over a few hours, have your contractions gotten closer together, lasting longer and feeling more intense. If not, it is not the actual labor. The biggest difficulties for

women experiencing a long pre-labor are the emotional and physical fatigue that accompanies it. To avoid this, it is important that you follow your normal routine as long as possible. Sleep if you are tired, eat if you are hungry and go about your normal day until contractions demand your attention. Early Labor After a few hours, days or weeks of pre-labor contractions, your body will begin to have rhythmic contractions that seem "different" to you. After a few hours you may realize that the contractions are becoming longer and stronger, and they are happening closer together. These are all signs that you have moved from pre-labor into early labor. In early labor, most women feel excited. The wonder "could this be it?" At the same time, their behavior displays this nervous excitement. Some women find that they feel restless, a little hungry and want to talk to someone. Many women find that this is when they experience Bloody Show and Lose their Mucus Plug. You may also experience a runny nose and an increased need to urinate. Your body will empty itself through several bowel movements that seem like a

mild diarrhea.

At this point contractions are generally less than 10

minutes apart and last 45-60 seconds long. Contractions will get stronger, closer together and longer with time. These contractions may be moderate to strong, and might feel like pressure in the pelvis, menstrual cramping or a dull backache. At this point, most women are more comfortable moving through their contractions.

Active Labor Eventually, the contractions that you have been experiencing will become stronger and more intense. You will also find that as time progresses the contractions are getting closer together and lasting longer. When this happens, you will have moved into active labor. For most women, active labor is the longest part of their labor. During this time, your body is opening the cervix so the baby can move into the birth canal (vagina). At this point your body is also preparing for your baby to be born by stretching the pelvis, preparing the colostrum and stimulating the baby's nervous and respiratory systems. You will find that as active labor progresses, you will become more serious or "focused" during your contractions. You may find yourself slowly moving from not talking during the peak of a contraction - to not talking during a contraction - to barely talking even between contractions. You may also find that your movements become slower

and more deliberate as you progress through active labor. Eventually you may even be at the point that moving between contractions is uncomfortable and difficult to manage. These are normal physical reactions to labor. As your body works harder to contract the uterus, you will naturally spend less energy on "non-labor" activities such as moving and talking. You will also find that your hunger naturally disappears so your body will not waste energy trying to digest food. For most women, the increased focus it takes to labor also prevents them from being concerned with societal norms leading to a decrease in modesty and the pleasantries of conversation. During active labor, mothers find that changing their activity and position as desired helps them to remain comfortable. This may be due to two factors. First, it prevents overstressing one or two muscle groups by varying the way you hold your body. Secondly, it allows you to respond to changes in the way your body feels, which may be caused by the movement of the baby through the pelvis. Although the desire for food disappears during labor, it is important to stay well hydrated. Dehydration will decrease the amount of work your muscles are able to do with each contraction, and it will decrease your ability to handle the stress and contractions. During active labor, some women find that making noise, called vocalization, with contractions helps to keep them relaxed during the contractions. Many women also find that

tuning out the world around them, sometimes called "going inside yourself," helps them to stay relaxed and handle contractions more effectively. Most women will develop some form of pattern or ritual

during active labor. This means that she will repeat the same responses to contractions for several contractions in a row. An example of a ritual may be walking in a circle between contractions; as the contraction begins she takes a deep breath and begins to moan; she leans over on her support person until the contraction is done; then she walks in a circle again until the next contraction begins. There appears to be some comfort afforded a woman by repeating what worked from the previous contraction. As you see these behaviors

build (vocalization, tuning out and using rituals), you will know that labor is progressing. By keeping track of the behaviors the physical signs (loss of hunger, loss of modesty and deliberate movement), and the emotional signs (focusing, decreasing talkativeness, decreasing humor) you can get a pretty good estimate of "how far" into labor the mother is. It is important to note though, that not every mother will respond in the same way or with the same behaviors and signs. Some mothers do continue to talk throughout labor, some mothers do not make noise, some mothers focus on contractions very early in labor. As you use these markers of progress you must look at the total picture of the laboring mother, not simply one marker or behavior.

