DEDICATION

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

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

INTRODUCTION
Someone once said, “pregnancy begins at that unfelt, unknown moment of time when a single, wiggling sperm penetrates a mature ovum. Even though this momentous event of fertilization occurs without notice, the changes, which take place within the mothers’ body in the next nine months, are undeniable and amazing. Yeah, our coming to earth is really magical and we should thank our mothers for they sacrificed their lives just to give us our precious gift… our LIFE. Childbirth is a good metaphor for life. It begins at time of conception, when long gestation by hard labor to bring forth a new creation. Mixed passion and discomfort strike before fulfillment. For every person going through the process of birth, there is a possibility of transformation at the individual and the family level. That’s why everyone views birth as the most critical time, a hopeful time. In many ways, birth has become crucible in which modern woman is around and burned; it is our testing place. But there’s value in this work. True-births have often been difficult and painful, but pain can be essential part of growth. Maternal and child care is a philosophy based on the consideration of a mother and child in relation to each other and consideration of a whole family with each meaningful relationship as well as its cultural and socio-economic environment of the client. The overall trust of maternity care is to assist each mother throughout the stage of pregnancy, labor and delivery and the puerperium in such a way that minimal discomfort will be experienced and to ensure optimal health and well being for the mother and her newborn. Sure care must also meet the psychological needs of the mother and her partner and their contribution to satisfactory infant- maternal bonding following delivery.

Obstetrics

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

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

Pregnancy
Period of time between fertilization of the ovum (conception) and birth, during which mammals carry their developing young in the uterus (see embryo). The duration of pregnancy in humans is about 280 days, equal to 9 calendar months. After the fertilized ovum is implanted in the uterus, rapid changes occur in the reproductive organs of the mother. The uterus becomes larger and more flexible, enlargement of the breasts begins, and alteration of renal function, blood volume, and blood cell count occur. Movement of the fetus and fetal heartbeat can be detected early in pregnancy. One test that has been used to determine pregnancy uses blood or urine samples to detect a hormone known as BhCG, found exclusively in pregnant women. Later, prenatal diagnostic tests such as alpha fetoprotein, amniocentesis, and chorionic villus sampling may be performed as screening measures for congenital defects. Ultrasound, a sonar device using high-frequency wavelengths, is used to detect defects, measure fetal heartbeat, and monitor growth of a fetus. Complications of pregnancy

include eclampsia, premature birth, and erythroblastosis fetalis (Rh incompatibility). Ectopic pregnancy, in which the fetus begins to develop outside the uterus, often in a fallopian tube, is another complication. It is often the result of scarring from a sexually transmitted disease. Smoking has been linked to low—birth weight infants; alcohol consumption during pregnancy has been linked to a group of defects called fetal alcohol syndrome. The technology relating to pregnancy has made great advances and has created a number of ethical issues. Many women in their 40s are now able to sustain successful pregnancies, due to technological devices that carefully monitor the progress of the fetus. In vitro fertilization and other infertility treatments have allowed even postmenopausal women to give birth. The use of fertility drugs has led to a marked increase in multiple births. Abortion, in which pregnancy is terminated prior to birth, has long been a subject of heated debate, and surrogate motherhood (see surrogate mother) has also raised ethical issues in recent years Reproduction is the process by which organisms produce more organisms like themselves. All living things, including humans, reproduce: it's one of the things that set us apart from nonliving matter. And because all living things eventually die, new creatures of the same kind must constantly be born to perpetuate a particular species. Interestingly, although the reproductive system is essential to keeping a species alive, unlike other body systems, it is not essential to keeping an individual being alive.

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

A missed period, spotting, or a period with less bleeding than normal Nausea or vomiting Tender, swollen, or tingling breasts Fatigue Changes in appetite or digestion Frequent urination and urgency

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

Anatomy and Physiology

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

Left Ovary

Right Ovary

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

Ovary and Fallopian Tube Ligaments

Uterine Tube and Ovary with

Most species have male and female organisms. Each sex has its own unique reproductive system. They are different in shape and structure, but both are specifically designed to produce, nourish, and transport either the egg or sperm. Unlike its male counterpart, the female reproductive system is almost entirely hidden within the pelvis. It

consists of organs that enable a woman to produce eggs (ova), to have sexual intercourse, to nourish and house the fertilized egg (ovum) until it is fully developed, and to give birth.

`Females also have external organs collectively called the vulva (which means "covering"). Located between the legs, the outer parts of the vulva cover the opening to a narrow canal called the vagina. The fleshy area located just above the top of the vaginal opening is called the mons pubis. A thin sheet of tissue called the hymen partially covers the opening of the vagina. Two pairs of skin flaps, the labia (which means "lips") surround the vaginal opening. The clitoris, which is located toward the front of the vulva where the folds of the labia join, is a small cylindrical structure similar to the male penis; it also contains erectile tissue. Inside the labia are openings to the urethra (the canal that carries urine from the bladder to the exterior of the body) and vagina. The outer labia and the mons pubis are covered by pubic hair in the sexually mature female. The female internal organs are the vagina, uterus, fallopian tubes, and ovaries. The vagina is a 3- to 6-inch-long tubular structure that extends from the vaginal opening to the uterus. It has muscular walls lined with mucous membrane, and it serves as the female organ of copulation (sexual intercourse) as well as the birth canal. It connects with the uterus, or womb, which houses the fetus during pregnancy. About 3 inches long and 2 inches wide and shaped like an inverted pear, the uterus is a muscular, expandable organ with thick walls At the lower part of the uterus is the cervix, which opens into the vagina. At the upper part, the fallopian tubes connect the uterus with the ovaries, two oval-shaped organs that lie to the right and left of the uterus. They produce, store, and release eggs through the fallopian tubes into the uterus. The ovaries also produce the hormones estrogen and progesterone. Also part of the

reproductive system are the breasts. Mammary glands inside the breasts secrete milk after childbirth.

Normal Physiology
The organs of sexual reproduction are the gonads, which are the ovaries in females and the testes in males. Females produce female gametes, or eggs; males produce male gametes, or sperm. Sexual reproduction is the fertilization of a female gamete by a male gamete. When a female is born, each of her ovaries has hundreds of thousands of eggs, but they remain dormant until her first menstrual cycle, which occurs during puberty. At this time, during adolescence, the pituitary gland secretes hormones that stimulate the ovaries to produce female sex hormones, including estrogen, which helps the female develop into a sexually mature woman. Also at this time, females begin releasing eggs as part of a monthly period called the menstrual cycle. Approximately once a month, during ovulation, an ovary discharges a tiny egg that reaches the uterus through one of the fallopian tubes. Unless fertilized by a sperm while in the fallopian tube, the egg dries up and is expelled about 2 weeks later from the uterus during menstruation. Blood and tissues from the inner lining of the uterus combine to form the menstrual flow, which usually lasts from 3 to 5 days. If a female and male have sexual intercourse within several days of ovulation, fertilization can occur. When the male ejaculates, about one tenth of an ounce of semen is deposited into the vagina. Between 200 and 300 million sperm are in this small amount of semen, and they "swim" up from the vagina through the cervix and uterus to meet the egg in the fallopian tube. It takes only one sperm to fertilize the egg. About a week after the sperm fertilizes the egg, the fertilized egg has become a multicelled blastocyst, a pinhead-sized hollow ball with fluid inside, now housed in the uterus. The blastocyst burrows itself into the lining of the uterus, called the endometrium. Estrogen causes the endometrium to thicken and become rich with blood, and progesterone, another hormone released by the ovaries, maintains the thickness of the endometrium so that the blastocyst can attach to the uterus and absorb nutrients from it. This process is called implantation. As cells from the blastocyst take in nourishment, the embryonic stage of development begins. The inner cells form a flattened circular shape called the embryonic disk, which will develop into a baby. The outer cells become thin membranes that form around the baby. The embryonic cells multiply thousands of times, move to new positions, and eventually become the embryo. After approximately 8 weeks, the embryo is about the size of an adult's thumb, but all of its parts - the brain and nerves, the heart and blood, the stomach and intestines, and the muscles and skin - have formed. During the fetal stage, which lasts from 9 weeks after fertilization to birth, development continues as cells multiply, move, and differentiate. The fetus floats in amniotic fluid inside the amniotic sac. Its oxygen and nourishment come from the mother's blood via the placenta, a disk-like structure that adheres to the inner lining of the uterus and is connected to the umbilical cord. The umbilical cord attaches the embryo at its navel to the mother's uterus. The umbilical arteries in the cord carry blood from the fetus to the placenta, and an umbilical vein returns blood from the placenta to the fetus. The amniotic fluid and membrane cushion the fetus against bumps and jolts to the mother's body.

