Fetal Circulation
Ductus arteriosus-when the baby is
FETAL CIRCULATION
PLACENTA
UMBILICAL VEIN
DUCTUS VENOSUS 40% LIVER
INFERIOR VENA CAVA
• Fetal life- lungs do not function, but
through umbilical cord (the one that will
provide the oxygen as well as the
nutrients into the fetus and removes the
waste from the fetus going to the placenta
going to the mother) and placenta (fetal
lungs, oxygenated blood passes through
the umbilical vein (red) which enters the
liver (40% of the blood) Umbilical
arteries, responsible for carrying
unoxygenated blood from the fetus to the
placenta.
• Three mechanisms
1. Ductus venosus
1. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
2.
termed (38-42 weeks), become the
ligamentus arteriosum that would hold
the heart in place. If it does not close, it
will become patent ductus arteriosus
3. Foramen ovale-found in between the
right and left atrium, a pint hole that
would allow the blood from right atrium
toleft atrium to shunt. Normally, it is
closed. After immediately after delivery,
it will close. If not, it will make baby
cyanotic, Tetralogy of Fallot (blue baby)
The blood from the placenta goes to the
umbilical vein, some of the blood goes to
the liver, some to the ductus venosus, all
go the inferior vena cava.
FOCUS OF FETAL DEVELOPMENT
First Trimester
o Organogenesis- Organogenesis
is the formation of organs
from the germ layers.
o -phase of embryonic
development that will start until
the birth of the baby
o -major body organs and systems
are formed
o -mother should not be exposed
to communicable diseases such
as German measles, chicken
pox, because organs will not
completely form
o Germ Layers-Endoderm,
mesoderm, ectoderm
Second Trimester
I. Period of continued growth and
development- will take on new
meanings for the fetus. Time
where you want to know the
sex of the fetus. Where
movement of fetus is felt- can
hear (best time to talk)
 o -eyes gradually open, can hear
any voice, weight and size
increases about 21 inches, 6-9
pounds, lungs start to mature
Third Trimester
o eriod of most rapid growth and
development- slow movement
and will position on the area
where he would descend
o Trying to position the head
down
o Hyperplasia happens- increase
cell, uterus enlarge to
o Hypertrophy- incerase size of
cells
o Post term 42 above
o 38-42 full term
o Pre term 28-37 weeks
o Below 28 is abortion
o First cry of the baby= lungs are
functioning, by 38 weeks, the
placenta started to regress its
function, considered as the foreign
body
Hegers sign- pelvic congestion due to
enlarging fetus
NORMAL ADAPTATION IN PREGNANCY
REPRODUCTIVE SYSTEM
o Uterus- uterine growth and
enlargement (under the influence of
estrogen with the myometrial cells in
the muscle fibers to undergo
hyperplasia-cells and hypertrophy-
fibers to accommodate growing
fetus)
o Braxton Hicks contractions-irregular
and painless contractions begins in 4
months or 16 weeks of gestation
o Becomes globular (4th month =
16 weeks)
o Goodell’s sign (4th week)-
stimulation during the course of
pregnancy in the estrogen and
2. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
progesterone hormone, cervical
softening
o Hegar’s sign (8th week)-
softening of the lower uterine
segments causefd by pelvic
congestion due to enlarging fetus
o Chadwick’s sign (8th to 10th
week)-earliest sign, bluish
purple discoloration/hue,
increased estrogen by increasing
blood flow and engorgement that
causes discoloration
o Cervix- earliest sign of
pregnancy which is having
discoloration
o Ovaries- (no ovulation, do not
produce egg/ova, but produces
progesterone)
o Vagina- more acidic (pH 3.5 to 6 to
help control the number of pathogens
in the vaginal canal)
o Leukorrhea-increase white
discharges, causes the smell of
pregnant mothers, not
encouraged pantyliners, but
clean now and then
o Breast- enlarged– melanotropin
(secreted by pituitary gland that
causes nipple to be tender) colostrum
 (milk containing antibodies to protect
the body)-areola is darkened, nipple
is enlarged
o Spinnbarkeit test- to test is fertile or
reproduce, if it will not be cut off in
10 cm
• Musculoskeletal System
o Waddling walk
o Symphysis pubis may separate
lightly
• Circulatory System
o Increased blood volume 40% to 50%
(to supply metabolic demand)
o Physiologic anemia/pseudoanemia-
decreased RBC in the plasma
(normal)
o Supplemented by ferrous sulface
o Heart is displaced upward (left side,
if diaphragm is pushed below the
sternum)
o Increases cardiac output to 30%
o Supine hypotension/Vena-caval
syndrome (inferior vena cava is
compressed leading to decreased
cardiac output and cardiac venous
return )
o Increased WBC
o CR and RR increased to 10-15 bpm
o Varicosities and edema (retention of
water found in lower extremities
normal on 3rd trimester)
3. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
o Corticosteroids-contribute to moon-
face and pregnancy-induced
hypertension (ECLAM)
o Best position-left lateral position,
aside from decompressing,right
atrium will receive the blood from
IVC and SVC, If RLP, Mother’s RA
is also compressed
• Integumentary System
o Increased pigmentation
o chloasma/ melasma-increased
pigmentation on the face, mask of
pregnancy
o Striae gravidarum -streches
o Linea negra lining going up to the
sternum
o Increased
perspiration
o Palmar erythema- discoloration in
the palmar surface of the mother
• Gastrointestinal system
o Morning sickness (not a positive
indication, abnormal growth in the
cervix, Hmole (Hydatidiform mole
(HM), caused by increased secretion
of the Human chorionic
gonadotropin
o Increased salivation-ptyalin enzyme
that would decrease appetite
(ptyalism)
o Heartburn/pyrosis/dyspepsia (due to
relaxed sphincter between the
stomach and esophagus during
pregnancy, and relaxed gastric
content)
 o Decreased motility because of
increased progesterone leading
constipation
o Constipation
• Respiratory system
o Increases RR
o Dyspnea (diaphragm is displaced
about 2 cm upward by enlarging
fetus)
o Increased tidal volume (estrogen-
pump hypertrophy and
hyperplasia,progesterone-decreased
airway resistance by causing the
relaxation of the smooth muscles of
the bronchus, bronchioles and
alveoli)
o Increased vital lung capacity-
(maximum amount of air moved in
and out of the lungs with force
during respiration)
o Decreased residual volume
• Urinary
o Urinary frequency (uterus is lying on
the bladder, as the fetus grows, it
compresses the bladder, and leading
to frequency of urination-1st
trimester) (increased progesterone-
relaxation of the urethra and
sphincter relaxation
o Increases GFR (Glomerular filtration
rate) or the Glycosuria-2nd trimester,
increase in renal tubular reabsorption
present because of kidney’s inability,
indication of gestational diabetes
mellitus)
o UTI is common of preganncy
because of the relaxation of the
smooth muscles of the mother and
urinary sphincter, movement of
kidney in the urine is reduced
o asymptomatic bacteriuria refers to
isolation of bacteria in an
appropriately collected urine
specimen from an individual without
symptoms of urinary tract infection
(UTI)
4. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
• Endocrine System
o Increased metabolism of CHON
(protein) and CHO (carbohydrates)
o Increased insulin production by
pancreas
o Slight enlargement of the anterior
pituitary gland of mother, as well as
the thyroid gland, because of
uncreased circulation of
progesterone-induced effects
o Thyroxine (T4) hormones increase
and attaches into the globulin
o If mother has thyroidism. Mother is
discouraged to be pregnant
o Lactogen-hormone found in the
placenta that causes diminished
effectiveness of the insulin
o 2nd trimester- most number of CHO
leading to increase of insulin
production
• Weight Gain -not ideal to gain weight in
the first trimester and trimester, not
abrupt
o Weight distribution
▪ Fetus- 7lbs
▪ Placenta- 1 lb
▪ Amniotic fluid- 1.5lb
▪ Uterus- 2lb
▪ Blood volume-1lb
▪ Breast 1.5-3lbs
▪ Fluid 2 lbs
▪ Fats 4-6 lbs
▪ total 20-25lbs
▪
SIGNS OF PREGNANCY
• First Trimester
o Presumptive sign- least indicative of
pregnancy taken as simple entity
▪ Amenorrhea, morning sickness,
breast changes, fatigue, urinary
frequency, enlarging of uterus
(myoma)
o Probable signs (can be documented
by the examiner, not true diagnosis)
 ▪ Chadwick’s sign, Goodells,
Hegars, (+) HCG,-if present si
myoma
o Positive sign
▪ Ultrasound result
▪ Indication that individual is
pregnant
• Second Trimester
o Presumptive signs
▪ Quickening, skin pigmentation,
chloasma, linea negra, striae
gravidarum
o Probable signs
▪ Enlarged abdomen, Braxton
Hicks, Ballotement (examining
response)
o Positive sign
▪ FHT, fetal movements, fetal x-
ray
• Third Trimester
o Presumptive signs
▪ Quickening, skin pigmentation,
chloasma, linea negra, striae
gravidarum
o Probable signs
▪ Enlarged abdomen, fetal outline,
Ballotement (examining
response)
o Positive sign
▪ FHT, fetal movements,
visualization of fetus by USD
PRENATAL CARE
DATA GATHERING
o Demographic data (Name, age,
address, marital status and
complaint)-during delivery, mother
will follow the family name of the
father
o Obstetrical data
o LMP (last Menstrual Period)- 1st
day of LMP (kanus a ang unang
adlaw sa katapusang regla)
o AOG (age of Gestation)
5. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
▪ By weeks- based on LMP
▪ MC Donald’s method
(FH/4=no. In mos.) (32
cm/4=8 months)
▪ Barthonlomew’s rule-
through the examination
estimated AOG by the
relative position of the
uterus in the abdominal
cavity through IE
a. TPAL Scoring
(term+preterm+abortion+living)
b. EDC (expected date of confinement)
Nagele’s rule (-3+7+1)
c. EFW (Estimated fetal weight)-
Johnson’s rule FH-N x K (constant
155)
N-represents if it is enagaged or not
N= 11 not engaged, N=12 if
engaged
Example: 32 fundic height -11 (not
engaged) x 155
(constant)=3100grams to kg 3.1 to
lb=6.82 lb
d. GPA- Gravidity, Parity, Abortion in
pregnancy
Gravidity-Number of pregnancies a
woman have regardless of the
number of months
-Include present pregnancy
Parity- number of pregnancies who
reached age of viability (28 weeks)
Abortion-termination of pregnancy
before age of viability (below 28
weeks or 660 grams)
e. TPAL- Term-38-42 weeks AOG
Preterm-28-37 weeks
Post term-42 weeks above
Living number of children alive
f. Past Pregnancies- Methods of
delivery
-Place of delivery (home, hospital or
health center)
 g. Present Pregnancy (C/S section,
NSVD, NSVD assisted by vacuum,
assisted by forceps
-any complications by mother,
diabetic, hyperthyroidism
Medical Data- illness before
(hypertensive, asthmatic, during
pregnancy)
-because there are mothers who only
experience illness during the course of
pregnancy like diabetes mellitus (GDM)
-contour of the abdomen during the
course of pregnancy
Sample Computation
1. Mrs. K, a mother of 7 children, visits a
health center for prenatal checkup.
History is taken she had her LMP on
October 16, 2009. She abortion in 1996,
1999, 2001. She had a couple of
identical twins whom she delivered
prematurely in the year 2000 and 2004.
• (use March 16, 2010 as the date
of visit)
• A. EDC
• B. AOG in weeks
• C. GPA
• D. TPAL
Answers:
A. 7-23-10
6. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
B. 21 4/7
C. G9PsA3
D. T3P4A3L7
A. 10 16 09
-3 +7 +1
7
B. Oct. 15
Nov. 30
Dec. 31
Jan. 31
Feb. 28
Mar. 16
151/7 - 21weeks and 4 days/7
Calculate the estimated date delivery
using Naegele’s rule
Lynne is a 28 year-old woman who
comes to the clinic with a history of
amenorrhea and a positive pregnancy test
result. Her last menstrual period began on
May 31,2021. She bleeds for the usual
amount of time and reports that the amount
of blood loss was normal assuming that
Lynne had a 28 days cycle. Use the naegele’s
rule to calculate her estimated date of birth.
COMPUTATION
The mother has 4 living children and she is
38 weeks pregnant. The mother delivered the 1st
child at 36 weeks, the 2nd at 37 weeks, the rest
at 40 weeks and 39 weeks. She had two
abortions at 20 weeks. She had also a twin
gestation at 38 weeks but died after delivery.
A. G8 P5 A2
B. T4 P2 A2 L4
Assessment
1. Physical Exam
-check for gpa and tpal
-cephalocaudal assessment
-pay attention to teeth
-during pregnancy, there is an increased
hormone that causes the gums to be edematous,
which leads to bleeding during brushing, lesions
and dental problems that gives a pathway for the stage 3- extend to pelvic wall
pathogens to enter the bloodstream stage 4- beyond pelvic floor to the
-meticulous dental examination and dental care organs (especially in the breast)
is important for pregnant mothers to prevent f. Pelvic Measurement- Pelvimetry- to check if
infections and other infections the pelvis of the mother is appropriate for the
2. Pelvic Exam-inform the mother to empty shoulder as well as the head of the fetus, to
bladder first determine if it is appropriate for normal delivery
a. internal examination (IE)-to determine signs of or caesarian section or any like vacuum or
pregnancy like Chadwick, Hegar’s and Goodell’s forceps
Sign
-responsibility of nurse to have jot down
notebook to have different areas to check during
IE
-Time is determined on the wall clock of the
hospital
Dilatation (size of cervical opening, expressed in
cm and maximum opening of the cervix is up to
10 cms
Effacement-rugae in the vaginal canal,
expressed in percentage, part where the doctor
will palpate, maximum effacement is 100%
Bag of Water-if it is leaking or intact
Station-how the baby is engaged in the pelvic
cavity, expressed in positive or negative
Negative-baby is still floating, not engaged in the
pelvic cavity
Positive-engaged
Presentation-cephalic (head-common),
shoulder (transverse), back (breech), common
Breech-in caesarian section
b. vaginal Speculum-instrument that is inserted
In the vagina of the mother to visually see what
is the alterations in the vagina
-to see signs
c. transvaginal ultrasound-to check the
presentation as well as the total health status of
the fetus
d. ballottement-through IE done
e. Papanicolaou test (PAP Smear)-examination to
determine the presence of malignancies
staging of malignant cells:
stage 1- confined to the cervix
stage 2- extend beyond the cervix-might
be in the rectum

7. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente

g. Leopold’s Maneuver-noninvasive method of
assessing fetal presentation, position and
attitude. This method is also used to locate the
fetal back before applying the fetal monitor.
1. Fundal grip- fetal position-when the
nurse towards the head, hands in is the
abdomen
2. Umbilical grip- fetal back & extremities
3. Pawlik’s grip- engagement, you cannot
move the head of the baby
4. Pelvic grip- fetal attitude-bent or
extended head
8. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
FUNDAL GRIP
Determine presentation.
Stand beside the woman facing her. Place back
of the hands on the uterine fundus and palpate
the contents of the fundus. If the buttocks are in
the fundus, indicating a vertex presentation
(which is true 96% of the time), you will feel a
soft, irregular object that does not move easily.
However, if the head in the fundus, indicating a
breech presentation, you will palpate a smooth,
hard, round, mobile object.
UMBILICAL GRIP
2. Determine position.
Place both hands on the maternal
abdomen, one on each side. Use one hand to
support the abdomen while you palpate the
opposite side with the other hand. Repeat the
procedure.
PELVIC GRIP
3. Confirm Presentation
Place one hand over the symphysis pubis
and and attempt to grasp the part that is
presenting to the pelvis between your
thumb and fingers of one hand. In the
vast majority of cases you will feel a
hard, round fetal head. If the part moves
easily, it is unengaged. If the part is not
movable, engagement probably has
occurred. If the breech is presenting, you
will feel a soft irregular object.