Transition As the body adjusts to accommodate the last few centimeters of dilation, just before you begin pushing, the hormone levels are so high that you will see undeniable physical signs. Observation of these signs alert you to the fact that you are in transition. Transition is generally the shortest part of labor, lasting 15 minutes to half an hour on average. However, this is also the most intense part of labor for many women. Some women find that being reminded that they are in transition increases their ability to handle the intensity. The major

emotional marker for this stage is giving up. It is in this part of labor that most women ask for medication. This is unfortunate since the shortness of this stage of labor may cause the mother to be pushing before she has received any medical pain relief. When physical signs indicate transition, it may be best to hold out, handling the contractions as best as possible. Physical signs of transition include shaking or trembling which may resemble shivering or could be stronger. Nausea and vomiting are also common signs. In addition to these, some women will feel hot and cold flashes or have cold sweats. Other women may begin burping or hiccupping as the body prepares. Another physical sign is the inability to relax or be comfortable. A woman who was handling labor well may suddenly find that she has no idea what to do and nothing is comfortable any more. At this point, it is the job of her coach or labor partner to assist her into various positions

in an attempt to find the one that will keep her most comfortable. During transition, contractions will be long and close. They may be 90 seconds long and two minutes apart, which gives you a 30 second rest time between contractions. The contractions may double peak, or they may seem to be one right after the other without any break. Transition is the time when the mother is the most emotionally needy as well. Some women need constant reassurance that they are ok and the baby is fine. This may be due to the overall "giving up" and feeling that she is out of control. Most women will respond well to positive encouragements and some require no special consideration other than giving them the physical and emotional space to labor. The "giving

up" or feeling out of control may be recognized by comments the mother makes. It is not uncommon for a mother to say, "I can't do this," or "I need something." Recognize that this is not the mother asking for medication, but for help. She can no longer handle the labor the way she has been, and she needs to do something different. Pushing One of the most common questions among first time mothers is, "When will I know it's time to push?" The most common answer among experienced mothers is, "You'll just know!" The body is designed to begin pushing when pushing will provide assistance at getting the baby out. When you need to push has very little to do with your

dilation, although the general medical practice is to prevent pushing until the cervix is dilated to 10 and begin pushing immediately when 10 is reached. This came into practice in an attempt to prevent the cervix from swelling, however it is now known that the cervix is more likely to swell from pushing without an urge than it is from pushing before reaching a specified dilation. As the baby descends into the

birth canal (vagina), the head or other presenting part puts pressure on the rectum. This pressure stimulates the nerves of the rectum which send a signal to bear down and empty the bowels. It feels exactly like having to go to the bathroom. Sometimes the pressure is overwhelming, and the mother's body pushes involuntarily. You may recognize this by her bearing down, grunting, bracing herself against a sturdy object or by her exclaiming "I have to push!" Other times the urge to push begins mildly, with urges to push only at the peak of the contractions. If the urge is only at the peak, changing position will

either take the urge away, or will allow the baby to slip further into the birth canal and begin strong urges to push. Some women find that simply leaning forward is enough to remove the pressure from gentle urges to push. If the urge to push is not strong, it may be better to change position or lean into the contraction until the pushing urge is strong. This helps to prevent fatigue and allows the strongest pushing to be done when it will be the most effective.

When left alone to push as necessary, most women will do between 3 and 5 pushes that last approximately 6 seconds in one contraction. The variation in length, duration and number of urges in a contraction is due to the position of the baby. Sometimes the baby moves enough with a push that for the next contraction the uterus needs to contract to get tight against the baby again to push on the baby and put pressure on the rectum. Every contraction will have a different pushing pattern. Some mothers find that they have no urge to push, the baby is simply pushed out by the contractions of the uterus. Most women find that some form of breath holding and contracting of the abdominal muscles similar to a bowel movement feels the most comfortable. Pushing is done when the baby is outside of the mother. This can take anywhere from 20 minutes to over three hours. After the baby is out, the third stage of labor begins. This is the expulsion of the placenta. It is generally less than 20 minutes and is no more uncomfortable than giving a moderate push when the pelvis feels full.