Pregnancy lasts an average of 266 days. When the baby is ready for birth, its head presses on the cervix, which begins to relax and widen to get ready for the baby to pass into and through the vagina, which has enlarged to become the birth canal. The mucus that has formed a plug in the cervix loosens, and with amniotic fluid, comes out through the vagina when the mother's "water" breaks. When contractions begin, the uterine walls contract as they are stimulated by the pituitary hormone oxytocin. The contractions cause the cervix to widen and begin to open. After several hours of this widening, the cervix is dilated (opened) enough for the baby to come through. The baby is pushed out of the uterus, through the cervix, and along the birth canal. The baby's head usually comes first; the umbilical cord comes out with the baby and is cut after the baby is delivered. The last stage of the birth process involves the delivery of the placenta, which is now called the afterbirth. It has separated from the inner lining of the uterus, and through further contractions of the uterus it is expelled with its membranes and fluids.

Menstruation
A menstrual cycle (also termed a female reproductive cycle) can be defined as episodic uterine bleeding in response to a cyclic hormonal changes. It is the process that allows for conception and implantation of a new life. The purpose of a menstrual cycle is to bring an ovum to maturity and renew a uterine tissue bed that will be responsible for its growth should it be fertilized. Menarche, the first menstrual period in girls, may occur as early as age 8- 9 or as late as 17 and still be within normal limits. Because menarche may occur as early as age 9 years, it is good to include health teaching information on menstruation to both girls and their parents as early as 4th grade as part of routine care. It is a poor introduction to sexuality and womanhood for a girl to begin menstruation unwarned and unprepared for the important internal function it represents. The length of menstrual cycle differs from woman to woman, but the accepted average length is 28 days (from the beginning of one menstrual flow to the beginning of the next). However, it is not unusual for cycles to be as short as 23 days or as long as 35 days. The length of the average menstrual flow is (termed memses) is 2 to 7 days although women may have periods as short as 1 day or as long as 9 days. Because there is such variation in length, frequency, and amount of menstrual flow and such variation in he onset of menarche, many women have questions about what is considered normal. Contact with health care personnel during the yearly health examination or pre- natal visit is often the first opportunity some women have to ask question they have had for sometime.

PHASES OF MENSTRUAL CYCLE 1. Proliferative Phase

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

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

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

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

TEACHING ABOUT MENSTRUAL HEALTH

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

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

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

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

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

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

Stages of Fetal Development
In just 38 weeks, a fertilized egg matures from a single cell carrying all the necessary genetic material to a fully developed fetus ready to born. Fetal growth and development is typically divided into three periods. Pre- embryonic (First 2 weeks beginning with fertilization); embryonic (from 3 weeks through 8), and fetal (from week 8 through birth). Ovum Zygote Embryo Fetus Conceptus From ovulation to fertilization From fertilization to implantation From implantation to 5 – 8 weeks From 5 – 8 weeks until term Developing embryo or fetus and placental structures throughout pregnancy

Milestones of Fetal Growth and Development
The life of the fetus is generally measured from the time of ovulation or fertilization (ovulation age), but the length of pregnancy is generally measured from the first day of the last menstrual period (gestational age). Because ovulation and

fertilization take place about 2 weeks after the last menstrual period, the ovulation age of the fetus is always 2 weeks less than the length of the pregnancy or the gestational age. Both ovulation and gestational age are also sometimes measured in lunar months (4 - week periods) or in trimesters (3- month. Period) rather than in weeks. In lunar months, a pregnancy is 10 months (40 weeks or 280 days) long; a fetus grows in utero 9.5 lunar months or three full trimesters (38 weeks or 266 days)

End of 4 Gestation Weeks
At the end of the 4th week gestation, the human embryo is rapidly growing formation of cells but does not resemble a human being yet. • Length: 0.75 to 1 cm. • Weight: 400 mg. • The spinal cord is formed and fused at the midpoint. • Lateral wings that will form the body are folded forward to fuse at the midline. • Head folds forwards, becoming prominent, comprising about one third of the entire structure. • The back is bend so the head almost touches the tip of the tail. • The rudimentary heart appears as a prominent budge on the anterior surface. • Arms and legs are bud like structures. • Rudimentary eyes, ears and nose are discernible.

End of 8 Gestation Weeks
• • • • • • • • • • Length: 2.5 cm (1cm). Weight: 20 g. Organogenesis is complete. The heart, with a septum and values, is beating rhythmically. Facial features are definitely discernible. Extremities have developed. External genitalia are present, but sex is not distinguished by simple observation. Primitive tail regressing. Abdomen appears large as the fetal intestine is growing rapidly. Sonogram shows gestational sac, diagnostic of pregnancy.

End of 12 Gestation Weeks (First Trimester)
• • • • • • • Length: 7 to 8 cm. Weight: 45 g. Nail beds are forming on fingers toes. Spontaneous movements are possible, although usually too faint to be felt by the mother. Some reflexes, such as Babinski reflex are present. Bone ossification centers are forming. Tooth buds are present.

• • •

Sex is distinguishable by outward appearance. Kidney secretion has begun, although urine may not be evident in amniotic fluid. Heart beat is available by a Doppler

End of 16 Gestation Weeks
• • • • • • • Length: 10 to 17 cm. Weight: 55 to 120 g. Fetal heart sounds are audible with an ordinary stethoscope. Lanugo (fine, downy hair on the back and arms of newborns, apparently serving as a source of insulation for body heart) is well formed. Liver and pancreas are functioning. Fetus actively swallows amniotic fluid, demonstrating an intact but uncoordinated swallowing reflex, urine is present in amniotic fluid. Sex can be determined by ultrasound.

End of 20 Gestation weeks
• • • • • • • • • • Length: 25 cm. Weight: 223 g. The mother can sense spontaneous fetal movements. Antibody production is possible. Hair forms, extending to include eyebrows and hair on the head. Meconium is present in the upper intestine. Brown fat, a special fat that will aid in temperature regulation at birth, begins to be formed behind the kidneys, sternum and posterior neck. Fetal heart beat is strong – enough to be audible Vernix caseosa, a cream cheese -like substance produced by the sebaceous gland that serves as a protective skin covering intrauterine life, begins to form. Definite sleeping and activity patterns are distinguishable (the fetus has developed biorhythms that will guide sleep /wake patterns throughout life).

End of 24 Gestation Weeks (Second Trimester)
• Length: 28- 36 cm. • Weight: 550 g. • Passive antibody transfer from mother to fetus probably begins as early as 20th week of gestation, certainly by the 24th week of gestation. Infants born before antibody transfer has taken place have natural immunity and need more than the usual protection against infectious disease in the newborn period until the infant’s own store pf immunoglobulins can build up. • Meconium is present as far as the rectum. • Active production of lung surfactant begins. • Eyebrows and eyelashes are well defined. • Eyelids, previously fused since the 12th week, are now open. • Pupils are capable of reacting to light. • When fetuses reach 24 weeks or 601 g, they have achieved a practical low- end age of viability if they are cared for after birth in a modern intensive care facility. • Hearing can be demonstrated by response to sudden sound.

End of 28 Gestation Weeks
• • • • • • Length: 35 to 38 cm. Weight: 1,200 g. Lung alveoli begin to mature, and surfactant can be demonstrated in amniotic fluid. Testes begin to descend into the scrotal sac from the lower abdominal cavity. The blood vessels of the retina are extremely susceptible to damage from high oxygen concentrations (an important consideration when caring for preterm infants who need oxygen). The eyes open.

End of 32 Gestations Weeks
• • • • • • • • Length: 38-43 cm. Weight: 1,600 g. Subcutaneous fat begins to be deposited (the former is stringy “ Little old man” appearance is lost). Fetus is aware of sounds outsides the mothers body. Active Moro reflex is present. Birth position (vertex or breech) may be assumed. Iron stores that provide iron for the time during which the neonate will ingest only milk after the birth are beginning to be developed. Finger nails grow to reach the end of the fingertips.

End of 36 Gestation weeks
• • • • • • • • • • • • • • Length: 42 to 49 cm. Weight: 1,900 to 2,700 g (5 – 6 lbs). Body stores of glycogen, iron, carbohydrate and calcium are augmented. Additional amounts of subcutaneous fat are deposited. Sole of the foot has only one or two crisscross crisscross creases compared with the full crisscross pattern that will be evident at term. Amount of lanugo begins to diminish. Most babies turn into vertex or head – down presentation during this month.

End of 40 gestation Weeks (Third Trimester)
Length: 48 to 52 cm (crown to rump, 35 to 37 cm). Weight: 3,000g (7 – 7.5 lbs). Fetus kicks actively, hard enough to cause the mother considerable discomfort. Fetal hemoglobin begins its conversion to adult hemoglobin. The conversion is so rapid that, at birth about 20% hemoglobin will be adult in character. Vernix caseosa is fully formed. Fingernails extend over the fingertips. Creases on the soles of the feet cover at least two thirds of the surface.