PAWLICK’S GRIP
4. Determine the attitude.
Begin the last step by turning to face the
woman’s feet. Use finger pads of the first three
fingers of each hand. Palpate in a downward
motion in the direction of the symphysis pubis. If
a hard bony prominence is felt on the side
opposite the fetal back, you have located the
fetal brow, and the fetus is in an attitude of
flexion. If the bony prominence is found on the
same side as the fetal back, you are palpating the
occiput, and the fetus in in an attitude of
extension.
2. Vital Signs
Increase in RR-add 5-10 if it is a pregnant
mother
Increase in BP-Ask mother regarding
past BP, IF 130/90-Normal because of
the demand of the fetus for oxygenation
-If there is an increase of 30 mmHg
systolic, and 15 mmHg diastolic, that
would give an alarm because it is could
be (pregnancy-induced hypertension or
Eclampsia)
4. Blood studies-mother is subject to CBC to
check for hemoglobin level as well as the
hematocrit in preparation to delivery, normally it
is 500 cc loss, the mother can still manage, if
caesarian- 1000cc- it would cause hemodilation
to the mother
9. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
-It is also important to know the blood type of
the mother
5. Urine Exam-pregnancy test after 6 weeks
-used to check the presence of protein and
albumin which is an indication
-urine dipstick test
-albumin- if the patient is hypertensive or
eclamptic
-If benedict test is done to determine the glucose
in urine, which could be indication of GDM
-also important to know presence of infection
DANGERS OF PREGNANCY
Complications may arise in the course of
pregnancy. It is important to report
immediately, so it can be dealt before if
something happens to the patient.
A. Vaginal bleeding
-No matter how slight the bleeding is,
report because it might lead to
complications.
- Placenta previa- low implantation of
placenta that would cause painless
bleeding as the baby will push against
the cervical opening (minute rupture of
blood vessels)
- Abruptio placenta- premature
separation of placenta, presented with
vaginal bleeding but painful
- Premature labor- does not reach age of
viability (28 weeks below)
- Threatened abortion (nothing done to
the pregnancy but there is already
bleeding that occurs naturally):
• Spontaneous abortion- aborted w/o
things done or miscarriage
• Septic abortion-something is done
to remove the baby, like quack
doctors
• Induced abortion- caused by
artificial or mechanical means to
stop pregnancy and remove the
baby
 • Therapeutic abortion- performed
by licensed physicians as a form of
treatment.
• If mother is having cancer and
having chemotherapy, therapeutic
abortion is given.
B. Persistent vomiting-1 or 2 times a
day is normal
Hyperemesis gravidarum- due to
systemic infection. This will deplete
nutritional supply to the fetus that will
cause dehydration
• Admit to hospital and IV Fluid to
infuse
C. Chills and fever- due to infection/
dehydration/ benign gastroenteritis
(MEDICATIONS)
D. Sudden escape of fluid from vagina
- PROM- Premature rupture of
Membrane (may indicate preterm
labor) The uterine cavity is no longer
sealed against the infection (amniotic
fluid will prevent infection)
- If the fetus is too small, when the Bag of
water rupture, the cord will descend
first causing interruption of
oxygenation, or it might cause umbilical
prolapse
- The head does not fit snugly into the
cervix so the umbilical cord will come
first which may lead to prolapse
- What doctors do is to push the baby’s
presenting part and cord
E. Abdominal or chest pain
- May be due to Ectopic pregnancy, as
fetus enlarges, the fallopian tube
cannot extend its size
- Abruptio placenta or the premature
separation of the placenta
- Uterine rupture
- Pulmonary embolism-caused by blood
or air causing blockage
F. Swelling of face and fingers
(pregnancy-induced hypertension)
10. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
-If swelling in the face and fingers is present,
hypertension is present.
G. Rapid weight gain
Weight should be gradual. Weight
pattern is more important
H. Flashes of lights or dots before the
eyes (hypertension in pregnancy)
I. Dimness or blurring of vision
(hypertension in pregnancy)
J. Severe headache cannot be relieved
with medication (hypertension in
pregnancy)
K. Decreased urine output (oliguria)
DISCOMFORTS IN PREGNANCY
FIRST TRIMESTER
1. NAUSEA AND VOMITING-due to increased
HCG level that would lead to changes in
carbohydrate metabolism
a. Eat dry crackers-it should be before arising,
let mother in upright position
b. Small frequent feeding-during the day
c. low fat meals-oily foods will stimulate
vomiting
d. Avoid fried foods
e. Avoid antiemetics-medications that would
decrease the incidence of vomiting
2. SYNCOPE-fainting caused by increase in
blood volume or anemia or fatigue or sudden
position changes
a. Sit with feet elevated
b. Change position slowly
c. Left lateral position-to relieve pressure of the
uterus and inferior vena cava
FIRST THROUGH THIRD TRIMESTER
3. BREAST TENDERNESS-due to increased
estrogen and progesterone
a. Use supportive bra with elastic strap- breast
is engorged so it is heavy
b. Avoid soap in the nipples and areola-this can
cause some dryness and minute cracks
4. INCREASED VAGINAL DISCHARGES-cause of
the lavagement increased estrogen level and
blood supply in the vaginal epithelium as well as
the cervix
a. Proper cleaning and hygiene
b. Wear cotton underwear-absorb discharges or
use pantyliners without scent and changed
every 4 hours
c. Avoid douching-fluid could be forced into the
uterine cervix
d. Consult physician if infection is suspected-if
the smell is accompanied by foul smell
e. Full bath daily to wash accumulated
secretions in the body
5. NASAL STUFFINESS-1st to 3rd trimester due
to estrogen, which causes swelling in the nasal
tissues as well as dryness in the tissues
a. Use humidifier-boiling water
b. Avoid nasal sprays and antihistamines
(medication that would help to humidify the
nasal portion of the mother)
6. FATIGUE-due to increased metabolic
requirement which can be relieved by rest and
sleep
a. Frequent rest periods-do not sleep in the
morning, after lunch is recommended, rest
periods should be arranged within the day
-avoid stimulants
b. Regular exercise-fitted in the number of
months, be encouraged by walking 30 minutes
c. Avoid stimulants
7. URINARY FREQUENCY AND URGENCY-the
normal occurrence due to the pressure of the
growing fetus or anterior bladder, increased
progesterone, it will relax the muscle in the
urethra
a. Increase oral fluid intake-
b. Limit fluid intake in the evening
c. Void at regular intervals-have urination every
2 hours
d. Sleep on the side at night-left lateral;
e. Wear perineal pads if necessary-non-scented
pantyliners every 4 hours.
11. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
SECOND AND THIRD TRIMESTER
8. HEARTBURN or dyspepsia-increased
progesterone level that maintain the pregnancy
of the mother causes decreased GI motility and
esophageal reflux, displacement of the stomach
by enlarging fetus
a. Small frequent feeding
b. Sit upright for 30 minutes after meal
c. Drink milk between meals
d. Avoid fatty and spicy foods
e. Avoid antacids (one that would help coat the
abdominal wall to prevent heartburn) unless
prescribed by physician
9. ANKLE EDEMA-observe if it is also occurring
in the face, proteinuria-lead to hypertension
causing relaxation of the blood vessels, causing
vasodilation, venostasis, increasing pressure to
the ankle of the mother due to increasing
weight of the fetus
a. Elevate legs at least twice a day
b. Wear support stockings-not be narrow as it
will constrict blood vessels and impede
circulation
c. Avoid one position for long periods of time-
should be on the left side lying position to
increase glomerular filtration rate (which will
give good venous return)
d. Avoid diuretics- medications that would help
eliminate the urine
10. VARICOSE VEINS-due to the weight of the
distended uterus that will puts pressure on the
vein returning blood in the lower extremities.
As a result, there will weakening of the walls of
the vein and venous congestion occurs
a. Wear support stockings
b. Elevate feet when sitting
c. Lying with feet and hips elevated-supported
with pillow
d. Move out while standing
e. Avoid pressure on lower legs
f. Avoid leg crossing-sole attached on the floor
g. Avoid standing or sitting in long period of
time
h. Avoid constricting clothing
11. HEADACHES-occur as a result in changes in
the blood volume and vascular tone
a. Change position slowly
b. Apply cool cloth at forehead-in a lying
position
c. Eat small snack
d. Use pain relievers when prescribed or
acetaminophen
12. HEMORRHOIDS-due to increased venous
pressure or caused by constipation, blood
vessels that protrude
Mothers are given ferrous sulfate-this will cause
constipation
a. Warm sitz bath-ordered by the doctor
b. High fiber diet (apple causes constipation)
c. Increase oral fluid intake-2 liters per hour
d. Exercise-walking, a person who is sitting in
one position will lead to constipation
e. Apply ointments/suppositories as prescribed-
need doctor’s order, given in SPH is to relieve
constipation is medications
13. CONSTIPATION-due to decreased intestinal
motility that would cause displacement in the
intestine and as well as taking iron
a. High fiber diet
b. Increase oral fluid intake
c. Exercise
d. Avoid laxatives-suppositories
14. SHORTNESS OF BREATH-
a. Rest periods
b. Elevate head while sleeping-45 degrees bed
or moderate high back rest
c. Avoid overexertion-
15. BACKACHE-waddling walk, as the pregnancy
progresses, due to exaggerated lumbosacral
growth
a. Encourage rest
b. Use body mechanics
c. Wear Low-heeled shoes
d. Exercises
e. Sleep on firm mattress
12. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
16. LEG CRAMPS-as a result of altered calcium
and phosphorus content and pressure in the
nerves due to prolonged sitting
a. Exercise
b. Elevate and dorsiflex the feet while resting
c. Increase calcium intake
RECOMMENDED EXERCISE
Safety precautions for exercises during
pregnancy should be observed. Never exercise
to the point of fatigue. Always rise from the
floor to prevent orthostatic hypotension. To rise
on the floor, roll on the side first to prevent
strain in the abdominal muscles.
1. Tailor sitting-with the legs parallel so
that one does not compress, this will
strengthen the thighs and the structure
of the perineal muscles
2. Squatting-done third trimester to have
her EDC and tighten the structure of the
muscles, balance, help to balance
3. Pelvic Floor contraction (Kegel’s
Exercise)-to help the uterine muscles to
strengthen, squeeze surrounding the
vagina
4. Abdominal Muscle contraction-tighten
abdominal muscles and help to relax
like blowing a candle
5. Pelvic Rocking-makes the lumbar spine
more flexible and help to lengthen or
stretch the spine of the mother, during
deliver mother is extended in her
lithotomy position, to facilitate proper
delivery of the fetus
 LABOR
⮚ A series of events when the product
of conception is expelled out from
the woman’s body.
⮚ Regular uterine contractions cause
progressive dilatation of the cervix
and sufficient muscular force to
allow the baby to be pushed outside.
⮚ Usually begins when the fetus is
sufficiently mature.
⮚ series of event which the uterus
contraction expel the placenta???

13. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
THEORIES OF LABOR
1. Uterine stretch theory
- contraction of the uterus would
indicate labor begins.
- any hollow organ, when stretched
to maximum, will contract or explode
2. Oxytocin and prostaglandin
theory
- works together to inhibit calcium
binding in muscle cells, raising
intracellular calcium thus activating
contractions.
- the pressure on the cervix,
stimulates the pituitary gland, which
works with prostaglandin
3. Progesterone deprivation theory
- a decrease in progesterone causes
uterine changes
- labor pain occurs.
- when there is a decrease of
progesterone, the uterine contracts
4. Prostaglandin theory
- prostaglandin stimulates
myometrium thus labor onset to
contract.
- initiation of labor contraction is
caused by the interplay of the
adrenal gland of the fetus
5. Placental aging theory
- insufficient nutrients to reach the
fetus, no longer produce estrogen
and progesterone. Thus, labor
begins.
-when it reaches the full term, the
placenta will be considered a foreign
body
-one of the mechanisms is to expel
the placenta
-placenta will decrease in fxn
below ischial spine-positive (ex. +2),
crowning
(-2) taas pa sa ischial spine
-the size of the fetus will fit in the
pelvis of the mother done through
pelvimetry
diagonal conjugate-AP diameter
transverse diameter-inlet of the
pelvis
gynecoid-appropirate for childbirth
2. Passenger- fetus and placenta
-composes placenta and the fetus
3. Power- uterine contraction, uterine
muscles, and mother’s ability to
push during contraction
a. once there is contraction-
mother will start pushing
4. Psyche- mother’s psychological
condition
-Emotional condition of the mother
5. Position, maternal position-
London(standing) the gravity push
the baby
Philippines (lithotomy position)
THE PELVIS

COMPONENTS OF LABOR (5 P’s)

1. Passageway- mother’s pelvis,
cervix and vagina
a. during labor, coccyx bone would
move to allow the baby to pass
ischial spine-where you will imagine

14. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 9

Gynecoid
- most appropriate for normal spontaneous
vaginal delivery (NSVD)

Platypeloid
- broad and flat
- transvers, not allowed for NSVD,; bears no
resemblance

Antropoid
- resembling the pelvis, posterior
presentation

Android
- inlet is a little bit triangular
- shaped as heart
- natrow lateral view

15. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 AREAS OF CONCERN: Station- relationship of the fetal
Internal Os presenting part to the level of the ischial
External Os spine
Thinning of Vaginal Canal
expressed by centimeters, max is 10cm

iF THIN, THIS AS A PAPER

Durine IE, if the doctor will tell about
effacement, expressed in percentage.

halfway-shaving
Retractor is used
Engagement- settling of the fetal
presenting part into the ischial spine
-if not reached in the ischial spine, not
engaged,
-expressed in positive or negative (not
engaged)
- -3,-4,-5 is floating -If it is in 7-8 cm already, the mother is
placed in the delivery table
-0 is in the level of Ischial spine -ADMISSION DIRECT DR: mother is
-+3, +4, +5-the baby is crowning placed directly to the delivery table,
-IE is done once ideally in the shift, it will skipping the Emergency room
contract further the myometrium
-MULTIPARA: multiple pregnancies; Figure: VERTEX CEPHALIC
thus may not be engaged PRESENTATION
-PRIMIPARA: non-engaged of the head
in the beginning of the labor; thus
indicating complications (abnormal
presentation, abnormal position,
abnormal presentation of the fetal head
like Anencephaly)

16. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente

DILATION
- opening of the cervical os
- from 1 cm-10 cms (fully dilated cervix)
- due to uterine contraction and
amniotic fluid
- if there will be rupture of the bag of water
you expect for faster effect of uterine
contraction
Gravida 1-okay ra
Gravida 10-good luck, fast stretching of
uterus because of Multipara Number of
pregnancy, will not abot sa table
EFFACEMENT
- thinning of the cervical canal
-rogue kay mawala
- expressed in % (100% is a fully dilated
cervix)
Primipara-there is none engagement of the
head in the beginning of labor> some
complications like abnormal presentation
or the abnormality of the feral heal
Anencephaly-baby has no skull
Multipara-multiple pregnancy
VAGINAL CANAL
- one of the passageway of the fetus
- has rugae and capable of stretching but
can be lacerated: (inside, not in the
perineum)
17. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
-lying inn is not allowed to handle first
delivery
-first baby- in the hospital (because
complications from first baby cannot be
detected and treated in the lying inn)
a. 1st degree- skin is lacerated
b. 2nd degree- skin and muscles
c. 3rd degree- external sphincter of rectum
together with skin and muscles
d. 4th degree- mucus membrane of rectum
- suturing is done
- In lying inn, the owner will allow nurses to
do the suturing and IE
PERINEUM
Episiorrhaphy-repair of the surgical cut
site of episiotomy:
a. Median episiotomy
b. Right mediolateral
c. Left mediolateral
Equipment in DR:
-Ward notebook
-Jot down notebook exclusive for or and dr
-Information from the case/patient should be
signed by CI and Head NURSES and
written in log notebook (if not, you have to
repeat a case)
-3 cases of cord care
PASSENGER- FETUS AND PLACENTA
• fetal skull of the fetus is the largest part of
the body
• the least compressible of all parts (fetal
skull)
• the most frequent presenting part
-to allow the fetus to come out, it should be
under go in the process of molding
(overlapping)
-Suture lines help in the process of
delivery> This undergoes overlapping/
molding> Facilitates in the delivery> Goes
back to its original form
Anterior fontanel- diamond-
-6 months to heal
 -affects delivery if its too long
Posterior fontanel- closes right after delivery -Vertex: usual presenting part of the fetus
-sometimes it closes after 3 months (rare
cases)