Third Stage of Birth: Delivery of Placenta

In this, the shortest stage of labor, lasting no more than 5 to 20 minutes, placental separation and expulsion take place, following delivery of the baby. The placenta will separate from the wall of the uterus and be expelled from the body, along with the umbilical cord and other membranes . The placenta is examined to check if it is intact and if not, the rest of the placenta is removed from the uterus. For the mother the main risks in this stage of birth are hemorrhage during or after separation of the placenta, as well as retention of the placenta. Postpartum hemorrhage is one of the main causes of maternal mortality; the large majority of these cases occurring in developing countries. The incidence of postpartum hemorrhage and retention of the placenta is increased if predisposing factors are present, such as multiple pregnancy or polyhydramnios , and complicated labor . Therefore the mother is often given an oxytocin to decrease estimated postpartum blood loss. Description of Station What does it look like? Fetal station is the position of the fetal presenting part and its descent into the pelvis...how far has the fetus descended...the ischial spines of the maternal pelvis are used to describe 0 station.

Fetal Lie

The fetal lie is described by the relationship of the long axis of the fetus to the long axis of the mother. This is a vertical lie. It is the most common fetal lie.

This picture shows the transverse lie of the of an oblique lie of the

This is a picture

fetus. This is a problem with a term baby and problem in a term pregnancy. labor approaching.

fetus and is a

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

Caring for a brand new baby can be overwhelming and tiring. It includes adjusting to round-the-clock diaper changes and feedings. Ideally, new mothers should receive significant support from partners, other family members, and friends. The new mother's partner can and should participate in most aspects of newborn care. Even during breastfeeding, partners can help to ensure that the mother is comfortable and receiving adequate nourishment. S o m e c a r e

b a s i c s i n c l u d e :

o f

n e w b o r n

I n f a n t s m i l k o r

n e e d f o r m u l a

b r e a s t o n l y . o f f e r s t o b o t h t h e i r

B r e a s t f e e d i n g m a n y a d v a n t a g e s a n d

i n f a n t s

m o t h e r s , i s f o o d h e a l t h H o w e v e r , f o r m u l a t h e t h e

a n d b e s t

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

f o r a n d a i s

y o u r

b a b y ' s

d e v e l o p m e n t . m a j o r b r a n d o f i f t o

s u f f i c i e n t c h o o s e s n o t

m o t h e r

b r e a s t f e e d . b a b i e s o t h e r

N e w b o r n n o t n e e d a n y

d o f o o d .

I n f a n t s w a r m a n d

n e e d

t o

b e

c o m f o r t a b l e . s h o u l d b e f o r

B a b i e s d r e s s e d t h e a r e b a b y

a p p r o p r i a t e l y I f

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

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

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

B a b i e s

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i r r i t a b i l i t y

e l e v a t e d t e m p e r a t u r e .

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f r e e

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e x p o s i n g s k i n t o

t r e a t m e n t . n e e d t o b e

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s h o u l d u n t i l f a l l s

b e t h e o f f A f t e r c a n

s p o n g e - b a t h e d u m b i l i c a l ( a b o u t t h a t c o r d

1 0 - 1 4 o c c u r s ,

d a y s ) . b a b i e s

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n e e d t h a n d a y . l e a d

W a s h i n g t o d r y b e A f t e r p o w d e r s I f d r y o r c a n

o f t e n

s k i n . w a r m ,

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s h o u l d h o t . a n d

b a t h i n g , a r e s k i n n o t

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d e v e l o p s , ( l i k e I f

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c a p , " o n

i n c l u d e s w e e k l y

s h a m p o o l i k e

p r o d u c t

S e b u l e x .

T h e s h o u l d e v e r y

u m b i l i c a l b e 4 - 6

c o r d c l e a n e d

h o u r s

w i t h

r u b b i n g c o t t o n .

a l c o h o l

a n d

I n f a n t s B a b i e s

n e e d s l e e p t h e

s l e e p . m a n y d a y , h o u r s a n d

t h r o u g h o u t s l e e p f r o m n e x t . w e e k s , s l e e p r o o m . p l a c e d S l e e p i n g h a s b e e n i n

p a t t e r n s o n e D u r i n g b a b y t h e t o

d i f f e r t h e f e w

f i r s t

b a b i e s t h e

s h o u l d p a r e n t s ' s h o u l d b e

B a b i e s o n o n

t h e i r t h e

b a c k s . a b d o m e n t o S I D S d e a t h

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

( s u d d e n s y n d r o m e ) .