In primiparas (women having their first baby), the fetus often sinks into the birth canal during these last 2 weeks, giving the mother a feeling that her load is being

lightened. This event is termed lightening. It is the fetal announcement that the third trimester of pregnancy has ended and birth is at hand.

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

Evolution of the Western Family
The patriarchal family, which prevailed among the ancient Hebrews, Greeks, and Romans, is often associated with polygamy. In Rome, the paterfamilias was the only person recognized as an independent individual under the law. He possessed all religious rights as priest of the family ancestor cult, all economic rights as sole owner of the family property, and power of life and death over the members of the family. At his death, his name, property, and authority descended to his male heirs. The Roman system was transferred in many of its details into both the canon and secular law of Western Europe. In the 19th century, when the Western nations began to grant women equal rights with men with respect to the ownership of property, the control of children, divorce, and the like, basic changes took place in the structure of the family, and the rights and protections associated with it. The state has also intervened to modify the authority of parents over their children. At the same time, education has shifted increasingly from the household to the school. The effect has been to loosen traditional family ties. In Western Europe, where legislation provides equal financial benefits and legal standing to all children, families have increasingly come to consist of one or two

unwed parents and children, especially in Scandinavia and other part of N Europe. Another factor affecting the modern Euro-American family was the Industrial Revolution, which removed from the home to the factory many economic tasks, such as baking, spinning, and weaving. Economic and social conditions have discouraged the presence of the husband and father in the home; in industrial communities the wife and mother also is often employed outside the home, leaving the children to be cared for by others. Sociologists and psychologists find in these changed relations of the members of the family to each other and of the family to the community at large the source of many problems such as divorce, mental illness, and juvenile delinquency.

RESPONSIBLE PARENTHOOD Responsible Parenthood
We affirm the principle of responsible parenthood. The family, in its varying forms, constitutes the primary focus of love, acceptance, and nurture, bringing fulfillment to parents and child. Healthful and whole personhood develops as one is loved, responds to love, and in that relationship comes to wholeness as a child of God. Each couple has the right and the duty prayerfully and responsibly to control conception according to their circumstances. They are, in our view, free to use those means of birth control considered medically safe. As developing technologies have moved conception and reproduction more and more out of the category of a chance happening and more closely to the realm of responsible choice, the decision whether or not to give birth to children must include acceptance of the responsibility to provide for their mental, physical, and spiritual growth, as well as consideration of the possible effect on quality of life for family and society. To support the sacred dimensions of personhood, all possible efforts should be made by parents and the community to ensure that each child enters the world with a healthy body and is born into an environment conducive to the realization of his or her full potential. When through contraceptive or human failure an unacceptable pregnancy occurs, we believe that a profound regard for unborn human life must be weighed alongside an equally profound regard for fully developed personhood, particularly when the physical, mental, and emotional health of the pregnant woman and her family show reason to be seriously threatened by the new life just forming. We reject the simplistic answers to the problem of abortion that, on the one hand, regard all abortions as murders, or, on the other hand, regard abortions as medical procedures without moral significance. When an unacceptable pregnancy occurs, a family—and most of all, the pregnant woman is confronted with the need to make a difficult decision. We believe that continuance of a pregnancy that endangers the life or health of the mother, or poses other serious problems concerning the life, health, or mental capability of the child to be, is not a moral necessity. In such cases, we believe the path of mature Christian judgment may indicate the advisability of abortion. We support the legal right to abortion as established by the 1973 Supreme Court decision. We encourage women

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

 encourage men and women to actively demonstrate their responsibility by creating a family context of nurture and growth in which the children will have the opportunity to share in the mutual love and concern of their parents;  be aware of the fears of many in poor and minority groups and in developing nations about imposed birth-planning, oppose any coercive use of such policies and services, and strive to see that family-planning programs respect the dignity of each individual person as well as the cultural diversities of groups.

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

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

Nursing Diagnosis- is a statement that describes a patient’s actual or potential
health problem, which are potentially responsive to nursing therapy.

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

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

Evaluation- it measures the client’s response to nursing actions and the client’s
progress toward achieving goals. Evaluation is the ongoing and occurs when the nurse has contact with a client. The emphasis is on client outcomes. The nurse evaluates

whether the client’s behavior or responses reflect a reversal or improvement in a nursing diagnosis or maintenance of a healthy state.

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

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

Maternal History 1. Obstetrical Score G2P1(2-0-01)
G1- 2007- M- NSD- Cephalic- TBA-Alive G2- 2009- M- NSD- Cephalic- TBA-Alive

2. History of Present Pregnancy
1. LMP- February. 11, 2009 2. EDD- October 18, 2009: date of delivery: october 09,2009 3. AOG- 36 1/7 week

3. Physiological and Psychological Changes of Pregnancy

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

4. Past Health History
a. Family History Her mother is hypertensive and her father has arthritis. Both parents are not diabetic, doesn’t have asthma and non-TB carriers. b. Personal and Social History The patient is non- smoker and non-alcoholic drinker.

5. Prenatal check up: (/ ) yes ( ) no when : every week
where: barangay health center by whom: midwife frequency: every week

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

7. Reactions/ feelings regarding the newly born baby
A. they were so very happy because another member of the family was Added to them and they thank god because it is a healthy baby boy.

8. Reactions /feelings about breastfeeding?

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

9. Medications taken during pregnancy.
( ) Iron preparation ( ) Multivitamins ( x ) None

Gordon’ s Functional Health Pattern in Reproductive System 1. Health Perception- Health Management
o She stated that he has not suffered form any illness except for toothache. She said that she takes in one Ponstan, relief of pain was observed but there was recurrent pain. There was no minor infections with signs and symptoms of cough, fever and headache. She is aware and conscious of personal hygiene, safety and comfort. She takes a bath twice to thrice a day. She showed independence and autonomy in performing activities of daily living.

2. Nutritional- Metabolic Pattern
o The patient eats green leafy vegetables. Due to financial constraints, foods high in protein, high in calories and CHO was not eaten that much. She drinks adequate amount of water(6-8 g/day)

3. Elimination Pattern
o There were no problem in bowel elimination. Regular bowel habits are observed by the patient. At present, the patient urinate 3x/day, no significant changes in bowel elimination.

4. Activity-Exercise Pattern
o She use to perform her daily and takes care of her child and her husband.

5. Sleep-Rest
o She has a good sleeping habit during the entire pregnancy except for interrupted sleep prior to the delivery of her baby. She usually wakes up at night due to impending delivery. The patient had no night sweats.

6. Cognitive-Perceptual
o When the patient used to have her menstrual period, she experienced minor headache, irritability, bloating and breast tenderness. Not all signs exist at he same time before and during the menstruation period. Sometimes experience tolerable cramping before and during her menstrual period. She took pain reliever during her menstrual cramps. She didn’t have pain in her genital area. No vaginal itching, pain or dryness.

7. Self-perception- Self-Concept
o As a woman, patient’s problem with her reproductive system makes her anxious. She want also to undergo BTL because she is at risk for pregnancy especially

with her condition of having Polio. This was acquired when she was still a baby when she was rushed to the hospital due to convulsion. According to her, due to over dosage of medication that was administered to her, thus resulting the said condition.

8. Role-Relationship
o The patient had monthly sexual intercourse with her husband. She does not like to have another baby. She plans to under BTL. But with her decision, she has a good relationship with her husband and her family. With that, she still perform her responsibilities like taking care of her child and the needs within the family.

9. Sexuality-Reproductive
o There’s no history of reproductive problems in the patient’s family. Her menarche begun when she was 14 years old.

10. Coping-Stress
o She states that whenever she is angry due to the stubbornness of her children, she just sit down and take a rest, and at the same time drinks water to ease the tension she felt.

11. Value-Belief
o She was born Catholic and her cultural background influenced her sexual activities and her feelings about herself as a woman. She believes that she can still perform a lot of task and continually express various human emotions to other people despite of her condition.

Physical Assessment General Appearance
Patient is 31 year old, ambulatory, thin built, ambulatory morena in complexion, hair is unkept and the client was not dressed properly. There is also presence of slight body odor, too. She does her usual activities of daily living. Patient is conscious, coherent and oriented into spheres of time, place, and person, she is not also in cardiorespiratory distress. V/S: 110/80 mmHg T: 36.7 c RR: 18 cpm PR: 85bpm

Head to toe assessment
Body Parts Head Skull Scalp/Hair Technique Used Findings Analysis Palpation, size, The skull is round, shape, contour, any appropriate to body Normal lumps and size. There is no deformities. bulginess and tenderness. Inspection, The hair is evenly Normal appearance, color, distributed, there’s no distribution, texture, manifestation of

Face

Eyes

presence of lice, nits. Inspection, note symmetry, shape, expressions, appearance and movements. Inspection

baldness. No lice and nits present. Normal The face is oval, there’s balance of eyebrows, nasolabial Normal folds and sides of the mouth. There is a slight eyebags, eyebrows are present bilaterally. It moves proportionally. No swelling or lesions Eyelids are intact. The eyelashes is evenly distributed along the lid margins and curved outward. There is no protrusions. no swelling or lesions. Sclera is white with visible veins. Pale conjunctiva Ears are proportional with no protuberance, has no lumps or swelling.