Vertex Presentation
-the most appropriate

Military Presentation
-body is not flexed

Full extension
-the baby may have taken some of the
water from the bag of water; may cause
aspiration when the baby is out; will cause
Anterior fontanel obstruction of the respiratory system of the
-aka bregma baby
-Diamond-shaped fontanel
-close at 18 months

Anteroposterior Diameter of the head

18. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 Fetal Lie
-relation of the long axis of the fetus to the
long axis of the mother

19. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 -Needed to be CS

Single Footling breech

-if the doctor is experienced, this may be
delivered normally
The skull is capable of molding to effectively
deliver fetus outside delivery
Umbilical prolapse
-delikado

Twin pregnancy
-There must be 2 FHT
-confirmed in ultrasound

20. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 Position-position of the fetal presenting part
to he specific quadrant of the mother

Quadrants:
Upper quadrant (right and left)
Lower quadrant (right and left)

normal FHT (fetal heart tone) 120-160

-indicate which quadrant you have taken the
FHT

21. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
-Ex: RUQ 120
FETAL LANDMARKS
Occiput - vertex/cephalic presentation (O)
Mentum- chin/ face presentation (M)
Sacrum - in breech presentation (Sa)
Acromion - scapula/shoulder presentation
(A)
• Auscultation of FHT
- through stethoscope
-Leopold’s maneuver should be done before
this
• Sonography (USD)

FETAL POSITION -represented by 3-letter

abbreviation.
1ST letter - L (left) or R (right) quadrant
2ND - fetal landmarks (OMSaA)
3RD - A (anterior), P (posterior) T
(transverse) Left Occiput Anterior
presentation

Right Occiput Anterior

-Ex: LOA (Left occiput anterior)

METHODS TO DETERMINE FETAL

POSITION
• Leopold's manuever
- Helps in locating the position of fetus
-noninvasive method of assessing fetal
presentation, position and attitude. This
method is also used to locate the fetal back
before applying the fetal monitor.
• IE/Vaginal exam
- done by physician only Left Occiput Transverse

22. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 Right Occiput Transverse Direct Occiput Posterior

Direct Occiput Anterior

Left Occiput Posterior

Right Sacrum Posterior

Right Occiput Posterior

23. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente

No contraction = no pushing
-only blow with air
-pushing should only start when the dilation
is in 8cm
-stop the pushing after the count of 10
UTERINE CONTRACTION
Duration-referring to the beginning of
contraction up to the end of the same
contraction
-To check: Palms should be over the
abdomen of the mother
-”Ma’am, check lang nako ug nagkusog
na imong tiyan?”
-should be timed
Frequency- beginning of contraction to the
beginning of another contraction
-should be time
Intensity- start of the contraction up to the
peak of contraction
-maindent pa ang fingers,
-kasing tigas ng agtang
increment-increase in contraction
-ACME-: peak of contraction
- DECREMENT: decreasing in contraction;
the contraction subsided
-time-an ang kamot sa abdomen; in
seconds
(SEQUENCE:INCREMENT>ACME>DECR
EMENT)
Contraction- surest sign that labor is
already starting
-monitor intensity, duration, and frequency
24. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
PRELIMINARY SIGNS OF LABOR
1. Lightening
2. Braxton Hick's contraction
- irregular and painless contractions
begins in 4 months or 16 weeks of
gestation
3. Cervical changes
- accompanied by cervical effacement
as well as dilatation
- There are clear secretions with
blood streaks
4. Bloody Show
- Cervical changes with blood
5. Loss of weight
- during expected date of
confinement, mother’s appetite is
lost
6. Increase in activity level
SIGNS OF TRUE LABOR
⮚ Uterine Contractions
⮚ Effacement- shortening and thinning
of the cervical canal expressed in %
(fully dilated cervix is 100%)
⮚ Dilation- opening of the cervical os
from 1 cm- 10 cms (fully dilated
cervix)
⮚ Uterine changes-
- Upper uterine segment
becomes thick and active to expel
out the fetus
- Lower uterine segment
becomes thin and because of the
pressure, it will help the fetus push
out
⮚ Physiological retraction ring
- is formed the boundary between
the lower and upper uterine
segment
DIFFERENCE BETWEEN FALSE AND
TRUE LABOR
FALSE LABOR
• Irregular interval contractions
• Pain in the abdomen
• Intensity remains the same
• Intervals remain long
• Walking gives relief
• No bloody show
• No cervical changes
• Contractions stops with sedation
TRUE LABOR
• Regular interval of contraction
• Starts at the back to abdomen
• Contractions are intensified
• Intervals gradually shorten
• Intensified by walking
• With bloody show
• Cervical dilatation and effacement
• Does not stop with sedation
STAGES OF LABOR
First stage - Dilatation/Dilation stage
-expect rupture of bag of water
- Beginning of true labor contractions
and ends with the full dilatation of
cervix
- rupture of amniotic fluid
different phases: - EVERY 15 MINUTES
Latent Phase
-mild intensity of the abdomen
- early time of labor
- 2-3 cm dilatation
- contractions are of regular short
duration
- excited mother
- 15-30 seconds tapart
- Takes about 8-12 hours
- Implement health teachings Ma’am,
during sa active phase mo, pwede
ka mag blow. Push like murag
nalibang ug tubol; labor must be
consistent para di magbalik-balik
ang ulo ni baby
- Take fht and other vital signs
EVERY HOUR
Active Phase (accelerated phase)
- cervix is 4-7 cm
25. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
- rapid increase of duration
- Frequency take 3-5 seconds
- duration is about 30 seconds and of
moderate intensity
- mother is losing control of herself
(eg. shouting and crying mother)
-oa era of the mother (!!!)
-never give health teachings (pt is
not interested)
-monitor vital signs (don’t take bp if
nagbusog ang tiyan ng mother-increased
pressure in the peripheral ___
-do not take fht (if there is
contraction of the uterus, the fht will lower
down) because of the vagus nerve which
will stimulate bradycardia
- fetal heart tone (N: 120-160)
-fht every 30 min monitoring
- Take fht and other vital signs EVERY 30
MINUTES
Transitional Phase
- 8-10 cm
- PA and IE is done
- get all info of pt
- Take fht and other vital signs
- this is the time, the baby is about to
expel
Fetal Heart Tone
- If fht is abnormal, advice the mother
to change position (LEFT side lying
position, left lateral position, sim’s
position, left recumbent position);
Not on the right because the right
artery may be compressed
- Through FHT, we will know that
there is fetal distress
Fetal Distress
-thrashing
-fetal tachycardia
-fetal bradycardia
-poop (???)
-giving emotional support
Second Stage- Fetal expulsion stage -lowspinal injected in 5th lumbar space
-announce that the baby is out (Ex. •Epidural
BABY OUT, at 2:13pm) •
-declare also the gender Side effect- post anesthesia headache,
-give emotional support to the mother hypotension