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n e e d

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

i n c l u d e s

t a l k i n g

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a n d

h o l d i n g

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I n f a n t s C r y i n g

" t a l k " a n d t o d a y . a r e i n

b a b i e s s e v e r a l B a b i e s h u n g r y , p a i n , o r

s i c k , h a v e a

a n g r y , a w e t b a b y

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W h e n e v e r t h e

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

c o n s i d e r f i r s t . a l s o

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r e a s o n , t h e y m a y

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w h o

t h e i r c a l l e d u s u a l l y a f e w

h o u r s

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m o n t h s . y o u c a n

I f t r y :

t h i s

o c c u r s ,

o

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b a b y

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d u r i n g s / h e

p e r i o d s i s n o t

o

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t h e

o

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t h e

b a b y

m o r e

d u r i n g

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o

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o

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r o c k i n g t h e b a b y

o r

I n f a n t s

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m e d i c a l

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g o o d

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D u r i n g w i t h a

" w e l l - b a b y h e a l t h i n f a n t d e v e l o p m e n t m o n i t o r e d . p r o v i d e r s c o m m o n c o n d i t i o n s

p r o v i d e r , a n d b e

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

c h i l d h o o d a n d p r o v i d e

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

APGAR The APGAR scoring provides a valuable index for assessing the newborn’s condition at birth. The APGAR Score standardizes infant evaluation and serves as a baseline for future evaluations. Using the APGAR system, the infant is assessed at one minute and 5 minutes after birth. An infant whose total score is under 4 is in serious danger and needs resuscitation. A score of 4 to 6 means that the condition is guarded and the baby may need clearing of the airway and

supplementary oxygen. A score of 7 to 10 is considered good. The highest score is 10. Immediate Puerperium: Sign Heart Rate Respirato ry Effort Muscle Tone Reflex Irritability Color No Response Blue pale Body Flaccid 0 Absent Absent 1 Slow <100 Slow, irregular, weak cry Some flexion of Cry and 2 2 >100 Good strong cry Well flexed 2 Score 2 2

extremities Grimace

withdrawal of foot pink, Completely pink 10 2

extremities blue

The first 24 hours after birth, or the immediate puerperium, is a critical stage. This is the time when your uterus has to contract well, in order to stop the bleeding from the site of placental attachment. It is also the initiation of breastfeeding and bonding. Occasionally, this is the time that most life threatening complications of delivery manifest.

These include postpartum excessive bleeding, collapse of the circulation, cardiac failure, etc. These are not common, but even with normal vaginal birth there is a risk of death of about 1 in 10,000 women. This risk may be more in women with pre-existing medical conditions like anaemia, hypertension or heart diseases. It is also more with operative deliveries. Hence you will be advised to stay in hospital for at least 24 hours following childbirth. Early Puerperium: This refers to the 2<sup>nd to 7<sup>th day post delivery where major changes start in your genital tract. This is probably also the time of maximum adjustment when you come to terms with your new role as ‘mother’. You will also be going home with your baby in this period. There are many relatively minor, yet significant bodily changes you should be aware of. These include: Lochia / Vaginal discharge: This term refers to the discharge from the vagina, coming mainly from shedding of the inner lining of the uterus. For the first 4 days, there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You may need to use 2 pads at a time, changing 3 – 4 times a day. However, if you find it very heavy, or large clots keep coming out, you must inform your doctor. Usually by the 5<sup>th day the flow

becomes much less, and may now be more of a blood stained yellowish-brown discharge. You may still require sanitary protection, about 2 – 3 pads a day. This discharge called ‘lochia serosa’ usually stops by the end of the second week after which it becomes a plain white discharge. Good hygiene and care of episiotomy will prevent infection. Any foul smell in the discharge should be reported to your doctor. Urination: The first day you must pass urine at least 2 – 3 hourly, despite pain in the stitches. This is because the bladder may become overfull without you realize it, which can cause problems, especially infections later. During the first week, you may notice that you seem to be passing a lot of urine. This is because your body is removing some of the excess water and salt that was retained in pregnancy. Stools:

You may not have a good bowel motion for the first 2 days following delivery, for various reasons. One is that you have not eaten much during labor, you are exhausted and sleepy. Secondly you may be having pain in the stitches of the episiotomy It is important to take a

high fiber diet and plenty of liquids to prevent hard stools. You may need a mild laxative for a few days.