Eyelids and Eyelashes Eyeballs Conjunctivae and sclera Lid margins, secretions, position, distribution.

Normal Normal Pale conjunctiva is due to poor nutrition

Note any protrusions Note the color and appearance.

Ear

Inspection, symmetry, size, color, discharges. Palpation, firmness and tenderness

Normal

Nose

Inspection, placement, discharges patency

The pinna is firm and there is no pain when it is touched. The color is same as the other body parts and has no discharges. Symmetric, in midline Normal and proportion to other and facial features. No deformity, inflammation or skin lesions. Patent. Presence of dental carries Due to poor water intake.

Mouth

Inspection, color, slight halitosis shape, moisture, symmetry, Lips appearance The lips are dark , dry and there are cracks Teeth and Gums but no lesions. Color, appearance, Teeth are yellow and well aligned, free presence of dental from carries carries at upper teeth,

Tongue Size, color, shape, symmetry, moisture , movement Inspection, symmetry, position Palpation, lumps and masses Inspection, symmetry, color, deformities Palpation, lumps, masses

Neck

Thorax

Breast/Abdomen Inspection, color, symmetry, contour Palpation, tender, lumps, masses, distention Percussion

gums are dark red in color. White to yellow in color, it is moist and moves freely. The neck is center, no enlargement present Normal when it moves. No lumps, bums, scar, swelling or masses. There is uniformity of the thorax. Skin color is the same with the rest Normal of the body. There are no lesions, lumps and masses. Breast is symmetrical n shape, no cracks and discharges, no lumps and tenderness, brown nipples. Abdomen is proportional bilaterally, there’s 5 ‘ of incision Normal /tenderness at the RLQ due to her operation. The umbilicus is in the center. No discoloration and inflammation. Normal bowel sounds heard. Normal Normal Normal

Upper extremities Shoulders Elbow Elbow Wrist and Hand Nails Lower extremities Genitalia

Inspection, symmetry, size, deformities, Shoulders are lesions, swelling proportional, no redness malformation or protruding present. There is o malformation, swelling or redness. There is no bulging, redness, deformities, swelling and nodules present. The nails are dirty Inspection No discharges on the penis, swelling or tenderness. Legs equal in length, no scaling, no lesions,

Does not cut his finger and toe nails. Normal

there are calluses in both foot, no swelling or any masses.

Leopold's Maneuvers First Maneuver (Upper uterine segment or the uterine fundus)
Nurse faces woman's head Palpate uterine fundus Determine the height the uterine fundus Determine what fetal part is in the uterine fundus Palpation of the Uterine Fundus Will usually indicate the fetal part situated in the fundus; usually a fetal head; infrequently a fetal breech. Place hands on either side of the fundal area so that the fingers of both hands almost tough each other (face the woman's head). A somewhat hard and roundish shape, which when moved back and forth between the finger pads, also moves the entire fetus usually indicates a fetal breech. Press gently and firmly with finger pads. A very hard round well defined shape which can be moved back and forth (balloted) usually indicates a fetal head.

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

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

Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part)
Provides information about the presenting part: breech or head, attitude (flexion or extension), and station (level of descent of the presenting part). Examiner faces woman's feet Place hands on either side of the lower abdomen with finger pads at the lower uterine pole (bikini line) and thumbs directed toward the umbilicus. Carefully move fingers of each hand towards each other in a downward and inward manner using gentle pressure. The nurse's thumbs should point towards the woman's umbilicus. If

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

Findings from Leopold's Maneuver
• •

• • •

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

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

Mc Donald’s Rule:
Measurement of the height of the fundus using a tape measure. The distance from the symphisis pubis to the level xyphoid process. Used to calculate the AOG. Eq: Fundic height (cm) x 2/7 = AOG in lunar months Fundic height (cm) x 8/7 = AOG in weeks.

Bartolomew’s Rule:
Height of fundus is used to determine the AOG. Fundic height is used to determined by palpation and by relating it to the different landmark in the abdomen: umbilicus: symphisis pubis and xiphoid process.

12 wks - level of syphisis pubis 16 wks - halfway between umbilicus and symphisis pubis 20 wks - level of umbilicus 24 wks - 2 finger breaths above umbilicus 30 wks - midway between umbilicus and xiphoid process 34 wks - just below xiphoid process 36 wks - at the level of xiphoid process 40 wks - at 34 wks level due to lightening

Johnson’s Rule:
Used to calculate the fetal weight in grams. Fundic height in (cm) - N x K = weight of the fetus K= 155 (constant) N- 12 (engaged) 11 (not engaged) Eq: 30 - 12 x 155 = 18 x 155 = 2790 gms.

Haase’s Rule:
Is used to determine length of fetus A. During the first half of pregnancy, square the number of months B. During the second half of pregnancy, multiply the number of months by five.

Beliefs and Practices
Belief and Practices Prenatal Rationale Clinical Significance

So that the mother will not give birth to a twin baby The baby’s skin will have Do not eat dark foods dark complexion So that the baby will Avoid hiding of foods came out naturally Always have a garlic on Protection from your pocket “aswang” Do not see a dying The baby will come out person grasping from breath and may die Intrapartal For easy delivery Nobody should stay on the door or near the stair. ‘Atang’ are the ones they Member of the family offer to the spirits to help should give ‘atang’ to the the people who are kind anitos to help the woman to them in labor Let the mother eat soft To make the mother’s boiled egg and drink lard birth canal slippery thus Do not eat twin banana

No scientific basis No scientific basis No scientific basis No scientific basis No scientific basis but may affect the mother emotionally. Doorsteps or stairs has no connection with the progress of labor. Has nothing to do with the progress of labor

No scientific basis because the birth canal

facilitate easy delivery of will surely give wayto the the baby baby to be delivered Kick every corner of the To facilitate easy delivery No scientific basis house during labor Post Partal To prevent post partal Mother should not take a complications bath for 9 days after delivery So that mother will not Mother should wear thick get sick clothes and confine to bed after delivery To make Keep the baby’s first cut intelligent hair and finger nails the Taking a bath is very important to promote good hygiene

Mother should have exercise and can work as long as she can for early wound healing and peristalsis baby No Scientific basis

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

This is a picture of an oblique lie fetus and is a problem in a term

CARE OF NEWBORN What is new born care?
Caring for a brand new baby can be overwhelming and tiring. It includes adjusting to round-the-clock diaper changes and feedings. Ideally, new mothers should receive significant support from partners, other family members, and friends. The new mother's partner can and should participate in most aspects of newborn care. Even during breastfeeding, partners can help to ensure that the mother is comfortable and receiving adequate nourishment. Some basics of newborn care include:

Infants need breast milk or formula only.

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

Infants need to be warm and comfortable.

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

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

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

Infants need to be clean.

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

The umbilical cord should be cleaned every 4-6 hours with rubbing alcohol and cotton.

Infants need sleep.

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

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

Infants cry.

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

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

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

APGAR
The APGAR scoring provides a valuable index for assessing the newborn’s condition at birth. The APGAR Score standardizes infant evaluation and serves as a baseline for future evaluations. Using the APGAR system, the infant is assessed at one minute and 5 minutes after birth. An infant whose total score is under 4 is in serious danger and needs resuscitation. A score of 4 to 6 means that the condition is guarded and the baby may need clearing of the airway and supplementary oxygen. A score of 7 to 10 is considered good. The highest score is 10.

Sign Heart Rate Respirator y Effort

0 Absent Absent

1 Slow <100 Slow, irregular, weak cry

2 >100 Good cry strong

Score 2 2

Muscle Tone Reflex Irritability

Flaccid No Response

Some flexion Well flexed of extremities Grimace Cry and

2 2

withdrawal of Blue pale Body blue 10 foot pink, Completely pink 2

Color

extremities

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

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

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

Immediate Puerperium:
The first 24 hours after birth, or the immediate puerperium, is a critical stage. This is the time when your uterus has to contract well, in order to stop the bleeding from the site of placental attachment. It is also the initiation of breastfeeding and bonding. Occasionally, this is the time that most life threatening complications of delivery manifest. These include postpartum excessive bleeding, collapse of the circulation, cardiac failure, etc. These are not common, but even with normal vaginal birth there is a risk of death of about 1 in 10,000 women. This risk may be more in women with preexisting medical conditions like anaemia, hypertension or heart diseases. It is also more with operative deliveries. Hence you will be advised to stay in hospital for at least 24 hours following childbirth.