Third Stage- Placental Stage Elevate legs- to induce venous return on the
- brain, we d not deprive the brian from
oxygen
Fourth Stage- Recovery Fast drip-full, label lalagyan ng plaster, sa
- level ng 300 ilagay, resume previous drip,,
regulate the regulator into 120 cc/hr
FIRST STAGE OF LABOR Let patient lie for 12 hours and IOFI
14. Start IVF as ordered
15. Assist in amniotomy (artificial rupture of
membranes)
16. Watch out for SUBIRBA
17. Emotional support

WHEN TO POSITION PATIENT FOR

DELIVERY?
S - Severe uterine contraction
-complete dilation of the cervix
U - Urge to defecate
-because of the pressure of the
presenting part
B - Bearing down sensation
-increasing but we have to inform when
NURSING CARE DURING THE 1ST STAGE to do the pushing
1. Admission care I - Increase bloody show
2. Data gathering -vaginal discharges is becoming
3. Assisting IE increased
4. Leopold’s manuever R - Ruptured Bag of Water
5. Fetal Heart Tone (FHT) Monitoring B - Bulging of the perineum
6. Uterine Contraction Monitoring -you cannot identify where is the minora
7. Promote change in position and majora
8. Empty the bladder A - Anal dilation
9. Hygiene -pwet ng manok
10. Enema administration - depends if there
is an order Spontaneously ruptured- no need
11. Perineal preparation artificial rupture
12. Analgesic administration as ordered
13. Assist in the administration of regional
anesthesia- (sedation)
-
-pudendal-sacrospinous ligament
-paracervical

26. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 INTERNAL ROTATION
CARDINAL MOVEMENTS -allow the vertex
OR -extension begging the rotation
MECHANISMS OF LABOR
-passage of the fetus through te birth
canal that involves number of different
position changes to keep the smallest
diameter of the fetal head always
presenting to the smallest diameter of
the fetal head
THE DESCENT
-downward movement of the biparietal
diameter of the fetal heal with the pelvic
inlet
-inlet is already engaged during the
pushing of the mother
Stations of presentation- Fetal Head
positions during descent
INTERNAL ROTATION

.
FLEXION
-as the descent occurs, the fetal head
reaches the pelvic floor
Extension Beginning (rotation complete)

27. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
EXTENSION External Rotation (Shoulder rotation)
EXPULSION
-right hand, slide sa likod hanggang sa
extremities ng bata
-maslide tungod sa vernix caseosa

Extension Complete
Expulsion
EXTERNAL ROTATION
HEAD IS VISIBLE
External Rotation (Restitution)
-plus 3
-after the two shoulder, the whole body
follows

External Rotation (Restitution)

EXTERNAL ROTATION

28. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
CROWNING ASSIST IN THE EXTERNAL ROTATION
-plus 4 -once the baby is already out you have to
wipe the face to avoid aspiration
-labia is already pedamatus

EASING THE HEAD OUT INITIAL AUCTIONING OF MOUTH AND

NOSE
-the nurse should push the labia to help
the mother to eas

DELIVER THE SHOULDER

-once the cord is coiled, ease first the
cord

29. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
DELIVER THE BODY

CLAMPING AND CUTTING THE

THOROUGH SUCTIONING OF THE
UMBILICAL CORD
NEWBORN
-fold the chord, and check the pulsation
-once the baby is out, you need to do the
declaration - the clamp should be 2 inches from the
base of placenta
-Suction while the baby’s body is still in.
-2 inches from the clamp, place the
-Wipe the face when the body is fully out
forceps
then facilitate the Unang Yakap
-before you close the clamp, check 1st
-Upon expulsion of the baby, declare the
the pulsation. If there’s no pulsation,
time and its sex (Ex. Baby out at 2:32,
clamp it.
baby is a girl)
-The baby will stay in the mother’s chest
for 90 minutes. But if the baby’s Apgar
Score is not good, then 90 minutes is not
applicable

NURSING CARE ON SECOND STAGE

1. Lithotomy position
2. Perineal flushing
3. Drape aseptically

30. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
4. Teach breathing technique during uterine uniform from getting splashed by
relaxation blood
- When the cord is already separated
5. Teach pushing technique during uterine
form the baby, it gets longer. Thus,
contraction
you have to coil it until the perineum
6. Assist episiotomy of the mother (hold the tip of the
scissor to serve as stopper)
7. Do ritgen’s maneuver
- The doctor puts pressure using OS 2. Placental delivery
to the lacerated part of perineum Schultz delivery- fetal, shiny
until the baby goes out Duncan delivery- maternal, dirty,
rough
8. Ease head out, wipe face and do initial
suctioning Detachment and Delivery of 1st Placenta

9. Wait for external rotation - If placenta is not complete, the

doctor will clean it manually or
10. Pull head downward and upward to through the use of an instrument
deliver the shoulders - If this is not thoroughly removed, the
mother will continue to bleed
11. Deliver the body
12. Take note of time of delivery and sex of
the baby
13. Place baby on mother’s abdomen
14. Palpate for the pulsation of the cord
15. Clamp the cord near the vulva
16. Milk the cord towards the baby
17. Clamp 1 inch apart from initial clamping
18 Cut the cord.
THIRDSTAGE OF LABOR
(PLACENTAL STAGE)
1. Placental separation
a. Calkin’s sign-uterus becomes
globular and firm
b. Uterus rises above the abdomen
c. Sudden gush of blood
d. Lengthening of the cord
- While waiting for the baby to come
out, stay in the middle or in front of
the perineum. But during placental
separation, move aside to avoid

31. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 9. Promote uterine contraction:
- massage the hypogastric area
- Apply ice pack on the hypogastric
area
- Administer medication:
Oxytocin/Maleate (usually the IV has
oxytocin already)
- Empty the bladder
10. Inspect perineum for lacerations
11. Assist in episiorrhaphy
12. Do perineal care
DELIVER THE PLACENTA
13. Apply contoured brief/adult diaper
- the mother can’t be placed in the
stretcher if bleeding is seen in the
diaper
14. Make patient comfortable
- when covering the lower extremities,
seal or tuck in the end part of the
blanket

NEONATAL PERIOD
1. Airway
NURSING CARE ON THIRD STAGE
- wipe mouth and nose
1. Wait for signs of placental separation - suction
2. Do Brandt Andrew’s Maneuver - stimulate to cry (by massaging the
back)
- While coiling the cord, you are - oxygen administration (Attach a
massaging it cone-shape paper to serve as the
baby’s breathing mask)
3. Do Crede’s Maneuver
- hook to respiratory machine
- The coiling of the cord -
-
4. Gently pull the placenta downward 1. Temperature
5. Take not for the time of placental delivery - dry the baby
- wrap with towel
6. Check for type of placental delivery: - gooseneck lamp; or placing plastic in
the crib before the lamp (to maintain
7. Take BP once the placenta is out
the heat in the nursery)
8. Check for completeness of cotyledons - avoid unnecessary exposure
- place inside incubator

32. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 2. Proper identification
- name bond (Ex. Baby Girl Atillo and
the date of delivery)
- foot prints
3. Care of the cord
- milking the cord
- cord dress aseptically (not done to
pre-term unless the doctor orders
which is also dependent on the
baby’s weight; also because it is
where the IV is injected)
4. Care of the eyes
Crede's prophylaxis (prevents
ophthalmia
neonatorum) - terramycin
5. Vitamin K injection
6. Newborn assessment
APGAR scoring- done on the first 1
and 5 mins of life
Score interpretation
0-4= Poor
in serious danger and needs
resuscitation
5-6= condition is guarded
may need airway clearing and
oxygen
Baby needs to be monitored closely
7-10= good
newborn is doing well
7. Anthropometric measurements
Birth weight= 2.5-3.5 kgs
Length= 45-55 cms
Head circumference= 32-35.5 cms
Chest circumference= 30-33 cms
33. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
abdominal circumference= 28-30
cms
8. Vital signs
Heart rate= 120-160 bpm
Respiratory'= 40-60 bpm
Temp(rectal)- 36-37.6
-if the legs are bending, just follow its
contour when measuring
-Head circumference: make sure to not
include fingers
-Chest circumference: basis is the nipple
of the baby ( should be inline with the
nipple, and make sure to check if its
parallel with the back of the baby)
9. Head to toe assessment
a. Head- biggest part of the body of
the baby
moldings
fontanels
- will close at 18 months
(anterior), and after delivery
or at 3 months (posterior)
caput succedaneum
- this is a condition of the head
of the newborn cause by
edema
- Birth-related trauma due to
pressure
- Subsides for a couple of
days
- No treatment is needed
- But the baby may experience
discomfort
cephalhematoma
- blood clot, pressure caused
by vacuum or forceps
 - caused by rupture of the
blood vessels in the
periosteum
- - no treatment CAPUT SUCCEDANEUM
- serous anguinosa
- we just need to put the head
cup of the newborn to
subside
suture lines
anencephaly
- When the brain of fetus is not
protected by a skull
- Brain is seen (only the
membrane covers it)
- Caused by Vitamin A
deficiency
b. Face CEPHALHEMATOMA
blink reflex
- Present til death -composed of blood in between scalp due to
strabismus pressure exerted during vacuum extraction
- Usually babies experience or forceps (that is usually done to ease the
strabismus delivery of the mother)
ears should be even or above
outer eye canthus
MOLDINGS
Anterior Fontanel
-sunkens if baby is having discomfort
-suture lines undergoes molding para lumiit

c. Chest= witch milk- normal upon

delivery to both sex of babies

d. Abdomen= check the umbilical

cord
= gastroschisis-
absence of abdominal
wall
- one of the neural
defect
e. Genitals
= should void within the 1st 24
hours

34. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 “if naka wiwi ang baby you
should inform the staff nurse, kay
if dili naka ihi there's a problem”
=pseudomenses- Labia is
prominent and with blood, but
this is normal and will just
eradicate
=testes should be descended
(cryptorchidism- undescended
testes which lead to infertility)
=preterm male has less rugae in
the scrotum
= labia minora is prominent
f. Extremities
=flexed
=creases on the palm (Simean
crease- only one crease)
polydactyl- extra toes or fingers
(usually often asked by the
mother)
syndactyly — webbing of fingers
=amelia- absence of upper
extremities
-needs further assessment
=tocophilia- absence of lower
extremities
-usually causes by teratogens
=clubfoot
g. Skin
= color
- through Apgar Score
=Mongolian spots
- Marking of the skin after
birth, that will eventually
disappear
- Found in the back, at the
buttocks, spine, and should
- Present because of
melanocytes or the cell that
produces melanin, that
remains in the deeper layer
- Congenital-normal
melanocytosis
35. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
= vernix caseosa
- this is the white cheese
substance but it is not be
removed
- helps the adjustment of the
baby in external temperature
- -helps regulate the
temperature
- it melts and remove
= lanugo
- fine hair that can be found in
the shoulder
- it is due to unpigmented first
hair but it will be disappear
= Milia
- White spots like pimples,
found in the face of the
newborn but prominent on
the nose
- Do not prick and remove
because it will just disappear
after weeks
- Due to the sweat glands of
the baby that is being
blocked
- needs no treatment
- If persists for 2-3 months,
seek medical consultation
MILIA
MONGOLIAN SPOTS
 - bluish discoloration
—-diri ra kutob madi—----------
4TH stage- Puerperium / PP
36. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
Puerperium/ postpartum period/ 4th
trimester/ recovery stage
- 6-8 weeks period after childbirth
during this time, the mother when admitted
has short stay, allowed to go home after 24
hrs, cesarean 3 days
-Post partum hemorrhage occurs mostly at
home
Involution- reproductive organs return to its
non-pregnant state
-The uterus is expected to contract
immediately because if not, it may cause
hemorrhage
Subinvolution- failure of the reproductive
organ to return to its non-pregnant state
-checking of the substances left inside
Exfoliation- placental site heals by scaling
off dead tissues
-When the placenta detaches from the
endometrium
Atony- uterus does not have good muscle
tone and consequently relaxes
-if the uterus relax it leads also postpartum
hemorrhage
PRINCIPLES OF PUERPERIUM
• Promotion of healing and prevention of
illness
-One of the responsibility of the nurse is the
prevent the occurrence of illness
-We have to promote the wellness of the
client, continuously monitor the uterine
status of the mother, monitor vital signs to
know if there are alterations inside the body
o the mother, and CV
-We do not expect constipation
-assess religiously different areas of the
mother to check if there are some risk that
may happen
• Prevent postpartal complications
• establish successful lactation
Expanded Breastfeeding Promotion Act
..RA 10028
Pituitary gland-produce oxytocin for
lactation
• Motivate use of family planning method
• Provide emotional and psychological
support
-this is where the mother usually are
neglected, check the wife mga goy,
postpartum blues will occur
POSTPARTUM ASSESSMENT
(AV BUBBLEHER)
A = Appearance (when you check the color
of the skin, lips and all)
V = Vital Signs
B = Breasts
U = Uterus
B = Bladder
B = Bowel
L = Lochia
E = Episiotomy/Episiorrhaphy
H = Homan’s sign
E = Emotion
R = Rhogam
VITAL SIGNS
37. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
Temperature
- increase on the 1st 24 hrs-
dehydration/effort in labor
after 24 hours - infection
after 3-4 day- milk production
-check the milk coming out from the
nipples
-VS q15 if Post Partum
500ml of blood lost including
electrolytes
Pulse
- decrease due to decrease cardiac
output
Blood pressure
- slightly decrease
- -peripheral bradycardia 50-70 bpm
- first 6-10 days which is normal
Tachycardia- occurs less frequent-r/t
to increased blood loss and
prolonged labor and birth
-base to the previous blood pressure
-+30 is systolic/ +30 in
diastolic=postpartum hypertension
-it should remain constant
Respiratory rate
- no changes
- expect 16-24 (without illness)
- slight elevation
BREASTS
- drop in estrogen and
progesterone
you will also, note that there will be
engorging (until the clavicle) of the
 breast and will undergo physiological
changes
-check nipples if it is not inverted

- lactating
- you have to health teaching, warm
compress to increase breast milk

colostrum is present

Let-down reflex
- When the breasts starts to relax
- warm and tender
- engorged
- milk is produced by the 3rd – 4th
day
- veins are apparent
- Especially when engorging
UTERUS
6-12 hours
-Undergoes drastic changes during
postpartum Immediately after birth

- size is reduce: -put ice the hypogastric area

immediately after delivery- 1000 gms
after end of 1s week -500gms
after 6 weeks - 50 gms
- placental site is sealed off
- cervical os are narrowed
- painful during contraction (the after
pain that doesn’t need any pain medication
only anti-inflammatory combined with
analgesic)
- let the uterus be contracted
FUNDAL HEIGHT POST PARTUM
BLADDER
Voiding should occur 4-6 hours postpartum
(6-8 hrs)
In C/S, we can monitor in the urobag
-Apply cold water in the mons pubis
BOWEL
-Chromic 2O-leave it in the perineum
area
• becomes more active soon after birth
• peptide hormone relaxin,-high
circulating levels during pregnancy,
depresses bowel motility
• continued effects of of progesterone on the
smooth muscles
-decreased bowel motility

38. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
• bowel movement typically delayed until
2nd or 3rd puerperal date
• bowel tone is slowed
• during labor, restriction of food (NPO)
• fear of tearing the stiches
LOCHIA
- discharges of the uterus after
delivery
- -also present in cesarean section or
NSVD
Lochia rubra -1-3 days bloody red in
color
Lochia serosa-4-10 days, pink or
brown color
Lochia alba- 10-14 dyas creamy,
yeIIowish color
If it is red after 10 days, refer
because it might be postpartum hemorrhage
- pattern should not reverse
- increase in activity
- decrease in breastfeeding
(the discharges of the mother is few)
- not offensive in odor
- without large clots
- present in CS
EPISIOTOMY
• midline or mediolateral
• lacerations -1st degree-skin , mucus
membrane
2nd degree-skin,mucus membrane,fascia
3rd degree- skin , mucus membrane,
muscles, rectal sphincter
4th degree- involve all these structures plus
anal wall
39. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
Assessment REEDA-redness, edema ,
ecchymosis, discharges and approximation
-Redness: Betadine is not used in DR
because it may mask the redness of the site
-Ecchymosis: referring to discoloration. The
may turn to blue aside from res
-Discharges: Not foul smelling
-Approximation of suture lines: take note of
the number of stitches
HOMAN’S SIGN
- Refers to the deep tendon
reflexes
- Assessed through dorsiflexion of
lower extremities
• used in assessment of deep venous
thrombosis (DVT) in the leg
• varicosities and signs of thrombophlebitis
(THROMBUS FORMATION)
inflammatory process that causes blood clot
to form and block one or more veins
pedal pulses may be obstructed by
thrombophlebitis and should be
palpated with each assessment
EMOTIONAL STATUS
• sense of elation immediately after birth.
-the postpartum will occur
• mother wanted to talk about her labor and
delivery
• exhausted, need rest and sleep to restore
her body to health
• normally during the 1st 24 hours - passive,
preoccupied with own needs, talkative if
unable to sleep
• 1-2 days beginning to assume
responsibility
 - NPO
Rh INCOMPATIBILITY
-Epektib sa 2nd, 3rd and 4th pregnancy Weight Loss
• possible when two specific circumstances - Diuresis
exist:
- Diaphoresis
-mother is Rh negative
- return to prepregnant weight at 6th week
-fetus is Rh positive -the father is
PROGRESSIVE CHANGES
Rh positive causes no harm to the mother,
but affects the fetus Lactation
*Inside the mother’s womb is the
Positive
-During 1st pregnancy, the Rh
negative of the mother cannot detect that
there is Rh positive na present
-But during the succeeding
pregnancies, the Rh negative will engulf the
Rh positive and will affect the fetus
Rhogam- Rh immune globulin, unsensitized
-28/7AOG,72 hrs PP-IM Icterus Gravis-RBC
are destroyed, fetal bilirubin increases=
-helps to immunize the Rh negative of the
mother so that when the Rh positive enters,
it will not be destroyed by the Rh negative
kernicterus-bilirubin encephalopathy
Erythroblastosis fetalis
-causing death to the fetus
Coomb’s test

Retrogressive changes
Exhaustion
- sleeplessness
- fetal movements
- after pains
- energy expenditures

40. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
 THE CLUTCH OR FOOTBALL HOLD

SIDELYING OR RECLINING POSITION

HEALTH TEACHINGS FOR BREAST

FEEDING
1. Hand washing before and after
2. Clean nipple with water
3. Expose nipple to air
4. Feed the baby in short frequent intervals
and lengthen gradually
5. Alternate the breasts
6. Proper positioning
7. Adequate maternal nutrition and increase
OFI
8. Wear well-fitted bra THE CRADDLE
PROPER ATTACHMENT
Chin of the baby touches mother’s breast
Baby grasp not only the nipple but also the
areola Lower lip turned outward
Mouth wide open
PROPER POSITIONING
a. Head and lower body part must be
aligned
b. Baby is facing the mother
THE CROSS-OVER HOLD
c. Tummy to tummy

41. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente

BREASTFEEDING
B - Best for baby, also best for mommy
R - Reduces the incidence of allergies
E - Economical - no waste
A - Antibodies to protect baby against
infection
S - Sterile and pure; stool inoffensive
T - Temperature is always ideal
F - Fresh milk never goes off
E - Easy once establish
E - Eradicates feeding difficulties
D - digested easily
I - Immediately available
N - Nutritionally optimal; No mixing
required
G - Gastroenteritis greatly reduced
DIFFERENT BURPING TECHNIQUE
• Over the lap
• Tummy to tummy
• Over the shoulder
• Holding the baby supported with one hand
EMOTIONAL PHASE OF PUEPERIUM
1. Talking-in Phase
42. by: Reynaldo Sumalinog, &
Sid Rian Frederick V. Laurente
- woman is passive and dependent
- prefers talking about pregnancy,
labor and delivery
- uncertain in caring for newborn
- energies are focused on bodily
concerns
- uninterrupted sleep is important
- additional nourishment is necessary
- happens 1-2 days after delivery
2. Talking-hold Phase
- woman begin to initiate action
- interested in taking care of newborn
- asserts independence
- mother focuses on regaining control
over her bodily functions — bowel
and bladder; strength and
endurance
- happens 2 to 4 days after delivery
3. Letting-go Phase
- gives up old role
- ready for her new role
- postpartum depression most
commonly occurs
NURSING DIAGNOSES:
• Actual/potential Fluid volume deficit
related to excessive bleeding of
birthing process/postpartum atony
• Pain related to uterine cramping
(afterpains) or perineal sutures or
tissue damage related to childbirth
• Potential for impaired urinary
elimination related to perineal edema
• Urinary retention related to bladder
edema secondary to trauma during
delivery
• Altered Pattern of Urinary
Elimination related to postpartum
Diure5is
• Risk for Constipation related to loss
of bowel sensation after childbirth
 • Acute pain / Alteration in comfort 7. Initiate breastfeeding
related to tissue damage secondary to
8. Monitor VS and watch for indications
birthing process
of hypovolemic shock
COMMON POST PARTUM
9. Prepare and assist for repair of
COMPLICATIONS
laceration, removal of fragments or
I. Hemorrhage blood loss more evacuation of hematoma
than 500 cc
10. Emotional support
a. Early post partum hemorrhage
II. Post Partum infection
» lacerations
a. Infection of the perineum
- cervix
> pain, heat, feeling of pressure in the
- vagina perineum, inflammation, redness, 1-2
sutures slough off, febrile
- labia
> remove the suture, drain and
- perineum
resuture
> hot sitz or warm compress
> atony — relaxed or boggy uterus
> perilight
causes: large babies
cesarean birth
b. Endometritis — infection of the
augmentation of labor
uterine endometrium
placental accidents
> abdominal tenderness
dystocia
> uterine atony
b. Late postpartum hemorrhage
> dark brown foul smelling lochia
> retained placental fragments > You -
> Management: oxytocin and fowler’s
pulled too hard on the cord-inversion of
position
uterus
> ruptured uterus
c. Mastitis
NURSING INTERVENTIONS
SOURCE OF INFECTION
1. Monitor fundus frequently
1. Endogenous (primary)
2. Massage the uterus
- Normal flora
3. Apply ice pack in the abdomen 2. Exogenous source
- Hospital personnel
4. Empty the bladder - Excessive obstetric manipulation
5. Regulate IVF as ordered - Break in aseptic technique
- Coitus in late pregnancy
6. Administer oxytocic agents - PROM
(Oxytocin/Maleate)

43. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente
III. Thromboplebitis Concentrate on Antepartal (changes during
pregnancy), Intrapartum (when mother is
⮚ Signs and symptoms: already having the labor)
pain, stiffness, redness
swelling Not so much with the Postpartum (after
fever and chills delivery of the mother and placenta)
(+) Homan’s sign

⮚ Management
bed rest
elevate affected part analgesics
anticoagulant
elastic support to the affected part

⮚ Avoid:
frequent mobilization
thrombolytic agents
massage

POSTPARTUM DEPRESSION
• ” Many mothers experience a
“let down“ feeling after giving birth
related to the magnitude of the birth
experience and doubts about the
ability to cope effectively with the
demands of childbearing.
• ”This depression is mild and
transient, beginning 2 to 3 days after
delivery and resolving 1 to 2 weeks

HEALTH TEACHING
⮚ Self -Care
⮚ Infant care
⮚ Resumption of intercourse
⮚ PP exercises
⮚ Danger signs to be reported

COVERAGE FOR THE EXAM:

From the beginning to end.

44. by: Reynaldo Sumalinog, &

Sid Rian Frederick V. Laurente