Breast:

The first day you will have only a watery, yellowish discharge, not looking like ‘real’ milk coming from the breasts. This is called colostrum and it is rich in many nutritive factors that are needed by your baby. You must feed your baby at this time. By the third day, the milk flow increases a lot, due to hormonal changes in your body. Regular feeding is important to prevent engorgement. Link to engorged breast in Breastfeeding. After – Pains: The delivery is over. You have borne with labor pains. So now you may be worried that you are still getting a cramping lower abdominal pain off and on. Don’t worry, there is nothing left inside! This is a normal phenomenon, which occurs due to the uterus contracting in response to oxytocin, a natural body hormone. This is more marked when you are breastfeeding. Link to letdown reflex in Breastfeeding. It is nature’s way of getting your uterus back to the normal size. If the pain is

severe, or you are having other symptoms like fever or excess bleeding, you need to inform your doctor. Early Puerperium: This refers to the 2<sup>nd to 7<sup>th day post delivery where major changes start in your genital tract. This is probably also the time of maximum adjustment when you come to terms with your new role as ‘mother’. You will also be going home with your baby in this period. There are many relatively minor, yet significant bodily changes you should be aware of. These include: Lochia / Vaginal discharge: This term refers to the discharge from the vagina, coming mainly from shedding of the inner lining of the uterus. For the first 4 days, there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You may need to use 2 pads at a time, changing 3 – 4 times a day. However, if you find it very heavy, or large clots keep coming out, you must inform your doctor. Usually by the 5<sup>th day the flow becomes much less, and may now be more of a blood stained yellowish-brown discharge. You may still require sanitary protection, about 2 – 3 pads a day. This discharge called ‘lochia serosa’ usually stops by the end of the second week after which it becomes a plain white discharge. Good hygiene and care of episiotomy will prevent

infection. Any foul smell in the discharge should be reported to your doctor. Urination: The first day you must pass urine at least 2 – 3 hourly, despite pain in the stitches. This is because the bladder may become overfull without you realize it, which can cause problems, especially infections later. During the first week, you may notice that you seem to be passing a lot of urine. This is because your body is removing some of the excess water and salt that was retained in pregnancy. Stools:

You may not have a good bowel motion for the first 2 days following delivery, for various reasons. One is that you have not eaten much during labor, you are exhausted and sleepy. Secondly you may be having pain in the stitches of the episiotomy It is important to take a high fiber diet and plenty of liquids to prevent hard stools. You may need a mild laxative for a few days.

Breast:

The first day you will have only a watery, yellowish discharge, not looking like ‘real’ milk coming from the breasts. This is called colostrum and it is rich in many nutritive factors that are needed by your baby. You must feed your baby at this time. By the third day, the milk flow increases a lot, due to hormonal changes in your body. Regular feeding is important to prevent engorgement. Link to engorged breast in Breastfeeding. After – Pains: The delivery is over. You have borne with labor pains. So now you may be worried that you are still getting a cramping lower abdominal pain off and on. Don’t worry, there is nothing left inside! This is a normal phenomenon, which occurs due to the uterus contracting in response to oxytocin, a natural body hormone. This is more marked when you are breastfeeding. Link to letdown reflex in Breastfeeding. It is nature’s way of getting your uterus back to the normal size. If the pain is severe, or you are having other symptoms like fever or excess bleeding, you need to inform your doctor. Care of Episiotomy:

If you have had stitches on your perineum there are a few things you need to do, particularly in the first week, to make yourself comfortable and keep healthy.

Cleaning the area at least twice a day, with local dilute antiseptic solution like Savlon or Dettol. E – com. This is a must after passing stools, and washing with water should be done after passing urine. Remember, always wash from front to back, never the other way, to prevent infection.

Local application of antiseptic creams such as Soframycin, Metrogyl gel, Betadine E – com may be useful to prevent infection. This is usually done twice daily, after bath and before going to sleep at night.

Pain relieving methods such as hot seitz baths, hot water washes or hot water bag may be useful. For a seitz bath you need a round tub large enough for your bottom to fit in, in which hot water with dilute antiseptic solution is kept. These measures make you feel better, usually.

Another way of getting pain relief is local application of ointment such as 2% xylocaine, E – com, which acts as a local pain-reliever.

Infrared lamp to apply day heat to the area of stitches may be given to you in hospital.

Oral medications such as antibiotics to prevent infection, or pain killer tablets (paracetamol, ibuprofen, etc. E – com) should only be

taken as advised by your doctor.