Early Puerperium:

This refers to the 2<sup>nd to 7<sup>th day post delivery where major changes start in your genital tract. This is probably also the time of maximum adjustment when you come to terms with your new role as ‘mother’. You will also be going home with your baby in this period. There are many relatively minor, yet significant bodily changes you should be aware of. These include:

Lochia / Vaginal discharge:
This term refers to the discharge from the vagina, coming mainly from shedding of the inner lining of the uterus. For the first 4 days, there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You may need to use 2 pads at a time, changing 3 – 4 times a day. However, if you find it very heavy, or large clots keep coming out, you must inform your doctor. Usually by the 5<sup>th day the flow becomes much less, and may now be more of a blood stained yellowish-brown discharge. You may still require sanitary protection, about 2 – 3 pads a day. This discharge called ‘lochia serosa’ usually stops by the end of the second week after which it becomes a plain white discharge. Good hygiene and care of episiotomy will prevent infection. Any foul smell in the discharge should be reported to your doctor.

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

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

Breast:
The first day you will have only a watery, yellowish discharge, not looking like ‘real’ milk coming from the breasts. This is called colostrum and it is rich in many nutritive factors that are needed by your baby. You must feed your baby at this time. By the third day, the milk flow increases a lot, due to hormonal changes in your body. Regular feeding is important to prevent engorgement. Link to engorged breast in Breastfeeding.

After – Pains:

The delivery is over. You have borne with labor pains. So now you may be worried that you are still getting a cramping lower abdominal pain off and on. Don’t worry, there is nothing left inside! This is a normal phenomenon, which occurs due to the uterus contracting in response to oxytocin, a natural body hormone. This is more marked when you are breastfeeding. Link to letdown reflex in Breastfeeding. It is nature’s way of getting your uterus back to the normal size. If the pain is severe, or you are having other symptoms like fever or excess bleeding, you need to inform your doctor.

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

• • •

Cleaning the area at least twice a day, with local dilute antiseptic solution like Savlon or Dettol. E – com. This is a must after passing stools, and washing with water should be done after passing urine. Remember, always wash from front to back, never the other way, to prevent infection. Local application of antiseptic creams such as Soframycin, Metrogyl gel, Betadine E – com may be useful to prevent infection. This is usually done twice daily, after bath and before going to sleep at night. Pain relieving methods such as hot seitz baths, hot water washes or hot water bag may be useful. For a seitz bath you need a round tub large enough for your bottom to fit in, in which hot water with dilute antiseptic solution is kept. These measures make you feel better, usually. Another way of getting pain relief is local application of ointment such as 2% xylocaine, E – com, which acts as a local pain-reliever. Infrared lamp to apply day heat to the area of stitches may be given to you in hospital. Oral medications such as antibiotics to prevent infection, or pain killer tablets (paracetamol, ibuprofen, etc. E – com) should only be taken as advised by your doctor. Most doctor use stitches, which dissolve on their own and / or fall off after a few days. Ask your doctor if you need to come back to show the stitches.

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

thyroid function may be causing these feelings.Remember that these feelings are not uncommon. You are not the only mother who is not feeling ‘100% maternal love’ all the time, particularly soon after delivery. Be good to yourself, pamper yourself also, and talk about what you feel. Soon, you too will feel on ‘top of the world’!

Resuming Activities:
As discussed earlier, it takes up to 6 weeks for your body to recover from the changes of pregnancy. So, be patient with yourself. Listen to your body and do as much as you feel up to, Different women have different abilities to deal with their health changes. However, in most cases, after a normal vaginal delivery, you will be able to resume your daily personal care activities within a day, and your household routine within a week, Don’t overexert yourself – This is the time you need to devote to yourself and your baby. Take help, involve your partner, Link to Father’s role, and others available to make your life easier. After a complicated childbirth, or after a caesarean delivery your recovery may take twice as much time, so be patient.

Postnatal Exercises:
Sexual Activity is best avoided in the early post delivery period. This is because your stitches may be raw or painful, and your genital tract is prone to infection, particularly in the 1<sup>st week. Complete restoration of the lining of the uterus, including the placental site, is not complete. Hence traditionally some advise abstinence till 6 weeks following delivery.However, if you have had an uncomplicated birth, and are not having any problems, you could resume your sexual life earlier. You and your partner may have been deprived of each other, particularly in the last month of pregnancy. Hence, it is not unusual to feel the need to renew your sex – life. Until you feel comfortable for actual penetrative sexual intercourse, other displays of caring and affection can suffice. Hugging, kissing, petting or touching is not forbidden at anytime during pregnancy or post-delivery.

Lactational Amenorrhoea:
Link to Lactation amenorrhoea in Preventing Pregnancy. While you are exclusively breastfeeding, Link to exclusive breastfeeding in Breastfeeding, the hormonal changes is your body act on the genital tract to suppress ovulation and menstruation. Link to female reproductive, tract, ovulation, and menstruation. You may not get your periods for a few months. Some women do not start menstruating for up to a year, depending on the pattern and frequency of breastfeeding. Timing Menstruation Earliest ovulation Average time for ovulation. No lactation 6 – 12 weeks 4 weeks 8 – 10 weeks If lactation established 36 weeks (average) 12 weeks 17 weeks (variable)

Does this mean you cannot get pregnant? The answer is NO. About 5% of women get pregnant before they start menstruating, post-delivery. Lactational amenorrhoea (absence of periods) does protect you from pregnancy to some extent. However, you

can rely completely on Lactational amenorrhoea as a method of preventing pregnancy ONLY IF ALL 3 preconditions listed below are satisfied:

Contraception:
If you are relying on lactational amenorrhoea. If not, that brings us to the important question: Are you ready for another pregnancy? You need to give your body time to recover, your baby time to grow up and yourself time to adjust to the new role of ‘mother’. Of course, it is a question of personal choice but a minimum gap of 2 years is recommended between successive pregnancies . So, how can you prevent pregnancy during the post-delivery period? There are many methods available. During the post partum period, however, certain factors need to be kept in mind: Whether breastfeeding or not. Frequency of sexual intercourse. For how long pregnancy prevention is required. The final choice is also influenced by your personal needs and experience.

Others: Condoms
Condoms are a good, locally acting method, which are reliable if used correctly and consistently. They have no side effects and are useful for couples with less frequent sexual intercourse.

IUCDs or ‘loops’:
These are a very reliable method, requiring one visit to the doctor for insertion, which can be done easily without anaesthesia. They are effective for average 3 – 5 years (depends on the device) and are independent of the sexual act, unlike condoms. This is a very popular method for women with one or more children. Infact, can be used as an option to permanent procedure. The IUCD can be inserted at the first postnatal visit. Link (6 weeks from childbirth) or later, even if you do not have periods, provided your internal checking is normal.

Oral Contraception pills:
These are a type of hormonal contraception. During the period of exclusive breastfeeding the combined Oral Contraception pills (containing Estrogen + Progesterone) may reduce the breast milk flow. Hence are not popularly recommended. Once weaning is begun, there can be used safely.

Sterilisation:
This is a permanent method, which can be opted for after you have completed your family. This is a procedure which can be done easily immediately post-delivery (puerperial sterilization) or at the time of caesarean section. For both these options, you

need to discuss the pros and cons with your doctor and spouse before delivery, ideally in one early antenatal period. Some prefer to wait until the youngest child is older, preferably above 1 year old, before doing this permanent procedure. As an interval procedure, 6 weeks or more after delivery, it is usually done by laparoscopy.

First Postnatal Visit:
You and your baby have been through a lot. After you go home, and you recover from childbirth, your doctor will need to see you at least once to confirm that your recovery is complete. The first check up is usually 6 weeks from delivery. It may be earlier, about 3 weeks, if you have needed special care or had any problem in delivery. At the first visit, your doctor will check Your weight. Blood pressure. Signs of anaemia. Your breasts. Your episiotomy scar (should be dissolved by now). Your uterus (to see if it is shrinling back to normal size).

You may need to do some tests. You need to discuss the following issues with your doctor Restoration of your complete health. Postnatal exercises Diet and nutrition. Your baby’s health. Immunization schedule. Continuing exclusive breastfeeding Contraception.

ESTABLISH SUCCESSFUL LACTATION
In most of the hospital they require the mothers who delivered there to breast reed as soon as possible because the baby will receive colostrums that contains gamma globulins. Advantages of breath feeding to the mother are: It is economical in terms of money and effort, more rapid involution, loss incidence of cancer of the breast. For the baby: closer mother infant relationship, contains antibodies that protect against common illness, less incidence of gastrointestinal diseases and always available at the right temperatures.