Most doctor use stitches, which dissolve on their own and / or fall off after a few days. Ask your doctor if you need to come back to show the stitches.

Post Partum Blues: There are many changes, which have happened to you in the past 9 months, and even more are happening now. You may be feeling a little left out or dissociated from your surroundings. Link to introduction of puerperium The swings in your hormone levels are maximum in the first week. Your baby may be keeping you awake all the time, your breasts feel sore, and your stitches are hurting ……. Many things add up to make you feel down. Many women feel low or depressed soon after delivery – in fact, it is so common that there is a medical team for it, called ‘fifth day blues’! Talk to your partner, your friends, an older relative or your health care persons. Ask for help with the baby if you are tired. Have a good cry. Take a break, sleep for a while and you will feel better. If this feeling of depression does not settle in a few days, then perhaps you should see your doctor for help, Sometimes an underlying hormonal problem like low thyroid function

may be causing these feelings.Remember that these feelings are not uncommon. You are not the only mother who is not feeling ‘100% maternal love’ all the time, particularly soon after delivery. Be good to yourself, pamper yourself also, and talk about what you feel. Soon, you too will feel on ‘top of the world’! Resuming Activities: As discussed earlier, it takes up to 6 weeks for your body to recover from the changes of pregnancy. So, be patient with yourself. Listen to your body and do as much as you feel up to, Different women have different abilities to deal with their health changes. However, in most cases, after a normal vaginal delivery, you will be able to resume your daily personal care activities within a day, and your household routine within a week, Don’t overexert yourself – This is the time you need to devote to yourself and your baby. Take help, involve your partner, Link to Father’s role, and others available to make your life easier. After a complicated childbirth, or after a caesarean delivery your recovery may take twice as much time, so be patient. Postnatal Exercises: Sexual Activity is best avoided in the early post delivery period. This is because your stitches may be raw or painful, and your genital tract is prone to infection, particularly in the 1<sup>st week. Complete

restoration of the lining of the uterus, including the placental site, is not complete. Hence traditionally some advise abstinence till 6 weeks following delivery.However, if you have had an uncomplicated birth, and are not having any problems, you could resume your sexual life earlier. You and your partner may have been deprived of each other, particularly in the last month of pregnancy. Hence, it is not unusual to feel the need to renew your sex – life. Until you feel comfortable for actual penetrative sexual intercourse, other displays of caring and affection can suffice. Hugging, kissing, petting or touching is not forbidden at anytime during pregnancy or post-delivery. Lactational Amenorrhoea: Link to Lactation amenorrhoea in Preventing Pregnancy. While you are exclusively breastfeeding, Link to exclusive breastfeeding in Breastfeeding, the hormonal changes is your body act on the genital tract to suppress ovulation and menstruation. Link to female

reproductive, tract, ovulation, and menstruation. You may not get your periods for a few months. Some women do not start menstruating for up to a year, depending on the pattern and frequency of

breastfeeding. Timing Menstruation Earliest ovulation Average time No lactation 6 – 12 weeks 4 weeks for 8 – 10 weeks If lactation established 36 weeks (average) 12 weeks 17 weeks (variable)

ovulation. Does this mean you cannot get pregnant? The answer is NO. About 5% of women get pregnant before they start menstruating, post-delivery. Lactational amenorrhoea (absence of periods) does protect you from pregnancy to some extent. However, you can rely completely on Lactational amenorrhoea as a method of preventing pregnancy ONLY IF ALL 3 preconditions listed below are satisfied: Contraception: If you are relying on lactational amenorrhoea. If not, that brings us to the important question: Are you ready for another pregnancy? You need to give your body time to recover, your baby time to grow up and yourself time to adjust to the new role of ‘mother’. Of course, it is a question of personal choice but a minimum gap of 2 years is recommended between successive pregnancies . So, how can you prevent pregnancy during the post-delivery period?

There are many methods available. During the post partum period, however, certain factors need to be kept in mind: Whether breastfeeding or not. Frequency of sexual intercourse. For how long pregnancy prevention is required. The final choice is also influenced by your personal needs and experience. Others:

Condoms Condoms are a good, locally acting method, which are reliable if used correctly and consistently. They have no side effects and are useful for couples with less frequent sexual intercourse. IUCDs or ‘loops’: These are a very reliable method, requiring one visit to the doctor for insertion, which can be done easily without anaesthesia. They are effective for average 3 – 5 years (depends on the device) and are independent of the sexual act, unlike condoms. This is a very popular method for women with one or more children. Infact, can be used as an option to permanent procedure. The IUCD can be inserted at the first postnatal visit. Link (6 weeks from childbirth) or later, even if you do not have periods, provided your internal checking is normal. Oral Contraception pills: These are a type of hormonal contraception. During the period of exclusive breastfeeding the combined Oral Contraception pills

(containing Estrogen + Progesterone) may reduce the breast milk flow. Hence are not popularly recommended. Once weaning is begun, there can be used safely. Sterilisation:

This is a permanent method, which can be opted for after you have completed your family. This is a procedure which can be done easily immediately post-delivery (puerperial sterilization) or at the time of caesarean section. For both these options, you need to discuss the pros and cons with your doctor and spouse before delivery, ideally in one early antenatal period. Some prefer to wait until the youngest child is older, preferably above 1 year old, before doing this permanent procedure. As an interval procedure, 6 weeks or more after delivery, it is usually done by laparoscopy. First Postnatal Visit: You and your baby have been through a lot. After you go home, and you recover from childbirth, your doctor will need to see you at least once to confirm that your recovery is complete. The first check up is usually 6 weeks from delivery. It may be earlier, about 3 weeks, if you have needed special care or had any problem in delivery. At the first visit, your doctor will check Your weight. Blood pressure. Signs of anaemia. Your breasts. Your episiotomy scar (should be dissolved by now). Your uterus (to see if it is shrinling back to normal size).

You may need to do some tests. You need to discuss the following issues with your doctor Restoration of your complete health. Postnatal exercises Diet and nutrition. Your baby’s health. Immunization schedule. Continuing exclusive breastfeeding Contraception. ESTABLISH SUCCESSFUL LACTATION In most of the hospital they require the mothers who delivered there to breast reed as soon as possible because the baby will receive colostrums that contains gamma feeding to the mother are: globulins. Advantages of breath

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 Cardiac Rate 130/90 mmHg 80 bpm

Respiratory Rate 24 cpm

Temperature

37.5 c

1. Condition of the Uterus I checked the fundus with my clients back flat an bed with her feet together and knees apart. I asked her to empty her bladder and she was able to do it. With one supporting the lower fundus just above the symphisis pubis, I cupped my hands around the fundus and rotated it gently. I noted that the fundus smaller. is getting firmer and slowly getting

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 breastfeeding. to eat most especially after

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 breastfeed 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 preterm 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 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. wake up breastfeeding is more effective if the

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 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 oxytocin which in form

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. and relax the muscles surrounding the vagina as

2. Contract

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 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 pubococcygeal strengthening of exercise before, water into the vagina. Hold for 3 secs.

muscles are strengthened. In addition to 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 infront of

exhales normally. Holding her finger about 6 inches

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 on the first day postpartum, because started

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 abdominal muscles. 2. Chin – to chest – chin to chest exercise is excellent for the her

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 voiding. She will feel her perineal 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 as if the trying to stop if she is

muscles working

touch and lowers them slowly to her sides. She should rest a moment, then repeat the exercise 5 times. 5. Abdominal Crunches - It s advisable to wait until to 10th and 12th day after delivery before attempting abdominal crunches. Lying flat an her back with knees bent a woman folds her arms across her chest and raises herself to a sitting position. This

exercise expenses a great deal foe effort and tires a postpartum woman easily. She should be cautioned to begin it very gradually and work up slowly to doing it 10 times in a row.

Choosing to be in the college of nursing entails a lot of hard work and perseverance to achieve the degree you’ve been aiming for. You need to give your best shot in every situation the school is putting you, we are like animals we lash out in order to survive. I, Sarrah Jane A. De Guzman, a now graduating student is now ready to meet and face the world’s demands. I’ve grown up and achieved the confidence needed to reach success yet as humble as can be. My parent’s, together with the institution aided in my quest for

wisdom and proper values which I’ll be needing as my weapons as I come to reach the top of the mountain. I once used to be naïve but as I mature and reach this stage, I’ve come to know that you can never reach your destination if you’re unwilling to move your feet. And now I’m coming out from my shell to meet the wonderful future I have of becoming a Registered Nurse.

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