Postpartum Assessment
BP Cardiac Rate Respiratory Rate Temperature 120/80 mmHg 70 bpm 20 cpm 37. c

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

2. Lochia
According to my client the lochias smell is fleshy with no foul smelling odor. The first discharge was bright red bloody and this lasted for 3 dys. After 3 days a pint discharge was noted. On the 7th day I was able to notice pink brown, serous with no foul smelling discharges. On the 10th day, my client to continue monitoring her Jochia discharges and note its characteristics. There should not be a foul smelling order and this will only lasts for 6 weeks.

3. Perineum
It is in good condition. No lacerations and no hematomas found.

4. Urinary System
She was able to void 5 hours after delivery.

5. Intestinal Elimination
No hemorrhoids, able to defacate the next day after delivery.

6. Breast
Absence of any cracks, nipples protruded and erect. Breastfeed was done 1 hours after delivery.

7. Nutrition
I encouraged her to eat green leafy vegetables, foods rich in iron like liver. I also asked her to eat egg, meat, plenty of soup. Verbalized she has increased in appetite and loves to eat most especially after breastfeeding.

Breastfeeding
Breast milk is preferred method of feeding a newborn because it provides nukerous health benefits to both the mother and the infant. it remains the ideal nutritional source for infants through the first year of life. Nurses can play a major role in teaching women about the benefits of breastfeeding and providing anticipatory guidance for problems that may occur by implementing steps such as: • Educating all pregnant woman about the benefits and management of breastfeeding. • Helping women initiate breastfeeding within half an hour of birth. • Assisting mothers to breast-feed and maintain lactation even if they should be separated from their infant. • Not giving newborns food or drink other than breast milk unless medically indicated.

• Not giving pacifies to breastfeeding infant. • Practicing rooming- in (allow mothers and infants to remain together) 24 hours a day. • Encouraging breastfeeding on demand. • Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from the birthing center or hospital. The mother gains several physiologic benefits from breast feedings, such as: breastfeeding may serve as a protective function in preventing breast cancer, the released of oxytocin from the posterior pituitary aids uterine involution and successful breastfeeding can have an empowering effect because it is a skill only woman can master. Breastfeeding also reduces the cost of feeding and preparation time. Many women feel that breastfeeding enhances the formation of a true symbiotic bond with their child. Breastfeeding has major physiologic advantages for the baby. Breast milk contains secretary immunoglobulin A, which binds large molecules of foreign proteins, including viruses and bacteria and keeps them from being absences to the GIT into the infant.

Prolactin
An anterior pituitary hormone, acts on the acinar cells of the mammary gland to stimulate the production of milk. In addition, when infants sucks at the breast, nerve impulses travel from the nipple to the hypothalamus to stimulate the production of prolactin releasing factor.

Colustrum
A thin watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies, is secreted by the acinar breast cells starting in the 4th month of preganancy.

Lactoferin
Is an iron binding protein in breast milk that interferes with growth of pathogenic bacteria.

Lysozyme
In breast milk apparently actively destroys bacteria by lying their cell membranes, possibly increasing the effectiveness of antibodies.

Leukocytes
In breast milk provide protection against common respiratory infections invaders.

L bifidus

Interferes with the colonization of pathogenic bacteria, in GIT. the incidence of diarrhea. Breast milk also contains ideal electrolyte and mineral composition for human infant growth.

Advantage of breastfeeding
Little controversy exist about breastfeeding as the best nutrition for human infants, but the decisions to breastfeed depends on what would please the woman the most and make and make her most comfortable. If she is comfortable and pleased with what she is doing, her infant will be comfortable and pleased, will enjoy being fed, and will thrive. Breastfeeding is contraindicated in only a few circumstances, such as: • An infant with galactosemia (such infant cannot digest the lactose in milk • Herpes lesions on the mothers nipples • Mother is on restricted nutrient diet that prevents quality milk production • Mother is receiving medications that are inappropriate for breastfeeding, such as lithum or methotrexate. • Maternal exposure to radioactive compounds, as could happen during thyroid testing • Breast cancer

Advantage for the mother
A woman gains several physiologic benefits from breastfeeding, including: Breastfeeding may serve a protective function in preventing breast cancer The release of oxytocin from the posterior pituitary gland aids in uterine involution Successful breastfeeding can have an empowering effect because it is a skill only woman can master. Breastfeeding, also reduces the cost of feeding and preparation time. Many women feel that breastfeeding provides the best opportunity to enhance the formation of a true symbiotic bond with their child. Although this does occur readily with breastfeeding, a woman who holds her baby to bottle- feed can form this bond equally well. some woman believe that breastfeeding is a fool proof contraceptive technique. Some feel breastfeeding will help them lose their weight gained during pregnancy. This also is not true, and women who are breastfeeding need to concentrate on eating a well balance diet to ensure that her milk is rich in nutrients. Some woman are reluctant to breastfeed because they fear that having to be available to feed the baby every 3 or 4 hours will tie them down.

Advantage for the Baby
Breastfeeding has many physiologic advantages for the baby. Breast milk contains contains immunoglobulin A (IgA), which binds large molecules of foreign proteins, including bacteria and viruses. Thus keeping them from being absorbed through the gastrointestinal tract into the infant. Lactoferin is an iron binding protein in breast milk that interferes with growth of pathogenic bacteria. Lysozyme in breast milk apparently actively destroys bacteria by lying their cell membranes, possibly increasing the effectiveness of antibodies. Leukocytes in breast milk provide protection against common respiratory infections invaders. L bifidus interferes with the colonization of pathogenic bacteria, in GIT. the incidence of diarrhea. Breast milk also contains ideal electrolyte and mineral composition for human infant growth. Breast milk contains more linoleic acid, an essential amino acid for skin integrity, and less sodium, potassium, calcium and phosphorous than do many formulas. Breast milk also has a better balance of trace elements, such as zinc, than formulas do. These levels of nutrients are enough to supply the infants needs, yet they spare the infant’s kidneys from having to process a high renal solute load of unused nutrients. One disadvantage of breast milk is that it may carry microorganisms such as hepatitis B and cytomegalovirus, although the risk to infant is small. HIV is carried at a high enough level in breast milk that women who are HIV positive are advised not to breast feed.

Preparing for Breastfeeding
Ask all women during pregnancy whether they plan to breast- feed or formula feed their newborn. Thinking about feeding in advance allows couples to make informed choices. Some fathers experience jealousy at the thought of breastfeed ing. Physical preparation such as nipple rolling, advised in the past as a way of making the nipple more protuberant is no longer advised. This is unnecessary because few women have inverted or non protuberant nipples, plus oxytocin, released by this maneuver, could lead to pre-term labor (nipple rolling is used to create uterine contractions for stress test). Practicing breast massage to move the milk forward in the milk ducts (manual expression of milks) maybe helpful. This can help a woman who feels hesitant about handling her breast to grow accustomed to doing so, allowing her to assist with milk production in the first few days after birth. Manual expressions consists of supporting the breast firmly, then placing the thumbs and forefinger on the opposite sides of the breast just behind the areolar margin, first pushing backward toward the chest wall and then downward until secretion begins to flow. Teach woman not to used soap on their breasts during pregnancy because soap tends to dry and crack nipples. The occasional woman who has inverted nipples may need to wear a nipple cup (a plastic shell) to help the nipples become more protuberant.

BEGINNING BREASTFEEDING

Breastfeeding should begin as soon as possible, ideally while the woman is still in the delivery or birthing room and while the infant is in the first reactivity period. This practice has several advantages infant suckling stimulates release of oxytocin which in turns stimulates uterine contracts to prevent hemorrhage, promotes closer maternal and infant relationship, prevents breast engorgement: If it is not possible to start breastfeeding right after delivery, initiate breastfeeding, then, after 4 to 8 hours when the mother has already rested on her condition and stable.

HOW TO FEED
1. Instruct mother to relax first before feeding, anxiety and fatigue interferes with the let down reflex 2. Wash hands and assume a comfortable position. The mother can breastfeed lying down or sitting, which ever is comfortable for her and her baby. 3. If the baby is asleep or sleepy talking or rubbing baby’s soles will gently wake him or or wake up breastfeeding is more effective if the baby is awake. 4. Guide baby to the breast by stimulating rooting reflex, touch the cheek nearest the breast. The baby will respond by turning his head and opening his mouth. 5. Press the breast away from the nose with a finger if the baby’s nose is blocked by the breast. 6. Let the baby’s mouth grasp both the nipple and areola. 7. Feed the baby for only 2 to 3 minutes during the first time, then, increase feeding time by one minute each day until the infant is fad for ten minutes on each breast 8. When removing the baby from the breasts, pull the chin down or place a finger in the corner of the mouth to break the suction. Pulling the baby from the breasts is painful and can cause sore nipple. 9. On the next feeding, place infant on the breast where she or he last fed during the previous feeding. 10. Instruct mother to burp infant after feeding by placing baby on her lap on a prone position or positioning him or her in sitting upright. 11. Signs of proper feeding: • The baby’s mouth group both nipple and areola. • The other breast flows with milk. Infant sucking stimulates release of oxytocin which in form stimulates milk let down reflex. • The mother feels after pains or uterine cramping while breastfeeding, this is due to release of oxytocin. 12. It is not unusual to haves scanty milk supply during the first few days after delivery. There is no need to offer milk formula to the infant. Placing infant regularly on the breasts will stimulate milk production. Maintenance of successful lactation requires that breasts are completely emptied at each feeding so that they will completely fill again. The more the baby suckles, the more milk is produced. 13. Instruct the mother to avoid: • Smoking • Oral contraceptives because they decrease milk supply • Drugs passed to infant via breast milk.

Problems of breastfeeding: 1. Breast Engorgement

Breast engorgement usually occurs during the 3rd to 4th day after delivery. The mother complains of pain and tenderness, the breast are reddish, tense, shiny, hot to touch and feels firm and nodular. Breast engorgement is not cause by milk or infection but by lymphatic and venous congestion. When the breast are engorged, the infant will not be able to grasp the nipple effectively and pain can cause the mother to avoid or refused breastfeeding.

Management:
• Give analgesics before feeding to provide pain relief • Give breast more often to empty breast with milk and prevent further engorgement • Initiate breastfeeding as soon as possible after delivery to prevent engorgement. • Let warm water run over the breast or apply warm compress to improve circulation and promote comfort if the mother plans breastfeed. If the mother does not plan to breastfeed, apply ice packs. • Reassure mother that engorgement is temporary and it will subside after 24 hours.

2. Sore and Crack Nipples Causes:
• Forceful pulling of the infant after feeding • Improper sucking - infant grasping only the nipple during feeding • Breastfeeding too long • Nipple remaining moist for a long time due to leakage of milk Management: • Expose to air after feeding to let nipples dry • Use of loose fitting clothing and leaving bra unsnapped to let air circulate in the breast for a few minutes • Limit amount of time of feeding to allow nipple to healed • Use of nipple shield • Exprese milk usually or by breast pump if breastfeeding causes too much pain to maintain milk supply • Sore nipples are not contraindication to breastfeeding unless the mother cannot tolerate the discomfort caused by infant suckling. She can express milk from her breasts and give it to infant using feeding bottle.

GENERAL HEALTH TEACHING 1. Pre-natal care Visits
 Blood pressure will be monitored each month. While low blood pressure is rarely a reason for concern, an abnormal increase may be sign of problems that can affect you and your baby.  Weight is normal for your body to gain weight or experience a little ankle swelling due to water retention during pregnancy. Your doctor will advice you about how much weight gain is good for you.

 Urinalysis, bodily functions will be determined through this test. It will also detect diabetes, kidney and bladder infections, and early signs of many problems in pregnancy.  Blood test, samples will be taken to determine blood type and Rh factor to check for anemia and other blood diseases, and to screen for potential birth defects.  Ultrasound or sonograms, will be done to check for twins, baby’s position, and due date accuracy. Breast exam, may be done on your first pre-natal visit. Advice will be given on breastfeeding as well as nipple and breast preparation.  Abdominal exam, the doctor will measure the size of your uterus, which shows the growth of you baby, as well as check the baby’s position.  Pelvic exam, on your first prenatal visit, your doctor will perform a vaginal exam to evaluate the size of your birth canal. Unless absolutely necessary, this exam will not be repeated until just before the baby is due, when changes such as dilation and effacement of the cervix will be measured.  1st visit: 32 weeks: visit must be every 4 weeks  2nd visit: 32-36 weeks: visit must be every 2 weeks  3rd visit: 36-40 weeks: visit must be once every week

2. Work
 you can go to work, but take care not to strain yourself or subject yourself to stress.  Avoid prolonged standing or sitting.  Provide deep breathing, foot circling and relaxation.

3. Sleep
 get plenty of bed rest. In the last months of your term, you may have some difficulty sleeping. Try to nap when you have the chance.

4. Exercise
 moderate exercise, such as relaxed swimming, is allowed. Take care not to overheat.  Kegel’s exercise is recommended to strengthen the muscles around the reproductive organs and improve muscle tone.

5. Travel
 routine travel, such as daily commute, is allowable. Airplane flights are possible usually until the last trimester of your pregnancy.  Proper use of seatbelt and headrest and lap belts must be done.  Avoid long trips especially on the 1st and 3rd trimester but can travel in 2nd trimester.  Periods of activity and rest must be done fro 15 mins. every 2 hours for emptying of bladder.  In high altitudes regions, lowered O2 mav cause hypoxia or fetal brain damage , It may be pressurized.

6. Nutrition
 quality of your diet is essential. Your doctor may give you advice on a particular set of foods you can eat, given your condition. He may also prescribe vitamin and mineral supplements. Avoid salty, too-sweet, and fatty foods.  Drink 8-12 glasses of liquid a day, juices may be included to lower the pH of urinary tract.  Increase caloric intake to prevent maternal underweight.  Eat variety of foods and maintain small, frequent feeding.

7. Hygiene
 keep yourself clean always. Bathe regularly to keep your body cool. Do not use feminine washes or douches unless advised by your doctor.  Do not use bath tub, can alter balance  Do not bath if there is vaginal bleeding and rupture of membranes.  Warm showers can be therapeutic, relax tensed tired muscles, helps counter insomnia, makes us feel fresh.  Can swim but no diving to prevent traumatic injury.

8. Sexual activity
 contrary to what some people say, sexual intercourse is not harmful to the baby. However, take care not to put too much weight on the abdomen. Try other position instead. If you have been exposed to any sexually transmitted disease, report it to your doctor immediately.  Provide a safe, open, non-judgmental atmosphere,  Provide comfortable environment, offer alternatives and show illustrations.  Avoid sexual intercourse during the 1st and 3rd trimester.

9. Smoking
 Stop! Smoking depletes much- needed oxygen and may cause birth defects.

10. Drinking
 alcohol can harm your baby and should not be ingested during pregnancy.  Avoid alcoholic beverages to prevent growth retardation and musculoskeletal deformities.

11. Caffeine
 limit your intake or cut it altogether, it hinders the body absorption of certain nutrients like iron.

12. Medications/Drugs
 self-treatment must be discouraged.  All drugs, including aspirin should be limited and careful record of therapeutic agents used should be used.  Consult your physician who undergone medications to reduce the cause of possible teratogenecity or fetal drug toxicity.

13. Immunizations
 Tetanus toxoid must be given to pregnant woman.  Do not give medications such as measles, mumps and polio vaccine due to potential teratogenecity.

14. Dental care
 Adequate calcium and phosphorus in the teeth must be included on the diet.  Dental tooth extraction is prohibited during pregnancy.

EXERCISES DURING PREGNANCY

KEGEL EXERCISES
Are exercises designed to strengthen the pubococcygeal muscles. They should be done about 3 times a day. Exercises are as follows: 1. Squeeze the muscles surrounding the vagina as if stopping the flow of urine. Hold for 3 secs. Relax repeat 10 times. 2. Contract and relax the muscles surrounding the vagina as rapidly as possible 10 to 25 times. 3. Imagine that you are sitting in a bath tub of water and squeeze muscles as if sucking water into the vagina. Hold for 3 secs. Relax Repeat 10 times. 4. Push out with the vagina as if expelling something from it. Hold for 3 secs. Relax Repeat 10 times. It may take as long as 6 weeks of exercise before, pubococcygeal muscles are strengthened. In addition to strengthening urinary control and preventing stress incontinence, exercises can lead to increased sexual enjoyment because of the tightened vaginal muscles.

PERINEAL AND ABDOMINAL EXERCISES 1. Tailor sitting - strengthens the things and stretches perineal muscles to make
them more supple. A woman could use this position for TV watching, telephone conversations, or playing with an older child. It is good to plan on sitting in this position for at least 15 minutes. Should also practice this position for 15 mins a day.

2. Squatting – stretches the perineal muscles. Should also practice this position
for 15 mins a day. For the pelvic muscles to stretch, the woman most keep her feet flat on the floor.

3. Pelvic Floor Contractions – done during the course of daily activities as
well. Perineal muscle – strengthening exercise will be helpful in the postpartum period as well as to promote perineal healing, to increase sexual responsiveness, and to help to prevent stress incontinence.

4. Abdominal muscles contractions – help strengthen abdominal muscles
during pregnancy. Strong abdominal muscles can also contribute to effective second – stage pushing during labor and help to prevent constipation. Abdominal contractions can be done in standing or lying position along the pelvic floor contractions. The woman merely tightens here abdominal muscles, then relaxes, she can repeat the exercise as often as she wished during the day. Another way to do the same thing is to practice blowing out a candle”. The women takes a fairly deep inspiration, then exhales normally. Holding her finger about 6 inches infront of herself, as if were a candle, she than exhales forcibly, pushing out residual air from her lungs.

5. Pelvic Rocking – helps relieve backache during pregnancy and early labor
by making the lumbar spine more flexible. It can be done in a variety of positions. On hand on knees, lying down, sitting or standing. The woman arches her back, trying lengthening or stretching her spine. She holds the position for I minutes, then hallows her back. A woman can do this at the end of the day a bout five times to relieve back pain and make herself more comfortable for the night.

POST PARTAL EXERCISES
MUSCLE STRENGTHENING EXERCISE 1. Abdominal Breathing – abdominal breathing maybe started on the first day postpartum, because it is a relatively easy exercise. Lying flat on her back on sitting, a woman should breath slowly and deeply in and out 5 minds, using her abdominal muscles. 2. Chin – to chest – chin to chest exercise is excellent for the second day. Lying on chin forward on her chest without moving any other part of her body while exhaling. She should start this gradually, repeating it no more than 5 times the first time and then increasing it to 10-15 times in succeeding. The exercises can be done 3 to 4 times a day. She will feel the abdominal muscles pull and tighten if she is doing it correctly. 3. Perineal Contraction – If a woman is not already if she is doing it correctly. Of alleviating perineal discomfort, it is a good one to add on the third day. She would tighten and relax her perineal muscles 10-15 times in succession as if the trying to stop voiding. She will feel her perineal muscles working if she is doing it correctly. 4. Arm Raising - Arm raising helps both the breasts and the abdomen return to good time is a good exercise to add on the fourth day. Lying an back, arms at her sides, a woman moves arms out from her sides until they are perpendicular to her body. She time raises them over her body until they are perpendicular to her body. She then raises them over her body until her hands touch and lowers them slowly to her sides. She should rest a moment, then repeat the exercise 5 times. 5. Abdominal Crunches - It s advisable to wait until to 10th and 12th day after delivery before attempting abdominal crunches. Lying flat an her back with knees bent a woman folds her arms across her chest and raises herself to a sitting position. This exercise expenses a great deal foe effort and tires a postpartum woman easily. She should be cautioned to begin it very gradually and work up slowly to doing it 10 times in a row.

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

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

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

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

Evaluation
The client attained good breathing pattern after a day when practiced and applied all the intervention.

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

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

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

Intervention
Back massage offered. • Back massage promote circulation, helps relax the back thereby relieving pain. 2. Advised to exercised regularly • Exercise will relieve discomfort and decrease body tension thereby pain will be lessen. 3. Advised to have proper body mechanics. • Good posture minimized hollow curvature of the lower back which causes strain. 1.

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

Assessment
Subjective: “Idi kalman pay nga saanak makatakki, nu dad-duma natangken ti takkik” as verbalized by the patient. Objective: • Facial grimaced • Hard stool

Nursing Diagnosis
Alteration in Bowel Elimination: constipation r/t increasing size of the uterus which will decrease the mobility of the intestine secondary to pregnancy.

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

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

Evaluation
The patient has been verbalized to defacates easily.

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

Nursing Diagnosis
Alteration in Comfort: Pain r/t rapid uterine contraction during the latest phase.

Planning
The patient will be able to feel a lesser degree of pain after 1 hour.

Intervention
1. Advised the patient to do breathing exercise. Breathing exercises will help the client to relax thus reduce the perception of pain. 2. Provided comfort measures like back rub. Providing comfort measures will help the client psychologically. It promotes relaxation and physical comforts. 3. Encourage patient to void. This will keep the bladder free of distension which can result to discomfort, result in possible trauma, interfere with the fetus to descend and prolong labor. 4. Encourage diversional activity. This will help the will help divert away the attention of the client from labor making time pass more quickly. This will help also to decrease perception of pain.

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

Assessment
Subjective: “ Nasakit! Madikun!” as verbalized by the patient. Objective: • Excessive perspiration • Facial grimace • Restlessness

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

Planning
The patient will be able to feel lesser degree of pain after 24 hours.

Intervention
1. Provided comfort measure like back rubbing, touching the face or hand of the client. • Helps the client psychologically. Promotes relaxation and physical comfort which help reduce perception of pain. 2. Encouraged diversional activities like listening to a solemn music. • Helps divert away the attention of the client from labor and delivery and helps decrease the perception of pain. 3. Advised the client to do breathing exercise.

It promotes relaxation, will help reduce perception of pain.

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

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

Nursing Diagnosis
Alteration in Comfort: Acute pain r/t second stage of labor and strong uterine contraction.

Planning
The client will be able to experience reduce pain as a result of uterine after 1 hour.

Intervention
1. Advised client to push only during uterine contraction. • Unnecessary movement will add up to mothers agony’ 2. Gave her back massage • Massaging the back contributes to pain reduction. 3. Tried to distract attention • The pain becomes more tolerable when client becomes less aware of it. 4. Kept her constantly informed by her progress of labor. • The will help relieved anxiety. 5. Position in side lying or fowlers position. • Proper positioning promotes comfort and reduces irritation.

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

Assessment
Subjective: “Saan ku kaya ti sakit nan” as verbalized by the patient. Objective:

• • •

Diaphoresis Unwilling to be left alone Body malaise

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

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

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

Evaluation
The client verbalized reduce discomfort and pain after an hour.

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

Nursing Diagnosis
Alteration in Comfort: After pain r/t uterine involution.

Planning
After 3 hours to 4 days, there would be decrease discomfort of pain felt by the patient.

Intervention
1. Gently massage the fundus. • Will stimulate the uterus to contract which will lead to uterine involution and prevent excessive bleeding. 2. Ice pack apply over the abdomen. • Cold compress promotes vasoconstriction will lead to involution of the uterus. It also provides local anesthesia. 3. Encouraged Kegel’s exercise. • Aids in healing and recovery of pubococcygeal muscle tone and prevent urinary stasis. 4. Advised early activity and ambulation as early as possible. • It enhances circulation, facilitates bowel and bladder function thereby promoting healing. 5. Explained reason why discomfort occur. • For the understanding of the mother that it is the normal occurrence it would ease discomfort and anxiety.

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

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

Nursing Diagnosis
Alteration in Comfort: Breast engorgement r/t venous and lymphatic filling of the alveolar cells with milk.

Planning
After 3 days, the patient will experience lesser degree of pain as evidenced by letdown reflex, and client verbalization of being relieved from pain.

Intervention
1. Advised the client to apply cold compress. • To numb the nerve endings. 2.Let the baby suck the breast of the mother. • To lessen the volume of milk in the alveolar duct which will lessen the breast engorgement. 3. Advised the mother to avoid putting pressure on the breast.

• •

Pressure will just add to the degree of pain felt. 4. Encouraged the client to use fitting brassiere. For support of breast.

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

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

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

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

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

Evaluation
Client anxiety level was lessened after 3 hours as manifested by clients feeling little okay.

CONTENTS
Acknowledgement Dedication Introduction The Female Reproductive System Menstruation
• • Phases of Menstrual Cycle Teaching About Menstrual Health

Stages of Fetal Development
• Milestones of Fetal Growth and Development

Nursing Assessment Form Maternal Data- based Assessment Guide Leopold’s Manuever Fetal Estimates
• • • • • Nagele’s Rule Mc Donald’s Rule Haase’s Rule Johnson’s Rule Bartholomew’s Rule

Risk Indication Form Laboratory Examination Beliefs and Practices General Physical Assessment Tool

Stages of Labor Mechanisms of Labor The Placenta Immediate Care for the Newborn APGAR Scoring Puerperium Postpartal Assesstment Breastfeeding
• • Beginning of Breastfeeding How to Feed

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

Postpartal Exercises Nursing Care Plan Documentation

Medical Colleges of Northern Philippines
Alimannao Hills, Penablanca, Cagayan

Is Hereby Presented To The Faculty of College of Nursing

Submitted by: LIONEL RICHIE C. BELISARIO

THE AUTHOR

Being a nursing student is one of the greatest courses in the entire universe. It offer you sacrifices and hardship in order to pass. Being one in the college of nursing is an honor to me as a student nurse like me. As they always say many are called but few are chosen. I’m LIONEL RICHIE C. BELISARIO student. Simple and industrious and luck enough to reach at this level. May the almighty God may guide me along may journey being a student nurses to become a registered nurse in the near future.

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

Presented to: Mr.Christopher Gunacao RN ADVISER Ms.Karen Castillo RN LEVEL III Clinical Coordinator Ms. Liezel Canapi RN,MSN LEVEL IV Clinical Coordinator

Approved by: Ms.Cheryll JM Gumabay RM,RN,MSN Dean of Colleges of Nursing

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